IDENTIFICATION

CLUSTER NUMBER___________
HOUSEHOLD NUMBER__________
NAME OF HOUSEHOLD HEAD_____________
NAME AND LINE NUMBER OF ELIGIBILE WOMAN______________

INTERVIEWER VISITS

DATE__________
INTERVIEWER'S NAME_________
RESULT

NEXT VISIT ________
DATE_____
TIME_______

FINAL VISIT
DAY________
MONTH________
YEAR_________
INT. CODE______________
RESULT

TOTAL NUMBER OF VISITS

SUPERVISOR
NAME__________
NUMBER_________

FIELD EDITOR
NAME__________
NUMBER___________

OFFICE EDITOR
NUMBER_________

KEYED BY
NUMBER__________

INTRODUCTION AND CONSENT

Introductory Statement:
My name is __________________________. I am working for Mitra and Associates, a private research organization located in Dhaka. We are conducting a survey about health all over Bangladesh under the authority of the National Institute of Population Research and Training (NIPORT), Medical Education and Family Welfare Division, Ministry of Health and Family Welfare (MOHFW). The information we collect will help the government to plan health and family planning services. Your household was selected for the survey. The questions usually take about 30-60 minutes. All of the answers you gibe will be confidential and will not be shared with anyone other than members of our survey team. You don't have to be in the survey, but we hope you will agree to answer the questions since your views are important. If I ask you any question you don't want to answer, just let me know and I will go on to the next question or you can stop the interview at any time.

Why is the study being done?
The survey aims to provide information to address the monitoring and evaluation needs of the Fourth Health, Population and Nutrition Sector Program (HPNSP) and to provide managers and policy makers involved in this program with the information that they need to effectively plan and execute future interventions.

What is involved in the study?
You have been selected as a respondent in this survey. I would like to ask you some questions about you and your children.

What will you have to do if you agree to participate?
Since you have been selected as a respondent in this study, I shall be thankful if you provide your valuable response on certain issues. If some questions cause you embarrassment or make you feel uncomfortable, you can refuse to answer them.

What are the risks and benefits of this study?
By providing information you will not have any risk whatsoever, rather this will help the government and policy planners to evaluate, strengthen and refocus national effort to improve health, population and nutrition programs.

Confidentiality:
Whatever information you provide will be kept strictly confidential. it will be used for research purposes and will be seen only by staff and researchers at the organizations mentioned.

Is there any compensation for participating in the study?
Your participation in the study is voluntary and promises no financial benefit.

Right to refuse or withdraw:
Participation in this survey is voluntary and you can choose not to answer any individual questions or all of the questions. However, we hope that you will participate in this survey since your views are important.

Who do i contact if I have a question or problem?
If you wish to know more about your rights as a participant in this study you may write the Bangladesh Medical Research Council (BMRC), Mohakhali, Dhaka or Mitra and Associates, Main Road 1, House 35, Senpara Parbata, Mirpur 10, Dhaka or Phone 9025410, 9025412. If you have further questions regarding the nature of this study you may also contact NIPORT, 13/1 Sheikh Shaheb Bazar, Azimpur, Dhaka-1205 or Phone 9662495, 58611206.

At this time, do you want to ask me anything about the survey?

May I begin the interview now?

Participant's Name: _______________
(or legal guardian if participant is a minor - note relationship): ______________
Signature (or thumb print): ______________
Date: ___________

Name of witness: _____________
Signature: ______________
Date: _______________

Name of person obtaining consent: ______________
(Must be study investigator or individual who has been designated to obtain consent)
Signature: ____________
Date: _____________________

SECTION 1. RESPONDENT'S BACKGROUND

101. RECORD THE TIME.

102. How long have you been living continuously in (NAME OF CURRENT CITY, TOWN, OR VILLAGE OF RESIDENCE)?

IF LESS THAN ONE YEAR, RECORD '00' YEARS.

103. Just before you moved here, did you live in a city, in a town, or in a rural area?

104. Before you moved here, which DIVISION did you live in?

104A. Do you have a national ID card?

104B. Would you please show me your national ID card?

105. In what month and year were you born?

106. How old were you at your last birthday?

COMPARE AND CORRECT 105 AND/OR 106 IF INCONSISTENT.

106A. Are you now married, separated, deserted, divorced, widowed, or have you never been married?

107. Have you ever attended school/madrasha?

107A. What type of school have you last attended?

108. What is the highest level of school you attended: primary, secondary, or higher?

109. What is the highest class you completed at that level?

IF COMPLETED LESS THAN ONE YEAR AT THAT LEVEL, RECORD '00'.

110. CHECK 108:

111. Now I would like you to read this sentence to me.

SHOW CARD TO RESPONDENT

IF RESPONDENT CANNOT READ WHOLE SENTENCE, PROBE: Can you read any part of the sentence to me?

112. CHECK 111:

113. Do you read a newspaper or magazine at least once a week, less than once a week or not at all?

114. Do you listen to the radio (including FM and community radio) at least once a week, less than once a week or not at all?

115. Do you watch television at least once a week, less than once a week or not at all?

116. Do you own a mobile phone?

117. Do you use your mobile phone for any financial transactions?

118. Do you have an account in a bank or other financial institution that you yourself use?

122. What is your religion?

SECTION 2. REPRODUCTION

201. Now I would like to ask you about all the births you have had during your life. Have you ever given birth?

202. Do you have any sons or daughters to whom you have given birth who are now living with you?

203.

a) How many sons live with you?
b) And how many daughters live with you?

IF NONE, RECORD '00'.

204. Do you have any sons or daughters to whom you have given birth who are alive but do not live with?

205.

a) How many sons are alive but do not live with you?
b) And how many daughters are alive but do not live with you?

IF NONE, RECORD '00'.

206. Have you ever given birth to a boy or girl who was born alive but later died?
IF NO, PROBE: Any baby who cried, who made any movement, sound, or effort to breathe, or who showed any other signs of life even if for a very short time?

207.

a) How many boys have died?
b) And how many girls have died?

208. SUM ANSWERS TO 203, 205, AND 207, AND ENTER TOTAL. IF NONE, RECORD '00'.

209. CHECK 208:
Just to make sure that I have this right, you have had in TOTAL __________ births during your life. Is that correct?

210. CHECK 208:

211. Now I would like to record the names of all your births, whether still alive or not, starting with the first one you had.
RECORD NAMES OF ALL THE BIRTHS IN 212. RECORD TWINS AND TRIPLETS ON SEPARATE ROWS. IF THERE ARE MORE THAN 10 BIRTHS, USE AN ADDITIONAL QUESTIONNAIRE, STTARTING WITH THE SECOND ROW.

