Attachment 9a Phase 8 Standard Questionnaire English, Mail
Form Approved
OMB No. 0920-xxxx
Exp. Date xx/xx/xxxx
Pregnancy Risk Assessment Monitoring System (PRAMS)
Phase 8 Standard Questions
NOTE: Skip A1–A5 if the mother was not trying to get pregnant (E5).
A1 is required if A2, A4 or A5 is used.
BEFORE A1, if E6, E5, E3 are used, insert instruction box that says, “If you were not trying to get pregnant when you got pregnant with your new baby, go to Question…”
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.
No Go to Question ##
Yes
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
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
A5. How many cycles of fertility treatments (complete or incomplete) did you have before you got pregnant with your new baby?
1 cycle
2 to 3 cycles
4 to 6 cycles
7 or more cycles
NOTE: Skip
B1 if infant is not alive or not living with the mother (Core 32
and/or Core 33).
Skip B1 if the mother ever breastfed
(Core 35).
Change the skip arrow on Core Q35 from “no” to “yes” and AFTER B1, insert instruction box that says, “If you did not breastfeed your new baby, go to Question .…”
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: ________________________________
NOTE: Skip
B2 if infant is not alive or not living with the mother (Core
32 and/or Core 33).
Skip B2 if the mother did not breastfeed
or is still breastfeeding (Core 35 and/or Core 36).
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 husband or partner did not support breastfeeding
My baby was jaundiced (yellowing of the skin or whites of the eyes)
Other Please tell us: ______________________________________
NOTE: Skip
B3 if infant is not alive or not living with the mother (Core 32
and/or Core 33).
Skip B3 if infant was not born in a hospital
(Core 31).
Skip B3 if mother said that she did not breastfeed (Core 35).
BEFORE B3, insert instruction box that says, “If your baby was not born in a hospital, go to Question ##.”
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.
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.
B4. During your most recent pregnancy, what did you think about breastfeeding your new baby? Check ONE answer
I knew I wanted to breastfeed
I thought I might breastfeed
I knew I would not breastfeed
I didn’t know what to do about breastfeeding
NOTE: Skip B5–B6 if infant is not alive or not living with the mother (Core 32 and/or Core 33).
B6 needs B5, but B5 can be used alone.
B5. Did anyone suggest that you not breastfeed your new baby?
No Go to Question ##
Yes
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: ____________________________________
NOTE: B12 must be used with B7-B8. Skip B7-B8 if mother was not on WIC during her pregnancy (B12). B8 goes before B7.
B7. When you went for WIC visits during your most recent pregnancy, did you receive information on breastfeeding?
No
Yes
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?
No
Yes
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
NOTE: Skip B10-B11 if infant is not alive or not living with the mother (Core 32 and/or Core 33).
Skip
B10 if mother said that she did not breastfeed (Core 35).
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)?
[BOX] Weeks OR [BOX] Months
My baby was less than 1 week old
My baby has not had any liquids other than breast milk
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)?
[BOX] Weeks OR [BOX] Months
My baby was less than 1 week old
My baby has not eaten any foods
B12. (Phase 7, Core 27) During your most recent pregnancy, were you on WIC (the Special Supplemental Nutrition Program for Women, Infants, and Children)?
No
Yes
NOTE: Skip B13, B14, B15, B16 if mother did not breastfeed (Core 35).
B13. (NEW) 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:______________________________________________
B14. (NEW) Have you used a breast pump to express milk to feed to your new baby?
No Go to Question X
Yes
NOTE: B15 and B16 require B14, but B14 can be used alone.
B15. (NEW) Did your health insurance pay for a breast pump for you to use with your new baby?
No
Yes, but I had to make a co-payment
Yes, with no co-payment
I did not have health insurance
I don’t know
B16. (NEW)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: _____________________________
NOTE: Skip C1–C3 if infant is not alive or not living with the mother or is still in the hospital (Core 32 and/or Core 33, and Core 31).
C2 and/or C3 need C1. C1 can be used alone. If C1 is used alone, it does not need to be skipped if infant is not alive or not living with the mother, or if the baby is still in the hospital.
C1. Are you currently in school or working?
No, I don’t go to school or work Go to Question ##
Yes, I go to school or work outside the home
Yes, I go to school or work from home
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 Go to Question ##
NOTE: C3 requires C2, with the skip arrow off of the last answer option. If C3 is not added, remove the skip in C2.
C3. While you are away from your new baby for school or work, how often do you feel that he or she is well cared for? Check ONE answer
Always
Often
Sometimes
Rarely
Never
C4. At any time during your most recent pregnancy, did you work at a job for pay?
No Go to Question ##
Yes
NOTE: C5 and C6 need C4 (skip goes to C11 in this series. If C11 is not used, skip to the next topic).
C5. During your most recent pregnancy, how many hours did you work per week at your main job?
40 or more hours per week
21 – 39 hours per week
20 hours per week or less
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 Go to Question ##
I was laid off or fired from my job Go to Question ##
NOTE: C7 requires C4 (skip C7 if C4 is no). If C7 is no and not returning, skip C8-C10 and C14 (mom goes to C11 in this series, if used, or to next topic).
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 Go to Question ##
No, but I will be returning
Yes
NOTE: C8 requires C7 (and C4).
If a state adds a state-specific option to C8, insert “I took…” for options such as Family Medical Leave and “I took leave and used…” for options such as Temporary/Short-term Disability Insurance.
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
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
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
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
NOTE: C12 and C13 require C4.
C12. (NEW) 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:
C13. (NEW) 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
NOTE: C14 requires C8. Add a skip arrow to C8 response option “I did not take any leave” that goes to C9, (or C10, C11), if used, or to next topic.
C14. (NEW) How many weeks or months of leave, in total, did you take or will you take?
[BOX] Weeks OR [BOX] Months
Less than 1 week
NOTE: Skip D1–D2 if infant is not alive or not living with the mother (Core 32 and/or Core 33).
D2 needs D1, but D1 can be used alone.
D1. Is your new baby a boy or a girl?
Boy
Girl Go to Question ##
D2. Did you have your new baby boy circumcised?
No
Yes
E2 added to Core 46
NOTE: Skip
E3 if mother was not using birth control when she got pregnant (E6).
BEFORE E3, insert instruction box that says, “If you or your husband or partner was not doing anything to keep from getting pregnant, go to Question.…”
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 in the arm (Nexplanon® or Implanon®)
Contraceptive patch (OrthoEvra®) or vaginal ring (NuvaRing®)
IUD (including Mirena®, ParaGard®, Liletta®, or Skyla®)
Natural family planning (including rhythm method)
Withdrawal (pulling out)
Other Please tell us: ____________________________
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.
No
Yes
E5. (Phase 7, Core 14) When you got pregnant with your new baby, were you trying to get pregnant?
No
Yes Go to Question X
NOTE: E5 is a required filter for E6.
E6. (Phase 7, Core 15) 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.
No
Yes
NOTE: E6 is a required filter or E7.
E7. (Phase 7, Core 16) 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: _________________________
F1-F3 replaced with Core 39, 40 & 41
NOTE: Inserting F4 after Core 39 requires the skip arrow to be changed from “Never” to “Always” so the filter will work properly.
AFTER F4 and BEFORE Core 40 insert this instruction box: “If your baby never sleeps alone in his or her own crib or bed, go to Question #.”
F4. (NEW) Who does your new baby usually sleep with when he or she is not sleeping alone? Check ALL that apply
Me
My husband or partner
Someone else Please tell us: ________________________
G1. Have you ever heard or read that taking a vitamin with folic acid can help prevent some birth defects?
No Go to Question ##
Yes
NOTE: G1 and G2 can be used alone. However, if they are used together, skip G2 if mother has never heard or read about folic acid (answered No to G1).
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: _____________________________
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
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, nurse, or other health care worker said it was a good idea
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
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
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
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
NOTE: Skip G8 if mother took a multivitamin 1 or more times a week (Core 5).
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: ____________________________
NOTE: Skip H1–H2 if infant is not alive or not living with the mother (Core 32 and/or Core 33).
H1. Do you have health insurance or Medicaid for your new baby?
No
Yes
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 Marketplace 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
NOTE: Skip H3–H4 if infant is not alive or not living with the mother (Core 32 and/or Core 33).
H4 must be used with H3, but H3 can be used alone.
H3. Is your new baby in the Child Health Insurance Program (CHIP)?
