using virginia prams data to assess the impact of wic and home visiting programs on birth outcomes...
TRANSCRIPT
Using Virginia PRAMS data to Using Virginia PRAMS data to assess the impact of WIC and Home assess the impact of WIC and Home Visiting Programs on birth outcomes Visiting Programs on birth outcomes
August 10, 2011
Monisha Shah
GSIP Intern
PurposePurpose
• To present findings from our analysis of PRAMS data to program managers and stakeholders.
Research QuestionResearch Question
• Did women who participated in WIC and/or Home Visiting Programs during pregnancy have better birth outcomes than women who do not participate but who could potentially benefit from the programs?
• Pregnancy Risk Assessment Monitoring System• Public health surveillance provides a factual
basis for rational decision-making.• PRAMS Goals:
– Improve the health of mothers & infants by reducing adverse outcomes (LBW, IM) and
– Assist in planning, implementing and evaluating MCH policies and programs in VA
What is PRAMS?What is PRAMS?
States Participating in PRAMS, 2011States Participating in PRAMS, 2011
OK
AK
GA
FL
SC
AL
NC
CO
NM AR
IL
NY
ME
WV
WA
LA
UTOH
NE
HI
VT
MD
NYC
MS
OR MN
MI
TX
RI
NJ
WYWISD
PA
TN
MO VA
DE
MA
Prior to 2006
Funded in 2006
Note: With the addition of Virginia and 8 other new states, PRAMS represents approximately 75% of all US live births
VA PRAMS EligibilityVA PRAMS Eligibility
• Must be a VA resident• Infant must have been born in VA• Date criteria: 2 – 6 months old• Infants may not have been included in a
previous sampling frame• Twins and triplets: only one infant is sampled
Virginia PRAMS: SamplingVirginia PRAMS: Sampling
• Randomly select 100 infants each month from eligible live births
• Sample is stratified by birth weight
~50 LBW infants
~50 NBW infants
PRAMS MethodologyPRAMS Methodology • Two modes of data collection;
– a survey conducted by mailed questionnaire and
– a survey by telephone.
• Total data collection cycle lasts approximately 94 days
• Once collected, data sent to CDC
• Representative of all births in VA
Virginia PRAMS collects…Virginia PRAMS collects…• Preconception
– Pre-pregnancy BMI– Multivitamin use– Pregnancy intention– Health insurance status
• During Pregnancy
– Content and source of prenatal care– Alcohol and tobacco use– Attitudes and feelings about pregnancy– Health insurance status
• Post-pregnancy – maternal health
– Labor and delivery– Infant health care– Postpartum depression– Health insurance status– Post pregnancy – infant health
MethodsMethods
• Weighted 2007-2008 VA PRAMS data were used to examine birth outcomes among women who participated in WIC or Home Visiting programs during pregnancy compared to women who did not participate in the programs but who could potentially benefit from the programs.
• Chi square tests and multivariate logistic regression were used to measure and quantify the association between program participation and birth outcomes.
Infant Health OutcomesInfant Health Outcomes• Low Birth Weight
– Births less than 2,500 grams• Very Low Birth Weight
– Births less than 1,500 grams• Preterm Birth
– Births less than 37 weeks completed gestation• Well-Baby Check at any time• Infant Sleep Position
– Infant most often lied on back• Infant Smoke Exposure
– Infant exposed to smoke postpartum
Maternal Health and Breastfeeding OutcomesMaternal Health and Breastfeeding Outcomes
• Breastfeeding Initiation
• Breastfeeding Duration– Still breastfeeding at 2, 3, and 4 months
• Maternal Postpartum Check Up
• Postpartum Contraceptive Use
• Smoking During Pregnancy to Postpartum- If the mother increased or decreased smoking
WIC Participation and Comparison GroupWIC Participation and Comparison Group• “During your most recent pregnancy, were
you on WIC (the Special Supplemental Nutrition Program for Women, Infants, and Children)?”
