Ep. 88: PRAMS for Dads – Empowering Fathers in Pregnancy Health

For decades, the Centers for Disease Control and Prevention (CDC) has partnered with state health departments to conduct the Pregnancy Risk Assessment Monitoring System (PRAMS). Aimed at new mothers, the PRAMS survey asks women to provide information about their health, attitudes, and experiences before, during, and shortly after pregnancy.

By the mid-twenty-teens, however, it was realized that surveying new fathers could also provide valuable insights and information about the health of both their newborn children and their partners. This led to the launch of a pilot PRAMS for Dads survey in Georgia. PRAMS for Dads is now in five states and growing, providing valuable public health data that informs public education, programming, outreach and policy development. We talked with two leaders of the PRAMS for Dads movement about its origins, growth and integration with PRAMS, which provides a clearer picture of the health of families across the U.S.

Guests:
Craig Garfield, MD, Professor of Pediatrics at Northwestern University and Attending Pediatrician, Ann & Robert H. Lurie Children's Hospital of Chicago

Clarissa Simon, MD, PhD, Research Scientist, Ann & Robert H. Lurie Children's Hospital of Chicago

Carol Vassar, producer/host

Views expressed by guests do not necessarily reflect the views of the host or management.

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Transcript

Carol Vassar, podcast host/producer:

Welcome to Well Beyond Medicine, the Nemours Children's Health podcast. Each week we'll explore anything and everything related to the 80% of child health impacts that occur outside the doctor's office. I'm your host, Carol Vassar, and now that you're here, let's go.

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Carol Vassar, podcast host/producer:

More than 35 years ago, the Center for Disease Control and Prevention, partnering with state health departments across the nation, launched the Pregnancy Risk Assessment Monitoring System, or PRAMS. Its primary purpose then as now is to collect state-specific population-based data on maternal health, attitudes and experiences before, during, and shortly after pregnancy. Once validated, that data can be used to improve the health of mothers and babies all over the nation through education, programming, outreach, and policy development.

By the 20-teens, though, there was a realization that perhaps there was a missing piece in the PRAMS puzzle: dads. After all, an article co-authored by today's guests and published in the American Journal of Public Health in 2018 states that, and I quote, "Paternal involvement with a baby is strongly associated with better prenatal and postnatal maternal health and with improved developmental outcomes for children." That article talks about a pilot project launched in Georgia called PRAMS for Dads. Joining me to discuss PRAMS for Dads today are Dr. Craig Garfield, professor of pediatrics at Northwestern University, and an attending pediatrician at Lurie Children's Hospital in Chicago. And Dr. Clarissa Simon, a research scientist at Lurie Children's. Our conversation begins with a closer look at the original PRAMS survey. Here's Dr. Craig Garfield.

Dr. Craig Garfield, Ann & Robert H. Lurie Children’s Hospital of Chicago:

The Pregnancy Risk Assessment Monitoring System, or PRAMS, that CDC has been fielding for over 35 years, gives us outstanding data on what's happening for mothers in the perinatal period. So, the time from pregnancy through to the first year of life gives us really great data on mom's access to healthcare. Did they get to see a practitioner in the first trimester? How did their pregnancy go? What happened around the delivery time period? What happened in the post-delivery or the postnatal period? So, how is mom's mental health, physical health, how is breastfeeding going? What are their safe sleep behaviors? Really, really important and essential information when we want to understand the health and well-being of a new baby and of that mother. And the basis for, it is probably the gold standard for that perinatal period, understanding the health of mothers and children.

It's technically a cross-sectional sample of the PRAMS states, which, at the end of the day, when they do the statistical magic in the background, represents about 81% of births across the United States and many of the territories as well. And it is a random sample, so anyone giving birth in Connecticut, for example, those moms get randomized to be selected from the birth certificate to receive the survey. And the survey for maternal PRAMS is given by mail and by phone, and then all of that information is collected every month as a new sample, and they collect that all through the year. And then, they are able to not only look within a state but compare different states to other states and look over time as well at the results in the PRAMS study.

Carol Vassar, podcast host/producer:

And that's yielded gobs and gobs of information that you can bring forward and really help to make sure they're as healthy as possible, I'm assuming?

