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For graduate midwives to effectively provide high quality care to women and their families, they must be supported by a well functioning health service. Two decades of economic and structural reform have capped expenditure, restricted public budgets and resulted in generalised depletion of the health care workforce and the environments in which they provide care.

Three hospitals, three rural health centres and one Aide Post were visited as part of this review (for full list see Table One in Section 3 of this report). Whilst a comprehensive review of health services was not included in the Terms of Reference a walk-through assessment was undertaken and some of the deficiencies identified that would influence the ability of midwives to reduce the high levels of maternal and child health morbidity and mortality.

The facility assessment tool (Appendix 5) was used as a guide to assess the general condition and hygiene of the facility, water and sanitation facilities and infection control and waste management practices.

Equipment

Many key informants reported that the essential equipment and medical supplies were often not available and influenced the quality of care they were able to offer. Birthing bundles frequently ran out requiring staff to soak instruments in antiseptic solution for reuse on birthing women. Suture material was often not available and led to clinical midwives keeping their own supply of needles soaked in solution for use on perineal repair. Sphygmomanometers were often broken in labour wards and antenatal clinics resulting in the inability to monitor women’s blood pressure, essential in the appropriate management of preeclampsia. Syntocinon and other oxytocics frequently were unavailable that would result in increasing rates of post partum haemorrhage and difficulties in managing haemorrhages when they occurred.

The current system relies on the pharmacy to replenish supplies. It appears there is an urgent need to address the process.

Minimum standards developed by NDoH are not enforced and most health services do not have the resources or funding to implement the standards.

Workforce

Much of the maternity care for women in PNG is provided by non-midwives, namely registered nurses and Community Health Workers. This includes all hospitals, included the Port Moresby General Hospital, although a larger percentage of non- midwifery care can be found in smaller hospitals and rural health centres. In the smaller rural health facilities visited by the review team CHWs provided all care to women and only when complications arose was a nurse or a midwife summonsed.

Although the CHWs are acknowledged as having a wealth of experience and indeed, are the backbone of health services, serious concerns were raised on the quality of care women received when complications occurred. The opportunity to interview CHWs were limited as the review team were usually met by senior staff and when CHWs sat in on focus group discussions, they rarely spoke of their experiences or opinions of the service. On several occasions, more senior staff were not available and CHWs were questioned on the type of care they provided to women in childbirth. Although the numbers of interviewees was small, it was clearly apparent that the CHWs had limited knowledge on the causes or management of women with complications. If PNG is to address the high levels of maternal and perinatal mortality and morbidity, CHWs require closer supervision and more education on the early detection and referral of maternal complications.

At each facility, the review team requested to see case notes for any labouring or postnatal women at the facility. Documentation was minimal and the level of care was of concern, particularly in the rural facilities. Observations were taken on each woman on admission to labour ward and included maternal temperature and pulse, fetal heart rate, strength and frequency of contractions and a vaginal examination. Often these were the only observations recorded for the duration of labour. Many of the women in rural facilities did not have a recorded blood pressure and the intramuscular administration of ergometrine was routine for management of third stage and each woman was placed on oral ergometrine three times a day for several days post

delivery. The administration of ergometrine is contraindicated in the presence of elevated blood pressure.

In the larger hospitals, observations included blood pressure and appeared to be conducted more frequently than once on admission.

Fee for service payment

According to National Health Policy and the National Health Plan, all maternity services (antenatal, birth and postnatal) are supposed to be provided free of charge. However, as the National Department of Health has no authority over the provinces (due to the Organic Law) the Hospitals, Health Clinics and Aid Posts ignore the National Health Policy and set fees for these services. The fees vary though usually involve K10-20 for admission and K2-5 for outpatients appointments including antenatal clinics. In addition, some women were charged an extra fee for blood tests (K2). Although the fees appear minimal, they are likely to be unaffordable for many women in PNG and would act as a deterrent to access services.

Maternal Complications and Life threatening emergencies

In order to determine the appropriate response to and management of maternal obstetric emergencies educators, clinical staff and students were asked their opinion and management of two common maternal emergencies: PPH and pre-eclampsia. These two conditions were chosen as they are two of the most common causes of maternal mortality and both can be dramatically reduced with early recognition and prompt and appropriate management.

Post Partum Haemorrhage

Active management of the third stage of labour (delivery of the placenta) is known to significantly decrease the amount of blood lost during childbirth and is recommended by leading international agencies to be offered to women as part of routine management by skilled attendants in childbirth (ICM and FIGO, 2004).

Active Management of the Third Stage involves the routine administration of a uterotonic agent following the birth of the anterior shoulder or immediately following

of the cord and a small gush of blood) and the placenta is removed using controlled cord traction (Lalonde et al., 2006).

