BetterObstetricsinRuralNigeria(BORN)Study
HouseholdQuestionnaire
A.CoverPage
IdentificationSection
1.
2.
3.
4.
StateName:
LGAName:
PHCName:
InterviewerName:
5. Isacompetentrespondentpresentintheselectedhousehold?
€ Yes
€ No
6. Istheentirehouseholdawayforanextendedperiod?
a. Yes
b. No
ADMINISTERCONSENT
7. Consentgiven?
€ Yes
€ No
B.HouseholdRoster
Name
Whoisprovidingthe
information?
1.HHHead
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
1.
WhatisNAME'srelationshiptotheheadof
thehousehold?
€
€
€
€
€
€
€
€
€
€
€
€
€
€
€
2.
Headofhousehold
Spouse(wife/husband)
Ownson/daughter
Stepson/daughter
Son/daughterin-law
Grandchild
Brother/sister
Parent
Parentinlaw
Niece/nephew
Otherrelative
Domestichelp
Othernon-relative
Co-wife
Other(Specify):
WhatisNAME’sdateofbirth?
Month/Day/Year
€ Unknown
3.
WhatisNAME’sestimatedage?
4.
WhatisNAME’scurrentmaritalstatus?
a.
b.
c.
d.
e.
f.
Nevermarried
Monogamouslymarried
Polygamouslymarried
Civilunion
Divorced/Separated
Widowed
5.
IsNAMEmaleorfemale?
€ Male
€ Female
6.
HasNAMEbeenpregnantatanytimesince
January2009regardlessoftheoutcomeof
thepregnancy?
€ Yes
€ No
7.
IsNAME’Snaturalmotheralive?
€ Yes
€ No
8.
DoesNAME’Smotherusuallyliveinthe
household?
€ Yes
€ No
9.
IsNAME’Snaturalfatheralive?
€ Yes
€ No
10. DoesNAME’Snaturalfatherusuallylivein
thishousehold?
€ Yes
€ No
11. HasNAMEeverattendedschool?
€ Yes
€ No
12. Highestlevelofschoolingattained
1.Pre-Primary/Kindergarten
€ One
€ Two
€ Three
2.PrimarySchool
€
€
€
€
€
€
One
Two
Three
Four
Five
Six
3.SecondarySchool
€
€
€
€
€
€
One
Two
Three
Four
Five
Six
4.LowerSix
5.UpperSix
6.NCE/OND/‘AL’level
7.BA/BSC/HND
8.Mastersorhigher
9.AttendedKoranicSchool
13. IsNAMEcurrentlygoingtoschool
€ Yes
€ No
C.HouseholdCharacteristics
14. Whatisthemainsourceofdrinkingwaterfor
membersofyourhousehold?
PipedWater
€
€
€
€
Pipedintodwelling
Pipedintoyard/plot
Publictap/standpipe
Tubewellorborehole
DugWell
€ Protectedwell
€ Unprotectedwell
WaterfromSpring
€ Protectedspring
€ Unprotectedspring
Rainwater
Tankertruck
Cartwithsmalltank
Surfacewater(river/pond/stream)
Bottledwater
Other(Specify):
15. Whatkindoftoiletfacilitydomembersofyour
householdusuallyuse?
Flushorpourflushtoilet
Pitlatrine
€ VentilatedimprovedPitlatrine
€ Pitlatrinewithslab
€ Pitlatrinewithoutslab/Openpit
Compostingtoilet
Buckettoilet
Hangingtoilet/hangingLatrine
Nofacility/bush/field
Other(Specify):
16. Doyousharethistoiletfacilitywithother
households?
€ Yes
€ No
17. Howmanyhouseholdsincludingyoursusethis
toiletfacility?
____
€ Don’tknow
18. Whattypeoffueldoesyourhouseholdmainly
useforcooking?
€
€
€
€
€
€
€
€
€
€
€
€
€
19. Doyouhaveaseparateroomthatisusedasa
kitchen?
