IDENTIFICATION

PLACE NAME _________________________

NAME OF HOUSEHOLD HEAD __________________

DISTRICT _____________________ ___

CLUSTER NUMBER __

HOUSEHOLD NUMBER ___

HOUSEHOLD SELECTED FOR MALE INTERVIEW, ANTHROPOMETRY, AND BLOOD WORK?

NAME AND LINE NUMBER OF WOMAN __________________ ___

WOMAN SELECTED FOR DOMESTIC VIOLENCE

INTERVIEWER VISITS

FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE __________
INTERVIEWER'S NAME ___________
RESULT* _____________

NEXT VISIT:
DATE __________
TIME ___________

FINAL VISIT
DAY ____
MONTH ____
YEAR ___
INTERVIEWER CODE ____
RESULT* _____

TOTAL NO. OF VISITS __

LANGUAGE OF QUESTIONNAIRE**:

LANGUAGE OF INTERVIEW**: ___

NATIVE LANGUAGE OF RESPONDENT***: ___

TRANSLATOR USED

SUPERVISOR
NAME ________ ___
DATE ________

FIELD EDITOR
NAME ________ ___
DATE ________

OFFICE EDITOR____

KEYED BY____

SECTION 1. RESPONDENT'S BACKGROUND

INTRODUCTION AND CONSENT

INFORMED CONSENT

Hello. My name is __________ and I am working with the National Statistical Office.
We are conducting a national survey that asks women (and men) about various health issues.
We would very much appreciate your participation in this survey.
This information will help the government to plan health services.
The survey usually takes between 30 and 60 minutes to complete.
Whatever information you provide will be kept strictly confidential and will not be shared with anyone other than members of our survey team.

Participation in this survey is voluntary, and if we should come to 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.
However, we hope that you will participate in this survey since your views are important.
At this time, do you want to ask me anything about the survey?
May I begin the interview now?

Signature of interviewer: ___________________ Date: _________

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

101. RECORD THE TIME.

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

103. Just before you moved here, did you live in a city, in a town, or in the rural area?

104. In the last 12 months, on how many separate occasions have you traveled away from your home community and slept away?
IF NUMBER OF TRIPS IS GREATER THAN 95, WRITE 95.

105. In the last 12 months, have you been away from your home community for more than one month at a time?

106. In what month and year were you born?

107. How old were you at your last birthday?
COMPARE AND CORRECT 106 AND/OR 107 IF INCONSISTENT.

108. Have you ever attended school?

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

110. What is the highest (class/form/year) you completed at that level?

111. CHECK 109:

112. 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?

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

113A. CHECK 107:
AGE

113B. Have you ever participated in a vocational training program such as carpentry, tinsmithing, tailoring, photoprocessing, or any other vocational training program?

114. CHECK 112:

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

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

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

118. What is your religion?

119. What is your tribe or ethnic group?

SECTION 2. REPRODUCTION

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

202. Do you have any sons or daughters to whom you have given birth who are now living 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 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 make 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 LINES.
(IF THERE ARE MORE THAN 12 BIRTHS, USE AN ADDITIONAL QUESTIONNAIRE, STARTING WITH THE SECOND ROW).

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

213. Were any of these births twins?

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

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)

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?

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

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

224. CHECK 215 AND ENTER THE NUMBER OF BIRTHS IN 2005 OR LATER.
IF NONE, RECORD '0' AND SKIP TO 226.

225. FOR EACH BIRTH SINCE JANUARY 2005, ENTER 'B' IN THE MONTH OF BIRTH IN THE CALENDAR.
WRITE THE NAME OF THE CHILD TO THE LEFT OF THE 'B' CODE.
FOR EACH BIRTH, ASK THE NUMBER OF MONTHS THE PREGNANCY LASTED AND RECORD 'P' IN EACH OF THE PRECEDING MONTHS ACCORDING TO THE DURATION OF PREGNANCY.
(NOTE: THE NUMBER OF 'P's 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.
ENTER 'P's IN THE CALENDAR, BEGINNING WITH THE MONTH OF INTERVIEW AND FOR THE TOTAL NUMBER OF COMPLETED MONTHS.

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

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

230. When did the last such pregnancy end?

231. CHECK 230:

232. How many months pregnant were you when the last such pregnancy ended?
RECORD NUMBER OF COMPLETED MONTHS. ENTER 'T' IN THE CALENDAR IN THE MONTH THAT THE PREGNANCY TERMINATED AND 'P' FOR THE REMAINING NUMBER OF COMPLETED MONTHS.

233. Since January 2005, have you had any other pregnancies that did not result in a live birth?

234. ASK THE DATE AND THE DURATION OF PREGNANCY FOR EACH EARLIER NON-LIVE BIRTH PREGNANCY BACK TO JANUARY 2005.
ENTER 'T' IN THE CALENDAR IN THE MONTH THAT EACH PREGNANCY TERMINATED AND 'P' FOR THE REMAINING NUMBER OF COMPLETED MONTHS.

