Carolina Pregnancy Risk Assessment Monitoring Research Articles

Exercise during pregnancy and its association with gestational weight gain.

We examined the association between exercise during pregnancy and meeting gestational weight gain recommendations. Data came from the 2009 South Carolina Pregnancy Risk Assessment Monitoring System (n = 856). Women reported their participation in exercise/sports activities before and during pregnancy, including the number of months and types of exercise. We developed an exercise index (EI), the product of the number of months spent in exercise and average metabolic equivalents for specific exercise. The 2009 Institute of Medicine's guideline was used to categorize gestational weight gain into three classes: inadequate, adequate, and excessive. Multinomial logistic regression models were used to adjust for confounders. Over 46 % of women exceeded the recommended weight gain during pregnancy. Nearly one third (31.9 %) of women reported exercising ≥3 times a week at any time during pregnancy. Compared to women who did not report this level of exercise during pregnancy, exercising women were more likely to meet gestational weight gain recommendations (32.7 vs. 18.7 %) and had a lower odds of excessive gestational weight gain [adjusted odds ratio (AOR) 0.43, 95 % confidence interval 0.24-0.78]. Women with an EI above the median value of those women who exercised or women who exercised ≥3 times a week for 6-9 months during pregnancy had lower odds of excessive gestational weight gain (AOR for EI 0.20, 0.08-0.49; AOR for months 0.26, 0.12-0.56, respectively). Our findings support the need to promote or increase exercise during pregnancy to reduce the high proportion of women who are gaining excessive weight.

Does Amount of Weight Gain During Pregnancy Modify the Association Between Obesity and Cesarean Section Delivery?

Two-thirds of reproductive-aged women in the United States are overweight or obese and at risk for numerous associated adverse pregnancy outcomes. This study examined whether the amount of weight gained during pregnancy modifies the prepregnancy body mass index (BMI)-cesarean delivery association. A total of 2,157 women aged 18-45 who participated in the 2008-2009 North Carolina Pregnancy Risk Assessment Monitoring System had complete information on prepregnancy BMI, maternal weight gain, and mode of delivery on infant birth certificates. Logistic regression was used to obtain odds ratios (ORs) and 95 percent confidence intervals (CIs) to model the association between prepregnancy BMI and cesarean delivery, and a stratified analysis was conducted to determine whether maternal weight gain was an effect modifier of the prepregnancy BMI-cesarean delivery association. Obese women had 1.78 times the odds of cesarean delivery as compared with women with a normal BMI (95% CI: 1.44-2.16). When adjusted for race/ethnicity, live birth order, household income, and education, the association increased in magnitude and remained statistically significant (OR = 2.01, 95% CI: 1.63-2.43). In stratified analyses, the obesity-cesarean delivery association persisted and remained statistically significant among all maternal weight gain categories. Health care practitioners should stress the importance of achieving a healthy prepregnancy weight and gaining an appropriate amount of weight during pregnancy to reduce the risk of cesarean delivery and other adverse pregnancy outcomes.

WIC Participation and Breastfeeding in South Carolina: Updates from PRAMS 2009–2010

Few studies examined breastfeeding initiation and duration among mothers who were eligible for the Women Infants Children (WIC) program and did not participate. This study is sought to understand the role of WIC participation and poverty level in breastfeeding initiation and duration in South Carolina. The data came from the 2009-2010 South Carolina Pregnancy Risk Assessment Monitoring System (unweighted N = 1,796). All participants were classified as WIC participants, income-eligible non-WIC participants, and income-ineligible non-WIC participants. Logistic regression models were used to analyze the association between breastfeeding initiation and WIC participation. The Kaplan-Meier method and Cox proportional hazards models were used to determine whether the continuation of breastfeeding and hazards of discontinuing breastfeeding differed by WIC participation groups. In South Carolina, two out of three women (67.2%) initiated breastfeeding. The breastfeeding initiation rate was higher among income-ineligible (84.0%) and income-eligible (78.9%) non-WIC participants than among WIC participants (55.5%). Compared to WIC participants, both income-ineligible [odds ratio (OR) = 2.1, 95% confidence interval (CI) 1.2-4.0] and income-eligible (OR = 2.6, 95% CI 1.1-4.3) non-WIC participants were more likely to initiate breastfeeding. Among mothers who already initiated breastfeeding, after adjusting covariates, the hazard ratios for weaning within 34 weeks postpartum were not significantly different by WIC participation groups. This study confirmed WIC participants were less likely to initiate breastfeeding. Once initiated, WIC participation did not significantly impact breastfeeding duration in the early postpartum period. Poverty status may not play an important role in explaining disparities in breastfeeding initiation between WIC and non-WIC participants.

