Case Report Forms_FamilyPlanning

Current contraception 1. Are you currently pregnant? (select one) check one Yes 1 No 0 Unknown/Don't know 999 No answer -2 Not applicable 101 2. Have you given birth in the last month? (select one) check one Yes 1 No 0 Unknown/Don't know 999 No answer -2 Not applicable 101 3. Are you currently sexually active? (select one) check one Yes 1 No 0 Unknown/Don't know 999 No answer -2 Not applicable 101 4. Have you used a condom in the last month? (select one) check one Yes 1 No 0 Unknown/Don't know 999 No answer -2 Not applicable 101 5. If yes to question #4, in the past month, in what proportion of sex acts have you used a condom? (select one) All the time 1 Most of the time (more than half the time) 2 Some of the time (less than half the time 3 Unknown/Don't know 999 No answer -2 Specify 7. If using condoms to prevent pregnancy in question #6, why did you choose to use condoms instead of other forms of contraception? (select one) check one Specify _____ 100 Unknown/Don't know 999 No answer -2 Specify Specify Specify Specify 11. Rate your overall experience with your current method (select one) check one Very satisfied 1 Satisfied 2 Neutral 3 Unsatisfied 4 Very unsatisfied 5 12. If you used a form of permanent or non-permanent contraception in the last month in question #8 or #9, do you plan to continue using this method in the future? (select one) check one Yes 1 No 0 Unknown/Don't know 999 No answer -2 Not applicable 101 13. If you used a form of permanent or non-permanent contraception in the last month in question #8 or #9, are you currently concerned about side effects from your current form of birth control? (select one) check one Yes 1 No 0 Unknown/Don't know 999 No answer -2 Not applicable 101 Oral contraception - current use 14. If currently using oral contraceptives, how long have you been using oral contraceptives? check one _____ days 1 _____ months 2 _____ years 3 No answer -2 Not applicable/Never used 101 Unknown/Don't know 999 15. What type of oral contraceptive are you using? (select one) check one Progesterone only pill 1 Combined oral contraceptive pill 2 Unknown/Don't know 999 Injectable contraception - current use 16. If currently using injectable contraceptives, how long have you been using injectable contraceptives? check one _____ days 1 _____ months 2 _____ years 3 No answer -2 Not applicable/Never used 101 Unknown/Don't know 999 17. What type of injectable are you using? (select one) check one Depo/DMPA 1 Net-en 2 Unknown/Don't know 999 IUD contraception - current use 18. If currently using an IUD, how long have you had the IUD? check one _____ days 1 _____ months 2 _____ years 3 No answer -2 Not applicable/Never used 101 Unknown/Don't know 999 19. What type of IUD are you using? (select one) check one Copper/5-year 1 Copper/10-year 2 Hormonal/5-year 3 Unknown/Don't know 999 Implantable contraception - current use 20. If currently using a contraceptive implant, how long have you used the contraceptive implant? check one _____ days 1 _____ months 2 _____ years 3 No answer -2 Not applicable/Never used 101 Unknown/Don't know 999 21. What type of contraceptive implant are you using? (select one) check one Norplant 1 Jadelle 2 Implanon 3 Nexplanon 4 Zarin/Sina 5 Unknown/Don't know 999 22. If type of implant is unknown, how many rods are in your arm? (select one) check one 1 1 2 2 6 3 Unknown/Don't know 999 No answer -2 Permanent contaception - current use 23. If currently using a permanent method, how long ago did you have the procedure done? check one _____ days 1 _____ months 2 _____ years 3 No answer -2 Not applicable/Never used 101 Unknown/Don't know 999 Natural methods - current use 24. If currently using lactational amenorrhea, how old is your baby? check one _____ days 1 _____ months 2 _____ years 3 Unknown/Don't know 999 No answer -2 Not applicable 101 25. If currently using lactational amenorrhea, have your menses resumed since the pregnancy? check one Yes 1 No 0 Unknown/Don't know 999 No answer -2 Not applicable 101 26. If currently using lactational amenorrhea, how many times during the day does your baby breastfeed? check one None (0 times) 0 _____ times 1 Unknown/Don't