PRAMS Livebirth Phase 9 Standard Mail Questionnaire (Eng

Pregnancy Risk Assessment Monitoring System (PRAMS)

Att 10e - PRAMS Livebirth Phase 9 Standard Mail Questionnaire - ENGLISH

OMB: 0920-1273

Document [docx]
Download: docx | pdf

Attachment 10e – PRAMS Livebirth Phase 9 Standard Mail Module - English




Form Approved

OMB No. 0920-xxxx

Exp. Date xx/xx/xxxx













Pregnancy Risk Assessment Monitoring System (PRAMS)



Phase 9 Standard (Module) Mail Questionnaire – English





Assisted Reproduction and Fertility



NOTE: Skip A1–A5 if the mother was not trying to get pregnant (E5).
A1 is required if A2, A4 or A5 are used.


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 healthcare provider 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. (MOD)

Did you use any of the following fertility treatments to help you get pregnant with your new baby?


Check ALL that apply



Fertility-enhancing drugs prescribed by a doctor to stimulate ovulation

Intrauterine insemination or artificial insemination (treatments in which sperm, but NOT eggs, were collected and medically placed into the uterus)

Assisted reproductive technology (treatments in which a woman’s eggs or embryos were handled in the laboratory, such as in vitro fertilization [IVF] with or without, intracytoplasmic sperm injection [ICSI], or other related procedures)

Other medical treatment

Please tell us:____________________________________________________________

I wasn’t using fertility treatments to help me get pregnant with my new baby









A4.

(MOD)

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 6 months

7 months to less than 1 year

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








Breastfeeding


NOTE: Skip B1 if infant is not alive or not living with the mother (Core 33 and/or Core 34).
Skip B1 if the mother ever breastfed (Core 35).


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 other things going on

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: ____________________________________________________




If you didn’t breastfeed your new baby, go to Question #.


NOTE: Skip B2 if infant is not alive or not living with the mother (Core 33 and/or Core 34).
Skip B2 if the mother did not breastfeed or is still breastfeeding (Core 35).

B2.

What were your reasons for stopping breastfeeding?


Check ALL that apply

My baby had difficulty latching or nursing

Breast milk alone didn’t satisfy my baby

I thought my baby wasn’t gaining enough weight

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

I thought I wasn’t producing enough milk, or my milk dried up

I had too many other things going on

I felt it was the right time to stop breastfeeding

I got sick or had to stop for medical reasons

I went back to work

I went back to school

My spouse or partner didn’t 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 33 and/or Core 34).
Skip B3 if infant was not born in a hospital (Core 32).



If your baby was not born in a hospital, go to Question #.


B3.

(MOD)

During your hospital stay after your new baby was born, did any of the following things happen?



For each one, check No or Yes.




No Yes

Hospital staff talked to me about how to breastfeed (how often and long to breastfeed)

 

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

 

Hospital staff helped me learn how to breastfeed

 

I breastfed as soon as possible after my baby was born

 

My baby was placed in skin-to-skin contact as soon as possible after birth

 

My baby was fed only breast milk at the hospital

 

Hospital staff helped me recognize when my baby was hungry

 

The hospital gave me a gift pack with formula

 

The hospital gave me information about who I could contact for breastfeeding support when I left the hospital


 

Hospital staff tied or blocked my tubes

 

Hospital staff placed an IUD

 

Hospital staff placed a contraceptive implant in my arm

 

Hospital staff gave me a contraceptive shot/injection

 


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: B12 must be used with B7-B8. Skip B7-B8 if mother was not on WIC during her pregnancy (B12). B8 goes before B7.


B12.

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



No Go to Question #

Yes







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




NOTE: Skip B9, B10, B11 if infant is not alive or not living with the mother (Core 33 and/or Core 34).


Skip B10 if mother said that she did not breastfeed (Core 35).


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/friends

I discussed feeding only breast milk to my baby with my healthcare provider

I decided not to breastfeed my baby










B10.

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


Write ONE answer

My baby was:


_______ Week(s) OR


_______ Month(s)

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 they ate food (such as baby cereal, baby food, or any other food)?


Check ONE answer



My baby was:


______Week(s) OR


______Month(s)

My baby was less than 1 week old

My baby has not eaten any foods



NOTE: Skip B13, B14, B16 if mother did not breastfeed (Core 35).

B16 requires B14, but B14 can be used alone


B13.

After your new baby was born, did you get any of the following kinds of help with breastfeeding?





For each one, check No or Yes.











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.

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







No Go to Question #



Yes












B16. (MOD)

Where did you get the breast pump that you used with your new baby?


Check ALL that apply



I got it for free from WIC

I got it for free from the hospital

I got it as a gift or borrowed from someone else

My health insurance paid for it

I rented or bought it myself

I had one from a previous child

Other


Please tell us:)______________________________________________




B17.

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 or Yes.



No Yes

A doctor

 

A nurse or midwife

 

A doula

 

A breastfeeding or lactation specialist

 

My baby’s doctor or healthcare provider

 

A breastfeeding support group

 

A breastfeeding hotline or toll-free number

 

Websites or apps about pregnancy or infant care

 

Social media (such as Facebook, Instagram, TikTok)

 

Family or friends

 

Other

 


Please tell us:______________________________________



Occupational Status and Workplace Leave


NOTE: Skip C1–C2 if infant is not alive or not living with the mother or is still in the hospital (Core 33 and/or Core 34, and Core 32).

C2 requires 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?


Check ALL that apply


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 in school or working?


Check ONE answer

My spouse or partner 

Baby’s grandparent 

Other close family member or relative 

Friend or neighbor 

Babysitter, nanny, or other childcare provider 

Staff at day care center 

Other


Please tell us:___________________________

The baby is with me while I am in school or working Go to Question #


C4.

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



No Go to Question #

Yes




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 don’t plan to return Go to Question #

No, but I will be returning

Yes




NOTE: C8 requires C7 and C4.

If a site adds a site-specific option to C8, insert “Yes, I took…” for options such as Family Medical Leave and “Yes, 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



Yes, I took paid leave from my job

Yes, I took unpaid leave from my job

Site-specific options (Leave or disability programs)

No, I didn’t 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 following things affect your decision about taking leave from work after your new baby was born?

For each one, check No or Yes.



No Yes

I couldn’t 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 doesn’t have paid leave

 

My job doesn’t offer a flexible work schedule

 

I hadn’t built up enough leave time to take any or more time off

 


C11.

(MOD)

After your new baby was born, did your spouse or partner take time off from work?


Check ONE answer



No, they didn’t take leave from work

Yes, they took paid leave from work

Yes, they took unpaid leave from work

Yes, they took paid and unpaid leave from work

My spouse or partner didn’t work at a job for pay

I didn't have a spouse or partner




NOTE: C14 requires C8. Add a skip arrow to C8 response option “I didn’t take any leave” that goes to C9, (or C10, C11), if used, or to next topic.


C14.

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


Write ONE answer



_______Week(s) OR


[BOX] Month(s)

Less than 1 week




Contraception

Also see B3 for contraception during hospital stay after delivery


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.

