Melbourne School of Population and Global Health - Theses
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ItemImproving the Quality of Maternal and Newborn Care in East New Britain, Papua New Guinea( 2022)Quality care improves maternal and newborn health outcomes. Quality maternal and newborn care refers to the provision of evidence-based and respectful care to women and newborns by experienced and competent healthcare providers in a well-equipped and supportive environment. There is a need to prioritise improving the quality of maternal and newborn care globally, especially in low- and middle-income countries, such as Papua New Guinea, where women and newborns experience high rates of morbidity and mortality during pregnancy, childbirth and the postpartum period. Papua New Guinea is a country situated in the South Pacific region, with a population of around nine million. East New Britain is a rural province in the Islands region of Papua New Guinea, with a population of approximately 400,000. Most Papua New Guineans live in rural and remote areas like East New Britain, making healthcare access geographically challenging. Geographical access issues can be further compounded by financial and cultural factors, as well as health system limitations such as health workforce shortages, inadequate health service infrastructure and a lack of essential medicines and supplies. Implementing interventions to improve the quality of maternal and newborn care in Papua New Guinea must be preceded by a systematic and comprehensive assessment of the quality of maternal and newborn care provided and experienced. This PhD study aimed to fill this knowledge gap and examined the provision and experience of quality maternal and newborn care in five health facilities in East New Britain using a three-phased participatory methodology called partnership-defined quality. This PhD study was part of the Gutpela Helt Sevis, Helti Mama Bel, Helti Beibi Stadi (Quality of Pregnancy, Childbirth and Newborn Health Services Study), and sits within the Healthy Mothers, Healthy Babies research program. The Healthy Mothers, Healthy Babies program was established in 2015, and is led by Burnet Institute in partnership with the East New Britain Provincial Health Authority, Papua New Guinea Institute for Medical Research, University of Papua New Guinea and the Kirby Institute, University of New South Wales. A multiple methods design and a partnership-defined quality approach were used. Firstly, a scoping review of the evidence on interventions to improve the quality of maternal and newborn care in low and middle-income Pacific island countries was undertaken to inform the design of the quality improvement study. This review found that many initiatives to improve quality care were being implemented in the Pacific, including in Papua New Guinea. Most initiatives focused on the clinical service level, with very few addressing system-wide improvements or patient experiences of care. Enablers to quality improvement initiatives included community engagement, collaborative partnerships, staff education and training and alignment with local priorities. Barriers included little to no involvement with provincial and national health departments, restrictive donor-defined objectives, contractual obligations and funding delays. The review was followed by a focused study using quantitative and qualitative data collection techniques in East New Britain to: i) describe community members’ perspectives and experiences of quality care during childbirth and the immediate postnatal period; ii) examine the perspectives and experiences of women, their partners and health providers regarding labour and birth companionship; iii) appraise early newborn care practices and identify opportunities for improvement; and iv) to identify feasible and effective strategies to optimise the quality of maternal and newborn care in participating facilities. The findings from the quality improvement study are presented in three key areas – what the community thought about the quality of care provided; issues around labour and birth, such as companionship; and care of the newborn, including early newborn care practices. Community members emphasised the importance of effective communication and competent and respectful health providers. Women and partners wanted companions present during labour and birth, whilst health providers had mixed views. Only 30% of women had a companion present during labour, and 10% at birth. Most newborns received at least one essential newborn care practice in the first hour of life, such as immediate and thorough drying (97%). Multiple barriers to quality care were identified, including an insufficient workforce, critical infrastructure and utility constraints, and poor availability of medicines and equipment. This thesis demonstrates gaps in both the provision and experience of maternal and newborn care in East New Britain. This thesis highlights that a sufficient and well-supported health workforce within an enabling environment is vital to achieving quality maternal and newborn care. Policies that promote and support quality care are needed at all levels of the health system in East New Britain, and quality improvement needs to be embedded into routine practice. Gaps in the quality of maternal and newborn care can be filled by local quality improvement initiatives, such as supporting women to have a companion of choice present during labour and birth. Lastly, community engagement and leadership are essential for effective quality improvement interventions to improve maternal and newborn health.
