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collection of information unless it displays a current valid OMB control number. Send comments
regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE,
MS D-74, Atlanta, Georgia 30333; ATTN: PRA (XXXX-XXXX)
We would like to learn about your
experiences to help improve care for
women who experience stillbirths. The
questions on this survey are about your
pregnancy when your baby died, except
when noted. We understand that some
questions may be sensitive, but we
appreciate any information you are able
to share.
Please check the box next to your answer
or follow the directions included with the
question. You may be asked to skip some
questions that do not apply to you.
BEFORE PREGNANCY
The first questions are about you.
1.
2.
Inches
OR
Centimeters
4.
Kilos
What is your date of birth?
Month
Day
Year
During the 3 months before you got pregnant,
did you have any of the following health
conditions? For each one, check No if you did
not have the condition or Yes if you did.
No Yes
a. Type 1 or Type 2 diabetes (not
gestational diabetes or diabetes that
starts during pregnancy)................................
b. High blood pressure or hypertension........
c. Depression...........................................................
d. Asthma..................................................................
e. Thyroid problems..............................................
f. PCOS (polycystic ovarian syndrome).........
g. Anxiety..................................................................
5.
During the month before you got pregnant,
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
Just before you got pregnant, how much did
you weigh?
Pounds OR
3.
The next questions are about the time before
you got pregnant.
How tall are you without shoes?
Feet
Form Approved
OMB No. 0920-1273 1
Exp. Date xx/xx/xxxx
We would like to find out about your
pregnancy history.
6.
How many times have you been pregnant?
Please include this pregnancy and ALL
pregnancies you have had (both losses and live
births).
1 time
2 to 4 times
5 to 7 times
8 or more times
Go to Page 2, Question 12
Go to Page 2, Question 7
2
7.
Before this pregnancy, did you have any
babies who were born alive?
No
Yes
8.
Go to Question 10
Did your last baby who was born alive weigh
5 pounds, 8 ounces (2.5 kilos) or less at birth?
No
Yes
9.
Was your last baby who was born alive born
earlier than 3 weeks before his or her due
date?
No
Yes
10. Before this pregnancy, did you have any
pregnancies that ended in a loss?
No
Yes
Go to Question 12
11. Please indicate the number of previous losses
you had that ended in each of the following
time periods (not including this baby):
Number of pregnancies that ended before
12 weeks
Number of pregnancies that ended
between 12 and 27 weeks
Number of pregnancies that ended at 28
weeks or later
12. When you got pregnant with this baby, were
you trying to get pregnant?
No
Yes
The next questions are about your health
insurance coverage before, during, and
after your pregnancy.
13. During the month before you got pregnant,
what kind of health insurance did you have?
Check ALL that apply
Private health insurance from my job or the job
of my husband or partner
Private health insurance from my parents
Private health insurance from the Health
Insurance Marketplace or HealthCare.gov
Medicaid
TRICARE or other military health care
Indian Health Service (IHS) or tribal
Please tell us:
Other health insurance
I did not have any health insurance during the
month before I got pregnant
14. During your pregnancy, what kind of health
insurance did you have for your prenatal
care?
Check ALL that apply
I did not go for
Go to Question 15
prenatal care
Private health insurance from my job or the job
of my husband or partner
Private health insurance from my parents
Private health insurance from the Health
Insurance Marketplace or HealthCare.gov
Medicaid
TRICARE or other military health care
Indian Health Service (IHS) or tribal
Please tell us:
Other health insurance
I did not have any health insurance for my
prenatal care
3
15. What kind of health insurance do you have
now?
Check ALL that apply
Private health insurance from my job or the job
of my husband or partner
Private health insurance from my parents
Private health insurance from the Health
Insurance Marketplace or HealthCare.gov
Medicaid
TRICARE or other military health care
Indian Health Service (IHS) or tribal
Other health insurance
Please tell us:
I do not have health insurance now
DURING PREGNANCY
The next questions are about the prenatal
care you received during your pregnancy.
