Maternal and Child Health Program Annual Report 2010

Maternal and Child Health Program - Fundasaun Alola

DECEMBER 2010

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Acknowledgements We would like to acknowledge the ongoing collaboration of the Ministry of Health (MoH) both at the National and district levels, including staff in 10 MoH district facilities - Dili, Mantuto, Baucau, Lospalos, Viqueque, Aileu, Ainaro, Ermera, Liquica and Oecusse – who supported the implementation of Fundasaun Alola’s Maternal and Child Health Program (MCH) throughout 2010.

We appreciatively acknowledge the donors – large and small - that provided funding assistance to Alola's MCH program in 2010, including UNICEF, ENI, Gulbenkian Foundation, Oxfam Australia, Merri Community Health Services, ConocoPhillips, Woodside and Fundasaun Alola’s friends from around the world who have contributed to our Maternity Packs project through the Australian Foundation for the Peoples of Asia and the Pacific (AFAP), and Alola Australia. In addition, we would like to express our thanks to the University of New South Wales, our partners in the implementation of the Harmony in the Family research project.

Thanks goes too to several of our key stakeholders - Bairo Pite Clinic, Clinic Café Timor, TimorLeste Assistensia Intergadu Saude (TAIS), Health Alliance International (HAI), Timor Leste World Vision, and all of our friends from the Nutrition Working Group, who have assisted Fundasaun Alola in the implementation of the MCH program.

Lastly, our achievements in 2010 would not have been possible without the hard work and dedication of the MCH program staff, and the support that we received from our colleagues at Fundasaun Alola.

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A. Executive Summary In 2010, in order to achieve the goals of Fundasaun Alola and to contribute to the achievement of the United Nations Millennium Development Goals (No. 4: Reduction in Child Mortality and No. 5: Improve Maternal Health), Fundasaun Alola continued its Maternal and Child Health Program (MCH) in three main areas: health-facility-based, community-based and research. In 2010, the MCH program maintained its strong focus on promoting infant and young child feeding, newborn care, safe motherhood initiatives and family planning or birth spacing, hospital play rooms, and recently extended to the Community Management of Acute Malnutrition (CMAM).

Activities resulting from the above focuses included The Baby Friendly Hospital Initiative (BFHI); Infant and Young Child Feeding (IYCF) refresher training for health workers in Dili and Baucau Hospitals; IYCF training, safe motherhood, and family planning training for Mother Support Group (MSG) members; the provision of IYCF counselling in health facilities in ten districts; IYCF promotion to rural communities; play room set-ups at Dili and Baucau hospitals. The program's recent expansion has undertaken the Community Management of Acute Malnutrition program, and an ongoing research project on understanding anger and its consequences amongst women in conflict-affected Timor Leste: Implications for enhancing sustainable development.

In 2010, Alola was able to extend the MSG by using the SHIO model in 16 villages across 7 districts: Oecusse(4), Manatuto (2) , Baucau(2) , Viqueque(2) , lautem(3), Aileu(2) and Ainaro (1) . As a result, a total of 53 maternal and child health community groups (MGS/SHIO) were stablished in 57 villages across the country with 248 new members. The program was initiated through consultation with local authorities; identification of a suitable program location; socialisation to community; participatory problem analysis for the village facilitators; participatory problem analysis workshop for the community members; a workshop on regulations and socialisation of the regulations to the community; and finally, the inauguration of the group.

The MCH facility-based program activities supported skin-to-skin contact for 3526 newborn babies, and provided breastfeeding counselling to 4245 women at the Dili National Hospital, 1195 women at Baucau Referral Hospital, 261 at Maubisse and 193 in Oecusse. An additional 161 women received treatment for breastfeeding problems. 1673 women received maternity packs that were distributed by MCH program staff in Baucau, Maubisse and Oecusse referral hospitals following expansion in 2010.

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The program also trained 374 SHIO members in IYCF, basic safe motherhood and family planning. As soon as they received training the SHIO members provide information on Dangers Signs During Pregnancy, Childbirth, postpartum health and the benefits of Breastfeeding to 7113 Pregnant and 4214 Lactation women at Community Health Centres and SISCa Posts. During the socialisation of SHIO programs, approximately 500 people watched movies about breastfeeding and Safe Motherhood.

In 2010, Alola set up two play rooms for young patients, one at each Dili National Hospital and Baucau Referral Hospital. The play rooms provide a place in which parents and their children who are staying at the hospital can access games, draw, tell stories, and watch children's movies. The play rooms also serve to provide a place/distribution centre for information, particularly relating to breast feeding and complementary feeding. The training on IYCF, basic safe motherhood, Newborn Care and family planning to MSG and SHIO members is very helpful for early detection of problems and results in members having the skills to make quick decision about when to refer cases through MSG/SHIO networks. In 2010, 297 pregnant women were referred to deliver at health facilities for a normal birth or due to complications, 155 women received Family Planning support, and 34 children were assisted by MSG/SHIO member to receive treatment on malnutrition.

One important MCH program activity involved conducting community discussion forums in each MSG/SHIO on various topics, such as IYCF, Family Planning, Women's Nutrition, and Tuberculosis to 136 participants. 500 participants across 10 villages attended a breastfeeding week quiz, and all of these villages now have new MSG/SHIO groups. 293 out of 665 babies were assessed to be in the 'healthy' category because they fulfilled the criteria of The Baby Contest for World Breastfeeding Week based, on the WHO Child Growth and Development Chart. 323 babies had received exclusive breastfeeding for the first six months with support from their local MSG/SHIO members.

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B. Program Background Fundasaun Alola established its Maternal and Child Health (MCH) Program in February 2003, through the National Breastfeeding Association (NBFA). Since 2006 to 2010 Fundasaun Alola has extended its MCH program to include maternity packs, women’s health, newborn care, safe motherhood initiative and Play room at Dili National Hospital and Baucau referral Hospital.

In 2009, NBFA was handed over to the Ministry of Health’s (MoH) Nutrition Department. To facilitate the handover process, Fundasaun Alola seconded a senior staff member for two days to work with MoH. The staff member assisted the coordination and implementation of the Baby Friendly Hospital Initiative (BFHI), provided breastfeeding training for health workers, and advocated for a breastfeeding policy and International Code for Breastmilk Substitutes.

