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DEMOCRATIC REPUBLIC OF CONGO
MINISTRY OF PLANNING AND MODERNIZATION
MINISTRY OF PUBLIC HEALTH

DEMOGRAPHIC AND HEALTH SURVEY
WOMAN'S QUESTIONNAIRE

CONFIDENTIAL

IDENTIFICATION

RESPONDENT POOL

POOL ____

NAME OF LOCATION (NEIGHBORHOOD/VILLAGE) ____

NAME OF HEAD OF HOUSEHOLD ____

CLUSTER NUMBER

CLUSTER ____

HOUSEHOLD NUMBER

HOUSEHOLD ____

FORMER PROVINCE

FORMER PROVINCE ____

NEW PROVINCE

NEW PROVINCE ____

URBAN/RURAL

URBAN 1
RURAL 2

KINSHASA - MAIN CITY OF PROVINCE - OTHER CITY - CITY - STATE - RURAL

RESIDENCE ____
KINSHASA 1
MAIN CITY OF PROVINCE 2
OTHER CITY 3
CITY-STATE 4
RURAL 5

NAME AND LINE NUMBER OF WOMAN ____

CHECK COVER OF HOUSEHOLD QUESTIONNAIRE: WAS THE HOUSEHOLD SELECTED FOR THE MEN'S SURVEY, THE ANEMIA, MALARIA, HIV, AND VACCINATIONS TESTS, AND THE ANTHROPOMETRIC MEASUREMENTS? (YES 1, NO 2)

HOUSEHOLD SELECTED FOR MEN'S SURVEY ____

IF NO ( 2) CHECK QUESTION 293A OF THE HOUSEHOLD QUESTIONNAIRE FOR THE SELECTION OF THE WOMAN ELIGIBLE FOR THE SECTION ON "DOMESTIC VIOLENCE." IF THE WOMAN WHO YOU ARE SURVEYING WAS SELECTED FOR THE DOMESTIC VIOLENCE MODULE, RECORD 1 IN THE SPACE TO THE RIGHT; OTHERWISE RECORD 2 (YES 1, NO 2).

WOMAN SELECTED FOR DOMESTIC VIOLENCE MODULE ____

INTERVIEWER VISITS
FIRST VISIT
DATE ____
INTERVIEWER'S NAME ____
RESULT*

NEXT VISIT:
DATE ____
TIME ____

SECOND VISIT
DATE ____
INTERVIEWER'S NAME ____
RESULT*

NEXT VISIT:
DATE ____
INTERVIEWER'S NAME ____
RESULT*

THIRD VISIT DATE ____
INTERVIEWER'S NAME ____
RESULT*

FINAL VISIT
DAY ____
MONTH ____
YEAR 201_
INTERVIEWER CODE ____
RESULT

TOTAL NUMBER OF VISITS ____

*RESULT CODES:

1 COMPLETED
2 NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME AT TIME OF VISIT
3 ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME
4 POSTPONED
5 REFUSED
6 DWELLING VACANT OR ADDRESS NOT A DWELLING
7 DWELLING DESTROYED
8 DWELLING NOT FOUND
9 OTHER (SPECIFY)

LANGUAGE OF QUESTIONNAIRE ____

LANGUAGE CODES:

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

LANGUAGE OF INTERVIEW ____

LANGUAGE CODES:

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

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 ___. I am working with the Ministry of Planning and the Ministry of Health. We are conducting a survey about health all over the Democratic Republic of Congo. The information we collect will help the government to improve health services. Your household was selected for the survey. The questions usually take about 30 to 60 minutes. Based on the terms of article 8 and 9 of the Decree of February 11, 2010, all of the answers you give will be confidential and will not be shared with anyone other than members of our survey team. You don't have to be in the survey, but we hope you will agree to answer the questions since your views are important. If I ask you any question you don't want to answer, just let me know and I will go on to the next question or you can stop the interview at any time.

In case you need more information about the survey, you may contact the person listed on the card that has been given to your household.

Do you have any questions?
May I begin the interview?

SIGNATURE OF INTERVIEWER: ____ DATE: ____

RESPONDENT AGREES TO BE INTERVIEWED 1 (CONTINUE)
RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2 (END)

101) RECORD THE TIME

HOUR ____
MINUTES ____

102) In what month and year were you born?

MONTH
DON'T KNOW MONTH 98
YEAR 19
DON'T KNOW YEAR 9998

103) How old were you at your last birthday?
COMPARE AND CORRECT 102 AND/OR 103 IF INCONSISTENT

AGE IN COMPLETED YEARS ____

104) Have you ever attended school?

YES 1
NO 2 (GO TO 108)

105) What is the highest level of school you attended: Primary, Secondary, or higher?

PRIMARY 1
SECONDARY 2
HIGHER 3

106) What is the highest (grade/form/year) you completed at this level?*
IF COMPLETED LESS THAN ONE YEAR AT THAT LEVEL, RECORD 0

GRADE/FORM/YEAR ____

107) CHECK 105:

PRIMARY
SECONDARY OR HIGHER (GO TO 110)

108) Now I would like you to read this sentence to me.

SHOW CARD TO RESPONDENT

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

CANNOT READ AT ALL 1
ABLE TO READ ONLY PARTS OF SENTENCE 2
ABLE TO READ WHOLE SENTENCE 3
NO CARD WITH REQUIRED LANGUAGE (SPECIFY LANGUAGE) 4
BLIND/VISUALLY IMPAIRED 5

109) CHECK 108:

CODE '2', '3', OR '4' CIRCLED
CODE '1' OR '5' CIRCLED (GO TO 111)

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

AT LEAST ONCE A WEEK 1
LESS THAN ONCE A WEEK 2
NOT AT ALL 3

111) Do you listen to the radio at least once a week, less than once a week or not at all?

AT LEAST ONCE A WEEK 1
LESS THAN ONCE A WEEK 2
NOT AT ALL 3

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

AT LEAST ONCE A WEEK 1
LESS THAN ONCE A WEEK 2
NOT AT ALL 3

113) What is your religion?

CATHOLIC 11
PROTESTANT 12
SALVATION ARMY 13
KIMBANGUIST [AFRICAN CHRISTIAN SECT] 14
OTHER CHRISTIAN 15
MUSLIM 16
BUNDU DIA KONGO 17
VUVAMU 18
ANIMIST 19
NO RELIGION 20
OTHER (SPECIFY) 96

113A) Are you Congolese?

YES 1
NO 2 (GO TO 115)

114) What is your tribe?
RECORD NAME OF TRIBE

BAKONGO OF THE NORTH AND OF THE SOUTH OF THE RIVER 11
BAS-KASAI AND KWILU-KWANGO 12
CENTRAL CUVETTE 13
UBANGI AND ITIMBIRI-NGIRI 14
UELE; LAKE ALBERT 15
BASELE-KOMO, MANIEMA AND KIVU 16
KASAI; KATANGA; TANGANYIKA 17
LUNDA 18
PIGMY 19
OTHER (SPECIFY) 96

115) In the last 12 months, how many times have you been away from for one or more nights?

NUMBER OF TIMES ____
NONE 00 (GO TO 201)

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

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

TOTAL BIRTHS ____

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
NO (PROBE AND CORRECT 201-208 AS NECESSARY)

210) CHECK 208:

ONE OR MORE BIRTHS
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 212. RECORD TWINS AND TRIPLETS ON SEPARATE ROWS.
(IF THERE ARE MORE THAN 12 BIRTHS, USE AN ADDITIONAL QUESTIONNAIRE, STARTING WITH THE SECOND ROW.)

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

RECORD NAME ____
BIRTH HISTORY NUMBER ____

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

BOY 1
GIRL 2

214) Were any of these births twins?

SING 1
MULT 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)

HOUSEHOLD LINE NUMBER ____ (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), including any children who died after birth?

YES 1 (ADD BIRTH)
NO 2 (NEXT BIRTH)

222) Have you had any live births since the birth of (name of last birth)? IF YES, RECORD BIRTH(S) IN TABLE.

YES 1
NO 2

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

NUMBERS ARE THE SAME
NUMBERS ARE DIFFERENT (PROBE AND RECONCILE)

224) CHECK 215:
ENTER THE NUMBER OF BIRTHS IN 2008 OR LATER.

NUMBER OF BIRTHS ____
NONE 0

226) Are you pregnant now?

YES 1
NO 2 (GO TO 230)
UNSURE 8 (GO TO 230)

227) How many months pregnant are you?

MONTHS ____

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

YES 1 (GO TO 230)
NO 2

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

LATER 1
NO MORE 2

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

YES 1
NO 2 (GO TO 238)

231) When did the last such pregnancy end?

Month ____
Year ____

232) CHECK 231:
LAST PREGNANCY ENDED IN JAN 2008 OR LATER

LAST PREGNANCY ENDED BEFORE JAN. 2008 (GO TO 238)

233) How many months pregnant were you when the last such pregnancy ended?

MONTHS ____

234) Since January 2008, have you had any other pregnancies that did not result in a live birth?

YES 1
NO 2

236) Did you have any miscarriages, abortions or stillbirths that ended before 2008?

YES 1
NO 2 (GO TO 238)

237) When did the last such pregnancy that terminated before 2008 end?

MONTH ____
YEAR ____

238) 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

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

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

240) 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

SECTION 3. CONTRACEPTION

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

Have you ever heard of (Method)?

01) FEMALE STERILIZATION
PROBE: Women can have an operation to avoid having any more children
Have you ever heard of (method)?
YES 1
NO 2
02) MALE STERILIZATION
PROBE: Men can have an operation to avoid having any more children
Have you ever heard of (method)?
YES 1
NO 2
03) IUD
PROBE: Women can have a loop or coil placed inside them by a doctor or a nurse.
Have you ever heard of (method)?
YES 1
NO 2
04) INJECTABLES
PROBE: Women can have an injection by a heath provider that stops them from becoming pregnant for one or more months.
Have you ever heard of (method)?
YES 1
NO 2
05) IMPLANTS
PROBE: Women can have one or more small rods placed in their upper arm by a doctor or nurse which can prevent pregnancy for one or more years.
Have you ever heard of (method)?
YES 1
NO 2
06) PILL
PROBE: Women can take a pill every day to avoid becoming pregnant
Have you ever heard of (method)?
YES 1
NO 2
07) CONDOM
PROBE: Men can put a rubber sheath on their penis before sexual intercourse.
Have you ever heard of (method)?
YES 1
NO 2
08) FEMALE CONDOM
PROBE: Women can place a sheath in their vagina before sexual intercourse.
Have you ever heard of (method)?
YES 1
NO 2
08A) BEADS (CYCLE BEADS OR FIXED DAY METHOD)
PROBE: A woman uses a string of colors beads to know which days she could get pregnant. On the days she could get pregnant, she uses a condom or does not have sexual intercourse.
Have you ever heard of (method)?
YES 1
NO 2
09) SUPPOSITORY, FOAM, JELLY
PROBE: Women can insert a suppository, put foam or cream in their vagina before sexual intercourse.
Have you ever heard of (method)?
YES 1
NO 2
10) RHYTHM METHOD
PROBE: To avoid pregnancy, women do not have sexual intercourse on days of the month they think they can get pregnant.
Have you ever heard of (method)?
YES 1
NO 2
11) WITHDRAWAL
PROBE: Men can be careful and pull out before climax.
Have you ever heard of (method)?
YES 1
NO 2
12) EMERGENCY CONTRACEPTION
PROBE: As an emergency measure, within three days after they have unprotected sexual intercourse, women can take special pills to prevent pregnancy.
Have you ever heard of (method)?
YES 1
NO 2
13) Have you heard of any other ways or methods that women or men can use to avoid pregnancy?
YES 1
(SPECIFY)
(SPECIFY)
NO 2

302) CHECK 226:

NOT PREGNANT OR UNSURE
PREGNANT (GO TO 313)

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

YES 1
NO 2 (GO TO 313)

304) Which method are you using?
CIRCLE ALL MENTIONED
IF MORE THAN ONE METHOD MENTIONED, FOLLOW SKIP INSTRUCTION FOR HIGHEST METHOD IN LIST.

