PRAMS Stillbirth Phone Questionnaire (English)

Attachment 9c – PRAMS UT Stillbirth Phone Questionnaire – English

Form Approved

OMB No. 0920-1273

Exp. Date xx/xx/xxxx

Pregnancy Risk Assessment Monitoring System (PRAMS)

Utah Stillbirth (SOARS) Phone Questionnaire – English

Public reporting of this collection of information is estimated to average 25 minutes per response, including the time for reviewing instructions and completing and reviewing the collection of information. An agency many not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a current valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (XXXX-XXXX)INTERVIEWER: Please indicate the number that corresponds to the respondent’s answer.

We would like to learn about your experiences to help improve care for women who experience stillbirths. The questions on this survey are about your pregnancy when your baby died, except when noted. We understand that some questions may be sensitive, but we appreciate any information you are able to share.

First, I would like to ask a few questions about you.

1. How tall are you without shoes?

(PROBE: About how tall?)

(Don’t read) 1 Feet ______

2 Inches ______ [Range: 4-6 feet/0-11 inches]

OR

3 Centimeters______ [Range: 120-210 centimeters]

8 Refused

9 Don’t know/don’t remember

2. Just before you got pregnant, how much did you weigh?

(PROBE: About how much?)

(Don’t read) 1 Number of pounds_______ [Range: 36-400 pounds/kilos]

OR

2 Number of kilos_______

8 Refused

9 Don’t know/don’t remember

3. What is your date of birth?

______ / ______ / ______ [Range: 10-55 years of age]

Month Day Year

(Don’t read) 88/88/8888 Refused

99/99/9999 Don’t know/don’t remember

The next questions are about the time before you got pregnant with this baby.

4. I’m going to read a list of health conditions. For each one, please tell me if you had it during the 3 months before you got pregnant. Did you have______?

(PROBE: During the 3 months before you got pregnant, did you have______?)

Condition	(Don’t read)
	No (1)	Yes (2)	Refused (8)	Don’t know (9)
Type 1 or Type 2 diabetes. This is not the same as gestational diabetes or diabetes that starts during pregnancy.
High blood pressure or hypertension
Depression
Asthma
Thyroid problems
PCOS or polycystic ovarian syndrome
Anxiety

5. During the month before you got pregnant, how many times a week did you take a multivitamin, a prenatal vitamin, or a folic acid vitamin? Please tell me which of the following best describes you.

(PROBE: About how many times a week did you take a multivitamin, a prenatal vitamin, or a folic acid vitamin?)

1. You didn’t take a multivitamin, prenatal vitamin, or folic acid vitamin in the month before you got pregnant

2 1 to 3 times a week

3 4 to 6 times a week

4 Every day of the week

(Don’t read) 8 Refused

9 Don’t know/don’t remember

6. How many times have you been pregnant? Please include ALL pregnancies you have had (both losses and live births).

(PROBE: How many times have you been pregnant?)

1 1 time  INTERVIEWER: Go to Question 12

2 2 to 4 times

3 5 to 7 times

4 8 or more times

(Don’t read) 8 Refused  INTERVIEWER: Go to Question 12

9 Don’t know/don’t remember  INTERVIEWER: Go to Question 12

7.	Before this pregnancy , did you ever have any other babies who were born alive?

(Don’t read) 1 No  INTERVIEWER: Go to Question 10

2 Yes

8 Refused  INTERVIEWER: Go to Question 10

9 Don’t know/don’t remember  INTERVIEWER: Go to Question 10

8.	Did the baby born just before this pregnancy weigh 5 pounds, 8 ounces or (2.5 kilos) or less at birth?

(Don’t read) 1 No

2 Yes

8 Refused

9 Don’t know/don’t remember

9.	Was your last baby who was born alive born earlier than 3 weeks before his or her due date?

(Don’t read) 1 No

2 Yes

8 Refused

9 Don’t know/don’t remember

10. Before this pregnancy, did you ever have any pregnancies that ended in a loss?

(Probe: Before this pregnancy, did you have any losses?)

