Unsafe abortion and unsupervised births: understanding the challenges of pregnancy and childbirth in the rural highlands of Papua New Guinea

Abstract

INTRODUCTION Papua New Guinea (PNG) has one of the highest maternal mortality ratios in the world. Postpartum haemorrhage is the leading cause of maternal death, followed by sepsis related to childbirth and unsafe abortion, the same reasons as identified in other low-resource settings. PNG has a high rate of unsupervised births, with an estimated 60% of women giving birth unsupervised. Focussing on the leading causes of maternal mortality, the overall aim of this thesis is to describe women’s perceptions and experiences of pregnancy and childbirth from one setting in the Eastern Highlands of PNG; and to describe a community-based intervention to improve maternal health outcomes. This thesis comprises of three studies, divided into two themes: (1) unsafe abortion; and (2) community perceptions and experiences of pregnancy and childbirth. METHODS Theme One: Unsafe abortion Through a mixed methods approach, a six month prospective study was undertaken at the Eastern Highlands Provincial Hospital. Women admitted to hospital following both spontaneous and induced abortion were identified through the review of medical records. Clinical and socio-demographic data were captured using a study-specific case note record form. Semi structured and in-depth interviews were undertaken to provide further insight into women’s experiences following induced abortion. Health care workers perceptions relating to abortion were also explored. Theme Two: Community experiences and perceptions of pregnancy and childbirth Two studies were included in theme two. Both took place in the remote, rural area of Unggai Bena district, Eastern Highlands Province, an area with a high rate of unsupervised births. The first of these two studies used qualitative methods to identify knowledge, perceptions and experiences of pregnancy and childbirth. Focus group discussions, undertaken with men and women in the community, were followed by in depth interviews. During the in depth women’s personal experiences relating to pregnancy and childbirth, especially their reasons for giving birth outside a formal health facility, were explored. The second study was designed following the findings from the first study. Through a community based intervention study, communities in the study site were provided with key messages relating to the importance of supervised, health facility births and recognising postpartum haemorrhage. Women attending antenatal clinic were invited to participate in a prospective study. After individual instruction 200 women were enrolled and provided with a clean birth kit which included 600mcg of misoprostol (a drug for reducing postpartum haemorrhage), for oral self-administration following an unsupervised birth. All women were followed-up postpartum when data relating to the acceptability of the intervention were collected using a study specific semi-structured questionnaire. All qualitative data were analysed through a content analysis approach using continuous comparison. All qualitative data were managed using NVivo v.9 (QSL International 2010), a qualitative software data package. Quantitative data were analysed using STATA v10.0 or v12.1 (StataCorp Ltd, TX, USA). FINDINGS Theme One: Unsafe abortion Unsafe abortion to end an unwanted pregnancy resulting in severe, acute morbidity was identified among young women presenting to the Eastern Highlands Provincial Hospital. Compared to those women who presented following a spontaneous abortion, those presenting following an induced abortion were significantly more likely to be younger, unmarried and a student (either at school or university). Obtained illegally, misoprostol was the most frequently used method to end pregnancy. Theme Two: Community experiences and perceptions of pregnancy and childbirth. Despite knowledge relating to complications that can occur during childbirth, many women continued to give birth, unsupervised in the community. Women faced numerous challenges in accessing care, particularly during childbirth. The implementation of a community-based package of interventions, providing clean birth kits and misoprostol for self-administration was feasible and highly acceptable in this setting. Through review of the findings identified in this thesis, one key factor emerged that influenced maternal health outcomes: access to health care. This key factor underpins the uptake of appropriate health care for two vulnerable groups of women: women with poorly timed pregnancies; and women during pregnancy and childbirth. CONCLUSION In the absence of safe abortion services, women are putting their lives at risk to end an unwanted pregnancy. Their lives are put further at risk from delayed health care seeking due to fear of repercussions from their family, health care workers and the legal framework surrounding abortion. Improved access to safe abortion services together with the review of post abortion care services in PNG could help in reducing the burden of maternal mortality and morbidity from unsafe, induced abortions. Constrained by numerous socio-cultural and geographical barriers and a deteriorating and poorly functioning health system, women continue to give birth unsupervised in the community. Identifying and providing appropriate community-based strategies may provide a short term solution to improve maternal health outcomes in remote, rural settings.