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What is NE PRAMS? The Nebraska Pregnancy
Risk Assessment Monitoring System is an ongoing population‐based
surveillance system of maternal behaviors and
experiences before, during, and after pregnancy. NE PRAMS is a joint research project between the
Nebraska Department of Health and Human Services and the Centers for Disease
Control and Prevention (CDC). It is an initiative to reduce
infant mortality and low birth weight and was developed to supplement vital records data by providing state‐specific data to be used for planning and evaluating perinatal
health programs. The data presented in this fact sheet reflect live births of Nebraska mothers during the years of
2004‐2007.
Lifespan Health Services Public Health Division Nebraska Department of Health and Human Services
What is an unintended pregnancy? Unintended pregnancies are defined as pregnancies which, at the time of conception, are either mistimed (the woman did not want to be pregnant until later) or unwanted (the woman did not want to be pregnant at any time). PRAMS asks new mothers: “Thinking back to just before you got pregnant with your new baby, how did you feel about becoming pregnant?”
I wanted to be pregnant sooner I wanted to be pregnant later I wanted to be pregnant then I did not want to be pregnant
then or at any time in the future (“never”).
If a mother answers “later” or “never,” the pregnancy is considered to be unintended.
Why is unintended pregnancy an important issue?
Research has shown that unintendedness of pregnancy is associated with poor pregnancy outcomes for the infant (such as prematurity).2,3,4
An unintended pregnancy can have a negative impact on the mother’s physical, emotional or economic well‐being. These can in turn affect the baby and the family.5,6
A woman who plans her
pregnancy can take steps to become healthier before she conceives, such as: taking folic acid quitting smoking abstaining from alcohol addressing medical
conditions.7
In 2006, unintended pregnancies accounted for 33.4% to 59.5% of pregnancies in the 24 states with PRAMS data reported by the CDC. Nebraska was in the middle, ranked 12th. 1
NOTE: Unintended pregnancies are not necessarily unwanted pregnancies. PRAMS mothers sometimes write as a comment beside the above question – “Didn’t mind if I got pregnant.” Many women who did not intend to become pregnant find they want the pregnancy once they become aware of it. According to NE PRAMS, an estimated 40.9% of Nebraska
mothers reported unintended pregnancies. This represents an estimated 10,366 births per year during 2004‐2007.
40%
60%
80%
NOTE: All results described above as "significant" remained significant after statistical adjustment (page 4).
20%
0%
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0%
0%
20%
40%
60%
80%
100%
0%
20%
40%
60%
80%
100%
. . . had more stressful life events.
They were significantly more likely to experience:
problems with husband or partner such as separation, divorce, or physical abuse during pregnancy.
financial problems such as losing a job, moving, homelessness, not being able to pay bills.
behavior problems of their own or someone close to them such as drinking, drugs, physical fights, abuse, jail, illness or death.
Health Related Behaviors
Inadequate folic acid before
pregnancy
Nebraska mothers who had not intended to become pregnant. . .
. . . had more risk factors before pregnancy.
They were significantly more likely to have:
no health insurance or Medicaid coverage just before becoming pregnant.
experienced physical abuse before pregnancy.
. . . had more high‐risk behaviors.
They were significantly more likely to:
smoke cigarettes before and during pregnancy.
get inadequate folic acid (vitamins) before pregnancy.
start prenatal care late (after the first trimester).
never breastfeed, or quit within the first month.
PRAMS and Unintended Pregnancy - Page 2
Lifespan Health Services Public Health Division Nebraska Department of Health and Human Services
Pre‐Pregnancy Risk Factors
Previous preterm or low birth
weight birth
No post‐high school
education
No health insurance or Medicaid
Physical abuse by partner or
someone else
Smoker before
pregnancy
Late or no prenatal care
Breastfed less than 4 weeks
Never breastfed
Stressful Life Events(During the 12 months before the birth)
Partner Financial Behaviors
10% 20% 30% 40%0%
Characteristics of the Two Groups of Women NOT Intending Pregnancy
Risk factor Group 1: Didn’t use contraception
Group 2: Contraception failed
Low Income* 59% 58% No post‐high school education
55% 45%
Smoked before pregnancy
42% 32%
Previous preterm low birth weight baby
19% 15%
Teen (under 20) 16% 13% *Low Income is defined as below 185% of Federal Poverty Level
PRAMS asks mothers: “When you got pregnant with your new baby, were you or your husband or partner doing anything to keep from getting pregnant?” Based on responses to this question it is estimated that nearly half (47.2%) of the 10,366 Nebraska mothers with unintended pregnancies each year had not been doing anything to keep from getting pregnant. The remaining 52.8% had been doing something to prevent the pregnancy, but their contraceptive efforts had failed.
