Perinatal Society of Sri Lanka
Presidential Address - 2021
"Excellence in Perinatal Care through Research Training and Audit"I am honoured and privileged to stand before you as the
President of the Perinatal Society of Sri Lanka
I wish to thank, the Perinatal Society of Sri Lanka, for
electing me as the 20th president, for the year 2021.
I would like to thank the immediate past President Dr.
Kaushyala Kasthuriaratchi and her council and all the past presidents for their
excellent contribution to improve the perinatal care during their COVID ridden
difficult period of time.
I hope I would be able to continue the good work to fulfill
the aspirations of the membership.
I am also fully aware of the commitment and dedication of past
presidents in achieving targets and what we are today.
I wish to take an oath before you that I will at all times uphold
traditions, integrity and decorum of this high office. I will also maintain its
high standards for the betterment of perinatal care and actively promote the
postgraduate education in Sri Lanka during my tenure in office.
Sri Lanka being a middle-income country with
per-capita GDP of 3852 US$ in 2019, has
indicators that reflect satisfactory overall health status of the population.
The infant mortality rate and the maternal mortality rate in Sri Lanka are among
the lowest in South East Asian region.
For the Year 2019, Neonatal mortality rate (7.0 per 1000
live births), Infant mortality rate (10.5 per 1000 live births), under-five
mortality rate (11 per 1000 live births).
Maternal Mortality Rate (32.0 deaths per 100,000 live births
in 2018)
[28.8 deaths per 100,000 liver Births in 2019
(Provisional)].
The population growth rate has reached 0.6% in 2019 with a
total fertility rate 2.2 per woman which is close to the population replacement
level.
In ancient Sri Lanka, the health system that prevailed for
safeguarding the health of people was based on the traditional systems of
medicine including Ayurveda.
According to Mahawamsa, king Pandukabhaya has established
lying-in-homes in various parts of the country.
King Buddhadasa had mastered midwifery as well and said to
have performed a surgery on a woman to deliver her child.
The allopathic system of medicine was introduced by the
Portuguese in 1505
The British established military hospitals and dispensaries
which provided medical care to the civilian population
Maternal and Child health services in Sri Lanka has a long
history.
The first organized effort towards providing care and
attention to childbearing women was made in 1879 with the establishment of the
De Soysa Lying-in-home, now known as De Soysa Maternity Hospital (DMH) for
women.
The Maternal and Child Health (MCH) Department of the
Colombo Municipality was established in 1906. Since then the number of
hospitals with facilities for delivery has increased rapidly.
The need for developing preventive and promotive services
was recognized by the government as early as 1920’s.
Health Unit system was initiated with the
establishment of the first Health Unit in Kalutara in 1926.
This system provided domiciliary as well as clinic-based
services during pregnancy, trained assistance at delivery and domiciliary
services for the postnatal mother and the infant.
By 1950, 91 Health Units were established and by 2003 there
were 280 units, which are termed Medical Officer of Health areas now
Since 1989, the country’s administration has been
decentralized with devolution of administrative power to nine Provincial
Councils.
There are 6785 PHM areas, and PHMs work as front-line health
worker providing domiciliary care to mothers and children within the community.
She has a well demarcated geographic area with an average
population of 3,000 to 5,000
The PHM is a member of the team providing services at field
and institutional clinics and links the domiciliary services to clinics and
institutional care.
Parallel to the expansion of the health unit system
throughout out the country, curative care services were developed through the
establishment of a network of healthcare institutions ranging from Central
Dispensaries at the lowest level to the General Hospital, now known as the
National Hospital of Sri Lanka, in the capital city of Colombo at the highest
level.
Total number of 192 hospitals units and 6785 number of
Primary Medical Care Units in the country at present.
There is no record of the commencement of Premature Baby
Units in this country. As far as we know, most of the hospitals with maternity
units had a space for Premature baby units (PBU). Although it is named as PBU,
all low-birth-weight babies, premature and sick infants , asphyxiated and abandoned
babies were admitted to these units. All what was offered in these units for
the babies was warmth through incubators or other methods, oxygen through head
box or hood, IV fluid, NG feeding and IV antibiotics. Regular blood sugar
facilities were not available. Hand washing was not done according to universal
precautions.
