Preconception Health Indicators Among Women — Texas, 2002–2010

The first few weeks after conception are the most critical for fetal development; because most women are not aware that they are pregnant until after this critical period, health-care interventions should begin before conception. Promoting preconception health is an essential component of any broad strategy to prevent adverse pregnancy outcomes. Women who are planning pregnancy or could become pregnant should have a preconception health evaluation and adopt appropriate health behaviors. The Pregnancy Risk Assessment Monitoring System (PRAMS) tracks maternal behaviors, experiences, and health conditions, including preconception health. PRAMS is a state-specific, population-based surveillance system. The Texas Department of State Health Services analyzed PRAMS responses regarding preconception health of Texas women who delivered a live-born infant during 2002−2010. Among women who responded, 48% had no health-care insurance coverage before pregnancy and 46% reported an unintended pregnancy. In addition, 45% of the women reported consuming alcohol during the 3 months before pregnancy, and 18% reported binge drinking. Differences in demographic and socioeconomic variables were observed for the majority of preconception health indicators. Compared with non-Hispanic white women, non-Hispanic black and Hispanic women reported a 20% higher prevalence of not consuming a daily multivitamin and of being physically inactive, and approximately twice the prevalence of prepregnancy diabetes. Women without health-care coverage (public or private) before pregnancy generally were more likely to report unfavorable behavioral characteristics and health conditions compared with women with health-care coverage, regardless of whether the pregnancy was planned or not. Targeted public health interventions addressing the observed disparities in the preconception health and health care of women in Texas are needed.

PRAMS is an ongoing, state- and population-based surveillance system that collects data regarding maternal behaviors, experiences, and health before, during, and after pregnancy (1). Since 2002, Texas birth certificate records have been used each month to select a stratified random sample of approximately 200 women who gave birth to a live-born infant within the prior 2–3 months, to whom a self-administered questionnaire* is then mailed. Up to three questionnaires are sent to those who do not respond. Women who do not respond to any of the survey attempts are contacted and interviewed by telephone. During 2002–2010, 22% of interviews were conducted by telephone. Contact efforts end when the women reach 9 months postpartum. A total of 26,435 birth records were selected and 16,035 mothers completed a survey. After excluding records for which race was categorized as "other," data from 15,386 respondents aged 13–47 years who delivered during 2002–2010 in Texas were analyzed. The analyses were restricted to Hispanics and non-Hispanic blacks and whites because of the heterogeneity and small sample size of other races/ethnicities. The mean weighted survey response rate during this 9-year period was 62% (range: 54%–67%), with no clear trend. Data were weighted to account for the complex sample design, nonresponse, and noncoverage (exclusion from the sampling frame). Prevalence estimates and crude prevalence ratios of preconception health indicators were calculated by race/ethnicity, education, age, health-care coverage before pregnancy, whether delivery was paid for by Medicaid, and whether the pregnancy was intended.† Alcohol consumption, smoking,§ and physical inactivity¶ were determined for the 3 months before pregnancy, and multivitamin use was determined for the month before pregnancy.**

A high proportion of respondents reported suboptimal preconception health indicators. Overall, 46% reported that their current pregnancy was unintended; 75% reported not taking daily multivitamins (63% reported not taking multivitamins at all) during the month before pregnancy; 17% reported smoking; 45% reported consuming alcohol, and 18% reported binge drinking; and 40% were physically inactive during the 3 months before pregnancy (Table 1). Poor health and poor access to health care also were reported. Reports of suboptimal preconception health†† included being underweight (5%), overweight (24%), obese (22%), or anemic (13%). Among surveyed women, 48% had no health-care coverage before pregnancy, and of those who had health-care coverage before pregnancy, 17% were covered through Medicaid.

The unfavorable preconception health indicators varied considerably by demographic factors (Table 2). Compared with non-Hispanic white women, non-Hispanic black women and Hispanic women had a 50% and 30% higher prevalence, respectively, of obesity, and a 20% higher prevalence of physical inactivity, being overweight, and not consuming a daily multivitamin. The most striking racial/ethnic differences were observed for chronic medical conditions. Compared with non-Hispanic white women, non-Hispanic black women had three times the prevalence of hypertension and anemia and two times the prevalence of diabetes. Among Hispanic women, the prevalence of diabetes was 80% higher and the prevalence of anemia was 60% higher than among non-Hispanic white women. The prevalence of alcohol consumption and binge drinking during the 3 months before pregnancy were highest among groups of women who were non-Hispanic white, aged 20–34 years, had more than a high school education, had health-care coverage before pregnancy, had an unintended pregnancy, and for whom Medicaid did not pay for delivery.