FEMALE STERILIZATION A (GO TO 307)
MALE STERILIZATION B (GO TO 307)
IUD C (GO TO 308A)
INJECTABLES D (GO TO 308A)
IMPLANTS E (GO TO 308A)
PILL F
CONDOM G (GO TO 306)
FEMALE CONDOM H (GO TO 308A)
CYCLE BEADS I (GO TO 308A)
FOAM/JELLY J (GO TO 308A)
RHYTHM METHOD K (GO TO 308A)
WITHDRAWAL L (GO TO 308A)
OTHER MODERN METHOD X (GO TO 308A)
OTHER TRADITIONAL METHOD Y (GO TO 308A)

305) What is the brand name of the pills you are using?
IF DON'T KNOW BRAND, ASK TO SEE THE PACKAGE.

OVRETTE 01 (GO TO 308A)
EXCLUTON 02 (GO TO 308A)
MICROLUT 03 (GO TO 308A)
MICROGYNON 04 (GO TO 308A)
DUOFEM 05 (GO TO 308A)
OVRAL 06 (GO TO 308A)
COMBINATION 3 07 (GO TO 308A)
OTHER (SPECIFY) 96 (GO TO 308A)
DON'T KNOW 98 (GO TO 308A)

306) What is the brand name of the condoms you are using?
IF DON'T KNOW THE BRAND, ASK TO SEE THE PACKAGE.

PRUDENCE 01 (GO TO 308A)
OK 02 (GO TO 308A)
DOUBLE BUTTERFLY 03 (GO TO 308A)
INNOTEX 04 (GO TO 308A)
BENELUX 05 (GO TO 308A)
PROTECTOR 06 (GO TO 308A)
TRUST 07 (GO TO 308A)
KAMAX EURO 08 (GO TO 308A)
DAVIGNA 09 (GO TO 308A)
KAMATSURA 10 (GO TO 308A)
LATEX CONDOM 11 (GO TO 308A)
LATEX FACTORI 12 (GO TO 308A)
PREVANTOR 13 (GO TO 308A)
INDUS 14 (GO TO 308A)
OTHER (SPECIFY) 96 (GO TO 308A)
DON'T KNOW 98 (GO TO 308A)

307) In what facility did the sterilization take place?
PROBE TO IDENTIFY THE TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE

(NAME OF PLACE) ____
PUBLIC SECTOR
GOVERNMENT HOSPITAL 11
GOVERNMENT HEALTH CENTER 12
FAMILY PLANNING CLINIC 13
MOBILE CLINIC 14
MATERNITY 15
VOLUNTARY TESTING CENTER 16
OTHER PUBLIC SECTOR (SPECIFY) 17
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC 21
PRIVATE HEALTH CENTER 22
PRIVATE DOCTOR'S OFFICE 23
OTHER PRIVATE MEDICAL SECTOR (SPECIFY) 26
OTHER (SPECIFY) 96
DON'T KNOW 98

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

MONTH ____
YEAR ____

308A) Since what month and year did you start using (CURRENT METHOD) without stopping?
PROBE: For how long have you been using (CURRENT METHOD FIRST MENTIONED) now without stopping?

MONTH ____
YEAR ____
ALL GO TO 314

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

YES 1 (GO TO 324)
NO 2 (GO TO 324)

314) CHECK 304:
CIRCLE METHOD CODE.
IF MORE THAN ONE METHOD CODE CIRCLED IN 304, CIRCLE CODE FOR HIGHEST METHOD IN LIST.

FEMALE STERILIZATION 01 (GO TO 317A)
MALE STERILIZATION 02 (GO TO 326)
IUD 03
INJECTABLES 04
IMPLANTS 05
PILL 06
CONDOM 07
FEMALE CONDOM 08
CYCLE BEADS 09
FOAM/JELLY 10
RHYTHM METHOD 11 (GO TO 315A)
WITHDRAWAL 12 (GO TO 326)
OTHER MODERN METHOD 95 (GO TO 326)
OTHER TRADITIONAL METHOD 96 (GO TO 326)

315) You first started using (CURRENT METHOD) in (DATE FROM 308/308A). Where did you get it at that time?

315A) Where did you learn how to use the rhythm/lactational amenorrhea method?
PROBE TO IDENTITY THE TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

(NAME OF PLACE) ____
PUBLIC SECTOR
GOVERNMENT HOSPITAL 11
FAMILY PLANNING CLINIC 12
GOVERNMENT HEALTH CENTER 13
MATERNITY 14
FIELDWORKER 15
OTHER PUBLIC SECTOR (SPECIFY) 16
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC 21
PHARMACY 22
NGO 23
PRIVATE HEALTH CENTER 24
PRIVATE DOCTOR'S OFFICE 25
DOCTOR 26
MOBILE CLINIC 27
FIELDWORKER 28
OTHER PRIVATE MEDICAL SECTOR (SPECIFY) 29
OTHER SOURCE
SHOP 31
RELIGIOUS INSTITUTION 32
FRIEND/RELATIVES 33
BAR/NIGHTCLUB 34
OTHER (SPECIFY) 96

316) CHECK 304:
CIRCLE METHOD CODE:
IF MORE THAN ONE METHOD CODE CIRCLED IN 304, CIRCLE CODE FOR HIGHEST METHOD IN LIST.

IUD 03
INJECTABLES 04
IMPLANTS 05
PILL 06
CONDOM 07 --GO TO 323
FEMALE CONDOM 08 (GO TO 320)
CYCLE BEADS 09 (GO TO 320)
FOAM/JELLY 10 (GO TO 320)
RHYTHM METHOD 11 (GO TO 326)

317) At that time, where you told about side effects or problems you might have with the method?

YES 1
NO 2

317A) When you got sterilized, were you told about side effects or problems you might have with the method?

YES 1 (GO TO 319)
NO 2

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

YES 1
NO 2 (GO TO 320)

319) Were you told what to do if you experienced side effects or problems?

YES 1
NO 2

320) CHECK 317:
CODE 1 CIRCLED
At that time, were you told about other methods of family planning that you could use?

CODE '2' CIRCLED
When you obtained (CURRENT METHOD FROM 314) from (SOURCE OF METHOD FROM 307 OR 315), were you told about other methods of family planning that you could use?

YES 1 (GO TO 322)
NO 2

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

YES 1
NO 2

322) CHECK 304:
CIRCLE METHOD CODE.
IF MORE THAN ONE METHOD CODE CIRCLED IN 304, CIRCLE CODE FOR HIGHEST METHOD IN LIST.

FEMALE STERILIZATION 01 (GO TO 326)
MALE STERILIZATION 02 (GO TO 326)
IUD 03 (GO TO 326)
INJECTABLES 04
IMPLANTS 05 (GO TO 326)
PILL 06
CONDOM 07
FEMALE CONDOM 08
CYCLE BEADS 09
FOAM/JELLY 10
RHYTHM METHOD 11 (GO TO 326)
WITHDRAWAL 12 (GO TO 326)
OTHER MODERN METHOD 95 (GO TO 326)
OTHER TRADITIONAL METHOD 96 (GO TO 326)

323) Where did you obtain (CURRENT METHOD) the last time?
PROBE TO IDENTITY THE TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

(NAME OF PLACE) ____
PUBLIC SECTOR
GOVERNMENT HOSPITAL 11
FAMILY PLANNING CLINIC 12
GOVERNMENT HEALTH CENTER 13
MATERNITY 14
FIELDWORKER 15
OTHER PUBLIC SECTOR (SPECIFY) 16
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC 21
PHARMACY 22
NGO 23
PRIVATE HEALTH CENTER 24
PRIVATE DOCTOR'S OFFICE 25
DOCTOR 26
MOBILE CLINIC 27
FIELDWORKER 28
OTHER PRIVATE MEDICAL SECTOR (SPECIFY) 29
OTHER SOURCE
SHOP 31
RELIGIOUS INSTITUTION 32
FRIEND/RELATIVES 33
BAR/NIGHTCLUB 34
OTHER (SPECIFY) 96

324) Do you know of a place where you can obtain a method of family planning?

YES 1
NO 2 (GO TO 326)

325) Where is that?
Any other place?
PROBE TO IDENTITY THE TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

(NAME OF PLACE(S)) ____
PUBLIC SECTOR
GOVERNMENT HOSPITAL A
FAMILY PLANNING CLINIC B
GOVERNMENT HEALTH CENTER C
MATERNITY D
FIELDWORKER E
OTHER PUBLIC SECTOR (SPECIFY) F
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC G
PHARMACY H
NGO I
PRIVATE HEALTH CENTER J
PRIVATE DOCTOR'S OFFICE K
DOCTOR L
MOBILE CLINIC M
FIELDWORKER N
OTHER PRIVATE MEDICAL SECTOR (SPECIFY) O
OTHER SOURCE
SHOP P
RELIGIOUS INSTITUTION Q
FRIEND/RELATIVES R
BAR/NIGHTCLUB S
OTHER (SPECIFY) X

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

YES 1
NO 2

327) 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)

328) Did any staff member at the health facility speak to you about family planning methods?

YES 1
NO 2

SECTION 4. PREGNANCY AND POSTNATAL CARE

401) CHECK 224:

ONE OR MORE BIRTHS IN 2008 OR LATER
NO BIRTHS IN 2008 OR LATER (GO TO 556)

402) CHECK 215: ENTER IN THE TABLE THE BIRTH HISTORY NUMBER, NAME, AND SURVIVAL STATUS OF EACH BIRTH IN 2008 OR LATER. ASK THE QUESTIONS ABOUT ALL THESE BIRTHS. BEGIN WITH THE LAST BIRTH. (IF THERE ARE MORE THAN 3 BIRTHS, USE LAST 2 COLUMNS OF ADDITIONAL QUESTIONNAIRES).

Now I would like to ask some questions about your children born in the last five years. (We will talk about each separately).

403) BIRTH HISTORY NUMBER FROM 212 IN BIRTH HISTORY

LAST BIRTH ____
BIRTH HISTORY NUMBER ____
NEXT-TO-LAST BIRTH ____
BIRTH HISTORY NUMBER ____
SECOND-FROM-LAST BIRTH ____
BIRTH HISTORY NUMBER ____

404) FROM 212 AND 216:

Name ____
Living ____
Dead ____

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

YES 1 (GO TO 408)
NO 2

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

LATER 1
NO MORE 2 (GO TO 408)

407) How much longer did you want to wait?

MONTHS 1
YEARS 2
DON'T KNOW 998

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

YES 1
NO 2 (GO TO 415)

409) Whom did you see?
Anyone else?
PROBE TO IDENTIFY EACH TYPE OF PERSON AND RECORD ALL MENTIONED.

HEATH PROFESSIONAL
DOCTOR A
NURSE B
MIDWIFE C
OTHER PERSON
"MIDWIFE" D
VILLAGE MATRON E
TRADITIONAL PRACTITIONER F
VILLAGE/NEIGHBORHOOD MOTHER G
OTHER (SPECIFY) X

410) Where did you receive this antenatal care for this pregnancy?
Anywhere else?
PROBE TO IDENTITY THE TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

(NAME OF PLACE(S))
HOME
YOUR HOME A
OTHER HOME B
PUBLIC SECTOR
GOVERNMENT HOSPITAL C
GOVERNMENT HEALTH CENTER D
GOVERNMENT HEALTH POST E
OTHER PUBLIC SECTOR (SPECIFY) F
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC G
OTHER PRIVATE MEDICAL SECTOR (SPECIFY) H
OTHER (SPECIFY) X

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

MONTHS
DON'T KNOW 98

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

NUMBER OF TIMES ____
DON'T KNOW 98

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

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

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

414) During (any of) your antenatal care visit(s), were you told about things to look out for that might suggest problems with the pregnancy?

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 418)
DON'T KNOW 8 (GO TO 418)

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

TIMES ____
DON'T KNOW 8

417) CHECK 416:

2 OR MORE TIMES (GO TO 421)
OTHER

418) At any time before this pregnancy, did you receive any tetanus injections?

YES 1
NO 2 (GO TO 421)
DON'T KNOW 8 (GO TO 421)

419) Before this pregnancy, how many times did you receive a tetanus injection?
IF 7 OR MORE TIMES, RECORD 7

TIMES ____
DON'T KNOW 8

420) How many years ago did you receive the last tetanus injection before this pregnancy?

