ZPER Maternal Hospital-based Questionnaire - English

Attachment 7a

Zika Postpartum Emergency Response (ZPER)

Maternal Hospital-based Questionnaire

English

The first questions are about you.

1. What is your date of birth?

MONTH/DAY/YEAR

2. What is the highest level of education that you have completed?

Less than high school diploma

High school diploma or GED

Some college

Completed college

Competed graduate school

3. How many weeks pregnant were you when you delivered?

____weeks

I don’t know

4. What municipality do you live in now? If you live in multiple locations, please write the name of the municipality where you live most of the time.

____________Name of municipality

5. Are you currently married?

Yes

No

6. What kind of health insurance did you have to pay for your delivery? Check ALL that apply

Private health insurance from my job or the job of my husband or partner

Private health insurance from my parents

Private health insurance that I bought myself

Mi Salud or Medicaid

Other health insurance  Please tell us: _____________________________

I didn’t have health insurance to pay for my delivery

The next questions are about Zika virus. Zika virus infection is an illness that is most often spread by the bite of a mosquito, but it may also be spread by having sex with a man who has the Zika virus.

7. During your most recent pregnancy, how worried were you about getting infected with Zika virus? Check ONE answer

Very worried

Somewhat worried

Not at all worried

I had never heard of Zika virus during my most recent pregnancy  Go to Question 14

8. During your most recent pregnancy, how worried were you about having a child with microcephaly or another birth defect linked to Zika virus? Microcephaly is a birth defect where a baby’s head is smaller than expected when compared to babies of the same sex and age.

Very worried

Somewhat worried

Not at all worried

9. While you were pregnant, which ONE of these sources did you trust the most for receiving information about Zika virus? Check ONE answer

Healthcare worker (for example, a family doctor, OB/GYN, midwife, other medical professionals)

Other pregnant women

Family or friends

The Centers for Disease Control and Prevention (CDC)

The Puerto Rico Department of Health

Television or radio news

Social network sites like Facebook

Websites about pregnancy or other topics  Please tell us: ________________

Some other source  Please tell us: ___________________

10. At any time during your most recent pregnancy, did you talk with a doctor, nurse, or other healthcare worker about Zika virus?

Yes, a healthcare worker talked with me without my asking about it

Yes, a healthcare worker talked with me, but only after I asked about it

No  Go to Question 14

11. During your most recent pregnancy, did a doctor, nurse or other healthcare worker offer you a test for Zika virus? Check ALL that apply

Yes, during the first 3 months of my pregnancy (1^st trimester)

Yes, during the middle 3 months of my pregnancy (2^nd trimester)

No

12. During your most recent pregnancy, did you get tested for Zika virus? Check ALL that apply

Yes, I got tested during the first 3 months of my pregnancy (1^st trimester)

Yes, I got tested during the middle 3 months of my pregnancy (2^nd trimester)

No

13. During your most recent pregnancy, did a doctor, nurse, or other healthcare worker tell you that you had Zika virus infection?

Yes, after the test for Zika virus in my 1^st trimester

Yes, after the test for Zika virus in my 2^nd trimester

No

The next questions are about avoiding mosquito bites.

14. During your most recent pregnancy, did you do any of the following things to avoid mosquito bites in your home? For each one, check No if you did not do it or Yes if you did.

Yes No

1. Always used screens on open doors  

2. Always used screens on open windows  

3. Kept unscreened doors and windows closed  

4. Always used fans or air conditioning  

5. Eliminated accumulated water from my house and yard on a weekly basis  

6. Slept under a mosquito bed net  

15. During your most recent pregnancy, how often did you use a mosquito repellent on your exposed skin when you went outside, even if you were only outside for a short time?

Every day

Most days

Some days

Never  Go to Question 17

16. When you used mosquito repellent on your exposed skin, how many times a day did you apply it?

More than once a day

Once a day

17. When you did not wear mosquito repellent during your most recent pregnancy, what were your reasons for not wearing it? Check ALL that apply

I did not like the way it smelled

I did not like the way it made my skin feel

I worried about the chemicals in the repellent harming my baby

I worried about the chemicals in the repellent harming me

Mosquito repellent was too expensive

I forgot to reapply it

Other reason  Please tell us: ______________________________________________

18. During your most recent pregnancy, how often did you wear long sleeves and long pants?

Every day

Most days

Some days

Never

19. When you did not wear long sleeves and long pants during your most recent pregnancy, what were your reasons? Check ALL that apply

It was too hot to wear long sleeves or long pants

I did not have clothes with long sleeves or long pants

My clothes with long sleeves or long pants no longer fit due to pregnancy

Other  Please tell us: ____________________________________________

20. Were you on WIC during your most recent pregnancy? WIC is the Special Supplemental Nutrition Program for Women, Infants, and Children.

