PRAMS Phase 8 Questionnaire (Core Questions plus State-selected Standard Modules)

This document includes all core and standard questions available for the Pregnancy Risk Assessment Monitoring System (PRAMS) Phase 8 questionnaire that are currently being used by one or more states, and organized by topic. Many questions contain response options that are related to more than one topic, but are listed under the primary topic. Additional questions on a topic that are not in current use can be found in the Phase 8 Standard Document.

Within each topic or sub-topic, questions are organized into two categories: Core and Standard. Core questions are listed sequentially within a topic, with the question number from the basic core questionnaire. Likewise, standard questions are listed sequentially within a topic, with the number of the standard question cited. All questions are shown in English and are in the form used in the self-administered mail questionnaires. Interviewer-administered versions and Spanish translations are also available.

Abuse

Physical

Core Questions

In the 12 months before you got pregnant with your new baby, did any of the following people push, hit, slap, kick, choke, or physically hurt you in any other way? For each person, check No if they did not hurt you during this time, or Yes if they did.

No Yes

My husband or partner
My ex-husband or ex-partner
State option (Another family member)
State option (Someone else)

During your most recent pregnancy, did any of the following people push, hit, slap, kick, choke, or physically hurt you in any other way? For each person, check No if they did not hurt you during this time, or Yes if they did.

No Yes

My husband or partner
My ex-husband or ex-partner
State option (Another family member)
State option (Someone else)

Standard Questions

Z9. During any of the following time periods, did your husband or partner threaten you, limit your activities against your will, or make you feel unsafe in any other way? For each time period, check No if it did not happen then or Yes if it did.

No Yes

a. During the 12 months before I got pregnant

b. During my most recent pregnancy

c. Since my new baby was born

Used by: AK79, IA72, IL75, IN75, MD64, OH87, VA77, WY63

Z13. Since your new baby was born, have any of the following people pushed, hit, slapped, kicked, choked, or physically hurt you in any other way? For each person, check No they have not done anything to you or Yes if they have.

No Yes

My husband or partner
My ex-husband or ex-partner
State-added option (Another family member)
State-added option (Someone else)

Used by: ME75, PA81

State Developed Questions

NV3. During the time period before you were 18 years of age, how often did the following things happen to you? For each item, check N if it never happened, O if it happened once, MO if it happened more than once, or DK if you don’t know.

N O MO DK

a. How often did your parents or adults in your home ever slap, hit, kick,

punch, or beat each other up?

b. Before age 18, how often did a parent or adult in your home ever hit,

beat, kick, or physically hurt you in any way? Do not include spanking

Emotional/Sexual

Standard Questions

Z1. During your most recent pregnancy, did any of the following things happen to you? For each thing, check No if it did not happen to you or Yes if it did.

No Yes

My husband or partner threatened me or made me feel unsafe in some way
I was frightened for my safety or my family’s safety because of the
anger or threats of my husband or partner
My husband or partner tried to control my daily activities, for example,
controlling who I could talk to or where I could go
My husband or partner forced me to take part in touching or any sexual activity when
I did not want to

Used by: AR52, DC40, IN42, KS41, MS48, PA55, PR69, SD46, SDT37, WA38, WI48

Z2. Since your new baby was born, have any of the following things happened to you? For each thing, check No if it did not happen to you or Yes if it did.

No Yes

My husband or partner threatened me or made me feel unsafe in some way
I was frightened for my safety or my family’s safety because of the
anger or threats of my husband or partner
My husband or partner tried to control my daily activities, for example,
controlling who I could talk to or where I could go
My husband or partner forced me to take part in touching or any sexual activity when
I did not want to

Used by: DC62, LA65, KS63, MN67, PA82, SDT62

Z7. During the 12 months before your new baby was born, did you miss any doctor appointments because you were worried about what your partner would do if you went?

Yes

Used by: OH48

Z8. Before you got pregnant with your new baby, did your husband or partner ever try to keep you from using your birth control so that you would get pregnant when you didn’t want to? For example, did they hide your birth control, throw it away or do anything else to keep you from using it?

Yes

Used by: IN70

State Developed Questions

N O MO DK

a. How often did your parents or adults in your home ever slap, hit, kick,

punch, or beat each other up?

b. Before age 18, how often did a parent or adult in your home ever hit,

beat, kick, or physically hurt you in any way? Do not include spanking

c. How often did a parent or adult in your home ever swear at you, insult you,

put you down?

d. How often did anyone at least 5 years or older than you or an adult, ever

touch you sexually?

e. How often did anyone at least 5 years or older than you or an adult, try

to make you touch sexually?

f. How often did anyone at least 5 years or older than you or an adult, force

you to have sex?

SD75. While you were growing up, during your first 18 years of life, did any of the following things happen often or very often?

No Yes

a. Did a parent or other adult in the household swear at you, insult you,

put you down, or humiliate you OR act in a way that made you afraid

that you might be physically hurt?

b. Did a parent or other adult in the household push, grab, slap, or throw

something at you OR ever hit you so hard that you had marks or were

injured?

c. Did you feel that no one in your family loved you or thought you were

important or special OR your family didn’t look out for each other, feel

close to each other, or support each other?

d. Did you feel that you didn’t have enough to eat, had to wear dirty

clothes, and had no one to protect you OR your parents were too

drunk or high to take care of you or take care of you or take you to

the doctor if you needed it?

e. Was your mother or stepmother pushed, grabbed, slapped, or had

something thrown as her OR sometimes, often or very often kicked,

bitten, hit with a fist, or hit with something hard OR ever repeatedly

hit at least a few minutes or threatened with a gun or knife?

Used by: ND71, SD74, SDT71

Alcohol Use

Core Questions

Have you had any alcoholic drinks in the past 2 years? A drink is 1 glass of wine, wine cooler, can or bottle of beer, shot of liquor, or mixed drink.

Yes

During the 3 months before you got pregnant, how many alcoholic drinks did you have in an average week?

14 drinks or more a week

8 to 13 drinks a week

4 to 7 drinks a week

1 to 3 drinks a week

Less than 1 drink a week

I didn’t drink then

Standard Questions

JJ1. During the 3 months before you got pregnant, how many times did you drink 4 alcoholic drinks or more in a 2 hour time span?

6 or more times

4 to 5 times

2 to 3 times

1 time

I didn’t have 4 drinks or more in a 2 hour time span

Used by: AK41, CO39, HI40, IA38, MD32, ME38, NE52, NJ46, OK33, SD42, VT39

JJ2. During the last 3 months of your pregnancy, how many times did you drink 4 alcoholic drinks or more in a 2 hour time span?

6 or more times

4 to 5 times

2 to 3 times

1 time

I didn’t have 4 drinks or more in a 2 hour time span

Used by: AK43, HI42, MD34

JJ3. During the last 3 months of your pregnancy, how many alcoholic drinks did you have in an average week?

14 drinks or more a week

8 to 13 drinks a week

4 to 7 drinks a week

1 to 3 drinks a week

Less than 1 drink a week

I didn’t drink then

Used by: AK42, CO40, CT42, DE45, GA45, HI41, LA37, MD33, ME39, MN38, MO46, MS44, MT43, NC42, NE53, NJ49, NYS42, OH43, PA48, SD43, TN53, TX42, VA43, VT40, WA34, WY30

State specific questions

NE83. Since your new baby born, how many alcoholic drinks do you have in an average week?

14 drinks or more a week

8 to 13 drinks a week

4 to 7 drinks a week

1 to 3 drinks a week

Less than 1 drink a week

I don’t drink

Assisted Reproduction and Fertility

Standard Questions

A1. Did you take any fertility drugs or receive any medical procedures from a doctor, nurse, or other health care worker to help you get pregnant with your new baby? This may include infertility treatments such as fertility-enhancing drugs or assisted reproductive technology.

Yes

Used by: AL17, CT19, MA18, MO21, NYC18

A2. Did you use any of the following fertility treatments during the month you got pregnant with your new baby? Check ALL that apply

Fertility-enhancing drugs prescribed by a doctor (fertility drugs include Clomid^®, Serophene^®,Pergonal^®, or other drugs that stimulate ovulation)

Artificial insemination or intrauterine insemination (treatments in which sperm, but NOT eggs, were collected and medically placed into a woman’s body)

Assisted reproductive technology (treatments in which BOTH a woman’s eggs and a man’s sperm were handled in the laboratory, such as in vitro fertilization [IVF], gamete intrafallopian transfer [GIFT], zygote intrafallopian transfer [ZIFT], intracytoplasmic sperm injection [ICSI], frozen embryo transfer, or donor embryo transfer)

Other medical treatment: Please tell us:

I wasn’t using fertility treatments during the month that I got pregnant with my new baby

Used by: CT20, MA19, MO22, NYC19

A4. How long had you been trying to get pregnant before you took any fertility drugs or used any medical procedures to help you get pregnant with your new baby? Do not count long periods of time when you and your partner were apart or not having sex.

0 to 5 months

6 to 11 months

1 to 2 years

3 to 4 years

5 to 6 years

More than 6 years

Used by: AL18

Breastfeeding

Core Questions

Before or after your new baby was born, did you receive information about breastfeeding from any of the following sources? For each one, check No if you did not receive information from this source, or Yes if you did.

No Yes

My doctor
A nurse, midwife, or doula
A breastfeeding or lactation specialist
My baby’s doctor or health care provider
A breastfeeding support group
A breastfeeding hotline or toll-free number
Family or friends
Other: please tell us

Did you ever breastfeed or pump breast milk to feed your new baby, even for a short period of time?

Yes

Are you currently breastfeeding or feeding pumped milk to your new baby?

Yes

How many weeks or months did you breastfeed or feed pumped milk to your baby?

Less than 1 week

Weeks OR Months

Standard Questions

B1. What were your reasons for not breastfeeding your new baby? Check ALL that apply

I was sick or on medicine

I had other children to take care of

I had too many household duties

I didn’t like breastfeeding

I tried but it was too hard

I didn’t want to

I went back to work

I went back to school

Other: Please tell us:

Used by: AL59, AR59, FL52, IA50, IL52, LA48, KY52, ME55, MI44, MO59, MT58, NV45, NC53, NH46, PR48, RI46, SC59, SDT44, TX56, VA55

B2. What were your reasons for stopping breastfeeding? Check ALL that apply

My baby had difficulty latching or nursing

Breast milk alone did not satisfy my baby

I thought my baby was not gaining enough weight

My nipples were sore, cracked, or bleeding or it was too painful

I thought I was not producing enough milk, or my milk dried up

I had too many other household duties

I felt it was the right time to stop breastfeeding

I got sick or I had to stop for medical reasons

I went back to work

I went back to school

My partner did not support breastfeeding

My baby was jaundiced (yellowing of the skin or whites of the eyes)

Other: Please tell us:

Used by: AL62, FL55, IA53, IN54, KY56, ME58, MI47, MO62, MT61, NC27, ND44, NE65, NH49, NV48, NYC53, NYS54, PR52, SC63, SD55, SDT47, VA58, WA50, WY48

B3. This question asks about things that may have happened at the hospital where your new baby was born. For each item, check No if it did not happen or Yes if it did happen.

No Yes

a. Hospital staff gave me information about breastfeeding

b. My baby stayed in the same room with me at the hospital

c. I breastfed my baby in the hospital

d. Hospital staff helped me learn how to breastfeed

e. I breastfed in the first hour after my baby was born

f. My baby was placed in skin-to-skin contact within the first hour of life

g. My baby was fed only breast milk at the hospital

h. Hospital staff told me to breastfeed whenever my baby wanted

i. The hospital gave me a breast pump to use

j. The hospital gave me a gift pack with formula

k. The hospital gave me a telephone number to call for help with breastfeeding

l. Hospital staff gave my baby a pacifier

Used by: AK56, AL63, AR62, CO53, GA58, IN55, LA52, MA54, ME61, MN53, MO63, MS63, NC58, ND45, NE66, NJ65, NM50, NYC54, NYS55, OK45, OR44, PR53, TX59, UT59, VT52, WI57, WV52, WY49

B4. During your most recent pregnancy, what did you think about breastfeeding your new baby? Check ONE answer

I knew I would breastfeed

I thought I might breastfeed

I knew I would not breastfeed

I didn’t know what to do about breastfeeding

Used by: NYC29, NYS30, WY19

B5. Did anyone suggest that you not breastfeed your new baby?

Yes

Used by: MS65

B6. Who suggested that you not breastfeed your new baby? Check ALL that apply

My husband or partner

My mother, father, or in-laws

Other family member or relative

My friends

My baby’s doctor, nurse, or other health care worker

My doctor, nurse, or other health care worker

Other: Please tell us:

Used by: MS66

B7. When you went for WIC visits during your most recent pregnancy, did you receive information on breastfeeding?

Yes

Used by: AL32, LA25

B8. During your most recent pregnancy, when you went for your WIC visits, did you speak with a breastfeeding peer counselor or another WIC staff person about breastfeeding?

Yes

Used by: MS31, NJ36, NYS29

B9. Before your new baby was born, did any of the following things happen? Check ALL that apply

Someone answered my questions about breastfeeding

I was offered a class on breastfeeding

I attended a class on breastfeeding

I decided or planned to feed only breast milk to my baby

I discussed feeding only breast milk to my baby with my family

I discussed feeding only breast milk to my baby with my health care worker

I chose not to breastfeed my baby

Used by: UT52, VT47

B10. How old was your new baby the first time he or she had liquids other than breast milk (such as formula, water, juice, or cow’s milk)?

Weeks OR Months

My baby was less than 1 week old

My baby has not had any liquids other than breast milk

Used by: AK57, CO54, HI53, IL55, MA53, MS64, NE67, NM51, NYC55, OK46, OR45, PR54, TX60

B11. How old was your new baby the first time he or she ate food (such as baby cereal, baby food, or any other food)?

Weeks OR Months

My baby was less than 1 week old

My baby has not eaten any foods

Used by: AK58, CO55, HI54, IL56, ME62, NE68, NYC56, PR55

B12. During your most recent pregnancy, were you on WIC (the Special Supplemental Nutrition Program for Women, Infants, and Children)?

Yes

Used by: AK26, AL31, CO27, CT30, FL28, HI25, LA24, MA30, MO33, MS30, NE39, NH22, NJ35, NYC30, NYS28, PA36, RI24, TN38, UT28

B13. After your new baby was born, did you receive the kinds of help with breastfeeding that are listed below? For each one, check No if you did not receive this kind of breastfeeding help, or Yes if you did.

No Yes

Someone to answer my questions

Help getting my baby positioned correctly

Help knowing if my baby was getting enough milk

Help with managing pain or bleeding nipples

Information about where to get a breast pump

Help using a breast pump

Information about breastfeeding support groups

Other: Please tell us:

Used by: KY53, LA49, NC54, NM45, PR49, SC60

B14. Have you used a breast pump to express milk to feed to your new baby?

Yes

Used by: ME59, MI48, NM48, UT57

B15. Did your health insurance pay for a breast pump for you to use with your new baby?

Yes, but I had to make a co-payment

Yes, with no co-payment

I did not have health insurance

I don’t know

Used by: ME60, NM49

B16. Where did you get the breast pump or pumps that you use with your new baby? Check ALL that apply

From the hospital for free

Rented from the hospital or doctor’s office

Bought new from a hospital or doctor’s office

Bought new from a store or online website

Received new as a gift

Bought used or someone gave it to me used

I had one from a previous child

Other: Please tell us:

Used by: MI49, UT58

State specific questions

NJ90. Since your new baby was born, did a doctor, nurse, or other health care worker talk with you about any of the following things listed below? For each item, check No if no one talked with you about it or Yes if someone did.

a. Whether you or your baby are having any problems with breastfeeding

b. How to contact breastfeeding support groups

Cancer

Supplemental Questions

1. Have any of your family members listed below who are related to you by blood had ovarian cancer? For each family member, check No if she has not had ovarian cancer, Yes if she has, or DK if you don’t know.

	Family member	Had Ovarian Cancer
		No	Yes	DK
a.	My mother
b.	My mothers’ mother
c.	My father’s mother

2. Have any of your other family members who are related to you by blood had ovarian cancer? For each family member, check No if she has not had ovarian cancer, Yes if she has, DK if you don’t know, or NA if the option does not apply to you.

	Family Member	Had Ovarian Cancer
		No	Yes	DK	NA
a.	Sister(s) IF YES, how many have had ovarian cancer? _____
b.	Aunt(s) IF YES, how many have had ovarian cancer? _____
c.	Female cousin(s) IF YES, how many have had ovarian cancer? _____

3. Have any of your family members listed below who are related to you by blood had breast cancer? For each family member, check No if they have not had breast cancer, Yes if they have, or DK if you don’t know.

