Timor-Leste: Struggling With Maternal Mortality In A New Land
By Joanne Beilby
Introduction
Maternal mortality is an issue of serious concern in many developing countries. In Timor-Leste, a small country located in south-eastern Asia, north-west of Australia, reduction in the maternal mortality rate has been identified as a key development goal and accordingly targeted by the government of Timor-Leste and the United Nations in the Millennium Development Goals set down for member nations.
The average life expectancy in Timor-Leste is sixty years for males and sixty-two years for females.[i] As statistical data is rudimentary at best, it will be supplanted with credible primary accounts from sources such as the United Nations Development Assistance Framework and the United Nations Integrated Mission in Timor-Leste. Through these accounts and more, this essay will discuss the magnitude and causes of maternal mortality in Timor-Leste and the area specific causes that persist.
What is Maternal Mortality?
According to the World Health Organisation, maternal death is defined as:
“...the death of a woman while pregnant or within 42 days after termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes.”[ii]
Where cause of death has been unable to be determined adequately, the International Classification of Diseases 10th revision, has appended the above definition with a new category known as ‘pregnancy related death,’ and defined it as:
“...the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the cause of death.”[iii]
(For the purposes of this essay, both definitions shall be considered relevant.)
Maternal Mortality In Timor-Leste: Making A Real Difference, Fast.
In Timor-Leste, the magnitude of maternal deaths amounts to 420-890 deaths per every 100,000 pregnancies, (est. 2009).[iv] This is known as the Maternal Mortality Ratio (MMR). The birth rate is 26.25 per every 1,000 population (est. 2009), in a country with a total population of 800,000 - 1.1 million. (est. 2009).[v] All of these statistics add up to paint a very bleak picture. Unfortunately, the adequacy of the statistics is such that they are estimates only. There is no national census in Timor-Leste and relevant academic publications are limited. Further, it is estimated that only 22% of births are reported and many published statistics by necessity include verbal autopsies and significant extrapolation between rural and urban districts, which it is argued invalidates the data. Often, data is not presented or quantified, is heavily biased, and must be discounted. Misclassification and under-reporting of data often goes without consideration.
According to UNICEF, one in thirty-five women have a life-time risk of maternal mortality.[vi] Many field workers verbally report that the statistical data is barely an indicator of the true problem.[vii]
None-the-less, we do know that the joint governmental and United Nations goal is to improve maternal health, by reducing the maternal mortality ratio by a total of three-quarters between the period 1990 and 2015.[viii] The Millennium Development Goal is staged and a 30% reduction is targeted for 2015. Accordingly, the aim is to increase births attended by a skilled birth attendant from the current 19% to 60% in 2015.
The United Nations Millennium Development Goal Development Plan cites a combination of factors for the high maternal mortality ratio. These include a low level of antenatal care, particularly in rural areas, and poor distribution of obstetric services for both safe deliveries and emergency care. Birth spacing has been inadequate and the overall nutrition and health status of women of child bearing age is poor.[ix]
“[With the Government of Timor-Leste], a number of strategies have been developed and adopted [...]to reduce maternal mortality and morbidity through broader availability and access to maternal services. These include reproductive health, immunisation, nutrition, health promotion and family planning strategies, and increase preventative care.”[x]
The major causes of maternal mortality can be either direct or indirect. Direct causes of maternal mortality in Timor-Leste include haemorrhage, sepsis, unsafe abortion, obstructed labour and hypertensive diseases of pregnancy, such as eclampsia. Indirect causes include malaria and anaemia.[xi] It is more important than ever that broad primary health care is developed for Timorese mothers. A report by the United Nations Development Assistance Framework 2009-2013 details targeting maternal and neonatal Tetanus with an immunisation programme that has successfully reached 80% in coverage. Section 41 of the document states:
“The immunization coverage rate continued to improve; measles coverage reached 75 per cent by mid-2008, with the critical 80 per cent benchmark expected to be reached soon. The Government, with support from UNICEF and the World Health Organization (WHO), launched a national tetanus toxoid vaccination campaign in 2008 in the hope of eliminating maternal and neonatal tetanus by 2010. Preliminary reports show that more than 80 per cent of targeted women (12-45 years of age) received one dose of tetanus toxoid vaccine during the first round.”
The same document and sub section proceeds to discuss the efforts to increase training for skilled birth attendants with the opening of a new midwifery faculty at the Timor-Leste University.
“WHO actively supported new training courses for nurses and midwives, which started in September 2008, and the Government opened a new faculty in midwifery at the national university, with the support of UNFPA”.
