Core State Preconception Health Indicators — Pregnancy Risk Assessment Monitoring System and Behavioral Risk Factor Surveillance System, 2009

Cheryl L. Robbins, PhD

Lauren B. Zapata, PhD

Sherry L. Farr, PhD

Charlan D. Kroelinger, PhD

Brian Morrow, MA

Indu Ahluwalia, PhD

Denise V. D'Angelo, MPH

Danielle Barradas, PhD

Shanna Cox, MSPH

David Goodman, PhD

Letitia Williams, MPH

Violanda Grigorescu, MD

Wanda D. Barfield, MD

Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC

Corresponding author: Cheryl L. Robbins, PhD, Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC. Telephone: 404-718-6115; E-mail: ggf9@cdc.gov.

Abstract

Problem/Condition: Promoting preconception health can potentially improve women's health and pregnancy outcomes. Evidence-based interventions exist to reduce many maternal behaviors and chronic conditions that are associated with adverse pregnancy outcomes such as tobacco use, alcohol use, inadequate folic acid intake, obesity, hypertension, and diabetes. The 2006 national recommendations to improve preconception health included monitoring improvements in preconception health by maximizing public health surveillance (CDC. Recommendations to improve preconception health and health care—United States: a report of the CDC/ATSDR Preconception Care Work Group and the Select Panel on Preconception Care. MMWR 2006;55[No. RR-6]).

Reporting Period Covered: 2009 for 38 indicators; 2008 for one indicator.

Description of Surveillance Systems: The Pregnancy Risk Assessment Monitoring System (PRAMS) is an ongoing state- and population-based surveillance system designed to monitor selected self-reported maternal behaviors, conditions, and experiences that occur shortly before, during, and after pregnancy among women who deliver live-born infants. The Behavioral Risk Factor Surveillance System (BRFSS) is an ongoing state-based telephone survey of noninstitutionalized adults aged ≥18 years in the United States that collects state-level data on health-related risk behaviors, chronic conditions, and preventive health services. This surveillance summary includes PRAMS data from 29 reporting areas (n = 40,388 respondents) and BRFSS data from 51 reporting areas (n = 62,875 respondents) for nonpregnant women of reproductive age (aged 18–44 years).

To establish a comprehensive, nationally recognized set of indicators to be used for monitoring, evaluation, and response, a volunteer group of policy and program leaders and epidemiologists identified 45 core state preconception health indicators, of which 41 rely on PRAMS or BRFSS as data sources. This report includes 39 of the 41 core state preconception health indicators for which data are available through PRAMS or BRFSS. The two indicators from these data sources that are not described in this report are human immunodeficiency virus (HIV) testing within a year before the most recent pregnancy and heavy drinking on at least one occasion during the preceding month.

Ten preconception health domains are examined: general health status and life satisfaction, social determinants of health, health care, reproductive health and family planning, tobacco and alcohol use, nutrition and physical activity, mental health, emotional and social support, chronic conditions, and infections. Weighted prevalence estimates and 95% confidence intervals (95% CIs)for 39 indicators are presented overall and for each reporting area and stratified by age group (18–24, 25–34, and 35–44 years) and women's race/ethnicity (non-Hispanic white, non-Hispanic black, non-Hispanic other, and Hispanic).

Results: This surveillance summary includes data for 39 of 41 indicators: 2009 data for 23 preconception health indicators that were monitored by PRAMS and 16 preconception health indicators that were monitored by BRFSS (one BRFSS indicator uses 2008 data). For two of the indicators that are included in this report (prepregnancy overweight or obesity and current overweight or obesity), separate measures of overweight and obesity were reported.

All preconception health indicators varied by reporting area, and most indicators varied significantly by age group and race/ethnicity. Overall, 88.9% of women of reproductive age reported good, very good, or excellent general health status and life satisfaction (BRFSS). A high school/general equivalency diploma or higher education (social determinants of health domain) was reported by 94.7% of non-Hispanic white, 92.9% of non-Hispanic other, 91.1% of non-Hispanic black, and 70.9% of Hispanic women (BRFSS). Overall, health-care insurance coverage during the month before the most recent pregnancy (health-care domain) was 74.9% (PRAMS). A routine checkup during the preceding year was reported by 79.0% of non-Hispanic black, 65.1% of non-Hispanic white, 64.3% of other, and 63.0% of Hispanic women (BRFSS). Among women with a recent live birth (2–9 months since date of delivery), selected PRAMS results for the reproductive health and family planning, tobacco and alcohol use, and nutrition domains included several factors. Although 43% of women reported that their most recent pregnancy was unintended (unwanted or wanted to be pregnant later), approximately half (53%) of those who were not trying to get pregnant reported not using contraception at the time of conception. Smoking during the 3 months before pregnancy was reported by 25.1% of women, and drinking alcohol 3 months before pregnancy was reported by 54.2% of women. Daily use of a multivitamin, prenatal vitamin, or a folic acid supplement during the month before pregnancy was reported by 29.7% of women.

Selected BRFSS results included indicators pertaining to the nutrition and physical activity, emotional and social support, and chronic conditions domains among women of reproductive age. Approximately one fourth (24.7%) of women were identified as being obese according to body mass index (BMI) on the basis of self-reported height and weight. Overall, 51.6% of women reported participation in recommended levels of physical activity per U.S. Department of Health and Human Services physical activity guidelines. Non-Hispanic whites reported the highest prevalence (85.0%) of having adequate emotional and social support, followed by other races/ethnicities (74.9%), Hispanics (70.5%), and non-Hispanic blacks (69.7%). Approximately 3.0% of persons reported ever being diagnosed with diabetes, and 10.2% of women reported ever being diagnosed with hypertension.

Interpretation: The findings in this report underscore opportunities for improving the preconception health of U.S. women. Preconception health and women's health can be improved by reducing unintended pregnancies, reducing risky behaviors (e.g., smoking and drinking) among women of reproductive age, and ensuring that chronic conditions are under control. Evidence-based interventions and clinical practice guidelines exist to address these risks and to improve pregnancy outcomes and women's health in general. The results also highlight the need to increase access to health care for all nonpregnant women of reproductive age and the need to encourage the use of essential preventive services for women, including preconception health services. In addition, system changes in community settings can alleviate health problems resulting from inadequate social and emotional support and environments that foster unhealthy lifestyles. Policy changes can promote health equity by encouraging environments that promote healthier options in nutrition and physical activity. Finally, variation in the preconception health status of women by age and race/ethnicity underscores the need for implementing and scaling up proven strategies to reduce persistent health disparities among those at highest risk. Ongoing surveillance and research in preconception health are needed to monitor the influence of improved health-care access and coverage on women's prepregnancy and interpregnancy health status, pregnancy and infant outcomes, and health disparities.

Public Health Action: Public health decision makers, program planners, researchers, and other key stakeholders can use the state-level PRAMS and BRFSS preconception health indicators to benchmark and monitor preconception health among women of reproductive age. These data also can be used to evaluate the effectiveness of preconception health state and national programs and to assess the need for new programs, program enhancements, and policies.

Background

Promoting preconception health is an important Healthy People 2020 strategy for preventing adverse pregnancy outcomes and improving women's health overall (1). Establishing healthy behaviors and improving women's health before conception is essential especially because approximately half (49%) of all pregnancies in the United States are unintended (2). Unintended pregnancy rates vary by age and race/ethnicity, with younger and minority women having the highest unintended pregnancy rates (2). Persistent age and racial/ethnic disparities also have been documented for certain reproductive outcomes (e.g., preterm birth, fetal growth restriction, and infant death) (3–7) and for maternal risk factors (e.g., tobacco use, alcohol use, failure to consume adequate folic acid, obesity, hypertension, and diabetes) (8–13). These maternal risk factors are associated with preterm birth, spontaneous abortion, stillbirth, fetal death, sudden infant death syndrome, and having infants with low birthweight, fetal growth restricttion, fetal alcohol spectrum disorders, and neural tube defects and other birth defects (14–24). Evidence-based interventions targeting these risk factors can improve health outcomes in women and infants (17,18,25–34).

In 2006, the CDC/ATSDR Preconception Care Work Group and a select panel of experts published a strategic plan focused on improving the health and well-being of women and men of reproductive age (35). The plan included four goals, 10 recommendations, and 40 action steps and served as a call to action for improving the status of preconception health and preconception care in the United States. Those recommendations laid the foundation for the development of the National Initiative on Preconception Health and Health Care, which convened workgroups and developed strategies for promoting preconception health and preconception care (36). The term preconception health generally refers to the health of women of reproductive age before or between pregnancies. The term preconception care has been defined as a set of interventions that endeavor to identify and modify biomedical, behavioral, and social risks to a woman's health or pregnancy outcome through prevention and management (35,37). One of the 10 recommendations in the national strategic plan included monitoring improvements in preconception health and health care by maximizing existing public health surveillance systems.

This report is the first descriptive, state-level summary of core state preconception health indicators available in 2009 PRAMS and BRFSS data and provides prevalence estimates overall, stratified by age group and race/ethnicity. The report was developed in response to the CDC/ATSDR Preconception Care Work Group's recommendation to monitor improvements in preconception health by maximizing public health surveillance.

Introduction

Before release of the CDC/ATSDR Preconception Care Work Group's recommendations, few states or other entities monitored changes in preconception health over time because of a lack of uniform indicators for assessing preconception health and preconception care. To establish a comprehensive, nationally recognized set of indicators to be used for monitoring, evaluation, and response, a volunteer group of policy and program leaders and epidemiologists in seven states (California, Delaware, Florida, Michigan, North Carolina, Texas, and Utah) identified 45 core state preconception health indicators (multiple measures exist for some indicators). The list of indicators and the selection process have been described elsewhere (38). Of the 45 indicators, 41 used PRAMS (n = 24) or BRFSS (n = 17) as data sources; four rely on other data sources (which are not described in this report). The work group categorized the indicators into 10 domains. Health care is one of the domains and it includes several indicators of preconception care. Hereafter, the term preconception health encompasses both preconception health and preconception care.

Although numerous publications have reported national prevalence estimates of some of the preconception health indicators for women of reproductive age using BRFSS or National Health Interview Survey data (9,12,39–41), only one surveillance summary has been published on preconception health that uses population-based data and reports estimates by state (8). That summary preceded the development of the 45 core state preconception health indicators and summarized prevalence estimates for 10 of the core state indicators that were available from 2004 PRAMS data and that were defined the same in 2009 (i.e., prepregnancy drinking, nonuse of contraception prepregnancy, current contraceptive use, diabetes, physical abuse, types of social support, receipt of a postpartum checkup, hypertension, previous preterm birth, and prepregnancy smoking); those data serve as a baseline for monitoring changes over time for the 26 reporting areas included in the previous summary (8,38). Because it samples women of reproductive age with recent live births, PRAMS is an ideal data source for examining preconception and interconception health characteristics. Several states have used PRAMS data since publication of the previous summary to examine the status of preconception health in their own state and monitor changes (42–44).

