Infant Feeding Questionnaire

1. What is your age: ______

2. When is your due date? ______

3. How many weeks pregnant are you? ______

4. How many weeks pregnant were you when you discovered you were pregnant? ______

5. How many prenatal care visits (doctor’s office, Birth Circle etc.) have you had so far with this pregnancy? ______

6. What race(s) or ethnicity do you consider yourself to be?

(Check all that apply)

□American Indian or Alaska Native

□Asian

□Black or African American

□Hispanic/Latino

□Native Hawaiian or Other Pacific Islander

□White/Caucasian

□Other (please specify): ______

7. Which of the following best describes your current relationship situation?

□Married

□Not married, but in a committed relationship

□Actively dating, NOT in a committed relationship

□Divorced/Separated

□Single, not in a relationship

□Widowed

□Other (please specify):______

8. What is the highest level of school you have completed?

☐8th grade or less

☐Some high school, but did not graduate

☐High school graduate or GED

☐Some college or 2 year degree

☐College degree (Bachelor’s or Graduate)

9. Are you currently employed?

☐No

☐Yes – Full time

☐Yes – Part time

For each of the following statements, please choose the answer that best describes your opinion. Please mark your answer by circling the number that is closest to how you feel. There are no right or wrong answers.

Breastfeeding …

10 / will lower my risk of breast cancer. / 1 / 2 / 3 / 4 / 5 / 6 / 7
11 / will lower my risk of ovarian cancer. / 1 / 2 / 3 / 4 / 5 / 6 / 7
12 / will increase my risk of headaches. / 1 / 2 / 3 / 4 / 5 / 6 / 7
13 / will lower my risk of developing diabetes. / 1 / 2 / 3 / 4 / 5 / 6 / 7
14 / will increase my risk of a breast infection. / 1 / 2 / 3 / 4 / 5 / 6 / 7
15 / will make it harder to lose weight after my baby is born. / 1 / 2 / 3 / 4 / 5 / 6 / 7
16 / will protect my hand joints. / 1 / 2 / 3 / 4 / 5 / 6 / 7
17 / will lower my blood pressure. / 1 / 2 / 3 / 4 / 5 / 6 / 7
18 / will lower my libido/sex drive. / 1 / 2 / 3 / 4 / 5 / 6 / 7
19 / will delay my menstrual period after my baby is born. / 1 / 2 / 3 / 4 / 5 / 6 / 7
20 / will save my family money. / 1 / 2 / 3 / 4 / 5 / 6 / 7
21 / will build up my baby’s immunity. / 1 / 2 / 3 / 4 / 5 / 6 / 7
22 / will reduce the chancemy baby will have to be hospitalized. / 1 / 2 / 3 / 4 / 5 / 6 / 7
23 / will make my baby healthier. / 1 / 2 / 3 / 4 / 5 / 6 / 7
24 / will help me bond with my baby. / 1 / 2 / 3 / 4 / 5 / 6 / 7
25 / will be easy / 1 / 2 / 3 / 4 / 5 / 6 / 7
26 / means that I have to do all feedings. / 1 / 2 / 3 / 4 / 5 / 6 / 7
27 / means that I might have to nurse in public. / 1 / 2 / 3 / 4 / 5 / 6 / 7
28 / If I smoke, I cannot breastfeed. / 1 / 2 / 3 / 4 / 5 / 6 / 7

