**PRAMS**

**Phase Four Questionnaire**

**Topic Reference**

**TABLE OF CONTENTS**

ABOUT THIS DOCUMENT [6]{.underline}

1\. ABUSE [7]{.underline}

A. PHYSICAL [7]{.underline}

B. EMOTIONAL [9]{.underline}

2\. ASSISTED REPRODUCTION [12]{.underline}

3\. BREASTFEEDING [13]{.underline}

4\. CONTRACEPTION [17]{.underline}

A. PRE-CONCEPTION [17]{.underline}

B. CONCEPTION [18]{.underline}

C. POSTPARTUM [19]{.underline}

5\. DELIVERY [23]{.underline}

A. METHOD [23]{.underline}

6\. DOUCHING [24]{.underline}

7\. DRUG USE [25]{.underline}

A. ALCOHOL [25]{.underline}

B. TOBACCO [26]{.underline}

a\. Tobacco Use [26]{.underline}

b\. Smoking Cessation [28]{.underline}

C. OTHER [31]{.underline}

8\. HEALTH INSURANCE [33]{.underline}

A. MATERNAL [33]{.underline}

B. INFANT [36]{.underline}

a\. General [36]{.underline}

b\. Child Health Insurance Program [37]{.underline}

9\. HIV AND SEXUALLY TRANSMITTED DISEASES [38]{.underline}

A. HIV [38]{.underline}

B. SEXUALLY TRANSMITTED DISEASES [39]{.underline}

10\. MATERNAL HEALTH CARE [41]{.underline}

A. MEDICATIONS [41]{.underline}

B. VACCINATIONS [41]{.underline}

a\. Vaccinations [41]{.underline}

b\. Barriers [42]{.underline}

C. POSTPARTUM CHECKUP [42]{.underline}

D. EPILEPSY OR SEIZURE TREATMENT [43]{.underline}

E. DISCRIMINATION [44]{.underline}

11\. HOUSEHOLD CHARACTERISTICS [46]{.underline}

A. RESIDENTS [46]{.underline}

B. NUMBER OF ROOMS [47]{.underline}

C. TELEPHONE COVERAGE [47]{.underline}

D. MOBILITY [47]{.underline}

12\. INCOME [49]{.underline}

13\. INFANT HEALTH CARE [58]{.underline}

A. WELL BABY CARE [58]{.underline}

B. VACCINATIONS [60]{.underline}

C. SICK BABY CARE [61]{.underline}

D. CIRCUMCISION [62]{.underline}

E. SCREENING [63]{.underline}

14\. INFANT MORTALITY [65]{.underline}

15\. INJURY PREVENTION [66]{.underline}

16\. PREGNANCY RECOGNITION [70]{.underline}

17\. LENGTH OF STAY [71]{.underline}

A. INFANT [71]{.underline}

B. MATERNAL [71]{.underline}

18\. MENTAL HEALTH [72]{.underline}

19\. MORBIDITY [74]{.underline}

A. INFANT [74]{.underline}

a\. Gestational Age [74]{.underline}

b\. ICU Admission [74]{.underline}

B. MATERNAL [74]{.underline}

a\. Preconceptional [74]{.underline}

b\. Prenatal and Intrapartum [75]{.underline}

c\. Postpartum [76]{.underline}

d\. General [77]{.underline}

20\. ORAL HEALTH [79]{.underline}

21\. PARENT AND INFANT CHARACTERISTICS [81]{.underline}

A. INFANT DEMOGRAPHICS [81]{.underline}

B. MATERNAL DEMOGRAPHICS [81]{.underline}

C. PATERNAL DEMOGRAPHICS [81]{.underline}

D. PARENTAL RELATIONSHIP [81]{.underline}

22\. PHYSICAL ACTIVITY AND WORK [83]{.underline}

23\. PRE-CONCEPTION READINESS [86]{.underline}

24\. PREGNANCY INTENTION [87]{.underline}

A. MATERNAL [87]{.underline}

B. PATERNAL [88]{.underline}

25\. PRENATAL CARE [91]{.underline}

A. BARRIERS [91]{.underline}

B. CONTENT [91]{.underline}

C. LOCATION [97]{.underline}

D. SATISFACTION [99]{.underline}

E. INITIATION [100]{.underline}

26\. INCENTIVE [101]{.underline}

27\. QUESTIONNAIRE DETAILS [101]{.underline}

28\. REPRODUCTIVE HISTORY [102]{.underline}

A. AGE AT MENARCHE AND CONCEPTION OF FIRST BIRTH [102]{.underline}

B. PREVIOUS PREGNANCY OUTCOME [102]{.underline}

29\. CHILD CARE [104]{.underline}

30\. SMOKE EXPOSURE [106]{.underline}

A. INFANT [106]{.underline}

B. MATERNAL [107]{.underline}

31\. SLEEPING BEHAVIORS [109]{.underline}

32\. SOCIAL SERVICES [110]{.underline}

A. WIC [110]{.underline}

B. OTHER PREGNANCY AND INFANT SERVICES [111]{.underline}

C. GOVERNMENT ASSISTANCE [114]{.underline}

33\. STRESS [116]{.underline}

34\. SOCIAL SUPPORT [117]{.underline}

35\. NUTRITION [121]{.underline}

A. MATERNAL WEIGHT [121]{.underline}

B. VITAMIN USE AND FOLIC ACID [121]{.underline}

C. FOOD INSUFFICIENCY [123]{.underline}

**ABOUT THIS DOCUMENT**

This document includes all core, standard, and state-developed questions
available for the Pregnancy Risk Assessment Monitoring System (PRAMS)
Phase Four questionnaire organized by topic. Many questions are related
to more than one topic. The question is included under the one topic
that best captures the question=s intent and content. Cross-references
are included to related topics and questions.

Within each topic or sub-topic, questions are organized into three
categories: Core, Standard, and State-Developed. Core questions are
listed sequentially within a topic, with the question number from the
basic core questionnaire (without inserted standard questions) cited.
Likewise, standard questions are listed sequentially within a topic,
with the number of the standard question cited, the states using the
question listed, the number of the standard question as it appears in
the state=s questionnaire cited, and any modifications made to the
question by a particular state listed. State-developed questions are
organized alphabetically by state within a topic, with the state and
question number both cited. In the case where there are no questions
pertaining to a topic within one of the three categories (core,
standard, and state-developed), that category is omitted. All questions
are shown in English and are in the form used in the self-administered
questionnaires. Interviewer-administered versions and Spanish
translations are also available.

**1. ABUSE**

**A. PHYSICAL**

**Core**

**32** During the 12 months before you got pregnant, did your husband or
partner push, hit, slap, kick, choke, or physically hurt you in any
other way?

>  No
>
>  Yes

**33** During the 12 months before you got pregnant, did anyone else
physically hurt you in any way?

>  No
>
>  Yes

**34** During your most recent pregnancy, did your husband or partner
physically hurt you in any way?

>  No
>
>  Yes

**35** During your most recent pregnancy, did anyone else physically
hurt you in any way?

>  No
>
>  Yes

**Standard**

**Z1d** This question is about things that may have happened during your
most recent pregnancy. For each thing, circle Y (Yes) if it happened to
you or circle N (No) if it did not.

During your most recent pregnancyB

**No Yes**

d\. Your husband or partner forced you to take part in any sexual

activity when you did not want to (including touch that made

> you feel uncomfortable N Y

**Used by: CO73(2002+) MN82**

**Z2a-b** This question is about things that may have happened since
your most recent delivery. For each thing, circle Y (Yes) if it happened
to you or circle N (No) if it did not.

Since your most recent deliveryB

**No Yes**

a\. Your husband or partner pushed, hit, slapped, kicked, choked or

> physically hurt you in any other way N Y
>
> b\. Someone else physically hurt you in any way N Y

**Used by:** *See State-Developed NC77(2000-01)/NC79(2002+), SC72a-b,
WA72a*

**Z2f** This question is about things that may have happened since your
most recent delivery. For each thing, circle Y (Yes) if it happened to
you or circle N (No) if it did not.

Since your most recent deliveryB

**No Yes**

f\. Your husband or partner forced you to take part in any sexual

activity when you did not want to (including touch that made

> you feel uncomfortable N Y

**State-Developed**

**MI73g-i** This question is about things that may have happened during
the 12 months before your new baby was born. For each item, circle Y
(Yes) if it happened to you or N (No) if it didn\'t. It may help to use
the calendar.

> **No Yes**
>
> g\. You sought medical care for an injury caused by someone pushing,
>
> hitting, slapping, kicking, choking, or otherwise hurting you N Y
>
> h\. You were forced to do sexual things that you did not want to do N
> Y
>
> i\. You were forced to have sex with someone who refused to practice
>
> safe sex with you N Y

**NC77(2000-01)/**

**NC79(2002+)**

> a\. Since your delivery, did your husband push, hit, slap, kick,
> choke, or physically hurt you in any other way?
>
>  No
>
>  Yes
>
> b\. Since your delivery, did anyone else push, hit, slap, kick, choke,
> or physically hurt you in any other way?
>
>  No
>
>  Yes

**SC72a-b**

> a\. Since you had your new baby, did your husband or partner
> physically hurt you in any way?
>
>  No
>
>  Yes
>
> b\. Since you had your new baby, did anyone else physically hurt you
> in any way?
>
>  No
>
>  Yes

**WA72** a. After your baby was born, did your husband push, hit, slap,
kick, choke, or physically hurt you in any other way?

>  No
>
>  Yes

**Related Topics**

Prenatal Care, Content: Core 20k, Standard R5, State-developed
NC69-71(2000-01)/NC74-76(2002+)

Social Support: UT80-81

**B. EMOTIONAL**

**Standard**

**Z1a-c** This question is about things that may have happened during
your most recent pregnancy. For each thing, circle Y (Yes) if it
happened to you or circle N (No) if it did not.

During your most recent pregnancyB

**No Yes**

a\. Your husband or partner threatened you or made you feel

> unsafe in some way N Y

b\. You were frightened for the safety of yourself or your family

> because of the anger or threats of your husband or partner N Y

c\. Your husband or partner tried to control your daily activities,

for example, controlling who you could talk to or where you

> could go N Y

**Used by: CO73(2002+) MN82**

**Z2c-e** This question is about things that may have happened since
your most recent delivery. For each thing, circle Y (Yes) if it happened
to you or circle N (No) if it did not.

Since your most recent deliveryB

**No Yes**

c\. Your husband or partner threatened you or made you feel

> unsafe in some way N Y

d\. You were frightened for the safety of yourself or your family

> because of the anger or threats of your husband or partner N Y

e\. Your husband or partner tried to control your daily activities,

for example, controlling who you could talk to or where you

> could go N Y

**State-Developed**

**AK77** During any of the following time periods, did your husband or
partner threaten you, limit your activities against your will, or make
you feel unsafe in any other way? For each time period, circle Y (Yes)
if it has happened to you or N (No) if it has not.

**No Yes**

a\. During the 12 months before you got pregnant N Y

b\. During your most recent pregnancy N Y

c\. Since your new baby was born N Y

**MI73d-f** This question is about things that may have happened during
the 12 months before your new baby was born. For each item, circle Y
(Yes) if it happened to you or N (No) if it didn\'t. It may help to use
the calendar.

> **No Yes**
>
> d\. You felt afraid of your partner or someone living in your home N Y
>
> e\. You felt controlled or isolated by your partner or someone
>
> living in your home N Y
>
> f\. You were repeatedly called names, told you were worthless,

ugly, or verbally threatened by your partner or someone

> important to you N Y

**NC76(2000-01)/**

**NC78(2002+)**

> How often in the past year have the following things happened to you?
> Please circle the number of times.

**Number of times**

> a\. My partner insulted or swore at me. 0 1 2 3-5 6-10 11 or more
>
> b\. My partner destroyed something belonging to me. 0 1 2 3-5 6-10 11
> or more
>
> c\. My partner used threats to make me have sex when
>
> I didn=t want to. 0 1 2 3-5 6-10 11 or more
>
> d\. My partner threatened to hit or throw something

at me. 0 1 2 3-5 6-10 11 or more

**RI79/**

**WA72 b**

> After your baby was born, did your husband or partner limit your
> activities, threaten you, or make you feel unsafe in any other way?
>
>  No
>
>  Yes

**Modifications:**

**RI79** Replaces AAfter your baby was born@ with ASince your delivery@

**2. ASSISTED REPRODUCTION**

**Standard**

**A1** Did you take any fertility drugs to help you get pregnant with
your new baby? (Fertility drugs include Clomid, Serophene, Pergonal or
any other drugs which you may have taken to help you get pregnant.)

>  No
>
>  Yes

**Used by: AL15(2000-01) IL14 MD16 ME14 NE14 OK14 RI14 UT14**

**A2** Did you use any medical procedures (assisted reproductive
technology) to help you get pregnant with your new baby? (Assisted
reproductive technology procedures include in vitro fertilization, IVF,
GIFT, ZIFT, embryo transfer and donor oocytes.)

>  No
>
>  Yes

**Used by: AL16(2000-01) IL15 MD17 ME15 NE15 OK15**

**Modifications:**

**IL15** oocytes and eggs

**A3** How many months had you been trying to get pregnant?

>  0-3 months
>
>  4-6 months
>
>  7-12 months
>
>  13-24 months
>
>  \>24 months

**3. BREASTFEEDING**

**Core**

**45** Did you ever breastfeed or pump breast milk to feed your new baby
after delivery?

>  No Next topic or standard B1
>
>  Yes

**46** Are you still breastfeeding or feeding pumped milk to your new
baby?

>  No  Q47 or standard B2
>
>  Yes  Q48

**47** How many weeks or months did you breastfeed or pump milk to feed
your new baby?

Weeks OR Months

>  Less than 1 week

**48** How old was your baby the first time you fed him or her anything
besides breast milk? Include formula, baby food, juice, cow=s milk,
water, sugar water, or anything else you fed your baby.

Weeks OR Months

>  My baby was less than one week old
>
>  I have not fed my baby anything besides breast milk

**Standard**

**B1** What were your reasons for not breastfeeding your new baby? Check
all that apply.

>  I had other children to take care of
>
>  I had too many household duties
>
>  I did not like breastfeeding
>
>  I did not want to be tied down
>
>  I was embarrassed to breastfeed
>
>  I went back to work or school
>
>  My husband or partner did not want me to breastfeed
>
>  I wanted my body back to myself
>
>  Other  Please tell us:

**Used by: AR51 CO49(2000-01) DE53 GA50 IL52(2000-01)/IL54(2002+) LA49
ME48 MI48 MN52 MT48 NJ48 NY55 NYC49 NC50(2002+) OH50 OK50 RI51 UT48
WV52**

**Modifications:**

**IL52(2000-01)/IL54(2002+) TX52**

Add the option:

 A doctor or other health professional told me that I could not or
should not breastfeed

**OK50**

Add the options:

 Unable to breastfeed with previous children

 Other family members (relatives) did not want me to breastfeed

Drop the options:

 I did not want to be tied down

 I wanted my body back to myself

**B2** What were your reasons for stopping breastfeeding? Check all that
apply.

>  My baby had difficulty nursing
>
>  Breast milk alone did not satisfy my baby
>
>  I thought my baby was not gaining enough weight
>
>  My baby became sick and could not breastfeed
>
>  My nipples were sore, cracked, or bleeding
>
>  I thought I was not producing enough milk
>
>  I had too many other household duties
>
>  I felt it was the right time to stop breastfeeding
>
>  I became sick and could not breastfeed
>
>  I went back to work or school
>
>  My husband or partner wanted me to stop breastfeeding
>
>  I wanted or needed someone else to feed the baby
>
>  Other  Please tell us:

**Used by: AR56 CO52(2000-01)/CO51(2002+) DE56 GA53
IL55(2000-01)/IL57(2002+) LA52 ME51 MI50 MN55 MT51 NY58 NYC52
NC53(2002+) ND49 OR48 TX55 UT51 WV55**

**Modifications:**

**IL55(2000-01)/IL57(2002+)**

Adds  A doctor or other health professional advised me to stop
breastfeeding.

>  I was taking medications.

**B3** This question asks about things that may have happened at the
hospital where your new baby was born. For each item, circle Y (Yes) if
it happened or circle N (No) if it did not happen.

**No Yes**

> a\. Hospital staff gave me information about breastfeeding N Y
>
> b\. My baby stayed in the same room with me at the hospital N Y
>
> c\. I breastfed my baby in the hospital N Y

d\. I breastfed my baby in the first hour after my baby was born N Y

> e\. Hospital staff helped me learn how to breastfeed N Y
>
> f\. My baby was fed only breast milk at the hospital N Y
>
> g\. Hospital staff told me to breastfeed whenever my baby wanted N Y
>
> h\. The hospital gave me a gift pack with formula N Y

i\. The hospital gave me a telephone number to call for help with

> breastfeeding N Y
>
> j\. My baby used a pacifier in the hospital N Y

**Used by: AL75(2000-01)/AL71(2002+) AR52 CO53(2002+) FL52
IL78(2000-01)/IL81(2002+) LA75 NE71 NYC54 ND70 OH76 OR50 TX57 WV57**

**Modifications:**

**NE71** Asks c,e,f only; f is modified AMy baby was only breastfed
while at the hospital@

**LA75** Asks only a-e.

**WV57** Omits options d and j.

**B4** During your most recent pregnancy, what did you think about
breastfeeding your new baby? Check one answer.

>  I knew I would breastfeed
>
>  I thought I might breastfeed
>
>  I knew I would not breastfeed
>
>  I didn=t know what to do about breastfeeding

**Used by: AR53 MI46 OH77**

**State-Developed**

**AL72(2002+)**

> When you went for WIC visits for your new baby, did you receive
> information on breastfeeding?