By 1985, around 20% of live births in Sri Lanka were low
birth weight.
Yet 60-70% of the deaths that occur in this group of
low-birth-weight babies, around 50% were pre-term babies.
The year 1985 was a landmark for neonatology services in
this country.
With the establishment of the Medical Intensive Care Unit at
Lady Ridgeway Hospital in 1985, mechanical ventilation was started.
Before that newborns were sent to the National Hospital for
ventilation.
Sri Jayawardanepura General Hospital (SJGH) went into
commission in the year 1985 and the NICU started functioning in 1987 with the
JICA grant.
This is the first recorded fully equipped Neonatal intensive
care unit in the country.
Respiratory support to the ill newborns was commenced in
July 1988 with the availability of the CPAP system and ventilation of babies
was commenced in late 1988 with the availability of two Baby Bird ventilators.
Technical support was provided by the KEIO University of
Japan and local JICA office coordinated this activity.
Initially neonatal care was supported by Japanese nurses for
a few years.
Dr. D.A.Sonnadara took a untiring lead to establish both
NICU’s at Sri Jayawardenapura and Lady
Ridgeway Hospital.
Improvement of Maternal and childcare was not possible
without the contribution of local non-governmental organizations like perinatal
society of Sri Lanka, Sri Lanka College of Paediatricians and Sri Lanka College
of obstetricians & Gynaecologists and College of Community Physicians Sri
Lanka.
The Perinatal Society of Sri Lanka (PSSL) was inaugurated on
29th April 2001 under the auspices of Sri Lanka College of
Paediatricians, Sri Lanka College of Obstetricians & Gyanaecologists, Sri
Lanka College of Community Physicians and UNICEF at the Lady Ridgeway Hospital
for children in Colombo.
The inaugural meeting was attended by fifty-four
participants with the founder President being Prof. Indraji Amarasnghe and I am
happy to see you in the audience along with other founder members like Dr.
Srilal De Silva.
The perinatal society started with Nineteen life members and
eight ordinary members who joined the society at this meeting.
A council representing all specialties involved in perinatal
care was appointed.
First annual session was held in 2003 at the Lady Ridgeway
Hospital.
Professional colleges of this country has contributed to
improve the perinatal care since its inception.
In 2005, at the request of the College of Paediatricians,
Post-Graduate Institute of Medicine recognized and commenced in
sub-specilization in Neonatology.
Master Training on Neonatal Advanced Life support was
held from the 12th to the 15th of September 2006 at the Lady Ridgeway
Hospital the first time in this country, by the Resuscitation council of UK.
A workshop of Master Training on Advanced Neonatal
Ventilation was held on the the 7th, 8th, 9th
and 10th of April 2008 at LRH Colombo by Prof Ashok Deorari, Prof of
Neonatology and his faculty from India.
Workshop on Perinatal and Neonatal Post Mortem was
held jointly by the College of Pathologists and the College of Forensic
Pathologists on 23rd of February 2007 to sensitize the memberships
about the need for perinatal postmortem.
Many activities were started by the Perinatal society such
as neonatal hearing Screening programme in 2008, CPAP ventilation in 2009, ROP
screening and treatment in 2008 and Congenital hypothyroidism screening in
2008.
Concepts of brain cooling in was introduced at the annual
session in 2009 by PSSL and concept of
pulse oximetry was introduced by SL College of Paediatricians in 2013 at its
annual session.
Members of SLCOG helped to establish MS in Gynaecology and
Obstetrics through the PGIM in 1984 which was changed to MD in 2001.
With increased intake of the trainees the MS in Obstetric by
PGIM has resulted in expansion of services upto to Base Hospital and
upwards.
Safe Motherhood Initiative which was launched in Nairobi in
1987, is being rolled out in outstation hospitals to improve the quality of
obstetric emergencies.
SLCOG conducted its first Safe motherhood programme in
Anuradhapura in 1991. Second in Matale sponsored by UNICEF in 1992.
SLCOG has continued to conduct safe motherhood programmes
every year regularly across the country and facilitate the policy dialog with
the health administrators at a local level.
SLCOG is proud to have sustained a good practice initiated
by a Global Programme.
