IN-HOSPITAL MATERNAL SURVEY: English version

PRAMS ZPER 2.0 – IN-HOSPITAL MATERNAL SURVEY: English version

Form Approved

OMB No.0920-XXXX

Exp. Date xx/xx/20xx

Public reporting burden of this collection of information is estimated to average 25 minutes, 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 CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74,  Atlanta, Georgia 30333; ATTN:  PRA (0920-XXXX).

English

PRAMS-ZPER 2.0 In-Hospital Maternal Survey (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? (Check one answer.)

Less than high school diploma

High school diploma or General Education Diploma (GED)

Some college or technical school

Completed college

Some graduate school

Completed graduate school

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

____weeks

____ I don’t know

4. In which 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 do you have to pay for your delivery?

(Check all that apply.)

I do not have health insurance of any kind

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 paid for myself or that someone else paid for me

Government health insurance/Medicaid (also known as Mi Salud or Reforma)

Other health insurance  Please tell us: _____________________________

The following questions are about 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

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.) (Check one answer.)

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

WIC or the Special Supplemental Nutrition Program for Women, Infants, and Children

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? (Check one answer.)

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 16

11. Did a doctor, nurse or other healthcare worker offer you a test for Zika virus at any of the following times? (For each time period, check Yes if you were offered a test then, or No if you were not.)

		Yes	No
a.	Before my most recent pregnancy		
b.	During the 1st trimester		
c.	During the 2nd trimester		
d.	During the 3rd trimester		

12. Did you get tested for Zika virus at any of the following times? (For each time period, check Yes if you were tested then, or No if you were not.)

		Yes	No
a.	Before my most recent pregnancy		
b.	During the 1st trimester		
c.	During the 2nd trimester		
d.	During the 3rd trimester		

If you did not get tested for Zika virus infection, go to Question 15.

13. Where did you get tested for Zika virus? (For each time period when you got tested for Zika, check the box for the location where you received the test.)

		Doctor’s Office	Health Department Clinic	Hospital	Laboratory, either private or commercial	Other Location
a.	Before my most recent pregnancy					
b.	During the 1st trimester					
c.	During the 2nd trimester					
d.	During the 3rd trimester					

14. How long after being tested did you receive your Zika test result? (For each time period when you got tested for Zika, check the box for the amount of time you had to wait to receive the result.)

		Less than one month after being tested	One month or more after being tested	I haven’t received my test result	I don’t remember
a.	Before my most recent pregnancy				
b.	During the 1st trimester				
c.	During the 2nd trimester				
d.	During the 3rd trimester				

15. Did a doctor, nurse, or other healthcare worker tell you that you had Zika virus infection at any of the following times? (For each time period, check Yes if you were told you had Zika virus then, or No if you were not.)

		Yes	No
a.	Before my most recent pregnancy		
b.	During the 1st trimester		
c.	During the 2nd trimester		
d.	During the 3rd trimester		

The following questions are about avoiding mosquito bites.

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

		Yes	No
a.	Always used screens on open doors		
b.	Always used screens on open windows		
c.	Always kept unscreened doors and windows closed		
d.	Always used fans or air conditioning		
e.	Eliminated standing water from my house and yard on a weekly basis		
f.	Slept under a mosquito bed net		
g.	Set up mosquito traps

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

		Yes	No
a.	Indoor spraying of my house for mosquitos		
b.	Outdoor spraying around my house and in my yard for mosquitos		
c.	Application of larvicides around the outside of my house		

18. During your most recent pregnancy, how often did you use a mosquito repellent on your exposed skin or clothing when you went outside, even if you were only outside for a short time? (Check one answer.)

Always

Sometimes

Rarely or when I saw mosquitos

Never  Go to Question 20

19. When you used mosquito repellent on your exposed skin or clothing, how many times a day did you apply it?(Check one answer.)

