Women’s Awareness and Healthcare Provider Discussions about Zika Virus during Pregnancy, United States, 2016–2017

We surveyed women with a recent live birth who resided in 16 US states and 1 city during the 2016 Zika outbreak. We found high awareness about the risk of Zika virus infection during pregnancy and about advisories to avoid travel to affected areas but moderate levels of discussions with healthcare providers.

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).

Conclusions
These findings highlight interactions between pregnant women and their healthcare providers in 17 sites during the height of the 2016 Zika outbreak. Awareness of ZIKV was found to be high, as was awareness of CDC travel advisories to avoid 1000 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 26, No. 5, May 2020 travel to Zika-affected areas during pregnancy (both >90%). This awareness was likely obtained from multiple sources, given that only half of women who heard of ZIKV reported discussing it with their healthcare provider during pregnancy. Similar results have been reported in other studies (9,10). Even though awareness was high, disparities existed, related to the smaller proportion of Hispanic and non-Hispanic black women who reported initiating discussions with providers about ZIKV. These differences suggest the opportunity to promote patient advocacy so that patients of all backgrounds feel comfortable asking about key topics if they are not raised by the provider, especially in the case of public health threats. Our assessment is not without limitations. Data represent only women who recently gave birth to live infants in the 17 sites included in this analysis. Women seen in practices that conducted screening for travel history before a woman talked to her provider may not have reported counseling, especially if they were determined to be at low risk during the screening. Information is self-reported by the mother 2-6 months following the birth of her infant and may be subject to recall and social desirability bias.
PRAMS is the largest state-and populationbased surveillance system in the United States that samples women who delivered live infants. PRAMS was augmented to collect timely data regarding patient and provider interactions related to ZIKV. Information from this analysis can fill data gaps and address the need to understand interactions between pregnant women and their healthcare providers regarding ZIKV.