WOMAN'S LAST AND FIRST NAME___________

QUESTIONNAIRE NUMBER__________

REGION_______

PREFECTURE____________

LOCATION_________

LEVEL________

COUNTING ZONE OR NEIGHBORHOOD___________

PLOT NUMBER___________

HOUSEHOLD NUMBER_________

WOMAN'S ORDER NUMBER___________

INTERVIEWER VISITS

DATE________
INTERVIEWER'S NAME________

RESULT_________

NEXT VISIT
DATE______
TIME __________

FINAL VISIT
DAY_________
MONTH______
INT. NUMBER_______
RESULT CODE_______

NO. OF VISITS________

FIELD EDITED BY
NAME_______
DATE______

OFFICE EDITED BY
NAME___________
DATE_______

KEYED BY____________

SECTION 1. RESPONDENT'S BACKGROUND

100) RECORD THE NUMBER OF PERSONS LISTED IN THE HOUSEHOLD SCHEDULE

101) RECORD THE NUMBER OF CHILDREN AGED 5 AND UNDER LISTED IN THE HOUSEHOLD SCHEDULE WHO NORMALLY LIVE IN THE HOUSEHOLD.

102) RECORD THE TIME: the time at the beginning of the interview

103) For most of the time until you were 12 years old, did you live in Lome, in another capital, in another city or in the countryside?
(NAME OF LOCATION)
INTERVIEWER: IF CITY/COUNTRYSIDE, SPECIFY

104) First I would like to ask some questions about you and your family. How long have you been continuously live in (NAME OF LOCATION)?

105) Just before you moved here, did you live in Lome, in another capital, in another city or in the countryside?
(NAME OF LOCATION)________
INTERVIEWER: IF CITY/COUNTRYSIDE, SPECIFY

106) In what month and year were you born?
INTERVIEWER: CODE THE RESPONSE 1-PRECISE 2-ESTIMATED

107) How old are you?
INTERVIEWER: RECORD AGE IN YEARS COMPETED. COMPARE AND CORRECT 106 AND/OR 107 IF INCONSISTENT. CODE THE ANSWER

108) What is your religion?

109) What is your nationality?

110) What is your ethnicity?
INTERVIEWER: SEE THE LIST OF ETHNICITIES

111) Have you ever attended school?

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

113) What is the highest year you completed at this level?

114) INTERVIEWER: CHECK 112

115) Can you read a letter or newspaper in a national or foreign language easily, with difficulty, or not at all?

116) Do you usually listen to the radio at least once a week?

117) Which station do you listen to often?

118) Do you frequently listen to the following programs:

RADIO LOME:

RADIO KARA:

119) What is the major source of drinking water for members of your household?

120) What is the major source of non-drinking water for members of your household
(ex. For cooking, for washing hands…)?

121) What type of toilet facility does your household use?

122) At what age do the children start using the same toilet as the adults?

123) What type of lighting do you use in this household?

124) What do you use to cook food?

125) Does your house have:

126) Does any member of your household own:

127) What is the floor of your dwelling made of?

128) What are the walls of your dwelling made of?

129) What is the roof of your dwelling made of?

130) How many livable rooms does your household have?

131) What is the occupation status of your dwelling?

132) Are you a member of a women's association or group?
IF YES: What type of organization is it?

SECTION 2. REPRODUCTION

201) Now I would like to ask you about all the births you have had during your life. Have you ever had a live 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?
INTERVIEWER: IF NONE, RECORD '00'

204) Do you have any sons or daughters you have given birth to 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?
INTERVIEWER: IF NONE, RECODE '00'

206) Have you ever given birth to a boy or girl who was born alive but later died?
IF NO, PROBE: did you give birth to a boy or girl who only lived a few hours of a few days?

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

208) INTERVIEWER: SUM ANSWERS TO 203, 205, AND 207 AND ENTER TOTAL.

209) INTERVIEWER: CHECK: Just to makes sure that I counted all your children, did you have in total ____ children during your life?
IF NO, PROBE AND CORRECT 203 TO 209

210) INTERVIEWER: CHECK 208:

TABLE 1: BIRTH HISTORY

211) What is the name of your (1st, 2nd…) child?

INTERVIEWER: RECORD TWINS ON SEPARATE LINES. IN THE 3RD SPACE, RECORD THE TYPE OF BIRTH.

212) (NAME OF CHILD) Is he/she a boy or a girl?

213) Is (NAME) still alive?

