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Surveillance of Preconception Health Indicators Among Women Delivering Live-Born Infants --- Oklahoma, 2000--2003

Promoting preconception health of women is a key public health strategy in the United States to decrease morbidity and mortality associated with adverse maternal and infant outcomes. In 2006, CDC published 10 recommendations for improving the health of women before pregnancy (1); one recommendation proposed maximizing public health surveillance to monitor preconception health. Toward this end, data collected in Oklahoma (the only state to develop a detailed survey question on preconception health) during 2000--2003 from the Pregnancy Risk Assessment Monitoring System (PRAMS) were analyzed to 1) estimate the prevalence of women who did not report three selected preconception health indicators, (i.e., pre-pregnancy awareness of folic acid benefits,* multivitamin consumption, and receipt of health-care counseling§) and 2) identify those subpopulations of women who were more likely not to report these indicators. Results of this analysis indicated that 21.5% of Oklahoma women with a recent live birth were not aware of folic acid benefits before they became pregnant, 73.5% did not consume multivitamins at least four times per week during the month before pregnancy, and 84.8% did not receive preconception counseling from a health-care provider. Subpopulations of women with characteristics (at the time of conception) significantly associated (p<0.05) with not reporting at least two of the three indicators included those who were younger, were unmarried, had <12 years of education, had no health insurance, had an unintended pregnancy, or had a previous live birth. Other states might use this analysis to help develop preconception health questions to be included in their own PRAMS surveys; Oklahoma state and local health officials can use the results to help prioritize preconception health objectives and identify subpopulations of women in need of targeted programs.

PRAMS is an ongoing state- and population-based surveillance system designed to monitor self-reported behaviors and experiences that occur before, during, and after pregnancy among women who deliver live-born infants. PRAMS is administered by CDC in collaboration with state health departments and follows standard data-collection procedures. Self-reported survey data are linked to birth certificate data and weighted for sample design, nonresponse, and noncoverage. The PRAMS questionnaire consists of core questions that appear on all state surveys and state-developed questions tailored to meet the individual needs of states. Additional details regarding PRAMS have been described previously (4).

Data from Oklahoma were analyzed because Oklahoma was the only state to develop a detailed question for its PRAMS questionnaire regarding preconception health: "Before you became pregnant with your new baby, did any of these things happen? a) You heard or read that taking vitamins with folic acid could help prevent some birth defects; and b) you received advice or counseling from a health-care provider to prepare for becoming pregnant." Preconception multivitamin use was ascertained from a PRAMS core question used by all states: "In the month before you got pregnant with your new baby, how many times a week did you take a multivitamin (a pill that contains many different vitamins and minerals)?" The percentage of women who did not report each of these indicators was estimated overall and stratified by selected characteristics. To identify significant associations between women in subpopulations with selected characteristics and not reporting each indicator, multiple logistic regression was used to calculate adjusted odds ratios (AORs) and 95% confidence intervals (CIs). All calculations were performed using data weighted to Oklahoma population data. The average annual weighted survey response rates during 2000--2003 was 81.3% (range: 79.9%--83.7%).

Results indicated that, during 2000--2003, among Oklahoma women who had recently delivered a live-born infant, 21.5% were not aware of folic acid benefits before they became pregnant, 73.5% did not consume multivitamins at least four times per week during the month before pregnancy, and 84.8% did not receive preconception counseling from a health-care provider (Table). Lack of awareness of folic acid benefits before pregnancy was greatest among women who were aged <20 years (39.4%), black (40.7%), or enrolled in Medicaid (39.2%). The prevalence of not consuming multivitamins at least four times a week in the month before pregnancy was greatest among women who were aged <20 years (87.4%), who were unmarried (85.2%), who had <12 years of education (83.9%), who had no health insurance (84.1%), or whose pregnancy was unintended (84.4%). Not receiving preconception counseling was most common among women who were Hispanic (91.4%), who were unmarried (90.1%), who had no health insurance (92.3%), or whose pregnancy was unintended (93.4%).

