Review
The health and well-being of mothers and newborns beyond Sustainable Development Goals (SDGs)
2024 年 12 巻 2 号 p. 21-27
詳細
2024 年 12 巻 2 号 p. 21-27
The Maternal and Child Health (MCH) Handbook was created in Japan about 76 years ago, when Japan was a poor country with high infant and maternal mortality, with the aim of promoting health and well-being for mothers, newborns, and children. Today, MCH Handbook programs have been introduced in more than 50 countries and regions in Asia, Africa, America, and Europe. The MCH Handbook is an indispensable tool in our efforts to crystallize the idea of leaving no one behind. Each country in Asia and Oceania has its own culture and customs of pregnancy, delivery, and child-rearing. Each culture should be respected as worthy, and good practices and lessons should be learned and shared. We hope that the MCH Handbook will promote health and well-being for mothers, newborns, children, and families, while celebrating many elements of their traditional culture.
The MCH Handbook, which is designed to be kept by the family, contains health records and information on pregnancy, delivery, and child health. MCH Handbooks are distributed, mostly free of charge, in connection with MCH services run by local governments or health institutions. While the roles and contents of MCH Handbooks greatly vary by country and area, all have the following three essential characteristics.1)
First, each MCH Handbook contains health records—both the mother’s and the child’s—plus information on pregnancy, delivery, and child health in just one booklet. This is how the MCH Handbook can guarantee a continuum of care and why it is distinct from other child health records, such as those used in the United States, or health handbooks targeting women and children separately, as in the case of France. Second, the MCH Handbook is given to the family. Parents keep their MCH Handbook at home and manage medical records entered by doctors or midwives. The role of home-based records differs from that of medical records kept at hospitals. Third, the MCH Handbook can be used as a guide for pregnancy and child-rearing: it provides essential health information on high-risk pregnancies, delivery, childhood diseases, child growth and development, and immunization. The MCH Handbook is usually the only healthcare-related guide available in rural areas in developing countries.
The MCH Handbook in Japan consists of the following:
1) General information on the pregnant woman,
2) Certificate of birth registration,
3) Pregnancy records, including body weight, blood and urine test results, and blood pressure,
4) Delivery records, including information on the process, the mother’s condition, and the baby’s Apgar score and birth weight,
5) Child health records, including the growth curve and health checkup and dental care records,
6) Immunization records and records of childhood illnesses, etc., and
7) Health education materials, including information on healthy pregnancy and birth, neonate care, and child care.
Attached to the Japanese MCH Handbook are coupons for free antenatal examinations and a certificate of registration. In addition, there are spaces where parents can write about the developmental milestones reached by their children as well as messages for them to read when they are older.
Japan introduced the MCH Handbook after the Second World War. Since then, the country’s infant mortality rate (IMR) has shown a drastic and constant decrease from 76.0 (per 1,000 live births) in 1947 to 1.8 in 2022 (Figure 1)—the lowest in the world—with about a 50% decrease every decade; 60.1 in 1950, 30.7 in 1960, 13.1 in 1970, 7.5 in 1980, and 4.6 in 1990.2) The decrease rate of IMR was constant and lower than the decrease rate of the target of Millennium Development Goals (MDGs). The life expectancy at birth as of 2022 was 87.09 years for females and 81.05 for males; this female life expectancy is the longest in the world. The maternal mortality ratio (MMR) has also shown a drastic decrease from 176.1 (per 100,000 live births) in 1947 to 3.4 in 2022 (Figure 2).
Sources: Ministry of Health, Welfare and Labor, Japan
Sources: Ministry of Health, Welfare and Labor, Japan
In 1948, Boshi Techo (Handbook for Mothers and Children) was introduced by the Japanese Ministry of Health and Welfare for the first time. This 20-page handbook included medical records on maternal care, delivery, and child health checkups (Photo 1). Six pages were dedicated to recording the distribution of milk and clothes during post-war rationing. Midwives and public health nurses played a major role in the promotion of the handbook, and its coverage reached almost 100%. In 1965, Boshi Kenko Techo (Maternal and Child Health Handbook) was developed for distribution to all pregnant women under the Maternal and Child Health Act. Information on maternal care and child-rearing, along with a space to be filled in by parents, was added to the 46-page revamped handbook.