235. Did you have any miscarriages, abortions or stillbirths that ended before 2005?

236. When did the last such pregnancy that terminated before 2005 end?

237. When did your last menstrual period start?

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

239. Is this time just before her period begins, during her period, right after her 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.

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

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

302. Have you ever used (METHOD)?

303. CHECK 302:

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

305. ENTER '0' IN THE CALENDAR IN EACH BLANK MONTH. (GO TO 333)

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

307. Now I would like to ask you about the first time that you did something or used a method to avoid getting pregnant. How many living children did you have at that time, if any?
IF NONE, RECORD '00'.

308. CHECK 302 (01):

309. CHECK 226:

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

311. Which method are you using?
CIRCLE ALL MENTIONED.
IF MORE THAN ONE METHOD MENTIONED, FOLLOW SKIP INSTRUCTION FOR HIGHEST METHOD IN LIST.
311A. CIRCLE 'A' FOR FEMALE STERILIZATION.

312. What brand of pills are you using?
IF BRAND IS LISTED, CIRCLE THE MATCHING CODE. IF BRAND IS NOT LISTED, RECORD NAME OF BRAND. IF RESPONDENT DOES NOT KNOW WHAT BRAND OF PILLS SHE IS USING, ASK TO SEE THE PACKAGE.

313. What brand of condoms are you using?
IF BRAND IS LISTED, CIRCLE THE MATCHING CODE. IF BRAND IS NOT LISTED, RECORD NAME OF BRAND. IF RESPONDENT DOES NOT KNOW WHAT BRAND OF CONDOMS SHE IS USING, ASK TO SEE THE PACKAGE.
IF MORE THAN ONE, ASK WHICH BRAND DOES SHE MAINLY USE.

316. In what facility did the sterilization take place?
PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.
IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.

317. CHECK 311/311A:

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

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

318. How much did you (your husband/partner) pay in total for the sterilization, including any consultation you (he) may have had?

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

319A. Since what month and year have you been using (CURRENT METHOD) without stopping?
PROBE: For how long have you been using (CURRENT METHOD) now without stopping?

320. CHECK 319/319A, 215 AND 230:
ANY BIRTH OR PREGNANCY TERMINATION AFTER MONTH AND YEAR OF START OF USE OF CONTRACEPTION IN 319/319A.

321. CHECK 319/319A:

322. 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 TO PROBE FOR EARLIER PERIODS OF USE AND NONUSE, STARTING WITH MOST RECENT USE, BACK TO JANUARY 2005.
USE NAMES OF CHILDREN, DATES OF BIRTH, AND PERIODS OF PREGNANCY AS REFERENCE POINTS.

ENTER METHOD USE CODE OR '0' FOR NONUSE IN EACH BLANK MONTH.

ILLUSTRATIVE QUESTIONS:

323. CHECK 311/311A:
CIRCLE METHOD CODE: IF MORE THAN ONE METHOD CODE CIRCLED IN 311/311A, CIRCLE CODE FOR HIGHEST METHOD IN LIST.

324. Where did you obtain (CURRENT METHOD) when you started using it?
324A. Where did you learn how to use periodic abstinence?
IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER, OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.

324B. CHECK 311/311A:
CIRCLE METHOD CODE: IF MORE THAN ONE METHOD CODE CIRCLED IN 311/311A, CIRCLE CODE FOR HIGHEST METHOD IN LIST.

324C. Were you ever advised that this contraceptive method does not protect against AIDS or other sexually-transmitted disease?

325. CHECK 311/311A:
CIRCLE METHOD CODE: IF MORE THAN ONE METHOD CODE CIRCLED IN 311/311A, CIRCLE CODE FOR HIGHEST METHOD IN LIST.

326. You obtained (CURRENT METHOD FROM 323) from (SOURCE OF METHOD FROM 316 OR 324) in (DATE FROM 319/319A). At that time, were you told about side effects or problems you might have with the method?

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

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

329. CHECK 326:

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 323) from (SOURCE OF METHOD FROM 316 OR 324), were you told about other methods of family planning that you could use?

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

331. CHECK 311/311A:
CIRCLE METHOD CODE: IF MORE THAN ONE METHOD CODE CIRCLED IN 311/311A, CIRCLE CODE FOR HIGHEST METHOD IN LIST.

332. Where did you obtain (CURRENT METHOD) the last time?
PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.
IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.

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

334. Where is that? Any other place?
PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE(S). IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.

335. In the last 12 months, were you visited by a HSA or CBDA who talked to you about family planning?

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

337. 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 NUMBER, NAME, AND SURVIVAL STATUS OF EACH BIRTH IN 2005 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).

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

403. BIRTH HISTORY NUMBER FROM 212

404. FROM 212 AND 216 IN BIRTH HISTORY

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

406. How much longer would you have liked to wait?
IF PERIOD IS LESS THAN 2 YEARS, RECORD IN MONTHS. PROBE TO GET THE EXACT PERIOD OF TIME IF IT IS NOT CLEAR.

