Maternal and Child Health Program Annual Report

(2009)

Prepared by: Veronica Correia

MCH Program Manager Fundasaun Alola

Acknowledgement We would like to acknowledge the collaboration of the Ministry of Health (MoH) both at national and dis-trict level, including MoH health facilities in the nine districts of Ainaro, Aileu, Baucau, Dili, Ermera, Liquisa, Manatuto, Oe-cusse and Viqueque, who supported the implementation of Fundasaun Alola’s Ma-ternal and Child Health (MCH) Program in 2009.

We appreciatively acknowledge our donors and friends who provided funding assistance to the MCH pro-gram in 2009; UNICEF, the World Health Organization (WHO), ENI, Gulbenkian Foundation, Oxfam Aus-tralia, Merri Community Health Services, ConocoPhilips; and Fundasaun Alola’s friends from around the world who 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 also like to thank the University of New South Wales as our partners in the implementation of Harmony in the Family research project.

We would also like to thank our stakeholders, Bairo Pite Clinic, Clinic Café Timor, Timor-Leste Assisten-sia Intergadu Saude (TAIS), Health Alliance International (HAI), 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 2009 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.

A. Executive Summary In 2009, 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 2009, the MCH program had a strong focus on promoting infant and young child feeding, newborn care, safe mother-hood initiative and family planning or birth spacing. The MCH program undertook many activities including, The Baby Friendly Hospital Initiative (BFHI); Infant and Young Child Feeding (IYCF) training for health workers in Ermera and Manatuto; IYCF training, safe motherhood, and family planning training for Mother Support Group (MSG) members; the provision of IYCF counseling at health facilities in nine districts; IYCF promotion to rural communities; and research project on understanding anger and its consequences amongst women in conflict-affected Timor Leste: Implications for enhancing sustainable development. The MCH facility-based program achieved success with 1362 newborn babies receiving skin-to-skin support, 3892 women receiving breastfeeding counseling at Dili National Hospital, 1159 women receiving breastfeeding counseling at Baucau Referral Hospital and 160 women treated for breastfeeding problems. MCH program also distributed 6002 Ma-ternity Packs to women who were delivering at hospitals, including Bairo Pite Clinic. The MCH community-based program achieved the establishment of nine new MSG in Timor-Leste, with 125 new mem-bers. The program also trained 117 MSG members in IYCF, basic safe motherhood and family planning, and counseled 3683 women in the benefits of breastfeeding, whilst also giving them information on their antenatal visit to health facili-ties. In addition, 6722 women received counseling and information on breastfeeding when they attended their postnatal or child immunization visit, 602 people attended the showing of a breastfeeding film, 478 children and their parents at-tended a cooking demonstration, and 508 people attended IYCF seminars held in various remote areas. The program also enabled 542 families to receive a household visit from MCH community group (MSG and SHIO) and MCH staff, 57 women to be referred to hospital for delivery in condition of normal birth and/or obstetric complications, and 17 babies to be referred to a health facility because of illness. With the assistance of the MCH program, 52 people attended a community discussion forum in Ainaro, 288 women partook in a breastfeeding week quiz, 162 babies were deemed healthier because they fulfilled the criteria of The Baby Contest for World Breastfeeding Week based on the WHO children growth and development chart , and 317 babies were fully and exclusive breastfed for the first six months.

B. Program Background Fundasaun Alola established its Maternal and Child Health (MCH) Department in February 2003, through the establishment of the National Breastfeeding Association (NBFA). Since 2006, Fundasaun Alola has extended its MCH program to include a safe motherhood initiative, a focus on newborn care, and the promotion of birth spacing. In 2009, NBFA was handed over to the Ministry of Health’s (MoH) Nutrition Department. To facilitate the hand-over process, Fundasaun Alola seconded a senior staff member for two days to work with MoH. The staff mem-ber 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 an International Code for Breastmilk Substitutes. Fundasaun Alola is still committed to promoting breastfeeding and timely and appropriate complementary feed-ing 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 37 Mother Support Groups (MSG) and three Suku Hadomi Inan no Oan (SHIO), with more than 400 members in nine 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 counseling by MSG members at Dili National Hospital and Baucau Referral Hospital. This counseling was successful in extending the coverage and promotion of breast-feeding. 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 counseling at hospitals, Community Health Centers (CHC) and Health Posts, as well as Servisu Integradu Saude Comunitaria (SISCa) posts, which continue to benefit preg-nant 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 modeled on the Indo-nesian program, known as Desa Siaga (Siap, Antar Jaga), and was introduced to reduce maternal and child mortality, and address the Millennium Development Goals No. 4 and No. 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 plan-ning 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, which pro-vides all new mothers with clothing, baby needs, and breastfeeding and other postpartum health promotion materials. MSG members recruited to work in this program provide ongoing support when mothers return home.

