1

Evaluation of Maternal Smoking Surveillance

Systems in Massachusetts

Lizzie Harvey, MPHCDC/CSTE Applied Epidemiology Fellow

Massachusetts Department of Public HealthJune 14, 2011

Disclosure

• No significant financial interest or other relationships with the manufacturer(s) ofany commercial product(s) or provider(s) of any commercial services discussed in this presentation and with any commercial supports of the activity

• Massachusetts Department of Public Health RaDAR and PRAMS clearance

2

3

Objective

• To evaluate maternal smoking surveillance through the Massachusetts Pregnancy Risk Assessment Monitoring System (PRAMS)

4

Importance of Maternal Smoking Surveillance

• Maternal smoking during pregnancy is associated with babies who are:– 1.4-3.0 times more likely to die of Sudden

Infant Death Syndrome (SIDS)– at 30% higher odds of premature delivery– 2.3 times more likely to deliver term low birth

weight infants

5

Maternal Smoking Relevance in US and Massachusetts

• Healthy People 2020 Objective– Increase smoking cessation during pregnancy

• CDC Winnable battle• National Performance Measure

– Smoking in the last trimester

• MA Priorities– Improve the health and well being of women in their childbearing

years– Support reproductive and sexual health by improving access to

education and services

• Opportunity for Intervention in MA– Tobacco Cessation and Prevention Program

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Existing Surveillance System:Massachusetts Birth

Certificate (BC)

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MA Birth Certificate

• Maternal smoking questions since 1986

• Since 1996, two questions:

8

Maternal Smoking in Massachusetts: Birth Certificate Data

% MA Women Reporting Smoking during Pregnancy on the Birth Certificate

6.97.5

13.1

0

3

6

9

12

15

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

MA PRAMS

initiation

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Massachusetts Pregnancy and Risk Assessment Monitoring System

(MA PRAMS) as a Surveillance System

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PRAMS Background

Population-based data on maternal attitudes and behaviors, before, during, and shortly after pregnancy

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MA PRAMS Background

• Initiated in 2007

• 80 questions (54 Core, 16 Standard, 10 MA developed)

• 2-6 months post-partum

• Administered in English and Spanish only

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MA PRAMS

Screener

Last 3 months

of pregnancy

3 months

before pregnancy

Current use

13

Maternal Smoking Data Comparison

3 mo.

Pregnancy Post-partumPre-Pregnancy

PRAMS

3.8 mo.

BC

Conception12 mo. Delivery

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Methods

• Data Sources:– 2007-2008 MA PRAMS (N=2,997)– Linked to 2007-2008 MA BC data (N=2,997)

• Analysis:– Frequencies, prevalence estimates, sensitivity,

positive predictive value, kappa coefficients, chi square

– SAS 9.2 and SUDAAN 10.0

• Reference:– CDC: Updated Guidelines for Evaluating Public

Health Surveillance Systems (2001)

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CDC: System Attributes

• Simplicity• Flexibility • Data Quality• Acceptability• Sensitivity• Positive Value Predictive• Representativeness• Timeliness • Stability

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Simplicity

MA BC• Entire population (~75,000 births/year) • DPH Parent

Worksheet with 2 smoking questions

• 49 licensed birth hospitals in MA

MA PRAMS• Population-based

mixed-methodology survey

(~1,500/year)• 4 questions on 80

question survey• Mail survey to

stratified sample of birth population

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Flexibility

MA BC• Iterations of maternal

smoking surveillance– 1986– 1996– 2011

• 2011 implementation of electronic 2003 standard birth certificate

MA PRAMS • Maternal smoking

questions Core• Compare to other states• Opportunity to select

standard and state-specific questions

• Other measures related to smoking knowledge and behaviors

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Data Quality

Maternal Smoking Surveillance Data Quality: Missing Fields, 2007-08

0.25 0.24 0.30 0.30

2.70 2.60

2.10 2.10

0.00

1.00

2.00

3.00

Cig UsePrior

Cig UseDuring

Cig UsePrior

Cig UseDuring

Screener 3 MonthsPrior

Last 3Months

Now

BC Pre Merge BC Post Merge PRAMS

% M

issi

ng

N=156,734 N=2,997 N=2,997

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Acceptability

MA BC• Mandatory

participation– General Law (Ch. 111,

s.24B)

• Stigma on maternal smoking

MA PRAMS• Not required by law

– Can refuse survey and refuse individual questions

• Infant outcome at 4 months post-partum may determine how mother will respond

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Sensitivity Analysis

113 79

20 2714

MA PRAMS

S

NS

192

2734

133 2793 2926

Sensitivity: 113/ (113 + 20) = 0.850

Smoking DURING Pregnancy

MA PRAMS captured 85% of all maternal smoking

during pregnancy identified by the BC

MA BC

S NS

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Predictive Value Positive (PVP)

113 79

20 2714

192

2734

133 2793 2926

PVP: 113/ (113 + 79) = 0.589

Smoking DURING Pregnancy

58.9% of all maternal smoking during pregnancy identified by MA PRAMS were cases identified by the birth certificate

