Evaluation of Maternal Smoking Surveillance Systems in Massachusetts
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Evaluation of Maternal Smoking Surveillance
Systems in Massachusetts
Lizzie Harvey, MPHCDC/CSTE Applied Epidemiology Fellow
Massachusetts Department of Public HealthJune 14, 2011
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Disclosure
• No significant financial interest or other relationships with the manufacturer(s) ofany commercial product(s) or provider(s) of any commercial services discussed in this presentation and with any commercial supports of the activity
• Massachusetts Department of Public Health RaDAR and PRAMS clearance
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Objective
• To evaluate maternal smoking surveillance through the Massachusetts Pregnancy Risk Assessment Monitoring System (PRAMS)
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Importance of Maternal Smoking Surveillance
• Maternal smoking during pregnancy is associated with babies who are:– 1.4-3.0 times more likely to die of Sudden
Infant Death Syndrome (SIDS)– at 30% higher odds of premature delivery– 2.3 times more likely to deliver term low birth
weight infants
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Maternal Smoking Relevance in US and Massachusetts
• Healthy People 2020 Objective– Increase smoking cessation during pregnancy
• CDC Winnable battle• National Performance Measure
– Smoking in the last trimester
• MA Priorities– Improve the health and well being of women in their childbearing
years– Support reproductive and sexual health by improving access to
education and services
• Opportunity for Intervention in MA– Tobacco Cessation and Prevention Program
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Existing Surveillance System:Massachusetts Birth
Certificate (BC)
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MA Birth Certificate
• Maternal smoking questions since 1986
• Since 1996, two questions:
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Maternal Smoking in Massachusetts: Birth Certificate Data
% MA Women Reporting Smoking during Pregnancy on the Birth Certificate
6.97.5
13.1
0
3
6
9
12
15
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
MA PRAMS
initiation
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Massachusetts Pregnancy and Risk Assessment Monitoring System
(MA PRAMS) as a Surveillance System
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PRAMS Background
Population-based data on maternal attitudes and behaviors, before, during, and shortly after pregnancy
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MA PRAMS Background
• Initiated in 2007
• 80 questions (54 Core, 16 Standard, 10 MA developed)
• 2-6 months post-partum
• Administered in English and Spanish only
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MA PRAMS
Screener
Last 3 months
of pregnancy
3 months
before pregnancy
Current use
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Maternal Smoking Data Comparison
3 mo.
Pregnancy Post-partumPre-Pregnancy
PRAMS
3.8 mo.
BC
Conception12 mo. Delivery
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Methods
• Data Sources:– 2007-2008 MA PRAMS (N=2,997)– Linked to 2007-2008 MA BC data (N=2,997)
• Analysis:– Frequencies, prevalence estimates, sensitivity,
positive predictive value, kappa coefficients, chi square
– SAS 9.2 and SUDAAN 10.0
• Reference:– CDC: Updated Guidelines for Evaluating Public
Health Surveillance Systems (2001)
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CDC: System Attributes
• Simplicity• Flexibility • Data Quality• Acceptability• Sensitivity• Positive Value Predictive• Representativeness• Timeliness • Stability
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Simplicity
MA BC• Entire population (~75,000 births/year) • DPH Parent
Worksheet with 2 smoking questions
• 49 licensed birth hospitals in MA
MA PRAMS• Population-based
mixed-methodology survey
(~1,500/year)• 4 questions on 80
question survey• Mail survey to
stratified sample of birth population
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Flexibility
MA BC• Iterations of maternal
smoking surveillance– 1986– 1996– 2011
• 2011 implementation of electronic 2003 standard birth certificate
MA PRAMS • Maternal smoking
questions Core• Compare to other states• Opportunity to select
standard and state-specific questions
• Other measures related to smoking knowledge and behaviors
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Data Quality
Maternal Smoking Surveillance Data Quality: Missing Fields, 2007-08
0.25 0.24 0.30 0.30
2.70 2.60
2.10 2.10
0.00
1.00
2.00
3.00
Cig UsePrior
Cig UseDuring
Cig UsePrior
Cig UseDuring
Screener 3 MonthsPrior
Last 3Months
Now
BC Pre Merge BC Post Merge PRAMS
% M
issi
ng
N=156,734 N=2,997 N=2,997
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Acceptability
MA BC• Mandatory
participation– General Law (Ch. 111,
s.24B)
• Stigma on maternal smoking
MA PRAMS• Not required by law
– Can refuse survey and refuse individual questions
• Infant outcome at 4 months post-partum may determine how mother will respond
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Sensitivity Analysis
113 79
20 2714
MA PRAMS
S
NS
192
2734
133 2793 2926
Sensitivity: 113/ (113 + 20) = 0.850
Smoking DURING Pregnancy
MA PRAMS captured 85% of all maternal smoking
during pregnancy identified by the BC
MA BC
S NS
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Predictive Value Positive (PVP)
113 79
20 2714
192
2734
133 2793 2926
PVP: 113/ (113 + 79) = 0.589
Smoking DURING Pregnancy
58.9% of all maternal smoking during pregnancy identified by MA PRAMS were cases identified by the birth certificate
MA PRAMS
S
NS
MA BC
S NS
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But wait…the BC is not a gold standard! True maternal smoking rate unknown
Kappa Coefficients measure agreement between categorical items taking chance into account
Value of KStrength of
agreement
< 0.20 Poor
0.21 - 0.40 Fair
0.41 - 0.60 Moderate
0.61 - 0.80 Good
0.81 - 1.00 Very good
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Kappa Coefficient Analysis
20 79113
Maternal Smoking
DURING Pregnancy
N=2,997
BC PRAMS
Κ = 0.68 (95% CI = 0.62 – 0.74)
