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

Maternal and Child Health (MCH) Handbook is an integrated home-based record of health conditions of and health service utilizations by both a mother and her child, throughout pregnancy, delivery, postnatal, newborn and childhood stages. MCH Handbook has been increasingly drawing an international attention as an effective tool for MCH self-monitoring and subsequent timely and adequate MCH service utilizations. For instance, it was reported that ownership of MCH Handbook was significantly associated with having delivery assisted by trained personnel, receiving maternal care, and completing 12 doses of child immunizations for seven diseases, in Indonesia [1]. Having been expected to play a catalytic role in ensuring a continuum of seamless maternal, newborn and child care [1, 2] for achieving towards the Millennium Development Goal (MDG) 4 and 5, MCH Handbook has been implemented as an essential part of maternal and child health system in both developing and developed countries [3, 4]. MCH Handbook promotes health education and serves as the technically reliable source of the information for referring a patient to a higher/lower health facility and for collecting data in health surveys [5].

Vietnam, one of the eight ‘On-Track’ countries in both Millennium Development Goals (MDGs) 4 and 5, is making a successful progress in reducing maternal mortality ratio by 78 % from 233 in 1990 to 49 per 100,000 livebirths in 2013, and under-five mortality rate by 53 % from 51 in 1990 to 24 per 1,000 livebirths in 2013 [6]. Yet, these reductions have been achieved nationwide in a less equal manner. The discrepancies in both maternal mortality ratio and under-five mortality rate between provinces are significant. For instance, under-five mortality rate in Central Highland region (39.8) is 2.9 times and 1.7 times higher than respectively South East region (13.5) and national average (24) [7]. Similarly, maternal mortality ratio in North West Region (169) is 2.5 times higher than national average (67) [8]. Thus, to realize more equally lower under-five-mortality rate and maternal mortality ratio, it is key to ensure adequately frequent antenatal checkups and access to neonatal and child health care services in the provinces where MCH services are less accessible.

To address these challenges, the Vietnamese Ministry of Health (MoH), in collaboration with Japan International Cooperation Agency (JICA), implemented the standardized MCH Handbook for its nationwide scaling-up, through its field-piloting in four provinces with different profiles (Dien Bien, Hoa Binh, Thanh Hoa and An Giang) from 2011 to 2014. The standardized MCH Handbook was composed of recording section and guidance section for respective maternal and child health stages, i.e. pregnancy, delivery, postnatal, newborn and childhood. As of 30 September 2014, a total of 552,204 pregnant women and mothers with infants registered at local commune health centers in the four provinces received and used the MCH Handbooks.

This study is aimed at estimating the changes in pregnant women’s behavior towards the frequencies of their antenatal care service utilizations and their subsequent exclusive breastfeeding practices up to six months of age, through the MCH Handbook interventions in the four provinces of Vietnam. 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. Thus, this study serves as the first assessment of pregnant women’s behavioral changes through the interventions of MCH home-based records (incl. child vaccination cards) in Vietnam.

In this study, the changes in pregnant women’s behaviors toward antenatal care service utilizations and subsequent exclusive breastfeeding practices through MCH Handbook intervention were assessed, by comparing between pre-intervention and post-intervention data.

Table 2 presents the characteristics of mothers interviewed in the survey (post-intervention), in comparison with those of pregnant women and mothers of children under three years of age interviewed in 2011 (pre-intervention). Overall, socioeconomic and socio-demographic status of the interviewees were homogeneous between pre- and post-interventions. Table 3 presents the KAP variables in a manner that compares between pre- and post-interventions. The variables related to the use of MCH Handbook were measured only in post-intervention, as MCH Handbooks had been neither distributed nor used at the time of pre-intervention. Moreover, in pre-intervention, the two variables related to knowledge about antenatal care and breastfeeding had been measured among pregnant women, while another two variables related to their practices had been measured among mothers of children. This is because there was always risk that knowledge at time of pregnancy does not necessarily ensure their practices until and after delivery.

This study confirmed the likelihood of contribution of MCH Handbook intervention to the increase both in antenatal care service utilizations by pregnant women and in exclusive breastfeeding practices for initial six-months by mothers. However, its way of contributing differs between these two types of health seeking behaviors.

