Most health professionals and parents in Mongolia refer to the Maternal and Child Health Handbook as the “pink booklet”. It is used to monitor the health of pregnant women and children. Initially the handbook was used in Bulgan Province but now it is one of the most essential documents in the primary health settings in Mongolia. The handbook has a significant contribution to improving maternal and child health, and identifying complications early in pregnancy by increasing involvement of parents, raising health awareness and enhancing communication between health providers and pregnant women. Under the Ensuring Participation of People with Disabilities and Improving Services Project, which is being implemented by the Ministry of Labor and Social Protection and Asian Development Bank, the handbook is being updated. Disability specialist of the project implementation unit E.Byambasuren gave the following interview about this work.

Why are you updating the Maternal and Child Health Handbook?

This handbook is a key tool for community-based child development assessment and early detection of health problems. In other words, it helps early detection with the involvement of the public (parents, family members, kindergarten teachers, health workers, etc.) to determine if a child has any developmental delays. It is effective for enhancing client-provider communication about health, raise health awareness, identify complications early in pregnancy, and promote antenatal care visits.

The current model of the early detection system is based on hospitals or health facilities. But our main goal is to convert it to a social-oriented model. Such a transition would improve the current version of the pink booklet. Secondly, we aim to increase the awareness and knowledge of the public, and expand the use of handbooks. There is a common misconception among the public that maternal and child health handbooks are for the use of family doctors only. Therefore, we aim to change this by increasing the use of handbooks. In other words, parental involvement will be improved.

It is important to train exemplary mothers and fathers who keep and use the handbook regularly, and are able to seek immediate medical attention and receive appropriate treatment and care if their child shows some kind of stunted growth or development. In short, the handbook will be updated, its use will be increased, and the early detection system will be changed. An issue of transferring the pink booklet to electronic form is being discussed. The Ministry of Health is also paying close attention to this issue.

Can you explain in detail how the health-based model will be transferred to a socially-oriented model?

This means changing the perception and attitude that the pink booklet should be kept and maintained by medical staff and family doctors. In other words, children’s development should be assessed based on assessments and observations by all those who interact with them, such as parents, guardians, and kindergarten and school teachers. With this change, the handbook will become a participatory tool for child development assessment. As the system is being changed, it will be necessary to include this content in university curriculums. Therefore, we’re planning to introduce a long-term course to provide pediatricians and preschool and primary school teachers with knowledge and understanding of child development assessment and methodology.

You mentioned that the Maternal and Child Health Handbook will eventually become electronic. Does that mean people can keep notes in the booklet in both writing and digitally?

We will make it possible for citizens to use it both ways. It is common for parents to lose their handbooks. The transition to electronic form will create a unified database. It will be possible for parents to store their children’s information for a long time. This means that each child will be able to see their own development history when they become an adult. It is important for parents to have a reliable archive for storing their children’s information, as well as a research tool and source for scientists and researchers. In particular, in Japan, a mobile application is used to assess child development. We will localize it. After updating the handbook, it will be transferred online.

  The current handbook contains a variety of questions to assess a child’s physical and mental development. Will these questions be changed?

Improvements are being made to make everything about the booklet simpler, clearer and more optimal rather than for the purpose of changing it. There is an age of stage question (ASQ). Internationally, there are a variety of tools for early detection and diagnosis of childhood developmental delays. Each country uses a different methodology. Licenses are issued after national research teams thoroughly review the methodology and verify its validity and reliability. There are several types of indicators of child development, such as physical development, language, mental and behavioral, intellectual and social. Since the start of the project, we have tried several times to use the ASQ license in Mongolia. However, it has not been introduced on the grounds that it could not be used in developing countries. Therefore, we decided to update the pink booklet’s questionnaire based on the internal resources of our consultants. This work is in full swing.

What changes will be made to the structure of the handbook? Will it have guidelines specifically for parents, family members, doctors and kindergarten teachers, respectively?

It is not possible to give details at this time. However, our consultants will develop guidelines for parents and primary care units, or family group practitioners, on how to assess a child’s development. Once it is standardized, an updated version of the handbook will be introduced. In this context, several trainings are planned. Training and counseling activities will be organized for parents, primary care physicians, nurses and decision-making officials.

Is there a standard or fixed amount of time to update such tools used to assess and support children’s health and development?

There are many different tools for assessing child development internationally. Of these, the ones that meet the quality requirements, are reliable, and are validated by experiments and evidence are used after formalization and licensing. Accordingly, we intend to conduct certain experiments and research as part of the work to update the pink booklet. As a result, Mongolia will have a standard tool like other countries. All indicators and stages of development from unborn baby to the age of five are listed in the pink booklet.

Will the updated version have the same age groups as the current version?

The issue of conducting a longer-term assessment of child development is being considered.

What are the benefits of updating the Maternal and Child Health Handbook?

There are many advantages. For example, if there are parents who do not understand developmental delays of social relations, they may not notice if their child shows symptoms of such disorders. However, if parents pay close attention to the questions and information in the handbook, they will be able to find it out easily. By clearly reflecting the specifics of each stage of development, parents will be able to evaluate and analyze their children objectively. It is important to not only identify visual, auditory, and motor disabilities but also assess the development of social communication, language, and cognition. We do not have this kind of evaluation. 

Developmental delays are exacerbated by a lack of timely detection, diagnosis and attention. Early detection of developmental delays, on the other hand, is a preventive measure. There are many tools to detect this. The updated version of the pink booklet will be one. The handbook we use now is not that bad. It is based on the Denver Developmental Screening Test, one of the international standard methodologies for child development assessment. But we need to improve it. There are some methodologically unclear things. The methodology for assessing child development should be clearer and differentiated more specifically.

When is deadline for introducing the updated handbook?

The first version of the pink booklet is scheduled to be released by November 31. Then, a consultative meeting will be held with a participation of experts from relevant organizations and members of the technical working group. Their suggestions will be reflected. It may take a long time for the overall update.

 In addition, it is important to detect developmental delays in children at an early stage, and then see a specialist to confirm the diagnosis. The pink booklet is an early detection tool. We aim to introduce the Bauman method, which is widely used in the European Union, in evaluation of pediatricians in secondary and tertiary levels of hospitals. This means that it will be possible to use another internationally accepted method of diagnosis and verification. In this context, instrumental analysis methods will be used. We are working to organize capacity building training for doctors in this area.