SKILLED CARE DURING CHILDBIRTH

SKILLED CARE DURING CHILDBIRTH COUNTRY PROFILES >> TUNISIA SRI LANKA MALAYSIA BOTSWANA >> Saving Women s Lives, Improving Newborn Health

>> Skilled Care During Childbirth: Country Profiles Table of Contents 1 Introduction 22 Tunisia 16 Sri Lanka 10 Malaysia 4 Botswana Prepared by Rahna Rizzuto and Shafia Rashid Design by Doris Halle Design, NYC Family Care International, Inc. 2002 Not-for-profit organisations may reproduce the contents of this publication freely, as long as it is not used for commercial purposes. FCI would appreciate acknowledgements and copies of any reproductions.

>> Skilled Care During Childbirth: Country Profiles Introduction The Scope of the Problem Globally, over half a million women die from the complications of pregnancy and childbirth each year with nearly all of these deaths (99 percent) occurring in the developing world. For every woman who dies, 30 to 50 women suffer injury, infection, and/or disease. More than a decade of research has shown that most maternal deaths and disabilities can be prevented if women have access to good quality health services during pregnancy and childbirth. However, many women do not receive such care: just half of all deliveries in developing countries take place with a skilled attendant, with rates in some countries as low as 8%. In addition to the lack of good quality, accessible, safe motherhood services, a range of social, economic, and cultural factors contribute to women s poor maternal health these include women s disproportionate poverty, unequal access to education, low social status, and lack of income and employment opportunities. While there has been limited progress at the global level in reducing maternal mortality and morbidity, a number of low- and middle-income countries have achieved measurable success in reducing maternal deaths. The four countries profiled in this report (Botswana, Malaysia, Sri Lanka, and Tunisia) demonstrate that maternal mortality can be reduced if political will and resources are mobilised around women s health and empowerment. Ensuring Skilled Care During Childbirth In 1987, when the global Safe Motherhood Initiative was launched, representatives from a range of international agencies and governments committed themselves to the goal of reducing maternal deaths. Since then, much has been learned about which interventions are most effective, and the focus has shifted from predicting obstetric complications to managing them appropriately. Experts agree that one of the most essential interventions is to ensure that all women are cared for by a professional health worker (midwife, nurse, or doctor) with midwifery skills during the most dangerous period during and immediately after childbirth. Skilled attendants, when supported by a functioning referral system, can fulfill the following critical functions: Ensure that all deliveries are conducted hygienically and according to accepted medical practices, thereby preventing complications that are caused or exacerbated by poor care; Identify complications promptly and manage them appropriately either by treating or referring women to a higher level of care; Provide high-quality, culturally-appropriate, and considerate care, ensuring necessary follow-up and linkages with other services, including antenatal and postpartum care, as well as family planning, postabortion care, and treatment of sexually transmitted infections. In October 1999, the Safe Motherhood Inter-Agency Group (IAG) launched a multi-step strategy to assess the importance and potential impact of skilled care during childbirth as a means of reducing maternal mortality. Key components of this strategy included: The preparation of a comprehensive paper reviewing the evidence on skilled care during childbirth; A Technical Consultation, held in April 2000 at World Health Organization (WHO) Headquarters in Geneva, which gathered leading experts in the field of safe motherhood to assess the evidence on skilled care during childbirth, and to develop key strategies for implementing the intervention in a range of developing country settings; A set of informational materials relating to the critical components of skilled care during childbirth. These materials include: a policy brief, an information booklet, and country profiles on skilled care during childbirth (see country profiles in this document); 1

>> Skilled Care During Childbirth: Country Profiles Introduction An international conference Saving Lives: Skilled Attendance at Childbirth held in November, 2000 in Tunisia. The aim of the conference was to facilitate the development of national-level action plans on skilled care during childbirth in selected countries in sub-saharan Africa and South Asia. In addition, four developing countries (Botswana, Malaysia, Sri Lanka, and Tunisia) shared strategies and lessons learned in decreasing maternal mortality and increasing the coverage of skilled attendants. In preparation for the Tunisia conference, the four low maternal mortality countries developed case studies on their country s experiences in implementing skilled care during childbirth as a key intervention in reducing maternal mortality. Following the conference, the profiles were expanded to serve as illustrative examples of the national-level programmatic strategies that led to high coverage of skilled care during childbirth (see country profiles highlighted in this document). Ingredients of Success Botswana, Malaysia, Sri Lanka, and Tunisia have all achieved measurable success in improving skilled care and reducing maternal mortality. In these four countries, coverage of skilled care increased significantly with rates currently exceeding 90%. In the countries where data is available, maternal mortality ratios dramatically declined from several thousand maternal deaths per 100,000 live births to 20 60 over a span of 30 50 years. These experiences illustrate that middle- and low-income settings can achieve near-universal coverage of skilled care during childbirth if political will and resources are mobilised to improve women s status and their access to basic health services. Employing a multi-faceted approach, these countries implemented a range of complementary, mutually-reinforcing strategies, with the goal of improving maternal health and saving women s lives: Mobilising political commitment at the highest level: In Botswana, a series of conferences and meetings during the 1990s galvanised political commitment to safe motherhood among high-level government officials, including the President, Members of Parliament, and the House of Chiefs. Subsequently, a national safe motherhood programme, with reduction of maternal mortality as a key goal, was established. Investing in social and economic development such as female literacy and education, poverty reduction, and basic human rights with particular emphasis on the poor and vulnerable: Sri Lanka has demonstrated consistent, long-term support to ensuring the social welfare of its citizens. Since 1945, free education from primary- to university-level has been made available on an equal basis for both men and women resulting in a population with an overall literacy rate of 91%. Health care is also provided free of charge in an effort to ensure access for poor and underserved groups. All citizens enjoy basic human rights and political freedoms, which have been enshrined in the national constitution and several charters. Professonalising midwifery care: In Malaysia and Tunisia, the Government invested in the expansion of community-based midwifery personnel who were trained and legally registered, based on a defined set of competencies. These midwives formed the backbone of each country s rural health services system. Strengthening health systems and promoting access to care in health facilities: Beginning in the 1950s, Malaysia established a strong primary health care infrastructure an extensive network of rural health facilities providing maternal health services was built; and skilled providers were trained and deployed to staff these facilities. The Government placed high priority on providing free health care and ensuring that health facilities were equitably distributed in an effort to reach the rural poor. 2

>> Skilled Care During Childbirth: Country Profiles Introduction Improving access to emergency obstetric services and establishing referral and transport systems: In Sri Lanka, the establishment of a network of primary health care centres was supported by the development of specialised obstetric services to treat emergency complications. Subsidised transport systems were established between primary and referral facilities, and from 1960 80, the number of rural facilities providing basic and comprehensive emergency obstetric care increased dramatically. Ensuring access to family planning services: In 1965, Tunisia implemented a national family planning programme as part of its basic health care system. The Government partnered with non-governmental organisations (NGOs), religious leaders, and the media in a social mobilisation campaign to promote family planning. Midwives became the key cadres of health providers providing family planning and maternal care. Improving the quality of available services through effective monitoring systems (e.g. maternal death audits): Developed and refined over a period of 40 years, Malaysia s system for investigating the cause of maternal deaths provides a mechanism for continuously improving the quality of existing health services by highlighting reasons for sub-standard care, assessing the quality of antenatal and obstetric care, and identifying improvements in maternal health programmes. Encouraging community involvement and investment in maternal health care: Botswana has developed a range of information, education, and communication (IEC) activities to raise awareness about safe motherhood and encourage the use of services. These include printed materials, radio, and health education sessions. What These Profiles Contain Each of the country profiles includes: basic socio-demographic information; the policy and supporting framework for reducing maternal mortality and improving skilled care; the main interventions that were or are being implemented that relate to the goal of increasing skilled care during childbirth; and a box summarising the main ingredients of each country s success story. These profiles are intended to provide a descriptive overview of the process in the four countries that led to a reduction in maternal mortality and improvements in skilled care during childbirth. Adapted from reports prepared by the low maternal mortality teams and supplemented from published and unpublished literature, the primary aim of these profiles is to provide concrete examples of countries that have been successful in improving maternal health through increased coverage of skilled care during childbirth. As such, the profiles complement the other components of the Skilled Care During Childbirth Information Kit, in particular the Skilled Care During Childbirth Information Booklet and Policy Brief, which provide policy and programmatic guidelines for individuals and organisations working to improve coverage of skilled care. The country profiles are designed for programme planners and managers working in governments, NGOs, and professional associations; and representatives of funding agencies, technical assistance, and research organisations active in the field. In addition, these profiles may be useful to policy-makers and members of the media interested in health and development issues. The representatives of the low maternal mortality country teams included: Mabel Magowe and Lucy Sejo Maribe (Botswana); Drs. Raj Karim, Ravindran Jegasothy, and Mahani Yusoff (Malaysia); Dr. Anoma Jayathilaka and Daya Kumurage (Sri Lanka); and Dr. Mounira Garbouj and Atf Gherissi (Tunisia). 3

