Pregnancy Risk Assessment Monitoring System (PRAMS)

Massachusetts PRAMS Phase 6 – 2009 Survey
Please mark your answers. Follow the directions included with the questions. If no directions are presented, check the box next to your answer or fill in the blanks. Because not all questions will apply to everyone, you may be asked to skip certain questions.

First, we would like to ask a few questions about you and the time before you got pregnant with your new baby.   

1.   During the 12 months before you got pregnant with your new baby, did you do any of the following things?  For each item, circle Y (Yes) if you did it or N (No) if you didn’t.  
	                                                                                                                                                    No     Yes
a.	I was dieting (changing my eating habits) in order to lose weight ………………………………..…….…N	Y
b.	I was exercising 3 or more days of the week……………………………………………………………….N	Y
c.	I was regularly taking prescription medicines …………………………..…………………………….…...N	Y
d.	I visited a doctor to be checked or treated for diabetes (high blood sugar)…………………………………N	Y 
e.	I visited a doctor to be checked or treated for high blood pressure…………………………………………N	Y
f.	I visited a doctor to be checked or treated for depression or anxiety……………………………………….N	Y
g.	I talked to a health care worker about my family medical history …   …….…………………………….N	Y
h.	I had my teeth cleaned by a dentist or dental hygienist……………………………………………..……  .N	Y

2.	During the month before you got pregnant with your new baby, were you covered by any of these types of health insurance plans? Check all that apply

Health insurance from a job (your job or the job of your husband, partner or parents)
Health insurance that you or someone else paid for (not from a job)
Medicaid (MassHealth)
TRICARE or other military health care
Commonwealth Care		
Other source => Please tell us
[BOX]
I did not have any health insurance 

3.	During the month before you got pregnant with your new baby, how many times a week did you take a multivitamin, a prenatal vitamin, or a folic acid vitamin? 

I didn’t take multivitamins, prenatal vitamins or folic acid vitamins at all
1 to 3 times a week
4 to 6 times a week
Every day of the week

4.	Just before you got pregnant with your new baby, how much did you weigh?

[BOX]  Pounds  OR  [BOX]  Kilos

5.	 How tall are you without shoes?

[BOX]  Feet  [BOX]  Inches
OR  [BOX]  Meters

6.	What is your date of birth?

[BOX]	[BOX]	19[BOX]	
Month	Day	Year	

7.	Would you say that, in general, your health is—

Excellent
Very good
Good
Fair
Poor

8.	Before you got pregnant with your new baby, were you ever told by a doctor, nurse or other health care worker that you had Type I or Type II diabetes?   This is not the same as gestational diabetes. 
No 
              Yes

9.	Before you got pregnant with your new baby, did you ever have any other babies who were born alive?  

No  º  Go to Question 13
Yes

10.	Did the baby born just before your new one weigh more than 5 pounds, 8 ounces (2.5 kilos) at birth?

No
Yes

11.	Was the baby just before your new one born early, more than 3 weeks before his or her due date?

No
Yes

12.	Before you had your new baby, did you ever have a baby by cesarean delivery (when a doctor cuts through the mother’s belly to bring out the baby)?

No  
Yes

The next questions are about the time when you got pregnant with your new baby. 

13.	Thinking back to just before you got pregnant with your new baby, how did you feel about becoming pregnant? Check one answer

I wanted to be pregnant sooner
I wanted to be pregnant later
I wanted to be pregnant then
I didn’t want to be pregnant then or at any time in the future

14.	When you got pregnant with your new baby, were you trying to get pregnant?

No  º  Go to Question 15
Yes  º  Go to Question 17

15.	When you got pregnant with your new baby, were you or your husband or partner doing anything to keep from getting pregnant? (Some things people do to keep from getting pregnant include not having sex at certain times [natural family planning or rhythm] or withdrawal, and using birth control methods such as the pill, condoms, cervical ring, IUD, having their tubes tied, or their partner having a vasectomy.)

No
Yes  º  Go to Question 19

16.	What were your reasons or your husband’s or partner’s reasons for not doing anything to keep from getting pregnant? Check all that apply

I didn’t mind if I got pregnant
I thought I could not get pregnant at that time
I had side effects from the birth control method I was using
I had problems getting birth control when I needed it
I thought my husband or partner or I was sterile (could not get pregnant at all)
My husband or partner didn’t want to use anything
Other  º  Please tell us:
[BOX]

If you were not trying to get pregnant when you got pregnant with your new baby, go to Question 19.