More than once a day

Once a day

20. What were your reasons for not wearing mosquito repellent during your most recent pregnancy? (Check all that apply.)

I did not like the way it smelled or it made me nauseous

I did not like the way it made my skin feel

I worried about the chemicals in the repellent harming me

I worried about the chemicals in the repellent harming my baby

I forgot to apply it

I had an allergy or it made my skin itch

I didn’t think I needed it

I was rarely outside

Mosquito repellent was too expensive

Other reason  Please tell us: ________________

21. During your most recent pregnancy, how often did you wear long sleeves and long pants? (Check one answer.)

Every day  Go to Question 23

Most days

Some days

Never

22. 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

I was rarely outside

Other  Please tell us: ____________________________________________

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

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

Yes Go to Question 25

No

24. Why didn’t you have sex with a male partner at any time during your most recent pregnancy? (Check one answer.)

I didn’t have a partner  Go to Question 30

I was trying to avoid Zika infection  Go to Question 28

I didn’t want to have sex  Go to Question 28

Some other reason  Please tell us: ____________ Go to Question 28

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

		Yes	No, to avoid Zika	No, for another reason
a.	First 3 months			
b.	Second 3 months			
c.	Last 3 months			

26. How often did your partner use a condom when you had sex together 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 28. Otherwise go to Question 27.

27. 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 know I was pregnant

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

I didn’t think a condom would prevent Zika infection

I didn’t think Zika was still a problem

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

My partner or I had an allergy

Other  Please tell us: ___________________

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

Yes

No

I don’t know

29. During your most recent pregnancy, did a doctor, nurse or other health care worker tell anyone who lived with you that they were infected with Zika virus? (For each person, check Yes if they were told that they had Zika virus during your pregnancy, or No if they were not told.)

		Yes	No
a.	My husband or male partner		
b.	Another family member		
c.	Another person who lived with me		

The following questions are about the time before your pregnancy.

30. Thinking back to just before you got pregnant with your new baby, which ONE of the following statements best describes how you felt about having a baby? (Check one answer.)

I wanted to be pregnant later, because of the risks associated with Zika virus

I wanted to be pregnant later, because of other reasons

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

1. When you got pregnant, what relationship did you have with your new baby’s father? (Check one answer.)

He was my husband (legally married)

He was my partner (not legally married, but a long-term partner)

He was my boyfriend (a casual partner)

Other  Please tell us: ________________________

31. Thinking back to just before you got pregnant with your new baby, how did your new baby’s father feel about you becoming pregnant? (Check one answer.)

He wanted me to be pregnant later, because of the risks associated with Zika virus

He wanted me to be pregnant later, because of other reasons

He wanted me to be pregnant sooner

He wanted me to be pregnant then

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

He wasn’t sure what he wanted

I don’t know

32. Before you got pregnant with your new baby, did a doctor, nurse, or other health care worker talk to you about how to prepare for a healthy pregnancy and baby?

No

Yes

33. 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  Go to Question 36

No

34. What were your reasons or your husband’s or partner’s reasons for not doing anything to keep from getting pregnant? (Check all that apply.)

I didn’t mind if I got pregnant

I thought I could not get pregnant at that time

I had side effects from the birth control method I was using

I had problems getting birth control when I needed it

I thought my husband or partner or I was sterile (could not get pregnant at all)

My husband or partner didn’t want to use anything

I forgot to use a birth control method

Other  Please tell us: _________________________

If you or your husband or partner were not doing anything to keep from getting pregnant, go to Question 37.

35. 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 during your pregnancy and after delivery.

34. 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 Question 41

35. During your most recent pregnancy, did anyone ever go with you to your prenatal care visits? (Check one answer.)

Yes, my husband or partner

Yes, someone else  Go to question 41

No  Go to question 41

34. How often did your husband or partner go with you to your prenatal care visits? (Check one answer.)

Every time

Sometimes

Only when I was going to have a procedure (such as an ultrasound)

Never

35. How often did you try to schedule your prenatal care visits so that your husband or partner could attend? (Check one answer.)

Every time

Sometimes

Only when I was going to have a procedure (such as an ultrasound)

Never

34. 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 Yes if they did or No if they did not.)

		Yes	No
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		
f.	Using mosquito repellent on my skin or clothing		
g.	The risk of Zika virus passing to my baby during pregnancy		
h.	Birth defects associated with Zika virus or Zika Congenital Syndrome		

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

		Yes	No
a.	Tubes tied or blocked (female sterilization)		
b.	IUD (Mirena®, Skyla®, Liletta®, ParaGard®)		
c.	Contraceptive implant (Nexplanon®)		
f.	Contraceptive shot/injection (Depo-Provera®)		
g.	A prescription method (such as birth control pills, the patch, or ring)		

Thank you for answering these questions!

Your answers will help us keep pregnant women and their babies healthy.

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