with your help, more babies can be healthier.1 before pregnancy first, we would like to ask a few...

With your help,more babies can be healthier.

Pregnancy Risk Assessment Monitoring System (PRAMS)

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BEFORE PREGNANCY

First, we would like to ask a few questionsabout you and the time before you gotpregnant with your new baby.

1. At any time during the 12 months before yougot pregnant with your new baby, did you doany of the following things? For each item,circle Y (Yes) if you did it or circle N (No) ifyou did not.

No Yesa. I was dieting (changing my eating

habits) to lose weight . . . . . . . . . . . . . N Yb. I was exercising 3 or more days

of the week . . . . . . . . . . . . . . . . . . . . . N Yc. I was regularly taking prescription

medicines other than birth control . . . N Yd. I visited a health care worker to

be checked or treated for diabetes. . . . N Ye. I visited a health care worker to

be checked or treated for highblood pressure . . . . . . . . . . . . . . . . . . . N Y

f. I visited a health care worker tobe checked or treated for depressionor anxiety . . . . . . . . . . . . . . . . . . . . . . N Y

g. I talked to a health care workerabout my family medical history . . . . N Y

h. I had my teeth cleaned by a dentistor dental hygienist. . . . . . . . . . . . . . . . N Y

2. During the month before you got pregnantwith your new baby, were you covered byany of these health insurance plans?

q Health insurance from your job or the job of your husband, partner, orparents

q Health insurance that you or someone elsepaid for (not from a job)

q Medicaidq TRICARE or other military health careq Other source(s) Please tell us:

q I did not have any health insurance beforeI got pregnant

3. During the month before you got pregnantwith your new baby, how many times aweek did you take a multivitamin, aprenatal vitamin, or a folic acid vitamin?

q I didn’t take a multivitamin, prenatal vitamin, or folic acid vitamin at all

q 1 to 3 times a weekq 4 to 6 times a weekq Every day of the week

4. Just before you got pregnant with your newbaby, how much did you weigh?

Pounds OR Kilos

Check all that apply

Please mark your answers. Follow thedirections included with the questions. If no directions are presented, check thebox next to your answer or fill in theblanks. Because not all questions willapply to everyone, you may be asked toskip certain questions.

PRAMS_NYC_12_2_Eng_v1.qxd 12/2/08 3:08 PM Page 1

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5. How tall are you without shoes?

Feet Inches

OR Meters

6. What is your date of birth?

Month Day Year

7. Before you got pregnant with your newbaby, were you ever told by a doctor, nurse,or other health care worker that you hadType 1 or Type 2 diabetes? This is not thesame as gestational diabetes or diabetes thatstarts during pregnancy.

q Noq Yes

8. Before you got pregnant with your newbaby, did you ever have any other babieswho were born alive?

q Noq Yes

9. Did the baby born just before your new one weigh more than 5 pounds, 8 ounces(2.5 kilos) at birth?

q Noq Yes

10. Was the baby just before your new one bornmore than 3 weeks before his or her duedate?

q Noq Yes

Go to Question 11

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The next questions are about the time whenyou got pregnant with your new baby.

11. Thinking back to just before you gotpregnant with your new baby, how did youfeel about becoming pregnant?

q I wanted to be pregnant soonerq I wanted to be pregnant laterq I wanted to be pregnant thenq I didn’t want to be pregnant then

or at any time in the future

12. When you got pregnant with your newbaby, were you trying to get pregnant?

q Noq Yes

13. When you got pregnant with your newbaby, were you or your husband or partnerdoing anything to keep from gettingpregnant? (Some things people do to keepfrom getting pregnant include not having sexat certain times [natural family planning orrhythm] or withdrawal, and using birth controlmethods such as the pill, condoms, vaginalring, IUD, having their tubes tied, or theirpartner having a vasectomy.)

q Noq Yes Go to Question 15

Go to Question 16

Check one answer

Go to Question 14


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14. What were your reasons or your husband’sor partner’s reasons for not doing anythingto keep from getting pregnant?

