A Mobile Health Intervention to Increase Uptake of Prenatal Care in Syrian Refugee Population in Turkey
Phase: NA
Conditions: Prenatal Care, Pregnancy
Sponsor: HERA Inc

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A MOBILE HEALTH INTERVENTION TO 
INCREASE UPTAKE OF PRENATAL CARE IN 
SYRIAN REFUGEE POPULATION IN TURKEY 
Study Protocol and Statistical Analysis Plan (SAP) 
Protocol Identification Number: HeraInc 
Clinicaltrials.gov identifier: XXXXXXXX 
09/02/2021 

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STATISTICAL ANALYSIS PLAN (SAP) 
  
A MOBILE HEALTH INTERVENTION TO INCREASE UPTAKE OF 
PRENATAL CARE IN SYRIAN REFUGEE POPULATION IN TURKEY 
  
  
Principal Investigator   
 
Yesim Yasin, MD, PhD  
Assistant Professor of Public Health  
Acibadem Mehmet Ali Aydinlar University  
School of Medicine 
Department of Medical Sciences  
Istanbul, Turkey  
  
Protocol Identification Number          HeraInc 
Clinicaltrials.gov Identifier                XXXXXX 
  
Author                                                 Aral Surmeli, MD, MA       
Public Health                                                       
                                                            Harvard T. H. Chan School of Public Health 
 
 
 
 
 
Massachusetts, USA 
                                                            
  
Senior Statistician                              David Hoeflin, PhD 
SAP Version and date                         0.1 (08/31/2021)          
SAP Reviewers                                   Enju Liu, PhD 
  
  
  
  
  

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1.     Signature page  
  
Principal Investigator  
  
_____________________________ 
  
Senior Statistician 
  
_____________________________ 
  
  
Author 
_____________________________ 
  
  
   
  
  
  
  
  
  
  
  
  
  
  
  
 
 
  

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2.     Abbreviations 
  
  
WHO              World Health Organization  
MoH               Ministry of Health  
HERA            Health Recording Application 
 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
 
 
  
  

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 3.     Table of contents 
1.     Signature page ………………………………………………………………………….. 2 
2.     Abbreviations ………………………..……..…………………………………..………. 3 
3.     Table of contents ………………………………………………………………….……. 4 
4.     Modification history ……………………………………………………………………. 5 
5.     Introduction ……………………………………………………………………….……. 5 
5.1.  Background and Rationale of the Study ………………………………….……….. 5 
5.2.  Objectives ……………..…………………………………………………………... 6 
5.3. Hypotheses …………………………………………………….………………….... 6 
6.     Study methods ……………………………………………………………………….…. 6 
6.1.  Study Type ………………………………………………………………….……... 6 
6.2.  Study Procedure ……………………………………………………………….…... 7 
6.2.1.     Recruitment Strategy ………..……………………………………………. 8 
6.3.  Study Population …………………...……………………………………….…….. 8  
6.3.1.     Eligibility .……………………..….……………………………………… 8 
6.4.  Sample Size Determination ………………………………………………….……. 9  
6.5.  Randomization Strategy ………...……………………………………………...…  9 
7.    Outcomes ……………………………………..……………………..…………….…... 10  
7.1.  Populations and subgroups to be analyzed Per Protocol (PP) ……………………..10 
8.    Analysis.. ……………………………………..……………………..…………….….... 11  
8.1.  Primary Outcome ……………………………………..…………………….……. 11 
8.2.  Secondary Outcomes ……………………………………..…………….…………11 
8.3.  Missing Data ……………………………………………...…………….…………11 
8.4.  Timing of the Final Analysis ……………………………..…………….…………11 
  
  
  
  
 
 
   

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4.     Modification History  
  
Unique 
Identifier for 
SAP Version 
Date of SAP 
Version 
Authors 
Changes From the Previous 
Version 
Draft V0.1 
08/31/2021 
Aral Surmeli 
Not applicable – first version 
  
5.     Introduction  
The purpose of this study is to assess the effectiveness of mobile phone-based appointment 
reminder notifications sent through the HERA app in increasing the uptake of 4 WHO 
recommended prenatal visits among the Syrian refugee population. 
  
The purpose of this Statistical Analysis Plan (SAP) is to document technical and detailed 
specifications for the final analysis of the data collected from protocol XXXXXX.   
  