MA PRAMS

S

NS

MA BC

S NS

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But wait…the BC is not a gold standard! True maternal smoking rate unknown

Kappa Coefficients measure agreement between categorical items taking chance into account

Value of KStrength of

agreement

< 0.20 Poor

0.21 - 0.40 Fair

0.41 - 0.60 Moderate

0.61 - 0.80 Good

0.81 - 1.00 Very good

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Kappa Coefficient Analysis

20 79113

Maternal Smoking

DURING Pregnancy

N=2,997

BC PRAMS

Κ = 0.68 (95% CI = 0.62 – 0.74)

Good Agreement

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Kappa Coefficient Analysis

2497 98 32 27 --

32 70 14 5 0

-- 10 58 34 0

-- -- 9 11 0

0 0 0 -- 0

Non smoker

Quitter

# cigs dec.

# cigs sa/inc.

NS resumed

Non Quitter # cigs # cigs NS

Smoker dec. sa/inc. resumed

--: 1-4 values suppressed

MA BC

MA PRAMS

Κ = 0.53

95% CI:

0.49 – 0.57

Moderate

Agreement

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Representativeness

% MA Women Smoking during Pregnancy

Combined, 10.2

BC, 6.9

PRAMS, 9.3

0

3

6

9

12

15

1996 1998 2000 2002 2004 2006 2008 2010

Year

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Representativeness: Maternal Smoking by Data Source

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7.2

17.6

9.3

12.6

18.8

10.2

0

5

10

15

20

25

Smoked Before Pregnancy

Smoked During Pregnancy

Smoked Post-Pregnancy

% o

f Mot

hers

BC

PRAMS

Combined

↑34%

↑42%

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Representativeness: Differences in Reporting

20 79113

Maternal Smoking

DURING Pregnancy

BC PRAMS

Who is reporting on PRAMS but not on BC?

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Demographic Characteristics of those who report maternal smoking during pregnancy

on PRAMS (N=192)Characteristic % PRAMS only % PRAMS and BC Chi-square p-value

White Race (vs. non white)

63.3 65.5 0.75

Black Race (vs. non black)

21.5 19.5 0.72

≥HS grad 73.4 77.0 0.57

≥College 32.9 40.7 0.27

≥ 30 years 26.6 29.2 0.69

Hispanic Ethnicity 35.4 17.7 0.005

Spanish Language 13.9 1.8 0.002

Married 24.1 23.9 0.98

Had Pre-pregnancy insurance

49.4 46.9 0.74

WIC 77.9 69.6 0.21

LBW 7.6 14.2 0.16

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Representativeness

MA BC• Population data• Stigma of maternal

smoking• Self-report• Recall bias

MA PRAMS• Stratified sampling by

race/ethnicity– 30% non response

• English and Spanish only• Stigma of maternal

smoking potentially decreased

• Self-report• Recall bias

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Limiting

Step

TimelinessMA BC MA PRAMS

DPH Parent Worksheetcompleted

49 Registrars Data Entry

Registry of Vital Records and Statistics

MDPH Birth Report

PRAMS Survey completed

Data Entry

Birth File Closed

Data weighted by CDC

PRAMS ReportPublic Health Action!

Limiting

Step

Public Health Action!

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Stability

MA BC• Required by law• 2003 Revised Birth

Certificate Implementation 2011

• Investment in Vital Information Partnership System (VIP) 2011

• MassCHIP

MA PRAMS• 5 year funding

approved 2011-2016– Decreased funding

than previous cycle

• PRAMS website• PONDER (MA

specific) and CPONDER

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Conclusions: MA PRAMS System Attributes

Simplicity: 4 questions

Flexibility: Ability to add state specific questions

Data Quality: Low % missing; survey data

Acceptability: Overall stigma potentially decreased

Sensitivity: Increased case

Positive Predictive Value: ascertainment

Representativeness: Higher ascertainment of maternal smoking; Additional measure of post-partum smoking

Timeliness: No real time data; 2 year lag

Stability: 5 year competitive funding from CDC (2011-16)

Kappa statistic

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Recommendations• Use PRAMS as a valuable data source in addition to BC to understand burden of maternal smoking

• Use PRAMS to fill the data gap regarding maternal smoking in post-partum period

• Use other PRAMS data to inform actionable interventions in maternal smoking

Prenatal patient education

Postpartum smoking environment

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Next Steps

• Add 2009 MA PRAMS data to analysis• Assess impact of new BC data on maternal

smoking• Continue work with the Tobacco Cessation

and Prevention Program– Identify women who are not reporting on the birth

certificate but reporting in PRAMS– Reach out to prenatal providers for universal

screening of maternal smoking behaviors and referrals to cessation programs

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AcknowledgementsHafsatou Diop, MDPH Office of Data Translation