The technical and financial support was from UNICEF, IPPF
& FIGO in collaboration with Family Health Bureau.
Registration of births and deaths became compulsory as early
as 1897, and since 1921 the administrative report of the Registrar General
devoted a special section to maternal mortality. The ready availability of
statistics facilitated the evaluation of MCH services
The target was to reduce child mortality indicators by 2/3
between 1990 and 2015.
Starting at a baseline of 21.5/1,000 live births in 1990,
the country has made progressed to 9.6/1,000 live births in 2010, very slightly
off track to meeting the goal of 7/1,000 for 2015.
Sri Lanka’s initial maternal mortality ratio of 85/100,000
live births in 1990 decreased to 35/100,000 by 2010. This is on track to
meeting the MDG target of 21/100,000 maternal deaths by 2015.
Unfortunately, these MDGs were not achieved by Sri Lanka.
Few countries in the region achieved health indicators of
MDG goals
It is interesting to find out why this was not achieved in
our country, despite having well structured health system
Role of non-governmental international organizations are to
support the improvement in maternal and newborn care programmes.
Maybe to decide on strategies, policies, identify bottle
necks and minimize inequities in the deprived segment of the service.
They also provides technical support and capacity building
to improve perinatal activities in the country.
We are thankful to the Ministry of Health for facilitating
Maternal and Newborn Review in 2007 .
The objective was to identify the gaps and make
recommendation for further improvement of maternal and newborn health in the
country.
This review clearly identified that there is provision to
further improvement of maternal and newborn care in the country both at the
institutional level and the field level.
There is a need to plan for high quality newborn care in all
hospitals and at field to ensure accessibility to quality services in all parts
of the country.
Based on these recommendations of Maternal and Newborn
Review in 2007, Ministry of Health has implemented almost all these strategies.
Over the period, Ministry of Health was able to publish
recommendations made by the Maternal and Newborn Review in 2007.
Unfortunately, Maternal and newborn healthcare workers
receive ad hoc nature of in-service training.
This is one of the barriers for poor quality of the patient
outcome.
Therefore,
this review report recommended to improve the training to these categories
Same is with medical officers and specialist in Paediatrics
and Obstetrics and Gynecologists.
Although they are subject specialist their understanding on
Maternal and Newborn policy is poor.
This is simply because no Maternal and Newborn specialist in
this country.
Community Physicians obtain their degree by thesis and then
specialize the subjects they are assigned to.
The 2030 agenda for Sustainable Development, which has 17
Sustainable Development Goals, was adopted by countries in 2016.
Out of the 17 goals, mainly SDG 3 is concerned with maternal
and child health.
Under SDG 3, there are 13 core indicators and 38 health
indicators related to maternal and child health.
According to the updated sustainable development goals, MMR,
NMR and under 5 mortality rates are on track or maintaining SDG
achievement.
Paediatricians and Neonatologists have to work hard to
achieve these targets.
Obstetricians will have to really work hard to achieve the
sustainable development goals.
Over the years we see a improvement of national statistics.
Whether it is driven by Ministry of Health or by the
Consultants in the respective field or as a college is question that needs to
be explored.
Anthony Leo quoted, I quote “Healthcare delivery has worked
as well as it has developed to date because clinicians are bright, hard
working, and well-intentioned – not because of good system design or
systematic data use”. Unquote.
This remark applies in our context, as I strongly feel,
members of professional colleges contribute to improve the national
statistics.
And it is not data driven improvement.
Ministry publish “Maternal and child health policy” and
National Strategic Plan documents from time to time.
According to the Ministry of Health, “This gives guidance to
achieve national goals based on the challenges faced demographically as well as changes in expectation of the
people.
Such a documented policy provides the much-needed direction
to strategic planning, implementation, monitoring and evaluation of MCH
programme to address such issues effectively”.
Various documents have been published by Ministry of Health,
utilizing the resources of donor agencies to improve the national statistics.
In order to reduce MMR, various strategies have been
introduced by the Ministry of Health.
These are the some of activities undertaken by the Ministry
of Health towards improvement of maternal and childcare in the country.
First ever five days of Master training course on “Essential
Newborn Care” was conducted in Myanmar, organized and sponsored by WHO in 2006.
Few consultant paediatricians and community physicians in the FHB participated
in this programme.
