Hawassa University

College of Agriculture
School of Nutrition, Food Science and Technology
Department of Applied Human Nutrition
Checklist and Questionnaire for data collection on Low Birth Weight and Associated
Factors among New-Born Babies at Sawula General Hospital and Sawula Health
Center: A Case-Control Study.

Questionnaire
This questionnaire is prepared for the collection of socio demographic, obstetric, nutritional, and other
information that are important for the assessment of associated factors for low birth weight among new
borne at Sawla General Hospital and Health centre in Sawla Town, Gofa Zone. All this information will be
retrieved from the delivery mothers, ANC registration book and birth card without mentioning the name of
the clients from March 1 to 30, 2023. This information will be collected by health care providers possibly
working in the delivery room of the selected hospitals.

Interviewer’s Name: ______________________ Code: _____ Signature: ___________

Supervisor’s Name: _______________________ Code: _____ Signature: ____________

Date: _________________

Note the Exclusion criteria from clinical records:

Twins or multiple birth 1: YES 2: NO
have any congenital anomalies and still birth 1: YES 2: NO
Is the child birth weight greater than 4kg 1: YES 2: NO

If ―Yes to any of the exclusion criteria, stop the collection of data.

Name of the Hospital 1. Sawula General Hospital
2. Sawula Health Center
Status 1. Case 2. Control
Section I. Measurement
No Coding categories Questions and filter Skip Code
01 Neonatal birth weight in grams? In kg:_______
02 Sex of the newborn? Male ____1
Female ___2
03 Gestational age (GA) _______weeks
04 Height of the mother Height in cm____
05 MUAC ( Take left hand if right handed, and By cm……
right hand if left- handed)
06 Maternal BMI (Kg/m2) (Kg/m2)________
Section II. Socio Demographic Characteristics of Mother
07 Age at your last birth day? Age in completed years:_______
08 Religion 1.Orthodox 2 Muslim
3 Protestant 4 Catholic 5. Other ……

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09 Ethnicity 1. Gofa 2. Amhara 3. Oromo 4. Gurage
3. Tigre 6. Other
10 Marital status 1. Married 2. Separated 3. single
4. widowed
11 Maternal education 1. Illiterate 2. Primary (1–8) 3.Secondary 4.
Higher
12 Maternal occupation 1 House wife 2. Merchant
3 Gov’t Employee 4. Private 5. Other………
13 Household Monthly Income _____ Birr/ month
Section III. Obstetric History
14 Total number of pregnancy Number:______
15 Total number of births? Number of gravida______
16 Birth-to-birth interval by month Number of months:______
17 Have you ever had an abortion? 1. Yes
2. No
18 How many abortions did you have? Number of abortions:___
Section IV. Current Pregnancy History
If the mother had ANC follow-up, fill the required data by asking the mother and from the ANC
card when available
19 How did you give birth? Vaginal delivery----------1
That is mode of delivery. Assisted delivery--------2
Cesarean section----------3
20 Have you ever weighed prior your pregnancy 1. Yes
(recent one) or Prior 12 gestational weeks of 2. No
your current pregnancy 3. Do not remember
21 If yes what was your weight in kg? Weight of the mothers:___
Do not remember ---------
22 Have you ever weighed prior your pregnancy 1. Yes
(recent one) or Prior 12 gestational weeks of your 2. No
current pregnancy 3. Do not remember
23 What was your weight in the last Weight Weight of the mothers:___
measurement taken? Do not remember --------
24 Have you visited health facility for 1. Yes
ANC for current pregnancy? 2. No
25 At what months of the current 1. At ________ months
pregnancy you started ANC? 2. Don't know/not sure
26 How many times did you receive antenatal care
during your current pregnancy? Number of visits: _________
27. As part of your antenatal care during this Service Yes No
pregnancy, were any of the following done at least Weight 1 2
once? BP 1 2
 Was your weight measured? Urine 1 2
 Was Your BP measured Blood 1 2
 Did you give a urine sample
 Did you give a blood sample
28 During (any of) your antenatal care visit(s), 1. Yes
were you told about the Signs of pregnancy 2. No
complications? 3. Do not remember

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29 Which signs of pregnancy Service Yes No
Complications were you told about? Vaginal bleeding 1 2
Vaginal gush of Fluid 1 2
Severe headache 1 2
Blurred vision 1 2
Fever 1 2
Abdominal pain 1 2
30 During this pregnancy, were you given or did 1. Yes
you buy any iron tablets? 2. No 3. Do not remember
31 During the whole pregnancy, for how many
days did you take the tablets? No of Days:_____
32 Have you ever been told that you have chronic 1. Yes
hypertension? 2. No
33 During this pregnancy, have you 1. Yes
been told that you have developed 2. No
Pregnancy induced hypertension?
34 During your current pregnancy, have you been told 1. Yes
that you have anemia? 2. No
35 What was her hemoglobin level on her current
pregnancy, if available? --------g/dl
36 Have you ever been told that you have Diabetes 1. Yes
Mellitus? 2. No
37 During this pregnancy, did you have any history of 1. Yes
vaginal bleeding prior to the onset of labor or 2. No
delivery?
Section V. Maternal nutritional status
38 Have you get nutritional counseling during 1. Yes
current pregnancy 2. No
39 Were you taking additional meals during current 1. Yes
pregnancy 2. No
40 How many additional meals on average do you
take in a day during current pregnancy? Number of additional meals per day ________
41 At what time do you take the additional meals? 1. Day time 2. Night time 3. Both day & night
42 During your pregnancy, did you take drinks 1. Yes
containing alcohol? 2. No
43 If 42 yes, How often were you taking alcohol 1. Daily
drinks? 2. 3 times per week
3. 1 times per week
4. Once a month
44 During your current pregnancy, did you ever 1. Yes
chew khat? 2. No
45 If 44 yes, How often were you chewing 1. Daily 2. 3 times per week
khat? 3. 1 times per week 4. Once a month
46 During your current pregnancy, did you ever 1. Yes
Smoke? 2. No
47 If 46 yes, how often were you smoking? 1. Daily
2. 3 times per wk
3. 1 times per wk
4. Once a month

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