Pregnancy Risk Assessment Monitoring System (PRAMS)

**Phase 5 Core Questionnaire**

**First, we would like to ask a few questions about you and the time
before you got pregnant with your new baby. Please check the box next to
your answer.**

1\. *Just before* you got pregnant, did you have health insurance? Do
not count Medicaid.

No

Yes

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

No

Yes

3\. During the *month* *before* you got pregnant with your new baby, how
many times a week did you take a multivitamin or a prenatal vitamin?
These are pills that contain many different vitamins and minerals.

I didn't take a multivitamin or a prenatal vitamin at all

1 to 3 times a week

4 to 6 times a week

Every day of the week

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

  --------------------- ----------------------- --------------------------
  **\[BOX\]**           **\[BOX\]**             **19\[BOX\]**

  Month                 Day                     Year
  --------------------- ----------------------- --------------------------

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

**\[BOX\]** Pounds **OR** **\[BOX\]** Kilos

6\. How tall are you without shoes?

**\[BOX\]** Feet **\[BOX\]** Inches

**OR** **\[BOX\]** Centimeters

**[Insertion point for Standard question(s) L10]{.underline}**

**[Insertion point for Standard question(s) L17]{.underline}**

**[Insertion point for Standard question(s) L11]{.underline}**

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

No **Go to Question 10**

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

**[Insertion point for Standard question(s) P7--P8]{.underline}**

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

10\. Thinking back to *just before* you got pregnant with your *new*
baby, how did you feel about becoming pregnant? Check [one]{.underline}
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

**[Insertion point for Standard question(s) Q4]{.underline}**

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

No

Yes **Go to Question 14**

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 \[rhythm\] or withdrawal, and using birth control methods
such as the pill, condoms, cervical ring, IUD, having their tubes tied,
or their partner having a vasectomy.)

No

Yes **Go to Question 14**

13\. What were your or your husband's or partner's reasons for not doing
anything to keep from getting pregnant? Check [all]{.underline} 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 husband or partner or I was sterile (could not get pregnant
at all)

My husband or partner didn't want to use anything

Other Please tell us:

**\[BOX\]**

**[Insertion point for Standard question(s) E3]{.underline}**

**[Insertion point for Standard question(s) A1--A3]{.underline}**

**The next questions are about the prenatal care you received during
your most recent pregnancy. Prenatal care includes visits to a doctor,
nurse, or other health care worker before your baby was born to get
checkups and advice about pregnancy.** (It may help to look at the
calendar when you answer these questions.)

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.)

**\[BOX\]** Weeks **OR** **\[BOX\]** Months

I don't remember

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

**\[BOX\]** Weeks **OR** **\[BOX\]** Months

I didn't go for prenatal care

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

No

Yes

I didn't want prenatal care **Go to Question 18**

17\. Here is a list of problems some women can have getting prenatal
care. For each item, circle Y (Yes) if it was a problem for you during
your most recent pregnancy or circle N (No) if it was not a problem or
did not apply to you.

**No Yes**

a\. I couldn't get an appointment when I wanted one N Y

b\. I didn't have enough money or insurance to pay for my visits N Y

c\. I had no way to get to the clinic or doctor's office N Y

d\. I couldn't take time off from work N Y

e\. The doctor or my health plan would not start care as early as I
wanted N Y

f\. I didn't have my Medicaid card N Y

g\. I had no one to take care of my children N Y

h\. I had too many other things going on N Y

i\. I didn't want anyone to know I was pregnant N Y

j\. Other N Y

Please tell us:\
**\[BOX\]**

**If you did not go for prenatal care, go to Page #, Question 20.**

**[Insertion point for Standard question(s) R15]{.underline}**

18\. How was your prenatal care paid for? Check [all]{.underline} that
apply

Medicaid

Personal income (cash, check, or credit card)

Health insurance or HMO (including insurance from your work or your
husband's work)

# State-specific 

# State-specific

Other Please tell us:

