How PRAMS (a maternal surveillance system) influences

Public Health in AlabamaRhonda Stephens, Alabama PRAMS Coordinator

Presentation to UAB School of Public HealthFebruary 23, 2004

What is PRAMS?

Pregnancy Risk Assessment Monitoring System

CDC initiative to reduce infant mortality and low birthweight babies

Population-based survey of women with live births in Alabama

ID and monitor selected maternal experiences and behaviors occuring before, during, and after birth

PRAMS in Alabama

February 1993 - AL began data collection

Works closely w/ Family Health Services

Revisions are made to reflect guidelines or emerging issues, & improve the questionnaire

PRAMS Steering Committee advises on survey questions, uses and dissemination of data, making contacts to put data to use

People involved in Alabama PRAMS

AL PRAMS team located in Center for Health Statistics, ADPH in Montgomery

CDC partners with states and oversees PRAMS project

Contract with UAB Survey Research Unit in Birmingham

Members of Steering Committee from all over Alabama

Data Collection

Data collection procedures and instruments standardized to allow state comparisons

Statewide-5 mailings(3 questionnaires) followed by phone follow-up for nonresponders

Preletter, Mail1, Tickler, Mail 2&3, Phone

Mail in English or Spanish, no Spanish phone

Core, State-specific, and State-developed questions on survey

State-Developed Question 64.During your most recent pregnancy, did a doctor, nurse, or

other health care worker tell you that you had any of the following diseases or infections? For each one, circle Y (Yes) if you were told you had the disease or infection or circle N (No) if you were not told you had the disease or infection.

Circle all that apply. No Yes

a. Urinary Tract Infection (UTI)…………….N Yb. Yeast Infections……………………………N Yc. Group B Strep (Beta Strep)………………N Yd. Bacterial Vaginosis…………………………N Ye. Trichomoniasis (Trich)…………………….N Yf. Chlamydia…………………………………...N Yg. Genital warts (HPV)……………………….N Yh. Herpes……………………………………….N Yi. Gonorrhea…………………………………..N Yj. Syphilis………………………………………N Yk. Pelvic Inflammatory Disease (PID)……..N Yl. Human Immunodeficiency Virus (HIV)…N Y

SamplingApprox. 160-200 women randomly sampled each month from birth certificate file 2-4 months after birth

Stratified Sampling Design: 4 strata 1. Medicaid low birth weight 2. Medicaid normal birth weight 3. Non-Medicaid low birth weight 4. Non-Medicaid normal birth weight

Mothers of low birth weight babies and Medicaid deliveries are oversampled

PRAMS data applied to Public Health Practice in Alabama

1. Unintended Births & Contraception

PRAMS is the source for unintended birth data in AlabamaUnintended births associated with poorer birth outcomesUse of contraception could decrease unintended pregnanciesHealthy People 2010 goal is to increase percent of intended pregnancy to 70%

When Mother Intended to Become Pregnant (Q11), Alabama PRAMS 2001

Sooner17.0%

Then34.1%

Later36.6%

Did Not Want12.3%

Intended

51.1%

Unintended

48.9%

Family PlanningMedicaid Family Planning Waiver –expanded Medicaid eligibility for FP services in 15 states

PRAMS data on intendedness, birth control, & sources of stress presented in planning stages

‘PlanFirst’ 5-yr demonstration program began in Alabama on Oct. 1, 2000: Alabama must prove it has met its objectives:

One is lowering the rate of unintended births in Alabama women to save Alabama money

Dr. Bronstein is an investigator

Unintended Births in Alabama(Q11), Alabama PRAMS 1993-2001

50.549.3

48.0 47.949.2

47.9 47.4 48.1 48.9

40

45

50

55

60

1993 1994 1995 1996 1997 1998 1999 2000 2001

Per

cent

Uni

nten

ded

*No significant change in percent unintended from 1993 to 2001.

Mother Not Planning Pregnancy Using Birth Control at Conception

(Q12,13,&14), Alabama PRAMS 2001

Yes41.9%

No58.1%

4.4

9.0

13.5

21.7

25.7

35.6

0 20 40

I didn't mind

Thought I couldnot get pregnant

Husband/Partnerdid not want touse anythingHad side effectsfrom birthcontrolThoughthusband/partneror I was sterileProblems gettingbirth control

Percent

2. Folic Acid

PRAMS has had questions on folic acid awareness and use of multivitamins

Worked with March of Dimes to publish a fact sheet in October, 2003

Percent of Mothers Who Took A Multivitamin Before Pregnancy (Q3),Alabama PRAMS 2001

Didn't Take At All64.8%

1-3 Times a Week8.8%

4-6 Times a Week4.3%

7 Days a Week22.1%

3. SmokingAlabama Smoking Cessation-Reduction in Pregnancy Trial (SCRIPT)

PRAMS data showed: 14.5% of AL mothers smoked during pregnancy Medicaid mothers almost twice as likely to smoke as

Non-Medicaid mothers

UAB and ADPH collaborated to launch SCRIPT in 8 counties from Oct. 1996 – Sept. 2001

Percent of Mothers who Smoked (Q29,30,&31), Alabama PRAMS 1993-2001

23.7 23.3

28.1

25.226.2

23.6 24.523.0

26.9

14.5 15.216.2

15.2 14.5 14.4 14.1 14.015.6

19.2

21.523.6

21.022.7

20.6 20.919.5

22.4

1012141618202224262830

1993 1994 1995 1996 1997 1998 1999 2000 2001

Per

cent

who

Sm

oked

Before Pregnancy During Pregnancy At Time of Survey

*No significant change in percent who smoked from 1993 to 2001.

