Pregnancy Risk Assessment And Monitoring System Research Articles

Preconception care utilization: Self-report versus claims-based measures among women with Medicaid.

The objective of this study is to compare self-reported preconception care utilization (PCU) among Medicaid-covered births to Medicaid claims. We identified all Medicaid-covered births to women ages 15-45 in 26 states in the year 2012 among the Pregnancy Risk Assessment and Monitoring System (PRAMS) survey and Medicaid Analytic eXtract (MAX) claims data, and identified preconception services in the latter using diagnosis codes published by Health and Human Services' Office of Population Affairs. We fit mixed-effects logistic regression models for the probability of PCU on sociodemographic factors (age, race, and ethnicity) and clinical diagnoses (depression, diabetes, or hypertension), separately for each dataset. Among 652,929 women delivering in MAX, 28.1% received at least one claims-based preconception service while an estimated 23.6% (95% CI 22.1-25.3) of PRAMS respondents reported receiving preconception care. Adjusting for age, chronic diseases, and state, PCU rates in both MAX and PRAMS were higher for non-Hispanic Black versus non-Hispanic White women (OR 1.51, 95% CI 1.49-1.54 and OR 2.05, 95% CI 1.60-2.62, respectively). Adjusting for differences in age, race and ethnicity, and state, PCU rates were higher for patients with diabetes (OR 1.34, 95% CI 1.29-1.40 and OR 1.82, 95% CI 1.16-2.85) or hypertension (OR 1.22, 95% CI 1.18-1.27 and OR 1.85, 95% CI 1.41-2.44). While Hispanic and Asian women were also more likely to report PCU than their non-Hispanic White counterparts (OR 2.07, 95% CI 1.53-2.80 and OR 3.37, 95% CI 2.28-4.98), they were less likely to have received it (OR 0.74, 95% CI 0.73-0.75 and OR 0.65, 95% CI 0.63-0.67). In conclusion, comparing self-report to claims measures of PCU, we found similar trends in the differences between non-Hispanic Black and White women, and between those with vs. without diabetes and hypertension. However, the two data sources differed in trends in other racial/ethnic groups (differences between Hispanic vs. non-Hispanic White women, and between Asian vs. non-Hispanic White women), and in those with vs. without depression. This suggests that while Medicaid claims can be a useful tool for studying preconception care, they may miss certain types of care among some sub-groups of the population or be subject to reporting differences that are hard to surmise. Both data sets have potential benefits and drawbacks as research tools.

Emergency Preparedness in Tennessee Women with a Recent Live Birth.

To assess emergency preparedness (EP) actions in women with a recent live birth. Weighted survey procedures were used to evaluate EP actions taken by women with a recent live birth responding to an EP question assessing eight preparedness actions as part of the 2016 Tennessee Pregnancy Risk Assessment and Monitoring System (PRAMS) survey. Factor analysis was used to group preparedness actions. Overall, 82.7% [95% Confidence Interval (CI) 79.3%, 86.1%] of respondents reported any preparedness actions, with 51.8% (95% CI 47.2%, 56.4%) completing 1-4 actions. The most common actions were having supplies at home (63.0%; 95% CI 58.5%, 67.4%), an evacuation plan for children (48.5%; 95% CI 43.9%, 53.2%), supplies in another location (40.2%; 95% CI 35.6%, 44.7%), and a communication plan (39.7%; 95% CI 35.1%, 44.2%). Having personal evacuation plans (31.6%; 95% CI 27.3%, 36.0%) and copies of documents in alternate locations (29.3%; 95% CI 25.0%, 33.5%) were least common. Factor analysis yielded three factors: having plans, having copies of documents, and having supplies. Specific preparedness actions varied by education and income level. Most Tennessee women (about 8 in 10 women) with a recent live birth reported at least one EP action. A three-part EP question may be sufficient for assessing preparedness in this population. These findings highlight opportunities to improve public health education efforts around EP.

