Association of Mental Health Conditions, Recent Stressful Life Events, and Adverse Childhood Experiences with Postpartum Substance Use - Seven States, 2019-2020.

Most pregnancy-related deaths due to mental health conditions, which include overdose and poisoning related to substance use disorder, occur during the late (43-365-day) postpartum period (1). Adverse childhood experiences and stressful life events are associated with increased substance use during pregnancy (2,3). Pregnancy Risk Assessment Monitoring System (PRAMS) respondents in seven states with high opioid overdose mortality rates were recontacted 9-10 months after giving birth in 2019 and asked about postpartum prescription opioid misuse,* tobacco use, unhealthy alcohol use,† and use of other substances.§ Substance and polysubstance use prevalence estimates were calculated, stratified by mental health and social adversity indicators. Overall, 25.6% of respondents reported postpartum substance use, and 5.9% reported polysubstance use. The following conditions were associated with higher substance and polysubstance use prevalence in postpartum women: depressive symptoms, depression, anxiety, adverse childhood experiences, and stressful life events. Substance use prevalence was higher among women who experienced six or more stressful life events during the year preceding the birth (67.1%) or four adverse childhood experiences related to household dysfunction (57.9%). One in five respondents who experienced six or more stressful life events in the year before giving birth and 26.3% of women with four adverse childhood experiences reported postpartum polysubstance use. Clinical and community- and systems-level interventions to improve postpartum health can include screening and treatment for depression, anxiety, and substance use disorders during the postpartum period. Evidence-based strategies can prevent adverse childhood experiences and mitigate the immediate and long-term harms.¶.

Pandemic-related stressors and mental health among women with a live birth in 2020.

The objective of this analysis was to assess the associations between pandemic-related stressors and feeling more anxious/depressed, among women with a live birth. We analyzed data from the Pregnancy Risk Assessment Monitoring System (PRAMS) COVID-19 maternal experiences supplement, implemented in 29 U.S. jurisdictions from October 2020-June 2021, among women with a live birth during April-December 2020. We examined stressors by type (economic, housing, childcare, food insecurity, partner, COVID-19 illness) and score (number of stressor types experienced [none, 1-2, 3-4, or 5-6]). Outcomes were feeling 1) more anxious and 2) more depressed than usual due to the pandemic. We calculated adjusted prevalence ratios estimating associations between stressors and outcomes. Among 12,525 respondents, half reported feeling more anxious and 28% more depressed than usual. The prevalence of stressor types was 50% economic, 41% childcare, 18% partner, 17% food insecurity, 12% housing, and 10% COVID-19 illness. Respondents who experienced partner stressors (anxious aPR: 1.81, 95% CI: 1.73-1.90; depressed aPR: 3.01, 95% CI: 2.78-3.25) and food insecurity (anxious aPR: 1.79, 95% CI: 1.71-1.88; depressed aPR: 2.32, 95% CI: 2.13-2.53) had the largest associations with feeling more anxious and depressed than usual. As stressor scores increased, so did the aPRs for feeling more anxious and more depressed due to the pandemic. COVID-19 stressors, not COVID-19 illness, were found to be significantly associated with feeling more anxious and depressed. Pregnant and postpartum women might benefit from access to supports and services to address pandemic-related stressors/social-determinants and feelings of anxiety and depression.

Timing of Postpartum Depressive Symptoms.

Introduction: Postpartum depression is a serious public health problem that can adversely impact mother-child interactions. Few studies have examined depressive symptoms in the later (9-10 months) postpartum period. Methods: We analyzed data from the 2019 Pregnancy Risk Assessment Monitoring System (PRAMS) linked with data from a telephone follow-up survey administered to PRAMS respondents 9 to 10 months postpartum in 7 states (N = 1,954). We estimated the prevalence of postpartum depressive symptoms (PDS) at 9 to 10 months overall and by sociodemographic characteristics, prior depression (before or during pregnancy), PDS at 2 to 6 months, and other mental health characteristics. We used unadjusted prevalence ratios (PRs) to examine associations between those characteristics and PDS at 9 to 10 months. We also examined prevalence and associations with PDS at both time periods. Results: Prevalence of PDS at 9 to 10 months was 7.2%. Of those with PDS at 9 to 10 months, 57.4% had not reported depressive symptoms at 2 to 6 months. Prevalence of PDS at 9 to 10 months was associated with having Medicaid insurance postpartum (PR = 2.34; P = .001), prior depression (PR = 4.03; P <.001), and current postpartum anxiety (PR = 3.58; P <.001). Prevalence of PDS at both time periods was 3.1%. Of those with PDS at both time periods, 68.5% had prior depression. Conclusion: Nearly 3 in 5 women with PDS at 9 to 10 months did not report PDS at 2 to 6 months. Screening for depression throughout the first postpartum year can identify women who are not symptomatic early in the postpartum period but later develop symptoms.

