is much more than just a mother and wife
In the mythical history of the world, from time immemorial, women
had been assigned a role that is a singularly privileged entity.
They have been cherished, admired and even idolized, but it is only
in the recent past of world history that the human race has deemed
it fit to even consider the rights of women.
rights mean gender equality. It means recognizing that the woman's
role is not only to be that of a wife and mother subservient to
the male sex but to be that of an independent human being with rights
of her own. Political and legal rights are rights guaranteed by
governments and legal systems; and economic and social rights are
those which enable women to use these political and civil rights,
to participate in society in a meaningful way. These include the
right to food and shelter, family life, and a decent standard of
living, education and employment.
and reproductive rights
Sexual and reproductive rights of women are based on the
rights of the adolescent girl and woman in the child-bearing age.
In summary these rights rest on the recognition of the basic rights
of individuals to decide freely if and when they should marry, when
they should embark on the first pregnancy, the spacing and number
of children they wish to have, the ability to attain the highest
standard of sexual and reproductive health, and freedom from relevant
diseases. It also includes the right to make decisions concerning
reproduction, sans any form of discrimination, coercion and violence
and the right to information and education.
right to liberty and security of the person should be invoked to
protect the woman at risk from female genital mutilation or subjected
to forced pregnancy, sterilization or abortion. A woman has a right
to decide on the embarkation of a pregnancy, consenting to be sterilized
or undergoing an abortion.
In spite of laws against genital mutilation of females, this ill-treatment
occurs in many parts of Africa and to a lesser extent in certain
parts of Asia. Female Genital Mutilation (FGM) can be classified
into four types and the commonest practised in Sri Lanka is female
circumcision. Many forms of FGM are prohibited by legal or administrative
measures in at least 18 countries worldwide.
Adolescents comprise 1.5 billion of the world's population. In Sri
Lanka the adolescent population is around 12%. Surveys reveal the
lack of accurate information about sexuality in this group. Dissemination
of knowledge is difficult as some parents object to sex education
in schools particularly in the rural areas. However educating adolescents
regarding sexuality, protection against pregnancy and sexually transmitted
diseases, the different methods of contraception available and their
usage, and the dangers of abortion are vitally important.
a study done in Galle by Professor Malik Gunawardena et al with
regard to sexual activity, around 30% of girls in the university
entrance class were found to be sexually active. The majority was
from the upper social classes. In this study, 11% of girls in the
A'Level class reported being sexually abused. Sixty-five percent
of them were from the lower socio-economic strata. The abuser was
probably an immediate family member. Birth registration data in
Sri Lanka indicate that 7% of all births in 2000 were attributed
to girls aged 15-18 years of age. The actual number of pregnancies
in this age group is not known because data on abortion and miscarriage
number of pregnancies in mothers who are less than 15 years of age,
was 119 in 1997 and from 15 to 19 years of age, it was 28061. In
a study done in Sri Lanka from the abortion clinics in the five
districts of Gampaha, Kurunegala, Matale, NuwaraEliya and Ratnapura
it was found that of 786 women, 24 or 3% were under 20 years of
age. This was a study done by Prof. Lalani Rajapakse.
In response to the social problems adolescents are exposed to, some
countries have special clinics for them. In Sri Lanka, such clinics
have been organized in Galle and the Colombo South Teaching Hospital.
There are plans to have many more adolescent clinics in the country
with assistance from UNICEF.
history of maternal mortality in Sri Lanka is one of our proudest
achievements. According to the civil registration system, Sri Lanka's
maternal mortality ratio has shown a dramatic fall in the second
half of the 1990s and it is presently around 58/100,000 live births
in the year 2001, the best ratio in South Asia.
an analysis at district level in Sri Lanka shows that there are
discrepancies in the different parts of the country. Maternal mortality
in the Nuwara Eliya district was 160/100,000 live births, Batticaloa
120/100,000 live births, Jaffna/Killino-chi/Mullaitivu were 100/100,000
live births, whilst in the Colombo district it was only about 18/100,000
estate areas, Eastern Province, Northern Province and border villages
thus show a higher maternal mortality. This is possibly due to poverty,
lack of education, and a consequent lack of knowledge among these
women, together with a dearth of optimum health care facilities
and/or difficulty in accessing health care services available in
An analysis of the maternal mortality ratio in Sri Lanka
over the years has shown that it took 17 years to show a reduction
from 200 per 100,000 live births to 100 per 100,000 live births.