Within the surveyed population, 59% of women reported that Medicaid paid for delivery. Medicaid paid for deliveries among women with incomes ≤185% of the federal poverty level. Women for whom Medicaid paid for delivery and those who did not have health-care coverage before pregnancy had a higher prevalence of smoking, physical inactivity, not consuming daily multivitamins, and adverse health conditions (Table 1). Among women with an intended pregnancy, lack of health-care coverage before pregnancy was associated with a 70% higher prevalence of anemia, 50% higher prevalence of being underweight, 30% higher prevalence of obesity and not consuming daily multivitamins, and 20% higher prevalence of physical inactivity (Table 3). For women with unintended pregnancies, lack of health-care coverage before pregnancy was associated with slightly higher prevalences of no daily multivitamin use, smoking, overweight, and anemia. During 2002–2010, statistically significant increases over time were observed in health-care coverage before pregnancy (52% to 59%), binge drinking (15% to 21%), and obesity (17% to 24%). In multivariate models that controlled for age, race/ethnicity, education, and pregnancy intent, Medicaid-paid deliveries predicted higher levels of anemia, diabetes, obesity, smoking, physical inactivity, and lower levels of daily multivitamin consumption, compared with deliveries that were not paid for by Medicaid.

CDC recommends a minimum response rate of 65% for minimal nonresponse bias. Because PRAMS response rates in Texas were lower than the CDC-recommended levels, key demographic variables for responders and nonresponders were compared. Response rates were lowest among non-Hispanic black women (48%), women with a high school education or less (55%), and younger women (54% and 58% for women aged ≤19 years and 20–34 years, respectively).

Reported by

Rochelle Kingsley, MPH, Rebecca Martin, PhD, Mark Canfield, PhD, Amy Case, MAHS, Texas Dept of State Health Svcs. Diana Bensyl, PhD, Div of Applied Sciences, Scientific Education and Professional Development Program Office; Noha H. Farag, MD, PhD, EIS Officer, CDC. Corresponding contributor: Noha H. Farag, [email protected], 512–776–6304.

Editorial Note

Every health-care visit provides an opportunity to assess and address unhealthy behaviors and health conditions known to adversely affect pregnancy outcomes. Therefore, access to health care and use of health-care services are crucial for improving women's pregnancy outcomes. Nearly half (48%) of Texas women surveyed by PRAMS did not have any health-care coverage before their pregnancy. Of the 52% of women who did have health-care coverage before pregnancy, 17% had coverage through Medicaid, and 59% of all deliveries in Texas were paid for by Medicaid. Women who qualify for Medicaid at delivery are low-income women who often are at greatest risk for adverse pregnancy outcomes, and most in need of essential preconception care services. This gap in coverage means that low-income women who cannot afford preconception care, but who are at greatest risk for adverse pregnancy outcomes, are missing essential preconception care services. Ensuring access to subsidized preconception health-care services for low-income women might help to close this gap between the time Medicaid coverage begins at delivery and the time preconception health care is most needed, before pregnancy begins.

Hispanic women accounted for 50% of live-births in Texas in 2009 (2), but only 37% of Hispanic women had health-care coverage before conception. Given the rapidly increasing Hispanic population in Texas, more efforts and outreach are needed to enroll low-income women, especially Hispanics, in Medicaid before they become pregnant.

However, even some of the women in Texas who had health-care coverage and a planned pregnancy also had some preconception health indicators (e.g., obesity, smoking, and limited multivitamin use) that could be improved. Therefore, having access to health-care does not ensure that women will seek it or that they will receive the appropriate content of preconception care. In the U.S. health-care system, preconception care has not received as much attention as care received during pregnancy (3). A two-pronged approach would be ideal to address these issues. First, women need to have access to preconception health-care services. Second, effective implementation and use of preconception health-care services by women and their providers could be attained through training and targeted educational messages. Since CDC's publication in 2006 of recommendations to improve preconception health (4), numerous efforts have been initiated to support this goal (5). Texas was one of seven states represented on a committee convened in 2007 to propose measurable preconception health indicators at the state level (6). In 2011, the Texas legislature appropriated $4.1 million for the Texas Department of State Health Services to fund the Healthy Texas Babies initiative. The purpose of the initiative is to decrease infant mortality by implementing evidence-based interventions at the community level. The primary goal of this initiative is to reduce the preterm birth rate by 8% over 2 years and save $7.2 million in Medicaid costs for that period.

