Background: Immunization coverage varies across Papua New Guinea. In East New Britain (ENB) Province in 2022, only 65.5% and 50.2% of children under one year received their first dose of pentavalent (DTP1) and measles–rubella (MR1) vaccine, respectively. This study aimed to examine barriers and enablers to routine immunization in areas of un(der)-vaccination in ENB. Methods: A face-to-face survey was conducted with caregivers of children aged 12–23 months in ENB. We used Poisson regression to calculate incidence rate ratios (IRR) and 95% confidence intervals (95% CI) for factors associated with timely receipt of DTP1 or MR1 vaccines, defined as a child who was vaccinated between –2 and +30 days of the vaccine schedule. Delayed receipt is defined as a child who was vaccinated >30 days from the recommended due date. Results: Among 237 caregivers surveyed, 59.9% of children were vaccinated within the “timely” window for DTP1 and 34.1% for MR1. Timely DTP1 receipt was associated with a facility-based birth (IRR:1.93; 95% CI: 1.10–3.38) and trusting healthcare workers “very much”, compared to “a little or moderately” (IRR:1.53; 95% CI: 1.17–1.99). For MR1, the caregiver having completed tertiary/vocational education (IRR:1.79; 95% CI: 1.15–2.78), reporting taking a child to be vaccinated is affordable (IRR:1.52; 95% CI: 1.04–2.22), and healthcare workers explaining immunization services and answering associated questions (IRR:1.68; 95% CI: 1.18–2.41) were associated with timely vaccination. Conclusions: Activities to improve timely vaccination in ENB could include strengthening healthcare worker interpersonal communication skills to optimize trust and incentivizing women to give birth in a health facility.

BACKGROUND:Mycoplasma genitalium infection in pregnancy is increasingly reported at similar frequencies to other sexually transmitted infections (STIs). Knowledge on its contribution to adverse pregnancy outcomes is very limited, especially relative to other STIs or bacterial vaginosis (BV). Whether M. genitalium influences birthweight remains unanswered. METHODS:Associations between birthweight and M. genitalium and other STIs (Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis) and BV in pregnancy were examined in 416 maternal-newborn pairs from a prospective cohort study in Papua New Guinea. FINDINGS:Compared to uninfected women, M. genitalium (-166.9 g, 95% confidence interval [CI]: -324.2 to -9.7 g, p = 0.038) and N. gonorrhoeae (-274.7 g, 95% CI: -561.9 to 12.5 g, p = 0.061) infections were associated with lower birthweight in an adjusted analysis. The association for C. trachomatis was less clear, and T. vaginalis and BV were not associated with lower birthweight. STI prevalence was high for M. genitalium (13.9%), N. gonorrhoeae (5.0%), and C. trachomatis (20.0%); co-infections were frequent. Larger effect sizes on birthweight occurred with co-infections of M. genitalium, N. gonorrhoeae, and/or C. trachomatis. CONCLUSION:M. genitalium is a potential contributor to lower birthweight, and co-infections appear to have a greater negative impact on birthweight. Trials examining the impact of early diagnosis and treatment of M. genitalium and other STIs in pregnancy and preconception are urgently needed. FUNDING:Funding was received from philanthropic grants, the National Health and Medical Research Council, and the Burnet Institute. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Quality maternal and newborn healthcare is essential to improve experiences and health outcomes for mothers and babies. In many low to middle income countries, such as Papua New Guinea, there are initiatives to increase antenatal care attendance and facility births. To develop and implement initiatives that are appropriate, relevant, and contextualised to a community, it is important to understand how quality of care is perceived and defined by different maternal and newborn healthcare stakeholders. The aim of this study was to understand how women, their partners, healthcare professionals, healthcare managers, and provincial health administrators in East New Britain, Papua New Guinea define quality of pregnancy, childbirth, and immediate postnatal care. An exploratory qualitative study underpinned by a partnership-defined quality approach was undertaken. In total, 42 participants from five different healthcare facilities in East New Britain, Papua New Guinea, were interviewed. These included women, partners, healthcare professionals, healthcare managers, and provincial health administrators. Interviews were analysed using thematic analysis, assisted by NVivo computer software. Four themes were identified aligning with the journey a woman takes throughout the health system. These included (I) Ensuring Access: Arriving at the health centre, (II) Experiencing Positive Care: What the staff do, (III) Having the Bare Minimum: Resources available to the service, and (IV) Meeting Expectations: Outcomes of care. Stakeholder groups had significant overlap in how quality of care was defined, however women and partners focussed more on elements relating to experience of care, while clinical stakeholders focussed on elements relating to provision of care. There is a gap in how stakeholders define quality maternal and newborn healthcare, and the quality of the care which is administered and received.