C. Objectives Goal: Healthy women and children in Timor-Leste.

Purpose: To contribute to the reduction of maternal and child mortality in Timor-Leste.

Objective: 1. To promote early initiation and exclusive breastfeeding to six months and timely complementary feeding

practice to two years 2. To improve women’s health through education, information and community networks 3. To improve women and children’s health through strengthening community action and empowerment 4. To ensure effective, efficient and collaborative implementation of MCH Program

D. MCH Achievements in 2009

Friendly Hospital Initiative (BFHI) Timor-Leste has two accredited BFHI hospitals. They are, the Dili National Hospital which was accredited in 2005, and the Baucau Referral Hospital, accredited in 2006. During the 2006 crisis, Dili National Hospital was utilized as a camp for Internally Dis-placed People (IDP) and therefore could not maintain its BFHI status. Fundasaun Alola, MoH, UNICEF and WHO, set up a team in 2008 to follow-up and monitor the BFHI in Timor-Leste. In September 2009, the team conducted an internal re-assessment regarding the implementation of the 10 Steps of Successful Breastfeeding initiative at Dili National Hospital, and used the information gathered to assess whether the hospital could be BFHI re-accredited. In addition, Fundasaun Alola facilitated the implementation of BFHI refresher training for health workers at Dili National Hospital. The BFHI refresher training course was con-ducted in two phases; the first phase took place on 22 to 24 September 2009 and was attended by 18 people; the second phase took place on 28 to 30 September 2009 and was attended by 17 people.

Infant and Young Child Feeding Training for Health Workers The Infant and Young Child Feeding (IYCF) training is an integration course on breastfeeding coun-seling, complementary feeding counseling, and HIV and infant feeding. The IYCF training manual for health workers covers 43 sessions. The training is recognized internationally, and Fundasaun Alola has permission from the International Baby Food Action Network (IBFAN) to utilize the IYCF training manual to facilitate training to health workers in Timor-Leste.

IYCF training was lead by master trainers who had at-tended the 13 days intensive course. Fundasaun Alola now has three staff members who are qualified to conduct IYCF training. In 2007 and 2008, the IYCF course for health workers was implemented in four districts; Aileu, Ainaro, Lautem and Oe-cusse. In 2009, Fundasaun Alola facilitated IYCF training to 36 health workers in two districts and con-ducted training over seven days. In Ermera, IYCF training was conducted from 12 to 21 October, and attended by 15 people; training in Manatuto was conducted from 16 to 23 November, and was attended by 21 people. The training was aided by good collaboration and coordination be-tween Fundasaun Alola, MoH and the Health Science Institute.

MCH – Health Facility-based Program

Picture 1: BFHI Initiative Refresher Training for Health Workers at Dili National Hospital

Picture 2: IYCF Training for Health Workers in Manatuto District

Picture 3: Clinical Practice Session

Infant and Young Child Feeding Centre Establishment and Inauguration

The IYCF Centre was established to provide a confidential and comfort-able space for women who are visiting a health facility for antenatal and postnatal care, and for those who have breastfeeding problems. The centre is run by Fundasaun Alola MSG members and MCH field officers. The centre is equipped with a television, DVD player and practical infor-mation kits, which the MSG members and field officers can utilize to counsel each woman who visits the centre. In 2009, Fundasaun Alola, in collaboration with MoH, inaugu-rated three IYCF centers in the districts of Aileu, Ainaro and Oe-cusse. In Aileu and Ainaro, the centre is based at the Com-munity Health Centre (CHC), and the centre in Oe-cusse is based at the Referral Hospital.

Safe Motherhood and Newborn Care

Initiative at Hospitals Fundasaun Alola’s MCH program has been established at two hospitals in Timor-Leste. In 2009, Fundasaun Alola employed five MCH staff to work at Dili National Hospital and two MCH staff to work at Baucau Re-ferral Hospital. The project implemented in each hospital focuses on the issue of safe motherhood, through the provision of Maternity Packs and newborn care, including skin-to-skin contact, counseling of mothers on the first initiation of breastfeeding, and exclusive breastfeeding for the first six months. Admission to Maternity Ward at Dili National Hospital and Baucau Referral Hospital Based on data collected by the MCH program, 4610 women were admit-ted to the maternity ward at Dili National Hospital in 2009. Of these, 4288 women went there for delivery, 182 sought post abortion care, and 140 were admitted due to gravida hypermesis (severe morning sickness dur-ing pregnancy). At Baucau Referral Hospital, the total number of women admitted to the maternity ward in 2009 was 1159. Of these, 1103 came to give birth and 56 were admitted for post abortion care.

