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NEPAL DEMOGRAPHIC AND HEALTH SURVEY 2011 WOMAN???S QUESTIONNAIRE

NAME AND CODE OF DISTRICT _____________

NAME AND CODE OF VILLAGE/MUNICIPALITY _____________

WARD NUMBER _____________

CLUSTER NUMBER _____________

NAME AND LINE NUMBER OF WOMAN _____________

NAME OF HOUSEHOLD HEAD _____________

WOMAN SELECTED FOR DOMESTIC VIOLENCE MODULE

YES 1
NO 2

INTERVIEWER VISITS

VISIT 1

DATE _____________
INTERVIEWER???S NAME _____________
RESULT* _____________

*RESULT CODES:

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

NEXT VISIT:
DATE _____________
TIME _____________

VISIT 2

DATE _____________
INTERVIEWER???S NAME _____________
RESULT* _____________

NEXT VISIT:
DATE _____________
TIME _____________

VISIT 3

DATE _____________
INTERVIEWER???S NAME _____________
RESULT* _____________

NEXT VISIT:
DATE _____________
TIME _____________

FINAL VISIT

DAY_____________
MONTH _____________
YEAR _____________
INT. NUMBER _____________
RESULT_____________

TOTAL NUMBER OF VISITS

LANGUAGE OF QUESTIONNAIRE: ENGLISH

LANGUAGE OF INTERVIEW _____________

NATIVE LANGUAGE OF RESPONDENT _____________

TRANSLATOR USED

YES 1
NO 2

LANGUAGE CODES:

NEPALI 1
BHOJPURI 2
MAITHILI 3
OTHER 6

SUPERVISOR

NAME _____________
DATE _____________

OFFICE EDITOR _____________

KEYED BY _____________

SECTION 1. RESPONDENT???S BACKGROUND

INFORMED CONSENT

Hello. My name is ____________________________. I am working with MINISTRY OF HEALTH AND POPULATION. We are conducting a survey about health all over Nepal. The information we collect will help the government to plan health services. Your household was selected for the survey. The questions usually take about 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 tam. No part of this interview is being recorded in tape or video. You don???t have to be in the survey, but we hope you will agree to answer the questions since your views are important. If I ask you any question you don???t want to answer, just let me know and I will go on to the next question or you can stop the interview at any time.

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

SIGNATURE OF INTERVIEWER: _____________
DATE: _____________

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

101) RECORD THE TIME.

HOUR __________
MINUTES __________

101A) COLLECT ANY RELEVANT DOCUMENTS THAT MAY HAVE INFORMATION ON THE RESPONDENT???S AGE AND HER CHILDREN???S AGE AND IMMNISATIONS.

102) In what month and year were you born?

MONTH __________
DON???T KNOW MONTH 98
YEAR __________
DON???T KNOW YEAR 9998

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

AGE IN COMPLETED YEARS __________

104) Have you ever attended school?

YES 1
NO 2 (GO TO 107)

105) What is the highest grade you completed?
IF COMPLETED LESS THAN ONE GRADE, RECORD ???00???.

GRADE _________

106) CHECK 105:

GRADE 5 OR LOWER (GO TO 107)
GRADE 6 OR HIGHER 9 (GO TO 110)

107) Now I would like you to read this sentence to me.
SHOW CARD TO RESPONDENT.
IF RESPONDENT CANNOT READ THE WHOLE SENTENCE, PROBE:
Can you read any part of the sentence to me?

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

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

YES 1
NO 2

109) CHECK 107:

CODE ???2???, ???3???, OR ???4??? CIRCLED (GO TO 110)
CODE ???1??? OR ???5??? CIRCLED (GO TO 111)

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

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

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

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

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

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

113) What is your religion?

HINDU 1
BUDDHIST 2
MUSLIM 3
KIRAT
CHRISTIAN 5
OTHER (SPECIFY) _________ 6

114) What is your caste/ethnicity?
WRITE CASTE/ETHNICITY ON LINE PROVIDED.

(CASTE/ETHNICITY)_________________

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

NUMBER OF TIMES ________
NONE 00 (GO TO 201)

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

YES 1
NO 2

Now I would like to ask you about all the pregnancies that you have had during your life. By this I mean all the children born to you whether they were born alive or dead whether they are still living or not, whether they live with you or somewhere else, and all the pregnancies that you had that did not result in a live birth. I understand that it is not easy to talk about children who have died, or pregnancies that ended before full term, but it is important that you tell us about all of them, so that the government can develop programs to improve children???s health.

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

YES 1
NO 2 (GO TO 206)

202) Do you have any sons or daughters to whom you have given birth who are now living with you?

YES 1
NO 2 (GO TO 204)

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

SONS AT HOME __________
DAUGHTERS AT HOME __________

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

YES 1
NO 2 (GO TO 206)

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

SONS ELSEWHERE __________
DAUGHTERS ELSEWHERE _________

206) Have y9ou ever given birth to a boy or girl who was born alive but later died?
IF NO, PROBE: Any baby who cried or showed signs of life but did not survive?

YES 1
NO 2 (GO TO 208)

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

BOYS DEAD________
GIRLS DEAD ________

208) Women sometimes have pregnancies that do not result in a live born child. That is, a pregnancy can end in a miscarriage, or the child can be born dead. Have you ever had a pregnancy that did not end in a live birth?

YES 1
NO 2 (GO TO 210)

209) How many pregnancies have you had that did no end in a live birth?

PREGNANCY LOSSES _________

210) SUM ANSWERS TO 203, 205, 207 AND 209, AND ENTER TOTAL. IF NONE, RECORD ???00???.

TOTAL PREGNANCIES __________

211) CHECK 210:
Just to make sure that I have this right: you have had in TOTAL ______ pregnancies during your life. Is that correct?

YES (GO TO 212)
NO (PROBE AND CORRECT 201-210 AS NECESSARY).

212) CHECK 210:

ONE OR MORE PREGNANCIES (GO TO 213)
NO PREGNANCY (GO TO 234)

213) Now I would like to record all your pregnancies, whether born alive, born dead, or lost before full term, starting with the first one you had.
RECORD ALL THE PREGNANCIES IN 215. RECORD TWINS AND TRIPLETS ON SEPARATE LINES.
(IF THERE ARE MORE THAN 12 PREGNANCIES, USE AN ADDITIONAL QUESTIONNAIRE STARTING WITH THE SECOND ROW).

214) PREGNANCY HISTORY NUMBER____

215) Think back to your first pregnancy. Was that a single or multiple pregnancy?

SING. 1
MULT. 2

216) Was the baby born alive, born dead, or lost before birth?

BORN ALIVE 1 (SKIP TO 218)
BORN DEAD 2
LOST BEFORE FULL TERM 3 (SKIP TO 226)

217) Did that baby cry, move, or breathe when it was born?

YES 1
NO 2 (GO TO 226)

218) What name was given to the child?

(NAME) ________________

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

BOY 1
GIRL 2

220) In what moth and year was (NAME) born?
PROBE: When is his/her birthday?

MONTH _______
YEAR _______

221) Is (NAME) still alive?

YES 1
NO 2 (GO TO 225)

222) IF BORN ALIVE AND STILL LIVING:
How old was (NAME) at his/her last birthday?
RECORD AGE IN COMPLTED YEARS.

AGE IN YEARS_______

223) Is (NAME) living with you?

YES 1
NO 2

224) RECORD HOUSEHOLD LINE NUMBER OF CHILD (RECORD ???00??? IF CHILD NOT LISTED IN HOUSEHOLD).

HOUSEHOLD LINE NUMBER __________ (NEXT PREGNANCY, THEN GO TO 229)

225) 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.

DAYS 1 _______
MONTHS 2_______
YEARS 3 _______
(NEXT PREGNANCY, THEN GO TO 229)

226) IF BORN OR LOST BEFORE BIRTH:
In what month and year did this pregnancy end?

MONTH _________
YEAR ________

227) How many months did this pregnancy last?
RECORD IN COMPLETED MONTHS.

MONTHS __________

228) Did you or someone else do something to end this pregnancy?

YES 1
NO 2

229) Were there any other pregnancies between the previous pregnancy and this pregnancy?

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

233) C
FOR EACH BIRTH SINCE BAISAKH 2062, 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 ?????? 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.) CHECK 227 FOR EACH PREGNANCY THAT DID NOT END IN A LIVE BIRTH. CHECK 228. IF YES (CODE ???1??? CIRCLED), ENTER ???A??? FOR ABORTION OR ???C??? (IF CODE ???2??? CIRCLED) FOR MISCARRIAGE OR ???S??? FOR STILL BIRTH, IN CALENDAR IN THE MONTH THAT THE PREGNANCY TERMINATED AND ???P??? FOR THE REMAINING NUMBER OF COMPLETED MONTHS OF PREGNANCY.

234) Are you pregnant not?

YES 1
NO 2 (GO TO 237)
UNSURE 8 (GO TO 237)

235) How many months pregnant are you?
C
RECORD NUMBER OF COMPLETED MONTHS.
ENTER ???P??? IN THE CALENDAR, BEGINNING WITH THE MONTH OF NITERVIEW AND FOR THE TOTAL NUMBER OF COMPLETED MONTHS.

MONTHS _____________

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

YES 1 (GO TO 237A)
NO 2

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

LATER 1
NO MORE 2

237A) CHECK 226 AND 228:

HAD ABORTION SINCE 2062 (1 CIRCLED IN 228) (GO TO 237B)
DID NOT HAVE ABORTION SINCE 2062 (2 CIRCLE IN 228 OR NOT ASKED) (GO TO 238)

237B) What was the main reason you decided to have this (last) abortion?

HEALTH OF MOTHER 01
RISK OF BIRTH DEFECT 02
NO MONEY TO TAKE CARE OF BABY 03
TOTO YOUNG TO HAVE CHILD 04
NOT READY TO BE A MOTHER 05
WANTED TO CONTNIUE SCHOOLING 06
DID NOT LOVE THE FATER 07
WANTED TO DELAY CHILDBEARING 08
WANTED TO CONTINUE WORKING 09
WANTED TO SPACE CHILD 10
PARTNER DID NOT WANT CHILD 11
CHILD???S SEX 12
BECAUSE OF RAPE 13
TO AVOID SHAME 14
AFRAID OF PARENTS 15
NO ONE TO HELP LOOK AFTER CHILD 16
PARENTS INSISTED 17
FATHER OF CHILD DIED 18
OTHER (SPECIFY) _____________ 96

237C) What did you do to end this pregnancy?

DRANK MILK/COFFEE/OTHER LIQUID WITH LOTS OF SUGAR 01
DRANK HERBAL CONCOCTION 02
DRANK OTHER HOME REMEDIES 03
USED ANY HERBAL ANEMA 04
INSERTED HERB/OTHER SUBSTANCE IN THE VAGINA 05
TOOK TABLETS (UNSPECIFIED) 06
HEAVY MASSAGE 07
D AND C 08
MANUAL VACUUM ASPIRATION 09
INJECTION 10
SALINE INSTILLATION 11
MEDICAL ABORTION 12
OXYTOCIN 13
CATHETER 14
EXCESSIVE PHYSICAL ACTIVITY 15
OTHER 96

237D) Who did you see to get this done?
PROBE: Anyone else?
CIRCLE ALL MENTIONED.

HEALTH PROFESSIONAL
DOCTOR 1
NURSE/MIDWIFE B
HEALTH ASST/HLTH. WKR C
MCH WORKER D
VHW E
OTHER PERSON
PHARMACIST/CHEMICAL SELLER F
TRADITIONAL BIRTH ATTENDANT G
FCHV H
RELATIVE/FRIEND I
TRADITIONAL PRACTITIONER J
OTHER (SPECIFY) ________________ X
NO ONE Y

237E) Where did you go to get this done?