NO WIC Comparison Group
Not privately insured during pregnancyAND
Either on Medicaid or uninsured during pregnancy or had no prenatal care at all
ANDDid not receive Food Stamps or TANF during pregnancy
YES WIC Participation Group
WIC Participants Comparison Group (No WIC)
Maternal Characteristic % %
Age <20 12.41 6.58
20-24 38.29 35.65 25-29 29.27 34.34
30+ 20.03 23.43Education
<HS 29.98 28.64 HS 43.33 40.90
>HS 26.69 30.46Race
White, NH 39.31 70.28 Black, NH 35.97 15.15
Hispanic 24.72 14.57
WIC Participants Comparison Group (No WIC)
Maternal Characteristic % %
Smoked Last 3 Mo of Preg
No 81.71 79.28 Yes 18.29 20.72
Marital Status Not Married 65.77 54.83
Married 34.23 45.17Parity
Primiparous 63.64 60.53 Multiparous 36.36 39.47
Income Low (<$20,000) 56.76 61.27
Mid ($20,000-$49,999) 37.77 24.78
High (>=50,000) 5.47 13.95
WIC Participants Comparison Group (No WIC)
Preconception Health Characteristics % %Maternal BMI
Underweight or Normal weight 48.9 56.2Overweight or obese 51.1 43.8
Multivitamin use Vitamin Everyday 14.8 9.4
Incomplete or No Use 85.2 90.6Stressors
No Stressors 15.2 26.81-2 stressors 36.6 32.63-5 stressors 37.4 29.9
6-18 stressors 10.8 10.7Homeless
Yes 6.4 6.8No 93.6 93.2
Jobless Yes 7.9 0.4No 92.1 99.6
WIC Participants Comparison Group (No WIC)
Preconception Health Characteristics % %Pregnancy Intention
Unintended 57.4 54.1Intended 42.6 45.9
Previous Low Birth Weight Yes 21.9 10.2No 78.1 89.8
Previous Preterm Yes 17.1 5.8No 82.9 94.2
Any Abuse Ever No 87.8 86.5Yes 12.2 13.5
Pregnancy Preparedness Unplanned 32.4 29.2
Planned 29.1 28.2Neither planned nor unplanned 38.4 42.7
Insurance Status BEFORE pregnancy Medicaid 15.3 7.0
Private Insurance 31.7 20.8Uninsured 53.0 72.2
Participation in Home Visiting Program and Participation in Home Visiting Program and Comparison GroupComparison Group
• “During your most recent pregnancy, did you get any of these services? Visits to your home by a nurse or other health care worker?”
NO HV Comparison Group
Not privately insured during pregnancyAND
Either on Medicaid or uninsured during pregnancy or had no prenatal care at all
ANDDid not receive Food Stamps or TANF during pregnancy
YES HV Participation Group
HV Participation Comparison Group (No HV)
% %Maternal BMI
Underweight or Normal weight 57.80 49.12Overweight or obese 42.20 50.88
Multivitamin use Vitamin Everyday 23.96 10.43
Incomplete or No Use 76.04 89.57Stressors
No Stressors 22.22 16.311-2 stressors 35.32 30.363-5 stressors 33.82 38.37
6-18 stressors 8.64 14.96Homeless
Yes 2.89 7.61No 97.11 92.39
Jobless Yes 7.85 6.24No 92.15 93.76
HV Participation Comparison Group (No HV)
Pregnancy Intention Unintended 47.06 59.12
Intended 52.94 40.88Previous Low Birth Weight
Yes 19.97 18.74No 80.03 81.26
Previous Preterm Yes 22.30 11.64No 77.70 88.36
Any Abuse Ever No 96.09 83.49Yes 3.91 16.51
Pregnancy Preparedness Unplanned 23.78 33.25
Planned 44.77 25.59Neither planned nor unplanned 31.45 41.16
Insurance Status BEFORE pregnancy Medicaid 12.03 15.88
Private Insurance 39.61 14.32Uninsured 48.36 69.81
ResultsResults
Frequency Weighted Freq. Percent 95% CL
Freq
Missing
WIC during pregnancy 387 69,552 34.73 (30.89, 38.58) 13
Home Visiting 107 20,039 10.19 (7.67, 12.70) 27
9.1
1.4
8.8
9.9
1.8
8.7
0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
9.0
10.0
11.0
12.0
Low Birth Weight (<2500 grams)***
Very Low Birth Weight (<1500 grams)***
Preterm Birth (<37 weeks Gestation)***
WIC Participation and Infant Birth Outcomes
WIC Participation WIC Comparison Group
66.5
50.0 49.9
38.8
78.1
49.3
36.8
15.5
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
100.0
Initiated Breastfeeding** BF at 2 months*** BF at 3 months*** BF at 4 months**
WIC Participation and Breastfeeding Outcomes
WIC Participation WIC Comparison Group
79.9
87.0 87.3
99.1
61.8
93.5
83.0
90.7
0
10
20
30
40
50
60
70
80
90
100
Adequately Used Prenatal Care*
Increased smoking from pregnancy to postpartum*
Maternal Postpartum Check up**
Postpartum Contraceptive Use***
WIC Participation and Maternal Health Outcomes
WIC Participation WIC Comparison Group
98.4
62.9
10.9
89.4
56.8
17.6
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
100.0
Well- Baby Check at Any Time* Infant Exposed to Smoke*** Back Sleep Position***
WIC Participation and Infant Health Outcomes
WIC Participation WIC Comparison Group
7.6
1.6
6.0
8.8
1.1
5.9
0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
9.0
10.0
11.0
12.0
Low Birth Weight (<2500 grams)***
Very Low Birth Weight (<1500 grams)***
Preterm Birth (<37 weeks Gestation)***
Home Visiting Participation and Infant Birth Outcomes
HV Participation HV Comparison Group
76.7
54.4
47.6
59.1
67.3
47.0 45.8
30.0
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
100.0
Initiated Breastfeeding** BF at 2 months*** BF at 3 months*** BF at 4 months**
Home Visiting Participation and Breastfeeding Outcomes
HV Participation HV Comparison Group
84.4
98.0
91.2 89.6
68.3
97.1
88.7
83.1
0
10
20
30
40
50
60
70
80
90
100
Adequately Used Prenatal Care*
Increased smoking from pregnancy to postpartum***
Maternal Postpartum Check up***
Postpartum Contraceptive Use***
Home Visiting Participation and Maternal Health Outcomes
HV Participation HV Comparison Group
98.0
58.9
96.896.2
62.0
85.6
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
100.0
Well- Baby Check at Any Time*** Back Sleep Position*** Infant Exposed to Smoke*
Home Visiting Participation and Infant Health Outcomes
HV Participation HV Comparison Group
Results
• Women who were on WIC were 17 times more likely to still be breastfeeding at 3 months postpartum than the Comparison group [AOR: 17.436, 95% CI: (3.068, 99.113)].
