DEMOGRAPHIC AND HEALTH SURVEYS
NEWBORN CARE MODULE
MODEL WOMAN'S QUESTIONNAIRE
PLACE NAME __________
NAME OF HOUSEHOLD HEAD __________
CLUSTER NUMBER __ __ __ __
HOUSEHOLD NUMBER __ __ __ __
NAME AND LINE NUMBER OF WOMAN __________
(1) This section should be adapted for country-specific survey design.
FIRST VISIT:
DATE ______
INTERVIEWER'S NAME ________
RESULT* ________
SECOND VISIT:
DATE ______
INTERVIEWER'S NAME ________
RESULT* ________
THIRD VISIT:
DATE ______
INTERVIEWER'S NAME ________
RESULT* ________
NEXT VISIT:
DATE ______
TIME ______
FINAL VISIT:
DAY __ __
MONTH __ __
YEAR __ __ __ __
INT. NO. __ __ __ __
RESULT* __
TOTAL NUMBER OF VISITS: __
*RESULT CODES:
2 NOT AT HOME
3 POSTPONED
4 REFUSED
5 PARTIALLY COMPLETED
6 INCAPACITATED
7 OTHER (SPECIFY) __________
LANGUAGE OF QUESTIONNAIRE** 01
LANGUAGE OF INTERVIEW** __ __
NATIVE LANGUAGE OF RESPONDENT** __ __
TRANSLATOR USED (YES = 1, NO = 2)
LANGUAGE OF QUESTIONNAIRE** ENGLISH
**LANGUAGE CODES
02 LANGUAGE 2
03 LANGUAGE 3
04 LANGUAGE 4
05 LANGUAGE 5
06 LANGUAGE 6
SUPERVISOR
NAME ______
NUMBER __ __ __ __
FIELD EDITOR
NAME ______
NUMBER __ __ __ __
OFFICE EDITOR
NUMBER __ __
KEYED BY
NUMBER __ __
SECTION 4: PREGNANCY AND POSTNATAL CARE
NB1. Was (NAME) wiped dry within a few minutes after birth?
NO 2
DON'T KNOW 8
NB2. How long after the birth was (NAME) bathed for the first time? IF LESS THAN 1 HOUR, RECORD '00' HOURS; IF LESS THAN 24 HOURS, RECORD HOURS; OTHERWISE, RECORD DAYS.
HOURS 1 ____
DAYS 2 ____
DON'T KNOW 998
NB3. CHECK 430: PLACE OF DELIVERY
CODE 21-36 (GO TO NB7)
NB4. What was used to cut the cord?
KNIFE 2
SCISSORS 3
OTHER (SPECIFY) ______ 6
DON'T KNOW 8
NB5. Was it new or had it ever been used before?
USED BEFORE 2
DON'T KNOW 8
NB6. Was it boiled before it was used to cut the cord?
NO 2
DON'T KNOW 8
NB7. Was anything applied to the stump of the cord at any time?
NO 2 (GO TO 434B)
DON'T KNOW 8 (GO TO 434B)
NB8. (1) What was applied? Anything else?
OTHER ANTISEPTIC (ALCOHOL, SPIRIT, GENTIAN VIOLET) B
MUSTARD OIL C
ASH D
ANIMAL DUNG E
OTHER (SPECIFY) __________ X
CH1. (2) CHECK NB7: SUBSTANCE APPLIED TO CORD
CODE 'A' CIRCLED (GO TO CH3)
CH2. (2) (3) Was chlorhexidine applied to the stump at any time? SHOW SAMPLE OF CHLORHEXIDINE.
NO 2 (GO TO 434B)
DON'T KNOW 8 (GO TO 434B)
CH3. (2) (3) How long after the cord was cut was chlorhexidine first applied? IF LESS THAN 1 HOUR, RECORD '00' HOURS; IF LESS THAN 24 HOURS, RECORD HOURS; OTHERWISE, RECORD DAYS.
DAYS 2 ____
DON'T KNOW 998
CH4. (2) (3) For how many days was chlorhexidine applied to the stump?
2-7 DAYS 2
MORE THAN 7 DAYS 3
DON'T KNOW 8
CH5. (2) (3) How many times per day was chlorhexidine applied to the stump: once a day, twice a day, three times a day, or four or more times a day?
TWICE A DAY 2
THREE TIMES A DAY 3
FOUR OR MORE TIMES A DAY 4
DON'T KNOW 8
(1) Substances applied to the umbilical cord, and terminology used to refer to them should be adapted to the local context.
(2) Questions on chlorhexidine are suggested only for countries with national chlorhexidine programs.
(3) Use local term for chlorhexidine.