Who decides to have sex? Exploring the perceptions of Timorese women and men through a reproductive justice lens.

Despite national policies to support sexual rights, Timorese women are constrained when making sexual and reproductive health decisions. Contextual understanding of sexual decision making is vital for effective engagement by sexual and reproductive health service providers with communities. An intersectional reproductive justice approach broadens the sexual rights lens allowing for an examination of multi-system factors impacting on sexual rights and health. Using the Matrix of Domination as a conceptual framework, we explored Timorese perceptions around decisions to have sex, and examined intersecting systems of oppression impacting on these decisions. Our study adopted a critical medical anthropological approach using ethnographic methods. A decolonising methodology aimed to make Timorese worldviews central to the analysis. Nine focus group discussions with 80 men and 17 individual reproductive history interviews with women were held in 4 of Timor-Leste's 13 municipalities during October 2015. Findings suggest that decisions to have sex are framed in terms of wishes and rights; however, it was the perceived entitlements of men that were prioritised and predominantly men who made these decisions. Violence, coercion and unwanted pregnancies were linked to decisions about sex, and identified as potential consequences for women, impacting on women's health and sexual rights.

What influences a woman's decision to access contraception in Timor-Leste? Perceptions from Timorese women and men.

Timor-Leste's Maternal Mortality Ratio remains one of the highest in Asia. There is ample evidence that maternal deaths may be reduced substantially through the provision of good-quality modern methods of contraception. Many Timorese women wish to stop or delay having children. However, even when health services make contraception available, it does not mean that people will use it. Collaborating with Marie Stopes Timor-Leste, this qualitative research project used decolonising methodology to explore perceived influences contributing to contraceptive choices, and gain insight into how women's decisions to access contraception in Timor-Leste occur. Over two fieldwork periods (2013 and 2015), we used focus group discussions and structured interviews to speak with 68 women and 80 men, aged 18-49 years, across four districts of Timor-Leste. Findings demonstrate that the decision to access contraception is often contentious and complicated. These tensions echo concerns and ambiguities contained within global and national reproductive health policy. Overwhelmingly, participants emphasised that despite her wishes, a woman can only rarely exercise her right to access contraception freely and independently. She is most often constrained by family, cultural, traditional and educational influences.

Body Mapping to Explore Reproductive Ethno-Physiological Beliefs and Knowledge of Contraception in Timor-Leste.

Maternal mortality remains a significant public health challenge for Timor-Leste. Although access to quality family planning measures may greatly reduce such deaths, consideration of indigenous perceptions, and how they influence reproductive health decision-making and behavior, is crucial if health services are to provide initiatives that are accepted and helpful in improving reproductive health outcomes. We aimed to demonstrate that body mapping is an effective method to traverse language and culture to gain emic insights and indigenous worldviews. The authors' two qualitative research projects (2013 and 2015) used a decolonizing methodology in four districts of Timor-Leste, body mapping with 67 men and 40 women to illuminate ethno-physiology and indigenous beliefs about conception, reproduction, and contraception. Body mapping provided a beneficial conduit for identifying established indigenous reproductive perceptions, understandings, and vocabulary, plus fears surrounding contraception. This may inform health service provision and engagement, ultimately improving the reproductive health of community members.

The decision to seek care antenatally and during labour and birth - Who and what influences this in Timor-Leste? A qualitative project exploring the perceptions of Timorese women and men.

BACKGROUND: While global maternal deaths have decreased significantly, hundreds of thousands of women still die from pregnancy and birth complications. Interventions such as skilled birth attendants, emergency transportation to health facilities and birth preparedness have been successful at reducing such deaths, however barriers to seeking, reaching, and receiving respectful care persist. OBJECTIVE: This study aimed to identify what influences people's decisions to seek antenatal care and care during labour and birth in Timor-Leste, a low-middle income newly independent nation in South East Asia with a high maternal death rate. The study aimed to provide emic/local insights to help midwives and maternal health providers tailor care and resources appropriately, thus improving maternal health. DESIGN: This qualitative study with a decolonising methodology, was designed to explore the perceptions of reproductive aged Timorese women and men, situating Timorese worldviews in the centre of the research process. Data collection occurred in four municipalities of Timor-Leste in October 2015 and included 9 focus group discussions with 80 men, and 17 individual reproductive history interviews with women. FINDINGS: An expanded 'Three Delays' model was used to frame the findings. The study found multiple factors impacting on decisions to seek antenatal care and care during labour and birth. Husbands, history, minimal birth preparedness, ethno-physiological beliefs (personal perceptions of how the body works), infrastructure limitations, geographical location, hospital policies and staff attitudes influenced and potentially delayed the decision to seek or reach care. KEY CONCLUSION AND IMPLICATIONS FOR PRACTICE AND POLICY: Policies and programs that increase accessibility of midwives and encourage birth preparedness are vital. Given the current locus of power in families in Timor-Leste, it is imperative that men are educated regarding the importance of care from skilled providers, and supported to access such care with their partners. Culturally respectful, inclusive and quality care needs to be emphasised so that trust is established between health providers and communities.