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DEMOGRAPHIC AND HEALTH SURVEY
WOMAN'S QUESTIONNAIRE

MINISTRY OF PLANNING
CONGO DEMOCRATIC REPUBLIC

IDENTIFICATION

RESPONDENT POOL _________

NAME OF LOCATION (NEIGHBORHOOD/VILLAGE) _________

NAME OF HOUSEHOLD HEAD ___________

CLUSTER NUMBER _____

HOUSEHOLD NUMBER ______

PROVINCE _____

URBAN/RURAL

URBAN 1
RURAL 2

RESIDENCE:

KINSHASA 1
PROVINCIAL CAPITAL 2
OTHER CITIES 3
CITY 4
RURAL 5

NAME AND LINE NUMBER OF WOMAN _____

CHECK COVER OF HOUSEHOLD QUESTIONNAIRE: WAS THIS HOUSEHOLD SELECTED FOR THE QUESTIONS ON "DOMESTIC VIOLENCE"?
IF NO, RECORD '2' IN THE SPACE ON THE RIGHT.
IF YES, CHECK SCHEDULE 500B FOR THE SELECTION OF ELIGIBLE WOMEN IN THE SECTION ON "DOMESTIC VIOLENCE". WAS THE WOMAN YOU ARE INTERVIEWING SELECTED? IF YES, RECORD '1' IN THE SPACE ON THE RIGHT; IF NO, RECORD '2'.

WOMAN SELECTED ____

INTERVIEWER VISITS

FIRST VISIT: (REPEAT FOR SECOND AND THIRD VISITS)
DATE ______
INTERVIEWER'S NAME _______________
RESULT* _____

NEXT VISIT: (FOR INTERVIEWS 1 AND 2)
DATE _____
TIME _____

FINAL VISIT:
DAY _____
MONTH _____
YEAR 2007
INT. NUMBER ____
RESULT ___

RESULT CODES:

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

TOTAL NUMBER OF VISITS ____

LANGUAGE OF QUESTIONNAIRE:

FRENCH 1

LANGUAGE OF INTERVIEW: _________

FRENCH 1
KIKONGO 2
LINGALA 3
SWAHILI 4
TSHILUBA 5
OTHERS 6

INTERPRETER

YES 1
NO 2

SUPERVISOR

NAME _________
DATE _____

FIELD EDITOR

NAME ________
DATE _____

OFFICE EDITOR ____

KEYED BY ____

SECTION 1. RESPONDENT'S BACKGROUND

INTRODUCTION AND CONSENT

INFORMED CONSENT

Hello. My name is ___ and I am working with the Ministry of Planning. We are conducting a national survey about women and children's health. We would very much appreciate your participation in this survey. I would like to ask you some questions about your health (and your children's health). The information will help the government to plan health services. The questions usually take about 20 to 45 minutes. Whatever information you provide will be kept strictly confidential and will not be shared with anyone.

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

At this time, do you want to ask me anything 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)

101) RECORD THE TIME.

HOUR ____
MINUTES ____

102) First I would like to ask some questions about you and your household. For most of the time until you were 12 years old, did you live in a large city, a city, or a rural location?

IF CITY, ASK THE NAME OF THE CITY ________________
LARGE CITY 1
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.

YEARS ____

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

104) Just before you moved here, did you live in a large city, a city, or a rural location?

IF CITY, ASK THE NAME OF THE CITY. __________
LARGE CITY 1
CITY 2
RURAL 3

105) In what month and year were you born?

MONTH ____
DON'T KNOW MONTH 98
YEAR 19__
DON'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 11)

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

PRIMARY 1
SECONDARY 2
HIGHER 3

109) What is the highest (grade/form/year) you completed at this level?

GRADE ____

110) CHECK 108:

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

111) Now I would like you to read this sentence out loud to me; read as much as 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
CAN READ CERTAIN PARTS 2
CAN READ THE WHOLE SENTENCE 3
NO CARD IN LANGUAGE (SPECIFY LANGUAGE) _______ 4
BLIND/VISUALLY IMPAIRED 5

112) Have you ever participated in a literacy program or any other program that involved 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' OR '5' CIRCLED (GO TO 115)

114) Do you read a newspaper or 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) In the last 12 months, how many times have you traveled outside of your community and slept somewhere other than your home?

NUMBER OF TRIPS ____
NONE 00 (GO TO 119)

118) In the last 12 months, have you been away from home for more than one month at a time?

YES 1
NO 2

119) What is your religion?

CATHOLIC 01
PROTESTANT 02
SALVATION ARMY 03
KIMBANGUIST 04
OTHER CHRISTIAN 05
ISLAM 06
ANIMIST 07
NO RELIGION 08
OTHER (SPECIFY) _____ 96

120) What is your tribe?

(RECORD NAME OF TRIBE) ____________________
BAKONGO NORTH AND SOUTH OF RIVER 01
BAS-KASAI AND KWILU-KWANGO 02
CENTRAL CUVETTE 03
UBANGI AND ITIMBIRI-NGIRI 04
UELE; LAKE ALBERT 05
BASELE-KOMO, MANIEMA AND KIVU 06
KASAI, KATANGA, TANGANIKA 07
LUNDA 08
PYGMY 09
OTHER (SPECIFY) _____ 10

120A) I would like to ask you a question about the tribe of your biological parents. Do (did) they belong to the same tribe?

YES 1
NO 2

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?

YES 1
NO 2 (GO TO 206)

202) Do you have any sons or 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?
And 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 who 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?
And 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 but did not survive?

YES 1
NO 2 (GO TO 208)

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

BOYS DEAD ____
GIRLS DEAD ____

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

TOTAL ___

209) CHECK 208:
Just to makes 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)

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 Q212. RECORD TWINS AND TRIPLETS ON SEPARATE LINES.

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

(NAME) ________

213) Were any of these births twins?

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 ____ (GO TO NEXT BIRTH)
(GO TO 221)

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

YES 1
NO 2

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

YES 1 (ADD BIRTH TO Q212)
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 __
FOR EACH LIVING CHILD: CURRENT AGE IS RECORDED __
FOR EACH DEAD CHILD: AGE AT DEATH IS RECORDED __
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 SINCE 2002 OR LATER. IF NONE, RECORD '0'.

BIRTHS ___

226) Are you pregnant now?

YES 1
NO 2 (GO TO 229)
NOT SURE 8 (GO TO 229)

227) How many months pregnant are you?
RECORD NUMBER OF COMPLETED MONTHS.

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
NO MORE/DID NOT WANT 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 TERMINATED IN JANUARY 2002 OR LATER (GO TO 232)
LAST PREGNANCY TERMINATED BEFORE JANUARY 2002 (GO TO 237)

232) How many months pregnant were you when the last such pregnancy ended?
RECORD THE NUMBER OF COMPLETED MONTHS.

MONTHS ___

233) Have you had any other pregnancies that did not result in a live birth?

YES 1
NO 2 (GO TO 237)

235) Have you had any pregnancies that ended before January 2002 that did not result in a live birth?

YES 1
NO 2 (GO TO 237)

236) When did the last such pregnancy end before 2002?

MONTH __
YEAR ____

237) When did you last menstrual period start?

(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 240)
DON'T KNOW 8 (GO TO 240)

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 HAD ENDED 3
HALFWAY BETWEEN TWO PERIODS 4
OTHER (SPECIFY) _____ 6
DON'T KNOW 8

240) Are there any children who depend primarily on you?

YES 1
NO 2 (GO TO 301)

241) Among these children who depend primarily on you, are there any that are 18 years old or younger?

YES 1
NO 2 (GO TO 301)

242) Now I would like to talk about the children ages 18 and under who depend primarily on you.

Have you made any arrangements for someone to take care of these children if you were to get sick or if you were no longer able to take care of them?

YES 1
NO 2
NOT SURE 8

SECTION 3. CONTRACEPTION

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.

CIRCLE CODE 1 IN 301 FOR EACH METHOD MENTIONED SPONTANEOUSLY. THEN CONTINUE 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 heard of (METHOD)?

01) FEMALE STERILIZATION: Women can have an operation to avoid having any more children.
YES 1
NO 2 (GO TO 02)
02) MALE STERILIZATION: Men can have an operation to avoid having any more children.
YES 1
NO 2 (GO TO 03)
03) PILL: women can take a pill every day to avoid becoming pregnant.
YES 1
NO 2 (GO TO 04)
04) IUD: Women can have a loop or coil placed inside them by a doctor or a nurse.
YES 1
NO 2 (GO TO 05)
05) INJECTABLES: Women can have an injection by a heath provider which stops them from becoming pregnant for one or more months.
YES 1
NO 2 (GO TO 06)
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 07)
07) CONDOM: Men can put a rubber sheath on their penis before sexual intercourse.
YES 1
NO 2 (GO TO 08)
08) FEMALE CONDOM: Women can place a sheath in their vagina before sexual intercourse.
YES 1
NO 2 (GO TO 09)
09) DIAPHRAGM: Women can place a thin flexible disk in their vagina before intercourse.
YES 1
NO 2 (GO TO 10)
10) SUPPOSITORY, FOAM OR JELLY: Women can place a suppository, jelly or cream in their vagina before intercourse.
YES 1
NO 2 (GO TO 12)
12) RHYTHM OR PERIODIC ABSTINENCE: 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 13)
13) WITHDRAWAL: Men can be careful and pull out before climax.
YES 1
NO 2 (GO TO 14)
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 15)
15) Have you heard of any other ways or methods that women or men can use to avoid pregnancy?
YES 1 (SPECIFY) _____
NO 2

302) Have you ever used (METHOD)?

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 (GO TO 02)
02) MALE STERILIZATION: Men can have an operation to avoid having any more children. Have you ever had a partner who had operation to avoid having any more children?
YES 1
NO 2 (GO TO 03)
03) PILL: women can take a pill every day to avoid becoming pregnant.
YES 1
NO 2 (GO TO 04)
04) IUD: Women can have a loop or coil placed inside them by a doctor or a nurse.
YES 1
NO 2 (GO TO 05)
05) INJECTABLES: Women can have an injection by a heath provider which stops them from becoming pregnant for one or more months.
YES 1
NO 2 (GO TO 06)
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 07)
07) CONDOM: Men can put a rubber sheath on their penis before sexual intercourse.
YES 1
NO 2 (GO TO 08)
08) FEMALE CONDOM: Women can place a sheath in their vagina before sexual intercourse.
YES 1
NO 2 (GO TO 09)
09) DIAPHRAGM: Women can place a thin flexible disk in their vagina before intercourse.
YES 1
NO 2 (GO TO 10)
10) SUPPOSITORY, FOAM OR JELLY: Women can place a suppository, jelly or cream in their vagina before intercourse.
YES 1
NO 2 (GO TO 12)
12) RHYTHM OR PERIODIC ABSTINENCE: 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 13)
13) WITHDRAWAL: Men can be careful and pull out before climax.
YES 1
NO 2 (GO TO 14)
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 15)
15) OTHER METHOD(S) (SPECIFY) _____
YES 1 (SPECIFY) _____
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)

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

How many living children did you have at that time, if any?
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 using?
311A) CIRCLE 'A' FOR FEMALE STERILIZATION.

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

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

312) Why do you use the pill over another method?

