Introduction

Home-based records (HBRs) are used in over 163 countries or territories [1]. These records are paper or electronic documents that pregnant women and caregivers commonly maintain and use in the household to monitor the health of the household’s children. The contents of HBRs cover one or more components of preventive or curative antenatal, postnatal, newborn, and child health, including vaccination and nutrition. These records may improve maternal, newborn and child health and development in both developed and developing countries [2–4]. Demographic health surveys from 1993 to 2013 indicate prevalence of country-specific HBR usage was at least 90% in all regions around the world, except for South-East Asia, where prevalence was estimated to be 84% [5]. However, use of HBRs is inconsistent across and within countries; and despite the benefits shown in primary studies, parents and health care practitioners often underutilize HBRs or use them inappropriately [1, 3].

In 2015, the number of maternal deaths due to preventable pregnancy- or childbirth-related complications was 303,000 [6], of which 99% occurred in settings of limited resources [7]. In 2016, 5.6 million children under age five died from preventable causes [8]. Most of these deaths occurred in low- and middle-income countries (LMICs) [8]. The UN Sustainable Development Goal 3 calls for an end to the preventable deaths of children under age five, by 2030 [9].

HBRs are a simple, globally applicable intervention that may improve the health and lives of women and children. HBRs have a unique role in linking mothers and caregivers to maternal, newborn and child health information and health care. In addition, health education messages are often included in these records so as to promote better health care seeking, healthy behaviours, and safe home care practices. HBRs come in different forms, starting with the most basic antenatal or vaccination-only cards, and progressing to vaccination-plus cards, maternal and child health books, and electronic records. Electronic records provide patients with access to their health information through the internet, cellular devices, and tablets. The growth of electronic HBRs reflects the increasing trend in the digitization of health care [10].

In 1994, World Health Organization (WHO) recommended that all women of childbearing age should have home-based maternal records [11]. More recently, the WHO has developed guidance to improve the use and design of HBRs for immunisation [12]. Additionally, the WHO’s health systems interventions to improve the utilisation and quality of antenatal care include women-held case notes [13]. Although, in 1992, a WHO collaborative study [2] evaluated the process and functioning of HBRs for maternal health in eight countries, global evidence on their effects on maternal, newborn and child health has never been systematically reviewed, nor has a global assessment of the benefits of using different types of HBRs been conducted [14]. The objective of this review is to synthesise and compare the evidence of the health and cost effectiveness of HBRs for improving maternal, newborn and child health outcomes, including empowerment outcomes for women. This study also aims to determine whether particular types of HBRs improve these outcomes more than others.

Methods

Search strategy and selection criteria

We followed the PRISMA reporting guidelines [15] for the design and reporting of this systematic review and meta-analysis. This study addresses women and other caregivers, and practitioners (P), home-based records (I), versus limited or no use of home-based records (C) using international consensus outcomes (O). We used the GRADE approach to systematically estimate the certainty of the evidence for each outcome (Table 1) [16]. We published a protocol on the Cochrane Equity Methods website [17].

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Table 1. Certainty of evidence and definitions.

https://doi.org/10.1371/journal.pone.0209278.t001

Results

We screened 16,419 titles and abstracts for eligibility on the effectiveness and cost-effectiveness of home-based records. In all, 14 studies met our inclusion criteria (Fig 1). Studies were excluded at the full text stage due to irrelevant population (n = 2), full text could not be retrieved (n = 1), and study design or irrelevant intervention (n = 109) (S2 File).

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Fig 1. PRISMA flow diagram.

https://doi.org/10.1371/journal.pone.0209278.g001

Among the included studies were 9 RCTs, 1 cluster RCT and a three-year follow-up, and 2 controlled trials. We did not find any eligible ITS studies. Studies were conducted in high-income countries: Australia (n = 1), England (n = 4), Norway (n = 1), United States of America (USA) (n = 1); and in low- and middle-income countries: Cambodia (n = 1), Indonesia (n = 1), Mongolia (n = 1) and Pakistan (n = 2). Table 2 shows the intervention and population descriptions; Fig 2 shows a summary of the risk of bias.

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Fig 2. Risk of Bias summary.