No
Yes Go to Question ##
H4. Why didn’t you enroll your new baby in CHIP? Check ALL that apply
I didn’t know about the program
I already had insurance
I didn’t think he or she was eligible
Other Please tell us: _____________________________
NOTE: Skip H5-H7 if the baby did not have insurance (H2).
If H5, H6 and/or H7 is used, add a skip arrow to the last answer option in H2.
H5. Does the cost of health insurance for your new baby cause financial problems for you or your family
now?
No
Yes
H6. Do you or someone else make regular payments to pay for the health insurance that you have for your new baby now, including having money taken out of your paycheck or your husband, partner, or parent’s paycheck?
No
Yes About how much per month? _____
H7. Do you have copayments for medical visits when you use your new baby’s health insurance now?
No
Yes
NOTE: Skip I3 and I9 if mom indicated in I8 that she was tested during pregnancy or delivery.
I3 must be used with or I9, but I9 can be used alone.
BEFORE I3, include instruction box stating “If you did not have an HIV test before this pregnancy, go to Question x.”
I3. When were you tested before this pregnancy? Check ONE answer
Less than 6 months before I got pregnant
6 months to 1 year before I got pregnant
More than 1 year before I got pregnant
I4-I6 replaced with I9
I8. (Phase 7, Core 20) At any time during your most recent pregnancy or delivery, did you have a test for HIV (the virus that causes AIDS)?
No
Yes Go to Question x
I don’t know Go to Question x
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: __________________________
J1 replaced with modified version is now Phase 8 Core 47
NOTE: Skip J2 if mom has not had a postpartum checkup.
J2. (NEW) 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
State-specific option
Other Please tell us: _____________________
NOTE: Skip J3 if mom had a postpartum checkup.
If J3 is added, the skip arrow on Core 46 should be switched from “no” to “yes”; (J2 and) Core 47 will need an instruction to skip.
AFTER J3, add: “If you did not have a postpartum checkup, go to Question #...”.
J3. (NEW) Did any of these things keep you from having a postpartum checkup? 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 Please tell us: ____________________________
NOTE: Skip J4 if mom has not had a postpartum checkup.
J4. (NEW) How did you feel about the care you
got during your postpartum checkup? For
each item, check No if you
were not satisfied or
Yes if you were satisfied.
No Yes
a. The amount of time you had to wait
b. The amount of time the doctor, nurse, or health care worker 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
NOTE: Skip J5 if mom had a routine care visit.
If J5 is added, the skip arrow on Core 6 should be switched from “no” to “yes” and Core 7 will need an instructional skip.
AFTER J5, add: “If you did not have any health care visits, go to Question #...”.
J5. (NEW) Why didn’t you have any health care visits in the 12 months before you got pregnant with your new baby? 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 Please tell us: _______________________________
NOTE: Skip K1 if mother has not had a previous infant born alive (FF5 is a required filter).
K1. Before you had your new baby, did you ever have a baby by cesarean delivery or c-section (when a doctor cuts through the mother’s belly to bring out the baby)?
No
Yes
K3. How was your new baby delivered?
Vaginally
Cesarean delivery (c-section)
NOTE: Skip K4 if mother did not have prenatal care (Core 13).
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
NOTE: If using K5 with K14, drop the last answer option (I didn’t have my baby in the hospital) and add a skip arrow to K14’s last answer option.
K5. After you were admitted to the hospital to deliver your new baby, were you transferred to another hospital before your baby was born?
No
Yes
I didn’t have my baby in the hospital
NOTE: Skip K6 and K7 if the mother did not have a cesarean delivery for her new baby (K3).
K6 and K7 must be used with K3, but K3 may be used alone.
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
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 pre-eclampsia, 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: ____________________________
K8. Did you plan or schedule a cesarean delivery (c-section) at least one week before your new baby was born?
No
Yes
NOTE: K10 needs K9, but K9 can be used alone.
K9. Did your doctor, nurse, or other health care worker try to induce your labor (start your contractions using medicine)?
No Go to Question ##
Yes
I don’t know Go to Question ##
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 pre-eclampsia)
I wanted to schedule my delivery
I wanted to give birth with a specific health care provider
Other Please tell us:_____________________
NOTE: Skip K11-K12 if the baby was not born in the hospital (Core 31).
Add a skip arrow to Core 31 response option “My baby was not born in a hospital” if K11 and/or K12 is inserted.
K11. After your baby was born, was he or she transferred to another hospital?
No
Yes
K12. After your baby was born, were you transferred to another hospital?
No
Yes
K13. When was your baby due?
[BOX] |
/[BOX] |
/20___[BOX] |
Month |
Day |
Year |
K14. When did you go into the hospital to have your baby?
[BOX] |
/[BOX] |
/20___[BOX] |
Month |
Day |
Year |
I didn’t have my baby in a hospital
K15. When were you discharged from the hospital after your baby was born?
[BOX] |
/[BOX] |
/20___[BOX] |
Month |
Day |
Year |
I didn’t have my baby in a hospital
K16. (Phase 7, Core 41) After your baby was delivered, was he or she put in an intensive care unit (NICU)?
No
Yes
I don’t know
L1. Other than prenatal vitamins, did you take any over-the-counter or prescribed medicine during pregnancy, even for a short period of time?
No
Yes
L2. Have you ever had German measles (rubella) or been vaccinated for German measles?
No
Yes
L3. Have you ever had chickenpox (varicella) or been vaccinated for chickenpox?
No
Yes
L4. Have you ever taken medicine on a regular basis to control seizures or epilepsy?
No Go to Question ##
Yes
NOTE: Skip L5–L7 if mother has never taken medicine to control seizures or epilepsy (L4).
L5-L7 need L4, but L4 can be used alone.
L5. During your most recent pregnancy, did you take medicine on a regular basis to control seizures or epilepsy?
No Go to Question ##
Yes
NOTE: L6 and L7 need L5, but L5 can be used alone.
L6. When did you start taking the medicine?
I started taking the medicine during my pregnancy
I started taking the medicine in the year before I got pregnant
I started taking the medicine more than a year before I got pregnant
L7. How many seizures did you experience during your most recent pregnancy?
None
1
2
3 or more
NOTE:
Skip L9 if mother has not had a postpartum checkup (Core 53).
L9 is part of Phase 8, Core 47
L10. Before you got pregnant, would you say that, in general, your health was—
Excellent
Very good
Good
Fair
Poor
Response options for L11 will now be added directly to Core 4 if this question is selected. Recommended minimum grouping for selecting L11 includes options a, e, & f. |
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
NOTE: Skip L14 if mother got a flu shot (Core 16).
Add skip arrows to both “yes” response options on Core 16 if L14 is inserted.
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:
________________________________
L15. Have you ever had a flu shot?
No
Yes
L16 is part of Phase 8, Core 47
NOTE: Skip L18 if health care worker didn’t talk with mother about preparing for pregnancy (L27). L27 must be used before L18.
L17 was incorporated into Core 8 for Phase 8; a modified version to serve as a filter for L18 was developed and named L27.
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 did.
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
NOTE: Skip L19 if mother did not get a flu shot (Core 16).
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 Please tell us: ______________________
L20. At any time during your most recent pregnancy, were you sick with a fever?
No
Yes
L21. At any time during your most recent pregnancy, did a doctor, nurse, or other health care worker tell you that you had the flu?
No Go to Question ##
Yes
NOTE: Skip L22 and L23 if mother was not told by a health care worker that she had the flu (L21).
L22. Were you hospitalized for the flu during your most recent pregnancy?
No
Yes
L23. Did you take a medicine prescribed by your doctor or other health care worker called Tamiflu® or oseltamivir, or an inhaled medicine called Relenza® or zanamivir during your pregnancy to treat the flu?
No
Yes
L24. (Modified). 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).
No
Yes
I don’t know
L26. (Phase 7, Core 7) 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 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
L27. (Modified L17) 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?
No
Yes
L28. (NEW) Since your new baby was born, have you been told that you have thyroid problems by a doctor, nurse, or other health care worker?
No Go to Question x
Yes
L29. (NEW) What kind of thyroid problem do you have? Check ONE answer
Hypothyroidism (underactive thyroid)
Hyperthyroidism (overactive thyroid)
Both hypothyroidism and hyperthyroidism
Other Please tell us: __________________________
I don’t know
L30. (NEW) 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…………………………………………………
L31. (NEW) Have you ever been told that you have Polycystic Ovarian Syndrome or PCOS by a doctor, nurse, or other health care worker?
