prams texas pregnancy risk assessment monitoring...
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TEXAS DEPARTMENT OFSTATE HEALTH SERVICES
Annual Report 2004
PRAMSTexas Pregnancy Risk Assessment
Monitoring System
Office of Title V and Family Health
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This publication was supported in part by funding from the Centers for Disease Control and Prevention (CDC) (Award #: 5 UR6 DP000479-02) and the Texas Maternal and Child Health Title V Program. The contents of this publication are solely the responsibility of
the authors and do not necessarily represent the views of the CDC.
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Texas Pregnancy Risk Assessment Monitoring System
Annual Report 2004
For more information about PRAMS and additional results please visit http://www.dshs.state.tx.us/mch/
Contact Information
Questions regarding the information in this book or other questions about PRAMS should be directed to:
Eric A. Miller, PhD, PRAMS CoordinatorTexas Department of State Health Services
Office of Title V and Family Health512-458-7111 ext. 2935
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Table of Contents
Acknowledgements .................................................................................................... 6
Glossary ..................................................................................................................... 8
Executive Summary .................................................................................................... 9
Background .............................................................................................................. 11
Methodology ............................................................................................................ 12
Maternal Child Health in Texas ................................................................................. 13
Obesity and Diabetes ............................................................................................... 16
Pre-Pregnancy Obesity .................................................................................. 16
Diabetes ......................................................................................................... 17
Pregnancy Intention ................................................................................................. 19
Prenatal Health ......................................................................................................... 22
Prenatal Care ................................................................................................. 22
Barriers to Prenatal Care ................................................................................23
Prenatal Vitamins, Multivitamins, and Folic Acid ............................................25
Tobacco and Alcohol ................................................................................................ 28
Smoking ......................................................................................................... 28
Alcohol ........................................................................................................... 30
Abuse ....................................................................................................................... 33
Infant Health ............................................................................................................. 35
Breastfeeding .................................................................................................35
Sleep Position .................................................................................................37
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AcknowledgementsThis Annual Report would not be possible without the contributions of all the women who paticipated in PRAMS.
We would also like to thank the following people for their time and help with PRAMS and contributions to this book:
PRAMS Steering Committee
Martin Arocena, PhD, Mental Health and Substance Abuse Services, DSHS
Fouad Berahou, PhD, PRAMS Principle Investigator, Office of Title V and Family Health, DSHS
Charlotte Brooks, M.Ed., Office of Title V and Family Health, DSHS
Charles Brown, MD, Obstetrician/Gynecologist
Mark Canfield, PhD, Birth Defects Epidemiology and Surveillance Branch, DSHS
Rom Haghighi, PhD, Office of Title V and Family Health, DSHS
John Hellsten, PhD, Environmental Epidemiology and Injury Surveillance, DSHS
Karen Littlejohn, Director, March of Dimes, Texas Chapter
Sharon K. Melville, MD, MPH, HIV/STD Epidemiology and Surveillance Branch, DSHS
Ramdas Menon, PhD, Center for Health Statistics, DSHS
Eric Miller, PhD, Office of Title V and Family Health, DSHS
Alicia Novoa, MPH, Public Policy Research Institute, Texas A&M University
Christina Sebestyen, MD, Obstetrician/Gynecologist
Additional Department of State Health Services Staff
Becky Brownlee, Governmental Affairs
Brian Castrucci, MPH, Office of Title V and Family Health
Kathy Clantanoff, RN, Office of Title V and Family Health
Ben Crowder, Applications Development
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Evelyn Delgado, Assistant Commissioner, Family and Community Health Services
Hillary Foulkes, MPH, CSTE Fellow, Office of Title V and Family Health
Chan McDermott, MPA, Office of Title V and Family Health
Gita Mirchandani, PhD, Office of Title V and Family Health
Clint Moehlman, Office of Title V and Family Health
Scott Shively, Office of Title V and Family Health
Marilyn Walker, Office of Title V and Family Health
Steve Horst, ESO Graphics Department
Public Policy Research Institute, Texas A&M University
Jim Dyer, PhD
Darby Johnson
Chris McClendon
Alicia Novoa, MPH
Stacy Rhodes
Andrea Sesock
Staff and interviewers
In memory of Hillary B. Foulkes, MPH (1983 – 2007), Council of State and Territorial Epidemiologists Fellow for the Department of State Health Services.
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Glossary
Body Mass Index (BMI): A measure calculated by taking a person’s weight (in kilograms) and dividing by their height squared (in meters). Adults are commonly placed in the categories below based on their BMI:
Underweight: less than 19.8 kg/m2
Normal weight: 19.9 to 24.9 kg/m2
Overweight: 25 to 29.9 kg/m2
Obese: 30 kg/m2 or more
Low birthweight – Birth of an infant weighing less then 2500g (5lbs 8oz).
Perinatal – There are varying definitions of the perinatal period. In this re-port, it is defined as the time period spanning from just before pregnancy (~3-5 months) to after birth (~1 month).
Prenatal – The time period occurring or existing before birth.
Preterm Birth – Birth of an infant before 37 weeks of gestation.
Prevalence – The proportion of individuals in a defined population who have a particular attribute or disease.
Rate – The frequency of a particular occurrence during a specified time period in a defined population.
Risk factor – A characteristic or exposure associated with a particular outcome.
