PRAMS Livebirth Core Phase 8 Phone Questionnaire (Englis

Pregnancy Risk Assessment Monitoring System (PRAMS)

Att 7c-PRAMS Phase 8 Core_Livebirth_Phone_ENGLISH

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

OMB: 0920-1273

Document [docx]
Download: docx | pdf

Attachment 7c Phase 8 Core Phone Questionnaire - English

0


Form Approved

OMB No. 0920-xxxx

Exp. Date xx/xx/xxxx






Pregnancy Risk Assessment Monitoring System (PRAMS)




Phase 8 Core Phone Questionnaire



























Public reporting of this collection of information is estimated to average 25-35 minutes per response, including the time for reviewing instructions and completing and reviewing the collection of information. An agency many not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a current valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (XXXX-XXXX)



INTERVIEWER: Please indicate the number that corresponds to the respondent’s answer.


First, I would like to ask a few questions about you.


  1. How tall are you without shoes?


(PROBE: About how tall?)


(Don’t read) 1 Feet ______

2 Inches______ [Range: 4-6 feet/0-11 inches]

OR

3 Centimeters______ [Range: 120-210 centimeters]


8 Refused

9 Don’t know/don’t remember

Validation Warnings:

Height unit: Zero is not a valid response

Feet: Zero is not a valid response

Feet: 9 is the only valid response if Height unit = 9

Inches: 99 is the only valid response if Height unit = 9

Centimeters: Not a valid response. Please enter a number between 120 and 210.

Centimeters: 999 is the only valid response if Height unit = 9


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

(PROBE: About how much?)


(Don’t read) 1 Number of pounds_______ [Range: 36-400 pounds/kilos]

OR

2 Number of kilos_______


8 Refused

9 Don’t know/don’t remember

Validation Warnings:

Weight unit: Zero is not a valid response

Pounds/Kilos: Zero is not a valid response

Pounds/Kilos: 999 is the only valid response if Weight unit = 9







  1. What is your date of birth?


______ / ______ / ______ [Range: 10-55 years of age]

Month Day Year


(Don’t read) 88/88/8888 Refused

99/99/9999 Don’t know/don’t remember

Validation Warnings:

Month/Day: Zero is not a valid response

Year: Mother's Year of Birth should be no less than 10 years and no greater than 55 years from the current year.




The next questions are about the time before you got pregnant with your new baby.


Insertion point for Previous Pregnancy Outcomes Series: (former core 4-6 [FF5-FF7], FF4, K1)

Insertions point for former Core 7 [L26]

Insertion point for Standard question(s) L10



  1. I’m going to read a list of health conditions. For each one, please tell me if you had it during the 3 months before you got pregnant with your new baby. Did you have______?


(PROBE: During the 3 months before you got pregnant with your new baby, did you have______?)


Condition

(Don’t read)

No

(1)

Yes

(2)

Refused

(8)

Don’t know

(9)

    1. Type 1 or Type 2 diabetes. This is not the same as gestational diabetes or diabetes that starts during pregnancy.





    1. High blood pressure or hypertension





    1. Depression





    1. State-added options from standard L11





Validation Warnings:

Zero is not a valid response



Insertion point for Standard question(s) L11 (add as options to core 4)


  1. During the month before you got pregnant with your new baby, how many times a week did you take a multivitamin, a prenatal vitamin, or a folic acid vitamin? Please tell me which of the following best describes you.


(PROBE: About how many times a week did you take a multivitamin, a prenatal vitamin, or a folic acid vitamin?)


  1. You didn’t take a multivitamin, prenatal vitamin, or folic acid vitamin in the month before you got pregnant

2 1 to 3 times a week

3 4 to 6 times a week

4 Every day of the week


(Don’t read) 8 Refused

9 Don’t know/don’t remember

Validation Warnings:

Zero is not a valid response


Insertion point for Standard question(s) G8



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


Don’t read: 1 No Go to Question [Core 9]

2 Yes


8 Refused Go to Question [Core 9]

9 Don’t know/Don’t remember Go to Question [Core 9]



Insertion point for Standard question(s) J5


  1. I’m going to read a list of types of health care visits. For each one, please tell me if you had that kind of visit in the 12 months before you got pregnant with your new baby. Did you have _____?



(PROBE: What type of health care visit did you have in the 12 months before you got pregnant with your new baby? Did you have___________?)


