1 First, we would like to ask a few questions 6. How tall are you without shoes? about you and the time before you became pregnant with your new baby. Please Feet Inches check the box next to your answer. OR Centimeters 1. Just before you got pregnant, did you have health insurance? (Do not count Medicaid.) 7. Before your new baby, did you ever have ‘ No any other babies who were born alive? ‘ Yes ‘ No º Go to Question 10 ‘ Yes 2. Just before you got pregnant, were you on Medicaid? 8. Did the baby born just before your new one ‘ No weigh 5 pounds, 8 ounces (2.5 kilos) or less ‘ Yes at birth?

‘ No 3. In the month before you got pregnant with ‘ Yes your new baby, how many times a week did you take a multivitamin (a pill that contains many different vitamins and minerals)? 9. Was the baby just before your new one born more than 3 weeks before its due date? ‘ I didn’t take a multivitamin at all ‘ 1 to 3 times a week ‘ No ‘ 4 to 6 times a week ‘ Yes ‘ Every day of the week

10. Thinking back to just before you got 4. What is your date of birth? pregnant, how did you feel about becoming pregnant?

Check one answer Month Day Year ‘ I wanted to be pregnant sooner ‘ I wanted to be pregnant later 5. Just before you got pregnant, how much did ‘ I wanted to be pregnant then you weigh? ‘ I didn’t want to be pregnant then or at any time in the future

Pounds OR Kilos 2 15 11. When you got pregnant with your new The next questions are about the prenatal Please use this space for any additional comments you would like to make about the health of baby, were you trying to become care you received during your most recent mothers and babies in Ohio. pregnant? pregnancy. Prenatal care includes visits to a doctor, nurse, or other health care ‘ No ‘ Yes º Go to Question 14 worker before your baby was born to get checkups and advice about pregnancy. (It 12. When you got pregnant with your new may help to look at a calendar when you baby, were you or your husband or answer these questions.) partner doing anything to keep from getting pregnant? (Some things people do 14. How many weeks or months pregnant to keep from getting pregnant include not were you when you were sure you were having sex at certain times [rhythm], and pregnant? (For example, you had a using birth control methods such as the pill, pregnancy test or a doctor or nurse said you Norplant®, shots [Depo-Provera®], were pregnant.) condoms, diaphragm, foam, IUD, having their tubes tied, or their partner having a vasectomy.) Weeks OR Months

‘ No ‘ I don’t remember ‘ Yes º Go to Question 14

13. What were your or your husband’s or 15. How many weeks or months pregnant partner’s reasons for not doing anything were you when you had your first visit for to keep from getting pregnant? prenatal care? (Don’t count a visit that was only for a pregnancy test or only for WIC Check all that apply [the Special Supplemental Nutrition Program for Women, Infants, and Children].) ‘ I didn’t mind if I got pregnant ‘ I thought I could not get pregnant at that time Weeks OR Months ‘ I had side effects from the birth control method I was using ‘ I didn’t go for prenatal care ‘ 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:

Thanks for answering our questions!

