Pregnant, postpartum, and lactating people, and infants have unique needs during public health emergencies, including nuclear and radiological incidents. This report provides information on the CDC Division of Reproductive Health's emergency preparedness and response activities to address the needs of women of reproductive age (aged 15-49 years), people who are pregnant, postpartum, or lactating, and infants during a radiation emergency. Highlighted preparedness activities include: (1) development of a quick reference guide to inform key questions about pregnant, postpartum, and lactating people, and infants during radiation emergencies; and (2) exercising the role of reproductive health experts during nuclear and radiological incident preparedness activities.

Objectives This study examines emergency preparedness behaviors among women with a recent live birth in Hawaii.Methods Using the 2016 Hawaii Pregnancy Risk Assessment Monitoring Survey we estimated weighted prevalence of eight preparedness behaviors.Results Among 1010 respondents (weighted response rate=56.3%), 79.3% reported at least one preparedness behavior and 11.2% performed all eight behaviors. The prevalence of women with a recent live birth in Hawaii reporting preparedness behaviors includes: 63.0% (95% CI: 58.7-67.1%) having enough supplies at home for at least seven days, 41.3% (95% CI: 37.1-45.6%) having an evacuation plan for their child(ren), 38.7% (95% CI: 34.5, 43.0) having methods to keep in touch, 37.8% (95% CI: 33.7, 42.1) having an emergency meeting place, 36.6% (95% CI: 32.6, 40.9) having an evacuation plan to leave home, 34.9% (95% CI: 30.9, 39.2) having emergencies supplies to take with if they have to leave quickly, 31.8% (95% CI: 27.9, 36.0) having copies of important documents, 31.6% (95% CI: 27.7, 35.8) having practiced what to do.Conclusion One in ten women practiced all eight behaviors indicating more awareness efforts are needed among this at-risk population in Hawaii. Hawaii can measure the effect of interventions to increase preparedness by tracking this question over time.“What is already known on this subject?”Preparedness is associated with reduced vulnerability, and postpartum women are considered an at-risk population in the post-disaster period with special clinical needs. One prior study has assessed disaster preparedness among postpartum women.“What this study adds?”This is the first study to describe a methodology to analyze the eight-part PRAMS emergency preparedness question. Among recently postpartum women in Hawaii, about 80% practiced at least one of eight emergency preparedness measures assessed and about 10% practiced all behaviors.Competing Interest StatementThe authors have declared no competing interest.Funding StatementCDC provides annual funding to participating PRAMS sites through a cooperative agreement.Author DeclarationsI confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.YesThe details of the IRB/oversight body that provided approval or exemption for the research described are given below:Ethics approval PRAMS protocol has been reviewed and approved by Centers for Disease Control and Preventions Institutional Review Board and approved as human subjects research (HSR #2233). Consent to participate All survey respondents provided verbal consent via phone or implied consent by returning a completed questionnaire. All necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived.YesI understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).Yes I have followed all appropriate research reporting guidelines and uploaded the relevant EQUATOR Network research reporting checklist(s) and other pertinent material as supplementary files, if applicable.Yes

This report provides historical context and rationale for coordinated, systematic, and evidence-based public health emergency preparedness and response (EPR) activities to address the needs of women of reproductive age. Needs of pregnant and postpartum women, and infants-before, during, and after public health emergencies-are highlighted. Four focus areas and related activities are described: (1) public health science; (2) clinical guidance; (3) partnerships, communication, and outreach; and (4) workforce development. Finally, the report summarizes major activities of the Division of Reproductive Health's EPR Team at the Centers for Disease Control and Prevention.

OBJECTIVE: The aim of this study was to examine emergency preparedness behaviors among women with a recent live birth in Hawaii. METHODS: Using the 2016 Hawaii Pregnancy Risk Assessment Monitoring System, we estimated weighted prevalence of 8 preparedness behaviors. RESULTS: Among 1010 respondents (weighted response rate, 56.3%), 79.3% reported at least 1 preparedness behavior, and 11.2% performed all 8 behaviors. The prevalence of women with a recent live birth in Hawaii reporting preparedness behaviors includes: 63.0% (95% CI: 58.7-67.1%) having enough supplies at home for at least 7 days, 41.3% (95% CI: 37.1-45.6%) having an evacuation plan for their child(ren), 38.7% (95% CI: 34.5-43.0%) having methods to keep in touch, 37.8% (95% CI: 33.7-42.1%) having an emergency meeting place, 36.6% (95% CI: 32.6-40.9%) having an evacuation plan to leave home, 34.9% (95% CI: 30.9-39.2%) having emergency supplies to take with them if they have to leave quickly, 31.8% (95% CI: 27.9-36.0%) having copies of important documents, and 31.6% (95% CI: 27.7-35.8%) having practiced what to do during a disaster. CONCLUSIONS: One in 10 women practiced all 8 behaviors, indicating more awareness efforts are needed among this population in Hawaii. The impact of preparedness interventions implemented in Hawaii can be tracked with this question over time.

