Baseline assessment for maternal and newborn care in Timor Leste MCH in Developing Countries January 11, 2011

Timor-Leste (formerly East Timor)

A brief history of East Timor Colonized by the Portuguese Colonized by the Portuguese Illegally invaded and brutally occupied by Indonesia Illegally invaded and brutally occupied by Indonesia In 1999, the East Timorese overwhelmingly voted for independence from Indonesia In 1999, the East Timorese overwhelmingly voted for independence from Indonesia In May 2002 East Timor became the independent nation of Timor-Leste In May 2002 East Timor became the independent nation of Timor-Leste

Timorese suffered untold abuses of human rights at the hands of the Indonesian military during 24 years of illegal occupation

An estimated 1/3 of the Timorese population died as a result of the Indonesian occupation

Violence against women, including rape and sexual slavery, was widespread and systematic

After the 1999 referendum, the military and their militias carried out a campaign of violence that destroyed 75-80% of the country’s infrastructure.

Many of the destroyed buildings are yet to be rebuilt

After 3 weeks, the violence was ended by an international peace keeping force led by the UN in September In 2002 the UN transferred government functions to the Timorese.

Timor-Leste in 2004: situation analysis

The Timorese culture is strong, complex, and family/clan-centered

A subsistence agriculture economy, with very high urban unemployment

Poverty: Timor-Leste is the poorest country in Asia: 40% of the population living under the international poverty line

Basic Health Statistics Maternal Mortality Rate = /100,000 † Infant Mortality Rate = 84/1,000 †† Neonatal Mortality Rate = 43/1,000 †† Under 5 Mortality Rate = 109/1,000 †† Life Expectancy at birth = 62 ††† † Data Source: Health Profile: Democratic Republic of Timor Leste †† Data Source: TL DHS 2003 †††Data Source: The World Bank Group, Timor Leste Data Profile

Maternal Mortality Ratio: a country comparison Data Source: United Nations Statistics Division – Demographic, Social and Housing Statistics

The total fertility in 2003 was the highest recorded (post-conflict “rebound” fertility) in the world – 7.8 (post-conflict “rebound” fertility)

96-98% of Timorese reported they were Catholic

Language – four languages were in active use: percent fluent (2003): Women Men Tetum74%80% Portuguese1.2%2.3% Indonesian22%32% English0.2%0.2%

The health infrastructure was being rebuilt

Health facilities access -- Rural populations had moved back to their ancestral homes, and so health services were less accessible than previously

Timorese trained human resource pool was very small, health system still under development Approximately 20 Timorese physicians at time of independence Approximately 20 Timorese physicians at time of independence A large pool of trained midwives, but suboptimal training, little management/leadership experience A large pool of trained midwives, but suboptimal training, little management/leadership experience Smaller MOH staff (IMF restrictions on total health staff numbers) than previously Smaller MOH staff (IMF restrictions on total health staff numbers) than previously Multiple uncoordinated international agencies in operation Multiple uncoordinated international agencies in operation Very little routinely collected health data available Very little routinely collected health data available

Challenge: Low health care utilization (due to ? traditional beliefs, distrust of the health system) Historically, utilization in Timor was lower than many of the Indonesian provinces Historically, utilization in Timor was lower than many of the Indonesian provinces Traditional beliefs about health and healing remain very strong, traditional healers prominent Traditional beliefs about health and healing remain very strong, traditional healers prominent 90% of deliveries occur at home, most without a skilled birth attendant 90% of deliveries occur at home, most without a skilled birth attendant Antenatal care 44%, postpartum and newborn care virtually nil Antenatal care 44%, postpartum and newborn care virtually nil Contraceptive prevalence 8.5% Contraceptive prevalence 8.5%

Timorese Strengths Strong and determined people Strong and determined people Revitalization of ancient, traditional culture and ‘national’ identity Revitalization of ancient, traditional culture and ‘national’ identity Health personnel now in training both nationally and internationally Health personnel now in training both nationally and internationally Strong MOH leadership Strong MOH leadership Timor oil reserves should provide economic boost in future years Timor oil reserves should provide economic boost in future years

What else did we need to know?