By 1964, the IMR in Japan—which was roughly twice that of the United States in 1950—had dropped below the IMR in the United States (Fig. 3), despite the fact that Japan was still a relatively poor country. A joint Japanese and US research team concluded that Japan’s low IMR could be attributed to a combination of five factors: its narrow socio-economic distribution, the high value placed on childbearing, the national health insurance system, population-based screening and health check-ups, and the use of the MCH Handbook.3) The role of MCH Handbooks can be adapted to a country’s child health situation.
Sources: U.S. Department of Health and Human Services Ministry of Health, Welfare and Labor, Japan
When the IMR in Japan was high, the focus of the MCH Handbook was on fighting malnutrition and infectious diseases. By 1970, the IMR had dropped to less than 10 per 1,000 live births, and the MCH Handbook played an important role in Japan’s efforts to promote population-based screening and strengthen early detection and early treatment for children with illnesses and disabilities. From 1991, municipalities, towns, and villages started distributing the MCH Handbook under decentralization, and the MCH Handbook was once again updated. The revised national version of the MCH Handbook consisted of 48 pages, with some room left for local governments to add further information based on their own local needs. In 2012, the 2002 national version was amended to include information on high-risk pregnancy, a stool color chart for the early detection of biliary atresia, and discussion of male partner participation. Today, with the number of newborns drastically decreasing, psychosocial support for childrearing has become one of the most critical issues requiring special attention.
MCH Handbooks have been adopted around the world. Thanks to the support of UNICEF, the Japan International Cooperation Agency (JICA), NGOs, and several other organizations, countries other than Japan have introduced MCH Handbook programs, inspired by the success of Japan in achieving a reduction in IMR before realizing economic development.4)
There are a wide variety of programs aimed at improving maternal, neonatal, and child health in many countries in Asia and Africa. Interventions have been carried out at different times in different places and by different healthcare workers, and have been run by many donor organizations. Although in most countries it can be very difficult to realize a continuum of care across time and location, the introduction of a MCH Handbook program can help ensure continuation of maternal, neonatal, and child health care. Parents can easily obtain appropriate information and understand how they should care for their children by referring to the handbook for continuous guidance from pregnancy to childhood. MCH Handbooks have been produced in various colors and sizes (Photos 2, 3), and today, more than 50 countries and regions in Asia, Africa, America, and Europe have their own MCH Handbook programs in place.
Advantages of MCH Handbooks have been summarized on the basis of practice and experience in many countries. The introduction of the MCH Handbook in Cambodia was aimed at increasing antenatal attendance, deliveries with skilled birth attendants, deliveries at a health facility, and maternal knowledge.5) The MCH Handbook in Indonesia was designed to increase knowledge and promote changes in maternal and child health-related behaviors by strengthening communication between health professionals and mothers with children.6) According to the results of a meta-analysis, mothers who used the MCH Handbook during pregnancy had a higher level of knowledge than those who did not.7) Another meta-analysis revealed that the MCH Handbook can increase maternal health service utilization, especially antenatal care (ANC) visits, deliveries by skilled health professionals, and early breastfeeding practice.8)
One of the advantages is that parents, health volunteers, and health professionals can easily understand the MCH Handbook; this strengthens the continuum of care for maternal, neonatal, and child health. In Indonesia, when “Mother’s Cards” and “Child Growth Cards” were distributed separately, most mothers visited health centers without the cards. It was very difficult for mothers to manage and keep track of several kinds of cards. When different programs are implemented within MCH services, the MCH Handbook can help providers and users to understand each activity within each program and how they fit together to provide a comprehensive continuum of care.
The second advantage is that parents, health volunteers, and health professionals can share knowledge and information about maternal health and child growth. The MCH Handbook promotes communication and coordination among different parties, and this is a very important role especially in countries where many people consider that pregnant women do not need to attend health facilities during pregnancy, because they think that pregnancy is not an illness.