Extremely

Unlikely

Neither

Extremely

Likely

29 / It is likely that I will try to breastfeed after my baby is born. / 1 / 2 / 3 / 4 / 5 / 6 / 7
30 / My continued breastfeeding for1 month is likely. / 1 / 2 / 3 / 4 / 5 / 6 / 7
31 / My continued breastfeeding for6 monthsis unlikely . / 1 / 2 / 3 / 4 / 5 / 6 / 7
32 / I want to breastfeed my baby. / 1 / 2 / 3 / 4 / 5 / 6 / 7
33 / Breastfeeding my baby is important. / 1 / 2 / 3 / 4 / 5 / 6 / 7
34 / I think I will enjoy breastfeeding my baby. / 1 / 2 / 3 / 4 / 5 / 6 / 7
35 / I would rather not to breastfeed my baby. / 1 / 2 / 3 / 4 / 5 / 6 / 7
36 / Most people who are important to me think I should breastfeed for at least 6 months. / 1 / 2 / 3 / 4 / 5 / 6 / 7
37 / Most mothers like me will breastfeed for 6 months. / 1 / 2 / 3 / 4 / 5 / 6 / 7
38 / Whether or not I breastfeedfor 6months is entirely up to me. / 1 / 2 / 3 / 4 / 5 / 6 / 7
39 / My breastfeedingfor 6monthsis under my control. / 1 / 2 / 3 / 4 / 5 / 6 / 7
40 / I am sure that I am able to breastfeed for 6 months. / 1 / 2 / 3 / 4 / 5 / 6 / 7
41 / I am confident that I can learn to successfully breastfeed / 1 / 2 / 3 / 4 / 5 / 6 / 7
42 / Breastfeeding for 6 months will be exhausting. / 1 / 2 / 3 / 4 / 5 / 6 / 7
43 / Breastfeeding for 6 month will be difficult. / 1 / 2 / 3 / 4 / 5 / 6 / 7
44 / Breastfeeding for 6 months will be rewarding. / 1 / 2 / 3 / 4 / 5 / 6 / 7
45 / Breastfeeding for 6 months will be relaxing. / 1 / 2 / 3 / 4 / 5 / 6 / 7
46 / Breastfeeding for 6 months will be easy. / 1 / 2 / 3 / 4 / 5 / 6 / 7
47 / Breastfeeding for 6 months will be embarrassing. / 1 / 2 / 3 / 4 / 5 / 6 / 7
48 / I am comfortable breastfeeding in public places. / 1 / 2 / 3 / 4 / 5 / 6 / 7

Extremely

Unlikely

Neither

Extremely

Likely

49 / My baby’s father thinks that I should breastfeed. / 1 / 2 / 3 / 4 / 5 / 6 / 7 N/A
50 / My mother thinks that I should breastfeed. / 1 / 2 / 3 / 4 / 5 / 6 / 7 N/A
51 / My other family members think that I should breastfeed. / 1 / 2 / 3 / 4 / 5 / 6 / 7 N/A
52 / Older generations think that I should breastfeed. / 1 / 2 / 3 / 4 / 5 / 6 / 7 N/A
53 / Health Professionals think that I should breastfeed. / 1 / 2 / 3 / 4 / 5 / 6 / 7 N/A
54 / My close friends think that I should breastfeed. / 1 / 2 / 3 / 4 / 5 / 6 / 7 N/A
55 / My co-workers think that I should breastfeed. / 1 / 2 / 3 / 4 / 5 / 6 / 7 N/A
56 / I will use a pump to pump my milk. / 1 / 2 / 3 / 4 / 5 / 6 / 7
57 / I will have breastfeeding complications such as sore nipples, latching problems or pain with nursing. / 1 / 2 / 3 / 4 / 5 / 6 / 7
58 / I will have to return to work or school full time (21 hours or more
per week). / 1 / 2 / 3 / 4 / 5 / 6 / 7
59 / I will have to return to work or school part time (20 hours or less
per week). / 1 / 2 / 3 / 4 / 5 / 6 / 7
60 / I will have a work or school schedule flexible enough to allow me to breastfeed. / 1 / 2 / 3 / 4 / 5 / 6 / 7
How many times in your LIFE have you… / Number of times
A. been pregnant?
B. given birth?
C. breastfed a baby?

61.

62. When you got pregnant with this pregnancy, did you feel ready to have a baby?

☐Yes

☐No

☐Don’t know/Not sure

63. In the last year, how many times did you visit the following health care locations to get

care for yourself?

Health care setting / Number of times in last year
Emergency room
Family planning clinic ( like Planned Parenthood,)
Urgent Care, Minute clinic, or walk-in clinic
Private doctor’s office
Community Clinic
The Birth Circle

THANK YOU for Completing This Survey