Behavioral Risk Factor Surveillance System State-Added Questions: Leveraging an Existing Surveillance System to Improve Knowledge of Women’s Reproductive Health

Abstract

As the prevalence of chronic conditions among women of reproductive age continues to rise, studies assessing the intersection of chronic disease and women’s reproductive health status are increasingly needed. However, many data systems collect only limited information on women’s reproductive health, thereby hampering the appraisal of risk and protective factors across the life span. One way to expand the study of women’s health with minimal investment in time and resources is to integrate questions on reproductive health into existing surveillance systems. In 2013, previously validated questions on women’s self-reported reproductive history, use of contraception, and infertility were added to the Behavioral Risk Factor Surveillance System (BRFSS) by seven states (Connecticut, Kentucky, Massachusetts, Mississippi, Ohio, Texas, and Utah); all female respondents aged 18–50 years were included in the pool of respondents for these state-added questions. Of 8691 women who completed the questions, 13.2% reported ever experiencing infertility and 59.8% of those at risk for unintended pregnancy reported using contraception at last intercourse. The information garnered from the state-added reproductive health questions can be augmented with the BRFSS core questions on health-related risk behaviors, chronic conditions, and use of preventive services. Expanding existing data collection systems with supplemental questions on women’s reproductive health can provide important information on risk factors and outcomes that may not be available from other sources.

Introduction

THE RISING PREVALENCE of chronic conditions among women of reproductive age underscores the need for a life course perspective to reduce morbidity and mortality in both current and future generations.^1,2 Estimates from the Centers for Disease Control and Prevention’s (CDC’s) Pregnancy Risk Assessment Monitoring System (PRAMS) and Behavioral Risk Factor Surveillance System (BRFSS) indicate that nearly one quarter of U.S. women 18–44 years of age were obese and approximately half participated in recommended levels of physical activity.³ In addition, ~3% of women reported being diagnosed with diabetes and 10% reported being diagnosed with hypertension.³ Although the health status of reproductive-aged women in the United States has improved over the past four decades, the burden of chronic disease is increasing with consequent effects on the physical and mental health status of women.⁴ In addition, considerable health disparities remain and may be exacerbated by barriers to healthcare access and socioeconomic and cultural inequities.^4,5 Furthermore, our understanding of women’s health risks is often incomplete with limited information on risk and protective factors across the life span. As such, there is a continued need for new and innovative studies of women’s reproductive health, especially those assessing the joint effects of chronic diseases and their associated risk factors.

One way to rapidly and inexpensively expand the surveillance of women’s reproductive health with minimal resources is to leverage existing public health surveillance systems. This process capitalizes on an established infrastructure by augmenting existing data collection systems with supplemental information on other factors that impact women’s health. In addition to providing a feasible and efficient mechanism for collecting information, this approach allows research and program staff to evaluate associations between risk behaviors and reproductive outcomes that otherwise may not be investigated. The purpose of this report is to highlight the implementation of a set of state-added questions on women’s reproductive health within CDC’s BRFSS in 2013. The twelve question set included a series of questions on pregnancy history and intentions, use of contraception, and infertility diagnosis and treatment. These questions, when combined with BRFSS core questions on health-related risk behaviors, chronic conditions, and use of preventive services,⁶ provide an unique opportunity to evaluate the reproductive health for women between 18 and 50 years of age.

History of the BRFSS and Women’s Reproductive Health State-Added Questions

Established in 1984, the BRFSS is the longest continuously conducted health-related telephone survey in the world and collects state-specific data on risk behaviors and preventive health practices for all 50 states, Washington DC, Puerto Rico, Guam, and U.S. Virgin Islands.⁶ Landline and cellular telephone surveys have been included since 2011. A randomly selected adult living in the household is interviewed for the landline survey; the cellular telephone survey collects information from an adult who resides in a private residence or college housing and does not have an alternate landline. The BRFSS questionnaire has three parts: (1) the core component that consists of a standard set of questions used by all states, (2) optional modules, which are CDC-supported sets of questions on specific topics that states can elect to use on their questionnaires, and (3) state-added questions, which are questions developed or acquired by individual states and added to their questionnaires. Call back surveys can be also added to BRFSS depending on public health priorities and availability of funding.

The women’s reproductive health questions were developed to support the goals of the Preconception Health and Healthcare (PCHHC) Initiative, a public–private partnership composed of federal agencies and private sector organizations established in 2006 to implement action steps as outlined in CDC’s National Recommendations to Improve Preconception Health and Healthcare.^7,8 A key objective of the Action Plan was to reduce chronic disease and improve health before and between pregnancies among women of reproductive age. To inform the development of effective intervention and prevention strategies, recommendations were made to explore multiple data sources for a better understanding of women’s health needs and risk exposures, including access to healthcare and personal behaviors.

