PRAMS Phase 9 Cognitive Testing Report

Cognitive Interview Evaluation of the Pregnancy Risk Assessment Monitoring System
(PRAMS), Phase 9 Questions
Annie MacFadyen
Collaborating Center for Questionnaire Design and Evaluation Research
National Center for Health Statistics
March 2023
Interview team (alphabetically): Dánae Corado, Lauren Creamer, Annie MacFadyen, Erika Martinez
Picazo, Alisú Schoua-Glusberg, Amanda Wilmot

Suggested Citation: MacFadyen, A. (2023). Cognitive Evaluation of the Pregnancy Risk Assessment
Monitoring System (PRAMS), Phase 9 Questions. National Center for Health Statistics - CCQDER.
Hyattsville, MD. Q-Bank report.

Introduction
This report documents findings from a cognitive interview evaluation of a subset of survey questions for
the Pregnancy Risk Assessment Monitoring System (PRAMS), Phase 9 questionnaire. The evaluation was
carried out by the Collaborating Center for Questionnaire Design and Evaluation Research (CCQDER) at
the National Center for Health Statistics (NCHS) on behalf of the Division of Reproductive Health (DRH),
National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP).
The findings of this study serve the dual purposes of both providing information about the constructs
captured by the questions and about how patterns of interpretation may be related to socio-linguistic
context. Additionally, the study examined inconsistencies in the ways respondents interpreted and
responded to the questions, uncovering possible sources of response error. The report provides
question-by-question summaries of study findings and documents changes made to the questionnaire
based on interim findings during data collection. Findings from this study may be used to assist question
design and understandings of the survey data.
Background
The PRAMS 1 is a jurisdiction-specific surveillance system focused on collecting population-based data on
various maternal behaviors, attitudes, and experiences before, during, and shortly after pregnancy. The
data from PRAMS are used to inform programs and policies aiming to improve maternal and infant
health outcomes. The PRAMS questionnaire has two parts – the core questions asked by all sites and a
set of standard questions which are selected by each site.
1

Pregnancy Risk Assessment Monitoring System | CDC

1

Since its development in 1987, the PRAMS questionnaire has undergone periodic evaluations and
revisions. CCQDER has performed cognitive interview evaluations to assist with these changes over the
years. With each revision, or phase, of the questionnaire, some of the questions are changed and
sometimes new questions are added. The questions included for evaluation in this project included a
subset of both core and standard questions which are either modified PRAMS Phase 8 questions,
questions adapted from other surveys (such as the Maternal and Infant Health Assessment (MIHA) 2, the
Mothers on Respect Index (MORi) (Vedam et al. 2017), the Black Women’s Health Study 3, and Hunger
Vital Signs4), or new questions, developed for the upcoming Phase 9 version of PRAMS. New questions
were developed following a working group review by divisional subject matter experts.
Method
Cognitive interviewing
This evaluation utilized in-depth, one-on-one cognitive interviews. The cognitive interviewing method
allowed researchers to gain a better understanding of the mental processes of respondents when they
answer survey questions within the context of their individual life experiences and circumstances
(Miller, 2011). Particular attention was paid to the ways in which respondents interpreted questions
about racism and discrimination, patient-centered and respectful care, early maternal warning signs,
and infant sleep practices
A total of 50 interviews were conducted with mothers, aged 18 and over, whose baby was up to 12
months old between May and August 2022. Thirty interviews were conducted in English and 20 were
conducted in Spanish. Interviews were no longer than one hour in length, and they were conducted
remotely through Zoom video calls. Respondents completed their confidentiality paperwork before the
interview began, and they were mailed a $50 renumeration via FedEx after the interview ended.
PRAMS is primarily a self-administered, paper-and-pencil (PAPI) survey, with a smaller number or
interviews administered over the telephone. To approximate these two survey modes, cognitive
interviews for this project were conducted either through self-administration via screensharing or
through interviewer administration. For the self-administered format, interviews began with the
interviewer sharing the questionnaire virtually using screen sharing. Respondents using a computer for
the interview were given remote control to complete the questionnaire as a fillable PDF. Respondents
using a smartphone or tablet told the interviewers which answer to record for each question, since the
Zoom application did not support the remote-control functionality for those devices. Screen sharing
worked well for all interviews, regardless of the device used. After respondents finished the selfadministered questionnaire, interviewers ended remote control but kept the questionnaire visible to
respondents. For the interviewer-administered format, interviewers read questions and response
options aloud to respondents.
The interviewers then asked follow-up questions designed to reveal information about how respondents
interpreted the questions, what aspects of their lives were relevant to those interpretations, and the
Maternal and Infant Health Assessment (ca.gov)
Black Women's Health Study | Boston University (bu.edu)
4
The Hunger Vital Sign™ - Children's HealthWatch (childrenshealthwatch.org)
2
3

2

way they then formulated a response to each question. In this regard, the cognitive interviews elicited
rich narratives from respondents that were often personal and were unique to each respondent.
Sampling and respondent characteristics
As part of a qualitative method, the sample selection for this study was purposive and based on the
questions under evaluation. Because the questions evaluated in this study are designed for people who
had a live birth up to 12 months prior, recruitment focused on women who had recently given birth.
Beyond that criterion, respondents were recruited with the goal of producing a diverse sample and
across a range of characteristics including respondents’ race, ethnicity, education level achieved, and
household income. Respondents were recruited through a variety of media, including online
advertisements. Table 1 summarizes the demographic information of the sample. Future research
exploring maternal behaviors, attitudes, and experiences may benefit from recruiting respondents with
lower educational attainment and midrange household income, as the sample achieved for this study
had a high proportion of respondents with a college or graduate degree as well as those with household
incomes within the lower and upper ranges.
Table 1: Sample composition by language of the interview, n=50

Age of Respondent
Under 30
30-39
40 and over
Ethnicity/Race of respondent
Hispanic (H)
American Indian/Alaska Native (H)
Black or African American (H)
White (H)
Unspecified (H)
Non-Hispanic (NH)
Asian (NH)
Black or African American (NH)
More than one race (NH)
White (NH)
Education of respondent
Less than High School (no diploma)
High School Diploma or GED
Some college (no degree)
2- or 4- year college Degree
Graduate degree
Household income
$0-$19,999
$20,000-$44,999
$45,000-$79,999

English
(n=30)

Spanish
(n=20)

Total
(n=50)

12
16
2

10
8
2

22
24
4

1
1
7
11

1
1
7
11

3
7
4
16

3
7
4
16

0
3
1
11
15

4
4
6
6
0

4
7
7
17
15

1
1
7

13
6
0

14
7
7
3

$80,000 or more
Unspecified

21
0

0
1

21
1

Data analysis
Analysis of cognitive interviewing data followed a systematic process of data reduction and synthesis
from interview to report (Miller et al., 2014). Interviews were video recorded 5, and interviewers used
those video recordings to create question-by-question summary notes about the ways respondents
interpreted and responded to each question. Summary notes include key quotations from respondents
and relevant, observed behaviors and body language. Wherever this report quotes respondents’
verbatim statements, italics are used. Comparisons were made within interviews and across interviews
by question. Summary notes and respondent answers to each question were entered into CCQDER’s QNotes software 6, which is an application designed specifically by CCQDER for cognitive interview studies.
Themes were then developed by categorizing the differences and similarities among individual patterns
of interpretation.
Question set
Seventy-eight questions were evaluated in the study. However, probing focus was given to new
questions and those items not previously validated in other survey contexts. Due to the number of
questions evaluated and the time limitations of each cognitive interview, respondents received either
the first or second half of the total question set.
The questionnaire was amended twice during data collection based on the performance of the
questions. For example, in some cases reference periods were added or adjusted to aid respondents in
recalling the appropriate information. In other cases, response categories were clarified or simplified as
needed to make them less cognitively burdensome. The first update affected both the English and
Spanish versions. The second update affected only the Spanish version.
Questionnaire changes are noted in the question-by-question summaries, and the final version of the
questions are provided with the summaries. In a few cases, there were notable differences between the
two questionnaire modes. Those differences are addressed in the question summaries where
appropriate.
An overview of findings is described next followed by a question-by-question analysis of all items tested
organized by question topic.
Overarching findings
Timeframe considerations
At times, respondents made mistakes with question timeframes. While respondents were adept at
separating pregnancy-specific time periods such as ‘during pregnancy,’ ‘during delivery,’ and ‘after
delivery,’ as in the respectful care questions C14, C15, and C16, timeframes that included pre-pregnancy
were more commonly considered in error. For example, questions about care during preconception
One recording did not save due to Zoom conversion failure. Summary notes were written up based on the
interviewer’s hand-written interview notes.
6
https://www.cdc.gov/nchs/CCQDER/products/QNotes.htm
5

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such as A3 (‘In the 12 months before you got pregnant with your new baby, did you have any of the
following healthcare visits with a doctor, nurse, or other healthcare worker, including a dental or mental
health worker?’) were more challenging for respondents to conceptualize. Several respondents
erroneously interpreted the timeframe as “12 months before your new baby was born” rather than “12
months before you got pregnant with your new baby,” leading some to underrepresent the medical care
they received in the year prior to becoming pregnant.
Also, timeframe error occurred in the case of questions that utilized the timeframe “12 months before
your new baby was born.” For example, one respondent to A11 (For each of the statements below,
check the box that best describes your situation during the 12 months before your new baby was born.)
only considered the timeframe when she knew that she was pregnant, therefore underrepresenting the
food insecurity she experienced just prior to becoming pregnant.
Prior pregnancy experience
Whether a respondent had a prior pregnancy and how old their child was in comparison to their
newborn baby was an important variable in understanding some respondents’ answers. Prior
pregnancy experiences affected not only respondent viewpoints and confidence approaching medical
care, but it also impacted the behaviors and experiences captured in the questionnaire.
Any question asking about the preconception timeframe could also capture the prior pregnancy of a
respondent whose two youngest children were very close in age. A3 and A4, which cover preconception
care, were highly affected by respondents’ prior pregnancies in cases of two children close in age or if
the respondent had a miscarriage in the months prior to becoming pregnant with their new baby. In
those cases, the questions functioned more as prenatal questions for a prior pregnancy.
Also, questions with open-ended timeframes were affected. For instance, Question A5 asks about blood
pressure monitoring, with one response option reading ‘before my most recent pregnancy.’ One
respondent, for example, answered ‘Yes’ to ‘before my most recent pregnancy’ because she had
checked her blood pressure regularly during her prior pregnancy – which was literally before her most
recent pregnancy. She did not check her blood pressure between pregnancies.
Finally, having had prior pregnancy experience affected what services respondents needed and wanted
during their stay at the hospital where they delivered their new baby. B11, for instance, asked about
breastfeeding support at the hospital, including whether the respondent had help learning to breastfeed
or recognizing when the baby was hungry. Respondents with older children sometimes selected ‘No’
because they did not need the support, even in cases when breastfeeding support was offered and
available. As one respondent said, “They didn’t officially give any guidance. They did offer. […] I’d have
to say ‘no’ because they didn’t need to.”
Memory of events and conversations
Many respondents struggled to recall certain conversations that they had with their healthcare
providers. While respondents confidently remembered and reported on how they felt during certain
timeframes (as with the respectful care questions C14-C16) or their own behaviors, such as whether
they drank alcohol during any of the three trimesters of pregnancy (as in B7 and B8), respondents
5

tended to use reason (rather than recall) to answer questions that asked them to report on whether a
healthcare provider had ‘asked them’ or ‘talked to them’ about something. Recall challenges were more
evident for the questions that consisted of checklists of healthcare activities during the preconception,
prenatal, and postpartum time periods (A4, B4, C13). To make up for difficulties remembering,
respondents sometimes answered items based on what they thought was ‘typically’ asked on an intake
form or what their doctor ‘would probably’ have asked them, saying, for example, “Um, I don't think so
[…] If they did it would have been like one of the first questions when I first got pregnant.”
Administration mode
As mentioned above in the methods section, two administration modes were used in this study: a selfadministered version and an interviewer-administered version. There were some cases where mode
affected how respondents answered and the types of response error that emerged.
In the interviewer-administered version, some questions were cumbersome to read aloud, particularly
in the Spanish-language version. This was especially the case for response items that were in the form
of a Yes/No list. In some cases, respondents listening to response options read-aloud selected the first
answers that seem to fit their experiences before hearing the entire list – causing some to change their
answers during administration and resulting in response error for others. This was seen, for instance, in
A12 (During your postpartum checkup, did a healthcare provider do any of the following things?’) and
D21 (‘What kind of birth control are you using now to keep from getting pregnant?’). In other cases,
respondents seemed to lose track of the question intent as the list progressed. For example, B4 (‘During
any of your prenatal care visits, did a healthcare provider do any of the following things?’) offers a long
list of possible conversations that could have taken place during prenatal care appointments. Some
respondents answered based on their behavior rather than what healthcare providers asked.
Some respondents who completed the self-administered version had errors in their completion due to
the placement of ‘No’ and ‘Yes.’ Respondents in those cases expected the ‘Yes’ response to be listed
first rather than ‘No.’ These errors were discovered during review and probing with the respondent
after administration was complete.
Spanish language considerations
The question-by-question summaries below incorporate data from both the English- and Spanishlanguage respondents. In cases where Spanish-language participants had unique interpretations or
cases of response error, a separate section titled ‘Spanish-language considerations’ is included to help
highlight language-specific concerns.
In cases where translation questions arose, that is also noted below in the question-by-question
findings. For example, A16 covers breastfeeding duration (‘¿Por cuántas semanas o meses amamantó a
su bebé, le dio pecho o lo alimentó con leche materna?’). Respondents generally understood both
“amamantar” and “lactar” to mean breastfeeding or feeding breast milk. The respondent who
exclusively pumped to feed her baby referred to that as “lactó.” But, she was able to answer A16
correctly, stating that she is still breastfeeding or feeding pumped milk to her new baby.

Question-by-Question Findings
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The following section details question-by-question findings. The questions are grouped by topic in the
following order:

Topic
Gender and sexual identity ..................................................................................................................... 8
Preconception Care............................................................................................................................... 10
Blood pressure monitoring ................................................................................................................... 13
Reproductive coercion .......................................................................................................................... 15
Alcohol.................................................................................................................................................. 15
Food Insecurity ..................................................................................................................................... 18
Contraception services after delivery ................................................................................................... 21
Mental health screening ....................................................................................................................... 23
Generalized Anxiety.............................................................................................................................. 24
Breastfeeding duration ......................................................................................................................... 27
Transportation ...................................................................................................................................... 28
Preventing sexually transmitted infections........................................................................................... 29
Discrimination ...................................................................................................................................... 30
Adverse childhood experiences ............................................................................................................ 33
Health insurance during pregnancy ...................................................................................................... 39
Smoking and e-cigarettes...................................................................................................................... 40
Stressors ............................................................................................................................................... 43
Early maternal warning signs ................................................................................................................ 44
Family leave .......................................................................................................................................... 48
Cohabitation ......................................................................................................................................... 48
Infant sleep practices ............................................................................................................................ 49
Vaccination ........................................................................................................................................... 58
Postpartum contraception .................................................................................................................... 61
Racism .................................................................................................................................................. 64
Water testing ........................................................................................................................................ 69
Prenatal care......................................................................................................................................... 69
Disability ............................................................................................................................................... 74
Doula support ....................................................................................................................................... 75
Postpartum care ................................................................................................................................... 76
Patient-centered and respectful care.................................................................................................... 81
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Support for the baby............................................................................................................................. 85
Support for the respondent .................................................................................................................. 87
Firearms ................................................................................................................................................ 88

Gender and sexual identity
A1: Choose the option that best describes your gender:
□ Female
□ Male
□ Trans male/trans man
□ Genderqueer or gender nonconforming
□ Prefer to self-describe Please tell us:
A1: Seleccione la opción que mejor describe su género:
□ Femenino
□ Masculino
□ Hombre trans
□ Género no conforme o “genderqueer”
□ Otro Por favor díganos:
In discussion of what gender means to them, respondents variously considered the biological and
cultural aspects of sex, gender, and identity. For example, one respondent said, “I suppose female
means like… the first thing I think of is like XX chromosomes, but I suppose technically I don’t know. It’s
not like I have ever looked at my own chromosomes.” Whereas another respondent, considering gender
expression and identity said, “Yeah, I think for me gender, what it is showing, I think of female, male,
transgender, all those great things.”
All respondents asked this question characterized themselves as female. While some respondents may
not have been familiar with terms like, ‘genderqueer or gender nonconforming,’ the presence of these
options did not cause error. However, the lack of diversity in the sample, in the absence of respondents
identifying as transgender, non-binary, or another gender, significantly limits this study’s evaluation of
this question. Recent publications have recommended other approaches to measuring gender identity,
including the National Academies of Sciences, Engineering, and Medicine (NASEM) report Measuring
Sex, Gender Identity, and Sexual Orientation (2022) and a cognitive evaluation study by Miller and
Willson (2023). The NASEM report recommended a two-step approach, asking first ‘sex assigned at
birth’ followed by ‘current gender.’ Alternatively, Miller and Willson (2023) recommended a one-step
gender question, noting that a ‘mark all that apply’ format promoted inclusivity and was effective to
collect non-binary gender information for diverse, population-based surveys. The final recommended
phrasing used by Miller and Willson (2023) was ‘You may select more than one answer. Are you:’ and
the answer categories were ‘1. Male, 2. Female, 3. Transgender, non-binary, or another gender.’
Changes to the question wording
8

The only change that occurred with this question was on the Spanish questionnaire. The final response
option was changed from ‘prefiero describirio…Por favor díganos’ to ‘Otro Por favor díganos.’
A2: Choose the option that best describes your
sexual orientation:
□ Heterosexual or “straight”
□ Gay
□ Lesbian
□ Bisexual
□ Prefer to self-describe Please tell us:
A2: Seleccione la opción que mejor describe su orientación sexual:
□ Heterosexual
□ Homosexual o “Gay”
□ Lesbiana
□ Bisexual
□ Prefiero describirlo Por favor díganos:
In considering their sexual orientation, respondents tended to discuss their sexual attraction to men or,
their partnership with a man. For instance, one respondent explained the term ‘straight’ in the
following way: “Um, someone who is only attracted to an opposite sex. Yeah, I wouldn’t say totally
because I don’t think there is any female who is totally straight in my opinion.” All but one respondent
characterized themselves as heterosexual or straight, and one Spanish-language respondent selfdescribed as “feminino.” The lack of diversity in the sample, in the absence of respondents identifying as
gay, lesbian, bisexual, or in another way, significantly limits this study’s evaluation of this question.
CCQDER has examined the topic of sexual orientation previously, particularly for inclusion on the
National Health Interview Survey (NHIS)7. This prior work has established a response category –
‘Straight, that is not lesbian or gay.’ – for heterosexual-identifying respondents that aimed to minimize
errors due to miscomprehension of the term ‘heterosexual,’ as seen in this study by one Spanishspeaking respondent (Miller and Ryan, 2011). The sexual orientation question designed by CCQDER for
population-based surveys is the following: ‘Do you think of yourself as…’ and the response options are
‘1. Lesbian or gay, 2. Straight, that is not lesbian or gay, 3. Bisexual, 4. Something else:_____.’
Spanish-language consideration:
The term ‘heterosexual’ was unfamiliar to one Spanish-language respondent, but she selected
‘heterosexual’ through a process of elimination. She did not identify with any other response options.
The respondent who self-described as “feminine” interpreted ‘sexual orientation’ erroneously as
biological sex. She said, “It is what each person prefers to be, or feels he/she is... as he/she describes
/him/herself as a man or a woman [translated from Spanish by the interviewer].” This coincides with
prior findings by Milesi et al. (2017) who that found that ‘heterosexual’ was an unfamiliar term, to some
7

NHIS - National Health Interview Survey (cdc.gov)

9

Spanish-speaking respondents. The authors recommended using the following question to reduce error
and incidence of ‘don’t know’ responses among Spanish speakers: ‘¿Cuál de las siguientes mejor
representa su manera de pensar en sí mismo? 1. Lesbiana o gay, 2. No lesbiana o gay, o sea,
heterosexual, 3. Bisexual, 4. Otra cosa, 5. No sé la respuesta.’
Changes to the question wording
The wording of this question was not changed during data collection.

Preconception Care
A3: In the 12 months before you got pregnant with your new baby, did you have any of the following
healthcare visits with a doctor, nurse, or other healthcare worker, including a dental or mental health
worker? For each item, check No if you did not have a visit or Yes if you did.
No Yes
a. Regular checkup at my family doctor’s office.......................................................................................□ □
b. Regular checkup at my OB/GYN’s office...............................................................................................□ □
c. Visit for an illness or chronic condition.................................................................................................□ □
d. Visit for an injury...................................................................................................................................□ □
e. Visit for family planning or birth control...............................................................................................□ □
f. Visit for depression or anxiety...............................................................................................................□ □
g. Visit to have my teeth cleaned..............................................................................................................□ □
A3: En los 12 meses antes de quedar embarazada de su nuevo bebé, ¿usted fue a alguna de las
siguientes visitas de atención médica?

No Sí
a. Chequeo de rutina con un médico de familia...................................................................................... □ □
b. Chequeo de rutina con un ginecólogo-obstetra................................................................................... □ □
c. Vista asociada a una herida, enfermedad o condición crónica............................................................ □ □
d. Visita a un centro de cuidado de urgencias o a la sala de emergencias............................................... □ □
e. Visita asociada a planificación familiar o anticonceptivos................................................................... □ □
f. Vista por depresión o ansiedad............................................................................................................. □ □
g. Vista para una limpieza dental............................................................................................................. □ □
Overall, respondents viewed this question as asking about both where medical appointments took place
and topics covered in medical appointments. Therefore, respondents selected multiple answers to
account for single appointments, as needed. For example, one respondent who discussed family
planning during her appointments at her OB/GYN office, for instance, selected ‘yes’ to both ‘Regular
checkup at my OB/GYN’s office’ and ‘Visit for family planning or birth control.’ In her case, all her
OB/GYN appointments were focused on family planning. Likewise, another respondent selected
‘Regular checkup at my family doctor’s office’ and ‘Visit for an illness or chronic condition’ because her
primary care doctor managed her chronic condition.
Apart from selecting multiple categories to account for single appointments, key factors that affected
response were respondents’ interpretation of the response categories, meaning, how respondents
accounted for their specific experiences, and their understanding of the timeframe of the question.
10

Interpretation of response categories
Respondents considered a ‘visit for family planning and birth control’ to either refer to family planning
advice and birth control management at their OB/GYN, such as an intrauterine device (IUD) removal or
discussion of birth control options, or they considered it as referring to treatments received specifically
for infertility. As mentioned above, those who discussed birth control at their OB/GYN appointments
tended to select both ‘regular checkup at my OB/GYN’s office’ and ‘Visit for family planning or birth
control.’ One respondent hesitated when selecting a ‘visit for family planning or birth control’ because
she was unsure if her infertility treatments should be included there. She explained, “I'm guessing that
falls under family planning because we were planning to have a family, but I have also heard family
planning especially bundled with birth control to mean not covering infertility. So, I'm not entirely sure
how to answer this.” She ultimately selected ‘yes’ but noted that she would have done additional
internet research on ‘family planning’ if she were completing the survey at home.
Those who had medical visits related to a prior pregnancy within the question timeframe had different
ways of accounting for those visits. For example, one respondent was unsure how to account for visits
related to her miscarriage. She explained, “I was trying to figure out whether the ‘illness’ would be
considered a miscarriage...I wasn't sure where to categorize the miscarriage.” She did not select any
option to account for visits related to her miscarriage because she felt those visits were neither ‘regular
checkups’ nor visits for an ‘illness’ or ‘injury.’ Other respondents who had full term pregnancies
generally considered their prenatal and postpartum appointments as ‘regular checkups at the OB/GYN’s
office,’ though one respondent counted those as ‘visits for an illness or chronic condition.’ As she
explained, “I mean if you consider pregnancy a condition, which I think they do, I mean, so yes. I mean it
is a condition. It’s funny to think of it that way.”
Finally, one respondent answered ‘yes’ to ‘Regular checkup at my OB/GYN’s office’ initially thinking
about a visit to address her urinary tract infection, because her urologist and OB/GYN share an office
building. She literally considered the urology appointment to be physically at her OB/GYN’s office.
During probing, she also noted, “I’m pretty sure I had a PAP in that timeframe too,” so she ultimately did
not select option B in error.
Occurrences of error and potential error
Instances of response error occurred both due to misinterpretation of the question timeframe and also,
in one case, accidentally marking the incorrect response column.
The timeframe for the question was challenging for some respondents to conceptualize. As one
respondent said, “Oh a year beforehand…oh I really have to think back. Well, it was covid, it was precovid, so I have to remember.” Another remarked, “Okay, I have to do some math here.” Several
respondents erroneously interpreted the timeframe as “12 months before your new baby was born”
rather than “12 months before you got pregnant with your new baby,” leading some to underrepresent
the medical care they received in the year prior to becoming pregnant.
One respondent who completed the self-administered version had errors in her completion due to the
placement or ‘no’ and ‘yes.’ She expected the ‘yes’ responses to be listed first rather than ‘no.’
11

Changes to the question wording
In the Spanish questionnaire, this question was shortened to simplify the text. Also, the word ‘visita’
replaced ‘consulta’ in the answer categories for clarification.
A4. During any of your healthcare visits in the 12 months before you got pregnant, did a healthcare
provider do any of the following things?
No Yes
Recommend...
a. I take a vitamin with folic acid...............................................................................................................□ □
Talk to me about...
b. My weight ............................................................................................................................................□ □
c. Checking my blood pressure at home or outside of my doctor’s office................................................□ □
d. Sexually transmitted infections such as chlamydia, gonorrhea, syphilis, or HIV ……………………..……….□ □
Ask me if...
e. I smoked cigarettes or used e-cigarettes or other forms of smokeless tobacco ..................................□ □
f. Someone was hurting me emotionally or physically.............................................................................□ □
g. I was feeling down or depressed ..........................................................................................................□ □
Test me for…
h. HIV……………………………………………………………………………………………………………….………………………………….□ □
A4. En alguna de las visitas de atención médica que tuvo en los 12 meses antes de quedar
embarazada, ¿un proveedor de salud hizo alguna de las siguientes cosas?

