COMMITTEE OF PLANNING AND STATISTICS/MINISTRY OF HEALTH
NATIONAL OFFICE OF STATISTICS AND INFORMATION
REPUBLIC OF MALI

IDENTIFICATION

NAME OF PLACE____________
CLUSTER NUMBER_______
LAST NAME AND FIRST NAME OF HEAD OF HOUSEHOLD_______________
PLOT NUMBER_______
HOUSEHOLD NUMBER__________
REGION____________

URBAN/RURAL MILIEU

BAMAKO, OTHER CITIES, OTHER TOWNS, RURAL

WOMAN'S FIRST AND LAST NAME AND LINE NUMBER

WOMAN SELECTED FOR DOMESTIC VIOLENCE IN HOUSEHOLD?
CHECK KISH SELECTION TABLE ON THE HOUSEHOLD QUESTIONNAIRE

HOUSEHOLD SELECTED FOR MEN'S SURVEY
(CHECK COVER PAGE OF HOUSEHOLD QUESTIONNAIRE) (FOR Q542 AND 543)

INTERVIEWER VISITS

(REPEAT FOR SECOND AND THIRD INTERVIEWERS)
DATE________
INTERVIEWER'S NAME____________
RESULT*______________

NEXT VISIT
DATE________
TIME__________

FINAL VISIT
DAY____
MONTH____
YEAR 2012
INTERVIEWER______
RESULT*____

TOTAL NUMBER OF VISITS________

*RESULTS CODE:

LANGUAGE OF QUESTIONNAIRE: FRENCH

LANGUAGE OF INTERVIEW________

INTERPRETER

SUPERVISOR
NAME____________
DATE______________

FIELD EDITOR
NAME_____________
DATE____________

OFFICE EDITOR_______

KEYED BY__________

SECTION 1. RESPONDENT'S BACKGROUND

INTRODUCTION AND CONSENT

Hello. My name is _______. I am working with INFO-STAT, which is executing this survey in collaboration with the Committee of Planning and Statistics (CPS) of the Ministry of Health and the National Office of Statistics and Information (INSTAT). We are conducting a survey about health all over Mali. The information we collect will help the government to improve health services. Your household was selected for this survey. The questions usually take between 30 to 60 minutes. All of the answers you give will be confidential and will not be shared with anyone other than members of our survey team. You are not obligated to participate in this survey, but we hope you will agree to participate because your opinion is very important. If it happens that I ask you any question you don't want to answer, tell me and I will pass onto the next question; you can also stop the interview at any moment.

If you would like more information about the survey, you may contact the person listed on the card that has already been given to your household.

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

SIGNATURE OF INTERVIEWER______________ DATE_________

101) RECORD THE TIME

102) In what month and year were you born?

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

104) Have you attended school?

105) What is the highest level of school you achieved: fundamental 1 (1st cycle), fundamental 2 (2nd cycle), secondary (high school or technical school), or higher?

106) What is the highest (grade/form/year) you completed at this level?
IF COMPLETED LESS THAN ONE YEAR AT THAT LEVEL, RECORD 00

107) CHECK 105:

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 a part of the sentence to me?

109) CHECK 108:

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

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

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

113) What religion do you practice?

114) What is your ethnicity?

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

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

SECTION 2. REPRODUCTION

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

202) Do you have any sons or daughters to whom you have given birth who currently live with you?

203) How many sons live with you?
And how many daughters live with you?
IF NONE, RECORD '00'

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

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

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?

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

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

209) CHECK 208:
Just to makes sure that I have this right: you have had in total ____births during your life. Is that correct?

210) CHECK 208:

211) Now I would like to record the names of all your births, whether still alive or not, starting with the first one you had.
RECORD NAMES OF ALL THE BIRTHS IN 212. RECORD TWINS AND TRIPLETS ON SEPARATE ROWS. (IF THERE ARE MORE THAN 12 BIRTHS, USE AN ADDITIONAL QUESTIONNAIRE, STARTING WITH THE SECOND ROW.)

212) What name was given to you (FIRST/NEXT) baby?

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

214) Were any of these births twins?

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

216) Is (NAME) still alive?

