By Dinithi Gunasekera
Within the expansive forte of global healthcare, Sri Lanka holds an impressive figure of 6.1 deaths per 1,000 live births in terms of infant mortality rates as of 2019. United Nations Children’s Fund (UNICEF) data reveals that neonatal mortality in the island is at four per 1,000 live births. The Yale School of Medicine notes that the role played by public health midwives (PHMs) has had a significant effect on these figures, given that their service has impacted health indices since their beginnings in the 1920s.
Since the early 20th Century in Sri Lanka, PHMs have delivered community-level maternal and child healthcare. PHMs are frontline health workers providing domiciliary care to women and children within the community and are the link between the community and institutional health care.
“I can affirm with complete confidence that the midwife and MOH (Medical Officer of Health) network is in supreme condition within Sri Lanka and is on a par with that of any developed country. This is what complements the country’s minimal child mortality rates and untimely pregnant mother death rates, and high life expectancy.
“It has little to do with propagation of hospitals or infrastructure and treatment provided at these hospitals, and more to do with the highly detailed holistic approach undertaken by this network,” Ministry of Health Senior Registrar Medical Administration and Directorate of Healthcare Quality and Safety Dr. Himali Wijegunasekara stated, commending the service of the midwife network in Sri Lanka.
Sri Lanka’s success story
The Sunday Morning Brunch spoke to a couple of dedicated midwives who obliged to the questions we had amidst their hectic schedule.
Samanthi Mallika Karunanayaka, who is attached to the Negombo MOH Office, undertakes midwife care in the area of Kochchikade. Having served as a midwife for 29 years, she said the first priority was and always will be optimum child and maternal health and family planning.
“Our scope has clearly expanded through the years, especially in the face of current events and the pandemic situation, extended towards the avenues of child development, vaccination schemes, non-communicable diseases (NCDs), adolescent health, and regional epidemiology. Our network plays a key role in strengthening surveillance of communicable diseases, the current Covid scenario being a prime example.”
As per the World Health Organisation (WHO) guidelines, PHMs undertake the 40-hour WHO/UNICEF breastfeeding counselling training programme, an established and comprehensive programme that covers all necessary topics and includes hands-on clinical training. Today, Sri Lanka has one of the top breastfeeding outcomes in the world with 99% of children ever breastfed and 82% breastfed exclusively in the first six months in 2016, according to multiple longitudinal studies, to which PHMs are eligible for sizable credit.
How the network works, according to Dr. Wijegunasekara, is that each PHM has an established geographic area and maintains a register for all females of reproductive age and families with children less than five years of age.
Residing in the community, PHMs make systematic home visits to provide care to pregnant women, postpartum women, newborns, and children under the age of five. This includes breastfeeding counselling and support. Families are requested to attend relevant clinics and weekly health workshops are conducted, in which necessary health education is introduced in addition to measurement and regular tracking of weight, the BMI (body mass index), blood sample health, vaccination history and status specifically regarding tetanus and rubella, blood pressure, sugar levels, and overall immunity. Additionally, all necessary vitamin and mineral supplements are duly provided.
PHMs are also a key link between the community and institutional healthcare; they routinely assist at the maternal and child/family planning health services clinic and encourage those in their community to attend. Personalised and individual home visits, education and advice, and nutrition and health tracking are also carried out from the part of the midwife as a service pregnant mothers are entitled to by the State.
“It’s truly a very detailed and long-term process that involves a lot of paperwork, registration, record-tracking, and administration,” Dr. Wijegunasekara stressed.
A day in the life of a midwife
“It is hard work. It is difficult work, but at the end of it all, it is remarkably fulfilling,” expressed PHM Samanthi.
PHM Nirmala, when contacted multiple times, was accommodating enough to receive us from her end while, on all days being on field, courteously excusing herself for the bustling nature of her schedule. That in itself speaks volumes.
Further into the exchange, PHM Samanthi elaborated on the technical aspects of a midwife’s work.
“Usual work shifts within a normal context consists of field duty from 8 a.m. to 4 p.m. In clinics, it’s from 7.30 a.m. to 3.30 p.m. Additionally, we are on call 24 hours per day. In the case of an emergency, for example, a delivery, we are the first to attend to that need.
“My phone is always on, even sharp at 12 midnight. Some mothers contact us to talk about struggles within the family. Even if it’s such a trivial thing, such as a clash with the husband or in a more severe case of domestic abuse, they entrust us with their stories and pains. There have been instances in which the wife and the husband were unable to confront their own issues and which we have mediated for them, at times, in collaboration with our team of doctors and other officials,” she explained.
“Given that our work largely expands beyond our mandate most of the time, it is safe to say that the work we do exceeds the balance in ratio of what we receive as payment. That is, of course, measured in monetary terms,” added PHM Samanthi when asked about a concerning factor in her field.