The Assessment Health Facility / Staff Assessment in 4 districts Health Facility / Staff Assessment in 4 districts District health team questionnaire District health team questionnaire Interviews / observations at 32 clinics Interviews / observations at 32 clinics 30 clinic managers30 clinic managers 4 nurses and 46 midwives4 nurses and 46 midwives 49 mothers attending clinic49 mothers attending clinic Focus group discussions with midwives Focus group discussions with midwives Community Assessment in 2 districts Community Assessment in 2 districts Focus group discussions with leaders, men and women Focus group discussions with leaders, men and women Interviews with mothers Interviews with mothers Interviews with dukuns (TBAs) Interviews with dukuns (TBAs) Review of data for recent DHS Survey Review of data for recent DHS Survey

Key Findings from the HFA: Clinics Clinics Lack adequate not private, not clean, not staffed at night and not inclusive of cultural traditions. No place for care/resuscitation of the baby.Lack adequate space for ANC/delivery: not private, not clean, not staffed at night and not inclusive of cultural traditions. No place for care/resuscitation of the baby. Limited amenities for deliveries: water and electricity often not available.Limited amenities for deliveries: water and electricity often not available. Lack adequate lack communication, insufficient transport (ambulances and fuel budgets), 2 health centers and 18 health posts have no road access in wet season.Lack adequate logistics for emergency referral: lack communication, insufficient transport (ambulances and fuel budgets), 2 health centers and 18 health posts have no road access in wet season. Supplies: Shortages of some basic medications and family planning supplies. No equipment/supplies for neonatal care and resuscitation at birth.Supplies: Shortages of some basic medications and family planning supplies. No equipment/supplies for neonatal care and resuscitation at birth.

Content of services:Content of services: Limited health education activities Limited health education activities ANC includes little or no counseling ANC includes little or no counseling No regular system for postnatal care of mothers/newborns No regular system for postnatal care of mothers/newborns few postpartum home visits (transport, distance)few postpartum home visits (transport, distance) few babies are seen at HF before 1month of age (seclusion)few babies are seen at HF before 1month of age (seclusion) Very few outreach activities to communities Very few outreach activities to communities No health activities for MCH include men No health activities for MCH include men Most mobile clinics do not do ANC (and none do postnatal care) Most mobile clinics do not do ANC (and none do postnatal care)

Key findings of the Community Assessment

Pregnancy period Women tend to understand the importance of antenatal care and will go for care when it is reasonably accessible Women tend to understand the importance of antenatal care and will go for care when it is reasonably accessible Some women also seek care from dukuns, or traditional birth attendants Some women also seek care from dukuns, or traditional birth attendants Most women take traditional medicines during pregnancy, have other traditional practices to safeguard the pregnancy Most women take traditional medicines during pregnancy, have other traditional practices to safeguard the pregnancy Some fear taking iron tablets or vitamins fearing a large baby and difficult delivery Some fear taking iron tablets or vitamins fearing a large baby and difficult delivery

Little understanding of value of a skilled birth attendant for a ‘normal’ delivery Strong preference for a home delivery Traditional home delivery practices: 1.dark, private location on specially-built bed of bamboo, with labor, delivery, and postpartum period by an open fire 2.ample use of hot water for compresses, drinking, bathing 3.active role of the husband during labor 4.rope hanging from the ceiling to assist with pushing during the final stages 5.placenta is treated carefully, either buried in/near the home or hung in a tree Delivery practices

Postpartum period The practice of postpartum care provided by a midwife or nurse is virtually nonexistent The practice of postpartum care provided by a midwife or nurse is virtually nonexistent Traditional ways of caring for mothers following delivery include 40 days of seclusion by a fire (“sitting fire”), special foods, hot water to drink/bathe with, and rest Traditional ways of caring for mothers following delivery include 40 days of seclusion by a fire (“sitting fire”), special foods, hot water to drink/bathe with, and rest

Newborn period “Newborn care” = clinic visit for immunizations at age 1 month “Newborn care” = clinic visit for immunizations at age 1 month Universal breastfeeding, but with early supplementation, often no colostrum given Universal breastfeeding, but with early supplementation, often no colostrum given Parents often recognize the signs of newborn illness Parents often recognize the signs of newborn illness Newborn morbidity/mortality are often ascribed to supernatural (or social) causes, so often a delay in seeking medical attention Newborn morbidity/mortality are often ascribed to supernatural (or social) causes, so often a delay in seeking medical attention At age 3-5 days, special family ceremony and feast to welcome the new baby (fase matan), including the birth attendant At age 3-5 days, special family ceremony and feast to welcome the new baby (fase matan), including the birth attendant

Question: how might you use these baseline findings to develop one or two activities to promote : Antenatal care? Antenatal care? Use of a skilled birth attendant? Use of a skilled birth attendant? An early postpartum check? An early postpartum check? An early newborn care check? An early newborn care check?