Sri Lanka's success in improving maternal health.

Sri Lanka is a low income country which has achieved remarkable results in reducing maternal mortality. The maternal mortality ratio (MMR) was halved within three years between 1947 and 1950, (1) and at present the MMR stands at 92 deaths per 100, 000 live births (2)--far better than the MMR of 540 of nearby India. (3) This is an achievement for a country with a per capita gross national income around US$ 1,200, with one third of the population living below the poverty line in most provinces. The state offers free antenatal care through home visits and clinics, and there is an average of five clinic visits per pregnancy, with 92% of deliveries taking place in state run hospitals (4) Successive governments have invested in the development of a health structure that places equal emphasis on field and institutional care, resulting in services that cover every home through trained Family Health Workers and a network of hospitals providing simple but adequate emergency obstetric care facilities.

One of the key factors underlying this success story is the commitment of the policy makers, health care providers and educators. Sri Lanka has a legacy of stressing the importance of health and education, which has been instrumental in the development of its maternal health programmes and policies. With schooling made compulsory for all children in 1942, the literacy rates crossed the 70% mark by 1946 and reached 92% by 1992, with the gap between men and women starting to close early and reaching 2.5% at present. (5) Sri Lanka has the highest gender-related development index ranking of any South Asian country, and a number of government mechanisms, including the Ministry of Women's Affairs, the Women's Bureau and the National Committee on Women ensure that priority is given to women's needs and concerns.

Since the development of the Civil Medical Department in 1857, the Sri Lankan government has assumed the responsibility for providing health care. It set up the first maternity hospital, De Soysa Maternity Hospital, with a donation from a philanthropist, but it is entirely government run. The Ministry of Health (MoH) has also been active in gaining the support of NGOs and international agencies to initiate different maternal health programmes. The government used this external assistance as a launching pad, but subsequently mainstreamed programmes in such areas as family planning, nutrition and immunisation. Although Sri Lankan society is traditionally quite conservative, family planning was introduced as early as 1953 by a voluntary organisation, the Family Planning Association, which started a network of service delivery outlets, which were later incorporated into the MoH. (6) The decline of the total fertility rate (TFR) was slow until the early 1970s but accelerated in the early 1980s. Currently, Sri Lanka's TFR is 1.9, which is low compared to other South Asian countries, and is due in part to a contraceptive prevalence rate of 70%. (7)

Sri Lanka resisted the strategy of training traditional birth attendants as a measure to reduce maternal mortality. Sri Lanka invested heavily in training midwives who are among the frontline health workers who provide family planning care in the community. There are approximately 5,000 such workers in service, each serving a population of 2,000-4,000. Their duties include distributing oral contraceptives and condoms, family planning education and counselling, and immunisation. (8) A milestone in monitoring maternal health in Sri Lanka was the establishment of the Maternal Mortality Review, which is a complete review taking place at three levels--institutional, regional and national--with the last review being conducted with the assistance of the Professional Colleges. The strategy of institutionalising deliveries has worked well in this geographically small country. Today, the institutional delivery rate is 97%, with 92% of the deliveries taking place in government institutions and 60% of women delivering in hospitals manned by specialists. Only 2% of births take place in the home, often with the assistance of a trained Family Health Worker; however, home deliveries were responsible for 22% of the maternal deaths that took place in 1996. (9)

Endnotes

(1) Liljestrand, Jerker; Pathmanathan, Indra (eds.). 2003. Investing in Maternal Health: Investing in Maternal Health: Learning from Malaysia and Sri Lanka. Washington, D.C, USA: The World Bank.

(2) Family Health Bureau, Sri Lanka Ministry of Health. 2004. Maternal Mortality Review.

(3) WHO. 2005. World Health Report 2005: Make Every Mother and Child Count. Geneva, Switzerland: WHO.

(4) Department of Census and Statistics; Ministry of Health, Nutrition and Welfare. 2000. Sri Lanka Demographic and Health Survey.

(5) WHO, 2005.

(6) Liljestrand, Jerker; Pathmanathan, Indra (eds.). 2003.

(7) World Health Organization. Core Health Indicators. http://www3.who.int/whosis/core/core_select_ process.cfm

(8) Center for Reproductive Rights. 2004. Women of the World: Laws and Policies Affecting Their Reproductive Lives, South Asia. New York, USA: CRR.

(9) Family Health Bureau, Sri Lanka Ministry of Health. 2004.

By Dr. Lakshmen Senanayake FRCOG FSLOG MA Consultant Obstetrician & Gynecologist, 546/2 Nawaka Road Rajagiriya, Sri Lanka, [e-mail]