**First we would like to ask you about your pregnancies. Please check
the box next to the best a answer.**

**1. Not counting your most recent**  **No ---\> Go to Question 4**

**birth, did you have any other**  **Yes**

**babies who were born alive?**

**2. Of these babies, did the one**  **No**

**just before your new baby**  **Yes**

**weigh *less* than 5 pounds,**

**8 ounces at birth?**

**3. Was that baby born *more* than**  **No**

**3 weeks before its due date?**  **Yes**

**Next are some questions about the pregnancy related to your most
recent birth. You may**

**want to use the calendar to help you answer the questions.**

**4. How many weeks or months \_\_\_\_ Weeks or \_\_\_\_ Months**

**pregnant were you when you were**

***sure* you were pregnant? (For**  **I don\'t remember**

**example, you had a pregnancy test**

**or a doctor or nurse said you were**

**pregnant.)**

**5. How many weeks or months pregnant \_\_\_\_ Weeks or \_\_\_\_
Months**

**were you when you first thought**

**you *might* be pregnant?**  **I don\'t remember**

**6. When you were sure you were**  **No**

**pregnant, were you on Medicaid?**  **Yes**

**7. Thinking back to just before you**  **I wanted to be pregnant
sooner**

**were pregnant, how did you feel**  **I wanted to be pregnant later**

**about becoming pregnant?**  **I wanted to be pregnant then**

***Check the best answer.***  **I didn't want to be pregnant then**

**or at any time in the future**

  **I don't know**

**The next questions are about prenatal care you got during the
pregnancy that ended with**

**your most recent birth. Prenatal care includes visits to a doctor or
nurse before your baby**

**was born to check your blood pressure or the baby's heart beat, tests
of your blood and**

**urine, examinations such as sonogram or ultrasound, and advice. It
does not include WIC**

**(Supplemental Food Program for Women, Infants, and Children) or
delivery of the baby.**

**You may want to use the calendar to help you answer the questions.**

**8. How many weeks or months \_\_\_\_ Weeks or \_\_\_\_ Months**

**pregnant were you when you had**

**your first visit for prenatal care?**  **I did not go for prenatal
care**

***Don't count a visit that was only***

***for a pregnancy test or a visit***

***only for WIC.***

**9. Did you get prenatal care as early**  **No**

**in your pregnancy as you wanted?**  **Yes ---\> Go to Question 11**

  **I did not want prenatal**

**care ---\> Go to Question 11**

**10. Did any of these things keep you from**  **I had no one to take
care of my children getting care as early as you wanted?**  **I had no
way to get to the clinic or office *Check all that apply.***  **I
couldn't get a doctor or nurse to take me as a patient**

  **I couldn't get an appointment earlier**

**in my pregnancy**

  **I didn't think that I was pregnant**

  **I didn't have enough money or**

**insurance to pay for my visits**

  **I didn't know where to go**

  **Other ---\> Please tell us:**

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**11. How many visits for prenatal care \_\_\_\_ Visits**

**did you have?**

***Don't count visits for WIC.***  **I did not go for prenatal**

**care ---\> Go to Question 22**

**12. Did you have as many visits for**  **Yes ---\> Go to Question
14**

**prenatal care as you wanted?**  **I did not want prenatal**

**care ---\> Go to Question 14**

  **I wanted to go for fewer**

**visits ---\> Go to Question 14**

  **I wanted to go for more visits**

**13. Did any of these things keep you**  **I had no one to take care
of my children**

**from having as many visits as you**  **I had no way to get to the
clinic or office**

**wanted?**  **I didn't have enough money or**

***Check all that apply.* insurance to pay for my visits**

  **I didn't know where to go**

  **Other ---\> Please tell us:**

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**If you did not go for prenatal care, Skip to Question 22 on Page 4.**

**14. Where did you go *most of the time***  **Hospital clinic**

**for your prenatal visits?**  **Health department clinic (free**

**Don't include visits for WIC. government clinic)**

***Check one answer.***  **Private doctor's office or HMO**

  **I did not go for prenatal care**

  **Other ---\> Please tell us:**

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**15. How satisfied were you with the prenatal care you got?**

