Factors affecting the utilisation of maternal, newborn, and child health services in Indonesia: the role of the Maternal and Child Health Handbook

Continuum of care in maternal and child health in Indonesia

AIM

This paper aims to empirically analyze the socioeconomic and demographic correlates of maternal and child health (MCH) care utilization in Indonesia using the continuum of care (CoC) concept.

BACKGROUND

The concept of CoC has emerged as an important guiding principle in reproductive, maternal, newborn, and child health. Indonesia's maternal mortality rate, neonatal mortality, and under-five mortality rates are among the highest in the Southeast Asian region.

METHODS

Using pooled data from four successive waves of the nationally representative Indonesian Demographic and Health Survey (IDHS) conducted in the years 2002, 2007, 2012, and 2017, we use multivariate regression models to analyze care across four components of the continuum: antenatal care (ANC), institutional delivery, postnatal care for children, and full immunization (IM).

FINDINGS

CoC at each stage of MCH care has improved continuously over the period 2002-2017 in Indonesia. Despite this, just less than one out of two children receive all four components of the CoC. The overall coverage of CoC from its second stage (four or more ANC visits) to the final stage (full child IM) is driven by the dropouts at the ANC visit stage, followed by the loss of postnatal checkups and child IM. We find that the probability of a child receiving CoC at each of the four stages is significantly associated with maternal age and education, the household's socioeconomic and demographic characteristics, and economic status.

CONCLUSION

Complete CoC with improved, affordable, and accessible MCH care services has the potential to accelerate the progress of Sustainable Development Goal 3 by reducing maternal and childhood mortality risks. Our findings show that in Indonesia, the CoC continuously declines as women proceed from ANC to other MCH services, with a sharp decline observed after four ANC visits. Our study has identified key socioeconomic characteristics of women and children that increase their probability of failing to access care.

Factors influencing health service utilization among mothers for under-five children: A cross-sectional study in Khulna district of Bangladesh

Although Bangladesh has made significant progress in reducing child mortality, proper utilization of health services for under-five children among mothers remains one of the major challenges. Hence, this study was designed to investigate the factors influencing health service utilization among mothers for under-five children in the Khulna district of Bangladesh. Administering a semi-structured interview schedule, data were collected from 364 randomly selected mothers from the study area between June and August 2021. At first, Pearson’s Chi-square test was conducted to measure the association between outcome and predictor variables. Multivariable logistic regression model was used to identify the factors associated with utilization of health services. Overall, about 59 percent of the mother received health services from unqualified doctors during their children’s illness and the rest of them (41.5%) seek care from the qualified doctors. Results of regression analysis revealed that long duration of illness (AOR = 2.338; CI: 1.175–4.649; p = 0.015), the severity of illness (AOR = 6.402; CI: 3.275–12.513; p<0.001), and higher cost of treatment (AOR = 7.371; CI: 3.297–16.480; p<0.001) were the significant predictors of utilization of health services from the qualified doctors for under-five children. Thus, the study suggests that to reduce under-five child mortality by ensuring proper utilization of health services, it is necessary to raise awareness among mothers, improve transport facilities, establish need-based health care centers, and lower treatment costs.

Maternal and child health handbook to improve continuum of maternal and child care in rural Bangladesh: Findings of a cluster randomized controlled trial

