Changes in Breastfeeding and Related Maternity Care Practices After Hurricanes Irma and Maria in Puerto Rico

Background: Breastfeeding is recommended globally for most infants, especially during and after natural disasters when risk of adverse outcomes increases because of unsanitary conditions and lack of potable water. Materials and Methods: Using 2017-2019 data from Puerto Rico's Pregnancy Risk Assessment Monitoring System for 2,448 respondents with a recent live birth, we classified respondents into 4 hurricane exposure time periods based on infant birth month and year relative to when Hurricanes Irma and Maria occurred: (1) prehurricane; (2) acute hurricane; (3) posthurricane, early recovery; and (4) posthurricane, long-term recovery. We examined the association between maternity care practices during delivery hospitalization and exclusive breastfeeding at 3 months overall and stratified by time period. We also examined the associations between each maternity care practice and exclusive breastfeeding separately by time period. Results: Exclusive breastfeeding at 3 months was higher during the acute hurricane time period (adjusted prevalence ratio [aPR]: 1.43, 95% confidence interval: 1.09-1.87) than the prehurricane time period. Supportive maternity care practices were positively associated with exclusively breastfeeding, and practices that are risk factors for discontinuing breastfeeding were negatively associated with exclusive breastfeeding. Breastfeeding in the first hour (aPR range: 1.51-1.92) and rooming-in (aPR range: 1.50-2.58) were positively associated with exclusive breastfeeding across all time periods, except the prehurricane time period. Receipt of a gift pack with formula was negatively associated with exclusive breastfeeding (aPR range: 0.22-0.54) across all time periods. Conclusions: Maternity care practices during delivery hospitalization may influence breastfeeding behaviors and can improve breastfeeding during and after natural disasters. Strategies to maintain and improve these practices can be further supported during and after natural disasters.

Rape and Sexual Coercion Related Pregnancy in the United States

INTRODUCTION

Sexual violence is a major public health problem in the U.S. that is associated with numerous health impacts, including pregnancy. U.S. population-based estimates (2010-2012) found that three million women experienced a rape-related pregnancy during their lifetimes. The current study presents more recent estimates of rape and sexual coercion-related pregnancy and examines prevalence by demographic characteristics.

METHODS

Data years 2016/2017 were pooled from the National Intimate Partner and Sexual Violence Survey, a random-digit-dial telephone survey of U.S. non-institutionalized adults 18 years and older. The analysis, conducted in 2023, examined lifetime experience of rape-related pregnancy, sexual coercion-related pregnancy, or both among U.S. women. Authors calculated prevalence estimates with 95% CIs and conducted pairwise chi-square tests (p-value<0.05) to describe experiences by current age, race/ethnicity, and region of residence among U.S. women overall and among victims.

RESULTS

One in 20 women in the U.S., or over 5.9 million women, experienced a pregnancy from either rape, sexual coercion, or both during their lifetimes. Non-Hispanic Multiracial women experienced a higher prevalence of all three outcomes compared with non-Hispanic White, non-Hispanic Black, and Hispanic women. Among victims who experienced pregnancy from rape, 28% experienced a sexually transmitted disease, 66% were injured, and over 80% were fearful or concerned for their safety.

CONCLUSIONS

Pregnancy as a consequence of rape or sexual coercion is experienced by an estimated six million U.S. women. Prevention efforts may include healthcare screenings to identify violence exposure and use of evidence-based prevention approaches to reduce sexual violence.

Pandemic-related stressors and mental health among women with a live birth in 2020

The objective of this analysis was to assess the associations between pandemic-related stressors and feeling more anxious/depressed, among women with a live birth. We analyzed data from the Pregnancy Risk Assessment Monitoring System (PRAMS) COVID-19 maternal experiences supplement, implemented in 29 U.S. jurisdictions from October 2020-June 2021, among women with a live birth during April-December 2020. We examined stressors by type (economic, housing, childcare, food insecurity, partner, COVID-19 illness) and score (number of stressor types experienced [none, 1-2, 3-4, or 5-6]). Outcomes were feeling 1) more anxious and 2) more depressed than usual due to the pandemic. We calculated adjusted prevalence ratios estimating associations between stressors and outcomes. Among 12,525 respondents, half reported feeling more anxious and 28% more depressed than usual. The prevalence of stressor types was 50% economic, 41% childcare, 18% partner, 17% food insecurity, 12% housing, and 10% COVID-19 illness. Respondents who experienced partner stressors (anxious aPR: 1.81, 95% CI: 1.73-1.90; depressed aPR: 3.01, 95% CI: 2.78-3.25) and food insecurity (anxious aPR: 1.79, 95% CI: 1.71-1.88; depressed aPR: 2.32, 95% CI: 2.13-2.53) had the largest associations with feeling more anxious and depressed than usual. As stressor scores increased, so did the aPRs for feeling more anxious and more depressed due to the pandemic. COVID-19 stressors, not COVID-19 illness, were found to be significantly associated with feeling more anxious and depressed. Pregnant and postpartum women might benefit from access to supports and services to address pandemic-related stressors/social-determinants and feelings of anxiety and depression.

Timing of Postpartum Depressive Symptoms

Introduction

Postpartum depression is a serious public health problem that can adversely impact mother-child interactions. Few studies have examined depressive symptoms in the later (9-10 months) postpartum period.

Methods

We analyzed data from the 2019 Pregnancy Risk Assessment Monitoring System (PRAMS) linked with data from a telephone follow-up survey administered to PRAMS respondents 9 to 10 months postpartum in 7 states (N = 1,954). We estimated the prevalence of postpartum depressive symptoms (PDS) at 9 to 10 months overall and by sociodemographic characteristics, prior depression (before or during pregnancy), PDS at 2 to 6 months, and other mental health characteristics. We used unadjusted prevalence ratios (PRs) to examine associations between those characteristics and PDS at 9 to 10 months. We also examined prevalence and associations with PDS at both time periods.

Results

Prevalence of PDS at 9 to 10 months was 7.2%. Of those with PDS at 9 to 10 months, 57.4% had not reported depressive symptoms at 2 to 6 months. Prevalence of PDS at 9 to 10 months was associated with having Medicaid insurance postpartum (PR = 2.34; P = .001), prior depression (PR = 4.03; P <.001), and current postpartum anxiety (PR = 3.58; P <.001). Prevalence of PDS at both time periods was 3.1%. Of those with PDS at both time periods, 68.5% had prior depression.

Conclusion

Nearly 3 in 5 women with PDS at 9 to 10 months did not report PDS at 2 to 6 months. Screening for depression throughout the first postpartum year can identify women who are not symptomatic early in the postpartum period but later develop symptoms.

Polysubstance use during pregnancy: The importance of screening, patient education, and integrating a harm reduction perspective

BACKGROUND

Substance use during pregnancy is associated with poor health outcomes. This study assessed substance use, polysubstance use, and use of select prescription medications during pregnancy.

METHODS

We analyzed 2019 data from the Pregnancy Risk Assessment Monitoring System in 25 United States jurisdictions that included questions on prescription medications, tobacco, and illicit substance use during pregnancy. Alcohol and electronic cigarette use were assessed during the last three months of pregnancy, and all other substances and medications were assessed throughout pregnancy. Weighted prevalence estimates and 95% confidence intervals (CIs) were calculated.

