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BURKINA FASO DEMOGRAPHIC AND HEALTH SURVEY EDSBF-III, 2003
WOMEN'S QUESTIONNAIRE

IDENTIFICATION

PLACE NAME ______
NAME OF HOUSEHOLD HEAD _______
CLUSTER NUMBER ______
HOUSEHOLD UNIT NUMBER _______
REGION _______
VILLAGE _______

URBAN/RURAL:

URBAN 1
RURAL 2

BIG CITY/OTHER CITY/RURAL:

OUAGADOUGOU 1
OTHER CITY 2
RURAL 3

NAME OF FEMALE RESPONDENT _____

LINE NUMBER OF FEMALE RESPONDENT _____

CHECK HOUSEHOLD QUESTIONNAIRE COVER: IS THE ANEMIA TEST/HIV TEST ANTICIPATED FROM THIS HOUSEHOLD?

YES 1
NO 2

INTERVIEWER VISITS

FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE ______
INTERVIEWER'S NAME ______

RESULT______

1 COMPLETED
2 NOT AT HOME
3 DEFERRED
4 REFUSED
5 PARTIALLY COMPLETED
6 INCAPACITATED
7 OTHER (SPECIFY) _____

NEXT VISIT
DATE ______
TIME ______

FINAL VISIT
DAY _____
MONTH _____
YEAR 2003
INT. NUMBER ______
RESULT __________
TOTAL NUMBER OF VISITS _____

LANGUAGE OF QUESTIONNAIRE: 01

LANGUAGE OF INTERVIEW _____

FRENCH 1
MORÉ 2
DIOULA 3
FOULFOULDÉ/PEUL 4
SÉNOUFO 5
OTHER 6

INTERPRETER USED:

YES 1
NO 2

SUPERVISOR
NAME ______
DATE ______

FIELD EDITOR
NAME ______
DATE ______

OFFICE EDITOR ______
KEYED BY ______

SECTION 1: SOCIO-DEMOGRAPHIC CHARACTERISTICS OF THE RESPONDENTS

INTRODUCTION AND CONSENT:

CONSENT AFTER INFORMATION:

Hello. My name is _______ and I am working with the National Institute of Demography and Statistics. We are in the process of conducting a national survey on the health of women and children. We would very much appreciate your participation in this survey. I would like to ask you questions about your health (and the health of your children). This information will be useful to the government in order to put health services in place. The survey usually takes between 20 and 45 minutes. The information you will give us is strictly confidential and will not be shared with anyone.

Participation in this survey is completely voluntary and you may refuse to answer any or all of the questions. However, we hope you will participate in the survey since your views are important to us.

Do you have any questions to ask me about the survey?
May I begin the interview now?

SIGNATURE OF INTERVIEWER ______
DATE ______

RESPONDENT AGREES TO BE INTERVIEWED 1 (GO TO 101)
RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2 (END INTERVIEW)

101. RECORD THE TIME:

HOUR _____
MINUTES_____

To begin, I would like to ask you questions about yourself and your household.

102. Until the age of 12, did you mostly live in OUAGADOUGOU, in another city, or in a rural setting?

OUAGADOUGOU 1
OTHER CITY 2
RURAL 3

103. How long have you been living continuously in (NAME OF CURRENT PLACE OF RESIDENCE)? IF LESS THAN ONE YEAR, RECORD '00' YEARS.

NUMBER OF YEARS _____

ALWAYS 95 (GO TO 105)
VISITOR 96 (GO TO 105)

104. Just before you moved here, did you live in OUAGADOUGOU, in another city, or in a rural setting?

OUAGADOUGOU 1
OTHER CITY 2
RURAL 3

105. In what month and year were you born?

MONTH ______
DOESN'T KNOW MONTH 98
YEAR ______
DOESN'T KNOW YEAR 9998

106. How old were you at your last birthday?
COMPARE AND CORRECT 105 AND/OR 106 IF INCONSISTENT.

AGE IN COMPLETED YEARS _______

107. Have you ever attended school?

YES 1
NO 2 (GO TO 111)

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

PRIMARY 1
MIDDLE SCHOOL 2
HIGH SCHOOL 3
HIGHER 4

109. What is the highest grade you completed at that level?
RECORD '00' FOR LESS THAN ONE YEAR COMPLETED AND '8' FOR DOESN'T KNOW.

GRADE _____
PRIMARY
0 LESS THAN ONE YEAR COMPLETED
1 1ST GRADE
2 2ND GRADE
3 3RD GRADE
4 4TH GRADE
5 5TH GRADE
8 DOESN'T KNOW
MIDDLE SCHOOL
0 LESS THAN ONE YEAR COMPLETED
1 6TH GRADE
2 7TH GRADE
3 8TH GRADE
4 9TH GRADE
5 FPP
8 DOESN'T KNOW
HIGH SCHOOL
0 LESS THAN ONE YEAR COMPLETED
1 10TH GRADE
2 11TH GRADE
3 12TH GRADE
4 FPB
8 DOESN'T KNOW
POST-SECONDARY
0 LESS THAN ONE YEAR COMPLETED
1 ONE YEAR
2 TWO YEARS
3 THREE YEARS
4 FOUR YEARS
5 FIVE OR MORE YEARS
8 DOESN'T KNOW

109A. CHECK 106:

AGE 24 YEARS OR YOUNGER (GO TO 109B)
AGE 25 YEARS OR MORE (GO TO 110)

109B. Are you currently attending school?

YES 1 (GO TO 110)
NO 2

109C. What is the main reason you stopped going to school?

GOT PREGNANT 01
GOT MARRIED 02
TO WATCH CHILDREN 03
FAMILY NEEDED HELP IN FIELDS/AT WORK 04
COULD NOT PAY FEES 05
HAD TO EARN MONEY 06
SUFFICIENTLY EDUCATED 07
FAILED IN SCHOOL 08
NO LONGER LIKED SCHOOL 09
SCHOOL INACCESSIBLE/TOO FAR 10
OTHER (SPECIFY) ______ 96
DOESN'T KNOW 98

110. CHECK 108:

PRIMARY (GO TO 111)
SECONDARY OR HIGHER (GO TO 114)

111. Now I would like you to read this sentence to me; read the most of it you can.

SHOW CARD TO RESPONDENT.

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

CANNOT READ AT ALL 1
ABLE TO READ ONLY PARTS OF SENTENCE 2
ABLE TO READ WHOLE SENTENCE 3
NO CARD WITH REQUIRED LANGUAGE (SPECIFY LANGUAGE) ______ 4

112. Have you ever participated in a literacy program or any other program that involves learning to read or write (not including primary school)?

YES 1
NO 2

113. CHECK 111:

CODE '2', '3', OR '4' CIRCLED (GO TO 114)
CODE '1' CIRCLED (GO TO 115)

114. Do you read a newspaper or a magazine almost every day, at least once a week, less than once a week or not at all?

ALMOST EVERY DAY 1
AT LEAST ONCE A WEEK 2
LESS THAN ONCE A WEEK 3
NOT AT ALL 4

115. Do you listen to the radio almost every day, at least once a week, less than once a week or not at all?

ALMOST EVERY DAY 1
AT LEAST ONCE A WEEK 2
LESS THAN ONCE A WEEK 3
NOT AT ALL 4

116. Do you watch television almost every day, at least once a week, less than once a week or not at all?

ALMOST EVERY DAY 1
AT LEAST ONCE A WEEK 2
LESS THAN ONCE A WEEK 3
NOT AT ALL 4

117. What is your religion?

CATHOLIC 1
PROTESTANT 2
MUSLIM 3
TRADITIONAL/ANIMIST 4
NOT RELIGIOUS/NONE 5
OTHER (SPECIFY) _____ 6

118. What is your ethnicity?

BOBO 01
DIOULA 02
FULFULDE/PEUL 03
GOURMATCHE 04
GOUROUNSI 05
LOBI 06
MOSSI 07
SENOUFO 08
TOUAREG/BELLA 09
OTHER (SPECIFY) _____ 96
DOESN'T KNOW 98

119. Have you ever consumed alcoholic beverages?

YES 1
NO 2 (GO TO 124)

120. Have you ever been intoxicated after consuming alcoholic beverages?

YES 1
NO 2

121. Over the past three months, how many days have you consumed alcoholic beverages?

NUMBER OF DAYS _____
NONE/NEVER 95 (GO TO 124)

122. CHECK 120:

YES, HAS BEEN INTOXICATED (GO TO 123)
NO, HAS NEVER BEEN INTOXICATED (GO TO 124)

123. Over the past three months, how many times have you been intoxicated?

NUMBER OF TIMES ____
NONE/NEVER 95

124. Over the past three months, have you received an injection?

YES 1
NO 2 (GO TO 201)

125. Over the past three months, how many times have you received an injection?

NUMBER OF INJECTIONS ____
EVERY DAY 95

126. The last time you had an injection, who gave you the shot?

HEALTH PROFESSIONAL 1
PHARMACIST 2
TRADITIONAL HEALER 3
FRIEND/RELATIVE 4
RESPONDENT HERSELF 5
OTHER (SPECIFY) _____ 6

SECTION 2: REPRODUCTION

Now I would like to ask about all the births you have had during your life.

201. Have you ever given birth?

YES 1
NO 2 (GO TO 206)

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

YES 1
NO 2 (GO TO 204)

203. How many sons live with you?
How many daughters live with you?
IF NONE, RECORD '00'.

SONS AT HOME _____
DAUGHTERS AT HOME ______

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

YES 1
NO 2 (GO TO 206)

205. How many sons are alive but do not live with you?
How many daughters are alive but do not live with you?
IF NONE, RECORD '00'.

SONS ELSEWHERE _____
DAUGHTERS ELSEWHERE _____

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 or showed signs of life at birth but did not survive?

YES 1
NO 2 (GO TO 208)

207. How many boys have died?
How many girls have died?
IF NONE, RECORD '00'.

BOYS DEAD _____
GIRLS DEAD _____

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

TOTAL ______

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

YES (GO TO 210)
NO (PROBE AND CORRECT 201-208 AS NECESSARY)

210. CHECK 208:

ONE OR MORE BIRTHS (GO TO 211)
NO BIRTHS (GO TO 226)

Now I would like to record the names of all your births, whether still alive or not, starting with the first one you had.

211. RECORD NAMES OF ALL THE BIRTHS IN 212. RECORD TWINS AND TRIPLETS ON SEPARATE LINES. IF THERE ARE MORE THAN 12 BIRTHS, USE AN ADDITIONAL QUESTIONNAIRE, STARTING WITH THE SECOND ROW.

212. What name was given to your (first/next) baby?

NAME______

213. Was (NAME) a single birth or part of a multiple birth?

SINGLE 1
MULTIPLE 2

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

BOY 1
GIRL 2

215. In what month and year was (NAME) born?
PROBE: What is his/her birthday?

MONTH _____
YEAR _____

216. Is (NAME) still alive?

YES 1
NO 2 (GO TO 220)

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

AGE IN YEARS ______

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

YES 1
NO 2

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

LINE NUMBER _____ (FIRST CHILD, GO TO NEXT BIRTH; OTHERS, GO TO 221)

220. IF DEAD: How old was (NAME) when he/she died?
IF '1 YEAR', PROBE: How many months was (NAME)?

RECORD DAYS IF LESS THAN 1 MONTH; MONTHS IF LESS THAN TWO YEARS; OR YEARS.

DAYS 1 _____
MONTHS 2 _____
YEARS 3 _____

221. Were there any other live births between (NAME OF PREVIOUS BIRTH) and (NAME)?
[DO NOT ASK FOR FIRST BIRTH]

YES 1
NO 2

[GO BACK AND REPEAT 212-221 FOR EACH ADDITIONAL BIRTH]

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

YES 1
NO 2

223. COMPARE 208 WITH NUMBER OF BIRTHS IN HISTORY ABOVE AND MARK:

NUMBERS ARE SAME:
CHECK: FOR EACH BIRTH, YEAR OF BIRTH IS RECORDED. ____
CHECK: FOR EACH LIVING CHILD, CURRENT AGE IS RECORDED. ____
CHECK: FOR EACH DEAD CHILD, AGE AT DEATH IS RECORDED. ____
CHECK: FOR AGE AT DEATH 12 MONTHS OR 1 YEAR, PROBE TO DETERMINE EXACT NUMBER OF MONTHS. _____
NUMBERS ARE DIFFERENT (PROBE AND RECONCILE)

224. CHECK 215 AND ENTER THE NUMBER OF BIRTHS IN 1998 OR LATER.
IF NONE, RECORD '0'.

NUMBER OF BIRTHS ____

225. FOR EACH BIRTH SINCE JANUARY 1998, WRITE 'N' IN THE MONTH OF BIRTH IN THE CALENDAR. FOR EACH BIRTH, ASK THE NUMBER OF MONTHS THE PREGNANCY LASTED AND RECORD 'G' IN EACH OF THE PRECEDING MONTHS ACCORDING TO THE DURATION OF PREGNANCY.

NOTE: THE NUMBER OF G's MUST BE ONE LESS THAN THE NUMBER OF MONTHS THAT THE PREGNANCY LASTED. WRITE THE NAME OF THE CHILD TO THE LEFT OF CODE N.

226. Are you pregnant now?

YES 1
NO 2 (GO TO 229)
UNSURE 8 (GO TO 229)

227. How many months pregnant are you?

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

NUMBER OF MONTHS ____

228. At the time you became pregnant, did you want to become pregnant then, did you want to wait until later, or did you not want to have any more children at all?

THEN 1
LATER 2
NOT AT ALL/NO MORE CHILDREN 3

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

YES 1
NO 2 (GO TO 237)

230. When did the last such pregnancy end?

MONTH _____
YEAR _____

231. CHECK 230:

LAST PREGNANCY ENDED IN JANUARY 1998 OR LATER (GO TO 232)
LAST PREGNANCY ENDED BEFORE JANUARY 1998 (GO TO 237)

232. How many months pregnant were you when the last such pregnancy ended?
RECORD NUMBER OF COMPLETED MONTHS. ENTER 'F' IN THE CALENDAR IN THE MONTH THAT THE PREGNANCY TERMINATED AND 'G' FOR THE REMAINING NUMBER OF COMPLETED MONTHS.

NUMBER OF MONTHS ____

233. Since January 1998, have you had any other pregnancies that did not result in a live birth?

YES 1
NO 2 (GO TO 237)

234. ASK THE DATE AND THE DURATION OF PREGNANCY FOR EACH EARLIER NON-LIVE BIRTH PREGNANCY BACK TO JANUARY 1998.

ENTER 'F' IN THE CALENDAR IN THE MONTH THAT EACH PREGNANCY TERMINATED AND 'G' FOR THE REMAINING NUMBER OF COMPLETED MONTHS.

