Antenatal Care Uptake Survey Form
Please complete this brief survey about your experiences with antenatal care. Your responses are confidential and will help improve services.
What is your age group?
*
Please Select
Under 18
18-24
25-34
35-44
45 and above
Have you attended any antenatal care visits during your most recent pregnancy?
*
Yes
No
How many antenatal care visits did you attend?
*
Please Select
None
1-2 visits
3-4 visits
5 or more visits
When did you attend your first antenatal care visit?
*
First trimester (0-12 weeks)
Second trimester (13-27 weeks)
Third trimester (28 weeks or later)
Did not attend
Please indicate your level of agreement with the following statements about antenatal care services.
*
Rows
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
The facility was easy to access.
1
2
3
4
5
Staff were respectful and supportive.
6
7
8
9
10
I received enough information about my health.
11
12
13
14
15
Appointments were scheduled at convenient times.
16
17
18
19
20
How satisfied were you with the antenatal care services you received?
*
1
2
3
4
5
What were the main barriers, if any, to attending antenatal care? (Select all that apply)
Cost
Distance to facility
Lack of information
Family or work commitments
No barriers
Other
If you would like to share any additional comments about your experience with antenatal care, please write them below.
Submit Survey
Should be Empty: