The Pregnancy Risk Assessment Monitoring System (PRAMS): Current Strengths and Opportunities for Growth

By nearly every seminal measure of maternal and infant health, the United States is struggling to make much-needed gains. We continue to rank poorly relative to other developed countries for both maternal and infant mortality, fueled in part by deep sociodemographic disparities.^1,2 Furthermore, severe maternal morbidity, which is 100 times more common than maternal death, continues to significantly affect outcomes for both mothers and their infants,³ and preliminary data for 2017 indicate that preterm birth, the second most common cause of infant mortality, has increased for a third consecutive year.⁴

To address these adverse outcomes, public health agencies, researchers, policymakers, service providers, and advocates have continued to ask critical questions. Why do these public health challenges persist? Who is most affected and why? What are the most effective and efficient means by which we as a nation can finally achieve the health outcomes that all families deserve? For the past three decades, the Pregnancy Risk Assessment Monitoring System (PRAMS) has served as an essential source of data on the myriad of demographic, behavioral, health, and contextual factors that can inform our answers to these pressing questions.

The descriptive report by Shulman et al. (p. 1305) featured in this issue of AJPH offers a clear, yet detailed description of this data collection system with applications for both long-time and novice users. Importantly, the authors make a cogent argument for the broad utility of the data for public health practice and policymaking. In this editorial, I highlight some of the unique strengths of the data system and consider opportunities to improve and extend the utility and functionality of this critical data source.

A DISTINCTIVE AND SUCCESSFUL MODEL

The report highlights several strengths of the PRAMS model. Chief among these is the demonstrated utility of the system to inform national and, perhaps more importantly, state-level policy and programming. The contribution of PRAMS to the latter is the result of several factors, including the breadth and depth of content and the ability to tailor survey administration by state. By design, PRAMS collects information on a range of topics across the preconception, pregnancy, and postpartum continuum. This breadth of content allows for the exploration of associations between health-related behaviors and attitudes before, during, and shortly after pregnancy and health outcomes for both mothers and infants while accounting for contextual factors.

PRAMS has achieved this broad scope by implementing a distinctive tiered structure composed of both core and standardized optional content, which states can select, as well as the option to develop state-specific items. This approach is further augmented by opportunities to address emerging issues through topic-specific supplements such as the 2016–2017 PRAMS Zika Supplement. The flexibility around the selection of content is complemented by the ability of each state to tailor selected aspects of survey administration, ranging from the application of state-specific branding, to the use of targeted incentives, to the specification of priority population groups for oversampling, and even to the fielding of state-supported follow-up studies to design a data collection effort that most effectively addresses local needs and priorities.

The success of this model is evident in the wide use of PRAMS data (alone and linked to other systems) to inform state policy deliberations⁵ and monitor the effect of programmatic investments such as those made by the Health Resources and Services Administration’s Title V Maternal and Child Health Services Block Grant and Healthy Start programs.

OPPORTUNITIES FOR GROWTH

The demonstrable value of PRAMS data at both the national and the state levels is well documented, but opportunities to safeguard and extend the utility of this resource are important to consider. First, although designed to maintain data quality and provide states with a clear performance objective, the application of a response rate threshold for public data release (55%) may nevertheless hinder the use of these data to inform public policy debates and the monitoring of public investments to the fullest extent possible. Moreover, the exclusion of states based on this threshold approach can impair trend analyses and generalizability given that response rates vary geographically. To be sure, state survey administrators should be implementing consistent efforts to achieve optimal response rates. However, declining response rates have been observed across the spectrum of federal household surveys prompting a deeper discussion of the relative importance of nonresponse bias rather than response rates, per se.⁶ From this perspective, the decision to release all state data, including those with low response rates, may better serve the PRAMS stated goal to “support the use of data to develop policies and programs that aim to decrease maternal and infant morbidity and mortality” (Shulman et al., p. 1305) if complemented by efforts to assess and address nonresponse bias.

A second area of possible growth for the PRAMS program may be broadly characterized as data timeliness and accessibility. The current data cycle of approximately two years can create challenges for states (and the nation) who need to use these data for timely decision-making in response to current and emergent public health threats to the maternal and child health population. Ensuring timely data access in formats that can be easily retrieved by diverse user groups is difficult. However, opportunities exist to tackle different aspects of this hurdle. One such option may be to explore the use of Internet-based data collection. Experience from the recently redesigned National Survey of Children’s Health suggests that Web-based data collection approaches can yield administrative efficiencies—including increased timeliness—while providing a tailored, user-friendly platform for data collection.⁷ In part because of these efficiencies, the National Survey of Children’s Health is now annual with a public data release approximately eight months after the conclusion of data collection. However, given that PRAMS includes the postpartum period and the sampling frame is based on birth certificates, additional efforts to accelerate birth file finalization or use of provisional data for weighting also will be necessary to significantly improve the timeliness of PRAMS data.

CONCLUSIONS

Since 1987, PRAMS has served as an increasingly important tool in our efforts to better understand and more effectively address the complex interplay of individual and systems-level factors that influence the health of our nation’s mothers and infants. The report featured in this month’s edition of AJPH showcases the strengths of the system and provokes our consideration of opportunities to continue to expand this important resource and extend its application to both persistent and emerging challenges in maternal and child health.