93553 Knowledge Brief Health, Nutrition and Population Global Practice SRI LANKA: MATERNAL AND REPRODUCTIVE HEALTH AT A GLANCE Sameh El-Saharty, Naoko Ohno, Intissar Sarker, Federica Secci, and Kumari Vinodhani Navaratne November 2014 Country Context KEY MESSAGES: Sri Lanka is an island nation with a population of 20 • Sri Lanka has met the MDG targets of million. In 2012, per capita income was US $2,923. From poverty, primary education and gender 2003 to 2012, the economy grew at 6.4 percent annually. Post-conflict, growth increased to 8 percent in May 2009. and is on track to meet other MDGs, The private sector drove growth together with public including for maternal health and reconstruction in the North and Eastern Provinces. Nearly HIV/AIDS. two million Sri Lankans sent remittances in 2013, about 1, 2 • Sri Lanka’s maternal mortality has 10 percent of GDP. historically been low. Utilization of Twenty-five percent of Sri Lanka’s population is maternal health care such as antenatal under 15. Declining fertility and increased longevity has care and skilled birth attendance is nearly resulted in rapid population aging. By 2036, more than 22 universal. percent of the population will be over 60 with 61 1, 2 dependents per 100 adults. • Access to maternal health services is fairly equitable by residence and wealth quintile, From 2002 to 2009, the population living below the while there are some areas with worse-off poverty line declined from 23 to 9 percent. The poverty outcomes, including the conflict-affected head count ratio at $1.25 and $2 a day is respectively 4.1 provinces and the estates sector. and 23.8 percent. Inequality in per capita consumption expenditure fell during this period: the Gini coefficient • The total fertility rate has declined to 2.3 in declined from 0.41 to 0.36. Pockets of poverty exist in the 2012. More than a half of currently married Provinces of Eastern, Northern, Uva, and the estate 1, 2 women are using a modern contraceptive sector. method. Achievements in health and education are notable. Sri • Sri Lanka has initiated a number of key Lanka achieved the MDG target of halving extreme interventions to increase adolescents’ poverty and is on track for most MDGs, including maternal access for sexual and reproductive health health and HIV/AIDS. It achieved universal primary services; improve quality of RMNCH education and gender equality early. Adult literacy is services through establishing guidelines nearly universal. Progress on malnutrition and child and conducting maternal death audits; and mortality targets is slower: U5MR and IMR are 9.6 and 8.3 per 1,000 live births. Sri Lanka ranks 75 of 148 countries improving maternal BMI. in the Gender Inequality Index (2012). 3 Page 1 HNPGP Knowledge Brief  MDG Target 5a: Reduce the MMR by three-quarters, between 1990 and 2015 Birth intervals of less than 24 months are considered Sri Lanka’s maternal mortality ratio (MMR) has too short. Some 10.1 percent of children are born within historically been low compared to other countries in 24 months of the previous birth in Sri Lanka. The median the region. MMR declined from 49 deaths per 100,000 number of months since the preceding birth is 50.2 live births in 1990 to 29 in 2013 (figure 1). Maternal 5 months. mortality declined 40 percent with an average annual 4 decline of 2.2 percent between 1990 and 2013. Early childbearing affects maternal health outcomes. In Sri Lanka, however, this does not appear to be an issue. The median age at first marriage among women aged 25-49 is 23.3 years and the median age at first birth among the same cohort is 25.1 years. The percentage of women age 15-19 that have begun childbearing is only 5 6.4 percent. The adolescent fertility rate is 16.9 births 1 per 1,000 women ages 15–19. Pregnancy Outcomes Complete and timely antenatal care (ANC) is a necessary component for positive pregnancy outcomes. As of 2007, 99.4 percent of women sought ANC from a skilled provider. Further, 92.5 percent of women received the recommended four or more ANC visits. Nearly all women (99.7 percent) had their blood Fertility pressure measured which is one of the components in a 5 CPR (any method) has increased from about 66.1 package of ANC services. percent in 1993 to 68.4 percent in 2007. Modern methods are the main choice of contraceptives and are Skilled birth attendance (SBA) is critical in reducing used by 52.5 percent of currently married women. Female maternal deaths. In the Maldives, skilled birth attendance sterilization (16.3 percent), injectables (14.8 percent) and by a skilled provider has historically been high. It has the pill (8.1percent) are the most commonly used form of increased from 94.1 percent in 1993 to 98.6 percent in 1 modern methods. Traditional methods are used by 15.9 2007 (figure 3). Over 98 percent of births are delivered percent of currently married women. While contraceptive in a health facility (94 percent in a public sector facility 5 prevalence has increased, there is still an unmet need of and 4.2 percent in a private sector facility). 