(Don’t read)


Type of Visit

No

(1)

Yes

(2)

Refused

(8)

Don’t know

(9)

a.

A regular checkup at your family doctor’s office





b.

A regular checkup at your OB/GYN’s office





c.

A visit for an illness or chronic condition





d.

A visit for an injury





e.

A visit for family planning or birth control





f.

A visit for depression or anxiety





g.

A visit to have your teeth cleaned by a dentist or dental hygienist





h.

Some other type of visit





i.

If Yes: What was that? ________________________________

___________________________________________________

______________________________________________________









  1. During any of your health care visits in the 12 months before you got pregnant, did a doctor, nurse, or other health care worker do any of the following things?


(PROBE: Did a doctor, nurse, or other health care worker ______?)

Activity

(Don’t read)

No

(1)

Yes

(2)

Refused

(8)

Don’t know

(9)

  1. Tell you to take a vitamin with folic acid





  1. Talk to you about maintaining a healthy weight





  1. Talk to you about controlling any medical conditions such as diabetes

or high blood pressure





  1. Talk to you about your desire to have or not have children





  1. Talk to you about using birth control to prevent pregnancy





  1. Talk to you about how you could improve your health before a pregnancy





  1. Talk to you about sexually transmitted infections such as chlamydia, gonorrhea, or syphilis





  1. Ask you if you were smoking cigarettes





  1. Ask you if someone was hurting you emotionally or physically





  1. Ask you if you were feeling down or depressed





  1. As you about the kind of work you do





  1. Test you for HIV, the virus that causes AIDS





Validation Warnings:

Zero is not a valid response


Insertion point for Standard question(s): L27, L18


The next questions are about your health insurance coverage before, during, and after your pregnancy with your new baby.


  1. I’m going to read a list of different types of health insurance. For each one, please tell me if you had this kind of health insurance during the month before you got pregnant with your new baby. Did you have ______?


(PROBE: What kind of health insurance did you have during the month before you got pregnant with your new baby?)


Type of Insurance

(Don’t read)

No

(1)

Yes

(2)

Refused

(8)

Don’t know

(9)

  1. Private health insurance from your job or the job of your husband or partner





  1. Private health insurance from your parents





  1. Private health insurance from the <State> Health Insurance Marketplace or <state website> or HealthCare.gov





  1. Medicaid or <state Medicaid name>





  1. State-specific (Other government plan such as SCHIP/CHIP)





  1. State-specific (Other government plan not listed such as MCH)





  1. State-specific (TRICARE or other military health care)





  1. State-specific (IHS or tribal)





  1. Did you have some other health insurance during the month before you got pregnant?





  1. IF YES, ASK: What was that?

__________________________________________________________________________

__________________________________________________________________________

INTERVIEWER: Go to Question [Core 10] if the mother answered YES to any of the insurance options listed above.

  1. Would you say that you did not have any health insurance during the month before you got pregnant?


(Interviewer: If the mother answered that she did not have any health insurance, check YES.)






Insertion point for Standard question(s): DD4, DD5, DD6, DD7


  1. What kind of health insurance did you have during your most recent pregnancy for your prenatal care? I’m going to read the list of options again. For each one, please tell me if you had this kind of health insurance for your prenatal care. First, let me ask: (READ item a)


(PROBE: What kind of health insurance did you have during your most recent pregnancy for your prenatal care?


Type of Insurance

(Don’t read)

No

(1)

Yes

(2)

Refused

(8)

Don’t know

(9)

  1. Did you have prenatal care?

(INTERVIEWER: If the mother did not have prenatal care, mark NO and go to Question [Core 11].)





  1. Private health insurance from your job or the job of your husband or partner





  1. Private health insurance from your parents





  1. Private health insurance from the <State> Health Insurance Marketplace or <state website> or HealthCare.gov





  1. Medicaid or <state Medicaid name>





  1. State-specific (Other government plan such as SCHIP/CHIP)





  1. State-specific (Other government plan not listed such as MCH)





  1. State-specific (TRICARE or other military health care)





  1. State-specific (IHS or tribal)





  1. Did you have some other health insurance for your prenatal care?





  1. IF YES, ASK: What was that?

__________________________________________________________________________

__________________________________________________________________________

INTERVIEWER: Go to Question [Core 11] if the mother answered YES to any of the insurance options listed above.