Fundasaun Alola is still committed to promoting breastfeeding and timely and appropriate complementary feeding for children under the age of two in Timor-Leste. Therefore, starting in 2009, Fundasaun Alola replaced NBFA with the Breastfeeding Promotion Program (BPP). The program targets health facilities, communities and the general population.

Since the establishment of the NBFA, Fundasaun Alola has set up 53 Mother Support Groups (MSG) and Suku Hadomi Inan no Oan (SHIO) in 57 out of 441 villages, with more than 1000 members in ten districts of Timor-Leste. The initial guidelines of the MSGs were to promote colostrums and exclusive breastfeeding for the first six months.

In 2007, Fundasaun Alola piloted the provision of counselling by MSG members at Dili National Hospital and Baucau Referral Hospital. This counselling was successful in extending the coverage and promotion of breastfeeding. It also aided and expanded the knowledge and skills of MSG members, which they had previously gained through training provided by the MCH team. Due to the success of the program, Fundasaun Alola will continue to support MSG members to provide counselling at hospitals, Community Health centres (CHC) and Health Posts, as well as Servisu Integradu Saude Comunitaria (SISCa) posts, which continue to benefit pregnant and lactating women.

In consultation with MoH, Fundasaun Alola also piloted a community-based safe motherhood program in Liquica District during 2007/2008, known as Suku Hadomi Inan no Oan (SHIO). SHIO is modelled on an Indonesian program, known as Desa Siaga (Siap, Antar Jaga), and was introduced to reduce maternal and child mortality, and address Millennium Development

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Goals numbers 4 and 5. The objectives of SHIO are to raise community awareness about birth preparedness; recognize danger signs during pregnancy, child birth and postpartum; and to assist and support women with obstetric complications with transport to a health facility. SHIO was successful in increasing the number of antenatal care visits, skilled birth attendants and family planning in piloted villages.

Another exciting new initiative is Fundasaun Alola’s Newborn Care Program. This program provides additional midwife support in Dili and Baucau hospitals to promote skin-to-skin contact, and immediate and exclusive breastfeeding education for all new mothers. Essential to this program is the Maternity Pack project that still exists at Baucau Referral Hospital and recently expanded to Maubisse and Oecusse Referral Hospital, which provides all new mothers with clothing, baby goods, and postpartum health promotion materials. MSG members have been recruited to work in this program to provide ongoing support when mothers return home.

C. Project Objectives MCH Vision: To improve the health of women and children in Timor-Leste

MCH Goal: To contribute to the reduction of maternal and children mortality in Timor-Leste

MCH Program Objectives: 1.

To promote good practices of infant and young child feeding across the country through Mother Support Groups and SHIO.

2.

To promote and support the safe motherhood initiative and reproductive health through the establishment of MSG/SHIO networks.

3.

To promote and encourage facility-based delivery through the provision of maternity packs hospitals.

4.

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Promoting and supporting newborn care at hospitals.

D.Maternal and Child Health Activities Achieved in 2010 MCH - Facility-based Program activities Infant and Young Child Feeding Training for Doctors Infant and Young Child Feeding is an intensive course designed to combine three topics in one course - breastfeeding, complementary feeding and infant feeding, & HIV Counselling. This training is developed by IBFAN (Infant Baby Food Action Network) and Breastfeeding Promotion of India (BPI).

In July, Fundasaun Alola assisted the Ministry of Health and UNICEF to organise IYCF training for the doctors, midwives and nurses. This training was prioritised for doctors to participate, however the limited number of Timorese doctors meant that midwives and nurses were invited to fill the gap. The IYCF training was conducted over 13 days, including 6 days Training of Trainer to prepare master trainers, and 7 days for counselling specialist training. The training was conducted from 12 to 26 July 2010 and facilitated by Prof. M.M.A Faridi, an IYCF Course Director from India. The training resulted in 5 master trainers consisting of 3 Timorese doctors and two midwives, as well as 24 counselling specialists consisting of 12 doctors (General Practitioners).

The Infant and Young Child Feeding training for doctors is crucial, as the doctors have a significant influence on mothers and family decisions on infant feeding, as they are often trusted by communities. The doctors’ role is very important to improving the infant feeding practices in Timor-Leste.

Baby Friendly Hospitals Initiative (BFHI) Fundasaun Alola assisted with a re-assessment of baby friendly hospitals in Dili National Hospital and Baucau Referral Hospital. The assessment was undertaken on the 2nd and 3rd of August in Baucau Referral Hospital, and the 5th and 6th in Dili National Hospital. The reassessment identified that there is no written breastfeeding policy in either of the hospitals to communicate to all staff; bottle feeding was discovered; and antenatal classes on breastfeeding only conducted in Baucau Referral Hospital in the Out-Patient Department

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(OPD). Antenatal classes on breastfeeding were not found to be conducted in the Out-Patient Department (OPD) in Dili National Hospital as this hospital only attends to referral cases from community health centres and districts. The recommendation from Dr. Faridi is to delay accreditation of each hospital under the Baby Friendly Hospital Initiative, until they have improved their practices. Therefore, these two hospitals could not be accredited in 2010 as planned.

For the effective implementation of BFHI, awareness-raising need occur among all workers at these hospitals including security guards, cooks and cleaners. Therefore, in September, Fundasaun Alola in collaboration with the Ministry of Health undertook to socialise the BFHI for cleaners with objectives to promote, support and protect breastfeeding. The training was attended by 35 cleaners.

With regards to fulfilling the criteria of BFHI, Fundasaun Alola, together with the Ministry of Health, also conducted refresher training on Infant and Young Child Feeding over 3 days for health workers in Baucau hospital. The training was attended by 14 people, 10 female and 4 female.

Assistance and Support at Hospitals To strengthen national programs on IYCF in Timor-Leste, Fundasaun Alola has initiated the promotion of IYCF at Health Facilities by recruiting 10 people as MSG members and one midwife working in the Dili National Hospital, Baucau, Maubisse and Oecusse referral hospitals. The objective is to support the newborn care program that has been implemented in the maternity ward, including the promotion of skin-to-skin contact and early initiation of breastfeeding. The program provides information and comprehensive assistance to eliminate barriers to successful breastfeeding during the mothers' and babies stay at the hospital, and the distribution of Maternity Packs which provide clothing for mothers and babies, as well as breastfeeding and other post-partum material information.

