1.  Introduction

 Improving maternal and child health has been highlighted as a key public health concern since the year 2000, with the development of the Millennium Development Goals (MDGs). Compared to the other six MDGs, goal 4 for children’s health and goal 5 for women’s health continue to lag behind. To facilitate progress toward achieving these two goals, the global health community now pays special attention to Maternal, Neonates, and Child Health (MNCH) [1-5]. Larger and more effective interventions and investment in MNCH are necessary to achieve these health-related MDGs [6]. Providing quality care during pregnancy and child delivery remain a major challenge [7]. To fill these gaps, both demand- and supply-side interventions are necessary [8].  In this context, several countries adopted the Maternal and Child Health Handbook (the MCH Handbook) as a tool to promote better knowledge and service-seeking behavior among women [9].

 The World Health Organization (WHO) has recommended the use of home-based records as a viable tool for ensuring the continuity of care for mothers and children before and after pregnancy [10]. Specifically, the WHO has identified some key recording tools such child health records, child immunization cards and counseling cards for childcare [10]. The MCH Handbook is a home-based health record for both the mother and child. It records the health condition of the mother throughout pregnancy, delivery, and the postnatal period, as well as the condition of the child before, at, and after birth, including immunization records and growth monitoring. It also contains health education information related to MNCH. The MCH Handbook can be used to monitor the health of a woman and her child, keep record of the utilization of health services, promote health education, and provide information when either mother or child is referred. The MCH Handbook may empower women by facilitating greater participation in their own medical care [11].

The objective of this review was to examine the effect of MCH Handbooks on the promotion of maternal and child health in developing countries.

 2.  Methods

 2.1  Summary of Methods

 A systematic literature review and meta-analysis was carried out to examine the effect of the MCH Handbook on maternal and child health care. The focus was on different variables related to maternal health and child health such as changes in mothers’ knowledge, practice and attitude. This review was conducted using the methods outlined in the Cochrane Handbook for Systematic Reviews of Interventions [12] and is reported according to the PRISMA Checklist.

 2.2  Literature Search

 A literature search was carried out for articles published in Medline, Pub Med, the Cochrane Library and Google Scholar. The literature search included the following search terms and keywords: “MCH Handbook” OR “Maternal and child health handbook” OR "Home-based record" OR "Paper-based record" OR "personal health record" OR "Child health record/book" OR "maternal health record/book" OR "Maternal and child health record/book" OR "Vaccination record/card". The search term contained both controlled word and free text.

In addition, references were manually identified from the reference lists of key papers found during the searches and a few studies were manually identified as published online but not yet listed in literature databases. The search was not restricted to studies published in English - although only those with translations to English were included. In order to be included, studies had to identify and measure effects of MCH Handbook on maternal and child health. The included analyses primarily used a meta-analysis of different variables related to maternal and child health in pre and post MCH Handbook situations. Narrative results were also presented if relevant in a separate table. Full papers were obtained and formally assessed for all studies that appeared to be potentially relevant. In addition, available abstracts related to effectiveness of MCH Handbook were also considered if relevant and sufficient for presentations in this review, acknowledging the limitation of this inclusion.

 Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid MEDLINE(R) (1946 to April 16 2017), Embassy (1974 to April 16 2017) were systematically searched and also were searched in Google Scholar, Cochrane data base and were reviewed the 350 hits for potentially eligible studies (see PRISMA). Moreover, 10 articles were identified from additional sources.

 2.3  Selection of studies

 All identified articles were merged into a common file, and duplicates were deleted. Results were divided among two reviewers who independently examined the assigned articles and classified each as “Exclude”, “Include”, or “Unsure.” A third reviewer settled discrepancies.  Initial screening began with a title screen. Articles needed to include the words “MCH Handbook”, “Maternal and Child Health Care”. Next, abstracts were retrieved and screened to determine eligibility. Finally, full-text articles were retrieved and screened for inclusion.

 2.4  Eligibility Criteria

 2.4.1 Inclusion criteria

 For title and abstract screening process, first we looked for existing Systematic Reviews (SR) on the MCH Handbook and its effectiveness Inclusion criteria for Title and Abstract Screening

Study type:  We excluded reviews that were clearly narrative reviews or overviews of a topic that do not include reporting and synthesis of results of trials. We included relevant conference abstracts (and checked for follow-up publications), as far as they described to be a SR or original studies.  We were looking for any primary study identified to conduct this systematic review.

Population: Studies including mothers using MCH Handbook and not using MCH Handbook (control). 

Intervention and comparison related: Intervention and comparison were mothers using the MCH Handbook and mothers not using the MCH Handbook. Interventions that were not relevant were excluded at the full-text screening stage.

Reported information (outcomes): The articles reporting maternal and child health-related variables in relation to MCH Handbook’s effect were included. Variables included knowledge of mother on antenatal care visits, danger signs, breast feeding, and vaccination.  Practice-related variables were practice of antenatal care visits/continue of care, birth weight measured within 48hrs, delivery at health facility, trained attendant at birth, mother’s tetanus taxied, breast feeding, child vaccination, vitamin A and iron supplementation.  Finally, attitude-related variables included positive changes in attitude on pregnancy care, support of health staff during pregnancy, child care, and the role of their husband during the pregnancy period.

