Maternal health in East Medical Elective, Bairo Pite Clinic; April – May 2011

Introduction

The democratic republic of Timor-Leste () resides on the south eastern extremity of the Indonesian archipelago, it has been independent since 1999, when the Indonesian occupation ended. The violent and bloody nature of the Indonesian withdrawal meant few escaped persecution and a large proportion of the nation’s infrastructure was destroyed. Currently East Timor is considered to be one of the ten poorest countries in the world with more than 40% of civilians living below the poverty line and the health care expenditure per capita An outreach clinic in Kasnafa, a rural district around being a mere US$58 in 20071. The Ministry 50 miles from the capital city, Dili of Health (MoH) was established in 2002 to In light of this I decided that maternal health in address the gap in medical provision in East East Timor was a fitting and worthwhile focus Timor, but despite this many of the nation’s for my medical elective. I carried out my health care needs remain largely unmet. placement at the Bairo Pite clinic (BPC) in the heart of the nation’s capital, Dili. BPC has Maternal health is a particular neglected been directed by Dr Dan Murphy since the aspect of the health care system with an occupation ended, re-utilising an old military estimated maternal mortality rate (MMR) of clinic as a public health outlet. It is funded 830 per 100,000 live births and an infant primarily by non-governmental organizations mortality rate (IMR) of 80-90 per 1,000 live (NGOs) and charity, and has evolved from a births2,3. These statistics are made even crisis-orientated clinic to a community health more relevant by the fact that Timor is one of service, operating within the national health the world’s most fertile nations, with the care system. average parity being 6.5 in 20064. The high MMR and IMR are partially attributed to Currently the clinic boasts a large maternal several specific health-related problems that health department, which carries out around the MoH has acknowledged, and aims to 600 antenatal consultations and delivers over tackle. These include; lack of funding, lack of 100 babies per month6. In addition BPC offers public health-awareness, communicable an outreach scheme, which aims to train ‘lay’ disease (Malaria, TB, HIV/AIDS), lack of midwives in relatively isolated village access (on average it is 70 minutes walk to a communities, in order to educate local women health outlet), maternal and infanct about pregnancy and labour in an attempt malnutrition and poor human resources5. reduce both maternal and child morbidity.

Page 1 Aims: Box 1: Millennium development goals and maternal health • To get an insight into the maternal health care pathway in East Timor and identify any Improving maternal health and reducing potential barriers accessing medical child mortality are 2 or the 8 Millennium services development goals to be achieved by 2015, • To gain an appreciation of the similarities to help reach this target WHO have outlined and differences in ante, peri and post natal standard criteria expected to be care in East Timor and in the UK performed/discussed during an antenatal • To use the knowledge and skills I have consultation (those in GREEN were carried aquired during my time at medical school to out by Bairo Pite clinic): help to improve maternal health services at BPC • Confirmation of pregnancy • To learn more about Timorese culture and • Monitoring of progress of pregnancy and tradition, both in terms of health care and assessment of maternal and fetal well-being society including nutritional status • Syphilis testing and treatment of syphilis • Detection of problems complicating pregnancy My Experience: (anaemia, hypertensive disorders, bleeding, mal-presentations, multiple pregnancy) On my first day at BPC I was surprised by the • Respond to other reported needs size of the facility, which hosts a 48 bed • Tetanus immunization inpatient capacity as well as the maternal • Anaemia prevention and control (iron and folic acid supplementation) health facilities previously mentioned. I met Dr • Treatment of mild to moderate pregnancy Murphy; the only doctor on site, who gave me complications (anaemia, urinary tract and a brief tour and overview of how the clinic was vaginal infection) run and took me on the morning ward round. • Post abortion care and family planning Afterwards, I made my way to the maternity • Pre-referral treatment of severe complications unit, immediately noticing the large numbers of (pre-eclampsia, eclampsia, bleeding, infection women waiting to been seen by the midwives, and complicated abortion) many of whom had travelled for over two hours • Support for women living with violence and for their consultation. Each woman was issued HIV a queue slip and patiently waited, sometimes for several hours, to be seen. Attending the clinics also meant that I got to talk to local mothers about their experiences of Sitting in on antenatal clinics meant I was able the care they received during their pregnancy. to experience firsthand the constituents of a Generally they were extremely pleased with primary antenatal assessment at BPC. During the standard of care they provided by the the consultation, a full medical history and clinic, despite the long waiting times and basic pregnancy history was taken, in addition each facilities. I also learned that this was the first mother was weighed, had a blood pressure time the majority of the women had ever measurement, a blood sample taken and if sought professional medical advice. BPC has necessary had the pregnancy confirmed by a a close relationship with the community urine sample. These techniques are in partially owing to the work undertaken Dr accordance with the recommended Murphy during the humanitarian crisis in 1999. components of a antenatal consultation, as The Timorese people, even those attending outlined by the World Health Organisation the clinic remain wary of the government run (WHO), in the 2015 millennium goals on health care centers. Therefore I was not improving maternal health (see box 1)7. surprised to learn that only 19% births attended by a skilled professional; a dramatic

Page 2 contrast to the UK where the figure is over 99%1.

