1. Using Virginia PRAMS data to assess the impact of WIC and Home Visiting Programs on birth outcomes August 10, 2011 Monisha Shah GSIP Intern

2. Purpose To present findings from our analysis of PRAMS data to program managers and stakeholders.

3. Research 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?

4. 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?

5. States Participating in PRAMS, 2011 WY WISD 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

6. VA 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

7. Virginia PRAMS: Sampling Randomly select 100 infants each month from eligible live births Sample is stratified by birth weight ~50 LBW infants ~50 NBW infants

8. PRAMS 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

9. 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

10. Methods 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.

11. Infant 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

12. Maternal 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

13. WIC 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 pregnancy AND Either on Medicaid or uninsured during pregnancy or had no prenatal care at all AND Did not receive Food Stamps or TANF during pregnancy YES  WIC Participation Group

14. WIC Participants Comparison Group (No WIC) Maternal Characteristic % Age <20 12.416.58 20-24 38.2935.65 25-29 29.2734.34 30+ 20.0323.43 Education <HS 29.9828.64 HS 43.3340.90 >HS 26.6930.46 Race White, NH 39.3170.28 Black, NH 35.9715.15 Hispanic 24.7214.57

15. WIC Participants Comparison Group (No WIC) Maternal Characteristic % Smoked Last 3 Mo of Preg No 81.7179.28 Yes 18.2920.72 Marital Status Not Married 65.7754.83 Married 34.2345.17 Parity Primiparous 63.6460.53 Multiparous 36.3639.47 Income Low (<$20,000) 56.7661.27 Mid ($20,000- $49,999) 37.7724.78 High (>=50,000) 5.4713.95

16. WIC Participants Comparison Group (No WIC) Preconception Health Characteristics% Maternal BMI Underweight or Normal weight 48.956.2 Overweight or obese 51.143.8 Multivitamin use Vitamin Everyday 14.89.4 Incomplete or No Use 85.290.6 Stressors No Stressors 15.226.8 1-2 stressors 36.632.6 3-5 stressors 37.429.9 6-18 stressors 10.810.7 Homeless Yes 6.46.8 No 93.693.2 Jobless Yes 7.90.4 No 92.199.6

17. WIC Participants Comparison Group (No WIC) Preconception Health Characteristics% Pregnancy Intention Unintended 57.454.1 Intended 42.645.9 Previous Low Birth Weight Yes 21.910.2 No 78.189.8 Previous Preterm Yes 17.15.8 No 82.994.2 Any Abuse Ever No 87.886.5 Yes 12.213.5 Pregnancy Preparedness Unplanned 32.429.2 Planned 29.128.2 Neither planned nor unplanned 38.442.7 Insurance Status BEFORE pregnancy Medicaid 15.37.0 Private Insurance 31.720.8 Uninsured 53.072.2

18. Participation in Home Visiting Program and Comparison Group Participation in Home Visiting Program and Comparison 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 pregnancy AND Either on Medicaid or uninsured during pregnancy or had no prenatal care at all AND Did not receive Food Stamps or TANF during pregnancy YES  HV Participation Group

19. Home Visiting Participants Comparison Group (No HV) Maternal Characteristic % Age <20 7.8312.67 20-24 40.3035.84 25-29 31.7631.31 30+ 20.1120.18 Education <HS 30.4031.17 HS 38.3641.61 >HS 31.2327.22 Race White, NH 47.8449.58 Black, NH 35.9531.01 Hispanic 16.2119.40

20. Home Visiting Participants Comparison Group (No HV) Maternal Characteristic % Smoked Last 3 Mo of Preg No 78.1879.76 Yes 21.8220.24 Marital Status Not Married 56.0668.50 Married 43.9431.50 Parity Primiparous 61.8864.60 Multiparous 38.1235.40 Income Low (<$20,000) 53.9463.72 Mid ($20,000- $49,999) 21.6131.96 High (>=50,000) 24.454.32

21. HV Participation Comparison Group (No HV) % Maternal BMI Underweight or Normal weight 57.8049.12 Overweight or obese 42.2050.88 Multivitamin use Vitamin Everyday 23.9610.43 Incomplete or No Use 76.0489.57 Stressors No Stressors 22.2216.31 1-2 stressors 35.3230.36 3-5 stressors 33.8238.37 6-18 stressors 8.6414.96 Homeless Yes 2.897.61 No 97.1192.39 Jobless Yes 7.856.24 No 92.1593.76

22. HV Participation Comparison Group (No HV) Pregnancy Intention Unintended 47.0659.12 Intended 52.9440.88 Previous Low Birth Weight Yes 19.9718.74 No 80.0381.26 Previous Preterm Yes 22.3011.64 No 77.7088.36 Any Abuse Ever No 96.0983.49 Yes 3.9116.51 Pregnancy Preparedness Unplanned 23.7833.25 Planned 44.7725.59 Neither planned nor unplanned 31.4541.16 Insurance Status BEFORE pregnancy Medicaid 12.0315.88 Private Insurance 39.6114.32 Uninsured 48.3669.81

23. Results Frequency Weighted Freq. Percent 95% CL Freq Missing WIC during pregnancy 38769,55234.73(30.89, 38.58)13 Home Visiting10720,03910.19(7.67, 12.70)27

24. 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 ParticipationWIC Comparison Group Percent

25. 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 ParticipationWIC Comparison Group Percent

26. 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 ParticipationWIC Comparison Group Percent

27. 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 ParticipationWIC Comparison Group Percent

28. 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 ParticipationHV Comparison Group Percent

29. 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 ParticipationHV Comparison Group Percent

30. 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 ParticipationHV Comparison Group Percent

31. 98.0 58.9 96.8 96.2 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 ParticipationHV Comparison Group Percent

32. 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.

33. 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.

34. 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.

35. 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.

36. Conclusions 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

37. Public 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

38. 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.

39. 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.

40. 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.

41. Conclusions Participation in home visiting programs during pregnancy increased breastfeeding initiation and postpartum contraceptive use while reducing the risk of low birth weight.

42. Public Health Implications These findings demonstrate home visiting has a positive effect on optimal health and development of women and infants.

43. Limitations 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

44. Limitations 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