Millennium Development Goals 5A (Reduce Maternal Mortality) and 5B (Achieve Universal Access To Reproductive Health) need to be addressed concurrently. In the realisation of these objectives, the various strategies to reduce maternal mortality must be linked to and predicated on achieving universal access to reproductive health in Timor-Leste. Only 27% of the total population is urbanised.[xii] Rural isolation means inequality for many women in many areas and access to antenatal care and skilled birth attendants is problematical. The population resides primarily on one half of the major island, East Timor; however significant numbers of women are also refugees from the independence war with Indonesia. There are also residents on three other remote islands. Access issues are central to reducing the maternal mortality ratio.
Timor-Leste: New Nation, New Opportunities
For the world’s newest country, Timor-Leste has struggled and succeeded in many areas. On joining the United Nations in 2003, Timor-Leste determined itself to meet the Millennium Development Goals as set down by the United Nations to all member nations: a brave undertaking. Of the key goals detailed in, “Timor-Leste 2005, Millennium Development Goals, Where Are We Now?” one is dedicated to improving maternal health and another complementary goal to combating HIV/AIDS, malaria and other diseases.
Disease and Maternal Morbidity: Addressing Central Causes
Currently, the capacity of Timor-Leste to respond to Public Health threats is minimal and as a result, development in public health, particularly broad primary health care measures, forms part of the Millennium Development Goals for 2015. Timor-Leste lies in an area endemic to malaria and other mosquito borne diseases such as Filariasis, Dengue Fever and Chikungunya.[xiii] It also has an increasing incidence of Tuberculosis and HIV/AIDS prevalence with little health literacy and knowledge of prevention of sexually transmitted diseases.[xiv] There are no available statistics for female literacy rates. All of these factors impact detrimentally on the maternal mortality ratio. Strategies towards realising the goals of 2015 look to combat these factors through the building of inter-sectoral initiatives, (known as the Inter-sectoral Action Framework), strengthening of disease surveillance systems and increasing awareness of important public health concerns.[xv] Inter-sectoral framework building is advocated through increased community participation designed to particularly address the health factors that enable the spread of disease.
Complete coverage of malaria endemic areas is being aggressively pursued by both non-governmental organisations, such as Rotary International and the Bill and Melinda Gates Global Development Program, along with governmental agencies. As a priority, work is focused on the distribution of impregnated nets to pregnant women and children under five years, as netting remains the most efficacious method of malaria control. The diagnosis of malaria cases and provision of treatment is under focus as maternal mortality and malaria in Timor-Leste are significantly interrelated.
“[The adoption of] a broad primary health care approach has led to the following:
• Introduction of standard treatment guidelines for diseases implemented in health facilities;
• Monitoring of disease through an integrated disease surveillance system;
• Distribution of treated bed nets;
• Allocation of resources for purchasing drugs and supplies; and
• Develop cross-sector strategies to address vector and health determinants...”[xvi]
Politics & Pregnancy: Independence & Gender Based Crime In Timor-Leste
Causes of maternal mortality are broad in Timor-Leste; a country still suffering the fallout of longstanding political issues related to independence. It is estimated that independence from Indonesia on May 20th, 2002 continues to result in 100,000 (est. 2007) internally displaced persons, (IDP). This includes over 16,500 families. Nine IDP camps remain open in Dili and Baucau and violence against women continues to be a source of human rights abuse pushing the maternal mortality ratio higher.[xvii] Often, attempts to repatriate displaced persons results in further violence, particularly over land ownership rights, and many Timorese are choosing to remain in West Timor rather than risk disputes during the repatriation process. Section 45 of the United Nations, Development Assistance Framework UNDAF 2009-2013, Republic of Timor-Leste, illustrates these circumstances:
“As at 20 January, a total of 16,500 internally displaced families registered for
assistance under the Government’s National Recovery Strategy (see S/2008/501,
para. 45). Fifty-four camps in Dili and Baucau (out of 63) have closed...”[xviii]
Disease Transmission in IDP Camps: A Case For Bringing Mothers Home
Repatriation and justice issues are only the tip of the ice-berg when considering the impact of IDP camps in Timor-Leste. Disease transmission is made easier where people live in high density, poor hygiene conditions. Water borne disease such as bacterial and protozoal diarrhoea, hepatitis A, and typhoid fever can take hold easily and prove stubborn to eradicate. Coupled with poor immunisation rates, poor health literacy and poor access to medication and medical treatment, internally displaced Timorese living in IDP camps often find themselves residing in the best conditions for disease transmission. For women with the potential to develop post-partum sepsis, the conditions in an IDP camp can be deadly.