know 999 No answer -2 27. If currently using lactational amenorrhea, how many times during the night does your baby breastfeed? check one None (0 times) 0 _____ times 1 Unknown/Don't know 999 No answer -2 28. If currently using lactational amenorrhea, have you fed your baby any food or drink other than breastmilk yet? check one Yes 1 No 0 Unknown/Don't know 999 No answer -2 Not applicable 101 Barriers to contraception Specify Past contraception 30. If yes to FP8 or FP9, have you or your partner ever used a different contraceptive method to delay or avoid pregnancy? (select one) check one Yes 1 No 0 Unknown/Don't know 999 No answer -2 Not applicable 101 Specify 32. In your lifetime, how long have you used oral contraceptives? check one _____ days 1 _____ months 2 _____ years 3 No answer -2 Not applicable/Never used 101 Unknown/Don't know 999 33. How long ago was your last oral contraceptive use? check one _____ days 1 _____ months 2 _____ years 3 No answer -2 Not applicable/Never used 101 Unknown/Don't know 999 34. In your lifetime, how long have you used injectable contraceptives? check one _____ days 1 _____ months 2 _____ years 3 No answer -2 Not applicable/Never used 101 Unknown/Don't know 999 35. How long ago was your last injection? check one _____ days 1 _____ months 2 _____ years 3 No answer -2 Not applicable/Never used 101 Unknown/Don't know 999 36. In your lifetime, how long have you used an IUD? check one _____ days 1 _____ months 2 _____ years 3 No answer -2 Not applicable/Never used 101 Unknown/Don't know 999 37. How long ago did you get your last IUD inserted? check one _____ days 1 _____ months 2 _____ years 3 No answer -2 Not applicable/Never used 101 Unknown/Don't know 999 38. In your lifetime, how long have you used implants? check one _____ days 1 _____ months 2 _____ years 3 No answer -2 Not applicable/Never used 101 Unknown/Don't know 999 39. How long ago did you get your last implant inserted? check one _____ days 1 _____ months 2 _____ years 3 No answer -2 Not applicable/Never used 101 Unknown/Don't know 999 40. In your lifetime, how long have you used the rhythm or standard days method? check one _____ days 1 _____ months 2 _____ years 3 No answer -2 Not applicable/Never used 101 Unknown/Don't know 999 41. How many times have you used emergency contraception in the last year? check one None (0 times) 0 _____ times 1 Unknown/Don't know 999 No answer -2 Other, specify _____ 100 Specify 42. Would you use [insert method selected from question #31] as a method again? (select one) check one Yes 1 No 0 Unknown/Don't know 999 No answer -2 Not applicable 101 Discontinuation (start or switch) 43. In the past 1 year, have you or your partner switched from or discontinued a method? (select one) check one Yes 1 No 0 Unknown/Don't know 999 No answer -2 Not applicable 101 Specify Specify Specify 47. If yes to question #43, were you happy with the method you switched to? (select one) check all that apply Very satisfied 1 Satisfied 2 Neutral 3 Unsatisfied 4 Very unsatisfied 5 Very satisfied 1 Satisfied 2 Neutral 3 Unsatisfied 4 Very unsatisfied 5 Pregnancy intent 48. When you got pregnant with this pregnancy, did you want to have a baby or another baby at some time? (select one) check one Yes 1 No 0 Unknown/Don't know 999 No answer -2 Not applicable 101 49. If yes to question #48, did the pregnancy occur (select one): check one Sooner than you wanted 1 Later than you wanted 2 At about the time you wanted 3 50. Which statement is most true about this pregnancy? (select one) check one I was trying to become pregnant 1 I did not care whether I became pregnant or not 2 It was God's will whether I became pregnant or not 3 I don't know if I was trying to prevent a pregnancy or not 4 I was trying to prevent a pregnancy 5 Other, specify_____ 100 Specify 51. Were you or your partner doing anything to keep from getting pregnant? (select one) check one Yes 1 No 0 Unknown/Don't know 999 No answer -2 Not applicable 101 Specify 53. If using oral contraception, male condoms, natural methods, abstinence, herbal methods, emergency contraception, or "other" in question #52, how regularly were you using [method specified in question #52] when you got pregnant? (select one) check one All of the time 1 Most of the time (more than half the time) 2 Some of the time (less than half the time) 3 Unknown/Don't know 999 No answer -2 54. If using injectables in question #52, did you miss an injection? (select one) check one Yes 1 No 0 Unknown/Don't know 999 No answer -2 Not applicable 101 55. If using the IUD or implant in question #52, did you have your [method specified in question #52] removed? (select one) check one Yes 1 No 0 Unknown/Don't know 999 No answer -2 Not applicable 101 56. If using vaginal ring in question #52, did you replace your ring every cycle? (select one) check one Yes 1 No 0 Unknown/Don't know 999 No answer -2 Not applicable 101 Specify Contraception intent 58. Have you started using contraception since your last visit? (select one) check one Yes 1 No 0 Unknown/Don't know 999 No answer -2 Not applicable 101 59. If yes to question #58, how long ago did you start? check one _____ days 1 _____ months 2 _____ years 3 No answer -2 Not applicable/Never used 101 Unknown/Don't know 999 Specify 61. If no to question #58, do you intend to start? (select one) check one Yes 1 No 0 Unknown/Don't know 999 No answer -2 Not applicable 101 62. If yes to question #61, when do you intend to start use of contraception? (select one) check one Today 1 ≤ 2 weeks 2 > 2 weeks 3 Around time of resuming sex 4 Other, specify ____ 100 Unknown/Don't know 999 Specify 63. If yes to question #61, what method will you use? (select one) check one None 0 Oral contraception (combination, progestin-only) 1 Injectable contraception (Depro Provera; DMPA) 2 Intrauterine device (IUD/IUCD, coil, copper, Mirena, Skyla) 3 Implants (Norplant, Nexplanon, Implanon, Jadelle, Femplant, Zarin) 4 Vaginal ring (NuvaRing) 5 Tubal ligation/female sterilization (TL, bilateral tubal ligation) 6 Vasectomy/male sterilization 7 Male condoms 8 Abstinence 9 Lactation (lactational amenorrhea method; LAM) 10 Herbal methods 11 Standard days method (periodic abstinence) 12 Withdrawal 13 Rhythm/calendar method 14 Emergency contraception 15 No answer -2 Other, specify_____ 100 Specify Specify 66. If yes to question #58 or #61, have you discussed the decision to delay or avoid pregnancy with your husband/partner? (select one) check one Yes 1 No 0 Not yet, but I will 2 Unknown/Don't know 999 No answer -2 67. Would you say that using contraception is mainly your decision, mainly your husband/partner's decision or did you both decide together? (select one) check one My decision 1 Partner decision 2 Both 3 No answer -2 Experience with family planning services 68 Has anyone ever discussed family planning or contraception with you? (select one) check one Yes 1 No 0 Unknown/Don't know 999 No answer -2 Not applicable 101 69 If no to question #68, do you know of a place where you can obtain a method of family planning? (select one) check one Yes 1 No 0 Unknown/Don't know 999 No answer -2 Not applicable 101 Specify Specify Specify 73 If yes to health care setting in #70, how long ago was the last discussion? _____ days 1 _____ months 2 _____ years 3 No answer -2 Not applicable/Never used 101 Unknown/Don't know 999 74 If yes to question #68, was the discussion in a group setting? (select one) check one Yes 1 No 0 Unknown/Don't know 999 No answer -2 Not applicable 101 75 If yes to group setting in #74, was your partner present for the discussion? (select one) check one Yes 1 No 0 Unknown/Don't know 999 No answer -2 Not applicable 101 Specify Specify 78 Are you currently concerned about side effects from family planning? (select one) check one Yes 1 No 0 Unknown/Don't know 999 No answer -2 Not applicable 101 Specify Specify Specify Specify 83 If yes to a health care setting in #70, did you obtain the method you wanted to delay or avoid getting pregnant during that visit? (select one) check one Yes 1 No 0 Unknown/Don't know 999 No answer -2 Not applicable 101 Specify 85 Were you satisfied with the methods discussed? (select one) check one Very satisfied 1 Satisfied 2 Neutral 3 Unsatisfied 4 Very unsatisfied 5 Very satisfied 1 Satisfied 2 Neutral 3 Unsatisfied 4 Very unsatisfied 5 86 Were you satisfied with the amount of time