No Go to Question x
Yes
I don’t know Go to Question x
L32. (NEW) How did your doctor, nurse, or other health care worker find out that you had Polycystic Ovarian Syndrome, or PCOS? Check ALL that apply
Ultrasound of my abdomen and pelvis
Blood tests (including measurements of hormones)
Because of my irregular periods
Because of my skin condition or acne
Because of the increased hair growth on my body
Because of my weight
Other Please tell us:______________________________
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?
No
Yes
M3 added to Core 18
Note: Skip M4 if mom does not indicate she had depression in Core 18 (Q18, item c).
BEFORE M4, add instruction: “If you had depression during your most recent pregnancy, go to Question #*. Otherwise, go to Question #.” (*this being the next question inserted—M4)
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?
No
Yes
M5. Since your new baby was born, has a doctor, nurse, or other health care worker told you that you had depression?
No Go to Question ##
Yes
M6. Since your new baby was born, have you asked for help for depression from a doctor, nurse, or other health care worker?
No
Yes
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
Note: Skip M8 and M9 if mom does not indicate she had depression in Core 18 (Q18, item c).
BEFORE M9/M8, add instruction: “If you had depression during your most recent pregnancy, go to Question #*. Otherwise, go to Question #.” (*this being the next question inserted—M9 or M8)
M8. At any time during your most recent pregnancy, did you take prescription medicine for your depression?
No
Yes
M9. At any time during your most recent pregnancy, did you get counseling for your depression?
No
Yes
Note: M10 and M11 need M5, but M5 can be used alone. Skip M10 and M11 if M5 is no.
M10. Since your new baby was born, have you taken prescription medicine for your depression?
No
Yes
M11. Since your new baby was born, have you gotten counseling for your depression?
No
Yes
Note: M12 and M21 must be used together.
M12. Since your new baby was born, how often have you felt panicky?
Always
Often
Sometimes
Rarely
Never
M13. At any time during your most recent pregnancy, did a doctor, nurse, or other health care worker tell you that you had anxiety?
No Go to Question ##
Yes
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?
No
Yes
M15. Since your new baby was born, has a doctor, nurse, or other health care worker told you that you had anxiety?
No Go to Question ##
Yes
M16. Since your new baby was born, have you asked for help for anxiety from a doctor, nurse, or other health care worker?
No
Yes
Note: M17 and M18 need M13, but M13 can be used alone.
M17. At any time during your most recent pregnancy, did you take prescription medicine for your anxiety?
No
Yes
M18. At any time during your most recent pregnancy, did you get counseling for your anxiety?
No
Yes
Note: M19 and M20 need M15, but M15 can be used alone.
M19. Since your new baby was born, have you taken prescription medicine for your anxiety?
No
Yes
M20. Since your new baby was born, have you gotten counseling for your anxiety?
No
Yes
Note: M21 must be used with M12.
M21. Since your new baby was born, how often have you felt restless?
Always
Often
Sometimes
Rarely
Never
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?
No Go to Question ##
Yes
NOTE: N2 needs N1, but N1 can be used alone.
N2. How many weeks or months pregnant were you when you were told to stay in bed?
[BOX] Weeks OR [BOX] Months
NOTE: N3 needs N1, but N1 can be used alone.
N3. How often were you able to follow your provider’s instruction to stay in bed?
Always Go to Question ##
Often Go to Question ##
Sometimes
Rarely
Never
NOTE: N4 needs N3, but N3 can be used alone.
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 not have 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: ______________
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?
No
Yes
I don’t know
NOTE: Skip N6-N7 if the mother did not have gestational diabetes during this pregnancy (Core 18, item a). BEFORE N6/N7, add instruction that says, “If you had gestational diabetes during your most recent pregnancy, go to Question #*. Otherwise, go to Question #.” (*being the next question inserted—N6 or N7)
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?
No
Yes
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.
No Yes
a. Refer me to a nutritionist
b. Talk to me about the importance of exercise
c. Talk to me about getting to and staying at a healthy weight after delivery
d. Suggest that I breastfeed my new baby
e. Talk to me about my risk for Type 2 diabetes
NOTE: Skip N8 if mother did not have any problems during this pregnancy (N9), so N8 needs N9 but N9 can
be used alone.
BEFORE N8, insert instruction box that says, “If you did not have any of the problems listed above, go to
Question ##.”
N8b. Did you go to the hospital or emergency room because of any of the problems listed above?
No Go to Question xx
Yes
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
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
(preterm premature rupture of membranes [PPROM])
I had to have a blood transfusion
I was hurt in a car accident
O1. Since your new baby was born, have you had any medical problems that caused you to go to the hospital and stay overnight?
No Go to Question ##
Yes
NOTE: O2 and O3 need O1, but O1 can be used alone.
O2. When was the first time you had to go into the hospital and stay overnight after your new baby was born?
[BOX] |
/[BOX] |
/[BOX] |
Month |
Day |
Year |
I don’t know
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: ____________________________
O4. Since your new baby was born, have you been tested for diabetes or high blood sugar?
No Go to Question ##
Yes
NOTE: O5 needs O4, but O4 can be used alone.
O5. Since your new baby was born, did a doctor, nurse, or other health care worker tell you that you had diabetes?
No
Yes Go to Question ##
NOTE: O6 needs both O4 and O5.
O6. Did a doctor, nurse, or other health care worker tell you that you had prediabetes, borderline diabetes or high blood sugar?
No
Yes
P1. When you got pregnant, did your new baby’s father live with you?
No
Yes
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: ________________________
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? [BOX]
Children aged 1 year to 5 years How many children? [BOX]
Children aged 6 years and over How many children? [BOX]
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
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? [BOX]
Children aged 1 year to 5 years How many children? [BOX]
Children aged 6 years and over How many children? [BOX]
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 live alone
P5. Do you have a husband or partner who lives with you now?
No
Yes
P6. When you got pregnant, how old was your new baby’s father?
[BOX] Years old
I don’t know
P7. How old were you when you had your first menstrual period?
[BOX] Years old
P8. How old were you when you got pregnant for the first time?
[BOX] Years old
P9. Do you have a telephone in your home that has been working (in service) for the past month?
No Go to Question ##
Yes
Note: P10 needs P9, but P9 can be used alone.
P10. Is your telephone number listed in the most recent telephone book under your last name and current address?
Yes
Telephone unlisted
Telephone listed under another name or address
P11. Which rooms are in the house, apartment, or trailer where you live? Check ALL that apply
Living room
Separate dining room
Kitchen
Bathroom(s)
Recreation room, den, or family room
Finished basement
Bedrooms How many? [BOX]
P12. Counting yourself, how many people live in your house, apartment, or trailer?
[BOX] Adults (people aged 18 years or older)
[BOX] Babies, children, or teenagers (people aged 17 years or younger)
NOTE: P13a and P13b do not have to be used together.
BEFORE P13b, insert instruction box that says, “If you don’t have complete plumbing facilities in your
home, go to Question ##.”
P13a. Which of the following utilities do you have in your house, apartment, or trailer? For each item, check No if you do not have the utility or Yes if you have the utility.
No Yes
a. Complete plumbing facilities (including hot
and cold running water, a flush toilet,
and a bathtub or
shower)
b. Electricity
c. A telephone from which you can make and receive calls (including cell phones)
P13b. Do you get the water you use in your house, apartment, or trailer from a city or county water supply or from a private well?
City or county water supply
Private well
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?
No
Yes
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 Go to Question ##
Never Go to Question ##
Note: P16 needs P15, but P15 can be used alone.
P16. During the 12 months before your new baby was born, did you do any of the following things because you felt it was unsafe to leave or return to the neighborhood where you lived? For each item, check No if you did not do it or Yes if you did.
No Yes
a. I missed doctor or other appointments
b. I limited grocery or other shopping
c. I stayed with other family members or friends
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?
No
Yes
P18. During the 12 months before your new baby was born, what were the sources of your household’s income? Check ALL that apply
Money from family or friends
Money from a business, fees, dividends, or rental income
Paycheck or money from a job
Food stamps or WIC (the Special Supplemental Nutrition Program for Women, Infants, and Children)
Aid such as Temporary Assistance for Needy Families (TANF), welfare, public assistance, general
assistance, or Supplemental Security Income (SSI)
Unemployment benefits
Child support or alimony
Social security, workers’ compensation, disability, veteran benefits, or pensions
Other Please tell us: ______________________________
P19. (Phase 7, Core 36) 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
Q1. Which of the following statements best describes you during the 3 months before you got pregnant? Check ONE answer
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
Q2. Which of the following statements best describes your husband or partner during the 3 months before you got pregnant? Check ONE answer
Wanted me to get pregnant
Partly wanted me to get pregnant and partly wanted me not to get pregnant
Didn’t care one way or the other whether I got pregnant
Didn’t especially want me to get pregnant
Wanted very much for me not to get pregnant
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
Wanted me to be pregnant sooner
Wanted me to be pregnant later
Wanted me to be pregnant then
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
NOTE: Skip Q4 if mom wanted to be pregnant sooner, then, not then or any time in future, or if she wasn’t sure (Core 12). Add a skip arrow to Core Q12 for the last four responses.