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

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

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

GO TO NEXT BIRTH/ Q. 221

220) IF DEAD: How old was (NAME) when he/she died?
IF '1 YR', PROBE: How many months old was (NAME)?
RECORD DAYS IF LESS THAN 1 MONTH; MONTHS IF LESS THAN TWO YEARS, OR YEARS.

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

(REPEAT QUESTIONS 212-221 FOR ALL BIRTHS)

222) Have you had any live births since the birth of (NAME OF LAST BIRTH)?
IF YES, RECORD BIRTHS IN TABLE.

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

224) CHECK 215:
ENTER THE NUMBER OF BIRTHS IN 2007 OR LATER.

225) C:
FOR EACH BIRTH SINCE JANUARY 2007, ENTER "N" IN THE MONTH OF BIRTH IN THE CALENDAR. WRITE THE NAME OF THE CHILD TO THE LEFT OF THE CODE "N" FOR EACH BIRTH. ASK THE NUMBER OF MONTHS THE PREGNANCY LASTED AND RECORD "G" IN EACH OF THE PRECEDING MONTHS ACCORDING TO THE DURATION OF THE PREGNANCY. (NOTE: THE NUMBER OF GS MUST BE ONE LESS THAN THE NUMBER OF MONTHS THAT THE PREGNANCY LASTED.)

226) Are you pregnant now?

227) How many months pregnant are you?
RECORD NUMBER OF COMPLETED MONTHS.
C: ENTER G's IN THE CALENDAR, BEGINNING WITH THE MONTH OF INTERVIEW AND FOR THE TOTAL NUMBER OF COMPLETED MONTHS.

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

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

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

230A) Among these terminated pregnancies, were there any:

Miscarriages?
Abortions?
Stillbirths?

231) When did the last pregnancy of this type end?

232) CHECK 231:

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

234) Since January 2007, have you had any other pregnancies that did not result in a live birth?

235) ASK THE DATE AND DURATION OF PREGNANCY FOR EACH EARLIER NON-LIVE BIRTH PREGNANCY BACK TO JANUARY 2007.
C: ENTER "F" IN THE CALENDAR IN THE MONTH THAT EACH PREGNANCY TERMINATED AND "G" FOR THE REMAINING NUMBER OF COMPLETED MONTHS.

236) Did you have any miscarriages, abortions or stillbirths that ended before 2007?

237) When did the last pregnancy of this type that terminated before 2007 end?

238) When did you last menstrual period start?

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

240) Is this time just before the period begins, during the period, right after the period has ended, or halfway between two periods?

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. What methods have you already heard about?

302) CHECK 226:

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

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

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

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

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

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

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

310) CHECK 308/308A

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

USE CALENDAR FOR REFERENCE OF TIMES OF USE AND NONUSE, STARTING WITH MOST RECENT USE, BACK TO JANUARY 2007 (6)
USE NAMES OF CHILDREN, DATES OF BIRTH, AND PERIODS OF PREGNANCY AS REFERENCE POINTS.

C: IN COLUMN 1, ENTER THE CODE FOR THE METHOD USED OR USE CODE "0" FOR NONUSE IN EACH BLANK MONTH.

ILLUSTRATIVE QUESTIONS:
When was the last time you used a method? Which method was that?
When did you start using that method? How long after the birth of (NAME)?
How long did you use the method afterwards?

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

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

ILLUSTRATIVE QUESTIONS:
Why did you stop using the (METHOD)? Did you become pregnant while using (METHOD), did you stop to get pregnant, or did you stop for some other reason?
IF DELIBERATELY STOPPED TO BECOME PREGNANT, ASK: How many months did it take you to get pregnant after you stopped using (METHOD)? AND ENTER "0" IN EACH SUCH MONTH IN COLUMN 1.

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

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

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

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.

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

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

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

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

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

320) CHECK 317:

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

CODE '1' NOT CIRCLED-When you obtained (CURRENT METHOD FROM 314) from (SOURCE OF METHOD FROM 307 OR 315), were you told about other methods of family planning that you could use?

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

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

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.

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

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.

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

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

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

SECTION 4. PREGNANCY AND POSTNATAL CARE

401) CHECK 224:

402) CHECK 215: ENTER IN THE TABLE THE BIRTH HISTORY LINE NUMBER, NAME, AND SURVIVAL STATUS OF EACH BIRTH IN 2007 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 one child at a time).

