Dr Patrick Koliwan has a decade of experience working in urban and rural areas in PNG and believes there’s a need for greater use of family planning and contraceptives. He says better education, improving community perceptions and embarking on national awareness campaigns would lift contraceptive use, and result in improved lives for younger women by managing pregnancy and childbirth. Dr Koliwan was a participant in the 2017 Australia-PNG Emerging Leaders Dialogue.
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I was 20 years old when I first assisted to deliver a baby as a medical student. I remember quite clearly the anxiety and the distress of it all. There was a lot of huffing and puffing along with the sweat and tears of uncertainty – which all came from me of course. The mother that was actually in the process of giving birth was quite calm and laboured efficiently through her contractions to produce a beautiful healthy baby boy. I on the other hand was a nervous wreck by the end of the whole event. Lucky for me I had three more years to get my nerves in order before I experienced my own metaphoric rebirth as a fully-fledged health worker in PNG.
I am thankfully much more confident in my abilities these days and have delivered hundreds of babies since that day over ten years ago. Many were delivered in the Port Moresby General Hospital Labour Ward, the biggest referral hospital in PNG. Some have been delivered in the back of ambulances on bumpy rural roads, some by flashlight in tiny dark village birth houses. I once delivered a baby in a precariously balanced dugout canoe by the side of a river as it broke its banks during a tropical downpour. Most of these babies have survived, some have not. Many of the mothers endured difficult, exhausting labours with life threatening complications such as obstruction, haemorrhagic shock, toxic septicaemia and anaemic heart failure. While it is impossible to remember every delivery, they have all given me special perspective and a small but greatly appreciated insight into what it means to be a woman in PNG.
Women in PNG are dealt a difficult hand even from birth and many are almost instantly burdened with the traditional responsibilities of Melanesian culture that accompany their gender. It is not rare to see young female children in the company of their mothers assisting in daily household chores, fetching water, collecting firewood and tending to gardens. Many families will keep female children at home to help with domestic duties, overlooking them for educational opportunities in favour of male children. It is not just their circumstances at birth that may negatively impact them; it is estimated that more than two thirds of women from all socioeconomic backgrounds in PNG will be a victim of family violence at some point in their lifetime. Indeed the staggering prevalence of violence towards women has become a staple backdrop in the international media portrayal of modern day PNG.
Midwives training at Pacific Adventist University PAU, outskirts of Port Moresby, PNG. Photo taken by Ness Kerton for AusAID/Flickr
It is considered that one of the most important roles of a woman within PNG society is the production and nurturing of children. It is an inevitable expectation of many Melanesian cultures that any woman in a long term relationship or marriage must raise a family. The combination of women’s poor social status, deeply embedded cultural values and a struggling health system, has resulted in an extremely high amount of births occurring outside the safety net of health worker supervision. About 50 percent of total births in PNG will occur without the presence of a qualified midwife. Health reporting can be erratic in PNG and in 2013 Professor of Obstetrics and Gynaecology Glen Mola proposed that the best estimate for PNG’s maternal mortality rate is that 545 women die per 100,000 live births every year. To put this in perspective, fewer than 10 women in Australia die per 100,000 live births each year.
Reducing maternal mortality has long been an integral part of PNG’s blueprint for national advancement and development. Aside from increasing the availability of quality maternal healthcare, one of the principal strategies for reducing maternal mortality is to prevent unplanned pregnancies through the use of safe and accessible family planning. According to the WHO, only a third of PNG women of reproductive age use any form of contraceptives.
While there are challenges with drug supply, I have been to many health centres in both urban and rural PNG where there were more than adequate stocks of contraceptives available but with very little clientele. Although national drug shortages do happen, contraceptive stocks are kept in relatively good supply by various international stakeholders. Contraceptives are available free of charge in most public and NGO run clinics in PNG and many will offer the full spectrum of choices from condoms to progesterone implants.
With reasonable access to contraceptives at minimal cost, this raises the question as to why two thirds of women in PNG are not actively using contraceptives. I have found in my experience that there are three main areas that affect the perception of contraceptive use in PNG.
Misinformation and hysteria are not uncommon in PNG and while some incidents make for good stories, some can be harmful to the community. A year ago there was a rumour in my village that there were crates of gold from World War Two buried in the middle of a neighbouring hamlet. It took less than 48 hours to assemble a dedicated digging team along with a gaggle of curious spectators from the surrounding villages. They dug for almost a week, varying their excavation sites and of course found nothing. There was a lot of commotion for a few days but it eventually settled down and village life returned to normal, aside from a few new craters in the tranquil landscape. It was a harmless hoax and everyone had a good laugh while the instigators of the rumour and the gold expedition leaders spent weeks lying low in order to avoid ridicule. While this is a comical example of the results of propagating misinformation, there are many mistruths that are applied to health interventions like vaccination that can be extraordinarily destructive to people and their communities. The ridiculous #antivaxxer movement in the west is one example. Thankfully this has not taken in PNG, where too many mothers know firsthand the devastation of deadly childhood disease epidemics. Vaccinating children is a priority for most families.