YEARS AGO ____

421) During this pregnancy, were you given or did you buy iron tablets or iron syrup?
SHOW TABLES/SYRUP

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

422) During the whole pregnancy, for how many days did you take the tables or syrup?
IF ANSWER NOT NUMERIC, PROBE FOR APPROXIMATE NUMBER OF DAYS.

DAYS
DON'T KNOW 998

423) During this pregnancy, did you take any drug for intestinal worms?

YES 1
NO 2
DON'T KNOW 8

424) During this pregnancy, did you take any drugs to keep you from getting malaria?

YES 1
NO 2 (GO TO 430)
DON'T KNOW 8 (GO TO 430)

425) What drugs did you take?
RECORD ALL MENTIONED. IF TYPE OF DRUG IS NOT DETERMINED, SHOW TYPICAL ANTIMALARIAL DRUGS TO RESPONDENT.

SP/FANSIDAR A
CHLOROQUINE B
OTHER (SPECIFY) X
DON'T KNOW Z

426) CHECK 425:
SP/FANSIDAR TAKEN FOR MALARIA PREVENTION

CODE A CIRCLED
CODE A NOT CIRCLED (GO TO 430)

427) How many times did you take (SP/Fansidar) during this pregnancy?

TIMES ____

428) CHECK 409:
ANTENATAL CARE FROM HEALTH PERSONNEL DURING THIS PREGNANCY

CODE A, B, OR C CIRCLED
OTHER (GO TO 430)

429) Did you get the (SP/Fansidar) during any antenatal care visit, during another visit to a health facility, or from another source?

ANTENATAL VISIT 1
ANOTHER FACILITY VISIT 2
OTHER SOURCE 6

430) 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

431) Was (NAME) weighed at birth?

YES 1
NO 2 (GO TO 433)
DON'T KNOW 8 (GO TO 433)

432) How much did (NAME) weigh?
RECORD WEIGHT IN KILOGRAMS FROM HEALTH CARD, IF AVAILABLE

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

433) Who assisted with the delivery of (NAME)?
Anyone else?
PROBE FOR THE TYPE OF PERSON AND RECORD ALL PERSON ASSISTING.
IF RESPONDENT SAYS NO ONE ASSISTED, PROBE TO DETERMINE WHETHER ANY ADULTS WERE PRESENT AT THE DELIVERY.

HEATH PROFESSIONAL
DOCTOR A
NURSE B
MIDWIFE C
OTHER PERSON
"MIDWIFE" D
VILLAGE MATRON E
TRADITIONAL PRACTITIONER F
VILLAGE/NEIGHBORHOOD MOTHER G
OTHER (SPECIFY) X
NO ONE ASSISTED Y

434) Where did you give birth to (NAME)?
PROBE TO IDENTITY THE TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

(NAME OF PLACE(S)) ____
HOME
YOUR HOME 11 (GO TO 438)
OTHER HOME 12 (GO TO 438)
PUBLIC SECTOR
GOVERNMENT HOSPITAL 21
GOVERNMENT HEALTH CENTER 22
GOVERNMENT HEALTH POST 23
OTHER PUBLIC SECTOR (SPECIFY) 26
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC 31
OTHER PRIVATE MEDICAL SECTOR (SPECIFY) 36
OTHER (SPECIFY) 96 (GO TO 438)

434A) How long after (NAME) was delivered did you stay there?
IF LESS THAN ONE DAY, RECORD HOURS.
IF LESS THAN ONE WEEK, RECORD DAYS.

HOURS 1 ____
DAYS 2 ____
WEEKS 3 ____
DON'T KNOW 998

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

YES 1
NO 2

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

YES 1 (GO TO 439)
NO 2

437) Did anyone check on your health after you left the facility?

YES 1 (GO TO 439)
NO 2 (GO TO 442)

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

YES 1
NO 2 (GO TO 442)

439) Who checked on your health at that time?
PROBE FOR MOST QUALIFIED PERSON.

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

440) How long after delivery did the first check take place?
IF LESS THAN ONE DAY, RECORD IN HOURS. IF LESS THAN ONE WEEK, RECORD DAYS.

HOURS 1 ____
DAYS 2 ____
WEEKS 3 ____
DON'T KNOW 998

442) In the two months after (NAME) was born, did any health care provider or a traditional birth attendant check on his/her health?

YES 1
NO 2 (GO TO 446)
DON'T KNOW 8 (GO TO 446)

443) How many hours, days, or weeks after the birth of (NAME) did the first check take place?
IF LESS THAN ONE DAY, RECORD IN HOURS. IF LESS THAN ONE WEEK, RECORD DAYS.

HOURS AFTER BIRTH 1
DAYS AFTER BIRTH 2
WEEKS AFTER BIRTH 3
DON'T KNOW 998

444) Who checked on (NAME)'s health at that time?
PROBE FOR THE MOST QUALIFIED PERSON.

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

445) Where did this first check of (NAME) take place?
PROBE TO IDENTITY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

(NAME OF PLACE(S)) ____
HOME
YOUR HOME 11
OTHER HOME 12
PUBLIC SECTOR
GOVERNMENT HOSPITAL 21
GOVERNMENT HEALTH CENTER 22
GOVERNMENT HEALTH POST 23
OTHER PUBLIC SECTOR (SPECIFY) 26
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC 31
OTHER PRIVATE MEDICAL SECTOR (SPECIFY) 36
OTHER (SPECIFY) 96

446) In the first two months after delivery, did you receive a vitamin A dose like (this/any of these)?
SHOW COMMON TYPES OF AMPOULES/CAPSULES/SYRUPS

YES 1
NO 2
DON'T KNOW 8

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

YES 1 (GO TO 449)
NO 2 (GO TO 450)

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

YES 1
NO 2 (GO TO 452)

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

MONTHS ____
DON'T KNOW 98

450) CHECK 226:
IS RESPONDENT PREGNANT?

NOT PREGNANT
PREGNANT OR NOT SURE (GO TO 452)

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

YES 1
NO 2 (GO TO 453)

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

MONTHS
DON'T KNOW 98

453) Did you ever breastfeed (NAME)?

YES 1 (GO TO 455)
NO 2

454) CHECK 404: CHILD IS LIVING?

LIVING (GO TO 460)
DEAD (GO BACK TO 405 IN NEXT COLUMN; OR IF NO MORE BIRTHS, GO TO 501)

455) 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 ____

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

YES 1
NO 2 (GO TO 458)

457) What was (NAME) given to drink?
Anything else?
RECORD ALL LIQUIDS MENTIONED.

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

458) CHECK 404:
IS CHILD LIVING?

LIVING
DEAD (GO BACK TO 405 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 501)

459) Are you still breastfeeding (NAME)?

YES 1
NO 2

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

YES 1
NO 2
DON'T KNOW 8

461) (GO BACK TO 405 IN NEXT COLUMN, OR, IF NO MORE BIRTHS, GO TO 501)

SECTION 5. CHILD IMMUNIZATION, HEALTH AND NUTRITION

501) ENTER IN THE TABLE THE BIRTH HISTORY NUMBER, NAME, AND SURVIVAL STATUS OF EACH BIRTH IN 2008 OR LATER. ASK THE QUESTIONS ABOUT ALL OF THESE BIRTHS. BEGIN WITH THE LAST BIRTH. (IF THERE ARE MORE THAN 3 BIRTHS, USE LAST 2 COLUMNS OF ADDITIONAL QUESTIONNAIRES.)

502) BIRTH HISTORY NUMBER FROM 212 IN BIRTH HISTORY

LAST BIRTH ____
BIRTH HISTORY NUMBER ____
NEXT-TO-LAST BIRTH ____
BIRTH HISTORY NUMBER ____
SECOND-FROM-LAST BIRTH ____
BIRTH HISTORY NUMBER ____

503) FROM 212 AND 216

NAME ____
LIVING
DEAD (GO TO 503 IN NEXT COLUMN OR, IF NO MORE BIRTHS, GO TO 553)

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

YES, SEEN 1 (GO TO 506)
YES, NOT SEEN 2 (GO TO 509)
NO CARD 3

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

YES 1 (GO TO 509)
NO 2

506)
1) COPY DATES FROM THE CARD
2) WRITE 44 IN DAY COLUMN IF CARD SHOWS THAT A DOSE WAS GIVEN, BUT NO DATE IS RECORDED.

BCG ____
POLIO 0 (POLIO GIVEN AT BIRTH) ____
POLIO 1 ____
POLIO 2 ____
POLIO 3 ____
DTC/HEPB/HIB 1 ____
DTC/HEPB/HIB 2 ____
DTC/HEPB/HIB 3 ____
MEASLES ____
YELLOW FEVER ____
VITAMIN A (MOST RECENT) ____

507) CHECK 506:

BCG TO YELLOW FEVER ALL RECORDED (GO TO 511)
OTHER

508) Has (NAME) received any vaccines that are not recorded on this card, including vaccinations received in a national immunization day campaign?
RECORD 'YES' ONLY IF RESPONDENT MENTIONS AT LEAST ONE OF THE VACCINATIONS IN 506 THAT ARE NOT RECORDED AS HAVING BEEN GIVEN.

YES 1 (PROBE FOR VACCINATIONS AND WRITE 66 IN THE CORRESPONDING DAY COLUMN IN 506 (GO TO 511))
NO 2 (GO TO 511)
DON'T KNOW 8 (GO TO 511)

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

YES 1
NO 2 (GO TO 511)
DON'T KNOW 8 (GO TO 511)

510) Please tell me if (NAME) had any of the following vaccinations:

510A) A BCG vaccination against tuberculosis, that is, an injection in the left forearm that usually causes a scar?

YES 1
NO 2
DON'T KNOW 8

510B) Polio vaccine, that is, two drops in the mouth?

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

510C) Was the first polio vaccine given just after birth or later?

JUST AFTER BIRTH 1
LATER 2

510D) How many times was the polio vaccine given?

NUMBER OF TIMES ____

510E) A DTC/HepB/Hib vaccination, that is, an injection given in the thigh or buttocks, sometimes at the same time as polio drops?

YES 1
NO 2 (GO TO 510G)
DON'T KNOW 3 (GO TO 510G)

510F) How many times was the DTC/HepB/Hib vaccination given?

NUMBER OF TIMES ____

510G) An injection or an MMR injection that is, a shot in the left arm at the age of 9 months or older, to prevent him/her from getting measles?

YES 1
NO 2
DON'T KNOW 8

510H) A yellow fever vaccination, that is, a shot in the right arm at the age of 9 months or older,- to prevent him/her from getting yellow fever?

YES 1
NO 2
DON'T KNOW 8

511) Within the last six months, was (NAME) given a vitamin A dose like (this/any of these)?
SHOW COMMON TYPES OF AMPOULES/CAPSULES/SYRUPS.

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

513A) In the last six months, was (NAME) given a mebendazole table like this one?
SHOW 500 MG TABLET FOR CHILDREN AGE 12-59 MONTHS

YES 1
NO 2
DON'T KNOW 8

513B) Has (NAME) ever had the measles?

YES 1
NO 2 (GO TO 514)
DON'T KNOW 9 (GO TO 514)

513C) How old was (NAME) when he/she had the measles?

MONTHS ____
DON'T REMEMBER 98

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

YES 1
NO 2 (GO TO 525)
DON'T KNOW (GO TO 525)

515) Was there any blood in the stools?

YES 1
NO 2
DON'T KNOW 8

516) Now I would like to know how much (NAME) was given to drink during the diarrhea (including breastmilk). 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

517) 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

518) Did you seek advice or treatment for the diarrhea from any source?

YES 1
NO 2 (GO TO 522)

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

(NAME OF PLACE(S)) ____
PUBLIC SECTOR
HOSPITAL A
HEALTH CENTER B
HEALTH POST C
MATERNITY D
COMMUNITY AGENT E
MOBILE CLINIC F
FIELDWORKER G
OTHER PUBLIC (SPECIFY) H
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC K
PHARMACY J
PRIVATE DOCTOR K
TRAVELING NURSE L
OTHER PRIVATE MEDICAL SECTOR (SPECIFY) M
OTHER SOURCE
SHOP N
TRADITIONAL PRACTITIONER O
TRAVELLING PEDDLER P
OTHER (SPECIFY) X

520) CHECK 519:

TWO OR MORE CODES CIRCLED
ONLY ONE CODE CIRCLED (GO TO 522)

521) Where did you first seek advice or treatment?