(Don’t read) 1 No  INTERVIEWER: Go to Question 12

2 Yes

8 Refused  INTERVIEWER: Go to Question 12

9 Don’t know/don’t remember  INTERVIEWER: Go to Question 12

11. Please indicate the number of previous losses you had that ended in each of the following time periods (not including this baby). I’m going to read the time periods, for each one tell me the number of pregnancy losses you had during that time period.

(PROBE: How many pregnancy losses did you have _________?)

_____ Before 12 weeks

_____ Between 12 and 27 weeks

_____ At 28 weeks or later

(Don’t read) 8 Refused

9 Don’t know/don’t remember

12. When you got pregnant with this baby, were you trying to get pregnant?

(Don’t read) 1 No

2 Yes

8 Refused

9 Don’t know/don’t remember

The next questions are about your health insurance coverage before, during, and after your pregnancy.

13. I’m going to read a list of different types of health insurance. For each one, please tell me if you had this kind of health insurance during the month before you got pregnant. Did you have ______?

(PROBE: What kind of health insurance did you have during the month before you got pregnant?)

Type of Insurance	(Don’t read)
	No (1)	Yes (2)	Refused (8)	Don’t know (9)
Private health insurance from your job or the job of your husband or partner
Private health insurance from your parents
Private health insurance from the Health Insurance Marketplace or HealthCare.gov
Medicaid
TRICARE or military health care
IHS or tribal
Did you have some other health insurance during the month before you got pregnant?
IF YES, ASK: What was that? _____________________________________________________________ ________________________________________________________________________________________
INTERVIEWER: Go to Question 14 if the mother answered YES to any of the insurance options listed above.
Would you say that you did not have any health insurance during the month before you got pregnant? (Interviewer: If the mother answered that she did not have any health insurance, check YES.)

14. What kind of health insurance did you have during your pregnancy for your prenatal care? Prenatal care includes visits to a doctor, nurse, or other health care worker before you baby was delivered to get checkups and advice about pregnancy. I’m going to read the list of options again. For each one, please tell me if you had this kind of health insurance for your prenatal care. First, let me ask: (READ item a)

(PROBE: What kind of health insurance did you have during your pregnancy, for your prenatal care?)

Type of Insurance	(Don’t read)
	No (1)	Yes (2)	Refused (8)	Don’t know (9)
Did you have prenatal care? (INTERVIEWER: If the mother did not have prenatal care, mark NO, and go to Question 15.)
b. Private health insurance from your job or the job of your husband or partner
c. Private Health insurance from your parents Private health insurance from your parents
d. Private health insurance from the Health Insurance Marketplace or HealthCare.gov
e. Medicaid
f. TRICARE or military health care
g. IHS or tribal
h. Did you have some other health insurance for your prenatal care?
i. IF YES, ASK: What was that?
INTERVIEWER: Go to Question 15 if the mother answered YES to any of the insurance options listed above.
j. Would you say that you did not have any health insurance to pay for your prenatal care? (Interviewer: If the mother answered that she did not have any health insurance for prenatal care, check YES.)

15. What kind of health insurance do you have now? I’m going to read the list of types of health insurance one last time. For each one, please tell me if you have this kind of health insurance now. Do you have ?

(PROBE: What kind of health insurance do you have now?)

Type of Insurance	(Don’t read)
	No (1)	Yes (2)	Refused (8)	Don’t know (9)
a. Private health insurance from your job or the job of your husband or partner
b. Private Health insurance from your parents Private health insurance from your parents
c. Private health insurance from the Health Insurance Marketplace or HealthCare.gov
d. Medicaid
e. TRICARE or military health care
f. IHS or tribal
g. Do you have some other health insurance ?
h. IF YES, ASK: What was that? ___
INTERVIEWER: Go to Question 16 if the mother answered YES to any of the insurance options listed above.
i. Would you say that you did not have any health insurance now? (Interviewer: If the mother answered that she does not have any health insurance , check YES.)

DURING PREGNANCY

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

16. How many weeks or months pregnant were you when you had your first visit for prenatal care?

(PROBE: How many weeks or months pregnant were you?)