	Family member	Had Breast Cancer
		No	Yes	DK
a.	My mother
b.	My mother’s mother
c.	My father’s mother
d.	My father
e.	My mother’s father
f.	My father’s father

4. Have any of your other family members who are related to you by blood had breast cancer? For each family member, check No if they have not had breast cancer, Yes if they have, DK if you don’t know, or NA if the option does not apply to you.

	Family Member	Had Breast Cancer
		No	Yes	DK	NA
a.	Sister(s) IF YES, how many have had breast cancer?______
b.	Brother(s) IF YES, how many have had breast cancer?_______
c.	Aunt(s) IF YES, how many have had breast cancer?______
d.	Uncle(s) IF YES, how many have had breast cancer?_______
e.	Cousin(s) IF YES, how many have had breast cancer?______

5. Has any woman in your family who is related to you by blood had breast cancer at age 50 or younger?

Yes

I don’t know

6. Has any woman in your family who is related to you by blood had both breast AND ovarian cancer?

Yes

I don’t know

7. Have any of your family members related to you by blood had bilateral breast cancer (breast cancer on both sides)?

Yes

I don’t know

8. Do you have Ashkenazi Jewish heritage?

Yes

I don’t know

9. Have you ever talked to a genetic counselor about your risk for cancer based on your family history?

No  Go to end

Yes

10. What was the MAIN reason you talked to a genetic counselor about your risk for cancer? Check ONE answer

My doctor recommended it

I requested it

A family member suggested it

I heard or read about it in the news

Other  Please tell us: _________________________

11. Thinking about your MOST RECENT visit to a genetic counselor for cancer risk, what kind of cancer was it for? Check ALL that apply

Breast cancer

Ovarian cancer

Other  Please tell us: ________________________________________

All Cancer supplement questions used by: CO, MI, UT, WA

12. Have you ever had genetic testing for a gene mutation connected to breast or ovarian cancer? A mutation is a change in a gene that increases the risk for hereditary cancer. Genetic testing is done by taking a sample of your saliva or blood.

Yes

I don’t know

Additional Cancer Supplement question used by: MI

Child Care

Standard Questions

C1. Are you currently in school or working?

No, I don’t go to school or work

Yes, I go to school or work outside the home

Yes, I go to school or work from home

Used by: MD65, NE84

C2. Which one of the following people spends the most time taking care of your new baby when you are at school or work? Check ONE answer

My husband or partner

Baby’s grandparent

Other close family member or relative

Friend or neighbor

Babysitter, nanny, or other child care provider

Staff at day care center

Other: Please tell us:

The baby is with me while I am at school or work

Used by: MD66, NE85

C3. While you are away from your new baby for school or work, how often do you feel that she or he is well cared for? Check ONE answer

Always

Often

Sometimes

Rarely

Never

Used by: MD67

Contraception

Core Questions

Are you or your husband or partner doing anything now 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

What are your reasons or your husband’s or partner’s reasons for not doing anything to keep from getting pregnant now? Check ALL that apply

I want to get pregnant

I am pregnant now

I had my tubes tied or blocked

I don’t want to use birth control

I am worried about side effects from birth control

I am not having sex

My husband or partner doesn’t want to use anything

I have problems paying for birth control

Other: Please tell us:

What kind of birth control are you or your husband or partner using now to keep from getting pregnant? Check ALL that apply

Tubes tied or blocked (female sterilization or Essure^®)

Vasectomy (male sterilization)

Birth control pills

Condoms

Shots or injections (Depo-Provera^®)

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

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

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

Natural family planning (including rhythm method)

Withdrawal (pulling out)

Not having sex (abstinence)

Other: Please tell us:

Standard Questions

E3. 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 (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:

Used by: AL16, AR18, AZ17, CO17, FL20, GA20, HI16, KY18, MI16, MT20, NC20, NE23, OH19, OR16, SC19, TN24, VA16, WA16

E4. Before you got pregnant with your new baby, had you ever heard or read about emergency birth control (the “morning-after pill”)? This combination of pills is used to prevent pregnancy up to 5 days after unprotected sex.

Yes

Used by: KS66, SC79

E5 When you got pregnant with your new baby, were you trying to get pregnant?

Yes

Used by: AK14, AL13, AR15, AZ15, CO15, CT16, DE19, FL17, GA17, HI13, IA13, IL16, LA13, KY15, MA15, ME13, MI13, MN14, MO18, MT18, NC17, NE20, NJ21, NYC15, NYS13, OH16, OK13, OR13, PA19, SC16, SD17, SDT13, TN21, TX13, UT18, VA14, VT15, WA13, WV16

E6. 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

Used by: AK15, AL14, AR16, AZ16, CO16, CT17, DE20, FL18, GA18, HI14, IA14, IL17, LA14, KY16, MA16, ME14, MI14, MN15, MO19, MT19, NC18, NE21, NJ22, NYC16, NYS14, OH17, OK14, OR14, PA20, SC17, SD18, SDT14, TN22, TX14, VA15, WA14, WV17

E7. 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:

Used by: AL15, AR17, CT18, FL19, GA19, HI15, IA15, IA18, LA15, KY17, MA17, ME15, MI15, MO20, NC19, NE22, NJ23, NYC17, NYS15, OH18, OR15, SC18, SDT15, TN23, TX15, WA15

Delivery Method

Standard Questions

K1. Before you had your new baby, did you ever have a baby by cesarean deliver y or c-section (when a doctor cuts through the mother’s belly to bring out the baby)?

Yes

Used by: MD5

K3. How was your new baby delivered?

Vaginally

Cesarean delivery (c-section)

Used by: CT47, MD38, ME47, MS51, MT50, NM37, PR41, SC51, TN57, TX49, VA49, WA40, WY39

K4. How did the doctor, nurse, or other health care worker who provided your prenatal care suggest you deliver your new baby? Check ONE answer

He or she suggested I deliver my baby vaginally (naturally)

He or she suggested I have a cesarean delivery (c-section)

He or she didn’t suggest how I deliver my baby

Used by: VA21

K5. After you were admitted to the hospital to deliver your new baby, were you transferred to another hospital before your baby was born?

Yes

I didn’t have my baby in the hospital

Used by: IN43

K6. Which statement best describes whose idea it was for you to have a cesarean delivery (c-section)? Check ONE answer

My health care provider recommended a cesarean delivery before I went into labor

My health care provider recommended a cesarean delivery while I was in labor

I asked for the cesarean delivery

Used by: MD40, ME49, MS53, MT52, NM38

K7. What was the reason that your new baby was born by cesarean delivery (c-section)? Check ALL that apply

I had a previous cesarean delivery (c-section)

My baby was in the wrong position (such as breech)

I was past my due date

My health care provider worried that my baby was too big

I had a medical condition that made labor dangerous for me (such as heart condition, physical disability)

I had a complication in my pregnancy (such as preeclampsia, placental problems, infection, preterm labor)

My health care provider tried to induce my labor, but it didn’t work

Labor was taking too long

The fetal monitor showed that my baby was having problems before or during labor (fetal distress)

I wanted to schedule my delivery

I didn’t want to have my baby vaginally

Other: Please tell us

Used by: CT48, MD39, ME47, MS52, MT51, PR42, SC52, TX50, WA41, WY40

K8. Did you plan or schedule a cesarean delivery (c-section) at least one week before your new baby was born?

Yes

Used by: ME46, MS50, MT49

K9. Did your doctor, nurse, or other health care worker try to induce your labor (start your contractions using medicine)?

Yes

I don’t know

Used by: IN45, MT47, NJ54, PR39, TX47, WY37

K10. Why did your doctor, nurse, or other health care worker try to induce your labor (start your contractions using medicine)? Check ALL that apply

My water broke and there was a fear of infection

I was past my due date

My health care provider worried about the size of the baby

My baby was not doing well and needed to be born

I had a complication in my pregnancy (such as low amniotic fluid or preeclampsia)

I wanted to schedule my delivery

I wanted to give birth with a specific health care provider

Other: Please tell us:

Used by: IN46, MT48, PR40, TX48, WY38

State Specific Questions

NJ86. When you first learned you were pregnant with your new baby, did you prefer it be delivered vaginally (naturally) or by cesarean delivery?

Vaginally

By cesarean

NJ87. During any of your prenatal care visits, did your doctor, nurse, or any other health care worker talk with you about the risks and benefits of vaginal (natural) versus cesarean delivery?

Yes

NJ88. How was your new baby delivered?

Vaginally

I went into labor but had to have a cesarean delivery

I didn’t go into labor and had a cesarean delivery

Drug Use

DRUG1

During any of the follow time periods, did you use marijuana or hash in any form? For each time period, check No if you did not use then or Yes if you did.

During the 12 months before I got pregnant

During my most recent pregnancy

Since my new baby was born

Used by: AK72, HI69, ME77, MI70, NH69, OR58

DRUG2

During the month before you got pregnant, did you take or use any of the following drugs for any reason? For each item, check No if you did not use it or Yes if you did.

Over-the-counter pain relievers such as aspirin, Tylenol®, Advil®, or Aleve®

Prescription pain relievers such as hydrocodone (Vicodin®), oxycodone (Percocet®), or codeine

Adderall®, Ritalin®, or another stimulant

Marijuana or hash

Synthetic marijuana (K2, Spice)

Methadone, naloxone, subutex, or Suboxone®

Heroin (smack, junk, black tar, Chiva)

Amphetamines (uppers, speed, crystal meth, crank, ice, agua)

Cocaine (crack, rick, coke, blow, snow, nieve)

Tranquilizers (downers, ludes)

Hallucinogens (LSD/acid, PCP/angel dust, Ecstasy, Molly, mushrooms, bath salts)

Sniffing gasoline, glue, aerosol spray cans, or paint to get high (huffing)

Used by: AK73, LA68, KY71, ME78, MT79, ND58, NM71, OH79, SD68, SDT63, VT65, WI73, WY64

DRUG3

During your most recent pregnancy, did you take or use any of the following drugs for any reason? For each item, check No if you did not use it or Yes if you did.

Over-the-counter pain relievers such as aspirin, Tylenol®, Advil®, or Aleve®

Prescription pain relievers such as hydrocodone (Vicodin®), oxycodone (Percocet®), or codeine

Adderall®, Ritalin® or another stimulant

Marijuana or hash

Synthetic marijuana (K2, Spice)

Methadone, naloxone, subutex, or Suboxone®

Heroin (smack, junk, black tar, Chiva)

Amphetamines (uppers, speed, crystal meth, crank, ice, agua)

Cocaine (crack, rock, coke, blow, snow, nieve)

Tranquilizers (downers, ludes)

Hallucinogens (LSD/acid, PCP/angel dust, Ecstasy, Molly, mushrooms, bath salts)

Sniffing gasoline, glue, aerosol spray cans, or paint to get high (huffing)

Prescription antidepressants or selective serotonin reuptake inhibitors (SSRIs) such as Prozac, Zoloft, or Lexapro

Used by: AK74, AZ79, DC66, IN71, KS67, KY72, MO82, MT80, ND59, NV61, PR70, SD71, SDT64, VT66, WI74, WV68

Standard Questions

U6. How would you describe the way you got the pain relievers that you used during your most recent pregnancy?

I had a current prescription

I had pain relievers left over from an old prescription

I got the pain relievers without a prescription

Used by: IN72, KY73, NV62

U9. During any of your prenatal care visits, did a doctor, nurse, or other health care worker refer you to treatment because of drug use [prescribed or non-prescribed drugs]?

Yes

I didn’t go for prenatal care

Used by: IN73, KY74, ND60

U10. After your baby was born, did a doctor or nurse, or other health care worker tell you that your baby had drug withdrawal or neonatal abstinence syndrome?

Yes

Used by: KY75, ND61

State specific questions

CO75. During any of the follow time periods, did you use marijuana or hash in any form? For each time period, check No if you did not use then or Yes if you did.

During the 3 months before I got pregnant

During the first 3 months of my pregnancy

During the last 3 months of my pregnancy

At any time during my most recent pregnancy

Since my new baby was born

MI71. During any of the follow time periods, did you use prescription pain relievers, such as hydrocodone (Vicodin®), oxycodone (Percocet®), or codeine? For each time period, check No if you did not use then or Yes if you did.

During the 12 months before I got pregnant

During my most recent pregnancy

Since my new baby was born

VT67. During any of the follow time periods, did you use Methadone, Suboxone®, or another drug used for maintenance treatments? For each time period, check No if you did not use then or Yes if you did.

During the 12 months before I got pregnant

During my most recent pregnancy

Since my new baby was born

Used by: MT81, VT67

NH68. Why did you use marijuana or hash?

To relieve nausea

To relieve vomiting

To relieve stress or anxiety

To relieve a chronic condition

For fun or to relax

Other reason: Please tell us

Emergency Preparedness

Standard Questions

KK4. Below is a list of things that some people do to prepare for a disaster. For each item, check No if it is not something you have done to prepare for a disaster, or Yes if it is.

No Yes

I have an emergency meeting place for family members (other than my home)
My family and I have practiced what to do in case of a disaster
I have a plan for how my family and I would keep in touch if we were separated
I have an evacuation plan if I need to leave my home and community
I have an evacuation plan for my child or children in case of a disaster (permission for day care or school to release my child to another adult)
I have copies of important documents like birth certificates and insurance policies in a safe place outside my home
I have emergency supplies in my home for my family such as enough extra water, food, and medicine to last for at least three days
I have emergency supplies that I keep in my car, at work, or at home to take with me if I have to leave quickly

Used by: HI72, TN87

Family Health History

Standard Questions

GG1. Does anyone in your family have sickle cell disease or sickle cell trait?

Yes

I don’t know

Used by: SC80

GG2. During your most recent pregnancy, did you receive counseling or were you informed about sickle cell disease?

Yes

Used by: SC81

HH1. Have any of your close family members who are related to you by blood (mother, father, sisters, or brothers) had any of the conditions listed below? For each item, check No if no one in your family has the condition, Yes if someone in your family has the condition, or DK if you don’t know.

No Yes DK

a. Diabetes

b. Heart attack before age 55

c. High blood pressure (hypertension)

d. Breast cancer before age 50

e. Ovarian cancer

Used by: NJ85

Health Insurance

Maternal

Core Questions

During the month before you got pregnant with your new baby, what kind of health insurance did you have? 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 from the <State> Health Insurance Market Place or <statewebsite>, or Healthcare.gov

Medicaid (required: state Medicaid name)

State-specific option (Other government plan or program such as SCHIP/CHIP)

State-specific option (Other government plan or program not listed above such as MCH program, indigent program or family planning program)

State-specific option (TRICARE or other military health care)

State-specific option (IHS or tribal)

Other health insurance: Please tell us:

I did not have any health insurance during the month before I got pregnant

During your most recent pregnancy, what kind of health insurance did you have for your prenatal care? Check ALL that apply

I did not go for prenatal care: Go to Question 11

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

Private health insurance from my parents

Private health insurance from the <State> Health Insurance Market Place or <statewebsite>, or Healthcare.gov

Medicaid (required: state Medicaid name)

State-specific option (Other government plan or program such as SCHIP/CHIP)

State-specific option (Other government plan or program not listed above such as MCH program, indigent program or family planning program)

State-specific option (TRICARE or other military health care)

State-specific option (IHS or tribal)

Other health insurance: Please tell us:

I did not have any health insurance to pay for my prenatal care

What kind of health insurance do you have now? 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 from the <State> Health Insurance Market Place or <statewebsite>, or Healthcare.gov

Medicaid (required: state Medicaid name)

State-specific option (Other government plan or program such as SCHIP/CHIP)

State-specific option (Other government plan or program not listed above such as MCH program, indigent program or family planning program)

State-specific option (TRICARE or other military health care)

State-specific option (IHS or tribal)

Other health insurance: Please tell us:

I do not have health insurance now

Standard Questions

DD1. Did you try to get Medicaid coverage during your most recent pregnancy?

Yes

Used by: VA78

DD2. Did you have any problems getting Medicaid during your most recent pregnancy?

Yes

Used by: VA79

DD7. What was the reason that you did not have any health insurance during the month before you got pregnant with your new baby? Check ALL that apply

Health insurance was too expensive

I could not get health insurance from my job or the job of my husband or partner

I applied for health insurance, but was waiting to get it

I had problems with the health insurance application or website

My income was too high to qualify for Medicaid

My income is too high to qualify for a tax credit from Healthcare.gov or the <State> Health Care Market Place

I didn’t know how to get health insurance

State-specific (I am not a US citizen or I don’t have the right residency documents)

Other: Please tell us

Used by: KS10, NJ15, UT14, VA10

DD10. Did the cost of health insurance for your prenatal care cause financial problems for you or your family?