Newborn Care (Skin-to-skin)

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Picture 4: Inauguration of IYCF Centre at Oe-cusse Referral Hospital

Newborn Care Support Skin-to-skin Skin-to-skin contact is crucial for the health of newborn babies and their mothers because it helps babies to breastfeed immediately within one hour of life. Skin-to-skin contact helps protect the baby from hypoterm, as-sists babies to get colostrums, helps women to deliver the placenta shortly after giving birth, and prevents women from experiencing postpartum hemorrhage. During 2009, the skin-to-skin contact initiative was only performed at Dili National Hospital. Of the 4340 babies born at Dili National Hospital in 2009, 2690 of these per-formed skin-to-skin contact with their mothers immedi-ately after birth. However, 1650 babies were unable to perform skin-to-skin contact with their mothers because of obstetric and neonatal complications, including deliv-ery via cesarean section. Newborn care, and especially skin-to-skin contact, was facilitated by MCH staff working at Dili National Hospital.

The graph below shows that more than half of the babies born at the hospital were assisted by MCH staff, and the rest were assisted by midwives.      

Picture 5: MCH staff help mother and newborn with skin-to-skin contact

Breastfeeding Counseling The MCH program’s breastfeeding counseling provided at Dili Na-tional Hospital and Baucau Referral Hospital specifically targets women and their families. The counseling includes family members, because Fundasaun Alola recognizes that a woman’s family is a vital support network, especially once she has been discharge from hos-pital. The counseling was also provided to women who suffered from gravida hyperemesis and to those who miscarried. In 2009, There were 3892 women out of 4610 women received breastfeeding counseling at Dili National Hospital. Of these, 718 women did not received counseling because of a public holiday. In Baucau Referral Hospital, all of the 1159 women admitted to the maternity ward, as well as 2103 family members, received breastfeeding counseling and information. These statistics show that breastfeeding promotion and counseling at hospitals in Timor-Leste is greatly assisted by the presence of MCH staff. In addition to the MCH program’s work at Dili National Hospital’s maternity ward, services were also provided to assist women in the hospital’s ICU ward. For example, MCH staff assisted 30 women whilst they were in medical isolation, made home visits to 16 women experiencing breast problems, and assisted 4 women when they had to have a medical and breastfeeding consultation over the telephone. The table below shows breastfeeding problems that were treated by MCH staff in 2009.

Immunization At Dili National Hospital, the MCH midwife also helps vaccinate new-born babies in the maternity ward. In 2009, the midwife vaccinated 1911 babies for BCG and Polio, and distributed Vitamin A in tablet form to 1100 women.

No  Cases  Number 

1  Inverted nipple  60 2  Breast engorgement  38 

3  No breast milk in the first day after delivery 

25 

4  Sore nipples  2 

5  Mastitis  6 

6  Breast cancer  2 

7  Breast mioma  1 

8  Jaudience baby  3 

9  Sepsis (women) – in postpartum occurring at home 

3 

10  Sepsis (women) – in postpartum occurring at hospital 

3 

11  Express breast-milk  17 

12  Referral from doctors to MCH staff 

3 

  Total  160 cases 

Safe Motherhood Initiative - Distribution of Maternity Packs A 2003 MoH Demographic Health Survey report showed that only 10 per cent of women in Timor-Leste had access to a health facility for maternal delivery. The report indicated that most deliveries occur at home with the assistance of a Traditional Birth Attendant (TBA), in what the MCH program considers an unsafe and unclean environment. One of MoH’s strategies is to reduce the maternal and neonatal mortal-ity rate by promoting a safe motherhood initiative and facility-based delivery, i.e. delivery in a health centre or hospital. To promote MoH strategies, Fundasaun Alola initiated the Maternity Packs project, with the main objective being to encourage and motivate women to seek out a safe and clean delivery. The project has a particular emphasis on poor women and women who live in rural areas. Maternity Packs are offered to women who deliver their babies in hospital, and those who are admitted to hospital because of bleeding, and abortion or miscarriage. In 2009, 4199 Maternity Packs were dis-tributed in Dili National Hospital, 1103 were distributed in Baucau Referral Hospital, and 700 distributed at Bairo Pite Clinic.