No Sí
Habló conmigo sobre...
a. Mi peso................................................................................................................................................. □ □
b. Chequearme la presión regularmente................................................................................................. □ □
c. Mis deseos de tener o no tener hijos................................................................................................... □ □
d. Métodos anticonceptivos..................................................................................................................... □ □
e. Cómo podría mejorar mi salud antes del embarazo............................................................................ □ □
f. Las enfermedades de transmisión sexual como clamidia, gonorrea, sífilis o VIH................................. □ □
Me preguntó si...
g. Fumaba cigarrillos o usaba cigarrillos electrónicos u otros tipos de tabaco sin
humo........................................................................................................................................................ □ □
h. Alguien me estaba lastimando emocional o físicamente..................................................................... □ □
i. Me sentía decaída o deprimida............................................................................................................. □ □

Me hizo la prueba de...
j. VIH......................................................................................................................................................... □ □
k. Sífilis...................................................................................................................................................... □ □
Respondents generally considered this question to be asking about conversations they had with and
recommendations they were given by the doctors and nurses who provided them with medical care.
12

Whether answering questions on an intake form counted or not for the purposes of this question varied
among the respondents. Additionally, whether the healthcare providers were aware that the
respondent was trying to conceive or indeed if the respondent was pregnant 12 months prior to
becoming pregnant with their new baby were both important context considerations for the kinds of
conversations respondents remembered having with their healthcare providers. One respondent
remarked on not being asked about folic acid in the following way: “I didn’t mention trying to get
pregnant, so they didn’t.”
Those who were more literal in their considerations marked ‘no’ to response items, even if they had
been asked on a form, when a face-to-face conversation had not taken place. For example, one
respondent said, “They run like, yeah, they test for all of that because some of those can affect the baby
if you’re pregnant. But did they talk to me about them? No. But they ran the standard panel of tests
that are given to every pregnant woman.” In this case, the respondent’s previous pregnancy was within
a year to becoming pregnant with her new baby, so she had included prenatal visits from a prior
pregnancy in her response.
For some, remembering conversations and recommendations during preconception was difficult. In
cases where respondents did not remember what their doctor recommended or discussed, they either
made a best guess based on a typical doctor’s visit or they answered ‘no,’ erring on the side of caution.
Response error
One Spanish-language respondent considered the question to be asking about her own behaviors rather
than what a doctor, nurse, or other healthcare provider had asked or recommended. She answered
‘yes’ to taking a vitamin with folic acid, for instance, because she had read that it was recommended.
The respondent’s consideration was in part due to not taking the timeframe into account. In fact, the
respondent had not been to the doctor at all for two years prior to becoming pregnant.
Changes to the question wording
In the Spanish-language questionnaire, the term ‘visitas’ replaced ‘consultas’ and ‘proveedor’ replaced
‘un doctor.’ Additionally, answer categories were altered to be more simplified and specific and to
capture certain phenomena that were missed. For instance, the update included asking about Syphilis
(‘Sifilis’) and a woman’s wishes to have or not to have children (‘Mis deseos de tener o no tener hijos’).

Blood pressure monitoring:

A5: Have you regularly monitored your blood pressure at home or outside of a healthcare visit during
any of the following time periods?
No Yes
a. Before my most recent pregnancy .......................................................................................................□ □
b. During my most recent pregnancy…………………………………………………………………………………….……..………□ □
c. Since my new baby was born……………………………………………………………………………………………….……..……□ □
A5: ¿Usted se ha monitoreado la presión regularmente en el hogar o en otro lugar fuera de una visita
médica durante los siguientes períodos de tiempo?
No Sí
13

a. Antes de mi embarazo más reciente.................................................................................................... □ □
b. Durante mi embarazo más reciente..................................................................................................... □ □
c. Desde que nació mi nuevo bebé.......................................................................................................... □ □
Respondents generally considered the question to be asking whether they checked their blood pressure
on their own, outside of their regularly scheduled office visits. Some respondents were directed to
check their blood pressure at home by their medical provider and others decided to check their blood
pressure independently.
Response selection depended on how respondents considered the time periods in the question and also
their interpretation of checking ‘regularly.’ For example, one respondent selected ‘before pregnancy’
because she had checked her blood pressure regularly during her prior pregnancy – which was literally
before her most recent pregnancy. She did not check her blood pressure between pregnancies. Those
who checked their blood pressure just a handful of times (one to three times) post-pregnancy
consistently did not count that as ‘regular’ checking.
Occurrences of error and potential error:
Cases of response error occurred for two reasons, resulting in both false positives and false negatives.
First, some respondents (across modes and languages) counted blood pressure checking that occurred
at their doctor’s office when answering, resulting in false positives. For instance, one Spanish-language
respondent who completed the interviewer-administered version said ‘yes’ to ‘after my baby was born’
because her blood pressure had been checked at the hospital.
The second reason for response error is that a few respondents did not count home blood pressure
monitoring when they felt that the time they did check was not ‘enough’ to count for the question. For
example, one respondent who had been directed by her midwife to check her blood pressure at home
daily for the last several weeks of pregnancy said, “So for most of the pregnancy I didn’t monitor it at
home, it was just the very end and since the baby was born, I monitored it in the weeks afterwards, but
not since then.” She had answered ‘yes’ only to ‘since my baby was born.’ Likewise, another respondent
had monitored her blood pressure at home for five months prior to pregnancy and two months into her
pregnancy. She only answered ‘yes’ to ‘before my most recent pregnancy’ and explained her response
in the following way: “I don’t think it would count actually because it’s just 2 months into my pregnancy.
Yeah, I don’t think it’ll count.”
Spanish-language considerations
In terms of language, respondents overall did understand “la presión” to mean ‘blood pressure’ and
were not confused by the terminology.
Changes to the question wording
The wording of this question was not changed during data collection.

14

Reproductive coercion
A6. Before you got pregnant with your new baby, did your spouse or partner ever refuse to use a
condom when you wanted them to use one?
□ No
□ Yes
□ I did not have a partner at that time, or I was in
a same sex relationship
A6: Antes de quedar embarazada de su nuevo bebé, ¿alguna vez su esposo(a) o pareja se negó a usar
un condón cuando usted quería que usara uno?
□ No
□ Sí
□ No tenía una pareja en ese momento o mi pareja es del mismo sexo
Respondents viewed the question to be asking about birth control agreement and mutual decisionmaking. First, respondents considered their birth control methods, first and foremost, thinking: ‘Do I use
condoms?’ Then, if they had used condoms, respondents considered whether there had been a
disagreement or concern when using condoms. For example, one respondent said that she and her
husband had “never had problems like that.” And then she explained, “What came to my mind was the
argument about kids. I told you he wanted three and not two, but within that period we never had
arguments inside our sexual life, so that’s the whole scenario that came to my head.” Secondarily, a few
respondents considered protection from sexually transmitted diseases in addition to pregnancy.
In one case, a respondent answered ‘yes’ to this question because she had asked her partner to wear a
condom, but he would not. The respondent explained,
“I had no plans to get pregnant again, for the second time because I already had a baby, I
already had experience and I wanted my baby to grow up so I could have another one later and
not struggle with two very young children. I told him to take care of himself, I would tell him to
take care of himself and to use condoms and he said no, that he didn't like them. He wouldn't
wear it.” (Translated from Spanish by the interviewer)
Changes to the question wording
The wording of this question was not changed during data collection.

Alcohol

A10: During your most recent pregnancy, did a doctor, nurse, health worker, or home visitor tell you
that it was okay to drink a little alcohol during pregnancy?
□ No
□ Yes
A10: Durante su embarazo ¿algún proveedor de salud o visitadora al hogar le dijo que estaba bien
beber un poco de alcohol durante el embarazo?
15

□ No
□ Sí
Respondents considered the question to be asking about recommendations they received about alcohol
use, and not whether they themselves considered a little alcohol to “be ok.” For instance, one
respondent who answered ‘yes’ had decided not to drink alcohol at all during pregnancy. She explained,
“I mentioned it to a provider because she had told me, ‘oh if you want to have the occasional glass of
wine that’s fine.’ And I had said, ‘I thought I read an article that said maybe it’s not fine.’ But she had
said, ‘no it really is fine.’”
While most respondents thought the question was referring to recommendations by medical providers
only, respondents interpreted the term ‘home visitor’ inconsistently, and that had implications for
question response in a few cases. Some respondents considered ‘home visitor’ to include family or
friends – anyone who visited the house. As one respondent who answered ‘yes’ explained, “Now they
are sneaking in this ‘home visitor’ thing which is a whole new realm of friends, family, coworkers. It's just
kinda throwing me off. I'm just going to assume it means someone who is close enough to me to visit me
at home.” Others considered ‘home visitor’ to be some sort of visiting health worker, based on the
context of the question. In those cases, respondents excluded recommendations about alcohol that
they received from family and friends when answering.
Changes to the question wording
The wording of this question was not changed during data collection.
B7 During your most recent pregnancy, did you have any alcoholic drinks during...

No Yes
a. The first 3 months of pregnancy (1 trimester)? This includes the time before knowing you were
pregnant................................................................................................................................................... □ □
b. The second 3 months of pregnancy (2nd trimester)?........................................................................... □ □
c. The last 3 months of pregnancy (3rd trimester)?.................................................................................. □ □
st

B7: Durante su embarazo más reciente, ¿Tomó alguna bebida alcohólica durante...

No Sí
a. Los primeros 3 meses del embarazo (1er trimestre)? Esto incluye el tiempo antes de que supiera que
estaba embarazada.................................................................................................................................. □ □
b. Los segundos 3 meses del embarazo (2do trimestre)?........................................................................ □ □
c. Los últimos 3 meses del embarazo (3er trimestre)?............................................................................ □ □
Respondents considered the question to be asking about whether they drank alcohol during the three
trimesters of their pregnancy. Overall, the question accurately captured drinking during the first
trimester before respondents knew they were pregnant. In some cases, respondents read the question
as “did you have any alcohol at all,” answering ‘yes’ to include “small sips” and not simply full drinks.
Whether or not respondents considered sips of alcohol as ‘drinks’ had the most impact on question
response consistency, producing an overall overestimation in this set of respondents.

16

Occurrences of error
Apart from a few cases of error in which respondents overcounted ‘sips’ of alcohol, another error
occurred when a respondent should have answered ‘yes’ to both the first and second trimester, though
she only marked ‘yes’ to her second. In that case, she misread the italicized typeface, and she only
counted alcohol she drank after she knew she was pregnant. She explained, “I probably drank an
exorbitant amount before I found out, like week 5, 6, 7 because I didn’t find out until week 8. And, I
remember I was so stressed. Week 6 and 7 I drank so much wine. And, by ‘so much wine’ I mean like
two glasses a night. But I think I found out at week 8.”
Changes to the question wording
The wording of this question was not changed during data collection.
B8: During your most recent pregnancy, did you have 4 or more alcoholic drinks in a 2-hour
time span during…

No Yes
a. The first 3 months of pregnancy (1st trimester)? This includes the time before knowing you were
pregnant……………………………………………………………………………………………………………………………………....…… □ □
b. The second 3 months of pregnancy (2nd trimester)?........................................................................... □ □
c. The last 3 months of pregnancy (3rd trimester)?.................................................................................. □ □
B8: Durante su embarazo más reciente, ¿tomó 4 bebidas alcohólicas o más en un lapso de 2 horas
durante...
No Sí
a. Los primeros 3 meses del embarazo (1er trimestre)? Esto incluye el tiempo antes de que supiera que
estaba embarazada.................................................................................................................................. □ □
b. Los segundos 3 meses del embarazo (2do trimestre)?........................................................................ □ □
c. Los últimos 3 meses del embarazo (3er trimestre)?............................................................................ □ □
Respondents considered the question to be asking about whether they drank a significant amount of
alcohol at one time during the three trimesters of their pregnancy. Most respondents selected ‘no,’
consistent with their response and explanation to Question B7 (‘During your most recent pregnancy, did
you have any alcoholic drinks during…’), even in cases where they had occasionally had a few sips or a
full drink of alcohol during pregnancy.
Occurrences of error
Two respondents selected ‘yes’ for their first trimester in likely overestimation. One such respondent
reported that she only had one drink per week. And, in another case, a respondent said that she had
four drinks over four hours on one occasion. She explained, “We were driving. It was downtown, we
couldn’t drink that much because I was driving.”
Changes to the question wording
The wording of this question was not changed during data collection.

17

Food Insecurity
A11: For each of the statements below, check the box that best describes your situation during
the 12 months before your new baby was born.
For each statement, check:
O if it was often true
S if it was sometimes true, or
N if it was never true.

OSN
a. I worried whether my food would run out before I got money to buy more................................... □ □ □
b. The food that I bought just didn’t last, and I didn’t have money to get more.................................. □ □ □
A11. Indique con qué frecuencia le ocurrió lo siguiente durante los 12 meses antes de que naciera su
nuevo bebé.
a. Me preocupaba que la comida se acabaría antes de tener dinero para comprar más
□ Frecuentemente □ A veces □ Nunca
b. La comida que compré simplemente no duraba y no tenía dinero para comprar o conseguir más
□ Frecuentemente □ A veces □ Nunca
Respondents considered this question to be about food insecurity, sometimes even using that phrase.
They sometimes thought about pandemic-related shortages or issues with the supply chain, or even
running out of specifics in the week (like milk) before buying more. However, none of those
considerations ultimately fed into response selection. Those who selected something other than ‘never’
did have worries around their income and food purchase. For example, one respondent answered
‘sometimes’ to A and ‘never’ to B because she had been placed on unpaid leave during her pregnancy.
Unique interpretation
One respondent interpreted “my food” as her breastmilk. But, this was still related to money and
getting food due to formula shortage and price. She was worried during her pregnancy about having
breastmilk once her baby was born. She explained,
“Well I always was a little bit concerned about the future. Especially because I wanted the food
that my child would have would be coming from my breast and I really wanted to make sure
that that’s what they were getting. But because of my experience during my first pregnancy or
after, I was just very much feeling I don’t know if this is going to be possible, but I am going to go
through it and see how it goes. So I was very worried about that because formula is expensive
and now we have a formula shortage in the US. So those are the concerns.” (Answered ‘often’ to
A, ‘never’ to B)
Occurrence of error:
One respondent likely answered ‘never’ to A in error, because just become becoming pregnant she had
her salary withheld for two months and her husband was a contractor with an unreliable month-tomonth income. During the final month of salary delay, she became pregnant. The respondent did not
count this, as she did not know she was pregnant at the time, and she did not consider the time period
’12 months before your new baby was born.’ She said, “So within that period I was broke as hell, but my
18

husband was there and my savings a bit, but if I was pregnant at that point I would have thought about
a lot of things because I didn’t know how long it was going to hold, I didn’t know when they were going
to release the salary or not.”
Spanish-language consideration
The question was challenging to read aloud for the interviewer-administered format, in that,
interviewers felt the question could be reworded to increase clarity. Also, in one case, a respondent was
confused by the intent of the question. She thought that it was asking if she was prepared and eager to
have a child in the 12 months before the baby was born. Only after the interviewer reread the question
and reviewed the response options did the respondent understand the intent of the question as asking
about food security.
Spanish-language participants received an updated version of the self-administered format which
decreased the cognitive burden of the grid format found in the English version.
Changes to the question wording
In the Spanish language version of the questionnaire, the question wording was changed to be more
direct and less wordy without changing the overall meaning. The original phrasing of the question was
‘Para cada una de las siguientes declaraciones, marque la opción que mejor represente cual fue su
situación durante los 12 meses antes de que naciera su nuevo bebé.’
B9: During your most recent pregnancy, which of these statements best describes the food eaten in
your household?
□ Enough of the kinds of food I wanted to eat (go to B11)
□ Enough, but not always the kinds of food I wanted to eat (go to B11)
□ Sometimes not enough to eat
□ Often not enough to eat
B9: Durante su embarazo más reciente, ¿cuál de estas afirmaciones describe mejor los tipos de
alimentos que había en su hogar?
□ Suficiente de los tipos de comida que yo quería comer
□ Suficiente, pero no siempre el tipo de comida que yo quería comer
□ A veces no habia suficiente para comer
□ Frecuentemente no habia suficiente para comer
Respondents considered this question in one of two ways. First, most respondents understood that the
question was intending to capture food security. In these cases, respondents did not account for
pandemic related supply-chain issues or pregnancy cravings in their response. Second, some
respondents viewed the question as asking about their food preferences and access to preferred foods,
apart from financial restraint. Many Spanish-language respondents interpreted the question in the
second way, and in those cases, answered based on pregnancy-related diet restrictions and self-limiting
of pregnancy cravings. As one respondent who answered, ‘enough, but not always the kinds of foods I
wanted to eat’ said, “Because of the cravings and so on, and at the same time trying to take care of my
weight. I buy what I need, meat, salad, chicken, fish, but I tried to limit myself a little with sugars and
19

carbohydrates. Sometimes I felt like eating something sweet, and I didn't have it because I hadn't bought
it (Translated from Spanish by the interviewer).”
Several respondents who ultimately answered the question based on food security were not confident
that was the correct interpretation. For example, one respondent who answered ‘enough of the kinds
of foods I wanted to eat’ said, “And I didn’t think they care about if I wanted my chicken that I cooked
yesterday versus getting a burger. I don’t think you guys care about that. So, what I think you were
trying to get to was did I have enough like [stammers] food. I don’t know what you are trying to get at
to be honest.” Also, one respondent read ahead to the follow-up question, B10 (‘Why did you not have
enough to eat?’), to ascertain that this question was asking about food security. After doing so, she was
comfortable answering, ‘enough, but not always the kinds of foods I wanted to eat’ because that
selection would not route her to B10.
One respondent, a Spanish-language participant, reported true food scarcity, and her response correctly
captured her experience. She said that sometimes she and her husband only had money to pay rent and
other bills, and not food, since she had to stop working due to pregnancy-related illness. She selected,
‘sometimes not enough to eat.’
Changes to the question wording
The wording of this question was not changed during data collection.
B10: Why did you not have enough to eat?
□ I couldn’t afford to buy more food
□ I couldn’t get out to buy food (for example, didn’t have transportation or had mobility or health
problems that kept me from getting out)
□ I was afraid to go or didn’t want to go out to buy food
□ I couldn’t get groceries or meals delivered to me
□ The stores didn’t have the food I wanted
B10: ¿Por qué no tuvo suficiente para comer?
□ El dinero no me daba para comprar más comida
□ No podía salir a comprar comida (por ejemplo, no tenía transporte o tenía problemas de movilidad o
de salud que me impedían salir)
□ Tenía miedo de ir o no quería salir a comprar comida
□ No lograba conseguir que me hicieran entrega de comida o de la compra
□ Las tiendas no tenían la comida que quería
This question was asked of respondents who answered ‘Sometimes not enough to eat’ or ‘Often not
enough to eat’ to Question B9, “During your most recent pregnancy, which of these statements best
describes the food eaten in your household?” One respondent, who was a Spanish-language
participant, was routed to this question based on her response ‘sometimes not enough to eat’ to
Question B9. In discussion of B9, she had explained that sometimes she and her husband only had
money to pay rent and other bills, and not food, since she had to stop working due to pregnancy-related

20

illness. She did not understand ‘I couldn’t get groceries or meals delivered to me’ (“No pude conseguir
que me entregaran la comida o la compra.”), and so she selected all but that response option.
One respondent completing the self-administered version of the questionnaire answered this question
in error, having misread the skip pattern.
Changes to the question wording
The wording of this question was not changed during data collection.

Contraception services after delivery

A12. During your hospital stay after your new baby was born, did a doctor, nurse, or other healthcare
worker do any of the following things?
No Yes
a. Talk with me about birth control methods I can use after giving birth................................................ □ □
b. Tie or block my tubes (female sterilization)......................................................................................... □ □
c. Place an IUD (ParaGard®, Mirena®, Liletta®, Kyleena®, Skyla®)............................................................□ □
d. Place a contraceptive implant (Nexplanon®)....................................................................................... □ □
e. Give me a contraceptive shot/injection (Depo-Provera®)....................................................................□ □
f. Give me or prescribe a contraceptive method to start myself at a later time (birth control pills, patch,
ring, condoms, etc.)..................................................................................................................................□ □
A12. Durante su estadía en el hospital para el nacimiento de su nuevo bebé, ¿algún proveedor de
salud hizo alguna de las siguientes cosas?

No Sí
a. Habló conmigo sobre los métodos anticonceptivos que puedo usar después del parto..................... □ □
b. Me operó para no tener hijos (amarraron las trompas o ligaron los tubos)........................................ □ □
c. Me puso un dispositivo intrauterino o DIU.......................................................................................... □ □
d. Me puso un implante anticonceptivo.................................................................................................. □ □
e. Me puso una inyección anticonceptiva................................................................................................ □ □
f. Me dio o recetó un método anticonceptivo para que lo comenzara en otro momento (como píldoras
anticonceptivas, parche, anillo)............................................................................................................... □ □
Respondents viewed this question as asking about contraception recommendations and actions that
may have occurred when they were in the hospital to deliver their new baby. Most respondents were
able to clearly differentiate what did and did not occur at the hospital, and they did not include
contraception care from separate postpartum appointments in this question.
Occurrences of error
There were two cases of false positives for item F, ‘give me or prescribe a contraceptive method to start
myself at a later time.’ In one these cases, the respondent had spoken with the doctor about “natural
family planning,” and she counted that conversation twice by selecting both A (talk with me about birth
control methods) and F (give me or prescribe me a contraceptive method). In the other case, the
respondent emphasized that her memory of her time in the hospital was very hazy. She selected F in
21

error because she had received birth control pills from her OBGYN prior to delivery, not at the hospital.
Additionally, she marked ‘yes’ to C (place an IUD) in error as well. When she first heard item C she said,
“Uh, yeah. Yes. Yes. Uh, maybe, I’m not too sure, I don’t think I remember.” But, upon later probing, she
corrected herself and said that she knows that she did not receive an IUD at the hospital.
Changes to the question wording
In the Spanish-language version of the questionnaire, the term ‘proveedor de salud’ replaced ‘médico,
enfermera u otro profesional de la salud’ to be more concise. Similarly, the second and third response
items, items B and C, were simplified and reworded to better align with the way respondents
themselves referred to tubal ligation and intrauterine devices.
B11: This question asks about things that may have happened at the hospital where your new baby
was born. For each item, check No if it did not happen or Yes if it did happen.
No Yes
a. Hospital staff tied or blocked my tubes (female sterilization)............................................................. □ □
b. Hospital staff inserted an IUD (ParaGard®, Mirena®, Liletta®, Kyleena®, Skyla®).................................□ □
c. Hospital staff inserted a contraceptive implant (Nexplanon®).............................................................□ □
d. Hospital staff gave me a contraceptive shot/injection (Depo-Provera®)..............................................□ □
e. Hospital staff talked to me about how to breastfeed (how often and long to breastfeed)................. □ □
f. My baby stayed in the same room with me at the hospital................................................................. □ □
g. Hospital staff helped me learn how to breastfeed............................................................................... □ □
h. I breastfed as soon as possible after my baby was born...................................................................... □ □
i. My baby was placed in skin-to-skin contact as soon as possible after birth..........……………………..………□ □
j. My baby was fed only breast milk at the hospital................................................................................. □ □
k. Hospital staff helped me recognize when my baby was hungry.......................................................... □ □
l. The hospital gave me a gift pack with formula..................................................................................... □ □
m. The hospital gave me information about who I could contact for breastfeeding support when I left
the hospital…………………………………………………………………………………………………………………………………….... □ □
B11. Esta pregunta es acerca de las cosas que pudieron haber sucedido en el hospital donde nació su
nuevo bebé. Para cada una, marque No, si no sucedió, o Sí, si sucedió.
No Sí
a. El personal del hospital me operó para no tener más bebés (me ligaron o amarraron las trompas... □ □
b. El personal del hospital me puso un DIU.............................................................................................. □ □
c. El personal del hospital me puso un implante anticonceptivo en el brazo.......................................... □ □
d. El personal del hospital me puso una inyección anticonceptiva ......................................................... □ □
e. El personal del hospital me habló sobre como amamantar o darle pecho a mi bebé (cuando y por
cuanto tiempo)......................................................................................................................................... □ □
f. Mi bebé se quedó conmigo en el mismo cuarto en el hospital............................................................ □ □
g. El personal del hospital me ayudó a aprender como amamantar....................................................... □ □
h. Amamanté a mi bebé lo antes posible después de que nació............................................................. □ □
i. Mi bebé fue colocado en contacto piel a piel lo antes posible después de que nació.......................... □ □
j. Mi bebé solo fue alimentado con leche materna mientras estuvo en el hospital…………………………….. □ □
k. El personal del hospital me ayudó a reconocer cuando es que mi bebé tenía hambre....................... □ □
22

l. El hospital me dio un paquete de regalo que incluía fórmula............................................................... □ □
m. El hospital me dio información acerca de a quien contactar si necesito ayuda para amamantar una
vez saliera del hospital............................................................................................................................. □ □
Respondents considered this question to be asking about both the contraception and breastfeeding
support at the hospital where they gave birth to their new baby. For some, the double functionality of
the question was surprising, but it did not cause confusion or response error as such.
Respondents responded according to the services they received or actions that occurred for their
circumstance, and they did not answer generally based on what the hospital offered. The factor that
affected breastfeeding support responses most was whether the respondent had prior experience with
breastfeeding an older child. Many respondents with older children explained that they answered ‘no’
to the breastfeeding support items because they did not need the help. For example, one respondent
said, “They didn’t officially give any guidance. They did offer. […] I’d have to say ‘no’ because they didn’t
need to.” Additionally, some respondents did not need help breastfeeding from the hospital staff
because they had outside help from other lactation experts and assistants.
There is potential for inconsistency among respondents whose babies were immediately transferred to a
NICU for care after delivery. In one case, a respondent’s baby was taken to a NICU at a different hospital
from the one where she gave birth. She was thinking about the hospital where she gave birth for most
items, but for the breastfeeding care items, she was thinking about the hospital where her baby was
taken to the NICU.
Spanish-language considerations
Respondents were familiar with IUDs generally, but they referred to them in different ways. Some
respondents noted that most commonly, they refer to IUDs as “Diu,” as an acronym and not an
abbreviation. Those who did not know that acronym did know the term “dipositivo intrauterino.” With
regards to the vocabulary used to describe breastfeeding, most respondents understood and used
“amamantar.” All respondents understood that “lactar” could be used to refer to breastfeeding, even
in cases where respondents preferred another word, such as “amamantar” or “dar pecho”
Changes to the question wording
Minor changes were made to the Spanish-language version to simplify a few of the response items
about contraception. Items B, C, and D were updated to remove the band names of the contraception
devices and injections, as they were unnecessary for item comprehension.

