Women's Questionnaire (With Birth History) v3.0

7/31/2019 Women's Questionnaire (With Birth History) v3.0

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AZERBAIJAN NATIONAL NUTRITION SURVEY

2012

QUESTIONNAIRE FOR INDIVIDUAL WOMEN

WOMANS INFORMATION PANEL WM

This questionnaire is to be administered to all women age 15 through 49 (see Household Listing Form, column HL7). A

separate questionnaire should be used for each eligible woman.

WM1. Cluster number: WM2. Household number:

___ ___ ___ ___ ___

WM3. Womans name: WM4. Womans line number:

Name ___ ___

WM5. Interviewer name and number: WM6. Day / Month / Year of interview:

Name ___ ___ ___ ___ / ___ ___ / ___ ___ ___ ___

Repeat greeting if not already read to this woman:

WEAREFROM (COUNTRY-SPECIFICAFFILIATION). WEAREWORKINGONAPROJECTCONCERNEDWITHFAMILYHEALTH

ANDEDUCATION. I WOULDLIKETOTALKTOYOUABOUTTHESESUBJECTS. THEINTERVIEWWILLTAKEABOUT (NUMBER)MINUTES. ALLTHEINFORMATIONWEOBTAINWILLREMAINSTRICTLYCONFIDENTIALANDYOURANSWERSWILLNEVERBESHAREDWITHANYONEOTHERTHANOURPROJECTTEAM.

If greeting at the beginning of the household questionnaire

has already been read to this woman, then read thefollowing:

NOW I WOULDLIKETOTALKTOYOUMOREABOUTYOURHEALTHANDOTHERTOPICS. THISINTERVIEWWILLTAKEABOUT(NUMBER) MINUTES. AGAIN, ALLTHEINFORMATIONWEOBTAINWILLREMAINSTRICTLYCONFIDENTIALANDYOUR

ANSWERSWILLNEVERBESHAREDWITHANYONEOTHERTHANOURPROJECTTEAM.

MAY I STARTNOW?

YES, PERMISSIONISGIVENGo to WM10 to record the time and then bEGINTHEINTERVIEW.

NO, PERMISSIONISNOTGIVENCOMPLETEWM7. DISCUSSTHISRESULTWITHYOURSUPERVISOR.

WM7. Result of womans interview Completed.............................................................01Not at home...........................................................02Refused.................................................................03Partly completed....................................................04Incapacitated.........................................................05

Other (specify)_____________________________96

WM8. Field edited by (Name and number):

Name___________________________ ___ ___

WM9. Data entry clerk (Name and number):

Name____________________________ ___ ___

WM10.Record the time. Hour and minutes......................__ __ : __ __


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WOMANS BACKGROUND WB

WB1. INWHATMONTHANDYEARWEREYOUBORN? Date of birthMonth................................................__ __DK month...............................................98

Year .......................................__ __ __ __DK year..............................................9998

WB2. HOWOLDAREYOU?

Probe: HOWOLDWEREYOUATYOURLASTBIRTHDAY?

Compare and correct WB1 and/or WB2 if

inconsistent

Age (in completed years)......................__ __

WB3. HAVEYOUEVERATTENDEDSCHOOLORPRESCHOOL?

Yes..............................................................1No...............................................................2 2WB7

WB4. WHATISTHEHIGHESTLEVELOFSCHOOLYOUATTENDED? Preschool....................................................0

Primary........................................................1Secondary...................................................2Higher..........................................................3

0WB7

WB5. WHATISTHEHIGHESTGRADEYOUCOMPLETEDATTHATLEVEL?

If less than 1 grade, enter 00

Grade...................................................__ __

WB6. Check WB4:

Secondary or higher. Go to Next Module

Primary Continue with WB7

WB7. NOW I WOULDLIKEYOUTOREADTHISSENTENCETOME.

Show sentence on the card to the respondent.

If respondent cannot read whole sentence,probe:

CANYOUREADPARTOFTHESENTENCETOME?

Cannot read at all........................................1Able to read only parts of sentence..............2Able to read whole sentence........................3

No sentence inrequired language___________________4

(specify language)

Blind / mute, visually / speech impaired.... .. .5


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MATERNAL AND NEWBORN HEALTH MN

This module is to be administered to all women with a live birth in the 2 years preceding date of interview.Check child mortality module CM13 and record name of last-born child here _____________________.