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Executive Summary
The Pregnancy Risk Assessment Monitoring System (PRAMS), sponsored by the Centers for Disease Control and Prevention (CDC),
is intended help reduce infant mortality and low birthweight by collecting useful information from mothers after delivery of a live infant. It is a population-based surveillance system designed to identify and monitor selected maternal experiences before, during, and after pregnancy. The PRAMS questionnaire addresses many topics, including prenatal care, obstetric history, use of alcohol and cigarettes, exposure to secondhand smoke, knowledge of folic acid, multivitamin use, access to care, physical abuse, pregnancy intention, and breastfeeding. Data from PRAMS have been used to increase understanding of maternal behaviors and experiences and their relationships with adverse pregnancy outcomes. Additionally, PRAMS data help identify high-risk groups and are used in planning and assessing perinatal health programs. This is a summary of some of the important indicators of maternal and infant health in Texas.
Obesity and Diabetes· Approximately 20% of women were obese just before they became pregnant.· Almost 10% of women developed diabetes during pregnancy (gestational diabetes).
Unintended Pregnancy· Almost 50% of women had an unintended pregnancy. · Women who had an unintended pregnancy were more likely to have delayed prenatal care (after the first trimester).
Prenatal Care· Almost three quarters of women received prenatal care in the first trimester.· Among women who did not get prenatal care as early as they wanted, the most common barriers were “not enough money or insurance,” “didn’t have Medicaid card,” and “couldn’t get an appointment.”
Prenatal Vitamins, Multivitamins, and Folic Acid· Over half of the women did NOT take a prenatal vitamin or multivitamin in the month before pregnancy.· Just over half of women aged 19 years or less knew folic acid prevented birth defects.
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Smoking· Approximately 15% of women smoked three months before they became pregnant.· The percent of low birthweight infants was double among women who smoked compared to women who did not. Alcohol· Almost half of women reported drinking during the three months before pregnancy.· Almost 10% reported drinking during the last three months of pregnancy.
Abuse· Almost 10% of women were physically hurt by a husband, partner, ex- husband or ex- partner in the 12 months before pregnancy or during pregnancy. · The prevalence of physical abuse was approximately five times higher among women who were not married.
Breastfeeding· Almost three quarters of women initiated breastfeeding after their most recent pregnancy.· Almost half of women breastfed at least nine weeks.
Sleep Position· Approximately half of the women most often placed their infants on their backs to sleep.
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PRAMS Background
Theexperiencesandbehaviorsofwomenbefore,duringandafterpregnancycanhaveimportantimplicationsfortheirhealthandthehealthoftheir
infants.Thereareanumberoffactors,suchasunhealthybehaviorsandpooraccesstohealthcare,whichcanleadtoadversepregnancyoutcomes,includinginfantmorbidity,and/ormortality.
ThePregnancyRiskAssessmentMonitoringSystem(PRAMS),sponsoredbytheCentersforDiseaseControlandPrevention(CDC),isintendedtohelpreduceinfantmortalityandlowbirthweightbycollectingusefulinformationfrommothersafterdeliveryofaliveinfant.Itisapopulation-basedsurveillancesystemdesignedtoidentifyandmonitorselectedmaternalexperiencesbefore,during,andafterpregnancy.InTexas,PRAMSisconductedbytheDepartmentofStateHealthServices(DSHS).TexasinitiatedPRAMSdatacollectioninMay�00�,andcurrentlyparticipatesalongwith��otherstates,NewYorkCity,andtheYanktonSiouxTribeofSouthDakota.
PRAMS enhances data from birth certificates by providing more in-depth informationandincludinginformationthatisnotavailableelsewhere.ThePRAMSquestionnaireaddressesmanytopics,includingprenatalcare,obstetrichistory,useofalcoholandcigarettes,exposuretosecondhandsmoke,knowledgeoffolicacid,multivitaminuse,accesstocare,HIVtesting,physicalabuse,pregnancyintention,andbreastfeeding.
DatafromPRAMShavebeenusedtoincreaseunderstandingofmaternalbehaviorsandexperiencesandtheirrelationshipwithadversepregnancyoutcomes.Additionally,PRAMSdatahelpidentifyhigh-riskgroupsandareused
inplanningandassessingperinatalhealthprograms.ThisreporthighlightssomeoftheimportantindicatorsofmaternalandinfanthealthinTexas.
Actual quotes from women who participated in PRAMS are displayed throughout this report.
“Thank you for doing important research for the health of mothers and babies in Texas.”
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PRAMS Methodology
Eachyear,approximately�,�00womeninTexasarerandomlyselectedfrom birth certificates of live births to participate in PRAMS. The sample
consists of biological mothers of infants aged 60 to 180 days and is stratified by race/ethnicity(African-American,Hispanic,white/other)andbirthweight(lessthan��00grams,and��00gramsormore).BecausePRAMSdataarepopulation-based, findings from data analyses can be generalized to an entire state’s populationofwomenhavingalivebirth.
Randomly-selected mothers are first contacted by mail. If there is no response afterthreesurveymailings,themothersarethencontactedtocompletethesurveybyphone.Staffalsoattempttoobtaincompletedinterviewswithmothersofdeceasedinfants.Themajorityofresponsesareobtainedthroughthemailedsurvey.
ThePRAMSsurveyis��questionsandconsistsofcorequestionsthatareaskedinallparticipatingstatesandseveraladditionalquestionsthatareselectedbyeachstate.AllsurveydataaresenttotheCDCforcleaningandweighting.ThedataareweightedtorepresentalllivebirthsinTexasandareadjustedforsamplingprobabilities,nonresponse,andnoncoverage.AnalysisofdataisconductedusingSUDAANstatisticalsoftwaretoaccountforthecomplexsampling.