I also tried to explore the issue of the high fertility rate (average parity of 6.5) by talking to women in the clinic about why they have such large families. Firstly I found that most of the women didn’t consider a family of 6 or 7 to be large, rather that it was ‘the norm’. Many explained that they had lost children and that also encouraged them to have larger families. When I researched this further I found that in East Timor there is a high mortality in children The waiting room in the antenatal department at under 5 years; 91.5 infant deaths per 1000 live Bairo Pite Clinic births, mainly due to infectious diseases such as malaria and measles. Observation

I attempted to discuss the issue of family During my time in the antenatal department, planning and contraception, however this did one thing that I found particularly interesting not seem to be well received and I ascertained and unexpected was the emphasis on that birth control and restricting family size was screening for HIV. Even though HIV is a strategy employed under unpopular currently not considered a major health Indonesian rule and many women still consider problem in East Timor, unexpectedly the it oppressive. Therefore it is not surprising that incidence is increasing. Multiple factors only 10% of use have been identified including lack of public 1,8 contraception of any kind . awareness about the transmission and implications of HIV and AIDs and safe Outreach sexual practice 8. In response to this BPC has been working with the Implementing One of the biggest barriers to health care in AIDS Prevention and Care Project (IMPACT) East Timor is access to services, with up to and it is policy that every pregnant women three quarters of the population living in rural that attends the clinic has a full sexual areas. In light of this, BPC has an outreach history taken and a HIV test. service which aims to train and educate lay midwives in these remote areas to deal with Sadly, during my time at the clinic I the maternal health care needs of their witnessed mothers-to-be given the heart- community. I was able to speak to the sinking news that they were HIV positive. facilitator of the project, Dr Ida, who explained However I was impressed by the package of that the program was not only aimed at care that was then put into place to support improving maternal health, but empowering such women; including education on local women, increasing awareness of, and minimizing the risk of transmission to their attempting to change attitudes toward health baby and the administration of the care problems. The program is being well appropriate anti-retroviral drugs. received by local women and at least 11 villages are now on board. detrimental to health and ‘local remedies’ are often favoured over conventional medicines. I Timor, despite being a predominantly Catholic was told by some of the Timorese staff at the country, has its own cultural beliefs and clinic of one such local tradition which is still practices, particularly in more isolated areas. practiced; if a mother is enduring a long or Some of these beliefs and rituals can be difficult labour, the ‘treatment’ is to push

Page 3 forcefully on the fundus to get the baby out This is a stark contrast to the UK where most as quickly s possible. This obviously has life women will have the option for some form of threatening implications on both mother and pain relief during labour and up to 50% of baby and another reason why BPC are women opt for epidural analgesia9. educating and training communities. I was luckily able to go on a few outreach clinics The BPC midwifes are highly skilled and and see the work of the local midwifes, and experienced, but if any complications are even conduct some of my own known about; for example a breach baby, Dr consultations. Initially this was an Murphy insists on being present to ensure the intimidating prospect, especially since at one delivery is as safe as possible. After the birth, clinic I was expected to see over 14 mothers both mother and baby are taken to the in one morning! During the consultations my maternity ward, where they remain until they role was to advise on things like nutrition, are deemed fit for discharge. Neonatal sepsis check for pre-eclampsia and gestational is a highly preventable but devastating diabetes, as well as safely treating urinary condition accounting for 12% of deaths in tract and other basic infections. infants under 1 year old in East Timor1. To try to reduce this figure Dr Murphy insists that three key concepts are taught to new mothers, including; exclusive, breast feeding, hand hygiene and early recognition of signs of illness .