Physical Activity and Hypertensive Complications During Pregnancy: Findings From 2004 to 2006 North Carolina Pregnancy Risk Assessment Monitoring System

Preexisting hypertension in women who become pregnant is associated with hypertensive complications during pregnancy. These complications account for about 15% of maternal deaths. Several studies suggest that the risk of hypertensive complications during pregnancy is reduced by physical activity; other studies, however, found no such protective effect of physical activity. This population-based study investigated the association between physical activity and hypertensive complications during pregnancy using data from the North Carolina Pregnancy Risk Assessment Monitoring System (PRAMS), an ongoing, population-based, cross-sectional survey of women who delivered live infants. Data collected from 3348 women who participated in PRAMS between 2004 and 2006 were analyzed. Physical activity levels before pregnancy and during pregnancy were assessed using PRAMS self-reported questionnaires. The diagnosis of hypertensive complications during pregnancy was determined from birth certificate data. Multivariate logistic regression was used to estimate the association between physical activity and hypertensive complications and to control for potential confounders. The data showed no evidence of a strong association between physical activity before pregnancy and hypertensive complications during pregnancy. However, a dose-response relationship between physical activity and hypertensive complications during pregnancy was found after adjustment for prepregnancy body mass index for women participating in physical activity for 1 to 4 days per week (adjusted odds ratio [OR], 0.63; 95% confidence interval [CI], 0.45–0.90), and those participating for 5 or more days per week (OR, 0.46; 95% CI, 0.20–1.02). There was a statistically significant protective effect of physical activity only among women who were physically active both before and during pregnancy (adjusted OR, 0.65; 95% CI, 0.44–0.96). These findings suggest that women who engage in physical activity during pregnancy are less likely to develop pregnancy-related hypertensive complications.

Infant feeding experiences among teen mothers in North Carolina: Findings from a mixed-methods study

BackgroundAdolescent mothers in the U.S. are much less likely to initiate breastfeeding than older mothers, and teens who do initiate breastfeeding tend to breastfeed for shorter durations. The purpose of this mixed-methods study is to investigate breastfeeding practices, barriers and facilitators among adolescent mothers ages 17 and younger.MethodsQuantitative descriptive analyses are conducted using data from the North Carolina Pregnancy Risk Assessment Monitoring System (PRAMS). The population-based sample comprises 389 teens ages 13-17 giving birth to a live born infant in North Carolina in 2000 - 2005 and in 2007. Qualitative analyses are based on in-depth interviews with 22 Black, White and Hispanic teen mothers residing in rural and urban areas of North Carolina conducted between November 2007 and February 2009.ResultsIn quantitative analyses, 52% (196 of 389) of North Carolina teen mothers initiated breastfeeding, but half of those who initiated breastfeeding (92/196) stopped within the first month postpartum. Hispanic teens (44/52 or 89%) were much more likely than Black (61/159 or 41%) or White teens (87/164 or 52%) to initiate breastfeeding and to continue for a longer duration. Nearly sixty two percent (29/52) of Hispanic respondents breastfed for greater than four weeks as compared to 16% (29/159) of Black respondents and 26% (39/164) of White respondents. Common barriers to breastfeeding initiation and continuation included not liking breastfeeding, returning to school, nipple pain, and insufficient milk. Qualitative data provided context for the quantitative findings, elucidating the barriers and facilitators to breastfeeding from the teens' perspective and insight into the ways in which breastfeeding support to teens could be enhanced.ConclusionsThe large number of adolescents ceasing breastfeeding within the first month points to the need for more individualized follow-up after hospital discharge in the first few days postpartum, to address common technical challenges and to provide assistance managing the transition back to school. Provision of an extra home visit or outpatient visit for teens within the first few days following hospital discharge, and advocacy to make schools more compatible with breastfeeding, could potentially help teens who desire to breastfeed to successfully continue. These interventions warrant further research to test their effectiveness among adolescents.