Data Limitations
In�00�,�,�00womenparticipatedinPRAMSwithanoverallweightedresponserateof��%.Becausecharacteristicsofwomenwhorespondmightdifferfromthoseofwomenwhodonot,thereportedestimatesarepotentiallybiasedandmightnotberepresentativeofallmothersoflivebirthsinTexas.Inaddition,datafromPRAMSareself-reportedandsomemothersmightnotaccuratelyrecalleventsorcertainbehaviorsmightbeover-orunderreported.
Therearetoofewwomenofrace/ethnicitiesotherthanBlack/African-AmericanandHispanictosampleseparatelyandwerecombinedwiththewhiteracecategory.Therefore,womenofotherrace/ethnicitiescannotbeexaminedseparately.
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Figure 1. Infant Mortality Rates in Texas and the United States; 1995-2004
5
6
7
8
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
Rat
e pe
r 100
0 Li
ve B
irths
Texas United States
Maternal and Child Health in Texas Infant Mortality
InTexas,thereareapproximately��0,000birthsperyear.Themortalityrateofinfantsagedlessthanoneyearin�00�was�.�per�000births,whichwas
lowerthanthenationalrate(�.�/�000births).However,similartothenationalrate,therewasanincreaseintheinfantmortalityrateafter�000(Figure�).In�000,theinfantmortalityrateinTexaswasatitslowestpointof�.�per�000birthsandincreasedto�.�per�000in�00�.Itisunclearwhataccountsfortherecentincrease[�].
*Centers for Disease Control and Prevention. National Center for Health Statistics. Vital Stats. http://www.cdc.gov/nchs/datawh/vitalstats/vitalstats_perinatal1.htm.
Figure 1. Infant Mortality Rate in Texas and the United States, 1995-2004*
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Figure 2. Infant Mortality Rates for Infants Aged Less Than or Equal to 1 Year by Race/Ethnicity; Texas and the United
States,* 2004
12.8
5.6 5.6
13.7
5.6 5.7
0
5
10
15
20
African-American Hispanic White**
Rat
e pe
r 100
0 Li
ve B
irths Texas United States
*Preliminary 2004 data (http://www.cdc.gov/nchs/data/nvsr/nvsr54/nvsr54_19.pdf)**Vital statistics data and does not include “other” race/ethnicities
Thereisalsoasubstantialdisparityinmortalityratesbyrace/ethnicity.Themortalityratesforwhitenon-HispanicinfantsandHispanicinfantsin�00�wereboth�.�per�000livebirths.TherateamongAfrican-Americaninfantswasmorethandoubleat��.�per�000(Figure�).
*Preliminary�00�data(http://www.cdc.gov/nchs/data/nvsr/nvsr��/nvsr��_��.pdf)**Vitalstatisticsdataanddoesnotinclude“other”race/ethnicities
Low Birthweight
Lowbirthweightisoneofthestrongestriskfactorsforinfantmortality.Infantsbornlessthan��00gramsareata25 times higher risk of deathcomparedtoinfantsbornat��00gramsormore[�].Lowbirthweightisalsoassociatedwithanumberoflong-termdisabilities,includingcerebralpalsy[�],autism[�,�],mentalretardation[�],andvision[�]andhearingimpairments[�].Inaddition,there are substantial financial costs associated with low birthweight. The cost of hospitalization for delivery of a low birthweight infant has been reported to be approximatelythreetimeshigherthananinfantofadequatebirthweight[�].In�00�,therewereover�0,000infantsborninTexaswithlowbirthweight.Byrace/ethnicity,thepercentoflowbirthweightinfantsmirrorstherateofinfantmortality(Figure�).
Figure 2. Infant Mortality Rate of Infants Less Than 1 Year of Age by Race/Ethnicity — Texas and the United States,*2004
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Figure 3. Low Birthweight Births (<2500 grams) by Race/Ethnicity; Texas, 2004
13.9
7.2 7.4
0
5
10
15
20
African-American Hispanic White
Perc
ent
* http://soupfin.tdh.state.tx.us/birth.htm
References
�. MacDorman,M.F.,etal.,Explaining the 2001-02 infant mortality increase: data from the linked birth/infant death data set.NatlVitalStat Rep,�00�.��(��):p.�-��.�. Ellenberg,J.H.andK.B.Nelson,Birth weight and gestational age in children with cerebral palsy or seizure disorders.AmJDisChild,����. ���(�0):p.�0��-�.�. Maimburg,R.D.andM.Vaeth,Perinatal risk factors and infantile autism. ActaPsychiatrScand,�00�.���(�):p.���-��.�. Larsson,H.J.,etal.,Risk factors for autism: perinatal factors, parental psychiatric history, and socioeconomic status.AmJEpidemiol,�00�. ���(�0):p.���-��;discussion���-�.�. Mervis,C.A.,etal.,Low birthweight and the risk for mental retardation later in childhood.PaediatrPerinatEpidemiol,����.�(�):p.���-��.�. Gallo,J.E.andG.Lennerstrand,A population-based study of ocular abnormalities in premature children aged 5 to 10 years.AmJ Ophthalmol,����.���(�):p.���-��.�. Bergman,I.,etal.,Cause of hearing loss in the high-risk premature infant. JPediatr,����.�0�(�):p.��-�0�.�. Lewit,E.M.,etal.,The direct cost of low birth weight.FutureChild,����. �(�):p.��-��.