COST/LESS EXPENSIVE 01 (GO TO 316A)
MORE AVAILABLE 02 (GO TO 316A)
WAS PRESCRIBED 03 (GO TO 316A)
MORE EFFECTIVE 04 (GO TO 316A)
NO SIDE EFFECTS 05 (GO TO 316A)
IT SUITS ME 06 (GO TO 316A)
ONLY KNOWN METHOD 07 (GO TO 316A)
REVERSIBLE METHOD 08 (GO TO 316A)
OTHER (SPECIFY) _____ X (GO TO 316A)

313) In what facility did the sterilization take place?

SOURCE IS HOSPITAL, HEALTH CENTER, OR CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.

(NAME OF PLACE) _______________
PUBLIC SECTOR
HOSPITAL 11
CLINIC 12
HEALTH OUTPOST/CENTER 13
MATERNITY CENTER 14
OTHER PUBLIC (SPECIFY) ____16
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/POLYCLINIC 21
HEALTH CENTER 22
MEDICAL OFFICE 23
OTHER PRIVATE MEDICAL (SPECIFY) _____ 24
OTHER (SPECIFY) _______ 96

DON'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
DON'T KNOW 8

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

316A) Since what month and year have you been using (FIRST METHOD FROM Q311) without stopping? PROBE: In what month and year did you start using (FIRST METHOD FROM Q311) now without stopping?

MONTH _____
YEAR _____

316B) CHECK 316/316A, 215, and 230:

THERE WAS A BIRTH IN 215 OR A PREGNANCY IN 230 THAT ENDED IN A MISCARRIAGE, AN ABORTION, OR A STILLBIRTH AFTER THE MONTH AND THE YEAR OF THE START OF THE USE OF CONTRACEPTION BASED ON 316/316A.
IF YES: GO BACK TO 316/316A TO CORRECT, PROBE TO RECORD THE MONTH AND THE YEAR OF THE START OF THE CONTINUED USE OF THE CURRENT METHOD. (DATE MUST BE AFTER THAT OF THE LAST BIRTH OR THE LAST PREGNANCY).

YES 1
NO 2 (GO TO 317)

317) CHECK 316/316A:

YEAR IS 2002 OR LATER (GO TO 319)
YEAR IS 2001 OR BEFORE (GO TO 327)

319) CHECK 311/311A:
CIRCLE THE METHOD CODE:
IF MORE THAN ONE METHOD CODE CIRCLED IN 311/311A, CIRCLE THE CODE FOR THE HIGHEST METHOD 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
SUPPOSITORY/FOAM/JELLY 10
RHYTHM METHOD 12 (GO TO 331)
WITHDRAWAL 13 (GO TO 331)
OTHER METHOD 96 (GO TO 331)

320) Where did you obtain (CURRENT METHOD) when you started using it?

IF SOURCE IS HOSPITAL, HEALTH CENTER, OR CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.

(NAME OF PLACE) _________
PUBLIC SECTOR
HOSPITAL 11
CLINIC 12
HEALTH OUTPOST/CENTER 13
MATERNITY CENTER 14
OTHER PUBLIC (SPECIFY) _____16
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/POLYCLINIC 21
PHARMACY 22
AMO-CONGO 23
HEALTH CENTER 24
MEDICAL OFFICE 25
TRAVELING NURSE 26
FIELDWORKER 27
OTHER PRIVATE MEDICAL (SPECIFY) _____29
OTHER SOURCE
SHOP 31
CHURCH 32
RELATIVES/FRIENDS 33
OTHER (SPECIFY) _____ 96

321) CHECK 311/311A:
CIRCLE METHOD CODE:

IF MORE THAN ONE METHOD CODE CIRCLED IN 311/311A, CIRCLE THE CODE FOR THE HIGHEST METHOD IN 311/311A.

PILL 03
IUD 04
INJECTABLES 05
IMPLANTS 06
CONDOM 07 (GO TO 327)
FEMALE CONDOM 08 (GO TO 325)
DIAPHRAGM 09 (GO TO 325)
SUPPOSITORY/FOAM/JELLY 10 (GO TO 325)

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

YES 1 (GO TO 324)
NO 2

323) Were you ever told by a health worker 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: 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 worker 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 METHOD CODE CIRCLED IN 311/311A, CIRCLE THE CODE FOR THE HIGHEST METHOD 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
SUPPOSITORY/FOAM/JELLY 10
RHYTHM METHOD 12 (GO TO 331)
WITHDRAWAL 13 (GO TO 331)
OTHER METHOD 96 (GO TO 331)

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

IF SOURCE IS HOSPITAL, HEALTH CENTER, OR CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.

(NAME OF PLACE) __________
PUBLIC SECTOR
HOSPITAL 11 (GO TO 331)
CLINIC 12 (GO TO 331)
HEALTH OUTPOST/CENTER 13 (GO TO 331)
MATERNITY CENTER 14 (GO TO 331)
OTHER PUBLIC (SPECIFY) _____ 16 (GO TO 331)
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/POLYCLINIC 21 (GO TO 331)
PHARMACY 22 (GO TO 331)
AMO-CONGO 23 (GO TO 331)
HEALTH CENTER 24 (GO TO 331)
MEDICAL OFFICE 25 (GO TO 331)
TRAVELING NURSE 26 (GO TO 331)
FIELDWORKER 27 (GO TO 331)
OTHER PRIVATE MEDICAL (SPECIFY) _____ 29 (GO TO 331)
OTHER SOURCE
SHOP 31 (GO TO 331)
CHURCH 32 (GO TO 331)
RELATIVES/FRIENDS 33 (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 this?

IF SOURCE IS HOSPITAL, HEALTH CENTER, OR CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.

(NAME OF PLACE) __________

Another place?
RECORD ALL MENTIONED.

PUBLIC SECTOR
HOSPITAL A
CLINIC B
HEALTH OUTPOST/CENTER C
MATERNITY CENTER D
OTHER PUBLIC (SPECIFY) ____ E
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/POLYCLINIC G
PHARMACY H
AMO-CONGO I
HEALTH CENTER J
MEDICAL OFFICE K
PRIVATE DOCTOR L
TRAVELLING NURSE M
FIELDWORKER N
OTHER PRIVATE MEDICAL (SPECIFY) ____ 0
OTHER SOURCE
SHOP P
CHURCH Q
RELATIVES/FRIENDS R
OTHER (SPECIFY) ____ X

331) In the last 12 months, were you visited by a field worker 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 any staff member at the health facility speak to you about family planning methods?

YES 1
NO 2

SECTION 4A. PREGNANCY, POSTNATAL CARE, AND BREASTFEEDING

401) CHECK 224:

ONE OR MORE BIRTHS IN 2002 OR LATER (GO TO 402)
NO BIRTHS IN 2002 OR LATER (GO TO 487)

402) ENTER THE LINE NUMBER, NAME, AND SURVIVAL STATUS OF EACH BIRTH IN 2002 OR LATER. ASK THE QUESTIONS ABOUT ALL OF THESE BIRTHS. BEGIN WITH THE LAST BIRTH. (IF THERE ARE MORE THAN 3 BIRTHS, USE LAST TWO COLUMNS OF ADDITIONAL QUESTIONNAIRE).

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 Q212.

LINE NUMBER ____

404) FROM Q212 AND Q216

NAME ________
LIVING (GO TO 405)
DEAD (GO TO 405)

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 (GO TO 407)
LATER 2
NOT AT ALL 3 (GO TO 407)

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

MONTHS 1 ___
YEARS 2 ____
DON'T KNOW 998

407) Did you see anyone for antenatal care for this pregnancy? IF YES: Whom did you see? Anyone else? PROBE FOR THE TYPE OF PERSON AND RECORD ALL PERSONS SEEN.

[ASK FOR MOST RECENT BIRTH ONLY]

IF NO, CIRCLE CODE 'Y'.

HEALTH PROFESSIONAL
DOCTOR A
NURSE B
MIDWIFE C
BIRTH ATTENDANT D
OTHER PERSON
VILLAGE MATRON E
TRADITIONAL PRACTITIONER F
NEIGHBORHOOD/VILLAGE MOTHER G
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 FOR MOST RECENT BIRTH ONLY]

MONTHS ___
DON'T KNOW 98

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

NUMBER OF TIMES ___
DON'T KNOW 98

410) CHECK 409:
NUMBER OF TIMES RECEIVED ANTENATAL CARE.
[ASK FOR MOST RECENT BIRTH ONLY]

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

411) How many months pregnant were you the last time you received antenatal care?
[ASK FOR MOST RECENT BIRTH ONLY]

MONTHS ___
DON'T KNOW 98

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

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

WEIGHT
YES 1
NO 2
HEIGHT
YES 1
NO 2
BLOOD PRESSURE
YES 1
NO 2
URINE
YES 1
NO 2
BLOOD
YES 1
NO 2

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

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

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

YES 1
NO 2
DON'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?

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

416) During this pregnancy, how many times did you get this tetanus injection?

NUMBER OF TIMES ___
DON'T KNOW 8

417) During this pregnancy, were you given or did you buy iron tablets?
SHOW TABLETS. [ASK FOR MOST RECENT BIRTH ONLY]

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

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

NUMBER OF DAYS ____
DON'T KNOW 998

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

YES 1
NO 2
DON'T KNOW 8

420) During this pregnancy, did you suffer form night blindness?
[ASK FOR MOST RECENT BIRTH ONLY]

YES 1
NO 2
DON'T KNOW 8

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

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

422) What drugs did you take? Any other drugs?
[ASK FOR MOST RECENT BIRTH ONLY]

RECORD ALL MENTIONED. IF THE TYPE OF DRUG CANNOT BE DETERMINED SHOW THE ANTIMALARIALS TO THE RESPONDENT.

SP/FANSIDAR A
CHLOROQUINE B
AMODIAQUINE C
QUININE D
MALAXIN E
ALARITAB F
ARINATE G
ARTESUNATE H
MEFLOQUINE I
UNKNOWN DRUG Z

OTHER (SPECIFY) _____ X

422A) CHECK 422:
TYPE OF DRUG TAKEN DURING PREGNANCY TO PREVENT MALARIA
[ASK FOR MOST RECENT BIRTH ONLY]

CODE 'A' CIRCLED (GO TO 422B)
CODE 'A' NOT CIRCLED (GO TO 422E)

422B) How many times did you take SP/FANSIDAR during this pregnancy?
[ASK FOR MOST RECENT BIRTH ONLY]

NUMBER OF TIMES ___

422C) CHECK 407:
PRENATAL CARE DURING THIS PREGNANCY
[ASK FOR MOST RECENT BIRTH ONLY]

CODE 'A', 'B', OR 'C' CIRCLED (GO TO 422D)
OTHER CODE CIRCLED (GO TO 422E)

422D) When you were pregnant with (NAME), did you get SP/FANSIDAR during an prenatal visit, during a different visit in a heath care facility, or from another source?
[ASK FOR MOST RECENT BIRTH ONLY]

PRENATAL VISIT 1
OTHER MEDICAL VISIT 2
OTHER SOURCE (SPECIFY) ____ 6

422E) CHECK 422:
TYPE OF DRUG TAKEN DURING PREGNANCY TO AVOID MALARIA
[ASK FOR MOST RECENT BIRTH ONLY]

CODE 'B' CIRCLED (GO TO 422F)
CODE 'B' NOT CIRCLED (GO TO 423)

422F) How many times did you take CHLOROQUINE during this pregnancy?
[ASK FOR MOST RECENT BIRTH ONLY]

NUMBER OF TIMES ___

422G) CHECK 407:
PRENATAL CARE DURING THIS PREGNANCY
[ASK FOR MOST RECENT BIRTH ONLY]

CODE 'A', 'B', OR 'C' CIRCLED (GO TO 422H)
OTHER CODE CIRCLED (GO TO 423)

422H) When you were pregnant with (NAME), did you get the CHLOROQUINE during a prenatal visit, during a different visit to a health facility, or from another source?
[ASK FOR MOST RECENT BIRTH ONLY]

PRENATAL VISIT 1
OTHER MEDICAL VISIT 2
OTHER SOURCE (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
DON'T KNOW 8

424) Was (NAME) weighed at birth?