The SAARC Development Fund MCH Project is mainly focusing on
improving neonatal care. One component of this project is to introduce a
training module on “Facility Based Care of Sick Neonate at Referral Health
Facility” to improve the quality of care for the newborn.
The Technical Advisory Committee on newborn and child Health
has recommended undertaking this Master training Programme following which,
with necessary revisions these modules can be used for in-service training of
the neonatal care unit staff. The faculty
consisted of Dr Ravinder Nath Salhan – MCH consultant, Dr Harish Kumar Chellani – MCH consultant, Dr
Satish Saluja – NNF Specialist, Dr
Sushma Nangia – NNF Specialist. Thiis programme was held from 7th
to 10th July 2012 at FHB Class room.
In 2010, Members of the PSSL collaborated with the FHB in
development of the Feto-Infant Mortality Surveillance system. The formats
developed and are ready for pilot testing. On 21st November 2013
Ministry of Health issued a circular initiated by the FHB (FHB/EH/26/2013) on
Pilot Implementation of the Feto-Infant Mortality Surveillance System.
Number of equipment needed for Maternal and child care
received by SDF / MCH project were distributed through the Bio-Medical
Engineering Service. Letter FHB/INBU/SDF/2012. To create a newborn corner
in each labour room and make essential equipment available
During the COVID-19 pandemic, there have been substantial
shifts in the way that maternity care is delivered. Care provision has had to
be modified and maternity units have faced many new issues. The effects of
these changes on maternity outcomes have not yet been measured, and it is
unclear whether these changes have widened or narrowed existing inequalities.
Health department should take the lead of update the staff
and try to improve the maternal and child health services.
Professional colleges should formulate the modules depending
on the need. They should play the advocacy role.
Clinical leaders with the support of Director of the
hospital and quality assurance department should facilitate these modules
All the benefits should go to Junior staff in the hospital
who needs clinical training and these
interventions will support them to improve the quality of care.
Team dynamic training is the focus now, not individual training.
Therefore we as clinicians who are members of the colleges,
have a bigger role to play if we are to achieve these targets
Scientific analysis of morbidity and mortality by the
professional colleges by the way of confidential inquiries will help to
identify the root cause analysis and to decide on the strategies.
Very often these problems are based on geography, hospital
based, or unit based
Ministry should empower the colleges in order to achieve
these targets.
Regular review meetings should be organized by the Ministry
I would like to divert your attention to the hierarchy of
Intervention effectiveness.
This is very important for policy makers, clinicians and
politicians.
This is extracted from the National center for patient
safety of US department of veterans affairs
You will appreciate, the place occupied by education and
training is the foundation of an effective intervention. But in order for it to
be effective at the ground level you need to have rules, policies, reminders,
check lists and double checks, automation or computerization and forcing
functions.
Forcing functions are not possible without a strong
political commitment.
Unless, clinicians, professional organisations, policy
makers together with commitment by politicians adhere to a hierarchy of
effective Intervention, it would not be possible to achieve the SGD goals.
Personal egos and boundaries kill this opportunity
Shortcomings in the form of failing to empower the
professional colleges and absence of regular review meetings was one of the
many reasons we were unable to achieve these Millennium development Goals.
In 2019, in an another Induction Program two game changing
innovative programs were introduced in neonatology by Dr Surantha Perera, Past
President of PSSL. It is one of the most advanced comprehensive programs to
improve neonatal care in Sri Lanka.
It was the establishment of Therapeutic hypothermia and
Nitric Oxide therapy Program at national level. Already these machines were
distributed to the level III Neonatal Intensive Care Units following in house
training program.
As the 20th President of PSSL I pledge my fullest support
for these advanced programs during my tenure and I will help them to launch
these at national level.
I am concluding my presidential speech by thanking all of
you for your patient listening. I acknowledge following individuals for their
tremendous support given to me.
Acknowledgments
- My teachers from school, undergraduate studies and postgraduate studies.
- Dr. Srilal de Silva
- Dr. Sanjeewa Godakanda
- Dr. Deepika Attygalle
- Dr. Pradeep De Silva
- Prof. Hemantha Dodampahala
- Dr. Lakshantha Peiris
- My parents and family
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