  1. Would you say that you did not have any health insurance for your prenatal care?


(Interviewer: If the mother answered that she did not have any health insurance, check YES.)






Insertion point for Standard question(s) DD8, DD9, DD10, DD11

Insertion point for Standard question(s) DD12, DD13, DD14, DD15, DD16

  1. What kind of health insurance do you have now? I’m going to read the list of types of health insurance one last time. For each one, please tell me if you have this kind of health insurance now. Do you have ______?


(PROBE: What kind of health insurance do you have now?)


Type of Insurance

(Don’t read)

No

(1)

Yes

(2)

Refused

(8)

Don’t know

(9)

  1. Private health insurance from your job or the job of your husband or partner





  1. Private health insurance from your parents





  1. Private health insurance from the <State> Health Insurance Marketplace or <state website> or HealthCare.gov





  1. Medicaid or <state Medicaid name>





  1. State-specific (Other government plan such as SCHIP/CHIP)





  1. State-specific (Other government plan not listed such as MCH)





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





  1. State-specific option (IHS or tribal)





  1. Do you have some other health insurance?





  1. IF YES, ASK: What is that?

__________________________________________________________________________

__________________________________________________________________________

INTERVIEWER: Go to Question [Core 12] if the mother answered YES to any of the insurance options listed above.

  1. Would you say that you do not have any health insurance now?

(Interviewer: If the mother answered that she does not have any health insurance, check YES.)







Insertion point for Standard question(s): DD17, DD18, DD19, DD20, DD21


  1. Thinking back to just before you got pregnant with your new baby, how did you feel about becoming pregnant? I’m going to read a list of options. Please choose the one that best describes how you felt.


(PROBE: Just before you got pregnant with your new baby, how did you feel about becoming pregnant?)


1 You wanted to be pregnant later

2 You wanted to be pregnant sooner

3 You wanted to be pregnant then

4 You didn’t want to be pregnant then or at any time in the future

5 You weren’t sure what you wanted


(Don’t read) 8 Refused

9 Don’t know/don’t remember

Validation Warnings:

Zero is not a valid response


Insertion point for Standard question: former core 13 [Q4]

Insertion point for Preconception Contraception Series: (former core 14-16 [E5, E6-E7] & E3)

Insertion point for Fertility & Fertility Treatment Series: (E5,Q7, A1–A2, A4, A5)


The next questions are about the prenatal care you received during your most recent pregnancy. Prenatal care includes visits to a doctor, nurse, or other health care worker before your baby was born to get checkups and advice about pregnancy. It may help to look at the calendar when you answer these questions.

Insertion point for Standard question: R19



  1. How many weeks or months pregnant were you when you had your first visit for prenatal care?

(PROBE: How many weeks or months pregnant were you?)


(Don’t read) 1 Number of weeks______ (Range: 1-40 weeks)

OR

2 Number of months______ (Range: 1-9 months)


3 You didn’t go for prenatal care → Go to Question [Core 15]

8 Refused Go to Question [Core 15]

9 Don’t know/don’t remember Go to Question [Core 15]


NOTE: If a state uses R20, Refused/Don’t know goes to R20.


Validation Warnings:

First Prenatal Care unit: Zero is not a valid response

Weeks/Months: Zero is not a valid response

Weeks/Months: 99 is the only valid response if 1st Prenatal Care unit = 9


Insertion point for Standard question(s): R20, R21

Insertion point for Standard question(s): R15

Insertion point for Standard question(s): former core 19 [R22], R6, R7, R8, R9, R10, R11, R12, R14, R16


  1. During any of your prenatal care visits, did a doctor, nurse, or other health care worker ask you any of the following things?


(PROBE: During your prenatal care visits, did a doctor, nurse, or other health care worker ask you ______?)