Physical Activity and Hypertensive Complications During Pregnancy: Findings from 2004 to 2006 North Carolina Pregnancy Risk Assessment Monitoring System

Hypertensive complications during pregnancy occur in nearly 8 percent of pregnancies and account for 15 percent of all maternal mortalities in the United States. The purpose of this study was to investigate further the association between physical activity and hypertensive complications during pregnancy using data from a population-based surveillance system. This study included 3,348 participants from the 2004 to 2006 North Carolina Pregnancy Risk Assessment Monitoring System. Hypertensive complications during pregnancy were assessed using birth certificate data, and physical activity levels before pregnancy and during pregnancy were self-reported on questionnaires. Multivariate logistic regression was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs) while controlling for confounders. Although no strong association was found between physical activity before pregnancy and hypertensive complications during pregnancy, a dose-response relationship emerged for the physical activity during pregnancy-hypertensive complications association after adjustment for prepregnancy body mass index (physical activity for 1-4 days per week: OR=0.63, 95% CI: 0.45-0.90; physical activity for 5+ days per week: OR=0.46, 95% CI: 0.20-1.02). When levels of physical activity before and during pregnancy were combined, a statistically significant protective effect was seen only for women who indicated that they were physically active both before and during pregnancy (adjusted OR=0.65, 95% CI: 0.44-0.96). In this population-based study, physical activity, particularly during pregnancy, was associated with a lower risk of hypertensive complications during pregnancy. During a healthy pregnancy, health care practitioners may recommend that women engage in physical activity as one way to potentially prevent the development of this critical condition.

Maternal Obesity and Breast‐feeding Practices Among White and Black Women

Despite the increase in obesity among women of reproductive ages, few studies have considered maternal obesity as a risk factor for breast-feeding success. We tested the hypothesis that women who are obese (BMI = 30-34.9) and very obese (BMI >or=35) before pregnancy are less likely to initiate and maintain breast-feeding than are their normal-weight counterparts (BMI = 18.5-24.9) among white and black women. Data from 2000 to 2005 South Carolina Pregnancy Risk Assessment Monitoring System (PRAMS) were used. The overall response rate was 71.0%; there were 3,517 white and 2,846 black respondents. Black women were less likely to initiate breast-feeding and breast-fed their babies for a shorter duration than white women. Compared to normal-weight white women, very obese white women were less likely to initiate breast-feeding (odds ratio: 0.63; 95% confidence interval (CI) = 0.42, 0.94) and more likely to discontinue breast-feeding within the first 6 months (hazard ratio (HR) = 1.89; 95% CI: 1.39, 2.58). Among black women, prepregnancy BMI was neither associated with breast-feeding initiation nor with breast-feeding continuation within the first 6 months. Because very obese white women are less likely to initiate or continue breast-feeding than other white women, health professionals should be aware that very obese white women need additional breast-feeding support. Lower rates of breast-feeding among black women suggest that they should continue to be the focus of the programs and policies aimed at breast-feeding promotion in the United States.

Exercise During Pregnancy and Cesarean Delivery: North Carolina PRAMS, 2004–2005

The current rate of cesarean delivery in the United States is 31 percent. Previous studies have suggested that exercise during pregnancy may be associated with a lower risk of cesarean delivery, but sample sizes were small and methods often inadequate. This study examined whether or not an association exists between prenatal exercise and delivery mode using data from the 2004 and 2005 North Carolina Pregnancy Risk Assessment Monitoring System (PRAMS) survey. PRAMS postpartum questionnaire responses about frequency of exercise during the last 3 months of pregnancy for 1,955 women without a prior cesarean delivery were linked to birth certificates. Among 1,342 women delivering at term, exercise was not associated with delivery mode in this data set: compared with women exercising less than once a week, neither women exercising one to four times per week nor those exercising five times or more per week had an altered risk of cesarean (risk ratio [RR] [95% confidence limit] [CL] 0.89 [0.69-1.15], 1.04 [0.66-1.64], respectively, adjusted for parity, gestational age, hypertension). Among 613 women delivering preterm, the results were also not statistically significant, but a compelling trend toward a protective effect could be seen (RR [95% CL] 0.65 [0.38-1.13], 0.62 [0.29-1.33]). Maternal self-reported frequency of exercise during pregnancy was not associated with a reduced risk of cesarean delivery. Larger studies with better exposure ascertainment may provide a more definitive answer.