Background Globally, 2.5 million babies die in the first 28 days of life each year with most of these deaths occurring in low- and middle-income countries. Early recognition of newborn danger signs is important in prompting timely care seeking behaviour. Little is known about women’s knowledge of newborn danger signs in Papua New Guinea. This study aims to assess this knowledge gap among a cohort of women in East New Britain Province. Methods This study assessed knowledge of newborn danger signs (as defined by the World Health Organization) at three time points from a prospective cohort study of women in East New Britain Province, factors associated with knowledge of danger signs after childbirth were assessed using logistic regression. This study includes quantitative and qualitative interview data from 699 pregnant women enrolled at their first antenatal clinic visit, followed up after childbirth ( n = 638) and again at one-month post-partum ( n = 599). Results Knowledge of newborn danger signs was very low. Among the 638 women, only 9.4% knew three newborn danger signs after childbirth and only one knew all four essential danger signs defined by Johns Hopkins University ‘Birth Preparedness and Complication Readiness’ Index. Higher knowledge scores were associated with higher gravidity, income level, partner involvement in antenatal care, and education. Conclusion Low levels of knowledge of newborn danger signs among pregnant women are a potential obstacle to timely care-seeking in rural Papua New Guinea. Antenatal and postnatal education, and policies that support enhanced education and decision-making powers for women and their families, are urgently needed.

Pregnant women in resource-limited settings are highly susceptible to anemia and iron deficiency, but the etiology of postpartum anemia remains poorly defined. To inform the optimal timing for anemia interventions, changes in iron deficiency-attributable anemia through pregnancy and postpartum need to be understood. In 699 pregnant Papua New Guinean women attending their first antenatal care appointment and following up at birth and 6 and 12 months postpartum, we undertake logistic mixed-effects modeling to determine the effect of iron deficiency on anemia and population attributable fractions, calculated from odds ratios, to quantify the contribution of iron deficiency to anemia. Anemia is highly prevalent during pregnancy and 12 months post-partum, with iron deficiency increasing the odds of anemia during pregnancy and, to a lesser extent, postpartum. Iron deficiency accounts for R72% of anemia during pregnancy and 20%-37% postpartum. Early iron supplementation during and between pregnancies could break the cycle of chronic anemia in women of reproductive age.

Most stillbirths (84%) occur in low- and middle-income countries. Recognising maternal danger signs with timely care-seeking and attendance at the health facility could help to reduce the risk of stillbirth. Earlier work conducted by our group in Papua New Guinea (PNG) identified high rates of stillbirth and early neonatal deaths with contributing factors including women having a lack of knowledge of pregnancy related danger signs. In this community-based study we will conduct focus group discussions and individual interviews among pregnant and non-pregnant women, community members (including men, community leaders and elders) and health care workers who provide maternity care in two sites in PNG. We seek to explore the knowledge, attitudes and practices in relation to maternal and newborn danger signs among women and their communities. We will work with collaborators and partners to develop culturally appropriate key health messages and a program to embed these within a birth preparedness and complications readiness program to be implemented in a wider study in PNG and across the Asia-Pacific region. We will identify and present results relating to key themes, including knowledge and awareness of danger signs (reduced fetal movements, premature rupture of membranes) in pregnancy and sleep positions of pregnant women. We will present an outline of key messages to be included within culturally appropriate education and information materials and forums. The design of locally-produced, culturally appropriate messages that can be delivered easily and equitably to communities will improve outcomes for pregnant women and their newborn.

