Baseline assessment forBaseline assessment formaternal and newborn carematernal and newborn care

in Timor Lestein Timor Leste

MCH in Developing CountriesJanuary 11, 2011

Timor-Leste (formerly East Timor)

A brief history of East TimorA brief history of East Timor

Colonized by the Portuguese 1515-Colonized by the Portuguese 1515-19741974

Illegally invaded and brutally occupied Illegally invaded and brutally occupied by Indonesia 1975-1999by Indonesia 1975-1999

In 1999, the East Timorese In 1999, the East Timorese overwhelmingly voted for overwhelmingly voted for independence from Indonesiaindependence from Indonesia

In May 2002 East Timor became the In May 2002 East Timor became the independent nation of Timor-Lesteindependent 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 1999. 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 thepoorest countryin Asia: 40% ofthe populationliving under the international povertyline

Basic Health Statistics

Maternal Mortality Rate = 660-800/100,000†

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

130

230

380

450

540

660

0

100

200

300

400

500

600

700

Vietnam Indonesia Bangladesh Cambodia India Timor Leste

Data Source: United Nations Statistics Division – Demographic, Social and Housing Statistics

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

96-98% of Timorese reported they were Catholic

Language – four languages were in active Language – four languages were in active use:use:

percent fluent (2003):percent fluent (2003):

Women Men

Tetum 74% 80%Portuguese 1.2% 2.3%Indonesian 22% 32%English 0.2% 0.2%

The health infrastructure was being rebuiltThe health infrastructure was being rebuilt

Health facilities access -- Rural populations had Health facilities access -- Rural populations had moved back to their ancestral homes, and so health moved back to their ancestral homes, and so health

services were less accessible than previouslyservices were less accessible than previously

Timorese trained human resource pool was Timorese trained human resource pool was very small, health system still under very small, health system still under

developmentdevelopment

Approximately 20 Timorese physicians at time of Approximately 20 Timorese physicians at time of independenceindependence

A large pool of trained midwives, but suboptimal A large pool of trained midwives, but suboptimal training, little management/leadership experience training, little management/leadership experience

Smaller MOH staff (IMF restrictions on total health Smaller MOH staff (IMF restrictions on total health staff numbers) than previouslystaff numbers) than previously

Multiple uncoordinated international agencies in Multiple uncoordinated international agencies in operationoperation

Very little routinely collected health data availableVery little routinely collected health data available

Challenge: Low health care utilization Challenge: Low health care utilization (due to ? traditional beliefs, (due to ? traditional beliefs, distrust of the health system)distrust of the health system)

Historically, utilization in Timor was lower than Historically, utilization in Timor was lower than many of the Indonesian provincesmany of the Indonesian provinces

Traditional beliefs about health and healing Traditional beliefs about health and healing remain very strong, traditional healers prominent remain very strong, traditional healers prominent

90% of deliveries occur at home, most without a 90% of deliveries occur at home, most without a skilled birth attendantskilled birth attendant

Antenatal care 44%, postpartum and newborn Antenatal care 44%, postpartum and newborn care virtually nilcare virtually nil

Contraceptive prevalence 8.5%Contraceptive prevalence 8.5%

Timorese Strengths Timorese Strengths

Strong and determined people Strong and determined people Revitalization of ancient, traditional culture Revitalization of ancient, traditional culture

and ‘national’ identityand ‘national’ identity Health personnel now in training both Health personnel now in training both

nationally and internationallynationally and internationally Strong MOH leadershipStrong MOH leadership Timor oil reserves should provide economic Timor oil reserves should provide economic

boost in future yearsboost in future years

What else did we need to What else did we need to know?know?