Despite major advances in prenatal care, the incidence of adverse pregnancy outcomes is higher in the United States than in most developed countries (7). The first few weeks after conception are the most critical for fetal development; because most women are not aware that they are pregnant until after this critical period, health-care interventions should begin before conception. CDC recommendations call for providing risk assessment and counseling to all women of childbearing age during primary care visits (4). The findings in this report indicate that Texas women often have risk behaviors and chronic medical conditions during the preconception period that place them at increased risk for adverse pregnancy outcomes. Because 46% of pregnancies in Texas were unintended, it is important for women of childbearing age to receive preconception care during encounters with the health-care system. However, a sizeable percentage of women who had a planned pregnancy and health-care coverage also had unfavorable preconception health indicators, suggesting that the presence of health-care coverage does not ensure necessarily that it is used appropriately. Education messages targeting health-care providers and women of reproductive age are needed to close the gap. The 2006 CDC recommendations call for increasing consumer awareness through use of information and tools appropriate across varying age, literacy, and cultural/linguistic contexts (4).

The findings in the report are subject to at least three limitations. First, the Texas PRAMS average response rate during 2002–2010 was 62%; CDC sets a response rate threshold of 65% for minimal nonresponse bias. Despite the fact that data are weighted to account for nonresponse, this does not eliminate the possibility of nonresponse bias. However, because the response rates were lower among women who were younger, black, or had less education, and these are the groups of women that have worse preconception health profiles, the actual preconception health status of women in Texas is likely less favorable and the disparities greater than reported here. Second, PRAMS data are self-reported and subject to recall bias and other biases inherent in self-reported survey data. Finally, results are generalizable only to women who recently delivered a live-born infant and not to all women of childbearing age. Despite these limitations, PRAMS is a useful tool for monitoring progress toward improving preconception health through effective policies and interventions (8).

Although CDC and several national organizations provide recommendations and practice guidelines for preconception care, Texas levels of preconception indicators have not improved over time and are suboptimal compared with the Healthy People 2020 targets of 33.1% daily multivitamin intake and 100% abstinence from binge drinking.§§ Evidence-based preconception interventions that require access to costly services are useful only if women have health care providing those services to them. Providing preconception health care at any encounter with the health-care system to all women who can become pregnant might improve pregnancy outcomes in Texas.

Acknowledgments

Kristin Neland, Medicaid/CHIP Div, Texas Health and Human Svcs Commission; Texas A&M Public Policy Research Institute. Indu B. Ahluwalia, PhD, Lauren B. Zapata, PhD, Div of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

References

1. Schulman H, Gilbert BC, Lansky A. The Pregnancy Risk Assessment Monitoring System (PRAMS): current methods and evaluation of 2001 response rates. Public Health Rep 2006;121:74–83.
2. Texas Department of State Health Services. 2009 natality file. Austin, TX: Center for Health Statistics, Texas Department of State Health Services; 2012. Available at http://www.dshs.state.tx.us/chs/vstat/vs09/anrpt.shtm. Accessed July 23, 2012.
3. Atrash H, Jack BW, Johnson K, et al. Where is the "W"oman in MCH? Am J Obstet Gynecol 2008;199(6 Suppl 2):S259–65.
4. CDC. Recommendations to improve preconception health and health care—-United States. MMWR 2006;55(No. RR–6).
5. Association of Maternal and Child Health Programs. Preconception health success stories. Pulse. Nov 2008. Available at http://www.amchp.org/aboutamchp/newsletters/pulse/archive/2008/november08/pages/successstories.aspx. Accessed June 20, 2012.
6. Broussard DL, Sappenfield WB, Fussman C, Kroelinger CD, Grigorescu V. Core state preconception health indicators: a voluntary, multi-state selection process. Matern Child Health J 2011;15:159–68.
7. MacDorman MF, Mathews TJ. Behind international rankings of infant mortality: How the United States compares with Europe. NCHS data brief, no 23. Hyattsville, MD: US Department of Health and Human Services, CDC, National Center for Health Statistics; 2009. Available at http://www.cdc.gov/nchs/data/databriefs/db23.pdf. Accessed July 20, 2012.
8. Institute of Medicine. Child and adolescent health and healthcare quality: measuring what matters. Washington, DC: The National Academies Press; 2011.