Two-Year Test-Retest Reliability of the Breastfeeding Duration Question Used By the Pregnancy Risk Assessment Monitoring System (PRAMS): Implications for Research.

INTRODUCTION: A large literature exists on positive sequelae of breastfeeding, relying heavily on maternal self-reported infant feeding behaviors. Many such studies use PRAMS data, though estimates of reliability for the breastfeeding duration question on PRAMS have not been published. METHODS: We used data from Oregon PRAMS (respondents are a median 3.5 months postpartum) and PRAMS-2 (median 25 months) to assess test-retest reliability of maternal self-reported breastfeeding duration, among women who had weaned prior to completing the PRAMS survey. RESULTS: The sample-wide kappa for the paired, self-reported breastfeeding duration was 0.014, and the intraclass correlation coefficient was 0.17, both of which indicate poor agreement. More than 80% of women reported a longer duration on PRAMS-2; the median (interquartile range) difference was +1.0 (0.31 - 2.1) months. DISCUSSION: Recent literature on this topic from high-income countries falls into two categories: entirely retrospective versus "prospective" reliability assessments. Entirely retrospective assessments (both inquiries occur well after weaning) universally report exceedingly high reliability, whereas "prospective" assessments (women report infant feeding behavior during infancy, immediately after weaning, and some years later are asked to replicate their original answer) universally report poorer reliability. Interestingly, all "prospective" reliability studies, including ours, found that women over-report past breastfeeding durations by about 1 month upon the second inquiry. Researchers need not refrain from using maternal self-reported breastfeeding durations, because participants are largely still ranked correctly, relative to each other. However, such research efforts must avoid attempting to determine any optimal threshold duration.

The Evolution of State-Based Dental Sealant Programs in Oregon Within the Context of the State Health Care Transformation Process.

CONTEXT: The 2007 Oregon Smile Survey of first, second, and third graders found that, since the first (2002) Smile Survey, all major measures of Oregon children's oral health had worsened. The Centers for Disease Control and Prevention recommends 2 interventions proven effective in preventing dental caries (cavities) in a population: community water fluoridation and school dental sealant programs. Repeated attempts at the state level to mandate water fluoridation had failed. State government therefore moved to increase the number of school dental sealant programs. OBJECTIVES: The objective of this article is to demonstrate how 2 interventions and subsequent statewide collaboration addressed the deterioration of children's oral health from 2002 to 2007. DESIGN: An 11-year observational study to increase the number of schools in Oregon with dental sealant programs in the state of Oregon during health care transformation. INTERVENTIONS: (1) Providing state general funds for a state school dental sealant program and (2) establishing an incentivized sealant metric for the Coordinated Care Organizations contracted to serve the Medicaid population. RESULTS: In school year (SY) 2006-2007, only 26% (n = 92) of the state's eligible elementary schools had dental sealant programs. By SY 2013-2014, the use of state general funds increased the number of schools served to 78% (363 schools). By SY 2017-2018, with the establishment of the sealant metric, state and local programs served 92% (n = 473) of the eligible early elementary grades and 65% (n = 172) of the newly eligible middle school grades. CONCLUSION: Providing state general funds and establishing a sealant metric increased the number of schools served by school dental sealant programs and may have contributed to recent improvements in oral health.

Women Who Bedshare More Frequently at 14 Weeks Postpartum Subsequently Report Longer Durations of Breastfeeding.

INTRODUCTION: Breastfeeding rates in the United States continue to fall short of Healthy People 2020 goals. Bedsharing has been promoted as a way of increasing breastfeeding durations. METHODS: We used prospectively collected Oregon Pregnancy Risk Assessment Monitoring System (PRAMS) and PRAMS-2 data from 2276 women to explore whether bedsharing frequency predicts age at weaning. Bedsharing was assessed at 14 weeks after birth (PRAMS), and duration of breastfeeding was assessed at 2 years after birth (PRAMS-2). Cox proportional hazards models controlled for primiparity, cesarean birth, marital status, employment status, maternal race and ethnicity, and pregravid body mass index. RESULTS: Women in this sample reported high rates of bedsharing: only 15.7% of PRAMS respondents said they never shared a bed with their infant. We also observed a dose-response association between bedsharing frequency and breastfeeding duration when the analysis controlled for covariables: women who reported more frequent bedsharing at 14 weeks postpartum were more likely to wean later. Hazard ratios ranged from 1.18 (95% CI, 1.02-1.35) for "often" versus "always" bedsharing to 1.92 (95% CI, 1.66-2.24) for "never" versus "always." In other words, at any given infant age, women who always bedshared were more likely to keep breastfeeding. Women who always bedshared at 14 weeks postpartum breastfed their infant for a median of 13 months (95% CI, 12-14), compared with 10 months (95% CI, 9-11) for women who never bedshared at 14 weeks. DISCUSSION: Although we cannot rule out confounding by breastfeeding intention, our results suggest that bedsharing in early infancy might lead to later weaning. Regardless of infant feeding method, given the frequency of bedsharing reported by women in this and other samples, clinicians encountering pregnant and postpartum women should teach safe bedsharing practices.