The use of contraceptives comes with its own set of myths. I have heard everything from “You won’t have any strength to work afterwards” to “It sucks all the blood out from your body”. When I first started inserting progesterone implants in Gulf Province in 2013 I had many complaints from nearby villages that I was inserting devices into women with the ‘mark of the beast’ – a symbol of the antichrist. Needless to say these rumours came from people who had not embraced family planning. The rising popularity of social media has become a dangerous vehicle for spreading misinformation like this and can have serious consequences, especially with the high numbers of young impressionable people in PNG that are active on platforms such as Facebook.
Unfortunately many health facilities will only provide basic education before diving into prescribing such an important health intervention. Without good quality education sessions, women may take their pills incorrectly, miss their Depo injections or panic at the sight of breakthrough bleeding from the implant. This leads to a dissatisfying experience with contraceptive use, they may tell others and the story propagates through the community in various wild iterations of escalating negativity. In the most extreme examples, this can even lead to threats on health workers in the community.
The remedy to the problem is to increase personal education and awareness. When it comes to prescribing contraceptives it requires comprehensive client education. A detailed history of sexual activity, good knowledge of the client’s menstrual cycle and their expectations of raising children will greatly guide a health worker's recommendations. What may work well for one woman may not necessarily work for another. Addressing any of the client’s concerns and the possible side effects is also very important as well as a plan of action, should the chosen contraceptive method be inappropriate. This takes time, a lot of time, and requires the client to have at the very least a basic understanding of the mechanisms of the female reproductive cycle – especially for hormonal forms of contraception. More than one session may need to be scheduled before the client is fully prepared to undertake family planning contraception. Good patient-health worker relationships are the foundations of a successful family planning program.
There are a lot of misconceptions about women using contraception within the community. It is acceptable to be married with children and be using contraception for family planning. However, it is frowned upon if you are a single or unmarried female actively seeking out contraceptives. There is a ludicrous local belief that unattached women that use any form of contraceptives are ‘pamuks’ (promiscuous) or they are sex workers. In December of 2015 a 20 year old woman was found to have a packet of condoms in her bag after a search by police in Port Moresby. She was escorted to the police station without charges and forced to eat two of the condoms under threat of imprisonment if she didn’t. The incident was filmed by one of the officers and has since gone viral on social media. There are unlikely to be any repercussions for the officers involved.
Young men and women see these stories and they hear what their community leaders say and it becomes a significant part of their formative informal education on reproductive health. It is extremely sad that children will carry these mistruths into adulthood and be completely unprepared for the onset of sexual maturity. While reproductive health is taught in the school system, it is often done incompletely or incorrectly, as it is a very small section of the health syllabus. The UN Population Fund aims to improve this by implementing quality sex education in PNG schools. At the clinic where I practice in urban Port Moresby, I have found that many young women who present with unplanned first time pregnancies had little formal knowledge about family planning despite completing high school.
The role of the church also has a huge hand to play in the community perception of family planning. The majority of PNG citizens identify as Christians and their religious affiliation can greatly affect their choices in contraception. While the Catholic Church has well documented views on family planning, there are many other churches that have more progressive approaches to contraception and include it as part of their core health services.
Changing community perception takes a long time, especially with regards to sensitive cultural issues such as reproductive health. A collaborative, concentrated effort is needed combining churches, health facilities and schools as well as community health programs to bring the education and awareness to the people. A difficult task but not one I believe is impossible.
National promotion of the family planning message
The message behind family planning is an important one, however there are some serious flaws in the way the message is being promoted at a national level. The focus of the family planning message seems to be on the act of reproduction itself and its outcomes - and the target audience seems to be almost exclusively women. There is a recurring theme when you look at the promotional material that is given out in family health clinics, they almost always feature women and their babies. As a result it is very rare to see men turn up with their children for immunization day or accompany their partners to their family planning or antenatal appointments. Indirectly the message reinforces the narrative that reproductive and family health in PNG is strictly women’s business.
There are so many other dimensions to the concept of family planning that are worth promoting. Family planning allows young people to complete their education to the best of their abilities and opens up opportunities for further study beyond high school. It allows them to be exposed to formal employment and explore the job market before settling on a career. Well-planned families are able to better budget the household income with a modicum of financial control. Children from well-planned families have better educational opportunities and they are healthier. Women with adequately spaced pregnancies are less likely to become victims of maternal morbidity.
It is equally important to engage men in the promotion of reproductive health awareness as well. Men and women who are well informed about their bodies are more likely to make healthy and responsible decisions when it comes to sex. This is key to breaking the cultural taboo which prevents our society from openly talking about safe sexual choices. Support from a partner is absolutely essential for the success of any type of contraceptive use and it may also strengthen the emotional connection between partners, allowing them to speak freely about a host of other issues and reducing the potential for gender-based violence.
Those are the messages that I like to promote in my own practice in order to broaden the potential target audience for contraceptive use, and change the perception of what family planning and contraception are all about. In fact many times I refrain from using the term ‘family planning’ in favour of the term ‘life planning’ which I feel is more appropriate for young people. While there are indeed tough times ahead for this country, I am optimistic that Papua New Guinea has a bright future if we are able to effectively manage our most precious resource – our people, for a healthy, happy and vibrant population.