SKILLED CARE DURING CHILDBIRTH - Family Care International

SKILLED CARE 

DURING CHILDBIRTH 

COUNTRY PROFILES >> 

TUNISIA 

SRI LANKA 

MALAYSIA 

BOTSWANA 

>> Saving Women’s Lives, Improving Newborn Health

Skilled Care During Childbirth: Country Profiles 

Table of Contents 

1 Introduction 

22 Tunisia 

16 Sri Lanka 

10 Malaysia 

4 Botswana 

Prepared by Rahna Rizzuto and Shafia Rashid 

Design by Doris Halle Design, NYC 

© Family Care International, Inc. 2002 

Not-for-profit organisations may reproduce the contents of this publication freely, 

as long as it is not used for commercial purposes. FCI would appreciate acknowledgements 

and copies of any reproductions.

Skilled Care During Childbirth: Country Profiles Introduction 

The Scope of the Problem 

Globally, over half a million women die from the complications of pregnancy and childbirth each 

year—with nearly all of these deaths (99 percent) occurring in the developing world. For every woman 

who dies, 30 to 50 women suffer injury, infection, and/or disease. 

More than a decade of research has shown that most maternal deaths and disabilities can be prevented 

if women have access to good quality health services during pregnancy and childbirth. However, many 

women do not receive such care: just half of all deliveries in developing countries take place with a 

skilled attendant, with rates in some countries as low as 8%. In addition to the lack of good quality, 

accessible, safe motherhood services, a range of social, economic, and cultural factors contribute to 

women’s poor maternal health—these include women’s disproportionate poverty, unequal access to 

education, low social status, and lack of income and employment opportunities. 

While there has been limited progress at the global level in reducing maternal mortality and morbidity, 

a number of low- and middle-income countries have achieved measurable success in reducing maternal 

deaths. The four countries profiled in this report (Botswana, Malaysia, Sri Lanka, and Tunisia) 

demonstrate that maternal mortality can be reduced if political will and resources are mobilised 

around women’s health and empowerment. 

Ensuring Skilled Care During Childbirth 

In 1987, when the global Safe Motherhood Initiative was launched, representatives from a range of 

international agencies and governments committed themselves to the goal of reducing maternal 

deaths. Since then, much has been learned about which interventions are most effective, and the focus 

has shifted from predicting obstetric complications to managing them appropriately. Experts agree that 

one of the most essential interventions is to ensure that all women are cared for by a professional 

health worker (midwife, nurse, or doctor) with midwifery skills during the most dangerous period—during 

and immediately after childbirth. Skilled attendants, when supported by a functioning referral system, 

can fulfill the following critical functions: 

• Ensure that all deliveries are conducted hygienically and according to accepted medical practices, 

thereby preventing complications that are caused or exacerbated by poor care; 

• Identify complications promptly and manage them appropriately—either by treating or referring 

women to a higher level of care; 

• Provide high-quality, culturally-appropriate, and considerate care, ensuring necessary follow-up and 

linkages with other services, including antenatal and postpartum care, as well as family planning, 

postabortion care, and treatment of sexually transmitted infections. 

In October 1999, the Safe Motherhood Inter-Agency Group (IAG) launched a multi-step strategy to 

assess the importance and potential impact of skilled care during childbirth as a means of reducing 

maternal mortality. Key components of this strategy included: 

• The preparation of a comprehensive paper reviewing the evidence on skilled care during childbirth; 

• A Technical Consultation, held in April 2000 at World Health Organization (WHO) Headquarters in 

Geneva, which gathered leading experts in the field of safe motherhood to assess the evidence on 

skilled care during childbirth, and to develop key strategies for implementing the intervention in a 

range of developing country settings; 

• A set of informational materials relating to the critical components of skilled care during childbirth. 

These materials include: a policy brief, an information booklet, and country profiles on skilled care 

during childbirth (see country profiles in this document); 

1


• An international conference “Saving Lives: Skilled Attendance at Childbirth” held in November, 

2000 in Tunisia. The aim of the conference was to facilitate the development of national-level action 

plans on skilled care during childbirth in selected countries in sub-Saharan Africa and South Asia. 

In addition, four developing countries (Botswana, Malaysia, Sri Lanka, and Tunisia) shared strategies 

and lessons learned in decreasing maternal mortality and increasing the coverage of skilled attendants. 

In preparation for the Tunisia conference, the four “low maternal mortality” countries developed 

case studies on their country’s experiences in implementing skilled care during childbirth as a key 

intervention in reducing maternal mortality. Following the conference, the profiles were expanded to 

serve as illustrative examples of the national-level programmatic strategies that led to high coverage 

of skilled care during childbirth (see country profiles highlighted in this document). 

Ingredients of Success 

Botswana, Malaysia, Sri Lanka, and Tunisia have all achieved measurable success in improving skilled 

care and reducing maternal mortality. In these four countries, coverage of skilled care increased 

significantly—with rates currently exceeding 90%. In the countries where data is available, maternal 

mortality ratios dramatically declined from several thousand maternal deaths per 100,000 live births 

to 20–60 over a span of 30–50 years. 

These experiences illustrate that middle- and low-income settings can achieve near-universal coverage 

of skilled care during childbirth if political will and resources are mobilised to improve women’s 

status and their access to basic health services. 

Employing a multi-faceted approach, these countries implemented a range of complementary, 

mutually-reinforcing strategies, with the goal of improving maternal health and saving women’s lives: 

• Mobilising political commitment at the highest level: In Botswana, a series of conferences and 

meetings during the 1990s galvanised political commitment to safe motherhood among high-level 

government officials, including the President, Members of Parliament, and the House of Chiefs. 

Subsequently, a national safe motherhood programme, with reduction of maternal mortality as a key 

goal, was established. 

• Investing in social and economic development—such as female literacy and education, poverty 

reduction, and basic human rights—with particular emphasis on the poor and vulnerable: Sri Lanka 

has demonstrated consistent, long-term support to ensuring the social welfare of its citizens. Since 

1945, free education from primary- to university-level has been made available on an equal basis 

for both men and women—resulting in a population with an overall literacy rate of 91%. Health care 

is also provided free of charge in an effort to ensure access for poor and underserved groups. All 

citizens enjoy basic human rights and political freedoms, which have been enshrined in the national 

constitution and several charters. 

• Professonalising midwifery care: In Malaysia and Tunisia, the Government invested in the expansion 

of community-based midwifery personnel who were trained and legally registered, based on a 

defined set of competencies. These midwives formed the backbone of each country’s rural health 

services system. 

• Strengthening health systems and promoting access to care in health facilities: Beginning in the 

1950s, Malaysia established a strong primary health care infrastructure—an extensive network of 

rural health facilities providing maternal health services was built; and skilled providers were trained 

and deployed to staff these facilities. The Government placed high priority on providing free health 

care and ensuring that health facilities were equitably distributed in an effort to reach the rural poor. 

2


• Improving access to emergency obstetric services and establishing referral and transport systems: 

In Sri Lanka, the establishment of a network of primary health care centres was supported by the 

development of specialised obstetric services to treat emergency complications. Subsidised transport 

systems were established between primary and referral facilities, and from 1960–80, the number of 

rural facilities providing basic and comprehensive emergency obstetric care increased dramatically. 

• Ensuring access to family planning services: In 1965, Tunisia implemented a national family 

planning programme as part of its basic health care system. The Government partnered with 

non-governmental organisations (NGOs), religious leaders, and the media in a social mobilisation 

campaign to promote family planning. Midwives became the key cadres of health providers providing 

family planning and maternal care. 

• Improving the quality of available services through effective monitoring systems (e.g. maternal 

death audits): Developed and refined over a period of 40 years, Malaysia’s system for investigating 

the cause of maternal deaths provides a mechanism for continuously improving the quality of existing 

health services—by highlighting reasons for sub-standard care, assessing the quality of antenatal and 

obstetric care, and identifying improvements in maternal health programmes. 

• Encouraging community involvement and investment in maternal health care: Botswana has 

developed a range of information, education, and communication (IEC) activities to raise awareness 

about safe motherhood and encourage the use of services. These include printed materials, radio, and 

health education sessions. 

What These Profiles Contain 

Each of the country profiles includes: basic socio-demographic information; the policy and supporting 

framework for reducing maternal mortality and improving skilled care; the main interventions that 

were or are being implemented that relate to the goal of increasing skilled care during childbirth; and 

a box summarising the main ingredients of each country’s success story. 

These profiles are intended to provide a descriptive overview of the process in the four countries that 

led to a reduction in maternal mortality and improvements in skilled care during childbirth. Adapted 

from reports prepared by the “low maternal mortality” teams ✝ and supplemented from published and 

unpublished literature, the primary aim of these profiles is to provide concrete examples of countries 

that have been successful in improving maternal health through increased coverage of skilled care 

during childbirth. As such, the profiles complement the other components of the Skilled Care During 

Childbirth Information Kit, in particular the Skilled Care During Childbirth Information Booklet and 

Policy Brief, which provide policy and programmatic guidelines for individuals and organisations 

working to improve coverage of skilled care. 

The country profiles are designed for programme planners and managers working in governments, 

NGOs, and professional associations; and representatives of funding agencies, technical assistance, and 

research organisations active in the field. In addition, these profiles may be useful to policy-makers 

and members of the media interested in health and development issues. 

✝ The representatives of the low maternal mortality country teams included: Mabel Magowe and Lucy Sejo Maribe (Botswana); 

Drs. Raj Karim, Ravindran Jegasothy, and Mahani Yusoff (Malaysia); Dr. Anoma Jayathilaka and Daya Kumurage (Sri Lanka); 

and Dr. Mounira Garbouj and Atf Gherissi (Tunisia). 

3

Skilled Care During Childbirth: Country Profiles Botswana 

TUNISIA 

SRI LANKA 

MALAYSIA 

Botswana 

Introduction 

Population size (millions) (1) 1.6 

Population distribution (%) (1) 

Rural 50 

Urban 50 

Adult illiteracy rate (%) (1) 

Male 25 

Female 20 

GDP (US$ millions) (1) 5,285 

% GDP spent on health* 2.5 

Total fertility rate (1) 4.0 

Contraceptive prevalence (%) (2) 33 

National maternal mortality ratio ✝ 480 

Skilled care during childbirth 

requires the presence of a 

doctor or midwife, or a nurse 

with midwifery skills, who is 

trained to manage normal 

labour and delivery, recognise 

complications, and offer 

either emergency treatment 

or immediate referral to health 

centres for more advanced 

care. Skilled care also 

requires functioning referral 

and transport systems and 

necessary drugs, equipment, 

and supplies. 

Botswana is a landlocked country in the centre of Southern Africa, bordered by Namibia, South Africa, 

Zambia, and Zimbabwe. Its population is small but rapidly growing, with a trend toward urbanisation. 

