2024 Volume 12 Issue 4 Pages 73-83
The Maternal and Child Health (MCH) handbook is an essential home-based health promotion tool and recording instrument that ensures utilization of maternal and child care services among pregnant women, mothers, and children. To recognize the significance of effective MCH and MCH Handbook programs, the International Committee on MCH Handbook organizes the biennial International Conference on MCH Handbook, that brings together experts and stakeholders from around the globe. In 2024, the 14th International Conference on MCH Handbook was staged concurrently with the 1st Regional Conference on MCH in the Philippines’ CaLaBaRZon Region. The first day of the conference highlighted MCH handbook implementation and evaluation from 18 different countries and MCH recommendations from international organizations such as the World Health Organization (WHO), United Nations Children’s Fund (UNICEF), and Japan International Cooperation Agency (JICA). The second day of the conference featured the MCH situation and MCH handbook implementation in the CaLaBaRZon Region and ways forward towards effective MCH care. The conference concluded with the formal introduction of the Manila Declaration, with renewed commitment and strengthened collaboration towards effective implementation and sustainability of the MCH Handbook program, to ensure a safe beginning and thriving future to mothers and children in CaLaBaRZon and worldwide.
The International Committee on the Maternal and Child Health (MCH) Handbook organizes the biennial International Conference on MCH Handbook to bring together key stakeholders and specialists who have valuable expertise and experiences on MCH. The collaborative event serves as a platform for knowledge and experience-sharing on the development and implementation of the MCH handbook as well as present the influence of the handbook in improving key MCH indicators.
The MCH handbook was first published in Japan in 1948 to address high maternal mortality rates attributable to post-war diseases and poor health service delivery. The handbook proved successful in improving MCH outcomes during that time. Since then, the handbook has been introduced in more than 50 countries. International advocacy and best practice sharing on the MCH handbook began in 1998 with the First International Symposium for MCH Handbook held in Tokyo, Japan.
In May 2024, the highly-anticipated fourteenth commencement of the conference was held in Manila, Philippines, in collaboration with the Department of Health–Center for Health and Development (CHD) CaLaBaRZon (Cavite, Laguna, Batangas, Rizal, Quezon) Region and the University of the Philippines–Manila (UPM), with the thematic title, “Safe Beginnings: 1st Regional Conference on Maternal and Child Health in CaLaBaRZon”. The two-day event was attended on-site by 20 international participants, 208 local participants, with more than 200 participants who registered in Zoom and other online platforms.
The general objective was to create a dynamic platform for knowledge exchange, collaboration, and actionable insights, ultimately contributing to a global movement for safer and healthier beginnings for mothers and children worldwide. In this article, we present a synthesis of the recently concluded 2024 International Conference on MCH Handbook.
The conference kicked off with a discussion of the conference objectives and the program, including its alignment with the 8-Point Action Agenda strategy. This was led by Dr. Mark Nicholas O. Santos of CHD CaLaBaRZon, Family Health Cluster Head. Messages of support from key figures followed, including:
･ Her Imperial Highness, Crown Princess Akishino, president of the Imperial Gift Foundation Boshi-Aiiku-Kai who expressed her unwavering support for the International Committee on MCH Handbook;
･ In lieu of Dr. Anna Marie Celina Garfin, Director IV of the Disease Control and Prevention Bureau, Department of Health Philippines delivered by Dr. Ann Ysabel Gonzales–Andres, Medical Officer IV, National Safe Motherhood Program Focal;
･ Ms. Seiko Noda, former Minister of Internal Affairs of the House of Representatives, Japan and Chairperson of NPO Himawari who shared relevant laws and existing challenges in Japan for promoting MCH;
･ Mr. Reynaldo San Juan, Jr., Vice Governor of Rizal Province who emphasized the ‘first 1,000 days’ as a window of opportunity for MCH;
･ Dr. Sumire Sorano, Maternal Health Specialist of the World Health Organization - Western Pacific Region who lauded the MCH handbook for its visible impact to MCH
･ Dr. Anne Detjen, Health Specialist of Child and Development, United Nations Children’s Fund (UNICEF) who shared timely guidelines and frameworks created by WHO and UNICEF to further strengthen MCH care services, such as the Global Strategy for Women’s, Children’s, and Adolescent’s Health (2016), Nurture Care Framework (2018), and the Guidelines on Scheduled Child and Adolescent Well-Care Visits (2024);
･ Ms. Haruko Kamei, Director-General of the Human Development Department, Japan International Cooperation Agency (JICA) who highlighted the importance of issuing home-based records; and
･ Dr. Michael L. Tee, Chancellor of the University of the Philippines Manila (UPM) who highlighted the partnership between UPM and the International Committee on MCH Handbook and emphasized the continuing support of UPM constituents for maternal, child, and reproductive health innovation and policy development in the country
The first keynote message was delivered by Dr. Glenn Mathew G. Baggao, Undersecretary of the Philippines Department of Health (DOH). He emphasized the Philippines’ goal of attaining universal health care through the 8-Point Action Agenda, which contains provisions on ensuring quality MCH. He also highlighted the importance of building networks and exchanging knowledge for MCH in order to better empower mothers and children.
