A woman attends a family planning clinic at Port Moresby General Hospital. The weekly clinic is frequently full to capacity, seeing up to 80 women, and offers family planning advice and health screening including pap smears. Photo: Jo Chandler
- Port Moresby: The pop-up clinic rigged under the palm trees of Port Moresby’s Joyce Bay looks to be a rudimentary concoction of blue tarpaulins and tired tent frames.
Half a dozen young women queue outside on plastic chairs in the shade, outnumbered by their children. Toddlers play at their feet on another tarp stretched over the dirt.
Mothers and their children outside the Marie Stopes PNG reproductive health outreach clinic during a visit to Joyce Bay settlement, Port Moresby. Photo: Jo Chandler
A couple of guards keep unobtrusive watch behind a banner declaring that the Marie Stopes International reproductive health outreach team is on site. While clinic visits are mostly enthusiastically received, tensions around sex, gender and power can never be taken lightly in the volatile settlements.
Despite the challenging conditions, inside the tent nurse Joyce Kaman oversees a slick, sterile operation. Drapes, dressings, instruments and equipment are arranged according to protocols evolved to cope with extreme conditions and zero services. Under the adjoining canopy another nurse collects histories, counsels, and provides information on the contraceptive menu on offer – injections, the pill and the new fast-firming favourite, long-acting hormonal implants.
Though the transient clinic will be dismantled at the end of the day, there’s not much to distinguish it from many of the shanty homes in the surrounding precinct, where tin and scavenged timber are thriftily wrangled to accommodate the exploding population.
A Port Moresby mother and her newborn get a health check at the Port Moresby General Hospital weekly family planning clinic. Photo: Jo Chandler
Joyce Bay has no sewerage system servicing its best-guess 10,000 plus population, just pit toilets that overflow in the rainy season, with obvious health consequences. Clean water flows in some sectors but not all, and is often a mere trickle. There’s electric power available for those who can afford it or can wrangle illegal connections.
Once known as Horse Camp, this is one of the oldest of the sprawling settlement neighbourhoods that are home to nearly half of the Papua New Guinea capital’s 1 million people. In common with similar precincts, Joyce Bay’s population is spiralling upwards, according to a 2013 Asian Development Bank survey. It put the average household size at nine, but observed that often more than 15 people were sharing each dwelling.
Recent fieldwork by an Australian National University academic found that in a large proportion of these households the only income is from women selling food, soap, cigarettes and betel nut in residential markets. They juggle this around looking after their children, collecting firewood, and queuing for water. This is the daily reality for the women waiting their turn in the blue tent.
The weekly family planning clinic at Port Moresby General Hospital. The clinic is frequently full to capacity, seeing up to 80 women, and offers family planning advice and health screening including pap smears. Photo: Jo Chandler
Hani, 22, has two children, a girl and a boy, aged three and one. She and her husband have decided that two is enough for now. She came to the clinic last month for advice and now, having signed her consent, steps into the tent to have an implant inserted in her upper arm. This device offers up to four years of contraception if she keeps it.
She lies on a stretcher and nurse Kaman applies some local anaesthetic, but mostly relies on the tactics of chat and distract as her gloved hands move through the practiced routine. For a few seconds as she makes the incision Hani’s squirming feet point hard at the roof. Minutes later she’s happily on her way with a baby on each hip.
In Papua New Guinea the most reliable official maternal health statistics (now almost 10 years old) reported that 44 per cent of women like Hani – of fertile age and in a relationship – had an “unmet need” for contraception. The 2011 national census figures, published last year, put the birth rate at a staggering 3.1 per cent. The population is now estimated to be nudging 7.8 million, up 50 per cent from 5.2 million in 2000.
Mothers wait their turn to see a nurse at the Marie Stopes PNG reproductive health outreach clinic during a visit to Joyce Bay settlement, Port Moresby. Photo: Jo Chandler
The 2006 PNG national health survey revealed that maternal deaths in PNG were among the highest in the world, and that they had doubled in a decade to 733 per 100,000 births. Mostly this is due to the scarcity of health services across the nation’s vast, wild landscape. In rural areas – home to 80 per cent of the population – the lifetime risk of dying in pregnancy is one in 25, but even in urban areas like Joyce Bay it’s one in 35. In Australia the equivalent statistic is one in 9000.