€ Yes
€ No
20. Mainmaterialforthefinishofthefloor
Electricity
LPG
Naturalgas
Biogas
Kerosene
Coal,lignite
Charcoal
Wood
Straw/shrubs/grass
Agriculturalcrop
Animaldung
Nofoodcookedinhousehold
Other(Specify):
Naturalfloor
€ Earth/sand
€ Dung
Rudimentaryfloor
€ Woodplanks
€ Palm/bamboo
Finishedfloor
€
€
€
€
€
€
21. Mainmaterialforfinishoftheroof
Parquetorpolishedwood
Vinylorasphaltstrips
Ceramictiles
Cement
Carpet/rug
Other(Specify):
Naturalroofing
€ Noroof
€ Thatch/palmleaf
Rudimentaryroofing
€
€
€
€
Rusticmat
Palm/bamboo
Woodplanks
Cardboard
Finishedroofing
€
€
€
€
€
Metal/zinc
Wood
Ceramictiles
Cement
Roofingshingles
Other(Specify):
22. Mainmaterialforfinishoftheexterior
Naturalwalls
€ Nowalls
€ Cane/palm/trunks
€ Dirt(mud)
Rudimentarywalls
€
€
€
€
€
Bamboowithmud
Stonewithmud
Plywood
Cardboard
Reusedwood
Finishedwalls
€
€
€
€
€
Cement
Stonewithlime/cement
Bricks
Cementblocks
Woodplanks/shingles
Other(Specify):
23. Howmanyroomsintotalareinyour
household,includingroomsforsleepingandall
otherrooms?
24. Howmanyroomsareusedforsleeping?
25. Doesyourhouseholdhaveelectricity?
€ Yes
€ No
26. Doesyourhouseholdhavethefollowingitems
whichareingoodworkingorder?
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
Aradio
Atelevision
Amobiletelephone
Alandlinetelephone
Arefrigerator
AcableTV
Ageneratingset
Airconditioner
Acomputer
Electriciron
Afan
€
€
€
€
€
€
Acanoe
Abicycle
Amotorcycleormotorscooter
Ananimal-drawncart
Acarortruck
Aboatwithamotor
27. Doesanymemberofthishouseholdown
28. Doesanymemberofthishouseholdownany
agriculturalland?
€ Yes
€ No
29. Doesanymemberofthishouseholdhavea
bankaccount?
€ Yes
€ No
D.Mortality
30. Havetherebeenanydeathsinthishousehold
withinthelast10years?
€ Yes
€ No
31. Howmanydeaths?
32. Whendidhe/shedie?
Month/Day/Year
33. Howoldwashe/shewhentheydied?
______YEARS(IFOLDERTHANONEYEAR)
______MONTHS(IFLESSTHANONEYEAR)
______DAYS(IF1MONTHORLESS)
34. Whatwashis/herrelationshiptotheheadof
thehousehold?
€
€
€
€
€
€
€
€
€
€
€
€
€
€
€
35. Sexofindividual
€ Male
€ Female
36. WasNAMEpregnantwhenshedied?
€ Yes
€ No
37. Didshedieduringchildbirth?
38. Didshediewithintwomonthsaftertheendofa
pregnancyorchildbirth?
Headofhousehold
Spouse(wife/husband)
Ownson/daughter
Stepson/daughter
Son/daughterin-law
Grandchild
Brother/sister
Parent
Parentinlaw
Niece/nephew
Otherrelative
Domestichelp
Othernon-relative
Co-wife
Other_____________
€ Yes
€ No
€ Yes
€ No
39. Wheredidshegivebirth?
€
€
€
€
€
€
€
€
€
Yourhome
Otherhome
Govt.Hospital
(EnterPHCnamefromQ.3)
OtherPrimaryHealthCareCenter(PHC)
Otherpublichealthfacility
PrivateHospital/clinic
Maternity/Nursinghome
Other________
SECTION E ONWARDS IS FOR FOR ALL WOMEN IN THE HOUSEHOLD WHO
REPORTED BEING PREGNANT BETWEEN JANUARY 2009 AND THE DATE OF
INTERVIEW
E.RespondentCharacteristics
40. Whatisyourdateofbirth?
DD/MM/YY
€ Unknown
41. Whatisyourestimatedage?
42. Whatisyourethnicgrouportribe?
€
€
€
€
Fulani
Hausa
Igbo
Yoruba
Other(Specify):
43. Whatisyourreligion?
44. Howlonghaveyoubeenlivinginyourcurrent
placeofresidence?
45. Iwouldlikeyoutoreadthissentencetome:
“Themangoestohisfarmeveryday.”
46. Asidefromyourownhousework,haveyou
doneanyworkinthelastsevendays?