The table below shows data on the support provided by MSG at each Dili National Hospital, and Baucau, Maubise and Oecusse Referral Hospitals in 2010. No

Activities

1

Total number of mothers that delivered in Hospital

2

8

Total number of mothers that

Dili

Baucau

4711

1195

70

1106

Maubisse 272 277

Oecusse 258 260

Total 6436 1713

received maternity packs 3

Total number of babies born

4

Babies sex

5 6

7

4791

1135

280

Female (F)

2286

576

139

117

3118

Male M)

2505

556

141

137

3339

80

53

6

4

143

Normal

3922

987

208

223

5350

Caesarean

578

130

56

25

789

Forceps

28

3

-

3

34

Twins

246

6452

Type of delivery

Newborn Care and first initiation Total number of babies that received skin-to skin contact

3294

0

232

Breastfeeding

3526

Total number of mothers received Breastfeeding

261 4245

1195

193

Counselling

5894

Total number of families that received Breastfeeding

514 5183

152

85

Counselling 8

9

5943

Breast and Breastfeeding Problem Inverted Nipple

73

2

-

5

80

Engorgement

29

0

1

9

39

No breastmilk

27

0

3

1

31

Mastitis

4

4

1

2

11

Obstetrics complications Preeclampsia

17

3

5

3

28

Eclampsi

8

4

2

3

17

Sepsis/ infection

16

4

1

6

27

732

69

18

12

831

Asphyxia

139

16

3

4

162

Premature

66

44

7

6

123

Jaundice

2

0

5

3

10

Maternal Mortality rate

5

2

-

4

11

13

Neonatal mortality

24

0

1

0

25

14

IUFD (Intra Uteri Foetal Death)

117

33

9

14

173

10

Abortion

11

Newborn Complication

12

9

Mortality

Breastfeeding Counselling at hospitals by MSG To strengthen national programs on IYCF in Timor-Leste, Fundasaun Alola has initiated the promotion of IYCF at Health Facilities by recruiting 10 people as MSG members and one midwife working in the Dili National Hospital, Baucau, Maubisse and Oecusse referral hospitals. The objective is to support the newborn care program that has been implemented in the maternity ward, including the promotion of skin-to-skin contact and early initiation of breastfeeding. The program provides information and comprehensive assistance to eliminate barriers to successful breastfeeding during the mothers' and babies stay at the hospital, and the distribution of Maternity Packs which provide clothing for mothers and babies, as well as breastfeeding and other postpartum material information. The provision of breastfeeding counselling in health facilities is a core initiative of the MCH program to support mothers with successful breastfeeding. Support is provided to mother to put a newborn baby directly on the breast to feed as soon as possible after birth, as well as to take action when there is a problem for breastfeeding mothers or their baby. Family members, especially the women's husband, eldest daughter, aunt and grandmother tend to be the people closest to the mother, who can then support exclusive breastfeeding, and are thus also key targets for the distribution of information and counselling about the benefits of breastfeeding for mothers, babies and families.

In 2010, there were 5894 women and 5943 relatives’ families’ that received breastfeeding counselling at Dili National Hospital, and in Baucau, Maubisse and Oecusse referral hospitals. At Dili National Hospital, MCH staffs provide breastfeeding counselling in the Maternity, Postnatal, Podiatric and Perinatology wards, and in other wards as requested or required to provide assistance to mothers and babies who have problems with breastfeeding. The Staff of

the MCH program succefully addressed 44 instances of the bottle feeding that family brought from home after provide counselling to mother and family to breastfeed. Some breast problems that were successfully handled by the MCH staff in 2010 included 80 cases of inverted nipples, 19 cases of one breast inverted nipple, 39 cases of engorged breasts, 31 cases of no breast milk, 11 cases of Mastitis and 6 cases of sore nipples.

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Maternal and Neonatal Mortality Rate and Stillbirth Data In 2010, 11 mothers died at these facilities as the result of childbirth - 5 at Dili National Hospital, 4 at Oecusse and 2 at Baucaua Referral Hospital. There were no maternal deaths at Maubisse Referral Hospital. The causes of these deaths are related to obstetric complications: Preeclampsia and eclampsi, severe anaemia (with HB 2gr %), ruptured uteri with severe anaemia, and severe anaemia with hypertension and infection.

Besides these deaths, there were 25 neonatal moralities; 24 at Dili National Hospital, and one at Maubisse, though none at Baucau or Oecusse referral Hospitals. Case of neonatal mortality related to Hydrocephalus, Premature, and miconium aspirasi with severe asphyxia. An additional 56 stillbirth occurred, 33 at Baucau, 14 at oecusse and 9 at Maubisse referral Hospital

Safe motherhood – Maternity Packs Distribution The Maternity Packs Project was initiated to increase the number of health facility deliveries in Timor-Leste, as based on DHS that in 2003 it was only 9%. We believe that this project has made a valuable contribution to increasing the number of facility-based deliveries to 22%, as reflected in DHS 2009/10. The program has been evaluated internally and we trust that this model will continue to encourage health facility deliveries. In 2010, Fundasaun Alola expanded its program to two referral hospitals in Timor-Leste Maubisse Referral Hospital and Oecusse Referral Hospital. The distributions of the maternity packs in these 2 hospitals also contributed to the gradual increase of deliveries in these facilities. In 2010, the Ministry of Health assumed responsibility for distributing maternity packs in Dili National Hospital. Distribution Maternity Packs Data Month January February March April May June July August September October November December Total

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Number of Women that Received Maternity Packs Baucau Referral Hospital Oecusse Referral Hospital 89 78 26 88 29 92 26 111 30 92 16 102 19 101 26 96 29 95 21 95 25 46 11 1083 254

Maubisse Referral Hospital 11 21 27 26 32 29 31 25 24 28 23 277

Newborn Care – Breastfeeding Promotion Breastfeeding is a crucial component of newborn care. The first initiation of breastfeeding is crucial to the ongoing successful breastfeeding. DHS data indicates that the prelacteal feeding is reduced. In terms of newborn care, Fundasaun Alola is assisting midwifes at the Dili National and Baucau Referral Hospitals to perform skin to skin contact after delivery, and help with the first initiation of breastfeeding, with objectives to reduce infant mortality. Skin to Skin contact is important because a mother’s chest can provide the optimal temperature for a baby, and comfort for both the mother and baby. When a newborn baby licks its mother’s skin it Swallows “safe” bacteria which colonises the baby’s gut to prevent “harmful” bacteria growing. This further serves to stimulate uterine contractions to reduce bleeding and Stimulates milk flow. In Timor-Leste, skin to skin contact is only encouraged in two hospitals - Dili National Hospital and Oecusse Referral Hospital, predominantly by Fundasaun Alola’s MCH staff working at these hospitals. 3294 babies are detailed as having had skin to skin contact with their mother immediately after delivery, and 1504 as unable to have skin to skin contact with their mother because of the obstetrics and neonatal complications (at Dili National Hospital). At Oecusse Referral Hospital, 232 babies received skin to skin contact with their mother immediately on delivery.

