family planning programming in timor-leste

Family Planning Programming in Timor-Leste

Maternal and Child Health in Developing CountriesFebruary 7, 2012

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Outline and Flow

A quick review of global family planning

A situational analysis of Timor-Leste prior to designing & implementing a family planning (FP) pogram

Small group work to discuss key questions that will be presented

Group report out Finish the Timor story

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Family Planning: Unmet Need Globally

WHO estimates that 200 million couples in developing countries would like to delay or stop childbearing but are not using any method of contraception

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MDG 5: Improve Maternal Health

5a: Reduce by ¾ maternal mortality Maternal mortality ratio Proportion of births attended by skilled health

personnelAdded in 2005:

5b: Universal access to reproductive health Antenatal care visits (at least 1, at least 4) Adolescent birth rate Contraceptive prevalence rate Unmet need for family planning

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FP has the potential to prevent maternal deaths (~32%) and newborn/infant/child death (~10%)

Spacing pregnancies at least 3 years = healthier moms and healthier babies

The Benefits of Family Planning

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Decreases unintended and unwanted pregnancies ( induced abortion & miscarriages)

Offers women more opportunities for education, employment, community involvement

Can prevent the transmission of HIV Can prevent MTCT of HIV by avoiding

unintended pregnancies among HIV+ women Slows population growth—reduces poverty,

hunger, and is positive for the environment

The Benefits of Family Planning

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The Methods

Combined oral contraceptives (COC), “the pill” contains 2 hormones: estrogen and progestogen

Progestogen-only Pills (POP) “the mini pill” Implants

small, flexible rods or capsule place udner the skin of the upper arm, long lasting at 3-5 years

Injections (Depo Provera) progestogen injectables, every 2-3 months

IUD small flexible device inserted into the uterus; 5-10

years

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Methods (cont)

Condoms (male and female) Sterilization (male and female)

Vasectomy (males), tubal ligation (females) Standard Days/Cycle beads Lactational Amenorrhea (LAM)

requires exclusive breastfeeding an infant for up to 6 months

Traditional Methods calendar, withdrawal, periodic abstinence,

herbs

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Contraceptive Use in Asia Among WRA Family Planning Worldwide

2008 Data Sheet

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Contraceptive Use among WRA Timor:Leste

Data Source: DHS 2009/10

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Global Trends in Induced Abortion

From 19952003 the # of abortions / 1000 WCBA worldwide fell from 3529 2008 only declined to 28

Nearly half of all abortions worldwide are unsafe

~All unsafe abortions occur in developing countries

In 2008, 6 million abortions in developed countries and 38 million in developing countries

Abortion accounts for 13% maternal mortality

World Abortion Law MapKey:

Green

Abortion never legal, or legal only when necessary to save the life of the mother or protect her physical health

Yellow

Abortion legal in "hard cases", such as rape, incest, and/or deformed child.

Red

Abortion legal for social reasons (e.g. mother says she can't afford a child), or to protect the mother's "mental health" (definitions and requirements vary).

Purple

Abortion legal at any time during pregnancy for any reason.

http://www.pregnantpause.org, 2002

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Timor-Leste: The birth of a new nation

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Timor-Leste: Where is it?

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Maternal and Infant Mortality & TFR

Maternal Mortality: 660-800/100,000 live births (WHO 2003)

Infant Mortality : 60/1000 live births* Under 5 Mortality: 83/1000 live births* Total Fertility: 7.8*

* Demographic and Health Survey 2003

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MOH Health System Post-Independence Vote (supply-side)

Human resource pool at low level; few Timorese doctors; poorly

trained health staff

MOH ‘under construction’ with the development of policies and

strategic approaches

Health facilities destroyed and poorly equipped

Midwives the backbone of the health system

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Community Utilization of Health Services(demand-side)

t

Distrust and very low utilization of government health services

Increased dispersion of the population

Strong traditional beliefs and practices regarding health

and care seeking

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Utilization of Maternal Health Services

90% of women deliver at home

20% of births were attended by a SBA

Only 10% current users of a modern contraceptive

Postpartum and newborn care negligible

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2003 DHS Family Planning Data