***For each of the things listed below, circle the best answer. If you
went to more***

***than one place for prenatal care, answer for the place where you got*
most *of***

***your care.***

**How satisfied were you with . . . Satisfied Dissatisfied**

**a. The amount of time you had to wait after**

**you arrived for your visits . . . . . . . . . . . . . . . . . . . . .
. . . S D**

**b. The amount of time the doctor or nurse**

**spent with you during your visits . . . . . . . . . . . . . . . . . .
S D**

**c. The advice you got on how to take care of yourself . . . . S D**

**d. The hours the office or clinic was open . . . . . . . . . . . . . .
S D**

**e. The understanding and respect that the**

**staff showed toward you as a person . . . . . . . . . . . . . . . . S
D**

**16. When you went for prenatal care, did a**  **No**

**doctor, nurse, or other health worker ask**  **Yes**

**you if you were smoking?**

**17. Did a doctor or nurse talk with**  **No**

**you about how smoking during**  **Yes**

**pregnancy could affect your baby?**

**18. When you went for prenatal care,**  **No**

**did a doctor, nurse, or other**  **Yes**

**health worker ask you if you were**

**drinking alcoholic beverages (beer,**

**wine, wine cooler, or liquor)?**

**19. Did a doctor or nurse talk with**  **No**

**you about how drinking during**  **Yes**

**pregnancy could affect your baby?**

**20. Did a doctor, nurse, or other**  **No**

**health worker talk with you**  **Yes**

**about what you should eat during**

**your pregnancy?**

**21. How was your prenatal care paid**  **Medicaid**

**for?**  **Personal income (cash, check, or**

***Check all that apply.* credit card)**

  **Insurance or HMO**

  **I still owe**

  **Other ---\> Please tell us:**

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**22. During your pregnancy, were**  **No**

**you on WIC?**  **Yes**

**23. How much did you weigh during \_\_\_\_ Pounds**

**the *3 months before* you became**

**pregnant?**  **I don\'t know**

**24. How tall are you without shoes? \_\_\_\_ feet \_\_\_\_ inches**

**25. How much did *you* weigh *when***  **Less than 5 pounds, 8
ounces**

***you were born?***  **5 pounds, 8 ounces, or more**

  **I don't know**

**26. a. Not counting your hospital**  **No ---\> Go to Question 27**

**stay for delivery, did you have**  **Yes, I stayed \_\_\_\_ nights**

**to stay overnight in a hospital**

**for any kind of problem during**

**your pregnancy?**

**b. What was the date during your \_\_\_\_ / \_\_\_\_ / \_\_\_\_**

**pregnancy when you went into the month day year**

**hospital?**

**c. Why did you stay in the hospital?**  **Vaginal bleeding or
placenta problems**

***Check all that apply.***  **Diabetes (high blood sugar)**

  **High blood pressure or toxemia**

  **Kidney infection**

  **Nausea, vomiting, or dehydration**

  **Premature labor or contractions more**

**than 3 weeks before my due date**

  **Other ---\> Please tell us:**

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**The next questions are about cigarette smoking and alcohol drinking.**

