1. 1 Evaluation of Maternal Smoking Surveillance Systems in Massachusetts Lizzie Harvey, MPH CDC/CSTE Applied Epidemiology Fellow Massachusetts Department of Public Health June 14, 2011

2. Disclosure No significant financial interest or other relationships with the manufacturer(s) of any 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. 3 Objective To evaluate maternal smoking surveillance through the Massachusetts Pregnancy Risk Assessment Monitoring System (PRAMS)

4. 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. 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

6. 6 Existing Surveillance System: Massachusetts Birth Certificate (BC)

7. 7 MA Birth Certificate Maternal smoking questions since 1986 Since 1996, two questions:

8. 8 Maternal Smoking in Massachusetts: Birth Certificate Data MA PRAMS initiation

9. 9 Massachusetts Pregnancy and Risk Assessment Monitoring System (MA PRAMS) as a Surveillance System

10. 10 PRAMS Background Population-based data on maternal attitudes and behaviors, before, during, and shortly after pregnancy

11. 11 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

12. 12 MA PRAMS Screener Last 3 months of pregnancy 3 months before pregnancy Current use

13. 13 Maternal Smoking Data Comparison 3 mo. PregnancyPost-partum Pre-Pregnancy PRAMS 3.8 mo. BC Conception 12 mo.Delivery

14. 14 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)

15. 15 CDC: System Attributes Simplicity Flexibility Data Quality Acceptability Sensitivity Positive Value Predictive Representativeness Timeliness Stability

16. 16 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

17. 17 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

18. 18 Data Quality N=156,734N=2,997

19. 19 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

20. 20 Sensitivity Analysis 11379 202714 MA PRAMS S NS 192 2734 133 27932926 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

21. 21 Predictive Value Positive (PVP) 11379 202714 192 2734 133 27932926 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

22. 22 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 K Strength of agreement < 0.20Poor 0.21 - 0.40Fair 0.41 - 0.60Moderate 0.61 - 0.80Good 0.81 - 1.00Very good

23. 23 Kappa Coefficient Analysis 2079113 Maternal Smoking DURING Pregnancy N=2,997 BC PRAMS Κ = 0.68 (95% CI = 0.62 – 0.74) Good Agreement

24. 24 Kappa Coefficient Analysis 2497983227-- 32701450 --1058340 -- 9110 000--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

25. 25 Representativeness

26. 26 Representativeness: Maternal Smoking by Data Source ↑34% ↑42%

27. 27 Representativeness: Differences in Reporting 2079113 Maternal Smoking DURING Pregnancy BC PRAMS Who is reporting on PRAMS but not on BC?

28. 28 Demographic Characteristics of those who report maternal smoking during pregnancy on PRAMS (N=192) Characteristic% PRAMS only% PRAMS and BCChi-square p-value White Race (vs. non white) 63.365.50.75 Black Race (vs. non black) 21.519.50.72 ≥HS grad73.477.00.57 ≥College32.940.70.27 ≥ 30 years26.629.20.69 Hispanic Ethnicity35.417.70.005 Spanish Language13.91.80.002 Married24.123.90.98 Had Pre-pregnancy insurance 49.446.90.74 WIC77.969.60.21 LBW7.614.20.16

29. 29 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

30. 30 Limiting Step Timeliness MA BC MA PRAMS DPH Parent Worksheet completed 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!

31. 31 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

32. 32 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

33. 33 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

34. 34 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

35. 35 Acknowledgements Hafsatou 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

36. 36 References/Resources CDC Tobacco Use and Pregnancy: http://www.cdc.gov/reproductivehealth/TobaccoUsePregnancy/index.htm (Accessed 6/2011) http://www.cdc.gov/reproductivehealth/TobaccoUsePregnancy/index.htm CDC Winnable Battle: Tobacco: http://www.cdc.gov/WinnableBattles/Tobacco/index.htmlhttp://www.cdc.gov/WinnableBattles/Tobacco/index.html (Accessed 6/2011) CDC PRAMS: http://www.cdc.gov/prams/http://www.cdc.gov/prams/ (Accessed 6/2011) CPONDER: http://www.cdc.gov/prams/CPONDER.htmhttp://www.cdc.gov/prams/CPONDER.htm (Accessed 6/2011) MA PRAMS: http://www.mass.gov/dph/pramshttp://www.mass.gov/dph/prams (Accessed 6/2011) MassCHIP: http://www.mass.gov/dph/masschiphttp://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) http://www.malegislature.gov/Laws/GeneralLaws/PartI/TitleXVI/Chapter111/Section24B 2003 Revised Birth Certificate: http://www.cdc.gov/nchs/data/dvs/birth11-03final-ACC.pdfhttp://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) http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5013a1.htm 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.

37. 37 Questions? Contact Information: Lizzie Harvey, MPH CDC/CSTE Applied Epidemiology Fellow Massachusetts Department of Public Health Lizzie.Harvey@state.ma.us (617) 624-5559

38. 38 Extra Slides

39. 39 Resources in MA Massachusetts Smokers’ Helpline QuitWorks

40. 40 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 answer No one is allowed to smoke anywhere inside my home Smoking is allowed in some rooms or at some times Smoking is permitted anywhere inside my home

41. 41 2003 Standard BC

42. 42 Impact of 2003 BC 3 mo. PregnancyPost-partum Pre-Pregnancy PRAMS 3.8 mo. BC Conception 12 mo.Delivery

43. 43 Demographic Characteristics of those who report maternal smoking before pregnancy on PRAMS (N=372) Characteristic% PRAMS only% PRAMS and BCChi-square p-value White Race (vs. non white) 58.965.40.20 Black Race (vs. non black)22.815.90.09 ≥HS grad79.181.30.60 ≥College42.445.30.57 ≥ 30 years26.629.20.69 Hispanic Ethnicity29.817.80.007 Spanish Language9.51.87<0.001 Married32.928.50.36 Had Pre-pregnancy insurance 59.454.90.38 WIC63.263.40.98 LBW8.99.40.87

44. 44 Sensitivity Analysis 214158 402499 MA PRAMS S NS MA BC S NS 372 2539 25426572911 Sensitivity: 214 / (214 + 40) = 0.842 11379 202714 MA PRAMS S NS 192 2734 133 27932926 Sensitivity: 113/ (113 + 20) = 0.850 Smoking BEFORE PregnancySmoking 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

45. 45 Predictive Value Positive 214158 402499 372 2539 25426572911 PVP: 214 / (214 + 158) = 0.575 11379 202714 192 2734 133 27932926 PVP: 113/ (113 + 79) = 0.589 Smoking BEFORE PregnancySmoking 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. 46 Kappa Coefficient Analysis 40158214 Maternal Smoking PRIOR to Pregnancy N=2,997 BC PRAMS 2079113 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

47. 47 Representativeness: Differences in Reporting 40158214 Maternal Smoking PRIOR to Pregnancy BC PRAMS 2079113 Maternal Smoking DURING Pregnancy BC PRAMS Who is reporting on PRAMS but not on BC?