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Community Survey
*
1.
What is your age range?
(Required.)
15-19
20-23
24-29
30-35
36-40
40+
*
2.
Do you identify as a Black/African American mother?
(Required.)
Yes
No
*
3.
Are you currently pregnant?
(Required.)
Yes
No
4.
If you're pregnant, how far along are you in your pregnancy?
First trimester
Second trimester
Third trimester
N/A
5.
Have you given birth within the last 12 months?
Yes
No
*
6.
Do you reside in LA County?
(Required.)
Yes
No
7.
Have you or are you currently experiencing any of the following mental health concerns?
Postpartum depression
Depression
Anxiety
Stress
Grief
Other (please specify)
8.
Do you know someone who has experienced any of the following mental health concerns?
Postpartum depression
Depression
Anxiety
Stress
Grief
Other (please specify)
9.
Have you or are you currently experiencing any of the following physical health concerns?
Preeclampsia
High blood pressure
Gestational diabetes
Brest cancer
Diabetes
High cholesterol
Other (please specify)
10.
Have you or are you currently experiencing any financial challenges?
Credit issues
No savings
Job loss
Struggling to pay bills
Other (please specify)
11.
Do you have health insurance?
Yes
No
12.
If insured, are you underinsured?
Yes
No
N/a
13.
Do you know your maternity leave rights i.e. FMLA?
Yes
No
14.
Do you (or did you) feel cared for or valued during childbirth and pre-natal visits?
Yes
No
15.
If so, please explain why.
16.
During your prenatal care visits, how long did your provider spend with you?
Less than five minutes
Up to 10 minutes
10 to 20 minutes
20 minutes and more
N/a
17.
Did you (do you) feel rushed during your prenatal care visits?
Yes
No
N/a
18.
Based on your prenatal visits, how prepared and comfortable did/do you feel about giving birth?
Not comfortable
Slightly comfortable
Neutral
Mostly comfortable
Very comfortable
N/a
19.
Do you have a mental health provider?
Yes
No
20.
Is your mental health provider Black/African American?
Yes
No
N/a
21.
Do you have a birthing provider?
Yes
No
N/a
22.
What type of birthing provider do you have?
Doctor
Obgyn
Doula
Midwife
N/a
Other (please specify)
23.
Is your birthing provider Black/African American?
Yes
No
N/a
24.
If you have a doula or midwife, please explain why you chose this type of provider?
25.
Do you prefer being helped by a Black/African American provider?
Yes
No
26.
Are you comfortable with being helped by a non-Black provider that is empathetic, genuine and aware of your challenges as a Black mother?
Yes
No
27.
If not, please explain why.
28.
What are some characteristics you would like to see in a healthcare provider?
29.
Do you prefer a homeopathic (non-traditional/Eastern modalities/natural), pharmaceutical (traditional/Western medicine), or holistic (homeopathic, pharmaceutical and mental wellness) approach to your healthcare needs?
Homeopathic
Pharmaceutical
Holistic
N/a
Other (please specify)
30.
Please explain why.
31.
Do you know what resources are available to you during and after pregnancy?
Yes
No
N/a
32.
Are the any other comments or concerns you’d like to share regarding 1) mental health, 2) gaps in services/service delivery, and/or 3) ways to serve our community that are culturally appropriate and holistic.