403) BIRTH HISTORY LINE NUMBER FROM 212 IN BIRTH HISTORY

404) FROM QUESTIONS 212 AND 216

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

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

407) How much longer did you want to wait?

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

409) Who did you consult with?
Anyone else?
PROBE TO IDENTIFY EACH TYPE OF PERSON AND RECORD ALL MENTIONED.

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.

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

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

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

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

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

415) During this pregnancy, were you given an injection in the arm to prevent the baby from getting tetanus, that is, convulsions after birth?

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

417) CHECK 416:

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

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

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

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

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.

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

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

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

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

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

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

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

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

431) Was (NAME) weighed at birth?

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

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

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.

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

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

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

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

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

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

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.

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

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.

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

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.

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

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

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

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

450) CHECK 226:
IS RESPONDENT PREGNANT?

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

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

453) Did you ever breastfeed (NAME)?

454) CHECK 404: IS THE CHILD LIVING?

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

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

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

458) CHECK 404:
IS CHILD LIVING?

459) Are you still breastfeeding (NAME)?

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

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 LINE NUMBER, NAME, AND SURVIVAL STATUS OF EACH BIRTH IN 2007 OR LATER. ASK THE QUESTIONS ABOUT ALL OF THESE BIRTHS, STARTING WITH THE LAST BIRTH. (IF THERE ARE MORE THAN 3 BIRTHS, USE LAST 2 COLUMNS OF ADDITIONAL QUESTIONNAIRES.)

502) BIRTH HISTORY LINE NUMBER FROM 212 IN BIRTH HISTORY

503) FROM 212 AND 216

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

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

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.

507) CHECK 506:

508) Has (NAME) received any vaccines that are not recorded on this card, including vaccinations given 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.

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

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

510A) A BCG vaccination against tuberculosis, that is, an injection in the arm or shoulder that usually causes a scar?

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

510C) Was the first polio vaccine given in the first two weeks after birth or later?

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

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

510F) How many times was the DPT vaccination given?

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

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.

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.

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

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

515) Was there any blood in the stools?

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?

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?

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

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.

520) CHECK 519:

521) Where did you first seek advice or treatment?
USE LETTER CODE FROM 519

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?

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

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

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

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

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

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

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

530) CHECK 525: DID THEY HAVE A FEVER?

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?

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?

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

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.

535) CHECK 534:

536) Where did you first seek advice or treatment?
Use letter code from 534

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

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

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

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

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

542) CHECK 538:
CHLOROQUINE (B) GIVEN

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

544) CHECK 538:
AMODIAQUINE (C) GIVEN

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

546) CHECK 538: QUININE (D) GIVEN

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

548) CHECK 538: COMBINATION WITH ARTEMISININ (CTA) (E) GIVEN

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

550) CHECK 538: OTHER ANTIMALARIAL (F) GIVEN

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

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 2007 OR LATER LIVING WITH THE RESPONDENT

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

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

556) Have you ever heard of a special product called [NAME OF ORS PACKET OR PRE-PACKAGED ORS LIQUID] you can get for the treatment of diarrhea?

557) CHECK 215 AND 218, ALL ROWS: NUMBER OF CHILDREN BORN IN 2010 OR LATER LIVING WITH RESPONDENT

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 based drinks?
C) broth or soup?
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 [BRAND NAME OF COMMERCIALLY FORTIFIED BABY FOOD, E.G. CERELAC]?
I) bread, rice, noodles, porridge, corn, or any other foods made from grains?
J) pumpkin, carrots, squash or sweet potatoes that are yellow or orange inside?
K) potatoes, white yams, manioc, cassava, or any other foods made from roots?
L) any dark green, leafy vegetables?
M) ripe mangoes, papayas or [INSERT ANY OTHER LOCALLY AVAILABLE VITAMIN A-RICH FRUITS]?
N) any other fruits or vegetables?
O) liver, kidney, heart or any other organ meats?
P) any beef, pork, lamb, goat, chicken or duck?
Q) eggs?
R) fresh or dried fish or shellfish?
S) any foods made from beans, peas, lentils, peanuts or other nuts?
T) cheese or other food made from milk?
U) any other solid, semi-solid, or soft food?

