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Disparities in Universal Prenatal Screening for Group B Streptococcus North Carolina, 2002-2003

Disparities in Universal Prenatal Screening for Group B Streptococcus North Carolina, 2002-2003. Heidi Brown 1 , Stephanie Schrag 2 , Matt Avery 3 1 – Brown Medical School, CDC Experience Fellow

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Disparities in Universal Prenatal Screening for Group B Streptococcus North Carolina, 2002-2003

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  1. Disparities in Universal Prenatal Screening for Group B Streptococcus North Carolina, 2002-2003 Heidi Brown1, Stephanie Schrag2, Matt Avery3 1 – Brown Medical School, CDC Experience Fellow 2 – National Center for Infectious Diseases, Division of Bacterial & Mycotic Diseases, Respiratory Diseases Branch 3 – North Carolina State Center for Health Statistics

  2. Overview • What is group B strep? • How are we doing with universal screening? • How many? • Who? • How can we do better?

  3. Streptococcus agalactiaeGroup B streptococcus (GBS) Leading infectious cause of neonatal morbidity & mortality NEONATAL GBS: • Timing & Transmission: • Early-onset (<7 days old) - intrapartum • Late-onset (7 – 90 days old) - neonatal • Manifestations: • sepsis • pneumonia • meningitis

  4. Mother to Infant GBS Transmission 10 – 35% GBS colonized mother 50% 50% Non-colonized newborn Colonized newborn 98% 2% Early-onset sepsis, pneumonia, meningitis Asymptomatic 5% Neurologic sequelae Death

  5. Prevention of Perinatal Transmission Intrapartum Antibiotics GBS colonized mother 50% 50% Non-colonized newborn Colonized newborn 98% 2% Early-onset sepsis, pneumonia, meningitis Asymptomatic 5% Neurologic sequelae Death

  6. Who should get antibiotics? 1996: 2 equally acceptable strategies 1) late prenatal culture-based GBS screening - if GBS+, then antibiotics administered 2) prophylactic antibiotics to any woman with defined risk factors for GBS colonization or transmission

  7. Policy Change! 2002: NEJM retrospective cohort study Screening >50% more effective than risk-based 2002: CDC, AAP, ACOG - updated guidelines: UNIVERSAL culture-based screening for vaginal and rectal GBS colonization at 35-37 weeks’ gestation

  8. Objectives • Among pregnant women in North Carolina during 2002-2003, to: 1) examine rates of reported GBS screening and knowledge of GBS screening status 2) identify risk factors for: a) not being screened for GBS b) lack of knowledge of GBS screening status

  9. Pregnancy Risk AssessmentMonitoring System (PRAMS) • Monthly mail / telephone survey • Population-based, random, stratified sample • Women who have recently delivered a liveborn infant • Core & standard questions • 3 GBS questions in standard / optional component

  10. Pregnancy Risk AssessmentMonitoring System (PRAMS) • Survey data linked to birth certificate data • Weighted for sample design, nonresponse, and noncoverage • > 70% response rate  usable data • 2 year lag between data collection and availability

  11. Participating PRAMS States

  12. Data Analysis • North Carolina PRAMS 2002 & 2003 • 2002 & 2003 similar  combined data • “At any time during your most recent pregnancy, did you get tested for the bacteria Group B Strep (or Beta Strep)?” • Yes • No • I don’t know

  13. Data Analysis • Point estimates & 95% confidence intervals (CIs) calculated for: • “No” vs. “Yes” – excluding “I don’t know” • “I don’t know” vs. “Yes” – excluding “No” • Univariate analysis p<0.2  initial multivariable models • Logistic regression • Main effects p<0.05  final multivariable models

  14. Results - Demographics • 235,599 live births in North Carolina • 4,128 women included in PRAMS sample • 3,027 responded (73%) • 73% White, 22% Black, 5% Other • 12% Hispanic ethnicity • 49% Delivery paid by Medicaid • Primary Source of Prenatal Care: • 68% Private doctor / HMO • 28% Hospital or health department clinic • <1% no prenatal care

  15. Results – Prenatal Screening • 82% received HIV testing during pregnancy • 82% healthcare worker discussed GBS

  16. Lack of GBS Screening among Women with Known Screening Status • Age <24 years • < High school education • Hispanic ethnicity • Unmarried • Delivery paid by Medicaid • Prenatal care at clinic or elsewhere • No insurance before pregnancy • Lack of prenatal HIV testing

  17. Lack of GBS Screening among Women with Known Screening Status AOR (95% CI) • Age <24 years • < High school education • Hispanic ethnicity 0.3 (0.2 – 0.5) • Unmarried • Delivery paid by Medicaid • Prenatal care at clinic or elsewhere 0.6 (0.4 – 0.9) • No insurance before pregnancy • Lack of prenatal HIV testing 0.4 (0.3 – 0.6) controlled for gestational age

  18. Lack of Knowledge of GBS screening status, compared with screened women • Age <24 years • < High school education • Hispanic ethnicity • Unmarried • Delivery paid by Medicaid • Prenatal care at clinic or elsewhere • No insurance before pregnancy • Lack of prenatal HIV testing • Black race (versus White) • Other race (versus White) • Unintended pregnancy • Receipt of WIC benefits during pregnancy

  19. Lack of Knowledge of GBS screening status, compared with screened women AOR (95% CI) • Age <24 years • < High school education • Hispanic ethnicity 0.1 (0.1 – 0.2) • Unmarried • Delivery paid by Medicaid 0.4 (0.3 – 0.5) • Prenatal care at clinic or elsewhere 0.5 (0.4 – 0.7) • No insurance before pregnancy • Lack of prenatal HIV testing 0.6 (0.4 – 1.0) • Black race (versus White) 0.6 (0.4 – 0.8) • Other race (versus White) 0.3 (0.2 – 0.5) • Unintended pregnancy • Receipt of WIC benefits during pregnancy

  20. Summary – No GBS Screening • Among women participating in North Carolina PRAMS during 2002-2003: • 72% were screened for GBS during pregnancy • Risk factors for lack of screening: • Hispanic ethnicity • Prenatal care from hospital / health department clinic • Lack of prenatal HIV test

  21. Summary – Unknown GBS Screening • 19% did not know GBS screening status • Risk factors for lack of knowledge: • Hispanic ethnicity • Prenatal care from hospital / health department clinic • Lack of prenatal HIV test • Black race or other race • Delivery paid for by Medicaid

  22. Limitations • Self-reported survey so GBS screening status cannot be confirmed • Healthcare providers might not use same wording as PRAMS question • Cannot generalize findings to entire country • No baseline data with which to compare screening rates

  23. What does it all mean? 1996 2002 Healthy People 2010 early - onset late - onset Data from ABCs (national projections of invasive disease)

  24. Discussion: Linking Data and Policy to Programs • How can we prevent missed opportunities for prevention? • Two-pronged approach: • encourage prenatal care providers to screen women for and educate women about GBS • educate pregnant women so that they may ask for prenatal screening and discuss their GBS status with labor & delivery staff • How can we improve perinatal GBS prevention in NC? • Target efforts to minimize disparities • Hispanic women • Women who miss other recommended prenatal interventions • Hospital / health department clinics

  25. Targeting Messages

  26. Program Materials Available from CDC • Brochures available in English and Spanish • http://www.cdc.gov/groupbstrep/ • For limited copies, call 404-639-2215 (CDC) • For bulk orders, call 1-877-252-1200

  27. Acknowledgments North Carolina State Center for Health Statistics • M. Avery • P. Buescher • Z. Gizlice CDC/NCID/DBMD/RDB • S. Schrag • J. Cory • C. Greene

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