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John W Bolnga

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John W Bolnga is a senior specialist Obstetrician and Head of Obstetrics and Gynecology services at the Madang Provincial Health Authority,Madang which is a busy teaching hospital in Papua New Guinea. As Professor of O&G at the Divine Word University and Honorary lecturer and external examiner with the School of Medicine and Health sciences with the University of Papua New Guinea, he does lots of teachings, supervisory roles for Doctors,midwives,HEO's,paramedics,general nurses and also heads a small but vibrant clinical research unit. His area of interest is in clinical research in resource limited settings, leading to implementation and policy changes. As a senior clinical reserach fellow with PNG Institute of Medical Research and established researcher,he collaborates widely internationally and locally and has won many prizes ,awards, scholarships and also research grants individually and with collaborations with national and international institutions.He continues to contribute as a reviewer to many international peer reviewed journals and academic supervisory roles.

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Middle East Technical University

Joao Paulo Papa

Universidade Estadual Paulista "Júlio de Mesquita Filho"

University of California, San Diego

Cesar Perez Rodriguez

Anadolu University

Saúl Domínguez-Isidro

Universidad Veracruzana

Elibeth Rascón

Universidad Tecnologica de Cancún

Universidade de Brasília - UnB

T. Mavromoustakos

National & Kapodistrian University of Athens

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Papers by John W Bolnga

Acceptability and sustainability of a point-of-care HPV ‘self-collect, screen-and-treat’ for cervical cancer prevention in Papua New Guinea: A qualitative exploration of key informants’ perspectives

medRxiv (Cold Spring Harbor Laboratory), Sep 27, 2023

Maternal Near-misses at a Provincial Hospital in Papua New Guinea: A Prospective Observational Study

Obstetric Anesthesia Digest, Sep 1, 2018

Background: Maternal near-miss indices are World Health Organisation (WHO) recognised indicators ... more Background: Maternal near-miss indices are World Health Organisation (WHO) recognised indicators that may improve our understanding of factors associated with maternal morbidity and mortality. In Papua New Guinea (PNG) where maternal mortality is among the highest in the world, only one study has documented near-miss indices in a tertiary-level hospital, but none from provincial hospitals where the majority of underprivileged women access healthcare services. Aims: To determine the near-miss ratio, maternal mortality index (MMI), and associated maternal indices for Modilon Hospital in Madang Province of PNG. Methods: All women attending Modilon Hospital who met the WHO maternal near-miss definition and/or a WHO-modified (PNG-specific) near-miss definition, were prospectively enrolled. Results: There were 6019 live births during the audit period; 163 women presented with life-threatening conditions (153 near-misses and 10 maternal deaths). The maternal near-miss ratio was 25.4/1000 live births and the maternal mortality ratio (MMR) was 166/100 000 live births, with a maternal death to near-miss ratio of 1:15.3. The severe maternal outcome ratio was 27.1/1000 live births and the total mortality index was 6.8%. Higher proportions of near-miss women were aged ≥30 years, nulliparous, illiterate, from rural communities, lacked formal employment, referred from peripheral health facilities, unbooked, had history of still births and were anaemic. Conclusion: Sociodemographic factors such as women's rights, education level and status in society, in addition to appropriate health reforms with greater financial and political support are urgently needed to ensure underprivileged women in rural PNG have access to family planning, supervised deliveries and skilled emergency obstetric care.

Improving maternal and newborn health and reducing stillbirths in the Western Pacific Region – current situation and the way forward

The Lancet Regional Health - Western Pacific, Mar 1, 2023

Effects of Plasmodium falciparum infection on umbilical artery resistance and intrafetal blood flow distribution: a Doppler ultrasound study from Papua New Guinea

Malaria Journal, Jan 19, 2017

Background: Doppler velocimetry studies of umbilical artery (UA) and middle cerebral artery (MCA)... more Background: Doppler velocimetry studies of umbilical artery (UA) and middle cerebral artery (MCA) flow help to determine the presence and severity of fetal growth restriction. Increased UA resistance and reduced MCA pulsatility may indicate increased placental resistance and intrafetal blood flow redistribution. Malaria causes low birth weight and fetal growth restriction, but few studies have assessed its effects on uteroplacental and fetoplacental blood flow. Methods: Colour-pulsed Doppler ultrasound was used to assess UA and MCA flow in 396 Papua New Guinean singleton fetuses. Abnormal flow was defined as an UA resistance index above the 90th centile, and/or a MCA pulsatility index and cerebroplacental ratio (ratio of MCA and UA pulsatility index) below the 10th centile of population-specific models fitted to the data. Associations between malaria (peripheral infection prior to and at ultrasound examination, and any gestational infection, i.e., 'exposure') and abnormal flow, and between abnormal flow and birth outcomes, were estimated. Results: Of 78 malaria infection episodes detected before or at the ultrasound visit, 62 (79.5%) were Plasmodium falciparum (34 sub-microscopic infections), and 16 were Plasmodium vivax. Plasmodium falciparum infection before or at Doppler measurement was associated with increased UA resistance (adjusted odds ratio (aOR) 2.3 95% CI 1.0-5.2, P = 0.047). When assessed by 'exposure' , P. falciparum infection was significantly associated with increased UA resistance (all infections: 2.4, 1.1-4.9, P = 0.024; sub-microscopic infections 2.6, 1.0-6.6, P = 0.051) and a reduced MCA pulsatility index (all infections: 2.6, 1.2-5.3, P = 0.012; sub-microscopic infections: 2.8, 1.1-7.5, P = 0.035). Sub-microscopic P. falciparum infections were additionally associated with a reduced cerebroplacental ratio (3.64, 1.22-10.88, P = 0.021). There were too few P. vivax infections to draw robust conclusions. An increased UA resistance index was associated with histological evidence of placental malaria (5.1, 2.3-10.9, P < 0.001; sensitivity 0.26, specificity 0.93). A low cerebroplacental Doppler ratio was associated with concurrently measuring small-for-gestational-age, and with low birth weight. Discussion/conclusion: Both microscopic and sub-microscopic P. falciparum infections impair fetoplacental and intrafetal flow, at least temporarily. Increased UA resistance has high specificity but low sensitivity for the detection of placental infection. These findings suggest that interventions to protect the fetus should clear and prevent both microscopic and sub-microscopic malarial infections.