 No

 Yes

**AL77(2000-2001)**

> When you went for WIC visits for your new baby, did you receive
> information on breastfeeding?

 No

 Yes

**NM69(2000)/**

**NM67(2001)**

> At your workplace or school, what happens when a mother wants to
> breastfeed? Check all that apply.

 She can keep her baby and the baby can breastfeed as needed

 She can use break time to breastfeed the baby

 She can use break time to pump milk

 It is hard to use breaks or find a place to pump or breastfeed

 She is not allowed to breastfeed the baby at work

 I am not working or going to school

 I don=t know

**NM70(2002+)**

> At your workplace or school, what happens when a mother wants to
> breastfeed? Check all that apply.

 She can keep her baby and the baby can breastfeed as needed

 She can use break time to breastfeed the baby

 She can use break time to pump milk

 It is hard to use breaks or find a place to pump or breastfeed

 She is not allowed to breastfeed the baby at work

 I don=t know

**Related Topics**

Prenatal Care, Content: Core20

Pregnancy and Infant Services: NM63, NM64, WA66, WA70

**4. CONTRACEPTION**

**A. PRE-CONCEPTION**

**State-Developed**

**OR66** Before you got pregnant with your new baby, did you know there
was free or low cost birth control at health departments and Planned
Parenthood clinics?

>  No
>
>  Yes

**OR67** Before you got pregnant with your new baby, had you ever heard
or read about emergency birth control (the Amorning-after pill@)? This
special combination of regular birth control pills is used to prevent
pregnancy up to three days after unprotected sex.

>  No
>
>  Yes

**OR68** When you got pregnant with your new baby, what kinds of birth
control were you or your husband or partner using? Check all that apply.

>  Pill
>
>  Condoms
>
>  Foam, jelly, cream
>
>  Diaphragm
>
>  Norplant
>
>  Shots (Depo-Provera)
>
>  Shots (Lunelle)
>
>  Withdrawal
>
>  IUD (Intrauterine Device)
>
>  Natural Family Planning (Rhythm)
>
>  Other  Please tell us: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**OR69** When you got pregnant with your new baby, would you have used a
*different* birth control method if you had insurance that paid for it?

>  No
>
>  Yes

**OR70** When you got pregnant with your new baby, where were you or
your husband or partner getting your birth control method(s)? Check all
that apply.

>  A family planning clinic (for example, Planned Parenthood)
>
>  A health department clinic
>
>  A community health center
>
>  A private gynecologist
>
>  A general or family physician
>
>  A drug store or other store
>
>  Other  Please tell us: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
>  No place

**OR71** When you got pregnant with your new baby, would you have used a
birth control method if you had insurance that paid for it?

>  No
>
>  Yes

**SC67** During the 3 months before you got pregnant were you or your
husband/partner using any of the following birth control methods to keep
from getting pregnant? Check all that apply.

>  Tubes tied (sterilization)
>
>  Vasectomy (sterilization)
>
>  Pill
>
>  Condoms (rubbers)
>
>  Norplant (little tubes placed under the skin)
>
>  Shots (Depo-Provera)
>
>  Foam, jelly, cream or suppositories
>
>  Diaphragm, cap, or sponge
>
>  Rhythm method / natural family planning
>
>  I am not planning to have sex (abstinence)
>
>  Other  Please tell us: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
>  I was not using birth control

**B. CONCEPTION**

**Core**

**12** When you got pregnant with your new baby, were you or your
husband or partner doing anything to keep from getting pregnant? (Some
things people do to keep from getting pregnant include not having sex at
certain times (rhythm), and using birth control methods such as the
pill, Norplant, shots (Depo-Provera), condoms, diaphragm, foam, IUD,
having their tubes tied, or their partner having a vasectomy.)

>  No

 Yes

**13** What were you or your husband or partner=s 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 could not get pregnant at that time
>
>  I had side effects from the birth control method I was using
>
>  I had problems getting birth control when I needed it
>
>  I thought my partner or I was sterile (could not get pregnant at
> all)
>
>  My husband or partner did not want to use anything
>
>  Other  Please tell us:

**Standard**

**E3** When you got pregnant with your new baby, what were you or your
husband or partner doing to keep from getting pregnant? Check all that
apply.

>  Pill
>
>  Condoms
>
>  Foam, jelly, cream
>
>  Norplant7
>
>  Shots (Depo-Provera7)
>
>  Withdrawal
>
>  Tubes tied (sterilization)
>
>  Vasectomy (sterilization)
>
>  Other  Please tell us:

**Used by: MI14 MN16**

**C. POSTPARTUM**

**Core**

**56** Are you or your husband or partner doing anything now to keep
from getting pregnant? Some things people do to keep from getting
pregnant include having their tubes tied or their partner having a
vasectomy, using birth control methods like the pill, Norplant, shots
(Depo-Provera) condoms, diaphragm, foam, IUD, and not having sex at
certain times (rhythm).

>  No
>
>  Yes

**57** What are you or your husband or partner=s reasons for not doing
anything to keep from getting pregnant *now*? Check all that apply.

>  I am not having sex
>
>  I want to get pregnant
>
>  I don=t want to use birth control
>
>  My husband or partner doesn=t want to use anything

-   I don=t think I can get pregnant (sterile)

-   I can=t pay for birth control

-   I am pregnant now

-   Other  Please tell us:

**Standard**

**E1** What kind of birth control are you or your husband or partner
using now to keep from getting pregnant? Check all that apply.

>  Tubes tied (sterilization)
>
>  Vasectomy (sterilization)
>
>  Pill
>
>  Condoms
>
>  Foam, jelly, cream
>
>  Norplant7
>
>  Shots (Depo-Provera7)
>
>  Withdrawal
>
>  Other  Please tell us:

**Used by: AL64(2000-01)/AL61(2000+) AR77 CO68(2000-01)/CO65(2002+) DE69
FL65 LA66 MS59 MT67 NE63 NY71 NC63(2000-01)/NC64(2002+) OH66 OK63 RI64
SC61 VT64 WV71**

**Modifications:**

**OK63**

Adds:  IUD

>  Diaphragm
>
>  Rhythm method/natural family planning
>
>  I=m not having sex (abstinence)
>
>  Film, foam, jelly, cream

**OR79**

Rewords question: Drops Ato keep from getting pregnant.@

Adds:  Diaphragm

>  Shots (Lunelle)
>
>  IUD (Intrauterine Device)
>
>  Natural Family Planning (Rhythm)

**AR77**

Adds:  IUD

>  Natural family planning (rhythm)

**State-Developed**

**OR80** Where are you or your husband or partner getting your birth
control method(s) now? Check all that apply.

>  A family planning clinic (for example, Planned Parenthood)
>
>  A health department clinic
>
>  A community health center
>
>  A private gynecologist
>
>  A general or family physician
>
>  A drug store or other store
>
>  Other  Please tell us: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
>  No place

**Related Topics**

Prenatal Care, Content: Core 20e, Standard R5

Maternal Health Care, Postpartum: Standard E2, Q2 State-developed
NM66(2000)

**5. DELIVERY**

**A. METHOD**

**Standard**

**K1** Before you had your new baby, did you ever have a baby delivered
by cesarean section (when a doctor cuts through the mother=s belly to
bring out the baby)?

>  No
>
>  Yes

**K2** How did you expect your new baby to be delivered, vaginally
(naturally) or by cesarean section?

>  Vaginally
>
>  Cesarean section

**K3** How was your new baby delivered?

>  Vaginally
>
>  I went into labor, but had to have a cesarean section
>
>  I did not go into labor and had to have a cesarean section

**K4** How did the doctor, nurse or other health care worker who
provided your prenatal care suggest you deliver your new baby?

>  They suggested I deliver my baby vaginally (naturally)
>
>  They suggested I have a cesarean section
>
>  They did not suggest how I deliver my baby

**Related Topics**

Prenatal Care, Content: State-developed WV84

Health Insurance: Core 40

**6. DOUCHING**

**State-Developed**

**MS67** Did you douche at anytime during your most recent pregnancy?

>  No  Go to Question 69
>
>  Yes

**MS68** How often did you douche during your most recent pregnancy?

>  Daily
>
>  4-6 times a week
>
>  2-3 times a week
>
>  Once a week
>
>  2-3 times a month or less often

**NYC74**

About how often did you use vaginal douches in the [6 months
before]{.underline} your most recent pregnancy?

>  I didn=t use vaginal douches
>
>  Once a month or less
>
>  Several times a month
>
>  Once a week
>
>  Several times a week
>
>  Other  Please tell us:
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**7. DRUG USE**

**A. ALCOHOL**

**Core**

**28** 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

**29a** During the *3 months before* you got pregnant, how many
alcoholic drinks did you have in an average week?

>  I didn\'t drink then
>
>  Less than 1 drink a week
>
>  1 to 3 drinks a week
>
>  4 to 6 drinks a week
>
>  7 to 13 drinks a week
>
>  14 drinks or more a week
>
>  I don\'t know

**29b** During the *3 months before* you got pregnant, how many times
did you drink 5 or more alcoholic drinks in one sitting?

Times

>  I didn\'t drink then
>
>  I don=t know

**30a** During the last 3 months of your pregnancy, how many alcoholic
drinks did you have in an average week?

>  I didn\'t drink then
>
>  Less than 1 drink a week
>
>  1 to 3 drinks a week
>
>  4 to 6 drinks a week
>
>  7 to 13 drinks a week
>
>  14 drinks or more a week
>
>  I don\'t know

**30b** During the last 3 months of your pregnancy, how many times did
you drink 5 or more alcoholic drinks in one sitting?

Times

>  I didn\'t drink then
>
>  I don=t know

**State-Developed**

**AK79/**

**NE80** Since your baby was born, how many alcoholic drinks do you have
in an average week? (A drink is one glass of wine, one wine cooler, one
can or bottle of beer, one shot of liquor, or one mixed drink.)

>  I don=t drink
>
>  Less than 1 drink a week
>
>  1 to 3 drinks a week
>
>  4 to 6 drinks a week
>
>  7 to 13 drinks a week
>
>  14 or more drinks a week
>
>  I don=t know

**AK80** Since your new baby was born, how many times have you had 5 or
more alcoholic drinks at one sitting?

\_\_\_\_\_ Times

>  I don=t drink
>
>  I don=t know

**Related Topics**

Prenatal Care, Content: Core 20c, Standard R5a, State-developed ME73

Pregnancy and Infant Services: State-developed NM63, NM64, WA69, WA70

**B. TOBACCO**

**a. Tobacco Use**

**Core**

**24** Have you smoked at least 100 cigarettes in the past 2 years? (A
pack has 20 cigarettes)

>  No
>
>  Yes

**25** In the *3 months before* you got pregnant, how many cigarettes or
packs of cigarettes did you smoke on an average day? (A pack has 20
cigarettes)

\_\_\_\_\_\_ Cigarettes OR \_\_\_\_\_\_ Packs

>  Less than 1 cigarette a day
>
>  I didn\'t smoke
>
>  I don\'t know

**26** In the *last 3 months* of your pregnancy, how may cigarettes or
packs of cigarettes did you smoke on an average day?

\_\_\_\_\_\_\_ Cigarettes OR \_\_\_\_\_\_ Packs

>  Less than 1 cigarette a day
>
>  I didn\'t smoke
>
>  I don\'t know

**27** How many cigarettes or packs of cigarettes do you smoke on an
average day *now*?

\_\_\_\_\_\_\_ Cigarettes OR \_\_\_\_\_ Packs

>  Less than 1 cigarette a day
>
>  I don\'t smoke
>
>  I don\'t know

**State-Developed**

**AK78** During any of the following time periods, did you use smokeless
tobacco (chew or snuff)? For each time period, circle Y (Yes) if you
used then or N (No) if you did not use then.

**No Yes**

> a\. During the 12 months before you got pregnant N Y
>
> b\. During your most recent pregnancy N Y
>
> c\. Since your new baby was born N Y

**NJ68** In the *first 3 months* of your pregnancy, how many cigarettes
or packs of cigarettes did you smoke on an average day? (A pack has 20
cigarettes)

\_\_\_\_\_\_ Cigarettes OR \_\_\_\_\_\_ Packs

>  Less than 1 cigarette a day
>
>  I didn\'t smoke
>
>  I don\'t know

**NJ69** In the *second 3 months* of your pregnancy, how may cigarettes
or packs of cigarettes did you smoke on an average day?

\_\_\_\_\_\_\_ Cigarettes OR \_\_\_\_\_\_ Packs

>  Less than 1 cigarette a day
>
>  I didn\'t smoke
>
>  I don\'t know

**NJ70** Were you smoking when you found out for sure that you were
pregnant?

 No

 Yes

**b. Smoking Cessation**

**Standard**

**AA1** During any of your prenatal care visits, did a doctor, nurse, or
other health care worker advise you to stop smoking?

 No

 Yes

 I had quit smoking before my first prenatal care visit

**Used by: IL78(2002+) MN79 TX75**

**AA2** Listed below are some things about smoking. For each thing,
circle Y (Yes) if it applied to you during your most recent pregnancy or
circle N (No) if it did not.

During your most recent pregnancy, did youB

**No Yes**

> a\. Set a specific date to stop smoking N Y
>
> b\. Use a nicotine nasal spray or nicotine inhaler N Y

c\. Take a pill like Zyban (also known as Wellbutrin or

> Bupropion) to help you quit N Y
>
> d\. Use nicotine gum N Y
>
> e\. Use a nicotine patch N Y
>
> f\. Attend a class or program to stop smoking N Y
>
> g\. Use booklets, videos, or other materials to help you quit N Y
>
> h\. Go to counseling for help with quitting N Y

**Used by: HI66(2002+)**

**AA3** Listed below are some things about smoking that a doctor, nurse,
or other health care worker might have done during any of your prenatal
care visits. For each thing, circle Y (Yes) if it applied to you during
any of your prenatal care visits or circle N (No) if it did not.

During any of your prenatal care visits, did

a doctor, nurse, or other health care workerB

> **No Yes**
>
> a\. Spend time with you discussing how to quit N Y
>
> b\. Suggest that you set a specific date to stop smoking N Y
>
> c\. Prescribe a nicotine nasal spray or nicotine inhaler N Y

d\. Prescribe a pill like Zyban (also known as Wellbutrin or

> Buproprion) to help you quit N Y
>
> e\. Recommend using nicotine gum N Y
>
> f\. Recommend using a nicotine patch N Y
>
> g\. Suggest you attend a class or program to stop smoking N Y

h\. Provide you with booklets, videos, or other materials to

> help you quit smoking on your own N Y
>
> i\. Refer you to counseling for help with quitting N Y

**Used by: CO72(2002+) HI65(2002+)**

**State-Developed**

**AK81** Would you like to completely quit smoking cigarettes within the
next 6 months?

>  No
>
>  Yes

**AK82**/

**NJ74** Listed below are some reasons that discourage people from
quitting smoking. Please circle Y (Yes) if it is a reason for you or N
(No) if it is not a reason.

**No Yes**

a\. Cost of medicines, products, or classes to help you quit N Y

b\. Fear of gaining weight N Y

c\. Loss of a way to handle stress N Y

d\. Other people around me smoke N Y

e\. Craving for a cigarette N Y

> f\. Lack of support from others to quit N Y
>
> g\. Some other reason N Y

Please tell us:

**Modifications:**

**NJ74** splits option Aa@ above into two separate options:

a\. Cost of medicines or products to help you quit

b\. Cost of classes to help you quit

**AK83** If you were trying to quit smoking and cost were not an issue,
would you use any of the following programs, products, or medicine to
help you quit? For each thing, circle Y (Yes) if you would use it or N
(No) if you would not.

**No Yes**

> a\. Nicotine patch, gum, nasal spray, or inhaler N Y
>
> b\. Zyban, or other non-nicotine prescription medicine N Y
>
> c\. A quit smoking class or group N Y
>
> d\. Books, pamphlets, video, or audio tapes N Y
>
> e\. A telephone helpline to quit smoking N Y
>
> f\. Something else N Y

Please tell us: \_\_\_\_\_\_\_\_\_\_

**NJ65** At any time during your prenatal care, did a doctor, nurse, or
other health care worker discuss any of these things with you? For each
item, circle Y (Yes) if someone discussed it with you or N (No) if no
one discussed it with you.

**No Yes**

> a\. Ask if you were smoking cigarettes N Y
>
> b\. Suggest that you quit smoking N Y
>
> c\. Suggest a program or strategy for quitting N Y

**NJ71** At any time during your pregnancy did you stop smoking for one
day or longer because you were trying to quit?

>  No
>
>  Yes

**NJ72** At any time during your pregnancy did you attempt to cut back
the number of cigarettes you smoked during your pregnancy?

>  No
>
>  Yes

**NJ73** If you tried to quit or cut back the number of cigarettes you
were smoking, what method did you use? Check all that apply.