Prenatal care includes visits to a doctor,
nurse, or other health care worker during
your pregnancy to get checkups and advice
about pregnancy. (It may help to look at the
calendar when you answer these questions.)
16. How many weeks or months pregnant were
you when you had your first visit for prenatal
care?
Weeks
I didn’t go for
prenatal care
Go to Question 17
OR
Months
Go to Question 18
17. During any of your prenatal care visits, did a
doctor, nurse, or other health care worker ask
you any of the things listed below? For each
item, check No if they did not ask you about it or
Yes if they did.
No Yes
a. If I knew how much weight I should
gain during pregnancy...................................
b. If I was taking any prescription
medication...........................................................
c. If I was smoking cigarettes.............................
d. If I was drinking alcohol..................................
e. If someone was hurting me emotionally
or physically.........................................................
f. If I was feeling down or depressed................
g. If I was using drugs such as marijuana,
cocaine, crack, or meth...................................
h. If I wanted to be tested for HIV (the
virus that causes AIDS)....................................
i. If I planned to breastfeed my new baby...
j. If I planned to use birth control after my
baby was born....................................................
k. If I knew how to track my baby’s
movements..........................................................
l. If I knew about recommended sleeping
positions during pregnancy..........................
18. During this pregnancy, were you on WIC (the
Special Supplemental Nutrition Program for
Women, Infants, and Children)?
No
Yes
19. During the 12 months before your baby was
delivered, did you get a flu shot?
Check ONE answer
No
Yes, before my pregnancy
Yes, during my pregnancy
4
20. During your pregnancy, did you have any of
the following health conditions? For each one,
check No if you did not have the condition or
Yes if you did.
No Yes
a. Gestational diabetes (diabetes that
started during this pregnancy)...................
b. High blood pressure (that started during
this pregnancy), pre-eclampsia or
eclampsia..............................................................
c. Depression...........................................................
d. Anxiety..................................................................
21. Did you have any of the following problems
during your pregnancy? For each item, check
No if you did not have the problem or Yes if you
did.
No Yes
a. Vaginal bleeding................................................
b. Kidney or bladder (urinary tract)
infection (UTI)......................................................
c. Severe nausea, vomiting, or
dehydration that sent me to the
doctor or hospital..............................................
d. Cervix had to be sewn shut (cerclage for
incompetent cervix).........................................
e. Complications with the placenta (such
as abruptio placentae or placenta
previa)....................................................................
f. Labor pains more than 3 weeks before
my baby was due (preterm or early
labor)......................................................................
g. Water broke more than 3 weeks before
my baby was due (preterm premature
rupture of membranes [PPROM])................
h. I had to have a blood transfusion................
i. I was hurt in a car accident............................
j. Decreased fetal movement or a change
in fetal movement.............................................
k. Fever of 101° or higher.....................................
l. A gut feeling that something was
wrong.....................................................................
22. During your pregnancy, did a doctor, nurse,
or other health care worker tell you that you
had any of the following infections? For each
item, check No if you were not told that you had
the infection or Yes if you were.
No Yes
a. Yeast infections...................................................
b. Urinary tract infection (UTI)...........................
c. Cytomegalovirus (CMV)..................................
d. Genital warts (HPV)...........................................
e. Herpes....................................................................
f. Chlamydia.............................................................
g. Gonorrhea............................................................
h. Pelvic inflammatory disease (PID)...............
i. Syphilis..................................................................
j. Group B Strep (Beta Strep).............................
k. Bacterial vaginosis.............................................
l. Trichomoniasis (Trich)......................................
m. Listeria...................................................................
n. Toxoplasmosis....................................................
o. Other......................................................................
Please tell us:
The next questions are about smoking and
alcohol use around the time of pregnancy
(before, during, and after). We are not
asking these questions because we think
you did anything to affect your baby. We
ask similar questions of other women on a
different survey.
23. Have you smoked any cigarettes in the past
2 years?
No
Yes
Go to Question 24
Go to Question 27
5
24. In the 3 months before you got pregnant, how
many cigarettes did you smoke on an average
day? A pack has 20 cigarettes.
The next questions are about using other
tobacco products around the time of
pregnancy.
