Many health workers, including skilled birth attendants in remote and rural areas lack access to diagnostic information and specialists to support them in their care. Lack of access to high quality obstetric care results in high maternal mortality rates ( MMR) and MMR are highest in remote areas. In Australia, Aboriginals and women in remote areas are 3 times more likely to experience complications during pregnancy and birth. In Timor Leste, the MMR is 600-100000 births. This is 100 times more than in Australia. In Timor Leste the majority of women live and birth in remote areas where access to obstetric care is limited due to lack of trained personnel, infrastructure and the availability of diagnostic equipment. The use of skilled birth attendants (SBA) is increasing which has been shown to improve MMR but their education and resources are limited, and in remote areas they often work alone and thus do not have the support of colleagues or access to sophisticated diagnostic information interpreted by experts to support them in their clinical decision making. In Timor, as in many developing countries malnutrition in childhood affects the development of the pelvis making these women more likely to suffer protracted and obstructed labour. This is difficult to diagnose until labour starts but the earlier it is recognised, the more time there is to transfer to a facility with EmOC. The fetal heart rate in relation to maternal contractions and the maternal heart rate is the best way to monitor early signs of fetal distress that may indicate obstructed labour. This is a complex skill.A stethoscope or better still a Doppler is the best way to monitor the FHR and variability in it but it is recognising patterns that indicate distress that is difficult. In areas without access to highly skilled obstetric care often it is not recognised early enough and women do not arrive at a facility in time to act to save both their life and the life of the baby.

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