PREGNANCY RISK ASSESSMENT MONITORING SYSTEM (PRAMS) UTAH QUESTIONNAIRE

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1 PREGNANCY RISK ASSESSMENT MONITORING SYSTEM (PRAMS) UTAH QUESTIONNAIRE First, we wuld like t ask yu a few questins abut the time befre yur new baby was brn. Please check the bx next t the best answer. 1. Befre yur new baby, did yu ever have any ther babies wh were brn alive? N >G t Questin 4 Yes 2. Did the baby just befre yur new ne weigh 5 punds, 8 unces r less at birth? N Yes 3. Was the baby just befre yur new ne brn mre than 3 weeks befre its due date? N Yes Next are sme questins abut the time just befre and during yur pregnancy with yur new baby. It may help t lk at the calendar when yu answer these questins. 4. Hw many weeks r mnths pregnant were yu when yu were sure yu were pregnant? (Fr example, yu had a pregnancy test r a dctr r nurse said yu were pregnant.) Weeks r Mnths I dn t remember 5. Thinking back t just befre yu gt pregnant, hw did yu feel abut becming pregnant? Check the best answer. I wanted t be pregnant sner I wanted t be pregnant later I wanted t be pregnant then I didn t want t be pregnant then r at any time in the future I dn t knw 6. Just befre yu gt pregnant, did yu have health insurance? Dn t cunt Medicaid. N Yes 7. Just befre yu gt pregnant, were yu n Medicaid? N Yes 8. When yu gt pregnant with yur new baby, were yu r yur husband r partner using any kind f birth cntrl? Birth cntrl means the pill, cndms, diaphragm, fam, rhythm, Nrplant, shts (Dep-Prvera ) r ANY ther way t keep frm getting pregnant. N Yes >G t Questin Why were yu r yur husband r partner nt using any birth cntrl? Check all that apply. I wanted t get pregnant I didn t think I culd get pregnant I had side effects frm the birth cntrl I used I didn t want t use birth cntrl I didn t think yu were ging t have sex My husband r partner didn t want t use birth cntrl Other Please tell us:

2 The next questins are abut the prenatal care yu gt during yur mst recent pregnancy. Prenatal care includes visits t a dctr, nurse, r ther health care wrker befre yur baby was brn t get check-ups and advice abut pregnancy. It may help t lk at a calendar when yu answer these questins. 10. Hw many weeks r mnths pregnant were yu when yu had yur first visit fr prenatal care? Dn t cunt a visit that was nly fr a pregnancy test r nly fr WIC (Wmen, Infants, and Children s Nutritin Prgram). Weeks r Mnths I did nt g fr prenatal care 11. Did yu get prenatal care as early in yur pregnancy as yu wanted? N Yes -->G t Questin 13 I did nt want prenatal care -->G t Questin Did any f these things keep yu frm getting prenatal care as early as yu wanted? Check all that apply. I culdn t get an appintment earlier in my pregnancy I didn t have enugh mney r insurance t pay fr my visits I didn t knw that I was pregnant I had n way t get t the clinic r dctr s ffice I culdn t find a dctr r a nurse wh wuld take me as a patient I had n ne t take care f my children I had t many ther things ging n Other Please tell us: If yu did nt g fr prenatal care, g t questin During each mnth f yur pregnancy, abut hw many visits fr prenatal care did yu have? If yu dn t knw exactly hw many, please give us yur best guess. Dn t cunt visits fr WIC. It may help t use the calendar. Mnth f Pregnancy First mnth Secnd mnth Third mnth Furth mnth Fifth mnth Sixth mnth Seventh mnth Eighth mnth Ninth mnth Hw many visits? I did nt g fr prenatal care G t questin Where did yu g mst f the time fr yur prenatal visits? Dn t include visits fr WIC. Check ne answer. Hspital clinic Health department clinic Private dctr s ffice Cmmunity health clinic Other Please tell us: 15. Hw was yur prenatal care paid fr? Check all that apply. Medicaid Persnal incme (cash, check r credit card) Health insurance Indian Health Service (IHS) Other please tell us:

