1. Family Planning Programming in Timor-Leste Maternal and Child Health in Developing Countries February 2011

2. HEALTH ALLIANCE INTERNATIONAL Why Family Planning Matters  Spacing pregnancies at least 3 years = healthier moms and healthier babies  Contributes to women’s empowerment through more opportunities in education, employment, community involvement  FP is one of the most cost effective life saving public health interventions in the world (Mosely)

3. HEALTH ALLIANCE INTERNATIONAL Map of Timor-Leste

4. HEALTH ALLIANCE INTERNATIONAL Timor-Leste: New nation in 2002

5. HEALTH ALLIANCE INTERNATIONAL The Indonesian Legacy 24 years of brutal Indonesian military occupation An estimated 100,000 – 250,000 died, human rights abuses: torture, imprisoned, rape, forced displacement Keluarga Berencana Indonesian FP program ‘Dua anak cukup’ Coercive family planning programming in East Timor

6. HEALTH ALLIANCE INTERNATIONAL Post-conflict Age Pyramid - 2003 A dearth of males aged in their twenties A very youthful population with 52% of the population < 15 years A post-independence baby boom

7. HEALTH ALLIANCE INTERNATIONAL Religion & Culture Strong animist beliefs and practices are prevalent among Timorese 97% of Timorese identify as Catholic

8. HEALTH ALLIANCE INTERNATIONAL Household Characteristics Majority of the population live in rural areas, often hard to access 28% of households have electricity urban = 74% rural areas = 3% - 20% Only about half of households obtain their drinking water from a protected source

9. HEALTH ALLIANCE INTERNATIONAL Education and Literacy For older women 40-44 years of age, 81% have received no schooling Overall, 37% of the population have received no schooling 44% of women and 43% of men are unable to read

10. HEALTH ALLIANCE INTERNATIONAL Household Characteristics Radio: 64% ever listen TV: 35% ever watch Newspaper: 18% ever read 4% of households have a motorcycle, 1.5% a private car/truck GNI per capita in 2003 = $460/year Firewood is the major source of cooking fuel

11. HEALTH ALLIANCE INTERNATIONAL MOH Health System Post-Independence Vote (supply-side) Human resource pool at low level; few Timorese doctors; new Program to train CHWs MOH ‘under construction’ with the development of policies and strategic approaches Health facilities destroyed and poorly equipped Midwives the backbone of the Health—lots of training provided Safe Motherhood/FP

12. HEALTH ALLIANCE INTERNATIONAL Community Utilization of Health Services (demand-side) t Distrust and very low utilization of government health services Difficult access to reach a health facility Strong traditional beliefs and practices regarding health and care seeking

13. HEALTH ALLIANCE INTERNATIONAL Utilization of Services 90% of women deliver at home 20% of births were attended by a SBA Only 10% current users of a modern contraceptive Postpartum and newborn care negligible

14. HEALTH ALLIANCE INTERNATIONAL Baseline Data  MMR: 800/100,000  IMR: 80-90/1000 l  Under five mortality: 120-130/1000

15. HEALTH ALLIANCE INTERNATIONAL 2003 DHS Family Planning Data TFR at 7.8 births per woman is the highest in the world Over 60% of women cannot spontaneously identify a method of contraception Overall, “ideal” family size is 5.7 children Only 19% of women have ever used contraception 10% currently using a method

16. HEALTH ALLIANCE INTERNATIONAL Percentage of Women Wanting No More Children by Current Parity: Country Comparison Number of living children 0123456 Timor Leste 20031.13.46.211.017.424.033.7 Cambodia 20003.07.828.344.151.551.051.6 Indonesia 2002/32.811.358.479.488.990.489.2 Philippines 19981.416.853.274.684.887.189.1 Vietnam 20021.615.791.993.994.696.291.2

17. HEALTH ALLIANCE INTERNATIONAL Your turn! How would you propose HAI respond to the situational analysis in order to develop a program to promote demand for family planning What additional information do you need? What are some key strategies you would you employ? What are 2-3 key messages you would recommend?

18. HEALTH ALLIANCE INTERNATIONAL HAI Program: ‘Promoting community demand for child spacing in Timor-Leste’ Baseline Qualitative Assessment  Describe the prevailing knowledge, beliefs, practices, preferences and care-seeking behaviors related child spacing  What & who influences reproductive choices?  What do women and families want with regard to spacing their children or limiting family size?  How do community members access and use information regarding child spacing?

19. HEALTH ALLIANCE INTERNATIONAL “My mother said I should have many children because I am the only girl in the my family.” “Two to three children is not enough for me, I would like to have nine children. “ “Because people have many children they can’t afford to feed them and have not money to pay for the school fee.”

20. HEALTH ALLIANCE INTERNATIONAL “When we want to stop having babies then we inform the Kukunain (magic/mystic man), so that they can ask at the Sacred House and we will not get pregnant again.” “The number of children is determined by the husband’s parents. We just do whatever they say because they gave the dowry for us.” (female respondent) “I think for child spacing ideally 2 to 5 years to have a child again, should give time to the mother to get strong again.”

21. HEALTH ALLIANCE INTERNATIONAL Improve capacity of MOH family planning services  Partner with MOH to improve the quality of services delivered through integrated MNC supervision visits of MWs  Provided follow-up FP skills check for MWs  Conducted workshops to train MWs on working in communities and improving counseling skills  Developed health promotion tools and provided MOH staff and CHW training for use in communities

22. HEALTH ALLIANCE INTERNATIONAL Increase community demand Emphasized the notion of child spacing versus limiting family size  Community level health promotion  Benefits of spacing your children  Target men and family members as well as women  Increase knowledge of modern methods  Debunking some myths  For legitimacy and entry into communities, worked closely with MOH, Church and Village Chiefs/Leaders

23. HEALTH ALLIANCE INTERNATIONAL Child Spacing Film: Espaco Oan Developed and produced a culturally relevant two- part film  MOH and Church buy-in  Work with community stakeholders to schedule community viewing  Train local NGO team to show film conduct community conversation  Village-based community viewing with follow-up discussion

24. HEALTH ALLIANCE INTERNATIONAL Bringing Espaco Oan to communities

25. HEALTH ALLIANCE INTERNATIONAL ‘Mai Ita Koko’ (Come lets try): CHW home visits

26. HEALTH ALLIANCE INTERNATIONAL Results: 2003 & 2010 DHS  TFR decreased: 7.8 to 5.7  CPR doubled: 10% to 22% (still lots to do!)  Significant increase in desire to delay or limit childbearing  Desire to have another child soon: 32.4% to 8.5%  Desire to have another child later: 10.5% to 35.7%  Desire no more children: 17% to 34.7%

27. HEALTH ALLIANCE INTERNATIONAL Results: 2003 DHS/HAI 2008 Survey

28. HEALTH ALLIANCE INTERNATIONAL Thank you!