235. Did you have any miscarriages, abortions or stillbirths that ended before 1998?

YES 1
NO 2 (GO TO 237)

236. When did the last such pregnancy that terminated before January 1998 end?

MONTH _____
YEAR _____

237. When did your last menstrual period start?
RECORD THE DATE, IF GIVEN.

DATE, IF GIVEN_____________
DAYS AGO 1 ____
WEEKS AGO 2 ____
MONTHS AGO 3 ____
YEARS AGO 4 ____

IN MENOPAUSE/HAS HAD HYSTERECTOMY 994
BEFORE LAST BIRTH 995
NEVER MENSTRUATED 996

238. From one menstrual period to the next, are there certain days when a woman is more likely to become pregnant if she has sexual relations?

YES 1
NO 2 (GO TO 301)
DOESN'T KNOW 8 (GO TO 301)

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

JUST BEFORE HER PERIOD BEGINS 1
DURING HER PERIOD 2
RIGHT AFTER HER PERIOD HAS ENDED 3
HALFWAY BETWEEN TWO PERIODS 4
OTHER (SPECIFY) _____ 6
DOESN'T KNOW 8

SECTION 3: CONTRACEPTION

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

CIRCLE CODE '1' IN 301 FOR EACH METHOD MENTIONED SPONTANEOUSLY. THEN PROCEED DOWN COLUMN 301, READING THE NAME AND DESCRIPTION OF EACH METHOD NOT MENTIONED SPONTANEOUSLY. CIRCLE CODE '1' IF METHOD IS RECOGNIZED AND CODE '2' IF NOT RECOGNIZED. THEN, FOR EACH METHOD WITH CODE '1' CIRCLED IN 301, ASK 302.

301. Which ways or methods have you heard about?
FOR METHODS NOT MENTIONED SPONTANEOUSLY, ASK: Have you ever heard of (METHOD)?

01. FEMALE STERILIZATION: Women can have an operation to avoid having any more children.
YES 1
NO 2 (GO TO NEXT METHOD)
02. MALE STERILIZATION: Men can have an operation to avoid having any more children.
YES 1
NO 2 (GO TO NEXT METHOD)
03. PILL: Women can take a pill every day to avoid becoming pregnant.
YES 1
NO 2 (GO TO NEXT METHOD)
04. IUD: Women can have a loop or coil placed inside them by a doctor or a nurse.
YES 1
NO 2 (GO TO NEXT METHOD)
05. INJECTABLES: Women can have an injection by a health provider that stops them from becoming pregnant for one or more months.
YES 1
NO 2 (GO TO NEXT METHOD)
06. IMPLANTS: Women can have several small rods placed in their upper arm by a doctor or nurse which can prevent pregnancy for one or more years.
YES 1
NO 2 (GO TO NEXT METHOD)
07. CONDOM: Men can put a rubber or latex sheath on their penis before sexual intercourse.
YES 1
NO 2 (GO TO NEXT METHOD)
08. FEMALE CONDOM: Women can place a latex sheath in their vagina before sexual intercourse.
YES 1
NO 2 (GO TO NEXT METHOD)
09. DIAPHRAGM: Women can place a diaphragm in their vagina before sexual intercourse.
YES 1
NO 2 (GO TO NEXT METHOD)
10. MOUSSE OR GEL: Women can insert a suppository, or put gel or cream inside their vagina before sexual intercourse.
YES 1
NO 2 (GO TO NEXT METHOD)
11. LACTATIONAL AMENORRHEA METHOD (LAM): Up until 6 months after giving birth, a woman can use a method that consists of nursing frequently, day and night, and that prevents her from getting her period again.
YES 1
NO 2 (GO TO NEXT METHOD)
12. RHYTHM METHOD: Every month that a woman is sexually active she can avoid pregnancy by not having sexual intercourse on the days of the month she is most likely to get pregnant.
YES 1
NO 2 (GO TO NEXT METHOD)
13. WITHDRAWAL: Men can be careful and pull out before climax.
YES 1
NO 2 (GO TO NEXT METHOD)
14. EMERGENCY CONTRACEPTION: As an emergency measure after unprotected sexual intercourse, women can take special pills at any time within three days to prevent pregnancy.
YES 1
NO 2 (GO TO NEXT METHOD)
15. Have you heard of any other ways or methods that women or men can use to avoid pregnancy? IF YES, LIST UP TO TWO OTHER METHODS.
YES 1
NO 2
(SPECIFY) _____

302. Have you ever used (METHOD)?
[THIS QUESTION IS ASKED ABOUT EACH METHOD IN 301 WITH '1' or '2' CIRCLED.]

01. FEMALE STERILIZATION: Women can have an operation to avoid having any more children. Have you ever had an operation to avoid having any (more) children?
YES 1
NO 2
02. MALE STERILIZATION: Men can have an operation to avoid having any more children. Have you ever had a partner who had an operation to avoid having any (more) children?
YES 1
NO 2
03. PILL: Women can take a pill every day to avoid becoming pregnant.
YES 1
NO 2
04. IUD: Women can have a loop or coil placed inside them by a doctor or a nurse.
YES 1
NO 2
05. INJECTABLES: Women can have an injection by a health provider that stops them from becoming pregnant for one or more months.
YES 1
NO 2
06. IMPLANTS: Women can have several small rods placed in their upper arm by a doctor or nurse which can prevent pregnancy for one or more years.
YES 1
NO 2
07. CONDOM: Men can put a rubber or latex sheath on their penis before sexual intercourse.
YES 1
NO 2
08. FEMALE CONDOM: Women can place a latex sheath in their vagina before sexual intercourse.
YES 1
NO 2
09. DIAPHRAGM: Women can place a diaphragm in their vagina before sexual intercourse.
YES 1
NO 2
10. MOUSSE OR GEL: Women can insert a suppository, or put gel or cream inside their vagina before sexual intercourse.
YES 1
NO 2
11. LACTATIONAL AMENORRHEA METHOD (LAM): Up until 6 months after giving birth, a woman can use a method that consists of nursing frequently, day and night, and that prevents her from getting her period again.
YES 1
NO 2
12. RHYTHM METHOD: Every month that a woman is sexually active she can avoid pregnancy by not having sexual intercourse on the days of the month she is most likely to get pregnant.
YES 1
NO 2
13. WITHDRAWAL: Men can be careful and pull out before climax.
YES 1
NO 2
14. EMERGENCY CONTRACEPTION: As an emergency measure after unprotected sexual intercourse, women can take special pills at any time within three days to prevent pregnancy.
YES 1
NO 2
15. OTHER METHOD(S) (SPECIFY) _____
YES 1
NO 2

303. CHECK 302:

NOT A SINGLE "YES" (NEVER USED) (GO TO 304)
AT LEAST ONE "YES" (EVER USED) (GO TO 307)

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

YES 1
NO 2 (GO TO 329)

306. What have you used or done?
CORRECT 302 AND 303 (AND 301 IF NECESSARY).

Now I would like to ask you about the first time that you did something or used a method to avoid getting pregnant.

307. How many living children did you have at that time?
IF NONE, RECORD '00'.

NUMBER OF CHILDREN ____

308. CHECK 302 (01):

WOMAN NOT STERILIZED (GO TO 309)
WOMAN STERILIZED (GO TO 311A)

309. CHECK 226:

NOT PREGNANT OR UNSURE (GO TO 310)
PREGNANT (GO TO 329)

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

YES 1
NO 2 (GO TO 329)

311. Which method are you currently using?
311A. CIRCLE 'A' FOR FEMALE STERILIZATION.
CIRCLE 'B' FOR MALE STERILIZATION.

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

FEMALE STERILIZATION A (GO TO 313)
MALE STERILIZATION B (GO TO 313)
PILL C
IUD D (GO TO 316A)
INJECTABLES E (GO TO 312D)
IMPLANTS F (GO TO 316A)
CONDOM G (GO TO 316A)
FEMALE CONDOM H (GO TO 316A)
DIAPHRAGM I (GO TO 316A)
FOAM/JELLY J (GO TO 316A)
LACTATIONAL AMEN. METHOD K (GO TO 316A)
RHYTHM METHOD L (GO TO 316A)
WITHDRAWAL M (GO TO 316A)
OTHER (SPECIFY) ______ X (GO TO 316A)

312A. May I see the package of pills you are using?
IF THE PACKAGE IS SHOWN, CIRCLE THE CODE THAT CORRESPONDS TO THE BRAND.

PILPLAN 1 (GO TO 312C)
LOFEMENAL 2 (GO TO 312C)
CONFIANCE 3 (GO TO 312C)
EUGYNON 4 (GO TO 312C)
OVRETTE 5 (GO TO 312C)
OTHER (SPECIFY) _____ 6 (GO TO 312C)
PACKAGE NOT SHOWN 8

312B. Do you know the brand name of the pills you are using?
IF YES: What is the name?

PILPLAN 1
LOFEMENAL 2
CONFIANCE 3
EUGYNON 4
OVRETTE 5
OTHER (SPECIFY) _____ 6
DOESN'T KNOW NAME 8

312C. How much does a package of pills cost you?
NOTE THE PRICE FOR ONE MONTH/CYCLE IN CFA FRANCS.

PRICE IN CFA FRANCS ______ (GO TO 316A)

FREE 9996 (GO TO 316A)
DOESN'T KNOW 9998 (GO TO 316A)

312D. Do you know the commercial name of the injection you received the last time?
IF YES: What is the name?

NORISTERAT 1 (GO TO 316A)
DEPOPROVERA 2 (GO TO 316A)
OTHER (SPECIFY) _____ 6 (GO TO 316A)
DOESN'T KNOW NAME 8 (GO TO 316A)

313. Where did the sterilization take place?

IF IT IS A PUBLIC HOSPITAL OR A PRIVATE HOSPITAL OR CLINIC, WRITE THE NAME OF THE ESTABLISHMENT. PROBE TO DETERMINE THE PROPER TYPE OF SECTOR AND CIRCLE THE APPROPRIATE CODE.

IF CODES 'A' AND 'B' ARE CIRCLED IN 311, ASK 313-317 ON FEMALE STERILIZATION ONLY.

NAME OF PLACE______
PUBLIC SECTOR
HOSPITAL 11
HEALTH CENTER 12
DISPENSARY 13
MEDICAL POST 14
OTHER PUBLIC (SPECIFY) ______ 16
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC 21
PRIVATE DOCTOR 23
OTHER PRIVATE MEDICAL (SPECIFY) ______ 26
OTHER (SPECIFY) ______ 96
DOESN'T KNOW 98

314. CHECK 311:

CODE 'A' CIRCLED: Before your sterilization operation, were you told that you would not be able to have any (more) children because of the operation?

CODE 'B' CIRCLED: Before the sterilization operation, was your husband/partner told that he would not be able to have any (more) children because of the operation?

YES 1
NO 2
DOESN'T KNOW 8

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

MONTH______
YEAR______

316A. Since what month and year have you been using (FIRST METHOD FROM 311) without stopping?

PROBE: Since what month and year have you been using (FIRST METHOD FROM 311) without stopping?

MONTH______
YEAR______

316B. CHECK 316/316A, 215 AND 230:

WAS THERE WAS AT 215 A BIRTH OR AT 230 A PREGNANCY TERMINATED BY MISCARRIAGE, ABORTION OR STILLBIRTH AFTER MONTH AND YEAR OF START OF USE OF CONTRACEPTION IN 316/316A?

YES (GO BACK TO 316/316A, PROBE AND RECORD MONTH AND YEAR AT START OF CONTINUOUS USE OF CURRENT METHOD. MUST BE AFTER LAST BIRTH OR PREGNANCY TERMINATION)

NO (GO TO 317)

317. CHECK 316/316A:

YEAR IS 1998 OR LATER (GO TO 319)
YEAR IS 1997 OR EARLIER (GO TO 327)

319. CHECK 311/311A: CIRCLE METHOD CODE.
IF MORE THAN ONE CODE IS CIRCLED IN 311/311A, CIRCLE THE CODE OF THE FIRST METHOD CIRCLED IN 311/311A.

FEMALE STERILIZATION 01 (GO TO 322)
MALE STERILIZATION 02 (GO TO 331)
PILL 03
IUD 04
INJECTABLES 05
IMPLANTS 06
CONDOM 07
FEMALE CONDOM 08
DIAPHRAGM 09
FOAM/JELLY 10
LACTATIONAL AMEN. METHOD 11 (GO TO 320A)
RHYTHM METHOD 12 (GO TO 331)
WITHDRAWAL 13 (GO TO 331)
OTHER METHOD 96 (GO TO 331)

320. Where did you obtain (METHOD FROM 319) when you first began using it?

IF IT IS A PUBLIC HOSPITAL OR A PRIVATE HOSPITAL OR CLINIC, WRITE THE NAME OF THE ESTABLISHMENT. PROBE TO DETERMINE THE PROPER TYPE OF SECTOR AND CIRCLE THE APPROPRIATE CODE.

NAME OF PLACE______
PUBLIC SECTOR
HOSPITAL 11
HEALTH CENTER 12
DISPENSARY 13
MEDICAL POST 14
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC 21
PRIVATE HEALTH CENTER 22
PHARMACY/MEDICINE DEPOT 23
PRIVATE DOCTOR 24
PF/FISA CENTER 25
OTHER SOURCE
DBC AGENT 31
STORE 32
KIOSK 33
CHURCH 34
RELATIVES/FRIENDS 35
OTHER (SPECIFY) _____ 96

320A. Where did you learn to use the lactational amenorrhea method?

IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER, OR CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO DETERMINE THE TYPE OF SECTOR AND CIRCLE THE APPROPRIATE CODE.

NAME OF PLACE_____
PUBLIC SECTOR
HOSPITAL 11
HEALTH CENTER 12
DISPENSARY 13
MEDICAL POST 14
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC 21
PRIVATE HEALTH CENTER 22
PRIVATE DOCTOR 24
PF/FISA CENTER 25
OTHER SOURCE
DBC AGENT 31
MEDIA SPOTS 32
STORE 33
KIOSK 34
CHURCH 35
RELATIVES/FRIENDS 36
OTHER (SPECIFY) ______ 96

321. CHECK 311/311A: CIRCLE METHOD CODE.
IF MORE THAN ONE CODE IS CIRCLED IN 311/311A, CIRCLE THE CODE OF THE FIRST METHOD CIRCLED IN 311/311A.

PILL 03
IUD 04
INJECTABLES 05
IMPLANTS 06
CONDOM 07 (GO TO 328)
FEMALE CONDOM 08 (GO TO 325)
DIAPHRAGM 09 (GO TO 325)
FOAM/JELLY 10 (GO TO 325)
LACTATIONAL AMEN. METHOD 11 (GO TO 325)

322. You obtained your (CURRENT METHOD) from (SOURCE OF METHOD FROM 313 OR 320). At that time, were you told about side effects or problems you might have from using the method?

YES 1 (GO TO 324)
NO 2

323. Were you ever told by a health or family planning worker about side effects or problems you might have with the method?

YES 1
NO 2 (GO TO 325)

324. Were you told what to do if you experienced side effects or problems?

YES 1
NO 2

325. CHECK 322:

CODE '1' CIRCLED: At that time, were you told about other methods of family planning that you could use?

CODE '1' NOT CIRCLED: When you obtained (CURRENT METHOD) from (SOURCE OF METHOD FROM 313 OR 320) were you told about other methods of family planning that you could use?

