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Achieving Millennium Development Goals 4 and 5 in Sri Lanka

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Achieving Millennium Development Goals 4 and 5 in Sri Lanka DOI: 10.1111/j.1471-0528.2011.03115.x Review article www.bjog.org Achieving Millennium Development Goals 4 and 5 in Sri Lanka H Senanayake,a M Goonewardene,b,c A Ranatunga,c,d R Hattotuwa,c S Amarasekera,c I Amarasinghee,c a Faculty of Medicine, University of Colombo, Sri Lanka b Faculty of Medicine, University of Ruhuna, Sri Lanka c Sri Lanka College of Obstetricians and Gynaecologists d Castle Street Hospital for Women, Colombo, Sri Lanka e Faculty of Medicine, University of Peradeniya, Sri Lanka Correspondence: Prof H Senanayake, Department of Obstetrics and Gynaecology, Faculty of Medicine, University of Colombo, 25 Kynsey Road, Colombo 08, Sri Lanka. Email [email protected] Accepted 21 July 2011. Sri Lanka has an exemplary record in maternal and child health vast majority of deliveries, of which 99% occur in hospitals. care. Provision of free education for over 60 years has helped to Although on target with the Millennium Development Goals, empower women. Medical care is accessible and provided free of some challenges that still remain are maternal death from charge. The maternal mortality ratio and the other indices of postpartum haemorrhage and unsafe abortion, and perinatal maternal and neonatal health have shown uninterrupted deaths due to congenital abnormalities and prematurity. improvement since 1930. Midwives and the policy to increase Keywords Infant mortality rate, maternal mortality rate, their presence has been the key to success. Public health midwives Millennium Development Goals 4 and 5, Sri Lanka. provide care at the doorstep. Institutional midwives carry out the Please cite this paper as: Senanayake H, Goonewardene M, Ranatunga A, Hattotuwa R, Amarasekera S, Amarasinghe I. Achieving Millennium Development Goals 4 and 5 in Sri Lanka. BJOG 2011;118 (Suppl. 2):78–87. 2 Background to Sri Lanka health is 0.23%. The adult literacy rate is 89.7% for females and 92.6% for males. The mean age at marriage for Sri Lanka is held out as a model for maternity care in non- women is 23.2 years, which represents a decline compared industrialised countries.1 On a meagre budget it produces with the previously observed upward trend.3 The terrain is indices that are more in line with countries whose per geographically not difficult. A 30-year-long armed conflict capita gross national incomes are ten-fold greater. The lat- affecting mainly the northern and eastern parts of the est maternal mortality ratio (MMR) for Sri Lanka is 33.4 country was concluded in 2009. per 100 000 live births in 2008 (Annual Maternal Mortality The achievements of Sri Lanka are the result of favour- Review, Family Health Bureau, Colombo, Sri Lanka, able policies that have continued uninterrupted for more unpublished data). When compared with rates from indus- than six decades. The hallmark of these is that they are trialised countries that are about a third of this and figures indigenous and of low cost. There have been two vital from other South Asian countries that are ten-fold higher, non-health interventions. The first of these is the provision the MMR for Sri Lanka becomes very impressive. Indeed, of free education without discrimination, up to completion it is a story of success amidst adversity. A study of how this of university education. This contributed greatly to delay- was achieved by a low resource country could help save the ing the age at marriage, thereby reducing teenage pregnan- lives of mothers in many other parts of the world. cies. Education also empowered women and gave them Sri Lanka is a small island with a land area of approxi- access to electronic and print media which have enabled mately 62 700 km2 and a population of approximately them to have a greater awareness regarding health. The sec- 20 million. Free health services are available to all. The ond is the provision of healthcare services free of charge. gross national income per capita is approximately US$1540 The important health interventions were a gradual and approximately 1.8% of gross domestic product is spent expansion and enhancement of the healthcare facilities on health care; the expenditure on maternal and child ensuring easy accessibility of organised primary and tertiary 78 ª 2011 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2011 RCOG MDGs 4 and 5 in Sri Lanka healthcare services, combined with surveillance and appro- (Annual Maternal Mortality Review, Family Health Bureau, priate action. Improved infrastructure and low-cost trans- Colombo, Sri Lanka, unpublished data) (Figure 2). port facilities also contributed. There is a significant disparity, however, in the MMR in the different districts of Sri Lanka (Figure 3) (Annual Maternal and newborn health Maternal Mortality Review, Family Health Bureau, Co- statistics lombo, Sri