The second keynote message was delivered by Dr. Yasuhide Nakamura, Chairman of the International Committee on MCH Handbook. Dr. Nakamura discussed the value of the MCH handbook in achieving outcomes toward universal health care and enhanced primary health care. He provided an overview of the history of the MCH handbook which was first published in Japan in 1948. The MCH handbook was meant to be used as a home-based record combining information about the mother and the child, with pregnant mothers being the target audience. Implementation of the handbook turned out to be highly effective in improving key maternal and child health indicators, paving the way for a series of international collaborations and declarations to further promote the handbook. According to the MCH Handbook Bangkok Declaration (2018), the MCH handbook is an essential family-based tool to promote the “continuum of care” for all mothers and children, especially during the first 1,000 days after birth. The Toronto Declaration (2022) further advocates the use of the handbook as it ‘integrates diversity, equity, and inclusion principles’ into healthcare. To conclude the keynote message, Dr. Nakamura imparted that the MCH handbook ‘should be used in the spirit of self-reliance and self-determination based on the primary care approach and universal health coverage’.
Ms. Keiko Osaki of JICA discussed the 2018 World Health Organization (WHO) recommendations on home-based records for maternal, newborn, and child health. The first recommendation is to use home-based records as a complement to facility-based records in order to improve care-seeking behavior, husband support, MCH practices, and communication between the health worker and patient. The second recommendation encourages policy makers to involve stakeholders in implementation of home-based records in order to tailor-fit the format and contents to the users of the records. She emphasized the role of home-based records in reducing missed opportunities for health care, such as its role in increasing vaccination rates in Kenya. In spite of these WHO recommendations, the proper utilization of home-based records is a recurring problem in many countries. There are challenges to properly implementing home-based records, including frequent stock-outs, low rate of utilization, low perceived need for use, and subpar quality or inadequate contextualization for users. In response to these challenges, WHO, JICA, and UNICEF created the Strengthening implementation of home-based records for maternal, newborn and child health: a guide for country programme managers in 2022 in order to provide a systematic guide for a more efficient implementation of the MCH home-based records. The guide emphasizes a “user-centered approach”, where the home-based record must cater to the needs and priorities of (1) women, parents and caregivers; (2) health workers; and (3) programme managers.
Additionally, context-specific presentations on 18 countries were carried out to broaden the perspective of participants regarding the various practices and implementation strategies for the MCH handbook.
Thailand. The MCH situation and handbook rollout in Thailand was discussed by Dr. Sarawut Boonsuk from the Ministry of Public Health in Thailand. Dr. Boonsuk presented how Thailand performed better compared to its neighboring countries with regard to key MCH indicators such as total fertility rate, maternal mortality ratio, low birth weight, malnutrition/overweight rate, and stunting rate.
Currently, Thailand offers three types of MCH handbook: (1) the Pink Book which contains health records and screening results as well as information on self-care and health promotion; (2) the Developmental Surveillance and Promotion Manual for Normal Child which monitors the physical and behavioral milestones of developmentally normal children two years and younger; and (3) the Developmental Assessment for Intervention Manual for High-risk Child which caters to children vulnerable to developmental delays.
Dr. Boonsuk further described their health system delivery and use of home-based medical record, including their Health Book Application containing the MCH Handbook (mothers and children 0–5 years); three different assessment charts for school age (6–19), working age (20–59), and older persons (60 and above); and health information campaigns.
Indonesia. Dr. Agustin Kusumayati from Universitas Indonesia focused on the MCH handbook of Indonesia, known as ‘Buku Kesehatan Ibu dan Anak’ or ‘Buku KIA’. The handbook had been introduced to the country in 1994 by Dr. Nakamura in place of separate recording cards, and this initiative has since been receiving financial support from the government, including funding for revisions every five years.
The Buku Kia has two main components: maternal and under-five, both of which are further subdivided into recording and information sections. The recording section of the maternal part contains charts or checklists for iron supplementation, birth planning, antenatal care, weekly monitoring during pregnancy, monitoring during postpartum period, records of delivery process, postpartum, and referral services. This part also features information on pregnancy, nutrition, the delivery process, postpartum period, and breastfeeding. For the under-five part, there are records for neonatal care, physical growth, vitamin supplements, developmental milestones, immunizations, and childhood sickness. The information section features nutrition, significant symptoms, and child development.
The Riset Kesehatan Dasar (RISKESDAS) survey reveals that while there is a high coverage of mothers possessing the handbook, utilization and completion of the checklists remain low. Dr. Kusumayati raised the issue of isolated MCH handbooks being used by some health facilities contrary to the prescribed Buku Kia. She further highlighted the importance of the Mother Class as part of their strategy to strengthen MCH handbook utilization. Less than a quarter of mothers who took the RISKESDAS survey attended at least one Mother Class. To better improve MCH handbook utilization, Dr. Kusumayati recommended mass promotion of the Buku Kia and attendance to the Mother Class.
Japan. Dr. Nakamura provided an overview of the MCH situation in Japan from its time as a developing society to a developed one. The first ever MCH handbook was published in 1948, followed by reforms for free medical care for premature babies in 1958, and the creation of the National Health Insurance System in 1961. The initiatives to improve MCH in the country along with strong political support and community engagement in these initiatives have reflected as reductions in maternal and infant mortality indicators in the 1960s, with Japan overtaking the United States in infant mortality reduction by 1964. Dr. Nakamura emphasized that strengthening basic primary care, MCH handbook utilization, and reinforcing the role of nurses and midwives in MCH were the keys to reducing maternal and infant mortality in the country even prior to technological advancements in healthcare. Midwives played an especially important role in providing health services and health education in villages with a scarcity of doctors.