Use this childs name in the following questions, where indicated.

MN1. DIDYOUSEEANYONEFORANTENATALCAREDURINGYOURPREGNANCYWITH (name)?

Yes..............................................................1

No...............................................................2 2MN5

MN2. WHOMDIDYOUSEE?

Probe:

ANYONEELSE?

Probe for the type of person seen and circle all

answers given.

Health professional:Doctor.....................................................ANurse / Midwife........................................BAuxiliary midwife.....................................C

Other personTraditional birth attendant........................FCommunity health worker........................G

Other (specify)________________________X

MN3. HOWMANYTIMESDIDYOURECEIVEANTENATALCAREDURINGTHISPREGNANCY? Number of times...................................__ __

DK.............................................................98

MN4. ASPARTOFYOURANTENATALCAREDURINGTHISPREGNANCY, WEREANYOFTHEFOLLOWINGDONEATLEASTONCE:

[A] WASYOURBLOODPRESSUREMEASURED?

[B] DIDYOUGIVEAURINESAMPLE?

[C] DIDYOUGIVEABLOODSAMPLE?

Yes No

Blood pressure.................................1 2

Urine sample....................................1 2

Blood sample...................................1 2

MN5. DOYOUHAVEACARDOROTHERDOCUMENTWITHYOUROWNIMMUNIZATIONSLISTED?

MAYISEEITPLEASE?

If a card is presented, use it to assist with

answers to the following questions.

Yes (card seen)...........................................1Yes (card not seen).....................................2No...............................................................3

DK...............................................................8

MN6. WHENYOUWEREPREGNANTWITH (name), DIDYOURECEIVEANYINJECTIONINTHEARMORSHOULDERTOPREVENTTHEBABYFROMGETTINGTETANUS, THATISCONVULSIONSAFTERBIRTH?

Yes..............................................................1

No...............................................................2

DK...............................................................8

2MN9

8MN9

MN7. HOWMANYTIMESDIDYOURECEIVETHISTETANUSINJECTIONDURINGYOURPREGNANCYWITH (name)?

If 7 or more times, record 7.

Number of times........................................__

DK...............................................................8 8MN9

MN8. How many tetanus injections during last pregnancy were reported in MN7?

At least two tetanus injections during last pregnancy. Go to MN12

Only one tetanus injection during last pregnancy. Continue with MN9

MN9. DIDYOURECEIVEANYTETANUSINJECTIONATANYTIMEBEFOREYOURPREGNANCYWITH (name), EITHER

TOPROTECTYOURSELFORANOTHERBABY?

Yes..............................................................1

No...............................................................2 2MN12


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DK...............................................................8 8MN12

MN10. HOWMANYTIMESDIDYOURECEIVEATETANUSINJECTIONBEFOREYOURPREGNANCYWITH (name)?

If 7 or more times, record 7.

Number of times........................................__

DK...............................................................8 8MN12

MN11. HOWMANYYEARSAGODIDYOURECEIVETHELASTTETANUSINJECTIONBEFOREYOURPREGNANCYWITH (name)?

Years ago.............................................__ __

MN12. Check MN1 for presence of antenatal care during this pregnancy:

Yes, antenatal care received. Continue with MN13

No antenatal care receivedGo to MN17

MN13. DURINGANYOFTHESEANTENATALVISITSFORTHEPREGNANCY, DIDYOUTAKEANYMEDICINEIN

ORDERTOPREVENT YOUFROMGETTINGMALARIA?

Yes..............................................................1No...............................................................2

DK...............................................................8

2MN17

8MN17

MN14. WHICHMEDICINESDIDYOUTAKETOPREVENTMALARIA?

Circle all medicines taken. If type of medicine is

not determined, show typical anti-malarial torespondent.

SP / Fansidar..............................................AChloroquine.................................................B

Other (specify)________________________XDK...............................................................Z

MN15. Check MN14 for medicine taken:

SP / Fansidar taken. Continue with MN16

SP / Fansidar not taken. Go to MN17

MN16. DURINGTHISPREGNANCY, HOWMANYTIMESDIDYOUTAKE SP/ FANSIDAR? Number of times...................................__ __

DK.............................................................98

MN17. WHOASSISTEDWITHTHEDELIVERYOF (name)?

