This was the logic employed by many young women in the days of Timor-Leste’s independence nearly two decades ago. Family planning was a question of simple but tragic arithmetic: families had more children with the expectation that not all of them would survive.
Jacinta, a 37-year-old farmer from the semi-rural town of Gleno in the country’s coffee-rich Ermera municipality, has seven children. “Five still living,” she says. She wears the all-black outfit customary for women mourning the death of a close family member; a sister died several months ago. The black clothes would usually come off after a year, but for countless women in those first few years of independence, the outfits simply stayed on as deaths occurred in close succession.
Bare statistics of infant mortality can obscure everyday realities. There were 165 deaths per 1,000 live births in the last decade of Indonesia’s occupation of Timor-Leste, or one in six babies. In a country whose population was only about 750,000 at the time, many Timorese experienced these numbers as a direct source of pain: a lost child could be a niece or nephew, a cousin, a sibling.
A post-independence baby boom and efforts to repopulate families saw Timor-Leste’s birth rate climb to 7.77 children per woman between 2000 and 2003—then the world’s highest, according to the 2003 Timor-Leste Demographic and Health Survey.
Rebuilding families after the brutality of the 24-year-long occupation—which saw contraception covertly and forcefully used as what has been referred to as a tool of extermination against the Timorese—and managing the sad realities of childhood illnesses, limited food and clean water, and low immunisation rates, was a daunting challenge.
They were pushed to the brink, but the Timorese people survived. Their families endured. Now, what they need is support to thrive.
But how do you manage a population, enable women to choose their futures, and steer a nation on a path to prosperity against a complex post-conflict backdrop of poverty, loss and near-extinction?
A policy pathway upon independence
Months after the 2002 end of the United Nations transitional government and Timor-Leste’s return to full independence, the new Ministry of Health set its policy team to work with the United Nations Population Fund (UNFPA) to develop the country’s first family-planning policy.
The policy recognised Timor-Leste’s unfavourable spot at the top of the world’s birth rate index and the grave risk of maternal mortality. Policymakers sought to ensure that reproductive health services were “available in an effective way at every health facility” in the country—not only for improvements in individual well-being, but for the health of Timor-Leste as a nation.
“The policy is rights-based, voluntary, and moderate,” says UNFPA Timor-Leste’s assistant country representative, Domingas Bernado, who has worked with the agency since it opened its Dili office in 2003. The independent Timorese development monitoring organisation, La’o Hamutuk, considers the policy, which entered into force in March 2004, to be inclusive, progressive, consultative, and embraced by leaders in government, civil society and, crucially, religion.
Timor-Leste’s population is approximately 98% Catholic, with the church playing an important, influential and positive role in family, social and cultural life. While Catholicism doesn’t support artificial or modern methods of contraception—permitted, promoted and distributed under Timor-Leste’s policy—Bernado says local church leaders respect that it’s the Ministry of Health’s job to promote education and information about family planning.
“[The policy] was widely consulted,” she says. “The church didn’t say no. They can’t promote modern methods, but the Bishop [of Dili] said the government must do what it is supposed to provide.”
By promoting family planning, the Ministry of Health has seen the maternal mortality rate halve since independence, avoiding hundreds of deaths per year
By promoting family planning, the Ministry of Health has seen the maternal mortality rate halve since independence, avoiding hundreds of deaths per year. Its policy requires all health facilities to provide reproductive services, including reproductive counselling, and offer “complete and accurate information” about “an appropriate range” of contraceptive methods to clients.
At community health clinics, scattered through bigger villages in the largely rural country, clinicians are required to offer five methods of artificial contraception, in addition to information about natural family planning: injections, implants, the contraceptive pill, condoms and intra-uterine devices. At health posts—smaller clinics in more remote areas—clinicians must offer injections, implants and condoms.
Bernado says the UNFPA audits stock levels annually and the only method of contraception occasionally unavailable is condoms, because clinicians stock them based on demand, which is sometimes low—people tend not to ask for them, likely due to a common belief that people who use condoms are promiscuous.
Despite this, Timor-Leste’s contraceptive use rate remains one of the lowest in the Asia-Pacific region, with approximately 26% of people using any form of contraception. As it turns out, the presence of a political will to provide isn’t enough without deeper changes to societal mindsets.
Young women suffer lack of information
According to the country’s most recent national Demographic Health Survey, conducted in 2016, more than one-third of sexually active unmarried women say they want to use family planning, but only about half of those have access. Family planning sector workers tell New Naratif that clinics run out of supplies—some say they’ve seen expired stock sitting in rural clinics—while some practitioners refuse contraception to unmarried women, and many women feel too shy or embarrassed to ask, and so don’t.
It’s a particularly significant problem for teenagers.
A small qualitative report commissioned by the Government of Timor-Leste, UNFPA, and Plan International in 2017 describes teenage pregnancy as the principal cause of early marriage in Timor-Leste and says that both teen pregnancy and child marriage rates could decline dramatically if young people have better access to comprehensive sex education and sexual health services.
Nearly one in four Timorese women will have a baby before the age of 20, and pregnancy perpetuates teen marriage: population data shows that most Timorese women get married and have their first child within the same year.
While teen pregnancy is recognised in Timor-Leste as a health concern—the maternal mortality rate for mothers aged 15 to 19 years is twice as high as that for older mothers—it can’t be considered separately from the complex social and historical significance of having children in Timor-Leste, particularly when taking the history of population control under Indonesian occupation into account.
In a context where some older women’s memories of having their reproductive rights curbed is still fresh, children are cherished, many women want babies, and a woman’s first pregnancy is cause for celebration.
