Kristina Wint, AMCHP Program Manager, Women & Infant Health
Early this year, the Centers for Disease Control and Prevention (CDC) announced the release of 2018 data from the Pregnancy Risk Assessment Monitoring System (PRAMS).
Developed in 1987, the system aims to support efforts to reduce infant morbidity and mortality by providing data that are not available through other sources. PRAMS data are useful in identifying groups of women and infants that are in high risk categories for negative health outcomes. PRAMS reports on approximately 83 percent of U.S. births. Public health officials and researchers use these data to help improve the wellness of women, infants, and their families.
PRAMS data have been useful for expanding the literature base for a variety of topics, including but not limited to, safe sleep, breastfeeding, mental and behavioral health, contraception use, and access to health care.
How are the Data Derived?
After sampling state birth certificate files, researchers identify participants and survey them via mail. If the people contacted do not answer the mailing, they are subsequently called, using standardized instruments.
PRAMS Data Analyses
Data Analysis on Safe Sleep Practices
Analyzing 2016 PRAMS data from 29 states, researchers compiled a current population-level analysis on safe sleep practices. In examining the data, researchers found that the majority of families placed infants to sleep on their back. When the researchers took a state-level, more granular look at the data, they found that sociodemographic and state/regional norms were not related to variations in safe sleep practices. This analysis opens the door for further research to determine the precise factors that are related to and cause variation in safe sleep and sudden infant death/sudden unexpected infant death syndromes.
Data Analysis on Long-Acting Reversible Contraception Use
PRAMS data have also been key to understanding the prevalence of long-acting reversible contraception (LARC) use. While, age, race/ethnicity, education, access to health insurance, and other factors have an impact both on contraceptive use and the choice of contraceptive, the utilization rate of LARCs tends to be lower in comparison to less effective methods. This PRAMS analysis found that nearly 1 in 6 postpartum women with a recent live birth and 1 in 4 postpartum women using contraception choose to use LARCs, demonstrating an increase in LARC utilization from previous years. Using the data as a foundation, researchers may explore and conduct additional analyses to understand the access, barriers, and intentions of women’s contraception choices.
Data Analysis on Electronic Vapor Products
Because the PRAMS instrument is a standardized tool, researchers can also perform state-to-state analyses. An analysis of PRAMS data from Oklahoma and Texas explored the use of electronic vapor products (EVPs). Researchers were able to analyze participants’ EVP and cigarette use, as well as the participants’ knowledge regarding the potential harm of EVPs. From the analysis, researchers learned that of women who reported using EVPs before, during, or after pregnancy, 38.4 percent used an EVP with nicotine and 26.4 percent did not know whether the EVP used contained nicotine. When participants were asked why they chose EVPs, reasons included believing that the EVP would help with quitting or reducing cigarette use and that the EVP was less harmful than cigarettes. Oklahoma and Texas health officials used the findings from this analysis to tailor smoking cessation education, counseling, and treatments that consider perceptions and misconceptions about EVP use.
PRAMS data for the above topics and others are available now; learn more and make a data request here.
Other Uses of PRAMS Now and in the Future
As PRAMS continues to collect data and improve upon its processes and questions, researchers will perform more analyses. Over the next year and beyond, data will become available for analysis for a variety of new topics, from opioid use to father involvement.
Responding to the growing crisis in opioid use, PRAMS now has an Opioid Supplement questionnaire to elicit more information about substance use in pregnancy and postpartum. Following the same PRAMS guidelines, the supplement consists of 13 questions included at the end of the PRAMS survey. The supplement asks participants questions related to their substance use, experience with counseling, and knowledge on use risk. In addition to the questions in the supplement, researchers are proposing an Opioid Call-Back questionnaire, which would sample participants in counties where opioid use and opioid deaths are high, 9 to 10 months postpartum, to gather even more detailed data on a variety of metrics in relationship to substance use. The supplements include topics such as reasons and frequency of opioid use, understanding of risks to self and baby, reasons for receiving or not receiving treatment, comorbidities, breastfeeding, and access to supportive services. The data collected in late 2019 included these questions, and datasets were available upon request in the spring of 2020.