2.4.2 Exclusion criteria

Non-original studies, structured abstracts, project records, letters/commentary, case reports, and case series were excluded.

Duplicates: When we came across duplicate citations, moved into the specific folder.

2.5  Full text screening

The first step was title and abstract screening to identify studies appearing to meet the inclusion criteria, potentially relevant, or with sufficient information to make a clear judgment to be included. The second step was screening those studies after retrieving the full texts.

2.6  Data extraction and management

The included full text articles were randomly shuffled using Endnote X6 and then the articles were assigned to each reviewer for data extraction. A third reviewer handled dissension. Studies meeting the inclusion criteria were included for data extraction. A standardized data extraction form was developed, which was pilot tested on two full-text articles. Each team member independently reviewed the full-text article and the following details were Extracted: basic characteristics including first author, publication year; study population (type of population either mother using MCH Handbook or not, age), setting, country, interventions, outcomes (knowledge, practice and attitude related to maternal and child health/care), and additional comments (if any).

2.7 Data Analysis (Quantitative and Narrative synthesis)

Two investigators independently collected data for patient characteristics, diagnosis, treatments, setting, follow-up, and outcomes using a pretested data abstraction form. The quality/risk of bias was assessed for each outcome from the studies using the Cochrane risk of bias tool for RCTs [13]. Data were analyzed by using RevMan 5.2 (The Nordic Cochrane Center, Copenhagen, Denmark). Relative risks (e.g. Risk Ratios [RRs]) were calculated by pooling results from RCTs and non-RCTs comparing MCH Handbook and not MCH Handbook. Also, a narrative summary of the included studies with narrative findings were presented in a Table 1 with all other study characteristics such as basic study information characteristics- first author, publication year; study population (type of population either mother using MCH Handbook or not, age), setting, country, interventions, findings as a result of MCH Handbook utilization and additional comments (if any).

2.8  Assessment of methodological quality of included studies

Two investigators evaluated the certainty of the evidence for each outcome using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach, and resolved any discrepancies [13]. The following GRADE domains were assessed: risk of bias, inconsistency, imprecision, indirectness, publication bias, magnitude of effect, and opposing plausible confounding [13].

3.   Results

3.1  Search results

Among 359 non-duplicate records identified from the electronic database search and from other sources, 30 articles in full text were retrieved after title and abstract screening (Figure 1). After exclusion of articles that were not relevant, 14studies were included. Seven articles were found for the quantitative analysis, and seven articles were found for the narrative summary.  Only one article was an RCT and the rest were nonrandomized studies comparing effect of MCH Handbooks to non- MCH Handbooks or pre and post-MCH Handbook situations. Figure -1

3.2  Comparisons of effect of MCH Handbook and Non-MCH Handbook

Only one RCT and six non-RCTs were identified for comparing the effect of MCH Handbook and non-MCH Handbook. These seven studies compared the effects of MCH Handbook and non-MCH Handbook on maternal knowledge, practice and attitude on MCH health care. [14-20]. when direct comparisons within studies were available, relative risks and risk differences were calculated (Figures 2-4) and also variables measured related to knowledge, practice and attitude were shown in the same figures. When comparing women’s knowledge of antenatal care visits between non-MCH Handbook and MCH handbook scenarios, the RR was 0.81 (95%CI 0.78-0.84).

Similarly, when comparing non-MCH Handbook Users to MCH handbook users, MCH handbook users had lower knowledge of a range of topics including danger signs (RR 0.51; 95% confidence interval [CI] 0.45-0.59),  breast feeding (RR 0.73; 95% CI 0.69-0.78), and vaccination (RR 0.18; 95% CI 0.11-0.28). In situations where the MCH Handbook was not used, practice-related events were less likely to occur such as practice of antenatal care visits/continue of care (RR 0.76; 95% CI 0.67-0.87), birth weight measured within 48hrs (RR 0.81; 95% CI 0.79-0.82), delivery at health facility (RR 0.82; 95% CI 0.62-1.08), trained attendant at birth (RR 0.85; 95% CI 0.78-0.93), mother’s tetanus taxied(RR 0.47; 95% CI 0.42-0.53), breast feeding (RR 0.24; 95% CI 0.03-1.68),  child vaccination (RR 0.37; 95% CI 0.25-0.57), vitamin A and iron supplementation (RR 0.08; 95% CI 0.03-0.20). 

Finally, studies examined the impact of the MCH handbook use compared to situations where the MCH Handbook was not used on attitude-related variables.  It was found that non-MCH Handbook users were less likely to experience positive attitude-related variables such as positive changes in attitude on pregnancy care (RR 0.33; 95% CI 0.14-0.81), support of health staff during pregnancy (RR 0.58; 95% CI 0.32-1.05), child care (RR 0.43; 95% CI

0.21-0.90), and the role of their husband during the pregnancy period (RR 0.89; 95% CI 0.38-0.2.08) Detailed results are shown in Figures 2-4. The study characteristics of all these seven studies are also presented in (Table 1).

