1. MCH in Developing Countries January 10, 2012

2. 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

3. Timor-Leste (formerly East Timor)

6. Colonized by the Portuguese 1515-1974 Illegally invaded and brutally occupied by Indonesian military 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

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

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

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

10. Timor-Leste 2004 situation analysis: what we already knew

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

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

13. A subsistence agriculture economy, with very high urban unemployment

14. Poverty: Timor-Leste was the poorest country in Asia: 40% of the population living under the international poverty line

15. 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

16. Maternal Mortality Ratio: a country comparison Data Source: United Nations Statistics Division – Demographic, Social and Housing Statistics

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

18. Religion: 96-98% of Timorese were Catholic

19. percent fluent (2003): Women Men Tetum74%80% Portuguese1.2%2.3% Indonesian22%32% English0.2%0.2%

21. Referral facilities: Dili National Hospital

23. 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

24. 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%

25. Strong and determined people Revitalization of ancient, traditional culture and ‘national’ identity Health personnel in training both nationally and internationally Strong MOH leadership Timor oil reserves expected to provide an economic boost in future years

27. 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

28. 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.

29. 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 communities No health activities for MCH include men Most mobile clinics do not do ANC (and none do postnatal care)

31. 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

32. 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 labor 4.rope hanging from the ceiling to assist with pushing during the final stages 5.placenta is treated carefully, either buried in/near the home or hung in a tree Delivery practices

33. 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

34. “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

35. Antenatal care? Use of a skilled birth attendant? An early postpartum check? An early newborn care check?

36. Thank you!