5. 1.    Background and Rationale of the Study   
According to the UN, The Syrian refugee crisis is the worst humanitarian crisis since World War 
2[1]. Since the start of the Syrian Civil War in 2011, 12 million Syrians have been forcibly displaced 
from their homes. Turkey hosts nearly 4 million of these refugees, which constitutes the largest 
population of refugees in the world.[2] Healthcare services are free in Turkey for the Syrian refugee 
population through national insurance; however, demand-side barriers such as language, not 
knowing where to receive care, and fear of deportation persist. Pregnant Syrian women are 
especially vulnerable to barriers to care. Peer-reviewed studies in Turkish hospitals indicate that 
refugee women are more likely to die during and after labor[3]; additionally, less than 50% of 
pregnant Syrians attend at least four prenatal care visits[4]. 
  
A robust body of research evidence supports the use of mobile phone-based reminder platforms to 
increase timely, complete access to health services. Mobile phone-based reminders have been 
shown in randomized controlled trials and systematic reviews to increase the uptake of various 

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services, including prenatal care.[5][6] A systematic review found that the majority of text message 
reminder interventions improved health outcomes.[7] Mobile phone penetration is high among 
Syrian refugees in Turkey[8] and qualitative studies demonstrate that mobile health interventions 
are acceptable and feasible for Syrian refugees.[9] 
  
5. 2.    Objectives   
The primary objective of this study is to evaluate the impact of mobile phone-based reminders on 
the uptake of prenatal care among pregnant Syrian refugee women. More specifically, the study 
assesses the effectiveness of mobile phone-based reminders by measuring the percent increase in 
the number of prenatal appointments attended by intervention arm participants compared to the 
control arm participants.  
  
  
5. 3.    Hypotheses  
Null hypothesis: Sending reminders on participants’ upcoming appointments 2 weeks before, 1 
day before, and on the day of the appointment will not have any effect on the number of 
appointments that are attended. Thus, the mean number of visits will not vary significantly across 
the 3 arms. 
  
Alternative hypothesis: Sending reminders on participants’ upcoming appointments 2 weeks 
before, 1 day before, and on the day of the appointment will result in a percent increase on the 
number of appointments that are attended by the intervention group compared to the control 
groups.  
  
6.     Study Methods 
6. 1.    Study Type  
This is a behavioral intervention study using an unblinded, parallel groups, randomized 
controlled study design. The intervention group (“Reminder”) will download and use the HERA 
application to receive appointment reminders through push notifications. The control group (“No 
reminder”) will not be using the HERA application, and therefore won’t be provided with any 
reminders. The third group will also be a non-notified control group, i.e., “No reminder” as well. 

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The third group’s data will be collected retrospectively via hospital records.  The intent of the 
3rd arm is to estimate the “true” baseline for the number of visits without any extra attention 
given by the medical staff, in order to prevent inadvertent behavior modification through 
perceived observation bias.  
   
6. 2.    Study Procedure 
Pregnant Syrian refugee women who are in their first trimester of pregnancy will be enrolled in 
the study. Participants will be enrolled from the Obstetrics and Gynecology department of 
refugee health clinics in Istanbul. Participants will be randomized and enrolled into intervention 
or either of the two control arms (refer to section 6.5. Randomization Strategy for details).  
For the intervention arm, participants will be given the consent form. After having consented to 
participate in the study, they will be given the socioeconomic and health history form. In what 
follows, they will receive a 30-minutes brief about the mobile app HERA and will be asked to 
download it. The mobile application will automatically plan out the dates of further prenatal care 
appointments based on the date of the last menstruation. Participants will receive reminders in 
the form of push notifications for prenatal checkup dates for 6 months. Reminders will be sent at 
the following intervals: 1) 2 weeks before, 2) 1 day before and 3) on the day of the recommended 
appointment. After the recommended appointment date, participants will receive push 
notifications asking whether or not they went to the appointment in weekly intervals  for 1 
month. This reminder algorithm will be used for each prenatal checkup for a total of three 
appointments post the baseline visit: once in second trimester and two in third trimester, using 
the World Health Organization and Turkish Ministry of Health prenatal checkup calendar. At the 
end of 6 months of follow up time, participants in the intervention arm will be contacted via 
phone call to ask for any remaining appointments or unanswered notifications. Completeness of 
3 prenatal care appointments post the baseline visit, as recommended by WHO and implemented 
by Turkish MoH will be compared to the control groups. 
  