3 16. During any f yur prenatal care visits, did a dctr, nurse, r ther health care wrker talk with yu abut any f the things listed belw? Fr each thing, please circle Y (Yes) if smene talked with yu abut it r N (N) if n ne talked with yu abut it. What yu shuld eat during yur pregnancy N Y Hw smking during pregnancy culd affect yur baby N Y Breast-feeding yur baby N Y Hw drinking alchl during pregnancy culd affect yur baby N Y Using a seat belt during yur pregnancy N Y Birth cntrl methds t use after yur pregnancy N Y The kinds f medicines that were safe t take during yur pregnancy N Y Hw using illegal drugs culd affect yur baby N Y Hw yur baby grws and develps during yur pregnancy N Y What t d if yur labr starts early N Y Hw t keep frm getting HIV (the virus that causes AIDS) N Y Getting yur bld tested fr HIV (the virus that causes AIDS) N Y Physical abuse t wmen by their husbands r partners N Y 17. During yur pregnancy, were yu n WIC? N Yes 18. Just befre yu gt pregnant, hw much did yu weigh? Punds I dn t knw 19. Hw tall are yu withut shes? Feet inches 20. Have yu ever heard r read that taking the vitamin flic acid can help prevent sme birth defects? N Yes The next questins are abut smking cigarettes and drinking alchl. 21. Have yu smked at least 100 cigarettes in yur entire life? N >G t Questin 25 Yes 22. In the 3 mnths befre yu gt pregnant, hw many cigarettes r packs f cigarettes did yu smke n an average day? (A pack has 20 cigarettes.) Cigarettes r Packs Less than 1 cigarette a day I didn t smke I dn t knw

4 23. In the last 3 mnths f yur pregnancy, hw many cigarettes r packs f cigarettes did yu smke n an average day? (A pack has 20 cigarettes.) Cigarettes r Packs Less than 1 cigarette a day I didn t smke I dn t knw 24. Hw many cigarettes r packs f cigarettes d yu smke n an average day nw? Cigarettes r Packs Less than 1 cigarette a day I didn t smke I dn t knw 25a. During the 3 mnths befre yu gt pregnant, hw many alchlic drinks did yu have in an average week? (A drink is: One glass f wine, One wine cler, One can r bttle f beer, One sht f liqur, One mixed drink.) I didn t drink then Less than 1 drink a week 1 t 3 drinks a week 4 t 6 drinks a week 7 t 13 drinks a week 14 drinks r mre a week I dn t knw 25b. During the 3 mnths befre yu gt pregnant, hw many times did yu drink 5 r mre alchlic drinks at ne sitting? Times I didn t drink then I dn t knw 26a. During the last 3 mnths f yur pregnancy, hw many alchlic drinks did yu have in an average week? I didn t drink then Less than 1 drink a week 1 t 3 drinks a week 4 t 6 drinks a week 7 t 13 drinks a week 14 drinks r mre a week I dn t knw 26b. During the last 3 mnths f yur pregnancy, hw many times did yu drink 5 r mre alchlic drinks at ne sitting? Times I didn t drink then I dn t knw

5 The next questins are abut times yu may have had t stay in the hspital while yu were pregnant. Please DO NOT COUNT the time yu went t the hspital t have yur baby. 27. Nt cunting the time yu went t the hspital t have yur baby, hw many ther times during yur pregnancy did yu g int a hspital and stay at least ne night? Nne---->G t Questin 30 1 time 2 times 3 times 4 times r mre 28. What prblems caused yu t stay in the hspital? Check all f the prblems that yu had. Labr pains mre than 3 weeks befre yur due date (Premature labr) High bld pressure (preeclampsia r txemia) Vaginal bleeding r placenta prblems Nausea, vmiting r dehydratin Kidney r bladder infectin High bld sugar (diabetes) Other Please tell us: 29. Hw many mnths pregnant were yu the first time yu had t g int a hspital and stay at least ne night? Mnths Pregnancy can be a difficult time fr sme wmen. The next questins are abut sme things that may have happened t yu befre and during yur mst recent pregnancy. 30. This questin is abut things that may have happened during the 12 mnths befre yu delivered yur new baby. This includes the mnths befre yu gt pregnant. Fr each thing, circle Y (Yes) if it happened t yu r N (N) if it did nt. It may help t use the calendar. A clse family member was very sick and had t g int the hspital N Y Yu gt separated r divrced frm yur husband r partner N Y Yu mved t a new address N Y Yu were hmeless N Y Yur husband r partner lst his jb N Y Yu lst yur jb even thugh yu wanted t g n wrking N Y Yu and yur husband r partner argued mre than usual N Y Yur husband r partner said he did nt want yu t be pregnant N Y Yu had a lt f bills yu culdn t pay N Y Yu were invlved in a physical fight N Y Yu r yur husband r partner went t jail N Y Smene very clse t yu had a bad prblem with drinking r drugs N Y Smene very clse t yu died N Y The next questins are abut physical abuse. Physical abuse means pushing, hitting, slapping, kicking, r any ther way f physically hurting smene. 31. During the 12 mnths befre yu gt pregnant with yur new baby, did any f these peple physically abuse yu? Check all that apply. My husband r partner A family r husehld member ther than my husband r partner A friend Smene else Please tell us: N ne physically abused me during the 12 mnths befre I gt pregnant