212. What name was given to your (first/next baby) baby?
RECORD NAME. BRTH HISTORY NUMBER

213. Is (NAME) a boy or a girl?

214. Were any of these births twins?

215. On what day, month, and year was (NAME) born?

216. Is (NAME) still alive?

217. IF ALIVE: How old was (NAME) at (NAME)'s last birthday?
RECORD AGE IN COMPLETED YEARS.

218. IF ALIVE: Is (NAME) living with you?

219. IF ALIVE: RECORD HOUSEHOLD LINE NUMBER OF CHILD. RECORD '00' IF CHILD NOT LISTED IN HOUSEHOLD.

220. IF DEAD: How old was (NAME) when (he/she) died?

IF '12 MONTHS' OR '1 YR', Did (NAME) have (his/her) first birthday?
THEN ASK : Exactly how many months old was (NAME) when (he/she) died?
RECORD DAYS IF LESS THAN 1 MONTH; MONTHS IF LESS THAN TWO YEARS, OR YEARS.

221. Were there any other live births between (NAME OF PREVIOUS BIRTH ) AND (NAME), including any children who died after birth?

222. Have you had any live births since the birth of (NAME OF LAST BIRTH)?

223. COMPARE 208 WITH NUMBER OF BIRTHS IN BIRTH HISTORY

224. CHECK 215: ENTER THE NUMBER OF BIRTHS IN 2012 OR LATER

225. FOR EACH BIRTH IN 2012 OR LATER, ENTER 'B' IN THE MONTH OF BIRTH IN THE CALENDAR. WRITE THE NAME OF THE CHILD TO THE LEFT OF THE 'B" CODE. FOR EACH BIRTH, ASK THE NUMBER OF COMPLETED MONTHS THE PREGNANCY LASTED AND RECORD 'P' IN EACH OF THE PRECEDING MONTHS ACCORDING TO THE DURATION OF PREGNANCY. (NOTE: THE NUMBER OF 'P'S MUST BE ONE LESS THAN THE NUMBER OF MONTHS THAT THE PREGNANCY LASTED.)

226. Are you pregnant now?

227. How many months pregnant are you?

RECORD NUMBER OF COMPLETED MONTHS. ENTER 'P'S IN THE CALENDAR, BEGINNING WITH THE MONTH OF INTERVIEW AND FOR THE TOTAL NUMBER OF COMPLETED MONTHS.

228. When you got pregnant, did you want to get pregnant at that time?

229. CHECK 208: TOTAL NUMBER OF BIRTHS

ONE OR MORE

a) Did you want to have a baby later on or did you not want any more children?

NONE

b) Did you want to have a baby later on or did you not want any children?

229C. Have you ever heard of menstrual regulation (MR)?

229D. Have you ever used MR?

229E. In the last three years did you use MR?

229G. Have you heard about drugs available for MR?

229H. Have you ever used drugs for MR?

229I. Did you use any MR drug in the last three years?

230. Have you ever had a pregnancy that miscarried, was aborted, or ended in a stillbirth?

231. When did the last such pregnancy end?

232. CHECK 231:

233. In what month and year did the preceding such pregnancy end?

234. How many months pregnant were you when that pregnancy ended?

235. Since January 2012, have you had any other pregnancies that did not result in a live birth?

236. FOR EACH PREGNANCY THAT DID NOT END IN A LIVE BIRTH IN 2012 OR LATER, ENTER 'T' IN THE CALENDAR IN THE MONTH THAT THE PREGNANCY TERMINATED AND 'P' FOR THE REMAINING NUMBER OF COMPLETED MONTHS OF PREGNANCY.

IF THERE ARE MORE THAN FOUR PREGNANCIES THAT DID NOT END IN A LIVE BIRTH, USE AN ADDITIONAL QUESTIONNAIRE STARTING ON THE SECOND LINE.

237. Did you have miscarriages, abortions or stillbirths that ended before 2012?

238. When did the last such pregnancy that terminated before 2012 end?

239. When did your last menstrual period start?

240. From one menstrual period to the next, are there certain days when a woman is more likely to become pregnant?

241. Is this time just before her period begins, during her period, right after her period ended, or halfway between two periods?

242. After the birth of a child, can a woman become pregnant before her menstrual period has returned?

243. CHECK 215 AND 216:

244. COPY INFORMATION IN 212, 213, 215, AND 220 FOR EACH CHILD BORN IN 2007 OR LATER WHO DIED

246. CHECK 220: AGE AT DEATH RECORDED IN DAYS, MONTHS OR 2-4 YEARS

247. Now I would like to ask further questions about your child(ren) who died.
On what day, month and year did (NAME) die?

248. CHECK 247: YEAR OF DEATH

249. CHECK 248: ENTER THE NUMBER OF DEATHS SINCE JANUARY 2012 (CODE 1).
IF NONE, RECORD '0' AND SKIP TO 301

250. CHECK 249: IF ONE OR MORE, READ THE FOLLOWING STATEMENT:

We would like to get more information on the circumstances around the deaths of young children so that the government can provide services to help reduce these deaths. We would like to come back and talk with you about your child(ren's) death. Is this okay?

SECTION 3. CONTRACEPTION

301. Now i would like to talk about family planning - the various ways or methods that a couple can use to delay or avoid a pregnancy.

301A. Have you heard about EMERGENCY CONTRACEPTION PILLS (ECP)? As an emergency measure after unprotected sexual intercourse, women can take special pills at any time within three days to prevent pregnancy?

301B. Have you ever used ECP?

301C. Did you use ECP in the last 12 months?

301D. Have you heard about LACTATIONAL AMENORRHEA METHOD (LAM)? Up to 6 months after childbirth, a woman can use a method that requires she breastfeeds frequently, day and night, and that her menstrual period has not returned.

301E. Have you ever used LAM?

302. CHECK 106A:

302A. CHECK 226:

303. Are you or your husband currently doing something or using any method to delay or avoid getting pregnant?

304. Which method are you using?

RECORD ALL MENTIONED. IF MORE THAN ONE METHOD MENTIONED, FOLLOW SKIP INSTRUCTION FOR HIGHEST METHOD IN LIST.

305. What is the brand name of the pills you are using?

ID DON'T KNOW THE BRAND, ASK TO SEE THE PACKAGE. IF PACKAGE NOT SEEN, SHOW THE BRAND CHART AND CIRCLE THE BRAND NAME OF PILLS.

306. What is the brand name of the condoms you are using?

IF DON'T KNOW THE BRAND, ASK TO SEE THE PACKAGE. IF PACKAGE NOT SEEN, SHOW THE BRAND CHART AND CIRCLE THE BRAND NAME OF PILLS.

307. In what facility did the sterilization take place?

PROBE TO IDENTIFY THE TYPE OF SOURCE. IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

308. In what month and year was the sterilization performed?

309. Since what month and year have you been using (CURRENT METHOD) without stopping?

PROBE: For how long have you been using (CURRENT METHOD) now without stopping?

310. CHECK 308 AND 309, 215 AND 231: ANY BIRTH OR PREGNANCY TERMINATION AFTER MONTH AND YEAR OF START USE OF CONTRACEPTION IN 308 OR 309

311. CHECK 308 AND 309:

312. I would like to ask you some questions about the times you or your husband may have used a method to avoid getting pregnant during the last few years.