Dr. Craig Garfield, Lurie Children's Hospital:

Exactly, and it gives us really good information. Even like, are moms exposed to secondhand smoke? Are moms using any substances? Things that are any kind of key public health initiative. Breastfeeding safely, access to healthcare, mental health, physical health, all of those things are included in the PRAMS survey.

Carol Vassar, podcast host/producer:

And dad's addition to this is relatively recent, it's 2018, I believe. Clarissa, tell me about how this all came about, that dads were finally included in their own study under PRAMS for Dads.

Dr. Clarissa Simon, Ann & Robert H. Lurie Children’s Hospital of Chicago:
 
So we began working actually, directly with CDC and the Georgia Department of Public Health in 2018 and 2019 to field PRAMS for Dads. We worked with them to develop a survey aimed at better understanding fathers' experiences during the perinatal periods around the time of the birth of a child. And the data that we collect is from fathers who are paired with mothers who are already being sampled for PRAMS. So we're able to link the data reported by mothers and fathers in the same family and then connect that to infant birth certificate information. So, to really get a full picture of a family and what's going on with the family during the time around the birth of a child. So we're able to collect very similar public health information, so information on breastfeeding, safe sleep, information on access to healthcare, paternal leave, which is a really hot button issue right now, workplace leave, and really look at what's going on not only with fathers during this time, but again, connect it to what's going on with mothers.

Carol Vassar, podcast host/producer:

And Dr. Garfield, you became involved pretty much at the beginning. Weren't you a new dad at the time?

Dr. Craig Garfield, Ann & Robert H. Lurie Children’s Hospital of Chicago:
 
I was a newer dad. My children are obviously older now, but I became involved when the CDC approached us to say we wanted to ask you some questions because of the work that you're doing with fathers right now, where we had been trying to figure out what the role of fathers were. There seemed to be a shift in not only society's expectations of dads and their involvement with their families, but dads themselves seemed like they wanted to be more involved and in different ways than maybe their father or their grandfather was.

And so what was happening on the maternal PRAMS surveys was that mothers were writing in the margins of the surveys with their pen and paper, why is the only question that you asked me about my partner was, did my partner hit, kick, beat or slap me during pregnancy? And then, they went on to write that the only way that they made it through the pregnancy was with the help and support of their partner. And so, CDC recognized that they were really missing a key voice here in the well-being of not only the baby but also the mother when they weren't asking questions around what the role of the partner is and how they might support the partner.

Carol Vassar, podcast host/producer:

Well, let's talk about the importance of talking to dads who seem to now want to be more involved than in previous generations, and why it's important to look at their health and how they feel in that period when their partner is pregnant and when their partner has given birth and the child is home. How does that influence the health of a child?

Dr. Craig Garfield, Ann & Robert H. Lurie Children’s Hospital of Chicago:
 
Yeah, it's a really great question. Traditionally, our model has been that this is a mother and an infant, and that's what we call the dyad, the mom and the baby, that's all we want to ask about, that's all we really care about or think about. Even in pediatrics, we often tailor most of our conversations, and I was as much at fault of this as a younger physician, of having a family come in and asking questions specifically about how's breastfeeding going. How's the baby sleeping? How are they pooping? Blah, blah, blah, and really ignoring the other partner, whether it's a dad or same-sex couple, I'm really focusing on the mom and checking on breastfeeding and all those sorts of things like that.

When we actually started to do some interviews with kind of low-income dads, if you saw them on the street, you'd kind of be worried about who this guy was. People who we have our own stereotypes about, and we asked them, what did having a baby do for you, in terms of your health and your wellbeing? And they told us that it actually made them start to think about how to do things different. They wanted to be there, and by being there, that meant to be there when they graduated kindergarten, be there when they graduated high school when their child graduated high school, and be there for their child. And that made them then think about making different choices in what they were doing and how they were living their lives. And so we actually wrote that up in a paper exploring, what is it that having a child does for men's expectations about them and their life.