214) In what month and year was (NAME)'s birth?
PROBE: What is he/her birthday?
INTERVIEWER: USE THE SAME CODES AS FOR Q. 106

215) IF DEAD: What was his/her age when he/she died?
INTERVIEWER: RECORD THE AGE DAYS IF LESS THAN 1 MONTH; MONTHS IF LESS THAN TWO YEARS, OR YEARS COMPLETED.

216) IF STILL ALIVE: How old is (NAME)?
INTERVIEWER: RECORD THE AGE IN COMPLETED YEARS.

217) IF STILL ALIVE: Is he/she living with you?

515) CHILD'S ORDER NUMBER

218) INTERVIEWER: CHECK THAT THE NUMBER OF RECORDED BIRTHS CORRESPONDS TO THE CONTENTS OF 208

219) Are you pregnant?

220) How many months pregnant are you?

221) Since you have been pregnant, have you been given any injection to prevent the baby from getting tetanus, that is, convulsions after birth?

222) Have you had an antenatal visit for this pregnancy?

223) Who did you see the first time?
INTERVIEWER: PROBE AND RECORD THE CODE OF THE MOST QUALIFIED PERSON.

224) In what month of your pregnancy did you have your first antenatal visit?

225) How long ago did your last menstrual period start?

226) When during her monthly cycle do you think a woman has the greatest chance of becoming pregnant?

227) PERSONS PRESENT (DURING THIS FIRST PART OF THE INTERVIEW)

SECTION 3. CONTRACEPTION

301) Now I would like to talk about a different topic. There are different traditional or modern ways or methods that a couple can use to delay or space out pregnancy. Do you know any of these methods or have you heard of them?

INTERVIEWER: CIRCLE CODE 1 IN 302 FOR EACH METHOD MENTIONED SPONTANEOUSLY. FOR EACH METHOD NOT MENTIONED, READ THE DESCRIPTION, ASK 302 AND CIRCLE CODE 2 IF THE METHOD IS RECOGNIZED. ASK 303 TO 305 FOR EACH METHOD CODED 1 OR 2 IN 301-302.

Table 2

302) Have you ever heard of (METHOD)?

303) Have you ever used (METHOD)?

304) Where could you go to obtain (METHOD)?

305) In your opinion, what is the main problem, if any, with using (METHOD)?

306) INTERVIEWER:

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

308) What have you used or done?
INTERVIEWER: CORRECT 302-303 AND OBTAIN INFORMATION FOR 304-305 IF NECESSARY

309) INTERVIEWER: CHECK 303:

310) When you last used periodic abstinence, how did you measure the days where you needed to abstain?

311) How many living children did you have when you first did something or used a method to avoid getting pregnant?
IF NONE, ENTER 00

312) INTERVIEWER: CHECK 219 AND 303

313) Are you and your husband currently doing something or using any method to delay or avoid getting pregnant?

314) Which method are you using?

315) Where did you (your partner) obtain (CURRENT METHOD) the last time?

316) Why do you not use one of the methods I just described to delay or space out pregnancy?

317) Do you intend to use a method to avoid pregnancy at any time in the future?

318) Which method would you prefer to use?

319) Do you plan to use (PREFERRED METHOD) in the next 12 months?

320) Where do you plan to obtain advice or supplies for (PREFERRED METHOD)?

321) There are some women who do not want to get pregnant but do not use any of the methods (that I just listed) to delay or space out pregnancies. What do you think are the main reasons for this?
INTERVIEWER: CIRCLE ALL RESPONSES GIVEN.
PROBE: Other reasons?

322) Do you think it's acceptable to have information about family planning on the radio or television?

SECTION 4. HEALTH AND BREASTFEEDING OF CHILDREN UNDER 5 YEARS

401) INTERVIEWER: CHECK 214:

INTERVIEWER: ENTER THE LINE NUMBER, THE NAME, AND THE SURVIVAL STATUS OF EACH BIRTH SINCE JANUARY 1983 IN TABLE 3, STARTING WITH THE LAST BIRTH.

402) When you were pregnant with (NAME), did you have an antenatal consultation?
IF YES: Who did you consult the first time?
INTERVIEWER: PROBE AND CIRCLE THE CODE OF THE MOST QUALIFIED PERSON.

403) In what month did you have your first antenatal visit?

404) When you were pregnant with (NAME) did you get an injection to protect your child against tetanus?

