Changes in Commercial Insurance Claims for Contraceptive Services During the Beginning of the COVID-19 Pandemic-United States, January 2019-September 2020.

OBJECTIVE: We describe changes in commercial insurance claims for contraceptive services during the beginning of the COVID-19 pandemic. METHODS: We analyzed commercial insurance claims using IQVIA PharMetrics Plus data from more than 9 million U.S. females aged 15-49 years, enrolled during any month, January 2019 through September 2020. We calculated monthly rates of outpatient claims for intrauterine devices (IUDs), implants, and injectable contraception and monthly rates of pharmacy claims for contraceptive pills, patches, and rings. We used Joinpoint regression analysis to identify when statistically significant changes occurred in trends of monthly claims rates for each contraceptive method. We calculated monthly percentages of claims for contraceptive counseling via telehealth. RESULTS: Monthly claims rates decreased for IUDs (-50%) and implants (-43%) comparing February 2020 with April 2020 but rebounded by June 2020. Monthly claims rates for injectables decreased (-19%) comparing January 2019 with September 2020, and monthly claims rates for pills, patches, and rings decreased (-22%) comparing July 2019 with September 2020. The percentage of claims for contraceptive counseling occurring via telehealth was low (<1%) in 2019, increased to 34% in April 2020, and decreased to 9-12% in June-September 2020. CONCLUSIONS: Substantial changes in commercial insurance claims for contraceptive services occurred during the beginning of the COVID-19 pandemic, including transient decreases in IUD and implant claims and increases in telehealth contraceptive counseling claims. Contraceptive claims data can be used by decision makers to identify service gaps and evaluate use of interventions like telehealth to improve contraceptive access, including during public health emergencies.

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.

Pregnancy Risk Assessment Monitoring System for Dads: A piloted randomized trial of public health surveillance of recent fathers' behaviors before and after infant birth.

BACKGROUND: Becoming a father impacts men's health and wellbeing, while also contributing to the health and wellbeing of mothers and children. There is no large-scale, public health surveillance system aimed at understanding the health and behaviors of men transitioning into fatherhood. The purpose of this study was to describe piloted randomized approaches of a state-based surveillance system examining paternal behaviors before and after their infant's birth to better understand the health needs of men and their families during the transition to parenthood. METHODS: During October 2018-July 2019, 857 fathers in Georgia were sampled 2-6 months after their infant's birth from birth certificates files and surveyed via mail, online or telephone, in English or Spanish, using two randomized approaches: Indirect-to-Dads and Direct-to-Dads. Survey topics included mental and physical health, healthcare, substance use, and contraceptive use. FINDINGS: Weighted response rates (Indirect-to-Dads, 33%; Direct-to-Dads, 31%) and population demographics did not differ by approach. Respondents completed the survey by mail (58%), online (28%) or telephone (14%). Among 266 fathers completing the survey, 55% had a primary care physician, and 49% attended a healthcare visit for themselves during their infant's mother's pregnancy or since their infant's birth. Most fathers were overweight or had obesity (70%) while fewer reported smoking cigarettes (19%), binge drinking (13%) or depressive symptoms (10%) since their infant's birth. CONCLUSIONS: This study tests a novel approach for obtaining population-based estimates of fathers' perinatal health behaviors, with comparable response rates from two pragmatic approaches. The pilot study results quantify a number of public health needs related to fathers' health and healthcare access.

Persistent Racial/Ethnic Disparities in Supine Sleep Positioning among US Preterm Infants, 2000-2015.

