CHECKLIST – QUESTIONNAIRE FOR THE STUDY ON COMPLIANCE TO

PRENATAL CARE AMONG MOTHERS IN BARANGAY SABONG AND BAAS

LAMITAN CITY, BASILAN PROVINCE

Direction: Kindly fill-out the spaces below of the needed information and check the line
of your preference according to the questions asked. Please answer the questions with
utmost honesty.

PART I. Demographic Profile

Complete name (optional): _______________________

Birth date: _______________________
Address: _______________________
Contact Number: _______________________

Age: ___ 15- 20 ____ 21-25 ____ 26-30 ____ 31-35

___ 36-40 ____ 41-45 ____ 45 above

Civil Status: ___ Married ___ Single

___ Separated

Educational Attainment:
___ College graduate
___ High School Graduate
___ Elementary Graduate
___ Others
___ College level
___ High School level
___ Elementary level

Religion:
___ Islam ___ Roman Catholic
___ Protestant ___ Others

Ethnicity:
___ Yakan ___ Tausug
___ Samal ___ Bisayan
___ Zamboangeňo ___ Others

Proximity of house from the Health Center:

____<50m ____ 500-750m
____ 50-250m ____ 750-1000m
____ 250-500m ____ >1000m
 Socio-Economic Status: (Monthly Income)
___ <5000 ___ 5,000-10,000
___10,000-15,000 ___ 15,000-20,000
___ >20,000

Obstetric History: 1. Gravida (Number of Pregnancies)

___1-2 ___3-4 ___5-6 ___7 or more
2. Parity (Number of Deliveries)
___1-2 ___3-4 ___5-6 ___7 or more
3. Abortion
___1-2 ___3-4 ___5-6 ___7 or more
4. Living (alive)
___1-2 ___3-4 ___5-6 ___7 or more

Part II: Awareness on Prenatal Visit and Prenatal Care Services.

Direction: Read each statement carefully and please check the following responses
that best represents your answer about each statement. Please answer the questions
with utmost honesty.

QUESTIONS YES NO
AWARENESS ON PRENATAL VISIT AND SERVICES
1. Do you know that prenatal visit is important for all pregnant
mothers?
2. Do you know that prenatal care services are available at the
nearby health care facility?
3. Do you know that prenatal visit provides health services which will
assess the mother’s well being as well as of the baby?
4. Do you know that tetanus toxoid, vitamin and mineral supplements
are available at the health care facility?
5. Do you know the prenatal visit schedule at the nearby health care
facility?
6. Do you know that a pregnant mother must have a minimum of 4
prenatal visits?
7. Do you know that prenatal visit helps identify pregnancy-related
problems?
8. Do you know that prenatal visit helps you prepare for labor and
delivery
9. Do you know that having no prenatal visit may increase health
risks during pregnancy both on mother and the baby?
10. Do you know that prenatal visit gives you an opportunity to ask
about pregnancy-related complications and motherhood?
Part III: Compliance on Prenatal Visit and Prenatal Care Services.
Direction: Read each statement carefully and please check the following responses
that best represents your answer about each statement. Please answer the questions
with utmost honesty.

QUESTIONS YES NO
COMPLIANCE ON PRENATAL VISITS
1. When found pregnant, did you go to any of these nearby
healthcare facilities for prenatal check up as soon as possible?
a. Hospital
b. Health Center
c. Private Clinic
d. Others: ___________
2. Have you visited for prenatal checkup once a month during the first
trimester (1-3 months) of pregnancy?
3. Have you visited for prenatal checkup once a month during the
second trimester (4-6 moths) of pregnancy?
4. Have you visited for prenatal checkup once every two weeks during
the seventh (7th) to eighth (8th) month of pregnancy?
5. Have you visited for prenatal checkup every week during the ninth
(9th) month pregnancy?
6. Was the importance of prenatal checkup explained to you clearly?
7. Did you completely understand the importance of receiving
prenatal care?
COMPLIANCE ON PRENATAL CARE SERVICES
8. Have you received iron supplement from the health care facility?
9. Have you taken iron supplement everyday or as instructed by the
health care personnel?
10. Have you received folic acid supplement from the health care
facility?

11. Have you taken folic acid supplement everyday or as instructed by

the health care personnel?
12. Has there been a day you intentionally missed a dose of your
supplements?
13. Was the importance of taking these supplements explained to you
clearly?
14. Have you completely understood why these supplements are
important during pregnancy?
15. Have you received the first shot of tetanus toxoid during your first
pregnancy?
16. Did you come back to the health care facility for the second shot of
tetanus toxoid after one (1) month from the first shot?
17. Did you feel some discomfort when injected with tetanus toxoid?
18. Was the importance of receiving a shot of tetanus toxoid explained
 to you before it was injected?
19. Have you completely understood the importance of tetanus toxoid
vaccine?
20. After receiving the first shot, do you fear of receiving again another
shot of tetanus toxoid?

Part IV: Factors that motivate and hinder compliance to prenatal care services
and prenatal visits.
Direction: Read each statement carefully and please check the following responses
that best represents your feelings about each statement. Please answer the questions
with utmost honesty.

QUESTIONS YES NO
FACTORS THAT MOTIVATE COMPLIANCE
1. I go for prenatal check up because it helps prevent pregnancy-
related complications.
2. I go for prenatal check up because I received supplements that
keep me healthy.
3. I go for prenatal check up because everyone at the health center
helps me overcome physiological and psychological changes
during pregnancy.
4. I go for prenatal check up because it helps to keep my baby
healthy.
5. I go for prenatal checkup because it prepares me for labor and
delivery.
FACTORS THAT HINDER COMPLIANCE
6. I don’t go for prenatal checkup because of financial insufficiency.
7. I don’t go for prenatal checkup because I fear the pain caused by
injection.
8. I don’t go for prenatal checkup because it is too far from our house.
9. I don’t go for prenatal checkup because the health care personnel
are unapproachable.
10. I don’t go for prenatal checkup because I’m too busy doing
household chores.
11. I don’t go for prenatal checkup because it is against our cultural
beliefs and practices.
12. I don’t go for prenatal checkup because I fear neighbors will know
that I am pregnant.
13. I don’t’ go for prenatal checkup because of safety and security
reasons.
14. I don’t go for prenatal checkup because I don’t feel it is important.
15. I don’t go for prenatal checkup because of inadequacy of
transportation.