(Don’t read) 1 Number of weeks______ (Range: 1-40 weeks)

OR

2. Number of months______ (Range: 1-9 months)

3 You didn’t go for prenatal care  INTERVIEWER: Go to Question 18

8 Refused  INTERVIEWER: Go to Question 18

9 Don’t know/don’t remember  INTERVIEWER: Go to Question 18

17. During any of your prenatal care visits, did a doctor, nurse, or other health care worker ask you any of the following things?

(PROBE: During your prenatal care visits, did a doctor, nurse, or other health care worker ask you _____?)

Subject	(Don’t read)
	No (1)	Yes (2)	Refused (8)	Don’t know (9)
a. If you knew how much weight you should gain during pregnancy
b. If you were taking any prescription medication
c. If you were smoking cigarettes
d. If you were drinking alcohol
e. If someone was hurting you emotionally or physically
f. If you were feeling down or depressed
g. If you were using drugs such as marijuana, cocaine, crack, or meth
h. If you wanted to be tested for HIV (the virus that causes AIDS)
i. If you planned to breastfeed your new baby
j. If you planned to use birth control after your baby was born
k. If you knew how to track your baby's movements
l. If you knew about recommended sleeping positions during pregnancy

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

(PROBE: During your most recent pregnancy, were you on WIC, the Special Supplemental Nutrition Program for Women, Infants, and Children?

(Don’t read) 1 No

2 Yes

8 Refused

9 Don’t know/don’t remember

19. During the 12 months before your baby was delivered, did you get a flu shot? I’m going to read you three options. Please tell me which one applies to you

1 No, you did not get a flu shot 12 months before your baby died

2 Yes, you did get a flu shot before your pregnancy

3 Yes, you did get a flu shot during your pregnancy

(Don’t read) 8 Refused

9 Don’t know/don’t remember

20. I’m going to read a list of health conditions. For each one, please tell me if you had it during your pregnancy. Did you have

___ ?

(PROBE: During your pregnancy, did you have ?)

Condition	(Don’t Read)
	No (1)	Yes (2)	Refused (8)	Don’t know (9)
a. Gestational diabetes or diabetes that started during this Pregnancy
b. High blood pressure that started during this pregnancy, pre-eclampsia, or eclampsia
c. Depression
d. Anxiety

21. I’m going to read a list of problems. For each one, please tell me if you had it during your pregnancy.

(PROBE: During your pregnancy, did you have ?)

Condition	(Don’t Read)
	No (1)	Yes (2)	Refused (8)	Don’t know (9)
a. Did you have vaginal bleeding?
b. Did you have a kidney or bladder (urinary tract) infection (UTI)?
c. Did you have severe nausea, vomiting, or dehydration that sent you to the doctor or hospital?
d. Did your cervix have to be sewn shut also known as cerclage for incompetent cervix)?
e. Did you have complications with the placenta, such as abruptio placentae or placenta previa)?
f. Did you have labor pains more than 3 weeks before your baby was due, or preterm or early labor?
g. Did your water break more than 3 weeks before your baby was due, also known as preterm premature rupture of membranes or PPROM?
h. Did you have a blood transfusion?
i. Were you hurt in a car accident?
j. Did you experience decreased fetal movement or a change in fetal movement?
k. Did you have a fever of 101 or higher?
l. Did you have a gut feeling that something was wrong?

22. I’m going to read a list of infections. For each one, please tell me if a doctor, nurse, or other health care worker told you that you had the infection during your pregnancy? Did someone tell you that you had ______?

(PROBE: During your pregnancy, did a doctor, nurse, or other health care worker tell you that you had ______?)

