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Service Providers Template -Form Fill
Survey information
Q01
Name of Interviewer
Q02
code of Interviewer
Q03
Name of Supervisor
Q04
code of Supervisor
Q05
State Code
Assam
Madhya Pradesh
Rajasthan
Q06
District Code
Q06_1
Assam
Goalpara
Dibrugarh
Q06_2
Madhya Pradesh
Chhatarpur
Shivpuri
Panna
Rewa
Tikamgarh
Raisen
Q06_3
Rajasthan
Pali
Chittorgarh
Karauli
Banswara
Jaisalmer
Sikar
Q07
Block Code
Q08
Type of location
Urban
Rural
Q09
Village Name/town name
Q10
Name of facility
Q11
Code of facility
Q12
GPS Coordinates:
Q13
Date of the interview
Q14
Interview start time
Q15
Interview end time
Q16
Age of the respondent in complete years
Q17
Gender of the respondent
Male
Female
Q18
Type of facility
Primary Health Centre
PHC-Health and wellness Centre
Sub-centre
SC - Health and Wellness Centre
Q19
In your current position, and as a part of your work for this facility, do you personally provide any family planning services?
Yes
No
Q20
Result of the Interview
Interview started & completed
Interview Incomplete/ interrupted
Facility is closed temporarily
Other (Specify)
Q21
Do you consent to participate in the research ?
Yes
No
Background Information of the Respondent
A01
What is your education qualification?
Class 12th
GNM Course
ANM Course
BSc Nursing
MSc Nursing
BAMS
BHMS
BUMS
MBBS
MD
MS
DNB
BA/BSc in Psychology
MA in Psychology
Other (specify)
A02
What is your current designation at this facility?
MPW
ANM
LHV
Community Health Officer (CHO)
Staff Nurse
FP Counsellor/ health counsellor or educator
Medical officer/ Doctor
A03
Are you permanent or contractual?
Permanent
Contractual
A04
How long have you been working in the current position?
A05
How long have you been working in this facility?
A06
For how long have you been providing family planning services in total?
Knowledge and Practice assessment of the service provider
B01
Have you received any in-service training, training updates, or refresher training in any of the following topics
B01_1
General counselling on Healthy Timing and Spacing of Pregnancy (HTSP)
Yes, within 2 years
Yes, over 2 years ago
No Inservice training Or updates
B01_2
Clinical Training on Oral Pills (Mala-N, Chhaya)
Yes, within 2 years
Yes, over 2 years ago
No Inservice training Or updates
B01_3
Antara- IM / DMPA IM administration
Yes, within 2 years
Yes, over 2 years ago
No Inservice training Or updates
B01_4
Interval IUCD insertion
Yes, within 2 years
Yes, over 2 years ago
No Inservice training Or updates
B01_5
PPIUCD insertion
Yes, within 2 years
Yes, over 2 years ago
No Inservice training Or updates
B01_6
Implant insertion
Yes, within 2 years
Yes, over 2 years ago
No Inservice training Or updates
B01_7
Perform clinical training on NSV
Yes, within 2 years
Yes, over 2 years ago
No Inservice training Or updates
B01_8
Clinical training on mini laparotomy (minilap)
Yes, within 2 years
Yes, over 2 years ago
No Inservice training Or updates
B01_9
Clinical training on female sterilization (laparoscopy)
Yes, within 2 years
Yes, over 2 years ago
No Inservice training Or updates
B01_10
Post-partum family planning counselling
Yes, within 2 years
Yes, over 2 years ago
No Inservice training Or updates
B01_11
Post-abortion family planning counselling
Yes, within 2 years
Yes, over 2 years ago
No Inservice training Or updates
B02
In last 12 months (April 2023 to March 2024) have you received any training covering following topics related to family planning?
New Contraceptive methods such as Chhaya
Contraceptive methods like DMPA IM
New Missions / Initiatives (MPV) launched by government
Refresher training on counselling
Training on VCAT Module (IPAS)
None of the above
Other (Specify)
B03
Do you think you have adequate training on the following services:
B03_1
Counsel on Family Planning
Yes
No
B03_2
Provide Oral Pills – Mala -N
Yes
No
B03_3
Provide Oral Pills – Chhaya
Yes
No
B03_4
Provide Emergency contraceptives
Yes
No
B03_5
Administer injectable contraceptives - DMPA- IM
Yes
No
B03_6
Insert Interval IUCD
Yes
No
B03_7
Insert PPIUCD (within 48 hrs of delivery)
Yes
No
B03_8
Insert Implant
Yes
No
B03_9
Post-partum family planning counselling
Yes
No
B03_10
Post-abortion family planning counselling
Yes
No
B04
Do you provide, or counsel on the following services?