In March 2012, a round table was convened at the 29th annual BRFSS meeting in Atlanta, Georgia. Seventeen states expressed an interest in implementing the reproductive health questions. CDC’s Division of Reproductive Heath provided funding for the project, enabling seven states (Connecticut, Kentucky, Massachusetts, Mississippi, Ohio, Texas, and Utah) to administer the reproductive health questions with the 2013 survey. Given the intention to cover key aspects of reproductive health, the questions were categorized in three sections (four questions each): reproductive history, family planning and contraception, and infertility. To be included in the reproductive health module, the questions had to be already field tested or implemented in other surveys. Existing surveys such as PRAMS⁹ and the National Health and Nutrition Examination Survey (NHANES)¹⁰ served as the source for the eight questions on reproductive history and family planning and contraception. Four state field-tested questions developed for another project¹¹ were used to assess infertility. In total, the reproductive health questions included self-reported gravidity, parity, method of delivery, pregnancy intentions, use and type of contraception, reasons for not using contraception, infertility or difficulty staying pregnant, and use of infertility treatments and outcome of the treatment (Table 1).

Table 1.

List of State-Added Questions Regarding Women’s Reproductive Health Added in the 2013 BRFSS

Section	Question	Response options
Reproductive history	How many times have you been pregnant?	01–76 77 = Don’t know/not sure 88 = None/zero/never 99 = Refused
	How many vaginal deliveries have you had?	01–76 77 = Don’t know/not sure 88 = None/zero/never 99 = Refused
	How many cesarean deliveries have you had?	01–76 77 = Don’t know/not sure 88 = None/zero/never 99 = Refused
	How many of your deliveries resulted in a live birth?	01–76 77 = Don’t know/not sure 88 = None/zero/never 99 = Refused
Family planning and contraception	How do you feel about having a child now or sometime in the future?	1 = You don’t want to have one 2 = You do want to have one, <12 months from now 3 = You do want to have one, between 12 months to <2 years from now 4 = You do want to have one, between 2 years to <5 years from now 5 = You do want to have one, five or more years from now 6 = You do want to have one, but not sure when or don’t have a timeline 7 = Don’t know/not sure 8 = Unable to have children/hysterectomy 9 = Refused
	Did you or your spouse or partner do anything the LAST TIME YOU HAD SEX to keep you from getting pregnant?	1 = Yes 2 = No 3 = No partner/not sexually active 4 = In a same-sex relationship 7 = Don’t know/not sure 9 = Refused
	What did you or your spouse or partner do the LAST TIME YOU HAD SEX to keep you from getting pregnant?	01 = Female sterilization (e.g., tubal ligation, Essure, and Adiana) 02 = Male sterilization (vasectomy) 3 = Contraceptive implant (e.g., Implanon) 04 = Hormonal IUD (e.g., Mirena) 05 = Copper-bearing IUD (e.g., ParaGard) 06 = IUD, type unknown 07 = Shots/injections (e.g., Depo-Provera) 08 = Birth control pills, any kind 09 = Contraceptive patch (e.g., Ortho Evra) 10 = Contraceptive ring (e.g., NuvaRing) 11 = Male condoms 12 = Diaphragm, cervical cap, or sponge 13 = Female condoms 14 = Not having sex at certain times (rhythm or natural family planning) 15 = Withdrawal (or pulling out) 16 = Foam, jelly, film, or cream 17 = Emergency contraception (morning after pill) 18 = Other method, specify 77 = Don’t know/not sure 99 = Refused
	Some reasons for not doing anything to keep you from getting pregnant the LAST TIME YOU HAD SEX might include wanting a pregnancy, not being able to pay for birth control, or not thinking that you can get pregnant. What was your main reason for not doing anything the LAST TIME YOU HAD SEX to keep you from getting pregnant?	01 = You didn’t think you were going to have sex/no regular partner 02 = You just didn’t think about it/don’t care if you get pregnant 03 = You want a pregnancy 04 = You or your partner don’t want to use birth control 05 = You or your partner don’t like birth control/side effects 06 = You couldn’t pay for birth control 07 = You had a problem getting birth control when you needed it 08 = Religious reasons 09 = Lapse in use of a method 10 = Don’t think you can get pregnant (infertile or too old) 11 = You had tubes tied (sterilization) 12 = You had a hysterectomy 13 = Your partner had a vasectomy (sterilization) 14 = You are currently breast-feeding 15 = You just had a baby/postpartum 16 = You are pregnant now 17 = Same-sex partner 18 = Forced to have sex 19 = Under the influence of alcohol or drugs 20 = Other reason 77 = Don’t know/not sure 99 = Refused
Infertility	Have you or your spouse or partner ever experienced infertility, including difficulty staying pregnant?	1 = Yes, I have 2 = Yes, my spouse or partner has 3 = Yes, we both have 4 = Yes, but undetermined 5 = No 6 = Never tried to get pregnant 7 = Don’t know/not sure 9 = Refused
	Was it infertility, difficulty staying pregnant, or both?	1 = Infertility 2 = Difficulty staying pregnant 3 = Both 7 = Don’t know/not sure 9 = Refused
	Did you or your spouse or partner receive any of the following treatments?	01 = Drugs to improve or stimulate ovulation such as Clomid®, Serophene®, or Pergonal® 02 = Artificial insemination or intrauterine insemination 03 = Assisted reproductive technology 04 = Another type of surgical treatment for infertility
	Note: Up to six responses are allowed.	05 = A consultation with an infertility specialist 06 = Something else [specify] 07 = Or, you have not received medical consultation or treatment for infertility 77 = Don’t know/not sure 99 = Refused
	What was the result of the most recent treatment? Did you.	1 = Become pregnant and are still pregnant 2 = Become pregnant and had a baby 3 = Become pregnant, but the pregnancy was not maintained 4 = Did not become pregnant, but are still trying 5 = Did not become pregnant and have stopped trying 6 = You are currently receiving infertility treatment 7 = Don’t know/not Sure 9 = Refused

