Denise V. D'Angelo

Correlates of Seasonal Influenza Vaccine Coverage Among Pregnant Women in Georgia and Rhode Island

OBJECTIVE: To identify facilitators of and barriers to pregnant women being vaccinated against seasonal influenza by identifying factors associated with influenza vaccination during pregnancy among women who had recently given birth to a live infant. METHODS: We analyzed pooled data from Georgia (n=2,692) and Rhode Island (n=2,732) participants in the 2006 and 2007 surveys of the Pregnancy Risk Assessment and Monitoring System, which conducts cross-sectional surveys of women with live births. SUDAAN software was used for analysis to account for complex survey design. We estimated rates of seasonal influenza vaccination among pregnant women in Georgia and Rhode Island and identified factors associated with being vaccinated. RESULTS: The prevalence of immunization for seasonal influenza in 2006 and 2007 combined was 18.4% (95% confidence interval [CI]: 15.9–21.1) in Georgia and 31.9% (95% CI 29.8–34.0) in Rhode Island. Multivariable analyses showed that in Georgia, multiparous women were significantly less likely to have been vaccinated than primiparous women (adjusted odds ratio [OR] 0.60; 95% CI 0.40–0.89). In Georgia, among those not vaccinated, 43% indicated that their health care providers did not mention anything about the seasonal influenza vaccination. In Rhode Island, women whose health care provider encouraged them to be vaccinated (adjusted OR 56.62; 95% CI 37.43–85.63) and those who did not smoke cigarettes (adjusted OR 1.92; 95% CI 1.25–2.94) were significantly more likely to be vaccinated. CONCLUSION: Our findings indicate a need for strategies to promote seasonal influenza vaccine use among pregnant women. Health care providers can play a significant role in increasing influenza vaccination coverage rates among pregnant women by advising women to be vaccinated and by addressing their concerns about vaccine safety. LEVEL OF EVIDENCE: III

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.

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.

Brief Scales to Detect Postpartum Depression and Anxiety Symptoms

BACKGROUND Depressive and anxiety disorders in the postpartum period cause significant suffering for women. State public health officials across the country use the Centers for Disease Control and Prevention (CDC)-sponsored Pregnancy Risk Assessment Monitoring System (PRAMS) to assess health behaviors and conditions, including depression and anxiety, that occur around the time of pregnancy. The purpose of the present study was to validate two to three items that could be included on the PRAMS questionnaire to detect depression and anxiety among postpartum women in a surveillance system. METHODS A comprehensive set of 16 depression and anxiety items was developed and tested in a final sample of 1077 postpartum women, 353 of whom completed Structured Clinical Interview for DSM-IV (SCID) interviews to determine the presence of a major depressive episode (MDE) and generalized anxiety disorder (GAD). Regression analyses reduced candidate items to 5 each for MDE and GAD. Responses were scored on a 5-point scale ranging from never (1) to always (5), and 2 and 3 item combinations of these items were examined for their psychometric properties as indicators of MDE and GAD. RESULTS Item sets varied in their psychometric properties. The combination of depressed mood, felt hopeless, and slowed down >  9 (out of a possible total of 15) yielded the highest positive predictive value (PPV=60) and estimated MDE prevalence most accurately (24.4% vs. 25.4% true prevalence). The combination of felt panicky, felt restless, and problems sleeping >9 estimated GAD prevalence most accurately (20.2% vs. 15.7% true prevalence) and had high specificity (83%). CONCLUSIONS Depression and anxiety can be detected using very few items, which makes assessment feasible in surveillance systems, such as PRAMS, and in primary care settings that have severe limits on time for depression and anxiety screening.

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 Organizations 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.

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 womens 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.

State-specific estimates of complete smoke-free home rules among postpartum women, 2010

BACKGROUND Secondhand smoke exposure increases an infants risk of morbidity and mortality. We provide state-specific estimates for and characterize postpartum women with complete smoke-free home rules. METHODS Data were analyzed from 26 states and New York City (n=37,698) from the 2010 Pregnancy Risk Assessment Monitoring System, a population-based survey of women who recently delivered live-born infants. We calculated state-specific estimates of complete rules and assessed associations between complete rules and selected characteristics. RESULTS Overall, 93.6% (95% CI: 93.1-94.1) of women with recent live births had complete smoke-free home rules (86.8% [West Virginia] to 98.6% [Utah]). Demographic groups with the lowest percentage of rules were women who smoked during pregnancy/postpartum (77.6%), were non-Hispanic Black (86.8%), never initiated breastfeeding (86.8%), < 20 years of age (87.1%), <

Implementation Science and the Pregnancy Risk Assessment Monitoring System

15,000 annual income (87.6%), < 12 years of education (88.6%), unmarried (88.6%), initiated prenatal care late/had no prenatal care (88.8%), had Medicaid coverage (89.7%), had an unintended pregnancy (90.3%), and enrolled in WIC (90.6%). CONCLUSIONS Prevalence of complete smoke-free home rules was high among women with recent live births; however, disparities exist by state and among certain sub-populations. Women, particularly smokers, should be educated during and after pregnancy about secondhand smoke and encouraged to maintain 100% smoke-free homes.

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

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 Preventions 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.