q I didn’t mind if I got pregnant q I thought I could not get pregnant at that

time q I had side effects from the birth control

method I was using q I had problems getting birth control when

I needed it q I thought my husband or partner or I was

sterile (could not get pregnant at all) q My husband or partner didn’t want to use

anythingq Other Please tell us:

15. When you got pregnant with your newbaby, what were you or your husband orpartner using to keep from gettingpregnant?

q Tubes tied or closed (female sterilization)q Vasectomy (male sterilization)q Pillq Condomsq Injection once every 3 months

(Depo-Provera®) q Withdrawal (pulling out)q Other Please tell us:



If you or your husband or partner was notdoing anything to keep from getting pregnant,go to Question 16.

The next questions are about the prenatalcare you received during your most recentpregnancy. Prenatal care includes visits toa doctor, nurse, or other health care workerbefore your baby was born to get checkupsand advice about pregnancy. (It may help tolook at the calendar when you answer thesequestions.)

16. How many weeks or months pregnant wereyou when you were sure you were pregnant?(For example, you had a pregnancy test or adoctor or nurse said you were pregnant.)

Weeks OR Months

q I don’t remember

17. How many weeks or months pregnant wereyou when you had your first visit forprenatal care? Do not count a visit that wasonly for a pregnancy test or only for WIC (theSpecial Supplemental Nutrition Program forWomen, Infants, and Children).

Weeks OR Months

q I didn’t go for prenatal care Go to , Question 19

DURING PREGNANCY

{

Go to Page 4, Question 18


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18. Did you get prenatal care as early in yourpregnancy as you wanted?

q Noq Yes

19. Did any of these things keep you fromgetting prenatal care at all or as early as youwanted? For each item, circle T (True) if itwas a reason that you didn’t get prenatal carewhen you wanted or circle F (False) if it wasnot a reason for you or if something does notapply to you.

True Falsea. I couldn’t get an appointment

when I wanted one . . . . . . . . . . . . . . T Fb. I didn’t have enough money or

insurance to pay for my visits . . . . . T Fc. I had no transportation to get to

the clinic or doctor’s office . . . . . . . T Fd. The doctor or my health plan

would not start care as earlyas I wanted . . . . . . . . . . . . . . . . . . . . T F

e. I had too many other thingsgoing on . . . . . . . . . . . . . . . . . . . . . . T F

f. I couldn’t take time off from workor school. . . . . . . . . . . . . . . . . . . . . . T F

g. I didn’t have my Medicaid card . . . . T Fh. I had no one to take care of my

children. . . . . . . . . . . . . . . . . . . . . . . T Fi. I didn’t know that I was pregnant . . T Fj. I didn’t want anyone else to know

I was pregnant . . . . . . . . . . . . . . . . . T Fk. I didn’t want prenatal care . . . . . . . . T F

Go to Question 20

If you did not go for prenatal care, go to Question 22.

20. Did any of these health insurance planshelp you pay for your prenatal care?

q Health insurance from your job or the job of your husband, partner, or parents


q Medicaid q TRICARE or other military health care q PCAPq Other source(s) Please tell us:

q I did not have health insurance to helppay for my prenatal care



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21. During any of your prenatal care visits, did a doctor, nurse, or other health care workertalk with you about any of the things listedbelow? Please count only discussions, notreading materials or videos. For each item,circle Y (Yes) if someone talked with youabout it or circle N (No) if no one talked withyou about it.