559) CHECK 558 (CATEGORIES G THROUGH U)

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) eat?

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

561A) I would like to ask you questions about liquids or foods that you had yesterday during the day or at night. I am interested in whether you had the item I mention even if it was combined with other foods.

For example, if you ate gruel with millet made with a vegetable sauce, you should respond "yes" to all the food I will list and that are ingredients of the gruel or the vegetable sauce.

Please don't mention small quantities of foods for used for seasoning or as condiments (like peppers, spices, herbs, fish powder or). I will ask you about each food separately.
At any time during the day or night, did you eat or drink:

A) milk such as boxed, powdered, or fresh animal milk?
B) bread, rice, noodles, corn, porridge, or any other foods made from grains?
C) pumpkin, carrots, squash or sweet potatoes that are yellow or orange inside?
D) white potatoes, white yams, manioc, cassava, or any other foods made from roots?
E) any dark green, leafy vegetables?
F) ripe mangoes, papayas or [INSERT ANY OTHER LOCALLY AVAILABLE VITAMIN A-RICH FRUITS]?
G) any other fruits or vegetables?
H) liver, kidney, heart or any other organ meats?
I) any beef, pork, lamb, goat, chicken or duck?
J) eggs?
K) fresh or dried fish, mollusks, or shellfish?
L) any foods made from beans, peas, lentils, peanuts or other nuts?
M) cheese or other food made from milk?
N) Any oil, fat, or butter, or any food made from these products?
O) Any sweet foods, such as chocolate, candy, pastries, cakes, or cookies?
P) Condiments for flavor, such as peppers, spices, herbs, or fish powder?
Q) white worms, snails, or insects?
R) foods made of red palm oil, red palm nut, red sauce made from palm grain paste?

SECTION 6. MARRIAGE AND SEXUAL ACTIVITY

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

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

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

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

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

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

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

608) Are you the first, second?wife?

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

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: I would like to talk about the first time you were married or started living with a man as if married. In what month and year were you married or did you start living with a man as if married for the first time?

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

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?

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.

616) When was the last time you had sexual intercourse with this person?
ONLY FOR SECOND AND THIRD TO LAST PARTNERS

QUESTIONS 617-626 REPEATED FOR SECOND TO LAST AND THIRD TO LAST SEXUAL PARTNERS

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

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

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

620) CHECK 609:

621) CHECK 613:

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

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 IF 95 OR MORE, WRITE 95.

624) How old is this person?

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

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

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

628) PRESENCE OF OTHERS DURING THIS SECTION

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

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.

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

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

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.

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

SECTION 7. FERTILITY PREFERENCES

701) CHECK 304:

702) CHECK 226:

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?

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?

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?

706) CHECK 226:

707) CHECK 303:USING A CONTRACEPTIVE METHOD?

708) CHECK 705:

709) CHECK 704:

WANTS TO HAVE A/ANOTHER CHILD--You 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.

710) CHECK 303: USING A CONTRACEPTIVE METHOD?

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

712) CHECK 216:

HAS LIVING CHILDREN- If you could go back to the time where 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.

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?

714) In the last few months have you:

Heard about family planning on the radio?
Seen anything about family planning on the television?
Read something on family planning in a newspaper or magazine?

715) COUNTRY-SPECIFIC QUESTIONS ON MEDIA MESSAGES ABOUT FAMILY PLANNING

716) CHECK 601:

717) CHECK 303: USING A CONTRACEPTIVE METHOD?

718) Would you say that using contraception is mainly your decision, mainly your (husband's/partner's) decision, or a common decision you both decided together?

719) CHECK 304:

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

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

801) CHECK 601 AND 602:

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

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

804) What was the highest level of school he attended: fundamental 1 (1st cycle), fundamental 2 (2nd cycle), secondary (high school or technical school), or higher?

805) What was the highest (grade/form/year) he completed at that level?
IF COMPLETED LESS THAN ONE YEAR AT THAT LEVEL, RECORD 00.

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?

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

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?

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?

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

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?

