0920-20FO Att.4b-Prenatal Survey-Revised

Form Approved
OMB No. 0920-1333
Exp. Date 4/30/2024

Feeding My Baby and Me: IFPS-III: PRENATAL

The information you are being asked to provide is authorized to be collected under Section 301 of The Public Health Service Act (42 USC 241). Providing this information is voluntary. CDC will use this information in its study, Feeding My Baby and Me (also known as the Infant Feeding Practices Study III), in order to learn more about the choices mothers make in feeding their babies and toddlers in the first 2 years of life. This information will support efforts to improve the health of our nation’s children. This information will be shared with a contractor, Westat, with which CDC has entered into an agreement to assist with carrying out this study.

Public reporting burden of this collection of information varies from 2 to 24 minutes with an average of 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-1333)

Have you had your baby?

• Yes [INELIGIBLE]

• No

[IF INELIGIBLE START INELIGIBILITY SCREEN]

DEMOGRAPHICS

A16. What is your current marital status?

• Single, never married

• Now married

• Domestic partnership

• Widowed

• Divorced

• Separated

A17. What is the highest degree or level of school you have completed?

• Less than high school

• High school diploma or GED

• 2-year or 3-year college degree (AA degree)

• Vocational school diploma

• 4-year college degree (BA, BS degree)

• Doctoral or graduate degree (MA, MBA, PhD, JD, MD)

A5. Are you [or your spouse or partner] currently serving in the armed services (e.g., Army, Navy, Marines, Air Force, or Coast Guard) on active duty?

• Yes

• No

• Don't know

[PROGRAMMER: DISPLAY FILL in A5 [or your spouse or partner] ONLY IF A16 = NOW MARRIED OR DOMESTIC PARTNERSHIP]

A4. Counting yourself, how many people live in your household? Include all members who live in your household for at least 9 months of the year.

________________ People < 17 years of age

________________ People 18 and older

A6. Which income range category represents the total combined income of all members of your household during the past 12 months? Please include any income from all sources (employment, pensions, social security, etc.).

• Less than $5,000

• $5,000 to $7,499

• $7,500 to $9,999

• $10,000 to $12,499

• $12,500 to $14,999

• $15,000 to $19,999

• $20,000 to $24,999

• $25,000 to $29,999

• $30,000 to $34,999

• $35,000 to $39,999

• $40,000 to $49,999

• $50,000 to $59,999

• $60,000 to $74,999

• $75,000 to $99,999

• $100,000 to $149,999

• $150,000 or more

A13. Thinking about your pregnancies before this one, how many of these pregnancies resulted in a live birth?

________ live births

• No previous pregnancies

D12A. Have you ever breastfed any children? [PROGRAMMER – ONLY ASK IF A13 ≥1. SKIP IF LIVE BIRTHS IS MISSING OR ZERO]

• Yes [CONTINUE TO D12B]

• No [SKIP TO H3]

D12B. Thinking about all of the children you breastfed, how many months total did you breastfeed (your best guess)?

• Less than 1 month

• 1 to 6 months

• 7 to 12 months

• 13 to 23 months

• 24 months or more

HEALTH AND LIFESTYLE

H3. How many weeks pregnant were you when you went for your first prenatal visit?

• 8 weeks or less

• 9 to 12 weeks

• 13 to 27 weeks

• 28 weeks or more

• Never had a prenatal visit

A19. What type of health insurance coverage do you have:

• Private (e.g., Aetna, Blue Cross/Blue Shield, Tricare)

• Public (e.g., Medicaid, Indian Health Service)

• Other

• Don't know

• None, I do not have health insurance coverage

A22. During this pregnancy, did you, or your family, ever receive any of the following:

	Yes	No	Don’t know
Supplemental nutrition assistance benefits sometimes called SNAP or Food Stamps?
Temporary assistance to needy families sometimes called TANF or welfare?
Free or reduced price meals from the National School Lunch or School Breakfast Program or the Summer Foods Program?
Are you receiving any food or free meals from another source such as a food bank church or community center?

H4. On average, how many cigarettes do you smoke a day now?

