Mapedir qcombined final 19 may2008_shaded

Woman’s Identification Number ___ ___ /___ ___ / ___ ___ ___ / ___ ___ ___ ___ ___ ___ ___ / ___ ___
S T / D S / B L K / V I L L A G E/ H H

MATERNAL VERBAL AUTOPSY QUESTIONNAIRE
FOR SUSPECTED MATERNAL DEATHS
Instructions to interviewers: Use this format for suspected maternal deaths. Section 1 will be complete when your supervisor gives
you the format. Use this information to help you locate the household.

Section 1: Available background information (supervisor to complete before the interview)

1.1 Name of deceased woman

1.2 Address of woman’s usual residence
__________ / __________ / _________ / __________
( village / block / district / state )


1.3 Where did she stay during her fatal 1. her own home (other than with her in-laws)
illness? 2. her in-law’s home
3. her parent’s home
4. formal health facility where she (aborted/labored and
delivered)
5. Other (specify ____________________________)
8. Don’t know
1.4 What is the address of this place (where she stayed
during her fatal illness)? __________ / __________ / _________ / __________
( village / block / district / state )
This is the basis of the woman’s identification #
1.5 Name of head of household of this place (where she
stayed during her fatal illness)

1.6 Relationship of head of household of this place (where
she stayed during her fatal illness) to the woman

1.7 Date of woman’s death ___ ___ / ___ ___ / ___ ___ ___ ___
(D D / M M / Y Y Y Y )

1.8 Date of death notification ___ ___ / ___ ___ / ___ ___ ___ ___
(D D / M M / Y Y Y Y )

1.9 Key informant’s name

Section 2: Information about the interview

2.1 Interviewer’s 2.2 Interviewer’s
name designation

2.3 Recorder’s 2.4 Recorder’s
name designation

2.5 Date of first 2.6 Date of last
interview ___ ___ / ___ ___ / ___ ___ ___ ___ interview ___ ___ / ___ ___ / ___ ___ ___ ___
(D D / M M / Y Y Y Y ) (D D / M M / Y Y Y Y )

Section 3: Background information from respondents

Introduce yourself and the purpose of your visit. Say that we are trying to improve the care of women and children. Ask to speak
to the person(s) who knows the most about the circumstances of the woman’s death. This might be her sister, mother, mother-in-
law or other person. In some cases you may need to speak with more than one person to learn about different stages of the
illness. If someone you need to speak with is not available, arrange a time to return when s/he will be home. Read the consent
form to the respondent(s) and ask for her/his participation. Each respondent must consent to be interviewed.
Relationship to the deceased woman Were you with her Were you with her
(husband, sister, mother, mother-in-law, during the during the (labor and Were you with her
Respondents brother, birth attendant, specify other) pregnancy? delivery/abortion)? when she died?

3.1
1. Yes
2. No  1. Yes
2. No  1. Yes
2. No 
3.2
1. Yes
2. No  1. Yes
2. No  1. Yes
2. No 
3.3
1. Yes
2. No  1. Yes
2. No  1. Yes
2. No 
MAPEDIR questionnaire—maternal death inquiry May 19, 2008 Page 1


Read: First I would like to ask you about the circumstances of ’s death.
3.4 What was ’s age at the time of death? __ __ Years
(DK = 88)


3.5 Where did she die? 1. Home (her/relative/friend/informal prvdr)
2. Hospital/Other formal health facility
3. On route to a formal health facility
4. On route to home from a health facility
5. Other
8. Don’t know


3.6 Was she pregnant at the time of death, or did she 1. Yes, pregnant or within 6
die within 6 weeks after a pregnancy ended? weeks after a pregnancy
ended
[If the respondent is uncertain, then discuss that 2. No If 2 or 8, go to Section 10
the pregnancy could have been ended by an 8. Don’t know
abortion, stillbirth, delivery of the baby, or the
woman’s death]

Section 4: Information about the woman and her family

Read: Now I would like to ask some questions about and her family.