Botswana is also youthful: in 2000, approximately 42% of its citizens were under the age of 15. (1) 

At independence in 1966, Botswana was one of the poorest countries in Africa with Gross National 

Product (GNP) per capita of about US$12. However, the discovery of diamonds, coupled with prudent 

economic management and political stability, dramatically increased the GNP per capita to US$3,300 

by the year 2000. 

Trends in health and development: Government spending on the public sector exceeds 30% of Gross 

Domestic Product (GDP), of which 8% is spent on health. (3) This investment in infrastructure and 

services has led to tremendous improvements in a number of health and social indicators, including 

the under-five mortality rate, access to clean drinking water, and life expectancy at birth. Botswana’s 

total fertility rate experienced a steady decline, from 6.1 children per woman in 1980 to 4.0 children 

in 2000. (1) In education, Botswana has achieved significant improvements in female primary 

education enrolment and adult literacy levels. 

Despite these achievements in health and development, Botswana is now struggling with one of the 

highest HIV infection rates in the world. An estimated 35% of the adult population is HIV infected, ✦ 

and in 1998 approximately 35% of pregnant women were HIV positive. + 

Maternal health: In 1973, the Ministry of Health (MOH) formally established a national Maternal and 

Child Health/Family Planning (MCH/FP) programme, coordinated by the MCH/FP Unit in the MOH. As 

part of the national programme, the Government developed a network of health care infrastructure 

throughout the country for provision of integrated MCH/FP services (see section on Developing Health 

Services Infrastructure). 

Although antenatal, delivery, and postnatal services were made available to women in the 1970s, 

Botswana’s maternal health situation did not improve. In 1984, one-third of women gave birth without 

a skilled attendant present during childbirth and just over half sought postpartum care. In 1993, a 

study of maternal deaths found that haemorrhage, sepsis, and obstructed labour accounted for almost 

* This reflects public health expenditures, as percentage of GDP, and consist of recurrent and capital spending from government 

budgets and social health insurance funds. 

✝ The maternal mortality ratio or MMR is the number of women who die during pregnancy or childbirth per 100,000 live births. 

This estimate is from the publication, Maternal Mortality in 1995: Estimates developed by WHO, UNICEF, UNFPA, and is assumed 

to be high given the relatively high coverage and good quality services of Botswana’s health system. The government conducted 

a pilot study to test data collection tools for an upcoming study that will produce a revised estimate of maternal mortality and 

provide data on the leading causes of maternal mortality and circumstances surrounding maternal deaths. 

✦ 1999. 

+ 1998, sentinel surveillance. 

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60% of maternal deaths (see Figure 1). (4) In addition, 18% of maternal deaths were among teenagers 

between 15 to 19 years, and sepsis (mainly due to unsafe abortion) accounted for 33% of these deaths. 

FIGURE 1 > 

CAUSES OF MATERNAL MORTALITY 

Botswana’s response has been a focused, carefully planned safe motherhood programme (see next 

section), which aims to significantly improve the quality and coverage of maternal health care. The 

1996 Botswana Family Health Survey indicates that use of maternal health services has improved (see 

Figure 2): coverage of antenatal care (ANC) has increased to 94%; the percentage of assisted deliveries 

increased to 87%; and postpartum coverage to 85%. 

16% 

17% 

9% 

28% 

30% 

FIGURE 2 > 

SELECTED INDICATORS FROM THREE BOTSWANA FAMILY HEALTH SURVEYS 

100% 

80% 

60% 

40% 

1984 

Haemorrhage 

Sepsis 

Hypertension 

Indirect causes 

Obstructed labour 

20% 

0% 

23 24 17 23 33 42 90 92 94 66 78 87 54 71 85 

Teenage 

Pregnancy 

Contraceptive 

Prevalence 

ANC 

Attendance 

Supervised 

Deliveries 

Postnatal Care 

*ANC attendance is at least 4–5 times during pregnancy, starting before 24 weeks. 

1988 

1996 

Laws, Policies, and Related Programmes 

Laying the groundwork: In October 1990, a high-level delegation led by the current President, 

Mr. Festus Mogae, attended the Southern African Development Cooperation (SADCC) Safe Motherhood 

Conference in Zimbabwe. Following the conference, a series of activities were undertaken to raise 

awareness, involve local organisations, and gather specific information about the problem so that a 

national plan could be developed (see sidebar on next page). 

The National Programme: Safe motherhood is an integral component of the broader health 

programme. The MCH/FP Unit in the Family Health Division is responsible for coordinating the safe 

motherhood programme using a broad-based, multi-sectoral approach to address the wider range 

of problems that increase maternal morbidity and mortality. The programme’s overall goals include: (5) 

• Improving the quality, efficiency, and effectiveness of MCH/FP services; 

• Increasing the accessibility of services; 

• Strengthening and developing IEC and data collection systems; 

• Improving organisation and management of MCH/FP services; and 

• Reducing the incidence and consequences of unsafe induced abortion.* 

The supporting policy framework: As part of its holistic approach to women’s health and development, 

the Government has formulated a series of policies that bolster safe motherhood goals, including: 

• Family Planning Policy Guidelines and Services Standards (1987) confirm the right of all individuals 

to reproductive health services based on choice; and specify the types of services to be provided, the 

cadres of staff to provide these services, and the groups to receive them. These guidelines were 

revised in 1994 to remove medical barriers to family planning. 

• National Health Policy (1995) recommends public and private sector partnership in matters of health 

and attention to high-risk groups. 

* Abortion in Botswana is permitted in the following circumstances: if the pregnancy could endanger the pregnant woman’s life; 

if the pregnancy is a result of rape case or incest; or if a serious disability of the foetus can be determined. 

5


SAFE MOTHERHOOD: 

STEP-BY-STEP 

In November 1990, a 

conference for the Members 

of Parliament and the House 

of Chiefs was held in 

Gaborone to publicise the 

issue and mobilise political 

support. At the same time, 

the Family Health Division 

of the Ministry of Health 

organised a workshop on 

communication strategies 

for safe motherhood 

and HIV/AIDS prevention. 

In 1992, a multisectoral 

Safe Motherhood Task Force 

was established to help 

develop, implement, and 

monitor a national safe 

motherhood programme. 

The Task Force meets regularly 

and includes representatives 

from the government, 

NGOs, and training institutions, 

among others. 

In 1993, two key studies 

were conducted to help 

formulate a national plan: 

> Safe Motherhood in 

Botswana: Situation Analysis 

which reviewed available 

information on the extent of 

maternal mortality and its 

causes and consequences, as 

well as other women’s health 

issues, and recommended 

corrective strategies; 

> Determinants of Maternal 

Mortality in Botswana: 

An institutional, household and 

community perspective, 

conducted by the MCH/FP 

Unit and UNICEF, which 

examined maternal mortality 

records between 1990–1992 

to identify direct and 

indirect causes of maternal 

mortality. 

• Policy on Women and Development (1995) advocates adolescent-friendly reproductive health 

services in the context of women and development. 

• National Population Policy (1996) states that the individual is central to development efforts and that 

the goal of health and social services is “improved quality of life and living standards of all people 

in Botswana.” 

Critical Interventions to Increase Skilled Care During Childbirth 

A series of focused interventions have contributed to Botswana’s success in lowering maternal 

mortality and increasing rates of skilled care during childbirth: 

Developing Health Services Infrastructure 

Botswana has developed a well-distributed health services network such that the majority of the 

population (86%) lives within 15 km of a health facility. The health care system is structured along 

the following lines: 

• District/referral hospitals (1:100,000–350,000 population) have an operating theatre to perform 

C-sections, blood transfusions, and other advanced services. 

• Primary hospitals (1:12,000–35,000 population) are found in remote, low-density areas and staffed 

by medical officers and registered nurse-midwives. These facilities provide the same advanced 

emergency services available in district hospitals. 

• Health clinics (1:5,000–10,000 population) are staffed by registered nurses and family welfare 

educators (FWEs), and provide MCH services, treatment and diagnosis of common diseases, and 

simple laboratory tests. 

• Health posts emphasise preventive care (basic MCH/FP services, environmental health, first aid, and 

diagnosis and treatment of common diseases). Health posts are staffed primarily by FWEs, although 

some have nurses on staff. Each village with a population of 500–1,000 has a health post. 

• Mobile clinics reach remote populations on a monthly schedule, and are staffed by registered nurses 

or midwives. The mobile clinics provide limited primary health services (simple curative and basic 

MCH services). 

Health posts are open from 7:30AM to 4:30PM five days a week, while health clinics, primary hospitals, 

and district/referral facilities are open around the clock. 

Access to facilities and services varies and remains problematic in remote areas (such as the western, 

northern and northwestern parts of the country), though many facilities have been upgraded and new 

health units are being developed as an ongoing government project. Since 1996, there has been greater 

emphasis on increasing the number of health clinics and posts with trained nurses and midwives who 

provide basic maternal health services in communities (see Figure 3), and improving links to referral 

levels for emergency care. 

FIGURE 3 > 

NUMBER OF HEALTH FACILITIES BY TYPE (HEALTH STATISTICS REPORT 1997) 

800 

600 

720 710 

400 

253 273 

133 146 

200 

1996/1997 

77 86 

63 51 

16 16 14 17 

0 2000 

District 

Hospital 

Primary 

Hospital 

Clinic 

with 

Maternity 

Clinic 

without 

Maternity 

Health 

Post with 

Nurse 

Health 

Post 

without 

Nurse 

Mobile 

Stops 

6


Drugs are provided under the rules of the Drugs Regulatory Committee, and are generally available, 

although some shortages exist, mainly in very remote areas. Equipment and supplies for basic maternal 

health services are also generally available (6) , though distribution and logistical problems do result in 

the frequent unavailability of such small yet necessary items as the angle poise lamp or blood 

pressure machines. Emerging programmes (i.e. the Programme for the Prevention of Mother-to-Child 

Transmission of HIV) have helped secure more and better equipment (i.e., silicon vacuum cups have 

replaced metal cups for vacuum extraction). 

Establishing Transport & Referral Systems 

A referral system links health posts with health clinics and hospitals. Protocols have been developed that 

allow a health provider to send a patient directly to a facility where specific services can be obtained 

(for example, in an emergency, a woman may be referred directly from a health post to a 

district hospital). For referral, most health facilities have a radio and receiver, at least one vehicle, and 

a telephone. In cases where the only vehicle is unavailable, paid transport from private sources will 

be arranged. 

Investing in Health Personnel 

Botswana has invested in improving the training and distribution of key cadres of health providers 

providing maternity services. Nurses and midwives form the backbone of the health care system 

and are the main providers of maternal health care. Most nurses provide routine antenatal and family 

planning services; those with midwifery skills provide the more complex family planning, antenatal, 

delivery, and postpartum care. Midwives trained in life-saving skills attend obstetric emergencies and 

co-manage obstetric medical/surgical complications with doctors. 

In addition to doctors, nurses, and midwives, FWEs play a role in providing maternal health services. 

