The ubiquitous midwife
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The rain had ceased and Kussi Amma Sera and her two ‘amba yahaluwo’ (mango friends) were seated under the margosa tree chatting about events in their village and so on. “Nangi, ara midwife nona hariyata udaw karanawa apey gamme kattiyata (that midwife Madam is very helpful in our village),” Kussi Amma Sera was telling Serapina with Mabel Rasthiyadu listening intently.
KAS was referring to the public health midwife (PHM) and responding to a comment by Serapina on how the family of a migrant worker in West Asia was being helped by the local PHM. “Eya saukhya-ta vada boho deval walata udaw karanna danna-wa (apart from health, there are many others things that she helps with),” Serapina had been saying, explaining how the public health midwife was not only checking on the care and attention given to the children of the female migrant worker but also providing them psychosocial support.
Coincidental or what, when the phone rang at that moment, it was ‘Koththamalli’ Perera, the Kokatath Thailaya (oil for any ailments) expert who has a remedy for any health issue, wanting to discuss the same topic. “I say … there was this interesting discussion on digital health and one of the most interesting points was how the public health midwife is enhancing the health delivery service in rural areas,” he was saying.
“Oh … is that so?” I replied.
“Yep, some of them have smart phones and they are collecting a lot of data … in many ways, going beyond the call of duty,” continued Koththamalli.
“Ah …” I smile and then gently tell him: “I was also present at that discussion.”
“Ah … what? Where?” he stuttered and then, saying our goodbyes, we parted company.
Koththamalli was not the only one impressed by the role of the public health midwife; I and many others in the audience at the Forum on Digital Health organized by Sri Lanka Telecom and held at the Jetwing Colombo hotel, too, were amazed by the role of this ubiquitous worker.
Unlike many years ago going on bicycles, trained public health midwives today travel on mopeds or scooters with some armed with smartphones.
The discussion itself was a voyage of discovery on how far Sri Lanka is grasping new technology in building skills and collecting key health sector data.
Earlier known as e-health and now moving to digital health, experts in health informatics (a new area of specialty) spoke on the digital health eco-system focusing on how information is gathered, development of a central health data system and role of the public health midwife in the data collection process.
Once the data are collected – in the current case in 10 major hospitals covering 25 per cent of the population – it is recorded on a central Hospital Information Management System (HIMS). While this system collects data – inserted by 1,500 medical officers in hospitals collected from 6 million patients per year entering hospitals for in-house or OPD care — data from public health midwives through smart phones help to check on the mother-and- child nutrition status in rural areas, among other matters.
The smart phone device is used to collect data which go into a central system and provides a continuous flow of information from the health worker which goes right up to the policymaker, one expert said.
The entire digital health ecosystem allows government hospitals to enter data of patients on registration and on discharge. The systems also help the back end and when hospital pharmacies run out of stocks there are alerts giving such an indication, far ahead of expected shortages.
OPDs have queue management systems while, in some instances, mobile apps containing patient details are also available for doctors doing ward rounds.
At the forum, Professor Vajira Dissanayake, President of the Health Informatics Society of Sri Lanka, and specialists, Dr. Nishan Siriwardena, Dr. Pamod Amarakoon and Dr. Buddika Dayaratne lamented on how difficult it was to build this health information system since many of the big IT software players were more interested in overseas clients than local ones. Eventually, the team, after mobilising local developers, created an information system that cost Rs. 900,000 compared to Rs. 90 million if undertaken by a corporate developer!
The information flow at the forum was amazing in the context that apart from Sri Lanka being often praised for its effective public health system, the technology being used to gather information on the health status of the country was a new plus.
At the end of the session, I was not the only one who was moved by the brilliance of these doctors, the audience too was. But to many the role of the public health midwife, earlier known as family health worker, was striking and in particular how effective this system is – not only dealing with maternal and child care but also being a “shoulder to cry on” and a “listening post”.
What it means is that PHMs are often called upon to settle non-health family issues when a drunken husband abuses a wife, a child has been playing truant in school or a mother is close to taking her own life, etc.
Searching for more information on PHMs, we are told that the system began in the late 1920s and over the years the midwife has been offering a package of services including counselling and family planning unlike in countries like India where health workers do different things. In fact, many countries are looking at the Sri Lanka model owing to its efficiency.
In addition to handling maternal and child health, the 6,500 midwives who fan out across the country, each handling 6,000 homes, also engage in tackling gender based violence and drunken husbands.
Respected in the village, these workers also deal with women who are prone to depression after pregnancy. They look into the care of children of migrant mothers as this segment is high risk.
Many are unaware that the midwife, who is trained to deliver a baby among other skills, is also present in urban areas but in cities like Colombo, they face many challenges. “In Colombo, the women are mostly at work and not at home, when PHMs go visiting. Another challenge is that these households close the gate or shut the door in the face of the PHM thinking it’s below their dignity to use this free and efficient public health service,” one expert explained.
Many of the international accolades coming to Sri Lanka like the low rate of maternal and infant mortality, the country having nearly 100 per cent of births in hospitals and high levels of immunisation are all due to the efforts of public health midwives. Their services are seen as very valuable in rural Sri Lanka where resources are scarce.
Tuesday’s discussion on digital health ecosystem also provided a platform to profile not only the importance of the public health midwife but the need to improve the dignity of this silent workforce. And in an era where the remaining links between local government authorities and a village household is the postman or the grama sevaka which would likely end in the next 50 years, the role of the public health worker is rapidly being re-defined and has come to stay, hopefully, for good.
“Mahattaya, e-gollange padi wedikaranna ona,” Kussi Amma Sera interjects, having heard me earlier talking to Koththamalli, as I furiously type this piece on the computer.
“Ov (yes)”, I nod in agreement. Not only should their wages be increased but also their dignity to a level where they are also welcome in affluent urban settings.