Probe:

ANYONEELSE?

Probe for the type of person assisting and circle

all answers given.

If respondent says no one assisted, probe todetermine whether any adults were present at

the delivery.

Health professional:Doctor.....................................................ANurse / Midwife........................................BAuxiliary midwife.....................................C

Other personTraditional birth attendant........................FCommunity health worker........................G

Relative / Friend......................................H

Other (specify)________________________XNo one........................................................Y


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MN18. WHEREDIDYOUGIVEBIRTHTO (NAME)?

Probe to identify the type of source.

If unable to determine whether public or private,

write the name of the place.

(Name of place)

HomeYour home.............................................11Other home............................................12

Public sectorGovt. hospital.........................................21

Govt. clinic / health centre......................22Govt. health post....................................23Other public (specify)________________26

Private Medical SectorPrivate hospital......................................31Private clinic...........................................32Private maternity home..........................33Other private

medical (specify)_________________36

Other(specify)_______________________96

11MN20

12MN20

96MN20

MN19. WAS (NAME) DELIVEREDBYCAESAREANSECTION?THATIS, DIDTHEYCUTYOURBELLYOPENTOTAKETHEBABYOUT?

Yes..............................................................1No...............................................................2

MN20. WHEN (name) WASBORN, WASHE/SHEVERYLARGE, LARGERTHANAVERAGE, AVERAGE, SMALLERTHANAVERAGE, ORVERYSMALL?

Very large....................................................1Larger than average....................................2Average.......................................................3Smaller than average...................................4Very small....................................................5

DK...............................................................8

MN21. WAS (NAME) WEIGHEDATBIRTH? Yes..............................................................1

No...............................................................2

DK...............................................................8

2MN23

8MN23

MN22. HOWMUCHDID (NAME) WEIGH?

Record weight from health card, if available.From card........................1 (kg) __ . __ __ __

From recall......................2 (kg) __ . __ __ __

DK.......................................................99998

MN23. HASYOURMENSTRUALPERIODRETURNEDSINCETHEBIRTHOF (NAME)?

Yes..............................................................1

No...............................................................2

MN24. DIDYOUEVERBREASTFEED (NAME)? Yes..............................................................1No...............................................................2 2Next

Module

MN25. HOWLONGAFTERBIRTHDIDYOUFIRSTPUT(NAME) TOTHEBREAST?

If less than 1 hour, record 00 hours.

If less than 24 hours, record hours.

Otherwise, record days.

Immediately.............................................000

Hours................................................1 __ __

Days.................................................2 __ __

Dont know / remember......................998

MN26. INTHEFIRSTTHREEDAYSAFTERDELIVERY, WAS(name) GIVENANYTHINGTODRINKOTHERTHANBREASTMILK?

Yes..............................................................1No...............................................................2 2Next

Module


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MN27. WHATWAS (name) GIVENTODRINK?

Probe:

ANYTHINGELSE?

Milk (other than breast milk)........................APlain water..................................................BSugar or glucose water...............................CGripe water.................................................DSugar-salt-water solution.............................EFruit juice.....................................................F

Infant formula..............................................GTea / Infusions............................................HHoney...........................................................I

Other (specify)________________________X

POST-NATAL HEALTH CHECKS PN

This module is to be administered to all women with a live birth in the 2 years preceding the date of interview.

Check child mortality module CM13 and record name of last-born child here _____________________.Use this childs name in the following questions, where indicated.

PN1. Check MN18: Was the child delivered in a health facility?

Yes, the child was delivered in a health facility (MN18=21-26 or 31-36) Continue with PN2

No, the child was not delivered in a health facility (MN18=11-12 or 96) Go to PN6

PN2. NOW I WOULDLIKETOASKYOUSOMEQUESTIONSABOUTWHATHAPPENEDINTHEHOURSANDDAYSAFTERTHEBIRTHOF (name).

YOUHAVESAIDTHATYOUGAVEBIRTHIN (name ortype of facility in MN18). HOWLONGDIDYOUSTAYTHEREAFTERTHEDELIVERY?

If less than one day, record hours.If less than one week, record days.

Otherwise, record weeks.