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ItemRisk factors for anaemia during pregnancy and postpartum in Papua New Guinea: a cohort study( 2020)Anaemia in pregnancy is a substantial public health problem, particularly in resource-limited settings where every second pregnant woman is estimated to be anaemic. This thesis aimed to address gaps in our knowledge of maternal anaemia in order to inform effective prevention strategies in resource-limited settings. Specifically, this thesis sought to determine: the drivers of haemoglobin level changes in pregnancy and the first 12 months postpartum; the interactions between key anaemia risk factors; and the impact of maternal anaemia on infant haemoglobin and iron stores. This was done using a cohort of 699 women and their infants living in the East New Britain province of Papua New Guinea. Firstly, I determined the relationship between red blood cell genetic polymorphisms, anaemia and the malaria-causing Plasmodium species (spp.) infection in pregnant women; and the subsequent effects on birthweight. Women with the homozygous alpha+-thalassemia genotype had significantly lower haemoglobin levels and babies with significantly lower birthweight compared to wildtype individuals, with the association between alpha+-thalassemia and birthweight mediated largely through mechanisms independent of maternal haemoglobin levels. There were no significant associations between genetic polymorphisms and maternal Plasmodium spp. infection. These findings contribute to our current understanding of how genetic polymorphisms influence pregnancy outcomes. Secondly, I determined the contribution of iron deficiency to maternal anaemia and assessed temporal changes in haemoglobin and ferritin levels from enrolment through to 12 months postpartum. Haemoglobin levels remained consistently low, with at least 69 percent anaemic throughout the study period (haemoglobin <110g/l in pregnancy; haemoglobin <120g/l postpartum). Ferritin levels were more dynamic with iron deficiency (ferritin <15 micrograms/l) highly prevalent in pregnancy (>80%), but less so in the postpartum period (~30%). Iron deficiency was identified as a key intervenable anaemia risk factor, associated with a significant 5-fold increased odds of anaemia over the entire study period, compared to iron replete. Plasmodium spp. infection was also an important intervenable risk factor for maternal anaemia throughout the study period. Thirdly, I investigated the relationship between host iron status and Plasmodium spp. infection during pregnancy and postpartum periods, in order to inform the safety of iron supplementation as an anaemia prevention strategy. Host iron status (replete/deficient) was not significantly associated with the prevalence of peripheral Plasmodium spp. infection at any evaluation time, suggesting iron supplement use is safe in this setting. Inflammation was shown to confound the relationship between host iron status and infection, biasing results towards a protective effect for iron deficiency; highlighting the need for future studies assessing this relationship to adjust for inflammation. Finally, I assessed the impact of maternal anaemia on infant haemoglobin and ferritin stores from birth through to 12 months old. Severe iron deficiency anaemia in pregnancy was associated with significantly lower infant haemoglobin and ferritin levels during the study period; demonstrating that maternal haemoglobin and ferritin levels in pregnancy impact newborn and infant stores. This suggests that infant anaemia could be prevented by targeting maternal anaemia during pregnancy. Overall, this thesis outlines the high burden of anaemia during pregnancy, as well as the first 12 months postpartum for women in the East New Britain province of Papua New Guinea, and provides a comprehensive assessment of maternal anaemia aetiology. The data suggests that effective provision of iron supplementation both during and between pregnancies, in conjunction with malaria prevention strategies, would significantly reduce maternal anaemia prevalence and improve infant haemoglobin and iron stores.
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ItemA survey of non-communicable disease and the associated risk factors in three different study sites in Papua New Guinea( 2020)Introduction Non-Communicable Diseases (NCDs) are the leading cause of death and morbidity throughout the world, with the greatest burden in low- and middle-income countries (LMICs). Of the estimated 17.9 million CVD deaths in 2016, more than 10 million occurred in LMIC countries. Coronary heart disease and stroke were the two major causes contributing to these deaths. Papua New Guinea (PNG) is categorized as a lower-middle-income country according to World Bank criteria and it is experiencing rapid economic growth as a result of large-scale mineral and gas resource developments. These economic changes are contributing to epidemiological transitions associated with rapid lifestyle changes that, in turn, are leading to increases in cardiovascular diseases and diabetes. NCDs and associated risk factors have not been well investigated in PNG, however, several small studies conducted over the past 40 years have been suggestive of increasing prevalence of NCDs and their associated risk factors (Chapter 3). The aim of this research is to establish an up-to-date NCD risk factor prevalence data enabling a better understanding of the differences in these risk factors in relation to socio-economic status in three locations in PNG. The present study was undertaken during the construction phase of a large-scale gas development which was projected to more than double the gross domestic product (GDP) of PNG. The study was designed to provide baseline prevalence data on NCD risk factors in the initial years of a gas project impact site (West Hiri) and in two non-project impact sites (Asaro and Karkar Island). It was also anticipated that the study findings would provide up-to-date NCD risk factor prevalence data to help the national government plan services and develop cost-effective interventions. This thesis describes the methods used and presents the initial findings for NCD risk factors in a survey of three different socio-demographic populations of PNG. Methods The analysis of the data presented in the results sections of this thesis was based on the NCD Risk factor survey. The survey was a cross-sectional study of the prevalence of NCD risk factors across three different sites namely West Hiri in Central province, Asaro in Eastern Highlands province and Karkar Island in Madang province. A modified questionnaire based on the WHO STEPwise instrument was used for data collection. In addition, physical measurement and biochemical samples were collected from participants (Chapter 4). Results A total of 785 participants participated in the survey. The prevalence of NCD risk factors varied markedly different across the three sites. The metabolic risk factors such as obesity, elevated blood pressure, increased total cholesterol and HbA1c levels were higher in West Hiri compared to the other two sites (Chapter 5). Further analysis of the data was done to investigate the association between socio-economic status (SES), and the CVD risk factors. Findings show that elevated CVD risk factors were common among all SES groups, but metabolic risk factors were more prevalent among homemakers, peri-urban West Hiri and Asaro and among the highest quintile groups. Adults in the peri-urban West Hiri had higher risk of obesity, hypertension, abnormal lipids and elevated HbA1c. Similarly, Asaro adults had increased risk of central obesity, hypertension, elevated triglycerides and MetS compared to the residents of rural Karkar Island (Chapter 6). Conclusion The research reported in this thesis adds to our understanding of the associations between SES and CVD risk factors in a LMIC like PNG. Data from high income countries show a negative correlation with socio-economic status, however findings from our study showed the association between CVD risk factors and SES varied greatly depending on the type of SES measure used. Understanding these associations is important to inform the government to develop appropriate and effective prevention and control strategies. With this information at hand, the government would be able to make informed decisions and prioritize its prevention and control strategies targeting high risk populations or settings in the country.
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ItemMortality Patterns in Papua New Guinea( 2020)Abstract Introduction Little is known about mortality rates and cause of death (COD) patterns in Papua New Guinea (PNG), because there is a lack of high-quality mortality data. The use of demographic and statistical models which use no local data to estimate mortality has created much uncertainty about actual mortality and COD patterns in PNG. This thesis aims to address this knowledge gap by applying novel demographic and statistical methods to available local data to estimate all-cause mortality (adult mortality, child mortality and life expectancy) and COD by sex for PNG and each of its provinces. Methods A range of demographic and statistical methods were used to estimate mortality rates and COD patterns. The adult mortality rate (45q15) was estimated using the orphanhood method applied to data reported in the 2000 and 2011 national censuses. The under-five mortality rate (5q0) was calculated using the maternal age cohort method using summary birth history data from the 2000 and 2011 national censuses. The 45q15 and 5q0 estimates were entered into model life tables to produce estimates of life expectancy at birth. Cause-specific mortality fractions (CSMFs) were calculated as the average of estimates obtained from two methods: the empirical cause method and the expected cause patterns method. A composite index was constructed using the means of education, economic and health access indicators from various data sources to assess the plausibility of mortality and COD estimates. Results The 45q15 for PNG in 2011 was estimated as 269 per 1,000 for males and 237 per 1,000 for females with substantial inter-provincial variations in both sexes. The under-five mortality was estimated as 68 per 1,000 live births for males and 58 per 1,000 live births for females, and life expectancy was 62.0 years for males and 64.3 years for females. Provinces with a low composite index had comparatively high levels of 45q15 and 5q0, and low life expectancy for both sexes. Conversely, provinces with a higher composite index reported lower 45q15 and 5q0, and higher life expectancy. Both Infectious diseases and noncommunicable diseases (NCDs) accounted for 45% of the deaths each, with the former accounting for more than half the deaths in several provinces (e.g. Gulf and Sandaun). Provinces with higher CSMFs from emerging NCDs (e.g. ischaemic heart disease and stroke) were those in which socioeconomic status was comparatively high. Conclusion The major findings of this thesis are that adult mortality in PNG is relatively high compared with other low- and middle-income countries and that provincial variations in all-cause mortality and COD correlate with levels of development as measured by the composite index. The level of epidemiological transition is not uniform across the country with noncommunicable diseases emerging in provinces with higher levels of socioeconomic development. It is recommended that PNG urgently address the major causes of persistently high premature adult and child mortality and strengthen the collection of routine mortality and COD data through verbal autopsies to ensure the availability of reliable and timely data for policymakers to improve PNG’s population health.