The third advantage is that MCH Handbooks with illustrations and figures/photos are very useful as health education materials.
The fourth advantage is that the MCH Handbook is a flexible tool. Its contents can be edited easily according to each country’s culture and socioeconomic status. As in the case of the MCH Handbook in Japan, the contents have been modified to reflect the changing needs of health professionals and mothers. While many medical interventions have adverse reactions if altered, adapting the MCH Handbook has no side effects. We strongly recommend developing MCH Handbooks based on the growth chart, posters, and guidelines of the target country, instead of merely translating the Japanese MCH Handbook.
The fifth advantage is that there are key persons in each country who have been working very hard to develop and improve MCH Handbooks. Among these key persons are those who have participated in training programs in Japan.
The MCH Handbook alone cannot achieve a reduction in IMR or MMR; however, MCH Handbook programs will contribute to changes in the behavior of mothers, encourage a better relationship between health professionals and mothers, and lead to improvements in maternal and child health care.
Parents treasure their MCH Handbooks for a long period of time. Managing the medical and health records of their children for themselves is a starting point for health participation, one of the key principles of primary health care. It was wonderful to see that mothers and children brought their own MCH Handbooks to their health examinations in Indonesia. They would like to manage their health information by themselves, so they cherish their MCH Handbooks very much. Medical records kept in the MCH Handbook serve as a useful referral document when a pregnant mother or a child is referred to a hospital by a health center. In Indonesia, the late Prof. Azrur Azwar said, “When parents keep their MCH Handbooks, they can communicate their concerns to health professionals. The MCH Handbook empowers parents.”
The MCH Handbook is often the only healthcare guide available to family members at home. Donor-driven health programs produce beautiful posters and pamphlets that are displayed at health centers and hospitals. However, parents may not remember information about nourishing food when they are cooking back at home. When the MCH Handbook is kept at home, parents can read it any time. Information on maternal and child health, nutrition, immunization, and infectious disease control, including HIV/AIDS, malaria, and tuberculosis, can all be integrated into a single MCH Handbook.
The MCH Handbook is also a gift from parents to their child, a tool that parents can use to express their love. In Japan, most parents keep their MCH Handbooks until their children are married. A mother of two girls said, “I wrote down the first word spoken by my children in their MCH Handbooks. Rereading the MCH Handbooks reminds me of the period when they were little and I feel empowered.” A mother of one boy and one girl said, “I received my own MCH Handbook from my mother. I often compare my children’s MCH Handbooks to my own.” Prof. Miriam Were from Kenya noted, “The MCH Handbook is a tool that allows a mother to express her love for her child. It has the power to send this message to the next generation.”
Challenges for MCH Handbook programs include costs, loss, and illiteracy. In addition, the MCH Handbook itself may be perceived as having some disadvantages, depending on the situation of countries and regions. First, printing one MCH Handbook is more expensive than printing one health card. However, when more than three kinds of cards are printed, the cost of printing one MCH Handbook is lower. In other words, organizations controlling the budget for printing health cards can cooperate to make printing MCH Handbooks more cost-effective.
The second challenge is that, when the MCH Handbook is lost, all the records therein are lost. While the likelihood of losing a handbook is lower than that of losing a single card, unexpected events may occur, such as a natural disaster or civil war. Thus, the utilization of both analog and digital versions of the MCH Handbook should be considered in order to integrate the handbook with digital information on MCH by applying information and communication technology (ICT).
The third challenge is illiteracy in parents. There is concern that mothers with low education may not be able to understand the contents of the MCH Handbook. However, a survey conducted in Indonesia revealed that mothers with low education were able to gain a greater amount of information about health through the MCH Handbook than mothers with high education. The MCH Handbook should be distributed to all mothers, leaving no one behind. When targeting parents with low education, the contents should be adapted accordingly, such as including illustrations and figures or photos with simple messages.