PRAMS data have also been instrumental in the collection of population-based data on disability and pregnancy. The Washington Group Short Set of Questions on Disability (WG-Short Set), a standardized assessment of disability, was added to PRAMS in 2019 and initial data became available for analysis in early 2020. With the inclusion of this supplement, we now have the capacity for a more robust understanding and can perform comparisons of the experience of pregnancy and birth between women with and without a disability.
Beginning in 2018, the PRAMS sampling methodology was modified in Utah to survey all women who experienced a stillbirth using fetal death certificates. This surveillance system, the Study of Associated Risks of Stillbirth (SOARS), was designed to provide the state with important and timely data on risk factors associated with stillbirth. The survey includes questions on prenatal, obstetric, and postpartum health care following the stillbirth to supplement data from medical records and fetal death certificates. The SOARS pilot showed positive preliminary results, with a high response rate and multiple positive comments.
As public health begins to embody the “mother-baby-family” triad, the need to close the gap in research on the crucial role of partners and fathers becomes more apparent. The CDC’s Division of Reproductive Health in collaboration and partnership with Northwestern University, have been exploring the feasibility of developing and conducting a PRAMS-like survey with new fathers. Between October 2018 and June 2019, PRAMS for Dads was piloted in Georgia with positive outcomes. Two methods of contacting participants were assessed, with comparable response rates. This indicates that PRAMS for Dads has the potential to collect important population-level data on the relationship between paternal factors and pregnancy outcomes as well as the unique issues fathers face in their transition to fatherhood.
PRAMS is a timely and important resource to help the MCH field understand a variety of health issues that affect women, infants, and families. As new threats to maternal, infant, and child health emerge, such as natural disasters and infectious disease pandemics like COVID-19, PRAMS data will guide the way for learning how to best address and prevent these issues. PRAMS data are among the available resources to help public health officials and researchers as well as the communities served maintain and preserve good health and wellness.
 Hirai, A. H., Kortsmit, K., Kaplan, K., Reiney, E., Warner, L., Parks, S. E., Perkins, M., Koso-Thomas, M., D’Angelo, D. V., & Shapiro-Mendoza, C. K. (November 2019). Prevalence and factors associated with safe infant sleep practices. Pediatrics, 144(5) e20191286. https://doi.org/10.1542/peds.2019-1286
 Oduyebo, T., Zapata, L. B., & Boutot, M. E., et al. (2019). Factors associated with postpartum use of long-acting reversible contraception. Am J Obstet Gynecol, (221) 43, e1-11.
 Kapaya, M., D’Angelo, D. V., & Tong, V. T., et al. (2019). Use of electronic vapor products before, during, and after pregnancy among women with a recent live birth — Oklahoma and Texas, 2015. (2019). Morbidity and Mortality Weekly Report, 68,189–194. DOI: http://dx.doi.org/10.15585/mmwr.mm6808a1external icon
 D’Angelo, D. V., Cernich, A., Harrison, L., Kortsmit, K., Thierry, J. M., Folger, S., & Warner, L. (2020). Disability and pregnancy: A cross-federal agency collaboration to collect population-based data about experiences around the time of pregnancy. Journal of Women’s Health, 29(3), 291-296.
 Stone, N., Baksh, L., Alagarin, B. & Smith, P. (n.d.). Study of Associated Risks of Stillbirth (SOARS). https://mihp.utah.gov/wp-content/uploads/SOARS_StarLegacy_Poster2019_REVISED.pdf.
 Garfield, C. F., Simon, C. D., Harrison, L., Besera, G., Kapaya, M., Pazol, K., Boulet, S., Grigorescu, V., Barfield, W., & Warner, L. (2018). Pregnancy Risk Assessment Monitoring System for Dads: Public health surveillance of new fathers in the perinatal period. American Journal of Public Health, 108(10), 1314–1315. https://doi.org/10.2105/AJPH.2018.304664