>  Medications such as nicotine patches, gum, nasal sprays, or inhalers
>
>  Self-help materials such as booklets or videos
>
>  A telephone hotline
>
>  An Internet web-site
>
>  Face-to-face counseling
>
>  Class or program
>
>  Other  Please tell us:
>
>  I just quit or cut back on my own

**NJ75** Did you use any of these New Jersey programs while you were
pregnant or since your new baby was born? Circle Y (Yes) if you used the
program or circle N (No) if you did not use it.

**No Yes**

a\. NJ Quitline, a toll-free telephone hotline to help people quit
smoking N Y

b\. NJ Quitnet, an Internet web-site to help people quit smoking N Y

c\. NJ Quitcenter, a counseling program to help people quit smoking N Y

**ND66** What did your doctor, nurse, or other health care worker tell
you about smoking during pregnancy? Check one answer.

>  Told me to quit
>
>  Told me to cut down
>
>  Didn=t talk to me about my smoking, even though I smoke
>
>  Didn=t talk to me about my smoking, because I don=t smoke
>
>  Other  Please tell us:

**OR76** During any of your prenatal care visits or after your most
recent delivery, did a doctor, nurse, or other health care worker ever
advise you to quit smoking?

 Yes, during my prenatal care visits

 Yes, after my delivery

 Yes, both times

 No

 No, I didn=t smoke at that time

**Related Topics**

Prenatal Care, Content: Core 20a, Standard R3

Pregnancy and Infant Services: Standard V1, State-developed NM63, NM64,
WA69, WA70

**C. OTHER**

**State-Developed**

**AK70** During any of the following time periods, did you smoke
marijuana or hash? For each time period, circle Y (Yes) if you smoked
then or N (No) if you did not smoke then.

**No Yes**

> a\. During the 12 months before you got pregnant N Y
>
> b\. During your most recent pregnancy N Y
>
> c\. Since your new baby was born N Y

**AK71** During any of the following time periods, did you use cocaine
or crack? For each time period, circle Y (Yes) if you used then or N
(No) if you did not use then.

**No Yes**

> a\. During the 12 months before you got pregnant N Y
>
> b\. During your most recent pregnancy N Y
>
> c\. Since your new baby was born N Y

**HI63(2000-01)/**

**HI67(2002+)**

> Did you use any of these drugs when you were pregnant? For each item,
> circle Y (Yes) if it is true or N(No) if it is not true.

**No Yes**

> a\. Prescription drugs (what kinds?) N Y

b\. Marijuana (pot, bud) or Hashish (hash) N Y

> c\. Amphetamines (uppers, ice, speed, crystal, crank) N Y

d\. Cocaine (rock, coke, crack) or Heroin (smack, horse) N Y

e\. Tranquilizers (downers, ludes) or Hallucinogens (LSD/acid,

PCP/angel dust, ecstasy) N Y

f\. Sniffing gasoline, glue, hairspray, or other aerosols N Y

**HI64(2000-01)/**

**HI68(2002+)**

> Did you use any of these drugs in the month before you got pregnant?
> For each item, circle Y (Yes) if it is true or N(No) if it is not
> true.
>
> **No Yes**
>
> a\. Prescription drugs (what kinds?) N Y

b\. Marijuana (pot, bud) or Hashish (hash) N Y

c\. Amphetamines (uppers, ice, speed, crystal, crank) N Y

d\. Cocaine (rock, coke, crack) or Heroin (smack, horse) N Y

e\. Tranquilizers (downers, ludes) or Hallucinogens (LSD/acid,

PCP/angel dust, ecstasy) N Y

f\. Sniffing gasoline, glue, hairspray, or other aerosols N Y

**Related Topics**

Prenatal Care, Content: Core 20g, Standard R5

Pregnancy and Infant Services: State-developed NM63, NM64, WA69, WA70

Stress: Core 31l

**8. HEALTH INSURANCE**

**A. MATERNAL**

**Core**

**1** *Just before* you got pregnant, did you have health insurance?
Don=t count Medicaid.

>  No

 Yes

**2** *Just before* you got pregnant, were you on Medicaid?

>  No
>
>  Yes

**19** How was your prenatal care paid for? Check all that apply.

>  Medicaid
>
>  Personal income (cash, check, or credit card)
>
>  Health insurance/HMO
>
>  State option
>
>  State option
>
>  Other  Please tell us:

**State options:**

City or County Indigent Fund (NM, TX)

Colorado Resident Discount Program

Dr. Dynasaur (VT)

Health Department or Parish Health Unit (LA)

I still owe (GA, NY, NYC, ME, WA)

Indian Health or Tribal Health (MT)

Indian Health Service (MN, MS, NM, ND, OR, UT)

Indian Health Service or Tribal clinic (NE)

Medipass (FL)

Medicaid or Quest (HI)

Medicaid Managed Care (Wellness Option, Share Advantage, Primary Care +)
(NE)

Military coverage (MS, ND)

Military coverage, TRICARE, or Veterans Affairs (AR, CO, DE, GA, ME, OH,
WA )

Military insurance or CHAMPUS (MT)

New Jersey FamilyCare (NJ)

PCAP (Prenatal Care Assistance Program) (NY, NYC)

RIte Care (RI)

State hospital (LA)

State Maternal and Child Health Program (WV)

Tricare or Military (TX)

**40** How was your delivery paid for? Check all that apply.

>  Medicaid
>
>  Personal income (cash, check or credit card)
>
>  Health insurance/HMO
>
>  State option
>
>  State option
>
>  Other  Please tell us:

**State options:**

City or County Indigent Fund (NM, TX)

Colorado Resident Discount Program

Dr. Dynasaur (VT)

Health Department or Parish Health Unit (LA)

I still owe (GA, ME, NY, NYC, WA)

Indian Health or Tribal Health (MT)

Indian Health Service (MN, MS, NM, ND, OR, UT)

Indian Health Service or Tribal Clinic (NE)

Medipass (FL)

Medicaid or Quest (HI)

Medicaid Managed Care (Wellness Option, Share Advantage, Primary Care +)
(NE)

Military coverage (MS, ND)

Military coverage, TRICARE, or Veterans Affairs (AR, CO, DE, GA, ME, OH,
WA )

Military insurance or CHAMPUS (MT)

New Jersey FamilyCare (NJ)

PCAP (Prenatal Care Assistance Program) (NY, NYC)

RIte Care (RI)

State hospital (LA)

State Maternal and Child Health Program (WV)

Tricare or Military (TX)

**State-Developed**

**FL70(2000-01)**

> Did you try to get Medicaid coverage during this pregnancy?
>
>  No  Go to Question 71
>
>  Yes

**FL70(2002+)**

> Did you try to get Medicaid coverage during your most recent
> pregnancy?
>
>  No  Go to Question 71
>
>  Yes

**FL71** Did you have any trouble getting Medicaid during your
pregnancy?

>  No
>
>  Yes

**NM67(2000)/**

**NM68(2001)**

> What is the name of your health insurance?
>
>  Cimarron
>
>  Lovelace
>
>  Presbyterian
>
>  Blue Cross/Blue Shield
>
>  Indian Health Service (PHS)
>
>  Military coverage
>
>  I don=t have health insurance
>
>  I don=t know
>
>  Other    Please tell us:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**NM64(2002+)**

> During prenatal care, what was the name of your health insurance?
>
>  Cimarron
>
>  Lovelace
>
>  Presbyterian
>
>  Blue Cross/Blue Shield
>
>  Indian Health Service (PHS)
>
>  Military coverage
>
>  I don=t have health insurance
>
>  I don=t know
>
>  Other    Please tell us:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**NE70** Which of these things happened during your pregnancy? Check all
that apply.

>  I had a hard time getting help from the Medicaid staff
>
>  I did not understand how to use my Medicaid card or what was covered
>
>  I did not get all of the Medicaid services I needed
>
>  I had problems finding a doctor who would accept me as a Medicaid
> patient
>
>  I was assigned to a doctor that I did not choose
>
>  I had problems with Medicaid=s transportation service
>
>  My doctor or nurse treated me differently from other patients
>
>  I did not have any problems with Medicaid

**OK73** Was your prenatal health care covered by any type of Medicaid
funded health plan? (This includes SoonerCare, SoonerChoice, SoonerPlus,
or any other Medicaid funded plan.)

>  No
>
>  Yes

**Related Topics**

Prenatal Care, Barriers: Core17

Prenatal Care, Location: NC71

**B. INFANT**

**a. General**

**Standard**

**H1** Do you have health insurance or Medicaid for your new baby?

>  No New topic
>
>  Yes

**Used by: AR62 CO64(2000-01)/CO61(2002+) DE65 HI56(2000-01)/HI57(2002+)
IL65(2000-01)/IL67(2002+) LA59 MI62 MT62 NY67 RI73
UT64(2000-01)/UT63(2002+)**

**H2** What type of insurance is your new baby covered by? Check all
that apply.

>  Medicaid (State Program Name)
>
>  Private insurance or HMO
>
>  State-specific
>
>  Other  Please tell us:

**State options:**

Child Health Insurance Program (CHIP) (CO, DE, IL, MT)

ARKids (AR)

Child Health Plus (NY)

Medicaid or QUEST (HI)

MICHILD (MI)

Indian Health Clinic or Tribal Health Clinic (MT)

RIte Care (RI)

**Used by: AR63 CO65(2000-01)/CO62(2002+) DE66
HI57(2000-2001)/HI58(2002+) IL66(2000-01)/IL68(2002+) LA60 MI63 MT63
NY68 RI74 UT65(2000-01)/UT64(2002+)**

**Modifications:**

**DE65** Doesn=t use filter question. Adds \>My new baby is not covered
by insurance= instead.

**RI74** Requests plan name: ARIte Care  Enter Plan Name:
\_\_\_\_\_\_\_\_\_\_\_\_\_ (United, Neighborhood, Blue Chip, etc.)@.
Doesn=t include instruction ACheck all that apply.@

**H5** When your new baby goes for well-baby checkups, who pays for
those visits? Check all that apply.

>  Medicaid
>
>  Personal income (cash, check, or credit card)
>
>  Health insurance or HMO
>
>  State-specific
>
>  State-specific

 Other  Please tell us:

**State options:**

Medicaid Managed Care (Medicaid Choice) (NYC)

Child Health Plus (NYC)

Indian Health Service (UT)

**Used by: ME61 MI61 NYC62 UT60(2000-01)**

**State-Developed**

**OK76a** *After* you delivered your new baby, did any of these things
happen? For each item, circle N (No) if it did not happen, Y (Yes) if it
did happen, or DK (Don=t Know) if you don=t know if it happened.

**N Y DK**

a\. Your new baby was covered by some type of health insurance N Y DK

**b. Child Health Insurance Program**

**Standard**

**H3** Is your new baby in the Child Health Insurance Program (CHIP)?

>  No
>
>  Yes

**Used by: FL61 IL67(2000-01)/IL69(2002+) MI64**

**H4** Why didn=t you enroll your new baby in CHIP? Check all that
apply.

>  I already had insurance
>
>  I didn=t think he/she was eligible
>
>  I didn=t know about the program
>
>  Other  Please tell us:

**Used by: FL62 IL68(2000-01)/IL70(2002+) MI65 MT64
UT66(2000-01)/UT65(2002+)**

**Related Topics**

Infant Health Care, Well Baby Care: Standard X2

Infant Health Care, Sick Baby Care: FL72

**9. HIV AND SEXUALLY TRANSMITTED DISEASES**

**A. HIV**

**Standard**

**I1.** At any time during your most recent pregnancy or delivery, did
you have a blood test for HIV (the virus that causes AIDS)?

 No

>  Yes  Next topic

 I don=t know

**Used by: AR24 DE25 FL21 GA21 IL25(2000-01)/IL26(2002+) NE25 NY22 NYC22
NC21(2000-01)/NC22(2002+) OH24 OK23 SC22 WV25**

**I2** Had you been tested for HIV before this pregnancy?

>  No Go to I4
>
>  Yes Go to I3

**Used by: DE23 GA22 WV26**

**I3** When were you tested before this pregnancy? Check one answer.

 6 months before you got pregnant

 6 months to 1 year before you got pregnant

 More than 1 year before you got pregnant

**Used by: DE24 GA23**

**I4** What were your reasons for not having an HIV test during your
most recent pregnancy? Check all that apply.

 I was not offered the test

 I did not think I was at risk for HIV

 I agreed to be tested but had difficulty getting the test done

 I was afraid of getting the result

 I had already been tested and did not think I needed to be tested
again

 Other  Please tell us:

**Used by: AR25 DE26 GA24 NY23 NYC23 NC23(2002+) OK24 SC23**

**State-Developed**

**OR75** During your most recent pregnancy, did you have a blood test
for HIV (the virus that causes AIDS?

 No

 Yes

 I don\'t know

**Related Topics**

Prenatal Care, Content: Core 20, Standard R5, AL74

Pre-conception Readiness: OK69d.

**B. SEXUALLY TRANSMITTED DISEASES**

**State-Developed**

**MS65** During your most recent pregnancy, did you have vaginal
infections (for example, yeast, bacterial vaginosis, and/or sexually
transmitted diseases \[STDs\])?

 No Go to Question 67

 Yes

**NC72(2000-01)**

> Did you have any vaginal infections (for example, yeast, vaginosis, or
> STDs) during your most recent pregnancy?

 No

 Yes

 I don=t know

**MS66/**

**NC73(2000-01)**

> What kind of vaginal infection did you have during your most recent
> pregnancy? Check all that apply.

 Yeast

 Vaginosis

 Chlamydia

 Gonorrhea

 Other vaginal infection

Please tell us:\_\_\_\_\_\_\_\_\_\_\_\_\_

 I don=t know

**Modifications:** MS66 question reads AWhich vaginal infections did you
have during your most recent pregnancy?@

**NC74(2000-01)**

> Did you ask a doctor, nurse, or other health care worker for advice or
> treatment for your vaginal infection?

 No

 Yes

**NYC75**

> During your most recent pregnancy, were you told by a doctor or other
> health care worker that you had a sexually transmitted disease (STD)
> or venereal disease (VD), a urinary tract infection (UTI), or any
> other vaginal infection? (Examples of STDs, VD, and vaginal infections
> are Trichomoniasis (Trich), Chlamydia, Pelvic Inflamatory Disease
> (PID), Gonorrhea, Bacterial Vaginosis, Group B Streptococcus (Strep or
> GBS), etc.)

 No  Go to Marital Status Question

 Yes

 I don=t know

**NYC76**

> What disease or infection were you told you had? Check all that apply.

 Trichomoniasis (Trich)

 Chlamydia

 Pelvic Inflamatory Disease (PID)

 Gonorrhea

 Bacterial Vaginosis

 Group B Streptococcus (Strep or GBS)

 Urinary Tract Infection (UTI)

 Other, please tell us: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**10. MATERNAL HEALTH CARE**

**A. MEDICATIONS**

**Standard**

**L1** Other than prenatal vitamins, did you take any over-the-counter
or prescribed medications during pregnancy, even for a short period of
time?

>  No
>
>  Yes

**Related Topics**

Breastfeeding: IL65

Prenatal Care, Content: Core20f.

Epilepsy Treatment: Standard L4 - L6

**B. VACCINATIONS**

**a. Vaccinations**

**Standard**

**L2** Have you ever had German measles (rubella) or been vaccinated for
German measles?

>  No
>
>  Yes

**Used by: MD36 MS69**

**L3** Have you ever had chickenpox (varicella) or been vaccinated for
chickenpox?

 No

 Yes

**Used by: MD37 MS70 ND69**

**L12** During your most recent pregnancy, did a doctor, nurse, or other
health care worker offer you a flu shot or tell you to get one?

 No

 Yes

**L13** Did you get a flu shot during your most recent pregnancy?

 No

 Yes

**Used by: RI23**

**L15** Have you ever had a flu shot when you were ***not*** pregnant?

 No

 Yes

**b. Barriers**

**Standard**

**L14** What were your reasons for not getting a flu shot during your
most recent pregnancy? Check all that apply.

>  My doctor did not mention anything about a flu shot during my
> pregnancy
>
>  My doctor recommended against getting a flu shot
>
>  I wanted to avoid medications during my pregnancy
>
>  I was worried about side effects of the flu shot for me
>
>  I was worried that the flu shot might harm my baby
>
>  I was worried about the cost of the flu shot
>
>  I forgot or missed getting a flu shot
>
>  I don=t like shots or needles
>
>  I did not think the flu shot would work
>
>  I did not think I needed it

 Other  Please tell us:

**Used by: RI24**

**Modifications:** RI24: Adds option AMy doctor did not have the
vaccine@; deletes options 6-10.

**C. POSTPARTUM CHECKUP**

**Standard**

**L8** Since your new baby was born, have you had a post-partum check-up
for yourself? (A post-partum check-up is the regular check-up a woman
has after she gives birth.)

 No

 Yes

**Used by: AR78 DE70 MN68 MT69 NYC67 RI65 SC62 TX69
UT70(2000-01)/UT69(2002+) WV72**

**L9** At that visit, did a doctor, nurse, or other health care worker
discuss family planning or birth control with you?

 No

 Yes

**Used by: DE71 SC63**

**E2** After your new baby was born, did a doctor, nurse, or other
health care worker with you about using birth control?