RESULTS

Nearly one-fifth of respondents who reported use of any substance reported use of at least one other substance during pregnancy. Cigarettes (8.1%; 95% CI 7.6-8.7%) and alcohol (7.4%; 95% CI 6.7-8.1%) were the most frequently reported substances, followed by cannabis (4.3%; 95% CI 3.9-4.7%). Substance use was higher among individuals who reported having depression or using antidepressants during pregnancy compared with those who did not report depression or antidepressant use. Illicit drug use prevalence was low (0.5%, 95% CI 0.4-0.7%); however, respondents reporting heroin use also frequently reported use of illicit stimulants (amphetamines: 51.7%, 95% CI 32.1-71.3% or cocaine: 26.5%, 95% CI 11.9-41.1%). Although prenatal clinician screening for alcohol and cigarette use was approximately 95%, fewer respondents (82.1%) reported being screened for cannabis or illicit substance use during pregnancy.

CONCLUSIONS

One in five individuals who reported use of any substance during pregnancy engaged in polysubstance use, highlighting the importance of comprehensive screening and evidence-based interventions including harm reduction.

Associations of Adverse Childhood Experiences With Pregnancy and Infant Health

INTRODUCTION

Adverse childhood experiences are associated with a host of negative outcomes; however, few have studied cumulative adverse childhood experiences in the context of pregnancy and infant health. This study examines state-level prevalence of adverse childhood experiences and associations with pregnancy- and infant health‒related indicators.

METHODS

The study used 2016-2018 Pregnancy Risk Assessment Monitoring System population-based data from 5 states. Analyses were conducted for individual states and grouped states using similar adverse childhood experience items. Thirteen adverse childhood experience measures were included across 3 domains: abuse, neglect, and household challenges. Adverse childhood experience scores were calculated for the number of adverse childhood experiences experienced (0, 1, 2, ≥3) on the basis of available state measures. Fourteen pregnancy- and infant health‒related indicators were examined, including unwanted pregnancy, adequate prenatal care, experiences during pregnancy (e.g., smoking, abuse, depression), gestational diabetes, hypertensive disorders of pregnancy, birth outcomes (e.g., preterm birth), and breastfeeding. Adjusting for demographics, parity, health insurance status, and educational attainment, prevalence ratios and 95% CIs were calculated to examine the associations between pregnancy- and infant health‒related indicators and adverse childhood experience scores.

RESULTS

Over 50% of respondents reported at least 1 adverse childhood experience and 13%-31% reported ≥3 adverse childhood experiences, depending on the state. Significant associations were identified in all adjusted models between adverse childhood experiences and unwanted pregnancy, smoking, physical abuse, and depression during pregnancy.

CONCLUSIONS

Adverse childhood experiences are associated with risk factors that impact pregnancy and infant health. Preventing and mitigating adverse childhood experiences is an important strategy to improve pregnancy- and infant health‒related indicators.

Rapid Population-Based Surveillance of Prenatal and Postpartum Experiences During Public Health Emergencies, Puerto Rico, 2016‒2018

The Pregnancy Risk Assessment Monitoring System-Zika Postpartum Emergency Response study, implemented in Puerto Rico during the Zika virus outbreak (2016-2017) and after Hurricanes Irma and María (2017-2018), collected pregnancy-related data using postpartum hospital-based surveys and telephone follow-up surveys. Response rates of 75% or more were observed across five study surveys. The study informed programs, increased the Puerto Rico Department of Health's capacity to conduct maternal‒infant health surveillance, and demonstrated the effectiveness of this methodology for collecting data during public health emergencies. (Am J Public Health. 2022;112(4):574-578. https://doi.org/10.2105/AJPH.2021.306687).

Response to "The Time has Come for All States to Measure Racial Discrimination: A Call to Action for the Pregnancy Risk Assessment Monitoring System (PRAMS)"

We respond to a recent call to action for the Pregnancy Risk Assessment Monitoring System (PRAMS) to include a "core" question or validated measure on discrimination to allow for systematic assessment of the impact of racial discrimination on adverse birth outcomes among a large population-based sample in the United States. We outline activities of the CDC PRAMS project that relate to this call to action.

Workplace Leave and Breastfeeding Duration Among Postpartum Women, 2016-2018

Objectives. To examine associations of workplace leave length with breastfeeding initiation and continuation at 1, 2, and 3 months. Methods. We analyzed 2016 to 2018 data for 10 sites in the United States from the Pregnancy Risk Assessment Monitoring System, a site-specific, population-based surveillance system that samples women with a recent live birth 2 to 6 months after birth. Using multivariable logistic regression, we examined associations of leave length (< 3 vs ≥ 3 months) with breastfeeding outcomes. Results. Among 12 301 postpartum women who planned to or had returned to the job they had during pregnancy, 42.1% reported taking unpaid leave, 37.5% reported paid leave, 18.2% reported both unpaid and paid leave, and 2.2% reported no leave. Approximately two thirds (66.2%) of women reported taking less than 3 months of leave. Although 91.2% of women initiated breastfeeding, 81.2%, 72.1%, and 65.3% of women continued breastfeeding at 1, 2, and 3 months, respectively. Shorter leave length (< 3 months), whether paid or unpaid, was associated with lower prevalence of breastfeeding at 2 and 3 months compared with 3 or more months of leave. Conclusions. Women with less than 3 months of leave reported shorter breastfeeding duration than did women with 3 or more months of leave. (Am J Public Health. 2021;111(11):2036-2045. https://doi.org/10.2105/AJPH.2021.306484).

Preventing Vector-Borne Transmission of Zika Virus Infection During Pregnancy, Puerto Rico, USA, 2016-20171

We examined pregnant women’s use of personal protective measures to prevent mosquito bites during the 2016–2017 Zika outbreak in Puerto Rico. Healthcare provider counseling on recommended measures was associated with increased use of insect repellent among pregnant women but not with wearing protective clothing.

The Impact of Dental Insurance and Medical Insurance on Dental Care Utilization During Pregnancy

OBJECTIVE

To measure the association between dental and medical insurance with the receipt of dental cleaning during pregnancy.

METHODS

We analyzed Pregnancy Risk Assessment Monitoring System (PRAMS) data from 2012 to 2015 on 145,051 women with a recent live birth from 36 states. We used adjusted prevalence ratios [aPR] from multivariable regression to examine the association of dental and medical insurance with receipt of dental cleaning during pregnancy, controlling for selected covariates that influence dental care utilization.

RESULTS

Seventy-seven percent (77%) of all women reported having dental insurance during pregnancy. Receipt of dental cleaning before pregnancy was strongly associated with dental cleaning during pregnancy. Among women without pre-pregnancy dental cleaning who had dental insurance, those with Medicaid medical insurance had a significantly higher prevalence of dental cleaning during pregnancy [aPR = 1.42, 95% CI (1.32 - 1.52)], compared to those private medical insurance. Among women without pre-pregnancy dental cleaning, those without dental insurance but with Medicaid medical insurance were about 70% less likely to have dental cleaning during pregnancy compared to those with dental and private medical insurance.

CONCLUSIONS FOR PRACTICE

With or without dental insurance, pre-pregnancy dental cleaning was strongly associated with dental cleaning during pregnancy. Dental insurance was an important determinant of dental utilization. Medical insurance had an independent and positive effect. This effect varied by private versus Medicaid medical insurance. Programs which provide women with dental insurance both before and during pregnancy could improve the oral health of maternal and infant populations.

Disability and Pregnancy: A Cross-Federal Agency Collaboration to Collect Population-Based Data About Experiences Around the Time of Pregnancy

Many reproductive-aged women with a disability can achieve successful healthy pregnancies; however, they may face challenges accessing prenatal and postpartum care and finding providers who are knowledgeable about their specific condition. Depending on the nature of the disability, some women may also be at increased risk for adverse maternal and infant outcomes such as pre-eclampsia, infection, anemia, primary cesarean delivery, or preterm birth. Population-based data are needed to better understand the pregnancy and postpartum experiences of women living with disability. The National Institutes of Health and the Centers for Disease Control and Prevention (CDC) collaborated to address these data gaps by leveraging CDC's Pregnancy Risk Assessment Monitoring System (PRAMS) to gather information about disability among women who have had a recent live birth. Data collection began in 2019. Information gathered through PRAMS can be used to guide the development of clinical practices guidelines, intervention programs, and other initiatives of federal, state, and local agencies to improve services and the health of women of reproductive age living with disability.