They are primary school graduates who educate and motivate the community on issues related to safe 

motherhood—encouraging women to deliver in an institutional setting, and providing counselling and 

health education to communities living within a five kilometre radius of health posts. 

Training programmes: Over the last ten years, Botswana has improved and expanded training of 

health personnel providing midwifery care. In 1993, the National Task Force for Safe Motherhood 

commissioned a small expert group to review training for health providers. This group reviewed existing 

standards, protocols, and training manuals, and made the following improvements: 

• Pre-service midwifery training: The midwifery curriculum was increased to an 18-month programme 

with greater emphasis on antenatal care, labour, and delivery. It emphasised prevention and care 

strategies to improve maternal well-being. New content was added on the underlying causes of poor 

maternal health; safety and care during pregnancy, childbirth, and post-partum; and emergency care. 

• Since 1994, 562 midwives have gone through the training programme. Plans to increase the number 

of midwives to meet national targets and service requirements are underway. One obstacle to meeting 

this goal is the limited capacity of training institutions. Currently, there are only three midwifery 

training schools, as opposed to eight registered nurse training schools. Additional training sites for 

midwives are planned in the Southeast region of the country. 

• Other reproductive health training: Training for midwives in family planning has also been 

strengthened under the Botswana Population Sector Assistance Programme. Emphasis is placed on 

clinical skills and counselling, integration of STI/HIV/AIDS into family planning, and prevention, 

screening, and management of sexually transmitted infections. 

• In-service life-saving skills education: A six-week curriculum on high-risk pregnancies and life-saving 

skills has also been introduced for midwives and doctors. Skills include: procedures for completion 

7


of delivery (such as evacuation of the uterus for incomplete, inevitable abortion; vacuum extraction; 

and manual removal of retained placenta), repair of third degree lacerations, breech extraction, and 

newborn resuscitation. In addition, doctors receive training in the repair of fourth degree lacerations 

and emergency caesarean section. Between 1994–1995, 68 midwives and 12 medical officers were 

trained in this programme. 

Competency-based training is provided to all existing staff to ensure that they have the necessary 

skills in: 

• Counselling and communicating with patients; 

• General programme management; 

• Treatment of high-risk and complicated maternity cases; 

• New developments in contraceptive technology; and 

• Management of STIs, particularly AIDS. 

Supervision: The senior staff member within each unit is responsible for the daily supervision of 

midwives. The MCH/FP Unit in the MOH conducts yearly supervisory visits at the district level to 

monitor progress in implementation of programmes. 

Despite considerable improvements, Botswana suffers from a shortage of qualified health personnel. 

The HIV/AIDS situation has further exacerbated the already inadequate levels of personnel. Specialists 

such as obstetricians, paediatricians, and surgeons are only found in the country’s two referral hospitals. 

Since Botswana does not have a medical training school for doctors, 85% of the doctors employed by 

the Government are expatriates. 

Nurses and midwives are also in critically short supply (see Table 1). In 1997, there were only 

41.3 nurses (including midwives, registered nurses without midwifery skills, and enrolled nurses) per 

10,000 population. 

TABLE 1 > 

RATIO OF HEALTH PERSONNEL (PER 10,000 PEOPLE) 

1991 

1993 

1996 

1997 

Doctors 

2.3 

2.3 

4.0 

4.2 

Nurses 

(includes midwives) 

22.3 

23.1 

39.6 

41.3 

Family Welfare Educators 

(FWEs) 

5.0 

5.0 

7.3 

7.5 

Total 

29.6 

30.4 

50.9 

53.0 

Establishing Standards and Protocols 

Standards and protocols for routine maternity care and the management of high-risk and emergency 

services have been reviewed and improved. Protocols have been developed for general care, to specify 

which services will be provided at each type of facility, and for referral. These tools are used to guide 

in-service and pre-service training for midwives and other health providers. 

The obstetric record, a tool for recording the progress of pregnancy, labour, delivery and postpartum 

care, was revised in 1995. The tool provides a mechanism for monitoring women during antenatal 

care, delivery (it includes a partograph), and postnatal care. A woman retains this record throughout 

pregnancy, and she is free to visit any health facility for antenatal, delivery, and postnatal services. 

8


Community Outreach 

An IEC strategy was developed during the 1990s to raise awareness within communities and to 

encourage the use of services. The strategy included materials such as posters, wall charts, and 

pamphlets, as well as a video in local languages and English, with an accompanying booklet for more 

information. Radio is also used extensively. Health talks are given every morning at the clinics on a 

range of topics including the need for skilled care during childbirth. However, monitoring shows that 

most facilities still do not have these materials. (6) Where they are available, the nurses and midwives 

do not use them adequately as reference. 

Monitoring and Evaluating the Safe Motherhood Programme 

Monitoring and evaluation is an integral part of the national safe motherhood programme. While the 

programme has not been evaluated as an entity, the Family Health Division monitors and evaluates 

its progress on an on-going basis through support visits, and conducts more targeted research as the 

need arises. It also releases yearly statistical reports, which are used to help evaluate the performance 

of its programmes. 

In 1996, two studies helped to highlight the strengths and weaknesses of the evolving safe motherhood 

programme. The Situation Analysis of the Maternal and Child and Family Planning Programme and 

the Botswana Family Health Survey identified a number of areas for improvement (such as inadequacies 

in training, staffing, and equipment, and access to care in remote areas), along with strategies to 

address them. 

Public Expenditure on Health 

As Table 2 indicates, government expenditure in the public sector has generally exceeded 35% of GDP. 

Since 1995, government expenditures on health have almost doubled (from US$45 million to US$89 

million in 1999). (7) With the advent of HIV/AIDS, however, the government has had to reprogramme 

funds to address the epidemic, reducing the already inadequate levels of funding for current 

programmes such as life-saving skills training. 

For additional information about 

Botswana’s safe motherhood programme, contact: 

Mrs. Lucy Maribe 

Principal Health Officer, MCH/FP Division 

Ministry of Health 

P.O. Box 992 

Family Health Division 

Gaborone Botswana 

Tel: 267 353 561 

Fax: 267 302 092 

E-mail: lmaribe@gov.bw 

TABLE 2 > 

PUBLIC AND HEALTH EXPENDITURES 

(SELECTED YEARS) 

YEAR 

1981 

1991 

1994 

1996 

2000 

Public 

Expenditure 

(% of GDP) 

37.9 

43.2 

34.1 

35.5 

39.6 

THE KEYS TO BOTSWANA’S 

SUCCESS ARE: 

> A carefully planned national 

strategy based on research and 

pronounced political support. 

> Collaboration and integration 

at all levels. 

> Significant resources invested 

in health, in real value and 

as percentage of Government 

spending. 

> Trained personnel for management 

of obstetric emergencies. 

> Improved access to health 

facilities and services. 

> Integrated MCH/FP services 

(supermarket approach). 

> Availability of midwives at all 

levels of the health care system. 

> Good referral system from 

the lowest level facility to the 

highest level. 

> Availability of emergency 

obstetric services in hospitals. 

Health Share 

of Public 

Expenditure 

5.2 

5.1 

6.1 

6.0 

8.0 

Sources 

1 World Development Indicators 2002. World Bank, Washington DC, 2002. 

2 1988, any method. World Contraceptive Use 2001. United Nations Population Division. Department of Social and Economic Affairs. New York, May, 2002. 

3 2000; Common Country Assessment (CCA) 2001. 

4 L. Owuor-Omondi, et al., Determinants of Maternal Mortality in Botswana: An Institutional, Household and Community Perspective, Ministry of Health, 1993. 

5 Safe Motherhood Task Force, Safe Motherhood in Botswana: A Situation Analysis, 1992. 

6 B. Baakile, L. Maribe, et al. A Situational Analysis of the Maternal and Child and Family Planning. Africa Project II, Population Council, Nairobi, Kenya, 1996. 

7 Statistical Bulletin, Central Statistics Office, Botswana Ministry of Finance and Development Planning, 1999. 

9

Skilled Care During Childbirth: Country Profiles Malaysia 

TUNISIA 

SRI LANKA 

Malaysia 

BOTSWANA 

Introduction 



Rural 43 

Urban 57 


Male 9 

Female 17 


% GDP spent on health 1.4 



National maternal 

mortality ratio (3) 39 


requires the presence of a doctor 

or midwife, or a nurse with 

midwifery skills, who is trained 

to manage normal labour and 

delivery, recognise complications, 

and offer either emergency 

treatment or immediate referral 

to health centres for more 

advanced care. Skilled care 

also requires functioning referral 



and supplies. 

Malaysia lies in the heart of Southeast Asia. It is an extremely diverse country with numerous 

ethnic groups in 13 states and 2 federal territories. It has a steadily growing population, with a trend 

toward urbanisation. 

Since its independence in 1957, Malaysia has made a strong commitment to health and development, 

especially in the area of women’s health and safe motherhood. Malaysia has moved from a fragmented, 

rudimentary health care system, especially in rural areas, to an extensive infrastructure that provides 

comprehensive health care to more than 90% of its population, with many services (antenatal care, 

immunisations) free of charge. 

As a result of this investment, life expectancy in Malaysia has risen to 73 years for women and 70 for 

men (from less than 50 years in 1957); infant mortality has dropped from 30 deaths per 1,000 live 

births in 1980 to 8 in 2000; and the total fertility rate declined from 6.7 in 1957 to 3.0 in 2000. 

Malaysia’s commitment to women extends into all areas of development: women have equal rights in 

education, voting, and employment. Over the last decade, more girls than boys have enrolled in tertiary 

education. Approximately 48% of women are in the paid workforce, and women hold senior 

government positions. 

Maternal health: Maternal mortality has fallen dramatically in Malaysia over a period of 60 years, 

from 1,100 per 100,000 live births in 1933 to 39 deaths per 100,000 live births in 1995 (3,4) (see Figure 1). 

A central factor in this decline has been high-level government commitment to ensuring that 

quality maternal health services are accessible to the vast majority of the population, particularly in 

underserved and rural areas. 

An extensive community-based programme provides primary health care services, including 

immunisations, antenatal care, and delivery services, to the rural population. Skilled birth attendants 

(primarily midwives) are the first point of contact for maternity care through home visits, and in 

village health clinics and hospitals. (4) 

Between 1949–1997, the percentage of live births attended by a skilled health provider increased 

dramatically—from approximately 30% to over 95%. (4) During this period, government midwives 

increasingly conducted home deliveries and demand for childbirth in public sector hospitals expanded 

considerably. In 1995, of the 98% of births attended by skilled health providers, 66% were delivered 

in government hospitals, 20% in private hospitals or maternity homes, and 12% at home. (5) 

Currently, most maternal deaths are due to: postpartum haemorrhage, severe anaemia, hypertensive 

disorders of pregnancy, puerperal sepsis, and obstructed labour. Abortion is permitted to save the life 

of the pregnant woman and to preserve her physical or mental health; deaths from unsafe abortion 

account for less than 1% of total maternal deaths. (6) 

10


FIGURE 1 > 

MATERNAL MORTALITY TREND IN PENINSULAR MALAYSIA (1933–1995) 

1200 

MATERNAL DEATHS PER 

100,000 LIVE BIRTHS 

1000 

800 

600 

400 

200 

0 

1930 1940 1950 1960 1970 1980 1990 

YEAR 


Laws and policies supportive of maternal health in general and skilled care during childbirth in 

particular have been in place since the colonial period. After independence, the national government 

accorded high priority to the goal of maternal mortality reduction by investing in a range of 

programmes and strategies to improve MCH (see next section). 