Previous outbreaks suggest that pregnant women with Ebola virus disease (EVD) are at increased risk for severe disease and death. Healthcare workers who treat pregnant women with EVD are at increased risk of body fluid exposure. Despite the absence of pregnant women with EVD in the United States, CDC activated the Maternal Health Team (MHT), a functional unit dedicated to emergency preparedness and response issues, on October 18, 2014. We describe major activities of the MHT. A high-priority MHT activity was to publish guiding principles early in the response. The MHT also prepared guidance documents, provided guidance and technical support for hospital preparedness, and addressed inquiries. We analyzed maternal health inquiries received through CDC-INFO, MHT, and CDC's Medical Investigations Team from August 2014 to December 2015. Internal call logs used to capture, monitor, and track inquiries for the three data sources were merged. Inquiries not related to maternal health issues and duplicates were removed. Each inquiry was categorized by route (email/phone), inquirer type, and topic. In total, 201 inquiries were received from clinicians, public health professionals, and the public. The predominant topic was related to infection control for high-risk situations such as labor and delivery. During the Ebola response, most inquiries were received via email rather than telephone, a notable shift compared to the H1N1 emergency response. Lessons learned during the H1N1 and Ebola responses are currently informing CDC's Zika Response, an unprecedented emergency response primarily focused on reproductive health issues.

In an emergency, the needs of women of reproductive age, particularly pregnant and postpartum women, introduce unique challenges for public health and clinical care. Incorporating reproductive health issues and considerations into emergency preparedness and response is a relatively new field. In recent years, several resources and tools specific to reproductive health have been developed. However, there is still a need for training about the effects of emergencies on women of reproductive age. In an effort to train medical and public health professionals about these topics, the CDC Division of Reproductive Health developed Reproductive Health in Emergency Preparedness and Response, an online course that is available across the United States.

This study describes the prevalence and correlates of past-year intimate partner violence (IPV) among displaced women. We used bivariate and multivariate analyses to assess the relationships between IPV and select variables of interest. Multivariate logistic regression modeling revealed that women who had experienced outsider violence were 11 times as likely (adjusted odds ratio [AOR] = 11.21; confidence interval, CI [5.25, 23.96]) to have reported IPV than women who had not experienced outsider violence. IPV in conflict-affected settings is a major public health concern that requires effective interventions; our results suggest that women who had experienced outsider violence are at greater risk of IPV.

United States (U.S.) pregnant and postpartum (P/PP) women and their infants may be particularly vulnerable to effects from disasters. In an effort to guide post-disaster assessment and surveillance, we initiated a collaborative process with nationwide expert partners to identify post-disaster epidemiologic indicators for these at-risk groups. This 12 month process began with conversations with partners at two national conferences to identify critical topics for P/PP women and infants affected by disaster. Next we hosted teleconferences with a 23 member Indicator Development Working Group (IDWG) to review and prioritize the topics. We then divided the IDWG into three population subgroups (pregnant women, postpartum women, and infants) that conducted at least three teleconferences to discuss the proposed topics and identify/develop critical indicators, measures for each indicator, and relevant questions for each measure for their respective population subgroup. Lastly, we hosted a full IDWG teleconference to review and approve the indicators, measures, and questions. The final 25 indicators and measures with questions (available online) are organized by population subgroup: pregnant women (indicators = 9; measures = 24); postpartum women (indicators = 10; measures = 36); and infants (indicators = 6; measures = 30). We encourage our partners in disaster-affected areas to test these indicators and measures for relevancy and completeness. In post-disaster surveillance, we envision that users will not use all indicators and measures but will select ones appropriate for their setting. These proposed indicators and measures promote uniformity of measurement of disaster effects among U.S. P/PP women and their infants and assist public health practitioners to identify their post-disaster needs.

