FORM1: MOTHER'S QUESTIONNAIRE
PART 1: IDENTIFICATION / No / 1 / 6 / 1-4 / 1-99A / B / C / D
A: 1. Guntur, 2. Gajah B. Form number, C. Visit number ..? D. Participant number..
1. Name of household head / : / 1b.1.1.2. Address / : / 1b.1.2.
Dukuh/dusun / 1b.1.3.
RT RW / 1b.1.4.
Village : / 1b.1.5.
Subsdistrict: 1. Guntur 2. Gajah / 1b.1.6.
Telephone number / 1b.1.7.
3. Mother's name / : / 1b.1.8.
4. Father's name / : / 1b.1.9.
5. Place and date of birth of father / : / 1b.1.10.
6. Education / : / 1b.1.11.
7. Occupation / : / 1b.1.12.
8. Grandmother's name / : / 1b.1.13.
9. Number of children / : / 1b.1.14.
10. Child's name / : / 1b.1.15.
11. Sex / 1. Boy
2. Girl / 1b.1.16.
12. Date of birth of child / : / 1b.1.17.
13. Birth weight / : / grams / 1b.1.18.
14. Length at birth / cm / 1b.1.19.
15. Body weight (now) / : / grams / 1b.1.20.
16. Length (now) / cm / 1b.1.21.
Interviewer's name: ______Sign ______
Date of interview……………………………………... / 2 / 0Visit number / 2nd / 3rd / 4th / d / d / m / m / y / y / y / y
Supervisor's name …………………………………………. Sign ………………………….
Date of checked ……….…………………...... ……… / 2 / 0d / d / m / m / y / y / y / y
PART 2: PRACTICE
I want to ask you a little bit about yourself and your activities related to breastfeeding
1. / Did you have plan to breastfeed your baby? / 1. Yes / 2. No, go to Part 2 / 1b.2.1.If yes : For how long you have breastfed your baby? / ______/ months / 1b.2.2.
2. / How deep do you want to breastfeed? / a. I really want to breastfeed my baby,
b. Sometimes I want to breastfeed my baby, sometimes I do not want
c. Sometimes think, a better formula
d. I think a better formula
e. Not sure / 1b.2.3.
3. / How confident are your ability to breastfeed? / a. Feel confident with my ability to breastfeed
b. Feel not confident with my ability to breastfeed
c. Do not know / 1b.2.4.
4. / How is your husband's view on breastfeeding / a. Prefer if I breastfeed
b. No matter how I breastfeed
c. Prefer if I bottlefeed
d. Supports in 2 ways: breastfeeding and bottle feeding
e. Do not know / 1b.2.5.
5. / How is your mother's view towards breastfeeding? / a. Prefer if I breastfeed
b. No matter how I breastfeed
c. Prefer if I bottlefeed
d. Supports in 2 ways: breastfeeding and bottle feeding
e. Do not know / 1b.2.6.
6. / How is the voluntary health worker's view toward breastfeeding? / a. Prefer if I breastfeed
b. No matter how I breastfeed
c. Prefer if I bottlefeed
d. Supports in 2 ways: breastfeeding and bottle feeding
e. Do not know / 1b.2.7.
7. / How is the village head's view toward breastfeeding? / a. Prefer if I breastfeed
b. No matter how I breastfeed
c. Prefer if I bottlefeed
d. Supports in 2 ways: breastfeeding and bottle feeding
e. Do not know / 1b.2.8.
8. / How is the Muslim scholar's view on breastfeeding? / a. Prefer if I breastfeed
b. No matter how I breastfeed
c. Prefer if I bottlefeed
d. Supports in 2 ways: breastfeeding and bottle feeding
e. Do not know / 1b.2.9.
9. / How is the health staff's view toward breastfeeding? / a. Prefer if I breastfeed
b. No matter how I breastfeed
c. Prefer if I bottlefeed
d. Supports in 2 ways: breastfeeding and bottle feeding
e. Do not know / 1b.2.10.
10. / How is the midwife's view toward breastfeeding? / a. Prefer if I breastfeed
b. No matter how I breastfeed
c. Prefer if I bottlefeed
d. Supports in 2 ways: breastfeeding and bottle feeding
e. Do not know / 1b.2.11.
PART 3: FEEDING PRACTICES
Now, I would like to know about your baby's feeding practices
1. / Where did you give birth to (NAME)? / a. At homeb. Hospital
c. Maternity
d. Other ______/ 1b.3.1.
2. / Who assisted with the delivery of
(NAME)? / a. Doctor
b. Midwife
c. Nurse
d. Traditional birth attendant
e. Kader
f. Relatives / friends
g. Other, please specify ______
h. No one / 1b.3.2.
3. / How long after birth did you first put
(NAME) to the breast?