Eleven studies examined narrative findings on the same issues. [9,21-27] The available data suggested that there is positive effect of MCH Handbook on maternal and child health the quality of the evidence for almost all outcomes was low because there was only one RCT (with small sample size). The rest of the studies were non-randomized studies that compared the non-MCH Handbook with MCH Handbook and had low quality because of imprecise results due to few events and participants in the studies (Figure -2-4).

4.   Discussion

The present systematic review of the literature was conducted to inform decision making about effect of the MCH Handbook on maternal and child care.  Unfortunately, although not unexpectedly, only one RCT was found that compared MCH Handbook and its effect on maternal and child care and measured only one outcome important to decision making. Thus, due to the lack of RCTs and scarcity of outcomes, the search also included nonrandomized studies. Nonetheless, results from this study suggest that users of the MCH Handbook tended to have better outcomes of knowledge, practice, and attitude-related variables compared to non-users of the MCH Handbook. Further, narrative findings highlighted the MCH Handbook as a tool to increase ownership of immunization records, increase use of maternal health services, and increase knowledge related to topics such as exclusive breastfeeding.  Thus, results from the meta-analysis and the narrative summary suggest that the MCH Handbook may have a positive effect on maternal child health and ultimately may be a useful tool to improve maternal and child health care and outcomes.

Similar results were found in a systematic review on the effect of the MCH Handbook.  A systematic review conducted by Baequni and Nakamura (2012) [27] found that mothers who used the MCHHB during pregnancy had higher levels of knowledge (OR 1.44, 95% CI: 1.22 -1.70) than whose did not use MCHHB during pregnancy. However, although the MCH Handbook may be a useful tool, evidence suggests varying uptake and utilization among various populations.   One study found that utilization of the MCH Handbook is still less widespread than expected, especially among clients of private health services in Thailand [28]. A retrospective review by Nakamura (2010) [29] showed that 13,271 of guardians in Japan who visited 18-month health examinations of their children in 1999 used the MCH Handbook. As well, almost all guardians had read and written in their MCH Handbook, which shows that the MCH Handbook was highly utilized in Japan. 

 However, many guardians felt that the MCH Handbook was not so easy to utilize and the articles on dental health were not widely used.  Thus, further research may be needed to examine the appropriateness of content and how the tool can be designed to ensure the tool is user-friendly. The results from this systematic review also align with the conclusions from the Tokyo Declaration, which noted that the MCH Handbook is critical to facilitate reciprocal communication between families and health care providers, and to empower women and their families to take an active role in their health care. 

The MCH handbook may be an effective tool for communication with health providers and husbands, for both highly educated and less-educated women during their first pregnancy. Results suggested that although less-educated women rarely read the handbook themselves at home, they became familiar with health information and options related to MCH through personalized guidance that was provided by health providers at health facilities utilizing MCH handbook [30,31].  Research has also shown that women with lower education have received more of their health information from the MCH Handbook than women of other educational groups, which demonstrates that the MCH Handbook can be a beneficial health education tool even if a mother is not highly educated [29]. Thus, the MCH Handbook can be an effective tool to promote the maternal and child health care, and may offer an alternative tool to existing, fragmented home record tools for educating mothers for better maternal and child health care.

Similarly, Bhuiyan (2009) noted that the MCH handbook provides mothers and families with valuable information that can empower women to participate in their health care and actively engage with primary health care providers.

The present review used a comprehensive and systematic search strategy.  Rigorous procedures were used to screen potential papers, and quality of papers was thoroughly assessed using GRADE criteria. However, there are some notable limitations of this review.  The quality of many of the studies was relatively low due to small sample sizes.   Although restricting the search to only randomized controlled trials could have potentially provided the highest quality of evidence, there was a dearth of RCTs on this topic.  Thus, the present search included nonrandomized controlled trials, which can be heavily influenced by confounders. 

As can be seen in Figures 2-4, many studies were likely heavily influenced by selection bias, performance bias, and detection bias.  Additionally, there was a broad range of variables reported in the studies included in the meta-analysis.  The range of variables reported resulted in difficulty determining heterogeneity. Additional research from other countries where the MCH Handbook has been implemented to further discern the effect of the MCH Handbook in maternal and child health care at a global level, since results from a few selected countries may not be generalizable to all mothers around the world. 

Figure 1: PRISMA.

Figure 2: Comparison between MCH Handbook vs No MCH Handbook: Impact on Knowledge.

Figure 3: Comparison between MCH Handbook vs No MCH Handbook: Impact on Practice.

Figure 4: Comparison between MCH Handbook vs No MCH Handbook: Impact on Attitude. Table 2

Table 1: Study characteristics of included studies for meta-analysis

Table 2: Narrative summary of results from different studies.

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