Every birth in Virginia produces a record. The record is precise. It is also incomplete.

A birth certificate can show how much a newborn weighed, whether the child arrived early and how often the mother received prenatal care. It cannot show whether she felt safe at home, experienced discrimination, had support after delivery or could obtain the care she needed. Yet those experiences may help explain why some mothers and babies fare better than others.

Virginia has one way to obtain that information: ask the mothers themselves. Each month, about 150 women are selected for the Pregnancy Risk Assessment Monitoring System, a national surveillance project conducted by the Centers for Disease Control and Prevention and state health departments. Once selected, a mother cannot be replaced. If she does not answer, her experience is absent from the evidence used to shape maternal health programs and policy.

The job of collecting those answers now belongs to the Center for Public Policy’s Survey and Evaluation Research Laboratory at the L. Douglas Wilder School of Government and Public Affairs. Through a new partnership with the Virginia Department of Health, SERL manages the commonwealth’s PRAMS data collection and helps preserve Virginia’s contribution to the only national surveillance system that produces state-level information about mothers’ experiences before, during and shortly after pregnancy.

The work requires technical expertise. It also requires trust. Busy new mothers must be persuaded to open an unfamiliar envelope, answer an unknown caller and share private details of their lives. VDH leaders believe Virginia Commonwealth University’s name and SERL’s local presence may help reassure them that the request is legitimate and that their answers matter.

“It is the only source of data that really gets into the experiences of moms,” said Kenesha Smith Barber, MSPH, Virginia PRAMS coordinator and epidemiologist at VDH. “There’s really no other source of data that has that information.”

The CDC and state health departments created PRAMS in 1987. Virginia joined in 2006, with SERL assisting during the pilot phase before VDH brought data collection in-house. Nearly two decades later, the department returned to SERL for the capacity and expertise needed to sustain the work.

Preparation took close to a year. SERL trained interviewers, readied student staff and built systems that meet federal standards. Outreach begins with a letter and a link to complete the survey online. Paper questionnaires in English and Spanish, reminders and telephone calls follow. Undergraduate and graduate students, recent alumni and a Wilder Fellow are among those helping administer the survey.

For Candace Price-Stafford, senior research specialist and PRAMS project manager at SERL, the partnership also marks a return to maternal and child health research. Earlier in her career, she helped evaluate Richmond Healthy Start, an initiative that used case management and other services to reduce infant mortality in the city. PRAMS places her earlier in the chain, helping produce the evidence that allows programs to identify where help is needed.

Once SERL securely transfers the completed responses to VDH, personal experiences become public health data. The department connects the answers with birth certificate records and analyzes the findings across race, income, geography and insurance status. Virginia’s results also become part of the CDC’s national PRAMS data, allowing researchers to compare maternal experiences and birth outcomes across participating states and jurisdictions.

The mothers who answered may never see what happens next. VDH uses PRAMS findings in Virginia’s State Health Assessment and State Health Improvement Plan. Researchers examine relationships between mothers’ experiences and health outcomes. State programs and local health districts use the data to pursue funding, redirect services and identify communities whose needs may not be met.

“PRAMS serves as one of those baselines,” said Charli Williams, Virginia PRAMS program manager at VDH. “It helps us understand what can be, what should be, what is working and what is needed in the commonwealth.” 

The numbers are clinical. Their consequences can be personal.

In 2010 and 2011, PRAMS found that only 45% of new mothers in Virginia reported seeing a dentist during pregnancy. Among mothers enrolled in Medicaid, the rate was 24%. The findings also revealed substantial racial differences: 54% of white mothers reported receiving dental care, compared with 27% of Black mothers and 25% of Hispanic mothers.

At the time, Virginia Medicaid did not provide routine or preventive dental coverage during pregnancy. VDH included the findings in its Oral Health Burden Report, and the Virginia Oral Health Coalition used the evidence to show state leaders the consequences of that gap. In 2015, Virginia extended comprehensive dental benefits to pregnant Medicaid recipients. By the time Virginia documented the results, more than 14,000 women had received services that would not previously have been covered.

PRAMS has also helped Virginia examine access to contraception and the prevalence of unintended or mistimed pregnancies. VDH used the findings alongside program records to support continued public investment in the Contraceptive Access Initiative, which provides contraceptive care to uninsured Virginians with low incomes.

The initiative began in 2018 with an emphasis on long-acting reversible contraceptives. In 2020, it expanded to cover all contraceptive methods approved by the U.S. Food and Drug Administration, allowing patients and providers to select the option best suited to an individual’s needs. PRAMS findings have been cited in reports to the Virginia General Assembly to establish contraceptive access as a public health issue and support the case for sustaining the program.

The effect is not always a new benefit or a statewide policy change. A local health district may redirect a program. An agency may discover that a service is failing to reach a particular population. A grant application may gain the evidence needed to compete for funding. These decisions draw less notice, but they help determine who receives assistance and who remains beyond the reach of those services. 

Some findings raise questions that are harder to answer. Virginia continues to see poorer outcomes among Black mothers and infants. By collecting information about income, education, insurance, discrimination and racism, PRAMS allows researchers to examine the conditions surrounding those disparities rather than assume that individual behavior explains them.

No single questionnaire can be credited with producing a policy change. Most mothers will never know whether something they shared influenced a funding request, a health district’s priorities or a report to the General Assembly. That is rarely how public policy works. Individual experiences accumulate, patterns emerge and evidence builds.

Some mothers appear to understand the stakes. In the space provided at the end of the questionnaire, respondents have left notes thanking researchers for allowing them to share their stories.

“Policies and programs should be shaped by the people they are intended to serve,” Stafford said. “This research allows women to directly influence the programs and policies that affect them and their babies.”

Each mother answers in private. Together, their experiences reveal whom Virginia’s programs are reaching, whom they are missing and where policy may need to change. SERL gives those experiences a place in the evidence that shapes public decisions.