Background: Maternal death is a big problem around the world and it is often preventable. Almost ... more Background: Maternal death is a big problem around the world and it is often preventable. Almost every country faced the same problem although the Maternal Mortality Ratio (MMR) varies between countries. Maternal death is tragedy for individual women, for families, and for communities because maternal death has implications for the whole family and an impact that rebounds across generations. According to data from the WHO, everyday in 2017, approximately 810 women died from preventable causes related to pregnancy and child birth (WHO, 2019). Over the last twenty years, there has been good progress worldwide to decrease maternal mortality (Sai et al, 2014). In Timor-Leste the maternal mortality rate decreased from 557 per 100,000 livebirths in 2010 to 218 per 100,000 livebirths in 2015. However, this is still very high. This MMR is still one of the highest in the world. (DHS TL 2010 and DHS TL 2015). Establishment of Basic Emergency Obstetric Care (BEmOC), poor road condition, limita...
A report on the knowledge, attitudes and practices of midwives when they encounter survivors of d... more A report on the knowledge, attitudes and practices of midwives when they encounter survivors of domestic violence and sexual assault in Timor-Leste. Based on in-depth interviews with 36 midwives and 12 community leaders, this report explores cultural and health system factors that influence midwives' practices and outlines a way forward for building a strong primary health care approach to addressing violence against women and children in Timor.
Despite national policies to support sexual rights, Timorese women are constrained when making se... more Despite national policies to support sexual rights, Timorese women are constrained when making sexual and reproductive health decisions. Contextual understanding of sexual decision making is vital for effective engagement by sexual and reproductive health service providers with communities. An intersectional reproductive justice approach broadens the sexual rights lens allowing for an examination of multi-system factors impacting on sexual rights and health. Using the Matrix of Domination as a conceptual framework, we explored Timorese perceptions around decisions to have sex, and examined intersecting systems of oppression impacting on these decisions. Our study adopted a critical medical anthropological approach using ethnographic methods. A decolonising methodology aimed to make Timorese worldviews central to the analysis. Nine focus group discussions with 80 men and 17 individual reproductive history interviews with women were held in 4 of Timor-Leste's 13 municipalities during October 2015. Findings suggest that decisions to have sex are framed in terms of wishes and rights; however, it was the perceived entitlements of men that were prioritised and predominantly men who made these decisions. Violence, coercion and unwanted pregnancies were linked to decisions about sex, and identified as potential consequences for women, impacting on women's health and sexual rights.
While global maternal deaths have decreased significantly, hundreds of thousands of women still d... more 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. 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. 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. Da...
The health sector is a critical partner in the response to violence against women, but little is ... more The health sector is a critical partner in the response to violence against women, but little is known about how to translate international guidelines and sustainable good practice in remote and under-resourced health systems. Aim: Thisresearchexploresthebarriersandenablersthat midwivesreportinrespondingtodomesticandsexual violenceinTimor-Leste,acountrywithaveryhighrateofviolenceagainstwomen.Theaimis toinformasystems approachtohealthprovidertrainingandengagementapplicabletoTimor-Lesteandotherlow-resourcesettings. Methods: In 2016 we conducted qualitative interviews and group discussions with 36 midwives from rural health settings, community health centres and hospitals in three municipalities of Timor-Leste. Findings: A range of individual, health system and societal factors shape midwives' practice. While training provided the foundation for knowing how to respond to cases of violence, midwives still faced significant health system barriers such as lack of time, privacy and a supportive environment. Key enablers were support from colleagues and health centre managers. Conclusion: Health provider training to address violence against women is important but tends to focus on individual knowledge and skills. There is a need to shift toward systems-based approaches that engage all staff and managerswithina health facility,work creativelyto overcomebarrierstoimplementation,and link them with wider community-based resources.
Timor-Leste's Maternal Mortality Ratio remains one of the highest in Asia. There is ample evi... more Timor-Leste's Maternal Mortality Ratio remains one of the highest in Asia. There is ample evidence that maternal deaths may be reduced substantially through the provision of good-quality modern methods of contraception. Many Timorese women wish to stop or delay having children. However, even when health services make contraception available, it does not mean that people will use it. Collaborating with Marie Stopes Timor-Leste, this qualitative research project used decolonising methodology to explore perceived influences contributing to contraceptive choices, and gain insight into how women's decisions to access contraception in Timor-Leste occur. Over two fieldwork periods (2013 and 2015), we used focus group discussions and structured interviews to speak with 68 women and 80 men, aged 18-49 years, across four districts of Timor-Leste. Findings demonstrate that the decision to access contraception is often contentious and complicated. These tensions echo concerns and ambigu...
Maternal mortality remains a significant public health challenge for Timor-Leste. Although access... more Maternal mortality remains a significant public health challenge for Timor-Leste. Although access to quality family planning measures may greatly reduce such deaths, consideration of indigenous perceptions, and how they influence reproductive health decision-making and behavior, is crucial if health services are to provide initiatives that are accepted and helpful in improving reproductive health outcomes. We aimed to demonstrate that body mapping is an effective method to traverse language and culture to gain emic insights and indigenous worldviews. The authors' two qualitative research projects (2013 and 2015) used a decolonizing methodology in four districts of Timor-Leste, body mapping with 67 men and 40 women to illuminate ethno-physiology and indigenous beliefs about conception, reproduction, and contraception. Body mapping provided a beneficial conduit for identifying established indigenous reproductive perceptions, understandings, and vocabulary, plus fears surrounding c...