OBJECTIVE: To assess trends in racial disparity in supine sleep positioning (SSP) across racial/ethnic groups of infants born early preterm (Early preterm; <34 weeks) and late preterm (Late preterm; 34-36 weeks) from 2000 to 2015. STUDY DESIGN: We analyzed Pregnancy Risk Assessment Monitoring System data (a population-based perinatal surveillance system) from 16 US states from 2000 to 2015 (Weighted N = 1 020 986). Marginal prevalence of SSP by year was estimated for infants who were early preterm and late preterm, adjusting for maternal and infant characteristics. After stratifying infants who were early preterm and late preterm, we compared the aOR of SSP trends across racial/ethnic groups by testing the time-race interaction. RESULTS: From 2000 to 2015, Non-Hispanic Black infants had lower odds of SSP compared with Non-Hispanic White infants for early preterm (aOR 0.61; 95% CI 0.47-0.78) and late preterm (aOR 0.44; 95% CI 0.34-0.56) groups. For Hispanic infants, there was no statistically significant difference for either preterm group when compared with Non-Hispanic White infants. aOR of SSP increased (on average) annually by 10.0%, 7.3%, and 7.7%, respectively, in Non-Hispanic White, Non-Hispanic Black, and Hispanic early preterm infants and by 5.8%, 5.9%, and 4.8% among Non-Hispanic White, Non-Hispanic Black, and Hispanic late preterm infants. However, there were no significant between-group differences in annual changes (Early preterm: P = .11; Late preterm: P = .25). CONCLUSIONS: SSP increased for all racial/ethnic preterm groups from 2000 to 2015. However, the racial/ethnic disparity in SSP among early preterm and late preterm groups persists.

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.

Paternal Involvement and Maternal Perinatal Behaviors: Pregnancy Risk Assessment Monitoring System, 2012-2015.

OBJECTIVES: Paternal involvement is associated with improved infant and maternal outcomes. We compared maternal behaviors associated with infant morbidity and mortality among married women, unmarried women with an acknowledgment of paternity (AOP; a proxy for paternal involvement) signed in the hospital, and unmarried women without an AOP in a representative sample of mothers in the United States from 32 sites. METHODS: We analyzed 2012-2015 data from the Pregnancy Risk Assessment Monitoring System, which collects site-specific, population-based data on preconception, prenatal and postpartum behaviors, and experiences from women with a recent live birth. We calculated adjusted prevalence ratios (aPRs) and 95% confidence intervals (CIs) to examine associations between level of paternal involvement and maternal perinatal behaviors. RESULTS: Of 113 020 respondents (weighted N = 6 159 027), 61.5% were married, 27.4% were unmarried with an AOP, and 11.1% were unmarried without an AOP. Compared with married women and unmarried women with an AOP, unmarried women without an AOP were less likely to initiate prenatal care during the first trimester (married, aPR [95% CI], 0.94 [0.92-0.95]; unmarried with AOP, 0.97 [0.95-0.98]), ever breastfeed (married, 0.89 [0.87-0.90]; unmarried with AOP, 0.95 [0.94-0.97]), and breastfeed at least 8 weeks (married, 0.76 [0.74-0.79]; unmarried with AOP, 0.93 [0.90-0.96]) and were more likely to use alcohol during pregnancy (married, 1.20 [1.05-1.37]; unmarried with AOP, 1.21 [1.06-1.39]) and smoke during pregnancy (married, 3.18 [2.90-3.49]; unmarried with AOP, 1.23 [1.15-1.32]) and after pregnancy (married, 2.93 [2.72-3.15]; unmarried with AOP, 1.17 [1.10-1.23]). CONCLUSIONS: Use of information on the AOP in addition to marital status provides a better understanding of factors that affect maternal behaviors.

Disparities in the Prevalence of Excess Heart Age Among Women with a Recent Live Birth.

Background: Understanding and addressing cardiovascular disease (CVD) risk has implications for maternal and child health outcomes. Heart age, the modeled age of an individual's cardiovascular system based on risk level, and excess heart age, the difference between a person's heart age and chronological age, are alternative simplified ways to communicate CVD risk. Among women with a recent live birth, we predicted heart age, calculated prevalence of excess heart age (≥5 years), and examined factors associated with excess heart age. Materials and Methods: Data were analyzed in 2017 from 2009 to 2014 Pregnancy Risk Assessment Monitoring System (PRAMS). To calculate heart age we used maternal age, prepregnancy body mass index, systolic blood pressure, smoking status, and diabetic status. Weighted prevalence and prevalence ratios compared the likelihood of excess heart age across racial/ethnic groups by selected factors. Results: Prevalence of excess heart age was higher in non-Hispanic black women (11.8%) than non-Hispanic white women (7.3%, prevalence ratio [PR], 95% confidence interval [CI]: 1.62, 1.49-1.76) and Hispanic women (4.9%, PR, 95% CI: 2.39, 2.10-2.72). Prevalence of excess heart age was highest among women who were without health insurance, obese or overweight, engaged in physical activity less than thrice per week, or were smokers in the prepregnancy period. Among women with less than high school education, non-Hispanic black women had a higher prevalence of excess heart age than Hispanic women (PR, 95% CI: 4.01, 3.15-5.10). Conclusions: Excess heart age may be an important tool for decreasing disparities and encouraging CVD risk reduction among certain groups of women.

