Participation in survey research among mothers with a recent live birth: A comparison of mothers with living versus deceased infants - Findings from the Pregnancy Risk Assessment Monitoring System, 2016-2019.

BACKGROUND: Despite high infant mortality rates in the United States relative to other developed countries, little is known about survey participation among mothers of deceased infants. OBJECTIVE: To assess differences in survey response, contact and cooperation rates for mothers of deceased versus. living infants at the time of survey mailing (approximately 2-6 months postpartum), overall and by select maternal and infant characteristics. METHODS: We analysed 2016-2019 data for 50 sites from the Pregnancy Risk Assessment Monitoring System (PRAMS), a site-specific, population-based surveillance system of mothers with a recent live birth. We assessed differences in survey participation between mothers of deceased and living infants. Using American Association for Public Opinion Research (AAPOR) standard definitions and terminology, we calculated proportions of mothers who participated and were successfully contacted among sampled mothers (weighted response and contact rates, respectively), and who participated among contacted mothers (weighted cooperation rate). We then constructed multivariable survey-weighted logistic regression models to examine the adjusted association between infant vital status and weighted response, contact and cooperation rates, within strata of maternal and infant characteristics. RESULTS: Among sampled mothers, 0.3% (weighted percentage, n = 2795) of infants had records indicating they were deceased at the time of survey mailing and 99.7% (weighted percentage, n = 344,379) did not. Mothers of deceased infants had lower unadjusted weighted response (48.3% vs. 56.2%), contact (67.9% vs. 74.3%) and cooperation rates (71.1% vs. 75.6%). However, after adjusting for covariates, differences in survey participation by infant vital status were reduced. CONCLUSIONS: After covariate adjustment, differences in PRAMS participation rates were attenuated. However, participation rates among mothers of deceased infants remain two to four percentage points lower compared with mothers of living infants. Strategies to increase PRAMS participation could inform knowledge about experiences and behaviours before, during and shortly after pregnancy to help reduce infant mortality.

Rapid Population-Based Surveillance of Prenatal and Postpartum Experiences During Public Health Emergencies, Puerto Rico, 2016‒2018.

The Pregnancy Risk Assessment Monitoring System-Zika Postpartum Emergency Response study, implemented in Puerto Rico during the Zika virus outbreak (2016-2017) and after Hurricanes Irma and María (2017-2018), collected pregnancy-related data using postpartum hospital-based surveys and telephone follow-up surveys. Response rates of 75% or more were observed across five study surveys. The study informed programs, increased the Puerto Rico Department of Health's capacity to conduct maternal‒infant health surveillance, and demonstrated the effectiveness of this methodology for collecting data during public health emergencies. (Am J Public Health. 2022;112(4):574-578. https://doi.org/10.2105/AJPH.2021.306687).

Design and Methodology of the Study of Associated Risks of Stillbirth (SOARS) in Utah.

OBJECTIVES: The Utah Study of Associated Risks of Stillbirth (SOARS) collects data about stillbirths that are not included in medical records or on fetal death certificates. We describe the design, methods, and survey response rate from the first year of SOARS. METHODS: The Utah Department of Health identified all Utah women who experienced a stillbirth from June 1, 2018, through May 31, 2019, via fetal death certificates and invited them to participate in SOARS. The research team based the study protocol on the Pregnancy Risk Assessment Monitoring System surveillance of women with live births and modified it to be sensitive to women's recent experience of a stillbirth. We used fetal death certificates to examine survey response rates overall and by maternal characteristics, gestational age of the fetus, and month in which the loss occurred. RESULTS: Of 288 women invited to participate in the study, 167 (58.0%) completed the survey; 149 (89.2%) responded by mail and 18 (10.8%) by telephone. A higher proportion of women who were non-Hispanic White (vs other races/ethnicities), were married (vs unmarried), and had ≥high school education (vs

Preventing Vector-Borne Transmission of Zika Virus Infection During Pregnancy, Puerto Rico, USA, 2016-20171.

We examined pregnant women's use of personal protective measures to prevent mosquito bites during the 2016-2017 Zika outbreak in Puerto Rico. Healthcare provider counseling on recommended measures was associated with increased use of insect repellent among pregnant women but not with wearing protective clothing.

Vital Signs: Prescription Opioid Pain Reliever Use During Pregnancy - 34 U.S. Jurisdictions, 2019.

