Interviewer: Please complete this section prior to visiting the facility for the assessment
Name and title of responding provider: ______
Sex of responding provider (circle one): Male | Female
Provider’s position in the facility: 1 Physician
2 Nurse
3 Midwife
4 Clinical officer
5 Other (specify): ______
According to your knowledge, the role of this provider in provision of TOP services in this facility is:
1 Principal provider of TOP procedures (provides most procedures)
2 Secondary provider of TOP procedures (provides some procedures)
3 Participates in a supporting role for procedures
4 In-charge (provides few TOP procedures)
5 In-charge (provides no TOP procedures)
When did the provider receive TOP training?
Month: ______
Year (circle one): 2009 | 2010 | 2011
Facility Name: ______Facility Code: ______
Interviewer Name: ______Interviewer Code: ______
Interviewer: Use this form to guide discussion withthe trained TOP provider selected for the assessment at each facility. Do not read text in italics.
Section 1. Facility Background
101 / For how long have you worked here? / 1 One year or less
2 Three years or less
3 More than three years
102 / How do women find out about the TOP services provided here?
(Read responses and circle all that apply) / 1 Friend/Family member/Partner
2 Health care provider
3 Traditional healer (Ng’anga)
4 Radio
5 Pamphlet
6 Street drama
7 Signs/posters
8 Other (specify): ______
99 Does not know/No answer
103 / Other than trained TOP providers, have any other members of the facility administration or management participated in a values clarification workshop? / 0 No
1 Yes
104 / Does this facility’s administration or management support the introduction/continuation of termination of pregnancy services? / 0 No
1 Yes
105 / Are there people at this facility who might oppose induced abortion services or training? / 0 No
1 Yes
Section 2. Current TOP Service
201 / How many trained providers provide TOP services in this facility? / Total full-time: ______
Total visiting: ______
202 / How many trained providers provide supportive services for TOP but do not provide the care directly? / Total full-time: ______
Total visiting: ______
203 / Which days of the week are TOP services available?
Circle all that apply / 1 Monday
2 Tuesday
3 Wednesday
4 Thursday
5 Friday
6 Saturday
7 Sunday
204 / When are TOP services available? / 1 During regular clinic hours (8-16 hrs )
2 Other (specify): ______
______
205 / Is there a sign in your facility for the PAC/TOP room? / 0 No
1 Yes
206 / Do TOP clients go through the same intake processes as other maternal health and delivery clients? / 0 No
1 Yes
207 / Please describe your facility’s process for how a woman who comes for TOP presents for a termination of pregnancy in your facility.
(Include the flow of TOP clients including days and times of booking, ultrasound, registration, appointments and cervical priming.)
208 / Has this process changed since you started providing TOP with medication? / 0 No
1 Yes
209 / How is pregnancy status assessed at your facility?
(Circle all that apply) / 1 Pregnancy test
2 Physical examination
3 Ultrasound
4 Other (specify): ______
210 / Does your facility have routine access to pregnancy test kits? / 0 No
1 Yes
211 / Do you currently have access to an ultrasound machine on site? / 0 No Go to question
1 Yes
212 / Does this facility conduct routine ultrasounds on first trimester abortion clients? / 0 No
1 Yes
213 / When women come here for TOP, do they ask for TOP with medication? / 0 No
1 Yes
214 / Is there anyone in this facility who still performs TOP with D&C in the first trimester? / 0 No
1 Yes
215 / Is anyone in this facility trained to use MVA for either PAC or TOP? / 0 No Go to question 217
1 Yes
216 / How is the pain experienced by women who receive MVA addressed in your facility? / 1 They are given ibuprofen in the facility
2 They are given paracetamol in the facility
3 They are given diclofenac in the facility
4 They are told to purchase analgesics from their local pharmacy
5 They are given a prescription to purchase analgesics from their local pharmacy
6 MVA clients are not given or told about pain medication
7 Other (specify): ______
217 / In an average month, how many women come to this facility for a TOP who are 10-12 weeks pregnant? / # of women: ______
218 / In an average month, how many women come to this facility for a TOP who are more than 12 weeks pregnant? / # of women: ______
219 / Are second trimester services available at this facility? / 0 No
1 Yes Go to question 221
220 / IF NO, What happens to women who come in requesting TOP in the second trimester? / 1 Refer them to another public facility
2 Refer them to a private facility
3 Refer them to antenatal care
4 Other (specify): ______
221 / Do you ever have to turn TOP clients away because there are too many for you to see in one day? / 0 No
1 Yes
222 / Do you ever have to turn TOP clients away because there is no trained provider on duty? / 0 No Go to question 225
1 Yes
223 / IF YES, How often does this happen? / 1 Less than once a week
2 About once a week
3 More than once a week
224 / IF YES, What do you tell those clients? / 1 Refer them to another facility
2 Ask them to return at another time
3 Other (specify): ______
225 / What happens when an adolescent comes to your facility for TOP?