4.1 How many years of school did complete?
__ __ Years
(<1 = 00; DK = 88)


4.2 At the time of her death, was she… 1. married?
2. widowed?
[Read the choices to the respondent.] 3. divorced or separated?
4. single (never married)? If 4 or 8, go to Q4.3
8. Don’t know

4.2.1 What was ‘s age when she (first) married?
__ __ Years
(DK = 88)

4.2.2 How many years of school did her husband complete?
__ __ Years
(<1 = 00; DK = 88)


4.3 Who was the main breadwinner in her family? 1. Husband
2. Herself
3. Other

4.4 What was the main breadwinner’s occupation?


4.5 Was the main breadwinner… 1. fully employed?
2. seasonally employed?
[Read the choices to the respondent] 3. unemployed
8. Don’t know If 1, 3 or 8, go to Q4.6
4.5.1 If seasonally employed (2), ask:
About how many months per year did s/he work?
__ __ Months
(<1 = 00; DK = 88)


4.6 What is the family’s religion? 1. Hindu
2. Muslim
3. Christian
4. Other
8. Don’t know


4.7 What is the family’s caste? 1. SC
2. ST
3. Other
8. Don’t know


4.8 What type of house does the family live in? 1. Kutcha
2. Kutcha-Pucca
3. Pucca
8. Don’t know


4.9 Does the family have its own toilet? 1. Yes
2. No
8. Don’t know



4.10 Does the house have electricity? 1. Yes
2. No
8. Don’t know


4.11 Does the family have a BPL card? 1. Yes
2. No
8. Don’t know


4.12 Do you know about the benefits of the BPL card? 3. Yes
4. No

If 2, go to Section 5
4.12.1 Please tell me the benefits of the card. 1. Subsidized ration ................. 1. □
2. Kerosene oil......................... 2. □
Prompt: Is there anything else? 3. Housing ............................... 3. □
4. Health care .......................... 4. □
[Multiple answers allowed. 5. Referral transport ................. 5. □
Check all choices that the respondent mentions] 6. Other.................................... 6. □

Section 5: Pregnancy history

Read: Now I would like to ask you about ‘s past pregnancies.

5.1 Not including the current pregnancy how many times was she ever pregnant,
whether a child was born or not?
__ __
(DK = 88)
5.2 How many of her past pregnancies ended in a birth, including stillbirths?
__ __
(DK = 88)


5.3 Were any of her past pregnancies delivered by a 1. Yes
C-section? 2. No
8. Don’t know

Section 6: Circumstances of the woman’s death (and the baby’s outcome)

Read: Now I would like to ask you about ‘s general health and her current pregnancy.

6.1 Did have any of the following Yes No DK
problems before the pregnancy began? 1. Coughing blood ................... 1. □ 1. □ 1. □
2. Fits ....................................... 2. □ 2. □ 2. □
[Read the problems list slowly and check “Yes,” 3. Other.................................... 3. □ 3. □ 3. □
“No” or “Don’t know” for each.] (specify other) ...................... (___________________________)

6.2 Was she ever told by a doctor or nurse that she 1. Anemia ................................ 1. □ 1. □ 1. □
had any of the following illnesses before her 2. Heart disease ...................... 2. □ 2. □ 2. □
pregnancy began? 3. Diabetes .............................. 3. □ 3. □ 3. □
4. Cancer ................................. 4. □ 4. □ 4. □
[Read the problems list slowly and check “Yes,” 5. Hypertension ....................... 5. □ 5. □ 5. □
“No” or “Don’t know” for each.] 6. Tuberculosis ........................ 6. □ 6. □ 6. □
7. Epilepsy ............................... 7. □ 7. □ 7. □
8. Other.................................... 8. □ 8. □ 8. □
(specify other) ...................... (___________________________)

6.3 How many months did the current pregnancy last?
__ __ Months
(DK = 88)


6.4 Did seek any antenatal care for the 1. Yes
pregnancy from an ANM, nurse or qualified 2. No
doctor? 8. Don’t know
If 2 or 8, go to Q6.5
6.4.1 If yes, ask:
How many times did she receive antenatal care from an ANM, nurse or qualified __ __
doctor? (DK = 88)



Read: Now, I’d like to ask you about the circumstances of ‘s death.


