Data source

Data were from the Pregnancy Risk Assessment Monitoring System (PRAMS) for 2009-2010. PRAMS provides population-based data on self-reported maternal behaviors and experiences before, during, and after pregnancy among women who have had a recent live birth. Women are sampled from a frame of states’ birth certificate files 2-6 months after delivery. A stratified systematic sampling method is used to over-sample mothers with adverse birth outcomes and racial/ethnic minority groups. The PRAMS questionnaire was a combination of core questions that are asked by all states and standard questions that states can choose to include; thus, each state has a unique PRAMS questionnaire. Four states (MD, MI, NJ, OH) chose to include the questions on reported receipt of PCC and the questions on receipt of specific pregnancy-related preventive health messages and maternal behaviors before and during pregnancy. PRAMS required a minimum response rate of 65% to release the 2009-2010 data. Further details of PRAMS methods (which includes sampling, stratification, weighting, questionnaire, data collection, and data management) are described elsewhere.

Data analysis

Only women who answered “yes” to the question, “Before you got pregnant with your new baby, did you talk with a doctor, nurse, or other health care worker to prepare for a healthy pregnancy and baby?” were asked to answer the questions on specific health messages received before pregnancy (32.2% of the total sample; n = 10,267 women). PCC messages received and corresponding behaviors that were examined included taking vitamins with folic acid before pregnancy, dieting to lose weight or exercising before pregnancy, smoking during pregnancy, and drinking alcohol during pregnancy ( Table 1 ).

Vitamin use was assessed with the question, “During the month before you got pregnant with your new baby, how many times a week did you take a multivitamin, a prenatal vitamin, or a folic acid vitamin?” Responses were coded as yes (range, 1–7 times each week; 76% of women reported daily use) vs no.

Only women who were overweight or obese before pregnancy were included in the analyses on dieting and exercising before pregnancy. Maternal prepregnancy overweight and obesity were determined from self-reported height and weight data that were collected at the time of survey completion. Dieting and exercising before pregnancy were assessed with the following question: “At any time during the 12 months before you got pregnant with your new baby, did you do any of the following things? For each item, circle Y (Yes) if you did it or N (No) if you did not.” “I was dieting (changing my eating habits) to lose weight” and “I was exercising ≥3 days of the week” were coded as yes or no.

Likewise, only women who reported smoking or alcohol use in the past 2 years were asked about smoking and alcohol use during pregnancy. Thus, the analyses that were related to smoking and drinking were restricted to women who reported use in the past 2 years. Women who reported smoking any cigarettes in the past 2 years were asked further, “In the last 3 months of your pregnancy, how many cigarettes did you smoke on an average day?” with any smoking coded as yes. Women who reported having any alcoholic drinks in the last 2 years were further asked, “During the last 3 months of your pregnancy, how many alcoholic drinks did you have in an average week?”; any reported drinking was coded as yes.

Separate weighted multivariable logistic regression models were used to assess the association between receipt of specific PCC messages (exposure) and maternal behaviors before and during pregnancy (outcomes). The following potential covariates were assessed for their association with maternal behaviors before and during pregnancy: state, maternal age (≤19, 20-24, 25-29, 30-34, or ≥35 years old), race/ethnicity (non-Hispanic white, non-Hispanic black, non-Hispanic Asian, non-Hispanic other, Hispanic), maternal education (<12, 12, or ≥12 years), household income (<$25,000, $25,000-34,999, $35,000-49,999, ≥$50,000), marital status (married, unmarried), parity (0, ≥1), prepregnancy insurance status (Medicaid, private, none, other), prepregnancy maternal body mass index (<18.5, 18.5-24.9, 25-29.9, ≥30 kg/m ² ), adequacy of prenatal care determined by calculation of the Kotelchuck index (composite score that summarizes prenatal care based on the number and timing of prenatal visits), and pregnancy intention. Variables that were found to be significant at a probability value of ≤ .05 in the bivariate analysis with PCC or in the fully adjusted model were included in the final multivariate models. Data analyses were completed with survey procedures in SAS software (version 9.3; SAS Institute, Research Triangle Park, NC). This study was deemed exempt for review by the Nationwide Children’s Hospital Institutional Review Board.