Subject

(Don’t read)

No

(1)

Yes

(2)

Refused

(8)

Don’t know

(9)

  1. If you knew how much weight you should gain during pregnancy





  1. If you were taking any prescription medication





  1. If you were smoking cigarettes





  1. If you were drinking alcohol





  1. If someone was hurting you emotionally or physically





  1. If you were feeling down or depressed





  1. If you were using drugs such as marijuana, cocaine, crack, or meth





  1. If you wanted to be tested for HIV, the virus that causes AIDS





  1. If you planned to breastfeed your new baby





  1. If you planned to use birth control after your baby was born





Validation Warnings:

Zero is not a valid response



Insertion point for Standard question(s): R17, R18, R13, K4

Insertion point for Standard question: R1

Insertion point for HIV Testing Series: (former core 20 [I8], I9, I3)

Insertion point for Standard questions: G5, G1-G4


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


(Don’t read) 1 No

2 Yes

8 Refused

9 Don’t know/don’t remember

Validation Warnings:

Zero is not a valid response


  1. During the 12 months before the delivery of your new baby, did you get a flu shot? I’m going to read you three options. Please tell me which one applies to you.


1 No

2 Yes, before your pregnancy

3 Yes, during your pregnancy


(Don’t read) 8 Refused

9 Don’t know/don’t remember

Validation Warnings:

Zero is not a valid response


Insertion point for Standard question(s): L19, L14, L15, L24



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



(Don’t read) 1 No

2 Yes

8 Refused

9 Don’t know/don’t remember



Validation Warnings:

Zero is not a valid response





Insertion point for Oral Health Series: (former core 24 [Y7], Y5, Y8, Y6)

Insertion point for Childbirth class &Home Visitation Series: (former Core 25 [R23], former Core 26 [V21], V13, V14, V15, V20)

Insertion point for Standard question(s): former Core 27 [B12], B8, B7, B4

  1. I’m going to read a list of health conditions. For each one, please tell me if you had it during your most recent pregnancy. Did you have______?


(PROBE: During your most recent pregnancy, did you have______?)


Condition

(Don’t read)

No

(1)

Yes

(2)

Refused

(8)

Don’t know

(9)

    1. Gestational diabetes or diabetes that started during this pregnancy





    1. High blood pressure that started during this pregnancy, pre-eclampsia, or eclampsia





    1. Depression





    1. State-added options





Validation Warnings:

Zero is not a valid response


Insertion point for Standard question(s): N6, N7, M4, M9, M8,

Insertion point for Standard question(s): N9, N8b, N8c, N1-N4,

Insertion point for Standard question(s): N5, EE3



The next questions are about smoking cigarettes before, during, and after pregnancy.


  1. Have you smoked any cigarettes in the past 2 years?


(Don’t read) 1 No → Go to Question [Core 23]

2 Yes

8 Refused → Go to Question [Core 23]

9 Don’t know/don’t remember → Go to Question [Core 23]

Validation Warnings:

Zero is not a valid response



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


(PROBE: In the 3 months before you got pregnant, about how many cigarettes did you smoke on an average day?)


1 41 cigarettes or more a day

2 21 to 40 cigarettes

3 11 to 20 cigarettes

4 6 to 10 cigarettes

5 1 to 5 cigarettes

6 Less than 1 cigarette

7 You didn’t smoke then


(Don’t read) 8 Refused

9 Don’t know/don’t remember

Validation Warnings:

Zero is not a valid response


  1. In the last 3 months of your pregnancy, how many cigarettes did you smoke on an average day? Did you smoke______?


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


1 41 cigarettes or more a day

2 21 to 40 cigarettes

3 11 to 20 cigarettes

4 6 to 10 cigarettes

5 1 to 5 cigarettes

6 Less than 1 cigarette

7 You didn’t smoke then


(Don’t read) 8 Refused

9 Don’t know/don’t remember

Validation Warnings:

Zero is not a valid response


Insertion point for Standard Questions: (AA1, AA3)

Insertion point for Standard Questions: (AA2, AA12, AA6, AA10)



  1. How many cigarettes do you smoke on an average day now? Do you smoke______?


(PROBE: About how many cigarettes do you smoke on an average day? A pack has 20 cigarettes.)


1 41 cigarettes or more a day

2 21 to 40 cigarettes

3 11 to 20 cigarettes

4 6 to 10 cigarettes

5 1 to 5 cigarettes

6 Less than 1 cigarette

7 You don’t smoke now


(Don’t read) 8 Refused

9 Don’t know/don’t remember

Validation Warnings:

Zero is not a valid response


Insertion point for Standard question(s): (AA8, AA5)

Insertion point for Standard question(s): AA9, AA7, U1, U2


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


  1. I am going to read a list of products. For each one, please tell me if you used it at any time in the past 2 years? Have you used _____?


