Of women in 13 states who had a live birth in 1997, 17-31% had entered prenatal care after their first trimester or had received no care at all; in most states, the proportion was significantly lower than it had been in 1993. Similarly, the proportion of women who attempted to breastfeed their newborn (48-87%) improved in most states. However, levels of other behaviors and experiences that may be associated with unfavorable outcomes for both women and their newborns--unintended pregnancy, smoking and physical abuse during pregnancy--remained unchanged. These are among the highlights of findings from the Pregnancy Risk Assessment Monitoring System (PRAMS).¹

PRAMS is an ongoing, state- and population-based surveillance system that gathers information on important maternal health indicators. Data are collected each month through questionnaires mailed to a sample of women who delivered a live-born infant in the previous 2-6 months. Thirteen states participating in PRAMS had data available for 1997: Alabama, Alaska, Arkansas, Colorado, Florida, Georgia, Maine, New York (excluding New York City), North Carolina, Oklahoma, South Carolina, Washington and West Virginia. The study utilized both PRAMS and birth certificate data; PRAMS data from earlier years were used to identify trends within states.

Unintended Pregnancy and Contraception

Women were asked what their attitude toward a pregnancy had been just before they became pregnant. Those who reported that they had wished to become pregnant at that time or sooner were classified as having had an intended pregnancy, while those who said that they had wanted to become pregnant later or never were classified as having had an unintended pregnancy. The rate of unintended pregnancy in 1997 ranged from 34% (in Maine) to 50% (in Oklahoma and South Carolina). Only two states saw any significant change in the prevalence of unintended pregnancies since 1993; Georgia demonstrated a decrease from 52% to 45%, and New York showed an increase from 33% to 38%.

Age, education, race and Medicaid status all had significant effects on whether a woman experienced an unintended pregnancy. In every state, women younger than 20 had the highest prevalence of unintended pregnancy (61-85%). In eight states, the proportion of women who reported an unintended pregnancy decreased steadily as their age increased; only 16-40% of women who were older than 35 reported this situation. Between one-half and three-fourths of women who had less than 12 years of education, who were black or who received Medicaid had not intended to conceive, significantly higher proportions than were found among women with more education, white women and women who were not receiving Medicaid. In Oklahoma, Hispanic women were significantly less likely to report this outcome than were non-Hispanic women (34% vs. 52%).

Women who said that their pregnancy had been unintended were asked if they had been using any contraceptive method when they conceived. In each state, 37-48% of women had been doing so at the time the pregnancy occurred; the lowest proportion was in Arkansas, and the highest was in Maine. The prevalence of contraceptive use was unchanged from the level in 1996, the only other year for which these data were available, and generally did not differ significantly by maternal characteristics. In Alaska and Florida, however, contraceptive use was more prevalent among women who had had 12 years or more of education than among their less-educated counterparts.

Timing of Prenatal Care

In the 13 states, 17-31% of women had entered prenatal care late (i.e., they had begun care after their first three months of pregnancy or had not received any prenatal care). The lowest prevalence of late entry into prenatal care was in Maine, and the highest was in Oklahoma. A decline in the prevalence of late entry into prenatal care was observed in eight of the 10 states with data available for 1993-1997; late entry in two states (Oklahoma and Washington) did not change significantly.

Women younger than 20 were the most likely to have received late prenatal care in every state (35-53%). In seven states, higher proportions of black women than white women entered prenatal care after the first three months of pregnancy or sought no care. White women had a lower prevalence of late entry than women of other races (excluding black women) in Colorado and Florida. In four states (Colorado, Georgia, New York and Washington), Hispanic women were significantly more likely than non-Hispanic women to have entered prenatal care late. Overall, the probability of late entry decreased as a woman's level of education increased. Some 31-51% of women with less than 12 years of education entered prenatal care after the first trimester or received no care, compared with 8-21% of women with more than 12 years of education. Medicaid recipients were more likely to report late care (27-42%) than were women not receiving Medicaid (6-24%).