This report includes 39 of the 41 core state preconception health indicators for which data are available through PRAMS or BRFSS. The state-level findings for 39 preconception indicators described in this report can be used by public health decision makers, program planners, researchers, and other key stakeholders to benchmark and monitor preconception health among women of reproductive age. These data also can be used to evaluate the effectiveness of preconception health state and national programs, and to assess the need for new programs, program enhancements, and policies.

Methods

To describe the status of preconception health by state, CDC estimated the baseline prevalence of 38 preconception indicators from PRAMS and BRFSS using 2009 data and one indicator using 2008 data. These indicators can be monitored at the state level for ongoing surveillance of the status of preconception health among women of reproductive age.

PRAMS Description and Data Collection

PRAMS is an ongoing U.S. state- and population-based surveillance system that was established in 1987 as part of an Infant Health Initiative when congressional funding was provided to CDC to establish state-based programs. PRAMS was designed to monitor selected self-reported maternal behaviors, conditions, and experiences that occur shortly before, during, and after pregnancy among women who deliver live-born infants in participating U.S. states and New York City (hereafter referred to as reporting areas). PRAMS is administered by CDC in collaboration with state health departments.

Details on the PRAMS methods have been described previously (45) and are available on the PRAMS website (http://www.cy118119.com/PRAMS). All PRAMS reporting areas use a standardized data collection method developed by CDC. PRAMS reporting areas select a monthly stratified sample of 100–300 new mothers from recent birth certificates, and annual sample sizes range from 1,162 to 3,008 per reporting area. PRAMS uses mixed-mode data collection in which up to three self-administered questionnaires are mailed and up to 15 telephone calls are made to followup with nonresponders during the first 9 months of the postpartum period. The first questionnaire usually is mailed 2–3 months after the delivery of a live-born infant to allow for collection of information about postpartum maternal and infant experiences. Survey data are linked to selected birth certificate data and weighted for sample design, nonresponse, and noncoverage. The PRAMS questionnaire consists of two parts (core and standard/optional questions) and is revised periodically to reflect changing priorities and emerging issues. All reporting areas ask the core questions, and the standard questions are chosen by each state from a pretested list developed by CDC or states.

PRAMS data are from 29 reporting areas representing approximately 55% of 4 million live births in the United States during 2009. All participating PRAMS reporting areas that had achieved an overall weighted response rate of ≥65% were included. The response rate is calculated as the number of responding mothers divided by the number of mothers sampled. Because comparable years for PRAMS and BRFSS data were used in this surveillance summary and because the maximum number of preconception health variables available through BRFSS occurs in odd years, this surveillance summary relies on 2009 data, which is the most current odd year in which data from both sources were available.

BRFSS Description and Data Collection

BRFSS is an ongoing state-based telephone survey of noninstitutionalized adults in the United States aged ≥18 years that has been conducted since 1984 by state and territorial health departments with assistance from CDC. BRFSS is the largest continuously conducted telephone survey in the world, with approximately 400,000 adult interviews completed each year. BRFSS is the main source of data for states on health risk behaviors, chronic health conditions, and preventive health services primarily related to chronic disease and injury in the United States.

Details on BRFSS methods have been described previously (46,47) and are available on the BRFSS website (http://www.cy118119.com/brfss). BRFSS uses a multistage sampling design created on the basis of random-digit–dialing methods to select a representative sample in each state and territory. Trained interviewers administer the BRFSS questionnaire using a computer-assisted telephone interviewing system. Data are collected monthly by each state and territory and then submitted to CDC for processing. The BRFSS questionnaire consists of three parts: the core component (which includes the fixed core, rotating core, and emerging core), optional modules, and state-added questions. Although all BRFSS reporting areas ask the same core questions, optional module and state-added questions are included at the discretion of the state or territory to address their specific health-care concerns.

Since 2007, BRFSS has been conducted in all 50 states, the District of Columbia (DC), the Commonwealth of Puerto Rico, Guam, and the U.S. Virgin Islands. This report includes data on nonpregnant women aged 18–44 years from 51 reporting areas including the 50 U.S. states and DC. The 2009 BRFSS cooperation rate (i.e., the proportion of all respondents interviewed of all eligible units in which a respondent was selected and actually contacted) ranged from 55.0% in California to 88.0% in Kentucky (2009 median: 75.0%), and the 2009 BRFSS response rate (percentage eligible for whom an interview was completed) ranged from 37.9% in Oregon to 66.9% in Nebraska (median: 52.5%) according to the guidelines of the Council of American Survey and Research Organizations. Although newer BRFSS data exist, for consistency with the most current PRAMS data, this report includes 2009 BRFSS data for all variables, with one exception: data for 2008 were used for the variable on whether women had received a Papnicolaou (Pap) test within the previous 3 years because this variable is included every other year and was not included in 2009. The 2008 median BRFSS cooperation and response rates were similar (75.0% and 53.3%, respectively).

Indicators

This report includes data on 39 of the 41 core state preconception health indicators for which data are available through PRAMS or BRFSS (38). The two exceptions are the indicators HIV testing within a year before the most recent pregnancy and heavy drinking on at least one occasion during the preceding month. PRAMS is not structured to produce valid estimates of HIV testing within a year before the most recent pregnancy because of a skip pattern that prompts the query only for women who were not tested during pregnancy. Data were included on three of the four alcohol consumption indicators.

All 16 indicators monitored by BRFSS are reported for 51 reporting areas, and 16 indicators monitored by PRAMS are reported for all 29 PRAMS reporting areas (Table 1). The remaining seven indicators that are monitored by PRAMS were reported for selected reporting areas that opted to add the question to their core surveys. In this report, separate prevalence estimates for current overweight and current obesity are reported rather than a combined estimate of overweight or obesity (BRFSS); likewise, separate estimates for prepregnancy overweight and obesity (PRAMS) were reported.

Data Analysis

All indicators were estimated among women of reproductive age (18–44 years). For each reporting area, weighted prevalence estimates and 95% confidence intervals (CIs) of indicators are presented overall and stratified by age group (18–24, 25–34, and 35–44 years) and race/ethnicity (non-Hispanic white, non-Hispanic black, non-Hispanic other, and Hispanic). The overall median, minimum, and maximum values also are presented. Among the total sample, chi-square tests were conducted to assess differences in indicators by age group and race/ethnicity. Differences were considered statistically significant when the p-value was <0.05. Because of the quantity of comparisons, tests of statistical significance were not conducted by reporting area. In accordance with the reporting policy of the specific surveillance system, when the denominator was <30 for PRAMS or <50 for BRFSS, prevalence estimates were not reported. In addition, prevalence estimates made on the basis of 30–59 respondents (PRAMS) or 50–59 respondents (BRFSS) are reported and footnoted, and all missing observations (<10%) are excluded. All analyses were conducted using weighted data and statistical software to account for the complex survey design (48).

Results

Results are presented by preconception health domains (Box) as described by the state work group (38). Data are presented for 39 indicators (Table 1). All indicators used data from either PRAMS (n = 23) or BRFSS (n = 16).

Domain 1: General Health Status and Life Satisfaction

Health Status (BRFSS)

Women considered to have good or better general health were those who reported that their general health at the time of the survey was good, very good, or excellent, versus fair or poor. In 2009, among women aged 18–44 years, the estimated overall prevalence of women who reported good or better general health for the 51 reporting areas was 88.9% (range: 84.5% [West Virginia] to 94.9% [North Dakota]; median: 90.0%;) (Table 2). For all reporting areas combined, the prevalence of this indicator varied significantly by age group and race/ethnicity. Specifically, 90.7% of women aged 18–24 years reported that their general health was good, very good, or excellent, compared with 89.5% of those aged 25–34 years and 87.3% of those aged 35–44 years. In addition, 91.8% of non-Hispanic white women reported good or better general health, compared with 88.9% of women who identified themselves as other race/ethnicity, 85.5% of non-Hispanic black women, and 80.9% of Hispanic women.

Domain 2: Social Determinants of Health

Educational Status (BRFSS)

High school/General Educational Development (GED) or higher education was defined as having completed at least the 12th grade or having received a GED certificate by the time of the survey. In 2009, among women aged 18–44 years, the estimated overall prevalence of women who reported high school/GED or higher education for the 51 reporting areas was 89.7% (range: 79.4% [California] to 97.2% [Vermont]; median: 91.9%) (Table 3). For all reporting areas combined, the prevalence of this indicator varied significantly by age group and race/ethnicity. Specifically, 90.9% of women aged 35–44 years reported high school/GED or higher education, compared with 89.9% of those aged 25–34 years, and 87.2% of those aged 18–24 years. In addition, 94.7% of non-Hispanic white women reported high school/GED or higher education, compared with 92.9% of women who identified themselves as other race/ethnicity, 91.1% of non-Hispanic black women, and 70.9% of Hispanic women.

Domain 3: Health Care

Current Health-Care Coverage (BRFSS)

Current health-care coverage was defined as having some type of health-care coverage at the time of the survey, including health insurance, prepaid plans, or government plans. In 2009, among women aged 18–44 years, the estimated overall prevalence of women who reported current health-care coverage for the 51 reporting areas was 80.1% (range: 64.5% [Texas] to 94.8% [DC]; median: 82.1%) (Table 4). For all reporting areas combined, the prevalence of this indicator varied significantly by age group and race/ethnicity. Specifically, 84.6% of women aged 35–44 years reported current health-care coverage, compared with 78.5% of those aged 25–34 years and 74.2% of those aged 18–24 years. In addition, 85.8% of non-Hispanic white women reported current health-care coverage, compared with 81.4% of women who identified themselves as other race/ethnicity, 78.0% of non-Hispanic black women, and 61.2% of Hispanic women.

Health-Care Coverage During the Month Before Pregnancy (PRAMS)

Health-care coverage during the month before pregnancy was defined as having any kind of health-care coverage (e.g., health insurance or government plan) during the month before pregnancy. In 2009, among women aged 18–44 years with a recent live birth, the estimated overall prevalence of women who had health-care coverage during the month before pregnancy for 29 reporting areas was 74.9% (range: 59.4% [Texas] to 94.0% [Massachusetts]; median: 78.2%) (Table 5). For all reporting areas combined, the prevalence of this indicator varied significantly by age group and race/ethnicity. Specifically, 84.6% of women aged 35–44 years reported health-care coverage during the month before pregnancy, compared with 79.8% of those aged 25–34 years, and 62.0% of those aged 18–24 years. In addition, 82.9% of women who identified themselves as other race/ethnicity reported health-care coverage during the month before pregnancy, compared with 81.9% of non-Hispanic white women, 76.0% of non-Hispanic black women, and 50.3% of Hispanic women.