Maternal and Neonatal Mortality and Still Birth Data In addition to other responsibilities, MCH staff also collected data on infant mortality from Dili National Hospital and Baucau Referral Hospital maternity wards. Statistics from Dili National Hospital show that, in 2009, there were five maternal mortality cases due to obstetric compli-cations; amnion embolic fluid (two cases), eclampsia (one case) and sepsis (two cases). In addition, there were 18 neonatal mortalities and 95 stillbirths. At Baucau Referral Hospital, there was one maternal mortality case due to obstetric complications and delayed obstetric assistance after arrival at hospital, and 47 stillbirths.

Play Room for Young Patients at Hospitals In December 2009, Fundasaun Alola, in collaboration with MoH, estab-lished a play room at Dili National Hospital and Baucau Referral Hospi-tal. On 18 December 2009, both play rooms were inaugurated by Ms. Madalena Hajan the Vice Minister for Health and Ms Kirsty Sword Gus-mao, chairperson of Fundasaun Alola. Representatives from MoH, Guarda Nacional Republicana who was donated the toys for the play room, the MoH and hospital representative also attended. Each play room is equipped with children’s toys and reading books, with the ob-jective being to make the hospital a friendly and inviting place and to ensure that children, who are admitting to hospital, can continue to play and study.

Picture 6: MCH staff help mother who has breast problem

Picture 8: Inauguration of Play room at Dili National

Hospital

Picture 9: Play room daily activities

Picture 7: Distribution of Maternity Packs

Establishment of Nine New Mother Support Groups The MCH program successfully facilitated the establishment of nine new Mother Support Groups (MSG) in six districts. The new MSGs are in Ermera (Ponilala and Railaco), Manatuto (Laclubar and Laclo), Dili (Becora), Baucau (Triloka), Ainaro (Maubesi and Hatudu) and Oe-cusse (Oe-sono). The number of new MSG members in each location is shown in the table below:

No District Sub-district

Village Number of Members

Date of Estab-lishment

Total Popula-tion

Donor

1 Oe-cusse Pante-Makasar

Costa- Oe-sono

10 January 2009 9574 Oxfam Austra-lia

2 Dili Cristo Rei Becora 9 September 2009 18057 UNICEF

3 Ermera Ermera Ponilala 14 May 2009 3056 Gulbenkian Foundation and UNICEF 4 Railaco Lihu 14 May 2009 1228

5 Manatuto Laclo Lacumesak 20 May 2009 2167

6 Laclubar Batara 20 May 2009 1609

7 Baucau Triloka 9 October 2009 2052 UNICEF

8 Ainaro Maubesi Horai-Quic 19 September 2009 1188 ENI

9 Hatudu Leolima 21 September 2009 4976

Total 125 mem-bers

Infant and Young Child Feeding, Safe Motherhood and Family Planning Trainings of New and Existing Mother Support Groups

To enable each MSG member to provide peer counseling in their community, the MCH team provided four days training for new and existing MSG members. The training was spread over three days, covering IYCF, and one day covering basic safe motherhood and family planning topics. In 2009, the MCH team trained 177 MSG members. The details are shown in the table below: No District Sub-district Village Training venue Number of

participants Date of Training Donor

1 Dili Cristo Rei Becora Fundasaun Alola 30 5-7 October UNICEF 2 Ermera Ermera Ponilala Sede Suku 14 24-26 September 3 Railaco Lihu Sede Suku 19 (including 5 par-

ticipants from Gleno MSG)

26-28 October

4 Manatuto Laclo Lacumesak Sede Suku 10 30 Nov-3 Dec

5 Laclubar Batara Sede Suku 10 26-28 October 6 Baucau Vila Trilolo and Cai-

bada Makasae Baucau Referral Hos-pital

12 4-6 Nov

7 Baucau Baucau Vila Triloka CHC Triloka 9 30 Sep-3 October 8 Ainaro Maubesi Hohorai kiik Sede Suku 21 ENI

9 Hatudu Leolima Sede Suku 23 (including 2 MSG members from Soro MSG)

10 Liquisa Liquisa Dato CHC training room 19 (consisting of MSG and SHIO members from Tibar, Mota-ulun and Guico)

14-16 September UNICEF

11 Oe-cusse Pante-Makasar Costa – Oesono Office of Oe-cusse District Administra-tor

10 30 Jan to 2 Feb Oxfam Australia

Total participants 177 people

MCH – Community-based Programs

To increase the coverage of IYCF promotion, MSG members are encouraged to provide counseling at CHCs, Health Posts and SISCa. Counseling at CHCs and Health Posts takes place twice a week based on the vaccination and antenatal care schedule, while counseling at SISCa takes place on a monthly basis. The counseling provides opportunities for MSG members to utilize the skills and knowledge that they have acquired in training, to in-crease MSG member confidence in talking with mothers and com-munity health workers, and to ensure pregnant women are able to detect whether they have any breast problems related to feeding immediately prior to delivery. Another benefit of the counseling is that some women who have access to MSG members become in-terested in the work of the MSG, and become a member them-selves. The counseling receives good support from midwives at CHCs. In 2009, 3683 women received breastfeeding counseling from MSG members during their antenatal visit, and 6722 received breastfeed-ing counseling during their postnatal or child immunization visit. The table below shows the number of women who received coun-seling in 2009 from MSG members at hospitals, CHCs, Health Posts and SISCa:

Picture 10: Counseling at Community Health Centre

MSG Counseling Activities at Health Facilities and Servisu Integradu Saude Comunitaria (SISCa)

Picture 11: MCH staff and MSG member counseled pregnant women at SISCa Post

No

Districts Counseling location

Health Facility (Hospital, CHC and HP

SISCa

Pregnant women

Lactating women

Pregnant women

Lactating women

1 Dili 772 1160 77 133

2 Ainaro 157 202 1 19

3 Aileu 154 458 128 122

4 Baucau 758 1499 - 620

5 Manatuto 27 - - 237

6 Oe-cusse 722 1228 243 554

7 Viqueque 204 - - - 8 Liquisa 163 209 63 102

9 Ermera 142 176 9 3

Total 3099 4932 584 1790

Infant and Young Child Feeding Promotion to Remote Communities

The MCH team initiated a strategy to promote IYCF to remote communities in nine districts. The Rural Health Promotion program covers three main activities; the showing of a breastfeeding film, a cooking demonstration on complementary feeding for young babies aged six months to two years, and an IYCF seminar targeting com-munity leaders, mothers, youth and other community members.

Details about the Rural Health Promotion program are set out in the table below:

No District Sub-district

Location of Film show

Participants Date of imple-mentation

Donor

BF show Cooking Dem-onstration

Seminar

1 Aileu Remexio Maumeta 30 people - 30 people July, 27th Merri Community Health Service

Aileu Vila Sarlala 44 people - - September, 18th

2 Ainaro Ainaro Soru Craic 23 people September, 17th ENI

Mau-Ulo 27 people December, 11th

3 Baucau Vemasse Loilubu - 16 people October, 16th UNICEF

Waiga’e 105 people December, 11th

Baucau Waisa 73 people

4 Dili Cristo Rei Sede Suku Hera

12 people 50 parent and their children

24 people November 16th

Metinaro Metinaro 18 people 26 parent and their children

53 people

Metinaro Manleu 27 people 25 parent and their children

40 people

5 Liquisa Bazartete Tibar, Fahiten

27 people 30 parent and their children

22 people November 13th

Tibar, Beduku

- 10 parent and their children

27 people September 7th

6 Ermera

Railaco Railaco Leten

23 people 34 parent and their children

60 people November 24th

Aldeia Hi 20 people 15 parent and their children

16 people November 25th

Ermera Ponilala, Sakoko

56 people 35 parent and their children

29 people December 2nd

Ermera Ponilala, Hatupose

59 people 25 parent and their children

56 people December 3rd

7 Oe-cusse Nitibe Suku Bona, Aldeia Kuan Tuan

32 parent and their children

27 people November, 10th to 11th

8 Viqueque Viqueque Craras 58 people October 8th

9 Manatuto Laclubar Lei 108 people

Total 602 people 282 parent and their children

508 peo-ple

Picture 13: Cooking demonstration

Household Visit To provide more support and assistance to women in sustaining and maintaining exclusive breastfeeding and timely appropriate comple-mentary feeding, MSG members provided visits to households in their communities. These home visits took place approximately two times a week, and intensive visits were conducted if required. Occasionally, a MCH field officer would accompany MSG members during home visits that occurred during the monthly regular meeting. This collaboration would also occur when a MSG member had a seri-ous breastfeeding case in their community and/or when there were newborn babies. In 2009, 542 households received a visit from MSG members and MCH staff across nine districts.

Picture 14: MSG conducted household visit

Referrals Made by Mother Support Group and

Suku Hadomi Inan no Oan Members MSG and SHIO members are conscious of the importance of a health facility-based delivery. In 2009, MSG and SHIO members referred 57 women to a health facility for childbirth, and referred 17 children with various illnesses to a health facility in their area. In Oe-cusse, several MSG members are skilled Traditional Birth At-tendants (TBA). Since these TBAs have received training on safe motherhood (recognizing the danger signs during pregnancy, delivery and postpartum) they are now encouraging other women to access a health facility for the safe and clean delivery of their baby. As a direct result of the training received, one TBA, who lives close to a CHC, referred two women to a health facility for delivery and has stated that he will continue to refer women to health facilities to ensure the safe and clean delivery of babies in his community.

