19.2 Survey

OMB #: 0925-0593

OMB Expiration Date: 8/31/2014

Pregnancy Loss/Still Birth/Neonatal Death (PLSND) (SAQ), Phase 2g

OMB Specification

Pregnancy Loss/Still Birth/Neonatal Death (PLSND) (SAQ)

Event Category:	Trigger-Based
Event:	Child Loss
Administration:	PV1, PV2, Birth
Instrument Target:	Child
Instrument Respondent:	Pregnant Woman; Biological Mother
Domain:	Questionnaire
Document Category:	Questionnaire
Method:	Self-Administered
Mode (for this instrument*):	In-Person, PAPI
OMB Approved Modes:	In-Person, PAPI
Estimated Administration Time:	6 minutes
Multiple Child/Sibling Consideration:	In-Person, PAPI; Phone, PAPI; Web-based, CAI
Special Considerations:	N/A
Version:	1.1
MDES Release:	4.0

*This instrument is OMB-approved for multi-mode administration but this version of the instrument is designed for administration in this/these mode(s) only.

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Pregnancy Loss/Still Birth/Neonatal Death (PLSND) (SAQ)

TABLE OF CONTENTS

GENERAL PROGRAMMER INSTRUCTIONS: 1

FOLLOW-UP QUESTIONNAIRE: PLSND SAQ SPECIFICATION 3

FOR OFFICE USE ONLY 18

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Pregnancy Loss/Still Birth/Neonatal Death (PLSND) (SAQ)

GENERAL PROGRAMMER INSTRUCTIONS:

WHEN PROGRAMMING INSTRUMENTS, VALIDATE FIELD LENGTHS AND TYPES AGAINST THE MDES TO ENSURE DATA COLLECTION RESPONSES DO NOT EXCEED THOSE OF THE MDES. SOME GENERAL ITEM LIMITS USED ARE AS FOLLOWS:

DATA ELEMENT FIELDS	MAXIMUM CHARACTERS PERMITTED	DATA TYPE	PROGRAMMER INSTRUCTIONS
ADDRESS AND EMAIL FIELDS	100	CHARACTER
UNIT AND PHONE FIELDS	10	CHARACTER
_OTH AND COMMENT FIELDS	255	CHARACTER	Limit text to 255 characters
FIRST NAME AND LAST NAME	30	CHARACTER	Limit text to 30 characters
ALL ID FIELDS	36	CHARACTER
ZIP CODE	5	NUMERIC
ZIP CODE LAST FOUR	4	NUMERIC
CITY	50	CHARACTER
DOB AND ALL OTHER DATE FIELDS (E.G., DT, DATE, ETC.)	10	NUMERIC CHARACTER	DISPLAY AS MM/DD/YYYY STORE AS YYYY-MM-DD HARD EDITS: MM MUST EQUAL 01 TO 12 DD MUST EQUAL 01 TO 31 YYYY MUST BE BETWEEN 1900 AND CURRENT YEAR.
TIME VARIABLES	TWO-DIGIT HOUR AND TWO-DIGIT MINUTE, AM/PM DESIGNATION	NUMERIC	HARD EDITS: HOURS MUST BE BETWEEN 00 AND 12; MINUTES MUST BE BETWEEN 00 AND 59

Instrument Guidelines for Participant and Respondent IDs:

PRENATALLY, THE P_ID IN THE MDES HEADER IS THAT OF THE PARTICIPANT (E.G. THE NON-PREGNANT WOMAN, PREGNANT WOMAN, OR THE FATHER).

POSTNATALLY, A RESPONDENT ID WILL BE USED IN ADDITION TO THE PARTICIPANT ID BECAUSE SOMEBODY OTHER THAN THE PARTICIPANT MAY BE COMPLETING THE INTERVIEW. FOR EXAMPLE, THE PARTICIPANT MAY BE THE CHILD AND THE RESPONDENT MAY BE THE MOTHER, FATHER, OR ANOTHER CAREGIVER. THEREFORE, MDES VERSION 2.2 AND ALL FUTURE VERSIONS CONTAIN A R_P_ID (RESPONDENT PARTICIPANT ID) HEADER FIELD FOR EACH POST-BIRTH INSTRUMENT. THIS WILL ALLOW ROCs TO INDICATE WHETHER THE RESPONDENT IS SOMEBODY OTHER THAN THE PARTICIPANT ABOUT WHOM THE QUESTIONS ARE BEING ASKED.