Young Patients Play Room at Hospitals In December 2019, Supported by New Community Church, Fundasaun Alola in collaboration with MoH have established 2 Play Rooms at Dili National Hospital and Baucau Referral Hospital. Both play Room were inaugurate by Ms. Madalena Hajan the Vice Minister of Health and Ms. Kirsty Sword Gusmao , chairperson of

Fundasaun

Alola. Representatives from MoH , Guard National of Republican -Portugal who was donated the toys for the Play room. Play rooms provide a place in which parents and their children who are under hospital care can access games, draw, tell stories, and watch children's movies, after the children have a check-up from the doctors. The Play Rooms also provide a location and forum in which to distribute information relating to breast feeding and

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complementary feeding. The Play Rooms are lead by the MSG members who have been recruited as Alola employees at both of these hospitals. The play rooms have a very positive impact in the hospital by helping parents entertain and engage with their children during recovery time, and providing a place for children to become more relaxed. The Play Rooms provide an outlet to assist parents to cope with their child's illness and are expected to provide an example for the government for expansion in other hospitals in the future.

The objectives set out the Play Room at the hospital are: 

To provide a well-equipped play room for parents and children who come to the hospital, especially for those who need to stay several days in the hospital during recovery from illness;



Share and provide information on breastfeeding and complementary feeding to mothers and family members who bring their children to the play room, especially for parents that their children in the treatment of malnutrition;



Provide an opportunity to Mothers Support Group members (MSG) to work directly with mothers to share knowledge that they have acquired as MSG members.

The total number of children that accessed the Dili and Baucau Hospital Play Rooms was 4953. An additional 901 parents and family members received breastfeeding counselling at Dili National Hospital.

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MCH Community-based Program activities Expansion of the MSG and SHIO to 15 Villages in 7 Districts Fundasaun Alola, with the support of UNICEF, Moreland Community Health Services, ENI and Gulbenkian Foundation, extended its MSG and SHIO for promoting infant and young child feeding, safe motherhood, newborn care, and family planning. MSG and SHIO groups have been established across 16 villages in 7 districts: Viqueque, Baucau, Manatuto, Oecusse, Lautem, Aileu and Ainaro.

The details of the establishment process are described below:

1.Consultation and Socialisation Upon identifying potential villages in which to establish MSGs and SHIOs, the MCH team conducted consultation meetings with district authorities, especially District Administrator and the head of District Health Services, heads of district MCH and nutrition. The village selected needed to fulfil specific criteria, including the availability of a village midwife and the willingness of the community leader to participate in the establishment processes. The Consultation meetings were held in January to April 2010.

Following consultation with district authorities, the MCH team contacted the chief of the selected villages, organized meetings to inform them about the program, and organized community members to attend the program socialisation meeting in the community.

Socialisation activities were implemented with the assistance from village chiefs, who invited community and community leaders from each hamlet to the meeting. The meetings held in each village maintained a key objective to select and identify community members who are willing to actively participate in MSGs. After the selection of the members, the groups were invited to discuss and nominate an individual to become the local facilitator. These members attended training in participatory problem analysis to enable them to facilitate PPA workshop in their community.

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The details of consultation and socialisation meetings are shown below: No

District

Sub-district

Villages

Activities

Total Participants

Date of the socialisation

1

Oecusse

Pante

Costa –

Socialisation

22 people

22-23.4.2010

Makasar

Kutete Cunha

Socialisation

19 people

24-25.4.2010

Lifau

Socialisation

21 people

16.4.2010 and 19.4.2010

2

Oe-Silo

Bobometo

Socialisation

Manatut

Manatuto

Cribas

Consultation meeting with

o

Vila

26 people

20-21.4.2010 13.4.2010

district authorities Socialisation to community

34 people include

16.4.2010

midwife Laclubar

Manelima

Consultation with sub-

14.4.2010

district authorities and community leaders

3

Baucau

Venilale

Socialisation to community

31 people include

groups

midwife

Uma Ana

Coordination with district

Ulo

authorities and community

22.4.2010

15.4.2010

leaders Socialisation to community

22 people include

19.4.2010

midwife Vemasse

Loilubu

Coordination meeting with

15.4.2010

community leaders Socialisation to community

25 people include

20.4.2010

midwife 4

Viquequ

Lacluta

e

Ossu

Socialisation to community

23 people

30.4.2010

Ossu decima

Socialisation to community

25 people

01/05/10

Lospalos

Leuro

Socialisation to community

20 people

1/06/2010

Tutuala

Tutuala

Socialisation to community

25 people

3/06/2010

Lautem

Maina II

Socialisation to community

40 people

7/06/2010

6Ainaro

Ainaro Vill

kassa

Socialisation to community

20 people

20/4/2010

7

Laulara

Madabeno

Socialisation to community

30 people include

9/10/2010

5

Laut

Dilor

em

Chefe Suku Remixio

Maumeta

Socialisation to community

18 people include Chefe Suku

15

22/10/2010

2. Participatory Problem Analysis (PPA) Training of Trainer for Village Facilitators To empower community members and to enable them to facilitate maternal and child health participatory problem analysis workshops in their villages, the Alola MCH team conducted 3 days ToT in PPA for the village facilitators. The training was held in Dili, from 3 to 5 May 2010. Fourteen participants representing 10 villages attended the training. There were seven female participants and seven male participants. The training covered facilitation skills, social mapping, history of the obstetric and childhood illness it also covered general cases of emergency, and identifying gendered domestic activities as means of assessing gender discrimination occurring in communities that might also contribute to the poor health of women during the maternal period.

The participants expressed that they were feeling pleased at acquiring new knowledge and skills which they would not ordinarily have access to in their village. They committed to contributing to the implementation of the program in their villages.