Women's Awareness and Healthcare Provider Discussions about Zika Virus during Pregnancy, United States, 2016-2017

We surveyed women with a recent live birth who resided in 16 US states and 1 city during the 2016 Zika outbreak. We found high awareness about the risk of Zika virus infection during pregnancy and about advisories to avoid travel to affected areas but moderate levels of discussions with healthcare providers.

Prevalence and Factors Associated With Safe Infant Sleep Practices

OBJECTIVES

To examine prevalence of safe infant sleep practices and variation by sociodemographic, behavioral, and health care characteristics, including provider advice.

METHODS

Using 2016 Pregnancy Risk Assessment Monitoring System data from 29 states, we examined maternal report of 4 safe sleep practices indicating how their infant usually slept: (1) back sleep position, (2) separate approved sleep surface, (3) room-sharing without bed-sharing, and (4) no soft objects or loose bedding as well as receipt of health care provider advice corresponding to each sleep practice.

RESULTS

Most mothers reported usually placing their infants to sleep on their backs (78.0%), followed by room-sharing without bed-sharing (57.1%). Fewer reported avoiding soft bedding (42.4%) and using a separate approved sleep surface (31.8%). Reported receipt of provider advice ranged from 48.8% (room-sharing without bed-sharing) to 92.6% (back sleep position). Differences by sociodemographic, behavioral, and health care characteristics were larger for safe sleep practices (∼10-20 percentage points) than receipt of advice (∼5-10 percentage points). Receipt of provider advice was associated with increased use of safe sleep practices, ranging from 12% for room-sharing without bed-sharing (adjusted prevalence ratio: 1.12; 95% confidence interval: 1.09-1.16) to 28% for back sleep position (adjusted prevalence ratio: 1.28; 95% confidence interval: 1.21-1.35). State-level differences in safe sleep practices spanned 20 to 25 percentage points and did not change substantially after adjustment for available characteristics.

CONCLUSIONS

Safe infant sleep practices, especially those other than back sleep position, are suboptimal, with demographic and state-level differences indicating improvement opportunities. Receipt of provider advice is an important modifiable factor to improve infant sleep practices.

Preventing Sexual Transmission of Zika Virus Infection during Pregnancy, Puerto Rico, USA, 20161

We examined condom use throughout pregnancy during the Zika outbreak in Puerto Rico during 2016. Overall, <25% of women reported consistent condom use during pregnancy. However, healthcare provider counseling was associated with a 3-fold increase in consistent use, reinforcing the value of provider counseling in Zika prevention efforts.

Prevalence and maternal characteristics associated with receipt of prenatal care provider counseling about medications safe to take during pregnancy

Use of some medications during pregnancy can be harmful to the developing fetus, and discussion of the risks and benefits with prenatal care providers can provide guidance to pregnant women. We used Pregnancy Risk Assessment Monitoring System data collected for 2015 births aggregated from 34 US states (n = 40,480 women) to estimate the prevalence of self-reported receipt of prenatal care provider counseling about medications safe to take during pregnancy. We examined associations between counseling and maternal characteristics using adjusted prevalence ratios (aPR). The prevalence of counseling on medications safe to take during pregnancy was 89.2% (95% confidence interval [CI]: 88.7-89.7). Women who were nulliparous versus multiparous (aPR 1.03; 95% CI: 1.02-1.04), who used prescription medications before pregnancy versus those who did not, (aPR 1.03; 95% CI: 1.02-1.05), and who reported having asthma before pregnancy versus those who did not, (aPR 1.05; 95% CI: 1.01-1.08) were more likely to report receipt of counseling. There was no difference in counseling for women with pre-pregnancy diabetes, hypertension, and/or depression compared to those without. Women who entered prenatal care after the first trimester were less likely to report receipt of counseling (aPR 0.93; 95% CI: 0.91-0.96). Overall, self-reported receipt of counseling was high, with some differences by maternal characteristics. Although effect estimates were small, it is important to ensure that information is available to prenatal care providers about medication safety during pregnancy, and that messages are communicated to women who are or might become pregnant.

Factors associated with postpartum use of long-acting reversible contraception

BACKGROUND

Contraception use among postpartum women is important to prevent unintended pregnancies and optimize birth spacing. Long-acting reversible contraception, including intrauterine devices and implants, is highly effective, yet compared to less effective methods utilization rates are low.

OBJECTIVES

We sought to estimate prevalence of long-acting reversible contraception use among postpartum women and examine factors associated with long-acting reversible contraception use among those using any reversible contraception.

STUDY DESIGN

We analyzed 2012-2015 data from the Pregnancy Risk Assessment Monitoring System, a population-based survey among women with recent live births. We included data from 37 sites that achieved the minimum overall response rate threshold for data release. We estimated the prevalence of long-acting reversible contraception use in our sample (n = 143,335). We examined maternal factors associated with long-acting reversible contraception use among women using reversible contraception (n = 97,013) using multivariable logistic regression (long-acting reversible contraception vs other type of reversible contraception) and multinomial regression (long-acting reversible contraception vs other hormonal contraception and long-acting reversible contraception vs other nonhormonal contraception).

RESULTS

The prevalence of long-acting reversible contraception use overall was 15.3%. Among postpartum women using reversible contraception, 22.5% reported long-acting reversible contraception use, which varied by site, ranging from 11.2% in New Jersey to 37.6% in Alaska. Factors associated with postpartum long-acting reversible contraception use vs use of another reversible contraceptive method included age ≤24 years (adjusted odds ratio = 1.43; 95% confidence interval = 1.33-1.54) and ≥35 years (adjusted odds ratio = 0.87; 95% confidence interval = 0.80-0.96) vs 25-34 years; public insurance (adjusted odds ratio = 1.15; 95% confidence interval = 1.08-1.24) and no insurance (adjusted odds ratio = 0.73; 95% confidence interval = 0.55-0.96) vs private insurance at delivery; having a recent unintended pregnancy (adjusted odds ratio = 1.44; 95% confidence interval = 1.34-1.54) or being unsure about the recent pregnancy (adjusted odds ratio = 1.29; 95% confidence interval = 1.18-1.40) vs recent pregnancy intended; having ≥1 previous live birth (adjusted odds ratio = 1.40; 95% confidence interval = 1.31-1.48); and having a postpartum check-up after recent live birth (adjusted odds ratio = 2.70; 95% confidence interval = 2.35-3.11). Hispanic and non-Hispanic black postpartum women had a higher rate of long-acting reversible contraception use (26.6% and 23.4%, respectively) compared to non-Hispanic white women (21.5%), and there was significant race/ethnicity interaction with educational level.

CONCLUSION

Nearly 1 in 6 (15.3%) postpartum women with a recent live birth and nearly 1 in 4 (22.5%) postpartum women using reversible contraception reported long-acting reversible contraception use. Our analysis suggests that factors such as age, race/ethnicity, education, insurance, parity, intendedness of recent pregnancy, and postpartum visit attendance may be associated with postpartum long-acting reversible contraception use. Ensuring all postpartum women have access to the full range of contraceptive methods, including long-acting reversible contraception, is important to prevent unintended pregnancy and optimize birth spacing. Contraceptive access may be improved by public health efforts and programs that address barriers in the postpartum period, including increasing awareness of the availability, effectiveness, and safety of long-acting reversible contraception (and other methods), as well as providing full reimbursement for contraceptive services and removal of administrative and logistical barriers.