B04_1
Condom
Yes, provide / prescribe
Yes, counsel
None
B04_2
Oral Pills - Mala N
Yes, provide / prescribe
Yes, counsel
None
B04_3
Oral Pills - Chhaya
Yes, provide / prescribe
Yes, counsel
None
B04_4
Emergency contraceptives
Yes, provide / prescribe
Yes, counsel
None
B04_5
Injectables - DMPA- IM
Yes, provide / prescribe
Yes, counsel
None
B04_6
Interval IUCD
Yes, provide / prescribe
Yes, counsel
None
B04_7
PPIUCD (within 48hrs of delivery)
Yes, provide / prescribe
Yes, counsel
None
B04_8
Implants
Yes, provide / prescribe
Yes, counsel
None
B04_9
Female Sterilization
Yes, provide / prescribe
Yes, counsel
None
B04_10
Male Sterilization
Yes, provide / prescribe
Yes, counsel
None
B05
Now I would like to ask you specifically about the contraceptive methods that you provide.
B05A
What is the eligible minimum age for <METHOD>?
B05A_1
Condom
B05A_2
Oral Pills -MALA-N
B05A_3
Oral Pills -Chhaya
B05A_4
Emergency Pills
B05A_5
Injectables -DMPA-IM
B05A_6
IUCD
B05A_7
Implants
B05A_8
Female Sterilization
B05A_9
Male Sterilization
B05B
What is the eligible maximum age for <METHOD>?
B05B_1
Condom
B05B_2
Oral Pills -MALA-N
B05B_3
Oral Pills -Chhaya
B05B_4
Emergency Pills
B05B_5
Injectables -DMPA-IM
B05B_6
IUCD
B05B_7
Implants
B05B_8
Female Sterilization
B05B_9
Male Sterilization
B05C
Is there a minimum number of children a person must have before <METHOD> should be offered?
B05C_1
Condom
B05C_2
Oral Pills -MALA-N
B05C_3
Oral Pills -Chhaya
B05C_4
Emergency Pills
B05C_5
Injectables -DMPA-IM
B05C_6
IUCD
B05C_7
Implants
B05C_8
Female Sterilization
B05C_9
Male Sterilization
B05D
What is that minimum number of children?
B05D_1
Condom
B05D_2
Oral Pills -MALA-N
B05D_3
Oral Pills -Chhaya
B05D_4
Emergency Pills
B05D_5
Injectables -DMPA-IM
B05D_6
IUCD
B05D_7
Implants
B05D_8
Female Sterilization
B05D_9
Male Sterilization
B05E
Does husband’s consent is required for <METHOD>?
B05E_1
Condom
Yes
No
B05E_2
Oral Pills -MALA-N
Yes
No
B05E_3
Oral Pills -Chhaya
Yes
No
B05E_4
Emergency Pills
Yes
No
B05E_5
Injectables -DMPA-IM
Yes
No
B05E_6
IUCD
Yes
No
B05E_7
Implants
Yes
No
B05E_8
Female Sterilization
Yes
No
B05E_9
Male Sterilization
Yes
No
B05F
Would you offer <METHOD> to an unmarried person?
B05F_1
Condom
Yes
No
B05F_2
Oral Pills -MALA-N
Yes
No
B05F_3
Oral Pills -Chhaya
Yes
No
B05F_4
Emergency Pills
Yes
No
B05F_5
Injectables -DMPA-IM
Yes
No
B05F_6
IUCD
Yes
No
B05F_7
Implants
Yes
No
B05F_8
Female Sterilization
Yes
No
B05F_9
Male Sterilization
Yes
No
B05G
Would you offer <METHOD> to a newly married women who have come alone to the facility?
B05G_1
Condom
Yes
No
B05G_2
Oral Pills -MALA-N
Yes
No
B05G_3
Oral Pills -Chhaya
Yes
No
B05G_4
Emergency Pills
Yes
No
B05G_5
Injectables -DMPA-IM
Yes
No
B05G_6
IUCD
Yes
No
B05G_7
Implants
Yes
No
B05G_8
Female Sterilization
Yes
No
B05G_9
Male Sterilization
Yes
No
B06
A woman can get pregnant if she is 6 months postpartum and exclusively breastfeeding.
True
False
Don’t know
B07
When a woman comes for IUCD, what all information do you gather from her?
B07A
Demography
Age of the women
Number of children
Age of the youngest child
B07B
Contraceptive use
Past Experience with family planning methods
Last method use
Cause of discontinuation
B07C
Use of IUCD
Previous use of IUCD
Experience of side-effects from IUCD
B07D
Menstruation
Date of last menstrual period
Regularity of period
Bleeding/Spotting between periods or after intercourse
B07E
Obstetric history
Details of deliveries and abortions
Details of post-partum/post abortion infections
Any complaint of abnormal vaginal discharge
Any medical illness
Don’t gather any information
B08
What method specific information do you provide the woman before IUCD insertion?
Different FP methods available
How method works
Process of inserting IUCD
Possible side-effects
Follow-up dates
Tests to be done
Examinations to be done
Duration of effectiveness
Failure rates
Time to return of fertility on discontinuation
Don’t know
Other (Specify)
B09
Do you inform woman about side-effects they may experience due to IUCDs?
Yes
No
B10
What are the possible side-effects of IUCDs you inform woman about?
Pain, light bleeding, and/or cramps for few days after insertion
Experience of heavier bleeding, longer bleeding, and or more cramping than usual
Spotting between the periods
Backache, during and after insertion of IUCD
Can travel to other parts of the body such as heart and brain
Can cause discomfort to woman's partner during intercourse
Can cause injury to woman's private parts
Weight gain
Can cause white discharge
Can cause Reproductive tract infection
Other (Specify)
B11
What are the conditions in which you say that IUCD is not suitable for women?