HOME
YOUR HOME A
OTHER HOME B
GOVT. SECTOR
GOVT. HOSPITAL C
PHC CENTER (SPECIFY) __________ D
HEALTH POST E
SUB-HEALTH F
PHC OUTREACH G
OTHER GOVT. (SPECIFY) __________ H
NON-GOVT. (NGO)
MARIE STOPES I
FPAN (SPECIFY) __________ K
PRIVATE MED. SECTOR
PVT. HOSPITAL/CLINIC NURSING HOME (SPECIFY) ___________ L
OTHER PRIVATE MED. (SPECIFY) ___________ M
OTHER (SPECIFY) _____________ X

237F) Did you have any complications when you had this abortion?

YES 1
NO 2

237G) In the first one month after the abortion, did you have any health problems because of the abortion?

YES 1
NO 2

237H) How much did you pay for the following services?
RECORD 9995 IF SERVICE NOT TAKE.

ABORTION SERVICE ______________
POST ABORTION SERVICE ____________

237I) Did anyone talk to you about family planning methods during your post abortion visit?

YES 1
NO 2
DON???T KNOW 8

238) When did you last menstrual period start?

(DATE IF GIVEN)______________
DAYS AGO 1 _________
WEEKS AGO 2 _________
MONTHS AGO 3 _________
YEARS AGO 4 _________
IN MENOPAUSE/HAS HAD HYSTERECTOMY 994
BEFORE LAST BIRTH 995
NEVER MENSTRUATED 996

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

YES 1
NO 2 (GO TO 241A)
DON???T KNOW 8 (GO TO 241A)

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

JUST BEFORE HER PERIOD BEGINS 1
DURING HER PERIOD 2
RIGHT AFTER HER PERIOD HAS ENDED 3
HALFWAY BETWEEN TWO PERIODS 4
OTHER (SPECIFY) ____________ 6
DON???T KNOW 8

241A) Is abortion legal in Nepal?

YES 1
NO 2 (GO TO 241C)
DON???T KNOW 8 (GO TO 241C)

241B) What are the conditions under which a woman can have an abortion in Nepal?

PREGNANCY OF 12 WEEKS OR LESS GESTATION FOR ANY WOMAN A
PREGNANCY OF 18 WEEKS IF IT IS A RESULT OF RAPER OR INCEST B
PREGNANCY OF ANY DURATION IF THE LIFE OF MOTHER IS AT RISK C
PREGNANCY OF ANY DURATION IF MOTHER???S PHYSICAL AND MENTAL HEALTH AT RISK D
FETUS IS DEFORMED E
OTHER (SPECIFY) ___________ X
DON???T KNOW Z

241C) Do you know of a place where a woman can go to get a safe abortion?

YES 1
NO 2 (GO TO 301)
DON???T KNOW 8 (GO TO 301)

241D) 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 OR CLINIC IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME OF THE PLACE.

(NAME OF PLACE(S)) ______________________
PUBLIC SECTOR
GOVT. HOSPITAL/CLINIC A
PHC CENTER B
HEALTH POST C
SUB-HEALTH POST D
PHC OUTREACH E
FCHV F
OTHER GOVT. (SPECIFY) _____________ G
NON-GOVT. (NGO) SECTOR
MARIE STOPES H
FPAN I
OTER NGO (SPECIFY) ___________ J
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC/NURSING HOME K
PHARMACY L
PRIVATE DOCTOR M
OTHER PRIVATE MEDICAL (SPECIFY) ____________ N
OTHER SOURCE
TBA O
OTHER (SPECIFY) _____________ X

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 pregancy. Have you ever heard of (METHOD)?

01) Female Sterilization. PROBE: Women can have an operation to avoid having any more children.
YES 1
NO 2
02) Male Sterilization. PROBE: Men can have an operation to avoid having any more children.
YES 1
NO 2
03) IUD PROBE: Women can have a loop or coil placed inside them by a doctor or a nurse.
YES 1
NO 2
04) Injectables. PROBE: Women can have an injection by a health provider that stops them from becoming pregnant for one or more months.
YES 1
NO 2
05) Implants. PROBE: Women can have on or more small rods placed in their upper arm by a doctor or nurse which can prevent pregnancy for one or more years.
YES 1
NO 2
06) Pill. PROBE: Women can take pill every day to avoid becoming pregnant.
YES 1
NO 2
07) Condom. PROBE: Med can put a rubber sheath on their penis before sexual intercourse.
YES 1
NO 2
08) Rhythm Method. PROBE: Every month that a woman is sexually active she can avoid pregnancy by not having sexual intercourse on the days of the month she is most likely to get pregnant.
YES 1
NO 2
09) Withdrawal. PROBE: Men can be careful and pull out before climax.
YES 1
NO 2
10) Emergency Contraception. PROBE: As an emergency measure, within three/five days after they have unprotected sexual intercourse, women can take special pills to prevent pregnancy.
YES 1
NO 2
11) Have you heard of any other ways or methods that women or men can use to avoid pregnancy?
YES 1
NO 2

302) CHECK 234:

NOT PREGNANT OR UNSURE (GO TO 303)
PREGNANT (GO TO 311)

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

YES 1
NO 2 (GO TO 311)

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

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

305) What is the brand name of the pills you are using?
IF DON???T KNOW THE BRAND, ASK TO SEE THE PACKAGE.

NILOCON WHITE 01
SUNAULO GULAPH 02
FEMINYL 03
FEMICON 04
OK PILLS 05
OTHER (SPECIFY) ___________ 96
DON???T KNOW 98

306) What is the brand name of the condoms you are using?
IF DON???T KNOW THE BRAND, ASK TO SEE THE PACKAGE.

DHAAL 01 (GO TO 308A)
PANTHER 02 (GO TO 308A)
BLACK COBRA 03 (GO TO 308A)
KAMASUTRA 04 (GO TO 308A)
JODI 05 (GO TO 308A)
NUMBER 1 (GO TO 308A)
MOHP-NO BRAND 07 (GO TO 308A)
LILY 08 (GO TO 308A)
VEGA 09 (GO TO 308A)
SKINLESS SKIN 10 (GO TO 308A)
SAFETY 11 (GO TO 308A)
GOLD 12 (GO TO 308A)
OTHER (SPECIFY) ____________ 96 (GO TO 308A)
DON???T KNOW 98 (GO TO 308A)

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

(NAME OF PLACE) __________________
PUBLIC SECTOR
GOVT. HOSPITAL/CLINIC 11
PHC CENTER 12
MOBILE CLINIC 13
OTHER GOVT. (SPECIFY) _____________ 14
NON-GOVT. (NGO) SECTOR
FPAN 21
MARIE STOPES 22
ADRA 23
NEPAL RED CROSS 24
UMN 25
OTHER NGO (SPECIFY) _____________ 26
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC/NURSING HOME 31
OTHER PRIVATE MEDICAL (SPECIFY) ____________ 36
OTHER (SPECIFY) ____________ 96
DON???T KNOW 98

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

MONTH ___________
YEAR ___________

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

MONTH__________
YEAR __________

309) CHECK 308/308A, 220 AND 226:
ANY BIRTH OR PREGNANCY TERMINATION AFTER MONTH AND YEAR OF START OF USE OF CONTRACEPTION IN 308/308A

YES (GO BACK TO 308/308A, PROBE AND RECORD MONTH AND YEAR AT START OF CONTINUOUS USE OF CURRENT METHOD (MUST BE AFTER LAST BIRTH OR PREGNANCY TERMINATION).
NO (GO TO 310)

CHECK 308/308A:

YEAR IS 2062 OR LATER
C
ENTER CODE FOR METHOD USED IN MONTH OR INTERVIEW IN THE CALENDAR AND IN EACH MONTH BACK TO THE DATE STARTED USING.
YEAR IS 2061 OR EARLIER
C
ENTER CODE FOR METHOD USED IN MONTH OF INTERVIEW IN THE CALENDAR AND EACH MONTH BACK IN BAISAKH 2062. THEN SKIP TO 322

311) I would like to ask you some questions about the time you or your partner may have used a method to avoid getting pregnatn during the last few years.
USE CALENDAR TO PROBE FOR EARLIER PERIODS OF USE AND NONUSE, STARTING WITH MOST RECENT USE, BACK TO BAISKAH 2062.
USE NAMES OF CHILDREN, DATES OF BIRTH, AND PERIOD OF PREGNANCY AS REFERENCE POINTS.
C
IN COLUMN 1, ENTER METHOD USE CODE OR ???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 then?

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

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

ILLUSTRATIVE QUESTION: Why did you stop using the (METHOD)? Did you become pregnant while using (METHOD), or 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 ETHER ???0??? IN EACH SUCH MONTH IN COLUMN 1.

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

NO METHOD USED (TO GO 313)
ANY METHOD USED (GO TO 314)

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

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

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

NO CODE CIRCLED 00 (GO TO 324)
FEMALE STERILZATION 01 (GO TO 371A)
MALE STERILIZATION 02 (GO TO 326)
IUD 03
INJECTABLES 04
IMPLANTS 05
PILL 06
CONDOM 07
FEMALE CONDOM 08
DIAPHRAGM 09
FOAM/JELLY 10
RHYTHM METHOD 12 (GO TO 315A)
WITHDRAWAL 13 (GO TO 326)
OTHER MODERN METHOD 95 (GO TO 326)
OTHER TRADITIONAL METHOD 96 (GO TO 326)

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

PUBLIC SECTOR
GOVT. HOSPITAL/CLINIC 11
PHC CENTER 12
HEALTH POST 13
SUB-HEALTH POST 14
PHC OUTREACH 15
MOBILE CLINIC 17
FCHV 18
CONDOM BOX 19
OTHER GOVT. (SPECIFY) ___________ 16
NON-GOVT. (NGO) SECTOR
FPAN 21
MARIE STOPES 22
ADRA 23
NEPAL RED CROSS 24
UMN 25
OTHER NGO. (SPECIFY) __________ 26
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC/NURSING HOME 31
PHARMACY 32
SANGINI OUTLET 33
OTHER PRIVATE MEDICAL (SPECIFY) ___________ 36
OTHER SOURCE
SHOP 41
FRIEND/RELATIVE 42
OTHER (SPECIFY) ___________ 96

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

(NAME OF PLACE) ________________
PUBLIC SECTOR
GOVT. HOSPITAL/CLINIC 11
PHC CENTER 12
HEALTH POST 13
SUB-HEALTH POST 14
PHC OUTREACH 15
MOBILE CLINIC 17
FCHV 18
CONDOM BOX 19
OTHER GOVT. (SPECIFY) ___________ 16
NON-GOVT. (NGO) SECTOR
FPAN 21
MARIE STOPES 22
ADRA 23
NEPAL RED CROSS 24
UMN 25
OTHER NGO. (SPECIFY) __________ 26
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC/NURSING HOME 31
PHARMACY 32
SANGINI OUTLET 33
OTHER PRIVATE MEDICAL (SPECIFY) ___________ 36
OTHER SOURCE
SHOP 41
FRIEND/RELATIVE 42
OTHER (SPECIFY) ___________ 96

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

IUD 03
INJECTABLES 04
IMPLANTS 05
PILL 06
CONDOM 07 (GO TO 323)
FEMALE CONDOM 08 (GO TO 320)
DIAPHRAGM 09 (GO TO 320)
FOAM/JELLY 10 (GO TO 320)
RHYTHM METHOD 12 (GO TO 326)

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

YES 1 (GO TO 319)
NO 2

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?

