Effect of a maternal and child health handbook on maternal knowledge and behaviour: a community-based controlled trial in rural Cambodia

Maternal and child health (MCH) handbooks are comprehensive home-based booklets designed to integrate MCH records. Although empirical evidence suggests the handbooks are more effective than current card-type records, this has not been scientifically demonstrated. The objectives of this study were to evaluate the impact of the MCH handbook on maternal knowledge and behaviour as measured by antenatal care (ANC) attendance, delivery with skilled birth attendants (SBAs) and delivery at a health facility. The Cambodian version of the MCH handbook was developed and introduced in two health centres, and two other health centres served as controls. Pre-intervention and post-intervention surveys were conducted with 320 women from the intervention areas and 320 women from the control areas who had given birth within 1 year before the survey. We evaluated the impact of the handbook by using difference-in-differences (DID) analysis and calculated adjusted odds ratios for pre-post changes in key indicators by using logistic regression. In addition, we interviewed multiparous women, health staff and health volunteers to assess the acceptance and cultural appropriateness of the handbook. Content analysis was performed with the English-translated transcriptions. The DID analyses revealed that all key indicators increased in the intervention group against counterfactual assumptions. The intervention also increased maternal knowledge of all topics addressed except for the risk of severe bleeding after delivery; this may be attributable to the influence of cultural belief. Logistic regression showed that the intervention increased ANC attendance, delivery with SBAs and delivery at a health facility, even after adjusting for maternal age, education and economic conditions. The qualitative data indicated that the handbook was well received and culturally appropriate. Thus, the MCH handbook is a reasonable and superior alternative to current card-type maternal records.