Infection	(Don’t Read)
	No (1)	Yes (2)	Refused (8)	Don’t know (9)
a. A yeast Infection
b. A urinary tract infection (UTI)
c. Cytomegalovirus (CMV)
d. Genital warts (HPV)
e. Herpes
f. Chlamydia
g. Gonorrhea
h. Pelvic Inflammatory Disease (PID)
i. Syphilis
j. Group B Strep
k. Bacterial vaginosis
l. Trichomoniasis (Trich)
m. Listeria
n. Toxoplasmosis
o. Were you told you had any other infections?
p. INTERVIEWER: If YES, ask: What was that? __________________________________________________ __________________________________________________________________________________

The next questions are about smoking and alcohol use around the time of pregnancy (before, during, and after). We are not asking these questions because we think you did anything to affect your baby. We ask similar questions of other women on a different survey.

23. Have you smoked any cigarettes in the past 2 years?

(Don’t read) 1 No → INTERVIEWER: Go to question 27

2 Yes

8 Refused → INTERVIEWER: Go to question 27

9 Don’t know/don’t remember → INTERVIEWER: Go to question 27

24. In the 3 months before you got pregnant, how many cigarettes did you smoke on an average day? A pack has 20 cigarettes. Did you smoke____?

(PROBE: In the 3 months before you got pregnant, about how many cigarettes did you smoke on an average day?)

1 41 cigarettes or more a day

2 21 to 40 cigarettes

3 11 to 20 cigarettes

4 6 to 10 cigarettes

5 1 to 5 cigarettes

6 Less than 1 cigarette

7 You didn’t smoke then

(Don’t read) 8 Refused

9 Don’t know/don’t remember

25. In the last 3 months of your pregnancy, how many cigarettes did you smoke on an average day? Did you smoke______?

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

1 41 cigarettes or more a day

2 21 to 40 cigarettes

3 11 to 20 cigarettes

4 6 to 10 cigarettes

5 1 to 5 cigarettes

6 Less than 1 cigarette

7 You didn’t smoke then

(Don’t read) 8 Refused

9 Don’t know/don’t remember

26. How many cigarettes do you smoke on an average day now? Do you smoke_____?

(PROBE: About how many cigarettes do you smoke on an average day? A pack has 20 cigarettes.)

1 41 cigarettes or more a day

2 21 to 40 cigarettes

3 11 to 20 cigarettes

4 6 to 10 cigarettes

5 1 to 5 cigarettes

6 Less than 1 cigarette

7 You don’t smoke now

(Don’t read) 8 Refused

9 Don’t know/don’t remember

27. I am going to read a list of products. For each one, please tell me if you used it at any time in the past 2 years? Have you used _____?

(PROBE: In the past 2 years, have you used _______?)

		(Don’t Read)
	Product	No (1)	Yes (2)	Refused (8)	Don’t know (9)
a.	E-cigarettes or other electronic nicotine products (PROBE: E-cigarettes or electronic cigarettes and other electronic nicotine products such as vape pens, e-hookahs, hookah pens, e-cigars, and e-pipes are battery-powered devices that use nicotine liquid rather than tobacco leaves, and produce vapor instead of smoke.)
b.	Hookah (PROBE: A hookah is a water pipe used to smoke tobacco. It is not the same as an e-hookah or hookah pen.)

INTERVIEWER: If the respondent did NOT use e-cigarettes or other electronic nicotine products in the past 2 years, go to Question 30.

28. During the 3 months before you got pregnant, on average, how often did you use e-cigarettes or other electronic nicotine- products? Did you use them_____?

(PROBE: During the 3 months before you got pregnant, about how many times did you use them? Was it ____?)

1 More than once a day

2 Once a day

3 2 to 6 days a week

4 1 day a week or less

5 You did not use e-cigarettes or other electronic nicotine products then

(Don’t read) 8 Refused

9 Don’t know/don’t remember

29. During the last 3 months of your pregnancy, on average, how often did you use e-cigarettes or other electronic

nicotine- products? Did you use them_____?

(PROBE: During the last 3 months of your pregnancy, about how many times did you use them? Was it ____?)

1 More than once a day

2 Once a day

3 2 to 6 days a week

4 1 day a week or less

5 You did not use e-cigarettes or other electronic nicotine products then

(Don’t read) 8 Refused

9 Don’t know/don’t remember

30. 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.

