REPUBLIC OF LIBERIA
MINISTRY OF PLANNING AND ECONOMIC AFFAIRS
COUNTY___
DISTRICT____
TOWN/VILLAGE____
EA NUMBER____
CLUSTER NUMBER____
STRUCTURE NUMBER_____
HOUSEHOLD NUMBER_____
LINE NUMBER OF WOMAN_____
NAME OF WOMAN_____
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE____
INTERVIEWER NAME____
NOT AT HOME 2
DEFERRED 3
REFUSED 4
PARTLY COMPLETED 5
OTHER (SPECIFY) ________ 6
FINAL VISIT
MONTH____
YEAR____
INTERVIEWER NAME
RESULT
SECTION 1. RESPONDENT'S BACKGROUND
100) RECORD NUMBER OF PEOPLE LISTED IN THE HOUSEHOLD SCHEDULE
MINUTES___
102) For most of the time, when you were a young girl, did you live in a village, in a town, in Monrovia, or in another city?
TOWN 2
MONROVIA 3
ANOTHER CITY 4
103) In what month and year were you born?
DON'T KNOW MONTH 98
DON'T KNOW YEAR 98
104) How old are you?
COMPARE AND CORRECT 103 AND/OR 104 IF INCONSISTENT.
105) Can you read a letter or newspaper easily, with difficulty or not at all?
WITH DIFFICULTY 2
NOT AT ALL 3
106) Have you ever attended school?
NO 2 (GO TO 111)
107) What was the highest level of school you attended: primary, secondary, vocational, or higher?
SECONDARY 2
VOCATIONAL 3
HIGHER 4
108) What was the last grade you completed at that level?
111) Do you listen to a radio at least once a week?
NO 2
112) Where is the main place people in this house get drinking water in the dry season?
OUTSIDE PIPE 2
WELL WITH COVER 3
WELL WITHOUT COVER 4
RIVER OR STREAM 5
RAINWATER 6
OTHER (SPECIFY) ________ 7
113) What do people in this house use for toilet?
OUTSIDE TOILET (PUBLIC) 2
OUTSIDE TOILET (PRIVATE 3
BUSH, NO FACILITIES 4
OTHER (SPECIFY) ________ 5
114) In this house do you have:
NO 2
NO 2
NO 2
NO 2
121) Which religion (church) do you belong to?
CATHOLIC 2
MUSLIM 3
TRADITIONAL 4
NONE 5
OTHER (SPECIFY) ________ 6
BELLE 2
DEY 3
GBANDI 4
GIO 5
GOLA 6
GREBO 7
KISSI 8
KPELLE 9
KRAHN 10
KRU/SAPO 11
LORMA 12
MANDINGO 13
MANO 14
MENDE 15
VAI 16
NONE 17
OTHER 18
123) MAIN MATERIAL OF THE ROOF?
ZINC, METAL 2
CONCRETE 3
ASPHALT, ASBESTOS 4
OTHER (SPECIFY) ________ 5
201) Now I would like to ask about all the children that you born including the ones that are not living. Have you ever born any children?
NO 2 (GO TO 206)
202) Do you have any son or daughter you born who is living with you now?
NO 2 (GO TO 204)
203) How many sons live with you? And how many daughters live with you?
IF NONE ENTER 00
204) Do you have any son or daughter you born who is not living with you?
NO 2 (GO TO 206)
205) How many sons do not live with you? And how many daughters do not live with you?
IF NONE ENTER 00
206) Have you ever born a boy or a girl who was born alive but later died?
PROBE: Any boy or girl who when was born was crying but died later on?
NO 2 (GO TO 208)
207) How many boys have died? And how many girls have died?
IF NONE ENTER 00
208) SUM ANSWERS TO 203, 205, AND 207 AND ENTER TOTAL.
209) Just to make sure that I have this right, you have had (TOTAL) live births during your life. Is that correct?
NO 2 (PROBE AND CORRECT AS NECESSARY)
ONE OR MORE BIRTHS 2
Now I want to write the names of all your own births whether they are still living or not. Please start with your first born. (RECORD THE NAMES OF ALL THE BIRTHS IN 211.)
211) What name was given to your (first, next) baby?
RECORD TWINS ON SEPARATE LINES AND MARK WITH BRACKET
212) Is (NAME) a boy or a girl?
GIRL 2
NO 2
PROBE: What is his/her birthday? OR: In what season?
RECORD IN COMPLETED YEARS.