Quality maternal and newborn care is essential for improving the health of mothers and babies. Low- and middle-income countries, such as Papua New Guinea (PNG), face many barriers to achieving quality care for all. Efforts to improve the quality of maternal and newborn care must involve community in the design, implementation, and evaluation of initiatives to ensure that interventions are appropriate and relevant for the target community. We aimed to describe community members’ perspectives and experiences of maternal and newborn care, and their ideas for improvement in one province, East New Britain, in PNG. We undertook a qualitative descriptive study in partnership with and alongside five local health facilities, health care workers and community members, using a Partnership Defined Quality Approach. We conducted ten focus group discussions with 68 community members (identified through church, market and other community-based groups) in East New Britain PNG to explore perspectives and experiences of maternal and newborn care, identify enablers and barriers to quality care and interventions to improve care. Discussions were transcribed verbatim. A mixed inductive and deductive analysis was conducted including application of the World Health Organisation (WHO) Quality Maternal and Newborn Care framework. Using the WHO framework, we present the findings in accordance with the five experience of care domains. We found that the community reported multiple challenges in accessing care and facilities were described as under-staffed and under resourced. Community members emphasised the importance of good communication and competent, caring and respectful healthcare workers. Both women and men expressed a strong desire for companionship during labor and birth. Several changes were suggested by the community that could immediately improve the quality of care. Community perspectives and experiences are critical for informing effective and sustainable interventions to improve the quality of maternal and newborn care and increasing facility-based births in PNG. A greater understanding of the care experience as a key component of quality care is needed and any quality improvement initiatives must include the user experience as a key outcome measure. Improving the care provided to, and experienced by, women and their families during pregnancy and childbirth is important for improving the health of mothers and babies. Community members should be involved in thinking about appropriate ways to improve care. Papua New Guinea (PNG) is a country in the Pacific which faces multiple challenges to improving care during pregnancy and birth. We aimed to understand what community members think about care provided and experienced during labour and birth in East New Britain, a rural province of PNG. We worked with five health facilities, health workers and community members in East New Britain to develop a qualitative research project. We carried out 10 focus group discussions with community members in East New Britain to understand what the provision and experience of care was like during labour and birth, and ways that it could be improved. We found that community members identified multiple challenges in getting to facilities and many facilities were found to have not enough supplies, equipment, or staff. Community members wanted staff that were good at their work but also caring and respectful. Women wanted to have support people present during labour and birth and many men wanted to be present too. Our results show that it is important to understand what the community thinks about the quality of care during labour and birth and this information is helpful to design effective activities to improve the care provided and experienced.

Companionship during labour and birth is a critical component of quality maternal and newborn care, resulting in improved care experiences and better birth outcomes. Little is known about the preferences and experiences of companionship in Papua New Guinea (PNG), and how it can be implemented in a culturally appropriate way. The aim of this study was to describe perspectives and experiences of women, their partners and health providers regarding labour and birth companionship, identify enablers and barriers and develop a framework for implementing this intervention in PNG health facilities. A mixed methods study was conducted with five facilities in East New Britain, PNG. Data included 5 facility audits, 30 labour observations and 29 in-depth interviews with women who had recently given birth, partners and maternity care providers. A conceptual framework was developed drawing on existing quality care implementation frameworks. Women and partners wanted companions to be present, whilst health providers had mixed views. Participants described benefits of companionship including encouragement and physical support for women, better communication and advocacy, improved labour outcomes and assistance with workforce issues. Adequate privacy and space constraints were highlighted as key barriers to address. Of the women observed, only 30% of women had a companion present during labour, and 10% had a companion at birth. A conceptual framework was used to highlight the interconnected inputs required at community, facility and provincial health system levels to improve the quality of care. Key elements to address included attitudes towards companionship, the need for education and training and restrictive hospital policies. Supporting women to have their companion of choice present during labour and birth is critical to improving women's experiences of care and improving the quality of maternal and newborn care. In order to provide companionship during labour and birth in PNG, a complex, intersecting, multi-faceted approach is required.