YES 1
NO 2 (GO TO 425A)
DON'T KNOW 8 (GO TO 425A)

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

GRAMS FROM CARD 1 _____
GRAMS FROM RECALL 2 _____
DON'T KNOW 99998

425A) Does (NAME) have a birth certificate?
IF NO, PROBE: Has (NAME)'s birth ever been registered with the civil authority?

YES 1 (GO TO 426)
NO 2
DON'T KNOW 8

425B) Why wasn't (NAME)'s birth declared to the state?

COST 1
DISTANCE 2
LATE 3
NOT INFORMED 4
NOT NECESSARY 5
OTHER (SPECIFY) _____ 6
DON'T KNOW 8

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

PROBE FOR THE TYPE OF PERSON. RECORD ALL PERSONS MENTIONED.
IF RESPONDENT SAYS NO ONE ASSISTED HER, PROBE TO DETERMINE IF ANY ADULT WAS PRESENT AT BIRTH.

HEALTH PROFESSIONAL
DOCTOR A
NURSE B
MIDWIFE C
BIRTH ATTENDANT D
OTHER PERSON
VILLAGE MATRON E
TRADITIONAL PRACTITIONER F
NEIGHBORHOOD/VILLAGE MOTHER G
OTHER (SPECIFY) _____ X
NO ONE Y

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

IF SOURCE IS HOSPITAL, HEALTH CENTER OR CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.

(NAME OF PLACE) _____________
HOME
YOUR HOME 11 (GO TO 429)
OTHER HOME 12 (GO TO 429)
PUBLIC SECTOR
HOSPITAL 21
HEALTH CENTER 22
HEALTH OUTPOST 23
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 cesarean section?

YES 1 (GO TO 433)
NO 2 (GO TO 433)

429) After (NAME) was born, did a health professional or village birth attendant give you an exam?

YES 1
NO 2 (GO TO 433)

430) How many days or weeks after delivery did the first check take place?
RECORD '00' DAYS IF SAME DAY.
[ASK FOR MOST RECENT BIRTH ONLY]

DAYS AFTER DELIVERY 1 _____
WEEKS AFTER DELIVERY 2 _____
DON'T KNOW 998

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

HEALTH PROFESSIONAL
DOCTOR 11
NURSE 12
MIDWIFE 13
BIRTH ATTENDANT 14
OTHER PERSON
VILLAGE MATRON 21
TRADITIONAL PRACTITIONER 22
NEIGHBORHOOD/VILLAGE MOTHER 23
OTHER (SPECIFY) _____ 96

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

IF SOURCE IS HOSPITAL, HEALTH CENTER OR CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.

(NAME OF PLACE) ___________
HOME
YOUR HOME 11
OTHER HOME 12
PUBLIC SECTOR
HOSPITAL 21
HEALTH CENTER 22
HEALTH OUTPOST 23
OTHER PUBLIC (SPECIFY) 26
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC 31
OTHER PRIVATE MEDICAL (SPECIFY) _____ 36
OTHER (SPECIFY) _____ 96

433) In the first two months after delivery, did you receive a vitamin A dose like this?
SHOW CAPSULE. [ASK FOR MOST RECENT BIRTH ONLY]

YES 1
NO 2
DON'T KNOW 8

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

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) How many months after the birth of (NAME) did you not have a period?

MONTHS ____
DON'T KNOW 98

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

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

438) Have you resumed sexual intercourse since the birth of (NAME)?
[ASK FOR MOST RECENT BIRTH ONLY]

YES 1
NO 2 (GO TO 440)

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

MONTHS ____
DON'T KNOW 98

440) Did you ever 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, before your milk began flowing 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 your milk began flowing regularly?
Anything else? RECORD ALL LIQUIDS MENTIONED.

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

444) CHECK 404:
IS CHILD 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)?

MONTHS ___
DON'T KNOW 98

447) CHECK 404:
IS CHILD 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 NUMBER.

NUMBER OF NIGHTTIME FEEDINGS ____

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

NUMBER OF DAYLIGHT FEEDINGS ____

450) Did (NAME) drink anything form a bottle with a nipple yesterday or last night?

YES 1
NO 2
DON'T KNOW 8

451) Was sugar added to any of the foods or liquids given to (NAME) yesterday?

YES 1
NO 2
DON'T KNOW 8

452) How many times did (NAME) eat pureed, solid, or semi-solid foods yesterday during the day or at night? IF 7 OR MORE TIMES, RECORD '7'.

NUMBER OF TIMES ___
DON'T KNOW 8

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

SECTION 4B. VACCINATION, HEALTH, AND NUTRITION

454) ENTER IN THE TABLE THE LINE NUMBER, NAME, AND SURVIVAL STATUS OF EACH BIRTH OCCURRING IN 2002 OR LATER. ASK THE QUESTIONS FOR ALL BIRTHS. START WITH THE LAST BIRTH. (IF THERE ARE MORE THAN 3 BIRTHS, USE THE LAST TWO COLUMNS OF THE ADDITIONAL QUESTIONNAIRE).

455) LINE NUMBER FROM Q212.

LINE NUMBER __

456) FROM Q212 AND Q216.

NAME ___________
LIVING _____ (GO TO 458)
DEAD _____ (GO TO 456 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 484)

458) Do you have a pre-schooling card where (NAME)'s vaccination are written down?
IF YES: May I please see it?

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

459) Have you ever had a pre-schooling vaccination card for (NAME)?

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

460) (1) COPY VACCINATION DATES 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 (GIVEN AT BIRTH)
DAY ___
MONTH ___
YEAR _____
POLIO 1
DAY ___
MONTH ___
YEAR _____
POLIO 2
DAY ___
MONTH ___
YEAR _____
POLIO 3
DAY ___
MONTH ___
YEAR _____
DTcoq 1
DAY ___
MONTH ___
YEAR _____
DTcoq 2
DAY ___
MONTH ___
YEAR _____
DTcoq 3
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, DTcoq 1-3, MEASLES, AND/OR YELLOW FEVER.

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

462) Did (NAME) 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)
DON'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 forearm that usually causes a scar?

YES 1
NO 2
DON'T KNOW 8

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

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

463C) When was the first polio vaccine received, just after birth or later?

JUST AFTER BIRTH 1
LATER 2
DON'T KNOW 8

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

NUMBER OF TIMES ___

463E) A DTcoq vaccination, that is, an injection in the thigh sometimes given at the same time as polio drops?

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

463F) How many times?

NUMBER OF TIMES __

463G) A malaria vaccine, meaning an injection in the left arm around the age of 9 months?

YES 1
NO 2
DON'T KNOW 8

463H) An injection to prevent yellow fever, meaning an injection done in the arm around the age of 9 months?

YES 1
NO 2
DON'T KNOW 8

464) Did (NAME) receive any of these vaccinations during the last two years in a national immunization day campaign?

YES 1
NO 2 (GO TO 466)
NO VACCINES IN THE LAST 2 YEARS 3 (GO TO 466)
DON'T KNOW 8 (GO TO 466)

465) During the national immunization day campaign, did (NAME) get any of these vaccinations?
RECORD ALL MENTIONED.

MULTI-ANTIGEN OCT/NOV 2004 A
POLIO SEPT-NOV 2005 C
MEASLES OCT 2005 D
OTHER Z

465A) Did (NAME) get a dose of vitamin A like this one during the last 6 months?
Show capsule

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

465B) When did (NAME) get the vitamin A?

CAMPAIGN A
ROUTINE B
ILLNESS C
OTHER X

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

YES 1
NO 2
DON'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)
DON'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?

YES 1
NO 2
DON'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 for the fever/cough?

YES 1
NO 2 (GO TO 472)

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

PUBLIC SECTOR
HOSPITAL A
HEALTH CENTER B
HEALTH OUTPOST C
MATERNITY CENTER D
OTHER PUBLIC (SPECIFY) ____ E
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/POLYCLINIC G
PHARMACY H
HEALTH CENTER I
TRAVELING NURSE K
OTHER PRIVATE MEDICAL (SPECIFY) _____ L
OTHER SOURCE
SHOP M
TRADITIONAL PRACTITIONER N
OTHER (SPECIFY) _____ X

472) CHECK 466:
HAD A FEVER?

'YES' TO 466 (GO TO 472A)
'NO'/'DON'T KNOW' TO 466 (GO TO 475)

472A) Does (NAME) currently have a fever?

YES 1
NO 2
DON'T KNOW 8

472B) Has (NAME) had convulsions at any time in the last 2 weeks?

YES 1
NO 2
DON'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 to treat the fever?

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

474) What drugs did (NAME) take?
RECORD ALL MENTIONED.
ASK TO SEE THE DRUGS IF TYPE OF DRUG IS UNKNOWN. IF THE TYPE OF DRUG CANNOT BE DETERMINED, SHOW THE RESPONDENT TYPICAL ANTIMALARIALS.

ANTIMALARIAL DRUGS
SP/FANSIDAR A
CHLOROQUINE B
AMODIAQUINE C
QUININE D
MALAXIN E
MALARITAB F
ARINATE G
ARTESUNATE H
MEFLOQUINE I
OTHER
ASPIRIN J
PARACETAMOL K
OTHER (SPECIFY) _____ X
DON'T KNOW Z

474A) Did (NAME) get an injection or suppository to treat (the fever/convulsions)?

INJECTION A
SUPPOSITORY B
OTHER Y
DON'T KNOW Z

474B) CHECK 474:
TYPE OF DRUG?

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

474C) How long after the (fever/convulsions) started did (NAME) first take SP/Fansidar?

SAME DAY 0
NEXT DAY 1
TWO DAYS AFTER 2
THREE DAYS OR MORE AFTER FEVER 4
DON'T KNOW 8

474D) How many days in a row did (NAME) take SP/Fansidar?
IF 7 DAYS OR MORE, RECORD '7'.

DAYS ___
DON'T KNOW 8

474E) Did you have the SP/Fansidar in your home, or did you get it from another source?
IF MORE THAN ONE SOURCE, ASK: Where did you get the SP/Fansidar the first time?

AT HOME 1
OTHER SOURCE 2
DON'T KNOW 8

474F) CHECK 474:
TYPE OF DRUG?

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

474G) How long after the (fever/convulsions) started did (NAME) first take Chloroquine?

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

474H) How many days in a row did (NAME) take Chloroquine?
IF 7 DAYS OR MORE, RECORD '7'.

DAYS ___
DON'T KNOW 8

474I) Did you have the Chloroquine in your home, or did you get it from another source?
IF MORE THAN ONE SOURCE, ASK: Where did you get the Chloroquine the first time?

