Equatorial Guinea - Campaign to End Fistula

QUESTIONNAIRE 3: (Addressed to women with fistula)
Province: ……………..........................................................................................................................
District:…………..................................................................................................................................
Location:…………...............................................................................................................................
Civil status:.......................................................................................…………....................................
Name:.….......................................Family names:.…….......................................Age:........…..years
Profession: .................................................................……………………...........................................
Etnic group:......................... Place of residence:...............................................................………….
Number of deliveries:............................... Number of pregnancies: ...................................………….
Instructions level: Illiterate Primary Secondary Superior Other
Source of incomes: Housband Family Same woman Mendicity Other (indicate)
....................................................................................................…………..........................................
ABOUT FISTULA
1. Age of woman at first delivery:..……..............................................…………............................
2. Age of woman during fistula apparition:………………….............................…………............…
3. Fistula ancianity (years, months, weeks):………....................................................……………
4. With how many deliveries did you get your fistula?:..................................................………….
5. Was it a planned/wanted pregnancy? Yes No
6. How long was the delivery? (hours)......................…………........................................…………
7. Was it an assisted delivery?: Yes No
8. Place of delivery:..........................................................................................................…………
9. How did you get to the place of delivery?......................................................................…………
10. Was it a transfert?: Yes No
If yes, with which means?.............……………….........................................................………….
11. At what distance?: …....................................................................................................………….
12. Nature of delivery:
Normal
- Spontaneous
- Manual handling
- Instrumental handling
Caesarean
Alive child
Dead child
13. Distance between the place of residence and the nearest health structure:………………….....
14. Distance from place of residence to the nearest chirurgical unit:……….....................................
15. Patients possible pre/post operatory accomodation (family level): Yes No
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