BRFSS, Behavioral Risk Factor Surveillance System.

To help ensure adequate response rates, the set of reproductive health questions was included as state-added questions rather than a callback survey. The reproductive health state-added questions were asked as part of the state’s monthly BRFSS sample, but the range of months over which these questions were asked varied by state. The target population was women 18–50 years of age who were included in the BRFSS sampling; therefore, adding questions to the end of the BRFSS did not require additional resources for further randomization or adjustments to sample design weights. All female respondents aged 18–50 years within a given month were included in the pool of respondents for the additional reproductive health questions. To make sure the data were representative of all women aged 18–50 years in each state, women with responses to at least one of the following three state-added questions on reproductive health: ‘‘How many times have you been pregnant?,’’ ‘‘How do you feel about having a child now or sometime in the future?,’’ and ‘‘Have you or your spouse or partner ever experienced infertility, including difficulty staying pregnant?’’ were reweighted for each state using iterative raking procedures that included five variables: age, race/ethnicity, marital status, education, and telephone source. If a woman did not have a response to at least one of the above questions, she was excluded from the dataset.

Prevalence of Selected Reproductive Health Indicators

To examine the status of reproductive health among women in the seven states that implemented the state-added questions on reproductive health, we estimated the prevalence of self-report of ever having infertility (unable to become pregnant after a year of trying) or difficulty staying pregnant (unable to stay pregnant after a year of trying), use of any infertility treatments among women reporting infertility or difficulty staying pregnant, desire for a child sometime in the future, and use of any contraception at last intercourse among women at-risk of unintended pregnancy (women who were not currently pregnant, did not have a hysterectomy, were sexually active, did not report a same-sex partner, and did not want to be pregnant <12 months from time of survey). Overall, 8691 women in the seven participating states completed the state-added reproductive health questions for a weighted sample size of 13.1 million women 18–50 years of age. A total of 13.2% of women reported ever having infertility or difficulty staying pregnant; of those, 51.7% used some type of fertility treatment, including ovulation-inducing medications, intrauterine insemination, assisted reproductive technology, or other treatment (Table 2). Nearly half (46.6%) of the women who were not pregnant reported the desire to have a child sometime in the future, and 59.8% of women at-risk for unintended pregnancy reported the use of contraception at last sexual intercourse. There was variation by age, race/ethnicity, and education status for some indicators, indicating potential disparities that may require further exploration.

Table 2.

