Code number
Age of Pregnant woman in completed years
Parity of respondent
Number of Living children
Ethnicity
Religion
Highest Education level attained
Marital status
What do you do for a living
Is this your first pregnancy? (If 'Yes' then SKIP to question 17 in section
Did you attend any ANC visit during the last pregnancy? (If response is 'No'
If 'Yes' in question 12, How many ANC visits did you make during the last pr
What was the outcome of your last pregnancy?
Where did the last delivery take place?
Who assisted you during the last delivery?
How old is the baby now? (State in completed months)
Gestation age at the first visit (in weeks)
How many ANC visits did you make during the last pregnancy
Did you make any preparation for this delivery?
Secured warm dresses and other items like basin for the baby
Bought mama kit,
Bought mackintosh (kaveera),
Saved some money,
Decided where to deliver from,
Identified a caretaker for the remaining children while I am away,
Identifying means of transport to health facility during onset of labour
Did you fall sick during the pregnancy?
If yes where did you first go for help/care?
Did the VHT make any visits to discuss with you about your pregnancy and pre
If yes how many visits did she/he make during your pregnancy
Was this pregnancy maintained up to the time for delivery
Mode of delivery of the current baby
Place of delivery
Who attended to you during delivery
In your view was this labour
Did you develop any complications during the delivery?
If Yes in 14 Which complication: (Circle all that apply)
Labour was too long
heavy Vaginal bleeding
Swelling of the feet
Convulsions
Ruptured uterus
Obstructed labour
None
Was the baby born alive
What instrument was used for cutting the cord?
What material was used to tie the cord?
What substance was applied on the cord? (circle as many as applies)
Application of powder on the stump
Application of animal waste
Application of soot powder
Salt water
Herbal medicines
Other substances, specify
Nothing
At what stage after delivery was the newborn dried up?
At what stage was the newborn wrapped up in a warm cloth?
What was the timing of the first bath after delivery?
How soon after delivery was breastfeeding initiated
Did you give any pre-lacteal feeds?
(if Yes in 24 ) Which feeds were given to the baby? (circle all that apply)
Water only
Water with sugar
Water with glucose
Water with tea
Other (specify)
What was the reason for offering pre-lacteal feeds for the baby
Did you make any postnatal visits to the health facility
How many postnatal visits so far have you made
How early was the first visit
Did the VHT visit you after delivery
If Yes in 30 how many times did the VHT visit you after the delivery (Write
Is the newborn already immunised for
Polio zero
Confirmed Polio 0 vaccination card
BCG
Confirmed BCG vaccination with card
Confirm BCG scare in absence of card
Did this newborn fall ill in the first four weeks after delivery (one month)
If yes in question 33 how did you detect the illness? (Circle all that apply
Failure to feed
Excessive crying
Less activity
Warm to touch
Discharging umbilicus
Where or from whom did you seek for care first?
How soon after you realised the symptoms did you seek for care?
What in your view was the cause of illness for the baby?
Are you giving anything extra to the baby in addition to breast milk?
If Yes in 38, what feeds are you giving?
Are you pregnant at the moment?
What contraceptive method are you using to prevent getting pregnant?
If none in 41, have you considered avoiding pregnancy?
If Yes in 42 what method(s) are you planning to use?
Before becoming pregnant with the current baby did you use any Family Planni
If yes in 44, which method of Family Planning did you use?
Request for a urine sample to carry out a pregnancy test Pregnancy results