Denise V. D’Angelo

Association between Acculturation and Breastfeeding among Hispanic Women: Data from the Pregnancy Risk Assessment and Monitoring System

Background: Breastfeeding rates are typically higher among Hispanic women; however, they vary by acculturation status in that those more acculturated are less likely to breastfeed than those who are less acculturated. This study examined the association between acculturation and breastfeeding behaviors using population-based data. Methods: Data (N = 8942) from the Pregnancy Risk Assessment Monitoring System (PRAMS) were used for analysis. Acculturation status was determined using self-reported Hispanic ethnicity and the language in which the women responded to the PRAMS survey, either English or Spanish. Hispanic women who responded to the survey in Spanish were categorized as less acculturated than those who responded in English. Breastfeeding indicators used were: initiation, duration to ≥ 10 weeks, and exclusive breastfeeding to ≥ 10 weeks. Results: The prevalence rates of breastfeeding initiation, duration, and exclusive breastfeeding to ≥ 10 weeks were significantly higher among less acculturated than among highly acculturated. More acculturated were less likely to initiate breastfeeding (prevalence ratio [PR] = 0.88; 95% CI, 0.86-0.90), less likely to breastfeed ≥ 10 weeks (PR = 0.77; 95% CI, 0.72-0.82), and less likely to report exclusive breastfeeding to ≥ 10 weeks (PR =,0.70; 95% CI, 0.58-0.85). The relationship between breastfeeding continuation and acculturation persisted after adjusting for covariates in that more acculturated were less likely to breastfeed to ≥ 10 weeks (adjusted prevalence ratio [APR] = 0.81; 95% CI, 0.75-0.87), as did the relationship between exclusivity and acculturation; more acculturated were less likely to report exclusive breastfeeding (APR = 0.69; 95% CI, 0.55-0.87). Conclusions: Breastfeeding promotion efforts must include culturally/linguistically supportive services to assure that women are able to make optimal infant feeding decisions.

Contraceptive counseling and postpartum contraceptive use

OBJECTIVE The objective of the study was to examine the associations between prenatal and postpartum contraceptive counseling and postpartum contraceptive use. STUDY DESIGN The Pregnancy Risk Assessment Monitoring System 2004-2008 data were analyzed from Missouri, New York state, and New York City (n = 9536). We used multivariable logistic regression to assess the associations between prenatal and postpartum contraceptive counseling and postpartum contraceptive use, defined as any method and more effective methods (sterilization, intrauterine device, or hormonal methods). RESULTS The majority of women received prenatal (78%) and postpartum (86%) contraceptive counseling; 72% received both. Compared with those who received no counseling, those counseled during 1 time period (adjusted odds ratio [AOR], 2.10; 95% confidence interval [CI], 1.65-2.67) and both time periods (AOR, 2.33; 95% CI, 1.87-2.89) had significantly increased odds of postpartum use of a more effective contraceptive method (32% vs 49% and 56%, respectively; P for trend < .0001). Results for counseling during both time periods differed by type of health insurance before pregnancy, with greater odds of postpartum use of a more effective method observed for women with no insurance (AOR, 3.51; 95% CI, 2.18-5.66) and Medicaid insurance (AOR, 3.74; 95% CI, 1.98-7.06) than for those with private insurance (AOR, 1.87; 95% CI, 1.44-2.43) before pregnancy. Findings were similar for postpartum use of any contraceptive method, except that no differences by insurance status were detected. CONCLUSION The prevalence of postpartum contraceptive use, including the use of more effective methods, was highest when contraceptive counseling was provided during both prenatal and postpartum time periods. Women with Medicaid or no health insurance before pregnancy benefited the most.

Vital Signs: Trends and Disparities in Infant Safe Sleep Practices — United States, 2009–2015

INTRODUCTION There have been dramatic improvements in reducing infant sleep-related deaths since the 1990s, when recommendations were introduced to place infants on their backs for sleep. However, there are still approximately 3,500 sleep-related deaths among infants each year in the United States, including those from sudden infant death syndrome, accidental suffocation and strangulation in bed, and unknown causes. Unsafe sleep practices, including placing infants in a nonsupine (on side or on stomach) sleep position, bed sharing, and using soft bedding in the sleep environment (e.g., blankets, pillows, and soft objects) are modifiable risk factors for sleep-related infant deaths.

