In 2006, the Public Health Work Group (PHWG) of the Centers for Disease Control and Prevention (CDC) Preconception Health and Health Care Initiative Steering Committee, in partnership with other national experts and organizations, published ten recommendations for public health practitioners to enhance and monitor preconception health and health care (Johnson 2006). Two of these recommendations specifically 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. In December 2007, the PHWG convened a separate committee (working group) of maternal and child health program managers, epidemiologists, and data managers from seven states (California, Delaware, Florida, Michigan, North Carolina, Texas, and Utah) to specify preconception health domains (i.e., priority areas) and propose currently measurable preconception health indicators at the state level. Representatives from the seven states worked to develop a final list of 45 Core State Preconception Health and Health Care Indicators within 11 different domains. These indicators are meant to allow states to uniformly define, collect, and report on data relevant to the health status of reproductive aged women between the ages of 18 and 44 years. (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. It is recommended by the working group that future efforts in the indicator development process be expanded to include these populations.) References: Johnson K, Posner SF, Biermann J, Cordero JF, Atrash HK, Parker CS, Boulet S, Curtis MG, CDC/ATSDR Preconception Care Work Group, Select Panel on Preconception Care. Recommendations to improve preconception health and health care – United States. MMWR Recomm Rep 2006 Apr 21; 55(RR-6):1-23.
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The working group identified the following 11 preconception health and health care domains as well as sub-domains, which distinguish specific areas of importance within each domain. Please click here to download all of the indicators. Please proceed to the forums to provide your comments.
The Working Group welcomes your feedback about the indicators and their descriptions through the forum. We will use comments received on or before September 4, 2009 to consider potential revisions and to enhance the information provided within the indicator descriptions. The Working Group recognizes the set of indicators is not perfect and represents only a starting point. Future efforts will be needed to improve this set of surveillance indicators as more data about the impact of preconception health and health care programs become available. In addition, there are currently no nationwide surveillance systems that specifically collect data from reproductive aged women. 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. Jump to Forum: Core State Preconception Health and Health Care Indicators FORUM
Indicators were not recommended for some sub-domains based on the determination that no appropriate existing measures were available for the development of related indicators. These determinations were reached after thorough evaluation of the available measures and by consensus of the working group. In addition, 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.
Indicator measures originate from five different data systems providing state-level data. While these data resources provide valuable information relevant to preconception health, no data system is immune to limitations. A description of each data system as well as associated strengths and limitations are outlined below.
Annual Social and Economic Supplement (ASEC) of the Current Population Survey (CPS) http://www.census.gov/cps/ ASEC is a supplement of the CPS, which is conducted each year and provides timely and official estimates of poverty rates as well as 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) http://www.cdc.gov/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 after the survey, 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 noncoverage (e.g., inability to contact certain higher risk populations such as low income or homeless mothers), nonresponse (e.g., refusal to participate in the survey or to answer specific questions), or measurement issues (e.g., social desirability, inaccuracies of self-reported information, or recall bias). Measurement bias may be more substantial when measuring social variables. Some indicators originating from the BRFSS are not core items (i.e., appear annually in all states) but rather are optional items, which are selectively added by individual states. The BRFSS sample includes women of reproductive age who cannot become pregnant as well as those who effectively use contraception and will never become pregnant. Furthermore, assessing a women’s ability to become pregnant (i.e., hysterectomy, sterilization, or same sex partners) is not asked every year of the survey. Therefore, the BRFSS-defined indicator measures are not limited to those women who are potentially able to become pregnant.
National Sexually Transmitted Diseases Database (NSTD) http://www.cdc.gov/std/stats NTSD was developed by the CDC for real-time active surveillance of nationally notifiable sexually transmitted infections including chlamydia, gonorrhea and syphilis. These infections are reportable conditions; however actual reporting by states to the CDC is voluntary. Differing reporting policies and surveillance activities between localities and states may lead to underestimates of true infection rates in some areas (Gorwitz). In addition, publicly supported health care institutions tend to report STIs more completely than private practitioners. Therefore, data may not be representative of entire populations under consideration. Finally, some infections may be substantially underreported.
National Vital Statistics System (NVSS) http://www.cdc.gov/nchs/nvss.htm NVSS registers all vital events that take place within the United States, 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. Some birth certificate variables are more reliable than others (David 1980). Data incompleteness may be an issue with birth certificates as well as inaccuracies in reporting, which can result in information bias.
Pregnancy Risk Assessment Monitoring System (PRAMS) http://www.cdc.gov/prams PRAMS is a surveillance partnership between the CDC and state health departments, which 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, similar to the BRFSS, nonrepsonse, noncoverage, and measurement biases may also affect data quality. Like some indicators drawn from the BRFSS, a few indicators are based on PRAMS optional items (i.e., standard 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. References: Gorwitz RJ, Webster LA, Nakashima AK, Greenspan JR. Sexually transmitted diseases. Reproductive health of women: from Data to Action -- CDC’s public health surveillance for women, infants and children. Retrieved from: http://www.cdc.gov/Reproductivehealth/ProductsPubs/DatatoAction/pdf/rhow2.pdf David RJ. The quality and completeness of birthweight and gestational age data in computerized birth files. Am J Public Health 1980; 70:964-73.