6 32. During yur mst recent pregnancy, did any f these peple physically abuse yu? Check all that apply. My husband r partner A family r husehld member ther than my husband r partner A friend Smene else Please tell us: N ne physically abused me during my pregnancy -- G t questin During yur mst recent pregnancy, wuld yu say that yu were physically abused mre ften, less ften, r abut the same cmpared with the 12 mnths befre yu gt pregnant? Check nly ne. I was physically abused mre ften during my pregnancy I was physically abused less ften during my pregnancy I was physically abused abut the same during my pregnancy N ne physically abused me during the 12 mnths befre I gt pregnant The next questins are abut yur labr and delivery. 34. When was yur baby due? 35. When was yur baby brn? _/_/_ mnth day year _/_/_ mnth day year 36. When did yu g int the hspital t have yur baby? _/_/_ mnth day year I did nt have my baby in a hspital 37. When yu had yur baby, hw many nights did yu stay in the hspital? Nights I did nt stay vernight in the hspital I did nt have my baby in a hspital 38. When yur baby was brn, hw many nights did he r she stay in the hspital? Nights My baby did nt stay vernight in the hspital My baby was nt brn in a hspital 39. When yur baby was brn, was he r she put in an intensive care unit? N Yes I dn t knw 40. Hw was yur delivery paid fr? Check all that apply Medicaid Persnal incme (cash, check r credit card) Health insurance Indian Health Service (IHS) Other Please tell us:

7 41. Is yur baby alive nw? N---> When did yur baby die? / / mnth day year Yes ---> Is yur baby living with yu nw? N Yes If yur baby is nt alive r is nt living with yu nw, g t questin Fr hw many weeks did yu breast-feed yur new baby? Weeks I didn t breast-feed my baby ---->G t Questin 44 I breast-fed less than 1 week---->g t Questin 44 I m still breast-feeding 43. Hw many weeks ld was yur baby the first time yu fed him r her anything besides breast milk? Include frmula, baby fd, juice, cw s milk r anything else. Weeks My baby was less than ne week ld I haven t fed my baby anything besides breast milk 44. Abut hw many hurs a day, n average, is yur new baby in the same rm with smene wh is smking? Hurs My baby is never in the same rm with smene wh is smking. 45. Hw d yu put yur new baby dwn t sleep mst f the time? Check ne answer. On his r her side On his r her back On his r her stmach 46. Hw many times has yur baby been t a dctr r nurse fr rutine well baby care? Dn t cunt the times yu tk yur baby fr care when he r she was sick. It may help t use the calendar. Times My baby hasn t been fr rutine well baby care----->g t Questin When yur baby ges fr rutine well baby care, where d yu take him r her? Check all the places that yu use. Hspital clinic Health department clinic Private dctr s ffice Cmmunity health clinic Other Please tell us: The next questins are abut yur family and the place where yu live.

8 48. Which rms are in the huse, apartment, r trailer where yu live? Check all that yu have. Bedrms -- hw many? Living rm Separate dining rm Kitchen Bathrm(s) Recreatin rm, den r family rm Finished basement 49. Hw many peple live in yur huse, apartment, r trailer. Cunt yurself. Babies, children, r teens aged 17 r yunger Adults aged 18 r lder Hw many? 50. What were the surces f yur family incme during the past 12 mnths? Check all that apply. Mney frm a jb r business Aid such as FEP (frmerly AFDC), welfare, public assistance, general assistance, fd stamps, r SSI Unemplyment benefits Child supprt r alimny Fees, rental incme, cmmissins, interest, r dividends Scial security, wrkers cmpensatin, veteran benefits, r pensins Other - Please tell us: 51. What is tday s date? // mnth day year 52. What is yur date f birth? // mnth day year If yu did nt g fr prenatal care, g t Questin At any time during yur prenatal care, did a dctr, nurse, r ther health care wrker ask yu r talk with yu abut any f the things listed belw? Fr each thing, circle Y (Yes) if smene talked with yu abut it r N (N) if n ne talked with yu abut it. Diseases r birth defects that culd run in yur family? N Y Ding tests t see if yur baby had a birth defect r genetic disease? N Y Hw much weight yu shuld gain during yur pregnancy? N Y If yu were smking? N Y If yu were drinking alchlic beverages (beer, wine, wine cler, r liqur)? N Y 54. During yur mst recent pregnancy, wh wuld have helped yu if a prblem had cme up? (Fr example, wh wuld have helped yu if yu needed t brrw $50 r if yu gt sick and had t be in bed fr several weeks?) Check all that apply. My husband r partner My mther, father, r in-laws Other family member r relative A friend Smene else -- Please tell us: N ne wuld have helped me