PURPOSE: Having an emergency plan may reduce negative effects of disaster on the health of postpartum women and their infants. However, little is known about the prevalence of emergency plans among postpartum women. In 2009, Arkansas added a question to the Pregnancy Risk Assessment Monitoring System surveillance system about whether women who gave birth that year had an emergency plan. In this study, we first describe the sociodemographic characteristics, disaster experience, and region of residence of postpartum women in Arkansas who indicated that they had an emergency plan for their families in 2009, and second, examine associations between sociodemographic characteristics and disaster experience and the presence of an emergency plan. METHODS: Multivariable logistic regression (n = 1,173) was conducted to examine associations between maternal race/ethnicity, sociodemographic characteristics, region of residence, disaster experience, and having a disaster plan. We adjusted for maternal education, federal poverty level, and family size in our final model. FINDINGS: Forty-eight percent (n = 559) of women reported having an emergency plan. Hispanic women were less likely to report having a plan compared with non-Hispanic White women (n = 102 [10%]; adjusted prevalence ratio [aPR], 0.6; 95% confidence interval [CI], 0.4-0.9). Families with five or more members were more likely to have a plan compared with smaller families (n = 123 [11%]; aPR, 1.3; 95% CI, 1.1-1.6). CONCLUSIONS: Policymakers and public health practitioners can use these results to promote emergency planning among postpartum women in Arkansas, with special outreach to postpartum women who are Hispanic or have smaller families.

OBJECTIVE: To review the safety and pharmacokinetics of antimicrobials recommended for anthrax postexposure prophylaxis and treatment in pregnant women. DATA SOURCES: Articles were identified in the PubMed database from inception through December 2012 by searching the keywords (["pregnancy]" and [generic antibiotic drug name]). Additionally, we searched clinicaltrials.gov and conducted hand searches of references from REPROTOX, TERIS, review articles, and Briggs' Drugs in Pregnancy and Lactation. METHODS OF STUDY SELECTION: Articles included in the review contain primary data related to the safety and pharmacokinetics among pregnant women of 14 antimicrobials recommended for anthrax postexposure prophylaxis and treatment (amoxicillin, ampicillin, chloramphenicol, clindamycin, ciprofloxacin, doripenem, doxycycline, levofloxacin, linezolid, meropenem, moxifloxacin, penicillin, rifampin, and vancomycin). TABULATION, INTEGRATION, AND RESULTS: The PubMed search identified 3,850 articles for review. Reference hand searching yielded nine additional articles. In total, 112 articles met the inclusion criteria. CONCLUSIONS: Overall, safety and pharmacokinetic information is limited for these antimicrobials. Although small increases in risks for certain anomalies have been observed with some antimicrobials recommended for prophylaxis and treatment of anthrax, the absolute risk of these antimicrobials appears low. Given the high morbidity and mortality associated with anthrax, antimicrobials should be dosed appropriately to ensure that antibiotic levels can be achieved and sustained. Dosing adjustments may be necessary for the beta-lactam antimicrobials and the fluoroquinolones to achieve therapeutic levels in pregnant women. Data indicate that the beta-lactam antimicrobials, the fluoroquinolones, and, to a lesser extent, clindamycin enter the fetal compartment, an important consideration in the treatment of anthrax, because these antimicrobials may provide additional fetal benefit in the second and third trimesters of pregnancy.

We examined methodological issues in studies of disaster-related effects on reproductive health outcomes and fertility among women of reproductive age and infants in the United States (US). We conducted a systematic literature review of 1,635 articles and reports published in peer-reviewed journals or by the government from January 1981 through December 2010. We classified the studies using three exposure types: (1) physical exposure to toxicants; (2) psychological trauma; and (3) general exposure to disaster. Fifteen articles met our inclusion criteria concerning research focus and design. Overall studies pertained to eight different disasters, with most (n = 6) focused on the World Trade Center attack. Only one study examined pregnancy loss, i.e., occurrence of spontaneous abortions post-disaster. Most studies focused on associations between disaster and adverse birth outcomes, but two studies pertained only to post-disaster fertility while another two examined it in addition to adverse birth outcomes. In most studies disaster-affected populations were assumed to have experienced psychological trauma, but exposure to trauma was measured in only four studies. Furthermore, effects of both physical exposure to toxicants and psychological trauma on disaster-affected populations were examined in only one study. Effects on birth outcomes were not consistently demonstrated, and study methodologies varied widely. Even so, these studies suggest an association between disasters and reproductive health and highlight the need for further studies to clarify associations. We postulate that post-disaster surveillance among pregnant women could improve our understanding of effects of disaster on the reproductive health of US pregnant women.