Figure 1 presents the hypothetical KAP process of antenatal care service utilizations and exclusive breastfeeding practices, that was estimated in this study. Prior to MCH Handbook intervention, 91.9 % of pregnant women in the four provinces had been already equipped with knowledge about need for three or more antenatal checkups. There was only a slight increase in the proportion of pregnant women with the knowledge after the intervention (93.7 %, P = 0.1559). Thus, health workers at commune health centers must have been skilled enough to advise pregnant women to have at least three antenatal checkups at their initial visit, even without and prior to MCH Handbook intervention. Therefore, contribution of MCH Handbook intervention to the increase in knowledge of antenatal care needs is likely to have been either complementary or limited. On the other hand, the proportion of pregnant women who made three or more antenatal care visits significantly increased from 67.5 % (pre-intervention) to 92.2 % (post-intervention) (P < 0.001). This implies that MCH handbook is likely to have effectively encouraged pregnant women to ensure three or more antenatal care visits during pregnancy, by making their antenatal care seeking attitude more proactive (Fig. 1). Trinh et al. [16] reported that initial guidance on three-time antenatal care visits by health workers is key to continuation of antenatal care in rural Vietnam. Yet, our study implies that health workers’ verbal guidance at initial antenatal care visit has limited effectiveness on their practices and that pregnant women’s ownership and self-review of MCH Handbook further motivate them to complete three antenatal checkups. As of 2012, the mean proportion of pregnant women who made three or more antenatal care visits in the four provinces (76.0 %) was lower than that in their nine adjacent provinces (82.9 %). Note that, however, it increased up to 92.2 % in 2013 (Table 4). This figure is higher than mean proportion in the nine adjacent provinces (82.9 %) as of 2012 [17]. This may imply an increase in the proportion of pregnant women who made three or more antenatal care visits in the adjacent provinces could be expected through the introduction of MCH Handbook. The Vietnamese MoH stipulates three or more antenatal care visits [18], while WHO globally recommends four or more [19]. Application of this relaxed national standard might have been rather effective, by serving as a more realistic and friendly standard particularly for pregnant women living in the areas less accessible to health services. Without revising the national standard of necessary number of antenatal care visits, Vietnam has made a remarkable progress towards achieving MDG 5 as one of only nine on-track countries [20]. Thus, MCH Handbook will be expected to continue to play a key role in keeping pregnant women informed of this minimum requirement of antenatal care visits.

MCH Handbook helped significantly increase both the proportion of pregnant women and mothers who have knowledge about exclusive breastfeeding for initial six months and the proportion of mothers who practice it. One may say that not a small number of mothers might have willingly provided pleasing responses to the interviewers. To prevent these inaccurate responses, their verbal responses were double-checked against the data in breastfeeding record pages of MCH Handbook. Note that 68.1 % of mothers recorded the results of exclusive breastfeeding practices (Fig. 1; Table 3). Moreover, when those not recording the data in MCH Handbook insisted their exclusive breastfeeding practices, their responses were double-checked against their family members’ observations and views. Thus, the proportion of those practicing breastfeeding for initial six months is unlikely to have been overestimated. Any intervention other than MCH Handbook might have contributed to this increase, too. While admitting its possibilities to a certain extent, we believe MCH Handbook intervention is the most powerful driving force which contributed to the increase not only in knowledge but also in attitude and practices towards exclusive breastfeeding among mothers. This is because MCH Handbook was the only major project-type intervention in the four provinces during 1.5-year period from pre-intervention survey (December 2011-January 2012) and post-intervention surveys (July-August 2013).

In Vietnam, exclusive breastfeeding has been neither well known nor practiced until recently [21]. Therefore, home-based records such as MCH Handbook could serve as one of the tools which expedite exclusive breastfeeding practices by keeping mother more routinely exposed to its guidance at home. Yet, not all the mothers, particularly those less literate, do not read MCH Handbook by themselves as expected (e.g. the thirdly quoted FGD participant). Supplementary behavior change communication should be the key to promoting and ensuring at-home MCH Handbook reading (e.g. face-to-face guidance, MCH-related social events). Hagiwara et al. [5] reported effectiveness of MCH Handbook on behavior changes in exclusive breastfeeding practices among mothers in Palestine. They stressed the importance of personalized guidance on the use of MCH Handbook for ensuring mothers’ knowledge about exclusive breastfeeding and danger signs during pregnancy.

This study has limitations in precision and generalizability of changes in mothers’ KAP towards their maternal and child health seeking behaviors. Those limitations are attributed primarily to lack of consideration on counterfactual effectiveness due to absence of a control group, and also to the challenges in controlling various variables confounding with KAP due to availability of only pre-aggregated baseline data for fewer variables. This study has limitations also in precisely specifying the causality between MCH Handbook intervention and the increase in the KAP related to antenatal care and exclusive breastfeeding. This is primarily because this study was designed to compare between two separate cross-sectional datasets of pre- and post-interventions. To address these limitations, either a randomized control trial or at least a longitudinal cohort study is necessary.

The results of study imply that MCH Handbook contributed to the increase in pregnant women’s practices of three or more antenatal care visits and in both knowledge about and practice of exclusive breastfeeding. While there is room for improvement in the level of data recording in it, the study confirmed that MCH Handbook plays a catalytic role in ensuring a continuum of maternal, newborn and child care.

In Vietnam, numerous home-based records for maternal and child health have been implemented in many parts of the country in a fragmented manner [22]. Therefore, it is an urgent task to standardize and integrate those currently existing home-based records into one. To address the issue, the Vietnamese MoH announced that the MCH Handbook piloted in the four provinces should be nationally scaled up as a single nationally standardized MCH home-based record, in August 2015. As MCH Handbook needs to be distributed to 1 million newly pregnant women per annum in the entire country, a national strategic plan for MCH Handbook operation should be carefully developed to ensure its operational sustainability.

There has been no reported case that attempted to estimate effectiveness and impact of home-based record intervention in Vietnam. In this respect, this study serves as the critical initial milestone for the future MCH home-based record deployment in the country.