Figure 3. Low Birthweight (<2500 grams) Births by Race/Ethnicity–Texas, 2004*
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Figure 4. Pre-Pregnancy Obesity by Race/Ethnicity
26.1
20.617.4
0
10
20
30
40
50
African-American Hispanic White/Other
Perc
ent
“…Doctors should put more emphasis on doing
some form of daily exercise such as walking or
swimming.”
Obesity and Diabetes Pre-Pregnancy Obesity
Numerouscomplicationsareassociatedwithobesity,includingadversepregnancyoutcomesthatimpactbothmaternalandinfanthealth.Women
whoareobese[BodyMassIndex(BMI)of�0kg/m�ormore]whenbecomingpregnantareatagreaterriskofpregnancycomplications(e.g.hypertension,gestationaldiabetes)[�],laboranddeliverycomplications(e.g.pre-eclampsia)[�],andhavingacesareansectiondelivery[�].Infantsofwomenwhoareobeseareatagreaterriskofbirthdefects[�,�],fetalandneonataldeath[�],andbeinglargeforgestationalage(macrosomia)[�,�].
uInPRAMS,thehighestprevalenceofpre-pregnancyobesitywasamongAfrican-Americanwomen,followedbyHispanicandwhite/otherwomen(Figure�).
Percent of women who were obese (BMI ≥ 30) just before they became pregnant: 20%
Figure 4. Pre-Pregnancy Obesity (BMI ≥ 30kg/m2) by Race/Ethnicity
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Figure 5. Pre-Existing Diabetes and Gestational Diabetes
1.3
9.2
0
5
10
15
20
Pre-Existing Diabetes Gestational Diabetes
Perc
ent
Diabetes
Diabetesisoneofthemajorcomplicationsofobesity.Forwomenwhohavediabetesordevelopdiabetesduringpregnancy,goodcontrolofbloodsugarisessentialforahealthypregnancy.Womenwhohavepoorlycontrolleddiabetesareatamuchhigherriskofhavingababywithbirthdefects,havingamiscarriageorstillbirth,andmacrosomia[�-�0].Inaddition,womenwhodevelopdiabetesduringtheirpregnancy(gestationaldiabetes)aremorelikelytodevelopgestationaldiabetesinfuturepregnanciesandareatgreaterriskofdevelopingtypeIIdiabetesinthefuture[��,��].
uTheprevalenceofwomenwhoreportedhavingdiabetespriortopregnancywas�.�%.Ninepercentofwomenreportedhavingdiabetesthatstartedduringtheirpregnancy(Figure�).
Figure 5. Pre-Existing Diabetes and Gestational Diabetes
References
�. Baeten,J.M.,E.A.Bukusi,andM.Lambe,Pregnancy complications and outcomes among overweight and obese nulliparous women.AmJPublic Health,�00�.��(�):p.���-�0.�. Cedergren,M.I.,Maternal morbid obesity and the risk of adverse pregnancy outcome.ObstetGynecol,�00�.�0�(�):p.���-��.�. Chu,S.Y.,etal.,Maternal obesity and risk of cesarean delivery: a meta- analysis.ObesRev,�00�.�(�):p.���-��.
��
�. Watkins,M.L.,etal.,Maternal obesity and risk for birth defects. Pediatrics,�00�.���(�Part�):p.����-�.�. Waller,D.K.,etal.,Prepregnancy obesity as a risk factor for structural birth defects.ArchPediatrAdolescMed,�00�.���(�):p.���-�0.�. Cnattingius,S.,etal.,Prepregnancy weight and the risk of adverse pregnancy outcomes.NEnglJMed,����.���(�):p.���-��.�. Clausen,T.D.,etal.,Poor pregnancy outcome in women with type 2 diabetes.DiabetesCare,�00�.��(�):p.���-�.�. Macintosh,M.C.,etal.,Perinatal mortality and congenital anomalies in babies of women with type 1 or type 2 diabetes in England, Wales, and Northern Ireland: population based study.Bmj,�00�.���(���0):p.���.�. Towner,D.,etal.,Congenital malformations in pregnancies complicated by NIDDM.DiabetesCare,����.��(��):p.����-��.10. O’Sullivan, J.B., Gestational diabetes. Unsuspected, asymptomatic diabetes in pregnancy.NEnglJMed,����.���:p.�0��-�.11. O’Sullivan, J.B., Diabetes mellitus after GDM. Diabetes,����.�0Suppl �:p.���-�.��. Kim,C.,D.K.Berger,andS.Chamany,Recurrence of gestational diabetes mellitus: a systematic review.DiabetesCare,�00�.�0(�):p.����-�.
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Figure 6. Unintended Pregnancies by Race/Ethnicity.
67.3
46.237.1
0
20
40
60
80
100
African-American Hispanic White/Other
Perc
ent
Pregnancy Intention
Almost�0%ofpregnanciesintheUnitedStatesareunintended[�],meaningthepreg-
nancywasmistimedorunwantedatthetimeofconception.Unintendedpregnanciesareassoci-atedwithanumberofbehaviorsthatcanleadtoadversepregnancyoutcomes,suchassmoking,alcoholintake,anddelayedprenatalcare.
uInTexas,theprevalenceofunintendedpregnancyamongwomenrespondingtothesurveyis��%,whichissimilartothenationalprevalenceof��%.Amongwomenwhohadanunintendedpregnancy,��%ofthepregnanciesweremistimedand��%wereunwanted.
u There were significant differences in the prevalence of unintended preg- nanciesbyrace/ethnicityandage.Thehighestprevalenceofunintended pregnancieswasamongAfrican-Americanwomen,followedbyHispanicandwhite/otherwomen(Figure�).
