The fertility rate in East Timor is one of the highest in the world. The government and the United Nations want to rein in population growth in one of Asia's poorest nations, but spreading the word about contraception can be tricky in a country where most people are Roman Catholic.
The United Nations Population Fund, or UNFPA, says East Timorese women give birth to an average of 6.38 children during their lives. That fertility rate is second only to Afghanistan.
The country's strategy for addressing the population growth is centered on spacing, or urging mothers to wait at least three years between births.
Mariano Redondo, communications officer for the UNFPA in East Timor, says an adequate interval between children is critical for minimizing infant and maternal mortality. "The mortality rate increases because women, they don't have time to recover from one pregnancy to the next one. And also children suffer because they don't have the same opportunities if there are like 10 children in the house instead of two or three," Redondo.
The U.N. says about one in eight infants died in 2004, and the maternal mortality ratio is about 660 deaths per 100,000 live births.
Redondo says family planning is the key to reducing those numbers, and talking about spacing is one way to open the door for discussion about contraception.
But overt efforts endorsing artificial contraception are difficult. The Catholic Church is a powerful voice in East Timor, and it opposes contraceptives methods such as condoms, the pill, injections or surgery.
Redondo says family planning advocates have begun talking with church officials on the issue, and to ease tension about birth control methods. He says the church has started to support reproductive health education programs. "We are working together with the - not only with the Ministry of Health, but with the Catholic Church. We held this first seminar on family planning in December 2009 and we had the endorsement of the Catholic Church, which was a big achievement, a big step to start like working on these issues," he said.
Aurea Celina Martins da Cruz, the Health Ministry's family planning officer, acknowledges there are cultural and religious barriers to family planning.
But she says stemming the fertility rate is a top priority, and the only way to do that is to ensure women have clear information about their options.
She says the biggest difficulty in family planning for is that the majority of the country is Catholic, and local traditions and attitudes about the methods are key factors that influence the country's strategy.
Alita Verdial is the chief executive officer of the Alola Foundation, an East Timor charity helping women and children. She says due to the stigma regarding artificial contraception, many women prefer to receive hormone injections, which are easier to conceal.
"And some of the women say 'Oh, actually I use that modern contraception, but I use injections because I don't want my husband to know about this.' And it means that women still have a lack of power to make decisions for herself and power of negotiation in the family," she said.
She says family planning advocates are better off looking for common ground with religious leaders than focusing on differences. "We can't change the church. You know - that's from the Vatican. But I think we need to have more dialogue with the church," she said.
Melinda Mousaco is the East Timor director for the reproductive services charity Marie Stopes International. She says family planning advocates do not encounter much resistance from church officials in the field. But she says pressure from the church on government leaders can affect policy.
"It's really caution, I guess, from the ministry of health's perspective, of not wanting to put the church offside. They are - yeah - being cautious about that relationship, of how they move forward and how they promote family planning nationally, so that they have the church on board," she said.
Mousaco says about half the country's population is younger than 15, and there is a strong link between sex education for adolescents and hopes for reining in population growth. "If we want to slow down population growth in this country, where the economy is obviously developing slowly, development is only progressing slowly, employment opportunities are obviously not going to grow overnight, if then 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.
With help from the UNFPA, the government and the Alola Foundation, Marie Stopes has established family planning clinics and education programs in Dili and 3 rural districts, and hopes to expand into all 13 of the county's districts by 2014.