• Midwives, the backbone of the healthcare system, are under strain

While Sri Lanka’s maternal and infant healthcare system has long been considered a regional success story, especially in a country defined by resource scarcity, a growing structural vulnerability threatens its hard-won gains as the country grapples with recovery and stabilisation.

At present, Sri Lanka’s Maternal Mortality Ratio (MMR) stands at 25 per 100,000 live births, based on data from 2023. Meanwhile, its Neonatal Mortality Rate (NMR) is 7.2 per 1,000 live births and the Infant Mortality Rate (IMR) is 10.2 per 1,000 live births. 

Speaking to The Sunday Morning, Sri Lanka College of Obstetricians and Gynaecologists (SLCOG) President Prof. Rukshan Fernandopulle noted that these metrics were comparable to the United States, while placing the country ahead of its South Asian neighbours.

“We are doing well, but to sustain it, we have to keep up the momentum. That means maintaining services, facilities, and the supply chain,” Prof. Fernandopulle explained.

Highlighting the historical trajectory of this success, he noted: “When we look at our MMR after independence in the 1950s, we were at 500 per 100,000 births; countries like India were even higher. Today, India has caught up significantly, but its figures are more than four or five times higher than ours. It is the same with Nepal and Pakistan. Only the Maldives comes close to our performance.”

Midwives under pressure

Sri Lanka’s antenatal care system is widely acknowledged for its effectiveness, with regular monitoring at the grassroots. Midwives remain central to this success, operating as the backbone of community-level maternal healthcare. However, this backbone is showing signs of strain.

According to Government Midwifery Services Association (GMSA) President Devika Kodithuwakku, while the dedication of Public Health Midwives (PHMs) in the field when it comes to infant and maternal care remains unchanged, they are facing certain challenges in their operating environment that need to be addressed by the authorities.

She stressed that the duties of midwives were being performed exactly according to guidelines, with three antenatal visits per month, nutritional advice, and constant monitoring.

“However, if we can fill the shortage of midwives and reduce our field population assigned to each midwife to suit the needs of the present, we can provide a service that is more effective than what we see today,” she said.

According to her, midwives continue to advise pregnant mothers regarding the method of obtaining food to ensure proper nutrition. However, with the prevailing crisis, she noted that it was difficult to know how well pregnant mothers were following the instructions, given the difficulties in accessing nutritious food, especially for those in rural areas who are unable to focus on the nutrition or quantity of meals.

Moreover, the logistical cost of care has also risen. Prof. Fernandopulle noted that while midwives were spread across the country, their ability to conduct frequent household visits had been hampered by exorbitant transport costs and the lingering effects of the fuel crisis.

Meanwhile, postnatal care is less easily measured. The SLCOG President noted: “Postnatal care is difficult to quantify, since the performance indicators are not that clear. However, we have a good post-delivery care system with Medical Officers of Health, midwives, etc. We have the system in place, but things can improve.”

Demographic turning point

According to Prof. Fernandopulle, beyond service delivery, Sri Lanka faces a deeper structural challenge in its plummeting birth rate.

“The biggest problem we face as a country is that our birth rates are declining very sharply,” he warned. “In 2024, there were approximately 230,000 births. Just 10–12 years ago, there were 350,000 births. This means that new births have fallen by more than 100,000 in that short span.”

According to the Department of Census and Statistics, the provisional number of live births for 2025 stood at 214,570. A decade ago, in 2015, the number of live births stood at 336,097, showing a decline of over 120,000.

This shift carries long-term economic implications.

“The problem is that we are approaching the level of birth rates in developed countries like North America and Japan,” Prof. Fernandopulle warned. “The most dangerous part is that those countries are able to afford their dwindling populations since they are wealthy. If our birth rate continues to fall, as a poor country, Sri Lanka will need more people to contribute to the economy. That is why it’s important that our working population does not shrink.

“We are in very bad shape because our population won’t be enough to look after the needs of the people of the country, because the population will be ageing while economic productivity will be low,” he added.

As the local working population shrinks, he warned that developing nations would be simultaneously offering incentives to attract Sri Lanka’s remaining youth and skilled professionals.

Necessary improvements

Against this backdrop, professionals acknowledge that work needs to be done urgently to strengthen Sri Lanka’s lauded maternal healthcare system.

Kodithuwakku noted that while Sri Lanka’s maternal and child healthcare system was globally renowned and outperformed regional neighbours, significantly greater focus was needed from the authorities to advance and sustain the system.

“The Ministry of Health must act to develop our maternal and child healthcare system beyond its current state. As an association, and also as citizens, our goal should be to transform our Maternal Mortality Rate into a single-digit figure. That is when we win as a country. 

“It won’t do to stay boasting that we reduced maternal and infant deaths in our country compared to the numbers we used to have. We should strive to become a model for the world and bring our target to a much lower value. We can’t make it zero, but we must work together to bring it to a single-digit rate,” she said.

With PHMs being central to this progress, Kodithuwakku pointed out that attention was lacking in this regard.

“I don’t know if a new programme is being launched to address these needs. In particular, the shortage of PHMs must be filled. Previously, despite the shortage, there was no effort to reduce the population per midwife.” She also noted that there were difficulties in training more midwives in order to increase the current cadre.

The GMSA President further pointed out that with the theme of this year’s International Day of the Midwife, held on 5 May, being ‘One Million More Midwives,’ the world was also looking to add more midwives to the midwife service and improve maternal and child health services in qualitative terms.

“In Sri Lanka, the midwife service is one that shows results. It is a service through which we were able to show data demonstrating the high quality of our country’s health system. Therefore, there should be a programme to uplift that service. Yet, regretfully, we don’t see a specific strategy to achieve this at present,” she noted.

Echoing the need for a focused strategy, Prof. Fernandopulle pointed out that the focus should be on refining the existing machinery. 

“What we have achieved so far over the years since independence must be sustained, rather than taking U-turns and finding new ways, to ensure we don’t lose our way. We must make our current systems more effective, efficient, transparent, and equitable, rather than venturing down uncharted paths or conducting experiments,” he said.