Figure 6. Unintended Pregnancies by Race/Ethnicity
“We knew it could happen but we didn’t think it would.”
“I think if a women is thinking of becoming pregnant, she needs to prepare herself mentally and physically for the changes ahead…”
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Figure 8. Delayed Prenatal Care by Pregnancy Intention
34.6
21.8
0
10
20
30
40
50
Unintended Pregnancy Planned Pregnancy
Perc
ent
Figure 7. Unintended Pregnancies by Age
62.354.5
39.0
27.2
0
20
40
60
80
100
19 20-24 25-34 35+Age in Years
Perc
ent
uTheprevalenceofunintendedpregnancyismuchhigheramongyoungeragegroups.Over�0%ofpregnanciesamongwomenaged��yearsandyoungerwereunintendedcomparedto��%amongwomenaged��yearsorolder(Figure�).
Figure 7. Unintended Pregnancies by Age
Womenwithanunintendedpregnancyaremorelikelytohavedelayedprenatalcare (after first trimester). This problem can be further compounded if a woman didnothavehealthinsurancewhenshebecamepregnant.
u In Texas, the prevalence of women with delayed prenatal care (after firsttrimester)wasapproximately��%higheramongwomenwhohadanunin-tendedpregnancy(Figure�).
Figure 8. Delayed Prenatal Care (After First Trimester) by Pregnancy Intention
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References
�. Finer,L.B.andS.K.Henshaw,Disparities in rates of unintended pregnan- cy in the United States, 1994 and 2001.PerspectSexReprodHealth, �00�.��(�):p.�0-�.
Percent of unintended pregnancies among women who did not have health insurance or Medicaid just before they became pregnant: 50%
“Due to my age and the fact that I was in high school at the time I was pregnant, I did not seek medical attention for fear of my parents and no means of money, I had no job and no time to go see a doctor.”
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Figure 9. First Trimester Prenatal Care by Age.
59.464.3
78.3 81.3
0
20
40
60
80
100
19 20-24 25-34 35+Age in Years
Perc
ent
Prenatal Health
Prenatal Care
Prenatalcareplaysanimportantroleinahealthypregnancy.Prenatalcarevisitsprovidehealthcareprofessionalstheopportunitytoassessmaternal
health,monitorthepregnancy,promoteandreinforcehealthybehaviors,andobservechangesthatcouldthreatenthehealthofthemotherorchild.Entryinto prenatal care after the first trimester has been found to be associated with anumberofadversepregnancyoutcomes,includingprematurity[�],lowbirthweight[�,�],andinfant[�]andmaternalmortality[�].
u There is a significant difference in the prevalence of first trimester prenatal carebyage.Theprevalenceofwomenaged��yearsoryoungerreceiving prenatal care in the first trimester was approximately 20% lower thanwomenaged��yearsandolder(Figure�).
Figure 9. First Trimester Prenatal Care by Age
u There were also significant differences by race/ethnicity. The prevalence of women receiving prenatal care in the first trimester was approximately�0%higheramongwomenwhowereofwhite/otherrace/ethnicitycomparedtoAfrican-AmericanandHispanicwomen(Figure�0).
Percent of women who received prenatal care in the first trimester: 73%
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Figure 11. First Trimester Prenatal Care by Insurance Status Just Before Pregnancy.
60.0
85.1
0
20
40
60
80
100
No Health Insurance Health Insurance or Medicaid
Perc
ent
Figure 10. First Trimester Prenatal Care by Race/Ethnicity
63.9 64.9
83.9
0
20
40
60
80
100
African-American Hispanic White/Other
Perc
ent
Figure 10. First Trimester Prenatal Care by Race/Ethnicity
Barriers to Prenatal CareThereareanumberofbarriersthatmightpreventordelaywomenfromreceivingprenatalcareasearlyastheywant.Lackofmoneyorhealthinsuranceisoftencitedasareasonfordelayingprenatalcare.
u The prevalence of women who received prenatal care in the first trimester was significantly higher among women who had health insurance or Medicaidbeforetheybecamepregnant(Figure��).
Figure 11. First Trimester Prenatal Care by Insurance Status Just Before Pregnancy
Percent of women without health insurance or Medicaid just before they became pregnant: 51%%
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Figure 12. Lack of Health Insurance or Medicaid Just Before They Became Pregnant by Race/Ethnicity.
44.7
68.0
32.3
0
20
40
60
80
100
African-American Hispanic White/Other
Perc
ent
u There were significant differences in the prevalence of women who wereuninsuredjustbeforetheybecamepregnantbyrace/ethnicity.Almost�0%ofHispanicwomenreportednothavinghealthinsuranceorMedicaidjustbeforetheybecamepregnant.Thisismorethandoublethepercentofwomenofwhite/otherrace/ethnicities.Approximately��%ofAfrican-Americanwomenwereuninsuredjustbeforetheybecamepregnant(Figure��).
Figure 12. Lack of Health Insurance or Medicaid Just Before Pregnancy by Race/Ethnicity
uAmongwomenwhodidnotgetprenatalcareasearlyastheywanted, the most common barriers were “not enough money or insurance,” “didn’t have Medicaid card,” and “couldn’t get an appointment.” Women couldselectmorethanoneanswer(Figure��).