(Don’t read) 1 No → INTERVIEWER: Go to Question 33

2 Yes

8 Refused → INTERVIEWER: Go to Question 33

9 Don’t know/don’t remember → INTERVIEWER: Go to Question 33

31. During the 3 months before you got pregnant, how many alcoholic drinks did you have in an average week? Did you have______?

(PROBE: During the 3 months before you got pregnant, about how many alcoholic drinks did you have in an average week?)

1 14 drinks or more a week

2 8 to 13 drinks a week

3 4 to 7 drinks a week

4 1 to 3 drinks a week

5 Less than 1 drink a week

6 You didn’t drink then

(Don’t read) 8 Refused

9 Don’t know/don’t remember

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

(PROBE: During the last 3 months of your pregnancy, about how many alcoholic drinks did you have in an average week?)

1 14 drinks or more a week

2 8 to 13 drinks a week

3 4 to 7 drinks a week

4 1 to 3 drinks a week

5 Less than 1 drink a week

6 You didn’t drink then

(Don’t read) 8 Refused

9 Don’t know/don’t remember

Pregnancy can be a difficult time. The next questions are about things that may have happened before and during your pregnancy.

33. Did you have depression during your pregnancy?

(PROBE: At any time during your pregnancy, did you have depression?)

(Don’t read) 1 No → INTERVIEWER: Go to question 37.

2 Yes

8 Refused→ INTERVIEWER: Go to question 37

9 Don’t know/don’t remember→ INTERVIEWER: Go to question 37

34. At any time during your pregnancy, did you ask for help for depression from a doctor, nurse, or other health care worker?

(Don’t read) 1 No

2 Yes

8 Refused

9 Don’t know/don’t remember

35. At any time during your pregnancy, did you get counseling for your depression?

(Don’t read) 1 No

2 Yes

8 Refused

9 Don’t know/don’t remember

36. At any time during your pregnancy, did you take prescription medicine for your depression?

(Don’t read) 1 No

2 Yes

8 Refused

9 Don’t know/don’t remember

37. I’m going to read a list of things that may have happened during the 12 months before your baby was delivered. For each one, please tell me if it happened to you. It may help to look at the calendar.

(PROBE: During the 12 months before your baby was delivered____?)

Item	(Don’t Read)
	No (1)	Yes (2)	Refused (8)	Don’t know (9)
Did a close family member get very sick and have to go into the hospital?
Did you get separated or divorced from your husband or partner?
Did you move to a new address?
d . Were you homeless or did you have to sleep outside, in a car, or in a shelter?
e. Did your husband or partner lose their job?
f. Did you lose your job even though you wanted to go on working?
Did you or your husband or partner have a cut in work hours or pay?
Were you apart from your husband or partner due to military deployment or extended work-related travel?
Did you argue with your husband or partner more than usual?
Did your husband or partner say they didn’t want you to be pregnant?
k. Did you have problems paying the rent, mortgage, or other bills?
l. Did your husband, partner or you go to jail?
m. Did someone very close to you have a problem with drinking or drugs?
n. Did someone very close to you die?

INTERVIEWER: Questions 38 and 39 should NOT be asked if the mother is a minor (under the age of 18). Skip to question 40.

38. In the 12 months before you got pregnant, did any of the following people push, hit, slap, kick, choke, or physically hurt you in any other way?

Person	(Don’t read)
	No (1)	Yes (2)	Refused (8)	Don’t know (9)
a. Your husband or partner
b. Your ex-husband or ex-partner
c. Someone else

39. During your pregnancy, did any of the following people push, hit, slap, kick, choke, or physically hurt you in any other way?

Person	(Don’t read)
	No (1)	Yes (2)	Refused (8)	Don’t know (9)
a. Your husband or partner
b. Your ex-husband or ex-partner
c. Someone else

The next questions are about your baby and your experiences around the time of delivery. We are interested in learning how to improve the care received by women who have a stillbirth. We understand that some of these options may not apply to you.

40. On what date was your baby due?

(PROBE: When was your baby due?)