Association Between a History of Hookah Use and Breastfeeding Duration

Background: There is limited evidence on the relationship between hookah use and breastfeeding. This study examines the association between a history of hookah use and breastfeeding duration among women in the United States. Materials and Methods: This cross-sectional study examined 96,392 women from the Pregnancy Risk Assessment and Monitoring System (PRAMS) 2016-2019 data. The main outcome of interest was any breastfeeding for at least 3 months. Descriptive statistics, chi-square test, and multivariable regression analyses were performed. Results: Overall, 68.3% of women breastfed for at least 3 months and 4.6% reported using hookah in the last 2 years. Women who reported using hookah in the last 2 years were significantly less likely to breastfeed for at least 3 months compared with women who did not report using hookah in the last 2 years (56.0% versus 68.9%; p < 0.001). In the multivariable model, the odds of breastfeeding for at least 3 months were significantly lower in women who used hookah in the last 2 years compared with those who did not use hookah; odds ratio (95% confidence interval) 0.82 (0.74-0.92; p < 0.001). Additionally, the odds of breastfeeding for at least 3 months were significantly lower for dual users of hookah and cigarettes 0.48 (0.33-0.68; p < 0.001). Conclusion: A history of hookah use is associated with early weaning, independent of potential confounders. This finding suggests the need for educating women about the negative consequences of hookah use on breastfeeding during preconception, prenatal, and postpartum care encounters.

The frequency of pregnancy recognition across the gestational spectrum and its consequences in the United States

The frequency of pregnancy recognition across the gestational spectrum and its consequences in the United States

New York State Paid Family Leave Law Associated with Increased Breastfeeding Among Black Women.

Background: While breastfeeding has increased during the past 50 years, disparities continue, with Black women having the lowest rates. Use of paid leave has been associated with longer breastfeeding duration. Objective: Evaluate the impact of New York (NY)'s Paid Family Leave (PFL) law on breastfeeding, after it became effective on January 1, 2018. Materials and Methods: Women in NY (excluding NY City), who gave birth in 2016-2019 and completed the Pregnancy Risk Assessment and Monitoring System (PRAMS) survey, were included. Data from PRAMS and the NY State Expanded Birth Certificate were combined. Changes in breastfeeding initiation and duration and use of paid leave were compared, before and after NY's PFL law became effective, with separate analysis by sociodemographic factors. Results: Before NYPFL, Black women were least likely to initiate breastfeeding and breastfed for the shortest duration. After NYPFL went into effect, breastfeeding initiation and duration to 8 weeks increased for Black women, but not for other racial/ethnic groups; these findings persisted after adjustment for sociodemographic factors. Use of paid leave after childbirth increased 15% overall, with greater increases among Black women and Hispanic women. Conclusions: Implementation of the NYPFL law was associated with increased breastfeeding among Black women and increased use of paid leave by all. Greater increases in breastfeeding among Black women significantly reduced breastfeeding disparities by race/ethnicity. More widespread implementation of PFL programs in the United States would promote equity in the use of paid leave, which could reduce disparities in breastfeeding initiation and duration and possibly improve infant and maternal health outcomes.

Surveillance of Hypertension Among Women of Reproductive Age: A Review of Existing Data Sources and Opportunities for Surveillance Before, During, and After Pregnancy.

Hypertension is one of the largest modifiable risk factors for cardiovascular disease in the United States, and when it occurs during pregnancy, it can lead to serious risks for both the mother and child. There is currently no nationwide or state surveillance system that specifically monitors hypertension among women of reproductive age (WRA). We reviewed hypertension information available in the Behavioral Risk Factor Surveillance System (BRFSS), National Health and Nutrition Examination Survey (NHANES), National Health Interview Survey (NHIS), and Pregnancy Risk Assessment and Monitoring System (PRAMS) health surveys, the Health care Cost and Utilization Project administrative data sets (National Inpatient Sample, State Inpatient Databases, Nationwide Emergency Department Sample, and State Emergency Department Database and the Nationwide Readmissions Database), and the National Vital Statistics System. BRFSS, NHIS, and NHANES and administrative data sets have the capacity to segment nonpregnant WRA from pregnant women. PRAMS collects information on hypertension before and during pregnancy only among women with a live birth. Detailed information on hypertension in the postpartum period is lacking in the data sources that we reviewed. Enhanced data collection may improve opportunities to conduct surveillance of hypertension among WRA.

Parity and the Association Between Maternal Sociodemographic Characteristics and Breastfeeding.

