Evaluation of Maternal
Smoking Surveillance
Systems in Massachusetts
Lizzie Harvey, MPH
CDC/CSTE Applied Epidemiology Fellow
Massachusetts Department of Public Health
June 14, 2011
1
Disclosure
• No significant financial interest or other
relationships with the manufacturer(s) of
any commercial product(s) or provider(s)
of any commercial services discussed in
this presentation and with any commercial
supports of the activity
• Massachusetts Department of Public
Health RaDAR and PRAMS clearance
2
Objective
• To evaluate maternal smoking surveillance
through the Massachusetts Pregnancy
Risk Assessment Monitoring System
(PRAMS)
3
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
4
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
5
Existing Surveillance System:
Massachusetts Birth
Certificate (BC)
6
MA Birth Certificate
• Maternal smoking questions since 1986
• Since 1996, two questions:
7
Maternal Smoking in Massachusetts:
Birth Certificate Data
% MA Women Reporting Smoking during Pregnancy on
the Birth Certificate
15
13.1
12
9
7.5
6.9
6
3
0
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
MA PRAMS
8
initiation
Massachusetts Pregnancy
and Risk Assessment
Monitoring System
(MA PRAMS)
as a Surveillance System
9
PRAMS Background
Population-based
data on maternal
attitudes and
behaviors, before,
during, and shortly
after pregnancy
10
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
11
MA PRAMS
Screener
3 months
Last 3 months
before pregnancy
of pregnancy
Current use
12
Maternal Smoking Data
Comparison
Pre-Pregnancy
12 mo.
Pregnancy
Conception
3 mo.
Post-partum
Delivery 3.8 mo.
BC
PRAMS
13
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)
14
CDC: System Attributes
•
•
•
•
•
•
•
•
•
Simplicity
Flexibility
Data Quality
Acceptability
Sensitivity
Positive Value Predictive
Representativeness
Timeliness
Stability
15
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
16
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 statespecific questions
• Other measures related
to smoking knowledge
and behaviors
17
Data Quality
Maternal Smoking Surveillance Data Quality: Missing
Fields, 2007-08
% Missing
3.00
2.70
2.60
2.10
2.10
Last 3
Months
Now
2.00
1.00
0.25
0.24
0.30
0.30
Cig Use
Prior
Cig Use
During
Cig Use
Prior
Cig Use
During
0.00
BC Pre Merge
BC Post Merge
N=156,734
N=2,997
Screener
3 Months
Prior
PRAMS
N=2,997
18
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
19
Sensitivity Analysis
Smoking DURING Pregnancy
MA BC
MA PRAMS
S
NS
S
113
79
192
NS
20
2714
2734
133
2793
2926
Sensitivity: 113/ (113 + 20) = 0.850
MA PRAMS captured 85% of all maternal smoking
during pregnancy identified by the BC
20
Predictive Value Positive (PVP)
Smoking DURING Pregnancy
MA BC
MA PRAMS
S
S
NS
NS
113
79
192
20
2714
2734
133
2793
2926
PVP: 113/ (113 + 79) = 0.589
58.9% of all maternal smoking during pregnancy identified by MA PRAMS were
cases identified by the birth certificate
21
But wait…the BC is not a gold
standard! True maternal
smoking rate unknown
Kappa Coefficients
measure agreement
between categorical
items taking chance
into account
Value of K
Strength of
agreement
< 0.20
Poor
0.21 - 0.40
Fair
0.41 - 0.60
Moderate
0.61 - 0.80
Good
0.81 - 1.00
Very good
22
Kappa Coefficient Analysis
Maternal Smoking
DURING Pregnancy
N=2,997
20
BC
113
79
PRAMS
Κ = 0.68 (95% CI = 0.62 – 0.74)
Good Agreement
23
Kappa Coefficient Analysis
MA BC
Non
Quitter
Smoker
Non smoker
2497 98
MA PRAMS
# cigs
# cigs
NS
dec.
sa/inc.