A REMINDER:

ALL RESPONDENTS MUST BE CONSENTED AND HAVE RECORDS IN THE PERSON, PARTICIPANT, PARTICIPANT_CONSENT AND LINK_PERSON_PARTICIPANT TABLES, WHICH CAN BE PRELOADED INTO EACH INSTRUMENT. ADDITIONALLY, IN POST-BIRTH QUESTIONNAIRES WHERE THERE IS THE ABILITY TO LOOP THROUGH A SET OF QUESTIONS FOR MULTIPLE CHILDREN, IT IS IMPORTANT TO CAPTURE AND STORE THE CORRECT CHILD P_ID ALONG WITH THE LOOP INFORMATION. IN THE MDES VARIABLE LABEL/DEFINITION COLUMN, THIS IS INDICATED AS FOLLOWS: EXTERNAL IDENTIFIER: PARTICIPANT ID FOR CHILD DETAIL.

FOLLOW-UP QUESTIONNAIRE: PLSND SAQ SPECIFICATION

PLS01000. Thank you for agreeing to participate in the study.  This self-administered questionnaire will take about 6 minutes to complete.

 

The first section of the questionnaire asks questions about your most recent pregnancy (prior to your current pregnancy if you are now pregnant), including how the pregnancy ended.

PLS02000/(NUM_CARRIED). How many babies did you carry during your most recent pregnancy, including any that were not born alive?

 

l___l___l Number of babies carried

Label	Code	Go To
Not sure	1

SOURCE

Pregnancy Loss, Stillbirth, and Infant Death Instrument (developed for the National Children’s Study by Battelle)

PLS03000. The next questions ask about what happened with each baby you carried during your most recent pregnancy.

 

If you were pregnant with one baby (or are unsure), please answer Question PLS04000 and then go to Question PLS09000.

 

If you were pregnant with more than one baby, please go to Question PLS05000.

PLS04000/(ONE_PREG_END). How did your most recent pregnancy end?

Label	Code	Go To
A stillbirth at or after 20 weeks of pregnancy	1
A miscarriage, that is, an involuntary, unplanned pregnancy loss before 20 weeks of pregnancy	2
An induced abortion or voluntary termination	3
The delivery of a live-born baby	4
None of the above	5

SOURCE

National Population Health Survey 1992, Mother’s Survey 

PARTICIPANT INSTRUCTIONS

Please go to Question PLS09000.

PLS05000/(MULT_NUM_STILLBORN). How many of your babies were stillborn, that is, lost at or after 20 weeks of pregnancy?

 

l___l___l Number of babies

SOURCE

National Population Health Survey 1992, Mother’s Survey 

PLS06000/(MULT_NUM_MISCARRIAGE). How many of your babies were lost due to a miscarriage, that is, an involuntary, unplanned pregnancy loss before 20 weeks of pregnancy?

 

l___l___l Number of babies

SOURCE

National Population Health Survey 1992, Mother’s Survey 

PLS07000/(MULT_NUM_ABORT). If your pregnancy involved an induced abortion or elective reduction, how many fetuses were aborted or reduced?

 

l___l___l Number of babies

SOURCE

National Population Health Survey 1992, Mother’s Survey 

PLS08000/(MULT_NUM_BORN_ALIVE). How many of your babies were born alive?

 

l___l___l Number of babies

SOURCE

National Population Health Survey 1992, Mother’s Survey 

PLS09000/(ECTOPIC _PREG). Did your most recent pregnancy involve an ectopic pregnancy, in which the embryo implanted outside of the uterus?  (These are sometimes called tubal pregnancies because these pregnancies most often occur in the Fallopian tubes.) 