YES 1 (GO TO 327)
NO 2

326. Were you ever told by a health or family planning worker about other methods of family planning that you could use?

YES 1
NO 2

327. CHECK 311/311A: CIRCLE METHOD CODE:
IF MORE THAN ONE CODE IS CIRCLED IN 311/311A, CIRCLE THE CODE OF THE FIRST METHOD CIRCLED IN 311/311A.

FEMALE STERILIZATION 01 (GO TO 331)
MALE STERILIZATION 02 (GO TO 331)
PILL 03
IUD 04
INJECTABLES 05
IMPLANTS 06
CONDOM 07
FEMALE CONDOM 08
DIAPHRAGM 09
FOAM/JELLY 10
LACTATIONAL AMEN. METHOD 11 (GO TO 331)
RHYTHM METHOD 12 (GO TO 331)
WITHDRAWAL 13 (GO TO 331)
OTHER METHOD 96 (GO TO 331)

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

IF IT IS A PUBLIC HOSPITAL OR A PRIVATE HOSPITAL OR CLINIC, WRITE THE NAME OF THE ESTABLISHMENT. PROBE TO DETERMINE THE PROPER TYPE OF SECTOR AND CIRCLE THE APPROPRIATE CODE.

NAME OF PLACE______
PUBLIC SECTOR
HOSPITAL 11 (GO TO 331)
HEALTH CENTER 12 (GO TO 331)
DISPENSARY 13 (GO TO 331)
MEDICAL POST 14 (GO TO 331)
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC 21 (GO TO 331)
PRIVATE HEALTH CENTER 22 (GO TO 331)
PHARMACY/MEDICINE DEPOT 23 (GO TO 331)
PRIVATE DOCTOR 24 (GO TO 331)
PF/FISA CENTER 25 (GO TO 331)
OTHER SOURCE
DBC AGENT 31 (GO TO 331)
STORE 32 (GO TO 331)
KIOSK 33 (GO TO 331)
CHURCH 34 (GO TO 331)
RELATIVES/FRIENDS 35 (GO TO 331)
OTHER (SPECIFY) _____ 96 (GO TO 331)

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

YES 1
NO 2 (GO TO 331)

330. Where is that?

IF IT IS A PUBLIC HOSPITAL OR A PRIVATE HOSPITAL OR CLINIC, WRITE THE NAME OF THE ESTABLISHMENT. PROBE TO DETERMINE THE PROPER TYPE OF SECTOR AND CIRCLE THE APPROPRIATE CODE.

NAME OF PLACE_______
PUBLIC SECTOR
HOSPITAL A
HEALTH CENTER B
DISPENSARY C
MEDICAL POST D
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC E
PRIVATE HEALTH CENTER F
PHARMACY/MEDICINE DISPENSARY G
PRIVATE DOCTOR H
PF/FISA CENTER I
OTHER SOURCE
DBC AGENT J
STORE K
KIOSK L
CHURCH M
RELATIVES/FRIENDS N
OTHER (SPECIFY) ______ X

331. In the last 12 months, were you visited by a fieldworker who talked to you about family planning?

YES 1
NO 2

332. In the last 12 months, have you visited a health facility for care for yourself (or your children)?

YES 1
NO 2 (GO TO 401)

333. Did a staff member at the health facility speak to you about family planning methods?

YES 1
NO 2

333A. The last time you or your children went to the CSB, did you find your prescribed medications?

ENTIRELY 1
PARTIALLY 2
NONE 3

333B. The last time you or your children went to the CSB, did you find the prices of medication to be expensive, average, or cheap?

EXPENSIVE 1
AVERAGE 2
AFFORDABLE/CHEAP 3

333C. The last time you or your children went to the CSB, how much did you pay for the medication (PRICE IN CFA FRANCS)?

CFA FRANCS ______

CFA 99995 OR MORE 99995
DOESN'T KNOW 99998

333D. The last time you or your children went to the CSB, were you able to pay for medication yourself without borrowing from family, friends or neighbors?

YES 1
NO 2

SECTION 4A: PREGNANCY, POSTNATAL CARE AND BREASTFEEDING

401. CHECK 224:

ONE OR MORE BIRTHS SINCE JANUARY 1998 (GO TO 402)
NO BIRTHS IN SINCE JANUARY 1998 (GO TO 486)

402. ENTER IN THE TABLE THE LINE NUMBER, NAME, AND SURVIVAL STATUS FOR EACH BIRTH SINCE 1998. ASK THE QUESTIONS FOR ALL BIRTHS. BEGIN WITH THE LAST BIRTH. IF THERE ARE MORE THAN 2 BIRTHS, USE LAST COLUMN OF ADDITIONAL QUESTIONNAIRES.

Now I would like to ask you some questions about the health of all your children born in the last five years. We will talk about each separately.

403. LINE NUMBER FROM 212:

LINE NO. _____

[404-471 ARE REPEATED FOR EACH BIRTH, BEGINNING WITH THE MOST RECENT BIRTH. IF MORE THAN 2 BIRTHS, USE LAST COLUMN OF ADDITIONAL QUESTIONNAIRES]

404. FROM 212 AND 216:

NAME _____
LIVING ____
DEAD ____

405. At the time you became pregnant with (NAME), did you want to become pregnant then, did you want to wait until later, or did you not want to have any (more) children at all?

THEN 1 (MOST RECENT BIRTH: GO TO 407; OTHER BIRTHS: GO TO 423)
LATER 2
NOT AT ALL 3 (MOST RECENT BIRTH: GO TO 407; OTHER BIRTHS: GO TO 423)

406. How much longer would you have liked to wait?

MONTHS 1 ____
YEARS 2 ____
DOESN'T KNOW 998

407. Did you receive prenatal care for this pregnancy?
IF YES: Whom did you see? Anyone else?
PROBE TO IDENTIFY EACH TYPE OF PERSON AND RECORD ALL MENTIONED.
[ASK ONLY FOR MOST RECENT BIRTH]

HEALTH PERSONNEL
DOCTOR A
NURSE/MIDWIFE/MEDICAL ASSISTANT B
OTHER PERSON
TRAINED TRADITIONAL BIRTH ASSISTANT C
UNTRAINED TRADITIONAL BIRTH ASSISTANT D
OTHER (SPECIFY) _______ X
NO ONE Y (GO TO 415)

408. How many months pregnant were you when you first received antenatal care for this pregnancy?
[ASK ONLY FOR MOST RECENT BIRTH]

NUMBER OF MONTHS ____
DOESN'T KNOW 98

409. How many times did you receive antenatal care during this pregnancy?
[ASK ONLY FOR MOST RECENT BIRTH]

NUMBER OF TIMES _____
DOESN'T KNOW 98

410. CHECK 409:
NUMBER OF PRENATAL CONSULTATIONS RECEIVED:
[ASK ONLY FOR MOST RECENT BIRTH]

ONE TIME (GO TO 412)
MORE THAN ONCE OR DOESN'T KNOW (GO TO 411)

411. How many months pregnant were you the last time you had a prenatal visit?
[ASK ONLY FOR MOST RECENT BIRTH]

NUMBER OF MONTHS ____
DOESN'T KNOW 98

412. During this pregnancy, were any of the following done at least once?
[ASK ONLY FOR MOST RECENT BIRTH]

Were you weighed?
Was your height measured?
Was your blood pressure measured?
Did you give a urine sample?
Did you give a blood sample?

WEIGHED
YES 1
NO 2
HEIGHT MEASURED
YES 1
NO 2
BLOOD PRESSURE MEASURED
YES 1
NO 2
URINE SAMPLE
YES 1
NO 2
BLOOD SAMPLE
YES 1
NO 2

413. Were you told about the signs of pregnancy complications?
[ASK ONLY FOR MOST RECENT BIRTH]

YES 1
NO 2 (GO TO 415)
DOESN'T KNOW 8 (GO TO 415)

414. Were you told where to go if you had any of these complications?
[ASK ONLY FOR MOST RECENT BIRTH]

YES 1
NO 2
DOESN'T KNOW 8

415. During this pregnancy, were you given an injection in the arm to prevent the baby from getting tetanus, that is, convulsions after birth?
[ASK ONLY FOR MOST RECENT BIRTH]

YES 1
NO 2 (GO TO 417)
DOESN'T KNOW 8 (GO TO 417)

416. During this pregnancy, how many times did you get this tetanus injection?
[ASK ONLY FOR MOST RECENT BIRTH]

NUMBER OF TIMES _____
DOESN'T KNOW 8

417. During this pregnancy, were you given or did you buy any iron tablets or syrup with iron in it? SHOW TABLETS/SYRUP.
[ASK ONLY FOR MOST RECENT BIRTH]

YES 1
NO 2 (GO TO 419)
DOESN'T KNOW 8 (GO TO 419)

418. During the whole pregnancy, for how many days did you take the iron tablets or syrup?
IF ANSWER IS NOT NUMERIC, PROBE FOR APPROXIMATE NUMBER OF DAYS.
[ASK ONLY FOR MOST RECENT BIRTH]

NUMBER OF DAYS _____
DOESN'T KNOW 998

419. During this pregnancy, did you have difficulty with your vision during daylight?
[ASK ONLY FOR MOST RECENT BIRTH]

YES 1
NO 2
DOESN'T KNOW 8

420. During this pregnancy, did you suffer from night blindness/(USE LOCAL NAME)?
[ASK ONLY FOR MOST RECENT BIRTH]

YES 1
NO 2
DOESN'T KNOW 8

421. During this pregnancy, did you take any drugs to keep you from getting malaria?
[ASK ONLY FOR MOST RECENT BIRTH]

YES 1
NO 2 (GO TO 423)
DOESN'T KNOW 8 (GO TO 423)

422. What was this medication?
[ASK ONLY FOR MOST RECENT BIRTH]

RECORD ALL MENTIONED. IF THE KIND OF MEDICATION IS UNKNOWN, SHOW RESPONDENT A SAMPLING OF ANTIMALARIAL MEDICATIONS.

FANSIDAR A
CHLOROQUINE/NIVAQUINE B
AMODIAQUINE/FLAVOQUINE C
QUININE D
UNKNOWN MEDICATION E
OTHER (SPECIFY) ______ X

422A. CHECK 422:
TYPE OF MEDICATION TAKEN DURING PREGNANCY TO AVOID MALARIA?
[ASK ONLY FOR MOST RECENT BIRTH]

CODE 'A' CIRCLED 1 (GO TO 422B)
CODE 'A' NOT CIRCLED 2 (GO TO 423)

422B. How many times did you take the medication FANSIDAR during this pregnancy?
[ASK ONLY FOR MOST RECENT BIRTH]

IF THE RESPONDENT DOES NOT KNOW THE NUMBER OF TIMES, ASK IF THE RESPONDENT TOOK THE MEDICATION ALL THROUGHOUT THE PREGNANCY OR FROM TIME TO TIME, THEN CIRCLE THE CORRESPONDING CODE.

NUMBER OF TIMES ____

DURING WHOLE PREGNANCY 93
FROM TIME TO TIME 94
DOESN'T KNOW/DOESN'T REMEMBER 98

422C. CHECK 407:
TYPE OF PERSONNEL THAT GAVE PRENATAL CARE DURING THIS PREGNANCY?
[ASK ONLY FOR MOST RECENT BIRTH]

CODE 'A', 'B', 'C' OR 'D' CIRCLED 1 (GO TO 422D)
OTHER CODE CIRCLED 2 (GO TO 423)

422D. When you were pregnant with (NAME), did you obtain Fansidar, Chloroquine/Nivaquine, Flavoquine/Amodiaquine or Quinine during a prenatal visit, or during another health-related visit, or from another source?
[ASK ONLY FOR MOST RECENT BIRTH]

PRENATAL VISIT 1
OTHER MEDICAL VISIT 2
DECIDED BY RESPONDENT HERSELF WITHOUT PRESCRIPTION 3
OTHER (SPECIFY) _____ 6

423. When (NAME) was born, was he/she very large, larger than average, average, smaller than average, or very small?

VERY LARGE 1
LARGER THAN AVERAGE 2
AVERAGE 3
SMALLER THAN AVERAGE 4
VERY SMALL 5
DOESN'T KNOW 8

424. Was (NAME) weighed at birth?

YES 1
NO 2 (GO TO 425AA)
DOESN'T KNOW 8 (GO TO 425AA)

425. How much did (NAME) weigh?
RECORD WEIGHT FROM HEALTH CARD, IF AVAILABLE.

GRAMS FROM CARD 1 ______
GRAMS FROM MEMORY 2 ______
DOESN'T KNOW 99998

425AA. Does (NAME) have a birth certificate?
IF YES: Can I see it, please?

YES, SEEN 1 (GO TO 426)
YES, NOT SEEN 2
NO BIRTH CERTIFICATE 8

425A. Was (NAME'S) birth reported to the Registrar General?

YES 1
NO 2
DOESN'T KNOW 8

426. 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.

HEALTH PERSONNEL
DOCTOR A
NURSE/MIDWIFE/MEDICAL ASSISTANT B
OTHER PERSON
TRAINED TRADITIONAL BIRTH ASSISTANT C
UNTRAINED TRADITIONAL BIRTH ASSISTANT D
RELATIVE/FRIEND E
OTHER (SPECIFY) _______ X
NO ONE Y

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

IF IT IS A PUBLIC HOSPITAL/CLINIC OR A PRIVATE CLINIC, WRITE THE NAME OF THE ESTABLISHMENT. PROBE TO DETERMINE THE PROPER TYPE OF SECTOR AND CIRCLE THE APPROPRIATE CODE.

NAME OF PLACE_______
HOME
RESPONDENT'S HOME 11 (GO TO 429)
OTHER HOME 12 (GO TO 429)
PUBLIC SECTOR
GOVT. HOSPITAL 21
GOVT. HEALTH CENTER 22
OTHER PUBLIC (SPECIFY) ______ 26
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC 31
OTHER PRIVATE MEDICAL (SPECIFY) ______ 36
OTHER (SPECIFY) ______ 96 (GO TO 429)

428. Was (NAME) delivered by caesarean section?

YES 1 (MOST RECENT BIRTH: GO TO 433; OTHERS: GO TO 435)
NO 2 (MOST RECENT BIRTH: GO TO 433; OTHERS: GO TO 435)

429. After the birth of (NAME), did a health care provider or traditional midwife examine you?

YES 1 (OTHER BIRTHS: GO TO 435)
NO 2 (MOST RECENT BIRTH: GO TO 433; OTHERS: GO TO 435)

430. How long after delivery did the first check take place?
[ASK ONLY FOR MOST RECENT BIRTH]
RECORD '00' IF THE SAME DAY.