YES 1
NO 2 (GO TO 320)

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

YES 1
NO 2

320) CHECK 317:

CODE ???1??? CIRCLED:
At that time, were you told about other methods of family planning that you could use?
YES 1 (GO TO 322)
NO 2
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?
YES 1 (GO TO 322)
NO 2

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

YES 1
NO 2

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

FEMALE STERILIZATION 01 (GO TO 326)
MALE STERILIZATION (GO TO 326)
IUD 03 (GO TO 326)
INJECTABLES 04
IMPLANTS 05 (GO TO 326)
PILL 06
CONDOM 07
FEMALE CONDOM 08
DIAPHRAGM 09
FOAM/JELLY 10
RHYTHM METHOD 12 (GO TO 326)
WITHDRAWAL 13 (GO TO 326)
OTHER MODERN METHOD 95 (GO TO 326)
OTHER TRADITIONAL METHOD 96 (GO TO 326)

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

________________ (NAME OF PLACE)
PUBLIC SECTOR
GOVT. HOSPITAL/CLINIC 11
PHC CENTER 12
HEALTH POST 13
SUB-HEALTH POST 14
PHC OUTREACH 15
MOBILE CLINIC 17
FCHV 18
CONDOM BOX 19
OTHER GOVT. (SPECIFY) ___________ 16
NON-GOVT. (NGO) SECTOR
FPAN 21
MARIE STOPES 22
ADRA 23
NEPAL RED CROSS 24
UMN 25
OTHER NGO. (SPECIFY) __________ 26
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC/NURSING HOME 31
PHARMACY 32
SANGINI OUTLET 33
OTHER PRIVATE MEDICAL (SPECIFY) ___________ 36
OTHER SOURCE
SHOP 41
FRIEND/RELATIVE 42
OTHER (SPECIFY) ___________ 96

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

YES 1
NO 2 (SKIP TO 326)

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

____________ (NAME OF PLACE(S))
PUBLIC SECTOR
GOVT. HOSPITAL/CLINIC A
PHC CENTER B
HEALTH POST C
SUB-HEALTH POST D
PHC OUTREACH E
MOBILE CLINIC F
FCHV G
CONDOM BOX H
OTHER GOVT. (SPECIFY) ___________ I
NON-GOVT. (NGO) SECTOR
FPAN J
MARIE STOPES K
ADRA L
NEPAL RED CROSS M
UMN N
OTHER NGO. (SPECIFY) __________ O
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC/NURSING HOME P
PHARMACY Q
SANGINI OUTLET R
OTHER PRIVATE MEDICAL (SPECIFY) ___________ S
OTHER SOURCE
SHOP T
FRIEND/RELATIVE U
OTHER (SPECIFY) ___________ X

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

YES 1
NO 2

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

YES 1
NO 2 (GO TO 401)

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

YES 1
NO 2

SECTION 4. PREGNANCY AND POSTNATAL CARE

401) CHECK 323:

ONE OR MORE BIRTHS IN 2062 OR LATER (GO TO 402)
NO BIRTHS IN 2062 OR LATER (GO TO 542)

402) CHECK 220: ENTER IN THE TABLE LINE NUMBER, NAME, AND SURVIVAL STATUS OF EACH BIRTH IN 2062 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 some questions about your children born in the last five years. (We will talk about each separately).

403) PREGNANCY HISTORY NUMBER FROM 214 IN PREGNANCY HISTORY

PREGNANCY HISTORY NUMBER ____________

404) FROM 218 AND 221

NAME ____________
LIVING
DEAD

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

YES 1 (SKIP TO 408 FOR LAST BIRTH, 424 FOR OTHER BIRTHS)
NO 2

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

LATER 1
NO MORE 2 (SKIP TO 408 FOR LAST BIRTH 424 FOR OTHER BIRTHS)

407) How much longer did you want to wait?

MONTHS 1 ________
YEARS 2 ________
DON???T KNOW 998

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

YES 1
NO 2 (SKIP TO 414B)

409) Whom did you see?
Anyone else?
PROBE TO IDENTIFY EACH TYPE OF PERSON AND RECORD ALL MENTIONED.
IF FCHV NOT MENTIONED PROBE

HEALTH PERSONNEL
DOCTOR 1
NURSE/MIDWIFE B
HEALTH ASST./AHW C
MCH WORKER D
VHW E
OTHER PERSON
TRADITIONAL BIRTH ATTENDANT F
FCHV G
OTHER X (SPECIFY) ________
NO ONE Y (SKIP TO 414B)

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

(NAME OF PLACE(S)) _____________
HOME
YOUR HOME A
OTHER HOME B
GOVT. SECTOR
GOVT. HOSPITAL C
PHC CENTER D
HEALTH POST E
SUB-HEALTH POST F
PHC OUTREACH G
OTHER GOVT. (SPECIFY) ___________ H
NON-GOVT. (NGO) SECTOR
FPAN I
MARIE STOPES J
ADRA K
UMN L
OTHER NGO. (SPECIFY) __________ M
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC/NURSING HOME N
OTHER PRIVATE MEDICAL (SPECIFY) ___________ O
OTHER (SPECIFY) __________ X

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

MONTHS ________
DON???T KNOW 98

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

NUMBER OF TIMES _________
DON???T KNOW 98

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

Was your blood pressure measured?
YES 1
NO 2
Did you give a urine sample?
YES 1
NO 2
Did you give a blood sample?
YES 1
NO 2

413A) During (any of) your antenatal care visit(s), were you advised to use a skilled birth attendant?

YES 1
NO 2
DON???T KNOW 8

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

YES 1
NO 2
DON???T KNOW 8

414A) Were you told where to go if you had any problems with the pregnancy?

YES 1
NO 2
DON???T KNOW 8

414B) What kind of preparation did you make beforehand for the delivery of (NAME)?
Anything else?
CIRCLE ALL MENTIONED

SAVED MONEY 1
ARRANGED FOR TRANSPORT B
FOUND BLOOD DONOR C
CONTACTED HLTH WKR TO HELP WITH DELIVERY D
BOUGHT SAFE DELIVER KIT E
ARRANGED FOOD F
ARRANGED CLOTHES G
OTHER (SPECIFY) ___________ X
NO PREPARATION Y

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

YES 1
NO 2 (SKIP TO 418)
DON???T KNOW 8

417) CHECK 416:

2 OR MORE TIMES (SKIP TO 421)
OTHER (GO TO 418)

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

YES 1
NO 2 (SKIP TO 412)
DON???T KNOW 8 (SKIP TO 412)

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

TIMES __________
DON???T KNOW 8

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

YEARS AGO __________

421) During this pregnancy, were you given or did you buy any iron/folic acid tablets?

YES 1
NO 2 (SKIP TO 423)
DON???T KNOW 8 (SKIP TO 423)

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.

DAYS ___________
DON???T KNOW 998

422A) CHECK 422:

LESS THAN 180 DAYS (GO TO 422B)
OTHER (SKIP TO 423)

422B) What is the main reason for not taking the iron/folic acid tablets for at least 180 days?

DID NOT LIKE IT 1
DID NOT RECEIVE COMPLETE DOSE 2
NOT AVAILABLE 3
DID NOT KNOW 4
OTHER (SPECIFY) __________ 6

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

YES 1
NO 2
DON???T KNOW 8

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

VERY LARGE 1
LARGER THAN AVERAGE 2
AVERAGE 3
SMALLER THAN AVERAGE 4
VERY SMALL 5
DON???T KNOW 8

425) Was (NAME) weighed at birth?

YES 1
NO 2 (SKIP TO 427)
DON???T KNOW 8 (SKIP TO 427)

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

KG FROM CARD
1 ________. __________
KG FROM RECALL
2 ________. __________
DON???T KNOW 99998

427) Who assisted with the delivery of (NAME)
Anyone else?
PROBE FOR THE TYPE(S) OF PERSON(S) AND RECORD ALL MENTIONED.
IF FCHV NOT MENTIONED PROBE
IF RESPONDENT SAYS NO ONE ASSISTED, PROBE TO DETERMINE WHETHER ANY ADULTS WERE PRESENT AT THE DELIVERY.

HEALTH PERSONNEL
DOCTOR 1
NURSE/MIDWIFE B
HEALTH ASST./AHW C
MCHW D
VHW E
OTHER PERSON
TRADITIONAL BIRTH ATTENDANT F
FCHV G
RELATIVE/FRIEND H
OTHER (SPECIFY) ___________ X
NO ONE (SKIP TO 428)

427A) Immediately after delivery of (NAME) did you receive an injection in the thigh or buttock?

YES 1
NO 2

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

(NAME OF PLACE) ______________

428A) Did you receive cash incentive for transportation from the facility after the delivery of (NAME)?

YES 1
NO 2
DON???T KNOW 8

428B) Did the facility charge you any amount for the delivery of (NAME)?

YES 1
NO 2
DON???T KNOW 8

428C) How long did it take you to reach the facility for delivery of (NAME)?

MINUTES ____________
DON???T KNOW 998

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

YES 1
NO 2 (SKIP TO 430)

429A) Was it planned or was it carried out due to complication?

PLANNED 1
COMPLICATION 2

430) After you gave birth to (NAME), did anyone check on your health while you were still in the facility?

YES 1 (SKIP TO 433)
NO 2

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

YES 1 (SKIP TO 433)
NO 2 (SKIP TO 436)

431A) Why didn???t you deliver in a health facility?
PROBE: Any other reason?
RECORD ALL MENTIONED.

COST TOO MUCH A
FACILITY NOT OPEN B
TOO FAR/NO TRANSPORTATION C
DON???T TRUST FACILITY/POOR QUALITY SERVICE D
NO FEMALE PROVIDER AT FACILITY E
HUSBAND/FAMILY DID NOT ALLOW F
SECURITY CONCERNS G
NOT NECESSARY H
NOT CUSTOMARY I
CHILD BORN BEFORE REACHING FACILITY J
OTHER (SPECIFY) ________ X

431B) Was a special clean delivery kit used?
SHOW CLEAN DELIVERY KIT MARKED BY CRS.

YES 1 (SKIP TO 431D)
NO 2
DON???T KNOW 8

431C) When (NAME) was born, what instrument was used to cut the umbilical cord?

NEW/BOILED BLADE 1
USED BLADE 2
KNIFE 3
HASIYA 4
KHUKURI 5
SCISSORS 7
OTHER (SPECIFY) _________ 6
DON???T KNOW 8

431D) Was anything placed on the stump after the umbilical cord was cut?

YES 1
NO 2 (SKIP TO 431F)
DON???T KNOW 8 (SKIP TO 431F)

431E) What was placed on the stump?

OIL 1
ASH B
VERMILION C
OINTMENT/POWDER D
ANIMAL DUNG E
TURMERIC F
GHEE G
CHLORHEXIDINE H
OTHER (SPECIFY) __________ X
DON???T KNOW Z

431F) Was (NAME) dried before the placenta was delivered?

YES 1
NO 2
DON???T KNOW 8

431G) Was (NAME) placed on your belly/breast before delivery of the placenta?

YES 1
NO 2
DON???T KNOW 8

531H) Was (NAME) wrapped in cloth before the placenta was delivered?

YES 1
NO 2
DON???T KNOW 8

431I) How long after delivery was (NAME) bathed for the first time?
IF LESS THAN ONE DAY, RECORD HOURS. IF LESS THAN ONE WEEK, RECORD DAYS.

HOURS 1 _________
DAYS 2 _________
WEEKS 3 _________
DON???T KNOW 998

432) After you gave birth to (NAME), did anyone check on your health?

YES 1
NO (SKIP TO 436) 2

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

HEALTH PERSONNEL
DOCTOR 11
NURSE/MIDWIFE 12
HEALTH ASST./AHW 13
MCH WORKER 14
VHW 15
FCHV 16
OTHER (SPECIFY) __________ 96

433A) Did this person talk to you about using a family planning method?

YES 1
NO 2
DON???T KNOW 8

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

HOURS 1 _________
DAYS 2 __________
WEEKS 3 _________
DON???T KNOW 998

436) In the two months after (NAME) was born, did any health care provider check on his/her health?