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



No

Yes Go to Question #




NOTE: E5 is a required filter for E6 and Q7.


E6.

(MOD)

When you got pregnant with your new baby, were you or your spouse or partner doing anything to keep from getting pregnant? This can include having your tubes tied, using birth control pills, condoms, natural family planning, or other methods.



No

Yes




NOTE: E6 is a required filter for E3 and E7.


E7.

What were your 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 couldn’t get pregnant at that time

I didn’t want to use birth control

I had side effects from the birth control method I was using

I had problems getting birth control I wanted

I thought my spouse or partner or I was sterile (couldn’t get pregnant at all)

My spouse or partner didn’t want to use condoms

My spouse or partner didn’t want me to use birth control

I forgot to use a birth control method

Other

Please tell us:___________________________

NOTE: Skip E3 if mother was not using birth control when she got pregnant (E6).

If you or your spouse or partner was not doing anything to keep from getting pregnant, go to Question #.


E3.


What kind of birth control were you using when you got pregnant?


Check ALL that apply



Birth control pills

Condoms

Shots or injections

Contraceptive patch or vaginal ring

IUD

Contraceptive implant in the arm

Withdrawal (pulling out)

Natural family planning or fertility awareness methods (such as rhythm or calendar method or fertility apps)

Other


Please tell us:__________________________________________



Infant Sleep Environment


NOTE: Inserting F4 after Core 37 requires the skip arrow to be changed from “Never” to “Always” so the filter will work properly.


F4.

Who does your new baby usually sleep with when they are not sleeping alone?




Check ALL that apply





Me


My spouse or partner


A grandparent


My baby’s twin


An older sibling


Someone else



Please tell us:______________________



If your baby never sleeps alone in their own crib or bed, go to Question #.


F5.

Did a healthcare provider tell you to place your baby to sleep in the following ways?


For each one, check No or Yes.





No Yes

On their back to sleep


 

In a crib, bassinet, or portable crib


 

Without a blanket, soft toys, cushions, or pillows in my baby's crib or bed


 

Place my baby's crib, bassinet, or portable crib in my room


 




F6.


Did you get information about how to place your baby to sleep during any of the following times?



For each one, check No or Yes.




No Yes

During a prenatal care visit

 

In the hospital, when my baby was born

 

During my baby’s healthcare visit

 

During a postpartum care visit

 

Other

 


Please tell us:_________________



F7.

(NEW)

Did you get information about how to place your new baby to sleep from any of the following sources?



For each one, check No or Yes.




No Yes

My family doctor

 

My OB/GYN

 

A nurse or midwife

 

Doula or a childbirth educator

 

My baby’s doctor or healthcare provider

 

Websites or apps about pregnancy or infant care

 

Social media (such as Facebook, Instagram, TikTok)

 

Other sources

 


Please tell us:____________________________




Maternal Nutrition and Supplement Use


G9.

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



NOTE: G8 requires G9. Skip G8 if mother took a multivitamin 1 or more times a week (G9).



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:_______________________________



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 didn’t 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 didn’t 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









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




Health Insurance

Infant Health Insurance Coverage

NOTE: Skip H2 if infant is not alive or not living with the mother (Core 33 and/or Core 34).


H2.

What kind of health insurance is your new baby covered by now?


Check ALL that apply





Private health insurance (paid for by me, someone else, or through a job)

Medicaid (site Medicaid name)

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

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

Site-specific option (TRICARE or other military healthcare)

Site-specific option (IHS or tribal)

Other health insurance

Please tell us:_______________________________________

I don’t have any health insurance for my new baby





Maternal Health Insurance Coverage


NOTE: Skip DD7 if mother was insured during the month before she got pregnant (Core 6).


BEFORE DD7, insert instruction box that says, “If you did not have health insurance during the month before you got pregnant, go to Question DD7. If you did, go to Question #.”



If you did not have health insurance during the month before you got pregnant, go to Question DD7. If you did, go to Question #.

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 couldn’t get health insurance from my job or the job of my spouse 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 <Site> Health Insurance Marketplace or HealthCare.gov

I didn’t know how to get health insurance

Site-specific option (I’m not a US citizen, or I don’t have the right residency documents)

Other


Please tell us:_______________________________



NOTE: Skip DD11 if mother had health insurance during pregnancy (Core 7).


BEFORE DD11, insert instruction box that says, “If you did not have health insurance during your most recent pregnancy, go to Question DD11. If you did, go to Question #.”





If you did not have health insurance during your most recent pregnancy, go to Question DD11. If you did, go to Question #.

DD11. (MOD)

What was the reason that you did not have any health insurance during your most recent pregnancy?


Check ALL that apply



Health insurance was too expensive

I couldn’t get health insurance from my job or the job of my spouse 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 <Site> Health Insurance Marketplace or HealthCare.gov

I didn’t know how to get health insurance

Site-specific option (I’m not a US citizen, or I don’t have the right residency documents)

Other


Please tell us:­______________________________________________________________


NOTE: Skip DD20 if mother has health insurance now (Core 8).


BEFORE DD20, insert instruction box that says, “If you do not have health insurance now, go to Question DD20. If you do, go to Question #.”



If you do not have health insurance now, go to Question DD20. If you do, go to Question #.

DD20.

What is the reason that you do not have any health insurance now?


Check ALL that apply



Health insurance is too expensive

I can’t get health insurance from my job or the job of my spouse or partner

I applied for health insurance, but I’m 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 <Site > Health Insurance Marketplace or HealthCare.gov

I don’t know how to get health insurance

Site-specific (I’m not a US citizen, or I don’t have the right residency documents)

Other


Please tell us:______________________________________________

HIV and Sexually Transmitted Infections


EE3.

During your most recent pregnancy, did a healthcare provider tell you that you had any of the following infections?



For each one, check No or Yes.




No Yes

Genital warts (HPV)

 

Herpes

 

Chlamydia

 

Gonorrhea

 

Pelvic inflammatory disease (PID)

 

Syphilis

 

Group B Strep (Beta Strep)

 

Bacterial vaginosis

 

Trichomoniasis (Trich)

 

Yeast infection

 

Urinary tract infection (UTI)

 

Other

Please tell us:

 


NOTE: I9 needs I8, but I8 can be used alone.

Skip I9 if mom indicated in I8 that she was tested during pregnancy or delivery.


I8.

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







No



Yes Go to Question #



I don’t know Go to Question #











I9.

Why didn’t you have an HIV test during your most recent pregnancy or delivery?



Check ALL that apply





I wasn’t offered the test

I didn’t want to have the test

I already knew my HIV status

I didn’t think I was at risk for HIV

I didn’t want people to think I was at risk for HIV

I was afraid of getting the result

I was tested before this pregnancy and didn’t think I needed to be tested again

Other reason


Please tell us:





I10.


What are you doing now to keep from getting sexually transmitted infections (STIs), including HIV?