(Don’t read) ______ / ______ / 20____ [Range: Month 1-12; Day 1-31; Year = Surveillance year]

Month Day Year

88/88/8888 Refused

99/99/9999 Don’t know/don’t remember

41. On what date was your baby delivered?

(PROBE: When was your baby delivered?)

(Don’t read) ______ / ______ / 20____ [Range: Month 1-12; Day 1-31; Year = Surveillance year]

Month Day Year

88/88/8888 Refused

99/99/9999 Don’t know/don’t remember

42. On what date do you think your baby died?

(PROBE: When do you think your baby died?)

(Don’t read) ______ / ______ / 20____ [Range: Month 1-12;Day 1-31; Year = Surveillance year]

Month Day Year

88/88/8888 Refused

99/99/9999 Don’t know/don’t remember

43. On what date did you find out your baby died?

(PROBE: When did you find out your baby died?)

(Don’t read) ______ / ______ / 20____ [Range: Month 1-12;Day 1-31; Year = Surveillance year]

Month Day Year

88/88/8888 Refused

99/99/9999 Don’t know/don’t remember

44. Did your baby die before delivery or during delivery?

(PROBE: When did your baby die?)

1 Before delivery

2 During delivery

(Don’t read) 8 Refused

9 Don’t know/don’t remember

45. Please tell me which one of the following statements best describes how your new baby was delivered.

(PROBE: How was your baby delivered?)

1 You delivered vaginally → INTERVIEWER: Go to Question 47

2 You had a cesarean delivery or c-section

(Don’t read) 8 Refused → INTERVIEWER: Go to Question 47

9 Don’t know/don’t remember → INTERVIEWER: Go to Question 47

46. Which statement best describes whose idea it was for you to have a cesarean delivery (C-section)? Please tell me which one of the following statements best describes whose idea it was for you to have a cesarean delivery or c-section.

1 Your health care provider scheduled your cesarean delivery before your baby died

2 Your health care provider recommended a cesarean delivery before you went into labor

3 Your health care provider recommended a cesarean delivery while you were in labor

4 You asked for the cesarean delivery

(Don’t read) 8 Refused → INTERVIEWER: Go to Question 47

9 Don’t know/don’t remember → INTERVIEWER: Go to Question 47

47. On what date were you discharged from the hospital after your baby was delivered?

(PROBE: When were you discharged from the hospital after your baby was delivered?)

______ / ______ / 20____ [Range: Month 1-12;Day 1-31; Year = Surveillance year]

Month Day Year

(Don’t read) 76/76/7676 I didn’t have my baby in the hospital → INTERVIEWER: Go to Question 52

88/88/8888 Refused

99/99/9999 Don’t know/don’t remember

48. I’m going to read a list of things which may have been offered to you during your hospital stay. For each one, please tell me whether it was offered to you. Were you offered _____________?

(PROBE: Were any of these things offered during your hospital stay?)

Things	Don’t Read
	No (1)	Yes (2)	Refused (8)	Don’t Know (9)
a. Photographs of your baby
b. Photographs of your baby with family
c. Hand and/or footprints/impressions
d. Holding your baby
e. Bathing your baby
f. Dressing your baby
g. A baptism or blessing of your baby
h. Mementos (ex. Hat, clothes)
i. Funeral/memorial service resources
j. Support groups/peer volunteer resources
k. A visit with a religious leader (bishop, chaplain, pastor, priest, rabbi, imam, etc.)
l. A visit with a hospital social worker
m. Having your baby stay in your room
n. A cooling bed

49. I’m going to read a list of things which you may have received during your hospital stay. For each one, please tell me if it was received, and if so, please tell me if you felt it was helpful or not helpful. Did you receive _________? Was it helpful?

(PROBE: Did you receive these things during your hospital stay and if so were they helpful?)