YES 1
NO 2 (SKIP TO 440)
DON???T KNOW 8 (SKIP TO 440)

437) 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.

HRS AFTER BIRTH 1 __________
DAYS AFTER BIRTH 2 __________
WKS AFTER BIRTH 3 __________

438) Who checked on (NAME)???s health at that time?
PROBE FOR THE MOST QUALIFIED PERSON.
IF FCHV NOT MENTIONED PROBE

HEALTH PERSONNEL
DOCTOR 11
NURSE/MIDWIFE 12
HEALTH ASST./AHW 13
MCH WORKER 14
VHW 15
FCHV 16
OTHER (SPECIFY) __________ 96

439) Where did this first check of (NAME) take 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.

(NAME OF PLACE) _____________
HOME
YOUR HOME 11
OTHER HOME 12
GOVT. SECTOR
GOVT. HOSPITAL 21
PHC CENTER 22
HEALTH POST 23
SUB-HEALTH 24
PHC OUTREACH 25
OTHER GOVT. (SPECIFY) __________ 26
NON-GOVT. SECTOR
FPAN 31
MARIE STOPES 32
ADRA 33
UMN 34
OTHER GOVT. (SPECIFY) _________ 36
PRIVATE MED. SECTOR
PVT. HOSPITAL/CLINIC/N. HOME. 41
OTHER PRIVATE MED. (SPECIFY) __________ 46
OTHER (SPECIFY) __________ 96

440) In the first two months after delivery, did you receive a vitamin A dose like this?
SHOW VITAMIN A CAPSULES

YES 1
NO 2
DON???T KNOW 8

440A) After delivery were you given or did you buy any iron/folic acid tablets?
SHOW TABLETS.

YES 1
NO 2 (SKIP TO 441)
DON???T KNOW 8 (SKIP TO 441)

440B) After delivery, for how many days did you take the tablets?
IF ANSWER IS NOT NUMERIC, PROBE FOR APPROXIMATE NUMBER OF DAYS.

DAYS _______
DON???T KNOW 98

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

YES 1 (SKIP TO 443)
NO 2 (SKIP TO 444)

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

YES 1
NO 2 (SKIP TO 446)

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

MONTHS ________
DON???T KNOW 98

444) CHECK 234:
IS RESPONDENT PREGNANT?

NOT PREGNANT (GO TO 445)
PREGNANT OR UNSURE (SKIP TO 446)

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

YES 1
NO 2 (SKIP TO 447)

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

MONTHS __________
DON???T KNOW 98

447) Did you ever breastfeed (NAME)?

YES 1 (SKIP TO 449)
NO 2

448) CHECK 404: IS CHILD LIVING?

LIVING (SKIP TO 454)
DEAD (GO BACK TO 405 IN NEXT COLUMN; OR IF NO MORE BIRTHS, GO TO 501)

449) 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, RCORD DAYS.

IMMEDIATELY 000
HOURS 1 ________
DAYS 2 ________

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

YES 1
NO 2 (SKIP TO 452)

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

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

452) CHECK 404: IS CHILD LIVING?

LIVING (GO TO 453)
DEAD (GO BACK TO 405 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 501)

453) Are you still breastfeeding (NAME)?

YES 1
NO 2

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

YES 1
NO 2
DON???T KNOW 8

455) 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 PREGNANCY HISTORY NUMBER, NAME, AND SURVIVAL STATUS OF EACH BIRTH IN 2062 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) PREGNANCY HISTORY NUMBER FROM 214 IN BIRTH HISTORY

PREGNANCY HISTORY NUMBER __________

503) FROM 218 AND 221

NAME _____________
LIVING _____
DEAD_____ (GO TO 503 IN NEXT COLUMN OR, IF NO MORE BIRTHS, GO TO 539).

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

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

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

YES 1 (SKIP TO 509)
NO 2 (SKIP TO 509)

506)

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

BCG
DAY ______
MONTH ______
YEAR ______
POLIO 1
DAY ______
MONTH ______
YEAR ______
POLIO 2
DAY ______
MONTH ______
YEAR ______
POLIO 3
DAY ______
MONTH ______
YEAR ______
DPT 1/HEP B1
DAY ______
MONTH ______
YEAR ______
DAY 2/HEP B2
DAY ______
MONTH ______
YEAR ______
DAY 3/HEP B3
DAY ______
MONTH ______
YEAR ______
DPT1/HEP B1/Hib 1
DAY ______
MONTH ______
YEAR ______
DPT 2/HEP B2/Hib2
DAY ______
MONTH ______
YEAR ______
DPT 3/HEP B3/Hib3
DAY ______
MONTH ______
YEAR ______
MEASLES
DAY ______
MONTH ______
YEAR ______
JAPANESE ENCEPHALITIS
DAY ______
MONTH ______
YEAR ______

507) CHECK 506:

ALL RECORDED (GO TO 511)
OTHER (GO TO 508)

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

NAME ___________
YES 1 (PROBE FOR VACCINATIONS AND WRITE ???66??? IN THE CORRESPONDING DAY COLUMN IN 506) (SKIP TO 511)
NO 2 (SKIP TO 511)
DON???T KNOW 8 (SKIP TO 511)

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

YES 1
NO 2 (SKIP TO 511)
DON???T KNOW 8 (SKIP TO 511)

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

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

YES 1
NO 2
DON???T KNOW 8

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

YES 1
NO 2 (SKIP TO 510 D)
DON???T KNOW 8 (SKIP TO 510D)

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

NUMBER OF TIMES _____

510D) A DPT/HEP B/Hib vaccination, that is, an injectino given in the left thigh, usually at the same time as polio drops?

YES 1
NO 2 (SKIP TO 510F)
DON???T KNOW 8 (SKIP TO 510F)

510E) How many times was the DPT/HEPB/Hib vaccination given?

NUMBER OF TIMES ______

510F) A measles injection, that is, a shot in the right thigh at the age of 9 months or older - to prevent him/her from getting measles?

YES 1
NO 2
DON???T KNOW 8

510G) A Japanese encephalitis vaccination, that is, an injection given in the upper arm between the age of 12-23 months of age?

YES 1
NO 2
DON???T KNOW 8

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

YES 1
NO 2 (SKIP TO 511B)
NO VACCINATION IN THE LAST 2 YRS. 3 (SKIP TO 511B)
DON???T KNOW 8 (SKIP TO 511B)

511A) At which national immunization day campaigns did (NAME) receive the polio vaccinations?
RECORD ALL CAMPAIGNS MENTIONED.

CHAITRA 2066 A
JESTHA 2067 B
MAGH 2067
FALGUN 2067 D

511B) Did (NAME) receive a vitamin A capsule during the event in Kartik/Baisakh?
IF THE INTERVIEW IS BEFORE BAISAKH, ASK ABOUT KARTIK. IF THE INTERVIEW IS AFTER BAISAKH, ASK ABOUT BAISAKH. SHOW THE CAPSULE.

YES 1
NO 2
DON???T KNOW 8

512) If the last seven days, was (NAME) given VITA MISHRAN, or iron syrup like (this/any of these)?
SHOW VITA MISHRAN SACHET OR IRON SYRUP

YES 1
NO 2
DON???T KNOW 8

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

YES 1
NO 2
DON???T KNOW 8

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

YES 1
NO 2 (SKIP TO 525)
DON???T KNOW 8 (SKIP TO 525)

515) Was there any blood in the stools?

YES 1
NO 2
DON???T KNOW 8

516) Now I would like to know how much (NAME) was given to drink during the diarrhea (including breastmilk).
Was he/she given less than usual to drink, about the same amount, or more than usual to drink?
IF LESS, PROBE: Was he/she given much less than usual to drink or somewhat less?

MUCH LESS 1
SOMEWHAT LESS 2
ABOUT THE SAME 3
MORE 4
NOTHING TO DRINK 5
DON???T KNOW 8

517) When (NAME) has diarrhea, was he/she given less than usual to eat, about the same amount, more than usual, or nothing to eat?
IF LESS, PROBE: Was he/she given much less than usual to eat or somewhat less?

MUCH LESS 1
SOMEWHAT LESS 2
ABOUT THE SAME 3
MORE 4
STOPPED FOOD 5
NEVER GAVE FOOD 6
DON???T KNOW 8

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

YES 1
NO 2 (SKIP TO 522)

519) Where did you seek advice or treatment?
Anywhere else?
PROBE TO IDENTIFY EACH TYPE OF SOURCE.
IF FCHV NOT MENTIONED PROBE
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

____________ (NAME OF PLACE(S))
GOVT. SECTOR
GOVT. HOSPITAL/CLINIC A
PHC CENTER B
HEALTH POST C
SUB-HEALTH POST D
PHC OUTREACH CLINIC E
FCHV F
OTHER GOVT. (SPECIFY) __________ G
NON-GOVT. (NGO)
FPAN H
UMN I
OTHER NGO. (SPECIFY) __________ J
PRIVATE MED. SECTOR
PVT. HOSPITAL/CLINIC NURSING HOME K
PHARMACY L
OTHER PRIVATE MED. (SPECIFY) ________ M
OTHER SOURCE SHOP N
TRADITIONAL PRACTITIONER O
OTHER (SPECIFY) _____________ X

520) CHECK 519:

TWO OR MORE CODES CIRCLED (GO TO 521)
ONLY ONE CODE CIRCLED (SKIP TO 522)

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

FIRST PLACE _______

522) Was he/she given any of the following to drink at any time since he/she started having the diarrhea:

a) A fluid made from a special packet called Jeevan Jal/Navajeevan/Orestal?

FLUID FROM ORS PKT
YES 1
NO 2
DON???T KNOW 8
HOMEMADE FLUID
YES 1
NO 2
DON???T KNOW 8

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

YES 1
NO 2 (SKIP TO 525)
DON???T KNOW 8 (SKIP TO 525)

524) What (else) was given to treat the diarrhea?
Anything else?

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

524A) CHECK 524:
GIVEN ZINC?

CODE ???C??? CIRCLED
CODE ???C??? NOT CIRCLED (SKIP TO 525)

524B) How many days was (NAME) given zinc?

DAYS _______
DON???T KNOW 98

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

YES 1
NO 2
DON???T KNOW 8

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

YES 1
NO 2 (SKIP TO 529)
DON???T KNOW 8 (SKIP TO 529)

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

YES 1
NO 2 (SKIP TO 530)
DON???T KNOW (SKIP TO 530)

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

CHEST ONLY 1 (SKIP TO 530)
NOSE ONLY 2 (SKIP TO 530)
BOTH 3 (SKIP TO 530)
OTHER (SPECIFY) _______ 6 (SKIP TO 530)
DON???T KNOW 8 (SKIP TO 530)

529) CHECK 525:
HAD FEVER?

YES (GO TO 530)
NO OR DON???T KNOW (GO BACK TO 503 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 539)

530) 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 smae amount or more than usual to drink?
IF LESS, PROBE: Was he/she given much less than usual to drink or somewhat less?

MUCH LESS 1
SOMEWHAT LESS 2
ABOUT THE SAME 3
MORE 4
NOTHING TO DRINK 5
DON???T KNOW 8

531) When (NAME) had a (fever/cough), was he/she given less than usual to eat, about the same amount, more than usual, or nothing to eat?
IF LESS, PROBE: Was he/she given much less than usual to eat or somewhat less?