Details of the facilitator Village for participatory program analysis (PPA) No

District

Subdistrict

Villages/Hamlets

Participants Female Male

1

Oe-cusse

Pante Makasar

Oesilo Manatuto Manatuto Laclubar Baucau Venilale Vemase

Kutete Lifau Cunha Bobometo Cribas Manelima Uma Ana Ulo Loilubu

1 1 1 1 1 1 -

1 1 1 1 1 1 -

Date of training Total participants 2 people 3 - 5 May 2010 2 people 2 people 2 people 2 people 2 people -

4

Viqueque Lacluta Ossu

Dilor Ossu de Cima

1

1

2 people

5

Lautem

Leuro Tutuala Mahina II Total

1 1 1

1 1 1

2 people 2 people 2 people 20 people

2 3

16

Lospalos Tutuala Lautem

3. Participatory Problem Analysis Workshop with Community Members PPA workshops were held in villages to identify the main problems faced by the community regarding maternal and child health. The PPA involved communities to actively identify the problems faced by their community, and the actions taken by community in the past. This provides opportunity to identify other factors which contribute to maternal and child health morbidity and mortality, including the workload of women, and gender discrimination between women and men.

The PPA workshop serves to raise community awareness about gender equality and enabled community to identify stakeholders with whom they can work in the community in regard to health. Workshop participants were able to develop a morbidity map to represent the referral mechanism that should be in place, as well as health assistance that they could access both within and outside their villages.

The details of PPA workshop in every village are shown below: No

1

District

Oecusse

Sub-district

Pante Makasar

Villages

Costa – Kutete Cunha Lifau

2

3

Manatuto

Baucau

Oe-Silu

Bobometo

Manatuto Vila

Cribas

Laclubar

Manelima

Venilale

Uma Ana Ulo Loilubu

Vemasse 4

5

17

Viqueque

Lautem

Lacluta

Dilor

Ossu

Ossu decima

Lospalos

Leuro

Tutuala

Tutuala

Activities

PPA Workshop PPA workshop PPA workshop PPA workshop PPA workshop PPA workshop PPA workshop PPA workshop PPA workshop PPA workshop PPA workshop PPA workshop

Participants Female Male 11

9

Total Participants 20 people

11

10

21 people

10

11

21 people

14

6

20 people

25

13

38 people

14

18

32 people

11

12

23 people

16

7

23 people

12

11

23 people

22

10

32 people

12

6

18 people

13

9

21 people

Lautem

Maina II

6

Ainaro

Ainaro Villa

Kassa

7

Aileu

Laulara

Madabeno

Remixio

Maumeta

PPA workshop PPA workshop PPA workshop PPA workshop

Total participants

22

11

33 people

9

5

14 people

16

6

22 people

12

6

18 people

218

141

359 people

4. Workshop on Structure, Regulation and Socialisation of the Group Following the PPA community workshop, the Alola-MCH team conducted another workshop to discuss the structure and regulation for the groups and villages. The structure related to selection of the head of the group and determining which networks needed to be established in the community. In the 10 villages, the communities decided to have networks such as: 1)

Notification, Health Promotion Network and Family Planning Network;

2)

Fundraising Network; and

3)

Transportation Network.

The regulation component was used to regulate the MSG/SHIO group and community that support the group. This regulation includes behaviour change strategies and goals, such as encouraging every woman to exclusively breastfeed for the first six months, attend ANC, PNC and delivery at health facilities and/or assisted by health workers, and using the family planning methods for birth spacing. Regulation also governs fundraising within community, which is contributed to by every household, and transport support for women who will need it in the event of an emergency. Regulations are then socialised to the community and may be revised according to community input. On completion of this process, inauguration of the program occurred at Mass or another cultural event.

Details on the structure and regulation of workshops: No

1

18

District

Oe-cusse

Subdistrict

Villages/Hamlets

Pante Makasar

Kutete

Participants Female Male 11

9

Total participants 20 people

Date of training 5 – 8 July 2010

Lifau

12

8

20 people

Cunha

13

11

24 people

Oesilo

Bobometo

15

6

21 people

Manatuto Laclubar Venilale Vemase

Cribas Manelima Uma Ana Ulo Loilubu

31 21 9 13

7 7 11 5

38 people 28 people 20 people 18 people

12 – 15 July 2010 22 – 26 July 2010 16 – 20 July 2010 24 – 27 July 2010 31 Aug – 3 Sept 2010

2

Manatuto

3

Baucau

4

Viqueque

Lacluta Ossu

Dilor Ossu de Cima

10 21

12 16

22 people 37 people

19-22 July 2010

5

Lautem

Lospalos

Leuro

6

12

18 people

Tutuala

Tutuala

13

9

21 people

Lautem

Mahina II

22

11

33 people

Laulara

Madabeno

16

6

22 people

Remexio

Maumeta

9

5

14 people

5 – 8 July 2010 19 – 22 July 2010 12 – 15 July 2010 8 – 11 November 2010 9 – 12 November 2010

Ainaro Villa

Kassa

12

6

18 people

234

141

375

6

7

Aileu

Ainaro

Total participants

26 – 29 April 2010

5. Inauguration Inauguration is the final stage of establishing the new MSGs/SHIO program. The inauguration ceremony were planned to implement through the celebration of Mass or another cultural ceremony. In these 10 villages, some groups agreed to use a Mass celebration and other used a cultural ceremony. Inauguration was held to strengthen the commitment of the members who are joining the group. In Oecusse district, inauguration activities were officially opened by the Oecusse District Administrator and attended by UNICEF, District Health services, Fundasaun Alola, Community Leaders, NGOs and coordinators of rural area development from the Ministry of Development and Economy. In his speech the District Administrator encouraged community leaders such as heads of sub districts, villages and hamlets to work together with community volunteers to increase community awareness of the importance of exclusive breastfeeding for first six months, giving birth with

19

a skilled birth attendant, and promoting use of health facilities. The details of the inauguration ceremonies are shown below: No 1