No Yesa. How smoking during pregnancy

could affect my baby. . . . . . . . . . . . . . N Yb. Breastfeeding my baby . . . . . . . . . . . . N Yc. How drinking alcohol during

pregnancy could affect my baby . . . . . N Yd. Using a seat belt during my

pregnancy . . . . . . . . . . . . . . . . . . . . . . N Ye. Medicines that are safe to take during

my pregnancy . . . . . . . . . . . . . . . . . . . N Yf. How using illegal drugs could affect

my baby. . . . . . . . . . . . . . . . . . . . . . . . N Yg. Doing tests to screen for birth defects

or diseases that run in my family . . . . N Yh. The signs and symptoms of preterm

labor (labor more than 3 weeks beforethe baby is due) . . . . . . . . . . . . . . . . . . N Y

i. What to do if my labor starts early . . . N Yj. Getting tested for HIV (the virus

that causes AIDS) . . . . . . . . . . . . . . . . N Yk. What to do if I feel depressed during

my pregnancy or after my babyis born . . . . . . . . . . . . . . . . . . . . . . . . . N Y

l. Physical abuse to women by theirhusbands or partners . . . . . . . . . . . . . . N Y

22. At any time during your most recentpregnancy or delivery, did you have a testfor HIV (the virus that causes AIDS)?

q Noq Yesq I don’t know

23. During your most recent pregnancy, wereyou on WIC (the Special SupplementalNutrition Program for Women, Infants, and Children)?

q Noq Yes

24. During your most recent pregnancy, wereyou told by a doctor, nurse, or other healthcare worker that you had gestationaldiabetes (diabetes that started during thispregnancy)?

q Noq Yes


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

q 41 cigarettes or moreq 21 to 40 cigarettesq 11 to 20 cigarettesq 6 to 10 cigarettesq 1 to 5 cigarettesq Less than 1 cigaretteq I didn’t smoke then

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

q 41 cigarettes or moreq 21 to 40 cigarettesq 11 to 20 cigarettesq 6 to 10 cigarettesq 1 to 5 cigarettesq Less than 1 cigaretteq I didn’t smoke then

29. How many cigarettes do you smoke on anaverage day now? (A pack has 20 cigarettes.)

q 41 cigarettes or moreq 21 to 40 cigarettesq 11 to 20 cigarettesq 6 to 10 cigarettesq 1 to 5 cigarettesq Less than 1 cigaretteq I don’t smoke now

30. Which of the following statements bestdescribes the rules about smoking insideyour home now?

q No one is allowed to smoke anywhere inside my home

q Smoking is allowed in some rooms or at some times

q Smoking is permitted anywhere inside my home

Check one answer

25. Did you have any of the following problemsduring your most recent pregnancy? Foreach item, circle Y (Yes) if you had theproblem or circle N (No) if you did not.

No Yesa. Vaginal bleeding . . . . . . . . . . . . . . . . . N Yb. Kidney or bladder (urinary tract)

infection . . . . . . . . . . . . . . . . . . . . . . . N Yc. Severe nausea, vomiting, or

dehydration . . . . . . . . . . . . . . . . . . . . . N Yd. Cervix had to be sewn shut

(cerclage for incompetent cervix) . . . . N Ye. High blood pressure, hypertension

(including pregnancy-inducedhypertension [PIH]), preeclampsia,or toxemia . . . . . . . . . . . . . . . . . . . . . . N Y

f. Problems with the placenta (such asabruptio placentae or placenta previa) . . N Y

g. Labor pains more than 3 weeksbefore my baby was due (pretermor early labor) . . . . . . . . . . . . . . . . . . . N Y

h. Water broke more than 3 weeksbefore my baby was due (prematurerupture of membranes [PROM]). . . . . N Y

i. I had to have a blood transfusion . . . . N Yj. I was hurt in a car accident . . . . . . . . . N Y

The next questions are about smokingcigarettes around the time of pregnancy(before, during, and after).

26. Have you smoked any cigarettes in the past2 years?

q Noq Yes

Go to Question 30

Go to Question 27


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33a. During the last 3 months of your pregnancy,how many alcoholic drinks did you have inan average week?

q 14 drinks or more a weekq 7 to 13 drinks a weekq 4 to 6 drinks a weekq 1 to 3 drinks a weekq Less than 1 drink a weekq I didn’t drink

then

33b. During the last 3 months of your pregnancy,how many times did you drink 4 alcoholicdrinks or more in one sitting? A sitting is atwo hour time span.

q 6 or more times q 4 to 5 times q 2 to 3 times q 1 time q I didn’t have 4 drinks or more

in 1 sitting

Go to , Question 34

{The next questions are about drinkingalcohol around the time of pregnancy(before, during, and after).