Check ALL that apply

I’m not doing anything

Using condoms

I get tested for STIs/HIV

Mutual monogamy (partners only have sex with each other)

Other


Please tell us:____________________________________________




Postpartum Care


NOTE: Skip J3 if mom had a postpartum checkup.

If J3 is added, the skip arrow on Core 44 should be switched from “no” to “yes”.

AFTER J3, add: “If you did not have a postpartum checkup, go to Question #.”


J3.

Did any of these things keep you from having a postpartum checkup?


Check ALL that apply

I didn’t know I needed one

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

I felt fine and didn’t 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 other things going on

I couldn’t take time off from work or school

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

The doctor’s office was too far away

Other

Please tell us:________________________________________








If you did not have a postpartum checkup, go to Question #



J6.


Since your new baby was born, have you received follow-up care for any of the following?

For each item, check No if you didn’t get it, check Yes if you did get it, or check DH if you didn’t have the condition.




No Yes DH

Diabetes

  

Hypertension (high blood pressure)

  

Depression

  

Anxiety

  

Heart conditions (e.g., birth defects of the heart, fast or skipped heartbeat, heart failure, enlarged heart, heart attack, chest pain, heart transplant, pacemaker)

  


J7.


Overall, since my new baby was born, I have felt:



For each one, check No or Yes.




No Yes


Comfortable asking questions about the postpartum care that I received

 


Comfortable declining care if I didn't want it

 


Comfortable accepting the options for care that my provider recommended

 


I was able to choose the care options that I received

 


My providers treated me with respect

 


Satisfied with the postpartum care I received

 


Preconception Care


NOTE: Skip J5 if mom had a healthcare visit (Core 4).


If J5 is added, the instructional box after Core 4 should be changed to “If you didn’t have any healthcare visits in the 12 months before you got pregnant, go to Question #.”


AFTER J5, add: “If you didn’t have any healthcare visits, go to Question #.”



J5.

(NEW)

Why didn’t you have any healthcare visits in the 12 months before you got pregnant with your new baby?


Check ALL that apply



I didn’t know I needed one

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

I felt fine and didn’t 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 other things going on

I couldn’t take time off from work or school

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

The doctor’s office was too far away

Other

Please tell us:___________________________________________




If you didn’t have any healthcare visits, go to Question #.


Labor and Delivery


K3.

How was your new baby delivered?


Vaginally


Cesarean delivery (c-section)





NOTE: Skip K4 if mother did not have prenatal care (Core 10).


K4.

How did your prenatal provider suggest you deliver your new baby?




Check ONE answer






Suggested I deliver my baby vaginally (naturally)

Suggested I have a cesarean delivery (c-section)

Didn’t suggest how I deliver my baby






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 healthcare provider recommended a cesarean delivery before I went into labor

My healthcare 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 healthcare 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 healthcare 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 healthcare provider try to induce your labor using different methods to start your contractions (such as medications or thinning of the membrane)?



No Go to Question #

Yes

I don’t know Go to Question #




K10.

Why did your healthcare provider try to induce your labor?


Check ALL that apply



My water broke, and there was a fear of infection

I was past my due date

My healthcare 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 healthcare provider

Other


Please tell us:___________________________________________


K16.


After delivery, was your baby put in an intensive care unit (NICU)?



No

Yes

I don’t know





K17.


Overall, during the delivery of my baby, I felt:



For each one, check No or Yes.




No Yes

Comfortable asking questions about the labor and delivery care that I received

 

Comfortable declining care if I didn't want it

 

Comfortable accepting the options for care that my provider recommended

 

I was able to choose the care options that I received

 

My providers treated me with respect

 

Satisfied with the labor and delivery care I received

 


Preconception Health


L10.

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


Excellent


Very good


Good


Fair


Poor





Response options for L11 are added directly to Core 3 and/or Core 15 if this question is selected.


L11.

Additional options for Core 3 and/or Core 15




No Yes

Asthma

 

Anemia (poor blood, low iron)

 

Epilepsy (seizures)

 

Thyroid problems

 

PCOS (polycystic ovarian syndrome)

 


NOTE: Skip L18 if healthcare provider didn’t talk with mother about preparing for pregnancy (L27). L27 must be used before L18.



L27.

In the 12 months before you got pregnant with your new baby, did a healthcare provider talk to you about preparing for a pregnancy?



No Go to Question #

Yes



L18.


In the 12 months before you got pregnant with your new baby, did a healthcare provider talk with you about the following things?



For each one, check No or Yes.




No Yes

Getting vaccines 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 drugs not prescribed to me during pregnancy can affect a baby

 


L26.

At any time during the 12 months before you got pregnant with your new baby, did you do any of the following things?



For each one, check No or Yes.




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 healthcare provider checked me for diabetes

 

I talked to a healthcare provider about my family medical history

 

Vaccinations


Also see COVID-19 Vaccine Supplement

Maternal


NOTE: Skip L14 if mother got a flu shot (Core 13).


BEFORE L14, add: “If you got a flu shot before or during your pregnancy, go to Question #.”




If you got a flu shot before or during your pregnancy, go to Question #.




L14.

What were your reasons for not getting a flu shot during the 12 months before the birth of your new baby?



For each one, check No or Yes.




No Yes

My doctor didn’t mention anything about a flu shot

 

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

 

I was worried that the flu shot might harm my baby

 

I wasn’t worried about getting sick with the flu

 

I don’t think the flu shot works

 

I don’t normally get a flu shot

 

Other

 


Please tell us:_______________________



BEFORE L19, add: “If you didn’t get a flu shot before or during your pregnancy, go to Question #.”



If you didn’t get a flu shot before or during your pregnancy, go to Question #.



L19.

Where did you get your flu shot?


Check ONE answer



My OB/GYN’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 workplace or school

Other


Please tell us:______________________________________________________




Child Vaccinations


NOTE: Skip L33 if infant is not alive or not living with the mother (Core 33 and/or Core 34).


L33.


What are your plans for vaccinating your new baby?


Check ONE answer

My baby will be vaccinated the way my baby’s doctor recommends

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

My baby will get only some of the recommended vaccines

My baby will not get any vaccines





Mental Health


Note: M23 needs M22, but M22 can be used alone

M24 needs M22 and M23


M22.

Since your new baby was born, have you felt that you’ve needed mental health services such as counseling, medications, or support groups to help with feelings of anxiety, depression, grief, or other issues?   



No Go to Question #

Yes   



 

M23.


Were you able to get the mental health services that you needed?  



No  


Yes Go to Question #


 



M24.


Which of these statements explains why you did not get the mental health services you needed? 


Check ALL that apply



I couldn’t afford the cost 

I couldn’t get an appointment as soon as I needed

My health insurance doesn’t cover any type of mental health services

My health insurance doesn’t pay enough for mental health services

I didn’t know where to go to get services 

I was concerned that the information I shared might not be kept confidential 

I didn’t want others to find out that I needed treatment 

I was concerned that I might be committed to a psychiatric hospital  

I was concerned that I might have to take medicine 

I had no transportation, treatment was too far away, or the hours were not convenient 

I didn't have time (because of a job, childcare, or other commitments) 

Some other reason  


Please tell us:_______________________________________


Note: Skip M4 if mom does not indicate she had depression in Core 15 (Q15, item c).

