Supplementary Table 1 Source and rationale for each PRAMS question

Concept / Item / Source / Rationale
Demographics / Infant gender / New question / Gender was provided through delivery record. However, we chose to open the survey with this question for two reasons a) cross checking and validation with birth record b) gentle opening question to ease woman into the survey.
Age moved to Ireland / Many health behaviours and experiences of pregnancy are likely to vary by duration of time spent living in the country.
General health / SLAN / Self-rated health questions are predictive of overall morbidity and mortality and important also in assessing woman’s overall perception of her health.
Ethnicity / Many health behaviours and experiences of pregnancy are likely to vary by ethnicity.
Education / Many health behaviours and experiences of pregnancy are likely to vary by education.
Marital status / Many health behaviours and experiences of pregnancy are likely to vary by marital status.
Nationality / Many health behaviours and experiences of pregnancy are likely to vary by nationality.
Household income and dependents / Socio-economic status is often measured by equvalised income. Behaviours, experiences and health outcomes differ by socioeconomic status.
Height / PRAMS / Required for calculation of Body Mass Index [BMI].
Weight / Required for calculation of BMI.
Weight since pregnancy / Low pre-pregnancy weight for height, low maternal height, and low weight gain during pregnancy are all associated with low birth weight (1).
Baby alive now / Reducing infant mortality and investigating how infant mortality relates to risk factors before and during pregnancy are two of the primary goals of the PRAMS program in the United States and are also primary goals of PRAMS Ireland. Studying neonatal mortality and its association with risk factors during pregnancy and/or since birth will assist in targeting pre- and intra-pregnancy intervention programs (1).
Medical card status / GUI / Many health behaviours and experiences and health service use characteristics of pregnancy are likely to vary by medical card status.
Private health insurance status / Many health behaviours and experiences and health service use characteristics of pregnancy are likely to vary by health insurance status.
Working full time, return to work and reasons for going back to work / Ireland is currently undergoing economic recession. We chose these questions to estimate women’s level of employment prior to and since pregnancy.
Pregnancy History / Gravidity / ALSPAC / Many health behaviours and experiences of pregnancy are likely to vary by a woman’s pregnancy history.
Number of gravidities
First Pregnancy with current partner
No of live births
Previous Miscarriage
Previous abortion or termination
Previous stillborn
Previous neonatal death
Previous low birth weight
Previous preterm
Previous c section
Age first pregnant
Outcome of last pregnancy
Breastfed last baby
Health before pregnancy / Sexually transmitted infections [STIs] / ISSHR / STIs can affect fertility and complicate pregnancy and may have serious effects both on a woman and her developing baby. Some of these problems may be seen at birth; others may not be discovered until months or years later.
Health conditions before pregnancy / PRAMS / Health status prior to pregnancy is an important predictor of health during pregnancy and subsequent infant and maternal health.
Pregnancy Intention / Pre-pregnancy readiness / PRAMS / Assessing a woman’s readiness for pregnancy is an important determinant of a woman’s health behaviours during pregnancy and subsequently maternal and infant health.
Pregnancy intention / Women who are unaware of pregnancy may engage in risk taking behaviours such as smoking and drinking early in pregnancy that can affect fetal growth and development. Unwanted pregnancies carried to term may be associated with maternal risk taking behaviours throughout pregnancy and with infants who receive poor care and nurturing (1).
Pregnancy Recognition / Information about the month of pregnancy when the mother first suspected/first knew that she was pregnant is important for assessing initiation of antenatal care and changes in cigarette and alcohol use (1).
Intimate partner violence / Intimate partner violence in the year before pregnancy / PRAMS / It is not clear what role pregnancy plays in decreasing or escalating physical abuse. One potential risk factor is unintended pregnancy. A better understanding of the relationship between pregnancy, pregnancy intention, and physical violence could have important clinical and public health implications (1).
Intimate partner violence during pregnancy
Intimate partner violence since pregnancy
Physical activity / Physical activity before pregnancy / PRAMS / Physical activity is a major determinant of population health. Engaging in physical activity prior to and during pregnancy is part of ensuring health status during pregnancy.