MUCH LESS 1
SOMEWHAT LESS 2
ABOUT THE SAME 3
MORE 4
STOPPED FOOD 5
NEVER GAVE FOOD 6
DON???T KNOW 8

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

YES 1
NO 2 (SKIP TO 536)

533) Where did you seek advice or treatment?
Anywhere else?
PROBE TO IDENTIFY EACH TYPE OF SOURCE.
IF FCHV NOT MENTIONED PROBE
IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

(NAME OF PLACE(S)) ______________
GOVT. SECTOR
GOVT. HOSPITAL/CLINIC A
PHC CENTER B
HEALTH POST C
SUB-HEALTH POST D
PHC OUTREACH CLINIC E
FCHV F
OTHER GOVT. (SPECIFY) __________ G
NON-GOVT. (NGO)
FPAN H
UMN I
OTHER NGO. (SPECIFY) __________ J
PRIVATE MED. SECTOR
PVT. HOSPITAL/CLINIC NURSING HOME K
PHARMACY L
OTHER PRIVATE MED. (SPECIFY) ________ M
OTHER SOURCE SHOP N
TRADITIONAL PRACTITIONER O
OTHER (SPECIFY) _____________ X

534) CHECK 533:

TWO OR MORE CODES CIRCLED
ONLY ONE CODE CIRCLED (SKIP TO 536)

535) Where did you first seek advice or treatment?
USE LETTER CODE FROM 533.

FIRST PLACE ________

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

YES 1
NO 2 (GO BACK TO 503 IN NEXT COLUMN; OF, IF NO MORE BIRTHS, GO TO 539)
DON???T KNOW 8 (GO BACK TO 503 IN NEXT COLUMN; OF, IF NO MORE BIRTHS, GO TO 539)

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

ANTIMALARIAL DRUGS
CHLOROQUINE A
PRIMAQUINE B
QUININE C
OTHER (SPECIFY) ________ D
ANTIBIOTIC DRUGS
COTRIMOXAZOLE E
AMOXYCILLIN F
CIPROFLOXACIN G
PROCAINE PENICILLIN INJECTION H
OTHER DRUGS
PARACETAMOL I
IBUPROFEN J
COUGH SYRUP K
OTHER (SPECIFY) __________ X
DON???T KNOW Z

538) GO BACK TO 503 IN NEXT COLUMN, OR, IF NO MORE BIRTHS, GO TO 539.

539) CHECK 220 AND 223, ALL ROWS:
NUMBER OF CHILDREN BORN IN 2062 OR LATER LIVING WITH THE RESPONDENT

ONE OR MORE (RECORD NAME OF YOUNGEST CHILD LIVING WITH HER AND CONTINUE WITH 540) (NAME) ___________
NONE (GO TO 542)

540) The last time (NAME FROM 539) passed stools, what was done to dispose of the stools?

CHILD USED TOILET OR LATRINE 01
PUT/RINSED INTO TOILET OR LATRINE 02
PUT/RINSED INTO DRAIN OR DITCH 03
THROWN INTO GARBAGE 04
BURIED 05
LEFT IN THE OPEN 06
OTHER (SPECIFY) ____________ 96

541) CHECK 522(a) ALL COLUMNS:

NO CHILD RECEIVED FLUID FROM ORS PACKET (GO TO 542)
ANY CHILD RECEIVED FLUID FROM ORS PACKET (GO T 543)

542) Have you ever heard of a special product called Jeevan Jal/Navajeevan/Orestal you can get for the treatment of diarrhea?

YES 1
NO 2

543) CHECK 220 AND 223, ALL ROWS: NUMBER OF CHILDREN BORN IN 2065 OR LATER LIVING WITH THE RESPONDENT
ONE OR MORE (RECORD NAME OF YOUNGEST CHILD LIVING WITH HER AND CONTINUE WITH 544)

(NAME) _____________
NONE (GO TO 601)
ANTIMALARIAL DRUGS
CHLOROQUINE A
PRIMAQUINE B
QUININE C
OTHER (SPECIFY) _________ D
ANTIBIOTIC DRUGS
CORTIMOXAZOLE E
AMOXYCILLIN F
CIPROFLOXACIN G
PROCAINE PENICILLIN INJECTION H
OTHER DRUGS
PARACETAMOL I
IBUPROFEN J
COUGH SYRUP K
OTHER (SPECIFY) ________ X
DON???T KNOW Z

544) GO BACK TO 503 IN NEXT COLUMN; OR, IF NO MORE BIRTHS, GO TO 545.

545) CHECK 221 AND 224, ALL ROWS:
NUMBER OF CHILDREN BORN IN 2057 OR LATER LIVING WITH THE RESPONDENT

ONE OR MORE (GO TO 546)
NONE (GO TO 548)

546) The last time (NAME OF YOUNGEST CHILD) passed stools, what was done to dispose of the stools?

CHILD USED TOILET OR LATRINE 01
PUT/RINSED INTO TOILET OR LATRINE 02
PUT/RINSED INTO DRAIN OR DITCH 03
THROWN IN GARBAGE 04
BURIED 05
LEFT IN THE OPEN 06
OTHER (SPECIFY) _____________ 96

547) CHECK 526, ALL COLUMNS:

NO CHILD RECEIVED JEEVAL JAL OR NAVAJEEVAN OR OTHER ORS OR NOT ASKED (GO TO 548)
ANY CHILD RECEIVED JEEVAN JAL OR NAVAJEEAN OR OTHER ORS (GO TO 549)

548) Have you even heard of a special product called Jeevan Jall or Navajeevan you can get for the treatment of diarrhea?

YES 1 (GO TO 549)
NO 2

548A) Have you ever seen a packet like this?
SHOW PACKET OF JEEVAN JAL OR NAVAJEEVAN OR OTHER TYPES OF ORS.

YES 1
NO 2

549) CHECK 221 AND 224, ALL ROWS:

HAS AT LEAST ONE CHILD BORN IN 2059 OR LATER AND LIVING WITH HER (RECORD NAME OF YOUNGEST CHILD LIVING WITH HER (AND CONTINUE WITH 550) (NAME) _______________
DOES NOT HAVE ANY CHILDREN BORN IN 2059 OR LATER AND LIVING WITH HER (GO TO 601)

550) Now I would like to ask you about liquids or foods (NAME FOR 549) had yesterday during the day or at night.
Did (NAME FROM 549) (drink/eat):

Plain water?
Commercially produced infant formula such as Lactogen?
Any fortified baby food such as Cerelac, Nestum, Champion?
Any (other) porridge or gruel, such as Lito, Sarbottam Pitho?

PLAIN WATER
YES 1
NO 2
DON???T KNOW 8
FORMULA
YES 1
NO 2
DON???T KNOW 8
BABY CEREAL
YES 1
NO 2
DON???T KNOW 8
OTHER PORRIDGE/GRUEL
YES 1
NO 2
DON???T KNOW 8

551) Now I would like to ask you about (other liquids or foods that (NAME FROM 549)/you may have had yesterday during the day or at night. I am interested in whether your child/you had the item even if it was combined with other foods. (TO BE ASKED FOR THE CHILD AND MOTHER)
Did (NAME FROM 549)/you drink (eat):

a. Milk such as tinned, powdered, or fresh animal milk?
YES 1
NO 2
DON???T KNOW 8
b. Tea or coffee?
YES 1
NO 2
DON???T KNOW 8
c. Any other liquids?
YES 1
NO 2
DON???T KNOW 8
d. Any food such as roti or porridge, made from grains, like rice, millet, wheat, maize, buckwheat or barley?
YES 1
NO 2
DON???T KNOW 8
e. Pumpkin, carrots, squash or sweet potatoes (shakharkhanda) that are yellow or orange inside?
YES 1
NO 2
DON???T KNOW 8
f. White potatoes, white yams, colocasia, or any other foods made from roots?
YES 1
NO 2
DON???T KNOW 8
g. Any dark green, leafy vegetables such as colocasia leaves, spinach, amaranth leaves, mustard leaves, swiss chard?
YES 1
NO 2
DON???T KNOW 8
h. Ripe mangoes, papayas, apricot, persimmon?
YES 1
NO 2
DON???T KNOW 8
j. Liver, kidney, heart or other organ meats?
YES 1
NO 2
DON???T KNOW 8
k. Chicken, goat, lamb, buffalo, pork, duck, or any other meat?
YES 1
NO 2
DON???T KNOW 8
l. Eggs?
YES 1
NO 2
DON???T KNOW 8
m. Fresh or dried fish or shellfish?
YES 1
NO 2
DON???T KNOW 8
n. Any foods made from beans, peas, lentils (daal) or nuts?
YES 1
NO 2
DON???T KNOW 8
o. Cheese, yogurt or other milk products?
YES 1
NO 2
DON???T KNOW 8
p. Any ghee, oil, fats, or butter, or foods made with any of these?
YES 1
NO 2
DON???T KNOW 8
q. Any sugar foods such as chocolates, sweets, candies, pastries, cakes or biscuits?
YES 1
NO 2
DON???T KNOW 8
r. Any other solid or semi-solid food?
YES 1
NO 2
DON???T KNOW 8

552) CHECK 550 (LAST 2 CATEGORIES: BABY CEREAL OR OTHER PORRIDGE/GRUEL) AND 551 (CATEGORIES d THROUGH r FOR CHILD):

AT LEAST ONE "YES" (GO TO 553)
NOT A SINGLE "YES" (GO TO 601)

553) How many times did (name from 549) eat solid, semisolid, or soft foods yesterday during the day or at night?
IF 7 OR MORE TIMES, RECORD ???7???

NUMBER OF TIMES________
DON???T KNOW 8

601) CHECK 313:

HAS NOT HAD SEXUAL INTERCOURSE (131 IS 00) (GO TO 617)\
HAS HAD SEXUAL INTERCOURSE (READ STATEMENT)

READ TO RESPONDENTS
Now I need to ask you some more questions about relationships and sexual life. Once again, let me assure you that your answers are completely confidential. If we should come to any question that you don???t want to answer, just let me know and I will skip to the next question.

602) CHECK 108:

15-24 YEARS OLD (GO TO 603)
25-49 YEARS OLD (GO TO 606)

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

AGE OF PARTNER __________ (GO TO 604A)
DON???T KNOW 98

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

YES 1
NO 2
DON???T KNOW 8

604A) What was this person???s relationship to you?

HUSBAND 01
LIVE-IN-PARTNER 02
BOYFRIEND NOT LIVING WITH REPSONDENT 03
RELATIVE 04
CASUAL ACQUAINTANCE 05
SEX WORKER 06
OTHER (SPECIFY) ___________ 96

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

YES 1
NO 2
DON???T KNOW/DON???T REMEMBER 8

606) When was the last time you had sexual intercourse?
IF LESS THATN 12 MONTHS, ANSWER MUST BE RECORDED IN DAYS, WEEKS, OR MONTHS AGO. IF 12 MONTHS OR MORE, ANSWER MUST BE RECORDED IN YEARS AGO.

DAYS AGO 1 (GO TO 608)
WEEKS AGO 2 (GO TO 608)
MONTHS AGO 3 (GO TO 608)
YEARS AGO 4 (GO TO 617)

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

DAYS AGO 1
WEEKS AGO 2
MONTHS AGO 3

608) The last time you had sexual intercourse (with this other person), was a condom used?

YES 1
NO 2 (SKIP TO 610)

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

YES 1
NO 2

610) What was this person???s relationship to you?

HUSBAND 01 (SKIP TO 615)
LIVE-IN-PARTNER 02
BOYFRIEND NOT LIVING WITH RESPONDENT 03
RELATIVE 04
CASUAL ACQUAINTANCE 05
SEX WORKER CLIENT 06
OTHER (SPECIFY) _______ 96

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

DAYS 1
MONTHS 2
YEARS 3

612) CHECK 108:

15-24 YEARS OLD (GO TO 613)
25-49 YEARS OLD (GO TO 615)

613) How old is this person?

AGE OF PARTNER ________ (SKIP TO 615)
DON???T KNOW 98

614) Would you say this person is ten or more years older than you?

YES 1
NO 2
DON???T KNOW 8

615) Apart from this person, have you had sexual intercourse with any other person in the last 12 months?