Using Master Settlement Agreement Funds to Reduce Prenatal/Postpartum Smoking in North Carolina:

he North Carolina Health and Wellness Trust Fund Commission (HWTF) was established by the North Carolina General Assembly in May 2000 to receive 25% of the state’s share of the Tobacco Master Settlement Agreement in order to address the health needs of vulnerable and underserved populations in North Carolina. The HWTF addresses its statutory mission by investing in programs and establishing partnerships that focus on critical health needs in four major areas: youth tobacco use, obesity, health disparities, and access to medications. Governed by an 18-member commission of health care experts drawn from a variety of professions, the HWTF has embarked on these four major initiatives, all designed to reduce the economic and human suffering from preventable diseases. To date, the Health and Wellness Trust Fund has awarded over 250 grants that build capacity in local communities to prevent and treat chronic health issues. These local grantees make up the infrastructure that has enabled each of the Health and Wellness Trust Fund’s preventive initiatives to reach its overall goals. To enhance the impact of local grant infrastructure and to have a more sustainable impact statewide, the HWTF also designs and implements mass media campaigns and works to effect policy change at the local and state levels. Independent evaluations of its grant programs are conducted on an ongoing basis to measure and increase the effectiveness of all these strategies. Although North Carolina’s infant mortality rate has decreased dramatically in recent years, it still remains well above the national average. In 2008 North Carolina ranked 44th in the nation with 8.2 deaths per 1,000 births compared to the national rate of 6.8 deaths per 1,000 births. 1 According to the State Center for Health Statistics, three of the top four causes of infant death in North Carolina are directly associated with either maternal smoking during pregnancy and/or infant exposure to tobacco smoke after birth. 2 Analysis of the North Carolina Pregnancy Risk Assessment Monitoring System (PRAMS) found that 24.6% of women reported smoking before pregnancy, 13.8% during pregnancy, and 20.3% after pregnancy. And, of those who smoked before pregnancy and quit during pregnancy, roughly half began smoking again by the time they completed the PRAMS survey three to six months postpartum. 3 If it were possible to eliminate smoking entirely during pregnancy, the infant mortality rate for the state would drop an estimated 10% to 20%, with the most improvement coming in underserved and disadvantaged communities where women are more likely to smoke while pregnant. 4

Maternal smoking and the risk for clubfoot in infants

Clubfoot is one of the most common major birth defects, with a prevalence of approximately 1 per 1,000 live births. The etiology of clubfoot is complex and not well understood, and yet, few epidemiologic studies of risk factors have been conducted. Maternal smoking has been suggested as a possible risk factor. The purpose of this population-based, case-control study was to examine the association between maternal smoking and clubfoot. Data from the North Carolina Birth Defects Monitoring Program matched to North Carolina birth certificates and health services data were used in the analysis of 443 cases of clubfoot and 4,492 randomly sampled controls for the years 1999-2003. Smoking data were ascertained from the birth certificates, and the reliability of the data was assessed by comparing them with reported smoking from the North Carolina Pregnancy Risk Assessment Monitoring System. Multiple logistic regression was used to calculate crude and adjusted ORs and 95% CIs for smoking and clubfoot. The crude OR for maternal smoking during pregnancy and clubfoot was 1.49 (95% CI: 1.15, 1.92). Controlling for maternal age, race/ethnicity, infant's sex, and timing of prenatal care initiation did not appreciably change the results (adjusted OR 1.40; 95% CI: 1.07, 1.83). This study is consistent with the hypothesis that smoking during pregnancy is associated with a slightly increased risk of an infant being born with clubfoot. Further research is needed to confirm this association, and to identify potential genetic factors that may modify the magnitude of the risk.

