Key factors deterring women's engagement with skilled birth attendants in three districts of Timor-Leste. A qualitative descriptive study

Supporting Timor-Leste midwives and nurses through an educational program: An evaluative study

Little is currently known about the impacts of participation in a five-week Australian maternal and newborn health training program for Timorese midwives and nurses.

BACKGROUND

The maternal mortality rate in Timor-Leste is estimated to be around 204 per 100,000 live births, and there is a correlation between safe and quality maternal and newborn health services. Hence, there is a need to develop the nation's maternity workforce. Whilst numerous training programs have been geared towards improving the knowledge and skills of Timorese midwives and nurses, to date, no published study has evaluated their impact on participants.

AIM

To describe satisfaction of an Australian maternal and newborn health training program for Timorese midwives and nurses and its impact based upon the participants survey and qualitative evaluations.

METHODS

An evaluative study was conducted using a survey to explore the impacts of a five-week Australian residential training program on 12 Timorese midwives and one nurse.

FINDINGS

The survey data demonstrated an increase in the participants knowledge and skills required to provide enhanced maternal and newborn care; post-training, most participants demonstrated increased knowledge of obstetric emergencies. The participants showed the most pronounced increase in Advanced Clinical Skills in the subjects of fetal assessment, neonatal resuscitation and obstetric emergencies. The qualitative data identified two main themes and six subthemes related to professionalism, communication, and connections.

CONCLUSION

An Australian residential training program, provided in collaboration with local Rotary clubs can enhance the development of maternal and newborn healthcare skills for midwives and nurses from Timor-Leste.

Adoption of policies to improve respectful maternity care in Timor-Leste

INTRODUCTION

There are now well-established global standards for supporting improvement in women's experience of maternity services, including frameworks for the prevention of mistreatment during childbirth. To support initiatives to improve the quality of care in maternal health services in Timor-Leste, we examine the adoption of global respectful maternity care standards in the national intrapartum care policy and in three urban birth facilities in Dili.

METHODS

From May to July 2022, we conducted a desk review of the Timor-Leste National Intrapartum Care Standards and Clinical Protocols for Referral Facilities and Community Health Centres. This was followed by a health-facility audit of policies, guidelines and procedures in three main maternity facilities in the capital, Dili to examine the extent to which the WHO (2016) standards for women's experiences of care have been adopted.

RESULTS

Despite the availability of global guidelines, key standards to improve women's experience of care have not been included in the National Intrapartum Care guidelines in Timor-Leste. There was no mention of avoiding mistreatment of women, needing informed consent for procedures, or strengthening women's own capability and confidence. In the policy wording, women tended to be distanced from the care 'procedures' and the protocols could be improved by taking a more woman-centred approach. The results of the health facility assessment showed extremely low use of standards that improve women's experiences of care. Health Facility 1 and 2 met two of the 21 quality measures, while Health Facility 3 met none of them.

CONCLUSION

The discourse communicated through policy fundamentally affects how health care issues are framed and how policies are enacted. Given the findings of this study, combined with previously documented issues around quality of care and low satisfaction with maternal health services, there is a need for a fundamental shift in the culture of care for women. This will require an immediate focus on leadership, training and policy-frameworks to increase respectful care for women in health facilities. It will also require longer-term effort to address the power imbalances that drive mistreatment of women within and across social systems, and to support models of care that inherently foster understanding and compassion.

Patient-Defined Cultural Safety in Perinatal Interventions: A Qualitative Scoping Review

Problem

Cultural safety is an approach to patient care designed to facilitate respect of patients' cultural needs and address inequities in care in culturally diverse situations.

Background

Much literature considers culturally safe care during the perinatal period, yet little is known about how patients experience and understand cultural safety. This is despite patient-defined care being one of the definitions of cultural safety.

Question Hypothesis or Aim

This scoping review investigates what is known from existing qualitative literature about patients' experience of cultural safety frameworks in perinatal interventions.

Methods

A search for "cultural safety" OR "culturally safe" in PubMed, Ovid Medline, Ovid Embase, Cumulated Index to Nursing and Allied Health Literature, Scopus, Scielo, and Latin America and the Caribbean Literature on Health Sciences returned 2233 results after deduplication. Title-abstract and full-text screenings were conducted to identify qualitative studies of cultural safety from perinatal patients' perspectives. Seven studies were included in the final analysis. Data were open coded using NVivo.

Findings

Three themes were identified: (1) care that acknowledged that their lives were different from patients in the dominant culture, (2) receiving care in community, and (3) care providers who respected their choices and culturally specific knowledge.

Discussion

This research shows how cultural safety intersects with other equity-based frameworks used in midwifery and obstetrics.

Conclusion

Building on this research could lead to new protocols that address complex social and physical needs of marginalized people during the perinatal period.