Reflection

Doing my elective at a busy and diverse clinic like Bairo Pite enabled me to gain experience working in a range of areas, including the antenatal and labour units and the outreach clinics. Spending time in each department helped me to develop new skills and a broad A new born baby being weighed by midwife in the knowledge base. Firstly, I feel that by taking delivery suite. part in antenatal consultations I learned about Delivery suite the screening tests, health checks and counseling provided to Timorese women. On Aside from my time in the antenatal reflection I appreciate how different these were department I also visited the labour ward, to the standard components of an antenatal where I was able to observe and facilitate the consultation in the UK; highlighting the contrast birth of 2 healthy babies. I was given the in health and social issues between the two opportunity to do on-calls in the delivery suit, countries. which entailed staying over night on the ward and is where I saw my first ever delivery. It also allowed me converse with local mothers Given that I had never assisted during and find out about their attitudes and opinions childbirth, I relied heavily on the midwife to toward the care they received at BPC during guide me through the daunting task. She their pregnancy, which is very important when showed me where to position myself and how considering possible improvements to the to instruct the mother during contractions. service they receive. Based on this I put Epidurals are not available at the clinic and forward some of my own ideas on how to most of the mothers have no pain relief during enhance patient care, including creating a labour, thus helping a mother with breathing patient information leaflet that could be given exercises were was mainstay method of to new and expectant mothers containing key keeping her calm and focused. information on their pregnancy.

Page 4 Having the opportunity to go on outreach learned a great deal about maternal health. clinics enabled me to see firsthand how BPCs Working at BPC enabled me to gain insight initiative on training ‘lay’ midwives was being into the ante, peri and post natal services put into practice. The enthusiasm of the available and the main maternal health care villages toward the project was encouraging needs in a developing country such as East and made me appreciate the importance of Timor. I feel my attitude to Maternal health has engaging local communities when attempting changed and that I now appreciate the diverse to implement health strategies in developing nature of health and psychosocial problems it countries. In addition, carrying out my own encompasses. I hope that through the work I maternal health checks whilst attending the did with the team at BPC, in the maternity mobile clinics has not only helped developed department and on outreach clinics, I have my knowledge in the area of maternal health, made positive impact on Maternal health care but also improved my confidence in my own in East Timor. abilities as a student doctor.

My favorite area was working in the maternity Acknowledgements: unit; following a mother through labour to the birth of her child was a novel and highly I would like to thank the Wellbeing of rewarding experience. Before this I had never Women, the Royal College of Obstetricians attended a birth, thus had to develop new skills and Gynaecologists, and Ethicon for and knowledge in a new subtype of medicine; supporting my elective work. As well as Dr which was initially challenging, but very Dan Murphy for supervising me during my worthwhile. Working with the Timorese elective placement. Finally a mention to midwifes challenged my preconceptions that Mat Lynn for the use of his photographs. their knowledge and expertise would not match that of UK trained practitioners and how their role is made even more demanding by the Written by: Charlotte March limited resources available. References

Key learning points: 1. World Health Organization, World health statistics 2010, http://www.who.int/whosis/whostat/EN_WHS10_Full.pdf, • The differences in the facilities and accessed 12th April 2011 treatments available in BPC and clinics in 2. R.L. Wally, Maternal mortality in East Timor, The Lancet, 2001, volume 358, issue 9280, Page 505, the UK 3. UNICEF, Multiple Indicator Cluster Survey, 2002, Dili, • The complexity of the pathway from Timor-Leste: May 2003 antenatal care through to delivery and post 4. United Natiions Department of Economic and Social Affairs, Population Division, ‘United Nations World natal care and the range of health, Population Prospects, 2006 revision, 2007, New York psychological and social problems that need 5. East Timor Health profile – 2002. health minister to be addressed during this period. 6. Bairo Pite clinic website, mother and child, http://bairopiteclinic.org/activities-mother-child/, accessed • The importance of community based 15th June 2011 healthcare in both East Timor via the 7. United Nations, Millenium development goals, 2000, outreach clinics and in the UK through http://www.un.org/millenniumgoals/, accessed 14th June 2011 general practice. 8. US AID, East Timor final report, USAID’S ImplementIng AIDS prevention and care (IMPACT) project, 2005, http://www.fhi.org/NR/rdonlyres/e37dmhfejztyo67cagt4gfs Summary amqy4yw2beyuctaw4le5jckz7bka4sjkfbeoze36puwbx6aty rnr7yi/EastTimor100606Finalenhv.pdf accessed 01/07/2011, accessed 29th June 2011 Overall I thoroughly enjoyed my medical 9. Epidural anaesthesia, elective and found it to be a motivating, http://www.pregnancy.org/article/epidural-anesthesia, interesting and novel experience from which I accessed 16th June 2011

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