By: Rati Bishnoi, Special Projects Intern at Women Deliver
While Timor-Leste obtained independence almost 10 years ago, it continues to suffer the aftereffects of a decades-long independence struggle against Indonesia and to face many challenges, such as building its health system and lowering its high fertility and maternal mortality rates.
One unique challenge in Timor-Leste is a widespread perception among the Timorese people that the previous regime wanted to control the size of their population with forced contraception, according to a recent Health Alliance International report. Grappling with this legacy in addition to cultural practices, such as a dowry system in which new wives are expected to provide children, and a religious context that opposes contraception has contributed to low contraceptive use and knowledge. According to Health Alliance International, only 8 percent of women use any contraceptive method, only 38 percent of ever-married women and 30 percent of ever-married men can recognize a contraceptive, and less than one-third know how to obtain contraceptive supplies or information.
A high fertility rate combined with low contraceptive usage and a still-developing health system makes Timor-Leste one of the most dangerous places to give birth in Southeast Asia. According to the World Health Organization, Timor-Leste’s maternal mortality rate is estimated at 370 deaths for every 100,000 live births.
Though health officials wanted to work to reduce the maternal deaths, they also recognized that Timor-Leste’s history demanded a particularly sensitive and careful approach to promoting the benefits of family planning. As a result, program officials conducted a qualitative assessment in select regions to gather information on the Timorese people’s beliefs, practices, and knowledge of family planning. The assessment confirmed that most families did not favor family planning as a means for limiting family size, but did embrace it as a way for spacing pregnancies.
To combat misinformation and rumors, Health Alliance International partnered with the Timorese Ministry of Health to create a program that addressed the lack of accurate information about family planning methods and incorporated education into existing maternal care programs. The first part of the program focused on making midwives the hub of information regarding family planning. Ministry of Health Midwives were trained by Health Alliance International “master trainer” midwives on conducting procedures, such as placing intrauterine devices and inserting contraceptive implants. This training supported midwives clinical, outreach, and motivational skills. The second component focused on using home visits and group meetings with men and women to talk about family planning and promote behavior change. For example, midwives used simple, culturally relevant, and action-oriented images and messages to encourage women and families to use skilled birth attendants during deliveries or employ a family planning method during the postpartum period.
To address community member fears regarding the benefits of family planning, health officials used a two part film to provide credible evidence about the importance of perinatal care and birth spacing.
Focus groups with viewers of the film revealed that most families accepted the message that spacing children by three years was beneficial for the health of women and children and a family’s financial stability. A household survey of the program in 2008 revealed that contraceptive prevalence rate in regions where the integrated family planning and maternal health approach was adopted was 26 percent, up from 8 percent five years earlier. There was also a dramatic increase in knowledge with the proportion of women who could recognize at least one family planning method spiking to 83 percent compared to 38 percent in 2003.
According to Health Alliance International, the program’s success suggests that “rural communities, even very traditional ones” may be open to using family planning to better space births and improve maternal and child health. In addition, showing that family planning and child spacing are beneficial to the health and welfare of women and infants also helps midwives view family planning as “a logical and essential element of their work.”
Photo via United Nations Photo