This document summarizes family planning efforts in Timor-Leste, a country with a total fertility rate of 7.8 births per woman, the highest in the world. It describes the history of conflict and destruction in Timor-Leste and the current state of its weak health system. It then outlines a program conducted by Health Alliance International to promote child spacing, including producing an educational film, home visits by community health workers, and working with the Ministry of Health and local leaders. Evaluation found the program increased contraceptive prevalence and knowledge of family planning methods.

1. Promoting child spacing in a post-conflict setting: The case of Timor-Leste 18th Annual GHEC Conference 7 th Annual Western Regional International Health Conference April 3 – 5, 2009

2. Geography

3. The Indonesian Legacy 24 years of brutal Indonesian military occupation 100,000 – 250,000 died many more torture, imprisoned, raped, displaced f Keluarga Berencana Indonesian FP program ‘ Dua anak cukup’ Coercive family planning practices in East Timor

4. Walking to polls, waiting in long lines, 98.5% of Timorese voted overwhelmingly for independence

6. 1999 Post-Vote Destruction

7. Timor-Leste 2002 The newest nation in the world

8. Religion & Culture Strong animist beliefs and practices throughout the country 97% of Timorese identify as Catholic

9. MOH Health System Post-Independence Vote Human resource at low level few Timorese doctors MW’s with poor skills Evolving MOH working to develop policies and strategic approaches Health facilities destroyed and poorly equipped High UN agency and INGO presence

10. Community Utilization of Health Services t Distrust and low utilization of government health services Increased dispersion of the population Strong traditional beliefs and practices regarding health and care seeking

11. Utilization of Health Services 2003 61% of pregnant women received prenatal care 90% of women deliver at home 20% of births were attended by a SBA

12. Family Planning Data 2003 TFR at 7.8 births per woman is the highest in the world Only 24% of women express a desire to limit future child bearing 18.5% of women recognized any contraceptive method Only 19% of women have ever used contraception and 9.7% are currently using a method

14. “ When we want to stop having babies then we inform the Kukunain (magic/mystic man), so that they can ask at the Sacred House and we will not get pregnant again.” “ We have our own tradition to follow for spacing our children…. ash is taken from the traditional birthing fire and carried to a faraway place. But if the ash is taken to a nearby place, the mother will get pregnant again in a short time.”

15. “ How many children we have is up to God” “ The number of children is determined by the husband’s parents. We just do whatever they say because they gave the dowry for us” (female respondent) “ I think ideally 2 to 5 years to have a child again, should give time to the mother to get strong again.”

19. ‘ Mai Ita Koko ’ (Come lets try): Community Health Worker Home Visits

20. Try a new behavior: home poster

22. Thank you!