A Review of Available Data on the Health of the Latino Population in North Carolina

To portray major health problems and conditions in the Latino population of North Carolina. Presentation of descriptive information from North Carolina data sets on Latino health issues, with whites and African Americans as comparison groups. Statewide data on the health of the Latino population are provided from the following data sets: North Carolina Behavioral Risk Factor Surveillance System (BRFSS), death certificates, North Carolina Office of the Chief Medical Examiner records, sexually transmitted disease reports, reported pregnancies, certificates of live birth, North Carolina Pregnancy Risk Assessment Monitoring System (PRAMS), and North Carolina Birth Defects Monitoring Program (BDMP) cases. Review of existing data systems. Latinos in North Carolina have high death rates from motor vehicle injuries and homicide. Latinos who die from unintentional injuries, homicide, and suicide are much more likely than whites or African Americans to have a high blood alcohol level. Latinos are less likely than other groups to have health insurance. Latinos have much higher pregnancy rates, both for teens and older women, and are more likely to begin prenatal care late or have no prenatal care. Rates of sexually transmitted disease are higher than those for whites but lower than those for African Americans. Latinos are more likely to initiate breastfeeding. Latinos have a higher rate of neural tube defects compared to the other groups, while being less likely to take folic acid every day before pregnancy. Despite lower family incomes, later entry into prenatal care, and higher rates of certain birth defects, Latinos had the lowest rates of low birth weight and infant mortality. Lower rates of smoking during pregnancy among Latinos may partially account for the better birth outcomes. Many of the health issues among Latinos in North Carolina are consistent with the fact that they are a very young, mainly recently-arrived, immigrant population with more males than females. These findings may provide a basis for designing more effective health improvement programs for the Latino population of North Carolina.

Physical abuse of women before, during, and after pregnancy.

Clinicians who care for new mothers and infants need information concerning postpartum physical abuse of women as a foundation on which to develop appropriate clinical screening and intervention procedures. However, no previous population-based studies have been conducted of postpartum physical abuse. To examine patterns of physical abuse before, during, and after pregnancy in a representative statewide sample of North Carolina women. Survey of participants in the North Carolina Pregnancy Risk Assessment Monitoring System (NC PRAMS). Of the 3542 women invited to participate in NC PRAMS between July 1, 1997, and December 31, 1998, 75% (n = 2648) responded. Prevalence of physical abuse during the 12 months before pregnancy, during pregnancy, and after infant delivery; injuries and medical interventions resulting from postpartum abuse; and patterns of abuse over time in relation to sociodemographic characteristics and use of well-baby care. The prevalence of abuse before pregnancy was 6.9% (95% confidence interval [CI], 5.6%-8.2%) compared with 6.1% (95% CI, 4.8%-7.4%) during pregnancy and 3.2% (95% CI, 2.3%-4.1%) during a mean postpartum period of 3.6 months. Abuse during a previous period was strongly predictive of later abuse. Most women who were abused after pregnancy (77%) were injured, but only 23% received medical treatment for their injuries. Virtually all abused and nonabused women used well-baby care; private physicians were the most common source of care. The mean number of well-baby care visits did not differ significantly by maternal patterns of abuse. Since well-baby care use is similar for abused and nonabused mothers, pediatric practices may be important settings for screening women for violence.