Mental health screening
A13: Has a healthcare worker asked you, in person or on a form, about feeling down, depressed,
anxious, or irritable during the following time periods?
No Yes
a. During my most recent pregnancy....................................................................................................... □ □
b. Since my new baby was born............................................................................................................... □ □
23

A13. ¿Algún proveedor de salud le ha hecho una serie de preguntas, ya sea en persona o en un
formulario, para saber si se sentía decaída, deprimida, ansiosa o irritable durante los siguientes
períodos de tiempo?

No Sí
a. Durante mi embarazo más reciente..................................................................................................... □ □
b. Desde que nació mi bebé..................................................................................................................... □ □
Respondents understood that this question was asking about mental health screening. Additionally,
several respondents mentioned postpartum depression as the key concern that the screeners aimed to
assess. Both those who did and did not experience anxiety and depression correctly accounted for
screening that occurred either on a form or in a conversation. In some cases, respondents were asked
by their new baby’s pediatrician and not necessarily their OB/GYN. As one respondent noted, “During
all my appointments during my pregnancy I was asked questions, in all my appointments I was asked the
questionnaire, and after the pregnancy, also my child's pediatrician has asked me these surveys
(translated from Spanish by the interviewer).”
Changes to the question wording
The Spanish-language version of this question was changed slightly to increase readability and clarity
while maintaining the overall meaning. The old version of the question was the following: “¿Un
proveedor de atención médica le preguntó, en persona o en un formulario, si se sentía decaída,
deprimida, ansiosa o irritable durante alguno de los siguientes períodos de tiempo?”

Generalized Anxiety

A14: Since your new baby was born, how often have you felt nervous, anxious, or on edge?
□ Always
□ Often
□ Sometimes
□ Rarely
□ Never
A14: Desde que nació su nuevo bebé, ¿con qué frecuencia se ha sentido nerviosa, ansiosa o tensa?
□ Siempre
□ Frecuentemente
□ A veces
□ Rara vez
□ Nunca
Respondents’ considerations of this question depended on their own history of mental health issues and
how long ago it had been since their baby was born. Considerations of anxiety and nervousness
included diagnosed obsessive compulsive disorder, diagnosed anxiety, manageable day-to-day
nervousness, irritability from lack of sleep, and general nerves from becoming a new mother.

24

In cases where respondents were managing diagnosed mental health illnesses, they were thinking about
both how they were feeling and how disruptions in their regular medications during pregnancy affected
them as well.
Those who had delivered their new baby nearly a year prior to their interview had a harder time
assessing their experience. For instance, one respondent who answered ‘sometimes’ said, “I feel like it
has been so long since she was born. It depends on which time period you ask me about. I’ll say
sometimes then, I’ll average the difference.” In contrast, another respondent whose baby was just a few
weeks old answered ‘often’ and explained that her lack of sleep affected her response. She said, “Not so
much nervous or anxious but definitely on edge.. Like irritable.”
Changes to the question wording
The wording of this question was not changed during data collection.
A15: Since your new baby was born, how often have you not been able to stop or control worrying?
□ Always
□ Often
□ Sometimes
□ Rarely
□ Never
A15: Desde que nació su nuevo bebé, ¿con qué frecuencia no ha podido parar o controlar sus
preocupaciones?
□ Siempre
□ Frecuentemente
□ A veces
□ Rara vez
□ Nunca
Similar to A14 above (“Since your new baby was born, how often have you felt nervous, anxious, or on
edge”), respondents’ considerations were affected by their experience with mental health concerns and
also how long it had been since their baby was born. Considerations of worrying that respondents
thought about included extreme anxiety from obsessive compulsive disorder, diagnosed anxiety,
sadness, and the expected worries about having a new baby.
In cases where respondents were managing diagnosed mental health illnesses, they were thinking about
both how they were feeling and how disruptions in their regular medications during pregnancy affected
them as well. As one respondent explained, “I should say ‘always’ but I’m on medication so I’ll say
‘often.’”
Those who had given birth several months prior accounted for changes in their emotions over time. For
example, one respondent said, “When I first gave birth, it was all the time. And now it’s more like I’ve
gotten used to it, so, yeah, I would just say ‘often’ there are times where it gets really bad. But I’ve
gotten used to it and sometimes I just let it pass and don’t let it get to me.”
25

Respondents with newborns who had given birth recently focused more on adjusting to life with the
new baby. For example, one respondent whose new baby was unplanned explained her response of
‘often’ in the following way: “He is like a new puzzle piece. He has to fit in. We have to make him fit in
the home, in our life. It's been hard on me because I'm mostly who has to deal with him (translated from
Spanish by the interviewer).”
Changes to the question wording
The wording of this question was not changed during data collection.
B18: For each item below, check the box that best describes how often you have felt or experienced
these things since your new baby was born.
For each item, check:
A if you always do
O if you often do
S if you sometimes do
R if you rarely do
N if you never do
AOSRN
a. Felt down, depressed, or hopeless............................................................................................. □ □ □ □ □
b. Had little interest or little pleasure in doing things.................................................................... □ □ □ □ □
c. Felt nervous, anxious, or on edge............................................................................................... □ □ □ □ □
d. Not been able to stop or control worrying................................................................................. □ □ □ □ □
B18: Para cada una de las opciones a continuación, indique con qué frecuencia se ha sentido de esa
manera desde que nació su nuevo bebé.
Para cada una, marque:
S si fue Siempre
F si fue Frecuentemente
A si fue A veces
R si fue Rara vez
N si fue Nunca
SFARN
a. Se ha sentido mal, deprimida o sin esperanza........................................................................... □ □ □ □ □
b. Ha tenido poco interés o placer en hacer cosas......................................................................... □ □ □ □ □
c. Se ha sentido nerviosa, ansiosa o tensa..................................................................................... □ □ □ □ □
d. Se ha sentido que no puede parar o controlar sus preocupaciones.......................................... □ □ □ □ □
Respondents viewed this question as asking about their emotional state since their baby was born. This
question is specifically asking about postpartum experiences, and most respondents attributed their
answers directly to the stressors of having a new baby to care for and keep safe. As one respondent
explained, “It’s definitely all from her [the baby]. How to take care of her, how to keep her safe, so yeah.
I’m always fretting about something.” This respondent ‘rarely’ felt depressed (item A) or had little
interest in doing things (item B), but ‘often’ felt anxious (item C) and unable to stop worrying (item D). A
26

few respondents also mentioned other factors affecting their mental state such as prior history with
anxiety and other stressors, like finances and work.
Some respondents noted that their feelings had fluctuated since giving birth. In those cases,
respondents attempted to average their feelings across time. As one respondent explained, “I would
not say that these events have been evenly distributed over the period since my new baby was born. So,
like I felt down depressed and hopeless pretty often in the very immediate postpartum period, like in the
first 2 days, but since then I've been super cheerful, so I think overall I'm going to say ‘rarely’ [Item A].”
The self-administered version of this question is a relatively complex grid pattern of four items and five
response options. This evaluation did not find specific evidence of error related to the format of the
question; but as a caveat, no respondents with an educational attainment of less than high school were
given self-administered questionnaires due to technological limitations at their homes. Given that
caveat though, one respondent noted that the grid was organized in a clear manner. Moving left to
right, responses shift from more severe signs of mental health concerns to less severe in a consistent
manner across the four items, decreasing chances for accidental end-to-end error.
Changes to the question wording
The wording of this question was not changed during data collection.

Breastfeeding duration

A16: How many weeks or months did you breastfeed or feed pumped milk to your baby?
□ I did not breastfeed my baby, even for a short period of time
□ I breastfed my baby for less than 1 week
□ I breastfed my baby for: _____ weeks OR ____ months
□ I’m still breastfeeding or feeding pumped milk to my new baby
A16: ¿Por cuántas semanas o meses amamantó a su bebé, le dio pecho o lo alimentó con leche
materna?
□ Nunca amamanté a mi bebé
□ Amamanté a mi bebé menos de 1 semana
□ Amamanté a mi bebé: ______ Semanas O _____ Meses
□ Todavía estoy amamantando o alimentando a mi bebé con leche materna
All respondents understood this question to be asking about the duration of time they fed breast milk to
their baby, either by the breast or by pumped milk in a bottle. Those who had stopped breastfeeding
were able to estimate within a few weeks how long they had breastfed. During testing for this
evaluation, the format of the self-administered version of the question was updated to be clearer. After
the update, respondents generally understood that if they were still breastfeeding, they need only select
‘I am still breastfeeding or feeding pumped milk to my new baby.’ However, some respondents still
provided two responses: 1) that they were still breastfeeding and also 2) the duration, which was the
same as their baby’s age.

27

Of note: This question was sensitive to one respondent who felt shame that she had not breastfed her
baby longer. The interviewer noticed that the respondent had anxiety around this question, but the
interview was able to progress without respondent becoming distressed.
Spanish-language consideration
Respondents generally understood both “amamantar” and “lactar” to mean breastfeeding or feeding
breast milk. Some respondents specified that “amamantar” meant feeding their baby directly from the
breast, whereas “lactar” referred to pumped milk or even meaning that the baby is fed breastmilk, but
not necessarily from the breast. The respondent who exclusively pumped to feed her baby referred to
that as “lactó.” That respondent was able to answer correctly, stating that she is still breastfeeding or
feeding pumped milk to her new baby.
Changes to the question wording
Both the English and Spanish versions of this question were updated during data collection to increase
clarity. An instruction to select one answer was added, and the phrase ‘I breastfed my baby for…’ was
added to second and third response options to decrease confusion. After these edits were made, there
was less incidence of confusion with this question. In addition to these changes, the Spanish version
changed from using ‘lactar’ to ‘amamantar’ across the question and response options to better align
with respondents’ use of these words.

Transportation

A17: Has lack of transportation kept you from medical appointments, meetings, work, or from getting
things needed for daily living? [Check all that apply]
□ No
□ Yes, it has kept me from medical appointments
□ Yes, it has kept me from non-medical meetings, appointments, or work
□ Yes, it has kept me from getting things needed for daily living
A17: ¿La falta de transporte le ha impedido acudir a citas médicas, reuniones, el trabajo o hacer
recados o diligencias? (Marque TOTAS las que correspondan)
□ No
□ Sí, me ha impedido acudir a citas médicas
□ Sí, me ha impedido acudir a reuniones o citas que no eran médicas o al trabajo
□ Sí, me ha impedido ir a hacer recados o diligencias
Respondents understood this question to be asking about their ability to move freely either with a car or
using public transportation. Additionally, they considered the question as assessing whether
transportation was a barrier to getting medical care or going on necessary trips for work or day-to-day
life. As one respondent who answered ‘no’ explained, “I don't have a car, my husband takes it to work
but there is no problem because it is easy to use public transportation here, or he can give me a ride if he
has to. I have no problem with that.” Another respondent who answered ‘no’ mentioned other barriers,
explaining that she had missed medical appointments because she could not find childcare.

28

Those who marked ‘yes’ indicated that they had missed medical and non-medical appointments. No
respondent indicated having a lack of transportation keeping them from getting things they needed for
daily living.
Changes to the question wording
In the Spanish version of this question, phrase ‘conseguir las cosas necesarias para la vida diaria’ was
changed to ‘hacer recados o diligencias’ in order to be more concise and clearer.

Preventing sexually transmitted infections

A18: What are you doing now to keep from getting sexually transmitted infections (STIs), including
HIV?
□ I am not doing anything
□ Using condoms
□ Testing for STI/HIV
□ Mutual monogamy (two partners agreeing to only have sex with each other)
□ Other Please tell us:
A18: ¿Qué está haciendo usted actualmente para evitar contraer infecciones de transmisión sexual
(ITS), incluyendo el VIH?
□ No estoy haciendo nada
□ Usando condones
□ Me hago pruebas de ITS / VIH
□ Monogamia mutua (pareja solo tienen relaciones sexuales entre sí)
□ Otro Por favor díganos:
Respondents understood that the question was asking about prevention of STIs specifically and not
prevention of pregnancy. Even in cases where respondents and their partners used condoms to prevent
pregnancy, they did not select ‘using condoms’ as their answer here.
Sources of error and potential error:
For this question there are two primary sources of possible error. The first is the order of the response
options. For interviewer-administered instruments, respondents tended to say ‘I am not doing anything’
before all the response options were read aloud, and then they switched their response to ‘mutual
monogamy’ once they heard that option. Reordering the response options may help prevent errors.
Secondly, Spanish-language respondents, even those in committed relationships, much more frequently
selected ‘I am not doing anything’ rather than ‘mutual monogamy’ whereas English-language
respondents more often selected ‘mutual monogamy.’ Several Spanish-language respondents noted
that they either did not understand ‘monogamia mutua’ or, they thought it referred to having sex with
more than one person.
Of note: One respondent who did not have a partner at all selected ‘I am not doing anything.’
Therefore, in this sample, that response option indicated people in committed relationships and people
with no partner.
29

Changes to the question wording
The wording of this question was not changed during data collection.

Discrimination
A19: Have you ever experienced discrimination or were prevented from doing something, hassled, or
made to feel inferior because of the things listed below? For each item, check
No if you have never experienced discrimination because of it or Yes if you have.
No Yes
a. My race or skin color............................................................................................................................ □ □
b. My disability status...............................................................................................................................□ □
c. My immigration status......................................................................................................................... □ □
d. My age.................................................................................................................................................. □ □
e. My weight............................................................................................................................................. □ □
f. My income............................................................................................................................................ □ □
g. My sex/gender...................................................................................................................................... □ □
h. My sexual orientation.......................................................................................................................... □ □
i. My religion.............................................................................................................................................□ □
j. My language skills or accent.................................................................................................................. □ □
k. My type of health insurance or lack of health insurance......................................................................□ □
l. My substance use (alcohol, tobacco, other drugs).................................................................................□ □
m. My involvement with the justice system (jail, prison)........................................................................ □ □
n. Another reason………………………………………………………………………………………………………………………………..□ □
Please tell us:
A19: ¿En algún momento se ha sentido discriminada, le han impedido o dado problemas en hacer algo
o le han hecho sentir que es inferior a otra persona por alguna de las siguientes razones? Para cada
una, marque No si no le ha ocurrido por esa razón o Sí, si le ha ocurrido.
No Sí
a. Mi raza, etnicidad o el color de mi piel................................................................................................ □ □
b. Por alguna discapacidad....................................................................................................................... □ □
c. Mi estatus de inmigración.................................................................................................................... □ □
d. Mi edad................................................................................................................................................ □ □
e. Mi peso................................................................................................................................................ □ □
f. Mi salario ............................................................................................................................................. □ □
g. Mi sexo o género................................................................................................................................. □ □
h. Mi orientación sexual.......................................................................................................................... □ □
i. Mi religión............................................................................................................................................ □ □
j. Mi idioma o acento............................................................................................................................... □ □
k. El tipo de seguro médico que tengo o porque no tengo seguro médico............................................. □ □
l. Por mi uso de substancias (alcohol, tabaco u otras drogas) ................................................................. □ □
m. Dado a que he estado involucrada en el sistema judicial (cárcel o prisión)........................................ □ □
n. Otra...................................................................................................................................................... □ □
Por favor díganos:
30

For this question on discrimination across a person’s life, respondents considered both an accumulation
of micro-aggressions as well as salient, memorable life events, even if they occurred in childhood. Some
respondents felt that discrimination had occurred, but they could not necessarily pinpoint an example.
This was particularly the case for ‘sex/gender’- based discrimination, whereby some respondents
assumed they must have been discriminated against for being a woman but did not consider a specific
example when answering. Overall, how respondents answered depended on whether they felt ‘made to
feel inferior’ for any of the reasons listed in the response options.
White-identifying respondents sometimes grappled with whether what they experienced could be
considered ‘discrimination,’ and instead they focused on wording in the question such as ‘prevented
from doing something’ or ‘made to feel inferior.’ For instance, one respondent said, “At one point my
husband lost his health insurance when my son was a baby and we had to cancel some surgeries until I
could get him picked up. I wouldn’t say it was discrimination.” (Answered ‘yes’ to ‘lack of health
insurance’) Likewise, another respondent reported,
“My husband and I had trouble conceiving – I had a provider refuse to treat me for infertility
because of my weight […] I always feel weird with the word ‘discrimination’ because I feel like
I’m privileged person, I guess. I don’t feel like I’m suffering because of them, but they are
technically discrimination.” (reported ‘yes’ to weight)
Pregnancy-specific considerations
Respondents who reported that they had experienced age-based discrimination associated the
discrimination they faced with their pregnancies. Some felt they were made to feel inferior for being
“too young” to have a child, whereas others felt they were made to feel inferior for having a “geriatric
pregnancy.”
Answers that respondents wrote in for ‘other’ included the following: ‘pregnancy,’ ‘height’ (being very
petite), and ‘employment status.’ Discrimination on the basis of pregnancy was also reported by
another respondent, however she selected ‘sex/gender’ for that circumstance instead of writing in
‘pregnancy’ for ‘other.’
Of note
Income can be difficult for respondents to gauge. One respondent considered her time as a graduate
student on a low income, but ultimately, she did not select ‘income.’
Spanish-language considerations
One Spanish-language respondent reported having experienced discrimination based on her
immigration status and selected ‘Mi estatus de inmigración.’ Other respondents’ immigrant experiences
were reported in other ways however, and some respondents directly compared their experiences in
the United States with their home countries. For example, one respondent selected ‘weight’ and
explained that she had never been made fun of for her weight in her home country, but that happens
now in the United States. Another respondent who selected ‘my religion’ and ‘my race or skin color’
said that she cannot speak freely about her religion in the United States and that she is made to feel
“like you don’t belong here because you weren’t born here.”
31

In one likely false negative, a Spanish-language respondent reported ‘no’ to all items but did say that she
was fired from her job when her employer found out she was pregnant. It seemed to be a pattern that
Spanish-language respondents were less likely to utilize the ‘other’ category as compared to Englishlanguage respondents.
Changes to the question wording
The wording of this question was not changed during data collection.
B19: Did you experience discrimination or were you prevented from doing something, hassled, or
made to feel inferior while getting healthcare during your pregnancy, at delivery, or at postpartum
care? For each item, check No if you did not experience discrimination because of it or Yes if you did.
No Yes
a. My race or skin color............................................................................................................................ □ □
b. My disability status.............................................................................................................................. □ □
c. My immigration status......................................................................................................................... □ □
d. My age.................................................................................................................................................. □ □
e. My weight............................................................................................................................................. □ □
f. My income............................................................................................................................................ □ □
g. My sex/gender...................................................................................................................................... □ □
h. My sexual orientation.......................................................................................................................... □ □
i. My religion............................................................................................................................................ □ □
j. My language skills or accent.................................................................................................................. □ □
k. My type of or lack of health insurance................................................................................................. □ □
l. My substance use (alcohol, tobacco, other drugs)................................................................................ □ □
m. My involvement with the justice system (jail, prison)........................................................................ □ □
n. Another reason.................................................................................................................................... □ □
Please tell us:
B19: Durante su emabrazo, en el parto o durante su cuidado prenatal, ¿sintió que fue discriminada,
que le impidieron o le dieron problemas en hacer algo, o le han hecho sentir que es inferior a otra
persona por alguna de las siguientes razones?
No Sí
a. Mi raza o el color de mi piel................................................................................................................. □ □
b. Por alguna discapacidad....................................................................................................................... □ □
c. Mi estatus de inmigración.................................................................................................................... □ □
d. Mi edad................................................................................................................................................ □ □
e. Mi peso................................................................................................................................................. □ □
f. Mi salario............................................................................................................................................... □ □
g. Mi sexo o género.................................................................................................................................. □ □
h. Mi orientación sexual........................................................................................................................... □ □
i. Mi religion............................................................................................................................................. □ □
j. Mi idioma o acento............................................................................................................................... □ □
k. El tipo de seguro médico que tengo o porque no tengo seguro médico............................................. □ □
32

l. Mi uso de sustancias (alcohol, tabaco, otras drogas)............................................................................ □ □
m. Dado a que he estado involucrada en el sistema judicial (cárcel o prisión)........................................ □ □
n. Otra...................................................................................................................................................... □ □
Por favor díganos:
Respondents in the sample generally did not indicate that they experienced discrimination or were
prevented from doing something in the context of healthcare during their recent pregnancy, delivery, or
postpartum care. While some did note that they felt tired of being called ‘geriatric,’ none marked ‘my
age’ for that reason. Also, at times respondents explained that they felt rushed or pushed into
something or treated unkindly, but it was not clear if the cause was discrimination or on what basis
discrimination was occurring. For example, one respondent who reported that she felt ‘picked on’ and
pushed during labor and delivery hesitated to select ‘race or skin color,’ and so she left that response
item blank. She answered based on how she personally felt, which was she felt she was treated as a
child. So, she answered ‘yes’ to ‘my age’ and ‘my sex/gender.’ She explained, “I don’t know if it was
race or age. I don’t know. I don’t think it was race.”
Spanish-language consideration
For the interviewer-administered version, there is a switch between ‘you’ and ‘me’ that was
cumbersome for interviewers when read aloud, whereas it functioned well in a self-administered
format.
Changes to the question wording
The wording of this question was not changed during data collection.
Comparison between question A19 and B19:
A19 asks respondents to consider their whole lives as opposed to B19 which asks respondents to
consider their experiences while getting healthcare during pregnancy. As such, A19 provoked a much
wider variety of responses and considerations. Additionally, respondents frequently cited healthcarerelated concerns when responding to A19. For example, a respondent answered ‘my weight’ and ‘my
age’ for A19 said, “I’ve gotten older, and the whole BMI thing like ‘eeehh’ and I’m like, ‘relax, I’m an old
lady I’m a little bit fluffy.’ I wish there was more of a sensitivity to that, especially in the medical world.”
Of note for both questions:
One respondent noted that options L and M seemed out of place in comparison to the others. She said,
“I feel like the wording of the ‘addiction’ question is a little bit funky because it implies that there is one
and whether there was discrimination about it.”

