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The questions below are specifically asking about your current pregnancy. For the purposes of this questionnaire, placental accreta spectrum (PAS) includes placenta accreta, increta, and percreta.
Please enter the best email address to contact you:
* must provide value
What is your country of residence during this pregnancy?
United States
Other
If living in the United States, which state is your primary residence for this pregnancy?
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Other
If other, please specify here:
If living outside of the United States, please list your current country of residence:
How would you describe the area where you live?
Urban (an area that is a highly populated city) Suburban (an area that is typically on outskirts/adjacent to a city, with medium population density) Rural (an area that is open, spread out, with smaller population density) Other
If you answered "other", please describe the area where you live:
Please answer the following questions about any prior pregnancies.
Is this your first pregnancy?
Yes
No
In summary, how many of the following have you had? (Please enter a number).
Please enter your total number of pregnancies
(including this pregnancy and including any prior live births, miscarriages, abortions, or other pregnancy losses)
Please enter your number of currently living children (that you gave birth to)
Please enter your total number of prior live, full-term births
Full term is greater than 37 weeks pregnant, or within 3 weeks of your due date
Please enter your total number of prior live, premature births
Premature birth is a birth before the 37th week of pregnancy, or more than 3 weeks before your due date
Please list the total number of prior vaginal deliveries you have had
Please list the total number of prior cesarean deliveries you have had
Around the time of any prior cesarean delivery, were you ever told about the increased risk of abnormal placentas in future pregnancies (ie, placenta previa and/or placenta accreta spectrum)?
Yes
No
Please enter your total number of prior miscarriages
A miscarriage is a spontaneous pregnancy loss before 20 weeks of pregnancy
Please enter your total number of surgical abortions
A surgical abortion is when a pregnancy is ended with a dilation and curettage (D&C) or a dilation and evacuation (D&E) procedure
Please enter your total number of medical abortions
A medical abortion is when a pregnancy is ended with a medication
Please enter your total number of prior stillbirths
A stillbirth is the birth of a baby with no signs of life at or after the 20th week of pregnancy
Were you diagnosed with any of the following during or after any of your prior pregnancies?
If other, please specify:
Was there concern for placenta accreta spectrum (PAS, or when the placenta abnormally grows into the uterus or beyond) in any of your prior pregnancies?
Yes
No
Uncertain
excluding current pregnancy
If there was concern for placenta accreta spectrum, was this diagnosis confirmed after delivery of that pregnancy?
Yes
No
Uncertain
Did you personally provide breastmilk (ie, breastfeed at breast and/or breastpump and bottlefeed self-produced breastmilk) for your newborn following any of your prior deliveries?
Yes
No
If you did not breastfeed / breastpump following prior deliveries, what were the reasons for not doing so? Please check all that apply.
If other, please specify here:
Remembering your prior deliveries, what was the longest length of time that you breastfed/breastpumped for?
Less than a few hours While I was in the hospital Less than one month after coming home 6 weeks 3 months 1 year Over 1 year Other
If other, please specify here:
Please answer the following questions about your medical history.
Have you ever been diagnosed with hypertension (high blood pressure) that is not related to pregnancy (ie, chronic essential hypertension)?
Yes
No
Have you ever been diagnosed with diabetes that is not related to pregnancy (ie, either Type 1 or Type 2 DM)?
Yes
No
Have you ever had surgery of your uterus when you were not pregnant (for example, hysteroscopy for removal of a fibroid or uterine septum)?
Yes
No
Please specify what type of uterine surgery:
Did you utilize a fertility assistance method to achieve this pregnancy (such as a fertility medication like clomiphene or letrozole, or intrauterine insemination or in vitro fertilization)?
Yes
No
If you did utilize a fertility assistance method for this pregnancy, was it in vitro fertilization (IVF)?
Yes
No
If you did utilize IVF, was it a frozen embryo transfer?
Yes
No
Have you ever been diagnosed with depression that is not related to pregnancy?
Yes
No
Are you currently taking medication for treatment of your depression?
Yes
No
Are you currently engaged in therapy for treatment of your depression?
Yes
No
Have you ever been diagnosed with anxiety that is not related to pregnancy?
Yes
No
Are you currently taking medication for treatment of your anxiety?
Yes
No
Are you currently engaged in therapy for treatment of your anxiety?
Yes
No
Is there anything else about your medical history that you would like to share? (Free text)
Has your current pregnancy been complicated by any of the following issues thus far? (Please check all that apply)
If other, please specify:
What type of medical professional are you following with this pregnancy?