So, when you look at men's life expectancy compared to women in 1920, there was one gap between women and men: women living longer than men. Now, it's almost six years, where women outlive men by about six years. So when you think about, what are the levers for change in the health of a man as they're going through their lifespan? Having a child is one of those big levers, and we don't really capitalize that in pediatrics, it's not really where our training is. And in healthcare, more generally, men are the least likely to have a doctor, a primary care doctor, and to be involved in the healthcare system, even with the advent of the Affordable Care Act, which did bring in a lot of younger men into the healthcare system. They still really run quite far behind that of women. And that becomes important, Carol, when you start thinking about the health and well-being of a father and how that can impact the relationship with the baby and the relationship with the mom. When you're looking at the physical health or the mental health or, as Clarissa mentioned, the use of leave, how does that help dads feel comfortable and confident in taking care of their babies from the very beginning, and there's really good research that shows that if dads are involved early, they're more likely to be involved later on too, regardless of marital status.

Carol Vassar, podcast host/producer:

So it's been six years. What have you found thus far, Clarissa?

Dr. Clarissa Simon, Ann & Robert H. Lurie Children’s Hospital of Chicago:
 
Well, we've been able to work with a number of additional states since that time, which has been very exciting, so we're learning as we go. But in terms of the Georgia pilot, we've looked at a number of different factors. So, one thing that we found was that fathers who are supportive of breastfeeding, their babies are more likely to breastfeed for longer. So that's a very actionable outcome, that we can see where fathers can provide the social support to actually improve health for infants.

We were also able to link, like I said earlier, our PRAMS for Dads' data with our PRAMS data, and we found that mother's depressive symptoms are associated with father's healthcare interaction. So we can also see, when we're talking about infant health, we can connect that to maternal health while paternal health can also influence those factors as well. So those are some of the things that we found.

We also looked at the overall prevalence of a lot of these factors. So we see that about half of fathers don't have a primary care physician. They don't often go to the doctor. I, myself, am a mother, I see the doctor all the time. When I had my kids, I was going in all the time. My husband, sometimes he came with me and sometimes he didn't. So it's really an interesting kind of snapshot of what's going on with fathers. We found that 10% of fathers endorsed depressive symptoms, about 70% were overweight or had obesity. So again, a lot of the same factors that are being collected on mothers, we also were able to look at for fathers.

Carol Vassar, podcast host/producer:

I'm curious: how did you find the dads? I think Dr. Garfield may have alluded to this earlier, but how did you find the dads? How did you find the dads and moms together to do the PRAMS studies?

Dr. Craig Garfield, Ann & Robert H. Lurie Children’s Hospital of Chicago:
 
So we mirror the successful PRAMS survey done from the CDC, and what we do is we take those moms that have already been randomized at the state level. So, out of everybody that gave birth that month, they did a random selection, which is probably the best way, from a research point of view, to get really reliable data. We took those moms, and we then sent the survey to their partners. We had to work really hard to figure out how to get unmarried couples.

So, about 60% of births in the country right now across the whole country are to married couples, and 40% are to unmarried couples. So if you're married, on the birth certificate, mom's information and dad's information in terms of mailing a survey out to them or contacting them, is considered the same. If you're unmarried, there's another step that the partner has to take, that the dad has to take, and that's filling out the acknowledgment of parenting or acknowledgment of paternity; it's called different things in different states. And what we found in this process is that we really don't have very good data for the non-birth partner when it comes to reaching out from a public health perspective. So that was one big learning from our initial pilot.

Interestingly, different states do different things. So, for example, in Massachusetts, where we now have fielded a survey, they mark off what the gender of the non-birth parent is. So we're actually able to send to those that are fathers and males, we're able to send one survey and those that might be in the same-sex couple, and it's another female, we can actually be as inclusive as possible because we want to learn from our past behaviors and be as inclusive as possible. So you learn a lot from trying to reach out to these different populations, and what we now are seeing in the five states that we're in, we're in Ohio, Michigan, North Dakota, Massachusetts, and Georgia, is that the birth certificate collects different information and we have to dive a little bit deeper into each of those different birth certificates to get good information for the dad to reach out to them for the survey.

Carol Vassar, podcast host/producer:

Now, PRAMS for moms is nationwide, is it not?

Dr. Craig Garfield, Ann & Robert H. Lurie Children’s Hospital of Chicago:

Correct.

Carol Vassar, podcast host/producer:

And PRAMS for Dads is in just five states. What is the possibility that we're going to see this in more states soon?