6.5 Did she die while having an abortion or 1. Yes, during an abortion
within 6 weeks after having an 2. Yes, within 6 weeks after an abortion
abortion? 3. No
8. Don’t know If 1, go to Q6.6
If 3 or 8, go to Q6.9 (Antenatal)

Abortion questions follow – Ask these questions only if she died during or after an abortion
6.5.1 If she died after an abortion, ask:
How many days after the abortion did she die?
__ __ days
(<1 day = 00 days; DK = 88)


6.6 Was the abortion spontaneous or 1. Spontaneous
induced, including MTP? 2. Induced, including MTP
8. Don’t know


6.6.1 If the abortion was induced, ask: 1. Oral medicine
How was it induced? 2. Traditional vaginal herbal application
3. Vaginal tablet
4. Instrumentation
[Record the highest risk method 8. Don’t know
mentioned]


6.7 If the abortion was spontaneous, ask: 1. Home (her/relative/friend/informal prvdr)
Where was the abortion completed? 2. Sub-center
3. PHC/BPHC
If the abortion was induced or don’t 4. Government hospital
know, ask: 5. Private clinic/center
Where did she have the abortion? 6. Private hospital
7. On route to formal health facility
8. Other
88. Don’t know


6.8 If the abortion was spontaneous, ask: 1. No one (completed spontaneously)
Who completed the abortion? 2. Herself
3. Relative/friend
If the abortion was induced or don’t 4. Dai This was an abortion death
know, ask: 5. Quack
Who performed the abortion? 6. ANM After answering Q6.8,
7. Nurse
[Record the highest level provider
go to Q7.17
8. General doctor
mentioned] 9. Obstetrician
10.Other
88. Don’t know

Antenatal questions follow – Ask these questions only if she did not die during or after an abortion


6.9 Did she die while still pregnant, before 1. Yes
labor began? 2. No
8. Don’t know
If 2 or 8, go to Q6.11 (L&D)
6.10 How long was the illness that led to her death?
__ __ __ Days
(<1 day = 000 days; DK = 888)
[Convert response to days: use 1 month = 30 days]
This was an antenatal death

After answering Q6.10,
go to Q7.1
Labor & Delivery questions follow – Ask these questions only if she did not die before labor began


6.11 Did she die during labor or delivery or 1. Yes, during labor and delivery
within 6 weeks after delivery, including 2. Yes, within 6 weeks after the delivery
a stillbirth? 3. No
8. Don’t know If 1, go to Q6.12
If 3 or 8, go to Section 10



6.11.1 If she died after the delivery, ask:
How many days after the delivery did she die?
__ __ Days
(<1 day = 00 days; DK = 88)


6.12 Did she have a plan where to deliver 1. Yes
the baby? 2. No
8. Don’t know


6.12.1 If she had a delivery plan, ask: 1. Home (her/relative/friend/informal prvdr)
Where was it planned for the baby to 2. Sub-center
be delivered? 3. PHC/BPHC
4. Government hospital
5. Private clinic/center
6. Private hospital
7. Other
8. Don’t know


6.13 Where did she (labor/deliver the 1. Home (her/relative/friend/informal prvdr)
baby)? 2. Sub-center
3. PHC/BPHC
[Read “labor” if she died before 4. Government hospital If 1, 8 or 88, go to Q6.14
delivering.] 5. Private clinic/center
6. Private hospital
7. On route to formal health facility
8. Other
88. Don’t know