BACKGROUND: Prescription opioid use during pregnancy has been associated with poor outcomes for mothers and infants. Studies using administrative data have estimated that 14%-22% of women filled a prescription for opioids during pregnancy; however, data on self-reported prescription opioid use during pregnancy are limited. METHODS: CDC analyzed 2019 data from the Pregnancy Risk Assessment Monitoring System (PRAMS) survey in 32 jurisdictions and maternal and infant health surveys in two additional jurisdictions not participating in PRAMS to estimate self-reported prescription opioid pain reliever (prescription opioid) use during pregnancy overall and by maternal characteristics among women with a recent live birth. This study describes source of prescription opioids, reasons for use, want or need to cut down or stop use, and receipt of health care provider counseling on how use during pregnancy can affect an infant. RESULTS: An estimated 6.6% of respondents reported prescription opioid use during pregnancy. Among these women, 21.2% reported misuse (a source other than a health care provider or a reason for use other than pain), 27.1% indicated wanting or needing to cut down or stop using, and 68.1% received counseling from a provider on how prescription opioid use during pregnancy could affect an infant. CONCLUSIONS AND IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: Among respondents reporting opioid use during pregnancy, most indicated receiving prescription opioids from a health care provider and using for pain reasons; however, answers from one in five women indicated misuse. Improved screening for opioid misuse and treatment of opioid use disorder in pregnant patients might prevent adverse outcomes. Implementation of public health strategies (e.g., improving state prescription drug monitoring program use and enhancing provider training) can support delivery of evidence-based care for pregnant women.

Vital Signs: Postpartum Depressive Symptoms and Provider Discussions About Perinatal Depression - United States, 2018.

INTRODUCTION: Perinatal depression is a complication of pregnancy that can result in adverse maternal and infant outcomes. Screening to identify pregnant and postpartum women with depressive symptoms is recommended to provide diagnosis, treatment, and follow-up care to reduce poor outcomes. METHODS: CDC analyzed 2018 data from the Pregnancy Risk Assessment Monitoring System to describe postpartum depressive symptoms (PDS) among women with a recent live birth and to assess whether health care providers asked women about depression during prenatal and postpartum health care visits, by site and maternal and infant characteristics. RESULTS: Among respondents from 31 sites, the prevalence of PDS was 13.2%, ranging from 9.7% in Illinois to 23.5% in Mississippi. The prevalence of PDS exceeded 20% among women who were aged ≤19 years, were American Indian/Alaska Native, smoked during or after pregnancy, experienced intimate partner violence before or during pregnancy, self-reported depression before or during pregnancy, or whose infant had died since birth. The prevalence of women reporting that a health care provider asked about depression during prenatal care visits was 79.1% overall, ranging from 51.3% in Puerto Rico to 90.7% in Alaska. The prevalence of women reporting that a provider asked about depression during postpartum visits was 87.4% overall, ranging from 50.7% in Puerto Rico to 96.2% in Vermont. CONCLUSIONS AND IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: The prevalence of self-reported PDS varied by site and maternal and infant characteristics. Whether providers asked women about perinatal depression was not consistent across sites. Provision of recommended screenings and appropriate referrals for diagnosis, treatment, and follow-up care can ensure early and effective management of depression to reduce adverse maternal and infant outcomes.

Women's Awareness and Healthcare Provider Discussions about Zika Virus during Pregnancy, United States, 2016-2017.

We surveyed women with a recent live birth who resided in 16 US states and 1 city during the 2016 Zika outbreak. We found high awareness about the risk of Zika virus infection during pregnancy and about advisories to avoid travel to affected areas but moderate levels of discussions with healthcare providers.

Disability and Pregnancy: A Cross-Federal Agency Collaboration to Collect Population-Based Data About Experiences Around the Time of Pregnancy.

Many reproductive-aged women with a disability can achieve successful healthy pregnancies; however, they may face challenges accessing prenatal and postpartum care and finding providers who are knowledgeable about their specific condition. Depending on the nature of the disability, some women may also be at increased risk for adverse maternal and infant outcomes such as pre-eclampsia, infection, anemia, primary cesarean delivery, or preterm birth. Population-based data are needed to better understand the pregnancy and postpartum experiences of women living with disability. The National Institutes of Health and the Centers for Disease Control and Prevention (CDC) collaborated to address these data gaps by leveraging CDC's Pregnancy Risk Assessment Monitoring System (PRAMS) to gather information about disability among women who have had a recent live birth. Data collection began in 2019. Information gathered through PRAMS can be used to guide the development of clinical practices guidelines, intervention programs, and other initiatives of federal, state, and local agencies to improve services and the health of women of reproductive age living with disability.

