Baseline assessment for maternal and newborn care in Timor Leste

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Baseline assessment formaternal and newborn
carein Timor Leste
MCH in Developing Countries January 10, 2008
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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 had 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 countrys 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 today situation analysis
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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 lives 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 report they are Catholic
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Challenge language four languages are in
active use

• percent fluent (2003)
• Women Men
• Tetum 74 80
• Portuguese 1.2 2.3
• Indonesian 22 32
• English 0.2 0.2

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Challenge Rebuilding the health infrastructure
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Challenge Access -- Rural populations have moved
back to their ancestral homes, and so health
services are less accessible than previously
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Challenge Timorese trained human resource pool
is 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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Timor today 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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• 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
• Mobile clinics do not all 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
• Many women also seek care from dukuns, or
  traditional birth attendants
• Most women take traditional medicines during
  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 (fase matan),
  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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