>> Skilled Care During Childbirth: Country Profiles Botswana TUNISIA SRI LANKA MALAYSIA Botswana Introduction Population size (millions) (1) 1.6 Population distribution (%) (1) Rural 50 Urban 50 Adult illiteracy rate (%) (1) Male 25 Female 20 GDP (US$ millions) (1) 5,285 % GDP spent on health* 2.5 Total fertility rate (1) 4.0 Contraceptive prevalence (%) (2) 33 National maternal mortality ratio 480 Skilled care during childbirth requires the presence of a doctor or midwife, or a nurse with midwifery skills, who is trained to manage normal labour and delivery, recognise complications, and offer either emergency treatment or immediate referral to health centres for more advanced care. Skilled care also requires functioning referral and transport systems and necessary drugs, equipment, and supplies. Botswana is a landlocked country in the centre of Southern Africa, bordered by Namibia, South Africa, Zambia, and Zimbabwe. Its population is small but rapidly growing, with a trend toward urbanisation. Botswana is also youthful: in 2000, approximately 42% of its citizens were under the age of 15. (1) At independence in 1966, Botswana was one of the poorest countries in Africa with Gross National Product (GNP) per capita of about US$12. However, the discovery of diamonds, coupled with prudent economic management and political stability, dramatically increased the GNP per capita to US$3,300 by the year 2000. Trends in health and development: Government spending on the public sector exceeds 30% of Gross Domestic Product (GDP), of which 8% is spent on health. (3) This investment in infrastructure and services has led to tremendous improvements in a number of health and social indicators, including the under-five mortality rate, access to clean drinking water, and life expectancy at birth. Botswana s total fertility rate experienced a steady decline, from 6.1 children per woman in 1980 to 4.0 children in 2000. (1) In education, Botswana has achieved significant improvements in female primary education enrolment and adult literacy levels. Despite these achievements in health and development, Botswana is now struggling with one of the highest HIV infection rates in the world. An estimated 35% of the adult population is HIV infected, and in 1998 approximately 35% of pregnant women were HIV positive. + Maternal health: In 1973, the Ministry of Health (MOH) formally established a national Maternal and Child Health/Family Planning (MCH/FP) programme, coordinated by the MCH/FP Unit in the MOH. As part of the national programme, the Government developed a network of health care infrastructure throughout the country for provision of integrated MCH/FP services (see section on Developing Health Services Infrastructure). Although antenatal, delivery, and postnatal services were made available to women in the 1970s, Botswana s maternal health situation did not improve. In 1984, one-third of women gave birth without a skilled attendant present during childbirth and just over half sought postpartum care. In 1993, a study of maternal deaths found that haemorrhage, sepsis, and obstructed labour accounted for almost * This reflects public health expenditures, as percentage of GDP, and consist of recurrent and capital spending from government budgets and social health insurance funds. The maternal mortality ratio or MMR is the number of women who die during pregnancy or childbirth per 100,000 live births. This estimate is from the publication, Maternal Mortality in 1995: Estimates developed by WHO, UNICEF, UNFPA, and is assumed to be high given the relatively high coverage and good quality services of Botswana s health system. The government conducted a pilot study to test data collection tools for an upcoming study that will produce a revised estimate of maternal mortality and provide data on the leading causes of maternal mortality and circumstances surrounding maternal deaths. 1999. + 1998, sentinel surveillance. 4

>> Skilled Care During Childbirth: Country Profiles Botswana 60% of maternal deaths (see Figure 1). (4) In addition, 18% of maternal deaths were among teenagers between 15 to 19 years, and sepsis (mainly due to unsafe abortion) accounted for 33% of these deaths. FIGURE 1 > CAUSES OF MATERNAL MORTALITY Botswana s response has been a focused, carefully planned safe motherhood programme (see next section), which aims to significantly improve the quality and coverage of maternal health care. The 1996 Botswana Family Health Survey indicates that use of maternal health services has improved (see Figure 2): coverage of antenatal care (ANC) has increased to 94%; the percentage of assisted deliveries increased to 87%; and postpartum coverage to 85%. 16% 17% 9% 28% 30% FIGURE 2 > SELECTED INDICATORS FROM THREE BOTSWANA FAMILY HEALTH SURVEYS 100% 80% 60% 40% 1984 Haemorrhage Sepsis Hypertension Indirect causes Obstructed labour 20% 0% 23 24 17 23 33 42 90 92 94 66 78 87 54 71 85 Teenage Pregnancy Contraceptive Prevalence ANC Attendance Supervised Deliveries Postnatal Care *ANC attendance is at least 4 5 times during pregnancy, starting before 24 weeks. 1988 1996 Laws, Policies, and Related Programmes Laying the groundwork: In October 1990, a high-level delegation led by the current President, Mr. Festus Mogae, attended the Southern African Development Cooperation (SADCC) Safe Motherhood Conference in Zimbabwe. Following the conference, a series of activities were undertaken to raise awareness, involve local organisations, and gather specific information about the problem so that a national plan could be developed (see sidebar on next page). The National Programme: Safe motherhood is an integral component of the broader health programme. The MCH/FP Unit in the Family Health Division is responsible for coordinating the safe motherhood programme using a broad-based, multi-sectoral approach to address the wider range of problems that increase maternal morbidity and mortality. The programme s overall goals include: (5) Improving the quality, efficiency, and effectiveness of MCH/FP services; Increasing the accessibility of services; Strengthening and developing IEC and data collection systems; Improving organisation and management of MCH/FP services; and Reducing the incidence and consequences of unsafe induced abortion.* The supporting policy framework: As part of its holistic approach to women s health and development, the Government has formulated a series of policies that bolster safe motherhood goals, including: Family Planning Policy Guidelines and Services Standards (1987) confirm the right of all individuals to reproductive health services based on choice; and specify the types of services to be provided, the cadres of staff to provide these services, and the groups to receive them. These guidelines were revised in 1994 to remove medical barriers to family planning. National Health Policy (1995) recommends public and private sector partnership in matters of health and attention to high-risk groups. * Abortion in Botswana is permitted in the following circumstances: if the pregnancy could endanger the pregnant woman s life; if the pregnancy is a result of rape case or incest; or if a serious disability of the foetus can be determined. 5