Percent of women who did NOT receive prenatal care as early as they wanted: 23%%
“I traveled 90 miles for adequate care for myself
and my baby.”
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Figure 13. Barriers to Prenatal Care Among Women Who Did Not Get Care as Early as They Wanted*
uNotknowingtheimportanceofearlyprenatalcareisanotherreasonforlate entry into prenatal care (after first trimester). Among the 27% of women who did not receive prenatal care in the first trimester, 50% reported that theyreceivedprenatalcareasearlyastheywanted.
Prenatal Vitamins, Multivitamins, and Folic Acid
Gettingenoughfolicacid(aBvitamin)earlyinpregnancycanhelppreventcertain major birth defects [5], but it can be difficult to get the recommended daily amountoffolicacidthroughdietalone.Therefore,theCDCrecommendsthatallwomenofchildbearingagetakeaprenatalvitaminorfolic-acidcontainingvitamineveryday[�].Thecriticalperiodoffetaldevelopmentformanybirthdefectsisduring the first few weeks of pregnancy. Because women might not realize they are pregnantuntilafterthiscriticalperiod,itisimportantthatwomentakeaprenatalvitaminorafolicacid-containingmultivitaminbeforetheybecomepregnant.
*Womencouldselectmorethanoneanswer.
“ My pregnancy was planned so I was on prenatal vitamins and eating a healthy diet.”
Didn’t have enough money
Didn’t have Medicaid card
Couldn’t get an appointment
Lack of transportation
Other reason
Doctor or health plan
didn’t start
Pregnancy was a secret
No child care
Couldn’t take time off work
as early as wanted
Figure 13. Barriers to Prenatal Care Among Women Who Did Not Get Prenatal Care as Early as They Wanted*
6.0
10.1
12.5
14.1
16.6
19.8
22.0
31.9
33.9
44.2
0 10 20 30 40 50
Couldn't take time off work
Too busy
No child care
Doctor or health plan didn't startas early as wanted
Pregnancy was a secret
Lack of transportation
Other Reason
Didn't have Medicaid card
Couldn't get an appointment
Didn't have enough money
Percent
��
Figure 14. Lack of Multivitamin or Prenatal Vitamin Use in the Month Before Pregnancy by Age.
76.967.5
57.7
40.7
0
20
40
60
80
100
19 20-24 25-34 35+Age in Years
Perc
ent
uThelargestdifferenceinprevalenceofprenatalvitaminormultivitaminuseinthemonthbeforepregnancyisbyage.Seventy-sevenpercentofteenagedmothersdidNOTtakeaprenatalormultivitamininthemonthbeforepregnancycomparedto��%amongwomenaged��yearsandolder.
Figure 14. Lack of Multivitamin or Prenatal Vitamin Use in the Month Before Pregnancy by Age
Oneexplanationforthedisparityinthenumberofwomenwhodonottakeamultivitamin or prenatal vitamin is a lack of knowledge of the benefits of folic acidamongyoungeragegroups.In�00�,asurveyofwomeninTexasfoundthatonly��%ofwomenaged��yearsandyoungerknewthatfolicacidpreventedbirthdefects[�].AlthoughknowledgeoffolicacidishigherinPRAMSbecauseitisasampleofwomenwitharecentpregnancy,thedisparityinknowledgebyageisstillevident.
Percent of women who did NOT take a prenatal vitamin or multivitamin in the month before pregnancy: 61%
“ I wished I could have afforded to take vitamins.”
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Figure 15. Knowledge that Folic Acid Prevents Birth Defects
85.785.0
74.8
55.3
0
20
40
60
80
100
19 20-24 25-34 35+Age in Years
Perc
ent
uOnly��%ofteenagemothersknewfolicacidpreventedbirthdefectscomparedto��%amongwomenaged��yearsandolder(Figure��).
Figure 15. Knowledge that Folic Acid Prevents Birth Defects by Age
References
�. Showstack,J.A.,P.P.Budetti,andD.Minkler,Factors associated with birthweight: an exploration of the roles of prenatal care and length of gestation.AmJPublicHealth,����.��(�):p.�00�-�.�. Fisher,E.S.,J.P.LoGerfo,andJ.R.Daling,Prenatal care and pregnancy outcomes during the recession: the Washington State experience.AmJ PublicHealth,����.��(�):p.���-�.�. Gortmaker,S.L.,The effects of prenatal care upon the health of the newborn.AmJPublicHealth,����.��(�):p.���-�0.�. Koonin,L.M.,etal.,Maternal mortality surveillance, United States, 1979-1986.MMWRCDCSurveillSumm,����.�0(�):p.�-��.�. CDC.Folic Acid Basics.�00�[cited�0/0�/�00�];Availablefrom: http://www.cdc.gov/ncbddd/folicacid/basics.htm.�. CDC.Folic Acid PHS Recommendations.�00�[cited�0/0�/�00�]; Availablefrom: http://www.cdc.gov/ncbddd/folicacid/health_recomm.htm.7. Canfield, M.A., et al., Folic acid awareness and supplementation among Texas women of childbearing age.PrevMed,�00�.��(�):p.��-�0.
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Figure 16. Low Birthweight (<2500g) Births by Smoking Status
13.9
6.7
0
5
10
15
20
Smoked During the Last 3 Monthsof Pregnancy
Did Not Smoke
Perc
ent
Tobacco and Alcohol Smoking
Smokingduringpregnancyisassociatedwithnumerous
adversepregnancyoutcomes,includinganincreasedriskofspontaneousabortion,ectopicpregnancy,andprematureruptureofmembranes[�].Infantsofmotherswhosmokeareatagreaterriskforpretermbirth,lowbirthweight,andanumberofbirthdefects[�].
uThepercentofwomenwhosmokedandhadalowbirthweightinfantwasapproximatelydoublethatofwomenwhodidnotsmoke(Figure��).