Stressful Life Events and Self-Reported Postpartum Depressive Symptoms 13-24 Months After Live Birth Among Non-Hispanic American Indian/Alaska Native Mothers in Oregon: Results from a Population-Based Survey.

OBJECTIVES: We explored the association between stressful life events and postpartum depressive symptoms among non-Hispanic American Indian and Alaska Native (AI/AN) mothers. METHODS: We analyzed self-reports of stressful life events and depressive symptoms from 298 AI/AN respondents and conducted logistic regression to examine their association. RESULTS: Of the AI/AN mothers who responded, 29.7% reported depressive symptoms during their second postpartum year. Partner-related and traumatic stressful life events were significantly associated with increased risk of postpartum depressive symptoms. CONCLUSIONS: AI/AN women should receive intensive screening for depression through the second postpartum year. Programs that address stressful life events may be part of a plan to decrease postpartum depression.

Prenatal Depression Screening by Certified Nurse-Midwives, Oregon.

INTRODUCTION: About 18% of pregnant women have major or minor depression during pregnancy, but many are neither screened nor treated. Lack of treatment can have serious adverse consequences for the woman and her child. Since 2002, the American College of Nurse-Midwives has advised midwives to integrate prevention, universal screening, treatment, and/or referral for depression into the care they provide. The American College of Obstetricians and Gynecologists' 2015 guidelines recommend screening at least once in the perinatal period using a standardized, validated tool. A consensus has not been reached by professional organizations about the specifics of whether and when to screen for prenatal depression. The objective of this study is to understand the prenatal screening practices of midwives who practice in Oregon. METHODS: We surveyed all 162 Oregon-licensed certified nurse-midwives (CNMs). The survey asked about practice characteristics, demographics, screening, and perceived barriers to screening. The survey was administered electronically from October through December 2014. RESULTS: The response rate was 37%. Among the 53 CNM respondents who had provided prenatal care in the previous year, 50 (94%) reported screening for prenatal depression, and 38 (72%) reported the use of a standardized screening tool on more than 90% of prenatal patients. Thirty-five (66%) CNMs reported using the Edinburgh Postnatal Depression Scale. More than 60% of respondents indicated that availability of mental health services and insurance constraints were barriers to screening. DISCUSSION: We explored prenatal depression screening practices of CNMs. Most Oregon CNMs use a standardized screening tool. We suggest 2 strategies to overcome barriers to screening: incorporation of a standardized screening tool into electronic medical records and negotiation with insurance companies. More research is needed to clarify when and how often pregnant women should be screened for depression and how to increase the number of women who receive treatment.

Tetanus, diphtheria, pertussis vaccination coverage before, during, and after pregnancy - 16 States and New York City, 2011.

In June 2011, the Advisory Committee on Immunizations Practices (ACIP) recommended 1 dose of a tetanus, diphtheria, and acellular pertussis (Tdap) vaccine during pregnancy for women who had not received Tdap previously. Before 2011, Tdap was recommended for unvaccinated women either before pregnancy or postpartum. In October 2012, ACIP expanded the 2011 recommendation, advising pregnant women to be vaccinated with Tdap during each pregnancy to provide maternal antibodies for each infant. The optimal time for vaccination is at 27-36 weeks' gestation as recommended by ACIP. In response to ACIP's Tdap recommendation for pregnant women in 2011, CDC added a supplemental question to the Pregnancy Risk Assessment Monitoring System (PRAMS) survey to determine women's Tdap vaccination status before, during, or after their most recent delivery. This report describes overall and state-specific Tdap vaccination coverage around the time of pregnancy using data from 6,852 sampled women who delivered a live-born infant during September-December 2011 in one of 16 states or New York City (NYC). Among the 17 jurisdictions, the median percentage of women with live births who reported any Tdap vaccination was 55.7%, ranging from 38.2% in NYC to 76.6% in Nebraska. The median percentage who received Tdap before pregnancy was 13.9% (range = 7.7%-20.1%), during pregnancy was 9.8% (range = 3.8%-14.2%), and after delivery was 30.9% (range = 13.6%-46.5%). The PRAMS data indicate a wide variation in Tdap vaccination coverage among demographic groups, with generally higher postpartum coverage for non-Hispanic white women, those who started prenatal care in the first trimester, and those who had private health insurance coverage. This information can be used for promoting evidence-based strategies to communicate the importance of ACIP guidelines related to Tdap vaccination coverage to women and their prenatal care providers.