Review authors' judgements (Low, Unclear and High) about each risk of bias item for each individual study using the Cochrane Risk of Bias tool.

https://doi.org/10.1371/journal.pone.0209278.g002

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Table 2. Characteristics of included studies.

https://doi.org/10.1371/journal.pone.0209278.t002

No RCTs or controlled trials reported on maternal mortality, pregnancy nutrition, the number of postpartum visits, care seeking for postpartum complications, postpartum family planning, growth monitoring, development monitoring, continued breastfeeding and warmth and hygiene of the newborn. We did not identify any evidence comparing different types and designs of HBRs, and therefore results are reported considering HBRs as a single intervention. A complete summary of outcomes, effect sizes and certainty of evidence is provided in GRADE evidence profiles (S3 File).

Child health outcomes

Among child health outcomes, evidence indicates that HBRs may have an impact on immunisation rates, growth and development. Age-appropriate immunisation, including a three-dose series of diphtheria-pertussis-tetanus (DPT) by seven months of age, improved with newly designed immunisation cards and educational interventions (Fig 3). In Pakistan, studies completed in both rural and urban areas show that using a redesigned immunisation card results in a significant improvement in immunisation uptake, compared to a standard expanded program on immunisation (EPI) card (OR: 2·39, 95% CI: 1·45–3·92) (GRADE certainty of evidence: moderate) [29, 30]. In Indonesia, after using the MCH handbook, there were fewer underweight children (OR 0·33, 95% CI 0·12–0·94; GRADE certainty of evidence: very low) and fewer children with stunted growth (OR 0·53, 95% CI 0·30–0·92; GRADE certainty of evidence: low), after adjusting for maternal BMI and child birth weight [26]. In Mongolia, a 3-year follow-up showed a reduced risk of cognitive development delay in children (OR 0·32, 95% CI:0·14–0·73, p-value = 0.007) (GRADE certainty of evidence: very low) [31]. Similarly, in Indonesia, the use of the MCH handbook is shown to influence husbands’ involvement in providing their child with developmental stimulation (OR 1·62 95% CI:1·06–2·48).

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Fig 3. Meta-analysis of childhood vaccination (DTP) series completion among individuals using HBRs as compared to no HBR (1.1.1) or existing EPI cards (1.1.2).

https://doi.org/10.1371/journal.pone.0209278.g003

Respondents using the MCH handbook in Indonesia were more concerned about continuity of care throughout the maternal, newborn and child period. They were more likely to receive multiple services, including two doses of tetanus immunisation, antenatal care four times, professional assistance during child delivery, ensure that their child took vitamin A supplements, exclusively breastfeed during infancy, and begin complementary feeding in 6–9 months (OR 7·13, 95% CI: 2·43–20·90; GRADE certainty of evidence: low) [26]. After a two year follow up, both intervention and control groups saw improvements in bringing their HBRs to more than two facilities, on more than two occasions, or filled in by more than two health personnel (GRADE certainty of evidence: very low) [26].

Discussion

HBRs show modest impacts on maternal and child health outcomes, including antenatal clinic attendance, improving childhood immunisation rates, and promote feelings of control and empowerment among women. While several studies report on the prevalence of different kinds of HBRs between countries, the design, use and complexity of these records vary [3, 5]. Countries have identified the need for a standardised HBR so as to improve data transferability and secure the accuracy of data recording and transcription [33]. With a standardised design and proper utilisation between different health providers, these records could promote continuous maternal and child health care [34]. Since each country has its own challenges in delivering health care, different regional, social, and economic factors affect their ability to deliver proper health services to women and children. Organisations have highlighted the need for stakeholder engagement in the design, distribution, and implementation of HBRs for maternal and child health, so as to ensure the successful uptake and sustainability of these records [35, 36]. Additionally, there is no high quality evidence available that compares electronic versus paper HBRs for maternal and child health. Further research, here, is necessary. Finally, there is a need for more research that compares integrated HBRs (e.g., MCH Handbooks) and stand-alone records (e.g., vaccination cards, growth charts).

This systematic review provides insights into the effectiveness of HBRs on maternal, newborn and child health outcomes. High quality evidence indicates that HBRs may facilitate the identification of pregnancy complications [25]. Two RCTs show no effect on the reduction of neonatal mortality. However, findings from Japan suggest that HBRs may have played an important role in reducing this country’s infant mortality rate to one of the lowest in the world [37]. In Vietnam, MCH handbook usage shows similar decreases in the mortality rates of mothers during and shortly after pregnancy and of children under age five [4]. In Mongolia, it is also shown that HBRs have the potential to reduce child morbidity, as a three-year follow-up shows their protective effect on child cognitive development. This clinically important effect may have come from the frequent use of the part of the home-based record that increases mothers’ awareness of their children's developmental milestones and enhances their efforts to interact with their children [26, 31].

