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Example 5: Maternal Health in Sri Lanka

The fifth United Nations Millennium Development Goal (MDG) is to reduce the maternal mortality ratio by three quarters between 1990 and 2015 (UN).  Maternal mortality is “the death of a woman while pregnant or within about two months after the end of the pregnancy” (Center 2). “Poor women, WB are far more likely to die during pregnancy than better-off women” and may leave children behind, perpetuating the “transmission of poverty from one generation to the next.” One fifth of childhood burden of disease can be attributed to maternal mortality (Center 2).  “Over 529,000 women die each year as a result of complications during pregnancy, childbirth, or the postpartum period” and most of these deaths are in developing countries (WB).  Beyond maternal mortality, “20 million women will endure life long disabilities such as pelvic pain, incontinence, obstetric fistula, anemia, and infertility” (WB).  Childbirth is a natural event in life, and in most cases, women can go through pregnancy without complications.  “Interventions to detect pregnancy-related health problems are well-known and require relatively little in the way of advanced technology” (Center 2).  Some maternal deaths cannot be avoided, but with the presence of a functioning health system, most complications can be disallowed.

Building leadership in skilled birth attendants in Sri Lanka has shown that the fifth MDG of reducing maternal mortality is an attainable goal in impoverished settings. Sri Lanka is an island nation off the coast of southern India.  Sri Lanka has considerable access to public education and “89 percent of Sri Lankan adult woman are literate” (Center 2).  In Sri Lanka, improved maternal health has not over-burdened the country financially. In fact, “many countries have achieved better outcomes by [simply] using their existing resources” (WB).  This “undisputed success story” has meant the “consistent decline in maternal mortality for over 5 decades” and can be attributed to “a wide network of maternal services” (Sri Lanka MDG Report).  One of the most important service providers is the Public Health Midwife (PHM).  Main maternal interventions according to the World Bank are to ensure a skilled attendance at delivery and improve health systems, encourage delayed marriage, address unwanted pregnancies and poorly timed pregnancies, improve coverage and quality of prenatal and postpartum care, and promote cross-cultural linkages, including enhancing community participation.  Improving the capacity of the health system and coverage of quality prenatal and postpartum care includes training healthcare staff in midwifery skills and to promote skilled attendance at home and in facilities.

Sri Lankan PHMs are trusted professionals trained in 18-month programs who report to a network of midwives and supervisors and each midwife serves a population of 3,000 to 5,000 in their local area (Center 2).  The Sri Lanka health care system used close monitoring and enabling the government to find areas of needed improvement.  Steady, impressive declines in maternal morbidity have meant Sri Lanka has been able to “halve the maternal deaths (relative to the number of live births) every six to 12 years since 1935” (Center 2).  Today, instead of the use of midwifery, most women attend clinics for deliveries.  Attending clinics provides for a supervised birth, yet postnatal and postpartum care is weak and the coverage of this service needs to be improved (Sri Lanka MDG Report).  There are still very high inter-district variations with high MMR (maternal deaths per 100,000) in conflict areas and hard to reach plantation areas.  These geographic areas can be targeted by building leadership in the PHM sector.

The World Health Organization Regional Office for South East Asia (WHO SEARO) is helping to engage community leaders through nursing and midwifery workforce management.  A global imbalance is occurring where countries are recruiting midwifes and nurses from each other due to a shortage (WHO SEARO).  Excellence in leadership, clinical, teaching and management standards is necessary for a competent workforce.  Midwives and nurses may lack basic funding and equipment, work in unsafe areas, be subject to physical or verbal abuse, and they may have poor technical supervision (WHO SEARO 5).  Countries reported a need for the strengthening of leadership in nurses/midwives associations.  There is no systematic, sustainable approach to leadership development and management development in the SEARO countries.  WHO SEARO assessed leadership competence in 10 countries in South East Asia and found midwives and nurses needed to have more opportunities to have input in policy and planning and more capacity and capability to effectively contribute.  One cost-effective recommended solution to enable leadership competence is to provide the workforce with more opportunities for mentoring.  Other solutions to improve leadership competence and input included strategic planning in basic curricula, increasing involvement of junior nurses/midwives in health policy formulation and planning activities, supporting sustainable programs for leadership development, improving awareness of health policies and plans in the community, and strengthening cooperation between different levels of the health workforce (WHO SEARO 9).

Other country development goals, arising from the assessment to build leadership include: “expanding opportunities for training at executive and top levels to senior nurses/midwives”, “developing effective leadership at the Ministry of Health level and at each health facility”, “mentoring senior and potential nurse/midwife leaders (the ‘next generation’) by multidisciplinary colleagues”, “developing career paths”, “creating posts for competent nurse/midwife managers”, “developing a plan for staff development and an opportunity for nurses and midwives to apply their leadership and management competency, through continuous training at all levels”, and “developing nurse leaders’ exchange programs with other countries” (WHO SEARO 39).  A leadership team could consist of senior nurses and midwifes who have been trained in leadership and management.  The leadership team could help facilitate relationships between different sectors of the health workforce and advocate for and represent the nurses and midwives to the Ministry of Health.

New nurses and midwives can be recruited to lead by providing training opportunities, career advancement opportunities, ensuring good working conditions and efficiently organized work, developing flexible working patterns, reviewing admission policies to attract more talented people to the field, reviewing the conditions for recruitment, and involving nurses and midwives in policy planning.  Collaboration across groups can take place through the development of a “collaborating research center” or encouraging the implementation of mutual research between different nurses/midwives nationally and internationally (WHO SEARO 19).  Credit and motivation will be distributed through providing housing, welfare, mutual courtesy and respect, consultation on health policy matters, work safety and security for those in risky climates, and an incentive system that provides opportunity for advancement.  Finding and enabling talented Public Health Midwife leaders to apply their talents in the Sri Lankan context and other countries will help support an environment where maternal mortality rates decrease and access to prenatal and postpartum care increases.


The Millennium Development Goals Report 2006. New York: United Nations, 2006. 12-13. 25 Nov. 2007 

Nursing and Midwifery Workforce Management Analysis of Country Assessments. World Health Organization Regional Office for South-East Asia. New Delhi: SEARO Technical Publication No. 26, 2003. 27 Dec. 2007

"Public Health At a Glance, Maternal Mortality." The World Bank. 2006. 27 Nov. 2007

Saving Mother’s Lives in Sri Lanka.  Center for Global Development.  2007.  1-9.  25 Nov. 2007

Sri Lanka: Millennium Development Goals Country Report 2005. World Health Organization Regional Office for South-East Asia. 2006. 1-6. 25 Nov. 2007