Good Agreement
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Kappa Coefficient Analysis
2497 98 32 27 --
32 70 14 5 0
-- 10 58 34 0
-- -- 9 11 0
0 0 0 -- 0
Non smoker
Quitter
# cigs dec.
# cigs sa/inc.
NS resumed
Non Quitter # cigs # cigs NS
Smoker dec. sa/inc. resumed
--: 1-4 values suppressed
MA BC
MA PRAMS
Κ = 0.53
95% CI:
0.49 – 0.57
Moderate
Agreement
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Representativeness
% MA Women Smoking during Pregnancy
Combined, 10.2
BC, 6.9
PRAMS, 9.3
0
3
6
9
12
15
1996 1998 2000 2002 2004 2006 2008 2010
Year
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Representativeness: Maternal Smoking by Data Source
14
7.2
17.6
9.3
12.6
18.8
10.2
0
5
10
15
20
25
Smoked Before Pregnancy
Smoked During Pregnancy
Smoked Post-Pregnancy
% o
f Mot
hers
BC
PRAMS
Combined
↑34%
↑42%
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Representativeness: Differences in Reporting
20 79113
Maternal Smoking
DURING Pregnancy
BC PRAMS
Who is reporting on PRAMS but not on BC?
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Demographic Characteristics of those who report maternal smoking during pregnancy
on PRAMS (N=192)Characteristic % PRAMS only % PRAMS and BC Chi-square p-value
White Race (vs. non white)
63.3 65.5 0.75
Black Race (vs. non black)
21.5 19.5 0.72
≥HS grad 73.4 77.0 0.57
≥College 32.9 40.7 0.27
≥ 30 years 26.6 29.2 0.69
Hispanic Ethnicity 35.4 17.7 0.005
Spanish Language 13.9 1.8 0.002
Married 24.1 23.9 0.98
Had Pre-pregnancy insurance
49.4 46.9 0.74
WIC 77.9 69.6 0.21
LBW 7.6 14.2 0.16
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Representativeness
MA BC• Population data• Stigma of maternal
smoking• Self-report• Recall bias
MA PRAMS• Stratified sampling by
race/ethnicity– 30% non response
• English and Spanish only• Stigma of maternal
smoking potentially decreased
• Self-report• Recall bias
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Limiting
Step
TimelinessMA BC MA PRAMS
DPH Parent Worksheetcompleted
49 Registrars Data Entry
Registry of Vital Records and Statistics
MDPH Birth Report
PRAMS Survey completed
Data Entry
Birth File Closed
Data weighted by CDC
PRAMS ReportPublic Health Action!
Limiting
Step
Public Health Action!
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Stability
MA BC• Required by law• 2003 Revised Birth
Certificate Implementation 2011
• Investment in Vital Information Partnership System (VIP) 2011
• MassCHIP
MA PRAMS• 5 year funding
approved 2011-2016– Decreased funding
than previous cycle
• PRAMS website• PONDER (MA
specific) and CPONDER
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Conclusions: MA PRAMS System Attributes
Simplicity: 4 questions
Flexibility: Ability to add state specific questions
Data Quality: Low % missing; survey data
Acceptability: Overall stigma potentially decreased
Sensitivity: Increased case
Positive Predictive Value: ascertainment
Representativeness: Higher ascertainment of maternal smoking; Additional measure of post-partum smoking
Timeliness: No real time data; 2 year lag
Stability: 5 year competitive funding from CDC (2011-16)
Kappa statistic
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Recommendations• Use PRAMS as a valuable data source in addition to BC to understand burden of maternal smoking
• Use PRAMS to fill the data gap regarding maternal smoking in post-partum period
• Use other PRAMS data to inform actionable interventions in maternal smoking
Prenatal patient education
Postpartum smoking environment
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Next Steps
• Add 2009 MA PRAMS data to analysis• Assess impact of new BC data on maternal
smoking• Continue work with the Tobacco Cessation
and Prevention Program– Identify women who are not reporting on the birth
certificate but reporting in PRAMS– Reach out to prenatal providers for universal
screening of maternal smoking behaviors and referrals to cessation programs
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AcknowledgementsHafsatou Diop, MDPH Office of Data Translation
Karin Downs, MDPH Bureau of Family Health and Nutrition
Thomas Land, MDPH Tobacco Cessation and Prevention Program
Emily Lu, MDPH PRAMS Coordinator
Alice Mroszczyk, MDPH Privacy and Data Access Office
Maria Vu, MDPH Registry of Vital Records and Statistics
