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“Here in Sri Lanka, every birth is recorded and every death is questioned. This sets a standard for many of us to look at,” said World Bank South Asia HNP Sector Manager Julie McLaughlin in her opening speech at the South Asia High Level Forum on Sexual and Reproductive Health on Monday (26) in Negombo.
“While much of the world has declared success in maternal and reproductive health, both the African region and South Asian region are still struggling to achieve MDG5,” she added. “Through this three-day forum in host country Sri Lanka, hopefully we can learn a lot from Sri Lanka’s achievements.”
Sri Lanka has made many achievements in health and education. It has met the MDG target of halving extreme poverty and is on track to meet most of the other MDGs. Among the targets achieved early are those related to universal primary education and gender equality.
The adult literacy rate is nearly universal. The country is expected to meet the goals of maternal health and HIV/AIDS. Progress on reaching the goals related to malnutrition and child mortality is slower: the U5MR and IMR are 9.6 and 8.3 per 1,000 live births. Sri Lanka ranks 75 of 148 countries in the Gender Inequality Index (2012).
The MMR has historically been lower than in other regional countries. It fell from 49 deaths per 100,000 live births in 1990 to 29 in 2013, for an average annual decline of 2.2%.
Minister of Health Mithrapala Sirisena who attended the forum as the Chief Guest commended Sri Lanka’s triumph as a country in the South Asian region that has achieved Millennium Development Goals with its minimal maternal mortality rate. “Women’s health is essential for the well-being of the country,” he said. “The health indicators for infant and maternal mortality are best in the region and within the MDG. This demonstrates the successful achievement of our policies.”
The forum was organised by World Bank Group to provide an opportunity for the countries in the South Asia Region to share experiences and learn the state-of-the-art knowledge about successful interventions that have accelerated the achievement of the fifth Millennium Development Goal, which aims to reduce maternal mortality.
It was represented by H4 partners WHO, UNICEF and UNFPA, who made substantial contributions to the discussions. The forum discussed several topics including family planning, antenatal care, skilled birth attendance, and adolescent health. It also examined the key enablers and drivers of the successful strategies at the household, community, health service delivery and policy levels that may be useful for charting the post MDG agenda.
Fertility in Sri Lanka
The contraceptive prevalence rate (CPR; any method) increased from 66.1% in 1993 to 68.4% in 2007. Modern methods are the main choice of contraceptives and are used by 52.5% of currently married women. Female sterilisation (16.3%), injectables (14.8%) and the pill (8.1%) are the most commonly used form of modern methods. Traditional methods are used by 15.9% of currently married women. There is still an unmet need of 7.3%. The already-low total fertility rate declined further from 2.5 to 2.3 between 1990 and 2012.
Birth intervals of less than 24 months are considered too short: 10.1% of children are born within 24 months of the previous birth. The median number of months since the preceding birth is 50.2.
Early childbearing affects maternal health outcomes in many countries, but does not seem to be an issue in Sri Lanka. The median age at first marriage among women 15-49 is 23.3 years and that at first birth among the same cohort is 25.1 years. The share of women age 15-19 that have begun childbearing is only 6.4%. The adolescent fertility rate is 18 births per 1,000 women age 15-19.
Pregnancy outcomes
Complete and timely antenatal care (ANC) is a necessary component for positive pregnancy outcomes. As of 2007, 99.4% of women sought ANC 
from a skilled provider; 92.5% of women received the recommended four or more ANC visits; 99.7% of women had their blood pressure measured (one of the components in a package of ANC services).
Skilled birth attendance (SBA) is critical in reducing maternal deaths
Skilled birth attendance has historically been high and increased from 94.1% in 1993 to 98.6% in 2007. Of births, 98.2% are delivered in a healthy facility (94% in a public sector facility and 4.2% in a private sector facility). Government sector institutions cater to 94.5% of the deliveries, those in the private sector 5.4%. Within the Government sector, 93% of births take place in a health facility where comprehensive emergency obstetric care is available.
Postnatal care is another important component for maternal health, especially for managing post-delivery complications. It is recommended that postnatal care for mothers occur within the first two days of delivery; 90.8% of women sought this type of care from a skilled provider within the first two days of delivery.
While maternal health care utilisation is high, problems are still encountered in access to health services. Overall, 47.3% of women age 15-49 encountered at least one problem in access health care when sick. The biggest problem was getting money for treatment (22.3%). Other reasons included: not wanting to go alone (21.6%), distance to a facility (19.5%), and having to take transport (19.3%).
Equity in access to maternal health services
Access to maternal health services is fairly equitable. Little variation is observed across residence and wealth quintiles. The CPR is highest in rural (69.9%) and estate (64.7%) areas. In urban areas, it is 59.9%.
The CPR across wealth quintiles is interesting. It is highest among the poorest two wealth quintiles, with an almost 10 percentage point gap between the two (72.7% versus 63%).
SBA is high and there is little variation across residence. In urban areas, SBA is 99.2%, in rural areas 98.7%, and in estate areas 96.5%. Across wealth quintiles, SBA remains high. There is only a two point difference between the richest (99.4%) and poorest quintiles (97.4%).