Routine Checkup During the Past Year (BRFSS)

Routine checkup during the preceding year was defined as having visited a doctor for a routine checkup within the preceding year. In 2009, among women aged 18–44 years, the estimated overall percentage of women who reported having had a routine checkup during the preceding year for the 51 reporting areas was 66.3% (range: 51.4% [Oklahoma] to 77.3% [DC]; median: 66.4%) (Table 6). For all reporting areas combined, the prevalence of this indicator varied significantly by age group and race/ethnicity. Specifically, 69.6% of women aged 35–44 years reported a routine checkup during the preceding year, compared with 65.0% of those aged 18–24 years, and 63.5% of those aged 25–34 years. In addition, 79.0% of non-Hispanic black women reported a routine checkup during the preceding year, compared with 65.1% of non-Hispanic white women, 64.3% of women who identified themselves as other race/ethnicity, and 63.0% of Hispanic women.

Postpartum Checkup (PRAMS)

Postpartum checkup was defined as visiting a health-care provider for a postpartum checkup after a mother's most recent live birth. In 2009, among women aged 18–44 years with a recent live birth, the estimated overall prevalence of receiving a postpartum checkup for 16 reporting areas was 88.2% (range: 84.2% [Texas] to 94.4% [Massachusetts]; median: 89.1) (Table 7). For all reporting areas combined, the prevalence of this indicator varied significantly by age group and race/ethnicity. Specifically, 90.5% of women aged 25–34 years reported a postpartum checkup, compared with 90.0% of those aged 35–44 years, and 83.7% of those aged 18–24 years. In addition, 91.6% of non-Hispanic white women reported a postpartum checkup, compared with 88.3% of women who identified themselves as other race/ethnicity, 86.6% of non-Hispanic black women, and 80.3% of Hispanic women.

Teeth Cleaned During the 12 Months Before Pregnancy (PRAMS)

Having a teeth cleaning during the 12 months before pregnancy was defined as visiting a dentist or dental hygienist for a teeth cleaning in the 12 months before becoming pregnant. In 2009, among women aged 18–44 years with a recent live birth, the estimated overall prevalence of having a teeth cleaning for 29 reporting areas was 51.3% (range: 39.9% [Georgia] to 65.8% [Massachusetts]; median: 53.8) (Table 8). For all reporting areas combined, the prevalence of this indicator varied significantly by age group and race/ethnicity. Specifically, 61.8% of women aged 35–44 years reported having their teeth cleaned in the 12 months before pregnancy, compared with 55.1% of those aged 25–34 years and 40.2% of those aged 18–24 years. In addition, 58.6% of non-Hispanic white women reported having their teeth cleaned in the 12 months before pregnancy, compared with 48.4% of women who identified themselves as other race/ethnicity, 43.0% of non-Hispanic black women, and 36.5% of Hispanic women.

Recent Papanicolaou Test (BRFSS)

Recent Papanicolaou (Pap) test was defined as having had a Pap test within the past 3 years. In 2008, among women aged 18–44 years, the estimated overall prevalence of women who had a recent Pap test for the 51 reporting areas was 84.2% (range: 73.0% [Utah] to 91.3% [DC]; median: 84.6%) (Table 9). For all reporting areas combined, the prevalence of this indicator varied significantly by age group and race/ethnicity. Specifically, 89.7% of women aged 25–34 years reported a recent Pap test, compared with 88.2% of those aged 35–44 years and 68.6% of those aged 18–24 years. In addition, 87.4% of non-Hispanic black women reported a recent Pap test, compared with 84.6% of non-Hispanic white women, 83.5% of Hispanic women, and 77.6% of women who identified themselves as other race/ethnicity.

Preconception Counseling from a Health-Care Provider (PRAMS)

Receiving preconception counseling was defined as talking with a doctor, nurse, or other health-care worker about five or more of 11 possible lifestyle behaviors and prevention strategies before the pregnancy of her most recent live-born infant. In 2009, among women aged 18–44 years with a recent live birth, the estimated overall prevalence of receiving preconception counseling for four reporting areas was 18.4% (range: 17.7% [Ohio] to 19.8% [Maryland]; median: 18.4%) (Table 10). Differences by age group or race/ethnicity were not statistically significant.

Domain 4: Reproductive Health and Family Planning

Previous Preterm Birth Among Multiparous Women (PRAMS)

Previous preterm birth was defined as a live birth (before the respondent's most recent live birth) having been delivered >3 weeks before the due date; women whose most recent live birth was their first birth were excluded. In 2009, among multiparous women aged 18–44 years with a recent live birth, the estimated overall prevalence of previous preterm birth for 29 reporting areas was 14.4% (range: 10.6% [Oklahoma] to 19.6% [Mississippi]; median: 13.0%) (Table 11). For all reporting areas combined, the prevalence of this indicator varied significantly by age group and race/ethnicity. Specifically, 16.8% of women aged 18–24 years reported a previous preterm birth, compared with 14.1% of those aged 25–34 years and 12.1% of those aged 35–44 years. In addition, 17.5% of non-Hispanic black women reported a previous preterm birth, compared with 17.1% of Hispanic women, 13.5% of women who identified themselves as other race/ethnicity, and 12.6% of non-Hispanic white women.

Previous Fetal Death, Miscarriage, or Stillbirth Among Multiparous Women (PRAMS)

Among multiparous women, previous fetal death, miscarriage, or stillbirth was defined as having experienced at least one fetal death (i.e., infant died before being born), miscarriage, or stillbirth in the 12 months before getting pregnant with the most recent live-born infant. In 2009, among multiparous women aged 18–44 years with a recent live birth, the estimated overall prevalence of previous fetal death, miscarriage, or stillbirth for two reporting areas was 14.9% (range: 14.4% [Wisconsin] to 18.2% [Delaware]; median: 16.3%) (Table 12). Differences by age group or race/ethnicity were not statistically significant.

Unintended Pregnancy (PRAMS)

Unintended pregnancy was defined as a pregnancy among women who, just before their most recent pregnancy, wanted to be pregnant later or did not want to be pregnant then or at any time in the future. In 2009, among women aged 18–44 years with a recent live birth, the estimated overall prevalence of women who reported that the pregnancy was unintended for 29 reporting areas was 42.9% (range: 32.4% [Massachusetts] to 56.1% [Mississippi]; median: 41.4%) (Table 13). For all reporting areas combined, the prevalence of this indicator varied significantly by age group and race/ethnicity. Specifically, 61.6% of women aged 18–24 years reported that the pregnancy was unintended, compared with 35.4% of those aged 25–34 years and 29.2% of those aged 35–44 years. In addition, 65.2% of non-Hispanic black women reported that the pregnancy was unintended, compared with 45.9% of Hispanic women, 37.9% of women who identified themselves as other race/ethnicity, and 37.3% of non-Hispanic white women.

Contraceptive Nonuse at Time of Conception Among Women Not Trying to Get Pregnant (PRAMS)

Among women not trying to get pregnant, contraceptive nonuse at the time of conception was defined as women who reported that neither they nor their husbands or partners were doing anything to keep from getting pregnant at the time of conception. In 2009, among women aged 18–44 years with a recent live birth who were not trying to get pregnant, the estimated overall prevalence of contraceptive nonuse at the time of conception for 29 reporting areas was 52.6% (range: 46.7% [Washington] to 58.1% [West Virginia]; median: 53.5%) (Table 14). For all reporting areas combined, the prevalence varied significantly by age group and race/ethnicity. Specifically, 54.5% of women aged 18–24 years not trying to get pregnant reported contraceptive nonuse at the time of conception, compared with 51.3% of those aged 35–44 years and 51.1% of those aged 25–34 years. In addition, 55.4% of women who identified themselves as other race/ethnicity who were not trying to get pregnant reported contraceptive nonuse at time of conception, compared with 54.5% of non-Hispanic black women, 54.1% of non-Hispanic white women, and 45.9% of Hispanic women.

Postpartum Contraceptive Use (PRAMS)

Postpartum contraceptive use was defined as current use of a birth control method by women or their husbands or partners to keep from getting pregnant including natural family planning (e.g., the rhythm methods or withdrawal). In 2009, among women aged 18–44 years with a recent live birth, the estimated overall prevalence of women who reported current contraceptive use for 29 reporting areas was 85.1% (range: 74.9% [New Jersey] to 90.1% [Utah]; median: 85.9%) (Table 15). For all reporting areas combined, the prevalence of this indicator varied significantly by age group and race/ethnicity. Specifically, 86.2% of women aged 18–24 years reported postpartum contraceptive use, compared with 85.2% of those aged 25–34 years and 82.4% of those aged 35–44 years. In addition, 85.9% of non-Hispanic white women reported postpartum contraceptive use, compared with 85.7% of Hispanic women, 83.7% of non-Hispanic black women, and 78.7% of women who identified themselves as other race/ethnicity.

Use of Assisted Reproductive Technology Among Women Trying to Get Pregnant (PRAMS)

Among women trying to get pregnant, use of assisted reproductive technology was defined as use of fertility drugs or receipt of any medical procedures from a doctor, nurse, or other health-care worker to help them get pregnant before their most recent pregnancy. In 2009, among women aged 18–44 years with a recent live birth trying to get pregnant, the estimated overall prevalence of reported use of assisted reproductive technology for eight reporting areas was 11.1% (range: 8.3% [Maine] to 15.5% [Delaware]; median: 10.5%) (Table 16). For all reporting areas combined, the prevalence of this indicator significantly varied by age group and race/ethnicity. Specifically, approximately 20.7% of women aged 35–44 years trying to get pregnant reported use of assisted reproductive technology, compared with 10.3% of those aged 25–34 years and 3.9% of those aged 18–24 years. Additionally, 13.5% of women who identified themselves as other race/ethnicity reported use of assisted reproductive technology, compared with 12.0% of non-Hispanic white women, 9.4% of non-Hispanic black women, and 5.5% of Hispanic women.

Domain 5: Tobacco and Alcohol Use

Current Smoking (BRFSS)

Current smoking was defined as smoking ≥100 cigarettes in a lifetime and currently smoking cigarettes every day or some days at the time of the interview. In 2009, among women aged 18–44 years, the estimated overall prevalence of smoking for the 51 U.S. reporting areas was 18.7% (range: 8.3% [Utah] to 30.9% [West Virginia]; median: 20.1%) (Table 17). For all reporting areas combined, the prevalence of this indicator varied significantly by age group and race/ethnicity. Specifically, 20.4% of women aged 25–34 years were current smokers, compared with 18.7% of those aged 18–24 years and 17.2% of those aged 35–44 years. In addition, 22.0% of non-Hispanic white women were current smokers, compared with16.9% of women who identified themselves as other race/ethnicity, 15.7% of non-Hispanic black women, and 9.8% of Hispanic women.