5 7.3 percent. While fertility was already low, the total fertility rate has declined from 2.5 to 2.3 between 1990 1 and 2012 (figure 2). Page 2 HNPGP Knowledge Brief  Postnatal care is another important component for CPR across wealth quintiles is interesting in Sri maternal health especially for the management of Lanka. CPR is highest among the poorest two wealth post delivery complications. It is recommended that quintiles than the richest quintile. There is almost a 10 postnatal care for mothers occur within the first two days percentage point difference between the poorest quintile of delivery. Over 90 percent of women sought this type of (72.7 percent) and the richest quintile (63 percent) (figure 5 care from a skilled provider within the first two days of 5). 5 delivery. While maternal health care utilization is high in Sri Lanka, problems are still encountered in accessing health services. Overall, 47.3 percent of women aged 15-49 encountered at least one problem in accessing health care when sick. The biggest problem identified was getting money for treatment (22.3 percent). Other reasons included: not wanting to go alone (21.6 percent), distance to a facility (19.5 percent), having to take transport (19.3 5 percent). Equity in Access to Maternal Health Services Access to maternal health services is fairly equitable in Sri Lanka. Little variation is observed across residences and wealth quintiles. CPR is highest in rural (69.9 percent) and estate (64.7 percent) areas. In urban 5 Skilled birth attendance is high and there is little areas, CPR is 59.9 percent (figure 4). variation across residences. In urban areas, skilled birth attendance is 99.2 percent, in rural areas it is 98.7 5 percent and in estate areas it is 96.5 percent (figure 6). Page 3 HNPGP Knowledge Brief  Key Strategies to Improve Maternal and Reproductive Health Outcomes Addressing increasing demands from youth and adolescents: Sri Lanka has initiated a number of key interventions that include: strengthening the legal framework, including SRH into the curriculum of vocational training centers and universities, strengthening FP services for sexually active youth and adolescents, developing a minimum health care package to non-school going adolescents, and strengthening nutritional interventions for adolescents. Improving quality of RMNCH services: The government is implementing Quality Assurance measures in maternal and newborn care, including Across wealth quintiles, skilled birth attendance setting standards, establishing guidelines, instituting remains high. There is only a two point difference assessment tools and accreditation processes, and between the richest quintile (99.4 percent) and the 5 conducting maternal death audits, including near-miss poorest quintile (97.4 percent) (figure 7). inquiry. Given the concern over maternal nutrition, the government is also implementing programs to improve maternal BMI. The government has initiated several interventions to improve FP, including advocacy for politicians and religious leaders, implementing the behavior change communication strategy, strengthening male participation in FP, and building the counseling capacity of health workers. Recognizing the importance of preventing cancer, cancer screening services have been scaled up, along with introducing alternative screening strategies to prevent cervical cancer. Key Challenges The national-level impressive achievements in maternal and child health mask inequalities between regions and much worse outcomes among the poor, the conflict- affected populations and workers in the estates sector. References: Over-utilization of tertiary care hospitals with regard to the place of delivery needs special attention, largely 1. World Bank. World Development Indicators 2014: Accessed 19 due to high educational achievement and relatively May 2014 easy geographical access. Nearly all deliveries take 2. Sri Lanka:Country Program Snapshot. March 2014, the World Bank place in government hospitals in Sri Lanka, of those, 75 3. UNDP. 2013 Human Development Report Gender Inequality Index percent occurs in larger hospitals that provide CEmOC. 4. WHO, UNICEF, UNFPA and The World Bank. 2014. Trends in This has led to overcrowding larger hospitals and Maternal Mortality: 1990 to 2013: World Health Organization 5. Department of Census and Statistics (DCS) and Ministry of underutilization of smaller facilities. Lastly, similar to Healthcare and Nutrition (MOH). 2009. Sri Lanka Demographic and other SAR countries, malnutrition among mothers and Health Survey 2006-07. Colombo, Sri Lanka: DCS and MOH children continues to be a challenge. Over a fifth (21 percent) of children under-five years of age are underweight and over 40 percent of pregnant and lactating mothers have been found to have anemia. For more information on this topic, go to: www.worldbank.org/health. Page 4