Improving accessibility of emergency obstetrics and newborn care (EmONC)
According to the hospital discharge policy of Sri Lanka, after delivery, a woman is observed for at least 24 hours at the health institution, and has four post-partum visits by home visits within 42 days. The Government in 2012, carried out a comprehensive EmONC survey to best identify the gaps in services available for maternal and newborn care by district level. The survey’s recommendations are being reviewed.
In 2013, the Ministry of Health (Family Health Bureau) developed national norms and standards for improving the quality of EmONC services in Sri Lanka.
Countdown to MDG5 and the post-MDG agenda
In terms of progress there is a mixed picture in the South Asian region. In terms of MDG 5 the region is doing reasonably well. The mortality rate for infants, the under-five child mortality and maternal mortality is less and are moving in the right direction.
“Progress towards MDG in the region has in general been going well but there are two areas where there is less than expected progress,” noted WB HNP Director Tim Evans, in his keynote address.
“There is still the issue of nutrition where undernourishment and poor nutrition remains a problem relative to progress seen in other regions. The other issue is access to basic sanitation which is also lagging relative to other regions,” he said.
Dr. Evans noted significant disparities between residents in urban and rural dwellings and similarly richer and poorer population.
Inequity in access to maternal health services is a barrier to MDG 5. SBA has increased but wide disparities remain, especially across wealth quintiles. The largest gaps between the richest and poorest are in Nepal, India and Afghanistan. Sri Lanka has a very equitable distribution of SBA with only two percentage points separating the poorest from the richest.
Setting expectations
Chaired by Ministry of Health Sri Lanka Medical Services Additional Secretary Dr. Amal Harsha de Silva, the first session of the forum comprised panellists WB South Asia HNP Sector Manager Julie McLaughlin, WHO Country Representative F.R. Mehta, UNFPA Country Director Alain Sibenaler and UNICEF Country Representative Una McCauley.
What requires attention now are those populations which are lagging behind. “When I go to Bangladesh, and I visit the Ministry of Health, I see fabulous numbers. When I go to an urban slum, every mother I meet has seven children,” said McLaughlin.
“In Pakistan we know that numbers are still quite a big challenge for us. But in both cases I see that it’s related to gender, it’s related to quality – one of the things we’ve spent a lot of time talking about – incentivising access, building facilities and paying for transport so that women can get to the hospital.”
“I was in a facility in Karachi where they had 60 physicians with only five nurses to work with those 60 physicians. I wouldn’t even recommend people to go there in order to deliver,” she commented.
Reiterating her thoughts on how in Sri Lanka every birth is recorded and every death is questioned and investigated, she added, “But one thing that is lacking here is quality. This is something across the region which we are trying to tackle together.”
Maternal and reproductive health in South Asia
South Asia has made sterling progress in reducing maternal mortality. The MMR declined from 550 deaths per 100,000 live births in 1990 to 190 in 2013. Between 1990 and 2013 South Asia experienced the world’s sharpest fall in maternal mortality (65%) with an average annual decline of 4.4%. But it carries the second highest share of maternal mortality in the world behind Sub-Saharan Africa.
The total fertility rate (TFR) declined from 4.2 in 1990 to 2.6 in 2012. The contraceptive prevalence (CPR) rate increased from 41.3% to 52.3% between 1990 and 2010. South Asia lags however, behind all but one other region in skilled birth attendance (SBA). While it has increased from 36.2% in 2000 to 49.8% in 2010, further progress is needed.
Four countries in South Asia have achieved replacement level fertility of 2.3: Bangladesh, Bhutan, Maldives and Sri Lanka, while India and Nepal are close to doing so. Afghanistan has the highest in the region at 5.1.
Contraceptive prevalence is high in the region, with Sri Lanka having a CPR of 68.4% and Afghanistan having the lowest at 21.2%.
Early marriage and pregnancy affect maternal health outcomes in South Asia
Bangladesh has the lowest median age at first marriage (15.5 years) and at first birth (18.1 years). The adolescent fertility rate fertility rate (AFR) for South Asia is 38.8 births per 1,000 women age 15-19. AFR is highest in Afghanistan and Bangladesh and lowest in Maldives.
While contraceptive prevalence has increased throughout the region, there is still an unmet need for contraception. The unmet need is highest in Maldives and lowest in Sri Lanka. Sri Lanka has the highest antenatal care coverage in the region, while Afghanistan has the lowest.
SBA is highest in Sri Lanka and the Maldives while Bangladesh is lowest in SBA and has one of the highest CPRs in the region.
Population challenges: Moving forward
The second session was chaired by Tim Evans and comprised panellists Population Reference Bureau Visiting Scholar John May, UNFPA PD Technical Advisor Christophe Lefranc, Pakistan Population Council Senior Associate and Country Director Zeba Sathar and WB South Asia HNP Senior Health Policy Specialist Sameh El-Saharty.
El-Saharty speaking on population and family planning policy harmonisation in Bangladesh, suggested what the Ministry of Health can do to improve access and coverage of family planning. “Expand supply and demand for LAPMs, increase the family planning program focus on the hard-to-reach areas and lagging divisions, and use innovate approaches to increase coverage, RBF and use of mobile phones,” he said.
Pix by Upul Abayasekara
