http://my.ibpinitiative.org/DisplayKnowledge.aspx?c=7b47857a-349e-4eb2-bcba-fe6d95c04fbe&f=44a7373e-dcdc-46dd-b37c-8ea5ba3fb43b&i=32a29121-0f4f-4529-8bf8-0e3521f53eaf
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Sri Lanka being a low income country is boasting of achievements on maternal and infant mortality rates in par with developed countries. Key factorsbehind this success story and novel strategies focused on further reductionof both mortalities need to be shared at international level.
The crux of this achievement is the public health service delivery systemwhich covers each and every household in the island. Public Health Midwives(PHMs), with basic training on filed health care, cater for 3000 - 5000population or nearly 800 - 1000 households in a designated healthadministrative locality. She is accountable for maternal and child healthcare of the each house hold under her purview. This domiciliary carenetwork has prompted tremendously health status of women and children inthis country. The spectrum of her service ranges from registration ofeligible couples, preconceptional counseling, antenatal care, intrapartumcare at field (if necessary), postpartum care, family planning promotion,neonatal care, promotion of exclusive breast feeding, immunization, earlychildhood care, growth monitoring, school health and adolescent reproductivehealth services in a life course approach.Linked with them are the supervisory staffs, Supervising PHM, Public HealthNursing Sister and Regional Health Care Manager. The supervision includesformal field visits to informal surprise checks. Review of service deliveryis done at local conferences (3-5 PHMs) and monthly conferences (all PHMsin a regional administrative area) where each PHM is supposed to presentprogress of her performances. The system is in-built with appraisals atvarious levels.
Publich Health Information system originates from the daily logs of the PHMdiary cascading in to a national level network which is continuouslymonitored at national level by the Family Health Bureau -the focal point formaternal and child health (MCH) in the country. The review system has beenexpanded from district level to national level with the participation of allthe stakeholders of MCH.
Sri Lanka introduced maternal death audits in 1982 and now it has beenupgraded to a National Maternal Mortality Surveillance System with a networkof maternal death information network and regular national level reviewsystem throughout the country. Sri Lanka has excelled in maternal mortalityreduction with the latest provisional MMR figure of 33.4 per 100000 livebirths for the year 2008. Learning from what went wrong at ground levelhelped fine tuning maternal care service delivery in the entire country.Capacity building of PHM, the grass root health care worker, is modelledbased on findings and recommendations of national maternal mortalityreviews. This is of importance with the increase of proportion of indirectmaternal deaths in Sri Lanka to develop skills of PHM on obstetric medicalconditions and what is expected from them. Early detection and approriatereferral is the theme as practiced universally. Novel strategies -eg. rapidcommunication with clinicians, targeted health education, high risk approachin family planning promotion- will undoubtedly help in further decline inmaternal mortality in Sri Lanka.
Sri Lanka hopes to reduce the catering population for each PHM with furtherexpanding scope of her domicillary care.
Kapila Jayaratne
Sri Lanka
Kapila Jayaratne, Sri Lanka has excelled in maternal mortality reduction of 33.4 per 100000 live births for the year 2008. Learning from what went wrong at ground level helped fine tuning maternal care service delivery in the entire country. Capacity building of PHM, the grass root health care worker, is modeled based on findings and recommendations of national maternal mortality reviews. This is of importance with the increase of proportion of indirect maternal deaths in Sri Lanka to develop skills of PHM on obstetric medical conditions and what is expected from them. Early detection and appropriate referral is the theme as practiced universally. Novel strategies -e.g. Rapid communication with clinicians, targeted health education, high risk approach in family planning promotion- will undoubtedly help in further decline in maternal mortality in Sri Lanka.
Femi Oladapo: Thanks to Kapila for sharing Sri Lanka's success story with the rest of the world. There is no doubt that building a formidable health team at the grassroots level based on evidence from situation analysis would go a long way in reducing the high rates of maternal and newborn mortality in many countries. It has to be acknowledged, though, that not many low income countries have the a strong public health service delivery system as described for Sri Lanka and the same initiative could have different outcomes in another setting. It would be nice if Kapila can provide the forum with more information about the training of these Public Health Midwives so that everyone can appreciate the degree of competence required to achieve a similar feat. Obviously, there is a wide range of services they can render particularly in the area of health promotion. The strength of this kind of health system probably still lies in a good referral system, appropriate supervision, monitoring and evaluation and incentivization of the workforce. The question we need to ask is this, is the success of this health policy intervention dependent on specialized workforce that can provide emergency obstetric care? Or how far could these PHM go to save the life of a woman when the need arises? For example do they perform manual removal of the placenta, give uterotonics or magnesium sulfate for pre-eclampsia?
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