**\[BOX\]**

19\. 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\. How smoking during pregnancy could affect my baby N Y

b\. Breastfeeding my baby N Y

c\. How drinking alcohol during pregnancy could affect my baby N Y

d\. Using a seat belt during my pregnancy N Y

e\. Birth control methods to use after my pregnancy N Y

f\. Medicines that are safe to take during my pregnancy N Y

g\. How using illegal drugs could affect my baby N Y

h\. Doing tests to screen for birth defects or diseases that run in my
family N Y

i\. What to do if my labor starts early N Y

j\. Getting tested for HIV (the virus that causes AIDS) N Y

k\. Physical abuse to women by their husbands or partners N Y

**[Insertion point for Standard question(s) R1--R4]{.underline}**

**[Insertion point for Standard question(s) R12]{.underline}**

**[Insertion point for Standard question(s) R14]{.underline}**

**[Insertion point for Standard question(s) R5]{.underline}**

**[Insertion point for Standard question(s) R13]{.underline}**

**[Insertion point for Standard question(s) R9--R11]{.underline}**

**[Insertion point for Standard question(s) R6--R8]{.underline}**

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

No

Yes

I don't know

**[Insertion point for Standard question(s) I7]{.underline}**

**[Insertion point for Standard question(s) I4--I6]{.underline}**

**[Insertion point for Standard question(s) I2--I3]{.underline}**

## Insertion point for Standard question(s) G5

**[Insertion point for Standard question(s) G1--G4]{.underline}**

**[Insertion point for Standard question(s) L12--L15]{.underline}**

**The next questions are about your most recent pregnancy and things
that might have happened during your pregnancy.**

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

No

Yes

**[Insertion point for Standard question(s) B7]{.underline}**

22\. Did you have any of these problems during your most recent
pregnancy? For each item, circle Y (Yes) if you had the problem or
circle N (No) if you did not.

**No Yes**

a\. High blood sugar (diabetes) that started *before* this pregnancy N Y

b\. High blood sugar (diabetes) that started *during* this pregnancy N Y

c\. Vaginal bleeding N Y

d\. Kidney or bladder (urinary tract) infection N Y

e\. Severe nausea, vomiting, or dehydration N Y

f\. Cervix had to be sewn shut (incompetent cervix) N Y

g\. High blood pressure, hypertension (including pregnancy-induced
hypertension\
\[PIH\], preeclampsia, or toxemia) N Y

h\. Problems with the placenta (such as abruptio placentae or placenta
previa) N Y

i\. Labor pains more than 3 weeks before my baby was due (preterm or
early labor) N Y

j\. Water broke more than 3 weeks before my baby was due\
(premature rupture of membranes \[PROM\]) N Y

k\. I had to have a blood transfusion N Y

l\. I was hurt in a car accident N Y

**If you did not have any of these problems, go to Question 24.**

23\. Did you do any of the following things because of these problems?
For each item, circle Y (Yes) if you did that thing or circle N (No) if
you did not.

**No Yes**

a\. I went to the hospital or emergency room and stayed less than 1 day
N Y

b\. I went to the hospital and stayed 1 to 7 days N Y

c\. I went to the hospital and stayed more than 7 days N Y

d\. I stayed in bed at home more than 2 days because of my doctor's or
nurse's advice N Y

**[Insertion point for Standard question(s) N1--N4]{.underline}**

**[Insertion point for Standard question(s) L4--L7]{.underline}**

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

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

No **Go to Question 28**

Yes

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

41 cigarettes or more

21 to 40 cigarettes

11 to 20 cigarettes

6 to 10 cigarettes

1 to 5 cigarettes

Less than 1 cigarette

None (0 cigarettes)

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

41 cigarettes or more

21 to 40 cigarettes

11 to 20 cigarettes

6 to 10 cigarettes

1 to 5 cigarettes

Less than 1 cigarette

None (0 cigarettes)

**[Insertion point for Standard question(s) AA6]{.underline}**

27\. How many cigarettes do you smoke on an average day *now*?
(A pack has 20 cigarettes.)