The current version of the MCH handbook contains the following components for the maternal part: information about pregnancy and records on body weight, laboratory tests, physical examination, delivery course, and immunization records. Subsequently, the child part of the handbook consists of the following components: information on neonate and child care and records on birth weight, APGAR (Appearance, Pulse, Grimace, Activity and Respiration) score, growth charts, immunization records, metabolic disease screening, physical and intellectual development, childhood illnesses, and dental health. In some municipalities, handbook utilization extends until the school age, with the addition of health examinations aligned with school health programs.
In order to invite inclusivity, Japan maintains its position to use both paper-based and electronic MCH records to cater to users across generations. According to Dr. Nakamura, the younger generations are more likely to utilize the MCH handbook mobile application, Himawari no Kai. The handbook is further translated in ten international languages to cater to families and health care workers of different nationalities. Dr. Nakamura added that there are sub-variations to the MCH handbook. The Little Baby Handbook specifically caters to babies under 1,500 grams and is distributed in neonatal intensive care units. The Twin Book is an MCH handbook specifically created for mothers of multiple births. There are also versions of the MCH handbook for mothers or children with special needs. The+Happy is made for mothers of children with chromosomal disorders such as down syndrome and distributed by the Japan Down Syndrome Society. There is a Braille version of the MCH handbook published by the Japan Family Planning Association for blind mothers. The Handbook for Pregnant and Child-rearing Mothers with Intellectual Disabilities simplifies MCH concepts for mothers with limited intellectual abilities.
On the second day of the conference, Ms. Akemi Bando from the Little Baby Circle National Network added further context by discussing the Little Baby Handbook used specifically for low birth weight babies. This handbook is distributed mainly in neonatal intensive care units of public health centers. She added that families were consulted by local governments across prefectures during the development of the handbook.
South America. Dr. Lourdes Herrera Cadillo from Asahi University discussed the MCH handbook situation in the South American countries of Mexico, Paraguay, Dominican Republic, Chile, Peru, Argentina, and Ecuador. She explained that the top-down approach for health directives still prevails for these countries, resulting in little consideration or input from the grassroots. In the context of MCH, the MCH handbooks are implemented without much explanation and involvement of the community, resulting in low utilization of the instrument. In Mexico, JICA started a project to introduce the MCH handbook in 1992 and 1998, locally. The handbook lasted for a few years before reverting back to separate health cards for the mother and the child due to public preference for the latter. Health policies in the Dominican Republic, Chile, Paraguay, and Peru also favor the separation of handbooks for maternal and child health records.
The only countries cited to have implemented the MCH handbook are Argentina and Ecuador. The MCH handbook has been in use in Argentina since 1983 and is utilized by mothers of children aged 19 and below. Dr. Herrera cited metabolic disease screening, infant obesity prevention, father participation, and infectious diseases as some of the contents within the handbook. In Ecuador, initial implementation was supported by UNICEF in 2016, with the integration of the originally-separate maternal and child records. However, Dr. Herrera added that utilization of the handbook remains relatively low in Ecuador due to the top-down approach issues.
Dr. Herrera particularly explained the MCH situation of Peru, in which a mobile application has been developed specifically for maternal care records and antenatal visits. The MCH efforts in Peru have led to a steady decrease in maternal mortality ratio; however, high-risk pregnancy continues to be a problem, contributing to 70% of total maternal deaths. To address high-risk pregnancies, an MCH handbook for high-risk mothers is currently being conceptualized. It shall contain monitoring charts specific to high-risk pregnancy and information about high-risk pregnancies, such as associated factors, warning signs, and management of warning signs.
Canada, Bangladesh, and the United States. In a recorded presentation, Dr. Shafi Bhuiyan of the University of Memphis, with his students, discussed the Toronto Declaration and the MCH handbook context in Canada, Bangladesh and the United States.
The 13th International Conference on MCH Handbook held in 2022 concluded with the Toronto Declaration, which promoted the integration and sustainability of the MCH handbook as a tool for health service delivery. The declaration has five provisions: (1) the MCH handbook integrates equity, diversity, and inclusion principles into healthcare; (2) the MCH handbook assures a holistic approach (physical, mental, social well-being) to healthcare services; (3) the digitalization of the MCH handbook supports the establishment of a population database to enhance social accountability towards health care education, tackling misinformation, improving adherence to health management and prevention, and preparedness for public health emergencies; (4) the sustainability of the MCH handbook program demands multisectoral, multilevel, and diversified approaches; and (5) the MCH handbook is a global standard self-care tool aligned with the five core goals to achieve Universal Health Coverage.
The MCH handbook in Canada tackled the areas of breastfeeding, maternal and child immunization, vitamin supplementation, antenatal care, family planning, maternal nutrition, smoking and alcohol during pregnancy, safe delivery, pregnancy complications, and child development.
In Bangladesh, a third edition of the MCH handbook is currently in production. This handbook shall contain information on antenatal care, breastfeeding, nutrition, immunization, postnatal care, family planning, and other health promotional messages for safe pregnancy and delivery. Some challenges raised by Dr. Bhuiyan and his students include ethnic diversity, different traditions and religious beliefs, language barriers, and gaps in literacy and decision-making. Emphasis was placed on the lack of knowledge by most rural mother participants on crucial pregnancy information, such as danger signs of pregnancy. To address these challenges, the developers of the handbook must ensure that the handbook is culturally-appropriate in region-specific contexts. Moreover, four strategic objectives were introduced in order to improve the impact of MCH handbooks: (1) zero home deliveries, (2) sensitization of safe institutional delivery by ensuring the availability of care providers in facilities, (3) emphasis on community engagement in order to build a sense of trust between the implementers and the community, and (4) establishment of web-based services to increase accessibility of the handbook. In response to the knowledge gap problem, Mr. Hanfi presented his dissertation on providing effective prenatal health education in the urban poor settlements of Bangladesh in order to improve health-seeking behavior and health care use of MCH services.