The uterotonic agent of choice in PNG is syntometrine, which involves mixing of two solutions from two ampoules – 5 units of syntocinon with 0.5milligrams of ergometrine, neither of which are refrigerated. The routine administration of syntometrine has been discontinued in many countries due to the higher side effects of ergometrine (nausea, vomiting and increase in blood pressure), contraindications for use with women with elevated blood pressure, and the need to store ergometrine between 2 and 8 degrees Celsius (requiring refrigeration). Oxytocin (syntocinon), however, can be stored between 15 and 30 degrees Celsius for up to three months (Hogerzeil et al., 1993). For these reasons, international agencies therefore recommend the use of oxytocin (syntocinon) as the drug of choice for active management of third stage (Lalonde et al., 2006).

Furthermore, a recent Cochrane review found no advantage of ergometrine over syntocinon in the prevention of post partum haemorrhage of over 1000mls (McDonald et al., 2005) though a small though statistically significant difference with blood loss of between 500ml and 1000ml was found. With the current practice in PNG requiring the use of two ampoules, that the ergometrine is not stored according to international recommendations, and that some women do not have their blood pressure checked on admission to labour ward, it appears reasonable that the routine use of syntocinon only is considered.

All educators, clinical staff and students were asked to describe their management of third stage. Most respondents were able to describe the steps of administration of syntometrine and controlled cord traction; although several students were unaware this was termed ‘active management’. However some respondents (educators, clinicians and students) discussed feeling for (or stimulating) the uterus to contract before delivering the placenta. At one of the institutions (UPNG) the clinical ‘checklist’ to measure competence included a list of ‘performance indicators’ for management of third stage. The first performance indicator is recorded as directing the student to ‘rub the fundus to contract’, prior to administration of an oxytocic or

it can cause excessive blood loss resulting in a postpartum haemorrhage and for it to be formally taught to new students requires urgent attention.

The frequency of practice of stimulating the uterus prior to expulsion of the placenta in the clinical area was difficult to determine. The review team, however, believe it is relatively common practice and should be discouraged through dissemination of an memo, development of a policy or whatever other action the NDoH believes will reach the maximum number of providers, including CHWs.

When active management is not possible due to the lack of availability of uterotonic agents, physiological (or expectant) management of third stage is recommended. In focus groups with some of the new graduates, the students were asked what they would do if oxytocics were not available. They responded that they should continue to apply controlled cord traction to remove the placenta. This practice should be discouraged as physiological management of the third stage relies on no interference by the attendant other than putting the baby to the breast and ensuring the woman is an upright position to facilitate the expulsion of the placenta by the mother using physiological means. By continuing to apply controlled cord traction, the woman is at increased risk of PPH, particularly in the absence of available oxytocics that are also required in the management of PPH (ICM and FIGO 2004).

Management of post partum haemorrhage commonly involves intravenous administration of an oxytocic infusion. When clinical staff and students were asked about the dose of syntocinon used in the infusion, hospital staff reported using 20 units per 1000 mls.

Misoprostol is another drug available for the management of PPH and has proven to be very effective in stimulating a sustained contraction in a previously atonic uterus. Misoprostol is currently available in some health facilities in PNG though is primarily used for induction of labour. Although it is a ‘Category A’ drug which can be ordered by all health care workers (PNG NDoH, 2002), current practice in PNG makes it unavailable for use by health staff other than doctors. In PMGH it is kept in the locked drug cupboard and requires the authorisation of a medical officer prior to

being used inappropriately for the termination of pregnancy. Misoprostol is quite affordable (similar to oxytocics), does not require refrigeration or IV access (given per rectum) and could have a significant impact on the prevalence rates of PPH if more widely available.

Stakeholders also reported that retained placenta appeared to be a significant issue in the rural areas, often requiring expensive referral in the absence of a midwife or doctor, or worse, death by haemorrhage for the woman. Students’ access to performing manual removal of the placenta varied amongst the students with some students reporting no opportunity to learn this skill and others doing 2 or 3 throughout their practical experience. If new graduates are returning to rural areas with no other specialist support it is essential that they are competent to manually remove a placenta and this requires more exposure to the procedure within their midwifery program. It should also be noted that the high rates of retained placenta may in part be associated with the inappropriate management of third stage and if this was corrected, less women should experience the complication.

Pre-eclampsia and Eclampsia

Pre-eclampsia is a multi-system disorder of pregnancy and a common cause of maternal death in PNG and internationally. The most common presentation of pre- eclampsia is an elevated blood pressure (international definition being two readings of 140 systolic AND/OR 90 diastolic at least 30 minutes apart). However to meet the criteria of pre-eclampsia (and distinguish between conditions such as ‘hypertension in pregnancy’ or pre-existing essential hypertension, the elevated blood pressure should be accompanied by at least one other manifestation. Usually this is proteinuria, due to renal impairment. Other signs of worsening pre-eclampsia include neurological signs: vision changes, frontal headache, and hyper-reflexia, liver involvement including a palpable, or tender liver, abnormal liver function tests, and blood dyscrasias indicating coagulopathies or haemolysis. Whilst generalised oedema can be a sign of pre- eclampsia, this is considered to be an unreliable sign, particularly given the fairly common presentation of lower limb oedema in normal healthy women.

severe pre-eclampsia and eclampsia is one of the most common causes of maternal mortality.