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).

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.

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).

Opportunities to Address Men's Health During the Perinatal Period - Puerto Rico, 2017.

Decreased use of health care services (1), increased exposure to occupational hazards, and higher rates of substance use (2) might contribute to men's poorer health outcomes when compared with such outcomes for women (3). During the transition to fatherhood, paternal health and involvement during pregnancy might have an impact on maternal and infant outcomes (4-6). To assess men's health-related behaviors and participation in fatherhood-related activities surrounding pregnancy, the Puerto Rico Department of Health and CDC analyzed data from the paternal survey of the Pregnancy Risk Assessment Monitoring System-Zika Postpartum Emergency Response (PRAMS-ZPER)* study. Fewer than one half (48.3%) of men attended a health care visit for themselves in the 12 months before their newborn's birth. However, most fathers attended one or more prenatal care visits (87.2%), were present at the birth (83.1%), and helped prepare for the newborn's arrival (e.g., by preparing the home [92.4%] or purchasing supplies [93.9%]). These findings suggest that opportunities are available for public health messaging directed toward fathers during the perinatal period to increase attention to their own health and health behaviors, and to emphasize the role they can play in supporting their families' overall health and well-being.

The Impact of Dental Insurance and Medical Insurance on Dental Care Utilization During Pregnancy.

OBJECTIVE: To measure the association between dental and medical insurance with the receipt of dental cleaning during pregnancy. METHODS: We analyzed Pregnancy Risk Assessment Monitoring System (PRAMS) data from 2012 to 2015 on 145,051 women with a recent live birth from 36 states. We used adjusted prevalence ratios [aPR] from multivariable regression to examine the association of dental and medical insurance with receipt of dental cleaning during pregnancy, controlling for selected covariates that influence dental care utilization. RESULTS: Seventy-seven percent (77%) of all women reported having dental insurance during pregnancy. Receipt of dental cleaning before pregnancy was strongly associated with dental cleaning during pregnancy. Among women without pre-pregnancy dental cleaning who had dental insurance, those with Medicaid medical insurance had a significantly higher prevalence of dental cleaning during pregnancy [aPR = 1.42, 95% CI (1.32 - 1.52)], compared to those private medical insurance. Among women without pre-pregnancy dental cleaning, those without dental insurance but with Medicaid medical insurance were about 70% less likely to have dental cleaning during pregnancy compared to those with dental and private medical insurance. CONCLUSIONS FOR PRACTICE: With or without dental insurance, pre-pregnancy dental cleaning was strongly associated with dental cleaning during pregnancy. Dental insurance was an important determinant of dental utilization. Medical insurance had an independent and positive effect. This effect varied by private versus Medicaid medical insurance. Programs which provide women with dental insurance both before and during pregnancy could improve the oral health of maternal and infant populations.

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.

Influenza and Tdap Vaccination Coverage Among Pregnant Women - United States, April 2020.

Vaccination of pregnant women with influenza vaccine and tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap) can decrease the risk for influenza and pertussis among pregnant women and their infants. The Advisory Committee on Immunization Practices (ACIP) recommends that all women who are or might be pregnant during the influenza season receive influenza vaccine, which can be administered at any time during pregnancy (1). ACIP also recommends that women receive Tdap during each pregnancy, preferably during the early part of gestational weeks 27-36 (2,3). Despite these recommendations, vaccination coverage among pregnant women has been found to be suboptimal with racial/ethnic disparities persisting (4-6). To assess influenza and Tdap vaccination coverage among women pregnant during the 2019-20 influenza season, CDC analyzed data from an Internet panel survey conducted during April 2020. Among 1,841 survey respondents who were pregnant anytime during October 2019-January 2020, 61.2% reported receiving influenza vaccine before or during their pregnancy, an increase of 7.5 percentage points compared with the rate during the 2018-19 season. Among 463 respondents who had a live birth by their survey date, 56.6% reported receiving Tdap during pregnancy, similar to the 2018-19 season (4). Vaccination coverage was highest among women who reported receiving a provider offer or referral for vaccination (influenza = 75.2%; Tdap = 72.7%). Compared with the 2018-19 season, increases in influenza vaccination coverage were observed during the 2019-20 season for non-Hispanic Black (Black) women (14.7 percentage points, to 52.7%), Hispanic women (9.9 percentage points, to 67.2%), and women of other non-Hispanic (other) races (7.9 percentage points, to 69.6%), and did not change for non-Hispanic White (White) women (60.6%). As in the 2018-19 season, Hispanic and Black women had the lowest Tdap vaccination coverage (35.8% and 38.8%, respectively), compared with White women (65.5%) and women of other races (54.0%); in addition, a decrease in Tdap vaccination coverage was observed among Hispanic women in 2019-20 compared with the previous season. Racial/ethnic disparities in influenza vaccination coverage decreased but persisted, even among women who received a provider offer or referral for vaccination. Consistent provider offers or referrals, in combination with conversations culturally and linguistically tailored for patients of all races/ethnicities, could increase vaccination coverage among pregnant women in all racial/ethnic groups and reduce disparities in coverage.