This study aimed to evaluate the effectiveness of maternal and child health handbook (MCH) enhanced by mobile tools and to generate evidence informing the adoption of the program in Bangladesh. A cluster randomized controlled trial (RCT) has been implemented in Lohagora of Narail District and Dhamrai of Dhaka District. Unions of the study settings were randomly allocated in either one of three groups: (1) Intervention 1 using both mobile platform and MCH, (2) Intervention 2 using MCH alone, or (3) the Control. A total of 3,002 participants were recruited. The interventions were designed to promote two-way communications between pregnant women/their families and community health workers by an empowering approach. A total of 3,002 pregnant women were recruited. As the results, the interventions both significantly improved the utilization of CoC, although the overall proportion of CoC was relevantly low: 2.79% in the Control (95% CI: 1.37–3.54%), 6.16% in Intervention 2 (95% CI: 4.67–7.86%), and 7.89% in Intervention 1 (95% CI: 6.29–9.90%). Neonatal mortality rate with and without CoC was 5.43 per 1,000 (95% CI: 3.63–9.57 per 1,000) and 34.8 per 1,000 (95% CI: 24.3–45.4 per 1,000), respectively. Our study indicated the effectiveness of the interventions by leveraging MCH and a mobile platform to promote uptake of CoC throughout prepartum, intrapartum and postpartum/neonatal periods, potentially bringing long-lasting benefits to mothers and their offspring. The explicit approach is expected to guide policy makers to adopt MCH interventions in primary healthcare strengthening at the community level.

Trial registration:UMIN000025628 Registered June 13, 2016.

Prevalence and factors associated with child health record book utilization among parents attending government health clinics in Putrajaya, Malaysia

BACKGROUND

Use of a child health record book has long been established in Malaysia. The objective of the study was to determine the proportion of optimum child health record book utilization and its associated factors among parents attending government child health clinics in Putrajaya, the administrative capital of Malaysia.

METHODS

A cross-sectional study was conducted among randomly selected group of 450 parents using a self-administered questionnaire. Optimum utilization of the book was defined as respondents reading all sections and recording comments in the book. Independent variables studied were sociodemographic characteristics; antenatal and breastfeeding history; child health and immunization status; perceptions and level of knowledge on the book and child health; and healthcare providers' performance. A multiple logistic regression analysis was used to identify the associated factors of optimum utilization.

RESULTS

Out of 450 study participants, 415 completed the questionnaire and 150 (36.1%) were found to optimally utilized the book. Participants who read all sections totalled 245 (59.0%), and 242 (58.3%) respondents reported to record some comments in the book. Optimum utilization of the book was associated with older parents' age (adjusted odds ratio [AOR]: 1.06, 95% confidence interval [CI] 1.01-1.11) and higher education attainment (AOR: 2.21, 95% CI 1.24-3.91), with a good level of knowledge on child health record books and general child health (AOR: 3.87, 95% CI 2.27-6.61; AOR: 2.05, 95% CI 1.25-3.36) and among parents who delivered their children in government hospitals (AOR: 2.93, 95% CI 1.11-7.73).

CONCLUSIONS

The prevalence of child health record book utilization was low at 36.1% but difficult to compare with other studies. Based on the findings, improving the parents' knowledge of the book and general child health, particularly among younger parents with lower educational levels, and delivering the book to institutions outside government hospitals might be useful to increase the utilization.

Maternal and Child Health Handbook use for maternal and child care: a cluster randomized controlled study in rural Java, Indonesia

Background

Effectiveness of the Maternal and Child Health Handbook (MCHHB), a home-based booklet for pregnancy, delivery and postnatal/child health, was evaluated on care acquisition and home care in rural Java, a low service-coverage area.

Methods

We conducted a health centre-based randomized trial, with a 2-year follow-up. Intervention included (i) MCHHB provision at antenatal care visits; (ii) records and guides by health personnel on and with the MCHHB; and (iii) sensitization of care by volunteers using the MCHHB.

Results

The follow-up rate was 70.2% (183, intervention area; 271, control area). Respondents in the intervention area received consecutive MCH services including two doses of tetanus toxoid injections and antenatal care four times or more during pregnancy, professional assistance during child delivery and vitamin A supplements administration to their children, after adjustment for confounding variables and cluster effects (OR = 2.03, 95% CI: 1.19–3.47). In the intervention area, home care (continued breastfeeding; introducing complementary feeding; proper feeding order; varied foods feeding; self-feeding training; and care for cough), perceived support by husbands, and lower underweight rates and stunting rates among children were observed.

Conclusion

MCHHB use promoted continuous care acquisition and care at home from pregnancy to early child-rearing stages in rural Java.

