Since the early 20th century in Sri Lanka, the Public Health Midwife (PHM) has delivered community-level maternal and child healthcare. The PHM is the “front line” health worker providing domiciliary care to women and children within the community and is the link between the community and institutional health care. All PHMs undertake the 40-hour WHO/UNICEF breastfeeding counseling training program, an established and comprehensive program that covers all necessary topics and includes hands-on clinical training. A longitudinal study in Sri Lanka on the effect of training public health midwives on exclusive breastfeeding reported a highly significant increase in the percentage of mothers breastfeeding their infants for 6 months, as well as the median duration of exclusive breastfeeding–all for a relatively low cost. Today, Sri Lanka has one of the top breastfeeding outcomes in the world with 99% of children ever-breastfed and 82% breastfed exclusively in the first six months in 2016.
Description & Context
ince the early 20th century in Sri Lanka, the Public Health Midwife (PHM) has delivered community-level maternal and child healthcare. The PHM is the “front line” health worker providing domiciliary care to women and children within the community (1). Each PHM has an established geographic area with a population ranging from 3,000 to 5,000 and maintains a register for all females of reproductive age and families with children less than 5 years (1). Residing in the community, PHMs make systematic home visits to provide care to pregnant women, post-partum women, newborns, and children under five (1,2). This includes breastfeeding counseling and support (1). The PHM is also a key link between the community and the institutional health care; she routinely assists at the Maternal and Child/Family Planning Health Services clinic and encourages those in her community to attend (2). All PHMs undertake the 40-hour WHO/UNICEF breastfeeding counseling training program, an established and comprehensive program that covers all necessary topics and includes hands-on clinical training (3,8).
In 2015, there were approximately 4,654 PHMs (5) serving the maximum 5,000 population stipulated. This falls short of covering all of Sri Lanka’s women, young children, and newborns but Sri Lanka is focused on having every mother and newborn under a PHM. In 2012, the WBTi report cited an improvement in Mother Support and Community Outreach, receiving full marks on the criteria, “all women have access to community-based support systems and services on infant and young child feeding” (6).
Today, Sri Lanka has one of the top breastfeeding outcomes in the world with 99% of children ever-breastfed and 82% breastfed exclusively in the first six months in 2016 (7).
The comprehensive, established WHO/UNICEF breastfeeding counseling training program takes a total of 40 hours and is divided into 33 sessions that use a variety of teaching methods including (8):
- Clinical practice
- Work in smaller groups with discussion
- Clinical practice (four 2-hour sessions)
Sessions are run by designated Ministry of Health trainers who have an extensive online guide as a resource (8). Breastfeeding knowledge/skills participants (PHMs) are trained are include:
- The importance of breastfeeding (Session 1), including proper infant feeding terms and the currently recommended practices over the dangers of artificial feeding.
- The local breastfeeding situation (Session 2)
- The physiology behind breastfeeding, including proper suckling (Session 3)
- How to assess and observe a proper breastfeed (Session 4 and 5)
- Non-verbal and verbal communication skills to communicate with breastfeeding mothers (Session 6).
- Health care practices (Session 8)
- Clinical practice (Session 9, 13)
- Positioning a baby at the breast (Session 10)
- How to build confidence and give support to breastfeeding mothers (Session 11).
- Breast conditions such as inverted nipples and solutions (Session 14)
- Refusal to breastfeed (Session 16)
- How to take a breastfeeding history (Session 17)
- Breast examination (Session 19)
- Low-birth weight and sick babies (Session 26)
- Increasing breastmilk and relactation (Session 27)
- Sustaining breastfeeding (Session 28)
- Changing practices (Session 30)
- Women’s nutrition, health and facility (Session 31)
- Women and work (Session 32)
After the learning sessions, there is often a session focused solely on exercises and examples.
The dual challenges of providing health care in rural settings and retention issues with PHMs led the government of Sri Lanka to encourage their development and work in remote environments through a number of strategies and incentives:
- PHMs from remote rural areas are given preference during recruitment.
- More than 90% of PHMs are posted in rural settings after the training and are required to serve for 5 years (9).
- Each province in the country has at least one regional Maternal Child Health training center.