>  No
>
>  Yes

**Used by: AL61(2000-01)/AL58(2000+) CO69(2000-01)/CO66(2002+)
IL71(2000-01)/IL73(2002+) MD74 MT68 NY72 NYC66 ND61 OH67
UT69(2000-01)/UT68(2002+) VT65**

**State-Developed**

**NM66(2000)/**

**NM65(2001)/**

**NM67(2002+)**

> Since your delivery, did you see a doctor, nurse, midwife for yourself
> for any of these reasons? Check all that apply.

 I received a routine checkup (6 weeks postpartum, after delivery)

 I received care for a health problem

 I received a birth control method

 I did not see anyone

**OK76b-c**

> *After* you delivered your new baby, did any of these things happen?
> For each item, circle N (No) if it did not happen, Y (Yes) if it did
> happen, or DK (Don=t Know) if you don=t know if it happened.

**N Y DK**

> b\. You had a checkup for yourself within six weeks after you
> delivered your

new baby N Y DK

> c\. A doctor, nurse, or other health care worker talked with you about
> using

birth control within six weeks after you delivered your new baby N Y DK

**Related Topics**

Postpartum Morbidity: Standard 01-03

Length of Stay: Core37

Prenatal Care, Content: Core20e, WV84

Social Support: ME83

**D. EPILEPSY OR SEIZURE TREATMENT**

**Standard**

**L4** Have you ever taken medication(s) on a regular basis to control
seizures or epilepsy?

 No

 Yes

**L5** During your most recent pregnancy, did you take medication(s) on
a regular basis to control seizures or epilepsy?

 No

 Yes

**L6** When did you start taking the medicine?

 I started taking the medicine during my pregnancy

 I started taking the medicine in the year before I became pregnant

 I started taking the medicine more than a year before I became
pregnant

**L7** How many seizures, if any, did you experience during your most
recent pregnancy?

 None

 1

 2

 3 or more

**E. DISCRIMINATION**

**State-Developed**

**MI72** When you went to get health care during the 12 months before
your new baby was born, were you treated better than people of other
races, worse than people of other races, the same as people of other
races, or did you only get health care with other patients who were the
same race as you? Check one answer.

 Better than other races

 Worse than other races

 The same as other races

 Only got health care with other patients of the same race

 No health care in the past 12 months

 Don=t know/Not sure

**NM72(2002+)**

> During your pregnancy, you probably had to get different kinds of
> health-related services. These may have included clinic visits,
> doctor=s or nurse=s visits, applying for health insurance, applying
> for Medicaid, getting help for a family problem. Were you ever
> unfairly treated in getting such services because ofB

Check all that apply.

 Being female

 Your race

 Your age

 Your tribe

 Your culture

 Your citizenship

 Your height or weight

 Some other aspect of your physical appearance

 Other  Please tell us:

 I have not been treated unfairly

**Related topics**

Prenatal Care, Satisfaction: Standard R1

Stress: State-Developed MI73a-c

**11. HOUSEHOLD CHARACTERISTICS**

**A. RESIDENTS**

**Core**

**59** Counting yourself, how many people live in your house, apartment,
or trailer?

Adults (People 18 or older)

Babies, children, or teens (People age 17 or younger)

**Standard**

**P3** When you got pregnant, who lived in the same house with you?
Check all that apply.

 My husband or partner

 Children aged 5 years and under  How many?

 Children aged 6 years and over  How many?

 My mother

 My father

 My husband=s or partner=s parent(s)

 Friend or roommate

 Other relative

 Other  Please tell us:

 I lived alone

**P4** Who lives in the same house with you now? Check all that apply.

 My husband or partner

 Children aged 5 years and under  How many?

 Children aged 6 years and over  How many?

 My mother

 My father

 My husband=s or partner=s parent(s)

 Friend or roommate

 Other relative

 Other  Please tell us: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

 I live alone

**Used by: UT75(2000-01)/UT74(2002+)**

**P5** Do you have a husband or partner who lives with you *now*?

 No

 Yes

**Related topics**

Parent and Infant Characterisitcs, Parental Relationships: Standard P1

**B. NUMBER OF ROOMS**

**Core**

**58** Which rooms are in the house, apartment, or trailer where you
live? Check all that apply.

 Living room

 Separate dining room

 Kitchen

 Bathroom(s)

 Recreation room, den or family room

 Finished basement

 Bedrooms  How many?

**C. TELEPHONE COVERAGE**

**Standard**

**P9** Do you have a telephone in your home that has been working (in
service) for the past month?

>  No
>
>  Yes

**Used by: AK64 TX73**

**P10** Is your telephone number listed in the most recent telephone
book under your last name and current address?

>  Yes
>
>  Telephone unlisted
>
>  Telephone listed under another name or address

**D. MOBILITY**

**State-Developed**

**RI83** How many times have you moved in the last three years?

\_\_\_\_\_\_\_ Number of times

**RI84** During the next three years, do you plan on:

Check one answer.

>  Staying in your current home or apartment
>
>  Moving to a different home or apartment in the same neighborhood
>
>  Moving to a different neighborhood in the same city
>
>  Moving to a different city

**12. INCOME**

**Core**

**60** What were the sources of your household=s income during the past
12 months? Check all that apply.

 Paycheck or money from a job

>  Aid such as Temporary Assistance for Needy Families, welfare, public
> assistance, general assistance, Food Stamps or Supplemental Security
> Income

 Unemployment benefits

 Child support or alimony

 Social Security, Worker=s Compensation, veterans benefits, or pensions

 Money from a business, fees, dividends or rental income

 Money from family or friends

 Other  Please tell us:

**Standard**

**J1** How many people, including yourself, depended on this income?

People

**Used by: AK85 CO80 DE77 IL82(2000-01)/IL85(2002+) LA81 MD86 ME71 MI82
NE82 NM72(2001)/NM75(2002+) NYC80 OH72 OK80b OR64
UT78(2000-01)/UT77(2002+) VT69 WV81**

**Modifications:**

**NE82:** Adds \>depended on this income when you got pregnant with your
new baby?=

  People

**OK80b** Adds \>*when you got pregnant*=

**State-Developed**

**AK84**

> Please check your total household income for last year. Include all
> money your household received. Check one answer.

 \$10,000 or less

 \$10,001 to \$15,000

 \$15,001 to \$20,000

 \$20,001 to \$25,000

 \$25,001 to \$30,000

 \$30,001 to \$35,000

 \$35,001 to \$40,000

 \$40,001 to \$45,000

 \$45,001 to \$50,000

 \$50,001 to \$55,000

 \$55,001 to \$60,000

 More than \$60,000

**AR86(2000-2001)**

> What was the total income before taxes for the people living in your
> household *during the 12 months before* your delivery? Check the box
> that was closest to your household income. All information will be
> kept private. Your answer will not affect any services that you are
> now getting.

 Below \$8,000

 \$8,000 to \$13,000

 \$13,000 to \$18,000

 \$18,000 to \$23,000

>  \$23,000 to \$28,000
>
>  \$28,000 to \$38,000
>
>  \$38,000 to \$48,000

 Over \$48,000

**AR86(2002+)**

> What was the total income before taxes for the people living in your
> household *during the 12 months before* your delivery? Check the box
> that was closest to your household income. All information will be
> kept private. Your answer will not affect any services that you are
> now getting.

 Less than \$8,000

 \$8,000 to \$13,000

 \$13,001 to \$18,000

 \$18,001 to \$23,000

>  \$23,001 to \$28,000
>
>  \$28,001 to \$38,000
>
>  \$38,001 to \$48,000

 More than \$48,000

**CO79**

> What was your total household income, before deductions and taxes, for
> the *12 months before your delivery?* Include ANY income or money you
> could use (for example, job, TANF/Colorado Works, child support,
> etc.). Check the box that was closest to your total income for the 12
> months before your delivery.

 Under \$8000

 \$8,000-\$11,999

 \$12,000-\$15,999

 \$16,000-\$19,999

 \$20,000-\$24,999

 \$25,000-\$29,999

 \$30,000-\$39,999

 \$40,000 or more

**DE76**

> One important thing about getting good health care is your income.
> This information will help provide better services to all mothers and
> babies. Your answer will not affect any services you are now getting.
>
> What was the total income before taxes for the people living in your
> household during the 12 months before your delivery? Check the box
> that was closest to your income.
>
>  \$7,999 or less

 \$8,000 to \$9,999

 \$10,000 to \$11,999

 \$12,000 to \$13,999

 \$14,000 to \$15,999

 \$16,000 to \$17,999

 \$18,000 to \$19,999

 \$20,000 to\$24,999

 \$25,000 to \$29,999

 \$30,000 to \$34,999

>  \$35,000 to \$39,999

 \$40,000 to \$50,000

 \$50,000 or more

**FL76** What is your total *monthly* household income before taxes?
Include any income or money you could use (for example, your income from
a job, or your husband=s or partner=s income, child support,
unemployment, monthly support from friends or relatives, etc.) All
information you give us will be kept private.

 Less than \$650

 \$651B\$1,300

 \$1,301B\$2,100

 \$2,101B\$3,300

 \$3,301B\$4,200

 \$4,201 or more

**GA82**

> What was your total family income, *before taxes*, during the 12
> months before you delivered your most recent baby?

 Under \$8,000

 \$ 8,000-\$11,999

 \$12,000-\$15,999

 \$16,000-\$19,999

 \$20,000-\$24,999

 \$25,000-\$29,999

 \$30,000-\$39,999

 \$40,000 or more

**HI68(2000-01)/**

**HI76(2002+)**

> Please check your total family income for last year. Include all money
> your family received. Check one answer.

 Less than \$10,000

 \$10,001 to \$15,000

 \$15,001 to \$20,000

 \$20,001 to \$25,000

 \$25,001 to \$30,000

 \$30,001 to \$35,000

 \$35,001 to \$40,000

 \$40,001 to \$45,000

 \$45,001 to \$50,000

 More than \$50,000

**IL81(2000-01)/**

**IL84(2002+)**

> Which best describes your annual household income from all sources?

 Less than \$10,000

 \$10,000 to less than \$15,000

 \$15,000 to less than \$20,000

 \$20,000 to less than \$25,000

 \$25,000 to less than \$35,000

 \$35,000 to less than \$50,000

 \$50,000 or more

**LA80/**

**RI86** What was the total income before taxes for the people living in
your household during the 12 months before your delivery? Check the box
that was closest to your income.

 \$7,999 or less

 \$8,000 to \$9,999

 \$10,000 to \$11,999

 \$12,000 to \$13,999

 \$14,000 to \$15,999

 \$16,000 to \$17,999

>  \$18,000 to \$19,999
>
>  \$20,000 to \$24,999
>
>  \$25,000 to \$29,999
>
>  \$30,000 to \$34,999
>
>  \$35,000 to \$39,999
>
>  \$40,000 or more

**MD85/**

**ME85**

> In the twelve months before your delivery, what was your total
> household income? Include income from all sources, before taxes.

 Under \$8,000

 \$8,000 - \$11,999

 \$12,000 - \$15,999

 \$16,000 - \$19,999

 \$20,000 - \$24,999

 \$25,000 - \$29,999

 \$30,000 - \$39,999

 \$40,000 or more

**MI81** What was the total annual family income before taxes during the
12 months before your delivery? (Include your income and income of
others living with you.) Check the box that gives the best estimate.

 \$0 to \$5,000

 \$5,001 - \$10,000

 \$10,001 - \$15,000

 \$15,001 - \$20,000

 \$20,001 - \$25,000

 \$25,001 - \$30,000

 \$30,001 - \$35,000

 \$35,001 - \$40,000

 \$40,001 or more

**NE81** What was your family=s income, before deductions and taxes,
*when you got pregnant with your new baby?* Include ANY income or money
you could use (for example, job, AFDC, child support, etc.). Please give
us your best guess. All information will be kept private.

\$\_\_\_\_\_\_\_  Monthly  OR  \$\_\_\_\_\_\_  Yearly

**NC81(2000-01)/**

**NC82(2002+)**

> In the twelve months before your most recent delivery, what was your
> *total family income* before taxes? Include your income, your
> husband=s or partner=s income, and any other income that you may have
> had. Your answer will not affect your eligibility for any services you
> are now getting.

 \$7,999 or less

 \$8,000 to \$9,999

 \$10,000 to 11,999

 \$12,000 to 13,999

 \$14,000 to 15,999

 \$16,000 to \$17,999

 \$18,000 to \$19,999

 \$20,000 to \$24,999

 \$25,000 to \$29,999

 \$30,000 to \$39,999

 \$40,000 to \$49,999

 \$50,000 or more

**NM71(2000-2001)/**

**NM74(2002+)**

> During the 12 months before you delivered, what was your family=s
> income, before deductions and taxes? Include ANY income or money you
> could use. Please give us your best guess. All information will be
> kept private.

\$\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ every week

\$\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ every two weeks

\$\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ every month

**NYC79/**

**NY84(2000-01)/**

**NY85(2002+)**

In the 12 months before your most recent delivery, what was your total
family income before

> taxes? Including your income, your husband=s or partner=s income, and
> any other income you may have had. All information you give us will be
> kept private.

 Less than \$10,000

 \$10,000-\$14,999

 \$15,000-\$19,999

 \$20,000-\$24,999

 \$25,000-\$34,999

 \$35,000-\$49,999

 \$50,000-\$74,999

 \$75,000 or more

 Do not know/Not sure

 Refused

**OH71**

> Which category best describes your annual household income from all
> sources? Include your income and the income of others living with you.

 Less than \$10,000

 \$10,000 to less than \$15,000

 \$15,000 to less than \$20,000

 \$20,000 to less than \$25,000

 \$25,000 to less than \$35,000

 \$35,000 or more

**OK80**

> **a.** What was your family=s income, before deductions and taxes,
> when you got pregnant with your new baby? Include ANY income or money
> you could use. (For example, job, AFDC, child support, etc.) Please
> give us your best guess. All information will be kept private.
>
> \$\_\_\_\_\_\_\_\_  Monthly  OR  \$\_\_\_\_\_\_   Yearly

**OR63**

> Before you got pregnant with your new baby, what was your monthly
> family income (before deductions and taxes)? Include ANY income or
> money you can use. All information will be kept private.

 \$719 or below

 \$720-\$969

 \$970-\$1,219

 \$1,220-\$1,319

 \$1,320-\$1,789

 \$1,790-\$2,259

>  \$2,260-\$2,719
>
>  \$2,720-\$3,189
>
>  \$3,190-\$3,649
>
>  \$3,650-\$4,119
>
>  \$4,120 and above

**SC73** What was the total income before taxes for the people living in
your household during the 12 months before your delivery? Check the box
that was closest to your household income. All information will be kept
private. Your answer will not affect any services that you are now
getting.

 \$7,999 or less

 \$8,000 to \$9,999

 \$10,000 to \$11,999

 \$12,000 to \$13,999

 \$14,000 to \$15,999

 \$16,000 to \$17,999

>  \$18,000 to \$19,999
>
>  \$20,000 to \$24,999
>
>  \$25,000 to \$29,999
>
>  \$30,000 to \$34,999
>
>  \$35,000 to \$39,999
>
>  \$40,000 or more

**UT77(2000-01)/**

**UT76(2002+)**

> What was your total household income during the 12 months before you
> delivered your most recent baby?

 Less than \$10,000

 \$10,000 to less than \$15,000

 \$15,000 to less than \$20,000

 \$20,000 to less than \$25,000

 \$25,000 to less than \$35,000

 \$35,000 to less than \$50,000

 \$50,000 to less than \$75,000

 \$75,000 or more

**VT82** What is your annual household income from all sources and
before taxes?

 Less than \$12,000 (Less than \$1,000 monthly)

 \$12,000 - \$15,999 (\$1,000 - \$1,333 monthly)

 \$16,000 - \$19,999 (\$1,334 - \$1,666 monthly)

 \$20,000 - \$24,999 (\$1,667 - \$2,083 monthly)

 \$25,000 - \$29,999 (\$2,084 - \$2,499 monthly)

 \$30,000 - \$39,999 (\$2,500 - \$3,333 monthly)

 \$40,000 or more (\$3,334 or more monthly)

**WA65**

> When you found out that you were pregnant, what was your family\'s
> total monthly income before taxes? Please count wages, child support,
> unemployment or welfare checks, and money support from relatives or
> friends. Please check the best answer.

 Under \$500

 \$500 - \$999

 \$1,000 - \$1,199

 \$1,200 - \$1,399

 \$1,400 - \$1,699

 \$1,700 - \$2,099

 \$2,100 - \$2,599

 \$2,600 - \$2,999

 \> \$3,000

**WV80**

> Check which of the following categories best describes you annual
> household income from all sources. Please include yourself and
> everyone who lives with you.

 Less than \$17,000

 \$17,001-\$19,000

 \$19,001-\$25,500

 Over \$25,500

**13. INFANT HEALTH CARE**

**A. WELL BABY CARE**

**Core**

**51** Was your baby seen by a doctor, nurse or other health care
provider in the first week after he or she left the hospital?

