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

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 PRAMS ⁹ 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 project ¹¹ 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).

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.

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.