Affordable Care Act-dependent Insurance Coverage and Access to Care Among Young Adult Women With a Recent Live Birth

BACKGROUND

The Affordable Care Act (ACA)-dependent coverage Provision (the Provision), implemented in 2010, extended family insurance coverage to adult children until age 26.

OBJECTIVES

To examine the impact of the ACA Provision on insurance coverage and care among women with a recent live birth.

RESEARCH DESIGN, SUBJECTS, AND OUTCOME MEASURES

We conducted a difference-in-difference analysis to assess the effect of the Provision using data from the Pregnancy Risk Assessment Monitoring System among 22,599 women aged 19-25 (treatment group) and 22,361 women aged 27-31 years (control group). Outcomes include insurance coverage in the month before and during pregnancy, and at delivery, and receipt of timely prenatal care, a postpartum check-up, and postpartum contraceptive use.

RESULTS

Compared with the control group, the Provision was associated with a 4.7-percentage point decrease in being uninsured and a 5.9-percentage point increase in private insurance coverage in the month before pregnancy, and a 5.4-percentage point increase in private insurance coverage and a 5.9-percentage point decrease in Medicaid coverage during pregnancy, with similar changes in insurance coverage at delivery. Findings demonstrated a 3.6-percentage point increase in receipt of timely prenatal care, and no change in receipt of a postpartum check-up or postpartum contraceptive use.

CONCLUSIONS

Among women with a recent live birth, the Provision was associated with a decreased likelihood of being uninsured and increased private insurance coverage in the month before pregnancy, a shift from Medicaid to private insurance coverage during pregnancy and at delivery, and an increased likelihood of receiving timely prenatal care.

The Pregnancy Risk Assessment Monitoring System (PRAMS): Overview of Design and Methodology

Data System. The Pregnancy Risk Assessment Monitoring System (PRAMS) is an ongoing state-based surveillance system of maternal behaviors, attitudes, and experiences before, during, and shortly after pregnancy. PRAMS is conducted by the Centers for Disease Control and Prevention's Division of Reproductive Health in collaboration with state health departments. Data Collection/Processing. Birth certificate records are used in each participating jurisdiction to select a sample representative of all women who delivered a live-born infant. PRAMS is a mixed-mode mail and telephone survey. Annual state sample sizes range from approximately 1000 to 3000 women. States stratify their sample by characteristics of public health interest such as maternal age, race/ethnicity, geographic area of residence, and infant birth weight. Data Analysis/Dissemination. States meeting established response rate thresholds are included in multistate analytic data sets available to researchers through a proposal submission process. In addition, estimates from selected indicators are available online. Public Health Implications. PRAMS provides state-based data for key maternal and child health indicators that can be tracked over time. Stratification by maternal characteristics allows for examinations of disparities over a wide range of health indicators.

Nondaily Smokers' Characteristics and Likelihood of Prenatal Cessation and Postpartum Relapse

Introduction

This study aimed to calculate the prevalence of pre-pregnancy nondaily smoking (<1 cigarette/day), risk factors, and report of prenatal provider smoking education; and assess the likelihood of prenatal cessation and postpartum relapse for nondaily smokers.

Methods

We analyzed data from 2009 to 2011 among women with live-born infants participating in the Pregnancy Risk Assessment Monitoring System. We compared characteristics of pre-pregnancy daily smokers (≥1 cigarette/day), nondaily smokers, and nonsmokers (chi-square adjusted p < .025). Between nondaily and daily smokers, we compared proportions of prenatal cessation, postpartum relapse (average 4 months postpartum), and reported provider education. Multivariable logistic regression calculated adjusted prevalence ratios (APR) for prenatal cessation among pre-pregnancy smokers (n = 27 360) and postpartum relapse among quitters (n = 13 577).

Results

Nondaily smokers (11% of smokers) were more similar to nonsmokers and differed from daily smokers on characteristics examined (p ≤ .001 for all). Fewer nondaily smokers reported provider education than daily smokers (71.1%, 86.3%; p < .001). A higher proportion of nondaily compared to daily smokers quit during pregnancy (89.7%, 49.0%; p < .001), and a lower proportion relapsed postpartum (22.2%, 48.6%; p < .001). After adjustment, nondaily compared to daily smokers were more likely to quit (APR: 1.65; 95% confidence interval [CI]: 1.58-1.71) and less likely to relapse postpartum (APR: 0.55; 95% CI: 0.48-0.62).

Conclusions

Nondaily smokers were more likely to quit smoking during pregnancy, less likely to relapse postpartum, and less likely to report provider education than daily smokers. Providers should educate all women, regardless of frequency of use, about the harms of tobacco during pregnancy, provide effective cessation interventions, and encourage women to be tobacco free postpartum and beyond.

Implication

Nondaily smoking (<1 cigarette/day) is increasing among US smokers and carries a significant risk of disease. However, smoking patterns surrounding pregnancy among nondaily smokers are unknown. Using 2009-2011 data from the Pregnancy Risk Assessment Monitoring System, we found pre-pregnancy nondaily smokers compared to daily smokers were 65% more likely to quit smoking during pregnancy and almost half as likely to relapse postpartum. Providers should educate all women, regardless of frequency of use, about the harms of tobacco during pregnancy, provide effective cessation interventions, and encourage women to be tobacco free postpartum and beyond.

Contraceptive Use Among Nonpregnant and Postpartum Women at Risk for Unintended Pregnancy, and Female High School Students, in the Context of Zika Preparedness - United States, 2011-2013 and 2015

Zika virus infection during pregnancy can cause congenital microcephaly and brain abnormalities (1,2). Since 2015, Zika virus has been spreading through much of the World Health Organization's Region of the Americas, including U.S. territories. Zika virus is spread through the bite of Aedes aegypti or Aedes albopictus mosquitoes, by sex with an infected partner, or from a pregnant woman to her fetus during pregnancy.* CDC estimates that 41 states are in the potential range of Aedes aegypti or Aedes albopictus mosquitoes (3), and on July 29, 2016, the Florida Department of Health identified an area in one neighborhood of Miami where Zika virus infections in multiple persons are being spread by bites of local mosquitoes. These are the first known cases of local mosquito-borne Zika virus transmission in the continental United States.(†) CDC prevention efforts include mosquito surveillance and control, targeted education about Zika virus and condom use to prevent sexual transmission, and guidance for providers on contraceptive counseling to reduce unintended pregnancy. To estimate the prevalence of contraceptive use among nonpregnant and postpartum women at risk for unintended pregnancy and sexually active female high school students living in the 41 states where mosquito-borne transmission might be possible, CDC used 2011-2013 and 2015 survey data from four state-based surveillance systems: the Behavioral Risk Factor Surveillance System (BRFSS, 2011-2013), which surveys adult women; the Pregnancy Risk Assessment Monitoring System (PRAMS, 2013) and the Maternal and Infant Health Assessment (MIHA, 2013), which surveys women with a recent live birth; and the Youth Risk Behavior Survey (YRBS, 2015), which surveys students in grades 9-12. CDC defines an unintended pregnancy as one that is either unwanted (i.e., the pregnancy occurred when no children, or no more children, were desired) or mistimed (i.e., the pregnancy occurred earlier than desired). The proportion of women at risk for unintended pregnancy who used a highly effective reversible method, known as long-acting reversible contraception (LARC), ranged from 5.5% to 18.9% for BRFSS-surveyed women and 6.9% to 30.5% for PRAMS/MIHA-surveyed women. The proportion of women not using any contraception ranged from 12.3% to 34.3% (BRFSS) and from 3.5% to 15.3% (PRAMS/MIHA). YRBS data indicated that among sexually active female high school students, use of LARC at last intercourse ranged from 1.7% to 8.4%, and use of no contraception ranged from 7.3% to 22.8%. In the context of Zika preparedness, the full range of contraceptive methods approved by the Food and Drug Administration (FDA), including LARC, should be readily available and accessible for women who want to avoid or delay pregnancy. Given low rates of LARC use, states can implement strategies to remove barriers to the access and availability of LARC including high device costs, limited provider reimbursement, lack of training for providers serving women and adolescents on insertion and removal of LARC, provider lack of knowledge and misperceptions about LARC, limited availability of youth-friendly services that address adolescent confidentiality concerns, inadequate client-centered counseling, and low consumer awareness of the range of contraceptive methods available.

