Making Delivery Birth-Friendly in Timor-Leste
In 2004 when HAI commenced a maternal and newborn health program, maternal mortality was estimated at 800 per 100,000 live births, infant mortality was 80-90/1000 live births, and 120 children per 1000 died before reaching age five. Utilization of health services was also very low. Only about half of women receive any antenatal care during pregnancy, use of a skilled birth attendant was less that 20%, and fewer than 10% of births occurred at a health facility. At that time the fertility rate was very high at 7.8 and not surprisingly, use of a family planning method very low at 9%.
Watch a video about Birth Friendly Facilities, created by HAI for the Timorese Ministry of Health.
Addressing the Challenges
At the beginning of our maternal and newborn health program in Timor-Leste, HAI 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, preferening an upright delivery position supported by a family member and a rope secured around roof rafters during the final stage 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. HAI's 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.
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, typically a midwife. HAI staff worked closely with local communities and district health staff to establish each BFF site. Local preferences are honored, and local labor and materials used whenever possible when the facilities are constructed.
The BFFs are fully integrated into and staffed by the MOH. HAI provides technical support for supportive supervision of midwives, data collection and analysis, and conducts health promotion activities in BFF communities to educate about the value of antenatal care and delivery with a skilled birth attendant.
Impact
Seven months after the opening of the two BFFs, an implementation evaluation was conducted to assess utilization, community and health staff satisfaction, and identify barriers to use. The evaluation revealed a high degree of satisfaction with the BFFs among health staff and mothers and family members who used the facilities. They were universally very pleased with the quality of their experience. Women most frequently mention comfort and peace of mind knowing that a midwife will be there to help them in case of a complication and they appreciated the ability to follow traditional customs and have family members present during the delivery. 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, most of the reasons cited for not using the BFF point to a lack of preparation for the birth event. New intensified efforts in our BFF communities will include the use of recently produced short videos that promote and train on creating a birth plan and the importance of having a skilled birth attendant at delivery. HAI will also be working to expand the recognition and utilization of the BFF as a community gathering space supporting community dialogue and exchange on a variety of topics related to women's health.
Changing community norms in a practice such as childbirth that is infused with strong traditional and generational values will take time. In Timor the goal is to assure that every woman has a safe and clean delivery that is assisted by a skilled provider preferably at a health facility. One step toward that goal is creating welcoming environments, such as BFFs, where women can deliver with the comfort of knowing that a skilled provider will assist her and in a setting that honors her traditional practices.
Watch a video about Birth Friendly Facilities, created by HAI for the Timorese Ministry of Health.
"Bemvindo ba Ita Nia Uma Partu" (Welcome to your Birth Friendly Facility) was developed for screenings in communities across Timor-Leste. Screenings of the video are followed by a facilitated discussion for women and families about how to ensure a safe delivery with the assistance a skilled birth attendant (In Tetum with English subtitles).