NO 2
RECORD IN DAYS IF LESS THAN ONE MONTH; IN MONTHS IF LESS THAN TWO YEARS
MONTHS____
YEARS____
218A) COMPARE 208 WITH NUMBER OF BIRTHS IN HISTORY ABOVE AND CHECK:
NUMBERS ARE DIFFERENT 2 (PROBE AND RECONCILE)
219) Did you have your period in the last four weeks?
NO 2
NO 2 (GO TO 223)
NOT SURE 8 (GO TO 223)
221) How many months since you have been pregnant?
222) Since you have been pregnant, were you given any injection to keep the baby from getting tetanus or jerking after he was born?
(PROBE: Do you have a health card?)
NO 2
DON'T KNOW 8
223) From the time a woman's period starts to the time the next one starts, when do you think a woman is most likely to get pregnant?
SOON AFTER HER PERIOD HAS ENDED 2
RIGHT BETWEEN THE TWO PERIODS 3
JUST BEFORE HER PERIOD BEGINS 4
AT ANY TIME 5
OTHER (SPECIFY) ________ 6
DOES NOT KNOW 8
HAD BIRTH SINCE JANUARY 1981 2
225) Did you ever give (NAME OF LAST CHILD) the breast?
NO 2 (GO TO 232)
226) IF ALIVE: Are you still giving him/her the breast?
IF DEAD: CIRCLE CODE 2
NO 2 (GO TO 232)
227) How many times did you give the baby the breast last night, between sundown and sunrise?
CHILD SLEEPS AT THE BREAST 88
228) How many times did you give the baby the breast yesterday during the daylight hours?
AS OFTEN AS CHILD WANTED 88
229) At any time yesterday or last night, was (NAME OF LAST BIRTH) given any of the following?
READ OUT CODING CATEGORIES
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
WAS GIVEN FOODS OR LIQUIDS 2
231) Were any of these given in a bottle with a nipple?
NO 2
232) When you were pregnant with (NAME OF LAST BIRTH), were you given any injection to keep the baby from getting tetanus or jerking after he was born?
NO 2
DON'T KNOW 8
233) When you were pregnant with (NAME OF LAST BIRTH), did you see anyone for a check on that pregnancy?
NO 2 (GO TO 234A)
234) Who did you see?
PROBE FOR TYPE OF PERSON AND RECORD MOST QUALIFIED
TRAINED NURSE/MIDWIFE 2
TRADITIONAL BIRTH ATTENDANT 3
OTHER (SPECIFY) ________ 4
234A) Where was (NAME OF LAST BIRTH) born?
HOSPITAL OR CLINIC 2
OTHER (SPECIFY) ________ 3
235) Who helped you deliver (NAME OF LAST BIRTH)?
PROBE FOR TYPE OF PERSON AND RECORD THE MOST QUALIFIED
NURSE OR MIDWIFE 2
TRADITIONAL BIRTH ATTENDANT 3
RELATIVE 4
OTHER (SPECIFY) ________ 5
NO ONE 6
236) Have your periods come back since the birth of this child?
NO 2
237) Have you started men business since (NAME OF LAST BIRTH) was born?
NO 2
238) Before you got pregnant with (NAME OF LAST BIRTH), did you want to have more children?
NO 2 (GO TO 302)
DON'T KNOW 8
239) Were you glad that you were pregnant then, or did you prefer to wait?
PREFERRED TO WAIT 2
DON'T KNOW 8
302) Here we will talk about something different. There are many ways that a man or woman can keep a woman from getting pregnant. Which of these ways do you know or have you heard about?
CIRCLE CODE 1 IN 303 FOR EACH METHOD MENTIONED SPONTANEOUSLY. FOR EACH METHOD NOT MENTIONED, READ THE NAME AND THE DESCRIPTION, ASK 303 AND CIRCLE CODE 2 IF METHOD IS RECOGNIZED. THEN ASK 304-305 FOR EACH METHOD AS APPROPRIATE.
303) Have you ever heard of this method?
YES, PROBED 2
NO 3
YES, PROBED 2
NO 3
YES, PROBED 2
NO 3
YES, PROBED 2
NO 3
YES, PROBED 2
NO 3
YES, PROBED 2
NO 3
YES, PROBED 2
NO 3
YES, PROBED 2
NO 3
YES, PROBED 2
NO 3
(SPECIFY)____
YES, PROBED 2
NO 3
304) Have you ever used (METHOD)?
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
(SPECIFY)____
NO 2
305) Do you know of a place or a person where you can get (METHOD)?
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
AT LEAST ONE "YES" IN 304 (EVER USED) 2
NEVER USED RHYTHM OR SAFE PERIOD 2 (GO TO 311)
310) When you were using the rhythm method or the safe period, how did you know which days you had to keep from going with your man?
