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a b s t r a c t a r t i c l e i n f o Keywords:Maternal morbidity Maternal mortality Reproductive mortality Sri Lanka Sri Lanka, a non-industrialized country with limited resources, has been able to achieve a maternal mortality ratio that is markedly lower than the ratios of similar countries. Many factors have contributed to Sri Lanka's success story. A political commitment to the cause and implementation of clear policies through wellstructured and organized community-based and institutional healthcare services-expanded to cover the whole country and provided free of charge-have been the foundation of maternal and child health (MCH) services in the country. The healthcare programs have been well accepted and utilized by the people as the literacy rate is more than 90% for both men and women. Public health midwives form the backbone of MCH services and provide frontline reproductive health care. More than 98% of deliveries occur in hospitals and are attended by midwives. Furthermore, 85% of women in Sri Lanka deliver in facilities served by specialist obstetricians/gynecologists. The Sri Lanka College of Obstetricians and Gynecologists plays a leading role by assisting the Family Health Bureau in making policies and guidelines, training staff, and acting as team leaders for maternity care services. This was evident after the tsunami in December 2004. National maternal mortality reviews, monitoring and evaluation of MCH activities, and relatively high contraceptive prevalence rates have also contributed to the success in Sri Lanka, which could serve as a model for other countries.

Cardiac disease is a major cause of maternal mortality in Sri Lanka, second only to postpartum hemorrhage. Rheumatic mitral valve disease is responsible for more than a third of maternal deaths from cardiac disease. Substandard care was identified in all cases; strategies to improve care could allow a reduction in maternal cardiac deaths.

BackgroundLiterature shows that choice for unsafe abortion is often driven by poverty. However, factors related to the family formation behaviour of women are also implied as determinants of this decision. This study assessed which family formation characteristics of women are associated with the risk of unsafe abortion, without being confounded by their low socio-economic status among Sri Lankan women admitted to hospital following post-abortion complications.MethodsAn unmatched case–control study was conducted in nine hospitals in eight districts in Sri Lanka among 171 women with post-abortion complications following unsafe abortion (Cases) and 600 postpartum mothers admitted to same hospitals during the same period for delivery of term unintended pregnancies (Controls). Interviewer-administered-questionnaires obtained demographic, socio-economic and family formation related characteristics. Risk factors of abortion were assessed by odds-ratio (OR), adjusted for their socio-economic status in logistic regression analysis.ResultsLow socio-economic status, characterised by low-education (adjusted OR = 1.5; 95 % CI = 1.1–2.4) and less/unskilled occupations (2.3; 1.4–3.6) was a significant risk factor for unsafe abortion. Independent of this risk, being unmarried (9.3; 4.0–21.6), failure in informed decisions about desired family size (2.2; 1.4–3.5), not having a girl–child (2.2; 1.4–3.4) and longer average birth intervals (0.7 years; 0.6–0.8) signified the vulnerability of women for unsafe abortion. Cases were as fast as the controls in their family completion (4.3 versus 4.5 years; p = 0.4), but were at increased risk for abortion, if their average birth intervals (including the last one) were longer. Previous contraceptive use, age at reproductive events or partners’ characteristics did not impart any risk for abortion.ConclusionsLow socio-economic status is not the most influencing risk factor for unsafe abortions leading to complications, but many other factors in relation to their family formation characteristics that are independent of their low socio-economic status.

A Primary Healthcare-System-Strengthening Project (PSSP) is implemented by the Ministry of Health, Sri Lanka, with funding support from the World Bank for providing quality care through primary medical care institutions (PMCIs). We used an explanatory mixed-methods study to assess progress and challenges in human resources, drug availability, laboratory services and the health management information system (HMIS) at PMCIs. We conducted a checklist-based assessment followed by in-depth interviews of healthcare workers in one PMCI each in all nine provinces. All PMCIs had medical/nursing officers, but data entry operators (44%) and laboratory technicians (33%) were mostly not available. Existing staff were assigned additional responsibilities in PSSP, decreasing their motivation and efficiency. While 11/18 (61%) essential drugs were available in all PMCIs, buffer stocks were not maintained in >50% due to poor supply chain management and storage infrastructure. Only 6/14 (43%) essential laboratory investigations were available in >50% of PMCIs, non-availability was due to shortages of reagents/consumables and lack of sample collection–transportation system. The HMIS was installed in PMCIs but its usage was sub-optimal due to perceived lack of utility, few trained operators and poor internet connectivity. The PSSP needs to address these bottlenecks as a priority to ensure sustainability and successful scale-up.