41 cigarettes or more

21 to 40 cigarettes

11 to 20 cigarettes

6 to 10 cigarettes

1 to 5 cigarettes

Less than 1 cigarette

None (0 cigarettes)

**[Insertion point for Standard question(s) U1--U2]{.underline}**

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 **Go to Question 31**

Yes

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

14 drinks or more a week

7 to 13 drinks a week

4 to 6 drinks a week

1 to 3 drinks a week

Less than 1 drink a week

I didn't drink then

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

6 or more times

4 to 5 times

2 to 3 times

1 time

I didn't have 5 drinks or more in 1 sitting

I didn't drink then

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

14 drinks or more a week

7 to 13 drinks a week

4 to 6 drinks a week

1 to 3 drinks a week

Less than 1 drink a week

I didn't drink then

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

6 or more times

4 to 5 times

2 to 3 times

1 time

I didn't have 5 drinks or more in 1 sitting

I didn\'t drink then

**Pregnancy can be a difficult time for some women. These next questions
are about things that may have happened before and during your most
recent pregnancy.**

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 circle N (No) if it did not. (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\. I got separated or divorced from my husband or partner N Y

c\. I moved to a new address N Y

d\. I was homeless N Y

e\. My husband or partner lost his job N Y

f\. I lost my job even though I wanted to go on working N Y

g\. I argued with my husband or partner more than usual N Y

h\. My husband or partner said he didn't want me to be pregnant N Y

i\. I had a lot of bills I couldn't pay N Y

j\. I was in a physical fight N Y

k\. My husband or partner or I went to jail N Y

l\. Someone very close to me had a bad problem with drinking or drugs N
Y

m\. Someone very close to me died N Y

**[Insertion point for Standard question(s) P14--P16]{.underline}**

**[Insertion point for Standard question(s) BB1]{.underline}**

**The next questions are about the time during the *12 months before*
you got pregnant with your new baby.**

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

No

Yes

32b. During the *12 months before* you got pregnant, were you physically
hurt in any way by your husband or partner?

No

Yes

## Insertion point for Standard question(s) Z3

**The next questions are about the time during your most recent
pregnancy.**

33a. During your most recent pregnancy, did an ex-husband or ex-partner
push, hit, slap, kick, choke, or physically hurt you in any other way?

No

Yes

33b. During your most recent pregnancy, were you physically hurt in any
way by your husband or partner?

No

Yes

**[Insertion point for Standard question(s) Z4]{.underline}**

**[Insertion point for Standard question(s) M7]{.underline}**

**The next questions are about your labor and delivery.** (It may help
to look at the calendar when you answer these questions.)

**[Insertion point for Standard question(s) K1--K4]{.underline}**

**34. When was your baby due?**

  ---------------------- ------------------------ ------------------------
  **\[BOX\]**            **\[BOX\]**              **\[BOX\]**

  Month                  Day                      Year
  ---------------------- ------------------------ ------------------------

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

  ---------------------- ------------------------ ------------------------
  **\[BOX\]**            **\[BOX\]**              **\[BOX\]**

  Month                  Day                      Year
  ---------------------- ------------------------ ------------------------

I didn't have my baby in a hospital

### Insertion point for Standard question(s) K5

**36. When was your baby born?**

  ---------------------- ------------------------ ------------------------
  **\[BOX\]**            **\[BOX\]**              **\[BOX\]**

  Month                  Day                      Year
  ---------------------- ------------------------ ------------------------

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

  ---------------------- ------------------------ ------------------------
  **\[BOX\]**            **\[BOX\]**              **\[BOX\]**

  Month                  Day                      Year
  ---------------------- ------------------------ ------------------------

I didn't have my baby in a hospital

**38. How was your delivery paid for?** Check [all]{.underline} that
apply

Medicaid

Personal income (cash, check, or credit card)

Health insurance or HMO (including insurance from your work or your
husband's work)

*State-specific*

*State-specific*

Other Please tell us:

\[BOX\]

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

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

No

Yes

I don't know

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

Less than 24 hours (less than 1 day)

24 to 48 hours (1 to 2 days)

3 days

4 days

5 days

6 days or more

My baby was not born in a hospital

My baby is still in the hospital **Go to Question 43**

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

No **Go to Question 51**

Yes

**42. Is your baby living with you now?**

No **Go to Question 51**

Yes

**[Insertion point for Standard question(s) B4]{.underline}**

43\. Did you ever breastfeed or pump breast milk to feed your new baby
after delivery?

