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Monitoring Breastfeeding and Complementary Feeding Behaviors

Mothers of children under 12 months of age

(Verify that the child is less than 12 months old and continue. If the child is exactly 12 months or older, thank the mother and discontinue the interview)

Form number:____________________

District:_________________________

Sub-district:______________________

Village:_______________________________

House number:_________________________

NGO:________________________________

Name of Supervisor:___________________________ Signature: ____________________

Date of Interview:

Notes: Please record any observations you made during the interview in this space.

Section 1: Background

First, I want to ask you a few questions about yourself and your youngest child.

1	What is your youngest child’s name? *(use this name in remaining questions)*
2	How old is (name of child)? Record age in completed months.	_________	months
3	Date of birth of child
4	Date of birth verified using child growth card/available record?	1. Yes	2. No
5	Sex of child	1. Boy	2. Girl

Section 2: Feeding History

Now I'd like to ask you specific questions about the things (name of child) eats or drinks.

6	Have you ever breastfed (name of child)?	1. Yes	2. No (Skip to 11)
7	How long after birth did you put (name of child) to the breast? If “immediately” or less than 1 hour, record “00” hours. If less than 24 hours, record hours. Otherwise, record days.	_______ Hours
7		_______ Days
8	Are you still breastfeeding (name of child)?	1. Yes	2. No
9	Since this time yesterday, has (name of child) received (insert each item here)?
A	Breastmilk	1. Yes	2. No
B	Plain water	1. Yes	2. No
C	Teas, millet water, fruit juice, sweetened water, herbal teas, etc.	1. Yes	2. No
D	Milk (fresh cow milk, tin milk, baby formula, other)	1. Yes	2. No
E	ORS	1. Yes	2. No
F	Other liquids	1. Yes	2. No
G	Fruits	1. Yes	2. No
H	Semi-solid foods (porridge, tom brown, rice water, weanimix, cerelac, soup)	1. Yes	2. No
I	Solids or mushy foods (meat, fish, eggs, beans, nuts, yam, kenkey, rice, potatoes, petepete, yama, stew, etc)	1. Yes	2. No
J	Other semi-solid foods, solids	1. Yes	2. No

Section 3: LAM

Now I'd like to ask you specific questions about birth spacing.

10	Are you currently doing something or using any method to delay or avoid getting pregnant?	1. Yes	2. No (Skip to 12)
11	Which method are you currently using?	Lactational Amenorrhea Method.................................... Female Sterilization................... Male Sterilization...................... Pill........................................... IUD......................................... Injections................................. Condom.................................. Diaphragm............................... Periodic Abstinence.................. Withdrawal.............................. Breastfeeding............................ Other ___________________	1 2 3 4 5 6 7 8 9 10 11 12
12	Have you heard of LAM?	1. Yes	2. No

(CHECK THE QUESTIONNAIRE TO MAKE SURE THAT ALL RESPONSES
HAVE BEEN PROVIDED)

Thank you very much for your time and for helping us
as we try to make children’s health better.

Do you have any questions for me?

Section 4: Analysis

From section 2, indicate below whether the required behavior was performed.

13	Was breastfeeding timely initiated (That is Q7 = 00 hours) TIBF	1. Yes	0. No
14	If the child is less than 6 months, is he/she exclusively breastfed (That is Q9A = Yes and Q9b – Q9J = No) EBR	1. Yes	0. No
15	If the child is 6-9 months, has complementary feeding started (That is Q9A = Yes and any one or more of Q9G – Q9J = Yes) TICF	1. Yes	0. No
16	If child is less than 6 months, does mother use LAM? (Q11 = 1)	1. Yes	0. No