This article provides the evidence for contraceptive need to prevent unintended pregnancy during an emergency response, discusses the most appropriate types of contraceptives for disaster situations, and details the current provisions in place to provide contraceptives during an emergency response.

OBJECTIVE: To describe the worldwide experience of Bacillus anthracis infection reported in pregnant, postpartum, and lactating women. DATA SOURCES: Studies were identified through MEDLINE, Web of Science, Embase, and Global Health databases from inception until May 2012. The key words (["anthrax" or "anthracis"] and ["pregna*" or "matern*" or "postpartum" or "puerperal" or "lact*" or "breastfed*" or "breastfeed*" or "fetal" or "fetus" or "neonate" or "newborn" or "abort*" or "uterus"]) were used. Additionally, all references from selected articles were reviewed, hand searches were conducted, and relevant authors were contacted. METHODS OF STUDY SELECTION: The inclusion criteria were: published articles referring to women diagnosed with an infection due to exposure to B anthracis during pregnancy, the postpartum period, or during lactation; any article type reporting patient-specific data; articles in any language; and nonduplicate cases. Non-English articles were professionally translated. Duplicate reports, unpublished reports, and review articles depicting previously identified cases were excluded. TABULATION, INTEGRATION, AND RESULTS: Two authors independently reviewed articles for inclusion. The primary search of the four databases yielded 1,340 articles, and the secondary crossreference search revealed 146 articles. Fourteen articles met the inclusion criteria. In total, 20 cases of B anthracis infection were found, 17 in pregnant women, two in postpartum women, and one case in a lactating woman. Among these reports, 16 women died and 12 fetal or neonatal losses were reported. Of these fatal cases, most predated the advent of antibiotics. CONCLUSIONS: Based on these case reports, B anthracis infection in pregnant and postpartum women is associated with high rates of maternal and fetal death. Evidence of possible maternal-fetal transmission of B anthracis infection was identified in early case reports.

INTRODUCTION AND BACKGROUND: Women of reproductive age, in particular women who are pregnant or fewer than 6 months postpartum, are uniquely vulnerable to the effects of natural disasters, which may create stressors for caregivers, limit access to prenatal/postpartum care, or interrupt contraception. Traditional approaches (e.g., newborn records, community surveys) to survey women of reproductive age about unmet needs may not be practical after disasters. Finding pregnant or postpartum women is especially challenging because fewer than 5% of women of reproductive age are pregnant or postpartum at any time. METHODS: From 2009 to 2011, we conducted three pilots of a sampling strategy that aimed to increase the proportion of pregnant and postpartum women of reproductive age who were included in postdisaster reproductive health assessments in Johnston County, North Carolina, after tornadoes, Cobb/Douglas Counties, Georgia, after flooding, and Bertie County, North Carolina, after hurricane-related flooding. RESULTS: Using this method, the percentage of pregnant and postpartum women interviewed in each pilot increased from 0.06% to 21%, 8% to 19%, and 9% to 17%, respectively. CONCLUSION AND DISCUSSION: Two-stage cluster sampling with referral can be used to increase the proportion of pregnant and postpartum women included in a postdisaster assessment. This strategy may be a promising way to assess unmet needs of pregnant and postpartum women in disaster-affected communities.

The objective of the study is to identify racial disparities in prenatal care (PNC) utilization and to examine the relationship between PNC and preterm birth (PTB), low birth weight (LBW) and infant mortality in Mississippi. Retrospective cohort from 1996 to 2003 linked Mississippi birth and infant death files was used. Analysis was limited to live-born singleton infants born to non-Hispanic white and black women (n = 292,776). PNC was classified by Kotelchuck's Adequacy of Prenatal Care Utilization Index. Factors associated with PTB, LBW and infant death were identified using multiple logistic regression after controlling for maternal age, education, marital status, place of residence, tobacco use and medical risk. About one in five Mississippi women had less than adequate PNC, and racial disparities in PNC utilization were observed. Black women delayed PNC, received too few visits, and were more likely to have either "inadequate PNC" (P < 0.0001) or "no care" (P < 0.0001) compared to white women. Furthermore, among women with medical conditions, black women were twice as likely to receive inadequate PNC compared to white women. Regardless of race, "no care" and "inadequate PNC" were strong risk factors for PTB, LBW and infant death. We provide empirical evidence to support the existence of racial disparities in PNC utilization and infant birth outcomes in Mississippi. Further study is needed to explain racial differences in PNC utilization. However, this study suggests that public health interventions designed to improve PNC utilization among women might reduce unfavorable birth outcomes especially infant mortality.

