The 10th International Conference on MCH Handbook Effect of a maternal and child health handbook on maternal knowledge and behavior a community-based controlled trial in rural Cambodia Satoko Yanagisawa Aichi Prefectural University)
Basic Indicators of Cambodia Indicators 2001 2015 Population 13,441,000 15,578,000 GNI per capita (USD) 270 1,020 Life expectancy at birth 56 69 Total adult literacy rate (%) 68 74 Infant mortality rate (per 1000) 97 25 Under five mortality rate (per 1000) 138 29 Underweight (moderate-severe) (%) 45 24 Maternal mortality rate (per 100,000) 440 161 Skilled attendant at birth (%) 32 89 UNICEF. The State of The World s Children 2002 & 2016.
Why MCH handbook? Perinatal period is the time when the most mothers and children die. Yet, perinatal period is the time when the least information available. Antenatal care 4+ Skilled attendant at birth Home delivery Urban 85.3% Rural 73.9% Urban 97.8% Rural 87.6% Urban 5.9% Rural 18.7% Cambodia Demographic and Health Survey 2014.
Why MCH handbook? Each sector develops its own recording system resulting in various kinds of records mothers have to manage. The lack of record integration makes a information gap among services. MCH Handbook bridges the gap.
Objectives 1. Develop Cambodian version of MCH handbook. 2. Conduct pilot implementation in selected areas. 3. Evaluate the impact of the MCH handbook on maternal knowledge and behavior.
Study Site: Kampong Cham Province Ponhea-Krek-Dombae (PKD) Population: 205 000 Referral hospital: 1 Health Centers: 16 Memut Population: 134 000 Referral hospital: 1 Health Centers: 10
Development of MCH Handbook Develop MCH Handbook and operating system Test the cultural appropriateness Revise the handbook Indicators for evaluation Study site selection Introduction of the handbook 4 health centers Intervention 2 MCH handbook Control 2 Child Growth Card Mother Health Record Baseline survey Implementation Post intervention survey
Development of Cambodian MCH Handbook First version Second version Final version Concept construction Khmer test version Revised version for intervention Test cultural appropriateness Interviews & FGDs Mothers(Khmer, Cham) Nurses & midwives
Study Design Mixed method: quantitative + qualitative Quantitative study Pre- and post-intervention surveys Women given birth 1 year before the surveys Two-stage cluster sampling Intervention pre 320 post 320 Control pre 320 post 320 Key Indicators Antenatal care (ANC) attendance Delivery with skilled birth attendants (SBA) Delivery at a health facility
Study Design Qualitative study Individual interviews Multiparous who had used both the MCH handbook & standard Child Growth Card/ Mother Health Record Health center nurses & midwives Village Health Volunteers (VHVs) & Traditional Birth Attendants (TBAs) 20 8 10
Frequency of ANC At least once 4 times or more (%) 100 90 80 70 60 50 40 30 20 10 0 Intervention Control (%) 50 40 30 20 10 0 * Intervention Control Pre Post Pre Post
Delivery with SBA (%) 90 80 70 60 50 40 30 20 10 0 ** Intervention Pre Post Control
Delivery at Health Facilities 80 70 60 50 ** ** (%) 40 30 20 10 0 Intervention Pre Post Control
Maternal knowledge: Danger signs Knowledge items Danger signs during pregnancy Pre-post increase (%) Intervention(I) Control(C) Effect (I-C) Swelling 31.5 19.1 12.4 Persistent vomiting 20.6 2.5 18.1 Bleeding from vagina 40.3 20.6 19.7 Premature rapture of membrane 16.6 5.3 11.3 Danger signs during delivery Prolonged labor 20.9 15.0 5.9 Severe bleeding after birth 3.4 8.5-5.1 Malpresentation 7.2 0.7 6.5 Placenta accreta 3.8 3.2 0.6 Convulsion 3.5-0.3 3.8
Maternal knowledge: Prevention and childrearing Behavior items Pre-post increase (%) Intervention(I) Control(C) Effect (I-C) Know at least one method to prevent anemia 23.7 17.5 6.2 Know at least one mode of transmission of intestinal parasites 27.8 17.9 9.9 Know that HIV can be transmitted from mother to child 18.4 10.9 7.5 Early breastfeeding 16.2 10.0 6.2
Advantages of the MCH handbook Mothers Health Staff Attractive appearance More health information with illustrations/pictures Illustrations/pictures convey messages to the illiterate Ease of storage/use because the records are combined Fewer chances of losing the handbook Durable Inclination to read the handbook/interest in the handbook Communication tool with husband Easy estimation of the expected date More frequent bringing of the handbook to ANC clinics Fewer instances of reissuing of the handbook Easy handling because the records are combines The handbook and health education by health staff had a combined effect Disadvantages of the MCH handbook Health staff Columns of the antenatal growth chart are too small More time required to fill the handbook The material of the cover page is difficult to write on Some contents are new, and health volunteers do not as yet understand them well. Some information is not updated
Advantages of MCH handbook to child growth card/mother health record MCH handbook positively influenced the promotion of ANC attendance, delivery with SBA and delivery at health facility. The MCH handbook was associated with increased health care knowledge in mothers. The qualitative data indicated that the handbook was well received and culturally appropriate. The handbook also served to facilitate communication between husbands and wives in terms of maternal health and family planning.
Conclusion Both the quantitative and qualitative analysis showed positive impact of the MCH handbook on maternal knowledge and behavior. Twenty years have passed since the first home-based maternal record was introduced. Policy makers should consider more effective alternatives. The MCH handbook is a reasonable and superior alternative to current card-type maternal and child records.
Memorial to Mr. Hang Vuthy