€
€
€
€
€
€
Catholic
Anglican
Born-againChristian
Moslem
Traditionalist
Other(Specify):
Years___Months____
€
€
€
€
Cannotreadatall
Abletoreadonlypartsofsentence
Abletoreadwholesentence
Blind/visuallyimpaired
€ Yes
€ No
47. Asyouknow,somewomentakeupjobsfor
whichtheyarepaidincashorkind.Otherssell
things,haveasmallbusinessorworkonthe
familyfarmorinthefamilybusiness.Inthelast
sevendays,haveyoudoneanyofthesethings
oranyotherwork?
€ Yes
€ No
48. Althoughyoudidnotworkinthelastseven
days,doyouhaveanyjoborbusinessfrom
whichyouwereabsentforleave,illness,
vacation,maternityleaveoranyothersuch
reason?
€ Yes
€ No
49. Haveyoudoneanyworkinthelast12months?
€ Yes
€ No
50. Whatisyouroccupation,thatis,whatkindof
workdoyoumainlydo?
51. Doyoudothisworkforamemberofyour
family,forsomeoneelse,orareyouselfemployed?
€
€
€
€
€
€
€
€
€
€
€
€
€
€
€
€
Farming
Laboring/building
Fishing
Officejob
Trading/Business
Teacher
Soldier/Policeman/Securityguard
Mechanic
Bar/restaurantattendant
Housemaid/Gardener
Driver/Conductor
Vendor
Doctor/Nurse/Healthcareprofessional
Student
Okada(motorcycle)
Other,specify
€ Familymember
€ Someoneelse
€ Self-employed
52. Doyouusuallyworkthroughouttheyear,ordo
youworkseasonally,oronlyonceinawhile?
53. Areyoupaidincashorkindforthisworkorare
younotpaidatall?
54.
Howmuchareyoupaidforthiswork?
€ Throughouttheyear
€ Seasonally/Partoftheyear
€ Onceinawhile
€
€
€
€
Cashonly
CashandKind
Kindonly
Notpaid
N_______________
€
Daily
€
Weekly
€
Monthly
€
Other
55. Asidefromhisownhousework,hasyour
spouse/partnerdoneanyworkinthelast
sevendays?
€ Yes
€ No
56. Althoughhedidnotworkinthelastseven
days,didhehaveanyjoborbusinessfrom
whichhewasabsentforleave,illness,
vacation,oranyothersuchreason?
€ Yes
€ No
57. Hashedoneanyworkinthelast12months?
€ Yes
€ No
58. Whatishisoccupation,thatis,whatkindof
workdoeshemainlydo?
€
€
€
€
€
€
€
€
€
€
€
€
€
€
€
€
Farming
Laboring/building
Fishing
Officejob
Trading/Business
Teacher
Soldier/Policeman/Securityguard
Mechanic
Bar/restaurantattendant
Housemaid/Gardener
Driver/Conductor
Vendor
Doctor/Nurse/Healthcareprofessional
Student
Okada(motorcycle)
Other,specify
59. Doesheusuallyworkthroughouttheyear,or
doesheworkseasonally,oronlyonceina
while?
€ Throughouttheyear
€ Seasonally/Partoftheyear
€ Onceinawhile
60. Whousuallydecideshowthemoneyyouearn
willbeused:mainlyyou,mainlyyour
husband/partner,oryouandyour
husband/partnerjointly?
€
€
€
€
€
Respondent
Husband/partner
Respondentandhusband/partnerjointly
Someoneelse
Other
€
€
€
€
More
Less
Aboutthesame
Don’tknow
€
€
€
€
€
Respondent
Husband/partner
Respondentandhusband/partnerjointly
Someoneelse
Other
61. Wouldyousaythatthemoneythatyouearnis
morethanwhatyourhusband/partnerearns,
lessthanwhatheearns,oraboutthesame?
62. Whousuallymakesdecisionsabouthealthcare
foryourself:you,yourhusband/partner,you
andyourhusband/partnerjointly,orsomeone
else?
F.Contraception
63.
Wouldyouliketohaveanotherchild,orwould
youprefernottohaveany(more)children?
€
€
€
€
64.
Comparingwithyou,doyouthinkyourpartner
wantsmorechildren,fewerchildren,orthesame
numberofchildren?
€ Same
€ More
€ Fewer
65.
Doyouapproveordisapproveofcouplesusing
contraceptivemethodstoavoidgettingpregnant?
€ Approve
€ Disapprove
€ NeitherApprovenorDisapprove
66.
Whichcontraceptivemethodshaveyouheardof?