Home-based records for poor mothers and children in Afghanistan, a cross sectional population based study

BACKGROUND

No studies have examined distribution, retention and use of maternal and child health (MCH) home-based records (HBRs) in the poorest women in low income countries. Our primary objective was to compare distribution of the new Afghanistan MCH HBR (the MCH handbook) to the poorest women (quintiles 1-2) with the least poor women (quintiles 3-5). Secondary objectives were to assess distribution, retention and use of the handbook across wealth, education, age and parity strata.

METHODS

This was a population based cross sectional study set in Kama and Mirbachakot districts of Afghanistan from August 2017 to April 2018. Women were eligible to be part of the study if they had a child born in the last 6 months. Multivariable logistic regression models were constructed to adjust for clustering by district and potential confounders decided a priori (maternal education, maternal age, parity, age of child, sex of child) and to calculate adjusted odds ratios (aOR), 95% confidence intervals (95% CI) and corresponding p values. Principal components analysis was used to create the wealth quintiles using standard methods. Wealth categories were 'poorest' (quintiles 1,2) and 'least poor' (quintiles 3,4,5).

RESULTS

1728/1943 (88.5%) mothers received a handbook. The poorest women (633, 88.8%) had similar odds of receiving a handbook compared to the least poor (990, 91.7%) (aOR 1.26, 95%CI [0.91-1.77], p value 0.165). Education status (aOR 1.03, 95%CI [0.63-1.68], p value 0.903) and age (aOR 1.39, 95%CI [0.68-2.84], p value 0.369) had little effect. Multiparous women (1371, 91.5%) had a higher odds than primiparous women (252, 85.7%) (aOR 1.83, 95%CI [1.16-2.87], p value 0.009). Use of the handbook by health providers and mothers was similar across quintiles. Ten (0.5%) women reported that they received a book but then lost it.

CONCLUSIONS

We were able to achieve almost universal coverage of our new MCH HBR in our study area in Afghanistan. The handbook will be scaled up over the next three years across all of Afghanistan and will include close monitoring and assessment of coverage and use by all families.

Adapting home-based records for maternal and child health to users' capacities

Home-based records have been used in both low- and high-income countries to improve maternal and child health. Traditionally, these were mostly stand-alone records that supported a single maternal and child health-related programme, such as the child vaccination card or growth chart. Recently, an increasing number of countries are using integrated home-based records to support all or part of maternal and child health-related programmes, as in the maternal and child health handbook. Policy-makers’ expectations of home-based records are often unrealistic and important functions of the records remain underused, leading to loss of confidence in the process, and to wasted resources and opportunities for care. We need to examine the gaps between the functions of the records and the extent to which users of records (pregnant women, mothers, caregivers and health-care workers) are knowledgeable and skilful enough to make those expected functions happen. Three key functions, with increasing levels of complexity, may be planned in home-based records: (i) data recording and storage; (ii) behaviour change communication, and (iii) monitoring and referral. We define a function–capacity conceptual framework for home-based records showing how increasing number and complexity of functions in a home-based record requires greater capacity among its users. The type and functions of an optimal home-based record should be strategically selected in accordance not only with demands of the health system, but also the capacities of the record users.

Effectiveness of home-based records on maternal, newborn and child health outcomes: A systematic review and meta-analysis

Home-based records (HBRs) may improve the health of pregnant women, new mothers and their children, and support health care systems. We assessed the effectiveness of HBRs on maternal, newborn and child health reporting, care seeking and self-care practice, mortality, morbidity and women's empowerment in low-, middle- and high-income countries. We conducted a systematic search in MEDLINE, EMBASE, CENTRAL, Health Systems Evidence, CINAHL, HTA database, NHS EED, and DARE from 1950 to 2017. We also searched the WHO, CDC, ECDC, JICA and UNAIDS. We included randomised controlled trials, prospective controlled trials, and cost-effectiveness studies. We used the Cochrane Risk of Bias tool to appraise studies. We extracted and analyzed data for outcomes including maternal, newborn and child health, and women's empowerment. We synthesized and presented data using GRADE Evidence Profiles. We included 14 studies out of 16,419 identified articles. HBRs improved antenatal care and reduced likelihood of pregnancy complications; improved patient-provider communication and enhanced women's feelings of control and empowerment; and improved rates of vaccination among children (OR: 2·39, 95% CI: 1.45-3·92) and mothers (OR 1·98 95% CI:1·29-3·04). A three-year follow-up shows that HBRs reduced risk of cognitive delay in children (p = 0.007). HBRs used during the life cycle of women and children in Indonesia showed benefits for continuity of care. There were no significant effects on healthy pregnancy behaviors such as smoking and consumption of alcohol during pregnancy. There were no statistically significant effects on newborn health outcomes. We did not identify any formal studies on cost or economic evaluation. HBRs show modest but important health effects for women and children. These effects with minimal-to-no harms, multiplied across a population, could play an important role in reducing health inequities in maternal, newborn, and child health.