Currently pregnant
Unusual bleeding between menstrual periods
Genital cancers, trophoblastic disease (Tumor) or pelvic tuberculosis
Ulcer on the vulva, vagina or the cervix
pain in lower abdomen while moving the cervix
Tenderness in the pelvic region
Purulent cervical discharge
Anatomical abnormality of the uterine cavity
Unable to determine the size and/ or position of the uterus
Zero/ low parity women
Don’t know any condition
Others (specify)
B12
If you find a woman not suitable for IUCD, what do you do?
Explain her reasons for not providing IUCD
Explain/ provide her other FP methods
Provide her with IUCD even if it is unsuitable
Do not provide her with any other method
Other (Specify)
B13
What examination do you do before inserting IUCD?
Pallor
Pulse rate
Blood Pressure
Lower abdominal tenderness and masses (swelling in one part of belly)
External genitalia examination
Bimanual examination
Speculum examination of the vagina and cervix
None
Other (Specify)
B14
What lab tests do you ask for before inserting IUCD?
Pregnancy test
Blood test
Urine test for sugar
No test
Other (Specify)
B15
How long do you keep a woman after IUCD insertion?
Discharge immediately
Keep for at least 30 min
Keep for at least 1hr
Keep for >1hr
Other (Specify)
B16
What all instruction do you give to IUCD woman before discharging?
IUCD insertion may lead to changes in menstrual patterns
Come for check-up after first menstruation
Check IUCD thread after every menstruation for few months
Return if there are any specific complain
Visit a provider if she experiences any other health problem
Return/ follow-up visit after 6 months after insertion
Don’t give any instructions
Other (Specify)
B17
What are the immediate warning signs after IUCD insertion that you educate the woman about?
Pregnancy symptoms
Abdominal pain
Pain during intercourse
Infections or unusual vaginal discharge
Not feeling well, fever, chills
Problem with string
Heavy bleeding
Other (Specify)
B18
What follow-up mechanism do you have/facility has, i.e., how do you/facility ensure that IUCD women receive follow-up services on scheduled time?
Phone calls are made to remind woman about follow-up date
Outreach workers visit home for follow-up visit
Outreach workers remind women about the follow-up date.
Write the follow-up date on the prescription
Automatic/ Reminder messages sent to women
No follow up mechanism in place
Other (Specify)
B19
What are some of the benefits of IUCD as a contraceptive which you explain to the women?
Suitable for use by most women
Safe for use in breastfeeding women
One-time procedure and longtime protection
No requirement of daily attention or special attention before sexual intercourse
Effective immediately after insertion
Acts as an emergency contraceptive if inserted within five days of unprotected sexual intercourse
Immediate return of fertility upon removal of IUCD
No drug interaction
May help protect against endometrial and cervical cancer
Don’t discuss/ explain any benefit
B20
Can the use of an IUCD provide protection against HIV and other sexually transmitted infections (STIs)?
Yes
No
B21
How soon after vaginal childbirth can a woman have an intrauterine contraceptive device (IUCD) inserted if she desires one?
48hrs
Other (Specify)
Don’t know
B22
When a woman comes to initiate injectable, what all information do you gather from her?
Age of the women
Number of children
Past Experience with family planning methods
Last method use
Cause of discontinuation
Date of last menstrual period
Regularity of period
Any medical illness
Weight
Any other medication the women is currently taking
Don’t ask anything
Other (specify)
B23
What method specific information do you provide woman before giving injectable?
Different FP methods available
How injectable works
Need to be taken every three months
Side-effects
Follow-up dates
Tests to be done
Examinations to be done
Duration of effectiveness
Failure rates
Time to return of fertility on discontinuation
Other (Specify)
B24
Do you inform woman about side-effects they may experience due to injectable?
Yes
No
B25
What are the side-effects of injectable you inform the women about?
Menstrual period may become irregular or stop
Spotting between two periods
Weight gain
Can induce abortion
Can cause menopause
Can make women permanently infertile
Can lead to spotting
Can reduce eyesight
Other (Specify)
B26
Why don’t you inform woman about the side-effects?
There are no side-effects
I don’t know about any side-effect
Woman will get frightened
Women will not opt the method
Others (Specify)
B27
What are the benefits of Injectables you inform the women about?
Safe, highly effective with long term contraceptive benefits
Convenient and easy to use
Acts for 3 months with a grace period of 4 weeks
Completely reversible
Private and confidential method
Does not interfere with sexual intercourse/pleasure
Pelvic examination not required prior to use
Suitable for women who are not eligible to use an oestrogen containing contraceptive.
Suitable for breast feeding women (after 6 weeks postpartum) as it does not affect quantity, quality and composition of breast milk
Provides immediate postpartum (in non-breastfeeding women) and post – abortion contraception
Don’t inform the women about any benefits
Others (Specify)
B28
What are the factors that restrict the use of contraceptive injection (DMPA-IM) in women?