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.

Sexually Transmitted Diseases Among Pregnant Women: 5 States, United States, 2009-2011.

Introduction Screening for specific sexually transmitted diseases (STDs) during pregnancy has been a longstanding public health recommendation. Prior studies have described associations between these infections and socioeconomic factors such as race/ethnicity and education. Objectives We evaluated the prevalence of STDs and the correlation socioeconomic factors have with the presence of these infections among pregnant women in the United States. Methods We conducted an analysis using self-reported data from 12,948 recently pregnant women from the Pregnancy Risk Assessment Monitoring System (PRAMS) in 5 states during 2009-2011. Responses to questions about curable STDs (chlamydia, gonorrhea, syphilis, trichomoniasis) diagnosed during pregnancy were utilized to calculate weighted STD prevalence estimates and 95% confidence intervals (CI). A logistic regression was also conducted to identify maternal socioeconomic characteristics significantly associated with STDs; results are displayed as adjusted prevalence ratios (aPR). The PRAMS protocol was approved at PRAMS participating sites and by CDC's Institutional Review Board. Results Overall, 3.3% (CI 2.9-3.7) reported ≥ 1 curable STD during her most recent pregnancy. The adjusted STD prevalence was higher among women with younger age (aPR, 2.4; CI 1.8-3.4), non-Hispanic black race/ethnicity (aPR, 3.3; CI 2.4-4.1), unmarried status (aPR, 2.1; CI 1.4-3.0), no college education (aPR, 1.4; CI 1.0-1.9), annual income < $25,000 (aPR, 2.0; CI 1.3-3.2), and no pre-pregnancy health insurance (aPR, 1.4; CI 1.1-1.8). Conclusions for Practice This is the largest study of prevalence of self-reported curable STDs among U.S. pregnant women. Differences in STD prevalence highlight the association between certain socioeconomic factors and the presence of STDs.

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.

Disparities in gestational age-specific fetal mortality rates in the United States, 2009-2013.

PURPOSE: Although studies have examined overall temporal changes in gestational age-specific fetal mortality rates, there is little information on the current status of racial/ethnic differences. We hypothesize that differences exist between racial/ethnic groups across gestational age and that these differences are not equally distributed. METHODS: Using the 2009-2013 data from US fetal death and live birth files for non-Hispanic white (NHW); non-Hispanic black (NHB); Hispanic; and American Indian/Alaska Native (AIAN) women, we conducted analyses to examine fetal mortality rates and estimate adjusted prevalence rate ratios and 95% confidence intervals (CIs). RESULTS: There were lower risks of fetal mortality among NHB women (aPRR = 0.76; 95% CI = 0.71-0.81) and Hispanic women (aPRR = 0.89; 95% CI = 0.83-0.96) compared with NHWs at 22-23 weeks' gestation. For NHB women, the risk was higher starting at 32-33 weeks (aPRR = 1.11; 95% CI = 1.04-1.18) and continued to increase as gestational age increased. Hispanic and AIAN women had lower risks of fetal mortality compared with NHW women until 38-39 weeks. CONCLUSIONS: Further examination is needed to identify causes of fetal death within the later pregnancy period and how those causes and their antecedents might differ by race and ethnicity.

Perinatal Disparities Between American Indians and Alaska Natives and Other US Populations: Comparative Changes in Fetal and First Day Mortality, 1995-2008.