Effectiveness of the Maternal and Child Health handbook in Burundi for increasing notification of birth at health facilities and postnatal care uptake

Background: In Burundi, birth certificate ownership (56.4%) and postnatal care (PNC) coverage (30%) remain low. Birth certificates prove birth registration and allow clients to receive free medical care including PNC. To obtain birth certificates, notification of birth by witnesses is indispensable. However, use of existing parallel home-based records for mother and child has prevented clients from successfully receiving notification of birth and related information.

Objective: To assess the effectiveness of the Maternal and Child Health (MCH) handbook for increasing notification of birth at health facilities and PNC uptake.

Methods: Pre- and post-introduction measurement were applied including: (i) structured interviews with two different sets of randomly selected mothers having infants aged less than six weeks at the pre- or post-studies; and (ii) secondary data from the national health management information system.

Results: 95.1% of mothers had an MCH handbook post-study. Significant improvement was observed in the proportion of mothers receiving notification of birth at health facilities, from 4.6% to 61.0% (95% confidence interval [CI]: 55.9%–66.2%), and the proportion of mothers receiving guidance on PNC, from 35.9% to 64.2% (95% CI: 59.2%–69.3%). The annual PNC coverage (43.9% to 54.2%; p < 0.05) in the Gitega District significantly increased from 2013 to 2014. Among MCH handbook owners, mothers giving birth at hospitals/clinics had 2.62 higher odds (95% CI: 1.63–4.22) of obtaining notification of birth than mothers giving birth at health centers. Conversely, mothers delivering at hospitals/clinics had 0.51 lower odds (95% CI: 1.63–4.22) of receiving PNC guidance than mothers delivering at health centers.

Conclusions: As previous studies showed, the MCH handbook appeared to help health personnel provide guidance on PNC, thereby it may have increased PNC. Furthermore, this study suggests the handbook contributed to every birth being counted. However, to increase the effectiveness of the handbook, health personnel should be encouraged toward its proper use.

Mobile-health tool to improve maternal and neonatal health care in Bangladesh: a cluster randomized controlled trial

BACKGROUND

In Bangladesh, the targets on reduction of maternal mortality and utilization of related obstetric services provided by skilled health personnel in Millennium Development Goals 5 remains unmet, and the progress in reduction of neonatal mortality lag behind that in the reduction of infant and under-five mortalities, remaining as an essential issue towards the achievement of maternal and neonatal health targets in health related Sustainable Development Goals (SDGs). As access to appropriate perinatal care is crucial to reduce maternal and neonatal deaths, recently several mobile platform-based health programs sponsored by donor countries and Non-Governmental Organizations have targeted to reduce maternal and child mortality. On the other hand, good health-care is necessary for the development. Thus, we designed this implementation research to improve maternal and child health care for targeting SDGs.