It does not protect against STI/RTI and HIV infection
Once taken its action cannot be stopped immediately
It causes changes in the menstrual cycle and bleeding
It has to be repeated every 3 months
Return of fertility takes 7-10 months from date of last injection
Cannot be given in few medical conditions/diseases
Other myths and misconceptions
Don’t inform the women about any limitations
Others (Specify)
B29
What examinations do you do before giving injectable?
Ask about menstruation to exclude pregnancy
Other (Specify)
B30
What are the health conditions in which Injectables are contraindicated?
Breastfeeding <6 weeks postpartum
Older age, smoking, diabetes, and known dyslipidemia (high fat or cholesterol)
High blood pressure (Systolic 140 - 159 or diastolic 90 - 99 mm Hg)
Current and history of heart disease (vascular disease)
Blood clot (Acute Deep Vein Thrombosis /pulmonary embolism)
Stroke (history of cerebrovascular accident)
Unexplained vaginal bleeding
Other (Specify)
Don’t know any condition
B31
What instructions do you give to woman before sending her after administration of the injectable?
Instruct women not to massage or apply hot fomentation to the injection site
Should come for next injection after 3 months
Have sex after 12 hours of taking injection
Inform women about grace period in case of any delay in taking subsequent injections
In case of any warning sign, she should visit facility
Follow up date
None / No instructions given
Other (Specify)
B32
What follow-up mechanism do you have/facility has, i.e., how do you/facility ensure that injectable woman receive follow-up services on scheduled time?
Phone calls are made to remind womens about follow-up date.
Outreach workers visit home for follow-up visit
Outreach workers remind women about the follow-up date.
Write the follow-up date on the prescription
Automatic/ Reminder messages sent to women
Helpline number
No follow up mechanism in place
Other (Specify)
B33
What is the preferred injection site for administering Antara-IM?
Upper arm (deltoid muscle)
Buttocks (gluteal muscle, upper outer portion)
Other (Specify)
B34
Is Amenorrhea (absence of periods) because of Injectables is harmful for the women’s future fertility?
Yes
No
B35
What is the recommended grace period for administering injectables?
Up to 2 weeks earlier and 4 weeks later from the scheduled date
Other (Specify)
Don’t know
B36
When does fertility return after taking the last injection of DMPA-IM?
7-10 months after taking the last injection of DMPA-IM
Other (Specify)
Don’t know
B37
What all information do you gather from the woman before prescribing her birth control implants?
Age of the women
Number of children
Past Experience with family planning methods
Last method use
Cause of discontinuation
Date of last menstrual period
Regularity of period
Any medical illness
Weight
Any other medication the women is currently taking
Don’t ask anything
B38
What method specific information do you provide woman before prescribing her birth control implants?
Various family planning methods exist
How implant works
Need to be taken every three years
Side-effects
Follow-up dates
Tests to be done
Examinations to be done
Duration of effectiveness
Failure rates
Time to return of fertility on discontinuation
Other (Specify)
B39
What are the benefits of Implants you inform the women about ?
Safe and highly effective
A walk-in procedure and once inserted, effective for 3 years
Completely reversible with an early return to fertility
Suitable for women who have blood pressure >160/100 mmHg, diabetes >20 years of duration or with end-organ damages or other vascular diseases
Suitable for breastfeeding women
May be used by women of any age or parity if they are at risk of pregnancy
Does not interfere with sexual intercourse and pleasure
Don’t inform about any benefits
Other (Specify)
B40
Do you inform woman about side-effects they may experience due to implants?
Yes
No
B41
What are the side-effects you inform the women about?
Menstrual period may become irregular or stop
Spotting between two periods
Weight gain
Headache
Acne
Enlarged ovarian follicles
Breast tenderness
Dizziness
Mood changes
Nausea
Can induce abortion
Can cause menopause
Can make women permanently infertile
Can travel to other parts of the body
Other (Specify)
B42
Why don’t you inform woman about the side-effects of Implants?
There are no side-effects of Implants
I don’t know about any side-effect
Women will get frightened
Women will not opt the method
Others (Specify)
B43
What examinations do you do before prescribing implants as contraceptives?
Pregnancy test
Blood Pressure
Clinical breast examination
Check Blood clots in legs/ lungs
Don’t do any examination
Other (Specify)
B44
What are the conditions in which Implants are not recommended?
Acute Deep Vein Thrombosis/Pulmonary Embolism
Unexplained vaginal bleeding
Past history of breast cancer (no evidence of disease for at least 5 years)
Severe liver disease (cirrhosis, hepatocellular adenoma, malignant hepatoma)
Certain cases of Systemic Lupus Erythematosus (Autoimmune Disease)
Ischemic heart disease, stroke, migraine with aura
Don’t know any condition
Other (Specify)
B45
What are the factors that restrict the use of contraceptive Implant in women?
Requires a minor procedure for insertion and removal by a trained service provider
Changes in menstrual bleeding pattern are common
May be visible under the skin in some women
Does not protect a woman from reproductive tract infections (RTIs) and sexually transmitted infections (STIs) including HIV/AIDS
Other myths and misconceptions
Don’t inform about any limitation
Other (Specify)
B46
What instructions do you give to woman before sending her after the implant placement?