(Breastfeeding initiation) / a. Less than one hour … minutes
b. 1-24 hours : ….. hours
c. More than 24 hours :……. days
d. Do not remember
e. Do not know / 1b.3.3.
4. / Before doing breastfeeding initiation, had midwife anything done during waiting? / a. Yes
b. No
c. Do not know, go to 5 / 1b.3.4.
5. / If yes, what did she do? / a. Cleaning the baby with a soft cloth
b. Bathing the baby
c. Checking baby
d. Waiting for me, I was tired
e. I do not want
f. I do not know / 1b.3.5.
6. / When was the first breast milk come? / …………………..hours after birth / 1b.3.6.
7. / How much? / spoons / 1b.3.7.
8. / Did you give the first yellowish breastmilk? / a. Yes
b. No / 1b.3.8.
9. / Before putting (NAME) in the mother's chest for the first time, was there any drinks / food offered to your baby? / a. Yes
b. No
c. Do not know, go to 5 / 1b.3.9.
10. / If yes, what was offered? / a. Plain water
b. Honey
c. Water Sugar / Sugar
d. Milk formula
e. Other, specify ...... / 1b.3.10.
11. / Before the first breastmilk came, was there any drinks / food offered to your baby? / a. Yes
b. No
c. Do not know, go to 5 / 1b.3.11.
12. / If yes, what is offered? / a. Plain water
b. Honey
c. Water Sugar / Sugar
d. Milk formula
e. Other, specify ...... / 1b.3.12.
13. / Do you currently breastfeed your baby? / 1. Yes / 2. No / 1b.3.13.
14. / Do you give your baby any drink / dairy / food? / 1. Yes / 2. No, go to 10 / 1b.3.14.
15. / a. Have you given any food/drink since yesterday? (recall 24 hours) / 1. No
2. Yes
Note drink/food/supplement below / Age when fed in weeks / 1b.3.15.
weeks / 1b.3.16.
weeks / 1b.3.17.
weeks / 1b.3.18.
weeks / 1b.3.19.
weeks / 1b.3.20.
weeks / 1b.3.21.
weeks / 1b.3.22.
weeks / 1b.3.23.
16. / b. Have you given any food/drink since 7 days ago? (recall ) / 1. No
2. Yes
Note drink/food/supplement below / Age when fed in weeks / 1b.3.24.
weeks / 1b.3.25.
weeks / 1b.3.26.
weeks / 1b.3.27.
weeks / 1b.3.28.
weeks / 1b.3.29.
weeks / 1b.3.30.
weeks / 1b.3.31.
weeks / 1b.3.32.
17. / c. Have you given any food/drink since birth? (recall ) / 1. No
2. Yes
Note drink/food/supplement below / Age when fed in weeks / 1b.3.33.
weeks / 1b.3.34.
weeks / 1b.3.35.
weeks / 1b.3.36.
weeks / 1b.3.37.
weeks / 1b.3.38.
weeks / 1b.3.39.
weeks / 1b.3.40.
weeks / 1b.3.41.
I want to ask you about breastfeeding difficulties you have ever felt since 2 months ago.. / 1b.3.42.
18. / Have you ever felt your baby was often fussy / crying? / 1.Yes / 2.No / 1b.3.43.
How to cope?
Continue breastfeeding / 1.Yes / 2.No / 1b.3.44.
Stopping breastfeeding / 1.Yes / 2.No / 1b.3.45.
Mother drink herbal medicine, specify: / 1.Yes / 2.No / 1b.3.46.
Feeding / drinking baby, please specify: / 1.Yes / 2.No / 1b.3.47.
Go to the doctor, clinic, health workers, midwives / 1.Yes / 2.No / 1b.3.48.
Do nothing / 1.Yes / 2.No / 1b.3.49.
Other, specify: / 1.Yes / 2.No / 1b.3.50.
19. / Have you ever felt the baby refused to breastfeed? / 1.Yes / 2.No / 1b.3.51.
How to cope?
Continuing breastfeeding / 1.Yes / 2.No / 1b.3.52.
Stopping breastfeeding / 1.Yes / 2.No / 1b.3.53.
Drink herbal medicine mother, specify: / 1.Yes / 2.No / 1b.3.54.
Feeding / drinking baby, please specify: / 1.Yes / 2.No / 1b.3.55.
Go to the doctor, clinic, health workers, midwives / 1.Yes / 2.No / 1b.3.56.
Do nothing / 1.Yes / 2.No / 1b.3.57.
other: / 1.Yes / 2.No / 1b.3.58.
20. / Have you ever experience with breast engorgement ? / 1.Yes / 2.No / 1b.3.59.
How to cope?
expressing milk / 1.Yes / 2.No / 1b.3.60.