CDC/CSTE Applied Epidemiology Fellowship Program
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References/ResourcesCDC Tobacco Use and Pregnancy: http://www.cdc.gov/reproductivehealth/TobaccoUsePregnancy/index.htm
(Accessed 6/2011)CDC Winnable Battle: Tobacco:
http://www.cdc.gov/WinnableBattles/Tobacco/index.html (Accessed 6/2011)CDC PRAMS:
http://www.cdc.gov/prams/ (Accessed 6/2011)CPONDER:
http://www.cdc.gov/prams/CPONDER.htm (Accessed 6/2011)MA PRAMS:
http://www.mass.gov/dph/prams (Accessed 6/2011)MassCHIP:
http://www.mass.gov/dph/masschip (Accessed 6/2011)MA General Laws regarding birth information collection:
http://www.malegislature.gov/Laws/GeneralLaws/PartI/TitleXVI/Chapter111/Section24B (Accessed (6/2011)
2003 Revised Birth Certificate: http://www.cdc.gov/nchs/data/dvs/birth11-03final-ACC.pdf (Accessed 6/2011)
CDC Updated Guidelines for Evaluating Public Health Surveillance Systems: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5013a1.htm (Accessed 6/2011)
Kappa Statistics: Cohen, J. (1968). Weighted kappa: Nominal scale agreement provision for scaled disagreement or partial credit. Psychological Bulletin, 70(4), 213.
Dietz, PM, et al. Infant Morbidity and Mortality Attributable to Prenatal Smoking in the U.S. Am J Prev Med 2010;39(1) 45-52.
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Questions?
Contact Information:
Lizzie Harvey, MPH
CDC/CSTE Applied Epidemiology Fellow
Massachusetts Department of Public Health
(617) 624-5559
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Extra Slides
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Resources in MA
• Massachusetts Smokers’ Helpline
• QuitWorks
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Additional PRAMS Questions on Maternal Smoking
New 2009 Core:Which of the following statements best describes the rules about smoking inside your home now? Check one answerNo one is allowed to smoke anywhere inside my homeSmoking is allowed in some rooms or at some timesSmoking is permitted anywhere inside my home
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2003 Standard BC
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Impact of 2003 BC
3 mo.
Pregnancy Post-partumPre-Pregnancy
PRAMS
3.8 mo.
BC
Conception12 mo. Delivery
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Demographic Characteristics of those who report maternal smoking before pregnancy
on PRAMS (N=372)Characteristic % PRAMS only % PRAMS and BC Chi-square p-value
White Race (vs. non white)
58.9 65.4 0.20
Black Race (vs. non black)
22.8 15.9 0.09
≥HS grad 79.1 81.3 0.60
≥College 42.4 45.3 0.57
≥ 30 years 26.6 29.2 0.69
Hispanic Ethnicity 29.8 17.8 0.007
Spanish Language 9.5 1.87 <0.001
Married 32.9 28.5 0.36
Had Pre-pregnancy insurance
59.4 54.9 0.38
WIC 63.2 63.4 0.98
LBW 8.9 9.4 0.87
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Sensitivity Analysis
214 158
40 2499
MA PRAMS
S
NS
MA BC
S NS
372
2539
254 2657 2911
Sensitivity: 214 / (214 + 40) = 0.842
113 79
20 2714
MA PRAMS
S
NS
192
2734
133 2793 2926
Sensitivity: 113/ (113 + 20) = 0.850
Smoking BEFORE Pregnancy Smoking DURING Pregnancy
MA PRAMS captured 84.2% of all maternal smoking prior to pregnancy and
85% of all maternal smoking during pregnancy identified by the BC
MA BC
S NS
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Predictive Value Positive
214 158
40 2499
372
2539
254 2657 2911
PVP: 214 / (214 + 158) = 0.575
113 79
20 2714
192
2734
133 2793 2926
PVP: 113/ (113 + 79) = 0.589
Smoking BEFORE Pregnancy Smoking DURING Pregnancy
57.5% of all maternal smoking prior to pregnancy and 58.9% of all maternal smoking during pregnancy identified by MA PRAMS were cases identified by the birth certificate
MA PRAMS
S
NS
MA PRAMS
S
NS
MA BC
S NS
MA BC
S NS
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Kappa Coefficient Analysis
40 158214
Maternal Smoking
PRIOR to Pregnancy
N=2,997
BC PRAMS
20 79113
Maternal Smoking
DURING Pregnancy
N=2,997
BC PRAMS
Κ = 0.64 (95% CI = 0.60 – 0.69)
Good Agreement
Κ = 0.68 (95% CI = 0.62 – 0.74)
Good Agreement
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Representativeness: Differences in Reporting
40 158214
Maternal Smoking
PRIOR to Pregnancy
BC PRAMS
20 79113
Maternal Smoking
DURING Pregnancy
BC PRAMS
Who is reporting on PRAMS but not on BC?