Subpopulations of women with characteristics significantly associated with lack of pre-pregnancy awareness of folic acid benefits included those who were aged <20 (AOR = 1.9), 20--24 (AOR = 1.5), or >35 (AOR = 1.5) years, compared with those aged 25--34 years; who were black (AOR = 2.0) or American Indian (AOR = 1.5), compared with those who were white; who were unmarried (AOR = 1.8), compared with those who were married; who had <12 (AOR = 2.3) or 12 (AOR = 2.1) years of education, compared with those who had >12 years of education; or whose pregnancy was unintended (AOR = 1.5), compared with those whose pregnancy was intended (Table). Subpopulations of women with characteristics significantly associated with not consuming multivitamins at least four times per week 1 month before pregnancy included those who were aged <20 (AOR = 1.8) or 20--24 (AOR = 1.7) years; who were unmarried (AOR = 1.5); who had 12 years of education (AOR = 1.5); who had no health insurance (AOR = 1.7), compared with those who had private insurance; whose pregnancy was unintended (AOR = 2.6); or who had a previous live birth (AOR = 1.4), compared with those who did not have a previous live birth. Subpopulations of women with characteristics significantly associated with not receiving preconception counseling included those who were Hispanic (AOR = 1.9), compared with those who were not Hispanic; uninsured (AOR = 2.2); whose pregnancy was unintended (AOR = 5.1); or who had a previous live birth (AOR = 1.9).

Reported by: D Lorenz, MSPH, A Lincoln, MSW, MSPH, S Dooley, MS, Oklahoma State Dept of Health. DV D'Angelo, MPH, SD Hillis, PhD, PA Marchbanks, PhD, KM Curtis, PhD, LM Williams, MPH, CB Prince, PhD, B Morrow, MA, N Harris, PhD, SF Posner, PhD, Div of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion; LB Zapata, PhD, EIS Officer, CDC.

Editorial Note:

Educational activities and media campaigns have been conducted since the early to mid-1990s to increase awareness of the importance of folic acid in preventing neural tube defects. The U.S. Public Health Service recommends that all women of childbearing age consume >400 µg of folic acid daily through either supplementation or fortified foods (2). Findings in this report suggest that 78.5% of Oklahoma mothers during 2000--2003 were aware of the benefits of folic acid consumption. This represents an increase from 1995, when 66.4% of Oklahoma PRAMS participants reported folic acid awareness (5). However, lack of awareness was greater among women in certain subpopulations. For example, women with <12 years of education were more than twice as likely as women with >12 years of education to not be aware of folic acid benefits.

Despite high awareness of the benefits of taking vitamins with folic acid, 73.5% of women sampled (68.8% of those who were aware of folic acid's benefits and 87.9% of those who were not aware) did not consume multivitamins at least four times per week during the 1 month before pregnancy, although multivitamins typically contain folic acid (6). This finding suggests that, although most women were aware of folic acid's value in preventing certain birth defects, they might not have known that folic acid should be taken before conception to maximize benefits. This hypothesis was supported by findings from a national telephone survey of women aged 18--45 years that determined that, although 79% of respondents had heard or read about folic acid, only 10% of these women knew that folic acid should be taken before pregnancy (7). The fact that women with unintended pregnancies were 2.6 times as likely as women with intended pregnancies not to consume multivitamins at least four times per week during the month before conception might be of particular concern, considering that half of all pregnancies in the United States are unintended (8) and unintended pregnancies are more likely to have complications (9).

With regard to the third indicator, 84.8% of the women sampled (72.1% with intended pregnancies and 93.4% with unintended pregnancies) did not receive preconception counseling from a health-care provider. In addition, 92.3% of women with no health insurance and 91.4% of Hispanic women did not receive counseling. Since 2006, CDC has recommended offering, as a component of maternity care, one pre-pregnancy visit for women planning pregnancy (1). Examples of preconception interventions for improving pregnancy outcomes that might be incorporated into preconception counseling include folic acid supplementation, rubella and hepatitis B vaccination, screening and treatment for human immunodeficiency virus/acquired immunodeficiency syndrome and sexually transmitted infections, smoking-cessation counseling, diabetes management, and obesity control (1). In this analysis, women with a previous live birth were 1.9 times as likely as women without a previous live birth not to receive preconception counseling. Although women with a previous live birth likely believe they are better prepared for pregnancy and therefore might not seek counseling, new health concerns warranting risk assessment and appropriate interventions can emerge during interconception care; therefore, preconception counseling is recommended for all women planning pregnancy.

