The Mother and Child Health Handbook (2008), by the Palestinian Ministry of Health

In 2008, the Palestinian Ministry of Health published the Mother and Child Health Handbook, herafter the Handbook, to help improve health outcomes for pregnant women in the West Bank and Gaza, Palestine. The Handbook is a portable health record and information booklet that women can use to record and track health information from pregnancy through early childhood and across health providers. It includes templates for recording health data as well as information on proper growth milestones and healthy lifestyle choices. Each woman receives one Handbook during her pregnancy. Development of the Handbook occurred during a time when pregnant women were unable to access health facilities or receive necessary care due to regional conflicts. Since the Palestinian Ministry of Health began distributing the Handbook in Palestine in 2008, maternal and infant mortality rates have diminished around 46% and 35%, respectively, supporting the idea that providing women with basic prenatal and postnatal health information is an effective intervention for improving maternal and infant health.

The Handbook published by the Palestinian Ministry of Health was not the first such maternal and child health booklet ever produced. One of the contributors and funders of the Handbook was the Japan International Cooperation Agency, or JICA. The JICA is an administrative agency of the Japanese government that is devoted to improving the lives of individuals in developing countries. Launched shortly after World War II, JICA created the first mother and child handbook in 1948 to combat high rates of mother and infant mortality in Japan. The Japanese handbook contributed to improving children’s health in the following decades. It was the first medical record booklet of maternal and child health in the world, designed to track pregnancy, birth outcomes, immunizations, and child development.

Later on, other countries adapted versions of the health handbook, beginning in 1993 with Indonesia. Salatiga City, Indonesia, became one of the first cities to receive the handbook from JICA, though the Indonesian Ministry of Health chose to modify the handbook to fit the city’s local characteristics and culture. The maternal mortality rate at the time was around 0.39 percent and the infant mortality rate was around 5.7 percent, and health professionals did not assist with over fifty percent of births. According to JICA, compared to neighboring countries like Singapore and Thailand, the maternal and infant mortality rates in Indonesia were five to ten times higher. As of 2003, the Indonesian Ministry of Health and JICA had distributed over 2.22 million handbooks. By 2004, the percentage of births assisted by a health professional rose to seventy-one percent compared to over fifty percent of births not being assisted by a healthcare professional in 1993. In 2007, the Japanese government commenced a program to support the spread of handbooks in other developing countries, including Palestine, upon seeing the widespread success of the handbook in Indonesia.

From 2005 to 2008, JICA and the Palestinian Ministry of Health collaborated to develop a Palestinian version of the handbook, a project prompted by the disruptions to maternal health services during and after the Al-Aqsa Intifada (uprising). The Al-Aqsa Intifada, which lasted from 28 September 2000 to around September 2005, was an uprising by Palestinians against the Israeli occupation. It began when Ariel Sharon, then prime minister of Israel, ordered an assault on the Al-Aqsa Mosque with over 1,000 police and soldiers. That provocation led to heightened violence and subsequent clashes between Palestinians and Israelis over the five-year period, which led to pregnant women being unable to access health facilities or receive necessary care due to limited mobility, curfews, and closure of checkpoints. That resulted in a disconnected continuum of care in which perinatal care services were uncoordinated, resulting in a need for better medical information distribution for mothers.

JICA supported the Palestinian handbook in two phases, with the first phase being distribution and second phase being improvement of the materials. During the first phase, from 2005 to 2008, JICA, United Nations Relief and Works Agency for Palestine Refugees in the Near East, or UNRWA, and the Palestinian Ministry of Health translated the Handbook into Arabic and distributed it in Ramallah, Palestine, and Jericho, Palestine, before distributing it nationwide in 2008. UNRWA is a Palestinian-based organization that provides direct humanitarian and development services to Palestinian refugees in the West Bank, Gaza, Lebanon, Syria, and Jordan. The Palestinian Ministry of Health, like the Indonesian Ministry of Health, developed the Palestinian version of the handbook separate from the Japanese version to address Palestinian issues in the health sector and harmonize it with the existing health system in Palestine. Some of those issues include discontinuity of care due to violence between Palestine and Israel, and Palestinians being unable to see one healthcare provider or one health station due to limited mobility.

During the second phase, JICA, UNRWA, and the Palestinian Ministry of Health aimed to improve the services and management related to the Palestinian Handbook, and to promote a continuum of care among health care providers by expanding and strengthening its use. In 2009, those groups established the National Coordination Committee, or NCC, to train healthcare providers in the application of the Handbook. They started with 900 health care providers who trained in the application of the Handbook, and an additional 560 healthcare providers who trained in antenatal care throughout the West Bank. The NCC promoted and supervised nationwide implementation of the Handbook as a national common tool among healthcare providers and coordinated with other national Palestinian programs, like UNRWA, to promote services like child growth monitoring and maternal and child nutrition.

