Timor-Leste Health Care Seeking Behaviour Study - Secretaria de ...

drug compliance. 27 Some providers explained that they did so out of frustration and concern for thehealth of the woman or child.No providers reflected on the effects of their anger on the patient. Reports from some usersindicated a reluctance to call a midwife in the event of difficult labour, anticipating the midwife maybe angry if she was called late and the condition of the woman in labour was already grave.While a patient may seek assistance when their condition is already grave and arrive late at a facility,invoking health worker anger, their family might blame the provider who treated them in the eventof the patient’s death. Delay in seeking assistance can also generate a sequence of events whichmay lead to a patient’s death, something which the provider might then be blamed for. For example,after a two-day labour, a TBA was called and she assisted the delivery of the baby, and also cut thecord, and then the woman bled heavily and experienced retained placenta [kaan la mai]. As the TBAwas unable to deal with this complication, the following morning – already delayed – the familycalled a midwife who was unable to assist with delivery of the placenta but inserted an IV drip andadministered an oxytocin injection and arranged for a NCBA (Coffee Co-operative clinic) vehicle totake the woman to Dili national hospital where she died two hours later. The community allegedthat the midwife was to blame (dun sala) and the midwife had to be subsequently transferred toanother sub-district.However, it was also mentioned in relation to blame (fo sala) that where a provider had been called(bolu) to a patient’s home by their family, and where a negative outcome resulted, the family of thepatient must take partial responsibility for the outcome because they had called the provider. Anurse gave the example that three weeks after a TBA delivered a baby (first baby of mother) itdeveloped swelling to the head [ulun bubu] and the family took the baby to the CHC where it wasexamined by a doctor. The repondent (nurse) then said to the family: “Something has happened andwho can you blame [fo sala] because the TBA who assisted was not obliged to assist, but you calledher to assist”. The nurse went on to explain that a TBA is only concerned with the baby being bornand not concerned about any health effects of unclean instruments being used, such as tetanus, andthat for first birth especially, assistance should be sought from a midwife.The risk of a provider being blamed for a negative outcome may have implications for spontaneousoutreach activity, e.g. where a provider initiates a home visit rather than having been invited by thefamily to attend. (See Appendix 5 for FGD extract on ‘blame’.)Further in relation to delay, some providers understood factors that caused patient delay such aslong distance and lack of transport, belief in custom (adat) causing the illness, and use of traditionalmedicine first. In relation to transport, one provider mentioned that communities should be moreproactive in assisting ill people or women approaching the period of labour to help ensure access toa health facility. Providers understood that first level delay was often caused by user views that theillness may be caused by custom factors, such as neglect of customary duties, or socialtransgressions, and required a customary response to determine and resolve the cause (see Box 14).A range of conditions were at times associated with custom factors – including appendicitis, severediarrhoea and difficulties encountered during labour.27 Time constraints could constrain providers from conducting preventative activities.Timor-Leste Health Care Seeking Behaviour Study | 200950