Another student under Dr. Bhuiyan presented the MCH situation of Shelby county in Memphis, Tennessee. Shelby county is reported to have one of the highest pregnancy-related mortality rates across the United States, yielding more than three times the national average. One of the key factors contributing to this figure is the access concerns which disproportionately affect black American women. As such, the MCH handbook is currently being targeted as an intervention to resolve this problem, with the goal of addressing socioeconomic and racial disparities and proactively empowering the mothers towards health-seeking behaviors.
Angola. Mr. Toru Sadamori from JICA discussed the progress of MCH handbook dissemination in Angola. The Angola Ministry of Health, with support from JICA, has been implementing the MCH handbook since 2014. In 2017, the PROMESSA Project (Project to Improve Mother and Child Health through the Implementation of the Maternal and Child Health Handbook) was implemented in three selected provinces in order to further boost the reach of the MCH handbook. The impact of the project was evaluated by the end of 2022, which found an increase in prenatal and antenatal care visits and more proactive actions from service providers and mothers. The success of the project led to its expansion plan which aims to target all eighteen provinces of Angola by 2025.
Burundi. Dr. Oscar Ntihabose from the Burundi Ministry of Public Health provided context on how the MCH handbook has been faring in Burundi. The MCH handbook was introduced by UNICEF, GAVI, and other developmental partners in 2013, replacing all isolated MCH “notebooks”. In order to secure the successful implementation of this instrument, the health committees in Burundi released a joint decree for establishing MCH health records, which contains the following strategies: free health care for pregnant women and children under five, decentralization of services to improve geographic access, community involvement and health promotion, and use of evaluative indicators for the MCH handbook to improve its sustainability. Dr. Ntihabose reported several operational challenges that threaten the rollout of MCH handbooks: recurrent national stockouts of the handbook, improper filling of the handbook by health providers, lack of knowledge on MCH key messages by health providers and clients, non-use in private facilities, and lack of utilization in the birth registries. Some strategies proposed to address the operational challenges are to organize training workshops for both health providers and clients, creating a task force for MCH handbook implementation which would conduct routine situational analyses and coordinate with other health programs, and securing adequate program budget for more secure rollout and stock management.
Gabon. The MCH situation and MCH handbook implementation in Gabon was discussed by Ms. Aline Sylvie of the Gabon Ministry of Health and Ms. Junko Watanabe of JICA. MCH remains a challenge in the country, with enduring high maternal and infant mortality rates. To address this recurring problem, a number of strategies have been developed by the Ministry of Health, including the dissemination of the MCH handbook in 2013 with support from JICA. These strategies have largely been derived from recommendations laid out during the 8th International Conference on the MCH Handbook held in Kenya last 2012. In 2022, the handbook had been revised to improve the layout and integrate new sections such as postpartum care and danger signs in children. Gabon aims to improve MCH handbook implementation by further studying its funding mechanisms, drafting a national guideline for its use, training service providers on its use, and enhancing advertisement of the handbook use through visual cartoons.
Nigeria. Dr. Ogechi Akalonu from the Federal Ministry of Health in Nigeria presented the implementation progress of their MCH handbook, as aligned with their mandates to develop primary health care. With the help of several development partners and inputs from various stakeholders, the MCH handbook was contextualized in Nigeria as a home-based record for not just MCH but a broad range of topics in primary care. The handbook contains five dimensions: (1) the health dimension containing records and information on immunization, pneumonia, diarrhea, malaria, newborn care, birth registration, mother to child transmission, child spacing, and insect-treated nets; (2) the WASH dimension discussing handwashing, sanitation and hygiene; (3) early childhood development consisting of developmental milestones, stimulations for psychosocial development, and learning opportunities; (4) nutrition through breastfeeding, complementary feeding, vitamin supplementation as well as screening for physical growth and malnutrition; and (5) antenatal/prenatal care containing history and physical/psychological screening during pregnancy, labor and delivery. Dr. Akalonu highlighted their plan of distributing training modules and tracking handbook utilization as activities for the remainder of 2024.
Kenya. Dr. Hellen Barsosio of the Centre for Global Health Research in Kenya presented an innovative strategy of using ScanForm, a photoscan application which digitizes written health records through artificial intelligence and instantly uploads captured data in a prescribed data dashboard. The application is interoperable across commonly utilized software such as Microsoft Excel and is automated for continuous data quality assessment. Kenya has been using this application for six years to conduct malaria surveillance, resulting in more timely, accurate data capture and less time and energy used for manual encoding among health staff. As such, Dr. Barsosio conducted a pilot study on using the application for MCH services. The pilot study is currently ongoing, but has thus far yielded more accurate captures of MCH handbook records and reduced workflow steps for MCH health staff.
On the second day of the conference, regional and provincial updates on the Philippine MCH situation and MCH handbook–specifically from the CaLaBaRZon Region–were discussed.
