Colombo, Sri Lanka – Ariyaseeli Gunaweera, known as Ari to all, is a supervising public health midwife in Sri Lanka. She is, as a result, a person of some importance.
Ajith Kumarasiri certainly thinks so – when Ari sends him on an errand, he hurries to get it done, returning with a large 10cc syringe in just a few minutes.
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“Here, cut it from here,” says public health midwife Kumudini Kumari as she shows the young father where to shear through the syringe so that the end with the needle falls away.
Having plied his blue hacksaw blade enthusiastically, Ajith is taught how to manipulate the plunger so that finally he has in his hands a crude yet effective breast pump. The midwives’ affordable, DIY solution is perfect for this corner of Colombo – a set of apartment blocks occupied by working-class families on low incomes.
In one of the apartment’s two small bedrooms, just the sight of Ari is enough to bring a smile to Shanthini Kumarasiri’s face. At only three-days-old, her little boy doesn’t have a name yet.
Shanthini has been worried. Her son is so thin that the bones in his chest protrude. Ajith’s mother Kumari Manel shares her daughter-in-law’s relief at Ari’s arrival. She is sure all will be well now, and remembers that reassuring feeling from when she was pregnant with her own son and the midwives came to visit. This is an intimate relationship with the state that spans generations.
With kind eyes and gentle hands, Ari and Kumudini work with the young mother to check the flow of milk from her breasts and quickly determine that one is blocked. Chatting all the while, they find a way to ease her discomfort, feed the child, and teach the first-time parents how to prevent the problem from recurring.
The baby calms and stretches in his grandmother’s lap as he hungrily empties the cup of milk that the midwife spoons into his mouth.
According to their official schedule Ari and Kumudini are on track – midwives are expected to pay four postpartum visits; two in the first 10 days, and another two within the first two months. In 2013, according to data collected by Sri Lanka’s Family Health Bureau, 92.2 percent of new mothers who were identified and registered were visited at least once by a midwife in that critical postpartum period.
Each visit involves a thorough check-up of mother and child. As the boy grows, he and his parents will also visit the nearby clinic. The midwives will watch him closely until he is five years old, checking his growth and development and ensuring that he is up to date on critical vaccine shots. The attention and support provided by the midwives feels deeply personal, and it is free.
As the midwives finish up and prepare to leave, Kumari Manel serves them a glass of cold, sweet, neon orange soda. She is full of gratitude. “No one else will come to help us, only the midwives come,” she says.
‘Womb to tomb’ healthcare
Sri Lanka’s commitment to maternal and child health goes back more than a century.
In 1879, the doors of the De Soysa Lying-in-Home, possibly the very first maternity hospital in Asia, were thrown open to expectant mothers. It was here that the first training school for Sri Lankan midwives began operating in 1881. Between 1941 and 2009, the number of trained midwives in the country multiplied from 347 to 8,741.
Like most modern midwives, Ari received her diploma from the National Institute of Health Sciences – that was more than two decades ago.
Today, the country has at least 7,000 midwives, and along with a cadre of public health inspectors, they are the “ultimate grassroots workers,” says Dr Ruwan Wijayamuni, the chief medical officer of health at the Public Health Department.
They offer what he describes as “womb to tomb” coverage, with each public health midwife responsible on average for some 3,000 people. According to official estimates, nearly 15 million people come under the purview of the Family Health Programme.
‘An inspiring success’: Sri Lanka’s maternal mortality ratio
The system is so successful that Sri Lanka has a maternal and child health record that is the envy of South Asia. Nowhere is this better reflected than in the maternal mortality ratio or MMR.
This critical figure is drawn from the number of maternal deaths per 100,000 live births, in a given time.
In 1955, less than a decade after Sri Lanka celebrated its independence, some 405 women died for every 100,000 live births. In 2013, Sri Lanka’s MMR was 32. Compare this with the island’s closest neighbours: in India, 189 women died for every 100,000 live births in 2013, in Nepal, it was 291 that same year, while in Bangladesh it was 201.