€
€
€
€
€
€
€
€
€
€
€
€
€
€
€
Pill
IUD
Injectables
Implants
Foamorjelly
Diaphragm
Femalecondom
Malecondom
Femalesterilization
Malesterilization
Lactationalamenorrheamethod
Rhythm/naturalmethod
Withdrawal
Othermodernmethod,specify
Othertraditionalmethod(Specify):
€
€
€
€
€
€
€
€
€
€
€
€
€
€
€
Pill
IUD
Injectables
Implants
Foamorjelly
Diaphragm
Femalecondom
Malecondom
Femalesterilization
Malesterilization
Lactationalamenorrheamethod
Rhythm/naturalmethod
Withdrawal
Othermodernmethod,specify
Othertraditionalmethod(Specify):
67.
Haveyoueverused…
Haveanotherchild
Nomorechildren
Can'tgetpregnant
Undecided/don'tknow
68.
Areyoucurrentlydoingsomethingorusingany
methodtodelayoravoidgettingpregnant?
€ Yes
€ No
69.
Whichmethodareyouusingtoprevent
unwantedpregnancies?
€
€
€
€
€
€
€
€
€
€
€
€
€
€
€
70.
Howlonghaveyoubeenusingthecurrent
method?
Pill
IUD
Injectablese.g.depoprovera
Implantse.g.norplant
Foamorjelly
Diaphragm
Femalecondom
Malecondom
Femalesterilization
Malesterilization
Lactationalamenorrheamethod
Rhythm/naturalmethod
Withdrawal
Othermodernmethod,specify
Othertraditionalmethod,specify
_____Years______Months
G.PregnancyandBirthHistory
71.
Areyoucurrentlypregnant?
72.
Howmanymonthspregnantareyou?
€ Yes
€ No
€ Don’tknow
ForeachbirthsinceJanuary2009
73.
Whatisthechild’sdateofbirth?
_______Day_______Month______Year
74.
Doesthechildhaveabirthcertificate?
€ Yes
€ No
75.
Wasitasinglebirthormultiplebirthe.g.twins?
€ Single
€ Multiple
76.
Whatisthesexofthechild?
€ Male
€ Female
77.
Ischildstillalive?
€ Yes
€ No
78.
Howoldwasthechildwhenhe/shedied?
79.
Atthetimeyoubecamepregnantwithbaby,didyou
wanttobecomepregnantthen,didyouwantto
waituntillater,ordidyounotwanttohaveany
(more)childrenatall?
€ Then
€ Later
€ Nomorechildren
80.
Duringthispregnancy,didyouseeanyonefor
antenatalcare?
€ Yes
€ No
81.
Whydidn’tyouattendantenatalcare?
€
€
€
€
€
€
€
€
€
€
€
€
€
€
€
€
€
€
Tooexpensive
Toofar
Toobusy
Self-treated
Wastooearlyinpregnancy
Facilityhaspoorstructure
Facilitypoorlystocked
Poorstaffattitude
Poorstaffknowledge
Poorqualityofcare
Servicenotavailable
Notransportation
Didnotneed/Notnecessary
Inconvenienthours
Longwaitingtimes
Preferhomecare
Familydidn'twantmetogo
Other(Specify):
€
€
€
€
€
Yourhome
Otherhome
Govt.Hospital
(EnterPHCnamefromQ.3)
OtherPrimaryHealthCareCenter
(PHC)
Otherpublichealthfacility
PrivateHospital/clinic
Maternity/Nursinghome
Other
82.
Whatwouldyousaywasthemostimportantreason
fromabove?
83.
Wheredidyoureceivemostofyourantenatalcare?
€
€
€
€
84.
Whoprovidedmostofyourcare?
Doctor
Nurse/Midwife
Auxiliarymidwife
CommunityHealthExtensionWorker
(CHEW)
€ TraditionalBirthAttendant(TBA)
€ Noone
€ Others(specify)
€
€
€
€
85.
Howmanymonthspregnantwereyouwhenyou
firstreceivedantenatalcareforthispregnancy?
86.
Howmanytimesintotaldidyoureceiveantenatal
careduringthispregnancy?
87.
Duringthosevisits,wasanyofthefollowingdone
duringatleastonevisit?
