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Improving Access to Care: Birth facilities and maternity waiting homes in Timor-Leste

Wayte, Kayli J., Barclay, Lesley M. and Kelly, Paul M. (2007). Improving Access to Care: Birth facilities and maternity waiting homes in Timor-Leste. Darwin NT, Australia: Charles Darwin University.

Document type: Research Report
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Author Wayte, Kayli J.
Barclay, Lesley M.
Kelly, Paul M.
Title of Report Improving Access to Care: Birth facilities and maternity waiting homes in Timor-Leste
Publication Date 2007
Publisher Charles Darwin University
Place of Publication Darwin NT, Australia
Abstract The maternity waiting home strategy was developed as a pilot project in Timor-Leste in 2005. The aim was to increase the utilisation of health facilities for birth, particularly for women living in rural and remote areas. The ultimate goal of maternity waiting homes was to reduce the high maternal and neonatal mortality rates observed throughout the country. This report provides an evaluation of the maternity waiting home strategy in Timor-Leste from 2005 to 2007.

A mixed methods approach was used for this investigation. It consisted of 106 qualitative interviews in eight districts. These interviews explored why the strategy was or was not successful, and why some women chose to birth in a facility and others did not. A quantitative analysis of the number of births, deaths, referrals and user’s area of residence was conducted for two maternity establishments that have been functioning for longer than six months, namely Lospalos and Same.

The findings show that:
• The original maternity waiting home strategy has not been successful in Timor-Leste, despite the concept being piloted in two districts and being taken up by local authorities in four districts. This is because no maternity establishments are functioning as waiting homes. Instead, the maternity waiting home idea has been adapted to the local context and transformed into two different types of maternity establishments: accommodation services in Lospalos and stand-alone birth facilities in Same, Laleia and Bazartete. The maternity establishments in Cailaco and Atabae could not be evaluated as they are not yet functioning, despite construction being completed for one year and for six months, respectively.

• Maternity establishments, backed by transport and promoted to the community, are associated with a modest increase in facility births in Same, but no such correlation is observed in Lospalos. Contrary to the objectives of the maternity waiting home strategy, women are not likely to attend a maternity establishment prior to labour and the women who do attend are most likely to live within 5km.

• Maternity establishments are not associated with a reduction in the number of inter-uterine fetal deaths or neonatal deaths, mainly due to a lack of emergency obstetric care at the facilities and ongoing public health problems. Maternity establishments are associated with an increase in the frequency of referral, indicating a possible increase in access to emergency obstetric care. Due to inadequate routine data collection it is difficult to conclude whether these referrals result in improved pregnancy outcomes.

• Women and families who used the maternity establishments were very satisfied with the service, and appreciated having a space just for mothers and families. Women were more likely to use the maternity establishment if they lived close by, had access to transport, had a bad birth outcome in the past, were first time mothers, or they or their husband had a secure job.

• Women who gave birth at home usually had other children at home and saw birth as a normal process not requiring hospital care. Women found it difficult to get to a facility for birth for various reasons. For example they did not know the exact date when they would deliver; the birth came on too quickly especially for multiparous women; there was no public or private transport to the village; there was limited transport at the health facility; the rainy season would not allow this because the roads were washed away.

Providing equitable maternity care services for poorer women in rural and remote areas is an ongoing challenge. As maternity establishments are much less likely to cater to women who live more than 25km away, it is important to strengthen currently under-resourced health posts and sub-district health centres. It is essential that women who are having difficulties attending maternity establishments have access to outreach services. All women need access to both a skilled attendant at birth and timely referral to a district health centre capable of emergency obstetric care. In order to achieve this, five recommendations are listed in order of priority:

1. Adequately resource existing health posts and lower-level health centres. Important resources currently missing are midwives, motorbikes, radio or telephone communication and basic supplies and equipment (Appendix 1). Priority should be given to attaining complete population coverage, and equipping midwives to provide outreach services, attend home births, and conduct timely referrals. All midwives, regardless of where they are posted, should receive ongoing training on women-centred care, how to recognize and refer complications and basic emergency obstetric care techniques.

2. Support existing maternity establishments that have already been built. The establishments in Atabae and Cailaco are designed to be maternity waiting homes, however, considering the experience from other districts it is useful to keep a flexible approach to implementation. It appears that the establishment in Atabae would be most useful for providing accommodation services, while the establishment in Cailaco would be more suited to a birth centre. Once they begin to function, follow up evaluations should be conducted at both sites.

3. Improve basic emergency obstetric care in all district centres. Emergency obstetric care training must include ongoing practice and supervision and should be provided to both doctors and midwives. Priority needs to be given to district centres that are furthest from comprehensive emergency obstetric care. Maternal death audits should be implemented as part of routine quality improvement practices at the district level, and should include both facility deaths and those that occur in the community.

4. Improve facilities for normal births at sub-district health centres. Having a special area for mothers, babies and families separate from general inpatients is an important incentive for birthing in a facility, as is the availability of transport. Whenever implemented, stand-alone birth facilities must be integrated with a health centre and there should be continuity of care with antenatal services rather than separating these programs. Stand-alone birth facilities and accommodation services are expensive, however, and are most often used by women who live within 5km. They should not be implemented at the expense of outreach or assistance for women in remote areas.

5. Maternity waiting homes should only be considered once adequate, decentralized birthing services have been established. Maternity waiting homes, as defined in the international literature, can only reduce the risk of perinatal death for high risk pregnancies (Chandramohan et al 1995). Therefore, if maternity waiting homes are established in the long-term they should be situated near district health centres which have comprehensive emergency obstetric care, and should only be for women and families who require that level of care.

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