Kayli Wild

Birth choices in Timor-Leste: a framework for understanding the use of maternal health services in low resource settings.

The high rate of maternal mortality in Timor-Leste is a persistent problem which has been exacerbated by the long history of military occupation and ongoing political crises since independence in 1999. It is similar to other developing countries where there have been slow declines in maternal mortality despite 20 years of Safe Motherhood interventions. The national Ministry of Health, United Nations (UN) agencies and non-government organisations (NGOs) have attempted to reduce maternal mortality by enacting policies and interventions to increase the number of births in health centres and hospitals. Despite considerable effort in promoting facility-based delivery, most Timorese women birth at home and the lack of midwives means few women have access to a skilled birth attendant. This paper investigates factors influencing access to and use of maternal health services in rural areas of Timor-Leste. It draws on 21 interviews and 11 group discussions with Timorese women and their families collected over two periods of fieldwork, one month in September 2006 and five months from July to December 2007. Theoretical concepts from anthropology and health social science are used to explore individual, social, political and health system issues which affect the way in which maternal health services are utilised. In drawing together a range of theories this paper aims to extend explanations around access to maternal health services in developing countries. An empirically informed framework is proposed which illustrates the complex factors that influence womens birth choices. This framework can be used by policy-makers, practitioners, donors and researchers to think critically about policy decisions and where investments can have the most impact for improving maternal health in Timor-Leste and elsewhere.

The tyranny of distance: maternity waiting homes and access to birthing facilities in rural Timor-Leste

OBJECTIVE To examine the impact of maternity waiting homes on the use of facility-based birthing services for women in two remote districts of Timor-Leste. METHODS A before-and-after study design was used to compare the number of facility-based births in women who lived at different distances (0-5, 6-25, 26-50 and > 50 km) from the health centre before and after implementation of maternity waiting homes. Routine data were collected from health centre records at the end of 2007; they included 249 births in Same, Manufahi district, and 1986 births in Lospalos, Lautem district. Population data were used to estimate the percentage of women in each distance category who were accessing facility-based care. FINDINGS Most facility-based births in Same (80%) and Lospalos (62%) were among women who lived within 5 km of the health centre. There was no significant increase in the number of facility-based births among women in more remote areas following implementation of the maternity waiting homes. The percentage of births in the population that occurred in a health facility was low for both Manufahi district (9%) and Lautem district (17%), and use decreased markedly as distance between a womans residence and the health facilities increased. CONCLUSION The maternity waiting homes in Timor-Leste did not improve access to facility-based delivery for women in remote areas. The methods for distance analysis presented in this paper provide a framework that could be used by other countries seeking to evaluate maternity waiting homes.

Moving Beyond “Health Education”: Participatory Filmmaking for Cross-Cultural Health Communication

In the process of developing short films with women in Australian Aboriginal (Yolŋu) communities in northeast Arnhem Land, questions arose about how the content and the process of production were defined and adjusted to suit both parties. This research examines how filmmakers take roles as health educators and how Yolŋu women as the “actors” define and direct the film. It explores ways that the filmmakers tried to ensure that Yolŋu identity was maintained in a biomedical agenda through the use of storytelling in language. An important dialogue develops regarding ownership and negotiation of health information and knowledge, addressing this intersection in a way that truly characterizes the spirit of community-based participatory research. Although the filmmaking processes were initially analyzed in the context of feminist and educational empowerment theories, we conclude that Latour’s (2005) theory of actor networks leads to a more coherent way to explore participatory filmmaking as a health education tool. The analysis in this work provides a framework to integrate health communication, Indigenous women’s issues, and filmmaking practices. In contrasting participatory filmmaking with health promotion and ethnographic film, the importance of negotiating the agenda is revealed.

Agenda setting and evidence in maternal health: connecting research and policy in Timor-Leste

The evidence-based policy (EBP) movement has received significant attention in the scientific literature; however, there is still very little empirical research to provide insight into how policy decisions are made and how evidence is used. The lack of research on this topic in low- and middle-income countries is of particular note. We examine the maternity waiting home policy in Timor-Leste to understand the role of context, policy characteristics, individual actors, and how evidence is used to influence the policy agenda. The research tracked the maternity waiting home policy from 2005 to 2009 and is based on in-depth interviews with 31 senior policy-makers, department managers, non-government organization representatives, and United Nations advisors. It is also informed by direct observation, attendance at meetings and workshops, and analysis of policy documents. The findings from this ethnographic case study demonstrate that although the post-conflict context opened up space for new policy ideas senior Ministry of Health officials rather than donors had the most power in setting the policy agenda. Maternity waiting homes were appealing because they were a visible, non-controversial, and logical solution to the problem of accessing maternal health services. Evidence was used in a variety of ways, from supporting pre-determined agendas to informing new policy directions. In the pursuit of EBP, we conclude that the power of research to inform policy lies in its timeliness and relevance, and is facilitated by the connection between researchers and policy-makers.