Bandage can be removed the next day
Protective dressing can be removed three to four days after insertion
Keep the insertion area dry for two days to prevent infection
There may occur some bruises and a little bleeding on the affected area
To use condom/ non hormonal method for the first week
In case of any warning sign, she should visit the facility
Follow up date
Don’t give any instructions
Other (Specify)
B47
What follow-up mechanism do you have/facility has, i.e., how do you/facility ensure that implant woman receive follow-up services on scheduled time?
Phone calls are made to remind women about follow-up date.
Outreach workers visit home for follow-up visit
Outreach workers remind women about the follow-up date.
Write the follow-up date on the prescription
Automatic/ Reminder messages sent to women
No mechanism in place
Other (Specify)
B48
Where is contraceptive Implant inserted?
Just under the skin of a woman’s upper arm
Other (specify)
Don’t know
B49
When does fertility return after removal of the Implant?
Immediately after removal
Other (Specify)
Don’t know
B50
When a woman comes for Oral contraceptives, what all information do you gather from her?
Age of the women
Number of children
Past Experience with family planning methods
Last method use
Cause of discontinuation
Date of last menstrual period
Regularity of period
Details of deliveries and abortions
Detail about breast feeding
Any medical illness
Weight
Smoking habit
Symptoms of Sexually Transmitted Infection
Any other medication the women is currently taking
Don’t ask anything
Other (specify)
B51
What method specific information do you provide the woman/woman before prescribing the OCPs?
Duration of the pills
Duration of effectiveness
Failure rates
Side-effects
Time to return of fertility on discontinuation
Don’t provide any information
Other (Specify)
B52
What are the benefits of Combined Oral Contraceptives (COCs)/28-days pills you inform the women about ?
Highly effective reversible, easy to use and safe for most women
Regulate the menstrual cycle and reduces menstrual flow (which is useful to anaemic women)
Decrease the risk of ovarian and uterine cancer, benign breast disease and incidence of acne
Do not interfere with sexual intercourse
Pelvic exam not mandatory before use
Immediate return of fertility on discontinuation
Don’t inform about any benefits
Others (Specify)
B53
What are the factors that restrict the use of Combined Oral Contraceptives (COCs)/28-days pills in women?
Must be taken every day
Require regular/dependable supply
Do not protect against STIs and HIV
Risk of developing cardiovascular disease in Women over 35 years of age and who smoke
Other myths and misconceptions
Don’t discuss about any limitations
Other (Specify)
B54
What are the conditions in which Combined Oral Contraceptives (COCs) are contra-indicated?
Breastfeeding women < 6 months postpartum
Non-breastfeeding women < 3 weeks postpartum
Women who smoke >15 cigarettes/day and 35 years old
Deep vein thrombosis (DVT)
Heart disease
Bleeding disorders
Liver disease or tumours
Recurrent migraine headaches with focal neurological symptoms
Unexplained vaginal bleeding
Breast cancer
Currently taking. Medicine for TB or for epilepsy (fits)
Other (Specify)
Don’t know any condition
B55
Do you inform the woman about possible side effects of Combined Oral Contraceptives (COCs)?
Yes
No
B56
What are the possible side -effects of Combined Oral Contraceptive (COC) Pills you inform them about?
Abdominal/Pelvic pain
Chest pain
Headache/ Numbness in any limb
Eye symptoms- blurred vision/seeing double/not able to see
Severe pain in calves/ thighs
Irregular and no bleeding
Heavy Bleeding
Difficulty in breathing
Severe headache
Numbness in any limb
Blurred vision
Severe pain in calves/ thighs
Reduced milk production in nursing mothers
Weight change
Acne
Breast Tenderness (Woman not breastfeeding)
Nausea or dizziness
Vomiting or Diarrhoea
Risk of cancer
Risk of infertility
Lead to birth defects
Can cause abortion
Don’t discuss any side effects
Other (Specify)
B57
Why don't you inform the woman about possible side effects from COC pills?
There are no side-effects
I don’t know about any side-effect
Women will get frightened
Women will not accept the method
Others (Specify)
B58
What are the benefits of Centchroman Contraceptives (COCs)/weekly pills?
Highly Safe and effective, non-steroidal non-hormonal reversible method
Easy to use orally twice a week for first three months and once a week there after
Can be used safely by lactating mothers
Free from side effects commonly associated with hormonal oral contraceptives (such as nausea, dizziness, weight gain, etc.)
Does not interfere with sexual intercourse
Can be started without a pelvic examination
Immediate return of fertility on discontinuation
Has no effect on platelet aggregation, lipid profile and HDL cholesterol
No teratogenic effect
Effective in managing
Dysfunctional uterine bleeding
Can prevent breast cancers, uterine cancers and protection against demineralization of bone
Don’t discuss any benefits
Others (Specify)
B59
What are the factors that restrict the use of Centchroman Contraceptives (COCs)/weekly pills in women?
Require regular/ dependable supply
Prolongation of the menstruation cycle in some Women
Do not protect against STIs and HIV
Other myths and misconceptions
Don’t discuss any limitations
Other (Specify)
B60
What are the conditions in which Centchroman Contraceptives/ Weekly pills are contra-indicated?