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

408. Where did you receive antenatal care for this pregnancy? Anywhere else?
PROBE TO IDENTIFY TYPE(S) OF SOURCE(S) AND CIRCLE THE APPROPRIATE CODE(S). IF UNABLE TO DETERMINE IF A HOSPITAL, HEALTH CENTER, OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.
[FOR LAST BIRTH ONLY]

409. How many months pregnant were you when you first received antenatal care for this pregnancy?
[FOR LAST BIRTH ONLY]

410. How many times did you receive antenatal care during this pregnancy?
[FOR LAST BIRTH ONLY]

411. As part of your antenatal care during this pregnancy, were any of the following done at least once?
[FOR LAST BIRTH ONLY]

412. During (any of) your antenatal care visit(s), were you told about the signs of pregnancy
complications?
[FOR LAST BIRTH ONLY]

413. Were you told where to go if you had any of these complications?
[FOR LAST BIRTH ONLY]

414. During this pregnancy, were you given an injection in the arm to prevent the baby from getting tetanus?
[FOR LAST BIRTH ONLY]

415. During this pregnancy, how many times did you get this tetanus injection?
[FOR LAST BIRTH ONLY]

416. CHECK 415:
[FOR LAST BIRTH ONLY]

417. At any time before this pregnancy, did you receive any tetanus injections, either to protect
yourself or another baby?
[FOR LAST BIRTH ONLY]

418. Before this pregnancy, how many other times did you receive a tetanus injection?
IF 7 OR MORE TIMES, RECORD '7'.
[FOR LAST BIRTH ONLY]

419. In what month and year did you receive the last tetanus injection before this pregnancy?
[FOR LAST BIRTH ONLY]

420. How many years ago did you receive that tetanus injection?
[FOR LAST BIRTH ONLY]

421. During this pregnancy, were you given or did you buy any iron tablets?
SHOW TABLETS.
[FOR LAST BIRTH ONLY]

422. During the whole pregnancy, for how many days did you take the tablets?
IF ANSWER IS NOT NUMERIC, PROBE FOR APPROXIMATE NUMBER OF DAYS.
[FOR LAST BIRTH ONLY]

423. During this pregnancy, did you take any drug for intestinal worms?
[FOR LAST BIRTH ONLY]

426. During this pregnancy, did you take any drugs to keep you from getting malaria?
[FOR LAST BIRTH ONLY]

427. What drugs did you take?
PROBE: Any other?
RECORD ALL MENTIONED. IF TYPE OF DRUG IS NOT DETERMINED, SHOW TYPICAL ANTIMALARIAL DRUGS TO RESPONDENT.
[FOR LAST BIRTH ONLY]

428. CHECK 427:
DRUGS TAKEN FOR MALARIA PREVENTION.
[FOR LAST BIRTH ONLY]

429. How many times did you take (SP/Fansidar or Novidar SP) during this pregnancy?
[FOR LAST BIRTH ONLY]

430. CHECK 407:
ANTENATAL CARE FROM HEALTH PERSONNEL DURING THIS PREGNANCY
[FOR LAST BIRTH ONLY]

431. Did you get the (SP/Fansidar or Novidar SP) during any antenatal care visit, during another visit to a health facility or from another source?
[FOR LAST BIRTH ONLY]

431A. Did you take the (SP/Fansidar or Novidar SP) under direct observation by the health worker each time, or did you take it at home?
[FOR LAST BIRTH ONLY]

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

433. Was (NAME) weighed at birth?

434. How much did (NAME) weigh?
RECORD WEIGHT IN KILOGRAMS FROM MOTHER'S HEALTH CARD, IF AVAILABLE.

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

436. Where did you give birth to (NAME)?
PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.
IF UNABLE TO DETERMINE IF A HOSPITAL, HEALTH CENTER, OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.

438. Was (NAME) delivered by caesarean section?

439. Before you were discharged after (NAME) was born, did any health care provider check on your health?
[FOR LAST BIRTH ONLY]

440. How long after delivery did the first check take place?
IF LESS THAN ONE DAY, RECORD HOURS. IF LESS THAN ONE WEEK, RECORD DAYS.
[FOR LAST BIRTH ONLY]

441. Who checked on your health at that time?
PROBE FOR MOST QUALIFIED PERSON.
[FOR LAST BIRTH ONLY]

442. After you were discharged, did any health care provider or a traditional birth attendant check on your health?
[FOR LAST BIRTH ONLY]

444. After (NAME) was born, did any health care provider or a traditional birth attendant check on your health?
[FOR LAST BIRTH ONLY]

445. How long after delivery did the first check take place?
IF LESS THAN ONE DAY, RECORD HOURS. IF LESS THAN ONE WEEK, RECORD DAYS.
[FOR LAST BIRTH ONLY]

446. Who checked on your health at that time?
PROBE FOR MOST QUALIFIED PERSON.
[FOR LAST BIRTH ONLY]

447. Where did this first check take place?
PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.
IF UNABLE TO DETERMINE IF A HOSPITAL, HEALTH CENTER, OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.
[FOR LAST BIRTH ONLY]