USE LETTER CODE FROM 519
FIRST PLACE

522) Was he/she given any of the following to drink at any time since he/she started having the diarrhea?
a) A fluid made from a special packet called (Local Name for ORS Packet)?
b) A pre-packaged ORS liquid?
c) A government-recommended homemade fluid?

FLUID FORM ORS PACKET
YES 1
NO 2
DON'T KNOW 8
ORS LQD
YES 1
NO 2
DON'T KNOW 8
HOMEMADE FLUID
YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2 (GO TO 525)
DON'T KNOW 8 (GO TO 525)

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

PILL OR SYRUP
ANTIBIOTIC A
ANTIMOTILITY B
ZINC C
OTHER (NOT ANTIBIOTIC, ANTIMOTILITY OR ZINC) D
UNKNOWN PILL OR SYRUP E
INJECTION
ANTIBIOTIC F
NON-ANTIBIOTIC G
UNKNOWN INJECTION H
(IV) INTRAVENOUS I
HOME REMEDY/HERBAL MEDICINE J
OTHER (SPECIFY) X

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

YES 1
NO 2 (GO TO 527)
DON'T KNOW 8 (GO TO 527)

526) At any time during the illness, did (NAME) have blood taken from his/her finger or heal for testing?

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2 (GO TO 530)
DON'T KNOW 8 (GO TO 530)

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

YES 1
NO 2 (GO TO 531)
DON'T KNOW 8 (GO TO 531)

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

CHEST ONLY 1 (GO TO 531)
NOSE ONLY 2 (GO TO 531)
BOTH 3 (GO TO 531)
OTHER (SPECIFY) 6 (GO TO 531)
DON'T KNOW 8 (GO TO 531)

530) CHECK 525:
HAD FEVER?

YES
NO OR DON'T KNOW (GO BACK TO 503 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 553)

531) Now I would like to know how much (NAME) was given to drink (including breastmilk) during the illness with a (fever/cough). 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

532) When (NAME) had a (fever/cough), 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

533) Did you seek advice or treatment for the illness from any source?

YES 1
NO 2 (GO TO 537)

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

(NAME OF PLACE(S)) ____
PUBLIC SECTOR
HOSPITAL A
HEALTH CENTER B
HEALTH POST C
MATERNITY D
COMMUNITY AGENT E
MOBILE CLINIC F
FIELDWORKER G
OTHER PUBLIC (SPECIFY) H
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC K
PHARMACY J
PRIVATE DOCTOR K
TRAVELING NURSE L
OTHER PRIVATE MEDICAL SECTOR (SPECIFY) M
OTHER SOURCE
SHOP N
TRADITIONAL PRACTITIONER O
MARKET P
OTHER (SPECIFY) X

535) CHECK 534:

TWO OR MORE CODES CIRCLED
ONLY ONE CODE CIRCLED (GO TO 537)

536) Where did you first seek advice or treatment?

USE LETTER CODE FROM 534
FIRST PLACE ____

537) At any time during the illness, did (NAME) take any drugs for the illness?

YES 1
NO 2 (GO BACK TO 503 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 553)
DON'T KNOW 8 (GO BACK TO 503 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 553)

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

ANTIMALARIAL DRUGS
SP/FANSIDAR A
CHLOROQUINE B
AMODIAQUINE C
QUININE D
COMBINATION WITH ARTEMISININ (CTA) PROTO. RDC: ARTESUNATE/AMODIAQUINE, ARTEMETHER/LUMEFANTRINE E
OTHER CTA: ARSUCAM/CO-ARINATE/ETC F
MALAXIN G
MALARITAB H
ARINATE I
ARTESUNATE J
MEFLOQUINE K
OTHER ANTIMALARIAL (SPECIFY) L
ANTIBIOTIC
PILL/SYRUP M
INJECTION N
OTHER DRUGS
ASPIRIN O
PARACETAMOL P
OTHER (SPECIFY) X
DON'T KNOW Z

539) CHECK 538:
ANY CODE A-L CIRCLED?

YES
NO (GO BACK TO 503 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 553)

540) CHECK 538:
SP/FANSIDAR (A) GIVEN

CODE A CIRCLED
CODE A NOT CIRCLED (GO TO 542)

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

SAME DAY 0
NEXT DAY 1
TWO DAYS AFTER FEVER 2
THREE DAYS OR MORE AFTER FEVER 3
DON'T KNOW 8

542) CHECK 538:
CHLOROQUINE (B) GIVEN

CODE B CIRCLED
CODE B NOT CIRCLED (GO TO 544)

543) How long after the fever started did (NAME) first take Chloroquine?

SAME DAY 0
NEXT DAY 1
TWO DAYS AFTER FEVER 2
THREE DAYS OR MORE AFTER FEVER 3
DON'T KNOW 8

544) CHECK 538:
AMODIAQUINE (C) GIVEN

CODE C CIRCLED
CODE C NOT CIRCLED (GO TO 546)

545) How long after the fever started did (NAME) first take Amodiaquine?

SAME DAY 0
NEXT DAY 1
TWO DAYS AFTER FEVER 2
THREE DAYS OR MORE AFTER FEVER 3
DON'T KNOW 8

546) CHECK 538:

QUININE (D) GIVEN
CODE D CIRCLED
CODE D NOT CIRCLED (GO TO 548)

547) How long after the fever started did (NAME) first take Quinine?

SAME DAY 0
NEXT DAY 1
TWO DAYS AFTER FEVER 2
THREE DAYS OR MORE AFTER FEVER 3
DON'T KNOW 8

548) CHECK 538:
COMBINATION WITH ARTEMISININ (CTA) PROTO. RDC: ARTESUNATE/AMODIAQUINE, ARTEMETHER/LUMEFANTRINE (E) GIVEN

CODE E CIRCLED
CODE E NOT CIRCLED (GO TO 549A)

549) How long after the fever started did (NAME) first take (Combination with artemisinin (CTA) Proto. RDC)?

SAME DAY 0
NEXT DAY 1
TWO DAYS AFTER FEVER 2
THREE DAYS OR MORE AFTER FEVER 3
DON'T KNOW 8

549A) CHECK 538:
OTHER CTA: ARSUCAM/CO-ARINATE/ETC (F) GIVEN

CODE D CIRCLED
CODE D NOT CIRCLED (GO TO 550)

549B) How long after the fever started did (NAME) first take Other CTA: Arsucam/Co-Arinate/etc?

SAME DAY 0
NEXT DAY 1
TWO DAYS AFTER FEVER 2
THREE DAYS OR MORE AFTER FEVER 3
DON'T KNOW 8

550) CHECK 538:
OTHER ANTIMALARIAL GIVEN

CODE G-L CIRCLED
CODE G-L NOT CIRCLED(GO BACK TO 503 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 553)

551) How long after the fever started did (NAME) first take (Other antimalarial)?

SAME DAY 0
NEXT DAY 1
TWO DAYS AFTER FEVER 2
THREE DAYS OR MORE AFTER FEVER 3
DON'T KNOW 8

552) GO BACK TO 503 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 553.

553) CHECK 215 AND 218, ALL ROWS:
NUMBER OF CHILDREN BORN IN 2008 OR LATER LIVING WITH THE RESPONDENT

ONE OR MORE (RECORD NAME OF YOUNGEST CHILD LIVING WITH HER AND CONTINUE TO 554)
NONE (GO TO 556)

554) The last time (NAME FROM 553) passed stools, what was done to dispose of the stools?

CHILD USED TOILET OR LATRINE 01
PUT/RINSED INTO TOILET OR LATRINE 02
PUT/RINSED INTO DRAIN OR DITCH 03
THROWN INTO GARBAGE 04
BURIED 05
LEFT IN THE OPEN 06
OTHER (SPECIFY) 07

555) CHECK 522A AND 522B, ALL COLUMNS:

NO CHILD RECEIVED FLUID FROM ORS PACKET OR PRE-PACKAGED ORS LIQUID
ANY CHILD RECEIVED FLUID FROM ORS PACKET OR PRE-PACKAGED ORS LIQUID (GO TO 557

556) Have you ever heard of a special product called ORS, for example Orasel, you can get for the treatment of diarrhea?

YES 1
NO 2

557) CHECK 215 AND 218, ALL ROWS:
NUMBER OF CHILDREN BORN IN 2011 OR LATER LIVING WITH RESPONDENT

ONE OR MORE (RECORD NAME OF YOUNGEST CHILD LIVING WITH HER AND CONTINUE TO 558)
NONE (GO TO 601)

558) Now I would like to ask you about liquids or foods that (NAME FROM 557) had yesterday during the day or at night. I am interested in whether your child had the item I mention even if it was combined with other foods.

Did (NAME FROM 557) (drink/eat):

a) Plain water?
b) Juice or juice drinks?
c) Clear broth?
d) Milk such as tinned, powdered, or fresh animal milk? IF YES: How many times did (NAME) drink milk?
e) Infant formula? IF YES: How many times did (NAME) drink infant formula?
f) Any other liquids?
g) Yogurt? IF YES: How many times did (NAME) eat yogurt?
h) Any commercially fortified baby food like [brand name of commercially fortified baby food, e.g. Cerelac]?
i) Rice, corn, millet, sorghum, noodles, porridge, or other foods made from grains?
j) Pumpkin, yams or red or yellow squash, carrots, sweet potatoes that are yellow or orange inside?
k) White potatoes, white yams, manioc, cassava, white sweet potatoes or any other foods made from roots?
l) Any dark green, leafy vegetables?
m) Ripe mangoes, papayas?
n) Any other fruits or vegetables (for example: banana, apple, applesauce green beans, avocado, tomato)?
o) Liver, kidney, heart or any other organ meats?
p) Any meat, such as beef, pork, lamb, goat, chicken or duck?
q) Eggs?
r) Fresh or dried fish or shellfish?
s) Other foods based in beans, soy, peas, lentils, or nuts?
t) Cheese or other food made from milk?
u) Any other solid, semi-solid, or soft food?

A) WATER
YES 1
NO 2
DON'T KNOW 8
B) JUICE
YES 1
NO 2
DON'T KNOW 8
C) BROTH
YES 1
NO 2
DON'T KNOW 8
D) MILK
IF YES: How many times did (NAME) drink milk?
IF 7 OR MORE TIMES, RECORD '7'.
YES 1
NO 2
DON'T KNOW 8
NUMBER OF TIMES DRANK MILK ____
E) INFANT FORMULA
IF YES: How many times did (NAME) drink infant formula?
IF 7 OR MORE TIMES, RECORD '7'.
YES 1
NO 2
DON'T KNOW 8
NUMBER OF TIMES DRANK FORMULA ____
F) OTHER LIQUIDS
YES 1
NO 2
DON'T KNOW 8
G) YOGURT?
IF YES: How many times did (NAME) ate yogurt?
IF 7 OR MORE TIMES, RECORD '7'.
YES 1
NO 2
DON'T KNOW 8
NUMBER OF TIMES ATE YOGURT ____
H) FORTIFIED BABY FOOD?
YES 1
NO 2
DON'T KNOW 8
I) GRAINS
YES 1
NO 2
DON'T KNOW 8
J) PUMPKIN, CARROTS, RED PEPPER, SQUASH OR SWEET POTATOES
YES 1
NO 2
DON'T KNOW 8
K) ROOTS
YES 1
NO 2
DON'T KNOW 8
L) DARK GREEN LEAFY VEGETABLES
YES 1
NO 2
DON'T KNOW 8
M) MANGOES, APRICOTS, DRIED PEACHES, OR PAPAYAS
YES 1
NO 2
DON'T KNOW 8
N) OTHER FRUITS OR VEGETABLES
YES 1
NO 2
DON'T KNOW 8
O) ORGAN MEATS
YES 1
NO 2
DON'T KNOW 8
P) MEAT
YES 1
NO 2
DON'T KNOW 8
Q) EGGS
YES 1
NO 2
DON'T KNOW 8
R) FISH OR SHELLFISH
YES 1
NO 2
DON'T KNOW 8
S) BEANS, PEAS, LENTILS, OR NUTS
YES 1
NO 2
DON'T KNOW 8
T) CHEESE/FOOD MADE FROM MILD
YES 1
NO 2
DON'T KNOW 8
U) OTHER SOLID, SEMI-SOLID, OR SOFT FOOD
YES 1
NO 2
DON'T KNOW 8

559) CHECK 558 (CATEGORIES "g" THROUGH "u"):

NOT A SINGLE YES
AT LEAST ONE YES (GO TO 561)

560) Did (NAME) eat any solid, semi-solid or soft foods yesterday during the day or at night?
IF YES, PROBE: What kind of solid, semi-solid, or soft foods did (NAME FROM 557) eat?