AT HOME 1
OTHER SOURCE 2
DON'T KNOW 8

474J) CHECK 474:
TYPE OF DRUG?

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

474K) How long after the (fever/convulsions) started did (NAME) first take Amodiaquine?

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

474L) How many days in a row did (NAME) take Amodiaquine?
IF 7 DAYS OR MORE, RECORD '7'

DAYS ___
DON'T KNOW 8

474M) Did you have the Amodiaquine in your home, or did you get it from another source?
IF MORE THAN ONE SOURCE, ASK: Where did you get the Amodiaquine the first time?

AT HOME 1
OTHER SOURCE 2
DON'T KNOW 8

474N) CHECK 474:
TYPE OF DRUG?

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

474O) How long after the (fever/convulsions) started did (NAME) first take quinine?

SAME DAY 1
NEXT DAY 2
TWO DAYS AFTER 3
THREE DAYS AFTER 4
DON'T KNOW 8

474P) How many days in a row did (NAME) take quinine?
IF 7 DAYS OR MORE, RECORD '7'.

DAYS __
DON'T KNOW 8

474Q) Did you have the quinine in your home, or did you get it from another source?
IF MORE THAN ONE SOURCE, ASK: Where did you get the quinine the first time?

AT HOME 1
OTHER SOURCE 2
DON'T KNOW 8

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

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

474S) What was done for (NAME)'s (fever/convulsions)?
Anything else?
RECORD ALL MENTIONED.

CONSULTED TRADITIONAL PRACTITIONER A
DABBED WITH MOIST COMPRESS B
GIVEN MEDICAL PLANTS C
OTHER (SPECIFY) _____ X

474SA) How much in total did you pay for the care for (NAME)'s fever?

COST_______
FREE 99995
DON'T KNOW 99996

474T) Was (NAME) given any drug for intestinal worms in the last six months?

YES 1
NO 2
DON'T KNOW 8

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

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

478) Was he/she given any of the following to drink?

a) A fluid made from a special packet called [local name of ORS packet]?
b) A government recommended homemade fluid?

FLUID FROM PACKET
YES 1
NO 2
DON'T KNOW 8
HOMEMADE FLUID
YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2 (GO TO 481)
DON'T KNOW (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/HERBAL MEDICINE 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 SOURCE IS HOSPITAL, HEALTH CENTER OR CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE(S).

(NAME OF PLACE) __________
PUBLIC SECTOR
HOSPITAL A
HEALTH CENTER B
HEALTH OUTPOST C
MATERNITY CENTER D
OTHER PUBLIC (SPECIFY) _____ E
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/POLYCLINIC G
PHARMACY H
MEDICAL OFFICE I
TRAVELING NURSE K
OTHER PRIVATE MEDICAL (SPECIFY) _____ L
OTHER SOURCE
SHOP M
TRADITIONAL PRACTITIONER N
OTHER (SPECIFY) _____ X

482A) How much in total did you pay for the care for (NAME)'s diarrhea?

TOTAL______
FREE 99995
DON'T KNOW 99998

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

484) CHECK 215 AND 218, ALL ROWS:
NUMBER OF CHILDREN BORN IN 2002 OR LATER LIVING WITH THE RESPONDENT

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

485) What do you usually do with your (youngest) child's stools when he/she doesn't use the toilet?

CHILD USED TOILET OR LATRINE 01
PUT INTO TOILET OR LATRINE 02
PUT OUTSIDE DWELLING 03
PUT OUTSIDE OF COURTYARD 04
BURY IN COURTYARD 05
GETS RID OF IT BY WASHING IT WITH WATER 06
USES DISPOSABLE DIAPERS 07
USES WASHABLE DIAPERS 08
DOESN'T GET RID OF THEM 09
OTHER (SPECIFY) ____ 96

486) CHECK 478A FOR ALL COLUMNS:

NO CHILD RECEIVED ORS PACKET OR QUESTION NOT ASKED (GO TO 487)
ONE CHILD RECEIVED ORS PACKET (GO TO 488)

487) Have you ever heard of a special product called Orasel you can get for the treatment of diarrhea? SHOW ORS PACKET.

YES 1
NO 2

488) CHECK 218:

ONE OR MORE CHILDREN LIVING WITH HER (GO TO 488A)
NO CHILDREN LIVING WITH HER (GO TO 490)

488A) Sometimes children have serious illnesses and they must be taken to a health care establishment immediately. What types of symptoms would prompt you to take your child to a health care establishment immediately?

CANNOT DRINK OR NURSE A
GETS SICKER B
DEVELOPS A FEVER C
BREATHING RAPIDLY D
DIFFICULTY BREATHING E
BLOOD IN STOOLS F
DIFFICULTLY DRINKING G
NOT PLAYING H
CONSTANTLY CRYING I
OTHER (SPECIFY) _____ X

489) When (your child/one of your children) is seriously ill, can you yourself decide that he/she needs to be taken somewhere for medical treatment?

IF THE RESPONDENT ANSWERS THAT NONE OF HER CHILDREN HAVE BEEN SERIOUSLY ILL, ASK: If (your child/one of your children) is seriously ill, could you yourself decide that he/she needs to be taken somewhere for medical treatment?

YES 1
NO 2
DEPENDS 3

490) Now I would like to ask you questions about health care for yourself.

There are different reasons that prevent women from getting advice or medical treatment for themselves. When you are ill and want advice or medical treatment, which of the following are a serious problem or not?

Knowing where to go.
Getting permission to go.
Getting money for treatment.
Not close to a health care establishment.
Having to take transportation.
Not wanting to go alone.
Worrying that there is no female health care professional.

WHERE TO GO
SERIOUS PROBLEM 1
NOT A SERIOUS PROBLEM 2
PERMISSION
SERIOUS PROBLEM 1
NOT A SERIOUS PROBLEM 2
MONEY
SERIOUS PROBLEM 1
NOT A SERIOUS PROBLEM 2
DISTANCE
SERIOUS PROBLEM 1
NOT A SERIOUS PROBLEM 2
TRANSPORTATION
SERIOUS PROBLEM 1
NOT A SERIOUS PROBLEM 2
GOING ALONE
SERIOUS PROBLEM 1
NOT A SERIOUS PROBLEM 2
FEMALE PERSONNEL
SERIOUS PROBLEM 1
NOT A SERIOUS PROBLEM 2

491) CHECK 215 AND 218:

AT LEAST ONE CHILD BORN IN 2004 OR LATER LIVING WITH HER
RECORD THE NAME OF THE YOUNGEST CHILD LIVING WITH HER (AND CONTINUE TO 492)
(NAME) _______________
NO CHILD BORN IN 2004 OR LATER AND LIVING WITH HER (GO TO 495)

492) Now I would like to ask you about the liquids (NAME FROM Q491) drank over the last 7 days, including yesterday. How many days in the last 7 did (NAME FROM Q491) drink one or several of the following liquids?

FOR EACH LIQUID DRANK AT LEAST ONCE IN THE LAST 7 DAYS, ASK:
How many times total did (name from q. 491) drink during the day or night?

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

a) Water?
LAST 7 DAYS
NUMBER OF DAYS ___
YESTERDAY/LAST NIGHT
NUMBER OF TIMES ___
b) Baby formula?
LAST 7 DAYS
NUMBER OF DAYS ___
YESTERDAY/LAST NIGHT
NUMBER OF TIMES ___
c) Milk such as tinned, powdered, or fresh animal milk?
LAST 7 DAYS
NUMBER OF DAYS ___
YESTERDAY/LAST NIGHT
NUMBER OF TIMES ___
d) Fruit juice?
LAST 7 DAYS
NUMBER OF DAYS ___
YESTERDAY/LAST NIGHT
NUMBER OF TIMES ___
e) Other liquids such as sugar water, tea, coffee, carbonated beverages, or broths?
LAST 7 DAYS
NUMBER OF DAYS ___
YESTERDAY/LAST NIGHT
NUMBER OF TIMES ___

493) Now I would like to ask you about the foods (NAME FROM Q491) ate over the last 7 days, including yesterday. How many times in the last 7 days did (NAME FROM Q491) eat one or several of the following foods?

FOR EACH FOOD EATEN AT LEAST ONCE IN THE LAST 7 DAYS, ASK:
How many times total did (NAME FROM Q491) eat during the day or night?

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

a) Rice, corn, sorghum, gruel, or other grains?
LAST 7 DAYS
NUMBER OF DAYS ___
YESTERDAY/LAST NIGHT
NUMBER OF TIMES ___
b) Pumpkin, yam, red or yellow squash, carrots, or red sweet potatoes?
LAST 7 DAYS
NUMBER OF DAYS ___
YESTERDAY/LAST NIGHT
NUMBER OF TIMES ___
c) Other tuber based foods (for example; potatoes, white yams, manioc, white sweet potatoes, or other local tuber/roots)?
LAST 7 DAYS
NUMBER OF DAYS ___
YESTERDAY/LAST NIGHT
NUMBER OF TIMES ___
d) Any other green-leaf vegetable?
LAST 7 DAYS
NUMBER OF DAYS ___
YESTERDAY/LAST NIGHT
NUMBER OF TIMES ___
e) Mango, papaya?
LAST 7 DAYS
NUMBER OF DAYS ___
YESTERDAY/LAST NIGHT
NUMBER OF TIMES ___
f) All other fruit or vegetable (for example: banana, apple, applesauce, green beans, avocado, tomato)?
LAST 7 DAYS
NUMBER OF DAYS ___
YESTERDAY/LAST NIGHT
NUMBER OF TIMES ___
g) Meat, poultry, fish, shellfish, or eggs?
LAST 7 DAYS
NUMBER OF DAYS ___
YESTERDAY/LAST NIGHT
NUMBER OF TIMES ___
h) Other legume based foods (lentils, beans, soy, or peanuts)?
LAST 7 DAYS
NUMBER OF DAYS ___
YESTERDAY/LAST NIGHT
NUMBER OF TIMES ___
i) Cheese or yogurt?
LAST 7 DAYS
NUMBER OF DAYS ___
YESTERDAY/LAST NIGHT
NUMBER OF TIMES ___
j) All foods prepared with oil, fat, or butter?
LAST 7 DAYS
NUMBER OF DAYS ___
YESTERDAY/LAST NIGHT
NUMBER OF TIMES ___

494) How many meals do you usually eat per day?

NUMBER OF MEALS ____

495) Did you wash your hands before the last time you prepared a meal for your family?

YES 1
NO 2
NEVER PREPARED MEAL 3

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

YES, CIGARETTES A
YES, PIPE B (GO TO 501)
YES, OTHER TOBACCO C (GO TO 501)
NO Y (GO TO 501)

498) How many cigarettes have you smoked in the last 24 hours?

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 504)
YES, LIVING WITH A MAN 2 (GO TO 504)
NO, NOT IN UNION 3

502) Have you ever been married or lived with a man?

YES, WAS MARRIED 1
YES, LIVED WITH A MAN 2 (GO TO 510)
NO 3 (GO TO 518)

503) What is your current marital status: are you widowed, divorced, or separated?

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

504) Is your husband/partner living with you now or is he staying elsewhere?

LIVES WITH HER 1
STAYING ELSEWHERE 2

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

NAME ___________
LINE NUMBER ____

506) How old was your husband/partner at his last birthday?