>  No  **Go to Question 53**
>
>  Yes

**52** Was your baby seen at home or at a health care facility?

>  At home
>
>  At a doctor=s office, clinic, or other health care facility

**53** Has your baby had a well-baby checkup?

>  No  **Go to Question 56**
>
>  Yes

**54** How many times has your baby been to a doctor or nurse for a
well-baby checkup? It may help to use the calendar.

Times

**55** Where do you usually take your baby for well-baby checkups? Check
one answer.

>  Hospital clinic
>
>  Health department clinic
>
>  Private doctor\'s office or HMO clinic

 State specific option

 State specific option

 Other  Please tell us :

**State Options:**

Community health center (CO, FL, GA, IL, HI, NE, NY, NYC, OH, UT, VT)

HMO or PPO (GA)

Indian Health Service (NM)

Indian Health Service or Tribal clinic (NE)

Military facility (DE, HI, OH, WA)

Rural or migrant health clinic (FL)

Child Health Clinic (NYC)

Community clinic (NM)

Primary care clinic or community health center (LA)

Rural health center (VT)

Community or migrant health center (WA)

HMO (e.g., Prime One or CareLink) (WV)

**Standard**

**X1** Has your baby gone as many times as you wanted for a well-baby
checkup?

 No

 Yes

**Used by: AR67 NE76 OH62 RI75 UT61(2000-01)/UT60(2002+)**

**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 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 routine care

 Other  Please tell us:

**Used by: AR68 FL60 MN65 MT61 NE77 OH63 RI76 TX65
UT62(2000-01)/UT61(2002+)**

**Modifications:**

**RI76/**

**NE77:** modified the response options:

 I didn=t have enough money or my insurance did not cover it

 I couldn=t get to the doctor=s office or clinic during their office
hours

 The doctor=s office or clinic was too far away

 No one at the doctor=s office or clinic spoke my language

 The attitude of the doctor, nurse or the office staff

 I couldn=t take off from work or school

 I didn=t have anyone to take care of my other children

 Other  Please tell us:

**State-Developed**

**AL79(2000-01)/**

**AL74(2002+)**

> How old was your baby when he or she went for his or her first routine
> well baby care visit?

\_\_\_\_\_ Weeks old

 Less than 1 week

 My baby has never had a routine well baby care visit

**OR78**

> After your new baby was born, did a doctor, nurse, or other health
> care worker talk with you about how to prevent your baby from getting
> tooth decay?

 No

 Yes

**Related Topics**

Health Insurance, Infant: Standard H5

**B. VACCINATIONS**

**Standard**

**X3** Did your baby have any well baby shots or vaccinations before he
or she was 3 months old? (Don=t count shots or vaccinations given in the
hospital right after birth.)

>  No
>
>  Yes
>
>  My child has not had any well baby shots but he or she is not 3
> months old yet

**Used by: AR69 IL64(2000-01)/IL66(2002+) NM57(2002+) TX66
UT63(2000-01)/UT62(2002+)**

**Related Topics**

Prenatal Care, Content: State-developed; WV84

**X5** What do you think would be the best time to get information from
your doctor or nurse about baby shots? Please check one.

>  During prenatal care visits
>
>  In the hospital or birthing center, after my new baby=s delivery
>
>  At my new baby=s first visit to the doctor

**C. SICK BABY CARE**

**Standard**

**T1** How many times has your new baby gone for care when he or she was
sick?

\_\_\_\_\_\_\_ Times

 None  Next topic

 My baby has not been sick  Next topic

**Used by: AR70 CO61(2000-01) ME62 WV66**

**T2** Where have you taken your new baby when he or she was sick and
needed care?

>  Hospital clinic
>
>  Health department clinic
>
>  Hospital emergency room
>
>  Private doctor=s office
>
>  State-specific
>
>  State-specific

 Other  Please tell us:

**State Options:**

Community health clinic (CO)

> Rural Health Center (ME)

Family Practice Residency Program (ME)

HMO (e.g., Prime One or CareLink) (WV)

**Used by: AR71 CO62(2000-01) ME63 WV67**

**T3** Has your baby gone for care as many times as you wanted when he
or she was sick?

 No

 Yes

**Used by: AR72 CO63(2000-01) NYC63 WV68**

**Modifications:**

**NYC63:** Adds  My baby hasn=t been sick

**State-Developed**

**SC71** Do you have a doctor that you can get in contact with 24 hours
a day, 7 days a week, who will take care of your baby for both sick and
Awell baby@ care?

 No

>  Yes

**FL72** Was there a time when your new baby needed a doctor but you
could not afford it?

 No

 Yes

**D. CIRCUMCISION**

**Standard**

**D1** Is your new baby a boy or a girl?

 Boy

 Girl  Next topic

**Used by: AR73 MD65**

**D2** Did you have your new baby boy circumcised?

 No

 Yes

**Used by: AR74 MD66**

**E. SCREENING**

**State-Developed**

**HI70(2002+)**

> a\. When your new baby was born, was the baby=s hearing tested?

 I don=t know  **Go to Question 73**

 No  **Go to Question 73**

 Yes

b\. Did someone tell you what the test said about the new baby=s
hearing?

 I don=t remember  **Go to Question 73**

 No  **Go to Question 73**

 Yes

> c\. When someone told you what the test said about your new baby=s
> hearing, what did they tell you?
>
>  Your baby=s test showed no problems
>
>  Your baby should have another test

 Other  Please tell us:

**HI71(2002+)**

> After you were told about your new baby=s hearing test, you probably
> had many thoughts and feelings. Please read all the choices below and
> check the choices which are true about your thoughts and feelings at
> the time.
>
>  Not worried
>
>  A little worried
>
>  Very worried and upset
>
>  I wondered if I did something wrong or if it was my fault
>
>  I was too excited and busy with the new baby to pay much attention

 Other  Please tell us:

**HI72(2002+)**

Does your new baby have hearing loss or a hearing problem?

 No

 Yes

 I don=t know

**RI81** Are you aware that babies are tested in the hospital for the
following conditions? For each item, circle Y (Yes) if you are aware of
this or circle N (No) if you are not.

**No Yes**

> a\. Hearing loss N Y

b\. Conditions that run in families, such as sickle cell

> disease and PKU N Y

**14. INFANT MORTALITY**

**Core**

**42** Is your baby alive now?

 No

 Yes  Go to Q44

**43** When did your baby die?

Month Day Year

**15. INJURY PREVENTION**

**Standard**

**S1** Listed below are some things about safety. For each thing, circle
Y (Yes) if it applies to you or circle N (No) if it does not.

> **No Yes**
>
> a\. My infant was brought home from the hospital in an infant car seat
> N Y
>
> b\. My baby always or almost always rides in an infant car seat N Y
>
> c\. My home has a working smoke alarm N Y
>
> d\. There are **loaded** guns, rifles, or other firearms in my home N
> Y

**Used by: AL78(2000-01) GA81 IL76/(2000-01)/IL79(2002+) LA76 ME78 MN80
MT81 NY79(2000-01) NC79(2000-01) ND71 OH78 RI72 VT77** **WV82**

**Modifications:**

**IL 76(2000-01)/IL79(2002+):** Deletes option (d).

**NC79(2000-01):** added item e (There is a member of my household who
smokes inside my home)

**NY79(2000-01):** Deletes the word Aloaded@ from option (d).

**S2** Did you worry that wearing your seat belt during pregnancy would
hurt your baby?

 No

 Yes

**Used by: ND72**

**S3** Listed below are some statements about car seats. For each one,
circle T (True) if you agree with the statement or circle F (False) if
you do not agree.

> **True False**
>
> a\. New babies should be in rear-facing car seats T F
>
> b\. Car seats should not be placed in front of an air bag. T F

**Used by: ME79 VT78**

**S4** During the last three months of your most recent pregnancy, how
often did you wear a seatbelt when you drove or rode in a car? Check one
answer.

 Always

 Almost always

 Sometimes

 Rarely

 Never

**Used by: MD83 VT79**

**S5** Since you delivered your new baby, how often do you wear a
seatbelt when you drive or ride in a car? Check one answer.

 Always

 Almost always

 Sometimes

 Rarely

 Never

**Used by: ME80 MD84 VT80**

**State-Developed**

**AK69/**

**RI80** Have you ever heard or read about what can happen if a baby is
shaken?

 No

 Yes

**HI66(2000-01)/**

**HI73(2002+)**

> Listed below are some things that describe the care of your new baby.
>
> **Never Sometimes Always**
>
> a\. My new baby rides in an infant car seat N S A
>
> b\. My new baby rides in an infant car seat that faces
>
> the rear window of the car, truck, or van N S A
>
> c\. My new baby rides in an infant car seat in the back
>
> seat of the car, truck, or van N S A
>
> d\. My new baby sleeps on something soft, like a fluffy

blanket or comforter, soft pillow, featherbed,

> or sheepskin N S A
>
> e\. My new baby sleeps in the same bed with me N S A

**NE72** Listed below are some items that describe the care of your new
baby. For each item, circle A if it always applies to you, circle S if
it sometimes applies to you, or circle N if it never applies to you.

> **Always SometimesNever**
>
> a\. My new baby rides in an infant car seat A S N
>
> b\. My new baby takes a bottle to bed A S N
>
> c\. My new baby sleeps on something soft, like a fluffy
>
> blanket or comforter, soft pillow, featherbed, or sheepskin A S N

**ND73** Where did you get the car safety seat you are now using for
your baby. Check one answer.

 Purchased new for this baby

 Received new for this baby as a gift

 Had one from another of my babies

 Purchased used (at a rummage sale or thrift store)

 Received or purchased used from a family member or friend

 Given by hospital when baby was born

 Rented it from a car seat rental program

 We do not use a car safety seat

 Other  Please tell us:

**ND79** An educational program on Shaken Baby Syndrome Prevention is
being conducted in North Dakota. The message is to Never, Never, Shake a
Baby. Where have you heard or read this message? Check all that apply.

 Billboards along highways/roads

 On a poster

 In a brochure

 On the radio

 On a baby rattle

 On a milk carton

 On a videotape

 I have never seen or heard this message

 Other  Please tell us:

**RI82** In general, how much do you believe parents can prevent lead
poisoning in their children?

 Parents can completely prevent lead poisoning

-   Parents can somewhat prevent lead poisoning

 Parents cannot do much to prevent lead poisoning

 There is nothing parents can do to prevent lead poisoning

**SC70** Listed below are some statements about safety. For each item
circle A if it always applies to you, circle S if it sometimes applies
to you, or circle N if it never applies to you.

> **Always Sometimes Never**
>
> a\. My new baby rides in an infant car seat A S N
>
> b\. My new baby sleeps on a soft comforter, soft pillow,
>
> featherbed, or sheepskin A S N
>
> c\. If I leave my baby with another person, I instruct them to
>
> put my baby to sleep on his/her back A S N
>
> d\. I test my smoke alarm every 6 months to make sure
>
> the batteries are working A SN

**WA73** Listed below are some statements about safety. For each thing,
circle Y (Yes) if it applies to you, N (No) if it does not apply to you,
or DK (don=t know) if you are unsure.

> **No Yes Don\'t** **Know**
>
> a\. My home has a working smoke alarm that has been tested in
>
> the past year. N Y DK
>
> b\. The last time my baby rode in a car he or she was in a car
>
> safety seat. N Y DK

**Related Topics**

Prenatal Care, Content: Core 20d, NY78

Sleeping Behaviors: Core 50, Standard F1, State-developed AK71

Morbidity, Maternal: Core 22

**16. PREGNANCY RECOGNITION**

**Core**

**14** How many weeks or months pregnant were you when you were sure you
were pregnant? (For example, you had a pregnancy test or a doctor or
nurse said you were pregnant.)

Weeks OR Months

>  I don=t remember

**Related Topics**

Prenatal Care, Barriers: Core 17

**17. LENGTH OF STAY**

**A. INFANT**

**Core**

**39** After your baby was born, how long did he or she stay in the
hospital?

>  Less than 24 hours (Less than 1day)
>
>  24 - 48 hours (1-2 days)

 3 days

>  4 days
>
>  5 days
>
>  6 or more days
>
>  My baby was not born in a hospital
>
>  My baby did not stay overnight in the hospital

 My baby is still in the hospital

**Related Topics**

Infant Health Care, Well Baby Care: Core 51 52

Morbidity, Infant, ICU Admission: Core 38

**B. MATERNAL**

**Core**

**35** When did you go into the hospital to have your baby?

> Month Day Year

 I did not have my baby in a hospital

**37.** When were you discharged from the hospital after your baby was
born? It may help to use the calendar.

Month Day Year

 I did not have my baby in a hospital

**Related Topics**

Maternal Health Care, Postpartum: Q8

Morbidity, Maternal, Postpartum: Standard 01-03

**18. MENTAL HEALTH**

**Standard**

**M1** How would you describe the time during your 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

**Used by: AK37 DE40 MN39 NY42 NC38(2000-01)/NC37(2002+) RI38**

**M2** In the months after your delivery, would you say that you
were\...

Check one answer.

 Not depressed at all

 A little depressed

 Moderately depressed

 Very depressed

 Very depressed and had to get help

**Used by: AK67 CO67(2002+) DE72 LA67 MD75 ME66 MN69
NC64(2000-01)/NC65(2002+) NY73 RI66 TX70 UT71(2000-01)/UT70(2002+)
WA60**

**M3** At any time during your pregnancy or after delivery, did a
doctor, nurse, or other health care worker talk with you about Ababy
blues@ (postpartum depression)?

 No

 Yes

**Used by: AK66 MN70 MT70 UT72(2000-01)/UT71(2002+) WV73**

**State-Developed**

**AK68**

> Since you delivered your new baby, have either of the following things
> happened? For each thing, circle Y (Yes) if it has happened to you or
> N (No) if it has not.

**No Yes**

> a\. I wanted to see a professional about my depression. N Y
>
> b\. I went to see a professional about my depression. NY

**MI74** Have you ever been diagnosed with a mental illness by a health
professional?

>  No  Go to Question 77
>
>  Yes

**MI75** During your pregnancy, were you being treated for this illness?

>  No
>
>  Yes

**MI76** During your pregnancy, were you taking medications for this
illness?

>  No
>
>  Yes

**MI77** In the months after your delivery, would you say that for two
weeks or more you were:

 Not depressed at all  Go to Question 79

 A little depressed

 Moderately depressed

 Very depressed

**MI78** Since you delivered your new baby, have any of the following
things happened? For each thing, circle Y (Yes) if it has happened to
you or N (No) if it has not.

**No Yes**

> a\. I wanted to see a professional about my depression. N Y
>
> b\. I tried but was unable to see a professional about my depression.
> NY

c.  I received professional help for my depression. N Y

**Related Topics**

Prenatal Care, Content: State-developed NY78 WA66

Morbidity, Maternal: State-Developed RI85

**19. MORBIDITY**

**A. INFANT**

**a. Gestational Age**

**Core**

**34** When was your baby due?

Month Day Year

**36** When was your baby born?

Month Day Year

**b. ICU Admission**

**Core**

**38** After your baby was born, was he or she put in an intensive care
unit?

 No

 Yes

 I don\'t know

**Related Topics**

Infant Health Care, Sick Baby Care: Standard T1-T3

Length of Stay, Infant: Core 39

**B. MATERNAL**

**a. Preconceptional**

**Standard**

**L11** In the three months before you got pregnant, did you have any of
the following health problems?

> **No Yes**
>
> a\. Asthma N Y
>
> b\. High blood pressure (hypertension) N Y
>
> c\. High blood sugar (diabetes) N Y
>
> d\. Anemia (poor blood, low iron) N Y
>
> e\. Heart problems N Y

**Used by:** **MN8 TX7**

**Related Topics**

Pre-conception Readiness: State-developed OK67

**b. Prenatal and Intrapartum**

**Core**

**22** Did you have any of these problems during your pregnancy? For
each item, circle Y (yes) if you had the problem and N (No) if you did
not.

**No Yes**

> a\. Labor pains more than 3 weeks before your baby was due
>
> (preterm or early labor) N Y
>
> b\. High blood pressure (including pre-eclampsia or toxemia)
>
> or retained water (edema) N Y
>
> c\. Vaginal bleeding N Y
>
> d\. Problems with the placenta (such as abruptio placental,
>
> placenta previa) N Y
>
> e\. Severe nausea, vomiting or dehydration N Y
>
> f\. High blood sugar (diabetes) N Y
>
> g\. Kidney or bladder (urinary tract) infection N Y
>
> h\. Water broke more than 3 weeks before your baby was due
>
> (premature rupture of membranes, PROM) N Y
>
> i\. Cervix had to be sewn shut (incompetent cervix, cerclage) N Y
>
> j\. You were injured in a car accident N Y

**23** Did you do any of the following things because of these
problem(s)? Check all that apply.

 I went to the hospital or emergency room and stayed less than 1 day

 I went to the hospital and stayed 1-7 days

 I went to the hospital and stayed more than 7 days

 I stayed in bed at home more than 2 days because of my doctor or
nurse=s advice

**Standard**

**N1** At any time during your most recent pregnancy, were you told to
stay in bed for at least one week?

 No  Next topic

 Yes

**Used by: MD32 NY28 VT26**

**N2** How many weeks or months pregnant were you when you were told to
stay in bed?

> Weeks OR Months

**Used by: MD33 NY29**

**N3** How often were you able to follow your provider\'s instruction to
stay in bed?

 Always  Next topic

 Almost always  Next topic

 Sometimes

 Rarely

 Never

**Used by: MD34 NY30 VT27**

**N4** What types of support would have helped you to stay in bed for
the recommended time? Check all that apply.

 Help with child care

 Help with housework

 Knowing I would not lose my job

 Money to make up for not working

 Other  Please tell us:

**Used by: MD35 NY31 VT28**

**Related topics**

Delivery: Standard K3

HIV and Sexually Transmitted Disease: State-developed NC72 NC73 NYC80
NYC81

Physical Activity and Work: State-developed AL71 GA77

Pre-conception Readiness: State-developed OK69

Prenatal Care, Content: Core 20i, State-developed: NC68 OK77 WV84

**c. Postpartum**

**Standard**

**O1** Since you delivered your baby, have you had any medical problem
which caused you to go to the hospital and stay overnight?