Prevalence Of Ever Having Infertility Or Difficulty Staying Pregnant, Use Of Fertility Treatments, Pregnancy Intention, And Contraceptive Use At Last Intercourse Among Women 18–50 Years, 2013 BRFSS Reproductive Health Data For Connecticut, Kentucky, Massachusetts, Mississippi, Ohio, Texas, and Utah

	Infertility or difficulty staying pregnant		Received any infertility treatment a		Want a child in the future		Used any contraceptive at last intercourse b
	Unweighted n	Weighted% (95% CI)	Unweighted n	Weighted% (95% CI)	Unweighted n	Weighted% (95% CI)	Unweighted n	Weighted% (95% CI)
Overall	1272	13.2 (11.3–15.2)	649	51.7 (43.8–59.6)	2542	46.6 (43.5–49.6)	3874	59.8 (56.8–62.7)
Age
18–24	51	7.0 (3.8–12.3)	n < 30	—	874	92.4 (89.4–94.7)	584	70.9 (64.0–76.9)
25–29	120	11.3 (8.2–15.4)	39	22.9 (13.2–36.6)	583	76.5 (69.7–82.2)	455	68.0 (60.4–74.6)
30–34	176	14.9 (9.6–22.5)	87	69.3 (51.2–82.9)	521	52.2 (43.6–60.7)	621	58.0 (51.4–66.0)
35–39	250	13.6 (11.0–16.8)	147	55.1 (44.4–65.4)	306	22.5 (18.0–27.7)	679	58.9 (51.4–66.0)
40–44	267	15.8 (11.4–21.4)	142	69.5 (55.4–80.7)	157	15.1 (10.1–22.0)	675	53.0 (45.2–60.7
45–50	408	16.1 (12.7–20.1)	223	53.5 (40.4–66.2)	101	3.8 (2.8–5.2)	794	42.4 (37.2–47.8)
Race/ethnicity
Non-Hispanic white	1031	14.2 (12.2–16.4)	552	54.2 (46.3–61.8)	1785	42.6 (39.0–46.3)	2901	62.2 (58.8–65.5)
Non-Hispanic black	87	9.4 (6.0–14.4)	31	48.6 (27.0–70.8)	327	52.7 (44.2–61.0)	435	62.7 (53.9–70.8)
Hispanic	85	10.8 (6.4–17.7)	31	42.2 (17.7–71.3)	279	49.1 (41.7–56.6)	335	54.3 (46.3–62.0)
Other	69	20.6 (12.5–32.0)	35	58.8 (32.6–80.9)	151	63.2 (51.6–73.4)	137	47.2 (36.1–58.6)
Education
<High school	57	8.2 (4.4–14.8)	n < 30	—	137	38.3 (28.8–48.7)	166	42.0 (31.9–52.8)
High school	604	12.9 (10.4–15.9)	268	46.7 (35.1–58.8)	1401	50.2 (46.1–54.3)	1865	59.1 (56.0–63.6)
College	611	16.5 (13.8–19.5)	364	68.9 (60.6–76.1)	995	41.7 (36.8–46.7)	1772	67.3 (62.6–71.6)

^aAmong those reporting infertility or difficulty staying pregnant.

^bAmong women at-risk for unintended pregnancy (women who were not currently pregnant, did not have a hysterectomy, were sexually active, did not report a same-sex partner, and did not want to be pregnant <12 months from time of survey).

—Data not shown due to small sample size (n < 30).

CI, confidence interval.

Future Directions

The set of state-added questions on reproductive health developed for the 2013 BRFSS provides a unique opportunity to evaluate a broad array of factors associated with women’s reproductive health. Planned analyses include assessing the characteristics of women with infertility or difficulty staying pregnant, health-related quality of life for women with infertility, the relationship between pregnancy intention and contraceptive use, contraceptive use among sexually active women with disabilities, and contraceptive use among women between ages 45 and 50. States will also use the reproductive health data to prepare summary reports for state public health practitioners, policy makers, and the general public. The reproductive health questions may be included as state-added questions in future BRFSS surveys to monitor changes in the indicators over time. In addition, questions related to men’s reproductive health could be included, particularly as they relate to the areas of infertility,¹² preconception health,¹³ and contraceptive use.¹⁴

Discussion

Leveraging an existing surveillance system with previously tested questions is an efficient way to enhance surveillance of women’s reproductive health. The advantage of implementing such a module within the BRFSS is the ability to assess other state-based health-related information collected in the survey. The data can also be used to assess the impact of state-based policies such as Medicaid Family Planning Waivers. Factors such as healthcare access, chronic health conditions, and other health behaviors directly or indirectly influence reproductive health and warrant consideration in studies of women’s health. Even periodic expansion of existing data collection systems with supplemental questions on women’s reproductive health provides valuable information that may not be available from other data sources. These data provide important insight on factors that affect women’s health across the life span and can be used to inform health promotion and chronic disease prevention strategies.