Use of birth control prior to pregnancy of mothers who had not intendedto become pregnant. . .
PRAMS and Unintended Pregnancy - Page 3
Lifespan Health Services Public Health Division Nebraska Department of Health and Human Services
A woman’s intentions about pregnancy can be difficult to capture in a survey. She may have mixed feelings or “ambivalence” about becoming pregnant. She may actually intend NOT to plan her pregnancies. She may not remember accurately how she felt before becoming pregnant.
Among Nebraska mothers who reported that they didn’t intend pregnancy and weren’t using birth control, 30.2% selected “You didn’t mind if you got pregnant” as a reason.
This subset of the unintended pregnancy group represents an estimated 1,450 births annually (14% of all unintended pregnancies) that may not be truly unintended. Women who “didn’t mind” getting pregnant were less likely to be on Medicaid and more likely to have private insurance before pregnancy, less likely to start prenatal care late, more likely to be White or Asian, and less likely to experience stressful events than the others in the unintended group.
Reasons for NOT using ContraceptionAmong Women Reporting Unintended Pregnancies
Percent
Didn’t mind if you got pregnant
Thought you couldn’t get pregnant at that time
Husband or partner didn’t want to use anything
Had side effects from birth control
Had problems getting birth control
Thought you or your husband or partner was sterile
The large number of unintended and unplanned pregnancies . . .“. . . underscores the importance of promoting a woman’s health regardless of her pregnancy plans. A ‘life span’ approach to pregnancy outcome identifies the antecedents of poor perinatal outcome and links behaviors and risks across time, not solely during those periods in which a woman is pregnant.”7
Preconception Care Goal: Each woman, man, and couple should be encouraged to have a reproductive life plan.8
Acknowledgements Carol Gilbert, Debra Kane, Ashley Busacker, Laurin Kasehagen, Brenda Coufal, Jennifer Severe‐Oforah, and Debora Barnes‐Josiah, Paula Welter, Helena Meyers, Marci Crawford and Janette McCabe
For more information about NE PRAMS or other PRAMS data please contact Brenda Coufal, PRAMS Coordinator at (402) 471‐9044 or [email protected]
www.dhhs.ne.gov/prams/
Statistical Adjustment: In order to more accurately portray relationships between risk factors and health outcomes, we used a statistical approach called logistic regression to “adjust” or account for characteristics that might bias our understanding of important relationships.
For example, women without insurance are more likely to have unintended pregnancies, but this may only be because younger women are less likely to intend pregnancy and are less likely to have health insurance. To study the relationship between insurance and intendedness we need to adjust for age.
When we simultaneously adjusted for age, race, marital status and poverty, we found that a significant relationship still existed between intendedness of the pregnancy and each of the factors shown on page 2, with the exception of maternal education and previous preterm or low birth weight birth.
PRAMS and Unintended Pregnancy - Page 4
SOURCES:1. PRAMS CPONDER system, accessed 7/18/2009
http://www.cdc.gov/prams/cponder.htm 2. Hellerstedt WL, Pirie PL, Lando HA, et al. Differences in
preconceptional and prenatal behaviors in women with intended and unintended pregnancies. Am J Public Health 1998;88:663–666.
3. Kost K, Landry DJ, Darroch JE. The effects of pregnancy planning status on birth outcomes and infant care. Family Planning Perspectives 1998;30(5):223–230.
4. Sable MR, Spencer JC, Stockbauer JW, Schramm WF, Howell V, Herman AA. Pregnancy wantedness and adverse pregnancy outcomes: differences by race and Medicaid status. Family Planning Perspectives 1997;29(2):76–81.
5. Brown and Eisenberg. The best intentions: Unintended pregnancy and the well‐being of children and families. Washington, DC: National Academy Press 1995. Reporting the conclusions of the Committee on Unintended Pregnancy of the Institute of Medicine.
6. The Effects of Unintended Pregnancy on Infant, Child, and Parental Health: A Review of the Literature Jessica D. Gipson, Michael A. Koenig, and Michelle J. Hindin. Studies In Family Planning 2008; 39[1]:18–38
7. Misra DP, Guyer B, Allston A. Integrated perinatal health framework. A multiple determinants model with a life span approach. American Journal of Preventive Medicine 2003;25(1):65–75)
8. Centers for Disease Control and Prevention. Recommendations to improve preconception health and health care — United States: a report of the CDC/ ATSDR Preconception Care Work Group and the Select Panel on Preconception Care. MMWR 2006;55 (No. RR‐ 6)
Lifespan Health Services Public Health Division Nebraska Department of Health and Human Services
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Department of Health & Human Services