2

3

4

5

Distritu Oecusse

Sub-distritu Pante Makasar

Manatuto

Baucau

Viqueque

Lautem

Suku

Partisipantes

Data Inagurasaun

Costa – Kutete

48 people

4 Junho 2010

Cunha

75 people

7 Junho 2010

Lifau

36 people

8 Junho 2010

Oe-Silu

Bobometo

88 people

3 Junho 2010

Manatuto Vila

Cribas

67 people

10 Junho 2010

Laclubar

Manelima

87 people

10 Junho 2010

Venilale

Uma Ana Ulo

75 people

17 Junho 2010

Vemasse

Loilubu

49 people

17 Junho 2010

Lacluta

Dilor

96 people

01 Julho 2010 02 Julho 2010

Ossu

Ossu decima

56 people

Lospalos

Leurio

22 people

10 June 2010

Lautem

Mainha II

24 people

14 June 2010

Tutoala

Tutuala

35 people

17 June 2010

6

Ainaro

Ainaro Villa

Kassa

26 people

22 April 2010

7

Aileu

Remixio

Maumeta

27 people

25 october 2010

Laulara

Madabenu

35 people

27 0ctober 2010

Total

846

IYCF, Safe Motherhood, Newborn Care and Family Planning Training to New MSG Members To enhance the knowledge and skills of the MSG members in Viqueque, Baucau, Manatuto and Oe-cusse District Fundasaun Alola conducted four days training on infant and young child feeding, safe motherhood and family planning to the members of the MSG in 10 villages across four districts. Infant and young child feeding training consists

of

18

sessions

include

breastfeeding,

complementary feeding, counselling skills and infant feeding in emergency situations, as well as maternal nutrition. The Safe Motherhood training covers the importance of antenatal care, advantages of delivery at facilities and

20

postpartum care as well as recognizing danger signs during pregnancy, childbirth and postpartum. The family planning training is about types of modern contraceptives, natural contraceptives, and the advantages and disadvantages of each contraceptive method. This knowledge will help the MSG members to provide counselling to women and their families and disseminate information to their village communities. Details of the training are shown below: No

District

Sub-district

Villages/Hamlets Female

1

2 3 4 5

6 7

Oe-cusse

Pante Makasar

Kutete Lifau Cunha Oesilu Bobometo Manatuto Manatuto Cribas Laclubar Manelima Baucau Venilale Uma Ana Ulo Vemase Loilubu Viqueque Lacluta Dilor Ossu Ossu de Cima Lautem Lospalos Leuro Tutuala Tutuala Lautem Maina II Ainaro Ainaro Villa Kassa Aileu Laulara Madabeno Remixio Maumeta Total participants

11 12 13 15 31 21 9 13 10 21 12 13 22 12 16 9 240

Participants Male Total participants 9 20 people 8 20 people 11 24 people 6 21 people 7 38 people 7 28 people 11 20 people 5 18 people 12 22 people 16 37 people 6 18 people 9 21 people 11 33 people 6 18 people 6 22 people 5 14 people 134 374

Date of training

5 – 8 July 2010 12 – 15 July 2010 22 – 26 July 2010 16 – 20 July 2010 24 – 27 July 2010 31 Aug – 3 Sept 2010 19-22 July 2010 14-17/06/2010 21-24/06/2010 28- 30/06/2010 26-29/04/2010 8 -11/11/2010 8 – 11/11/2010

MSG Counselling Activities at Health Facilities and Integrated Community Health Service ( Servisu Integradu Saude Comuitaria = SISCa) Post A part from doing counselling at to the MSG member’s household, the members also provide counselling at health facilities and post SISCa nearby their group. The Alola MCH team and MSG members have a good collaboration and work coordination with CHC and Health workers in each district regarding the counselling activities. The schedule for health centre prepared by MSG/SHIO but for the SISCa is timetable from the health worker. The beneficiaries for the counselling are pregnant and lactation women and fathers who brought their children for immunization. Counselling occurred twice a week at health facilities and once a month at SISCa Post. In 2010, the MSG/SHIO members have able to counsel 4214 Pregnant and 5313 lactating women on breastfeeding and complementary feeding, across ten districts.

21

The details of the counselling are represented in the table below No

1 2 3 4 5 6 7 8 9 10

Districts

Dili Baucau Manatuto Oecusse Viqueque Lautem Liquisa Ermera Aileu Ainaro Total

Counselling location Health Facility (Hospital, SISCa Post CHC and HP Pregnant Lactating Pregnant Lactating women women women women 895 113 35 213 858 1675 144 448 306 330 57 141 601 256 84 265 225 418 25 80 256 138 126 75 145 216 97 92 143 15 43 312 396 81 213 3643 3589 571 1724

Monthly Community Discussion Forum Monthly Community Discussion Forums are a new strategy developed by Alola's MCH team to disseminate information on Infant and Young Child Feeding, safe motherhood, family planning and reproductive health as well as other health information to communities The topics discussed in the community forum relate to various health topics including communicable & non communicable diseases, reproductive health, hygiene, nutrition and so on. The community has expressed it is very interested in this activity, as the meeting provide an opportunity for them to receive information and discuss any concerns. Typically, communities have requested health-related topics of interest for discussion at future meetings. Monthly discussion forums were held in different hamlets

across 10 districts. The Fundasaun Alola and MSG members were able to facilitate community discussions in the 53 groups of the 57 villages that established MSG/SHIO groups in across 10 districts with approximate 500 community members.

22

Monthly Meeting with Mother Support Group and Suku Hadomi Inan no Oan = Village love its Mother and Children. Every month MSG and SHIO members met up regularly with the Alola staff in ten districts. The topics been discussed in the meeting is vary as chosen by the different group members and the schedule of the meeting was decided based on the request from the members. The opportunity also been used by the Alola staff to review the activities conducted by the members, sharing experiences, collect the community based data and to visit households. Apart from that during the meeting the staffs also discuss the obstacles faced by the members in both facility and community level such as how encourage and ensure a pregnant women take iron tablet and having regular Ante Natal care to the health facility or SISCa Post. Each monthly meeting were lead by either program officer or Field Officer who responsible for the District. The strategy of Fundasaun Alola for future monthly meetings is to develop a monthly meeting agenda and encourage the group to facilitate the meeting with attendance of MCH staff, to enable the group to learn how to organize and facilitate a meeting, and be independence in the future.

23

Celebration of Timor-Leste National Breastfeeding Months Internationally, the first week of August is celebrated as World Breastfeeding Week; however, in 2010 the Ministry of Health's nutrition department decided to promote breastfeeding around Timor-Leste throughout August.

