Elsevier

Midwifery

Volume 65, October 2018, Pages 35-42
Midwifery

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

https://doi.org/10.1016/j.midw.2018.05.013Get rights and content

Highlights

  • Delays to seek antenatal care and care during labour and birth persist in Timor-Leste.

  • Husbands, history and minimal birth preparedness influence these delays.

  • Delays are also influenced by emic beliefs, infrastructure limitations and geographical locations.

  • Perceptions of hospital policies, staff attitudes and the provision of respectful, quality care also contribute to delays seeking care.

Abstract

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.

Section snippets

Background

Maternal deaths have decreased globally by almost half since 1990 (Koblinsky et al., 2016), however hundreds of thousands of women, mainly in low-middle income nations, still die each year from pregnancy or childbirth complications (Starrs 2006; Alkema et al., 2016). The Safe Motherhood Technical consultation in 1997 declared “the single most critical intervention required for achieving Safe Motherhood is to ensure that a health worker with midwifery skills is present at every birth and

Study setting

This study was conducted in nine locations in four of Timor-Leste's 13 municipalities. Viqueque, Baucau, Ermera and Dili municipalities were selected based on contraceptive prevalence rates, total fertility rates and reported number of maternal deaths. The research team sought and were granted permission from the traditional leaders, and provided information about the study to communities. Rural, peri-urban and urban settings were included. Collaboratively designed data collection tools were

Findings

The following Tables 1 and 2 illustrate participant characteristics:

Note that participants have a higher than average educational status and that male ‘youth’ (18–25 years) participants in Ermera and Dili have not yet begun families (Ministry of Finance, 2010).

Antenatal care

Trusted caregivers, knowledge of the importance of antenatal care, perceptions of what was healthy or ‘normal’, and the role of the husband all contributed to whether, how and when women accessed antenatal care.

Care during labour and birth

As with the decision to seek antenatal care, both male and female participants nominated multiple barriers to women seeking care during labour and birthing at a facility, including lack of transport, financial constraints to pay for transport, poor condition of the roads and sociocultural considerations such as the staff at the facility ignoring cultural practices or perceptions. They also clarified the central role of husbands and the significance of ethno-physiological beliefs.

Discussion

The findings illustrate diverse factors impacting on the decision to seek antenatal care or care during labour and birth. To make sense of the findings, and understand them from a Timorese context, the researchers framed the discussion using the expanded ‘Three Delays Framework’ (Thaddeus and Maine, 1994; Bohren et al., 2014). The findings suggest that husbands, history, minimal birth preparedness, ethno-physiological beliefs, infrastructure limitations, hospital policies and staff attitudes

Husbands

Husbands were often the “deciders” in seeking care antenatally and for labour and birth. Gender equality and power relations are documented tensions in Timor-Leste (Niner, 2012; Wigglesworth et al., 2015). The distant history of colonisation and accompanying Catholicisation, coupled with more recent history of men returning to families and communities following independence, has contributed to a patriarchal society and an erosion of women's traditional power (Niner, 2011). Nationally,

Birth preparedness and complication readiness

A key component of birth preparedness is planning for access to and finances for transportation to reach care (Karkee et al., 2013). Many participants spoke of this being a barrier for accessing care during labour and for birth. Many Timorese live below the poverty line (Ministry of Finance, 2010) and quarantining money for transport may be unrealistic for many families. While maternal health care is provided free of charge in Timor-Leste, other direct or indirect costs associated with

Delays in receiving care

This delay did not feature prominently in this study's findings.

Referring to the literature, Timor-Leste has recognised its midwifery work force challenges and has begun to introduce strategies to address these, such as, establishing a school of Nursing and Midwifery at the National University (Ministry of Health, 2011). Timor-Leste has also established an incentives plan to encourage midwives to relocate to rural areas, recognising there remains a great need for adequate health coverage in

Misgivings about staff

Global perspectives highlight that respectful care is paramount to engage people and communities (Mathole et al., 2004; Evans, 2013). Some participants expressed distrust towards health facilities and staff, identifying lack of consideration of socio-cultural needs as a significant barrier to seeking care.

Also, whilst acknowledging that many Timorese have successfully blended animistic, traditional beliefs with Catholicism (Molnar, 2010), the new, ‘modern’ faith epistemologies emerging in

Limitations

The educational status of participants was higher than the general average (Ministry of Finance, 2010) which may have influenced the findings. Another potential limitation is the sample was from four of Timor-Leste's 13 municipalities– although small, Timor-Leste is recognised as diverse, so there may be factors affecting decisions to access care in other municipalities not highlighted in this study.

Policy implications

This research illustrates the multisystem, diverse factors influencing decisions to seek care antenatally or for labour and birth in Timor-Leste. Timor-Leste is to be congratulated on their national policies that support safe motherhood practices. However, this support needs a broader focus, taking into consideration workforce and infrastructure. Timor-Leste would be well advised to encourage, support, educate and respect their midwifery workforce, as midwives globally are recognised as pivotal

Funding sources

Heather Julie Wallace: yes: partial funding from Marie Stopes Timor-Leste.

Susan McDonald: yes: partial funding from Marie Stopes Timor-Leste.

Suzanne Belton: yes: partial funding from Marie Stopes Timor-Leste.

Agueda Isolina Miranda: yes: partial funding from Marie Stopes Timor-Leste.

Eurico da Costa: yes: partial funding from Marie Stopes Timor-Leste.

Livio da Conceicao Matos: yes: partial funding from Marie Stopes Timor-Leste.

Helen Henderson: yes: partial funding from Marie Stopes Timor-Leste.

Funding

This research was partially funded by Marie Stopes Timor-Leste.

Acknowledgements

The researchers thank the women and men who participated in this research.

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    1

    Present address: Menzies Institute of Health Research, Casuarina, Darwin 0909, Australia.

    2

    Present address: National University Timor Lorosa'e, Av. Cidade de Lisboa, Dili, Timor-Leste.

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