6.13.1 If at or on route to a health facility, ask:
What is the name and address of the
health facility?


6.13.2 When she started out for the health 1. Normal labor
facility, was she in normal labor or had 2. Her illness had already begun
her illness already begun? 3. Went for any other reason (e.g., ANC)
8. Don’t know


6.14 Who attended the (labor/delivery)? 1. Herself
2. Relative/friend
[Read “labor” if she died before 3. Dai
delivering.] 4. Quack
5. ANM
[Record the highest level provider 6. Nurse
mentioned.] 7. General doctor
8. Obstetrician
9. Other
88. Don’t know


6.15 How was the (baby delivered/delivery 1. Spontaneous vaginal (no drugs)
attempted)? 2. Mechanically induced (forceful external
pushing)
[Read “delivery attempted” if she died 3. Induced with drugs
before delivering.] 4. Forceps
. 5. C-section
8. Don’t know


6.16 What part of the baby came out first? 1. Head
2. Buttocks/Feet
3. Hand
4. No part delivered If 4, go to Section 7
8. Don’t know


6.17 What was the baby’s outcome? 1. Not delivered at time of mother’s death
2. Stillbirth
3. Born alive and died
4. Currently alive If 1, 2, 4 or 8, go to Section 7
8. Don’t know

6.17.1 If born alive and died (3), ask:
How many days old was the baby at death?
__ __ __ Days
(<1 day = 000 days, DK = 888)

This was a labor & delivery death Continue with Section 7.



Section 7: Illness complications

Read: Now, I’d like to ask you about the problems had during the last part of her pregnancy and the fatal illness.

Ask Q7.1 – 7.10 for Antenatal and Labor and Delivery deaths.


7.1 During the last part of the pregnancy, was she 1. Yes
breathless or very weak when doing her usual 2. No
work? 8. Don’t know


7.2 During the last part of the pregnancy or the fatal 1. Yes
illness, were her eyes or hands more pale than 2. No
usual? 8. Don’t know


illness, did a doctor or nurse tell her that she had 2. No
anemia? 8. Don’t know


illness, did she have blurred vision? 2. No
8. Don’t know


7.5 During the last part of her pregnancy or the fatal 1. Yes
illness, did she have a severe headache? 2. No
8. Don’t know


7.6 During the last part of her pregnancy or the fatal 1. Yes
illness, did a doctor or nurse tell her that she had 2. No
high blood pressure? 8. Don’t know


illness, did she have swelling of the hands or 2. No
face? 8. Don’t know


7.8 During the fatal illness, did she have severe 1. Yes
swelling of the legs? 2. No
8. Don’t know


7.9 During the fatal illness, was it very difficult for her 1. Yes
to breathe? 2. No
8. Don’t know


7.10 Did she have convulsions during the fatal illness? 1. Yes
2. No
8. Don’t know
If this was an antenatal
death, go to Q7.19
Ask Q7.11 – 7.16 for Labor and Delivery deaths.
7.11 How long was she in labor?
__ __ Hours
(<1 hour = 00; DK = 88)

7.12 For how long did she have to make an effort?
__ __ Hours
(<1 hour = 00; DK = 88)


7.13 Did she have labor pain that was worse than 1. Yes
normal labor pain and that started suddenly? 2. No
8. Don’t know


7.14 Did she have labor pain that improved or stopped 1. Yes
suddenly? 2. No
8. Don’t know


7.15 Was her liquor (amniotic fluid) foul smelling? 1. Yes
2. No
8. Don’t know

7.16 How long after the baby’s birth did the placenta come out?
__ __ Hours
(<1 hour = 00; DK = 88; Never =99)



Ask Q7.17 – 7.18 for Abortion and Labor and Delivery deaths.