International humanitarian assistance continues in Timor-Leste providing food for vulnerable mothers suffering fiscal hardship. Global food costs have been rising as supply has contracted making access to food more difficult and pushing prices higher. Through funds such as the United Nations World Food Programme, food is being distributed to pregnant and lactating mothers unable to ensure adequate supply of nutrition to themselves and their families. Often this assistance is primarily delivered to the IDP camps, with remote areas overlooked.
In Timor-Leste, maternal mortality is tied to the economic realities of the rest of the world. The government is focussing on building more durable solutions through its’ ‘National Recovery Strategy’ aimed at “improving housing, building community trust, security and stability, social protection and local socio-economic development”.[xix] In a country where poverty has increased to now see approximately 50% of the population living below the poverty line, this is going to be a challenge.
Conclusion
Through our analysis of Timor-Leste, we have seen that the magnitude of maternal mortality is very high, with one in thirty-five women having a lifetime risk of obstetric death. The causes of maternal death are many including haemorrhage, unsafe abortion, sepsis, hypertensive diseases of pregnancy, acute infectious diseases and chronic disease states such as malnutrition and anaemia. All are exacerbated by the many social, economic, geographic and political factors underpinning, driving, and in some cases, obstructing change.
Maternal mortality in Timor-Leste is a serious issue and a key indicator of the health of a nation. Many of the causes will be well addressed with comprehensive, quality, antenatal care backed with a strong primary health care programme. Through the Millennium Development Goals, these objectives are within reach, and with good second generational changes to health care programmes in Timor-Leste, accordingly so is safe motherhood for the Timorese.
[i] Source United Nations – Timor-Leste Millennium Development Goals
[ii] Source World health Organisation – Maternal Mortality Ratio Statistical Information
[iii] Source International Classification of Diseases – 10th Revision (2004)
[iv] Source United Nations – Timor-Leste Millennium Development Goals
[v] Source CIA World Fact Book Website - https://www.cia.gov/library/publications/the-world-factbook/geos/tt.html
[vi] Source UNICEF Timor-Leste Statistics: Women http://www.unicef.org/infobycountry/Timorleste_statistics.html
[vii] Source – Primary Interview with Chair, Maternal & Child Health Development (Rotary Australia), Chair, Rotarians Against Malaria (Rotary Australia), Chair Rotary Australia World Community Service (Rotary Australia). http://www.rotary9600.org/ram/
[viii] Source United Nations –Timor-Leste Millennium Development Goals
[ix] Ibid
[x] Ibid
[xi] Source Family Health International http://www.fhi.org/en/Topics/maternalmort.htm
[xii] Source CIA World Fact Book Website
[xiii] Ibid
[xiv] Source United Nations –Timor-Leste Millennium Development Goals
[xv] Source United Nations –Timor-Leste Millennium Development Goals
[xvi] Ibid
[xvii] Source section C16 of Report of the Secretary-General on the United Nations, Integrated Mission in Timor-Leste (for the period from 9 July 2008 to 20 January 2009)
[xviii] Source Walter Kälin, for United Nations, Development Assistance Framework UNDAF 2009-2013, Republic of Timor-Leste, June 2008, Dili
[xix] United Nations Security Council, 4 February 2009, Report of the Secretary-General on the United Nations, Integrated Mission in Timor-Leste (for the period from 9 July 2008 to 20 January 2009)
[1] Source United Nations – Timor-Leste Millennium Development Goals
[2] Source World health Organisation – Maternal Mortality Ratio Statistical Information
[3] Source International Classification of Diseases – 10th Revision (2004)
[4] Source United Nations – Timor-Leste Millennium Development Goals
[5] Source CIA World Fact Book Website - https://www.cia.gov/library/publications/the-world-factbook/geos/tt.html
[6] Source UNICEF Timor-Leste Statistics: Women http://www.unicef.org/infobycountry/Timorleste_statistics.html
[7] Source – Primary Interview with Chair, Maternal & Child Health Development (Rotary Australia), Chair, Rotarians Against Malaria (Rotary Australia), Chair Rotary Australia World Community Service (Rotary Australia). http://www.rotary9600.org/ram/
[8] Source United Nations –Timor-Leste Millennium Development Goals
[9] Ibid
[10] Ibid
[11] Source Family Health International http://www.fhi.org/en/Topics/maternalmort.htm
[12] Source CIA World Fact Book Website
[13] Ibid
[14] Source United Nations –Timor-Leste Millennium Development Goals
[15] Source United Nations –Timor-Leste Millennium Development Goals
[16] Ibid
[17] Source section C16 of Report of the Secretary-General on the United Nations, Integrated Mission in Timor-Leste (for the period from 9 July 2008 to 20 January 2009)
[18] Source Walter Kälin, for United Nations, Development Assistance Framework UNDAF 2009-2013, Republic of Timor-Leste, June 2008, Dili
[19] United Nations Security Council, 4 February 2009, Report of the Secretary-General on the United Nations, Integrated Mission in Timor-Leste (for the period from 9 July 2008 to 20 January 2009)
[20] Women In Timor-Leste (In Brief) Main data sources:
Life expectancy - United Nations Population Division.