Smoking Before Pregnancy (PRAMS)

Smoking before pregnancy was defined as smoking ≥100 cigarettes in the preceding 2 years and smoking any number of cigarettes, including less than one cigarette, on an average day during the 3 months before pregnancy. In 2009, among women aged 18–44 years with a recent live birth, the estimated overall prevalence of women who had smoked before pregnancy for 29 reporting areas was 25.1% (range: 12.8% [Utah] to 42.9% [West Virginia]; median: 27.2%) (Table 18). For all reporting areas combined, the prevalence of this indicator varied significantly by age group and race/ethnicity. Specifically, 35.8% of women aged 18–24 years reported smoking during the 3 months before pregnancy, compared with 21.7% of those aged 25–34 years and 14.1% of those aged 35–44 years. In addition, 30.8% of non-Hispanic white women reported smoking during the 3 months before pregnancy, compared with 22.7% of non-Hispanic black women, 18.7% of women who identified themselves as other race/ethnicity, and 12.4% of Hispanic women.

Current Secondhand Smoke Exposure (PRAMS)

Current secondhand smoke exposure was defined as smoking being allowed anywhere in the home or allowed in some rooms or at some times in the home at the time of the interview. In 2009, among women aged 18–44 years with a recent live birth, the estimated overall prevalence of current exposure to secondhand smoke for 29 reporting areas was 6.4% (range: 1.1% [Utah] to 14.3% [West Virginia]; median: 5.1%) (Table 19). For all reporting areas combined, the prevalence of this indicator varied significantly by age group and race/ethnicity. Specifically, 11.1% of women aged 18–24 years reported current secondhand smoke exposure, compared with 4.6% of those aged 25–34 years and 3.0% of those aged 35–44 years. In addition, 12.2% of non-Hispanic black women reported current secondhand smoke exposure, compared with 6.6% of non-Hispanic white women, 4.9% of women who identified themselves as other race/ethnicity, and 2.7% of Hispanic women.

Current Binge Drinking (BRFSS)

Current binge drinking was defined as drinking four or more alcoholic beverages in one sitting on at least one occasion during the preceding month at the time of the interview. In 2009, among women aged 18–44 years, the estimated overall prevalence of binge drinking for the 51 reporting areas was 15.2% (range: 6.6% [West Virginia] to 25.6% [North Dakota]; median: 16.4%) (Table 20). For all reporting areas combined, the prevalence of this indicator varied significantly by age group and race/ethnicity. Specifically, approximately 21.2% of women aged 18–24 years were binge drinkers, compared with 15.8% of those aged 25–34 years and 11.7% of those aged 35–44 years. In addition, 17.9% of non-Hispanic white women were binge drinkers, compared with 11.7% of women who identified themselves as other race/ethnicity, 11.0% of Hispanic women, and 10.1% of non-Hispanic black women.

Drinking Alcohol Before Pregnancy (PRAMS)

Drinking alcohol before pregnancy was defined as drinking any amount of an alcoholic beverage, including less than one drink, in an average week during the 3 months before pregnancy. In 2009, among women aged 18–44 years with a recent live birth, the estimated overall prevalence of reported drinking of any alcohol during the 3 months before pregnancy for 29 reporting areas was 54.2% (range: 24.0% [Utah] to 71.6% [Vermont]; median: 59.9%) (Table 21). For all reporting areas combined, the prevalence of this indicator varied by age group and race/ethnicity. Specifically, 56.5% of women aged 35–44 years reported alcohol use 3 months before pregnancy, compared with 56.3% of those aged 25–34 years and 49.6% of women aged 18–24 years. In addition, 65.7% of non-Hispanic white women reported alcohol use during the 3 months before pregnancy, compared with 44.2% of non-Hispanic black women, 39.7% of women who identified themselves as other race/ethnicity, and 32.2% of Hispanic women.

Binge Drinking Before Pregnancy (PRAMS)

Binge drinking before pregnancy was defined as drinking four or more drinks in one sitting at least once during the 3 months before pregnancy. In 2009, among women aged 18–44 years with a recent live birth, the estimated overall prevalence of reported binge drinking before pregnancy for 29 reporting areas was 24.4% (range: 11.8% [Utah] to 34.8% [Minnesota]; median: 25.8%) (Table 22). For all reporting areas combined, the prevalence of this indicator varied significantly by age group and race/ethnicity. Specifically, 26.2% of women aged 18–24 years reported binge drinking during the 3 months before pregnancy, compared with 24.9% of those aged 25–34 years and 17.8% of those aged 35–44 years. In addition, 30.7% of non-Hispanic white women reported binge drinking during the 3 months before pregnancy, compared with 17.2% of women who identified themselves as other race/ethnicity,15.3% of non-Hispanic black women, and 14.5% of Hispanic women.

Domain 6: Nutrition and Physical Activity

Fruit and Vegetable Intake (BRFSS)

Adequate fruit and vegetable intake was defined as reported combined consumption of fruits and vegetables at least five times per day. In 2009, among women aged 18–44 years, the estimated overall prevalence of reported consumption of fruits and vegetables at least five times per day for the 51 reporting areas was 25.2% (range: 13.4% [Oklahoma] to 33.5% [DC]; median: 25.2%) (Table 23). For all reporting areas combined, the prevalence of this indicator varied significantly by age group and race/ethnicity. Specifically, approximately 26.4% of women aged 35–44 years reported consuming fruits and vegetables at least five times per day, compared with 25.9% of those aged 25–34 years and 21.6% of those aged 18–24 years. In addition, 29.6% of women who identified themselves as other race/ethnicity reported consuming fruits and vegetables at least five times per day, compared with 25.0% of non-Hispanic white women, 24.3% of Hispanic women, and 24.2% of non-Hispanic black women.

Overweight Body Mass Index (BRFSS and PRAMS)

Body mass index (BMI) was calculated as weight (kg)/(height [m])2. Overweight (but not obese) was defined as having a BMI of 25.0–29.9 kg/m2. In 2009, among women aged 18–44 years, the estimated overall prevalence of overweight at the time of the interview for the 51 reporting areas was 26.6% (range: 20.0% [Virginia] to 33.0% [Alaska]; median: 26.3%) (Table 24). For all reporting areas combined, the prevalence of this indicator varied significantly by age group and race/ethnicity. Specifically, 28.3% of women aged 35–44 years were overweight, compared with 27.7% of those aged 25–34 years and 21.6% of those aged 18–24 years. In addition, 31.1% of Hispanic women were overweight, compared with 28.4% of non-Hispanic black women, 25.6% of women who identified themselves as other race/ethnicity, and 25.0% of non-Hispanic white women.

Among women with a recent live birth, the estimated overall prevalence of overweight just before the most recent pregnancy for 29 reporting areas was 24.9% (range: 21.2% [Wyoming] to 32.1% [Georgia]; median: 24.1%) (Table 25). The prevalence of this indicator varied significantly by race/ethnicity but not by age group. Specifically, 29.3% of Hispanic women were overweight just before they became pregnant, compared with 27.2% of non-Hispanic black women, 23.4% of non-Hispanic white women, and 23.3% of women who identified themselves as other race/ethnicity.

Obesity (BRFSS and PRAMS)

Being obese was defined as having a BMI of ≥30.0. In 2009, among women aged 18–44 years, the estimated overall prevalence of obesity for the 51 reporting areas at the time of the interview was 24.7% (range: 14.5% [Connecticut] to 36.4% [Mississippi]; median: 24.1%) (Table 26). For all reporting areas combined, the prevalence of this indicator varied significantly by age group and race/ethnicity. Specifically, 28.0% of women aged 35–44 years were obese, compared with 25.8% of those aged 25–34 years and 16.6% of those aged 18–24 years. In addition, 39.6% of non-Hispanic black women were obese, compared with 28.2% of Hispanic women, 21.7% of non-Hispanic white women, and 18.2% of women who identified themselves as other race/ethnicity.

Among women with a recent live birth, the estimated overall prevalence of prepregnancy obesity for 29 reporting areas was 22.1% (range: 14.4% [Colorado] to 29.0% [Mississippi]; median: 21.3%) (Table 27). Prevalence estimates of this indicator varied significantly by age group and race/ethnicity, similar to estimates of obesity at the time of the interview.

Folic Acid Supplementation During the Month Before Pregnancy (PRAMS)

Folic acid supplementation during the month before pregnancy was defined as taking a multivitamin, prenatal vitamin, or folic acid vitamin every day of the month before pregnancy. In 2009, among women aged 18–44 years with a recent live birth, the estimated overall prevalence of women who reported folic acid supplementation during the month before pregnancy for 29 reporting areas was 29.7% (range: 21.7% [West Virginia] to 38.2% [Vermont]; median: 30.9%) (Table 28). For all reporting areas combined, the prevalence of this indicator varied significantly by age group and race/ethnicity. Specifically, 42.4% of women aged 35–44 years reported folic acid supplementation during the month before pregnancy, compared with 34.5% of those aged 25–34 years and 16.1% of those aged 18–24 years. In addition, 34.2% of non-Hispanic white women reported folic acid supplementation during the month before pregnancy, compared with 33.0% of women who identified themselves as other race/ethnicity, 22.5% of Hispanic women, and 19.5% of non-Hispanic black women.

Participation in Recommended Levels of Physical Activity (BRFSS)

Participation in recommended levels of physical activity during the preceding year was defined as participating in enough moderate or vigorous physical activity in a usual week to meet the U.S. Department of Health and Human Services' recommended levels of physical activity (49). In 2009, among women aged 18–44 years, the estimated overall prevalence of women who reported participation in recommended levels of physical activity for the 51 reporting areas was 51.6% (range: 39.2% [Tennessee] to 62.4% [Idaho]; median: 53.5%) (Table 29). For all reporting areas combined, the prevalence of this indicator varied significantly by age group and race/ethnicity. Specifically, 53.5% of women aged 18–24 years reported participation in recommended levels of physical activity, compared with 52.8% of those aged 25–34 years and 49.7% of those aged 35–44 years. In addition, 55.3% of non-Hispanic white women reported participation in recommended levels of physical activity, compared with 47.7% of Hispanic women, 46.8% of women who identified themselves as other race/ethnicity, and 41.0% of non-Hispanic black women.

Domain 7: Mental Health

Frequent Mental Distress (BRFSS)

Frequent mental distress was defined as mental health that was not good for at least 14 of the preceding 30 days. In 2009, among women aged 18–44 years, the estimated overall prevalence of women who had frequent mental distress during the previous month for the 51 reporting areas was 13.2% (range: 8.0% [DC] to 18.3% [Arkansas]; median: 12.3%) (Table 30). For all reporting areas combined, the prevalence of this indicator varied significantly by race/ethnicity but not by age group. Specifically, 15.1% of non-Hispanic black women reported frequent mental distress, compared with 13.4% of Hispanic women, 12.9% of women who identified themselves as other race/ethnicity, and 12.8% of non-Hispanic white women.