Yes

Used by: NM11, NV13

DD11. What was the reason that you did not have any health insurance to pay for your prenatal care? Check ALL that apply

Health insurance was too expensive

I could not get health insurance from my job or the job of my husband or partner

I applied for health insurance, but was waiting to get it

I had problems with the health insurance application or website

My income was too high to qualify for Medicaid

My income is too high to qualify for a tax credit from Healthcare.gov or the <State> Health Care Market Place

I didn’t know how to get health insurance

State-specific (I am not a US citizen or I don’t have the right residency documents)

Other: Please tell us

Used by: IN12, PR12, SC13

DD12. 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 from the <State> Health Insurance Market Place or <statewebsite>, or Healthcare.gov

Medicaid (required: state Medicaid name)

State-specific option (Other government plan or program such as SCHIP/CHIP)

State-specific option (Other government plan or program not listed above such as MCH program, indigent program or family planning program)

State-specific option (TRICARE or other military health care)

State-specific option (IHS or tribal)

Other health insurance: Please tell us:

I did not have any health insurance to pay for my delivery

Used by: CO11, NE17, NJ17

DD20. What is the reason that you do not have any health insurance now? Check ALL that apply

Health insurance is too expensive

I cannot get health insurance from my job or the job of my husband or partner

I applied for health insurance, but was waiting to get it

I had problems with the health insurance application or website

My income was too high to qualify for Medicaid

My income is too high to qualify for a tax credit from Healthcare.gov or the <State> Health Care Market Place

I didn’t know how to get health insurance

State-specific (I am not a US citizen or I don’t have the right residency documents)

Other: Please tell us

Used by: NV15

Infant Coverage

Standard Questions

H2. What kind of health insurance is your new baby covered by now? 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 from the <State> Health Insurance Market Place or <state website> or Healthcare.gov

Medicaid (required: state Medicaid name)

State-specific option (Other government plan or program such as SCHIP/CHIP)

State-specific option (Other government plan or program not listed above such as MCH program, indigent program or family planning program)

State-specific option (TRICARE or other military health care)

State-specific option (IHS or tribal)

Other health insurance: Please tell us

I do not have any health insurance for my new baby

Used by: PA64, VA59, WV53

HIV and Sexually Transmitted Infections

Core Questions

During any of your health care visits in the 12 months before you got pregnant, did a doctor, nurse or other health care worker do any of the following things? For each item, check No if they did not or Yes if they did.

No Yes

Test me for sexually transmitted infections such as chlamydia, gonorrhea, or syphilis
Test me for HIV (the virus that causes AIDS)

During any of your prenatal care visits, did a doctor, nurse, or other health care worker ask you—

No Yes

If you wanted to be tested for HIV (the virus that causes AIDS)

Standard Questions

I8. At any time during your most recent pregnancy or delivery, did you have a test for HIV (the virus that causes AIDS)?

Yes

I don’t know

Used by: AK21, AL24, AR22, MA22, MD18, MS23, NE30, SC23, TN30

I9. Why didn’t you have an HIV test during your most recent pregnancy or delivery? Check ALL that apply

I was not offered the test

I did not want to have the test

I already knew my HIV status

I did not think I was at risk for HIV

I did not want people to think I was at risk for HIV

I was afraid of getting the result

I was tested before this pregnancy, and did not think I needed to be tested again

Other reason: Please tell us:

Used by: AL25, AR23, MA23, SC24

EE3. During your most recent pregnancy, did a doctor, nurse, or other health care worker tell you that you had any of the following infections? For each item, check No if you were not told that you had the infection or Yes if you were.

No Yes

Genital warts (HPV)

Herpes

Chlamydia

Gonorrhea

Pelvic inflammatory disease (PID)

Syphilis

Group B Strep (Beta Strep)

Bacterial vaginosis

Trichomoniasis (Trich)

Yeast infections

Urinary tract infection (UTI)

Other: Please tell us

Used by: DE34, FL30, MS34

State specific questions

FL73. Were you offered two HIV tests during your most recent pregnancy or delivery?

No, I wasn’t offered any HIV tests

No, I was just offered 1 test

Yes, I was offered 2 tests

FL74. At any time during your most recent pregnancy or delivery, did you have a test for HIV (the virus that causes AIDS)?

No, I did not have a test

Yes, I had one test

Yes, I had two tests

I don’t know

Home Visitation

Standard Questions

V13. Who was the home visitor that came to your home during your most recent pregnancy?

A nurse or nurse’s aide

A teacher or health educator

A doula or midwife

State option (Someone from the <Healthy Start or other Program Name>)

Someone else: Please tell us:

I don’t know

Used by: AR30, AZ26, NE38, OH27, PA33, TN37

V14. During your most recent pregnancy, how many times did the home visitor come to your home to help you learn how to prepare for your new baby?

1 time

2 to 4 times

5 or more times

Used by: PA34, WI28

V15. During your most recent pregnancy, did the home visitor who came to your home talk with you about any of the things listed below? For each one, check No if they did not talk with you about it or Yes if they did.

No Yes

How smoking during pregnancy could affect my baby
How drinking alcohol during pregnancy could affect my baby
Doing tests to screen for birth defects or diseases that run in my family
The importance of getting tested for HIV or other sexually transmitted infections
Physical or emotional abuse to women by their husbands or partners
Breastfeeding my baby
My emotional well-being

Used by: AZ27, PA35, VA29

V16. What kind of home visitor has come to your home since your new baby was born?

A nurse or nurse’s aide

A teacher or health educator

A doula or midwife

State option (Someone from the <Healthy Start or other Program Name>)

Someone else: Please tell us:

I don’t know

Used by: GA65, MT69, NYC63, OH67, SDT54, TN71

V17. Since your new baby was born, how many times has a home visitor come to your home to help you learn how to take care of yourself or your new baby?

1 time

2 to 4 times

5 or more times

Used by: WI64

V18. Since your new baby was born, did the home visitor who came to your home talk with you about any of the things listed below? For each one, check No if they did not talk with you about it or Yes if they did.

No Yes

Breastfeeding my baby  
How long to wait before getting pregnant again  
Family planning services or using contraception  
Postpartum depression  
Resources in my community to support new parents  
Getting to and staying at a healthy weight after delivery  
How to quit or keep from smoking  
How to get the health care that my baby or I need  

Used by: AR69, PA72, VA67

V21. During your most recent pregnancy, did a home visitor come to your home to help you prepare for your new baby? A home visitor is a nurse, a health care worker, a social worker, or other person who works for a program that helps pregnant women.

Yes

Used by: AR29, AZ25, DE31, NE37, NJ34, NYS27, OH26, PA32, TN36, VA28, WI27, WV27, WY18

V22. Since your new baby was born, has a home visitor come to your home to help you learn how to take care of yourself or your new baby? A home visitor is a nurse, a health care worker, a social worker, or other person who works for a program that helps mothers of newborns.

Yes

Used by: AR68, DE65, GA64, MA60, MT68, NJ73, NYC62, NYS61, OH66, PA71, SDT53, TN70, VA66, WI63, WV60, WY55

State-specific

CO76. Since your new baby was born, have you participated in any of the following? For each one, check No if you did not participate or Yes if you did.

b. Home visitation sessions

OR62. During your most recent pregnancy, were you offered home visiting services?? Home visiting is when a nurse, health care worker, social worker, or other person who works for a program that helps pregnant women comes to your home.

Yes

Used by: KS70, OR62

OR63. Did you accept the offer of home visiting services?

Yes

Used by: KS71, OR63

OR64. Why did you not accept the offer of home visiting services?

I didn’t think I needed it

I didn’t understand how it would help me

I did not want anyone in my home

Household member(s) didn’t want anyone in my home

Other

Please tell us:

Used by: KS72, OR64

Household Characteristics

Residents

Core Question

Is your baby living with you now?

Yes

Standard Questions

P3. When you got pregnant with your new baby, who lived in the same house with you? Check ALL that apply

My husband or partner

Children aged less than 12 months: How many children?

Children aged 1 year to 5 years: How many children?

Children aged 6 years and over: How many children?

My mother

My father

My husband’s or partner’s parent(s)

Friend or roommate

Other family member or relative

Other: Please tell us:

I lived alone

Used by: TX80

P4. Who lives in the same house with you now? Check ALL that apply

My husband or partner

Children aged less than 12 months: How many children?

Children aged 1 year to 5 years: How many children?

Children aged 6 years and over: How many children?

My mother

My father

My husband’s or partner’s parent(s)

Friend or roommate

Other family member or relative

Other: Please tell us:

I lived alone

Used by: TX81, WY65

P5. Do you have a husband or partner who lives with you now?

Yes

Used by: LA75, OH89

P12. Counting yourself, how many people live in your house, apartment, or trailer?

Adults (people aged 18 years or older)

Babies, children, or teenagers (people aged 17 years or younger)

Used by: NH85

State Specific Questions

NH64. During the 12 months before the delivery of your new baby, did you get your household tap water from a private water system such as a well?

Yes

NH65. During the 12 months before the delivery of your new baby, did a doctor, nurse, or other health care worker talk to you about getting your household water tested for any of the following things? For each one, check No if they did not talk to you about it or Yes if they did.

Arsenic

Lead

NH66. During the 12 months before the delivery of your new baby, did you have your well tested for any of the following things? For each one check No if your water was not tested for it or Yes if it was.

Arsenic

Lead

RI77. How many times have you moved in the last 3 years?

_______ Number of times

Income

Core Questions

During the 12 months before your new baby was born, what was your yearly total household income before taxes? Include your income, your husband’s or partner’s income, and any other income you may have received. All information will be kept private and will not affect any services you are now getting.

$0 to $16,000

$16,001 to $20,000

$20,001 to $24,000

$24,001 to $28,000

$28,001 to $32,000

$32,001 to $40,000

$40,001 to $48,000

$48,001 to $57,000

$57,001 to $60,000

$60,001 to $73,000

$73,001 to $85,000

$85,001 or more

During the 12 months before your new baby was born, how many people, including yourself, depended on this income?

People

Infant Health Care

Well Child Care

Standard Questions

X2. Did any of these things keep your baby from having a well-baby checkup? Check ALL that apply

I didn’t have enough money or insurance to pay for it

I had no way to get my baby to the clinic or doctor’s office

I didn’t have anyone to take care of my other children

I couldn’t get an appointment

My baby was too sick to go for a well-baby checkup

Other: Please tell us:

Used by: AZ57, IA60, KS56

X8. Where do you usually take your new baby for well-baby checkups? Check ONE answer

Private doctor’s office

Hospital clinic

Health department clinic

State-specific option

Other: Please tell us:

Used by: FL62

X9. Has your new baby had a well-baby checkup? A well-baby checkup is a regular health visit for your baby usually at 1, 2, 4, and 6 months of age.

Yes

Used by: AZ56, FL61, IA59, KS55, NE74, NJ72, PR61, TX67, WV59

X10. Was your new baby seen by a doctor, nurse, or other health care worker for a one week checkup after he or she was born?

Yes

My baby was still in the hospital at that time

Used by: AZ55, DE64, NJ71, TX66

X11. Since your new baby was born, how often have you been frustrated when you tried to get health care services for him or her?

Never

Rarely

Sometimes

Often

Always

I haven’t tried to get health care services for my new baby

Used by: SC69

X12. Why have you felt frustrated when you tried to obtain health care services for your new baby?

Check ALL that apply

The services that I needed were not available in my area

There were waiting lists or other problems getting an appointment

My health insurance would not pay for the services that I needed

Other: Please tell us

Used by: SC70

State specific questions

MI67. Please mark each state as true or false for your baby.

a. My baby received breast milk from a source other than me

b. My baby has a doctor, nurse, or medical practice where he or she is seen on a regular basis

c. My baby will see a dentist by his or her first birthday

OK63. Do you have someone you think of as your baby’s personal doctor or nurse? A personal doctor or nurse is a health professional who knows your baby well and is familiar with your baby’s health history. (This can be a general doctor, a pediatrician, a specialist doctor, a nurse practitioner, or a physician assistant.)

Yes

OK64. Can you contact your baby’s personal doctor or nurse 24-hours a day, seven days a week? Please include after-hours paging service or other ways to reach your health care provider after hours.

Yes

RI66. Do you have a doctor, nurse, or other health care worker that you can get in contact with 24-hours a day, seven days a week, who will take care of your baby for both sick and “well baby” care?

Yes

Sick Child Care

Standard Questions

T1. How many times has your new baby gone for care when he or she was sick?

Number of Times

None

My baby has not been sick

Used by: AZ 58, NM57

T3. Has your new baby gone for care as many times as you wanted when he or she was sick?

Yes

Used by: AZ59, NM58

T8. Did any of these things keep you from taking your baby for care when he or she was sick? Check ALL that apply

I didn’t have health insurance to pay for the visit

I couldn’t get an appointment

I didn’t have a regular doctor for my baby

I had no way to get my baby to the clinic or doctor’s office

I didn’t have anyone to take care of my other children

Other: Please tell us:

Used by: AZ60, NM59

State Specific Questions

RI67. In general, how easy is it to calm your baby when he or she is crying or fussy?

Very easy

Somewhat easy

Somewhat difficult

Very difficult

RI68. During the last 2 weeks, how many hours did your baby cry and/or fuss on an average 24 hour day?

Less than 1 hour per day

Between 1 and 2 hours per day

Between 3 and 5 hours per day

More than 5 hours per day

Vaccinations

Standard Questions

X3. Did your new baby have any well-baby shots or vaccinations before he or she was 3 months old? Do not count shots or vaccinations given in the hospital right after birth.

Yes

My child has not had any well-baby shots, but he or she is not 3 months old yet

Used by: MT67, TX68, UT65

MI66. What are your plans for vaccinating your new baby?

My baby will be vaccinated the way my doctor recommends

My baby will get every vaccine, but at different times than my doctor recommends

My baby will get only some of the recommended vaccines

My baby will not get vaccines

Used by: KS73, MI66

Education

State Specific Questions

RI69. Are you or any other family member currently reading or looking at books with your baby?

Yes

NYC86. During the past week, how many days did you or other family members read, sing, or tell stories to your new baby?

No days

1 or 2 days

3 or 4 days

5 or 6 days

Everyday

RI70. If you or any other family member are not currently looking at books with your new baby, at what age do you think you will start reading or looking at books with your new baby?

3-11 months old

1-2 years old

3-4 years old

5 and older

I probably will not read to my baby/child

RI71. During the past week, how many days did you or other family members read or look at books with your baby?

Did not read to the baby this week

1-3 days this week

4-7 days this week

RI72. About how many children’s books do you have in your home?

None

1-5

6-10

11 or more

Infant Morbidity and Mortality

Core Questions

After your baby was delivered, how long did he or she stay in the hospital?

Less than 24 hours (less than 1 day)

24 to 48 hours (1 to 2 days)

3 to 5 days

6 to 14 days

More than 14 days

My baby was not born in a hospital

My baby is still in the hospital

Is your baby alive now?

Yes

Standard Questions

K16. After your baby was delivered, was he or she put in an intensive care unit (NICU)?

Yes

I don’t know

Used by: DE51, KY46, MS55, NJ57, NM39, OH52, UT48

State Specific Questions

RI73. Are you aware that babies are tested in the hospital for the following conditions? For each item check No if you are not aware of this or Yes if you are.

a. Hearing Loss

b. Conditions that run in families such as sickle cell disease and PKU

Infant Sleep Environment

Core Questions

In which one position do you most often lay your baby down to sleep now? Check ONE answer

On his or her side

On his or her back m

On his or her stomach

In the past 2 weeks, how often has your new baby slept alone in his or her own crib or bed?

Always

Often

Sometimes

Rarely

Never

When your new baby sleeps alone, is his or her crib or bed in the same room where you sleep?

Yes

Listed below are some more things about how babies sleep. How did your new baby usually sleep in the past 2 weeks. For each item, check No if your baby did not usually sleep like this, or Yes if he or she did.

No Yes

In a crib, bassinet, or pack and play
On a twin or larger mattress or bed
On a couch, sofa, or armchair
In an infant car seat or swing
In a sleeping sack or wearable blanket
With a blanket
With toys, cushions, or pillows, including nursing pillows
With crib bumper pads (mesh or non-mesh)

Did a doctor, nurse, or other health care worker tell you any of the following things? For each thing, check No if they did not tell you, or Yes if they did

No Yes

Place my baby on his or her back to sleep
Place my baby to sleep in a crib, bassinet or pack and play
Place my baby’s crib or bed in my room
What things should and should not go in bed with my baby

Standard Question

F4. Who does your new baby usually sleep with when he or she is not sleeping alone? Check ALL that apply

My husband or partner

Someone else: Please tell us:

Used by: AK61, KY60, PA67

Influenza and Maternal Vaccinations

Core Questions

During the 12 months before the delivery of your new baby, did a doctor, nurse, or other health care worker offer you a flu shot or tell you to get one?