Label	Code	Go To
Yes	1
No	2

SOURCE

National Population Health Survey 1992, Mother’s Survey 

PLS10000. If you had a live birth in your most recent pregnancy and were pregnant with one baby (or are unsure), please answer Questions PLS11000, PLS12000, and PLS13000. Then go to Question PLS17000.

 

If you had a live birth in your most recent pregnancy and were pregnant with more than one baby, please answer Questions PLS14000, PLS15000, and PLS16000.

 

If you did not have a live birth in your most recent pregnancy, please go to Question PLS17000.

PLS11000/(ONE_PRETERM_DELIVER). Did you have a preterm delivery, that is, a delivery occurring before 37 weeks of pregnancy?

Label	Code	Go To
Yes	1
No	2

SOURCE

National Survey of Family Growth, Cycle 6 Main Study (Female CAPI-Lite)

PLS12000/(ONE_DIE). Did your baby die after it was born alive?

Label	Code	Go To
Yes	1
No	2

SOURCE

Pregnancy Loss, Stillbirth, and Infant Death Instrument (developed for the National Children’s Study by Battelle)

PLS13000/(ONE_BEFORE_28). Did your baby die before 28 days after birth? (This refers to the death of your baby up to but not including 28 days from the moment of birth.) 

Label	Code	Go To
Yes	1
No	2

SOURCE

Pregnancy Loss, Stillbirth, and Infant Death Instrument

PARTICIPANT INSTRUCTIONS

Please go to Question PLS17000.

PLS14000/(MULT_PRETERM). Did you have a preterm delivery, that is, a delivery occurring before 37 weeks of pregnancy?

Label	Code	Go To
Yes	1
No	2

SOURCE

National Survey of Family Growth, Cycle 6 Main Study (Female CAPI-Lite) 

PLS15000/(MULT_NUM_DIED). How many of your babies died after being born alive?

 

l___l___l Number of babies

SOURCE

Pregnancy Loss, Stillbirth, and Infant Death Instrument 

PLS16000/(MULT_NUM_BEFORE_28). How many of your babies died before 28 days after birth? (This refers to the death of your baby up to but not including 28 days from the moment of birth.)

 

l___l___l Number of babies

SOURCE

Pregnancy Loss, Stillbirth, and Infant Death Instrument 

PLS17000. Please answer the following questions about your most recent pregnancy (prior to your current pregnancy if you are now pregnant,) to help us understand the type of care you received, any problems you may have experienced, and any support you received after your loss.

PLS18000/(PRENATAL_PROV). Did you get any prenatal care from a doctor, nurse, or midwife during your most recent pregnancy?

Label	Code	Go To
Yes	1
No	2

SOURCE

National Maternal and Infant Health Survey -2 1988, Mother’s Survey 

PLS19000. During your most recent pregnancy, did you experience any of the complications or conditions listed in the questions below? Please review each item and check “yes” or “no” to tell us if you experienced it during your most recent pregnancy.

SOURCE

Pregnancy Loss, Stillbirth, and Infant Death Instrument 

PLS20000/(RECENT_COMPLIC_HTN). Hypertension

(High blood pressure)

Label	Code	Go To
Yes	1
No	2

SOURCE

Pregnancy Loss, Stillbirth, and Infant Death Instrument

PLS21000/(RECENT_COMPLIC_PRE_ECLAMP). Pre-eclampsia

(High blood pressure and excess protein in the urine after 20 weeks of pregnancy in a woman who previously had normal blood pressure)

Label	Code	Go To
Yes	1
No	2

SOURCE

Pregnancy Loss, Stillbirth, and Infant Death Instrument 

PLS22000/(RECENT_COMPLIC_HELLP). HELLP Syndrome 

(HELLP is “Hemolysis, Elevated Liver enzymes, Low Platelets”.  Syndrome includes the breakdown of red blood cells, elevated liver enzymes, and low platelet count.  It often follows a diagnosis of high blood pressure or pre-eclampsia.)

