Safe motherhood: a success story in Sri Lanka

28 World Health • 51 st Year, No. 1, Jonuory-februory 1998 Safe motherhood: a success story in Sri Lanka Pramilla Senanayake A young girl attending a school for street children in Colombo. W hen women are educated, they are better able to protect their own health. Photo WHO/L Taylor The number of women dying each year as a result of preg-nancy or childbirth has fallen dramatically in Sri Lanka - from about 5000 in the 1920s to 520 by 1990 and 250 now. In the 1920s, when maternal and chjld health services began, the maternal mortal- ity ratio was 2200 deaths per 100 OOO live births. Today the ratio is down to 66 per 100 OOO. Although the figure for industrial- ized countries is roughly a tenth of this, Sri Lanka compares favourably with other South Asian countries. In Sri Lanka, three key factors are believed to have had a strong influence on efforts to reduce the scale of maternal tragedy: govern- ment commitment to improving the education and health of the popula- tion ; improvements in health care delivery; and a well-executed family planning programme. Free educa- tion from the first year of schooling through to university level began in 1945, and by the 1980s the overall literacy rate had risen to 87%. In 1994, adult literacy was 87% for women and 93% for men - far higher than in some neighbouring countries, and with much less dis- parity between men and women. While levels of education in- creased for both men and women , the high levels of female education had several knock-on effects , includ- ing a rise in the age of marriage - a factor held to be responsible for the rapid decline in maternal mortality during the 1950s . When women are educated, there are health benefits both for themselves and for their families. They are more likely to When women are educated, they are more likely to take advantage of health services and antenatal care, and better able to understand information and follow instructions. take advantage of health services and antenatal care, and are better able to understand information and follow instructions. They are also more likely to practise family plan- ning. Farruly planning was introduced in the 1950s, with the formation of the Sri Lankan famjly planning association. Today, 40% of married women use modern methods of contraception and 22% use tradi- tional methods such as withdrawal and periodic abstinence. This in- crease in the use of contraception (from 32% in 1975 to 62% today) has also helped reduce maternal deaths by lowering the number of pregnancies and allowing women to space their pregnancies. The aver- age number of children per family is now 2.2 - far lower than in other South Asian countries. Another important reason for Sri Lanka's success in making mother- hood safer has been the availability of health services. About 93% of people have access to basic health care. A health care delivery unit can be found, on average, within 1.4 km of any home in Sri Lanka, and a free Western-style health care institution within 5 km. Although free health care services are provided, over half the population uses the private sector, which includes traditional and Western-style health care. World Health • SlstYear, No. 1, Jonuory-Februory 1998 A family in Sri Lanka. With the increased availability of family planning, most families can choose lo lead healthier lives. Photo Still Piclures/M Edwards © Maternal and child health ser- vices are now part of integrated reproductive health services. Primary health care is the first point of contact for pregnant women, and community midwives provide ante- natal care to almost 75% of women from early pregnancy. An impres- sive 94% of births take place in health facilities and, if complications arise, patients can be transferred by ambulance to 45 hospitals with specialist obstetricians. All first pregnancies and high-risk pregnan- cies are referred for delivery to facilities with obstetricians. Today over 50% of women give birth in World Health Day specialist institutions and these are now beginning to feel the strain. Nearly 6% of deliveries take place at home. While many are attended by trained personnel , those that are not give cause for concern. There is also some regional unevenness. In the north, for example, ongoing civil conflict and the poor living condi- tions of refugees have contributed to a maternal mortality ratio that is much higher than elsewhere. Unsafe abortions are believed to account for 5-9% of maternal deaths. Although abortion is illegal in Sri Lanka, about 25% of the population have access to safe abor- 29 tion services. Unwanted pregnan- cies are often the result of reliance on traditional methods of contracep- tion or of the restricted access of young people to family planning services and sexual health education. Abortions are three times more common among married women than among unmarried women. More than a third are repeat abor- tions - highlighting the need for post-abortion counselling. After counselling, an estimated 70% of women take up con- traception. There is also a need for more sympa- thetic treatment and care for women with abortion complications. An indication of government commitment to safe motherhood is the establishment in 1994 of the maternal death audit, which moni- tors all reported deaths of women as a result of pregnancy or childbirth. However, there remains a need for better monitoring and evaluation, especially of abortion-related deaths, and for sexual health education for all young people, if motherhood is to be made safer for all women. • Dr Pramilla Senanayake is Assistant Secretary General of the International Planned Parenthood Federation, Regent's College, Inner Circle, Regent's Park, London NW I 4NS, England World Health Day on 7 April 1998 will focus on the theme of Safe Motherhood, with activities taking place throughout the world in both developing and developed countr ies. In some settings, attention will be directed towards ensuring access to core, overcoming barriers such as distance, cost, and sociocultural factors. Elsewhere, attention wi ll be directed to improving the quality of core and avoiding unnecessa ry med ical interventions such as excessive rates of ca esarean deliveries. Around th e world, special efforts wi ll be mode to prevent unwanted pregnancies and the ir consequences, including unsafe abortions. The Colombo consensus In October 1997, over 250 people from more than 65 countries come together in Colombo, Sri Lanka, to review lessons learned in safe motherhood programmes and identify what works best to reduce maternal mortality. Foremost among the conclusions was that safe motherhood programmes need to pay more attention to the cr itical period around labour, childbirth , and the immediate postportum period. There was also ag reement that the use of tra ined trad itiona l birth attendants , on its own, is unlikely to reduce maternal deaths. What is needed is access for all women to high quality core from a health professional with midwifery skil ls who con deal w ith obstetric complications which often arise sudden ly and unpredictably. The year 1998 cou ld mark a turning-point for safe motherhood. In clos ing the Colombo meeting, Professor Fred Soi from Ghana , who was Chairman of the International Safe Motherhood Conference, held in Nairobi in 1987, and Chairman of the Internationa l Conference on Population and Development, held in Coiro in 1994, confidently affirmed that "we now know how to reduce the carnage of avoidable maternal deaths". Safe motherhood is a fundamental indicator of a society's respect for its female ci tizens. Said Professor Soi, "If governments mean what they soy about their commitment to the human ri ghts of women , they must ensure access to quality materna l core" .