Increased Food Insecurity Among Mothers of 2 Year Olds with Special Health Care Needs.

The objective of this study is to explore the association between having a child with special health care needs (CSHCN) and food insecurity when the child is 2 years old. We studied women who had a live birth in 2004-2005 and responded to Oregon's Pregnancy Risk Assessment Monitoring System (PRAMS) survey 3 months postpartum (Time 1) and the follow-up survey (PRAMS-2), when the child was 2 years old (Time 2). Women answering affirmatively to the PRAMS-2 question, "In the last 12 months, did you ever eat less than you felt you should because there was not enough money for food?" were considered food insecure. CSHCN status was identified by affirmative responses to questions about needs for ongoing services (Time 2). PRAMS and PRAMS-2 responses were weighted for study design and non-response. Results report weighted analyses, unless noted. Among 1812 mothers completing PRAMS-2, 13.6 % (unweighted) had a 2-year-old CSHCN and 11.9 % (unweighted) were food insecure at Time 2. The estimated prevalence of food insecurity at 2-year follow-up was 20.7 % among families of CSHCN and 9.7 % for others. After adjustment for Time 2 marital status, education, lifetime U.S. residence, income and health conditions, multivariable logistic regression revealed that odds of food insecurity were more than two times as great for CSHCN mothers 2 years post-partum compared to non-CSHCN mothers (adjusted odds ratio 2.6, 95 % confidence interval 1.3, 4.6). Families of CSHCN face increased risk for food insecurity. Improved understanding of causal determinants of food insecurity among households of CSHCN is needed.

Influenza vaccination of pregnant women: attitudes and behaviors of Oregon physician prenatal care providers.

In spite of increased risk of influenza complications during pregnancy, only half of US pregnant women get influenza vaccination. We surveyed physician prenatal care providers in Oregon to assess their knowledge and behaviors regarding vaccination of pregnant women. From September through November 2011, a state-wide survey was mailed to a simple random sample (n = 1,114) of Oregon obstetricians and family physicians. The response rate was 44.5 %. Of 496 survey respondents, 187 (37.7 %) had provided prenatal care within the last 12 months. Of these, 88.5 % reported that they routinely recommended influenza vaccine to healthy pregnant patients. No significant differences in vaccine recommendation were found by specialty, practice location, number of providers in their practice, physician gender or years in practice. In multivariable regression analysis, routinely recommending influenza vaccine was significantly associated with younger physician age [adjusted odds ratio (AOR) 2.01, 95 % confidence interval (CI) 1.29-3.13] and greater number of pregnant patients seen per week (AOR 1.95, 95 % CI 1.25-3.06). Among rural physicians, fewer obstetricians (90.3 %) than family physicians (98.5 %) had vaccine-appropriate storage units (p = 0.001). Most physician prenatal care providers understand the importance of influenza vaccination during pregnancy. To increase influenza vaccine coverage among pregnant women, it will be necessary to identify and address patient barriers to receiving influenza vaccination during pregnancy.

Amor y Salud (Love and Health): a preconception health campaign for second-generation Latinas in Oregon.

PURPOSE: To develop, and implement, a social marketing campaign to increase preconception health knowledge among second-generation Latinas in Oregon. DESIGN: Social marketing demonstration project. SETTING: Latino communities in five Oregon counties. SUBJECTS: Target populations included young Latinas (18-29 years old) born in the United States of immigrant parents in five Oregon counties, and their family members. Intervention. A radionovela, Amor y Salud, was developed that featured a Latina and her fiancé preparing for marriage and family. Social media, Web sites, and culturally relevant print materials promoted the radio campaign. MEASURES: Process data, social media metrics, Google analytics, online and intercept surveys were collected. ANALYSIS: Basic frequencies and descriptive statistics were used. RESULTS: Twelve episodes were produced in English and Spanish and played on nine radio stations a total of 2098 times. The Facebook page was viewed 11,000 times, and radionovela episodes were played a total of 776 times. CONCLUSION: Amor y Salud used mixed media--radio, social media, print materials--to encourage Latinas to consider their preconception health. Anecdotally, we heard positive comments from community members and local media regarding the radionovela; however, evaluation challenges prevent us from saying conclusively that knowledge on this topic increased.