Q4. (Phase 7, Core 13) 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
Q5. This question asks about feelings and concerns women sometimes have about becoming pregnant. For each item, check No if it did not apply to you when you found out you were pregnant with your new baby or Yes if it did.
No Yes
a. I was worried that I didn’t know enough about how to take care of a baby
b. I thought a new baby would keep me from
doing the things I was used to doing,
like working, going to
school, or going out
c. I looked forward to teaching and caring for a new baby
d. I looked forward to the new experiences that having a baby would bring
e. I looked forward to telling my friends that I was pregnant
f. I was worried that I did not have enough money to take care of a baby
g. I did not look forward to telling my friends that I was pregnant
h. I looked forward to buying things for a new baby
Q6. How did you feel when you found out you
were pregnant with your new baby?
Very unhappy to be pregnant
Unhappy to be pregnant
Not sure
Happy to be pregnant
Very happy to be pregnant
NOTE: Skip Q7 if mother was not trying to get pregnant (E5).
AFTER Q7, insert instruction box that says, “If you were trying to get pregnant when you got pregnant with
your new baby, go to Question ##.”
Q7. How many months were you trying to get pregnant? Do not count long periods of time when you and your partner were apart or not having sex.
0 to 3 months
4 to 6 months
7 to 12 months
13 to 24 months
More than 24 months
NOTE: Skip R1–R18 if mother had no prenatal care (Core 13).
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.
No Yes
a. The amount of time I had to wait
b. The amount of time the doctor, nurse, or midwife spent with me
c. The advice I got on how to take care of myself
d. The understanding and respect shown toward me as a person
R2 is combined with Core 14.
R3-R5 combined and promoted to core.
R6. Have you ever heard of the bacteria Group B Strep (Beta Strep) that mothers can pass to their newborns during birth?
No
Yes
R7. During any of your prenatal care visits, did a doctor, nurse, or other health care worker talk with you about the bacteria Group B Strep (Beta Strep)?
No
Yes
R8. At any time during your most recent pregnancy, did you get tested for the bacteria Group B Strep (Beta Strep)?
No
Yes
I don’t know
R9. During any of your prenatal care visits, did a doctor, nurse, or other health care worker talk with you about getting your blood tested for the disease called toxoplasmosis?
No
Yes
R10. 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
a. Not touching your mouth or eyes while handling raw meat
b. Cooking meat to “well done”
c. Washing hands and utensils after handling raw meat
d. Washing hands after contact with soil, sand,
litter, or any other material that may be
contaminated with
cat feces
e. Not feeding cats raw or undercooked meat
R11. At any time during your most recent pregnancy, did you have a blood test for the disease called toxoplasmosis?
No
Yes
I don’t know
R12. During any of your prenatal care visits, did a doctor, nurse, or other health care worker talk with you about taking multivitamins, prenatal vitamins, or folic acid vitamins during your pregnancy?
No
Yes
R13. At any time during your most recent pregnancy, did your regular prenatal care provider ask you to see a specialist doctor for help with any health problem(s)?
No
Yes
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?
No
Yes
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
State-specific option
Other Please tell us: ________________________
R16. During your most recent pregnancy, 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 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
BEFORE R17, insert instruction box that says, “If a doctor, nurse, or other health care worker did not tell
you how much weight you should gain during your most recent pregnancy, go to Question ….”
R17. How much weight did your doctor, nurse, or other health care worker tell you to gain during your most recent pregnancy? Check ONE answer and fill in blank if needed.
Between [BOX] Pounds and [BOX] Pounds
Between [BOX] Kilos and [BOX] Kilos
Exactly [BOX] Pounds OR [BOX] Kilos
I don’t remember
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?
No
Yes
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, nurse, or other health care worker said you were pregnant.
[BOX] Weeks OR [BOX] Months
I don’t remember
Note: If R20 is used without R21, insert instruction box that says, “If you did not get prenatal care, go to Question…”
R20. Did you get prenatal care as early in your pregnancy as you wanted?
No
Yes Go to Question ##
NOTE: R21 needs R20, but R20 can be used alone.
AFTER R21, insert instruction box that says, “If you did not get prenatal care, go to Question…”
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
R22. (Phase 7 Core#19). 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
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
R23. (Phase 7 Core #25) 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?
No
Yes
NOTE: Skip S1 if infant is not alive or not living with the mother (Core 32 and/or Core 33). Do not use S16-S17 if you use S1.
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
S2. Did you worry that wearing your seat belt during pregnancy would hurt your new baby?
No
Yes
NOTE: Skip S3 if infant is not alive, not living with the mother, or is still in the hospital (Core 31, 32, Core 33).
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
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
S5. Since your new baby was born, how often do you wear a seat belt when you drive or ride in a car?
Always
Often
Sometimes
Rarely
Never
NOTE: Skip S6–S9 if infant is not alive, is not living with the mother, or is still in the hospital (Core 32,Core 33, or Core 31).
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 Go to Question ##
NOTE: Skip S7–S9 if infant never rides in an infant car seat (S6).
S7, S8, and S9 need S6, but S6 can be used alone.
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
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
S9. Does the car, truck, or van that your new baby usually rides in have an airbag on the passenger side?
No
Yes
NOTE: Skip S10–S12 if infant is not alive, is not living with the mother, or is still in the hospital (Core 32, Core 33, or Core 31).
S10. Do you have an infant car seat(s) that you can use for your new baby?
No Go to Question ##
Yes
Note: S11 and S12 need S10, but S10 can be used alone.
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: ______________________
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: __________________________
NOTE: Skip S13 if infant is not alive or is not living with the mother (Core 32 or Core 33).
S13. Have you ever heard or read about what can happen if a baby is shaken?
No
Yes
S14. Was the house or apartment you live in now built after 1977?
No
Yes Go to Question ##
I don’t know Go to Question ##
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
NOTE: Skip S16-S17 if infant is not alive or not living with the mother (Core 32 and/or Core 33). Do not use S1 if you use S16-S17. S17 requires S16, but S16 can be used alone.
S16. Since your new baby was born, have you received information about infant products (such as cribs, medicines, toys) that should be taken off the market (product recalls)?
No Go to Question ##
Yes
S17. Where did you receive information about infant product recalls? Check ALL that apply
Product manufacturers
Doctor, nurses, or other health care worker
Newspaper, radio, TV, internet
Friends or family members
In-store recall notices
Other source Please tell us: ___________________
S18. Does the house or apartment you live in now have a carbon monoxide detector?
No
Yes
I don’t know
S19. Has the house or apartment you live in now ever been tested for radon?
No
Yes
I don’t know
NOTE: Skip T1–T3 if infant is not alive, is not living with the mother, or is still in the hospital (Core 32, Core 33, or Core 31).
T1. How many times has your new baby gone for care when he or she was sick?
[BOX] Times
None Go to Question ##
My baby has not been sick Go to Question ##
My baby is still in the hospital Go to Question ##
Note: T2 and T3 need T1, but T1 can be used alone.
T2. Where have you taken your new baby when he or she was sick and needed care? Check ALL that apply
Private doctor’s office
Hospital emergency room
Hospital clinic
Health department clinic
State-specific option
State-specific option
Other Please tell us: __________________________
T3. Has your new baby gone for care as many times as you wanted when he or she was sick?
No
Yes
NOTE: Skip T4–T5 if infant is not alive, is not living with the mother or is still in the hospital (Core 32 and Core 33 and Core 31.).
T4. Was your new baby jaundiced (yellowing of the skin or whites of the eyes)?
No Go to Question ##
Yes
NOTE: T5 needs T4, T4 can be used alone.
T5. Was your new baby readmitted to the hospital because of jaundice?
No
Yes
NOTE: Skip T6–T7 if infant is not alive, is not living with the mother, or is still in the hospital (Core 32, Core 33, or Core 31).
T6. How many times has your new baby gone to the hospital emergency room about his or her health? Please include emergency room visits that resulted in a hospital admission.
