Leslie Harrison

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 womens concerns about influenza vaccination safety during pregnancy.

Validation of selected items on the 2003 U.S. standard certificate of live birth: New York City and Vermont.

Objective. We assessed the validity of selected items on the 2003 revised U.S. Standard Certificate of Live Birth to understand the accuracy of new and existing items. Methods. We calculated sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of select variables reported on the birth certificate using the medical record as the gold standard for a representative sample of live births in New York City (n=603) and Vermont (n=664) in 2009. Results. In both sites, sensitivity was excellent (>90%) for Medicaid coverage at delivery, any previous live births, and current method of delivery; sensitivity was moderate (70%–90%) for gestational diabetes; and sensitivity was poor (<70%) for premature rupture of the membranes and gestational hypertension. In both sites, PPV was excellent for Medicaid coverage, any previous live births, previous cesarean delivery, and current method of delivery, and poor for premature rupture of membranes. In both sites, almost all items had excellent (>90%) specificity and NPV. Conclusion. Further research is needed to determine how best to improve the quality of data on the birth certificate. Future revisions of the birth certificate may consider removing those items that have consistently proven difficult to report accurately.

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.

Disparities in influenza vaccination coverage among women with live-born infants: PRAMS surveillance during the 2009-2010 influenza season.

Objectives. Vaccination during pregnancy significantly reduces the risk of influenza illness among pregnant women and their infants up to 6 months of age; however, many women do not get vaccinated. We examined disparities in vaccination coverage among women who delivered a live-born infant during the 2009–2010 influenza season, when two separate influenza vaccinations were recommended. Methods. Pregnancy Risk Assessment Monitoring System (PRAMS) data from 29 states and New York City, collected during the 2009–2010 influenza season, were used to examine uptake of seasonal (unweighted n=27,153) and pandemic influenza A(H1N1)pdm09 (pH1N1) (n=27,372) vaccination by racially/ethnically diverse women who delivered a live-born infant from September 1, 2009, through May 31, 2010. Results. PRAMS data showed variation in seasonal and pH1N1 influenza vaccination coverage among women with live-born infants by racial/ethnic group. For seasonal influenza vaccination, coverage was 50.5% for non-Hispanic white, 30.2% for non-Hispanic black, 42.1% for Hispanic, and 48.2% for non-Hispanic other women. For pH1N1, vaccination coverage was 41.4% for non-Hispanic white, 25.5% for non-Hispanic black, 41.1% for Hispanic, and 43.3% for non-Hispanic other women. Compared with non-Hispanic white women, non-Hispanic black women had lower seasonal (crude prevalence ratio [cPR] = 0.60, 95% confidence interval [CI] 0.55, 0.64) and pH1N1 (cPR=0.62, 95% CI 0.57, 0.67) vaccination coverage; these disparities diminished but remained after adjusting for provider recommendation or offer for influenza vaccination, insurance status, and demographic factors (seasonal vaccine: adjusted PR [aPR] = 0.80, 95% CI 0.74, 0.86; and pH1N1 vaccine: aPR=0.75, 95% CI 0.68, 0.82). Conclusion. To reduce disparities in influenza vaccination uptake by pregnant women, targeted efforts toward providers and interventions focusing on pregnant and postpartum women may be needed.

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.

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.

Trends in Prenatal Discussion and HIV Testing, 1996–2001: Pregnancy Risk Assessment Monitoring System

Objective: To assess trends in prenatal discussions about HIV testing and prenatal HIV testing during the period 1996–2001. Methods: Using data from the Pregnancy Risk Assessment Monitoring System, a population-based postpartum survey of women, we calculated the self-reported prevalences of discussion of prenatal HIV testing and testing. Data were analyzed using SUDAAN; trends were calculated by logistic regression for states having ≥3 years of data. Results: From 1996 to 2001, significant increases in prenatal discussions about HIV testing were seen in 15 of 17 states. During the period 1996–2001, the prevalence of testing increased significantly in 7 of 8 states. In all states, there was a significant, positive relationship between having a prenatal discussion about testing and having an HIV test (odds ratios ranged from 1.7 to 4.9). Conclusions: We found statistically significant increases in discussions and testing from 1996 through 2001, consistent with guidelines emphasizing routine prenatal testing. Health care providers may have a strong influence on women’s decisions to be tested. Because current guidelines call for simplified strategies to reduce barriers to universal prenatal HIV screening, trends in prenatal HIV testing should continue to be monitored to assess the impact of these changes.

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.

Implementation Science and the Pregnancy Risk Assessment Monitoring System

This paper describes the restructuring of the Pregnancy Risk Assessment Monitoring System (PRAMS), a surveillance system of the Centers for Disease Control and Prevention (CDC)s Division of Reproductive Health conducted for 25 years in collaboration with state and city health departments. With the ultimate goal to better inform health care providers, public health programs, and policy, changes were made to various aspects of PRAMS to enhance its capacity on assessing and monitoring public health interventions and clinical practices in addition to risk behaviors, disease prevalence, comorbidities, and service utilization. Specifically, the three key PRAMS changes identified as necessary and described in this paper are questionnaire revision, launching the web-based centralized PRAMS Integrated Data Collection System, and enhancing the access to PRAMS data through the web query system known as Centers for Disease Control and 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.

Pregnancy Risk Assessment Monitoring System for Dads: Public Health Surveillance of New Fathers in the Perinatal Period

The article discusses public health surveillance for new fathers in the perinatal period. Particular focus is given to how this relates to the Pregnancy Risk Assessment Monitoring System (PRAMS) in the U.S., a source of data and demographic information relating to pregnancy. Additional topics discussed include fatherhood and male health, paternal involvement and how it influences maternal and child health outcomes, and how PRAMS explores perinatal behaviors, attitudes and experiences.