resumed
32
27
--
Κ = 0.53
95% CI:
Quitter
32
70
14
5
0
0.49 – 0.57
Moderate
# cigs dec.
--
10
58
34
0
# cigs sa/inc.
--
--
9
11
0
NS resumed
0
0
0
--
0
--: 1-4 values
suppressed
Agreement
24
Representativeness
% MA Women Smoking during Pregnancy
15
12
Combined, 10.2
PRAMS, 9.3
9
BC, 6.9
6
3
0
1996
1998
2000
2002
2004
2006
2008
2010
Year
25
Representativeness: Maternal
Smoking by Data Source
25
18.8
17.6
% of Mothers
20
15
10
14
↑34%
12.6
10.2
9.3
7.2
↑42%
BC
PRAMS
Combined
5
0
Smoked Before Smoked During Smoked PostPregnancy
Pregnancy
Pregnancy
26
Representativeness:
Differences in Reporting
Maternal Smoking
DURING Pregnancy
20
BC
113
79
PRAMS
Who is reporting on PRAMS
but not on BC?
27
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
28
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
29
Timeliness
MA BC
MA PRAMS
DPH Parent Worksheet
completed
PRAMS Survey completed
49 Registrars Data Entry
Data Entry
Limiting
Step
Limiting
Registry of Vital Records
and Statistics
Birth File Closed
MDPH Birth Report
Data weighted by CDC
Public Health Action!
PRAMS Report
Step
30
Public Health Action!
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
31
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
Kappa
statistic ascertainment
Positive Predictive Value:
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)
32
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
33
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
34
referrals to cessation programs
Acknowledgements
Hafsatou Diop, MDPH Office of Data Translation
Karin Downs, MDPH Bureau of Family Health and
Nutrition
Thomas Land, MDPH Tobacco Cessation and Prevention
Program
Emily Lu, MDPH PRAMS Coordinator
Alice Mroszczyk, MDPH Privacy and Data Access Office
Maria Vu, MDPH Registry of Vital Records and Statistics
CDC/CSTE Applied Epidemiology Fellowship Program
35
References/Resources
CDC 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.
36
Questions?
Contact Information:
Lizzie Harvey, MPH
CDC/CSTE Applied Epidemiology Fellow
Massachusetts Department of Public Health
Lizzie.Harvey@state.ma.us
(617) 624-5559
37
Extra Slides
38
Resources in MA
• Massachusetts Smokers’ Helpline
• QuitWorks
39
Additional PRAMS Questions
on Maternal Smoking
New 2009 Core:
Which of the following
statements best
describes the rules
about smoking inside
your home now?
Check one answer
No one is allowed to
smoke anywhere inside
my home
Smoking is allowed in
some rooms or at some
times
Smoking is permitted
anywhere inside my
home
40
2003 Standard BC
41
Impact of 2003 BC
Pre-Pregnancy
12 mo.
Pregnancy
Conception
3 mo.
Post-partum
Delivery
3.8 mo.
BC
PRAMS
42
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
43
Sensitivity Analysis
Smoking BEFORE Pregnancy
MA BC
MA PRAMS
S
S
NS
Smoking DURING Pregnancy
MA BC
MA PRAMS
NS
S
NS
214
158
372
S
113
79
192
40
2499
2539
NS
20
2714
2734
254
2657
2911
133
2793
2926
Sensitivity: 214 / (214 + 40) = 0.842
Sensitivity: 113/ (113 + 20) = 0.850
MA PRAMS captured 84.2% of all maternal smoking prior to pregnancy and
85% of all maternal smoking during pregnancy identified by the BC
44
Predictive Value Positive
Smoking BEFORE Pregnancy
MA BC
MA PRAMS
S
S
NS
Smoking DURING Pregnancy
NS
S
214
158
372
40
2499
2539
254
2657
2911
PVP: 214 / (214 + 158) = 0.575
MA BC
MA PRAMS
S
NS
NS
113
79
192
20
2714
2734
133
2793
2926
PVP: 113/ (113 + 79) = 0.589
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
45
certificate
Kappa Coefficient Analysis
Maternal Smoking
Maternal Smoking
PRIOR to Pregnancy
DURING Pregnancy
N=2,997
N=2,997
40
BC
214
158
PRAMS
Κ = 0.64 (95% CI = 0.60 – 0.69)
Good Agreement
20
BC
113
79
PRAMS
Κ = 0.68 (95% CI = 0.62 – 0.74)
Good Agreement
46
Representativeness:
Differences in Reporting
Maternal Smoking
Maternal Smoking
PRIOR to Pregnancy
DURING Pregnancy
40
BC
214
20
158
PRAMS
113
BC
Who is reporting on PRAMS
but not on BC?
79
PRAMS
47