Professionalisation of midwifery: In 1932, legislation was introduced to regulate the practice of 

midwifery. Midwives as a cadre of health personnel were trained, certified, and legally registered based 

on demonstrated competency in a defined list of clinical skills. They were deployed as front-line 

community health workers to provide maternal care (see section Investing in Midwifery Personnel for 

information on training and supervision of midwifery personnel). (4) 

Registration of Births and Deaths: A system for the registration of births and deaths was introduced 

in the colonial period; in the 1950s a national civil registration system, based on the issuance of a 

personal identity card, provided a means of obtaining reliable vital statistics. 

Investments in Women: Several laws and policies that aim to improve women’s economic and social 

status, and foster equal access to educational opportunities, have provided an enabling environment 

for expanding access to skilled care: 

• National Women’s Policy ensures equal opportunities for education, employment, and access to basic 

health and social services; prevents discriminatory policies and practises; and empowers women. 

• Education Policy provides equal access for girls (and boys) to free primary and secondary education, 

and assistance with school uniforms, textbooks, and school meals for the poor. 

• Rural Development Policy provides basic infrastructure, including housing, schools, clinics, roads, 

transport, communication, and poverty alleviation programmes. 

• Vision 2020, a forward-looking policy, includes reduction of mortality within its nine priority actions 

for a caring society. 

Emphasis on Poverty Reduction: Malaysia’s efforts to improve maternal health and increase access to 

skilled care were implemented within the context of a poverty alleviation strategy that emphasised 

reducing gaps between the rich and poor. This has ensured that disadvantaged groups, particularly the 

rural poor, benefit more proportionately from health and social programmes. (4) 

Collaboration: With the goal of improving the quality of maternal health services, the Government 

has fostered a high level of collaboration at the policy, programme, and community levels: 

• Policies and standards: In 1971, National, State, and District MCH Committees were formed to help 

develop and oversee programme strategies and standards for care. These multi-sectoral committees 

draw on the expertise of medical specialists and public health personnel as well as key state- and 

district-level decision-makers. National policies, manuals, and protocols are developed by the 

National Committee and its task forces. Local maternal and child health problems are discussed at 

the district level and referred for policy or technical guidance as needed. 

NATIONAL SAFE 

MOTHERHOOD PROGRAMME 

Malaysia’s national safe motherhood 

programme has employed a 

multi-strategy approach to reducing 

maternal death, focusing on: 

> improving coverage by ensuring 

access to basic health services; 

> upgrading the quality of essential 

obstetric care in district hositals; 

> streamlining and improving 

referral and feedback systems; 

> enhancing providers’ capacity 

and skills for managing pregnancy 

and delivery complications; and 

> reporting maternal deaths. (7) 

11


• Programme development: Since the early 1990s, strategies to reduce maternal mortality have been 

developed at the local level using an inclusive District Team Problem Solving Approach. Teams identify 

their own problems, decide on the best solutions, design appropriate interventions, and formulate a 

district plan of action (see section Evaluation and Review of the Safe Motherhood Programme for 

further information). 

• Staff involvement: Medical, nursing, and midwifery associations are consulted to upgrade training for 

life-saving skills, and training curricula are reviewed by nursing and midwifery regulatory boards. 

• Community outreach: Women’s NGOs, community, and religious groups have played a role in 

community and family education, and increasing awareness in communities. 


Within the context of supportive policies and legislation to improve maternal health (see previous 

section), Malaysia implemented a series of phased interventions to expand access of the rural poor to 

health services and increase the quality of existing services through improved management and 

community mobilisation. 

Expanding Community Access to Health Services 

In 1955 the Government implemented an extensive rural health programme, with the aim of providing 

primary health care (including such maternity services as antenatal care, delivery services, and 

postpartum care) at the community level. Rural health clinics were built, public hospital services 

expanded, and increased numbers of skilled providers (principally midwives and nurses) were trained 

and deployed to serve rural communities. By 1977 most of the rural population lived within two-four 

kilometres of a health facility by tarred road. Those who live far from health clinics are served by 

mobile health teams. 

Investing in Midwifery Personnel 

Health workers that provide maternity care include midwives,* nurses, medical officers, and specialist 

obstetricians. Midwives are the front-line providers of maternity care in rural areas—they provide 

antenatal and postnatal care and perform all normal deliveries at health facilities or through home 

visits. Nurses provide back-up support to midwives by handling emergencies in cases where a doctor 

with obstetrical training is not available. While midwives and nurses are the first point of contact for 

maternity services, medical officers and specialist obstetricians provide the first line of referral care. 

Reorganisation of Rural Health Care 

In 1975, the existing three-tiered rural health system was reorganised into a two-tier system 

in order to widen the scope of services offered to mothers at first contact, provide greater access 

to doctors, and streamline the referral system. Community-based midwives were upgraded to 

multi-purpose nurses with additional skills (see footnote below). (6) 

Health Centres (1:20,000) Community Clinics (1:4,000) 

Staff 

Services 

Doctor, dental officer, medical 

assistants, public health nurse, assistant 

nurses, staff nurses, midwives, lab 

assistant, dispenser, clerical assistant. 

Out-patient care, MCH care, 

environmental health, health education, 

family planning, dispensary. 

Community health nurse/midwife. 

MCH care, home delivery, 

home visiting, minor ailments, 

family planning, immunisation. 

* Before 1978, midwives were trained as single purpose health providers; their training was subsequently expanded to include 

child health and basic outpatient care, while retaining their core midwifery functions. As a cadre of health professionals, 

midwives have become known as community nurses. 

12


Training programmes: All professional health personnel receive midwifery training that emphasises 

hands-on practical experience and mastery of clinical skills: 

• Midwives/community nurses undergo 2 1/2 years of competency-based training in midwifery and 

basic outpatient care, which includes a practical internship in district hospitals and health centres. 

Since 1987, community nurses have been trained to administer oxytocics and intravenous infusions 

for postpartum haemorrhage; since 1993, they have been trained in the use of the partograph to help 

prevent delay in referral. 

• Staff nurses and public health nurses undergo a 3 1/2 year nursing course; staff nurses receive an 

additional year of midwifery training, and public health nurses receive an additional year of public 

health training. 

• Since 1987, all medical officers posted in health clinics and hospitals undergo a 4 to 7 month 

training in obstetrics and gynaecology to improve their proficiency in handling pregnancy and 

obstetric complications. 

Supervision: Based on a supportive, competency-based approach, supervision takes place according 

to established protocols and manuals. A written supervisory checklist, covering such areas as facility 

maintenance, record keeping, and interpersonal skills, guides the supervision of midwifery personnel. 

Supervisory staff provide on-the-spot feedback on clinical and programmatic matters; visits take place 

on a regular, preset schedule, though surprise visits are also conducted. Midwives are supervised 

by nurses, and doctors are supervised through regular case audits. The obstetrician covering a district 

hospital holds discussions on emergency management of complications and the appropriateness of referral. 

Establishing Transport and Referral Systems 

Systems for communication, transport, and referral ensure that all health facilities have transport 

(e.g. ambulance) to a higher level of care and that communication mechanisms (e.g. telephone) allow 

staff to discuss management of cases with senior personnel. In addition, midwives link the community 

with institutional health facilities by recognising complications and referring women requiring 

emergency care to the nearest health clinic. 

As referral systems were established, health facilities were upgraded in phases to provide essential 

obstetric care. Standardised equipment, supply, and essential drug lists ensure that necessary equipment 

and supplies (e.g. drugs, blood) are available in all appropriate health facilities. 

Referral systems may cut across state boundaries for the speedy referral and treatment of emergency 

cases. In river, coastal, and island areas, police and marine boats are mobilised to transport near-term 

pregnant women to the nearest health facility before the flood season. 


In an effort to improve the quality of health care services and increase utilisation, continuous 

education and community involvement have been a central component of the Government’s rural 

health services programme: 

• Community and religious leaders and influential individuals encourage women with identified 

pregnancy risks to deliver in hospitals. 

• Women who have survived a complicated delivery share their experiences with other women 

and families. 

• TBAs, who are respected community members, have been made partners in a critical network that 

links the health system, TBAs, and the community (see sidebar). 

INVOLVING TRADITIONAL 

BIRTH ATTENDANTS 

Until the 1960s, TBAs conducted 

most deliveries in rural and 

remote areas. As part of its rural 

health services programme, 

the Government worked with 

TBAs as partners to improve 

women’s access to a skilled 

midwife or nurse at the time 

of childbirth. For a limited time, 

TBAs were trained in basic 

hygiene care and in recognising 

and referring complications 

to the health centre. TBAs also 

became registered and 

certified partners in the health 

care system. 

TBAs were encouraged to 

continue a range of traditional 

services (e.g. accompanying 

mothers to hospitals, 

being present during delivery 

to attend to customary rituals, 

and providing care for the 

mother and newborn) considered 

valuable to women. Health 

workers were trained to value 

the role of TBAs in providing 

such services and to work 

with them as full partners. As 

a result of this approach, most 

deliveries are now conducted 

by government midwives. 

TBAs still play a key role in 

certain remote and underserved 

communities. For example, in 

Sabah (East Malaysia) TBAs 

conducted 12% of total deliveries 

in 1994. 

13


Health workers offer community education in health clinics and at home. Community midwives 

conduct antenatal home visits to ensure that families and communities are aware of the need for 

skilled care during childbirth and to make advance arrangements for transport, child care, etc. to 

prevent delays. Mass media has been used extensively through national and regional networks to offer 

weekly programmes on women’s health issues. 

Improved Quality and Management 

of the Maternal Health Programme 

While the period following independence was focused on increasing access to basic maternity care (see 

previous section), subsequent efforts (between the 1970s and 1990s) emphasised improving the quality 

of available services through better management. Since the 1970s, the primary indicator used for 

evaluating the maternal health programme has been the proportion of births attended by a skilled 

attendant, with districts evaluated based on their performance on this key indicator. 

Monitoring Maternal Deaths: The system for monitoring maternal deaths evolved over a period of 40 

years—from informal, sporadic investigations to the systematic programme in place today. During the 

colonial period, deaths were reported to local police authorities, and the government midwife would 

obtain information on maternal deaths. Such investigations involved hospital and district-level 

administrators working with members of the family and community. High-level officials visited areas 

where a maternal death occurred to draw attention to the event and raise awareness about the 

possible cause and means of preventing the death in question. It was made clear that this was a 

non-punitive review with the aim of learning the cause and circumstances of the death, and addressing 

deficiencies in the health system. 

