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Background: Although maternal mortality has become a major focus on global public health agenda, maternal morbidity is a neglected area of research. The purpose of this paper is to present the burden of acute maternal illness during pregnancy. Methods: A cross sectional study was carried out in Anuradhapura district, Sri Lanka. Pregnant women residing in the Anuradhapura district with a gestational age more than 24 weeks through 36 weeks were recruited to the study using a two-stage cluster sampling technique. All pregnant women who consented participated in a detailed interview using a structured questionnaire. Self reported episodes of acute illness during pregnancy were the main outcome measures. Secondary outcomes were utilization of medical services and frequency of hospitalizations. Results: Nausea and vomiting during pregnancy (NVP) was experienced by 325 (69.7%) of the 466 pregnant women studied. Other common symptoms were backache (152, 32.6%), dizziness (112, 24.0%) and heartburn/regurgitation (107, 23.0%). Of the 421 pregnant women who reported ill health conditions 260 (61.8%) women sought medical treatment for these illnesses. Total number of episodes that needed treatment seeking were 373. Hospitalizations were reported by 83 (17.8%) pregnant women and the total number of hospitalizations was 109. The leading cause of hospitalization was NVP which accounted for 43.1% of total admissions and 49.1% of total days spent in hospitals. Conclusions: Minor maternal ill health conditions affecting day-to-day life have a major burden on pregnancy period. Evidence based management guidelines and health promotion strategies are needed to control and prevent these conditions, in order to provide comprehensive, good quality maternal health care. [ABSTRACT FROM AUTHOR]

Several limitations of emergency obstetric care (EmOC) indicators and benchmarks are analysed in this short paper, which synthesises recent research on this topic. A comparison between Sri Lanka and Zambia is used to highlight the inconsistencies and shortcomings in current methods of monitoring EmOC. Recommendations are made to improve the usefulness and accuracy of EmOC indicators and benchmarks in the future., (© 2012 Blackwell Publishing Ltd.)

Background: Ending preventable maternal deaths remains a challenge in low- and middle-income countries (LMICs). Society perceived causes and real-life observations can reveal the intangible causes of maternal deaths irrespective of formal maternal death investigations. This study reports complex patterns in which social determinants act towards paving the path to maternal deaths in a rural Sri Lankan setting. Methods: We conducted social autopsies for 15/18 maternal deaths (in two consecutive years during the past decade) in district A (pseudonymized). In-depth interviews of 43 respondents and observations were recorded in the same field sites. During thematic analysis, identified themes were further classified according to the World Health Organization framework for social determinants of health (SDH). The patterns between themes and clustering of social determinants based on the type of maternal deaths were analyzed using mixed methods. Results: Discernable social causes underpinned 12 out of 15 maternal deaths. Extreme poverty, low educational level, gender inequity, and elementary or below-level occupations of the husband were the characteristic structural determinants of most deceased families. Social isolation was the commonest leading cause manifesting as a reason for many other social factors and resulted in poor social support paving the path to most maternal deaths. A core set of poverty, social isolation, and poor social support acted together with alcohol usage, and violence leading to suicides. These core determinants mediating through neglected self-health care led to delay in health-seeking. Deficits in quality of care and neglect were noted at health institutions and the field. Conclusion: Social autopsies of maternal deaths revealed complex social issues and social determinants of health leading to maternal deaths in Sri Lanka, indicating the need for a socially sensitive health system. Plain English summary: Many women in low and middle-income countries die during pregnancy, childbirth, or postpartum due to preventable factors. Routine inquiries into these deaths conducted by health personnel focus mainly on problems in health systems, neglecting social causes. We explored how social factors paved the path to maternal deaths inquiring the immediate community. We conducted 43 interviews with close persons and observations of 15/18 deceased women within 2 consecutive years, in district A (pseudonymized) in Sri Lanka. We included all deaths that occurred in the hospital as well as the field during the study period. The patterns of social causes based on the type of maternal deaths were analyzed using mixed methods. Extreme poverty, low educational level, gender inequity, and elementary or below-level occupations of the husband were common in most deceased families. Social isolation was the commonest leading cause and resulted in poor social support making women helpless. We observe that poverty, social isolation, and poor social support at family and neighborhood level acted together with alcohol usage and violence, leading to suicides and to delay in health-seeking. Deficits in quality of health care and negligence were noted in hospitals and in field care provision. We conclude that it is of prime importance to identify social causes leading to deaths of women during pregnancy and postpartum, as prevention of these is possible through simple multisectoral interventions. The health system needs to be integrated with social interventions and systems at community level to identify women at risk. [ABSTRACT FROM AUTHOR]

Misoprostol, a WHO essential medicine indicated for labour induction, management of miscarriage and post-partum haemorrhage, as well as for induced abortion and treatment of post-abortion complications, come up for registration in Sri Lanka in December 2010. The decision on registration was postponed, indefinitely. This has wide-ranging implications, as misoprostol is widely available and used, including by health professionals in Sri Lanka, without guidance or training in its use. This paper attempts to situate the failure to register misoprostol within the broader context of unsafe abortion, drawing on data from interviews with physicians and health policymakers in Sri Lanka. It demonstrates how personal opposition to abortion infiltrates policy decisions and prevents the issue of unsafe abortion being resolved. Any move to reform abortion law and policy in Sri Lanka will require a concerted effort, spearheaded by civil society. Women and communities affected by the consequences of unsafe abortion need to be involved in these efforts. Regardless of the law, women will access abortion services if they need them, and providers will provide them. Decriminalizing abortion and registering abortion medications will make provision of abortion services safer, less expensive and more equitable. [ABSTRACT FROM AUTHOR]