Physical activity in the last three months of pregnancy
Folic acid / Folic acid before pregnancy / PRAMS / All women of childbearing age who are capable of becoming pregnant should consume 0.4 mg of folic acid per day in order to reduce the risk of having a child with a neural tube defect (NTD). Determining the proportion of women who take folic acid prior to pregnancy is vital (1).
Folic acid use among women of child bearing age and in the early months of pregnancy is a key public health guideline due to its role in the prevention of NTDs. Assessing women’s knowledge of the reasons for folic acid intake around the time of pregnancy allows us to estimate the extent to which this vital public health message is understood by women and what further work is required to ensure that all women of child bearing age are aware of the importance of folic acid use.
Folic acid intake in the first 3 months of pregnancy
Knowledge of folic acid intake
Multivitamin use / Multivitamin use before pregnancy / PRAMS / Iron, folic acid and other vitamins are essential for a healthy pregnancy.
Multivitamin use during pregnancy
Contraception & Assisted Reproductive Technologies [ART] / Contraception use before pregnancy / PRAMS / The contraceptive behaviour of women is of interest because of its relationship to unintended pregnancy, abortion, and sexually transmitted diseases (1).
Assisted reproductive technology [ART] before pregnancy / As maternal age increases in Ireland so too does the demand and use of reproductive technologies. We sought to determine the prevalence of ART is our sample.
Smoking / Lifetime smoking history / PRAMS / To obtain prevalence and amount of smoking to see if women reduced or quit during pregnancy and to see if women restarted smoking during the postnatal period. Cigarette smoking has been associated with lower fecundity and with higher rates of spontaneous abortion, abruptio placenta, placenta previa, preterm delivery, and small-for-gestational age birth. The children of mothers who smoke during pregnancy may continue to be smaller than average and may have slight deficits in neurological development. Children exposed to environmental tobacco smoke are at increased risk for several health problems, including lower respiratory infection, ear infection, and asthma. Infants exposed to tobacco smoke are at increased risk of sudden infant death syndrome [SIDS]. Measuring cigarette smoking before pregnancy and during the last three months allows us to assess change during pregnancy (1).
Smoking three months before pregnancy
Smoking quit status around the time of pregnancy
Smoking in the last trimester of pregnancy
Smoking in home
Medications / Prescribed medicines during pregnancy
Over the counter [OTC] medicines during pregnancy
Psycho-actives/recreational drug use during pregnancy / Growing up in Australia / Alcohol, smoking and medication use have a significant impact on infant outcomes. Documenting the prevalence of the use of medicines and drugs during pregnancy is important to determine the burden of use and trends in use over time.
Alcohol / Alcohol before and during pregnancy / New Question / Alcohol use during pregnancy can produce a range of teratogenic effects in the fetus. The most severe is fetal alcohol syndrome, which may include facial anomalies, reduced head circumference, and mental retardation(1). Few studies examine the dose, pattern and timing of alcohol use during pregnancy which may be important in determining risk to the foetus (2).
Stress / Life stressors during pregnancy / National Women’s Health Survey / Low birth weight is associated with objective adverse major life events and lack of social supports. Documenting the prevalence of adverse life events around the time of pregnancy is important.
Complications / Complications during pregnancy / GUI / Complications during pregnancy have a significant impact on subsequent maternal and infant health. Additionally complications of pregnancy are related to lifestyle and behaviours around the time of pregnancy.
Breastfeeding / Ever breastfed current baby / PRAMS / Breastfed infants have lower rates of hospital admissions, ear and respiratory infections, and diarrheal illnesses. Breastfeeding also can reduce health care expenditures by reducing infant morbidity(1).
Reasons for not breastfeeding / Investigating reasons for not breastfeeding is important in designing interventions and policy around breastfeeding.
Duration of breastfeeding / The longer the duration of breastfeeding, the greater the health benefits (1).
Reasons for stopping breastfeeding / The longer the duration of breastfeeding, the greater the health benefits (1). Thus, investigating reasons for stopping is important in increasing the duration of breastfeeding in the population.
Exclusive breastfeeding / While any breastfeeding is beneficial to the infant, exclusive breastfeeding confers the most benefits to the growing infant. Increasing exclusive breastfeeding prevalence is an important public health goal.