>> Skilled Care During Childbirth: Country Profiles Botswana SAFE MOTHERHOOD: STEP-BY-STEP In November 1990, a conference for the Members of Parliament and the House of Chiefs was held in Gaborone to publicise the issue and mobilise political support. At the same time, the Family Health Division of the Ministry of Health organised a workshop on communication strategies for safe motherhood and HIV/AIDS prevention. In 1992, a multisectoral Safe Motherhood Task Force was established to help develop, implement, and monitor a national safe motherhood programme. The Task Force meets regularly and includes representatives from the government, NGOs, and training institutions, among others. In 1993, two key studies were conducted to help formulate a national plan: > Safe Motherhood in Botswana: Situation Analysis which reviewed available information on the extent of maternal mortality and its causes and consequences, as well as other women s health issues, and recommended corrective strategies; > Determinants of Maternal Mortality in Botswana: An institutional, household and community perspective, conducted by the MCH/FP Unit and UNICEF, which examined maternal mortality records between 1990 1992 to identify direct and indirect causes of maternal mortality. Policy on Women and Development (1995) advocates adolescent-friendly reproductive health services in the context of women and development. National Population Policy (1996) states that the individual is central to development efforts and that the goal of health and social services is improved quality of life and living standards of all people in Botswana. Critical Interventions to Increase Skilled Care During Childbirth A series of focused interventions have contributed to Botswana s success in lowering maternal mortality and increasing rates of skilled care during childbirth: Developing Health Services Infrastructure Botswana has developed a well-distributed health services network such that the majority of the population (86%) lives within 15 km of a health facility. The health care system is structured along the following lines: District/referral hospitals (1:100,000 350,000 population) have an operating theatre to perform C-sections, blood transfusions, and other advanced services. Primary hospitals (1:12,000 35,000 population) are found in remote, low-density areas and staffed by medical officers and registered nurse-midwives. These facilities provide the same advanced emergency services available in district hospitals. Health clinics (1:5,000 10,000 population) are staffed by registered nurses and family welfare educators (FWEs), and provide MCH services, treatment and diagnosis of common diseases, and simple laboratory tests. Health posts emphasise preventive care (basic MCH/FP services, environmental health, first aid, and diagnosis and treatment of common diseases). Health posts are staffed primarily by FWEs, although some have nurses on staff. Each village with a population of 500 1,000 has a health post. Mobile clinics reach remote populations on a monthly schedule, and are staffed by registered nurses or midwives. The mobile clinics provide limited primary health services (simple curative and basic MCH services). Health posts are open from 7:30AM to 4:30PM five days a week, while health clinics, primary hospitals, and district/referral facilities are open around the clock. Access to facilities and services varies and remains problematic in remote areas (such as the western, northern and northwestern parts of the country), though many facilities have been upgraded and new health units are being developed as an ongoing government project. Since 1996, there has been greater emphasis on increasing the number of health clinics and posts with trained nurses and midwives who provide basic maternal health services in communities (see Figure 3), and improving links to referral levels for emergency care. FIGURE 3 > NUMBER OF HEALTH FACILITIES BY TYPE (HEALTH STATISTICS REPORT 1997) 800 600 720 710 400 253 273 133 146 200 1996/1997 77 86 63 51 16 16 14 17 0 2000 District Hospital Primary Hospital Clinic with Maternity Clinic without Maternity Health Post with Nurse Health Post without Nurse Mobile Stops 6

>> Skilled Care During Childbirth: Country Profiles Botswana Drugs are provided under the rules of the Drugs Regulatory Committee, and are generally available, although some shortages exist, mainly in very remote areas. Equipment and supplies for basic maternal health services are also generally available (6), though distribution and logistical problems do result in the frequent unavailability of such small yet necessary items as the angle poise lamp or blood pressure machines. Emerging programmes (i.e. the Programme for the Prevention of Mother-to-Child Transmission of HIV) have helped secure more and better equipment (i.e., silicon vacuum cups have replaced metal cups for vacuum extraction). Establishing Transport & Referral Systems A referral system links health posts with health clinics and hospitals. Protocols have been developed that allow a health provider to send a patient directly to a facility where specific services can be obtained (for example, in an emergency, a woman may be referred directly from a health post to a district hospital). For referral, most health facilities have a radio and receiver, at least one vehicle, and a telephone. In cases where the only vehicle is unavailable, paid transport from private sources will be arranged. Investing in Health Personnel Botswana has invested in improving the training and distribution of key cadres of health providers providing maternity services. Nurses and midwives form the backbone of the health care system and are the main providers of maternal health care. Most nurses provide routine antenatal and family planning services; those with midwifery skills provide the more complex family planning, antenatal, delivery, and postpartum care. Midwives trained in life-saving skills attend obstetric emergencies and co-manage obstetric medical/surgical complications with doctors. In addition to doctors, nurses, and midwives, FWEs play a role in providing maternal health services. They are primary school graduates who educate and motivate the community on issues related to safe motherhood encouraging women to deliver in an institutional setting, and providing counselling and health education to communities living within a five kilometre radius of health posts. Training programmes: Over the last ten years, Botswana has improved and expanded training of health personnel providing midwifery care. In 1993, the National Task Force for Safe Motherhood commissioned a small expert group to review training for health providers. This group reviewed existing standards, protocols, and training manuals, and made the following improvements: Pre-service midwifery training: The midwifery curriculum was increased to an 18-month programme with greater emphasis on antenatal care, labour, and delivery. It emphasised prevention and care strategies to improve maternal well-being. New content was added on the underlying causes of poor maternal health; safety and care during pregnancy, childbirth, and post-partum; and emergency care. Since 1994, 562 midwives have gone through the training programme. Plans to increase the number of midwives to meet national targets and service requirements are underway. One obstacle to meeting this goal is the limited capacity of training institutions. Currently, there are only three midwifery training schools, as opposed to eight registered nurse training schools. Additional training sites for midwives are planned in the Southeast region of the country. Other reproductive health training: Training for midwives in family planning has also been strengthened under the Botswana Population Sector Assistance Programme. Emphasis is placed on clinical skills and counselling, integration of STI/HIV/AIDS into family planning, and prevention, screening, and management of sexually transmitted infections. In-service life-saving skills education: A six-week curriculum on high-risk pregnancies and life-saving skills has also been introduced for midwives and doctors. Skills include: procedures for completion 7

>> Skilled Care During Childbirth: Country Profiles Botswana of delivery (such as evacuation of the uterus for incomplete, inevitable abortion; vacuum extraction; and manual removal of retained placenta), repair of third degree lacerations, breech extraction, and newborn resuscitation. In addition, doctors receive training in the repair of fourth degree lacerations and emergency caesarean section. Between 1994 1995, 68 midwives and 12 medical officers were trained in this programme. Competency-based training is provided to all existing staff to ensure that they have the necessary skills in: Counselling and communicating with patients; General programme management; Treatment of high-risk and complicated maternity cases; New developments in contraceptive technology; and Management of STIs, particularly AIDS. Supervision: The senior staff member within each unit is responsible for the daily supervision of midwives. The MCH/FP Unit in the MOH conducts yearly supervisory visits at the district level to monitor progress in implementation of programmes. Despite considerable improvements, Botswana suffers from a shortage of qualified health personnel. The HIV/AIDS situation has further exacerbated the already inadequate levels of personnel. Specialists such as obstetricians, paediatricians, and surgeons are only found in the country s two referral hospitals. Since Botswana does not have a medical training school for doctors, 85% of the doctors employed by the Government are expatriates. Nurses and midwives are also in critically short supply (see Table 1). In 1997, there were only 41.3 nurses (including midwives, registered nurses without midwifery skills, and enrolled nurses) per 10,000 population. TABLE 1 > RATIO OF HEALTH PERSONNEL (PER 10,000 PEOPLE) 1991 1993 1996 1997 Doctors 2.3 2.3 4.0 4.2 Nurses (includes midwives) 22.3 23.1 39.6 41.3 Family Welfare Educators (FWEs) 5.0 5.0 7.3 7.5 Total 29.6 30.4 50.9 53.0 Establishing Standards and Protocols Standards and protocols for routine maternity care and the management of high-risk and emergency services have been reviewed and improved. Protocols have been developed for general care, to specify which services will be provided at each type of facility, and for referral. These tools are used to guide in-service and pre-service training for midwives and other health providers. The obstetric record, a tool for recording the progress of pregnancy, labour, delivery and postpartum care, was revised in 1995. The tool provides a mechanism for monitoring women during antenatal care, delivery (it includes a partograph), and postnatal care. A woman retains this record throughout pregnancy, and she is free to visit any health facility for antenatal, delivery, and postnatal services. 8