17.	Did you take any fertility drugs or receive any medical procedures from a doctor, nurse, or other health care worker to help you get pregnant with your new baby? (This may include infertility treatments such as fertility-enhancing drugs or assisted reproductive technology.)

No  º  Go to Question 19
Yes

18.	Did you use any of the following fertility treatments during the month you got pregnant with your new baby? Check all that apply

Fertility-enhancing drugs prescribed by a doctor (fertility drugs include Clomid®, Serophene®, Pergonal®, or other drugs that stimulate ovulation) 
Artificial insemination or intrauterine insemination (treatments in which sperm, but NOT eggs, were collected and medically placed into a woman’s body)
Assisted reproductive technology (treatments in which BOTH a woman’s eggs and a man’s sperm were handled in the laboratory, such as in vitro fertilization [IVF], gamete intrafallopian transfer [GIFT], zygote intrafallopian transfer [ZIFT], intracytoplasmic sperm injection [ICSI], frozen embryo transfer, or donor embryo transfer)
I wasn’t using fertility treatments during the month that I got pregnant with my new baby
Other medical treatment  º  Please tell us:
[BOX]

The next questions are about the prenatal care you received during your most recent pregnancy. Prenatal care includes visits to a doctor, nurse, or other health care worker before your baby was born to get checkups and advice about pregnancy. (It may help to look at the calendar when you answer these questions.)

19.	How many weeks or months pregnant were you when you were sure you were pregnant? (For example, you had a pregnancy test or a doctor or nurse said you were pregnant.)

[BOX]  Weeks  OR  [BOX]  Months

I don’t remember

20.	How many weeks or months pregnant were you when you had your first visit for prenatal care? Do not count a visit that was only for a pregnancy test or only for WIC (the Special Supplemental Nutrition Program for Women, Infants, and Children).

[BOX]  Weeks  OR  [BOX]  Months → Go to Question 21

I didn’t go for prenatal care  → Go to Question 22

21. 	Did you get prenatal care as early in your pregnancy as you wanted?

No
Yes  → Go to Question 23

22.	Did any of these things keep you from getting prenatal care when you wanted?  For each item, circle T (True) if it was a reason that you didn’t get prenatal care when you wanted or circle F (False) if it was not a reason for you or if something does not apply to you

	True      False	
a.	I couldn’t get an appointment when I wanted one	T	F	
b.	I didn’t have enough money or insurance to pay for my visits	T	F	
c.	I had no transportation to get to the clinic or doctor’s office	T	F	
d.	The doctor or my health plan would not start care as early as I wanted	T	F	
e.	I had too many other things going on	T	F	
f.	I didn’t want anyone else to know I was pregnant	T	F
g.	I couldn’t take time off from work, school, or other activities	T	F
h.	I didn’t have my Medicaid (MassHealth) card	T	F
i.	I had no one to take care of my children	T	F	
j.     I didn’t know that I was pregnant………………………………………………………………..T	F
k.	I didn’t want prenatal care	T	F	

If you did not go for prenatal care, go to Page #, Question 26.

23.	      Did any of these kinds of health insurance plans help you pay for your prenatal care? Check all that apply

Health insurance from a job (your job or the job of your husband, partner or parents)
Health insurance that you or someone else paid for (not from a job)
Medicaid (MassHealth)
TRICARE or other military health care
Commonwealth Care
Other sources  º  Please tell us:
[BOX]
I did not have health insurance to help pay for my prenatal care 

24.	       During any of your prenatal care visits, did a doctor, nurse, or other health care worker talk with you about any of the things listed below? Please count only discussions, not reading materials or videos. For each item, circle Y (Yes) if someone talked with you about it or circle N (No) if no one talked with you about it.