It was apparent that many of the graduating students and experienced clinicians had very little knowledge around signs of severe pre-eclampsia and the impression gained from the review team was that life threatening conditions did not receive adequate attention throughout the education programs, nor in the clinical areas. When asked what were the signs of pre-eclampsia, most staff and students reported an elevated blood pressure, though on closer questioning many could not provide clear definitions of what constituted an ‘elevated’ blood pressure. When other signs were not provided, the students and clinicians were questions further. The question appeared to perplex most respondents and they almost universally could only suggest that oedema (some even stating ‘lower limb oedema’) was the only other sign they could provide.

Clinicians providing antenatal or intrapartum care throughout PNG do not have the capacity to test urine at the clinic level, which is currently only available at the laboratory level. However, the testing for proteinuria can be done simply at the clinical level by a dipstick. Whilst the application of urine testing may not be justifiable in terms of resource allocation in PNG, the availability of these dipsticks for women presenting with other signs of pre-eclampsia would be useful to distinguish those women who require urgent referral or more aggressive management.

It is acknowledged that sophisticated blood analysis is unrealistic for many health facilities in PNG, however educating the current and future workforce on some of the other clinical signs of severe pre-eclampsia would lead to earlier diagnosis and more appropriate management of this potentially life threatening disorder.

The management of severe pre-eclampsia is the administration of antihypertensives (usually hydralazine) to lower the blood pressure with intravenous magnesium sulphate to prevent or control eclamptic seizures. The use of diazepam in the management of eclamptic seizures has not been recommended for some time. However, it was listed as the first drug of choice in the laminated ‘wall charts’ found in many of the labour wards.

Throughout the review, most respondents were aware of magnesium sulphate, though many did not know why it was used, or how, and seemed to rely on the medical staff to have this information. In a major obstetric unit such as PMGH this may be understandable (though not acceptable). However in the rural areas, where medical staff are often not available, the lack of appropriate knowledge of the staff providing the care to women is of serious concern.

NDoH staff informed the review team that magnesium sulphate should be available at all hospitals and health centres. However it appears the drug was not available at many of the rural centres, nor did staff know how to use it.

To address the high levels of maternal mortality of pre-eclampsia and eclampsia, the knowledge and skills of all staff providing care to pregnant women must include the appropriate identification and management of this disorder.

HIV

Papua New Guinea was declared to have a generalized epidemic of HIV/AIDS in 2003. HIV prevalence among antenatal attendees is over 1.3 per cent in Port Moresby and 3.7 percent in some other areas. There has been significant resources provided to improve the rates of HIV screening and treatment in antenatal women. However the review team failed to observe any routine screening procedures offered to women in most of the facilities we visited. In the notes reviewed for inpatient obstetric patients, only the Haemoglobin and VDRL were recorded. When staff were questioned on the availability of HIV screening, most respondents replied that they did not have the facilities to screen women, or that when pre-test counselling was introduced that many of the women refused testing. This has led to the introduction of opt-out testing where pre-test counselling is given as a group but post-test counselling is done individually. This is an internationally recognised model, recommended by WHO as a means to ensuring maximum access to screening and treatment. However in the health facilities visited as part of this review, most women were not being counselled or screened for HIV. Testing kits, anti-retroviral medication and training are all available through the NDoH and donor agencies and health staff should be encouraged to screen more widely where these resources are available.

Resuscitation of the Newborn

It is generally accepted that approximately 10% of infants internationally will require some degree of assistance to breathe at birth (ILCOR, 2005). The vast majority of these infants will successfully establish respirations following some assistance with positive pressure ventilation, usually delivered via a self-inflating bag and mask.

During the walk through of each facility, the review team requested to look at the equipment available to resuscitate infants, should they require it. Whilst the larger facilities of PMGH and Goroka base hospital had an infant resuscitation cot and a bag and mask located within labour ward, on the two occasions we visited it was either not connected to oxygen or the oxygen bottle was empty. In other facilities such as the Modilon Hospital in Madang, the resuscitation equipment was located in the nursery, and in the smaller facilities, the staff could not locate the bag and mask though insisted they had one ‘somewhere’. When clinicians and students were questioned about the frequency and type of resuscitation administered to sick newborns, the review team were not reassured that this skill was highly developed amongst the staff. Most of the respondents reported they initiated ‘frog breathing’, even when a bag and mask was available. There is currently no evidence on the efficacy of frog breathing, but given that the appropriate equipment for effective resuscitation is available in the larger health facilities, adequate preparation of both students and staff is essential and will no doubt have a positive impact on neonatal morbidity and mortality.

Clinical Midwives

Reliable data on the midwifery workforce is currently not available. The PNG Nursing Council currently estimates midwifery numbers to be 567 although many of these midwives are no longer working in clinical positions. As already mentioned, it appears that graduates from midwifery courses over the past few years have not yet been registered (see Section 7 for more information). The National Department of Health, assisted by WHO, have developed a database that will provide accurate information on the nursing and midwifery workforce and will enable health planners to identify workforce shortages, particularly in the rural and remote areas. Operationalisation of this database, including the entry of labour-force data, must be

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