1. Making Facilities Birth-Friendly in Timor-Leste Susan Thompson, MPH Health Alliance International University of Washington, Seattle, WA

2. 2005 Baseline Assessment Common understanding that a MW should only be called if there is a problem Strong preference for home delivery Husbands/family play an active role in birth preparation & delivery Traditional birthing practices important

3. Negative Associations with Facility-based Births Lack of privacy No hot water No traditional wooden bed No rope hanging from ceiling Family members not always welcome

4. Concept Development: Birth-Friendly Facilities Create a comfortable space that respects desired traditional practices where women and families can delivery their babies Involvement with key stakeholders  Partnership with the MOH  Strong community socialization process  Connected health staff with communities Local investment  Rebuilt a destroyed building  Used local labor and materials Complete integration into MOH system

5. Birth-Friendly Facility: Program Objectives Increase # of women delivering with SBA Increase knowledge of benefits of SBA Improve linkages between community & health facility Improve health staff understanding of desired traditional birthing practices

6. Birth-Friendly Facilities

7. Inauguration of Birth-Friendly Facilities

8. Formative Evaluation Methods Qualitative – Semi-structured interviews – Key informant interviews – Focus group discussions – Observations Quantitative – Analysis of utilization trends

9. Evaluation Questions Who is the BFF serving? Are BFF users & providers satisfied? What factors influence use of the BFF? What are the barriers to utilization? Has knowledge changed in the community? Is SBA increasing?

10. Respondent Demographics BFF Users BFF Non- users Mean age26.4 years25.9 years No formal education33%56% Primary school education 27%22% Mean # of children3.134.22 Mean # of pregnancies3.734.89

11. Findings Non UsersUsers None had experience of a facility-based birth 50% of women had a previous facility-based birth Little experience of SBAHad more experience with SBA in the past Lack of family supportFamily supported decision Labor progressed quickly and/or at night

12. What influences the use of BFF? Knowing midwife is available Perception of safety/fear of complications BFF is “complete” with MW, medicines, equipment Traditional practices possible Family support Respect Families welcomed “I thought the BFF would be the same as the clinic, but when I saw inside and realized that there was a wooden bed and rope, I was really happy.”

13. Barriers to Using the BFF Lack of transportation Fear Unaware of benefit of SBA No birth plan “I thought about using the BFF, but I went into labor at night, and I was scared to walk to the clinic…I worried that I would deliver my baby while traveling to the facility.”

14. Skilled Birth Attendance: Maubara

15. Skilled Birth Attendance: Remexio

16. Brainstorming We would like you to think about how you would approach expanding the use of the Birth-Friendly Facilities. What programmatic adaptations could be implemented at the community or facility level?

17. What did we learn? Achieving change of deeply entrenched practices is a process which requires time Engaging communities throughout the entire process of a community-based program is the key to success Formative evaluation of the implementation phase can identify adaptation needs at an early stage

18. What did we learn? (cont) Birth planning needs more focused promotion Need outreach health promotion to remote areas with less access to health system MOH ownership key to sustainability Work with MOH & communities to expand the use of the BFF space