Infant Receipt of Health Care Services during the 2016-2017 Zika Virus Outbreak in Puerto Rico.

OBJECTIVE: To assess the receipt of health care services among live-born infants of women with and without evidence of Zika virus (ZIKV) infection while pregnant during the 2016-2017 ZIKV outbreak in Puerto Rico. METHODS: We used data from the Pregnancy Risk Assessment Monitoring System-Zika Postpartum Emergency Response study telephone surveys to examine maternal reports of the receipt of health care services by infants born in Puerto Rico from August through December 2016 and November through December 2017. Evidence of ZIKV infection was ascertained from the infant's birth certificate or was self-reported in the survey. RESULTS: Fourteen percent of women in 2016 and 9% in 2017 had evidence of ZIKV infection during pregnancy. Most infants of women with evidence of ZIKV received the recommended health care services in 2016 and 2017, respectively, including a hearing test (91% vs. 92%), developmental assessment (90% vs. 92%), and an eye exam (74% vs. 70%); fewer received a head scan (45% vs. 36%) and evaluation for physical therapy (17% vs. 10%). From 2016 to 2017, the proportion of infants having a personal doctor increased for all infants; for infants of women without evidence of ZIKV infection, receiving hearing, developmental, and eye assessments increased. CONCLUSION: Most infants of women with evidence of ZIKV infection during pregnancy received the recommended hearing and developmental assessments during the ZIKV outbreak. Experiences with increasing service capacity during the ZIKV outbreak can be evaluated to inform the response to future emergencies that affect maternal and child health.

US county-level estimation for maternal and infant health-related behavior indicators using pregnancy risk assessment monitoring system data, 2016-2018.

BACKGROUND: There is a critical need for maternal and child health data at the local level (for example, county), yet most counties lack sustainable resources or capabilities to collect local-level data. In such case, model-based small area estimation (SAE) could be a feasible approach. SAE for maternal or infant health-related behaviors at small areas has never been conducted or evaluated. METHODS: We applied multilevel regression with post-stratification approach to produce county-level estimates using Pregnancy Risk Assessment Monitoring System (PRAMS) data, 2016-2018 (n = 65,803 from 23 states) for 2 key outcomes, breastfeeding at 8 weeks and infant non-supine sleeping position. RESULTS: Among the 1,471 counties, the median model estimate of breastfeeding at 8 weeks was 59.8% (ranged from 34.9 to 87.4%), and the median of infant non-supine sleeping position was 16.6% (ranged from 10.3 to 39.0%). Strong correlations were found between model estimates and direct estimates for both indicators at the state level. Model estimates for both indicators were close to direct estimates in magnitude for Philadelphia County, Pennsylvania. CONCLUSION: Our findings support this approach being potentially applied to other maternal and infant health and behavioral indicators in PRAMS to facilitate public health decision-making at the local level.

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

Evolving Global Perspectives of Pharmacists: Dispensing Medical Cannabis.

Introduction: Different countries have employed a variety of methods for their populace to access medical cannabis. Objectives: The purpose of this literature review was to assess the international literature on pharmacists' beliefs and attitudes towards medical cannabis. Methodology: This literature review summarized the various countries that utilize pharmacies and pharmacists to dispense medical cannabis. The countries included in this review were: Australia, Canada, Denmark, Finland, Germany, Israel, Italy, Netherlands, Poland, Serbia, Switzerland, USA, and Uruguay. Discussion: The pharmacist perspective has been of key importance within the medical landscape, as they are the ones who not only dispense medication but also counsel and monitor patients and it is this perspective that is lacking. Conclusion: Overall, this review found that even though pharmacists are generally comfortable with dispensing medical cannabis; they still require further education to do so as safely and effectively as possible.

Response to "The Time has Come for All States to Measure Racial Discrimination: A Call to Action for the Pregnancy Risk Assessment Monitoring System (PRAMS)".

We respond to a recent call to action for the Pregnancy Risk Assessment Monitoring System (PRAMS) to include a "core" question or validated measure on discrimination to allow for systematic assessment of the impact of racial discrimination on adverse birth outcomes among a large population-based sample in the United States. We outline activities of the CDC PRAMS project that relate to this call to action.

Disaster Preparedness Among Women With a Recent Live Birth in Hawaii - Results From the Pregnancy Risk Assessment Monitoring System (PRAMS), 2016.

OBJECTIVE: The aim of this study was to examine emergency preparedness behaviors among women with a recent live birth in Hawaii. METHODS: Using the 2016 Hawaii Pregnancy Risk Assessment Monitoring System, we estimated weighted prevalence of 8 preparedness behaviors. RESULTS: Among 1010 respondents (weighted response rate, 56.3%), 79.3% reported at least 1 preparedness behavior, and 11.2% performed all 8 behaviors. The prevalence of women with a recent live birth in Hawaii reporting preparedness behaviors includes: 63.0% (95% CI: 58.7-67.1%) having enough supplies at home for at least 7 days, 41.3% (95% CI: 37.1-45.6%) having an evacuation plan for their child(ren), 38.7% (95% CI: 34.5-43.0%) having methods to keep in touch, 37.8% (95% CI: 33.7-42.1%) having an emergency meeting place, 36.6% (95% CI: 32.6-40.9%) having an evacuation plan to leave home, 34.9% (95% CI: 30.9-39.2%) having emergency supplies to take with them if they have to leave quickly, 31.8% (95% CI: 27.9-36.0%) having copies of important documents, and 31.6% (95% CI: 27.7-35.8%) having practiced what to do during a disaster. CONCLUSIONS: One in 10 women practiced all 8 behaviors, indicating more awareness efforts are needed among this population in Hawaii. The impact of preparedness interventions implemented in Hawaii can be tracked with this question over time.