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.

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.

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.

Factors associated with postpartum use of long-acting reversible contraception.

BACKGROUND: Contraception use among postpartum women is important to prevent unintended pregnancies and optimize birth spacing. Long-acting reversible contraception, including intrauterine devices and implants, is highly effective, yet compared to less effective methods utilization rates are low. OBJECTIVES: We sought to estimate prevalence of long-acting reversible contraception use among postpartum women and examine factors associated with long-acting reversible contraception use among those using any reversible contraception. STUDY DESIGN: We analyzed 2012-2015 data from the Pregnancy Risk Assessment Monitoring System, a population-based survey among women with recent live births. We included data from 37 sites that achieved the minimum overall response rate threshold for data release. We estimated the prevalence of long-acting reversible contraception use in our sample (n = 143,335). We examined maternal factors associated with long-acting reversible contraception use among women using reversible contraception (n = 97,013) using multivariable logistic regression (long-acting reversible contraception vs other type of reversible contraception) and multinomial regression (long-acting reversible contraception vs other hormonal contraception and long-acting reversible contraception vs other nonhormonal contraception). RESULTS: The prevalence of long-acting reversible contraception use overall was 15.3%. Among postpartum women using reversible contraception, 22.5% reported long-acting reversible contraception use, which varied by site, ranging from 11.2% in New Jersey to 37.6% in Alaska. Factors associated with postpartum long-acting reversible contraception use vs use of another reversible contraceptive method included age ≤24 years (adjusted odds ratio = 1.43; 95% confidence interval = 1.33-1.54) and ≥35 years (adjusted odds ratio = 0.87; 95% confidence interval = 0.80-0.96) vs 25-34 years; public insurance (adjusted odds ratio = 1.15; 95% confidence interval = 1.08-1.24) and no insurance (adjusted odds ratio = 0.73; 95% confidence interval = 0.55-0.96) vs private insurance at delivery; having a recent unintended pregnancy (adjusted odds ratio = 1.44; 95% confidence interval = 1.34-1.54) or being unsure about the recent pregnancy (adjusted odds ratio = 1.29; 95% confidence interval = 1.18-1.40) vs recent pregnancy intended; having ≥1 previous live birth (adjusted odds ratio = 1.40; 95% confidence interval = 1.31-1.48); and having a postpartum check-up after recent live birth (adjusted odds ratio = 2.70; 95% confidence interval = 2.35-3.11). Hispanic and non-Hispanic black postpartum women had a higher rate of long-acting reversible contraception use (26.6% and 23.4%, respectively) compared to non-Hispanic white women (21.5%), and there was significant race/ethnicity interaction with educational level. CONCLUSION: Nearly 1 in 6 (15.3%) postpartum women with a recent live birth and nearly 1 in 4 (22.5%) postpartum women using reversible contraception reported long-acting reversible contraception use. Our analysis suggests that factors such as age, race/ethnicity, education, insurance, parity, intendedness of recent pregnancy, and postpartum visit attendance may be associated with postpartum long-acting reversible contraception use. Ensuring all postpartum women have access to the full range of contraceptive methods, including long-acting reversible contraception, is important to prevent unintended pregnancy and optimize birth spacing. Contraceptive access may be improved by public health efforts and programs that address barriers in the postpartum period, including increasing awareness of the availability, effectiveness, and safety of long-acting reversible contraception (and other methods), as well as providing full reimbursement for contraceptive services and removal of administrative and logistical barriers.

Vital Signs: Burden and Prevention of Influenza and Pertussis Among Pregnant Women and Infants - United States.