AGE IN COMPLETED YEARS ___

507) Other than yourself, does your husband/partner have other wives or does he live with other women as if married?

YES 1
NO 2 (GO TO 510)
DON'T KNOW 8 (GO TO 510)

508) Including yourself, in total, how many other wives or partners does your husband currently have?

TOTAL NUMBER OF WIVES AND PARTNERS ___
DON'T KNOW 98

509) Are you the first, second…wife?

RANK ____

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

ONLY ONCE 1
MORE THAN ONCE 2

511) CHECK 510:

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

MARRIED/LIVED WITH MAN MORE THAN ONCE: I would like to talk about the first time you were married or started living with a man as if married. In what month and year were you married or did you start living with a man as if married for the first time?

MONTH ___
DON'T KNOW MONTH 98
YEAR ____ (GO TO 513)
DON'T KNOW YEAR 9998

512) How old were you when you started living with him?

AGE ____

513) CHECK 503: IS RESPONDENT CURRENTLY WIDOWED?

NOT ASKED OR NOT WIDOWED (GO TO 514)
WIDOWED (GO TO 516)

514) CHECK 510:

MARRIED MORE THAN ONCE (GO TO 515)
MARRIED ONCE (GO TO 518)

515) How did your previous marriage/union end?

DEATH/WIDOWHOOD 1
DIVORCED 2 (GO TO 518)
SEPARATION 3 (GO TO 518)

516) To whom did most of your late husband's property go to?

RESPONDENT 1 (GO TO 518)
OTHER SPOUSE 2
SPOUSE'S CHILDREN 3
SPOUSE'S FAMILY 4
OTHER (SPECIFY) _____ 5
NO PROPERTY 6

517) Did you receive any of your late husband's assets or valuables?

YES 1
NO 2

518) CHECK FOR THE PRESENCE OF OTHERS.
BEFORE CONTINUING, MAKE EVERY EFFORT TO ENSURE PRIVACY.

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

How old were you when you had sexual intercourse for the very first time (if ever)?

NEVER 00
AGE IN YEARS (GO TO 521)
FIRST TIME WHEN STARTED LIVING WITH (FIRST) HUSBAND/PARTNER 95 (GO TO 521)

520) Do you intend to wait until you get married to have sexual intercourse for the first time?

YES 1 (GO TO 544)
NO 2 (GO TO 544)
DON'T KNOW/NOT SURE 8 (GO TO 544)

521) CHECK 106:

15-24 YEARS OLD (GO TO 522)
25-49 YEARS OLD (GO TO 526)

522) The first time you had sexual intercourse, was a condom used?

YES 1
NO 2
DON'T KNOW/DON'T REMEMBER 8

523) How old was the person you first had sexual intercourse with?

AGE OF PARTNER ___ (GO TO 526)
DON'T KNOW 98

524) Was this person older than you, younger than you, or about the same age as you?

OLDER 1
YOUNGER 2 (GO TO 526)
ABOUT THE SAME AGE 3 (GO TO 526)
DON'T KNOW/DON'T REMEMBER 8 (GO TO 526)

525) Would you say this person was ten or more years older than you or less than ten years older than you?

TEN OR MORE YEARS OLDER 1
LESS THAN TEN YEARS OLDER 2
OLDER, UNSURE HOW MUCH 3

526) When was the last time you had sexual intercourse?
IF 12 MONTHS OR MORE, ANSWER MUST BE CONVERTED AND RECORDED IN YEARS.

DAYS AGO 1 ___
WEEKS AGO 2 ___
MONTHS AGO 3 ___
YEARS AGO 4 ___ (GO TO 539)

526A) Now I would like to ask you some questions about your recent sexual activity. Let me assure you again that your answers are completely confidential and will not be told to anyone. If we should come to any question that you don't want to answer, just let me know and we will go to the next question.

527) The last time you had sexual intercourse (with this second/third) person, was a condom used?

YES 1
NO 2 (GO TO 529)

528) Did you use a condom every time you had sexual intercourse with this person in the last 12 months?

YES 1
NO 2

529) The last time you had sexual intercourse (with this second/third) person, did you or this person drink alcohol?

YES 1
NO 2 (GO TO 531)

530) Were you or your partner drunk at that time?
IF YES: Who was drunk?

RESPONDENT ONLY 1
PARTNER ONLY 2
RESPONDENT AND PARTNER BOTH 3
NEITHER 4

531) What was your relationship to this person with whom you had sexual intercourse?
IF BOYFRIEND: Were you living together as if married?
IF YES, CIRCLE '02'
IF NO, CIRCLE '03'

HUSBAND 01 (GO TO 537)
LIVE-IN PARTNER 02 (GO TO 537)
BOYFRIEND NOT LIVING WITH RESPONDENT 03
CASUAL ACQUAINTANCE 04
PROSTITUTE 05
OTHER (SPECIFY) ____ 96

532) For how long (have you had/did you have) a sexual relationship with this person?
IF ONLY HAD SEXUAL RELATIONS WITH THIS PERSON ONCE, RECORD '01' DAYS.

DAYS 1 ____
MONTHS 2 _____
YEARS 3 _____

533) CHECK 106:

15-24 YEARS OLD (GO TO 534)
25-49 YEARS OLD (GO TO 537)

534) How old is this person?

AGE OF PARTNER ____ (GO TO 537)
DON'T KNOW 98

535) Was this person older than you, younger than you, or about the same age as you?

OLDER 1
YOUNGER 2 (GO TO 537)
ABOUT THE SAME AGE 3 (GO TO 537)
DON'T KNOW/DON'T REMEMBER 8 (GO TO 537)

536) Would you say this person was ten or more years older than you or less than ten years older than you?

TEN OR MORE YEARS OLDER 1
LESS THAN TEN YEARS OLDER 2
OLDER, UNSURE HOW MUCH 3

537) Apart from (this person/these two people), have you had sexual intercourse with any other person in the last 12 months?

YES 1 (GO TO 527 IN NEXT COLUMN)
NO 2 (GO TO 539)

538) In total, how many different people have you had sexual intercourse with in the last 12 months?

IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE.
IF NUMBER OF PARTNERS IS GREATER THAN 95, WRITE '95'.

NUMBER OF PARTNERS ____
DON'T KNOW 98

539) In total, how many different people have you had sexual intercourse with in your lifetime?
IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE.
IF NUMBER OF PARTNERS IS GREATER THAN 95, WRITE '95'.

NUMBER OF PARTNERS ____
DON'T KNOW 98

539A) CHECK COVER PAGE:
HOUSEHOLD SELECTED FOR MEN'S SURVEY?

NO (GO TO 540)
YES (GO TO 544)

540) CHECK 106:

18-49 YEARS OLD (GO TO 541)
15-17 YEARS OLD (GO TO 544)

541) CHECK FOR PRESENCE OF OTHER PEOPLE.
DO NOT CONTINUE UNTIL YOU ARE COMPLETELY ALONE WITH RESPONDENT.

PRIVACY OBTAINED 1
PRIVACY IMPOSSIBLE 2 (GO TO 544)

541A) Has anyone ever forced you to have sexual intercourse against your will?

YES 1
NO 2 (GO TO 544)

542) The first time you had sexual intercourse, did you want to have sexual intercourse, or were you forced against your will?

WANTED 1
WAS FORCED 2
REFUSED TO RESPOND/NO RESPONSE 3

543) Did anyone make you have sexual intercourse against your will in the last 12 months?

YES 1
NO 2
REFUSED TO RESPOND/NO RESPONSE 3

544) Do you know of a place where a person can get condoms?

YES 1
NO 2 (GO TO 601)

545) Where is that?
Any other place?
RECORD ALL MENTIONED.

IF SOURCE IS HOSPITAL, HEALTH CENTER OR CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.

(NAME OF PLACE) __________
PUBLIC SECTOR
HOSPITAL A
HEALTH CENTER B
HEALTH OUTPOST C
FAMILY PLANNING CLINIC D
COMMUNITY WORKER E
OTHER PUBLIC (SPECIFY) _____ F
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC/DOCTOR G
PHARMACY H
AMO-CONGO I
HEALTH AGENT J
OTHER PRIVATE MEDICAL (SPECIFY) ____ K
OTHER SOURCE
SHOP L
BAR/NIGHTCLUB M
KIOSK N
TABLIER O
FRIENDS/ACQUAINTANCES/RELATIVES P
OTHER (SPECIFY) _____ X

546) If you wanted to, could you yourself get a condom?

YES 1
NO 2
DON'T KNOW/NOT SURE 8

547) CHECK 527 FOR ALL COLUMNS:

AT LEAST ONE 'YES' (GO TO 548)
OTHER (GO TO 601)

548) Where did you get the condom last time?

IF SOURCE IS HOSPITAL, HEALTH CENTER OR CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.

(NAME OF PLACE) ______________
PUBLIC SECTOR
HOSPITAL 11
HEALTH CENTER 12
HEALTH OUTPOST 13
FAMILY PLANNING CLINIC 14
COMMUNITY WORKER 15
OTHER PUBLIC (SPECIFY) _____ 16
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC/DOCTOR 21
PHARMACY 22
AMO-CONGO 23
HEALTH AGENT 24
OTHER PRIVATE MEDICAL (SPECIFY) ____ 26
OTHER SOURCE
SHOP 31
BAR/NIGHTCLUB 32
KIOSK 33
TABLIER 34
FRIENDS/ACQUAINTANCES/RELATIVES 35
HOTEL/MOTEL 26
PARTNER HAD CONDOM 41
OTHER (SPECIFY) _____ 96
DON'T KNOW 98

SECTION 6. FERTILITY PREFERENCES

601) CHECK 311/311A:

NEITHER STERILIZED (GO TO 602)
HE OR SHE STERILIZED (GO TO 614)

602) CHECK 226:

NOT PREGNANT OR UNSURE: Now I have some question 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/DON'T KNOW AND PREGNANT 4 (GO TO 610)
UNDECIDED/DON'T KNOW AND NOT PREGNANT/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 this 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)
DON'T KNOW 998 (GO TO 609)

604) CHECK 226:

NOT PREGNANT OR NOT SURE (GO TO 604)
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 YEAR (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
SUBFECUND/INFECUND E
POSTPARTUM AMENORRHEIC F
BREASTFEEDING G
FATALISTIC H
OPPOSITION TO USE
RESPONDENT OPPOSED I
HUSBAND/PARTNER OPPOSED J
OTHER 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
DON'T KNOW Z

608) In the next few weeks, if you discovered that you were pregnant, would that be a big problem, a small problem, or no problem at all?

BIG PROBLEM 1
SMALL PROBLEM 2
NO PROBLEM 3
SAYS SHE CAN'T GET PREGNANT/NOT HAVING SEX 4

609) CHECK 310:
USING A CONTRACEPTIVE METHOD?

NOT ASKED (GO TO 610)
NOT CURRENTLY USING (GO TO 610)
CURRENTLY USING (GO TO 614)

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

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

611) Which 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)
SUPPOSITORY/FOAM/JELLY 10 (GO TO 614)
RHYTHM METHOD 12 (GO TO 614)
WITHDRAWAL 13 (GO TO 614)
OTHER (SPECIFY) ____ 96
UNSURE 98

612) What is the main reason that you think you will never use a contraceptive method at any time in the future?