>> Skilled Care During Childbirth: Country Profiles Botswana Community Outreach An IEC strategy was developed during the 1990s to raise awareness within communities and to encourage the use of services. The strategy included materials such as posters, wall charts, and pamphlets, as well as a video in local languages and English, with an accompanying booklet for more information. Radio is also used extensively. Health talks are given every morning at the clinics on a range of topics including the need for skilled care during childbirth. However, monitoring shows that most facilities still do not have these materials. (6) Where they are available, the nurses and midwives do not use them adequately as reference. Monitoring and Evaluating the Safe Motherhood Programme Monitoring and evaluation is an integral part of the national safe motherhood programme. While the programme has not been evaluated as an entity, the Family Health Division monitors and evaluates its progress on an on-going basis through support visits, and conducts more targeted research as the need arises. It also releases yearly statistical reports, which are used to help evaluate the performance of its programmes. In 1996, two studies helped to highlight the strengths and weaknesses of the evolving safe motherhood programme. The Situation Analysis of the Maternal and Child and Family Planning Programme and the Botswana Family Health Survey identified a number of areas for improvement (such as inadequacies in training, staffing, and equipment, and access to care in remote areas), along with strategies to address them. Public Expenditure on Health As Table 2 indicates, government expenditure in the public sector has generally exceeded 35% of GDP. Since 1995, government expenditures on health have almost doubled (from US$45 million to US$89 million in 1999). (7) With the advent of HIV/AIDS, however, the government has had to reprogramme funds to address the epidemic, reducing the already inadequate levels of funding for current programmes such as life-saving skills training. For additional information about Botswana s safe motherhood programme, contact: Mrs. Lucy Maribe Principal Health Officer, MCH/FP Division Ministry of Health P.O. Box 992 Family Health Division Gaborone Botswana Tel: 267 353 561 Fax: 267 302 092 E-mail: lmaribe@gov.bw TABLE 2 > PUBLIC AND HEALTH EXPENDITURES (SELECTED YEARS) YEAR 1981 1991 1994 1996 2000 Public Expenditure (% of GDP) 37.9 43.2 34.1 35.5 39.6 THE KEYS TO BOTSWANA S SUCCESS ARE: > A carefully planned national strategy based on research and pronounced political support. > Collaboration and integration at all levels. > Significant resources invested in health, in real value and as percentage of Government spending. > Trained personnel for management of obstetric emergencies. > Improved access to health facilities and services. > Integrated MCH/FP services (supermarket approach). > Availability of midwives at all levels of the health care system. > Good referral system from the lowest level facility to the highest level. > Availability of emergency obstetric services in hospitals. Health Share of Public Expenditure 5.2 5.1 6.1 6.0 8.0 Sources 1 World Development Indicators 2002. World Bank, Washington DC, 2002. 2 1988, any method. World Contraceptive Use 2001. United Nations Population Division. Department of Social and Economic Affairs. New York, May, 2002. 3 2000; Common Country Assessment (CCA) 2001. 4 L. Owuor-Omondi, et al., Determinants of Maternal Mortality in Botswana: An Institutional, Household and Community Perspective, Ministry of Health, 1993. 5 Safe Motherhood Task Force, Safe Motherhood in Botswana: A Situation Analysis, 1992. 6 B. Baakile, L. Maribe, et al. A Situational Analysis of the Maternal and Child and Family Planning. Africa Project II, Population Council, Nairobi, Kenya, 1996. 7 Statistical Bulletin, Central Statistics Office, Botswana Ministry of Finance and Development Planning, 1999. 9

>> Skilled Care During Childbirth: Country Profiles Malaysia TUNISIA SRI LANKA Malaysia BOTSWANA Introduction Population size (millions) (1) 23.3 Population distribution (%) (1) Rural 43 Urban 57 Adult illiteracy rate (%) (1) Male 9 Female 17 GDP (US$ millions) (1) 89,659 % GDP spent on health 1.4 Total fertility rate (1) 3.0 Contraceptive prevalence (%) (2) 55 National maternal mortality ratio (3) 39 Skilled care during childbirth requires the presence of a doctor or midwife, or a nurse with midwifery skills, who is trained to manage normal labour and delivery, recognise complications, and offer either emergency treatment or immediate referral to health centres for more advanced care. Skilled care also requires functioning referral and transport systems and necessary drugs, equipment, and supplies. Malaysia lies in the heart of Southeast Asia. It is an extremely diverse country with numerous ethnic groups in 13 states and 2 federal territories. It has a steadily growing population, with a trend toward urbanisation. Since its independence in 1957, Malaysia has made a strong commitment to health and development, especially in the area of women s health and safe motherhood. Malaysia has moved from a fragmented, rudimentary health care system, especially in rural areas, to an extensive infrastructure that provides comprehensive health care to more than 90% of its population, with many services (antenatal care, immunisations) free of charge. As a result of this investment, life expectancy in Malaysia has risen to 73 years for women and 70 for men (from less than 50 years in 1957); infant mortality has dropped from 30 deaths per 1,000 live births in 1980 to 8 in 2000; and the total fertility rate declined from 6.7 in 1957 to 3.0 in 2000. Malaysia s commitment to women extends into all areas of development: women have equal rights in education, voting, and employment. Over the last decade, more girls than boys have enrolled in tertiary education. Approximately 48% of women are in the paid workforce, and women hold senior government positions. Maternal health: Maternal mortality has fallen dramatically in Malaysia over a period of 60 years, from 1,100 per 100,000 live births in 1933 to 39 deaths per 100,000 live births in 1995 (3,4) (see Figure 1). A central factor in this decline has been high-level government commitment to ensuring that quality maternal health services are accessible to the vast majority of the population, particularly in underserved and rural areas. An extensive community-based programme provides primary health care services, including immunisations, antenatal care, and delivery services, to the rural population. Skilled birth attendants (primarily midwives) are the first point of contact for maternity care through home visits, and in village health clinics and hospitals. (4) Between 1949 1997, the percentage of live births attended by a skilled health provider increased dramatically from approximately 30% to over 95%. (4) During this period, government midwives increasingly conducted home deliveries and demand for childbirth in public sector hospitals expanded considerably. In 1995, of the 98% of births attended by skilled health providers, 66% were delivered in government hospitals, 20% in private hospitals or maternity homes, and 12% at home. (5) Currently, most maternal deaths are due to: postpartum haemorrhage, severe anaemia, hypertensive disorders of pregnancy, puerperal sepsis, and obstructed labour. Abortion is permitted to save the life of the pregnant woman and to preserve her physical or mental health; deaths from unsafe abortion account for less than 1% of total maternal deaths. (6) 10

>> Skilled Care During Childbirth: Country Profiles Malaysia FIGURE 1 > MATERNAL MORTALITY TREND IN PENINSULAR MALAYSIA (1933 1995) 1200 MATERNAL DEATHS PER 100,000 LIVE BIRTHS 1000 800 600 400 200 0 1930 1940 1950 1960 1970 1980 1990 YEAR Laws, Policies, and Related Programmes Laws and policies supportive of maternal health in general and skilled care during childbirth in particular have been in place since the colonial period. After independence, the national government accorded high priority to the goal of maternal mortality reduction by investing in a range of programmes and strategies to improve MCH (see next section). Professionalisation of midwifery: In 1932, legislation was introduced to regulate the practice of midwifery. Midwives as a cadre of health personnel were trained, certified, and legally registered based on demonstrated competency in a defined list of clinical skills. They were deployed as front-line community health workers to provide maternal care (see section Investing in Midwifery Personnel for information on training and supervision of midwifery personnel). (4) Registration of Births and Deaths: A system for the registration of births and deaths was introduced in the colonial period; in the 1950s a national civil registration system, based on the issuance of a personal identity card, provided a means of obtaining reliable vital statistics. Investments in Women: Several laws and policies that aim to improve women s economic and social status, and foster equal access to educational opportunities, have provided an enabling environment for expanding access to skilled care: National Women s Policy ensures equal opportunities for education, employment, and access to basic health and social services; prevents discriminatory policies and practises; and empowers women. Education Policy provides equal access for girls (and boys) to free primary and secondary education, and assistance with school uniforms, textbooks, and school meals for the poor. Rural Development Policy provides basic infrastructure, including housing, schools, clinics, roads, transport, communication, and poverty alleviation programmes. Vision 2020, a forward-looking policy, includes reduction of mortality within its nine priority actions for a caring society. Emphasis on Poverty Reduction: Malaysia s efforts to improve maternal health and increase access to skilled care were implemented within the context of a poverty alleviation strategy that emphasised reducing gaps between the rich and poor. This has ensured that disadvantaged groups, particularly the rural poor, benefit more proportionately from health and social programmes. (4) Collaboration: With the goal of improving the quality of maternal health services, the Government has fostered a high level of collaboration at the policy, programme, and community levels: Policies and standards: In 1971, National, State, and District MCH Committees were formed to help develop and oversee programme strategies and standards for care. These multi-sectoral committees draw on the expertise of medical specialists and public health personnel as well as key state- and district-level decision-makers. National policies, manuals, and protocols are developed by the National Committee and its task forces. Local maternal and child health problems are discussed at the district level and referred for policy or technical guidance as needed. NATIONAL SAFE MOTHERHOOD PROGRAMME Malaysia s national safe motherhood programme has employed a multi-strategy approach to reducing maternal death, focusing on: > improving coverage by ensuring access to basic health services; > upgrading the quality of essential obstetric care in district hositals; > streamlining and improving referral and feedback systems; > enhancing providers capacity and skills for managing pregnancy and delivery complications; and > reporting maternal deaths. (7) 11