A Call for Assistance In October 2009, a TBA based in Baqui (a sub village of Naimeco), was called to assist a woman who was going to give birth at home. The woman requested the TBA, who is a MSG member, to assist with the birth, but the TBA encouraged the woman to call the midwife. The woman refused to because she said she felt ashamed to be assisted by the midwife. The TBA lied to the woman, saying he was going out to boil some traditional medi-cine for her to drink, and that he would be back shortly. The TBA ran to the midwife’s house and asked her to help assist with the birth. When the midwife arrived, the mother was surprised to see her, but accepted the mid-wife’s assistance. The mother went on to have a safe delivery. When interviewed by MCH staff, the TBA said that he recognized that the woman’s life and the life of her un-born child were important, and therefore, he believed that a medically trained professional should assist the birth.

MSG member’s Experiences

Positive reinforcement Despite the positive story above, in one remote sub-village In Oe-lulan (a remote sub-village of Naimeco), far away from a CHC, the women always summon the TBA to assist with their deliveries. The TBA in this village has join the MSG and continues to assist, but only if the women promise to become MSG households members and practice breastfeeding and exclusive breastfeeding for the first six months. In November 2009, a woman who was assisted by the TBA also became a MSG household member and exclu-sively breastfed her newborn. During the first two months, the baby gained weight so well that when it was taken to a SISCa post, the baby did not register as malnourished and therefore, did not receive any supple-mentary feeding. The baby’s mother however, was dis-appointed that her baby did not receive supplementary feeding and blamed the TBA as he was the one who encouraged her to exclusively breastfeed. The MCH field officer stationed at the SISCa had to explain to the woman that it was a good thing that her baby did not need supplementary feeding, and that she should be proud that her baby was healthier because of being breastfed.

Monthly Community Discussion Forum

In April 2009, the MCH program piloted the Monthly Community Discussion Forum in Ainaro. The forum was conducted concur-rently with the MSG monthly meeting, and was organized by the MCH team and MSG members. During the forum, mothers had a chance to share their experiences with breastfeeding and com-plementary feeding their children. There were 54 pregnant and lactating women in attendance. Due to the success of the first forum in Ainaro, other forums took place in the villages of Ter-lola, Leolola and Poelau. The Monthly Community Discussion Forum is an excellent mechanism to distribute information to mothers and families, as well as providing an opportunity for open discussion. For this reason, Fundasaun Alola would like to expand the forum to en-compass other districts in 2010.

Picture 15: Monthly Community Discussion Forum in Ainaro District Mother Support Group Monthly

Monitoring Meetings In 2009, MSG monthly meetings occurred regularly in nine districts. Each month the MCH team facilitated the MSG meetings. The schedule of the meetings and the topics for discussion were usually determined by MSG member requests. Every month MSG members gathered in their areas to share their experiences and take part in activities in household counseling visits.

Develop and Printing Information Education and Communication

(IEC) Materials In 2009, Fundasaun Alola’s MCH department developed and printed new IEC materials, including posters and 2010 calen-dars. The IEC materials contain information about IYCF, and will be distributed to health facilities, health workers and com-munity members in early 2010.

Data on Exclusive Breastfeeding for First Six Months

In 2009, there were 317 babies who were exclusively breastfeeding for the first six months in nine MSG and SHIO districts. This number only includes households that are MSG and SHIO members were monitor. The table below shows the number of babies exclusively breastfed in each district:

District Number of babies who have completed exclu-

sively breastfeeding for the first six months

Aileu 16

Ainaro 9

Baucau 104

Dili 56

Ermera 15

Liquisa 35

Manatuto 20

Oe-cusse 33

Viqueque 29

Total 317

Picture 17: Monthly Monitoring Meeting in Oe-cusse Picture 16: IYCF Health Promotion Materials

The International theme of World Breastfeeding Week 2009 was, “Breastfeeding is a vital response in an emergency situation”. The National Theme chosen for Timor-Leste was, “Mothers’ milk saves lives. Mothers be ready to breastfeed in all circumstances”. To celebrate World Breastfeeding Week, the MCH department organized four main activities to take place in nine districts. These were; a Healthy Baby Contest, a breastfeeding quiz for MSG households, training for MSG members on Infant Feeding in an Emergency Situation, and a breastfeeding media campaign. 162 babies were selected as winners in the Healthy Baby Contest, 288 women participated in the breastfeeding quiz, and 460 MSG and SHIO members at-tended the training on Infant Feeding in an Emergency Situation. In addition, 32 banners were displayed in 13 districts and on television talk shows. The successful execution of International Breastfeeding Week 2009 activities was made possible by good coordination and collaboration with the District Health Services (DHS) and CHCs of each district, and participation from stakeholders such as district authorities and community leaders.