Objective: Although clinicians recognize the importance of breastfeeding for child health, breastfeeding initiation can be limited by maternal characteristics such as race/ethnicity, age at first birth, and educational attainment. We hypothesized that the strong influence of prior infant feeding experiences on multiparous women's decision to initiate and continue breastfeeding may mean that these maternal characteristics influence breastfeeding more strongly for primiparas than multiparas. Materials and Methods: Using Pregnancy Risk Assessment and Monitoring System (PRAMS) (Phase 8) survey data from 2016 to 2017, we analyzed mothers' responses to the supplemental question about parity, "Before you got pregnant with your new baby, did you ever have any other babies who were born alive?" Study variables were summarized by using weighted means and proportions and compared according to parity by using Wald tests. In the overall cohort, we evaluated the interaction between parity and each covariate by using logistic regression. Results: In our sample (N = 20,694), 40% of respondents were first-time mothers, and 88% had initiated breastfeeding. Primiparas were more likely to breastfeed than multiparas (92% versus 86%; p < 0.001), but they had shorter mean breastfeeding duration. On unadjusted analysis, four covariates were more strongly associated with breastfeeding initiation among primiparas than multiparas (maternal age, educational attainment, receiving breastfeeding information from a nurse or other medical professional, and receiving breastfeeding information from family or friends). Conclusions: Breastfeeding initiation is impacted more strongly by maternal characteristics for primiparas than multiparas.

HPV Prevalence and its Association with Perinatal Outcomes among Singleton Mothers: Analysis of Pregnancy Risk Assessment and Monitoring System (PRAMS) Data, 2004-2011

Background: Pregnancy may increase the risk of Human Papillomavirus (HPV) infection because of pregnancy induced immune suppression. The objective of this study was to use a large population-based dataset to estimate the prevalence of HPV infection and its association with adverse outcomes among pregnant women. Methods: We analyzed Pregnancy Risk Monitoring System data from 2004-2011 (N=26,085) to estimate the self-reported HPV infection. Survey logistic procedures were used to examine the relationship between HPV infection and adverse perinatal outcomes. Results: Approximately 1.4% of women were estimated to have HPV infection during their pregnancy. The prevalence of adverse outcomes in this sample was preterm birth (8.4%), preeclampsia (7.5%), low birth weight (6.3%) and premature rupture of membranes (2.8%). Compared to women without HPV infection, HPV infection positive women were much more likely to have had other infections such as chlamydia (9.23% vs. 2.12%, p-value &lt;.0001), Group B Strep (21.7% vs. 10.04%, p-value &lt;.0001), and herpes (7.17% vs. 1.07%, p-value &lt;.0001). After adjusting for other risk factors including other infections, HPV infection was significantly associated with low birth weight (OR: 1.94, 95% CI: 1.14-3.30). Conclusion: The study indicated a potential association between HPV infection and low birth weight. Because pregnant women with HPV infection are at higher risk of other infections, future research may focus on the roles of co-infection in the development of adverse perinatal effects.

Fertility treatment use and breastfeeding outcomes

About 15% of women aged 15-44 years in the United States experience infertility. Factors associated with infertility and fertility treatments may also be associated with lactation difficulties. Limited data exist examining the impact of infertility or mode of conception on breastfeeding outcomes. The objectives of this study were to report breastfeeding outcomes (initiation and duration at 8 weeks) among women who conceived spontaneously compared to women who conceived using fertility treatments (assisted reproductive technology [ART], intrauterine insemination, or fertility-enhancing drugs). Maternal-reported data from 4 states from the 2012-2015 Pregnancy Risk Assessment and Monitoring System (PRAMS) were used to explore use of fertility treatment and breastfeeding initiation and continuation at 8 weeks (n= 15,615). Data were weighted to represent all women delivering live births within each state; SAS survey procedures were used to account for PRAMS complex survey design. Stepwise, multivariable logistic regression, adjusted for maternal demographics, parity, plurality, mode of delivery, preterm birth, and maternal pre-pregnancy health conditions, was used to quantify the associations between fertility treatment use and breastfeeding. Mode of conception was not associated with breastfeeding outcomes when comparing women who conceived spontaneously to women who conceived using any fertility treatment. The odds of breastfeeding at 8 weeks were lower among women who conceived using ART, after adjusting for basic demographic covariates (adjusted odds ratio [aOR], 0.71; 95% confidence interval [CI], 0.52-0.97) and additionally adjusting for maternal health conditions (aOR, 0.68; 95% CI, 0.49-0.93), but this difference was no longer significant after adjusting for plurality and preterm birth (aOR, 0.74; 95% CI, 0.54-1.02). This study suggests that mothers who conceive using ART may breastfeed for shorter durations than mothers who conceive spontaneously, partially mediated by an increased likelihoodof multiples and infants born preterm. Studies are needed to elucidate these associations and to understand the intentions and barriers to breastfeeding among women who conceive with the help of ART.