Ms. Vanessa B. Bebida of CHD CaLabarzon, National Safe Motherhood Program discussed the MCH situation and program plans for the region. There are six indicators for evaluating MCH in the country: maternal mortality ratio, neonatal mortality ratio, adolescent birth rate, antenatal care coverage, postpartum visits, facility-based delivery, and skilled birth attendants. The region has seen an increase in all six indicators, with emphasis on maternal mortality ratio and adolescent birth rate. To address the rising indicators, some targeted initiatives have been created to be implemented across the region:
･ An “audio drama” to creatively inform the general population about family planning and pregnancy danger signs, with the intention of reaching geographically-isolated and disadvantaged areas;
･ Partnership with the Department of Social Welfare and Development in providing capacity-building and training modules entitled, “Kalusugan at Nutrisyon ng Magnanay”, especially targeting the beneficiaries of the Pantawid Pamilyang Pilipino Program;
･ Enhancement and standardization of monitoring tools and standard operating procedures for more systematic baseline monitoring and service provision in lying-in clinics;
･ Public-private partnerships among lying-in clinics to enhance data exchange, referral systems, service delivery, and regulatory processes;
･ Collaboration with the Philippine Obstetrical and Gynecological Society to improve surveillance of maternal and perinatal mortalities;
･ Provision of Basic, Emergency Obstetrics, and Newborn Care (BEmONC) training to health care workers as mandated by the Mandanas Ruling;
･ Online training sessions on various MCH topics for health care workers named “E-Turo Sessions;”
･ Objectives/target setting and program planning among provincial program coordinators
The regional health office aims to further strengthen primary health care in order to provide high-quality, resilient, and people-centered services. Subsequently, representatives from the city health offices of the covered provinces have provided their strategies for MCH.
Laguna. Ms. Liza Franco-Andaya of the Sta. Rosa City Health Office provided an overview on MCH handbook utilization in Sta. Rosa, Laguna. Maternal mortality ratio in Sta. Rosa as of 2020 is 78 per 100,000 live births, notably lower than the past years but nearly the same as the regional average. An attributable strategy to the decrease in maternal mortality is the dissemination of the MCH handbook. Despite the use of the handbook, some problems persisted such as the lack of perceived value for using the handbook, difficulty to understand the handbook due to inadequate literacy, and supply concerns. As such, a city-specific version of the MCH handbook dubbed as the “Mommy Rosa’s Health Access Diary” is currently being developed to better cater to the needs of Sta. Rosa users. This version aims to be more attractive to its target users by being more colorful and easier to understand for their locality. The handbook contains the usual contents such as information on safe motherhood, immunization, nutrition, growth monitoring, dental care, mental health, chronic comorbidities, adolescent health, and family planning. On the other hand, it also contains context-specific information such as PhilHealth packages, birth certificate application process, and Garantisadong Pambata services. Furthermore, this version is unique because of the reward system in which freebies may be given to mothers who complete their antenatal/postnatal care visits and immunizations. Overall, Mommy Rosa’s Health Access Diary improved MCH handbook utilization and consequently health service utilization in its pilot implementation sites, especially for teenage mothers, largely due to it being easier to understand and having a reward system. Given the success of the initial implementation of the handbook, it shall be expanded for use in other barangays in Sta. Rosa.
Quezon. Ms. Laarni Q. Luna from the City Health Office of Tayabas, Quezon, discussed the MCH services currently being provided in Quezon Province. Aligned with the regional office initiatives, the provincial health office also ensures that health workers catering to MCH services are trained under BEmONC. Ms. Luna highlighted the high uptake of antenatal care services in Tayabas, which she attributed to patient-centered interventions including regular home visits and constant coordination with barangay health workers and residents. A portion of the city budget is spent on targeted MCH programs like the annual “Buntis Congress” festival and weekly pre-marriage counseling for residents.
Dr. Felices Emerita P. Perez of CHD CaLaBaRZon presented her paper on implementing a mandatory registration system for all pregnancies as a strategy to reduce maternal mortality rate in Quezon. She found that well-designed, community-based pregnancy surveillance and registry systems helped to identify danger signs in pregnancy earlier, thus preventing further complications. The findings of the dissertation indicate that community support is present for registering pregnancies assuming confidentiality protocols are in place, but there is a lack of policy enforcement. Moreover, there are persisting sociodemographic and access barriers to enforcing the mandate, such as poor health literacy to reinforce salience, lack of logistic resources for enforcement, lack of financial capacity to travel to facilities, and perceived social stigma among teenage pregnant mothers.
Rizal. Dr. Rebecca B. Llamado, pediatric consultant of the Shalom Christian Bahay Paanakan, Inc., discussed the nutritional considerations for pregnant mothers in their facility. She reported that 23% of pregnant women in the Philippines were nutritionally at risk, while about 19% of neonates are born with low birth weight. This may carry over as childhood stunting, a problem currently affecting 29% of Filipino children under five. Dr. Llamado emphasized the significance of maternal nutrition in mitigating childbirth complications related to malnutrition and vitamin deficiency. Their facility currently refers to the guidelines from DOH Department Memorandum 2020-0092, Interim Nutritional Guidelines for Women of Reproductive Age. It includes guidelines for anthropometric monitoring and screening for nutrient-related comorbidities. The guideline also recommends the use of multiple micronutrient supplementation (MMS) for pregnant women, especially in areas where maternal malnutrition is prevalent. Multiple micronutrient supplementation is deemed more cost-effective than iron-folic acid supplementation as used in standard of care, with 500,000 disability-adjusted life years averted. For health promotion, the Pinggang Pinoy (Filipino Plate) is used as a visual tool to help pregnant women understand recommended dietary portions.