Generalist OBGYN doctor High risk OBGYN specialist doctor (Maternal fetal medicine specialist) Midwife (CNM) Family medicine doctor Other
If other, please specify here:
Have you been told that this pregnancy may be at an increased risk of being complicated by placenta accreta spectrum (PAS)?
Yes
No
How far along were you in this pregnancy at the time you were informed about the increased suspicion or clinical concern for placenta accreta spectrum diagnosis?
First trimester (before 13 weeks)
Second trimester (13 weeks through 26 weeks)
Third trimester (after 27 weeks)
Per your understanding, why is there concern for placenta accreta spectrum for this pregnancy? Please check all that apply.
If other, please explain here:
Has your doctor recommended a particular gestational age for delivery at this point in your pregnancy?
Yes
No
If so, what gestational age has she/he recommended for delivery?
Less than 34 weeks 34 weeks 35 weeks 36 weeks Greater than 37 weeks Other
If you answered "other" for gestational age recommended for delivery by your provider, please further specify here:
Please answer to nearest week
At this point in your pregnancy, has your doctor recommended how your pregnancy should be delivered? (Ie, has your doctor recommended a cesarean delivery or vaginal delivery?)
Yes
No
If so, what is the most likely mode of delivery that your doctor has recommended?
Likely vaginal delivery
Likely cesarean delivery without anticipated cesarean hysterectomy (ie, no planned removal of uterus at time of delivery)
Likely cesarean delivery WITH cesarean hysterectomy (ie, likely removal of the uterus at time of delivery)
Other
If other for anticipated mode of delivery, please specify here:
The option "
Have you been offered any of the following additional support services thus far in your pregnancy? Please check all that apply.
If other, please specify here:
The option "
What support services have you utilized thus far in your pregnancy? (Please check all that apply).
If other, please specify here:
The option "
Has your doctor talked to you about the potential RISK of any of the following occurring with regards to your pregnancy, delivery, or recovery? Please check all that apply.
If so, have you been offered any additional support to help through this period of initial postpartum separation from your newborn, given the risk of NICU and/or ICU admission?
Yes
No
What additional supports have you been offered to help with the risk of being separated from your newborn following delivery? Please check all that apply.
If other support, please specify here:
Is there anything else about the counseling and/or support services you have heard about or utilized this pregnancy that you would like to tell us about?
Are you planning on skin-to-skin if possible following delivery (ie, when your new baby is placed on your bare chest right after delivery)?
Yes
No
Undecided
I have not heard of this
Are you planning on rooming in (ie, a practice where mothers and infants stay together in the same room for 24 hours a day from the time newborns arrive until discharge from the hospital) if possible, following delivery?
Yes
No
Undecided
I have not heard of this
How do you hope to feed your newborn? Please check all that apply.
If other, please specify here:
How important is it to you to breastfeed or provide breastmilk to your baby?
Very important Somewhat important Neutral Slightly important Not at all important
How long are you hoping to breastfeed / pump / provide breastmilk for following delivery?
Less than a few hours While I am in the hospital Less than one month after coming home 6 weeks 3 months 1 year Over 1 year Uncertain at this time Other
If other, please specify here:
If you are not planning on breastfeeding / breastpumping following this delivery, why not? Please check all that apply.
If other, please specify here:
The option "
At this point in your pregnancy, have any of the following occurred to help prepare you for feeding your baby after delivery? Please check all that apply.
If other, please specify here:
If working, do you anticipate that your length of maternity leave will impact whether or not you meet your breastfeeding goals?
Yes
No
Not applicable
If there is anything additional you wish to share regarding your initial newborn feeding or bonding goals, please do so here:
As you are pregnant, we would like to know how you are feeling. Please check the answer that comes closest to how you have felt IN THE PAST 7 DAYS, not just how you feel today.
1. I have blamed myself unnecessarily when things went wrong
Yes, most of the time
Yes, some of the time
Not very often
No, never
2. I have been anxious or worried for no good reason
Yes, very often
Yes, sometimes
Hardly ever
No, not at all
3. I have felt scared or panicky for no very good reason
Yes, quite a lot
Yes, sometimes
No, not much
No, not at all
Over the last two weeks, how often were you bothered by the following problems?
Please respond to the following items about yourself and the baby you are expecting. There are no right or wrong answers. Your first impression is usually the best reflection of your feelings. Make sure you only mark one answer per statement.
Given how emotionally and physically challenging pregnancy can be, have you ever felt resentment toward this pregnancy?
