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Antenatal Care

Did you see anyone for antenatal care for the pregnancy prior to your most recent
delivery?
Answer

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Yes
No
Whom did you see?
Answer

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Doctor
Nurse
Health Worker
Health
Volunteer
Others
As part of your antenatal care during the pregnancy prior to your most recent
delivery, were any of the following done at least once?
Answer

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Abdomen
Examined
Received Iron
Tablets
Received TT
Vaccination
Weight Measured
Pressure Measured
Give Blood Sample
During any of your antenatal care visits with health workers during your pregnancy
prior to your ost recent delivery, were you counseled on:

Answer
Financial Preparation
Identifying Emergency Transport

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Options
Arrangement for Blood
Tetanus Vaccination
Immediate Breastfeeding after
birth
Care for the newborn
Did you receive tetanus toxoid injection when you were pregnant?

Answer

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Yes
No

Did you take iron/folic acid tablets when you were pregnant?

Answer

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Yes
No
When you were pregnant, did you receive less care and support from your family
members?

Answer

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Less than usual


Same as usual
More than as usual
What types of support/care did you receive from your family members?

Answer
Given more

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nutritious food
Advised for more
rest
Reduced Heavy
load
Advised/accompani
ed for physical
check-up
Others (Specify)

Delivery Care
Who assisted with your most recent delivery?

Answer

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Health Worker
Family
Relative/Friend
Others (Specify)
Nobody
Who else was present at the time of delivery?

Answer

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Husband
Other Family
Members
Relatives
Friends/Neighbors
Nobody
Cant remember
Where did you give birth in your most recent delivery?

Answer

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Hospital
Clinic/Nursing
Home
Home
Other
Was your child delivered by caesarean section?

Answer

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Yes
No
Did you bleed a lot more than normal immediately following the birth of your baby?

Answer

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Yes
No
Dont Know
In your opinion, what things need to be kept clean during childbirth?

Answer

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Clean Nails
Clean Hands
Blade
Surface on which cord is cut
Surface on which newborn is
placed
Thread
Perineum
Mothers Clothes
Clothes for wrapping baby
Before your delivery, have you seen, heard, or read anything about the importance
of delivering in a suitable health facility?

Answer

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Yes
No
Where did you see, hear, or read a message on importance of delivering in a
suitable health facility?

Answer

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()

From Health Worker


Community Groups
Poster, Pamphlets,
Leaflets
Newspapers
Radio
Television
Internet
Others
Post-Partum Care
In the early days after the delivery did you visit to health worker?

Answer

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Yes
No
What services, help or advice did your health worker provideyou or your newoborn
during the one month following your last delivery?

Answer
Diagnose or treat
illness in the
newborn
Provide Vitamin A

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for
mother/newborn
Provide iron tablets
for mother
Check deliveryrelated problems
on mother
Others
Did you receive advice from your health worker on any of the following topics during
one month following your last delivery?

Answer

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Take rest/avoid
work
Diet
Breastfeeding
Counseling
Avoid infection to
newborn
Post-partum
danger signs for
mother
Danger signs for
newborn
Family planning
Iron Tablets
In the first 42 days after delivery, did you receive a Vitamin A dose?

Answer

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Yes
No
Following your delivery, did a health worker counsel you on the following maternal
signs or issues?

Answer

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High Fever
Severe Lower
Abdominal Pain
Excessive Bleeding
Severe headache
Convulsions
Breast Problems
During the first six weeks, wht types of care/support did you receive from your
family members?

Answer

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Given more
nutritious food to
eat
Advised for more
rest
Reduced heavy
load
Advised/accompani
ed for check-up
Others
Who usually take care for your newborn during the six week periods?

Answer
Self
Mother in law
Father in law
Husband
Sister in law
Others
Immediate New Born Care
Was a clean Delivery Kit used during delivery?

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Answer

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Yes
No
Dont know
What instrument was used to cut the cord?

Answer

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Blade
Grass Cutter
(Hasiya)
Scissor
Others
Dont Know
Was the instrument used to cut cord boiled prior to use?

Answer

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Yes
No
Dont Know
Did the person who handled the baby, assisting with the delivery, washed hands
with soap and water first?

Answer

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Yes
No
Dont Know
Did anybody apply anyting on the stump after the babys cord was cut?

Answer

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Yes
No
What did they apply, if any?

Answer

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Oil
Ointment/powder
Turmeric powder
Ghee
Others
Was your baby wiped off/dried before the placenta was delivered?

Answer

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Yes
No
Dont Know
Was your baby wrapped in cloth or put on mothers body and covered with cloth
before the placenta was delivered?

Answer

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Yes
No
Dont Know
How long after birth was hour baby bathed for the first time?

Answer
Within 1 hour

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2-24 hours
After 24 hours
How long after birth did you first put the newborn to the breast?

Answer

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Within 1 hour
2-24 hours
Are you still breastfeeding?

Answer

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Yes
No
Newborn Care During First Month
What are the symptoms of the infant within one month after delivery indicating the
need to seek immediate health care?

Answer

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Poor sucking or not


able to suck
Fast Breathing
Fever
Pustules on skin
Umbilical infection
Others
What is the condition of your baby?

Answer
Baby Still Alive

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Baby Born Alive,


then died within 2
months
Baby Disabled
How many times newborns health was checked within four weeks after the
delivery?
No. of times