YES 1 (GO BACK TO 607 IN NEXT COLUMN)
NO 2 (SKIP TO 617)

616) 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.

NUMBER OF PARTNERS IN THE LAST 12 MONTHS _________
DON???T KNOW 98

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

YES 1
NO 2 (GO TO 701)

618) Where is that?
Any other place?
IF UNABLE TO DETERMINE IF A HOSPITAL, HEALTH CENTRE, OR CLINIC IS PUBLIC OR PRIVATE MEDICAL SECTOR, WRITE THE NAME OF THE PLACE(S).
RECORD ALL SOURCES MENTIONED

(NAME OF PLACE(S)) _______________

.

PUBLIC SECTOR
GOVT. HOSPITAL/CLINIC A
PHC CENTER B
HEALTH POST C
SUB-HEALTH POST D
PHC OUTREACH E
MOBILE CLINIC F
FCHV G
OTHER GOVT. (SPECIFY) ___________ H
NON-GOVT. (NGO) SECTOR
FPAN I
MARIE STOPES J
ADRA K
NEPAL RED CROSS L
UMN M
OTHER NGO. (SPECIFY) __________ N
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC/NURSING HOME O
PHARMACY P
OTHER PRIVATE MEDICAL (SPECIFY) ___________ Q
OTHER SOURCE SHOP R
FRIEND/RELATIVE S
OTHER (SPECIFY) ___________ T
OTHER (SPECIFY) ___________ X

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

YES 1
NO 2
DON???T KNOW/UNSURE 8

SECTION 7. FERTILITY PREFERENCES

701) CHECK 301:

NEVER MARRIED/WIDOWED/DIVORCED/SEPARATE (GO TO 713)
OTHER (CODE 1 AND 2) (GO TO 703)

702) CHECK 325/325A:

CODE ???A??? OR CODE ???B??? CIRCLED (GO TO 713)
OTHER (GO TO 703)

703) CHECK 236:

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?
HAVE (A/ANOTHER) CHILD 1
NO MORE/NONE 2 (GO TO 705)
SAYS SHE CAN???T GET PREGNANT 3 (GO TO 713)
UNDECIDED/DON???T KNOW:
AND PREGNANT 4 (GO TO 710)
AND NOT PREGNANT OR UNSURE 5 (709)
PREGNANT: Now I have some questions about the future. After the child you are expecting now, would you like to have another child, or would you prefer not to have any more children?
HAVE (A/ANOTHER) CHILD 1
NO MORE/NONE 2 (GO TO 705)
SAYS SHE CAN???T GET PREGNANT 3 (GO TO 713)
UNDECIDED/DON???T KNOW:
AND PREGNANT 4 (GO TO 710)
AND NOT PREGNANT OR UNSURE 5 (709)

704) CHECK 236:

NOT PREGNANT OR UNSURE: How long would you like to wait from now before the birth of (a/another) child?
MONTHS 1
YEARS 2
SOON/NOW 993 (GO TO 709)
SAYS SHE CAN???T GET PREGNANT 994 (GO TO 713)
AFTER GAUNA 995 (GO TO 709)
OTHER (SPECIFY) ___________ (GO TO 709)
DON???T KNOW 998 (GO TO 709)
PREGNANT: After the birth of this child you are expecting now, how long would you like to wait before the birth of another child?
MONTHS 1
YEARS 2
SOON/NOW 993 (GO TO 709)
SAYS SHE CAN???T GET PREGNANT 994 (GO TO 713)
AFTER GAUNA 995 (GO TO 709)
OTHER (SPECIFY) ___________ (GO TO 709)
DON???T KNOW 998 (GO TO 709)

705) CHECK 236:

NOT PREGNANT OR UNSURE (GO TO 706)
PREGNANT 709

706) CHECK 324: USING A CONTRACEPTIVE METHOD?

NOT ASKED (GO TO 707)
NOT CURRENTLY USING (GO TO 707)
CURRENTLY USING (GO TO 713)

707) CHECK 704:

NOT ASKED (GO TO 708)
24 OR MORE MONTHS OR 02 OR MORE YEARS (GO TO 708)
00-23 MONTHS OR 00-01 YEAR (GO TO 710)

708) CHECK 705:

NOT ASKED (GO TO 709)
24 OR MORE MONTHS OR 02 OR MORE YEARS (GO TO 709)
00-23 MONTHS OR 00-01 YEAR (GO TO 711)

709) CHECK 703 AND 704:

WANTS TO HAVE A/ANOTHER CHILD: You have said that you do not want (a/another) child soon. Can you tell me why you are not using a method to prevent pregnancy? Any other reason? RECORD ALL REASONS MENTIONED
NOT MARRIED A
FERTILITY-RELATED REASONS
NOT HAVING SEX B
INFREQUENT SEX C
HUSBAND AWAY D
MENOPAUSAL/HYSTERECTOMY E
CAN???T GET PREGNANT F
NOT MENSTRUATED SINCE LAST BIRTH G
BREASTFEEDING H
UP TO GOD/FATALISTIC I
OPPOSITION TO USE
RESPONDENT OPPOSED J
HUSBAND/PARTNER OPPOSED K
OTHERS OPPOSED L
RELIGIOUS PROHIBITION M
LACK OF KNOWLEDGE
KNOWS NO METHOD N
KNOWS NO SOURCE O
METHOD-RELATED REASONS
SIDE EFFECTS/HEALTH CONCERNS P
LACK OF ACCESS/TOO FAR Q
COSTS TOO MUCH R
PREFERRED METHOD NOTA AVAILABLE S
NO METHOD AVAILABLE T
INCONVENIENT TO USE U
INTERFERES WITH BODY???S NORMAL PROCESSES V
OTHER (SPECIFY) ___________ V
DON???T KNOW Z
WANTS NO MORE/NONE: You have said that you do not want any (more) children. Can you tell me why you are not using a method to prevent pregnancy? Any other reason?
RECORD ALL REASONS MENTIONED.
NOT MARRIED A
FERTILITY-RELATED REASONS
NOT HAVING SEX B
INFREQUENT SEX C
HUSBAND AWAY D
MENOPAUSAL/HYSTERECTOMY E
CAN???T GET PREGNANT F
NOT MENSTRUATED SINCE LAST BIRTH G
BREASTFEEDING H
UP TO GOD/FATALISTIC I
OPPOSITION TO USE
RESPONDENT OPPOSED J
HUSBAND/PARTNER OPPOSED K
OTHERS OPPOSED L
RELIGIOUS PROHIBITION M
LACK OF KNOWLEDGE
KNOWS NO METHOD N
KNOWS NO SOURCE O
METHOD-RELATED REASONS
SIDE EFFECTS/HEALTH CONCERNS P
LACK OF ACCESS/TOO FAR Q
COSTS TOO MUCH R
PREFERRED METHOD NOTA AVAILABLE S
NO METHOD AVAILABLE T
INCONVENIENT TO USE U
INTERFERES WITH BODY???S NORMAL PROCESSES V
OTHER (SPECIFY) ___________ V
DON???T KNOW Z

710) CHECK 303: USING A CONTRACEPTIVE METHOD?

NOT ASKED (GO TO 711)
NO, NOT CURRENTLY USING (GO TO 711)
YES, CURRENTLY USING (GO TO 712)

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

YES 1
NO 2
DON???T KNOW 8

712) CHECK 221:

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? PROBE FOR A NUMERIC RESPONSE.
NONE 00 (GO TO 714)
NUMBER ________
OTHER (SPECIFY) ___________ 96 (GO TO 714)
NO LIVING CHILDREN: If you could choose exactly the number of children to have in your whole life, how many would that be? PROBE FOR A NUMERIC RESPONSE.
NONE 00 (GO TO 714)
NUMBER ________
OTHER (SPECIFY) ___________ 96 (GO TO 714)

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

BOYS _________
GIRLS _________
EITHER _________
OTHER (SPECIFY) _________ 96

714) In the last few months have you:

Heard about family planning on the radio?
YES 1
NO 2
Seen anything about family planning on the television?
YES 1
NO 2
Read about family planning in a newspaper or magazine?
YES 1
NO 2
Read about family planning in brochure or flipchart?
YES 1
NO 2
Seen message on family planning in a poster, hoarding board or billboard?
YES 1
NO 2
Seen street dramas on family planning?
YES 1
NO 2

715) CHECK 601:

YES, CURRENTLY MARRIED (GO TO 716)
YES, LIVING WITH A MAN (GO TO 716)
NO, NOT IN UNION (GO TO 801)

716) CHECK 303: USING A CONTRACEPTIVE METHOD?

CURRENTLY USING (GO TO 717)
NOT CURRENTLY USING OR NOT ASKED (GO TO 719)

717) Would you say that using contraception is mainly your decision, mainly your (your husband???s/partner???s) decision, or did you both decide together?

MAINLY RESPONDENT 1
MAINLY HUSBAND/PARTNER 2
JOINT DECISION 3
OTHER (SPECIFY) __________6

718) CHECK 304:

NEITHER STERILIZED (GO TO 719)
HE OR SHE STERILIZED (GO TO 801)

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

SAME NUMBER 1
MORE CHILDREN 2
FEWER CHILDREN 3
DON???T KNOW 8

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

801) CHECK 601 AND 602:

CURRENTLY MARRIED/LIVING WITH A MAN (GO TO 802)
FORMERLY MARRIED/LIVED WITH A MAN (GO TO 803)
NEVER MARRIED AND NEVER LIVED WITH A MAN (GOT TO 806)

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

AGE IN COMPLETED YEARS

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

YES 1
NO 2 (GO TO 805)

804) What was the highest grade he completed?
IF COMPLETED LESS THAN ONE YEAR AT THAT LEVEL, RECORD ???00???.

GRADE _______
DON???T KNOW 98

805) CHECK 801:

CURRENTLY MARRIED: What is your (husband???s/partner???s occupation? That is, what kind of work does he mainly do?
OCCUPATION ______________________
FORMERLY MARRIED: What was your (last) (husband???s/partner???s) occupation? That is, what kind of work did he mainly do?
OCCUPATION ______________________

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

YES (GO TO 810)
NO 2

807) As you know, some women take up jobs for which they are paid in cash or kind. Other sell things, have a small business or work on the family business. In the last seven days, have you done any of these things or any other work?

YES 1 (GO TO 810)
NO 2

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

YES 1 (GO TO 810)
NO 2

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

YES 1
NO 2 (GO TO 813A)

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

OCCUPATION __________________

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

FOR FAMILY MEMBER 1
FOR SOMEONE ELSE 2
SELF-EMPLOYED 3

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

THROUGHOUT THE YEAR 1
SEASONALLY/PART OF THE YEAR 2
ONCE IN A WHILE 3

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

CASH ONLY 1 (GO TO 814)
CASH AND KIND 2 (GO TO 814)
IN KIND ONLY 3 (GO TO 814)
NOT PAID 4 (GO TO 814)

813A) Why are you not involved in any work aside from your own house work?

NO NEED TO WORK 1
WORKLOAD AT HOME 2
SMALL CHILDREN TO LOOK AFTER 3
FAMILY DOES NOT ALLOW 4
LOOKING FOR WORK 5
LACK EDUCATION/TRAINING 7
NO OPPORTUNITY 8
OTHER (SPECIFY) ____________ 6

814) CHECK 601:

CURRENTLY MARRIED (GO TO 815)
NOT IN UNION (GO TO 822)

815) CHECK 813:

CODE 1 OR 2 CIRCLED (GO TO 816)
OTHER (GO TO 818)

816) Who usually decides how the money you ear will be used; you, your (husband/partner) or you and you (husband/partner) jointly?