Hospital support for breastfeeding / Women who initiate breastfeeding at birth are more likely to continue to breastfeed once leaving hospital (1). Developing a supportive and encouraging atmosphere with appropriate resources at the hospital of birth is key in increasing breastfeeding prevalence.
Depression/Psychological wellbeing / Feelings since birth / PRAMS / Postnatal depression is a cause of reduced quality of life, family problems and infant bonding after birth (1). Examining the prevalence of feelings of depression and low mood and its correlates is important in developing strategies and policy to address postpartum depression [PPD] in Ireland.
Postnatal depression care received / Women may experience symptoms of PPD but not receive treatment; care or even a diagnosis of PPD. Examining diagnoses of PPD and reported feelings of PPD is an interesting and worthwhile process which can be used to inform improved diagnosis and prevention strategies in high risk groups.
Sleep position / Sleep position / PRAMS / SIDS is the leading cause of infant death in the postnatal period and accounts for 36% of deaths. Prone (on the stomach) infant sleeping position has emerged as a major modifiable risk factor for SIDS (1). Data on sleep position is not available in Ireland.
Health care before, during and after pregnancy / Health advice before pregnancy / PRAMS / Many pregnancies are unplanned. Advice which helps women adopt healthy behaviours before pregnancy can improve maternal and child health.
Initiation and provision of antenatal care
Barriers to receiving antenatal care
Satisfaction with antenatal care
Content of antenatal care / PRAMS / Inadequate use of antenatal care has been associated with increased risk of low-birth weight births, premature births, neonatal mortality, infant mortality, and maternal mortality. The receipt of early and consistent antenatal care allows for diagnosis and management of medical conditions that may affect the health of both mother and infant (1). Identifying barriers to antenatal care is important in increasing access to at risk groups (1). Satisfaction with antenatal care is important in determining the quality of care being delivered to women during pregnancy. The content of care itself is important given its role in providing targeted health advice to women to improve health outcomes (1).
Content of antenatal care: delivery mode / Caesarean section is rising dramatically in many countries including Ireland. Investigating the drivers of c section including advice given in antenatal care may allow us to investigate reasons for c section increases.
Gestational diabetes care / Gestational diabetes mellitus [GDM] affects approximately 12% of all pregnancies. If gestational diabetes is not detected and controlled, it can increase the risk of birth complications, such as shoulder dystocia (when the baby's shoulder gets stuck during the birth). It can also lead to babies being large for their gestational age (1). Thus, assessing the adequacy of care given to women with GDM is vital.
Reasons for c section / Caesarean section is rising dramatically in many countries including Ireland. Investigating the drivers of c section including the reasons women choose to have c section is important. Furthermore investigating the reasons for c section allows us to determine if they are emergency or elective sections.
Neonatal/special care admission / Admission to the neonatal/special care unit is an indication that a baby requires intensive medical attention. As the objective of PRAMS is to reduce infant mortality and morbidity investigating the prevalence of such admissions and factors associated with admission is an important goal of PRAMS in Ireland.
Ventilator use / Ventilator use may be a marker for poor health status in a new-born baby. As the objectives of PRAMS are to reduce infant mortality and morbidity ventilator use combined with other health outcomes may allow us to identify infants with increased morbidities.
Infant care: 2 week check-up, 6 week check-up and vaccines at 2 months / Appropriate well-child care has the potential to reduce infant morbidity and mortality through anticipatory guidance and early detection or prevention of health problems (1).
Postnatal check up / Postnatal check-ups ensure women are receiving appropriate care and services they need after birth.

Supplementary Table 2 Modifications made to PRAMS questions for PRAMS Ireland survey

Item / Source / Original Question [Deletions and changes highlighted]
Q26 / PRAMS / Before you got pregnant with your new baby, did a doctor, nurse, or other health care workermidwife or other healthcare professional talk with you about any of the things listed below? Please count only discussions, not reading materials or videos. For each item, tick Yes if someone talked with you about it or No if no one talked with you about it.
Taking vitamins with folic acid before pregnancy
Being a healthy weight before pregnancy
Getting my vaccines updated before pregnancy
Visiting a dentist or dental hygienist before pregnancy
Getting counselling for any genetic diseases that run in my family