Screening Mothers for Intimate Partner Abuse at Well-Baby Care Visits

Context Clinicians who care for new mothers and infants need information concerning postpartum physical abuse of women as a foundation on which to develop appropriate clinical screening and intervention procedures. However, no previous population-based studies have been conducted of postpartum physical abuse. Objectives To examine patterns of physical abuse before, during, and after pregnancy in a representative statewide sample of North Carolina women. Design, Setting, and Participants Survey of participants in the North Carolina Pregnancy Risk Assessment Monitoring System (NC PRAMS). Of the 3542 women invited to participate in NC PRAMS between July 1, 1997, and December 31, 1998, 75% (n=2648) responded. Main Outcome Measures Prevalence of physical abuse during the 12 months before pregnancy, during pregnancy, and after infant delivery; injuries and medical interventions resulting from postpartum abuse; and patterns of abuse over time in relation to sociodemographic characteristics and use of well-baby care. Results The prevalence of abuse before pregnancy was 6.9% (95% confidence interval [Cl], 5.6%-8.2%) compared with 6.1% (95% Cl, 4.8%-7.4%) during pregnancy and 3.2% (95% Cl, 2.3%-4.1 %) during a mean postpartum period of 3.6 months. Abuse during a previous period was strongly predictive of later abuse. Most women who were abused after pregnancy (77%) were injured, but only 23% received medical treatment for their injuries. Virtually all abused and nonabused women used well-baby care; private physicians were the most common source of care. The mean number of well-baby care visits did not differ significantly by maternal patterns of abuse. Conclusion Since well-baby care use is similar for abused and nonabused mothers, pediatric practices may be important settings for screening women for violence.

Stressful life events and physical abuse among pregnant women in North Carolina.

This study estimates the prevalence of stressful life events and physical abuse among North Carolina women prior to infant delivery, and examines potential associations between abuse and the other stressors. Data were from the North Carolina Pregnancy Risk Assessment Monitoring System, a statewide representative survey of over 2,600 postpartum women. The survey assessed women's sociodemographic characteristics and their experiences of physical abuse and 13 other stressful life events before delivery. The prevalences of each life event and abuse were estimated. Logistic regression modeled the probability of women having high levels of stressful life events in relation to physical abuse and sociodemographics. Most women were married, white, high school graduates, aged 20 or older. The most common stressful life events were residential moves, increased arguing with husbands/partners, family member hospitalizations, financial hardship, and deaths of loved ones. Fourteen percent of women had high levels of stressful events (5 or more), and almost 9% were physically abused. Abuse was positively associated with increased arguing with husbands/partners, physical fighting, having someone close with an alcohol/drug problem, becoming separated/divorced, and financial hardship. Logistic regression analysis showed that a high level of stressful life events was significantly more likely among women abused both before and during pregnancy (OR = 11.94) and among women abused before but not during pregnancy (OR = 14.19). The high frequency of multiple stressful events and abuse in women's lives suggests that women's care providers should ask their patients about these issues, and offer appropriate referral/interventions to those in need.

Intergenerational and environmental factors influencing pregnancy outcomes

PURPOSE: Factors that relate to the mother's own course of growth and development might influence later reproductive performances. This study examines the effect of maternal birth weight and maternal height and maternal weight gain, on term-small for gestational age (SGA) and preterm delivery.METHODS: Data used for this study were from the South Carolina Pregnancy Risk Assessment Monitoring System (PRAMS) and birth certificate files for 1993–1995. Since PRAMS data were weighted to adjust for sampling probabilities, non-response and survey design, Survey Data Analysis (SUDAAN) software was used in all analyses.RESULTS: Maternal birth weight was strongly associated with term SGA (OR = 3.65; 95% CI = 1.83–7.29), but not preterm delivery among black mothers; it was associated with preterm delivery (OR = 1.86; 95% CI = 1.09–3.17), but not term-SGA for white mothers. Maternal birth weight was associated with term SGA among nonsmokers only (OR = 2.34; 95% CI = 1.33–4.11). Maternal weight gain modified the effect of height on birth outcomes. Among women with inadequate weight gain, there was a 3-fold increase in risk for term-SGA (OR = 3.06; 95% CI = 2.41–3.89) for short maternal height, but not for preterm delivery. Among women with adequate plus weight gain, the association between short maternal height and term-SGA was 2.7 (95% CI = 0.55–9.43) compared to 3.67 (95% CI = 0.1.41–9.56) between short maternal height and preterm delivery. Maternal weight gain also modified the effect of maternal height on both outcomes for black mothers and for nonsmokers only.CONCLUSIONS: Findings indicate the need for interventions directed to those women who can benefit most from appropriate targeted weight gain recommendations. Therefore, prevention methods should be implemented to encourage short stature women to gain adequate weight during pregnancy.