Reducing Maternal Mortality in Papua New Guinea: Contextualizing Access to Safe Surgery and Anesthesia : Anesthesia & Analgesia

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Reducing Maternal Mortality in Papua New Guinea: Contextualizing Access to Safe Surgery and Anesthesia

Dennis, Alicia T. MBBS, PhD, MIPH, PGDipEcho, FANZCA

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Anesthesia & Analgesia 126(1):p 252-259, January 2018. | DOI: 10.1213/ANE.0000000000002550
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Abstract

Maternal mortality is a global health issue that results in over 289,000 young women dying each year.1 Maternal death is defined as the death of a woman while pregnant or within 42 days of termination of pregnancy, from any cause related to, or aggravated by, the pregnancy or its management but not from accidental or incidental causes.2,3 Maternal mortality ratio (MMR) is defined as the ratio of the number of women who die during childbirth or within 42 days of termination of pregnancy (numerator) divided by the number of live births (denominator), expressed as number of maternal deaths per 100,000 live births. The current global MMR is 216 deaths per 100,000 live births.4,5 Most deaths are preventable and occur in low- and middle-income countries.2,5 Access to safe surgery and anesthesia for cesarean delivery and for the management of complications of birth including postpartum hemorrhage are essential if maternal mortality is to be reduced.

Papua New Guinea (PNG) is a low–middle-income country located immediately to the north of Australia where the estimated maternal mortality rate is 215 per 100,000 live births. This value is imprecise, with estimates ranging from 98 to 733.6–12 The comparable statistic for Australia is 7.1 deaths per 100,000 live births.13 PNG has a population of approximately 7.6 million, the majority of whom live in rural areas.14 Rates of poverty are high with the country ranking 158th of the 188 countries on the United Nations Development Program Index; the greatest burden of disease is due to maternal, neonatal, and nutritional causes, accounting for 575,000 disability-adjusted life years (DALYs) in 2012.15 A DALY is a metric that is used to compare different populations and health conditions. It is the sum of the years of life lost due to premature mortality and the years of life lived with a disability. One DALY equals 1 year of healthy life lost.

Millennium Development Goal 5 aimed to reduce maternal mortality by 75% by 2015.16 In PNG, the MMR decreased by 54% from 480 in 1990 to approximately 220 in 2013 indicating that significant reductions in MMR and health improvements have occurred.15 The World Health Organization’s (WHO) Sustainable Development Goals aim to further reduce the global MMR to 70 by 2030.17 The Sustainable Development Goals17 and the Lancet Commission on Global Surgery18 address some of the fundamental problems leading to high maternal mortality which PNG needs to further address to achieve this MMR target by 2030 and its goal to be an upper–middle-income country by 2050.17,19,20

PNG has to overcome significant challenges to reach this target because the reasons for maternal death are not limited to the pathologies of obstetric hemorrhage, sepsis, high blood pressure, complications of delivery, unsafe abortion,21,22 and the interaction with preexisting communicable and noncommunicable diseases with pregnancy (diabetes, malaria, and human immunodeficiency virus).5,23–26 The causes of maternal mortality stem from fundamental in-country systemic issues including leadership and governance,27 a dispersed population with 85% of the people living in rural highlands with limited access to safe water and sanitation,28,29 a critical shortage of health workers,30–32 and a poor focus on the social determinants of health such as poverty, gender inequity, low education rates,33 and lack of effective health information systems.34–37 Most importantly, a fragile health infrastructure, with lack of widespread access to safe surgery and anesthesia for obstetric conditions including cesarean delivery, is a significant problem.18,38,39

Access to safe surgery and anesthesia in PNG was quantified in 2015 by Martin et al using the WHO situational analysis tool to assess emergency and essential surgical care.40 In their cross-sectional survey, they found that all 3 of the national/provincial hospitals had the capacity to provide cesarean delivery as all of these hospitals had uninterrupted supply of running water, electricity, and oxygen, as well as anesthetic machines, pulse oximetry, a blood bank, x-ray machine, and the ability to undertake hemoglobin measurement and urinalysis. Only one of these hospitals, however, had uninterrupted access to a resuscitation bag and mask for adults and children, and access to oxygen and mask tubing to connect to oxygen. For district and rural hospitals, where 80% of the population lives, 82% had capacity to undertake cesarean delivery. In these areas, <45% of hospitals had uninterrupted access to oxygen and <50% had uninterrupted access to an anesthetic machine, pulse oximetry, and a blood bank.40 Oxygen and mask tubing to connect oxygen was available in <30%. The World Federation of Societies of Anaesthesiologists has published standard of practice guidelines, and these hospitals would not pass these guidelines.41

Addressing only pathologies that result in death will have little impact on the critical problem of maternal mortality unless system issues are concurrently managed.42 These system problems have been classified by the WHO in its 2015 publication global strategy for women’s, children’s, and adolescents’ health.43 It addresses key areas for improvement in maternal health at a country level. These areas include enablers of intervention programs: strong country health plans; integrated delivery of health services, life-saving interventions, and commodities; adequate numbers of skilled and well-equipped health workers; good quality services, including access to safe surgery and anesthesia; and improved monitoring, evaluation, and accountability.18,43 Also included are key times in the life of a woman (from birth to postchildbearing years) when intervention programs can occur.44