Adverse childhood experiences
A20: These questions are about things that may have happened to you during your childhood, before
your 18th birthday. For each item, check No if it did not happen to you or Yes if it did.
Before your 18th birthday:
No Yes
a. Did you live with someone who was depressed, mentally ill, or suicidal?........................................... □ □
33

b. Did you live with someone who had a problem with alcohol or drug use?..................................……..□ □
c. Were you separated from a parent or guardian because they went to jail, prison, or a detention
center?..................................................................................................................................................... □ □
d. Did your parents or other adults in your home slap, hit, kick, punch, or beat each other up?........... □ □
e. Did a parent or other adult in your home hit, beat, kick, or physically hurt you in any way?.............. □ □
f. Did a parent or other adult in your home swear at you, insult you, or put you down?..................... □ □
g. Did an adult or person at least 5 years older than you ever make you do sexual things that you did not
want to do? (Count such things as kissing, touching, or being made to have sexual intercourse.)......... □ □
h. Was there an adult in your household who tried hard to make sure your basic needs were met, such
as looking after your safety and making sure you had clean clothes and enough to eat?...................... □ □
i. Was there an adult in your household who tried hard to make sure you felt loved, supported, valued,
and like you were special to them?.......................................................................................................... □ □
Before your 18th birthday:

No Yes
j. Did you feel that you were treated badly or unfairly because of your race or ethnicity? …………......... □ □
k. Did you ever feel that you were treated badly or unfairly because you are or people think you are
LGBTQIA+? This could include being treated badly because of who you are sexually attracted to or
because you express your gender in a way that is different than what people expect........................... □ □
l. Did you ever see someone get physically attacked, beaten, stabbed, or shot in your neighborhood? □ □
m. Were your parents or guardians divorced or separated?................................................................... □ □
A20: Las siguientes preguntas son acerca de cosas que le pueden haber ocurrido a usted durante su
infancia, antes de cumplir los 18 años. Antes de cumplir los 18 años...
No Sí
a. ¿Vivió con alguien que estaba deprimido, enfermo mental o suicida?............................................... □ □
b. ¿Vivió con alguien que tenía un problema de consumo de alcohol o drogas?.................................... □ □
c. ¿Estuvo separada de su mamá, papá o de la persona que estaba a cargo de usted porque ellos fueron
a la cárcel, prisión o a un centro de detención?...................................................................................... □ □
d. ¿Sus padres u otros adultos en su hogar se daban bofetadas, golpeaban, pateaban, apuñalaban o
peleaban físicamente entre ellos?........................................................................................................... □ □
e. ¿Sus padres u otro adulto en su hogar la golpeó, pateó o lastimó a usted físicamente de alguna
manera?................................................................................................................................................... □ □
f. ¿Su mamá, papá u otro adulto en el hogar le habló abusivamente a usted, la insultó o
menospreció?........................................................................................................................................... □ □
g. ¿Alguna vez un adulto o una persona al menos 5 años mayor que usted le hizo hacer cosas sexuales
que no quería hacer? (Cuente cosas como besar, tocar u obligar a tener relaciones sexuales).............. □ □
h. ¿Usted tenía un adulto en su hogar que se esforzaba por asegurarse de que usted tuviera todas las
necesidades básicas, como velar por su seguridad y asegurarse de que tuviera ropa limpia y suficiente
para comer?............................................................................................................................................. □ □
i. ¿Usted tenía un adulto en su hogar que se esforzaba por asegurarse de que usted se sintiera amada,
apoyada, valorada y que usted era especial para ellos?.......................................................................... □ □
Antes de cumplir los 18 años...
34

No Sí
j. ¿Usted sintió que fue tratada mal o injustamente por su raza o etnicidad?........................................ □ □
k. ¿Alguna vez sintió que fue tratada mal o injustamente porque usted es, o la gente pensaba que usted
era de la comunidad LGBTQIA+? Esto podría incluir ser maltratada dado al sexo o género al que esta
sexualmente atraída o porque expresa su género de una manera diferente a lo que la gente
espera....................................................................................................................................................... □ □
l. ¿Usted vio a alguien ser atacado físicamente, golpeado, apuñalado o disparado en su vecindario?.. □ □
m. ¿Sus padres se divorciaron o separaron?........................................................................................... □ □
Respondents understood that this question set aimed to capture adverse childhood experiences, some
even recognized the question set and named it as such. The question was time consuming, taking
several minutes, even for those without adverse childhood experiences. The question was also mentally
burdensome, in that it caused some respondents to recall abuse and neglect from their childhood.
Despite these challenging aspects, the question performed well to capture respondents’ experiences
and their subjective opinion of those experiences. For instance, there was a respondent who said that a
household member, her older brother, had a mental illness, even though he had not been officially
diagnosed. Also, violence related to disciplining was either counted or not in item E (‘Did a parent or
other adult in your home hit, beat, kick, or physically hurt you in any way?’) depending on the
respondents’ outlook of those experiences. Finally, one respondent reported ‘yes’ to item L (Did you
ever see someone get physically attacked, beaten, stabbed, or shot in your neighborhood?), but in the
case she considered she had heard the shot, and not seen it literally. She explained, “Maybe you’re not
supposed to do this, but honestly if I got this in the mail I would probably check yes and sort of
interpreted it myself and think like, well they’re asking about adverse childhood experiences and I feel
like it probably counts as adverse even if you don’t actually see it.”
Changes to the question wording
The wording of this question was not changed during data collection.
Positive childhood experiences
A21: These questions are about things that may have happened to you during your childhood,
before your 18th birthday. For each item, check
No if it did not happen to you or Yes if it did. Before your 18th birthday:

No Yes
a. Did you feel that you were able to talk to an adult in your family or other caring adult about your
feelings?................................................................................................................................................... □ □
b. Did you feel that you were able to talk to a friend about your feelings?............................................ □ □
c. Did you feel a sense of belonging in high school?................................................................................ □ □
A21: Las siguientes preguntas son acerca de cosas que le pueden haber ocurrido a usted durante su
infancia, antes de cumplir los 18 años. Antes de cumplir los 18 años...
No Sí
a. ¿Se sentía que podía hablar con un adulto en su familia u otro adulto cariñoso sobre sus
sentimientos?........................................................................................................................................... □ □
b. ¿Se sentía que podía hablar con un amigo sobre sus sentimientos?................................................... □ □
35

c. ¿Tuvo un sentido de pertenencia en la escuela secundaria?............................................................... □ □
Respondents understood this question as asking about whether they had positive emotional
connections in childhood, particularly as teenagers. The question performed well for English-language
respondents but for Spanish-language, there was an out-of-scope interpretation for item C (‘did you feel
a sense of belonging in high school?).
For the English-Language respondents, when considering item C, they thought about their self-esteem
while in high school, how close they were with their friends or peers, and whether they were socially
awkward or unpopular. For example, one respondent explained her response of ‘no’ to item C by
saying, “Oh I just wasn’t a popular kid, you know? I think very few people are popular kids. High school
was ok. It wasn’t awful, but it wasn’t great.” Some Spanish-language respondents interpreted a “sense
of belonging” (“sentido de pertenencia”) as referring to ownership over something or someone. For
example, one person thought it referred to feeling she belonged to someone based on how they treated
her.
Changes to the question wording
The wording of this question was not changed during data collection.
Social Support
A22: The following statements are about the people in your life and the support they provide you at
this time.
I have someone who...
No Yes
a. I can count on to loan me money for things like food or bills.............................................................. □ □
b. Can take care of my child(ren) when I need help................................................................................. □ □
c. Can help with daily chores if I’m sick.................................................................................................... □ □
d. Can take me to the clinic or doctor’s office if I need a ride................................................................. □ □
A22: Las siguientes preguntas son acerca de las personas en su vida y el apoyo que usted tiene
actualmente.

No Sí
a. ¿Tiene alguien con quién puede contar para que le preste dinero para cosas como comida o facturas
si lo necesitara?........................................................................................................................................ □ □
b. ¿Tiene alguien que puede cuidar a su(s) hijo(s) cuando necesita ayuda?........................................... □ □
c. ¿Tiene alguien que me podría ayudarla con las tareas diarias si esta enferma?................................. □ □
d. ¿Tiene alguien que podría llevarla a la clínica o al médico si lo necesitara?........................................ □ □
Respondents considered the question to be asking “who would I ask” for help with tangible day-to-day
needs. Whether respondents included their spouse or other household members when answering was
an important factor that affected response.
Those who included their spouse or other household members tended to answer ‘yes’ to more items.
For example, one respondent initially selected ‘yes’ only to A (loan me money) and D (offer a ride).
36

However, she changed her answer to ‘yes’ to all items during administration and explained that change
in the following way: “Yeah that’s the thing, I wasn’t thinking of my partner, I was thinking of family
members outside of the home. And I was like, ‘oh lady, you’re fine, think about it in general.’”
Respondents who only considered people outside the household for some or all of the question items
had more varied responses, sometimes indicating that they did not have someone outside the
household come over to drive them somewhere, for instance. Some respondents remarked that it was
odd to consider their spouse for this question because the question references financial assistance, and
they share a household income. For example, one respondent who answered ‘yes’ only to item C (help
with daily chores) explained, “My husband and I have a joint checking, we pay bills together and things
like that. So, I wouldn’t say he would ‘loan me money.’ So, for that equation, he wouldn’t come into
play.”
Changes to the question wording
The Spanish-language version of this question was changed to improve clarity. In the question stem,
‘declaraclones’ was replaced by ‘preguntas.’ Also, in the series of response items, ‘Tiene alguien’
replaced the starting verb ‘Puede.’
D22: The following statements are about the people in your life and the support they provide you at
this time.
No Yes
a. I have someone I can go to when I am feeling lonely.......................................................................... □ □
b. I have someone I can talk with about things that are important to me or how I’m feeling................ □ □
c. I have someone I can count on to listen to my problems, worries, and fears...................................... □ □
d. I have someone who shows me love and affection............................................................................. □ □
e. I have someone who does things with me to relax or to have fun...................................................... □ □
D22: Las siguientes declaraciones son acerca de las personas en su vida y el apoyo que le podrían estar
brindando actualmente.
No Sí
a. Tengo personas con las que puedo estar cuando me siento sola........................................................ □ □
b. Tengo personas con las que puedo hablar sobre cosas que son importantes para mí o sobre cómo me
siento........................................................................................................................................................ □ □
c. Tengo personas con las que puedo contar para que escuchen mis problemas, preocupaciones y
miedos...................................................................................................................................................... □ □
d. Tengo personas que me demuestran amor y cariño............................................................................ □ □
e. Tengo personas que hacen cosas conmigo para poder relajarme o divertirme.................................. □ □
Respondents interpreted this question as asking about whether they had emotional support from one
person or a small core set of people in their lives. They considered their intimate, close relationships
with people they trust. In contrast to A22 (measuring tangible social support), respondents consistently
thought about their spouses and other household members for this question. Many respondents also
thought of other close family members and friends as well.

37

When considering their answers, respondents took each item separately, and even those with strong
supportive relationships did not always select ‘yes’ to all items due to circumstances in their lives. In
explaining her ‘no’ response to item A (‘I have someone I can go to when I am feeling lonely’), one
respondent said,
“Often times when I am feeling kind of lonely, it’s like when my husband is working and stuff and
often it is hard to see someone, I mean it’s getting a little bit better with the warm weather, but
especially with the winter weather and our baby had a few minor health problems. Which
basically needed to avoid getting colds for a while. So, there wasn’t really anyone I could go to
because it’s very difficult to avoid colds in February if you go anywhere.”
Likewise, another respondent explained her ‘no’ response to item E (‘I have someone who does things
with me to relax or to have fun’) as having more to do with lack of free time with her husband. She
explained, “If I do things that relax me like going for a walk, that's very relaxing. But for things with my
partner, we always include the kids, and we don't have couple time, that's the only thing (translated
from Spanish by the interviewer).”
Changes to the question wording
The Spanish version of this question was slightly changed by replacing the word ‘sobre’ with ‘acerca.’
B22: Below is a list of items neighbors sometimes do for each other. For each item, check No if it does
not apply to your neighbors or Yes if it does.
No Yes
a. Do favors for each other or help each other out.................................................................................. □ □
b. Ask each other advice about personal things such as child rearing or job openings........................... □ □
c. Have parties or other get-togethers where other people in the neighborhood are invited................ □ □
d. Visit in each other’s homes or on the street........................................................................................ □ □
e. Watch over each other’s property...............………………………………………………………………………………..… □ □
B22: A continuación hay una lista de cosas que los vecinos a veces hacen unos por otros. Para cada
opción, marque No si no le aplica a sus vecinos o Sí, si le aplica.
No Sí
a. ¿Se hacen favores uno al otro?............................................................................................................ □ □
b. ¿Se dan consejos sobre asuntos personales como la crianza de niños o oportunidades de trabajo?. □ □
c. ¿Hacen fiestas o reuniones donde otras personas del vecindario son invitadas?............................... □ □
d. ¿Se visitan en los hogares o en la calle?............................................................................................... □ □
e. ¿Se vigilan la propiedad uno a al otro?................................................................................................ □ □
Respondents considered the question as asking about the relationships they have and support they
could expect to receive from their neighbors. Some thought of ‘neighbors’ as “right next door” whereas
others thought of the neighborhood or their apartment building more generally. Respondents in the
sample reported a range of community interaction and engagement. Some thought of their
relationships with neighbors as being like a close-knit family, with block parties, bingo nights, and
support networks. One respondent even mentioned that many of her neighbors were her actual
relatives. Other respondents explained that they simply had minimal contact with their neighbors. As

38

one respondent explained, “I don’t even know my neighbors […] I would love to! They don’t seem
interested.”
While the question captured variation in neighborhood dynamics and community across respondents,
two other factors that affected response were whether the respondent had recently moved and the
willingness of the respondent herself to engage with neighbors on a more personal level. Respondents
tended to answer based on what they had personally experienced and less so based on their
assumptions or expectations, and so those who had recently moved into a new neighborhood had not
had the opportunity to engage with their neighbors. One respondent who answered ‘yes’ only to item B
(ask each other advice) explained her answer in the following way: “It’s weird. We just moved, so we are
just getting to know our neighbors. So, I feel like many of these things are things that we will do in our
neighborhood but do not do now. ‘B’ is the only one that is kind of a ‘yes,’ and everything else is like, ‘no
we haven’t done that, but I could anticipate it happening.’” On the other hand, personal willingness to
engage with neighbors factored into response as well. One respondent explained her answer of ‘yes’ to
all items except for item B (ask each other advice) by saying, “I definitely would not ask a neighbor for
advice. I'm not that kind of person.”
Changes to the question wording
In the Spanish-language version of the question, item A was changed slightly from the original phrasing, ’
¿Se hacen favores uno al oltro o se ayuden?’

Health insurance during pregnancy
D2: During your most recent pregnancy, what kind of health insurance did you have?
□ Private health insurance (paid for by me, someone else, or through a job)
□ Medicaid
□ Other health insurance Please tell us:
□ I did not have any health insurance during my pregnancy
D2: Durante su embarazo más reciente, ¿qué tipo de seguro médico tenía usted?
□ Seguro médico privado (pagado por mí, de mi trabajo, del trabajo de mi esposo(a) o pareja, de mis
padres o a través del mercado de seguros de salud o HealthCare.gov)
□ Medicaid
□ Otro seguro médico Por favor escríbalo:
□ No tenía ningún seguro médico durante mi embarazo
Respondents understood that the question was asking about health coverage during pregnancy. They
consistently answered about the health insurance they had during their pregnancy, even if the insurance
had changed since then and even if their children had a different type of insurance. For example, one
who currently had private insurance through a job selected ‘Medicaid’ for this answer, because she was
covered by Medicaid during her recent pregnancy.
When selecting a response, a few respondents hesitated, but they were able come to an answer
through reason and a process of elimination. The relatively limited set of options allowed for
39

respondents to think through their answers confidently. For example, one respondent received health
insurance through her husband’s government job. She said, “If private health insurance through a job if
the job is provided like through the federal government or a state government, whether that counts as
like private or other. I’m guessing private.” She reasoned that the insurance company is private while
the government subsidizes the cost. Similarly, another respondent, who described herself as “terrible
with insurance,” reasoned her answer by elimination. She said, “[My job is] a private company, but we
get contracted out to government. So, I’m not sure how it works. […] Considering all the options, I’d
choose the top one, private insurance through my job.” Others with private insurance also those with
Medicaid were confident in their responses, and the category was clear for them.
Changes to the question wording
For the Spanish-language version, the first response option was lengthened to improve clarity. The
original wording was shorter: ‘Seguro médico privado (pagado por mí, otra persona o a través del
trabajo).’

Smoking and e-cigarettes
D3: Have you smoked any cigarettes in the past 2 years?
□ No (go to D5)
□ Yes
D3: ¿Ha fumado algún cigarrillo en los últimos 2 años?
□ No (Pase a la Pregunta D5)
□ Sí
Respondents interpreted this question as asking if they had smoked at all in the past two years,
including sharing a cigarette with someone, and not necessarily buying cigarettes. Only one respondent
answered ‘yes’ to this question. She said that although she quit smoking regularly five years ago, she has
had about two or three cigarettes on an occasional basis over the last two years. She explained, “It's
only been about two or three (cigarettes) because I went to a gathering, and I saw someone doing it and
I felt like it (translated from Spanish by the interviewer).” Other respondents noted that they had
completely quit prior to two years ago or they had never smoked at all in the past two years.
Changes to the question wording
The wording of this question was not changed during data collection.
D4: In the last 3 months of your pregnancy, how many cigarettes did you smoke on an
average day?
□ More than one pack (21 or more cigarettes)
□ One-half to one pack (11 to 20 cigarettes)
□ Less than half a pack (1 to 10 cigarettes)
□ I didn’t smoke then
D4: En los últimos 3 meses de su embarazo, ¿cuántos cigarrillos fumaba en un día normal?
40

□ Más de una cajetilla (21 cigarrillos o más)
□ Entre media a una cajetilla (11 a 20 cigarrillos)
□ Menos de media cajetilla (1 a 10 cigarrillos)
□ No fumé durante ese momento
This question is intended for respondents who answered ‘yes’ to Question D3 (‘Have you smoked any
cigarettes in the past 2 years?’). One person selected ‘yes’ to D3 and was routed to this question. The
respondent had explained in discussion of D3 that she quit smoking cigarettes regularly five years ago.
In the past two years she has only had two or three cigarettes when at social gatherings. Here she
selected ‘I didn’t smoke then’ because she did not smoke at all during her pregnancy.
A few respondents were accidentally asked this question due to missing skip patterns in the intervieweradministered version of the questionnaire. They all simply answered ‘not applicable’ or ‘I didn’t smoke
then’ without confusion.
Changes to the question wording
In the Spanish version of this question, the word ‘entre’ was added to beginning of the second response
option.
D5: During the last 3 months of your pregnancy, on average, how often did you use e-cigarettes or
other electronic nicotine products?
□ Every day
□ Some days
□ I did not use e-cigarettes or other electronic nicotine products then
D5: En los últimos 3 meses de su embarazo, en promedio, ¿con qué frecuencia usó cigarrillos
electrónicos u otros productos electrónicos con nicotina?
□ Todos los días
□ Algunos días
□ No usé cigarrillos electrónicos u otros productos electrónicos de nicotina en ese momento
Respondents considered this question to be asking about e-cigarette use and vaping during the final
trimester of pregnancy. No respondent reported that they had used e-cigarettes during the last
trimester, and all selected ‘I did not use e-cigarettes or other electronic nicotine products then.’
Respondents were not confused by the question, and they were familiar with e-cigarettes generally,
with some using the terms ‘vape’ and ‘vaping’ to describe these products.
Changes to the question wording
The wording of this question was not changed during data collection.
D6: In the past 2 years, did you ever use e-cigarettes or other electronic nicotine products as a way of
cutting down or stopping cigarette smoking?
□ No
□ Yes
41

D6: En los últimos 2 años, ¿ha usado los cigarrillos electrónicos u otros productos electrónicos con
nicotina para reducir o dejar de fumar cigarrillos?
□ No
□ Sí
Respondents viewed this question as asking about using vapes and e-cigarettes to help reduce cigarette
smoking. All respondents selected ‘no’ to this question. Respondents were not confused by the
question, and they were familiar with e-cigarettes generally, with some using the terms ‘vape’ and
‘vaping’ to describe these products. One respondent smoked two or three cigarettes in the past two
years, but she had quit smoking regularly five years ago. Also, she explained during probing to Question
D5 (‘During the last 3 months of your pregnancy, on average, how often did you use e-cigarettes or
other electronic nicotine products?’), that she only tried e-cigarettes previously, and she was not a
habitual user of those products.
Some respondents remarked that this question felt repetitive after answering ‘no’ to D3 (‘Have you
smoked any cigarettes in the past 2 years?’). Those who selected ‘no’ to D3 reasoned that they would
not then use e-cigarettes to cut down on smoking, since they did not smoke at all.
Changes to the question wording
The wording of this question was not changed during data collection.
C2: During the 3 months before you got pregnant, on average, how often did you use e-cigarettes or
other electronic nicotine products?
□ Every day
□ Some days
□ Did not use e-cigarettes or other electronic nicotine products then
C2: En los 3 meses antes de quedar embarazada, en promedio, ¿con qué frecuencia usó cigarrillos
electrónicos u otros productos electrónicos con nicotina?
□ Todos los días
□ Algunos días
□ No usé cigarrillos electrónicos u otros productos electrónicos de nicotina en ese momento
Respondents understood this question asking about their e-cigarette use immediately before becoming
pregnant. Respondents were not confused by the question, and they were familiar with e-cigarettes
generally, with some using the terms ‘vape’ and ‘vaping’ to describe these products. All but one
respondent selected ‘did not use e-cigarettes or other electronic nicotine products then.’ This was
because they either never smoked e-cigarettes at all, or they had used e-cigarettes during a prior
timeframe. One respondent answered ‘everyday’ and explained, “I’m done with it all. During early
pregnancy I guess I didn’t realize I was pregnant, but it was getting me very sick. Fortunately, it was just
her first weeks in my belly, I was vaping, unknowingly, but it helped me to stop. So that’s why I quit!”
Changes to the question wording
42

The wording of this question was not changed during data collection.

Stressors
D7: This question is about things that may have happened during the 12 months before your new
baby was born.
No Yes
a. A close family member was very sick and had to go into the hospital................................................. □ □
b. I got separated or divorced from my spouse or partner...................................................................... □ □
c. I was evicted or was forced to move.................................................................................................... □ □
d. I did not have a regular place to sleep at night.................................................................................... □ □
e. I was homeless or had to sleep outside, in a car, or in a shelter.......................................................... □ □
f. My spouse or partner said they didn’t want me to be pregnant……………………………………………………... □ □
g. My spouse or partner went to jail........................................................................................................ □ □
h. I went to jail…………………………………………………………………………………………….…………………………………….. □ □
D7: ¿Ocurrió algunas de las siguientes cosas durante los 12 meses antes de que naciera su nuevo
bebé?

No Sí
a. Me separé o me divorcié de mi ........................................................................................................... □ □
b. Fui desalojada o me obligaron a irme de donde estaba viviendo........................................................ □ □
c. No tenía un sitio donde podía dormir regularmente........................................................................... □ □
d. Era una persona sin hogar o vagabunda, o tuve que dormir en la calle, en un auto o en un
refugio……………………………………………………………………………………………………………………………………..………… □ □
e. Mi esposo(a), pareja o yo perdimos el trabajo..................................................................................... □ □
f. A mí o a mi esposo(a) o pareja nos bajaron la paga o redujeron las horas de trabajo……………………... □ □
g. Tuve problemas pagando la renta, alquiler, hipoteca u otras cuentas................................................ □ □
h. Mi esposo(a) o pareja estuvo en la cárcel............................................................................................ □ □
i. Yo estuve en la cárcel............................................................................................................................ □ □
j. Alguien cercano a mí tuvo problemas con el consumo de alcohol o uso de
drogas....................................................................................................................................................... □ □
k. Alguien cercano a mi estaba muy enfermo o murió............................................................................ □ □
Respondents understood that this question was asking about significant stressful experiences in the year
before their baby was born. The timeframe in the question, 12 months before delivery, required some
respondents to pause and calculate when that would be exactly. For some, whose babies were closer to
a year old, the calculation took them nearly two years prior. However, the experiences respondents
were thinking of were oftentimes memorable and salient. Respondents were able to recall events such
as serious illnesses, deaths, unwanted moves, and reservations around becoming pregnant. For
example, one English-language respondent who selected ‘yes’ to item C (‘I was evicted or forced to
move’), explained that while she and her husband were not legally evicted, they chose to move in order
to avoid a “toxic situation” and potential legal action.
Changes to the question wording
43

The Spanish version of this question was updated during evaluation and contained several additional
items as compared to the English version. The additional items functioned well for those respondents
who received this version. In that, the items were not confusing, and they enabled one respondent to
account for a close family member with a serious drug problem. Additionally, the question stem itself
was altered in the Spanish version. The original wording was, ‘Esta pregunta es sobre cosas que
pudieron haber sucedido durante los 12 meses antes del nacimiento de su nuevo bebé.’

