Well-Being in the Nation: A Living Library of Measures to Drive Multi-Sector Population Health Improvement and Address Social Determinants.

Policy Points Well-being In the Nation (WIN) offers the first parsimonious set of vetted common measures to improve population health and social determinants across sectors at local, state, and national levels and is driven by what communities need to improve health, well-being, and equity. The WIN measures were codesigned with more than 100 communities, federal agencies, and national organizations across sectors, in alignment with the National Committee on Vital and Health Statistics, the Foundations for Evidence-Based Policymaking Act, and Healthy People 2030. WIN offers a process for a collaborative learning measurement system to drive a learning health and well-being system across sectors at the community, state, and national levels. The WIN development process identified critical gaps and opportunities in equitable community-level data infrastructure, interoperability, and protections that could be used to inform the Federal Data Strategy.

Variation in Vaginal Birth After Cesarean by Maternal Race and Detailed Ethnicity.

Objective Our objective was to examine the likelihood of vaginal birth after cesarean (VBAC) for women in Massachusetts. Methods We used birth certificate data among term, singleton, vertex presentation births by repeat cesarean or VBAC to conduct logistic regression models to examine the likelihood of VBAC for women categorized into standard classifications of race and ethnicity and into 31 detailed ethnicities. Data were analyzed for the entire study period (1996-2010, N = 119,752) and for the last 5 years (2006-2010, N = 46,081). Results The adjusted odds of VBAC were lowest for non-Hispanic Black mothers (0.91, CI [0.85, 0.98]) and highest for Asian/Pacific Islander mothers (1.41, CI [1.31, 1.53]) relative to non-Hispanic White women. VBAC rates ranged from 5.8 % among Brazilians to 29.3 % among Cambodians. The adjusted odds of VBAC were lower for 7 of the 30 ethnic groups (range of AORs 0.40-0.89) and higher for 8 of the 30 ethnic groups (range of AORs 1.18-2.11) relative to self-identified American mothers. For the last 5 years, Asian/Pacific Islander mothers had a higher adjusted VBAC rate (1.39, CI [1.21, 1.60]), as did 9 of the 30 ethnic groups (range of 1.25-1.84). Only Brazilian mothers had lower rates (0.37, CI [0.27, 0.50]), relative to self-identified American mothers. Conclusions Detailed maternal ethnicity explains the variation in VBAC rates more precisely than broad race/ethnicity categories. Improvements in our public health data infrastructure to capture detailed ethnicity are recommended to identify and address disparities and improve the quality of maternity care.

Acculturation and maternal health behaviors: findings from the Massachusetts birth certificate.

BACKGROUND: Although prior studies have shown disparities in maternal health behaviors according to race/ethnicity and acculturation, whether these patterns are evident among new immigrant populations remains unclear. PURPOSE: To examine the associations among proxies of acculturation and maternal smoking during pregnancy and breastfeeding initiation within each major ethnic group in Massachusetts. METHODS: Data were from the Standard Certificate of Live Births on 1,067,375 babies by mothers from 31 ethnic groups for 1996-2009. Mothers reported whether they smoked during pregnancy and the birth facility recorded whether mothers started breastfeeding. The acculturation proxy combined mothers' country of birth and language preference: U.S.-born, foreign-born English-speaking, and foreign-born non-English speaking. For each ethnic group, adjusted logistic regression models were used to examine associations between the acculturation proxy and whether mothers smoked or initiated breastfeeding. Data were analyzed from 2012 to 2013. RESULTS: A lower proportion of foreign-born mothers had a high school degree or private insurance than U.S.-born mothers. However, foreign-born mothers who were English (range of AORs=0.07-0.93) or non-English speakers (AORs=0.01-0.36) were less likely to smoke during pregnancy than their U.S.-born counterparts. Foreign-born mothers who were English (AORs=1.22-6.52) or non-English speakers (AORs=1.35-10.12) were also more likely to initiate breastfeeding compared to U.S.-born mothers, except for some mothers with Asian ethnicities. CONCLUSIONS: The consistency of the associations of being foreign-born with less smoking and more breastfeeding suggests that for the majority of ethnic groups studied, acculturation in the U.S. results in poorer maternal health behaviors.

Affordable Care Act standards for race and ethnicity mask disparities in maternal smoking during pregnancy.