Measures Taken to Prevent Zika Virus Infection During Pregnancy - Puerto Rico, 2016.

Zika virus infection during pregnancy remains a serious health threat in Puerto Rico. Infection during pregnancy can cause microcephaly, brain abnormalities, and other severe birth defects (1). From January 1, 2016 through March 29, 2017, Puerto Rico reported approximately 3,300 pregnant women with laboratory evidence of possible Zika virus infection (2). There is currently no vaccine or intervention to prevent the adverse effects of Zika virus infection during pregnancy; therefore, prevention has been the focus of public health activities, especially for pregnant women (3). CDC and the Puerto Rico Department of Health analyzed data from the Pregnancy Risk Assessment Monitoring System Zika Postpartum Emergency Response (PRAMS-ZPER) survey conducted from August through December 2016 among Puerto Rico residents with a live birth. Most women (98.1%) reported using at least one measure to avoid mosquitos in their home environment. However, only 45.8% of women reported wearing mosquito repellent daily, and 11.5% reported wearing pants and shirts with long sleeves daily. Approximately one third (38.5%) reported abstaining from sex or using condoms consistently throughout pregnancy. Overall, 76.9% of women reported having been tested for Zika virus by their health care provider during the first or second trimester of pregnancy. These results can be used to assess and refine Zika virus infection prevention messaging and interventions for pregnant women and to reinforce measures to promote prenatal testing for Zika.

Disparities in Preconception Health Indicators — Behavioral Risk Factor Surveillance System, 2013–2015, and Pregnancy Risk Assessment Monitoring System, 2013–2014

Problem/Condition Preconception health is a broad term that encompasses the overall health of nonpregnant women during their reproductive years (defined here as aged 18–44 years). Improvement of both birth outcomes and the woman’s health occurs when preconception health is optimized. Improving preconception health before and between pregnancies is critical for reducing maternal and infant mortality and pregnancy-related complications. The National Preconception Health and Health Care Initiative’s Surveillance and Research work group suggests ten prioritized indicators that states can use to monitor programs or activities for improving the preconception health status of women of reproductive age. This report includes overall and stratified estimates for nine of these preconception health indicators. Reporting Period 2013–2015. Description of Systems Survey data from two surveillance systems are included in this report. The Behavioral Risk Factor Surveillance System (BRFSS) is an ongoing state-based, landline and cellular telephone survey of noninstitutionalized adults in the United States aged ≥18 years that is conducted by state and territorial health departments. BRFSS is the main source of self-reported data for states on health risk behaviors, chronic health conditions, and preventive health services primarily related to chronic disease in the United States. The Pregnancy Risk Assessment Monitoring System (PRAMS) is an ongoing U.S. state- and population-based surveillance system administered collaboratively by CDC and state health departments. PRAMS is designed to monitor selected maternal behaviors, conditions, and experiences that occur before, during, and shortly after pregnancy that are self-reported by women who recently delivered a live-born infant. This report summarizes BRFSS and PRAMS data on nine of 10 prioritized preconception health indicators (i.e., depression, diabetes, hypertension, current cigarette smoking, normal weight, recommended physical activity, recent unwanted pregnancy, prepregnancy multivitamin use, and postpartum use of a most or moderately effective contraceptive method) for which the most recent data are available. BRFSS data from all 50 states and the District of Columbia were used for six preconception health indicators: depression, diabetes (excluded if occurring only during pregnancy or if limited to borderline/prediabetes conditions), hypertension (excluded if occurring only during pregnancy or if limited to borderline/prehypertension conditions), current cigarette smoking, normal weight, and recommended physical activity. PRAMS data from 30 states, the District of Columbia, and New York City were used for three preconception health indicators: recent unwanted pregnancy, prepregnancy multivitamin use, and postpartum use of a most or moderately effective contraceptive method by women or their husbands or partners (i.e., male or female sterilization, hormonal implant, intrauterine device, injectable contraceptive, oral contraceptive, hormonal patch, or vaginal ring). Heavy alcohol use during the 3 months before pregnancy also was included in the prioritized set of 10 indicators, but PRAMS data for each reporting area are not available until 2016 for that indicator. Therefore, estimates for heavy alcohol use are not included in this report. All BRFSS preconception health estimates are based on 2014–2015 data except two (hypertension and recommended physical activity are based on 2013 and 2015 data). All PRAMS preconception health estimates rely on 2013–2014 data. Prevalence estimates of indicators are reported for women aged 18–44 years overall, by age group, race-ethnicity, health insurance status, and reporting area. Chi-square tests were conducted to assess differences in indicators by age group, race/ethnicity, and insurance status. Results During 2013–2015, prevalence estimates of indicators representing risk factors were generally highest and prevalence estimates of health-promoting indicators were generally lowest among older women (35–44 years), non-Hispanic black women, uninsured women, and those residing in southern states. For example, prevalence of ever having been told by a health care provider that they had a depressive disorder was highest among women aged 35–44 years (23.1%) and lowest among women aged 18–24 years (19.2%). Prevalence of postpartum use of a most or moderately effective method of contraception was lowest among women aged 35–44 years (50.6%) and highest among younger women aged 18–24 years (64.9%). Self-reported prepregnancy multivitamin use and getting recommended levels of physical activity were lowest among non-Hispanic black women (21.6% and 42.8%, respectively) and highest among non-Hispanic white women (37.8% and 53.8%, respectively). Recent unwanted pregnancy was lowest among non-Hispanic white women and highest among non-Hispanic black women (5.0% and 11.6%, respectively). All but three indicators (diabetes, hypertension, and use of a most or moderately effective contraceptive method) varied by insurance status; for instance, prevalence of current cigarette smoking was higher among uninsured women (21.0%) compared with insured women (16.1%), and prevalence of normal weight was lower among women who were uninsured (38.6%), compared with women who were insured (46.1%). By reporting area, the range of women reporting ever having been told by a health care provider that they had diabetes was 5.0% (Alabama) to 1.9% (Utah), and women reporting ever having been told by a health care provider that they had hypertension ranged from 19.2% (Mississippi) to 7.0% (Minnesota). Interpretation Preconception health risk factors and health-promoting indicators varied by age group, race/ethnicity, insurance status, and reporting area. These disparities highlight subpopulations that might benefit most from interventions that improve preconception health. Public Health Action Eliminating disparities in preconception health can potentially reduce disparities in two of the leading causes of death in early and middle adulthood (i.e., heart disease and diabetes). Public health officials can use this information to provide a baseline against which to evaluate state efforts to improve preconception health.

