reproducTive HealtH 62959 at a GLANce may 2011 Timor-LesTe country context Timor-Leste: mdG 5 status After East Timor’s independence in 1999, a militia invasion mdG 5A indicators destroyed most of the country’s infrastructure and nearly Maternal Mortality Ratio (maternal deaths per 100,000 live 370 its entire electrical grid. Seven years later, shortly after be- births) UN estimatea coming the state of Timor-Leste, conflict arose again which Births attended by skilled health personnel (percent) 29.9 required the intervention of a peacekeeping mission to re- mdG 5B indicators gain stability. Timor-Leste is now enjoying its longest pe- Contraceptive Prevalence Rate (percent) 22.3 riod of stability since independence. The country continues Adolescent Fertility Rate (births per 1,000 women ages 15–19) 53 to work on replacing lost infrastructure, strengthening civil Antenatal care with health personnel (percent) 86 administration, and employing young persons. Oil and nat- Unmet need for family planning (percent) 30.8 ural gas production is a major source of revenue. However, 37 percent of the population subsists on less than US $1.25 Source: Table compiled from multiple sources a The 2009–10 DHS estimate is 557. per day.1 Health systems are being strengthened as they were greatly weakened from years of conflict.2 mdG Target 5A: reduce by three-quarters, between Timor-Leste’s large share of youth population (45 percent 1990 and 2015, the maternal mortality ratio of the country population is younger than 15 years old1) provides a window of opportunity for high growth and pov- Timor-Leste has been making progress over the past two decades on erty reduction—the demographic dividend. But for this op- maternal health but it is not yet on track to achieve its 2015 targets.4 portunity to result in accelerated growth, the government Figure 1 n maternal mortality ratio 1990–2008 and 2015 target needs to invest in the human capital formation of its youth. 700 650 Gender equality and women’s empowerment are impor- 600 590 520 tant for improving reproductive health. Higher levels of 500 420 women’s autonomy, education, wages, and labor market 400 370 MDG participation are associated with improved reproductive 300 Target health outcomes.3 200 160 100 In Timor-Leste, slightly fewer numbers of girls are en- 0 rolled in secondary schools compared to boys with a ra- 1990 1995 2000 2005 2008 2015 tio of female to male primary enrollment of 94 percent.1 Source: 2010 WHO/UNICEF/UNFPA/World Bank MMR report. Three-fifths of adult women participate in the labor force1 that mostly involves work in agriculture. World Bank support for Health in Timor-Leste Economic progress and greater investment in human The Bank’s current Interim Strategy Note is for fiscal years 2010 to 2011. capital of women will not necessarily translate into bet- current project: ter reproductive outcomes if women lack access to repro- P104794 TP-Health Sector Strategic Plan Support Project (with $24 million from ductive health services. It is thus important to ensure that AusAID and World Bank) health systems provide a basic package of reproductive • Improve Health Service Delivery health services, including family planning.3 • Strengthen Support Services, Human Resource Development, and Management • Support Coordination, Planning and Monitoring • Support Innovation and Program Development pipeline project: National Health Sector Strategic Plan Support Project (with approx. $30 million from AusAID, EU and World Bank) previous Health project: THE WORLD BANK P093524 TP-Health sector support program (TF054512/1) n Key challenges as compared to 30 percent of women with secondary education or higher, and 19 percent for rural women versus 28 percent for urban women. High fertility Fertility has been declining over time but remains high Figure 3 n use of contraceptives among married women by wealth among the poorest. Total fertility rate (TFR) decreased from 7.8 quintile births per woman in 20035 to 5.7 births per woman in 2009–10.5 40 35 2.5 Fertility remains very high among the poorest Timorese at 7.3 in 30 31.7 22.3 Overall (All methods) contrast to 4.2 among the wealthiest (Figure 2). Similarly, TFR is 25 24.4 0.9 20 2.9 among women with more than secondary education and 6.1 0.9 1.1 15 0.5 16.9 14.5 15.5 10 among women with no formal education. It is also lower among 5 urban women at 4.9, compared to rural women at 6.0 births per 0 woman.5 Poorest Second Middle Fourth Richest Modern Methods Traditional Methods Figure 2 Total fertility rate by wealth quintile n Source: DHS Final Report, Timor-Leste 2009–10. 