Regional Health Forum WHO South-East Asia Region(Volume 6, Number 2)

Reproductive Health

Emergency Obstetric Care: The Key to Further Reducing Maternal Mortality in Sri Lanka
P C Gunasekera*, P S Wijesinghe#, I M R Goonewardene**

Introduction

"The reason for the higher female mortality in the adult age period may probably be found in early marriages and consequent diminished vitality. There is also no doubt that mortality in child bearing is excessive. It is said that the ascertainment rate of mortality in Ceylon is one death to 40 from accouchement against one in 185 in England. The fact that in the vast majority of the cases, the women are without skilled assistance at the time of delivery and that their troubles come upon their unmention-able hovels absolutely devoid of sanitary management strengthens the opinion that in this is to be found a very active cause of female mortality". - Lionel Lee 1891 ^(1).

One hundred and ten years later, maternal deaths still occur, but instead of women dying in their 'hovels', they now die in hospitals. Several maternal deaths, which occurred in government hospitals, were given prominence by the national media recently. Pregnancy and childbirth are physiological processes. Every maternal death is, therefore, a tragedy and in retrospect, many could have been prevented. These women who die are in the prime of their lives, most often with children and other dependants. A maternal death results in social and economic loss with serious consequences not only for the immediate family, especially her surviving children, but also for her community and the country. Sri Lanka's success in reducing maternal mortality, despite being a developing country, has been hailed in numerous international publications ^(2,3). The maternal mortality rate as reported in 1997 by the Registrar-General was 2.3 per 10 000 live births. Antenatal coverage is almost universal. In 1999, 93% of the births occurred in government institutions, 33% took place in teaching hospitals including the two maternity hospitals. Another 33% occurred in specialist units in other hospitals, while 27% took place in non-specialist units. Only 1% of births took place at home ⁽⁴⁾. Most complications occur at childbirth, and the presence of a professional nurse, midwife or doctor is crucial to take urgent life saving action.^(5,6). Women attended by professionals are less likely to have serious complications and receive treatment early, when the situation can still be controlled. Institutional deliveries are encouraged to ensure that a person with midwifery skills is present at every delivery. In 1999, 106 maternal deaths occurred in government hospitals of which 87.7 % were in teaching, provincial and base hospitals where specialist obstetric facilities are available. Hence the question we must ask ourselves is, are the institutions in Sri Lanka where births take place capable of managing obstetric complications, the key life-saving component of maternity care? Emergency obstetric care (EOC) is the term used to describe the elements of obstetric care needed for the management of normal and complicated pregnancy, delivery and the postpartum period. Basic EOC includes administration of antibiotics, oxytocics, anti-convulsants, manual removal of the placenta, removal of retained products, and assisted vaginal delivery with forceps or vacuum extractor. Comprehensive EOC includes all basic EOC functions plus Caesarean section and blood transfusion. Most rural hospitals, maternity units and peripheral units in Sri Lanka do not provide even basic EOC ^(7,8). Women quite rightly seek what is perceived to be the most technically advanced facility available because of concerns about safety. This results in under-utilization of the smaller hospitals and overcrowding of larger hospitals, which places heavy demands on staff in the latter diverting them from managing complicated pregnancies optimally. Sri Lanka has traded quality for equity of access to health services. While efforts are directed towards ensuring coverage of delivery, antenatal and postnatal care, less attention is paid to the quality of care provided. In fact, a past President of the Sri Lanka College of Obstetricians (SLCOG) observed the need for improvements in the quality of care in hospitals ⁽⁹⁾. Quality of care means much more than technology. It is using the available resources to provide the greatest health benefits, with the least health risks, to the greatest number of people.

What needs to be done

     Ensure skilled attendants at birth

A person with midwifery skills should be present at every delivery. While there is a shortage of staff of all categories, comparison of staff distribution between and within districts indicates problems of deployment. This requires long-term planning for the country’s human resource develop-ment. In 1999, of the 90 qualified obste-tricians and gynaecologists serving in government hospitals, 22 were based in the Colombo district where only 18% of births take place. Four districts did not have a specialist. Similarly, of the 52 anaesthetists, 24 were in the Colombo district while 12 districts had none. Hence, there is a need to ensure an equitable distribution of staff, particularly of the specialist grade. Moreover, district hospitals have been upgraded to base hospitals, creating a single specialist position. Several of these specialist obstetric units lack the infrastructure for even basic EOC. Even when such facilities are available, in the absence of the consultant, patients are transferred to another institution because junior doctors are not permitted to carry out surgical procedures without supervision. The Post Graduate Institute is currently training more doctors to fill this void of specialists in rural areas.

Only one percent of home deliveries occur in the country, but trained birth attendants perform only half of them. In absolute numbers, this amounts to approximately 1 500 births per year, concentrated in the more marginalized rural districts of the country. At least in these areas, a conscientious and deliberate effort must be made by health managers to provide opportunities for refresher training of community midwives in hospitals. Doing so will enable them to maintain their skills and enhance their confidence to attend to home deliveries when the need arises.