41 cigarettes or more
21 to 40 cigarettes
11 to 20 cigarettes
6 to 10 cigarettes
1 to 5 cigarettes
Less than 1 cigarette
I didn’t smoke then
E-cigarettes (electronic cigarettes) and other
electronic nicotine products (such as vape pens,
e-hookahs, hookah pens, e-cigars, e-pipes) are
battery-powered devices that use nicotine liquid
rather than tobacco leaves, and produce vapor
instead of smoke.
25. In the last 3 months of your pregnancy, how
many cigarettes did you smoke on an average
day? A pack has 20 cigarettes.
41 cigarettes or more
21 to 40 cigarettes
11 to 20 cigarettes
6 to 10 cigarettes
1 to 5 cigarettes
Less than 1 cigarette
I didn’t smoke then
26. How many cigarettes do you smoke on an
average day now? A pack has 20 cigarettes.
41 cigarettes or more
21 to 40 cigarettes
11 to 20 cigarettes
6 to 10 cigarettes
1 to 5 cigarettes
Less than 1 cigarette
I don’t smoke now
A hookah is a water pipe used to smoke tobacco. It
is not the same as an e-hookah or hookah pen.
27. Have you used any of the following products
in the past 2 years? For each item, check No if
you did not use it or Yes if you did.
No Yes
a. E-cigarettes or other electronic nicotine
products................................................................
b. Hookah..................................................................
If you used e-cigarettes or other electronic
nicotine products in the past 2 years, go to
Question 28. Otherwise, go to Page 6, Question
30.
28. During the 3 months before you got
pregnant, on average, how often did you
use e-cigarettes or other electronic nicotine
products?
More than once a day
Once a day
2-6 days a week
1 day a week or less
I did not use e-cigarettes or other electronic
nicotine products then
6
29. During the last 3 months of your pregnancy,
on average, how often did you use
e-cigarettes or other electronic nicotine
products?
More than once a day
Once a day
2-6 days a week
1 day a week or less
I did not use e-cigarettes or other electronic
nicotine products then
30. Have you had any alcoholic drinks in the past
2 years? A drink is 1 glass of wine, wine cooler,
can or bottle of beer, shot of liquor, or mixed
drink.
No
Yes
Go to Question 33
31. During the 3 months before you got pregnant,
how many alcoholic drinks did you have in an
average week?
14 drinks or more a week
8 to 13 drinks a week
4 to 7 drinks a week
1 to 3 drinks a week
Less than 1 drink a week
I didn’t drink then
32. During the last 3 months of your pregnancy,
how many alcoholic drinks did you have in an
average week?
14 drinks or more a week
8 to 13 drinks a week
4 to 7 drinks a week
1 to 3 drinks a week
Less than 1 drink a week
I didn’t drink then
Pregnancy can be a difficult time. The
next questions are about things that may
have happened before and during your
pregnancy.
33. Did you have depression during your
pregnancy?
No
Yes
Go to Question 37
34. During your pregnancy, did you ask for help
for depression from a doctor, nurse, or other
health care worker?
No
Yes
35. During your pregnancy, did you get
counseling for depression?
No
Yes
36. At any time during your pregnancy, did
you take prescription medicine for your
depression?
No
Yes
7
37. This question is about things that may have
happened during the 12 months before your
baby was delivered. For each item, check No if
it did not happen to you or Yes if it did. (It may
help to look at the calendar when you answer
these questions.)
No Yes
a. A close family member was very sick
and had to go into the hospital....................
b. I got separated or divorced from my
husband or partner...........................................
c. I moved to a new address...............................
d. I was homeless or had to sleep outside,
in a car, or in a shelter.......................................
e. My husband or partner lost their job.........
f. I lost my job even though I wanted to go
on working...........................................................
g. My husband, partner, or I had a cut in
work hours or pay..............................................
h. I was apart from my husband or partner
due to military deployment or extended
work-related travel............................................
i. I argued with my husband or partner
more than usual.................................................
j. My husband or partner said they didn’t
want me to be pregnant.................................
k. I had problems paying the rent,
mortgage, or other bills..................................
l. My husband, partner, or I went to jail........
m. Someone very close to me had a
problem with drinking or drugs...................
n. Someone very close to me died...................