Yes

During the 12 months before the delivery of your new baby, did you get a flu shot? Check ONE answer

Yes, before my pregnancy

Yes, during my pregnancy

Standard Questions

L3. Have you ever had chickenpox (varicella) or been vaccinated for chickenpox?

Yes

Used by: MN79

L24. During your most recent pregnancy, did you get a Tdap shot or vaccination? A Tdap

vaccination is a tetanus booster shot that also protects against pertussis (whooping cough).

Yes

I don’t know

Used by: AR26, DE28, HI21, IA21, LA22, MA26, MI23, MN22, MO29, MS26, MT78, NE33, NH17, NYC78, NYS21, OK20, PA28, TX25, UT23, VA24, VT22, WA22, WI23

CO74. Did you receive a Tdap vaccination before, during, or after your most recent pregnancy? A Tdap

vaccination is a shot that protects against tetanus, diphtheria, and pertussis (whooping cough). Tdap was new in 2005.

Yes, I received Tdap before my pregnancy

Yes, I received Tdap during my pregnancy

Yes, I received Tdap after my pregnancy

I don’t know

L14. What were your reasons for not getting a flu shot during the 12 months before the birth of your new baby? For each item, check No if it was not a reason for you or Yes if it was.

No Yes

a. My doctor didn’t mention anything about a flu shot

b. I was worried about side effects of the flu shot for me

c. I was worried that the flu shot might harm my baby

d. I was not worried about getting sick with the flu

e. I do not think the flu shot works

f. I don’t normally get a flu shot

g. Other

Please tell us:

Used by: MT25, NYC26, RI20, WA21

L19. Where did you get your flu shot? Check ONE answer

My obstetrician or gynecologist's office

My family doctor or other doctor's office

A health department or community clinic

A hospital

A pharmacy, drug store, or grocery store

My work place or school

Other place: Please tell us:

Used by: NYC25

Injury Prevention/Safety

General

Standard Questions

S1. Listed below are some statements about safety. For each one, check No if it does not apply to you or Yes if it does.

No Yes

a. I always used a seatbelt during my most recent pregnancy

b. My home has a working smoke alarm

c. There are loaded guns, rifles, or other firearms in my home

d. I have received information about infant products that should be taken off the market

(product recalls) since my new baby was born

Used by: IA74, PA84, TN83

S13. Have you ever heard or read about what can happen if a baby is shaken?

Yes

Used by: IA75, KY57, RI49, VA60

S14. Was the house or apartment you live in now built after 1977?

Yes

I don’t know

Used by: SC83

S15. Listed below are some things that may have happened since you moved into your house or apartment. For each one, check No if it does not apply to you or Yes if it does.

No Yes

I have had the home tested for lead
I have made changes to the home to remove paint or other things that have lead in them
The home was remodeled before I moved in

Used by: SC84

State specific questions

IA76. Have you shared what you know about the danger of shaking a baby with anyone else who takes care of your new baby?

Yes

ME81. Have you ever heard or read about what can happen if a baby is shaken from any of the following sources?

Magazine

Radio or television

Doctor, nurse, or other health care worker

Book

Family or friends

The Period of Purple Crying video

Other: Please tell us

ME82. Which of the following do you think is the most common cause of lead poisoning in children?

Drinking water

Dust from paint

Food

Toys

I don’t know or I am unsure

NH80. Listed below are some statements about safety. For each one, check No if it does not apply to you or Yes if it does.

I always used a seatbelt during my most recent pregnancy

My home has a working smoke alarm

My new baby always rides in a rear-facing car seat

The Poison Control Center phone number (1-800-222-1222) is accessible in my home

I know how to perform baby CPR

My home has a working carbon monoxide alarm

A health care worked talked with me about what happens if a baby is shaken

A health care worker talked with me about what to do for a crying baby to quiet him or her

Used by: NH80, KS74

Maternal Seat Belt Use

Standard Questions

R22. During any of your prenatal care visits, did a doctor, nurse, or other health care worker talk with you about any of the things listed below? Please count only discussions, not reading materials or videos. For each item, check No if no one talked with you about it or Yes if someone did.

No Yes

Using a seat belt during my pregnancy

S2. Did you worry that wearing your seat belt during pregnancy would hurt your new baby?

Yes

Used by: VA80

S4. During the last 3 months of your most recent pregnancy, how often did you wear a seat belt when you drove or rode in a car?

Always

Often

Sometimes

Rarely

Never

Used by: M076

Infant Car Seat Use

Standard Questions

S3. Listed below are some statements about infant car seats. For each one, check True if you agree with the statement or False if you do not agree.

True False

a. New babies should be in rear-facing car seats

b. Car seats should not be placed in front of an air bag

Used by: VT81

S6. When your new baby rides in a car, truck, or van, how often does he or she ride in an infant car seat?

Always

Often

Sometimes

Rarely

Never

Used by: MT83, PA85, TN84, VT80

S7. When your new baby rides in an infant car seat, is he or she usually in the front or back seat of the car, truck, or van?

Front seat

Back seat

Used by: TN85

S8. When your new baby rides in an infant car seat, is he or she usually facing forward or facing the rear of the car, truck, or van?

Facing forward

Facing the rear

Used by: TN86

S10. Do you have an infant car seat(s) that you can use for your new baby?

Yes

Used by: MT82, ND69, NH81, UT78, VT77

S11. How did you get your new baby’s infant car seat(s)? Check ALL that apply

I bought a car seat new

I received it new for this baby as a gift

I had one from another one of my babies

I bought a car seat used

I borrowed a car seat from a friend or family member

I borrowed or rented a car seat from a loaner program

The hospital where my new baby was born gave me a car seat

A community program gave me a car seat

Other: Please tell us:

Used by: VT78

S12. How did you learn to install and use your infant car seat(s)? Check ALL that apply

I read the instructions

A friend or family member showed me

A health or safety professional showed me

I figured it out myself

I already knew how to install it because I have other children

Some other way: Please tell us:

Used by: MT84, ND70, NH82, VT79

Marijuana

Supplemental Questions

At any time during the 3 months before you got pregnant OR during your most recent pregnancy, did you use marijuana or hash in any form?

No  Go to Question 6

Yes

During the 3 months before you got pregnant, how often did you use marijuana products in an average week?

Daily

2-3 times per week

Once a week

2-3 times per month

Once a month or less

I did not use in the 3 months before my pregnancy

During your most recent pregnancy, how often did you use marijuana products in an average week?

Daily

2-3 times per week

Once a week

2-3 times per month

Once a month or less

I did not use during my pregnancy  Go to Question 6

During your most recent pregnancy, how did you use marijuana? Check ALL that apply

Smoked it

Ate it

Drank it

Vaporized it

Dabbed it

Other  Please tell us: _________________

Why did you use marijuana products during pregnancy? For each one, mark No if it was not a reason for you or Yes if it was.

No Yes

a. To relieve nausea

b. To relieve vomiting

c. To relieve stress or anxiety

d. To relieve symptoms of a chronic condition

e. To relieve pain

f. For fun or to relax

g. Other  Please tell us: ________________________

During any of your prenatal care visits, did a doctor, nurse, or other health care worker do any of the following things? Please include if they asked you on a written form or in a conversation. For each one, mark No if they did not do this or Yes if they did.

No Yes

a. Ask you if you were using marijuana

b. Recommend that you use marijuana for any reason

c. Advise you not to use marijuana

d. Advise you not to breastfeed your baby while using marijuana

During any of your prenatal care visits, did a doctor, nurse, or other health care worker refer you to treatment because of drug use (prescribed or non-prescribed drugs)?

Yes

I did not use any drugs (or only used over-the-counter pain relievers) during my pregnancy

Since your new baby was born, have you used marijuana or hash in any form?

Yes

9. How long do you think it is necessary for a woman to wait after using marijuana to breastfeed her baby? Check ONE answer

I don’t think she needs to wait at all

I think it is best to wait until she is no longer high

I think it is best to wait at least 2-3 hours after she is no longer high

I don’t think it is safe to use marijuana at all while breastfeeding

During your most recent pregnancy, did you take prescription antidepressants or selective serotonin reuptake inhibitors (SSRIs) such as Prozac, Zoloft, or Lexapro?

Yes

11. During your most recent pregnancy, did you use prescription pain relievers such as hydrocodone (Vicodin®), oxycodone (Percocet®), or codeine?

No  Go to the end

Yes

How would you describe the way you got the prescription pain relievers that you used during your most recent pregnancy? Check ALL that apply

I had a current prescription

I had pain relievers left over from an old prescription

I got the pain relievers without a prescription

All Marijuana supplement questions used by: AK, ME, NM, NYS, PA, WV

Maternal Childhood Experiences

MIHA1. Some of these things might happen to people during childhood. Childhood experiences maybe important. Please tell us if any of these things ever happened to you from the time you were born through age 13.

a. Most of the time, I had an adult who believed in me and who I could count on to help me

b. A parent or guardian I lived with got divorced or separated

c. We had to move because of problems paying the rent or mortgage

d. Someone in my family or I went hungry because we could not afford enough food

e. A parent or guardian got in trouble with the law or went to jail

f. A parent or guardian I lived with had a serious drinking or drug problem

g. I was in foster care (removed from my home by the court or child welfare agency)

Used by: DC63, KS65, MI75, RI78

MIHA2. Thinking back to your childhood thought age 13, how often was it hard for your family to pay for basic needs like food or housing?

Very Often

Somewhat often

Not very often

Never

Used by: DC64, MI76, RI79

Maternal Health – General

Core Question

During the 3 months before you got pregnant with your new baby, did you have any of the following health conditions? For each one, check No if you did not have the condition or Yes if you did.

No Yes

Type 1 or Type 2 diabetes (NOT gestational diabetes or diabetes that starts during pregnancy)
High blood pressure or hypertension
Depression
State-added options from Standard L11

Standard Questions

L11. During the 3 months before you got pregnant with your new baby, did you have any of the following health conditions? For each one, check No if you did not have the condition or Yes if you did.

No Yes

a. Asthma

b. Anemia (poor blood, low iron)

c. Heart problems

d. Epilepsy (seizures)

e. Thyroid problems

f. PCOS (polycystic ovarian syndrome)

g. Anxiety

Used by: AR45, CT7, DE8, FL5, HI4, IA4, MD7, ME4, MI4, MN4, MO8, MS8, NJ7, NYC5, NYS4, OK4, PA9, UT7, WA4, WI7, WV5

Note: Response options for L11 will now be added directly to Core 4 if this question is selected.

L4. Have you ever taken medicine on a regular basis to control seizures or epilepsy?

Yes

Used by: NJ81

L5. During your most recent pregnancy, did you take medicine on a regular basis to control seizures or epilepsy?

Yes

Used by: NJ82

L10. Before you got pregnant, would you say that, in general, your health was—

Excellent

Very good

Good

Fair

Poor

Used by: MD6, NYC4, WI6, WV4

L30. Have you ever experienced any of the following health problems? For each condition, check No if you have not experienced it or Yes if you have.

No Yes

Irregular periods (menstruation)
Skin condition that causes pimples (acne)
Increased hair growth on the face, chest or other parts of the body
Being overweight or obese

Used by: UT75

L31. Have you ever been told that you have Polycystic Ovarian Syndrome or PCOS by a doctor, nurse or other health care provider?

Yes

I don’t know

Used by: UT76

NH70. Have you ever been diagnosed with Lyme disease?

Yes

I don’t know

NH71. Have you used any of the following sources to find information on pregnancy issues?

Internet search (such as Google)

Text messages

Social media (such as Facebook, Twitter)

Online discussion forum (sometimes called a bulletin board)

Magazine

Book

DVD Video

Online video (such as YouTube)

Cell phone apps

Other: Please tell us:

RI75. Have you ever been told by a doctor, nurse, or other health care worker that you had asthma?

Yes

RI76. Do you still have asthma?

Yes

Maternal Hospital Stay

Core Question

When was your new baby born?

Month/Day/Year

Standard Questions

K15. When were you discharged from the hospital after your baby was born?

Month/Day/Year

Used by: NJ55

Maternal Nutrition

Weight and Diet

Core Questions

How tall are you without shoes?

Feet and Inches

OR Centimeters

Just before you got pregnant with your new baby, how much did you weigh?

Pounds OR Kilos

Standard Question

II1. How much weight did you gain during your most recent pregnancy? Check ONE answer and fill in blank if needed.

I gained _______ pounds OR _______kilos

I didn’t gain any weight during my pregnancy

I don’t know

Used by: AK48, DE50, MS54, NJ56, SC53, WA42

G7a. During the last 3 months of your most recent pregnancy, about how many servings of fruit did you have in a day? Check ONE answer

Zero servings (none)

1 or 2 servings per day

3 or 4 servings per day

5 or more servings per day

Used by: TX78

G7b. During the last 3 months of your most recent pregnancy, about how many servings of vegetables did you have in a day? Check ONE answer

Zero servings (none)

1 or 2 servings per day

3 or 4 servings per day

5 or more servings per day

Used by: TX79

Vitamin Use and Folic Acid

Core Question

During the month before you got pregnant with your new baby, how many times a week did you take a multivitamin, a prenatal vitamin, or a folic acid vitamin?

I didn’t take a multivitamin, prenatal vitamin, or folic acid vitamin in the month before I got pregnant

1 to 3 times a week

4 to 6 times a week

Every day of the week

Standard Questions

G1. Have you ever heard or read that taking a vitamin with folic acid can help prevent some birth defects?

Yes

Used by: AK22, AL27, IL25, IN19, SC26, TX22

G2. Have you ever heard about folic acid from any of the following? Check ALL that apply

Magazine or newspaper article

Radio or television

Doctor, nurse, or other health care worker

Book

Family or friends

Other: Please tell us:

Used by: IL26, IN20

G3. Some health experts recommend taking folic acid for which one of the following reasons? Check ONE answer

To make strong bones

To prevent birth defects

To prevent high blood pressure

I don’t know

Used by: NYS18, SC28

G4. Which of the following things would cause you to take multivitamins, prenatal vitamins, or folic acid vitamins? Check ALL that apply

I didn’t usually eat the right foods

It prevented heart disease

It was good for my general health

It would help me have a healthy baby someday

My family or friends said it was a good idea

My doctor or nurse said it was a good idea

Used by: SC29

G5. During the last 3 months of your most recent pregnancy, how many times a week did you take a multivitamin, a prenatal vitamin, or a folic acid vitamin?

I did not take a multivitamin, prenatal vitamin or folic acid vitamin at all

1 to 3 times a week

4 to 6 times a week

Every day of the week

Used by: AL26, OH22, PR18, SC25

G6. During the past month, how many times a week did you take a multivitamin, a prenatal vitamin, or a folic acid vitamin?

I did not take a multivitamin, prenatal vitamin, or folic acid vitamin at all

1 to 3 times a week

4 to 6 times a week

Every day of the week

Used by: OH88, SC82

G8. During the month before you got pregnant with your new baby, what were your reasons for not taking multivitamins, prenatal vitamins, or folic acid vitamins? Check ALL that apply.

I wasn’t planning to get pregnant

I didn’t think I needed to take vitamins

I didn’t want to take vitamins

The vitamins were too expensive

The vitamins gave me side effects (such as nausea or constipation)

Other: Please tell us

Used by: FL7, IN6, MO10, MT9, OH8, SD9, TN10, UT9

Food Insufficiency

Standard Questions

P14. During the 12 months before your new baby was born, did you ever eat less than you felt you should because there wasn’t enough money to buy food?

Yes

Used by: CO42, IA40, KS38, ME41, MO48, NM33, OH45, OR33, PA50, WI43, WY32

P17. During the 12 months before your new baby was born, did you ever get emergency food from a church, a food pantry, or a food bank, or eat in a food kitchen?

Yes

Used by: AL50, ME42, MN40, PA51, UT44

Mental Health

Core Questions

During the 3 months before you got pregnant with your new baby, did you have any of the following health conditions? For each one, check No if you did not have the condition or Yes if you did.

No Yes

Depression

During your most recent pregnancy, were you told by a doctor, nurse, or other health care worker that you had any of the following conditions? For each one, check, No if you did not have the condition during your pregnancy, or Yes if you did.

No Yes

Depression

Since your new baby was born, how often have you felt down, depressed, or hopeless?

