PRAMS: Pregnancy Risk Assessment Monitoring System Explained

Introduction to PRAMS

The Pregnancy Risk Assessment Monitoring System (PRAMS) is a collaborative project involving state health departments and the Centers for Disease Control and Prevention (CDC). Unveiled in 1987, PRAMS gathers data relating to the experiences and attitudes of women prior to, during, and immediately following a pregnancy. Data collected is always specific to a given state, and the surveillance program covers up to 83% of infant births in the United States (CDC, 2017).

When PRAMS was launched, there was serious national and statewide concern about infant mortality, its reduction, and related disparities. Prenatal care with state support was also a focal area of interest. At the time, there was no state-level information that could adequately inform state or local program evaluation and development. PRAMS's structure makes possible a deeper inquiry into topics of reproductive health compared to the extensive but limited information contained in birth certificates (CDC, 2013).

Target Population and Surveillance Methods

PRAMS makes available data that cannot be found elsewhere. The data collected is used to identify infants and women exposed to health risks, to examine changes in health status, and to determine the progress made in enhancing the health of infants and mothers. Researchers use PRAMS data to investigate emerging issues in reproductive health. Local and state governments likewise use PRAMS for the planning and review of policies and programs designed to alleviate health concerns affecting infants and mothers (CDC, 2017).

PRAMS is a mixed-setting surveillance program designed to provide state governments with ongoing, population-based, state-specific information on selected maternal behaviors and experiences that occur before and during pregnancy and through a child's early infancy. Although the fundamental PRAMS methodology—consisting of a mailed questionnaire with telephone follow-up for non-respondents—has not changed, numerous states have intensified their efforts to locate and contact sampled women in order to maintain adequate response levels (Shulman, Gilbert, and Lansky, 2006).

The population of concern for PRAMS is all new mothers who give birth to a live-born baby within their state of residence during the surveillance period. A state's birth certificate record serves as the sampling frame for identifying new mothers. Women are sampled between two and six months after delivery. The PRAMS sample is stratified to ensure that subpopulations of specific public health interest are oversampled, such as mothers of low-birthweight babies and racial and ethnic minority communities (Shulman, Gilbert, and Lansky, 2006).

Maternal and Infant Health: Background and Clinical Significance

Effect of the Issue on Clients and Communities

Although significant advances have been made in medical care, substantial threats to maternal, child, and infant health remain in the United States. The most conspicuous challenge is the reduction of preterm birth rates, which increased by more than 20% between 1990 and 2006. Another persistent challenge is the reduction of infant mortality. In 2011, the U.S. infant mortality rate (IMR) was still higher than that of 46 other countries (Maternal, Infant, and Child Health, n.d.).

Noticeable progress has been made in the U.S. over the past half-century in reducing the IMR; however, more work remains to be done. Preliminary data showed that in 2011 the IMR fell overall to 6.05 deaths per 1,000 live births. This figure does not, however, capture the extent of geographical and racial disparities. Black infants of non-Hispanic descent experience death at nearly twice the rate of non-Hispanic white infants. Deaths associated with preterm births among Black infants occur at three times the rate seen among white infants. From a geographical perspective, the highest infant mortality rates are concentrated in the Southern states of the United States (CDC, 2013).

Effect of the Issue on the Health Care System

The wellbeing and health of children, infants, and mothers significantly influence the health of subsequent generations and can serve as an indicator of broader challenges facing communities, families, and health-care institutions. Healthy birth outcomes, timely recognition, and effective management of infant health issues are fundamental in averting disability and death among children and in enabling infants to grow to their full potential (Maternal, Infant, and Child Health, n.d.).

The infant mortality rate is a measure of infant deaths per 1,000 live births and serves not only as a marker of child and maternal health but also as a fundamental indicator of overall societal health (CDC, 2013).