Lanka, unpublished data). The highest rates have usually been seen in areas that were affected by the The total population is approximately 20 million. This is a 30-year armed conflict that ended in 2009 and the planta- projected estimate, since the last complete census was car- tion areas. It is significant that some areas outside these ried out in Sri Lanka in 1981. A partial census excluding areas such as Matara also feature in this category. the north and east (areas affected by the armed conflict) In Sri Lanka, stillbirth registration is often incomplete was conducted in 2001. The proportion of women of and therefore accurate national perinatal mortality rates are reproductive age (15–49 years) is estimated to be approxi- not available. The neonatal mortality rate (NMR) and the mately 27.8% of the population.5 The total fertility rate infant mortality rate (IMR) have improved in parallel with was 2.3% in 2007.4 The adolescent birth rate is 23 per the other MCH indicators8 Although the NMR and the 1000.6 The main contributors to this relatively low rate are IMR decreased to 10 and 15 per 1000 live births respec- early marriage not being a cultural consideration and the tively in 2005 from highs of 80 and 140 per 1000 live births empowerment of women due to free education. respectively in 1945,4 neonatal death as a percentage of the The decline of the MMR in Sri Lanka (33.4 per 100 000 total under-1-year mortality has increased from 55% in live births in 2008 from 2000 per 100 000 live births in 1945 to 75% in 2007.9 This is due to the reduction of 1930 (Annual Maternal Mortality Review, Family Health deaths by immunisation and those due to other infective Bureau, Colombo, Sri Lanka, unpublished data) is associ- causes such as diarrhoea; the main contributors to death in ated with some important landmarks [www.mdg.lk/inpag- this age group are related to prematurity and perinatal es/thegoals/mdgs_in_srilanka.shtml. Accessed 14 July 2011]7 events. (Figure 1). The establishment of a field health system for delivering maternal and child health (MCH) services in the Specific Millennium Development country in 1926, a steady increase in the number of gov- Goal (MDG) 4 and 5 targets for Sri ernment hospitals in the country from the 1930s, the com- Lanka by 2015 mencement of training of midwives in 1931, establishment of the Family Health Bureau (FHB) under the Ministry of The country-specific targets for Sri Lanka are shown in Health to oversee MCH activities in 1969 and the com- Table 1. mencement of the National Maternal Mortality Review in 1984 are salient events in this chronology. The MMR since Continuum of care the 1990s continues to show a significant downward trend Antenatal care Sri Lanka has a long history of antenatal care. The first antenatal clinic was conducted at the De Soysa Hospital for Women, Colombo, in 1921. Antenatal care coverage runs at 99% for the whole country. There may in fact be a Establishment of the duplication of care by public health midwives (PHM) and Family Health Bureau medical officers of health in the primary healthcare centres and by consultant obstetricians and gynaecologists in ter- NaƟonal maternal death tiary care centres. Approximately 51% of pregnant women review have had 9–15 antenatal visits (Table 2).10 A detailed 1941 – 129 hospitals9 history is recorded on the ‘mother’s card’ which is used nationally and measurement of blood pressure and exami- 1950 – 260 hospitals9 nation of urine for albuminuria forms part of antenatal care delivery. Public health midwives sometimes provide antenatal care on domiciliary visits (Figure 4). The 11 Figure 1. Maternal mortality ratio of Sri Lanka 1930–96. Source: improvement of antenatal care coverage is reflected in the Maternal Mortality Decline—The Sri Lankan Experience, Colombo: Family Health Bureau, Ministry of Health, Nutrition and Welfare, 2003. reduction of deaths due to preeclampsia: from 17 deaths in Figure published with the kind permission of the Director, Family Health 2005 the number of deaths fell to seven in 2008 (Annual Bureau. Maternal Mortality Review, Family Health Bureau, ª 2011 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2011 RCOG 79 Senanayake et al. 70 61 62 63 55.83 55.56 60 53 53.36 46.87 50 43 44 38 39.3 38.4 40 33.4 MMR 30 20 10 0 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Year Figure 2. Maternal mortality ratio of Sri Lanka 1995–2008. (Annual Maternal Mortality Review, Family Health Bureau, Colombo, Sri Lanka, unpublished data.) Mannar 69.91 Matara 67.9 Rathnapura 67.21 NuwaraEliya 66.34 Kegalle 57.16 Pulam 45.4 Galle 42.35 Badulla 35.76 Kandy 34.41 Hambantota 33.54 Sri Lanka 33.4 Vavuniya 33 Ampara 32.7 Bacaloa 31.6 Jaffna 31 Colombo 30.97 Gampaha 25.51 Kilinochchi 24.9 Trincomalee 24.19 Kalmunai 24.15 Monaragala 23.5 Anuradhapura 22.61 Kurunegala 21.81 Kalutara 21.4 Matale 20.47 Mullavu 19.72 Colombo MC 19.05 Polonnaruwa 14.4 0 1020304050607080 Figure 3.
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