Do Home Visiting Services Received During Pregnancy Improve Birth Outcomes? Findings from Virginia PRAMS 2007–2008

Reducing poor birth outcomes are national and state priorities. At the national level participation in home visiting services has gained momentum with the recent appropriation of federal funds for states to implement evidence-based maternal and child health home visiting programs. The effects of having a home visit are unknown at the state level. Using cross-sectional data from 2007 to 2008 Virginia Pregnancy Risk Assessment and Monitoring System (PRAMS), maternal and infant outcomes were examined. Women who had a home visit during pregnancy were assigned into the home visiting (HV) participation group and those who did not were assigned to the HV Comparison group and used for the analysis. Bivariate analyses, Rao-Scott chi square tests, and multivariate logistic regression measured and quantified the association between HV participation and outcomes. The HV Participation group were 87.5% less likely to have a low birth weight infant (0.13, 95% CI: 0.020, 0.78), 4.5 times more likely to initiate breastfeeding (aOR: 4.5, 95% CI: 1.05, 19.54), and 39 times more likely to use contraceptives postpartum (aOR: 38.55, 95% CI: 3.14, 473.21). Receiving home visiting services during pregnancy increased breastfeeding initiation and postpartum contraceptive use while reducing the risk of low birth weight.

Maternity Care Practices and Breastfeeding Experiences of Women in Different Racial and Ethnic Groups: Pregnancy Risk Assessment and Monitoring System (PRAMS)

Research shows that maternity care practices are important to promoting breastfeeding in the early post partum period; however, little is known about the association between maternity care practices and breastfeeding among different racial and ethnic groups. We examined the association between maternity care practices and breastfeeding duration to ≥10weeks overall and among various racial and ethnic groups using data from the Pregnancy Risk Assessment and Monitoring System (PRAMS). PRAMS is a state, population-based surveillance system that collects information on maternal behaviors. We used maternity care practices data from 11 states and New York City with response rates ≥70% from 2004 to 2006. Multiple maternity care practices were examined and the analysis adjusted for demographic characteristics, participation in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), lifestyle, and infant variables. The outcome variable for multivariable analysis was breastfeeding duration to <10weeks or ≥10weeks. PRAMS data show that 22.1% of women did not breastfeed, about 27.7% breastfed for <10weeks and 50.2% breastfed for ≥10weeks. Breastfeeding patterns varied with white and Hispanic women reporting highest breastfeeding initiation and duration prevalence. Overall, practices positively associated with ≥10 duration were: breastfeeding initiated within the first hour after birth (adjusted OR [AOR]=1.29; 95% CI: 1.16-1.45); fed breast milk only (AOR=2.40; 95% CI: 2.15-2.68); breastfed on demand (AOR=1.23; 95% CI 1.08-1.40) and receiving telephone support (AOR=1.20; 95% CI: 1.03-1.39). Maternity care practices associated with breastfeeding to ≥10weeks varied across three racial/ethnic groups. One practice, that of giving newborns breast milk only, was positively associated with breastfeeding duration of ≥10weeks across all three groups. Maternity care practices associated with breastfeeding continuation to ≥10weeks varied by race/ethnicity. For example: breastfeeding within the first hour, baby given a pacifier, and assistance from hospital staff, were significantly associated with breastfeeding duration among black and white women and not Hispanics. The practice of breastfeeding on demand was significantly associated with breastfeeding to ≥10weeks for black and Hispanic women and not for whites. Hospitals may want to examine the implementation of specific practices in relation to the cultural backgrounds of women to promote breastfeeding.