Clinical Care for Anxiety or Depression During the 12 Months Before Pregnancy (PRAMS)

Clinical care for anxiety or depression during the 12 months before pregnancy was defined as visiting a health-care provider to be checked or treated for anxiety or depression during the 12 months before pregnancy. In 2009, among women aged 18–44 years with a recent live birth, the estimated overall prevalence of receiving clinical care for anxiety or depression during the 12 months before pregnancy for 29 reporting areas was 11.2% (range: 6.8% [Hawaii] to 21.1% [Maine]; median: 12.8%) (Table 31). For all reporting areas combined, the prevalence of this indicator varied significantly by race/ethnicity but not by age group. Specifically, 13.2% of non-Hispanic white women reported receiving clinical care for anxiety or depression during the 12 months before pregnancy, compared with 9.8% of non-Hispanic black women, 7.9% of women who identified themselves as other race/ethnicity, and 7.3% of Hispanic women.

Postpartum Depressive Symptoms (PRAMS)

Experiencing postpartum depressive symptoms was defined as feeling down, depressed, or sad; hopeless; or slowed down by a substantial degree since the infant's birth. In 2009, among women aged 18–44 years with a recent live birth, the estimated overall prevalence of women who had postpartum depressive symptoms for 29 reporting areas was 11.9% (range: 7.7% [Illinois] to 19.9% in [Arkansas]; median: 12.4%) (Table 32). For all reporting areas combined, the prevalence of this indicator varied significantly by age group and race/ethnicity. Specifically, 14.7% of women aged 18–24 years reported postpartum depressive symptoms, compared with 10.7% of those aged 25–34 years and 10.0% of those aged 35–44 years. In addition, 14.1% of non-Hispanic black women reported postpartum depressive symptoms, compared with 11.8% of non-Hispanic white women, 11.1% of Hispanic women, and 10.2% of women who identified themselves as other race/ethnicity.

Domain 8: Emotional and Social Support

Physical Abuse During the 12 Months Before Pregnancy (PRAMS)

Physical abuse during the 12 months before pregnancy was defined as being pushed, hit, slapped, kicked, choked, or physically hurt in any other way by a husband or partner during the 12 months before pregnancy. In 2009, among women aged 18–44 years with a recent live birth, the estimated overall prevalence of women who reported physical abuse during the 12 months before pregnancy for 29 reporting areas was 3.8% (range: 1.9% [Oregon] and [Utah] to 5.7% [Oklahoma]; median: 3.5%) (Table 33). For all reporting areas combined, the prevalence of this indicator varied significantly by age group and race/ethnicity. Specifically, 6.7% of women aged 18–24 years reported physical abuse during the 12 months before pregnancy, compared with 2.6% of those aged 25–34 years and 1.9% of those aged 35–44 years. In addition, 5.7% of non-Hispanic black women reported physical abuse during the 12 months before pregnancy, compared with 5.0% of Hispanic women, 3.1% of women who identified themselves as other race/ethnicity, and 3.0% of non-Hispanic white women.

Mental Abuse During the 12 Months Before Pregnancy (PRAMS)

Women who experienced mental abuse during the 12 months before pregnancy were those who reported that a husband or partner threatened them, limited their activities against their will, or made them feel unsafe during the 12 months before pregnancy. In 2009, only the Alaska PRAMS asked about mental abuse. Among women in Alaska aged 18–44 years with a recent live birth, the estimated overall prevalence of women who experienced mental abuse during the 12 months before pregnancy was 2.4% (CI = 1.6–3.5). For Alaska, the prevalence of this indicator varied significantly by age group and race/ethnicity. Specifically, 3.5% (CI = 2.0–6.0) of women aged 18–24 years reported mental abuse during the 12 months before pregnancy, compared with 2.0% (CI = 1.1–3.6) of those aged 25–34 years and 0.3% (CI = 0.1–0.7) of those aged 35–44 years. In addition, 4.4% (CI = 2.8–6.9) of women who identified themselves as other race/ethnicity reported mental abuse during the 12 months before pregnancy, compared with 3.6% (CI = 0.8–14.5) of Hispanic women, 1.3% (CI = 0.6–3.0) of non-Hispanic white women, and 0.7% (CI = 0.2–2.3) of non-Hispanic black women.

Adequate Emotional and Social Support (BRFSS)

Adequate emotional and social support was defined as always or usually getting the social and emotional support needed. In 2009, among women aged 18–44 years, the estimated overall prevalence of women who reported adequate emotional and social support for the 51 reporting areas was 79.9% (range: 72.5% [Mississippi] to 88.4% [Oregon]; median: 81.5%) (Table 34). For all reporting areas combined, the prevalence of this indicator varied significantly by race/ethnicity but not by age. Specifically, 85.0% of non-Hispanic white women reported adequate emotional and social support, compared with 74.9% of women who identified themselves as other race/ethnicity, 70.5% of Hispanic women, and 69.7% of non-Hispanic black women.

Types of Social and Emotional Support Available to Women After Delivering Their Infant (PRAMS)

Social and emotional support available to women after delivering their infant was defined as having had three or more out of five types of social support available to them since they delivered their infant, including help with child care, help with housework, knowing they would not lose their jobs, having money to make up for not working, and other. In 2009, among women aged 18–44 years with a recent live birth, the estimated overall prevalence of women who had adequate social and emotional support available to them after delivering their infant for two reporting areas was 87.0% (range: 87.0% [Oklahoma] to 87.2% [Rhode Island]; median: 87.1%) (Table 35). For the two reporting areas combined, the prevalence of this indicator varied significantly by race/ethnicity but not by age. Specifically, 90.6.% of non-Hispanic white women reported adequate emotional and social support after delivery of their infant, compared with 87.2% of women who identified themselves as other race/ethnicity, 79.4% of non-Hispanic black women, and 75.5% of Hispanic women.

Domain 9: Chronic Conditions

Diabetes (BRFSS)

Women with diabetes were those who reported ever being told by a health-care provider that they had diabetes, not including gestational diabetes. In 2009, among women aged 18–44 years, the estimated overall prevalence of women who had diabetes for 51 reporting areas was 3.0% (range: 1.1% [Minnesota] to 6.2% [Tennessee]; median: 2.7%) (Table 36). For all reporting areas combined, the prevalence of this indicator varied significantly by age group and race/ethnicity. Specifically, 4.5% of women aged 35–44 years reported having diabetes, compared with 2.4% of those aged 25–34 years and 1.0% of women aged 18–24 years. In addition, 5.1% of non-Hispanic black women reported being diagnosed with diabetes, compared with 3.6% of Hispanic women, 3.3% of women who identified themselves as other race/ethnicity, and 2.3% of non-Hispanic white women.

Prepregnancy Diabetes (PRAMS)

Women with prepregnancy diabetes were those who reported ever being told by a health-care provider before their most recent pregnancy that they had type I or type II diabetes. In 2009, among women aged 18–44 years with a recent live birth, the estimated overall prevalence of women who had diabetes before pregnancy for 29 reporting areas was 2.1% (range: 1.3% [Minnesota] and [Utah] to 4.0% [Arkansas]; median: 2.1%) (Table 37). For all reporting areas combined, the prevalence of this indicator varied significantly by age group and race/ethnicity. Specifically, 3.4% of those aged 35–44 years reported having diabetes before pregnancy, compared with 2.0% of those aged 25–34 years and 1.8% of those aged 18–24 years. In addition, 3.1% of women who identified themselves as other race/ethnicity reported prepregnancy diabetes, compared with 2.7% of non-Hispanic black women, 2.0% of non-Hispanic white women, and 1.8% of Hispanic women.

Hypertension (BRFSS)

Women with hypertension were those who reported ever being told by a health-care provider that they had hypertension, not including hypertension during pregnancy. In 2009, among women aged 18–44 years, the estimated overall prevalence of women who had hypertension for 51 reporting areas was 10.2% (range: 5.4% [Nebraska] to 19.6% [Mississippi]; median: 9.5%) (Table 38). For all reporting areas combined, the prevalence of this indicator varied significantly by age group and race/ethnicity. Specifically, 14.7% of women aged 35–44 years reported hypertension, not including hypertension during pregnancy, compared with 8.5% of those aged 25–34 years and 4.7% of those aged 18–24 years. In addition, 19.2% of non-Hispanic black women reported hypertension, compared with 9.3% of non-Hispanic white women, 8.2% of Hispanic women, and 7.9% of women who identified themselves as other race/ethnicity.

Hypertension During the 3 Months Before Pregnancy (PRAMS)

Women with prepregnancy hypertension were those who reported having high blood pressure during the 3 months before their most recent pregnancy. In 2009, among women aged 18–44 years with a recent live birth, the estimated overall prevalence of women who had hypertension during the 3 months before pregnancy for 10 reporting areas was 3.0% (range: 1.4% [Utah] to 4.7% [West Virginia]; median: 3.5%) (Table 39). For all reporting areas combined, the prevalence of this indicator varied significantly by age group and race/ethnicity. Specifically, 5.3% of those aged 35–44 years reported hypertension during 3 months before pregnancy, compared with 2.7% of those aged 25–34 years and 2.5% of those aged 18–24 years. In addition, 6.6% of non-Hispanic black women reported having hypertension during 3 months before pregnancy, compared with 2.8% of women who identified themselves as other race/ethnicity, 2.5% of non-Hispanic white women, and 1.7% of Hispanic women.

Asthma (BRFSS)

Women with a current asthma diagnosis were those who reported that a doctor, nurse, or other health professional had ever told them that they had asthma and reported that they still have asthma. In 2009, among women aged 18–44 years, the estimated overall prevalence of women who reported currently having asthma for the 51 reporting areas was 10.7% (range: 6.8% [Georgia] to 15.1% [Massachusetts] and [North Dakota]; median: 11.0%) (Table 40). For all reporting areas combined, the prevalence of this indicator varied significantly by age group and race/ethnicity. Specifically, 12.9% of women aged 18–24 years reported currently having asthma, compared with 10.2% of those aged 25–34 years and 9.8% of those aged 35–44 years. In addition, 12.3% of non-Hispanic black women reported currently having asthma, compared with 11.3% of non-Hispanic white women, 9.8% of women who identified themselves as other race/ethnicity and 7.7% of Hispanic women.