Participants in the informed control arm will be given the consent form and will be asked for 
their contact information if consented. They will also be given the socioeconomic and health 
history form. Participants in the non-informed control group just will be given the socioeconomic 
and health history form. Both the informed and non-informed control group members will be 

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reached out at the end of the 6-month study period to be asked about the number of prenatal care 
appointments they attended. If unable to be reached, retrospective chart review of the 
participant’s medical record will be attempted, in order to obtain the number of attended prenatal 
care appointments.  
  
6. 2. 1. Recruitment Strategy 
Participants will be enrolled from the obstetrics and gynecology department of refugee health 
clinics in Istanbul, Turkey with the help of a translator (Turkish to Arabic). The enrollment will 
take place with the help of the physician.  
  
6. 3.    Study Population  
The population included in this study are pregnant Syrian refugee women between the ages of 18 
to 49, who are in their first trimester of pregnancy.  
 
6. 3. 1. Eligibility  
Inclusion Criteria: 
- Having the status of “Syrian under temporary protection”  
- Being in the first trimester of the pregnancy  
- Initial prenatal visit 
- Age equal or greater than 18 years and less than or equal to 49 
  
Exclusion Criteria: 
- Having a citizenship or a status other than “Syrian under temporary protection” 
- Not owning a mobile phone  
- Being unable to read and write  
- Not initial prenatal visit 
- Having a chronic disorder or high-risk pregnancy that requires the individual to go to 
the hospital frequently. Frequently is defined as more than 3 visits post the baseline visit. 
- While gestating, those that develop a high-risk pregnancy that requires more than 3 
visits post the baseline visit. 
  

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6. 4.    Sample Size Determination 
The primary outcome measure for the power and size calculation is the difference in the mean 
number of visits among the different arms of the study. We set our target detectable difference in 
means to be 0.5 or more additional visits. As the maximum standard deviation is 1.5 due to the 
restricted range of 0 to 3 visits, our target effect size is 0.5/1.5 = 0.33. Our calculation shows that 
each arm will need at least 40 patients to have a power of 90% and a two tailed significance level 
of 0.05. Due to the nature of refugees, we anticipate a high loss due to follow up and other 
reasons for dropout. Without prior information, we assume a 20% loss rate and therefore inflate 
the number of patients per arm by 25%. Thus, we plan to enroll 54 patients per arm for a total of 
162 individuals. The statistical software G*Power Version 3.1.9.6 available from the UCLA 
Institute for Digital Research & Education Statistical Consulting website; G*Power (ucla.edu), 
was used for the calculations. 
  
6. 5.    Randomization Strategy 
Subjects will be selected on the following basis: randomly select a week and recruit on 6 days of 
that week. On 3 of the days the selection process will start in the morning, denoted as AM, (the 
first part of the day that is expected to see half of the patients) and on the other 3 days the selection 
process will start in the afternoon, denoted as PM, (the second part of the day that is expected to 
see half of the patients.) For each AM/PM session, the first 27 subjects giving approval to be in 
the study will be randomly assigned into one of the 3 arms. It is estimated that 100 to 200 women 
use the hospital daily. Thus, we feel that most likely the daily target intakes will be met. However, 
if not met by the end of the AM/PM shift, the selection process will stop. After day 6 and before 
any data analysis, a check will be done on the sample sizes and additional subjects may be recruited 
by selecting another week to perform additional recruiting.  
  
This sampling plan requires that the number of women coming to see the medical staff be 
approximately the same day to day and AM to PM.   
  
Details of the random assignment to AM/PM and to groups are attached. The assignment of 
treatment and control groups to 0, 1 or 2 will be done prior to the start of subject recruitment but 
will not be shared with the data analyst until after the analysis is complete. 

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7. Outcomes  
  
Primary Outcome: 
The primary outcome of this study is the number of medical visits, following the initial baseline 
PNC visit, over the 6-month period prior to childbirth. 
  
Secondary analyses: 
In the secondary analyses, we will further examine other risk factors, including 
sociodemographic and reproductive medical history, on the number of medical visits during the 
study period.  The following additional data will be gathered: 
1.     Age 
2.     Highest level of education 
3.     Current employment status and profession if employed 
4.     Marital status 
5.     If married, whether the spouse is alive or deceased 
6.     If married, whether the spouse resides with the participant or not 
7.     Number of children 
8.     Ages of children 
9.     Miscarriage history, and the number and the timing of miscarriage, if any 
10.  Number of deceased children, if any  
11.  Number of times the participant gave birth to stillborn baby, if any  
12.  If prior pregnancies, the number of deliveries occurred at home and at a hospital 
13.  Type of delivery (vaginal, C-section) and the number of each type 
14.  Information on prenatal care appointments made during prior pregnancies, and the 
number of appointments attended 
15.  Information on medical conditions that require long-term medication use, if yes, the 
name of the condition and medication 
16.  Duration of time living in Turkey 
  
7.1. Populations and subgroups to be analyzed Per Protocol (PP) 
 

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All randomized study subjects not rejected over the observation period and having complete data 
will be the basis of the analysis. Subjects with missing data will be excluded from the analysis. 
This will be the primary population for the analysis. 
  