According to the World Health Organisation, up to 40 per cent of maternal deaths could be eliminated if unplanned pregnancies were prevented. Deaths of infants, children, and rates of poverty and hunger would also decrease, the data shows, with benefits flowing into female education, empowerment and economic engagement.
In a nation like PNG the barriers to women gaining access to family planning remain formidable. As catalogued in a 2010 report to the PNG Government and development partners, they include remoteness; lack of roads, transport and infrastructure; a critical shortage of health workers: cultural taboos, complex ethnic diversity, religious restrictions (abortion is illegal), education, poverty, myths and misinformation, and women’s lack of status and political voice.
But in just the past year or two, outreach efforts like the Marie Stopes clinic, taking new contraceptive technologies out to where women live, appear to be gaining popularity and political support despite some powerful resistance.
?”Desperate for contraception”
Though she’s a seasoned specialist volunteer on women’s health programs in far-flung corners of PNG, Sydney gynaecologist Philippa Ramsay is always overwhelmed by the reception she gets on the ground. “These women are desperate for contraception” she says.
“They are often pregnant at 15, and having their fifth child at 25. The teenagers just want to finish school before they have children, and the women – subsistence farmers – don’t want more children.”
Dr Ramsay opens the clinics with an information session, often delivered to large gatherings under trees where the branches are weighed with bags of sleeping babies swinging in the breeze.
Lately she’s been delivering a program initiated by a Rotarian and grandmother from Salamander Bay, NSW, Wendy Stein, which has provided 28,000 women with long term contraceptive implants in PNG in the past two years. The Spacim Pikinini initiative – the objective is to allow women to space, delay or stop births – is supported by Rotary and private donors.
“Initially we offered IUDs (intrauterine devices) but they require a very intimate procedure, lots of sterile equipment, decent light and maybe 30 minutes per patient. The women didn’t like it, taking off their underpants and putting legs in stirrups for a stranger. And sterile supply is a problem where there is no power.”
Now the program only offers implants, which have proved both popular and practical. “Implants take away the fear factor. They can watch each other have the procedure,” says Ramsay. “We can do implants in villages with no power and no running water, and we might do 100 to 150 in a day.”
The Sino-Implant used by this program is made of two small rods that are placed under the skin and release small amounts of female hormone. They are cheap ($US10), effective for up to five years, and can be removed at any time.
“We’ve gone back and surveyed women on Karkar Island a year after the implants went in, and only two out of 860 wanted them removed.” One was a woman who wanted a baby sooner, the other preferred an alternative method.
Ramsay says she hasn’t encountered much negative feedback apart from the fears of some men that the implants would make their wives promiscuous. “There were some rumours going around that we were sent by the Devil. But most women don’t believe that. I showed them pictures of my daughter having her implant put in, and they thought that was great.”
But there’s strong opposition to implants programs amongst some religious leaders in the overwhelmingly Christian and largely Catholic nation. Last May the Catholic bishops of PNG placed a full-page advertisement in the national newspapers condemning the “growing political ideology that links development with population control … Hormonal implants are promoted and injected on a massive scale with little thought about the physical, emotional and social effects on young girls and women and on the community as a whole”. The bishops cautioned the government against “the consequences of tampering with nature in this way”.
The letter prompted a full-page response from Professor Glen Mola, University of PNG’s head of reproductive health, accusing the bishops of saying “emotional and unscientific things” about contraceptives of proven efficacy and safety. “The direct links between infant, child and maternal death and disability, and frequency and number of pregnancies, are indisputable.”
Professor Mola also argued that church health services that refused to provide modern family planning should hand back a portion of their government funding to subsidise alternative providers. It’s estimated that 20 to 25 per cent of the population live in areas serviced by Catholic health and therefore only have access to natural family planning.
In September PNG Prime Minister Peter O’Neill endorsed the use of implants in parliament and said that correcting misconceptions about contraception was vital for sustainable population growth and reducing maternal deaths.