Trends in Repeat Births and Use of Postpartum Contraception Among Teens — United States, 2004–2015

Teen* childbearing (one or more live births before age 20 years) can have negative health, social, and economic consequences for mothers and their children (1). Repeat teen births (two or more live births before age 20 years) can constrain the mothers ability to take advantage of educational and workforce opportunities (2), and are more likely to be preterm or of low birthweight than first teen births (3). Despite the historic decline in the U.S. teen birth rate during 1991-2015, from 61.8 to 22.3 births per 1,000 females aged 15-19 years (4), many teens continue to have repeat births (3). The American College of Obstetricians and Gynecologists and the American Academy of Pediatrics both recommend that clinicians counsel women (including teens) during prenatal care about birth spacing and postpartum contraceptive use (5), including the safety and effectiveness of long-acting reversible methods that can be initiated immediately postpartum. To expand upon prior research assessing patterns and trends in repeat childbearing and postpartum contraceptive use among teens with a recent live birth (i.e., 2-6 months after delivery) (3), CDC analyzed data from the National Vital Statistics System natality files (2004 and 2015) and the Pregnancy Risk Assessment Monitoring System (PRAMS; 2004-2013). The number and proportion of teen births that were repeat births decreased from 2004 (82,997; 20.1%) to 2015 (38,324; 16.7%); in 2015, the percentage of teen births that were repeat births varied by state from 10.6% to 21.4%. Among sexually active teens with a recent live birth, postpartum use of the most effective contraceptive methods (intrauterine devices and contraceptive implants) increased from 5.3% in 2004 to 25.3% in 2013; however, in 2013, approximately one in three reported using either a least effective method (15.7%) or no method (17.2%). Strategies that comprehensively address the social and health care needs of teen parents can facilitate access to and use of effective methods of contraception and help prevent repeat teen births.

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.

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.