>  No  Next topic
>
>  Yes

**Used by: NYC68 WV74**

**O2** When was the first time you had to go into the hospital and stay
overnight after you had your baby? \_\_\_\_\_ \_\_\_\_\_\_ \_\_\_\_\_\_

Month Day Year

**Used by: WV75**

**O3** What kind of medical problem caused you to go into the hospital?

 Vaginal bleeding

 Fever or infection

 Other  Please tell us:

**Used by: NYC 69 WV76**

**Related Topics**

Length of Stay, Maternal: Core 35 37

Maternal Health Care, Postpartum: Q8 Standard State-developed NM66(2000)
and NM65(2001)

**d. General**

**Standard**

**L10** Would you say that, in general, your health is:

 Excellent

 Very good

 Good

 Fair

 Poor

**Used by: MN7**

**State-Developed**

**RI85** Are you limited in any way in any activities because of
physical, mental, or emotional problems?

 No

 Yes

**Related Topics**

Mental Health: Standard M1, M2

**20. ORAL HEALTH**

**Standard**

**Y1** This question is about the care of your teeth during your most
recent pregnancy. For each thing, circle Y (Yes) if it is true or N (No)
if it is not true.

**No Yes**

> a\. I needed to see a dentist for a problem N Y
>
> b\. I went to a dentist or dental clinic N Y
>
> c\. A dental or other health care worker talked with me about how to
> care
>
> for my teeth and gums N Y

**Used by: AL72(2000-01)/AL68(2002+) AR85 CO77 HI67(2000-01)/HI75(2002+)
IL79(2000-01)/IL82(2002+) LA79 NE78 MD82 ME76 MT74
NM62(2000-01)/NM63(2002+) NY79(2002+) ND77 OR72 TX81 WA67**

**Modifications:**

**NMQ 62** The format is changed to Check all the apply, so an
additional option AI did not go for dental care@ is added.

**Y2** How long has it been since you had your teeth cleaned by a
dentist or dental hygienist?

\_\_\_\_\_\_\_\_ Months

**Used by: AL73(2000-01)/AL69(2002+) CO78 IL80(2000-01)/IL83(2002+) ME77
NE79 NY80(2002+) ND78 TX82 VT81 WA68**

**State-Developed**

**NYC77**

> This question is about the care of your teeth and gums during your
> most recent pregnancy. For each item, circle Y (Yes) if it is true or
> N (No) if it is not true.

During my most recent pregnancyY

> **No Yes**
>
> a\. I went to a dentist or dental clinic for routine care such as
> teeth cleaning
>
> or regular check-up N Y
>
> b\. I had been told that I have problems with my teeth or gums such as
>
> cavities, gingivitis, root canal, etc. N Y
>
> c\. I had problems with my teeth or gums, but I did not see a dentist
> N Y
>
> d\. I went to a dentist or dental clinic for a problem with my teeth
> or gums. N Y
>
> e\. I received treatment for a problem with my teeth or gums NY
>
> f\. A dental or other health care worker talked to me about how to
> care for
>
> my teeth and gums N Y

**OR73**

How long has it been since you had your teeth cleaned by a dentist or a
dental hygienist?

 Within the past year (less than 12 months)

 1 to less than 2 years (12-23 months)

 2 to less than 5 years (24-59 months)

 5 or more years (60 or more months)

 Never

**Related Topics**

Pre-conception Readiness: State-developed OK69

**21. PARENT AND INFANT CHARACTERISTICS**

**A. INFANT DEMOGRAPHICS**

**Core**

**44** Is your baby living with you now?

 No 

 Yes

**B. MATERNAL DEMOGRAPHICS**

**Core**

**4** What is *your* date of birth?

Month Day Year

**C. PATERNAL DEMOGRAPHICS**

**Standard**

**P6** When you got pregnant, how old was your new baby=s father?

Years Old

 I don=t know

**Used by: AR82 FL75 GA68 LA70 ME69 NE66 NY77 OK72**

**Modifications:**

**OK72 and FL75:** When you had your new baby, how old was the baby=s
father?

**D. PARENTAL RELATIONSHIP**

**Standard**

**P1** When you got pregnant, did your new baby=s father live with you?

 No

 Yes

**Used by: GA70**

**Modifications:**

**GA70:** Did your new baby=s father live with you *at any time* during
the past 12 months?

**P2** When you got pregnant, what relationship did you have with your
new baby=s father?

 He was my husband (legally married)

 He was my partner (not legally married)

 He was my boyfriend

 He was a friend

 Other  Please tell us:

**Used by: AR81 GA67**

**State-Developed**

**NYC78**

> What is your marital status?

 Married

 Living with a steady partner or common law marriage

 Divorced

 Separated

 Single, Never Married

 Other, please tell us:

**OK71**

> Were you married when you got pregnant?

 No

 Yes

**OK77**

Do you currently live with this baby=s father?

 No

 Yes

**Related Topics**

Household Characteristics, Residents: Core 59, Standard P3-P5

**22. PHYSICAL ACTIVITY AND WORK**

**State-Developed**

**AL69(2000-01)/**

**AL65(2002+)**

> Did you work for pay at least ten hours per week during your
> pregnancy?

 Yes

 No  Next topic

**AL70(2000-01)/**

**AL66(2002+)**

> What was the last month of your pregnancy that you worked?

 First, second, or third month

 Fourth month

 Fifth month

 Sixth month

 Seventh month

 Eighth month

 Ninth month

**AL71(2000-01)/**

**AL67(2002+)**

> Did any of these things happen to you during your pregnancy? For each
> thing, check Y (Yes) if it did happen to you or circle N (No) if it
> did not.

**No Yes**

> a\. My doctor or nurse told me to stop going to work N Y
>
> b\. I had tiredness or work-related stress N Y
>
> c\. I had swelling in my ankles, hands, face or elsewhere N Y

**GA74**

> During your most recent pregnancy, did you work for pay for 10 hours
> or more per week?

 No

 Yes

**GA75**

> What was the last month of your pregnancy that you worked for pay for
> 10 hours or more per week? Check one answer.

 First, second, or third month

 Fourth month

 Fifth month

 Sixth month

 Seventh month

 Eighth month

 Ninth month

**GA76**

Did a doctor or nurse tell you that you should stop going to work?

 No

 Yes

**GA77**

Why did a doctor or nurse tell you that you should stop going to work?
Check all that apply.

 Early or preterm labor

 High blood pressure

 Vaginal bleeding

 Swelling, water retention, or edema

 Tiredness or work-related stress

 Twins or multiple births

 Other Please tell us:

**ME72**

> Before your pregnancy, did you participate in any regular exercise
> program?

 No

 Yes

**ME73**

> What type of exercise program did you participate in? Check all that
> apply.

 Aerobics

 Running/jogging

 Swimming

 Walking

 Other  please tell us:

**NJ76** During your most recent pregnancy, did you work outside the
home 10 hours or more per week?

 No

 Yes

**NJ77** What was the last month of your pregnancy that you worked 10 or
more hours per week? Check one answer.

 First, second, or third month

 Fourth month

 Fifth month

 Sixth month

 Seventh month

 Eighth month

 Ninth month

 I never stopped working

**Related Topics**

Smoke Exposure, Maternal, NJ78

**NM68 (2000)/**

**NM69 (2001)/**

**NM71(2002+)**

> Which of the following things were you doing in the past month? Check
> all that apply.

 Being a homemaker

 Unemployed

 Seasonal farm or construction work

 Working or going to school full time

 Working or going to school part-time

 Other  Please tell us:

**ND68** Which statement describes your exercise habits during
pregnancy? Check one answer.

>  Very little exercise (watch TV, read)
>
>  Sporadic exercise (walking once or twice a week, volleyball or
> bowling once a week)
>
>  Moderate exercise (regular walking, swimming, etc., for about 30
> minutes a day or 20 minutes of vigorous exercise at least three times
> a week)
>
>  Vigorous exercise (jog several miles a day, aerobics several times a
> week)

**Related Topics**

Breastfeeding: Standard B1 B2, State-developed NM67

Child Care: Standard C1-C3

**23. PRE-CONCEPTION READINESS**

**State-Developed**

**OK67**

> BEFORE you became pregnant with your new baby, did any of these things
> happen? For each item, circle N (No) if it did not happen, Y (Yes) if
> it did happen, or DK (Don=t Know) if you don\'t know if it happened.

**No Yes Don=t Know**

a\. You heard or read that taking vitamins with folic acid

could help prevent some birth defects N Y DK

b\. You were dieting (changed your eating habits) during

the 3 months prior to pregnancy in order to lose weight N Y DK

c\. You received advice or counseling from a health care

provider to prepare for becoming pregnant N Y DK

d\. You were tested for HIV (the virus that causes AIDS) N Y DK

e\. You were told you had diabetes (high blood sugar)

that was not related to being pregnant N Y DK

f\. You visited the dentist within 12 months before

> you became pregnant N Y DK

**Related Topics**

Morbidity, Maternal: Standard L11

**24. PREGNANCY INTENTION**

**A. MATERNAL**

**Core**

**10** Thinking back to just before you got pregnant, how did you feel
about becoming pregnant? Check one answer.

 I wanted to be pregnant sooner

 I wanted to be pregnant later

 I wanted to be pregnant then

 I didn\'t want to be pregnant then or at any time in the future

**11** When you got pregnant with your new baby were you trying to
become pregnant?

>  No
>
>  Yes 

**Standard**

**Q1** Which of the following statements best describes you *during the
3 months* before you became pregnant?

 I was trying to get pregnant

 I wasn=t trying to get pregnant or trying to keep from getting
pregnant

 I was trying to keep from getting pregnant but was not trying very
hard

 I was trying hard to keep from getting pregnant

**Used by: CO73(2000-01)/CO71(2002+) LA72 MN74 VT70**

**Q4** How much sooner did you become pregnant than you wanted?

 Less than 1 year

 1 year to less than 2 years

 2 years to less than 3 years

 3 years to less than 4 years

 4 years or more

**Q5** This question asks about feelings and concerns women sometimes
have about becoming pregnant. For each thing, please circle Y (Yes) if
it applied to you when you found out you were pregnant with your new
baby or circle N (No) if it did not.

> **No Yes**
>
> a\. I was worried that I didn=t know enough about how to take care of
>
> a new baby. N Y
>
> b\. 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. NY
>
> c\. I looked forward to teaching and caring for a new baby. N Y
>
> d\. I looked forward to the new experiences that having a baby
>
> would bring. N Y
>
> e\. I looked forward to telling my friends that I was pregnant. N Y
>
> f\. I was worried that I did not have enough money to take care
>
> of a baby. N Y
>
> g\. I did not look forward to telling my friends that I was pregnant.
> N Y
>
> h\. I looked forward to buying things for a new baby. N Y

**Q6** How did you feel when you found out you were pregnant with your
new baby? Were youC

 Very unhappy to be pregnant

 Unhappy to be pregnant

 Not sure

 Happy to be pregnant

 Very happy to be pregnant

**Used by: MN76**

**State-Developed**

**OK68**

> Just before you became pregnant with your new baby, would you say you
> probably wanted to become pregnant at that time or probably not? Check
> the best answer.

 I probably did not want to become pregnant at that time

 I didn=t mind if I became pregnant at that time

 I probably wanted to become pregnant at that time  Go to Question 72

**OK69**

> Did you become pregnant with your new baby sooner than you wanted?
> Check the best answer.

 No, I did not become pregnant sooner than I wanted

 Yes, I became pregnant sooner than I wanted

How much sooner? \_\_\_\_\_Months \_\_\_\_\_Years

 I didn=t want to become pregnant then or at any time in the future

**B. PATERNAL**

**Standard**

**Q2** Which of the following statements best describes your husband or
partner *during the 3 months* before you became pregnant?

 He wanted me to get pregnant

 He partly wanted me to get pregnant and partly wanted me not to get
pregnant

 He didn\'t care one way or the other whether I got pregnant

 He did not especially want me to get pregnant

 He wanted very much for me not to get pregnant

**Used by: DE11 LA73 VT71**

**Q3** Thinking back to just before you got pregnant, how did your
husband or partner feel about your becoming pregnant? Check one answer.

 He wanted me to be pregnant sooner

 He wanted me to be pregnant later

 He wanted me to be pregnant then

 He didn\'t want me to be pregnant then or at any time in the future

 I don=t know

 I didn=t have a husband or partner

**Used by: MN75 RI70**

**State-Developed**

**OK70**

> Thinking back to just before you got pregnant with your new baby, how
> did the baby=s father feel about you becoming pregnant? Check the best
> answer.

 He wanted me to be pregnant sooner

 He wanted me to be pregnant later

 He wanted me to be pregnant then

 He didn=t want me to be pregnant then or at any time in the future

 It didn=t matter to him when I became pregnant

 I don=t know

**WA64**

> Thinking back to just before you got pregnant, how did your husband or
> partner feel about your becoming pregnant? Please check the best
> answer.

 My husband or partner wanted me to be pregnant sooner

 My husband or partner wanted me to be pregnant later

 My husband or partner wanted me to be pregnant then

 My husband or partner didn\'t want me to be pregnant then or at any
time in the future

 It didn=t matter to my husband or partner when I became pregnant.

 I don\'t know

 I didn\'t have a husband or partner

**25. PRENATAL CARE**

**A. BARRIERS**

**Core**

**17** Did any of these things keep you from getting prenatal care as
early as you wanted? Check all that apply.

 I couldn\'t get an appointment earlier in my pregnancy

 I didn\'t have enough money or insurance to pay for my visits

 I didn\'t know that I was pregnant

 I had no way to get to the clinic or doctor=s office

 The doctor or my health plan would not start care earlier

 I did not have my Medicaid card

 I had no one to take care of my children

 I had too many other things going on

 Other  Please tell us:

**State-Developed**

**UT79(2002+)**

Did you have as many visits for prenatal care as you wanted?

 No

 Yes  Go to Question 81

**UT80(2002+)**

Did any of these things keep you from having as many prenatal care
visits as you wanted? Check all that apply.

 I had no one to take care of my children

 I had no way to get to the clinic or office

 I didn\'t have enough money to pay for my visits

 I didn\'t know where to go

 I had too many other things going on

 I did not have my Medicaid card

 I couldn\'t get appointments

 Other  Please tell us:

**B. CONTENT**

\-

**Core**

**20** During any of your prenatal care visits, did a doctor, nurse, or
other health care worker talk with you about any of the things listed
below? Please count only discussions, not literature or videos. For each
item, circle Y (Yes) if someone talked with you about it or circle N
(No) if no one talked with you about it.

> **No Yes**
>
> a\. How smoking during pregnancy could affect your baby N Y
>
> b\. Breastfeeding your baby N Y
>
> c\. How drinking alcohol during pregnancy could affect your baby N Y
>
> d\. Using a seat belt during your pregnancy N Y
>
> e\. Birth control methods to use after your pregnancy N Y
>
> f\. Medicines that are safe to take during your pregnancy N Y
>
> g\. How using illegal drugs could affect your baby N Y
>
> h\. Doing tests to screen for birth defects or diseases that run
>
> in your family N Y
>
> i\. What to do if your labor starts early N Y
>
> j\. Getting your blood tested for HIV(the virus that causes AIDS) N Y
>
> k\. Physical abuse to women by their husbands or partners N Y

**Standard**

**R2** At any time during your prenatal care, did a doctor, nurse, or
other health care worker talk with you about how much weight you should
gain during your pregnancy?

 No

 Yes

**Used by: AL24a(2000-01)/AL21a(2002+) CO21a HI21(2002+) IL23(2002+)
MS21 NC68b(2000-01) TX23 UT22g**

**R3** At any time during your prenatal care, did a doctor, nurse, or
other health care worker ask if you were smoking cigarettes?

 No

 Yes

**Used by: AR21 CO21b IL24a(2000-01)/IL25a(2002+) LA22 MD26 NE23 OH21
WA21 TX24 UT22d**

**Related Topics**

Drug Use, Tobacco, Smoking Cessation: AA1-AA3, NJ65

**R4** At any time during your prenatal care, did a doctor, nurse, or
other health care worker ask if you were drinking alcoholic beverages
(beer, wine, wine cooler, or liquor)?