METHODS/DESIGN

This cluster randomized trial will be conducted in Lohagora of Narail District and Dhamrai of Dhaka District. Participants are pregnant women in the respective areas. The total sample size is 3000 where 500 pregnant women will get Mother and Child Handbook (MCH) and messages using mobile phone on health care during pregnancy and antenatal care about one year in each area. The other 500 in each area will get health education using only MCH book. The rest 1000 participants will be controlled; it means 500 in each area. We randomly assigned the intervention and controlled area based on smallest administrative area (Unions) in Bangladesh. The data collection and health education will be provided through trained research officers starting from February 2017 to August 2018. Each health education session is conducting in their house. The study proposal was reviewed and approved by NCCD, Japan and Bangladesh Medical Research Council (BMRC), Bangladesh. The data will be analyzed using STATA and SPSS software.

DISCUSSION

For the improvement of maternal and neonatal care, this community-based intervention using mobile phone and handbook will do great contribution. Thus, a developing country where resources are limited received the highest benefit. Such intervention will guide to design for prevention of other diseases too.

TRIAL REGISTRATION

UMIN000025628 Registered June 13, 2016.

Cost savings through implementation of an integrated home-based record: a case study in Vietnam

OBJECTIVES

In Vietnam, there are three major home-based records (HBRs) for maternal and child health (MCH) that have been already nationally scaled up, i.e., Maternal and Child Health Handbook (MCH Handbook), Child Vaccination Handbook, and Child Growth Monitoring Chart. The MCH Handbook covers all the essential recording items that are included in the other two. This overlapping of recording items between the HBRs is likely to result in inefficient use of both financial and human resources. This study is aimed at estimating the magnitude of cost savings that are expected to be realized through implementing exclusively the MCH Handbook by terminating the other two.

STUDY DESIGN

Secondary data collection and analyses on HBR production and distribution costs and health workers' opportunity costs.

METHODS

Through multiplying the unit costs by their respective quantity multipliers, recurrent costs of operations of three HBRs were estimated. Moreover, magnitude of cost savings likely to be realized was estimated, by calculating recurrent costs overlapping between the three HBRs.

RESULTS

It was estimated that implementing exclusively the MCH Handbook would lead to cost savings of United States dollar 3.01 million per annum. The amount estimated is minimum cost savings because only recurrent cost elements (HBR production and distribution costs and health workers' opportunity costs) were incorporated into the estimation. Further indirect cost savings could be expected through reductions in health expenditures, as the use of the MCH Handbook would contribute to prevention of maternal and child illnesses by increasing antenatal care visits and breastfeeding practices.

CONCLUSION

To avoid wasting financial and human resources, the MCH Handbook should be exclusively implemented by abolishing the other two HBRs. This study is globally an initial attempt to estimate cost savings to be realized through avoiding overlapping operations between multiple HBRs for MCH.

Predictors of Health-Care Utilization Among Children 6-59 Months of Age in Zambézia Province, Mozambique

Globally, approximately 5.9 million children under 5 years of age died in 2015, a reduction of over 50% since 1990. Millennium Development Goal 4 established the goal of reducing child mortality by two-thirds by 2015. Multiple countries have surpassed this goal; however, regional and within-country inequities exist. We sought to study determinants of health-care utilization among children 6-59 months of age with fever, diarrhea, and respiratory symptoms in Zambézia Province, Mozambique. We conducted a population-based cross-sectional survey of female heads of household between April and May 2014. Mobile teams conducted interviews in 262 enumeration areas, with three distinct districts being oversampled for improved precision. Descriptive statistics and logistic regression using Stata 13.1 and R 3.2.2 were used to examine factors associated with health-care utilization. A total of 2,317 children were evaluated in this study. Mothers' median age was 26 years, whereas child median age was 24 months. The proportion of children reporting fever, diarrhea, or respiratory illness in the prior 30 days was 44%, 22%, and 22%, respectively. Health-care utilization varied with 65% seeking health care for fever, compared with 57% for diarrhea and 25% for respiratory illness. In multivariable logistic regression, the characteristics most associated with health-care utilization across illnesses were delivery of last child at a facility, higher maternal education, and household ownership of a radio. The decision or ability to use health care is a multifaceted behavior swayed by societal norms, values, socioeconomics, and perceived need. Recognizing the predictors of a particular population may offer useful information to increase uptake in health-care services.