Things			Don’t Read
	No (1)	Yes (2)	Refused (8)	Don’t Know (9)	Helpful (3)	Not Helpful (4)	Refused (8)	Don’t Know (9)
a. Photographs of your baby
b. Photographs of your baby with family
c. Hand and/or footprints/impressions
d. Holding your baby
e. Bathing your baby
f. Dressing your baby
g. A baptism or blessing of your baby
h. Mementos (ex. Hat, clothes)
i. Funeral/memorial service resources
j. Support groups/peer volunteer resources
k. A visit with a religious leader (bishop, chaplain, pastor, priest, rabbi, imam, etc.)
l. A visit with a hospital social worker
m. Having your baby stay in your room
n. A cooling bed

50. I’m going to read a list of things that may have happened before you left the hospital. For each one, please tell me if it happened to you or not.

(PROBE: Before you left the hospital, _____________________?)

Question	Don’t Read
	No (1)	Yes (2)	Refused (8)	Don’t Know (9)
a. Did you feel adequately supported by your doctor or midwife in your grieving process?
b. Did you feel adequately supported by the hospital nursing staff in your grieving process?
c. Did you feel adequately supported by the grief counseling staff in your grieving process?
d. Were you given any information about your breast milk coming in?
e. Were you given any information about what to do when your breast milk came in?
f. Were you given a bereavement packet with information on where to seek support?
g. Did the hospital staff give you the opportunity to ask questions?
h. Did your health care provider discuss with you what might have happened to your baby?

The next questions are about autopsy and other exams that may have been done to learn about what caused your baby’s death. We are trying to learn more about tests offered in hospitals. We understand that some of these options may not apply to you.

51. I’m going to read a list of tests that may have been offered to you during your hospital stay. For each one, please tell me if it was offered to you. Were you offered _______________?

Test	(Don’t read)
	No (1)	Yes (2)	Refused (8)	Don’t know (9)
a. Blood tests for you?
b. A detailed exam of the placenta?
c. A full or partial autopsy?
d. Genetic testing of the baby?

52. I’m going to read a list of tests that may have been performed on you and/or your baby? For each one, please tell me whether the test was performed.

Test	(Don’t read)
	No (1)	Yes (2)	Refused (8)	Don’t know (9)
a. Did they perform Blood tests on you?
b. Did they perform a detailed exam of the placenta?
c. Did the Placenta go to pathology?
d. Did they perform genetic testing of the baby?

53. Did your baby have a full or partial autopsy?

(Don’t read) 1 No

2 Yes → INTERVIEWER: Go to Question 55

8 Refused → INTERVIEWER: Go to Question 55

9 Don’t know/don’t remember → INTERVIEWER: Go to Question 55

54. I’m going to read a list of reasons some autopsies are not done. For each one, please tell me if it applies to you or not. Was it because _____________?)

(PROBE: What was the reason an autopsy was not done?)

Question	(Don’t read)
	No (1)	Yes (2)	Refused (8)	Don’t know (9)
a. An autopsy was too expensive
b. You were told it would not be covered by insurance
c. You declined for personal or religious reasons
d. You did not have enough information about the procedure
e. The doctors were able to determine the cause(s) of death without an autopsy
f. You were told that an autopsy would not provide any answers
g. An autopsy was not offered to you
h. Was there any other reason?
INTERVIEWER: If YES, ask: What was that? ________________________________________________________­­­­­­­­­­­­­­­­­_________________________

55. Did you learn what may have caused your baby’s death?

(Don’t read) 1 No  INTERVIEWER Go to Question 57

2 Yes

8 Refused  INTERVIEWER Go to Question 57

9 Don’t know/don’t remember  INTERVIEWER Go to Question 57

56. I’m going to read a list of things which may cause a baby’s death. For each one, please tell me if it was something that may have caused your baby’s death. Did _________ cause your baby’s death?

(PROBE: Would you say that your baby’s death was caused by _______________)

Question	(Don’t read)
	No (1)	Yes (2)	Refused (8)	Don’t know (9)
a. Complications with the cervix
b. Complications with the umbilical cord/cord accident
c. Placental abruption (separation of the placenta from the uterus)
d. Infection
e. Other complications with the placenta
f. Hypertension
g. Preterm (premature) labor
h. Diabetes
i. Membranes ruptured
j. Congenital defect(s)/birth defect(s)/chromosomal abnormalities
k. Was there any other cause?
INTERVIEWER: If YES, ask: What was that? ________________________________________________________­­­­­­­­­­­­­­­­­_________________________ __________________________________________________________________________________

The next questions are about your health since your baby was delivered.