Purpose: The direct impact of protracted conflict on population health and development is well understood. However, the extent of a war's impact on long-term health, and the opportunity costs, are less well understood. This research sought to overcome this gap by asking whether or not health outcomes in Sri Lanka would have been better in the absence of a 26-year war than they were in the presence of war. Methods: A counterfactual model of national and district-level health outcomes was created for Sri Lanka for the period 1982 to 2002. At the national level, the model examined life expectancy, infant mortality rate (IMR), and maternal mortality ratios (MMR). At the district level, it looked at IMR and MMR. The model compared outcomes generated by the counterfactual model to actual obtained health outcomes. It looked at the rate of change and absolute values. Results: The analysis demonstrated that war altered both rate of change and absolute health outcomes for the worse. The impact was most clearly evident at the district level. IMR was poorer than predicted in 10 districts; of these 8 were outside of the conflict zone. The MMR was worse than expected in 11 districts of which 9 were not in the conflict zone. Additionally, the rate of improvement in IMR slowed as a result of war in 16 districts whereas the rate of improvement in MMR slowed in 9. Conclusion: This project showed that protracted conflict degraded the trajectory of public health in Sri Lanka and hurt population health outside of the conflict zone. It further provided a novel methodology with which to better understand the indirect impact of conflict on population health by comparing what is to what could have been achieved in the absence of war. In so doing, this research responded to two public health challenges by providing a tool through which to better understand the human and opportunity costs of war and by answering a call for new methodologies. [ABSTRACT FROM AUTHOR]

Background: The recently published WHO guidelines on applications of ICD-10 to deaths during pregnancy, childbirth, and the puerperium (ICD-MM) aimed at enabling a comprehensive framework for international comparison of maternal deaths, which includes maternal suicides as a direct cause of maternal deaths. At present, most developing countries do not include suicide as a maternal death. Methods: We extracted and analysed data from the maternal death surveillance system in North Central Province of Sri Lanka for the period of 2005 to 2011, in order to identify the implications of this new classification on maternal mortality estimates. All reported deaths of pregnant women and women within 12 months of termination of pregnancy were included in this study. Causes of deaths were extracted and coded using ICD-10 reclassified according to new ICD-MM for maternal deaths. Results: Of the 118 deaths analysed, the maternal death investigation system had classified 53 (44.9%) deaths as maternal deaths. These 53 maternal deaths included one deaths due to suicied, out of 21(17.8%) suicide deaths among 118 reported deaths. Application of the new ICD-MM showed 83 maternal deaths which resulted in a 56.6% increase of number of maternal deaths in the province. Detailed analysis of all individual causes by ICD 10 codes showed that intentional self-poisoning by an exposure to pesticide (ICD code X63) as the leading cause of maternal deaths in NCP (n = 11, 13.3% of all maternal deaths) during this period. The estimated MMR in the study area based on the new classification in years 2009, 2010 and 2011 was 115, 103 and 88 per 100,000 live births respectively. Conclusions: The new classification system may have an immediate effect in raising maternal mortality thresholds, making the MDG Goal 5A more elusive for many countries. However, this new approach may ultimately lead to a more accurate understanding of maternal mortality, as well as the real number of maternal deaths attributed to suicide. This more accurate accounting has implications for policymakers andpractitioners globally as they strive to meet women's needs during pregnancy, including attention to detection and treatment for maternal depression, given its close correlation with maternal suicide. [ABSTRACT FROM AUTHOR]

Theory suggests that longer life expectancy encourages educational investment because a longer time horizon increases the value of investments that pay out over time. To estimate the magnitude of this effect, we examine a sudden drop in maternal mortality in Sri Lanka between 1946 and 1953, which sharply increased the life expectancy of girls. We assess whether girls' education relative to boys' increases more in areas with larger maternal mortality declines. We find that for every extra year of life expectancy, literacy increases by 0.7 percentage points (2%) and years of education increase by 0.11 years (3%). [ABSTRACT FROM AUTHOR]

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Sri Lanka reports impressive health indicators compared to its peers in the South Asian region. Maternal and infant mortality are relatively low, and several intractable communicable diseases have been eliminated. The publicly financed and delivered "free" healthcare system has been critical to these health achievements. Placing the country's healthcare system in historical context, this commentary analyses the contradictions and political tensions surrounding Sri Lanka's 2018 Universal Health Coverage (UHC) policy, with attention to the Ministry of Health's plans for public-private partnerships (PPP). As economic exigencies and private interests increasingly erode the 1951 "Free Health" policy, this commentary calls for a re-envisioning of UHC that can meet people's aspirations for health and social justice. [ABSTRACT FROM AUTHOR]