facility(based(postnatal(care(( in(sri(lanka:(( ·...
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Facility Based Postnatal Care in Sri Lanka: Achievements and Challenges
Dr. Kapila Jayaratne MBBS,MSc, DCH,MD (Com Med) Consultant Community Physician National Program Manager – Maternal & Child Morbidity and Mortality Surveillance
Dr. Nilmini Hemachandra MBBS,MSc, DCH,MD (Com Med) Consultant Community Physician
Family Health Bureau Ministry of Health - Sri Lanka
Sri Lanka
Overview of the Country Situation
3
Indicator Value Year
Land Area 62,705 Sq.Km 2009
Total PopulaAon 20.27 Million 2012
PopulaAon Density 326 Persons per Sq. Km 2012
PopulaAon growth 1.1 % 2009
GDP per Capita 3280 US$ 2013
Population below Poverty Line 8.9 % 2012
Literacy Rate 91.3 % >15 Yrs 2008 Unemployment Rate 5.8 % 2009
Life Expectancy Male
Female
74.0 70.3 77.9
Yrs 2007 2007
Human Development Index 0.702 (Min 0 – Max 1.0) 2013
MCH Service Delivery
Domiciliary Level
Local Level
Divisional (MOH) Level
District Level
National Level
Each household is designated to a PHM
Peripheral Hospitals
District General Hospitals Base Hospitals
Teaching Hospitals Provincial General Hospitals
Private Hospitals
< 5%
GP / OPD
Laboratory
Post-mortem
350,000 Live births
94% Deliveries
Maternal Mortality Ratio Sri Lanka 1995 - 2013
61.0
62.0
63.0
53.0 55.8
55.6
46.6
53.4
42.4 40.0
44.3
39.3 38.4
33.4
40.2
31.1 32.5
37.7
32.5
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
1995
19
96
1997
19
98
1999
20
00
2001
20
02
2003
20
04
2005
20
06
2007
20
08
2009
20
10
2011
20
12
2013
Source: FHB Maternal Mortality Surveillance System
2014 MMR = 32.0 per
100000 Live Births 112 deaths
7
34.4
29.5 30.5
28.4 27.2
24.2 23.2
22.6
20.2
18.4 19.5
17.7 17.9
16.3 16.9 16.5
17.3 16.3
14 13.4 13.3
12.2 12.2 11.2 11.7
18
10.9
9.3 9 9.9
0
5
10
15
20
25
30
35
40
1980
19
81
1982
19
83
1984
19
85
1986
19
87
1988
19
89
1990
19
91
1992
19
93
1994
19
95
1996
19
97
1998
19
99
2000
20
01
2002
20
03
2004
20
05
2006
20
07
2008
20
09
2010
Infa
nt M
orta
lity
Rat
e pe
r 100
0 Li
ve B
irths
Infant Mortality Rates in Sri Lanka from 1980-2010
Source: Registrar General’s Department; 2010
2010 IMR = 9.9 per 1000
Live Births
75.5
49.2 45.3
34.2 33.3 29.7 27
22.7 16.2 12.8 12.5 9.2 7.4 5.9
53.9 59.8 62.6 60 62.6 62.5 59.9
65.9 66.9 66.3
75.8 69.2
73.2 70.2
0
20
40
60
80
100
120
140
160
1945 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010
IMR NMR % NN deaths
Neonatal Mortality
Neonatal Mortality Rate = 6 per 1000 live births
Facility-‐based Post Natal Care
Na7onal Policy
• All postpartum women should be kept under strict supervision in a labour room at least for 2 hours aaer delivery.
• All women aaer delivery should be observed for at least 24 hours in a health insAtuAon.
Labour Room care -‐Evidence based interven.ons
1. Monitor general condiAon, vaginal bleeding, uterine contracAons, fundal height, pulse every 15 minutes
2. Measure blood pressure soon aaer the birth and document
3. IdenAfy danger features, intervene appropriately and referral if needed
Mother:
Newborn: 1. Skin to skin care 2. PrevenAon of hypothermia 3. Delayed cord clamping 4. ResuscitaAon if needed 5. IniAaAon of breast feeding 6. Vitamin K injecAon
Labour Room care -‐Evidence based interven.ons
• Monitoring of mother and baby every 4 hours
• Bedding in • Establishment of breast feeding • Vit. A mega dose for the mother • BCG immunizaAon • ExaminaAon of the mother by a Medical Officer before discharge including a vaginal examinaAon
Post-‐natal Ward -‐Evidence based interven.ons
• Newborn Screening Screening for birth defects and other morbidiAes before discharge by a medical officer:
-‐General examinaAon for macroscopic defects -‐AuscultaAon and pulse oxy meter (recently introduced) for heart diseases, -‐Heel prick blood sample for hypothyroidism
Post-‐natal Ward -‐Evidence based
interven.ons
• Counseling and providing informaAon for: -‐ -‐exclusive breast feeding -‐danger signals of mother and baby -‐maternal nutriAon -‐family planning -‐newborn care
• Birth registraAon • Referral for community based
postnatal care
Post-‐natal Ward -‐Evidence based interven.ons
Service providers • Obstetrician: On site & 24/7 On call • Paediatrician: On site & 24/7 On call • Medical officer-‐ Obstetric : 24/7 onsite • Medical Officer-‐ Paediatric/newborn: 24/7 On call
• Midwifery qualified nurses: 24/7 onsite • Midwives: 24/7 onsite
Documenta7on / Record keeping
Facilitate the con3nuum of care, data genera3on and accountability
• Partograph and MEOWS chart • Bed Head Ticket –Obstetric formats • Newborn Bed Head Ticket • Pregnancy Record: conAnued for post-‐natal home care
• Child Health Development Record: conAnued to home care
Con7nuum of Postnatal Care at Field level
Community-‐based postnatal care by Public health midwife: • 1st home visit: Day 2-‐5 • 2nd home visit: Day 6-‐10 • 3rd home visit: Day 14-‐21 • Postnatal field clinic visit: Day 28-‐35 • 4th Home visit: Around day 42
Contributory factors to achievements
• Free educaAon / Free healthcare • High level of literacy –female literacy / health literacy
• Strong poliAcal commitment • EffecAve field care • Death reviews (Maternal / Perinatal) and translaAng lessons learnt in to acAon
• Accountability culture • Commimed healthcare workers • Central level grip
• Quality of care -‐room for improvement • Human resource issues • Changing pamern of cause of obstetric morbidiAes and maternal deaths (Direct → Indirect)
• Neonatal deaths -‐60% perinatal causes –complex scenarios
• Low levels of neonatal and maternal deaths –further reducAon difficult
Challenges
Thank You
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