Karin Downs, MDPH Bureau of Family Health and Nutrition

Thomas Land, MDPH Tobacco Cessation and Prevention Program

Emily Lu, MDPH PRAMS Coordinator

Alice Mroszczyk, MDPH Privacy and Data Access Office

Maria Vu, MDPH Registry of Vital Records and Statistics

CDC/CSTE Applied Epidemiology Fellowship Program

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References/ResourcesCDC Tobacco Use and Pregnancy: http://www.cdc.gov/reproductivehealth/TobaccoUsePregnancy/index.htm

(Accessed 6/2011)CDC Winnable Battle: Tobacco:

http://www.cdc.gov/WinnableBattles/Tobacco/index.html (Accessed 6/2011)CDC PRAMS:

http://www.cdc.gov/prams/ (Accessed 6/2011)CPONDER:

http://www.cdc.gov/prams/CPONDER.htm (Accessed 6/2011)MA PRAMS:

http://www.mass.gov/dph/prams (Accessed 6/2011)MassCHIP:

http://www.mass.gov/dph/masschip (Accessed 6/2011)MA General Laws regarding birth information collection:

http://www.malegislature.gov/Laws/GeneralLaws/PartI/TitleXVI/Chapter111/Section24B (Accessed (6/2011)

2003 Revised Birth Certificate: http://www.cdc.gov/nchs/data/dvs/birth11-03final-ACC.pdf (Accessed 6/2011)

CDC Updated Guidelines for Evaluating Public Health Surveillance Systems: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5013a1.htm (Accessed 6/2011)

Kappa Statistics: Cohen, J. (1968). Weighted kappa: Nominal scale agreement provision for scaled disagreement or partial credit. Psychological Bulletin, 70(4), 213.

Dietz, PM, et al. Infant Morbidity and Mortality Attributable to Prenatal Smoking in the U.S. Am J Prev Med 2010;39(1) 45-52.

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Questions?

Contact Information:

Lizzie Harvey, MPH

CDC/CSTE Applied Epidemiology Fellow

Massachusetts Department of Public Health

Lizzie.Harvey@state.ma.us

(617) 624-5559

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Extra Slides

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Resources in MA

• Massachusetts Smokers’ Helpline

• QuitWorks

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Additional PRAMS Questions on Maternal Smoking

New 2009 Core:Which of the following statements best describes the rules about smoking inside your home now? Check one answerNo one is allowed to smoke anywhere inside my homeSmoking is allowed in some rooms or at some timesSmoking is permitted anywhere inside my home

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2003 Standard BC

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Impact of 2003 BC

3 mo.

Pregnancy Post-partumPre-Pregnancy

PRAMS

3.8 mo.

BC

Conception12 mo. Delivery

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Demographic Characteristics of those who report maternal smoking before pregnancy

on PRAMS (N=372)Characteristic % PRAMS only % PRAMS and BC Chi-square p-value

White Race (vs. non white)

58.9 65.4 0.20

Black Race (vs. non black)

22.8 15.9 0.09

≥HS grad 79.1 81.3 0.60

≥College 42.4 45.3 0.57

≥ 30 years 26.6 29.2 0.69

Hispanic Ethnicity 29.8 17.8 0.007

Spanish Language 9.5 1.87 <0.001

Married 32.9 28.5 0.36

Had Pre-pregnancy insurance

59.4 54.9 0.38

WIC 63.2 63.4 0.98

LBW 8.9 9.4 0.87

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Sensitivity Analysis

214 158

40 2499

MA PRAMS

S

NS

MA BC

S NS

372

2539

254 2657 2911

Sensitivity: 214 / (214 + 40) = 0.842

113 79

20 2714

MA PRAMS

S

NS

192

2734

133 2793 2926

Sensitivity: 113/ (113 + 20) = 0.850

Smoking BEFORE Pregnancy Smoking DURING Pregnancy

MA PRAMS captured 84.2% of all maternal smoking prior to pregnancy and

85% of all maternal smoking during pregnancy identified by the BC

MA BC

S NS

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Predictive Value Positive

214 158

40 2499

372

2539

254 2657 2911

PVP: 214 / (214 + 158) = 0.575

113 79

20 2714

192

2734

133 2793 2926

PVP: 113/ (113 + 79) = 0.589

Smoking BEFORE Pregnancy Smoking DURING Pregnancy

57.5% of all maternal smoking prior to pregnancy and 58.9% of all maternal smoking during pregnancy identified by MA PRAMS were cases identified by the birth certificate

MA PRAMS

S

NS

MA PRAMS

S

NS

MA BC

S NS

MA BC

S NS

46

Kappa Coefficient Analysis

40 158214

Maternal Smoking

PRIOR to Pregnancy

N=2,997

BC PRAMS

20 79113

Maternal Smoking

DURING Pregnancy

N=2,997

BC PRAMS

Κ = 0.64 (95% CI = 0.60 – 0.69)

Good Agreement

Κ = 0.68 (95% CI = 0.62 – 0.74)

Good Agreement

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Representativeness: Differences in Reporting

40 158214

Maternal Smoking

PRIOR to Pregnancy

BC PRAMS

20 79113

Maternal Smoking

DURING Pregnancy

BC PRAMS

Who is reporting on PRAMS but not on BC?