______ CIGARETTES PER DAY

• Do not smoke

H5. Not including yourself, how many people smoke inside your home most days? (Include both people living in your home and guests)

• 0

• 1

• 2

• 3

• 4 or more

H8. What was your weight just before you became pregnant?

______ Pounds

H9. What is your weight now?

_____ Pounds

H11. How tall are you?

______ feet ______ inches

H18. Before this pregnancy, has a doctor, nurse, or other health care worker ever told you that you had any of the following conditions?

Select all that apply

• High blood sugar or type 2 diabetes

• High blood pressure or hypertension

• Stroke or heart disease

• Asthma, eczema, or allergies to pollen, dust, animals, latex, medications, other

• Food allergy

• Infertility

• Depression

• COVID-19

H22. As best you know, which of the following health conditions do your baby's immediate relatives have? (Immediate relative includes, you, the baby's mother; the baby's father; or the Baby's Brothers or Sisters)

Select all that apply

• High blood sugar or type 2 diabetes

• High blood pressure or hypertension

• Stroke or heart disease

• Asthma, eczema, or allergies to pollen, dust, animals, latex, medications, other

• Food allergy

• Overweight or obesity

C47. During the past month, how many times a week did you take a vitamin that contained…

Answer for each vitamin/mineral

	Every day of the week	4 to 6 times a week	1 to 3 times a week	I did not take any vitamins with this in it
Folic acid?
Iodine?
Iron?
Vitamin D?

D29. During your pregnancy, did your healthcare provider ever talk to you about the importance of any of the following vitamins or minerals?

	Yes	No	Don’t know
Iodine
Vitamin D
Iron
Folic acid

It is not easy being pregnant, and it is OK to feel unhappy at times. We would like to know how you are feeling. Please select the answer which comes closest to how you have felt during the past week, not just how you are feeling today.

H13a. I have been able to laugh and see the funny side of things.

• As much as I always could

• Not quite so much now

• Definitely not so much now

• Not at all

H13b. I have looked forward with enjoyment to things.

• As much as I ever did

• Rather less than I used to

• Definitely less than I used to

• Hardly at all

H13c. I have blamed myself unnecessarily when things went wrong.

• Yes, most of the time

• Yes, some of the time

• Not very often

• No, never

H13d. I have been anxious or worried for no good reason.

• No, not at all

• Hardly ever

• Yes, sometimes

• Yes, very often

H13e. I have felt scared or panicky for no good reason.

• Yes, quite a lot

• Yes, sometimes

• No, not much

• No, not at all

H13f. Things have been getting to me

• Yes, most of the time I haven’t been able to cope at all

• Yes, sometimes I haven’t been coping as well as usual

• No, most of the time I have coped quite well

• No, I have been coping as well as ever

H13g. I have been so unhappy that I have had difficulty sleeping.

• Yes, most of the time

• Yes, sometimes

• Not very often

• No, not at all

H13h. I have felt sad or miserable.

• Yes, most of the time

• Yes, quite often

• Not very often

• No, not at all

H13i. I have felt so unhappy that I have been crying.

• Yes, most of the time

• Yes, quite often

• Only occasionally

• No, never

H13j. The thought of harming myself has occurred to me.

• Yes, quite often

• Sometimes

• Hardly ever

• Never

PROGRAMMER IF H13J = YES OR SOMETIMES, SHOW REFERRAL SCREEN THAT INCLUDES INFORMATION FOR A HOTLINE. IF H13J = HARDLY EVER OR NEVER, GO TO TEXT BEFORE A24a.

[START REFERRAL SCREEN]

Being pregnant can be difficult. If you need someone to talk to, there is help available. The resources listed below can help you through a confidential phone conversation or internet chat for free, 24 hours per day, 7 days per week.

{LIST OF RESOURCES TO COME, clickable phone number and URL for chat such as National Suicide Prevention Lifeline or Kristin Brooks Hope Center}

If you click on the links above you will leave the survey and be connected with the hotline. We’ll save your answers and your place on the survey and you can come back later to finish. If you want to talk with someone, but not right now, just click “NEXT” and we’ll show these links again at the end of the survey.

[END REFERRAL SCREEN]

These next questions are about the food eaten in your household in the last month, and whether you were able to afford the food you need.