PRAMS continues a long tradition of follow-up research in the Maternal and Child Health (MCH) field. In the 1920s, the United States Children's Bureau conducted the nation's first major in-depth study of infant mortality using a comparable follow-up methodology. In ten cities, every woman whose infant had died within the past year was systematically interviewed. The findings provided an early understanding of the nature of infant mortality in the United States, revealing that infant deaths occurred more frequently in low-income than in high-income households, among bottle-fed rather than breastfed infants, and among twins rather than singletons. Beginning in 1964 and every eight years through 1988, the National Center for Health Statistics (NCHS) conducted intensive national follow-up studies of live births and infant deaths, providing much of the foundational epidemiological knowledge about pregnancy and births—particularly regarding cigarette smoking and prenatal care use (Kotelchuck, 2006).

Program Goals and Interventions

PRAMS is designed to explore why some children are born in good health while others are not. PRAMS studies ask mothers about their new children and their pregnancies, and the responses inform researchers about factors contributing to infant and maternal health outcomes.

PRAMS makes data available to state health officials to enhance infant and maternal health. It enables states and the CDC to monitor variations in child and maternal health, thereby helping to reveal patterns in unintended pregnancy, infant health, smoking, breastfeeding, prenatal care, and related issues. PRAMS also supplements information contained in birth certificates, which is useful in planning and reviewing state infant and maternal health programs. Because PRAMS samples are drawn from women who delivered successfully, the results can be applied to the entire state population of women who recently gave birth. Because similar data collection methods are used in every participating state, PRAMS also makes cross-state comparisons possible (CDC, 2017).

PRAMS enhances the continuity of maternal and newborn health data from pregnancy through the early postpartum period. Professional boundaries between the obstetric and pediatric fields often restrict understanding of factors that span the prenatal and postnatal periods. PRAMS enables researchers to examine the sequelae of prenatal experiences into the early postnatal period. Life-span models have become increasingly recognized in the MCH and pediatric fields, yet few national or state public health databases address this critical early dyadic period from a longitudinal perspective. For example, PRAMS can help address questions such as how maternal prenatal exposure to toxins, vitamins, or stress affects subsequent infant development, or what effect prenatal care use, intimate partner abuse, or pregnancy weight gain has on later pediatric and women's health-care use (Kotelchuck, 2006).

An additional objective is addressing maternal wellbeing. Although PRAMS is, by name, a "pregnancy" database with an initial focus on birth outcomes, it is well positioned to address maternal health issues because it interviews new mothers directly. Recent efforts to use PRAMS records to examine intimate partner abuse, postpartum weight recovery, breastfeeding, smoking cessation, sexually transmitted infections, and maternal depression reflect an increasing focus on maternal wellbeing. PRAMS has the potential to serve as a standard national database for the U.S. Safe Motherhood initiative (Kotelchuck, 2006).

Supplementing disparity research is another major objective. Significant gaps persist between white and Black maternal and infant outcomes in the United States. PRAMS offers one of several mechanisms for investigating, in both national and state samples, emerging disparity hypotheses—including differential exposure to sexually transmitted infections, douching, intergenerational wealth, perceived racism, and infant sleep positions. PRAMS also provides opportunities to study the origins of the Hispanic birth outcome paradox, examining the roles of community, acculturation, and specific ethnic health behaviors. It additionally offers a means to analyze trends among American Indian/Alaska Native and Asian/Pacific Islander communities. As PRAMS expands to more states, researchers have begun using its data to analyze racial and social group disparities across states, a direction that should be further encouraged (Kotelchuck, 2006).

Monitoring community health systems is another important intervention. PRAMS has frequently been used to examine the use of prenatal care (PNC) services and Medicaid or other health insurance coverage, but it has not been used sufficiently to monitor involvement in and effects of other federal programs such as the Women, Infants and Children (WIC) program or Healthy Start, or to track local and state smoking cessation, home visitation, or case management services. PRAMS data could provide the essential evidence base for effective program planning and evaluation. PRAMS might be expanded to include more questions identifying federal, state, or local program involvement, or it could be oversampled in geographic areas with and without a given program intervention to support studies stratified by program participation or coverage (Kotelchuck, 2006).