Domain 10: Infections

Influenza Vaccination During the Preceding Year (BRFSS)

Influenza vaccination during the preceding year was defined as receiving an influenza vaccine during the preceding 12 months (either a vaccine injected into their arm or a vaccine sprayed into their nose). In 2009, among women aged 18–44 years, the estimated overall prevalence of women who reported receiving an influenza vaccination during the preceding year for the 51 reporting areas was 28.2% (range: 17.1% [Florida] to 48.7% [South Dakota]; median: 30.1%) (Table 41). For all reporting areas combined, the prevalence of this indicator varied significantly by age group and race/ethnicity. Specifically, 30.5% of women aged 35–44 years reported receiving an influenza vaccination during the previous year, compared with 27.8% of those aged 25–34 years and 24.3% of those aged 18–24 years. In addition, 30.7% of non-Hispanic white women reported receiving an influenza vaccination within the previous year, compared with 29.3% of women who identified themselves as other race/ethnicity, 22.9% of non-Hispanic black women, and 22.6% of Hispanic women.

Discussion

This report presents the status of 39 preconception health indicators monitored by PRAMS or BRFSS and the 10 preconception health domains recommended by the state working group (38). This is the first published surveillance summary that provides both national and reporting area-specific estimates of the recommended core preconception health indicators and provides an opportunity to monitor changes in preconception health over time (from 2004 to 2009).* As such, these findings can help public health decision makers, researchers, and key stakeholders to make state and national comparisons that can be used for needs assessments, resource allocation, and program evaluation. Since 2004, no significant changes occurred in the overall prevalence estimates for seven of the 10 indicators that were defined consistently with those previously reported (i.e., nonuse of contraception prepregnancy, current contraceptive use, diabetes, physical abuse, types of social support, receipt of a postpartum checkup, and hypertension) (8), whereas the status of three indicators (prepregnancy smoking, prepregnancy alcohol consumption, and previous preterm delivery) worsened. Cigarette smoking during the 3 months before pregnancy increased from 23.2% (CI = 22.5–23.9) in 2004 (8) to 25.1% (CI = 24.4–25.9) in 2009. Alcohol use during the same time periods increased from 50.1% (CI = 49.3–50.9) (8) to 54.2% (CI = 53.3–55.1). Previous preterm delivery increased from 11.9% (CI = 11.3–12.5) (8) to 14.4% (CI = 13.5–15.2).

The findings in this report suggest opportunities for improving the preconception health of U.S. women. From a public health perspective, one key strategy is to integrate preconception health care into the existing public health services (36). Well-established evidence supports preventive screening and interventions that improve women's health outcomes (e.g., smoking cessation, reduced alcohol consumption, and blood pressure and glucose control) (32,33,50,51). However, much of the evidence for preconception interventions is derived from studying populations of women at high risk for adverse birth outcomes (e.g., those who consume alcohol, smoke, or have histories of previous adverse birth outcomes) or other specific populations (e.g., women intending to get pregnant) (52). A recent literature review reported few published preconception interventions have demonstrated substantial effectiveness for improving pregnancy outcomes (52). The following sections highlight the status of key preconception health domains that included indicators with high prevalence and those that can lead to serious adverse effects on pregnancy outcomes (e.g., tobacco and alcohol use, nutrition and physical activity, and chronic conditions, health care, and reproductive health and family planning). Because nearly all indicators varied significantly by age, race/ethnicity, and reporting area, disparities also are summarized.

Tobacco and Alcohol Use

Tobacco use continues to be a crucial focus area for screening and intervention. Approximately one fourth of women of reproductive age reported prepregnancy smoking and approximately one fifth reported current smoking. Estimates of smoking during the 3 months before pregnancy are higher than the 2004 estimates (23.2%; CI = 22.5–23.9); however, the estimate of current smoking is similar to the previous estimate (17.9%; CI = 17.3–18.5) (8). Tobacco use during pregnancy is associated with spontaneous abortions, preterm births, and other adverse birth outcomes such as having infants who are small for gestational age or low birth weight, stillbirth, fetal death, and sudden infant death syndrome (14,53). Clinical practice guidelines have been developed for smoking and include screening reproductive age women for tobacco use (32,53). In addition, providing brief clinical interventions to tobacco users, in general, combined with referrals to telephone quit lines, improves quit rates (54).

Approximately one in four women with a recent live birth reported prepregnancy binge drinking and more than half (54%) reported drinking some alcohol during the 3 months before pregnancy. The estimate of any alcohol use during the 3 months before pregnancy in 2009 (54.2%; CI = 53.3–55.1) was higher than the 2004 estimate (50.1%; CI = 49.3–50.9) (8). Use of alcohol during pregnancy is associated with spontaneous abortions, stillbirth, preterm delivery, and sudden infant death syndrome (55), and has consistently been shown to result in lifelong disorders in children, known as fetal alcohol spectrum disorders (56,57). U.S. Department of Health and Human Services guidelines advise against any alcohol use if a woman is pregnant or considering becoming pregnant (15). Screening reproductive age women for alcohol use is recommended (15,33,58). Clinical practice guidelines have been developed for alcohol misuse and include counseling and behavioral strategies that include action plans, drinking diaries, stress management, or problem solving (33). Evidence supports the use of electronic devices (e.g., computers, telephones, or mobile devices) for screening women and brief interventions by clinicians to reduce excessive alcohol consumption (27,33,59).

Nutrition and Physical Activity

Scientific evidence and clinical practice guidelines support preconception care interventions that focus on several risk factors under the domain of nutrition and physical activity (28,29), namely obesity and inadequate folic acid intake. These two risk factors are associated with adverse pregnancy outcomes and were highlighted in the 2006 CDC recommendations to improve preconception health (35).

The findings in this report indicate that one in four women with a recent live birth was overweight and approximately one in five was obese before they became pregnant. In addition, 25% of nonpregnant women of reproductive age were obese. The 2009 estimate of prepregnancy obesity among this population (22.1%; CI = 21.3–22.9) is not statistically different from the 2004 estimate (21.9%; CI = 21.2–22.6) (8); however, the definition used for obesity (BMI ≥30.0) is more restrictive than that used previously (BMI >29.0), making comparisons difficult. Women of reproductive age should be screened for obesity (18,60) because maternal obesity is associated with chronic disease, cesarean delivery, and hypertensive disorders during pregnancy, and weight loss before pregnancy can reduce these risks (61–64). Physical activity, particularly when combined with a healthy diet, is effective for promoting weight loss (65) and also reduces the risk for numerous chronic diseases; however, only half of all women reported participating in weekly physical activity that meets recommended levels (49). Counseling to support improvements in diet and physical activity also can promote modest sustained weight loss (66). Experts recommend that overweight women be offered specific behavioral strategies to decrease caloric intake and increase physical activity and be encouraged to enroll in structured weight loss programs (29,67). The Guide to Community Preventive Services recommends technology-supported, multicomponent coaching or counseling interventions that use technology to promote weight loss and control (68). Finally, pharmacotherapy and surgery might be appropriate options for some women (66).

Approximately 30% of women reported taking a supplement that contained folic acid every day of the month before pregnancy. Folic acid deficiency before pregnancy increases the risk for neural tube defects in infants, but vitamin supplements can reduce occurrence of neural tube defects by two thirds, and clinical practice guidelines recommend folic acid supplementation (34). Clinicians should advise all women of reproductive age to take a multivitamin or otherwise increase their daily folic acid intake to 400 mg (17,29).

Chronic Conditions

Diabetes is an important area for intervention because it is associated with high risk for serious adverse pregnancy outcomes. The findings in this report documented an overall prevalence of self-reported prepregnancy diagnosed diabetes of 2.1% (CI = 1.9–2.4), which was similar to the 2004 estimate (1.8%; CI = 1.6–2.0) (8). Diabetes is a critical preconception health indicator for intervention because of the potential for severe adverse outcomes for the woman and future pregnancies, and availability of effective treatment (69). Women with diabetes before pregnancy have increased risk for pre-eclampsia, hypertension during pregnancy, cesarean delivery, and adverse birth outcomes such as spontaneous abortions, birth defects, preterm delivery, macrosomia, hypoglycemia, and fetal and infant death (19–21). Maternal diabetes also is associated with major congenital malformations, which are the leading cause of mortality and serious morbidity in infants of women diagnosed with diabetes (18). Evidence suggests that women diagnosed with diabetes who participate in preconception care to control their blood glucose before conception have markedly reduced rates of having infants with these malformations than women diagnosed with diabetes who do not participate in preconception care (18). The elements of preconception care that are needed to control blood glucose and minimize congenital malformations in women with diabetes include patient education about the interaction of diabetes, pregnancy, and family planning; diabetes self-management skills training; medical care and laboratory testing; and possibly mental health counseling for stress reduction and support for adherence to treatment.

Hypertension also is a prominent preconception indicator because of its potential for causing serious adverse pregnancy outcomes and its substantial prevalence among women of reproductive age. One in 10 nonpregnant women reported that they had ever been told that they have hypertension by a medical professional, and 3.0% indicated that they had hypertension during the 3 months before their most recent pregnancy. Hypertension before pregnancy poses serious risks to women if they become pregnant, including preeclampsia (23,70), placental abruption (22,23), and gestational diabetes (71–74). Women with hypertension also have an increased risk for adverse birth outcomes such as preterm delivery (23), infants that are small for gestational age (23), and infant death (22–24). Evidence suggests that a low-sodium diet can reduce blood pressure among persons with hypertension (30) and provider advice on lifestyle modifications can influence women's efforts to control their high blood pressure (31,75).

Health Care, Reproductive Health, and Family Planning

Women who do not receive needed preventive health services often do not have health insurance (76). The findings in this report indicate that one in four women with a recent live birth did not have health-care coverage during the month before pregnancy, which equates to approximately 500,000 U.S. women of reproductive age. Approximately 20% of women with a recent live birth reported receiving preconception counseling. In contrast, 88.2% of women received a postpartum checkup. The postpartum visit is an opportunity to provide evidence-based interconception care, particularly for women who had an adverse pregnancy outcome or whose last pregnancy was mistimed and to address chronic conditions that might have developed or been identified during pregnancy. Many women reported their most recent pregnancy was unintended (43%), yet more than half (53%) of those not trying to get pregnant were not using contraception at the time of conception.

Preventive health visits are opportunities to counsel patients who are not actively trying to get pregnant to use an effective contraception method that they are comfortable using and to address their health risk factors before pregnancy. The Affordable Care Act is designed to increase access to preventive health services by requiring new private health plans to cover a range of recommended preventive services with no cost sharing by the beneficiary, including preconception care during well-woman visits. Because the goals of preconception care are to optimize women's health before pregnancy, which includes contraceptive counseling, health-care access is integral to preconception health (77,78).