A24a. The food that (I/we) bought just didn't last, and (I/we) didn't have money to get more. Was that often, sometimes, or never true for (you/your household) in the last month?

• Often true

• Sometime true

• Never true

A24b. (I/we) couldn't afford to eat balanced meals

• Often true

• Sometime true

• Never true

A24c. In the last month, did (you/you or other adults in your household) ever cut the size of your meals or skip meals because there wasn't enough money for food?

• Yes

• No (GO TO A24E)

A24d. How often did this happen?

• Every week

• Some weeks but not every week

• Only 1 or 2 weeks

A24e. In the last month, did you ever eat less than you felt you should because there wasn't enough money for food?

• Yes

• No

A24f. In the last month, were you ever hungry but didn't eat because there wasn't enough money for food?

• Yes

• No

EMPLOYMENT

G10. Did you work for pay at any time from 3 months before you became pregnant up to the present time?

• Yes

• No (GO TO G12)

G11. Do/did you work mostly full-time or part-time?

• Full-time

• Part-time

G34. What do you do for your MAIN job? That is, what is your title and your typical job duties?

_____________

G35. For your MAIN job, what type of company do you work for? That is, what does the company make or do?

_____________

G12. Do you plan to work for pay during your baby's first year?

• Yes

• No (IF A16 = NOW MARRIED OR DOMESTIC PARTNERSHIP SKIP TO G33, ELSE SKIP TO C3)

G13. How many weeks after the baby is born do you plan to return to work?

• Fewer than 4 weeks

• 4 to 6 weeks

• 7 to 9 weeks

• 10 to 12 weeks

• 13 to 16 weeks

• 17 to 20 weeks

• 21 to 30 weeks

• More than 30 weeks

G14. How many hours per week do you plan to work for pay during your baby's first year?

• 1 to 9 hours per week

• 10 to 19 hours per week

• 20 to 29 hours per week

• 30 to 34 hours per week

• 35 to 40 hours per week

• More than 40 hours per week

G17. Thinking of work leave that you can use for maternity leave, how many weeks are you eligible for if you have no complications? (Select the number of weeks of leave you are eligible for in each of the categories listed below. If you have no leave that you can use, select 0 weeks in each.)

[PROGRAMMER: FOR EACH RESPONSE CREATE DROP DOWN SELECTION, 0, LESS THAN 1, 1 TO 52, MORE THAN 52]

__ weeks of fully paid parental leave

__ weeks of fully paid sick leave/vacation time

__ weeks of partially paid leave

__ weeks of unpaid leave

PROGRAMMER – ONLY DISPLAY G33 and G18 IF A16 = NOW MARRIED OR DOMESTIC PARTNERSHIP

G33. Does your spouse/partner currently work for pay?

• Yes

• No (GO TO G19)

G18. Thinking of work leave that your spouse/partner can use for parental leave, how many weeks is your spouse/partner eligible for? (Select the number of weeks of leave your spouse/partner used in each of the categories listed below. If your partner/spouse did not use parental leave, select 0 in all.)

[PROGRAMMER: FOR EACH RESPONSE CREATE DROP DOWN SELECTION, 0, LESS THAN 1, 1 TO 52, MORE THAN 52]

__ weeks of fully paid parental leave

__ weeks of fully paid sick leave/vacation time

__ weeks of partially paid leave

__ weeks of unpaid leave

PROGRAMMER – ONLY DISPLAY G19, COLUMN 2 IF A16 = NOW MARRIED OR DOMESTIC PARTNERSHIP

ONLY DISPLAY G19, COLUMN 1 IF G10 = YES

G19. Thinking of work leave that can be used, how many weeks do you and your [partner/spouse] plan to use: (Select the number of weeks in each of the categories listed below. If you or your [partner/spouse] do not plan to take any leave, select 0.)

[PROGRAMMER: FOR EACH RESPONSE CREATE DROP DOWN SELECTION, 0, LESS THAN 1, 1 TO 52, MORE THAN 52]

	You	Partner/spouse
Weeks of fully paid parental leave
Weeks of fully paid sick leave/vacation time
Weeks of partially paid leave
Weeks of unpaid leave

INFANT FEEDING

C3. What do you plan to feed your new baby in the first few weeks?

