Number range CHAPTERPregnancy Risk Assessment Monitoring System (PRAMS)

Phase 4 Core Questionnaire

**First, we would like to ask a few questions about you and the time
before you became 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\. 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 didn't take a multivitamin 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?

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

Month Day Year

5\. *Just before* you got pregnant, how much did you weigh?

Pounds **OR** Kilos

6\. How tall are you without shoes?

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

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

**[Insertion point for Standard question(s) L10-L11]{.underline}**

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

No º **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}**

10\. Thinking back to *just before* you got pregnant, 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 become
pregnant?

No

Yes º **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 \[rhythm\], 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 º **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 º 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 a
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? (Don't 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 **Go to Question 18**![](media/image1.emf){width="0.95in"
height="8.402777777777778e-2in"}

I didn't want prenatal care **Go to Question
18**![](media/image2.emf){width="0.45in"
height="8.402777777777778e-2in"}

17\. Did any of these things keep you from getting prenatal care as
early as you wanted?

**Check [all]{.underline} 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 didn't have my Medicaid card

I had no one to take care of my children

I had too many other things going on

Other º Please tell us:

**\[BOX\]**

**If you did not go for prenatal care, go to Page 4, Question 21.**

18\. Where did you go *most of the time* for your prenatal visits? (Do
not include visits for WIC.)

**Check [one]{.underline} answer**

Hospital clinic

Health department clinic

Private doctor's office or HMO clinic

Other º Please tell us:

**\[BOX\]**

19\. How was your prenatal care paid for?

**Check [all]{.underline} that apply**

Medicaid

Personal income (cash, check, or credit card)

Health insurance or HMO

Other º Please tell us:

**\[BOX\]**

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 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 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

**[Insertion point for Standard question(s) R1-R5]{.underline}**

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

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

**[Insertion point for Standard question(s) I1-I4]{.underline}**

**[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 pregnancy, were you on WIC (the Special Supplemental
Nutrition Program for Women, Infants, and Children)?

No

Yes

22\. Did you have any of these problems during your pregnancy? For each
item, circle **Y** (Yes) if you had the problem or circle **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 preeclampsia or toxemia) or retained
water (edema) N Y

c\. Vaginal bleeding N Y

d\. Problems with the placenta (such as abruptio placentae, 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 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 problem(s)?

**Check [all]{.underline} that apply**

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

I went to the hospital and stayed 1 to 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's or
nurse's advice

**[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 º **Go to Question 28**

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.)

**\[BOX\]** Cigarettes **OR** **\[BOX\]** 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 many cigarettes or
packs of cigarettes did you smoke on an average day?

**\[BOX\]** Cigarettes **OR** **\[BOX\]** 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*?

**\[BOX\]** Cigarettes **OR** **\[BOX\]** Packs

Less than 1 cigarette a day

I don't smoke

I don't know

**[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 º **Go to Question 31**

Yes

29\. a. 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

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

**\[BOX\]** Times

I didn't drink then

I don't know

30\. a. 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

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

**\[BOX\]** Times

I didn't drink then

I don't know

**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\. 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 didn't want you to be pregnant N Y

i\. You had a lot of bills you couldn't 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

32\. a. *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

> b\. *During the 12 months before you got pregnant*, did anyone else
> physically hurt you in any way?

No

Yes

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

No

Yes

> b\. *During your most recent pregnancy,* did anyone else physically
> hurt you in any way?

No

Yes

**[Insertion point for Standard question(s) M1]{.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

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

No

Yes

I don't know

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

Less than 24 hours (Less than 1 day)

24--48 hours (1--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

40\. How was your delivery paid for?

**Check [all]{.underline} that apply**

Medicaid

Personal income (cash, check, or credit card)

Health insurance or HMO

Other º Please tell us:

**\[BOX\]**

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

41\. What is today's date?

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

Month Day Year

42\. Is your baby alive now?

No

Yes º **Go to Question 44**

43\. When did your baby die?

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

Month Day Year

**Go to Page 11, Question 56**

44\. Is your baby living with you now?

No º **Go to Page 11, Question 56**

Yes

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

No º **Go to Question 49**

Yes

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

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

No

Yes º **Go to Question 48**

47\. 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}**

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.)

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

My baby was less than one week old

I have not fed my baby anything besides breast milk

**If your baby is still in the hospital, go to Page 11, Question 56.**

49\. 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 one hour a day

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

50\. 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}**

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 º **Go to Question 53**

Yes

52\. Was your new 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 º **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.)

**\[BOX\]** Times

55\. Where do you usually take your baby for well-baby checkups?

**Check [one]{.underline} answer**

Hospital clinic

Health department clinic

Private doctor's office or HMO clinic

Other º Please tell us:

**\[BOX\]**

**[Insertion point for Standard question(s) H5]{.underline}**

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

**[Insertion point for Standard question(s) X1-X3]{.underline}**

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

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

**The next few questions are about the time after you gave birth to your
new baby and things that may have happened after delivery.**

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 º **Go to Question 58**

57\. 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 º Please tell us:

**\[BOX\]**

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

**[Insertion point for Standard question(s) E2]{.underline}**

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

**[Insertion point for Standard question(s) M2-M3]{.underline}**

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

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

58\. Which rooms are in the house, apartment, or trailer where you live?

**Check [all]{.underline} that apply**

Living room

Separate dining room

Kitchen

Bathroom(s)

Recreation room, den, or family room

Finished basement

Bedrooms º How many? **\[BOX\]**

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

**\[BOX\]** Adults (people aged 18 years or older)

**\[BOX\]** Babies, children, or teenagers (people aged 17 years or
younger)

**[Insertion point for Standard question(s) P1-P6]{.underline}**

**[Insertion point for Standard question(s) P9-P10]{.underline}**

60\. What were the sources of your household's income during the past 12
months?

**Check [all]{.underline} that apply**

Paycheck or money from a job

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

Unemployment benefits

Child support or alimony

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

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

Money from family or friends

Other º Please tell us:

**\[BOX\]**

**[Insertion point for Standard question(s) J1]{.underline}**

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.***