Timorese women's experiences and expectations of skilled birth attendance in Timor-Leste: A qualitative inquiry.

OBJECTIVE: The study explores women's experiences and expectations of maternity care in Timor-Leste. METHOD: Qualitative, descriptive research using focused ethnography. Thirty women and seventeen health professionals from three districts in Timor-Leste were interviewed and/or participated in focus groups. RESULTS: Women's expectations of care include the provision of information, advice and clinical assessment from midwives who have the capacity to provide emergency obstetric care if required. Midwives' access to technology (for example: the fetal doppler), increased the women's confidence in services. The women also identified poor experiences, including angry, busy midwives, poor communication, and lack of privacy in antenatal and birthing services. The lack of privacy inhibits women's communication with health professionals. An absence of covers and multiple staff present during labour and birth embarrass the women and their families. Many Timorese women live in poverty and have poor literacy skills. These women want knowledgeable, approachable, and clinically competent midwives who can support them through their pregnancies and childbirth. Poor communication, angry, busy midwives and lack of privacy cause discomfort and embarrassment and may discourage the women and their family's uptake of skilled birth attendant (SBA) services. CONCLUSION: Midwives have a critical primary role in the provision of advice, information and care of Timorese women during the childbirth continuum. Continuing education of midwives with an emphasis on communication and culturally congruent care will improve women's satisfaction and childbirth outcomes. Impoverished women are particularly vulnerable when birthing in health care services. Attention to the women's privacy and her additional needs can include a focus on the birthing space and the number of staff who have access to it.

Security from above and below: A critical ethnography of the health response to violence against women in Timor-Leste.

International advocacy and evidence have been critical for shifting the pervasive issue of violence against women onto the health agenda. Guidelines and training packages, however, can be underpinned by Western principles of responding to individual survivors of violence and availability of specialist referral services, which may not be available in many countries. As Timor-Leste and other nations begin to build their health system response to violence against women, it is important to understand the current practices of health providers and the broader sociocultural context of providing care to survivors of violence. During 11 months in the field (February-December 2016), we conducted qualitative interviews with 48 midwives and community leaders in three municipalities in Timor-Leste. The findings reveal that midwives engage at both the individual and collective levels, providing medical care, advice and moral support to survivors of violence as well as gathering support for women within families and communities. Midwives therefore navigate both formal and informal spaces as they respond to domestic and sexual violence. In doing so, they are influenced by their own experiences as women, as health providers imbued with authoritative knowledge, and as part of the wider sociocultural system. We argue that while much progress has been made in frameworks for health systems responding to survivors of violence, more work needs to be done to understand how to support health providers in low- and middle-income countries as they engage with perpetrators, families and communities. There is a need for further discussion of how health systems can address the issue of domestic and sexual violence as a collective social problem, while foregrounding the needs and rights of those experiencing violence. This research has implications for the content of guidelines and training, and importantly, for developing mechanisms to deal with complex social issues within local health services.

Traditional medicine use in Timor-Leste.

BACKGROUND: Traditional medicine use is common amongst peoples in developing nations. Timor-Leste is no exception. However little is known about the prevalence, pattern, satisfaction with, cost or type of traditional medicine used in Timor-Leste. This study aims to describe the prevalence, nature and basic demographic factors associated with contemporary traditional medicine use in Timor-Leste. METHODS: A structured interview questionnaire was administered in Tetun to 50 surgical patients, 50 internal medicine patients, 50 hospital staff and 50 hospital visitors at Hospital Nacional Guido Valadares, Timor-Leste's major referral hospital. RESULTS: 60% of respondents reported having used traditional medicine; 32% within the last year. The greatest use was amongst surgical patients, the least amongst hospital staff. The frequency of traditional medicine use was comparable amongst all groups regardless of size of community, residence or level of education. Traditional medicine use in Timor-Leste is sufficiently common to represent part of the cultural norm. Factors described as promoting traditional medicine use included cost, limited access to other medical services and a belief that traditional medicine was free of side effects. Approximately half the patients reported using traditional medicine for their current illness and many for chronic illness in conjunction with conventional medicine. CONCLUSION: Traditional medicine use is common in Timor-Leste. Medical practitioners need to be cognizant of the common and potentially concomitant use of traditional medicine alongside conventional medicine when treating patients in Timor-Leste.