OBJECTIVE: This study compared maternal smoking during pregnancy between the new Patient Protection and Affordable Care Act (ACA) data collection standards and Federal Office of Management and Budget (OMB) standards. METHOD: Data were from the Massachusetts Standard Certificate of Live Births on 1,156,472 babies from 1996 to 2010. A parent reported whether the mother smoked during pregnancy (yes/no), her race (5 options) and, separately, her ethnicity (39 categories). Prenatal smoking rates were compared between the ACA and OMB standards. Detailed ethnicity from the birth certificate was then examined within all broad categories of the ACA standards: White, Black/African American, Other Hispanic, Other Asian/Pacific Islander, and Other categories. RESULTS: For Hispanic/Latina and Asian mothers, the ACA standards captured the variability in smoking across and within racial/ethnic groups more than the OMB standards. However, for White and Black/African American mothers, the broad ACA categories masked striking differences in prenatal smoking. While the overall prevalence among Whites was 10.2%, this ranged from 0.8% for Iranians to 21.0% for Cape Verdeans. Among Black/African Americans (7.6%), this ranged from 0.5% for Nigerians to 12.9% for African Americans. The ACA standards also combined ethnic groups with sizeable populations into Other Hispanics and Other Asian/Pacific Islanders. CONCLUSION: When population health surveys and other reporting tools are being revised, state and federal agencies should consider expanding all race/ethnicity categories to capture detailed ethnicity on everyone.

The influence of detailed maternal ethnicity on cesarean delivery: findings from the U.S. birth certificate in the State of Massachusetts.

BACKGROUND: Our objective was to examine the likelihood of primary cesarean delivery for women at low risk for the procedure in Massachusetts. METHODS: Birth certificate data for all births from 1996 to 2010 that were nulliparous, term, singleton, and vertex (NTSV; N = 427,393) were used to conduct logistic regression models to assess the likelihood of a cesarean delivery for each of the 31 ethnic groups relative to self-identified "American" mothers. The results were compared with broad classifications of race/ethnicity more commonly employed in research. RESULTS: While 23.3 percent of American women had primary cesarean deliveries, cesarean delivery rates varied from 12.9 percent for Cambodian to 32.4 percent for Nigerian women. Women from 21 of 30 ethnic groups had higher odds of a primary cesarean (range of adjusted odds ratios [AORs] 1.09-1.77), while only Chinese, Cambodian, and Japanese women had lower odds (range of AORs 0.66-0.92), compared with self-identified "Americans." Using broad race/ethnicity categories, Non-Hispanic black, Hispanic, and "Other" women had higher odds of cesarean delivery relative to Non-Hispanic white women (range of AORs 1.12-1.47), while there were no differences for Asian or Pacific Islander women. CONCLUSIONS: Detailed maternal ethnicity explains the variation in NTSV cesarean delivery rates better than broad race/ethnicity categories. Different patterns of cesarean delivery between ethnic groups suggest cultural specificity related to birth culture.

Singleton preterm birth: risk factors and association with assisted reproductive technology.

The objectives of this study were to determine risk factors for early (less than 34 weeks gestation) and late (34-36 weeks gestation) preterm singleton birth, by assisted reproductive technology (ART) status. We linked data from Massachusetts birth records and ART records representing singleton live births from 1997 through 2004. Using multinomial regression models, we assessed risk factors for early and late preterm birth by ART status. From 1997 to 2004 in Massachusetts, among non-ART births, risk factors for early and late preterm birth were similar and included women <15 and ≥ 35 years of age, those of non-white race or Hispanic ethnicity, those with ≤ 12 years of education, those with chronic diabetes, those with gestational diabetes, those with gestational hypertension, those who smoked during pregnancy, those who used fertility medications, and those who had not had a previous live birth. Among ART births, risk factors for early and late preterm birth differed and odds of early preterm birth were increased among women with ≤ 12 years of education while odds of late preterm birth were increased among women with gestational diabetes. Odds of both early and late preterm birth were increased among women of non-white race or Hispanic ethnicity and among women with gestational hypertension. Among non-ART births, increased risk for preterm birth was more strongly related to socioeconomic factors than among ART births. Medical conditions were associated with an increased risk for preterm birth regardless of women's ART status. Efforts to prevent preterm births should focus on reducing modifiable risk factors.

Setting the standards for collecting ethnicity data in the Commonwealth of Massachusetts.

The 1997 revision to Federal Office of Management and Budget (OMB) Directive No. 15 Race and Ethnic Standards for Federal Statistics and Administrative Reporting provides standard classifications for reporting broad race categories and Hispanic/non-Hispanic ethnicity. However, the current system may be masking disparities in health behaviors and outcomes across ethnic groups. Since 2000, the Massachusetts Department of Public Health has been developing an alternative approach to collecting race, ethnicity, and language preference data to better serve the local population. Our data collection tool adheres to OMB standards but captures detailed ethnicity data independent of broad race categories. We believe that training personnel is an essential component of data collection, and we are planning to develop online training materials. Although we encourage states to learn from our experience, data need to be comparable within and across states as well as over time to monitor health disparities.