NOT MARRIED 11
FERTILITY-RELATED REASONS
INFREQUENT SEX/NO SEX 22 (GO TO 614)
MENOPAUSAL/HYSTERECTOMY 23 (GO TO 614)
SUBFECUND/INFECUND 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)
DON'T KNOW 98 (GO TO 614)

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

YES 1
NO 2
DON'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.

NO CHILDREN 00 (GO TO 616)

NUMBER ____
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 it not matter?

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

616) Would you say that you approve or disapprove of couples using a contraceptive method to avoid getting pregnant?

APPROVE 1
DISAPPROVE 2
NO OPINION/UNSURE 3

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

On the radio?
On the television?
In a newspaper or magazine?

RADIO
YES 1
NO 2
TELEVISION
YES 1
NO 2
NEWSPAPER OR MAGAZINE
YES 1
NO 2

619) In the last few months, have you discussed the practice of family planning with your friends, your neighbors, or your relatives?

YES 1
NO 2 (GO TO 621)

620) With whom? Anyone else?
RECORD ALL PERSONS MENTIONED.

HUSBAND/PARTNER A
MOTHER B
FATHER C
SISTER(S) D
BROTHER(S) E
DAUGHTER(S) F
SON(S) G
MOTHER(S)-IN-LAW H
FRIEND(S)/NEIGHBOR(S) I
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:

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


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

MAINLY RESPONDENT 1
MAINLY HUSBAND/PARTNER 2
JOINT DECISION 3
OTHER (SPECIFY) _____ 6

624) Now I want to ask you about your husband's/partner's views on family planning.

Do you think your husband/partner approves or disapproves of couples using a contraceptive method to avoid pregnancy?

APPROVES 1
DISAPPROVES 2
DON'T KNOW 8

625) How many times in the last year have you talked to your husband/partner about family planning?

NEVER 1
ONCE OR TWICE 2
MORE OFTEN 3

626) CHECK 311/311A:

NEITHER STERILIZED (GO TO 627)
HE OR SHE STERILIZED (GO TO 628)

627) Do you think your husband/partner wants 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
DON'T KNOW 8

628) Husband and wives do not always agree in everything. Please tell me if you think a woman is justified refusing to have sex with her husband when:

She knows her husband has a disease that she can get during sexual intercourse?
She knows her husband has sex with women other than his wives?
She recently gave birth?
She is tired or not in the mood?

HAS STD
YES 1
NO 2
DON'T KNOW 8
OTHER WOMEN
YES 1
NO 2
DON'T KNOW 8
RECENT BIRTH
YES 1
NO 2
DON'T KNOW 8
TIRED/NOT IN MOOD
YES 1
NO 2
DON'T KNOW 8

629) 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?

YES 1
NO 2
DON'T KNOW 8

630) CHECK 501:

CURRENTLY MARRIED/IN UNION (GO TO 631)
NOT IN UNION (GO TO 701)

631) Can you refuse sexual intercourse with your husband when you do not wish to have intercourse?

YES 1
NO 2
DEPENDS/NOT SURE 8

632) Can you ask your husband to use a condom if you want him to use one?

YES 1
NO 2
DEPENDS/NOT SURE 8

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

701) CHECK 501 AND 502:

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

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, or higher?

PRIMARY 1
SECONDARY 2
HIGHER 3
DON'T KNOW 8 (GO TO 706)

705) What was the highest (grade/form/year) he completed at that level?

GRADE ___
DON'T KNOW 98

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?

OCCUPATION______________

707) Aside from your own housework, are you currently working?

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.
Are you currently doing 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
OTHER 6

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?

AT HOME 1
AWAY FROM HOME 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 in kind for this work or are you not paid at all?

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

717) Who mainly decides how the money you earn will be used?

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

718) On average, how much of your household's expenditures do your earnings pay for: almost none, less than half, about half, more than half, or all?

ALMOST NONE 1
LESS THAN HALF 2
ABOUT HALF 3
MORE THAN HALF 4
ALL 5
NONE, HER INCOME IS ALL SAVED 6

719) Who in your household usually has the final say on the following decisions?

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
Making large household purchases? ____
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
Making household purchases for daily needs? ____
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
Visits to 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 should be cooked every 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 AGE 10 AND UNDER
PRESENT/LISTENING 1
PRESENT/NOT LISTENING 2
NOT PRESENT 3
HUSBAND
PRESENT/LISTENING 1
PRESENT/NOT LISTENING 2
NOT PRESENT 3
OTHER MALES
PRESENT/LISTENING 1
PRESENT/NOT LISTENING 2
NOT PRESENT 8
OTHER FEMALES
PRESENT/LISTENING 1
PRESENT/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
YES 1
NO 2
DON'T KNOW 8
NEGLECTS CHILDREN
YES 1
NO 2
DON'T KNOW 8
ARGUES
YES 1
NO 2
DON'T KNOW 8
REFUSES SEX
YES 1
NO 2
DON'T KNOW 8
BURNS THE FOOD
YES 1
NO 2
DON'T KNOW 8

722) Were you sick at any time in the last two weeks?

YES 1
NO 2 (GO TO 726)

723) Did you receive medical care?

YES 1
NO 2 (GO TO 725)

724) How much did you pay for the medical care (consultations, drugs, etc)?

TOTAL _______ (GO TO 726)
FREE 99995 (GO TO 726)
DON'T KNOW 98 (GO TO 726)

725) Why did you not received medical care?
Any other reason?
RECORD ALL MENTIONED.

HIGH COST A
DISTANCE B
HEALTH CARE PERSONNEL NOT WELCOMING C
OTHER (SPECIFY) _____ X

726) Do you know of an illness called "fistula," meaning, when a woman has constant leakage of urine or stool?

YES 1
NO 2 (GO TO 801)

726A) What do you think is the main cause for this problem?

CHILDBIRTH 1
SURGERY 2
TRAUMA 3
DON'T KNOW 8

727) Are you currently experiencing urine and/or stool leakage from your vagina outside of "urination/defecation"?

YES 1
NO 2 (GO TO 729)

728) Have you ever experienced urine and/or stool leakage from your vagina outside of "urination/defecation"?

YES 1
NO 2 (GO TO 801)

729) How did this problem start?

AFTER CHILDBIRTH 1
AFTER SEXUAL ASSAULT 2 (GO TO 731)
AFTER SURGERY 3 (GO TO 731)
OTHER (SPECIFY) _____ 8 (GO TO 731)

730) You said that this happened after childbirth. Was it from your 1st, 2nd, 3rd…delivery?

DELIVERY RANK _____

731) How old were you when this happened (for the first time)?

AGE ___
DON'T KNOW 98

732) Have you ever received (are you currently getting) treatment?

YES 1
NO 2

SECTION 8. AIDS AND OTHER SEXUALLY TRANSMITTED INFECTIONS

801) Now I would like to talk about something else.

Have you ever heard of an illness called AIDS?

YES 1
NO 2 (GO TO 850)

802) Can people reduce their chance of getting the AIDS virus by having just one sex partner who is not infected and who has no other sex partners?

YES 1
NO 2
DON'T KNOW 8

803) Can people get the AIDS virus from mosquito bites?

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

805) Can people get the AIDS virus by sharing food with a person who has AIDS?

YES 1
NO 2
DON'T KNOW 8

806) Can people reduce their chance of getting the AIDS virus by not having sexual intercourse at all?

YES 1
NO 2
DON'T KNOW 8

807) Can people get the AIDS virus because of witchcraft or other supernatural means?

YES 1
NO 2
DON'T KNOW 8

808) Is there anything a person can do to avoid getting AIDS or the virus that causes AIDS?

YES 1
NO 2 (GO TO 810)
DON'T KNOW (GO TO 810)

809) What can a person do?
Anything else?
RECORD ALL WAYS MENTIONED.

ABSTAIN FROM SEX A
USE CONDOMS B
LIMIT SEX TO ONE PARTNER/STAY FAITHFUL TO ONE PARTNER C
LIMIT NUMBER OF SEXUAL PARTNERS D
AVOID SEX WITH PROSTITUTES E
AVOID SEX WITH PERSONS WHO HAVE MANY PARTNERS F
AVOID SEX WITH HOMOSEXUALS G
AVOID SEX WITH PERSONS WHO INJECT DRUGS INTRAVENOUSLY H
AVOID BLOOD TRANSFUSIONS I
AVOID INJECTIONS J
AVOID SHARING RAZORS/BLADES K
AVOID KISSING L
AVOID MOSQUITO BITES M
SEEK PROTECTION FROM TRADITIONAL PRACTITIONER N
OTHER (SPECIFY) _____ W
OTHER (SPECIFY) _____ X
DON'T KNOW Z

810) Is it possible for a healthy-looking person to have the AIDS virus?

YES 1
NO 2
DON'T KNOW 8

811) Can the virus that causes AIDS be transmitted from a mother to a child:

During pregnancy?
During delivery?
By breastfeeding?

PREGNANCY
YES 1
NO 2
DON'T KNOW 8
DELIVERY
YES 1
NO 2
DON'T KNOW 8
BREASTFEEDING
YES 1
NO 2
DON'T KNOW 8

812) CHECK 811:

AT LEAST ONE 'YES' (GO TO 813)
OTHER (GO TO 814)

813) Are there any special drugs that a doctor or a nurse can give to a woman infected with the AIDS virus to reduce the risk of transmission to the baby?

YES 1
NO 2
DON'T KNOW 8

814) Are there any special drugs that people infected with the AIDS virus can get from a doctor or nurse?

YES 1
NO 2
DON'T KNOW 8

815) CHECK 215:

LAST BIRTH SINCE JANUARY 2005 (GO TO 816)
NO BIRTHS (GO TO 824)
LAST BIRTH BEFORE JANUARY 2005 (GO TO 824)

816) CHECK 407:

SAW SOMEONE FOR ANTENATAL CARE (GO TO 817)
DIDN'T SEE ANYONE (GO TO 824)

817) Now I would like to ask you questions about your last birth. You told me that you saw someone for antenatal care during this pregnancy. During any of the antenatal visits for this pregnancy, did anyone talk to you about:

Babies getting the AIDS virus from their mother?
Things that you can do to prevent getting the AIDS virus?
Getting tested for the AIDS virus?

AIDS FROM MOTHER
YES 1
NO 2
DON'T KNOW 8
THINGS TO DO
YES 1
NO 2
DON'T KNOW 8
TESTED FOR AIDS
YES 1
NO 2
DON'T KNOW 8

818) Were you offered a test for that AIDS virus as part of your antenatal care?

YES 1
NO 2

819) I don't want to know the results, but were you tested for the AIDS virus as part of your antenatal care?

YES 1
NO 2 (GO TO 824)

820) I don't want to know the results, but did you get the results of the test?

YES 1
NO 2

821) Where was the test done?

IF SOURCE IS HOSPITAL, HEALTH CENTER OR CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.

(NAME OF PLACE) _____________
PUBLIC SECTOR
HOSPITAL 11
HEALTH CENTER/OUTPOST 12
ANONYMOUS VOLUNTEER SCREENING CENTER 13
MOBILE VOLUNTEER SCREENING CENTER 15
TRAVELING TREATMENT CENTER 16
OTHER PUBLIC (SPECIFY) _____ 17
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/POLYCLINIC 21
MOBILE VOLUNTEER SCREENING CENTER 22
TRAVELING TREATMENT CENTER 23
YOUTH SUPERVISING CENTER 24
OTHER PRIVATE MEDICAL (SPECIFY) ______ 26
OTHER (SPECIFY) _____ 96

822) Have you been tested for the AIDS virus since that time you were tested during your pregnancy?