Figure 16. Low Birthweight Births by Smoking Status
u The prevalence of smoking before and during pregnancy differs signifi-cantlybyrace/ethnicity.Hispanicwomenhadthelowestprevalenceofsmokingwhilethehighestprevalencewasamongwhite/otherwomen(Figure��).
“If I would not have been smoking during my pregnancy my baby would have been more healthier.”
Percent of women who smoked three months before they became pregnant: 16%
��
Figure 18. Smoking Before and During Pregnancy by Age
22.619.0
13.810.0
7.010.2
5.5 4.9
0
10
20
30
40
50
19 20-24 25-34 35+Age in Years
Perc
ent
Smoked 3 Months Before PregnancySmoked Last 3 Months of Pregnancy
Figure 17. Smoking Before and During Pregnancy by Race/Ethnicity
11.68.4
26.2
6.92.1
12.7
0
10
20
30
40
50
African-American Hispanic White/Other
Perc
ent
Smoked 3 Months Before PregnancySmoked Last 3 Months of Pregnancy
Figure 17. Smoking Before and During Pregnancy by Race/Ethnicity
uTheprevalenceofsmokingbeforepregnancydecreaseswitholderage.Comparedtosmokingbeforepregnancy,thereisasubstantiallylowerprevalenceofsmokingduringthelastthreemonthsofpregnancy,whichisnotstatisticallydifferentbyage(Figure��).
Figure 18. Smoking Before and During Pregnancy by Age
11.5
26.3
�0
Figure 19. Alcohol Intake Before and During Pregnancy
43.1
8.0
0
20
40
60
80
100
Drank Alcohol 3 Months BeforePregnancy
Drank Alcohol During Last 3Months of Pregnancy
Perc
ent
Alcohol
Alcoholconsumptionduringpregnancyisassociatedwithfetalalcoholspectrumdisorders(FASD)[�]andcertainbirthdefects[�].Becausewomenmightnotknowtheyarepregnantforseveralweeks,theCDCrecommendsthatwomenwhoaresexuallyactiveanddonotusebirthcontrolabstainfromdrinking[�].Addi-tionally,becausethereisnoknownsafeamountofalcoholtodrinkduringpreg-nancy,itisrecommendedthatallpregnantwomenabstainfromdrinking[�].
uApproximately��%ofwomenreporteddrinkingduringthethreemonthsbeforepregnancyand�%reporteddrinkingduringthelastthreemonthsof pregnancy(Figure��).
Figure 19. Alcohol Intake Before and During Pregnancy
Women who binge drink (defined as five or more drinks on the same occasion) are morelikelytohaveanunintendedpregnancyandaremorelikelytodrinkduringpregnancy[�].
uApproximately��%ofwomenreportedbingedrinkingduringthethreemonthsbeforepregnancy.Almost�%reportedbingedrinkingduringthelastthreemonthsofpregnancy(Figure�0).
��
Figure 21. Binge Drinking (5+ Drinks on 1 Occasion) 3 Months Before Pregnancy by Race/Ethnicity
12.2 12.0
21.7
0
10
20
30
40
50
African-American Hispanic White/Other
Perc
ent
Figure 20. Binge Drinking (5+ Drinks on 1 Occasion) Before and During Pregnancy
15.9
2.5
0
10
20
30
40
50
3 Months Before Pregnancy During the Last 3 Months ofPregnancy
Perc
ent
Figure 20. Binge Drinking (5+ Drinks on One Occasion) Before and During Pregnancy
uThehighestprevalenceofbingedrinkingbeforepregnancywasamongwhite/otherwomen(Figure��).
Figure 21. Binge Drinking Three Months Before Pregnancy by Race/Ethnicity
2.4
��
References
�. CDC.Tobacco Use and Pregnancy.�00�[cited�0/0�/�00�];Available from: http://www.cdc.gov/reproductivehealth/TobaccoUsePregnancy/index.htm.�. CDC.Fetal Alcohol Spectrum Disorders.�00�[cited�0/��/�00�]; Availablefrom:http://www.cdc.gov/ncbddd/fas/fasask.htm.�. Ernhart,C.B.,etal.,Alcohol teratogenicity in the human: a detailed as- sessmentofspecificity,criticalperiod,andthreshold.AmJObstet Gynecol,����.���(�):p.��-�.�. Naimi,T.S.,etal.,Binge drinking in the preconception period and the risk of unintended pregnancy: implications for women and their children. Pediatrics,�00�.���(�Part�):p.����-��.
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Figure 22. Any Physical Abuse Before and During Pregnancy Among Women Aged 18 Years and Older
9.3
6.6
0
5
10
15
20
Any Physical Abuse BeforePregnancy
Any Physical Abuse DuringPregnancy
Perc
ent
Abuse
Nationwide,approximately���,000pregnantwomenareaffectedbyintimatepartner
violenceeachyear[�].Thisincludesphysical,sexual,psychological,andemotionalabuse.In�00�,itwasreportedthathomicidewastheleadingcauseofinjurydeathamongpregnantandpostpartumwomen[�].Womenyoungerthan�0,African-American,andwithlateornoprenatalcarewerefoundtobeathighestrisk.Inadditiontophysicalandemotionalinjuriestothemother,
thereareanumberofadverseconsequencesthatcanaffectthedevelopingfetus,includingpretermbirth,lowbirthweightandfetalloss.