Label	Code	Go To
Yes	1
No	2

SOURCE

Pregnancy Loss, Stillbirth, and Infant Death Instrument 

PLS23000/(RECENT_COMPLIC_CERV_INCOMP). Cervical Incompetence 

(Condition where the cervix is too weak to stay closed during a pregnancy and begins to dilate without contractions before the baby is ready to be born.  Often treated with cerclage, that is, stitching the cervix closed.)

Label	Code	Go To
Yes	1
No	2

SOURCE

Pregnancy Loss, Stillbirth, and Infant Death Instrument 

PLS24000/(RECEN_COMPLIC_PLAC_ABRUP). Placental Abruption 

(Occurs when the placenta separates from the wall of the uterus prior to the birth of the baby)

Label	Code	Go To
Yes	1
No	2

SOURCE

Pregnancy Loss, Stillbirth, and Infant Death Instrument 

PLS25000/(RECENT_COMPLIC_TRAUMA). Trauma 

(Such as serious or critical bodily injury, wound, or shock)

Label	Code	Go To
Yes	1
No	2

SOURCE

Pregnancy Loss, Stillbirth, and Infant Death Instrument 

PLS26000/(RECENT_COMPLIC_INFECTION). Infection 

(Such as infections from a bacteria or virus)

Label	Code	Go To
Yes	1
No	2

SOURCE

Pregnancy Loss, Stillbirth, and Infant Death Instrument 

PLS27000/(RECENT_COMPLIC_UMBIL_CORD). Umbilical Cord Problems 

(Such as a knot in the cord, a leak in the cord, or the cord wraps around the baby’s neck)

Label	Code	Go To
Yes	1
No	2

SOURCE

Pregnancy Loss, Stillbirth, and Infant Death Instrument 

PLS28000/(RECENT_COMPLIC_PROM). Premature Rupture of Membranes 

(Occurs when the sac containing the developing baby and the amniotic fluid bursts or develops a hole prior to the start of labor, resulting in the leakage of amniotic fluid)

Label	Code	Go To
Yes	1
No	2

SOURCE

Pregnancy Loss, Stillbirth, and Infant Death Instrument 

PLS29000/(RECENT_COMPLIC_PRETERM_LABOR). Preterm Labor 

(Occurs when labor begins before 37 completed weeks of pregnancy)

Label	Code	Go To
Yes	1
No	2

SOURCE

Pregnancy Loss, Stillbirth, and Infant Death Instrument 

PLS30000/(RECENT_COMPLIC_RHEUM). Rheumatologic problems 

(Such as Lupus and other systemic autoimmune diseases)

Label	Code	Go To
Yes	1
No	2

SOURCE

Pregnancy Loss, Stillbirth, and Infant Death Instrument 

PLS31000/(RECENT_COMPLIC_CHROMOS). Diagnosis of fetal anomalies or chromosomal abnormalities 

(Such as when the fetus or baby’s body parts or organs are not formed normally or do not function normally)

Label	Code	Go To
Yes	1
No	2

SOURCE

Pregnancy Loss, Stillbirth, and Infant Death Instrument 

PLS32000/(RECENT_COMPLIC_GEST_DIABETES). Gestational Diabetes 

(Condition of high blood sugar during pregnancy among women without previously diagnosed diabetes)

Label	Code	Go To
Yes	1
No	2

SOURCE

Pregnancy Loss, Stillbirth, and Infant Death Instrument

PLS33000/(RECENT_COMPLIC_VOMIT). Severe Vomiting 

(Such as vomiting three to four times per day.  Sometimes called “hyperemesis” or “hyperemesis gravidarum”.)

Label	Code	Go To
Yes	1
No	2

SOURCE

Pregnancy Loss, Stillbirth, and Infant Death Instrument 

PLS34000/(RECENT_COMPLIC_UTERINE_CLOTS). Uterine blood clots 

(Also known as “subchorionic hematoma”)

Label	Code	Go To
Yes	1
No	2

SOURCE

Pregnancy Loss, Stillbirth, and Infant Death Instrument 

PLS35000/(RECENT_OTHER_COMPLIC). Did you experience any other complications during your recent pregnancy?