7.17 Did she have abdominal pain that did not go away 1. Yes
(after the abortion/between contractions/after the 2. No
delivery)? 8. Don’t know


7.18 Did she have foul smelling vaginal discharge 1. Yes
(after the abortion/during [or after] the delivery)? 2. No
8. Don’t know
[Read “…during or after..” if she died postpartum.] If 2 or 8, go to Q7.19
7.18.1 For Abortion deaths only:
__ __ Days
How long after the abortion did the discharge start? (DK = 88)

[Mark days and/or hours as needed. __ __ Hours
Example: 01 day and 05 hours; Example: 00 days and 10 hours] (<1 hour = 00; DK = 88)

Ask Q7.19 – 7.24 for All deaths: Abortion, Antenatal, Labor and delivery


7.19 Did she have fever during the fatal illness? 1. Yes
2. No
8. Don’t know
7.19.1 For Abortion deaths only:
__ __ Days
How long after the abortion did the fever start? (DK = 88)

[Mark days and/or hours as needed. __ __ Hours
Example: 01 day and 05 hours; Example: 00 days and 10 hours] (<1 hour = 00; DK = 88)


7.20 Did she have any vaginal bleeding (during the 1. Yes
abortion/during the last part of the pregnancy/ 2. No
before the delivery)? 8. Don’t know


7.20.1 Did she feel cold to touch after this bleeding 1. Yes
started? 2. No
8. Don’t know


7.21 During the fatal illness, did she have vaginal 1. Yes
bleeding that was too heavy? 2. No
8. Don’t know


7.21.1 Did she feel cold to touch after the heavy bleeding 1. Yes
started? 2. No
8. Don’t know


7.21.2 For deaths After Delivery only, ask: 1. …before the delivery?
Did the heavy bleeding start… 2. …during the delivery?
3. …after the delivery?
[Read the choices slowly and mark one answer] 8. Don’t know

7.21.3 For deaths After Delivery only, ask:
__ __ Hours
How long after the heavy bleeding started did she die?
(<1 hour = 00; DK = 88)


7.22 During the fatal illness, did she become 1. Yes
semiconscious? 2. No
8. Don’t know


7.23 During the fatal illness, did she become 1. Yes
unconscious? 2. No
8. Don’t know

If not semiconscious and not unconscious, go to Q7.24
7.23.1 How long was she semiconscious or unconscious?
__ __ __ Hours
(<1 hour = 000; DK = 888)




7.23.2 Was she semiconscious or unconscious until she 1. Yes
died? 2. No
8. Don’t know


7.24 Did she have any other problem? 1. Yes (specify)
2. No
8. Don’t know

7.24.1 If 1. Yes, specify:

Section 8: Injury


8.1 Did suffer an injury or accident of 1. Yes
any kind in the days before death? 2. No
8. Don’t know
If 2 or 8, go to Section 9


8.1.1 What kind of injury or accident did she suffer? 1. Motor vehicle accident
2. Fall
[Allow the respondent to answer spontaneously. If 3. Violence
s/he has difficulty identifying the injury, read all 4. Suicide
the choices slowly.] 5. Other
(specify other) ...................... (___________________________)
8. Don’t know

8.1.2 How long after the injury did she die?
__ __ __ Days
(<24 hours = 000; DK = 888)


8.1.3 Did she die from the injury? 1. Yes
2. No
8. Don’t know

Section 9: Care-seeking for obstetrical complications that led to the death


9.1 Now, please tell me, where was 1. Home (her/relative/friend/informal prvdr)
when her fatal illness began? 2. Hospital/Other formal health facility
3. On route to a formal health facility
4. On route to home from a health facility
5. Other
8. Don’t know


9.2 And what was the first thing she or her 1. Gave home care
family did for the illness? 2. Sought care from an informal provider
(includes at her own home)
Mark only the first action taken. 3. Sought formal health care
4. She was at the formal provider where If 4, go to Q9.11
she went for normal labor, to have an If 8, go to Q9.7
MTP, or any other reason when her
illness began
5. Other (specify other) .............................. (__________________________)
8. Don’t know


9.3 Who decided that this was the action 1. The woman, herself
to take? 2. Her husband
3. Her mother
[Only one response allowed. Record 4. Her mother-in-law
the main decision maker.] 5. Other male
6. Other female
8. Don’t know