>> Skilled Care During Childbirth: Country Profiles Malaysia Programme development: Since the early 1990s, strategies to reduce maternal mortality have been developed at the local level using an inclusive District Team Problem Solving Approach. Teams identify their own problems, decide on the best solutions, design appropriate interventions, and formulate a district plan of action (see section Evaluation and Review of the Safe Motherhood Programme for further information). Staff involvement: Medical, nursing, and midwifery associations are consulted to upgrade training for life-saving skills, and training curricula are reviewed by nursing and midwifery regulatory boards. Community outreach: Women s NGOs, community, and religious groups have played a role in community and family education, and increasing awareness in communities. Critical Interventions to Increase Skilled Care During Childbirth Within the context of supportive policies and legislation to improve maternal health (see previous section), Malaysia implemented a series of phased interventions to expand access of the rural poor to health services and increase the quality of existing services through improved management and community mobilisation. Expanding Community Access to Health Services In 1955 the Government implemented an extensive rural health programme, with the aim of providing primary health care (including such maternity services as antenatal care, delivery services, and postpartum care) at the community level. Rural health clinics were built, public hospital services expanded, and increased numbers of skilled providers (principally midwives and nurses) were trained and deployed to serve rural communities. By 1977 most of the rural population lived within two-four kilometres of a health facility by tarred road. Those who live far from health clinics are served by mobile health teams. Investing in Midwifery Personnel Health workers that provide maternity care include midwives,* nurses, medical officers, and specialist obstetricians. Midwives are the front-line providers of maternity care in rural areas they provide antenatal and postnatal care and perform all normal deliveries at health facilities or through home visits. Nurses provide back-up support to midwives by handling emergencies in cases where a doctor with obstetrical training is not available. While midwives and nurses are the first point of contact for maternity services, medical officers and specialist obstetricians provide the first line of referral care. Reorganisation of Rural Health Care In 1975, the existing three-tiered rural health system was reorganised into a two-tier system in order to widen the scope of services offered to mothers at first contact, provide greater access to doctors, and streamline the referral system. Community-based midwives were upgraded to multi-purpose nurses with additional skills (see footnote below). (6) Health Centres (1:20,000) Community Clinics (1:4,000) Staff Services Doctor, dental officer, medical assistants, public health nurse, assistant nurses, staff nurses, midwives, lab assistant, dispenser, clerical assistant. Out-patient care, MCH care, environmental health, health education, family planning, dispensary. Community health nurse/midwife. MCH care, home delivery, home visiting, minor ailments, family planning, immunisation. * Before 1978, midwives were trained as single purpose health providers; their training was subsequently expanded to include child health and basic outpatient care, while retaining their core midwifery functions. As a cadre of health professionals, midwives have become known as community nurses. 12

>> Skilled Care During Childbirth: Country Profiles Malaysia Training programmes: All professional health personnel receive midwifery training that emphasises hands-on practical experience and mastery of clinical skills: Midwives/community nurses undergo 2 1/2 years of competency-based training in midwifery and basic outpatient care, which includes a practical internship in district hospitals and health centres. Since 1987, community nurses have been trained to administer oxytocics and intravenous infusions for postpartum haemorrhage; since 1993, they have been trained in the use of the partograph to help prevent delay in referral. Staff nurses and public health nurses undergo a 3 1/2 year nursing course; staff nurses receive an additional year of midwifery training, and public health nurses receive an additional year of public health training. Since 1987, all medical officers posted in health clinics and hospitals undergo a 4 to 7 month training in obstetrics and gynaecology to improve their proficiency in handling pregnancy and obstetric complications. Supervision: Based on a supportive, competency-based approach, supervision takes place according to established protocols and manuals. A written supervisory checklist, covering such areas as facility maintenance, record keeping, and interpersonal skills, guides the supervision of midwifery personnel. Supervisory staff provide on-the-spot feedback on clinical and programmatic matters; visits take place on a regular, preset schedule, though surprise visits are also conducted. Midwives are supervised by nurses, and doctors are supervised through regular case audits. The obstetrician covering a district hospital holds discussions on emergency management of complications and the appropriateness of referral. Establishing Transport and Referral Systems Systems for communication, transport, and referral ensure that all health facilities have transport (e.g. ambulance) to a higher level of care and that communication mechanisms (e.g. telephone) allow staff to discuss management of cases with senior personnel. In addition, midwives link the community with institutional health facilities by recognising complications and referring women requiring emergency care to the nearest health clinic. As referral systems were established, health facilities were upgraded in phases to provide essential obstetric care. Standardised equipment, supply, and essential drug lists ensure that necessary equipment and supplies (e.g. drugs, blood) are available in all appropriate health facilities. Referral systems may cut across state boundaries for the speedy referral and treatment of emergency cases. In river, coastal, and island areas, police and marine boats are mobilised to transport near-term pregnant women to the nearest health facility before the flood season. Community Outreach In an effort to improve the quality of health care services and increase utilisation, continuous education and community involvement have been a central component of the Government s rural health services programme: Community and religious leaders and influential individuals encourage women with identified pregnancy risks to deliver in hospitals. Women who have survived a complicated delivery share their experiences with other women and families. TBAs, who are respected community members, have been made partners in a critical network that links the health system, TBAs, and the community (see sidebar). INVOLVING TRADITIONAL BIRTH ATTENDANTS Until the 1960s, TBAs conducted most deliveries in rural and remote areas. As part of its rural health services programme, the Government worked with TBAs as partners to improve women s access to a skilled midwife or nurse at the time of childbirth. For a limited time, TBAs were trained in basic hygiene care and in recognising and referring complications to the health centre. TBAs also became registered and certified partners in the health care system. TBAs were encouraged to continue a range of traditional services (e.g. accompanying mothers to hospitals, being present during delivery to attend to customary rituals, and providing care for the mother and newborn) considered valuable to women. Health workers were trained to value the role of TBAs in providing such services and to work with them as full partners. As a result of this approach, most deliveries are now conducted by government midwives. TBAs still play a key role in certain remote and underserved communities. For example, in Sabah (East Malaysia) TBAs conducted 12% of total deliveries in 1994. 13

>> Skilled Care During Childbirth: Country Profiles Malaysia Health workers offer community education in health clinics and at home. Community midwives conduct antenatal home visits to ensure that families and communities are aware of the need for skilled care during childbirth and to make advance arrangements for transport, child care, etc. to prevent delays. Mass media has been used extensively through national and regional networks to offer weekly programmes on women s health issues. Improved Quality and Management of the Maternal Health Programme While the period following independence was focused on increasing access to basic maternity care (see previous section), subsequent efforts (between the 1970s and 1990s) emphasised improving the quality of available services through better management. Since the 1970s, the primary indicator used for evaluating the maternal health programme has been the proportion of births attended by a skilled attendant, with districts evaluated based on their performance on this key indicator. Monitoring Maternal Deaths: The system for monitoring maternal deaths evolved over a period of 40 years from informal, sporadic investigations to the systematic programme in place today. During the colonial period, deaths were reported to local police authorities, and the government midwife would obtain information on maternal deaths. Such investigations involved hospital and district-level administrators working with members of the family and community. High-level officials visited areas where a maternal death occurred to draw attention to the event and raise awareness about the possible cause and means of preventing the death in question. It was made clear that this was a non-punitive review with the aim of learning the cause and circumstances of the death, and addressing deficiencies in the health system. In the 1980s, standard forms and procedures were developed in an effort to formalize the process of maternal death investigation; community leaders and supervisory personnel were involved in the investigation. In 1991, the existing system of maternal death investigations, the Confidential Enquiry of Maternal Deaths (CEMD), was established. Each maternal death is reviewed by committees at district, state, and national levels in a confidential, non-punitive, and timely manner to assess quality of antenatal and obstetric care, identify weaknesses and reasons for substandard care, and recommend improvements in maternal health programmes. Developing Standards and Protocols: The National MCH Committee (which consists of midwives, nurses, obstetricians, and representatives from academic and training institutions) defines standards for clinical care and referral through the development of manuals and protocols for different cadres of health providers, in collaboration with a range of stakeholders (see previous section on Laws, Policies, and Related Programmes). Standards and protocols are continuously revised and updated to reflect changing realities. In 1984 national guidelines for antenatal and obstetric care were formulated and management protocols were developed for major causes of maternal mortality (postpartum haemorrhage, severe anaemia, hypertensive disorders of pregnancy, puerperal sepsis, and obstructed labour). These guidelines were amended in 1996 to include obstetric indicators that reflect quality of care. Norms, procedures, and standards for maternal care have also been developed for upgrading training and skills of midwifery and nursing personnel, and strategies to increase deliveries by professional health workers. For example, a colour-coded system was developed for evaluating pregnant women to try to identify those at risk of complications so that they can receive appropriate care. 14

