[p. 1]

Women's Information Panel: WM

This module is to be administered to all women age 15 through 49.

WM1. Cluster number _ _ _

WM2. Household number _ _ _

WM3. Woman's name ____

WM4. Woman's line number _ _

WM5. Interviewer name and number____ _ _

WM6. Day/month/year of interview _ _ / _ _ / _ _ _ _

WM7. Result of women's interview
WM8. In what month and year were you born?

WM9. How old were you at your last birthday?

[p. 2]
WM10. Have you ever attended school?

WM11. What is the highest level of school you attended: primary, secondary, or higher?

WM12. What is the highest grade you completed at that level?

For interviewer: Check if the woman completed Primary level.
WM14. Now I would like you to read this sentence to me.
Show sentences to respondent. If respondent cannot read whole sentence, probe: Can you read part of the sentence to me?
[p. 3]
Child Mortality Module: CM

This module is to be administered to all women age 15-49. All questions refer only to live births.

CM1. Now I would like to ask about all the births you have had during your life. Have you ever given birth? I mean, to a child who ever breathed or cried or showed other signs of life ? even if he or she lived only a few minutes or hours?

CM2a. What was the date of your first birth?
I mean the very first time you gave birth, even if the child is no longer living, or whose father is not your current partner.
Skip to CM3 only if year of first birth is given. Otherwise, continue with CM2b.
CM2B. How many years ago did you have your first birth?

CM3. Do you have any sons or daughters to whom you have given birth who are now living with you?

CM4 How many sons live with you? How many daughters live with you?

CM5 Do you have any sons or daughters whom you have given birth who are alive but do not live with you?

CM6. How many sons are alive but do not live with you? How many daughters are alive but do not live with you?

CM7. Have you ever given birth to a boy or girl who was born alive but later died?

CM8. How many boys have died? How many girls have died?

CM9. Sum answers to CM4, CM6, and CM8
CM10 Just to make sure that I have this right, you have had (total number) births during your life. Is this correct?

[p. 4]
CM11. Of these (total number) births you have had, when did you deliver the last one (even if he or she has died)?
If day is not known, enter '98' in space for day.
CM12. Did the woman's last birth occur within the last 2 years?

CM13. At the time you became pregnant with (name), did you want to become pregnant then, did you want to wait until later, or did you want no (more) children at all?

[p. 5]
Tetanus Toxoid (TT) module: TT

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

TT1. Do you have a card or other document with your own immunizations listed?
If a card is presented, use it to assist with answers to the following questions.

TT2. When you were pregnant with your last child, did you receive any injection to prevent him or her from getting tetanus, that is convulsions after birth (an anti-tetanus shot, an injection at the top of the arm or shoulder)?

TT3: How many times did you receive this anti-tetanus injection during your last pregnancy?

How many anti-tetanus injections were registered during your last pregnancy? (based on response of TT3)
TT5. Did you receive any tetanus toxoid injection at any time before your last pregnancy? This includes TT injections during previous pregnancy or between pregnancies.

TT6. How many times did you receive it?

TT7. In what month and year did you receive the last tetanus injection?
Skip to TT8 if year of injection is not given.
TT8. How many years ago did you receive the last anti-tetanus injection?

[p. 6]
Maternal and newborn health module: MN

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

MN1. In the first two months after your last birth [the birth of name], did you receive a vitamin A dose like this?
Show 200,000 IU capsule or dispenser.
MN2. Did you see anyone for antenatal care for this pregnancy?
If yes: Whom did you see? Anyone else? Probe for the type of person seen and circle all answers given.
MN2A. Where did you receive the antenatal care?
If yes: Whom did you see? Anyone else? Probe for the type of person seen and circle all answers given.
MN3. As part of your antenatal care, were any of the following done at least once?

MN3A. Were you weighed during your last pregnancy?

MN3B. Was your blood pressure measured during your last pregnancy?

MN3C. Did you give a urine sample during your last pregnancy?

MN3D. Did you give a blood sample during your last pregnancy?

MN4. During any of the antenatal visits for the pregnancy, were you given any information or counseled about AIDS or the AIDS virus?

MN7. Who assisted with the delivery of your last child (name)? Anyone else?
Probe for the type of person assisting and circle all answers given
[p. 7]
MN8. Where did you give birth to (name)?
If source is hospital, health center, or clinic, write the name of the place below. Probe to identify the type of source and circle the appropriate code.
(Name of place) ____

MN9. When you last child (name) was born, was he/she very large, larger than average, average, smaller than average, or very small?

MN10. Was (name) weighed at birth?

MN11. How much did (name) weigh?

MN12. Did you ever breastfeed (name)

MN13. How long after birth did you first put (name) to the breast?
If less than 1 hour, record '00' hours. If less than 24 hours, record hours. Otherwise, record days.
[p. 8]
Marriage/union module: MA

MA.1 What is your marital status now?

MA5. Have you been married once or more than once?

MA6. In what month and year did you first marry or start living with a man as if married

MA6A. How old were you when you first got married?

MA6B. What is the family relationship with your first husband?
If woman has been married more than once, the first marriage is to be identified.
Contraception module: CP

CP1. I would like to talk with you about another subject - family planning - and your reproductive health. Are you pregnant now?

CP1A. At the time you became pregnant with (name), did you want to become pregnant then, did you want to wait until later, or did you want no (more) children at all?

CP2. Some people use various ways or methods to delay or avoid a pregnancy. Are you currently doing something or using any method to delay or avoid getting pregnant?

CP3. Which method are you using?
Do not prompt. If more than one method is mentioned, circle each one.
CP4A. Now I would like to ask some questions about the future. Would you like to have (a/another) child, or would you prefer not to have any (more) children?

CP4B. If currently pregnant: Now I would like to ask some questions about the future. after the child you are now expecting, would you like to have another child, or would you prefer not to have any (more) children?

CP4C. How long would you like to wait before the birth of (a/another) child?

CP4D. Check if woman is:
CP4E. Do you think you are physically able to get pregnant at this time?

[p. 10]
HIV/AIDS module: HA

HA1. Now I would like to talk with you about something else.
Have you ever heard of the virus HIV or an illness called AIDS?

HA2. Can people protect themselves from getting infected with the AIDS virus by having one sex partner who is not infected and also has no other partners?

HA4. Can people reduce their chance of getting the AIDS virus by using a condom every time they have sex?

HA5. Can people get the AIDS virus from mosquito bites?

HA6. Can people reduce their chance of getting infected with the AIDS virus by not having sex at all?

HA7. Can people get the AIDS virus by sharing food with a person who has aids?

HA7A. Can people get the aids virus by getting injections with a needle that was already used by someone else?

HA8. Is it possible for a healthy-looking person to have the AIDS virus?

HA9. Can the AIDS virus be transmitted from a mother to a baby?

HA9A. During pregnancy?

HA9B. During delivery?

HA9C. By breastfeeding?

HA10. If a female teacher has the AIDS virus but is not sick, should she be allowed to continue teaching in school?

HA11. Would you buy fresh vegetables from a shopkeeper or vendor if you knew that this person had the AIDS virus?

HA12. If a member of your family became infected with the AIDS virus, would you want it to remain a secret?

HA13. If a member of your family became sick with the AIDS virus, would you be willing to care for him or her in your household?

[p. 11]
HA15. I do not want to know the results, but have you ever been tested to see if you have HIV, the virus that causes AIDS?

HA18. At this time, do you know of a place where you can go to get such a test to see if you have the AIDS virus?

Follow instructions in your interviewer's manual.