“Sri Lanka represents a unique and inspiring success story in terms of the country’s achievements in maternal health,” says Ana Langer, the director of the Women and Health Initiative and the Maternal Health Task Force at the Harvard TH Chan School of Public Health.
She attributes the steady decline of maternal mortality over the past 60 years to factors such as consistent political will, universal health coverage, skilled birth attendance at 97 percent of deliveries and “the quality of care offered by the trained midwives, who are distributed across the country ensuring women’s access to it”.
Registers for life
Painstaking, accurate data-gathering has proved critical to Sri Lanka’s healthcare successes, and Ari and the other midwives devote much of their time to record keeping.
Ari maintains three registers. Young couples are entered into the Eligible Family Register. In theory at least, cohabiting couples, and women between the ages of 15 and 49 are also included in this list. Ari offers anyone who needs it advice on family planning, distributes contraception for free and even sits down with couples for informal counselling. Women who want to conceive are advised on how to space out pregnancies, prescribed certain supplements and vaccinated against rubella and tetanus.
When a woman becomes pregnant she is entered into a second register where her progress is tracked carefully. Registered women are offered an exhaustive package of services and are carefully monitored.
Those identified as having high-risk pregnancies are given specialist care. Once the child is born, he or she is given his own column in a new register – the Birth and Immunisation Register.
The attention of the midwife continues into the child’s adolescence when they will make contact again to impart sex education.
According to Ari, common problems faced by mothers include poverty, domestic violence and cantankerous mother-in-laws. She relies on her personal relationship with her charges to allow her to speak frankly to husband and wife, and takes an interest in everyone in the household, and even in the neighbours. They all have a role to play in the mother’s health, she believes.
It helps that she has known some of these people since they were children. “I am part of the family now,” says the 54-year-old, “so they listen to me.”
When things go wrong: ‘Every time a pregnant woman dies, two people die’
When things go wrong, midwives are the first to be held accountable.
Each maternal death is expected to be reported within 24 hours to the regional director of Health Services and the Family Health Bureau by the Ministry of Health, explains Dr KD Liyanaarachchi, the deputy chief medical officer and Ari’s immediate supervisor.
“We do a thorough investigation of each case. A doctor, a nursing sister and a midwife will all go into the field to talk to the families and to see if the mother was given proper service,” she says.
The data collected from the visit is compiled into a “maternal death case scenario”, a document that includes a post-mortem report, bedhead tickets and clinical, pregnancy, family planning and other field records.
Each scenario is reviewed at the field, institutional, district and national levels by the Family Health Bureau, in consultation with independent experts – allowing the authorities to systematically identify problems with the healthcare delivery.
“When we look at how other countries are doing in this region, we can boast that up to 99.4 percent of women in this country are cared for in hospitals,” says Dr Kapila Jayaratne, a national programme manager for the Family Health Bureau overseeing maternal and child morbidity and mortality surveillance. “In India, for instance, it is around 40 percent. For the other 60 percent you don’t know where they deliver, how they die, nothing.”
In the past year and a half alone, some 14 countries, including Bangladesh and Afghanistan have sent delegations to study Sri Lanka’s approach, says Jayaratne. The team is also often invited to conferences abroad to share their programme’s successes. “Always we get the applause for nearly five minutes when we make our presentation.”
For Ari, there are real women behind the statistics. She speaks of the last time she lost a mother, many years ago. Though Ari had her rushed to the hospital, the woman and her child died of blood pressure related complications.
“I felt worse than if I had driven a car and run over someone on the road,” she says. “We are responsible for these women, some we have taken care of for years.” Behind her glasses, her eyes shine with tears. She adds in a quiet voice: “Every time a pregnant mother dies, two people die.”
Can Sri Lanka keep it up?
Ari’s job is not getting any easier. One of the most commonly cited problems is the perennial shortage of midwives. Dr Wijayamuni says thanks to such staffing issues in the Colombo area, a midwife may be responsible for as many as 6,000 to 12,000 people, considerably more than the ideal of 3,000 per midwife.
