Evaluation of Pregnancy Intention in the Massachusetts Pregnancy Risk Assessment Monitoring System (PRAMS)

BACKGROUND: Unintended pregnancy has been associated with poor maternal behaviors and birth outcomes. Massachusetts has used the Behavioral Risk Factor Surveillance System (BRFSS) to monitor unintended pregnancy and inform the Title V program. Since 2007, Massachusetts has also been monitoring unintended pregnancies using the Pregnancy Risk Assessment Monitoring System (PRAMS), which could be a reliable alternative to BRFSS. This study proposed to use BRFSS data to evaluate pregnancy intention in PRAMS.

METHODS: PRAMS was evaluated according to the Centers for Disease Control and Prevention’s “Updated Guidelines for Evaluating Public Health Surveillance Systems”. The evaluation’s main focus was the analysis of pregnancy intention in PRAMS compared to BRFSS. Other surveillance system components, including timeliness and flexibility, were also assessed (results not included). The PRAMS question used to define pregnancy intention was: “Thinking back to just before you got pregnant with your newbaby, how did you feel about becoming pregnant?” The BRFSS questions were:  “Have you been pregnant in the last 5 years?” and “Thinking back to your last pregnancy, just before you got pregnant, how did you feel about becoming pregnant?”.  Data from 2008 and 2010 were analyzed for both surveys (PRAMS N=3022; BRFSS N=683). Chi-square tests determined similarity within datasets to ensure years could be combined. Since PRAMS respondents could not be linked to BRFSS respondents to calculate sensitivities and positive predictive values, similarity in pregnancy intention was evaluated using 95% confidence interval (CI) overlap of the prevalence of unintended pregnancy.  Covariates assessed included maternal demographics.

RESULTS: Covariates were not significantly different between 2008 and 2010, ensuring confidence in combined analysis. Non-Hispanic White (NHW), unmarried, and women with less than a high school education were more likely to report unintended pregnancy. PRAMS’s CIs overlapped with BRFSS for all covariates except for the following: <185%FPL (PRAMS=44.5%-52.5% and BRFSS=25.1%-43.6%); 185%+FPL (PRAMS= 17.9%-23.5% and BRFSS=9.3%-17.9%); married women (PRAMS=17.8%-22.5% and BRFSS=8.4%-15.9%); some college (PRAMS=38.2%-48.9% and BRFSS=15.1%-32.7%); and NHW (PRAMS=24.7%-31.2% and BRFSS=12.7%-21.8%).

CONCLUSIONS: The prevalence of unintended pregnancy in PRAMS and BRFSS overlapped for all indicators except 185%FPL and subgroups married women, women with some college education, and NHW women suggesting that PRAMS could be used to estimate pregnancy intention in lieu of BRFSS. PRAMS is a suitable alternative because it is administered two to six months postpartum, reducing the potential influence of recall bias. Additionally, PRAMS includes a larger sample population, improving generalizability among MA women.