Always

Often

Sometimes

Rarely

Never

Since your new baby was born, how often have you had little interest or little pleasure in doing things you usually enjoyed?

Always

Often

Sometimes

Rarely

Never

Standard Questions

L11. During the 3 months before you got pregnant with your new baby, did you have any of the following health conditions? For each one, check No if you did not have the condition or Yes if you did.

g. Anxiety

M2. At any time during your most recent pregnancy or after delivery, did a doctor, nurse, or other health care worker talk with you about “baby blues” or postpartum depression?

Yes

Used by: AL78, PA83

M4. At any time during your most recent pregnancy, did you ask for help for depression from a doctor, nurse, or other health care worker?

Yes

Used by: NE41, NH24, PA38, UT30

M5. Since your new baby was born, has a doctor, nurse, or other health care worker told you that you had depression?

Yes

Used by: AZ70, CO69, CT69, DC61, FL70, IL71, NH63, NYC72, NYS70, OH76, PA80, TX77

M6. Since your new baby was born, have you asked for help for depression from a doctor, nurse, or other health care worker?

Yes

Used by: AZ69, CT68, NE82, NH62, NYC71, NYS69, TX76

M7. How would you describe the time during your most recent pregnancy? Check ONE answer

One of the happiest times of my life

A happy time with few problems

A moderately hard time

A very hard time

One of the worst times of my life

Used by: DC67, RI64

M8. At any time during your most recent pregnancy, did you take prescription medicine for your depression?

Yes

Used by: MO35, NJ38, RI27

M9. At any time during your most recent pregnancy, did you get counseling for your depression?

Yes

Used by: RI26

M10. Since your new baby was born, have you taken prescription medicine for your depression?

Yes

Used by: CO70, FL72, IL72, NYC74, NYS72

M11. Since your new baby was born, have you gotten counseling for your depression?

Yes

Used by: AZ71, FL71, IL73, NYC73, NYS71

M12. Since your new baby was born, how often have you felt panicky?

Always

Often

Sometimes

Rarely

Never

Used by: AZ72, MD61

M13. At any time during your most recent pregnancy, did a doctor, nurse, or other health care worker tell you that you had anxiety?

Yes

Used by: NJ83

M14. At any time during your most recent pregnancy, did you ask for help for anxiety from a doctor, nurse, or other health care worker?

Yes

Used by: UT77

M15. Since your new baby was born, has a doctor, nurse, or other health care worker told you that you had anxiety?

Yes

Used by: AZ74

M16. Since your new baby was born, have you asked for help for anxiety from a doctor, nurse, or other health care worker?

Yes

Used by: AZ75, UT74

M17. At any time during your most recent pregnancy, did you take prescription medicine for your anxiety?

Yes

Used by: NJ84

M20. Since your new baby was born, have you gotten counseling for your anxiety?

Yes

Used by: AZ76

M21. Since your new baby was born, how often have you felt restless?

Always

Often

Sometimes

Rarely

Never

Used by: AZ73, MD62

State specific questions

OR60. During your most recent pregnancy, how often did you feel down, depressed, or hopeless?

Always

Often

Sometimes

Rarely

Never

OR61. During your most recent pregnancy, how often did you have little interest or little pleasure in doing things you usually enjoyed??

Always

Often

Sometimes

Rarely

Never

CO76. Since your new baby was born, have you participated in any of the following? For each one, check No if you did not participate or Yes if you did.

c. Counseling for depression of anxiety

d. Support group for depression of anxiety

IA69. The following questions ask about your emotional well-being during your most recent pregnancy. For each item, check No if it did not happen to you or Yes if it did.

a. I answered written questions asking me to rate my mood

b. A doctor, nurse, or other health care worker talked to me about postpartum depression

c. A doctor, nurse, or other health care worker told me I had depression

d. A doctor, nurse, or other health care worker recommended that I take a prescription medication for depression

e. I took medication for depression

f. A doctor nurse, or other health care worker recommended that I get counseling for depression

g. I received counseling for depression

Used by: IA69, IN74

IA70. The following questions ask about your emotional well-being since your new baby was born. For each item, check No if it did not happen to you or Yes if it did.

a. I answered written questions asking me to rate my mood

b. A doctor, nurse, or other health care worker told me I had depression

c. A doctor, nurse, or other health care worker recommended that I take a prescription medication for depression

d. I took medication for depression

e. A doctor nurse, or other health care worker recommended that I get counseling for depression

f. I received counseling for depression

Used by: IA70, IN76

NYC75. Since your new baby was born, was there a time when you thought you needed treatment of counseling for depression but didn’t get it?

Yes

Used by: KS76, NYC75

NYC76. What were your reasons for not getting treatment of counseling for depression? For each item, check No if it was not a reason for you or Yes it was.

a. I had trouble finding a provider that I liked

b. It seemed too difficult or overwhelmed

c. I was worried about the cost or could not afford it

d. I did not have time because of a job, childcare or another commitment

e. I could not find a provider who spoke my language

Used by: KS77, NYC76

MA79. Because of physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions?

Yes

DRUG2 During the month before you got pregnant, did you take or use any of the following drugs for any reason? For each item, check No if you did not use it or Yes if you did.

a. Prescription for depression or anxiety

Maternal Morbidity

Preconception

Core Question

During the 3 months before you got pregnant with your new baby, did you have any of the following health conditions? For each one, check No if you did not have the condition or Yes if you did.

No Yes

Type 1 or Type 2 diabetes (NOT gestational diabetes or diabetes that starts during pregnancy)
High blood pressure or hypertension
Depression

Standard Question

L11. During the 3 months before you got pregnant with your new baby, did you have any of the following health conditions? For each one, check No if you did not have the condition or Yes if you did.

No Yes

Asthma
Anemia (poor blood, low iron)
Heart problems
Epilepsy (seizures)
Thyroid problems
PCOS (polycystic ovarian syndrome)
Anxiety

Prenatal

Core Question

During your most recent pregnancy, were you told by a doctor, nurse, or other health care worker that you had any of the following conditions? For each one, check, No if you did not have the condition during your pregnancy, or Yes if you did.

No Yes

Gestational diabetes (diabetes that started during this pregnancy)
High blood pressure (that started during this pregnancy), pre-eclampsia or eclampsia
Depression

Standard Questions

N1. At any time during your most recent pregnancy, did a doctor, nurse, or other health care worker tell you to stay in bed for at least 1 week?

Yes

Used by: AL36

N3. How often were you able to follow your provider’s instruction to stay in bed?

Always

Often

Sometimes

Rarely

Never

Used by: AL37

N4. What types of support would have helped you to stay in bed for the recommended time? For each item, check No if it would have not helped or did not apply to you or Yes if it would have helped you.

No Yes

a. Help with child care

b. Help with housework

c. Knowing I wouldn’t lose my job

d. Money to make up for not working

e. Other

Please tell us:

Used by: AL38

N5. During your most recent pregnancy, did a doctor, nurse, or other health care worker give you a series of weekly shots of a medicine called Progesterone, Makena®, or 17P (17 alpha-hydroxyprogesterone) to try to keep your new baby from being born too early?

Yes

I don’t know

Used by: CO29, CT32, DC25, LA27, MA32, ME25, MN27, MO36, MS33, ND23, NH25, PR26, SC35, SD28, TX30, UT31, VA31, WI30

N6. During your most recent pregnancy, when you were told that you had gestational diabetes, did the doctor, nurse, or other health care worker tell you to make an appointment with a different doctor because of your gestational diabetes?

Yes

Used by: AR32

N7. During your most recent pregnancy, when you were told that you had gestational diabetes, did a

doctor, nurse, or other health care worker do any of the things listed below? For each item, check No

if it was not done or Yes if it was done.

No Yes

a. Refer you to a nutritionist

b. Talk to you about the importance of exercise

c. Talk to you about getting to and staying at a healthy weight after delivery

d. Suggest that you breastfeed your new baby

e. Talk to you about your risk for Type 2 diabetes

Used by: AR33, NYS32

N8b. Did you go to the hospital or emergency room because of any of the problem(s) listed above?

Yes

Used by: AL34

N8c. How many times did you go to the hospital or emergency room because of the problem(s)?

1 time

2 times

3 times

4 or more times

Used by: AL35

N9. Did you have any of the following problems during your most recent pregnancy? For each item, check No if you did not have the problem or Yes if you did.

No Yes

Vaginal bleeding
Kidney or bladder (urinary tract) infection (UTI)
Severe nausea, vomiting, or dehydration that sent me to the doctor or hospital
Cervix had to be sewn shut (cerclage for incompetent cervix)
Problems with the placenta (such as abruptio placentae or placenta previa)
Labor pains more than 3 weeks before my baby was due (preterm or early labor)
Water broke more than 3 weeks before my baby was due (premature rupture of membranes [PROM])
I had to have a blood transfusion
I was hurt in a car accident

Used by: AL33, DC24, DE33, OK23

Postpartum

Standard Questions

L30. Have you ever experienced any of the following health problems? For each condition, check No if you have not experienced it or Yes if you have.

No Yes

Irregular periods (menstruation)
Skin condition that causes pimples (acne)
Increased hair growth on the face, chest or other parts of the body
Being overweight or obese

Used by: UT75

O1. Since your new baby was born, have you had any medical problems that caused you to go to the hospital and stay overnight?

Yes

Used by: OK57

O3. What kind of medical problem caused you to go into the hospital? Check ALL that apply

Vaginal bleeding

Fever or infection

Other: Please tell us:

Used by: OK58

O4. Since your new baby was born, have you been tested for diabetes or high blood sugar?

Yes

Used by: AR75, CO66, MN64

O5. Since your new baby was born, did a doctor, nurse, or other health care worker tell you that you had diabetes?

Yes

Used by: AR76

O6. Did a doctor, nurse, or other health care worker tell you that you had prediabetes, borderline diabetes or high blood sugar?

Yes

Used by: AR77

State Specific Questions

MI68. In the last week, how much time, on average, did you spend sleeping each night?

0-3 hours

4-6 hours

7-8 hours

9+ hours

MI69. In the last week, how many times, on average, did you wake up at night?

_________ Times

I don’t know

NH83. After your recent pregnancy, did you get follow-up care for any of the following? For each item, check No if you did not get it, check Yes if you did get it, or check DH if you didn’t have this condition.

a. Diabetes

b. Hypertension

c. Depression

d. Lyme Disease

Occupational Status & Work Place Leave

Standard Questions

C4. At any time during your most recent pregnancy, did you work at a job for pay?

Yes

Used by: GA73, LA70, MA69, MD68, MN71, MO77, NC72, NH72, NM75, NYC81, NYS73, OH81, OR65, TN80, VT70, WI77

C6. Which of the following best describes your work schedule during the last month of your most recent pregnancy? Check ONE answer

I worked up to the time of delivery with no change in schedule

I cut back on my work hours

I took time off before the birth of my baby

I stopped working due to doctor’s orders

I quit my job

I was laid off or fired from my job

Used by: MN72

C7. Have you returned to the job you had during your most recent pregnancy? Check ONE answer

No, and I do not plan to return

No, but I will be returning

Yes

Used by: LA72, MA70, MD69, MN73, MO78, NC73, NH75, NM76, NYC82, NYS74, OH84, OR66, TN81, VT71, WI78

C8. Did you take leave from work after your new baby was born? Check ALL that apply

I took paid leave from my job

I took unpaid leave from my job

State-specific options (Leave or disability programs)

I did not take any leave

Used by: LA73, MA71, MD70, MN74, MO79, NC74, NH76, NM77, NYC83, NYS75, OH85, OR67, TN82, VT72, WI79

C9. How did you feel about the amount of time you were able to take off after the birth of your new baby? Check ONE answer

Too little time

Just the right amount of time

Too much time

Used by: MD72, V74

C10. Did any of the things listed below affect your decision about taking leave from work after your new baby was born? For each item, check No if it does not apply to you or Yes if it does.

No Yes

I could not financially afford to take leave  
I was afraid I’d lose my job if I took leave or stayed out longer  
I had too much work to do to take leave or stay out longer  
My job does not have paid leave  
My job does not offer a flexible work schedule  
I had not built up enough leave time to take any or more time off  

Used by: LA74, MA73, MD73, MN76, MO81, NC76, NH78, NYC85, NYS77, OR69, VT75, WI81

C11. Did your baby's father take leave from work after your new baby was born? Check ONE answer

No, he did not take leave from his job

Yes, he took paid leave from his job

Yes, he took unpaid leave from his job

Yes, he took paid and unpaid leave from his job

My baby's father was unemployed

I don’t know

Used by: NC77, WI82

C12. Please tell us about your MAIN job during your most recent pregnancy. What was your job title and what were your usual activities or duties?

Job title:

Job duties:

Used by: GA74, LA71, NH73, OH82

C13. Thinking about your MAIN job during your most recent pregnancy, what type of company did you work for (what did the company do or make)?

Type of company:

I don’t know

Used by: GA75, NH74, OH83

C14. How many weeks or months of leave, in total, did you take or will you take?

Weeks OR Months

Less than 1 week

Used by: AR37, FL34, MA72, MD71, MN75, MO80, NC75, NH77, NYC84, NYS76, OR68, VT73, WI80

Oral Health

Core Questions

What type of health care visit did you have in the 12 months before you got pregnant with your new baby? Check ALL that apply

Regular checkup at my family doctor or general practitioner’s office

Regular checkup at my OB/GYN’s office

Visit for an illness or chronic condition

Visit for an injury

Visit for family planning or birth control

Visit for depression or anxiety

Visit to have my teeth cleaned by a dentist or dental hygienist

During your most recent pregnancy, did you have your teeth cleaned by a dentist or dental hygienist?

Yes

Standard Questions

Y3. Since your new baby was born, have you had your teeth cleaned by a dentist or dental hygienist?

Yes

Used by: HI71, MA77

Y5. During your most recent pregnancy, what kind of problem did you have with your teeth or gums? For each item, check No if you did not have this problem during pregnancy or Yes if you did.

No Yes

I had cavities that needed to be filled
I had painful, red, or swollen gums
I had a toothache
I needed to have a tooth pulled
I had an injury to my mouth, teeth, or gums
I had some other problem with my teeth or gums

Please tell us:

Used by: KY25, MS29, NH20, NYS24, PR23, UT26, WV25

Y6. Did any of the following things make it hard for you to go to a dentist or dental clinic during your most recent pregnancy? For each item, check No if it was not something that made it hard for you to go to a dentist during pregnancy or Yes if it was. No Yes

I could not find a dentist or dental clinic that would take pregnant patients
I could not find a dentist or dental clinic that would take Medicaid patients
I did not think it was safe to go to the dentist during pregnancy
I could not afford to go to the dentist or dental clinic

Used by: AZ24, CO26, CT29, DC22, HI24, IA24, IN25, KY27, MA29, MN25, MO32, NC30, ND20, NH21, NYS26, RI23, PR24, SD26, TX28, UT27, VA27, VT25, WA63, WI26, WV26

Y7. This question is about the other care of your teeth during your most recent pregnancy. For each item, check No if it is not true or does not apply to you or Yes if it is true.

No Yes

I knew it was important to care for my teeth and gums during my pregnancy
A dental or other health care worker talked with me about how to care for my teeth and gums
I had insurance to cover dental care during my pregnancy
I needed to see a dentist for a problem
I went to a dentist or dental clinic about a problem

Used by: AR28, AZ23, CO25, CT28, DC21, DE30, GA26, HI23, IA23, IN24, KY24, MA28, ME23, MN24, MO31, MS28, MT27, NC29, ND21, NE35, NH19, NJ32, NV24, NYC28, NYS23, PA30, PR22, RI22, SC33, TN34, TX27, UT25, VA26, VT24, WI25, WV24

Y8. Did you get treatment from a dentist or another doctor for the problem that you were having during your pregnancy? Check ONE answer

Yes, I got treatment during my pregnancy

Yes, I got treatment after my pregnancy

Yes, I got treatment both during and after my pregnancy

Used by: KY26, NYS25

State specific questions

FL77. During your most recent pregnancy, did a doctor, nurse, or other health care worker do any of the things listed below? For each item, check No if it is not true or does not apply to you or Yes if it is true.

Ask me about my teeth and gums

Look at my teeth and gums

Talk with me about visiting a dentist or dental hygienist

Help me get dental care

Give me information about taking care or my teeth and gums

Give me information about taking care of my baby’s teeth and gums

ME83. DO you have any insurance that pays for some or all of your dental care? Please include dental insurance, prepaid plans such as HMOs, or government plans such as MaineCare or Medicaid.

