Skip to main content
NCBI home page
HHS Author Manuscripts logoLink to HHS Author Manuscripts
. Author manuscript; available in PMC: 2025 Apr 29.
Published in final edited form as: Matern Child Health J. 2021 Dec 1;26(1):12–14. doi: 10.1007/s10995-021-03279-0

Response to “The Time has Come for All States to Measure Racial Discrimination: A Call to Action for the Pregnancy Risk Assessment Monitoring System (PRAMS)”

Denise V D’Angelo 1, Ada Dieke 1, Letitia Williams 1, Holly B Shulman 1, Martha Kapaya 1, Suzanne Folger 1, Lee Warner 1
PMCID: PMC12039524  NIHMSID: NIHMS1981715  PMID: 34854025

Abstract

We respond to a recent call to action for the Pregnancy Risk Assessment Monitoring System (PRAMS) to include a “core” question or validated measure on discrimination to allow for systematic assessment of the impact of racial discrimination on adverse birth outcomes among a large population-based sample in the United States. We outline activities of the CDC PRAMS project that relate to this call to action.

Keywords: PRAMS, Survey design, Racial discrimination

Letter to the Editor

We appreciate the commentary by Joanna Almeida, Candice Belanoff, and Kristin F. Erbetta which acknowledges the negative impact of racial discrimination on maternal and infant health through social determinants, psychosocial stress, and weathering (Almeida et al., 2021). Centuries of racism in the United States have had a profound and negative impact on communities of color (Crear-Perry et al., 2021; Prather et al., 2016, 2018). In creating structures that generate or perpetuate unfair access to resources and opportunities based on race, racism affects social determinants of health (conditions where individuals live, learn, work, and play), which are key drivers of inequitable health outcomes for racial and ethnic minority groups (Bailey et al., 2017; Centers for Disease Control & Prevention, 2020; Jones, 2021).

On April 8, 2021, CDC Director Rochelle P. Walensky declared racism a serious public health threat and acknowledged that structural inequities have resulted in stark racial and ethnic health disparities that are severe, far-reaching, and unacceptable (Centers for Disease Control & Prevention, 2021b). In tandem, she announced the commitment of CDC to intensify efforts across the agency to address racism and health inequities. To obtain a better understanding of the impact of racial discrimination on maternal and infant health outcomes, CDC’s Pregnancy Risk Assessment Monitoring System (PRAMS) can be used as a rich source of representative surveillance data on a variety of topics from a unique population (Shulman et al., 2018).

PRAMS was born from the need to address disparities and slow declines in infant mortality rates in the late 1980s. The system has continued to provide valuable data to assess health disparities related to maternal and infant health since that time. Recently, work has begun on the development of a special questionnaire supplement on Social Determinants of Health for PRAMS. This supplement will include questions to assess interpersonal racial discrimination and social determinants of health and is expected to be available to PRAMS grantees and other maternal and infant health surveillance systems in 2022. While large scale adoption of the supplement is anticipated, implementation will be optional for sites.

In May 2021, CDC also launched the PRAMS Phase 9 Questionnaire Revision, with the goal of putting a new questionnaire in the field in 2023. The PRAMS questionnaire is typically revised every 3–5 years, providing an opportunity to evaluate existing content and include new questions (Centers for Disease Control and Prevention, 2021c). CDC works with federal and non-federal partners, subject matter experts, and state, territorial, and local health officials to revise and develop questionnaire content. Through this collaborative process, each phase of the PRAMS questionnaire collects data related to ongoing and emerging issues identified by the larger field of maternal and child health (MCH) experts. In the early stages of development of the Phase 9 questionnaire, health equity, social determinants of health, and interpersonal racial discrimination emerged as critically important topics to be considered for the new questionnaire. As the process continues, CDC PRAMS will determine which questions on racial discrimination will appear on the Core (asked by all PRAMS sites) and Standard (available for selection by sites) sections of the Phase 9 questionnaire..