Seasonal Influenza Vaccine Coverage Among Pregnant Women: Pregnancy Risk Assessment Monitoring System

Since 2004, the American College of Obstetricians and Gynecologists (ACOG) and the Advisory Committee on Immunization Practices (ACIP) have recommended that pregnant women receive the seasonal influenza vaccine, regardless of pregnancy trimester, because of their increased risk for severe complications from influenza. However, the uptake of the influenza vaccine by pregnant women has been low. During the 2009-2010 influenza season, pregnant women were identified as a priority population to receive the influenza A (H1N1) 2009 (2009 H1N1) monovalent vaccine in addition to the seasonal influenza vaccine. In this issue, we highlight information from the 10 states that collected data using the survey administered by the Pregnancy Risk Assessment and Monitoring System (PRAMS) about seasonal vaccine coverage among women with recent live births and reasons for those who chose not to get vaccinated. The combined estimates from PRAMS of influenza vaccination coverage for the 2009-2010 season, which included data from October 2009 to March 2010, from 10 states were 50.7% for seasonal and 46.6% for 2009 H1N1 vaccine among women with recent live births. Among women who did not get vaccinated, reasons varied from worries about the safety of the vaccines for self and baby to not normally getting the vaccination. Further evaluation is needed on ways to increase influenza vaccination among pregnant women, effectively communicate the risk of influenza illness during pregnancy, and address women's concerns about influenza vaccination safety during pregnancy.

Time From Pregnancy Recognition to Prenatal Care and Associated Newborn Outcomes

To examine the relationship between newborn outcomes and late prenatal care initiation after recognition of pregnancy. Secondary data analysis of the Pregnancy Risk Assessment and Monitoring System (PRAMS) data for the United States. Twenty-nine states. Women of childbearing age (135,623) who resided in 29 states in the PRAMS study who received prenatal care and had live births. Population-based survey from 2000 through 2004 that examined four newborn outcomes: prematurity, low birth weight (LBW), admission into Neonatal Intensive Care Unit (NICU), and infant mortality. The average time lag (difference between the time of pregnancy recognition and initiation of prenatal care) for the study was 3.2 weeks (99% CI [3.12, 3.21]). Women who recognized their pregnancies before 6 weeks had a longer lag time (3.5 weeks, 99% CI [3.43, 3.53]) than women who recognized their pregnancies later (2.1 weeks, 99% CI [1.96, 2.15]). After adjusting for confounders including the timing of pregnancy recognition, longer time lag was associated with reduced risks of prematurity (odds ratio [OR]=0.99, 99% Confidence Interval [CI] [0.97, 1.00], p<.01), LBW (OR=0.98, 99% CI [0.97, 0.99], p<.01) and NICU admission (OR=0.99, 99% CI [0.98, 1.00], p<.01) but not with infant mortality (OR=1.00, 99% CI [0.95, 1.05], p>.01). Average time lag from pregnancy recognition to prenatal care was not associated with poor newborn outcomes once results were adjusted for time of pregnancy recognition and other confounders.

Neighborhood Contextual Factors, Maternal Smoking, and Birth Outcomes: Multilevel Analysis of the South Carolina PRAMS Survey, 2000–2003

Previous studies investigating relationships among neighborhood contexts, maternal smoking behaviors, and birth outcomes (low birth weight [LBW] or preterm births) have produced mixed results. We evaluated independent effects of neighborhood contexts on maternal smoking behaviors and risks of LBW or preterm birth outcomes among mothers participating in the South Carolina Pregnancy Risk Assessment and Monitoring System (PRAMS) survey, 2000-2003. The PRAMS data were geocoded to 2000 U.S. Census data to create a multilevel data structure. We used a multilevel regression analysis (SAS PROC GLIMMIX) to estimate odds ratios (OR) and corresponding 95% confidence intervals (CI). In multivariable logistic regression models, high poverty, predominantly African American neighborhoods, upper quartiles of low education, and second quartile of neighborhood household crowding were significantly associated with LBW. However, only mothers resident in predominantly African American Census tract areas were statistically significantly at an increased risk of delivering preterm (OR 2.2, 95% CI 1.29-3.78). In addition, mothers resident in medium poverty neighborhoods remained modestly associated with smoking after adjustment for maternal-level covariates. The results also indicated that maternal smoking has more consistent effects on LBW than preterm births, particularly for mothers living in deprived neighborhoods. Interventions seeking to improve maternal and child health by reducing smoking during pregnancy need to engage specific community factors that encourage maternal quitting behaviors and reduce smoking relapse rates. Inclusion of maternal-level covariates in neighborhood models without careful consideration of the causal pathway might produce misleading interpretation of the results.