405) Who assisted with the delivery of (NAME)?
INTERVIEWER: PROBE AND CIRCLE THE CODE FOR THE MOST QUALIFIED PERSON

406) Have you ever fed (NAME) at the breast?

407) IF ALIVE: Are you still breastfeeding (NAME)?

408) How many months did you breastfeed (NAME)?

409) Has your period returned?

410) How many months after the birth of (NAME) did your period return?

411) Have you resumed sexual relations since the birth of (NAME)?

412) How many months after the birth of (NAME) did you resume sexual relations?

413) INTERVIEWER: CHECK 407 FOR LAST BIRTH:

414) How many times did you breastfeed last night between sundown and sunrise?

415) How many times did you breastfeed yesterday during the daylight hours?

416) At any time yesterday or last night, was (NAME OF LAST CHILD) given any of the following:

417) INTERVIEWER: CHECK 416

418) Were any of these given in a bottle with a nipple?

419) At the time you became pregnant with (NAME OF LAST BIRTH), did you want to have that child then, did you want to wait until later, or did you want no (more) children at all?

420) INTERVIEWER: CHECK 401
ENTER THE ORDER NUMBER, THE NAME, AND THE SURVIVAL STATUS OF EACH BIRTH SINCE JANUARY 1983 IN TABLE 4, STARTING WITH THE LAST BIRTH. THE HEADINGS IN TABLE 4 SHOULD BE EXACTLY THE SAME AS THOSE IN TABLE 3. ASK THE QUESTIONS ONLY FOR LIVING CHILDREN.

421) Has (NAME) ever been vaccinated against illnesses?

422) Do you have a health card for (NAME)? IF YES: May I see it, please?

423) Has (NAME) had diarrhea in the last 24 hours?

424) Has (NAME) had diarrhea in the last two weeks?

425) Did you take (NAME) to a health establishment to treat the diarrhea the last time?

426) Did (NAME) get an ORS packet to treat the diarrhea?

427) What was done to treat the diarrhea (other than the ORS)?
INTERVIEWER: CODE 1 FOR ALL TREATMENTS MENTIONED

428) Has (NAME) had a fever in the last two weeks?

429) Did you take (NAME) to a health establishment to treat the fever?

430) What was done to treat the fever?
INTERVIEWER: CODE FOR ALL TREATMENTS MENTIONED

431) Has (NAME) had difficulty breathing or rapid breathing in the last two weeks?

432) Did you take (NAME) to a health establishment to treat the breathing difficulty last time?

433) What was done to treat the problem?
INTERVIEWER: CODE 1 FOR TREATMENTS MENTIONED

434) Has (NAME) had measles?

435) Did you take (NAME) to a health establishment to treat the measles?

436) What was done to treat the measles?

437) FILTER: INTERVIEWER: CHECK 426 (ALL BIRTHS)

438) Have you ever heard of a special packet called ORS that one can get to treat diarrhea?

SECTION 5. MARRIAGE

501) Are you currently:

502) How many unions have you had?

503) TABLE 5: Can you please give me some information on your marriages or unions?

INTERVIEWER: RECORD IN 504 THE NAMES OF ALL THE WOMAN'S HUSBANDS (OR PARTNERS), STARTING WITH THE FIRST HUSBAND/PARTNER. NEXT, ASK THE QUESTIONS REGARDING THE 1ST HUSBAND BEFORE MOVING ON TO THE 2ND, ETC.

504) What was (is) your 1st, 2nd, etc husband's name?

505) What is (NAME)'s ethnicity or nationality?
INTERVIEWER: SEE LIST OF ETHNICITIES

506) What is your rank among the spouses of your marriage?

*507) INTERVIEWER: Q. 507 IS ASKED ONLY FOR THE FIRST MARRIAGE/UNION?
In what month and year were you married or did you starting living with (NAME)?

508) How old were you when you got married to (NAME)?

509) How long did the marriage last?
INTERVIEWER: IF THE ONLY OR LAST MARRIAGE:
For how long have you been married to (NAME)?
(GIVE THE ANSWER IN COMPLETED YEARS)

510) How many wives does (did) (NAME) have (had) including yourself (MAXIMUM NUMBER)?
INTERVIEWER: 5=5 OR MORE

511) How did this marriage end?

512) INTERVIEWER:

FOR PAST MARRIAGES: Did you always live with (NAME)?

FOR CURRENT MARRIAGE: Does (NAME) currently live with you?
(YES OR NO)

513) INTERVIEWER:
(1) CHECK Q502. CHECK THAT THE TOTAL NUMBER OF MARRIAGES CORRESPONDS WITH THE INFORMATION IN TABLE 5.