38. In the 12 months before you got pregnant,did
any of the following people push, hit, slap,
kick, choke, or physically hurt you in any
other way? For each person, check No if they
did not hurt you during this time or Yes if they
did.
No Yes
a. My husband or partner...................................
b. My ex-husband or ex-partner.......................
c. Someone else.....................................................
39. During your pregnancy, did any of the
following people push, hit, slap, kick, choke,
or physically hurt you in any other way? For
each person, check No if they did not hurt you
during this time or Yes if they did.
No Yes
a. My husband or partner...................................
b. My ex-husband or ex-partner.......................
c. Someone else.....................................................
AFTER PREGNANCY
The next questions are about your baby
and your experiences around the time
of delivery. We understand that some of
these options may not apply to you.
40. When was your baby due?
20
Month
Day
Year
41. When was your baby delivered?
20
Month
Day
Year
42. What date do you think your baby died?
20
Month
Day
I don’t know
Year
8
43. What date did you find out that your baby
died?
20
Month
Day
Year
I don’t know
44. When did your baby die?
Before delivery
During delivery
I don’t know
45. How was your baby delivered?
Go to Question 47
Vaginally
Cesarean delivery (c-section)
46. Which statement best describes whose idea
it was for you to have a cesarean delivery
(c-section)?
Check ONE answer
My health care provider scheduled my
cesarean delivery before my baby died
My health care provider recommended a
cesarean delivery before I went into labor
My health care provider recommended a
cesarean delivery while I was in labor
I asked for the cesarean delivery
47. When were you discharged from the hospital
after your baby was delivered?
20
Month
Day
I didn’t have my
baby in a hospital
Go to Question 48
48. Were you offered any of the following things
during your hospital stay? For each item, check
No if it was not offered or Yes if it was.
Year
Go to Page 10,
Question 52
No Yes
Photographs of my baby................................
Photographs of my baby with family.........
Hand and/or foot prints/impressions.........
Holding my baby...............................................
Bathing my baby................................................
Dressing my baby..............................................
Baptism or blessing of my baby...................
Mementos (ex. hat, clothes)...........................
Funeral/memorial service resources...........
Support groups/peer volunteer
resources...............................................................
k. Visit with a religious leader (bishop,
chaplain, pastor, priest, rabbi, imam,
etc.).........................................................................
l. Visit with a hospital social worker...............
m. To have my baby stay in my room...............
n. A cooling bed......................................................
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
9
49. Which of the following things did you receive
during your hospital stay? For those items that
were received, please indicate if you felt it was
helpful or not.
Received Helpful
No Yes No Yes
a. Photographs of my baby........
b. Photographs of my baby
with family....................................
c. Hand and/or foot
prints/impressions....................
d. Holding my baby.......................
e. Bathing my baby........................
f. Dressing my baby......................
g. Baptism or blessing of my
baby................................................
h. Mementos (ex. hat, clothes)...
i. Funeral/memorial service
resources.......................................
j. Support groups/peer
volunteer resources..................
k. Visit with a religious leader
(bishop, chaplain, pastor,
priest, rabbi, imam, etc.)..........
l. Visit with a hospital social
worker............................................
m. To have my baby stay in my
room...............................................
n. A cooling bed..............................
50. Did any of the following things happen to you
before you left the hospital? For each item,
check No if it did not happen or Yes if it did.
.
.
.
.
.
.
.
.
.
.
.
.
No Yes
a. I felt adequately supported by my
doctor or midwife in my grieving
process...................................................................
b. I felt adequately supported by the
hospital nursing staff in my grieving
process...................................................................
c. I felt adequately supported by the
grief counseling staff in my grieving
process...................................................................
d. I was given information about my breast
milk coming in....................................................
e. I was given information about what to
do when my breast milk came in.................
f. I was given a bereavement packet with
information on where to seek support......
g. The hospital staff gave me the
opportunity to ask questions........................
h. My healthcare provider discussed with
me what might have happened to my
baby........................................................................