USE CALENDAR TO PROBE FOR EARLIER PERIODS OF USE AND NONUSE, STARTING WITH MOST RECENT USE, BACK TO JANUARY 2012. USE NAMES OF CHILDREN, DATES OF BIRTH, AND PERIODS OF PREGNANCY AS REFERNCE POINTS.

IN COLUMN 1, ENTER METHOD USE CODE '0' FOR NONUSE IN EACH BLANK MONTH.

IN COLUMN 2, ENTER CODES FOR DISONTINUATION NEXT TO THE LAST MONTH OF USE. NUMBER OF CODES IN COLUMN 2 MUST BE SAME AS NUMBER OF INTERRUPTIONS OF METHOD USE IN COLUMN 1.

ASK WHY SHE STOPPED USING THE METHOD. IF A PREGNANCY FOLLOWED, ASK WHETHER SHE BECAME PREGNANT UNINTENTIONALLY WHILE USING THE METHOD OE DELIBERATELY STOPPED TO GET PREGNANT.

313. CHECK THE CALENDAR FOR USE OF ANY CONTRACEPTIVE METHOD IN ANY MONTH

314. Have you ever used anything or tried in any way to delay or avoid getting pregnant?

315. CHECK 304:

CIRCLE METHOD CODE:

IF MORE THAN METHOD CODE CIRCLED IN 304, CIRCLE CODE FOR HIGHEST METHOD IN LIST.

316. Where did you obtain (CURRENT METHOD) the last time?

PROBE TO IDENTIFY THE TYPE OF SOURCE.

IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

317. Do you know of a place where you can obtain a method of family planning?

318. Where is that? Any other place?

PROBE TO IDENTIFY EACH TYPE OF SOURCE. IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

319. In some places, there is a clinic set up for a day or part of a day in someone's house or in a school. During the past three months, was there any such clinic in this village or mohalla?

320. Did you visit such a temporary health clinic in the past three months?

321. What services did you receive?

322. Are you aware of any community clinic in your area?

323. Did you visit the community clinic in the past three months?

324. What services did you receive?

325. In the last 6 months, were you visited by a fieldworker who talked to you about family planning or gave you a family planning method?

326. Who visited you to talk about family planning or to give you family planning methods?

Anyone else?

327. During the last six months, how many times did a health worker or workers visit you to talk about family planning or to give you gamily planning methods?

328. When was the last time you were visited by a fieldworker who talked to you about family planning?

IF MORE THAN ONE WORKER VISITED:
When did the last worker visit you?
IF LESS THAN ONE MONTH AGO WRITE '0'.

SECTION 4. PREGNANCY AND POSTNATAL CARE

401. CHECK 215:

402. CHECK 215. RECORD THE BIRTH HISTORY NUMBER IN 403 AND THE NAME AND SURVIVAL STATUS IN 404 FOR EACH BIRTH IN 2014 OR LATER. ASK THE QUESTIONS ABOUT ALL OF THESE BIRTHS. BEGIN WITH THE LAST BIRTH.

Now I would like to ask some questions about your children born in the last three years. (We will talk about each separately.)
403. BIRTH HISTORY NUMBER FROM 212 IN BIRTH HISTORY

404. FROM 212 AND 216:

405. When you get pregnant with (NAME), did you want to get pregnant at that time?

406. CHECK 208:

ONLY ONE BIRTH: a) Did you want to have a baby later on, or did you not want any children?
MORE THAN ONE BIRTH: b) Did you want to have a baby later on, or did you not want any more children?

407. How much longer did you want to wait?

408. Did you see anyone for antenatal care for this pregnancy?

409. Whom did you see? Anyone else?

PROBE TO IDENTIFY EACH TYPE OF PERSON AND RECORD ALL MENTIONED.

IF YOU ARE NOT SURE OF THE DESIGNATATION OF THE PERSON, WRITE HER/HIS NAME AND ASK THE SUPERVISOR TO FIND OUT. CIRCLE THE APPROPRIATE CODE.

410. Where did you receive antenatal care for this pregnancy?

PROBE TO IDENTIFY THE TYPE OF SOURCE. IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

Anywhere else?

411. How many months pregnant were you when you first received antenatal care for this pregnancy?

412. How many times did you receive antenatal care during this pregnancy?

413. As part of your antenatal care during this pregnancy, were any of the following done at least once:

a) WEIGHT MEASURED

b) BLOOD PRESSURE MEASURED

c) URINE TEST

d) BLOOD TEST

e) ULTRASONOGRAPH

f) COUNSEL ON PREGNANCY DANGER SIGNS

g) COUNSELING ON FAMILY PLANING METHOD AFTER BIRTH

414A. During (any of) your antenatal care visit(s), were you told about signs of pregnancy complications?

414B. When you got pregnant with (NAME), did any fieldworker/community worker visit you at your home to counsel you on healthy pregnancy or give you a checkup?

414C. Who visited you?

IF YOU ARE NOT SURE OF THE DESIGNATION OF THE PERSON, WRITE HER/HIS NAME AND ASK THE SUPERVISOR TO FIND OUT. CIRCLE THE APPROPRIATE CODE.
NAME _______________

414D. What did they do:

a) WEIGHT MEASURED

b) BLOOD PRESSURE MEASURED

c) URINE TEST

d) BLOOD TEST

e) COUNSELING ON PREGNANCY DANGER SIGNS

414E. How many home visits did you receive during the last pregnancy?

420. During this pregnancy, were you given or did you buy any iron tablets or iron syrup?

SHOW TABLETS/SYRUPS.

421. During the whole pregnancy, for how many days did you take the tablets or syrup?

IF ANSWER IS NOT NUMERIC, PROBE FOR APPROXIMATE NUMBER OF DAYS.

427. Was (NAME) weighed at birth?

428. How much did (NAME) weigh?

RECORD WEIGHT IN KILOGRAMS FROM HEALTH CARD, IF AVAILABLE.

429. Who assisted with the delivery of (NAME)? Anyone else?

PROBE FOR THE TYPE(S) OF PERSON(S) AND RECORD ALL MENTIONED.

IF RESPONDENT SAYS NO ONE ASSISTED, PROBE TO DETERMINE WHETHER ANY ADULTS WERE PRESENT AT THE DELIVERY.

IF YOU ARE NOT SURE OF THE DESIGNATION OF THIS PERSON, WRITE HER/HIS NAME AND ASK THE SUPERVISOR TO FIND OUT. CIRCLE THE APPROPRIATE CODE.

430. Where did you give birth to (NAME)?

PROBE TO IDENTIFY THE TYPE OF SOURCE. IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

IF CODE 42 OR 43 IS CIRCLED, ASK THE NAME OF THE FACILITY

ASK FOR DISCHARGE LETTER OR OTHER DOCUMENT TO GET THIS INFORMATION.