To achieve positive outcomes, simply distributing MHC Handbooks is not sufficient. The MCH Handbook itself is not a tool that can alter the behavior of people and automatically reduce IMRs. However, when health personnel utilize the MCH Handbook to record health examination results and explain the information about high-risk pregnancies and the importance of nutrition to parents, it can become a very useful tool. Effective training for health personnel, including health volunteers, about how to maximize the usefulness of the MHC Handbook is a necessary component of successfully managing the program and ensuring proper use of the MHC Handbook.
For the success of an MCH Handbook program, the collaboration of health professionals at every health facility is indispensable. MCH Handbook programs are most effective when there are teams of health personnel working actively to promote the program, and where a sufficient health care system exists.
The MCH Handbook is not an end goal but rather a starting point. It is not a tool that directly reduces maternal and child deaths, but it can increase knowledge and promote changes in health-related behaviors of mothers and children by strengthening their communication with health professionals. It can be utilized as a basic tool to ensure the quality of lives of mothers, children, and families around the world. Many of the MCH Handbook’s innovative roles also fit well within the context of SDGs, which were adopted by the United Nations in 2015. The World Health Organization (WHO) recommendations regarding home-based records for maternal, newborn, and child health were published in September 2018.9) There are so many improvements of home-based records and the scientific proof of advantages of MCH handbook is requested.
The World Medical Association (WMA) Statement on the Development and Promotion of a MCH Handbook was announced in October 2018.10) The WMA recommends that constituent member associations and medical professionals promote the utilization and adaptation of MCH Handbooks, or equivalents, to local settings in order to leave no one behind with respect to SDGs, especially non-literate people, migrant families, refugees, minority people, and people in underserved or remote areas.
In summary, the roles of the MCH Handbook are as follows:
1) To leave no one behind: “No one left behind” is one of the philosophical foundations of SDGs. The MCH Handbook is recognized as a tool to improve the social inclusion of persons with disabilities, refugees, migrants, ethnic minorities, and the poor.
2) To ensure a continuum of maternal and child health care: the MCH Handbook can strengthen the continuum of care within the fields of maternal, neonatal, and child health, which can also be extended to cover the health of children of school age.
3) To promote a harmonized mélange of care within many health fields: The MCH Handbook is a book of All in ONE. Information from many health fields, such as maternal and child health, immunization, infectious diseases, nutrition, and family planning, are integrated into one book.
4) To offer a flexible tool that can be adapted to each country’s needs and culture. The MCH Handbook is very flexible and user friendly, because it is easy to add color pages, illustrations, figures, and photos if needed, or to reduce the number of pages due to financial constraints.
5) To empower women: The MCH Handbook can empower women by allowing them to keep and manage their own health information. It can also strengthen communication between health professionals and mothers. The MCH Handbook is a personal keepsake—it contains a record of childrearing efforts carried out by mothers and fathers.
6) To apply ICT to the MCH Handbook: The digital MCH Handbook is useful for people with low education or visual defects. It is expected that the information in the MCH Handbook can be integrated with digital MCH services by ICT.
The MCH Handbook is an indispensable tool in our efforts to crystallize the idea of leaving no one behind. Each country in Asia and Oceania has its own cultures and customs. Each culture should be respected as worthy, and good practices and lessons should be learned and shared to promote the use of the MCH Handbook for the benefit of a larger number of people. We hope strongly that the MCH Handbook will promote health and well-being for mothers, newborns, children, and families, while celebrating many elements of their traditional culture.
This paper was presented at the 22nd Congress of the Federation of Asia and Oceania Perinatal Societies (FAOPS). I am very grateful to Prof. Mamoru Tanaka (Congress Chair of FAOPS 2023) and Prof. Satoru Takeda (Co-chair of the workshop on Maternal and Child Health Handbook) for the opportunity to share our findings.
The author declares no relationships with companies or entities that could have a financial interest in the information presented. The absence of any conflicts of interest is hereby disclosed. This statement is made to affirm that no competing financial interests or personal relationships could bias the work or the interpretation of its results.