Batangas. Dr. Marie Scent Vera Fopalan Benedicto from the Batangas Medical Center provided an overview of best practices for MCH being done in their hospital. Batangas Medical Center is an apex hospital within a Service Delivery Network, which means that it is a premier tertiary hospital which caters to referrals for specialized services. As a certified BEmONC training hospital, MCH staff are required to undergo BEmONC training for skills on pharmaceutical administration and emergency response (i.e., newborn resuscitation) in both normal and high-risk pregnancies.
During pregnancy visits in the outpatient department, mothers are given health promotion on breastfeeding and nutrition, daily iron and folic acid supplementation, routine immunization of DPT (diphtheria-pertussis-tetanus) and influenza vaccine, and family planning. During labor, a partograph is used to record information about the progress of labor. Upon delivery, oxytocin must be administered and delayed cord clamping is applied. Thermoregulation, breastfeeding, and skin-to-skin contact are emphasized practices post-delivery. For preterm infants, kangaroo mother care is encouraged. All mothers are provided with a pamphlet containing information on the Expanded Program Immunization schedules.
Ms. Ana Liza R. Abrenica of the Batangas Provincial Health Office added that Batangas is prioritizing the strengthening of service delivery networks in order to improve referral systems. She attributed high maternal mortality as a consequence of the fragmented health system in the province. They are also in the process of strengthening coordination between public and private facilities. These strategies have a direct impact on maternal mortality reduction, from 86 per 100,000 live births in 2015 to only 16 per 100,000 live births in 2022. Moreover, the provincial health office aims to increase the functional capacities of health facilities by increasing funding and human resources.
Cavite. Ms. Heizel V. Creencia of the Cavite Provincial Health Office explained the MCH situation and strategies for their province. The maternal mortality curve in Cavite has been described as erratic due to frequent population migration. Ms. Creencia mentioned the need to further strengthen Service Delivery Networks in Cavite as its health facilities face a constant stream of patient referrals. She highlighted the importance of analyzing maternal death reviews as an evidence-based approach to identify the root causes of maternal deaths. She also expressed the importance of improving postnatal care practices in their facilities, with emphasis on addressing maternal mental health and early detection of potential complications during postpartum.
To wrap up the Philippine MCH situation, Dr. Mario Festin of the University of the Philippines - National Institute of Health discussed the updated WHO guidelines for antenatal care and its applicability in the local context. MCH is crucial to addressing seven intertwined Sustainable Development Goals, a significant aspect of which is antenatal care. Timely and evidence-based antenatal care is necessary to promote safe pregnancies and minimize complications during delivery. Given its critical importance, the World Health Assembly called for the creation of recommendatory guidelines for antenatal care. Although these guidelines are now widely disseminated, the Philippine National Demographic and Health Survey has still found a decreasing trend in antenatal care visits between 2017 and 2022. Moreover, the Philippines still uses the outdated recommendation of at least four or more antenatal visits throughout the course of pregnancy. Dr. Festin concluded that Filipino mothers deserve patient-centered, timely, quality and accessible antenatal care. In order to address these mandates, he recommended updating the local antenatal tools such as the Healthy Buntis, Happy Baby and The 9-Month Date Book to follow the most recent WHO antenatal care guidelines of eight contacts instead of at least four. It is also better for these isolated maternal instruments to be integrated in a standardized MCH handbook. Dr. Festin added that his institution is currently developing a mobile application for antenatal consultation and monitoring.
During the two-day conference, forums were held upon the conclusion of a set of presentations. Some of the key points during the forums are highlighted below.
Experiences from other countries. The speakers were asked to provide country experiences and best practices which can be used in the implementation of the handbook in the Philippines.
･ Dr. Herrera stated that a section for caring for mothers with special needs and a page for parents to write their concerns and experiences can be added. With regard to best practices on maximizing MCH handbook utilization by health workers, she suggested providing incentives to health workers who are compliant.
･ Dr. Ntihabose stated that implementation must be made more holistic and involve coordination with different partners.
･ Ms. Bando shared her experience in involving national and local stakeholders to gather support for the implementation of the Little Baby Book.
･ Ms. Osaki suggested facility-level monitoring of handbook implementation which may be assessed through national population or demographic-health surveys.
･ Dr. Nakamura noted that regular training of staff and volunteers is essential.
･ When asked how husbands can become more involved in the pregnancy process, Ms. Osaki and Dr. Nakamura provided examples from Japan, where “parent classes” are held during weekends on top of “mother classes” on weekdays in order to increase the MCH knowledge and involvement of the husband.
Digital MCH handbook. When asked if the app version of the MCH handbook can be advantageous in the Philippines, Dr. Nakamura answered that it has an advantage in reaching individuals who are accustomed to using devices such as the younger generation. However, the option for a paper-based handbook must still remain available for mothers who opt for physical copies or are less tech-savvy. To better aim for inclusivity, voice-assisted technology may be added, along with a special version for mothers who have intellectual disabilities. Dr. Osaki added that digitizing the handbook will mean shifting budget allocation towards strengthening information and communications technology (ICT) over printing fees.
Dr. Perez highlighted that an MCH application can be used strengthen the foundation for a pregnancy registration system in the Philippines because clients will be asked to input their information in the system, which is ideally interoperable with other information systems such as the Field Health Services Information System (FHSIS). Creating a dedicated pregnancy registration system will enhance surveillance and service delivery reach, especially teenage pregnancies. As such, Dr. Perez advocates the creation of a national policy for the implementation of a pregnancy registration system, including data-sharing access and cybersecurity implications. A web-based application is the goal for convenient remote access; but for now, a line list can be created in a spreadsheet tracker.