Yes

Pacifier Use

Infant

State specific

CO73. This question is about pacifier use in the hospital. For each state check, No if it did not apply or Yes if it did.

a. For calming

b. During a painful procedure

FL78. How often does your new baby go to sleep with a pacifier?

Always

Often

Sometimes

Rarely

Never

Parent and Infant Demographics

Infant

Core Question

When was your new baby born?

Month/Day/Year

Maternal

Core Question

What is your date of birth?

Month/Day/Year

State specific questions

OK65. When your first child was born, how old were you?

_______Years old

NM67. Are you Hispanic, Spanish, or Latina?

Yes

NM68. Which one or more of the following would you say is your race?

American Indian or Alaska Native

Tribe:_______________

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Other

Please tell us:

WY66. Are you a member of an American Indian tribe?

Yes

Used by: ND63, WY66

WY67. What is your tribal enrollment of your tribal affiliation?

Eastern Shoshone

Northern Arapahoe

Sioux

Crow

Northern Cheyenne

Shoshone Bannock

Other

Please tell us:

ND64. What is your tribal enrollment or primary tribal affiliation?

Three Affiliated Tribes (also known as MHA Nation, Mandan, Hidatsa, Arikara Nation, TAT, Nueta, and Sanhish)

Spirit Lake Tribe (also known as Santee Dakota, Devils Lake Sioux, Dakota Sioux, Mni Wakan, Oyate, Dakota)

Hunkpapa Lakota (also known as Standing Rock Sioux Tribe, Lakota, Hunkpapa, Sioux, Hunkpapa, Teton)

Turtle Mountain Band of Chippewa, Turtle Mountain Chippewa, Anishinabe, Ojibwa, Ojibway, Ojibwe, Saulteaux, Cree, Metis)

Other

Please tell us:

ND65. Is your baby’s father a member of an American Indian tribe?

Yes

ND66. What is your baby’s father’s tribal enrollment or primary tribal affiliation?

Three Affiliated Tribes (also known as MHA Nation, Mandan, Hidatsa, Arikara Nation, TAT, Nueta, and Sanhish)

Spirit Lake Tribe (also known as Santee Dakota, Devils Lake Sioux, Dakota Sioux, Mni Wakan, Oyate, Dakota)

Hunkpapa Lakota (also known as Standing Rock Sioux Tribe, Lakota, Hunkpapa, Sioux, Hunkpapa, Teton)

Turtle Mountain Band of Chippewa, Turtle Mountain Chippewa, Anishinabe, Ojibwa, Ojibway, Ojibwe, Saulteaux, Cree, Metis)

Other

Please tell us:

ND67. Is your baby a member of an American Indian tribe?

Yes

ND68. What is your baby’s tribal enrollment or primary tribal affiliation?

Three Affiliated Tribes (also known as MHA Nation, Mandan, Hidatsa, Arikara Nation, TAT, Nueta, and Sanhish)

Spirit Lake Tribe (also known as Santee Dakota, Devils Lake Sioux, Dakota Sioux, Mni Wakan, Oyate, Dakota)

Hunkpapa Lakota (also known as Standing Rock Sioux Tribe, Lakota, Hunkpapa, Sioux, Hunkpapa, Teton)

Turtle Mountain Band of Chippewa, Turtle Mountain Chippewa, Anishinabe, Ojibwa, Ojibway, Ojibwe, Saulteaux, Cree, Metis)

Other

Please tell us:

NM69. Which one of these best describes you?

American Indian or Alaska Native

Asian

Black or African American

Hispanic, Spanish, or Latina

Native Hawaiian or Other Pacific Islander

White

Other

Please tell us:

MA80. In what country were you born?

United States

Puerto Rico

Other Country

Please tell us:

Used by: DC73, MA80

MA81. How old were you when you moved to the United States?

____Age in years

Used by: DC74, MA81

ME84. Was the building built before 1950?

Yes

I don’t know or I am unsure

ME85. Do you own or rent the home?

Own

Rent

Other arrangement

Paternal

Standard Question

P6. When you got pregnant, how old was your new baby’s father?

Number of Years old

I don’t know

Used by: TX82

Parental Relationship

Standard Questions

P1. When you got pregnant, did your new baby’s father live with you?

Yes

Used by: OH78

P2. 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)

He was my boyfriend

He was a friend

Other: Please tell us

Used by: OH77

State specific questions

CT76. When your new baby’s father is with your baby, how often does he hug, kiss, hold, or play with the baby?

Always

Often

Sometimes

Rarely

Never

My new baby’ father doesn’t regularly spend time with my baby

Physical Activity

Standard Questions

L26. At any time during the 12 months before you got pregnant with your new baby, did you do any of the following things? For each item, check No if you did not do it or Yes if you did it.

No Yes

I was exercising 3 or more days of the week for fitness outside of my regular job

Used by: AK4, CT6, DE7, FL4, GA7, IL4, MO7, MS7, NC7, NE7, NV4, PA8, SD6, TN7

CC1. During the 3 months before you got pregnant with your new baby, how often did you participate in any physical activities or exercise for 30 minutes or more? For example, walking for exercise, swimming, cycling, dancing, or gardening.

Less than 1 day per week

1 to 2 days per week

3 to 4 days per week

5 or more days per week

I was told by a doctor, nurse, or other health care worker not to exercise

Used by: AL76, RI62

CC2. During the last 3 months of your most recent pregnancy, how often did you participate in any physical activities or exercise for 30 minutes or more?

Less than 1 day per week

1 to 2 days per week

3 to 4 days per week

5 or more days per week

I was told by a doctor, nurse, or other health care worker not to exercise

Used by: AL77, RI63

State specific questions

MA78. Do you have serious difficulty walking or climbing stairs?

Yes

OR75. Are you limited in any way in any activities because of physical, mental, or emotional problems?

Yes

Preconception Care and Readiness

Core Questions

In the 12 months before you got pregnant with your new baby, did you have any health care visits with a doctor, nurse, or other health care worker, including a dental worker?

Yes

What type of health care visit did you have in the 12 months before you got pregnant with your new baby? Check ALL that apply

Regular checkup at my family doctor or general practitioner’s office

Regular checkup at my OB/GYN’s office

Visit for an illness or chronic condition

Visit for an injury

Visit for family planning or birth control

Visit for depression or anxiety

Visit to have my teeth cleaned by a dentist or dental hygienist

Other: Please tell us:

During any of your health care visits in the 12 months before you got pregnant, did a doctor, nurse or other health care worker do any of the following things? For each item, check No if they did not or Yes if they did.

No Yes

Tell me to take a vitamin with folic acid
Talk to me about maintaining a healthy weight
Talk to me about controlling any medical conditions such as diabetes or high blood pressure
Talk to me about my desire to have or not have children
Talk to me about using birth control to prevent pregnancy
Talk to me about how I could improve my health before a pregnancy
Ask me if I was smoking cigarettes
Ask me if someone was hurting me emotionally or physically
Ask me if I was feeling down or depressed
Ask me about the kind of work I do
Test me for sexually transmitted infections such as chlamydia, gonorrhea, or syphilis
Test me for HIV (the virus that causes AIDS)

Standard Questions

J5. Why didn’t you have any health care visits in the 12 months before you for pregnant with your new baby?

I didn’t have health insurance to cover the cost of the visit

I felt fine and did not think I needed to have a visit

I couldn’t get an appointment when I wanted one

I didn’t have any transportation to get to the clinic or doctor’s office

I had too many things going on

I couldn’t take time off from work

Other: Please tell us_____________________

Used by: MN7, PR7

L18. Before you got pregnant with your new baby, did a doctor, nurse, or other health care worker talk with you about any of the things listed below about preparing for a pregnancy? Please count only discussions, not reading materials or videos. For each item, check No if no one talked with you about it or Yes if someone talked with you about it.

No Yes

Getting my vaccines updated before pregnancy
Visiting a dentist or dental hygienist before pregnancy
Getting counseling for any genetic diseases that run in my family
Getting counseling or treatment for depression or anxiety
The safety of using prescription or over-the-counter medicines during pregnancy
How smoking during pregnancy can affect a baby
How drinking alcohol during pregnancy can affect a baby
How using illegal drugs during pregnancy can affect a baby

Used by: AR10, AZ10, DE14, FL12, IL11, KY10, NE14, NJ13, RI10, SC10, TN15, VT10, WV11

No Yes

I was dieting (changing my eating habits) to lose weight
I was exercising 3 or more days of the week for fitness outside of my regular job
I was regularly taking prescription medicines other than birth control
A health care worker checked me for diabetes
I talked to a health care worker about my family medical history

Used by: AK4, CT6, DE7, FL4, GA7, IL4, MO7, MS7, NC7, NE7, NV4, PA8, SD6, TN7

L27. Before you got pregnant with your new baby, did a doctor, nurse or other health care worker talk to you about preparing for a pregnancy?

Yes

Used by: AR9, AZ9, DE13, FL11, IL10, KY9, MT13, NE13, NJ12, NV10, RI9, SC9, TN14, VT9, WV10

Pregnancy Intention

Maternal

Core Question

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

Maternal

Standard Questions

Q1. Which of the following statements best describe you during the 3 months before you got pregnant?

I was trying to get pregnant

I was trying to keep from getting pregnant but was not trying very hard

I was trying hard to keep from getting pregnant

Used by: IN68

Q4. How much longer did you want to wait to become pregnant?

Less than 1 year

1 year to less than 2 years

2 years to less than 3 years

3 years to 5 years

More than 5 years

Used by: CO14, MS17, NJ20, NYC14, PA18, TN20

Q6. How did you feel when you found out you were pregnant with your new baby?
Were you—

Very unhappy to be pregnant

Unhappy to be pregnant

Not sure

Happy to be pregnant

Very happy to be pregnant

Used by: IN69, ME76

Paternal/Partner

Standard Questions

Q3. Thinking back to just before you got pregnant with your new baby, how did your husband or partner feel about your becoming pregnant? Check ONE answer

He wanted me to be pregnant sooner

He wanted me to be pregnant later

He wanted me to be pregnant then

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

I don’t know

I didn’t have a husband or partner

Used by: MD63

Prenatal Care

Core Questions

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

During any of your prenatal care visits, did a doctor, nurse, or other health care worker ask you—

No Yes

If you knew how much weight you should gain during pregnancy
If you were taking any prescription medication
If you were smoking cigarettes
If you were drinking alcohol
If someone was hurting you emotionally or physically
If you were feeling down or depressed
If you were using drugs such as marijuana, cocaine, crack, or meth
If you wanted to be tested for HIV (the virus that causes AIDS)
If you planned to breastfeed your new baby
If you planned to use birth control after your baby was born

Standard Questions

R1. How did you feel about the prenatal care you got during your most recent pregnancy? If you went to more than one place for prenatal care, answer for the place where you got most of your care. For each item, check No if you were not satisfied or Yes if you were satisfied.

Were you satisfied with—

No Yes

a. The amount of time you had to wait

b. The amount of time the doctor, nurse, or midwife spent with you

c. The advice you got on how to take care of yourself

d. The understanding and respect shown toward you as a person

Used by: DC17, MS22, NE29, NM19, WI20

R14. During any of your prenatal care visits, did a doctor, nurse, or other health care worker talk with you about how eating fish containing high levels of mercury could affect your baby?

Yes

Used by: FL75, RI16

R15. Where did you go most of the time for your prenatal care visits? Do not include visits for WIC. Check ONE answer

Private doctor’s office

Hospital clinic

Health department clinic

State-specific option

Other: Please tell us:

Used by: IL22, KS17, MS19, NE27, NM17, NYC21, SC21, TX19

R16. During your most recent pregnancy, did a doctor, nurse, or other health worker talk with you about any of the things listed below? Please count only discussions, not reading materials or videos. For each one, check No if no one talked with you about it or Yes if someone did.

No Yes

Foods that are good to eat during pregnancy
Exercise during pregnancy
Programs or resources to help me gain the right amount of weight during pregnancy
Programs or resources to help me lose weight after pregnancy

Used by: IA17, PR16

R17. How much weight did your doctor, nurse, or other health care worker tell you to gain during your most recent pregnancy? Please check ONE answer and fill in the blank(s) next to the checked box.

Between Pounds and Pounds

Between Kilos and Kilos

Exactly Pounds OR Kilos

I don’t remember

Used by: CO21

R18. During any of your prenatal care visits, did a doctor, nurse, or other health care worker advise you not to drink alcohol while you were pregnant?

Yes

Used by: AK20, VT19

R19. How many weeks or months pregnant were you when you were sure you were pregnant? For example, you had a pregnancy test or a doctor or nurse said you were pregnant.

[BOX] Weeks OR [BOX] Months

I don’t remember

Used by: DE21, ME16, NC21, NJ24, OK15

R20. Did you get prenatal care as early in your pregnancy as you wanted?

Yes

Used by: AK17, AL20, CT22, DC14, DE23, FL22, IL20, IN16, KS15, LA17, ME18, MI18, MN17, MO24, NC23, ND14, NE25, NJ26, NM15, NV18, PA22, SD20, SDT17, TN26, TX17, VA18, WI17

R21. Did any of these things keep you from getting prenatal care when you wanted it? For each item, check No if it did not keep you from getting prenatal care or Yes if it did.

No Yes

I couldn’t get an appointment when I wanted one
I didn’t have enough money or insurance to pay for my visits
I didn’t have any transportation to get to the clinic or doctor’s office
The doctor or my health plan would not start care as early as I wanted
I had too many other things going on
I couldn’t take time off from work or school
I didn’t have my Medicaid (or state Medicaid name) card
I didn’t have anyone to take care of my children
I didn’t know that I was pregnant
I didn’t want anyone else to know I was pregnant
I didn’t want prenatal care

Used by: AK16, AL21, CT23, DC15, DE24, FL23, IL21, IN17, KS16, LA18, MI19, MN18, MO25, NC24, ND15, NE26, NJ27, NM16, NV19, PA23, SD21, SDT18, TN27, TX18, VA19, WI18

No Yes

How smoking during pregnancy could affect my baby
Breastfeeding my baby
How drinking alcohol during pregnancy could affect my baby
Using a seat belt during my pregnancy
Medicines that are safe to take during my pregnancy
How using illegal drugs could affect my baby
Doing tests to screen for birth defects or diseases that run in my family
The signs and symptoms of preterm labor (labor more than 3 weeks before the baby is due)
What to do if I feel depressed during my pregnancy or after my baby is born
Physical abuse to women by their husbands or partners

Used by: AL22, AR20, CO19, IL23, MS20, PA24, PR16, R16TN28, TX20, VT17, WV19

R23. During your most recent pregnancy, did you take a class or classes to prepare for childbirth and learn what to expect during labor and delivery?

Yes

Used by: MT28, NE36, NJ33, PA31, TN35

State specific questions

DE76. During any of your prenatal care visits, did a doctor, nurse, or other health care worker talk with you about fetal (baby) kick counts and how to do them? Please count only discussions, not reading materials or videos.

Yes

FL76. Did you take action to avoid eating fish containing high levels or mercury during your pregnancy?

Yes

NC71. During any of your prenatal care visits, did a doctor, nurse, or other health care worker talk with you about any of the following? For each item, check No if no one talked with you about it or Yes if someone did.

a. The “baby blues” or postpartum depression

b. What happens if a baby is shaken

c. What you might do with a crying baby to quiet him or her

d. Smoking or tobacco use

e. Second-hand smoke

ND62. The newborn blood spot screening test identifies babies at risk for certain disorders that may cause serious illness, disability, or death if not identified early. During your most recent pregnancy, did you read or hear anything about newborn blood spot screening from any of the following? Check ALL that apply

Indoor/outdoor billboards

Prenatal clinic or doctor’s office

Information packet from hospital

Health or Baby Fair

Social Media – Facebook/Instagram

Other: Please tell us:

I did not hear about newborn blood spot screening while pregnant

NYC77. During any of your prenatal care visits, did a doctor, nurse, or other health care worker recommend that you get a Tdap shot or vaccination? A Tdap vaccination is a tetanus booster shot that also protects against pertussis (whooping cough).

Yes

Used by: MT77, NYC77

NYC79. During which trimester did you receive the Tdap shot?

First

Second

Third

I don’t remember

NYC80. What were your reasons for not getting a Tdap shot or vaccination during your most recent pregnancy? For each item, check No if it was not a reason for you or Yes if it was.

a. My doctor didn’t mention anything about a Tdap shot

b. I was worried about side effects of the Tdap shot for me

c. I was worried that the Tdap shot might harm my baby

d. I was not worried about getting sick with pertussis

e. I do not think the Tdap shot works

f. I don’t normally get a Tdap shot

g. My insurance did not cover the Tdap shot

h. I don’t have insurance and could not afford the Tdap shot

i. I cannot receive the Tdap shot for medical reasons

j. I cannot receive the Tdap shot for religious reasons

k. Other

Please tell us:

SD69. Were you able to go to all of your recommended prenatal visits?