Dr. Craig Garfield, Ann & Robert H. Lurie Children’s Hospital of Chicago:

Well, anyone who's listening who is interested, please reach out to us. Clarissa and I have probably talked to 35 different states and jurisdictions about this project. Every single one of them is excited and recognizes the gap in the public health information that we have for fathers and partners and wants to do it. In addition to Ohio, Massachusetts, North Dakota, Georgia, Michigan, and New Jersey, it has now signed on board, and we're looking at hopefully getting Wisconsin and Maine by the end of this year as well.

As I said, all of the states understand the value of it and see the value of it. What they're missing are the resources. So we do not, like Maternal PRAMS, which is funded by the CDC, have any funding or support from the CDC to do anything beyond the actual pilot that we did with Georgia. So, every state has had to find a way to find the resources. That might come from a public-private partnership where a foundation says, we really want this information for our state. So that happened in Michigan with the Steelcase Foundation and the Kresge Foundation. They said, we want to know this about Kent County and we want to know this about Detroit, so we're fielding surveys there. That's what's happened in New Jersey, with the Burke Foundation stepping in to help with that. So that's one model. The other model is the state finds funding internally. So that's happened in North Dakota. New Jersey will follow up with more funding internally as well, from within the state.

And Clarissa and I are working really hard to even get the feds involved. So right before Father's Day, I was in DC, invited by representative Jimmy Gomez, who's the Founder of the Congressional Dads Caucus in the House, and he's a representative from California who you may recall, he brought his son Hodge onto the floor for a vote. He had him in a baby carrier, walked on the floor because he didn't have anyone to take care of his kid, and voted as many of us have, right? We've had our kids at work with us. It just happened to be his was on the floor of the Capitol, and he really recognizes the value of that. So he's pushing strongly on the federal levelers to try and get funding, as our really great colleagues from the Illinois delegation as well. Representative Kelly and Underwood, who both do wonderful work looking at black maternal health and wellbeing, are very instrumental. The Mamas Caucus at the House is also very supportive of this work, too.

So we're trying every angle we can because we recognized we can't wait 37 more years to get this data on fathers, if you really want to take the best care of our families and of our children.

Carol Vassar, podcast host/producer:

As you look at the states that you're working with now and the states you're about to be working at, the information that you have gleaned and you have made certain that it is accurate, can that be used in some way, shape, or form to help narrow health disparities?

Dr. Clarissa Simon, Ann & Robert H. Lurie Children’s Hospital of Chicago:

Yes, definitely. So one benefit of PRAMS is that the data that they collect is state representative. So, we use weighting, which is a way to approximate a sample to a population. So when we reach out to a certain group of fathers, we get the respondents that we get, but we are able to utilize statistical techniques so that it actually represents the entire state. And so what we want to do is to look at those inequities that we see. So are differences in, for example, how black fathers respond versus white fathers? Are there differences by income? What else do we find where we can look at those subgroups of fathers to try to reach them?

We found a lot of really interesting... When we're looking at workplace leave, we see that fathers who take longer leave are more likely to have paid leave, for example. So, one thing we know is that workplace leave for mothers and fathers in this country is not adequate, and for fathers, it's even less adequate. They don't take a lot of leave, but we know that that benefits children. So we would ideally like to, the data helps inform everything else, but if the data doesn't exist, then we can't really say anything population about it. So, there's amazing programs that we learn about in every state, community-based programming to try to reach fathers at risk, recently incarcerated fathers, low-income fathers, but they don't have the data to really inform what's going on during the perinatal period. There is no monitoring for fathers during that time, and so if we're able to collect the data, that can help inform the programming and inform the policy so that we can better reach fathers and better reduce health inequities and other health challenges in subgroups of dads and families.

Dr. Craig Garfield, Ann & Robert H. Lurie Children’s Hospital of Chicago:

I was just going to say I think what we realize after doing this for ten years is that what we don't measure, we don't know, and what gets measured gets managed. So when you have data like we've had for moms for 37 years, you can keep track of what's happening for mothers in the perinatal space. We have nothing, no equivalency for fathers, yet we recognize how important they are in their families. And the desire not only for the father to be involved, but for us within the healthcare system to think about how to ensure the best outcomes for children. And without that, a line of sight on the health and wellbeing of the father, we really are missing a key player in this whole team.