431. How long after (NAME) was delivered did you stay there?

IF LESS THAN ONE DAY, RECORD HOURS; IF LESS THAN ONE WEEK, RECORD DAYS.

432. Was (NAME) delivered by caesarean, that is, did they cut your belly open to take the baby out?

433. When was the decision made to have the caesarean section? Was it before or after your labor pains started?

433A. How many days before the delivery was the decision to have caesarean section made?

433D. Who proposed first to have the birth delivered by caesarean section, you, a family member, or a doctor?

433E. Were you or your family told the reasons for having the operation?

433F. What were the reasons for making the decision to have the caesarean section? Any other reason?

CIRCLE ALL MENTIONED.

433G. CHECK

433H. Did you have a caesarean section before this birth?

433I. Did you or any of your family members ever use a mobile phone to get health services or advise for you or (NAME) during your pregnancy or delivery?

433J. What was the reason the mobile phone was used? Any other reason?

CIRCLE ALL MENTIONED.

433K. Who did you call? Any other person?

CIRCLE ALL MENTIONED. IF YOU ARE NOT SURE OF THE DESIGNATION OF THIS PERSON, WRITE HER/HIS NAME AND ASK THE SUPERVISOR TO FIND OUT. CIRCLE THE APPROPRIATE CODE.

433L. How much did you pay in total for your last delivery? IF MORE THAN 999995, WRITE 999995.

433M. Where did you get the money for (NAME'S) delivery?

433N. CHECK 430: PLACE OF

433O. Now I would like to ask you about some specific questions about what was done with (NAME) during and immediately following delivery. Was a Clean Delivery Kit used during the delivery of (NAME)?

SHOW PICTURE OF DELIVERY KIT

433P. What was used to cut the cord?

433Q. Was the (INSTRUMENT IN 433P) boiled before the cord was cut?

433R. Was anything applied to the cord immediately after cutting and tying it?

433S. Did you or anyone else put chlorhexidine on the cord stump?

SHOW GOVERNMENT SUPPLIED SAMPLE AND MARKET SAMPLE.

433T. Other than chlorhexidine, what was applied to the cord after it was cut and tied?

433U. How long after birth was (NAME) dried?

433V. After the birth, was (NAME) put directly on the bare skin of your chest?

SHOW PICTURE OF SKIN-TO-SKIN POSITION.

433W. How long after delivery was (NAME) bathed for the first time?

IF LESS THAN ONE DAY, RECORD IN HOURS. IF LESS THAN ONE WEEK, RECORD IN DAYS.

434. CHECK 430: PLACE OF

OTHER (GO TO 434A)
CODE '11' OR '96' CIRCLED (GO TO 434I)

434A. To go to the facility where you gave birth to (NAME), did you move from another health facility, did you go there directly from your home, or from somewhere else that was not a health facility?

434B. From which facility did you move to the facility where you gave birth to (NAME)?

PROBE TO IDENTIFY THE TYPE OF SOURCE. IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

434C. Why did you move from one facility to the facility where you gave birth to (NAME)?

434D. Did a health worker go with you when you moved to the facility where you gave birth to (NAME)?

434E. What means of transport did you use to get from the previous facility to the facility where you gave birth to (NAME)?

434F. How long did it take you to reach the health facility?

PROBE FOR ESTIMATED TIME FROM WHEN DECISION WAS MADE TO GO TO THE FACILITY AND WHEN RESPONDENT ARRIVED.

434G. What means of transport did you use to get to the facility where you gave birth to (NAME)?

434H. Who arranged transportation to the health facility?

434I. CHECK 430: PLACE OF DELIVERY

435. I would like to talk to you about checks on your health after delivery, for example, someone asking you questions about your health or examining you? Did anyone check on your health while you were still in the facility?

435A. During this check, were you counseled about:

a. INFO ON FAMILY PLANNING METHODS

b. FAMILY P LANNING SOURCES

c. IMPORTANCE OF SPACING AND/OR LIMITING BIRTHS

d. IMMEDIATE IUD INSERTION

e. IMMEDIATE IMPLANT INSERTION

f. IMMEDIATE TUBAL LIGATION

g. USE OF LAM

h. PROGESTERONE PILL ONLY- APAN

i. EXCLUSIVE BREASTFEEDING

436. How long after delivery did the first check take place?

IF LESS THAN ONE DAY, RECORD HOURS. IF LESS THAN ONE WEEK, RECORD DAYS.

437. Who checked on your health at that time?

PROBE FOR THE MOST QUALIFIED PERSON. IF YOU ARE NOT SURE OF THE DESIGNATION OF THIS PERSON, WRITE HER/HIS NAME AND ASK THE SUPERVISOR TO FIND OUT. CIRCLE THE APPROPRIATE CODE.

438. Now I would like to talk to you about checks on (NAME)'s health after delivery- for example, someone examining (NAME), checking the cord, or seeing if (NAME) is OK. Did anyone check on (NAME)'s health while you were still in the facility?

439. How long after delivery was (NAME);s health first checked?

IF LESS THAN ONE DAY, RECORD HOURS. IF LESS THAN ONE WEEK, RECORD DAYS.

440. Who checked on (NAME)'s health at that time?

PROBE FOR THE MOST QUALIFIED PERSON. IF YOU ARE NOT SURE OF THE DESIGNATION OF THIS PERSON, WRITE HER/HIS NAME AND ASK THE SUPERVISOR TO FIND OUT. CIRCLE THE APPROPRIATE CODE.

441. Now I want to talk to you about what happened after you left the facility. Did anyone check on your health after you left the facility?

442. How long after delivery did that check take place?

IF LESS THAN ONE DAY, RECORD HOURS. IF LESS THAN ONE WEEK, RECORD DAYS.

443. Who checked on your health at that time?

PROBE FOR THE MOST QUALIFIED PERSON. IF YOU ARE NOT SURE OF THE DESIGNATION OF THIS PERSON, WRITE HER/HIS NAME AND ASK THE SUPERVISOR TO FIND OUT. CIRCLE THE APPROPRIATE CODE.

444. Where did the check take place?

PROBE TO IDENTIFY THE TYPE OF SOURCE. IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

445. I would like to talk to you about checks on (NAME)'s health after you left (FACILITY IN 430). Did any health care provider or a traditional birth attendant check on (NAME)'s health in the two months after you left (FACILITY IN 430)?

446. How many hours, days, or weeks after the birth of (NAME) did that check take place?

IF LESS THAN ONE DAY, RECORD HOURS. IF LESS THAN ONE WEEK, RECORD DAYS.

447. Who checked on (NAME)'S health at that time?

PROBE FOR THE MOST QUALIFIED PERSON. IF YOU ARE NOT SURE OF THE DESIGNATION OF THIS PERSON, WRITE HER/HIS NAME AND ASK THE SUPERVISOR TO FIND OUT. CIRCLE THE APPROPRIATE CODE.

