This survey was developed by a research team at the International Childbirth Initiative. You are invited to anonymously share your responses (with your personal information excluded) with the researchers to improve the quality of mental health screening. If you agree to share your responses, you may change your mind and opt-out at any time. Your participation in the research would enable us to strengthen support for mental health care for birthing persons across the U.S. and globally. Do you agree to have your responses, excluding personally identifying information, with the research team?*
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Yes
No
I don't know
Client ID
This survey was offered by your:
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Doula
Midwife
Lactation Consultant
Other
Name of Your Provider
*
This survey is
Self-completed
Completed with the provider present
1. What is your age?
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2. What was your sex assigned at birth?
*
Female
Male
Intersex
Prefer not to say
3. What is your gender identity?
*
Woman
Man
Transgender
Non-binary/Non-conforming
Other
Prefer not to say
4. What is your race?
*
Non-Hispanic White
Non-Hispanic Black
of African Descent
Latino or Hispanic
Asian
Native American
Native Hawaiian or Pacific Islander
Middle Eastern/North African (MENA)
Other
Prefer not to say
5. Including yourself, how many people currently live in your household?
*
6. What is your annual household income?
*
Less than $15,000
$15,000-$25,000
$25,000-$50,000
$50,000- $100,000
$100,000- $200,000
More than $200,000
Prefer not to say
7. What is your current employment status?
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Employed Full-Time
Employed Part-Time
Seeking opportunities
Retired
Not currently working
Prefer not to say
8. Highest level of school you attended:
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None
Primary
Secondary
Higher than secondary
9. What is your Relationship status?
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Single
In a relationship (separate households)
Living with Partner
Married
Widowed
Divorced
Separated
Prefer not to say
Childbirth Experience: 1. Where did you deliver?
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Hospital
Birth Center
At home
Other
2. What type of birth did you have?
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Vaginal
Assistal vaginal (forceps or vacuum)
Caesarean
I don't know
3. How many times have you given birth (including this one)?
*
4. What type of birth did you have previously? Select all that apply.
*
Vaginal
Assisted vaginal (forceps or vacuum)
Caesarean
I don't know
For the following questions, please reflect on your most recent birth experience:
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5. Each staff member introduced themselves to me the first time I met them.
No, none of them did
Few of them did
Some of them did
Most of them did
All of them did
6. Each staff member explained to me what their job was the first time I met them.
*
No, none of them did
Few of them did
Some of them did
Most of them did
All of them did
7. The staff/birth attendant spoke to me in a way I could easily understand
*
No, none of them did
Few of them did
Some of them did
Most of them did
All of them did
8. The staff/birth attendant made me feel I could talk about anything (concerns/fears/thoughts,etc.) with them.
*
No, none of them did
Few of them did
Some of them did
Most of them did
All of them did
9. I felt the staff/birth attendant protected my privacy while I was in labor
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Never
Rarely
Sometimes
Most of the time
Always
I don't know/not applicable
10. I felt the staff/birth attendant protected my privacy after giving birth.
*
Never
Rarely
Sometimes
Most of the time
Always
I don't know/not applicable
11. I felt the staff/birth attendant protected my privacy after giving birth.
*
Never
Rarely
Sometimes
Most of the time
Always
I don't know/not applicable
12. I felt the staff/birth attendance treated me respectfully whille I was in labor.
*
Never
Rarely
Sometimes
Most of the time
Always
I don't know/not applicable
Radio
Option 1
Option 2
13. I felt the staff/birth attendant treated my respectfully while giving birth.
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Never
Rarely
Sometimes
Most of the time
Always
I don't know/not applicable
14. I felt the staff/birth attendant treated me with respect after giving birth.
*
Never
Rarely
Sometimes
Most of the time
Always
I don't know/not applicable
15. Were you ever shouted, screamed, or cursed at by facility staff or a birth attendance?
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Never
Rarely
Sometimes
Most of the time
Always
I don't know/not applicable
16. Were you ever slapped, pinched, or physically mistreated by facility staff or a birth attendant?
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Never
Rarely
Sometimes
Most of the time
Always
I don't know/not applicable
17. As far as I could tell, staff treated me the same as other birthing persons at the facility, without discrimination.
*
Never
Rarely
Sometimes
Most of the time
Always
18. I believe that the staff/my birth attendant really care about what matters to me and my family (my beliefs and choices).
