PRAMS Livebirth Phase 8 Core Mail Questionnaire (English

Attachment 8a – PRAMS Livebirth Phase 8 Core Mail Questionnaire - English

Form Approved

OMB No. 0920-1273

Exp. Date xx/xx/xxxx

Pregnancy Risk Assessment Monitoring System (PRAMS)

Phase 8 Core Mail Questionnaire – English

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 may 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 (0920-1273)

Please check the box next to your answer or follow the directions included with the question. You may be asked to skip some questions that do not apply to you.

BEFORE PREGNANCY

The first questions are about you.

1. How tall are you without shoes?

[BOX] Feet [BOX] Inches

OR [BOX] Centimeters

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

[BOX] Pounds OR [BOX] Kilos

3. What is your date of birth?

[BOX]	/[BOX]	/[BOX]
Month	Day	Year

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

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

Insertion point for Standard question L26 [former Core 7]

Insertion point for Standard question L10

4. 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

1. Type 1 or Type 2 diabetes (not gestational diabetes

or diabetes that starts during pregnancy) * *

2. High blood pressure or hypertension * *

3. Depression * *

4. State-added options from Standard question L11 * *

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

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

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

1 to 3 times a week

4 to 6 times a week

Every day of the week

Insertion point for Standard question G8

6. 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?

No è Go to Question [Core 9]

Yes

Insertion point for Standard question J5

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

Regular checkup at my family doctor’s office

Regular checkup at my OB/GYN’s office

Visit for an illness or chronic condition

Visit for an injury

Visit for family planning or birth control

Visit for depression or anxiety

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

Other è Please tell us: _______________________________

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

No Yes

1. Tell me to take a vitamin with folic acid * *

2. Talk to me about maintaining a healthy weight * *

3. Talk to me about controlling any medical conditions such as diabetes

or high blood pressure * *

4. Talk to me about my desire to have or not have children * *

5. Talk to me about using birth control to prevent pregnancy * *

6. Talk to me about how I could improve my health before a pregnancy * *

7. Talk to me about sexually transmitted infections such as chlamydia,

gonorrhea, or syphilis * *

8. Ask me if I was smoking cigarettes * *

9. Ask me if someone was hurting me emotionally or physically * *

10. Ask me if I was feeling down or depressed * *

11. Ask me about the kind of work I do * *

12. Test me for HIV (the virus that causes AIDS) * *

Insertion point for Standard questions L27, L18

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

9. During the month before you got pregnant with your new baby, what kind of health insurance did you have? Check ALL that apply

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

Private health insurance from my parents

Private health insurance from the <State> Health Insurance 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 è Please tell us: _____________________________

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

Insertion point for Standard questions DD4, DD5, DD6, DD7

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

I did not go for prenatal care è Go to Question [Core 11]

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

Private health insurance from my parents

Private health insurance from the <State> Health Insurance 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 è Please tell us: _____________________________

I did not have any health insurance for my prenatal care

Insertion point for Standard questions DD8, DD9, DD10, DD11

Insertion point for Standard questions DD12, DD13, DD14, DD15, DD16

11. What kind of health insurance do you have now? Check ALL that apply

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

Private health insurance from my parents

Private health insurance from the <State> Health Insurance 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 è Please tell us: _____________________________

I do not have health insurance now

Insertion point for Standard questions DD17, DD18, DD19, DD20, DD21

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

I wanted to be pregnant later

I wanted to be pregnant sooner

I wanted to be pregnant then

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

I wasn’t sure what I wanted

Insertion point for Standard question Q4 [former Core 13]

Insertion point for Preconception Contraception Series E5, E6, E7 [former Core 14-16] & E3

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

DURING PREGNANCY

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

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

[BOX] Weeks OR [BOX] Months

I didn’t go for prenatal care è Go to Question [Core 15]

Insertion point for Standard questions R20, R21

Insertion point for Standard question R15

Insertion point for Standard questions R22 [former Core 19], R6, R7, R8, R9, R10, R11, R12, R14, R16

14. During any of your prenatal care visits, did a doctor, nurse, or other health care worker ask you any of the things listed below? For each item, check No if they did not ask you about it or Yes if they did.