• Breastfeed only (baby will not be given formula)

• Infant formula only (GO TO C4A)

• Both breast milk and infant formula

• Haven’t decided yet (GO TO C4A)

[PROGRAMMER: ONLY DISPLAY G28 IF G12 = YES]

G28. Do you plan to continue breastfeeding after you return to work?

• Yes

• No

• Do not know

D13. How old do you think your baby will be when you completely stop breastfeeding or feeding him or her pumped/expressed breast milk?

____ months [HAVE A DROP DOWN MENU FOR ONE MONTH – 24 MONTHS AND MORE THAN 24 MONTHS]

C4. [PROGRAMMER: DO NOT DISPLAY IF C3 = BOTH BREAST MILK AND INFANT FORMULA] How old do you think your baby will be when you first feed him or her formula?

____ months [HAVE A DROP DOWN OPTION FOR LESS THAN ONE MONTH AND “I do not plan to feed my baby formula” ALL OTHER RESPONSES ARE WRITE-IN FOR MONTH]

C4A. How old do you think your baby will be when you first feed him or her any other food besides breast milk or formula?

____ months [HAVE A DROP DOWN OPTION FOR LESS THAN ONE MONTH ALL OTHER RESPONSES ARE WRITE-IN FOR MONTH]

D3. How strongly do you agree or disagree with the following statements?

	Strongly agree	Agree	Neither agree nor disagree	Disagree	Strongly disagree
Infant formula is as good as breast milk
If a baby is breastfed, he or she will be less likely to be sick, such as having an ear infection, respiratory illness, diarrhea, etc.
Babies should be exclusively breastfed (fed only breast milk) for about the first 6 months
If a child was breastfed, he or she will be less likely to become obese
Mothers who are HIV positive can pass on the virus to their infants through breast milk.
Mothers who breastfeed are less likely to develop certain types of cancer like breast or ovarian cancer.
Mothers with COVID-19 should breastfeed or provide expressed breast milk to their infants.

THANK YOU FOR COMPLETING YOUR SURVEY!

[PROGRAMMER: DISPLAY CONTACT INFORMATION SECTION. ONCE CONTACT INFORMATION SECTION IS COMPLETE, DISPLAY REFERRAL SCREEN]

[START REFERRAL SCREEN]

Being pregnant can be difficult. If you need someone to talk to, there is help available. The resources listed below can help you through a confidential phone conversation or internet chat for free, 24 hours per day, 7 days per week.

{LIST OF RESOURCES TO COME, clickable phone number and URL for chat such as National Suicide Prevention Lifeline or Kristin Brooks Hope Center}

If you click on the links above you will leave the study website and be connected with the hotline.

[END REFERRAL SCREEN]

CONTACT INFORMATION SCREEN

PRENATAL SURVEY ONLY:

Thank you very much for completing the survey! Please take a moment to review your information and update as needed.

We can provide you with a link for $X immediately after you complete this survey or mail you a check. Which would you prefer?

Preference for receiving the money for the survey:

 Online gift card

 Check

Contact Information

Name*:

Cell Phone Number*:

Email address*:

*Would you prefer to receive study information through text or email or both?

 Text  Email  Both Text and Email

*This information is required.

Please provide your mailing address. We will use your address only to mail you a check if desired or to send you study communications if we cannot reach you by phone or email. Your address will never be shared with anyone else.

Address 1:

Address 2:

Zip code:

[PROGRAMMER: PRE-POPULATE STATE AND CITY]

Please provide the name and contact information of another person who would always know how to contact you (such as your partner, parent, or friend). We will contact them only if we cannot reach you by email or text. Please let them know they have your permission to share your contact information with the study.

Name:

Relationship to you: Spouse/Partner/Parent/Sibling/Other Relative/Friend

Phone Number:

Email address:

Thank you. [IF CHECK: Please look out for a check from Westat in 5 -7 business days IF VIRTUAL GIFT CARD: Look out for an email or text with a link to your online gift card]. Please make sure to come back to this website to let us know when the baby is born. You can also update your contact information at this website at any time if your phone number or email address changes.