Paternal Involvement and Maternal Perinatal Behaviors: Pregnancy Risk Assessment Monitoring System, 2012-2015.

OBJECTIVES: Paternal involvement is associated with improved infant and maternal outcomes. We compared maternal behaviors associated with infant morbidity and mortality among married women, unmarried women with an acknowledgment of paternity (AOP; a proxy for paternal involvement) signed in the hospital, and unmarried women without an AOP in a representative sample of mothers in the United States from 32 sites. METHODS: We analyzed 2012-2015 data from the Pregnancy Risk Assessment Monitoring System, which collects site-specific, population-based data on preconception, prenatal and postpartum behaviors, and experiences from women with a recent live birth. We calculated adjusted prevalence ratios (aPRs) and 95% confidence intervals (CIs) to examine associations between level of paternal involvement and maternal perinatal behaviors. RESULTS: Of 113 020 respondents (weighted N = 6 159 027), 61.5% were married, 27.4% were unmarried with an AOP, and 11.1% were unmarried without an AOP. Compared with married women and unmarried women with an AOP, unmarried women without an AOP were less likely to initiate prenatal care during the first trimester (married, aPR [95% CI], 0.94 [0.92-0.95]; unmarried with AOP, 0.97 [0.95-0.98]), ever breastfeed (married, 0.89 [0.87-0.90]; unmarried with AOP, 0.95 [0.94-0.97]), and breastfeed at least 8 weeks (married, 0.76 [0.74-0.79]; unmarried with AOP, 0.93 [0.90-0.96]) and were more likely to use alcohol during pregnancy (married, 1.20 [1.05-1.37]; unmarried with AOP, 1.21 [1.06-1.39]) and smoke during pregnancy (married, 3.18 [2.90-3.49]; unmarried with AOP, 1.23 [1.15-1.32]) and after pregnancy (married, 2.93 [2.72-3.15]; unmarried with AOP, 1.17 [1.10-1.23]). CONCLUSIONS: Use of information on the AOP in addition to marital status provides a better understanding of factors that affect maternal behaviors.

Preventing Sexual Transmission of Zika Virus Infection during Pregnancy, Puerto Rico, USA, 20161.

We examined condom use throughout pregnancy during the Zika outbreak in Puerto Rico during 2016. Overall, <25% of women reported consistent condom use during pregnancy. However, healthcare provider counseling was associated with a 3-fold increase in consistent use, reinforcing the value of provider counseling in Zika prevention efforts.

Intimate Partner Violence Before and During Pregnancy, and Prenatal Counseling Among Women with a Recent Live Birth, United States, 2009-2015.

Background: Intimate partner violence (IPV) is a leading cause of injury for reproductive-aged women. Clinical guidelines exist to assist providers in counseling women for IPV, but information on provider counseling among pregnant women from population-based sources is limited. Materials and Methods: Data for 2009-2015 from 37 states and New York City participating in the Pregnancy Risk Assessment Monitoring System (PRAMS) were analyzed (n = 258,263). We compared prevalence estimates overall and by site, of physical IPV occurring before and/or during pregnancy, and prenatal counseling on physical IPV. Multivariable logistic regression was used to identify factors associated with receiving prenatal counseling on physical IPV. Results: Overall, 3.8% of women reported experiencing any physical IPV in the 12 months before and/or during pregnancy (range: 1.5% [Connecticut] to 7.2% [Mississippi]). Prevalence of prenatal IPV counseling was 51.0% (range: 30.2% [Utah] to 63.1% [New Mexico]). Receipt of prenatal counseling on depression predicted a fourfold increase in prevalence of receiving counseling on physical IPV (adjusted prevalence ratio [aPR] = 4.20, 95% confidence interval [CI]: 4.06-4.34). In addition, non-Hispanic black race versus non-Hispanic white race, and having less than a high school education were associated with higher prevalence of receipt of IPV counseling ([aPR = 1.16, 95% CI: 1.14-1.18] and [aPR = 1.11, 95% CI: 1.08-1.13], respectively). Conclusion: Almost 4% of women with a recent live birth reported physical IPV before and/or during pregnancy. Only half of women received counseling on IPV during prenatal care, with counseling rates varying widely among states. Increased adherence to guidelines for universal screening and counseling of women could ensure all women are offered appropriate support and referral.