447A. In the two months after (NAME) was born, did any health care provider or a traditional birth attendant check on your health for a second time?
[FOR LAST BIRTH ONLY]

447B. How many days or weeks after the birth of (NAME) did the second check take place?
IF LESS THAN ONE WEEK, RECORD DAYS.
[FOR LAST BIRTH ONLY]

448. CHECK 439:
[FOR LAST BIRTH ONLY]

449. In the two months after (NAME) was born, did any health care provider or a traditional birth attendant check on his/her health?
[FOR LAST BIRTH ONLY]

450. How many hours, days or weeks after the birth of (NAME) did the first check take place?
IF LESS THAN ONE DAY, RECORD HOURS. IF LESS THAN ONE WEEK, RECORD DAYS.
[FOR LAST BIRTH ONLY]

451. Who checked on (NAME)'s health at that time?
PROBE FOR MOST QUALIFIED PERSON.
[FOR LAST BIRTH ONLY]

452. Where did this first check for (NAME) take place?
PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.
IF UNABLE TO DETERMINE IF A HOSPITAL, HEALTH CENTER, OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.
[FOR LAST BIRTH ONLY]

452A. In the two months after (NAME) was born, did any health care provider or a traditional birth attendant check on his/her health for a second time?
[FOR LAST BIRTH ONLY]

452B. How many days or weeks after the birth of (NAME) did the second check take place?
IF LESS THAN ONE WEEK, RECORD DAYS.
[FOR LAST BIRTH ONLY]

453. In the first two months after delivery, did you receive a vitamin A dose (like this/any of
these)?
SHOW COMMON TYPES OF CAPSULES.
[FOR LAST BIRTH ONLY]

454. Has your menstrual period returned since the birth of (NAME)?
[FOR LAST BIRTH ONLY]

455. Did your period return between the birth of (NAME) and your next pregnancy?
[REPEAT QUESTION FOR ALL BIRTHS SINCE 2005 EXCEPT THE LAST BIRTH]

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

457. CHECK 226:
IS RESPONDENT PREGNANT?

458. Have you begun to have sexual intercourse again since the birth of (NAME)?

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

460. Did you ever breastfeed (NAME)?

461. How long after birth did you first put (NAME) to the breast?
IF LESS THAN 1 HOUR, RECORD IN MINUTES. IF LESS THAN 24 HOURS, RECORD HOURS. OTHERWISE, RECORD DAYS.
[FOR LAST BIRTH ONLY]

462. In the first three days after delivery, was (NAME) given anything to drink other than breast milk?
[FOR LAST BIRTH ONLY]

463. What was (NAME) given to drink? Anything else?
RECORD ALL LIQUIDS MENTIONED.
[FOR LAST BIRTH ONLY]

464. CHECK 404:
IS CHILD LIVING?
[FOR LAST BIRTH ONLY]

465. Are you still breastfeeding (NAME)?
[FOR LAST BIRTH ONLY]

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

467. CHECK 404:
IS CHILD LIVING?

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

471. GO BACK TO 405 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 501.

SECTION 5. CHILD IMMUNIZATION AND HEALTH AND CHILD'S AND WOMAN'S NUTRITION

501. ENTER IN THE TABLE THE LINE NUMBER, NAME, AND SURVIVAL STATUS OF EACH BIRTH IN 2005 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

503. FROM 212 AND 216

503A. Has (NAME) received a vitamin A dose (like this/any of these) in the past six months?
SHOW COMMON TYPES OF CAPSULES.

504. Do you have a Health Passport for (NAME)?
IF YES: May I see it please?

505. Did you ever have a Health Passport for (NAME)?

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

506A. CHECK 506:

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

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

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

509A. A BCG vaccination against tuberculosis, that is, an injection in the arm or shoulder that usually causes a scar?

509B. Polio vaccine, that is, drops in the mouth?

509C. Was the first polio vaccine received in the first two weeks after birth or later?

509D. How many times was the polio vaccine received?

509E. A DPT/Pentavalent (DPT-HepB-Hib) vaccination, that is, an injection given in the thigh or buttocks, sometimes at the same time as polio drops?

509F. How many times was a DPT/ Pentavalent (DPT-HepB-Hib) vaccination received?

509G. A measles injection or an MMR injection - that is, a shot in the thigh at the age of 9 months or older - to prevent him/her from getting measles?

510. Were any of the vaccinations (NAME) received during the last two years given as part of a national immunization day campaign?

517. Has (NAME) taken any drug for intestinal worms in the last six months?

517A. Is (NAME) currently enrolled in a programme at a health facility that provides food support, such as likuni phala or chiponde?

517B. What programme does (NAME) participate in?

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

519. Was there any blood in the stools?

520. 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?

521. 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?

522. Did you seek advice or treatment for the diarrhea from any source?

523. Where did you seek advice or treatment? Anywhere else?
PROBE TO IDENTIFY EACH TYPE OF SOURCE AND CIRCLE THE APPROPRIATE
CODE(S).
IF UNABLE TO DETERMINE IF A HOSPITAL, HEALTH CENTER, OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.