Hours................................................1 __ __

Days.................................................2 __ __

Weeks...............................................3 __ __

Dont know / remember............................998

PN3. I WOULDLIKETOTALKTOYOUABOUTCHECKSON(name)SHEALTHAFTERDELIVERY FOREXAMPLE,SOMEONEEXAMINING (name), CHECKINGTHECORD,ORSEEINGIF (name) ISOK.

BEFOREYOULEFTTHE (name or type of facility inMN18), DIDANYONECHECKON (name)SHEALTH?

Yes..............................................................1No...............................................................2

PN4. ANDWHATABOUTCHECKSONYOUR HEALTH IMEAN, SOMEONEASSESSINGYOURHEALTH, FOREXAMPLEASKINGQUESTIONSABOUTYOURHEALTHOREXAMININGYOU.

DIDANYONECHECKONYOUR HEALTHBEFOREYOULEFT (name or type or facility in MN18)?

Yes..............................................................1No...............................................................2

PN5. NOW I WOULDLIKETOTALKTOYOUABOUTWHATHAPPENEDAFTERYOULEFT (name or type offacility in MN18).

DIDANYONECHECKON (name)SHEALTHAFTERYOULEFT (name or type of facility in MN18)?

Yes..............................................................1No...............................................................2

1PN11

2PN16


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PN6. Check MN17: Did a health professional, traditional birth attendant, or community health worker assist with thedelivery?

Yes, delivery assisted by a health professional, traditional birth attendant, or communityhealth worker (MN17=A-G) Continue with PN7

No, delivery not assisted by a health professional, traditional birth attendant, or communityhealth worker (A-G not circled in MN17) Go to PN10

PN7. YOUHAVEALREADYSAIDTHAT (person orpersons in MN17) ASSISTEDWITHTHEBIRTH. NOWI WOULDLIKETOTALKTOYOUABOUTCHECKSON(name)SHEALTHAFTERDELIVERY, FOREXAMPLEEXAMINING (name), CHECKINGTHECORD, ORSEEINGIF (name) ISOK.

AFTERTHEDELIVERYWASOVERANDBEFORE(person or persons in MN17) LEFTYOU, DID(person or persons in MN17) CHECKON (name)SHEALTH?

Yes..............................................................1No...............................................................2

PN8. ANDDID (person or persons in MN17) CHECKONYOUR HEALTHBEFORELEAVING?

BYCHECKONYOURHEALTH, I MEANASSESSINGYOURHEALTH, FOREXAMPLEASKINGQUESTIONS

ABOUTYOURHEALTHOREXAMININGYOU.

Yes..............................................................1No...............................................................2

PN9. AFTERTHE (person or persons in MN17) LEFTYOU, DIDANYONECHECKONTHEHEALTHOF(name)?

Yes..............................................................1No...............................................................2

1PN11

2PN18

PN10. I WOULDLIKETOTALKTOYOUABOUTCHECKSON(name)SHEALTHAFTERDELIVERY FOREXAMPLE,SOMEONEEXAMINING (name), CHECKINGTHECORD,ORSEEINGIFTHEBABYISOK.

AFTER (name) WASDELIVERED, DIDANYONECHECKONHIS/HERHEALTH?

Yes..............................................................1No...............................................................2 2PN19

PN11. DIDSUCHACHECKHAPPENONLYONCE, ORMORETHANONCE?

Once............................................................1More than once............................................2

1PN12A

2PN12B

PN12A. HOWLONGAFTERDELIVERYDIDTHATCHECKHAPPEN?

PN12B. HOWLONGAFTERDELIVERYDIDTHEFIRSTOFTHESECHECKSHAPPEN?

If less than one day, record hours.

If less than one week, record days.Otherwise, record weeks.

Hours................................................1 __ __

Days.................................................2 __ __

Weeks...............................................3 __ __



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PN13. WHOCHECKEDON (name)SHEALTHATTHATTIME?

Health professionalDoctor.....................................................ANurse / Midwife........................................BAuxiliary midwife.....................................C

Other personTraditional birth attendant........................F

Community health worker........................GRelative / Friend......................................H

Other (specify)________________________X

PN14. WHEREDIDTHISCHECKTAKEPLACE?


If unable to determine whether public or private,

write the name of the place.

(Name of place)


Public sectorGovt. hospital.........................................21Govt. clinic / health centre......................22

Govt. health post....................................23Other public (specify)________________26

Private medical sectorPrivate hospital......................................31Private clinic...........................................32Private maternity home..........................33Other private

medical (specify)_________________36

Other(specify)_______________________96

PN15. Check MN18: Was the child delivered in a health facility?