Compress with warm water / 1.Yes / 2.No / 1b.3.61.
continue breastfeeding infants / 1.Yes / 2.No / 1b.3.62.
Smearing lotion, cream, oil / 1.Yes / 2.No / 1b.3.63.
Compress with the plants / cabbage, etc / 1.Yes / 2.No / 1b.3.64.
drink herbal medicine / 1.Yes / 2.No / 1b.3.65.
Stopping breastfeeding / 1.Yes / 2.No / 1b.3.66.
Go to the doctor, clinic, health workers, midwives / 1.Yes / 2.No / 1b.3.67.
Other (specify) ...... / 1.Yes / 2.No / 1b.3.68.
Do nothing / 1.Yes / 2.No / 1b.3.69.
Do not know / 1.Yes / 2.No / 1b.3.70.
No response / 1.Yes / 2.No / 1b.3.71.
21. / Have you ever experienced nipple pain / cracking? / 1.Yes / 2.No / 1b.3.72.
How do you cope?
Smearing with breast milk and let dry / 1.Yes / 2.No / 1b.3.73.
Smearing lotion, cream, oil / 1.Yes / 2.No / 1b.3.74.
Smearing with gentian violet / 1.Yes / 2.No / 1b.3.75.
Mother drinking herbal medicine, specify: / 1.Yes / 2.No / 1b.3.76.
Cold compress powder, tumbuh2an / cabbage, etc / 1.Yes / 2.No / 1b.3.77.
Go to the doctor, clinic, health workers, midwives / 1.Yes / 2.No / 1b.3.78.
Continue breastfeeding infants / 1.Yes / 2.No / 1b.3.79.
Stopping breastfeeding / 1.Yes / 2.No / 1b.3.80.
Other, please specify: ...... / 1.Yes / 2.No / 1b.3.81.
Do nothing / 1.Yes / 2.No / 1b.3.82.
Do not know / 1.Yes / 2.No / 1b.3.83.
No response / 1.Yes / 2.No / 1b.3.84.
22. / Have you ever felt the breast milk is not enough / clear / watery? / 1.Yes / 2.No / 1b.3.85.
How to cope?
Continue breastfeeding infants / 1.Yes / 2.No / 1b.3.86.
Stopping breastfeeding / 1.Yes / 2.No / 1b.3.87.
Mother drinking herbal medicine, specify: / 1.Yes / 2.No / 1b.3.88.
Feeding / drinking baby, please specify: / 1.Yes / 2.No / 1b.3.89.
Go to the doctor, clinic, health workers, midwives / 1.Yes / 2.No / 1b.3.90.
Do nothing / 1.Yes / 2.No / 1b.3.91.
Other, please specify: ...... / 1.Yes / 2.No / 1b.3.92.
23. / Have you ever felt the hungry baby? / 1.Yes / 2.No / 1b.3.93.
C / How to cope?
Continue breastfeeding infants / 1.Yes / 2.No / 1b.3.94.
Mother drinking herbal medicine, specify: / 1.Yes / 2.No / 1b.3.95.
Feeding / drinking baby, please specify: / 1.Yes / 2.No / 1b.3.96.
Go to the doctor, clinic, health workers, midwives / 1.Yes / 2.No / 1b.3.97.
Do nothing / 1.Yes / 2.No / 1b.3.98.
Other (specify): / 1b.3.99.
PART 4: SUPPORT TO FEED
1. / Have your husband ever given support to provide food / drink other than breast milk? / 1.Yes / 2.No / 1b.4.1.If yes, what kind of support? / 1b.4.2.
2. / Have your grandmother ever given support to provide food / drink other than breast milk? / 1.Yes / 2.No / 1b.4.3.
If yes, what kind of support? / 1.Yes / 2.No / 1b.4.4.
3. / Have midwives ever given support to provide food / drink other than breast milk? / 1.Yes / 2.No / 1b.4.5.
If yes, what kind of support? / 1.Yes / 2.No / 1b.4.6.
4. / Have health workers ever given support to provide food / drink other than breast milk? / 1.Yes / 2.No / 1b.4.7.
If yes, what kind of support? / 1.Yes / 2.No / 1b.4.8.
5. / Have cadres ever given support to provide food / drink other than breast milk? / 1.Yes / 2.No / 1b.4.9.
If yes, what kind of support? / 1.Yes / 2.No / 1b.4.10.
6. / Have Muslim scholars / public figure ever given support to provide food / drink other than breast milk? / 1.Yes / 2.No / 1b.4.11.
If yes, what kind of support? / 1.Yes / 2.No / 1b.4.12.
7. / Have a neighbor / friend ever given support to provide food / drink other than breast milk? / 1.Yes / 2.No / 1b.4.13.