57. Since your baby was delivered, have you had a postpartum checkup for yourself? A postpartum checkup is the regular checkup a woman has about 4-6 weeks after she gives birth.

(Don’t read) 1 No  INTERVIEWER Go to Question 59

2 Yes

8 Refused  INTERVIEWER Go to Question 59

9 Don’t know/don’t remember  INTERVIEWER Go to Question 59

58. During your postpartum checkup, did your doctor, nurse, or other health care worker do any of the following things? I am going to read a list of things. Did they____________?

(PROBE: Did a doctor, nurse, or other health care worker____ ?)

Things	(Don’t read)
	No (1)	Yes (2)	Refused (8)	Don’t know (9)
a. Talk to you about how long to wait before getting pregnant again
b. Talk to you about birth control methods you can use after giving birth

59. Since your baby was delivered, have you received support or counseling for your grief?

1 No

2 Yes INTERVIEWER: Go to Question 61

(Don’t read) 8 Refused INTERVIEWER: Go to Question 61

9 Don’t know/don’t remember INTERVIEWER: Go to Question 61

60. I’m going to read a list of reasons that may have kept you from receiving support or counseling. For each one, please tell me if it is one of the reasons you did not get support or counseling. Was it because______?

(PROBE: What are the reasons you did not get support or counseling?)

Reasons	(Don’t read)
	No (1)	Yes (2)	Refused (8)	Don’t know (9)
a. You felt fine and did not think you needed support or counseling
b. You didn’t know where to go for counseling
c. You didn’t have insurance to cover the cost of counseling
d. You were not aware of support groups in your area
e. Is there any other thing that kept you from getting support or counseling?
INTERVIEWER: If YES, ask: What was that? ________________________________________________________­­­­­­­­­­­­­­­­­_________________________ __________________________________________________________________________________

61. Are you pregnant now?

(Don’t read) 1 No  INTERVIEWER: Go to Question 63

2 Yes

8 Refused  INTERVIEWER: Go to Question 63

9 Don’t know/don’t remember INTERVIEWER:  Go to Question 63

62. What was the first day of your last period?

(PROBE: When was the first day of your last period?)

______ / ______ /20_____

Month Day Year

(Don’t read) 77/77/7777 You did not have a period before you became pregnant again

88/88/8888 Refused

99/99/9999 Don’t know/don’t remember

The last questions are about the time during the 12 months before your baby was delivered.

63. During the 12 months before your baby was delivered, what was your yearly total household income before taxes? Include your income, your husband’s or partner’s income, and any other income you may have received. All information will be kept private and will not affect any services you are now getting. I’m going to read you a list of options. You can stop me when I read your household income level. Was your yearly household income from ____________?

(PROBE: During the 12 months before your baby was delivered, what was your yearly total household income before taxes?)

1. $0 to $16,000

2. $16,001 to $20,000

3. $20,001 to $24,000

4. $24,001 to $28,000

5. $28,001 to $32,000

6. $32,001 to $40,000

7. $40,001 to $48,000

8. $48,001 to $57,000

9. $57,001 to $60,000

10. $60,001 to $73,000

11. $73,001 to $85,000

12. $85,001 or more

(Don’t read) 88 Refused

99 Don’t know

64. During the 12 months before your baby was delivered, how many people, including yourself, depended on this income?

_________People (RANGE: 1-30 people)

(Don’t read) 8 Refused

9 Don’t know/don’t remember

Is there anything else you would like to share about your pregnancy and baby?

INTERVIEWER: Record respondent’s verbatim comments below.

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________­____________

Thank you for answering these questions. By answering these questions, you are helping us find out why stillbirths happen and how we can improve the care received by families. Again, please accept our deepest sympathies to you and your family on the loss of your baby.

INTERVIEWER:

65. Fill in today’s date

______ / ______ / 20____

Month Day Year

33