Birth choices in Timor-Leste: a framework for understanding the use of maternal health services in low resource settings

The high rate of maternal mortality in Timor-Leste is a persistent problem which has been exacerbated by the long history of military occupation and ongoing political crises since independence in 1999. It is similar to other developing countries where there have been slow declines in maternal mortality despite 20 years of Safe Motherhood interventions. The national Ministry of Health, United Nations (UN) agencies and non-government organisations (NGOs) have attempted to reduce maternal mortality by enacting policies and interventions to increase the number of births in health centres and hospitals. Despite considerable effort in promoting facility-based delivery, most Timorese women birth at home and the lack of midwives means few women have access to a skilled birth attendant. This paper investigates factors influencing access to and use of maternal health services in rural areas of Timor-Leste. It draws on 21 interviews and 11 group discussions with Timorese women and their families collected over two periods of fieldwork, one month in September 2006 and five months from July to December 2007. Theoretical concepts from anthropology and health social science are used to explore individual, social, political and health system issues which affect the way in which maternal health services are utilised. In drawing together a range of theories this paper aims to extend explanations around access to maternal health services in developing countries. An empirically informed framework is proposed which illustrates the complex factors that influence women's birth choices. This framework can be used by policy-makers, practitioners, donors and researchers to think critically about policy decisions and where investments can have the most impact for improving maternal health in Timor-Leste and elsewhere.