In the 1980s, standard forms and procedures were developed in an effort to formalize the process of 

maternal death investigation; community leaders and supervisory personnel were involved in the 

investigation. In 1991, the existing system of maternal death investigations, the Confidential Enquiry 

of Maternal Deaths (CEMD), was established. Each maternal death is reviewed by committees at district, 

state, and national levels in a confidential, non-punitive, and timely manner to assess quality of 

antenatal and obstetric care, identify weaknesses and reasons for substandard care, and recommend 

improvements in maternal health programmes. 

Developing Standards and Protocols: The National MCH Committee (which consists of midwives, 

nurses, obstetricians, and representatives from academic and training institutions) defines standards 

for clinical care and referral through the development of manuals and protocols for different cadres 

of health providers, in collaboration with a range of stakeholders (see previous section on Laws, 

Policies, and Related Programmes). 

Standards and protocols are continuously revised and updated to reflect changing realities. In 1984 

national guidelines for antenatal and obstetric care were formulated and management protocols were 

developed for major causes of maternal mortality (postpartum haemorrhage, severe anaemia, 

hypertensive disorders of pregnancy, puerperal sepsis, and obstructed labour). These guidelines were 

amended in 1996 to include obstetric indicators that reflect quality of care. 

Norms, procedures, and standards for maternal care have also been developed for upgrading training 

and skills of midwifery and nursing personnel, and strategies to increase deliveries by professional 

health workers. For example, a colour-coded system was developed for evaluating pregnant women to 

try to identify those at risk of complications so that they can receive appropriate care. 

14


Evaluation and Review of the Safe Motherhood Programme: Regular, periodic evaluations and 

assessments are conducted on specific aspects of maternal care, and the results are used to modify and 

improve services. For example: 

• In 1984, a functional analysis of the health care system found deficiencies in training and supervision, 

as well as hostile environments in facilities, long waiting times, and non-systematic patient flow in 

clinics. As a result, norms and procedures were revised to reduce unnecessary procedures, and 

increase antenatal and postpartum visits; adapt the nursing and midwifery curriculum; improve 

interpersonal communication; and formulate a standard checklist for supportive supervision. 

• The Quality Assurance Programme was introduced in 1986 as a continuous assessment system for 

quality of care. Indicators of antenatal and obstetric quality of care were used to correct weaknesses 

in the health system and improve substandard care. In 1999, process indicators were added to ensure 

early action could be taken to avert maternal death. 

• Since the early 1990s, maternal mortality reduction strategies have been identified through a District 

Team Problem-Solving Approach, where districts identify deficiencies in care, determine 

strategies/solutions, and design interventions to address these difficulties through the development 

of a district plan of action. In 1999, a review found that the team approach to problem solving 

between health and hospital personnel was not easy to sustain, but that community outreach and 

mobilisation had increased women’s willingness to deliver in hospitals, reduced the incidence of 

births before arrival, and increased skilled care during deliveries. 

TABLE 1 > 

PUBLIC EXPENDITURE ON HEALTH 

SERVICES AND MATERNAL HEALTH 

CARE AS PERCENT OF GDP (4) 

Total Maternal 

Period Health Health 

Services Care 

1950–55 NA NA 

1956–60 1.54 NA 

1961–65 1.71 NA 

1966–70 NA NA 

1971–75 1.79 0.32 

1976–80 1.63 0.36 

1981–85 1.59 0.41 

1986–90 1.51 0.40 

1991–95 1.44 0.37 

Public Expenditure on Maternal Health 

Since the 1950s, total public expenditure for health care has averaged about 1.4 to 1.8% of GDP; total 

expenditure on maternal health care in public sector hospitals and community services has been at 

modest levels—averaging 0.38% of GDP (see Table 1). (4) 

Maternal health services are largely provided through the public sector, and services, including skilled 

care at childbirth, are free-of-charge to the poor and mostly free to other groups. The Government has 

made concerted efforts to remove financial barriers, such as subsidising transport for emergency cases. 

For additional information about Malaysia’s 

safe motherhood programme contact: 

Raj Karim 

Regional Director 

International Planned Parenthood Federation 

246 Lorong Enau, off Jalan Ampang 

East and South East Asia and Oceania Regional Office (ESEAOR) 

Kuala Lumpur 50450 Malaysia 

Tel: 60 3 456 61 22/246/308 

Fax: 60 3 456 6386 

E-mail: rk@ippf.po.my 

THE KEYS TO MALAYSIA’S 

SUCCESS ARE: 

> High-level policy commitment 

to the goal of reducing maternal 

deaths and improving skilled 

care during childbirth. 

> Decentralized, multi-strategy 

approach which targets 

specific problems and addresses 

them through incremental 

and systematic improvements 

in health services, and hospital 

and community systems. 

> Collaboration at the policy, 

programme, and community levels. 

> Monitoring and evaluation 

systems to track improvements 

and determine deficiencies 

in care. 

> Community involvement 

and empowerment, including 

partnership with TBAs. 

Sources 


2 1994, any method. World Contraceptive Use 2001. United Nations Population Division. Department of Social and Economic Affairs. New York, May 2002. 

3 1995; Maternal Mortality in 1995: Estimates developed by WHO, UNICEF, UNFPA. WHO, Geneva, 2001. 

4 Indra Pathmanathan and Jerker Liljestrand, eds. Investing Effectively in Maternal Health: Malaysia and Sri Lanka. World Bank, Washington DC, 2002. In process. 

5 Safe Motherhood and the World Bank: Lessons from 10 years of Experience, Human Development Network Series, World Bank, 1999. 

6 1996; Report on the Confidential Enquiries into Maternal Deaths in Malaysia 1995-1996. Ministry of Health, Malaysia, 2000. 

7 A.T. Lim, Sharifah Tahir, and A. Vasanthamala. Combating Maternal Mortality: Lessons from Pasir Mas, Malaysia. International Council on Management 

of Population Programmes, 1998. 

15

Skilled Care During Childbirth: Country Profiles Sri Lanka 

TUNISIA 

Sri Lanka 

MALAYSIA 

BOTSWANA 

Introduction 


Population distribution (%) 

Rural 76 

Urban 24 


Male 6 

Female 11 








requires the presence of a doctor 

or midwife, or a nurse with 

midwifery skills, who is trained to 

manage normal labour and 

delivery, recognise complications, 

and offer either emergency 

treatment or immediate referral 

to health centres for more 

advanced care. Skilled care 

also requires functioning referral 



and supplies. 

The Democratic Socialist Republic of Sri Lanka is an island situated in the Indian Ocean. The 

population is primarily rural with an agriculturally-based economy. 

Sri Lanka has long been dedicated to ensuring the social welfare and health of its citizens. Since 

the 1930s, comprehensive health services have been free of charge, and in 1945, the Government 

established a policy of universal free education from year one to university level—resulting in an overall 

literacy rate of 91% by 2000.* 

Sri Lanka has seen similar improvements in other health and social indicators: infant mortality fell 

from 82 deaths per 1,000 live births in 1950 to 15 deaths per 1,000 live births in 1997, (4) life expectancy 

has risen to 73 years; fertility declined steadily from 5.1 in 1953 to 2.1 in 2000; use of both traditional 

and modern contraceptive methods rose to 66% by 1993. (2) 

Investments in women’s health and development have been a central component of Sri Lanka’s 

success story. Women have equal rights in education, voting, and employment. They are guaranteed 

equality under the national constitution (1978), and are accorded human rights and freedoms on an 

equal basis with men. (5) 

Maternal health: Maternal mortality has declined considerably over the past five decades—from 1,660 

deaths per 100,000 live births in 1947 (5) to 60 deaths in 1995. (3) Skilled care during childbirth increased 

from 27% in 1939 to 89% in 1996. (4) Today, most women in Sri Lanka have access to skilled care 

during pregnancy and labour—almost all women (99%) receive antenatal care, 90% of women deliver 

in institutional settings, and 95% of births are assisted by a skilled attendant. 

MCH has received high priority in the Government’s primary health care policy and infrastructure. 

Since the mid-1920s, a wide network of community-based health facilities have provided basic 

preventive services—including antenatal care, skilled care during childbirth, and postpartum care—in 

domiciliary and clinic settings. (6) 

Although Sri Lanka has the lowest maternal mortality ratio in South Asia (as well as the highest 

contraceptive prevalence rate), (6) it is continuing to refine its programme to reduce deaths and disability 

even further. In provinces where civil unrest continues to be a problem, maternal mortality is twice as 

high. It is estimated that approximately 3–4% of deliveries (amounting to a total of 14,000 deliveries 

each year) do not receive any skilled assistance. These take place mainly in remote areas (such as the 

plantation sector) and areas subjected to civil conflict. In addition, some women still prefer to deliver 

* % age 15 and above. Human Development Report 2002, United Nations Development Programme, New York, 2002. 

16


at home, unassisted by a skilled attendant, for cultural reasons. Research also shows that two thirds 

of maternal mortality and morbidity is due to preventable causes and over 70% of infant deaths take 

place during the neonatal period. Abortion is illegal in all circumstances except to save the life of the 

woman, and unsafe abortion is estimated to cause approximately 7–10% of maternal deaths (see Figure 1). 


Sri Lanka has demonstrated sustained, high-level commitment to safe motherhood during the colonial 

and post-independence periods. A number of legal and policy initiatives have helped to create a 

supportive framework for reducing maternal mortality and improving access to skilled care during 

childbirth, including: 

Professionalisation of midwifery: Beginning in the late 1800s, midwives were trained to competency 

in clinical skills and officially registered as a cadre of health personnel. These health providers were 

deployed to an extensive network of domiciliary and institutional rural health services. Midwifery 

became a highly prestigious profession, and midwives were well-respected in the communities they 

served. The situation remains the same today. 

Vital registration system: As far back as 1897, a system for the registration of births and deaths was 

in place, and since 1921 a special section on maternal mortality was included. Not only does the 

availability of vital statistics make it possible to create awareness of the extent of the problem and 

mobilise action, but it also provides a mechanism to evaluate and improve MCH services. 

Integration of family planning services: Family planning services have been available as part of MCH 

care since 1965. The integration of these services facilitated the wide acceptance of family planning 

and fuelled a sharp decline in fertility rates. (4) 

Investments in women: As outlined in the previous section, Sri Lanka has made significant investments 

in elevating the status of women through policies that promote female education and facilitate 

women’s participation in political and social life. 

Collaboration: In recent times, the President or Minister of Health appoints a multi-sectoral task force 

with representation from relevant ministries, professional bodies, and NGOs for the formulation of 

national policies. Sometimes, subcommittees are appointed to ensure that the various sectors (central 

and regional) and professional bodies (i.e. College of Obstetricians, midwifery associations, etc.) can 

consider details of implementation before the policy is formulated. The 1998 Population and 

Reproductive Health Policy, which includes safe motherhood as one of its goals, was developed by a 

task force consisting of representatives from the MOH, Ministry of Women’s Affairs, the Women’s 

Bureau, academics, and NGOs. 