INTRODUCTION: Vaccinating pregnant women with influenza vaccine and tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap) can reduce influenza and pertussis risk for themselves and their infants. METHODS: Surveillance data were analyzed to ascertain influenza-associated hospitalization among pregnant women and infant hospitalization and death associated with influenza and pertussis. An Internet panel survey was conducted during March 27-April 8, 2019, among women aged 18-49 years who reported being pregnant any time since August 1, 2018. Influenza vaccination before or during pregnancy was assessed among respondents with known influenza vaccination status who were pregnant any time during October 2018-January 2019 (2,097). Tdap receipt during pregnancy was assessed among respondents with known Tdap status who reported a live birth by their survey date (817). RESULTS: From 2010-11 to 2017-18, pregnant women accounted for 24%-34% of influenza-associated hospitalizations per season among females aged 15-44 years. From 2010 to 2017, a total of 3,928 pertussis-related hospitalizations were reported among infants aged <2 months (annual range = 262-743). Maternal influenza and Tdap vaccination coverage rates reported as of April 2019 were 53.7% and 54.9%, respectively. Among women whose health care providers offered vaccination or provided referrals, 65.7% received influenza vaccine and 70.5% received Tdap. The most commonly reported reasons for nonvaccination were believing the vaccine is not effective (influenza; 17.6%) and not knowing that vaccination is needed during each pregnancy (Tdap; 37.9%), followed by safety concerns for the infant (influenza =15.9%; Tdap = 17.1%). CONCLUSIONS AND IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: Many pregnant women do not receive the vaccines recommended to protect themselves and their infants, even when vaccination is offered. CDC and provider organizations' resources are available to help providers convey strong, specific recommendations for influenza and Tdap vaccination that are responsive to pregnant women's concerns.

Use of Electronic Vapor Products Before, During, and After Pregnancy Among Women with a Recent Live Birth - Oklahoma and Texas, 2015.

Electronic vapor products (EVPs) comprise a diverse group of devices, including electronic cigarettes (e-cigarettes). EVP users inhale an aerosol that typically contains nicotine, flavorings, and other additives (1). Nicotine is a developmental toxicant that adversely affects pregnancy and infant outcomes (2). Data from the 2015 Pregnancy Risk Assessment Monitoring System (PRAMS) for Oklahoma and Texas were analyzed to estimate population-based EVP use among women with a recent live birth. EVP use before pregnancy (defined as >3 months before pregnancy) and around the time of pregnancy (defined as any time during the 3 months before pregnancy, the last 3 months of pregnancy, or 2-6 months after delivery), reasons for EVP use, and dual use of EVPs and cigarettes were assessed. Prevalence of EVP use was 10.4% before pregnancy and 7.0% around the time of pregnancy, including 1.4% during the last 3 months of pregnancy. Among women using EVPs during the last 3 months of pregnancy, 38.4% reported use of EVPs containing nicotine, and 26.4% were unsure of nicotine content. Among women who had used EVPs and cigarettes, dual use prevalence was 38.0% in the 3 months before pregnancy, 7.7% during the last 3 months of pregnancy, and 11.8% in the 2-6 months after delivery. The most frequently reported reasons for EVP use around the time of pregnancy were curiosity (54.0%), the perception that EVPs might help with quitting or reducing cigarette smoking (45.2%), and the perception of reduced harm to the mother, when compared with cigarette smoking (45.2%). Clear messages that EVP use is not safe during pregnancy are needed, and broad, barrier-free access to evidence-based tobacco cessation strategies need to be made available.

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.

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.

Influenza and Tdap Vaccination Coverage Among Pregnant Women - United States, April 2018.

Vaccinating pregnant women with influenza and tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccines can reduce the risk for influenza and pertussis for themselves and their infants. The Advisory Committee on Immunization Practices (ACIP) recommends that all women who are or might be pregnant during the influenza season receive influenza vaccine, which can be administered any time during pregnancy (1). The ACIP also recommends that women receive Tdap during each pregnancy, preferably from 27 through 36 weeks' gestation (2). To assess influenza and Tdap vaccination coverage among women pregnant during the 2017-18 influenza season, CDC analyzed data from an Internet panel survey conducted during March 28-April 10, 2018. Among 1,771 survey respondents pregnant during the peak influenza vaccination period (October 2017-January 2018), 49.1% reported receiving influenza vaccine before or during their pregnancy. Among 700 respondents who had a live birth, 54.4% reported receiving Tdap during their pregnancy. Women who reported receiving a provider offer of vaccination had higher vaccination coverage than did women who received a recommendation but no offer and women who did not receive a recommendation. Reasons for nonvaccination included concern about effectiveness of the influenza vaccine and lack of knowledge regarding the need for Tdap vaccination during every pregnancy. Provider offers or referrals for vaccination in combination with patient education could reduce missed opportunities for vaccination and increase vaccination coverage among pregnant women.