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Questionnaire template

Maternal Health Services Evaluation

Evaluates the quality, affordability, access and satisfaction of a facility's antenatal, birth and postnatal care over the past year.

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Questions in this template

Service Quality

  1. We are working to improve care for mothers and babies at our facility. Please tell us about your experience with our services.

  2. In the past 12 months, have you used any of our maternal health services?

    Choose one:

    • Yes
    • No

  3. How would you rate the quality of each service?

    Condition: Shown to respondents who used the services

    • Care during pregnancy (antenatal)
    • Care after the birth (postnatal)
    • Care during labour and birth

    For each row: choose one:

    • Very poor
    • Poor
    • Neither poor nor good
    • Good
    • Very good
    • Did not use

Access and Cost

  1. Which of these services were affordable for you?

    Condition: Shown to respondents who used the services

    Choose any that apply:

    • Antenatal care
    • Postnatal care
    • Labour and birth care
    • None of these

  2. Was each service easy to get at our facility?

    Condition: Shown to respondents who used the services

    • Antenatal care
    • Postnatal care
    • Labour and birth care

    For each row: choose one:

    • Yes
    • Not sure
    • No

Satisfaction and Suggestions

  1. On a scale from 1 to 10, how satisfied are you with each service?

    Condition: Shown to respondents who used the services

    • Antenatal care
    • Postnatal care
    • Labour and birth care

    For each row: choose one:

    • 1 - Not at all satisfied
    • 2
    • 3
    • 4
    • 5
    • 6
    • 7
    • 8
    • 9
    • 10 - Very satisfied

  2. What could we do to improve our maternal health services?

    Open answer