9 The fllwing questins are abut birth cntrl and family planning. Birth cntrl means having yur tubes tied, vasectmy, the pill, cndms, diaphragm, fam, rhythm, Nrplant, shts (Dep-Prvera ), r ANY ther way t keep frm getting pregnant. 55. Are yu r yur husband r partner using any kind f birth cntrl nw? N >G t Questin 57 Yes 56. What kind f birth cntrl peple are yu r yur husband r partner using nw? Check all that apply and then g t Questin 58. Tubes tied (sterilizatin) Vasectmy (sterilizatin). Pill Cndms Fam, jelly, cream Nrplant Shts (Dep-Prvera ) Withdrawal Abstinence Other - Please tell us: 57. What are yur reasns fr nt using any birth cntrl? Check all that apply. I am nt having sex I want t get pregnant I dn t want t use birth cntrl My husband r partner desn t want t use birth cntrl I dn t think I can get pregnant I can t pay fr birth cntrl I am pregnant nw Other Please tell us: If yur baby is nt alive r is nt living with yu nw, g t questin 60. If yu never breast-fed yur new baby, g t questin D yu breast-feed yur new baby nw? N Yes >G t Questin What were yur reasns fr stpping breast-feeding? Check all that apply. I didn t want t keep breast-feeding I had t g t wrk r schl I tried but yur baby didn t breast-feed very well I didn t have enugh milk I felt it was the right time t stp My baby was nt with me I was taking medicine Other Please tell us: 60. In the mnths after yur delivery, wuld yu say that yu were - Check the best answer. Nt depressed at all A little depressed Mderately depressed Very depressed Very depressed and had t get help

10 61. What was yur ttal husehld incme during the 12 mnths befre yu delivered yur mst recent baby? Less than $10,000 $10,000 t less than $15,000 $15,000 t less than $20,000 $20,000 t less than $25,000 $25,000 t less than $35,000 $35,000 t less than $50,000 $50,000 t less than $75,000 $75,000 r mre 62. Hw many peple, including yurself, depended n this incme? Peple If yu were nt physically abused by anyne during the 12 mnths befre r during yur mst recent pregnancy, g t the end f the survey. The next questins are abut physically abuse. Physical abuse means pushing, hitting, slapping, kicking, r any ther way f physically hurting smene. 63. When yu were physically abused during the 12 mnths befre r during yur mst recent pregnancy, wh did yu receive help frm? Fr each ne, circle Y (Yes) if it applies t yu r circle N (N) if it des nt. Family member N Y Friend N Y My dctr N Y Emergency rm r urgent care medical facility N Y Other health care prvider N Y Cunselr, therapist, r scial wrker N Y Religius advisr N Y Law enfrcement N Y Statewide Dmestic Vilence Infrmatin Line ( LINK) N Y Other If yes, please tell us: N Y I didn t get any help N Y If yu did receive any help when yu were physically abused by anyne during the 12 mnths befre r during her mst recent pregnancy, g t the end f the survey. 63. If yu did nt receive help, please tell us what kept yu frm receiving help. Fr each thing, circle Y (Yes) if it applies t yu r circle N (N) if it des nt. I did nt knw where t get help. N Y I did nt have the mney t pay fr services. N Y I was afraid the persn wh physically hurt me wuld find ut N Y It was my fault that I was physically hurt. N Y I thught the abuse wuld stp. N Y I did nt have smene t tend my children N Y I was afraid smene wuld take my children away frm me N Y I did nt have a way t get there N Y I did nt want any help N Y Other - If yes, please tell us: N Y Please use this space fr any additinal cmments yu wuld like t make abut the health f mthers and babies in Utah. Thanks fr answering ur questins! Yur answers will help us t wrk t make Utah mthers and babies healthier.

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