No Yes

1. If I knew how much weight I should gain during pregnancy * *

2. If I was taking any prescription medication * *

3. If I was smoking cigarettes * *

4. If I was drinking alcohol * *

5. If someone was hurting me emotionally or physically * *

6. If I was feeling down or depressed * *

7. If I was using drugs such as marijuana, cocaine, crack, or meth * *

8. If I wanted to be tested for HIV (the virus that causes AIDS) * *

9. If I planned to breastfeed my new baby * *

10. If I planned to use birth control after my baby was born * *

Insertion point for Standard questions R17, R18, R13, K4

Insertion point for Standard question R1

Insertion point for HIV Testing Series: I8 [former Core 20], I9, I3

Insertion point for Standard questions G5, G1-G4

15. 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?

No

Yes

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

No

Yes, before my pregnancy

Yes, during my pregnancy

Insertion point for Standard questions L19, L14, L15, L24

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

No

Yes

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

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

Insertion point for Standard questions B12 [former Core 27], B8, B7, B4

18. During your most recent pregnancy, 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

1. Gestational diabetes (diabetes that started during this pregnancy)

2. High blood pressure (that started during this pregnancy), pre-eclampsia or eclampsia

3. Depression

4. State added options

Insertion point for Standard questions N6, N7, M4, M9, M8

Insertion point for Standard questions N9, N8b, N8c, N1-N4

Insertion point for Standard questions N5, EE3

The next questions are about smoking cigarettes around the time of pregnancy (before, during, and after).

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

No → Go to Question [Core 23]

Yes

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

41 cigarettes or more

21 to 40 cigarettes

11 to 20 cigarettes

6 to 10 cigarettes

1 to 5 cigarettes

Less than 1 cigarette

I didn’t smoke then

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

41 cigarettes or more

21 to 40 cigarettes

11 to 20 cigarettes

6 to 10 cigarettes

1 to 5 cigarettes

Less than 1 cigarette

I didn’t smoke then

Insertion point for Standard questions AA1, AA3

Insertion point for Standard questions AA2, AA12, AA6, AA10

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

41 cigarettes or more

21 to 40 cigarettes

11 to 20 cigarettes

6 to 10 cigarettes

1 to 5 cigarettes

Less than 1 cigarette

I don’t smoke now

Insertion point for Standard questions AA8, AA5

Insertion point for Standard questions AA9, AA7, U1, U2

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

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

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

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

No Yes

1. E-cigarettes or other electronic nicotine products * *

2. Hookah * *

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

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

If you used e-cigarettes or other electronic nicotine products in the past 2 years, go to Question [Core 24]. Otherwise, go to Question [Core 26].

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

More than once a day

Once a day

2-6 days a week

1 day a week or less

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

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

More than once a day

Once a day

2-6 days a week

1 day a week or less

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

Insertion point for Standard questions AA13, AA14

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

26. 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.

No è Go to Question [Core 28]

Yes

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

14 drinks or more a week

8 to 13 drinks a week

4 to 7 drinks a week

1 to 3 drinks a week

Less than 1 drink a week

I didn’t drink then

Insertion point for Standard questions JJ1, JJ3 [former Core 35], 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 questions P19 [former Core 36], P14, P17, P15, P16

Insertion point for Standard questions BB1, Z7

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

No Yes

1. My husband or partner * *

2. My ex-husband or ex-partner * *

3. State option (Another family member) * *

4. State option (Someone else) * *

Insertion point for Standard question Z14

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

No Yes

1. My husband or partner * *

2. My ex-husband or ex-partner * *

3. State option (Another family member) * *

4. State option (Someone else) * *

Insertion point for Standard question Z1

AFTER PREGNANCY

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

Insertion point for Standard questions K13, K14, K5

30. When was your new baby born?

[BOX]	/[BOX]	/20___[BOX]
Month	Day	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 question K16 [former Core 41]

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

Less than 24 hours (less than 1 day)

24 to 48 hours (1 to 2 days)

3 to 5 days

6 to 14 days

More than 14 days

My baby was not born in a hospital

My baby is still in the hospital è Go to Question [Core 34]

Insertion point for Standard questions K11, K12

32. Is your baby alive now?

No è We are very sorry for your loss. Go to Question [Core 43]

Yes

33. Is your baby living with you now?

No è Go to Question [Core 43]