Early maternal warning signs
C9: During your most recent pregnancy, did anyone talk to you about the “warning signs” you should
watch for during and after your pregnancy that require immediate medical attention? Some of these
“warning signs” include fever, frequent or severe headaches, or severe stomach pain.
□ No
□ Yes
C9: Durante su embarazo más reciente, ¿alguien habló con usted acerca de cuáles son los síntomas de
advertencia que debería velar durante y después del embarazo ya que pueden estar asociados a
posibles problemas de salud que requieren atención médica inmediata? Algunos de estos síntomas
pueden incluir fiebre, dolores de cabeza frecuentes o intensos, o dolor de estómago intenso.
□ No
□ Sí
Respondents considered ‘warning signs’ as both pregnancy and postpartum medical concerns that could
lead to an emergency. Those at higher risk due to diabetes or high blood pressure during pregnancy had
a clear idea of cautionary pregnancy warning signs. Whereas respondents without pregnancy risk
factors had an easier time remembering postpartum warning signs that they could occur after delivery
as opposed to warning signs during pregnancy.
Regarding pregnancy symptoms, some respondents talked about being indirectly questioned about early
symptoms or told to watch out for early-stage signs, rather than being warned about emergency
situations directly. For example, one respondent said, “Mostly I think from my doctor. I think it was in
general – not necessarily communicated all the time. ‘how are you feeling what’s going on with your
body.’ And if I said I had a headache, then they’d ask me more questions about it.” Respondents viewed
this approach was doctors “not trying to scare” them.
Those who answered ‘no’ to this question generally had a negative overall impression about their care.
As one respondent explained, “It was me asking questions. It was me who always called with a question
or whatever.” Likewise, another respondent explained that her prenatal care doctor always rushed her
out the door and never talked to her about anything.
Occurrence of error
One Spanish-language respondent initially answered ‘yes’ thinking about someone who would visit her
at home to explain what to expect over the course of her pregnancy. However, during probing, she said

44

that no one told her about medical warning signs such as fever, severe headaches, or severe stomach
pain.
Changes to the question wording
The wording of this question was not changed during data collection.
D8: Before or after your new baby was born, did you receive information about the warning signs of
both pregnancy and postpartum complications from any of the following sources?
No Yes
a. My doctor............................................................................................................................................. □ □
b. My baby’s doctor or healthcare provider............................................................................................ □ □
c. A nurse or midwife............................................................................................................................... □ □
d. Doula.................................................................................................................................................... □ □
e. Home visitor......................................................................................................................................... □ □
f. Family of friends……………………………………………………………………………………………………………………………… □ □
g. Websites or applications about pregnancy or other topics………………………………………………………..……. □ □
h. Social media (such as Facebook, Instagram, or TikTok)…………………………………………………………………... □ □
i. Other sources: Please tell us
D8: Durante su embarazo más reciente, ¿usted recibió información de alguna de las siguientes
fuentes acerca de las señales de advertencia que están relacionadas con complicaciones durante el
embarazo y el periodo postparto?
No Yes
a. Un proveedor médico (como un médico, una enfermera o una partera)............................................ □ □
b. Sitios web o redes sociales (como Facebook, Instagram o Twitter)..................................................... □ □
c. Cualquier fuente que haya usado la frase “Escúchela” (como una página web, en las redes social o un
folleto)...................................................................................................................................................... □ □
d. Familiares o Amistades........................................................................................................................ □ □
Respondents understood that the question was asking about who gave them information about
pregnancy and postpartum complications. The question does not specify which pregnancy and
postpartum complications they should consider, therefore, the complications that respondents recalled
and considered varied. Such complications included physical complications and symptoms as well as
psychological conditions.
Interpretations of ‘warning signs’
Respondents considered a variety of concerns, both physical and mental, when thinking about this
question. Many thought about conditions like high blood pressure, severe headache, uncontrolled
bleeding, fever, signs of infection, blood clots, swelling, and postpartum depression and anxiety.
Respondents oftentimes considered a variety of signs and symptoms of complications. As one
respondent listed what she remembered, she said, “severe headache, uncontrollable bleeding – or
bleeding that uses more than one pad in an hour, blurry vision, uh god I should know more.”
Some respondents also considered pregnancy warning signs more broadly to include ‘signs that labor is
coming,’ such as their water breaking. Or, as one respondent said, “Something is wrong with the baby
45

and labor needs to happen.” Another respondent, thinking about her specific, personal experience,
considered physical postpartum complications such as tearing that required follow-up care.
Like C9 (‘During your most recent pregnancy, did anyone talk to you about the “warning signs” you
should watch for during and after your pregnancy that require immediate medical attention?’) some
respondents noted that doctors did not want to give them too much information about warning signs.
Perhaps they worried about “doing more harm than good.”
A few respondents could not recall what any warning signs might be, but they still answered the
question, recalling conversations and information given to them in a more general sense. For example,
one respondent who selected ‘nurse or midwife’ and ‘websites or applications about pregnancy or other
topics’ was primarily thinking about the large packet of information she received from the hospital at
discharge. She said, “Yeah and it’s overwhelming the amount of stuff they give you. And, it’s not – like
no new mom has time to sit there and read that stuff. I don’t know a single one.”
Formulating a response
In some cases, it was difficult for the respondent to recall who gave them information about warning
signs. In part, that was due to receiving this type of information several times across a period of months
from different sources. While respondents did typically report one primary source of information, they
tried to account for all sources when responding. And, for others the source was simply unclear. For
example, one respondent said that her HMO health care is highly automated, and she receives
electronic messages, but she does not really know who is sending them exactly. She also noted that the
response options did not cover her experience: “I got some stuff from the hospital [informational
packets], but you did not cover that directly.”
Of note:
In some cases, respondents who did not have ‘home visitors’ or ‘doulas’ as part of their care team felt
that they should leave those options blank, rather than answering ‘yes’ or ‘no,’ as those items did not
apply to them. Also, the term ‘home visitor’ itself was not interpreted consistently by respondents.
Some viewed this as referring to family and friends who come to the house, whereas others thought of a
‘home visitor’ as a traveling nurse who comes to the house.
Spanish-language consideration
Some respondents were not familiar with “Escúchela” from item C (‘Cualquier fuente que haya usado la
frase “Escúchela” (como una página web, en las redes social o un folleto)’). However, one such
respondent selected item C regardless.
Changes to the question wording
Both the English and Spanish versions of the question were updated early in data collection to update
the response options. “Other social services” was removed as an option and a write-in field was added
as well as “Websites or applications about pregnancy or other topics” and “Social media (such as
Facebook, Instagram, TikTok)” to account for respondents reporting receiving information from online
sources. Additionally, the Spanish response options were further changed to be more concise, as is
reflected in the final version shown here. Rather than having multiple response options for medical
46

personnel, the final response options consolidated the options into four categories of information
sources. Also, the time reference for the Spanish question wording was changed from, “Antes o
después del nacimiento de su nuevo bebé.”
D9: During any of the following time periods, did a doctor, midwife, nurse, or other healthcare
provider talk with you about the warning signs of both pregnancy and postpartum complications?
No Yes
a. During the 12 months before I got pregnant………………….................................................................... □ □
b. During my most recent pregnancy....................................................................................................... □ □
c. During my labor and deliver hospitalization......................................................................................... □ □
d. Since my new baby was born............................................................................................................... □ □
D9: Durante alguno de los siguientes períodos de tiempo, ¿un proveedor de salud le habló sobre los
síntomas o señales de advertencia que están relacionadas con complicaciones durante el embarazo y
el periodo postparto?
No Sí
a. Durante los 12 meses antes de quedar embarazada........................................................................... □ □
b. Durante mi embarazo más reciente..................................................................................................... □ □
c. Mientras estuve hospitalizada para el parto y nacimiento.................................................................. □ □
d. Desde que nació mi nuevo bebé.......................................................................................................... □ □
Respondents considered the question to be asking about the timeframe when they received information
about warning signs. This question does not specify which pregnancy and postpartum complications
they should consider. Therefore, the complications that respondents recalled and considered varied.
Such complications included physical complications and symptoms as well as psychological conditions.
They thought about things like high blood pressure, severe headache, uncontrolled bleeding, fever, signs
of infection, blood clots, swelling, postpartum depression, and anxiety. Respondents’ considerations
from D8 above (‘Before or after your new baby was born, did you receive information about the warning
signs of both pregnancy and postpartum complications from any of the following sources?’) carried over
and were consistent for this question.
Formulating a response
When selecting their answers, respondents tried to remember when specific conversations occurred
with multiple people. This was more challenging for respondents who had a prior pregnancy, as the
information they received was often less detailed than it had been during their first pregnancy. For
instance, one respondent whose new baby was just two weeks old said, “It was only two weeks ago,
you’d think I’d remember any of it. I can’t remember. They give you a whole big folder of information
and I think there is a booklet in there. So, if I was significantly concerned then I could go look it up. Also,
it was limited because there was ‘oh you’ve done this before.’” She ultimately selected ‘During my
recent pregnancy’ and ‘During my labor and delivery hospitalization.’
Those who selected ’During the 12 months before I got pregnant’ had medical reasons for being told
about pregnancy complications that were not related to their most recent pregnancy (that is, apart from
the person who selected the response in error). For instance, one respondent had been diagnosed with
47

prediabetes prior to becoming pregnant, so she was regularly told at doctor’s appointments about her
risks if she were to become pregnant. Another respondent explained that prior to her most recent
pregnancy, she was told about warning signs when she was in the hospital due to having a miscarriage.
Occurrence of error
One respondent who received the interviewer-administered version answered ’During the 12 months
before I got pregnant’ in error because she misheard and thought the question was asking ‘During the
12 months before delivery.’
Changes to the question wording
The Spanish version was changed slightly to simplify and shorten the question. ‘Un proveedor de salud’
replaced the longer phrase ‘un médico, partera, enfermera u otro proveedor de atención médica.’

Family leave
D11: After your new baby was born, did your spouse or partner take time off from work?
□ No, they did not take leave from work
□ Yes, they took paid leave from work
□ Yes, they took unpaid leave from work
□ Yes, they took paid and unpaid leave from work
□ My spouse or partner was unemployed
□ I didn’t have a spouse or partner
D11: Después de que nació su nuevo bebé, ¿su esposo(a) o pareja tomó tiempo libre del trabajo?
□ No, no tomó tiempo libre
□ Sí, tomó tiempo libre con paga
□ Sí, tomó tiempo libre sin paga
□ Sí, tomó tiempo libre del trabajo con y sin paga
□ Mi esposo(a) o pareja estaba desempleado
□ No tenía esposo(a) o pareja
Respondents viewed this question as asking about their partner’s leave after the baby was born. In the
case of those asked, all respondents’ partners were also the biological father of their new babies.
Respondents were able to confidently report whether their partner took leave, and if it was paid leave,
unpaid leave, or a mix of paid and unpaid – as well as for how long. No respondent selected ‘My spouse
or partner was unemployed’ or ‘I didn’t have a spouse or partner.’
Changes to the question wording
The wording of this question was not changed during data collection.

Cohabitation

D12: This question is about your spouse or partner, who may or may not be the biological parent of
your new baby. Please choose the statement that best describes the current living arrangement.
□ Lives with me all of the time
48

□ Lives with me some of the time
□ Does not live with me
□ I do not have a spouse or partner
D12: Esta pregunta es sobre su esposo(a) o pareja, que puede ser o no el padre de su nuevo bebé. Por
favor dígame cuál de las siguientes opciones mejor describe su situación de vivienda.
□ Vive conmigo todo el tiempo
□ Vive conmigo parte del tiempo
□ No vive conmigo
□ No tengo esposo(a) o pareja
Respondents understood this question as asking about the living arrangement between their partner
and themselves. This question did not cause confusion for respondents in the sample. However, all
those asked answered ‘lives with me all the time.’ In one case, a respondent noted that her she is often
alone with her children because her husband travels for work often. She nevertheless selected ‘lives
with me all the time’ since her husband has no other permanent residence, and, as she said, “He is
home. He does live here.”
Changes to the question wording
The wording of this question was not changed during data collection.

Infant sleep practices
B12. In the past 2 weeks, how did you place your baby to sleep at night and during naps?

No Yes
a. On their side......................................................................................................................................... □ □
b. On their back........................................................................................................................................ □ □
c. On their stomach.................................................................................................................................. □ □
B12. En las últimas 2 semanas, ¿cómo colocó a su bebé a dormir por las noches o para siestas?

No Sí
a. De lado................................................................................................................................................. □ □
b. Boca arriba........................................................................................................................................... □ □
c. Boca abajo............................................................................................................................................ □ □
Respondents considered this question as asking about their baby’s sleeping position. Most respondents
thought about how they personally placed their baby down to sleep and answered accordingly.
However, some respondents included ‘contact napping’ or falling asleep in their arms when answering,
and some thought about all positions their baby moves through while they sleep, even when they were
not placed down in those positions. This variation affected how respondents answered the question.
For example, one respondent whose baby was 12 days old at the time of the interview answered ‘on
their back’ only. She specifically excluded ‘contact naps’ that occurred on and off for the first few days
after delivery. By contrast, another respondent who placed her baby on her back when sleeping in the
crib answered ‘yes’ to both ‘on their back’ and ‘on their stomach’ because, as she explained, “Now she is
49

able to lay next to me and breast feed which is saving both of us a lot of and giving both of us a lot of
extra sleep. She sometimes does fall asleep next to me.”
Consideration of SIDS
Several respondents recognized that this question may have to do with assessing risk of Sudden Infant
Death Syndrome (SIDS). Some respondents who reported other sleep positions besides ‘on their back’
justified their answers by explaining that they were aware of SIDS risks. For example, one respondent
explained, “So there’s always there the concern with back to sleep is SIDS and stuff like that, but actually
breastfeeding is pretty protective, has a good protection against it.” Another said, “I know back to sleep
is best, that’s what’s recommended […] We understand the risks of SIDS, and she uses a pacifier and that
minimizes the risk because she has something in her mouth to make sure she is breathing. But she is a
tummy sleeper.”
Potential for error: timeframe
Some respondents answered more generally about how their baby sleeps, and they did not consider the
two-week timeframe. That did not, however, cause response error in the case of this study sample.
Changes to the question wording
Early in data collection, the time reference phrase ‘in the past two weeks’ was added to the question
stem. Also, “at night and during naps” was added in order to clarify the question intent. For the Spanish
version, there were additional minor grammatical changes to further clarify the question.
B13: In the past 2 weeks, when you were sleeping, how often did your new baby sleep alone in their
own crib or bed?
□ Always
□ Often
□ Sometimes
□ Rarely
□ Never (go to Question B15)
B13: En las últimas 2 semanas, mientras usted dormía, ¿con qué frecuencia su nuevo bebé dormía
solo en su propia cuna o cama?
□ Siempre
□ Frecuentemente
□ A veces
□ Casi nunca
□ Nunca (Pasa a la Pregunta B15)
There was some variation in what situations respondents considered when answering the question.
Some thought about the question as intended: asking where their baby was located when they – the
respondent – fell asleep themselves. As one respondent said, “There have definitely been times, after
like I breastfeed […] we both are asleep, and she is not in her crib or bed. But other times, I do not fall
asleep when she gets done breastfeeding, I burp her, wrap her up and put her in her bassinette.”
(Answered ‘Often’). As another example, a respondent answered ‘rarely’ since her baby does not want
50

to sleep in his crib. She explained, “He is very attached to me; he does not want to detach (translated
from Spanish by the interviewer).” Other interpretations of the question included how often the
respondent was apart from the baby while the baby slept, how often the baby slept in their crib anytime
– including daytime napping when the respondent was awake, and how the baby was placed to sleep
initially. These interpretations are described more below in ‘Occurrences of response error.’
Respondents recognized the question to be asking about a ‘safe sleep’ practice of having your baby
alone in their own crib. As one respondent said, “I want to say ‘always’ because I know that’s what
you’re supposed to say.” She was a bit embarrassed, but ultimately answered ‘often’ because
sometimes she fell asleep during a contact nap.
One respondent disregarded the two-week timeframe because she had recently been on vacation, in an
atypical sleeping setup. She answered ‘always’ according to her normal routine and explained, “Right
now he is sleeping with me in my bed in the last two weeks because we are on vacation, visiting my
brother. But at home never (translated from Spanish by the interviewer).”
Occurrences of response error
One respondent interpreted the question as asking how often her baby sleeps apart from her. She
answered ‘rarely’ because a few times her mother took the baby for a nap in a different room of the
house. A few respondents included ‘naps’ and daytime sleeping when they themselves were awake.
For example, one respondent answered ‘sometimes’ because the baby naps in her arms during the day,
and another respondent answered ‘often,’ thinking about occasional naps her baby takes in the Mobi
wrap (while the respondent is awake). Finally, one respondent answered ‘Always,’ because she was
only considering how the baby was initially placed to sleep, not how the night progressed. She said,
“She’s pretty bad. I want to say every night, even 6-7am. She wakes up at 7am and has at least an hour
of time in our bed.”
Changes to the question wording
Early in data collection, the time reference phrase ‘in the past two weeks’ was added to the question
stem.
B14: In the past 2 weeks, was your baby’s crib or bed
in the same room where you or another adult
slept?
□ No
□ Yes
B14: En las últimas 2 semanas, ¿la cuna de su bebé ha estado en el mismo cuarto donde usted u otro
adulto duerme?
□ No
□ Sí
This question is intended for those who answered anything other than ‘Never’ to Question B13 (‘In the
past 2 weeks, when you were sleeping, how often did your new baby sleep alone in their own crib or
51

bed?’). Respondents considered this question to be asking if a bassinette or crib was located where an
adult slept at night, regardless of where the baby regularly sleeps. Generally, ‘yes’ indicated that a crib
or bassinette was in the respondent’s bedroom. In one case, a respondent answered ‘yes’ because she
slept on a mattress in the nursery. Additionally, one respondent who used a baby box or in-bed sleeper
considered the question to be asking about the location of the baby box, and she answered ‘yes.’ No
respondent asked this question answered ‘no.’
Changes to the question wording
Early in data collection, the time reference phrase ‘in the past two weeks’ was added to the question
stem.
B15: In the past 2 weeks, where have you placed your new baby to sleep at night and during naps?
No Yes
a. In a crib, portable crib, or bassinet....................................................................................................... □ □
b. On a twin or larger mattress or bed..................................................................................................... □ □
c. On a couch, sofa, or armchair............................................................................................................... □ □
d. In an infant car seat.............................................................................................................................. □ □
e. In a swing, rocker, or other inclined sleeper........................................................................................ □ □
f. In an in-bed sleeper.............................................................................................................................. □ □
g. In a baby box........................................................................................................................................ □ □
h. In a baby board or cradle board........................................................................................................... □ □
i. Other (please tell us)….......................................................................................................................... □ □
En las últimas 2 semanas, ¿dónde ha acostado a su bebé a dormir por las noches o para siestas?

No Sí
a. Una cuna, cuna portátil o moisés......................................................................................................... □ □
b. Una cama tamaño “twin” o más grande…………………………………………………………………………..…………….. □ □
c. Un sofá, butaca o sillón........................................................................................................................ □ □
d. Un asiento de bebé para el auto (“car seat”)....................................................................................... □ □
e. Un columpio, mecedora u otra cama inclinada.................................................................................... □ □
f. Una cunita pequeña que se pone sobre la cama de un adulto............................................................. □ □
g. Una cuna tablero indígena (“babyboard” o “cradleboard”)................................................................. □ □
h. Otro (por favor díganos)....................................................................................................................... □ □
Respondents either thought about physically placing their baby down someplace to sleep or they
thought about all the places their baby has fallen asleep. The way respondents answered varied based
on how they accounted for ‘accidental naps,’ such as falling asleep in the car seat or whether they
included times they placed their baby someplace to sleep and it did not ‘work.’ For example, one
respondent explained why she did not mark ‘in infant car seat’ or ‘On a twin or larger mattress or bed’ in
the following way: “He’s fallen asleep in the car seat but I haven’t placed him to sleep there. Sometimes
I’ll take him out in the stroller and be like, ‘please go to sleep.’ But it’s not necessarily a ‘sleeping place.’”
By contrast, another respondent included the car seat and remarked, “I mean if we are driving
somewhere like to her appointments she’ll sleep, so yes.”

52

Situations not captured by this question were contact naps and attempted naps, when a respondent
tried to place the baby for a nap, but the baby did not fall asleep. Regarding contact naps, even those
respondents who regularly placed their baby to sleep on themselves did not include this in the ‘other’
category. Also, two respondents mentioned placing their baby to sleep in either a swing or a stroller,
but since their baby never actually fell alseep there, neither counted those locations when answering.
‘Other’ category
Items included in the ‘other’ category included a pack-and-play playpen and a nursing pillow.
Spanish-language consideration
Playpens were accounted for differently between the two languages. A Spanish-language respondent
considered 'cuna portátil' to be equivalent to a 'corralito,' the playpen where her baby normally sleeps.
So, she selected item A (Una cuna, cuna portátil o moisés). However, one English-language respondent
marked ‘other’ to account for naps in the pack-and-play playpen.
Changes to the question wording
Early in data collection, the time reference phrase ‘in the past two weeks’ was added to the question
stem. Also, “at night and during naps” was added in order to clarify the question intent. Additionally,
minor grammatical changes were made to the Spanish version.
B16: In the past 2 weeks, has your new baby been placed to sleep with the following?

No Yes
a. A sleeping sack or wearable blanket.................................................................................................... □ □
b. A blanket.............................................................................................................................................. □ □
c. Soft toys, cushions, or pillows, including nursing pillows..................................................................... □ □
d. Crib bumper pads (mesh or non-mesh)………………………………………………………………………………………….. □ □
e. Other.................................................................................................................................................... □ □
Please tell us:
B16: En las últimas 2 semanas, ¿ha colocado a su bebé a dormir con alguna de las siguientes cosas?
No Sí
a. Un saco de dormir................................................................................................................................ □ □
b. Manta donde esta envuelto el bebé.................................................................................................... □ □
c. Edredones, mantas, cobijas, o sábanas no ajustadas........................................................................... □ □
d. Juguetes suaves, cojines o almohadas, incluyendo almohadas para amamantar……………………………. □ □
e. Protectores de cuna (de malla o sin malla).......................................................................................... □ □
f. Otro....................................................................................................................................................... □ □
Por favor díganos:
For this question, respondents considered the items they placed inside their baby’s crib, bassinette, or
baby box – including what the baby was wearing, apart from pajamas. Since this question was fifth in a
series about baby sleep practices, some respondents were particularly sensitive to the idea that the
question may be used to assess the risk of SIDS. This led respondents to assume that some of the
answer options were ‘correct’ and others were ‘incorrect,’ according to what is considered ‘safe sleep.’
53

For example, one respondent selected ‘no’ to all items because she thought that all the answer options
were “not recommended.” She explained that her daughter goes to sleep with only “herself. All that
stuff I know is not recommended and also not necessary. She’s not yet ready.” Similarly, Englishlanguage respondents who selected ‘A blanket’ oftentimes explained that they understood that blankets
could be considered unsafe. One respondent who selected ‘A blanket’ explained that she understood
the risk of SIDS and only used a thin, burping cloth, wrapped around her baby’s legs, similar to a
swaddle. She said, “I know she can’t suffocate with it like with anything else like a thick blanket, she
could put it over her face and not know how to get it off her face or one of her pillows or a teddy bear.
She hasn’t even gotten to the point where she’s holding a teddy bear yet, she just started holding things
and gripping.”
Accounting for swaddles and pacifiers
Respondents classified swaddles inconsistently. Since ‘A swaddle’ was not specifically one of the answer
options, those who swaddled their baby accounted for that as either ‘a blanket,’ ‘other,’ or the question
did not capture swaddling at all – and they selected ‘no’ to all items. When one respondent selected ‘A
blanket,’ referring to swaddling, she explained that she did not put a blanket over her baby, because
that was unsafe.
A ‘pacifier’ was the most common ‘other’ category item that respondents wrote in or described. Apart
from several respondents using the ‘other’ category to account for pacifiers, one respondent selected
‘other’ to account for the baby’s swaddle. Some respondents noted that pacifier use is recommended
to reduce SIDS. Since respondents viewed this section of questions on baby sleep as related to SIDS risk
reduction and prevention, answering ‘pacifier’ was not only logical to respondents, but it was also
important to explaining how they keep their baby safe when they are asleep.
Occurrence of error:
One respondent answered ‘yes’ to ‘crib bumper pads’ because the side walls of her baby’s bassinette
are mesh, as part of the construction.
Spanish-language consideration
During data collection, some respondents said they had never heard of a 'saco de dormir o manta
ponible o envolvente' whereas others said that a ‘manta ponible o envolente’ (wearable blanket) was
simply the blanket used to swaddle a baby. The answer items were changed to clarify different types of
blankets from swaddles. One respondent who correctly selected the updated option B (‘Manta donde
esta envuelto el bebé’) explained that she wraps her baby with a blanket to sleep. Future studies may
benefit from additional evaluation of these updated answer items, in particular relation to Spanishlanguage terms for swaddling.
Changes to the question wording
Early in data collection, the time reference phrase ‘in the past two weeks’ was added to the question
stem. As mentioned in the above section ‘Spanish-language consideration,’ the answer categories were
changed to clarify meaning. Response items A, B, and C were changed from ‘Un saco de dormir o una
manta ponible o envolvente,’ ‘Una manta o sábana,’ and ‘Juguetes suaves, cojines o almohadas,
incluidas las almohadas para lactar o amamantar’, respectively.
54

B17: Did you get information about how to place your baby to sleep from any of the following
sources?

No Yes
a. My family doctor.................................................................................................................................. □ □
b. My OB/GYN.......................................................................................................................................... □ □
c. A nurse or midwife............................................................................................................................... □ □
d. A doula or a child birth educator......................................................................................................... □ □
e. My baby’s doctor or healthcare provider............................................................................................. □ □
f. Websites or applications about pregnancy or other topics.................................................................. □ □
g. Social media (such as Facebook, Instagram, TikTok)…………………………………………………………………….…. □ □
h. Other sources (please tell us)............................................................................................................... □ □
B17: ¿Obtuvo información sobre cómo colocar a su bebé para dormir de alguna de las siguientes
fuentes?

No Sí
a. Su médico de familia............................................................................................................................ □ □
b. Su obstetra/ginecólogo ....................................................................................................................... □ □
c. Una enfermera o partera...................................................................................................................... □ □
d. Una “doula” o educadora de parto...................................................................................................... □ □
e. El médico o proveedor de atención médica de mi bebé...................................................................... □ □
f. Páginas de internet o applicaciones del embarazo o cuidado de bebés............................................... □ □
g. Redes sociales (como Facebook, Instagram, TikTok)............................................................................ □ □
h. Otras fuentes........................................................................................................................................ □ □
Por favor díganos:
Respondents considered this question as asking about their sources of information on how to place their
baby to sleep safely.

Overall respondents did not have difficulty remembering where they heard about ‘safe sleep’ practices.
And most reported multiple sources. Even those who felt their time in the hospital was “a total blur”
remembered being told key takeaways such as ‘back to sleep’ and how to swaddle. Some respondents
who had older children had difficulty remembering exactly where they got the information about
placing their baby to sleep for their new baby, because they were simply aware of their own knowledge
and practices they had accumulated over time. As with D17 (‘Did you get information about how to
place your baby to sleep during any of the following times?’), respondents had better recall for more
recent conversations, such as with nurses in the hospital or repeated conversations with their child’s
pediatrician.
Sources noted in ‘Other’
Initially, many respondents were selecting ‘Other’ to account for various online sources, including
Facebook groups, websites, and applications. During data collection, the response options F and G
regarding ‘websites’ and ‘social media’ helped to reduce instances of respondents selecting ‘Other’ and

55

filling in online sources. As one respondent said, “There is a whole cottage industry. There is a sleep
specialist I follow [on Instagram].”
One Spanish-language respondent who selected ‘other’ filled in “The WIC office,” explaining that her
assigned assistant spoke with her over the phone about how to place her baby down to sleep.
Finally, one respondent entered ‘pediatrician’ under ‘other’ rather than selecting ‘My baby’s doctor or
healthcare provider.
Mode
One respondent who received the interviewer-administered version was confused at first when she
heard item A, ‘my family doctor’ and wondered if that referred to her child’s pediatrician. She selected
‘yes’ at first, and the changed her mind to ‘no’ upon hearing option E, ‘my baby’s doctor or healthcare
provider.’ Reordering the answer items may reduce potential for error.
Changes to the question wording
Early in data collection, additional response items F and G were added to account for online and other
sources of information about how to place a baby to sleep.
D16. Did a doctor, nurse, or other healthcare worker tell you to place your baby to sleep in the
following ways?

No Yes
a. On their back ....................................................................................................................................... □ □
b. In a crib, bassinet, or portable crib...................................................................................................... □ □
c. Without a blanket, soft toys, cushions, or pillows in my baby’s crib or bed........................................ □ □
d. Place my baby’s crib, bassinet, or portable crib in my room............................................................... □ □
D16. ¿Un proveedor de salud le dijo que acostara a su bebé de las siguientes maneras?