The next questions are about autopsy and
other exams that may have been done
to learn about what caused your baby’s
death. We are trying to learn more about
tests offered in hospitals. We understand
that some of the options may not apply to
you.
.
.
51. Were any of the following tests offered to you
during your hospital stay? For each test, check
No if it was not offered or Yes if it was.
No Yes
a.
b.
c.
d.
Blood tests (mother).........................................
Detailed exam of placenta.............................
Autopsy (full or partial)....................................
Genetic testing of the baby...........................
10
52. Were any of the following tests performed on
you and/or your baby? For each test, check No
if it was not performed or Yes if it was.
56. Which of the following things may have
caused your baby’s death?
Check ALL that apply
No Yes
a.
b.
c.
d.
Complications with the cervix
Complications with the umbilical cord/cord
accident
Placental abruption (separation of the placenta
from the uterus)
Infection
Other complications with the placenta
Hypertension
Preterm (premature) labor
Diabetes
Membranes ruptured
Congenital defect(s) / birth defect(s)/
chromosomal abnormalities
Other
Please tell us:
Blood tests (mother).........................................
Detailed exam of placenta.............................
Placenta went to pathology..........................
Genetic testing of the baby...........................
53. Did your baby have a full or partial autopsy?
No
Yes
Go to Question 55
54. What were the reasons that the autopsy was
not done?
Check ALL that apply
An autopsy was too expensive
I was told it would not be covered by insurance
I declined for personal or religious reasons
I did not have enough information about the
procedure
The doctors were able to determine the
cause(s) of death without an autopsy
I was told that an autopsy would not provide
any answers
An autopsy was not offered to me
Other
Please tell us:
The next questions are about your health
since your baby was delivered.
57. Since your baby was delivered, have you
had a postpartum checkup for yourself? A
postpartum checkup is the regular checkup a
woman has about 4-6 weeks after she gives
birth.
No
Yes
55. Did you learn what may have caused your
baby’s death?
No
Yes
Go to Question 56
Go to Question 57
Go to Question 59
58. During your postpartum checkup, did a
doctor, nurse, or other health care worker
do any of the following things? For each item,
check No if they did not do it or Yes if they did.
No Yes
a. Talk to me about how long to wait
before getting pregnant again.....................
b. Talk to me about birth control
methods I can use after giving birth..........
11
59. Since your baby was delivered, have you
received support or counseling for feelings
of grief?
No
Yes
Go to Question 61
60. Did any of the following things keep you
from receiving support or counseling?
Check ALL that apply
I felt fine and do not think I needed support or
counseling
I didn’t know where to go for counseling
I didn’t have insurance to cover the cost of
counseling
I was not aware of support groups in my area
Other
Please tell us:
The last questions are about the time
during the 12 months before your baby was
delivered.
63. During the 12 months before your baby
was delivered, what was your yearly total
household income before taxes? Include your
income, your husband’s or partner’s income, and
any other income you may have received. All
information will be kept private and will not affect
any services you are now getting.
61. Are you pregnant now?
No
Yes
Go to Question 63
62. What was the first day of your last period?
20
Month
Day
Year
I did not have a period before I became
pregnant again
$0 to $16,000
$16,001 to $20,000
$20,001 to $24,000
$24,001 to $28,000
$28,001 to $32,000
$32,001 to $40,000
$40,001 to $48,000
$48,001 to $57,000
$57,001 to $60,000
$60,001 to $73,000
$73,001 to $85,000
$85,001 or more
64. During the 12 months before your baby
was delivered, how many people, including
yourself, depended on this income?
People
65. What is today’s date?
20
Month
Day
Year
12
Please use this space for any additional comments you would like to
share about your pregnancy and baby.
Thank you for answering these questions. By answering these questions, you are helping
us find out why stillbirths happen and how we can improve the care received by families.
Again, please accept our deepest sympathies to you and your family on the loss of your
baby.
| File Type | application/pdf |
| File Modified | 2022-10-03 |
| File Created | 2018-06-11 |