(PROBE: In the past 2 years, have you used _______?)


(Don’t Read)


Product

No

(1)

Yes

(2)

Refused

(8)

Don’t know

(9)

a.

E-cigarettes or other electronic nicotine products

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





b.

Hookah

(PROBE: A hookah is a water pipe used to smoke tobacco. It is not the same as an e-hookah or hookah pen.)





c.

State added option (Chewing tobacco, snuff, snus, or dip)





d.

State added option (Cigars, cigarillos, or little filtered cigars)





Validation Warnings:

Zero is not a valid response



INTERVIEWER: If the respondent did NOT use e-cigarettes or other electronic nicotine products in the past 2 years, go to Question [Core 26].


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

1 More than once a day

2 Once a day

3 2 to 6 days a week

4 1 day a week or less

5 You did not use e-cigarettes or other electronic nicotine products then


(Don’t’ read) 8 Refused

9 Don’t know/don’t remember

Validation Warnings:

Zero is not a valid response


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


1 More than once a day

2 Once a day

3 2 to 6 days a week

4 1 day a week or less

5 You did not use e-cigarettes or other electronic nicotine products then


(Don’t’ read) 8 Refused

9 Don’t know/don’t remember


Validation Warnings:

Zero is not a valid response


Insertion point for Standard question(s): AA13, AA14


The next questions are about drinking alcohol around the time of pregnancy.


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


(Don’t read) 1 No → Go to Question [Core 28]

2 Yes

8 Refused → Go to Question [Core 28]

9 Don’t know/don’t remember → Go to Question [Core 28]

Validation Warnings:

Zero is not a valid response



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


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


1 14 drinks or more a week

2 8 to 13 drinks a week

3 4 to 7 drinks a week

4 1 to 3 drinks a week

5 Less than 1 drink a week

6 You didn’t drink then


(Don’t read) 8 Refused

9 Don’t know/don’t remember

Validation Warnings:

Zero is not a valid response


Insertion point for Standard question(s): JJ1, former core 35 [JJ3], JJ2


Pregnancy can be a difficult time. The next questions are about things that may have happened before and during your most recent pregnancy.


Insertion point for Standard question(s): former core 36 [P19], P14, P17, P15, P16

Insertion point for Standard question(s): BB1, Z7


  1. In the 12 months before you got pregnant with your new baby, did any of the following people push, hit, slap, kick, choke, or physically hurt you in any other way?


Item

(Don’t read)

No

(1)

Yes

(2)

Refused

(8)

Don’t know

(9)

  1. Your husband or partner





  1. Your ex-husband or ex-partner





  1. State option (Another family member)





  1. State option (Someone else)





Validation Warnings:

Zero is not a valid response


Insertion point for Standard question(s): Z14



  1. During your most recent pregnancy, did any of the following people push, hit, slap, kick, choke, or physically hurt you in any other way?


Item

(Don’t read)

No

(1)

Yes

(2)

Refused

(8)

Don’t know

(9)

  1. Your husband or partner





  1. Your ex-husband or ex-partner





  1. State option (Another family member)





  1. State option (Someone else)





Validation Warnings:

Zero is not a valid response


Insertion point for Standard question(s): Z1



The next questions are about the time since your new baby was born.



Insertion point for Standard question(s): K13, K14, K5


  1. On what date was your new baby born?


(PROBE: When was your new baby born?)


(Don’t read) ______ / ______ / 20____ [Range: Month 1-12;Day 1-31; Year = Surveillance year]

Month Day Year


88/88/8888 Refused

99/99/9999 Don’t know/don’t remember

Validation Warnings:

Month/Day/Year: Zero is not a valid response

Year: Year must be current birth year.


Insertion point for Labor Interventions Series: K9, K10, K8, K3, K7, K6

Insertion point for Standard questions: K15, II1 (former core 40)

Insertion point for Standard questions: K16 (former core 41)


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


(PROBE: Did he or she stay in the hospital for______?)