The PRAMS survey asks mothers specifically about physical violence before and duringtheirpregnancy.
uInTexas,�%ofwomenreportedbeingphysicallyhurtinthe��monthsbeforepregnancyand�%duringpregnancy(Figure��).
Figure 22. Any Physical Abuse Before and During Pregnancy Among Women Aged 18 Years and Older
“I wish someone would have talked with me about
marital problems and violence in the home. Not
everyone is as happy as they pretend to be.”
��
Figure 23. Any Physical Abuse During Pregnancy Among Women Aged 18 Years and Older by Marital Status
2.8
14.5
0
5
10
15
20
Married Not Married
Perc
ent
u Women who were not married had a significantly higher prevalence ofphysicalabuseduringpregnancy(Figure��).
Figure 23. Any Physical Abuse During Pregnancy Among Women Aged 18 Years and Older by Marital Status
References
1. Gazmararian, J.A., et al., Prevalence of violence against pregnant women. Jama,����.���(��):p.����-�0.�. Chang,J.,etal.,Homicide: a leading cause of injury deaths among pregnant and post-partum women in the United States, 1991-1999.AmJ PublicHealth,�00�.��(�):p.���-�.
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Figure 24. Breastfeeding Initiation After Most Recent Pregnancy by Race/Ethnicity
53.1
74.5 77.0
0
20
40
60
80
100
African-American Hispanic White/Other
Perc
ent
Infant Health Breastfeeding
Breastfeedingprovidessubstantialbenefits to both mother and child.
Infantsreceivecompletenutritionfrombreastmilkaswellasantibodiesthathelpprotect against infection. Benefits to moth-ersincludequickerpregnancyweightreduction,lessbleedingafterdelivery,andpossiblereducedrisksofbreastandovariancancers[�].
u There was a significant difference in the prevalence of breastfeedinginitiationafterthemostrecentpregnancybyrace/ethnicity.Only��%ofAfrican-Americanwomeninitiatedbreastfeedingcomparedtoover�0%amongwomenwhowereofHispanicandwhite/otherrace/ethnicities(Figure��).
Figure 24. Breastfeeding Initiation After Most Recent Pregnancy by Race/Ethnicity
“No one in the hospital helped me with breastfeeding or answered any questions.”
Percent of women who initiated breastfeeding after their most recent pregnancy: 73%
��
Figure 25. Breastfeeding Initiation After Most Recent Pregnancy by Age
53.6
71.477.8 81.5
0
20
40
60
80
100
19 20-24 25-34 35+Age in Years
Perc
ent
uTheprevalenceofbreastfeedingalsodiffersbyagegroup.Theprevalenceincreaseswitholderageandissubstantiallyloweramongteenagemothers(Figure��).
Figure 25. Breastfeeding Initiation After Most Recent Pregnancy by Age
TheAmericanAcademyofPediatricsrecommendsthatwomenbreastfeedexclu-sivelyforsixmonths[�]andtheHealthyPeople�0�0targetis�0%ofwomenwhobreastfeedforsixmonths[�].BecausewomenbecomeeligibleforPRAMSat two months after delivery, the data were analyzed for the prevalence of women whobreastfedforatleastnineweeks.
“My job didn’t allow me to pump as often as I needed to.”
��
Figure 26. Breastfeeding for at Least 9 Weeks After Most Recent Pregnancy
20.9
38.9
55.360.0
0
20
40
60
80
100
19 20-24 25-34 35+Age in Years
Perc
ent
uTheoverallpercentofwomenwhobreastfedatleastnineweekswas��%.Theprevalencesubstantiallyincreaseswithage(Figure��).
Figure 26. Breastfeeding for at Least Nine Weeks After Most Recent Pregnancy
Sleep position
Amonginfantsagedoneto��months,SuddenInfantDeathSyndrome(SIDS)istheleadingcauseofdeath[�].Placinganinfantonitsbacktosleephasbeenidentified as way to help reduce the risk of SIDS. In 1996, the percent of infants whowereconsistentlyplacedontheirbackstosleepintheU.S.was��%.TheHealthyPeople�0�0targetis�0%[�].
“I do not believe that putting babies on their backs helps reduce SIDS. I believe it raised chances of choking.”
“I would just like to say thanks to the media and magazines for emphasizing the importance of keeping babies on their backs only to sleep. I think it’s very important.”
��
Figure27. Infants Most Often Placed on Their Backs to Sleep by Race/Ethnicity
25.1
46.4
62.9
0
20
40
60
80
100
African-American Hispanic White/Other
Perc
ent
uInTexas,�00�PRAMSdataindicatethatthepercentofinfantsplacedontheirbackstosleepwas��%.Theprevalencedifferedbyrace/ethnicityandwaslowestamongAfrican-Americanwomen(Figure��).
Figure 27. Infants Most Often Placed on Their Backs to Sleep by Race/Ethnicity
References
�. Gartner,L.M.,etal.,Breastfeeding and the use of human milk.Pediatrics, �00�.���(�):p.���-�0�.�. Healthy People 2010,U.S.DHHS,Editor.�000,GovernmentPrinting Ofice.�. CDC.Sudden Infant Death Syndrome.�00�[cited�0/0�/�00�];Available from:http://www.cdc.gov/SIDS/index.htm.
��
�0 3/2008