As with any public health surveillance system, PRAMS is designed to be provide information that is action-oriented. Addressing racial and ethnic disparities in preterm birth between Black and White persons in the United States mentioned in the commentary, and other health inequities, require actionable data that can inform programs and policies. PRAMS data are analyzed by researchers to investigate ongoing and emerging issues in the field of maternal and infant health. The data are also used by state and local health departments and other public health professionals to plan or review programs and policies aimed at reducing health problems among mothers and infants (Centers for Disease Control and Prevention, PRAMS Data to Action 2021a). PRAMS data have been linked to community-level indicators that may be measures of structural racism, as noted in the commentary (Nkansah-Amankra et al., 2010; Nkansah-Amankra, 2010). In addition, CDC has disseminated findings from available PRAMS data to increase the understanding of the differences by race and ethnicity in experiences and health conditions around the time of pregnancy (Mpofu et al., 2020; Robbins et al., 2018; D’Angelo et al. 2015; Ahluwalia et al., 2014). PRAMS sites actively publish on disparities, as well (Stanhope and Hogue, 2020; Austin et al., 2019; Salm Ward et al., 2016; Liu & Tronick, 2013). We look forward to creating a richer body of information on reproductive health inequities and their causes via updates to the questionnaire. In addition, we look to our partners and fellow researchers to help promote the use of PRAMS data to inform strategies that could improve health care access and the provision of respectful care, even as updates to the questionnaire are in progress.

PRAMS, as a leading source of information on maternal experiences before, during, and after pregnancy, depends on the individuals who take the survey. National declines in response rates for surveillance systems, including PRAMS, make clear the need for improved approaches to data collection to ensure the representativeness of the data. Collaboration from MCH experts and trusted community sources to raise awareness about PRAMS and promote the survey may improve participation. PRAMS sites have experimented with alternative methods to increase response rates such as hand delivery of surveys to WIC participants (Ahluwalia et al., 2015) and hospital-based surveillance at the time of birth (D’Angelo et al., 2017). Some PRAMS sites have independently offered web-based surveys as a mode for data collection (Binkley et al., 2017), and CDC PRAMS is in the process of developing a web-based survey for all sites to use to facilitate participation.

Again, we appreciate the commentary’s call to action highlighting the importance of collecting representative, systematic data to fully examine effects of racial discrimination on health outcomes. CDC will continue to work to ensure that PRAMS can be used to obtain a better understanding of the impact of racial discrimination and social determinants of health on maternal and child health with the ultimate goal of addressing barriers to individuals achieving optimal health.

Significance.

Social determinants of health, which are influenced by racism and racial discrimination, are key drivers of inequitable health outcomes for racial and ethnic minority groups. The Pregnancy Risk Assessment Monitoring System (PRAMS), which collects information on behaviors and experiences before, during, and shortly after pregnancy, is engaged in the process of developing a special questionnaire supplement on Social Determinants of Health and a new Phase 9 version of the questionniare. These are opportunities to explore adding survey questions to allow for the systemaitic assessment of the impact of racial discrimination on maternal and infant health among a large population-based sample.

Funding

No funding was received to prepare this letter. Authors have no financial disclosures.

Footnotes

CDC Disclaimer:

The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Declarations

Conflict of interest Authors have no conflicts of interest.