BEFORE M4, add instruction: “If you had depression during your most recent pregnancy, go to Question M4. If you didn’t, go to Question #.”




M4.

At any time during your most recent pregnancy, did you ask for help for depression from a healthcare provider?



No

Yes


M5.

Since your new baby was born, has a healthcare provider 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 healthcare provider?



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 15 (Q15, item c).

BEFORE M9/M8, add instruction: “If you had depression during your most recent pregnancy, go to Question M9/M8. If you didn’t, go to Question #.”


If you had depression during your most recent pregnancy, go to Question M9/M8. If you didn’t, go to Question #.



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


M14.

At any time during your most recent pregnancy, did you ask for help for anxiety from a healthcare provider?



No

Yes


M15.

Since your new baby was born, has a healthcare provider 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 healthcare provider?



No

Yes


Note: Skip M17 and M18 if mom does not indicate she had anxiety in Core 15 (Q15, item d).

BEFORE M17/M18, add instruction: “If you had anxiety during your most recent pregnancy, go to Question M18/M17. If you didn’t, go to Question #.”



If you had anxiety during your most recent pregnancy, go to Question M18/M17. If you didn’t, go to Question #.



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



Maternal Morbidity


N1.

At any time during your most recent pregnancy, did a healthcare provider 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?


Write ONE answer




______Weeks OR


______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 one, check No or Yes.




No Yes

Help with childcare

 

Help with housework

 

Knowing I wouldn’t lose my job

 

Money to make up for not working

 

Other

 


Please tell us:________________________________



N5.

During your most recent pregnancy, did a healthcare provider 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 N7 if the mother did not have gestational diabetes during this pregnancy (Core 15, item a). BEFORE N7, add instruction that says, “If you had gestational diabetes during your most recent pregnancy, go to Question N7. If you didn’t, go to Question #.”


N7.

(MOD)

During your most recent pregnancy, when you were told that you had gestational diabetes, did a healthcare provider do any of the things listed below?



For each one, check No or Yes.



GRID: No/Yes

No Yes

Refer me to a nutritionist

 

Talk to me about the importance of exercise

 

Talk to me about getting to a healthy weight after delivery

 

Talk to me about my risk for Type 2 diabetes

 



N9.

Did you have any of the following problems during your most recent pregnancy?


For each one, check No or Yes.




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

 


O4.

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



No Go to Question #

Yes


O7.


Have you experienced any of the following things during your pregnancy or after your baby was born?



For each one, check No or Yes.




No Yes

I felt something wasn’t right with my health

 

I felt my concerns for my health weren’t taken seriously

 

I felt my doctor ignored my concerns about my health or symptoms

 


O8.


Have you regularly monitored your blood pressure at home or outside of a healthcare visit during the time periods listed below?



For each one, check No or Yes.




No Yes

During the 12 months before my most recent pregnancy

 

During my most recent pregnancy

 

Since my new baby was born

 


Maternal Warning Signs


O9.


Since your new baby was born, have you received information about warning signs of postpartum complications from any of the following sources?







No Yes

A healthcare provider (such as a doctor, nurse, or midwife)

 

Websites or social media (such as Facebook, Instagram, or Twitter)

 

Any source of information that used the slogan ‘Hear Her’ (such as a website, social media, or paper handout)


 

Family or friends

 





O10.


Did a healthcare provider talk with you about the warning signs of both pregnancy and postpartum complications during any of the following time periods?



For each one, check No or Yes.




No Yes

During the 12 months before I got pregnant

 

During my most recent pregnancy

 

During my labor and delivery hospitalization

 

Since my new baby was born

 





Food Security and Economic Stability


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



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


NOTE: P21 needs P20 but P20 can be used alone.


P20.


During the 12 months before your new baby was born, which of these statements best describes the food in your household?


Check ONE answer



Enough of the kinds of food I wanted to eat Go to Question #

Enough, but not always the kinds of food I wanted to eat Go to Question #

Sometimes not enough to eat

Often not enough to eat


P21.


Why didn’t you have enough to eat?


Check ALL that apply



I couldn’t afford to buy more food

I couldn’t get out to buy food (for example, didn’t have transportation or had mobility or health problems that kept me from getting out)

I was afraid or didn’t want to go out to buy food

I couldn’t get groceries or meals delivered

The stores didn’t have the food I wanted



P22.

During the 12 months before your new baby was born, how often were you unable to afford to eat balanced meals? A balanced meal includes all the types of food that you think should be in a healthy meal. For example, a starch like potatoes or rice, vegetables or fruit, and some protein like meat, fish, cheese, or eggs.   

Always 

Usually

Sometimes 

Rarely 

Never 


P23.


What is your living situation today?


Check ONE answer

I have a steady place to live  

I have a place to live today, but I’m worried about losing it in the future 

I don’t have a steady place to live (I’m temporarily staying with others, in a hotel, in a shelter, living outside on the street, on a beach, in a car, abandoned building, bus or train station, or in a park) 

 


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



Neighborhood and Built Environment


P15.

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



Always

Often

Sometimes

Rarely

Never



Family Planning


Q1.

Which of the following statements best describes you during the 3 months before you got pregnant with your new baby?


Check ONE answer

I was trying to get pregnant

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

I was trying hard to keep from getting pregnant




Q2.

Which of the following statements best describes your spouse or partner during the 3 months before you got pregnant with your new baby?


Check ONE answer

Wanted me to get pregnant

Didn’t care one way or the other whether I got pregnant

Didn’t want me to get pregnant




Q3.

Thinking back to just before you got pregnant with your new baby, how did your spouse 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 spouse 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 9). Add a skip arrow to Core 9 for the last four responses.


Q4.

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

Less than 1 year

1 year to less than 2 years

2 years to less than 3 years

3 years to 5 years

More than 5 years



Q5.

When you found out you were pregnant with your new baby, did you have any of the following feelings or concerns?


For each one, check No or Yes.




No Yes

I was worried that I didn’t know enough about how to take care of a baby

 

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

 

I looked forward to teaching and caring for a new baby

 

I looked forward to the new experiences that having a baby would bring

 

I looked forward to telling my friends that I was pregnant

 

I was worried that I didn’t have enough money to take care of a baby

 

I didn’t look forward to telling my friends that I was pregnant

 

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




If you were trying to get pregnant when you got pregnant with your new baby, go to Question #.



Prenatal Care


NOTE: Skip R24 if mother had no prenatal care (Core 10).


R24.


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


Write ONE answer




____Week(s) OR


____Month(s)




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 one, check No or Yes.




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 wouldn’t 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

 

The doctor’s office was too far away

 


NOTE: Skip R6-R16, R25 if mother had no prenatal care (Core 10).


R6.

Have you ever heard of the bacteria Group B Strep or Beta Strep that mothers can pass to their newborns during birth?



No

Yes


R7.

During any of your prenatal care visits, did a healthcare provider talk with you about the bacteria Group B Strep or Beta Strep?