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

814) Are you paid in cash or in kind for this work or are you not paid at all?

815) CHECK 601:

816) CHECK 814:

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

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?

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?

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

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

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

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

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

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

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 sexual intercourse with him?
If she burns the food?

SECTION 9. HIV/AIDS

901) I would now like us to talk about another subject. Have you ever heard of an illness called AIDS?

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

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

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

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

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

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

908) Can the virus that causes AIDS be transmitted from a mother to a baby?

During pregnancy?
During delivery?
During breastfeeding?

909) CHECK 908:

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?

911) CHECK 208 AND 215:

912) CHECK 408 FOR LAST BIRTH:

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:

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

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

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

917) Where was the test done?

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

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

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

920) CHECK 434 FOR LAST BIRTH

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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?

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

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?

938) CHECK 613:

939) CHECK 937: HEARD ABOUT OTHER SEXUALLY TRANSMITTED INFECTIONS?

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 that you got through sexual contact?

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

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

943) CHECK 940, 941, AND 942:

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

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

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?

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

948) CHECK 601:

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

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

SECTION 10. OTHER HEALTH ISSUES

1001) Now I would like to ask you some other questions relating to health problems. 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 IF THE IINJECTIONS WERE DAILY FOR 3 MONTHS OR MORE, RECORD 90. IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE.

1002) Among these injections, how many were administered by a doctor, a nurse, a pharmacist, a dentist, or 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.

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

1004) Do you currently smoke cigarettes?

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

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

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

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 major problem or not?

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

1009) Are you covered by any health insurance?

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

SECTION 11. FEMALE GENITAL CUTTING

1101) Have you ever heard of female circumcision?

1102) In some countries, there is a practice in which a girl may have part of her genitals cut. Have you ever heard about this practice?

1103) Have you yourself ever been circumcised?

1104) Now I would like to ask you what was done to you at that time. Was any flesh removed from the genital area?

1105) Was the genital area just nicked without removing any flesh?

1106) Was your genital area stitched closed?

1107) How old were you when you were circumcised?
IF THE RESPONDENT DOES NOT KNOW THE EXACT AGE, PROBE TO GET AN ESTIMATE.

1108) Who performed the circumcision?

1109) CHECK 213, 215, 216:

CHECK 213, 215, AND 216: ENTER IN THE TABLE THE BIRTH HISTORY NUMBER AND NAME OF EACH LIVING DAUGHTER BORN IN 1997 OR LATER. ASK THE QUESTIONS ABOUT ALL OF THESE DAUGHTERS. BEGIN WITH THE YOUNGEST DAUGHTER. (IF THERE ARE MORE THAN 6 DAUGHTERS, USE ADDITIONAL QUESTIONNAIRES).

Now I would like to ask you some questions about your (daughter/daughters).

1110) Birth history number and NAME of each living daughter born in 1997 or later

1111) Is (NAME OF DAUGHTER) circumcised?

1112) How old was (NAME OF DAUGHTER) when she was circumcised?
IF THE RESPONDENT DOES NOT KNOW THE AGE, PROBE TO GET AN ESTIMATE.

1113) Was her genital area sewn closed?
PROBE: was the genital area closed?

1114) Who performed the circumcision?

1115) GO BACK TO 1111 IN NEXT COLUMN; OR, IF NO MORE DAUGHTERS, GO TO 1116

1116) Do you believe that female circumcision is required by your religion?

1117) Do you think that female circumcision should be continued, or should it be stopped?

SECTION 12. FISTULA

1201) Sometimes a woman can have a problem of constant leakage of urine or stool from her vagina during the day and night. This problem usually occurs after a difficult childbirth, but may also occur after a sexual assault or after pelvic surgery. Have you ever experienced a constant leakage of urine or stool from your vagina during the day and night?

1202) Have you ever heard of this problem?

1203) Did this problem start after you delivered a baby or had a stillbirth?

1204) Did this problem start after a normal labor and delivery, or after a very difficult labor and delivery?

1205) What do you think caused this problem?

1206) How many days after [CAUSE OF PROBLEM FROM 1203 OR 1205] did the leakage start? ENTER '90' IF 90 DAYS OR MORE.

1207) Have you sought treatment for this condition?