3. Smoking (cont.)SCRIPT participants more than twice as likely to quit smoking (17%) as control group (9%).

Because SCRIPT’s methods were effective, they are now taught as “best practice” for caring for pregnant smokers in Alabama. PRAMS smoking data used for training

Led to ATOFF, smoking cessation program for all women 18-44 and their partners in SCRIPT counties

4. Breastfeeding and WIC

Provide WIC with annual analysis of topics by WIC status during & after pregnancy The WIC program is interested in increasing the rates of breastfeeding among their clients. Published a Breastfeeding Fact sheet with WIC for their educators and physicians – August, 2003Questions added to PRAMS for WIC to better serve clients

Receipt of Breastfeeding Information at WIC Visits (Q77), Alabama PRAMS 1996 - 2001

90.5 89.987.7

82.4

75.1 73.3

50

60

70

80

90

100

1996 1997 1998 1999 2000 2001

Per

cent

Rec

eivi

ng I

nfor

mat

ion

*Statistically significant decline in percent receiving info from 1996 to 2001.

Breastfeeding question added to PRAMS for WIC

47. What were your reasons for not breastfeeding your new baby? Check all that apply 

I had other children to take care ofI had too many household dutiesI didn’t like breastfeedingI didn’t want to be tied downI was embarrassed to breastfeedI went back to work or schoolI wanted my body back to myselfOther Please tell us:_________________

4. Breastfeeding and WIC (cont.)

Alabama Breastfeeding Conversion Initiative (ABC) began November 3, 2003 Pilot program to increase breastfeeding rates through

education during pregnancy Alabama PRAMS data on breastfeeding was presented

to the breastfeeding educators on Oct. 17, 2003

Collaborated with Gift of Life to: Design study design – control and intervention group Develop pretest and posttest, using some PRAMS

questions

Percent of Mothers Who Breastfed (Q49,50,&51), Alabama PRAMS 2001

1 week or more28.5%

Less than 1 week4.4%

Did Not Breastfeed

46.3%

Still Breastfeeding at time of survey

20.8%

5. Dental Care

Presented Dental Care data at MCH Epi meeting

CDC PRAMS analyzing several states’ data

Collaborating with Alabama Dental Director to produce fact sheet and present data to Alabama OB/GYNS annual meeting

Months Since Last Dental Cleaning (Q73), Alabama PRAMS 2001

38.0

10.9

29.8

10.0

4.0 2.15.3

05

10152025303540

6 mthsor less

7-11mths

12-23mths

24-35mths

36-47mths

48-59mths

5 yearsor more

Number of Months Since Last Cleaning

Per

cent

6. SIDS

Present updates of data to subcommittee of State Committee of Public Health

Annually include in Infant Mortality report to State Health Officer, Dr. Williamson

Percent of Infants Sleeping on Back (Q54), Alabama PRAMS 1996-2001

27.033.7

38.744.5

51.447.9

0

10

20

30

40

50

60

1996 1997 1998 1999 2000 2001

Per

cent

of I

nfan

ts S

leep

ing

on B

ack

*Significant increase from 1996 to 2001.

SIDS DEATH RATES

122.8 117.4 108.491.9 85.4 80.7

53.10

20406080

100120140

1995 1996 1997 1998 1999 2000 2001

Rat

e p

er 1

00, 0

00 b

irth

s

*

7. Medicaid

Medicaid is a variable that we stratify by, so all data analyzed by Medicaid status

Present PRAMS data by Medicaid status to Medicaid meetings

Alabama Medicaid Director presents data to Alabama OB/GYN meetings

Data requests for Medicaid data

Unintended Births by Method of Payment for Delivery, Alabama PRAMS 1993-2001

65.6 68.662.9

68.8 66.5 68.8 66.2 67.4 68.9

36.5 34.629.5

34.8 31.1 33.6 32.0 32.232.5

0

10

20

30

40

50

60

70

80

1993 1994 1995 1996 1997 1998 1999 2000 2001

Per

cent

Uni

nten

ded

Medicaid Non-Medicaid* No significant change in either category from 1993 to 2001.

PRAMS Fact Sheets & Special Reports

MCH Chartbook – Oct, 2002

Unmarried Chartbook– Feb, 2003

Breastfeeding fact sheet– Aug, 2003

Folic Acid fact sheet– Oct, 2003

Hispanic Databook – March, 2004

Dental Care fact sheet in planning stages

Low Birth Weight fact sheet is planned

PRAMS Information

Website: www.adph.org

Click ‘Fast Find’, ‘Health Statistics’ Click ‘PRAMS’

Latest publications are on the website

Alabama PRAMS Coordinator: Rhonda Stephens

PRAMS phone number: (334)206-2700