€
€
€
€
€
€
€
€
€
€
€
€
€
Wereyouweighed
Wasyourheightmeasured
Wasyourbloodpressuremeasured
Didyougiveaurinesample
Didyougiveabloodsample
Didtheproviderpalpateyourtummy
Wasyouruterineheightmeasured
(thisiswhentheprovidermeasures
yourtummyusingameasurement
tape)
Didthehealthworkeraskforyour
bloodtype
Didyoureceiveadviceonthediet
duringyourpregnancy
Wereyoucounseledonnewborn
care
Wereyoucounseledon
breastfeeding
WereyoucounseledandTestedfor
HIV
Wereyoutoldaboutthesignsof
pregnancycomplications
88.
Duringthispregnancy,wereyougivenaninjection
inthearmtopreventthebabyfromgettingtetanus,
thatis,convulsionsafterbirth?
€ Yes
€ No
€ Don’tknow
89.
Duringthispregnancy,didyoutakeanydrugsto
keepyoufromgettingmalaria?
€ Yes
€ No
€ Don’tknow
90.
Duringthispregnancy,wereyougivenordidyou
buyanyirontabletsorironsyrup?
€ Yes
€ No
€ Don’tknow
91.
Didyouexperienceanyofthefollowingduringthe
pregnancy?
€
€
€
€
€
€
€
€
€
€
€
€
€
€
Severeheadache
Blurredvision
Reduced/Absentfetalmovement
HighBloodpressure
Difficultybreathing
Lossofconsciousness
Swollenhandsandface
Convulsions
Excessivevaginalbleeding
Severelowerabdominalpain
Highfever
Waterbreakwithoutlabor
Don’tknow
Others,specify
92.
Wheredidyougivebirth?
€
€
€
€
€
Yourhome
Otherhome
Govt.Hospital
EnterPHCnamefromQ.3
OtherPrimaryHealthCareCenter
(PHC)
Otherpublichealthfacility
PrivateHospital/clinic
Maternity/Nursinghome
Other
€
€
€
€
93.
Didyouplantogivebirthathome?
€ Yes
€ No
94.
Whatwasyourreasonfornotgivingbirthinahealth
facility?
€
€
€
€
€
€
€
€
€
€
95.
Whoassistedwiththedeliveryofthispregnancy?
Costtoomuch
Facilitynotopen
Facilitytoofar
Notransportation
Don'ttrustfacility/poorquality
service
Nofemaleprovideratfacility
Husband/familydidnotallow
Notnecessary
Notcustomary
Other(specify)
Doctor
Nurse/Midwife
Auxiliarynurse/midwife
CommunityHealthExtensionWorker
(CHEW)
€ TraditionalBirthAttendant(TBA)
€ Noone
€ Others(specify)
€
€
€
€
96.
Didyouplantogivebirthatthisplaceordidyougo
therebecauseyouexperiencedproblemsduring
labor/delivery?
€ Planned
€ Becauseofcomplications
97.
Howdidyougotothehealthfacility?
€
€
€
€
€
€
€
€
€
98.
Howlongdidittaketoreachthefacility?
99.
Howmuchdidyoupayfortransportationtothis
facility?Includethecostofanyonewho
accompaniedyou
Ambulance
Privatecar
Taxi/bus
Cart
Motorbike
Boat
Onfoot
Bicycle
Other(specify)
______HOURS_____MINUTES
€
100. Inyouropinion,howweretheservicesinthis
facility?
€
€
€
€
101. Wouldyourecommendthisfacilitytoyoursisteror
friends?
€ Yes
€ No
102. Canyoutellmewhyyouhaverankedtheservicesas
Excellent/Good?
€
€
€
€
€
€
€
€
€
€
103. Canyoutellmewhyyouhaverankedtheservicesas
Average/Poor?
€
€
€
€
€
€
€
€
€
€
Excellent
Good
Average
Poor
Provideralwaysthere
Providerisverycompetent
Facilityalwaysopen
Staffrespondtomyquestions
Facilityalwayshasnecessary
medicines
Notalongwait
Stafftreatwomenwithrespect
Facilityisclean,sanitary
Other
Don’tknow
Oftenhealthworkernotthere
Providerisnotverycompetent
Oftenfacilityisclosed
Staffdonotanswermyquestions
Facilitydoesnothavenecessary
medicines
Longwaittobeseen
Stafftreatwomenpoorly
Facilityisdirty,unsanitary
Other
Don’tknow
104. Wasthedoctor/nurseonsitewhenyougottothe
facility?