Consumption of soda and other sugar-sweetened beverages by 2-year-olds: findings from a population-based survey.

OBJECTIVE: To determine risk factors for consumption of soda and other sugar-sweetened beverages (SSB) among 2-year-old children. DESIGN: The analysis was performed using three linked data sets: the 2004-2005 Oregon Pregnancy Risk Assessment Monitoring Survey (PRAMS); its longitudinal follow-up, 2006-2007 Oregon PRAMS-2; and 2004-2005 Oregon birth certificates. SETTING: PRAMS is a surveillance programme supported by the federal Centers for Disease Control and Prevention and implemented by participating state health departments. Using mixed methods, PRAMS surveys women 2-6 months after a live birth. Oregon PRAMS-2 re-interviews respondents shortly after the index child's second birthday. Oregon PRAMS oversamples minority women. SUBJECTS: Using monthly cohorts, we randomly selected 5851 women from the 2004-2005 birth certificates. In total 1911 women completed both PRAMS and PRAMS-2. The weighted response rate of PRAMS-2 was 43.5%. RESULTS: Almost half of mothers (49.9%) reported that their child drank SSB on at least 1 d/week. Mothers whose children drank SSB at least once weekly were more likely to have low income (adjusted OR=2.83, 95% CI 2.09, 3.83) and to eat out on ≥2 d/week (OR=2.11 %, 95% CI 1.66, 2.70). Hispanic and non-Hispanic black women were most likely to report that their child drank SSB at least once weekly. CONCLUSIONS: Half of mothers reported that their 2-year-old children drank SSB at least once weekly. Public health interventions and policies should address childhood SSB consumption including educating health-care providers and parents.

Physician care patterns and adherence to postpartum glucose testing after gestational diabetes mellitus in Oregon.

OBJECTIVE: This study examines obstetrician/gynecologists and family medicine physicians' reported care patterns, attitudes and beliefs and predictors of adherence to postpartum testing in women with a history of gestational diabetes mellitus. RESEARCH DESIGN AND METHODS: In November-December 2005, a mailed survey went to a random, cross-sectional sample of 683 Oregon licensed physicians in obstetrician/gynecologists and family medicine from a population of 2171. RESULTS: Routine postpartum glucose tolerance testing by both family physicians (19.3%) and obstetrician/gynecologists physicians (35.3%) was reportedly low among the 285 respondents (42% response rate). Factors associated with high adherence to postpartum testing included physician stated priority (OR 4.39, 95% CI: 1.69-7.94) and physician beliefs about norms or typical testing practices (OR 3.66, 95% CI: 1.65-11.69). Specialty, sex of physician, years of practice, location, type of practice, other attitudes and beliefs were not associated with postpartum glucose tolerance testing. CONCLUSIONS: Postpartum glucose tolerance testing following a gestational diabetes mellitus pregnancy was not routinely practiced by responders to this survey. Our findings indicate that physician knowledge, attitudes and beliefs may in part explain suboptimal postpartum testing. Although guidelines for postpartum care are established, some physicians do not prioritize these guidelines in practice and do not believe postpartum testing is the norm among their peers.

Is maternal food security a predictor of food and drink intake among toddlers in Oregon?

Food insecurity has detrimental effects on the mental, physical, and behavioral health of developing children. Few studies, however, have sought to determine whether associations exist between food insecurity and intake of vegetables, fresh or canned fruit, candy or cookies, French fries, fast food, water, milk, fruit juices, fruit drinks, soda, and sports drinks. To identify independent associations that exist between maternal food insecurity and food and drink intake among toddlers, population-based data from the 2006-2008 Oregon Pregnancy Risk Assessment Monitoring System follow-back survey (Oregon PRAMS-2) of 1,522 mothers of 2-year-old children were analyzed. Maternal food insecurity was defined as mothers' report of eating less because of lack of money for food. Typical weekly child food and drink intake was examined using polytomous logistic regression: 0-1 days/week, 2-3 days/week, and 4-7 days/week. Maternal food insecurity prevalence was 11.7 %. Compared to toddlers of food secure mothers, toddlers of food insecure mothers consumed vegetables (adjusted odds ratio [AOR] for 4-7 days/week = 0.31; 95 % confidence interval [CI] 0.12, 0.79) and fruit (AOR for 4-7 days/week = 0.25; 95 % CI 0.08, 0.75) fewer days of the week. Toddlers of food insecure mothers consumed soda (AOR for 4-7 days/week = 3.21; 95 % CI 1.12, 9.14) more days of the week. Maternal food insecurity is associated with weekly intake of certain foods and drinks. Among toddlers, consumption of fewer vegetables and fruit, and more soda may help explain the link between food insecurity and poor health.

Health risks of Oregon eighth-grade participants in the "choking game": results from a population-based survey.

OBJECTIVE: To examine the risk behaviors associated with participation in the "choking game" by eighth-graders in Oregon. METHODS: We obtained data from the 2009 Oregon Healthy Teens survey, a cross-sectional weighted survey of 5348 eighth-graders that questioned lifetime prevalence and frequency of choking game participation. The survey also included questions about physical and mental health, gambling, sexual activity, nutrition, physical activity/body image, exposure to violence, and substance use. RESULTS: Lifetime prevalence of choking game participation was 6.1% for Oregon eighth-graders, with no differences between males and females. Of the eighth-grade choking game participants, 64% had engaged in the activity more than once and 26.6% >5 times. Among males, black youth were more likely to participate than white youth. Among both females and males, Pacific Islander youth were much more likely to participate than white youth. Multivariate logistic regression revealed that sexual activity and substance use were significantly associated with choking game participation for both males and females. CONCLUSIONS: At >6%, the prevalence of choking game participation among Oregon youth is consistent with previous findings. However, we found that most of those who participate will put themselves at risk more than once. Participants also have other associated health risk behaviors. The comprehensive adolescent well visit, as recommended by the American Academy of Pediatrics, is a good opportunity for providers to conduct a health behavior risk assessment and, if appropriate, discuss the dangers of engaging in this activity.

Extended-use oral contraceptives and medically induced amenorrhea: attitudes, knowledge and prescribing habits of physicians.

BACKGROUND: The study was conducted to determine whether geographic location, primary specialty, attitudes and knowledge influence the prescribing habits of physicians regarding extended-use oral contraceptives (OC) and medically induced amenorrhea. STUDY DESIGN: Practice characteristics, contraceptive prescription habits, menstrual cycle physiology knowledge and attitudes about medically induced amenorrhea of Oregon obstetrics and gynecology (OBGYN) and family medicine physicians were assessed using either a cross-sectional postal or electronic mail survey. Attitudes were assessed using a series of Likert-style questions; multiple-choice responses were used to evaluate knowledge and prescribing habits. RESULTS: Of the 713 physicians in the sample (email 575, paper 138), 233 returned the survey, for an overall response rate of 32.7%. Over 90% (211/233) of respondents prescribed OCs; of these, 73.9% (155/211) stated that they prescribed extended-use OCs either often (23.5%) or sometimes (50.5%). Without adjusting for other factors, physicians reporting an OBGYN specialty (odds ratio [OR] 8.02, 95% confidence interval [CI]: 3.40-18.91) or an urban practice location (OR 2.75, 95% CI: 1.42-5.30) were more likely to report prescribing extended-use OCs. However, after adjusting for other factors, attitude was the only factor which remained significantly associated with prescribing (OR 1.85, 95% CI 1.41-2.42). CONCLUSION: Physicians' attitudes regarding medically induced amenorrhea influence the use of extended-cycle OC more than any other characteristic.

The impact of citizenship documentation requirements on access to medicaid for pregnant women in Oregon.

The federal Deficit Reduction Act of 2005 mandated citizenship documentation from all Medicaid applicants as a condition of eligibility and was implemented in Oregon on September 1, 2006. We assessed whether new citizenship documentation requirements were associated with delays in Medicaid authorization for newly pregnant eligible applicants during the first nine months of DRA implementation in Oregon. We conducted a pre-post analysis of administrative records to compare the length of time between Medicaid application and authorization for all newly pregnant, Medicaid-eligible applicants in Oregon (n = 29,284), nine months before and after September 1, 2006. We compared mean days from application to authorization (McNemar's), and proportion of eligible applicants who waited over 7, 30 and 45 days to be authorized (Pearson's coefficient). The mean number of days women waited for authorization increased from 18 days in the 9 months before DRA implementation to 22.6 days in the post-implementation 9 month period (P ≤ .001). The proportion of eligible applicants who waited 7, 30 and 45 days increased significantly following DRA implementation (P ≤ .001). The proportion of eligible applicants who were not authorized within the standard 45-day period increased from 6.9 to 12.5% following the DRA. Implementation of new citizenship documentation requirements was associated with significant delays in Medicaid authorization for eligible pregnant women in Oregon. Such delays in gaining insurance coverage can detrimentally affect access to early prenatal care initiation among a vulnerable population known to be at higher risk for certain preventable pregnancy-related complications.

