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She 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.

Women's 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.

Sexual 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.

The 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.

Genital mutilation
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.

Adolescent pregnancies
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.

In 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 are unavailable.

The 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.

Clinics for adolescents
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.

The 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.

However, 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 live births.

The 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 these areas.

Maternal mortality
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 health worker.

At 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.

Pregnancy 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.

An 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.

Primary 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.

Medical education
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.

An 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 is essential.

The 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.

With 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.

According 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.

Contraception
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.

Maternal 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.

Fifty-two 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.

Liver 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.

Transport 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 of labour.

Preventable deaths
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.

Pregnant 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.

Maternity leave
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 denied.

In 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.

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