MCH in Developing CountriesJanuary 10, 2012

Using a Timor-Leste maternal and newborn care project as a case example:

1.Explain background information needed for a baseline assessment, including country history and current setting

2.Describe the key components and results of the assessment

3.Brainstorm how the baseline information could be used to plan program approaches

Timor-Leste (formerly East Timor)

Colonized by the Portuguese 1515-1974Illegally invaded and brutally occupied

by Indonesian military 1975-1999In 1999, the East Timorese

overwhelmingly voted for independence from Indonesia

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

After the 1999 referendum, the military and their militias carried out a campaign of violence that

destroyed 75-80% of the country’s infrastructure.

Timor-Leste 2004 situation analysis: what we already knew

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

Violence against women, including rape and sexual slavery, had been widespread and systematic

A subsistence agriculture economy, with very high urban unemployment

Poverty:

Timor-Leste was 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 I ndonesia Bangladesh Cambodia I ndia Timor Leste

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

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

Religion: 96-98% of Timorese were Catholic

percent fluent (2003):

Women MenTetum 74% 80%Portuguese 1.2% 2.3%Indonesian 22% 32%English 0.2% 0.2%

Referral facilities: Dili National Hospital

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

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%

Strong and determined people Revitalization of ancient, traditional culture and

‘national’ identityHealth personnel in training both nationally and

internationallyStrong MOH leadershipTimor oil reserves expected to provide an

economic boost in future years

Health Facility / Staff Assessment in 4 districts

District health team questionnaire Interviews / observations at 32 clinics

30 clinic managers4 nurses and 46 midwives49 mothers attending clinic

Focus group discussions with midwives

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

womenInterviews with mothers Interviews with dukuns (TBAs)

Review of data for recent DHS Survey

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 basic amenities for deliveries: water and electricity often not available.

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

Supplies: Shortages of basic medications, family planning supplies. No equipment/supplies for neonatal care and resuscitation at birth.

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 1 month of

age (postpartum seclusion)Very few outreach activities to communitiesNo health activities for MCH include menMost mobile clinics do not do ANC (and none

do postnatal care)

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

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

• Strongly prefer home delivery• Traditional 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 labor4. rope hanging from the ceiling to assist with

pushing during the final stages5. placenta is treated carefully, either buried

in/near the home or hung in a tree

Delivery practices

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

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

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

Parents often recognize signs of newborn illness

Newborn morbidity/mortality ascribed to supernatural (or social) causes, so 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

Antenatal care?

Use of a skilled birth attendant?

An early postpartum check?

An early newborn care check?

Thank you!