     Improve training and ensure provider skills

The two six-month appointments in medicine, surgery, paediatrics or obstetrics and gynaecology undertaken during the internship are inadequate. An increase in the internship period to two years has been recommended in order to cover all four specialities. However, logistic problems such as the shortage of hospital quarters preclude this. On completion of internship, many are posted to district hospitals and other smaller institutions. Approximately 50% of them would not have had any further experience in obstetrics other than their undergraduate training. Junior doctors lacking in confidence in treating obstetric problems unnecessarily transfer patients to larger institutions, contri-buting to overcrowding. Hence, it is necessary to upgrade the clinical skills of junior doctors, especially in obstetrics, prior to posting them to such institutions.

     In-service training

All categories of staff working in institutions and among the community need regular in-service training. Continuing education of public and private sector staff is necessary in order to improve clinical acumen and the management of difficult cases. Health personnel must have a high index of suspicion for conditions like ectopic preg-nancy. The specialist obstetrician needs continuing professional development and should be familiar with recent advances in the specialty. Training on interpersonal communication skills is necessary. Behaviour change strategies need to focus not only on the provider’s skills but also on changes in attitude and demeanour. A ‘mother-friendly’ environment needs to be created. A third of all deliveries take place in units manned by non-specialist doctors. Hence there is a clear need to improve their skills and knowledge (8). A training programme towards a diploma in reproductive health should be introduced to address this issue.

     Ensure availability of quality obstetric services at referral centres for complications

Health authorities should seriously review underutilized rural hospitals, maternity units and peripheral units that do not provide even basic EOC and consider their closure. This will enable diversion of limited resources to hospitals and maternity units, which are used by the community enabling these hospitals to further improve their service. Unfortunately, closure of some of these institutions will not be feasible. Establishing a system to ensure adequate staff is available to manage obstetric emergencies 24 hours a day, including a functioning operating theatre, an anaesthetist and paediatrician is necessary. Staffing is inadequate especially at night ⁽¹⁰⁾. Creating two specialist obstetric units in all base hospitals will ensure that these institutions will provide comprehensive EOC on a daily 24 hours basis. At present, patients requiring comprehensive EOC are transferred to other institutions when the obstetrician is not in station. This results in delay in reaching and receiving appropriate care and in many instances, has cost women their lives. In addition, there should be sufficient numbers of anaesthetists, either consultants or trained doctors, available in these institutions.

Trained medical personnel do not man blood banks after hours except in the NationalHospital, Colombo, compelling intern medical officers to cross-match blood for obstetric emergencies. Mismatched blood transfusions have led to maternal deaths, albeit rarely. A proper 24-hour blood transfusion service should be a part of comprehensive EOC.

Ensuring availability and accessibility to quality EOC closer to where people live will no doubt contribute to reducing over-crowding in provincial and teaching hospitals and improving the quality of services provided by these institutions.

     Geographical distribution of institutions providing EOC

The Presidential Task Force on Health Policy of 1997 recommended the development of at least one hospital in each district. It is essential that this one hospital should provide comprehensive EOC. Since death from obstetric complications can occur within a few hours, EOC should be easily accessible to the population. The services provided by existing institutions and their accessibility to the catchment population must be ascertained. This would facilitate identifying institutions requiring upgrading to provide comprehensive or basic EOC and those smaller underutilized institutions, which should be closed. Furthermore, variation of the proportion of maternal death between districts can be reduced by such an exercise.

A patient in an institution that does not provide EOC, on developing an obstetric complication, will require transfer to another institution. This invariably leads to delays in providing EOC, sometimes resulting in disastrous consequences. Transport facilities should be available. Prior to transfer, it is necessary to ensure that the other institution is ready to receive the patient. If not, the patient is transferred once more to another institution, adding to the delay. Before transfer, all patients should be stabilized and preferably accompanied by a medical officer. Transfer of patients requiring intensive care or for lack of blood takes place from one district or province to another and even from specialist manned institutions. Setting up intensive care units and blood banks in each district will reduce the transfer of such patients.

The experience in Sri Lanka in relation to ‘waiting homes’ for women who find difficulty in accessing EOC services have had mixed results. Utilization of waiting homes is encouraged in the conflict-affected districts where transport in the night is difficult. However, there have been several instances where mothers have not availed themselves of this facility, mainly due to the reluctance to leave young children alone at home. In such situations, mobilization of community support and male participation in the rearing of children and support of the pregnant mother is crucial to enable the mother to have a safe delivery.

Quality assurance of emergency obstetric and neonatal care

     Improving infrastructure

Provision of adequate water supplies and electricity, and repairs to operating theatres would contribute to improvements in quality of care. This would minimize transfers to other institutions and overcrowding, but more importantly, win the confidence of the local community in the institution. A dedicated obstetric operating theatre is necessary. Having to share operating theatre facilities with other specialities may result in delays in providing care.