_______ Times
None Go to Question ##
I don’t know Go to Question ##
NOTE: Insert instruction box BEFORE T7 that says “If your new baby has never been to the hospital emergency room about his or her health, go to Question …” This skip applies if T6=0.
T7. How many of these visits were because of an accident, injury, or poisoning?
_______ Visits
None
I don’t know
NOTE: T8 requires T3.
T8. (NEW) 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: ___________________________
NOTE: U1 and U2 need AA7, but AA7 can be used alone. Skip U1 and U2 if no one is allowed to smoke inside the house at any time (AA7).
U1. Does your husband or partner smoke inside your home?
No
Yes
U2. Not including yourself or your husband or partner, does anyone else smoke cigarettes inside your home?
No
Yes
DRUG2. During the month before you got pregnant, did you take or use any of the following drugs for any
reason? Your answers are strictly confidential. For each item, check No if you did not use it or Yes if did.
No Yes
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)
DRUG3. During your most recent pregnancy, did you take or use any of the following drugs for any reason? Your answers are strictly confidential. For each item, check No if you did not use it or Yes if did.
No Yes
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)
NOTE: If DRUG2 or DRUG3 is not used, add a transition statement before LL17 that reads: “The next questions are about using different drugs around the time of pregnancy. Your answers are strictly confidential.”
U5 cannot be used if DRUG3 is used.
Skip U6 if the mother did not use prescription pain relievers (DRUG3). Before U6 add instruction that reads
” If you did not use prescription pain relievers during your most recent pregnancy, go to Question XX”
U5. During your most recent pregnancy, did you use prescription pain relievers such as hydrocodone (Vicodin®), oxycodone (Percocet®), or codeine?
No Go to Question #
Yes
U6. 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
U7. During your most recent pregnancy, did you use heroin, cocaine, amphetamines, or barbiturates such as phenobarbital?
No
Yes
U8. During your most recent pregnancy, did you take prescription antidepressants or selective serotonin reuptake inhibitors (SSRIs) such as Prozac, Zoloft, or Lexapro?
No
Yes
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)?
No
Yes
I did not use any drugs (or only used over-the-counter pain relievers) during my pregnancy
I didn’t go for prenatal care
U10. After your baby was born, did a doctor, nurse, or other healthcare worker tell you that your baby had drug withdrawal or neonatal abstinence syndrome?
No
Yes
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
NOTE: Skip V2 and V3 if infant is not alive or not living with the mother (Core 32 and/or Core 33).
BEFORE V2/V3 insert an instruction that says; “If your baby is not alive or is not living with you, go to Question #.”
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
V3. Since your new baby was born, have you used WIC services for yourself or your new baby?
No
Yes, only I am using WIC services
Yes, both my new baby and I use WIC services
Yes, only my new baby uses WIC services
V4. During the 12 months before your new baby was born, did you or any member of your household consider seeking help from the government because your income was low?
No
Yes
V5. During the 12 months before your new baby was born, did you or any member of your household apply for government payments such as welfare, TANF (Temporary Assistance for Needy Families), or other public assistance?
No
Yes Go to Question ##
Note: V6, V7, and V9 need V5, but V5 can be used alone.
V6. Did any of these things keep you from applying for government help? Check ALL that apply
I didn’t think I could get help because my household made too much money
I didn’t know how to apply
There was too much paperwork
I didn’t think I could get help because I am from another country
Other Please tell us:
NOTE: If V6 is used, add an instruction box BEFORE V7 that says, “If you or any member of your household did not apply for government payments, go to Question …”
V7. Did any of these happen to you when you applied for government assistance? Check ALL that apply
I received assistance
I was told I made too much money to get assistance
I was told I shouldn’t apply because I might need my benefits later
I was told I couldn’t get assistance because I am from another country
NOTE: V10 needs V9 and V9 needs V5
V9. Did you get welfare, TANF (Temporary Assistance for Needy Families), or other public assistance?
No
Yes Go to Question ##
V10. Why didn’t you get welfare, TANF (Temporary Assistance for Needy Families), or other public
assistance? Check ALL that apply
I was ineligible because of my income
I had reached my time limit
I had to fulfill work or other requirements
I had to return on another day to apply
I had previously lost TANF for another reason (administrative reasons, sanctions, etc.)
I am not a U.S. citizen
Other Please tell us: ______________________
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 feel you needed the service
or Yes if you felt you
needed 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 for family and personal problems
d. Help to quit smoking
e. Help to reduce violence in my home
f. Other
Please tell us:
_________________________
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 for family and personal problems
d. Help to quit smoking
e. Help to reduce violence in my home
f. Other
Please tell us: ________________________
NOTE: Skip V13, V14, V15, V20, if the mother did not have a home visitor (V21).
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
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
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
NOTE: Skip V16, V17, V18, and V19 if the mother did not have a postpartum home visitor (V22).
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
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
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
V19. (NEW) How did you feel about the care
you got from the home visitor since your new baby was born?
For each item, check No if you were not satisfied or Yes
if you were satisfied.
No Yes
a. The amount of time the home visitor spent with me
b. The advice I got on how to take care of myself and my baby
c. The understanding and respect shown toward me as a person
V20. (NEW) How did you feel about the care you
got from the home visitor during your most recent pregnancy?
For each item, check No if
you were not satisfied or
Yes if you were satisfied.
No Yes
a. The amount of time the home visitor spent with me
b. The advice I got on how to take care of myself
c. The understanding and respect shown toward me as a person
V21. (Phase 7, Core 26) 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.
No Go to Question x
Yes
NOTE: Skip V22 if the baby is not alive. DO NOT skip if the baby is not living with the mom or is still in the hospital (Core 33 and Core 31).
Skip arrow for Core 33 should go to V22 and the instruction box before Core Q38 should go to V22 if V22 is inserted.
V22. (Phase 7, Core 49) 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.
No Go to Question x
Yes
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
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 not have 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
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
NOTE: Skip W4 if infant is not alive, is not living with the mother, or if baby is still in the hospital (Core 32, Core 33, or Core 31).
BEFORE W4, add a skip instruction: “If your baby is not alive, is not living with you, or is still in the hospital, go to Question #.”
W4. Since you delivered your new baby, 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.
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
NOTE: Skip X1–X12 if infant is not alive, is not living with the mother, or is still in the hospital (Core 32, Core 33, or Core 31).
X1-X2, X4, X7, and X8 need X9, but X9 can be used alone.
X1. Has your new baby gone as many times as you wanted for a well-baby checkup?
No
Yes Go to Question ##
NOTE: X2 can be used without X1.
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: ___________________________
[
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.
No
Yes
My child has not had any well-baby shots, but he or she is not 3 months old yet
NOTE: Skip X4 if infant has not had a well-baby checkup; therefore, X4 needs the well-baby checkup question (X9).
X4. Did you have health insurance to pay for your baby’s well-baby checkups?
No
Yes
X5. What do you think would be the best time to get information from your doctor, nurse, or other health care worker about baby shots? Check ONE answer
During prenatal care visits
In the hospital or birthing center after my baby’s delivery
At my baby’s first visit to the doctor
NOTE: Skip X6 if infant did not have a one week checkup after he or she was born; therefore, X6 needs X10.
X6. Was your new baby seen at home or at a health care facility?
At home
At a doctor’s office, clinic, or other health care facility
NOTE: Skip X7–X8 if infant has not had a well-baby checkup (X9); therefore, X7 and X8 need X9.
X7. How many times has your new baby been to a doctor, nurse, or other health care worker for a well-baby checkup? (It may help to use the calendar.)
[BOX] Times
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
State-specific option
Other Please tell us: _________________________
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.
No Go to Question ##
Yes
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?
No
Yes
My baby was still in the hospital at that time
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?
Always
Often
Sometimes
Rarely Go to Question ##
Never Go to Question ##
I haven’t tried to get health care services for my new baby Go to Question ##
X12. Why have you felt frustrated when you tried to get health care services for your new baby?
Check ALL that apply
The services that my baby 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 my baby needed
Other Please tell us: ______________________________
NOTE: Skip Y2 if mom had teeth cleaned 12 months before or during pregnancy (Core 7, Core 17).
BEFORE Y2, add an instruction that says: “If you had your teeth cleaned by a dentist or dental hygienist in the 12 months before your got pregnant or during your pregnancy, go to Question #.”
Y2. Have you ever had your teeth cleaned by a dentist or dental hygienist?