8 7 Unmet need for contraception is high at 31 percent5 indi- 7.3 6.0 6.1 5.7 Overall 6 5.3 cating that women may not be achieving their desired family 5 4.2 4 size.7 Induced abortion remains a challenge as approximately 40 3 percent of all emergency obstetric care cases in two major hospi- 2 1 tals are due to incomplete and complicated abortions.8 0 Poorest Second Middle Fourth Richest Opposition to use is the predominant reason women do not Source: DHS Final Report, Timor-Leste 2009–10. intend to use modern contraceptives in future. Forty-six per- cent of women oppose using contraceptives, and 9 percent cite Adolescent fertility adversely affects not only young wom- husband/partner’s opposition as the main reason they do not in- en’s health, education and employment prospects but also that tend to use modern contraceptives in future.5 Fear of side effects of their children. Births to women aged 15–19 years have the (10 percent) and health concerns (8 percent) are also significant highest risk of infant and child mortality as well as a higher risk reasons cited. Cost and access are lesser concerns, indicating fur- of morbidity and mortality for the young mother.3, 6 In Timor- ther need to strengthen demand for family planning services. Leste, adolescent fertility rate is moderate at 53 reported births per 1,000 women aged 15–19 years. poor pregnancy outcomes Use of modern contraception is increasing. Use of contracep- tion among married women dropped from 25 percent in 1997 to While the majority of pregnant women use antenatal care, 7 percent in 2003 (partly due to disruption of family planning ser- institutional deliveries are less common. Nearly nine-tenths vice provision during the fight for independence) but has since in- of pregnant women receive antenatal care from skilled medi- creased to 21 percent in 2009–10.5 More married women use mod- cal personnel (doctor, nurse, or midwife) with 55 percent hav- ern contraceptive methods than traditional methods (21 percent ing the recommended four or more antenatal visits.5 However, and 1 percent, respectively). Injectables are the most commonly a smaller proportion, 30 percent deliver with the assistance of used method (16 percent), followed by the pill (2 percent). Use of skilled medical personnel. While 68 percent of women in the long-term methods such as intrauterine device and implants are wealthiest quintile delivered with skilled health personnel, only negligible. There are socioeconomic differences in the use of mod- 11 percent of women in the poorest quintile obtained such as- ern contraception among women: modern contraceptive use is 32 sistance (Figure 4). Further, 23 percent of all pregnant women percent among women in the wealthiest quintile and 15 percent are anaemic (defined as haemoglobin < 110g/L) increasing their among those in the poorest quintile (Figure 3).5 Similarly, just 15 risk of preterm delivery, low birth weight babies, stillbirth and percent of women with no education use modern contraception newborn death.9 Figure 4 n Birth assisted by skilled health personnel (percentage) Hiv prevalence is low in Timor-Leste and education by wealth quintile campaigns are underway 80 68.1 HIV prevalence in Timor-Leste is low and knowledge of HIV 70 60 and HIV prevention methods is relatively low, especially 50 amongst women. Despite concentrated efforts from the govern- 40 37.4 ment, less than half of the female population (44 percent) has 29.9% Overall 30 heard of HIV. One-third of women know that a healthy looking 20.6 20 14.1 10 10.6 person can have HIV, and 17 percent know where they can obtain 0 an HIV test. 30 percent of Timorese women and 45 percent of Poorest Second Middle Fourth Richest men know that condoms can help reduce risk of transmission. Source: DHS Final Report, Timor-Leste 2009–10. Thirteen percent of young women ages 15 to 24 know where to obtain condoms, and 2 percent of women in this age range used a Among all women ages 15–49 years who had given birth, 68 condom at first sexual intercourse. percent had no postnatal care within 6 weeks of delivery.5 Eighty-seven percent of women say they have serious prob- lems in accessing health care when they are sick because of concern that no drugs are available (Table 1).5 Further, 82 per- Technical Notes: cent cited the concern that no provider is available and three in Improving Reproductive Health (RH) outcomes, as outlined in the five women cited the concern that no female provider is avail- RHAP, includes addressing high fertility, reducing unmet demand for able. contraception, improving pregnancy outcomes, and reducing STIs. The RHAP has identified 57 focus countries based on poor Table 1. problems in accessing health care (women age 15–49) reproductive