No Sí
a. De espalda o boca arriba...................................................................................................................... □ □
b. En una cuna, moisés o cuna portátil.................................................................................................... □ □
c. Sin una manta, juguetes suaves, cojines o almohadas en la cuna o cama de mi bebé........................ □ □
d. Que colocara la cuna, moisés o cuna portátil de mi bebé en la habitación conmigo.......................... □ □
For this question, respondents thought about what advice they had been given by a healthcare provider.
They recognized the question was about “safe sleep,” often using that phrase and mentioning SIDS
prevention. The responses were not impacted by how their baby actually slept (in a co-sleeper or in
their crib, for instance), rather, respondents focused on what they had been advised when considering
their answers. All respondents who answered this question selected ‘Yes’ for A, B, and C. One
exception to that was a respondent who marked ‘no’ to C in error. There was some variation for option
D, with some respondents not recalling that specific instruction. One respondent even noted that their
baby’s pediatrician told her that it was “personal preference” in which room the baby slept.

56

This question read to some respondents as a ‘test’ to see if they knew the correct way to place their
baby to sleep. As one respondent filled out the self-administered version she said, “correct” to each
item as she selected it. She then said, “They’ll talk to you, because they emphasize the importance of
sleeping on their back.”
Occurrence of error
One Spanish-language respondent marked ‘no’ to option C (‘Sin una manta, juguetes suaves, cojines o
almohadas en la cuna o cama de mi bebé’) in error. She misheard the interviewer and thought the
question was asking if she placed her baby to sleep with blankets. She remarked, “Because of the
sudden infant death. The baby can suffocate on toys or blankets (translated from Spanish by the
interviewer).”
Changes to the question wording
In the Spanish version of the question, the term ‘un proveedor de salud’ replaced ‘Un médico,
enfermera u otro profesional de la salud,’ to help simplify and shorten the question.
D17: Did you get information about how to place your baby to sleep during any of the following
times?
No Yes
a. During a prenatal care visit.................................................................................................................. □ □
b. In the hospital, when my baby was born…………………………………………………………………………….............. □ □
c. During my baby’s healthcare visit......................................................................................................... □ □
d. During a postpartum care visit............................................................................................................. □ □
e. Other.................................................................................................................................................... □ □
Please tell us:
D17: ¿Le dieron información acerca de cómo acostar a su bebé para dormir durante alguno de los
siguientes momentos?
No Sí
a. Durante una visita prental.................................................................................................................... □ □
b. En el hospital, cuando nació mi bebé................................................................................................... □ □
c. Durante un chequeo de salud de mi bebé............................................................................................ □ □
d. Durante una visita posparto................................................................................................................. □ □
e. Otro...................................................................................................................................................... □ □
Por favor díganos:
For this question, respondents all interpreted the question as asking about their sources of information
for how to place their baby to sleep, specifically ‘safe sleep’ practices. Such practices included ‘Back to
sleep’ (“Boca arriba” for Spanish-language respondents) as well as the ‘ABCs,’ “Alone, on their Back, and
in a Crib.”
While respondents did not have difficulty answering D16 (‘Did a doctor, nurse, or other healthcare
worker tell you to place your baby to sleep in the following ways?’) about their knowledge of what they
had been told, this question was more difficult to recall all the times they had been told about safe sleep
57

practices for their baby. Several respondents noted getting “a folder” of information from the hospital
or at their baby’s pediatrician’s office. And many remembered having direct conversations with nurses
at the hospital, as those were more salient to them. This was also the case for B17 (‘Did you get
information about how to place your baby to sleep from any of the following sources?’) in which
respondents had better recall for more recent conversations, such as with nurses in the hospital or
repeated conversations with their child’s pediatrician. The more challenging timeframe to remember
was ‘During a prenatal care visit.’ As one respondent said, “Definitely at the hospital, I have to
remember what they said before the baby was born.” She left ‘A prenatal care visit’ and ‘During a
postpartum visit’ blank.
Many respondents mentioned learning about how to place their baby to sleep from internet sources of
all types. Some of these respondents accounted for those sources by selecting the ‘other’ category, and
thinking of websites, applications, and social media such as mom’s groups, Facebook or influencers on
Instagram. Some respondents did not select the ‘other’ category to account for those sources,
reasoning that these sources are just pervasive and attainable with casual internet browsing.
Spanish-language consideration/occurrence of error
One respondent did not understand the question as intended because she interpreted the question as
asking about ‘how to place her baby during any of these visits.’ She said, “I was thinking about how to
put him down when I was in... during the baby's health care visit, how to lay him down. How I should
place him while they are checking him. When they are checking him, I first put him on his back and then
we turn him around to check the back of his head (translated from Spanish by the interviewer).”
Changes to the question wording
The Spanish version of the question was changed for improved clarity. The prior version was the
following: “¿Obtuvo información sobre cómo colocar a su bebé para dormir durante alguno de los
siguientes momentos?

Vaccination

D18: What are your plans for vaccinating your new baby?
□ My baby will be vaccinated the way my baby’s doctor recommends
□ My baby will get every vaccine, but at different times than my baby’s doctor recommends
□ My baby will get only some of the recommended vaccines
□ My baby will not get vaccines
D18: ¿Cuáles son sus planes para vacunar a su nuevo bebé?
□ Mi bebé recibirá las vacunas acorde a como su doctor las recomiende
□ Mi bebé recibirá todas las vacunas recomendadas, pero en momentos diferentes a los que
recomienda su doctor
□ Mi bebé solo recibirá algunas de las vacunas recomendadas
□ Mi bebé no será vacunado

58

Respondents were all familiar with recommended vaccines and understood the question as asking about
their plans to follow the recommended schedule and series of vaccines. As one respondent said, “My
baby is on track to get all the recommended [vaccines] at the appropriate time.” One respondent
additionally thought about the illness prevention benefits her baby might receive through the vaccines
that she herself received, such as Tdap and COVID. She explained, “He got all the recommended
vaccines. He’s had several overall multiple different well visits. He got something at birth. He definitely
got some at birth as well as some stuff that they put in your eye, I think. While I was pregnant, I got the
COVID vaccine as well as the Tdap.”
All but one respondent answered ‘My baby will be vaccinated the way my baby’s doctor recommends.’
One respondent answered, ‘My baby will get every vaccine, but at different times than my baby’s doctor
recommends.’ She explained that her baby would be vaccinated fully, but she felt more comfortable
spacing out the injections. She said,
“I did it with my last one, and I’ll do it with this one too. I’m a firm believer in vaccines.
However, I don’t necessarily think my 8-pound baby needs to get four different shots all in one
sitting. So, for us it’s just, my pediatrician is fantastic, she’ll say ‘this is what is given at 1 month,
and this is why I’ll recommend this one today.’ And, I’ll just make extra nurse visits to go back.
So, I think we finish vaccines 6-9 months after the normal. But my kiddos will get all of them.
And I’ve never been given a hard time at my pediatrician’s office.”
Changes to the question wording
Minor grammatical changes were made to the Spanish-language version of this question for better flow
and clarity.
B2: During the 12 months before your new baby was born, did a doctor, nurse, or other healthcare
worker offer you the following shots or vaccinations?
No Yes
a. Flu shot................................................................................................................................................. □ □
b. Tdap..................................................................................................................................................... □ □
c. COVID-19.............................................................................................................................................. □ □
B2: Durante los 12 meses antes del nacimiento de su nuevo bebé, ¿un proveedor de salud le ofreció
ponerle alguna de las siguientes vacunas o inyecciones?
No Sí
a. Influenza (“flu”).................................................................................................................................... □ □
b. Tdap..................................................................................................................................................... □ □
c. COVID-19.............................................................................................................................................. □ □
Most respondents took this question literally as written and considered vaccines that were offered to
them during the 12 months before they delivered their new baby. In that, respondents generally
thought about recommended vaccines regardless of their choice to take the offered vaccine. One
respondent thought about the vaccines she received rather than those that were offered, though upon
probing the interviewer found that she did not, by chance, respond in error.

59

The phrase, ‘offer you’ was sometimes taken very literally. One respondent explained her answer of
‘no’ for ‘COVID-19’ by saying the following: “They didn’t really offer me a shot, but they talked to me
about it at every visit. ‘Have you gotten your shot have you gotten your booster?’ […] But they didn’t say,
‘would you like a covid shot today?’” Likewise, another respondent proactively asked if she should get a
Covid booster, and the doctor said yes. “But they weren't the ones to offer. So I think I should say 'No'."
Occurrences of error
A few respondents thought of the incorrect timeframe when answering the question, thinking instead of
’12 months before you became pregnant with your new baby.’ That affected response selection for
some. For instance, one respondent who got the Tdap during her second trimester erroneously
answered ‘no’ for the Tdap.
Selecting a response
An answer of ‘no’ could mean either they were not offered, or the vaccine was not necessary. For
instance, one respondent had just recently gotten her Tdap during a prior pregnancy. She said, “So I had
a Tdap just before that because I have a two-year-old. I have a newborn, so I had the Tdap during early
2020. So, the answer is ‘no.’”
Changes to the question wording
In the Spanish version of the question, the term ‘un proveedor de salud’ replaced ‘Un médico,
enfermera u otro profesional de la salud,’ to help simplify and shorten the question.
C1. Did you get the following shots or vaccinations before or during your pregnancy?
For each one, check:
BP for 3 Months before pregnancy
DP for During pregnancy
No for Did not get the shot or vaccination before or during pregnancy

BP DP No
a. Flu shot........................................................................................................................................ □ □ □
b. Tdap (protects against tetanus, diphtheria, pertussis, or whooping cough) ………………………….. □ □ □
c. COVID-19 .................................................................................................................................... □ □ □
C1. ¿Recibió las siguientes vacunas antes o durante el embarazo? Para cada una, marque: A si fue 3
Meses Antes del Embarazo D si fue Durante el Embarazo N si fue Did not get a shot before or during
pregnancy
ADN
a. Influenza (“flu”)................................................................................................................................. □ □ □
b. Tdap (protege contra el tétanos, la difteria y la tos ferina).............................................................. □ □ □
c. COVID-19........................................................................................................................................... □ □ □
Respondents viewed the question as asking about if and when they received certain vaccinations. Most
respondents were familiar these vaccines, though some could not remember clearly when they received
certain vaccines, especially the Tdap vaccine. However, the question was unclear to some respondents
and inconsistent across mode and language. Apart from more typical concerns of recall, that lack of
60

clarity and consistency made the question prone to response error. Some respondents wondered if
multiple selections were allowed across one item and other respondents did not take into account the ‘3
months’ before pregnancy timeframe, and rather thought of ‘anytime in their lives’ before pregnancy.
Mode consistency and timeframe errors
For the interviewer-administered version in English, the directions do not indicate ‘three months’ before
pregnancy and instead state only ‘before pregnancy.’ In addition to the issue of consistency between
modes, a timeframe of ‘before pregnancy’ was vague to respondents. Some were unsure whether to
count vaccines they received ever in their lives or only those they received recently. However, even
those who received the self-administered version did not see or take into account that the ‘before
pregnancy’ timeframe should be up to three months before. For example, one respondent selected
both ‘BP’ and ‘DP’ for the flu shot because she gets that shot annually. During probing, the respondent
realized that she only got one flu shot in the year before her new baby’s birth.
Question of multiple selection
Some respondents questioned if the question is ‘check all that apply’ or if they can select only one time
period per vaccine. For instance, one respondent who had the first shot in her Covid series before
pregnancy and the second shot during said, “So during is the more correct answer? I don’t know if I have
to choose one.” Then, regarding Tdap she said, “I guess I would also click both for Tdap because I’ve
gotten several Tdaps as an adult.”
Changes to the question wording
For the English-language version, the word ‘shot’ was added after ‘flu.’ When the Spanish-language
version was updated during data collection, the self-administered version mistakenly used English in the
question explanation of the ‘N’ answer category: ‘N si fue Did not get a shot before or during
pregnancy.’

Postpartum contraception

D19: Are you doing anything now to keep from getting pregnant?
□ No
□ Yes (go to question D21)
D19: ¿Usted o su esposo o pareja estan haciendo algo actualmente para evitar un embarazo? Esto
puede incluir ligarse los tubos, usar píldoras anticonceptivas, condones, seguir métodos naturales de
planificación familiar, entre otros.
□ No
□ Sí (Pase a la Pregunta D21)
Respondents viewed this question asking if they are doing something (including choosing to not have
sex) in order to keep from becoming pregnant. Those respondents who were in their immediate
recovery period after delivery hesitated when responding, but ultimately chose ‘yes.’ As one
respondent said, “Technically abstinence I guess.” Likewise, another said, “Yes? It’s kind of early
enough…[trailed off].” There were no instances of error with this group of respondents.
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Of note:
One self-administered respondent scrolled back and forth across the questionnaire to determine the
skip pattern.
Changes to the question wording
For the Spanish-language version, the additional explanation of what respondents should consider was
added for clarification.
D20: What are your reasons for not doing anything to keep from getting pregnant now? (check all that
apply)
□ I am pregnant now (Go to Question D22)
□ I want to get pregnant
□ I don’t mind if I get pregnant
□ My spouse or partner wants me to get pregnant
□ I had my tubes tied or blocked
□ I don’t want to use birth control
□ I am worried about side effects from birth control
□ I am not having sex
□ My spouse or partner doesn’t want to use condoms
□ My spouse or partner doesn’t want me to use birth control
□ We are same-sex spouses/partners
□ I need medical assistance to get pregnant
□ I have problems getting birth control I want
□ Other Please tell us:
D20: ¿Cuáles son las razones por las que usted no está haciendo algo para evitar un embarazo
actualmente? (Marque TODAS las que correspondan)
□ Estoy embarazada ahora (Pasa a la Pregunta D22)
□ Quiero quedar embarazada o no me molestaría quedar embarazada
□ Estoy operada (me ligaron o amarraron las trompas)
□ Mi esposo o pareja se operó (vasectomía)
□ No quiero usar anticonceptivos
□ Me preocupan los efectos secundarios de los anticonceptivos
□ Mi esposo(a) o pareja no quiere usar condones
□ Mi esposo(a) o pareja no quiere que use anticonceptivos
□ Mi pareja es del mismo sexo
□ Tengo problemas obteniendo el anticonceptivos quiero usar
□ No creo que pueda quedar embarazada porque estoy amamantando
□ No estoy teniendo relaciones sexuales
□ Otro Por favor díganos:
This question is intended for those who answered ‘no’ to Question D19 (‘Are you doing anything now to
keep from getting pregnant?’). Respondents consistently understood that this question as asking about
62

the reasons that they are not doing anything to prevent pregnancy. Five respondents were routed to
this question.
Formulating a response
One respondent was currently pregnant, and she marked ‘I am pregnant now.’ Two respondents, both
of whom were Spanish-language participants, selected ‘I don’t want to use birth control.’ One explained
that she was Catholic, so birth control goes against her religion. There were two cases of respondents
selecting ‘other’ and specifying reasons not listed. One respondent said that she had a history of
infertility and had used IVF to become pregnant previously. She preferred to select ‘other’ rather than ‘I
need medical assistance to get pregnant.’ The other respondent who selected ‘other’ wrote in
‘scheduled vasectomy.’ She was only two weeks postpartum, and she also selected ‘I am not having sex’
due to the recovery period after delivery.
Changes to the question wording
For the Spanish version of the question, a few changes were made to the response options. Two
options were combined to create the second response option, ‘Quiero quedar embarazada o no me
molestaría quedar embarazada.’ And, two response options about difficulty paying for or getting
contraceptives were combined. The fourth option regarding a vasectomy was added. And, finally,
grammatical and order changes were made to improve clarity and consistency in the question.
D21: What kind of birth control are you using now to keep from getting pregnant?
□ Tubes tied or blocked (female sterilization)
□ My spouse or partner had a vasectomy (male sterilization)
□ Birth control pills
□ Condoms
□ Shots or injections
□ Contraceptive patch or vaginal ring
□ IUD
□ Contraceptive implant in the arm
□ Natural family planning or fertility awareness methods (such as rhythm or calendar method, fertility
apps)
□ Lactational amenorrhea or LAM (I am breastfeeding and my period has not returned)
□ Withdrawal (pulling out)
□ Not having sex (abstinence)
□ Other Please tell us:
D21: ¿Qué clase de anticonceptivo está usando usted o su esposo o pareja ahora para evitar un
embarazo?
□ Ligadura de las trompas (operada)
□ Mi esposo o pareja se operó (vasectomía)
□ Pastillas anticonceptivas
□ Condones
□ Inyecciones
□ Parche anticonceptivo o anillo vaginal
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□ Dispositivo intrauterino o DIU
□ Implante anticonceptivo en el brazo
□ Método de planificación familiar natural (incluyendo el ritmo o aplicaciones de fertilidad)
□ Amamantar o lactar como método anticonceptivo (Amenorrea de la lactancia o MELA)
□ Otro Por favor escríbalo:
Respondents viewed this question as asking about what methods they were currently using to prevent
pregnancy. The methods were familiar to respondents and sufficient for their purposes, in that no
respondent selected ‘other.’ There may be a mode effect for this question, as it is a long list to read out
loud in the case of the interviewer-administered version. One respondent changed her answer during
administration because a ‘better’ answer appeared later on the list. She initially selected ‘natural family
planning or fertility awareness’ but then preferred ‘withdrawal’ as being more accurate.
Occurrence of error
While respondents were familiar with LAM, lactational amenorrhea, one English-language respondent
selected it because her period had not yet returned and not because she used it as a birth control
method. She explained, “We are not having sex, and after that it’ll be condoms. Also, my period hasn’t
come back.”
Spanish-language consideration
Spanish-language respondents were familiar with birth control methods described in the question,
including DIUs and MELA. Those who had not used those acronyms were still able to clearly describe
those methods. For example, one respondent said that she was not familiar with the term DIU
proceeded to accurately describe it as a T or Y-shaped device inserted into the vagina to prevent
pregnancy. Another respondent who had not heard of the term MELA understood that breastfeeding
could be used as a birth control method. She selected ‘Condones’ (condoms) and explained, “I am
breastfeeding, but I am not using it as a birth control method (translated from Spanish by the
interviewer).”
Of note:
Several respondents who were not using any method and should have been skipped to the next
question did not see the skip pattern.
Changes to the question wording
Due to misunderstanding and also to make this question more concise, ‘el hombre se retira,’
(withdrawal) was removed from the Spanish version. Additionally, a response option that referred to
abstinence was removed.

Racism
Paired Racism Questions
The following four questions measure perceived racism and discrimination. Respondents considered C17
and C18 as a pair and D23 and D24 as another pair. Considerations carried over between the two paired
questions, though respondents were mindful of the differences between the questions.
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C17: Throughout your life, how often have you worried that you might be treated or judged unfairly
because of your race, ethnicity, or skin color?
□ Very often
□ Somewhat often
□ Not very often
□ Never
C17: A través de su vida hasta, ¿cuán frecuentemente se ha sentido preocupada de que la traten
injustamente o juzgen por su raza, etnicidad o el color de su piel?
□ Frecuentemente
□ A veces
□ Rara vez
□ Nunca
Respondents considered the amount of worry they have felt about being mistreated. Some
respondents worried about physical harm, as in hate crimes, whereas others worried about being
passed over for a job or ‘othered.’ When formulating a response, most respondents answered based on
worry they have felt rather than experiences of racism or discrimination that they have faced, though
this was a blurry distinction for some. For a few respondents, there was a clear distinction between
experiencing discrimination and worrying about it. As one Spanish-language respondent who answered
‘never’ said, “It's just that that's how I was raised. I'm me and if you don't like it, that's your problem.”
In considering worry about themselves, respondents thought about how they present to others. For
instance, one respondent said, “So, I’m the whitest-looking person in my family. The rest of my family
looks much more Asian. There definitely have been times where maybe people don’t think they are Asian
but think they are Hispanic and have said things.” She answered ‘not very often’ for herself and
‘somewhat often’ for C18, regarding worrying about her loved ones. Another respondent considered
her Jewish identity for this question and said, “There are white supremacists who hate Jews all over the
country. I don’t worry about that. It’s more that I feel like, if people know I’m Jewish, I feel a bit
‘othered.’ People who have a sense of Judaism might look at me and think, ‘oh she might be Jewish.’
But my name isn’t Jewish, and I can kind of pass as ‘not.’” She answered ‘Not very often.’
Changes to the question wording
The wording of this question was not changed during data collection.
C18: Throughout your life, how often have you worried that a loved one like your partner, child, or
parent might be treated or judged unfairly because of their race, ethnicity, or skin color?
□ Very often
□ Somewhat often
□ Not very often
□ Never

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C18: A través de su vida, ¿con qué frecuencia usted se ha sentido preocupada que un ser querido,
como su pareja, hijo(a) o padres fueran tratados injustamente o juzgados por su raza, etnicidad o el
color de su piel?
□ Frecuentemente
□ A veces
□ Rara vez
□ Nunca
For this question respondents considered how worried they are that their loved ones may experience
discrimination or racism. In consideration of their loved ones, respondents variously thought of their
parents, their partners, and their children. Like concerns about themselves (for C17: ‘Throughout your
life, how often have you worried that you might be treated or judged unfairly because of your race,
ethnicity, or skin color?’), respondents thought about how their loved ones may present to others,
including whether they had accents, unusual names, darker skin tones, were immigrants, or had trouble
understanding English. Those with varied situations, (as in some they worry about more than others)
thought about the loved ones they worried about most. For example, one respondent who answered
‘Very often’ said, “Not my partner, because my partner is a white male, so I don’t worry about him. It’s
my parents who are immigrants and don’t speak English well. Most of the time I am worried about
them.” Like with C17 above, when formulating a response, most respondents answered based on worry
they feel rather than experiences of racism or discrimination that they have faced, though this was not a
clear distinction for some.
When thinking about where loved ones may experience racism, respondents thought a variety of
scenarios including the workplace, school, doctor’s offices and banks, and even family gatherings. As
one respondent who answered ‘very often’ said, “My husband is from [Another country]. And many
times, even family members will say, ‘he must be a terrorist.’ So, it can be very close people to me that
will hurt other close people to me. So yeah, it’s very prevalent.”
Changes to the question wording
The wording of this question was not changed during data collection.
D23: During your life until now, how often have you been discriminated against, prevented from
doing something, hassled, or made to feel inferior because of your race, ethnicity, or skin color?
□ Never
□ A few times a year
□ Once a month
□ Once a week
□ Almost every day
D23: Durante su vida hasta ahora, ¿cuán frecuentemente se ha sentido discriminada, que le impedido
o le han dado problemas en hacer algo, o le han hecho sentir que es inferior a otra persona por su
raza, etnicidad o el color de su piel?
□ Frecuentemente
□ Algunas veces
66

□ Rara vez
□ Nunca
Respondents considered this question to be asking about race or ethnicity-based discrimination
generally across their whole lives. Consideration included things like micro-aggressions and “passive
discrimination,” as one respondent said, such as inappropriate or offensive comments in a professional
or medical setting, as well as occurrences of discrimination by adults or other children during childhood.
For one Spanish-language respondent, discrimination based on ethnicity and discrimination based on
language ability were inseparable. She answered ‘a few times a year’ and explained that she felt
discriminated at times when she is shopping in stores for knowing very little English.
In one case, a respondent understood the question was asking about discrimination based on race,
ethnicity, or skin color, but she nonetheless answered based on a salient occurrence of pregnancyrelated discrimination. This case is described further in ‘occurrences of error’ below.
Those who felt that they had been discriminated on the basis of their race or ethnicity only a few times
in their lives responded ‘Never,’ since ‘a few times a year’ seemed too often for their experience. As
one respondents said, “Never or a few times. I’d say ‘never’ really.”
Occurrences of error
There were two cases of error, both among Spanish-language respondents. One respondent only
answered ‘A few times a year’ because she misheard the response options, and she should have
answered ‘never.’ Another respondent answered ‘once a month,’ explaining that discrimination
happened to her once. She explained, “It wasn’t because of my race, identity, or skin color. But, it was
because of my pregnancy (translated from Spanish by the interviewer).” She had been fired from her
job, once the employer found out she was pregnant. The respondent felt that this occurrence of
pregnancy-related discrimination was important to account for, so she answered based on this.
Changes to the question wording
To improve clarity, the Spanish version of the question was changed from the following: ‘Durante su vida
hasta ahora, ¿cuán frecuentemente ha sentido que han discriminad contra usted, que le han impedido
hacer algo, molestado o le han hecho sentir inferior por su raza, etnicidad o el color de su piel?’
D24: Have you ever been treated unfairly due to your race, ethnicity, or skin color in any of the
following circumstances? (check all that apply)
□ Job (hiring, promotion, firing)
□ Housing (renting, buying mortgage)
□ Police (stopped, searched, threatened)
□ In the courts
□ At school or my child’s school
□ Getting medical care
□ None of the above

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D24: ¿Alguna vez se ha sido tratada injustamente debido a su raza, etnicidad o el color de su piel en
alguna de las siguientes situationes?
No Yes
a. Empleo (contratación, promoción, despido)........................................................................................ □ □
b. Vivienda (alquiler, compra de hipoteca)…………………………………………………………………………………………. □ □
c. Policía (detenida, registrada, amenazada)........................................................................................... □ □
d. En las cortes......................................................................................................................................... □ □
e. En la escuela o la escuela de mi(s) hijo(s)……………………………………………………………………………………….. □ □
f. Recibiendo cuidado médico.................................................................................................................. □ □
Respondents considered where they had experienced discrimination in the particular settings laid out in
the question response options. The examples respondents noted were a mixture of passive comments
and specific, memorable instances carried over their considerations from D23 above (‘During your life
until now, how often have you been discriminated against, prevented from doing something, hassled, or
made to feel inferior because of your race, ethnicity, or skin color?’). Respondents thought of both D23
and this question as paired items on discrimination.
Formulating a response
The category ‘at school or my child’s school’ captured both respondents experiences growing up as a
child as well as interactions with other parents at their child’s school or daycare. In terms of ‘getting
medical care,’ one respondent recalled a specific, salient event. While she was overall happy with her
midwife, she had a bad experience with an ultrasound tech. She explained, “It was just one of the
ultrasound techs. One of the comments he made was just not appropriate. It was like, ‘oh interesting.
So that’s what we’re going to do.’ And, I did have to speak to the office manager about that.”
One respondent noted, when considering ‘job (hiring, promotion, firing)’ that it is hard to know. She
said, “With job hiring it’s hard to say, it’s kind of one of those things that you’ll never know for sure.”
Ultimately, she chose only, ‘at school or my child’s school,’ thinking of instances when she was in school
as a child. Also, another respondent who had reported discrimination when shopping in stores for
Question D23, marked ‘none of the above’ for this question, as no response option captured that
location.
Occurrence of error: a salient discriminatory experience
As in Question D23 above, (‘During your life until now, how often have you been discriminated against,
prevented from doing something, hassled, or made to feel inferior because of your race, ethnicity, or
skin color?’), one respondent understood that the question was asking about discrimination specifically
based on race, ethnicity, or skin color, but she nonetheless answered based on a pregnancy-related
instance of discrimination. She selected ‘Job (hiring, promotion, firing)’ because she had been fired from
her job when her employer found out she was pregnant.
Change to the question wording
The Spanish version of the question was changed to utilize a ‘yes’ and ‘no’ format rather than ‘select all
that apply. This change did not cause issues for those asked this version. Additionally, some

68

terminology was changed to improve clarity. ‘Empleo’ replaced ‘trabajo,’ and ‘cortes’ replaced
‘tribunales.’