References

  1. Ahluwalia IB, Ding H, Harrison L, Dngelo D, Singleton JA, Bridges C, & PRAMS Influenza Working Group. (2014). Disparities in influenza vaccination coverage among women with live-born infants: PRAMS surveillance during the 2009–2010 influenza season. Public Health Report, 129(5), 408–416. [DOI] [PMC free article] [PubMed] [Google Scholar]
  2. Ahluwalia IB, Harrison L, Simpson P, Wako E, Helms Shealy K, Kapaya M, Williams T, Williams L, & D’Angelo D. (2015). Pregnancy Risk Assessment Monitoring System and the W.K. Kellogg Foundation joint project to enhance maternal and child health surveillance: Focus on collaboration. Journal of Women’s Health (2002), 24(4), 257–260. [DOI] [PMC free article] [PubMed] [Google Scholar]
  3. Almeida J, Belanoff C, & Erbetta KF (2021). The time has come for all states to measure racial discrimination: A call to action for the pregnancy risk assessment monitoring system (PRAMS). Maternal and Child Health Journal. 10.1007/s10995-021-03160-0. [DOI] [PMC free article] [PubMed] [Google Scholar]
  4. Austin AE, Gottfredson NC, Zolotor AJ, Halpern CT, Marshall SW, Naumann RB, & Shanahan ME (2019). Trajectories of child protective services contact among Alaska Native/American Indian and non-Native children. Child Abuse and Neglect, 95, 104044. [DOI] [PMC free article] [PubMed] [Google Scholar]
  5. Bailey ZD, Krieger N, Agénor M, Graves J, Linos N, & Bassett MT (2017). Structural racism and health inequities in the USA: Evidence and interventions. Lancet, 389(10077), 1453–1463. [DOI] [PubMed] [Google Scholar]
  6. Binkley T, Beare T, Minett M, Koepp K, Wey H, & Specker B. (2017). Response to an online version of a PRAMS-like survey in South Dakota. Maternal and Child Health Journal, 21(2), 335–342. [DOI] [PubMed] [Google Scholar]
  7. Centers for Disease Control and Prevention [CDC]. (2020). Health Equity. Retrieved from https://www.cdc.gov/chronicdisease/healthequity/index.htm.
  8. Centers for Disease Control and Prevention [CDC]. (2021a). History of the PRAMS Questionnaire. Retrieved from https://www.cdc.gov/prams/questionnaire.htm#history.
  9. Centers for Disease Control and Prevention [CDC]. (2021b). Media Statement from CDC Director Rochelle P. Walensky, MD, MPH, on Racism and Health. Retrieved from https://www.cdc.gov/media/releases/2021/s0408-racism-health.html. [Google Scholar]
  10. Centers for Disease Control and Prevention [CDC]. (2021c). PRAMS Data to Action Success Stories. Retrieved from https://www.cdc.gov/prams/state-success-stories/data-to-action-success.html.
  11. Centers for Disease Control and Prevention [CDC]. (2021d). Social Determinants of Health: Know what affects health. Retrieved from https://www.cdc.gov/socialdeterminants/index.htm.
  12. Crear-Perry J, Correa-de-Araujo R, Lewis Johnson T, McLemore MR, Neilson E, & Wallace M. (2021). Social and structural determinants of health inequities in maternal health. Journal of Womens Health (larchmt)., 30(2), 230–235. [DOI] [PMC free article] [PubMed] [Google Scholar]
  13. D’Angelo DV, Le B, O’Neil ME, Williams L, Ahluwalia IB, Harrison LL, Floyd RL, Grigorescu VC, & Centers for Disease Control and Prevention (CDC). (2015). Patterns of health insurance coverage around the time of pregnancy among women with live-born infants-pregnancy risk assessment monitoring system, 29 States, 2009. MMWR Morbidity and Mortality Weekly Report Surveillance Summary, 64(4), 1–19. [PMC free article] [PubMed] [Google Scholar]