											No	Yes
a.	How smoking during pregnancy could affect my baby	N	Y
b.	Breastfeeding my baby	N	Y
c.	How drinking alcohol during pregnancy could affect my baby	N	Y
d.	Using a seat belt during my pregnancy	N	Y
e. 	Medicines that are safe to take during my pregnancy	N	Y
f.	How using illegal drugs could affect my baby	N	Y
g.	Doing tests to screen for birth defects or diseases that run in my family	N	Y
h.	The signs and symptoms of preterm labor (labor more than 3 weeks before the baby is due)….N	Y
i.	What to do if my labor starts early	N	Y
j.	Getting tested for HIV (the virus that causes AIDS)	N	Y
k.	What to do if I feel depressed during my pregnancy or after my baby is born
l.	Physical abuse to women by their husbands or partners	N	Y

25.	We would like to know how you felt about the prenatal care you got during your most recent pregnancy. If you went to more than one place for prenatal care, answer for the place where you got most of your care. For each item, circle Y (Yes) if you were satisfied or circle N (No) if you were not satisfied. 

Were you satisfied with—
		No	Yes
a.	The amount of time you had to wait after you arrived for your visits	N	Y
b.	The amount of time the doctor, nurse, or midwife spent with you during your visits	N	Y
c.	The advice you got on how to take care of yourself	N	Y
d.	The understanding and respect that the staff showed toward you as a person	N	Y

26.	At any time during your most recent pregnancy or delivery, did you have a test for HIV (the virus that causes AIDS)?

No
Yes  → Go to Question 30
I don’t know

27.	Were you offered an HIV test during your most recent pregnancy or delivery?

No  → Go to Question 30
Yes

28.	Did you turn down the HIV test?

No  → Go to Question 30
Yes

29.	Why did you turn down the HIV test? Check all that apply

I did not think I was at risk for HIV
I did not want people to think I was at risk for HIV 
I was afraid of getting the result
I was tested before this pregnancy, and did not think I needed to be tested again  º  Go to Question ## 
Other  º  Please tell us:
[BOX] 

30.	During your most recent pregnancy, were you on WIC (the Special Supplemental Nutrition Program for Women, Infants, and Children)?

No
Yes

31.        During your most recent pregnancy, were you told by a doctor, nurse or other health care worker that you had gestational diabetes (diabetes that started during this pregnancy)? 
   
No  → Go to Question 33
Yes

32.         During your most recent pregnancy, when you were told that you had gestational diabetes, did a doctor, nurse or other health care worker do any of the things listed below?
	No	Yes
a.	Refer you to a nutritionist	N	Y
b.	Talk to you about the importance of exercise	N	Y
c.     Talk to you about getting to and staying at a healthy weight after delivery	N	Y
d.	Suggest that you breastfeed your new baby	N	Y
e.	Talk to you about your risk for Type II diabetes	N	Y

33.	Did you have any of the following problems during your most recent pregnancy? For each item, circle Y (Yes) if you had the problem or circle N (No) if you did not.

		No	Yes
a.	Vaginal bleeding	N	Y
b.	Kidney or bladder (urinary tract) infection	N	Y
c.	Severe nausea, vomiting, or dehydration	N	Y
d.	Cervix had to be sewn shut (incompetent cervix)	N 	Y
e.	High blood pressure, hypertension (including pregnancy-induced hypertension 
[PIH], preeclampsia, or toxemia)	N	Y
f.	Problems with the placenta (such as abruptio placentae or placenta previa) 	N	Y
g.	Labor pains more than 3 weeks before my baby was due (preterm or early labor)	N	Y
h.	Water broke more than 3 weeks before my baby was due 
(premature rupture of membranes [PROM])	N	Y
i.	I had to have a blood transfusion	N	Y
j.	I was hurt in a car accident	N	Y

The next questions are about smoking cigarettes around the time of pregnancy (before, during, and after).

34. 	Have you smoked any cigarettes in the past 2 years?

No  º  Go to Question 38
Yes

35. 	In the 3 months before you got pregnant, how many cigarettes did you smoke on an average day? (A pack has 20 cigarettes.)

41 cigarettes or more
21 to 40 cigarettes
11 to 20 cigarettes
6 to 10 cigarettes
1 to 5 cigarettes
Less than 1 cigarette
I didn’t smoke then

36.	In the last 3 months of your pregnancy, how many cigarettes did you smoke on an average day? (A pack has 20 cigarettes.)