Between the 1940s and 1990s, Sri Lanka invested in a series of phased strategies to improve maternal 

and child health: 

• Improving access to community health services, including antenatal care and skilled care during 

childbirth, that are free of charge to the population; 

• Expanding specialised obstetric services; and 

FIGURE 1 > 

CAUSES OF MATERNAL MORTALITY 

33% 

10% 

7% 

26% 

13% 

11% 

Haemorrhage 

Hypertension 

Heart Disease 

Abortion 

Sepsis 

Other causes 

NATIONAL SAFE MOTHERHOOD 

PROGRAMME 

Reducing maternal mortality is a 

key goal in broad health policies 

and in the MCH Programme. 

At the national level, the 

Family Health Bureau, under 

the leadership of a MCH Director, 

is the central unit within the 

MOH responsible for planning, 

implementing, and monitoring 

all maternal health 

activities. The main priorities for 

safe motherhood include: 

> Promoting the equitable 

distribution of maternal health 

services to reduce intra- and 

inter-district disparities; 

> Improving the quality of antenatal, 

intranatal, and postnatal services 

through training and supervision; 

introduction of the partograph 

in certain hospitals; and a checklist 

of essential supplies and equipment; 

> Upgrading the process of risk 

assessment and referral, with 

an emphasis on essential and 

emergency obstetric care; and 

• Developing monitoring and evaluation systems to improve the quality of services. (4) > Systematic review of maternal 

deaths. 

17


THE PUBLIC HEALTH MIDWIFE 

The Public Health Midwife (PHM) 

is the “front line” health worker 

for providing domiciliary MCH and 

family planning services in the 

community. There are approximately 

4,600 PHMs in service through 

the health unit system, each serving 

a population ranging from 

3,000–5,000 people. Through 

systematic home visits, these 

midwives provide care to pregnant 

women, infants, and pre-school 

children, including: 

> One-on-one health education 

and counselling; 

> Identification and registration 

of all pregnant women; 

> Antenatal care; 

> Helping mothers plan their place 

of delivery; 

> Assisting with home deliveries 

as necessary; 

> Postpartum care and counselling; 

> Family planning counselling 

and provision of contraceptive pills 

and condoms to couples of 

reproductive age; 

> Reproductive health education 

for adolescents; 

> Encouraging women to seek 

screening for reproductive organ 

malignancies and schedule regular 

check-ups. 

Backed up by a well-structured 

institutional health system, 

PHMs link domiciliary services 

with clinic services. Their activities 

are supported by a system 

of record keeping which enables 

them to plan and monitor their 

routine activities. 

Through encouraging women to 

plan their delivery setting, 

PHMs are responsible for a high 

proportion of women (88%) 

delivering in government health 

facilities. They also ensure that 

about 65% of women receive 

postnatal care at least once during 

the first ten days after delivery. 

Improving Access to Community-Based Health Care 

In 1926, the Government established a “health unit” system to deliver community-based services, 

including MCH and family planning, to the vast majority of the population. Providing services at both 

the institutional (through health centres located in the community) and domiciliary level, each health 

unit serves populations ranging from 40,000–70,000. Health units are staffed by a Medical Officer of 

Health (in charge of the unit) and a team consisting of Public Health Nursing Sisters and Public Health 

Midwives (PHM) (see sidebar). Each health unit is further subdivided into PHM areas, which constitute 

the smallest working unit in the Government’s field health care system. 

By 1948, the health unit system had expanded to cover the entire country, and health workers were 

trained and deployed to staff health centres and provide services to women at home. By 1975, most 

of the population were living within 1.3 km of a health care facility. (4) 

Community-based health staff are trained and supervised according to the following: 

• The Public Health Midwife receives competency-based training in midwifery for a period of 18 

months (12 months at a school of nursing and six months in the community in a field training area). 

• The Public Health Nursing Sister receives three years of training at a School of Nursing, followed by 

six months of midwifery training, one-year of training in a post-basic nursing school, and six 

months of training in the field. 

• Medical Officers receive five years of training at the Faculty of Medicine, followed by one-year 

internship period (consisting of two appointments of six months each). Since 1915, all medical 

students are required to complete midwifery training. 

Regular in-service training for field staff is conducted to update knowledge and skills in MCH and 

family planning. Staff from each health unit attend monthly conferences where they receive training, 

supervision, and skills development. 

Supervision: Based on a supportive and non-punitive approach, supervision and monitoring is conducted 

at many levels and by several categories of staff. Medical Officers provide overall guidance and 

supervision of maternal health services within each health unit. Public Health Midwives are supervised 

by Supervising Public Health Midwives, who are in turn supervised by Public Health Nursing Sisters. 

The Public Health Midwife maintains records and registers which are reviewed by supervisory staff. 

Referral and Transport Systems: A system of ambulance services was instituted in 1926, and rapidly 

expanded by 1950 such that emergency transport was available in most health facilities. In cases 

where ambulances are unavailable, health staff can make arrangements for paying for other transport, 

for which they are reimbursed by the MOH. (4) 

Midwives working at the field level can call the Public Health Nursing Sister or the Medical Officer in 

their health unit to discuss emergency cases, and can refer women to the nearest clinic or hospital or 

directly to a higher-level referral facility. 

Community Outreach: The Ministry of Health conducts IEC activities to motivate mothers to attend 

health clinics and deliver in hospitals. Materials have been produced by the Family Health Bureau and 

the Health Education Bureau of the Ministry of Health to educate mothers on the health benefits of 

skilled care during childbirth. TV and radio programmes also provide useful information on health, 

nutrition, and other health-related topics by specialists in those fields. A highly educated population has 

been more receptive to health education activities, which has fostered increased utilisation of services. 

18


Expanding Access to Specialised Obstetric Services 

Sri Lanka’s community-based health system (see previous section) is linked to a three-tiered network 

of institutional facilities that provide a range of obstetric services: 

• Specialist hospitals (Teaching, Provincial, and Base Hospitals) are tertiary-level facilities that provide 

emergency obstetric care and other advanced services. Currently, there is a total of 50 specialist 

hospitals (1:400,000 population) staffed by specialist obstetricians. 

• Intermediate/Secondary institutions (District Hospitals and Peripheral Units) offer a wide range of 

in-patient care in addition to maternal health services. These institutions provide basic essential 

obstetric care, and refer women to specialist hospitals (by ambulance) if needed. 

• Primary institutions (Rural Hospitals, Cottage Hospitals, and Maternity Homes) provide services for 

outpatient care and normal deliveries. 

TABLE 1 > 

EXPANSION OF MATERNAL AND CHILD HEALTH SERVICES 

Maternity 

Health 

Hospitals* Homes Midwives + Centres 

1941 129 12 347 NA 

1945 153 34 542 503 

1950 263 99 1053 701 

1954 270 104 1854 NA 

1970 NA 128 2680 1122 

1980 357 100 3350 1344 

1986 389 88 4652 1778 

1989 400 83 5030 1880 

1993 410 78 6533 1905 

1996 426 60 6745 1950 

* Includes Teaching, Provincial, Base, District, Peripheral Units and Rural Hospitals, all of which have 

maternity unit facilities for deliveries. 

+ Includes both hospital and field midwives. 

Since the 1950s, the number of specialised institutions grew steadily (see Table 1), thus providing 

women with greater access to a physician (including specialist obstetricians) for maternity care. During 

the period between 1964–1983, the number of provincial and base hospitals increased by 30% and the 

number of district and peripheral hospitals by 41%. (4) 

As Figure 2 illustrates, institutional deliveries have progressively increased during the past four 

decades, due to improved access to facilities and regular contact with the Public Health Midwife. Of 

the total deliveries that take place in government facilities, nearly 70% occur in specialist hospitals, 

where ob/gyns, midwives, or nurses with midwifery skills conduct deliveries; over 20% occur at the 

secondary level; and approximately 10% at the primary level. A small percentage (3%) are conducted 

by government midwives at home. 

Referral and Transport Systems: All major hospitals have ambulance services for emergency transport 

to higher-level referral facilities. If ambulances or other hospital vehicles are not available, health staff 

can make arrangements to fund alternative transport services, to be paid for by the MOH. 

19


FIGURE 2 > 

PERCENTAGE OF DELIVERIES IN GOVERNMENT HOSPITALS 

INVESTIGATING EACH 

MATERNAL DEATH 

A system to investigate maternal 

deaths has been in place 

since the late 1950s. Initially, 

the Medical Officer of Health 

conducted the investigation into 

a maternal death using a prescribed 

form, and determined 

whether any follow-up action 

was necessary. In the 1980s, a 

formal system of maternal death 

reviews was introduced where 

a committee—chaired by the 

Director General of Health 

Services and comprising administrators, 

obstetricians, Medical 

Officers of Health, 

and members of the medical 

professional organisations— 

reviews the cause and 

circumstances surrounding 

each maternal death. 

Annual and quarterly maternal 

death reviews are conducted 

at the regional and central levels. 

Each death is analysed in-depth 

(not to find fault but to 

identify corrective action) using 

the Three Delays model. The 

appropriate measures that 

need to be taken to prevent 

such deaths are discussed with 

programme managers and 

service providers. The Family 

Health Bureau acts as the focal 

point for this system, and 

provides feedback on the issues 

discussed and the appropriate 

corrective actions needed 

for the future. Some examples 

of action taken as a result of 

maternal death reviews: 

establishing 24-hour ambulance 

systems, and appointing 

two specialist obstetricians to 

a referral institution. (4) 

PERCENT % 

100 

80 

60 

40 

20 

0 

1960 1965 1970 1975 1980 1985 1990 1995 

YEAR 

Monitoring & Evaluation Systems to Improve the Quality of Services 

In the period between 1960–1990, the Government placed greater emphasis on improving the quality 

of services through developing monitoring and evaluation systems. At the national level, all MCH and 

family planning activities were brought under one division, the Bureau of Family Health, headed by 

a MCH Director. The field reporting system was revamped in an effort to provide regular, systematic 

assessments of the programme and to identify areas needing improvement. (4) 

The Family Health Bureau coordinates routine monitoring and evaluation activities, including: 

• Annual maternal death audits at the regional and central levels (see sidebar); 

• Quarterly and annual maternal death reviews at the district level. 

A set of MCH-Management Information System (MIS) indicators has been developed for each of these 

activities, to guide supervision of health workers at the district, province, and national levels. 

Feedback and corrective guidance is promptly offered to health workers. 

Standards and protocols: Standards and protocols have been developed for most MCH activities. They 

guide training and organisation of health services, and are also prepared and circulated periodically 

among health workers to update their knowledge. Examples include: 

• A comprehensive manual for peripheral-level health workers on MCH and family planning (currently 

being revised) is used as a reference by health staff in their daily activities. 

