PRAMS: A Tool to Understanding and Addressing Prematurity

1. PRAMS: A Tool to Understanding and Addressing Prematurity Jo Ann Walsh Dotson RN MSN Montana DPHHS – Helena, MT And Nan Streeter RN MS Utah DOH – Salt Lake City, UT

2. What is PRAMS? • PRAMS stands for Pregnancy Risk Assessment Monitoring System. • PRAMS is a surveillance project of the Centers for Disease Control and Prevention (CDC) and state health departments. • PRAMS collects state-specific, population-based data on maternal attitudes and experiences prior to, during, and immediately following pregnancy.

3. Background of PRAMS • Initiated in 1987 • Infant mortality rates were no longer declining as rapidly as they had in prior years. • incidence of low-birth-weight infants had changed little in the previous 20  years. • Goal of PRAMS project is to improve the health of mothers and infants by reducing adverse outcomes such as low birth weight, infant mortality and morbidity, and maternal morbidity. • PRAMS provides state-specific data for planning and assessing health programs.

4. Importance of PRAMS • The PRAMS sample is chosen from all women who had a live birth recently, so findings can be applied to the state's entire population of women who have recently delivered a live born infant. • PRAMS allows CDC and the states to monitor changes in maternal and child health indicators (e.g., unintended pregnancy, prenatal care, breast-feeding, smoking, drinking, infant health).

5. State Participation in PRAMS 2004 VT RI NYC NJ DE MD HI http://www.cdc.gov/reproductivehealth/pramstates.htm

6. Type of PRAMS publication, CDC PRAMS publication database, 1988-Oct 2004 Rochat, Roger “Scientific Writing with PRAMS” Presented at the Annual PRAMS conference December 7, 2004/Atlanta, GA

7. Frequency of reporting on 18 topics based on PRAMS data, 1988-Oct 2004 Rochat, Roger “Scientific Writing with PRAMS” Presented at the Annual PRAMS conference December 7, 2004/Atlanta, GA

8. PRAMS Process • Survey of women with live born infants in previous 12 months • Standardized “core questions” with state option of additional questions. • Sample is drawn from birth certificates using a stratified random sampling technique • Stratification most frequently includes birthweight, maternal race/ethnicity, maternal education, maternal age, geographic area or Medicaid status

9. Data Collection • Mixed mode • Mailed self administered • Follow up with telephone survey if unsuccessful mail response • Self reported survey data linked to selected birth certificate data

10. Attitudes and feelings about most recent pregnancy Content and source of prenatal care Substance use – tobacco and alcohol Pregnancy-related morbidity Infant health care Maternal living conditions Mother’s knowledge of pregnancy related health issues PRAMS Core Question Topic Areas

11. Prematurity in the U.S. • Prematurity defined as birth prior to 37th completed week of gestation • Increased by 20% in the last decade • Accounts for 11% of all births in U.S. • 2/3 of infant deaths in U.S. occurred in infants who were LBW or preterm • A preterm infant costs 13 times the cost of a full term newborn

12. Factors Associated with Prematurity • Physiologic • Placental insufficiency • Genital tract infections • Hemorrhage or abruptio placenta • Incompetent cervix • Diabetes • Hypertension

13. Factors Associated with Prematurity (cont.) • Social stressors • Depression • Domestic violence • Psychiatric disorder • Homelessness (and “multiple residences) • Substance use • Tobacco • Alcohol • other drugs • Multiple births

14. Purpose/Uses of PRAMS r/t Prematurity • PRAMS may be used to inform policy makers about • The incidence of risk factors in their states • Characteristics of women with specific risk factors • Geographic/demographic clues to risk factors • Knowledge deficits existing in pregnant woman which may be addressed, potentially impacting prematurity • Successes (or failures) of efforts in the state to address risk factors

15. Basic Valuable information regarding comparative incidence Direct more in depth analysis Useful in legislative analysis Complex (Logistic Regression) Informs association and related instances Maternal Age Cigarette use Related to Prematurity incidence Analysis

16. Cigarette Smoking During PregnancyMMWR, 1999 • Purpose: Determine the incidence and impact of smoking during pregnancy • Sample: Maine (10,770 women) • Findings: • Smoking during last months of pregnancy decrease in women 20 and over • Women less than 20 did not have a significant decrease in incidence of smoking

17. Relationship Between Maternal Behaviors and Birth OutcomesBeck et al., 2002 • Purpose: Examine impact of behaviors and socioeconomic indicators on outcomes • Sample: 17 states • Findings: • Intendeness ranged from 33.7 – 52% • Late or no PNC 16.1 – 29.9% • Smoking from 6.2 – 27.2% • Physical abuse from 2.1 – 6.3% • Breast feeding initiation 48 – 89% • Breastfeeding duration from 34.9 – 78.1%

18. Prevalence and Patterns of Physical Abuse Before, During and After PregnancyMartin, Mackie, Kupper, Buescher & Moracco, 2001 • Purpose: Incidence of physical abuse around pregnancy • Sample: North Carolina (2,648 women) • Findings:

19. Montana PRAMS • Mothers who had a Live Birth in Montana within the Last Year • No spontaneous / intended abortions • No stillbirths • No Montana mothers who had their babies outside of Montana • Point in Time Survey

20. Point in Time Projects • Created by CDC to support rural/frontier efforts to initiate new mother surveys • Year One – Planning • Year Two – Data Collection • Year Three – Analysis and Report Development • Evaluate process and potential Jo Ann Dotson, “Montana PRAMS Project, A Point in Time” December 2002.

21. Pregnancy Intention: National PRAMS 1999 Surveillance Report, CDC Montana 2002 PRAMS Data

22. Late or No Entry to PNC PRAMS 1999 Surveillance Report, CDC Montana 2002 PRAMS Data

23. Domestic Violence by Partner During Pregnancy PRAMS 1999 Surveillance Report, CDC Montana 2002 PRAMS Data

24. Change in Alcohol Use Montana: 62.8 % Before 6.7 % During PRAMS 1999 Surveillance Report, CDC Montana 2002 PRAMS Data

25. Alcohol Use in 3 Months Before Pregnancy None 18% Any 82% All MT Mothers

26. Alcohol Use 3 Months Before Pregnancy by Mother’s Education Level 84 % 83 % 76 %

27. Change in Smoking from “Before” Pregnancy to “During” Pregnancy Montana: 28.5 % Before 15.6 % During PRAMS 1999 Surveillance Report, CDC Montana 2002 PRAMS Data

28. Smoking: Do You Smoke Now? Yes 21% Yes 43% No 23% No 57% No 79% Yes 76% All MT Mothers MT Mothers <20

29. Speaker Contact Info • Jo Ann Walsh Dotson, R.N., M.S.N. • Chief, Family and Community Health Bureau • Montana Department of Public Health and Human Services • 1400 Broadway PO Box 202951 • Helena MT 59620 • Phone: 406-444-4743 • FAX: 406-444-2606 • E-mail: jdotson@mt.gov