 No

 Yes

**Used by: AR22 CO21c IL24b(2000-01)/IL25b(2002+) MD27 OH22 WA21 UT22a**

**Modifiications:**

**CO21:** Combines R2, R3, R4

**No Yes**

a\. At any time during your prenatal care, did a doctor, nurse, or

other health care worker talk with you about how much weight

you should gain during your pregnancy? N Y

b\. Ask if you were smoking cigarettes? N Y

c\. Ask if you were drinking alcoholic beverages (beer, wine,wine

cooler, or liquor)? N Y

**R5** During any of your prenatal care visits, did a doctor, nurse, or
other health care worker ask you:

> **No Yes**
>
> a.. How much alcohol you were drinking? N Y
>
> b\. If someone was hurting you emotionally or physically? N Y

c\. If you were using illegal drugs (marijuana or hash, cocaine,

> crack, etc.)? N Y
>
> d\. If you wanted to be tested for HIV (the virus that causes AIDS)? N
> Y
>
> e\. If you planned to use birth control after your baby was born? N Y

**Used by: MN25 TX25 UT22**

**Modifications:**

**UT22**: Combines R2, R3, R4, R5 options b - e

**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 doctor, nurse, or
other health care worker talk with you about the bacteria group B strep
(or beta Strep)?

 No

 Yes

**Used by: NC73b(2002+)**

**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

**Used by: NC21(2002+)**

**R9** During any of your prenatal care visits, did a doctor, nurse, or
other health care worker talk with you about getting your blood tested
for the disease called toxoplasmosis?

 No

 Yes

**R10** During any of your prenatal care visits, did a doctor, nurse, or
other health care worker talk with you about any of the things listed
below? (Please count only discussions, not reading materials or videos.)
For each item, circle Y (Yes) if someone talked with you about it or
circle N (No) if no one talked with you about it.

> **No Yes**
>
> a\. Not touching your mouth or eyes while handling raw meat N Y
>
> b\. Cooking meat to \"well done\" N Y
>
> c\. Washing hands and utensils after handling raw meat N Y
>
> d\. Washing hands after contact with soil, sand, litter, or
>
> any other material that may be contaminated with cat feces N Y
>
> e\. Not feeding cats raw or undercooked meat N Y

**Used by: ND21**

**R11** At any time during your most recent pregnancy, did you have a
blood test for the disease called toxoplasmosis?

 No

 Yes

 I don\'t know

**State-Developed**

**AL24b(2000-01)/**

**AL21b(2002+)**

How many pounds did he or she recommend that you gain?

\_\_\_\_\_\_ Pounds

**AL74(2000-01)/**

**AL70(2002+)**

> During any of your prenatal care visits, did a doctor, nurse or other
> health care worker talk to you about how HIV (the virus that causes
> AIDS) could affect your baby?

 No

 Yes

**ME75**

What dietary topics did your health provider discuss with you during
your pregnancy? Check all that apply.

 Types of food to eat during pregnancy

 Appropriate amount of weight to gain

 Drinking alcoholic beverages

 I did not have any dietary counseling

 Other  please tell us:

**MS63** At any time during your prenatal care, did you have your blood
drawn to test for birth defects?

 No

 Yes  Go to Question 65

**MS64** What were your reasons for not having your blood drawn? Check
all that apply.

 I was not told about it

 I did not understand the reason for the test

 I do not like having my blood drawn

 I heard the results are unreliable

 I did not want to know if my baby had birth defects

 If a birth defect were found, one of my options would have been to
have an abortion

 The cost of the blood test was too high

**NC68(2000-01)**

> During any of your prenatal care visits, did a doctor, nurse, or other
> health care worker talk with you about any of the things listed below?
> For each item, circle Y (Yes) if someone talked with you about it or
> circle N (No) if no one talked with you about it.

**No Yes**

a\. Diseases or birth defects that could run in your family N Y

b\. How much weight you should gain during your pregnancy N Y

c\. Placing your baby to sleep on his or her back or side N Y

> d\. How vaginal infections (for example, yeast, vaginosis, STDs)
>
> may be related to the baby being born prematurely N Y
>
> e\. If someone was hurting you emotionally N Y

**NC73(2002+)**

> During any of your prenatal care visits, did a doctor, nurse, or other
> health care worker talk with you about any of the things listed below?
> For each item, circle Y (Yes) if someone talked with you about it or
> circle N (No) if no one talked with you about it.

**No Yes**

a\. Diseases or birth defects that could run in your family N Y

b\. The bacteria group B Strep (or beta Strep) that mothers can

> pass to their newborns during birth N Y

c\. Placing your baby to sleep on his or her back or side N Y

> d\. If someone was hurting you emotionally N Y

**NY78(2000-01)**

> This question is about things that a doctor, nurse, or other health
> care worker might have talked with you about when you went for
> prenatal care during your most recent pregnancy. For each thing,
> circle Y (Yes) if someone talked with you about it or N (No) if they
> did not.

**No Yes**

a\. How much vitamin A is safe to take during pregnancy N Y

b\. How long to wait before having another baby N Y

c\. Finding a doctor or nurse practitioner to care for your baby N Y

> d\. About the Ababy blues@ (postpartum depression) N Y

e\. When your baby should go in for a health checkup N Y

f\. Using a car safety seat for your baby N Y

g\. Having a working smoke alarm in your home N Y

**NY78(2002+)**

> This question is about things that a doctor, nurse, or other health
> care worker might have talked with you about when you went for
> prenatal care during your most recent pregnancy. For each thing,
> circle Y (Yes) if someone talked with you about it or N (No) if they
> did not.
>
> **No Yes**

a\. How much vitamin A is safe to take during pregnancy N Y

b\. How long to wait before having another baby N Y

> c\. About the Ababy blues@ (postpartum depression) N Y

**ND67** What did your doctor, nurse, or other health care worker tell
you about drinking during pregnancy? Check one answer.

>  Told me not to have any alcohol at all
>
>  Told me I could have alcohol for special events
>
>  Told me I could have one drink a day
>
>  Didn=t tell me anything about drinking or not drinking alcohol
>
>  Other  Please tell us:

**OK74** During your pregnancy did a doctor, nurse, or other health
professional talk with you about having blood test for any of the
following risks? For each item, circle N (No) if no one talked with you
about it, Y (Yes) if someone talked with you about it, or DK (Don=t
know) if you don\'t know if someone talked with you about it.

**No Yes Don\'t Know**

a\. Anemia N Y DK

b\. Hepatitis B N Y DK

c\. Rh Factor N Y DK

d\. Diabetes N Y DK

**OR74** During any of your prenatal care visits, did a doctor, nurse,
or other health care worker offer you a blood test to see whether your
baby had birth defects or diseases that run in your family?

 No

 Yes

**RI71/**

**WA66** At any time during your pregnancy, did a doctor, nurse or other
health care worker talk to you about the following things? For each
thing, circle Y (Yes) if it applies to you, N (NO) if it does not apply
to you, or DK (don=t know) if you are unsure.

**No Yes Don=t**

**Know**

a\. \"Baby blues\" or postpartum depression N Y DK

b\. How much weight you should gain during your pregnant N Y DK

c\. Diseases or birth defects that could run in your family

or your partner\'s family N Y DK

d\. Tests that could be done during your pregnancy to see

if your baby had a birth defect or genetic disease N Y DK

**Modifications:** RI71 does not offer the Adon=t know@ response.

**WV84** The following are things a doctor, nurse or other health care
worker might have talked to you about during your pregnancy or after
delivery. For each thing, circle Y (Yes) if someone talked with you
about it or N (No) if no one talked with you about it.

> **No Yes**
>
> a\. Childbirth education (classes on labor and delivery) N Y
>
> b\. High Risk Birth Score Program N Y
>
> c\. Parenting classes N Y
>
> d\. Right From the Start Program N Y
>
> e\. Immunization (shots) for your baby N Y
>
> f\. Diabetes (how it may affect you and your baby) N Y

**C. LOCATION**

**Core**

**18** Where did you go most of the time for your prenatal visits?
Don\'t include visits for WIC.

 Hospital clinic

 Health department clinic

 Private doctor\'s office/HMO clinic

 State specific option

 Other  Please tell us:

**State Options:**

Birthing center (FL)

Community health clinic/center (CO, FL, IL, OH, NM, NY, UT, VT)

Community or migrant health center (WA)

Family Practice Residency Program (ME)

HMO (e.g., Prime One or PrimeLink) (WV)

Indian Health Service (PHS) (NM)

Indian Health Service or Tribal clinic (NE)

Military facility (DE, GA, HI, OH, WA)

Neighborhood Clinic (NYC)

Nurse midwifes\' office or clinic (AR)

Non-nurse midwife\'s office or home (AR)

Primary care clinic or community health center (LA)

Rural health center (ME, VT)

State hospital (LA)

**State-Developed**

**NC69(2000-01)/**

**NC74(2002+)**

> How far did you travel (one way) to receive prenatal care? Check one
> answer.

 Less than 15 miles

 15-30 miles

 30-50 miles

 More than 50 miles

**NC70(2000-01)/**

**NC75(2002+)**

> Was this provider the closest one that you could go to for prenatal
> care?

 No

 Yes

**NC71(2000-01)/**

**NC76(2002+)**

> What were your reasons for going to this provider for prenatal care?
> Check all that apply.

 The only provider in my area that would accept me as a patient

 Their office was most convenient for me

 I selected this office from a list given to me by my insurance company

 Recommendation from a relative or friend

 They offered specialized services

 Referral from another doctor

 Other  Please explain:

**D. SATISFACTION**

**Core**

**16** Did you get prenatal care as early in your pregnancy as you
wanted?

 No

>  Yes

 I did not want prenatal care

**Standard**

**R1** We would like to know how you felt about the prenatal care you
got during your most recent pregnancy. If you went to more than one
place for prenatal care, answer for the place where you got most of your
care. For each thing, circle Y (Yes) if you were satisfied or N (No) if
you were not satisfied.

Were you satisfied with\...

**No Yes**

> a\. The amount of time you had to wait after you arrived for your
> visits N Y
>
> b\. The amount of time the doctor or nurse spent with you during your
> visits N Y
>
> c\. The advice you got on how to take care of yourself N Y

d\. The understanding and respect that the staff showed toward you as a

person N Y

**Used by: DE22 IL23(2000-01)/IL24(2002+) MD25 MN24 NE24 NY21 NYC21 TX22
WV22**

**Modifications:**

**NE24**: adds item

e\. The ability of staff to speak your language N Y

**Related topics**

Maternal Health Care, Discrimination: NM72(2002+)

**E. INITIATION**

**Core**

**15** How many weeks or months pregnant were you when you had your
first visit for prenatal care? Do not count a visit that was only for a
pregnancy test or only for WIC (Special Supplemental Nutrition Program
for Women, Infants, and Children).

Weeks OR Months

 I did not go for prenatal care

**26. INCENTIVE/FOLLOW-UP**

**State-Developed**

**ME86**

> Would you like us to send you a free certified copy of your baby\'s
> birth certificate (usual cost \$10)?

 No

 Yes

**UT83(2002+)**

> When your baby is two years old, we would like to contact you to see
> how he or she is doing. Your participation will help us to improve the
> health of Utah children. May we contact you?

 Yes

 No

**27. QUESTIONNAIRE DETAILS**

**Core**

**41** What is today\'s date?

\_\_\_\_\_ \_\_\_\_\_ \_\_\_\_\_

Month Day Year

**28. REPRODUCTIVE HISTORY**

**A. AGE AT MENARCHE AND CONCEPTION OF FIRST BIRTH**

**Standard**

**P7** How old were you when you had your first menstrual period?

\_\_\_\_\_ Years Old

**Used by: AK10 MD11**

**P8** How old were you when you got pregnant with your first baby?

Years Old

**Used by: AL10(2000-01) AK11 LA10 MD10 MT10 WV10** **SC10**

**Modifications:**

**FL69:** How old were you when your first baby was born?

  Years old

**OK81** When your first baby was born C

a\. How old were you?

\_\_\_\_ Years old

b\. How old was the baby\'s father?

\_\_\_\_ Years old

**B. PREVIOUS PREGNANCY OUTCOME**

**Core**

**7** Before your new baby, did you ever have any other babies who were
born alive?

>  No  Next topic
>
>  Yes

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

>  No

 Yes

**9** Was the baby just before your new one born more than 3 weeks
before its due date?

>  No
>
>  Yes

**29. CHILD CARE**

**Standard**

**C1** Are you currently in school or working outside the home?

 No 

 Yes

**Used by: AK74 CO74 FL73 GA78 LA77 MT79 NE73 NM69(2002+) ND74 TX79
VT74**

**Modifications:**

**FL73** Do you go to work or school outside the home?

 No    

 Yes

**C2** Who usually takes care of your new baby when you go to work or
school? Check one answer.

 My husband or partner

 Baby\'s teenage (13 or older) brother or sister

 Baby\'s pre-teen (12 or younger) brother or sister

 Other close relative

 Friend or neighbor

 Babysitter, nanny, or other child care provider

 Staff at a day-care center

 Other  Please tell us:

**Used by: AK76 CO75 FL74 GA79 LA78 MT80 NE74 ND75 TX80 VT75**

**Modifications:**

**FL74** Separates Husband/partner into two separate responses.

Adds: I take my baby with me to work or school

**NE74**: Modifies f. to: Babysitter, nanny, or someone hired to come
into your home

Modifies g to: Staff at a childcare center

Adds: Licensed family child care home

**State-Developed**

**OK76d** *After* you delivered your new baby, did any of these things
happen? For each item, circle N (No) if it did not happen, Y (Yes) if it
did happen, or DK (Don=t Know) if you don=t know if it happened.

**N Y DK**

d\. Your child attended a home day care or child day-care center N Y DK

**C3** When you leave your new baby to go to work or school, how often
do you feel that she/he is well cared for?

 Always

 Almost always

 Sometimes

 Rarely

 Never

**Used by: AK74 CO76 GA80 NE75 VT76**

**Related Topics**

Breastfeeding, NM67

Physical Activity and Work, NM69

**30. SMOKE EXPOSURE**

**A. INFANT**

**Core**

**49** About how many hours a day, on average, is your new baby in the
same room with someone who is smoking?

\_\_\_\_\_\_ Hours

 Less than one hour a day

 My baby is never in the same room with someone who is smoking

**Standard**

**U1** Does your husband or partner smoke inside your house?

>  No
>
>  Yes

 I don=t have a husband or a partner (option added 1/21/00)

**Used by: CO29** **IL35(2002+) NJ28**

**Modifications**

**IL35(2002+)** Does not include option 3 (don=t have husband or
partner)

**NJ28** Does not include option 3 (don\'t have husband or partner)

**U2** Not including yourself or your husband or partner, does anyone
else smoke cigarettes inside your house?

>  No
>
>  Yes

**Used by: CO30 NJ28**

**State-Developed**

**ND76** Which statement best describes the smoking behaviors of you,
your family, and friends when in your home or car? Check one answer.

>  No one smokes at all in the house or car (smokers have to go outside
> to smoke)
>
>  Smoking is restricted to one room of house (basement, etc.)
>
>  No one smokes when my baby is in the room or car
>
>  Smoking is allowed anytime in the house or car
>
>  Other  Please tell us:

**OR77** During any of your prenatal care visits or after your most
recent delivery, did a doctor, nurse, or other health care worker talk
with you about how secondhand smoke could affect your baby after birth?

 Yes, during my prenatal care visits

 Yes, after my delivery

 Yes, both times

 No

**OR81** Not including yourself, is there anyone in your household who
smokes cigarettes, cigars, or pipes?

>  No
>
>  Yes

**OR82** Which of the following statement best describes the rules about
smoking inside your home? Check one answer.

>  No one is allowed to smoke anywhere inside your home
>
>  Smoking is allowed in some places or at some times
>
>  Smoking is permitted anywhere inside your home

**Related Topics**

Drug Use, Tobacco: Core 27

**B. MATERNAL**

**State-Developed**

**NJ66** While you were pregnant did your husband or partner smoke
inside your house?

>  No
>
>  Yes

**NJ67** Not including yourself or your husband or partner, while you
were pregnant, did anyone else smoke cigarettes inside your house?

>  No
>
>  Yes

**NJ78** Did other employees frequently smoke in your work area or in
public work areas while you were there?

 No

 Yes

**ND65** While pregnant, were you regularly exposed to secondhand smoke
at your job (e.g., waitress in a smoking section of a restaurant?

 No

 Yes

 I didn\'t work outside the home

**31. SLEEPING BEHAVIORS**

**Core**

**50** How do you most often lay your baby down to sleep now? Check one
answer.

>  On his or her side
>
>  On his or her back
>
>  On his or her stomach

**Standard**

**F1** How often does your new baby sleep in the same bed with you or
anyone else?

>  Always
>
>  Almost always
>
>  Sometimes
>
>  Rarely
>
>  Never

**Used by: AL55(2000-01)/AL52(2002+) AK72 GA57 LA56 ME55 MI55 MN59 MT55
NJ54 ND53 OH56 VT56 WA52 WV60**

**Modifications:**

**AK72** Adds skip to never response

**State-Developed**

**AK73** How many other people sleep in the bed with your new baby?

>  One
>
>  Two
>
>  Three or more

**Related Topics**

Injury Prevention: State-Developed HI66d HI66e NE72c SC70c

Prenatal Care, Content: State-Developed, NC68c

**32. SOCIAL SERVICES**

**A. WIC**

**Core**

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

>  No
>
>  Yes

**Standard**

**V3** Since your new baby was born, have you used WIC services for your
new baby?

>  No
>
>  Yes

**Used by: AL76(2000-01)/AL73(2002+) HI74(2002+)
IL77(2000-01)/IL80(2002+) NY80(2000-01)/NY81(2002+) WV83**

**State-Developed**

**GA71** During your most recent pregnancy, what month did you get on
WIC?

>  1 to 3 months
>
>  4 to 6 months
>
>  7 to 9 months
>
>  I was already on WIC when I got pregnant
>
>  I did not go on WIC

**ME81** Is your new baby enrolled in WIC?

>  No
>
>  Yes

**MI79** Are you or your baby enrolled in WIC now?

>  My baby is on WIC  Go to Question 81
>
>  Both my baby and I are on WIC  Go to Question 81
>
>  I am on WIC
>
>  Neither I nor my baby are on WIC

**ME82/**

**MI80** Why wasn\'t your new baby enrolled in WIC? Check all that
apply.

>  He or she was not eligible
>
>  I didn\'t know about WIC
>
>  I didn\'t want to enroll my baby
>
>  Other  Please tell us:

**Modifications:** MI80, first option reads AMy baby was not eligible@

**Related Topics**

Breastfeeding: State-Developed, AL77

**B. OTHER PREGNANCY AND INFANT SERVICES**

**Standard**

**V1** During your most recent pregnancy, did you get any of these
services? Circle Y (Yes) if you got the service or N (No) if you did not
get it.