Implementation science and the pregnancy risk assessment monitoring system

This paper describes the restructuring of the Pregnancy Risk Assessment Monitoring System (PRAMS), a surveillance system of the Centers for Disease Control and Prevention (CDC)'s Division of Reproductive Health conducted for 25 years in collaboration with state and city health departments. With the ultimate goal to better inform health care providers, public health programs, and policy, changes were made to various aspects of PRAMS to enhance its capacity on assessing and monitoring public health interventions and clinical practices in addition to risk behaviors, disease prevalence, comorbidities, and service utilization. Specifically, the three key PRAMS changes identified as necessary and described in this paper are questionnaire revision, launching the web-based centralized PRAMS Integrated Data Collection System, and enhancing the access to PRAMS data through the web query system known as Centers for Disease Control and Prevention's PRAMS Online Data for Epidemiologic Research/PRAMStat. The seven action steps of Knowledge To Action cycle, an illustration of the implementation science process, that reflect the milestones necessary in bridging the knowledge-to-action gap were used as framework for each of these key changes.

Postpartum contraceptive use among women with a recent preterm birth

OBJECTIVE

The objective of the study was to evaluate the associations between postpartum contraception and having a recent preterm birth.

STUDY DESIGN

Population-based data from the Pregnancy Risk Assessment Monitoring System in 9 states were used to estimate the postpartum use of highly or moderately effective contraception (sterilization, intrauterine device, implants, shots, pills, patch, and ring) and user-independent contraception (sterilization, implants, and intrauterine device) among women with recent live births (2009-2011). We assessed the differences in contraception by gestational age (≤27, 28-33, or 34-36 weeks vs term [≥37 weeks]) and modeled the associations using multivariable logistic regression with weighted data.

RESULTS

A higher percentage of women with recent extreme preterm birth (≤27 weeks) reported using no postpartum method (31%) compared with all other women (15-16%). Women delivering extreme preterm infants had a decreased odds of using highly or moderately effective methods (adjusted odds ratio, 0.5; 95% confidence interval, 0.4-0.6) and user-independent methods (adjusted odds ratio, 0.5; 95% confidence interval, 0.4-0.7) compared with women having term births. Wanting to get pregnant was more frequently reported as a reason for contraceptive nonuse by women with an extreme preterm birth overall (45%) compared with all other women (15-18%, P < .0001). Infant death occurred in 41% of extreme preterm births and more than half of these mothers (54%) reported wanting to become pregnant as the reason for contraceptive nonuse.

CONCLUSION

During contraceptive counseling with women who had recent preterm births, providers should address an optimal pregnancy interval and consider that women with recent extreme preterm birth, particularly those whose infants died, may not use contraception because they want to get pregnant.

Patterns of Health Insurance Coverage Around the Time of Pregnancy Among Women with Live-Born Infants--Pregnancy Risk Assessment Monitoring System, 29 States, 2009

PROBLEM/CONDITION

In 2009, before passage of the 2010 Patient Protection and Affordable Care Act (ACA), approximately 20% of women aged 18-64 years had no health insurance coverage. In addition, many women experienced transitions in coverage around the time of pregnancy. Having no health insurance coverage or experiencing gaps or shifts in coverage can be a barrier to receiving preventive health services and treatment for health problems that could affect pregnancy and newborn health. With the passage of ACA, women who were previously uninsured or had insurance that provided inadequate coverage might have better access to health services and better coverage, including additional preventive services with no cost sharing. Because certain elements of ACA (e.g., no lifetime dollar limits, dependent coverage to age 26, and provision of preventive services without cost sharing) were implemented as early as September 2010, data from 2009 can be used as a baseline to measure the incremental impact of ACA on the continuity of health care coverage for women around the time of pregnancy.

REPORTING PERIOD COVERED

2009.

DESCRIPTION OF SYSTEM

The Pregnancy Risk Assessment Monitoring System (PRAMS) is an ongoing state- and population-based surveillance system designed to monitor selected maternal behaviors and experiences that occur before, during, and shortly after pregnancy among women who deliver live-born infants in selected U.S. states and New York City, New York. PRAMS uses mixed-mode data collection, in which up to three self-administered surveys are mailed to a sample of mothers, and those who do not respond are contacted for telephone interviews. Self-reported survey data are linked to birth certificate data and weighted for sample design, nonresponse, and noncoverage. Annual PRAMS data sets are created and used to produce statewide estimates of preconception and perinatal health behaviors and experiences in selected states and New York City. This report summarizes data from 29 states that conducted PRAMS in 2009, before the passage of ACA, and achieved an overall weighted response rate of ≥65%. Data on the prevalence of health insurance coverage stability (stable coverage, unstable coverage, and uninsured) across three time periods (the month before pregnancy, during pregnancy, and at the time of delivery) are reported by state and selected maternal characteristics. Women with stable coverage had the same type of health insurance (private or Medicaid) for all three time periods. Women with unstable coverage experienced a change in health insurance coverage between any of the three time periods. This includes movement from having no insurance coverage to gaining coverage, movement from one type of coverage to another, and loss of coverage. Women in the uninsured group had no insurance coverage during any of the three time periods. Estimates for health insurance stability across the three time periods and estimates of coverage during each time period are presented by state. Patterns of movement between the different types of health insurance coverage among women with unstable coverage are described by state and selected maternal characteristics.

RESULTS

In 2009, 30.1% of women who had a live birth experienced changes in health insurance coverage in the period between the month before pregnancy and the time of delivery, either because they lacked coverage at some point or because they moved between different types of coverage. Most women had stable coverage across the three time periods, reporting either private coverage (52.8%) or Medicaid coverage (16.1%) throughout. A small percentage of women (1.1%) reported having no health insurance coverage at any point. Overall, Medicaid coverage increased from 16.6% in the month before pregnancy to 43.9% at delivery. Private coverage decreased from 59.9% in the month before pregnancy to 54.6% at delivery. The percentage of women who were uninsured decreased from 23.4% in the month before pregnancy to 1.5% at the time of delivery. Among those who experienced changes in coverage, 74.4% reported having no insurance the month before pregnancy, 23.9% reported having private insurance, and 1.8% reported having Medicaid. Among those who started out uninsured before pregnancy, 70.2% reported Medicaid coverage, and 4.1% reported private coverage at the time of delivery. Among those who started out with private coverage, 21.3% reported Medicaid coverage at delivery, and 1.4% reported being uninsured. As a result of these transitions in health insurance coverage, 92.4% of all women who experienced a change in health insurance around the time of pregnancy reported Medicaid coverage at delivery. No women with unstable coverage who started out without insurance in the month before pregnancy reported being uninsured at the time of delivery. Women who reported unstable coverage were more likely to be young (aged <35 years), be a minority (black, Hispanic, or American Indian/Alaska Native), have a high school education or less, be unmarried, have incomes ≤200% of the federal poverty level (FPL), or have an unintended pregnancy compared with women with stable private coverage. Compared with women with stable Medicaid coverage, women with unstable coverage were more likely to be Hispanic but less likely to be teenagers (aged ≤19 years), be black, have a high school education or less, have incomes ≤200% of the FPL, or have an unintended pregnancy. Women with unstable coverage were more likely than women in either stable coverage group (private or Medicaid) to report entering prenatal care after the first trimester.

