PNG’s rocketing birthrate and high maternal mortality is making Obstetrics a high priority for this nearby nation’s medical system. Dr Nathan Kesteven visited Port Moresby General Hospital to meet staff and mothers…
Although Papua New Guinea is our nearest neighbour most Australians would have no idea that it has one of the higher maternal and infant mortality rates in the world. In Australia our maternal mortality rate (per 100,000 live births) is 6, in PNG it is 215!
The most common causes are post partum haemorrhage and infection - both related to poor access to birth support structures. In Australia less than 1% of women birth without trained staff present, in PNG that figure is probably around 55% (according to the Pacific Island Regional Development Goals, 2004). This means that most women birth without access to the basic and essential needs that prevent death and serious morbidity, outcomes that we in Australia very rarely see.
Recently I spent 10 days in the Port Moresby General Hospital (PMGH) observing how obstetrics is practised in PNG, at least in a hospital setting. PNG has a population growth rate of around 3% - this means that within 20 years the population will have doubled. This high level was reflected at PMGH - 40 births a day - that equates to 15,000 a year. By comparison, Lismore Base recorded 1155 births in 2016.
The labour ward is a large room divided in half with 12 cubicles on either side with curtains for privacy. There are 2-3 doctors on per shift, with around 4-5 midwives caring for the women who come in.
PMGH staff have access to all the essential obstetric medications / fluids that we have and next door is a theatre staffed 24 hrs a day. Interestingly the Caesarean section rate is only 6% (vs approx 30% here). Women, probably because of their younger age (most are around 25) and the need to avoid unnecessary surgery, are much more likely to have a normal vaginal delivery - this includes most twins and breeches.
A very important reason why sections are avoided is because many women may not come back to hospital if they get pregnant again and so are at risk if the uterus ruptures with subsequent labours.
The biggest common issue is dating pregnancies. A very large percentage of the women who came to PMGH present to Antenatal Clinic in their second or third trimester (and some presented to hospital in labour with no antenatal care at all). In these cases the EDC was a guesstimate taking into account the LMP and the quickening.
Very few women present to clinics in the first trimester or have a dating scan (private clinics exist but are costly) and the routine 20-week scan is an exception.
The HIV and syphilis status was known for all women (the labour ward had access to Point of Care (POC) testing for these two infections). Sometimes the haemoglobin was known, but often not. There is a lab on the hospital grounds, however the turnaround time is several hours even in an emergency (the junior doctor has to take the bloods to the lab, on the other side of the site, and asks them to process it quickly).
Coupled with this is the very low stock of available blood. In fact while I was there a woman died from a massive post partum haemorrhage, despite having a hysterectomy. A major contributing factor in this case was the fact that she had only been given two units of blood when she needed at least six.
There is a dedicated antenatal ward, where women who are in early / spurious labour go, but there is a far larger postnatal ward. The issue of family planning is pushed very strongly with all women and every day there are at least 5 who have a tubal ligation. Marie Stopes run an implant service in the hospital (this gives around 5 years of contraception) and at least 10-15 women each day have one inserted prior to discharge.
PNG presently trains 80 doctors a year. However, there is a newly opened medical school in Madang. As one can appreciate with a population of 7 million and 80 new doctors a year there is a significant deficit of medical practitioners across most of the country.
The country has training programs for Obstetrics, Surgery, General Medicine and for the last couple of years Rural Medicine (This is run by an Australian, Dr. David Mills). The doctors who do obstetrics do a four-year Master’s course and although they may not get the same degree of theoretical education as Australian doctors their practical experience is enormous.
On a final note, if you do feel like donating towards the improvement of maternal health in PNG, watch the video “Send Hope, not Flowers” - this charity funds another Australia doctor, Dr. Barry Kirby, who has developed a program to give women birthing kits. These can reduce maternal morbidity and mortality. You can also donate to Dr David Mills’s hospital in Kompian.