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

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

MORE THAN HIM 1 (GO TO 818)
LESS THAN HIM 2 (GO TO 818)
ABOUT THE SAME 3 (GO TO 818)
HUSBAND/PARTNER DOESN???T BRING IN ANY MONEY 4 (GO TO 819)
DON???T KNOW 8 (GO TO 818)

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

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

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

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

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

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

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

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

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

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

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

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

823A) Do you belong to any group? Please specify.

AMA SAMUHA A
BACHAT SAMUHA B
MAHILA SAMUHA C
OTHER (SPECIFY) __________ X
DOES NOT BELONG TO ANY GROUP Z

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

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

824A) In your opinion, should a husband hit or beat his wife for any reason at all?

YES 1
NO 2 (GO TO 901)
DON???T KNOW 8

825) In your opinion, is a husband justified in hitting or beating his wife in the following situations:

If she goes out without telling him?
YES 1
NO 2
DON???T KNOW 8
If she neglects the children?
YES 1
NO 2
DON???T KNOW 8
If she argues with him?
YES 1
NO 2
DON???T KNOW 8
If she refuses to have sex with him?
YES 1
NO 2
DON???T KNOW 8
If she burns the food?
YES 1
NO 2
DON???T KNOW 8

SECTION 9. HIV/AIDS

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

YES 1
NO 2 (GO TO 921)

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

YES 1
NO 2
DON???T KNOW 8

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

YES 1
NO 2
DON???T KNOW 8

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

YES 1
NO 2
DON???T KNOW 8

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

YES 1
NO 2
DON???T KNOW 8

906) Can people get the AIDS virus by touching someone who has AIDS?

YES 1
NO 2
DON???T KNOW 8

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

YES 1
NO 2
DON???T KNOW 8

908) Can the virus that causes AIDS be transmitted from a month to her baby:

During pregnancy?
YES 1
NO 2
DON???T KNOW 8
During delivery?
YES 1
NO 2
DON???T KNOW 8
By breastfeeding?
YES 1
NO 2
DON???T KNOW 8

909) CHECK 908:

AT LEAST ONE ???YES??? (GO TO 910)
OTHER (GO TO 911)

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

YES 1
NO 2
DON???T KNOW 8

911) I don???t want to know the results, but have you ever been tested to see if you have the AIDS virus?

YES 1
NO 2
DON???T KNOW 8

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

MONTHS AGO __________
TWO OR MORE YEARS 95

913) I don???t want to know the results, but did you get the results of the test?

YES 1
NO 2

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

(NAME OF THE PLACE) _______________
GOVT. SECTOR
GOVERNMENT HOSPITAL 11 (GO TO 917)
VCT CENTER 12 (GO TO 917)
OTHER GOVT. (SPECIFY) ___________ 16 (GO TO 917)
NON-GOVT. SECTOR
FPAN 21 (GO TO 917)
AMDA 22 (GO TO 917)
INF 23 (GO TO 917)
NEPAL RED CROSS 24 (GO TO 917)
OTHER GOVT. (SPECIFY) _________ 26 (GO TO 917)
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC/NURSING HOME 31 (GO TO 917)
OTHER PRIVATE MEDICAL (SPECIFY) _____________ 36 (GO TO 917)
OTHER (SPECIFY) ___________ 96 (GO TO 917)

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

YES 1
NO 2 (GO TO 917)

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

(NAME OF PLACE (S)) _____________________
GOVT. SECTOR
GOVERNMENT HOSPITAL A
VCT CENTER B
OTHER GOVT. (SPECIFY) ___________ C
NON-GOVT. SECTOR
FPAN D
AMDA E
INF F
NEPAL RED CROSS G
OTHER GOVT. (SPECIFY) _________ H
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC/NURSING HOME I
OTHER PRIVATE MEDICAL (SPECIFY) _____________ J
OTHER (SPECIFY) ___________ X

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

YES 1
NO 2
DON???T KNOW 8

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

YES, REMAIN A SECRET 1
NO 2
DON???T KNOW/NOT SURE/DEPENDS 8

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

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

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

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

921) CHECK 901:

HEARD ABOUT AIDS: Apart from AIDS, have you heard about other infections that can be transmitted through sexual contact?
YES 1
NO 2
NOT HEARD ABOUT AIDS: Have you heard about infections that can be transmitted through sexual contact?
YES 1
NO 2

922) CHECK 613:

HAS HAD SEXUAL INTERCOURSE (GO TO 923)
NEVER HAD SEXUAL INTERCOURSE (GO TO 930)

923) CHECK 921: HEARD ABOUT OTHER SEXUALLY TRANSMITTED INFECTIONS?

YES (GO TO 924)
NO (GO TO 925)

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

YES 1
NO 2
DON???T KNOW 8

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

YES 1
NO 2
DON???T KNOW 8

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

YES 1
NO 2
DON???T KNOW 8

927) CHECK 924, 925, AND 926:

HAS HAD AN INFECTION (ANY ???YES???) (GO TO 928)
HAS NOT HAD AN INFECTION OR DOES NOT KNOW (GO TO 93)

928) The last time you had (PROBLEM FROM 924/925/926), did you seek any kind of advice or treatment?

YES 1
NO 2 (GO TO 930)

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

(NAME OF PLACE(S)) _____________________
GOVT. SECTOR
GOVT. HOSPITAL/CLINIC A
PHC CENTER B
HEALTH POST C
SUB-HEALTH POST D
PHC OUTREACH CLINIC E
FAMILY PLANNING CLINIC F
MOBILE CLINIC G
FIELDWORKER H
OTHER GOVT. (SPECIFY) __________ I
NON-GOVT. (NGO)
FPAN J
AMDA K
ADRA L
INF M
NEPAL RED CROSS N
UMN O
OTHER NGO. (SPECIFY) __________ P
PRIVATE MED. SECTOR
PVT. HOSPITAL/CLINIC NURSING HOME Q
OTHER PRIVATE MED. (SPECIFY) ________ R
OTHER SOURCE OTHER (SPECIFY) _____________ X

930) If a wife knows her husband has a disease that she can get during sexual intercourse, is she justified in asking that they use a condom when they have sex?

YES 1
NO 2
DON???T KNOW 8

931) Is a wife justified in refusing to have sex with her husband when she know he has sex with other women?

YES 1
NO 2
DON???T KNOW 8

932) CHECK 601:

CURRENTLY MARRIED (GO TO 933)
NOT IN UNION (GO TO 1001)

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

YES 1
NO 2
DEPENDS/NOT SURE 8

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

YES 1
NO 2
DEPENDS/NOT SURE 8

SECTION 10. OTHER HEALTH ISSUES

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

NUMBER OF INJECTIONS __________
NONE 00 (GO TO 1003A)

1002) 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 90 OR MORE, OR DAILY FOR 3 MONTHS OR MORE, RECORD ???90???.
IF NON-NUMERIC ANSWER, PROBE TO GET AN ESTIMATE.

NUMBER OF INJECTIONS __________
NONE 00 (GO TO 1003A)

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

YES 1
NO 2
DON???T KNOW 8

1003A) CHECK 210:

ONE OR MORE PREGNANCIES (GO TO 1003B)
NONE (GO TO 1004)

1003B) Have you ever experienced signs of uterine prolapse (Patheghar Khasne/Ang Khasne)?

YES 1
NO 2 (GO TO 1004)

1003C) Did you seek treatment for this condition?

YES, MEDICAL TREATMENT 1
YES, TRADITIONAL METHODS 2
NO 3

1004) Do you currently smoke cigarettes?

YES 1
NO 2 (GO TO 1006)

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

NUMBER OF CIGARETTES _________

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

YES 1
NO 2 (GO TO 1008)

1007) What (other) type of tobacco do you currently smoke or use?

PIPE A
BIDI B
CHEWING TOBACCO C
SNUFF D
OTHER (SPECIFY) _____________ X

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

Getting permission to go to the doctor?
BIG PROBLEM 1
NOT A BIG PROBLEM 2
Getting money needed for advice or treatment?
BIG PROBLEM 1
NOT A BIG PROBLEM 2
The distance to the health facility?
BIG PROBLEM 1
NOT A BIG PROBLEM 2
Not wanting to go alone?
BIG PROBLEM 1
NOT A BIG PROBLEM 2

1008A) In the last few months have you heard or seen the following programs on the radio and/or television:

Jana Swastha Radio Karyakram?
YES 1
NO 2
Janasankhya Chetana ka Sworeharu Radio Karyakram?
YES 1
NO 2
Hamro Swastha Radio Karyakram?
YES 1
NO 2
Ama radio Karyakram?
YES 1
NO 2
Hamro Swastha TV Karyakram?
YES 1
NO 2
Jeevan Chakra TV Karyakram?
YES 1
NO 2
Thorai bhaye pugi sari TV Karyakram?
YES 1
NO 2
Ama TV Karyakram?
YES 1
NO 2
Sathi Sanga Manka Kura Radio Karyakram?
YES 1
NO 2
Jeevan Jyoti Radio Karyakram?
YES 1
NO 2

1008B) Which source of media do you prefer the most to receive health-related messages?

NEPAL RADIO 01
FM 02
TELEVISION 03
NEWSPAPER OR MAGAZINE 04
BROCHURE OR LEAFLET 05
FLIPCHART 06
POSTER 07
HOARDING/BILLBOARD 08
OTHER (SPECIFY) __________ 96

1009) CHECK 327

VISITED HEALTH FACILITY IN 12 MONTHS (GO TO 1009A)
NOT VISITED (GO TO 1009F)

1009A) Which health facilities did you visit last during the past 12 months for care for yourself of your children?
PROBE TO IDENTIFY 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.

(NAME OF PLACE(S)) ___________________
PUBLIC SECTOR
GOVT. HOSPITAL 11
PHC CENTER 12
HEALTH POST 13
SUB-HEALTH 14
PHC OUTREACH 15
MOBILE CLINIC 17
OTHER GOVT. (SPECIFY) __________ 16
NON-GOVT. SECTOR
FPAN 21
MARIE STOPES 22
ADRA 23
NEPAL RED CROSS 24
UMN 25
OTHER GOVT. (SPECIFY) _________ 26
PRIVATE MED. SECTOR
PVT. HOSPITAL/CLINIC/N. HOME. 31
OTHER PRIVATE MED. (SPECIFY) __________ 36
OTHER (SPECIFY) __________ 96

1009B) CHECK 1009A

CODES 11-17 CIRCLED (GO TO 1009C)
Did you pay the registration fee during your last visit to the health facility?
YES 1
NO 2
DON???T KNOW 8
OTHER CODES/NOT CIRCLED (GO TO 1009F)

1009C) Did you pay the registration fee during your last visit to the health facility?

YES 1
NO 2
DON???T KNOW 8

1009D) Were you prescribed any medicines/drug by the health care provider the last time you visited the health facility?

YES 1
NO 2 (GO TO 1009F)
DON???T KNOW 8 (GO TO 1009F)

1009E) Did you get any medicine/drug free of cost from the health facility?

YES, FULLY 1
YES, PARTIALLY 2
NOT AT ALL 3

1009F) Does a woman get free health services from a government health facility for the following services:

Post abortion service?
YES 1
NO 2
DON???T KNOW 8
Delivery service?
YES 1
NO 2
DON???T KNOW 8

1009G) Does a woman get a cash incentive if she delivers her baby at a government health facility?

YES 1
NO 2
DON???T KNOW 8

DOMESTIC VIOLENCE MODULE

1101) CHECK HOUSEHOLD QUESTIONNAIRE, COL. 9A AND COVER PAGE OF WOMAN QUESTIONNAIRE.

WOMAN SELECTED FOR THIS SECTION (GO TO 1102)
WOMAN NOT SELECTED (GO TO 1134)

1102) CHECK FOR PRESENCE OF OTHERS:
DO NOT CONTINUE UNTIL EFFECTIVE PRIVACY IS ENSURED.

