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
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