Yes

No  Go to Question 23

21. Did WIC give you a Zika Prevention Kit?

Yes

No

22. Did WIC offer you professional services to help reduce mosquitoes inside and outside of your home?

Yes

No

23. During your most recent pregnancy, did you receive any of the following professional services for mosquito control? For each one, check No if you did not receive the service or Yes if you did.

Yes No

1. Indoor spraying of my house for mosquitos

2. Outdoor spraying around my house and in my yard for mosquitos

3. Application of larvacides around the outside of my house

The next questions are about your husband or any male partner.

24. At any time during your most recent pregnancy, did you have sex with any male partner?

Yes Go to Question 26

No

25. Why didn’t you have sex with a male partner at any time during your most recent pregnancy?

I didn’t have a partner  Go to Question 31

I was trying to avoid Zika infection  Go to Question 29

I didn’t want to have sex  Go to Question 29

Some other reason  Please tell us: ____________ Go to Question 29

26. Did you have sex at any time during your pregnancy in the:

Yes / No, to avoid Zika / No for another reason

a. First 3 months

b. Second 3 months

c. Last 3 months

27. How often did your partner use a condom when you had sex during your pregnancy in the:

Every time/Sometimes/Never

a. First 3 months

b. Second 3 months

c. Last 3 months

If you used condoms every time you had sex during your most recent pregnancy, go to Question 29. Otherwise go to Question 28.

28. What were your reasons for not using condoms every time when having sex during your most recent pregnancy? Check ALL that apply

I didn’t think I needed to use condoms during pregnancy

I didn’t know you could get Zika virus from having sex

I didn’t think a condom would prevent Zika infection

I didn’t think my partner had Zika virus

I was not worried about getting the Zika virus

I didn’t want to use condoms

My partner didn’t want to use condoms

I could not get condoms when I needed them

I could not afford condoms

I forgot to use condoms

Other  Please tell us: ______________________________

29. During your most recent pregnancy, did your husband or any male partner get tested for Zika virus?

Yes

No

I don’t know

30. At any time during your most recent pregnancy, did a doctor, nurse, or other healthcare worker tell your husband or any male partner that he had Zika virus infection?

Yes

No

I don’t know

The next questions are about the time before your pregnancy.

31. Thinking back to just before you got pregnant with your new baby, how did you feel about becoming pregnant? Check ONE answer

I wanted to be pregnant later

I wanted to be pregnant sooner

I wanted to be pregnant then

I didn’t want to be pregnant then or at any time in the future

I wasn’t sure what I wanted

32. When you got pregnant with your new baby, were you or your husband or partner doing anything to keep from getting pregnant? Some things people do to keep from getting pregnant include having their tubes tied, using birth control pills, condoms, withdrawal, or natural family planning.

Yes

No  Go to Question 34

33. What method of birth control were you using when you got pregnant? Check ALL that apply

Birth control pills

Condoms

Shots or injections (Depo-Provera®)

Contraceptive implant in the arm (Nexplanon® or Implanon®)

Contraceptive patch (OrthoEvra®) or vaginal ring (NuvaRing®)

IUD (including Mirena®, ParaGard®, Liletta®, or Skyla®)

Natural family planning (including rhythm method)

Withdrawal (pulling out)

Other  Please tell us: ____________________________

The last questions are about health care you received after delivery and during your pregnancy.

34. Did you start (or will you start) any of the following birth control methods before leaving the hospital? For each one, check No if you did not start or will not start to use the method before leaving the hospital or Yes if you did or will.

Yes No

1. Tubes tied or blocked (female sterilization)

2. IUD (Mirena^®, Skyla^®, Liletta^®, ParaGard^®)

3. Contraceptive implant (Nexplanon^®)

4. Contraceptive shot/injection (Depo-Provera^®)

5. A prescription method such as birth control pills, the patch, or ring

35. How many weeks or months pregnant were you when you had your first visit for prenatal care?

_______ Weeks OR _______ Months

I didn’t go for prenatal care  Go to the end

36. During any of your prenatal care visits, did a doctor, nurse, or other healthcare worker talk to you about any of the things listed below? For each item, check No if they did not or Yes if they did.

Yes No

1. How to prevent mosquito bites during pregnancy  

2. Using condoms during sex to prevent Zika infection  

3. Types of clothes to wear to prevent mosquito bites  

4. Using mosquito repellent on my skin  

5. The risk of Zika virus passing to my baby during pregnancy  

Thank you for answering these questions! Your answers will help us keep pregnant women and their babies healthy.