Activities conducted by Alola during National Breastfeeding Week and the rest of the month were:

Seminar on Breastfeeding In 2010, for the first time, Fundasaun Alola and the Association of Timorese Doctors initiated a seminar on breastfeeding for doctors and women’s organisations. The seminar was held on 6th August 2010 and attended by approximately 40 participants. Prof. M. M. A. Faridi, course director of Infant and Young Child Feeding, spoke at the seminar, on topic relating to infant feeding, breastfeeding policy, the international code of breastmilk substitutes marketing, and the Baby Friendly Hospital Initiative. The seminar concluded with a Question and Answer session and received good feedback from participants. It provided a good forum for advocating breastfeeding policy and promotion in Timor-Leste, and will therefore look to become an annual event for raising awareness about the importance of breastfeeding for reducing under five age malnutrition and child mortality, as well as improving the health status of infants and young children in Timor-Leste.

Healthy Baby Contest The second activity conducted by Fundasaun Alola during National Breastfeeding Month was a Healthy Baby Contest, which provided a forum for the dissemination of breastfeeding information and hygiene promotion to communities in 10 districts. The objective of the healthy baby contest is to encourage all mothers to exclusively breastfeed their babies for the first six months, to take the baby to health facilities or SISCa post for monthly weighing, and to improve the infant and young child feeding practices.

24

665 were babies entered and 293 babies were selected as winners of the contest, based on five criteria: 1. Exclusively breastfed for their first six months; 2. Had undergone regular weighing and growth well as evidenced in their growth chart; 3. Had receive all vaccinations at the correct age (DPT3 for > 9 months and measles < 9 months); 4. Was born at a health facility; and 5. Could demonstrate good hygiene.

The winning babies received a prize from Fundasaun Alola. The event was attended by 1338 people including community leaders, district authorities and communities. Details are shown below: N o

MSG/SHIO Locations

District

1 2 3

MSG Nipane MSG Bausiu MSG Naimeco MSG Tenae MSG Oe-sono MSG Oelulan Ponilala Gleno Railaco Dato

Oecusse

4 5 6 7 8 9 1 0 1 1 1 2 1 3 1 4 1 5 1 6 1 7 1

No of Baby participan ts in contest 21 14 19

Number of Babies that fulfilled the criteria

12 15 20 25 30 10 20

7 9 8 10 10 9 10

37 33 45 35 45 15 29

5 8 10 12 5 1 7

42 41 55 47 50 16 36

Tibar

40

10

66

6

72

Mota-ulun

50

9

90

7

97

Guico

20

10

15

9

24

13

7

31

9

40

Baguia

19

9

23

6

29

Lavateri

9

4

23

8

31

Quelecai

9

5

18

8

26

Laga

11

6

18

5

23

Baucau I & II

25

Ermera

Liquisa

Baucau

10 8 9

Number of community participants Fema Male le 22 12 29 4 38 10

Total Attende es

34 33 48

Details

8 1 9 2 0 2 1 2 2 2 3 2 4 2 5

Venilale

19

9

25

6

31

Vemase

9

5

23

6

29

Triloka

23

12

24

10

34

37

20

47

4

51

15

10

20

9

29

24

14

23

6

29

84

13

50

9

59

25

20

70

10

80

Becora

30

10

66

3

69

Beto

15

10

54

7

61

Bebonuk

12

10

60

1

61

Aimutin

15

10

59

2

61

Number

665

293

1133

205

1338

Viqueqeu Lacomesak

Viqueqe u Manatu to

Manatuto Vila Batara

2 6 2 7 2 8 2 9 3 0 Total

Aiturilaran

Dili

29 babies were identified as malnourished based on their growth chart

Breastfeeding Quiz In 2010, Fundasaun Alola celebrated National Breastfeeding Month by conducting a breastfeeding quiz in 10 villages in which new Mother Support Groups and SHIO groups had been established. The quiz was conducted as part of information dissemination at the community level. The breastfeeding quiz involved members of the MSG and SHIO groups and was attended by approximate 500 people. The quiz was used as a mechanism

to

disseminate

information

on

breastfeeding to community members that attended. The team than won the quiz received a prize from Fundasaun Alola.

26

Hygiene Kits Distribution Concurrent with World Breastfeeding Week, Fundasaun Alola took the opportunity to undertake hygiene promotion with the objective to educate communities on how to prevent some communicable diseases. The hygiene promotion emphasised the importance of washing hands and brushing teeth. Along with community education, Alola distributed hygiene kits, donated by volunteers from Australia, to 2000 adults.

The CMAM Training The Community Management of Acute Malnutrition (CMAM) is one of the key national priorities identified by the Department of Nutrition to be achieved in 2010. The Alola Foundation is assisting the Ministry of Health and Department of Nutrition to extend the nutrition program to other districts. For the first three months, the Alola Foundation is assisting MoH to conduct CMAM socialisation for community leaders, CMAM training for PSF and health workers in 3 districts - Viqueque, Aileu and Ainaro.

During the first three months, Alola was only able to provide training for the Oecusse MSG, which was attended by 45 members. The training was conducted in 3 different locations - Sakato, OeSono and Baqui. Fifteen MSG members attended the CMAM training in each location.

27

Exclusive Breastfeeding supported by MSG/SHIO member The Global Strategy on Infant and Young Child Feeding (WHO, 2002) details that, 'Exclusively breastfeeding' means giving the infant nothing but breast milk (no water, no other liquids or foods) from 0 to 6 months. To support this, the initial actions of MSG/SHIO members were to provide counselling to women on exclusive breastfeeding for the first six months. As a result, their involvement contributes significantly to the development of the health sector in Timor-Leste. Based on the 2003 Demographic Health Survey, 30% of babies were exclusively breastfed for the first six months, whereas the 2009-10 survey revealed this to be 52%. A large number of exclusive breastfeeding mothers became members of the

MSG/SHIO

and

in

turn

provided

breastfeeding counselling to their friends.

Mothers

reported

that

exclusive

breastfeeding requires ongoing support from family, husbands and neighbours so mothers could not be influenced to give other food and drinks to their babies before 6 months of age. Details are shown below:

No

District

Total area of the Total of exclusive MSG/ SHIO group Breastfeeding babies

1 2 3 4 5 6 7 8 9 10

Baucau Lospalos / Lautem Viqueque

17 3 3

60 106 18

Manatuto Dili Aileu Ainaro Liquica Ermera Oecusse /Ambeno Total

5 5 3 4 4 3 10 57 villages

12 60 15 30 24 51 67 443

28

Referrals Cases by MSG/SHIO Member to Health Facilities Training on IYCF, Safe Motherhood, new born care, family planning and the Management of Acute Malnutrition to MSG/ SHIO members was undertaken in order to improve their knowledge and experience identifying danger signs in pregnancy, childbirth, post-partum, and improve their capacity to refer women to health facilities as required. MSG/SHIO members also provide advice to breastfeeding mothers who have recommenced menstruation to go to CHC to obtain contraception from the midwife and understand the importance of birth spacing. In Oecusse district, Oelulan SHIO members also identified children aged under 5 years who are malnourished for referral to the CHC. The CHC is able to provide malnutrition treatment with

supplementary food such as plumpynut. The SHIO members then assisted and monitored the child for a three month period to help parents understand how to administer plumpynut to their child until they return to a healthy weight. The families of identified children have expressed that they are very happy to have their children healthy again, and they value the presence of the SHIO members that assist them in addressing their children's malnutrition.