DAYS AFTER 1 ____
WEEKS AFTER 2 ____
DOESN'T KNOW 998

431. Who checked on your health at that time?
[ASK ONLY FOR MOST RECENT BIRTH]
PROBE FOR MOST QUALIFIED PERSON.

HEALTH PERSONNEL
DOCTOR 11
NURSE/MIDWIFE/MEDICAL ASSISTANT 12
OTHER PERSON
TRAINED TRADITIONAL BIRTH ASSISTANT 21
UNTRAINED TRADITIONAL BIRTH ASSISTANT 22
OTHER (SPECIFY) _______ 96

432. Where did this first check take place?
[ASK ONLY FOR MOST RECENT BIRTH]

HOME
RESPONDENT'S HOME 11
OTHER HOME 12
PUBLIC SECTOR
HOSPITAL 21
HEALTH CENTER 22
DISPENSARY 23
OTHER PUBLIC (SPECIFY) ______ 26
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC 31
OTHER PRIVATE MEDICAL (SPECIFY) ______ 36
OTHER (SPECIFY) _______ 96

433. In the two months after the birth, did you receive a dose of vitamin A such as this?
[ASK ONLY FOR MOST RECENT BIRTH]
SHOW PILL/GEL CAP/SYRUP.

YES 1
NO 2

434. Has your menstrual period returned since the birth of (NAME)?
[ASK ONLY FOR MOST RECENT BIRTH]

YES 1 (GO TO 436)
NO 2 (GO TO 437)

435. Did your period return between the birth of (NAME) and your next pregnancy?
[DO NOT ASK FOR MOST RECENT BIRTH]

YES 1
NO 2 (GO TO 439)

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

NUMBER OF MONTHS _____
DOESN'T KNOW 98

437. CHECK 226:
IS RESPONDENT PREGNANT?
[ASK ONLY FOR MOST RECENT BIRTH]

NOT PREGNANT (GO TO 438)
PREGNANT OR UNSURE (GO TO 439)

438. Have you begun to have sexual intercourse again since the birth of (NAME)?
[ONLY ASK FOR MOST RECENT BIRTH.]

YES 1
NO 2 (GO TO 440)

439. For how long after the birth of (NAME) did you not have sexual intercourse?

NUMBER OF DAYS 1 ____
NUMBER OF WEEKS 2 ____
NUMBER OF MONTHS 3 ____
DOESN'T KNOW 998

440. Did you breastfeed (NAME)?

YES 1
NO 2 (GO TO 447)

441. 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.

IMMEDIATELY 000
HOURS 1 _____
DAYS 2 _____

442. In the first three days after delivery and before the mother's breasts began to produce milk regularly, was (NAME) given anything to drink other than breast milk?

YES 1
NO 2 (GO TO 444)

443. What was (NAME) given to drink before the mother's breasts began to produce milk regularly?

MILK (OTHER THAN BREAST MILK) A
PLAIN WATER B
SUGAR OR GLUCOSE WATER C
CALMING INFUSIONS FOR COLIC D
SUGAR-SALT-WATER SOLUTION E
FRUIT JUICE F
INFANT FORMULA G
TEA/INFUSIONS H
HONEY I
OTHER (SPECIFY) _______ X

444. CHECK 404:
IS CHILD STILL LIVING?

LIVING (GO TO 445)
DEAD (GO TO 446)

445. Are you still breastfeeding (NAME)?

YES 1 (GO TO 448)
NO 2

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

NUMBER OF MONTHS______
DOESN'T KNOW 98

447. CHECK 404:
IS CHILD STILL LIVING?

LIVING (GO TO 450)
DEAD (GO BACK TO 405 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 454)

448. How many times did you breastfeed last night between sunset and sunrise?
IF ANSWER IS NOT NUMERIC, PROBE FOR APPROXIMATE ANSWER.

NUMBER OF NIGHTTIME FEEDINGS _____

449. How many times did you breastfeed yesterday during the daylight hours?
IF ANSWER IS NOT NUMERIC, PROBE FOR APPROXIMATE ANSWER.

NUMBER OF DAYTIME FEEDINGS _____

449A. Now I would like to know how much food you are eating since starting to breastfeed (NAME). Do you eat more than normal, as much as normal, or less than normal?

MORE THAN NORMAL 1
ABOUT NORMAL 2
LESS THAN NORMAL 3
DOESN'T KNOW 8

450. Did (NAME) drink anything from a bottle yesterday or last night?

YES 1
NO 2
DOESN'T KNOW 8

451. Was sugar added to any food or liquid that (NAME) was fed yesterday?

YES 1
NO 2
DOESN'T KNOW 8

452. Yesterday, day or night, how many times was (NAME) fed pureed, solid or semi-solid food? IF 7 TIMES OR MORE, RECORD '7'.

NUMBER OF TIMES ____
DOESN'T KNOW 8

453. GO BACK TO 405 IN NEXT COLUMN; OR IF NO MORE BIRTHS, GO TO 454.

SECTION 4B: VACCINATION AND HEALTH

454. WRITE THE LINE NUMBER, NAME, AND SURVIVAL STATUS OF EACH BIRTH SINCE JANUARY 1998.

ASK THE QUESTIONS FOR ALL BIRTHS. START WITH THE MOST RECENT BIRTH. (IF THERE ARE MORE THAN 2 BIRTHS, USE THE LAST COLUMN OF ADDITIONAL QUESTIONNAIRES.

455. LINE NUMBER FROM 212:

LINE NO. ______

456. FROM 212 AND 216:

NAME ________
LIVING ____
DEAD ____ (GO TO 456 IN NEXT COLUMN OR, IF NO MORE BIRTHS, GO TO 484)

457. Did (NAME) receive a vitamin A dose, like this one, within the last six months?
SHOW PILL/CAPSULE/SYRUP.

YES 1
NO 2
DOESN'T KNOW 8

458. Do you have a card where (NAME'S) vaccinations are written down?
IF YES: May I see it please?

YES, SEEN 1 (GO TO 460)
YES, NOT SEEN 2 (GO TO 462)
NO CARD 3

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

YES 1 (GO TO 462)
NO 2 (GO TO 462)

460. (1) COPY VACCINATION DATE FOR EACH VACCINE FROM THE CARD. (2) WRITE '44' IN DAY COLUMN IF CARD SHOWS THAT A VACCINATION WAS GIVEN, BUT NO DATE IS RECORDED.

BCG
DAY ____
MONTH ____
YEAR ____
POLIO 0 (POLIO GIVEN AT BIRTH)
DAY ____
MONTH ____
YEAR ____
POLIO 1
DAY ____
MONTH ____
YEAR ____
POLIO 2
DAY ____
MONTH ____
YEAR ____
POLIO 3
DAY ____
MONTH ____
YEAR ____
DPT 1
DAY ____
MONTH ____
YEAR ____
DPT 2
DAY ____
MONTH ____
YEAR ____
DPT 3
DAY ____
MONTH ____
YEAR ____
IMOVAX 1
DAY ____
MONTH ____
YEAR ____
IMOVAX 2
DAY ____
MONTH ____
YEAR ____
MEASLES
DAY ____
MONTH ____
YEAR ____
YELLOW FEVER
DAY ____
MONTH ____
YEAR ____
VITAMIN A (MOST RECENT)
DAY ____
MONTH ____
YEAR ____

461. Has (NAME) received any vaccinations that are not recorded on this card, including vaccinations received in a national immunization day campaign?
RECORD 'YES' ONLY IF RESPONDENT MENTIONS BCG, POLIO 0-3, DPT 1-3, AND/OR MEASLES VACCINES.

YES 1 (PROBE FOR VACCINATIONS AND WRITE '66' IN THE CORRESPONDING DAY COLUMN IN 460) (GO TO 464)
NO 2 (GO TO 464)
DOESN'T KNOW 8 (GO TO 464)

462. Did (NAME) ever receive any vaccinations to prevent him/her from getting diseases, including vaccinations received in a national immunization day campaign?

YES 1
NO 2 (GO TO 466)
DOESN'T KNOW 8 (GO TO 466)

463. Please tell me if (NAME) received any of the following vaccinations:

463A. A BCG vaccination against tuberculosis, that is, an injection in the arm or shoulder that usually causes a scar?

YES 1
NO 2
DOESN'T KNOW 8

463B. Polio vaccine, that is, drops in the mouth?

YES 1
NO 2 (GO TO 463E)
DOESN'T KNOW 8 (GO TO 463E)

463C. Was the first polio vaccine received just after birth or later?

JUST AFTER BIRTH 1
LATER 2

463D. How many times was the polio vaccine received?

NUMBER OF TIMES _______

463E. A DPT vaccination, that is, an injection given in the thigh or buttocks that is sometimes given at the same time as polio drops?

YES 1
NO 2 (GO TO 463G)
DOESN'T KNOW 8 (GO TO 463G)

463F. How many times?

NUMBER OF TIMES ____

463G. A measles injection?

YES 1
NO 2
DOESN'T KNOW 8

464. Did (NAME) receive any of these injections during a national vaccination day within the last two years?

YES 1
NO 2 (GO TO 466)
NO VACCINATION IN LAST 2 YEARS 3 (GO TO 466)
DOESN'T KNOW 8 (GO TO 466)

465. During which national vaccination day did (NAME) receive these vaccinations?
RECORD ALL MENTIONED IN FOLLOWING FORMAT: NAME/CAMPAIGN
(TYPE AND DATE).

1) ____________ A
2) ____________ B
3) _____________C
4) _____________D

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

YES 1
NO 2
DOESN'T KNOW 8

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

YES 1
NO 2 (GO TO 469)
DOESN'T KNOW 8 (GO TO 469)

468. When (NAME) had an illness with a cough, did he/she breathe faster than usual with short, rapid breaths or have difficulty breathing?

YES 1
NO 2
DOESN'T KNOW 8

469. CHECK 466 AND 467:
FEVER OR COUGH?

'YES' TO 466 OR 467 (GO TO 470)
OTHER (GO TO 475)

470. Did you seek advice or treatment when (NAME) had a (fever/cough)?

YES 1
NO 2 (GO TO 472)

471. Where did you seek advice or treatment?
Anywhere else? RECORD ALL MENTIONED.

PUBLIC SECTOR
GOVERNMENT HOSPITAL A
GOVERNMENT HEALTH CENTER B
GOVERNMENT HEALTH POST C
MOBILE CLINIC D
COMMUNITY HEALTH AGENT E
OTHER PUBLIC (SPECIFY) _______ F
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC G
PHARMACY H
PRIVATE DOCTOR I
MOBILE CLINIC J
COMMUNITY HEALTH AGENT K
OTHER PRIVATE MEDICAL (SPECIFY) _______ L
OTHER LOCATION
STORE M
TRADITIONAL HEALER N
OTHER (SPECIFY) ______ X

472. CHECK 466:
HAD FEVER?

'YES' TO 466 (GO TO 472A)
'NO' OR 'DOESN'T KNOW' TO 466 (GO TO 475)

472A. Does (NAME) have a fever now?

YES 1
NO 2
DOESN'T KNOW 8

472B. Has (NAME) had convulsions at any point in the last two weeks?

YES 1
NO 2
DOESN'T KNOW 8

472C. CHECK 466 AND 472B:
FEVER OR CONVULSIONS?

'YES' TO 466 OR 472B (GO TO 473)
OTHER (GO TO 475)

473. Did (NAME) take any drugs for the fever/convulsions?

YES 1
NO 2 (GO TO 474R)
DOESN'T KNOW 8 (GO TO 474R)

474. What drugs did (NAME) take?

RECORD ALL MENTIONED. ASK TO SEE THE MEDICATION IF THE TYPE OF MEDICATION IS UNKNOWN. IF THE TYPE OF MEDICATION CANNOT BE DETERMINED, SHOW THE RESPONDENT A COMMON ANTIMALARIAL DRUG.

ANTIMALARIAL DRUG
FANSIDAR A
CHLOROQUINE/NIVAQUINE B
AMODIAQUINE/FLAVOQUINE C
QUININE D
OTHER MEDICATIONS
ASPIRIN E
PANADOL F
IBUPROFEN/ACETAMINOPHEN G
OTHER (SPECIFY) ______ X
DOESN'T KNOW Z

474A. Has (NAME) had an injection or suppository to treat the fever/convulsions?

INJECTION A
SUPPOSITORY B
NONE Y
DOESN'T KNOW Z

474B. CHECK 474:
INDICATE TYPE OF MEDICATION:

CODE 'A' CIRCLED (GO TO 474C)
CODE 'A' NOT CIRCLED (GO TO 474F)

474C. How long after the beginning of the fever/convulsions did (NAME) begin to take Fansidar?

SAME DAY 1
NEXT DAY 2
TWO DAYS AFTER 3
THREE OR MORE DAYS AFTER THE FEVER 4
DOESN'T KNOW 8

474D. For how many consecutive days did (NAME) take Fansidar?
IF MORE THAN 7 DAYS, RECORD '7'.

NUMBER OF DAYS ____
DOESN'T KNOW 8

474E. Do you have Fansidar in the house, or did you get it from somewhere else?
IF MORE THAN ONE SOURCE MENTIONED, ASK: Where did you first obtain Fansidar?

AT THE HOUSE 1
HEALTH SERVICE/PERSONNEL/PHARMACY 2
STORE 3
OTHER 4
DOESN'T KNOW 8

474F. CHECK 474:
INDICATE TYPE OF MEDICATION.

CODE 'B' CIRCLED (GO TO 474G)
CODE 'B' NOT CIRCLED (GO TO 474J)

474G. How long after the beginning of the fever/convulsions did (NAME) begin to take Chloroquine or Nivaquine?

SAME DAY 1
NEXT DAY 2
TWO DAYS AFTER 3
THREE OR MORE DAYS AFTER THE FEVER 4
DOESN'T KNOW 8

474H. For how many consecutive days did (NAME) take Chloroquine or Nivaquine?
IF MORE THAN 7 DAYS, RECORD '7'.

NUMBER OF DAYS ____
DOESN'T KNOW 8

474I. Do you have Chloroquine or Nivaquine in the house, or did you get it from somewhere else? IF MORE THAN ONE SOURCE MENTIONED, ASK: Where did you first obtain Chloroquine or Nivaquine?

AT THE HOUSE 1
HEALTH SERVICE/PERSONNEL/PHARMACY 2
STORE 3
OTHER 4
DOESN'T KNOW 8

474J. CHECK 474:
INDICATE TYPE OF MEDICATION:

CODE 'C' CIRCLED (GO TO 474K)
CODE 'C' NOT CIRCLED (GO TO 474N)

474K. How long after the beginning of the fever/convulsions did (NAME) begin to take Flavoquine or Amodiaquine?

SAME DAY 1
NEXT DAY 2
TWO DAYS AFTER 3
THREE OR MORE DAYS AFTER THE FEVER 4
DOESN'T KNOW 8

474L. For how many consecutive days did (NAME) take Flavoquine or Amodiaquine?
IF MORE THAN 7 DAYS, RECORD '7'.

NUMBER OF DAYS ____
DOESN'T KNOW 8

474M. Do you have Flavoquine or Amodiaquine in the house, or did you get it from somewhere else? IF MORE THAN ONE SOURCE MENTIONED, ASK: Where did you first obtain Flavoquine or Amodiaquine?