Intersectoral collaboration for people-centred mental health care in Timor-Leste: a mixed-methods study using qualitative and social network analysis.

BACKGROUND: Intersectoral collaboration is fundamental to the provision of people-centred mental health care, yet there is a dearth of research about how this strategy operates within mental health systems in low- and middle-income countries. This is problematic given the known attitudinal, structural and resource barriers to intersectoral collaboration in high-income country mental health systems. This study was conducted to investigate intersectoral collaboration for people-centred mental health care in Timor-Leste, a South-East Asian country in the process of strengthening its mental health system. METHODS: This study employed a mixed-methods convergent design. Qualitative data elicited from in-depth interviews with 85 key stakeholders and document review were complemented with quantitative social network analysis to assess understandings of, the strength and structure of intersectoral collaboration in the Timorese mental health system. RESULTS: There was consensus among stakeholder groups that intersectoral collaboration for mental health is important in Timor-Leste. Despite resource restrictions discussed by participants, interview data and social network analysis revealed evidence of information and resource sharing among organisations working within the health and social (disability and violence support) sectors in Timor-Leste (network density = 0.55 and 0.30 for information and resource sharing, respectively). Contrary to the assumption that mental health services and system strengthening are led by the Ministry of Health, the mixed-methods data sources identified a split in stewardship for mental health between subnetworks in the health and social sectors (network degree centralisation = 0.28 and 0.47 for information and resource sharing, respectively). CONCLUSIONS: Overall, the findings suggest that there may be opportunities for intersectoral collaborations in mental health systems in LMICs which do not exist in settings with more formalised mental health systems such as HICs. Holistic understandings of health and wellbeing, and a commitment to working together in the face of resource restrictions suggest that intersectoral collaboration can be employed to achieve people-centred mental health care in Timor-Leste.

Key factors deterring women's engagement with skilled birth attendants in three districts of Timor-Leste. A qualitative descriptive study.

OBJECTIVE: To describe the barriers to women's access to maternity services in three districts of Timor-Leste. Research design/setting: Focused ethnography with data collection methods commensurate with a qualitative research design. SETTING AND PARTICIPANTS: Data was collected in three districts in Timor-Leste. Participants included seventeen stakeholders, health professionals and managers providing skilled birth attendance (SBA) in Timor-Leste and thirty women who have given birth and are competent to give consent. FINDINGS: Access to SBA services is seriously impeded by poor roads and lack of transportation, the poor condition and amenity of services, restricted hours of opening, the lack of availability of skilled SBA professionals and medical resources. Participants also commented upon the lack of privacy and multiple caregivers. Timorese patriarchal family structures, intergenerational decision-making and cultural attitudes towards reproductive health information and services potentially reduce women's access to reproductive health services. CONCLUSION: This data provides a comprehensive record of the multiple structural barriers to women's access to SBA services. The modified AAAQA framework provides categories and an organisational structure to these barriers to SBA services. IMPLICATIONS FOR PRACTICE: Maternity care in Timor-Leste is extremely poorly resourced. Midwives and other SBA will need to provide innovative low cost solutions if they are to consistently provide respectful culturally safe midwifery care. This includes the provision of privacy and a one to one midwifery relationship `with woman'. In addition, many women are unable to access SBA, where possible the MoH can consider strategies to improve the provision of SBA services to women birthing in community.

Intake of supplementary food during pregnancy and lactation and its association with child nutrition in Timor Leste.