PRAMS also provides a gateway for community voice and participation in research. Both the CDC and the Maternal and Child Health Bureau (MCHB) advocate for greater community participation in research and program improvement. PRAMS can function as an institutional mechanism for capturing the voices of new mothers. It should more systematically ask about women's perceptions of their MCH-related experiences. Women's attitudes, evaluations, and programmatic participation details should be central to the PRAMS questionnaire. Such data could help elucidate reasons for lower-than-expected program participation levels or gauge responses to potential program changes. PRAMS currently frames its mission as "from data to action," and it could and should equally embrace a "listening" orientation (Kotelchuck, 2006).

PRAMS also creates an emphasis on the birth experience itself. At present, PRAMS data focus primarily on maternal prenatal and postnatal behaviors and experiences associated with birth certification rather than on the childbirth encounter itself. Important issues around provider choice, labor support, and the sequelae of medical interventions and cesarean sections are among the topics that could be explored more thoroughly. The birth experience has receded as a public health focus, perhaps due to a lack of suitable data, and PRAMS could help reverse this trend (Kotelchuck, 2006).

Finally, PRAMS serves as a site for MCH scientific inquiry. PRAMS can be an important driver of improvements in the analytical framework of the MCH field. With its multiple state sites, PRAMS could be a significant locus for studies of MCH survey design and data collection modalities. Methodological innovations using PRAMS data should not be seen as the exclusive responsibility of the national PRAMS office; rather, PRAMS should actively encourage the broader MCH research community to use its multi-state samples to investigate methodological questions (Kotelchuck, 2006).

Conclusion

Through PRAMS, fundamental information is derived from collected data concerning infants, mothers, and families in the United States. PRAMS was originally intended to be a continuous information source on birth-related issues at the state and national level. It has proven highly adaptable in content, making it possible to address emerging issues in reproductive health—including intimate partner violence and maternal depression. Continued annual implementation is fundamental to the study of trends over time (Kotelchuck, 2006).

PRAMS stands at the center of a significant and enduring MCH research tradition in the United States. The program has grown substantially over the past fifteen years. Looking ahead, each state should be working toward its own comprehensive MCH data system. A national rollout of PRAMS is long overdue. The significance of this program extends well beyond its current scope, and it should be directed toward nationwide implementation for the benefit of all (Kotelchuck, 2006).

References

CDC (2017). What is PRAMS? Retrieved February 9, 2018, from https://www.cdc.gov/prams/index.htm

Centers for Disease Control and Prevention (CDC). (2013). CDC grand rounds: Public health approaches to reducing U.S. infant mortality. MMWR: Morbidity and Mortality Weekly Report, 62(31), 625.

Kotelchuck, M. (2006). Pregnancy Risk Assessment Monitoring System (PRAMS): Possible new roles for a national MCH data system. Public Health Reports, 121(1), 6–10.

Maternal, Infant, and Child Health. (n.d.). Retrieved January 17, 2018, from

Robbins, C. L., Zapata, L. B., Farr, S. L., Kroelinger, C. D., Morrow, B., Ahluwalia, I., … & Williams, L. (2014). Core state preconception health indicators—pregnancy risk assessment monitoring system and behavioral risk factor surveillance system, 2009. Morbidity and Mortality Weekly Report: Surveillance Summaries, 63(3), 1–62.

Shulman, H. B., Gilbert, B. C., & Lansky, A. (2006). The Pregnancy Risk Assessment Monitoring System (PRAMS): Current methods and evaluation of 2001 response rates. Public Health Reports, 121(1), 74–83.

Woodbury, R. M. (1926). Infant mortality and its causes: With an appendix on the trend of maternal mortality rates in the United States.