No

Yes


R8.

At any time during your most recent pregnancy, did you get tested for the bacteria Group B Strep or Beta Strep?



No

Yes

I don’t know



R12.

During any of your prenatal care visits, did a healthcare provider 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 problems?



No

Yes


R14.

During any of your prenatal care visits, did a healthcare provider 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

Site-specific option

Site-specific option

Other


Please tell us:____________________________


R16.

During your most recent pregnancy, did a healthcare provider talk with you about any of the things listed below? Please count only discussions, not reading materials or videos.




For each one, check No or Yes.




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

 





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 healthcare provider said you were pregnant.


Write ONE answer



______ Weeks OR


______ Months

I don’t remember


R25.


Overall, during my pregnancy, I felt:



For each one, check No or Yes.




No Yes

Comfortable asking questions about the prenatal care that I received

 

Comfortable declining care if I didn't want it

 

Comfortable accepting the options for care that my provider recommended

 

I was able to choose the care options that I received

 

My providers treated me with respect

 

Satisfied with the prenatal care I received

 


R23.

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



No

Yes





Injury Prevention and Safety


Also see Environmental Exposures Supplement


NOTE: Skip S1 if infant is not alive or not living with the mother (Core 33 and/or Core 34).



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

I always used a seatbelt during my most recent pregnancy

 

My home has a working smoke alarm

 

I have received information about infant products that should be taken off the market (product recalls) since my new baby was born

 

My home has a working carbon monoxide detector

 


NOTE: Skip S6 if infant is not alive, is not living with the mother, or is still in the hospital (Core 33, Core 34, or Core 32).


S6.


When riding in a car, truck, or van, how often does your baby ride in an infant car seat?

Always

Often

Sometimes

Rarely

Never Go to Question #


NOTE: Skip S10 and S12 if infant is not alive, is not living with the mother, or is still in the hospital (Core 33, Core 34, or Core 32).


S10.

Do you have an infant car seat that you can use for your new baby?



No Go to Question #

Yes


Note: S12 needs S10, but S10 can be used alone.

S12.

How did you learn to install and use your infant car seat?


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 33 or Core 34)


S13.

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



No

Yes


S20.


During the 12 months before your new baby was born, did a healthcare provider talk to you about getting your household water tested for any of the following things?



For each one, check No or Yes.




No Yes


Arsenic

 


Lead

 


Other contaminants

 


Please tell us:____________________________________________



NOTE: S22 needs S21, S23 needs S22 and S21, but S21 can be used alone.


S21.


Are any firearms kept in or around your home now?



No Go to Question #

Yes

I don’t know Go to Question #



S22.


Are any of these firearms now loaded?



No Go to Question #

Yes

I don't know Go to Question #




S23.


Are any of these loaded firearms also unlocked? Unlocked meaning you do not need a key, combination, or hand/fingerprint to get the gun or to fire it. Do not count a safety as a lock.



No

Yes

I don't know



Infant Healthcare

Sick Child Care


NOTE: Skip T1 and T3 if infant is not alive, is not living with the mother, or is still in the hospital (Core 33, Core 34, or Core 32).



T1.


Have you taken your new baby for care when he or she was sick?


Check ONE answer



No

Yes

My baby has not been sick Go to Question #


Note: T3 needs T1, but T1 can be used alone.


T3.

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



No

Yes Go to Question #



NOTE: T8 requires T3.


T8.

Did any of these things keep you from taking your baby for care when he or she was sick?


Check ALL that apply



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

I couldn’t get an appointment

I didn’t have a regular doctor for my baby

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

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

Other


Please tell us:_____________________________


Well Child Care


NOTE: Skip X2, X9, and X10 if infant is not alive, is not living with the mother, or is still in the hospital (Core 33, Core 34, or Core 32).

X2 needs X9, but X9 can be used alone


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

Yes Go to Question #


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:____________________________________________________________


X10.

Was your new baby seen by a healthcare provider for a one-week checkup after he or she was born?



No

Yes

My baby was still in the hospital at that time





Substance Use


Also see Marijuana Supplement and Opioid Supplement


NOTE: If using DRUG2/DRUG3, add transition statement: “The next questions are about using different drugs around the time of pregnancy. Your answers are strictly confidential.”


DRUG2.


During the month before you got pregnant, did you take or use any of the following medications or drugs for any reason?



For each one, check No or Yes.




No Yes

Medication for depression

 

Medication for anxiety

 

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


 

Adderall®, Ritalin®, or another stimulant

 

Methadone, Subutex®, Suboxone®, or buprenorphine

 

Naloxone

 

Marijuana or cannabis products (not including hemp or CBD-only products)

 

CBD products

 

Synthetic marijuana (K2 or Spice)

 

Kratom

 

Fentanyl or Heroin (smack, junk, Black Tar or Chiva)

 

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

 

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

 

Benzodiazepines (Valium®, Ativan®, Xanax®) or Tranquilizers (downers or ludes)

 

Hallucinogens (LSD/acid, PCP/angel dust, Ecstasy, Molly, mushrooms, or 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 medications or drugs for any reason?


For each one, check No or Yes.




No Yes

Medication for depression

 

Medication for anxiety

 

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


 

Adderall®, Ritalin®, or another stimulant

 

Methadone, Subutex®, Suboxone®, or buprenorphine

 

Naloxone

 

Marijuana or cannabis products (not including hemp or CBD-only products)

 

CBD products

 

Synthetic marijuana (K2 or Spice)

 

Kratom

 

Fentanyl or Heroin (smack, junk, Black Tar or Chiva)

 

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

 

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

 

Benzodiazepines (Valium®, Ativan®, Xanax®) or Tranquilizers (downers or ludes)

 

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

 

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

 



BEFORE U10, add:” If you did not use prescription pain relievers during your most recent pregnancy, go to Question #.”


U10.

After your baby was born, did a healthcare provider tell you that your baby had drug withdrawal or neonatal abstinence syndrome?



No

Yes



Social Services including Home Visitation


V1.

During your most recent pregnancy, did you use any of these services?


For each one, check No or Yes.




No Yes

Parenting classes

 

Counseling for depression or anxiety

 


NOTE: Skip V2 and V3 if infant is not alive or not living with the mother (Core 33 and/or Core 34).

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 or Yes.




No Yes

Parenting classes

 

Counseling for depression or anxiety

 



V3.

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


Check ONE answer

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




V11.


During your most recent pregnancy, did you feel you needed any of the following services?


For each one, check No or Yes.




No Yes

SNAP (the Supplemental Nutrition Assistance Program)

 

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

 

Counseling for family and personal problems

 

Help to quit smoking

 

Help to reduce violence in my home

 

Help to quit using drugs

 

Assistance with housing or rent

 

Other

 


Please tell us:_____________________________________________




V12.


During your most recent pregnancy, did you receive any of the following services?



For each one, check No or Yes.




