Cultural Considerations in Nursing
Saving MotherS’ LiveS in Sri Lanka �
T he reduction in deaths during pregnancy and delivery has long been held out as a major international public health goal, but many countries have had difficulties making prog-
ress toward it. Most observers now agree that there are no quick fixes, and that the solution will come with the strengthening of now-failing health systems in many poor countries, building up the training of professional and paraprofessional health workers, improving access to both basic and higher-level services, and ensuring the availability of basic medical supplies and medications to deal with obstetric problems. The case of Sri Lanka dem-
onstrates how rapidly progress can occur when those fundamental building blocks are in place.
Mothers Shouldn’t Die in Childbirth
Pregnancy and childbirth are natural events and typi- cally require little or no medical intervention for either mother or baby. But in about 15 percent of all preg- nancies, a severe complication affects the woman—for example, maternal diabetes or dangerously high blood pressure sets in, excessive bleeding occurs during child- birth, or the mother suffers from a serious postpartum
Case 6
Saving Mothers’ Lives in Sri Lanka
Geographic area: Sri Lanka
Health condition: in the �950s, the maternal mortality ratio in Sri Lanka was estimated at between 500 and 600 per �00,000 live births.
Global importance of the health condition today: Pregnancy-related complications annually claim the lives of 585,000 women. Some 99 percent of these deaths take place in developing countries, where women have a � in 8 chance of dying in their lifetime due to pregnancy-related causes, compared with the � in 4,800 chance in Western europe.
Intervention or program: Beginning in the �950s, the government of Sri Lanka made special efforts to ex- tend health services, including critical elements of maternal health care, through a widespread rural health network. Sri Lanka’s success in reducing maternal deaths is attributed to broad access to maternal health care, which is built upon a strong health system that provides free services to the entire population, includ- ing in rural areas; the professionalization of midwives; the systematic use of health information to identify problems and guide decision making; and targeted quality improvements to vulnerable groups.
Cost and cost-effectiveness: Sri Lanka has spent less on health—and achieved far more—than most countries at similar income levels. in india, for example, the maternal mortality ratio is more than 400 per �00,000 live births, and spending on health constitutes over 5 percent of gnP. in Sri Lanka, the ratio is less than one quarter of that, and the country spends only 3 percent of gnP on health.
Impact: Sri Lanka has halved maternal deaths (relative to the number of live births) at least every �2 years since �935. this has meant a decline in the maternal mortality ratio from between 500 and 600 maternal deaths per �00,000 live births in �950 to 60 per �00,000 today. in Sri Lanka today, skilled prac- titioners attend to 97 percent of the births, compared with 30 percent in �940.
2 Saving MotherS’ LiveS in Sri Lanka
infection. In about 1 to 2 percent of the cases, women often require major surgery and may die without effec- tive treatment of these complications.
Over and above the baseline risk of pregnancy, women are in danger of dying during pregnancy and childbirth if their general health is poor. Malnutrition, malaria, immune system deficiency, tuberculosis, and heart disease all contribute to maternal mortality. In addition, use of unsafe abortion services is a major risk factor for maternal death.
Maternal mortality,a the death of a woman while preg- nant or within about two months after the end of the pregnancy, echoes through families for many genera- tions. Women who die are in the prime of their lives and are likely to be leaving behind one or more children—a loss that places at risk those children’s social develop- ment, health, education, and future life chances. The death of a woman in childbirth is highly correlated with the survival of the child she is bearing; the risk of a child dying before age 5 is doubled if the mother dies in childbirth. At least one fifth of the burden of disease for children under 5 is associated with poor maternal health.1 Because poor women are far more likely to die than better-off women, maternal mortality is one of the factors contributing to the transmission of poverty from one generation to the next.