In 2009, three MSG members in the Ainaro district had newborn babies who were exclusively breastfed. These MSG members realized the importance of exclusive breastfeeding for the health of their babies and themselves. When interviewed by MCH staff, they stated that they wished to be a model for other women in their community, and to use their knowledge and skills to counsel and encourage other mothers to exclusively breastfeed their babies.

I am privilege to be a member of the Mother Support Group because with this group I have learnt about exclusive breastfeeding. I practice this with my newborn baby and she is now very healthy. I hope that other mothers can practice it with their babies as well so that their

babies can be healthy like mine. (Member of MSG Soro)

Mother Support Group members are ‘model’ mothers

Celebration of World Breastfeeding Week - 2009

Picture 20: Ainaro MSG member and her daughter

Picture 19: Participants of World Breastfeeding Week Celebration in Liquisa

Harmony in Family Research Project In 2009, Fundasaun Alola in partnership with the Psychiatry Research and Teaching Unit of the University of New South Wales (UNSW), conducted a research on Understanding anger and its consequences amongst women in conflict-affected Timor Leste: Implications for enhancing sustainable development. The Research Team from UNSW: Dr Susan Rees, Profes-sor Rosamund Thorpe, Professor Derrick Silove, and Professor Anthony Zwi. Alola: Ms Veronica Correia, Ms Teresa Verdial, Ms Mira Fonsesca, and Ms Eliza Savio. In a 2004 epidemiological study (Silove et al 2009) we established that anger is common and problematic for women in Timor Leste. This project aims to identify for the first time the impact of women’s anger on their wellbeing and their roles in re-building families, communities and society after mass conflict. The aims of the research are: 1. To assess women’s experiences of anger in rural Hera and urban Becora. To examine how anger manifests, how

women manage the problem and what effect it has on their lives. 2. To explore the origins and trajectory of anger affecting Timorese women within the social, cultural and political context. 3. To determine if a sense of injustice and disempowerment together mediate experiences of abuse and deprivation in

generating anger. 4. To assess the effects of anger on women’s personal well-being, as well as on their families and their communities. 5. To assess women’s perspectives as to whether existing community-level interventions are addressing the identified an-

tecedents, manifestations and/or consequences of anger. 6. To engage women and women’s groups in planning interventions drawing specifically on the findings of this research. Protecting women’s health and wellbeing is a human rights issue, as is the right of women to participate equally in education, communal decision-making and access to and control over resources in post-conflict societies. Social attitudes and struc-tures influence these opportunities and these factors interact with women’s personal capacities, motivations and sense of well-being, that, in turn, are affected by exposure to abuse, past and present, particularly if they are hindered by feelings of uncontrollable anger. This study will throw new light on the interaction of past human rights violations and ongoing injustices (including domestic violence) in obstructing women’s capacity to engage in development activities vital to the advancement of Timor Leste and potentially other post-conflict societies. The study will examine existing and perceived protective factors and the findings will be used to influence relevant social and health policies and to design an intervention.

Picture 21: Harmony in Family Research Project’s Team

E. Monitoring and Evaluation The MCH department conducts regular monthly meetings with all MSG members. The meetings give MSG members an opportunity to share their experiences with activities that are being implemented in their community, and provide a chance for MCH staff to give advice and address any issues had by MSG members. In 2009, The MCH program administered a short evaluation of the MSG in Oe-cusse. The result of the evaluation showed that most of the households who became MSG members felt that the MSG was crucial in assisting them to learn more about the importance of infant and young child feeding, safe motherhood and family planning or birth spacing. Maternity Packs Project Evaluation An external evaluation of the Fundasaun Alola Maternity Packs Project was conducted from November 2009 – January 2010. The purpose of the evaluation was to look at project effectiveness, seek feedback from stakeholders concerning the project and examine the extent to which maternity packs encourage women to deliver at hospital. The evaluation in-volved conducting approximately 30 interviews with key informants at health facilities where maternity packs were being distributed, with Fundasaun Alola staff and with Maternity Pack recipients in Dili, Baucau and Liquica districts. Ministry of Health data on hospital attendance at the two major hospitals was also examined. The evaluation was conducted by an MPH student from the University of New South Wales (UNSW), as part of the requirement for this degree. A Fundasaun Alola MCH staff member assisted in conducting all interviews. A key finding from the evaluation was that the maternity packs, and the health promotion conducted as part of the project, represent valuable forms of assistance for new mothers and their babies. Midwives also appreciated the program and felt that it helped them to provide a better standard of care to women who delivered at the health facility. It was difficult to draw a conclusion about the effect of the project in encouraging women to come to hospital for delivery however reports indicate that the maternity pack act as an incentive in Baucau, but are less important in Dili. However, in addition to the strong support for the project there were calls for Fundasaun Alola to improve the quality of items in the maternity pack and improve coordination with health key stakeholders involved in project implementation. Stronger monitoring and more regular evaluation of project activities, particularly in the area of health promotion, is also important for ensuring that these activities are implemented as planned and amended when required. It will also be a valuable source of evidence for measuring the impact of this project on the health of mothers and their families in Timor-Leste. F. Challenges and Solutions