• Protocols on management of obstetric emergencies and resuscitation of newborn infants have been 

prepared and given to the relevant staff. 

• Two new manuals are currently being prepared on Management of Obstetric Emergencies in the 

Periphery and Human Resource Development for Health Personnel with assistance from expert agencies 

in the field. 

• A national system has been developed to review each maternal death (see sidebar). 

A recent quality assessment of maternal care has identified some deficiencies in primary-level 

institutions, specifically with regard to communication and transport systems. For example, although 

most hospitals have ambulances and telephones, smaller institutions still lack such services and face 

difficulties in emergency transfer of patients to referral centres. Shortages of certain categories of 

health staff exist in particular regions of the country, and have hampered the provision of better 

quality care. 

20



Total government expenditure on health has ranged from 1.47 to 2.12 percent of GDP; of the total 

expenditure on health services, a modest percentage is spent on maternal health care (see Table 2). 

Prior to the 1990s, health services were funded primarily by the Government; funding to support 

health services has subsequently been provided by both government and household expenditures. (4) 

In addition to government funding, the safe motherhood programme also receives financial and 

technical support from international agencies; the main supporting agencies are UNICEF, WHO, 

UNFPA, and the World Bank. 

TABLE 2 > 

EXPENDITURE ON MATERNAL HEALTH CARE IN SRI LANKA: 

1950–1999 (4) 

Decade 

1950s 

1960s 

1970s 

Expenditure on 

Maternal Health Care 

0.28 

0.30 

0.26 

Total Government 

Health Expenditure 

1.95 

2.12 

1.81 

THE KEYS TO SRI LANKA’S 

SUCCESS ARE: 

> Consistent, long-term 

government commitment to 

health and development, 

with an emphasis on women’s 

equality. 

1980s 

1990s 

0.18 

0.16 

1.47 

1.53 

> Integration of maternal 

health into a broad health 

and development policy. 

1950–1999 

0.23 

1.79 

> Community-based health 

care, free of charge and 

widely accessible. 

For additional information about Sri Lanka’s 


Dr. Anoma Jayathilaka 


Family Health Bureau 

No. 231, De Saram Place 

Colombo, Sri Lanka 

Tel: 94 1 696 508 

Fax: 94 1 823 012 

E-mail: jayandse@sltnet.lk 

> Emphasis on training and 

quality of care. 

> Routine monitoring 

and review, including maternal 

death audits. 

Sources 


2 World Contraceptive Use 2001. United Nations Population Division, Department of Social and Economic Affairs. New York, May, 2001. 

3 1995; Maternal Mortality in 1995: Estimates developed by WHO, UNICEF, UNFPA. WHO, Geneva, 2001. A maternal mortality study 

[Maternal deaths in Sri Lanka: A review of estimates and causes 1996. Authors J. Nalin Rodrigo, Lakshman Fernando, Lakshman Senanayaka, 

Prasanna Gunasekara, Soma da Silva. UNICEF-assisted study] conducted in 1996 generated an MMR of 92 deaths per 100,000 live births. 

The study found that utilising vital registration systems to measure MMR can seriously undercount maternal deaths. 

4 Indra Pathmanathan and Jerker Liljestrand, eds. Investing Effectively in Maternal Health: Malaysia and Sri Lanka. World Bank, Washington DC, 2002. In process. 

5 World Bank Case Study on Sri Lanka, Institute on Reproductive Health and Health Reform, 2000. 

6 H.R. Seneviratne and L.C. Rajapaksa. “Safe Motherhood in Sri Lanka: A 100-year March.” International Journal of Gynaecology and Obstetrics 70 (2000): 113–124. 

21

Skilled Care During Childbirth: Country Profiles Tunisia 

Tunisia 

SRI LANKA 

MALAYSIA 

BOTSWANA 

Introduction 



Rural 35 

Urban 65 


Male 19 

Female 39 








requires the presence of a 

doctor or midwife, or a nurse 

with midwifery skills, who is 

trained to manage normal 

labour and delivery, recognise 

complications, and offer 

either emergency treatment 

or immediate referral to health 

centres for more advanced 

care. Skilled care also requires 

functioning referral and 

transport systems and necessary 

drugs, equipment, and supplies. 

Tunisia is the smallest of the North African countries, bordering Algeria, Libya, and the Mediterranean Sea. 

The health and living standards of all Tunisians have improved substantially in recent decades. For 

example, between 1970 and 2000, life expectancy increased from 55.6 to 72 years. In addition, infant 

mortality decreased from 135 to 26 deaths per 1,000 live births over the period 1970–2000. 

Since its independence in 1956, Tunisia has placed high priority on women’s health and well-being. 

Polygamy was abolished, education made mandatory for boys and girls, and in 1959, women were 

guaranteed equal rights, making them eligible to vote and hold public office. In the mid-sixties, 

Tunisia legalised abortion and began implementing a national family planning programme, which 

helped fuel a sharp decline in the total fertility rate from 6.2 in 1970 to 2.1 in 2000. 

Maternal health: Tunisia’s maternal mortality ratio has fallen dramatically over the past several 

decades—by 80 percent between 1971–1994—to its current level of 70 deaths per 100,000 live births. (2) 

Use of maternal health services has also increased impressively (see Figure 1): 92% of women receive 

antenatal care, and 82% deliver with a skilled attendant present. 

Since the 1960s, Tunisia has made a concerted effort to reduce maternal mortality. Maternal and infant 

health centres were established throughout the country, with midwives playing a primary role in 

delivering maternal health and family planning services. Several policies supportive of improving 

maternal health were instituted during the 1960s and 1970s (see next section). In 1990, a national 

maternal health programme was launched. 

FIGURE 1 > 

USE OF MATERNAL HEALTH AND FAMILY PLANNING 

100% 

80% 

60% 

40% 

1989 

20% 

1997 

0% 

2000 

Prenatal Care 

Skilled Care 

During Childbirth 

Postpartum Care 

Contraceptive 

Prevalence 

22



Between 1950–1970, Tunisia instituted a series of policies to promote women’s equality and status: 

• Personal Status Code (1956, 1964) abolished polygamy and repudiation, and raised the legal age of 

marriage (17 years for girls; 20 years for boys).* 

• Mandatory Schooling (1958) was instituted free of charge for girls and boys from the age of six. 

• National Constitution (1959) accorded women equal rights in social, economic, and administrative 

affairs; women were granted the right to vote and hold public office. 

In addition to establishing a supportive policy framework for improving maternal health and increasing 

access to skilled care during childbirth, Tunisia implemented a national family planning programme 

(1965) that was integrated into its basic health care system. Midwives became the key cadre of health 

personnel that provided family planning and maternal care. Also in 1965, abortion was made legal for 

women with 5 or more children during the first trimester; this law was subsequently amended to 

permit abortion on request during the first three months. ✝ 

In 1981, Tunisia developed a primary health care policy that prioritised maternal mortality reduction 

as a key objective. In the early 1990s, a number of oversight bodies were established to advise on 

women’s issues, including maternal health: 

• The Centre of Research, Study, Documentation, and Information on Women; 

• The Ministry in Charge of Women and Family Issues (responsible to the Prime Minister); 

• The National Council on Women; 

• The National Perinatal Commission, which was created to advise the Ministry of Health on maternal 

health strategies and standards. The Commission includes specialists in the field of perinatology, 

directors of pre-service training, heads of ob/gyn services (university and/or regional), national and 

regional planners, and midwives, as well as a representative of the National Office of Family and 

Population (ONFP). 

National Programme: While MCH has been identified as a priority issue since Tunisia’s independence, 

a national-level safe motherhood programme was not launched until 1990. During the period before 

1990, the main strategies to improve maternal health included: 

• Development of primary MCH infrastructure and services; 

• Implementation of a national family planning programme. 

In 1973, a separate division under the Ministry of Health, the Office of Family and Population (ONFP) 

was created to oversee the maternal health and family planning programmes. 

In 1989, Tunisia assessed its existing MCH services, and in 1990 developed a National Perinatal 

Programme to improve their quality and coordination. The programme has moved from a focus on 

the development and implementation of services based on the risk approach (Phase One) to a more 

targeted effort to reduce maternal mortality through specific goals for skilled care during childbirth 

(Phase Two). 

The 1990 National Perinatal 

Programme was designed to 

address insufficiencies in 

maternal services especially in 

rural areas, in particular: 

> A lack of human resources, 

especially midwives; 

> A lack of material resources; 

> The weak integration of 

MCH/FP activities in primary 

health centres (i.e., only 

47% offered antenatal care); 

> The absence of standards 

for care and of a clear definition 

of tasks; 

> Poor coordination between 

peripheral and referral facilities; 

and 

> Low utilisation of services 

by pregnant women: 50% did 

not seek antenatal care and 

35% of those who did attend 

their first visit did not return 

for follow-up. 

* The minimum age of marriage was raised to 17 for girls and 20 for boys in 1964. 

✝ After the first trimester, abortion can be performed on physical and mental health grounds. 

23


PHASE TWO: 

SETTING NEW GOALS 

Statistics on health and use of 

services gathered in 1994 were 

used to refine the National 

Perinatal Programme. Some of 

those findings were: 

> The national maternal 

mortality ratio was 69 deaths 

per 100,000 live births, varying 

from 54 in the east to 99 in 

the west; 

> Main causes of death: 

haemorrhage (31%), hypertension 

(19%), infection (11%), 

and cardiovascular disease 

(11%); 

> Time of death: at delivery 

(36%), within 42 days 

postpartum (34%), during 

pregnancy (22%); 

> Place of death: 72% in public 

health facilities (39% at the 

regional level, 23% in university 

facilities and 10% at the 

peripheral level), 3% in private 

facilities, and 19% at home; 

> Indirect causes of death: 

cultural inaccessibility (67%), 

non-use of antenatal care 

(57%), lack of family planning 

(38%). 

Phase One (1990–1996): 

Key strategies: 

• Defining service standards for antenatal and postnatal care; 

• Upgrading the skills of midwives and public health doctors and improving the quality of care 

through refresher training, supportive supervision, and curriculum integration; 

• Health education to promote each component of maternal care; 

• Research and evaluation (i.e., surveys, health information systems, monitoring and evaluation of 

activities); 

• Integrating maternal health and family planning promotion into the National Solidarity Funds 

26/26, a national initiative which aims to improve living conditions in underprivileged areas 

(e.g. drinking water, electricity, housing, literacy and education, health, local employment, and road 

infrastructure); and 

• Reducing inter- and intra-regional disparities through the Population and Family Health Project 

(1992–1996), financed by the World Bank to integrate maternal health and family planning services 

at peripheral health centres. 

Phase Two (1997–2000): To reduce maternal mortality to less than 50 deaths per 100,000 live births 

by ensuring that 90% of deliveries occur in attended environments. 

