Consumer Childbirth Survey

CHILDBIRTH SURVEY page 1 Please write explanatory notes in margins if needed. A. GENERAL INFORMATION 1. Age: 1a. ❑ 19 years or less

1b. ❑ 20-29

1c. ❑ 30-39

1d. ❑ 40 or more

2. Education: 2a. ❑ less than high school 2b. ❑ high school or equivalent 2c. ❑ some college 2d. ❑ 2 yr. College/ technical school 2e. ❑ 4 year college 2f. ❑ more than 4 year college 3. Employment: 3a. ❑ employed full time

4. Family Income:

3b. ❑ employed part time

4a. ❑ Less than $10,000 4b. ❑ $10,000-$24,999 4c. ❑ $25,000-$39,999

5. What do you know about nurse-midwives? 5a. ❑ nothing 5b. ❑ have heard of nurse-midwives 5c. ❑ know someone who went to a nurse-midwife 5d. ❑ know a nurse –midwife 5e. ❑ went to a nurse-midwife for care 5f. ❑ other

3c. ❑ not employed

4d. ❑ $40,000-$55,000 4e. ❑ more than $55,000

6. What do you know about birth centers? 6a. ❑ nothing 6b. ❑ have heard of birth centers 6c. ❑ know someone who went to a birth center 6d. ❑ went to a birth center for care 6e. ❑ other

PLEASE HOLD CONTROL AND CLICK HERE TO ACCESS SHORT VIDEO CLIPS. YOU MAY WATCH ONE, TWO, OR ALL THREE IF YOU WOULD LIKE. COMMENTS ON VIDEO:

7. Do you think nurse-midwives are a good idea for your community? 7a. ❑ yes 7b. ❑ no 7c. ❑ maybe 7d. ❑ don’t know 8. Do you think a birth center is a good idea for your community? 8a. ❑ yes 8b. ❑ no 8c. ❑ maybe 8d. ❑ don’t know

CHILDBIRTH SURVEY page 2 Check NONE if no births. Complete one column for each birth. 9. BIRTH EXPERIENCE(S)

NONE

1st

9a. Where did you give birth? 9a1. regular hospital 9a2. hospital birth room 9a3. birth center apart from hospital 9a4. home 9a5. other 9b. Who provided your care? 9b1. obstetrician 9b2. nurse-midwife 9b3. family doctor 9b4. lay midwife 9b5. other 9c. Did you take classes? 9c1. yes 9c2. no 9d. What kind of birth did you have? 9d1. natural childbirth 9d2. with medication (kind: ) 9d3. with anesthesia 9d4. with forceps 9d5. with episiotomy 9d6. cesarean section (reason:

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9d7. VBAC (Vaginal Birth After Cesarean) 9e. How did you feed your baby? 9e1. formula 9e2. breast (# months: ) 9e3. both 9f. How did you feel about your care? 9f1. great care 9f2. good care 9f3. could have been better care

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3rd

4th

5th

6th

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9f4. dissatisfied with care 9g. Comments

CHILDBIRTH SURVEY page 3 B. FUTURE BIRTH EXPERIENCE PREFERENCES If you were going to have a baby now… 10. Who would you want to be with you? (check all that apply) 10a. ❑ my husband/partner 10b. ❑ my mother 10c. ❑ my sister 10d. ❑ my friend 10e. ❑ other 11. Who would you want to take care of you? (check one) 11a. ❑ a nurse-midwife working with an obstetrician on call if I had problems 11b. ❑ an obstetrician 11c. ❑ my family doctor 11d. ❑ other 12. Where would you like to labor and birth? (check one) 12a. ❑ in a regular hospital unit 12b. ❑ in a birth room in a hospital 12c. ❑ in a birth center with the hospital available if I needed it 12d. ❑ at home with hospital available if I needed it 13. Birth centers may offer services other than routine prenatal, birth and postpartum care. Check the 10 services that would be most important to you. 13a. ❑ preparation for childbirth 13b. ❑ preparation for breastfeeding 13c. ❑ nutrition counseling 13d. ❑ help to stop smoking 13e. ❑ instruction in self care 13f. ❑ instruction in baby care 13g. ❑ a library of books and video tapes at the care provider’s office 13h. ❑ more time to talk with my doctor or midwife during prenatal visits 13i. ❑ A care provider with me all the time in active labor 13j. ❑ have my baby with me (not separate unless necessary) 13k. ❑ go home as soon after birth as possible 13l. ❑ help at home 3-4 hours a day for 3-4 days (for childcare, shopping, meal preparation, etc.) 13m. ❑ a home visit by the nurse or nurse-midwife the first or second day home 13n. ❑ my husband/partner to have paid leave from work to be at home for 1-2 weeks 13o. ❑ telephone calls from my nurse-midwife/doctor for first days at home 13p. ❑ an office visit with my nurse-midwife/doctor at 1 week after birth 13q. ❑ support/counseling for breastfeeding 13r. ❑ parent support group meetings during the first year 13s. ❑ lower cost for total care 13t. ❑ other

Thank you!