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Baseline assessment for maternal and newborn care in Timor Leste. MCH in Developing Countries January 12, 2010. Timor-Leste (formerly East Timor). A brief history of East Timor. Colonized by the Portuguese 1515-1974 Illegally invaded and brutally occupied by Indonesia 1975-1999

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Baseline assessment for maternal and newborn care in Timor Leste

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Baseline assessment for maternal and newborn care in timor leste l.jpg

Baseline assessment formaternal and newborn carein Timor Leste

MCH in Developing Countries

January 12, 2010


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Timor-Leste (formerly East Timor)


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A brief history of East Timor

  • Colonized by the Portuguese 1515-1974

  • Illegally invaded and brutally occupied by Indonesia 1975-1999

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

  • In May 2002 East Timor became the independent nation of Timor-Leste


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


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


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


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


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Many of the destroyed buildings are yet to be rebuilt


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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.


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Timor-Leste in 2004: situation analysis


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


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A subsistence agriculture economy, with

very high urban unemployment


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Poverty:

Timor-Leste is the

poorest country

in Asia: 40% of

the population

living under the

international poverty

line


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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


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Maternal Mortality Ratio: a country comparison

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


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The total fertility in 2003 was the highest recorded

in the world – 7.8 (post-conflict “rebound” fertility)


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96-98% of Timorese reported they were Catholic


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Language – four languages were in active use:

percent fluent (2003):

Women Men

Tetum74%80%

Portuguese1.2%2.3%

Indonesian22%32%

English0.2%0.2%


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The health infrastructure was being rebuilt


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


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

  • Approximately 20 Timorese physicians at time of independence

  • 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

  • Multiple uncoordinated international agencies in operation

  • Very little routinely collected health data available


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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

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

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

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

  • Contraceptive prevalence 8.5%


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Timorese Strengths

  • Strong and determined people

  • Revitalization of ancient, traditional culture and ‘national’ identity

  • Health personnel now in training both nationally and internationally

  • Strong MOH leadership

  • Timor oil reserves should provide economic boost in future years


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What else did we need to know?


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The Assessment

  • Health Facility / Staff Assessment in 4 districts

    • District health team questionnaire

    • Interviews / observations at 32 clinics

      • 30 clinic managers

      • 4 nurses and 46 midwives

      • 49 mothers attending clinic

    • Focus group discussions with midwives

  • Community Assessment in 2 districts

    • Focus group discussions with leaders, men and women

    • Interviews with mothers

    • Interviews with dukuns(TBAs)

  • Review of data for recent DHS Survey


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    Key Findings from the HFA:

    • Clinics

      • 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.

      • 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.


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    • Content of services:

      • Limited health education activities

      • ANC includes little or no counseling

      • No regular system for postnatal care of mothers/newborns

        • few postpartum home visits (transport, distance)

        • few babies are seen at HF before 1month of age (seclusion)

      • Very few outreach activities to communities

      • No health activities for MCH include men

      • Most mobile clinics do not do ANC (and none do postnatal care)


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    Key findings of the Community Assessment


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    Pregnancy period

    • 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

    • 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


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    Delivery practices

    • Little understanding of value of a skilled birth attendant for a ‘normal’ delivery

    • Strong preference for a home delivery

    • Traditional home delivery practices:

      • dark, private location on specially-built bed of bamboo, with labor, delivery, and postpartum period by an open fire

      • ample use of hot water for compresses, drinking, bathing

      • active role of the husband during labor

      • rope hanging from the ceiling to assist with pushing during the final stages

      • placenta is treated carefully, either buried in/near the home or hung in a tree


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    Postpartum period

    • 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


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    Newborn period

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

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

    • 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

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


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

    • Antenatal care?

    • Use of a skilled birth attendant?

    • An early postpartum check?

    • An early newborn care check?


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