No
Yes
Y3. Since your new baby was born, have you had your teeth cleaned by a dentist or dental hygienist?
No
Yes
Y4 deleted because information now captured in Core 7 & Core 17
NOTE: Skip Y5 and Y8 if mom did not have teeth or gum problems.
BEFORE Y5 and Y8 add an instruction box that says: If you did not have any problems with your teeth or gums during your pregnancy, go to Question ##.
Y5 and Y8 require Y7 but Y7 can be used alone
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: ___________
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 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
Y7. (Phase 7, Core 24). This question is about 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
Y8. (NEW) Did you get treatment from a dentist or another doctor for the problem that you were having during your pregnancy? Check ONE answer
No
Yes, I got treatment during my pregnancy
Yes, I got treatment after my pregnancy
Yes, I got treatment both during and after my pregnancy
Z1. (wording modification from Phase 7) 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
Z2. (wording modification) 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
Z3 – Z6 now are combined with Core 28-29
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?
No
Yes
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?
No
Yes
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
Z10 –Z12 Combined in new question Z13
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 hurt you during this time 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)
Z14. (NEW) During the 12 months before you got pregnant with your new baby, did 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
NOTE: Skip AA1, AA2, and AA3 if mother did not smoke during the 3 months before she got pregnant (Core 20).
BEFORE AA1, AA2, and AA3, insert instruction box that says, “If you did not smoke at any time in the 3 months before you got pregnant, go to Question …”
AA1. During any of your prenatal care visits, did a doctor, nurse, or other health care worker advise you to quit smoking?
No
Yes
I didn’t go for prenatal care
AA2. During your most recent pregnancy,
did you do any of the following things about quitting smoking?
For each thing, check No
if 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 me 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
h. Take a pill like Chantix® (also known as varenicline) to stop smoking
i. Try to quit on my own (e.g., cold turkey)
j. Other:
Please tell us: ______________________________________
NOTE: Skip AA3 if mother did not have any prenatal care (AA1). AA3 requires AA1.
Add skip arrow to AA1 off the “I didn’t go for prenatal care” option.
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 me discussing how to quit smoking
b. Suggest that I set a specific date to stop smoking
c. Suggest I attend a class or program to stop smoking
d. Provide me with booklets, videos, or other
materials to help me quit
smoking on my own
e. Refer me to counseling for help with quitting
f. Ask if a family member or friend would support my decision to quit
g. Refer me 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 me quit
l. Prescribe a pill like Chantix® (also known as varenicline) to help me quit
AA4 Deleted – not valid measure
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
NOTE: Skip AA6 if mother did not smoke during the 3 months before pregnancy (Core 20).
BEFORE AA6, insert instruction box that says, “If you did not smoke at any time in the 3 months before you got pregnant, go to Question …”
AA6. Did you quit smoking around the time of your most recent pregnancy? Check ONE answer
No
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
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
AA8. How many cigarette smokers, not including yourself, lived in your home during your most recent pregnancy?
[BOX] Number of smokers
AA9. How many cigarette smokers, not including yourself, live in your home now?
[BOX] Number of smokers
NOTE: AA10 must be used with AA6.
Skip AA10 and AA12 if the mother did not smoke 3 months before she got pregnant (Core 20).
BEFORE AA12, insert instruction box that says, “If you did not smoke at any time in the 3 months before you got pregnant, go to Question …”
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: ______________________
AA11 deleted – not valid measure
AA12. (NEW) 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
NOTE: Skip AA13 and AA14 if the mother never used hookah (Core 23).
BEFORE AA13 and AA14, insert instruction box that says, “If you used hookah in the past 2 years, go to Question <AA13>. Otherwise go to Question #.”
AA13. (NEW) 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 then
AA14. (NEW) 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 then
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?
No
Yes
BB2. Deleted due to evaluation results
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
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
NOTE: If state doesn’t choose CC1 with CC2, the list of examples will need to be added for CC2.
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
NOTE: Skip DD1–DD3 if mother was on Medicaid before she got pregnant (Core 9).
DD2 and DD3 need DD1, but DD1 can be used alone. DD2 and DD3 do not need to be used together.
BEFORE DD1, insert instruction box that says, “If you were on Medicaid (or state Medicaid name) before
you got pregnant, go to Question …”
DD1. Did you try to get Medicaid coverage during your most recent pregnancy?
No Go to Question ##
Yes
DD2. Did you have any problems getting Medicaid during your most recent pregnancy?
No
Yes
DD3. When did Medicaid coverage begin during your most recent pregnancy?
During the first 3 months of my pregnancy
During the second 3 months of my pregnancy
During the last 3 months of my pregnancy
I did not get Medicaid during my pregnancy
NOTE: Skip DD4, DD5, and DD6 if mother was not insured during the month before she got
pregnant (Core 9).
BEFORE DD4, DD5, and/or DD6, insert instruction box that says, “If the mother did not have health insurance
during the month before she got pregnant with her new baby, go to Question …”
DD4. Did you or someone else make regular payments for your health insurance before you got pregnant, including having money taken out of your paycheck or your husband, partner, or parent’s paycheck?
No
Yes About how much per month? _____
DD5. Did you have copayments for medical visits when you used your health insurance before you got pregnant?
No
Yes
DD6. Did the cost of health insurance cause financial problems for you or your family before you got
pregnant?
No
Yes
NOTE: Skip DD7 if mother was insured during the month before she got pregnant (Core 9).
BEFORE DD7, insert instruction box that says, “If you did not have health insurance during the month before you got pregnant, go to Question x. Otherwise, go to Question y”
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 was too high to qualify for a tax credit from the <State> Health Insurance Marketplace or HealthCare.gov
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: ___________________________________
NOTE: Skip DD8, DD9, and DD10 if mother did not have health insurance to pay for prenatal care or did not get prenatal care (Core 10).
If DD8, DD9, DD10, or DD11 are inserted, Core 10 skip arrow off “no prenatal care” will go to DD12-DD16 or Core 11.
BEFORE DD8, DD9, and/or DD10, insert instruction box that says, “If you had health insurance for your prenatal care, go to Question X. Otherwise, go to Question Y (DD11 or DD12 or Core 11)…”
DD8. Did you or someone else make regular payments for the health insurance that you used to pay for your prenatal care, including having money taken out of your paycheck or your husband, partner, or parent’s paycheck?
No
Yes About how much per month? _____
DD9. Did you have copayments for medical visits when you used your health insurance for prenatal care?
No
Yes
DD10. Did the cost of health insurance for your prenatal care cause financial problems for you or your family?
No
Yes
NOTE: Skip DD11 if the mom did not have prenatal care.
Skip DD11 if mother had health insurance to pay for prenatal care (Core 10).
DD11. What was the reason that you did not have any health insurance 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 was too high to qualify for a tax credit from the <State> Health Insurance Marketplace or HealthCare.gov
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: _____________________________________
NOTE: If DD12 is inserted, the skip arrow off of Core 10 “I did not get prenatal care” should be changed from Core 11 to DD12.
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 Marketplace 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 tribalOther health insurance Please tell us: _____________________________
I did not have any health insurance to pay for my delivery
NOTE: Skip DD13, DD14, and DD15 if mother did not have health insurance to pay for her delivery (DD12).
Add a skip arrow to “I did not have health insurance…” response option.
DD13. Did you or someone else make regular payments for the health insurance that you used to pay for your delivery, including having money taken out of your paycheck or your husband, partner, or parent’s paycheck?
No
Yes About how much per month? _____
DD14. Did you have copayments for medical visits when you used your health insurance for your delivery?
No
Yes
DD15. Did the cost of health insurance at the time of your delivery cause financial problems for you or your family?
No
Yes
NOTE: Skip DD16 if mother had health insurance to pay for her delivery (DD12).
BEFORE DD16, insert instruction box that says, “If you did not have health insurance to pay for your delivery, go to Question x. Otherwise, go to Question y”
DD16. What was the reason that you did not have any health insurance for your delivery? 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 was too high to qualify for a tax credit from the <State> Health Insurance Marketplace or HealthCare.gov
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: _______________________________________
NOTE: Skip DD17, DD18, and DD19 if mother does not have health insurance now (Core 11).
BEFORE DD17, DD18, and/or DD19, insert instruction box that says, “If the mother does not have health insurance now, go to Question…”
DD17. Do you or someone else make regular payments for the health insurance that you have now, including having money taken out of your paycheck or your husband, partner, or parent’s paycheck?
No
Yes About how much per month? _____
DD18. Do you have copayments for medical visits when you use your health insurance now?