Polycystic ovarian disease
Cervical hyperplasia
Recent history of jaundice or liver disease
Severe allergic state
Chronic illness, like tuberculosis or renal disease
Other (Specify)
Don’t know any condition
B61
Do you inform the woman about possible side effects of weekly pills?
Yes
No
B62
What are the possible side -effects of OCPs Centchroman (Chhaya) pill/weekly pill you inform them about?
Irregular and no bleeding
Heavy Bleeding
Abdominal/Pelvic pain
Chest pain
Difficulty in breathing
Severe headache
Numbness in any limb
Blurred vision
Severe pain in calves/ thighs
Reduced milk production in nursing mothers
Weight change
Acne
Breast Tenderness (Women not breastfeeding)
Nausea or dizziness
Vomiting or Diarrhoea
Risk of cancer
May lead to permanent infertility
Risk of birth defect in future pregnancies
Don’t discuss any side effects
Other (Specify)
B63
Why don't you inform the woman about possible side effects from weekly pills?
There are no side-effects
I don’t know about any side-effect
Women will get frightened
Women will not accept the method
Others (Specify)
B64
Do you also inform/provide instructions to the woman on what needs to be done if they fail to take any pill dosage?
Yes
No
B65
Do you instruct about when to get the next supply (before her daily/weekly pills are finished)?
Yes
No
B66
Do you instruct about the sources from where the daily/weekly OCPs can be purchased/ bought?
Yes
No
B67
What sources do you instruct for getting/ purchasing the OCPs?
ASHA
ANM
Health and Wellness Centre / Sub centres
Primary Health Centres
Community Health Centres
District Hospital
Pharmacies /Drugstores
Other (Specify)
B68
Centchroman pills/ Weekly pills should be taken twice a week for first 3 months and then once a week.
1
Don’t know
B69
What should a woman do if she forgets to take 1 pill of 28-days pill?
Take the pill as soon as possible
Other (Specify)
Don’t know
B70
When can a breastfeeding woman start taking Combined oral contraceptive pills/28-day pills?
6 months postpartum
Others(specify)
Don’t know
B71
What is recommended time for emergency contraceptive pill to be most effective after unprotected sex?
As soon as possible or Within 72 hours
Other (Specify)
Don’t know
B72
Can Emergency contraceptive pill induce abortion in a pregnant woman?
Yes
No
B73
Do you explain the steps of using a male condom (Nirodh)?
Yes
No
B74
Do you demonstrate all the necessary steps involved in usage of a condom on penile model?
Yes
No
B75
What instructions do you give to woman before using condom as contraceptives?
One condom should be used only once
Demonstrate removal of condom
In case there is slippage or rupture, ECPs should be taken
There should be consistent use if condom is being used as contraceptive
Don’t provide any instruction
Others (Specify)
B76
Do you inform the woman about the benefits of using condoms regularly?
Yes
No
B77
What all benefits of condom usage do you inform about?
Effective against unintended pregnancy
Prevents sexually transmitted infections
Other (Specify)
B78
Do you also inform the woman about irritation or latex allergies that may occur due to condom usage?
Yes
No
B79
Do you instruct about the sources from where the condom can be purchased/ bought?
Yes
No
B80
What sources do you instruct for getting/ purchasing the condoms?
ASHA
ANM
Health and Wellness Centre / Sub centres
Primary Health Centres
Community Health Centres
District Hospital
Pharmacies
Other (Specify)
B81
Have you heard of DMPA-SC Injectable Contraceptives?
Yes
No
B82
Have you received any in-service training update, or refresher training on Counselling of Self-administered Injectable Contraceptives in the last 12 months?
Yes
No
B83
How many months back did you receive the training on Antara SC/ DMPA SC in the last 12 months?
One month back
3 months back
6 months back
12 months back
Others (Specify)
B84
Do you think you have adequate training on administration of DMPA-SC?
Yes
No
B85
Do you provide services or counselling on DMPA-SC?
Yes, provide
Yes, only counsel
None
B86
What is the eligible minimum age for DMPA-SC?
B87
What is the eligible maximum age for DMPA-SC?
B88
Is there a minimum number of children a person must have before DMPA-SC should be offered?
Yes
No
B89
What is that minimum number of children?
B90
Does husband’s consent is required for DMPA-SC?
Yes
No
B91
Would you offer DMPA-SC to a newly married woman who have come alone to you?
Yes
No
B92
Would you offer DMPA-SC to an unmarried person?
Yes
No
B93
Will you give the choice for self-injection to the married woman of reproductive age on her first visit (for self-injection)?
Yes
No
B94
What is the duration of the effectiveness of DMPA-SC after the last injection?
7-10months
Other (Specify)
Don’t know
B95
What is the preferred injection site for administering DMPA-SC?
Upper arm (skin)
Abdomen
Thigh (outer anterior)
Other (Specify)
B96
Women should not be advised to self-inject DMPA-SC at home.
Strongly Agree
Agree
Disagree
Strongly Disagree
B97
Self-injection of DMPA-SC has more side effects.
Strongly Agree
Agree
Disagree
Strongly Disagree
B98
Self-administration of DMPA-SC is less reliable than having a healthcare professional administering it
Strongly Agree
Agree
Disagree
Strongly Disagree
Experience and practice of Family planning services at the facility
C01
How often do you greet/welcome the woman who have come to avail FP counselling or advice?