€ Yes
€ No
€ Don’tremember
105. Howmuchintotaldidyoupayforthedelivery
includingthecostofdrugs?
N______
106. Howmanynightsdidyouspendinthehealthfacility
beforeyouwereallowedtogohome?
107. Didyouexperienceanyhealthproblemsduring
laboranddelivery?
€ Retainedplacenta(Placentanot
delivered30minutesafterbaby)
€ Convulsions
€ Prolongedlabor(>12hrs)
€ Lossofconsciousness
€ Abnormalpresentatione.g.breech,
handorfeetcomingfirst
€ Excessivevaginalbleeding
€ Highfever
€ Others
€ NoProblems
108. Whenyouexperiencedthesesymptoms,wereyou
referredtoadifferenthealthfacility?
€ Yes
€ No
109. Towhichfacilitywereyoureferred?
€ GovernmentGeneralHospital
€ PrivateHospital/Clinic
€ Other(specify)
110. Didyougotothereferralfacility?
€ Yes
€ No
111. Whydidyounotgo?
€
€
€
€
€
€
€
€
€
€
112. Whatwasthemostimportantreason?
Costtoomuch
Facilitynotopen
Toofar
Notransportation
Don'ttrustfacility/poorquality
service
Nofemaleprovideratfacility
Husband/familydidnotallow
Notnecessary
Notcustomary
Other
113. Howdidyougotothereferralfacility?
114. Howlongdidittaketoreachthefacility?
€
€
€
€
€
€
€
€
€
Ambulance
Privatecar
Taxi/bus
Cart
Motorbike
Boat
Onfoot
Bicycle
Other
______HOURS_____MINUTES
115. Howmuchdidyoupayfortransportationtothis
facility?Includethecostofanyonewho
accompaniedyou
€
116. Didyoustayovernightinthereferralfacility?
€ Yes
€ No
117. Howmanynightsdidyouspendinthefacilitybefore
youwereallowedtogohome?
118. Howmuchintotaldidyoupayfortreatment
includingthecostofdrugs?
N________
119. Atwhattimeofthedaywasbabyborn?
€ 120. Wasbabybornpremature(i.e.before9months)?
€ Yes
€ No
121. WasthebabybornbyCaesareansection
(operation)?
€ Yes
€ No
122. Wasbabybornbyforcepsorvacuumextraction?
€ Yes
€ No
123. Whenbabywasborn,whatwashis/herrelative
size?
€
€
€
€
€
€
124. Wasbabyweighedatbirth?
€ Yes
€ No
125. Howmuchdidbabyweigh?
126. Didbabycryorbreatheeasilyimmediatelyafter
birth?
Verylarge
Largerthanaverage
Average
Smallerthanaverage
Verysmall
Don’tknow
______kg
€ Yes
€ No
127. Howlongafterbirthdidyoufirstputbabytothe
breast?
€
€
€
€
€
128. Didyougivebabythefirstliquidthatcamefrom
yourbreasts?
€ Yes
€ No
129. Wasbabyexclusivelybreastfedforsixmonths?
€
€
€
€
Yes
No
Babyislessthan6monthsold
Don’tremember
€
€
€
€
Difficultyorfastbreathing
Yellowskin/eyecolor(jaundice)
Poorsuckingorfeeding
Pus,bleeding,ordischargefrom
aroundtheumbilicalcord
Skinlesionsorblisters
Convulsions/spasms/rigidity
Lethargy/unconsciousness
Redorswolleneyeswithpus
Highfever
Other
130. Didbabyexperienceanyofthefollowingwithinthe
1st7daysofbeingborn?
€
€
€
€
€
€
Hours____
Days_____
Weeks_____
Don’tremember
Neverbreastfed
131. Didyougotoahealthfacilityforassistance?
€ Yes
€ No
132. Ifyes,wheredidyoureceivemostofthecare?
€ Govt.Hospital
€ EnterPHCNamefromQ.3
€ OtherPrimaryHealthCareCenter
(PHC)
€ Otherpublichealthfacility
€ PrivateHospital/clinic
€ Maternity/Nursinghome
€ Other
133. Howmuchdidyoupayfortransportationtothis
facility?Includethecostofanyonewho
accompaniedyou
€ 134. Howmuchintotaldidyoupayfortreatment
includingthecostofdrugs?
135. Afterbabywasborn,didanyhealthcareprovideror
atraditionalbirthattendantcheckonyourhealthor
thehealthofyournewborn?