Yes
No
Prefer not to answer
If there is anything additional about your current state of bonding with this baby that you wish to share, please do so here:
Please enter your date of birth:
Today M-D-Y
What is your estimated due date for this pregnancy?
Today M-D-Y
How old will you be at your anticipated delivery date? (in years)
What best describes your race? Please check all that apply.
If other, please specify here:
Please further specify here. Check all that apply.
If other, please specify here:
Please further specify here. Check all that apply.
If other, please specify here:
Please further specify here. Check all that apply.
If other, please specify here:
What gender do you identify as?
Male Female Transgender Non-binary Prefer not to answer Other
If other, please further specify here:
What best describes your partnership status for this pregnancy at this point in time? (Select one)
Married Not married, but living with a partner Not married, not living with a partner, but in a relationship Never married, not living with a partner, not in a relationship Divorced Separated Widowed Other:
If other, please describe here:
What best describes the highest grade or year of school you have completed at the current time of your pregnancy?
Never attended school or only attended kindergarten Grades 1 through 8 (elementary/middle school) Grades 9 through 11 (some high school/secondary school, no diploma) Grade 12 or GED (high school graduate, diploma or equivalent) College 1 year to 3 years (some college, Associate degree, or trade/technical/vocational school) College 4 years or more (college graduate, Bachelor's degree) Completed some postgraduate education beyond college Completed a Master's degree Completed a Ph.D, law (J.D.) or medical (M.D./ D.O.) degree or equivalent Prefer not to answer Other
If other, please further specify here:
During your current pregnancy, what is the best description of your employment status?
Work full-time Work part-time Not currently working, but looking for a job Not currently working and not looking for a job Not currently working and a student Full-time homemaker A member of the Armed Forces Not currently working and retired Not currently working due to disability or inability to work Prefer not to say Other
If other, please specify here:
If you are currently working full or part time, what is your industry field?
Agriculture Utilities Finance Entertainment Education Health care Information services Data processing Food services Hotel services Legal services Publishing Military Prefer not to say Other
If other, please specify here:
For patients in the United States - which best describes your total combined household income in the past year?
$0 - $9,999 $10,000 - $19,999 $20,000 - $29,999 $30,000 - $39,999 $40,000 - $49,999 $50,000 - $59,999 $60,000 - $69,999 $70,000 - $79,999 $80,000 - $89,999 $90,000 - $90,999 $100,000 - $149,999 $150,000 - $199,999 $200,000 or more per year Prefer not to answer Other Not applicable (ie, live outside the US)
If other, please further specify here:
For participants living outside of the United States - which best describes your total combined household income in the past year? Please consider your income in euros or your country's equivalent currency.
€0 - €9,999 €10,000 - €19,999 €20,000 - €29,999 €30,000 - €39,999 €40,000 - €49,999 €50,000 - €59,999 €60,000 - €69,999 €70,000 - €79,999 €80,000 - €89,999 €90,000 - €90,999 €100,000 - €149,999 €150,000 - €199,999 €200,000 or more per year Prefer not to answer Other Not applicable (I live in the United States)
If other, please further specify here:
What is your current identified religion, if any? Please check all that apply.
If other, please specify here:
What is your preferred language for speaking/reading?
English Arabic Burmese Cambodian Cantonese Cape Verdean Creole French Greek Hmong Haitian-Creole Italian Korean Mandarin Portuguese Russian Somali Spanish Toishanese Vietnamese Prefer not to answer Other
If other, please further specify here:
What is the best description of your current insurance status?
Private, employment-based Private, direct-purchase Military health insurance Public (Medicare, Medicaid, VA, other state/national public insurance) Indian Health Service No insurance Prefer not to answer Other
If other, please further specify here:
What is the best description of where you live at this time in your pregnancy?
Mobile home or trailer One-family house, detached One-family house attached to others A building for two families A building for three or more families No stable housing / homeless Prefer not to answer Other
If other, please further specify here:
At the current time of your pregnancy, how difficult is it to provide food, clothing, heat, rent/mortgage payments, and things for yourself/ your dependents?
Not difficult
Somewhat difficult
Very difficult
Extremely difficult
Prefer not to answer
Do you utilize publicly-available resources to help support yourself or your family at this time?
Yes
No
What resources do you use at this time? Please check all that apply.
If other, please further specify here:
Thank you so very much for taking the time to share your answers with us. We look forward to hearing more about your experience following your delivery on the postpartum survey that will be automatically sent to your provided email. We so appreciate the time and insight you are offering by participating in this survey to help optimize future pregnancy and postpartum care.