BACKGROUND:Renewed attention and investment is needed to improve the quality of care during the early newborn period to address preventable newborn deaths and stillbirths in Papua New Guinea (PNG). We aimed to assess early newborn care practices and identify opportunities for improvement in one province (East New Britain) in PNG.METHODS:A mixed-methods study was undertaken in five rural health facilities in the province using a combination of facility audits, labour observations and qualitative interviews with women and maternity providers. Data collection took place between September 2019 and February 2020. Quantitative data were analysed descriptively, whilst qualitative data were analysed using content analysis. Data were triangulated by data source.RESULTS:Five facility audits, 30 labour observations (in four of the facilities), and interviews with 13 women and eight health providers were conducted to examine early newborn care practices. We found a perinatal mortality rate of 32.2 perinatal deaths per 1000 total births and several barriers to quality newborn care, including an insufficient workforce, critical infrastructure and utility constraints, and limited availability of essential newborn medicines and equipment. Most newborns received at least one essential newborn care practice in the first hour of life, such as immediate and thorough drying (97%).CONCLUSIONS:We observed high rates of essential newborn care practices including immediate skin-to-skin and delayed cord clamping. We also identified multiple barriers to improving the quality of newborn care in East New Britain, PNG. These findings can inform the development of effective interventions to improve the quality of newborn care. Further, this study demonstrates that multi-faceted programs that include increased investment in the health workforce, education and training, and availability of essential equipment, medicines, and supplies are required to improve newborn outcomes.

Much about the range of pathogens, frequency of coinfection, and clinical effects of reproductive tract infections (RTIs) among pregnant women remains unknown. We report on RTIs (Mycoplasma genitalium, Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, Treponema pallidum subspecies pallidum, bacterial vaginosis, and vulvovaginal candidiasis) and other reproductive health indicators in 699 pregnant women in Papua New Guinea during 2015-2017. We found M. genitalium, an emerging pathogen in Papua New Guinea, in 12.5% of participants. These infections showed no evidence of macrolide resistance. In total, 74.1% of pregnant women had >= 1 RTI; most of these infections were treatable. We detected sexually transmitted infections (excluding syphilis) in 37.7% of women. Our findings showed that syndromic management of infections is greatly inadequate. In total, 98.4% of women had never used barrier contraception. These findings will inform efforts to improve reproductive healthcare in Papua New Guinea.

There is a pressing need for detailed knowledge of the range of pathogens, extent of co-infection and clinical impact of reproductive tract infections (RTIs) among pregnant women. We present prevalence and correlates of RTIs (Mycoplasma genitalium, Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, Treponema pallidum subspecies pallidum, bacterial vaginosis and vulvovaginal candidiasis) in a longitudinal study of women in pregnancy and postpartum in Papua New Guinea (PNG). 699 pregnant women were recruited at their first antenatal clinic visit and followed up at childbirth, one, six and twelve months postpartum. Self-collected vaginal swabs were tested for M.genitalium using real-time PlexPCR® (SpeeDx) which provides results for five point mutations associated with macrolide resistance. Urine samples or vaginal swabs were tested for C.trachomatis, N.gonorrhoea and T.vaginalis using GeneXpert. A vaginal smear was examined for BV and VVC. Routine antenatal services tested for syphilis using Alere DetermineTM Syphilis. Most pregnant women (74.1%) had at least one RTI, with a curable current sexually-transmitted infection (STI) detected in 37.7%. We found M. genitalium, an emerging pathogen in PNG, in 12.5% of pregnant women, decreasing to 6.1% at six months postpartum, with no evidence of macrolide resistance. Prevalence of other curable STIs (C. trachomatis, N. gonorrhoeae and T. vaginalis) were all high in in pregnancy (19.1%, 5.5% and 20.1% respectively), with prevalence decreasing immediately postpartum but rising again by 12 months postpartum. Clinical symptoms missed at least 75% of infections and there was little use of contraception; 98.4% report never having used barrier contraception. This study highlights a high prevalence of a RTIs in pregnancy and postpartum. Most of these infections are curable when diagnosis is made available and syndromic management alone is insufficient. This high prevalence of disease negatively affects sexual and reproductive health and these findings have important public health implications in PNG and the region.

