By: Olivia Sappenfield, MPH Office of Data Translation Bureau of Family Health and Nutrition

1. Evaluation of the Pregnancy Risk Assessment Monitoring System (PRAMS) as a Surveillance System for Pregnancy Intention By: Olivia Sappenfield, MPH Office of Data Translation Bureau of Family Health and Nutrition Massachusetts Department of Public Health

2. Unintended Pregnancy • All pregnancies wanted later or not at all • Association with poor birth outcomes including preterm birth, low birth weight (LBW), and small for gestational age (SGA)1-4 • Association with delayed and inadequate prenatal care, continued drinking, continued smoking during pregnancy1-4 • Represent about ½ of all births nationally • Cost more than $9 billion annually5,6 • Risk Factors • Maternal race/ethnicity, maternal age, maternal education, household income, marital status • Partner’s intention, desirability of partner, number of partners, contraceptive use

3. Pregnancy Intention in Massachusetts • State and Title V priority: “Support reproductive and sexual health by improving access to education and services” • State priority measure: “The percentage of pregnancies among women age 18 and over that are intended” • Traditionally reported using Behavioral Risk Factor Surveillance System (BRFSS) • Pregnancy intention asked every other year • Queries about pregnancies up to 5 years ago • PRAMS offers a valuable alternative • Data used to inform the Title V Block Grant and reports • Queries about pre-pregnancy contraceptive use

4. PRAMS • Population-based data on maternal attitudes and behaviors before, during, and shortly after pregnancy • Sampled from birth certificate file • Data collection began in 2007 • 80 questions (54 core, 16 standard, and 10 MA-specific) • Includes a mail and phone phase • Administered 2-6 months postpartum • English and Spanish surveys only

5. Methods • Adapted CDC’s “Updated guidelines for evaluating public health surveillance systems” • Initially developed for infectious disease surveillance systems • PRAMS stakeholder surveys • Usefulness and acceptability of PRAMS to monitor pregnancy intention • PRAMS staff surveys • Analytical comparison of BRFSS and PRAMS • Dependent variable: pregnancy intention • Independent variables: maternal age, maternal race/ethnicity, maternal education, marital status, and household income

6. Methods Continued • Pregnancy intention definition: • Unintended: wanted later or not at all • Intended: wanted then or sooner • PRAMS question: Thinking back to just before you got pregnant with your new baby, how did you feel about becoming pregnant? • BRFSS questions: 1) Have you been pregnant in the last 5 years 2) Thinking back to your last pregnancy, just before you got pregnant, how did you feel about becoming pregnant? • Chi-square tests to determine similarity of population from year to year • Inability to link data to assess sensitivity and PPV • Confidence interval overlap, means no significant difference

7. Results

9. Table 1 Continued

11. Table 2 Continued

12. 1Weighted Percents 2non-Hispanic

13. Table 3 Continued

14. Other Attributes • Flexibility • PRAMS conducted annually • States able to include state-specific questions • CDC changes to core questions (Phases) • Can adapt to add questions on emerging issues (e.g. H1N1) • Timeliness • 2-6 months postpartum vs. up to 5 years postpartum • Women surveyed postpartum – recall bias • Data Quality • Response rate consistently above 65% • Question response rate between 97.5% and 95% • Representativeness • Population-based, oversamples by race/ethnicity • Deliveries ending in live birth • Other Attributes: Simplicity, Acceptability, and Stability

15. Conclusion: PRAMS is an Acceptable System for Monitoring Pregnancy Intention • Considered an acceptable data source by researchers and by its study population • Timely surveillance system for state-level data on postpartum women • Prevalence of unintended pregnancy overlapped for all indicators except <185%FPL and certain subgroups (married, some college education, and NHW) • Concern because poorer women are more at risk of unintended pregnancy • Similarly represented less educated women and minority women, who are also more at risk • Can provide estimates for the magnitude of morbidity associated with pregnancy intention • Inform reproductive health programs • Used in home-visiting programs to assist in developing reproductive life plans

16. Strengths and Limitations of PRAMS • Retrospectively collects data-recall bias • Collects data soon after delivery • Capable of detecting trends that signal changes in pregnancy intention • Currently no “partner questions” • Ability to change PRAMS questions every year • Does not collect data on fetal death, spontaneous abortion, or induced abortion • Live births used for family planning programs • Live births used for population contraceptive need

17. References • D'Angelo D.V., Gilbert B.C., Rochat R.W., Santelli J.S., Herold J.M. Differences between mistimed and unwanted pregnancies among women who have live births. Perspectives on Sexual and Reproductive Health. 2004;36(5):192-7. • Kost K., Landry D.J., Darroch J.E. The effects of pregnancy planning status on birth outcomes and infant care. Family Planning Perspectives. 1998;30(5):223-30.4. • Sable M.R., Spencer J.C., Stockbauer J.W., et al. Pregnancy wantedness and adverse pregnancy outcomes: differences by race and medicaid status. Family Planning Perspectives. 1997;29:76-81. • Shah P.S., Balkhair T., Ohlsson A., et al. Intention to become pregnant and low birth weight and preterm birth: a systematic review. Maternal and Child Health Journal. 2011;15:205-16. • Finer L.B., Kost K. Unintended pregnancy rates at the state level. Perspectives on Sexual and Reproductive Health. 2011:43(2):78-87. • Monea E., Thomas A. Unintended pregnancy and taxpayer spending. Perspectives on Sexual and Reproductive Health. 43(2):88-93.

18. Questions & Comments Acknowledgements: • Susan Manning, MD, MPH • Emily Lu, MPH • Hafsatou Diop, MD, MPH • MA PRAMS Advisory Committee • MA PRAMS Staff Feel free to contact me at: Olivia Sappenfield olivia.sappenfield@state.ma.us