“It’s fulfilling work and many do not know about it. We do so much at times, just by talking to our beneficiaries and being there for them emotionally itself. They tell us that they await our care at times. They are comfortable with us enough to open up about their personal struggles and emotions. It feeds our soul, if it is done properly, of course.”
Relating more on her experiences, she talked about the communities of Sri Lanka. She expressed that people have so many problems and that some of them are like movies you watch at the cinema.
“You only think that certain incidents are exclusive to the big screen, but they are real experiences for some people. For some people, their problems are like a ball of entangled yarn.”
PHM Samanthi’s experiences as a midwife have not only revealed the plethora of hardships society goes through, but also the hidden beauties of it, relating to relatively well-to-do families in Negombo who request midwives to distribute bags of goods consisting of groceries to the less privileged in the community. This is a typical practice she has witnessed, which has heightened during the current pandemic situation.
Midwifery amidst Covid
The main priority is securing a mother’s life from mortality, decreasing the mortality rate towards the best possible level, even in the midst of Covid, according to both PHMs Samanthi and Nirmala as well as the MOH Office of Ja-Ela.
“Even at this moment, pregnant mothers are taken care of through our network to the best of our abilities by ensuring optimum health by regularly conducting body weight testing and providing them with the necessary vitamins and supplements such as folic acid.
“The goal is to ensure the best possible background and environment for healthy childbirth and child rearing. Clinics at regional MOH offices are held regularly for mothers who are more than 32 weeks pregnant or those at risk of contracting infection. Midwives play a vital role in ensuring that these clinics function smoothly,” commented a representative from the MOH Office in Negombo.
PHM Samanthi stated that currently, in addition to regular clinics, home visits to mothers who are at high risk of disease contraction are conducted while maintaining the same principle for those who are quarantined.
“We constantly affirm and educate the mothers on disease prevention with special regard given to Covid. As we are on amicable terms with these mothers, they contact and inform us about any and all updates in complete transparency, in the case of Covid contraction. Then, we connect with the regional PHI and MOH, after which necessary steps are taken. Additionally, to further ensure the safety of these mothers, we have allocated customised time slots for clinics and for vaccination programmes.”
With the wavy duty midwives are assigned within the circumstances of a highly contagious infection, it is safe enough to wonder if the safety of these frontline workers is aptly ensured.
The MOH offices we contacted confirmed that safety-wise, maximum steps and measures are taken with substantial safety gear and health guidelines to ensure the security of their employees.
“It is particularly risky as we are essentially first contact persons to possible Covid-positive patients as caring and attending to their needs require hands-on close contact with the mother and the child,” remarked PHM Samanthi. “There’s a lot of additional tasks we are assigned to, from clinics to specialised home visits, so when we visit our own home and families, it’s much later. Covid leaves no barriers for our interest in our duty. Regardless, the needful is attended to, even under strict safety regulations. There is no fear, there is no alien anxiety.”
“Optimum stimulation must be provided for all children upon birth. It is internationally accepted that the first three years of life are most crucial for brain development,” Family Health Bureau (FHB) Child Development and Special Needs Unit National Programme Manager Dr. Asiri Hewamalage stated.
Whatever extra stimulation given in the adult stage is not an apt equivalent to the role early brain development plays as it is the basal foundation, to which the midwife is a key player. However, their valuable service seems to be little known to the general public.
“One possible reason could be that VOGs (obstetrician and gynecologist) now conduct practices free of charge by this network privately. They have developed branding in a way that the go-to for pregnancies are private sector VOGs. It’s not necessary simply due to the existence of an already well-established system. It is just another added burden and an unnecessary cost and expenditure.”
Another factor brought forth is the deployment of more midwives and the multiplication and narrowing down of MOH areas in parallel with the rising population. A 2015 report states there are approximately 4,654 PHMs, serving a maximum of 5,000 population each. This falls short of covering all of Sri Lanka’s women, young children, and newborns.
“Additionally, people should also be made aware and be welcoming of the services. Don’t close your doors and your gates on these service providers,” Dr. Wijegunasekara said.
“The people in our areas know of our service and we appreciate them. There are always problems in data, suggesting deficiencies in our service and what we get in return. But for me, the fulfilment my profession rewards me with is profoundly gratifying. I have served in my field for over two decades and looking back, if I were to be in a different field, I can easily say that there is a lot more job satisfaction as a midwife, maybe not totally in a monetary perspective, but in an overall sense. What we will remember when we go into pension is that we did something that helped the people of this country,” concluded PHM Samanthi, leaving a passionate remark.
PHOTO © Ömürden Cengiz on Unsplash