€ Yes
€ No
136. Howlongafterdeliverydidthefirstchecktake
place?
€
€
€
€
€
137. Whocheckedonyourhealthoryournewborn
healthatthattime?
€
€
€
€
138. Wheredidthisfirstchecktakeplace?
Doctor
Nurse/Midwife
Auxiliarynurse/midwife
CommunityHealthExtensionWorker
(CHEW)
€ TraditionalBirthAttendant(TBA)
€ Noone
€ Others(specify)
€
€
€
€
€
€
€
€
€
139. Whatwasdonebythehealthworkerorothers
duringthehealthcheck?
140. Duringthefirst6weeksafterdeliverydidyou
experienceanyofthefollowinghealthproblems?
141. Didyougotoahealthfacilityforassistance?
Hours____
Days_____
Weeks_____
Months_____
Don’tremember
Yourhome
Otherhome
Govt.Hospital
[EnterPHCNamefromQ.3]
OtherPrimaryHealthCareCenter
(PHC)
Otherpublichealthfacility
PrivateHospital/clinic
Maternity/Nursinghome
Other
Examinedmybody
Checkedbreasts
Checkedforheavybleeding
Counseledondangersignsfor
newborn
€ Breastfeeding
€ Counseledonnutrition
€ Other(Specify)
€
€
€
€
€
€
€
€
€
€
€
€
€
€
Highfever
Lowerabdominalpain
Foulsmellingvaginaldischarge
Severebleeding
Convulsions
Lossofconsciousness
Swollenhands/face
Difficultybreathing
Severeheadache
Other(Specify)
€ Yes
€ No
142. Ifyes,wheredidyoureceivemostofthecare?
€ Govt.Hospital
€ EnterPHCNamefromQ.3
€ OtherPrimaryHealthCareCenter
(PHC)
€ Otherpublichealthfacility
€ PrivateHospital/clinic
€ Maternity/Nursinghome
€ Other
143. Didyoustayovernightinthehealthfacility?
€ Yes
€ No
144. Howmanynightsdidyouspendinthefacilitybefore
youwereallowedtogohome?
145. Howmuchintotaldidyoupayfortreatment
includingthecostofdrugs?
H.KnowledgeandPerceptions
146. Doyouknowofanyhealthproblemsthatcan
occurduringpregnancythatcouldendangerthe
lifeofapregnantwoman?
147. Doyouknowofanyhealthproblemsthatcan
occurduringlaborandchildbirththatcould
endangerthelifeofapregnantwoman?
Bleeding
Severeheadache
Blurredvision
Convulsions
Swollenhands/face
Highfever
Lossofconsciousness
Difficultybreathing
Severeweakness
Severeabdominalpain
Accelerated/reducedfetal
movement
€ Waterbreakswithoutlabor
€ Other(Specify):
€ Don’tknowany
€
€
€
€
€
€
€
€
€
€
€
Severebleeding
Severeheadache
Convulsions
Highfever
Lossofconsciousness
Prolongedlabor(>12hours)
Retainedplacenta(placentanot
delivered30minutesafterbaby)
€ Other(Specify):
€ Don’tknowany
€
€
€
€
€
€
€
148. Doyouthinkthereareanygoodreasonsfora
womantoreceiveantenatalcare?
€ Yes
€ No
149. Whatarethosereasons?
€
€
€
€
€
€
Preventmalaria
Healtheducation
Getmedicine
Preventanemiainpregnancy
Toseedoctor
Earlydetectionandmanagementof
complicationduringpregnancy
€ Other(Specify)
€ Don’tknowanyreasons
150. Wheredidyouhear/learnaboutthesereasons?
151. Doyouagree/disagreewiththefollowing
statement:
“Everywomanshouldgivebirthinahealth
facility”
€
€
€
€
€
€
€
€
€
€
€
€
€
€
€
Husband
Mother-in-law
Otherrelative
Friend
Radio
Television
Newspaper
Healthcareworker
ChurchorMosque
Communitymeeting
Townhall
Communitytheatre
SMSoncellphone
Internet
Towncrier
€
€
€
€
€
StronglyAgree
Agree
NeitherAgreenorDisagree
Disagree
StronglyDisagree
NowIwouldliketoaskyousomequestionsabout_____[EnterPHCnamefromQ.3]
152. Inyouropinion,howaretheservicesinthis
facility?
€
€
€
€
€
153. Wouldyourecommendthisfacilitytoyoursister
orfriends?