Your answers will help us work to make Ohio mothers and babies healthier. 14 3

77. During your most recent pregnancy, what 78. Listed below are some things about safety. 16. Did you get prenatal care as early in your If you did not go for prenatal care, go to did you think about breastfeeding your For each thing, circle Y (Yes) if it applies to pregnancy as you wanted? Page 4, Question 23. new baby? you or circle N (No) if it does not. No Yes ‘ No Check one answer a. My infant was brought home ‘ Yes 18. Where did you go most of the time for your Go to from the hospital in an infant ‘ I didn’t want prenatal visits? (Do not include visits for Question 18 ‘ I knew I would breastfeed car seat...... N Y prenatal care WIC.) ‘ I thought I might breastfeed b. My baby always or almost always Check one answer ‘ I knew I would not breastfeed rides in an infant car seat...... N Y ‘ I didn’t know what to do about c. My home has a working 17. Did any of these things keep you from breastfeeding smoke alarm ...... N Y getting prenatal care as early as you ‘ Hospital clinic d. There are loaded guns, rifles, or wanted? ‘ Health department clinic other firearms in my home...... N Y ‘ Private doctor’s office or HMO clinic Check all that apply ‘ Community health center or clinic ‘ Military facility ‘ I couldn’t get an appointment earlier in ‘ Other º Please tell us: 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 19. How was your prenatal care paid for? doctor’s office Check all that apply ‘ The doctor or my health plan would not start care earlier ‘ I didn’t have my Medicaid card ‘ Medicaid ‘ I had no one to take care of my children ‘ Personal income (cash, check, or credit ‘ I had too many other things going on card) ‘ Other º Please tell us: ‘ Health insurance or HMO ‘ Military coverage (including TRICARE Prime) ‘ Other º Please tell us: 4 13 20. During any of your prenatal care visits, 21. At any time during your prenatal care, did 75. Since you delivered your new baby, would 76. This question asks about things that may did a doctor, nurse, or other health care a doctor, nurse, or other health care you have the kinds of help listed below if have happened at the hospital where your worker talk with you about any of the worker ask if you were smoking you needed them? For each thing, circle new baby was born. For each item, circle things listed below? (Please count only cigarettes? Y (Yes) if you would have it or circle N (No) Y (Yes) if it happened or circle N (No) if it discussions, not reading materials or videos.) if not. did not happen. For each item, circle Y (Yes) if someone ‘ No No Yes No Yes talked with you about it or circle N (No) if ‘ Yes a. Hospital staff gave me no one talked with you about it. a. Someone to loan me $50...... N Y information about No Yes 22. At any time during your prenatal care, did b. Someone to help me if I were breastfeeding...... N Y a. How smoking during pregnancy a doctor, nurse, or other health care sick and needed to be in bed.....N Y b. My baby stayed in the same could affect your baby...... N Y worker ask if you were drinking alcoholic c. Someone to talk with about room with me at the hospital.....N Y b. Breastfeeding your baby...... N Y beverages (beer, wine, wine cooler, or my problems ...... N Y c. I breastfed my baby in the c. How drinking alcohol during liquor)? d. Someone to take care of hospital ...... N Y pregnancy could affect your my baby...... N Y d. I breastfed my baby in the first baby...... N Y ‘ No e. Someone to help me if I were hour after my baby was born.....N Y d. Using a seat belt during ‘ Yes tired and feeling frustrated with e. Hospital staff helped me learn your pregnancy ...... N Y my new baby...... N Y how to breastfeed ...... N Y e. Birth control methods to use 23. Have you ever heard or read that taking f. My baby was fed only breast after your pregnancy...... N Y the vitamin folic acid can help prevent milk at the hospital ...... N Y f. Medicines that are safe to take some birth defects? g. Hospital staff told me to If your baby was not born in a hospital, go to during your pregnancy...... N Y breastfeed whenever my Page 14, Question 77. g. How using illegal drugs could ‘ No baby wanted...... N Y affect your baby...... N Y ‘ Yes h. The hospital gave me a gift h. Doing tests to screen for birth pack with formula...... N Y defects or diseases that run in 24. At any time during your most recent i. The hospital gave me a your family ...... N Y pregnancy or delivery, did you have a telephone number to call for i. What to do if your labor blood test for HIV (the virus that causes help with breastfeeding...... N Y starts early...... N Y AIDS)? j. My baby used a pacifier j. Getting your blood tested for HIV in the hospital ...... N Y (the virus that causes AIDS) .....N Y ‘ No k. Physical abuse to women by ‘ Yes their husbands or partners...... N Y ‘ I don’t know