The main reasons for this reduction of maternal mortality in recent
years were the availability of skilled attendants at deliveries,
the increase of institutional deliveries, together with the development
of emergency obstetrics care in all hospitals islandwide. Prior
to 1940, less than 30% live births had skilled attendants and most
of these births took place in homes under the care of the family
present 94% of deliveries take place in institutions and 76% of
them are in secondary and tertiary hospitals under the care of a
consultant obstetrician. However in the Eastern Province 65% of
deliveries take place at home in the absence of trained birth attendants.
Transport facilities were not available after 6.00 p.m. due to the
situation which prevailed in the North and East and this could account
for the increased maternal mortality rates in these parts of the
country. Sri Lanka studies every maternal death in great detail
and every aspect is scrutinized. Information obtained from these
audits has contributed greatly to further improve the care provided
in our health sector.
itself is a normal biological process and is essentially a life-enhancing
situation. Even from a purely humanistic perspective, rather than
from an obstetric point of view, a maternal death is a tragedy and
no mother should die of pregnancy or its related causes. Studies
have shown that avoidable factors like delay in seeking care by
the pregnant mother, the lack of transport, inadequate facilities
and medical care at the place of delivery have contributed significantly
to maternal mortality.
analysis of the maternal deaths by the Three Delay Model shows that
the 1st delay is a delay on the part of the pregnant mother in deciding
to go to a hospital. The 2nd delay is due to a lack of transport
facilities available and the 3rd delay is due to a lack of facilities
at the place of delivery.
health care personnel from the midwives upwards play a pivotal role
in our maternity health care system. They carry out premarital counselling
of young girls of child bearing age, where any medical problems
present would be detected and the patient referred to hospital.
Pre-pregnancy counselling of young married couples is also carried
out to detect any medical problems which may have been missed earlier
or developed later. Advice regarding nutrition, family spacing and
contraceptive usage is also given. During pregnancy counselling,
the mother is regularly seen and advice given together with the
education of the husband and family members on her antenatal care.
Possible complications which can develop and action to be taken
in the case of such complications are explained to them.
Providing continuous medical education to primary health
care personnel to reinforce their knowledge is necessary. In order
to carry out all these functions, an adequate number of family health
workers is necessary. Vacancies in the cadre of family health workers,
and other categories of primary health care givers should be filled
as a matter of urgency.
analysis of maternal mortality by cause shows that post-partum haemorrhage
is still the main cause, an incidence of 24%. The availability of
blood transfusion services in hospitals which cater to maternity
cases should be made mandatory. Transferring patients to another
institution due to lack of transfusion facilities or obtaining blood
from another institution for transfusion can cause maternal death
due to delay. Establishing regional blood banks with provision of
adequate stocks of blood and blood products to institutions is important.
Provision of special intravenous solutions such as starch products
which could be used for volume replacement in emergency situations
number of deaths due to pregnancy induced hypertension though on
the decline, still remains high with an incidence of 16%. Multicentre
trials have shown that the use of intravenous magnesium sulphate
is efficacious in the treatment of eclampsia. The availability of
intravenous magnesium sulphate, in all hospitals islandwide and
of guidelines for its usage may assist in reducing maternal mortality
due to pregnancy induced hypertension.
respect to the institutional care of the pregnant mother, the availability
of Intensive Care Units or High Dependency Units in the Base and
General Hospitals are vitally important. This should be under the
care of a consultant anaesthetist or intensivist, with the availability
of a consultant physician to manage cases complicated by medical
problems and hypertensions.
to the statistics available, nearly 75% of the maternal deaths occurred
in the postpartum period, the largest number during the immediate
postpartum period and a lesser number up to 42 days after delivery.