Disparities

The findings in this report indicate that preconception health and health-care indicators were worse for women in certain age and race/ethnicity groups. Compared with older women (35–44 years), young women (18–24 years) frequently had a higher prevalence of risk factors or lower prevalence of protective factors in the following domains: health care, reproductive health, tobacco and alcohol use, mental health, and emotional support. Older women tended to have poorer preconception health in the nutrition and physical activity and chronic conditions domains. All but one indicator (i.e., self-reported experience of miscarriage, fetal death, or stillbirth within 12 months before having a live-born infant) was statistically significantly different by race/ethnicity. Compared with women of other racial/ethnic groups, non-Hispanic black women generally had poorer preconception health in the following domains: social determinants of health, health care, reproductive health, nutrition and physical activity, mental health, emotional support, and chronic conditions. Non-Hispanic white women had poorer preconception health in four of six tobacco and alcohol use indicators. Hispanic women reported less health-care access than women of other racial/ethnic groups. These age and racial/ethnic disparities are consistent with past reports (8,12,13,79) and highlight the need for strategic efforts to address health disparities and health equity. For example, health-care access might be improved among young women by increasing their awareness of services available through adolescent wellness examinations and college clinics. Additionally, implementing targeted, culturally relevant programs that improve health-care access can reduce racial/ethnic disparities and narrow the racial/ethnic disparities in other preconception health risk factors. Future research could further explore the racial/ethnic differences reported by examining possible explanations and developing and evaluating strategies to address the disparities.

Preconception health also varied by state, with southern states (as defined by the U.S. Census Bureau)† generally having the highest prevalence of preconception health problems and risky behaviors. In contrast, Utah had the most favorable prevalences of nine preconception health indicators. These geographic variations might reflect differences in demographic distributions (e.g., age, race, and socioeconomic status), which also are associated with preconception health. Sociocultural norms also might contribute to higher prevalence of some risk factors in southern states, such as smoking and obesity. Expanded health-care access through the Affordable Care Act and efforts to increase access to preconception care through integrating components of preconception care into existing public health programs can improve disparities. Future research should seek to describe these geographical differences in a more detailed way and examine the reasons that they exist.

Limitations

The findings in this report are subject to at least four limitations. First, PRAMS and BRFSS data are self-reported and subject to social desirability bias and recall bias, which could lead to inaccurate estimates (80). Negative behaviors (e.g., smoking, drinking, or exposure to secondhand smoke, particularly before pregnancy) might be underestimated and positive behaviors (e.g., having a postpartum checkup or current use of contraception) might be overestimated. Because chronic conditions often are undiagnosed and contingent on use of health care, self-reported past diagnoses underestimate the actual prevalence, particularly for diabetes and hypertension. National estimates without these biases are available from the National Health and Nutrition Examination Survey. Second, these results are not generalizable. PRAMS data were not available for all states, and PRAMS only surveys women who delivered live births. Therefore, PRAMS data do not represent women who had miscarriages or stillbirths, which are women who might have poorer preconception health. The BRFSS response rate varies by state, and no minimum threshold was required for inclusion. Therefore, BRFSS estimates in states with low response rates might not be representative of all women aged 18–44 years in those states. Third, limitations exist with respect to how certain indicators were defined. For example, the denominator for women who had a previous fetal death, miscarriage, or stillbirth might exclude women whose past pregnancies did not result in a live birth. Although this denominator is not ideal for the indicator, only information on previous live births was available. Finally, newer PRAMS and BRFSS data exist. The findings in this report might not be suitable for comparison to findings from future surveys because of recent changes in BRFSS survey methods and wording of certain questions (e.g., fruit and vegetable intake and physical activity). Despite these limitations, PRAMS and BRFSS can be valuable surveillance systems for monitoring preconception health at the state level, and this report fulfills the CDC/ATSDR Preconception Care Work Group's recommendation for monitoring preconception health (35).

Conclusion

Public health, economic, and sociologic considerations are important when developing strategies to address the persistent disparities that were identified in the various preconception health indicators. Evidence-based public health interventions could improve the preconception health indicators with high prevalence, and those that increase the risk for serious adverse effects on pregnancy outcomes, by focusing on reducing tobacco and alcohol use, promoting good nutrition and physical activity, and addressing chronic conditions (52). In addition, evidence-based preconception health interventions should be cost-effective (e.g., tobacco cessation during pregnancy and folic acid supplementation) (17,29,81,82). Finally, rather than focusing on changing individual behaviors, interventions could focus on changing policies and systems so that social environments foster healthy lifestyles and promote health equity. For example, increasing the unit price of tobacco (83), using regulatory authority to limit alcohol outlet density (84), and implementing thoughtful land-use policies that support physical activity (85) have been shown to be effective interventions. However, research demonstrating the effectiveness of these strategies on reducing disparities is lacking. The results also reinforce the need for continued efforts to expand health-care coverage for nonpregnant women of reproductive age and improve their preconception health through evidence-based clinical interventions and public health programs. Expanded access to and use of preventive services can improve health outcomes overall and reduce disparities among disadvantaged groups.

The findings in this report can be used by public health decision makers, researchers, and key stakeholders to benchmark the status of preconception health among women of reproductive age, evaluate the effectiveness of current preconception health programs, and assess program development needs. Developing, testing, and evaluating interventions might highlight effective strategies that could be modified to improve preconception health. Feasibility research and randomized trials also can be used to identify new preconception health strategies. PRAMS and BRFSS surveillance data provide comprehensive information about the status of preconception health at the state level. Ongoing surveillance and research are needed to monitor the effect of improved coverage and access to health care on women's preconception health status and pregnancy outcomes.