No Yes

SNAP (the Supplemental Nutrition Assistance Program)

 

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

 

Counseling for family and personal problems

 

Help to quit smoking

 

Help to reduce violence in my home

 

Help to quit using drugs

 

Assistance with housing or rent

 

Other

 


Please tell us:_________________________________



NOTE: Skip V13-V15 and V20, if the mother did not have a home visitor (V21).


V21.


During your most recent pregnancy, did a home visitor come to your home to help you prepare for your new baby? A home visitor is a nurse, healthcare provider, doula, childbirth educator, social worker, or another person who works for a program that helps you during your pregnancy.



No Go to Question #

Yes








V13.

(MOD)

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



Check ALL that apply

A nurse, nurse’s aide, or midwife

A teacher or health educator

A doula or childbirth educator

Site 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.

(MOD)

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 or Yes.




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

 

The importance of getting tested for sexually transmitted infections

 

If someone was hurting me emotionally or physically

 

Breastfeeding my baby

 

My emotional well-being

 


V20.


The following questions are about the care you got from the home visitor during your most recent pregnancy.


For each one, check No or Yes.




No Yes

Were you satisfied with the amount of time the home visitor spent with you?

 

Were you satisfied with the advice you got on how to take care of yourself and your baby?


 

Did you feel understood and respected by the home visitor?

 


NOTE: Skip V22 if the baby is not alive (Core 33). DO NOT skip if the baby is not living with the mom or is still in the hospital (Core 34 and Core 32).

Skip arrow for Core 34 should go to V22 and the instruction box before Core Q36 should go to V22 if V22 is inserted.


V22.

Since your new baby was born, has a home visitor come to your home to help you learn how to take care of yourself or your new baby? A home visitor is a nurse, healthcare provider, doula, social worker, or another person who works for a program that helps families with newborns.



No Go to Question #

Yes






NOTE: Skip V16, V18, and V19 if the mother did not have a postpartum home visitor (V22).


V16.


Who was the home visitor that came to your home since your new baby was born?



Check ALL that apply

A nurse, nurse’s aide, or midwife

A teacher or health educator

A doula or childbirth educator

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

Someone else


Please tell us: ________________________________

I don’t know


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?




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 a healthy weight

 

How to quit or keep from smoking

 

How to get the healthcare that my baby or I need

 


V19.

The following questions are about the care you got from the home visitor since your new baby was born.







No Yes

Were you satisfied with the amount of time the home visitor spent with you?

 

Were you satisfied with the advice you got on how to take care of yourself and your baby?

 

Did you feel understood and respected by the home visitor?

 


V23.


Did you use doula support during any of the following time periods? A doula is a trained pregnancy and labor companion who gives comfort, emotional support, and information during birth. A doula does not provide medical care.




For each one, check No or Yes.




No Yes

During my most recent pregnancy

 

During the birth of my most recent baby

 

Since my new baby was born

 

Social Support including Partner Experiences


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 spouse or partner

My mother, father, or in-laws

Other family member or relative

A friend

Religious community

Neighbors

Someone else


Please tell us: _________________________________

No one would have helped me

W3.

Since your new baby was born, 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 spouse or partner 

My mother, father, or in-laws 

Other family member or relative 

A friend 

Religious community 

Neighbors 

Someone else 


Please tell us: ___________________________________

No one would help me 


W5.


The following questions are about the people in your life and the support they provided you while you were pregnant.




For each one, check No or Yes.




No Yes

Did you have someone you could go to if you felt lonely?

 

Did you have someone you could talk with about things that were important to you or how you were feeling?


 

Did you have someone you could count on to listen to your problems, worries, and fears?

 

Did you have someone who showed you love and affection?

 

Did you have someone who did things with you to relax or have fun?

 

Did you have someone you could count on to loan you money for things like food or bills?

 

Did you have someone who could take care of your children if you needed help?

 

Did you have someone who could help with daily chores if you were sick?

 

Did you have someone who could take you to the clinic or doctor’s office if you needed a ride?

 



W6.


The following questions are about the people in your life and the support they provide you now.




For each one, check No or Yes.



No Yes

Do you have someone you can go to if you’re feeling lonely?

 

Do you have someone you can talk with about things that are important to you or how you’re feeling?


 

Do you have someone you can count on to listen to your problems, worries, and fears?

 

Do you have someone who shows you love and affection?

 

Do you have someone who does things with you to relax or have fun?

 

Do you have someone you can count on to loan you money for things like food or bills?

 

Do you have someone who can take care of your children if you need help?

 

Do you have someone who can help with daily chores if you’re sick?

 

Do you have someone who can take you to the clinic or doctor’s office if you need a ride?

 


W7.


Do your neighbors do any of the following things?



For each one, check No if it does not apply to your neighbors or Yes if it does.




No Yes

Do favors for each other or help each other out

 

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

 

Have parties or other get-togethers where other people in the neighborhood are invited

 

Visit in each other’s homes or on the street

 

Watch over each other’s property

 


W8.


Please choose the statement that best describes your current living arrangement with your spouse or partner.



Lives with me all of the time

Lives with me some of the time

Doesn’t live with me

I don’t have a spouse or partner


W9.


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



Always

Often

Sometimes

Rarely

Never

I don’t have a spouse or partner


W10.

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



Always

Often

Sometimes

Rarely

Never


W11.


When your new baby’s father, or other parent, is with the baby, how often do they hug, kiss, hold, or play with the baby?



Always

Often

Sometimes

Rarely

Never

My new baby’s father, or other parent, doesn’t regularly spend time with my baby



Oral Health


Y3.

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





No

Yes


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 one, check No or Yes.




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 one, check No or Yes.




No Yes

I couldn’t find a dentist or dental clinic that would take pregnant patients

 

I couldn’t find a dentist or dental clinic that would take Medicaid patients

 

I didn’t think it was safe to go to the dentist during pregnancy

 

I couldn’t afford to go to the dentist or dental clinic

 

I couldn’t find a dentist or dental clinic close by that I could get to

 



Y7.

The following statements are about the care of your teeth during your most recent pregnancy.



For each one, check No or Yes.




No Yes

I knew it was important to care for my teeth and gums during my pregnancy

 

A dental or other healthcare provider talked with me about how to care for my teeth and gums


 

I knew it was safe to go to the dentist during pregnancy

 

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.

Did you get treatment from a dentist or another healthcare provider for the dental 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







Intimate Partner Violence



Z1.


Did your current, or ex, spouse or partner do any of the following things during your most recent pregnancy?







No Yes

Threatened me or made me feel unsafe in some way

 

Made me afraid for my safety or my family’s safety because of their anger or threats

 

Tried to control my daily activities, for example, controlling who I could talk to or where I could go


 

Forced me to take part in touching or any sexual activity when I didn’t want to

 



Z2.

Has your current, or ex, spouse or partner done any of the following things since your new baby was born?







No Yes

Threatened me or made me feel unsafe in some way

 

Made me afraid for my safety or my family’s safety because of their anger or threats

 

Tried to control my daily activities, for example, controlling who I could talk to or where I could go


 

Forced me to take part in touching or any sexual activity when I didn’t want to

 


Z8.