Some questions related to the ScanForm application were directed to Dr. Barsosio. When asked how a scan application would help improve MCH outcomes, she explained that integrating raw data into data dashboards is now faster and easier, so this will improve the timeliness and completeness of MCH information which in turn can enhance the programmatic response. It will not be compromised by ICT problems because syncing will occur once the internet or server has been restored. Artificial intelligence is also capable of continuously training and correcting its algorithm to ensure data accuracy and quality. When Dr. Festin asked about the storage capacity of the application, she explained that data is stored in thecloud with unlimited storage. Dr. Barsosio noted that many challenges in implementation remain as they have just started the pilot phase. Dr. Ntihabose said the application has a lot of components for scanning, so this may compromise the time management of health workers. Dr. Barsosio acknowledged the need to revise the application by reducing the components to be scanned while still retaining core data.
Strategies for MCH in the Philippines. For the local representatives, issues concerning maternal well-being and health service access and delivery were discussed. Ms. Creencia was asked how she plans to address maternal mental health in Cavite. She shared her plan to pass an ordinance for institutionalizing mental service delivery and its referral protocols, along with coordination with program coordinators for programs related to maternal mental health. She also aimed to create a dedicated healthline with the name, Katawang Caviteño (Cavite Body) Ms. Andaya added that the Mommy Rosa handbook in Laguna already includes a mental health initiative targeting mothers who experience postpartum depression. They also hire licensed psychologists and psychiatrists in their facilities, in close collaboration with the National Center for Mental Health.
On the topic of maternal nutrition, Dr. Llamado was asked about the strategies used by their facility to enhance adherence of mothers to nutritional guidelines. She explained that they educate their patients in order to orient them about WHO guidelines and dissipate any misconceptions about nutrition, especially concerning the intake of MMS. For instance, health staff reassure patients that MMS is generally safe and cost-effective, having slight gastrointestinal to no side effects. They also recommend setting phone alarms to take MMS. When asked about distributing MMS to far-flung areas, Dr. Llamado answered that although the supply chain takes a longer time to reach these areas, they are still reached nonetheless. Health workers from far-flung areas are routinely invited to nutrition seminars organized by their partners. She added that these facilities may apply for development grants, and encouraged local chief executives to provide more support. Although MMS is already recommended in existing local guidelines, its national procurement is still subject to health technology assessment.
When asked about how women can reduce their risk of pregnancy complications, Dr. Luna suggested the strengthening of prenatal check-ups by initiating regular visits in Barangay Health Stations, especially during the first trimester. She highlighted the role of basic medical services, vitamin supplementation, and immunizations in reducing this risk. In case of preterm or low-weight births, Dr. Benedicto noted that kangaroo mother care is recommended until the infant reaches adequate weight.
A number of questions touched upon service delivery and referral networks for MCH. Ms. Abrenica was asked how the health service delivery networks in Batangas can ensure efficient communications between referrals. She stated that they have a committee for monitoring and evaluating the efficiency of referral networks. In contrast, Dr. Benedicto said that despite being operational, the Batangas referral system is still incomplete as some facilities are fragmented and the high volume of patient referrals affect operations in apex hospitals. She proposed cascading BEmONC training to the local health staff in order to capacitate smaller facilities and in turn decongest referrals in apex hospitals.
Regarding the monitoring and evaluation of birthing facilities in CaLaBaRZon, Ms. Bebida noted that upon evaluating four core indicators (service delivery, regulation, governance, accountability), they found that many birthing facilities are non-compliant with the minimum regulatory requirements and have yet to secure their license-to-operate. Some births are still being conducted in houses rather than birth facilities. Ms. Bebida emphasized the need to strengthen the implementation of policies for birthing facilities and practices.
Social determinants to MCH in the Philippines. On the topic of social determinants to MCH, most of the speakers pointed out the effect of health literacy and educational background in affecting health-seeking behavior. Access to health care is also crucial, as transportation costs and distance to the nearest facility were correlated to the number of timely antenatal care visits. Ms. Abrenica emphasized the importance of education which can impact behavior change. She noted that many clients still opt to travel to tertiary facilities despite having closer access to primary care facilities whose staff have been trained for BEmONC, likely attributed to the common perception that tertiary hospitals provide better quality of care. This mindset results in the congestion of tertiary facilities. Dr. Festin further stressed the role of education in shaping the attitudes of Filipinos on reproductive and sexual health. He suggested the integration of comprehensive sex education in school curriculums to see if these can bring down teenage pregnancy rates.
Socioeconomic status is an important variable because those with lower financial capacity are more likely to have lower educational attainment, poorer living conditions, and have reduced means of access care, overall leading to poorer health outcomes. Dr. Ramoncito C. Magnaye added that going to health check-ups would mean a day off from work or closing up small-scale businesses; this means a loss in livelihood for individuals who are not covered by employment laws for leave rights.
In addition to this, messages of support coming from CHD4A Local Chief Executives:
– Quezon. Hon. Angelina “Helen” D. L. Tan, (recorded);
– Laguna. Hon. Ramil L. Hernandez (delivered by Dr. Rene P. Bagamasbad, Provincial Health Officer of Laguna); and,
– Cavite. Hon. Juanito Victor C. Remulla (delivered by Dr. Nonie John L. Dalisay).
