mch in developing countries january 10, 2012. using a timor-leste maternal and newborn care project...
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MCH in Developing CountriesJanuary 10, 2012
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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
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Timor-Leste (formerly East Timor)
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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
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Timorese 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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After the 1999 referendum, the military and their militias carried out a campaign of violence that
destroyed 75-80% of the country’s infrastructure.
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Timor-Leste 2004 situation analysis: what we already knew
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The traditional Timorese culture is strong, complex, and family/clan-centered
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Violence against women, including rape and sexual slavery, had been widespread and systematic
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A subsistence agriculture economy, with very high urban unemployment
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Poverty:
Timor-Leste was thepoorest countryin Asia: 40% ofthe populationliving under the international povertyline
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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
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
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Fertility -- in 2003 it was the highest recorded in the world – 7.8 (post-conflict “rebound” fertility)
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Religion: 96-98% of Timorese were Catholic
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percent fluent (2003):
Women MenTetum 74% 80%Portuguese 1.2% 2.3%Indonesian 22% 32%English 0.2% 0.2%
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Referral facilities: Dili National Hospital
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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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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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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
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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
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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.
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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)
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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
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• 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
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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 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
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Antenatal care?
Use of a skilled birth attendant?
An early postpartum check?
An early newborn care check?
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Thank you!