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| Data entry sequence number: | Data entry initials: | ||||
|
Antenatal Client Exit Interview | |||||
| Facility name: | Facility code: | District code: | |||
| Type of facility (enter H=Hospital; C=Health Centre; P=Health Post): | |||||
| Facility administration (enter G=Government; M=Mission; P=Private): | |||||
| Date today: | Team code: | Surveyor code: | |||
|
Please see sampling instructions in Surveyor's Manual. WE ARE CONDUCTING A SURVEY OF MATERNAL HEALTH SERVICES PROVIDED IN THIS AREA, AND WOULD BE GRATEFUL IF YOU WOULD TAKE A FEW MINUTES TO ANSWER SOME QUESTIONS. WE WILL NOT RECORD YOUR NAME, AND YOUR ANSWERS WILL BE HELD IN STRICT CONFIDENCE. | |||
| {ANC1} | WHAT FORM OF TRANSPORT DID YOU USE
TO GET TO THE CLINIC TODAY?
Tick one box |
1 Walked
2 Horse, donkey, or other animal 3 Bicycle 4 Motorcycle 5 Automobile 6 Bus 9 Other - specify: | |
| {ANC2} | HOW LONG DID IT TAKE YOU TO REACH THIS FACILITY TODAY?
Enter response in minutes (for example enter 1 hour 30 minutes as 90 minutes) |
||
| {ANC3} | DO YOU HAVE YOUR ANTENATAL CARD WITH YOU TODAY?
If yes, ask to see the card and check subsequent responses Tick one box |
1 Yes 0 No | |
| {ANC4} | HOW LONG HAVE YOU BEEN PREGNANT?
Enter response in months If not known, enter 0 |
||
| {ANC5} | DURING WHICH MONTH OR WEEK OF THIS PREGNANCY DID YOU FIRST COME FOR
ANTENATAL CARE?
Enter response in months If not known, enter 0 |
||
| {ANC6} | HOW MANY TIMES HAVE YOU BEEN PREGNANT INCLUDING THIS TIME?
Enter number If respondent asks, include still births and abortions If first pregnancy, enter "1" and go to question ANC13 |
(If 1 ANC13) | |
| {ANC7} | HAVE YOU EVER HAD A CAESAREAN SECTION, STILLBIRTH OR FITS?
Tick one box If "no", go to question ANC9 |
1 Yes
0 No ( ANC9) | |
| {ANC8} | WHEN YOU MET THE NURSE TODAY, DID SHE ADVISE YOU TO GIVE BIRTH IN A HEALTH
FACILITY?
Tick box |
1 Yes
0 No | |
| {ANC9} | DID YOUR LAST BIRTH TAKE PLACE IN A HEALTH FACILITY?
Tick box If no, go to question ANC13 |
1 In facility
0 NOT in facility ( ANC13) | |
| {ANC10} | DID YOU HAVE TO PAY FOR YOUR LAST BIRTH? IF YES, HOW MUCH DID YOU PAY,
INCLUDING ALL FEES, DRUGS, AND SUPPLIES?
If no payment was made, enter 0 Enter amount in local currency |
||
| {ANC11} | WHEN YOU GAVE BIRTH LAST TIME, WHO
HELPED YOU AT THE MOMENT THAT THE
BABY WAS BORN?