Yes

SD70. Did any of these things keep you from going to your recommended prenatal visits? For each item, check No if it did not keep you from getting prenatal care or Yes if it did.

No Yes

a. I couldn’t get an appointment when I wanted one

b. I didn’t have enough money or insurance to pay for my visits

c. I didn’t have any transportation to get to the clinic or doctor’s office

d. I had too many other things going on

e. I couldn’t take time off from work of school

f. I didn’t have my Medicaid card

g. I didn’t have anyone to take care of my children

h. I didn’t want prenatal care

i. I was afraid I would be reported for using alcohol or drugs during pregnancy

j. Other

Please tell us:

WV69. The following are things a doctor, nurse, or other health care worker might have talked to you about during your pregnancy or after delivery? For each item, check No if no one talked with you about it or Yes if someone did.

a. High Risk Birth Score Program

b. Right from the Start Program

c. Immunization (shots) for my baby

d. Diabetes (how it may affect me and my baby)

Postpartum Care

Core Questions

Since your new baby was born, have you had a postpartum checkup for yourself? A postpartum checkup is the regular checkup a woman has about 4-6 weeks after she gives birth.

Yes

During your postpartum checkup, did a doctor, nurse, or other health care worker do any of the following things? For each item, check No if they did not do it or Yes if they did.

No Yes

Tell me to take a vitamin with folic acid
Talk to me about healthy eating, exercise, and losing weight gained during pregnancy
Talk to me about how long to wait before getting pregnant again
Talk to me about birth control methods I can use after giving birth
Give or prescribe me a contraceptive method such as the pill, patch, shot (Depo-Provera^®), NuvaRing^® or condoms
Insert an IUD (Mirena^®,ParaGard^®,or Skyla^®) or a contraceptive implant (Nexplanon^® or Implanon^®)
Ask me if I was smoking cigarettes
Ask me if someone was hurting me emotionally or physically
Ask me if I was feeling down or depressed
Test me for diabetes

Standard Questions

J2. Where did you go for your postpartum checkup?

My family doctor’s office

My OB/GYN’s office

Hospital clinic

Health department clinic

State-specific option

Other: Please tell us:

Used by: IL67, OH72

J3. Did any of these things keep you from having a postpartum visit? Check ALL that apply

I didn’t have health insurance to cover the cost of the visit

I felt fine and did not think I needed to have a visit

I couldn’t get an appointment when I wanted one

I didn’t have any transportation to get to the clinic or doctor’s office

I had too many things going on

I couldn’t take time off from work

Other reason: Please tell us

Used by: AZ65, IA65, IL66, MD57, SC75, UT70, VA72, WI69

State Specific Questions

NJ89. Since your new baby was born, did a doctor, nurse home visitor, or other health care worker talk with you about any of the things listed below? Please count only discussion, not reading materials or videos. For each item, check No if no one talked with you about it or Yes it someone did.

a. Whether you’ve been feeling sad or anxious

b. What to do when your baby cries excessively and won’t stop

c. That shaking or hitting your baby can cause serious harm

d. Putting your baby to sleep safely on his/her back and in his/her own crib

e. Sharing information about topics like shaking babies, crying babies, and safe sleep with people who help you care for your baby, like your husband or partner, a family member, babysitter, or caregiver

NM74. Please read each statement below about how you feel about your baby’s crying? For each one, check No if it did not apply to you or Yes if it did.

a. I can always get my baby to stop crying

b. In the past week, I have carried my baby in my arms or in a cloth baby carrier for 5 or more hours every day

c. I think that picking up a baby every time he or she cried will spoil the baby

d. I sometimes feel overwhelmed by my baby’s crying

OR74. Do you have one or more persons you think of as your personal doctor or nurse? A personal doctor or nurse is a health professional who is familiar with our health history. This can be a general doctor, a specialist doctor, a nurse practitioner, or a physician assistant.

Yes

Used by: DC72, OR74

Questionnaire Details

Core Question

What is today’s date?

Month/Day/Year

Reproductive History

General

Standard Questions

P8. How old were you when you got pregnant with your first baby?

Years old

Used by: DE73

Previous Pregnancies

Standard Questions

FF1. During the 12 months before you got pregnant with your new baby, did you have a miscarriage, fetal death (baby died before being born), or stillbirth?

Yes

Used by: DE74, TN79

FF3. How long ago did that pregnancy end?

Less than 6 months before getting pregnant with my new baby

6 to 12 months before getting pregnant with my new baby

Used by: DE75

FF4. What is the age difference between your new baby and the child you delivered just before your new one?

0 to 12 months

13 to 18 months

19 to 24 months

More than 2 years but less than 3 years

3 to 5 years

More than 5 years

Used by: CT5, PA7, SD5

FF5. Before you got pregnant with your new baby, did you ever have any other babies who were born alive?

Yes

Used by: CT4, DE4, GA4, MA4, MD4, MO4, MS4, MT4, NC4, NE4, NJ4, OH4, PA4, SD4, TN4, UT4, WI4

FF6. Did the baby born just before your new one weigh 5 pounds, 8 ounces (2.5 kilos) or less at birth?

Yes

Used by: DE5, GA5, MO5, MS5, MT5, NC5, NE5, NJ5, OH5, PA5, TN5, UT5

FF7. Was the baby just before your new one born earlier than 3 weeks before his or her due date?

Yes

Used by: DE6, GA6, MA5, MO6, MS6, MT6, NC6, NE6, NJ6, PA6, TN6, UT6, WI5

Social Support

Standard Questions

W1. During your most recent pregnancy, who would have helped you if a problem had come up? For example, who would have helped you if you needed to borrow $50 or if you got sick and had to be in bed for several weeks? Check ALL that apply

My husband or partner

My mother, father, or in-laws

Other family member or relative

A friend

Religious community

Someone else: Please tell us:

No one would have helped me

Used by: KS69, WI75

W2. During your most recent pregnancy, would you have had the kinds of help listed below if you needed them? For each one, check No if you would have not had it or Yes if you would have had it.

No Yes

a. Someone to loan me $50

b. Someone to help me if I were sick and needed to be in bed

c. Someone to take me to the clinic or doctor’s office if I needed a ride

d. Someone to talk with about my problems

Used by: DE78, HI68, IA73, OH80, VT68

W3. Since you delivered your new baby, who would help you if a problem came up? For example, who would help you if you needed to borrow $50 or if you got sick and had to be in bed for several weeks? Check ALL that apply

My husband or partner

My mother, father, or in-laws

Other family member or relative

A friend

Religious community

Someone else: Please tell us:

No one would help me

Used by: CT73, KS75, MN77, WI76

W4. Since you delivered your new baby, would you have had the kinds of help listed below if you needed them? For each one, check No if you would not have it or Yes if you would.

No Yes

a. Someone to loan me $50

b. Someone to help me if I were sick and needed to be in bed

c. Someone to talk with about my problems

d. Someone to take care of my baby

e. Someone to help me if I were tired and feeling frustrated with my new baby

Used by: AK78, IA77, IL74, MA74, NC78, OK62, RI65, VT76

State specific questions

MI73. This questions is about your husband or partner, who may or may not be the father of your new baby. Please choose the statement that best describes the current living arrangement.

My husband or partner lives with me all of the time

My husband or partner lives with me some of the time

My husband or partner does not live with me

I do not have a husband or partner

MI74. The following states are about your husband or partner, who may or may not be the father of your baby, and the support they provide you at this time. For each one, check No if it is not true most of the time or Yes if it is true.

a. My partner is someone I can count on for financial support if I need it

b. My partner is someone I can talk with about things that are important to me

c. My partner is someone who is affectionate toward me

d. My partner is someone who helps me care for my child(ren)

e. My partner is someone who understands how I am feeling

f. My partner is someone who talks with me and spends time with me

g. My partner I someone whom I can count on

h. My partner is someone who does things with me

OR72. Would you have the kinds of help listed below if you needed them? For each one, check No if you would not have it or Yes if you would.

a. Someone to loan me money for food or bills if I needed it

b. Someone who would help me if I were sick and needed to be in bed

c. Someone who would take me to the clinic or doctor’s office if I needed a ride

d. Someone I can count on to listen to me when I need to talk

e. Someone who shows me love and affection other than a child

OR73. Below is a list of items neighbors sometimes do for each other. For each item, check N if they never do AN is they almost never do, S if they sometimes do, F if they fairly often do VO if they very often do.

a. Do favors for each other?

b. Ask each other advice about personal things such as child rearing or job openings?

c. Have partied or other get-togethers where other people in the neighborhood are invited?

d. Visit in each other’s homes or on the street?

e. Watch over each other’s property?

Social Services

Standard Questions

B12. (Phase 7, Core 27) During your most recent pregnancy, were you on WIC (the Special Supplemental Nutrition Program for Women, Infants, and Children)?

Yes

Used by: AK26, AL31, CO27, CT30, FL28, HI25, LA24, MA30, MO33, MS30, MT29, NE39, NH22, NJ35, NYC30, NYS28, PA36, RI24, TN38, UT28

V1. During your most recent pregnancy, did you get any of these services? For each one, check No if you did not get the service and Yes if you did.

No Yes

a. Parenting classes

b. Counseling for depression or anxiety

Used by: DC68, MN68

V2. Since your new baby was born, have you used any of these services? For each one, check No if you did not use the service or Yes if you did.

No Yes

a. Parenting classes

b. Counseling for depression or anxiety

Used by: DC70, DE79, GA76, MN78

V3. Since your new baby was born, have you used WIC services for yourself or your new baby?

Yes, both my new baby and I use WIC services

Yes, only my new baby uses WIC services

Yes, only I am using WIC services

Used by: ME79, NH79

V11. During your most recent pregnancy, did you feel you needed any of the following services? For each one, check No if you did not receive the service or Yes if you received the service.
No Yes

a. Food stamps or money to buy food

b. WIC (the Special Supplemental Nutrition Program for Women, Infants, and Children)

c. Counseling information for family and personal problems

d. Help to quit smoking

e. Help to reduce violence in your home

f. Other

Please tell us:

Used by: AZ77

V12. During your most recent pregnancy, did you receive any of the following services? For each one, check No if you did not receive the service or Yes if you received the service.
No Yes

a. Food stamps or money to buy food

b. WIC (the Special Supplemental Nutrition Program for Women, Infants, and Children)

c. Counseling information for family and personal problems

d. Help to quit smoking

e. Help to reduce violence in your home

f. Help to quit using drugs

g. Other

Please tell us:

Used by: AR80, AZ78, DE77, LA69, MN69, NV63

State specific questions

CO76. Since your new baby was born, have you participated in any of the following? For each one, check No if you did not participate or Yes if you did.

a. Parenting classes

b. Home visitation sessions

c. Counseling for depression of anxiety

d. Support group for depression of anxiety

State Specific questions

ME80. Why wasn’t your new baby enrolled in WIC?

I didn’t think my new baby would be eligible

I was told that my baby didn’t qualify for WIC

I’m not sure what WIC is

WIC hours did not fit my schedule

The WIC office was too far away

I don’t need the services that WIC offers

Other

Please tell us:

NM72. During the most recent pregnancy, did you receive any of the following services? For each one, check No if you did not receive the service or Yes if you did.

a. Counseling or a support group for depression

b. Class or support group to stop smoking cigarettes

c. Help to reduce violence in my home

d. Health Start

e. Families FIRST case management

f. Doula or midwife support

g. Home visiting program

NM73. Since your new baby was born, have you used any of these services? For each one, check No if you did not receive the service or Yes if you did.

a. A breastfeeding class or peer counseling support

b. WIC for me or my baby

c. Families FIRST case management

d. Health Start

e. Counseling or a support group for depression

f. Breastfeeding help from a hospital or clinic

g. Breastfeeding help from a community program or lactation consultant

h. Home visiting program

VA81. Please tell us if you have heard of the following Virginia programs For each one, check No if you have not heard about it or Yes if you have.

a. Quit Now Virginia (1-800-Quit-Now)

b. 2-1-1 Virginia

c. Text4baby

d. Virginia Department of Healthy Family Planning Clinics

e. Care Connection for Children

f. Loving Steps/Healthy Start

g. Nurse – Family Partnership (NFP)

h. Healthy Families

i. Part C Early Intervention

j. Project LINK

k. CHIP of Virginia

l. Safety Seat Check Station

m. Low Income Safety Seat Program

n. Head Start

o. Early Head Start

Stress & Discrimination

Standard Questions

P15. During the 12 months before your new baby was born, how often did you feel unsafe in the neighborhood where you lived?

Always

Often

Sometimes

Rarely

Never

Used by: DC37, FL42, IL43, LA39, MN41, MO49, OH46, PA52, RI37, VA44, WI44

P17. During the 12 months before your new baby was born, did you ever get emergency food from a church, a food pantry, or a food bank, or eat in a food kitchen?

Yes

Used by: AL50, ME42, MN40, PA51, UT44

P19. This question is about things that may have happened during the 12 months before your new baby was born. For each item, check No if it did not happen to you or Yes if it did. (It may help to look at the calendar when you answer these questions.)

No Yes

A close family member was very sick and had to go into the hospital
I got separated or divorced from my husband or partner
I moved to a new address
I was homeless or had to sleep outside, in a car, or in a shelter
My husband or partner lost their job
I lost my job even though I wanted to go on working
My husband, partner, or I had a cut in work hours or pay
I was apart from my husband or partner due to military deployment or extended work-related travel
I argued with my husband or partner more than usual
My husband or partner said they didn’t want me to be pregnant
I had problems paying the rent, mortgage, or other bills
My husband, partner, or I went to jail
Someone very close to me had a problem with drinking or drugs
Someone very close to me died

Used by: AK44, AL49, CO41, CT43, DE46, FL41, GA46, IA39, IL42, IN38, KS37, KY42, LA38, NV36, MA42, ME40, MI35, MN39, MO47, MS45, NC43, NE54, NYC41, NYS43, OH44, OK34, OR32, PA49, SDT34, TX43, UT43, WA35, WI42, WY31

BB1. During the 12 months before your new baby was born, did you feel emotionally upset (for example, angry, sad, or frustrated) as a result of how you were treated based on your race?

Yes

Used by: FL43, GA47, IA41, IN39, MN42, MO50, NC44, NJ50, NYC42, OH47, SC47, VA45, WI45, WY33

BB3. Since your new baby was born, how often would you say you have been worried or stressed about having enough money to pay your bills?

Always

Often

Sometimes

Rarely

Never

Used by: DC71, OH86, SDT67, WI83

State specific questions

MA82. How often do you think about your race?

Constantly

Once a day

Once a week

Once a month

Once a year

Never

CT70. During the 12 months before your new baby was born, how often did you experience discrimination, or harassment, or were made to feel inferior because of your race, ethnicity, or culture?

Always

Often

Sometimes

Rarely

Never

Used by: CT70, DC65

CT71. Did you ever feel you were treated unfairly in getting these kinds of services because of any of the following? For each item, check No if you were not treated unfairly or Yes if you were treated unfairly.

My race, ethnicity, or culture

My age

The language I speak

My citizenship

My insurance or Medicaid status

I felt unfairly treated for other reasons

Please tell us:

Used by: CT71, DC69

VA76. During the 12 months before your new baby was born, did you experience discrimination, harassment, or were you made to feel inferior because of the things listed below? For each item, check No if you did not experience these things or Yes if you did experience them.

My race, ethnicity, or culture

My insurance or Medicaid status

My weight

My marital status

Other

Please tell us:

LA66. Have you ever experienced discrimination (felt like you were treated worse than other people) while getting any type of health or medical care? For each item, check No if you have never experienced discrimination because of it or Yes if you have.

My race or skin color

My immigration status

My age

My income

My sex/gender

My sexual orientation

My religion

Because I was pregnant

The language I speak

My type of health insurance or my lack of health insurance

OR77. Have you ever experienced discrimination (felt like you were treated worse than other people) in a situation other than getting any type of health or medical care? For each item, check No if you have never experienced discrimination because of it or Yes if you have.

My race or skin color

My immigration status

My age

My income

My sex/gender

My sexual orientation

My religion

Because I was pregnant

The language I speak

My type of health insurance or my lack of health insurance

MN70. Did you experience discrimination by health care providers during your prenatal care, labor, or delivery because of the things listed below? For each item, check No if you did not experience discrimination or Yes if you experienced discrimination.