524. CHECK 523:

525. Where did you first seek advice or treatment?
USE LETTER CODE FROM 523.

526. How many days after the diarrhea began did you first seek advice or treatment for (NAME)?
IF THE SAME DAY, RECORD '00'.

528. Was he/she given a fluid made from a special packet called THANZI or ORS?

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

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

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

533A. At any time during the illness, did (NAME) have blood taken from his/her finger or heel for testing?

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

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

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

537. CHECK 533:
HAD FEVER?

538. 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?

539. 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?

540. Did you seek advice or treatment for the illness from any source?

541. Where did you seek advice or treatment? Anywhere else?
PROBE TO IDENTIFY EACH TYPE OF SOURCE AND CIRCLE THE APPROPRIATE
CODE(S). IF UNABLE TO DETERMINE IF A HOSPITAL, HEALTH CENTER, OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.

542. CHECK 541:

543. Where did you first seek advice or treatment?
USE LETTER CODE FROM 541.

544. How many days after the illness began did you first seek advice or treatment for (NAME)?
IF THE SAME DAY, RECORD '00'.

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

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

550. CHECK 547:
ANY CODE A-G CIRCLED?

551. CHECK 547:
SP/FANSIDAR/NOVIDAR SP ('A') GIVEN

552. How long after the fever started did (NAME) first take SP/Fansidar or Novidar SP?

553. For how many days did (NAME) take the SP/Fansidar or Novidar SP?
IF 7 DAYS OR MORE, RECORD 7.

554. CHECK 547:
CHLOROQUINE ('B') GIVEN

555. How long after the fever started did (NAME) first take chloroquine?

556. For how many days did (NAME) take the chloroquine?
IF 7 DAYS OR MORE, RECORD 7.

557. CHECK 547:
AMODIAQUINE ('C') GIVEN

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

559. For how many days did (NAME) take the Amodiaquine?
IF 7 DAYS OR MORE, RECORD 7.

560. CHECK 547:
QUININE ('D') GIVEN

561. How long after the fever started did (NAME) first take quinine?

562. For how many days did (NAME) take the quinine?
IF 7 DAYS OR MORE, RECORD 7.

563. CHECK 547:
LA ('E') GIVEN

564. How long after the fever started did (NAME) first take LA?

565. For how many days did (NAME) take the LA?
IF 7 DAYS OR MORE, RECORD 7.

565A. How many times per day did (NAME) take the LA?

566. CHECK 547:
ARTESUNATE ('F') GIVEN

567. How long after the fever started did (NAME) first take (ARTESUNATE)?

568. For how many days did (NAME) take the (ARTESUNATE)?
IF 7 DAYS OR MORE, RECORD 7.

568A. CHECK 547:
AA/ASAQ (COMBINED AMODIAQUINE AND ARTESUNATE) ('G') GIVEN

568B. How long after the fever started did (NAME) first take (AA/ASAQ)?

568C. For how many days did (NAME) take the (AA/ASAQ)?
IF 7 DAYS OR MORE, RECORD 7.

569. CHECK 547:
OTHER ANTIMALARIAL ('H') GIVEN

570. How long after the fever started did (NAME) first take (OTHER ANTIMALARIAL)?

571. For how many days did (NAME) take the (OTHER ANTIMALARIAL)?
IF 7 DAYS OR MORE, RECORD 7.

572. GO BACK TO 503 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 575

575. CHECK 528, ALL COLUMNS:

576. Have you ever heard of a special product called THANZI-ORS or a pre-packaged ORS liquid you can get for the treatment of diarrhea?

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

578. Now I would like to ask you about liquids or foods (NAME FROM 577) had yesterday during the day or at night. Did (NAME FROM 577) (drink/eat):

579. Now I would like to ask you about solid or semi-solid (mushy) foods that (NAME FROM 577) may have had yesterday during the day or at night. I am interested in whether your child had the item even if it was combined with other foods.
Did (NAME FROM 577) eat:

580. CHECK 578i, 578j, AND 578k (BABY CEREAL OR OTHER PORRIDGE) AND
579a THROUGH 579q:

581. How many times did (NAME FROM 577) eat solid, semi-solid, or soft foods yesterday during the day or at night?
IF 7 OR MORE TIMES, RECORD '7'.

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 marital status now: are you widowed, divorced, or separated?

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

605. RECORD THE HUSBAND'S/PARTNER'S NAME AND LINE NUMBER FROM THE HOUSEHOLD QUESTIONNAIRE.
IF HE IS NOT 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 partners does your husband live with now as if married?

608. Are you the first, second, ? wife/partner?

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

610. CHECK 603:
IS RESPONDENT CURRENTLY WIDOWED?

611. CHECK 603:
IS RESPONDENT CURRENTLY WIDOWED?

612. How did your previous marriage or union end?

613. Who got most of the land and possessions, such as household goods, money, vehicles or livestock, that you and your husband owned?

613A. Did you receive any legal support or assistance following the property grabbing?