The findings in this report are subject to at least four limitations. First, these preconception health indicators are self-reported after delivery, and responses might be subject to recall bias. Second, assessment of multivitamin consumption might not accurately reflect intake of folic acid. Although most commonly available multivitamins contain the daily recommended amount of folic acid (6), folic acid can be consumed through other means (e.g., fortified foods or a supplement containing only folic acid). Third, although population based, these findings are generalizable only to mothers with recent live births in Oklahoma. Finally, because of the cross-sectional design of the study, the observed associations cannot be presumed to be causal.

Oklahoma state and local health officials can use these results to prioritize preconception health objectives. Although pre-pregnancy awareness of folic acid benefits was high, consumption of multivitamins was low, as was receipt of preconception counseling, even among those women whose pregnancy was intended. These data also can be used to identify subpopulations of women in need of outreach during the preconception period. For example, women who are younger, are unmarried, have less education, or are not planning pregnancy might benefit from targeted outreach to improve pre-pregnancy awareness of folic acid benefits and multivamin consumption. To improve rates of preconception counseling, access to care should be addressed, as well as tailoring messages to women who have had previous live births and might believe that counseling is not necessary. In addition, nearly 60% of pregnancies in Oklahoma were categorized as unintended, and those not planning pregnancy had increased odds of not being aware of the benefits of folic acid before pregnancy, not taking a multivitamin at least four times per week during the month before pregnancy, and not receiving preconception counseling; therefore, efforts to promote preconception health should target all women of reproductive age who are capable of becoming pregnant (10).

References

  1. CDC. Recommendations to improve preconception health and health care---United States. MMWR 2006;55(No. RR-6).
  2. CDC. Recommendations for the use of folic acid to reduce the number of cases of spina bifida and other neural tube defects. MMWR 1992;41(No. RR-14).
  3. Medical Research Council Vitamin Study Research Group. Prevention of neural tube defects: results of the Medical Research Council Vitamin Study: Medical Research Group. Lancet 1991;338:131--7.
  4. Shulman HB, Gilbert BC, Msphbrenda CG, Lansky A. The Pregnancy Risk Assessment Monitoring System (PRAMS): current methods and evaluations of 2001 response rates. Public Health Rep 2006;121:74--83.
  5. CDC. Are women with recent live births aware of the benefits of folic acid? MMWR 2001;50(No. RR-6):3--14.
  6. CDC. Surveillance for selected maternal behaviors and experiences before, during, and after pregnancy---Pregnancy Risk Assessment Monitoring System (PRAMS), 2000. MMWR 2003;52(No. SS-11).
  7. Green-Raleigh K, Carter H, Mulinare J, Prue C, Petrini J. Trends in folic acid awareness and behavior in the United States: the Gallup Organization for the March of Dimes Foundation Surveys, 1995--2005. Matern Child Health J 2006;10(5 suppl):S177--82.
  8. CDC. Monitoring progress toward achieving maternal and infant Healthy People 2010 objectives---19 states, Pregnancy Risk Assessment Monitoring System (PRAMS), 2000--2003. MMWR 2006;55(No. SS-9): 1--11.
  9. Kost K, Landry DJ, Darroch, JE. The effects of pregnancy planning status on birth outcomes and infant care. Fam Plann Perspect 1998; 30:223--30.
  10. Brundage SC. Preconception health care. Am Fam Physician 2002;65:2507--14.

* Increased consumption of folic acid (a member of the vitamin B complex) before conception and during the first trimester of pregnancy can reduce the incidence of neural tube defects by 50%--70% (2,3). The U.S. Public Health Service recommends that all women of childbearing age consume >400 µg of folic acid daily through either supplementation or fortified foods (2).

Most commonly available multiple vitamins contain >400 µg folic acid.

§ Since 2006, CDC has recommended that one preconception visit for women planning pregnancy be offered as a component of maternity care, to enable women to receive risk assessment, health education, and specific interventions to address identified risks before conception (1).

The PRAMS sample of women who have had a recent live birth is drawn from the state's birth certificate files. Each participating state samples 1,300--3,400 women per year. Women in certain smaller populations at higher risk are sampled at a higher rate to ensure adequate data. Selected women are first contacted by mail; women who do not respond to repeated mailings are subsequently contacted and interviewed by telephone. In Oklahoma, a total of 7,680 women completed the PRAMS survey during 2000--2003.

Table

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