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Women's Information Panel: WM

This module is to be administered to all women age 15 through 49 (see column HL6 of HH listing). Fill in one form for each eligible woman. Fill in the cluster and household number, and the name and line number of the woman in the space below. Fill in your name, number and the date.

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

Repeat greeting if not already read to this woman:
We are from ministry of health. We are working on a project concerned with family health and education. I would like to talk to you about this. The interview will take about 30 minutes. All the information we obtain will remain strictly confidential and your answers will never be identified. Also, you are not obliged to answer any question you don?t want to, and you may withdraw from the interview at any time. May i start now?

If permission is given, begin the interview. If the woman does not agree to continue, thank her, complete WM7, and go to the next interview. Discuss this result with your supervisor for a future revisit.

WM8. In what month and year were you born?

WM9. How old were you at your last birthday?

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 [Insert country specific term]

WM13. Check WM11:

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?

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?

If "no" probe by asking: 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?

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. Check CM11: Did the woman's last birth occur within the last 2 years, that is, since (day and month of interview in 2005)?

If child has died, take special care when referring to this child by name in the following modules

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?

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: If yes: how many times did you receive this anti-tetanus injection during your last pregnancy?

TT4. How many TT doses during last pregnancy were reported in TT3?

TT5. Did you receive any tetanus toxoid injection at any time before your last pregnancy?

TT6. How many times did you receive it?

TT7. In what month and year did you receive the last tetanus injection before that last pregnancy?

TT8. How many years ago did you receive the last anti-tetanus injection before that last pregnancy?

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.
Check child mortality module CM12 and record name of last-born child here ____
Use this child's name in the following questions, where indicated.

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.

MN3. As part of your antenatal care, were any of the following done at least once?

MN3A. Were you weighed?

MN3B. Was your blood pressure measured?

MN3C. Did you give a urine sample?

MN3D. Did you give a blood sample?

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

MN5. I don't want to know the results, but were you tested for the AIDS virus as part of your antenatal care?

MN6. I don't want to know the results, but did you get the results of the test?

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

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?
Record weight from health card, if available

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.

Marriage/union module: MA

MA1. Are you currently married or living together with a man as if married?

MA2. How old was your husband/partner on his last birthday?

MA3. Have you ever been married or lived together with a man?

MA4. What is your marital status now: are you widowed, divorced, or separated?

MA5. Have you been married or lived with a man only once or more than once?

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

MA7. Check MA6:

MA8. How old were you when you started living with your first husband/partner?

Security of tenure and durability of housing: ST

ST1. Do you feel secure from eviction from this dwelling?

Contraception module: CP

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

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.

CP4. Did you slept under a bednet last night?

CP5. If yes, was it a long lasting net or other net?

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?

HA3. Can people get infected with the AIDS virus because of witchcraft or other supernatural means?

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?

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?

HA14. Check MN5: Tested during antenatal care?

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?

HA16. I do not want you to tell me the results of the test, but have you been told the results?

HA17. Did you, yourself, ask for the test, was it offered to you and you accepted, or was it required?

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?

HA18A. If tested for HIV during antenatal care: other than at the antenatal clinic, do you know of a place where you can go to get a test to see if you have the AIDS virus?

Nutrition women: NW

NW1. Is she a nutrition woman?

NW2. Lab technician?s name and id

NW3. Day/month/year of sample collection: _ _ / _ _/ _ _ _ _

NW4. Label number for woman

NW5. Result of woman?s nutrition data collection

NW6. Woman?s weight

NW7. Woman?s height

NW8. Urine sample collected:

NW8A. If yes, 2 cryovials prepared?

NW8B. Is the woman pregnant?

NW9. Hemoglobin result collected:
Note: if Hb is less than 7g/dl, please repeat
Note: if Hb value is low, please refer to clinic

NW10A. Result of malaria test
Note: to be completed after slides are reaching port VILA/ melborne

NW11. Salt sample given to the lab technician by enumerator

NW12. Salt label

NW12A. Salt iodine level

NW8C. Urinary iodine concentration

Note: options of question NW10A were changed to include exact response of MP test and the questionnaire was updated accordingly. While, NW12A and NW8C were included to accommodate the lab results of salt iodine and urinary iodine respectively.