€ Yes
€ No
154. Canyoutellmewhyyouhaverankedtheservices
asExcellent/Good?
€
€
€
€
€
€
€
€
€
€
Excellent
Good
Average
Poor
Don’tknow
Provideralwaysthere
Providerisverycompetent
Facilityalwaysopen
Staffrespondtomyquestions
Facilityalwayshasnecessary
medicines
Notalongwait
Stafftreatwomenwithrespect
Facilityisclean,sanitary
Other
Don’tknow
155. Canyoutellmewhyyouhaverankedtheservices
asAverage/Poor?
€
€
€
€
€
€
€
€
€
€
Oftenhealthworkernotthere
Providerisnotverycompetent
Oftenfacilityisclosed
Staffdonotanswermyquestions
Facilitydoesnothavenecessary
medicines
Longwaittobeseen
Stafftreatwomenpoorly
Facilityisdirty,unsanitary
Other
Don’tknow
156. HaveyoueverheardabouttheMidwivesService
Scheme(MSS)Program?
€ Yes
€ No
157. Howdidyoufirsthearaboutit?
€
€
€
€
€
€
€
158.
€ Yes
€ No
€ Don’tKnow
IsthereanMSSfacilityinyourcommunity?
Radio/TV
Newspaper/magazine
Posters/pamphlets
Friends/neighbors
Healthworker
Warddevelopmentcommittee
Other
159. HowwouldyouratetheimpacttheMSShashad
onaccesstomidwivesinyourcommunity?
€
€
€
€
€
Largepositiveimpact
Moderatepositiveimpact
Smallpositiveimpact
Noimpact
Negativeimpact
160. HowwouldyouratetheimpacttheMSShashad
onqualityofmaternalhealthservicesinyour
community?
€
€
€
€
€
Largepositiveimpact
Moderatepositiveimpact
Smallpositiveimpact
Noimpact
Negativeimpact
161. HowwouldyouratetheimpacttheMSShashad
onhealthoutcomesinyourcommunity?
€
€
€
€
€
Largepositiveimpact
Moderatepositiveimpact
Smallpositiveimpact
Noimpact
Negativeimpact
I.ImmunizationHistory
162. DoyouhaveavaccinationcardwhereNAME’S
vaccinationsarewrittendown?
€ Yes,seen
€ Yes,notseen
€ No
163. BCG
Day/Month/Year
164. OPV0
Day/Month/Year
165. OPV1
Day/Month/Year
166. OPV2
Day/Month/Year
167. OPV3
Day/Month/Year
168. DPT1
Day/Month/Year
169. DPT2
Day/Month/Year
170. DPT3
Day/Month/Year
171. Measles
Day/Month/Year
st
172. VitaminA1
dose
Day/Month/Year
nd
173. Vitamin2
dose
Day/Month/Year
174. HasNAMEreceivedanyvaccinationorVitaminA
notrecordedonthiscard,includingvaccination
givenonanationalimmunizationdayorchild
healthweek?
€ Yes,Date:
€ No
175. DidNAMEeverreceiveanyvaccinationto
preventhim/herfromgettingdiseaseincluding
vaccinereceivedonnationalimmunizationday
orchildhealthweek?
€ Yes
€ No
176. DidNAMEreceiveaBCGvaccinationagainst
tuberculosisthatisaninjectionintheforearm
thatusuallycausesascar?
€ Yes
€ No
177. DidNAMEreceiveapoliovaccine—thatis,drops
inthemouth?
€ Yes
€ No
178. Whendidhe/shereceivethepoliovaccinethe
firsttime?
€ Justafterbirth
€ Later
179. Howmanytimeswasthepoliovaccinegiven?
180. DidNAMEreceiveaDPTvaccine—thatis,an
injectioninthethighusuallygivenatthesame
timeasthepoliovaccine?
181. HowmanytimeswastheDPTvaccinegiven?
€ Yes
€ No
182. DidNAMEreceiveameaslesinjectionoran
MMRinjection—thatis,aninjectioninthearm
attheageof9monthsoroldertopreventfrom
gettingmeasles?
€ Yes
€ No
183. DidNAMEreceivethismeaslesvaccinebefore
he/sheturnedoneyearold,orafter?
€ Before
€ After
184. DidNAMEeverreceiveavitaminAsupplement
duringanationalimmunizationcampaignor
childhealthweek?
€ Yes
€ No