41 cigarettes or more
21 to 40 cigarettes
11 to 20 cigarettes
6 to 10 cigarettes
1 to 5 cigarettes
Less than 1 cigarette
I didn’t smoke then

37.	How many cigarettes do you smoke on an average day now? (A pack has 20 cigarettes.)

41 cigarettes or more
21 to 40 cigarettes
11 to 20 cigarettes
6 to 10 cigarettes
1 to 5 cigarettes
Less than 1 cigarette
I don’t smoke now

38.	Which of the following statements best describes the rules about smoking inside your home now? Check one answer

No one is allowed to smoke anywhere inside my home
Smoking is allowed in some rooms or at some times
Smoking is permitted anywhere inside my home

The next questions are about drinking alcohol.  We are interested in the time before you were pregnant and the time during your pregnancy.

39.	Have you had any alcoholic drinks in the past 2 years? A drink is 1 glass of wine, wine cooler, can or bottle of beer, shot of liquor, or mixed drink.

No  º  Go to Question 42
Yes

40a.	During the 3 months before you got pregnant, how many alcoholic drinks did you have in an average week?

14 drinks or more a week
7 to 13 drinks a week
4 to 6 drinks a week
1 to 3 drinks a week
Less than 1 drink a week
I didn’t drink then  => Go to Question 41a

40b.	During the 3 months before you got pregnant, how many times did you drink 4 alcoholic drinks or more in one sitting? A sitting is a two hour time span.

6 or more times 
4 to 5 times 
2 to 3 times 
1 time 
I didn’t have 4 drinks or more in 1 sitting
I didn’t drink then

41a.	During the last 3 months of your pregnancy, how many alcoholic drinks did you have in an average week?

14 drinks or more a week
7 to 13 drinks a week
4 to 6 drinks a week
1 to 3 drinks a week
Less than 1 drink a week
I didn’t drink then  => Go to Question 42

41b.	During the last 3 months of your pregnancy, how many times did you drink 4 alcoholic drinks or more in one sitting?  A sitting is a two hour time span.

6 or more times 
4 to 5 times 
2 to 3 times 
1 time 
I didn’t have 4 drinks or more in 1 sitting
I didn't drink then

Pregnancy can be a difficult time for some women. These next questions are about things that may have happened before and during your most recent pregnancy.

42.	This question is about things that may have happened during the 12 months before your new baby was born. For each item, circle Y (Yes) if it happened to you or circle N (No) if it did not. (It may help to look at the calendar when you answer these questions.)

											No	Yes
a.	A close family member was very sick and had to go into the hospital	N	Y
b.	I got separated or divorced from my husband or partner	N	Y
c.	I moved to a new address	N	Y
d.	I was homeless	N	Y
e.	My husband or partner lost his job	N	Y
f.	I lost my job even though I wanted to go on working	N	Y
g.	I argued with my husband or partner more than usual	N	Y
h.	My husband or partner said he didn’t want me to be pregnant	N	Y
i.	I had a lot of bills I couldn’t pay	N	Y
j.	I was in a physical fight	N	Y
k.	My husband or partner or I went to jail	N	Y
l.	Someone very close to me had a bad problem with drinking or drugs	N	Y
m.	Someone very close to me died	N	Y

43.	During the 12 months before you got pregnant with your new baby, did your husband or partner push, hit, slap, kick, choke, or physically hurt you in any other way?
		
No
Yes

44.	During your most recent pregnancy, did your husband or partner push, hit, slap, kick, choke, or physically hurt you in any other way?

No
Yes

The next questions are about your labor and delivery. (It may help to look at the calendar when you answer these questions.)

45.	When was your baby due?

[BOX]	[BOX]	20___[BOX]	
Month	Day	Year	

46.	When did you go into the hospital to have your baby?

[BOX]	[BOX]	20___[BOX]	
Month	Day	Year	
I didn’t have my baby in a hospital

47.	When was your baby born?

[BOX]	[BOX]	20___[BOX]	
Month	Day	Year	

48.	How was your new baby delivered?

Vaginally => Go to Question 50
Cesarean delivery (c-section) => Go to Question 49

49.	Which statement best describes whose idea was it for you to have a cesarean delivery?  Check one answer.  

My health care provider recommended a cesarean delivery before I went into labor	
My health care provider recommended a cesarean delivery while I was in labor
I asked for the cesarean delivery before I went into labor	
I asked for the cesarean delivery while I was in labor

50.	When were you discharged from the hospital after your baby was born? 

[BOX]	[BOX]	20___[BOX]	
Month	Day	Year	

I didn’t have my baby in a hospital

51.	Did any of these kinds of health insurance plans help you pay for the delivery of your new baby? Check all that apply

Health insurance from a job (your job or the job of your husband, partner or parents)
Health insurance that you or someone else paid for (not from a job)
Medicaid (MassHealth)
TRICARE or other military health care
Commonwealth Care 
Other source  º  Please tell us:
[BOX]
I did not have a health insurance plan to help pay for my delivery 

The next questions are about the time since your new baby was born.

