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
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.
References (56)
- et al.
Global, regional, and national levels and trends in maternal mortality between 1990 and 2015, with scenario-based projections to 2030: a systematic analysis by the UN Maternal Mortality Estimation Inter-Agency Group
The Lancet
(2016) - et al.
Attitudes towards the legal context of unsafe abortion in Timor-Leste
Reproductive Health Matters
(2009) - et al.
Men's influences on women's reproductive health: medical anthropological perspectives
Social Science & Medicine
(2004) A review of cultural influence on maternal mortality in the developing world
Midwifery
(2013)- et al.
‘If I go with him, I can't talk with other women’: understanding women's resistance to, and acceptance of, men's involvement in maternal and child healthcare in northern Ghana
Social Science & Medicine
(2016) - et al.
Generating best evidence from qualitative research: the role of data analysis
Australian and New Zealand Journal of Public Health
(2007) - et al.
The focus group method: insights from focus group interviews on sexual health with adolescents
Social Science & Medicine
(2005) - et al.
Birth preparedness and skilled attendance at birth in Nepal: implications for achieving millennium development goal 5
Midwifery
(2013) - et al.
Quality maternity care for every woman, everywhere: a call to action
The Lancet
(2016) - et al.
A qualitative study of women's perspectives of antenatal care in a rural area of Zimbabwe
Midwifery
(2004)
Indigenous beliefs and practices that influence the delayed attendance of antenatal clinics by women in the Bohlabelo district in Limpopo, South Africa
Midwifery
‘They would never receive you without a husband’: paradoxical barriers to antenatal care scale-up in Rwanda
Midwifery
Safe motherhood beyond the year 2000: a global perspective
Midwifery
Maternal mortality, women's status, and economic dependency in less developed countries: a cross-national analysis
Social Science & Medicine
Safe motherhood initiative: 20 years and counting
The Lancet
The impact of violence against women on reproductive health and child mortality in Timor-Leste
Australian and New Zealand Journal of Public Health
Too far to walk: maternal mortality in context
Social science & medicine
Poor and pregnant in Africa: safe motherhood and human rights
Midwifery
Birth choices in Timor-Leste: a framework for understanding the use of maternal health services in low resource settings
Social Science & Medicine
Unintended consequences of policy decisions to reduce maternal mortality in the Asia Pacific
International Journal of Childbirth
Maternal deaths in eastern Indonesia: 20 years and still walking: an ethnographic study
BMC Pregnancy and Childbirth
Facilitators and barriers to facility-based delivery in low-and middle-income countries: a qualitative evidence synthesis
Reproductive Health
The mistreatment of women during childbirth in health facilities globally: a mixed-methods systematic review
PLoS Medicine
Why do women not use antenatal services in low-and middle-income countries? A meta-synthesis of qualitative studies
PLoS Medicine
Are we there yet? Data saturation in qualitative research
The Qualitative Report
Timor-Leste Demographic and Health Survey 2016: Key Indicators
"Under-utilization of antenatal care services in Timor-Leste: results from Demographic and Health Survey 2009–2010
BMC Pregnancy and Childbirth
Factors associated with non-utilisation of health service for childbirth in Timor-Leste: evidence from the 2009–2010 Demographic and Health Survey
BMC International Health and Human Rights
Cited by (12)
Timorese women's experiences and expectations of skilled birth attendance in Timor-Leste: A qualitative inquiry
2022, Sexual and Reproductive HealthcareCitation Excerpt :The provision of information to Timorese women during pregnancy and childbirth is essential. Wallace, conducting research in Timor-Leste [24], notes that there are many myths, ethno-physiological knowledges, and fears, in addition to a limited biomedical knowledge. This highlights a need for the provision of reproductive health education that is both correct and supportive to dispel myths and fears and increase biomedical knowledge.
The utilization of maternal health services at primary healthcare setting in Southeast Asian Countries: A systematic review of the literature
2022, Sexual and Reproductive HealthcareCitation Excerpt :After implementing integrated program, there was improvement in utilization of maternal health services in those countries; however, the trend still remained low particularly in rural regions [24]. Several studies in Timor Leste presented that the reduction of MMR has been a high priority for the Government [25–27]. As a new country, Timor Leste faces a range of public health challenges, including a high MMR.
Strengthening Kampala’s Urban Referral System for Maternal and Newborn Care Through Establishment of an Emergency Call and Dispatch Center
2023, Global Health Science and PracticeFactors Affecting Quality of Care in Maternal and Child Health in Timor-Leste: A Scoping Review
2022, Health Services Insights
- 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.