Label	Code	Go To
Yes	1
No	2	DEATH_CAUSE

SOURCE

Pregnancy Loss, Stillbirth, and Infant Death Instrument 

PLS36000/(RECENT_OTHER_COMPLIC_OTH). What other complications did you experience during your recent pregnancy? 

 

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

SOURCE

Pregnancy Loss, Stillbirth, and Infant Death Instrument 

PLS37000/(DEATH_CAUSE). Do you know the cause of your pregnancy loss or baby’s death? 

Label	Code	Go To
Yes	1
No	2	RECEIVE_RESOURCES

SOURCE

Pregnancy Loss, Stillbirth, and Infant Death Instrument 

PLS38000/(DEATH_CAUSE_OTH). What was the cause?

 

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

SOURCE

Pregnancy Loss, Stillbirth, and Infant Death Instrument 

PLS39000/(RECEIVE_RESOURCES). After your most recent pregnancy, did you receive any support or draw on any resources that helped you with your pregnancy loss or baby’s death, including from family, friends, health care providers, organizations, or other sources? 

Label	Code	Go To
Yes	1
No	2	PLS50000

SOURCE

Pregnancy Loss, Stillbirth, and Infant Death Instrument 

PLS40000. We would like to know what types of support or resources helped you after your recent loss.  Looking at the questions below, please answer “yes” or “no” to tell us whether any of the types of support or resources listed helped you after your pregnancy loss or baby’s death.

SOURCE

Pregnancy Loss, Stillbirth, and Infant Death Instrument

PLS41000/(SUPPORT_FAM_FRIEND). Emotional support from family or friends

Label	Code	Go To
Yes	1
No	2

SOURCE

Pregnancy Loss, Stillbirth, and Infant Death Instrument 

PLS42000/(SUPPORT_IN_PERSON_GROUP). In-person support group on pregnancy loss and infant death

Label	Code	Go To
Yes	1
No	2

SOURCE

Pregnancy Loss, Stillbirth, and Infant Death Instrument 

PLS43000/(SUPPORT_WEB_GROUP). Web-based support group on pregnancy loss and infant death

Label	Code	Go To
Yes	1
No	2

SOURCE

Pregnancy Loss, Stillbirth, and Infant Death Instrument 

PLS44000/(SUPPORT_BOOKS). Books and/or magazines on pregnancy loss and infant death

Label	Code	Go To
Yes	1
No	2

SOURCE

Pregnancy Loss, Stillbirth, and Infant Death Instrument 

PLS45000/(SUPPORT_MED_PROV). Information from medical care providers on pregnancy loss and infant death

Label	Code	Go To
Yes	1
No	2

SOURCE

Pregnancy Loss, Stillbirth, and Infant Death Instrument 

PLS46000/(SUPPORT_MED_TRT). Medical treatment 

Label	Code	Go To
Yes	1
No	2

SOURCE

Pregnancy Loss, Stillbirth, and Infant Death Instrument 

PLS47000/(SUPPORT_COUNSELING). Mental health counseling

Label	Code	Go To
Yes	1
No	2

SOURCE

Pregnancy Loss, Stillbirth, and Infant Death Instrument 

PLS48000/(SUPPORT_JOB_LEAVE). Paid or unpaid leave from your job, including maternity leave or family and medical leave

Label	Code	Go To
Yes	1
No	2

SOURCE

Pregnancy Loss, Stillbirth, and Infant Death Instrument 

PLS49000/(SUPPORT_OTH). What other types of support or resources helped you with your pregnancy loss or baby’s death?

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

SOURCE

Pregnancy Loss, Stillbirth, and Infant Death Instrument 

PLS50000. Please answer the following questions about your pregnancies prior to your most recent pregnancy.

PLS51000/(NUM_PREG_PRIOR). How many times have you been pregnant before your most recent pregnancy, including any that may have ended in a live birth, miscarriage, stillbirth, induced abortion, or ectopic pregnancy?