Interventions to detect pregnancy-related health problems before they become life threatening, and to manage major complications when they do occur, are well known and require relatively little in the way of advanced technology. What is required, however, is a health system that is organized and accessible—physi- cally, financially, and culturally—so that women deliver in hygienic circumstances, those who are at particularly high risk for complications are identified early, and help is available to respond to emergencies when they occur. Although some maternal deaths are unavoidable even under the most favorable circumstances, the vast major-
a The official definition of the maternal mortality ratio is the number of maternal deaths for every 100,000 live births. “Maternal” death refers to a death during pregnancy or within 42 days after the end of the pregnancy from a cause related to the pregnancy or its management. Thus, the death of a pregnant woman from an accident or an infec- tious disease not specifically related to the pregnancy would not count in the numerator.
ity can be prevented through systematic and sustained efforts.
Because of overall high health risks and weak health systems, almost all maternal deaths take place in de- veloping countries. Ninety-nine percent of the 585,000 maternal deaths each year occur in poor nations.
The extremes tell the story: Women in the poorest sub- Saharan countries have a 1 in 8 chance of dying during their lifetime because of pregnancy; Western European women have a risk of 1 in 4,800. And in the develop- ing world, maternal death is very much the tip of the iceberg: For each maternal death, somewhere between 30 and 50 other women experience serious injury or in- fection because of pregnancy and childbirth. In develop- ing countries, more than 40 percent of pregnancies lead to complications, illness, or permanent disability in the mother or child.2
During the past several decades, as child health indica- tors have generally improved in the developing world and even as fertility rates have fallen, the WHO esti- mates that maternal mortality has remained relatively unchanged at a high level. Some countries, however, have been able to make significant and sustained progress toward making pregnancy safer for women, even beyond what would be expected with general improvements in living conditions and female health. The lessons from those settings are now informing the approaches international agencies promote.
Sri Lanka’s Public Health Traditions
Sri Lanka, an ethnically diverse country of almost 20 million people living on a densely populated island in South Asia, has a storied history of public-sector com- mitment to human development. Although it is (and always has been) a poor country, with a current aver- age annual per capita income of $740, the development of social services even before independence in 1948 has far exceeded the gains made in countries at similar economic levels. Access to public education was rapidly expanded during the first half of the 1900s, and school- ing of girls has long been much more common in Sri Lanka than in neighboring countries in the region. As a result, 89 percent of Sri Lankan adult women are literate, compared with a South Asian average of 43 percent.3
Saving MotherS’ LiveS in Sri Lanka 3
Health services, too, have benefited from strong public- sector leadership. Going back to the 1930s, the govern- ment focused on expanding free health services in rural areas, with attention given to preventive services and especially control of major communicable diseases. Fi- nancing for this effort was derived largely from income taxes. Currently, life expectancy in Sri Lanka is 71 years for men and 76 for women, compared with 57 for men and 58 for women on average in low-income countries.3
One unusual asset to which Sri Lanka lays claim is a good civil registration system, which has been in place since 1867. This system, which first started recording maternal deaths around 1900, has provided valuable information for planning and monitoring progress. So, unlike in most poor countries where maternal mortality estimates are based on very imperfect sources and meth- ods, Sri Lanka benefits from relatively good data and a tradition within the public administration of using it.
Elements of Success
Sri Lanka’s success in reducing maternal deaths is at- tributed to widespread access to maternal health care, which is built upon a strong health system that provides free services to the entire population, the professional- ization and broad use of midwives, the systematic use of health information to identify problems and guide decision making, and targeted quality improvements. These elements have been introduced in steps, with em- phasis first on improving overall (and particularly rural) access to both lower- and higher-level facilities, then on reaching particularly vulnerable populations, and later on quality improvements.b
Access The first challenge in this country that is largely rural was access. The creation of a basic health service infra- structure, starting in the 1930s, extended access across rural areas to a range of preventive and curative servic- es, enabling initial improvements in maternal health. At the lowest level, the infrastructure consisted of health units staffed by a medical officer, who was responsible for…