Fragmented implementation of maternal and child health home-based records in Vietnam: need for integration

BACKGROUND

Home-based records (HBRs) are globally implemented as the effective tools that encourage pregnant women and mothers to timely and adequately utilise maternal and child health (MCH) services. While availability and utilisation of nationally representative HBRs have been assessed in several earlier studies, the reality of a number of HBRs subnationally implemented in a less coordinated manner has been neither reported nor analysed.

OBJECTIVES

This study is aimed at estimating the prevalence of HBRs for MCH and the level of fragmentation of and overlapping between different HBRs for MCH in Vietnam. The study further attempts to identify health workers' and mothers' perceptions towards HBR operations and utilisations.

DESIGN

A self-administered questionnaire was sent to the provincial health departments of 28 selected provinces. A copy of each HBR available was collected from them. A total of 20 semi-structured interviews with health workers and mothers were conducted at rural communities in four of 28 selected provinces.

RESULTS

Whereas HBRs developed exclusively for maternal health and exclusively for child health were available in four provinces (14%) and in 28 provinces (100%), respectively, those for both maternal health and child health were available in nine provinces (32%). The mean number of HBRs in 28 provinces (=5.75) indicates over-availability of HBRs. All 119 minimum required items for recording found in three different HBRs under nationwide scale-up were also included in the Maternal and Child Health Handbook being piloted for nationwide scaling-up. Implementation of multiple HBRs is likely to confuse not only health workers by requiring them to record the same data on several HBRs but also mothers about which HBR they should refer to and rely on at home.

CONCLUSIONS

To enable both health workers and pregnant women to focus on only one type of HBR, province-specific HBRs for maternal and/or child health need to be nationally standardised. Moreover, to ensure a continuum of maternal, newborn, and child health care, the HBRs currently fragmented into different MCH stages (i.e. pregnancy, delivery, child immunisation, child growth, and child development) should be integrated. Standardisation and integration of HBRs will help increase technical efficiency and financial sustainability of HBR operations.

Knowledge, attitude and practices: assessing maternal and child health care handbook intervention in Vietnam

BACKGROUND

Maternal and Child Health (MCH) Handbook, an integrated MCH home-based record, was piloted in four provinces of Vietnam (Dien Bien, Hoa Binh, Thanh Hoa and An Giang). The study is aimed at assessing the changes in pregnant women's behavior towards the frequencies of their antenatal care service utilizations and their subsequent breastfeeding practices up to six months of age, through the MCH Handbook intervention. This is because the levels of pregnant women's knowledge, attitude and practices (KAP) towards their antenatal care service utilizations and exclusive breastfeeding practices have been previously neither analyzed nor reported in relation to MCH home-based records in the country.

METHODS

To compare pre-intervention baseline in 2011, post-intervention data were collected in 2013. Structured interviews were conducted with randomly selected 810 mothers of children 6-18 months of age in the four provinces. A focus group discussion among mothers in each of four provinces was conducted.

RESULTS

There was no significant difference in pregnant women's knowledge about the need for ≥3 antenatal care visits between pre- and post-interventions. Yet, the proportion of pregnant women who made ≥3 antenatal care visits in post-intervention was significantly higher than in pre-intervention. Thus, MCH Handbook is likely to have contributed to practicing ≥3 antenatal care visits, by changing their attitude. The proportion of mothers who know the need for exclusive breastfeeding necessary during the initial six months significantly increased between pre- and post-interventions. The proportion of those practicing exclusive breastfeeding significantly increased between pre- and post-interventions, too. Thus, MCH Handbook is likely to have contributed to the increase in both knowledge about and practices of exclusive breastfeeding.

CONCLUSION

The results of study imply that MCH Handbook contributed to the increase in pregnant women's practices of ≥3 antenatal care visits and in their knowledge about and practice of exclusive breastfeeding. While there is room for improvement in the level of its data recording, the study confirmed that MCH Handbook plays a catalytic role in ensuring a continuum of maternal, newborn and child care. Note that this study is the first study that attempted to estimate pregnant women's behavioral changes through MCH Handbook intervention in Vietnam.