POSSIBLE APPROACHES TO REDUCING MATERNAL MORTALITY

T1
Table 1.:
Program Categories With Current Situation, Aspiration Targets, Plans for Improvement, Strengths, Weaknesses, and Recommendations for Improvement and Engagementa

Possible approaches to reducing maternal mortality can be divided into program categories with assessment of the current situation, aspiration targets, plans for improvement, strengths, weaknesses, and recommendations for improvement and engagement (Table 1).45,46

Enabling Environments

Stable, Humanitarian Government.

The World Bank Worldwide Governance Indicators show that PNG has low ratings in governance.27 Corruption, defined as public power exercised for private gain, is perceived to be significant, with low scores given for control of corruption. The rule of law, defined as quality of contract enforcement, property rights, the police, the courts, and the likelihood of crime and violence, is also perceived to be low.27 Within this setting, engagement with donors and other governments is challenging. To address this issue, the Australian government, PNG’s largest foreign aid donor, has been working closely to improve governance. An Aid Investment Plan to 2018 for PNG has been negotiated and outlines 3 strategic priority areas: promoting effective governance, enabling economic growth, and enhancing human development.47,48 Aside from reducing human suffering and premature death, the economic arguments for improving maternal health in PNG are strong as they result in improvements in productivity and reduced long-term national health costs.49,50 A total of US dollars 439.20 million is planned for the 2016–2017 period, 40% of which is targeted to address effective governance.51

Safe, Secure, and Clean Environment.

Fundamental infrastructure including roads, electricity, buildings, water, and sewage are essential to improving maternal health. PNG’s Department of National Planning and Monitoring has developed a medium-term development plan for 2016–2017 to address water, sanitation, and hygiene.52 In combination with PNG’s water, sanitation, and hygiene policy,29 it sets targets for access to safe water. These targets, however, are relatively modest indicating the challenges in achieving even a basic level of essential infrastructure. By 2017, the proportion of the rural population using an improved drinking water source is only targeted to increase from 33% to 35%, and the proportion of the rural population using improved sanitation facilities is targeted to increase from 13% to 20%. The proportion of health and education facilities with access to safe water is only targeted at 75% (increased from 50%), and the proportion of education and health institutions with hand washing facilities is targeted at 75% with no current data available.52 Road infrastructure is poor with only 39% of national roads in good condition, making access to health facilities difficult. In 2015, Australia funded upgrading and maintenance of 1400 km or 16% of PNG’s roads.51

Strong Health System With Access to Safe Surgery and Anesthesia.

Strengthening the health system in the area of improving access to safe surgery and anesthesia is likely to have significant positive effects by reducing maternal mortality with likely positive economic impacts. This might be due to lower costs to the health system, lower costs to the patient and family, the potential for women to enter the workplace, and the reduced costs of care for a child or children with a mother rather than childcare. Systems to facilitate appropriate antenatal assessment, appropriate review of maternal mortality, and individual/facility quality improvement indicators will likely lead to safer surgery and anesthesia and improved access to these services.

Stokes et al53 estimated that in a provincial center in PNG, maternal and communicable conditions treated with emergency surgery and anesthesia averted 3453 DALYs over a 3-month period. Extrapolating this to an annual total, it is estimated that over 13,000 DALYs would be saved in this province.

PNG’s National Health Policy specifies a minimum number of antenatal visits during a normal pregnancy; however, the national indicators, used for reporting outcomes, only aim for 80% of women to attend 1 antenatal appointment rather than the WHO’s recommended minimum number of 4 visits (Table 2).6,54 The health policy also covers the rights of every woman to have access to skilled care at birth, and broad guidelines for the discharge of mother and baby after a normal birth, postnatal follow-up visits, and review by a trained professional for the woman and baby.6,54 It is likely that lack of skilled birth attendants and postnatal professionals contributes to this health policy not being met. Essential drugs are also required for maternal health. There is a National Essential Drugs List that includes magnesium sulfate and oxytocin6,56; however, the supply chain is fragile and medication can only be guaranteed on an intermittent basis.