ABSTRACT: There is little evidence on maternal consumption of supplementary food on nutritional status of children. The objectives of this study were to measure the prevalence and determinants of supplementary food intake during pregnancy and lactation, and their association with nutritional status of under-five children in Timor Leste. METHODS: Cross-sectional data from Timor Leste Demographic and Health Survey on 5,993 mother (15-49 years) child dyads (<5 years) were included in the analysis. Self-reported intake of supplementary food intake was the explanatory variable. Child's nutritional status was assessed by stunting, wasting, and underweight and categorized according to WHO recommendations. RESULTS: The prevalence of taking supplementary food during pregnancy and lactation was, respectively, 29.1% (95% CI [27.2-31.0]) 31.0% (95% CI [29.1-33.0]), and that of taking iron supplement during pregnancy was close to three-fifths (63.1%, 95% CI [60.9-65.3]). The odds of taking supplementary food during pregnancy and lactation were lower among those in the younger age groups and higher among urban residents. Compared with mothers who had supplementary food during pregnancy and lactation, those did not have had respectively 1.36 (OR = 1.360, 95% CI [1.191-2.072]) and 1.15 times (OR = 1.152, 95% CI [1.019-1.754]) higher odds of having stunted, and 1.30 (OR = 1.307, 95% CI [1.108-1.853]) and 1.43 (OR = 1.426, 95% CI [1.140-1.863]) times higher odds of having underweight children. Those who had none of the supplements had respectively 1.67 (OR = 1.674, 95% CI [1.118-2.087]) and 1.63 (OR = 1.631, 95% CI [1.130-2.144]) times higher odds of having stunted and underweight children. CONCLUSION: A great majority of the mothers in Timor Leste are not taking supplementary food during pregnancy and lactation. We found a positive relationship between supplementary food intake during pregnancy and lactation with stunting and wasting among under-five children.

"I go I die, I stay I die, better to stay and die in my house": understanding the barriers to accessing health care in Timor-Leste.

BACKGROUND: Despite public health care being free at the point of delivery in Timor-Leste, wealthier patients access hospital care at nearly twice the rate of poorer patients. This study seeks to understand the barriers driving inequitable utilisation of hospital services in Timor-Leste from the perspective of community members and health care managers. METHODS: This multisite qualitative study in Timor-Leste conducted gender segregated focus groups (n = 8) in eight districts, with 59 adults in urban and rural settings, and in-depth interviews (n = 8) with the Director of community health centres. Communication was in the local language, Tetum, using a pre-tested interview schedule. Approval was obtained from community and national stakeholders, with written consent from participants. RESULTS: Lack of patient transport is the critical cross-cutting issue preventing access to hospital care. Without it, many communities resort to carrying patients by porters or on horseback, walking or paying for (unaffordable) private arrangements to reach hospital, or opt for home-based care. Other significant out-of-pocket expenses for hospital visits were blood supplies from private suppliers; accommodation and food for the patient and family members; and repatriation of the deceased. Entrenched nepotism and hospital staff denigrating patients' hygiene and personal circumstances were also widely reported. Consequently, some respondents asserted they would never return to hospital, others delayed seeking treatment or interrupted their treatment to return home. Most considered traditional medicine provided an affordable, accessible and acceptable substitute to hospital care. Obtaining a referral for higher level care was not a significant barrier to gaining access to hospital care. CONCLUSIONS: Onerous physical, financial and socio-cultural barriers are preventing or discouraging people from accessing hospital care in Timor-Leste. Improving access to quality primary health care at the frontline is a key strategy for ensuring universal access to health care, pursued alongside initiatives to overcome the multi-faceted barriers to hospital care experienced by the vulnerable. Improving the availability and functioning of patient transport services, provision of travel subsidies to patients and their families and training hospital staff in standards of professional care are some options available to government and donors seeking faster progress towards universal health coverage in Timor-Leste.

Use of medicines and adherence to standard treatment guidelines in rural community health centers, Timor-Leste.