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No, none of them
Yes, a few of them
Yes, some of them
Yes, most of them
Yes, all of them
I don't know, not applicable
19. The staff/birth attendant included me in the process of making decisions about my care and my baby's care, and provided me with the information to make decisions.
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Yes, I was included in decisions and had enough information
Yes, I was included in decisions but did not have enough information
Sometimes I was included
No, I was not included in most decisions or informed
I don't know /not applicable
20. During labor I was able to have a person/persons of my choice be with me
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Yes
No
I don't know
21. During labor, the staff encourage me to use comfort measures, other than drugs, for pain and comfort, like changing positions, massage, warm water, and others.
*
Yes, and I used them
Yes, but I did not use them
No, none of these were suggested
I don't know/ not applicable
22. I was given medicine (an epidural or another drug) for pain relief.
*
No, because I did not want any
No, even though I wanted it
No, because no medicines/epidual were avaiable
Yes, but I received it too late
Yes, when I wanted it
I don't know/not applicable
23. The staff/birth attendant encouraged me to have confidence in my own ability to have a safe and positive labour and birth.
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No, none of them did
Few of them did
Some of them did
Most of the did
I don't know/not applicable
24. Did you or your baby have any treatments or procedures that you did not want or have and did not agree to?
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Yes
No
I don't know
25. I felt that the staff (or my birth attendant) had what they needed to be happy in their work, and to do their jobs well.
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No, none of them
Yes, a few of them
Yes, some of them
Yes, most of them
Yes, all of them
I don't know/ not applicable
26. I felt that the staff were working together to help me.
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Never
Rarely
Sometimes
Most of the time
Always
I don't know/not aplicable
27. During my prenatal care or after I delivered, I was given information and advice about caring for my new baby.
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Yes
No
No, because I didn't want any
I don't know
28. During my prenatal care or after I delivered, I was given information and advice about family planning.
*
Yes
No
No, because I didn't want any
I don't know
29. During the birth, I felt that any procedures or emergency care my baby or I needed would be provided on time and by skilled staff.
*
Yes
No
I don't know
30. Although I or my newborn required an emergency transfer, I felt welcomed by the staff after my transfer.
*
Question 30 is about when birthing persons or their babies are transferred to a facility other than where they intended to deliver. If this did not happen to you, check the first box and continue to question 29.
Not applicable, I was not transferred to another facility
Yes, I felt welcome
No, I did not feel welcome
I don't know
31. During, my prenatal care or after I delivered, I was given information and advice about where to go for follow-up care (immunizations and check-ups).
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Yes, for both me and my baby
Yes, but only for me and not my baby
Yes, but only for my baby and not for me
No, neither for me, nor for my baby
I don't know
32. Before I left the facility (or before the birth attendance left), I was given information and advice about danger signs for me and my baby.
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Yes, for both me and my baby
Yes, but only for me and not my baby
Yes, but only for my baby and not for me
I don't know
33. The staff/my birth attendant helped me to breastfeed my baby as soon as possible after the birth.
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No, because I did not breastfeed
No, because I did not need help, I knew what to do
No, even though I needed help
Yes, I was helped, but not enough
Yes, I received the help I needed
I don't know
34. After the birth, the staff/birth attendant ensured that I was able to have my baby with me for undisturbed skin-to-skin contact. (Skin-to-skin contact means that directly after birth, the baby is dried off and placed on the mother's chest and left undisturbed.)