615. CHECK 609:

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

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

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

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

618. 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?

618A. The first time you had sexual intercourse, was it to participate in a cultural practice or ritual such as chinamwali or kuchosa fumbi?

621. CHECK 107:

622. The first time you had sexual intercourse, was a condom used?

623. How old was the person you first had sexual intercourse with?

624. Was this person older than you, younger than you, or about the same age as you?

625. Would you say this person was ten or more years older than you or less than ten years older than you?

626. Now I would like to ask you some questions about your recent sexual activity in the last 12 months. 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.

626A. 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.

627. When was the last time you had sexual intercourse with this person?
[REPEAT QUESTION FOR LAST THREE SEXUAL PARTNERS EXCEPT THE LAST PARTNER]

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

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

630. 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'.

630A. CHECK 609:

630B. CHECK 618:

631A. How long ago did you first have sexual intercourse with this (second/third) person?

631B. CHECK 630:

631C. How many times during the last 12 months did you have sexual intercourse with this person: once, twice, or more?

632. CHECK 107:

633. How old is this person?

634. Is this person older than you, younger than you, or about the same age?

635. Would you say this person is ten or more years older than you or less than ten years older than you?

638. Apart from [this person/these two people], have you had sexual intercourse with any other
person in the last 12 months?
[FOR LAST SEXUAL PARTNER AND SECOND-TO-LAST SEXUAL PARTNER ONLY]

639. In total, with how many different people have you had sexual intercourse in the last 12 months?
IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE. IF NUMBER OF PARTNERS IS GREATER THAN 95, WRITE '95.'
[FOR THIRD-TO-LAST SEXUAL PARTNER ONLY]

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

640A. CHECK 618A:

640B. Have you ever had sexual intercourse as part of a cultural practice or ritual, such as chinamwali or kuchosa fumbi?

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

642. Where is that? Anywhere else?
PROBE TO IDENTIFY EACH TYPE OF SOURCE AND CIRCLE THE APPROPRIATE
CODE(S). IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER, OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.

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

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

645. Where is that? Anywhere else?
PROBE TO IDENTIFY EACH TYPE OF SOURCE AND CIRCLE THE APPROPRIATE
CODE(S). IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.

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

SECTION 7. FERTILITY PREFERENCES

701. CHECK 311/311A:

702. CHECK 226:

NOT PREGNANT OR UNSURE: Now I have some questions about the future. Would you like to have (a/another) child, or would you prefer not to have any (more) children?

PREGNANT: Now I have some questions about the future. After the child you are expecting now, would you like to have another child, or would you prefer not to have any more children?

703. CHECK 226:

NOT PREGNANT OR UNSURE: How long would you like to wait from now before the birth of (a/another) child?

PREGNANT: After the birth of the child you are expecting now, how long would you like to wait before the birth of another child?

704. CHECK 226:

705. CHECK 310:
USING A CONTRACEPTIVE METHOD?

706. CHECK 703:

707. CHECK 702:

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

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

RECORD ALL REASONS MENTIONED.

708. CHECK 310:
USING A CONTRACEPTIVE METHOD?

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

713. 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.

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

716A. In the last few months have you heard about family planning:

716B. In the last few months, have you listened to any of the following program series about family planning or health on the radio?

717. CHECK 601:

718. CHECK 311/311A:

719. Does your husband/partner know that you are using a method of family planning?

720. Would you say that using contraception is mainly your decision, mainly your husband's/partner's decision, or did you both decide together?

721. CHECK 311/311A:

722. 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: primary, secondary, or higher?

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

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. CHECK 811:

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

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

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

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

818. CHECK 601:

819. CHECK 817:

820. Who usually decides how the money you earn will be used: mainly you, mainly your husband/partner, or you and your husband/partner jointly?

821. 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?

822. Who usually decides how your husband's/partner's earnings will be used: you, your husband/partner, or you and your husband/partner jointly?

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

824. Who usually makes decisions about making major household purchases?

825. Who usually makes decisions about making purchases for daily household needs?

826. Who usually makes decisions about visits to your family or relatives?

826A. Do you own this or any other house either alone or jointly with someone else?

826B. Do you own any land either alone or jointly with someone else?

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

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

SECTION 9. HIV/AIDS

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

902. Can people reduce their chance of getting the AIDS virus by having just one uninfected sex partner 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 reduce their chance of getting the AIDS virus by not having sexual intercourse at all?

907. Can people get the AIDS virus because of witchcraft or other supernatural means?

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

909. Can the virus that causes AIDS be transmitted from a mother to her baby:

910. CHECK 909:

911. 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?

912. Have you heard about special antiretroviral drugs that people infected with the AIDS virus can get from a doctor or a nurse to help them live longer?

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

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

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

932. 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?

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

942. CHECK 901:

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

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

943. CHECK 618:

944. CHECK 942:
HEARD ABOUT OTHER SEXUALLY TRANSMITTED INFECTIONS?

945. 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?

