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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Client ID
This survey was offered by your:
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Name of Your Provider
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This survey is
1. What is your age?
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2. What was your sex assigned at birth?
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3. What is your gender identity?
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4. What is your race?
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5. Including yourself, how many people currently live in your household?
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6. What is your annual household income?
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7. What is your current employment status?
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8. Highest level of school you attended:
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9. What is your Relationship status?
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Childbirth Experience: 1. Where did you deliver?
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2. What type of birth did you have?
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3. How many times have you given birth (including this one)?
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4. What type of birth did you have previously? Select all that apply.
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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.
6. Each staff member explained to me what their job was the first time I met them.
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7. The staff/birth attendant spoke to me in a way I could easily understand
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8. The staff/birth attendant made me feel I could talk about anything (concerns/fears/thoughts,etc.) with them.
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9. I felt the staff/birth attendant protected my privacy while I was in labor
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10. I felt the staff/birth attendant protected my privacy after giving birth.
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11. I felt the staff/birth attendant protected my privacy after giving birth.
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12. I felt the staff/birth attendance treated me respectfully whille I was in labor.
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13. I felt the staff/birth attendant treated my respectfully while giving birth.
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14. I felt the staff/birth attendant treated me with respect after giving birth.
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15. Were you ever shouted, screamed, or cursed at by facility staff or a birth attendance?
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16. Were you ever slapped, pinched, or physically mistreated by facility staff or a birth attendant?
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17. As far as I could tell, staff treated me the same as other birthing persons at the facility, without discrimination.
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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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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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20. During labor I was able to have a person/persons of my choice be with me
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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.
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22. I was given medicine (an epidural or another drug) for pain relief.
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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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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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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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26. I felt that the staff were working together to help me.
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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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28. During my prenatal care or after I delivered, I was given information and advice about family planning.
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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.
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30. Although I or my newborn required an emergency transfer, I felt welcomed by the staff after my transfer.
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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.
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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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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33. The staff/my birth attendant helped me to breastfeed my baby as soon as possible after the birth.
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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.)
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35. My baby was with me or my family all of the time, not moved to another room.
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36. My baby was fed only breast milk
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37. Before the birth, I expected my care during childbirth to be:
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38. Now I feel that my care was:
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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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40. Did you use any services to support your mental well-being during pregnancy (select all)?
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41. If you encountered challenges accessing services for your mental wellbeing during pregnancy, what were they?
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Mental Wellbeing: 1. Have you been diagnosed by a healthcare professional with any of the following? Check all that apply.
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Over the PAST TWO WEEKS, how often have you been bothered by any of the following problems?
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2. Little interest or pleasure in doing things
3. Feeling down, depressed, or hopeless?
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4. Trouble falling or staying asleep, or sleeping too much?
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5. Feeling tired or having little energy?
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6. Poor appetite or overeating?
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7. Feeling bad about yourself — or that you are a failure or have let yourself or your family down?
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8. Trouble concentrating on things, such as reading the newspaper or watching television?
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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?
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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?
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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.
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1. I have been able to laugh and see the funny side of things
2. I have looked forward with enjoyment to things
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3. I have been anxious or worried for no apparent reason
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4. I have blamed myself when things went wrong
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5. I have felt scared or panicky for no apparent reason
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6. I feel overwhelmed and that I cannot keep up with things
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7. I have felt sad or miserable
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8. I have been so unhappy that I have been crying
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9. The thought of harming myself has occurred to me
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10. How are you interested in being referred to services to support your mental well-being during pregnancy or postpartum?
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