1208) Why have you not sought treatment?
PROBE AND RECORD ALL MENTIONED

1209) From whom did you last seek treatment?

1210) Did you have an operation to fix the problem?

1211) Did the treatment stop the leakage completely?
IF NO: Did the treatment reduce the leakage?

SECTION 13. MATERNAL MORTALITY

1301A) Now I would like to ask you some questions about your brothers and sisters, that is, all of the children born to your natural mother, including those who are living with you, those living elsewhere, and those who have died. How many children did your mother give birth to, including you?

1302) CHECK 1301:

1303) How many births did your mother have before you were born?

1304) What was the NAME given to your oldest (next oldest) brother or sister)?

1305) Is (NAME) male or female?

1306) Is (NAME) still alive?

1307) How old is (NAME)?

1308) How many years ago did (NAME) die?

1309) How old was (NAME) when he/she died?
IF MAN, OR WOMAN DECEASED BEFORE AGE 12, GO TO NEXT COLLUMN.

1310) Was (NAME) pregnant when she died?

1311) Did (NAME) die during childbirth?

1312) Did (NAME) die within two months after the end of a pregnancy or childbirth?

1313) How many live born children did (NAME) give birth to during her lifetime?
IF NO OTHER BROTHERS OR SISTERS, GO TO 1400

SECTION 14. DOMESTIC VIOLENCE

1400) CHECK COVER PAGE OF HOUSEHOLD QUESTIONNAIRE [ON COVER PAGE]

1401) CHECK FOR PRESENCE OF OTHERS:
DO NOT CONTINUE UNTIL PRIVACY IS ENSURED.

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 Mali. Let me assure you that your answers are completely confidential and will not be told to anyone. Additionally, you are the only person in your household that is being asked these questions and no one will know that you were asked these questions.

1402) CHECK 601 AND 602:

1403) 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 see 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?

1404A) Now if you will permit me, I need to ask some more questions about your relationship with your (last) husband/partner. (Does/did) your last husband/partner ever:

1404B) IF YES: 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?
b) Threaten to hurt or harm you or someone you care about?
c) insult you or make you feel bad about yourself?

1405A) Did your (last) (husband/partner) ever do any of the following things to you:

1405B) IF YES: 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?
b) slap you?
c) twist your arm or pull your hair?
d) punch you with his fist or with something that could hurt you?
e) kick you, drag you, or beat you up?
f) try to choke you or burn you on purpose?
g) threaten you or attack you with a knife, gun, or other type of weapon?
h) physically force you to have sexual intercourse with him even when you did not want to?
i) physically force you to perform other sexual acts you did not want to?
j) force you with threats or in any other way to perform sexual acts you did not want to?

1406) CHECK 1405A (a-j):

1407) 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 A YEAR, WRITE "00"

1408) As a result of what your (last) husband/partner did to you, did you ever have:

a) bruises and aches?
b) eye injuries, sprains, dislocations, or burns?
c) deep wounds, broken bones, broken teeth, or any other serious injury?

1409) 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?

1410) In the last 12 months, how often have you done this to your (last) husband/partner: often, only sometimes, or not at all?

1411) Does (did) your husband/partner drink (alcohol)?

1412) How often does (did) he get drunk: often, only sometimes, or never?

1413) Are (were) you afraid of your (last) (husband/partner): many times, sometimes, or never?

1414) CHECK 609:

1415A) 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?

b) Did any previous (husband/partner) physically force you to have intercourse or perform any other sexual acts against your will?

1415B) IF YES: How long ago did this last happen?

1416) 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?

1417) Who has physically hurt you in this way?
Anyone else?
RECORD ALL MENTIONED

1418) In the last 12 months, how often has (this person/have these persons) physically hurt you: often, only sometimes, or not at all?

1419) CHECK 201, 226, AND 230:

1420) Has anyone ever hit, slapped, kicked or done anything else to hurt you physically while you were pregnant?

1421) Who has done any of these things to physically hurt you while you were pregnant?
Anyone else?
RECORD ALL MENTIONED

1422) CHECK 601 AND 602:

EVER MARRIED/EVER LIVED WITH A MAN: 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?

NEVER MARRIED/NEVER LIVED WITH A MAN: 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?