AT THE HOUSE 1
HEALTH SERVICE/PERSONNEL/PHARMACY 2
STORE 3
OTHER 4
DOESN'T KNOW 8

474N. CHECK 474:
INDICATE TYPE OF MEDICATION:

CODE 'D' CIRCLED (GO TO 474O)
CODE 'D' NOT CIRCLED (GO TO 474R)

474O. How long after the beginning of the fever/convulsions did (NAME) begin to take Quinine?

SAME DAY 1
NEXT DAY 2
TWO DAYS AFTER 3
THREE OR MORE DAYS AFTER THE FEVER 4
DOESN'T KNOW 8

474P. For how many consecutive days did (NAME) take Quinine?
IF MORE THAN 7 DAYS, RECORD '7'.

NUMBER OF DAYS ____
DOESN'T KNOW 8

474Q. Do you have Quinine in the house, or did you get it from somewhere else? IF MORE THAN ONE SOURCE MENTIONED, ASK: Where did you first obtain quinine?

AT THE HOUSE 1
HEALTH SERVICE/PERSONNEL/PHARMACY 2
STORE 3
OTHER 4
DOESN'T KNOW 8

474R. Was anything else done to treat (NAME)'s fever/convulsions?

YES 1
NO 2 (GO TO 475)
DOESN'T KNOW 8 (GO TO 475)

474S. What was done to treat (NAME)'s fever/convulsions?

CONSULTED TRADITIONAL HEALER A
SWABBED WITH MOIST COMPRESSES B
GAVE MEDICINAL PLANTS/TRADITIONAL MEDICATIONS C
OTHER (SPECIFY) ______ X
DOESN'T KNOW Z

475. Has (NAME) had diarrhea in the last 2 weeks?

YES 1
NO 2 (GO TO 483)
DOESN'T KNOW 8 (GO TO 483)

476. Now I would like to know how much (NAME) was given to drink during the diarrhea. Was he/she given less than usual to drink, about the same amount, or more than usual to drink?
IF LESS, PROBE: Was he/she given much less than usual to drink or somewhat less?

MUCH LESS 1
SOMEWHAT LESS 2
ABOUT THE SAME 3
MORE 4
NOTHING TO DRINK 5
DOESN'T KNOW 8

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

MUCH LESS 1
SOMEWHAT LESS 2
ABOUT THE SAME 3
MORE 4
STOPPED FOOD 5
NEVER GAVE FOOD 6
DOESN'T KNOW 8

478. Was he/she given any of the following to drink at any time since he/she started having the diarrhea:

a) A liquid prepared from an ORS packet/(LOCAL NAME FOR ORS PACKET)?
b) A homemade liquid recommended by the government?

A) FLUID FROM ORS PACKET
YES 1
NO 2
DOESN'T KNOW 8
HOMEMADE FLUID
YES 1
NO 2
DOESN'T KNOW 8

479. Was anything (else) given to treat the diarrhea?

YES 1
NO 2 (GO TO 481)
DOESN'T KNOW 8 (GO TO 481)

480. What (else) was given to treat the diarrhea? Anything else?
RECORD ALL TREATMENTS GIVEN.

PILL OR SYRUP A
INJECTION B
(IV) INTRAVENOUS C
HOME REMEDY/PLANTS D
OTHER (SPECIFY) ______ X

481. Did you seek advice or treatment for the diarrhea?

YES 1
NO 2 (GO TO 483)

482. Where did you seek advice or treatment? Anywhere else?

RECORD ALL MENTIONED. IF IT IS A PUBLIC HOSPITAL/CLINIC OR A PRIVATE CLINIC, WRITE THE NAME OF THE ESTABLISHMENT. PROBE TO DETERMINE THE PROPER TYPE OF SECTOR AND CIRCLE THE APPROPRIATE CODE.

NAME OF PLACE______
PUBLIC SECTOR
GOVERNMENT HOSPITAL A
GOVERNMENT HEALTH CENTER B
GOVERNMENT HEALTH POST C
MOBILE CLINIC D
COMMUNITY HEALTH AGENT E
OTHER PUBLIC (SPECIFY) _______ F
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC G
PHARMACY H
PRIVATE DOCTOR I
MOBILE CLINIC J
COMMUNITY HEALTH AGENT K
OTHER PRIVATE MEDICAL (SPECIFY) _______ L
OTHER LOCATION
STORE M
TRADITIONAL HEALER N
OTHER (SPECIFY) _______ X

483. RETURN TO 456 IN THE NEXT COLUMN OR (IF NO MORE BIRTHS, GO TO 484.)

484. CHECK 215 AND 218, ALL COLUMNS: NUMBER OF LIVING CHILDREN BORN IN 1998 OR LATER.

ONE OR MORE (GO TO 485)
NONE (GO TO 487)

485. When (YOUNGEST CHILD) does not use the toilet, what do you typically do to dispose of the stools?

CHILD ALWAYS USES TOILET OR LATRINE 01
THROWN INTO TOILET OR LATRINE 02
THROWN OUTSIDE OF THE DWELLING 03
THROWN OUTSIDE OF THE YARD 04
BURIED IN THE YARD 05
GET RID OF IT BY RINSING WITH WATER 06
USE DISPOSABLE DIAPERS 07
USE CLOTH DIAPERS 08
DOESN'T GET RID OF IT 09
OTHER (SPECIFY) _______ 96

486. CHECK 478(a), ALL COLUMNS:

NO CHILD RECEIVED ORS PACKET (GO TO 487)
ANY CHILD RECEIVED ORS PACKET (GO TO 488)

487. Have you ever heard of a special product called (Orasel OR OTHER LOCAL NAME FOR ORS PACKET) that you can get for the treatment of diarrhea?

YES 1
NO 2

488. CHECK 218:

ONE OR MORE CHILDREN LIVING WITH HER (GO TO 489)
NO CHILDREN LIVING WITH HER (GO TO 490)

489. When your child/one of your children is seriously ill, can you yourself decide to take the child to get medical treatment?

IF RESPONDENT SAYS THAT NONE OF HER CHILDREN HAVE EVER BEEN SERIOUSLY ILL, ASK: If your child/one of your children were to fall seriously ill, could you yourself decide to take the child to get medical treatment?

YES 1
NO 2
IT DEPENDS 3

Now, I would like to ask you questions having to do with your own health care.

490. Many different factors can prevent women from getting medical advice or treatment for themselves. When you are sick and want to get medical advice or treatment, does each of the following constitute a big problem, a small problem, or no problem?

Knowing where to go.
Getting permission to go.
Getting money needed for treatment.
No health facility nearby.
Having to take transport.
Not wanting to go alone.
Concern that there may not be a female health provider.

KNOWING WHERE TO GO
BIG PROBLEM 1
NOT A BIG PROBLEM 2
GETTING PERMISSION TO GO
BIG PROBLEM 1
NOT A BIG PROBLEM 2
GETTING MONEY NEEDED FOR TREATMENT
BIG PROBLEM 1
NOT A BIG PROBLEM 2
NO HEALTH FACILITY NEARBY
BIG PROBLEM 1
NOT A BIG PROBLEM 2
HAVING TO TAKE TRANSPORT
BIG PROBLEM 1
NOT A BIG PROBLEM 2
NOT WANTING TO GO ALONE
BIG PROBLEM 1
NOT A BIG PROBLEM 2
CONCERN THAT THERE MAY NOT BE A FEMALE HEALTH PROVIDER
BIG PROBLEM 1
NOT A BIG PROBLEM 2

491. CHECK 215 AND 218:

HAS AT LEAST ONE OR MORE CHILDREN BORN IN 1998 OR LATER LIVING WITH HER: RECORD NAME _______ (GO TO 492)

NO CHILDREN BORN IN 1998 OR LATER LIVING WITH HER (GO TO 494)

492. Now I would like to ask you what liquids (NAME FROM 491) has had over the last 7 days, including yesterday. How many days out of the last seven days did (NAME FROM 491) drink one of the following liquids?

FOR EACH OF THE LIQUIDS DRANK AT LEAST ONCE OVER THE LAST 7 DAYS, ASK: In total, during the day or night yesterday, how many times did (NAME FROM 491) drink:

a) Water?
b) Formula?
c) All other types of milk, such as boxed, powdered, or fresh animal milk?
d) Fruit juice?
e) Other liquids?

IF 7 TIMES OR MORE, RECORD '7'.
IF DOESN'T KNOW, RECORD '8'.

A) WATER
LAST SEVEN DAYS: NUMBER OF DAYS ____
YESTERDAY/LAST NIGHT: NUMBER OF TIMES ____
B) FORMULA
LAST SEVEN DAYS: NUMBER OF DAYS ____
YESTERDAY/LAST NIGHT: NUMBER OF TIMES ____
C) ALL OTHER TYPES OF MILK (BOXED, POWDERED, OR FRESH ANIMAL MILK)
LAST SEVEN DAYS: NUMBER OF DAYS ____
YESTERDAY/LAST NIGHT: NUMBER OF TIMES ____
D) FRUIT JUICE
LAST SEVEN DAYS: NUMBER OF DAYS ____
YESTERDAY/LAST NIGHT: NUMBER OF TIMES ____
E) OTHER LIQUIDS
LAST SEVEN DAYS: NUMBER OF DAYS ____
YESTERDAY/LAST NIGHT: NUMBER OF TIMES ____

493. Now I would like to ask you what foods (NAME FROM 491) has had over the last 7 days, including yesterday. How many days out of the last seven days did (NAME FROM 491) eat one of the following foods?

FOR EACH OF THE FOODS EATEN AT LEAST ONCE OVER THE LAST SEVEN DAYS, ASK: In total, during the day or night yesterday, how many times did (NAME FROM 491) eat:

a) Food made from grains (example: millet, sorghum, corn, rice, wheat, porridge, or other local grains)?
b) Red or yellow yams or squash, carrots, or sweet potatoes?
c) Other foods made from roots (example: potatoes, cassava root, or other local roots)?
d) Dark green, leafy vegetables?
e) Mangoes, papayas or other local fruits rich in vitamin A?
f) Any other fruits (example: banana, apple, green beans, avocado, tomato)?
g) Meat, poultry, fish, shellfish or eggs?
h) Any other foods made from plants (example: lentils, beans, soy, legumes, nuts)?
i) Cheese or yogurt?
j) Any foods made with oil, fats or butter?

IF 7 TIMES OR MORE, RECORD '7'.
IF DOESN'T KNOW, RECORD '8'.

A) FOOD MADE FROM GRAINS
LAST SEVEN DAYS: NUMBER OF DAYS ____
YESTERDAY/LAST NIGHT: NUMBER OF TIMES ____
B) RED OR YELLOW YAMS OR SQUASH, CARROTS, OR SWEET POTATOES
LAST SEVEN DAYS: NUMBER OF DAYS ____
YESTERDAY/LAST NIGHT: NUMBER OF TIMES ____
C) OTHER FOODS MADE FROM ROOTS
LAST SEVEN DAYS: NUMBER OF DAYS ____
YESTERDAY/LAST NIGHT: NUMBER OF TIMES ____
D) DARK GREEN, LEAFY VEGETABLES
LAST SEVEN DAYS: NUMBER OF DAYS ____
YESTERDAY/LAST NIGHT: NUMBER OF TIMES ____
E) MANGOES, PAPAYAS OR OTHER LOCAL FRUITS RICH IN VITAMIN A
LAST SEVEN DAYS: NUMBER OF DAYS ____
YESTERDAY/LAST NIGHT: NUMBER OF TIMES ____
F) ANY OTHER FRUITS
LAST SEVEN DAYS: NUMBER OF DAYS ____
YESTERDAY/LAST NIGHT: NUMBER OF TIMES ____
G) MEAT, POULTRY, FISH, SHELLFISH OR EGGS
LAST SEVEN DAYS: NUMBER OF DAYS ____
YESTERDAY/LAST NIGHT: NUMBER OF TIMES ____
H) ANY OTHER FOODS MADE FROM PLANTS
LAST SEVEN DAYS: NUMBER OF DAYS ____
YESTERDAY/LAST NIGHT: NUMBER OF TIMES ____
I) CHEESE OR YOGURT
LAST SEVEN DAYS: NUMBER OF DAYS ____
YESTERDAY/LAST NIGHT: NUMBER OF TIMES ____
J) ANY FOODS MADE WITH OIL, FATS OR BUTTER
LAST SEVEN DAYS: NUMBER OF DAYS ____
YESTERDAY/LAST NIGHT: NUMBER OF TIMES ____

494. Did you sleep under a mosquito net last night?

YES 1
NO 2

495. The last time you prepared a meal for your family did you wash your hands before beginning?

YES 1
NO 2
NEVER PREPARED MEALS 3

496. Do you currently smoke cigarettes or tobacco?
IF YES: What do you smoke? RECORD ALL MENTIONED.

YES, CIGARETTES A
YES, PIPE B
YES, OTHER TOBACCO C
NO Y

497. CHECK 496:

CODE 'A' CIRCLED (GO TO 498)
CODE 'A' NOT CIRCLED (GO TO 501)

498. In the last 24 hours, how many cigarettes (number of stems) have you smoked?

NUMBER OF CIGARETTES ____

SECTION 5: MARRIAGE AND SEXUAL ACTIVITY

501. Are you currently married or living with a man as if married?

YES, CURRENTLY MARRIED 1 (GO TO 505)
YES, LIVING WITH A MAN 2 (GO TO 505)
NO, NOT IN UNION 3

502. Have you ever been married or lived with a man as if married?

YES, FORMERLY MARRIED 1
YES, LIVED WITH A MAN 2 (GO TO 510)
NO 3 (GO TO 514)

504. What is your marital status now: are you widowed, divorced, or separated?

WIDOWED 1 (GO TO 510)
DIVORCED 2 (GO TO 510)
SEPARATED 3 (GO TO 510)

505. Is your husband/partner living with you now or is he staying elsewhere?

LIVING WITH HER 1
STAYING ELSEWHERE 2

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

NAME _____
LINE NO. _____

507. Does your husband/partner have any wives or partners other than you?

YES 1
NO 2 (GO TO 510)

508. How many other wives or partners does your husband have?

NUMBER OF WIVES _____
DOESN'T KNOW 98 (GO TO 510)

509. Are you the first, second, ... wife?

RANK _____

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

ONLY ONCE 1
MORE THAN ONCE 2

511. CHECK 510:

MARRIED/LIVED WITH A MAN ONLY ONCE: In what month and year did you start living with your husband/partner?

MARRIED/LIVED WITH A MAN MORE THAN ONCE: Now I would like to ask you about when you started living with your first husband/partner. In what month and year was that?

MONTH ____
DOESN'T KNOW MONTH 98
YEAR ____ (GO TO 514)
DOESN'T KNOW YEAR 9998

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

AGE ____

Now I need to ask you some questions about sexual activity in order to gain a better understanding of some important life issues.

514. How old were you when you had sexual intercourse for the very first time, if you have had it?

NEVER 00 (GO TO 524)

AGE IN YEARS _____

FIRST TIME WHEN STARTED LIVING WITH (FIRST) HUSBAND/PARTNER 95

515. How long has it been since the last time you had sexual intercourse?
RECORD IN NUMBER OF YEARS ONLY IF THE LAST TIME WAS MORE THAN A YEAR AGO. IF 12 MONTHS OR MORE, ANSWER MUST BE RECORDED IN YEARS.