*
Yes
No
I don't know
35. My baby was with me or my family all of the time, not moved to another room.
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No, because my baby was sick and was sent to the children's unit
No, my baby was not with me/us most of the time (not at all)
No, I didn't want my baby with me
Yes, my baby was with me/us most of the time
I don't know
36. My baby was fed only breast milk
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Yes
No, because my baby had complications and needed supplementary feeding
No, because I wanted my baby to have supplementary feeding
No, even though I did not my baby to have supplementary feeding
I don't know
37. Before the birth, I expected my care during childbirth to be:
*
Very bad
Poor
Neutral
Good
Very good
I don't know
38. Now I feel that my care was:
*
Very bad
Poor
Neutral
Good
Very good
I don't know
39. Thinking of your friends and family, if any of them were pregnant, would you advise them to deliver at this facility/with this birth attendant?
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Yes
Maybe
No
I don't know
40. Did you use any services to support your mental well-being during pregnancy (select all)?
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Individual therapist
Support group
Meditation
Holistic care
Information about activities I can do independently to support my mental health
No, I was not/am not intereseted in additional support
41. If you encountered challenges accessing services for your mental wellbeing during pregnancy, what were they?
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Too expensive/no insurance coverage
Inconvenient times
Difficult to schedule
Not comfortbale with available providers or support groups
Location was too far/ not accessible
My schedule was too busy
Other
Mental Wellbeing: 1. Have you been diagnosed by a healthcare professional with any of the following? Check all that apply.
*
Anxiety
Depression
PTSD
Other
None of the above
Prefer not to answer
Over the PAST TWO WEEKS, how often have you been bothered by any of the following problems?
*
2. Little interest or pleasure in doing things
Not at all
Several days
More than half the days
Nearly every day
3. Feeling down, depressed, or hopeless?
*
Not at all
Several days
More than half the days
Nearly every day
4. Trouble falling or staying asleep, or sleeping too much?
*
Not at all
Several days
More than half the days
Nearly every day
5. Feeling tired or having little energy?
*
Not at all
Several days
More than half the days
Nearly every day
6. Poor appetite or overeating?
*
Not at all
Several days
More than half the days
Nearly everyday
7. Feeling bad about yourself β or that you are a failure or have let yourself or your family down?
*
Not at all
Several days
More than half the days
Nearly every day
8. Trouble concentrating on things, such as reading the newspaper or watching television?
*
Not at all
Several days
More than half of the days
Nearly every day
9. Moving or speaking so slowly that other people could have noticed? Or so fidgety or restless that you have been moving a lot more than usual?
*
Not at all
Several days
More than half of the days
Nearly every day
10. How difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?
*
Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult
For the following, please choose the answer that comes closest to how you have felt IN THE PAST 7 DAYS- not just how you feel today.
*
1. I have been able to laugh and see the funny side of things
Yes, as much as always
Not as much as usual
Definitely less than I used to
Not at all
2. I have looked forward with enjoyment to things
*
Yes, as much as always
Not as much as usual
Definitely less than I used to
Not at all
3. I have been anxious or worried for no apparent reason
*
Yes, most of the time
Yes, some of the time
Not very often
No, never
4. I have blamed myself when things went wrong
*
Yes, most of the time
Yes, some of the time
Not very often
No, never
5. I have felt scared or panicky for no apparent reason
*
Yes, most of the time
Yes, some of the time
Not very often
No, never
6. I feel overwhelmed and that I cannot keep up with things
*
Yes, most of the time
Yes, some of the time
Not very often
No, never
7. I have felt sad or miserable
*
Yes, most of the time
Yes, some of the time
Not, very often
No, never
8. I have been so unhappy that I have been crying
*
Yes, most of the time
Yes, some of the time
Not very often
No, never
9. The thought of harming myself has occurred to me
*
Yes, most of the time
Yes, some of the time
Not very often
No, never
10. How are you interested in being referred to services to support your mental well-being during pregnancy or postpartum?
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Individual therapist
Support group
Meditation
Holistic care
Information about activities I can do independently to support my mental health
No, I was not /am not interested in additional support