Before you got pregnant with your new baby, did your spouse or partner ever try to keep you from using your birth control so that you would get pregnant when you did not 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 spouse or partner threaten you, limit your activities against your will, or make you feel unsafe in any other way?







No Yes

During the 12 months before I got pregnant

 

During my most recent pregnancy

 

Since my new baby was born

 


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 one, check No or Yes.



No Yes

My spouse or partner

 

My ex-spouse or ex-partner

 

Site-added option (Another family member)

 

Site-added option (Someone else)

 


Z15.


Before you got pregnant with your new baby, did your spouse or partner ever refuse to use a condom when you wanted them to use one?



No

Yes

I didn’t have a partner at that time, or I was in a same sex relationship






Tobacco and Nicotine Product Use and Cessation


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 OR during your pregnancy, go to Question #.”


AA1.

During any of your prenatal care visits, did a healthcare provider advise you to quit smoking?





No


Yes


I didn’t go for prenatal care








AA2.


During your most recent pregnancy, did you try any of the following things to quit smoking? 




For each one, check No or Yes.




No Yes

Set a specific date to stop smoking

 

Use a text-messaging program for help with quitting

 

Use websites or apps for help with quitting

 

Use social media for help with quitting (such as Facebook, Instagram, TikTok)

 

Call a national or state quit line

 

Attend a class or program to stop smoking

 

Go to counseling for help with quitting

 

Use a nicotine patch, gum, lozenge, nasal spray, or oral inhaler

 

Take a pill like Zyban® or Wellbutrin® (also known as bupropion) to stop smoking

 

Take a pill like Chantix® (also known as varenicline) to stop smoking

 

Try to quit on my own (e.g., cold turkey)

 

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.


During any of your prenatal visits, did a healthcare provider do any of the following things to help you quit smoking?




For each one, check No or Yes.




No Yes

Spend time with me discussing how to quit smoking

 

Suggest that I set a specific date to stop smoking

 

Suggest I attend a class or program to stop smoking

 

Provide me with booklets, videos, or other materials to help me quit smoking on my own

 

Refer me to counseling for help with quitting

 

Ask if a family member or friend would support my decision to quit

 

Refer me to a national or state quit line

 

Recommend using or prescribe a nicotine gum

 

Recommend using or prescribe a nicotine patch

 

Recommend using or prescribe a nicotine lozenge

 

Prescribe a nicotine nasal spray or nicotine oral inhaler

 

Prescribe a pill like Zyban® or Wellbutrin® (also known as bupropion) to help me quit

 

Prescribe a pill like Chantix® (also known as varenicline) to help me quit

 


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?






_____ Number of smokers





AA9.

How many cigarette smokers, not including yourself, live in your home now?



_____ Number of smokers


NOTE: AA10 must be used with AA6.

Skip AA10 if the mother did not smoke 3 months before she got pregnant (Core 20).


AA10.


Would any of the following things make it hard for you to quit smoking?



For each one, check No or Yes.




No Yes

Cost of medicines or products to help with quitting

 

Cost of classes to help with quitting

 

Fear of gaining weight

 

Loss of a way to handle stress

 

Other people smoking around me

 

Cravings for a cigarette

 

Lack of support from others to quit

 

Worsening depression

 

Worsening anxiety

 

Some other reason

 


Please tell us: _____________________________





Experiences of Discrimination and Racism


BB1.


During the 12 months before your new baby was born, how often did you feel emotionally upset (for example, angry, sad, or frustrated) because of how you were treated based on your race, ethnicity, or skin color?



Very often

Somewhat often

Not very often

Never


BB4.


During your life until now, how often have you worried that you might be treated or judged unfairly because of your race, ethnicity, or skin color?



Very often

Somewhat often

Not very often

Never


BB5.


During your life until now, how often have you worried that a loved one like your partner, child, or parent might be treated or judged unfairly because of their race, ethnicity, or skin color?



Very often

Somewhat often

Not very often

Never




BB6.


Have you ever experienced discrimination or were prevented from doing something, hassled, or made to feel inferior because of the things listed below?




For each item, check No if you did not experience discrimination because of it or Yes if you did.




No Yes

My race, ethnicity, or skin color

 

My disability status

 

My immigration status

 

My age

 

My weight

 

My income

 

My sex or gender

 

My sexual orientation

 

My religion

 

My language or accent

 

My type or lack of health insurance

 

My use of substances (alcohol, tobacco, or other drugs)

 

My involvement with the justice system (jail or prison)

 

Another reason

 


Please tell us: __________________________________


Physical Activity


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.


Check ONE answer



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 healthcare provider 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?


Check ONE answer



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 healthcare provider not to exercise


Reproductive History

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

Yes


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.

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



No Go to Question #

Yes


NOTE: FF5 must be used with FF6 and FF7.


FF6.

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



No

Yes


FF7.

Was the baby just before your new one born earlier than 3 weeks before their due date?



No

Yes





Demographic Information Including Maternal Weight


II1.

How much weight did you gain during your most recent pregnancy?


Write ONE answer



I gained _______ pounds


OR _______kilos

I didn’t gain any weight during my pregnancy

I don’t know




II2.


How tall are you without shoes?


Write ONE answer




_______ Feet &


_______ Inches


OR _______Centimeters




II3.

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


Write ONE answer




_______ Pounds OR


_______ Kilos






II4.

When was your new baby born?




Month/Day/Year


Month: _________


Day: _________


Year: _________





Alcohol Consumption


NOTE: If JJ1 and JJ5 are both used, a skip arrow should be added to JJ5 “I didn’t drink then” to skip JJ1.


JJ5.


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



Check ONE answer



14 or more drinks 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




JJ1.

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


NOTE: Skip JJ2 and JJ3 if mother did not drink during the last 3 months of her pregnancy (Core 27).


BEFORE JJ3, insert instruction box that says: “If you didn’t have any alcoholic drinks during the last 3 months of your pregnancy, go to Question #.”


If JJ2 and JJ3 are both used, a skip arrow should be added to JJ3 “I didn’t drink then” to skip JJ2.


JJ3.

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



Check ONE answer

14 or more drinks 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


JJ2.

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


JJ6.


During your most recent pregnancy, did a healthcare provider or home health visitor tell you that it was okay to drink a little alcohol during pregnancy?



No

Yes





Disaster and Emergency Preparedness

Also see Disaster Supplement


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


KK4.

Below is a list of things that some people do to prepare for a disaster. 



For each one, check No or Yes.




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 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 


 


Maternal Childhood Experiences

NOTE: LL1: Response items a-h are required for minimum assessment of adverse childhood events (ACEs). Response items i-m are optional (enhanced assessment of ACEs). Sites can select any or all of the optional response items.


LL1.


The next questions are about things that may have happened to you during your childhood, before your 18th birthday.




For each one, check No or Yes.




No Yes


Before your 18th birthday…


Did you live with someone who was depressed, mentally ill, or suicidal?

 

Did you live with someone who had a problem with alcohol or drug use?

 

Were you separated from a parent or guardian because they went to jail, prison, or a detention center?