Health research is crucial to understand a country's needs and to improve health outcomes. We con... more Health research is crucial to understand a country's needs and to improve health outcomes. We conducted a scoping review and analysis of existing health data in Timor-Leste to identify the health research priorities of the country. Published and unpublished health research in Timor-Leste from 2001 to 2011 that reported objectives, methods and results were identified. Key findings were triangulated with data from national surveys and the Health Management Information System; 114 eligible articles were included in the analysis, the leading topics of which were communicable (malaria, tuberculosis, HIV and sexually transmitted diseases and dengue) and noncommunicable (eye and mental health) diseases. There were 28 papers (25%) on safe motherhood, child health and nutrition, of which 20 (71%) were unpublished. The review of national indicators showed high infant, under-five and maternal mortality rates. Burden of disease is greatest in young children, with respiratory infections, febrile illnesses and diarrheal disease predominating. There is poor access to and utilization of health care. Childhood malnutrition is an important unresolved national health issue. There are several obstacles leading to underutilization of health services. The following topics for future health research are suggested from the review: nutrition, safe motherhood, childhood illness (in particular identifying the causes and cause-specific burden of severe respiratory, febrile and diarrheal diseases) and access to and use of health services.
Smoking initiation is concentrated among young people which strongly influences future smoking pr... more Smoking initiation is concentrated among young people which strongly influences future smoking prevalence. This study aimed to investigate the prevalence of smoking and other tobacco product use and potential determinants in a cross-sectional survey of 1 121 students aged 13 to 15 years in Dili, Timor-Leste. The prevalence of ever using a tobacco product was 40.4% (males 55.5%; females 23.8%) and of current use was 32.2% (males 45.3%; females 17.9%). In a logistic multivariable regression, factors associated with current use of any tobacco product were being male, ≥US$1 weekly pocket money, parents smoking, exposure at home, and exposure in other locations. The findings suggest that reducing the very high use of tobacco among adolescents in Timor-Leste will require new policy measures, enhanced enforcement of current legislation as well as a focused commitment to targeted smoke-free education campaigns, and community-based health promotion to support parents to quit smoking and not ...
Background: Maternal death is a big problem around the world and it is often preventable. Almost ... more Background: Maternal death is a big problem around the world and it is often preventable. Almost every country faced the same problem although the Maternal Mortality Ratio (MMR) varies between countries. Maternal death is tragedy for individual women, for families, and for communities because maternal death has implications for the whole family and an impact that rebounds across generations. According to data from the WHO, everyday in 2017, approximately 810 women died from preventable causes related to pregnancy and child birth (WHO, 2019). Over the last twenty years, there has been good progress worldwide to decrease maternal mortality (Sai et al, 2014). In Timor-Leste the maternal mortality rate decreased from 557 per 100,000 livebirths in 2010 to 218 per 100,000 livebirths in 2015. However, this is still very high. This MMR is still one of the highest in the world. (DHS TL 2010 and DHS TL 2015). Establishment of Basic Emergency Obstetric Care (BEmOC), poor road condition, limita...
A report on the knowledge, attitudes and practices of midwives when they encounter survivors of d... more A report on the knowledge, attitudes and practices of midwives when they encounter survivors of domestic violence and sexual assault in Timor-Leste. Based on in-depth interviews with 36 midwives and 12 community leaders, this report explores cultural and health system factors that influence midwives' practices and outlines a way forward for building a strong primary health care approach to addressing violence against women and children in Timor.
Despite national policies to support sexual rights, Timorese women are constrained when making se... more Despite national policies to support sexual rights, Timorese women are constrained when making sexual and reproductive health decisions. Contextual understanding of sexual decision making is vital for effective engagement by sexual and reproductive health service providers with communities. An intersectional reproductive justice approach broadens the sexual rights lens allowing for an examination of multi-system factors impacting on sexual rights and health. Using the Matrix of Domination as a conceptual framework, we explored Timorese perceptions around decisions to have sex, and examined intersecting systems of oppression impacting on these decisions. Our study adopted a critical medical anthropological approach using ethnographic methods. A decolonising methodology aimed to make Timorese worldviews central to the analysis. Nine focus group discussions with 80 men and 17 individual reproductive history interviews with women were held in 4 of Timor-Leste's 13 municipalities during October 2015. Findings suggest that decisions to have sex are framed in terms of wishes and rights; however, it was the perceived entitlements of men that were prioritised and predominantly men who made these decisions. Violence, coercion and unwanted pregnancies were linked to decisions about sex, and identified as potential consequences for women, impacting on women's health and sexual rights.
While global maternal deaths have decreased significantly, hundreds of thousands of women still d... more 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. 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. 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. Da...