>> Skilled Care During Childbirth: Country Profiles Malaysia Evaluation and Review of the Safe Motherhood Programme: Regular, periodic evaluations and assessments are conducted on specific aspects of maternal care, and the results are used to modify and improve services. For example: In 1984, a functional analysis of the health care system found deficiencies in training and supervision, as well as hostile environments in facilities, long waiting times, and non-systematic patient flow in clinics. As a result, norms and procedures were revised to reduce unnecessary procedures, and increase antenatal and postpartum visits; adapt the nursing and midwifery curriculum; improve interpersonal communication; and formulate a standard checklist for supportive supervision. The Quality Assurance Programme was introduced in 1986 as a continuous assessment system for quality of care. Indicators of antenatal and obstetric quality of care were used to correct weaknesses in the health system and improve substandard care. In 1999, process indicators were added to ensure early action could be taken to avert maternal death. Since the early 1990s, maternal mortality reduction strategies have been identified through a District Team Problem-Solving Approach, where districts identify deficiencies in care, determine strategies/solutions, and design interventions to address these difficulties through the development of a district plan of action. In 1999, a review found that the team approach to problem solving between health and hospital personnel was not easy to sustain, but that community outreach and mobilisation had increased women s willingness to deliver in hospitals, reduced the incidence of births before arrival, and increased skilled care during deliveries. TABLE 1 > PUBLIC EXPENDITURE ON HEALTH SERVICES AND MATERNAL HEALTH CARE AS PERCENT OF GDP (4) Total Maternal Period Health Health Services Care 1950 55 NA NA 1956 60 1.54 NA 1961 65 1.71 NA 1966 70 NA NA 1971 75 1.79 0.32 1976 80 1.63 0.36 1981 85 1.59 0.41 1986 90 1.51 0.40 1991 95 1.44 0.37 Public Expenditure on Maternal Health Since the 1950s, total public expenditure for health care has averaged about 1.4 to 1.8% of GDP; total expenditure on maternal health care in public sector hospitals and community services has been at modest levels averaging 0.38% of GDP (see Table 1). (4) Maternal health services are largely provided through the public sector, and services, including skilled care at childbirth, are free-of-charge to the poor and mostly free to other groups. The Government has made concerted efforts to remove financial barriers, such as subsidising transport for emergency cases. For additional information about Malaysia s safe motherhood programme contact: Raj Karim Regional Director International Planned Parenthood Federation 246 Lorong Enau, off Jalan Ampang East and South East Asia and Oceania Regional Office (ESEAOR) Kuala Lumpur 50450 Malaysia Tel: 60 3 456 61 22/246/308 Fax: 60 3 456 6386 E-mail: rk@ippf.po.my THE KEYS TO MALAYSIA S SUCCESS ARE: > High-level policy commitment to the goal of reducing maternal deaths and improving skilled care during childbirth. > Decentralized, multi-strategy approach which targets specific problems and addresses them through incremental and systematic improvements in health services, and hospital and community systems. > Collaboration at the policy, programme, and community levels. > Monitoring and evaluation systems to track improvements and determine deficiencies in care. > Community involvement and empowerment, including partnership with TBAs. Sources 1 World Development Indicators 2002. World Bank, Washington DC, 2002. 2 1994, any method. World Contraceptive Use 2001. United Nations Population Division. Department of Social and Economic Affairs. New York, May 2002. 3 1995; Maternal Mortality in 1995: Estimates developed by WHO, UNICEF, UNFPA. WHO, Geneva, 2001. 4 Indra Pathmanathan and Jerker Liljestrand, eds. Investing Effectively in Maternal Health: Malaysia and Sri Lanka. World Bank, Washington DC, 2002. In process. 5 Safe Motherhood and the World Bank: Lessons from 10 years of Experience, Human Development Network Series, World Bank, 1999. 6 1996; Report on the Confidential Enquiries into Maternal Deaths in Malaysia 1995-1996. Ministry of Health, Malaysia, 2000. 7 A.T. Lim, Sharifah Tahir, and A. Vasanthamala. Combating Maternal Mortality: Lessons from Pasir Mas, Malaysia. International Council on Management of Population Programmes, 1998. 15

>> Skilled Care During Childbirth: Country Profiles Sri Lanka TUNISIA Sri Lanka MALAYSIA BOTSWANA Introduction Population size (millions) (1) 19.4 Population distribution (%) Rural 76 Urban 24 Adult illiteracy rate (%) (1) Male 6 Female 11 GDP (US$ millions) (1) 16,305 % GDP spent on health 1.7 Total fertility rate (1) 2.1 Contraceptive prevalence (%) (2) 66 National maternal mortality ratio (3) 60 Skilled care during childbirth requires the presence of a doctor or midwife, or a nurse with midwifery skills, who is trained to manage normal labour and delivery, recognise complications, and offer either emergency treatment or immediate referral to health centres for more advanced care. Skilled care also requires functioning referral and transport systems and necessary drugs, equipment, and supplies. The Democratic Socialist Republic of Sri Lanka is an island situated in the Indian Ocean. The population is primarily rural with an agriculturally-based economy. Sri Lanka has long been dedicated to ensuring the social welfare and health of its citizens. Since the 1930s, comprehensive health services have been free of charge, and in 1945, the Government established a policy of universal free education from year one to university level resulting in an overall literacy rate of 91% by 2000.* Sri Lanka has seen similar improvements in other health and social indicators: infant mortality fell from 82 deaths per 1,000 live births in 1950 to 15 deaths per 1,000 live births in 1997, (4) life expectancy has risen to 73 years; fertility declined steadily from 5.1 in 1953 to 2.1 in 2000; use of both traditional and modern contraceptive methods rose to 66% by 1993. (2) Investments in women s health and development have been a central component of Sri Lanka s success story. Women have equal rights in education, voting, and employment. They are guaranteed equality under the national constitution (1978), and are accorded human rights and freedoms on an equal basis with men. (5) Maternal health: Maternal mortality has declined considerably over the past five decades from 1,660 deaths per 100,000 live births in 1947 (5) to 60 deaths in 1995. (3) Skilled care during childbirth increased from 27% in 1939 to 89% in 1996. (4) Today, most women in Sri Lanka have access to skilled care during pregnancy and labour almost all women (99%) receive antenatal care, 90% of women deliver in institutional settings, and 95% of births are assisted by a skilled attendant. MCH has received high priority in the Government s primary health care policy and infrastructure. Since the mid-1920s, a wide network of community-based health facilities have provided basic preventive services including antenatal care, skilled care during childbirth, and postpartum care in domiciliary and clinic settings. (6) Although Sri Lanka has the lowest maternal mortality ratio in South Asia (as well as the highest contraceptive prevalence rate), (6) it is continuing to refine its programme to reduce deaths and disability even further. In provinces where civil unrest continues to be a problem, maternal mortality is twice as high. It is estimated that approximately 3 4% of deliveries (amounting to a total of 14,000 deliveries each year) do not receive any skilled assistance. These take place mainly in remote areas (such as the plantation sector) and areas subjected to civil conflict. In addition, some women still prefer to deliver * % age 15 and above. Human Development Report 2002, United Nations Development Programme, New York, 2002. 16