DAYS AGO 1 ______
WEEKS AGO 2 _______
MONTHS AGO 3 _______
YEARS AGO 4 ______ (GO TO 524)

516. The last time you had sexual intercourse, was a condom used?

YES 1
NO 2 (GO TO 516F)

516A. What is the main reason that you used a condom on this occasion?

RESPONDENT WANTED TO AVOID STD'S/AIDS 1
RESPONDENT WANTED TO AVOID PREGNANCY 2
RESPONDENT WANTED TO AVOID STD'S/AIDS AND PREGNANCY 3
DIDN'T TRUST PARTNER/SUSPECTED PARTNER OF HAVING OTHER PARTNERS 4
PARTNER ASKED/INSISTED 5
OTHER (SPECIFY) ______ 6
DOESN'T KNOW 8

516B. Do you know the brand name of condom that was used on this occasion?
IF YES: What is the brand?

PRUDENCE 01
MOODS 02
NO BRAND 03
OTHER (SPECIFY) ______ 96
DOESN'T KNOW 98

516D. Did you procure these condoms or did you partner provide them?

RESPONDENT PROCURED THEM 1
PARTNER PROVIDED THEM 2 (GO TO 517)
SOMEONE ELSE PROVIDED THEM 3 (GO TO 517)

516E. How much did you pay for the condoms?
RECORD THE PRICE OF 4 CONDOMS IN CFAF.

PRICE OF 4 CONDOMS/CFAF _____ (GO TO 517)
GIFT/FREE 9996 (GO TO 517)

516F. What were the reasons a condom was not used during your last sexual encounter?

NOT IN THE HABIT A
PARTNER REFUSED B
DOESN'T LIKE CONDOMS C
IT REDUCES PLEASURE D
CONDOM TEARS E
CONDOM GIVES OFF A CERTAIN SMELL F
CONDOM IS NOT WELL LUBRICATED G
TRUST IN PARTNER H
FAITHFUL TO PARTNER I
AFRAID PARTNER SUSPECTS HER J
HAS ANOTHER METHOD OF CONTRACEPTION K
CONDOMS ARE TOO EXPENSIVE L
CONDOM NOT ON HAND M
COULDN'T FIND/GET A CONDOM N
CONDOMS ARE ASSOCIATED WITH STD'S O
CONDOMS ARE ASSOCIATED WITH CONTACT WITH PROSTITUTES Q
WANTS TO CONCEIVE S
OTHER (SPECIFY) _______ X
DOESN'T KNOW OF CONDOMS Z

517. What is your relationship to the person with whom you last had sexual intercourse?
IF BOYFRIEND OR FIANCÉ, ASK: Was your boyfriend/fiancé living with you at the time you last had sexual intercourse with him? IF YES, CIRCLE '1'. IF NO, CIRCLE '2'.

HUSBAND/LIVE-IN PARTNER 01 (GO TO 519)
BOYFRIEND/FIANCÉ 02
ANOTHER FRIEND 03
CASUAL ACQUAINTANCE 04
RELATIVE 05
CLIENT (PROSTITUTION) 06
OTHER (SPECIFY) ______ 96

518. For how long have you had sexual relations with this person?
IF ONLY HAD SEXUAL RELATIONS WITH THIS PERSON ONCE, RECORD '01' DAY.

NUMBER OF DAYS 1 _____
NUMBER OF WEEKS 2 _____
NUMBER OF MONTHS 3 _____
NUMBER OF YEARS 4 _____

519. Have you had sexual intercourse with another man in the last 12 months?

YES 1
NO 2 (GO TO 524)

520. The last time you had sexual intercourse with this other person, was a condom used?

YES 1
NO 2 (GO TO 520F)

520A. What is the main reason that you used a condom on this occasion?

RESPONDENT WANTED TO AVOID STD'S/AIDS 1
RESPONDENT WANTED TO AVOID PREGNANCY 2
RESPONDENT WANTED TO AVOID STD'S/AIDS AND PREGNANCY 3
DIDN'T TRUST PARTNER/SUSPECTED PARTNER OF HAVING OTHER PARTNERS 4
PARTNER ASKED/INSISTED 5
OTHER (SPECIFY) ______ 6
DOESN'T KNOW 8

520B. Do you know the brand name of condom that was used on this occasion?
IF YES: What is the brand?

PRUDENCE 01
MOODS 02
NO BRAND 03
OTHER (SPECIFY) ______ 96
DOESN'T KNOW 98

520D. Did you procure these condoms or did you partner provide them?

RESPONDENT PROCURED THEM 1
PARTNER PROVIDED THEM 2 (GO TO 521)
SOMEONE ELSE PROVIDED THEM 3 (GO TO 521)

520E. How much did you pay for the condoms?
RECORD THE PRICE OF 4 CONDOMS IN CFAF.

PRICE OF 4 CONDOMS/CFAF _____ (GO TO 521)
GIFT/FREE 9996 (GO TO 521)

520F. What were the reasons a condom was not used during your last sexual encounter?

NOT IN THE HABIT A
PARTNER REFUSED B
DOESN'T LIKE CONDOMS C
IT REDUCES PLEASURE D
CONDOM TEARS E
CONDOM GIVES OFF A CERTAIN SMELL F
CONDOM IS NOT WELL LUBRICATED G
TRUST IN PARTNER H
FAITHFUL TO PARTNER I
AFRAID PARTNER SUSPECTS HER J
HAS ANOTHER METHOD OF CONTRACEPTION K
CONDOMS ARE TOO EXPENSIVE L
CONDOM NOT ON HAND M
COULDN'T FIND/GET A CONDOM N
CONDOMS ARE ASSOCIATED WITH STD'S O
CONDOMS ARE ASSOCIATED WITH CONTACT WITH PROSTITUTES Q
WANTS TO CONCEIVE S
OTHER (SPECIFY) ______ X
DOESN'T KNOW OF CONDOMS Z

521. What is your relationship to this other man?
IF BOYFRIEND OR FIANCÉ, ASK: Was your boyfriend/fiancé living with you at the time you last had sexual intercourse with him? IF YES, CIRCLE '1'. IF NO, CIRCLE '2'.

HUSBAND/LIVE-IN PARTNER 01 (GO TO 523)
BOYFRIEND/FIANCÉ 02
ANOTHER FRIEND 03
CASUAL ACQUAINTANCE 04
RELATIVE 05
CLIENT (PROSTITUTION) 06
OTHER (SPECIFY) ______ 96

522. For how long have you had sexual relations with this other man?
IF ONLY HAD SEXUAL RELATIONS WITH THIS PERSON ONCE, RECORD '01' DAY.

NUMBER OF DAYS 1 _____
NUMBER OF WEEKS 2 _____
NUMBER OF MONTHS 3 _____
NUMBER OF YEARS 4 _____

523. In total, with how many people have you had sexual intercourse in the last 12 months?

NUMBER OF PARTNERS _____

524. Do you know of a place where a person can get condoms?

YES 1
NO 2 (GO TO 527)

525. Where is that? Any other place?
RECORD ALL MENTIONED.

IF IT IS A HOSPITAL, HEALTH CENTER OR CLINIC, WRITE THE NAME OF THE ESTABLISHMENT. PROBE TO DETERMINE THE PROPER TYPE OF SECTOR AND CIRCLE THE APPROPRIATE CODE.

NAME OF PLACE________
PUBLIC SECTOR
GOVERNMENT HOSPITAL A
GOVERNMENT HEALTH CENTER B
FAMILY PLANNING CLINIC C
MOBILE CLINIC D
GROUND AGENT E
OTHER PUBLIC (SPECIFY) ______ F
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC G
PHARMACY H
PRIVATE DOCTOR I
MOBILE CLINIC J
GROUND AGENT K
OTHER PRIVATE (SPECIFY) _____ L
OTHER LOCATION
STORE M
CHURCH N
FRIENDS/RELATIVES O
OTHER (SPECIFY) ______ X

526. If you wanted to, could you get yourself a condom?

YES 1
NO 2
DOESN'T KNOW/UNSURE 8

527. Do you know of a place where a person can get female condoms?

YES 1
NO 2 (GO TO 601)

528. Where is that? Any other place?
RECORD ALL MENTIONED.

IF IT IS A HOSPITAL, HEALTH CENTER OR CLINIC, WRITE THE NAME OF THE ESTABLISHMENT. PROBE TO DETERMINE THE PROPER TYPE OF SECTOR AND CIRCLE THE APPROPRIATE CODE.

NAME OF PLACE_______
PUBLIC SECTOR
GOVERNMENT HOSPITAL A
GOVERNMENT HEALTH CENTER B
FAMILY PLANNING CLINIC C
MOBILE CLINIC D
GROUND AGENT E
OTHER PUBLIC (SPECIFY) ______ F
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC G
PHARMACY/MEDICINE DISPERSAL CENTER H
PRIVATE DOCTOR I
MOBILE CLINIC J
GROUND AGENT K
OTHER PRIVATE (SPECIFY) _____ L
OTHER LOCATION
STORE/KIOSK M
CHURCH N
FRIENDS/RELATIVES O
OTHER (SPECIFY) _______ X

529. If you wanted to, could you get yourself a female condom?

YES 1
NO 2
DOESN'T KNOW/UNSURE 8

SECTION 6: FERTILITY PREFERENCES

601. CHECK 311/311A:

NEITHER HE NOR SHE STERILIZED (GO TO 602)
HE OR SHE STERILIZED (GO TO 614)

602. CHECK 226:

NOT PREGNANT OR UNSURE: 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?

PREGNANT: 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?

HAVE (A/ANOTHER) CHILD 1
NO MORE/NONE 2 (GO TO 604)
SAYS SHE CAN'T GET PREGNANT 3 (GO TO 614)
UNDECIDED/DOESN'T KNOW AND PREGNANT 4 (GO TO 610)
UNDECIDED/DOESN'T KNOW AND NOT PREGNANT OR UNSURE 5 (GO TO 608)

603. 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?

MONTHS 1 ____
YEARS 2 ____

SOON/NOW 993 (GO TO 609)
SAYS SHE CAN'T GET PREGNANT 994 (GO TO 614)
AFTER MARRIAGE 995 (GO TO 609)
OTHER (SPECIFY) _______ 996 (GO TO 609)
DOESN'T KNOW 998 (GO TO 609)

604. CHECK 226:

NOT PREGNANT OR UNSURE (GO TO 605)
PREGNANT (GO TO 610)

605. CHECK 310:
USING A CONTRACEPTIVE METHOD?

NOT ASKED (GO TO 606)
NOT CURRENTLY USING (GO TO 606)
CURRENTLY USING (GO TO 608)

606. CHECK 603:

NOT ASKED (GO TO 607)
24 OR MORE MONTHS OR 02 OR MORE YEARS (GO TO 607)
00-23 MONTHS OR 00-01 YEARS (GO TO 610)

607. CHECK 602:

WANTS TO HAVE A/ANOTHER CHILD: You have said that you do not want a/another child soon, but you are not using any method to avoid pregnancy. Can you tell me why you are not using a method? Any other reason?

WANTS NO MORE/NONE : You have said that you do not want any (more) children, but you are not using any method to avoid pregnancy. Can you tell me why you are not using a method? Any other reason?

RECORD ALL REASONS MENTIONED.

NOT MARRIED A
FERTILITY-RELATED REASONS
NOT HAVING SEX B
INFREQUENT SEX C
MENOPAUSAL/HYSTERECTOMY D
SUB-FECUND/IN FECUND E
POSTPARTUM AMENORRHEA F
BREASTFEEDING G
FATALISTIC H
OPPOSITION TO USE
RESPONDENT OPPOSED I
HUSBAND/PARTNER OPPOSED J
OTHERS OPPOSED K
RELIGIOUS PROHIBITION L
LACK OF KNOWLEDGE
KNOWS NO METHOD M
KNOWS NO SOURCE N
METHOD-RELATED REASONS
HEALTH CONCERNS O
FEAR OF SIDE EFFECTS P
LACK OF ACCESS/TOO FAR Q
COSTS TOO MUCH R
INCONVENIENT TO USE S
INTERFERES WITH BODY'S NORMAL PROCESSES T
OTHER (SPECIFY) ______ X
DOESN'T KNOW Z

608. In the weeks to come, if you were to discover that you were pregnant, would it be an important problem, a small problem, or would it not be a problem at all?

IMPORTANT PROBLEM 1
SMALL PROBLEM 2
NO PROBLEM 3
SAYS CAN'T GET PREGNANT/CAN'T HAVE SEX 4

609. CHECK 310:
USING A CONTRACEPTIVE METHOD?

NOT ASKED (GO TO 610)
NO, NOT CURRENTLY USING (GO TO 610)
YES, CURRENTLY USING (GO TO 614)

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

YES 1
NO 2 (GO TO 612)
DOESN'T KNOW 8 (GO TO 612)

611. Which contraceptive method would you prefer to use?

FEMALE STERILIZATION 01 (GO TO 614)
MALE STERILIZATION 02 (GO TO 614)
PILL 03 (GO TO 614)
IUD 04 (GO TO 614)
INJECTABLES 05 (GO TO 614)
IMPLANTS 06 (GO TO 614)
CONDOM 07 (GO TO 614)
FEMALE CONDOM 08 (GO TO 614)
DIAPHRAGM 09 (GO TO 614)
FOAM/JELLY 10 (GO TO 614)
LACTATIONAL AMEN. METHOD 11 (GO TO 614)
RHYTHM METHOD 12 (GO TO 614)
WITHDRAWAL 13 (GO TO 614)
OTHER METHOD (SPECIFY) _______ 96 (GO TO 614)
NOT SURE/DOESN'T KNOW 98 (GO TO 614)

612. What is the main reason that you think you will not use a contraceptive method at any time in the near or distant future?

NOT MARRIED 11
FERTILITY-RELATED REASONS
INFREQUENT SEX/NO SEX 22 (GO TO 614)
MENOPAUSAL/HYSTERECTOMY 23 (GO TO 614)
SUB-FECUND/IN FECUND 24 (GO TO 614)
WANTS AS MANY CHILDREN AS POSSIBLE 26 (GO TO 614)
OPPOSITION TO USE
RESPONDENT OPPOSED 31 (GO TO 614)
HUSBAND/PARTNER OPPOSED 32 (GO TO 614)
OTHERS OPPOSED 33 (GO TO 614)
RELIGIOUS PROHIBITION 34 (GO TO 614)
LACK OF KNOWLEDGE
KNOWS NO METHOD 41 (GO TO 614)
KNOWS NO SOURCE 42 (GO TO 614)
METHOD-RELATED REASONS
HEALTH CONCERNS 51 (GO TO 614)
FEAR OF SIDE EFFECTS 52 (GO TO 614)
LACK OF ACCESS/TOO FAR 53 (GO TO 614)
COSTS TOO MUCH 54 (GO TO 614)
INCONVENIENT TO USE 55 (GO TO 614)
INTERFERES WITH BODY'S NORMAL PROCESSES 56 (GO TO 614)
OTHER (SPECIFY) ______ 96 (GO TO 614)
DOESN'T KNOW 98 (GO TO 614)

613. Would you ever use a contraceptive method if you were married?

YES 1
NO 2
DOESN'T KNOW 8

614. 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.