The health sector is a critical partner in the response to violence against women, but little is ... more The health sector is a critical partner in the response to violence against women, but little is known about how to translate international guidelines and sustainable good practice in remote and under-resourced health systems. Aim: Thisresearchexploresthebarriersandenablersthat midwivesreportinrespondingtodomesticandsexual violenceinTimor-Leste,acountrywithaveryhighrateofviolenceagainstwomen.Theaimis toinformasystems approachtohealthprovidertrainingandengagementapplicabletoTimor-Lesteandotherlow-resourcesettings. Methods: In 2016 we conducted qualitative interviews and group discussions with 36 midwives from rural health settings, community health centres and hospitals in three municipalities of Timor-Leste. Findings: A range of individual, health system and societal factors shape midwives' practice. While training provided the foundation for knowing how to respond to cases of violence, midwives still faced significant health system barriers such as lack of time, privacy and a supportive environment. Key enablers were support from colleagues and health centre managers. Conclusion: Health provider training to address violence against women is important but tends to focus on individual knowledge and skills. There is a need to shift toward systems-based approaches that engage all staff and managerswithina health facility,work creativelyto overcomebarrierstoimplementation,and link them with wider community-based resources.
Timor-Leste's Maternal Mortality Ratio remains one of the highest in Asia. There is ample evi... more Timor-Leste's Maternal Mortality Ratio remains one of the highest in Asia. There is ample evidence that maternal deaths may be reduced substantially through the provision of good-quality modern methods of contraception. Many Timorese women wish to stop or delay having children. However, even when health services make contraception available, it does not mean that people will use it. Collaborating with Marie Stopes Timor-Leste, this qualitative research project used decolonising methodology to explore perceived influences contributing to contraceptive choices, and gain insight into how women's decisions to access contraception in Timor-Leste occur. Over two fieldwork periods (2013 and 2015), we used focus group discussions and structured interviews to speak with 68 women and 80 men, aged 18-49 years, across four districts of Timor-Leste. Findings demonstrate that the decision to access contraception is often contentious and complicated. These tensions echo concerns and ambigu...
Maternal mortality remains a significant public health challenge for Timor-Leste. Although access... more Maternal mortality remains a significant public health challenge for Timor-Leste. Although access to quality family planning measures may greatly reduce such deaths, consideration of indigenous perceptions, and how they influence reproductive health decision-making and behavior, is crucial if health services are to provide initiatives that are accepted and helpful in improving reproductive health outcomes. We aimed to demonstrate that body mapping is an effective method to traverse language and culture to gain emic insights and indigenous worldviews. The authors' two qualitative research projects (2013 and 2015) used a decolonizing methodology in four districts of Timor-Leste, body mapping with 67 men and 40 women to illuminate ethno-physiology and indigenous beliefs about conception, reproduction, and contraception. Body mapping provided a beneficial conduit for identifying established indigenous reproductive perceptions, understandings, and vocabulary, plus fears surrounding c...
Health research is crucial to understand a country's needs and to improve health outcomes. We con... more Health research is crucial to understand a country's needs and to improve health outcomes. We conducted a scoping review and analysis of existing health data in Timor-Leste to identify the health research priorities of the country. Published and unpublished health research in Timor-Leste from 2001 to 2011 that reported objectives, methods and results were identified. Key findings were triangulated with data from national surveys and the Health Management Information System; 114 eligible articles were included in the analysis, the leading topics of which were communicable (malaria, tuberculosis, HIV and sexually transmitted diseases and dengue) and noncommunicable (eye and mental health) diseases. There were 28 papers (25%) on safe motherhood, child health and nutrition, of which 20 (71%) were unpublished. The review of national indicators showed high infant, under-five and maternal mortality rates. Burden of disease is greatest in young children, with respiratory infections, febrile illnesses and diarrheal disease predominating. There is poor access to and utilization of health care. Childhood malnutrition is an important unresolved national health issue. There are several obstacles leading to underutilization of health services. The following topics for future health research are suggested from the review: nutrition, safe motherhood, childhood illness (in particular identifying the causes and cause-specific burden of severe respiratory, febrile and diarrheal diseases) and access to and use of health services.
Smoking initiation is concentrated among young people which strongly influences future smoking pr... more Smoking initiation is concentrated among young people which strongly influences future smoking prevalence. This study aimed to investigate the prevalence of smoking and other tobacco product use and potential determinants in a cross-sectional survey of 1 121 students aged 13 to 15 years in Dili, Timor-Leste. The prevalence of ever using a tobacco product was 40.4% (males 55.5%; females 23.8%) and of current use was 32.2% (males 45.3%; females 17.9%). In a logistic multivariable regression, factors associated with current use of any tobacco product were being male, ≥US$1 weekly pocket money, parents smoking, exposure at home, and exposure in other locations. The findings suggest that reducing the very high use of tobacco among adolescents in Timor-Leste will require new policy measures, enhanced enforcement of current legislation as well as a focused commitment to targeted smoke-free education campaigns, and community-based health promotion to support parents to quit smoking and not ...
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