1 Less than 24 hours, or less than 1 day

2 24 to 48 hours, or 1 to 2 days

3 3 to 5 days

4 6 to 14 days

5 More than 14 days


(Don’t read) 6 Your baby was not born in a hospital

7 Your baby is still in the hospital → Go to Question [Core 34]

8 Refused

9 Don’t know/don’t remember

Validation Warnings:

Zero is not a valid response



Insertion point for Standard question(s): K11, K12


  1. Is your baby alive now?


(Don’t read) 1 No → INTERVIEWER: “We are very sorry for your loss.” and Go to Question [Core 43]

2 Yes

8 Refused → Go to Question [Core 43]

9 Don’t know/don’t remember → Go to Question [Core 43]

Validation Warnings:

Zero is not a valid response


  1. Is your baby living with you now?


(Don’t read) 1 No → Go to Question [Core 43]

2 Yes

8 Refused → Go to Question [Core 43]

9 Don’t know/don’t remember → Go to Question [Core 43]

Validation Warnings:

Zero is not a valid response


Insertion point for Standard question(s) B9


  1. I’m going to read a list of sources of information on breastfeeding. For each one, please tell me if you received information from that source before or after your new baby was born. Did you receive information about breastfeeding your baby from ________?


(PROBE: Before or after your new baby was born, did you receive information about breastfeeding from __________?)



(Don’t read)


Sources

No

(1)

Yes

(2)

Refused

(8)

Don’t know

(9)

a.

Your doctor





b.

A nurse, midwife, or doula





c.

A breastfeeding or lactation specialist





d.

Your baby’s doctor or health care provider





e.

A breastfeeding support group





f.

A breastfeeding hotline or toll-free number





g.

Family or friends





h.

Some other source





i.

If Yes: What source was that? ________________________________

___________________________________________________

______________________________________________________





Validation Warnings:

Zero is not a valid response


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


(Don’t read) 1 No → Go to Question [Core 38]

2 Yes

8 Refused → Go to Question [Core 38]

9 Don’t know/don’t remember → Go to Question [Core 38]

Validation Warnings:

Zero is not a valid response


Insertion point for Standard question(s) B1

Insertion point for Standard question(s) B13


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


(Don’t read) 1 No

2 Yes → Go to Question [Core 38]

8 Refused → Go to Question [Core 38]

9 Don’t know/don’t remember → Go to Question [Core 38]

Validation Warnings:

Zero is not a valid response


  1. How many weeks or months did you breastfeed or pump milk to feed your baby?

(PROBE: About how many weeks or months?)


(Don’t read) 1 Less than 1 week


2 Number of weeks_______ (Range: 1-40)

OR

3 Number of months ______ (Range: 1-9)


8 88 Refused

9 99 Don’t know/don’t remember

Validation Warnings:

Breastfeeding Length unit: Zero is not a valid response

Weeks/Months: Zero is not a valid response

Weeks/Months: 41 is the only valid response if Breastfeeding Length unit = 5

Weeks/Months: 99 is the only valid response if Breastfeeding Length unit = 9


Insertion point for Standard questions: B2, B14-B16

Insertion point for Standard question(s): B3, B10, B11, B5, B6

Insertion point for Standard question(s): H2, H6, H7, H5, H1, H3, H4

Insertion point for Standard question(s): S13



INTERVIEWER: If the baby is still in the hospital, go to Question [Core 43].


  1. In which one position do you most often lay your baby down to sleep now? Is it______?


(PROBE: Which way do you lay him or her down most of the time?)


1 On his or her side

2 On his or her back

3 On his or her stomach


(Don’t read) 4 On side and back

5 On side and stomach

6 On back and stomach

7 On side, back, and stomach

8 Refused

9 Don’t know/don’t remember

Validation Warnings:

Zero is not a valid response


  1. In the past 2 weeks, how often has your new baby slept alone in his or her own crib or bed? Would you say it has been always, often, sometimes, rarely, or never?


(PROBE: How often does your new baby sleep alone in his or her own crib or bed?)


(Don’t read) 1 Always

2 Often

3 Sometimes

4 Rarely

5 Never Go to Question [Core 41]


8 Refused Go to Question [Core 41]

9 Don’t know/don’t remember Go to Question [Core 41]


Validation Warnings:

Zero is not a valid response


Insertion point for standard question(s): F4


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


(Don’t read) 1 No

2 Yes

8 Refused

9 Don’t know/don’t remember

Validation Warnings:

Zero is not a valid response


  1. I’m going to read a list of ways some babies sleep. For each item, please tell me if it is how your new baby usually slept during the past 2 weeks. Did your new baby usually sleep _____________?