YES 1 (GO TO 825)
NO 2

823) When was the last time you were tested for the AIDS virus?

LESS THAN 12 MONTHS AGO 1 (GO TO 831)
12-23 MONTHS AGO 2 (GO TO 831)
2 OR MORE YEARS AGO 3 (GO TO 831)

824) I don't want to know the result, but have you ever been tested to see if you have the AIDS virus?

YES 1
NO 2 (GO TO 829)

825) When was the last time you were tested?

LESS THAN 12 MONTHS AGO 1
12-23 MONTHS AGO 2
2 OR MORE YEARS AGO 3

826) The last time you had the test, did you yourself ask for the test, was it offered to you and you accepted, or was it required?

ASKED FOR TEST 1
OFFERED AND ACCEPTED 2
REQUIRED 3

827) I don't want to know the results, but did you get the results of the test?

YES 1
NO 2

828) Where was the test done?

IF SOURCE IS HOSPITAL, HEALTH CENTER OR CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.

(NAME OF PLACE) ___________
PUBLIC SECTOR
HOSPITAL 11 (GO TO 831)
HEALTH CENTER/OUTPOST 12 (GO TO 831)
ANONYMOUS VOLUNTEER SCREENING CENTER 13 (GO TO 831)
FAMILY PLANNING CLINIC 14 (GO TO 831)
MOBILE VOLUNTEER SCREENING CENTER 15 (GO TO 831)
TRAVELING TREATMENT CENTER 16 (GO TO 831)
OTHER PUBLIC (SPECIFY) _____ 17 (GO TO 831)
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/POLYCLINIC 21 (GO TO 831)
MOBILE VOLUNTEER SCREENING CENTER 22 (GO TO 831)
TRAVELING TREATMENT CENTER 23 (GO TO 831)
YOUTH SUPERVISING CENTER 24 (GO TO 831)
OTHER PRIVATE MEDICAL (SPECIFY) _____ 26 (GO TO 831)
OTHER (SPECIFY) _____ 96 (GO TO 831)

829) Do you know of a place where people can go to get tested for the AIDS virus?

YES 1
NO 2 (GO TO 831)

830) Where is that?
Any other place?
RECORD ALL PLACES MENTIONED.

IF SOURCE IS HOSPITAL, HEALTH CENTER OR CLINIC, WRITE THE NAME OF THE PLACE. PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.

(NAME OF PLACE) __________
PUBLIC SECTOR
HOSPITAL A
HEALTH CENTER/OUTPOST B
ANONYMOUS VOLUNTEER SCREENING CENTER C
FAMILY PLANNING CLINIC D
MOBILE VOLUNTEER SCREENING CENTER E
TRAVELING TREATMENT CENTER F
OTHER PUBLIC (SPECIFY) _____ G
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/POLYCLINIC H
MOBILE VOLUNTEER SCREENING CENTER I
TRAVELING TREATMENT CENTER J
YOUTH SUPERVISING CENTER K
OTHER PRIVATE MEDICAL (SPECIFY) _____ L
OTHER (SPECIFY) _____ X

831) Would you buy fresh vegetables from a shopkeeper or vendor if you knew that this person had the AIDS virus?

YES 1
NO 2
DON'T KNOW 8

832) 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
DON'T KNOW/DEPENDS 8

833) 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
DON'T KNOW/DEPENDS 8

834) In your opinion, if a female teacher has the AIDS virus but is not sick, should she be allowed to continue teaching in the school?

SHOULD BE ALLOWED 1
SHOULD NOT BE ALLOWED 2
DON'T KNOW/DEPENDS 8

835) Do you personally know someone who has been denied health services in the last 12 months because he or she has or is suspected to have the AIDS virus?

YES 1
NO 2
DON'T KNOW ANYONE WITH AIDS 3 (GO TO 840)

836) Do you personally know someone who has been denied involvement in social events, religious services, or community events in the last 12 months because he or she has or is suspected to have the AIDS virus?

YES 1
NO 2

837) Do you personally know someone who has been verbally abused or teased in the last 12 months because he or she has or is suspected to have the AIDS virus?

YES 1
NO 2

838) CHECK 835, 836, AND 837:

NOT A SINGLE 'YES' (GO TO 839)
AT LEAST ONE 'YES' (GO TO 840)

839) Do you personally know someone who has or is suspected to have the AIDS virus?

YES 1
NO 2

840) Do you agree or disagree with the following statement:
People with the AIDS virus should be ashamed of themselves.

AGREE 1
DISAGREE 2
DON'T KNOW/NO OPINION 8

841) Do you agree or disagree with the following statement:
People with the AIDS virus should be blamed for bringing the disease into the community.

AGREE 1
DISAGREE 2
DON'T KNOW/OPINION 8

842) Should children age 12-14 be taught about using a condom to avoid getting AIDS?

YES 1
NO 2
DON'T KNOW/DEPENDS 8

843) Should children age 12-14 be taught to wait until they get married to have sexual intercourse in order to avoid getting AIDS?

YES 1
NO 2
DON'T KNOW/DEPENDS 8

850) CHECK 801:

HEARD ABOUT AIDS: Apart from AIDS, have you heard about other infections that can be transmitted through sexual contact?

NOT HEARD ABOUT AIDS: Have you heard about infections that can be transmitted through sexual contact?

YES 1
NO 2 (GO TO 853)

851) If a man has a sexually transmitted disease, what symptoms might he have?
Any other signs or symptoms?
RECORD ALL SYMPTOMS MENTIONED.

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

852) If a woman has a sexually transmitted disease, what symptoms might she have?
Any other signs or symptoms?
RECORD ALL SYMPTOMS MENTIONED.

ABDOMINAL PAIN A
GENITAL DISCHARGE B
FOUL SMELLING DISCHARGE C
BURNING PAIN ON URINATION D
REDNESS/INFLAMMATION IN GENITAL AREA E
SWELLING IN GENITAL AREA F
GENITAL SORES/ULCERS G
GENITAL WARTS H
GENITAL ITCHING I
BLOOD IN URINE J
LOSS OF WEIGHT K
HARD TO GET PREGNANT/HAVE A CHILD L
OTHER (SPECIFY) _____ W
OTHER (SPECIFY) _____ X
NO SYMPTOMS Y
DON'T KNOW Z

853) CHECK 519:

HAS HAD SEXUAL INTERCOURSE (GO TO 854)
HAS NOT HAD SEXUAL INTERCOURSE (GO TO 901)

854) CHECK 850:

HAS HEARD OF SEXUALLY TRANSMITTED INFECTIONS (GO TO 855)
HAS NOT HEARD OF SEXUALLY TRANSMITTED INFECTIONS (GO TO 856)

855) Now I would like to ask you some questions about your health. During the last 12 months, have you had a disease which you got through sexual contact?

YES 1
NO 2
DON'T KNOW 8

856) Sometimes women experience a bad-smelling abnormal genital discharge. During the last 12 months, have you had a bad-smelling abnormal genital discharge?

YES 1
NO 2
DON'T KNOW 8

857) 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
DON'T KNOW 8

858) CHECK 855, 856, 857:

HAS HAD AN INFECTION (AT LEAST ONE 'YES') (GO TO 859)
HAS NOT HAD AN INFECTION OR DOES NOT KNOW (GO TO 901)

859) The last time you had (INFECTION FROM 855/856/857), did you seek any kind of advice or treatment?

YES 1
NO 2 (GO TO 861)

860) Where did you go?
Any other place?
CIRCLE ALL MENTIONED.

PUBLIC SECTOR
HOSPITAL A
HEALTH CENTER/OUTPOST B
ANONYMOUS VOLUNTEER SCREEN CENTER C
CENTER FOR SEXUALLY TRANSMITTED INFECTIONS D
FAMILY PLANNING CLINIC E
COMMUNITY AGENT F
MATERNITY CENTER G
OTHER PUBLIC (SPECIFY) _____ H
PRIVATE MEDICAL SECTOR
PRIVATE CLINIC/HOSPITAL/DOCTOR I
MATERNITY J
PHARMACY K
ANONYMOUS VOLUNTEER SCREENING CENTER L
HEALTH AGENT M
OTHER PRIVATE MEDICAL (SPECIFY) _____ N
OTHER SOURCE
TRADITIONAL PRACTITIONER Q
SHOP R
OTHER (SPECIFY) _____ X

861) The last time you had (INFECTION FROM 855/856/857), did your partner seek any kind of advice or treatment?

YES 1
NO 2 (GO TO 901)
PARTNER NOT INFORMED 3 (GO TO 901)
DON'T KNOW 8 (GO TO 901)

862) Where did he go?
Any other place?
CIRCLE ALL MENTIONED.

PUBLIC SECTOR
HOSPITAL A
HEALTH CENTER/OUTPOST B
ANONYMOUS VOLUNTEER SCREENING CENTER C
CENTER FOR SEXUALLY TRANSMITTED INFECTIONS D
FAMILY PLANNING CLINIC E
COMMUNITY AGENT F
MATERNITY CENTER G
OTHER PUBLIC (SPECIFY) ____ H
PRIVATE MEDICAL SECTOR
PRIVATE CLINIC/HOSPITAL/DOCTOR I
MATERNITY J
PHARMACY K
ANONYMOUS VOLUNTEER SCREENING CENTER L
HEALTH AGENT M
OTHER PRIVATE MEDICAL (SPECIFY) _____ N
OTHER SOURCE
TRADITIONAL PRACTITIONER Q
SHOP R
OTHER (SPECIFY) _____ X

SECTION 9. MATERNAL MORTALITY

901A) Now, I would like to ask you some questions about your brothers and sisters, that is, all of the children born to your biological mother.

Did your mother give birth to any children other than yourself?

YES 1
NO 2 (GO TO 901H)

901B) How many boys did your mother have who are still living?

BOYS LIVING ____

901C) Other than yourself, how many girls did your mother have who are still living?

GIRLS LIVING ____

901D) How many boys did your mother have who died?

BOYS DIED ___

901E) How many girls did your mother have who died?

GIRLS DIED ___

901F) Did your mother give birth to any other children, who you don't know if they are living or dead?

YES 1
NO 2 (GO TO 901H)

901G) How many other children did your mother give birth do, who you don't know if they are living or dead?

OTHER CHILDREN ___

901H) ADD THE ANSWERS FROM 901B, C, D, E, and G, ADD 1 (THE RESPONDENT) AND RECORD THE TOTAL.

TOTAL ___

901I) CHECK 901H:
Just to make sure that I've understood, including yourself, your mother give birth to _____ children total. Is that correct?

YES (GO TO 902)
NO (PROBE AND CORRECT 901A - 901H AS NECESSARY.

902) CHECK 901H:

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

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

NUMBER OF PRECEDING BIRTHS ___

Now I would like to make a list of all your sisters and brothers, whether they are still alive or not, starting with the oldest. RECORD THE NAME OF ALL THE SISTERS AND BROTHERS.

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)
DON'T KNOW 8 (GO TO NEXT COLUMN)

907) How old is (NAME)?