Yes

Insertion point for Standard question B9

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

No Yes

1. My doctor

2. A nurse, midwife, or doula

3. A breastfeeding or lactation specialist

4. My baby’s doctor or health care provider

5. A breastfeeding support group

6. A breastfeeding hotline or toll-free number

7. Family or friends

8. Other è Please tell us: ____________________________

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

No è Go to Question [Core 38]

Yes

Insertion point for Standard question B1

Insertion point for Standard question B13

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

No

Yes è Go to Question [Core 38]

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

Less than 1 week

[BOX] Weeks OR [BOX] Months

Insertion point for Standard questions B2, B14-B16

Insertion point for Standard questions B3, B10, B11, B5, B6

Insertion point for Standard questions H2, H6, H7, H5, H1, H3, H4

Insertion point for Standard question S13

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

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

On his or her side

On his or her back

On his or her stomach

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

Always

Often

Sometimes

Rarely

Never è Go to Question [Core 41]

Insertion point for Standard question F4

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

No

Yes

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

1. In a crib, bassinet, or pack and play 0 0

2. On a twin or larger mattress or bed 0 0

3. On a couch, sofa, or armchair 0 0

4. In an infant car seat or swing 0 0

5. In a sleeping sack or wearable blanket 0 0

6. With a blanket 0 0

7. With toys, cushions, or pillows, including nursing pillows 0 0

8. With crib bumper pads (mesh or non-mesh) 0 0

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

No Yes

1. Place my baby on his or her back to sleep

2. Place my baby to sleep in a crib, bassinet, or pack and play

3. Place my baby’s crib or bed in my room

4. What things should and should not go in bed with my baby

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

43. 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.

No

Yes è Go to Question [Core 45]

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

I want to get pregnant

I am pregnant now

I had my tubes tied or blocked

I don’t want to use birth control

I am worried about side effects from birth control

I am not having sex

My husband or partner doesn’t want to use anything

I have problems paying for birth control

Other è Please tell us: ________________________

If you or your husband or partner is not doing anything to keep from getting pregnant now, go to Question [Core 46].

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

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

Vasectomy (male sterilization)

Birth control pills

Condoms

Shots or injections (Depo-Provera^®)

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

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

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

Natural family planning (including rhythm method)

Withdrawal (pulling out)

Not having sex (abstinence)

Other è Please tell us: _____________________________

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

No è Go to Question [Core 48]

Yes

Insertion point for Standard questions J3, J2

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

No Yes

1. Tell me to take a vitamin with folic acid * *

2. Talk to me about healthy eating, exercise, and losing weight gained

during pregnancy * *

3. Talk to me about how long to wait before getting pregnant again * *

4. Talk to me about birth control methods I can use after giving birth * *

5. Give or prescribe me a contraceptive method such as the pill, patch,

shot (Depo-Provera^®), NuvaRing^®, or condoms * *

6. Insert an IUD (Mirena^®, ParaGard^®, Liletta^®, or Skyla^®) or a contraceptive

implant (Nexplanon^® or Implanon^®) * *

7. Ask me if I was smoking cigarettes * *

8. Ask me if someone was hurting me emotionally or physically * *

9. Ask me if I was feeling down or depressed * *

10. Test me for diabetes * *

Insertion point for Standard question J4

Insertion point for Standard questions O4-O6, O1-O3, L28, L29

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

Always

Often

Sometimes

Rarely

Never

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

Always

Often

Sometimes

Rarely

Never

Insertion point for Standard questions M6, M5, M11, M10

Insertion point for Standard questions M12, M21, M16, M15, M20, M19

Insertion point for Standard questions Z13, Z2

OTHER EXPERIENCES

The next questions are on a variety of topics.

[STATE-SPECIFIC SECTION]

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

Insertion point for Standard Question: P18

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

$0 to $16,000

$16,001 to $20,000

$20,001 to $24,000

$24,001 to $28,000

$28,001 to $32,000

$32,001 to $40,000

$40,001 to $48,000

$48,001 to $57,000

$57,001 to $60,000

$60,001 to $73,000

$73,001 to $85,000

$85,001 or more

(Note: States can add additional categories as long as the categories are collapsible back to the existing core categories.)

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

[BOX] People

52. What is today’s date?

[BOX]	/[BOX]	/20___[BOX]
Month	Day	Year