Unintended pregnancy is a major driver of poor maternal and child health in resource-limited settings. Data on pregnancy intention and use of family planning (FP) is scarce in Papua New Guinea (PNG), but are needed to inform public health strategies to improve FP accessibility and uptake. Data from a facility-based cross-sectional sample of 699 pregnant women assessed prevalence and predictors of unintended pregnancy and modern FP use among pregnant women in East New Britain Province, PNG. More than half (55%) the women reported their pregnancy as unintended. Few (18%) reported ever having used a modern FP method, and knowledge of different methods was low. Being single, separated or divorced (AOR 9.66; 95% CI 3.27–28.54), educated to a tertiary or vocational level (AOR 1.78 CI 1.15–2.73), and gravidity > 1 (AOR 1.43 for each additional pregnancy CI 1.29–1.59) were associated with unintended pregnancy; being accompanied by a male partner to ANC was associated with a reduced unintended pregnancy (0.46 CI 0.30–0.73). Factors associated with modern FP use included male partner involvement (AOR 2.26 CI 1.39–3.67) and gravidity > 1 (AOR 1.54 for each additional pregnancy CI 1.36–1.74). FP use also varied by the facility women attended. Findings highlight an urgent need for targeted interventions to improve FP knowledge, uptake and access, and male partner involvement, to reduce unintended pregnancies and their complications.

ABSTRACT There is a pressing need for detailed knowledge of the range of pathogens, extent of co-infection and clinical impact of reproductive tract infections (RTIs) among pregnant women. Here, we report on RTIs ( Mycoplasma genitalium, Chlamydia trachomatis , Neisseria gonorrhoeae , Trichomonas vaginalis , Treponema pallidum subspecies pallidum, bacterial vaginosis and vulvovaginal candidiasis) and other sexual and reproductive health indicators among 699 pregnant women in Papua New Guinea (PNG). We found widespread M. genitalium infection (12.5% of women), the first time this pathogen has been reported in PNG, with no evidence of macrolide resistance. Most pregnant women (76.2%) had at least one RTI, most of which are treatable. Excluding syphilis, sexually-transmitted infections were detected in 37.8% women. Syndromic management of infections is greatly inadequate and there was remarkably little use of contraception; 98.4% report never having used barrier contraception. This work has implications for improving maternal and child health in PNG. ARTICLE SUMMARY LINE This first report of Mycoplasma genitalium in Papua New Guinea finds a high burden (12.5%) among 699 pregnant women. Additionally, more than one in two women were positive for a treatable reproductive tract infection associated with poor health outcomes.

Background Routine immunization programs face many challenges in settings such as Papua New Guinea with dispersed rural populations, rugged geography and limited resources for transport and health. Low routine coverage contributes to disease outbreaks such as measles and the polio that re-appeared in 2018. We report on an in-depth local assessment that aimed to document immunization service provision so as to review a new national strategy, and consider how routine immunization could be better strengthened. Methods In East New Britain Province, over 2016 and 17, we carried out a cross-sectional assessment of 12 rural health facilities, staff and clients. The study was timed to follow implementation of a new national strategy for strengthening routine immunization. We used interview, structured observation, and records review, informed by theory-based evaluation, a World Health Organization quality checklist, and other health services research tools. Results We documented strengths and weaknesses across six categories of program performance relevant to national immunization strategy and global standards. We found an immunization service with an operational level of staff, equipment and procedures in place; but one that could reach only half to two thirds of its target population. Stronger routine services require improvement in: understanding of population catchments, tracking the unvaccinated, reach and efficiency of outreach visits, staff knowledge of vaccination at birth and beyond the first year of life, handling of multi-dose vials, and engagement of community members. Many local suggestions to enhance national plans, included more reliable on-demand services, integration of other family health services and increased involvement of men. Conclusions The national strategy addresses most local gaps, but implementation and resourcing requires greater commitment. Long-term strengthening requires a major increase in centrally-allocated resources, however there are immediate locally feasible steps within current resources that could boost coverage and quality of routine immunization especially through better population-based local planning, and stronger community engagement. Our results also suggest areas where vaccination campaigns in PNG can contribute to routine immunization services.