health outcomes, high maternal mortality, high fertility reason % and weak health systems. Specifically, the RHAP identifies high At least one problem accessing health care 95.9 priority countries as those where the MMR is higher than 220/100,000 Concern no drugs available 86.6 live births and TFR is greater than 3.These countries are also a sub- group of the Countdown to 2015 countries. Details of the RHAP are Concern no provider available 82.4 available at www.worldbank.org/population. Concern no female provider available 63.1 The Gender-related Development Index is a composite index Having to take transport 59.4 developed by the UNDP that measures human development in the Distance to health facility 53.3 same dimensions as the HDI while adjusting for gender inequality. Its Not wanting to go alone 43.2 coverage is limited to 157 countries and areas for which the HDI rank Getting money needed for treatment 35.6 was recalculated. Getting permission to go for treatment 23.1 Source: DHS final report, Timor-Leste 2009–10. Human resources for maternal health are limited with only 0.1 physicians per 1,000 population but nurses and midwives are National policies and strategies that have influenced slightly more common, at 2.19 per 1,000 population.1 reproductive health The National reproductive Health strategy 2004–2015 with 7 The high maternal mortality ratio at 370 maternal deaths per objectives aimed at improving access and delivery of reproductive 100,000 live births indicates that access to and quality of emer- health services, creating an enabling environment, and outlining the gency obstetric and neonatal care (EmONC) remains a chal- key actions to achieve the MDGs. lenge.4 n Key Actions to improve rH outcomes strengthen gender equality • Secure reproductive health commodities and strengthen sup- • Support women and girls’ economic and social empowerment. ply chain management to further increase contraceptive use as Strengthen employment prospects for girls and women. Edu- demand is generated and ensure their availability and acces- cate and raise awareness on the impact of early marriage and sibility in both urban and rural areas. child-bearing. • Educate and empower women and girls to make reproductive reducing maternal mortality health choices. Build on advocacy and community participation, • Address the inadequate human resources for health by urgently and involve men in supporting women’s health and wellbeing. training midwives and health personnel and deploying them to • Work at the grassroots level and through community cam- the poorest or hard-to-reach districts. paigns to prevent gender-based violence and promote gender • Invest in the provision of basic emergency obstetric care equality. (EmOC) which is still limited in rural areas; ensure that hospi- tals are able to provide comprehensive obstetric care in the case reducing high fertility of delivery complications. • Increase family planning awareness and utilization through • During antenatal care, educate pregnant women about the im- outreach campaigns; promote Community Based Distribution portance of delivery with a skilled health personnel and getting of family planning commodities, especially targeting rural and postnatal check. Encourage and promote community partici- remote communities. pation in the care for pregnant women and their children. • Provide quality family planning services that include coun- seling and advice, focusing on young and poor populations. reducing sTis/Hiv/Aids Highlight the effectiveness of modern contraceptive methods • Despite the low prevalence, efforts should focus on integrating and properly educate women on the health risks and benefits HIV/AIDS/STIs and family planning services in routine ante- of such methods. natal and postnatal care to ensure that HIV positive mothers • Promote the use of ALL modern contraceptive methods, in- are identified and their babies are born HIV-free. cluding long-term methods, through proper counseling which • Focus on increasing HIV and STIs knowledge and awareness may entail training/re-training health care personnel. through community outreach in both urban and rural areas. references: 8. Belton, Suzanne, Whittaker, Andrea, and Barclay, Lesley. 2009. Fundasaun Alola. Maternal Mortality, Unplanned Pregnancy and 1. World Bank. 2010. World Development Indicators. Washington DC. Unsafe Abortion in Timor-Leste: A Situational Analysis. http:// 2. United Nations Development Programme. The Millennium www.unhcr.org/refworld/pdfid/4a2f69572.pdf. Development Goals, Timor-Leste. 