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Core State Preconception Health Care Indicators
In 2006, the CDC Preconception Health and Health Care Initiative Steering Committee’s Public Health Work Group (PHWG), in partnership with other national experts and organizations, published recommendations for public health practitioners to enhance and monitor preconception health and health care, two of which addressed the use of surveillance data to provide evidence of the effectiveness of preconception programs and for monitoring improvements in preconception health and health care at the federal, state, and local levels. A separate working group of maternal and child health program managers, epidemiologists, and data managers from seven states was convened in 2007 to specify preconception health domains and priority areas and to propose measurable preconception health indicators at the state level. Representatives from those seven states (California, Delaware, Florida, Michigan, North Carolina, Texas, and Utah) developed a final list of 45 Core State Preconception Health and Health Care Indicators within 11 different domains. These indicators allow states to uniformly define, collect, and report on data relevant to the health status of women between the ages of 18 and 44 years. CSTE collected feedback on the indicators through September 2009 and finalized the indicators in 2010.
Note: Although reproductive age women include adolescents and women over the age of 45 years, the majority of women having a live birth are 18-44 years of age. Furthermore, adolescents and women over the age of 45 years may have risk factor profiles which differ from that of women aged 18-44 years. The working group recommends that future efforts in the indicator development process be expanded to include these populations.
Indicator Selection Process
The indicator selection process was conducted over a period of one and a half years. During this time, the working group developed preconception health domains and sub-domains; reviewed state-level data systems to identify potential indicators; prioritized 96 potential indicators based on a set of criteria that included public health importance, state-specific program and policy importance, data quality, data availability, and simplicity of the indicator; and used a consensus-based process to identify the final set of 45 core state preconception health and health care indicators.
Domains
The working group identified the following 11 preconception health and health care domains and sub-domains that distinguish specific areas of importance. Please click here to download all of the indicators (zip file).
General health status (pdf)
  • Self-rated health
Social determinants of health (pdf)
  • Education
  • Poverty
  • Housing
Health care (pdf)
  • Access to and utilization of health care
  • Access to dental care
  • Reproductive health care
  • Content and quality of care
  • Adequacy and satisfaction with care
Reproductive health and family planning (pdf)
  • Previous low birth weight infant
  • Previous preterm birth
  • Prior fetal death, miscarriage, or stillbirth
  • Inter-pregnancy interval/birth spacing
  • Pregnancy intention/wantedness
  • Contraception – Access, availability, and use
  • Use of assisted reproductive technology
Tobacco, alcohol, and substance abuse (pdf)
  • Smoking
  • Alcohol
  • Secondhand smoke exposure
  • Substances
Nutrition and physical activity (pdf)
  • Fruit and vegetable consumption
  • Obesity and overweight
  • Folic acid supplementation
  • Exercise/physical activity
Mental health (pdf)
  • General mental distress
  • Anxiety and depression
  • Postpartum depression
  • Stress
Emotional and social support (pdf)
  • Domestic abuse – physical and mental
  • Adequacy of support
Chronic conditions (pdf)
  • Diabetes
  • Hypertension
  • Asthma
  • Anemia
  • Arthritis
  • Epilepsy/seizures
Infections (pdf)
  • HIV
  • Sexually transmitted infections
  • Immunizations
  • Urinary tract infections and bacterial vaginosis
  • Periodontal disease
Genetic and epigenetics
  • Family history
  • Genetic screenings
Indicators were not recommended for some sub-domains, as no appropriate existing measures were available. These determinations were reached by working group consensus after thorough evaluation of available measures. The list of domains is not exhaustive; for example, environmental exposures was considered as a priority area but was not added since applicable data resources and relevant measures for reproductive aged women could not be identified. Future efforts are needed to improve the indicators as more data about the impact of preconception health and health care programs become available. To expand the scope of preconception health and health care domains and indicators, the working group recommends that future efforts focus on developing additional preconception health-related measures and adding questions to existing state-level surveillance systems.
Data Sources
Annual Social and Economic Supplement (ASEC) of the Current Population Survey (CPS)
ASEC is a supplement of the CPS, which is conducted annually and provides timely and official estimates of poverty rates and estimates and distributions of household income and individual earnings. ASEC data are of high quality and can be used to assess state-level trends and differences across states. However, ASEC data may yield large sampling errors for smaller states, which would require those states to combine multiple years of data to calculate indicators. ASEC data quality issues that have been noted include item nonresponse for certain income sources as well as some sources of income missing from the questionnaire (e.g., tips, bonuses, and government payments for child care to permit employment).
Behavioral Risk Factor Surveillance System (BRFSS)
The BRFSS collects information on health risk behaviors, preventive health practices, and health care access primarily related to chronic disease and injury using telephone surveys in all 50 states. BRFSS data are generally available within one year, and in many states BRFSS is the only source of timely data related to health behaviors. As the BRFSS was not developed to monitor preconception health, limiting the results to women aged 18 to 44 years substantially reduces the survey sample size, which may lead to unstable estimates in some states. Like other telephone surveys, BRFSS data might be subject to systematic error resulting from non-coverage, non-response, or measurement issues. Some indicators originating from the BRFSS are optional items, which are selectively added by individual states. Due to the BRFSS sample of women and the level of detail in the survey, the BRFSS-defined indicator measures are not limited to those women who are potentially able to become pregnant.
National Sexually Transmitted Diseases Database (NSTD)
NSTD was developed by CDC for real-time active surveillance of nationally notifiable sexually transmitted infections. These infections are reportable conditions, but reporting by states to CDC is voluntary. Differing reporting policies and surveillance activities between localities and states may lead to underestimates of true infection rates in some areas , and data may not be representative of the entire populations under consideration.
National Vital Statistics System (NVSS)
NVSS registers all vital events that take place in the U.S., including live births. There is no standard for completing birth certificates, with some information gathered by self-reports and other information collected from medical charts, and therefore birth certificate reliability varies . Data incompleteness and inaccuracies in reporting may be issues with birth certificates, which can result in information bias.
Pregnancy Risk Assessment Monitoring System (PRAMS)
PRAMS collects state-specific, population-based data on maternal attitudes and experiences before, during, and shortly after pregnancy. PRAMS, which collects data using mail and telephone surveys, has become an essential means in many states for monitoring changes in maternal and child health status. Similar to the BRFSS, the PRAMS data are self-reported and not verified by medical records, and non-response, non-coverage, and measurement biases may also affect data quality. A few indicators are based on PRAMS optional items, which are not used in all PRAMS states. The PRAMS target population is women having had a live birth rather than all women of reproductive age. However, PRAMS is currently the only data system that has been developed to specifically monitor the health of reproductive age women.
For more information about the indicators, please contact Nidal Kram. Click here to view other Chronic Disease/Maternal and Child Health/Oral Health Steering Committee activities.
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