Prevalence and maternal characteristics associated with receipt of prenatal care provider counseling about medications safe to take during pregnancy.

Use of some medications during pregnancy can be harmful to the developing fetus, and discussion of the risks and benefits with prenatal care providers can provide guidance to pregnant women. We used Pregnancy Risk Assessment Monitoring System data collected for 2015 births aggregated from 34 US states (n = 40,480 women) to estimate the prevalence of self-reported receipt of prenatal care provider counseling about medications safe to take during pregnancy. We examined associations between counseling and maternal characteristics using adjusted prevalence ratios (aPR). The prevalence of counseling on medications safe to take during pregnancy was 89.2% (95% confidence interval [CI]: 88.7-89.7). Women who were nulliparous versus multiparous (aPR 1.03; 95% CI: 1.02-1.04), who used prescription medications before pregnancy versus those who did not, (aPR 1.03; 95% CI: 1.02-1.05), and who reported having asthma before pregnancy versus those who did not, (aPR 1.05; 95% CI: 1.01-1.08) were more likely to report receipt of counseling. There was no difference in counseling for women with pre-pregnancy diabetes, hypertension, and/or depression compared to those without. Women who entered prenatal care after the first trimester were less likely to report receipt of counseling (aPR 0.93; 95% CI: 0.91-0.96). Overall, self-reported receipt of counseling was high, with some differences by maternal characteristics. Although effect estimates were small, it is important to ensure that information is available to prenatal care providers about medication safety during pregnancy, and that messages are communicated to women who are or might become pregnant.

Condom Use With Long-Acting Reversible Contraception vs Non-Long-Acting Reversible Contraception Hormonal Methods Among Postpartum Adolescents.

Importance: Increased use of long-acting reversible contraception (LARC; intrauterine devices [IUDs] and implants) has likely contributed to declining US teenage pregnancy and birth rates, yet sexually transmitted infection (STI) rates among teenagers remain high. While LARC methods are highly effective for pregnancy prevention, they, as with all nonbarrier methods, do not protect against STIs, including HIV. Studies of the general adolescent population suggest condom use is lower among LARC vs non-LARC hormonal methods users (birth control pill, contraceptive patch, vaginal ring, or injection). Despite the high use of LARC among postpartum teenagers, no studies have examined whether condom use differs by contraceptive method in this population. Objective: To compare condom use among sexually active postpartum teenagers using LARC vs those using non-LARC hormonal methods. Design, Setting, and Participants: Cross-sectional analysis using 2012 to 2015 data from the Pregnancy Risk Assessment Monitoring System (PRAMS), a multisite and population-based surveillance system that collects data on maternal attitudes, behaviors, and experiences before, during, and shortly after pregnancy. We used data from 37 sites. Using multivariable survey-weighted logistic regression, we assessed the association of condom use by contraceptive methods. Participants were teenage mothers (≤19 years) with a recent live birth reporting LARC or non-LARC hormonal method use. Data were analyzed between March 2018 and April 2018. Main Outcomes and Measures: Condom use with LARC vs condom use with non-LARC hormonal methods. Results: Among the 5480 (weighted N = 245 847) postpartum teenage mothers in our sample, most were aged 18 to 19 years, unmarried, had current Medicaid coverage, were first-time mothers, had reported their pregnancy was unintended, and almost half were non-Hispanic white. Overall, condom use was reported by 28.8% of these teenagers. Users of LARC compared with non-LARC hormonal methods were half as likely to use condoms (17.8% vs 35.6%; adjusted prevalence ratio [aPR], 0.50; 95% CI, 0.41-0.60). Users of IUDs (15.1%) were less likely to report condom use than those using an implant (21.5%; aPR, 0.70; 95% CI, 0.51-0.98), patch, ring, or injection users (24.9%; aPR, 0.61; 95% CI, 0.47-0.79), and pill users (47.2%; aPR, 0.32; 95% CI, 0.25-0.40). Conclusions and Relevance: Self-reported condom use was low overall among postpartum teenage mothers and lower among users of LARC vs non-LARC hormonal methods. Given the high rates of STIs among teenage mothers combined with higher use of LARC among postpartum teenaged mothers, interventions to promote condom use for STI/HIV prevention during the postpartum period are critically important.

A modified lateral flow assay, using serum, for the rapid identification of human and bovine cysticercosis in the absence of false positives.