8.   Analysis  
 
All outcomes will be presented using descriptive statistics, continuous data by the mean, 
standard deviation and a plot of the pdf. Binary and categorical variables will be presented in 
tables using counts. R version 4.0.5 will be used for all statistical analysis. 
  
8.1. Primary Analysis 
 
The primary analysis will be a standard one-way fixed effect ANOVA comparing the 3 arms. 
The resulting ANOVA results and the arm means with 95% confidence intervals will be 
presented. 
  
8.2. Secondary Analysis 
 
The effects of the sociodemographic and medical history factors on the primary outcome will be 
analyzed using the Poisson regression model. A standard regression results table will be 
presented to indicate which, if any, of these factors are significant influencers. 
  
8.3.   Missing Data  
To reduce the loss-to-follow-up risks: participant phone calls and review of hospital records for 
subjects with missing data will be performed. Currently there are no plans for attempting a 
multiple imputation analysis. 
  
8.4.    Timing of Final Analysis   
Final analysis will be run 6 months after the start of the randomized controlled trial, after having 
contacted participants.  
  
  
 
 

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[1] UN News.  Syria 'Worst Man-Made Disaster Since World War II' – UN Rights Chief. 
https://news.un.org/en/story/2017/03/553252-syria-worst-man-made-disaster-world-war-ii-un-
rights-chief. Accessed 16 September 2020. 
 
[2] Situation Syria Regional Refugee Response. UNHCR operational data website. 
https://data2.unhcr.org/en/situations/syria. Updated April 17, 2020. Accessed May 3, 2020. 
 
[3]Ozel S, Yaman S, Kansu-Celik H, Hancerliogullari N, Balci N, Engin-Ustun Y. Obstetric 
Outcomes among Syrian Refugees: A Comparative Study at a Tertiary Care Maternity Hospital 
in Turkey. Rev Bras Ginecol Obstet. 2018;40(11):673-679. doi:10.1055/s-0038-1673427 
[4]Roberton T, Weiss W; Jordan Health Access Study Team; Lebanon Health Access Study 
Team, Doocy S. Challenges in Estimating Vaccine Coverage in Refugee and Displaced 
Populations: Results From Household Surveys in Jordan and Lebanon. Vaccines (Basel). 
2017;5(3):22. Published 2017 Aug 12. doi:10.3390/vaccines5030022 
 
[5] Cormick G, Kim NA, Rodgers A, et al. Interest of pregnant women in the use of SMS (short 
message service) text messages for the improvement of perinatal and postnatal care. Reprod 
Health. 2012;9:9. Published 2012 Aug 6. doi:10.1186/1742-4755-9-9 
 
[6] Hasvold PE, Wootton R. Use of telephone and SMS reminders to improve attendance at 
hospital appointments: a systematic review. J Telemed Telecare. 2011;17(7):358-364. 
doi:10.1258/jtt.2011.110707 
 
[7] Hall AK, Cole-Lewis H, Bernhardt JM. Mobile text messaging for health: a systematic review 
of reviews. Annu Rev Public Health. 2015;36:393-415. doi:10.1146/annurev-publhealth-031914-
122855 
 
[8] Confidential Data. 
 
[9] Mesmar S, Talhouk R, Akik C, et al. The impact of digital technology on health of 
populations affected by humanitarian crises: Recent innovations and current gaps. J Public 
Health Policy. 2016;37(Suppl 2):167-200. doi:10.1057/s41271-016-0040-1 
  
 
 
 
 
 
 
 

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STUDY PROTOCOL 
  
A MOBILE HEALTH INTERVENTION TO INCREASE UPTAKE OF 
PRENATAL CARE IN SYRIAN REFUGEE POPULATION IN TURKEY 
  
  
Principal Investigator   
 
Yesim Yasin, MD, PhD  
Assistant Professor of Public Health  
Acibadem Mehmet Ali Aydinlar University  
School of Medicine 
Department of Medical Sciences  
Istanbul, Turkey  
  