Adult literacy - United Nations Educational, Scientific and Cultural Organization (UNESCO), including the Education for All 2000 Assessment.
School enrolment - UIS (UNESCO Institute for Statistics) and UNESCO , including the Education for All 2000 Assessment.
Contraceptive prevalence - Demographic and Health Surveys (DHS), Multiple Indicator Cluster Surveys (MICS), United Nations Population Division and UNICEF.
Antenatal care - DHS, Multiple MICS, World Health Organization (WHO), UNICEF.
Skilled attendant at delivery - DHS, MICS, WHO and UNICEF.
Maternal mortality - WHO and UNICEF.
+ The maternal mortality data in the column headed ‘reported’ are those reported by national authorities. Periodically, UNICEF, WHO and UNFPA evaluate these data and make adjustments to account for the well-documented problems of underreporting and misclassification of maternal deaths and to develop estimates for countries with no data. The column with ‘adjusted’ estimates for the year 2000 reflects the most recent of these reviews.
Notes
- Data not available.
x Indicates data that refer to years or periods other than those specified in the column heading, differ from the standard definition, or refer to only part of a country.
* Data refer to the most recent year available during the period specified in the column heading.
BIBLIOGRAPHY
Websites:
BBC News Country Profile, Timor-Leste, http://news.bbc.co.uk/2/hi/asia-pacific/country_profiles/1508119.stm Accessed 23.03.10
Central Intelligence Agency, World Fact Book, Timor-Leste, https://www.cia.gov/library/publications/the-world-factbook/geos/tt.html Accessed 23.03.10
Rotary Australia World Community Service, (RAWCS)
Books:
Letters & Reports:
United Nations Security Council, 4 February 2009, Report of the Secretary-General on the United Nations, Integrated Mission in Timor-Leste (for the period from 9 July 2008 to 20 January 2009)http://daccess-dds-ny.un.org/doc/UNDOC/GEN/N09/222/46/PDF/N0922246.pdf?OpenElement Accessed 24.03.10
United Nations, Development Assistance Framework UNDAF 2009-2013, Republic of Timor-Leste
Timor-Leste 2005, Millennium Development Goals, Where Are We Now?,
http://www.tl.undp.org/MDGs_File/Timor-Leste%202005%20MDG_Where%20are%20we%20now.pdf Accessed 25.03.10
http://www.tl.undp.org/MDGs_File/Timor-Leste%202005%20MDG_Where%20are%20we%20now.pdf Accessed 25.03.10
Websites:
World Health Organisation Fact sheet N°94, Malaria,http://www.who.int/mediacentre/factsheets/fs094/en/print.html accessed 24.03.10 accessed 28.03.10
Journal Articles:
Geneva, World Health Organization, Maternal mortality in 2000. Estimates developed by WHO, UNICEF and UNFPA, 2000.
X. F. Li, J. A. Fortney, M. Kotelchuck, and L. H. Glover, The postpartum period: the key to maternal mortality, International Journal of Gynecology & Obstetrics Volume 54, Issue 1, July 1996, Pages 1-10 |
Ashutosh Wali, Maya S. Suresh, Maternal Morbidity, Mortality, and Risk Assessment, Anesthesiology Clinics - Volume 26, Issue 1 (March 2008)
World Health Organisation, RBM Pregnant women and Infants. Geneva.http://malaria.who.int/pregnantwomenandinfants.html. Accessed 05.03.10.
United Nations Children's Fund. The state of the world's children. New York: Oxford University Press; 1998.
Baird JK. Neglect of Plasmodium vivax malaria. Trends Parasitol. 2007;23:533–539.
Hay SI, Guerra CA, Tatem AJ, Noor AM, Snow RW. The global distribution and population at risk of malaria: past, present, and future. Lancet Infect Dis. 2004;4:327–336.