514) ASK THE RESPONDENT TO CONNECT THE BIRTHS TO ONE OF HER MARRIAGES. RECORD THE NUMBER OF THE MARRIAGE IN THE SPACE IN COLUMN 515 (BIRTH HISTORY TABLE). FOR THE BIRTHS NOT ASSOCIATED WITH A MARRIAGE, RECORD CODE 00

516) For your last union, was your husband chosen by:

517) Was your last marriage a civil marriage, a religious marriage, a traditional marriage, or a private agreement between spouses without marriage?

518) INTERVIEWER: CHECK 208

519) Have you ever had sexual intercourse?

520) How old were when you first had sexual intercourse?

521) When was the last time you had sexual intercourse?

522) INTERVIEWER: CHECK 219

523) If you found out were you pregnant in the next month, what would you do?

524) Is there a family relationship between yourself and your (first) husband/partner?

525) PRESENCE OF OTHERS

SECTION 6. FERTILITY PREFERENCES

601) INTERVIEWER: CHECK 501:

602) Now I have some questions about the future.
INTERVIEWER: CHECK 219

NOT PREGNANT OR NOT SURE: Would you like to have a (another) child?

PREGNANT: After the child you are expecting, would you like to have other children?

603) How long would you like to wait before your next pregnancy?

604) How old should your youngest child be before the birth of your next child?
INTERVIEWER: IF NO LIVING CHILDREN, CIRCLE 96

605) For how long should a couple wait before starting sexual intercourse after the birth of a baby?

606) Do you think a mother who is still breastfeeding should start to have sexual relations again with her partner?

607) Do you think that your husband/partner approves or disapproves of couples using a method to delay or space out pregnancy?

608) How often have you talked to your husband/partner about contraception in the past 12 months?

609) In general, do you approve or disapprove of couples using a method to avoid or space out pregnancy?

610) INTERVIEWER: CHECK 208

NO CHILDREN: If you could choose exactly the number of children to have in your whole life, how many would that be?

HAS CHILDREN: If you could go back to the time you did not have any children and choose exactly the number of children to have in your whole life, how many would that be?

INTERVIEWER: PROBE TO GET A NUMBER

611) How many boys would you want and how many girls would you want?

SECTION 7. HUSBAND'S BACKGROUND AND WOMAN'S WORK

701) INTERVIEWER: CHECK 501

702) Did your current or most recent husband/partner ever attend school?

703) What is the highest level of school he attended?

704) What was the highest grade he completed?

705) INTERVIEWER: CHECK 703

706) Can (could) he read a letter or newspaper in any language?

707) What kind of work does (did) your husband/partner mainly do?
INTERVIEWER: SEE LIST OF PROFESSIONS

708) INTERVIEWER: VIEW 707

709) Does (did) he receive a regular weekly or monthly salary?

710) Does (did) your husband/partner work mainly for himself, for his family, for someone else?

711) Did he mainly work to be paid in cash or in kind?

712) Before you married, did you have a regular job?

713) When you were earning money then, did you turn most of it over to your family or did you keep most of it yourself?

714) Since you've been married (for the first time), have you ever worked regularly?

715) Are you currently working?

716) INTERVIEWER: CHECK 501

717) Have you ever worked?

718) What is (was) your main profession?
INTERVIEWER: SEE LIST OF PROFESSIONS

719) How did you use the money you earned?

720) INTERVIEWER: RECORD THE TIME

SECTION 8. WEIGHT AND LENGTH

801) INTERVIEWER: SEE TABLE 1. FOR EACH LIVING CHILD, BORN SINCE JUNE 1985 (MEANING BETWEEN 0 AND 36 MONTHS), RECORD THE ORDER NUMBER, THE BIRTH DATE, THE WEIGHT AND THE LENGTH.

FIRST AND LAST NAME _________

OBSERVATION

PERSON INTERVIEWED _____________

SPECIFIC QUESTIONS _____________

OTHER ASPECTS ____________

INTERVIEWER'S NAME_________
DATE________

SUPERVISOR'S OBSERVATIONS____________
SUPERVISOR__________
DATE_________

FIELD EDITOR'S AND DATA INPUT OFFICER'S OBSERVATIONS____________
FIELD EDITOR__________
DATE____________
DATA INPUT OFFICER ___________
DATE__________