**27. Have you smoked at least 100**  **No ---\> Go to Question 31**

**cigarettes in your entire life?**  **Yes**

**28. In the *3 months before* you got \_\_\_\_ Cigarettes or \_\_\_\_
packs**

**pregnant, how many cigarettes**

**or packs of cigarettes did you**  **Less than 1 cigarette a day**

**smoke on an average day?**  **I didn\'t smoke**

**A pack has 20 cigarettes.**  **I don't know**

**29. In the *last 3 months* of your \_\_\_\_ Cigarettes or \_\_\_\_
packs**

**pregnancy, how many cigarettes**

**or packs of cigarettes did you**  **Less than 1 cigarette a day**

**smoke on an average day?**  **I didn\'t smoke**

**A pack has 20 cigarettes.**  **I don't know**

**30. How many cigarettes or packs \_\_\_\_ Cigarettes or \_\_\_\_
packs**

**of cigarettes do you smoke on**

**an average day *now*?**  **Less than 1 cigarette a day**

  **I don\'t smoke**

  **I don't know**

**31. In the *3 months before* you got \_\_\_\_ Number of drinks a
week**

**pregnant, how many alcoholic**

**drinks did you have in an**  **Less than 1 drink a week**

**average week?**  **I didn\'t drink then**

**(A drink is: One glass of wine.**  **I don't know**

**One wine cooler.**

**One can or bottle of beer.**

**One shot of liquor.**

**One mixed drink.)**

**32. In the *last 3 months* of your \_\_\_\_ Number of drinks a week**

**pregnancy, how many alcoholic**

**drinks did you have in an**  **Less than 1 drink a week**

**average week?**  **I didn\'t drink then**

  **I don't know**

**33. This question is about things that may have happened during the 12
months**

**before your delivery. This includes the months before you got
pregnant. *For***

***each thing listed below, circle Y (Yes) if it happened to you or N
(No)***

***if it didn't. It may help to use the calendar.***

**No Yes**

**a. A close family member was very sick and had to see a doctor . . . .
. . . . . . . . . N Y**

**b. Another close relative was very sick and had to see a doctor . . .
. . . . . . . . . . . N Y**

**c. You got separated from your husband or partner. . . . . . . . . . .
. . . . . . . . . . . . N Y**

**d. You got divorced . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . N Y**

**e. You were homeless . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . N Y**

**f. You were involved in a physical fight . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . N Y**

**g. Your husband or partner physically hurt you . . . . . . . . . . . .
. . . . . . . . . . . . . . N Y**

**h. You were arrested . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . N Y**

**i. You were charged or convicted of an offense . . . . . . . . . . . .
. . . . . . . . . . . . . N Y**

**j. Your husband or partner was sent to jail . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . N Y**

**k. Your husband or partner lost his job . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . N Y**

**l. You got into debt over your head . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . N Y**

**m. You lost your job even though you wanted to go on working . . . . .
. . . . . . . N Y**

**n. Someone very close to you had a bad problem with drinking or drugs
. . . . . . N Y**

**o. Your husband or partner died . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . N Y**

**p. A close family member (other than your husband) died . . . . . . .
. . . . . . . . . . . N Y**

**q. A close friend died . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . N Y**

**r. A close family member tried to commit suicide . . . . . . . . . . .
. . . . . . . . . . . . . N Y**

**The next questions are about your labor and delivery and the time
right after you went home**

**from the hospital after your baby was born.**

**34. When you went in the hospital to \_\_\_\_ Nights**

**have your baby, how many nights**

**did you stay?**  **I did not stay in a hospital**

**35. When your baby was born, how \_\_\_\_ Nights**

**many nights did he or she stay**

**in the hospital?**  **My baby did not stay in a hospital**

  **I don't know**

**36. When your baby was born, was he**  **No**

**or she put in an intensive care**  **Yes**

**unit or premature nursery?**  **I don't know**

**37. Including the hospital costs,**  **Medicaid**

**how was your delivery paid for?**  **Personal inome (cash, check,
or**

***Check all that apply.* credit card)**

  **Insurance or HMO**

  **I still owe**

  **Other ---\> Please tell us:**

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**38. For how many weeks or months did \_\_\_\_ Weeks or \_\_\_\_
Months**

**you breastfeed your baby before**

**feeding him or her any other milk,**  **I didn't breastfeed**

**formula, or food?**  **I breastfed less than 1 week**

***Check all that apply.***  **I'm still breastfeeding and have
started**

**some formula or food, too (put number**

**of weeks or months you fed breastmilk**

**only, then Go to Question 40)**

  **I'm still breastfeeding and haven't fed**

**my baby any other milk, formula, or**

**food yet ---\> Go to Question 40**

**39. Did any of these things stop you**  **I didn't want to**

**from breastfeeding?**  **I was planning to go to work or school**

***Check all that apply.***  **I tried but my baby didn't breastfeed**

**very well**

  **My baby was not with me**

  **I think it's better for my baby to**

**be bottle-fed**

  **I was taking medicine**

  **I felt it was the right time to stop**

  **Other ---\> Please tell us:**

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**40. In the *week after* you went home**  **No ---\> Go to Question
42**