 

l___l___l Number of prior pregnancies

Label	Code	Go To
Not applicable (I have had no pregnancies before my most recent pregnancy.)	-7	PLS70000

SOURCE

National Population Health Survey 1992, Mother’s Survey

PLS52000/(NUM_PRIOR_MULT). How many of your prior pregnancies were multiple pregnancies (that is, you were pregnant with two or more babies)? 

 

l___l___l Number of prior pregnancies

SOURCE

National Survey of Family Growth, Cycle 6 Main Study (Female CAPI-Lite) 

PLS53000. The following questions ask about the outcomes of your pregnancies before your recent pregnancy.

 

If all of your prior pregnancies were multiple pregnancies, please read Question PLS54000 and answer Questions PLS55000 – PLS61000 and then go to Question PLS70000.

 

If all of your prior pregnancies were pregnancies with only one baby, please answer Questions PLS63000 - PLS69000.

 

If your prior pregnancies have included both multiple pregnancies and pregnancies with only one baby, please ready Question PLS54000 and  answer Questions PLS55000 – PLS69000. 

PLS54000. For the next set of questions, think about the outcomes of prior pregnancies before your most recent pregnancy.

PLS55000/(NUM_MULT_PRIOR_LIVE). How many of your prior multiple pregnancies involved the delivery of a live born baby? 

 

l___l___l Number of multiple pregnancies

SOURCE

National Population Health Survey 1992, Mother’s Survey 

PLS56000/(NUM_MULT_PRIOR_PRETERM). How many of your prior multiple pregnancies involved a preterm delivery, or a delivery occurring before 37 weeks of pregnancy? 

 

l___l___l Number of multiple pregnancies

SOURCE

National Survey of Family Growth, Cycle 6 Main Study (Female CAPI-Lite) 

PLS57000/(NUM_MULT_PRIOR_BEFORE_28). How many of your prior multiple pregnancies involved the death of a baby before 28 days after birth? (This refers to the death of your baby up to but not including 28 days from the moment of birth.) 

 

l___l___l Number of multiple pregnancies

SOURCE

Pregnancy Loss, Stillbirth, and Infant Death Instrument 

PLS58000/(NUM_MULT_PRIOR_MISCARRIAGE). How many of your prior multiple pregnancies involved a miscarriage, that is, an involuntary, unplanned pregnancy loss before 20 weeks of pregnancy? 

 

l___l___l Number of multiple pregnancies

SOURCE

National Population Health Survey 1992, Mother’s Survey 

PLS59000/(NUM_MULT_PRIOR_STILLBIRTH). How many of your prior multiple pregnancies involved a stillbirth at or after 20 weeks of pregnancy?

 

l___l___l Number of multiple pregnancies

SOURCE

National Population Health Survey 1992, Mother’s Survey 

PLS60000/(NUM_MULT_PRIOR_ABORTION). How many of your prior multiple pregnancies involved an induced abortion or voluntary termination? 

 

l___l___l Number of multiple pregnancies

SOURCE

National Population Health Survey 1992, Mother’s Survey

PLS61000/(NUM_MULT_PRIOR_ECTOPIC). How many of your prior multiple pregnancies involved an ectopic pregnancy, in which the embryo implanted outside of the uterus? (These are sometimes called tubal pregnancies because these pregnancies most often occur in the Fallopian tubes.)

 

l___l___l Number of multiple pregnancies

SOURCE

National Population Health Survey 1992, Mother’s Survey 

PLS62000. If all of your prior pregnancies were multiple pregnancies, please go to Question PLS70000.

 

If your prior pregnancies included pregnancies with one baby, continue with Question PLS63000.

PLS63000/(NUM_ONE_PRIOR_LIVE). For the next set of questions, think about the outcomes of all of your pregnancies with one baby only before your most recent pregnancy. How many of your prior pregnancies with one baby ended with the delivery of a live born baby? 