The AssessmentThe Assessment Health Facility / Staff Assessment in 4 Health Facility / Staff Assessment in 4

districtsdistricts District health team questionnaire District health team questionnaire Interviews / observations at 32 clinicsInterviews / observations at 32 clinics

• 30 clinic managers30 clinic managers• 4 nurses and 46 midwives4 nurses and 46 midwives• 49 mothers attending clinic 49 mothers attending clinic

Focus group discussions with midwivesFocus group discussions with midwives

Community Assessment in 2 districts Community Assessment in 2 districts Focus group discussions with leaders, men and Focus group discussions with leaders, men and

womenwomen Interviews with mothers Interviews with mothers Interviews with Interviews with dukuns dukuns (TBAs)(TBAs)

Review of data for recent DHS Survey Review of data for recent DHS Survey

Key Findings from the HFA:Key Findings from the HFA: ClinicsClinics

• Lack adequate Lack adequate space for ANC/delivery: not private, not not private, not clean, not staffed at night and not inclusive of cultural clean, not staffed at night and not inclusive of cultural traditions. No place for care/resuscitation of the baby.traditions. No place for care/resuscitation of the baby.

• Limited Limited amenities for deliveriesamenities for deliveries: water and electricity : water and electricity often not available.often not available.

• Lack adequate Lack adequate logistics for emergency referral: lack lack communication, insufficient transport (ambulances and communication, insufficient transport (ambulances and fuel budgets), 2 health centers and 18 health posts have fuel budgets), 2 health centers and 18 health posts have no road access in wet season.no road access in wet season.

• SuppliesSupplies: Shortages of some basic medications and : Shortages of some basic medications and family planning supplies. No equipment/supplies for family planning supplies. No equipment/supplies for neonatal care and resuscitation at birth. neonatal care and resuscitation at birth.

• Content of servicesContent 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 No regular system for postnatal care of

mothers/newborns mothers/newborns • few postpartum home visits (transport, few postpartum home visits (transport,

distance)distance)• few babies are seen at HF before 1month of few babies are seen at HF before 1month of

age (seclusion)age (seclusion) Very few outreach activities to communitiesVery few outreach activities to communities No health activities for MCH include menNo health activities for MCH include men Most mobile clinics do not do ANC (and none do Most mobile clinics do not do ANC (and none do

postnatal care) postnatal care)

Key findings Key findings of the of the

Community AssessmentCommunity Assessment

Pregnancy periodPregnancy period

Women tend to understand the importance of Women tend to understand the importance of antenatal careantenatal care and and willwill go for care when it is go for care when it is reasonably accessible reasonably accessible

Some women also seek care from Some women also seek care from dukuns,dukuns, or or traditional birth attendants traditional birth attendants

Most women take traditional medicines during Most women take traditional medicines during pregnancy, have other traditional practices to pregnancy, have other traditional practices to safeguard the pregnancysafeguard the pregnancy

Some fear taking iron tablets or vitamins fearing Some fear taking iron tablets or vitamins fearing a large baby and difficult deliverya 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 periodPostpartum period The practice of The practice of

postpartum care provided postpartum care provided by a midwife or nurse is by a midwife or nurse is virtually nonexistentvirtually nonexistent

Traditional ways of caring Traditional ways of caring for mothers following for mothers following delivery include 40 days delivery include 40 days of seclusion by a fire of seclusion by a fire (“sitting fire”),(“sitting fire”), special special foods, hot water to foods, hot water to drink/bathe with, and restdrink/bathe with, and rest

Newborn periodNewborn period

““Newborn care” = clinic visit for immunizations at Newborn care” = clinic visit for immunizations at age 1 monthage 1 month

Universal breastfeeding, but with early Universal breastfeeding, but with early supplementation, often no colostrum givensupplementation, often no colostrum given

Parents often recognize the signs of newborn Parents often recognize the signs of newborn illness illness

Newborn morbidity/mortality are often ascribed to Newborn morbidity/mortality are often ascribed to supernatural (or social) causes, so often a delay supernatural (or social) causes, so often a delay in seeking medical attention in seeking medical attention

At age 3-5 days, special family ceremony and At age 3-5 days, special family ceremony and feast to welcome the new baby feast to welcome the new baby (fase matan),(fase matan), including the birth attendantincluding the birth attendant

Question: how might you use these Question: how might you use these baseline findings to develop one or two baseline findings to develop one or two

activities to promoteactivities 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?