>> Skilled Care During Childbirth: Country Profiles Sri Lanka at home, unassisted by a skilled attendant, for cultural reasons. Research also shows that two thirds of maternal mortality and morbidity is due to preventable causes and over 70% of infant deaths take place during the neonatal period. Abortion is illegal in all circumstances except to save the life of the woman, and unsafe abortion is estimated to cause approximately 7 10% of maternal deaths (see Figure 1). Laws, Policies, and Related Programmes Sri Lanka has demonstrated sustained, high-level commitment to safe motherhood during the colonial and post-independence periods. A number of legal and policy initiatives have helped to create a supportive framework for reducing maternal mortality and improving access to skilled care during childbirth, including: Professionalisation of midwifery: Beginning in the late 1800s, midwives were trained to competency in clinical skills and officially registered as a cadre of health personnel. These health providers were deployed to an extensive network of domiciliary and institutional rural health services. Midwifery became a highly prestigious profession, and midwives were well-respected in the communities they served. The situation remains the same today. Vital registration system: As far back as 1897, a system for the registration of births and deaths was in place, and since 1921 a special section on maternal mortality was included. Not only does the availability of vital statistics make it possible to create awareness of the extent of the problem and mobilise action, but it also provides a mechanism to evaluate and improve MCH services. Integration of family planning services: Family planning services have been available as part of MCH care since 1965. The integration of these services facilitated the wide acceptance of family planning and fuelled a sharp decline in fertility rates. (4) Investments in women: As outlined in the previous section, Sri Lanka has made significant investments in elevating the status of women through policies that promote female education and facilitate women s participation in political and social life. Collaboration: In recent times, the President or Minister of Health appoints a multi-sectoral task force with representation from relevant ministries, professional bodies, and NGOs for the formulation of national policies. Sometimes, subcommittees are appointed to ensure that the various sectors (central and regional) and professional bodies (i.e. College of Obstetricians, midwifery associations, etc.) can consider details of implementation before the policy is formulated. The 1998 Population and Reproductive Health Policy, which includes safe motherhood as one of its goals, was developed by a task force consisting of representatives from the MOH, Ministry of Women s Affairs, the Women s Bureau, academics, and NGOs. Critical Interventions to Increase Skilled Care During Childbirth Between the 1940s and 1990s, Sri Lanka invested in a series of phased strategies to improve maternal and child health: Improving access to community health services, including antenatal care and skilled care during childbirth, that are free of charge to the population; Expanding specialised obstetric services; and Developing monitoring and evaluation systems to improve the quality of services. (4) FIGURE 1 > CAUSES OF MATERNAL MORTALITY 33% 10% 7% 26% 13% 11% Haemorrhage Hypertension Heart Disease Abortion Sepsis Other causes NATIONAL SAFE MOTHERHOOD PROGRAMME Reducing maternal mortality is a key goal in broad health policies and in the MCH Programme. At the national level, the Family Health Bureau, under the leadership of a MCH Director, is the central unit within the MOH responsible for planning, implementing, and monitoring all maternal health activities. The main priorities for safe motherhood include: > Promoting the equitable distribution of maternal health services to reduce intra- and inter-district disparities; > Improving the quality of antenatal, intranatal, and postnatal services through training and supervision; introduction of the partograph in certain hospitals; and a checklist of essential supplies and equipment; > Upgrading the process of risk assessment and referral, with an emphasis on essential and emergency obstetric care; and > Systematic review of maternal deaths. 17

>> Skilled Care During Childbirth: Country Profiles Sri Lanka THE PUBLIC HEALTH MIDWIFE The Public Health Midwife (PHM) is the front line health worker for providing domiciliary MCH and family planning services in the community. There are approximately 4,600 PHMs in service through the health unit system, each serving a population ranging from 3,000 5,000 people. Through systematic home visits, these midwives provide care to pregnant women, infants, and pre-school children, including: > One-on-one health education and counselling; > Identification and registration of all pregnant women; > Antenatal care; > Helping mothers plan their place of delivery; > Assisting with home deliveries as necessary; > Postpartum care and counselling; > Family planning counselling and provision of contraceptive pills and condoms to couples of reproductive age; > Reproductive health education for adolescents; > Encouraging women to seek screening for reproductive organ malignancies and schedule regular check-ups. Backed up by a well-structured institutional health system, PHMs link domiciliary services with clinic services. Their activities are supported by a system of record keeping which enables them to plan and monitor their routine activities. Through encouraging women to plan their delivery setting, PHMs are responsible for a high proportion of women (88%) delivering in government health facilities. They also ensure that about 65% of women receive postnatal care at least once during the first ten days after delivery. Improving Access to Community-Based Health Care In 1926, the Government established a health unit system to deliver community-based services, including MCH and family planning, to the vast majority of the population. Providing services at both the institutional (through health centres located in the community) and domiciliary level, each health unit serves populations ranging from 40,000 70,000. Health units are staffed by a Medical Officer of Health (in charge of the unit) and a team consisting of Public Health Nursing Sisters and Public Health Midwives (PHM) (see sidebar). Each health unit is further subdivided into PHM areas, which constitute the smallest working unit in the Government s field health care system. By 1948, the health unit system had expanded to cover the entire country, and health workers were trained and deployed to staff health centres and provide services to women at home. By 1975, most of the population were living within 1.3 km of a health care facility. (4) Community-based health staff are trained and supervised according to the following: The Public Health Midwife receives competency-based training in midwifery for a period of 18 months (12 months at a school of nursing and six months in the community in a field training area). The Public Health Nursing Sister receives three years of training at a School of Nursing, followed by six months of midwifery training, one-year of training in a post-basic nursing school, and six months of training in the field. Medical Officers receive five years of training at the Faculty of Medicine, followed by one-year internship period (consisting of two appointments of six months each). Since 1915, all medical students are required to complete midwifery training. Regular in-service training for field staff is conducted to update knowledge and skills in MCH and family planning. Staff from each health unit attend monthly conferences where they receive training, supervision, and skills development. Supervision: Based on a supportive and non-punitive approach, supervision and monitoring is conducted at many levels and by several categories of staff. Medical Officers provide overall guidance and supervision of maternal health services within each health unit. Public Health Midwives are supervised by Supervising Public Health Midwives, who are in turn supervised by Public Health Nursing Sisters. The Public Health Midwife maintains records and registers which are reviewed by supervisory staff. Referral and Transport Systems: A system of ambulance services was instituted in 1926, and rapidly expanded by 1950 such that emergency transport was available in most health facilities. In cases where ambulances are unavailable, health staff can make arrangements for paying for other transport, for which they are reimbursed by the MOH. (4) Midwives working at the field level can call the Public Health Nursing Sister or the Medical Officer in their health unit to discuss emergency cases, and can refer women to the nearest clinic or hospital or directly to a higher-level referral facility. Community Outreach: The Ministry of Health conducts IEC activities to motivate mothers to attend health clinics and deliver in hospitals. Materials have been produced by the Family Health Bureau and the Health Education Bureau of the Ministry of Health to educate mothers on the health benefits of skilled care during childbirth. TV and radio programmes also provide useful information on health, nutrition, and other health-related topics by specialists in those fields. A highly educated population has been more receptive to health education activities, which has fostered increased utilisation of services. 18

>> Skilled Care During Childbirth: Country Profiles Sri Lanka Expanding Access to Specialised Obstetric Services Sri Lanka s community-based health system (see previous section) is linked to a three-tiered network of institutional facilities that provide a range of obstetric services: Specialist hospitals (Teaching, Provincial, and Base Hospitals) are tertiary-level facilities that provide emergency obstetric care and other advanced services. Currently, there is a total of 50 specialist hospitals (1:400,000 population) staffed by specialist obstetricians. Intermediate/Secondary institutions (District Hospitals and Peripheral Units) offer a wide range of in-patient care in addition to maternal health services. These institutions provide basic essential obstetric care, and refer women to specialist hospitals (by ambulance) if needed. Primary institutions (Rural Hospitals, Cottage Hospitals, and Maternity Homes) provide services for outpatient care and normal deliveries. TABLE 1 > EXPANSION OF MATERNAL AND CHILD HEALTH SERVICES Maternity Health Hospitals* Homes Midwives + Centres 1941 129 12 347 NA 1945 153 34 542 503 1950 263 99 1053 701 1954 270 104 1854 NA 1970 NA 128 2680 1122 1980 357 100 3350 1344 1986 389 88 4652 1778 1989 400 83 5030 1880 1993 410 78 6533 1905 1996 426 60 6745 1950 * Includes Teaching, Provincial, Base, District, Peripheral Units and Rural Hospitals, all of which have maternity unit facilities for deliveries. + Includes both hospital and field midwives. Since the 1950s, the number of specialised institutions grew steadily (see Table 1), thus providing women with greater access to a physician (including specialist obstetricians) for maternity care. During the period between 1964 1983, the number of provincial and base hospitals increased by 30% and the number of district and peripheral hospitals by 41%. (4) As Figure 2 illustrates, institutional deliveries have progressively increased during the past four decades, due to improved access to facilities and regular contact with the Public Health Midwife. Of the total deliveries that take place in government facilities, nearly 70% occur in specialist hospitals, where ob/gyns, midwives, or nurses with midwifery skills conduct deliveries; over 20% occur at the secondary level; and approximately 10% at the primary level. A small percentage (3%) are conducted by government midwives at home. Referral and Transport Systems: All major hospitals have ambulance services for emergency transport to higher-level referral facilities. If ambulances or other hospital vehicles are not available, health staff can make arrangements to fund alternative transport services, to be paid for by the MOH. 19