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

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

‘ No ‘ Yes 12 5 69. Counting yourself, how many people live 72. How many people, including yourself, 26. Did you have any of these problems 27. Did you do any of the following things in your house, apartment, or trailer? depended on this income? during your pregnancy? For each item, because of these problem(s)? circle Y (Yes) if you had the problem or Check all that apply Adults (people aged 18 years or circle N (No) if you did not. older) People No Yes a. Labor pains more than 3 weeks ‘ I went to the hospital or emergency room Babies, children, or teenagers 73. During your most recent pregnancy, did before your baby was due and stayed less than 1 day (people aged 17 years or younger) you get any of these services? Circle (preterm or early labor)...... N Y ‘ I went to the hospital and stayed Y (Yes) if you got the service or circle b. High blood pressure (including 1 to 7 days 70. What were the sources of your household’s N (No) if you did not get it. preeclampsia or toxemia) or ‘ I went to the hospital and stayed more income during the past 12 months? No Yes retained water (edema) ...... N Y than 7 days c. Vaginal bleeding...... N Y ‘ I stayed in bed at home more than 2 days Check all that apply a. Childbirth classes ...... N Y d. Problems with the placenta because of my doctor’s or nurse’s advice b. Parenting classes...... N Y (such as abruptio placentae, ‘ Paycheck or money from a job c. Classes on how to stop placenta previa) ...... N Y ‘ Aid such as Temporary Assistance for smoking...... N Y e. Severe nausea, vomiting, or The next questions are about smoking Needy Families (TANF), welfare, public d. Visits to your home by a nurse or dehydration...... N Y cigarettes and drinking alcohol. assistance, general assistance, food other health care worker ...... N Y f. High blood sugar (diabetes) .....N Y stamps, or Supplemental Security Income e. Food stamps ...... N Y g. Kidney or bladder (urinary 28. Have you smoked at least 100 cigarettes in ‘ Unemployment benefits f. TANF (Welfare)...... N Y tract) infection...... N Y the past 2 years? (A pack has 20 cigarettes.) ‘ Child support or alimony h. Water broke more than 3 weeks ‘ Social security, workers’ compensation, 74. During your most recent pregnancy, would before your baby was due ‘ No º Go to Page 6, Question 32 veteran benefits, or pensions you have had the kinds of help listed below (premature rupture of membranes, ‘ Yes ‘ Money from a business, fees, dividends, if you needed them? For each thing, circle PROM) ...... N Y or rental income Y (Yes) if you would have had it or circle i. Cervix had to be sewn ‘ Money from family or friends N (No) if not. shut (incompetent cervix, 29. In the 3 months before you got pregnant, ‘ Other º Please tell us: No Yes cerclage) ...... N Y how many cigarettes or packs of cigarettes j. You were hurt in a car did you smoke on an average day? a. Someone to loan me $50...... N Y accident ...... N Y (A pack has 20 cigarettes.) b. Someone to help me if I were 71. Which category best describes your annual sick and needed to be in bed.....N Y household income from all sources? c. Someone to take me to the If you did not have any of these problems, go Cigarettes OR Packs Include your income and the income of others clinic or doctor’s office to Question 28. living with you. if I needed a ride...... N Y ‘ Less than 1 cigarette a day Check one answer d. Someone to talk with about ‘ I didn’t smoke my problems ...... N Y ‘ I don’t know ‘ Less than $10,000 ‘ $10,000 to less than $15,000 ‘ $15,000 to less than $20,000 If your baby is not alive or is not living with ‘ $20,000 to less than $25,000 you, go to Page 15. ‘ $25,000 to less than $35,000 ‘ $35,000 or more 6 11 30. In the last 3 months of your pregnancy, b. During the 3 months before you got The next few questions are about the time 66. What kind of birth control are you or your how many cigarettes or packs of cigarettes pregnant, how many times did you after you gave birth to your new baby and husband or partner using now to keep did you smoke on an average day? drink 5 alcoholic drinks or more in one things that may have happened after from getting pregnant? sitting? delivery. Check all that apply Cigarettes OR Packs Times 64. Are you or your husband or partner doing ‘ Tubes tied (sterilization) ‘ Less than 1 cigarette a day anything now to keep from getting ‘ Vasectomy (sterilization) ‘ I didn’t smoke ‘ I didn’t drink then pregnant? (Some things people do to keep ‘ Pill ‘ I don’t know ‘ I don’t know from getting pregnant include having their ‘ Condoms tubes tied or their partner having a ‘ Foam, jelly, cream vasectomy, using birth control methods like ‘ Norplant® 31. How many cigarettes or packs of cigarettes 34. a. During the last 3 months of your the pill, Norplant®, shots [Depo-Provera®], ‘ Shots (Depo-Provera®) do you smoke on an average day now? pregnancy, how many alcoholic drinks condoms, diaphragm, foam, IUD, and not ‘ Withdrawal did you have in an average week? having sex at certain times [rhythm].) ‘ Other º Please tell us:

