Breastfeeding by Disability Status in the United States: Pregnancy Risk Assessment Monitoring System, 2018-2020.

Objectives. To describe breastfeeding initiation and breastfeeding at 1, 2, and 3 months, and information sources on breastfeeding among women with a recent live birth by disability status. Methods. We analyzed October 2018 to December 2020 data from the Pregnancy Risk Assessment Monitoring System for 24 sites in the United States that included the Washington Group Short Set of Questions on Disability (seeing, hearing, walking or climbing stairs, remembering or concentrating, self-care, communicating). We defined disability as reporting "a lot of difficulty" or "cannot do this at all" on any of these questions. Results. Among 39 673 respondents, 6.0% reported disability. In adjusted analyses, breastfeeding was lower among respondents with disability at 2 (62.6% vs 66.6%; adjusted prevalence ratio [APR] = 0.94; 95% confidence interval [CI] = 0.89, 0.99) and 3 months (54.7% vs 59.6%; APR = 0.92; 95% CI = 0.86, 0.98) than those without disability. Respondents with disability were less likely to receive information from health care providers or support professionals (89.3% vs 92.3%), but as likely from breastfeeding or lactation specialists (78.1% vs 75.3%). Conclusions. Strategies to ensure women with disability, receive breastfeeding support, including breastfeeding information, could improve breastfeeding outcomes. (Am J Public Health. 2024;114(1):108-117. https://doi.org/10.2105/AJPH.2023.307438).

Effects of Community-Wide Teen Pregnancy Prevention Initiatives on Local Teen Birth Rates in the United States: A Synthetic Control Approach.

The impact of community-wide teen pregnancy prevention initiatives (CWIs) on local U.S. birth rates among adolescents aged 15 to 19 years was examined using synthetic control methodology within a quasi-experimental design. CWIs were implemented in 10 U.S. communities from 2010 to 2015. Each initiative implemented evidence-based teen pregnancy prevention interventions at local organizations and enhanced best practices in adolescent reproductive health care at local health centers, while engaging diverse community sectors. The synthetic control method was used to estimate the impact of each CWI on overall and race- and ethnicity-specific teen births relative to rates in synthetic control communities. Additionally, we estimated the overall effect of CWIs across communities by pooling results from the 10 synthetic control case studies using the mean percentile rank. Pooled data across all 10 communities indicated an estimated average of 6.6 fewer births per 1000 teens per year overall during the initiative relative to each community's synthetic control (p = .001). By race and ethnicity, there were an estimated average of 6.4 fewer births per 1000 teens per year among Black teens (p = .03), 10.7 fewer births among Hispanic teens (p = .03), and 4.2 fewer births (p = .10) among White teens. Results from individual communities indicated an intervention effect on overall and/or race/ethnicity-specific teen birth rates in five communities. This study demonstrates the value of synthetic control methods in evaluating community-level outcomes of programmatic efforts. Findings indicate the CWIs had a positive impact on teen birth rates and have the potential to address racial and ethnic disparities in those rates.

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.¶.

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).

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.

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.

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.

Assessment of the Cost-Effectiveness of a Brief Video Intervention for Sexually Transmitted Disease Prevention.

BACKGROUND: Cost-effective, scalable interventions are needed to address high rates of sexually transmitted diseases (STDs) in the United States. Safe in the City, a 23-minute video intervention designed for STD clinic waiting rooms, effectively reduced new infections among STD clinic clients. A cost-effectiveness analysis of this type of intervention could inform whether it should be replicated. METHODS: The cost-effectiveness of a brief video intervention was calculated under a baseline scenario in which this type of intervention was expanded to a larger patient population. Alternative scenarios included expanding the intervention over a longer period or to more clinics, including HIV prevention benefits, and operating the intervention part time. Program costs, net costs per STD case averted, and the discounted net cost of the intervention were calculated from a health sector perspective across the scenarios. Monte Carlo simulations were used to calculate 95% confidence intervals surrounding the cost-effectiveness measures. RESULTS: The net cost per case averted was $75 in the baseline scenario. The net cost of the intervention was $108,015, and most of the alternative scenarios found that the intervention was cost saving compared with usual care. CONCLUSIONS: Single session, video-based interventions can be highly cost effective when implemented at scale. Updated video-based interventions that account for the changing STD landscape in the United States could play an important role in addressing the recent increases in infections.

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

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

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.

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.

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.

Contraceptive Use Among Women at Risk for Unintended Pregnancy in the Context of Public Health Emergencies - United States, 2016.

Ensuring access to and promoting use of effective contraception have been identified as important strategies for preventing unintended pregnancy (1). The importance of ensuring resources to prevent unintended pregnancy in the context of public health emergencies was highlighted during the 2016 Zika virus outbreak when Zika virus infection during pregnancy was identified as a cause of serious birth defects (2). Accordingly, CDC outlined strategies for state, local, and territorial jurisdictions to consider implementing to ensure access to contraception (3). To update previously published contraceptive use estimates* among women at risk for unintended pregnancy† and to estimate the number of women with ongoing or potential need for contraceptive services,§,¶ data on contraceptive use were collected during September-December 2016 through the Behavioral Risk Factor Surveillance System (BRFSS). Results from 21 jurisdictions indicated that most women aged 18-49 years were at risk for unintended pregnancy (range across jurisdictions = 57.4%-76.8%). Estimates of the number of women with ongoing or potential need for contraceptive services ranged from 368 to 617 per 1,000 women aged 18-49 years. The percentage of women at risk for unintended pregnancy using a most or moderately effective contraceptive method** ranged from 26.1% to 65.7%. Jurisdictions can use this information to estimate the number of women who might seek contraceptive services and to plan and evaluate efforts to increase contraceptive use. This information is particularly important in the context of public health emergencies, such as the recent Zika virus outbreak, which have been associated with increased risk for adverse maternal-infant outcomes (2,4-6) and have highlighted the importance of providing women and their partners with resources to prevent unintended pregnancy.