S.

Question

1
2
3
4

Age
Address
Married since
Consagnious or
Nonconsagnious
5 What is the highest
level of your education
completed?

6 How many people live

in your household?
7 What is your husbands
occupation?

8 What is your monthly

house-hold income in
rupees?
9 How many people earn
in your family ?

10 Do you earn ?
11 Where do you work ?

Code

Yes
No
Primary=1
Lower Secondary=2
Matriculation=3
Never gone to school=4
Madressah/informal
education=5
4=1
5-7=2
8-10=3
10=4
Not employed=1
Labor work=2
driver=3
Govt employee=4
Business =5
Private firm=6
Student=7
military servant=8
Other(specify)=9
Specify
Specify

Yes
No
Business =1
Private firm=2
Govt servant=3
Teacher=4
Student=5
Unemployed/housewife=6

Skip

Response

12 Since how long you are

working?

Other(specify)=7
>6-12mths=1
2-3yrs=2
4-6yrs=3
7-9yrs=4
>10yrs=5

13

In how many
households do you
work daily?

14

Does anybody help you

in daily household
work?

15

Nutritional status

16

Dou you currently have

any disease or having
any medical treatment ?

Yes
No
(if yes then specify)

17

Are you dependant or

use to of taking any
particular thing ?

Yes
No
(option )

If yes then

Beetle nut
Beetle leaf
Beedi
Cigarette
Naswaar
Gutka

sensitize

18

How many children do

you have ?

1
2
3
4
5
>6=6
Yes
No

19

Any previous history of

abortion/misscarriage ?

Yes
No

If yes then, when and why

?
20

Type of current abortion ?

Induced
(if induced go to question
number 24 )
Spontaneous
(if spontaneous skip
question number 24 25 )

21

Did you have any

antenatal visits during this
pregnancy ?

Yes
No

22

If yes, how often ?

23

Cause of abortion ?

Trauma
Not known
Known then specify

24

FOR INDUCED
ABORTION
Cause of Abortion ?

Complete family size

Unwanted pregnancy*
Failure of contraception*
Financial issues
Gender based*
Medical reason, specify

25

What is your partners

opinion about this abortion
?

26

Any history of
gynaecological
procedure ?

Yes
(specify)
No

27

Do you use any

contraception method ?

Yes
No

28

If yes, then which method

do you use ?

29

Since when you using

30

Success rate

Physical Abuse
Now I will ask few sensitive questions regarding the behavior of your husband towards
you. You are free to answer any of them and at any time you can refuse to answer any of
them
31

Have you experienced

anybody doing any of these
acts in realtion?

Pushing violently=1
Pulling your hair=2
Holding you firmly=3
Kicking=4
Throwing a hard object=5
Slapping on face=6
Hitting you with fist=7
Hitting with hard object=8
Pinching=9
Making you stand or sit=10
Showing any weapon or
knife=11
Harm you with that
weapon=12
Twisting any body part=13
Throwing any liquid=14
Tie you with rope=15
Holding food from you=16
Holding other facilities
from you=17
Biting=18
Scratching=19
Spitting=20
Head shaking=21
Burning =22
Any other thing which
makes you
uncomfortable(specify)=23
Never=24

32

Who did this ?

Husband
Mother in Law
Sister in Law
Father in Law
Brother in Law
Others, specify

33

How often ?

34

Did you receive any

Yes=1
medical care for that abuse? No=2

35

Where did you receive it?

At clinic=1
At home=2
At dispensary=3
Any other(specify)=4

36

Were you admitted to any

hospital for that incident?

Yes=1
No=2

37

History of violence in
current pregnancy ?

Yes
No

38

If yes, how frequently ?

39

Do you think, was it the

reason behind abortion ?

Yes
No