(PROBE: In the past 2 weeks, would you say that your new baby slept_______?)

Description

(Don’t read)

No

(1)

Yes

(2)

Refused

(8)

Don’t know

(9)

  1. In a crib, bassinet, or pack and play





  1. On a twin or larger mattress or bed





  1. On a couch, sofa, or armchair





  1. In an infant car seat or swing





  1. In a sleeping sack or wearable blanket





  1. With a blanket





  1. With toys, cushions, or pillows, including nursing pillows





  1. With crib bumper pads, either mesh or non-mesh






Validation Warnings:

Zero is not a valid response


  1. Did a doctor, nurse, or other health care worker tell you any of the following things? I am going to read a short list.

(PROBE: Did a doctor, nurse, or other health care worker tell you __________?)

Description

(Don’t read)

No

(1)

Yes

(2)

Refused

(8)

Don’t know

(9)

  1. To place your baby on his or her back to sleep





  1. To place your baby to sleep in a crib, bassinet, or pack and play





  1. To place your baby’s crib or bed in your room





  1. What things should and should not go in bed with your baby






Validation Warnings:

Zero is not a valid response





Insertion point for Infant Well Care Visit Series: X10, X6, X9, X7, X8, X1, X4, X2, X3, X5, X11, X12

Insertion point for Infant Sick Care Series: T4, T5, T1, T2, T3, T8, T6, T7

Insertion point for Postpartum Home Visitation Series: V22 (former Core 49), V16, V17, V18, V19)



  1. Are you or your husband or partner doing anything now to keep from getting pregnant? Some things people do to keep from getting pregnant include having their tubes tied, using birth control pills, condoms, withdrawal, or natural family planning.



(Don’t read) 1 No

2 Yes → Go to Question [Core 45]

8 Refused → Go to Question [Core 46]

9 Don’t know/don’t remember → Go to Question [Core 46]

Validation Warnings:

Zero is not a valid response

  1. I’m going to read a list of reasons some women or their husbands or partners have for not doing anything to keep from getting pregnant. For each one, please tell me if it is one of the reasons for you or your husband or partner now. Is it because______?


(PROBE: Is one of the reasons you aren’t doing anything to keep from getting pregnant now because______?)



Reason

(Don’t read)

No

(1)

Yes

(2)

Refused

(8)

Don’t know

(9)

  1. You want to get pregnant





  1. You are pregnant now





  1. You had your tubes tied or blocked





  1. You don’t want to use birth control





  1. You are worried about side effects from birth control





  1. You are not having sex





  1. Your husband or partner doesn’t want to use anything





  1. You have problems paying for birth control





  1. Is there any other reason you’re not doing anything to keep from getting pregnant now?





  1. IF YES, ASK: What is the reason?

____________________________________________________________________________________

____________________________________________________________________________________

Validation Warnings:

Zero is not a valid response

Nine is not a valid response (mail only)



INTERVIEWER: If the respondent or her husband or partner is not doing anything to keep from getting pregnant now, go to Question [Core 46].



  1. I’m going to read a list of birth control methods. For each one, please tell me if you or your husband or partner is using this method now.


(PROBE: What are you or your husband or partner using now to keep from getting pregnant?)


Method

(Don’t read)

No

(1)

Yes

(2)

Refused

(8)

Don’t know

(9)

  1. Tubes tied or blocked, female sterilization, or Essure®





  1. Vasectomy or male sterilization





  1. Birth control pills





  1. Condoms





  1. Shots, injections or Depo-Provera®





  1. Contraceptive patch or OrthoEvra® or vaginal ring or NuvaRing®





  1. IUD, including Mirena® or ParaGard®, Liletta®, or Skyla®





  1. Contraceptive implant in the arm, including Nexplanon® or Implanon®





  1. Natural family planning including rhythm method





  1. Withdrawal or pulling out





  1. Not having sex or abstinence





  1. Are you or your husband or partner using anything else to keep from getting pregnant now?





  1. IF YES, ASK: What are you using?

____________________________________________________________________________________

____________________________________________________________________________________

Validation Warnings:

Zero is not a valid response

Nine is not a valid response (mail only)



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


(Don’t read) 1 No Go to Question [Core 48]

2 Yes

8 Refused Go to Question [Core 48]

9 Don’t know/don’t remember Go to Question [Core 48]

Validation Warnings:

Zero is not a valid response


Insertion point for Standard question: J3, J2


  1. During your postpartum checkup, did your doctor, nurse, or other health care worker do any of the following things? I am going to read a list of things. Did they __________?