Declining maternal smoking prevalence did not change low birthweight prevalence in Massachusetts from 1989 to 2004.

BACKGROUND: Maternal smoking is associated with low birthweight (LBW). LBW prevalence is increasing in the US. However, it is unclear whether a fall in maternal smoking has any impact on the LBW prevalence in Massachusetts, a state with a comprehensive tobacco control program since 1993. METHODS: Temporal patterns in prenatal maternal smoking and in LBW prevalence were quantified between 1989 and 2004, using Massachusetts Community Health Information Profile database. Yearly population-attributable-risk (PAR %) of singleton LBW live-births among pregnant smoking mothers were estimated based on a summary relative risk. The expected number of LBW babies attributable to reductions in maternal smoking in 2004 relative to 1989 was compared to the actual number of LBW babies in 2004. RESULTS: Of 88 929 and 74 554 singleton live-births, 4297 and 4004 LBW births occurred in 1989 and 2004, respectively. Between 1989 and 2004, maternal smoking prevalence significantly declined yearly by >or=6% (from 19.9% to 6.8%) but overall LBW prevalence increased yearly by <1% (from 4.8% to 5.4%), with a significant yearly increase (<1%) in moderately LBW (1500-2499 g) prevalence. Yearly PAR % declined from 20.3% (n = 872) to 8.0% (n = 320), with an expected total of 3745 [4297 - (872 - 320)] LBW babies in 2004 relative to 1989. However, actual LBW babies numbered 4004 in 2004. The 259 above predicted (4004 - 3745) LBW babies born in 2004 being attributed to factors other than prenatal maternal smoking. CONCLUSIONS: Massachusetts experienced a decline in prenatal maternal smoking prevalence, but an increase in moderately LBW prevalence has offset the potential gains apparently achieved due to reductions in maternal smoking prevalence.

Identifying Health Maintenance Organization membership through self-report of health plan name: ascertainment and reliability.

OBJECTIVE: To evaluate the feasibility and reliability of (1) identifying Health Maintenance Organization (HMO) membership by ascertaining self-reported health plan name in a telephone survey and (2) using external information to determine whether the plan was an HMO. METHODS: Respondents to the 1999-2001 Massachusetts Behavioral Risk Factor Surveillance System (BRFSS) and the 1999 Massachusetts Colorectal Cancer (CRC) survey were asked to name their health plan. The authors used information from external sources to classify the plan as an HMO or a non-HMO. Test-retest reliability of reported plan name was examined overall, by demographic characteristics, and by health plan name. Reliability of HMO classification was tested with the kappa statistic. RESULTS: More than 88 percent of respondents with commercial health insurance provided their health plan name; 84 percent reported a plan that could be assigned as either an HMO or a non-HMO. The percentage whose HMO status could be assigned differed by demographic characteristics. Among those assigned, the distribution of specific HMOs among survey respondents was similar to the distribution reported by the Massachusetts Division of Insurance. In a subsample, 78 percent reported the same health plan during a follow-up interview. Agreement was higher for men, and differed according to the plan reported at the first time point. Kappa for HMO classification from health plan name was 0.87. CONCLUSIONS: Self-report of health plan name is a feasible and reliable method to ascertain health insurance information in a telephone interview.

Perspectives on the Massachusetts Community Health Information Profile (MassCHIP): developing an online data query system to target a variety of user needs and capabilities.

The Massachusetts Community Health Information Profile (MassCHIP) has many distinctive features. These features evolved to maximize the usefulness of this query system for a broad group of users with varied needs, differing levels of knowledge about public health, and diverse experience using public health data. Three major features of MassCHIP help target our large user population. These features are as follows: (1) multiple avenues of entry to initiate queries ranging from an alphabetical list of simple topics to detailed International Classification of Disease codes; (2) the inclusion of data sets from other state agencies in addition to those of the Massachusetts Department of Public Health to reflect a broad view of public health; and (3) the capacity to retrieve data for multiple levels of geography, from the neighborhood through the state, including planning districts and hospitals. In this article, we discuss the history and design of MassCHIP, and focus on the features of MassCHIP that target a great variety of user needs and capabilities, and which are distinctive among Web-based data query systems.