**from the hospital, did you see**  **Yes**

**a doctor or nurse for yourself?**

**41. Why did you see a doctor or nurse?**  **Vaginal bleeding**

***Check all that apply.***  **Fever or infection**

  **Other ---\> Please tell us:**

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**42. Is your baby alive now?**

 **No ---\> When did your baby die? \_\_\_\_ / \_\_\_\_ / \_\_\_\_**

**month day year**

 **Yes ---\> Is your baby living**  **No**

**with you now?**  **Yes**

**If your baby is not alive or is not living with you now, Skip to
Question 48 on Page 10.**

**43. Before you took your new baby home**  **No**

**from the hospital, did you know where**  **Yes**

**you would take your baby if he or she**

**got sick?**

**44. Have you ever had a problem paying**  **My baby has not been
sick**

**for medical care when your baby was**  **No**

**sick?**  **Yes**

**45. How many times has your baby been \_\_\_\_ Times**

**to a doctor or nurse for baby**

**shots or *routine* well baby care?**  **None**

**46. a. Has your baby gone as many**  **No**

**times as you wanted for**  **Yes ---\> Go to Question 47**

***routine* well baby care?**

**b. Did any of these things keep**  **I didn't have enough money or**

**your baby from having *routine* insurance to pay for it**

**well baby care?**  **I couldn't get an appointment**

***Check all that apply.***  **I had no way to get the baby to**

**the clinic or office**

  **I didn't have anyone to take**

**care of my other children**

  **Other ---\> Please tell us:**

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**47. When your baby goes for baby shots**  **Hospital clinic**

**or other *routine* well baby care,**  **Private doctor\'s office or
HMO**

**where do you take him or her**  **My baby has not had a visit for**

**most of the time? shots or routine care**

***Check all that apply.***  **Other---\> Please tell us:**

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**The next questions are about your family and the place where you
live.**

**48. Which rooms are in the house,**  **Bedrooms ---\> how many?
\_\_\_\_**

**trailer, or apartment where you**  **Living room**

**live?**  **Separate dining room**

***Check all that you have.***  **Kitchen**

  **Bathroom(s)**

  **Recreation room, den, or family room**

  **Finished basement**

**49. a. How many babies, children, or \_\_\_\_ Person(s)**

**teens who are 17 years or**

**younger live with you?**  **None**

***Count your new baby.***

***Don\'t count yourself.***

**b. How many people who are 18 \_\_\_\_ Person(s)**

**years or older live with you?**

***Don\'t count yourself.***  **None**

**50. What were the sources of your**  **Wages or pay from a job**

**family income during the past**  **Aid such as AFDC, Welfare,
Public**

**12 months? Assistance, General Assistance,**

***Check all that apply.* Food Stamps, or SSI**

  **Unemployment benefits**

  **Child support or alimony**

  **Fees, rental income, commissions,**

**interest, dividends, or income from**

**business or farm**

  **Social Security, Workers\' Compensation,**

**Veterans benefits, or pensions**

  **Other ---\> Please tell us:**

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**51. What is today\'s date? \_\_\_\_ / \_\_\_\_ / \_\_\_\_**

**month day year**

**52. When were *you* born? \_\_\_\_ / \_\_\_\_ / \_\_\_\_**

**month day year**

**53. What was your due date? \_\_\_\_ / \_\_\_\_ / \_\_\_\_**

**month day year**

  **I don\'t know**

**54. When was your baby born? \_\_\_\_ / \_\_\_\_ / \_\_\_\_**

**month day year**

**Please use this space for any additional comments you would like to
make about the health of**

**mothers and babies in \_\_\_\_\_\_\_\_\_\_\_\_.**

***Thanks for answering our questions!***

***Your answers will help us work to make mothers and babies
healthier.***