- PHMs who remain in rural areas receive allowances, pension schemes, and subsidized mobile communication facilities (9).
have ongoing professional development opportunities irrespective of their
geographical posting (12).
Evidence of Implementation Strategy
A longitudinal study in Sri Lanka published in the Indian Journal of Pediatrics on the effect of training public health midwives on exclusive breastfeeding reported a highly significant increase in the percentage of mothers breastfeeding their infants for 6 months, as well as the median duration of exclusive breastfeeding (3) demonstrating that PHMs are an effective mode of health intervention; a 2014 UNICEF/WHO-sponsored webinar reports that Sri Lankan PHMs are particularly useful in helping mothers to continue to breastfeed when they return after their hospital birth: 91.4% report at least one postnatal home-visit by a PHM (4).
A 2015 report states there are approximately 4,654 PHMs (5) serving the maximum 5,000 population each. This falls short of covering all of Sri Lanka’s women, young children, and newborns but Sri Lanka is focused on having every mother and newborn under a PHM; a 2014 UNICEF/WHO-sponsored webinar reports that there are 329 health districts, further divided into 6,690 PHM areas (4). In 2012, the WBTi report on Sri Lanka cited an improvement in Mother Support and Community Outreach, receiving full marks on the criteria, “all women have access to community-based support systems and services on infant and young child feeding” (6). Today, Sri Lanka has one of the top breastfeeding outcomes in the world with 99% of children ever-breastfed and 82% breastfed exclusively in the first six months in 2016 (7). Furthermore, the WHO Global Health Workforce Alliance states that Sri Lankan government programs have ensured that health gaps in remote areas have been reduced and that trained PHMs are providing service in poor and remote areas of the country (9). PHMs have impacted health indices since their beginnings in the 1920s: the infant mortality rate has decreased from 263 in 1935 to now 8 per 1,000 live births in 2012 (9,10).
Cost and Cost-Effectiveness
The Center for Global Development praises the effectiveness and efficiency of public health midwives, claiming that they are part of the reason for good health outcomes despite the fact that Sri Lanka only spends 3% of its GNP on healthcare (9). This quote perfectly encapsulates their cost-effectiveness: “…because midwives can be trained and supported at relatively low cost, and have salaries that are far lower than medical doctors, the effective use of this cadre of health workers is one of the keys to saving mothers’ lives within a modest budget” (9).
Furthermore, the longitudinal study published in the Indian Journal of Pediatrics found that the “low-cost” training of public health midwives through the WHO/UNICEF 40-hour training program produced large increases in the percentage of mothers breastfeeding their infants for 6 months, as well as the median duration of
exclusive breastfeeding (3).
Perceptions and Experiences of Interested People
The WHO Global Health Workforce Alliance praises Sri Lanka for their PHM program who have bettered health in rural areas (9). In-country partners also look at the program favorably; Dr. A. Pubudu de Silva of Sri Lanka contributed statements to their report to stating, “Their services are immensely valued in rural settings where health resources are scarce” (9).
Furthermore, the fact that PHMs have remained in Sri Lanka since the beginning of the early 20th century speaks to their accepted and widely-established role in the community. They are considered a critical link between rural women and the health system, and it is widely maintained that they are key to sustaining the population’s confidence and satisfaction in the public health system that includes maternal benefits (11).
Benefits and Potential Damages and Risks
- It is essential that any training program use the most updated educational tools and breastfeeding and IYCF standards developed by WHO/UNICEF, such as the 40-hour training, as these standards represent optimal feeding practices and how to achieve them. Without these guiding documents and standards, improper practices could be promoted and taught, ultimately harming breastfeeding and the health of mothers and infants.
- The WHO/UNICEF 40-hour training course is taught at the discretion of the in-country supervisor/trainer so if the supervisor/trainer is remiss in their training, PHMs may not be fully educated and prepared to promote breastfeeding and support mothers.
- The 5-year bonding element of this program, combined with the benefits of further education, monetary incentives and career development offered, fosters a close connection to the community and alleviates problems with recruitment and retention of trained health workers (9). PHMs provide continuous care for a mother before, during, and after her pregnancy, then for her child, and is a huge benefit as they know the context of the mother’s life and her previous history.