The challenges of providing care for pregnant mothers and vaccinations for children are even greater than they first appear when you take into consideration the city’s large migrant population.
“I think it is remarkable, even though we have a large floating population which does not remain static like those in the villages, our immunisation coverage has been excellent,” he says of the Colombo area. “This is why we have no neonatal tetanus or diphtheria. We have eradicated polio and whooping cough.”
But will the public health services be able to maintain their stellar record without enough midwives to go into communities?
Ari believes the situation might improve if women are allowed to serve in the areas they are from instead of being assigned to distant locations.
Ari came to work in Colombo, though she was originally from the island’s southern province. She faced the practical challenges – the shocking cost of living in the city, the dearth of good accommodation – but also the social and emotional trials of adapting to her new profession.
Ari and her brother were orphaned in their 20s and went through some tough times. She found her husband on the job, as it were, when a more senior midwife took a shine to her and proposed that Ari marry her son, Don Nihal Wickramarachchi.
She has been a widow for several years now and lives close to her place of work, but says her colleagues at the Wanathamulla Mother and Child Welfare Centre all hail from outside Colombo. Some even commute 161km a day.
Jayaratne says that when the Family Health Bureau advertised for 5,000 new midwife positions, they received only 2,700 applications. In response they have begun relaxing the requirement that midwives have studied science in school, and are instead recruiting people from an arts and commerce background as well.
Although government jobs are usually sought after for their stability, it’s also easy to see why the basic salary for a new midwife, approximately 15,000 Sri Lankan rupees or just over a $100 a month, would have potential employees opting for careers in the private sector.
Ari says midwives are having to learn new skills to cope with the steep rise in non-communicable diseases. She now routinely encounters gestational diabetes and hypertensive disorders. In 2013, heart disease and respiratory diseases were the leading causes of maternal death in Sri Lanka.
When women develop such complications far away from good healthcare centres, or in areas with poor coverage, their lives are at risk.
“A large majority of the women who died due to a pregnancy-related cause in 2014 were either from rural (65 percent) or estate (10 percent) sectors,” Jayaratne noted in a report. He went on to flag that “it is also noticeable that a significant number of single females (10 percent) contributes to maternal deaths”.
In the face of social stigma, many unmarried pregnant women hesitate to utilise public services and others risk illegal abortions.
“The healthcare system is still lagging behind in encouraging single women to come forward to address their sexual health needs,” says Dr Sepali Kottegoda, the director of the Women and Media Collective in Sri Lanka. “There has to be a clear institutional response in terms of making it known that irrespective of your marital status, as a citizen you have the right to healthcare and as a person who is in need of it, you should seek it out.”
To improve maternal and child healthcare, Sri Lanka must now focus on quality.
“We have to prioritise quality over quantity, to take care of individual women now,” says Wijayamuni .”Each and every mother counts, each and every pregnancy counts.”
He would like to see midwives and public health inspectors given more training and allowed to pursue bachelor and master’s degrees in their field.
“They are the very first contact people at the grassroot level for the Ministry of Health, and their education is critical.”
‘I’m going to stay at home and rest’
Back on her rounds, Ari’s meets more families. Her unhurried pace is deceptive – typically she will make some 30 house calls in a day.
Following her white clad figure through a neighbourhood, it becomes evident that she is a magnet for both men and women. Mothers walking their children home from school stop on the street to have a quick word; others accost her on the stairs, waving test results and asking her to interpret the numbers.
In a largely patriarchal society, Ari says midwives like herself are the ones who tell the men what do when their partners experience morning sickness or how they can “talk” to the baby while he or she is still in the womb during the last trimester.
Even disapproving mother-in-laws will take her advice.
A devoted Buddhist, Ari sees her job as “not actually just caring for a person and combating disease. It is about bringing life to earth”.
This has been her calling, but when she retires in less than a decade, Ari says she is keeping her plans simple. “I am going to stay at home and rest.”