448. Where did this check of (NAME) take place?

PROBE TO IDENTIFY THE TYPE OF SOURCE. IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

449. I would like to talk to you about checks on your health after delivery, for example, someone asking you questions about your health or examining you. Did anyone check on your health after you gave birth to (NAME)?

450. How long after delivery did the first check take place?

IF LESS THAN ONE DAY, RECORD HOURS. IF LESS THAN ONE WEEK, RECORD DAYS.

451. Who checked on your health at that time?

PROBE FOR THE MOST QUALIFIED PERSON. IF YOU ARE NOT SURE OF THE DESIGNATION OF THIS PERSON, WRITE HER/HIS NAME AND ASK THE SUPERVISOR TO FIND OUT. CIRCLE THE APPROPRIATE CODE.

453. I would like to talk to you about checks on (NAME)'s health after delivery - for example, someone examining (NAME), checking the cord, or seeing if (NAME) is OK in two months after (NAME) was born, did any health care provider or a traditional birth attendant check on (NAME)'s health?

454. How many hours, days, or week after the birth of (NAME) did the first check take place?

IF LESS THAN ONE DAY, RECORD HOURS. IF LESS THAN ONE WEEK, RECORD DAYS.

455. Who checked on (NAME)'s health at the time?

PROBE FOR THE MOST QUALIFIED PERSON. IF YOU ARE NOT SURE OF THE DESIGNATION OF THIS PERSON, WRITE HER/HIS NAME AND ASK THE SUPERVISOR TO FIND OUT. CIRCLE THE APPROPRIATE CODE.

457. During the first two days after (NAME)'s birth, did any health care provider do the following:

a) Examine the cord?

b) Measure (NAME)'s temperature?

c) Counsel you on danger signs for newborns?

d) Counsel you on breastfeeding?

e) Observe (NAME) breastfeeding?

457A. In the first two months after delivery, did you receive a vitamin A dose like (this/any of these)?

SHOW COMMON TYPES OF CAPSULE/SYRUP.

458. Has your menstrual period returned since the birth of (NAME)?

459. Did your period return between the birth of (NAME) and your next pregnancy?

460. For how many months after the birth of (NAME) did you not have a period?

461. CHECK 226: IS RESPONDENT PREGNANT?

462. Have you had sexual intercourse since the birth of (NAME)?

463. For how many months after the birth of (NAME) did you not have sexual intercourse?

464. Did you ever breastfeed (NAME)?

465. CHECK 404: IS CHILD LIVING

466. How long after birth did you first put (NAME) to the breast?

IF LESS THAN 1 HOUR, RECORD '00' HOURS.; IF LESS THAN 24 HOURS, RECORD HOURS; OTHERWISE, RECORD DAYS.

467. In the first three days after delivery, was (NAME) given anything to drink other than breast milk?

468. CHECK 404: IS CHILD LIVING?

469. Are you still breastfeeding (NAME)?

469A. For how many months did you breastfeed (NAME)?

470. Did (NAME) drink anything from a bottle with a nipple yesterday or last night?

471. GO BACK TO 405 IN NEXT COLUMN; OR IF NO MORE BIRTHS, GO TO 501A.

SECTION 5A. CHILD IMMUNIZATION (LAST BIRTH)

501A. CHECK 215 IN THE BIRTH HISTORY: ANY BIRTHS IN 2014 OR LATER?

502A. RECORD THE NAME AND BIRTH HISTORY NUMBER FROM 212 OF THE LAST CHILD BORN IN 2014 OR LATER.

503A. CHECK 216 FOR CHILD:

504A. Do you have a card or other document where (NAME)'s vaccinations are written down?

505A. Did you ever have a vaccination card for (NAME)?

506A. CHECK 504A:

507A. May i see the card or other document where (NAME)'s vaccinations are written down?

508A. COPY DATES FROM THE CARD

WRITE '44' IN 'DAY' COLUMN IF CARD SHOWS THAT A DOSE WAS GIVEN, BUT NO DATE IS RECORDED.

509A. CHECK 508A: 'BCG' TO 'MEASLES AT 15 MONTHS', ALL RECORDED?

510A. In addition to what is recorded on (this document/these documents), did (NAME) receive any other vaccinations, including vaccinations received in campaigns or immunization days or child health days?

RECORD 'YES' ONLY IF THE RESPONDENT MENTIONS AT LEAST ONE OF THE VACCINATIONS IN 508A THAT ARE NOT RECORDED AS HAVING BEEN GIVEN.

511A. Did (NAME) ever receive any vaccinations to prevent (NAME) from getting diseases, including vaccinations received in campaigns or immunization days or child health days?

512A. Has (NAME) ever received a BCG vaccination against tuberculosis, that is, an injection in the left upper arm or shoulder that usually causes a scar?+E154

514A. Has (NAME) ever received a pentavalent vaccination, that is, an injection given in the thigh at the same time as polio drops and PCV?

515A. How many times did (NAME) receive the pentavalent vaccine?

516A. Has (NAME) ever received oral polio vaccine, that is, about two drops in the mouth to prevent polio?

517A. Did (NAME) receive the first oral polio vaccine in the first two weeks after birth or later?

518A. How many times did (NAME) receive the oral polio vaccine?

519A. Has (NAME) ever received a pneumococcal vaccination, that is, an injection in the thigh to prevent pneumonia?

520A. How many times did (NAME) receive pneumococcal vaccination?

521A. Has (NAME) ever received an IPV vaccination, that is, an injection in the thigh to prevent polio?

523A. Has (NAME) ever received a measles-rubella vaccination, that is, an injection into the muscles of the left thigh to prevent measles?

524A. How many times did (NAME) receive the measles-rubella vaccine?

525A. Did (NAME) receive any polio vaccine from the National Immunization Days (NIDs)?

526A. At which national immunization day campaigns did (NAME) receive vaccinations?

527A. Did (NAME) receive any measles-rubella vaccine from the National Measles-Rubella Campaign?

528A. CONTINUE WITH 501B

SECTION 5B. CHILD IMMUNIZATION (NEXT-TO-LAST BIRTH)

501B. CHECK 215 IN THE BIRTH HISTORY: ANY BIRTHS IN 2014 OR LATER?

502B. RECORD THE NAME AND BIRTH HISTORY NUMBER FROM 212 OF THE LAST CHILD BORN IN 2014 OR LATER.

503B. CHECK 216 FOR CHILD:

504B. Do you have a card or other document where (NAME)'s vaccinations are written down?

505B. Did you ever have a vaccination card for (NAME)?

506B. CHECK 504B:

507B. May i see the card or other document where (NAME)'s vaccinations are written down?

508B. COPY DATES FROM THE CARD\

WRITE '44' IN 'DAY' COLUMN IF CARD SHOWS THAT A DOSE WAS GIVEN, BUT NO DATE IS RECORDED.

509B. CHECK 508B: 'BCG' TO 'MEASLES AT 15 MONTHS', ALL RECORDED?