Smoking During Pregnancy

During the last three months of pregnancy, 11-24% of women in the 13 states smoked. Smoking was most common in West Virginia and least common in Georgia. The proportion of women who smoked during the last trimester has decreased significantly since the mid-1990s in two states (Georgia and Washington).

Two factors were consistently related to the prevalence of smoking. In all 13 states, women with more than 12 years of education were considerably less likely to smoke (4-11%) than were those with less than a high school education (23-51%). Except in Oklahoma, Medicaid recipients had a significantly higher prevalence of smoking late in pregnancy (17-40%) than women who did not receive Medicaid (5-15%).

In six states, white women were more likely to have smoked during the last trimester (13-24%) than were black women (4-18%). In Alaska, white women (15%) and black women (7%) smoked significantly less than women in the "other races" category (24%), which comprised mostly Native Alaskan women. Hispanic women in five states were much less likely to have smoked late in pregnancy than were their non-Hispanic counterparts; for example, in Oklahoma, 3% of Hispanic women reported smoking during the last trimester, compared with 21% of non-Hispanic women. Women in eight states who delivered a low-birth-weight infant (i.e., an infant weighing less than 2,500 g) were significantly more likely to have smoked than were those whose infants had a normal birth weight. Parity was a factor in one state (Alabama), where 11% of first-time mothers and 18% of those who had given birth before had smoked.

Physical Abuse During Pregnancy

Women who are physically abused (i.e., "hit, slapped, kicked, or physically hurt in any way") during pregnancy are believed to be in danger of adverse outcomes for themselves and for their infants. The proportion of women who were physically abused by a husband or partner during their most recent pregnancy ranged from 2% (in Washington) to 6% (in South Carolina). There was no significant change in the prevalence of abuse during pregnancy since 1996.

Levels of physical abuse differed significantly according to women's race in three states. In Alaska, white women were significantly less likely to be abused during pregnancy than were women of other races (3% vs. 7%). White women and black women were significantly more likely to experience physical abuse during pregnancy than were women of other races in Florida (4-5% vs. 1%). In Washington, black women were significantly more likely to be abused during pregnancy then were white women (6% vs. 2%). Hispanic women in Colorado reported significantly more physical abuse during pregnancy than non-Hispanic women (8% vs. 2%).

In eight states, women were more likely to experience physical abuse during pregnancy if they had less than 12 years of education than if they had more than a high school education. Medicaid recipients in nine states were more likely to be abused by their husbands or partners than women who did not receive Medicaid. Women who delivered a low-birth-weight infant in one state (Alaska) were significantly more likely to be physically abused during pregnancy than women who delivered a normal-birth-weight infant (9% vs. 4%).

Breastfeeding Initiation

When asked whether they had ever tried to breastfeed their new infant, 48-87% of women said they had. Washington and Alaska had the highest proportion of women trying to breastfeed, and Alabama and West Virginia had the smallest proportion. Seven states showed an increase in the initiation of breastfeeding since 1993.

In the majority of states, the proportion initiating breastfeeding increased as the age and level of education of the mothers increased. The proportion was significantly higher among white women than among black women in eight states, and was higher among Hispanic than among non-Hispanic women in Florida (80% vs. 64%). In every state except Washington, Medicaid recipients were less likely to initiate breastfeeding (33-82%) than were women who were not receiving Medicaid (59-89%). Mothers who gave birth to normal-weight infants had a higher likelihood of initiating breastfeeding than women who delivered low-birth-weight infants in seven states. In Georgia and South Carolina, first-time mothers had a significantly higher prevalence of breastfeeding intiation than multiparous mothers.--L. Gerstein

REFERENCE

1. Colley Gilbert BJ et al., Prevalence of selected maternal and infant characteristics, Pregnancy Risk Assessment Monitoring System (PRAMS), 1997, Morbidity and Mortality Weekly Report, 1999, 48(SS05):1-37.