To conclude the conference, the late Medical Center Chief of Batangas Medical Center, Dr. Ramoncito C. Magnaye lead the Pledge of Commitment of local participants to the ideals of the 1st Regional Conference on Maternal and Child Health (MCH) in CaLaBaRZon.
The International Committee on MCH Handbook formally introduced the provisions of the Manila Declaration for the 14th International Conference on MCH, as follows:
Maternal and Child Health (MCH) advocates, experts, practitioners, and policymakers from CaLaBaRZon (Region IV-A) and from 20 countries congregated in Manila, with additional online participation via the University of the Philippines Manila’s social properties (Facebook and Youtube) and Zoom Meeting platform, met at “Safe Beginnings: 1st Regional Conference on Maternal and Child Health (MCH) in CaLaBaRZon in partnership with 14th International Conference on the MCH Handbook”. This conference is a strategic opportunity to recognize the significance of effective MCH and MCH Handbook programs in ensuring a “safe beginning” for the health and well-being of both the mother and the child.
A safe beginning for every baby, which begins with a healthy mother, will improve health outcomes before, during, and after pregnancy. The MCH Handbook is a comprehensive instrument, designed to be kept by the family that contains integrated health records and information from pregnancy, delivery to child rearing. More than 50 countries and areas over the world have already implemented it as an essential measure to address the need to provide a continuum of care for maternal, neonatal, child and adolescent health in the manner of people-centered approach.
Following the Toronto Declaration adopted by the 13th International Conference on the MCH Handbook, held in Toronto in November 2022, the Manila Conference has provided an opportunity to reflect on what has been learned about development and implementation; to re-examine the values and effects of the use of the MCH handbook; and to identify the directions and strategies required to meet the requirements of Universal Health Care.
We, the participants of “Safe Beginnings: 1st Regional Conference on Maternal and Child Health (MCH) in CaLaBaRZon in partnership with 14th International Conference on the MCH Handbook”, hereby conclude and recommend:
1. That the MCH Handbook is an essential and effective family-based tool that can promote a “safe beginning” in the first 1,000 days of life and beyond for all mothers and children.
2. That the MCH Handbook should be recognized as a necessary component in health service delivery in MCH facilities and be used as guidance for all families to improve their health literacies on maternal and child care.
3. To ensure equitable access to care for all, including vulnerable groups:
a. the inclusion of information and care for mothers and children with special needs;
b. adequate access to convenient format of the MCH Handbook, digital version for pregnant women and mothers with supporting technologies and paper-based version for those with limited technological capacity; and
c. maximize all available resources and innovations to create opportunities for more partnership with local governments, scaling-up utilization, and inclusivity of users while ensuring data collection and improvement of civil registration for planning and programming.
4. To foster a sense of ownership of one’s health with the inclusion of a page/s for mothers and fathers to write their experiences/concerns that their children can read about.
5. To institutionalize the MCH Handbook within the frame of government policies and acclimate more data and evidence to help guide MCH-related decisions to develop and provide evidence-based programs and practices, which will facilitate optimal outcomes in mothers and newborns.
6. To ensure successful collaborative partnerships with various stakeholders, among others with local governments, professional organizations, academics and scientists, and civil society communities, to address common issues on MCH Handbook utilization and ensure sustainability of the MCH Handbook as an integrated part of MCH programs.
The Manila Declaration aims for the inclusive, equitable and sustainable implementation, monitoring and updating of the MCH handbook worldwide. It reflects the firm commitment of participants in the conference to draw upon the widest possible range of resources to utilize the MCH Handbook.
We, with renewed commitment and strengthened collaboration and a common goal towards effective implementation and sustainability of MCH Handbook program, have committed to ensure a safe beginning and thriving future to mothers and children in CaLaBaRZon and worldwide.
No one will be left behind.
This conference was able to serve as a dynamic sharing platform for knowledge and best practices concerning MCH. The insights of international and local representatives reflected how the MCH handbook had been instrumental in improving MCH outcomes across countries, in accordance with Universal Health Care. Various innovative strategies have been introduced for MCH to enhance service delivery and better engage pregnant women and mothers in maximizing available MCH services. Presentation materials and photos may be accessed via this link: https://conference.mchhandbook.com/
Safe Beginnings: 1st Regional Conference on Maternal and Child Health (MCH) in CaLaBaRZon in partnership with 14th International Conference on the MCH Handbook was made possible through the leadership and support of the Center for Health Development IV-A (CaLaBaRZon). We thank CHD CaLaBaRZon Assistant Secretary Ariel I. Valencia and his team for facilitating and advancing the conference.
We wish to acknowledge the University of the Philippines Manila, led by Chancellor Dr. Michael L. Tee and College of Arts and Sciences Dean Dr. Maria Constancia O. Carrillo, for institutional support. We also thank the members of the International Committee on Maternal and Child Health (MCH) Handbook for the continued collaboration which has enriched and opened avenues for sharing insights and knowledge within the global maternal and child health community.
We are grateful to the invited speakers for sharing their expertise and experience in the conference. To the participants, we salute you for your efforts in ensuring a safe beginning and thriving future to mothers and children in your respective communities.
Our sincerest gratitude to Dr. Satoru Takeda, Director of the Aiiku Research Institute for Maternal, Child Health and Welfare, Imperial Gift Foundation Boshi-Aiiku-Kai.
Finally, to Mrs. Erlinda de los Reyes, an amazing Filipina mother of three, and dedicated mothers globally, thank you for inspiring this effort, a true labor of love.
The authors of this manuscript declare no conflict of interest.