Protocol Identification Number          HeraInc 
Clinicaltrials.gov Identifier                XXXXXX 
  
Author                                                 Aral Surmeli, MD, MA       
Public Health                                                       
                                                            Harvard T. H. Chan School of Public Health 
 
 
 
 
 
Massachusetts, USA 
                                                            
  
 
 
 
  
  
  
  

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Study Identification 
Unique Protocol ID: HeraInc 
Brief Title: A Mobile Health Intervention to Increase Uptake of 
Prenatal Care in Syrian Refugee Population in Turkey 
Official Title: A Mobile Health Intervention to Increase Uptake of 
Prenatal Care in Syrian Refugee Population in Turkey 
Study Status 
Study Start:  October 1, 2021  
Primary Completion:  October 1, 2022  
Study Completion:  October 1, 2022  
Sponsor/Collaborators 
Sponsor: HERA Inc  
Responsible Party: Sponsor 
Collaborators: Medical Rescue Association (MEDAK), Turkey 
 
Oversight 
Human Subjects Review Board Status: Approved 
Approval Number: 2021-04/04 
Board Name: Acibadem Mehmet Ali Aydınlar University Medical Research 
Institutional Review Board Email: atadek@acibadem.edu.tr Address: 
 
 
Study Description 
 
Brief Summary: The purpose of this study is to assess the effectiveness of mobile 
phone-based appointment reminder notifications sent through the HERA 
app in increasing the uptake of 4 WHO recommended prenatal visits 
among Syrian refugee population. 
 
Detailed Description:  
Background: 12 million Syrians have been forcibly displaced from their 
homes since the start of Syrian Civil War in 2011. Despite Turkey 
providing free healthcare services through national insurance to nearly 4 
million refugees that it hosts, pregnant Syrian women are less likely to 
attend prenatal visits and more likely to die during and after labor. An 

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increase in the uptake of prenatal care may improve quality of life 
through healthy pregnancies and safer labor conditions in this population 
with double vulnerability. 
Mobile phone-based reminders have been shown in randomized 
controlled trials and systematic reviews to increase the uptake of various 
services, including prenatal care. Mobile phone penetration is high 
among Syrian refugees in Turkey and qualitative studies demonstrate that 
mobile health interventions are acceptable and feasible for Syrian 
refugees. 
Primary objective: To evaluate the impact of mobile phone-based 
reminders on the uptake of prenatal care among pregnant Syrian refugee 
women. More specifically, the study assesses the effectiveness of 
mobile phone-based reminders by measuring the percent increase in the 
number of prenatal appointments attended by intervention arm 
participants compared to the control arm participants. 
Study design: This is a behavioral intervention study using an un-blinded, 
parallel group, randomized controlled study design. 
Recruitment strategy: Participants will be enrolled from the obstetrics 
and gynecology department of refugee health clinics in Istanbul, Turkey 
with the help of a translator (Turkish to Arabic). The enrollment will take 
place with the help of the physician.  
Primary Outcome: The primary outcome of this study is the number of medical 
visits, following the initial baseline PNC visit, over the 6-month period prior to 
childbirth. 
Secondary outcomes: Secondary outcomes are based on the Sociodemographic 
and Health History form. The form gathers information about demographics of 
the participants (age, education, employment, marital status, number of children) 
and health history (previous pregnancies, delivery methods, miscarriages, 
stillborn, chronic conditions and medications. We will further examine these risk 
factors on the number of medical visits during the study period. 
 
Conditions 
Conditions: Prenatal Care, Pregnancy 
Keywords: Mobile health, Refugee 
 

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Study Design 
Study Type: Interventional 
Primary Purpose: Health Services Research 
Interventional Study Model: Parallel Assignment 
The intervention group cluster will use the HERA application to receive 
appointment reminders. The Informed and Non-Informed Control groups 
will not be using the HERA application. 
Number of Arms: 3 
Masking: None (Open Label)  
Allocation: Randomized  
Enrollment: 162 [Anticipated] 
Arms and Interventions 
 
Experimental: Reminder 
Participants will fill the sociodemographic and health history form. Participants 
will receive reminders in the form of push notifications for prenatal checkup dates 
automatically generated according to their pregnancy start data or initial check-up 
appointment for 6 months. Reminders will be sent at the following intervals: 1) 2 
weeks before the appointment, 2) 1 day before the appointment, and 3) on the day 
of appointment. After this date, participants will receive push notifications asking 
whether they went to the appointment or not weekly for 1 month. This reminder 
algorithm will be used for each prenatal checkup for a total of four appointments: 
once in first trimester, once in second trimester and two in third trimester, using 
the World Health Organization and Turkish Ministry of Health prenatal checkup 
calendar. At the end of 6 months of follow up period, participants will be 
contacted via phone call to ask for any remaining appointments or unanswered 
notifications. 
 