New options for child health surveillance by state health departments.

Until recently there were no child health surveillance instruments available to state health departments for children 1-14 years old. In recent years, several states have developed new surveillance instruments. This article includes information about examples of four types of child health surveys: (1) Behavioral Risk Factor Surveillance System (BRFSS) follow-back survey [phone-based in Colorado]; (2) Pregnancy Risk Assessment Monitoring System (PRAMS) re-interviews [PRAMS-based in Rhode Island]; (3) elementary school child health survey combined with dental screening and physical measurements of height and weight [school-based in Maine]; and (4) freestanding elementary school survey [school-based in Oregon]. The PRAMS-based survey was moderate in expense but addressed only issues related to 2 year olds. The phone-based survey was the most expensive but addressed issues of children 1-14 years old. The school-based surveys were moderate in expense, logistically complex, and were least likely to provide robust generalizable data.

Racial/ethnic disparities in gestational diabetes mellitus: findings from a population-based survey.

PURPOSE: We sought to explore racial/ethnic disparities in the prevalence of gestational diabetes mellitus (GDM) in a population-based sample. METHODS: Data from the Oregon Pregnancy Risk Assessment Monitoring System (PRAMS), a stratified, random sample of postpartum women who delivered in Oregon in 2004 and 2005 (n = 3,883; weighted response rate, 75.2%) and linked birth certificates were analyzed. Hispanic, non-Hispanic Black, non-Hispanic American Indian, and non-Hispanic Asian/Pacific Islander (API) women were oversampled. We categorized women as having had GDM if they gave an affirmative answer on the birth certificate or the PRAMS survey. RESULTS: Non-Hispanic API women had the highest prevalence of GDM (14.8%); this was true for women with both a normal and a high body mass index (BMI). Asian women were more likely to have had GDM than Pacific Islander women. On multivariate analysis, non-Hispanic APIs were significantly more likely to have a pregnancy complicated by GDM (adjusted odds ratio, 2.26; 95% confidence interval, 1.23-4.13) than non-Hispanic White women. CONCLUSION: Non-Hispanic API women, especially Asian women with both normal and high BMI, have increased risk of GDM. Future research should examine the unique risk factors experienced by Asians and health practitioners should be vigilant in screening for GDM regardless of BMI.

Racial/ethnic disparities in the receipt of smoking cessation interventions during prenatal care.

To explore racial/ethnic disparities in the receipt of optimal smoking cessation counseling during prenatal care. We used data from Oregon's perinatal surveillance system, the Oregon Pregnancy Risk Assessment Monitoring System (PRAMS) from 2000 to 2001. A stratified random sample of postpartum women were asked questions about events before, during and after pregnancy, including smoking and provision of smoking cessation counseling. The weighted response rate was 78.8% (n = 3,895). Receipt of a clinician protocol for smoking cessation intervention, called the Five A's (Ask, Advise, Assess, Assist, Arrange), was the outcome of interest. In the Oregon PRAMS survey, we asked women about three of the Five A's (Ask, Advise, Assist). Of 594 first trimester pregnant smokers, the majority were asked and advised about smoking by a prenatal care provider. However, a substantial proportion of women did not receive assistance to quit and only 42.2% received all three steps. Significant racial/ethnic variations were found only in the Assist step. Compared to non-Hispanic (NH) White women, NH American Indian women had lower odds (adjusted odds ratio [ORa]: 0.45; 95% confidence interval [95% CI] 0.24, 0.85) of receiving all three steps. In contrast, NH Black women had increased odds of receiving all three steps (ORa: 2.43; 95% CI 1.16, 5.10). We conclude that there is a need for prenatal care providers to address tobacco use, especially to Assist quitting, with all pregnant smokers. Healthcare systems should implement system prompts and supports for providers to remind them to address tobacco use with pregnant smokers.