AGE _____ (GO TO NEXT COLUMN)

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

YEARS AGO _____

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

IF DON'T KNOW, PROBE: Did (NAME) die before he/she was 12 years old?

IF YES, RECORD '95'. IF NO, ASK OTHER QUESTIONS TO OBTAIN AN ESTIMATE. FOR EXAMPLE: Did (NAME) die before getting married?

AGE _____ (IF MALE, OR FEMALE WHO DIED BEFORE 12 YEARS OF AGE, GO TO NEXT COLUMN)

910) Was (NAME) pregnant when she died?

YES 1 (GO TO 913)
NO 2

911) Did (NAME) die during childbirth?

YES 1 (GO TO 913)
NO 2

912) Did (NAME) die within two months after the end of a pregnancy or childbirth?

YES 1
NO 2

913) How many living children did (NAME) give birth to in her life?

NUMBER____ (GO TO NEXT COLUMN)

IF NO MORE BROTHERS OR SISTERS, GO TO 1001.

SECTION 10. DOMESTIC VIOLENCE

1001) CHECK THE FRONT COVER PAGE: THE WOMAN YOU ARE SURVEYING WAS SELECTED FOR THE QUESTIONS ON "DOMESTIC VIOLENCE"?

IF YES (GO TO 1002)
IF NO (GO TO 1016)

1002) CHECK FOR THE PRESENCE OF OTHERS:
DO NOT CONTINUE UNTIL EFFECTIVE PRIVACY IS ENSURED.
CIRCLE THE CODE CORRESPONDING TO THE SITUATION AND FOLLOW THE CONTINUATION INSTRUCTIONS.

PRIVACY OBTAINED 1
PRIVACY NOT POSSIBLE 2

READ TO ALL RESPONDENTS:
Now I would like to ask you questions about some certain parts of your life as part of a relationship. I know that some of these questions are very personal. However, your answers are crucial for helping to understand the condition of women in the Democratic Republic of Congo. Let me assure you that your answers are completely confidential and will not be told to anyone. Additionally, you are the only person in your household that is being asked these questions and no one will know that you were asked these questions. If someone arrives while we are talking, we will talk about something else.

1003) CHECK 501, 502, AND 504:

CURRENTLY MARRIED/LIVING WITH A MAN (GO TO 1004)
WIDOW/SEPARATED/DIVORCED (GO TO 1004)
NEVER MARRIED/NEVER LIVED WITH A MAN (GO TO 1008)

1004) Now if you will permit me, I need to ask some more questions about your relationship with your (last) husband/partner.

4A) (Does/did) your last husband/partner ever:

a) say or do something to humiliate you in front of others?
YES 1
NO 2 (GO TO B)
b) threaten you or someone close to you with harm?
YES 1
NO 2 (GO TO 1005)

4B) How many times did this happen during the last 12 months?

a) say or do something to humiliate you in front of others?
NUMBER OF TIMES ___
IF WIDOWED, DIVORCED OR SEPARATED 95
b) threaten you or someone close to you with harm?
NUMBER OF TIMES ___
IF WIDOWED, DIVORCED OR SEPARATED 95

1005) 5A) (Does/did) your (last) husband/partner ever:

a) Push you, shake you, or throw something at you?
YES 1
NO 2 (GO TO B)
b) slap you or twist your arm?
YES 1
NO 2 (GO TO C)
c) punch you with his fist or with something that could hurt you?
YES 1
NO 2 (GO TO D)
d) kick you or drag you?
YES 1
NO 2 (GO TO E)
e) try to strangle you or burn you?
YES 1
NO 2 (GO TO F)
f) threaten you with a knife, gun, or other type of weapon?
YES 1
NO 2 (GO TO G)
g) attack you with a knife, gun, or other type of weapon?
YES 1
NO 2 (GO TO H)
h) physically force you to have sexual intercourse with him even when you did not want to?
YES 1
NO 2 (GO TO I)
i) force you to perform other sexual acts you did not want to?
YES 1
NO 2 (GO TO 1006)

5B) How many times did this happen during the last 12 months?

a) Push you, shake you, or throw something at you?
NUMBER OF TIMES ___
IF WIDOWED, DIVORCED OR SEPARATED 95
b) slap you or twist your arm?
NUMBER OF TIMES ___
IF WIDOWED, DIVORCED OR SEPARATED 95
c) punch you with his fist or with something that could hurt you?
NUMBER OF TIMES ___
IF WIDOWED, DIVORCED OR SEPARATED 95
d) kick you or drag you?
NUMBER OF TIMES ___
IF WIDOWED, DIVORCED OR SEPARATED 95
e) try to strangle you or burn you?
NUMBER OF TIMES ___
IF WIDOWED, DIVORCED OR SEPARATED 95
f) threaten you with a knife, gun, or other type of weapon?
NUMBER OF TIMES ___
IF WIDOWED, DIVORCED OR SEPARATED 95
g) attack you with a knife, gun, or other type of weapon?
NUMBER OF TIMES ___
IF WIDOWED, DIVORCED OR SEPARATED 95
h) physically force you to have sexual intercourse with him even when you did not want to?
NUMBER OF TIMES ___
IF WIDOWED, DIVORCED OR SEPARATED 95
i) force you to perform other sexual acts you did not want to?
NUMBER OF TIMES ___
IF WIDOWED, DIVORCED OR SEPARATED 95

1006) Does (did) your (last) husband/partner drink alcohol?

YES 1
NO 2 (GO TO 1008)

1007) How often does (did) he get drunk: very often, only sometimes, or never?

VERY OFTEN 1
SOMETIMES 2
NEVER 3

1008) CHECK 1003:

MARRIED/LIVING WITH A MAN/SEPARATED/DIVORCED/WIDOWED: From the time you were 15 years old has anyone other than your (current/last) husband/partner hit, slapped, kicked, or done anything else to hurt you physically?

NEVER MARRIED/NEVER LIVED WITH A MAN: From the time you were 15 years old has anyone ever hit, slapped, kicked, or done anything else to hurt you physically?

YES 1
NO 2 (GO TO 1011)
NO ANSWER 3 (GO TO 1011)

1008A) Who has physically hurt you in this way?
PROBE: Anyone else?
RECORD ALL MENTIONED.

MOTHER A
FATHER B
STEP-MOTHER C
STEP-FATHER/MOTHER'S PARTNER D
SISTER E
BROTHER F
DAUGHTER G
SON H
EX-HUSBAND/EX-PARTNER I
FRIEND/CURRENT SEXUAL PARTNER J
EX-FRIEND/EX-SEXUAL PARTNER K
MOTHER-IN-LAW (HUSBAND'S MOTHER) L
FATHER-IN-LAW (HUSBAND'S FATHER) M
OTHER FEMALE IN-LAWS N
OTHER MALE IN-LAWS O
FEMALE FRIEND/ACQUAINTANCE P
MALE FRIEND/ACQUAINTANCE Q
TEACHER R
EMPLOYER S
STRANGER T
POLICE/SOLDIER U
OTHER (SPECIFY) _____ X

1008B) CHECK 1008A:

MORE THAN ONE PERSON MENTIONED (GO TO 1009)
ONLY ONE PERSON MENTIONED (GO TO 1010)

1009) Who has hit, slapped, kicked or done something to physically hurt you most often?

MOTHER 01
FATHER 02
STEP-MOTHER 03
STEP-FATHER/MOTHER'S PARTNER 04
SISTER 05
BROTHER 06
DAUGHTER 07
SON 08
EX-HUSBAND/EX-PARTNER 09
FRIEND/CURRENT SEXUAL PARTNER 10
EX-FRIEND/EX-SEXUAL PARTNER 11
MOTHER-IN-LAW (HUSBAND'S MOTHER) 12
FATHER-IN-LAW (HUSBAND'S FATHER) 13
OTHER FEMALE IN-LAWS 14
OTHER MALE IN-LAWS 15
FEMALE FRIEND/ACQUAINTANCE 16
MALE FRIEND/ACQUAINTANCE 17
TEACHER 18
EMPLOYER 19
STRANGER 20
POLICE/SOLDIER 21
OTHER (SPECIFY) _____ 96

1010) In the last 12 months, how many times has this person hit, slapped, kicked, or done anything else to physically hurt you?

NUMBER OF TIMES ___
IF WIDOWED, DIVORCED, OR SEPARATED 95

1011) CHECK Q201, Q226, AND Q229: LIVE BIRTHS, PREGNANCIES, STILLBIRTHS

HAD AT LEAST ONE PREGNANCY (GO TO 1012)
NEVER HAD A PREGNANCY [Q201 = 2, Q226 = (2 or 8), AND Q229 = 2] (GO TO 1014)

1012) Has anyone ever hit, slapped, kicked or done anything else to hurt you physically while you were pregnant?

YES 1
NO 2 (GO TO 1014)

1013) Who has done any of these things to physically hurt you while you were pregnant?
Anyone else?
RECORD ALL MENTIONED.

CURRENT HUSBAND/PARTNER A
MOTHER B
FATHER C
STEP-MOTHER D
STEP-FATHER/MOTHER'S PARTNER E
SISTER F
BROTHER G
DAUGHTER H
SON I
EX-HUSBAND/EX-PARTNER J
FRIEND/CURRENT SEXUAL PARTNER K
EX-FRIEND/EX-SEXUAL PARTNER K
MOTHER-IN-LAW (HUSBAND'S MOTHER) M
FATHER-IN-LAW (HUSBAND'S FATHER) N
OTHER FEMALE IN-LAWS O
OTHER MALE IN-LAWS P
FEMALE FRIEND/ACQUAINTANCE Q
MALE FRIEND/ACQUAINTANCE R
TEACHER S
EMPLOYER T
STRANGER U
POLICE/SOLDIER V
OTHER (SPECIFY) _____ X

THANK THE RESPONDENT FOR HER COOPERATION AND REASSURE HER ABOUT THE CONFIDENTIALITY OF HER ANSWERS. FILL OUT THE QUESTIONS BELOW WITH REFERENCE TO THE DOMESTIC VIOLENCE MODULE ONLY.

1014) DID YOU HAVE TO INTERRUPT THE INTERVIEW BECAUSE ONE OF THE FOLLOWING PERSONS WAS TRYING TO LISTEN, OR CAME INTO THE ROOM, OR INTERFERED IN ANY OTHER WAY?

HUSBAND
YES, ONCE 1
YES, MORE THAN ONCE 2
NO 3
OTHER MALE ADULT
YES, ONCE 1
YES, MORE THAN ONCE 2
NO 3
FEMALE ADULT
YES, ONCE 1
YES, MORE THAN ONCE 2
NO 3

1015) INTERVIEWER COMMENTS:
IF QUESTIONS 1003 TO 1014 WERE NOT ASKED, EXPLAIN THE REASONS

COMMENTS________________________________________________________

1016) RECORD THE TIME.

HOURS ___
MINUTES ___

INTERVIEWER'S OBSERVATIONS

TO BE FILLED IN AFTER COMPLETING INTERVIEW

COMMENTS ABOUT RESPONDENT: ______________________________
COMMENTS ON SPECIFIC QUESTIONS: ______________________________
ANY OTHER COMMENTS ______________________________

SUPERVISOR'S OBSERVATIONS: ________________________________________
NAME OF SUPERVISOR: __________
DATE: __________

EDITOR'S OBSERVATIONS: __________________________________
NAME OF EDITOR: __________
DATE: _________