Time of Pregnancy Recognition and Prenatal Care Use: A Population‐based Study in the United States

A woman who does not recognize her pregnancy early may not initiate prenatal care early. This study examined the relationship between the time of pregnancy recognition and the time of initiation of prenatal care, and the number of prenatal visits among women of childbearing age. This study analyzed the Pregnancy Risk Assessment and Monitoring System (PRAMS) data for the United States. The analysis sample was representative of resident women of childbearing age in 29 U.S. states who had live births within 2 to 6 months before being contacted. The data were weighed to reflect the complex survey design of the PRAMS, and binary and multinomial logistic regressions were used for the analyses. Most (92.5%) of the 136,373 women in the study had recognized their pregnancy by 12 weeks of gestation, and 80 percent initiated prenatal care within the first trimester. Early pregnancy recognition was associated with significantly increased odds of initiating prenatal care early (OR = 6.05, p < 0.01), after controlling for sociodemographic and prior birth outcome data, and was also associated with lower odds of having fewer than the recommended number of prenatal visits and higher odds of having more than the recommended prenatal visits (OR: <11 visits = 0.71 and >15 visits = 1.17, p < 0.01). Early pregnancy recognition was associated with improved timing and number of prenatal care visits. Promotion of early pregnancy recognition could be a means of improving birth outcomes by encouraging and empowering women to access prenatal care at a critical point in fetal development.

Maternal Social Support and Neighborhood Income Inequality as Predictors of Low Birth Weight and Preterm Birth Outcome Disparities: Analysis of South Carolina Pregnancy Risk Assessment and Monitoring System Survey, 2000–2003

Effects of income inequality on health and other social systems have been a subject of considerable debate, but only a few studies have used multilevel models to evaluate these relationships. The main objectives of the study were to (1) Evaluate the relationships among neighborhood income inequality, social support and birth outcomes (low birth weight, and preterm delivery) and (2) Assess variations in racial disparities in birth outcomes across neighborhood contexts of income distribution and maternal social support. We evaluated these relationships by using South Carolina Pregnancy Risk Assessment and Monitoring System (PRAMS) survey for 2000-2003 geocoded to 2000 US Census data for South Carolina. Multilevel analysis was used to simultaneously evaluate the association between income inequality (measured as Gini), maternal social relationships and birth outcomes (low birth weight and preterm delivery). The results showed residence in neighborhoods with medium levels of income inequality was independently associated with low birth weight (OR: 2.00; 95% CI 1.14-3.26), but not preterm birth; low social support was an independent risk for low birth weight or preterm births. The evidence suggests that non-Hispanic black mothers were at increased risks of low birth weight or preterm birth primarily due to greater exposures of neighborhood deprivations associated with low income and reduced social support and modified by unequal income distribution.

Late recognition of pregnancy as a predictor of adverse birth outcomes

We examined the relationship between the time of recognition of pregnancy and birth outcomes, such as premature births, low birthweight (LBW), admission to the neonatal intensive care unit (NICU), and infant mortality. A secondary analysis was performed using the Pregnancy Risk Assessment and Monitoring System (PRAMS) multistate data from 2000-2004. The sample consisted of 136,373 women who had a live childbirth. Analysis involved multiple logistic regression models, appropriately weighted for point and variance estimation to reflect the complex survey design of the PRAMS using STATA 9.2 (Stata Corp, College Station, TX). Approximately 27.6% recognized their pregnancy late (after 6 weeks of gestation). Late recognition was significantly associated with an increased odds of having premature births (odds ratio [OR], 1.09; 99% confidence interval [CI], 1.01-1.19), LBW (OR, 1.08; 99% CI, 1.01-1.15), and NICU admissions (OR, 1.12; 99% CI, 1.03-1.21). These results provide a rationale and an impetus for developing interventions that promote early recognition of pregnancy.