Tick one best response |
1 Nurse or midwife
2 Doctor or clinical officer 3 Ward or patient attendant 4 Medical assistant 5 Traditional birth attendant (TBA) 6 Mother or other family member 9 Other (specify): | |
| {ANC12} | AFTER YOUR LAST BIRTH, DID YOU HAVE A CHECK-UP? Tick box | 1 Yes 0 No | |
|
I WOULD NOW LIKE TO KNOW MORE ABOUT THE SERVICES THAT YOU RECEIVED DURING YOUR VISIT TODAY. DID THE STAFF... Ask about each service separately. |
Tick one box
for each service | |
| {ANC13A} | ...CHECK YOUR BLOOD PRESSURE? | 1 Yes 0 No |
| {ANC13B} | ...PERFORM AN ABDOMINAL EXAMINATION? | 1 Yes 0 No |
| {ANC13C} | ...LISTEN TO THE BABY'S HEARTBEAT? | 1 Yes 0 No |
|
I WOULD NOW LIKE YOU TO THINK ABOUT ALL OF YOUR VISITS DURING THIS PREGNANCY, INCLUDING TODAY. DURING ANY OF THESE VISITS, DID THE STAFF... Ask about each service separately |
Tick one box
for each service | |
| {ANC14A} | ...ASK ABOUT YOUR MEDICAL HISTORY? | 1 Yes 0 No |
| {ANC14B} | ...TAKE A BLOOD SAMPLE? | 1 Yes 0 No |
| {ANC14C} | ...TAKE A URINE SAMPLE? | 1 Yes 0 No |
| {ANC14D} | ...GIVE YOU IRON SUPPLEMENTS? | 1 Yes 0 No |
| {ANC14E} | ...GIVE YOU INFORMATION OR ADVICE ABOUT DIET AND NUTRITION? | 1 Yes 0 No |
| {ANC14F} | ... DISCUSS THE PLACE OF BIRTH? | 1 Yes 0 No |
| {ANC14G} | ... DISCUSS THE BENEFIT OF BIRTH IN THE HEALTH FACILITY? | 1 Yes 0 No |
| {ANC14H} | ...ADVISE YOU WHAT TO DO IF THERE IS A PROBLEM DURING YOUR PREGNANCY SUCH AS BLEEDING, CONVULSIONS OR FITS? | 1 Yes 0 No |
| {ANC14J} | ...GIVE MALARIA MEDICINE? | 1 Yes 0 No |
| {ANC14K} | ...DISCUSS CHILD SPACING OR FAMILY PLANNING? | 1 Yes 0 No |
| {ANC14L} | ...TALK ABOUT SEXUALLY TRANSMITTED DISEASES, HIV AND AIDS? | 1 Yes 0 No |
| {ANC14M} | ...GIVE YOU INFORMATION OR ADVICE ON HOW TO TAKE CARE
OF YOUR BABY? |
1 Yes 0 No |
| {ANC14N} | ...DISCUSS HOW YOU WOULD GET TO THE
HEALTH FACILITY IF THERE WERE AN EMERGENCY? |
1 Yes 0 No |
|
WHAT ARE SOME DANGER OR WARNING SIGNS OF A PROBLEM WITH YOUR PREGNANCY? Listen carefully. Probe for multiple responses. Do not read out list. |
Tick as many
box(es) as apply | |
| {ANC15A} | previous bad obstetric history / abdominal scars / previous stillbirth | |
| {ANC15B} | hypertension / headache / swelling / fits | |
| {ANC15C} | anaemia / pallor / fatigue / breathlessness | |
| {ANC15D} | cessation of fetal movement / baby does not move | |
| {ANC15E} | abnormal lie / position of fetus | |
| {ANC15F} | sepsis / foul smelling discharge / postpartum abdominal pain | |
| {ANC15G} | light bleeding / spotting | |
| {ANC15H} | haemorrhage / heavy bleeding | |
| {ANC15J} | multiple pregnancy / large abdomen | |
| {ANC15K} | obstructed / prolonged labour / "sun set two times" | |
| {ANC15L} | Other - specify: | |
| {ANC16} | NOT COUNTING WAITING TIME, HOW MANY MINUTES DID YOU SPEND WITH THE HEALTH
PERSONNEL TODAY?
Enter number of minutes |
|
| {ANC17} | TODAY, DID YOU HAVE A CHANCE TO MEET THE HEALTH CARE PROVIDER IN PRIVATE?
Tick box |
1 Yes
0 No |
| {ANC18} | DID THE STAFF TALK WITH YOU ABOUT THE PROGRESS OF YOUR PREGNANCY?
Tick box |
1 Yes
0 No |
| {ANC19} | DID YOU ASK ANY QUESTIONS TODAY?
Tick box If no, go to question ANC21 |
1 Yes
0 No ANC21 |
| {ANC20} | DID YOU UNDERSTAND THE ANSWERS TO YOUR QUESTIONS?
Tick box |
1 Yes
0 No |
| {ANC21} | DID THE STAFF ASK YOU TO COME BACK FOR ANOTHER VISIT?
Tick box |
1 Yes
0 No |
| {ANC22} | WHAT IS YOUR AGE? Enter age in years | |
|
THANK YOU FOR TAKING THE TIME TO SPEAK TO US TODAY. DO YOU HAVE ANY QUESTIONS THAT YOU WOULD LIKE TO ASK US? | ||
| 5 October 2000 | ||
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