Background: Previously we reported the use of a monoclonal antibody-based (HP10) antigen (Ag) detection lateral flow assay (LFA) for the diagnosis of extraparenchymal neurocysticercosis (EP-NCC). The assay performed well when used with cerebrospinal fluid (CSF) samples but not with their paired serum samples, due to false-positive reactions in some known negative control cases. Methods: Our novel modification involves pretreatment of serum samples using a combination of sodium deoxycholate and dithiothreitol. Results: The modification overcomes the problem of false positives when using negative serum samples from clinically characterized cases of EP-NCC and bovine cysticercosis. In general, there was good agreement between HP10 Ag enzyme-linked immunosorbent assay (ELISA) and the HP10 Ag-LFA, but the HP10 Ag-ELISA was marginally more sensitive than the modified HP10 Ag-LFA. Conclusions: The modified HP10 Ag-LFA provides a field test for the rapid identification of endemic human and bovine cysticercosis.

Affordable Care Act-dependent Insurance Coverage and Access to Care Among Young Adult Women With a Recent Live Birth.

BACKGROUND: The Affordable Care Act (ACA)-dependent coverage Provision (the Provision), implemented in 2010, extended family insurance coverage to adult children until age 26. OBJECTIVES: To examine the impact of the ACA Provision on insurance coverage and care among women with a recent live birth. RESEARCH DESIGN, SUBJECTS, AND OUTCOME MEASURES: We conducted a difference-in-difference analysis to assess the effect of the Provision using data from the Pregnancy Risk Assessment Monitoring System among 22,599 women aged 19-25 (treatment group) and 22,361 women aged 27-31 years (control group). Outcomes include insurance coverage in the month before and during pregnancy, and at delivery, and receipt of timely prenatal care, a postpartum check-up, and postpartum contraceptive use. RESULTS: Compared with the control group, the Provision was associated with a 4.7-percentage point decrease in being uninsured and a 5.9-percentage point increase in private insurance coverage in the month before pregnancy, and a 5.4-percentage point increase in private insurance coverage and a 5.9-percentage point decrease in Medicaid coverage during pregnancy, with similar changes in insurance coverage at delivery. Findings demonstrated a 3.6-percentage point increase in receipt of timely prenatal care, and no change in receipt of a postpartum check-up or postpartum contraceptive use. CONCLUSIONS: Among women with a recent live birth, the Provision was associated with a decreased likelihood of being uninsured and increased private insurance coverage in the month before pregnancy, a shift from Medicaid to private insurance coverage during pregnancy and at delivery, and an increased likelihood of receiving timely prenatal care.

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.

Sexually Transmitted Diseases Among Pregnant Women: 5 States, United States, 2009-2011.

Introduction Screening for specific sexually transmitted diseases (STDs) during pregnancy has been a longstanding public health recommendation. Prior studies have described associations between these infections and socioeconomic factors such as race/ethnicity and education. Objectives We evaluated the prevalence of STDs and the correlation socioeconomic factors have with the presence of these infections among pregnant women in the United States. Methods We conducted an analysis using self-reported data from 12,948 recently pregnant women from the Pregnancy Risk Assessment Monitoring System (PRAMS) in 5 states during 2009-2011. Responses to questions about curable STDs (chlamydia, gonorrhea, syphilis, trichomoniasis) diagnosed during pregnancy were utilized to calculate weighted STD prevalence estimates and 95% confidence intervals (CI). A logistic regression was also conducted to identify maternal socioeconomic characteristics significantly associated with STDs; results are displayed as adjusted prevalence ratios (aPR). The PRAMS protocol was approved at PRAMS participating sites and by CDC's Institutional Review Board. Results Overall, 3.3% (CI 2.9-3.7) reported ≥ 1 curable STD during her most recent pregnancy. The adjusted STD prevalence was higher among women with younger age (aPR, 2.4; CI 1.8-3.4), non-Hispanic black race/ethnicity (aPR, 3.3; CI 2.4-4.1), unmarried status (aPR, 2.1; CI 1.4-3.0), no college education (aPR, 1.4; CI 1.0-1.9), annual income < $25,000 (aPR, 2.0; CI 1.3-3.2), and no pre-pregnancy health insurance (aPR, 1.4; CI 1.1-1.8). Conclusions for Practice This is the largest study of prevalence of self-reported curable STDs among U.S. pregnant women. Differences in STD prevalence highlight the association between certain socioeconomic factors and the presence of STDs.

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.