The Handbook’s creators intended it to be a portable medical record that unites information from the different health sectors, given that women seeking MCH care tend to obtain health services from different health providers. It has three main functions: to serve as a portable medical record, a health education tool, and a tool for unifying standards of maternal and child health across Palestine. The Handbook’s creators designed it according to the continuum of care concept, which assumes that the health of women, newborns, and children are related. That model emphasizes the management of health services in a unified way, including the history, follow-up of pregnancy, delivery, and the child’s records. Healthcare providers from different parts of the Palestinian healthcare system, including the Palestinian Ministry of Health, UNRWA, non-governmental organizations, and private clinics and hospitals, write their assessments of maternal and child health status and update treatment, follow-up visits, and immunization records directly into the Handbook.

The Handbook is a compact fifty-three-page booklet that functions as both a workbook that individuals can write in and a source of information about health education. The first section, starting on page four and ending on page thirty-two, is a written record section for documenting maternal and child health. The written section provides structured pages for documenting maternal and child health information like previous pregnancies, child immunization, and growth charts. The second section, located from page thirty-three to page forty-eight, is a health education section providing health education for mothers and families that cover the full continuum of maternal and child health. That section provides illustrated instructional material for mothers and families on topics such as healthy pregnancy practices, immunization, breastfeeding, child nutrition, child development, dental care, accident prevention, and caring for a sick newborn. Pages forty-nine to fifty-three include blank pages for a parent to write “sweet memories” of their child, and the last page details a schedule for subsequent appointments and aims of the visit.

In the first section, or the written record section, the Handbook includes pages for recording details about the mother, father, and child. That is followed by a template for documenting previous pregnancies, including details like gestational age, mode and place of delivery, birth weight, and sex. Gestational refers to the period associated with pregnancy and fetal development. The booklet also contains a questionnaire for risk assessment of previous and current pregnancies, segments for antenatal follow-up and medical examinations, and hospital remarks documenting all aspects of delivery. Additional segments guide postnatal examinations, newborn assessments, family planning, and child immunization schedules. The Handbook includes growth parameters and charts for healthy height and weight in both girls and boys, alongside spaces for physicians to record child development, referrals of other healthcare providers, and ongoing follow-up.

After the record-keeping pages, the Handbook transitions to its second section, or the health education section. The health education section complements those records by addressing lifestyle guidance for pregnant women, immunization, breastfeeding, child nutrition, child development, dental care, accident prevention, and sick baby care. Each component is accompanied by illustrations, making the Handbook accessible to mothers regardless of their education level.

The lifestyle guide for pregnant women details precautions a pregnant woman might take and other tips they may use. For example, the Handbook recommends that pregnant women attend regular checkups to monitor fetal development and the mother’s blood pressure. That portion also suggests getting tetanus vaccinations, eating iron-rich food, and taking iron pills and folic acid supplements to prevent disease and anemia. It recommends staying clean to prevent infections, wearing loose cotton clothing for comfort, exercising lightly, going to family or mother and child health centers for emotional support, and resting well during pregnancy. Some precautions a pregnant woman may take are watching for bleeding, swelling, or reduced fetal movement, as this could be indicative of illness in the fetus.

The following two guides cover immunization and breastfeeding. For the immunization portion, the Handbook advises parents to bring children to the nearest health center for scheduled vaccines under the Palestinian national vaccine program, which protects Palestinian children from diseases including tuberculosis, polio, tetanus, measles, and other diseases. The Palestinian Ministry of Health also provides vaccines for all diseases it determines require vaccination. In addition to vaccinations, babies receive newborn screening for phenylketonuria, a disorder that impairs brain development and can cause intellectual disability, and for thyroid function, to ensure that the body has enough iodine, an essential mineral for healthy brain and body growth. The Handbook advises families to give vitamin A and D drops to their children daily and iron syrup as prescribed.

For the breastfeeding guide, the Handbook encourages breastfeeding shortly after birth to provide colostrum, or the first milk produced by the mother in the first few days after birth, to the baby, which strengthens their immunity and protects them from diseases. The booklet recommends that a mother exclusively breastfeed for six months and the Handbook details proper positioning for breastfeeding. It also states that breastfeeding lowers the risk of infection, aids the mother’s recovery after birth, delays the chances of a new pregnancy, and deepens mother-child bonding.