BASED ON BODY TEMPERATURE 2
BASED ON CERVICAL MUCUS (BILLINGS) METHOD 3
BASED ON BODY TEMPERATURE AND MUCUS 4
OTHER (SPECIFY) ________ 5
NOT PREGNANT, NOT SURE 2
313) Are you doing something now or using any method to keep you from getting pregnant?
NO 2 (GO TO 334)
314) Which method are you using now?
IUD 02
INJECTIONS 03
DIAPHRAGM, FOAM, JELLY 04
CONDOM, RAINCOAT 05
FEMALE STERILIZATION 06
MALE STERILIZATION 07
PERIODIC ABSTINENCE 08
WITHDRAWAL 09 (GO TO 401)
OTHER (SPECIFY) ________ 10 (GO TO 401)
315) Where did you get (METHOD) from, the last time?
IF RHYTHM OR SAFE PERIOD, ASK: Where did you get advice about this method?
CHURCH HOSPITAL OR CLINIC 2 (GO TO 401)
FPAL CLINIC 3 (GO TO 401)
PRIVATE DOCTOR/CLINIC 4 (GO TO 401)
PHARMACY/SHOP 5 (GO TO 401)
FIELD WORKER 6 (GO TO 401)
OTHER (SPECIFY) ________ 7(GO TO 401)
DON'T KNOW 8 (GO TO 401)
334) Do you think that you will do something to keep you from getting pregnant at any time in the future?
NO 2 (GO TO 337)
DON'T KNOW 8 (GO TO 337)
335) Which method do you think you will use?
IUD 02
INJECTIONS 03
DIAPHRAGM, FOAM, JELLY 04
CONDOM 05
FEMALE STERILIZATION 06
MALE STERILIZATION 07
RHYTHM, SAFE PERIOD 08
WITHDRAWAL 09 (GO TO 337)
OTHER (SPECIFY) ________ 10 (GO TO 337)
UNSURE 12 (GO TO 337)
336) Where or who will you go to get this method or to tell you about it?
CHURCH HOSPITAL OR HEALTH CLINIC 2
FPAL CLINIC 3
PRIVATE DOCTOR/CLINIC 4
PHARMACY/SHOP 5
FIELD WORKER 6
OTHER (SPECIFY) ________ 7
DOESN'T KNOW 8
337) Do you like for people to do anything to keep a woman from getting pregnant?
DOESN'T LIKE 2
DOESN'T KNOW/DEPENDS 8
401) CHECK 214 AND 217:
DEAD (GO TO NEXT BIRTH)
402) Do you have a vaccination card for (NAME)?
IF YES: May I see it please?
YES, NOT SEEN 2 (GO TO 404)
NO CARD 3
403) RECORD DATES FROM HEALTH CARD:
MONTH____
DAY____
YEAR____
MONTH____
DAY____
YEAR____
MONTH____
DAY____
YEAR____
MONTH____
DAY____
YEAR____
MONTH____
DAY____
YEAR____
MONTH____
DAY____
YEAR____
MONTH____
DAY____
YEAR____
MONTH____ (GO TO 405)
DAY____ (GO TO 405)
YEAR____ (GO TO 405)
404) Has (NAME) ever had a vaccination to prevent him/her from getting diseases?
NO 2
DON'T KNOW 8
405) Has (NAME) had running stomach in the last four weeks?
NO 2 (GO TO NEXT BIRTH)
DON'T KNOW 8 (GO TO NEXT BIRTH)
406) Did you or anybody else do something to treat the running stomach?
NO 2 (GO TO NEXT BIRTH)
DON'T KNOW 8 (GO TO NEXT BIRTH)
407) What was the treatment?
CIRCLE CODE 1 FOR ALL MENTIONED.
ANTIBIOTICS* 1 (GO TO NEXT BIRTH; IF NO MORE BIRTHS, GO TO 408)
ORAL REHYDRATION PACKET 1 (GO TO NEXT BIRTH; IF NO MORE BIRTHS, GO TO 408)
HOMEMADE DRINK OF SUGAR, SALT AND WATER 1 (GO TO NEXT BIRTH; IF NO MORE BIRTHS, GO TO 408)
OTHER____ 1 (GO TO NEXT BIRTH; IF NO MORE BIRTHS, GO TO 408)
*Antibiotics include: Ampicillin, Amoxicillin, Erythromycin, Gentrocin, Penicillin, Tetracycline, and Terramycin.
408) Has (NAME) had fever in the last four weeks?
