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East Timor Medical Elective, Bairo Pite Clinic; April – May 2011

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East Timor Medical Elective, Bairo Pite Clinic; April – May 2011 Maternal health in East Timor Medical Elective, Bairo Pite Clinic; April – May 2011 Introduction The democratic republic of Timor-Leste (East Timor) 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 women in East Timor 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.
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