Scaling Up Considerations
- It is important for community health workers, such as public health midwives, to be both from the community and selected/supported by the community in order to 1) have true insight on how to improve health on the ground and 2) to obtain trust. Without trust in the health worker, as well as comfort, people are less likely to take health recommendations.
- Sri Lanka has an excellent civil registration system, facilitating the assignment of public health midwives to cover the entire population, particularly rural ones (11). Civil registration systems should be regularly utilized and updated, ensuring that the population/areas with the worst health outcomes are being reached.
- It is crucial that
any training program is consistent across the country and is based on WHO/UNICEF documents and standards regarding IYCF, as these standards represent optimal feeding practices and how to achieve them.
Barriers to Implement
- With a large cadre of public health midwives, it is possible to have challenges of supervision and accountability. It is important that a monitoring/supervision program is in place to ensure quality health care is delivered in the community by the community health workers.
- While incredibly cost-effective as previously discussed, public health midwives do require an income; the government must allocate a certain sector of its health budget to recruiting and paying for training and salaries.
- Public health midwives work to increase health equity by reaching out to rural populations in their own community. In addition, for the Sri Lankan mothers that are illiterate, they practice behavior change communication (4). It is crucial that a country focuses these community health worker resources to improve unequal health outcomes in their country as in Sri Lanka.
1. Family Health Bureau, Ministry of Health, Sri Lanka. (2011). National Strategic Plan: Maternal and Newborn Health (2012-2016). Retrieved from http://www.fhb.health.gov.lk/web/index.php?option=com_phocadownload&view=category&id=29&Itemid=150&lang=en
2. Dr. A.T.P.L Abeykoon. (2010). Reproductive Health and Family Planning Programme in Sri Lanka: Achievements and Challenges. UNFPA. Retrieved from http://www.icomp.org.my/new/uploads/fpconsultation/srilanka.pdf
3. Agampodi, S. B., & Agampodi, T. C. (2008). Effect of Low Cost Public Health Staff Training on Exclusive Breastfeeding. The Indian Journal of Pediatrics, 75(11), 1115-1119. Retrieved from http://link.springer.com/article/10.1007/s12098-008-0185-4
4. Chandradasa, L., & Rowel, D. (2014). National Programme to Protect, Promote, and Support Breastfeeding in Sri Lanka. Paper presented at the Experience with Protection of Breastfeeding in SUN countries in Asia, Webinar. http://scalingupnutrition.org/wp-content/uploads/2014/08/140814-Breastfeeding-Webinar.pdf
5. Hiran. (2015). Training Course and Midwives Jobs in Ministry of Health. Student Sri Lanka: Educational Network. Retrieved from http://studentlanka.com/2015/06/27/midwife-training-course-in-sri-lanka-by-ministry-of-health/
6. World Breastfeeding Trends Initiative, IBFAN. (2012). WBTi Sri Lanka Report. Retrieved from http://www.worldbreastfeedingtrends.org/GenerateReports/report/WBTi-Srilanka-2012.pdf
7. Sri Lanka Department of Census and Statistics. (2017). Sri Lanka Demographic and Health Survey 2016. Retrieved from http://www.aidsdatahub.org/sites/default/files/publication/SriLanka_DHS_2016.pdf
8. WHO/UNICEF. (2011). Breastfeeding Counselling: A Training Course. Retrieved from http://www.who.int/maternal_child_adolescent/documents/pdfs/bc_trainers_guide.pdf
9. Dr. Pudubu De Silva. (2011). The Contribution of Public Health Midwives to the Better Health in Rural Communities in Sri Lanka. WHO: Global Health Workforce Alliance. Retrieved from http://www.who.int/workforcealliance/forum/2011/hrhawardscs28/en/
10. UNICEF. (2012). Sri Lanka Statistics. Retrieved from https://www.unicef.org/infobycountry/sri_lanka_statistics.html
11. Center for Global Development. (2004). Saving Mothers’ Lives in Sri Lanka. Retrieved from https://www.cgdev.org/doc/millions/MS_case_6.pdf
12. Rosskam E1, Pariyo G, Hounton S, Aiga H. (2012). Increasing skilled birth attendance through midwifery workforce management. Int J Health Planning and Management. Retrieved from https://onlinelibrary.wiley.com/doi/full/10.1002/hpm.2131