No
Yes
DD19. Does the cost of health insurance cause financial problems for you or your family now?
No
Yes
NOTE: Skip DD20 if mother has health insurance now (Core 11).
BEFORE DD20, insert instruction box that says, “If you do not have health insurance now, go to Question x. Otherwise go to Question y”
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 I am still waiting to get it
I had problems with the health insurance application or website
My income is too high to qualify for Medicaid
My income is too high to qualify for a tax credit from the <State> Health Insurance Marketplace or HealthCare.gov
I don’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: _________________________________
DD21. In the past 12 months, has the cost of health insurance caused financial problems for you or your
family?
No
Yes
I have not had health insurance
DD22. (NEW) In the 12 months before you got pregnant, how often did you feel frustrated when you tried to get health care services for yourself?
Never Go to Question ##
Rarely Go to Question ##
Sometimes
Often
Always
I did not try to get health care services then
DD23. (NEW) Why did you feel frustrated when you tried to get health care services for yourself?
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: ________________________________
Replaces EE1 & EE2
EE3. (Modified DE74). 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: ___________
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?
No Go to Question ##
Yes
NOTE: FF2 and FF3 need FF1, but FF1 can be used alone. FF2 and FF3 do not need to be used together.
NOTE: In the instruction text below, remove the “(s)” if only one question is used; if both FF2 and FF3 are used, then “question” should be made plural (i.e., …the next questions…).
If you had more than one miscarriage, fetal death, or stillbirth during the 12 months before you got pregnant with your new baby, please answer the next question(s) for the most recent one.
FF2. How long did that pregnancy last?
Less than 20 weeks (less than 4 months)
20 to 28 weeks (4 to 6 months)
More than 28 weeks (more than 6 months)
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
NOTE: FF5 must be used with FF4. Skip FF4 if mother has not had a previous infant born alive (FF5).
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
FF5. (Phase 7, Core 4) Before you got pregnant with your new baby, did you ever have any other babies who were born alive?
No Go to Question x
Yes
NOTE: FF5 must be used with FF6 and FF7.
FF6. (Phase 7, Core 5) Did the baby born just before your new one weigh 5 pounds, 8 ounces (2.5 kilos) or less at birth?
No
Yes
FF7. (Phase 7, Core 6) Was the baby just before your new one born earlier than 3 weeks before his or her due date?
No
Yes
GG1. Does anyone in your family have sickle cell disease or sickle cell trait?
No Go to Question ##
Yes
I don’t know Go to Question ##
NOTE: Skip GG2 if no one in the family has sickle cell disease or trait (GG1).
GG2. During your most recent pregnancy, did you receive counseling or were you informed about sickle cell disease?
No
Yes
HH1. (modified) 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 Don’t Know if you don’t know.
No Yes Don’t Know
a. Diabetes
b. Heart attack before age 55
c. High blood pressure (hypertension)
d. Breast cancer before age 50
e. Ovarian cancer
HH2a. Have any of your close family members who are related to you by blood (grandparents, parents, sisters, or brothers) ever been told by a doctor, nurse, or other health care worker that they had diabetes?
No Go to Question ##
Yes
HH2b. Who was told by a doctor, nurse, or other health care worker that they had diabetes?
My father
My father’s mother
My father’s father
My mother
My mother’s mother
My mother’s father
My sister(s) or brother(s)
Other
Please tell us: (uncles, aunts, cousins, children, etc.) ________________________________
HH3a. Have any of your close family members who are related to you by blood (grandparents, parents, sisters, or brothers) ever been told by a doctor, nurse, or other health care worker that they had heart problems?
No Go to Question ##
Yes
HH3b. Who was told by a doctor, nurse, or other health care worker that they had heart problems?
My father
My father’s mother
My father’s father
My mother
My mother’s mother
My mother’s father
My sister(s) or brother(s)
Other
Please tell us: (uncles, aunts, cousins, children, etc.) ________________________________
HH4a. Have any of your close family members who are related to you by blood (grandparents, parents, sisters, or brothers) ever been told by a doctor, nurse, or other health care worker that they had high blood pressure (hypertension)?
No Go to Question ##
Yes
HH4b. Who was told by a doctor, nurse, or other health care worker that they had high blood pressure (hypertension)?
My father
My father’s mother
My father’s father
My mother
My mother’s mother
My mother’s father
My sister(s) or brother(s)
Other
Please tell us: (uncles, aunts, cousins, children, etc.) ________________________________
HH5a. Have any of your close family members who are related to you by blood (grandparents, parents, sisters, or brothers) ever been told by a doctor, nurse, or other health care worker that they had depression?
No Go to Question ##
Yes
HH5b. Who was told by a doctor, nurse, or other health care worker that they had depression?
My father
My father’s mother
My father’s father
My mother
My mother’s mother
My mother’s father
My sister(s) or brother(s)
Other
Please tell us: (uncles, aunts, cousins, children, etc.) ________________________________
HH6a. Have any of your close family members who are related to you by blood (grandmother, mother, or sisters) ever been told by a doctor, nurse, or other health care worker that they had postpartum depression?
No Go to Question ##
Yes
HH6b. Who was told by a doctor, nurse, or other health care worker that they had postpartum depression?
My father’s mother
My mother
My mother’s mother
My sister(s)
Other
Please tell us: (aunts, cousins, children, etc.) ________________________________
HH7a. Have any of your close family members who are related to you by blood (grandparents, parents, sisters, or brothers) ever been told by a doctor, nurse, or other health care worker that they had anxiety?
No Go to Question ##
Yes
HH7b. Who was told by a doctor, nurse, or other health care worker that they had anxiety?
My father
My father’s mother
My father’s father
My mother
My mother’s mother
My mother’s father
My sister(s) or brother(s)
Other
Please tell us: (uncles, aunts, cousins, children, etc.) ________________________________
HH8. Did your mother or any sister who is related to you by blood have any of the following problems during any pregnancy? For each item, check No if no one in your family had the problem during pregnancy, Yes if someone had the problem during pregnancy, or Don’t Know if you don’t know.
No Yes Don’t Know
A baby that was born more than 3 weeks before the due date
Gestational diabetes (diabetes that started during pregnancy)
High blood pressure during pregnancy
CANCER SUPPLEMENT
NOTE: Add the following transition statement and definition before HH9: “A family medical history is a record of health information about a person and his or her close relatives. The following questions are about your family history of ovarian and breast cancer.”
HH9. 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 Don’t Know if you don’t know.
|
Family member |
Had Ovarian Cancer
|
||
|
|
No |
Yes |
Don’t know |
a. |
My mother |
|
|
|
b. |
My mothers’ mother |
|
|
|
c. |
My father’s mother |
|
|
|
HH10. 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, Don’t Know if you don’t know, or Not Applicable if the option does not apply to you.
|
Family Member |
Had Ovarian Cancer
|
|||
|
|
No |
Yes |
Don’t know |
Not Applicable |
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? _____ |
|
|
|
|
HH11. 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 ovarian cancer, Yes if they have, or Don’t Know if you don’t know.
Family member |
Had Breast Cancer
|
||
|
No |
Yes |
Don’t know |
My mother |
|
|
|
My mother’s mother |
|
|
|
My father’s mother |
|
|
|
My father |
|
|
|
My mothers’ father |
|
|
|
My father’s father |
|
|
|
HH12. 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, Don’t Know if you don’t know, or Not Applicable if the option does not apply to you.
|
Family Member |
Had Breast Cancer
|
|||
|
|
No |
Yes |
Don’t know |
Not applicable |
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?______ |
|
|
|
|
If no one in the mom’s family has had breast cancer, go to Question XX. |
HH13. Has any woman in your family who is related to you by blood had breast cancer before age 50?
No
Yes
I don’t know
HH14. Has any woman in your family who is related to you by blood had both breast AND ovarian cancer?
No
Yes
I don’t know
HH15. Have any of your family members related to you by blood had bilateral breast cancer (breast cancer on both sides)?
No
Yes
I don’t know
HH16. Do you have Ashkenazi Jewish heritage?
No
Yes
I don’t know
NOTE: Add the following transition statement and definition before HH17: “The next questions are about talking to a genetic counselor about your cancer risk. A genetic counselor is a trained professional who talks with you about the chances of having a health condition based on your family medical history.”
HH17. Have you ever talked to a genetic counselor about your risk for cancer based on your family history?