Yes, the child was delivered in a health facility (MN18=21-26 or 31-36) Continue with PN16

No, the child was not delivered in a health facility (MN18=11-12 or 96) Go to PN17

PN16. AFTERYOULEFT (name or type of facility inMN18), DIDANYONECHECKONYOUR HEALTH?

Yes..............................................................1No...............................................................2

1PN20

2NextModule

PN17. Check MN17: Did a health professional, traditional birth attendant, or community health worker assist with thedelivery?

Yes, delivery assisted by a health professional, traditional birth attendant, or community

health worker (MN17=A-G) Continue with PN18

No, delivery not assisted by a health professional, traditional birth attendant, or communityhealth worker (A-G not circled in MN17) Go to PN19

PN18. AFTERTHEDELIVERYWASOVERAND (person orpersons in MN17) LEFT, DIDANYONECHECKONYOUR HEALTH?

Yes..............................................................1No...............................................................2

1PN20

2NextModule


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PN19. AFTERTHEBIRTHOF (name), DIDANYONECHECKONYOUR HEALTH?

I MEANSOMEONEASSESSINGYOURHEALTH, FOREXAMPLEASKINGQUESTIONSABOUTYOURHEALTHOREXAMININGYOU.

Yes..............................................................1No...............................................................2 2Next

Module

PN20. DIDSUCHACHECKHAPPENONLYONCE, ORMORETHANONCE?

Once............................................................1More than once............................................2

1PN21A

2PN21B

PN21A. HOWLONGAFTERDELIVERYDIDTHATCHECKHAPPEN?

PN21B. HOWLONGAFTERDELIVERYDIDTHEFIRSTOFTHESECHECKSHAPPEN?

If less than one day, record hours.

If less than one week, record days.

Otherwise, record weeks.

Hours................................................1 __ __

Days.................................................2 __ __

Weeks...............................................3 __ __


PN22. WHOCHECKEDONYOUR HEALTHATTHATTIME? Health professionalDoctor.....................................................ANurse / Midwife........................................BAuxiliary midwife.....................................C

Other personTraditional birth attendant........................FCommunity health worker........................GRelative / Friend......................................H

Other (specify)________________________X

PN23. WHEREDIDTHISCHECKTAKEPLACE?


If unable to determine whether public or private,write the name of the place.

(Name of place)


Public sectorGovt. hospital.........................................21Govt. clinic / health centre......................22Govt. health post....................................23Other public (specify)________________26

Private medical sectorPrivate hospital......................................31

Private clinic...........................................32Private maternity home..........................33Other private

medical (specify)_________________36

Other(specify)_______________________96

ANTHROPOMETRY AN

After questionnaires for all women are complete, the measurer weighs and measures each woman.Record weight and height below, taking care to record the measurements on the correct questionnaire for each.

Check the womans name and line number on the household listing before recording measurements.

AN1.Measurers name and number: Name ___ ___

AN2.Result of height and weight measurement Either or both measured..............................1


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Woman not present.....................................2

Woman refused...........................................3

Other (specify)________________________6

2AN6

3AN6

6AN6

AN3. Womans weight Kilograms (kg)...........................__ __ __ . __

Weight not measured............................999.9

AN4. Womans height Centimetres (Cm)......................__ __ __ . __

Height not measured.............................999.9

AN5. Womans Mid Upper Arm Circumference(MUAC)

MUAC (cm).................................... __ __. __

MUAC not measured...........................9999.9

AN6. Is there another woman in the household who is eligible for measurement?

Yes Record measurements for next woman.

No Check if there are any other individual questionnaires to be completed in the household.


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WM11.Record the time. Hour and minutes......................__ __ : __ __

WM12. Check Household Listing Form, column HL9.Is the respondent the mother or caretaker of any child age 0-4 living in this household?

Yes Go to QUESTIONNAIRE FOR CHILDREN UNDER FIVE for that child and start the interview

with this respondent.

No End the interview with this respondent by thanking her for her cooperation.

Check for the presence of any other eligible woman, man or child under-5 in the household.


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Interviewers Observations

Field Editors Observations

Supervisors Observations

Women's Questionnaire (With Birth History) v3.0

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