Making Health Facilities “Birth Friendly”
At the beginning of our maternal and newborn health program in Timor-Leste in 2004, we conducted a community assessment to gain a better understanding of the knowledge, beliefs, practices, preferences and care seeking behavior related to maternal and newborn health. Through dozens of interviews and focus group discussions, community voices revealed some deeply entrenched traditional practices related to birthing.
Home births are important in Timorese tradition with many women delivering on specially prepared bamboo beds constructed by their husbands. There is a preference for an upright delivery position supported by a family member and a rope secured around roof rafters to support the woman during the last stages of labor. Family members commonly assist with the home birth by preparing hot drinks and special food to give to the mother and applying hot compresses to her body. In fact, heat is a very important element in Timorese birthing, and "sitting fire" (tuur ahi) describes the initial period after a woman gives birth. There is a commonly held belief that a fire should be lit during labor, and women and newborns should stay by the fire for a period of time varying from one week to 40 days. Women and children are understood to be vulnerable following birth and the "sitting fire" ritual is thought to protect their wellbeing.
Our community assessment also revealed a widespread lack of awareness of the benefits of delivering with a skilled birth attendant, and many negative associations with deliveries in a health facility. Negative associations included a lack of privacy for the birthing mother, lack of support for traditional birthing practices, and lack of space or permission for family members to attend the birth.
These conversations with communities informed the concept of a Birth Friendly Facility (BFF). A BFF is designed as a Timorese house located very near a health facility and is meant to provide a comfortable, culturally acceptable place for women to come to deliver their babies with a skilled birth attendant. Our staff worked closely with local communities and district health staff to establish each BFF site. Local preferences were honored, and local labor and materials used whenever possible during construction of the facilities.
Birth Friendly Facility in Timor-Leste
Birth-Friendly Facilities are comfortable, with private birthing rooms with wooden beds, a rope hanging from the ceiling, and colorful curtains on the windows. A local artist was hired to paint bright murals on the walls that depict messages of healthy maternal behaviors. Kitchen facilities are available where hot water and food can be prepared, and a separate room provides space for families.
Click here for a short tour of a Birth Friendly Facility.
The BFFs are fully integrated into and staffed by the Ministry of Health. We provide technical support for "supportive supervision" of midwives, data collection and analysis, and we conduct health promotion activities in BFF communities to educate about the value of antenatal, delivery, and postpartum care and child spacing.
In August 2009 HAI started work with the Ministry of Health to establish additional BFFs in four sub-district communities, taking advantage of the lessons learned from the first set of facilities.
Implementation evaluation
Seven months after the opening of the initial two BFFs, an implementation evaluation was conducted to assess utilization, community and health staff satisfaction, and identify barriers to use in order to make early course corrections. The evaluation found a high degree of satisfaction with the BFFs among health staff and mothers and family members who used the facilities.
Among women who did not use the facility, all stated their intent to use the BFF, but cited difficulty with finding transportation, labor that came on suddenly or late at night, and fear of walking at night or alone to the BFF. Overall, the reasons cited for not using the BFF all pointed to a lack of preparation for the birth event and revealed programmatic opportunities for the Ministry of Health and us in our continued work to ensure that women have access to a safe delivery with a skilled birth attendant.
Deeply held culturally practices, such as those in Timor-Leste around birthing, are often difficult practices to change. In addition, there are other barriers that prevent women from getting to facilities for delivery, such as long travel distances and limited transportation options. We routinely monitor BFF utilization data, which shows a gradual uptake in facility-based deliveries in the BFF communities.
Funding for the Birth Friendly Facilities came from AusAid, USAID and the Japanese Embassy.