To compare fetal and first day outcomes of American Indian and Alaskan Natives (AIAN) with non-AIAN populations. Singleton deliveries to AIAN and non-AIAN populations were selected from live birth-infant death cohort and fetal deaths files from 1995-1998 and 2005-2008. We examined changes over time in maternal characteristics of deliveries and disparities and changes in risks of fetal, first day (<24 h), and cause-specific deaths. We calculated descriptive statistics, odds ratios and confidence intervals, and ratio of odds ratios (RORs) to indicate changes in disparities. Along with black mothers, AIANs exhibited the highest proportion of risk factors including the highest proportion of diabetes in both time periods (4.6 and 6.5 %). Over time, late fetal death for AIANs decreased 17 % (aOR = 0.83, 95 % CI 0.72-0.97), but we noted a 47 % increased risk over time for Hispanics (aOR = 1.47, 95 % CI 1.40-1.55). Our data indicated no change over time among AIANs for first day death. For AIANs compared to whites, increased risks and disparities persisted for mortality due to congenital anomalies (ROR = 1.28, 95 % CI 1.03-1.60). For blacks compared to AIANs, the increased risks of fetal death (2005-2008: aOR = 0.60, 95 % CI 0.53-0.68) persisted. For Hispanics, lower risks compared to AIANs persisted, but protective effect declined over time. Disparities between AIAN and other groups persist, but there is variability by race/ethnicity in improvement of perinatal outcomes over time. Variability in access to care and pregnancy management should be considered in relation to health equity for fetal and early infant deaths.

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.

Maternal asthma, diabetes, and high blood pressure are associated with low birth weight and increased hospital birth and delivery charges; Hawai'i hospital discharge data 2003-2008.

Asthma, diabetes, and high blood pressure are common maternal conditions that can impact birth outcomes. Data from hospital discharges in Hawai'i were analyzed for 107,034 singleton births from 2003-2008. Categories were determined using the International Statistical Classification of Diseases, ninth revision (ICD-9) from linked delivery records of mother and infant. Prevalence estimates of asthma (ICD-9: 493), diabetes (ICD-9: 250,648.0, 648.8), high blood pressure (ICD-9: 401-405,642) as coded on the delivery record, low birth weight (<2500 grams), high birth weight (>4500 grams), Cesarean delivery, and median hospital charges were calculated. Median regression analysis assessed total hospital charges adjusting for maternal age, maternal race, insurance, and Cesarean delivery. Maternal asthma was present in 4.3% (95% confidence interval=4.1-4.4%), maternal diabetes was present in 7.7% (95% CI=7.6-7.9%), and maternal high blood pressure was present in 9.2% (95% CI=9.0-9.3%) of births. In the adjusted median regression analysis, mothers with asthma had $999 (95% CI: $886 to $1,112) higher hospital charges compared to those without; mothers with diabetes had $743 (95% CI: $636 to $850) higher charges compared to those without; and mothers with high blood pressure had $2,314 (95% CI: $2,194 to $2,434) higher charges compared to those without. Asthma, diabetes, and high blood pressure are associated with higher hospital delivery charges and low birth weight. Diabetes and high blood pressure were also associated with Cesarean delivery. An increased awareness of the impact of these conditions on both adverse birth outcomes and the development of chronic disease is needed.

Geographic variation in trends and characteristics of teen childbearing among American Indians and Alaska Natives, 1990-2007.

To study teen birth rates, trends, and socio-demographic and pregnancy characteristics of AI/AN across geographic regions in the US. The birth rate for US teenagers 15-19 years reached a historic low in 2009 (39.1 per 1,000) and yet remains one of the highest teen birth rates among industrialized nations. In the US, teen birth rates among Hispanic, non-Hispanic black, and American Indian/Alaska Native (AI/AN) youth are consistently two to three times the rate among non-Hispanic white teens. Birth certificate data for females younger than age 20 were used to calculate birth rates (live births per 1,000 women) and joinpoint regression to describe trends in teen birth rates by age (<15, 15-17, 18-19) and region (Aberdeen, Alaska, Bemidji, Billings, California, Nashville, Oklahoma, Portland, Southwest). Birth rates for AI/AN teens varied across geographic regions. Among 15-19-year-old AI/AN, rates ranged from 24.35 (California) to 123.24 (Aberdeen). AI/AN teen birth rates declined from the early 1990s into the 2000s for all three age groups. Among 15-17-year-olds, trends were approximately level during the early 2000s-2007 in six regions and declined in the others. Among 18-19-year-olds, trends were significantly increasing during the early 2000s-2007 in three regions, significantly decreasing in one, and were level in the remaining regions. Among AI/AN, cesarean section rates were lower in Alaska (4.1%) than in other regions (16.4-26.6%). This is the first national study to describe regional variation in AI/AN teen birth rates. These data may be used to target limited resources for teen pregnancy intervention programs and guide research.