Always
Often
Sometimes
Rarely
Never
C02
How much time does it take on an average per woman to counsel them on FP?
Less than 10 minutes
15 - 20 minutes
20 – 40 minutes
More than 40 minutes
Others(specify)
C03
Where is the counselling provided?
Waiting area
Separate closed space/ room for FP counselling
Integrated counselling and testing centre
OPD
Other (Specify)
C04
Does the counselling/ consultation take place in a space where the privacy and confidentiality of the woman is maintained?
Room with audio privacy
Room with visual privacy
Room with audio and visual privacy
No, there is no privacy
C05
If during counselling someone comes in the room, what do you do?
Stop for some time until the person is there in the room
Continue with counselling at a lower voice
Ask the person to return at some other time
Other (Specify)
C06
Do you have charts/manuals/audio visual aids to explain the services?
Yes
No
C07
How often do you use any charts/manuals/audio visual aids to explain the services?
Always
Often
Sometimes
Rarely
Never
C08
While giving antenatal care, do you counsel woman on family planning? Would you say always, often, sometimes, rarely or never?
Always
Often
Sometimes
Rarely
Never
C09
What are the topics you cover while counselling the woman who has come for ANC?
Importance of Family Planning after delivery
Health related information due to large family size
Healthy timing and spacing of pregnancies.
Detailed information about the method including method use, effectiveness, possible side effects & their management
Locations to access the family planning methods
Protection against Sexually transmitted Infections/Reproductive tract infections
Others (Specify)
C10
On what all family planning methods do you counsel the woman during ANC?
Condom
Oral Pills - Mala N
Oral Pills -Chhaya
ECP
Injectables = DMPA – IM
Injectables = DMPA – SC
Interval IUCD
PPIUCD
Implants
Conventional Vasectomy/ NSV
Mini laparotomy/ Female sterilization (Conventional Laparotomy)
PP Sterilization
Lactational Amenorrhea Method (LAM)
Standard Days methods
Rhythm Method
Withdrawal
Depends upon the parity
Others (Specify)
C11
Why don’t you provide counselling during ANC period?
I don’t know about any method
I don’t know about the steps followed during counselling
I don’t have enough time required for FP counselling
Woman don’t give time required for counselling
There is not adequate space / privacy required for FP counselling
I don’t have any job aid or posters to support FP counselling services
I feel ashamed/ hesitant in providing FP counselling
It is not my job to counsel, there are specific people to provide FP counselling
Other (Specific)
C12
At the time of admission/ after caesarean/ after delivery before or after conducting delivery, do you counsel woman on family planning? Would you say always, often, sometimes, rarely or never?
Always
Often
Sometimes
Rarely
Never
C13
What are the topics you cover while counselling the woman who has come at the time of At the time of admission/ after caesarean/ after delivery?
Importance of Family Planning after delivery
Health related information due to large family size
Healthy timing and spacing of pregnancies.
Detailed information about the method including method use, effectiveness, possible side effects & their management
Locations to access the family planning methods
Protection against Sexually transmitted Infections/Reproductive tract infections
Others (Specify)
C14
What contraceptives do you discuss with woman who have recently delivered?
Condom
Oral Pills - Mala N
Oral Pills -Chhaya
ECP
Injectables = DMPA – IM
Injectables = DMPA – SC
Interval IUCD
PPIUCD
Implants
Conventional Vasectomy/ NSV
Mini laparotomy/ Female sterilization (Conventional Laparotomy)
PP Sterilization
Lactational Amenorrhea Method (LAM)
Standard Days methods
Rhythm Method
Withdrawal
Depends upon the parity
Others (Specify)
C15
Do you counsel family members who accompany the woman for ANC or delivery?
Yes
No
C16
Whom do you counsel?
Husband
Mother-in-law
Other female relatives
Other male relatives
Others (Specify)
Attitude towards family planning of the respondent
D01
Now, I would like to know about your opinion on family planning. I will read few statements and you have to tell whether you strongly agree, agree, disagree or strongly disagree with these statements. There is no right or wrong answer.
D01_1
All women after their marriage should get pregnant as soon as possible to prove their fertility.
Strongly Agree
Agree
Disagree
Strongly Disagree
D01_2
Newly married woman/ couple should not be counselled on family planning.
Strongly Agree
Agree
Disagree
Strongly Disagree
D01_3
Any contraceptive use is not recommended till the family is complete.
Strongly Agree
Agree
Disagree
Strongly Disagree
D01_4
Newlyweds should only be advised on limited contraceptive options like non-hormonal methods especially condoms or traditional methods that do not affect fertility.
Strongly Agree
Agree
Disagree
Strongly Disagree
D01_5
Women are solely responsible for avoiding pregnancy through contraceptive use as they have to bear the consequences of unwanted/unintended pregnancy
Strongly Agree
Agree
Disagree
Strongly Disagree
D01_6
All women accessing the facility for abortion or delivery must receive offer of clinical contraceptive services like IUCD or Antara as it is difficult for woman to come again to facility.