This article reviews associations between disaster and the reproductive health of women, describes how Hurricane Katrina influenced our understanding about postdisaster reproductive health needs, and introduces a new toolkit that can help health departments assess postdisaster health needs among women of reproductive age.

We sought to describe characteristics of hospitalized reproductive-aged (15-44 years) women with seasonal (2005/2006 through 2008/2009) and 2009 pandemic influenza A (H1N1) virus infection. We used population-based data from the Emerging Infections Program in 10 US states, and compared characteristics of pregnant (n = 150) and nonpregnant (n = 489) seasonal, and pregnant (n = 489) and nonpregnant (n = 1088) pandemic influenza cases using chi(2) and Fisher's exact tests. Pregnant women represented 23.5% and 31.0% of all reproductive-aged women hospitalized for seasonal and pandemic influenza, respectively. Significantly more nonpregnant than pregnant women with seasonal (71.2% vs 36.0%) and pandemic (69.7% vs 31.9%) influenza had an underlying medical condition other than pregnancy. Antiviral treatment was significantly more common with pandemic than seasonal influenza for both pregnant (86.5% vs 24.0%) and nonpregnant (82.0% vs 55.2%) women. Pregnant women comprised a significant proportion of influenza-hospitalized reproductive-aged women, underscoring the importance of influenza vaccination during pregnancy.

CONTEXT: This article describes results of a process evaluation of a cooperative agreement between the Centers for Disease Control and Prevention's Division of Reproductive Health and 10 regional training centers to increase the number of reproductive health (RH) settings that integrate human immunodeficiency virus (HIV) prevention services at an appropriate level into routine care. OBJECTIVE: Our goal was to learn about the process of integrating HIV prevention into RH settings. DESIGN: We conducted a retrospective evaluation, using qualitative methods. SETTING: The clinics were from 10 US Department of Health and Human Services regions. PARTICIPANTS: We interviewed 16 key informants from 10 selected model clinics. MAIN OUTCOME MEASURES: The main outcome was organization change. RESULTS: The most common obstacles to integration were staff issues, logistics barriers, inadequate clinic structure to support integration, and staff training barriers. Using the transtheoretical model (TTM) applied to organizations, we documented organizational change as informants described their clinics' progression to integration and overcoming obstacles. All model clinics began in the contemplation stage of transtheoretical model. Every clinic exhibited at least 1 process of change for every stage. In the contemplation stage, most informants discussed fears about not changing, stated that the integration was consistent with the agency's mission, and described thinking about commitment to the change. In the preparation stage, all informants described building teams that supported integration of HIV prevention. During the action stage, informants talked about assessments of facilities, staff and protocols, commitments through grants or agreements, and then using training to support new behaviors and adopting new cognitions. In the maintenance stage, all reported changing policies, procedures, or protocols, most promoted helping relationships among the staff, and nearly all reported rewards for the new ways of working. CONCLUSIONS: RH settings were able to integrate HIV prevention services by employing a systematic process.

To document changes in birth rates, birth outcomes, and pregnancy risk factors among women giving birth after the 1997 Red River flood in North Dakota. We analyzed detailed county-level birth files pre-disaster (1994-1996) and post-disaster (1997-2000) in North Dakota. Crude birth rates and adjusted fertility rates were calculated. The demographic and pregnancy risk factors were described among women delivering singleton births. Logistic regression was conducted to examine associations between the disaster and low birth weight (<2,500 g), preterm birth (<37 weeks), and small for gestational age infants adjusting for confounders. The crude birth rate and direct-adjusted fertility rate decreased significantly after the disaster in North Dakota. The proportion of women giving birth who were older, non-white, unmarried, and had a higher education increased. Compared to pre-disaster, there were significant increases in the following maternal measures after the disaster: any medical risks (5.1-7.1%), anemia (0.7-1.1%), acute or chronic lung disease (0.4-0.5%), eclampsia (0.3-2.1%), and uterine bleeding (0.3-0.4%). In addition, there was a significant increase in births that were low birth weight (OR 1.11, 95% CI 1.03-1.21) and preterm (OR 1.09, 95% CI 1.03-1.16) after adjusting for maternal characteristics and smoking. Following the flood, there was an increase in medical risks, low birth weight, and preterm delivery among women giving birth in North Dakota. Further research that examines birth outcomes of women following a catastrophic disaster is warranted.