Water testing
B1: During the 12 months before your new baby was born, did a doctor, nurse, or other healthcare
worker talk to you about getting your household water tested for any of the following things? For
each one, check No if they did not talk to you about it or Yes if they did.
No Yes
a. Arsenic.................................................................................................................................................. □ □
b. Lead...................................................................................................................................................... □ □
c. Other contaminants.............................................................................................................................. □ □
Please tell us:
B1: En los 12 meses antes de que naciera su nuevo bebé, ¿un médico, enfermera u otro profesional de
la salud habló con usted acerca de hacerle pruebas al agua en su hogar para detectar algunas de las
siguientes cosas? Para cada una, marque No si no le hablaron sobre eso o Sí si lo hicieron.
No Sí
a. Arsénico................................................................................................................................................ □ □
b. Plomo................................................................................................................................................... □ □
c. Otros contaminantes............................................................................................................................ □ □
Por favor díganos:
Respondents consistently considered whether a healthcare worker had spoken to them about having
their water tested for certain contaminants. Respondents did not include conversations outside the
question timeframe or more general conversations about water that were not specific to testing. For
instance, one respondent said, “They have only asked me if we have well water or city water. We have
city water (translated from Spanish by the interviewer).”
Nearly all respondents selected ‘no’ to all items. In fact, some respondents were surprised or even
taken-aback by the question since they had not considered getting their water tested while pregnant.
As one respondent said, “I've actually never heard of testing the water while I was pregnant that's very
new...I've never even thought about it.” Another respondent was more alarmed, expressing concern
that her water was potentially unsafe. She said, “It is very dangerous?” Since this question was placed
first in the version of the questionnaire she received, she thought the question must be particularly
important to the survey designers.
Changes to the question wording
The wording for this question was not changed during data collection.

Prenatal care
B4: During any of your prenatal care visits, did a healthcare provider do any of the following things?
No Yes
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Talk to me about...
a. How much weight I should gain during pregnancy.............................................................................. □ □
b. Doing tests to screen for birth defects or diseases that run in my family........................................... □ □
c. The signs and symptoms of preterm labor (labor more than 3 weeks before the baby is due)........... □ □
d. What to do if I feel depressed during my pregnancy or after my baby is born................................... □ □
Ask me if...
e. I planned to breastfeed my new baby.................................................................................................. □ □
f. I planned to use birth control after my baby was born........................................................................ □ □
g. I was taking any prescription medication............................................................................................. □ □
h. I smoked cigarettes or used e-cigarettes or other forms of smokeless tobacco.................................. □ □
i. I was drinking alcohol............................................................................................................................ □ □
j. Someone was hurting me emotionally or physically............................................................................. □ □
k. I was using illegal drugs........................................................................................................................ □ □
l. I was using marijuana............................................................................................................................ □ □
m. I wanted to be tested for HIV.............................................................................................................. □ □
B4: Durante las visitas de cuidado prenatal, ¿un proveedor de salud hizo alguna de las siguientes
cosas?

No Sí
Habló conmigo sobre...
a. Cuanto peso debería aumentar durante el embarazo......................................................................... □ □
b. Las pruebas o exámenes que me podría hacer para detectar defectos de nacimiento o enfermedades
que corren en mi familia.......................................................................................................................... □ □
c. Las señales y síntomas de un parto prematuro (parto al menos 3 semanas antes de la fecha estimada
del nacimiento)........................................................................................................................................ □ □
d. Que debo hacer si me siento deprimida durante el embarazo o después del nacimiento de mi
bebé…………………………………………………………………………………………………………………………………………………… □ □
Me preguntó...
e. Si pensaba amamantar o darle pecho a mi nuevo bebé...................................................................... □ □
f. Si pensaba usar algún método anticonceptivo después de que naciera mi bebé................................ □ □
g. Si tomaba medicinas recetadas............................................................................................................ □ □
h. Si fumaba cigarrillos o usaba cigarrillos electrónicos (“vapes”) u otros tipos de tabaco sin humo..... □ □
i. Si estaba tomando alcohol.................................................................................................................... □ □
j. Si alguien me estaba lastimando emocional o físicamente................................................................... □ □
k. Si estaba usando drogas ilegales.......................................................................................................... □ □
l. Si estaba usando marihuana................................................................................................................. □ □
m. Si quería hacerme la prueba de VIH.................................................................................................... □ □

Respondents considered the prenatal care they received when answering these items. For those whose
babies were closer to a year old and for those who changed providers during their prenatal period, recall
challenges were more pronounced. An important factor in the way respondents thought about the

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question was whether they took the prompt language and the response items literally or more
generally, or even a combination of both across the question items.
Understanding the response items
Differences in interpretation arose depending on whether respondents took the question language
literally or more generally. For instance, the question implies that a direct conversation took place.
Therefore, while most respondents included information they received on forms, not all did. Also, some
respondents included related but indirect information they received while others did not. For item C,
‘talk to me about… The signs and symptoms of preterm labor (labor more than 3 weeks before the baby
is due),’ for example, one respondent who answered ‘yes’ said, “Yeah, every appointment they would
ask ‘any bleeding, any this’ so. Especially when I hit the third trimester. Any fluid, any leaking, they
would ask that.” She thought about being asked about symptoms more generally. Whereas another
respondent who answered ‘no’ explained, “I think they gave me regular labor signs, and I had certain
things where they said, ‘if that happens, then call us.’ I don’t think the ever said, ‘this is what preterm
labor is.’” Likewise, for item M, ‘Ask me if… I wanted to be tested for HIV,’ several respondents who
answered ‘no’ did so because the test was automatically completed without them having been ‘asked’
directly. One respondent explained, “No, but I think when they – because every time you go to a
doctor’s appointment, you have to do a urine, I think with the urine they incorporate the drug test, they
incorporate the STDs, HIV, the tests like when you have to urinate for them in a cup, they test for a lot, I
guess.” This respondent only knew she had been tested when she saw her results in her online portal.
Extra specificity in the response items or even the language in the question prompts ‘talk with me about’
and ‘ask me if’ led some more detail-oriented and literal respondents to answer ‘no’ when they should
have answered ‘yes.’ For instance, item B asks, ‘Doing tests to screen for birth defects or diseases that
run in my family.’ Some respondents answered ‘no’ even though their doctors had spoken with them
about genetic screening tests. As one respondent explained, “They talked about birth defects, but not
specifically ones that run in my family.” Whereas, in contrast, another respondent answered ‘yes’
reasoning, “It gets at what’s behind the question in that they did ask about tests regardless of whether
my family had it or not.”
Of note
Regarding item J, ‘Asked me if…someone was hurting me emotionally or physically,’ one respondent
who answered ‘yes’ said that her doctor only asked about feeling ‘safe at home.’ She said, “So if I was
being abused at work or something they would not have asked about it.”
Occurrence of error
One respondent misinterpreted the question items E through M as asking about her behaviors during
pregnancy rather than about what things her healthcare providers had asked her. For example, she
answered ‘no’ to ‘I was taking prescription medication.’ This respondent misinterpreted the prompting
language of ‘Ask me if…’ She had, however, correctly understood items A though D with the prompt
language ‘talk with me about.’ Indeed, response items taken alone without the prompt language of ‘talk
with me about’ or ‘ask me if’ seriously impacts the question construct captured.
Changes to the question wording
71

The wording of this question was not changed during data collection.
B5: During your most recent pregnancy, did a healthcare provider tell you that you had any of the
following health conditions?
No Yes
a. Gestational diabetes (diabetes that started during this pregnancy).................................................... □ □
b. High blood pressure (that started during this pregnancy), pre-eclampsia, or eclampsia.................... □ □
c. Depression............................................................................................................................................ □ □
d. Anxiety................................................................................................................................................. □ □
B5: Durante su embarazo más reciente, ¿un proveedor de salud le dijo que tenía alguna de las
siguientes condiciones de salud?

No Sí
a. Diabetes gestacional (diabetes que comenzó durante este embarazo)............................................... □ □
b. Presión alta (que desarrolló durante este embarazo), preeclampsia o eclampsia.............................. □ □
c. Depresión............................................................................................................................................. □ □
d. Ansiedad............................................................................................................................................... □ □
Respondents thought about conditions that arose for them during pregnancy and if they had been
diagnosed with any of the conditions listed in the response items. Those respondents with gestational
diabetes and high blood pressure that emerged during their recent pregnancy correctly answered ‘yes,’
and those conditions were captured by this question. Additionally, a respondent whose high blood
pressure arose post-pregnancy correctly answered ‘no’ to item B (high blood pressure). Depression and
anxiety were not as successfully captured. Some noted that anxiety and depression were different types
of conditions than diabetes and high blood pressure because there are not lab tests or simple exams to
determine anxiety and depression. As one respondent who answered ‘no’ to all items said, “No, they
didn’t tell me anything like this. But, I might have mentioned it to them. I definitely mentioned it to
them that I have anxiety and depression.” Likewise, another said, “I don’t think a doctor would…Like a
doctor would tell you if you had gestational diabetes or high blood pressure because that is factual and
they can see according to lab results or your vitals versus depression or anxiety, you would have to tell
them, ‘hey I’m feeling so and so.’”
Those few respondents who had preexisting conditions hesitated when selecting a response. As one
respondent who had high blood pressure prior to pregnancy said, “This question is confusing for me, I
have high blood pressure just generally. So, I wasn’t – not preeclampsia. But I was treated as if
preeclampsia was coming, even though it never did.” Ultimately, she selected ‘no’ to all items and
correctly went on to answer B6 (‘During your most recent pregnancy, did a doctor, nurse, or other
healthcare worker do any of the following things to help you manage your high blood pressure?’) which
is specifically for those with high blood pressure during pregnancy. Another respondent with preexisting
anxiety hesitated when answering and explained that she was already seeing a psychiatrist when she got
pregnant. Since she thought her medical chart showed that she was experiencing anxiety during
pregnancy she said ‘yes’ to D (Anxiety). She explained, “…but it wasn’t like a pregnancy-related…but it
was during pregnancy.”

72

Occurrence of error
One respondent continued her consideration from the prior question here (B4: ‘During any of your
prenatal care visits, did a healthcare provider do any of the following things?’), and she answered based
on whether her doctor had talked with her about these conditions. She answered ‘yes’ to ‘gestational
diabetes’ and ‘High blood pressure’ in error as she did not have either of those conditions.
Changes to the question wording
Respondents understood “presión alta” to indicate high blood pressure, and they did not need
additional qualifiers to indicate the medical condition. Therefore, the Spanish-language version was
changed to remove the word ‘arterial’ from item B.
B6: During your most recent pregnancy, did a doctor, nurse, or other healthcare worker
do any of the following things to help you manage your high blood pressure?

No Yes
a. Refer me to a different healthcare professional.................................................................................. □ □
b. Talk to me about regularly checking my blood pressure at home or outside of the healthcare
professional’s office during pregnancy.................................................................................................... □ □
c. Talk to me about getting to and staying at a healthy weight after pregnancy..................................... □ □
d. Talk to me about regularly checking my blood pressure at home or outside of the healthcare
professional’s office after pregnancy....................................................................................................... □ □
e. Talk to me about my risk for having high blood pressure (chronic hypertension) and heart disease
after pregnancy........................................................................................................................................ □ □
B6: Durante su embarazo más reciente, ¿proveedor de salud hizo alguna de las siguientes cosas para
ayudarle a manejar su presión alta?
No Sí
a. Me refirió a otro proveedor de salud................................................................................................... □ □
b. Me dijo que me tomara la presión regularmente durante el embarazo.............................................. □ □
c. Me habló sobre cómo lograr un peso saludable después del embarazo.............................................. □ □
d. Me habló sobre cómo deberia tomarme la presión regularmente después del embarazo................. □ □
e. Me habló sobre mi riesgo de desarrollar presión alta (hipertensión crónica) y enfermedades cardíacas
después del embarazo.............................................................................................................................. □ □
This question is intended for people who had high blood pressure during their prior pregnancy. The skip
pattern information was located between questions and not within the prior question, and the
instructions read as follows: ‘If you had high blood pressure before or during your pregnancy, go to
Question B6. If not, go to Question B7.’ Two respondents were correctly screened into the question
including one who had high blood pressure because of pregnancy and one respondent who had preexisting high blood pressure. The respondent with pre-existing high blood pressure was concerned that
her answer here would be seen as an error if taken out of context because she had answered ‘no’ to the
blood pressure item in the prior question (B5: During your most recent pregnancy, did a healthcare
provider tell you that you had any of the following health conditions? B. High blood pressure (that
started during this pregnancy, pre-eclampsia, or eclampsia)). Her high blood pressure was not related to
pregnancy as specified in the response item.
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The two respondents screened into this question viewed the question as asking about how they had
been directed to manage their high blood pressure, thinking specifically about blood pressure-related
advice, and not advice they had received that was unrelated to their blood pressure. Their responses
accurately reflected their specific circumstances. For instance, neither respondent selected item C (‘Talk
to me about getting to and staying at a healthy weight after pregnancy’) because their provider spoke
about healthy weight in a context outside their blood pressure issues.
Occurrences of error
Several respondents who should have skipped this question answered it because they did not see the
skip instructions. They responded according to what their providers had told them more generally
about blood pressure and weight loss and not because they had a blood pressure condition.
Changes to the question wording
In the Spanish-language version of the question, the term ‘proveedor de salud’ replaced ‘médico,
enfermera u otro profesional de la salud’ for the sake of brevity. Also, there were minor grammatical
changes to item B to improve clarity and flow.

Disability
B23: Prior to becoming pregnant, did you...

No Yes
a. Have serious difficulty hearing, or are you deaf................................................................................... □ □
b. Have serious difficulty seeing, even when wearing glasses, or are you blind...................................... □ □
c. Have serious difficulty walking or climbing stairs................................................................................. □ □
d. Have serious difficulty concentrating, remembering, or making decisions because of a physical,
mental, or emotional condition............................................................................................................... □ □
e. Have difficulty with dressing or bathing yourself................................................................................. □ □
f. Have difficulty doing errands alone such as visiting a doctor’s office or shopping because of a physical,
mental, or emotional condition............................................................................................................... □ □
B23: Antes de quedar embarazada, usted...

No Sí
a. ¿Tenía dificultades de audición o es sorda?......................................................................................... □ □
b. ¿Tenía dificultades de visión incluso cuando usaba espejuelos, o es ciega?....................................... □ □
c. ¿Tenía dificultades caminando o subiendo escaleras?......................................................................... □ □
d. ¿Tenía dificultades concentrandose, recordardando o tomando decisiones debido a una condición
física, mental o emocional?...................................................................................................................... □ □
e. ¿Tenía dificultades vistiendose o bañándose?..................................................................................... □ □
f. ¿Tenía dificultades haciendo cosas sola, como visitar el consultorio médico o ir de compras debido a
una condición física, mental o emocional?.............................................................................................. □ □

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Respondents generally viewed this question as asking about their functional difficulties prior to
becoming pregnant with their new baby. Though, in one case, a respondent said, “I’ve been walking the
whole pregnancy” when she selected ‘no’ to item C (‘Have serious difficulty walking or climbing stairs’).
Most respondents selected ‘no’ to all items, remarking that they have not had those difficulties. In two
cases, respondents with ADHD selected ‘yes’ to item D (‘Have serious difficulty concentrating,
remembering, or making decisions because of a physical, mental, or emotional condition’). As one
respondent explained, “I have ADHD so I definitely have a problem concentrating but nothing else.”
Changes to the question wording
The wording of this question was not changed during data collection.
B24: Because of a physical, mental, or emotional condition, do you have difficulty caring for yourself
or your newborn?
□ No
□ Yes
B24: Debido a una condición física, mental o emocional, ¿tiene dificultades cuidando de sí misma o de
su recién nacido?
□ No
□ Sí
Respondents considered this question to be asking about whether they had a serious, long-term health
condition that affected their ability to care for their new baby. As one respondent explained, “I think it
might be someone who is going through some depression or some illness...I don't know if sick is the right
word, but yes those are mental illnesses, depression, anxiety, that sort of thing (translated from Spanish
by the interviewer).” All respondents answered ‘no’ to this question. One respondent wondered how
to account for postpartum recovery, but she ultimately decided that it should not count for this question
and that she would not in a home survey situation.
Changes to the question wording
The wording of this question was not changed during data collection.

Doula support

C8: Did you use doula support during any of the following time periods? A doula is a trained
pregnancy and labor companion who gives comfort, emotional support, and information around the
time of pregnancy. A doula does not provide medical care.
No Yes
a. During my most recent pregnancy....................................................................................................... □ □
b. During the birth of my new baby......................................................................................................... □ □
c. Since my new baby was born............................................................................................................... □ □

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C8: ¿Recibió apoyo de una doula durante alguno de los siguientes períodos de tiempo? Una doula es
una persona entrenada para brindar consuelo, apoyo emocional e información durante el embarazo y el
parto. Una doula no brinda cuidado médico.
No Sí
a. Durante mi embarazo más reciente..................................................................................................... □ □
b. Durante el nacimiento de mi bebé....................................................................................................... □ □
c. Desde que nació mi bebé..................................................................................................................... □ □
Respondents understood the question as asking about the time periods in which they had support from
a doula, if indeed they did at all. Generally, respondents who were familiar with doulas considered
them to be non-medical pregnancy and birth support personnel, as stated in the question. Also, many
respondents viewed doulas as potentially serving an advocacy role, supporting new mothers’ intent and
wellbeing. Considerations of doula support covered a range of relationships including hired doulas,
family friends and family members who were professional doulas, a free online doula resource, and a
delivery support person provided by the hospital. Those who had a doula at any time in their pregnancy
or delivery accurately indicated at what times they had doula support. The following quotes are
indicative of the variety of doula experiences represented.
“She’s just an old friend from church. She’s been a doula for 50 years. She’s an older, very sweet
woman. As soon as I found out I was pregnant I knew I had to hire her.”
“Once the baby came out, she was gone.”
“…[my baby] was preterm, and it was the middle of the night, so she wasn’t on-call yet. And we
did meet with her postpartum.”
Occurrence of error
Spanish-language respondents were unclear the difference between a ‘doula’ and a ‘partera’ (midwife).
In most cases, respondents lack of familiarity with doulas did not lead to response error. However, in
one exception, a Spanish-language respondent answered ‘yes’ to ‘during the birth of my baby’ and ‘since
my new baby was born,’ thinking of a home visiting nurse that she was offered as part of the WIC
program. She said, “I think she is the nurse that comes over to my home to check the baby (translated
from Spanish by the interviewer).”
Changes to the question wording
The wording of this question was not changed during data collection.

Postpartum care
C10: Have you experienced any of the following things during your pregnancy or after your
baby was born?

No Yes
a. I felt something wasn’t right with my health....................................................................................... □ □
b. I felt my concerns for my health were not taken seriously.................................................................. □ □
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c. I felt my doctor ignored my concerns about my health or symptoms................................................. □ □
¿Se ha sentido de alguna de las siguientes formas durante su embarazo o después del nacimiento de
su bebé?
No Sí
a. Me sentía que algo no estaba bien con mi salud................................................................................. □ □
b. Me sentía que las preocupaciones que tenía sobre mi salud no eran tomadas en serio.................... □ □
c. Me sentía que mi médico estaba ignorando mis preocupaciones sobre mi salud o mis síntomas...... □ □
Respondents viewed this question as asking about their treatment by medical professionals during their
pregnancy, delivery, and postpartum experiences. Some of the concerns that respondents thought
about included being spoken to condescendingly, being ignored, or having their health put at risk
unnecessarily. Most respondents who selected ‘yes’ to any of the response items expressed
dissatisfaction with their care as explanation of their answer. For example, one respondent who
selected ‘yes’ to all three items said that her type one diabetes was poorly managed and dangerously
out of control during labor. She explained, “I asked them specifically to test that [diabetic ketoacidosis]
on multiple occasions and they would not do that, even when I was throwing up bile and yeah, a lot of
warning signs. I was telling them what labs to do, and they wouldn’t do anything.”
Respondents with health complications during pregnancy that were well managed and cared for did not
generally select ‘yes’ to any of the response items. For instance, one respondent with high blood
pressure explained her answer (‘no’ to all items) by saying the following: “I mean I felt fine. I was larger
and more tired than the first one [this was her second baby] and overall felt blah. But I felt that way
with the first one too. I don’t think that meant anything wasn’t right.” In one exception, a respondent
who was overall happy with her care selected ‘yes’ only to item A (‘I felt something wasn’t right with my
health’) because she had low blood pressure and vitamin D deficiency during pregnancy that made her
fatigued.
Spanish-language consideration
One Spanish-language respondent answered ‘yes’ to items A (‘I felt something wasn’t right with my
health’) and B (‘I felt my concerns for my health were not taken seriously’) but ‘no’ to item C (‘I felt my
doctor ignored my concerns about my health or symptoms’) because her doctor eventually did what she
asked, though he did not do so initially. She explained,
“I told him that with so many days of contractions and without dilating more than two
centimeters in a week, until the water broke, I would not dilate. He said that he was going to
induce labor and see if the contractions would be more frequent and more painful, and to see if I
would dilate, but no, I did not. It got to the point that I would not dilate. I don't know if I should
take it as him ignoring me, because in the end he had to do what I told him to do (translated
from Spanish by the interviewer).”
Changes to the question wording
The wording of this question was not changed during data collection.