TFR at 7.8 births per woman is the highest in the world

Over 60% of women cannot spontaneously identify a method of contraception

Overall, “ideal” family size is 5.7 children

Only 19% of women have ever used contraception and 10% are

currently using a method

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The Indonesian Legacy

24 years of brutal Indonesian military occupation

An estimated 180,000 died, human rights abuses: torture,

imprisoned, rape, forced displacement

Keluarga BerencanaIndonesian FP program

‘Dua anak cukup’

Coercive family planning programming in East Timor

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Post-conflict Age Pyramid - 2003

12 11 10 9 8 7 6 5 4 3 2 1 0 1 2 3 4 5 6 7 8 9 10 11 12

0-4

10-14

20-24

30-34

40-44

50-54

60-64

70-74

80+

Age

Gro

up

Percent of Total Population

A dearth of males aged in their twenties

A very youthful population with 52% of the population < 15 years

A post-independence baby boom

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Religion & Culture

Strong animist beliefs and practicesare prevalent among Timorese 97% of Timorese identify as Catholic

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Household Characteristics

Majority of the population live in rural areas, often hard to access

28% of households have electricity urban = 74%

rural areas = 3% - 20%

Only about half of households obtain their drinking water from a

protected source

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Education and Literacy

For older women 40-44 years of age, 81% have received

no schooling

Overall, 37% of the population have received no schooling

44% of women and 43% of men are unable to read

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Your turn! How would you propose HAI respond to the situational analysis in order

to develop a FP program that seeks to increase demand for, and ensure high quality FP services Timor-Leste?

1.What additional information do you feel you need, and how would you propose getting it?

2.What would be 1-2 key objectives and how would you propose measuring success?

3.What are 1-2 key strategies you would you employ to achieve our proposed outcomes goals?

4.What are 1-2 key messages you would recommend using to promote FP utilization?

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HAI Program: ‘Promoting community demand for child spacing in Timor-Leste’Baseline Qualitative Assessment Describe the prevailing knowledge,

beliefs, practices, preferences and care-seeking behaviors related child spacing

What & who influences reproductive choices?

What do women and families want with regard to spacing their children or limiting family size?

How do community members access and use information regarding child spacing?

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“My mother said I should have many children because I am the only girl in the my family.”

“Because people have many children they can’t afford to feed them and have not money to pay for the school fee.”“Because of barlaque (bride price) husbands and their families feel they can make decisions about how many children women have. ..”

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“When we want to stop having babies then we inform the Kukunain (magic/mystic man), so that they can ask at the Sacred House and we will not get pregnant again.”“How many children we have is up to God”

“We don’t want to be told to limit the number of children we have, this is what the Indonesians did.”

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Improve capacity of MOH family planning services

What we did: Emphasized the notion of child spacing versus

limiting family size Partner with MOH to improve the quality of

services delivered through integrated MNC supervision visits of MWs

Provided follow-up FP skills check for MWs Conducted workshops to train MWs on working in

communities and improving counseling skills Developed health promotion tools and provided

MOH staff and CHW training for use in communities

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Increase Community Demand What we did Community level health promotion

Benefits of spacing your children Knowledge of modern methods Debunking myths

For legitimacy and entry into communities, it is critical to work closely with MOH, Church and Village Chiefs

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Child Spacing Film: Espaco Oan Developed and produced a culturally

relevant two-part film MOH and Church buy-in Work with community stakeholders to

schedule community viewing Train local NGO team to show film

conduct community conversation Village-based community viewing with

follow-up discussion

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Bringing Espaco Oan to Communities

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‘Mai Ita Koko’ (Come lets try): CHW home visits

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Results: 2003 & 2010 DHS

TFR decreased: 7.8 to 5.7 CPR doubled: 10% to 22% Unmet need: dramatic increase Desire to have another child soon: 32.4% to 8.5% Desire to have another child later: 10.5% to

35.7% Desire no more children: 17% to 34.7%

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Results: 2003 DHS/HAI 2008 Survey

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Thank you!