1. Exclusive breastfeeding for the first six months. The MCH team noted that some women experienced diffi-culties when practicing exclusive breastfeeding for the first six months, often because of work (e.g. at harvest time). However, the MCH team also noted that as a direct result of the support provided by MSG members and MCH field officers, those women who can, are more likely to implement exclusive breastfeeding for the first six months.

2. Recruitment. Due to a lack of human resources, Fundasaun Alola’s Human Resources and MCH department experienced difficulties with increasing the scope of the MCH program in some districts. Therefore, in mid 2009, the MCH department recruited three new field staff, assigned to work in Ainaro, Aileu and Oe-cusse.

3. Transportation. The MCH team noted that district MCH field officers often experienced difficulties with transpor-tation. This was especially evident in Ainaro and Alieu, due to the lack of regularly available public transporta-tion. To address this issue, Fundasaun Alola sent a vehicle to Ainaro and Aileu, once a week each month.

4. Evaluation. Fundasaun Alola received assistance from the University of New South Wales to undertake an evaluation of our safe motherhood program, and in particular our Maternity Packs project.

5. Dependency. MSG and SHIO members are voluntary community groups and depend heavily on Fundasaun Alola. To reduce this dependency, Fundasaun Alola has developed a strategy to identify the community groups as Self Help Groups (SHG), and empower them through the Program Integration Package Initiative. This will help reduce their dependency on Fundasaun Alola, so that in the future they will be able to independently sus-tain themselves, without intensive support from Fundasaun Alola. The Program Integration Package Initiative will initially be piloted in four districts of Timor-Leste.

G. Lessons Learned The MCH program believes that to change community beliefs and behavior with regard to infant and young child feed-ing, safe motherhood and birth spacing, a community group should be established that will interact closely with the community, and can provide intensive support to women and their families. The MCH program found that the Suku Hadomi Inan no Oan (SHIO) approach is one of the best mechanisms to mobi-lize community support, to improve the health of women and children and to strengthen community networks. Another important achievement in 2009 is employing field staff to implement MCH activities in the districts of Ainaro, Aileu and Oe-cusse. Each field officer established a good relationship with community stakeholders, and provided support to MCH community group members in their districts. The MCH field officers assigned in Ainaro, Aileu and Oe-cussse, helped Fundasaun Alola to implement a cost effective project, and reduced expenses associated with the MCH program’s monthly monitoring visit. Fundasaun Alola believes that there is still a need to improve the MCH program in the districts. Data collected on counseling and exclusive breastfeeding for babies, safe motherhood, and family planning, as well as mortality and morbidity was difficult to record, and therefore, the MCH team has designed a database template to use when re-cording data in the future.

H. Closing On behalf of Fundasaun Alola and the MCH department, I would like to express our sincere gratitude to our donors who have provided invaluable support, especially with regard to the expansion of the MCH program to new districts, and the consolidation of the existing program. I would also like to express appreciation to our supporters and donors for being understanding and flexible regarding timelines and funding, as well as accepting changes (often unforeseen) that happened during the implementation process. The team recognizes that without the support we receive from our stakeholders and donors both individually and insti-tutionally, we would be unable to implement the MCH program; a program that we believe plays a crucial part in the future of the people of Timor-Leste. Hence, we very much appreciate the support they have given us. To sustain Fundasaun Alola’s MCH program and to expand the program into other districts, we continue to require a lot of support from our donors. We look forward to working with them in the future, for the improvement of women’s and children’s health, and ultimately the well-being of the people of Timor-Leste. Kind regards,

Veronica Correia MCH Program Manager Fundasaun Alola