Workplace Leave and Breastfeeding Duration Among Postpartum Women, 2016-2018.

Objectives. To examine associations of workplace leave length with breastfeeding initiation and continuation at 1, 2, and 3 months. Methods. We analyzed 2016 to 2018 data for 10 sites in the United States from the Pregnancy Risk Assessment Monitoring System, a site-specific, population-based surveillance system that samples women with a recent live birth 2 to 6 months after birth. Using multivariable logistic regression, we examined associations of leave length (< 3 vs ≥ 3 months) with breastfeeding outcomes. Results. Among 12 301 postpartum women who planned to or had returned to the job they had during pregnancy, 42.1% reported taking unpaid leave, 37.5% reported paid leave, 18.2% reported both unpaid and paid leave, and 2.2% reported no leave. Approximately two thirds (66.2%) of women reported taking less than 3 months of leave. Although 91.2% of women initiated breastfeeding, 81.2%, 72.1%, and 65.3% of women continued breastfeeding at 1, 2, and 3 months, respectively. Shorter leave length (< 3 months), whether paid or unpaid, was associated with lower prevalence of breastfeeding at 2 and 3 months compared with 3 or more months of leave. Conclusions. Women with less than 3 months of leave reported shorter breastfeeding duration than did women with 3 or more months of leave. (Am J Public Health. 2021;111(11):2036-2045. https://doi.org/10.2105/AJPH.2021.306484).

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.

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.

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.

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.

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.

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 Prevention's 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.

How can PRAMS survey response rates be improved among American Indian mothers? Data from 10 states.

OBJECTIVES: To examine the low response rates to the Pregnancy Risk Assessment and Monitoring System (PRAMS) survey for American Indian (AI) mothers by comparing characteristics of AI participants, AI non-participants, non-Hispanic White (NHW) participants, and NHW non-participants. METHODS: We analyzed 2000-2002 data from states whose population was at least 5% AI or Alaska Native (AN) (n = 10). Mothers who returned a questionnaire (regardless of completion) or who spoke by telephone with PRAMS personnel were defined as contacts. Mothers who completed a PRAMS questionnaire were defined as respondents. We described overall and state-specific maternal characteristics from birth certificates for both those who were contacted and those not contacted and computed contact and response rates. RESULTS: Contact rates varied by state, ranging from 49% to 92% for AI and AN mothers and 82-93% for NHW mothers. However, once contacted, most mothers completed a questionnaire (85-99%). Both AI and NHW mothers were less likely to be contacted if they were <29 years of age, unmarried, multiparous and had

The Pregnancy Risk Assessment Monitoring System (PRAMS): current methods and evaluation of 2001 response rates.

OBJECTIVES: Our objectives were to describe the methodology of the Pregnancy Risk Assessment Monitoring System (PRAMS), examine recent response rates, determine characteristics associated with response, and track response patterns over time. METHODS: PRAMS is a mixed-mode surveillance system, using mail and telephone surveys. Rates for response, contact, cooperation, and refusal were computed for 2001. Logistic regression was used to examine the relationship between maternal and infant characteristics and the likelihood of response. Response patterns from 1996 to 2001 were compared for nine states. RESULTS: The median response rate for the 23 states in 2001 was 76% (range: 49% to 84%). Cooperation rates ranged from 86% to 97% (median 91%); contact rates ranged from 58% to 93% (median 82%). Response rates were higher for women who were older, white, married, had more education, were first-time mothers, received early prenatal care, and had a normal birthweight infant. Education level was the most consistent predictor of response, followed by marital status and maternal race. From 1996 to 2001, response to the initial mailing decreased in all states compared, but the decrease was offset by increases in mail follow-up and telephone response rates. Overall response rates remained unchanged. CONCLUSIONS: The PRAMS mail/telephone methodology is an effective means of reaching most recent mothers in the 23 states examined, but some population subgroups are more difficult to reach than others. Through more intensive follow-up efforts, PRAMS states have been able to maintain high response rates over time despite decreases in response to the initial mailing.

Risk factors for legal induced abortion-related mortality in the United States.

OBJECTIVE: To assess risk factors for legal induced abortion-related deaths. METHODS: This is a descriptive epidemiologic study of women dying of complications of induced abortions. Numerator data are from the Abortion Mortality Surveillance System. Denominator data are from the Abortion Surveillance System, which monitors the number and characteristics of women who have legal induced abortions in the United States. Risk factors examined include age of the woman, gestational length of pregnancy at the time of termination, race, and procedure. Main outcome measures include crude, adjusted, and risk factor-specific mortality rates. RESULTS: During 1988-1997, the overall death rate for women obtaining legally induced abortions was 0.7 per 100000 legal induced abortions. The risk of death increased exponentially by 38% for each additional week of gestation. Compared with women whose abortions were performed at or before 8 weeks of gestation, women whose abortions were performed in the second trimester were significantly more likely to die of abortion-related causes. The relative risk (unadjusted) of abortion-related mortality was 14.7 at 13-15 weeks of gestation (95% confidence interval [CI] 6.2, 34.7), 29.5 at 16-20 weeks (95% CI 12.9, 67.4), and 76.6 at or after 21 weeks (95% CI 32.5, 180.8). Up to 87% of deaths in women who chose to terminate their pregnancies after 8 weeks of gestation may have been avoidable if these women had accessed abortion services before 8 weeks of gestation. CONCLUSION: Although primary prevention of unintended pregnancy is optimal, among women who choose to terminate their pregnancies, increased access to surgical and nonsurgical abortion services may increase the proportion of abortions performed at lower-risk, early gestational ages and help further decrease deaths. LEVEL OF EVIDENCE: II-2