YES 1 (GO BACK TO 558 TO RECORD FOOD EATEN YESTERDAY)
NO 2 (GO TO 601)

561) How many times did (NAME FROM 557) eat solid, semi-solid, or soft foods yesterday during the day or at night?
IF 7 OR MORE TIMES, RECORD 7

NUMBER OF TIMES ____
DON'T KNOW 8

SECTION 6. MARRIAGE AND SEXUAL ACTIVITY

601) Are you currently married or living together with a man as if married?

YES, CURRENTLY MARRIED 1 (GO TO 604)
YES, LIVING WITH A MAN 2 (GO TO 604)
NO, NOT IN UNION 3

602) Have you ever been married or lived together with a man as if married?

YES, FORMERLY MARRIED 1
YES, LIVED WITH A MAN 2
NO 3 (GO TO 612)

603) What is your current marital status: are you a widow, divorced, or separated?

WIDOW 1 (GO TO 609)
DIVORCED 2 (GO TO 609)
SEPARATED 3 (GO TO 609)

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

LIVES WITH HER 1
STAYING ELSEWHERE 2

605) RECORD THE LINE NUMBER OF HER HUSBAND/PARTNER ACCORDING TO THE HOUSEHOLD QUESTIONNAIRE. IF HE IS NOT A LISTED IN THE HOUSEHOLD, RECORD '00'.

NAME ____
LINE NO. ____

606) Does your husband/partner have other wives or does he live with other women as if married?

YES 1
NO 2 (GO TO 609)
DON'T KNOW 8 (GO TO 609)

607) Including yourself, in total how many wives or live-in partners does he have?

TOTAL NUMBER OF WIVES AND LIVE-IN PARTNERS ____
DON'T KNOW

608) Are you the first, second…wife?

RANK _____

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

ONCE 1
MORE THAN ONCE 2

610) CHECK 609:
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: Now I would like to talk about the your first (husband/partner). In what month and year did you start living with him?

MONTH _____
DON'T KNOW MONTH 98
YEAR ____ (GO TO 612)
DON'T KNOW YEAR 9998

611) How old were you when you first started living with him?

AGE _____

612) CHECK for the presence of others. Before continuing, make every effort to ensure privacy.

613) 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?

NEVER HAD SEXUAL INTERCOURSE 00 (GO TO 628)
AGE IN YEARS ____
FIRST TIME WHEN STARTED LIVING WITH (FIRST) HUSBAND/PARTNER 95

614) 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.

615) When was the last time you had sexual intercourse?
IF LESS THAN 12 MONTHS, ANSWER MUST BE RECORDED IN DAYS, WEEKS, OR MONTHS.
IF 12 MONTHS (ONE YEAR) OR MORE, ANSWER MUST BE RECORDED IN YEARS.

DAYS AGO 1
WEEKS AGO 2
MONTHS AGO 3
YEARS AGO 4 ____ (GO TO 627)

616) When was the last time you had sexual intercourse with this person?

DAYS AGO 1
WEEKS AGO 2
MONTHS AGO 3

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

YES 1
NO 2 (GO TO 619)

618) Was a condom used every time you had sexual intercourse with this person in the last 12 months?

YES 1
NO 2

619) 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 2
IF NO, CIRCLE 3

HUSBAND 1
LIVE-IN PARTNER 2
BOYFRIEND NOT LIVING WITH RESPONDENT 3 (GO TO 622)
CASUAL ACQUAINTANCE 4 (GO TO 622)
CLIENT/PROSTITUTE 5 (GO TO 622)
OTHER (SPECIFY) 6 (GO TO 622)

620) CHECK 609:

MARRIED ONLY ONCE
MARRIED MORE THAN ONCE (GO TO 622)

621) CHECK 613

FIRST TIME WHEN STARTED LIVING WITH HUSBAND (GO TO 623)
OTHER

622) How long ago did you first have sexual intercourse with this (second/third) person?

DAYS AGO 1
WEEKS AGO 2
MONTHS AGO 3
YEARS AGO 4

623) How many times during the last 12 months did you have sexual intercourse with this person?
IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE. IF NUMBER OF TIMES IS 96 OR MORE, WRITE 95.

NUMBER OF TIMES ____

624) How old is this person?

AGE OF PARTNER ____
DON'T KNOW 98

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

YES 1 (GO BACK TO 616 IN NEXT COLUMN)
NO 2 (GO TO 627)

626) 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 LAST 12 MONTHS ____
DON'T KNOW 98

627) 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 IN LIFETIME ____
DON'T KNOW 98

628) PRESENCE OF OTHERS DURING THIS SECTION:

CHILDREN UNDER 10
YES 1
NO 2
MALE ADULTS
YES 1
NO 2
FEMALE ADULTS
YES 1
NO 2

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

YES 1
NO 2 (GO TO 632)

630) Where is that? Any other place?
PROBE TO IDENTITY THE TYPE OF SOURCE. IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

(NAME OF PLACE(S)) ____
PUBLIC SECTOR
GOVERNMENT HOSPITAL A
FAMILY PLANNING CLINIC B
GOVERNMENT HEALTH CENTER C
FAMILY PLANNING CLINIC D
COMMUNITY LIAISON E
OTHER PUBLIC SECTOR (SPECIFY) F
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC G
PHARMACY H
NGO I
MOBILE CLINIC J
FIELDWORKER K
OTHER PRIVATE MEDICAL SECTOR (SPECIFY) L
OTHER SOURCE
SHOP M
BAR/NIGHTCLUB N
KIOSK O
TABLIER P
FRIEND/ACQUAINTANCE/RELATIVES Q
OTHER (SPECIFY) X

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

YES 1
NO 2
DON'T KNOW/UNSURE 8

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

YES 1
NO 2 (GO TO 701)

633) Where is that? Any other place?
PROBE TO IDENTITY THE TYPE OF SOURCE. IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

(NAME OF PLACE(S)) ____
PUBLIC SECTOR
GOVERNMENT HOSPITAL A
FAMILY PLANNING CLINIC B
GOVERNMENT HEALTH CENTER C
FAMILY PLANNING CLINIC D
COMMUNITY LIAISON E
OTHER PUBLIC SECTOR (SPECIFY) F
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC G
PHARMACY H
NGO I
MOBILE CLINIC J
FIELDWORKER K
OTHER PRIVATE MEDICAL SECTOR (SPECIFY) L
OTHER SOURCE
SHOP M
BAR/NIGHTCLUB N
KIOSK O
TABLIER P
FRIEND/ACQUAINTANCE/RELATIVES Q
OTHER (SPECIFY) X

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

YES 1
NO 2
DON'T KNOW/UNSURE 8

SECTION 7. FERTILITY PREFERENCES

701) CHECK 304:

NEITHER STERILIZED
HE OR SHE STERILIZED (GO TO 712)

702) CHECK 226:

PREGNANT
NOT PREGNANT OR UNSURE (GO TO 704)

703) 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 ANOTHER CHILD 1 (GO TO 705)
NO MORE 2 (GO TO 711)
UNDECIDED/DON'T KNOW 8 (GO TO 711)

704) 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?

HAVE (A/ANOTHER) CHILD 1
NO MORE/NONE 2 (GO TO 707)
SAYS SHE CAN'T GET PREGNANT 3 (GO TO 712)
UNDECIDED/DON'T KNOW (GO TO 710)

705) CHECK 226:
NOT PREGNANT OR NOT SURE: 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 710)
SAYS SHE CAN'T GET PREGNANT 994 (GO TO 712)
AFTER MARRIAGE 995 (GO TO 710)
OTHER (SPECIFY) 996 (GO TO 710)
DON'T KNOW 998 (GO TO 710)

706) CHECK 226:

NO PREGNANT OR UNSURE
PREGNANT (GO TO 711)

707) CHECK 303:
USING A CONTRACEPTIVE METHOD?

NOT CURRENTLY USING
CURRENTLY USING (GO TO 712)

708) CHECK 705:

NOT ASKED
24 OR MORE MONTHS OR 02 OR MORE YEARS
00-23 MONTHS OR 00-01 YEARS (GO TO 711)

709) CHECK 704:
WANTS TO HAVE A/ANOTHER CHILD: You have said that you do not want (a/another) child soon. Can you tell me why you are not using a method to prevent pregnancy? Any other reason?

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

RECORD ALL REASONS MENTIONED.

NOT MARRIED A
FERTILITY-RELATED REASONS
NOT HAVING SEX B
INFREQUENT SEX C
MENOPAUSAL/HYSTERECTOMY D
CAN'T GET PREGNANT E
NOT MENSTRUATED SINCE LAST BIRTH F
BREASTFEEDING G
UP TO GOD/FATALISTIC H
OPPOSITION TO USE
RESPONDENT OPPOSED I
HUSBAND/PARTNER OPPOSED J
OTHERS OPPOSED K
RELIGIOUS PROHIBITION L
LACK OF KNOWLEDGE
KNOWS NO METHOD M
KNOWS NO SOURCE N
METHOD-RELATED REASONS
SIDE EFFECTS/HEALTH CONCERNS O
LACK OF ACCESS/TOO FAR P
COSTS TOO MUCH Q
PREFERRED METHOD NOT AVAILABLE R
NO METHOD AVAILABLE S
INCONVENIENT TO USE T
INTERFERES WITH BODY'S NORMAL PROCESSES U
OTHER (SPECIFY) X
DON'T KNOW Z

710) CHECK 303: USING A CONTRACEPTIVE METHOD?

NOT ASKED
NO, NOT CURRENTLY USING
YES, CURRENTLY USING (GO TO 712)

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

YES 1
NO 2
DON'T KNOW 8

712) 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.

NONE 00 (GO TO 714)
NUMBER ____
OTHER (SPECIFY) 96 (GO TO 714)

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

BOYS ____
GIRLS ____
EITHER ____
OTHER (SPECIFY) 96

714) In the last few months have you:
a) Heard about family planning on the radio?
b) Seen anything about family planning on the television?
c) Read about family planning in a newspaper or magazine?

A) RADIO
YES 1
NO 2
B) TELEVISION
YES 1
NO 2
C) NEWSPAPER OR MAGAZINE
YES 1
NO 2

716) CHECK 601:

YES, CURRENTLY MARRIED
YES, CURRENTLY LIVING WITH A MAN
NO, NOT IN UNION (GO TO 801)

717) CHECK 303: USING A CONTRACEPTIVE METHOD?

CURRENTLY USING ____
NOT CURRENTLY USING OR NOT ASKED (GO TO 720)

718) Would you say that using contraception is mainly your decision, mainly 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

719) CHECK 304:

NEITHER STERILIZED
HE OR SHE STERILIZED (GO TO 801)

720) Does your (husband/partner) want the same number of children that you want, or does he want more or fewer than you want?

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

SECTION 8. HUSBAND'S BACKGROUND AND WOMAN'S WORK

801) CHECK 601 and 602:

CURRENTLY MARRIED/LIVING WITH A MAN
FORMERLY MARRIED/LIVING WITH A MAN (GO TO 803)
NEVER MARRIED AND NEVER LIVED WITH A MAN (GO TO 807)

802) How old was your (husband/partner) on his last birthday?

AGE IN COMPLETED YEARS ____

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

YES 1
NO 2 (GO TO 806)

804) What is the highest level of school you attended: Primary, Secondary, or higher?