Home-based records help pregnant women remember antenatal care visits, thereby preventing missed appointments, and increasing their number of antenatal visits [25–27, 38, 39]. Integrated home-based records that are implemented in other parts of the world, such as Burundi, have also helped health practitioners provide information on prenatal care, which has increased the number of prenatal care visits [40]. This is consistent with other studies in LMICs that report on the role of HBRs in increasing health service uptake and promoting patient health behaviours [34, 41–45]. Home-based records have no effect on improving health behaviours, such as smoking and alcohol consumption. However, it is important to note the almost three decades that separate these two RCTs; the opposing results of these studies may come from the improved knowledge, over time, of the impacts of smoking and drinking behaviours during pregnancy. Additionally, while the control mothers in the Lovell (1984) study were not holding their case notes during their health care visits, they did have access to them while they were waiting in the antenatal clinic and may have benefitted from access to this information.

The use of home-based records is recommended in resource-limited settings [31]. These records improve the relationship and communication between mothers and health care providers; they also enhance women’s feelings of empowerment and promote a more efficient use of health service resources [25, 28, 38, 46]. In Palestine, women who were part of a national program noted that it is easier to ask questions about their health when they are holding their own handbook; also, women with less education became more familiar with their maternal and child health information through the guidance of healthcare providers who use these home-based records [34]. Personalised guidance, such as face-to-face interactions or maternal- and child-health-related social events, is essential for mothers who are less literate and who are using home-based records; this ensures they understand the information on pregnancy and it improves their pregnancy-related behaviours [43]. However, these benefits depend on whether all parties are using the record. Contrary to popular belief, women do not misplace their records more often than hospitals do, and the added information these records provide does not cause users to become more anxious [47]. These results have implications for hospital administrators and health planners, and it is necessary to train health care providers on the appropriate use of these records [26, 31].

The use of HBRs, including information on vaccination and the implementation of redesigned immunisation records, increases immunisation uptake in children and mothers [25, 28, 29, 37, 38]. The redesigned immunisation card has led to a higher increase in DPT series completion in children in rural areas compared to those in urban areas [28, 29]. This suggests that this type of intervention is beneficial in areas of lower literacy and in rural areas [28]. In Ethiopia and Madagascar, redesigned immunisation cards have been implemented with success and have also served as examples for Ghana, Liberia, and Myanmar [34].

The goal of this review was to evaluate the effectiveness of HBRs on maternal and child health in order to determine the role these records play in improving health outcomes. Our review highlights key gaps in the economic implications of HBRs. A few studies [5, 32] show that the costs associated with HBRs are minimal; also, the quality of these studies’ methodology was poor. Studies on the cost of illness or cost-description, although important, do not address the potential downstream benefits of HBRs and the impact on vaccine-preventable diseases. To inform decisions on resource allocation, future studies should assess the cost-effectiveness of HBRs by comparing the cost of their implementation, including infrastructure, materials, supplies, and delivery, against their health and economic benefits.

Strengths and limitations

We used high quality methods to synthesise randomised controlled trials and controlled trials, conducted the first meta-analyses in this area, and used GRADE methods to assess the certainty of the effects. Limitations include a broad range of outcomes and, thus, too few studies available for meta-analyses. The number of studies was not sufficient to conduct subgroup analyses on various regions or low-income countries. Blinding for the intervention of the HBR was not feasible. There was heterogeneity in the interventions, particularly between integrated and non-integrated (card-type) HBRs. Most studies on electronic HBRs did not evaluate the effects of the electronic record, suggesting that more research is needed as electronic records begin to emerge. The available evidence was insufficient to use network meta-analysis to answer the question of the relative advantages of the different types of home-based records. In our systematic review, the studies did not use placebo designs and, instead, used several different interventions/comparisons. However, there was considerable heterogeneity in the outcome measures and this prevented a pooling of the effects.

Conclusions

HBRs show modest impacts on maternal and child health outcomes: improving antenatal clinic attendance, improving childhood immunisation rates and promoting feelings of control and empowerment among women. Electronic HBRs have begun to emerge as promising tools, but evidence gaps remain. Cost effectiveness studies are also needed for both electronic and paper HBRs.

Supporting information

Acknowledgments

The authors would like to acknowledge Joanna Vogel of WHO/MCA for coordinating the project and Anayda Gerarda Portela (WHO) and Helen Smith, of International Health Consulting Services Ltd, for review, verification and revising of GRADE. They would also like to acknowledge David Brown for his insights and Sarah Crispo of the Cochrane Equity Methods Group for her technical support.