Cigarettes OR Packs ‘ I didn’t drink then ‘ No ‘ Less than 1 drink a week ‘ Yes º Go to Question 66 ‘ Less than 1 cigarette a day ‘ 1 to 3 drinks a week ‘ I don’t smoke ‘ 4 to 6 drinks a week 67. After your new baby was born, did a ‘ I don’t know ‘ 7 to 13 drinks a week 65. What are your or your husband’s or doctor, nurse, or other health care worker ‘ 14 drinks or more a week partner’s reasons for not doing anything talk with you about using birth control? ‘ I don’t know to keep from getting pregnant now? 32. Have you had any alcoholic drinks in the ‘ No past 2 years? (A drink is 1 glass of wine, Check all that apply, ‘ Yes wine cooler, can or bottle of beer, shot of b. During the last 3 months of your then go to Question 67 liquor, or mixed drink.) pregnancy, how many times did you drink 5 alcoholic drinks or more in one ‘ I am not having sex The next questions are about your family ‘ No º Go to Question 35 sitting? ‘ I want to get pregnant and the place where you live. ‘ Yes ‘ I don’t want to use birth control ‘ My husband or partner doesn’t want to 68. Which rooms are in the house, apartment, Times use anything or trailer where you live? 33. a. During the 3 months before you got ‘ I don’t think I can get pregnant (sterile) pregnant, how many alcoholic drinks ‘ I didn’t drink then ‘ I can’t pay for birth control Check all that apply did you have in an average week? ‘ I don’t know ‘ I am pregnant now ‘ Other º Please tell us: ‘ Living room ‘ I didn’t drink then ‘ Separate dining room ‘ Less than 1 drink a week ‘ Kitchen ‘ 1 to 3 drinks a week ‘ Bathroom(s) ‘ 4 to 6 drinks a week ‘ Recreation room, den, or family room ‘ 7 to 13 drinks a week ‘ Finished basement ‘ 14 drinks or more a week ‘ Bedrooms º How many? ‘ I don’t know 10 7 56. How often does your new baby sleep in the 61. Where do you usually take your baby for Pregnancy can be a difficult time for some 36. a. During the 12 months before you got same bed with you or anyone else? well-baby checkups? women. These next questions are about pregnant, did your husband or partner push, hit, slap, kick, choke, or Check one answer things that may have happened before and ‘ Always during your most recent pregnancy. physically hurt you in any other way? ‘ Almost always ‘ Sometimes ‘ Hospital clinic ‘ No ‘ Rarely ‘ Health department clinic 35. This question is about things that may ‘ Yes ‘ Never ‘ Private doctor’s office or HMO clinic have happened during the 12 months ‘ Community health center or clinic before your new baby was born. For each b. During the 12 months before you got 57. Was your baby seen by a doctor, nurse, or ‘ Military facility item, circle Y (Yes) if it happened to you or pregnant, did anyone else physically other health care provider in the first week ‘ Other º Please tell us: circle N (No) if it did not. (It may help to use hurt you in any way? after he or she left the hospital? the calendar.) No Yes ‘ No ‘ No º Go to Question 59 a. A close family member was ‘ Yes ‘ Yes 62. Has your baby gone as many times as you very sick and had to go into the wanted for a well-baby checkup? hospital ...... N Y 37. a. During your most recent pregnancy, did b. You got separated or divorced your husband or partner push, hit, 58. Was your new baby seen at home or at a ‘ No from your husband or partner ....N Y slap, kick, choke, or physically hurt you health care facility? ‘ Yes º Go to Question 64 c. You moved to a new address.....N Y in any other way? d. You were homeless...... N Y ‘ At home e. Your husband or partner lost ‘ No ‘ At a doctor’s office, clinic, or other 63. Did any of these things keep your baby his job ...... N Y ‘ Yes health care facility from having a well-baby checkup? f. You lost your job even though you wanted to go on working ....N Y Check all that apply b. During your most recent pregnancy, did g. You argued with your husband anyone else physically hurt you in any 59. Has your baby had a well-baby checkup? or partner more than usual...... N Y way? ‘ I didn’t have enough money or insurance h. Your husband or partner said to pay for it ‘ No º Go to Question 62 he didn’t want you to be ‘ No ‘ I had no way to get my baby to the clinic ‘ Yes pregnant...... N Y ‘ Yes or office i. You had a lot of bills you ‘ I didn’t have anyone to take care of my couldn’t pay...... N Y other children 60. How many times has your baby been to a j. You were in a physical fight.....N Y ‘ I couldn’t get an appointment The next questions are about your labor doctor or nurse for a well-baby checkup? k. You or your husband or ‘ My baby was too sick to go for routine and delivery. (It may help to look at the (It may help to use the calendar.) partner went to jail...... N Y care l. Someone very close to you had calendar when you answer these questions.) ‘ Other º Please tell us: a bad problem with drinking or Times drugs...... N Y 38. When was your baby due? m. Someone very close to you died...... N Y

