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

Abstract IntroductionThere are now well-established global standards for supporting improvement in women’s experience of maternity services, including frameworks for the prevention of mistreatment during childbirth. Given the ongoing reports from Timor-Leste outlining poor quality of care in maternal health services and the low use of health facilities for birth, we aimed to examine the adoption of global respectful maternity care standards in intrapartum care policies in Timor-Leste. MethodsFrom May to July 2022, we conducted a desk review of the Timor-Leste National Intrapartum Care Standards and Clinical Protocols for Referral Facilities and Community Health Centres. This was followed by a health-facility audit of policies, guidelines and procedures in three main maternity facilities in the capital, Dili to examine the extent to which the WHO (2016) standards for women’s experiences of care have been adopted. ResultsDespite the availability of global guidelines, key standards to improve women’s experience of care have been omitted from the National Intrapartum Care guidelines in Timor-Leste. There was no mention of avoiding mistreatment of women, needing informed consent for procedures, or strengthening women’s own capability and confidence. In the policy wording, women tended to be distanced from the care ‘procedures’ and their involvement was framed around being told what to do during the birth process. The results of the health facility assessment showed extremely low use of standards that improve women’s experiences of care. Health Facility 1 and 2 met two of the 21 quality measures, while Health Facility 3 met none of them. ConclusionThe discourse communicated through policy fundamentally affects how health care issues are framed and how policies are enacted. Given the findings of this study, combined with the widespread documentation of poor quality of care, low satisfaction with maternal health services, and emerging stories of physical and verbal abuse of women during birth, there is a need for a fundamental shift in the culture of care for women in Timor-Leste. This will require an immediate focus on leadership, training and policy-frameworks to stop mistreatment of women in health facilities. It will also require a longer-term focus on addressing the power imbalances that drive disrespect and abuse of women within and across social systems, and understanding how to support relationship-based models of care that inherently foster understanding and compassion.