The child nutrition and child development guides in the Handbook assist mothers in supporting their child’s growth by outlining proper diets at each age and developmental milestones to observe. The child nutrition guide describes the nutrition of a child following breastfeeding. After the six-month period of exclusive breastfeeding, the Handbook recommends that mothers give the child complementary foods, like cereals, mashed vegetables, fruits, and other soft foods, in addition to breast milk to add other nutrients to the baby’s diet. From one to two years, children should eat balanced family meals that contain milk and dairy products while still breastfeeding. From ages two to five, children should eat the family’s food, avoid junk foods, and learn to eat independently. The Handbook guides parents to focus on healthy eating habits and ensure proper nutrition to support growth and development. The child’s development guide gives an overview of how mothers should observe their child. According to the Handbook, children grow in predictable stages. Infants first react to sounds and movements, then lift their heads, hold toys, and clap their hands. By one year, babies explore and understand the word no. By two years, they climb stairs, feed themselves, and name objects. By three years, they use the bathroom, tell stories, and play pretend.

The last three guides cover dental care, domestic accidents, and sick baby care. The dental care portion instructs parents to begin brushing a child’s teeth after the first year and to limit sweets, soda, and chips to protect children’s teeth from decay. The domestic accidents portion details protecting children from falls, burns, poisoning, and suffocation. The booklet recommends that parents secure stairs and windows, lock away sharp objects and chemicals, keep heaters and stoves out of a child's reach, and ensure proper ventilation in the house. The parent should supervise their child closely, removing unsafe toys or choking hazards. Lastly, the sick baby care portion suggests how a parent should respond when a child becomes ill. If their child has diarrhea, parents should increase fluids, continue breastfeeding, and give oral rehydration solutions. They can prepare oral rehydration solutions, which ensure the child is adequately hydrated, safely at home with boiled water, sugar, and salt, and offer it after each stool. Parents should avoid giving medicines without medical advice. For coughs and colds, parents may give more fluids and safe herbal drinks like chamomile or thyme but not antibiotics without consulting a doctor. They should keep the child comfortable and monitor breathing closely, staying alert for danger signs. Such signs, which indicate to parents that they should take the child to a health center, include the child experiencing diarrhea with blood, fevers that cause convulsions, rapid or difficult breathing, dehydration, persistent vomiting, or unusual weakness. Continuous crying, refusal to feed, or cold, dry skin also signal the need for urgent care.

The Handbook ends with blank pages for the mother to fill out memories with her child. At the end, there is an appointment log of upcoming appointments and the aims of those appointments.

Since the Palestinian Ministry of Health began distributing the Handbook in 2008, expectant mothers across Palestine and neighboring regions have widely adopted it. Between 2008 and 2011, Palestinian health authorities distributed 288,345 handbooks in the West Bank and 168,154 handbooks in Gaza. In 2010, JICA, the Palestinian Ministry of Health, and UNRWA introduced the Handbook in Jordan, Syria, and Lebanon to public, private, and non-profit health providers. By 2011, UNRWA distributed 75,912 handbooks in the West Bank and 65,984 handbooks in the Gaza Strip. Alongside distribution, the NCC trained more than 800 UNRWA health staff across the West Bank, Gaza, Jordan, Syria, and Lebanon on how to use the Handbook, incorporating World Health Organization updates on child growth monitoring and preconception care.

The wide reach of the Handbook also inspired digital access to its contents. UNRWA launched a mobile application, or app, version of the Handbook for Palestinian immigrants in Jordan in 2017. By 2018, 91,000 pregnant women and 425,000 infants and children from ages zero to five had registered with the app, making it easier to track health data and provide reminders about care. UNRWA extended the Handbook app across its fields of operation by 2019.

The Handbook has also served as a communication and counseling tool for healthcare providers working with pregnant women, fathers, and family members, contributing to improvements in maternal and child health among Palestinian people. According to the Palestinian Ministry of Health, the infant mortality rate dropped by nearly half from 2011 to 2021. In 2011, 18.8 infants died per every 1,000 live births. By 2021, that number had fallen to 9.6 deaths per 1,000 live births. Similarly, the maternal mortality rate decreased significantly, from 38 deaths per 100,000 live births in 2009 to 19.9 deaths per 100,000 live births in 2019, representing an overall decline of about 47.6%. The Palestinian Ministry of Health credits that drop to increased awareness among pregnant women facilitated by initiatives like the Handbook, and improvements in health services. As of 2023, Palestinian health authorities had distributed the Handbook to approximately 200,000 mothers each year, from 2008 to 2023, across Palestine, Syria, Lebanon, and Jordan.

The Handbook applied developmental and reproductive health knowledge to public health practice in Palestine. By functioning as a portable medical record, health education source, and a tool for standardizing maternal and child health practices across multiple healthcare providers, the Handbook helped integrate embryological and child development knowledge into healthcare delivery. Its documented success influenced later health initiatives, including other regional adaptations of the Handbook and the creation of the digital app version for easier access. 

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