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

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

948. CHECK 945, 946, AND 947:

949. The last time you had (PROBLEM FROM 945/946/947), did you seek any kind of advice or treatment?

950. Where did you go? Anywhere else?
PROBE TO IDENTIFY EACH TYPE OF SOURCE AND CIRCLE THE APPROPRIATE
CODE(S). IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER, VCT CENTER, OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.

951. Husbands and wives do not always agree on everything. If a wife knows her husband has a disease that she can get during sexual intercourse, is she justified in refusing to have sex with him?

952. 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?

955. CHECK 601:

956. Can you say no to your husband/partner if you do not want to have sexual intercourse?

957. Could you ask your husband/partner to use a condom if you wanted him to?

SECTION 10. OTHER HEALTH ISSUES

1001. Have you ever heard of an illness called tuberculosis or TB?

1002. How does tuberculosis spread from one person to another?
PROBE: Any other ways?
RECORD ALL MENTIONED.

1002A. Has a doctor or other healthcare professional ever told you that you had tuberculosis?

1002B. How long ago did a doctor or other healthcare professional tell you that you had tuberculosis: in the past year, more than one year ago, but less than five years ago, or more than five years ago?

1003) Can tuberculosis be cured?

1004. If a member of your family got tuberculosis, would you want it to remain a secret or not?

1005. 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 GREATER THAN 90, OR DAILY FOR 3 MONTHS OR MORE, RECORD '90'. IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE.

1006. Among these injections, how many were administered by a doctor, a nurse, a pharmacist, a dentist, or any other health worker?
IF NUMBER OF INJECTIONS IS GREATER THAN 90, OR DAILY FOR 3 MONTHS OR MORE, RECORD '90'. IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE.

1009. Do you currently smoke cigarettes?

1010. In the last 24 hours, how many cigarettes did you smoke?

1011. Do you currently smoke or use any other type of tobacco?

1012. What (other) type of tobacco do you currently smoke or use?
RECORD ALL MENTIONED.

1013. 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?

1020. Sometimes a woman can have a problem such that she experiences a 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 a pelvic surgery.
Have you ever experienced a constant leakage of urine or stool from your vagina during the day and night?

1021. Did this problem occur after a delivery?

1022. Did this problem occur after a normal labor and delivery, or after a very difficult labor and delivery?

1023. Was this baby born alive?

1024. Did this problem occur after a sexual assault?

1025. Did this problem occur after you had pelvic surgery?

1026. Did this problem occur after some other event happened to you?
IF YES: What happened?

1027. How many days after (ANSWER TO 1021/1024/1025/1026) did the leakage start?
IF MORE THAN 99 DAYS, WRITE '99'.

1028. Have you sought treatment for this condition?

1028A. How long after the problem started did you seek treatment?

1029. From whom did you last seek treatment?

1030. Did the treatment stop the problem?

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, 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?

1102. CHECK 1101:

1103. How many of these births did your mother have before you were born?

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

1105. Is (NAME) male or female?

1106. Is (NAME) still alive?

1107. How old is (NAME)?

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

1109. How old was (NAME) when he/she died?

1110. Was (NAME) pregnant when she died?

1111. Did (NAME) die during childbirth?

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

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

IF NO MORE BROTHERS OR SISTERS, GO TO 1200

SECTION 12. DOMESTIC VIOLENCE

1200. CHECK FRONT COVER

1201. CHECK FOR PRESENCE OF OTHERS:
DO NOT CONTINUE UNTIL EFFECTIVE PRIVACY IS ENSURED.

1202. CHECK 601 AND 602:

1203. 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?

1204. Now if you will permit me, I need to ask some more questions about your relationship with your (last) husband/partner. If we should come to any question that you do not want to answer, just let me know and we will go on to the next question.

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

1204B. How many times did this happen during the last 12 months?

1205A. (Does/did) your (last) husband/partner ever do any of the following things to you:

1205B. How often did this happen during the last 12 months: often, only sometimes, or not at all?

1206. CHECK 1205 (a-i):

1207. 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'.

1208. Did the following ever happen as a result of what your (last) husband/partner did to you:

1209. 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?

1210. CHECK 603:

1211. In the last 12 months, how often have you done this to your husband/partner: often, only sometimes, or not at all?

1212. Does (did) your husband/partner drink alcohol?

1213. How often does (did) he get drunk: often, only sometimes, or never?

1214. CHECK 601 AND 602:

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

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

1215. Who has hurt you in this way? Anyone else?
RECORD ALL MENTIONED.

1216. In the last 12 months, how often have you been hit, slapped, kicked, or physically hurt by this/these person(s):

1217. CHECK 201, 226, AND 229:

1218. Has anyone ever hit, slapped, kicked, or done anything else to hurt you physically while you were pregnant?

1219. Who has done any of these things to physically hurt you while you were pregnant? Anyone else?
RECORD ALL MENTIONED.

1220. CHECK 618: EVER HAD SEX?

1221. The first time you had sexual intercourse, would you say that you had it because you wanted to, or because you were forced to have it against your will?