9.4 How long after the illness began did s/he decide to do this?
__ __ Days
[Mark days, hours and/or minutes as needed. (DK = 88)
Example: 02 days, 13 hours and 30 minutes;
Example: 00 days, 05 hours and 00 minutes] __ __ Hours
(DK = 88)

__ __ Minutes
(DK = 88)



9.5 Which symptom(s) did
have at this time?

9.6 If Action 9.2 was not seeking formal 1. Did not think she was sick enough to
health care, then ask: need health care ..................................... 1. 
Did she/the family have any problems 2. No one was available to accompany her 2. 
that kept her from seeking formal 3. She had to attend to household duties ... 3. 
health care at that time? 4. Transportation not available ................... 4. 
5. Could not pay for transportation ............. 5. 
If Action 9.2 was seeking formal 6. Could not pay for the care
health care, then ask: provider/facility ....................................... 6. 
Did she/the family have to overcome 7. Other cost ............................................... 7. 
any problems in order to seek formal 8. Not satisfied with available health care... 8. 
health care at that time? 9. Her problem(s) require traditional care ... 9. 
10. Thought she was too sick to travel ......... 10. 
Prompt: Was there anything else? 11. Thought she would die no matter what ... 11. 
12. It was late at night .................................. 12. 
[Multiple answers allowed. Check all 13. Other(specify)…………………………. .... 13.  (______________________)
that apply. Check only “14” if she had 14. No careseeking problem......................... 14. 
no careseeking problem.] 88. Don’t know.............................................. 88. 

If the first action was to seek formal care (Q9.2=3), go to Q9.11


9.7 Did she seek formal health care at 1. Yes
any time during the fatal illness? 2. No
8. Don’t know
If 2 or 8, go to Open History


9.8 Who decided that she needed to seek 1. The woman, herself
health care? 2. Her husband
3. Her mother
[Only one response allowed. Record 4. Her mother-in-law
the main decision maker.] 5. Other male
6. Other female
8. Don’t know

9.9 How long after the fatal illness began did s/he decide to seek this care?
__ __ Days
[Mark days, hours and/or minutes as needed. (DK = 88)
Example: 01 day, 08 hours and 30 minutes;
Example: 00 days, 04 hours and 10 minutes] __ __ Hours
(DK = 88)

__ __ Minutes
(DK = 88)

9.10 Which symptom(s) did she have at
this time?


9.11 How many formal facilities was she taken to (or intended to go) before she died?

[Include any facility she did not reach because she died before leaving or on route.]

[Include the facility she went to for normal labor, an MTP, or any other reason if her
illness began at this facility.]

9.11.1 Mark the facility where she had an abortion or delivered (if this was an abortion or Aborted Delivered Died
L&D death and she was sick while at the facility) and where she died. here here Here

  
9.11.2 Name and address of the first facility
she went to: FACILITY 1

  
9.11.3 Name and address of the second
facility she went to: FACILITY 2

  
9.11.4 Name and address of the third facility
she went to: FACILITY 3



– MATRIX QUESTIONS – FACILITY 1 FACILITY 2 FACILITY 3
After (deciding to seek care/she was referred), how long 9.12 …home to fac1? 9.25 …facility1 to 2? 9.38 …facility2 to 3?
did it take to make the arrangements to go from…
__ __ Days __ __ Days __ __ Days
[Discuss that this includes the time needed to arrange (DK = 88) (DK = 88) (DK = 88)
for transportation and the money to pay for this and the
woman’s health care.] __ __ Hours __ __ Hours __ __ Hours
(DK = 88) (DK = 88) (DK = 88)
[Mark days, hours and/or minutes as needed.
Example: 01 day, 05 hours and 30 minutes; __ __ Minutes __ __ Minutes __ __ Minutes
Example: 00 days, 02 hours and 10 minutes] (DK = 88) (DK = 88) (DK = 88)
How did she/the family arrange 9.13 9.26 9.39
this money? 1. Had available 1. □ 1. □ 1. □
2. Borrowed 2. □ 2. □ 2. □
Multiple answers allowed. Check 3. Sold assets 3. □ 3. □ 3. □
all that apply. 4. Community fund 4. □ 4. □ 4. □
5. Govt. scheme 5. □ 5. □ 5. □
6. Other 6. □ 6. □ 6. □
8. Don’t know 8. □ 8. □ 8. □
How far is it from… 9.14 …home to fac 1? 9.27 …facility 1 to 2? 9.40 …facility 2 to 3?