NUMBER OF CHILDREN _____
OTHER (SPECIFY) _____ 96 (GO TO 616)

615. How many of these children would you like to be boys, how many would you like to be girls and for how many would the sex not matter?

NUMBER OF BOYS ____
OTHER (SPECIFY) _____ 96
NUMBER OF GIRLS ____
OTHER (SPECIFY) _____ 96
NUMBER OF EITHER ____
OTHER (SPECIFY) _____ 96

616. Would you say that you approve or disapprove of couples that use a method to avoid becoming pregnant?

APPROVE 1
DISAPPROVE 2
DOESN'T KNOW/NOT SURE 3

617. In the last few months have you heard about family planning:

On the radio?
On television?
In newspapers or magazines?
On posters?
In a prospectus/brochure?
At a cultural/educational performance?
At school?

ON THE RADIO
YES 1
NO 2
ON TELEVISION
YES 1
NO 2
IN NEWSPAPERS OR MAGAZINES
YES 1
NO 2
ON POSTERS
YES 1
NO 2
IN A PROSPECTUS/BROCHURE
YES 1
NO 2
CULTURAL/EDUCATIONAL PERFORMANCE
YES 1
NO 2
AT SCHOOL
YES 1
NO 2

618. In your opinion, is it appropriate or inappropriate to speak of family planning:

On the radio?
On television?
In newspapers or magazines?
On posters?
In a prospectus/brochure?
At a cultural/educational performance?
At school?

ON THE RADIO
APPROPRIATE 1
INAPPROPRIATE 2
ON TELEVISION
APPROPRIATE 1
INAPPROPRIATE 2
IN NEWSPAPERS OR MAGAZINES
APPROPRIATE 1
INAPPROPRIATE 2
ON POSTERS
APPROPRIATE 1
INAPPROPRIATE 2
IN A PROSPECTUS/BROCHURE
APPROPRIATE 1
INAPPROPRIATE 2
CULTURAL/EDUCATIONAL PERFORMANCE
APPROPRIATE 1
INAPPROPRIATE 2
AT SCHOOL
APPROPRIATE 1
INAPPROPRIATE 2

619. Over the last several months, have you discussed family planning with your friends, neighbors, or relatives?

YES 1
NO 2 (GO TO 621)

620. With whom did you discuss it? Anyone else?
RECORD ALL MENTIONED.

HUSBAND/PARTNER A
MOTHER B
FATHER C
SISTER(S) D
BROTHER(S) E
DAUGHTER(S) F
SON(S) G
MOTHER-IN-LAW H
FRIEND(S)/NEIGHBOR(S) I
HEALTH WORKERS J
PEER EDUCATORS K
OTHER (SPECIFY) ______ X

621. CHECK 501:

YES, CURRENTLY MARRIED (GO TO 622)
YES, LIVING WITH A MAN (GO TO 622)
NO, NOT IN UNION (GO TO 628)

622. CHECK 311/311A:

A CODE CIRCLED (GO TO 623)
NO CODE CIRCLED (GO TO 624)

623. You have said that you are currently using a method of contraception. Would you say that using contraception is mainly your decision, mainly your husband's/partner's decision, or did you both decide together?

DECISION OF RESPONDENT 1
DECISION OF HUSBAND/PARTNER 2
JOINT DECISION 3
OTHER (SPECIFY) ______ 6

Now I would like to ask you some questions about your husband's/partner's opinions on family planning.

624. Do you think that your husband/partner approves or disapproves of couples that use a method to avoid a pregnancy?

APPROVES 1
DISAPPROVES 2
DOESN'T KNOW 8

625. How many times over the last 12 months have you discussed family planning with your husband/partner?

NEVER 1
ONE OR TWO TIMES 2
MORE OFTEN 3

626. CHECK 311/311A:

NEITHER HE NOR SHE STERILIZED (GO TO 627)
HE OR SHE STERILIZED (GO TO 628)

627. Do you think that your husband/partner want the same number of children that you want, or does he want more or fewer than you want?

SAME NUMBER 1
MORE CHILDREN 2
FEWER CHILDREN 3
DOESN'T KNOW 8

628. Husbands and wives don't always agree on everything. Please, tell me if you think a woman is justified in refusing to have sexual intercourse with her husband when:

She knows that her husband has a sexually transmitted infection?
She knows that her husband has sexual intercourse with other women?
She has recently given birth?
She is tired or doesn't feel like it?

KNOWS HUSBAND HAS AN STD
YES 1
NO 2
DOESN'T KNOW 8
KNOWS HUSBAND HAS SEXUAL INTERCOURSE WITH OTHER WOMEN
YES 1
NO 2
DOESN'T KNOW 8
SHE HAS RECENTLY GIVEN BIRTH
YES 1
NO 2
DOESN'T KNOW 8
SHE IS TIRED OR DOESN'T FEEL LIKE IT
YES 1
NO 2
DOESN'T KNOW 8

SECTION 7: HUSBAND'S BACKGROUND AND WOMAN'S WORK

701. CHECK 501 AND 502:

CURRENTLY MARRIED/LIVING WITH A MAN (GO TO 702)
FORMERLY MARRIED/LIVING WITH A MAN (GO TO 703)
NEVER MARRIED AND NEVER LIVED WITH A MAN (GO TO 707)

702. How old was your husband/partner on his last birthday?

AGE IN COMPLETED YEARS ____

703. Did your (last) husband/partner ever attend school?

YES 1
NO 2 (GO TO 706)

704. What was the highest level of school he attended: primary, secondary (1st cycle), secondary (2nd cycle) or higher?

PRIMARY 1
SECONDARY (1ST CYCLE) 2
SECONDARY (2ND CYCLE) 3
HIGHER 4 (GO TO 706)
DOESN'T KNOW 8

705. What was the highest (grade/form/year) he completed at that level?
WRITE '0' FOR LESS THAN ONE YEAR COMPLETED AND '8' FOR DOESN'T KNOW.

GRADE/YEAR ____

706. CHECK 701:

CURRENTLY MARRIED/LIVING WITH A MAN: What is your husband's/partner's occupation? That is, what kind of work does he mainly do?

FORMERLY MARRIED/LIVED WITH A MAN: What was your (last) husband's/partner's occupation? That is, what kind of work did he mainly do?

HUSBAND'S OCCUPATION ______

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

YES 1 (GO TO 710)
NO 2

708. As you know, some women take up jobs for which they are paid in cash or kind. Others sell things, have a small business or work on the family farm or in the family business. Do you currently do any of these things or any other work?

YES 1 (GO TO 710)
NO 2

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

YES 1
NO 2 (GO TO 719)

710. What is your occupation, that is, what kind of work do you mainly do?

OCCUPATION _____

711. CHECK 710:

WORKS IN AGRICULTURE (GO TO 712)
DOES NOT WORK IN AGRICULTURE (GO TO 713)

712. Do you work mainly on your own land or on family land, or do you work on land that you rent from someone else, or do you work on someone else's land?

OWN LAND 1
FAMILY LAND 2
RENTED LAND 3
SOMEONE ELSE'S LAND 4

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

FOR FAMILY MEMBER 1
FOR SOMEONE ELSE 2
SELF-EMPLOYED 3

714. Do you usually work at home or away from home?

HOME 1
AWAY 2

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

THROUGHOUT THE YEAR 1
SEASONALLY/PART OF THE YEAR 2
ONCE IN A WHILE 3

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

CASH ONLY 1
CASH AND KIND 2
IN KIND ONLY 3 (GO TO 719)
NOT PAID 4 (GO TO 719)

717. Who usually decides how the money you earn will be used?

RESPONDENT 1
HUSBAND/PARTNER 2
RESPONDENT AND HUSBAND/PARTNER JOINTLY 3
SOMEONE ELSE 4
SOMEONE ELSE AND HUSBAND/PARTNER JOINTLY 5

718. On average, what percentage of the household expenses are paid for using the money you earn?

ALMOST NOTHING 1
LESS THAN HALF 2
ABOUT HALF 3
MORE THAN HALF 4
ALL OF THEM 5
NONE, ALL HER EARNINGS ARE KEPT 6

719. In your family, who usually has the last word in the following decisions:

Your own health care?
The purchase of important household items?
The purchase of daily household items?
Visiting family or relatives?
What food will be prepared each day?

YOUR OWN HEALTH CARE
RESPONDENT 1
HUSBAND/PARTNER 2
RESPONDENT AND HUSBAND/PARTNER JOINTLY 3
SOMEONE ELSE 4
RESPONDENT AND SOMEONE ELSE JOINTLY 5
DECISION NOT MADE/NOT APPLICABLE 6
PURCHASE OF IMPORTANT HOUSEHOLD ITEMS
RESPONDENT 1
HUSBAND/PARTNER 2
RESPONDENT AND HUSBAND/PARTNER JOINTLY 3
SOMEONE ELSE 4
RESPONDENT AND SOMEONE ELSE JOINTLY 5
DECISION NOT MADE/NOT APPLICABLE 6
PURCHASE OF DAILY HOUSEHOLD ITEMS
RESPONDENT 1
HUSBAND/PARTNER 2
RESPONDENT AND HUSBAND/PARTNER JOINTLY 3
SOMEONE ELSE 4
RESPONDENT AND SOMEONE ELSE JOINTLY 5
DECISION NOT MADE/NOT APPLICABLE 6
VISITING FAMILY OR RELATIVES
RESPONDENT 1
HUSBAND/PARTNER 2
RESPONDENT AND HUSBAND/PARTNER JOINTLY 3
SOMEONE ELSE 4
RESPONDENT AND SOMEONE ELSE JOINTLY 5
DECISION NOT MADE/NOT APPLICABLE 6
WHAT FOOD WILL BE PREPARED EACH DAY
RESPONDENT 1
HUSBAND/PARTNER 2
RESPONDENT AND HUSBAND/PARTNER JOINTLY 3
SOMEONE ELSE 4
RESPONDENT AND SOMEONE ELSE JOINTLY 5
DECISION NOT MADE/NOT APPLICABLE 6

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

CHILDREN UNDER 10 YEARS
PRESENT AND LISTENING 1
PRESENT BUT NOT LISTENING 2
NOT PRESENT 8
HUSBAND
PRESENT AND LISTENING 1
PRESENT BUT NOT LISTENING 2
NOT PRESENT 8
OTHER MALES
PRESENT AND LISTENING 1
PRESENT BUT NOT LISTENING 2
NOT PRESENT 8
OTHER FEMALES
PRESENT AND LISTENING 1
PRESENT BUT NOT LISTENING 2
NOT PRESENT 8

721. Sometimes a husband is annoyed or angered by things that his wife does. In your opinion, is a husband justified in hitting or beating his wife in the following situations:

If she goes out without telling him?
If she neglects the children?
If she argues with him?
If she refuses to have sex with him?
If she burns the food?

GOES OUT WITHOUT TELLING HIM
YES 1
NO 2
DOESN'T KNOW 8
NEGLECTS THE CHILDREN
YES 1
NO 2
DOESN'T KNOW 8
ARGUES WITH HIM
YES 1
NO 2
DOESN'T KNOW 8
REFUSES TO HAVE SEX WITH HIM
YES 1
NO 2
DOESN'T KNOW 8
BURNS THE FOOD
YES 1
NO 2
DOESN'T KNOW 8

SECTION 8: AIDS AND OTHER SEXUALLY TRANSMITTED INFECTIONS

Now I would like to talk about something else.

801. Have you ever heard of an illness called AIDS?

YES 1
NO 2 (GO TO 817)

802. Is there something people can do to avoid contracting AIDS or the virus that causes AIDS?

YES 1
NO 2 (GO TO 809)
DOESN'T KNOW 8 (GO TO 809)

803. What can one do? Anything else?
RECORD ALL MENTIONED.

ABSTAIN FROM HAVING SEX A
USE CONDOMS B
ONLY HAVE SEX WITH ONE PARTNER C
LIMIT NUMBER OF SEXUAL PARTNERS D
AVOID SEX WITH PROSTITUTES E
AVOID SEX WITH PEOPLE WITH LOTS OF PARTNERS F
AVOID SAME-PARTNER SEX G
AVOID SEX WITH PEOPLE WHO USE IV DRUGS H
AVOID BLOOD TRANSFUSIONS I
AVOID INJECTIONS J
AVOID SHARING RAZORS/BLADES K
AVOID KISSING L
AVOID MOSQUITO BITES M
SEEK PROTECTION FROM TRADITIONAL HEALERS N
OTHER (SPECIFY) _____ W
OTHER (SPECIFY) _____ X
DOESN'T KNOW Z

804. Can people reduce their chance of getting the AIDS virus by having just one uninfected sex partner who has no other sex partners?

YES 1
NO 2
DOESN'T KNOW 8

805. Can people get the AIDS virus from mosquito bites?

YES 1
NO 2
DOESN'T KNOW 8

806. Can people reduce their chance of getting the AIDS virus by using a condom every time they have sex?

YES 1
NO 2
DOESN'T KNOW 8

807. Can people get the AIDS virus by sharing food with a person who has AIDS?

YES 1
NO 2
DOESN'T KNOW 8

809. Is it possible for a healthy-looking person to have the AIDS virus?

YES 1
NO 2
DOESN'T KNOW 8

810. Do you personally know anyone who has the AIDS virus or is sick from AIDS, or someone who has died of AIDS?

YES 1
NO 2

811. Can the virus that causes AIDS be transmitted from a mother to her baby?

YES 1
NO 2 (GO TO 813)
DOESN'T KNOW 8 (GO TO 813)

812. When can the AIDS virus be transmitted from the mother to the child? Can it be transmitted:

During pregnancy?
During delivery?
By breastfeeding?

DURING PREGNANCY
YES 1
NO 2
DOESN'T KNOW 8
DURING DELIVERY
YES 1
NO 2
DOESN'T KNOW 8
BY BREASTFEEDING
YES 1
NO 2
DOESN'T KNOW 8

813. CHECK 501:

YES, CURRENTLY MARRIED/LIVING WITH A MAN (GO TO 814)
NO, NOT CURRENTLY MARRIED/LIVING WITH A MAN (GO TO 815)

814. Have you already spoken with your husband/partner about ways to avoid the AIDS virus?

YES 1
NO 2

815. If a member of your family got infected with the AIDS virus, would you want it to remain a secret or not?

YES, REMAIN A SECRET 1
NO 2
DOESN'T KNOW/NOT SURE 8

816. If a member of your family became sick with AIDS, would you be willing to care for her or him in your own household?