>> Skilled Care During Childbirth: Country Profiles Sri Lanka FIGURE 2 > PERCENTAGE OF DELIVERIES IN GOVERNMENT HOSPITALS INVESTIGATING EACH MATERNAL DEATH A system to investigate maternal deaths has been in place since the late 1950s. Initially, the Medical Officer of Health conducted the investigation into a maternal death using a prescribed form, and determined whether any follow-up action was necessary. In the 1980s, a formal system of maternal death reviews was introduced where a committee chaired by the Director General of Health Services and comprising administrators, obstetricians, Medical Officers of Health, and members of the medical professional organisations reviews the cause and circumstances surrounding each maternal death. Annual and quarterly maternal death reviews are conducted at the regional and central levels. Each death is analysed in-depth (not to find fault but to identify corrective action) using the Three Delays model. The appropriate measures that need to be taken to prevent such deaths are discussed with programme managers and service providers. The Family Health Bureau acts as the focal point for this system, and provides feedback on the issues discussed and the appropriate corrective actions needed for the future. Some examples of action taken as a result of maternal death reviews: establishing 24-hour ambulance systems, and appointing two specialist obstetricians to a referral institution. (4) PERCENT % 100 80 60 40 20 0 1960 1965 1970 1975 1980 1985 1990 1995 YEAR Monitoring & Evaluation Systems to Improve the Quality of Services In the period between 1960 1990, the Government placed greater emphasis on improving the quality of services through developing monitoring and evaluation systems. At the national level, all MCH and family planning activities were brought under one division, the Bureau of Family Health, headed by a MCH Director. The field reporting system was revamped in an effort to provide regular, systematic assessments of the programme and to identify areas needing improvement. (4) The Family Health Bureau coordinates routine monitoring and evaluation activities, including: Annual maternal death audits at the regional and central levels (see sidebar); Quarterly and annual maternal death reviews at the district level. A set of MCH-Management Information System (MIS) indicators has been developed for each of these activities, to guide supervision of health workers at the district, province, and national levels. Feedback and corrective guidance is promptly offered to health workers. Standards and protocols: Standards and protocols have been developed for most MCH activities. They guide training and organisation of health services, and are also prepared and circulated periodically among health workers to update their knowledge. Examples include: A comprehensive manual for peripheral-level health workers on MCH and family planning (currently being revised) is used as a reference by health staff in their daily activities. Protocols on management of obstetric emergencies and resuscitation of newborn infants have been prepared and given to the relevant staff. Two new manuals are currently being prepared on Management of Obstetric Emergencies in the Periphery and Human Resource Development for Health Personnel with assistance from expert agencies in the field. A national system has been developed to review each maternal death (see sidebar). A recent quality assessment of maternal care has identified some deficiencies in primary-level institutions, specifically with regard to communication and transport systems. For example, although most hospitals have ambulances and telephones, smaller institutions still lack such services and face difficulties in emergency transfer of patients to referral centres. Shortages of certain categories of health staff exist in particular regions of the country, and have hampered the provision of better quality care. 20

>> Skilled Care During Childbirth: Country Profiles Sri Lanka Public Expenditure on Maternal Health Total government expenditure on health has ranged from 1.47 to 2.12 percent of GDP; of the total expenditure on health services, a modest percentage is spent on maternal health care (see Table 2). Prior to the 1990s, health services were funded primarily by the Government; funding to support health services has subsequently been provided by both government and household expenditures. (4) In addition to government funding, the safe motherhood programme also receives financial and technical support from international agencies; the main supporting agencies are UNICEF, WHO, UNFPA, and the World Bank. TABLE 2 > EXPENDITURE ON MATERNAL HEALTH CARE IN SRI LANKA: 1950 1999 (4) Decade 1950s 1960s 1970s Expenditure on Maternal Health Care 0.28 0.30 0.26 Total Government Health Expenditure 1.95 2.12 1.81 THE KEYS TO SRI LANKA S SUCCESS ARE: > Consistent, long-term government commitment to health and development, with an emphasis on women s equality. 1980s 1990s 0.18 0.16 1.47 1.53 > Integration of maternal health into a broad health and development policy. 1950 1999 0.23 1.79 > Community-based health care, free of charge and widely accessible. For additional information about Sri Lanka s safe motherhood programme contact: Dr. Anoma Jayathilaka Ministry of Health Family Health Bureau No. 231, De Saram Place Colombo, Sri Lanka Tel: 94 1 696 508 Fax: 94 1 823 012 E-mail: jayandse@sltnet.lk > Emphasis on training and quality of care. > Routine monitoring and review, including maternal death audits. Sources 1 World Development Indicators 2002. World Bank, Washington DC, 2002. 2 World Contraceptive Use 2001. United Nations Population Division, Department of Social and Economic Affairs. New York, May, 2001. 3 1995; Maternal Mortality in 1995: Estimates developed by WHO, UNICEF, UNFPA. WHO, Geneva, 2001. A maternal mortality study [Maternal deaths in Sri Lanka: A review of estimates and causes 1996. Authors J. Nalin Rodrigo, Lakshman Fernando, Lakshman Senanayaka, Prasanna Gunasekara, Soma da Silva. UNICEF-assisted study] conducted in 1996 generated an MMR of 92 deaths per 100,000 live births. The study found that utilising vital registration systems to measure MMR can seriously undercount maternal deaths. 4 Indra Pathmanathan and Jerker Liljestrand, eds. Investing Effectively in Maternal Health: Malaysia and Sri Lanka. World Bank, Washington DC, 2002. In process. 5 World Bank Case Study on Sri Lanka, Institute on Reproductive Health and Health Reform, 2000. 6 H.R. Seneviratne and L.C. Rajapaksa. Safe Motherhood in Sri Lanka: A 100-year March. International Journal of Gynaecology and Obstetrics 70 (2000): 113 124. 21

>> Skilled Care During Childbirth: Country Profiles Tunisia Tunisia SRI LANKA MALAYSIA BOTSWANA Introduction Population size (millions) (1) 9.6 Population distribution (%) (1) Rural 35 Urban 65 Adult illiteracy rate (%) (1) Male 19 Female 39 GDP (US$ millions) (1) 19,462 % GDP spent on health 2.2 Total fertility rate (1) 2.1 Contraceptive prevalence (%) (2) 60 National maternal mortality ratio (3) 70 Skilled care during childbirth requires the presence of a doctor or midwife, or a nurse with midwifery skills, who is trained to manage normal labour and delivery, recognise complications, and offer either emergency treatment or immediate referral to health centres for more advanced care. Skilled care also requires functioning referral and transport systems and necessary drugs, equipment, and supplies. Tunisia is the smallest of the North African countries, bordering Algeria, Libya, and the Mediterranean Sea. The health and living standards of all Tunisians have improved substantially in recent decades. For example, between 1970 and 2000, life expectancy increased from 55.6 to 72 years. In addition, infant mortality decreased from 135 to 26 deaths per 1,000 live births over the period 1970 2000. Since its independence in 1956, Tunisia has placed high priority on women s health and well-being. Polygamy was abolished, education made mandatory for boys and girls, and in 1959, women were guaranteed equal rights, making them eligible to vote and hold public office. In the mid-sixties, Tunisia legalised abortion and began implementing a national family planning programme, which helped fuel a sharp decline in the total fertility rate from 6.2 in 1970 to 2.1 in 2000. Maternal health: Tunisia s maternal mortality ratio has fallen dramatically over the past several decades by 80 percent between 1971 1994 to its current level of 70 deaths per 100,000 live births. (2) Use of maternal health services has also increased impressively (see Figure 1): 92% of women receive antenatal care, and 82% deliver with a skilled attendant present. Since the 1960s, Tunisia has made a concerted effort to reduce maternal mortality. Maternal and infant health centres were established throughout the country, with midwives playing a primary role in delivering maternal health and family planning services. Several policies supportive of improving maternal health were instituted during the 1960s and 1970s (see next section). In 1990, a national maternal health programme was launched. FIGURE 1 > USE OF MATERNAL HEALTH AND FAMILY PLANNING 100% 80% 60% 40% 1989 20% 1997 0% 2000 Prenatal Care Skilled Care During Childbirth Postpartum Care Contraceptive Prevalence 22