1423) How old were you the first time you were forced to have sexual intercourse or perform any other sexual acts?

1424) Who was the person who was forcing you at that time?

1425) 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?

1426) CHECK 1405 (A-J), 1415, 1416, 1420, 1422, AND 1425:

1427) Thinking about what you yourself have experienced among the different things we have been talking about, have you ever tried to seek help?

1428) From whom have you sought help?
Anyone else?
RECORD ALL MENTIONED.

1429) Have you ever talked to anyone about this?

1430) As far as you know, did your father ever beat your mother?

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.

1431) 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?

1432) INTERVIEWER'S COMMENTS/EXPLANATION FOR NOT COMPLETING THE DOMESTIC VIOLENCE MODULE, GIVE REASONS_______________________

1433) RECORD THE TIME

INTERVIEWER'S OBSERVATIONS

TO BE FILLED IN AFTER COMPLETING INTERVIEW

COMMENTS ABOUT RESPONDENT: _____

COMMENTS ON SPECIFIC QUESTIONS: _____

OTHER COMMENTS: _____

SUPERVISOR'S OBSERVATIONS ____
NAME _____
DATE _____

EDITOR'S OBSERVATIONS ____
NAME _____
DATE _____

CALENDAR INSTRUCTIONS:

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

INFORMATION TO BE CODED FOR EACH COLUMN.

COLUMN 1: BIRTHS, PREGNANCIES, CONTRACEPTIVE USE**

COLUMN 2: DISCONTINUATION OF CONTRACEPTIVE USE

* YEAR OF FIELDWORK IS ASSUMED TO BE 2010. FOR FIELDWORK BEGINNING IN 2011 OR 2012, THE YEARS SHOULD BE ADJUSTED.

** RESPONSE CATEGORIES MAY BE ADDED FOR OTHER METHODS, INCLUDING FERTILITY AWARENESS METHODS.

2012*
12 Dec 01 ____ ____
11 Nov 02 ____ ____
10 Oct 03 ____ _____
09 Sept 04____ _____
08 Aug 05____ _____
07 Jul 06____ _____
06 Jun 07____ _____
05 May 08____ _____
04 Apr 09____ _____
03 Mar 10____ _____
02 Feb 11____ _____
01 Jan 12____ _____

2011*
12 Dec 13 ____ ____
11 Nov 14 ____ ____
10 Oct 15 ____ _____
09 Sept 16____ _____
08 Aug 17____ _____
07 Jul 18____ _____
06 Jun 19____ _____
05 May 20____ _____
04 Apr 21____ _____
03 Mar 22____ _____
02 Feb 23____ _____
01 Jan 24____ _____

2010*
12 Dec 25 ____ ____
11 Nov 26 ____ ____
10 Oct 27 ____ _____
09 Sept 28____ _____
08 Aug 29____ _____
07 Jul 30____ _____
06 Jun 31____ _____
05 May 32____ _____
04 Apr 33____ _____
03 Mar 34____ _____
02 Feb 35____ _____
01 Jan 36____ _____

2009*
12 Dec 37 ____ ____
11 Nov 38 ____ ____
10 Oct 39 ____ _____
09 Sept 40____ _____
08 Aug 41____ _____
07 Jul 42____ _____
06 Jun 43____ _____
05 May 44____ _____
04 Apr 45____ _____
03 Mar 46____ _____
02 Feb 47____ _____
01 Jan 48____ _____

2008*
12 Dec 49 ____ ____
11 Nov 50 ____ ____
10 Oct 51 ____ _____
09 Sept 52____ _____
08 Aug 53____ _____
07 Jul 54____ _____
06 Jun 55____ _____
05 May 56____ _____
04 Apr 57____ _____
03 Mar 58____ _____
02 Feb 59____ _____
01 Jan 60____ _____

2007*
12 Dec 61 ____ ____
11 Nov 62 ____ ____
10 Oct 63 ____ _____
09 Sept 64____ _____
08 Aug 55____ _____
07 Jul 66____ _____
06 Jun 67____ _____
05 May 68____ _____
04 Apr 69____ _____
03 Mar 70____ _____
02 Feb 71____ _____
01 Jan 72____ _____