PRIMARY 1
SECONDARY 2
HIGHER 3
DON'T KNOW 8 (GO TO 806)

805) What is the highest (grade/form/year) you completed at this level?*
IF COMPLETED LESS THAN ONE YEAR AT THAT LEVEL, RECORD 0

GRADE/FORM/YEAR ____
DON'T KNOW 98

806) CHECK 801:

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 ____

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

YES 1 (GO TO 811)
NO 2

808) 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. In the last seven days, have you done any of these things or any other work?

YES 1 (GO TO 811)
NO 2

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

YES 1 (GO TO 811)
NO 2

810) Have you done any work in the last 12 months?

YES 1
NO 2 (GO TO 815)

811) What is your occupation, that is, what kind of work do you mainly do?

812) 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

813) 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

814) Are you paid or do you ear 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 3
NOT PAID 4

815) CHECK 601:

CURRENTLY MARRIED/LIVING WITH A MAN
NOT IN UNION (GO TO 823)

816) CHECK 814:

CODE 1 OR 2 CIRCLED
OTHER (GO TO 819)

817) Who usually decides how the money you earn will be used: you, your (husband/partner), or you and your (husband/partner) jointly?

RESPONDENT 1
HUSBAND/PARTNER 2
RESPONDENT AND HUSBAND/PARTNER JOINTLY 3
OTHER (SPECIFY) 6

818) Would you say that the money that you earn is more than what your (husband/partner) earns, less than what he earns, or about the same?

MORE THAN HIM 1
LESS THAN HIM 2
ABOUT THE SAME 3
HUSBAND/PARTNER HAS NO EARNINGS 4 (GO TO 820)
DON'T KNOW 8

819) Who usually decides how the money your (husband/partner) earnings will be used: you, your (husband/partner), or you and your (husband/partner) jointly?

RESPONDENT 1
HUSBAND/PARTNER 2
RESPONDENT AND HUSBAND/PARTNER JOINTLY 3
HUSBAND HAS NO EARNINGS 4
OTHER (SPECIFY) 6

820) Who usually makes decisions about health care for yourself: you, your (husband/partner), you and your (husband/partner) jointly, or someone else?

RESPONDENT 1
HUSBAND/PARTNER 2
RESPONDENT AND HUSBAND/PARTNER JOINTLY 3
SOMEONE ELSE 4
OTHER (SPECIFY) 6

821) Who usually makes decisions about making major household purchases?

RESPONDENT 1
HUSBAND/PARTNER 2
RESPONDENT AND HUSBAND/PARTNER JOINTLY 3
SOMEONE ELSE 4
OTHER (SPECIFY) 6

822) Who usually makes decisions about visits to your family or relatives?

RESPONDENT 1
HUSBAND/PARTNER 2
RESPONDENT AND HUSBAND/PARTNER JOINTLY 3
SOMEONE ELSE 4
OTHER (SPECIFY) 6

823) Do you own this or any other house either alone or jointly with someone else?

ALONE ONLY 1
JOINTLY ONLY 2
BOTH ALONE AND JOINTLY 3
DOES NOT OWN 4

824) Do you own any land either alone or jointly with someone else?

ALONE ONLY 1
JOINTLY ONLY 2
BOTH ALONE AND JOINTLY 3
DOES NOT OWN 4

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

CHILDREN UNDER 10
PRESENT/LISTEN 1
PRESENT/NOT LISTEN 2
NOT PRESENT 3
HUSBAND
PRESENT/LISTEN 1
PRESENT/NOT LISTEN 2
NOT PRESENT 3
OTHER MALES
PRESENT/LISTEN 1
PRESENT/NOT LISTEN 2
NOT PRESENT 3
OTHER FEMALES
PRESENT/LISTEN 1
PRESENT/NOT LISTEN 2
NOT PRESENT 3

826) 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?

A) GOES OUT
YES 1
NO 2
DON'T KNOW 8
B) NEGLECTS CHILDREN
YES 1
NO 2
DON'T KNOW 8
C) ARGUES
YES 1
NO 2
DON'T KNOW 8
D) REFUSES SEX
YES 1
NO 2
DON'T KNOW 8
E) BURNS FOOD
YES 1
NO 2
DON'T KNOW 8

DON'T KNOW 8

Section 9. HIV/AIDS

901) Now I would like to talk about something else.
Have you ever heard of an illness called AIDS?

YES 1
NO 2 (GO TO 937)

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

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

904) 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

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

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2
DON'T KNOW 8

908) Can the virus that causes AIDS be transmitted from a mother to a baby?
a) During pregnancy?
b) During delivery?
c) By breastfeeding?

A) DURING PREGNANCY
YES 1
NO 2
DON'T KNOW 8
B) DURING DELIVERY
YES 1
NO 2
DON'T KNOW 8
C) BREASTFEEDING
YES 1
NO 2
DON'T KNOW 8

909) CHECK 908:

AT LEAST ONE YES
OTHER (GO TO 911)

910) 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

911) CHECK 208 and 215:

LAST BIRTH SINCE JANUARY 2011
NO BIRTHS (GO TO 926)
LAST BIRTH BEFORE JANUARY 2011 (GO TO 926)

912) CHECK 408 FOR LAST BIRTH:

HAD ANTENATAL CARE
NO ANTENATAL CARE (GO TO 920)

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

914) During any of the antenatal visits for your last birth were you given any information about:
a) Babies getting HIV from their mother?
b) Things that you can do to prevent getting HIV?
c) Getting tested for HIV?

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

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

YES 1
NO 2

916) 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 920)

917) Where was the test done?
PROBE TO IDENTIFY THE TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE

(NAME OF PLACE) ____
PUBLIC SECTOR
GOVERNMENT HOSPITAL 11
GOVERNMENT HEALTH CENTER 12
STAND-ALONG VCT CENTER 13
FAMILY PLANNING CLINIC 14
MOBILE VCT CLINIC 15
FIELDWORKER 16
TRAVELING TREATMENT CENTER 17
OTHER PUBLIC SECTOR (SPECIFY) 18
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/MEDICAL POLYCLINIC 21
MOBILE VCT CLINIC 22
TRAVELING TREATMENT CENTER 23
YOUTH CENTER 24
OTHER PRIVATE MEDICAL SECTOR (SPECIFY) 26
OTHER (SPECIFY) 96

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

YES 1
NO 2 (GO TO 924)

919) All women are supposed to receive counseling after being tested. After you were tested, did you receive counseling?

YES 1
NO 2
DON'T KNOW 8
ALL GO TO 924

920) CHECK 434 FOR LAST BIRTH

ANY CODE 21-36 CIRCLED
OTHER (GO TO 926)

921) Between the time you went for delivery but before the baby was born, were you offered a test for the AIDS virus?

YES 1
NO 2

922) I don't want to know the results, but were you tested for the AIDS virus at that time?

YES 1
NO 2 (GO TO 926)

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

YES 1
NO 2

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

YES 1 (GO TO 927)
NO 2

925) How many months ago was your most recent HIV test?

MONTHS AGO ____
TWO OR MORE YEAR AGO 96
ALL GO TO 932

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

YES 1
NO 2 (GO TO 930)

927) How many months ago was your most recent HIV test?

MONTHS AGO
TWO OR MORE YEARS AGO 96

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

YES 1
NO 2

929) Where was the test done?
PROBE TO IDENTIFY THE TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE

(NAME OF PLACE) ____
PUBLIC SECTOR
GOVERNMENT HOSPITAL 11
GOVERNMENT HEALTH CENTER 12
STAND-ALONG VCT CENTER 13
FAMILY PLANNING CLINIC 14
MOBILE VCT CLINIC 15
FIELDWORKER 16
TRAVELING TREATMENT CENTER 17
OTHER PUBLIC SECTOR (SPECIFY) 18
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/MEDICAL POLYCLINIC 21
MOBILE VCT CLINIC 22
TRAVELING TREATMENT CENTER 23
YOUTH CENTER 24
OTHER PRIVATE MEDICAL SECTOR (SPECIFY) 26
OTHER (SPECIFY) 96
ALL GO TO 932

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

YES 1
NO 2 (GO TO 932)

931) Where is that? Any other place?
PROBE TO IDENTIFY THE TYPE OF SOURCE.
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

(NAME OF PLACE) ____
PUBLIC SECTOR
GOVERNMENT HOSPITAL A
GOVERNMENT HEALTH CENTER B
STAND-ALONG VCT CENTER C
FAMILY PLANNING CLINIC D
MOBILE VCT CLINIC E
FIELDWORKER F
TRAVELING TREATMENT CENTER G
OTHER PUBLIC SECTOR (SPECIFY) H
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/MEDICAL POLYCLINIC I
MOBILE VCT CLINIC J
TRAVELING TREATMENT CENTER K
YOUTH CENTER L
OTHER PRIVATE MEDICAL SECTOR (SPECIFY) M
OTHER (SPECIFY) X

932) 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

933) 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/NOT SURE/DEPENDS 8

934) If a member of your family became sick with the virus that causes AIDS, would you be willing to care for her or him in your own household?

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

935) 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 BE ALLOWED 2
DON'T KNOW/NOT SURE/DEPENDS 8

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

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

937) CHECK 901:
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

938) CHECK 613:

HAS HAD SEXUAL INTERCOURSE
NEVER HAD SEXUAL INTERCOURSE (GO TO 946)

939) CHECK 937: Heard about other sexually transmitted infections?

YES
NO (GO TO 941)

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

YES 1
NO 2
DON'T KNOW 8

941) 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

942) 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

943) CHECK 940, 941, and 942:

HAS HAD AN INFECTION (ANY 'YES')
HAS NOT HAD AN INFECTION OR DOES NOT KNOW (GO TO 946)

944) The last time you had (infection from 940/941/942), did you seek any kind of advice or treatment?

YES 1
NO 2 (GO TO 946)

945) Where did you go? Any other place?
PROBE TO IDENTIFY THE TYPE OF SOURCE. IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE

(NAME OF PLACE(S)) ____

RECORD ALL MENTIONED.

PUBLIC SECTOR
GOVERNMENT HOSPITAL A
GOVERNMENT HEALTH CENTER B
STAND-ALONG VCT CENTER C
FAMILY PLANNING CLINIC D
MOBILE VCT CLINIC E
FIELDWORKER F
TRAVELING TREATMENT CENTER G
OTHER PUBLIC SECTOR (SPECIFY) H
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/MEDICAL POLYCLINIC I
MOBILE VCT CLINIC J
TRAVELING TREATMENT CENTER K
YOUTH CENTER L
OTHER PRIVATE MEDICAL SECTOR (SPECIFY) M
OTHER (SPECIFY) X

946) 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

947) Is a wife justified in refusing to have sex with her husband when she knows he has sex with (another woman, women other than his wife/wives)?

YES 1
NO 2
DON'T KNOW 8

948) CHECK 601:

CURRENTLY MARRIED/LIVING WITH A HUSBAND
NOT IN UNION (GO TO 1001)

949) Can you say no to your (husband/partner) if you do not want to have sexual intercourse?

YES 1
NO 2
DEPENDS/NOT SURE 8

950) Could you ask your (husband/partner) to use a condom if you wanted him to?

YES 1
NO 2
DEPENDS/NOT SURE 8

SECTION 10. OTHER HEALTH ISSUES

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

NUMBER OF INJECTIONS ____
NONE 00 (GO TO 1004)

1002) Among these injections, how many were administered by a doctor, a nurse, a pharmacist, a dentist, or another healthcare worker?
IF THE NUMBER OF INJECTIONS IS OVER 90 OR IF THERE WERE DAILY INJECTIONS IN THE LAST 3 MONTHS OR LONGER, RECORD 90.
IF THE RESPONSE IS NOT NUMERIC, PROBE TO OBTAIN AN ESTIMATE.

NUMBER OF INJECTIONS ____
NONE 00 (GO TO 1004)

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

YES 1
NO 2
DON'T KNOW 8

1004) Do you currently smoke cigarettes?

YES 1
NO 2 (GO TO 1006)

1005) In the last 24 hours, how many cigarettes did you smoke?

NUMBER OF CIGARETTES ____

1005A) The last time you bought cigarettes for personal use, how many cigarettes did you buy?

NUMBER OF CIGARETTES ____

1005B) In total, how much did you spend on this purchase?
AMOUNT IN CONGOLESE FRANCS

PRICE ____

1006) Do you currently smoke or use any (other) type of tobacco?