Key Strategies: In addition to focusing on priorities established in Phase One, the following strategies 

were identified: 

• Improving the quality of maternal care and family planning by creating partnerships among different 

levels of care; 

• Encouraging women to use health facilities; and 

• Establishing a system of maternal death audits in public sector hospitals. 


To increase the coverage of births that occur in a skilled environment, Tunisia implemented a series 

of focused interventions in maternal health: 

• Developing health services infrastructure; 

• Investing in midwifery personnel; 

• Community outreach; 

• Establishing monitoring and evaluating systems. 

Developing Health Services Infrastructure 

During the 1960s and 1970s, Tunisia invested in the development of primary MCH centres to provide 

family planning services, immunisation, antenatal care, and skilled assistance during childbirth. In 

1966, there were 89 such centres; by 1984, the number had increased to 141. 

At present, Tunisia is equipped with 152 public maternities, which provide a total of 2,847 ob/gyn 

beds. In 1998, there was one ob/gyn bed for every 61 births. The health infrastructure is organised 

along three levels: 

• The peripheral level: There are 112 peripheral maternities to ensure geographic access to skilled care. 

Eighty percent have a laboratory and a radiology service, and all have at least one ambulance. 

Almost one-quarter of public sector deliveries take place in these maternities. A public health physician 

oversees each peripheral maternity to ensure quality of care. 

The Government also runs some 1,957 public health centres (one for every 4,825 inhabitants); 90% 

of these centres provide integrated antenatal, postpartum, and family planning services. 

24


• The regional level: The 31 regional maternities are the “nerve centre” that links the peripheral and 

university facilities. Each has an operating theatre, laboratory, radiology service, and three 

ambulances, and each is staffed by a pool of nine midwives and 3–4 ob/gyns. These maternities 

account for 43% of all deliveries in public facilities. The rate of transfer to regional obstetrical units 

from peripheral maternities is 19%. 

The regional maternities were targeted in the second phase of the national programme. Efforts have 

been made to improve equipment and competencies, notably by creating partnerships between the 

regional and university maternity teams. 

• The university level: There are nine referral hospitals, located mainly in the Greater Tunis area, 

in three large university cities (Sousse, Monastir), and in the south (Sfax) of the country. Each has 

an operating wing and a 24-hour specialised medical service which enables them to deal with 

life-threatening complications. 

In addition, mobile teams provide family planning and basic maternal health services to semi-urban 

and rural areas without health facilities and health personnel. Currently, there are 54 mobile teams and 

12 mobile clinics operating in Tunisia. (3) 

TABLE 1 > 

SELECTED SERVICES PROVIDED BY HEALTH PERSONNEL (1988) (4) 

TBA 

Midwife Physician (Matrone) Other None 

Antenatal care (total) 34% 24% - - 42% 

Urban 35% 36% - - 28% 

Rural 31% 11% - - 57% 

Care during delivery (total) 53% 16% 18% 13% - 

Urban 61% 26% 8% 4% - 

Rural 43% 7% 28% 22% - 

Investing in Midwifery Personnel 

Investments in midwifery personnel have been a consistent strategy since the 1950s. In 1957, a 

ministerial decree established the scope of midwives’ preventive and curative roles in MCH, and in the 

1970s, the MOH developed a job description (profil du poste) for the midwife. 

Midwives are key providers of family planning services and the main cadre of health providers to 

attend deliveries, particularly in rural areas (see Table 1). Midwives are often the first point of contact 

for women seeking health services, with physicians providing more specialised services at higher 

levels of care. 

Training and Supervision Programmes: Training programmes have continuously been revised to 

upgrade the skills of midwives and public health doctors: 

• A mandatory four-month training course in obstetrics and gynaecology was added as a component 

of the two-year internship for general practitioners. 

• During the 1970s, pre-service training for midwives was extended to three years, and reformed based 

on a modular teaching approach focusing on three main topics: paediatrics, community health, 

and contraception. 

25


The National Perinatal Programme has established mechanisms for in-service training and supportive 

supervision: 

• A self-evaluation tool, called an “internship notebook,” was developed for midwifery students 

during the internship (practical training) period to monitor their progress in meeting training objectives; 

the notebook is reviewed by the internship supervisor, and at the end of the internship period is 

handed over to the student who remits it to the training instructor. 

• Refresher training was decentralised at the peripheral and regional levels of the health infrastructure. 

The frequency and content of refresher training is therefore determined locally, based on needs identified 

during supervision, as a result of evaluation findings, and at the request of health practitioners 

during meetings. 

• Supervisory guidelines were developed by the Ministry of Health as a standard tool for assessing 

practioners’ performance. Supervision is decentralised at the peripheral and regional health levels, 

and regional and peripheral teams are able to modify/adapt the tool according to local needs. 

Standards and protocols: Standards for provision of care are developed in collaboration with 

the National Perinatal Commission (as are the objectives and content of in-service training, and the 

choice of service strategies). A number of laws have been passed regulating the use of medication and 

attendance at delivery, including a decree by the Ministry of Public Health establishing the list of drugs 

that midwives may possess and prescribe. 

Similarly, “technical cards” on clinical management practices provide an official reference in defining 

the scope of intervention by midwives and physicians in the provision of maternal care. 


The National Perinatal Programme conducts education and information activities (using printed 

materials and audiovisual media) to highlight the benefits of maternal care for both maternal and child 

health. Materials are distributed to women in health facilities or during group education sessions 

organised and led by health workers. Raising community awareness about pregnancy complications 

and risk factors, and encouraging women to use appropriate services, are of the highest priority, 

especially in rural areas. 

A 1997 study found that, in spite of all efforts, problems of cultural accessibility persist. For example, 

60% of the women who delivered at home came from rural areas. Psychological and emotional 

reasons motivated the choice for 40% of them. Lack of knowledge was also a factor; for example, of 

the 46% of women who did not seek postpartum care, 73% said they were unaware of the schedule 

for postpartum care. 

Therefore, in collaboration with the National Solidarity Funds, which aim to improve living conditions 

in rural areas, the National Perinatal Programme is promoting integrated family and reproductive 

health in more than 800 underprivileged areas. A separate but related strategy is being developed to 

improve the atmosphere and acceptability of peripheral maternities to encourage women to use them. 

The National Perinatal Programme also works in coordination with the National Health Education 

Committee, a consortium of groups that include NGOs (e.g. the National Union of Tunisian Women, 

the Tunisian Family Planning Association, etc.), the majority political party (the Democratic 

Constitutional Assembly) and the Scouts. The Committee organises IEC activities at both the national 

and local levels. 

26


Establishing Monitoring & Evaluation Systems 

Evaluation and research are built into the National Perinatal Programme. A data collection system was 

developed and put into place in 1994 in order to provide a statistical record of MCH and family 

planning activities, and it has shown steady increases in the use of services. 

According to these statistics, the stated national goal for skilled care during childbirth has been met, 

though there are still problems in rural areas. In addition, seven national studies have been conducted 

to gauge the evolution and impact of the programme. As described in the preceding sections, the 

results from these studies have been used to refine the strategies, targets, and goals of the National 

Perinatal Programme. In the third phase of the programme, studies point to the need to expand 

services to focus on anaemia prevention and additional reproductive health problems (genital cancers, 

menopause, etc.), and also to introduce a new medical death certificate and extend maternal death 

audits to the private sector and domestic sphere. 


Tunisia spends 2.2% of its GDP on health. Government funding covers 91.5% of the national MCH 

budget, and the remaining 8.5% is contributed by international agencies. The National Perinatal 

Programme benefits from sustained cooperation with UNICEF, the World Bank, and WHO. 

For additional information about Tunisia’s 


Dr. Mounira Garbouj 

Director of Primary Health Care 


31 rue Khartoum 

Tunis 1002 Tunisia 

Tel: 216 1 789 148 

Fax: 216 1 789 679 

THE KEYS TO TUNISIA’S 

SUCCESS ARE: 

> Investing in women’s health 

and development, with an emphasis 

on promoting gender equality. 

> Ensuring skilled care for deliveries 

at all levels of the health care 

infrastructure. 

> Retaining midwives as the 

central maternal health providers, 

and the point of first contact 

for pregnant women. 

> Continual revision and updating 

of the midwifery curriculum. 

> Ensuring continuity of care 

through each stage of pregnancy, 

childbirth, and immediate 

postpartum period. 

> Multi-sectoral collaboration 

to tap the strengths of all potential 

partners, both public and private. 

> Conducting community outreach 

in underprivileged areas 

and addressing regional disparities. 

> Integrating the quality assurance 

process in maternal care. 

Sources: 


2 1995; Maternal Mortality in 1995: Estimates developed by WHO, UNICEF, UNFPA. WHO, Geneva, 2001. 

3 M. Boukhris. Family Health and Population Policy in Tunisia, 1992. 

4 Enquete Demographique et de Sante en Tunisie 1988. Ministère de la Sante Publique, Office National de la Famille 

et de la Population, Direction de la Population, Tunis, Tunisie and Institute for Resource Development/Macro Systems, Inc., 

October, 1989. 

27

Skilled Care During Childbirth: Country Profiles 

Acronyms 

ANC 

CEMD 

FWE 

FP 

GDP 

GNP 

HIV 

IAG 

IEC 

MCH 

MOH 

NGO 

ONFP 

PHM 

SADCC 

STI 

TBA 

UNICEF 

UNFPA 

WHO 

Antenatal Care 

Confidential Enquiry of Maternal Deaths 

Family Welfare Educator 

Family Planning 

Gross Domestic Product 

Gross National Product 

Human Immunodeficiency Virus 

Safe Motherhood Inter-Agency Group 

Information, Education, and Communication 

Maternal and Child Health 


Non-governmental Organisation 

Office of Family and Population (Tunisia) 

Public Health Midwife 

Southern Africa Development Cooperation 

Sexually Transmitted Infection 

Traditional Birth Attendant 

United Nations Children’s Fund 

United Nations Population Fund 

World Health Organization

Safe 

Motherhood 

For further information, please contact the 

secretariat of the Safe Motherhood Inter-Agency Group: 

Family Care International 

588 Broadway, Suite 503 

New York, NY 10012 USA 

1.212.941.5300 Telephone 

1.212.941.5563 Facsimile 

smi@familycareintl.org E-mail 

http://www.safemotherhood.org Web site 

United Nations Population Fund 

(UNFPA) 

World Bank 

International Planned Parenthood 

Federation (IPPF) 

World Health Organization 

International Confederation 

of Midwives 

Population Council 

International Federation 

of Gynecology and Obstetrics 

Safe Motherhood Network of Nepal 

Regional Prevention of Maternal 

Mortality Network (Africa) 

The principles and policies of each agency are governed by the relevant decisions of each agency’s 

governing body. Each agency implements the interventions described in this document in accordance 

with these principles and policies and within the scope of its mandate.

SKILLED CARE DURING CHILDBIRTH - Family Care International

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