T2
Table 2.:
Papua New Guinea’s Health Indicators Specific to Maternal Health Improvement

Since 2014, PNG has required that all maternal deaths are notified to a central authority and are reviewed and audited6,54; however, according to the WHO maternal death surveillance and response, there is no national death review committee.57 There are only intermittent meetings undertaken to review maternal deaths. Regular meetings may facilitate timely review of cases and even distribution of workload for those participating in the review process, as well as the production of an annual report with recommendations.6,54

In June 2016, the government of PNG released its National Report Assessment of Sector Performance for the years 2011–2015.55 The government monitored 29 indicators with national reporting rates of 84%. Eleven of these indicators are relevant to maternal health (Table 2). Unfortunately, over the last 5 years, there was no evidence of any improvement in most of the maternal health indicators with supervised birth, antenatal attendances, and family planning coverage decreasing over these recent years.55 Many of the indicator targets were not achieved, were below safe and acceptable international standards, and there were large provincial differences when the data were disaggregated (Table 2).58–61 Plans to address universal health coverage including access to safe surgery and anesthesia, health financing, increasing the health workforce,62 and health facility design and maintenance have been developed and are seen as requiring intergenerational change. Modest targets for health improvement in the next 33 years to 2050 are outlined in the Vision 2050 report: ensure that referral hospitals are adequately equipped to international standards, establish 1 basic health service center with 2 doctors and support personnel per district, and establish a Health Endowment Fund.63

Key Times

Concurrently with creating enabling environments, programs specifically addressing the issues at key times of a woman’s life are necessary to reduce maternal mortality.

Prepregnancy.

Risk detection and management and health optimization before pregnancy are important to decrease maternal mortality. Expansion of the midwifery workforce with additional training positions for midwifes in PNG is addressing some of the health workforce issues.64,65

Antenatal.

The antenatal period has been identified as a key time for early identification of problems, with the recommendation of at least 4 antenatal visits to enable this to occur. Mobile health programs are starting to be developed in PNG as a way to prevent delays in seeking help, getting to help, and being treated once at a health facility. With mobile health platforms such as a Childbirth Emergency Phone program, some barriers in communication have been solved and health workers have been able to address life-threatening birth complications.66 This program involved establishing a free solar-powered maternal health mobile phone in Milne Bay Province. This service facilitated communication between health care workers in the rural setting with the Alotau Provincial Hospital because the service was free to the workers. Communication involved alerting the hospital to patient arrivals, getting advice from the referral center for acute management of unwell pregnant women, management advice about identified high-risk women, and instructing staff how to stabilize women before transfer to the referral hospital.66

Birth and the Postpartum Period: Access to Safe Surgery and Anesthesia.

Access to safe emergency surgery and anesthesia at birth and in the postpartum period are crucial, enabling emergency cesarean delivery and emergency procedures to control hemorrhage and sepsis to be undertaken. Mother and baby gift programs and safe birth kits have been used successfully in PNG to assist with the uptake of supervised births and to increase the safety at birth.67 Safe birth kits include basic clean items that are required for a safe birth; a plastic sheet, soap, a pair of gloves, sterile scalpel blade, cords to tie the umbilical cord, and gauze squares.

Childhood.

Addressing poverty, ensuring adequate immunization, and prevention of illness and malnutrition in female children ensures that they grow up to be healthier adults and enter pregnancy with optimal health. Education remains an essential cornerstone for children, adolescents, and young women, so that they can access health information and develop health literacy.

Adolescence and Young Women.

Sexual and reproductive health educational activities and enabling access to family planning, contraception, and safe termination of pregnancy services for all who need them are essential to reducing maternal mortality.68 Men need to play an active role in family planning and have been involved in some recent programs.69–71 Churches contribute significantly to the delivery of health programs in PNG; however, their ideologies often differ from the goals of the National Health Plan in the area of family planning.72 National perceptions mean that family planning services are often viewed as only needed for married women. Consent from the husband, while not legally required, is culturally expected in many settings before a woman can obtain contraception.73 Young people also need access to psychologic support, good nutrition, programs that prevent injury and violence, especially gender-based violence, harmful practices, and substance abuse, all of which contribute to poor maternal health status if and when these women and girls become pregnant. These age groups also suffer from communicable and noncommunicable diseases that contribute to maternal mortality by compounding the risks of the pregnancy.

Postchildbearing.

The role of older women and grandparents in support and care of pregnant women is important as it enables important social and cultural information to be passed on to future generations as well as providing important education to pregnant women about the care of themselves and their baby.74 Programs for older women should focus on communicable and noncommunicable diseases, screening for cervical and breast cancer, ongoing education, and nutrition.

CONCLUSIONS

F1
Figure.:
An integrated system of enablers and keys times for intervention programs is shown. The enablers of intervention programs are on the outside of the triangle. These 3 broad categories cover the fundamental elements of a system that supports human development and improvement. The inner part of the triangle shows the life journey of a woman and key times when specific intervention programs can be developed.

To achieve improvements in maternal health, PNG needs to create an enabling environment for women to survive, thrive, and be transformed, and then institute evidence-based, cost-effective intervention packages to improve maternal health and decrease maternal mortality. These environments and programs need to be linked and integrated throughout the life course of a woman from prepregnancy; through pregnancy, birth, and postnatal care; childhood, adolescence, and young womanhood; to the postchildbearing years, and they need to include access to safe surgery and anesthesia as an essential component (Figure).43,44

DISCLOSURES

Name: Alicia T. Dennis, MBBS, PhD, PGDipEcho, MIPH, FANZCA.

Contribution: This author conceived the idea for the narrative review, undertook the literature review, analyzed the data, and wrote the review.

This manuscript was handled by: Angela Enright, MB, FRCPC.

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