(PROBE: Did a doctor, nurse, or other health care worker ______?)


Subject

(Don’t read)

No

(1)

Yes

(2)

Refused

(8)

Don’t know

(9)

  1. Tell you to take a vitamin with folic acid





  1. Talk to you about healthy eating, exercise, and losing weight gained during pregnancy





  1. Talk to you about how long to wait before getting pregnant again





  1. Talk to you about birth control methods you can use after giving birth





  1. Give or prescribe you a contraceptive method such as the pill, patch, shot or Depo-Provera®, NuvaRing®, or condoms










  1. Insert an IUD such as Mirena®, ParaGard®, Liletta®, or Skyla® or

a contraceptive implant such as Nexplanon® or Implanon®





  1. Ask you if you were smoking cigarettes





  1. Ask you if someone was hurting you emotionally or physically





  1. Ask you if you were feeling down or depressed





  1. Test you for diabetes





Validation Warnings:

Zero is not a valid response


Insertion point for Standard question: J4

Insertion point for Standard Question(s): O4-O6, O1-O3, L28, L29



  1. Since your new baby was born, how often have you felt down, depressed, or hopeless? Would you say that it’s been always, often, sometimes, rarely, or never?


(Don’t read) 1 Always

2 Often

3 Sometimes

4 Rarely

5 Never


8 Refused

9 Don’t know/don’t remember

Validation Warnings:

Zero is not a valid response





  1. Since your new baby was born, how often have you had little interest or little pleasure in doing things you usually enjoyed? Would you say that it’s been always, often, sometimes, rarely, or never?


(Don’t read) 1 Always

2 Often

3 Sometimes

4 Rarely

5 Never


8 Refused

9 Don’t know/don’t remember

Validation Warnings:

Zero is not a valid response



Insertion point for Standard question(s):, M6, M5, M11, M10

Insertion point for Standard question(s): M12, M21, M16, M15, M20, M19

Insertion point for Standard question(s): Z13, Z2




The next questions are on a variety of topics.


[STATE-SPECIFIC SECTION (Standards without insertion points and state-developed questions)]



The last questions are about the time during the 12 months before your new baby was born.


Insertion point for Standard Question(s) P18


  1. During the 12 months before your new baby was born, what was your yearly total household income before taxes? Include your income, your husband’s or partner’s income, and any other income you may have received. All information will be kept private and will not affect any services you are now getting. I’m going to read you a list of options. You can stop me when I read your household income level. Was your yearly household income from ______?


(PROBE: During the 12 months before your new baby was born, what was your yearly total household income before taxes?)


01 $0 to $16,000

02 $16,001 to $20,000

03 $20,001 to $24,000

04 $24,001 to $28,000

05 $28,001 to $32,000

06 $32,001 to $40,000

07 $40,001 to $48,000

08 $48,001 to $57,000

09 $57,001 to $60,000

10 $60,001 to $73,000

11 $73,001 to $85,000

12 $85,001 or more


(Don’t read) 88 Refused

99 Don’t know/don’t remember


Note: States can add additional categories as long as the categories are collapsible back to the existing core categories (i.e. may add upper or lower ranges beyond what is provided or split out existing categories into sub-categories)

Validation Warnings:

Zero is not a valid response


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


(Don’t read) ______ People [Range: 1-30 people]


88 Refused

99 Don’t know/don’t remember

Validation Warnings:

Zero is not a valid response






This finishes the interview. Is there anything you would like to say about your experiences around the time of your pregnancy or the health of mothers and babies in <STATE>?


INTERVIEWER: Record respondent’s verbatim comments below.


__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________


Thanks for answering our questions. Your answers will help us work to make <STATE> mothers and babies healthier. Goodbye.


INTERVIEWER:


  1. Fill in today’s date.

______ / ______ / 20____

Month Day Year

Validation Warnings:

Month/Day/Year: Zero is not a valid response

Year: Please enter year for Mother's questionnaire

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleJune 4, 2010
Authorndp8
File Modified0000-00-00
File Created2022-04-01
© 2024 OMB.report | Privacy Policy