Maternal Hospital-based Questionnaire - English Screensh

Attachment 7c - Hospital-based Survey for Mothers, 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 did not have health insurance to pay for my
delivery

1

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 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 Page 2, 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:

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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
Go to Question 14
‰‰ No
11. During your most recent pregnancy, did a doctor,
nurse, or other health care worker offer you a test
for Zika virus?
Check ALL that apply
‰‰ Yes, during the first 3 months of my pregnancy (1st
trimester)
‰‰ Yes, during the middle 3 months of my pregnancy
(2nd 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 (1st trimester)
‰‰ Yes, I got tested during the middle 3 months of my
pregnancy (2nd 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 1st trimester
‰‰ Yes, after the test for Zika virus in my 2nd 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

a. Always used screens on open doors............... 
b. Always used screens on open windows......... 
c. Kept unscreened doors and windows
closed.......................................................................... 
d. Always used fans or air conditioning.............. 
e. Eliminated accumulated water from my
house and yard on a weekly basis.................... 
f. Slept under a mosquito bed net.......................... 

No








15. During your most recent pregnancy, how often
did you use a mosquito repellent on your skin
when you went outside, even if you were only
outside for a short time?
Check ONE answer
‰‰ Every day
‰‰ Most days
‰‰ Some days
‰‰ Never

Go to Question 17

16. When you used mosquito repellent on your 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:

3
18. During your most recent pregnancy, how often
did you wear long sleeves and long pants?
‰‰ Every day
‰‰ Most days
‰‰ Some days
‰‰ Never

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

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

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

‰‰ Yes
‰‰ No

Go to Question 26

25. Why didn’t you have sex with a male partner at
any time during your most recent pregnancy?
Go to Page 4,
Question 31

‰‰ I didn’t have a partner
‰‰ I was trying to avoid
Zika infection
‰‰ I didn’t want to have sex
‰‰ Some other reason
Please tell us:

Go to Page 4,
Question 29

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

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

a. Indoor spraying of my house for
mosquitos................................................................. 
b. Outdoor spraying around my house and in
my yard for mosquitos.......................................... 
c. Application of larvacides around the
outside of my house.............................................. 

No





No, to avoid No, for
Zika
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
a. First 3 months........... 
b. Second 3 months..... 
c. Last 3 months............ 





Never





4

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 Page 5, 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:

5

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

a. Tubes tied or blocked (female
sterilization).............................................................. 
b. IUD (Mirena®, ParaGard®, Liletta®, or Skyla®).... 
c. Contraceptive implant (Nexplanon® ).............. 
d. Contraceptive shot/injection
(Depo-Provera®)....................................................... 
e. A prescription method such as birth control
pills, the patch, or ring.......................................... 

No







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

a. How to prevent mosquito bites during
pregnancy................................................................. 
b. Using condoms during sex to prevent
Zika infection........................................................... 
c. Types of clothes to wear to prevent
mosquito bites........................................................ 
d. Using mosquito repellent on my skin............. 
e. The risk of Zika virus passing to my baby
during pregnancy.................................................. 

No







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