No **Go to Question 47**

Yes

**[Insertion point for Standard question(s) B1]{.underline}**

44\. Are you still breastfeeding or feeding pumped milk to your new
baby?

No

Yes **Go to Question 46**

45\. How many weeks or months did you breastfeed or pump milk to feed
your baby?

**\[BOX\]** Weeks **OR** **\[BOX\]** Months

Less than 1 week

**[Insertion point for Standard question(s) B2]{.underline}**

46\. 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.

**\[BOX\]** Weeks **OR** **\[BOX\]** Months

My baby was less than 1 week old

I have not fed my baby anything besides breast milk

**[Insertion point for Standard question(s) B3]{.underline}**

**[Insertion point for Standard question(s) B5--B6]{.underline}**

**If your baby is still in the hospital, go to Page ##, Question 51.**

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

**\[BOX\]** Hours

Less than 1 hour a day

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

48\. How do you *most often* lay your baby down to sleep now? Check
[one]{.underline} answer

On his or her side

On his or her back

On his or her stomach

**[Insertion point for Standard question(s) F1]{.underline}**

49\. Was your new baby seen by a doctor, nurse, or other health care
worker during the first week after he or she left the hospital?

No

Yes

### Insertion point for Standard question(s) X6

**[Insertion point for Standard question(s) T4--T5]{.underline}**

50\. Has your new baby had a well-baby checkup? (A well-baby checkup is
a regular health visit for your baby usually at 2, 4, or 6 months of
age.)

No

Yes

**[Insertion point for Standard question(s) X7]{.underline}**

### Insertion point for Standard question(s) X8

**[Insertion point for Standard question(s) X4]{.underline}**

**[Insertion point for Standard question(s) X1--X2]{.underline}**

**[Insertion point for Standard question(s) X3]{.underline}**

**[Insertion point for Standard question(s) X5]{.underline}**

**[Insertion point for Standard question(s) T1--T3]{.underline}**

**[Insertion point for Standard question(s) H1--H4]{.underline}**

51\. 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 not having sex at certain times \[rhythm\] or
withdrawal, and using birth control methods such as the pill, condoms,
cervical ring, IUD, having their tubes tied, or their partner having a
vasectomy.)

No

Yes **Go to Question 53**

52\. What are your or your husband's or partner's reasons for not doing
anything to keep from getting pregnant *now*? Check [all]{.underline}
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:

**\[BOX\]**

**[Insertion point for Standard question(s) E1]{.underline}**

#### Insertion point for Standard question(s) E2

**[Insertion point for Standard question(s) L8--L9]{.underline}**

### Insertion point for Standard question(s) L16

**[Insertion point for Standard question(s) O1--O3]{.underline}**

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

**53. During the *12 months before* your new baby was born, what were
the sources of your household's income?** Check [all]{.underline} that
apply

Paycheck or money from a job

Money from family or friends

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

Aid such as Temporary Assistance for Needy Families (TANF), welfare,
WIC, public assistance, general assistance, food stamps, or Supplemental
Security Income

Unemployment benefits

Child support or alimony

Social security, workers' compensation, disability, veteran benefits, or
pensions

Other Please tell us:

**\[BOX\]**

**54. During the *12 months before* your new baby was born, what was
your total household income before taxes?** Include your income, your
husband's or partner's income, and any other income you may have used.
(All information will be kept private and will not affect any services
you are now getting.) Check [one]{.underline} answer

Less than \$10,000

\$10,000 to \$14,999

\$15,000 to \$19,999

\$20,000 to \$24,999

\$25,000 to \$34,999

\$35,000 to \$49,999

\$50,000 or more

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

**\[BOX\]** People

\[STATE-SPECIFIC SECTION (Standards without insertion points and
state-developed questions)\]

**56. What is today's date?**

  ---------------------- ------------------------ ------------------------
  **\[BOX\]**            **\[BOX\]**              **\[BOX\]**

  Month                  Day                      Year
  ---------------------- ------------------------ ------------------------

Please use this space for any additional comments you would like to make
about the health of mothers and babies in
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_.

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

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