31. Have you had any alcoholic drinks in thepast 2 years? A drink is 1 glass of wine, winecooler, can or bottle of beer, shot of liquor, ormixed drink.

q Noq Yes

32a. During the 3 months before you gotpregnant, how many alcoholic drinks did you have in an average week?

q 14 drinks or more a weekq 7 to 13 drinks a weekq 4 to 6 drinks a weekq 1 to 3 drinks a weekq Less than 1 drink a weekq I didn’t drink

then

32b. During the 3 months before you gotpregnant, how many times did you drink 4 alcoholic drinks or more in one sitting?A sitting is a two hour time span.

q 6 or more times q 4 to 5 times q 2 to 3 times q 1 time q I didn’t have 4 drinks or more

in 1 sitting

Go to Question 33a


{


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35. During the 12 months before you gotpregnant with your new baby, did yourhusband or partner push, hit, slap, kick,choke, or physically hurt you in any otherway?

q Noq Yes

36. During your most recent pregnancy, didyour husband or partner push, hit, slap,kick, choke, or physically hurt you in anyother way?

q Noq Yes

The next questions are about your laborand delivery. (It may help to look at thecalendar when you answer these questions.)

37. When was your baby due?

Month Day Year

38. When did you go into the hospital to haveyour baby?

Month Day Year

q I didn’t have my baby in a hospital

20

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Pregnancy can be a difficult time for somewomen. The next questions are aboutthings that may have happened before andduring your most recent pregnancy.

34. This question is about things that may havehappened during the 12 months before yournew 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 look at thecalendar when you answer these questions.)

No Yesa. A close family member was very sick

and had to go into the hospital . . . . . . N Yb. I got separated or divorced from my

husband or partner . . . . . . . . . . . . . . . N Yc. I moved to a new address . . . . . . . . . . N Yd. I was homeless . . . . . . . . . . . . . . . . . . N Ye. My husband or partner lost his job . . . N Yf. I lost my job even though I wanted

to go on working . . . . . . . . . . . . . . . . . N Yg. I argued with my husband or partner

more than usual. . . . . . . . . . . . . . . . . . N Yh. My husband or partner said he

didn’t want me to be pregnant . . . . . . N Yi. I had a lot of bills I couldn’t pay. . . . . N Yj. I was in a physical fight . . . . . . . . . . . N Yk. My husband or partner or I

went to jail . . . . . . . . . . . . . . . . . . . . . N Yl. Someone very close to me had a

problem with drinking or drugs . . . . . N Ym. Someone very close to me died . . . . . N Y


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AFTER PREGNANCY39. When was your baby born?

Month Day Year

40. When were you discharged from thehospital after your baby was born?

Month Day Year

q I didn’t have my baby in a hospital

41. Did any of these health insurance plans helpyou pay for the delivery of your new baby?

q Health insurance from your job or the job of your husband, partner, orparents


q Medicaid q TRICARE or other military health careq PCAPq Other source(s) Please tell us:

q I did not have health insurance to helppay for my delivery


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20The next questions are about the time sinceyour new baby was born.

42. After your baby was born, was he or sheput in an intensive care unit?

q Noq Yesq I don’t know

43. After your baby was born, how long did heor she stay in the hospital?

q Less than 24 hours (less than 1 day)q 24 to 48 hours (1 to 2 days)q 3 to 5 daysq 6 to 14 days q More than 14 daysq My baby was not born in a hospitalq My baby is

still in the hospital

44. Is your baby alive now?

q Noq Yes

45. Is your baby living with you now?

q Noq Yes



Go to , Question 46

{



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49. What were your reasons for stoppingbreastfeeding?

q My baby had difficulty latching ornursing

q Breast milk alone did not satisfy my baby q I thought my baby was not gaining

enough weight q My nipples were sore, cracked, or

bleeding q It was too hard, painful, or too time

consumingq I thought I was not producing enough

milk q I had too many other household duties q I felt it was the right time to stop

breastfeedingq I got sick and was not able to breastfeed q I went back to work or school q My baby was jaundiced (yellowing of the

skin or whites of the eyes) q Other Please tell us:


46. Did you ever breastfeed or pump breastmilk to feed your new baby after delivery,even for a short period of time?

q Noq Yes

47. Are you currently breastfeeding or feedingpumped milk to your new baby?

q Noq Yes

48. How many weeks or months did youbreastfeed or pump milk to feed your baby?

Weeks OR Months

q Less than 1 week

Go to Question 50

Go to Question 51b


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50. This question asks about things that mayhave happened at the hospital where yournew baby was born. For each item, circle Y (Yes) if it happened or circle N (No) if itdid not happen.

No Yesa. Hospital staff gave me

information about breastfeeding . . . . . N Yb. My baby stayed in the same room

with me at the hospital . . . . . . . . . . . . N Yc. I breastfed my baby in the hospital . . . N Yd. I breastfed in the first hour after

my baby was born . . . . . . . . . . . . . . . . N Ye. Hospital staff helped me learn

how to breastfeed . . . . . . . . . . . . . . . . N Yf. My baby was fed only

breast milk at the hospital . . . . . . . . . . N Yg. Hospital staff told me to breastfeed

whenever my baby wanted . . . . . . . . . N Yh. The hospital gave me a

breast pump to use . . . . . . . . . . . . . . . N Yi. The hospital gave me a gift pack

with formula . . . . . . . . . . . . . . . . . . . . N Yj. The hospital gave me a telephone

number to call for help with breastfeeding. . . . . . . . . . . . . . . . N Y

k. My baby used a pacifier in the hospital . . . . . . . . . . . . . . . . . . . . . . . . N Y

51a. How old was your new baby the first timehe or she drank liquids other than breastmilk (such as formula, water, juice, tea, orcow’s milk)?

Weeks OR Months

q My baby was less than 1 week oldq My baby has not had any liquids other

than breast milk

51b. How old was your new baby the first timehe or she ate food (such as baby cereal,baby food, or any other food)?

Weeks OR Months

q My baby was less than 1 week oldq My baby has not eaten any foods

52. In which one position do you most often layyour baby down to sleep now?

q On his or her sideq On his or her backq On his or her stomach

53. Was your new baby seen by a doctor, nurse,or other health care worker for a one weekcheck-up after he or she was born?

q Noq Yes

54. Are you or your husband or partner doinganything now to keep from gettingpregnant? (Some things people do to keepfrom getting pregnant include not having sexat certain times [natural family planning orrhythm] or withdrawal, and using birth controlmethods such as the pill, condoms, vaginalring, IUD, having their tubes tied, or theirpartner having a vasectomy.)

q Noq Yes Go to , Question 56

Check one answer

If your baby is still in the hospital, go to Question 54.


If your baby was not born in a hospital, go toQuestion 51a.


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55. What are your reasons or your husband’sor partner’s reasons for not doing anythingto keep from getting pregnant now?

q I am not having sexq I want to get pregnantq I don’t want to use birth controlq My husband or partner doesn’t want to

use anythingq I don’t think I can get pregnant (sterile)q I can’t pay for birth controlq I am pregnant nowq Other Please tell us:

56. What kind of birth control are you or yourhusband or partner using now to keep fromgetting pregnant?

q Tubes tied or closed (female sterilization)q Vasectomy (male sterilization) q Pill q Condoms q Injection once every 3 months

(Depo-Provera®) q Withdrawal (pulling out) q Not having sex (abstinence) q Other Please tell us:

57. Since your new baby was born, have you had a postpartum checkup for yourself? (A postpartum checkup is the regular checkupa woman has about 6 weeks after she givesbirth.)

q No q Yes



58. Below is a list of feelings and experiencesthat women sometimes have after childbirth.Read each item to determine how well itdescribes your feelings and experiences.Then, write on the line the number of thechoice that best describes how often youhave felt or experienced things this waysince your new baby was born. Use the scalewhen answering:

1 2 3 4 5Never Rarely Sometimes Often Always

a. I felt down, depressed, or sad. . . ___

b. I felt hopeless . . . . . . . . . . . . . . . ___

c. I felt slowed down . . . . . . . . . . . ___

The next questions are on a variety oftopics.