510B. In addition to what is recorded on (this document/these documents), did (NAME) receive any other vaccinations, including vaccinations received in campaigns or immunization days or child health days?

RECORD 'YES' ONLY IF THE RESPONDENT MENTIONS AT LEAST ONE OF THE VACCINATIONS IN 508B THAT ARE NOT RECORDED AS HAVING BEEN GIVEN.

511B. Did (NAME) ever receive any vaccinations to prevent (NAME) from getting diseases, including vaccinations received in campaigns or immunization days or child health days?

512B. Has (NAME) ever received a BCG vaccination against tuberculosis, that is, an injection in the left upper arm or shoulder that usually causes a scar?

514B. Has (NAME) ever received a pentavalent vaccination, that is, an injection given in the thigh at the same time as polio drops and PCV?

515B. How many times did (NAME) receive the pentavalent vaccine?

516B. Has (NAME) ever received oral polio vaccine, that is, about two drops in the mouth to prevent polio?

517B. Did (NAME) receive the first oral polio vaccine in the first two weeks after birth or later?

518B. How many times did (NAME) receive the oral polio vaccine?

519B. Has (NAME) ever received a pneumococcal vaccination, that is, an injection in the thigh to prevent pneumonia?

520B. How many times did (NAME) receive pneumococcal vaccination?

521B. Has (NAME) ever received an IPV vaccination, that is, an injection in the thigh to prevent polio?

523B. Has (NAME) ever received a measles-rubella vaccination, that is, an injection into the muscles of the left thigh to prevent measles?

524B. How many times did (NAME) receive the measles-rubella vaccine?

525B. Did (NAME) receive any polio vaccine from the National Immunization Days (NIDs)?

526B. At which national immunization day campaigns did (NAME) receive vaccinations?

527B. Did (NAME) receive any measles-rubella vaccine from the National Measles-Rubella Campaign?

528B. CHECK 215 IN BIRTH HISTORY: ANY MORE BIRTHS IN 2014 OR LATER?

SECTION 6. CHILD HEALTH AND NUTRITION

601. CHECK 224:

602. CHECK 215: RECORD THE BIRTH HISTORY NUMBER IN 603 AND THE NAME AND SURVIVAL STATUS IN 604 FOR EACH BIRTH IN 2012 OR LATER. ASK THE QUESTIONS ABOUT ALL OF THESE BIRTHS. BEGIN WITH THE LAST BIRTH.
IF THERE ARE MORE THAN 2 BIRTHS, USE LAST COLUMN OF ADDITIONAL QUESTIONNAIRE(S).
Now I would like to ask some questions about your children born in the last five years. (We will talk about each separately.)

603. BIRTH HISTORY NUMBER FROM 212 IN BIRTH HISTORY.

604. FROM 212 AND 216:

605. In the last six months, was (NAME) given vitamin A dose like any of these?
SHOW COMMON TYPES OF CAPSULES/SYRUPS.

606. In the last seven days, was (NAME) given iron pills, sprinkles with iron, or iron syrup like any of these?
SHOW COMMON TYPES OF PILLS/SPRINKLES/SYRUPS.

607. Was (NAME) given any drug for intestinal worms in the last six months?

608. Has (NAME) had diarrhoea in the last 2 weeks? (Local language has been added here)

609. CHECK 469: CURRENTLY BREASTFEEDING?

YES: Now I would like to know how much (NAME) was given to drink during the diarrhoea including breastmilk. Was (NAME) given less than usual to drink, about the same amount, or more than usual to drink?
IF LESS, PROBE: Was (NAME) given much less than usual to drink or somewhat less?

NO/NOT ASKED: Now I would like to know how much (NAME) was given to drink during the diarrhoea. Was (NAME) given less than usual to drink, about the same amount, or more than usual to drink?
IF LESS, PROBE: Was (NAME) given much less than usual to drink or somewhat less?

610. When (NAME) had diarrhoea, was (NAME) given less than usual to eat, about the same amount, more than usual, or nothing to eat?
IF LESS, PROBE: Was (NAME) given much less than usual to eat or somewhat less?

611. Did you seek advice or treatment for the diarrhoea from any source?

612. Where did you seek advice or treatment? Anywhere else?
PROBE TO IDENIFY THE TYPE OF SOURCE.
IF UNABLE TO IDENTIFY IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE(S).

615. Was (NAME) given any of the following at any time since (NAME) started having the diarrhoea:

a) a fluid made from a special packet called ORSaline PACKET?

b) A home-made sugar-salt water solution (laban gur)?

c) Zinc syrup?

d) Zinc tablets?

618. Has (NAME) been ill with a fever at any time in the last 2 weeks?

620. Has (NAME) had an illness with a cough at any time in the last 2 weeks?

621. Has (NAME) had fast, short, rapid breaths or difficulty breathing at any time in the last 2 weeks?

622. Was the fast or difficult breathing due to a problem in the chest or to a blocked or runny nose?

623. CHECK 618: HAD FEVER?

624. Did you seek advice or treatment for the illness from any source?

625. Where did you seek advice or treatment? Anywhere else?
PROBE TO IDENIFY THE TYPE OF SOURCE.
IF UNABLE TO IDENTIFY IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE(S).

626. CHECK 625:

627. Where did you first seek advice or treatment?
USE LETTER CODE FROM 625.

628. How many days after the illness began did you first seek advice or treatment for (NAME)?
IF THE SAME DAY RECORD '00'.

630. What drugs did (NAME) take? Any other drugs?
RECORD ALL MENTIONED.

646. GO BACK TO 604 IN NEXT COLUMN; OR IF NO MORE BIRTHS, GO TO 649.

649. CHECK 215 AND 218, ALL ROWS: NUMBER OF CHILDREN BORN IN 2015 OR LATER LIVING WITH THE RESPONDENT

NONE (GO TO 701)

650. Now I would like to ask you about liquids or foods that (NAME FROM 649) had yesterday during the day or at night. I'm interested in whether your child had the item I mention even if it was combined with other foods.
Did (NAME FROM 649) drink or eat:

a) Plain water?

b) Juice or juice drinks?

c) Clear broth?

d) Milk such as tinned, powdered, or fresh animal milk?
IF YES: How many times did (NAME) drink milk?

IF 7 OR MORE TIMES, RECORD '7'.

e) Infant formula?
IF YES: How many times did (NAME) drink infant formula?

IF 7 OR MORE TIMES, RECORD '7'.

f) Any other liquids?

g) Yogurt?
IF YES: How many times did (NAME) eat yogurt?