 

l___l___l Number of pregnancies with one baby

SOURCE

National Population Health Survey 1992, Mother’s Survey

PLS64000/(NUM_ONE_PRIOR_PRETERM). How many of your prior pregnancies with one baby ended with a preterm delivery, or a delivery occurring before 37 weeks of pregnancy?

 

l___l___l Number of pregnancies with one baby

SOURCE

National Survey of Family Growth, Cycle 6 Main Study (Female CAPI-Lite) 

PLS65000/(NUM_ONE_PRIOR_BEFORE_28). How many of your prior pregnancies with one baby ended with the death of a baby before 28 days after birth? (This refers to the death of your baby up to but not including 28 days from the moment of birth.)

 

l___l___l Number of pregnancies with one baby

SOURCE

Pregnancy Loss, Stillbirth, and Infant Death Instrument 

PLS66000/(NUM_ONE_PRIOR_MISCARRIAGE). How many of your prior pregnancies with one baby ended with a miscarriage, that is, an involuntary, unplanned pregnancy loss before 20 weeks of pregnancy?

 

l___l___l Number of pregnancies with one baby

SOURCE

National Population Health Survey 1992, Mother’s Survey 

PLS67000/(NUM_ONE_PRIOR_STILLBIRTH). How many of your prior pregnancies with one baby ended with a stillbirth at or after 20 weeks of pregnancy?

 

l___l___l Number of pregnancies with one baby

SOURCE

National Population Health Survey 1992, Mother’s Survey 

PLS68000/(NUM_ONE_PRIOR_ABORTION). How many of your prior pregnancies with one baby involved an induced abortion or voluntary termination? 

 

l___l___l Number of pregnancies with one baby

SOURCE

National Population Health Survey 1992, Mother’s Survey 

PLS69000/(NUM_ONE_PRIOR_ECTOPIC). How many of your prior pregnancies with one baby involved an ectopic pregnancy, in which the embryo implanted outside of the uterus?  (These are sometimes called tubal pregnancies because these pregnancies most often occur in the Fallopian tubes.) 

 

l___l___l Number of pregnancies with one baby

SOURCE

National Population Health Survey 1992, Mother’s Survey

PLS70000. Request for Your Medical Record:

 

Thank you for answering our questions about this difficult topic.  We appreciate your participation.  To better understand your loss, we would like to review your medical record related to your most recent pregnancy. Information from your medical record will only be seen by members of the NCS study team. Your doctors, hospitals, and other medical care providers can tell us more about your pregnancy and the care you and your baby received. What your medical care providers can tell us is also very important to understanding your loss.

 

• Please review the enclosed form titled, “HIPAA AUTHORIZATION FOR THE USE AND DISCLOSURE OF HEALTH INFORMATION”. 

 

• If you agree to give us permission to access your medical record related to your recent pregnancy, please complete and sign the form, and mail it to the NCS Study Office in the pre-addressed, stamped envelope marked “Release”.  The second copy of the form is for your records.  Before sealing the envelope please read the next set of instructions on this page.

 

Request for Your Baby’s Death Certificate:

 

In addition, if your recent pregnancy ended in a stillbirth or your infant died after being born alive, your baby’s death certificate can give us important details about the cause of death.  If your baby was stillborn or died after birth, we would like to request permission to access your baby’s death certificate.  All of the information we obtain will be kept strictly confidential and will only be seen by members of the NCS study team. 

 

• Please review the enclosed form that is titled, “HIPAA AUTHORIZATION FORM FOR RELEASE OF DEATH CERTIFICATE”. 

 

• If you agree to give us permission to access your baby’s death certificate, please place the completed and signed form into the pre-addressed, stamped envelope marked “Release” (with the medical record release) and mail it to the NCS Study Office.  The second copy of the form is for your records.

 

 

Thank you very much for your participation and answering our questions. We appreciate your participation in the National Children’s Study.

FOR OFFICE USE ONLY

FOU01000/(P_ID). Participant ID:___________________________________

Public reporting burden for this collection of information is estimated to average 6 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0593*). Do not return the completed form to this address.