This analysis simultaneously accounts for home visiting participation, maternal age, education, race, income, singleton births, and previous preterm birth.
Results
• Women who were on WIC were 97% more likely to have a postpartum visit than those who were in WIC Comparison group [AOR: 0.027 95%CI: (0.001, 0.503)].
This analysis simultaneously accounts for home visiting participation, maternal age, education, race, smoking status, income, marital status, singleton birth, parity, job status and previous preterm birth.
Results
• Women who were on WIC were times more likely to have a well baby visit than those who were in WIC Comparison group [AOR: 612.104, 95%CI: (7.182, >999.99)].
This analysis simultaneously accounts for home visiting participation, maternal age, education, race, smoking status, income, singleton births, previous low birth weight and previous preterm birth.
Results
• Women who were on WIC were 9.5 times more likely to expose their infant to smoke than those who were in WIC Comparison group [AOR: 9.477, 95%CI: (1.752, 51.27)].
This analysis simultaneously accounts for home visiting participation, maternal age, education, race, smoking status, income, marital status, singleton births, stress, vitamin use, any abuse during or before pregnancy, pregnancy preparedness, and previous preterm birth.
ConclusionsConclusions• Positive effects
• Participation in the WIC program during pregnancy increased odds of:
• breastfeeding at 3 months postpartum • having a postpartum check up• having a well baby check up
• Program improvement• Smoking during pregnancy• Infant smoke exposure
Public Health ImplicationsPublic Health Implications
• These findings can be used to inform program planning and policy development in Virginia’s WIC program.
• Future studies should examine whether longer participation in WIC improves outcomes and which activities of the program can be attributed to these improved outcomes
Results
• Women who had a health care worker or nurse visit their home during pregnancy were less likely to have a low birth weight infant than those who were in our comparison group [0.125, 95% CI: (0.020, 0.779)].
This analysis simultaneously accounts for WIC participation, maternal education, age, race, smoking status, singleton, parity, income, vitamin use, pregnancy preparedness, and previous low birth weight.
Results
• Women who had a visit by a health care worker or nurse to their home were 4.5 times more likely to initiate breastfeeding [AOR: 4.5 95% CI: (1.050, 19.544)] compared to women who were in the Comparison group.
This analysis simultaneously accounts for WIC participation, maternal education, race, smoking status, singleton, parity, income, vitamin use, and pregnancy preparedness.
Results
• Women who had a health care worker or nurse visit their home during pregnancy were more likely to be using post partum contraceptives than those who were in the comparison group [AOR: 38.55, 95% CI: (3.140, 473.212)].
This analysis simultaneously accounts for WIC participation, maternal age, education, race, singleton, parity, income, and women who had any abuse before or during pregnancy.
ConclusionsConclusions
• Participation in home visiting programs during pregnancy increased breastfeeding initiation and postpartum contraceptive use while reducing the risk of low birth weight.
Public Health ImplicationsPublic Health Implications
• These findings demonstrate home visiting has a positive effect on optimal health and development of women and infants.
LimitationsLimitations
• Biases– Recall Bias
• Women are asked questions from pre-pregnancy through up to 6 months post partum so might have a difficulty remembering information
– Response Bias• The women who participated in PRAMS might be
different than those who chose not to• Accounted for in the weighted data
LimitationsLimitations
• Small sample size– Limited to only two years of data
• The VA PRAMS data cannot tell us:– the length of participation– frequency of visits– types of services provided– type of home visiting program