1222. CHECK 601 AND 602:

EVER MARRIED/LIVED WITH A MAN: In the last 12 months, has anyone other than your (current/last) husband/partner forced you to have sexual intercourse against your will?

NEVER MARRIED/NEVER LIVED WITH A MAN: In the last 12 months has anyone forced you to have sexual intercourse against your will?

1223. CHECK 1221 AND 1222:

1224. CHECK 1205A(h) and 1205A(i):

1225. 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?

1226. How old were you the first time you were forced to have sexual intercourse or perform any other sexual acts?

1227. Who was the person who was forcing you at that time?

1228. CHECK 1205A (a-i), 1214, 1218, 1222 AND 1225:

1229. Thinking about what you yourself have experienced among the different things we have been talking about, have you ever tried to seek help to stop (the/these) person(s) from doing this to you again?

1230. From whom have you sought help? Anyone else?
RECORD ALL MENTIONED.

1231. Have you ever told anyone else about this?

1232. As far as you know, did your father ever beat your mother?

FILL OUT THE QUESTIONS BELOW WITH REFERENCE TO THE DOMESTIC VIOLENCE MODULE ONLY.

1233. 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?

1234. INTERVIEWER'S COMMENTS/EXPLANATION FOR NOT COMPLETING THE DOMESTIC VIOLENCE MODULE:____________________________

SECTION 13. HIV TESTING AND AIDS TREATMENT

1301. CHECK 208 AND 215:

1302. CHECK 407 FOR LAST BIRTH:

1303. CHECK FOR PRESENCE OF OTHERS. BEFORE CONTINUING, MAKE EVERY EFFORT TO ENSURE PRIVACY.

1304. During any of the antenatal visits for your last birth, were you given any information about:

1305. Were you offered a test for the AIDS virus as part of your antenatal care?

1306. Were you tested for the AIDS virus as part of your antenatal care?

1307. Did you get the results of the test?

1308. Where was the test done?
PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.
IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER, VCT CENTER, OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.

1309. Have you been tested for the AIDS virus since that time you were tested during your pregnancy?

1311. Have you ever been tested to see if you have the AIDS virus?

1312. When was the last time you were tested?

1313. The last time you had the test, did you yourself ask for the test, was it offered to you and you accepted, or was it required?

1314. Where was the test done? Anywhere else?
PROBE TO IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE APPROPRIATE CODE.
IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER, VCT CENTER, OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.

1315. Did you get the results of the test?

1316. CHECK 1307 and 1315:
RECEIVED RESULT OF TEST

1316A. CHECK FOR PRESENCE OF OTHERS:
DO NOT CONTINUE UNTIL EFFECTIVE PRIVACY IS ENSURED.

1317. Let me remind you that all of your answers are confidential, and that the information you provide is very important for the survey. Could you please tell me what was the result of your last test for the AIDS virus?

1318. Are you taking ARV medicines daily?

1319. Have you ever taken ARV medicines daily?

1320. CHECK 208 AND 215:

1321. Did you know you were positive before you gave birth to (NAME)?

1322. CHECK 1318 AND 1319:

1323. Were you taking ARV medicines daily when you gave birth to (NAME)?

1324. During the pregnancy or during labor and delivery of (NAME), were you offered medicine to reduce the risk of passing the AIDS virus to your baby?

1325. Did you take the medicine?

1326. While you were pregnant with (NAME), did you receive medicine to give to him/her after birth to reduce the chances that he/she would get the AIDS virus?

1327. During the first few days of life, did (NAME) take medicine to reduce the risk of getting the AIDS virus?

1328. CHECK 216 LAST ROW:
IS CHILD LIVING?

LIVING: Has (NAME) ever been tested to see if he/she has the AIDS virus?

DEAD: Was (NAME) ever tested to see if he/she has the AIDS virus?

1329. What was the result of (NAME)'s most recent (last) test?

1330. CHECK 216 LAST ROW:
IS CHILD LIVING?

1331. Is (NAME) currently taking ARVs daily?

1332. Do you know of a place where people can go to get tested for the AIDS virus?

1333. Where is that? Any other place?
PROBE TO IDENTIFY EACH TYPE OF SOURCE AND CIRCLE THE APPROPRIATE
CODE(S). IF UNABLE TO DETERMINE IF HOSPITAL, HEALTH CENTER, VCT CENTER, OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.

THANK THE RESPONDENT FOR HER COOPERATION AND REASSURE HER ABOUT THE CONFIDENTIALITY OF HER ANSWERS.

1334. INTERVIEWER'S COMMENTS/EXPLANATION FOR NOT FINISHING THE HIV TESTING AND AIDS TREATMENT MODULE:__________________________

1335. RECORD THE TIME.

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: _______________________

INSTRUCTIONS:
ONLY ONE CODE SHOULD APPEAR IN ANY BOX. ALL MONTHS SHOULD BE FILLED IN.

INFORMATION TO BE CODED FOR EACH COLUMN

BIRTHS, PREGNANCIES, CONTRACEPTIVE USE