52.	After your baby was born, was he or she put in an intensive care unit?

No
Yes
I don’t know

53.	After your baby was born, how long did he or she stay in the hospital?

Less than 24 hours (less than 1 day)
24 to 48 hours (1 to 2 days)
3 to 5 days
6 days to 14 days 
More than 14 days
My baby was not born in a hospital
My baby is still in the hospital  º  Go to Question 56

54.	Is your baby alive now?

No  º  Go to Question 62
Yes

55.	Is your baby living with you now?

No  º  Go to Question 62
Yes

56.	Did you ever breastfeed or pump breast milk to feed your new baby after delivery, even for a short period of time?

No  º  Go to Question 59b
Yes º  Go to Question 57

57.	Are you currently breastfeeding or feeding pumped milk to your new baby?

No
Yes  º  Go to Question 59a

58.	How many weeks or months did you breastfeed or pump milk to feed your baby?

[BOX]  Weeks  OR  [BOX]  Months

Less than 1 week

59a.	How old was your new baby the first time he or she drank liquids other than breast milk (such as formula, water, juice, tea, or cow’s milk)? 

 [BOX]  Weeks OR  [BOX]  Months

My baby was less than 1 week old
My baby has not had any liquids other than breast milk

59b.	How old was your new baby the first time he or she ate food (such as baby cereal, baby food or any other food)? 

[BOX]  Weeks OR  [BOX]  Months

My baby was less than 1 week old
My baby has not eaten any foods 

If your baby is still in the hospital, go to Question 62.

60.	In which one position do you most often lay your baby down to sleep now? Check one answer

On his or her side
On his or her back
On his or her stomach

61.	Was your new baby seen by a doctor, nurse, or other health care worker during the first week after he or she left the hospital?

No
Yes

62.	Are you or your husband or partner doing anything now to keep from getting pregnant? (Some things people do to keep from getting pregnant include not having sex at certain times [natural family planning or rhythm] or withdrawal, and using birth control methods such as the pill, condoms, cervical ring, IUD, having their tubes tied, or their partner having a vasectomy.)

No
Yes  º  Go to Question 64

63.	What are your reasons or your husband’s or partner’s reasons for not doing anything to keep from getting pregnant now? Check all that apply

I am not having sex
I want to get pregnant
I don’t want to use birth control
My husband or partner doesn’t want to use anything
I don’t think I can get pregnant (sterile)
I can’t pay for birth control
I am pregnant now
Other  º  Please tell us:
[BOX]

64.	Since your new baby was born, have you had a postpartum checkup for yourself? (A postpartum checkup is the regular checkup a woman has about 6 weeks after she gives birth.)

No  
Yes

65.	Below is a list of feelings and experiences that women sometimes have after childbirth.  Read each item to determine how well it describes your feelings and experiences.  Then, circle the choice that best describes how often you have felt or experienced things this way since your new baby was born.  Use the scale when answering:

a. I felt down, depressed or sad           	   1                         2                         3                         4                         5
                   				Never                  Rarely              Sometimes               Often                 Always

b. I felt hopeless                       	  1                         2                         3                         4                         5
                   			Never                  Rarely              Sometimes               Often                 Always

c. I felt slowed down 		     1                         2                         3                         4                         5
                   			Never                  Rarely              Sometimes               Often                 Always

Other Experiences

The next questions are on a variety of topics.

66.	This question is about things that may have happened during the 12 months before your new baby was born.  For each item, circle Y (Yes) if it happened to you or N (No) if it didn't. It may help to use the calendar.                                                                               										                                                                                                               											No	Yes
a.	I felt that my race or ethnic background contributed to the stress in my life………..	N	Y
b.	I felt emotionally upset (for example, angry, sad, or frustrated) as a result of
	how I was treated based on my race or ethnic background	……………………………N	Y
c.	I experienced physical symptoms (for example, a headache, an upset stomach,
	tensing of your muscles, or a pounding heart) that I felt were related to how I was
	treated based on my race or ethnic background……………………………………………N 	Y

67.	During the last 3 months of your most recent pregnancy, how often did you participate in any physical activities or exercise for 30 minutes or more? (For example, walking for exercise, swimming, cycling, dancing, or gardening.)