YES 1
NO 2 (GO TO 1007B)

1007) What (other) type of tobacco do you currently smoke or use?
RECORD ALL MENTIONED.

PIPE A
CHEWING TOBACCO B
SNUFF C
NATURAL HAND ROLLED TOBACCO D
OTHER (SPECIFY) X

1007A) Do you currently consume non-smoking tobacco every day, less than every day, or not at all?

EVERY DAY 1
LESS THAN EVERY DAY 2
NOT AT ALL 3

1007B) CHECK 1004 and 1006:

AT LEAST ONE YES
NOT A SINGLE YES (GO TO 1007D)

1007C) In the last 12 months, have you tried to stop smoking?

YES 1
NO 2

1007D) In the last 30 days, has anyone smoked inside of the places where you work?

YES 1
NO 2
DON'T WORK 3
DON'T KNOW 8

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

a) Getting permission to go to the doctor?
b) Getting money needed for advice or treatment?
c) The distance to the health facility?
d) Not wanting to go alone?

A) PERMISSION TO GO
BIG PROBLEM 1
NOT A BIG PROBLEM 2
B) GETTING MONEY
BIG PROBLEM 1
NOT A BIG PROBLEM 2
C) DISTANCE
BIG PROBLEM 1
NOT A BIG PROBLEM 2
D) GO ALONE
BIG PROBLEM 1
NOT A BIG PROBLEM 2

1009) Are you covered by any health insurance?

YES 1
NO 2 (GO TO 1011)

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

MUTUAL HEALTH ORGANIZATION A
HEALTH INSURANCE THROUGH EMPLOYER B
SOCIAL SECURITY C
OTHER PRIVATELY PURCHASED COMMERCIAL HEALTH INSURANCE D
OTHER (SPECIFY) X

SECTION 11. MATERNAL MORTALITY

1101) Now I would like to ask you some questions about your brothers and sisters, that is, all of the children born to your natural mother.
Did your mother give birth to any children other than yourself?

YES 1
NO 2 (GO TO 1101H)

1101B) How many boys did your mother have who are still living?

BOYS LIVING ____

1101C) Other than yourself, how many girls did your mother have who are still living?

GIRLS LIVING ____

1101D) How many boys did your mother have who died?

BOYS DIED ____

1101E) How many girls did your mother have who died?

GIRLS DIED ____

1101F) 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 1101H)

1101G) How many other children did your mother give birth to, who you don't know if they are living or dead?

OTHER CHILDREN ____

1101H) ADD THE ANSWERS FORM 1101, 1102, 1103, 1104, AND 1106
ADD 1 (THE RESPONDENT) AND RECORD THE TOTAL

TOTAL ____

1101I) CHECK 1101H:
Just to make sure that I've understood, including yourself, your mother gave birth to _____ children total. Is that correct?

YES
NO (PROBE AND CORRECT 1101A-1101H AS NECESSARY)

1102) CHECK 1101h:

TWO OR MORE BIRTHS
ONLY ONE BIRTH (RESPONDENT ONLY) (GO TO 1201)

1103) 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 brothers and sisters, whether they are still alive or not, starting with the oldest.
RECORD THE NAME OF ALL BROTHERS AND SISTERS FROM THE SAME BIOLOGICAL MOTHER.

1104) What was the name given to your oldest (next oldest) brother or sister?

NAME ____

1105) Is (NAME) male or female?

MALE 1
FEMALE 2

1106) Is (NAME) still alive?

YES 1
NO 2 (GO TO 1108)
DON'T KNOW 8 (GO TO NEXT SIBLING)

1107) How old is (NAME)?

AGE ____ (GO TO NEXT SIBLING)

1108) How many years ago did (NAME) die?

YEARS AGO ____

1109) How old was (NAME) when he/she died?
IF DON'T KNOW, PROBE:
Did (NAME) die before the age of 12?
IF YES, RECORD 95.
IF NO, ASK OTHER QUESTIONS TO GET AN ESTIMATE, FOR EXAMPLE: Did (NAME) die before getting married?

AGE AT DEATH ____

IF MAN, OR WOMAN DECEASED BEFORE AGED 12, GO TO NEXT SIBLING.

1110) Was (NAME) pregnant when she died?

YES 1 (GO TO 1113)
NO 2

1111) Did (NAME) die during childbirth?

YES 1 (GO TO 1113)
NO 2

1112) Did (NAME) die within two months after the end of a pregnancy or childbirth?

YES 1
NO 2

1113) How many live born children did (NAME) give birth to during her lifetime?

CHILDREN ____ (GO TO NEXT SIBLING, IF NO MORE BROTHERS OR SISTERS, GO TO 1201)

SECTION 12. CHILD DEVELOPMENT AND EARLY LEARNING

1201) CHECK COVER PAGE OF QUESTIONNAIRE:
HOUSEHOLD SELECTED FOR MEN'S SURVEY, ANEMIA, MALARIA, HIV, AND VACCINES TESTS AND ANTHROPOMETRIC MEASUREMENTS

NO
YES (GO TO 1336)

1201A) CHECK QUESTIONS 217 and 218:
DOES A CHILD BETWEEN AGES 0 AND 4 LIVE IN THIS HOUSEHOLD (217 IS 0-4 YEARS COMPLETED AND 218 IS 1)?

YES
NO 2 (GO TO 1300)

1202) CHECK QUESTION 217:
SELECT THE YOUNGEST CHILD BETWEEN AGES 0 AND 4, RECORD HIS/HER NAME AND LINE NUMBERS

NAME OF YOUNGEST CHILD FROM QUESTION 212 ____
LINE NUMBER OF YOUNGEST CHILD FROM QUESTION 219 ____

1203) Now I would like to ask you some questions about (NAME OF CHILD FROM QUESTION 1202), your youngest child between ages 0 and 4.

1203A) Does (NAME) have a birth certificate?

YES 1 (GO TO 1204)
NO 2
DON'T KNOW 8 (GO TO 1204)

1203B) Why doesn't (NAME) have a birth certificate?

COSTS TOO MUCH 1
TOO FAR 2
DIDN'T WANT TO PAY FEES 3
FEES FROM AGENT SEEMED ILLEGAL 4
BIRTH CERTIFICATE NOT COMPLETED BY PARENTS 5
DIDN'T KNOW WHERE TO DO IT 6
OTHER (SPECIFY) 7
DON'T KNOW 8

1204) How many children's books and picture books do you have for (NAME)?

NONE 00
NUMBER OF CHILDREN'S BOOKS 0____
TEN OR MORE BOOK 10

1205) I would like to ask you what objects (NAME) uses to play with while at home.
Does he/she play with:
a) Homemade toys (like dolls, cars, or other homemade toys)?
b) Toys from a store or a manufacture?
c) Household objects (like bowls or pots), or objects found outside (like sticks, stones, animals, shells, or leaves)?

A) HOMEMADE TOYS
YES 1
NO 2
DON'T KNOW 8
B) STORE
YES 1
NO 2
DON'T KNOW 8
C) HOUSEHOLD OR OUTSIDE
YES 1
NO 2
DON'T KNOW 8

IF THE RESPONDENT SAYS "YES" TO ONE OF THE ABOVE CATEGORIES, PROBE TO DETERMINE PRECISELY WHAT THE CHILD PLAYS WITH TO BE CERTAIN OF THE RESPONSE.

1206) Sometimes the adults who take care of the children have to leave the house to go shopping, do the laundry, or for other reasons and have to leave the young children.
During the last week, how many days was (NAME):
a) Left alone for more than one hour?
b) Left in the care of another child (meaning someone under 10 years old) for more than one hour?

Number of days alone for more than one hour ____
Number of days left with child for more than one hour ____

1207) CHECK QUESTION 217 and 218:
DOES A CHILD AGES 3 OR 4 LIVE IN THIS HOUSEHOLD (217 IS 3 OR 4 YEARS COMPLETED AND 218 IS 1)?

YES
NO (GO TO 1300)

1208) CHECK 217:
SELECT THE YOUNGEST CHILD OF 3 OR 4 YEARS, RECORD HIS/HER NAME AND LINE NUMBERS

NAME OF YOUNGEST CHILD OF 3 OR 4 YEARS FROM QUESTION 212 ____
LINE NUMBER OF YOUNGEST CHILD FROM 219 ____

1209) Now I would like to ask you some questions about (name of child from QUESTION 1208), your youngest child of 3 or 4 years.

1210) Is (NAME) in a preschool education program or an early learning class, in a public or private establishment, including nursery school or a community child-care center?

YES 1
NO 2
DON'T KNOW 8

1211) Within the last seven days, about how many hours did (NAME) go to that place?

NOMBRE D’HEURES

1212) During the last three days did you or a member of your family age 15 or old participate with (NAME) in one of the following activities:
IF YES, ASK: Who participated in this activity with (NAME)?
CIRCLE ALL MENTIONED.

a) Read books or looked at illustrated books with (NAME)?
b) Told stories to (NAME)?
c) Sang songs to (NAME), or with (NAME), including lullabies?
d) Took (NAME) for a walk outside of the house, the residence, the courtyard or the enclosure wall?
e) Played with (NAME)?
f) Spent time with (NAME), naming, counting, and/or drawing?

READ
IF YES, ASK: Who participated in this activity with (NAME)?
YES 1
NO 2
MOTHER A
FATHER B
OTHER PERSON X
NO ONE Y
TOLD STORIES
IF YES, ASK: Who participated in this activity with (NAME)?
MOTHER A
FATHER B
OTHER PERSON X
NO ONE Y
SANG SONGS
IF YES, ASK: Who participated in this activity with (NAME)?
MOTHER A
FATHER B
OTHER PERSON X
NO ONE Y
WALK
IF YES, ASK: Who participated in this activity with (NAME)?
MOTHER A
FATHER B
OTHER PERSON X
NO ONE Y
PLAYED
IF YES, ASK: Who participated in this activity with (NAME)?
MOTHER A
FATHER B
OTHER PERSON X
NO ONE Y
SPENT TIME WITH
IF YES, ASK: Who participated in this activity with (NAME)?
MOTHER A
FATHER B
OTHER PERSON X
NO ONE Y

1213) Now I would like to ask you some questions about the health and development of your child. Children do not all develop in the same manner and at the same speed. Some, for example, walk earlier than others. These questions relate to several aspects of your child's development.

Does (NAME) know or can he/she recite at least ten letters from the alphabet?

YES 1
NO 2
DON'T KNOW 8

1214) Can (NAME) read at least four simple, common words?

YES 1
NO 2
DON'T KNOW 8

1215) Can (NAME) list and recognize all digits from 1 to 10?

YES 1
NO 2
DON'T KNOW 8

1216) Can (NAME) grasp with two fingers a small object from the ground, like a stick or a pebble?

YES 1
NO 2
DON'T KNOW 8

1217) Is (NAME) ever too sick to play?

YES 1
NO 2
DON'T KNOW 8

1218) Is (NAME) able to follow simple instructions to do something correctly?

YES 1
NO 2
DON'T KNOW 8

1219) When you give (NAME) something to do, is he/she able to do it independently?

YES 1
NO 2
DON'T KNOW 8

1220) Does (NAME) get along well with other children?

YES 1
NO 2
DON'T KNOW 8

1221) Does (NAME) kick, bit, or hit other children or adults?

YES 1
NO 2
DON'T KNOW 8

1222) Is (NAME) easily distracted?

YES 1
NO 2
DON'T KNOW 8

SECTION 13. DOMESTIC VIOLENCE

1300) CHECK COVER PAGE OF HOUSEHOLD QUESTIONNAIRE

WOMAN SELECTED FOR THIS SECTION
WOMAN NOT SELECTED (GO TO 1336)

1301) CHECK FOR PRESENCE OF OTHERS:
DO NOT CONTINUE UNTIL PRIVACY IS ENSURED.

PRIVACY OBTAINED 1
PRIVACY NOT POSSIBLE (RETURN ONCE YOU ARE SURE TO BE ALONE WITH RESPONDENT) 2 (GO TO 1335)

READ TO THE RESPONDENT:
Now I would like to ask you questions about some other important aspects of a woman's life. You may find some of these questions 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 and no one else in your household will know that you were asked these questions.