References

1. US Department of Health and Human Services. Healthy People 2020. Washington, DC: CDC; 2013. Available at www.healthypeople.gov.
2. Finer LB, Zolna MR. Unintended pregnancy in the United States: incidence and disparities, 2006. Contraception 2011;84:478–85.
3. Anachebe NF, Sutton MY. Racial disparities in reproductive health outcomes. Am J Obstet Gyn 2003;188:S37–42.
4. Bryant AS, Worjoloh A, Caughey AB, Washington AE. Racial/ethnic disparities in obstetric outcomes and care: prevalence and determinants. Am J Obstet Gyn 2010;202:335–43.
5. Collins JW Jr, David RJ. Racial disparity in low birth weight and infant mortality. Clin Perinatol 2009;36:63–73.
6. Hogue CJ, Menon R, Dunlop AL, Kramer MR. Racial disparities in preterm birth rates and short inter-pregnancy interval: an overview. Acta Obstet Gynecol Scand 2011;90:1317–24.
7. Rowland Hogue CJ, Silver RM. Racial and ethnic disparities in United States: stillbirth rates: trends, risk factors, and research needs. Semin Perinatol 2011;35:221–33.
8. CDC. Preconception and interconception health status of women who recently gave birth to a live-born infant—Pregnancy Risk Assessment Monitoring System (PRAMS), United States, 26 reporting areas, 2004. MMWR 2007;56:(No. SS-10).
9. Denny CH, Floyd RL, Green PP, Hayes DK. Racial and ethnic disparities in preconception risk factors and preconception care. J Womens Health 2012;21:720–9.
10. Phares TM, Morrow B, Lansky A, et al. Surveillance for disparities in maternal health-related behaviors—selected states, Pregnancy Risk Assessment Monitoring System (PRAMS), 2000–2001. MMWR 2004;53:1–13.
11. Tong VT, Dietz PM, England LJ, et al. Age and racial/ethnic disparities in prepregnancy smoking among women who delivered live births. Prev Chronic Dis 201;8:A121.
12. Ahluwalia IB, Mack KA, Mokdad A. Report from the CDC. Changes in selected chronic disease-related risks and health conditions for nonpregnant women 18–44 years old BRFSS. J Womens Health 2005;14:382–6.
13. Weisman CS, Hillemeier MM, Chase GA, et al. Preconceptional health: risks of adverse pregnancy outcomes by reproductive life stage in the Central Pennsylvania Women's Health Study (CePAWHS). Women's health issues: official publication of the Jacobs Institute of Women's Health. 2006;16:216–24.
14. US Department of Health and Human Services. The health consequences of smoking: a report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services; 2004.
15. US Department of Health and Human Services. U.S. Surgeon General releases advisory on alcohol use in pregnancy. Atlanta, GA: US Department of Health and Human Services; 2005. Available at http://www.surgeongeneral.gov/news/2005/02/sg02222005.html.
16. Locksmith GJ, Duff P. Preventing neural tube defects: the importance of periconceptional folic acid supplements. Obstet Gynecol 1998;91:1027–34.
17. Lumley J, Watson L, Watson M, Bower C. Periconceptional supplementation with folate and/or multivitamins for preventing neural tube defects. Cochrane Database Syst Rev 2001:CD001056.
18. American Diabetes Association. Preconception care of women with diabetes. Diabetes Care 2004;27(Suppl 1):S76–8.
19. Crocker A, Farrell T. Pregnancy and pre-existing diabetes: key concerns. Hosp Med 2004;65:351–4.
20. Lapolla A, Dalfra MG, Fedele D. Pregnancy complicated by type 2 diabetes: an emerging problem. Diabetes Res Clin Pract 2008;80:2–7.
21. Walkinshaw SA. Pregnancy in women with pre-existing diabetes: management issues. Semin Fetal Neonatal Med 2005;10:307–15.
22. Ferrer RL, Sibai BM, Mulrow CD, et al. Management of mild chronic hypertension during pregnancy: a review. Obstet Gynecol 2000;96(5 Pt 2):849–60.
23. Livingston JC, Maxwell BD, Sibai BM. Chronic hypertension in pregnancy. Minerva Ginecol 2003;55:1–13.
24. Simpson LL. Maternal medical disease: risk of antepartum fetal death. Semin Perinatol 2002;26:42–50.
25. American College of Obstetricians and Gynecologists Committee on Obstetrics. Folic acid for the prevention of recurrent neural tube defects. Int J Gynaecol Obstet 1993;42:75–7.
26. Perry RJ, Keller PA, Fraser D, Fiore MC. Fax to quit: a model for delivery of tobacco cessation services to Wisconsin residents. WMJ 2005;104:37–40.
27. Clinical Preventive Services Task Force. Preventing excessive alcohol consumption: electronic screening and brief interventions. In: Guide to community preventive services. Atlanta, GA: Clinical Preventive Services Task Force; 2012. Available at http://www.thecommunityguide.org/alcohol/eSBI.html.
28. Atrash HK, Johnson K, Adams M, Cordero JF, Howse J. Preconception care for improving perinatal outcomes: the time to act. Matern Child Health J 2006;10(Suppl 5):S3–11.
29. Jack BW, Atrash H, Coonrod DV, et al. The clinical content of preconception care: an overview and preparation of this supplement. American J Obstet Gynecol 2008;199 (Suppl 2):S266–79.
30. Graudal NA, Hubeck-Graudal T, Gesche J. Effects of low sodium diet versus high sodium diet on blood pressure, renin, aldosterone, catecholamines, cholesterol, and triglyceride. Hoboken, NJ: John Wiley and Sons, Ltd; 2011.
31. Brunner EJ, Rees K, Ward K, Burke M, Thorogood M. Dietary advice for reducing cardiovascular risk. Cochrane Database Syst Rev 2007:CD002128.
32. US Preventive Services Task Force. Counseling and interventions to prevent tobacco use and tobacco-caused disease in adults and pregnant women 2009. Rockville, MD: US Preventive Services Task Force; 2009. Available at http://www.uspreventiveservicestaskforce.org/uspstf/uspstbac2.htm.
33. US Preventive Services Task Force. Screening and behavioral counseling interventions in primary care to reduce alcohol misuse, 2013. Rockville, MD: US Preventive Services Task Force; 2013. Available at http://www.uspreventiveservicestaskforce.org/uspstf/uspsdrin.htm.
34. US Preventive Services Task Force. Folic acid for the prevention of neural tube defects: recommendation statement. Ann Intern Med 2009;150:626–31.
35. CDC. Recommendations to improve preconception health and health care—United States: a report of the CDC/ATSDR preconception care work group and the select panel on preconception care. MMWR 2006;55(No. RR-6).
36. Floyd RL, Johnson KA, Owens JR, et al. A national action plan for promoting preconception health and health care in the United States (2012–2014). J Womens Health 2013;22:797–802.
37. Posner SF, Johnson K, Parker C, Atrash H, Biermann J. The national summit on preconception care: a summary of concepts and recommendations. Matern Child Health J 2006;10:S197–S205.
38. Broussard DL, Sappenfield WB, Fussman C, Kroelinger CD, Grigorescu V. Core state preconception health indicators: a voluntary, multi-state selection process. Matern Child Health J 2011;15:158–68.
39. Hayes DK, Fan AZ, Smith RA, Bombard JM. Trends in selected chronic conditions and behavioral risk factors among women of reproductive age, behavioral risk factor surveillance system, 2001–2009. Prev Chronic Dis 2011;8:A120.
40. Ward BW, Schiller JS. Prevalence of multiple chronic conditions among US adults: estimates from the National Health Interview Survey, 2010. Prev Chronic Dis 2013;10:E65.
41. Xaverius PK, Salas J. Surveillance of preconception health indicators in Behavioral Risk Factor Surveillance System: emerging trends in the 21st century. J Womens Health 2013;22:203–9.
42. Bish CL, Farr S, Johnson D, McAnally R. Preconception health of reproductive aged women of the Mississippi River Delta. Matern Child Health J 2012;16(Suppl 2):250–7.
43. CDC. Preconception health indicators among women—Texas, 2002–2010. MMWR 2012;61:550–5.
44. Cheng D, Schwarz EB, Douglas E, Horon I. Unintended pregnancy and associated maternal preconception, prenatal and postpartum behaviors. Contraception 2009;79:194–8.
45. Shulman HB, Gilbert BC, Lansky A. The Pregnancy Risk Assessment Monitoring System (PRAMS): current methods and evaluation of 2001 response rates. Public Health Rep 2006;121:74–83.
46. CDC. Surveillance of certain health behaviors and conditions among states and selected local areas— United States, 2010. MMWR 2013:(No. SS-1).
47. CDC. Behavioral Risk Factor Surveillance System operational and user's guide. Version 3.0. Atlanta, GA: CDC; 2006. Available at ftp://ftp.cdc.gov/pub/Data/Brfss/userguide.pdf.
48. Research Triangle Institute. SUDAAN: software for the statistical analysis of correlated data, release 10. Research Triangle Park, NC: Research Triangle Institute; 2008.
49. US Department of Health and Human Services. Physical activity guidelines for Americans. Hyattsville, MD: US Department of Health and Human Services; 2008. Available at http://www.health.gov/paguidelines.
50. US Preventive Services Task Force. Screening for high blood pressure: US Preventive Services Task Force reaffirmation recommendation statement. Ann Intern Med 2007;147:783–7.
51. US Preventive Services Task Force. Screening for type 2 diabetes mellitus in adults 2008. Rockville, MD: US Preventive Services Task Force. Available at http://www.uspreventiveservicestaskforce.org/uspstf/uspsdiab.htm.
52. Temel S, van Voorst SF, Jack BW, Denktas S, Steegers EA. Evidence-based preconceptional lifestyle interventions. Epidemiol Rev 2014;36:19–30.
53. American College of Obstetricians and Gynecologists. ACOG committee opinion number 471, November 2010. Smoking cessation during pregnancy. Obstet Gynecol 2010;116:1241–4.
54. Stead LF, Perera R, Lancaster T. Telephone counselling for smoking cessation. Cochrane Database Syst Rev. 2009; (3): CD002850. Available at http://www.thecochranelibrary.com/userfiles/ccoch/file/World%20No%20Tobacco%20Day/CD002850.pdf.
55. Bailey BA, Sokol RJ. Prenatal alcohol exposure and miscarriage, stillbirth, preterm delivery, and sudden infant death syndrome. Alcohol Res Health 2011;34:86–91.
56. Sokol RJ, Delaney-Black V, Nordstrom B. Fetal alcohol spectrum disorder. JAMA 2003;290:2996–9.
57. CDC. National Task Force on Fetal Alcohol Syndrome and Fetal Alcohol Effect: defining the national agenda for fetal alcohol syndrome and other prenatal alcohol-related effects. MMWR 2002;51:(No. RR-14).
58. American College of Obstetricians and Gynecologists. Substance abuse in pregnancy. Int J Gynaecol Obstet 1994;47:73–80.
59. American College of Obstetricians and Gynecologists. ACOG Committee Opinion Number 486, August 2011. At-risk drinking and alcohol dependence: obstetric and gynecologic implications. Obstet Gynecol 2011;118(2 Pt 1):383–8.
60. US Department of Health and Human Services. Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults. Bethesda, MD: US Department of Health and Human Services; 1998.
61. Chu SY, Callaghan WM, Kim SY, et al. Maternal obesity and risk of gestational diabetes mellitus. Diabetes Care 2007;30:2070–6.
62. Arendas K, Qiu Q, Gruslin A. Obesity in pregnancy: pre-conceptional to postpartum consequences. J Obstet Gynaecol Can 2008;30:477–88.
63. Chu SY, Kim SY, Schmid CH, et al. Maternal obesity and risk of cesarean delivery: a meta-analysis. Obes Rev 2007;8:385–94.
64. Gottlieb AG, Galan HL. Shoulder dystocia: an update. Obstet Gynecol Clin North Am 2007;34:501–31, xii.
65. Shaw KA, Gennat HC, O'Rourke P, Del Mar C. Exercise for overweight or obesity. Cochrane Database Syst Rev 2006:CD003817.
66. American College of Obstetricians and Gynecologists. The role of the obstetrician-gynecologist in the assessment and management of obesity. Washington, DC: American College of Obstetricians and Gynecologists; 2005.
67. Nawaz Haq, Katz L. American College of Preventive Medicine Practice policy statement: weight management counseling of overweight adults. Am J Prev Med 2001;21:73–8.
68. Community Preventive Services Task Force. Obesity prevention and control: technology-supported multicomponent coaching or counseling interventions to reduce weight and maintain weight loss (abbreviated). In: Guide to community preventive services; 2009. Atlanta, GA: Community and Preventive Services Task Force. Available at www.thecommunityguide.org/obesity/TechnicalCoaching.html.
69. Dunlop AL, Jack BW, Bottalico JN, et al. The clinical content of preconception care: women with chronic medical conditions. Am J Obstet Gynecol 2008;199(6 Suppl 2):S310–27.
70. Duckitt K, Harrington D. Risk factors for pre-eclampsia at antenatal booking: systematic review of controlled studies. BMJ 2005;330:565.
71. Hedderson MM, Ferrara A. High blood pressure before and during early pregnancy is associated with an increased risk of gestational diabetes mellitus. Diabetes Care 2008 31:2362–7.
72. McMahon MJ, Ananth CV, Liston RM. Gestational diabetes mellitus. Risk factors, obstetric complications and infant outcomes. J Reprod Med 1998;43:372–8.
73. Zetterstrom K, Lindeberg SN, Haglund B, Hanson U. Maternal complications in women with chronic hypertension: a population-based cohort study. Acta Obstet Gynecol Scand 2005;84:419–24.
74. Rey E, Couturier A. The prognosis of pregnancy in women with chronic hypertension. Am J Obstet Gynecol 1994;171:410–6.
75. Bombard JM, Robbins CL, Dietz PM, Valderrama AL. Preconception care: the perfect opportunity for health care providers to advise lifestyle changes for hypertensive women. Am J Health Promotion 2013 ;27(3 Suppl):S43–9.
76. DeVoe JE, Fryer GE, Phillips R, Green L. Receipt of preventive care among adults: insurance status and usual source of care. Am J Public Health 2003;93:786–91.
77. American College of Obstetricians and Gynecologists. ACOG Committee opinion number 313, September 2005. The importance of preconception care in the continuum of women's health care. Obstet Gynecol 2005;106:665–6.
78. Hillemeier MM, Weisman CS, Chase GA, Dyer AM, Shaffer ML. Women's preconceptional health and use of health services: implications for preconception care. Health Serv Res 2008;43(1 Pt 1):54–75.
79. Institutes of Medicine. Unequal treatment: confronting racial and ethnic disparities in health care (with CD). Smedley BD, Stith AY, Nelson AR, eds. Washington, DC: The National Academies Press; 2003.
80. Dietz PM, Homa D, England LJ, et al. Estimates of nondisclosure of cigarette smoking among pregnant and nonpregnant women of reproductive age in the United States. Am J Epidemiol 2011;173:355–9.
81. Adams KE, Markowitz S, Kannan V, et al. Reducing prenatal smoking: the role of state policies. Am J Prev Med 2012;43:34–40.
82. US Preventive Services Task Force. A clinical practice guideline for treating tobacco use and dependence: 2008 update. A U.S. Public Health Service report. Am J Prev Med 2008;35:158–76.
83. Community Preventive Services Task Force. Reducing tobacco use and secondhand smoke exposure: increasing the unit price of tobacco products (abbreviated) 2012. In: Guide to community preventive services. Atlanta, GA: Community Preventive Services Task Force; 2012. Available at www.thecommunityguide.org/tobacco/increasingunitprice.html.
84. Community Preventive Services Task Force. Preventing excessive alcohol consumption: regulation of alcohol outlet density 2007. In: Guide to community preventive services. Atlanta, GA: Community Preventive Services Task Force; 2010. Available at www.thecommunityguide.org/alcohol/outletdensity.html.
85. Community Preventive Services Task Force. Environmental and policy approaches to increase physical activity: community-scale urban design land use policies 2004. In: Guide to community preventive services. Atlanta, GA: Community Preventive Services Task Force; 2004. Available at www.thecommunityguide.org/pa/environmental-policy/communitypolicies.html.