My race, ethnicity, or culture

My insurance or Medicaid status

My weight

My marital status

Other

Please tell us:

VT69. Did you experience discrimination by health care providers during your prenatal care, labor, or delivery because of the things listed below? For each item, check No if you did not experience discrimination or Yes if you experienced discrimination.

My race, ethnicity, or culture

My insurance or Medicaid status

My weight

My marital status

My age

Prescription use of Suboxone®, Methadone, or other drug addiction treatment

Other

Please tell us:

NH84. Did you ever feel you were treated unfairly in getting these kinds of services because of any of the following? For each item, check No if you were not treated fairly or Yes if you were treated unfairly.

Your race or ethnic group

Your age

Your language or accent

Substance addiction

Insurance type (Medicaid, other)

Body weight

Income level

Religion

Sexual orientation

Some other reason

Please tell us:

CT72. This question is about things that may have happened during your most recent pregnancy? For each item, check No if it did not happen to you or Yes if it did.

a. I felt that my race or ethnic background contributed to the stress in my life

b. I felt emotionally upset (for example, angry, sad, or frustrated) as a result of how I was treated based on my race or ethnic background

c. I experienced physical symptoms (for example, a headache, an upset stomach, tensing of my muscles, or a pounding heart) that I felt were related to how I was treated based on my race or ethnic background

NM70. Within the past 12 months, when seeking health care, did you feel your experiences were worse than, the same as, or better than for people of others races (or ethnicities)?

Worse than other races

The same as other races

Better than other races

Worse than some races, better than others

I only encountered people of the same race

I did not have health care in past 12 months

Don’t know/Not sure

CT74. Since your new baby was born, how often does your husband or partner provide you with encouragement and emotional support?

Always

Often

Sometimes

Rarely

Never

CT75. Since your new baby was born, how often does your new baby’s father contribute things such as money, food, clothing, shelter, or health care to provide for your new baby’s basic needs?

Always

Often

Sometimes

Rarely

Never

Used by: CT75, SDT68

MI62. During the 12 months before your new baby was born, how often did you feel that when you went to get health care you were treated worse than people of other races or cultures?

Never

Sometimes

Usually

Always

I did not get health care then

MI63. During your most recent pregnancy, which of the following statements about basic needs applied to you? For each item, check No if it was not true or Yes if it was.

a. I had affordable, reliable transportation

b. I skipped meals or ate less because

c. I had safe housing

d. I had consistent and stable housing

e. My house or apartment was too crowded

f. I could keep basic utility services on (heat, water, lights)

g. I had access to a telephone when needed

h. I had other basic needs that were not met

Please tell us:

Used by: KS68, MI63, SDT65

OR71. In the past 12 months, have you needed or received any of the following? For each item, check DN if you didn’t need it N if you needed it but did not get it NG if you needed it and did get.

a. Food stamps or money to buy food

b. Other financial assistance (for example, AFDC, TANF, subsidized rent, etc.)

c. Help with an alcohol or drug problem

d. Help to stop smoking

e. Help with transportation

f. Help paying for education or job training

g. Help with a family violence

h. Help or counseling for other family or other personal problems

Used by: OR71, SDT66

MI72. The following statements are about the way you handle life events. Please check all that are true for you most of the time.

I tend to bounce back quickly after hard times

I have a hard time making it through stressful events

It does not take me long to recover from a stressful event

It is hard for me to snap back when something bad happens

I usually come through a difficult time with little trouble

I tend to take a long time to get over set-backs in my life

Used by: MI72, SD73, SDT69

NYC87. In the last 30 days, have you been concerned about having enough food for you or your family?

Yes

NV1. The following questions refer to the time period before you were 18 years of age? For each item, check No if you did not do it or Yes if you did.

No Yes

a. Did you live with anyone who was depressed, mentally ill, or suicidal?

b. Did you live with anyone who was a problem drinker or alcoholic?

c. Did you live with anyone who used illegal street drugs or who abused

prescription medications?

d. Did you live with anyone who served time or was sentenced to serve

time in a prison, jail, or other correctional facility?

NV2. During the time period before you were 18 years of age did you parents get separated or divorced?

Yes

They were never married

I don’t know

SD74. While you were growing up, during the first 18 years of life:

No Yes

a. Were you parents ever separated or divorced?

b. Did you live with anyone who was a problem drinker or alcoholic or

who used street drugs?

c. Was a household member depressed or mentally ill, or did a household

member attempt suicide?

d. Did a household member go to prison?

e. Did an adult or person at least 5 years older than you ever touch or

fondle you or have you touch their body in a sexual way OR attempt

or actually have oral, anal, or vaginal intercourse with you?

Used by: ND71, SD74, SDT70

Tobacco & Other Nicotine Products

Product Use

Core Questions

Have you smoked any cigarettes in the past 2 years?

Yes

In the 3 months before you got pregnant, how many cigarettes did you smoke on an average day? A pack has 20 cigarettes.

41 cigarettes or more

21 to 40 cigarettes

11 to 20 cigarettes

6 to 10 cigarettes

1 to 5 cigarettes

Less than 1 cigarette

I didn’t smoke then

In the last 3 months of your pregnancy, how many cigarettes did you smoke on an average day? A pack has 20 cigarettes.

41 cigarettes or more

21 to 40 cigarettes

11 to 20 cigarettes

6 to 10 cigarettes

1 to 5 cigarettes

Less than 1 cigarette

I didn’t smoke then

How many cigarettes do you smoke on an average day now? A pack has 20 cigarettes.

41 cigarettes or more

21 to 40 cigarettes

11 to 20 cigarettes

6 to 10 cigarettes

1 to 5 cigarettes

Less than 1 cigarette

I don’t smoke now

The next questions are about using other tobacco products around the time of pregnancy.

E-cigarettes (electronic cigarettes) and other electronic nicotine vaping products (such as vape pens, e-hookahs, hookah pens, e-cigars, e-pipes) are battery-powered devices that use nicotine liquid rather than tobacco leaves, and produce vapor instead of smoke.

Hookahs are water pipes used to smoke tobacco. These are not e-hookahs or hookah pens.

Have you used any of the following products in the past 2 years? For each item, check No if you did not use it, or Yes if you did.

No Yes

E-cigarettes or other nicotine-containing e-vaping products
Hookah
State added option (Chewing tobacco, snuff, snus, or dip)
State added option (Cigars, cigarillos, or little filtered cigars)

During the 3 months before you got pregnant, on average how often did you use e-cigarettes or other electronic nicotine products?

More than once a day

Once a day

2-6 days a week

1 day a week or less

I did not use e-cigarettes or other nicotine-containing e-vaping products then

During the last 3 months of your pregnancy, on average, how often did you use e-cigarettes or other electronic nicotine products?

More than once a day

Once a day

2-6 days a week

1 day a week or less

I did not use e-cigarettes or other nicotine-containing e-vaping products then

State specific questions

HI70. How often do you use e-cigarettes or other electronic nicotine products in an average week now?

More than once a day

Once a day

2-6 days a week

1 day a week or less

I do not use e-cigarettes or other electronic nicotine products now

Standard Questions

AA13. In the 3 months before you got pregnant, on average, how often did you smoke hookah?

Daily

2-3 times per week

Once a week

2-3 times per month

Once a month

I did not smoke hookah in the 3 months before I got pregnant

Used by: TN49

AA14. In the last 3 months of your pregnancy, on average, how often did you smoke hookah?

Daily

2-3 times per week

Once a week

2-3 times per month

Once a month

I did not smoke hookah in the last 3 months of my pregnancy

Used by: OH40, TN50

Smokeless Tobacco

State specific Questions

AK75. During your most recent pregnancy, did you ever use smokeless tobacco products such as chewing tobacco, snuff, snus, or iqmik?

Yes

AK76. Which smokeless tobacco product(s) did you use during your pregnancy?

Chewing tobacco, snuff, or snus

Iqmik (also known as black bull

Cessation

Standard Questions

AA1. During any of your prenatal care visits, did a doctor, nurse, or other health care worker advise you to quit smoking?

Yes

I didn’t go for prenatal care

Used by: AZ32, GA31, IL34, KS26, ME29, MT34, ND27, NH29, SC39, SD32, TN43, VT30, WV32

AA2. During your most recent pregnancy, did any of the following things about quitting smoking apply to you? For each thing, check No if it you did not do it, or Yes if you did.

No Yes

a. Set a specific date to stop smoking

b. Use booklets, videos, or other materials to help you quit

c. Call a national or state quit line or go to a website

d. Attend a class or program to stop smoking

e. Go to counseling for help with quitting

f. Use a nicotine patch, gum, lozenge, nasal spray or inhaler

g. Take a pill like Zyban^® (also known as Wellbutrin^® or Bupropion^®) to stop smoking

l. Take a pill like Chantix^®(also known as Varenicline) to stop smoking

h. Try to quit on your own (e.g., cold turkey)

i. Other:

Please tell us:

Used by: AR37, FL34, GA33, IA30, UT35, VA35, VT32, WV33

AA3. Listed below are some things about quitting smoking that a doctor, nurse, or other health care worker might have done during any of your prenatal care visits. For each thing, check No if it was not done or Yes if it was. No Yes

a. Spend time with you discussing how to quit smoking

b. Suggest that you set a specific date to stop smoking

c. Suggest you attend a class or program to stop smoking

d. Provide you with booklets, videos, or other materials to help you quit

smoking on your own

e. Refer you to counseling for help with quitting

f. Ask if a family member or friend would support your decision to quit

g. Refer you to a national or state quit line

h. Recommend using nicotine gum

i. Recommend using a nicotine patch

j. Prescribe a nicotine nasal spray or nicotine inhaler

k. Prescribe a pill like Zyban^® (also known as Wellbutrin^® or Bupropion^®) to help you quit

l. Prescribe a pill like Chantix^®(also known as Varenicline) to help you quit

Used by: AZ33, GA32, IL35, KS27, ME30, MT35, NH30, VT31

AA6. Did you quit smoking around the time of your most recent pregnancy?

No, but I cut back

Yes, I quit before I found out I was pregnant

Yes, I quit when I found out I was pregnant

Yes, I quit later in my pregnancy

Used by: AR38, GA35, HI30, IA29, KS28, KY32, OH32, SD34, UT36, WI34

AA10. Listed below are some things that can make it hard for some people to quit smoking. For each item, check No if it is not something that might make it hard for you or Yes if it is.

No Yes

a. Cost of medicines or products to help with quitting

b. Cost of classes to help with quitting

c. Fear of gaining weight

d. Loss of a way to handle stress

e. Other people smoking around me

f. Cravings for a cigarette

g. Lack of support from others to quit

h. Worsening depression

i. Worsening anxiety

j. Some other reason

Please tell us

Used by: AR39, GA36, HI31, IA31, KS29, KY33, OH33, SD35, WI35

AA12. During your most recent pregnancy, did your health insurance pay for medications or any other services to help you quit smoking? Check ONE answer

No, my insurance did not pay

Yes, but I had to make a co-payment

Yes, with no co-payment

I wasn’t trying to quit smoking

I didn’t have health insurance

I don’t know

Used by: GA34

AK77. Are you planning to stop smoking cigarettes?

Yes, within the next 30 days

Yes, more than 30 days from now but within the next 6 months

Yes, but not within the next 6 months

No, I don’t plan to stop

State specific questions

OR59. During any of your prenatal care visits or after your most recent delivery, did a doctor, nurse, or other health care worker ever advise you to quit smoking?

Yes, during my prenatal care visits

Yes, after my delivery

Yes, both times

I did not smoke at that time

Secondhand Exposure

Standard Question

AA5. Which of the following statements best describes the rules about smoking inside your home during your most recent pregnancy, even if no one who lived in your home was a smoker? Check ONE answer

No one was allowed to smoke anywhere inside my home

Smoking was allowed in some rooms or at some times

Smoking was permitted anywhere inside my home

Used by: AR42, GA38, IN31, MT37, SC41, VA37

AA7. Which of the following statements best describes the rules about smoking inside your home now, even if no one who lives in your home is a smoker? Check ONE answer

No one is allowed to smoke anywhere inside my home

Smoking is allowed in some rooms or at some times

Smoking is permitted anywhere inside my home

Used by: AK33, AR44, DE39, GA39, IN32, KS31, KY36, ME32, NE46, NH32, NV30, OH35, SDT28, TN45, TX36, WV36

AA8. How many cigarette smokers, not including yourself, lived in your home during your most recent pregnancy?

Number of smokers

Used by: AR41, HI33, NC36, TX35

AA9. How many cigarette smokers, not including yourself, live in your home now?

Number of smokers

Used by: AK33, AR43, HI34, KY35, MN32, WV35

U1. Does your husband or partner smoke inside your home?

Yes

Used by: AK34, DC30

U2. Not including yourself or your husband or partner, does anyone else smoke cigarettes inside your home?

Yes

Used by: AK35, DC31

State specific questions

OR70. Not including yourself, is there anyone in your household who smokes cigarettes, cigars, or pipes?

Yes

NH69. Is smoking allowed in the car that your baby most often rides in?

Yes

I don’t know

CO71. During any of your prenatal care visits, did a doctor, nurse, or other health care worker-

f. Discuss making your home smoke-free

g. Discuss making your car smoke-free

CO72. During any of your prenatal care visits or after your most recent delivery, did a doctor, nurse, or other health care worker talk with you about how secondhand smoke could affect your baby after birth?

Yes, during my prenatal care visits

Yes, after my delivery

Yes, both times

MI65. How many hours and minutes in the last week was your new baby in an enclosed space, such as a room or a vehicle, with someone who was smoking?

_______Hours ________Minutes

Zika

Supplemental Questions

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 5

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

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

Yes, a health care worker talked with me, but only AFTER I asked about it

During your most recent pregnancy, did you get a blood test for Zika virus?

Yes

During your most recent pregnancy, were you aware of recommendations that pregnant women should avoid travel to areas with Zika virus?

Yes

At any time during your most recent pregnancy, did you live or travel outside the 50 United States?

No  Go to Question 9

Yes

When did you live or travel outside the 50 United States during your most recent pregnancy and for how long? It may help to use a calendar. If you can’t remember the exact date, please just write down the month and year. If you took more than 2 trips, please fill in the information below for the FIRST two trips during your most recent pregnancy.

Trip Number 1

a) Location (country or territory): _____________________

b) First day of trip: __/__/__ (month/day/year)

c) Length of stay (number of days): __________

Trip Number 2

e) Location (country or territory):____________________

f) First day of trip: __/__/__ (month/day/year)

g) Length of stay (number of days): ____________

Did the place you lived in or travelled to have a tropical climate? These tend to be hot and humid places.

No  Go to Question 9

Yes

How often did you do things to try to avoid mosquito bites while you were living in or traveling to the places you listed above? Some things that people do to avoid mosquito bites include wearing long-sleeved shirts and long pants, using mosquito repellant, and staying inside places with air conditioning or screened windows and doors.

Every day

Some days

Never

There were no mosquitoes

At any time in the 6 months before your most recent pregnancy or during your pregnancy, did your husband or any male partner live or travel outside the 50 United States?

No  Go to Question 11

Yes

Did the place your husband or any male partner lived in or travelled to have a tropical climate? These tend to be hot and humid places.

Yes

I don’t know

During your most recent pregnancy, how often did you use condoms when you had sex with your husband or any male partner?

Every time Go to the end

Sometimes

Never

I didn’t have sex during my pregnancy  Go to the end

What were your reasons for not using condoms 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 can get Zika virus from having sex

I didn’t think my husband or male partner had Zika virus

I was not worried about getting Zika virus

I didn’t want to use condoms

My husband or male partner didn’t want to use condoms

Other Please tell us: _______________________________

All Zika supplemental questions used by: AL, CT, DC, FL, GA, IN, IL, MA, MD, MO, NJ, NYS, PA, PR, SC, TN, VA, VT, WV, WI

13. Did you think it was safe to use insect repellents with DEET during your pregnancy?

Yes

I don’t know

14. While you were pregnant, did you always take steps to ensure that small containers outside your home were drained or covered?

Yes

This does not apply to me

If you never heard of Zika virus during your most recent pregnancy, go to the end of the survey.

15. While you were pregnant, did you receive information about preventing Zika virus infection from any of these sources? For each one, check No if you did not receive information from this source or Yes if you did.

No Yes

A doctor, nurse, or other health care worker
Radio or television
Flyers or handouts
Health website or internet
Social media (Facebook, Twitter, etc.)
Billboard or bus advertisement
Other  Please tell us: ______________________

Additional Zika Questions used by: VA only

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PRAMS Phase 8 Questionnaire (Core Questions plus State-selected Standard Modules)

Pregnancy Risk Assessment Monitoring System (PRAMS)

Att 6-PRAMS Phase 8 Topic Reference Document