> **No Yes**
>
> a\. Childbirth classes N Y
>
> b\. Parenting classes N Y
>
> c\. Classes on how to stop smoking N Y
>
> d\. Visits to your home by a nurse or other health worker N Y
>
> e\. Food Stamps N Y
>
> f\. TANF (Welfare) N Y

**Used by: AL68(2000-01) AR84 GA72 IL75(2000-01)/IL77(2002+) LA74
NC75(2000-01)/NC77(2002+) NE69 NJ79 OH73**

**V2** Since you delivered your new baby, have you used any of these
services? Circle Y (Yes) if you used the service or N (No) if you did
not use it.

List of services\...

**V11**

During your most recent pregnancy, did you feel you ***needed*** any of
the following services? For each thing, circle Y (Yes) if you felt you
needed the service or N (No) if you did not feel you needed the service.

Did you ***need:***

> **No Yes**
>
> a\. Money to buy food, food stamps, or WIC vouchers N Y
>
> b\. Help with an alcohol or drug problem N Y
>
> c\. Help to reduce violence in your home N Y
>
> d\. Counseling information for family and personal problems N Y
>
> e\. Help to quit smoking N Y
>
> f\. Help with or information about breastfeeding N Y
>
> g\. Other N Y

 Please tell us: \_\_\_\_\_\_\_\_\_\_\_\_

**Used by: HI64(2002+)** **MN77 MT75 TX76 WA69**

**Modifications:**

**WA69** Rewords option (a) to Food, including money or coupons to buy
food, food stamps, WIC

**V12**

> During your most recent pregnancy, did you ***receive*** any of the
> following services? For each thing, circle Y (Yes) if you received the
> service or N (No) if you did not receive the service.

Did you ***receive:***

> **No Yes**
>
> a\. Money to buy food, food stamps, or WIC vouchers N Y
>
> b\. Help with an alcohol or drug problem N Y
>
> c\. Help to reduce violence in your home N Y
>
> d\. Counseling information for family and personal problems N Y
>
> e\. Help to quit smoking N Y
>
> f\. Help with or information about breastfeeding N Y
>
> g\. Other N Y

 Please tell us: \_\_\_\_\_\_\_\_\_\_\_\_

Used by: MN78 MT76 WA70

**Modifications:**

**WA70** Rewords option (a) to Food, including money or coupons to buy
food, food stamps, WIC

**State-Developed**

**NM63(2000-01)/**

**NM65(2002+)**

During your pregnancy, did you participate in any of these services?

>  Breastfeeding class or support group
>
>  Parenting class or support group
>
>  WIC class or discussion group about nutrition
>
>  Counseling about a personal or family problem
>
>  Home visiting services
>
>  Program for pregnant or parenting teenagers
>
>  Families FIRST
>
>  Program for protection from family violence
>
>  Program to stop using drugs or alcohol
>
>  A class or support group to stop smoking
>
>  I did not participate in any of the above

**NM64(2000-01)/**

**NM66(2002+)**

> *Since* your delivery, did you participate in any of these services?
> Check all that apply.
>
>  Breastfeeding class or support group
>
>  Parenting class or support group
>
>  WIC class or discussion group about nutrition
>
>  Counseling about a personal or family problem
>
>  Home visiting services
>
>  Program for pregnant or parenting teenagers
>
>  Families FIRST
>
>  Program for protection from family violence
>
>  Program to stop using drugs or alcohol
>
>  A class or support group to stop smoking
>
>  I did not participate in any of the above

**NC80(2000-01)/**

**NC81(2002+)**

> Please tell us if you have heard of the following North Carolina
> programs.

**No Yes**

> a\. First Step Hotline N Y

b\. Smart Start N Y

c\. Baby Love N Y

d\. Child Service Coordination (CSC) N Y

e\. WIC N Y

f\. Health Check/NC Choice for Children N Y

g\. Child Resource Line N Y

h\. Family Support Network N Y

i\. NC Family Health Resource Line (1-800-367-2229) N Y

**Related Topics**

Drug Use, Tobacco: State-Developed AK80

Prenatal Care, Content: WV84

**C. GOVERNMENT ASSISTANCE**

**Standard**

**V4** At any time during the last two years, have you or any member of
your household considered seeking help from the government because your
income was low?

>  No
>
>  Yes

**V5** Did you or any member of your household apply for government
payments such as welfare, AFDC (Aid to Families with Dependent
Children), TANF (Temporary Assistance to Needy Families) or other public
assistance?

>  No
>
>  Yes

**V6** Did any of these things keep you from applying for government
help? Check all that apply.

>  I did not think I could get help because my household made too much
> money
>
>  I did not know how to apply
>
>  There was too much paperwork
>
>  I did not want to use up my benefits
>
>  I did not think I could get help because I am from another country
>
>  Other  Please tell us:

**V7** Did any of these happen to you when you applied for government
assistance? Check all that apply.

>  You received assistance
>
>  You were told you made too much money to get assistance
>
>  You were told you should not apply because you might need your
> benefits later
>
>  You were told you could not get assistance because you were from
> another country

**V8** Between the time you became pregnant and now, have you applied
for TANF (Temporary Assistance to Needy Families)?

-   No 

-   Yes

**Used by: MD79 NY81(2000-01)/NY82(2002+)**

**Modifications:**

**MD79** Replaces TANF (Temporary Assistance to Needy Families) with TCA
(Temporary Cash Assistance)

**V9** Did you get TANF?

-   No 

-   Yes

**Used by: MD80 NY82(2000-01)/NY83(2002+)**

**Modifications**

**MD80:** Replaces TANF with TCA

**V10**

> Why didn=t you get TANF? Check all that apply.
>
>  You were ineligible due to your income
>
>  You had reached your time limit
>
>  You had to fulfill work or other requirements
>
>  You had to return on another day to apply
>
>  You had previously lost TANF for another reason (admin reasons,
> sanctions, etc)
>
>  You are not a citizen
>
>  Other  Please tell us:

**Used by: MD81 NY83(2000-01)/NY84(2002+)**

**Modifications:**

**MD80** Replaces TANF with TCA

**Related Topics**

Health Insurance, Maternal: Core 2 19 40, State-Developed FL69 FL70 NE70
OK76

Health Insurance, Infant: Standard H1- H5

**33. STRESS**

**Core**

**31** This question is about things that may have happened during the
12 months before your new baby was born. For each item, 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 go into the
> hospital N Y
>
> b\. You got separated or divorced from your husband or partner N Y
>
> c\. You moved to a new address N Y
>
> d\. You were homeless N Y
>
> e\. Your husband or partner lost his job N Y
>
> f\. You lost your job even though you wanted to go on working N Y
>
> g\. You argued with your husband or partner more than usual N Y
>
> h\. Your husband or partner said he did not want you to be pregnant N
> Y
>
> i\. You had a lot of bills you could not pay N Y
>
> j\. You were in a physical fight N Y
>
> k\. You or your husband or partner went to jail N Y
>
> l\. Someone very close to you had a bad problem with drinking or drugs
> N Y

m\. Someone very close to you died N Y

**Related Topics**

Abuse, Physical

Abuse, Emotional

Physical Activity or Employment:

**State-Developed**

**MI73a-c**

> This question is about things that may have happened during the 12
> months before your new baby was born. For each item, 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\. You felt that your race or ethnic background contributed to the
>
> stress in your life N Y
>
> b\. You felt emotionally upset (for example, angry, sad, or
> frustrated) as a
>
> result of how you were treated based on your race or ethnic background
> N Y
>
> c\. You experienced physical symptoms (for example, a headache, an
> upset

stomach, tensing of your muscles, or a pounding heart) that you felt
were

related to how you were treated based on your race or ethnic background
N Y

**Related Topics**

Maternal Health Care, Discrimination

**34. SOCIAL SUPPORT**

**Standard**

**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 you got sick and had to be in bed for several
weeks? Check all that apply.

 My husband or partner

 My mother, father, or in-laws

 Other family member or relative

 A friend

 Someone else  Please tell us:

 No one would have helped me

**Used by: GA73 HI65(2000-01)/HI69(2002+) NYC73 SC69 TX77
UT79(2000-01)/UT78(2002+)**

**W2** During your most recent pregnancy, would you have had the kinds
of help listed below if you had needed them? For each thing, circle Y
(Yes) if you would have had it or N (No) if not.

**No Yes**

> a\. Someone to loan me \$50 NY
>
> b\. Someone to help me if I were sick and needed to be in bed NY

k.  Someone to take me to the clinic or doctor=s office if I needed a
    ride N Y

l.  Someone to talk with about my problems NY

**Used by: MT77 OH74 SC68 WA71 TX78 VT72**

**Modifications:**

**SC68:** Adds items e. and f.:

e\. Someone to help me find a job if I needed it N Y

f\. Someone to help with grocery shopping or house cleaning N Y

**W3** Since you delivered your new baby, 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]{.underline} that apply.

>  My husband or partner
>
>  My mother, father, or in-laws
>
>  Other family member or relative
>
>  A friend
>
>  Someone else  Please tell us:
>
>  No one would help me

**Used by: ME 83 MN81**

**W4** Since you delivered your new baby, would you have the kinds of
help listed below if you needed them? For each thing, circle Y (Yes) if
you would have it or circle N (No) if not.

**No** **Yes**

> a\. Someone to loan me \$50 N Y
>
> b\. Someone to help me if I were sick and needed to be in bed N Y
>
> c\. Someone to talk with about my problems N Y
>
> d\. Someone to take care of my baby N Y

e\. Someone to help me if I were tired and feeling frustrated

> with my new baby N Y

**Used by: MT78 NC78(2000-01)/NC80(2002+) OH75 RI77 VT73**

**Modifications:**

**NC78(2000-01)/NC80(2002+)**

Asks only a - c. Adds option: d. Someone to take you to the clinic or
doctor=s office if you needed a ride

**RI77** Deletes option d. Adds option: e. Someone to take me and my
baby to the doctor=s office if I have no other way of getting there

**State-Developed**

**NM65(2000)/**

**NM66(2001)/**

**NM68(2002+)**

> Since your delivery, whom can you count on for support or help?
> Include those on whom you often rely for housekeeping, child care,
> money, or help with problems. Check all that apply.
>
>  My husband or partner
>
>  A relative, friend, or neighbor
>
>  A paid sitter or nanny
>
>  Day-care center staff
>
>  Someone else \--\> please tell us
> who\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
>  No one

**ME84**

> After the birth of your new baby, did any of the following people
> visit you at home? Check all that apply.

 Public health nurse

 Community health nurse

 Nurse from the hospital

 Healthy Families staff

 Early Head Start worker

 Parents as Teachers worker

 Social service caseworker

 Other\-\-\--\> Please tell us:\_\_\_\_\_\_\_\_

**OK78**

> How often does your baby=s father help you pay for baby supplies like
> diapers, clothes, and medicine?

 Always

 Most of the time

 Some of the time

 Almost never

 Never

**0K79**

> How often does your baby=s father help you care for your baby like
> giving baths, feeding, holding, changing diapers, or babysitting?

 Usually everyday

 At least once a week

 2B3 times a month

 Less than once a month

 Never

**RI78**

> In general, how easy is it to calm your baby when he or she is crying
> or fussy? Check one answer.

 Very easy

 Somewhat easy

 Somewhat difficult

 Very difficult

**UT80(2000-01)/**

**UT81(2002+)**

> When you were physically hurt during the 12 months before or during
> your most recent pregnancy, who did you receive help from? For each
> one, circle Y (Yes) if it applies to you or circle N (No) if it does
> not.

**No Yes**

> a\. Family member N Y
>
> b\. Friend N Y
>
> c\. My doctor N Y
>
> d\. Emergency room or urgent care medical facility N Y
>
> e\. Other health care provider N Y
>
> f\. Counselor, therapist, or social worker N Y
>
> g\. Religious advisor N Y
>
> h\. Law enforcement N Y
>
> i\. Statewide Domestic Violence Information Line N Y

(1-800-897-LINK)

> j\. Other N Y

If YES, please tell us:

> k\. I didn=t get any help N Y

**UT81(2000-01)/**

**UT82(2002+)**

> If you did not receive help, please tell us what kept you from
> receiving help. For each thing, circle Y (Yes) if it applies to you or
> circle N (No) if it does not.
>
> **No Yes**
>
> a\. I did not know where to get help N Y
>
> b\. I did not have the money to pay for services N Y
>
> c\. I was afraid the person who physically hurt me would find out N Y
>
> d\. It was my fault that I was physically hurt N Y

I thought the abuse would stop N Y

I did not have someone to tend my children N Y

m.  I was afraid someone would take my children away from me N Y

n.  I did not have a way to get there N Y

```{=html}
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```
?.  I did not want any help N Y

```{=html}
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```
j.  Other N Y

If YES, please tell us:

**Related Topics**

Abuse, Physical

Abuse, Emotional

**35. NUTRITION**

**A. MATERNAL WEIGHT**

**Core**

**5** *Just before* you got pregnant, how much did you weigh?

Pounds OR Kilos

**6** How tall are you without shoes?

Feet Inches OR Centimeters

**State-Developed**

**OK75 NE68**

> How much weight did you gain during your pregnancy?

  Pounds  OR    Kilos

 I lost weight during my pregnancy

 I don=t know

**B. VITAMIN USE AND FOLIC ACID**

**Core**

**3** In the month before you got pregnant with your new baby, how many
times a week did you take a multivitamin (a pill that contains many
different vitamins and minerals)?

>  I did not take a multivitamin at all
>
>  1 to 3 times a week
>
>  4 to 6 times a week
>
>  Every day of the week

**Standard**

**G1** Have you ever heard or read that taking the vitamin folic acid
can help prevent some birth defects?

>  No
>
>  Yes

**Used by: AK23 AR23 FL22 IL26(2000-01)/IL27(2002+) LA23 MD28 ME74 MT22
NC22(2000-01)/NC69(2002+) NYC24 OH23 RI22 TX26 WV23**

**G2** Have you ever heard about folic acid from any of the following?
Check all that apply.

>  Magazine or newspaper article
>
>  Radio or television
>
>  Doctor, nurse, or other health care provider
>
>  Book
>
>  Family or Friends
>
>  Other  Please tell us:

**Used by: FL23 NC23(2000-01)/NC71(2002+) NYC25 WV24**

**Modifications**:

**NC23:** Asks: Where did you hear about folic acid?

**G3** Some health experts recommend taking folic acid for which ONE of
the following reasons? Check one answer.

>  To make strong bones
>
>  To prevent birth defects
>
>  To prevent high blood pressure
>
>  I don=t know

**Used by: NM21 NY24 VT21**

**G4** Which of the following things would cause you to take a
multivitamin? Check all that apply.

>  I didn=t usually eat the right foods
>
>  It prevented heart disease
>
>  It was good for my general health
>
>  It would help me have a healthy baby someday
>
>  My family or friends said it was a good idea
>
>  My doctor or nurse said it was a good idea

**Used by: NC24(2000-01)/NC72(2002+) VT22**

**State-Developed**

**MI71**

> Before you became pregnant with your new baby, did either of the
> following things happen? For each item, circle Y (Yes) if it did
> happen, N (No) if it did not happen, or DK (Don=t Know) if you don=t
> know if it happened.

**No Yes Don=t Know**

a\. You heard or read that taking the vitamin folic acid or foods

that contain it (orange juice, citrus fruits, broccoli, green leafy

vegetables, and fortified cereal) could help prevent some

> birth defects N Y DK

b\. Your doctor or nurse instructed you on how to get enough

> folic acid N Y DK

**NC70(2002+)**

When did you ***first*** hear or read about folic acid?

>  Before I became pregnant
>
>  During my pregnancy
>
>  After my pregnancy was over

**OR65** Before you got pregnant with your new baby, had you ever heard
or read that taking the vitamin folic acid can help prevent some birth
defects?

>  No
>
>  Yes

**C. FOOD INSUFFICIENCY**

**NM70(2000-2001)/**

**NM73(2002+)**

> During the past 12 months, which one of the following statements best
> describes the food eaten by you and your family?

 Enough food to eat

 Sometimes not enough food to eat

 Often not enough food to eat

**Related Topics**

Prenatal Care, Content: State-Developed ME75