59. Before you got pregnant with your newbaby, had you ever heard or read aboutemergency birth control (the “morning-after pill”)? This combination of pills is usedto prevent pregnancy up to 3 days afterunprotected sex.

q Noq Yes

60. Did you receive medical treatment to helpyou get pregnant with your new baby?

q No q Yes

Go to Question 62

OTHER EXPERIENCES

If you or your husband or partner is not doinganything to keep from getting pregnant now,go to Question 57.

Go to Question 61


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65. Does your new baby usually sleep in thesame bed with you or another adult orchild?

q Noq Yes

66. Since your new baby was born, have youbeen tested for diabetes or high bloodsugar?

q No q Yes

67. Since your new baby was born, did a doctor,nurse, or other health care worker tell youthat you had diabetes?

q No q Yes

68. Did a doctor, nurse, or other health careworker tell you that you had prediabetes,borderline diabetes or high blood sugar?

q Noq Yes

69. Have you ever had your teeth cleaned by adentist or dental hygienist?

q No q Yes

70. How long has it been since you had yourteeth cleaned by a dentist or a dentalhygienist?

q Within the past year (less than 12 months)q 1 to less than 2 years (12 to 23 months)q 2 to less than 5 yearsq 5 or more years

Go to , Question 71

Go to Question 69

Go to Question 69

61. Which treatment(s) did you receive?

q Drugs to help you ovulate q Artificial/intrauterine insemination q In vitro fertilization (IVF) q Egg donation q Other Please tell us:

62. During your prenatal care, labor, ordelivery, do you feel you were ever treateddifferently because of any of the following?For each item, circle Y (Yes) if it happened orcircle N (No) if it did not happen.

No Yesa. My race . . . . . . . . . . . . . . . . . . . . . . . . N Yb. My culture. . . . . . . . . . . . . . . . . . . . . . N Yc. My ability to speak or

understand English . . . . . . . . . . . . . . . N Y

63. Where does your new baby usually sleep?

q In a crib, cradle or bassinetq On an adult bed or mattressq Someplace else? Please tell us:

64. Does your new baby usually sleep withbumpers, pillows, or toys?

q No q Yes

Check one answer


If your baby is not alive or is not living withyou now, go to Question 66.


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71. Are you currently in school?

q Noq Yes

72. Are you currently working outside thehome?

q Noq Yes

73. What language do you usually speak athome?

q Englishq Spanishq Russianq Chinese (includes Mandarin &

Cantonese)q Indian (includes Hindi & Tamil) q Creoleq Frenchq Other Please tell us:

74. Were you born outside the United States?(Please include Puerto Rico as outside of theUS.)

q No q Yes

75. How old were you when you moved to theUnited States?

Age in years

Go to Question 76

Check one answer

76. In the last 30 days, have you beenconcerned about having enough food foryou or your family?

q Noq Yes

The last questions are about the timeduring the 12 months before your new babywas born.

77. During the 12 months before your new babywas born, what was your yearly totalhousehold income before taxes? Includeyour income, your husband’s or partner’sincome, and any other income you may havereceived. (All information will be kept privateand will not affect any services you are nowgetting.)

q Less than $10,000q $10,000 to $14,999q $15,000 to $19,999q $20,000 to $24,999q $25,000 to $34,999q $35,000 to $49,999q $50,000 to $74,999q $75,000 or more

78. During the 12 months before your new babywas born, how many people, includingyourself, depended on this income?

People

79. What is today’s date?

Month Day Year

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

Thanks for answering our questions!

Your answers will help us work to make New York Citymothers and babies healthier.

December 2, 2008


with your help, more babies can be healthier.1 before pregnancy first, we would like to ask a few...

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