Strongly Agree
Agree
Disagree
Strongly Disagree
D01_7
Uneducated/less educated women should only be provided easy to use contraceptives options to reduce the risk of incorrect usage.
Strongly Agree
Agree
Disagree
Strongly Disagree
D01_8
I recommend contraceptives based on what I believe is best for the woman.
Strongly Agree
Agree
Disagree
Strongly Disagree
D01_9
Contraceptive counselling should not include hormonal methods for newlyweds as it may cause fertility return issues.
Strongly Agree
Agree
Disagree
Strongly Disagree
D01_10
Women who have no children should not be offered or given IUCD because it may lead to infection and infertility.
Strongly Agree
Agree
Disagree
Strongly Disagree
D01_11
All woman visiting facility for delivery should be offered sterilization only when family is complete.
Strongly Agree
Agree
Disagree
Strongly Disagree
D01_12
Uneducated/less educated women should not be provided CHHAYA pills as it is difficult to understand the schedule and has risk of incorrect usage.
Strongly Agree
Agree
Disagree
Strongly Disagree
D01_13
PPIUCD is the best choice for postpartum women seeking spacing between children.
Strongly Agree
Agree
Disagree
Strongly Disagree
D01_14
Daily COC hormonal pills like Mala N are not recommended post one year of use as it can make woman infertile.
Strongly Agree
Agree
Disagree
Strongly Disagree
D01_15
Antara should not give to zero parity woman as it leads to irregular menses and eventual infertility.
Strongly Agree
Agree
Disagree
Strongly Disagree
D01_16
Stoppage of monthly bleeding with the use of Antara Injection will lead to a collection of dirty blood in the woman’s body.
Strongly Agree
Agree
Disagree
Strongly Disagree
D01_17
Getting pregnant after use of oral contraceptive pills leads to birth defects in newborn.
Strongly Agree
Agree
Disagree
Strongly Disagree
D01_18
I provide contraceptive counselling to all women or couples, regardless of their parity status being zero or low.
Strongly Agree
Agree
Disagree
Strongly Disagree
D01_19
I offer contraceptives to newly married women/couples only when they ask for them.
Strongly Agree
Agree
Disagree
Strongly Disagree
D01_20
Contraceptive counselling should be given to couples and all contraceptive options should be discussed.
Strongly Agree
Agree
Disagree
Strongly Disagree
D01_21
Healthcare provider knows best about contraceptives thus they should choose a method for a woman and provide it to her irrespective of her choice.
Strongly Agree
Agree
Disagree
Strongly Disagree
Supply & Incentives related to contraceptive commodities.
E01
From where does this facility indents / procures the contraceptives commodities?
Primary Health Centre
Community Health Centre
Sub-district hospital
District hospital
Organizations working with Government
Others (specify)
Don’t know
E02
Are you involved in indenting of contraceptives commodities?
Yes
No
E03
How frequently do you indent / facilitate the indent of these contraceptive commodities?
Monthly
Quarterly
Bi-Annually
Annually
Others (specify)
E04
How do you raise the indent?
Manually
Digitally
Both
E05
How frequently do you get the complete indented stock?
Always
Often
Sometimes
Rarely
Never
E06
Have you witnessed any stockout of contraceptive commodity at your facility in last 12 months?
Yes
No
E07
For which contraceptive commodities has been stocked out in last 12 months?
Condom
Oral Pills - Mala N
Oral Pills - Chhaya
Emergency Contraceptive pills
Injectables = DMPA – IM
Injectables = DMPA – SC
IUCD
Implants
E08
How often do stockouts of following contraceptive commodities occur at your facility?
E08_1
Condom
Monthly
Quarterly
Bi-annually
Annually
E08_2
Oral Pills - Mala N
Monthly
Quarterly
Bi-annually
Annually
E08_3
Oral Pills - Chhaya
Monthly
Quarterly
Bi-annually
Annually
E08_4
Emergency Contraceptive pills
Monthly
Quarterly
Bi-annually
Annually
E08_5
Injectables = DMPA – IM
Monthly
Quarterly
Bi-annually
Annually
E08_6
Injectables = DMPA – SC
Monthly
Quarterly
Bi-annually
Annually
E08_7
IUCD
Monthly
Quarterly
Bi-annually
Annually
E08_8
Implants
Monthly
Quarterly
Bi-annually
Annually
E08_9
Pregnancy kits
Monthly
Quarterly
Bi-annually
Annually
E09
How many claims have you raised in the last 12 months for?
E09_1
IUCDs insertion
E09_2
PPIUCDs Insertion
E09_3
Male Sterilization
E09_4
Female Sterilization
E10
Did you receive any incentive in the last 12 months?
Yes
No
E11
For what activities did you receive incentives?
Ensuring spacing at birth 1 and 2
ELA- Promoting/practising sterilization and PPIUCD in last 12 months
Other (Specify)
E12
When was the Last meeting at PHC with MO / block facilitator/health manager conducted?
E13
What was discussed around family planning in last monthly meeting you attended?
Discussion around Sterilization
Discussion around PPIUCDs
Discussion around utilization of reversible contraceptives
Reviewing the supply of reversible contraceptives
Discussion around Training of the healthcare providers
Timely disbursements of incentives
Others (Specify)
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