(Read answers and ask the respondent to choose the best answer) / 1 No patient under age 18 is admitted or treated for TOP
2 Presence and consent of the patients’ parents or relatives is required
3 Presence and consent of the patients’ parents or relatives is recommended
4 Same as adults, no parental consent needed
5 Other, (specify): ______
______
226 / What is this facility’s referral hospital? / Name of hospital: ______
227 / How far is your facility from the referral hospital mentioned above?
(Mark only one answer) / 1 Less than 5 km
2 6-25km
3 26-50km
4 51-100km
5 More than 100 km
6 This facility is the highest-level hospital in the area
Section 3. Current PAC Service
301 / Are incomplete abortions treated at this facility? / 0 No Go to question 306
1 Yes
302 / How many trained providers provide PAC services in this facility? / Total full-time: ______
Total visiting: ______
303 / How many trained providers provide supportive services in the PAC unit but do not provide the care directly? / Total full-time: ______
Total visiting: ______
304 / Do you ever have to turn PAC clients away because there are too many for you to see in one day? / 0 No
1 Yes
305 / Do you ever have to turn PAC clients away because there is no trained provider on duty? / 0 No
1 Yes
306 / In the last year, has anyone died in your facility from what you feel were complications of an unsafe abortion? / 0 No
1 Yes
Section 4. Current Medication Abortion Service
401 / Do women come in specifically requesting medication abortion? / 0 No
1 Yes
402 / Are MA clients told to return to the facility to take misoprostol or are they told how and when to take the misoprostol at home? / 1 In the facility
2 At home
3 Other (specify): ______
403 / Do providers give follow-up appointments to MA clients? / 0 No Go to question 405
1 Yes
404 / IF YES, What proportion of MA clients return for their follow-up appointment? / 1 Less than 25%
2 Between 25% and 50%
3 About 50%
4 Between 50% and 75%
5 More than 75%
405 / How is the pain experienced by women who receive MA addressed in your facility? / 1 They are given ibuprofen in the facility
2 They are given paracetamol in the facility
3 They are given diclofenac in the facility
4 They are told to purchase analgesics from their local pharmacy
5 They are given a prescription to purchase analgesics from their local pharmacy
6 MA clients are not given or told about pain medication
7 Other (specify): ______
406 / As a TOP provider, which route of MA administration do you most often recommend to clients? / 1 Sublingual
2 Buccal
3 I don’t recommend a route; I encourage the woman to choose
4 Other (specify): ______
407 / Do you routinely give MA clients the take-home client information sheet on medication abortion? / 0 No
1 Yes
2 I don’t have any information sheets on MA
408 / Can you routinely access misoprostol from medical stores via the DHMT? / 0 No
1 Yes
409 / Has your facility planned for a re-supply of medication abortion drugs? / 0 No
1 Yes
410 / Has your facility ever tried to request Medabon or mifepristone from medical stores or the DHMT? / 0 No
1 Yes
411 / How does your facility’s TOP caseload after the introduction of MA compare to what it was before? / 1 There are fewer TOP procedures per month
2 The number of TOP procedures per month is the same
3 There are more TOP procedures per month
412 / Why do you think this is the case?
413 / Has the organization of TOP services changed in your facility since the introduction of MA services? / 0 No Go to question 415
1 Yes
414 / IF YES, How?
415 / Has this facility publicized or disseminated any information on the introduction of MA services in the community? / 0 No
1 Yes
416 / Can you please describe the methods used to disseminate information in the community?
417 / What are the most common questions women ask about MA?
418 / Do you think there are any misunderstandings about medication abortion that are prevalent in this community? / 0 No
1 Yes
419 / IF YES, What are they?
Section 5. Post-TOP Contraception
501 / Do you provide family planning on site to TOP clients before they leave the facility? / 0 No Go to question 503
1 Yes
502 / IF YES, What methods are available on site?
Circle all that apply / 1 IUDs
2 Injectables
3 Pills
4 Male Condoms
5 Female Condoms
6 Other (specify): ______
503 / Do you provide family planning in the TOP room to TOP clients before they leave the facility? / 0 No Go to question 505
1 Yes
504 / IF YES, What methods are available in the TOP room?
Circle all that apply / 1 IUDs
2 Injectables
3 Pills
4 Male Condoms
5 Female Condoms
6 Other (specify): ______
505 / Does your facility provide any of the following methods?
(Circle all that apply) / 1 IUD insertion/removal
2 BTL
3 Vasectomy
4 Implants
Thank you very much for your time. Do you have any questions?
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