Month Day Year 8 9 39. When did you go into the hospital to have 44. How was your delivery paid for? 49. Did you ever breastfeed or pump breast 53. How old was your baby the first time you your baby? milk to feed your new baby after delivery? fed him or her anything besides breast Check all that apply milk? (Include formula, baby food, juice, ‘ No cow’s milk, water, sugar water, or anything ‘ Medicaid ‘ Yes º Go to Question 51 else you fed your baby.) Month Day Year ‘ Personal income (cash, check, or credit card) 50. What were your reasons for not ‘ I didn’t have my baby in a hospital ‘ Health insurance or HMO breastfeeding your new baby? Weeks OR Months ‘ Military coverage (including TRICARE 40. When was your baby born? Prime) Check all that apply, ‘ My baby was less than one week old ‘ Other º Please tell us: then go to Question 54 ‘ I have not fed my baby anything besides breast milk

‘ I had other children to take care of Month Day Year ‘ I had too many household duties ‘ I didn’t like breastfeeding 41. When were you discharged from the If your baby is still in the hospital, go to The next questions are about the time ‘ I didn’t want to be tied down hospital after your baby was born? Page 11, Question 64. since your new baby was born. ‘ I was embarrassed to breastfeed (It may help to use the calendar.) ‘ I went back to work or school 45. What is today’s date? ‘ My husband or partner did not want me 54. About how many hours a day, on average, to breastfeed is your new baby in the same room with someone who is smoking? Month Day Year ‘ I wanted my body back to myself ‘ Other º Please tell us: Month Day Year ‘ I didn’t have my baby in a hospital Hours 46. Is your baby alive now? 42. After your baby was born, was he or she ‘ Less than one hour a day 51. Are you still breastfeeding or feeding put in an intensive care unit? ‘ My baby is never in the same room with ‘ No pumped milk to your new baby? ‘ Yes º Go to Question 48 someone who is smoking ‘ No ‘ No ‘ Yes 55. How do you most often lay your baby 47. When did your baby die? ‘ Yes º Go to Question 53 ‘ I don’t know down to sleep now?

43. After your baby was born, how long did 52. How many weeks or months did you Check one answer breastfeed or pump milk to feed your he or she stay in the hospital? Month Day Year baby? ‘ On his or her side ‘ Less than 24 hours (Less than 1 day) ‘ On his or her back Go to Page 11, Question 64 ‘ 24–48 hours (1–2 days) ‘ On his or her stomach Weeks OR Months ‘ 3 days ‘ 4 days 48. Is your baby living with you now? ‘ Less than 1 week ‘ 5 days ‘ 6 days or more ‘ No º Go to Page 11, Question 64 ‘ My baby was not born in a hospital ‘ Yes ‘ My baby is still in the hospital