The use of medicines and nurses'/midwives' adherence to standard treatment guidelines (STGs) were examined in Timor-Leste during the early stage of the nation's new health system development. A cross-sectional study was conducted as the quantitative element of mixed methods research. Retrospective samples from patient registration books and prospective observations were obtained in 20 randomly selected rural community health centers. The medicines use indicators, in particular the level of injection use, in Timor-Leste did not suggest overprescription. Prescribers with clinical nurse training prescribed significantly fewer antibiotics than those without such training (P < .01). The adjusted odds ratio of prescribing adherence for clinical nurse training, after accounting for confounders and prescriber clustering, was 6.6 (P < .01). STGs for nonphysician health professionals at the primary health care level have potential value in basic health care delivery, including appropriate use of medicines, in resource-limited communities when strategically developed and introduced.

Traditional Birth Attendance (TBA) in a health system: what are the roles, benefits and challenges: A case study of incorporated TBA in Timor-Leste.

BACKGROUND: One current strategy to overcome the issue of shortage of qualified health workers has focused on the use of community health workers in the developing countries to deliver health care services specifically to the most vulnerable communities in the rural areas. Timor-Leste is the one of the world's newest developing countries that has incorporated the traditional birth attendance in its health system through a family health promoter initiative in response to reproductive and child health, hence to improve primary health care delivery and increase number of healthcare workforce. METHODS: The study utilized a non-systematic review of the literature using key words such as community health workers, traditional birth attendants, reproductive health, child health and health outcomes. A case study from Timor-Leste was also used. RESULTS: Traditional birth attendants have performed wide variety of tasks including outreach and case finding, health and patient education, referrals, home visits and care management. Evidence indicated that there were, to varying degrees, positive associations between traditional birth attendance training and maternity care. Traditional birth attendance training was found to be associated with significant increases in attributes such as knowledge, attitude, behavior, advice for antenatal care, and pregnancy outcomes. However, some challenges faced by traditional birth attendants' role in encouraging women to go to health center for preventive services would be the compliance and refusal of the referral. The implementation case study from Timor-Leste shows that integrating traditional birth attendance into a national healthcare system through Family Health Promoter program has been programmatic effective. It is recommended that the implementation should consider regular communication between health staff and community leaders in recruiting members of family health promoters, and the use of supportive supervision tools to identify weaknesses in the management of this initiative. CONCLUSION: In Timor-Leste, incorporating traditional birth attendance through family health promoter program has played crucial roles in delivering and increasing access to reproductive health services by women in rural communities of the nation. Whilst it requires a long-term commitment and good partnership, the current reduction in maternal mortality ratio in Timor-Leste is encouraging and serves to illustrate how this initiative aims to improve primary health care delivery and increase number of healthcare workforce.

Responding to measles outbreak: closing the immunity gap in children of Timor-Leste

Background: An outbreak of measles was reported in Timor-Leste during 2011. A concertedresponse at national level utilized this opportunity to improve measles immunization coveragerates.Methods: Health Management Information System and Surveillance System data were utilized todescribe the outbreak. Attack rates and case fatality rates (CFR) were calculated using standardmethods. Evaluation surveys were used to access immunization coverage. Proceedings of weeklymeetings of the National Committee for Control of Disease Outbreaks were reviewed.Results: A total of 739 cases and 8 deaths were reported to the Surveillance Unit. Most (>82%)of the measles cases were reported from Dili and Ermera districts. The attack rate was 1.3 per1000 population and CFR was 1.1%. The response was coordinated by the National Committee forControl of Disease Outbreaks, which included case management, active and passive surveillance,communication and measles immunization among six-month to 14-year old children. Immunizationactivity targeted 495 000 children, i.e. almost one-half of the Timor-Leste population and achievedhigh coverage (85%).Conclusions: The outbreak highlighted gaps in the immunity against measles. The NationalCommittee for Control of Disease Outbreaks ensured a coordinated response which led to preventionof deaths from measles due to early case management with vitamin A supplementation, and highmeasles immunization coverage