Details are shown below: No

District

1 2 3 4 5 6 7 8 9 10

29

Baucau Lospalos / Lautem Viqueque Manatuto Dili Aileu Ainaro Liquica Ermera Oecusse /Ambeno

Cases Safe Motherhood 69 20 52 19 25 78 12 7 5 10

family Planning 25 15 23 18 36 17 10 11 Not reported

Malnutrition 5 5 8 3 5 3 5

Total

297

155

34 people

Harmonia Iha Famailia This project reflects a partnership between the Psychiatry Research and Teaching Unit, University of New South Wales and the Alola Foundation Timor Leste. The project is supported by a grant from the Australian Research Council (ARC). We designed the research project with the Alola Director and staff from the Maternal and Child Health Unit. We have consulted with a network of women's agencies and this network was involved in information sharing sessions and cross checking of findings. The naturalistic research approach was suitable to follow-up the findings of a previous epidemiological mental health study (known as ETMHENS study), particularly the common experience of anger amongst women that was considered problematic to the woman or her family (Silove et al 2009). A mixed methods approach was employed to recruit women from the existing ETMTHENS epidemiological data base, in essence, following up women five to six years later. From the database of 664 women participants, 177 were identified at baseline with anger (Silove et al 2009). We interviewed a sample of these women, half from rural Hera and the other half from urban Becora. We also interviewed a smaller sample of women who did not have anger in the ETMHENS study to allow for the examination of changes in anger status across time. Phase 1 of the research involved the application of semi-structured exploratory in-depth interviews. Phase 2 used a more structured approach, based on knowledge gathered in an iterative fashion from Phase 1. The final phase involved a focus group with staff members in NGOs and other agencies specifically working with women. These expert informants reflected on the causes and manifestations of anger observed from our interviews with women, and from their direct experiences with women they assist and support. The focus group considered the possible causes, perpetuating and protective factors, and the familial and social consequences.

We are currently analysing the data. Overall, there appears to be a degree of improvement in women’s level of anger over time although this trend needs to be confirmed by the ongoing analysis. Nevertheless, anger and its manifestations continue to present a major problem for women and their families. Early insights suggest that a complex pattern of disadvantage and distress lead at times to severe

30

manifestations of anger and frustration. Relevant factors include past trauma and loss, current socio-economic hardship, and changes in expectations in relation to traditional roles. These factors are impacting on women and their relationships, their capacities to parent and support the family, and their ability to engage more effectively in existing (or future) opportunities related to the development of Timor Leste.

We will be publishing reports on our research findings which will be widely circulated and discussed with the view to developing a strategy to translate findings into policy, interventions and existing programs during 2011 and 2012.

E.Professional Development for Alola’s Staff The following professional development was undertaken by Alola MCH staff through 2010:



Infant and Young Child Feeding Training



Newborn care training



Two week intensive English Course



Attending International Event



Complementary Feeding Promotion to reduce stunting



Advocacy enhancement



UN Conference



A call to an End to baby Infant food Promotions in Jakarta (supported by IBFAN)

F.Lessons Learned Two key lessons were learned during the implementation of projects in 2010:

1. The consultation and socialisation processes at the district level. This process is very helpful because of the involvement of district leaders to determine which remote villages cannot access health facilities (because of bad roads or rain that prevents health workers from reaching a community) and would benefit most from having MSG/SHIO groups established to enable communities to help each other to seek health care if there are mothers and infants who need emergency assistance at a health facility.

31

2. Midwife expectation of Alola staff presence at health facilities. Midwives at the Dili National Hospital, Baucau, Maubise and Oecusse have come to expect the presence of Fundasaun Alola’s staff at all times, but due to closure of the Fundasaun Alola office in Dili over Christmas and on other holidays, Alola staff are not always available to support. Without their presence at the hospital, some midwives have expressed they feel overwhelmed because of the breadth of their responsibilities. Midwives have said they are contacted by husbands and families about such problems as babies crying due to a lack of Breast milk; jaundice; breast engorgement or pain, and so on. Midwives do not have enough time to be able to help mothers and babies immediately after birth because the number of midwives is limited. When midwives are supported and have time to provide thorough counselling to the mother and can observe her and the baby during breastfeeding, problems can be identified and addressed early on. In order to minimise breastfeeding problems occurring with mothers and babies, Alolo’s MCH staff reschedule their holidays to ensure midwives are consistently supported to meet community needs.

G. Closing Remarks On behalf of Fundasaun Alola’s Maternal and Child Health Program team, I would like to offer our sincere gratitude to the donors who have kindly provided financial, technical and moral support to us in 2010. The support of our donors and partners has assisted us to conduct Facility-Based Activities and Community-Based Activities in 10 districts, particularly in remotes areas across in Timor-Leste.

We particularly appreciate the understanding and flexibility of our donors that has allowed for changes during program implementation to ensure best possible results.

We look forward to continuing to work with the MoH and all stakeholders to further extend and expand MCH’s program activities in Timor-Leste’s districts, to improve the practice of Infant and Young Child Feeding in Timor-Leste, and therefore to assist in the reduction of malnutrition and child mortality in Timor-Leste.

In 2010 Fundasaun Alola’s MCH Program required a significant amount of support from our donors to sustain and expand existing activities to an increased number of hospitals and

32

villages. With their support, we have had a successful year promoting Safe Motherhood through distribution of maternity packs at health facilities and Infant and Young Child Feeding at community-based group, and can see improvements in maternal and child health status in Timor-Leste. We look forward to continuing this work in 2011.

Kind Regards,

Angelina Fernandes Maternal and Child Health Program Manager Fundasaun Alola

33