 

Did your parents or other adults in your home slap, hit, kick, punch, or beat each other up?


 

Did a parent or other adult in your home hit, beat, kick, or physically hurt you in any way?


 

Did a parent or other adult in your home swear at you, insult you, or put you down?

 


Before your 18th birthday…


Did an adult or person at least 5 years older than you ever make you do sexual things that you didn’t want to do (such as kissing, touching, or having sexual intercourse)?



 

Was there an adult in your household who tried hard to make sure your basic needs were met, such as looking after your safety and making sure you had clean clothes and enough to eat?



 

Was there an adult in your household who tried hard to make sure you felt loved, supported, valued, and like you were special to them?


 


Before your 18th birthday…


Did you feel that you were treated badly or unfairly because of your race, ethnicity, or skin color?

 

Did you feel that you were treated badly or unfairly because you are or people think you are LGBTQIA+? This could include being treated badly because of who you’re sexually attracted to or because you express your gender in a way that is different than what people expect.




 

Did you see someone get physically attacked, beaten, stabbed, or shot in your neighborhood?


 

Were your parents or guardians divorced or separated?

 


LL2.

These questions are about things that may have happened to you during your childhood, before your 18th birthday.



For each one, check No or Yes.



GRID: No/Yes

No Yes


Before your 18th birthday…


Did you feel that you were able to talk to an adult in your family or other caring adult about your feelings?


 

Did you feel that you were able to talk to a friend about your feelings?

 

Did you feel a sense of belonging in high school?

 


Disability

Also see Disability Supplement


OO2.


Because of a physical, mental, or emotional condition, do you have difficulty caring for yourself or your newborn?



No

Yes



Sexual Orientation and Gender Identity


PP1.


How would you describe your gender?



Female

Male

Transgender

Genderqueer or gender nonconforming

Prefer to self-describe


Please tell us: _____________________________________________________


PP2.


How would you describe your sexual orientation?



Heterosexual or “straight”

Lesbian or Gay

Bisexual

Prefer to self-describe


Please tell us: __________________________________



Natural Disaster Module


KK5.

Were you living in or staying in an area that was affected by a disaster in the past year? This could be a natural disaster such as a hurricane, tornado, earthquake, etc., or a manmade disaster such as an explosion, chemical spill, etc.



No Go to the end

Yes



KK6.

How would you describe any damage to your home from the disaster? Check ONE answer



My home was not damaged

My home had minor damage, but the living areas were still livable

My home had major damage

My home was destroyed


KK7.

Did you experience any of the following because of the disaster?



No Yes

You felt like your life was in danger when the disaster struck

 

You were injured or became ill

 

A member of your household was injured or became ill

 

You walked through debris or floodwater

 

You were without electricity for one week or longer

 

Someone close to you died in the disaster

 

You saw someone die in the disaster

 

You were living in temporary housing or in conditions that you were not accustomed to


 

You lost personal belongings

 

You were separated from loved ones who you feel close to

 

You had trouble getting services or aid from the government

 

You had trouble dealing with insurance or disaster relief agencies

 

You had trouble getting clean drinking water

 

You had trouble getting enough food to eat

 

You felt unsafe because of the lack of order and security after the disaster

 


KK8.


After the disaster, where did you look FIRST for reliable information regarding the disaster and cleaning up or recovery efforts?


Check ONE answer



TV

Radio

Text messages

Neighbor or word of mouth

Flyers or posters

Local Newspaper

Social media sites like Facebook

Internet


Please tell us: ________________________

Other


Please tell us: ________________________



KK9.

After the disaster, how would you describe the amount of hard physical work you had to do to take care of your home and yard compared to the time before the disaster?

Check ONE answer



Much more physical work after the disaster

A little more physical work after the disaster

The same amount of physical work

Less physical work since the disaster

I didn’t do any physical work around the home and yard



KK10.

Did you or any member of your household receive any of the following types of aid as part of disaster relief efforts?



No Yes

Food

 

Water

 

Shelter

 

Clothing

 

Medicine

 

Financial assistance

 

Transportation services

 



KK11.

Since the disaster, have you felt that you have needed mental health services such as counseling, medications, or support groups to help with feelings of anxiety, depression, grief, or other problems?



No Go to Question KK14


Yes




KK12.

Were you able to get the mental health services that you needed?


No

Yes Go to Question KK14



KK13.

Did any of these things keep you from getting the mental health services that you needed after the disaster? Check ALL that apply



Road conditions made it unsafe to travel

I was sick or injured and couldn’t travel

I was afraid to leave where I was staying

I didn’t know where to go to get the services

Services were not available due to damage to clinic offices from the disaster

I couldn’t get an appointment when I wanted one

I was worried about what others would think if I went

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

I couldn’t take time off from work or school

I had no one to take care of children or other family members

I had too many other things going on

Other


Please tell us: ____________________________________________________



KK14.

Since the disaster, would you have the kinds of help listed below if you needed them?




No Yes

Someone to loan me $50

 

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

 

Someone to talk with about my problems

 



KK15.

Before the disaster, did you have an emergency plan for your family in case of disaster? For example, you and your family had talked about how to be safe if a disaster happened.



No

Yes






KK16.

Before the disaster, had you done any of the things listed below to prepare for a disaster? 




No Yes

You had an emergency meeting place for family members (other than your home)

 

You and your family had practiced what to do in case of a disaster

 

You had a plan for how you and your family would keep in touch if you were separated 

 

You had an evacuation plan if you needed to leave your home and community 

 

You had an evacuation plan for your child or children in case of a disaster (permission for day care or school to release your child to another adult)


 

You had copies of important documents like birth certificates and insurance policies in a safe place outside your home


 

You had emergency supplies in your home for your family such as enough extra water, food, and medicine to last for at least three days


 

You had emergency supplies that you kept in your car, at work, or at home to take with you if you needed to leave quickly 


 



Environmental Exposures Module


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?



No Yes

Strong degreasers such as oven cleaner or heavy-duty degreaser

 

Furniture or shoe polish

 

Bleach or bleach products (such as bathroom tile cleaner, drain cleaner, disinfectants)

 

Air fresheners or plug-ins

 

Incense or scented candles

 

Perfume or nail polish

 

Permanent pressed (wrinkle-free) clothes or curtains

 



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 10).

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.”


NN5.

During any of your prenatal care visits, did a healthcare provider talk with you about any of the things listed below? Please count only discussions, not reading materials or videos.



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 healthcare provider able to answer any questions about environmental exposures? (Environmental exposures include contact with chemicals, substances, or products inside or outside of your household such as bleach, household cleaning products, pesticides, or air pollution)


Check ONE answer



No

Yes

I didn’t ask a healthcare provider any questions about environmental exposures

I didn’t have any concerns about environmental exposures




File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitlePregnancy Risk Assessment Monitoring System (PRAMS)
SubjectPhase 9 Standard Questions and Supplements
AuthorRuffo, Nan M. (CDC/DDNID/NCCDPHP/DRH) (CTR)
File Modified0000-00-00
File Created2023-08-30

© 2024 OMB.report | Privacy Policy