Care should thus be directed towards monitoring of the postpartum
period. Regular follow-up by the field staff to detect post partum
sepsis is important. Domiciliary postpartum care should be strengthened
from what it is now.
Contraceptive advice should be given to the mother especially
in cases where she is at risk of dying from a subsequent pregnancy
due to a medical complication. Non-compliance with medical advice
to use contraceptives when indicated in life threatening situations
has led to death.
deaths due to indirect causes such as heart disease complicating
pregnancy appear prominent in the recent statistics available with
an incidence of 10%, as is anaemia, diabetes mellitus and liver
disease. A failure in the detection of heart disease by the health
care personnel at the primary care institutions and clinics may
be responsible for the increased number of deaths noted in the maternal
death review. The unmet need in family planning particularly in
heart disease is found to be an important factor.
percent cases of maternal deaths had occurred due to unwanted pregnancies
and in 46% due to wanted pregnancies. Had the unwanted pregnancies
been prevented by meeting the contraceptive needs these deaths in
turn would not have occurred.
disease complicating pregnancy causes maternal death. Early detection
and transfer to a suitable institution is necessary. Death due to
septic abortions remains a major problem. Sepsis related to delivery
needs early detection and aggressive treatment to prevent maternal
deaths. Availability of a labour room with optimum sterility is
of importance to prevent intepartium, postpartum and neonatal sepsis.
Proper procedures in sterilizing and packing linen used at deliveries
are of great importance.
facilities such as ambulances, to transfer patients to rea- ch appropriate
levels of care are necessary, especially in the district hospitals.
Patients should be stabilized and preferably accompanied by a medical
officer, a nurse or a family health worker during the transfer.
The receiving institution should be ready to take her over to prevent
further complications from occurring. Hospitals providing maternity
care should have at least two specialist obstetrician posts. If
not, relief arrangements must be made to ensure that at any given
time at least one obstetrician would be available in station. Use
of partograms in all labour rooms is essential to monitor the progress
Eighty-six percent of maternal deaths are preventable. It is the
duty of Provincial Councils, which are in charge of district and
provincial hospitals and field staff, to be aware of the problems
in their areas, and provide necessary support, equipment and staff
for optimum care which are a woman's right. Efforts should also
be directed towards reducing morbidity during childbirth leading
to subsequent ill-health, which is again her right.
women are entitled to dignity and privacy in the labour room. This
is their right, which is not often honoured in our country due to
the overcrowding in our hospitals. The possibility of ensuring this
right has to be looked into and an appropriate solution found.
Sri Lankan women should be empowered to decide on the kind of contraceptive
they would like to use without being coerced into either not using
contraception and thus having an unwanted pregnancy or using a method
which is suggested to her by her husband or other members of the
family. One of the main reasons for not using contraception is misinformation
regarding their safety. Media should be used to dispel these myths.
Family planning services should particularly target marginalized
areas. (Women such as those in the estate areas, in the remote parts
of the island and the North and East Region). Advice on use of contraception
must be given by institutional and field staff in the postpartum
period to prevent the unmet need.
In Sri Lanka, a woman is legally entitled to 84 working days maternity
leave in the government sector and by the Maternity Benefit Ordinance
covering the private sector. By this, she is able to bond with the
baby and exclusively breastfeed for 4 months. Thereafter she is
entitled to take time off from work for one hour per day to enable
her to breastfeed the baby. This is a right which should not be
Sri Lanka, abortions are not legalized, and are only permitted in
situations where it has to be performed to save the life of the
mother. The illegal abortion rate however is very high. Nearly 750-1000
abortions are performed daily and according to a review of maternal
deaths, illegal abortions was the 5th leading cause of direct maternal
death. Clearly then, the criminalization of abortion through a 1883
law, has not stopped the practice of illegal abortions in our country.