__ __ __ km __ __ __ km __ __ __ km
(<1 = 000; DK = 888) (<1 = 000; DK = 888) (<1 = 000; DK = 888)
What transportation method was 9.15 9.28 9.41
used to take her there? 1. Walk ..................... 1. If only walk, go 1. If only walk, go 1. If only walk, go
2. Rickshaw/cart ...... 2.  to Q9.17 2.  to Q9.30 2.  to Q9.43
Multiple answers allowed. Check 3. Bus....................... 3.  3.  3. 
all that apply. 4. Taxi/auto/trecker .. 4.  4.  4. 
5. Ambulance ........... 5.  5.  5. 
6. Other .................... 6.  6.  6. 
8. Don’t know ........... 8.  8.  8. 
9. Could not arrange 9.  ------ ------
How much did this cost? 9.16 9.29 9.42
__ __ __ __ Rp __ __ __ __ Rp __ __ __ __ Rp
(DK=8888; NA=9999) (DK=8888) (DK=8888)
How long did it take to travel to… 9.17 …facility 1? 9.30 …facility 2? 9.43 …facility 3?

[Mark days, hours and/or minutes as needed. __ __ Days
Example: 01 day, 05 hours and 30 minutes;
__ __ Days __ __ Days
(DK = 88; NA = 99) (DK = 88; NA = 99) (DK = 88; NA = 99)
Example: 00 days, 02 hours and 10 minutes]
__ __ Hours __ __ Hours __ __ Hours
(DK = 88; NA = 99) (DK = 88; NA = 99) (DK = 88; NA = 99)

__ __ Minutes __ __ Minutes __ __ Minutes
(DK = 88; NA = 99) (DK = 88; NA = 99) (DK = 88; NA = 99)
STOP: If the woman died before reaching the facility, go to (F1: Open History / F2 or F3: Section 10).
Which illness symptom(s) did she have while at… 9.18 …facility 1? 9.31 …facility 2? 9.44 …facility 3?

What did the 9.19 9.32 9.45
(facility/provider) do 1. IV fluid other than blood ............ 1. □ 1. □ 1. □
for her problem? 2. Massaged abdomen to stop the
bleeding ................................... 2. □ 2. □ 2. □
Prompt: Was there 3. Medicine to stop the bleeding ... 3. □ 3. □ 3. □
anything else? 4. Blood transfusion ...................... 4. □ 4. □ 4. □
5. Completed the abortion ............. 5. □ 5. □ 5. □
Multiple responses 6. C-section ................................... 6. □ 6. □ 6. □
allowed. Check all 7. Advise to buy outside medicine . 7. □ 7. □ 7. □
that apply. 8. Other (specify)........................... 8. □ (____________) 8. □ (____________) 8. □ (____________)
9. Nothing...................................... 9. □ If 9, go to Q9.21 9. □ If 9, go to Q9.34 9. □ If 9, go to Q9.47
88.Don’t know ................................ 88. □ If 88, go Q9.21 88. □ If 88, go Q9.34 88. □ If 88, go Q9.47



How much did all this care cost? 9.20 9.33 9.46
__ __ __ __ __ Rp __ __ __ __ __ Rp __ __ __ __ __ Rp
(DK = 88888) (DK = 88888) (DK = 88888)