Medicaid Coverage before Pregnancy: Pregnancy Risk Assessment and Monitoring System (PRAMS)

Access to healthcare, especially for women of reproductive age, is important to preconception, pregnancy, and postpartum care and ultimately to the well-being of women and their families. In this issue, we highlight data from the Pregnancy Risk Assessment and Monitoring System (PRAMS) regarding low-income women's access to Medicaid before becoming pregnant. From 1997 through 2006, the data showed considerable variation across the United States in the prevalence of Medicaid coverage before pregnancy among women with recent live births. Overall, approximately 15% of U.S. women participating in PRAMS reported coverage with Medicaid before pregnancy during 2006. State and local percentages ranged from 5% in Utah to 28% in New York City. Research is needed to understand how health insurance coverage affects access to preconception, prenatal, and postnatal services for reproductive-age women, especially low-income women. Research also is needed to identify how PRAMS data can be used to guide programs and policies intended to reduce adverse outcomes for mothers and infants.

Effects of Maternal Stress on Low Birth Weight and Preterm Birth Outcomes Across Neighborhoods of South Carolina, 2000–2003

Studies evaluating the effect of maternal stress on preterm birth (PTB) or low birth weight (LBW) and variations across neighborhood contexts have been inconclusive. The purpose of the study was to examine the relationships among neighborhood contexts, prenatal stress, and birth outcomes, and to further explore the modifying effects of neighborhood contexts. We evaluated this objective by using South Carolina Pregnancy Risk Assessment and Monitoring System (PRAMS), 2000-2003 data linked to the 2000 U.S. census data for 8064 women (N = 8064). Principal component analysis with varimax rotation was used to group stress constructs into four main domains (Financial, Emotional, Traumatic, and Spousal-related). We used multilevel logistic regression analysis to estimate the adjusted odds ratio for different models. Maternal stress was significantly associated with increased risks of low birth weight and preterm deliveries. Neighborhood high poverty and low education (upper quartiles) were independently associated with low birth weight but not preterm deliveries and stress appeared as a partial mediator of contextual effects on birth outcomes. The interaction models showed that the relationship between stress and LBW or PTB was modified by neighborhood contexts with risks being greater for infants born in disadvantaged neighborhoods. Effects of maternal stress on LBW and PTB outcomes may be different for mothers living in different neighborhood contexts. Therefore, investigations that fail to examine places of residence would most likely not identify mothers at risk of LBW or PTB. Policies to improve birth outcomes need to target both places of residence and specific mediating or moderating factors associated with deprived neighborhoods of residence.

How can PRAMS Survey Response Rates be Improved Among American Indian Mothers? Data from 10 States

To examine the low response rates to the Pregnancy Risk Assessment and Monitoring System (PRAMS) survey for American Indian (AI) mothers by comparing characteristics of AI participants, AI non-participants, non-Hispanic White (NHW) participants, and NHW non-participants. We analyzed 2000-2002 data from states whose population was at least 5% AI or Alaska Native (AN) (n = 10). Mothers who returned a questionnaire (regardless of completion) or who spoke by telephone with PRAMS personnel were defined as contacts. Mothers who completed a PRAMS questionnaire were defined as respondents. We described overall and state-specific maternal characteristics from birth certificates for both those who were contacted and those not contacted and computed contact and response rates. Contact rates varied by state, ranging from 49% to 92% for AI and AN mothers and 82-93% for NHW mothers. However, once contacted, most mothers completed a questionnaire (85-99%). Both AI and NHW mothers were less likely to be contacted if they were <29 years of age, unmarried, multiparous and had <or=12 years of education. Recognized predictors of response to PRAMS surveys were similar for AI and NHW mothers. Although contact rates among AI mothers were low when compared to whites, both AI and NHW mothers who were successfully contacted had high participation rates. Ultimately, evidence from states with high response rates for AI suggests that successful efforts will require experience and may be state-specific. In addition, increased state and tribal collaboration may facilitate improved PRAMS contact and response rates among AI.