IF 7 OR MORE TIMES, RECORD '7'.

h) Any [BRAND NAME OF COMMERCIALLY FORTIFIED BABY FOOD, E.G., Cerelac]?

i) Bread, rice, noodles, porridge, other foods made from grains?

j) Pumpkin, carrots, squash, or sweet potatoes that are yellow or orange inside?

k) White potatoes, white yams. manioc, cassava, or any other foods made from roots?

l) Any dark green, leafy vegetables?

m) Ripe mangoes, papayas, or [INSERT ANY OTHER LOCALLY AVAILABLE VITAMIN A-RICH]?

n) Any other fruits or vegetables?

o) Liver, kidney, heart, or other organ meats?

p) Any meat, such as beef, pork, lamb, goat, chicken, or duck?

q) Eggs

r) Fresh or dried fish or shellfish?

s) Any foods made from beans, peas, lentils, or nuts?

t) Cheese or other food made from milk?

u) Any other solid, semi-solid, or soft food?

651. CHECK 650 (CATEGORIES 'g' THROUGH 'u'):

652. Did (NAME FROM 649(eat any solid, semi-solid, or soft foods yesterday during the day or at night?
IF 'YES' PROBE: What kind of solid, semi-solid or soft foods did (NAME) eat?

653. How many times did (NAME FROM 649) eat solid, semi-solid, or soft foods yesterday during the last 24 hours, day or night?
IF 7 OR MORE TIMES, RECORD '7'.

SECTION 7. MARRIAGE AND SEXUAL ACTIVITY

701. CHECK 106A:

704. Is your husband living with you now or is he staying elsewhere?

705. RECORD THE HUSBAND'S NAME AND LINE NUMBER FROM THE HOUSEHOLD QUESTIONNAIRE. IF HE IS NOT LISTED IN THE HOUSEHOLD, RECORD '00'.

709. Have you been married or lived with a man only or more than once

710. CHECK 709:

MARRIED/LIVED WITH A MAN ONLY ONCE: In what month and year did you start living with your husband?
MARRIED/LIVED WITH A MAN MORE THAN ONCE: Now i would like to ask about your first husband. In what month and year did you start living with him?

711. How old were you when you first started living with him?

711A. Do you think you got married at an age that was right for you, or would you have preferred to marry earlier or later?

711B. At what age would have preferred to get married?

711C. Were you studying or attending school just before you got married?

711D. Did you continue your studies after marriage?
IF YES: For how long?

711E. Were you working outside the home just before you got married?

712. CHECK FOR PRESENCE OF OTHERS, BEFORE CONTINUING, MAKE EVERY EFFORT TO ENSURE.
Now I would like to ask some questions about sexual activity in order to gain a better understanding of some important life issues. Let me assure you again that your answers are completely confidential and will not be told to anyone. if we should to any question that you don't want to answer, just let me know and we will go to the next question.

713. How old were you when you had sexual intercourse for the very first time?

714. I would like to ask you about your recent sexual activity. When was the last you had sexual intercourse?
IF LESS THAN 12 MONTHS, ANSWER MUST BE RECORDED IN DAY, WEEKS OR MONTHS. IF 12 MONTHS (ONE YEAR) OR MORE, ANSWER MUST BE RECORDED IN YEARS.

715. How many times during the last month did you have sexual intercourse?
IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE. IF NUMBER OF TIMES IS 95 OR MORE, WRITE '95'.

SECTION 8. FERTILITY PREFERENCES

801. CHECK 106A:

801A. CHECK 304:

802. CHECK 226:

803. Now I have some questions about the future. After the child you are expecting now, would you like to have another child, or would you prefer not to have any more children?

804. Now I have some questions about the future. Would you like to have (a/another) child, or would you prefer not to have any (more) children?

805. CHECK 226:

NOT PREGNANT OR UNSURE: How long would you like to wait from now before the birth of (a/another) child?
PREGNANT: After the birth of the child you are expecting now, how long would you like to wait before the birth of another child?

806. CHECK 226:

807. CHECK 303: USING A CONTRACEPTIVE METHOD?

808. CHECK 805:

809. CHECK 714:

810. CHECK 804:

WANTS TO HAVE A/ANOTHER CHILD: You have said that you do not want (a/another) child soon. Can you tell me why you are not using a method to prevent pregnancy? Any other reason?
WANTS NO MORE/NONE: You have said that that you do not want any (more) children. Can you tell me why you are not using a method to prevent pregnancy? any other reason?
RECORD ALL REASONS MENTIONED.

811. CHECK 303L USING A CONTRACEPTIVE METHOD?

812. Do you think you will use a contraceptive method to delay or avoid pregnancy at any time in the future?

812A. Which contraceptive method would you prefer to use?

812B. What is the main reason that you think you will not use a contraceptive method at any time in the future?

813. CHECK 216:

HAS LIVING CHILDREN: If you could go back to the time you did not have any children and could choose exactly the number of children to have in your whole life, how many would that be?
NO LIVING CHILDREN: If you could choose exactly the number of children to have in your whole life, how many would that be?
PROBE FOR A NUMERIC RESPONSE.

814. How many of these children would you like to be boys, how many would you like to be girls and for how many would it not matter if it's a boy or a girl?

815. In the last month have you:

a) Heard about family planning on the radio?

b) Seen family planning messages on the television?

c) Read about family planning in a newspaper or magazine?

d) Read about family planning in a poster, billboard or leaflet?

e) Heard about family planning in community event?

f) Received a voice or text message about family planning on a mobile phone (SMS)?

g) Read about family planning in social media (Facebook, Twitter, etc.)

h) Read about family planning in a Website or on the internet?

816A. In the last month have you heard about family planning from any community health worker?

816B. Were these government or non-government workers?

817. CHECK 701:

818. CHECK 303: USING A CONTRACEPTIVE METHOD?

819. Would you say that using contraception is mainly your decision, mainly your husband's decision, or did you both decide together?

820, Would you say that not using contraception is mainly your decision, mainly your husband's decision, or did you both decide together?

821. CHECK 304:

822. Does your husband want the same number of children that you want, or does he want more or fewer than you want?

SECTION 9. HUSBAND'S BACKGROUND AND WOMAN'S WORK

901. CHECK 701:

902. How old was your husband on his last birthday?

903. Did your husband ever attend school?

903A. What type of schooling did your husband last attend?

904. What was the highest level of school he attended: primary, secondary, or higher?

905. What was the highest class he completed at that level?
IF COMLETED LESS THAN ONE YEAR AT THAT LEVEL, RECORD '00'.

906. Has your husband done any work in the last 7 days?

907. Has your husband done any work in the last 12 months?

908. What is his occupation? That is, what kind of work does he mainly do?

909. Aside from your own housework, have you done any work in the last seven days?

910. As you know, some women take up jobs for which they are paid in cashor kind. Others sell things, have a small business, or work on the family farm or in the family business. In the last seven days, have you done any of these things or any other work?

911. Although you did not work in the last seven days, do you have any job or business from which you were absent for leave, illness, vacation, maternity leave, or any other such resason?

912. Have you done any work in the last 12 months?

913. What is your occupation? That is, what kind of work do you mainly do?

914. Do you do this work for a member of your family, for someone else, or are you self-employed?

915. Do you usually work throughout the year, or do you do work seasonally, or only once in a while?

916. Are you paid in cash or kind for this work or are you not paid at all?

917. CHECK 701:

918. CHECK 916:

919. Who usually decides how the money you earn will be used: you, your husband, or you and your husband jointly?

921. Who usually decides how your husband's earnings will be used: you, your husband, or you and your husband jointly?

922. Who usually makes decisions about health care for yourself: you, your husband, you and your husband jointly, or someone else?