No Intervention: Informed Control No Reminder 
Participants will fill the sociodemographic and health history form. Their 
contact information will be gathered. Participants will be contacted at the end 
of 6 months and will be asked about the number of the prenatal care 
appointments they have attended during their pregnancy. 
 
No Intervention: Uninformed Control No Reminder 

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Participants will fill the sociodemographic and health history form. No contact 
information will be gathered. The purpose of this arm is to estimate the “true” 
baseline for the number of visits without any extra attention given by the medical 
staff. 
 
Outcome Measures 
Primary Outcome Measure: Rate of attendance for prenatal care visits: 
The number of 4 mandatory prenatal care appointments that are attended are 
presented here. 
 
Secondary Outcome Measure: Sociodemographic and Health information form 
data: Data about sociodemographic and health information of participants will be 
presented here.  
Eligibility 
Minimum Age: 18 Years  
Maximum Age: 49 Years 
Sex: Female  
Gender Based: No 
Accepts Healthy Volunteers: Yes 
Criteria:  
Inclusion Criteria: 
• Having the status of “Syrian under temporary protection” 
• Being in the first trimester of the pregnancy 
• Initial prenatal visit 
• Age equal or greater than 18 years and less than or 
equal to 49  
 
 
Exclusion Criteria: 
• Having a citizenship or a status other than “Syrian under 
temporary protection” 
• Not owning a mobile phone 
• Being unable to read and write 
• Not initial prenatal visit 
• Having a chronic disorder or high-risk pregnancy that requires 
the individual to go to the hospital frequently. Frequently is 
defined as more than 3 visits post the baseline visit. 
• While gestating, those that develop a high-risk pregnancy that 
requires more than 3 visits post the baseline visit. 

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Contacts/Locations 
Central Contact Person: Aral Surmeli, MD 
Telephone: +905353140179 
Email: a.surmeli@medak.org.tr 
Study Officials: Aral Surmeli, MD 
Study Principal Investigator Founder/CEO 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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Sociodemographic and Health History Form (will be filled with the assistance of a translator) 
 
1. Age:  
2. What is your highest level of education? 
a. Undergraduate  
b. High School  
c. Middle School  
d. Elementary school  
e. Can read  
f. Can not read  
3. Do you currently work? If yes, what is your profession?  
………………………………………….. 
 
 
4. Are you married? 
a. Yes 
b. No 
 
5. Is your spouse alive?  
a. Yes 
b. No 
 
6. Does your spouse live with you?  
a. Yes 
b. No  
 
7. How many children do you have? 
a. ………  
b. Doesn’t have any 
 
8. How old are your children? 
Child 1 age: ………  
Child 2 age: ………  
Child 3 age: ………  
Child 4 age: ………  
Child 5 age: ………  
 
If more add here:………………………………………….. 
 
 
9. Have you ever had a miscarriage?  
a. No 
b. Yes, …….. time(s) 
c. If yes, do you remember during which week of your pregnancy? 
………………………………………….. 
 
 

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10. Have you lost any children?  
a. Yes, ……….. time(s) 
b. No 
 
11. Did you ever give birth to a stillborn baby (at or after 28 weeks of gestation)?  
a. Yes, ……… time(s) 
b. No 
 
12. During your previous pregnancies, where did you give birth? (make sure to include all 
children) 
a. At home, ……… time(s) 
b. At a hospital, ……… time(s) 
 
13. What type of delivery did you undergo? (make sure to include all children) 
a. Vaginal birth, ……… time(s) 
b. C-sections, ……… time(s) 
i. If C-section, what was the reason (preference, medical emergency, etc.)? 
 
………………………………………….. 
 
 
14. Have you been to prenatal care appointments during your previous pregnancy? If yes, 
how many appointments have you been to?  
………………………………………….. 
 
 
15. Have you been diagnosed with a medical condition (diabetes, hypertension, asthma, 
etc.) that requires long-term medication use?  
a. No 
b. Yes, please specify ……………… 
i. If yes, what’s the name of the medication? 
……………………………………… 
 
16. For how long have you been living in Turkey?  
……………………