NO 2 (GO TO 411)
DON'T KNOW 8 (GO TO 411)
409) Did you or anybody else do something to treat the fever?
NO 2 (GO TO 411)
DON'T KNOW 8 (GO TO 411)
410) What was done?
CIRCLE CODE 1 FOR ALL MENTIONED
COUNTRY MEDICINE, HERBS 1
ANTIBIOTICS 1
OTHER_____ 1
*Antimalarials include: Any form of chloroquine, any other tablet to prevent malaria.
411) Has (NAME) suffered from coughing or difficult breathing in the last four weeks?
NO 2 (GO TO 414)
DON'T KNOW 8 (GO TO 414)
412) Did you or anybody else do something to treat the problem?
NO 2 (GO TO 414)
DON'T KNOW 8 (GO TO 414)
413) What was done?
CIRCLE CODE 1 FOR ALL MENTIONED.
ANTIBIOTICS* 1
COUNTRY MEDICINE, HERBS 1
TREATED IN HOSPITAL 1
OTHER____ 1
*Antibiotics include: Ampicillin, Amoxicillin, Erythromycin, Gentrocin, Penicillin, Tetracycline, and Terramycin.
414) Has (NAME) ever had measles?
NO 2 (GO TO NEXT BIRTH; IF NO MORE BIRTHS, GO TO 501)
DON'T KNOW 8 (GO TO NEXT BIRTH; IF NO MORE BIRTHS, GO TO 501)
501) Have you ever been married or lived with a man?
NO 2 (GO TO 508)
503) Are you now married, or living with a man, or are you widowed, divorced or no longer living together?
LIVING TOGETHER 2
WIDOWED 3 (GO TO 506)
DIVORCED 4 (GO TO 506)
NOT LIVING TOGETHER 5 (GO TO 506)
504) Does your man/husband have any other wife?
NO 2
506) Have you lived with only one man or more than one?
MORE THAN ONE 2
507) In what month and year did you start living with your (first) man?
DON'T KNOW MONTH 98
DON'T KNOW YEAR 98
507A) How old were you when you started living with him?
508) Have you ever done men business?
NO 2 (GO TO 518)
510) Now it is important to ask you some questions about men business. How old were you when you first did men business?
511) When was the last time you did men business?
WEEKS AGO____
MONTHS AGO_____
BEFORE LAST BIRTH 88
NOT PREGNANT/UNSURE 2
NO METHOD CIRCLED (NOT USING 2
514) Would you be upset if you became pregnant in the next few weeks?
NO 2 (GO TO 518)
515) What is the main reason that you are not using a method to avoid pregnancy?
TOO COSTLY 02 (GO TO 517)
MENOPAUSE/SUBFECUND 03 (GO TO 518)
DOESN'T KNOW METHODS 04 (GO TO 518)
DIFFICULT TO GET 05 (GO TO 518)
INFREQUENT SEX 06 (GO TO 518)
RELIGION 07 (GO TO 518)
BREASTFEEDING 08 (GO TO 518)
FEAR OF SIDE EFFECTS 09 (GO TO 518)
OPPOSED TO FAMILY PLAN 10 (GO TO 518)
OTHER (SPECIFY) ________ 11 (GO TO 518)
FEAR OF SIDE EFFECTS 2 (GO TO 518)
FEAR OF WOMAN BEING UNFAITHFUL 3 (GO TO 518)
RELIGION 4 (GO TO 518)
DOESN'T KNOW 8 (GO TO 518)
OTHER (SPECIFY) ________ 5 (GO TO 518)
517) How much do you think it would cost?
518) PRESENCE OF OTHERS AT THIS POINT
NO 2
NO 2
NO 2
NO 2
SECTION 6. FERTILITY PREFERENCES
602) SEE 503 AND CHECK:
ALL OTHERS 2 (GO TO 613)
603) I now have some questions about the future.
CHECK 220:
NOT PREGNANT: Would you like to have another child some day or would you like to not have any more children?
PREGNANT: After the child you are expecting, would you like to have another child some day or would you like not to have any more?
NO MORE 2 (GO TO 608)
UNDECIDED OR DON'T KNOW 8 (GO TO 608)
606) How long would you like to wait before you have a (another) child?
YEARS____ (GO TO 608)
DOESN'T KNOW 98
607) How old would your youngest child be?
DOESN'T KNOW 98
608) How long do you think a woman should wait until having one child before she should have the next one?
OTHER (SPECIFY) ________
609) After a woman just had a baby, how long should she wait before starting men business?