INTERPRETATION

In 2009, nearly one third of women reported lacking health insurance or transitioning between types of health insurance coverage around the time of pregnancy. The majority of women who changed health insurance status obtained coverage for prenatal care, delivery, or both through Medicaid. Health insurance coverage during pregnancy can help facilitate access to health care and allow for the identification and treatment of health-related issues; however, prenatal coverage might be too late to prevent the consequences of preexisting conditions and preconception exposures that could affect maternal and infant health. Continuous access to health insurance and health care for women of reproductive age could improve maternal and infant health by providing the opportunity to manage or treat conditions that are present before and between pregnancies.

PUBLIC HEALTH ACTION

PRAMS data can be used to identify patterns of health insurance coverage among women around the time of pregnancy. Removing barriers to obtaining health insurance for women who lack coverage, particularly before pregnancy, could improve the health of women and their infants. The findings in this report can be used by public health professionals, policy analysts, and others to monitor health insurance coverage for women around the time of pregnancy. In particular, 2009 state-specific data can serve as baseline information to assess and monitor changes in health insurance coverage since the passage of ACA.

Core state preconception health indicators - pregnancy risk assessment monitoring system and behavioral risk factor surveillance system, 2009

PROBLEM/CONDITION

Promoting preconception health can potentially improve women's health and pregnancy outcomes. Evidence-based interventions exist to reduce many maternal behaviors and chronic conditions that are associated with adverse pregnancy outcomes such as tobacco use, alcohol use, inadequate folic acid intake, obesity, hypertension, and diabetes. The 2006 national recommendations to improve preconception health included monitoring improvements in preconception health by maximizing public health surveillance (CDC. Recommendations to improve preconception health and health care-United States: a report of the CDC/ATSDR Preconception Care Work Group and the Select Panel on Preconception Care. MMWR 2006;55[No. RR-6]).

REPORTING PERIOD COVERED

2009 for 38 indicators; 2008 for one indicator. DESCRIPTION OF SURVEILLANCE SYSTEMS: The Pregnancy Risk Assessment Monitoring System (PRAMS) is an ongoing state- and population-based surveillance system designed to monitor selected self-reported maternal behaviors, conditions, and experiences that occur shortly before, during, and after pregnancy among women who deliver live-born infants. The Behavioral Risk Factor Surveillance System (BRFSS) is an ongoing state-based telephone survey of noninstitutionalized adults aged ≥18 years in the United States that collects state-level data on health-related risk behaviors, chronic conditions, and preventive health services. This surveillance summary includes PRAMS data from 29 reporting areas (n = 40,388 respondents) and BRFSS data from 51 reporting areas (n = 62,875 respondents) for nonpregnant women of reproductive age (aged 18-44 years). To establish a comprehensive, nationally recognized set of indicators to be used for monitoring, evaluation, and response, a volunteer group of policy and program leaders and epidemiologists identified 45 core state preconception health indicators, of which 41 rely on PRAMS or BRFSS as data sources. This report includes 39 of the 41 core state preconception health indicators for which data are available through PRAMS or BRFSS. The two indicators from these data sources that are not described in this report are human immunodeficiency virus (HIV) testing within a year before the most recent pregnancy and heavy drinking on at least one occasion during the preceding month. Ten preconception health domains are examined: general health status and life satisfaction, social determinants of health, health care, reproductive health and family planning, tobacco and alcohol use, nutrition and physical activity, mental health, emotional and social support, chronic conditions, and infections. Weighted prevalence estimates and 95% confidence intervals (95% CIs)for 39 indicators are presented overall and for each reporting area and stratified by age group (18-24, 25-34, and 35-44 years) and women's race/ethnicity (non-Hispanic white, non-Hispanic black, non-Hispanic other, and Hispanic).

RESULTS

This surveillance summary includes data for 39 of 41 indicators: 2009 data for 23 preconception health indicators that were monitored by PRAMS and 16 preconception health indicators that were monitored by BRFSS (one BRFSS indicator uses 2008 data). For two of the indicators that are included in this report (prepregnancy overweight or obesity and current overweight or obesity), separate measures of overweight and obesity were reported. All preconception health indicators varied by reporting area, and most indicators varied significantly by age group and race/ethnicity. Overall, 88.9% of women of reproductive age reported good, very good, or excellent general health status and life satisfaction (BRFSS). A high school/general equivalency diploma or higher education (social determinants of health domain) was reported by 94.7% of non-Hispanic white, 92.9% of non-Hispanic other, 91.1% of non-Hispanic black, and 70.9% of Hispanic women (BRFSS). Overall, health-care insurance coverage during the month before the most recent pregnancy (health-care domain) was 74.9% (PRAMS). A routine checkup during the preceding year was reported by 79.0% of non-Hispanic black, 65.1% of non-Hispanic white, 64.3% of other, and 63.0% of Hispanic women (BRFSS). Among women with a recent live birth (2-9 months since date of delivery), selected PRAMS results for the reproductive health and family planning, tobacco and alcohol use, and nutrition domains included several factors. Although 43% of women reported that their most recent pregnancy was unintended (unwanted or wanted to be pregnant later), approximately half (53%) of those who were not trying to get pregnant reported not using contraception at the time of conception. Smoking during the 3 months before pregnancy was reported by 25.1% of women, and drinking alcohol 3 months before pregnancy was reported by 54.2% of women. Daily use of a multivitamin, prenatal vitamin, or a folic acid supplement during the month before pregnancy was reported by 29.7% of women. Selected BRFSS results included indicators pertaining to the nutrition and physical activity, emotional and social support, and chronic conditions domains among women of reproductive age. Approximately one fourth (24.7%) of women were identified as being obese according to body mass index (BMI) on the basis of self-reported height and weight. Overall, 51.6% of women reported participation in recommended levels of physical activity per U.S. Department of Health and Human Services physical activity guidelines. Non-Hispanic whites reported the highest prevalence (85.0%) of having adequate emotional and social support, followed by other races/ethnicities (74.9%), Hispanics (70.5%), and non-Hispanic blacks (69.7%). Approximately 3.0% of persons reported ever being diagnosed with diabetes, and 10.2% of women reported ever being diagnosed with hypertension.

INTERPRETATION

The findings in this report underscore opportunities for improving the preconception health of U.S. women. Preconception health and women's health can be improved by reducing unintended pregnancies, reducing risky behaviors (e.g., smoking and drinking) among women of reproductive age, and ensuring that chronic conditions are under control. Evidence-based interventions and clinical practice guidelines exist to address these risks and to improve pregnancy outcomes and women's health in general. The results also highlight the need to increase access to health care for all nonpregnant women of reproductive age and the need to encourage the use of essential preventive services for women, including preconception health services. In addition, system changes in community settings can alleviate health problems resulting from inadequate social and emotional support and environments that foster unhealthy lifestyles. Policy changes can promote health equity by encouraging environments that promote healthier options in nutrition and physical activity. Finally, variation in the preconception health status of women by age and race/ethnicity underscores the need for implementing and scaling up proven strategies to reduce persistent health disparities among those at highest risk. Ongoing surveillance and research in preconception health are needed to monitor the influence of improved health-care access and coverage on women's prepregnancy and interpregnancy health status, pregnancy and infant outcomes, and health disparities.

PUBLIC HEALTH ACTION

Public health decision makers, program planners, researchers, and other key stakeholders can use the state-level PRAMS and BRFSS preconception health indicators to benchmark and monitor preconception health among women of reproductive age. These data also can be used to evaluate the effectiveness of preconception health state and national programs and to assess the need for new programs, program enhancements, and policies.