77

C11: After your recent pregnancy, did you get follow-up care for any of the following conditions? For
each item, check No if you did not get it, check Yes if you did get it, or check DH if you didn’t have this
condition.
No Yes DH
a. Diabetes......................................................................................................................................... □ □ □
b. Hypertension (high blood pressure).............................................................................................. □ □ □
c. Heart conditions (birth defects of the heart, fast or skipped heartbeat, heart failure, enlarged heart,
heart attack, chest pain, heart transplant, or pacemaker)................................................................ □ □ □
C11: Después de su embarazo más reciente, ¿recibió tratamiento de seguimiento para tratar alguna
de las siguientes condiciones? Para cada una, marque No si no la recibió, Sí, si la recibió o marque NT
si no tenía la condición.
No Sí NT
a. Diabetes......................................................................................................................................... □ □ □
b. Hipertensión (presion alta)............................................................................................................ □ □ □
c. Condiciones cardíacas o del corazón (defectos congénitos del corazón, latidos cardíacos acelerados o
salteados, insuficiencia cardíaca, agrandamiento del corazón, ataque cardíaco, dolor de pecho,
trasplante de corazón o marcapasos)............................................................................................... □ □ □
Respondents considered this question to be asking about any sort of medical care they received after
giving birth for diagnosed conditions associated with the response items listed in the question. Those
with both pregnancy-related conditions and pre-existing conditions, such as high blood pressure prior to
pregnancy or type one diabetes, were included in respondents’ answers. The follow-up care
respondents received varied, and it included visits with a regular physician and receiving medication
when leaving the delivery hospital. As one respondent who answered ‘yes’ to item B (‘hypertension
(high blood pressure)’) explained, “They gave me medicine to take, but I didn’t go see anybody after, so
[…] I would say yeah, just because it was a little bit high once I was leaving the hospital.”
Respondents who were screened or monitored for possible, developing conditions did not count that
type of care for the purposes of this question. As one respondent who answered ‘no’ to all items
explained, “Not exactly, but I did go to the doctor to do bloodwork to check for diabetes because one of
my feet [laugh] pulsates, I guess?”
Mode inconsistency and error
The two modes for the questionnaire offered different response options, and that affected the
consistency of response. The interviewer-administered version did not include a ‘Don’t have’ option for
the response items. Therefore, many respondents answered ‘no’ who would have selected ‘DH’ given
the self-administered version. In addition to the inconsistency in mode, one respondent did have true
response error in that she selected ‘no’ rather than ‘DH’ despite having received the self-administered
version. When filling out the questionnaire she remarked, “No, I don’t have any of these.”
Changes to the question wording
The Spanish version of this question was changed in a few ways. The question stem was altered from
the following: ‘Después de su embarazo más reciente, ¿recibió atención médica adicional para tratar
78

alguna de las siguientes condiciones?’ Also, the word ‘arterial’ from response option B, as it was
unnecessary for comprehension.
C12: Since your new baby was born, have you had a postpartum checkup for yourself? A
postpartum checkup is a regular health checkup you have up to 12 weeks after giving birth.
□ No (go to Question C14)
□ Yes
C12: Desde que nació su nuevo bebé, ¿usted ha ido a hacerce un chequeo posparto? Un chequeo
posparto es un chequeo regular antes de las 12 semanas después del parto.
□ No (Pase a la Pregunta C14)
□ Sí
For this question, respondents consistently considered whether they had gone to their healthcare
provider within 12 weeks of giving birth. Most respondents answered ‘yes’ and had attended their
postpartum appointment to check on their own health or to have long-term birth control placed, such as
an IUD or arm implant. Those who answered ‘no’ had not had a postpartum appointment for either
medical or personal reasons. In the first case, the appointment was planned, but had not happened yet,
as the delivery happened less than six weeks prior. Personal reasons for not having a postpartum
appointment included anxiety about leaving the house and simply never scheduling the appointment.
As one respondent explained, “No I think I skipped this. I have a little bit of ADHD, so it really was
difficult to get back to the doctor on time. Not for the 12 weeks. Nothing in the 12 weeks.”
Changes to the question wording
The wording of this question was not changed during data collection.
C13. During your postpartum checkup, did a healthcare provider do any of the following things? For
each item, check No if they did not do it or Yes if they did.
No Yes
a. Test me for diabetes............................................................................................................................. □ □
b. Prescribe medication for anxiety or depression.................................................................................. □ □
c. Prescribe birth control such as the pill, patch, ring, or shot (Depo-Provera®)..................................... □ □
d. Place an IUD (ParaGard®, Mirena®, Liletta®, Kyleena®, or Skyla®) or a contraceptive implant
(Nexplanon®)............................................................................................................................................ □ □
Talk to me about...
e. What to do if I feel depressed or anxious ............................................................................................ □ □
f. The warning signs of medical problems I might be at risk for in the future due to my pregnancy……. □ □
g. Checking my blood pressure at home or outside of my doctor’s office............................................... □ □
Ask me if...
h. I was smoking cigarettes or using e-cigarettes or other forms of smokeless tobacco ........................ □ □
i. Someone was hurting me emotionally or physically ............................................................................ □ □
C13. Durante su chequeo posparto, ¿un proveedor de salud hizo algunas de las siguientes cosas? Para
cada una, marque No, si no lo hicieron, o Sí, si lo hicieron.
79

No Sí

Habló conmigo sobre…
a. La alimentación saludable, el ejercicio y como perder el peso que aumenté durante el embarazo... □ □
b. Cuánto debo esperar antes de quedar embarazada otra vez.............................................................. □ □
c. Métodos anticonceptivos..................................................................................................................... □ □
d. Los signos de urgencia o síntomas que podría sentir en el futuro dado al embarazo y que podrían ser
peligrosos…………………………………………………………………………………………………………………………………………... □ □
e. Tomarme la presión regularmente...................................................................................................... □ □
Me preguntó...
f. Si fumaba cigarrillos o usaba cigarrillos electrónicos (“vapes”) u otros tipos de tabaco sin humo...... □ □
g. Si alguien me estaba lastimando emocional o físicamente.................................................................. □ □
h. Si me sentía deprimida o ansiosa ........................................................................................................ □ □
Hicieron…
i. Una prueba para diabetes .................................................................................................................... □ □
j. Una receta o recetaron medicamentos para la ansiedad o depresión................................................. □ □
This question was intended for those who answered ‘Yes’ to Question C12 (‘Since your new baby was
born, have you had a postpartum checkup for yourself? A postpartum checkup is a regular health
checkup you have up to 12 weeks after giving birth.’). Respondents considered actions taken and
conversations they had, or reasoned that they had, with their healthcare provider at their postpartum
appointment.
The question did not cause confusion overall, in that respondents understood the intent and content of
the question. However, when probed, respondents were not sure what item F (‘Talk to me about… The
warning signs of medical problems I might be at risk for in the future due to my pregnancy’) may refer
to. One respondent who selected ‘No’ to item F remarked,
“I guess if I read it again now and think about it, I guess I’m at risk for another preterm delivery.
I guess I’m at risk for that. No one really talked to me about it, I was given a big packet that I
could have that information. And, because we were sitting in the NICU for 5 days, I did go
through that packet, so I guess I read that information.”
Some respondents could not remember what they had been asked during their postpartum
appointment. In those cases, respondents made a best guess using their general understanding of what
typically is or is not on intake forms or typical questions from their health provider. For example,
regarding item H (‘Ask me if… I was smoking cigarettes or using e-cigarettes or other forms of smokeless
tobacco’) one respondent said, “Don’t remember. I’m sure it was on the intake form, so I’ll say yes.”
Likewise, when answering ‘no’ to items E (‘Talk to me about…What to do if I feel depressed or anxious’)
and F (‘Talk to me about…the warning signs of medical problems I might be at risk for in the future due
to my pregnancy’), one respondent said, “Um, I don't think so […] If they did it would have been like one
of the first questions when I first got pregnant.”
Possible incidence of error
One respondent, who completed an interviewer-administered version of the questionnaire, marked
‘yes’ to both items C (‘Prescribe birth control such as the pill, patch, ring, or shot (Depo-Provera®)’) and

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D (‘Place an IUD (ParaGard®, Mirena®, Liletta®, Kyleena®, or Skyla®) or a contraceptive implant
(Nexplanon®)’) to account for her Nexplanon implant procedure. She said ‘yes’ to item C because the
placement of a Nexplanon could be considered ‘prescribing’ that device. However, the respondent may
not have selected both C and D if item D came first in the order listed.
Changes to the question wording
The Spanish version of the question was changed in several ways. The term ‘proveedor de salud’
replaced ‘doctor, enfermera u otro profesional de la salud’ in the question stem. Additionally, the
question prompts, order of response items, and some words were updated to improve flow while
maintaining the meaning. The prior version, like the English version listed here, did not include a
prompt for items A through D.

Patient-centered and respectful care
The following three questions cover the topic of respectful care across three timeframes: during
pregnancy, during delivery, and postpartum. Respondents carefully considered each time frame
independently during administration and probing. Many respondents were cared for by different
medical care teams across the three time periods. Overall, for these ‘respectful care’ questions,
respondents with multiple providers within a timeframe tended to have a harder time ‘averaging’ their
feelings or selecting one provider over another on which to base their answers. Many respondents who
were unsatisfied with some part of their medical care felt they did not have options to accept or turn
down services. Additionally, some respondents with prior pregnancy and delivery experience noted that
their confidence levels and experience between their first and second pregnancies had increased, and
they felt that affected the way they answered.
C14: Overall, during my pregnancy, I felt…
For each item, check:
A if it was All of the time
M if it was Most of the time
F if it was a Few times
N if it was Never

AMFN
a. Comfortable asking questions about the prenatal care that I received........................................ □ □ □ □
b. Comfortable declining care that was offered................................................................................ □ □ □ □
c. Comfortable accepting the options for care that my provider recommended.............................. □ □ □ □
d. I was able to choose the care options that I received................................................................... □ □ □ □
e. My providers treated me with respect.......................................................................................... □ □ □ □
f. Satisfied with the prenatal care I received..................................................................................... □ □ □ □
C14: En general, durante el embarazo, me sentí…
Para cada una, marque:
T si fue Todo el tiempo
M si fue la Mayoría del tiempo
A si fue Algunas veces
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N si fue Nunca

TMAN
a. Cómoda haciendo preguntas sobre el cuidado prenatal que recibí.............................................. □ □ □ □
b. Cómoda rechazando cuidado médico que no quería.................................................................... □ □ □ □
c. Cómoda aceptando las opciones de cuidado médico que me estaba recomendando mi
proveedor……………………………………………………………………………………………………………………………………. □ □ □ □
d. Pude elegir las opciones de atención que recibí............................................................................ □ □ □ □
e. Mis proveedores me trataron con respeto.................................................................................... □ □ □ □
f. Satisfecha con la atención prenatal que recibí............................................................................... □ □ □ □
Respondents thought about the prenatal care they received when considering this question. How
respondents felt about their prenatal care, whether positive or negative, was salient and memorable.
Furthermore, respondents readily provided expansive explanations for their answers. Inconsistency
occurred, however, in how respondents based their answers – whether on their comfort level or their
behavior.
Respondents inconsistently answered based on their feelings or comfort level. In some cases,
respondents considered their behavior when selecting an answer for some items and not for others,
resulting in response error. This issue was particularly evident in the case of response item B
(‘Comfortable declining care that was offered’). Some respondents answered based on how often they
accepted or declined care, others answered based on their comfort level in accepting or declining care,
whereas still others were unsure how to respond since the situation was hypothetical for them – never
having wanted to decline care that was offered.
Multiple providers
Respondents who had multiple providers during their prenatal care approached their diversity of care in
one of two ways. They either tried to ‘average’ their experience or they answered based on their more
common experience. For example, one respondent who changed providers early in her pregnancy said,
“OBGYNs I felt were not great. So, I switched to somebody I felt was really respected me as a person
more. So, I found it difficult to say I did not want particular care from the OBGYN, and I felt comfortable
with it from the midwife.” In this respondent’s case, she answered ‘Most of the time’ to the items as an
average, although she would have answered ‘all the time’ if responding only about her midwife care
team. On the other hand, another respondent who answered based on her more regular visits with a
maternal fetal medicine doctor said,
“The maternal fetal medicine doctors had more a paternalistic approach to medicine than I’m
used to. So, sometimes I’d ask a question, and maybe I didn’t feel like I could ask my follow-up
questions […] The low-risk OB, I really liked her. She was the one that did the postpartum visit.
She just didn’t have much say in the decisions that were happening during the pregnancy. I
basically just went and saw her once in a while.”
Choice and respect
Some respondents discussed the fact that their care was not presented to them in terms of a ‘choice.’
Lack of options and pushing for choices affected respondents’ answers across the response items. As
one respondent who answered ‘Never’ to item D (‘I was able to choose the care options that I received‘)
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explained, “Never I guess because there is one option. You go with it or not. My town only had one OBGYN.” She went on to explain that her doctor always “came across as fake – fake respect” and that she
felt disrespected.
Response items E (‘My providers treated me with respect’) and F (‘Satisfied with prenatal care I
received’) captured various facets of respect and satisfaction, and respondents selected answers based
on their judgement of the quality of their prenatal care – including if they felt rushed, ignored, or
belittled. One respondent, who answered ‘Never’ to both E (‘My providers treated me with respect’)
and F (‘satisfied with prenatal care I received’), with type one diabetes said the following: “I had to push
to have options. If I pushed really hard I was able to have options and I was allowed to choose.”
Response item scale
The response scale did not create error per se, in that most respondents, apart from one Spanishlanguage respondent, were not specifically confused by the scale. But as described above, respondents
did sometimes base their answers on the frequency of a related behavior rather than their feelings or
comfort level. Response options of ‘Yes’ or ‘No,’ as in C15 and C16 below, may reduce instance of that
type of error.
Changes to the question wording
The wording of this question was not changed during data collection.
C15: Overall, during the delivery of my baby, I felt...

No Yes
a. Comfortable asking questions about the labor and delivery care that I received................................ □ □
b. Comfortable declining care that was offered....................................................................................... □ □
c. Comfortable accepting the options for care that my provider recommended.................................... □ □
d. I was able to choose the care options that I received.......................................................................... □ □
e. My providers treated me with respect................................................................................................. □ □
f. Satisfied with the labor and delivery care I received............................................................................ □ □
C15: En general, durante el parto de mi bebé, me sentí...

No Sí
a. Cómoda haciendo preguntas sobre la atención médica que recibí durante el parto y el nacimiento de
mi bebé..................................................................................................................................................... □ □
b. Cómoda rechazando cuidado médico que me estaban ofreciendo..................................................... □ □
c. Cómoda aceptando el cuidado médico que mi proveedor me estaba recomendando....................... □ □
d. Que pude elegir las opciones de atención que recibí.......................................................................... □ □
e. Que mis proveedores me trataron con respeto................................................................................... □ □
f. Satisfecha con la atención médica y cuidado que recibió durante el parto y el nacimiento de su
bebé……………………………………………………………………………………………………………………………………………………. □ □
Respondents viewed this question as asking about the care they received during their hospital stay for
the delivery of their baby. Generally, respondents included pre-delivery care at the hospital as well as
postpartum care immediately following the delivery when selecting their answers. As was the case with
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C14 above (‘Overall, during my pregnancy, I felt…’), how respondents felt about their delivery care,
whether positive or negative, was salient and memorable.
Respondents who had limited options or rushed deliveries answered based on what was medically
possible. As one respondent who answered ‘Yes’ to item C (‘Comfortable accepting the options for care
that my provider recommended’) said, “Yeah, I guess for what was medically possible, so I would say
yeah. For example, I didn’t want an epidural which was good because when they came back to give me
pain meds they were like, oh you are too far dilated. Or ‘we’ll have to give you a steroid shot, so you
don’t give birth in the ambulance as we are moving you from one hospital to another.’”
Multiple providers
Respondents answered this question based on their overall time during labor, delivery, and recovery at
the hospital or birthing center where they gave birth. Because of that, most respondents were cared for
by a number of providers which included doctors, nurses, and midwives. Those who had inconsistent
feelings about their providers tended to want to account for the ‘good ones’ in their answers, while still
fairly representing their dissatisfaction. For example, one respondent answered ‘Yes’ to all response
items except for item F (‘Satisfied with the labor and delivery care I received’). She answered ‘No’ to
item F because overall she felt that the hospital overall was “horrible.” She explained her ‘Yes’ response
to item E (‘My providers treated me with respect’) in the following way: “See I want to say ‘yes’ for the
ones who did and I want to say ‘no’ for the ones who did disrespect me, so I’ll just go ahead and say ‘yes’
[to item E], I really appreciate [one nurse] for making me feel good.”
Response option binary
The binary response options of Yes/No for this question (as opposed to a scale for C14 above)
encouraged respondents to generalize about their experience and provide an overarching outlook.
There was no occurrence of error due to respondents answering based on the frequency of their own
behaviors rather than their feelings, as was the case for C14.
Changes to the question wording
The wording of this question was not changed during data collection.
C16: Overall, after the delivery of my baby, I felt:

No Yes
a. Comfortable asking questions about the postpartum care that I received.......................................... □ □
b. I could make decisions on the type of care I received like declining care I did not want.................... □ □
c. Comfortable accepting the type of care that my healthcare providers recommended....................... □ □
d. I was able to choose the care options that I received.......................................................................... □ □
e. My providers treated me with respect................................................................................................. □ □
f. Satisfied with the postpartum care I received...................................................................................... □ □
g. My providers were listening to my concerns....................................................................................... □ □
C16: En general, después del nacimiento de mi bebé, me sentí…

No Sí
a. Cómoda haciendo preguntas sobre el cuidado posparto que estaba recibiendo................................ □ □
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b. Que podía tomar decisiones sobre el tipo de aque recibía, como rechazar algún servicio que no
quería…………………………………………………………………………………………………………………………………………………. □ □
c. Cómoda aceptando las opciones de cuidado médico que mi proveedor de salud me estaba
recomendando……………………………………………………………………………………………………………………………..……. □ □
d. Pude elegir las opciones de cuidado médico que recibí....................................................................... □ □
e. Que mis proveedores me trataron con respeto................................................................................... □ □
f. Satisfecha con el cuidado posparto que recibí...................................................................................... □ □
g. Que mis proveedores estaba escuchando mis preocupaciones........................................................... □ □
Respondents thought about their comfort and feelings during postpartum care. For their considerations
of ‘postpartum care,’ some respondents considered only their time in the hospital or birth center while
others thought about their postpartum follow-up care with their healthcare provider (or both, in some
cases). This inconsistency affected response, as some respondents had separate care teams and very
different experiences in the hospital versus outside the hospital. In some cases, in-hospital care was the
only postpartum care that the respondent had yet received, either because they had not yet had a
scheduled appointment, or they did not go to their recommended postpartum care appointment.
In one case, a respondent considered her baby’s care for item A (‘Comfortable asking questions about
the postpartum care that I received’). She said, “It was more about him than it was about me. And of
course, everyone cares more about the baby than the mommy! So, I felt a little bit more comfortable
because of him.”
Multiple providers
As with the Question C15 above (‘Overall, during the delivery of my baby, I felt...’), respondents tried to
account for multiple providers and experiences across their answers. For example, one respondent
answered ‘No’ to item F (‘Satisfied with the postpartum care I received ‘) to capture her dissatisfaction
with the hospital moving her around to four different rooms. Although she was happy with the medical
providers she saw, she explained, “It doesn’t really fit into any of these questions, like, all the providers I
saw [in the hospital] except for one nurse who was a bit obnoxious and not very nice, but everyone else
was lovely. But, the hospital experience was pretty terrible. But, it doesn’t seem like that fits into any of
these questions.”
Changes to the question wording
The wording of this question was not changed during data collection.

Support for the baby

C19: When your new baby’s father, or other parent, is with the baby, how often do they hug, kiss,
hold, or play with the baby?
□ Always
□ Often
□ Sometimes
□ Rarely
□ Never
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□ My new baby’s father, or other parent, doesn’t regularly spend time with my baby
C19: Cuando el papá de su nuevo bebé, o el otro padre, está con el bebé, ¿con que frecuencia juega,
abraza, besa, o carga al bebé?
□ Siempre
□ Frecuentemente
□ A veces
□ Rara vez
□ Nunca
□ El papá de mi nuevo bebé, o el otro padre, normalmente no pasa tiempo con el bebé
Respondents understood this question to be asking about how much attention and affection the baby’s
other parent gives to the baby. Considering the term ‘other parent,’ one respondent said, “Oh I just
assume you mean the non-gestational parent.” Respondents all answered based on the baby’s biological
father, as there were no cases of same-sex couples or adoptive fathers. In a few cases, the baby’s father
did not live with the respondent.
When selecting a response, some respondents answered based on attention and affection the baby’s
father gives when he is home and available, and others answered based on overall how much attention
and affection the baby’s father gives over the course of a day. For example, one respondent answered
‘always’ and explained, “Whenever he gets home from work, he hugs the baby (translated from Spanish
by the interviewer).” Whereas another respondent who answered ‘often’ gave the same reasoning. She
said, “Whenever he has a chance he does, but since he goes to work, it's not always (translated from
Spanish by the interviewer).” One respondent selected ‘often’ but described a co-parenting situation
where she and her husband share time between the new baby and their toddler. She said, “But that’s
not because he won’t do it, he just has become the default parent for the toddler.”
This question has the potential to be sensitive to single parents. One respondent said the following
about this and the following question, C20 (‘Since your new baby was born, how often
does your baby’s father or other parent contribute things such as money, food, clothing, shelter, or
healthcare to provide for your new baby’s basic needs?’): “They did give me a little bit of shock because I
would like the father to be involved in all this, but if he's not interested in being part of his life, I am not
going to force him to be there either.”
Changes to the question wording
The wording of this question was not changed during data collection.
C20: Since your new baby was born, how often does your baby’s father or other parent contribute
things such as money, food, clothing, shelter, or healthcare to provide for your new baby’s basic
needs?
□ Always
□ Often
□ Sometimes
□ Rarely
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□ Never
C20: Desde que nació su nuevo bebé, ¿con qué frecuencia su esposo(a) o pareja contribuye cosas
como dinero, comida, ropa, vivienda o cuidado médico para cubrir las necesidades básicas de su
nuevo bebé?
□ Siempre
□ Frecuentemente
□ A veces
□ Rara vez
□ Nunca
Respondents viewed this question as asking about material support for the new baby. Most
respondents answered ‘always’ and explained that they, lived in the same household as the baby’s
father, did “everything jointly,” or otherwise share parenting responsibilities. One respondent who was
the primary ‘breadwinner’ selected ‘always’ because her husband does all the cooking.
A few Spanish-speaking respondents selected ‘sometimes,’ ‘often,’ or ‘never.’ One respondent who
selected ‘often’ explained that she was the only working parent. Another respondent who did not live
with the baby’s father selected ‘sometimes,’ and explained that he was a good provider, giving her $50
per week to care for the children. There were too few cases of separated parents in this sample to
determine if respondents in households separate from the baby’s father answer based on amount of
money provided or frequency of the support given.
Spanish-language consideration
The Spanish language version of this question could be interpreted slightly differently from the English
version and with C19 (‘When your new baby’s father, or other parent, is with the baby, how often do
they hug, kiss, hold, or play with the baby?’) which refer to the baby’s father or other parent. Here, the
question refers to ‘husband or wife’ (esposo(a)).
Changes to the question wording
The wording of this question was not changed during data collection.

Support for the respondent
C22: Since your new baby was born, how often does your spouse or partner provide you with
encouragement and emotional support?
□ Always
□ Often
□ Sometimes
□ Rarely
□ Never
□ I currently do not have a spouse or partner

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C22: Desde que nació su nuevo bebé, ¿con qué frecuencia su esposo(a) o pareja le da ánimo a usted y
le brinda apoyo emocional?
□ Siempre
□ Frecuentemente
□ A veces
□ Rara vez
□ Nunca
□ No tengo esposo(a) o pareja
Respondents viewed this question in a few ways. Some considered this question to be asking about how
much their husband or partner cares for them. As one respondent who answered ‘always’ said, “Always
– he does really well caring for me.” Others however, viewed the question as asking about how often
their husband or partner specifically made an effort to cheer them up or let them take a break. For
example, one respondent selected ‘Sometimes’ and explained, that her husband always helps her and
supports her if she lets him know that she is tired. “I only say sometimes because unless I'm down he is
one of those guys who says ‘she's got it.'”
Occurrence of error
One Spanish-language respondent who was a single mother selected ‘Never’ rather than ‘I currently do
not have a spouse or partner.’ This may be a case of order effects, as the prior two questions asked
about the baby’s father and the support he does or does not give to the new baby.
Changes to the question wording
The wording of this question was not changed during data collection.

Firearms

C23:Are any firearms now kept in or around your home?
□ No (Go to the End)
□ Yes
□ Don’t Know/Not Sure (Go to the End)
C23: Actualmente, ¿tiene armas de fuego guardadas dentro o alrededor de su hogar?
□ No (Pase al final)
□ Sí
□ No sé / No estoy segura (Pase al final)
Respondents understood that this question was asking about firearms currently at their home. Those
who previously had a weapon in their home, but did not any longer, correctly answered ‘no.’ Only two
respondents selected ‘yes,’ and both had firearms for safety purposes. As one respondent said, “Yeah,
my husband bought a shotgun the week after my daughter was born […He is] Very paranoid now being a
‘girl-dad.’”
Changes to the question wording
88

The wording of this question was not changed during data collection.
C24: Are any of these firearms now loaded?
□ No (Go to the End)
□ Yes
□ Don’t Know/Not Sure (Go to the End)
C24: ¿Alguna de estas armas de fuego está cargada actualmente?
□ No (Pase al final)
□ Sí
□ No sé / No estoy segura (Pase al final)
This question is intended for respondents who answered ‘yes’ to Question C23 (‘Are any firearms now
kept in or around your home?’) Two respondents were screened into this question based on their
responses to C23. One selected ‘yes’ and one selected ‘no.’ The respondent who answered ‘yes’ said, “I
am not sure. I would assume just in case. He carries like a bag around with him. Not of guns, but there
is one in there just for his own protection when he’s out and about. So, I would assume at least one of
them is ready to go if needed.” She assumed ‘yes’ because her grandfather, who owns the firearms,
specifically has them for home safety. The respondent who answered ‘no’ was confident that her
husband’s shotgun was locked and unloaded.
Changes to the question wording
The wording of this question was not changed during data collection.
C25: Are any of these loaded firearms also unlocked? Unlocked meaning you do not need a key,
combination, or hand/fingerprint to get the gun or to fire it. Do not count a safety as a lock.
□ No
□ Yes
□ Don’t Know/Not Sure
C25: ¿Alguna de estas armas de fuego que están cargadas también están desbloqueadas? Por
“desbloqueada” queremos decir que no necesita una llave, combinación o una huella digital o de mano
para obtener el arma o dispararla. Esto no cuenta el seguro que tienen las armas que no permiten que la
dispare.
□ No
□ Sí
This question was intended for respondents who answered ‘yes’ to question C24 (‘Are any of these
firearms now loaded?’) Only one respondent was screened into this question, and she selected ‘No.’ In
her case, her grandfather owned the firearms in her home. While she assumed some of them were
currently loaded for home protection purposes, she said that they were locked.
Changes to the question wording
The wording of this question was not changed during data collection.
89

References
Committee on Measuring Sex, Gender Identity, and Sexual Orientation, Committee on National
Statistics, Division of Behavioral and Social Sciences and Education, et al. (2022). Measuring Sex, Gender
Identity, and Sexual Orientation. Washington, DC: National Academies Press.
Milesi, C., Morrison, H., Bautista, R., & Stern, M. (2017). Testing Alternative Response Options for
Spanish Translations of Sexual Identity Items for National Surveys. NORC at the University of Chicago.
Chicago, IL. https://wwwn.cdc.gov/QBank/Report.aspx?1177
Miller, K., Willson, S., Chepp, V., & Padilla, J.-L. (Eds.). (2014). Cognitive Interviewing Methodology.
Hoboken, NJ: John Wiley & Sons.
Miller, K., Ryan, J. M. . (2011). Design, Development and Testing of the NHIS Sexual Identity Question.
National Center for Health Statistics. Hyattsville, MD. https://wwwn.cdc.gov/QBank/Report.aspx?1087
Miller, K., & Willson, S.,2022, Development and Evaluation of a Single, Non-Binary Gender Question for
Population-Based Federal Health Surveys, Hyattsville, MD: National Center for Health Statistics - QDRL.
https://wwwn.cdc.gov/QBank/Report.aspx?1235
Vedam, S., Stoll, K., Rubashkin, N., Martin, K., Miller-Vedam, Z., Hayes-Klein, H., Jolicoeur, G., & the
CCinBC Steering Council. (2017). The Mothers on Respect (MOR) index: measuring quality, safety, and
human rights in childbirth, SSM Population Health, Vol. 3 (Pp. 201-210).
https://doi.org/10.1016/j.ssmph.2017.01.005

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