1302) CHECK 601 and 602:

CURRENTLY MARRIED/LIVING WITH A MAN
FORMERLY MARRIED/LIVED WITH A MAN (READ IN PAST TENSE AND USE 'LAST' WITH HUSBAND/PARTNER)
NEVER MARRIED/NEVER LIVED WITH A MAN (GO TO 1316)

1303) First, I am going to ask you about some situations which happen to some women. Please tell me if these apply to your relationship with your (last) husband/partner?
a) He (is/was) jealous or angry if you (talk/talked) to other men?
b) He frequently (accuses/accused) you of being unfaithful?
c) He (does/did) not permit you to meet your female friends?
d) He (tries/tried) to limit your contact with your family?
e) He (insists/insisted) on knowing where you (are/where) at all times?

A) JEALOUS
YES 1
NO 2
DON'T KNOW 8
B) ACCUSES
YES 1
NO 2
DON'T KNOW 8
C) NOT MEET FRIENDS
YES 1
NO 2
DON'T KNOW 8
D) NO FAMILY
YES 1
NO 2
DON'T KNOW 8
E) WHERE YOU ARE
YES 1
NO 2
DON'T KNOW 8

1304) Now if you will permit me, I need to ask some more questions about your relationship with your (last) husband/partner.
A) (Does/did) your last husband/partner ever:

a) Say or do something to humiliate you in front of others?
YES 1 (GO TO B)
NO 2
b) Threaten to hurt or harm you or someone you care about?
YES 1 (GO TO B)
NO 2
c) Insult you or make you feel bad about yourself?
YES 1 (GO TO B)
NO 2

B) How often did this happen during the last 12 months: often, only sometimes, or not at all?

a) Say or do something to humiliate you in front of others?
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
b) Threaten to hurt or harm you or someone you care about?
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
c) Insult you or make you feel bad about yourself?
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3

1305) A) Did your (last) (husband/partner) ever do any of the following things to you:

a) Push you, shake you, or throw something at you?
YES 1 (GO TO B)
NO 2
b) Slap you?
YES 1 (GO TO B)
NO 2
c) Twist your arm or pull your hair?
YES 1 (GO TO B)
NO 2
d) Punch you with his fist or with something that could hurt you?
YES 1 (GO TO B)
NO 2
e) Kick you, drag you, or beat you up?
YES 1 (GO TO B)
NO 2
f) Try to chock you or burn you?
YES 1 (GO TO B)
NO 2
g) Threaten you with a knife, gun, or other type of weapon?
YES 1 (GO TO B)
NO 2
h) Physically force you to have sexual intercourse with him even when you did not want to?
YES 1 (GO TO B)
NO 2
i) Physically force you to perform other sexual acts you did not want to?
YES 1 (GO TO B)
NO 2
j) Force you with threats or in any other way to perform sexual acts you did not want to?
YES 1 (GO TO B)
NO 2

B) How often did this happen during the last 12 months: often, only sometimes, or not at all?

a) Push you, shake you, or throw something at you?
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
b) Slap you?
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
c) Twist your arm or pull your hair?
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
d) Punch you with his fist or with something that could hurt you?
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
e) Kick you, drag you, or beat you up?
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
f) Try to chock you or burn you?
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
g) Threaten you with a knife, gun, or other type of weapon?
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
h) Physically force you to have sexual intercourse with him even when you did not want to?
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
i) Physically force you to perform other sexual acts you did not want to?
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3
j) Force you with threats or in any other way to perform sexual acts you did not want to?
OFTEN 1
SOMETIMES 2
NOT IN LAST 12 MONTHS 3

1306) CHECK 1305 (A-J):

AT LEAST ONE YES
NOT A SINGLE YES (GO TO 1309)

1307) How long after you first got married to/started living with your (last) husband/partner did (this/any of these things) first happen?
IF LESS THAN ONE YEAR, RECORD 00.

NUMBER OF YEARS ____
BEFORE MARRIAGE/BEFORE LIVING TOGETHER 95

1308) Did the following ever happen as a result of what your (last) husband/partner did to you:
a) You had cuts, bruises, or aches?
b) You had eye injuries, sprains, dislocations, or burns?
c) You had deep wounds, broken bones, broken teeth, or any other serious injury?

A) CUTS, BRUISES, ACHES
YES 1
NO 2
B) INJURIES
YES 1
NO 2
C) SERIOUS INJURIES
YES 1
NO 2

1309) Have you ever hit, slapped, kicked or done anything else to physically hurt your (last) husband/partner at times when he was not already beating or physically hurting you?

YES 1
NO 2 (GO TO 1311)

1310) In the last 12 months, how often have you done this to your (last) husband/partner: often, only sometimes, or not at all?

OFTEN 1
SOMETIMES 2
NOT AT ALL 3

1311) Does (did) your husband/partner drink (alcohol)?

YES 1
NO 2 (GO TO 1313)

1312) How often does (did) he get drunk: often, only sometimes, or never?

OFTEN 1
SOMETIMES 2
NEVER 3

1313) Are (were) you afraid of your (last) (husband/partner): many times, sometimes, or never?

MANY TIMES AFRAID 1
SOMETIMES AFRAID 2
NEVER AFRAID 3

1314) CHECK 609:

MARRIED MORE THAN ONCE
MARRIED ONLY ONCE (GO TO 1316)

1315) A) So far we have been talking about the behavior of your (current/last) (husband/partner). Now I want to ask you about the behavior of any previous (husband/partner).

a) Did any previous (husband/partner) ever hit, slap, kick or do anything else to hurt you physically?
YES 1 (GO TO B)
NO 2
b) Did any previous (husband/partner) physically force you to have intercourse or perform any other sexual acts against your will?
YES 1
NO 2

B) How long ago did this last happen?

a) Did any previous (husband/partner) ever hit, slap, kick or do anything else to hurt you physically?
0-11 MONTHS AGO
12 OR MORE MONTHS AGO
DON'T REMEMBER
b) Did any previous (husband/partner) physically force you to have intercourse or perform any other sexual acts against your will?
0-11 MONTHS AGO
12 OR MORE MONTHS AGO
DON'T REMEMBER

1316) CHECK 601 AND 602:
EVER MARRIED/EVER LIVED WITH A MAN:
From the time you were 15 years old has anyone other than (your/any) (husband/partner) hit you, slapped you, kicked you, 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 hit you, slapped you, kicked you, or done anything else to hurt you physically?

YES 1
NO 2 (GO TO 1319)
REFUSED TO ANSWER/NO ANSWER 6 (GO TO 1319)

1317) Who has physically hurt you in this way? Anyone else?
RECORD ALL MENTIONED

MOTHER/FATHER'S WIFE A
FATHER/MOTHER'S HUSBAND B
SISTER/BROTHER C
DAUGHTER/SON D
OTHER RELATIVE E
CURRENT BOYFRIEND F
EX-BOYFRIEND G
MOTHER-IN-LAW H
FATHER-IN-LAW I
OTHER IN-LAWS J
TEACHER K
EMPLOYER/SOMEONE AT WORK L
POLICE/SOLDIER M
OTHER (SPECIFY) X

1318) In the last 12 months, how often has (this person/have these persons) physically hurt you: often, only sometimes, or not at all?

OFTEN 1
SOMETIMES 2
NOT AT ALL 3

1319) CHECK 201, 226, and 230:

EVER BEEN PREGNANT (YES TO 201 OR 226 OR 230)
NEVER BEEN PREGNANT (GO TO 1322)

1320) Has anyone ever hit, slapped, kicked or done anything else to hurt you physically while you were pregnant?

YES 1
NO 2 (GO TO 1322)

1321) 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/STEP-MOTHER B
FATHER/STEP-FATHER C
SISTER/BROTHER D
DAUGHTER/SON E
OTHER RELATIVE F
FORMER HUSBAND/PARTNER G
CURRENT BOYFRIEND H
EX-BOYFRIEND I
MOTHER-IN-LAW J
FATHER-IN-LAW K
OTHER IN-LAWS L
TEACHER M
EMPLOYER/SOMEONE AT WORK N
POLICE/SOLDIER O
OTHER (SPECIFY) X

1322) CHECK 601 AND 602:

EVER MARRIED/EVER LIVED WITH A MAN
NEVER MARRIED/NEVER LIVED WITH A MAN (GO TO 1324)

1323) Now I want to ask you about things that may have been done to you by someone other than (your/any) (husband/partner).

At any time in your life, as a child or as an adult, has anyone ever forced you in any way to have sexual intercourse or perform any other sexual acts when you did not want to?

YES 1 (GO TO 1325)
NO 2 (GO TO 1327)
REFUSED TO ANSWER/NO ANSWER 3 (GO TO 1327)

1324) At any time in your life, as a child or as an adult, has anyone ever forced you in any way to have sexual intercourse or perform any other sexual acts when you did not want to?

YES 1
NO 2 (GO TO 1329)
REFUSED TO ANSWER/NO ANSWER 3 (GO TO 1329)

1325) Who was the person who was forcing you the first time?

CURRENT HUSBAND/PARTNER 01
FORMER HUSBAND/ PARTNER 02
CURRENT/FORMER BOYFRIEND 03
FATHER/STEP-FATHER 04
BROTHER/STEP-BROTHER 05
OTHER RELATIVE 06
IN-LAW 07
OWN FRIEND/ACQUAINTANCE 08
FAMILY FRIEND 09
TEACHER 10
EMPLOYER/SOMEONE AT WORK 11
POLICE/SOLDIER 12
PRIEST/RELIGIOUS LEADER 13
STRANGER 14
OTHER (SPECIFY) 96

1326) CHECK 601 AND 602:
EVER MARRIED/EVER LIVED WITH A MAN: In the last 12 months, has anyone other than (your/any) (husband/partner) physically forced you to have sexual intercourse when you did not want to?

NEVER MARRIED/NEVER LIVED WITH A MAN: In the last 12 months, has anyone physically forced you to have sexual intercourse when you did not want to?

YES 1 (GO TO 1328)
NO 2 (GO TO 1328)

1327) CHECK 1305a (H-J) AND 1315A (B):

AT LEAST ONE YES
NOT A SINGLE YES (GO TO 1329)

1328) CHECK 601 AND 602:
EVER MARRIED/EVER LIVED WITH A MAN: How old were you the first time someone including (your/any) (husband/partner) forced you to have sexual intercourse or perform any other sexual?

NEVER MARRIED/NEVER LIVED WITH A MAN: How old were you the first time someone forced you to have sexual intercourse or perform any other sexual acts?

AGE IN COMPLETED YEARS ____
DON'T KNOW 98

1329) CHECK 1305 (A-J), 1315A (A,B), 1316, 1320, 1323, AND 1324:

AT LEAST ONE YES
NOT A SINGLE YES (GO TO 1333)

1330) Thinking about what you yourself have experienced among the different things we have been talking about, have you ever tried to seek help?

YES 1
NO 2 (GO TO 1332)

1331) From whom have you sought help? Anyone else?
RECORD ALL MENTIONED.

OWN FAMILY A (GO TO 1333)
HUSBAND'S/PARTNER'S FAMILY B (GO TO 1333)
CURRENT/FORMER HUSBAND/PARTNER C (GO TO 1333)
CURRENT/FORMER BOYFRIEND D (GO TO 1333)
FRIEND E (GO TO 1333)
NEIGHBOR F (GO TO 1333)
RELIGIOUS LEADER G (GO TO 1333)
DOCTOR/MEDICAL PERSONNEL H (GO TO 1333)
POLICE I (GO TO 1333)
LAWYER J (GO TO 1333)
SOCIAL SERVICE ORGANIZATION K (GO TO 1333)
OTHER (SPECIFY) X (GO TO 1333)

1332) Have you ever told anyone about this?

YES 1
NO 2

1333) As far as you know, did your father ever beat your mother?

YES 1
NO 2
DON'T KNOW 8

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.

1334) DID YOU HAVE TO INTERRUPT THE INTERVIEW BECAUSE SOME ADULT 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

1335) INTERVIEWER'S COMMENTS/EXPLANATION FOR NOT COMPLETING THE DOMESTIC VIOLENCE MODULE

1336) RECORD THE TIME:

HOUR ____
MINUTE ____

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: ____