Carol Vassar, podcast host/producer:

What would you say, there are policymakers listening, public health leaders, healthcare leaders listening today and regular folk, what would you say to them about PRAMS for Dads that perhaps we haven't talked about as of yet?

Dr. Craig Garfield, Ann & Robert H. Lurie Children’s Hospital of Chicago:

I think the message is really, very simple. If we care about families and we care holistically about families and about children, regardless of your political views, regardless of what type of family you are, we need to be understanding from the very beginning how those families are set up for their health and wellbeing. And what PRAMS for Dads does in a very inclusive way is think about the family holistically. So, if someone is listening and says, gosh, does our state collect this information? How could we start to collect this information? We have a solution, we are ready to go. We offer the survey online, via mail and via the phone, and we are ready to implement it at whatever state level or even whatever region or county wants to do it. And that information helps inform our better decisions and our better policies.

Carol Vassar, podcast host/producer:

And programs that ultimately lead to the better health of children overall.

Dr. Craig Garfield, Ann & Robert H. Lurie Children’s Hospital of Chicago:

Exactly.

Carol Vassar, podcast host/producer:

Where do you want to see PRAMS for Dads in five years, ten years, Clarissa?

Dr. Clarissa Simon, Ann & Robert H. Lurie Children’s Hospital of Chicago:
 
Well, we've talked a lot about 30 by 30. So, ideally, we would like to have 30 states or jurisdictions by 2030, and that would be the goal. We'd love to just have more states join on and get this really important population representative public health monitoring of fathers to really better inform maternal and child health, father health, family health, and just overall public health to improve the lives of families.

Dr. Craig Garfield, Ann & Robert H. Lurie Children’s Hospital of Chicago:

I would echo the same thing. We have waited this long to get this information, we have a way to collect this information. We are lacking in the financial resources to do that, and as a country as gifted and committed to families as our country is, it seems that it should be an easy lift to reach our 30 by 30 goal. Our door's open, for those that care about fathers and families and children, we are always happy to talk with folks.

We actually just put out our website, which is if you look at the Family and Child Health Innovations Program or FCHIP, at Lurie Children's Hospital. We just in time for Father's Day, put a new little button on there that you can click for a dad's consult because that actually was what was happening clinically for me, where people would say, hey, I have this issue with this particular dad in this particular family. Can we do a dad's consult? And I would either talk with the provider or go and talk with the dad to see what's going on what are the issues. Oftentimes, I work a lot in a neonatal intensive care unit, so often, those dads are very scared, and for dads when they come across as scared, they can actually come across as being angry. So I would talk with a lot of dads and things.

I realize that that happens in research, too. We've had a number of people ask us questions: how can I improve reaching out to dads? What am I doing wrong? I want to reach dads, and we're not getting the response we wanted. So we actually put a little button on our website as FCHIP, that then asks you to fill out a very simple form. What are you after? That can be useful for people who are interested in either doing PRAMS for Dads, thinking about serving fathers in a different way, or just generally want to be more involved and more engaged with the fathers that they take care of.

Carol Vassar, podcast host/producer:

Dr. Craig Garfield is a professor of pediatrics at Northwestern University and an attending pediatrician at Lurie Children's Hospital in Chicago. He was joined in conversation by his colleague, Dr. Clarissa Simon, a research scientist at Lurie Children's.

Learn more about PRAMS for Dads and the dads consult using the link in the show notes for this

Music:

Well Beyond Medicine.

Carol Vassar, podcast host/producer:

Thanks to both Craig Garfield and Clarissa Simon for joining us today, and thanks to you, as always, for listening. Did you know that you can leave us a voicemail with your podcast feedback and episode topic suggestions? Just go to the Nemourswellbeyond.org website and hit the red button in the upper right-hand corner to leave your message. That's Nemourswellbeyond.org.

Production assistance for this episode is courtesy of Che Parker, Cheryl Munn, Susan Masucci, and Lauren Teta, and we thank them all. I'm Carol Vassar, until next time, remember, we can change children's health for good, Well Beyond Medicine.

Music:

Let's go, oh, oh, Well Beyond Medicine.