spent talking about family planing during your visit? (select one) check one Very satisfied 1 Satisfied 2 Neutral 3 Unsatisfied 4 Very unsatisfied 5 Very satisfied 1 Satisfied 2 Neutral 3 Unsatisfied 4 Very unsatisfied 5 87 Do you feel you received enough information to make an informed decision? (select one) check one Yes 1 No 0 Unknown/Don't know 999 No answer -2 Not applicable 101 88 Would you like more information? (select one) check one Yes 1 No 0 Unknown/Don't know 999 No answer -2 Not applicable 101 89 What kind of information would you like? check one Specify _____ 100 Unknown/Don't know 999 No answer -2 Specify Desired family size 90 Do you want to have any children in the future? (select one) check one Yes 1 No 0 Says she can't get pregnant 2 Undecided/Don't know 999 No answer -2 91 If yes to question #90, when would you like to have your next child? (select one) check one < or = 1 year 1 >1-2 year 2 >2-3 years 3 >3 years 4 Unknown/Don't know 999 ____months 2 ____years 3 Unknown/Don't know 999 No answer -2 92 If yes to question #90, how many more children do you want to have? check one Specify _____ 100 Unknown/Don't know 999 No answer -2 Specify 93 What is your ideal number of children? check one Specify _____ 100 Unknown/Don't know 999 No answer -2 Specify Partner opinion 94 Have you personally discussed FP with your partner one on one? (select one) check one Yes 1 No 0 Unknown/Don't know 999 No answer -2 Not applicable 101 95 If yes to question #94, how does your partner feel about using (or your using) family planning? (select one) check one Very Supportive 1 Somewhat supportive 2 Not very supportive 3 Not supportive at all 4 96 Would your partner be willing to receive counseling about family planning? (select one) check one Very willing 1 Somewhat willing 2 Not very willing 3 Not willing at all 4 97 Would you want to attend counseling about family planning with your partner present? (select one) check one Yes 1 No 0 Not yet, but I will 2 Unknown/Don't know 999 No answer -2 98 Do you want anymore children? (select one) check one Yes 1 No 0 Unknown/Don't know 999 No answer -2 Not applicable 101 99 If yes to question #98, how many more children do you want to have? check one Specify _____ 100 Unknown/Don't know 999 No answer -2 Specify 100 If yes to question #98, when would you like to have your next child? check one < or = 1 year 1 >1-2 year 2 >2-3 years 3 >3 years 4 Unknown/Don't know 999 ____months 2 ____years 3 Unknown/Don't know 999 No answer -2 Post-partum contaceptive use 101 Approximately how long since the end of your last pregnancy? check one ____months (if <1 year) 2 ____years (round to nearest) 3 No answer -2 102 How many times during the day does your baby breastfeed? check one None (0 times) 0 _____ times 1 Unknown/Don't know 999 No answer -2 103 How many times during the night does your baby breastfeed? check one None (0 times) 0 _____ times 1 Unknown/Don't know 999 No answer -2 104 Have you fed your baby any food or drink other than breastmilk yet? check one Yes 1 No 0 Unknown/Don't know 999 No answer -2 Not applicable 101 105 Have you resumed sexual intercourse since delivery? (select one) check one Yes 1 No 0 Unknown/Don't know 999 No answer -2 Not applicable 101 106 Have you or your partner started using family planning or switched family planning methods since delivery? (if last pregnancy <=1 year) (select one) check one I have started using contraception 1 I have switched methods 2 I started using contraception and then switched methods 3 No answer -2 FP and HIV care integration Specify Specify HIV prevention 110 When trying to get pregnant, did you do anything to prevent HIV transmission to your partner? (select one) check one Yes 1 No 0 Unknown/Don't know 999 No answer -2 Not applicable 101 111 If yes to question #110, what did you do? check one Specify _____ 100 Unknown/Don't know 999 No answer -2 Specify 112 When trying to get pregnant, did you do anything to prevent HIV transmission to your baby? (select one) check one Yes 1 No 0 Unknown/Don't know 999 No answer -2 Not applicable 101 113 If yes to question #112, what did you do? Specify _____ 100 Unknown/Don't know 999 No answer -2 Specify