By 8am, the reception room at the Marie Stopes International health clinic in Dili is overflowing with women waiting for reproductive health services.
About 450 patients are helped at the clinic each month but this is just a fraction of Timor-Leste's 1.1 million population, most of whom live in remote rural areas with scant access to health education and services.
According to the UN Population Fund (UNFPA), women in Timor-Leste - the world’s newest independent nation and also Asia’s poorest – give birth to an average 6.38 children during their lifetime, one of the highest fertility rates in the world and second only to Afghanistan.
Melinda Mousaco, the country director for Marie Stopes International Timor Leste, told IRIN that awareness of family planning and reproductive health, particularly in rural areas, is “next to nothing”.
“Because of a lack of education, accidental pregnancies happen frequently,” she said. “When we show basic reproductive anatomy or give information about women’s menstrual cycles, people often tell us ‘this is the first time I’ve heard this’.”
After independence, there was a baby boom. This is because during a crisis, there is no work and a lot of stress. People just live together with nothing to do, and of course their focus is sexual activity.
Timor-Leste gained formal independence from Indonesia in 2002 after a long separatist struggle and a surge of violence in 1999, and health experts cite conflict and unemployment as key factors in the country’s high population growth.
“After independence, there was a baby boom,” Alita Verdial, chief executive officer of the Alola Foundation. “This is because during a crisis, there is no work and a lot of stress. People just live together with nothing to do, and of course their focus is sexual activity.”
The country’s strategy for addressing the population growth is centred on spacing, urging mothers to wait three years between births.
Mariano Redondo, communications officer for UNFPA in Timor-Leste, said an adequate interval between children was critical to stemming infant and maternal mortality rates, and formed the backbone of the government’s family planning strategy.
“The mortality rate increases because women don’t have time to recover from one pregnancy to another. And children suffer because they don’t have the same opportunities if they have 10 children in the house instead of two or three, for example.”
According to a 2009 UN report on Timor-Leste’s Millennium Development Goals, the child mortality rate was 130 per 1,000 in 2004, the latest available figures, with a target of 96 per 1,000 by 2015.
According to UNFPA’s 2007 country population assessment, the maternal mortality ratio (MMR) was 660 deaths per 100,000 live births.
Photo: David Swanson/IRIN
Women in rural areas have little to no information on reproductive health
Despite provisions for the separation of church and state in the country’s constitution, the Catholic church remains a powerful voice in Timor-Leste and does not officially support contraceptive methods that rely on condoms, the pill, injections or surgery, Verdial said.
Due to religious norms and cultural pressure, most women seeking to limit their families prefer to receive hormonal injections, which are easier to conceal, she said.
“Women in the village tell me they prefer this method so their husbands will not find out, which means women still lack power in decision-making about the number of children in her family.”
She said family planning advocates had to find common ground with religious leaders.
“We can’t change the church,” Verdial said. “But we need to have more dialogue with the church on how we can improve the quality of life for the people of this country.”
However, according to Mousaco, reproductive health workers faced other cultural hurdles as well.
During the Indonesian occupation from 1975 to 1999, residents were subject to a family planning policy of “two children are enough”. Mousaco said negative associations with that programme still persisted.
“That’s a big barrier, we’ve found,” she said. “We try to avoid the term ‘family planning’ because the people immediately think we’re here to force [hormone] injections or something like that [on them]. Our policy is simply ‘children by choice, not by chance’.”
Two Timorese brothers on the streets of Dili. Many children do not get to eat enough food before going to school and find it hard to concentrate on their studies
Photo: David Swanson/IRIN
Two Timorese brothers on the streets of Dili. About half the country's population is below the age of 15
An early start
About half the country’s population is younger than 15, Mousaco said, and there was a strong link between adolescent reproductive health education and the nation’s hopes for reining in population growth.
Education is critical “if we want to slow down population growth in this country, where the economy is obviously developing slowly. But if they’re reproducing at a young age, we’ll continue to have that cycle of population growth that the country won’t be able to manage,” she said.
Luiza Barros, the government’s adolescent reproductive health officer, said the country’s efforts to inform young people were critical for the future of the nation.
“In the current generation of young people, many have already contracted sexually transmitted diseases such as HIV/AIDS, and many more are at risk. Information about reproductive health can help prevent this.”
This article was produced by IRIN News while it was part of the United Nations Office for the Coordination of Humanitarian Affairs. Please send queries on copyright or liability to the UN. For more information: https://shop.un.org/rights-permissions