Less than 1 day per week
1 to 2 days per week
3 to 4 days per week
5 or more days per week
I was told by a doctor, nurse, or other health care worker not to exercise

68.	During the last 3 months of your most recent pregnancy, about how many servings of fruits or vegetables did you have in a day? Check one answer

Less than 1 serving per day
1 or 2 servings per day
3 or 4 servings per day
5 or more servings per day

If your baby is not alive or is not currently living with your,  go to Question 72.

69.	In the last month, where did your new baby usually sleep? Check one answer
           
In a crib, cradle, or bassinet
On an adult bed or mattress with you or another person(s)
On an adult bed or mattress alone
On a sofa or couch
In a car seat or infant seat
Someplace else?    Please tell us: [BOX]

70. 	Have you ever heard or read about what can happen if a baby is shaken?

No
Yes

71. 	Listed below are some statements about safety. For each one, circle Y (Yes) if it applies to you or circle N (No) if it does not.

		No	Yes
a.	My baby was brought home from the hospital in an infant car seat	N	Y
b.	My baby always or almost always rides in an infant car seat	N	Y
c.	My home has a working smoke alarm	N	Y
d.	There are loaded guns, rifles, or other firearms in my home	N	Y

72.	Since your new baby was born, have you asked for help for depression from a doctor, nurse, or other health care worker?

No
Yes

73.	This question is about things that may have happened since your most recent delivery. For each thing, circle Y (Yes) if it happened to you or circle N (No) if it did not. 

Since your most recent delivery—
		No	Yes
a.	Your husband or partner threatened you or made you feel unsafe in some way	N	Y
b.	You were frightened for the safety of yourself or your family because of the anger or
threats of your husband or partner	N	Y
c.	Your husband or partner tried to control your daily activities, for example,
controlling who you could talk to or where you could go	N	Y
d.	Your husband or partner forced you to take part in touching or any sexual activity
when you did not want to	N	Y

74.	What type of health insurance are you covered by right now? Check all that apply

Health insurance from a job (your job or the job of your husband, partner or parents)
Health insurance that you or someone else paid for (not from a job)
Medicaid (MassHealth)
TRICARE or other military health care
Commonwealth Care		
Other source => Please tell us
[BOX]
I did not have any health insurance 

75.	Are you limited in any way in any activities because of physical, mental, or emotional problems?

No º  Go to Question 77
Yes

76.	For how long have your activities been limited because of physical, mental, or emotional problems?

[BOX]  Number of Days  OR   [BOX]  Number of Weeks  OR  [BOX]  Number of Months  OR  [BOX]  Number of Years

77.	Have you ever had your teeth cleaned by a dentist or dental hygienist?

No  º  Go to Question 79
Yes 

78.	Did you have your teeth cleaned by a dentist or dental hygienist during the time periods listed below? For each of the three time periods, circle Y (Yes) if you had your teeth cleaned then or circle N (No) if you did not have your teeth cleaned then. 

		No	Yes
a.	During my most recent pregnancy	N	Y
b.	After my most recent pregnancy	N	Y

The last questions are about the time during the 12 months before your new baby was born.

79.	During the 12 months before your new baby was born, what was your yearly total household income before taxes? Include your income, your husband’s or partner’s income, and any other income you may have received. (All information will be kept private and will not affect any services you are now getting.) Check one answer

Less than $10,000
$10,000 to $14,999
$15,000 to $19,999
$20,000 to $24,999
$25,000 to $34,999
$35,000 to $49,999
$50,000 to $64,999
$65,000 to $79,999
$80,000 or more

80.	During the 12 months before your new baby was born, how many people, including yourself, depended on this income?

[BOX]  People

81.	What is today’s date?

[BOX]	[BOX]	20___[BOX]	
Month	Day	Year	

Please use this space for any additional comments you would like to make about the health of mothers and babies in Massachusetts.

Thanks for answering our questions!

Your answers will help us work to make Massachusetts mothers and babies healthier.