Did the (facility/provider) refer 1. Yes 9.21 9.34 9.47

  
to another health care 2. No
facility? 8. Don’t know
If 2 or 8, go If 2 or 8, go If 2 or 8, go
to Q9.22 to Q9.35 to Q9.48
Why was she 9.21.1 9.34.1 9.47.1
referred?
1. For a certain problem (specify).. 1. □ (____________) 1. □ (____________) 1. □ (____________)
Multiple responses 2. Did not have blood .................... 2. □ 2. □ 2. □
allowed. Check all 3. For a procedure (specify) .......... 3. □ (____________) 3. □ (____________) 3. □ (____________)
that apply.
4. Lack of a specialist (specify) ..... 4. □ (____________) 4. □ (____________) 4. □ (____________)

5. Other (specify)........................... 5. □ (____________) 5. □ (____________) 5. □ (____________)

How long after this problem started was she referred? 9.21.2 9.34.2 9.47.2

[Include only her time in the facility if she had the
__ __ Days __ __ Days __ __ Days
problem when she arrived.] (DK = 88) (DK = 88) (DK = 88)

[Mark days, hours and/or minutes as needed. __ __ Hours __ __ Hours __ __ Hours
Example: 01 day, 05 hours and 30 minutes; (DK = 88) (DK = 88) (DK = 88)
(DK = 88) (DK = 88) (DK = 88)

How long was she at this facility? 9.22 9.35 9.48

[Mark days, hours and/or minutes as needed.
__ __ Days __ __ Days __ __ Days
Example: 01 day, 05 hours and 30 minutes; (DK = 88) (DK = 88) (DK = 88)
__ __ Hours __ __ Hours __ __ Hours
(DK = 88) (DK = 88) (DK = 88)

(DK = 88) (DK = 88) (DK = 88)

Was she taken to another health 1. Yes 9.23 …facility 1? 9.36 …facility 2?

 
facility after leaving… 2. No
8. Don’t know GO TO SECTION 10

If 8, go to Sctn 10 If 8, go to Sctn 10
If not taken to another facility,ask: 9.24 9.37
Did she/the family have any 1. No transportation ... 1.  1. 
problems that kept her from going 2. Transportation or
to another facility? health care cost...... 2.  2. 
3. Not satisfied with
If taken to another facility, ask: available care ......... 3.  3. 
Did she/the family have to 4. Thought she would
overcome any problems in order die no matter what . 4.  4. 
to go to another facility? 5. She died at F1/F2 .. 5. Go to Sctn 10 5. Go to Sctn 10

Prompt: Was there anything 6. Other (specify) ....... 6.  (____________) 6.  (____________)
else? 7. No careseeking
problem .................. 7.  7. 
[Multiple answers allowed. Check 8. Don’t know ............. 8.  8. 
all that apply.]

If she was taken to another facility… …go to Q9.25 …go to Q9.38
(start of Facility 2) (start of Facility 3)



Section 10: Reported cause of death


10.1 Did a doctor or nurse at the health facility tell you 1. Yes
the cause of ________’s death? 2. No
8. Don’t know
If 2 or 8, go to Open History
10.1.1 If 1. Yes, specify cause 1:

10.1.2 If 1. Yes, specify cause 2:

Open history

Read: Thank you for answering the many questions that I’ve asked. Would you like to tell me about the illness in your own words?
Also, is there anything else about her illness that I did not ask and you would like to tell me about?

After the respondent(s) finishes, ask: Is there anything else?

Write the respondent’s exact words. After s/he has finished, read this back and ask her to correct any errors in what you wrote.

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

END OF INTERVIEW
THANK RESPONDENT(S) FOR THEIR COOPERATION

Supervisor’s certification

The below supervisor certifies that s/he reviewed the information in this interview and verifies that it is correct and complete.

Supervisor’s Date of
name (written) certification ___ ___ / ___ ___ / ___ ___ ___ ___
(D D / M M / Y Y Y Y )

Supervisor’s
signature


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