Trends in smoking before, during, and after pregnancy--Pregnancy Risk Assessment Monitoring System, United States, 40 sites, 2000-2010

PROBLEM

Smoking during pregnancy increases the risk for complications such as fetal growth restriction, preterm delivery, and infant death. In 2002, 5%-8% of preterm deliveries, 13%-19% of term infants with growth restriction, 5%-7% of preterm-related deaths, and 23%-34% of deaths from sudden infant death syndrome were attributable to prenatal smoking in the United States.

REPORTING PERIOD COVERED

2000-2010.

DESCRIPTION OF SYSTEM

The Pregnancy Risk Assessment Monitoring System (PRAMS) was initiated in 1987 and is an ongoing state- and population-based surveillance system designed to monitor selected maternal behaviors and experiences that occur before, during, and after pregnancy among females who deliver live-born infants in the United States. Self-reported questionnaire data are linked to selected birth certificate data and are weighted to represent all women delivering live infants in the state. Self-reported smoking data were obtained from the PRAMS questionnaire and birth certificates. This report provides data on trends (aggregated and site-specific estimates) in smoking before, during, and after pregnancy from 40 PRAMS sites during 2000-2010.

RESULTS

For the majority of sites, smoking prevalence before, during, or after pregnancy did not change over time. During 2000-2010, smoking prevalence decreased in three sites (Minnesota, New York state, and Utah) for all three measures and in eight sites (Colorado, Illinois, New Jersey, New Mexico, New York City, Washington, Wisconsin and Wyoming) for one or two of the measures. Smoking prevalence increased for all three measures in three sites (Louisiana, Mississippi, and West Virginia); an increase in prevalence before pregnancy (only) occurred in Oklahoma, and an increase during and after pregnancy occurred in Maine. For a subgroup of 10 sites for which data were available for the entire 11-year study period (Alaska, Arkansas, Colorado, Hawaii, Maine, Nebraska, Oklahoma, Utah, Washington, and West Virginia), the prevalence of smoking before pregnancy remained unchanged, with approximately one in five women reporting smoking before pregnancy (23.6% in 2000 to 24.7% in 2010). The prevalence of smoking during pregnancy decreased (p = 0.04; linear trend assessed with logistic regression) from 13.3% in 2000 to 12.3% in 2010, and the prevalence of smoking after delivery decreased (p<0.01) from 18.6% in 2000 to 17.2% in 2010.

INTERPRETATION

The results indicate that efforts to reduce smoking prevalence among female smokers before pregnancy have not been effective; however, tobacco-control efforts have been minimally effective in reducing smoking prevalence during and after pregnancy. Current tobacco-control efforts in most sites might be insufficient to reach national objectives related to reducing prevalence of smoking during pregnancy.

PUBLIC HEALTH ACTION

States with no change in or increasing smoking prevalence before, during, and after pregnancy can help reduce prevalence through sustained and comprehensive tobacco-control efforts (e.g., mass media campaigns, coverage of tobacco cessation, 100% smoke-free policies, and tobacco excise taxes).

Estimates of smoking before and during pregnancy, and smoking cessation during pregnancy: comparing two population-based data sources

OBJECTIVES

We compared three measures of maternal smoking status--prepregnancy, during pregnancy, and smoking cessation during pregnancy-between the Pregnancy Risk Assessment Monitoring System (PRAMS) questionnaire and the 2003 revised birth certificate (BC).

METHODS

We analyzed data from 10,485 women with live births in eight states from the 2008 PRAMS survey, a confidential, anonymous survey administered in the postpartum period that is linked to select BC variables. We calculated self-reported prepregnancy and prenatal smoking (last trimester only) prevalence based on the BC, the PRAMS survey, and the two data sources combined, and the percentage of smoking cessation during pregnancy based on the BC and PRAMS survey. We used two-sided t-tests to compare BC and PRAMS estimates.

RESULTS

Prepregnancy smoking prevalence estimates were 17.3% from the BC, 24.4% from PRAMS, and 25.4% on one or both data sources. Prenatal smoking prevalence estimates were 11.3% from the BC, 14.0% from PRAMS, and 15.2% on one or both data sources. The percentages of prepregnancy smokers who indicated that they quit smoking by the last trimester were 35.1% from the BC and 42.6% from PRAMS. The PRAMS estimates of prepregnancy and prenatal smoking, and smoking cessation during pregnancy were statistically higher than the corresponding BC estimates (t-tests, p<0.05).

CONCLUSIONS

PRAMS captured more women who smoked before and during the last trimester than the revised BC. States implementing PRAMS and the revised BC should consider information from both sources when developing population-based estimates of smoking before pregnancy and during the last trimester of pregnancy.

Health status and health insurance coverage of women with live-born infants: an opportunity for preventive services after pregnancy

Most women in the US have access to health care and insurance during pregnancy; however women with Medicaid-paid deliveries lose Medicaid eligibility in the early postpartum period. This study examined the association between health insurance coverage at the time of delivery and health conditions that may require preventive or treatment services extending beyond pregnancy into the postpartum period. We used 2008 Pregnancy Risk Assessment Monitoring System data from 27 states (n = 35,980). We calculated the prevalence of maternal health conditions, including emotional and behavioral risks, by health insurance status at the time of delivery. We used multivariable logistic regression to assess the association between health insurance coverage, whether Medicaid or private, and maternal health status. As compared to women with private health insurance, women with Medicaid-paid deliveries had higher odds of reporting smoking during pregnancy (adjusted odds ratio [AOR]: 1.85, 95 % confidence interval [CI]: 1.56-2.18), physical abuse during pregnancy (AOR: 1.73, 95 % CI: 1.24-2.40), having six or more stressors during pregnancy (AOR: 2.48, 95 % CI: 1.93-3.18), and experiencing postpartum depressive symptoms (AOR: 1.24, 95 % CI: 1.04-1.48). There were no significant differences by insurance status at delivery in pre-pregnancy overweight/obesity, pre-pregnancy physical activity, weight gain during pregnancy, alcohol consumption during pregnancy, or postpartum contraceptive use. Compared to women with private insurance, women with Medicaid-paid deliveries were more likely to experience risk factors during pregnancy such as physical abuse, stress, and smoking, and postpartum depressive symptoms for which continued screening, counseling, or treatment in the postpartum period could be beneficial.

Mental illness surveillance among adults in the United States

Mental illnesses account for a larger proportion of disability in developed countries than any other group of illnesses, including cancer and heart disease. In 2004, an estimated 25% of adults in the United States reported having a mental illness in the previous year. The economic cost of mental illness in the United States is substantial, approximately $300 billion in 2002. Population surveys and surveys of health-care use measure the occurrence of mental illness, associated risk behaviors (e.g., alcohol and drug abuse) and chronic conditions, and use of mental health-related care and clinical services. Population-based surveys and surveillance systems provide much of the evidence needed to guide effective mental health promotion, mental illness prevention, and treatment programs. This report summarizes data from selected CDC surveillance systems that measure the prevalence and impact of mental illness in the U.S. adult population. CDC surveillance systems provide several types of mental health information: estimates of the prevalence of diagnosed mental illness from self-report or recorded diagnosis, estimates of the prevalence of symptoms associated with mental illness, and estimates of the impact of mental illness on health and well-being. Data from the CDC 2005-2008 National Health and Nutrition Examination Survey indicate that 6.8% of adults had moderate to severe depression in the 2 weeks before completing the survey. State-specific data from the CDC 2006 Behavioral Risk Factor Surveillance System (BRFSS), the most recent BRFSS data available, indicate that the prevalence of moderate to severe depression was generally higher in southeastern states compared with other states. Two other CDC surveys on ambulatory care services, the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey, indicate that during 2007-2008, approximately 5% of ambulatory care visits involved patients with a diagnosis of a mental health disorder, and most of these were classified as depression, psychoses, or anxiety disorders. Future surveillance should pay particular attention to changes in the prevalence of depression both nationwide and at the state and county levels. In addition, national and state-level mental illness surveillance should measure a wider range of psychiatric conditions and should include anxiety disorders. Many mental illnesses can be managed successfully, and increasing access to and use of mental health treatment services could substantially reduce the associated morbidity.

