AMCHP 2005 Conference PRAMS: A Tool to Understanding and Addressing Prematurity Jo Ann Walsh Dotson RN MSN Montana DPHHS – Helena, MT And Nan Streeter.

AMCHP 2005 Conference

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

AMCHP 2005 Conference

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.

AMCHP 2005 ConferenceBackground 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.

AMCHP 2005 Conference

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).

State Participation in PRAMS 2004

HI

VT

NJDEMD

RINYC

http://www.cdc.gov/reproductivehealth/pramstates.htm

Type of PRAMS publication, CDC PRAMS publication database, 1988-Oct 2004

Type of PRAMS publication, 1988-Oct 2004

Report 46%

Slide Presentation 35%

Journal Article 10%

Newspaper Article 3%

Pamphlet 3%

Thesis/Dissertation 2%

Abstract 1%

Rochat, Roger “Scientific Writing with PRAMS”

Presented at the Annual PRAMS conference December 7, 2004/Atlanta, GA

Frequency of reporting on 18 topics based on PRAMS data, 1988-Oct 2004

Unintended Pregnancy 18%Prenatal Care 15%Smoking 15%Physical Abuse 12%Alcohol 8%Breastfeeding 7%Family Planning 5%Illicit Drug Use 4%Folic Acid 4%Dental Care 2%Stress 2%HIV and HIV Counseling 2%Maternal Weight /BMI 1%Insurance 1%Depression 1%Birth Defects 1%Teen Pregnancy (3)Maternal Morbidity (1)

Rochat, Roger “Scientific Writing with PRAMS”

Presented at the Annual PRAMS conference December 7, 2004/Atlanta, GA

AMCHP 2005 ConferencePRAMS 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

AMCHP 2005 Conference

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

AMCHP 2005 ConferencePRAMS Core Question Topic Areas

• 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

AMCHP 2005 Conference

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

AMCHP 2005 Conference

Factors Associated with Prematurity

• Physiologic– Placental insufficiency– Genital tract infections– Hemorrhage or abruptio placenta– Incompetent cervix– Diabetes– Hypertension

AMCHP 2005 ConferenceFactors Associated with Prematurity

(cont.)• Social stressors

– Depression– Domestic violence– Psychiatric disorder– Homelessness (and “multiple residences)

• Substance use – Tobacco– Alcohol– other drugs

• Multiple births

AMCHP 2005 Conference

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

AMCHP 2005 Conference

Analysis

• 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

AMCHP 2005 ConferenceCigarette Smoking During Pregnancy

MMWR, 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

AMCHP 2005 ConferenceRelationship 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%

AMCHP 2005 ConferencePrevalence 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:

AMCHP 2005 Conference

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

AMCHP 2005 Conference

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.

Pregnancy Intention: National

PRAMS 1999 Surveillance Report, CDC Montana 2002 PRAMS Data

Unintended Pregnancy Among Women with a Live Birth, 1999

0 10 20 30 40 50 60

LouisianaArkansas

Montana 2002Alabama

OklahomaIllinois

S.CarolinaNew Mexico

AlaskaFlorida

North CarolinaOhio

ColoradoWest Virginia

WashingtonNew York *

MaineUtah

Sta

te

Percent

Late or No Entry to PNC

PRAMS 1999 Surveillance Report, CDC Montana 2002 PRAMS Data

Prevalence of Late (After First Trimester) or No Entry into Prenatal Care, 1999

0 10 20 30 40 50 60

OklahomaNew Mexico

LouisianaArkansas

AlaskaMontana

FloridaWashington

ColoradoIllinois

AlabamaN. CarolinaS.Carolina

OhioWest Virginia

UtahNew York *

Maine

Sta

te

Percent

Domestic Violence by Partner During PregnancyPrevalence of Physical Abuse by Husband or

Partner During Pregnancy, 1999

0 1 2 3 4 5 6 7 8 9 10

New MexicoArkansasLouisiana

S.CarolinaMontana 2002

New York *Ohio

West VirginiaAlaska

AlabamaFlorida

OklahomaIllinois

ColoradoNorth Carolina

WashingtonMaine

Utah

Sta

te

Percent

PRAMS 1999 Surveillance Report, CDC Montana 2002 PRAMS Data

Change in Alcohol Use

Montana: 62.8 % Before 6.7 % During

PRAMS 1999 Surveillance Report, CDC Montana 2002 PRAMS Data

Prevalence of Drinking 3 mths Before Pregnancy and During the Last 3 Mths of Pregnancy

0 10 20 30 40 50 60 70

Montana 2002

Maine

New York *

Colorado

Ohio

Alaska

Washington

New Mexico

Louisiana

Illinois

Florida

Oklahoma

S.Carolina

Alabama

North Carolina

Arkansas

West Virginia

Utah

Sta

te

Percent

Before Preg

During Preg

Alcohol Use in 3 Months Before Pregnancy

All MT Mothers

Any82%

None18%

Alcohol Use 3 Months Before Pregnancy by Mother’s Education Level

0

1000

2000

3000

4000

5000

under 12 12 over 12

any drks

no drks84 %

83 %

76 %

Change in Smoking from “Before” Pregnancy to “During” Pregnancy

Montana: 28.5 % Before 15.6 % During

Prevalence of Smoking 3 Mths Before Pregnancy and During the Last 3 Mths of Pregnancy

0 10 20 30 40 50

West Virginia

Ohio

Oklahoma

Arkansas

Alaska

Maine

Montana 2002

New York *

S.Carolina

New Mexico

North Carolina

Alabama

Colorado

Louisiana

Illinois

Washington

Florida

Utah

Sta

te

Percent

Before Preg"

During Preg

PRAMS 1999 Surveillance Report, CDC Montana 2002 PRAMS Data

Smoking: Do You Smoke Now?

Yes76%

No23%

All MT Mothers

No79%

Yes21%

Yes43%

No57%

MT Mothers <20

AMCHP 2005 Conference

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: [email protected]