No Go to end of cancer series
Yes
HH18. 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: _________________________
HH19. 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: ________________________________________
END OF CANCER SERIES
II1. (Phase 7, Core 40, modified) 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
NOTE: Skip JJ1 if mother did not drink during the 3 months before she got pregnant (Core 27).
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? Check ONE answer
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
NOTE: Skip JJ2 if mother did not drink during the last 3 months of her pregnancy (JJ3).
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? Check ONE answer
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
JJ3. (Phase 7, Core 35) During the last 3 months of your pregnancy, how many alcoholic drinks did you have in an average week? Check ONE answer
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
KK1. Do you currently have an emergency plan for your family in case of disaster? For example, you and your family have talked about how to be safe if a disaster happened.
No
Yes
KK2. During your most recent pregnancy, did you have an emergency plan for your family in case of disaster? For example, you and your family talked about how to be safe if a disaster happened.
No
Yes
KK3. How often do you worry about the possibility of a disaster happening to you or your family? Check ONE answer
Always
Sometimes
Never
KK4. (NEW) 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
MARIJUANA SUPPLEMENT QUESTIONS
DRUG1. / LL1. During any of the following 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.
No Yes
During the 12 months before I got pregnant
During my most recent pregnancy
Since my new baby was born
LL2. During any of the following periods, did anyone smoke marijuana products inside your home, including you? For each time period, check No if no one smoked marijuana inside your home then, or Yes if someone 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
|
□ |
□ |
|
|
|
LL3. During any of the following periods, did anyone keep edible marijuana products, such as brownies, cookies, or candy with THC, inside your home? For each time period, check No if no one kept marijuana inside your home then, or Yes if someone 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
|
□ |
□ |
LL4. Do you think pregnant women harm their unborn baby’s health if they use marijuana during pregnancy? Check ONE answer
No
Yes, slightly
Yes, moderately
Yes, greatly
LL5. Do you think pregnant women harm their own health if they use marijuana? Check ONE answer
No
Yes, slightly
Yes, moderately
Yes, greatly
LL6. At any time during your most recent pregnancy, did you use marijuana or hash in any form?
No Go to Question ##
Yes
LL7. 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
LL8. During your pregnancy, how did you use marijuana? Check ALL that apply
Smoke it
Eat it
Drink it
Vaporize it
Dab it
Other Please tell us: _________________
LL9. 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: ________________________
LL10. 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
LL11. During the first 3 months (1st trimester) of your 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 marijuana products then Go to Question X
LL12. During the first 3 months (1st trimester) of your pregnancy, how did you use marijuana? Check ALL that apply
Smoke it
Eat it
Drink it
Vaporize it
Dab it
Other Please tell us: _________________
LL13. During the middle 3 months of your 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 marijuana products then Go to Question X
LL14. During the middle 3 months of your pregnancy, how did you use marijuana? Check ALL that apply
Smoke it
Eat it
Drink it
Vaporize it
Dab it
Other Please tell us: _________________
LL15. During the last 3 months of your 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 marijuana products then Go to Question X
LL16. During the last 3 months of your pregnancy, how did you use marijuana? Check ALL that apply
Smoke it
Eat it
Drink it
Vaporize it
Dab it
Other Please tell us: _________________
NOTE: Skip LL17 if the mother did not have prenatal care (Core 13).
LL17. 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 you were asked on a form or verbally by your provider. For each one, mark No if they did not do this or Yes if they did.
No Yes
a. Ask me if I was using marijuana
b. Recommend that I use marijuana for any reason
c. Advise me not to use marijuana
d. Advise me not to breastfeed my baby while using marijuana
LL18. Since your new baby was born, have you used marijuana or hash in any form?
No Go to Question##
Yes
NOTE: Skip LL19 and LL20 if the infant is not alive or not living with the mother (Core 32 and/or Core 33) or if the mother is not currently breastfeeding (Core 36)
LL19. Since your new baby was born, how often do you use marijuana products in an average week? Check ONE answer
Daily
2-3 times per week
Once a week
2-3 times per month
Once a month or less
LL20. How long after you use marijuana do you wait before you breastfeed or pump milk? Check ONE answer and fill in the amount of time.
_____minutes
_____hours
_____days
LL21. 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
ZIKA SUPPLEMENT
NOTE: Add the following transition statement and definition before MM1: “These next questions are about Zika virus. Zika virus infection is an illness that is most often spread by the bite of a mosquito but may also be spread by having sex with a man who has the Zika virus.”
MM1. 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 MM5
MM2. At any time during your most recent pregnancy, did you talk with a doctor, nurse, or other healthcare worker about Zika virus? Check ONE answer
No
Yes, a healthcare worker talked with me without my asking about it
Yes, a healthcare worker talked with me, but only AFTER I asked about it
MM3. During your most recent pregnancy, did you get a blood test for Zika virus?
No
Yes
NOTE: Add the following transition statement before MM4: “The next questions are about travel during your most recent pregnancy.”
MM4. During your most recent pregnancy, were you aware of recommendations that pregnant women should avoid travel to areas with Zika virus?
No
Yes
MM5. At any time during your most recent pregnancy, did you live or travel outside the 50 United States?
No Go to MM9
Yes
MM6. 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 put 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
Location (country or territory): _____________________
First day of trip: __/__/__
Length of stay (number of days): __________
Trip Number 2
Location (country or territory):____________________
First day of trip: __/__/__
Length of stay (number of days): ____________
MM7. Did the place you lived in or travelled to have a tropical climate? These tend to be hot and humid places.
No Go to MM9
Yes
MM8. 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. Check ONE answer
Every day
Some days
Never
There were no mosquitoes
NOTE: Add the following transition statement before MM9: “The next questions are about your husband or any male partner.”
MM9. 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 MM11
Yes
MM10. 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.
No
Yes
I don’t know
MM11. During your most recent pregnancy, how often did you use condoms when you had sex with your husband or any male partner? Check ONE answer
Every time Go to end of Zika series
Sometimes
Never
I didn’t have sex during my pregnancy Go to end of Zika series
MM12. 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 the Zika virus
I didn’t want to use condoms
My husband or male partner didn’t want to use condoms
Other Please tell us: ______________________
ENVIRONMENTAL EXPOSURES SUPPLEMENT
NN1. During your most recent pregnancy, how often did you eat largemouth bass, tuna, shark, king mackerel
or swordfish?
3 or more times a week
1 to 2 times a week
1 to 3 times a month
Less than once a month
I didn’t eat those fish during my pregnancy Go to question ##
NN2. Where did you get largemouth bass, tuna, shark, king mackerel or swordfish that you ate during your
pregnancy? Check ALL that apply
From the grocery store
From a fish market or farmer’s market
From a restaurant
Caught by you or someone else from the ocean
Caught by me or someone else from a local river, stream, lake, or pond
Caught by me or someone else from one of the Great Lakes
Other Please tell us:
NN3. During your most recent pregnancy, did you use any of the following things every day or most days around your house or as part of your job? For each item, check No if you did not use it every day, or Yes if you did.
No Yes
Strong degreasers such as oven cleaner or heavy duty degreaser
Furniture or shoe polish
Bleach products without good ventilation
Clothes that were freshly dry-cleaned
Air fresheners, plug-ins or incense
Strong smelling perfume or deodorant
Strong smelling nail polish
NN4. During your most recent pregnancy, on average, how often did you eat food that was microwaved in a
plastic container? Check ONE answer
More than once a day
Once a day
2 to 6 times a week
Once a week
Less than once a week
Never
NOTE: Skip NN5 If the mother did not have prenatal care (Core 13).
NN5 can be combined with R14 (if used) by adding the response option, “How eating fish with high levels of
mercury during pregnancy could affect my baby.” R22e can also be combined with NN5 by adding it as a
response option “Medicines that are safe to take during my pregnancy.” Alternatively, one or more response
options from NN5 can be added to R22.
NN5. 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
How me being exposed to lead could affect my baby
How using pesticides, which are chemicals to kill insects, rodents or weeds during pregnancy, could affect my baby
How using water bottles or other bottles made of polycarbonate plastic (BPA, recycle #7) during pregnancy could affect my baby
NN6. During your most recent pregnancy, was a doctor, nurse, or other health care worker able to answer any questions about environmental exposures? Check ONE answer
No
Yes
I didn’t ask a health care worker any questions about environmental exposures
I didn’t have any concerns about environmental exposures
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | Pregnancy Risk Assessment Monitoring System (PRAMS) |
| Author | frq3 |
| File Modified | 0000-00-00 |
| File Created | 2021-06-23 |