Women's Awareness and Healthcare Provider Discussions About Zika Virus During Pregnancy, United States, 2016–2017

Letitia Williams; Denise V. D'Angelo; Brenda Bauman; Ada C. Dieke; Sascha R. Ellington; Carrie K. Shapiro-Mendoza; Shanna Cox; Philip Hastings; Holly Shulman; Leslie Harrison; Martha Kapaya; Wanda D. Barfield; Lee Warner


Emerging Infectious Diseases. 2020;26(5):998-1001. 

In This Article

The Study

The Pregnancy Risk Assessment Monitoring System (PRAMS) is a state-specific, population-based surveillance system implemented by the Centers for Disease Control and Prevention (CDC) and state and local health departments to collect information about experiences and behaviors before, during, and after pregnancy among women with a live birth. A stratified random sample is drawn from birth certificate records every month in each participating site. Women are surveyed by mail or telephone 2–6 months after a live birth. Data are weighted to account for the stratified sampling design and to adjust for differential nonresponse.[7] We analyzed PRAMS data from 16 US states and 1 city, referred to here as sites (Alabama, Connecticut, Florida, Illinois, Maryland, Massachusetts, Missouri, New Jersey, New York, Pennsylvania, South Carolina, Tennessee, Vermont, Virginia, West Virginia, and Wisconsin, plus New York City), for women who gave birth during March 2016–February 2017.

CDC and participating sites developed supplemental questions on ZIKV in 2016,[8] which sites voluntarily included in their surveys. Once added to the survey, the questions were integrated into the regular PRAMS data collection system, including data processing and weighting, and were considered part of the annual dataset.

We calculated prevalence estimates and 95% CIs for 3 ZIKV-related outcomes during pregnancy, a subset of the information collected in the supplement: never having heard of ZIKV, talking to a healthcare provider about ZIKV, and having knowledge of ZIKV-related travel advisories during pregnancy. We examined these outcomes by maternal demographics, including age, race/ethnicity, education, marital status, source of payment for delivery, infant birth month, and state of residence.

We used multivariable logistic regression to assess the relationships between maternal demographics and each outcome using adjusted prevalence ratios (aPRs) and 95% CIs. We adjusted models for all demographics examined, along with factors likely to influence access to healthcare and exposure to information about ZIKV. We completed our analyses using SAS version 9.4 (https://www.sas.com) and SAS-callable SUDAAN 11.0 (https://www.rti.org) software to account for PRAMS complex survey design.

Of 12,845 women sampled from the 17 sites during the study period, 8,711 (68%) women responded. Among respondents, most women were 25–34 years of age (59.7%), were non-Hispanic white (56.9%), had more than a high school education (65.1%), were married (61.3%), and reported private insurance as a source of payment for delivery (55.8%) (data not shown). Overall, 8.8% of women had never heard of ZIKV during their recent pregnancy. These women were more likely to be <35 years of age, be non-Hispanic black or of other race, have a high school education or less, be unmarried, and report Medicaid as a source of payment for delivery than women who had heard of ZIKV (Appendix, https://wwwnc.cdc.gov/EID/article/26/5/19-0727-App1.pdf).

Focusing on the subgroup of women who had heard about ZIKV during their pregnancy, we found that more than half (58.8%) reported talking to a healthcare provider about ZIKV. Nearly two thirds (63.5%) reported that their provider initiated the conversation; the remaining third (36.4%) reported that they initiated the conversation themselves (Table 1). Compared with non-Hispanic white women, non-Hispanic black women were more likely to have talked with a healthcare provider about ZIKV (aPR 1.12, 95% CI 1.04–1.20), as were women who gave birth during September 2016–February 2017 compared with those who gave birth in earlier months (aPR 1.19, 95% CI 1.13–1.26). However, women with a high school education or less (aPR 0.91, 95% CI 0.84–0.97), women who were not married (aPR 0.92, 95% CI 0.85–0.98), and women reporting Medicaid (aPR 0.88, 95% CI 0.82–0.94) or no insurance (aPR 0.77, 95% CI 0.2–0.96) at delivery were less likely to have talked with their healthcare provider about ZIKV (Table 2).

Most (91.9%) women reported knowledge of CDC travel advisories to avoid areas affected by Zika while pregnant (Table 1). Respondents reporting other non-Hispanic race versus non-Hispanic white women were less likely to have knowledge of the travel advisories (aPR 0.92, 95% CI 0.89–0.96), as were those with a high school education or less compared with women with more than a high school education (aPR 0.94, 95% CI 0.92–0.97) (Table 2).

In the adjusted analysis, women ≤24 years old were more likely not to have heard of ZIKV compared with women ≥35 years old (aPR 1.77, 95% CI 1.28–2.44), as were non-Hispanic black women compared with non-Hispanic white women (aPR 1.86, 95% CI 1.46–2.37) and non-Hispanic women of other races compared with non-Hispanic white women (aPR 2.41, 95% CI 1.85–3.13). In contrast, Hispanic women were more likely to have heard of ZIKV. Women with a high school education or less, women whose deliveries were paid for by Medicaid, and those who were uninsured at delivery were less likely to have heard of ZIKV compared with their counterparts with more than a high school education and private health insurance (Table 2).