Birth outcomes of intended pregnancies among women who used assisted reproductive technology, ovulation stimulation, or no treatment

OBJECTIVE

To study birth outcomes among live born infants conceived by women who used infertility treatment.

DESIGN

Population-based surveillance of women who recently delivered a live infant.

SETTING

The birth outcomes among infants whose mothers used assisted reproductive technology (ART) or ovulation stimulation medications alone were compared with the outcomes of infants conceived without treatment.

PATIENT(S)

Stratified random sample of women who were attempting conception and gave birth to a live infant in six US states (n = 16,748).

INTERVENTION(S)

Assisted reproductive technology and ovulation stimulation.

MAIN OUTCOME MEASURE(S)

Adjusted odds ratios for perinatal outcomes.

RESULT(S)

The prevalence of infertility treatment use overall among women attempting conception was 10.9% (5.4% ART procedures, 5.5% ovulation stimulation medications). Singletons of mothers who received ART procedures were more likely to be born with low birthweight, preterm, and small for gestational age (SGA) than singleton infants conceived without treatment. Singleton infants of mothers who used ovulation stimulation medications alone were more likely to be SGA than singleton infants conceived without treatment. No differences were found between ART and no treatment twin infants.

CONCLUSION(S)

Among singleton infants, ART is associated with decreased fetal growth, decreased gestational length, and SGA; ovulation stimulation alone is associated with SGA.

Physical violence against U.S. women around the time of pregnancy, 2004-2007

BACKGROUND

Previous research shows that the prevalence of intimate partner violence (IPV) around the time of pregnancy varies from 4% to 9%, but no studies have distinguished between abuse rates by former versus current partners.

PURPOSE

This study aims to estimate the prevalence of IPV among U.S. women shortly before and during pregnancy and to compare the rates and predictors of abuse perpetrated by current partners with the rates and predictors of abuse perpetrated by former partners.

METHODS

Using data from 27 states and New York City, the prevalence of physical abuse by current and former intimate male partners was estimated among 134,955 women who delivered a singleton, full-term infant in 2004-2007. Multivariable logistic regression was used to determine the demographic, pregnancy-related, and stress factors that predicted the risk of IPV.

RESULTS

Prevalence of IPV from either a former or current partner was 5.3% before and 3.6% during pregnancy. Prevalence of abuse by a former partner was consistently higher than the prevalence of abuse by a current partner. The three strongest predictors of IPV during pregnancy were the woman's partner not wanting the pregnancy (current: AOR=3.47, 95% CI=3.13, 3.85; former: AOR=3.22, 95% CI=2.90, 3.76); having had a recent divorce or separation (current: AOR=3.23, 95% CI=2.92, 3.58; former: AOR=3.54, 95% CI=3.20, 3.91); and being close to someone having a drug or alcohol problem (current: AOR=3.05, 95% CI=2.78, 3.36; former: AOR=2.97, 95% CI=2.70, 3.27). Maternal characteristics (age, education, race, marital status, woman did not want the pregnancy) were less important predictors.

CONCLUSIONS

Assessments of abuse should ask specifically about actions by both current and ex-partners.

Gestational weight gain among US women who deliver twins, 2001-2006

OBJECTIVE

Current guidelines recommend a gestational weight gain of 35-45 pounds for a twin pregnancy, but actual levels of weight gain during pregnancy among US women delivering twins are currently unknown.

STUDY DESIGN

We assessed gestational weight gain among 6345 US women who delivered twins from 2001 to 2006, using data collected from 28 states and New York City participating in a population-based surveillance system (PRAMS).

RESULTS

Approximately one-third of mothers who delivered twins gained 45 pounds or more during pregnancy. Weight gains were higher among women with lower prepregnancy body mass indexes. The percentage of twins with a normal birthweight increased with increasing gestational weight gains, except among obese women with the highest level of gain (>/= 65 pounds).

CONCLUSION

A notable percentage of US women who deliver twins gain above the current guidelines. The benefits of high gestational weight gain during twin pregnancies need to be balanced against an increased risk of maternal weight retention and later obesity.

Attempted breastfeeding before hospital discharge on both sides of the US-Mexico border, 2005: the Brownsville-Matamoros Sister City Project for Women's Health

INTRODUCTION

The US-Mexico border region has a growing population and limited health care infrastructure. Preventive health behaviors such as breastfeeding ease the burden on this region's health care system by reducing morbidity and health care costs. We examined correlates of attempted breastfeeding before hospital discharge on each side of the US-Mexico border and within the border region.

METHODS

The cross-sectional study included women who delivered a live infant in Matamoros, Tamaulipas, Mexico (n = 489), and Cameron County, Texas (n = 457), which includes Brownsville, Texas. We interviewed women before hospital discharge from August 21 through November 9, 2005. We used multivariate logistic regression to estimate the odds of attempted breastfeeding before hospital discharge in Cameron County, Texas, the municipality of Matamoros, Mexico, and the 2 communities combined.

RESULTS

Prevalence of attempted breastfeeding before hospital discharge was 81.9% in Matamoros compared with 63.7% in Cameron County. After adjusting for potential confounders, the odds of attempted breastfeeding before hospital discharge were 90% higher in Matamoros than in Cameron County (adjusted odds ratio [AOR], 1.93; 95% confidence interval [CI], 1.31-2.84 for the combined model). In the 2 communities combined, odds of attempted breastfeeding before hospital discharge were higher among women who had a vaginal delivery than among women who had a cesarean delivery (AOR, 1.98; 95% CI, 1.43-2.75) and were lower among women who delivered infants with a low birth weight than among women who delivered infants with a normal birth weight (AOR, 0.26; 95% CI, 0.15-0.44).

CONCLUSION

The rate of attempted breastfeeding in Matamoros was significantly higher than in Cameron County. Additional breastfeeding support and messages on the US side of the US-Mexico border are needed.

Differences between mistimed and unwanted pregnancies among women who have live births

CONTEXT

Mistimed and unwanted pregnancies that result in live births are commonly considered together as unintended pregnancies, but they may have different precursors and outcomes.

METHODS

Data from 15 states participating in the 1998 Pregnancy Risk Assessment Monitoring System were used to calculate the prevalence of intended, mistimed and unwanted conceptions, by selected variables. Associations between unintendedness and women's behaviors and experiences before, during and after the pregnancy were assessed through unadjusted relative risks.

RESULTS

The distribution of intended, mistimed and unwanted pregnancies differed on nearly every variable examined; risky behaviors and adverse experiences were more common among women with mistimed than intended pregnancies and were most common among those whose pregnancies were unwanted. The likelihood of having an unwanted rather than mistimed pregnancy was elevated for women 35 or older (relative risk, 2.3) and was reduced for those younger than 25 (0.8); the pattern was reversed for the likelihood of mistimed rather than intended pregnancy (0.5 vs. 1.7-2.7). Parous women had an increased risk of an unwanted pregnancy (2.1-4.0) but a decreased risk of a mistimed one (0.9). Women who smoked in the third trimester, received delayed or no prenatal care, did not breast-feed, were physically abused during pregnancy, said their partner had not wanted a pregnancy or had a low-birth-weight infant had an increased risk of unintended pregnancy; the size of the increase depended on whether the pregnancy was unwanted or mistimed.

CONCLUSION

Clarifying the difference in risk between mistimed and unwanted pregnancies may help guide decisions regarding services to women and infants.