YES 1
NO 2
DOESN'T KNOW/NOT SURE/DEPENDS 8

817. Apart from AIDS, have you heard about other infections that can be transmitted through sexual contact?

YES 1
NO 2 (GO TO 901)

818. What are the signs or symptoms in a man that make you think he may have a sexually transmitted infection?
INSIST: Anything else?
RECORD ALL MENTIONED.

ABDOMINAL PAIN A
GENITAL DISCHARGE B
FOUL-SMELLING DISCHARGE C
BURNING DURING URINATION D
RASH/INFLAMMATION IN GENITAL AREA E
SWELLING IN GENITAL AREA F
GENITAL SORES/ULCERS G
GENITAL WARTS H
GENITAL ITCHING I
BLOOD IN URINE J
WEIGHT LOSS K
IMPOTENCE L
OTHER (SPECIFY) ______ W
OTHER (SPECIFY) ______ X
NO SYMPTOMS Y
DOESN'T KNOW Z

819. What are the signs or symptoms in a woman that make you think she may have a sexually transmitted infection?
INSIST: Anything else?
RECORD ALL MENTIONED.

ABDOMINAL PAIN A
VAGINAL DISCHARGE B
FOUL-SMELLING DISCHARGE C
BURNING DURING URINATION D
RASH/INFLAMMATION IN GENITAL AREA E
SWELLING IN GENITAL AREA F
GENITAL SORES/ULCERS G
GENITAL WARTS H
GENITAL ITCHING I
BLOOD IN URINE J
WEIGHT LOSS K
DIFFICULTY GETTING PREGNANT/HAVING CHILDREN L
OTHER (SPECIFY) ______ W
OTHER (SPECIFY) ______ X
NO SYMPTOMS Y (GO TO 819B)
DOESN'T KNOW Z (GO TO 819B)

819A. If you had any of these symptoms, where would you go for advice or care?

PUBLIC SECTOR
HOSPITAL 11
HEALTH CENTER 12
DISPENSARY 13
MEDICAL POST 14
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC 21
PRIVATE HEALTH CENTER 22
PHARMACY/MEDICINE DISPERSAL CENTER 23
PRIVATE DOCTOR 24
PF/FISA CENTER 25
OTHER SOURCE
DBC AGENT 31
STORE 32
KIOSK 33
CHURCH 34
TRADITIONAL HEALER 35
RELATIVES/FRIENDS 36
OTHER (SPECIFY) _______ 96

819B. CHECK 514:

HAS HAD SEXUAL INTERCOURSE (GO TO 819C)
HAS NOT HAD SEXUAL INTERCOURSE (GO TO 901)

Now I would like to ask you some questions about your health in the last 12 months.

819C. During the last 12 months, have you had a sexually transmitted infection?

YES 1
NO 2
DOESN'T KNOW 8

819D. Sometimes women experience a bad smelling abnormal vaginal discharge. During the last 12 months, have you had a bad smelling abnormal vaginal discharge?

YES 1
NO 2
DOESN'T KNOW 8

819E. Sometimes women have a genital sore or ulcer. During the last 12 months, have you had a genital sore or ulcer?

YES 1
NO 2
DOESN'T KNOW 8

819F. CHECK 819C, 819D, AND 819E:

HAS HAD AN INFECTION (GO TO 819G)
HAS NOT HAD AN INFECTION (GO TO 901)

819G. The last time you had (INFECTION FROM 819C/819D/819E), did you seek any kind of advice or treatment?

YES 1
NO 2 (GO TO 819I)

819H. The last time you had (INFECTION FROM 819C/819D/819E), did you do any of the following things? Did you...

Seek advice from a health care worker in a hospital or clinic?
Seek advice or treatment from a traditional healer?
Seek advice or buy medication from a pharmacy or store?
Seek advice from family or friends?

ADVICE FROM HEALTH CARE WORKER IN A HOSPITAL/CLINIC
YES 1
NO 2
ADVICE OR TREATMENT FROM TRADITIONAL HEALER
YES 1
NO 2
ADVICE OR BUY MEDICATION FROM PHARMACY/STORE
YES 1
NO 2
ADVICE FROM FAMILY OR FRIENDS
YES 1
NO 2

819I. When you had (INFECTION FROM 819C/819D/819E), did you inform your sexual partner(s)?

YES 1
NO 2
CERTAIN ONES/NOT ALL 3

819J. When you had (INFECTION FROM 819C/819D/819E), did you do anything to avoid infecting your sexual partner(s)?

YES 1
NO 2 (GO TO 901)
PARTNER ALREADY INFECTED 3 (GO TO 901)

819K. What did you do to avoid infecting your partner(s)? Did you...

Stop having sexual intercourse?
Use a condom during sexual intercourse?
Take medication?

STOP HAVING SEXUAL INTERCOURSE
YES 1
NO 2
USE A CONDOM DURING SEXUAL INTERCOURSE
YES 1
NO 2
TAKE MEDICATION
YES 1
NO 2

SECTION 9: MORTALITY

Now, I would like to ask you some questions about your brothers and sisters, that is, all of the children born to your natural mother including those that live with you, those that live elsewhere, and those that are deceased.

901. To how many children did your mother give birth in total, including yourself?

NATURAL MOTHER'S NUMBER OF BIRTHS ____

902. CHECK 901:

TWO OR MORE BIRTHS (GO TO 903)
ONLY ONE BIRTH (RESPONDENT) (GO TO 1001)

903. How many of these births did your mother have before you were born?

NUMBER OF PRECEDING BIRTHS ____

904. What was the name given to your (oldest/next oldest) brother or sister?

NAME______

905. Is (NAME) male or female?

MALE 1
FEMALE 2

906. Is (NAME) still alive?

YES 1
NO 2 (GO TO 908)
DOESN'T KNOW 8 (GO TO NEXT COLUMN/BIRTH)

907. How old is (NAME)?

AGE _____ (GO TO NEXT COLUMN/BIRTH)

908. How many years ago did (NAME) die?

YEARS AGO _____

909. How old was (NAME) when he/she died?

AGE AT DEATH ______ (GO TO NEXT COLUMN/BIRTH)

[IF NO MORE BROTHERS OR SISTERS, GO TO 1001]

SECTION 10: FEMALE CIRCUMCISION

I would now like to interview you about a subject relating to women's health.

1001. Have you ever heard of female circumcision?

YES 1 (GO TO 1003)
NO 2

1002. In certain societies or countries such as Burkina Faso, a practice exists which consists of cutting a part of the external genital organs of girls. Have you ever heard of this practice?

YES 1
NO 2 (GO TO 1025)

1003. Have you been circumcised?

YES 1
NO 2 (GO TO 1009)

I would now like to ask you questions about what happened at that time.

1004. Did they cut some of your skin in the genital region?

YES 1 (GO TO 1006)
NO 2
DOESN'T KNOW 8

1005. Did they only cut into your genital area without removing any skin?

YES 1
NO 2
DOESN'T KNOW 8

1006. During your circumcision, did they completely close the vaginal opening by sewing a seam?

YES 1
NO 2
DOESN'T KNOW 8

1007. What age were you at the time of your circumcision?
IF THE RESPONDENT DOESN'T KNOW THE EXACT AGE, TRY TO OBTAIN AN ESTIMATE.

AGE IN FULL YEARS ____

DURING CHILDHOOD 95
DOESN'T KNOW 98

1008. Who performed your circumcision?

TRADITIONAL
TRADITIONAL CIRCUMCISER 11
TRADITIONAL MIDWIFE/MATRON 12
OTHER TRADITIONAL (SPECIFY) ______ 16
HEALTH CARE PROFESSIONALS
DOCTOR 21
NURSE/MIDWIFE 22
OTHER HEALTH CARE PROFESSIONAL (SPECIFY) ______ 26
DOESN'T KNOW 98

1009. CHECK 214 AND 216:

HAS AT LEAST ONE LIVING DAUGHTER (GO TO 1010)
HAS NO LIVING DAUGHTERS (GO TO 1019)

1010. Have any of your daughters undergone circumcision?
IF YES: How many?

NUMBER OF DAUGHTERS CIRCUMCISED ____
NO DAUGHTERS CIRCUMCISED 95 (GO TO 1018)

1011. Which of your daughters has most recently been circumcised?
INTERVIEWER: CHECK 212 AND RECORD THE DAUGHTER'S LINE NUMBER

NAME OF DAUGHTER _______
DAUGHTER'S LINE NO. ______

I would now like to ask you questions about what was done to (NAME OF DAUGHTER IN 1011) at that time.

1012. Did they remove any part of her genitals?

YES 1 (GO TO 1014)
NO 2
DOESN'T KNOW 8

1013. Did they only cut into her genital area without removing any skin?

YES 1
NO 2
DOESN'T KNOW 8

1014. During her circumcision, did they completely close the vaginal opening by sewing a seam?

YES 1
NO 2
DOESN'T KNOW 8

1015. What age was (NAME OF DAUGHTER IN 1011) at the time of her circumcision?
IF THE RESPONDENT DOESN'T KNOW THE EXACT AGE, TRY TO OBTAIN AN ESTIMATE.

AGE IN FULL YEARS ____

DURING CHILDHOOD 95
DOESN'T KNOW 98

1016. Who performed your daughter's circumcision?

TRADITIONAL
TRADITIONAL CIRCUMCISER 11
TRADITIONAL MIDWIFE/MATRON 12
OTHER TRADITIONAL (SPECIFY) ______ 16
HEALTH CARE PROFESSIONALS
DOCTOR 21
NURSE/MIDWIFE 22
OTHER HEALTH CARE PROFESSIONAL (SPECIFY) ______ 26
DOESN'T KNOW 98

1017. During or after they cut (NAME OF DAUGHTER IN 1011)'s genitals, did any of the following problems present themselves:

Excessive bleeding?
Difficulty urinating or retaining urine?
Swelling in the genital region?
Infection in the genital region/wound improperly healed?

EXCESSIVE BLEEDING
YES 1
NO 2
DOESN'T KNOW 8
DIFFICULTY URINATING OR RETAINING URINE
YES 1
NO 2
DOESN'T KNOW 8
SWELLING IN THE GENITAL REGION
YES 1
NO 2
DOESN'T KNOW 8
INFECTION IN THE GENITAL REGION/WOUND IMPROPERLY HEALED
YES 1
NO 2
DOESN'T KNOW 8

1018. In the future, do you intend to have your daughters circumcised?

YES 1
NO 2
DOESN'T KNOW 8

1019. What are the advantages for a girl to be circumcised?
INSIST: Other advantages? RECORD ALL MENTIONED.

BETTER HYGIENE A
SOCIAL RECOGNITION B
BETTER CHANCE FOR MARRIAGE C
PRESERVATION OF VIRGINITY/PREVENT PREMARITAL SEX D
MORE SEXUAL PLEASURE FOR THE MALE E
RELIGIOUS NECESSITY F
OTHER (SPECIFY) _______ X
NO ADVANTAGE Y

1020. What are the advantages for a girl not to be circumcised?
INSIST: Anything else? RECORD ALL MENTIONED.

LESS HEALTH PROBLEMS A
AVOID SUFFERING B
MORE SEXUAL PLEASURE FOR HERSELF C
MORE SEXUAL PLEASURE FOR THE MALE D
IN ACCORD WITH RELIGION E
OTHER (SPECIFY) ______ X
NO ADVANTAGE Y

1021. Do you think that the practice of female circumcision is a way to prevent girls from having premarital sex or do you think, on the contrary, that it has no effect?

PREVENTS PREMARITAL SEX 1
NO EFFECT 2
DOESN'T KNOW 8

1022. Do you think that female circumcision is demanded by your religion?

YES 1
NO 2
DOESN'T KNOW 8

1023. Do you think that the practice of female circumcision should continue or disappear?

CONTINUE 1
DISAPPEAR 2
DEPENDS 3
DOESN'T KNOW 8

1024. Do you think that men believe the practice of female circumcision should be maintained, or on the contrary, do you think they favor its abandonment?

MAINTAINED 1
ABANDONED 2
DEPENDS 3
DOESN'T KNOW 8

1024A. Do you think a law exists in Burkina that prohibits female circumcision?

YES 1
NO 2

1025. RECORD THE TIME:

HOUR ____
MINUTES ____

CALENDAR INSTRUCTIONS

ONLY ONE CODE SHOULD APPEAR IN ANY BOX.

BIRTHS AND PREGNANCIES CODES:

N BIRTH
G PREGNANCY
F END OF PREGNANCY

2003:
12 DEC 01 ____
11 NOV 02 ____
10 OCT 03 ____
09 SEPT 04 ____
08 AUG 05 ____
07 JUL 06 ____
06 JUN 07 ____
05 MAY 08 ____
04 APR 09 ____
03 MAR 10 ____
02 FEB 11 ____
01 JAN 12 ____

2002:
12 DEC 13 ____
11 NOV 14 ____
10 OCT 15 ____
09 SEPT 16 ____
08 AUG 17 ____
07 JUL 18 ____
06 JUN 19 ____
05 MAY 20 ____
04 APR 21 ____
03 MAR 22 ____
02 FEB 23 ____
01 JAN 24 ____

2001:
12 DEC 25 ____
11 NOV 26 ____
10 OCT 27 ____
09 SEPT 28 ____
08 AUG 29 ____
07 JUL 30 ____
06 JUN 31 ____
05 MAY 32 ____
04 APR 33 ____
03 MAR 34 ____
02 FEB 35 ____
01 JAN 36 ____

2000:
12 DEC 37 ____
11 NOV 38 ____
10 OCT 39 ____
09 SEPT 40 ____
08 AUG 41 ____
07 JUL 42 ____
06 JUN 43 ____
05 MAY 44 ____
04 APR 45 ____
03 MAR 46 ____
02 FEB 47 ____
01 JAN 48 ____

1999:
12 DEC 49 ____
11 NOV 50 ____
10 OCT 51 ____
09 SEPT 52 ____
08 AUG 53 ____
07 JUL 54 ____
06 JUN 55 ____
05 MAY 56 ____
04 APR 57 ____
03 MAR 58 ____
02 FEB 59 ____
01 JAN 60 ____

1998:
12 DEC 61 ____
11 NOV 62 ____
10 OCT 63 ____
09 SEPT 64 ____
08 AUG 65 ____
07 JUL 66 ____
06 JUN 67 ____
05 MAY 68 ____
04 APR 69 ____
03 MAR 70 ____
02 FEB 71 ____
01 JAN 72 ____

END OF THE LAST PREGNANCY THAT DID NOT TERMINATE IN A LIVE BIRTH BEFORE JANUARY 1998:

[IF THERE ARE NO PREGNANCIES OF THIS KIND, RECORD '00' FOR THE MONTH AND '0000' FOR THE YEAR.]

MONTH _____
YEAR ______

INTERVIEWER'S OBSERVATIONS

TO BE FILLED IN AFTER COMPLETING INTERVIEW

COMMENTS ABOUT RESPONDENT _____

COMMENTS ON SPECIFIC QUESTIONS _____

ANY OTHER COMMENTS _____

SUPERVISOR'S OBSERVATIONS _____
NAME _____
DATE _____

EDITOR'S OBSERVATIONS _____
NAME _____
DATE _____