     Strengthen supply logistics

Adequate drugs and other equipment are a prerequisite for providing quality services. Regular maintenance of equipment and training of staff in carrying maintenance is necessary. Satisfactory buffer stocks of essential items should be maintained.

     Interdisciplinary cooperation

Health professionals sometimes fail to recognize obvious medical conditions, and inappropriate or late interventions take place. It is recommended that combined manage-ment between physicians and obstetricians are adopted for patients with such conditions.

The Sri Lanka College of Obstetricians and Gynaecologists identified the minimum requirements necessary for an obstetric unit and labour ward including staffing, equipment and drugs. A partogram has been introduced; a step towards improving intrapartum care. Written protocols for the management of obstetric complications have been prepared and would be invaluable as a basis for training and supervision. Infection control measures should be strictly enforced, especially in labour rooms and operating theatres. It is also necessary to develop managerial guidelines on organization of services, human resources, management, training and logistics.

     Strengthening supervision, monitoring and evaluation

Effective supervision at all levels is necessary. It is also necessary to ensure more involvement of specialist staff in the management of critically ill patients at an early stage. An effective system for monitoring quality of care has to be ensured with better record keeping and data collection with greater emphasis on indicators of quality. Because of the difficulties in measuring maternal mortality, alternate indicators are necessary. Instead of using impact indicators, the use of process indicators focuses specifically on monitoring whether women who develop serious obstetric complications receive the services they need. UNFPA has developed several such indicators for developing countries ⁽¹¹⁾. However, although indicators such as percentage of deliveries in health institutions or percentage of births attended by trained health attendants are relevant for less developed countries, such indicators are inappropriate in the Sri Lankan context. Process indicators such as, number of institutions per 500 000 population providing basic EOC, case fatality rate and percentage of home deliveries attended by personnel trained in midwifery need to be incorporated into the health management information system.

Annually, the Family Health Bureau audits all maternal deaths. This is a unique system where each maternal death is carefully analyzed to identify the factors that contributed to the death. However, these audit results must be published and disseminated more widely both at the centre and sub-national levels in order to implement the recommendations.

     Enhancing community health and hospital liaison

Lack of communication between staff at the primary health care level and institutions leads to misunderstanding when patients are referred from the field. The Deputy Provincial Director of Health Service chairs the quarterly review meeting on family planning and maternal and child health for primary health staff. Senior hospital staff should also be included in these meetings. Such meetings at the district level increase communication between the primary health staff and the hospital-based clinical staff. Attendance at these meetings should be made compulsory for health staff. Such meetings can help identify and implement strategies for improvement in such areas as referral, emergency transport. In addition, it is recommended that influential community leaders be also invited to these meetings.

Legislative and policy actions

     Equitable distribution of resources among institutions

Reducing maternal mortality is a goal of the Population and Reproductive Health Policy of Sri Lanka ⁽¹²⁾. The responsibility for implementing this policy lies largely with the central Ministry of Health. The Thirteenth Amendment to the Constitution of Sri Lanka in 1987 set in motion a process of devolution of power to the provinces. However, the Provincial Councils are dependent on an allocation from the central government to implement these programmes. Provincial health ministries are responsible for health services in their respective areas including the management of institutions ranging from out patient facilities such as central dispensaries to maternity homes, rural, district, base and provincial hospitals. In recent years, several provincial institutions have been transferred to the control of the central Ministry of Health following re-classification as national or teaching hospitals. Provincial health autho-rities must guard financial resources available for infrastructure development of institutions identified to provide compre-hensive and basic EOC. In addition, the availability of personnel with the skills necessary, functional equipment, drugs and other supplies must be guaranteed.

     Setting and enforcing standards

With the gradual expansion of the private sector, it is also necessary to ensure that women deliver in facilities where EOC is available. This matter should receive attention in the review of the legislation of such institutions. Furthermore, there is a need to make those working in both the private and government health sectors accountable for their actions. The public demands it. Protocols and guidelines need to be developed for providing standardized routine maternal care and managing obstetric complications at each level of the health system. The responsibilities of health providers at each level for supervision, deployment and reporting procedures must be defined at the national level ⁽¹³⁾. The development and promotion of education and training curricula are important.

Conclusions

The knowledge and skills required to ensure that women give birth in safety exist in Sri Lanka. Sri Lanka has the potential to achieve safe motherhood and reduce its maternal mortality to very low levels comparable with the developed world. Yet, maternal deaths continue to occur. It appears that a majority of maternal deaths occur due to delays in providing EOC. This area has to be add-ressed urgently in order to maintain and improve the rate of reduction of maternal deaths. The political will to make drastic changes is a prerequisite if maternal deaths are to be reduced significantly. Preventing maternal death and disability is not only a health issue – it is also a moral issue underpinned by the guiding principles of human rights, social responsibility, partici-pation, and equity.

Acknowledgement

This study was supported by a grant from the World Health Organization.

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