PRIVACY OBTAINED 1
READ TO RESPONDENT
Now I would like to ask you questions about some other important aspects of a woman???s life. I know that some of these questions are very personal However, your answers are crucial for helping to understand the condition of women in Nepal. Let me assure you that your answers are completely confidential and will not be told to anyone and no one else will know that you were asked these questions.
PRIVACY NOT POSSIBLE 2 (GO TO 1133)

1103) CHECK 601 AND 602:

CURRENTLY MARRIED/LIVING WITH A MAN (GO TO 1104)
FORMERLY MARRIED/LIVED WITH A MAN (READ IN PAST TENSE)
NEVER MARRIED/LIVED WITH A MAN (GO TO 1115)

1104) 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?
YES 1
NO 2
DON???T KNOW 8
b) He frequently (accuses/accused) you of being unfaithful?
YES 1
NO 2
DON???T KNOW 8
c) He (does/did) not permit you to meet your female friends?
YES 1
NO 2
DON???T KNOW 8
d) He (tries/tried) to limit your contact with your family?
YES 1
NO 2
DON???T KNOW 8
e) He (insists/insisted) on knowing where you (are/were) at all times?
YES 1
NO 2
DON???T KNOW 8
f) He (does/did) not trust you with any money?
YES 1
NO 2
DON???T KNOW 8

1105) Now if you will permit me, I need to ask some more questions about your relationship with your (last) husband/partner.

A) (Does/did) your (last) husband/partner ever:
B) How often did this happen during the last 12 months: often, only sometimes, or not at all?

a) say or do something to humiliate you in front of others?
YES 1
NO 2
OFTEN 1
SOMETIMES 2
NOT AT ALL 3
b) threaten to hurt or harm you or someone close to you?
YES 1
NO 2
OFTEN 1
SOMETIMES 2
NOT AT ALL 3

c) insult you or make you feel bad about yourself?

YES 1
NO 2
OFTEN 1
SOMETIMES 2
NOT AT ALL 3

1106)
A: (Does/did) your (last) husband/partner ever do any of the following things to you:
B: How often did this happen during the last 12 months: often, only sometimes, or not at all?

a) push you, shake you, or throw something at you?
YES 1
NO 2
OFTEN 1
SOMETIMES 2
NOT AT ALL 3
b) slap you?
YES 1
NO 2
OFTEN 1
SOMETIMES 2
NOT AT ALL 3
c) twist your arm or pull your hair?
YES 1
NO 2
OFTEN 1
SOMETIMES 2
NOT AT ALL 3
d) punch you with his fist or with something that could hurt you?
YES 1
NO 2
OFTEN 1
SOMETIMES 2
NOT AT ALL 3
e) kick you, drag you or beat you up?
YES 1
NO 2
OFTEN 1
SOMETIMES 2
NOT AT ALL 3
f) try to choke you or burn you on purpose?
YES 1
NO 2
OFTEN 1
SOMETIMES 2
NOT AT ALL 3
g) threaten or attack you with a knife, gun, or any other weapon?
YES 1
NO 2
OFTEN 1
SOMETIMES 2
NOT AT ALL 3
h) physically force you to have sexual intercourse with him even when you did not want to?
YES 1
NO 2
OFTEN 1
SOMETIMES 2
NOT AT ALL 3
i) force you to perform any sexual acts you did not want to?
YES 1
NO 2
OFTEN 1
SOMETIMES 2
NOT AT ALL 3

1107) CHECK 1106A (a-i):

AT LEAST ONE ???YES??? (GO TO 1108)
NOT A SINGLE ???YES??? (GO TO 1110)

1108) How long after you first (got married to/started living with) your (last) husband/partner did (this/any of these things) first happen?
IF LESS THAN ONE YEAR, RECORD ???00???.

NUMBER OF YEARS __________
BEFORE MARRIAGE/BEFORE LIVING TOGETHER 95

1109) Did the following ever happen as a result of what your (last) husband/partner did to you:

a) You had cuts, bruises or aches?
YES 1
NO 2
b) You had eye injuries, sprains, dislocations or burns?
YES 1
NO 2
c) You had deep wounds, broken bones, broken teeth, or any other serious injury?
YES 1
NO 2

1110) Have you ever hit, slapped, kicked, or done anything else to physically hurt your (last) husband/partner at times when he was not already beating or physically hurting you?

YES 1
NO 2 (GO TO 1112)

1111) In the last 12 months, how often have you done this to your husband/parther: often, only sometimes, or not at all?

OFTEN 1
SOMETIMES 2
NOT AT ALL 3

1112) (Does/Did your husband/partner drink alcohol?

YES 1
NO 2 (GO TO 1114)

1113) How often (does/did) he get drunk: often, only sometimes, or never?

OFTEN 1
SOMETIMES 2
NEVER 3

1114) Are (were) you afraid of your (last) husband/partner: most of the time, sometimes, or never?

MOST OF THE TIME AFRAID 1
SOMETIMES AFRAID 2
NEVER AFRAID 3

1115) 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?
YES 1
NO 2 (GO TO 1118)
REFUSED TO ANSWER/NO ANSWER 3 (GO TO 1118)
NEVER MARRIED/NEVER LIVED WITH A MAN: From the time you were 15 years old has anyone ever hit, slapped, kicked, or done anything else to hurt you physically?
YES 1
NO 2 (GO TO 1118)
REFUSED TO ANSWER/NO ANSWER 3 (GO TO 1118)

1116) Who has hurt you in this way?
Anyone else?
RECORD ALL MENTIONED.

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

1117) In the last 12 months, how often have you been hit, slapped, kicked, or physically hurt by this/these person(s): often, only sometimes, or not at all?

OFTEN 1
SOMETIMES 2
NOT AT ALL 3

1118) CHECK 201, 208, AND 234:

EVER BEEN PREGNANT (YES ON 201 OR 308 OR 234) (GO TO 1119)
NEVER BEEN PREGNANT (GO TO 1121)

1119) Has anyone ever hit, slapped, kicked, or done anything else to hurt you physically while you were pregnant?

YES 1
NO 2 (GO TO 1121)

1120) Who has done any of these things to physically hurt you while you were pregnant?
Anyone else?
RECORD ALL MENTIONED.

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

1120A) Have you ever had a miscarriage or stillbirth as a result of these things?

YES 1
NO 2

1121) CHECK 1106A (h) and (i)

1106A (h) IS YES OR1106A (i) IS YES: Now I want to ask you about things that may have happened to you that were not done by your (current/last) 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 of perform any other sexual acts against your will?
YES 1
NO 2 (GO TO 1124)
REFUSED TO ANSWER/NO ANSWER 3 (GO TO 1124)
1106A (h) IS NO AND 1106A (i) = NO OR 1106A NOT ASKED: 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 of perform any other sexual acts against your will?
YES 1
NO 2 (GO TO 1124)
REFUSED TO ANSWER/NO ANSWER 3 (GO TO 1124)

1122) How old were you the first time you were forced to have sexual intercourse or perform any other sexual acts?

AGE IN COMPLETED YEARS __________
DON???T KNOW 98

1123) Who was the person who was forcing you at that time?

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

1124) CHECK 1106B (h) and (i)

1106B (h) = 1 OR 2 OR 1106B (i) IS 1 OR 2: In the last 12 months, has anyone other than your (current/last) husband/partner forced you to have sexual intercourse against your will?
YES 1
NO 2
1106B (h) IS 3 AND 1106B (i) IS 3 OR 1106B AND NOT ASKED: In the last 12 months has anyone forced you to have sexual intercourse against your will?
YES 1
NO 2

1125) CHECK 1106A (a-i), 1115, 1119, 1121, AND 1124:

AT LEAST ONE ???YES??? (GO TO 1126)
NOT A SINGLE ???YES??? (GO TO 1129)

1126) 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?

YES 1
NO 2 (GO TO 1128)

1127) From whom have you sought help?
Anyone else?
RECORD ALL MENTIONED.

OWN FAMILY A (GO TO 1129)
HUSBAND/LIVE-IN PARTNER???S FAMILY B (GO TO 1129)
CURRENT/LAST/LATE HUSBAND/LIVE-IN PARTNER C (GO TO 1129)
CURRENT/FORMER BOYFRIEND D (GO TO 1129)
FRIEND E (GO TO 1129)
NEIGHBOR F (GO TO 1129)
RELIGIOUS LEADER G (GO TO 1129)
DOCTOR/MEDICAL PERSONNEL H (GO TO 1129)
POLICE I (GO TO 1129)
LAWYER J (GO TO 1129)
SOCIAL SERVICE ORGANIZATION K (GO TO 1129)
OTHER (SPECIFY) _____________ X (GO TO 1129)

1128) Have you ever told anyone else about this?

YES 1
NO 2

1129) CHECK 613: EVER HAD SEX?

HAS EVER HAD SEX (GO TO 1130)
NEVER HAD SEX (GO TO 1131)

1130) 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?

WANTED TO 1
FORCED TO 2
REFUSED TO ANSWER/NO RESPONSE 3

1131) As far as you know, did your father ever beat your mother?

YES 1
NO 2
DON???T KNOW 8

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

1132) DID YOU HAVE TO INTERRUPT THE INTERVIEW BECAUSE SOME ADULT WAS TRYING TO LISTEN, OR CAME INTO THE ROOM, OR INTERFERED IN ANY OTHER WAY?

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

1133) INTERVIEWER???S COMMENTS/EXPLANATION FOR NOT COMPLETING THE DOMESTIC VIOLENCE MODULE

____________________________________________________________________________________________________________________________________________________________

1134) RECORD THE TIME.

HOUR __________
MINUTES _________

INTERVIEWER???S OBSERVATIONS

TO BE FILLED IN AFTER COMPLETING THE INTERVIEW

COMMENTS ABOUT RESPONDENT:
____________________________________________________________________________________________________________________________________________________________

COMMENTS ON SPECIFIC QUESTIONS:
____________________________________________________________________________________________________________________________________________________________

ANY OTHER COMMENTS:
____________________________________________________________________________________________________________________________________________________________

SUPERVISOR???S OBSERVATIONS
____________________________________________________________________________________________________________________________________________________________

NAME OF SUPERVISOR: _______________
DATE: ____________

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**

B BIRTHS
P PREGNANCIES
C MISCARRIAGE
A ABORTION
S STILLBORN

0 NO METHOD
1 FEMALE STERILIZATION
2 MALE STERILIZATION
3 IUD
4 INJECTABLES
5 IMPLANTS
6 PILL
7 CONDOM
8 FEMALE CONDOM
9 DIAPHRAGM
J FOAM OR JELLY
L RHYTHM METHOD
M WITHDRAWAL
X OTHER MODERN METHOD
Y OTHER TRADITIONAL METHOD

COLUMN 2: DISCONTINUATION OF CONTRACEPTIVE USE
0 INFREQUENT SEX
1 BECAME PREGNANT WHILE USING
2 WANTED TO BECOME PREGNANT
3 HUSBAND/PARTNER DISAPPROVED
4 WANTED MORE EFFECTIVE METHOD
5SIDE EFFECTS/HEALTH CONCERNS
6 LACK OF ACCESS/TOO FAR
7 COSTS TOO MUCH
8 INCONVENIENT TO USE
F UP TO GOD/FATALISTIC
A DIFFICULT TO GET PREGNANT/MENOPAUSAL
D MARITAL DISSOLUTION/SEPARATION
H HUSBAND AWAY
X OTHER (SPECIFY) ___________________
Z DON???T KNOW

FOR 2069, 2067, 2066, 2065 2064, 2063, AND 2062:

12 CHAITRA 01
11 FALGUN 02
10 MAGH 03
09 POUSH 04
08 MANGSIR 05
07 KARTIK 06
06 ASWIN 07
05 BHADRA 08
04 SRAWAN 09
04 ASHAD 10
02 JESTHA 11
01 BAISAKH 12