  14. D’Angelo DV, Salvesen von Essen B, Lamias MJ, Shulman H, Hernandez-Virella WI, Taraporewalla AJ, Vargas MI, Harrison L, Ellington SR, Soto L, Williams T, Rodriguez A, Shapiro-Mendoza CK, Rivera B, Cox S, Pazol K, Rice ME, Dee DL, Romero L, … Warner L. (2017). Measures taken to prevent Zika virus infection during pregnancy - Puerto Rico, 2016. MMWR Morbidity Mortal Weekly Report, 66(22), 574–578. [DOI] [PMC free article] [PubMed] [Google Scholar]
  15. Jones CP (2021). Addressing violence against children through anti-racism action. Pediatric Clinics of North America, 68(2), 449–453. 10.1016/j.pcl.2021.01.002. [DOI] [PubMed] [Google Scholar]
  16. Liu CH, & Tronick E. (2013). Rates and predictors of postpartum depression by race and ethnicity: Results from the 2004 to 2007 New York City PRAMS survey (Pregnancy Risk Assessment Monitoring System). Maternal and Child Health Journal, 17(9), 1599–1610. [DOI] [PubMed] [Google Scholar]
  17. Mpofu JJ, Smith RA, Patel D, Gillespie C, Cox S, Ritchey M, Yang Q, Morrow B, & Barfield W. (2020). Disparities in the prevalence of excess heart age among women with a recent live birth. Journal of Women’s Health (2002), 29(5), 703–712. [DOI] [PMC free article] [PubMed] [Google Scholar]
  18. Nkansah-Amankra S. (2010). Neighborhood contextual factors, maternal smoking, and birth outcomes: multilevel analysis of the South Carolina PRAMS survey, 2000–2003. Journal of Womens Health (larchmt), 19(8), 1543–1552. [DOI] [PubMed] [Google Scholar]
  19. Nkansah-Amankra S, Dhawain A, Hussey JR, & Luchok KJ (2010). Maternal social support and neighborhood income inequality as predictors of low birth weight and preterm birth outcome disparities: Analysis of South Carolina Pregnancy Risk Assessment and Monitoring System survey, 2000–2003. Maternal and Child Health Journal, 14(5), 774–785. [DOI] [PubMed] [Google Scholar]
  20. Prather C, Fuller TR, Marshall KJ, & Jeffries WL (2016). The impact of racism on the sexual and reproductive health of African American Women. Journal of Women’s Health (2002), 25(7), 664–671. [DOI] [PMC free article] [PubMed] [Google Scholar]
  21. Prather C, Fuller TR, Jeffries WL IV., Marshall KJ, Howell AV, Belyue-Umole A, & King W. (2018). Racism, African American women, and their sexual and reproductive health: A review of historical and contemporary evidence and implications for health equity. Health Equity, 2(1), 249–259. [DOI] [PMC free article] [PubMed] [Google Scholar]
  22. Robbins C, Boulet SL, Morgan I, D’Angelo DV, Zapata LB, Morrow B, Sharma A, Kroelinger CD Centers for Disease Control and Prevention (CDC). (2018). Disparities in Preconception Health Indicators - Behavioral Risk Factor Surveillance System, 2013–2015, and Pregnancy Risk Assessment Monitoring System, 2013–2014. MMWR Morbidity and Mortality Weekly Report Surveillance Summary, 67(1):1–16. Erratum in: Morbidity and Mortality Weekly Report Surveillance Summary, (2018), 67(16):479. [DOI] [PMC free article] [PubMed] [Google Scholar]
  23. Salm Ward TC, Robb SW, & Kanu FA (2016). Prevalence and characteristics of bed-sharing among Black and White infants in Georgia. Maternal and Child Health Journal, 20(2), 347–362. [DOI] [PubMed] [Google Scholar]
  24. Shulman HB, D’Angelo DV, Harrison L, Smith RA, & Warner L. (2018). The Pregnancy Risk Assessment Monitoring System (PRAMS): Overview of design and methodology. American Journal of Public Health, 108(10), 1305–1313. [DOI] [PMC free article] [PubMed] [Google Scholar]
  25. Stanhope KK, & Hogue CJ (2020). Stressful life events among new mothers in Georgia: Variation by race, ethnicity and nativity. Maternal and Child Health Journal, 24(4), 447–455. [DOI] [PubMed] [Google Scholar]

RESOURCES