2009. http://www.tl.undp.org/ 9. Worldwide prevalence of anaemia 1993–2005: WHO global da- MDGs/MDGs_File/UNDP_MDGReport_Final.pdf. tabase on anaemia/Edited by Bruno de Benoist, Erin McLean, 3. World Bank, Engendering Development: Through Gender Equality Ines Egli and Mary Cogswell. http://whqlibdoc.who.int/publica- in Rights, Resources, and Voice. 2001. tions/2008/9789241596657_eng.pdf. 4. Trends in Maternal Mortality: 1990–2008: Estimates developed by WHO, UNICEF, UNFPA, and the World Bank. 5. National Statistics Directorate (NSD) [Timor-Leste], Ministry of Finance [Timor-Leste], and ICF Macro. 2010. Timor-Leste Demographic and Health Survey 2009–10. Dili, Timor-Leste: NSD correspondence details [Timor-Leste] and ICF Macro. 6. WHO 2011. Making Pregnancy Safer: Adolescent Pregnancy. This profile was prepared by the World Bank (HDNHE, PRMGE, and Geneva: WHO. http://www.who.int/making_pregnancy_safer/top- EASHH). For more information contact, Samuel Mills, Tel: 202 473 ics/adolescent_pregnancy/en/index.html. 9100, email: smills@worldbank.org. This report is available on the 7. Samuel Mills, Eduard Bos, and Emi Suzuki. Unmet need for contra- following website: www.worldbank.org/population. ception. Human Development Network, World Bank. http://www. worldbank.org/hnppublications. Timor-LesTe reproducTive HeALTH AcTioN pLAN iNdicATors indicator Year Level indicator Year Level Total fertility rate (births/woman ages 15–49) 2009/10 5.7 Population, total (million) 2008 1.1 Adolescent fertility rate (births/1,000 women ages 15–19) 2008 53.1 Population growth (annual %) 2008 3.2 Contraceptive prevalence (% of married women ages 15–49) 2009/10 22.3 Population ages 0–14 (% of total) 2008 45.2 Unmet need for contraceptives (%) 2009/10 30.8 Population ages 15–64 (% of total) 2008 51.9 Median age at first birth (years) from DHS 2009/10 22.4 Population ages 65 and above (% of total) 2008 2.9 Median age at marriage (years) 2009/10 20.9 Age dependency ratio (% of working-age population) 2008 92.8 Mean ideal number of children for all women 2009/10 5.0 Urban population (% of total) 2008 27.3 Antenatal care with health /sonnel (%) 2009/10 86 Mean size of households — Births attended by skilled health /sonnel (%) 2009/10 29.9 GNI/capita, Atlas method (current US$) 2008 2460 Proportion of pregnant women with hemoglobin <110 g/L) 2008 22.9 GDP/capita (current US$) 2008 453 Maternal mortality ratio (maternal deaths/100,000 live births) 1990 650 GDP growth (annual %) 2008 13.2 Maternal mortality ratio (maternal deaths/100,000 live births) 1995 590 Population living below US$1.25/day 2007 37.2 Maternal mortality ratio (maternal deaths/100,000 live births) 2000 520 Labor force participation rate, female (% of female population ages 15–64) 2008 61.6 Maternal mortality ratio (maternal deaths/100,000 live births) 2005 420 Literacy rate, adult female (% of females ages 15 and above) — Maternal mortality ratio (maternal deaths/100,000 live births) 2008 370 Total enrollment, primary (% net) 2008 77.3 Maternal mortality ratio (maternal deaths/100,000 live births) target 2015 160 Ratio of female to male primary enrollment (%) 2008 93.9 Infant mortality rate (per 1,000 live births) 2008 75 Ratio of female to male secondary enrollment (%) — Newborns protected against tetanus (%) 2008 66 Gender Development Index (GDI) — DPT3 immunization coverage (% by age 1) 2009/10 64.2 Health expenditure, total (% of GDP) 2007 13.6 Pregnant women living with HIV who received antiretroviral drugs — Health expenditure, public (% of GDP) 2007 11.5 (%) Prevalence of HIV (% of population ages 15–49) — Health expenditure/capita (current US$) 2007 57.9 Female adults with HIV ( % of population ages 15+ with HIV) — Physicians (per 1,000 population) 2004 0.1 Prevalence of HIV, female (% ages 15–24) — Nurses and midwives (per 1,000 population) 2004 2.19 poorest-richest poorest/richest indicator survey Year poorest second middle Fourth richest Total difference ratio Total fertility rate DHS 2009/10 7.3 6.0 6.1 5.3 4.2 5.7 3.1 1.7 Current use of contraception (Modern method) DHS 2009/10 14.5 15.5 16.9 24.4 31.7 21.1 –17.2 0.5 Current use of contraception (Any method) DHS 2009/10 15.0 16.4 18.0 25.3 34.2 22.3 –19.2 0.4 Unmet need for family planning (Total) DHS 2009/10 35.0 30.1 33.5 28.0 27.9 30.8 7.1 1.3 Births attended by skilled health personnel DHS 2009/10 10.6 14.1 20.6 37.4 68.1 29.9 –57.5 0.2 (percent) development partners support for reproductive health in Timor-Leste WHo: Safe motherhood and reproductive health; uNiceF: Child protection; under-5 mortality; adolescent and youth; uNFpA: Reproductive health and rights, safe motherhood, EmOC, usAid: Maternal, newborn and child health adolescent reproductive health, gender based violence; AusAid: Maternal, newborn and child health.