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Fistula Module Questionnaire

F1) Sometimes a woman can have a problem of constant leakage of urine or stool from her vagina during the day and night. This problem usually occurs after a difficult childbirth, but it may also occur after a sexual assault or after pelvic surgery.

Have you ever experienced a constant leakage of urine or stool from your vagina during the day and night?

YES 1 (GO TO F3)
NO 2

F2) Have you ever heard of this problem?

YES 1 (GO TO NEXT SECTION)
NO 2 (GO TO NEXT SECTION)

F3) Did this problem start after you delivered a baby or had a stillbirth?

AFTER DELIVERED BABY 1
AFTER HAD STILLBIRTH 2
NEITHER 3 (GO TO F5)

F4) Did this problem start after a normal labor and delivery, or after a very difficult labor and delivery?

NORMAL LABOR/DELIVERY 1 (GO TO F6)
VERY DIFFICULT LABOR/DELIVERY 2 (GO TO F6)

F5) What do you think caused this problem?

SEXUAL ASSAULT 1
PELVIC SURGERY 2
OTHER (SPECIFY): _______ 6
DK 8 (GO TO F7)

F6) How many days after (CAUSE OF PROBLEM FROM F3 OR F5) did the leakage start?

(ENTER 90 IF 90 DAYS OR MORE)

NUMBER OF DAYS AFTER DELIVERY/OTHER EVENT ____

F7) Have you sought treatment for thus condition?

YES 1 (GO TO F9)
NO 2

F8) Why have you not sought treatment?

PROBE AND RECORD ALL MENTIONED.

DO NOT KNOW CAN BE FIXED A (GO TO NEXT SECTION)
DO NOT KNOW WHERE TO GO B (GO TO NEXT SECTION)
TOO EXPENSIVE C (GO TO NEXT SECTION)
TOO FAR D (GO TO NEXT SECTION)
POOR QUALITY OF CARE E (GO TO NEXT SECTION)
COULD NOT GET PERMISSION F (GO TO NEXT SECTION)
EMBARRASSMENT G (GO TO NEXT SECTION)
PROBLEM DISAPPEARED H (GO TO NEXT SECTION)
OTHER (SPECIFY): ____________ X (GO TO NEXT SECTION)

F9) From whom did you last seek treatment?

HEALTH PROFESSIONAL
DOCTOR 1
NURSE/MIDWIFE 2
OTHER PERSON
COMMUNITY/VILLAGE HEALTH WORKER 3
OTHER (SPECIFY): ________ 6

F10) Did you have an operation to fix the problem?

YES 1
NO 2

F11) Did the treatment stop the leakage completely?

IF NO: Did the treatment reduce the leakage?

YES, STOPPED COMPLETELY 1
NOT STOPPED BUT REDUCED 2
NOT STOPPED AT ALL 3
DID NOT RECEIVE TREATMENT 4