If yes, what kind of support? / 1.Yes / 2.No / 1b.4.14.
8. / Was there someone who have ever given support to provide food / drink other than breast milk? / 1.Yes / 2.No / 1b.4.15.
If yes, who? / 1b.4.16.
If yes, what kind of support? / 1b.4.17.
9. / Maternal weight / kg / 1b.4.18.
10. / Maternal height / cm / 1b.4.19.
11. / Number of children living / child / 1b.4.20.
12. / Number of children ever born / child / 1b.4.21.
13. / The number of children ever breastfed / child / 1b.4.22.
14. / The average amount of income the father / month / IDR / 1b.4.23.
15. / The average amount of income Mother / month / IDR / 1b.4.24.
16. / The average amount of other income / month / IDR / 1b.4.25.
1b.4.26.
1. / Since your child born, was there someone who helps lighten your burden so much easier to breastfeed? 1 yes 2 no, go to section 5 / 1. Yes / 2. No, go to part 5 / 1b.4.1.
2. / Was any support from the husband? 1 Yes 2 No / 1.Ya / 2.Tidak / 1b.4.2.
If yes, what kind of support? / 1b.4.3.
a. Offering help taking care the other children / 1.Yes / 2.No / 1b.4.4.
b. Helping the housework (washing, cleaning, cooking, shopping, etc., please specify: / 1.Yes / 2.No / 1b.4.5.
a. Encouraging for breastfeeding / 1.Yes / 2.No / 1b.4.6.
b. Encouraging mothers / 1.Yes / 2.No / 1b.4.7.
c. Holding a baby, bathing, burping, changing diapers, etc.: please specify / 1.Yes / 2.No / 1b.4.8.
d. Other, specify ...... / 1.Yes / 2.No / 1b.4.9.
3. / Was there any support from grandma? / 1.Yes / 2.No / 1b.4.10.
If yes, what kind of support? / 1b.4.11.
a. Offering help taking care the other children / 1.Yes / 2.No / 1b.4.12.
b. Helping the housework (washing, cleaning, cooking, shopping, etc., please specify: / 1.Yes / 2.No / 1b.4.13.
c. Encouraging for breastfeeding / 1.Yes / 2.No / 1b.4.14.
d. Encouraging mothers / 1.Yes / 2.No / 1b.4.15.
e. Holding a baby, bathing, burping, changing diapers, etc.: please specify / 1.Yes / 2.No / 1b.4.16.
f. Other, please specify ...... / 1.Yes / 2.No / 1b.4.17.
4. / Was there any support from the midwife? / 1.Yes / 2.No / 1b.4.18.
If yes, what kind of support? / 1b.4.19.
a. home visits / 1.Yes / 2.No / 1b.4.20.
b. training / counseling / 1.Yes / 2.No / 1b.4.21.
c. share experiences / 1.Yes / 2.No / 1b.4.22.
d. Other, please specify ...... / 1.Yes / 2.No / 1b.4.23.
5. / Was there any support from doctors, nurses, health center staff? / 1.Yes / 2.No
If yes, what kind of support? / 1b.4.24.
a. home visits / 1.Yes / 2.No / 1b.4.25.
b. counseling / training / counseling / 1.Yes / 2.No / 1b.4.26.
c. share experiences / 1.Yes / 2.No / 1b.4.27.
d. Other, specify ...... / 1.Yes / 2.No / 1b.4.28.
6. / Is there any support from voluntary health worker? / 1.Yes / 2.No / 1b.4.29.
If yes, what kind of support? / 1b.4.30.
a. home visits / 1.Yes / 2.No / 1b.4.31.
b. training / counseling / 1.Yes / 2.No / 1b.4.32.
c. share experiences / 1.Yes / 2.No / 1b.4.33.
d. Other, please specify ...... / 1.Yes / 2.No / 1b.4.34.
7. / Is there any support from Muslim scholars / village device? / 1.Yes / 2.No / 1b.4.35.
If yes, what kind of support? / 1b.4.36.
a. home visits / 1.Yes / 2.No / 1b.4.37.
b. education / training / 1.Yes / 2.No / 1b.4.38.
c. share experiences / 1.Yes / 2.No / 1b.4.39.
d. Other, please specify ...... / 1.Yes / 2.No / 1b.4.40.
8. / Is there support from the urban village / sub-district head? / 1.Yes / 2.No / 1b.4.41.
If yes, what kind of support? / 1b.4.42.
a. home visits / 1.Yes / 2.No / 1b.4.43.
b. counseling / training / counseling / 1.Yes / 2.No / 1b.4.44.
c. share experiences / 1.Yes / 2.No / 1b.4.45.
d. Other, please specify ...... / 1.Yes / 2.No / 1b.4.46.
PART 5. ENVIRONTMENT