Maternal health is one of the key gender and human rights issues facing many low- income countries throughout the world. Improving access before, during and after childbirth has the potential to save the lives of many women and infants.
Maternity waiting homes are an approach to improving the problem of access, and have been implemented widely across African countries since the 1960s. It is a dedicated house set up next to, or as part of, a health centre. They provide pregnant women with a place to stay in the weeks leading up to birth where they can be cared for with emergency obstetric care close by if it is needed.
Soon after Timor-Leste gained independence in 2002, maternity waiting homes were proposed by the Ministry of Health as a way to help improve access to birthing services for women in rural and remote areas."Timor-Leste has one of the highest maternal mortality rates in the world," says Dr Kayli Wild, a researcher at the Institute of Human Security and Social Change at La Trobe University. "It's estimated to be between 500 and 900 per 100,000 live births. Most women are not receiving skilled care at birth and serious barriers to accessing services remain. The Timor-Leste Ministry of Health, along with their development partners, are working hard to address this problem."
"The health of women in Timor- Leste is a huge issue," says Professor Nelson Martins, Timor- Leste's former Minister for Health. "With the limited human and non-human resources that we in the ministry have, we must utilise them in the most effective and efficient way. Maternity waiting homes are a good strategy on paper, but we must carefully assess the benefits against the costs before they are adopted widely and implemented across the country. We value Dr Wild's expertise and experience in conducting this evaluation in order to provide us with guidance and recommendations."
Dr Wild's PhD evaluated the first two maternity waiting homes to be established in the rural areas of Same, Manufahi district and Lospalos, Lautem district of Timor-Leste. Her research tracked the development of the policy and analysed health centre data over one year in each site.
Her analysis showed that the maternity waiting homes were not improving access for women in remote areas, and that most of the women who made use of the facility lived within 5 km of the health centre.
As a medical anthropologist, Dr Wild's research also examines the socio-cultural aspects of birth. She spoke extensively with expectant and new mothers in remote areas about the issues they face, in order to understand and map the factors which affect access to services.
"Many women, particularly those who have had previous home births and uncomplicated pregnancies, did not perceive a need for hospital birth," says Dr Wild. "Others preferred the safety of birthing in a facility, especially first time mothers or if something had gone wrong in a previous pregnancy, so women's needs are diverse. Underlying circumstances such as transport, preference for home birth and the need to improve quality of care weren't addressed by the maternity waiting homes."
She also found maternity waiting homes may be having unintended outcomes and their implementation may have actually reduced the medical care available to some women.
"When the new maternity waiting homes were built some midwives said they would no longer help women who were giving birth at home," she says. "This is a problem because it could reduce access to medical care for women living in the mountains. Incorporating the voices of women is critical for developing good maternal health policy and responsive systems into the future."
Dr Wild's findings contributed to a change in policy direction by the Ministry of Health, who have now invested in community- based health services, through the Servico Integrado Saude Communitaria (SISCa) program, to increase their reach in rural and remote areas.
"Through recommendations from various health research evaluations conducted in Timor- Leste, including Dr Wild's work, we have learned that we must find good strategies and with less cost to address both access and quality of health services to rural and marginal communities," says Professor Nelson Martins. "We have developed the SISCa program,with six main activities delivered at the village level."
"Maternal waiting homes will never solve all the problems of access to maternity care in Timor-Leste," says Dr Wild. "A flexible and adaptive health system that responds to the needs of women and families is required so that they can access the care appropriate to their situation."