Singh N, Shukla MM, Sharma VP. Epidemiology of malaria in pregnancy in central India. Bull World Health Organ. 1999;77:567–572.
Nosten F, McGready R, Simpson JA, Thwai KL, Balkan S, et al. Effects of Plasmodium vivax malaria in pregnancy. Lancet. 1999;354:546–549.
Poespoprodjo JR, Fobia W, Kenangalem E, Lampah DA, Warikar N, et al. Adverse pregnancy outcomes in an area where multidrug-resistant plasmodium vivax and Plasmodium falciparum infections are endemic. Clin Infect Dis. 2008;46:1374–1381.
Balk DL, Deichmann U, Yetman G, Pozzi F, Hay SI, et al. Determining global population distribution: methods, applications and data. Adv Parasitol. 2006;62:119–156.
Hay SI, Snow RW. The Malaria Atlas Project: developing global maps of malaria risk. PLoS Med.2006;3:e473. doi: 10.1371/journal.pmed.0030473.
Snow RW, Guerra CA, Noor AM, Myint HY, Hay SI. The global distribution of clinical episodes of Plasmodium falciparum malaria. Nature. 2005;434:214–217.
Hay SI, Smith DL, Snow RW. Measuring malaria endemicity from intense to interrupted transmission. Lancet Infect Dis. 2008;8:369–378.
Guerra CA, Gikandi PW, Tatem AJ, Noor AM, Smith DL, et al. The limits and intensity of Plasmodium falciparum transmission: implications for malaria control and elimination worldwide. PLoS Med.2008;5:e38. doi: 10.1371/journal.pmed.0050038.
Guerra CA, Snow RW, Hay SI. Mapping the global extent of malaria in 2005. Trends Parasitol.2006;22:353–358.
Guerra CA, Snow RW, Hay SI. Defining the global spatial limits of malaria transmission in 2005. Adv Parasitol. 2006;62:157–179.
Guerra CA. Mapping the contemporary global distribution limits of malaria using empirical data and expert opinion. Oxford: University of Oxford; 2007.
Tatem AJ, Guerra CA, Kabaria CW, Noor AM, Hay SI. Human population, urban settlement patterns and their impact on Plasmodium falciparum malaria endemicity. Malar J. 2008;7:218.
Center for International Earth Science Information Network (CIESIN)/Columbia University; International Food Policy Research Institute (IFPRI)/the World Bank/and Centro Internacional de Agricultura Tropical (CIAT). Global Rural Urban Mapping Project (GRUMP) alpha: Gridded Population of the World; version 2 with urban reallocation (GPW-UR). Palisades (New York): CIESIN; Columbia University; 2007.
United Nations Population Division; Department of Economic and Social Affairs. World population prospects; the 2006 revision; ST/ESA/SER.A/261/ES. New York: United Nations; 2007.
Hay SI, Noor AM, Nelson A, Tatem AJ. The accuracy of human population maps for public health application. Trop Med Int Health. 2005;10:1073–1086. [PubMed]
UNPD. World population prospects: population database. 2006.
Sedgh G, Henshaw S, Singh S, Ahman E, Shah IH. Induced abortion: estimated rates and trends worldwide. Lancet. 2007;370:1338–1345.
Stanton C, Lawn JE, Rahman H, Wilczynska-Ketende K, Hill K. Stillbirth rates: delivering estimates in 190 countries. Lancet. 2006;367:1487–1494.
Desai M, ter Kuile FO, Nosten F, McGready R, Asamoa K, et al. Epidemiology and burden of malaria in pregnancy. Lancet Infect Dis. 2007;7:93–104.
Hay SI, Guerra CA, Gething PW, Patil AP, Tatem AJ, et al. A world malaria map: Plasmodium falciparum endemicity in 2007. PLoS Med. 2009;6:e1000048. doi: 10.1371/journal.pmed.1000048.
Mutabingwa TK, Bolla MC, Li JL, Domingo GJ, Li X, et al. Maternal malaria and gravidity interact to modify infant susceptibility to malaria. PLoS Med. 2005;2:e407. doi: 10.1371/journal.pmed.0020407.
Le Hesran JY, Cot M, Personne P, Fievet N, Dubois B, et al. Maternal placental infection with Plasmodium falciparum and malaria morbidity during the first 2 years of life. Am J Epidemiol.1997;146:826–831.
Schwarz NG, Adegnika AA, Breitling LP, Gabor J, Agnandji ST, et al. Placental malaria increases malaria risk in the first 30 months of life. Clin Infect Dis. 2008;47:1017–1025.
No comments:
Post a Comment