923. Who usually makes decisions about making major household purchases?

924. Who usually makes decisions about visits to your family or relatives?

931. PRESENCE OF OTHERS AT THIS POINT (PRESENT AND LISTENING, PRESENT BUT NOT LISTENING, OR NOT PRESENT)

932. In your opinion, is a husband justified in hitting or beating his wife in the following situations:

a) if she goes out without telling him

b) If she neglects the children

c) If she argues with him?

d) If she refuses to have sex with him?

e) If she burns the food?

933. If a wife knows her husband has a disease that she can get during sexual intercourse, is she justified in asking that they use a condom when they have sex?

934. Is a wife justified in refusing to have sex with her husband when she knows he has sex with other women?

935. CHECK 701:

936. Can you say no to your husband if you do not want to have sexual intercourse?

937. Could you ask your husband to use a condom if you wanted him to?

SECTION 10. OTHER HEALTH ISSUES

1001. Now I would like to ask you some other questions relating to health matters. Have you had an injection for any reason in the last 12 months?
IF YES: How many injections have you had?
IF NUMBER OF INJECTIONS IS 90 OR MORE, OR DAILY FOR 3 MONTHS OR MORE, RECORD '90'. IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE.

1002. Among these injections, how many were administered by a doctor, a nurse, a pharmacist, a dentist, or any other health worker?
IF NUMBER OF INJECTIONS IS 90 OR MORE, OR DAILY FOR 3 MONTHS OR MORE, RECORD '90'. IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE.

1003. The last time you got an injection from a health worker, did he/she take the syringe and needle from a new, unopened package?

1008. Many different factors can prevent women from getting medical advice or treatment themselves. When you are sick and want to get medical advice or treatment, is each of the following a big problem or not a big problem?

a) Getting permission to go to the doctor?

b) Getting money needed for advice or treatment?

c) The distance to the health facility?

d) Not wanting to go alone?

1009. Are you covered by any health insurance?

1010. What type of health insurance are you covered by?
RECORD ALL MENTIONED.

1011. Do you have a health card which provide free or subsidized health care services?

1012. RECORD THE TIME.

INTERVIEWER'S OBSERVATIONS
TO BE FILLED IN AFTER COMPLETING INTERVIEW

COMMENTS ABOUT INTERVIEW:
___________________________________________________________
COMMENTS ON SPECIFIC QUESTIONS:
___________________________________________________________
ANY OTHER COMMENTS:
___________________________________________________________
SUPERVISOR'S OBSERVATIONS
___________________________________________________________
EDITOR'S OBSERVATION
___________________________________________________________

CALENDAR

INSTRUCTIONS: ONLY ONE CODE SHOULD APPEAR IN ANY BOX. COLUMN 1 REQUIRES A CODE IN EVERY MONTH.

CODES FOR EACH COLUMN:

COLUMN 1: BIRTHS, PREGNANCIES, CONTRACEPTIVE USE (2)

BIRTHS B
PREGNANCIES P
TERMINATIONS T

NO METHOD 0

FEMALE STERILIZATION 1
MALE STERILIZATION 2
IUD 3
INJECTABLES 4
IMPLANTS 5
PILL 6
CONDOM 7
EMERGENCY CONTRACEPTION PILL 8
LACTATIONAL AMENORRHEA METHOD 9
SAFE PERIOD/RHYTHM METHOD J
WITHDRAWAL K
OTHER MODERN METHOD X

OTHER TRADITIONAL METHOD Y
COLUMN 2: DISCONTINATION OF CONTRACEPTIVE USE

INFREQUENT SEX/HUSBAND AWAY 1
BECAME PREGNANT WHILE USING 2
WANTED TO BECOME PREGNANT 3
WANTED MORE EFFECIVE METHOD 4
SIDE EFFECTS/HEALTH CONCERNS 5

LACK OF ACCESS/TOO FAR 6
COSTS TOO MUCH 7
INCONVENIENT TO USE 8
UP TO GOD/FATALISTIC F
DIFFICULT TO GET PREGNANT/MENOPAUSAL A
MARITAL DISSOLUTION/SEPARATION D
OTHER (SPECIFY) __________________ X
DON'T KNOW Z

CALENDAR

2018

06 JUN 01 _____
05 MAY 02 _____
04 APR 03 ______
03 MAR 04 ______
02 FEB 05 _______
01 JAN 06 _______

2017

12 DEC 07 _______
11 NOV 08 _______
10 OCT 09 _______
09 SEP 10 _______
08 AUG 11 _______
07 JUL 12 _______
06 JUN 13 _______
05 MAY 14 _______
04 APR 15 _______
03 MAR 16 _______
02 FEB 17 _______
01 JAN 18 _______

2016

12 DEC 19 _______
11 NOV 20 _______
10 OCT 21 _______
09 SEP 22 _______
08 AUG 23 _______
07 JUL 24 _______
06 JUN 25 _______
05 MAY 26 _______
04 APR 27 _______
03 MAR 28 _______
02 FEB 29 _______
01 JAN 30 _______

2015

12 DEC 31 _______
11 NOV 32 _______
10 OCT 33 _______
09 SEP 34 _______
08 AUG 35 _______
07 JUL 36 _______
06 JUN 37 _______
05 MAY 38 _______
04 APR 39 _______
03 MAR 40 _______
02 FEB 41 _______
01 JAN 42 _______

2014

12 DEC 43 _______
11 NOV 44 _______
10 OCT 45 _______
09 SEP 46 _______
08 AUG 47 _______
07 JUL 48 _______
06 JUN 49 _______
05 MAY 50 _______
04 APR 51 _______
03 MAR 52 _______
02 FEB 53 _______
01 JAN 54 _______

2013

12 DEC 55 _______
11 NOV 56 _______
10 OCT 57 _______
09 SEP 58 _______
08 AUG 59 _______
07 JUL 60 _______
06 JUN 61 _______
05 MAY 62 _______
04 APR 63 _______
03 MAR 64 _______
02 FEB 65 _______
01 JAN 66 _______

2012

12 DEC 67 _______
11 NOV 68 _______
10 OCT 69 _______
09 SEP 70 _______
08 AUG 71 _______
07 JUL 72 _______
06 JUN 73 _______
05 MAY 74 _______
04 APR 75 _______
03 MAR 76 _______
02 FEB 77 _______
01 JAN 78 _______

REFERENCE DATES

YEAR OF FIELDWORK: 2017-2018
FIVE YEARS BEFORE SURVEY: 2012
CHILD OLDER THAN 5: 2011
CHILD UNDER 4: 2014
CHILD UNDER 3: 2015
CHILD UNDER 16: 2002