Felisima, a 27-year-old farmer from the rural Aileu municipality in Timor-Leste’s mountain foothills, became pregnant when she was 17, which led to her marriage. “In my community, you can’t be with a man if you’re not married,” she said.
Unmarried women have limited access to family planning information and many don’t know anything about sex or reproduction. They then fall pregnant by accident, which then leads to marriage and social encouragement to have more children.
“The first time I had sex was with my husband,” Felisima said. “I didn’t know anything about sex before, but since my husband asked me to do it, I agreed, even though I was very scared.”
She now has four healthy children and works hard in a women farmers’ cooperative to provide for them. “My children’s education is now the priority.”
“I managed to hide it from my family”
Sex and reproduction aren’t common topics of conversation in socially conservative communities in Timor-Leste. A Timorese girl might start dating openly in her late teens, but close-knit communities mean an absence of privacy, and pre-marital sex is frowned upon. Sex education is taught in some, but not all, schools. It’s usually taught in biology class, in a clinical, scientific sense. A Timorese teenager may learn what a fallopian tube is, and grow up knowing that menstruation is normal, but wouldn’t necessarily connect buying sanitary pads from a kiosk with pregnancy, sex or sexual attraction.
“I knew a little bit about how a baby is made, but not too much,” 19-year-old Natalia* told UNFPA researchers for the teenage pregnancy report. Raising her infant daughter alone after her boyfriend abandoned her when she discovered she was pregnant, Natalia dropped out of school early to have the child.
“I never went to see a doctor or have any consultation,” she said. “I even managed to hide it from my family. When I went into labour I told my father I had back pain, but he soon discovered I was having a baby.” She delivered the baby safely and is still living with her family.
The UNFPA report finds that limited access to contraception, poor knowledge of sex and reproduction, and reduced power in romantic relationships means that young women are vulnerable to pregnancy before they are ready. The report states that teenage pregnancy and early marriage have adverse consequences for many aspects of young people’s lives, affecting their health, education, employment opportunities and general well-being.
Girls who knows little about how their own bodies work, can’t access contraception, and have boyfriends who pressures them to go a little faster than they’re really comfortable with—these are the people family-planning workers in Timor-Leste say they’re most worried about.
Reproductive choice at risk
The sector suffered a scare in late 2017, when former Minister for Health Maria do Céu Sarmento Pina da Costa requested a revision of the 2004 family planning policy.
“They were concerned about this word ‘individual’; individuals can access family planning methods,” Ministry of Health family-planning programme manager Auria Celina Martins da Cruz tells New Naratif. “Who does that mean? Can very young children access contraception? So we changed it [in the draft policy] to kaben-na’in [married person] and adulto.”
While intended to clarify that family planning methods are available to adults, the use of the seemingly restrictive word “kaben-na’in” caused concern in some circles in Dili. Civil society and non-government organisations expressed concern that such a specific reference to married people would limit access to contraception for youth and unmarried people.
“[This will] deny Timorese women and girls their fundamental human rights to make decisions about and have control over their own bodies and risk seriously harming girls’ health”
“The policy completely excludes the young and unmarried, which will not only deny Timorese women and girls their fundamental human rights to make decisions about and have control over their own bodies but will perpetuate the practice of child marriage and risk seriously harming girls’ health,” said Fatima Soares, deputy country director of Plan International Timor-Leste, in an article published on the organisation’s website in August 2017.
Others working in the family planning sector privately expressed similar doubts to New Naratif over the intention of the draft policy.
On top of using a word that refers specifically to married people, the 2017 draft policy also favours using the natural Billings ovulation method as the primary form of contraception in Timor-Leste, arguing that it respects traditional, cultural, and religious beliefs. The Billings method involves identifying patterns—such as monitoring vaginal mucous—to determine a woman’s fertility, but the evidence of its effectiveness is unclear.
Under the current policy, all methods of contraception are considered equal. The 2017 draft policy—advocated by more conservative members of the government—would have healthcare providers push the Billings method over other forms. Women who go to clinics and health posts, then, would likely find it even more difficult to access other evidence-based forms of contraception.
A grassroots campaign mounted quickly, then-Minister for Health Rui de Araújo was petitioned, and the draft stalled as the government teetered towards an election. Dr de Araújo’s Fretilin party lost power in May this year; the tri-party coalition that governs the country has struggled to have several ministerial appointments—including the would-be Minister for Health—approved by the President, who has rejected nine candidates over suspected corruption. The draft policy remains unapproved and Dr de Araújo released a circular in late 2017 confirming the 2004 policy is still in force. As the country’s still without a health minister, the future of the policy is uncertain.
Dr Bernardo, from UNFPA, says panic is unnecessary, and reiterates that the policy won’t change. “The real problem isn’t the policy, the policy is very strong,” she says of the 2004 programme. “The challenge is now commodities.”
UNFPA, she says, is working closely with the Ministry of Health to help the government procure injections and intra-urinary devices to meet the growing demand for contraceptives. Since 2015, the organisation has also delivered a comprehensive training programme to primary health workers across the country to ensure contraceptive commodities are distributed appropriately and with proper counselling.
UNFPA’s first activity in Timor-Leste in 2003 was to help the embattled nation conduct its first census, counting every citizen of the newly independent nation. As the nation’s story shifts from conflict and suffering to national unity for development, perhaps the narrative of reproduction will also move from replacing a population, to enlivening the rights of citizens, accelerating human and economic development, and protecting and empowering Timor-Leste’s women.
* Name has been changed to protect privacy
Sophie Raynor is a freelance writer based in Dili, Timor-Leste, interested in gender, youth and politics in Southeast Asia. She is on Twitter @raynorsophie.