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

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 pregnancy 1-4 Represent about ½ of all births nationally Cost more than $9 billion annually 5,6 Risk Factors Maternal race/ethnicity, maternal age, maternal education, household income, marital status Partner’s intention, desirability of partner, number of partners, contraceptive use

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

PRAMS Population-based data on maternal attitudes and behaviors before, during, and shortly after pregnancy Sampled from birth certificate file Data collection began in 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

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

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

Results

Table 1. Descriptive characteristics of Massachusetts women (PRAMS 2008/2010, n= 2877; BRFSS 2008/2010, n=683) 1 PRAMS 08/10BRFSS 08/10 n% n% Overall % % Pregnancy Intention Intended % % Unintended % % Maternal Age years %545.5% years % % years % % Maternal Race/Ethnicity NH White % % NH Black %454.8% Hispanic % % NH Asian/Pacific Islander (PI) %326.6% 1 Weighted Percents 2 non-Hispanic

Table 1 Continued PRAMS 08/10BRFSS 08/10 n% n% Maternal Education <High School3428.9%524.1% High School % % Some College % % College or higher % % Marital Status Married % % Not married % % Household Income <185% Federal Poverty Level (FPL) % % 185+% FPL % % 1 Weighted Percents

Table 2. Descriptive characteristics of sample population by pregnancy intention (PRAMS 2008/2010, n= 3022; BRFSS 2008/2010, n=683 ) 1 PRAMS 2008/2010 BRFSS 2008/2010 IntendedUnintendedIntendedUnintended n%n% n%n% Overall % % % % Maternal Age years % %191.9%3519.8% years % % %9040.0% years % % %5440.2% Maternal Race/Ethnicity NH White % % %9665.4% NH Black % %253.5%2010.2% Hispanic % %728.3%5018.3% NH Asian/PI %1587.5%236.7%96.2% 1 Weighted Percents 2 non-Hispanic

Table 2 Continued PRAMS 2008/2010 BRFSS 2008/2010 IntendedUnintendedIntendedUnintended n%n% n%n% Overall % % % % Maternal Education <High School1977.1% %282.7%249.7% High School % %8314.1%4828.0% Some College % % %5224.1% College≤ % % %5938.2% Marital Status Married % % %6445.2% Not married % % % % Household Income <185% FPL % % %8948.1% 185+% FPL % % %5451.9% 1 Weighted Percents

Table 3. Comparison of unintended pregnancy prevalence among MA PRAMS and BRFSS respondents (PRAMS 2008/2010, n= 1019; BRFSS 2008/2010, n=183 ) 1 PRAMS 2008/2010BRFSS 2008/2010 Unintended Pregnancy %95% CI % Maternal Age years57.5%51.8%63.0%71.9%49.2%87.2% years26.0%23.3%28.8%19.8%14.6%26.3% years19.0%15.2%23.5%14.8%10.6%20.4% Maternal Race/Ethnicity NH White27.2%24.1%30.6%16.7%12.7%21.8% NH Black47.6%43.8%51.5%42.3%24.5%62.3% Hispanic41.0%37.5%44.7%35.6%23.7%49.6% NH Asian/PI28.0%24.5%31.8%19.0%8.2%38.2% 1 Weighted Percents 2 non-Hispanic

Table 3 Continued PRAMS 2008/2010BRFSS 2008/2010 Unintended Pregnancy %95% CI % Maternal Education <High School44.5%37.3%52.0%47.8%24.4%71.8% High School42.4%37.3%47.7%33.3%22.2%46.5% Some College42.6%37.4%48.1%22.7%15.1%32.7% College or higher17.3%14.7%20.2%13.2%9.5%18.0% Marital Status Married19.5%17.3%21.9%11.7%8.4%15.9% Not married53.8%49.5%58.1%48.6%38.8%58.5% Household Income <185% FPL48.0%43.9%52.0%33.7%25.1%43.6% 185%+ FPL20.1%17.5%23.0% 13.0%9.3%17.9% 1 Weighted Percents

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

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 Inform reproductive health programs Used in home-visiting programs to assist in developing reproductive life plans Used in home-visiting programs to assist in developing reproductive life plans

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

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): 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): 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: 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: Finer L.B., Kost K. Unintended pregnancy rates at the state level. Perspectives on Sexual and Reproductive Health. 2011:43(2): Monea E., Thomas A. Unintended pregnancy and taxpayer spending. Perspectives on Sexual and Reproductive Health. 43(2):88-93.

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