06.03.2013 Views

(PHCII) - MMH/MMS

(PHCII) - MMH/MMS

(PHCII) - MMH/MMS

SHOW MORE
SHOW LESS

Create successful ePaper yourself

Turn your PDF publications into a flip-book with our unique Google optimized e-Paper software.

ANNEX 1<br />

QUESTIONNAIRE ON FACTORS INFLUENCING LOW DELIVERIES IN<br />

HEALTH FACILITIES<br />

Name of Interviewer… … … … … … … … … ..<br />

Age of the mother… … … … … … … … … …<br />

Parity… … … … … … … … … … … … … … … ..<br />

TICK APPROPRIATELY<br />

1. Are you married?<br />

Married ( )<br />

Single ( )<br />

Divorced ( )<br />

2. What is your level of education?<br />

No education ( )<br />

Primary school ( )<br />

Secondary school ( )<br />

High education ( )<br />

3. Do you have children?<br />

Yes ( )<br />

No ( )<br />

If Yes, How Many… … … … … ..<br />

4. How many antenatal visits did you attend during your last<br />

pregnancy?… … … … …<br />

5. What risk factors are you told concerning pregnancy by health providers?<br />

… … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … …<br />

6. Were you diagnosed to have risk factors in your last pregnancy?<br />

… … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … …<br />

7. How far is your home place to health unit?<br />

(0 – 5) kms < 5 km ( )<br />

> 5km ( )<br />

40

Hooray! Your file is uploaded and ready to be published.

Saved successfully!

Ooh no, something went wrong!