OTHER (SPECIFY) ________
610) Is it all right for a mother to do men business when she is still giving her baby the breast?
NO 2
611) Do you think that your man will like for people to do something to keep a woman from getting pregnant?
DOESN'T LIKE 2
DOESN'T KNOW 8
612) How often have you talked to your man about this subject in the past year?
ONCE OR TWICE 2
MORE OFTEN 3
NO CHILDREN: If you could choose the number of children to have in your whole life, how many would that be?
HAS CHILDREN: If you could go back to the time when you didn't have any children, and if you could choose the number of children to have in your whole life, how many would that be?
RECORD SINGLE NUMBER, RANGE OR OTHER ANSWER
RANGE: BETWEEN___ AND ____
OTHER ANSWER (SPECIFY) ________
614) What type of woman do you think a man would prefer to marry: a woman who has given birth or a woman who has never given birth?
WOMAN WHO HAS NOT GIVEN BIRTH 2
DOESN'T KNOW 8
SECTION 7. HUSBAND'S BACKGROUND
701) SEE 501 AND CHECK:
ALL OTHERS 2 (GO TO 706)
ASK QUESTIONS ABOUT CURRENT OR MOST RECENT HUSBAND/PARTNER.
702) Can (could) your man (husband) read a letter or newspaper easily, with difficulty, or not at all?
WITH DIFFICULTY 2
NOT AT ALL 3
DOESN'T KNOW 8
703) Did he ever attend school?
NO 2 (GO TO 706)
DOESN'T KNOW 8 (GO TO 706)
704) What was the highest level of school he attended: Primary, secondary, vocational or higher?
SECONDARY 2
VOCATIONAL 3
HIGHER 4
DON'T KNOW 8 (GO TO 706)
705) What was the last grade he completed?
DON'T KNOW 98
706) In the past four weeks, did you buy:
READ OUT CODING CATEGORIES
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
SECTION 8. EXTRA HEALTH QUESTIONS
801) What can cause running stomach?
CIRCLE CODE 1 FOR ALL MENTIONED
DRINKING DIRTY WATER 1
EATING BAD FOOD 1
SORE IN STOMACH 1
OTHER ________ 1
802) Where is the nearest health clinic?
DOESN'T KNOW 8 (GO TO 808)
803) How long does it take to get there?
MINUTES____
804) In the past year have you been to this clinic for treatment?
NO 2 (GO TO 806)
805) What was the treatment for?
IF MORE THAN ONE VISIT, ASK ABOUT MOST RECENT VISIT.
COUGH 2
RUNNING STOMACH 3
ACCIDENT 4
PREGNANCY, CHILDBIRTH 5
VACCINATION 6
OTHER 7
WENT TO PHARMACY 2 (GO TO 808)
NOT SICK 3 (GO TO 808)
OTHER 4 (GO TO 808)
807) How much do you think it would cost to get treatment there?
808) Where is the nearest medicine store?
DOESN'T KNOW 8 (GO TO 813)
809) How long does it take to get there?
MINUTES____
810) In the past year, did you buy any medicines there?
NO 2 (GO TO 812)
811) What kind of medicine did you buy?
CIRCLE ONLY ONE
COUGH MEDICINE 2
OTHER ________ 3
812) Can you take injection at this store?
NO 2
DOESN'T KNOW 8
813) (IF VILLAGE) is there a Village Development Council in this village?
NO 2
DOESN'T KNOW 8
814) (IF VILLLAGE) is there a village health worker in this village?
NO 2
DON'T KNOW 8
MINUTES____
901) WHAT IS THE RESPONDENT'S NATIVE LANGUAGE?
BELLE 2
DEY 3
GBANDI 4
GIO 5
GOLA 6
GREBO 7
KISSI 8
KPELLE 9
KRAHN 10
KRU/SAPO 11
LORMA 12
MANDINGO 13
MANO 14
MENDE 15
VAI 16
ENGLISH 17
OTHER 18
902) IN WHAT LANGUAGE DID YOU CONDUCT THE INTERVIEW?
BELLE 2
DEY 3
GBANDI 4
GIO 5
GOLA 6
GREBO 7
KISSI 8
KPELLE 9
KRAHN 10
KRU/SAPO 11
LORMA 12
MANDINGO 13
MANO 14
MENDE 15
VAI 16
ENGLISH 17
OTHER 18
903) FOR HOW MUCH OF THE INTERVIEW DID YOU DEPEND ON A THIRD PERSON TO INTERPRET FOR YOU?
SOME OF THE INTERVIEW 2
MOST OF THE INTERVIEW 3
ALL OF THE INTERVIEW 4