Health awareness and skilled birth attendance: An assessment of sustainable development goal 3.1 in south and south-east Asia

BACKGROUND

The United Nation's Sustainable Development Goal 3.1 aims to reduce maternal mortality worldwide to 70 per 100,000 live births by 2030, which requires greater skilled birth attendant (SBA) coverage and increased health awareness. By evaluating relevant sociodemographic factors, this study aimed to identify different groups of women who lack health awareness and access to SBA services in eight selected low-and-middle-income countries (LMICs) of South and South-East Asia (SSEA), namely, Afghanistan, India, Indonesia, Myanmar, Nepal, Pakistan, Philippines, and Timor-Leste.

METHODS

Nationally representative Demographic and Health Surveys (DHS) on women aged 15-49 years were analysed with a pooled sample of 95,521. Complex survey-adjusted logistic regression models were fitted to assess sociodemographic factors, SBA coverage, and health awareness.

RESULTS

Women with higher health awareness were 44.4% (95% CI:1.32-1.58, p<0.001) more likely to access SBAs compared to the rest. Women and/or their partners with no or primary-level education, who were poorer, became young mothers (≤20 years), not involved in decision-making, or hardly exposed to media were less likely to seek SBAs and have higher health awareness. Women in rural areas with more children were also less likely to use SBAs. Timor-Leste, Afghanistan, Myanmar, and Nepal underperformed on SBA coverage amongst the selected LMICs of the SSEA region.

CONCLUSION

Health education and mass-media-driven awareness could be an interventional avenue for LMICs to increase SBA coverage. Future studies comparing health policies within the SSEA region are required to identify reasons behind some nations' underperformance, while others are on track to achieve SDG 3.1.

The utilization of maternal health services at primary healthcare setting in Southeast Asian Countries: A systematic review of the literature

The reduction of Maternal Mortality Ratio (MMR) remains a global health issue. Although major progress has been achieved in the past 15 years, the ratio is still high, especially in Low Middle-Income Countries. In the Southeast Asian region, most of the countries have not reached the Sustainable Development Goals target yet. Although the countries have several similarities in many aspects, such as community characteristics, cultural context, health systems, and geographical proximity, the MMR in the region presents interesting variations. The scope of this systematic review is to explore published literature on the utilization of maternal health services at the community healthcare centre setting in Southeast Asian countries. The databases PubMed, Web of Science, and Google Scholar were searched systematically to identify quantitative, qualitative and mixed methods studies published in 2000-2020. A total of 1876 records were found, out of which 353 full text were screened. Finally, 27 studies on utilization of maternal health services met the inclusion criteria and were selected for analysis from seven Southeast Asian countries: Cambodia, Indonesia, Lao PDR, Myanmar, The Philippines, Timor Leste and Vietnam. Most of the articles focused on the utilization of maternal health services at primary health care setting. Several themes on maternal health services utilization in the countries emerged, including cultural and socioeconomic factors contributed to the utilization of maternal health services, factors associated with the low utilization of ANC, determinants affected place of delivery and delivery assistance choice. The utilization of maternal health services at primary healthcare setting in seven Southeast Asian countries was identified in a small number of studies. Sociocultural barriers and disparities of health services provision are the major factors associated with low utilization of the services. Further research on strengthening the role of primary healthcare in maternal health services provision is required.

The Relationship between Maternal Participation in Household Decision-Making and Birth Attendant Selection: Evidence from Indonesia Demographic and Health Survey

BACKGROUND: The decreasing maternal mortality rate (MMR) is an important indicator in achieving health development. The Ministry of Health has mandated delivery assistance by competent health personnel to achieve the MMR targets set out in the UN sustainable development goals. AIM: This study aims to determine the relationship between maternal participation in household decision-making and the selection of birth attendant in Indonesia. METHODS: The study uses secondary data from the 2017 Indonesia demographic and health survey, as part of a cross-sectional and large-scale national survey. The study involved ever-married women of reproductive age (15–49 years) and had given birth in the last 5 years prior to the survey (n = 14,193). RESULTS: Of all birth attendants, 4,630 (32.6%) were non-health workers and 9,563 (67.4%) were health workers. Midwives account for the largest proportion of the health workers (61.8%). Decisions in healthcare, household expenses, visits to family/relatives’ decisions are significantly associated with birth attendant selection. However, husband’s income use decision had no significant relationship with birth attendant selection. The final multivariate model found that grand multipara mothers had a 1.9 times higher risk of choosing non-health birth attendants than primipara mothers (OR = 1.90, 95% CI = 1.60–2.25). CONCLUSION: Findings demonstrated the importance of improving health education for men and women as well as women’s decision-making autonomy. Health workers (especially midwives) should improve knowledge and communication between couples in choosing skilled birth attendants, especially for mothers with grand multiparity.