Maternal and newborn health indicators in Papua New Guinea – 2008–2018

Sexual and reproductive health matters, 2019

Papua New Guinea (PNG) is the most populous country in the Pacific with more than 9 million peopl... more Papua New Guinea (PNG) is the most populous country in the Pacific with more than 9 million people. Difficult terrain, poor roads and limited infrastructure mean providing effective health careespecially in rural areas, where most people liveis challenging. Women and newborns in PNG experience high rates of preventable morbidity and mortality; however, reliable data are often limited or unavailable. The aim of this paper is to provide an overview of research on key maternal and neonatal health (MNH) indicators conducted approximately over the past 11 years in PNG comparing research findings to global MNH estimates of the indicators. There was considerable variation in mortality indicators (maternal mortality ratio, neonatal mortality rate and stillbirth) reported across studies in PNG. Mortality was generally higher in rural areas. Rates of sexually transmitted infections (STIs) in pregnancy were consistently high, while anaemia in pregnancy, preterm birth and low birth weight varied widely between studies and settings. Breastfeeding seems to have been under-researched. There was a lack of data available on other indicators such as the adolescent birth rate, postnatal care provided to women and newborns, intermittent preventative treatment to prevent malaria in pregnancy and treatment to prevent mother-to-child transmission of HIV. Studies demonstrate the high burden of preventable maternal and newborn morbidity and mortality across PNG. Efforts to improve MNH outcomes need to be escalated.

Point-of-care testing and treatment of sexually transmitted infections to improve birth outcomes in high-burden, low-income settings: Study protocol for a cluster randomized crossover trial (the WANTAIM Trial, Papua New Guinea)

Wellcome open research, Nov 20, 2019

Background: Chlamydia trachomatis Neisseria gonorrhoeae and bacterial vaginosis have been associa... more

Twelve month follow-up of a contraceptive implant outreach service in rural Papua New Guinea

Australian & New Zealand Journal of Obstetrics & Gynaecology, Apr 1, 2017

Background: Poor access to contraception contributes to persistently high maternal mortality rate... more Background: Poor access to contraception contributes to persistently high maternal mortality rates in Papua New Guinea (PNG). Since 2012 contraceptive implants have been provided to women in rural areas of PNG through outreach services but follow-up data in these communities on continuation and acceptability is lacking. Objective: To gain insight into women's experience with contraceptive implants by assessing the acceptability, satisfaction, 12 month continuation rates and efficacy of contraceptive implants among women in rural PNG. Material and methods: We undertook a cross-sectional survey of women in two rural provinces who had received a contraceptive implant at least 12 months prior using a structured questionnaire. We sought information on device continuation rates, satisfaction scores, side effects and failure rates. Results: Of the 860 women surveyed, 97% (n = 836) still had the device in situ after 12 months and 92% (n = 793) were very happy with it. Seventy-six percent of women (n = 654) reported no side effects. Irregular bleeding was the most commonly reported side effect (n = 178, 20.6%) but only 7% (n = 13) said the bleeding was bothersome. Documented failure rates were 0.8% although pregnancy at the time of insertion could not be excluded in any of these cases. Conclusion: Twelve month implant follow-up data in this study showed high continuation rates and high levels of satisfaction among a rural population in PNG. Implants have the potential to lower maternal morbidity and mortality and simultaneously address the unmet need for contraception in these communities.

Impact of the contraceptive implant on maternal and neonatal morbidity and mortality in rural Papua New Guinea: a retrospective observational cohort study

Contraception, Jul 1, 2019

Using routinely collected birth data, this study sought to measure changes in maternal and neonat... more Using routinely collected birth data, this study sought to measure changes in maternal and neonatal morbidity and mortality after introduction of the levonorgestrel contraceptive implant into a large, rural island population in Papua New Guinea (PNG). Study design: We conducted a retrospective observational study of birth records from 4251 births that occurred between January 2010 and December 2016 on Karkar Island, PNG. The primary outcome was the change in crude birth rate (CBR) before (2010-2012) and after (2014-2016) introduction of the implant. Secondary outcomes were the change in rates (per year/1000 births) of severe postpartum hemorrhage, postpartum infection, hospital readmission, prematurity (b37 weeks), low birth weight (b2500 g) and maternal and neonatal mortality. We also studied changes in the number of pregnancies affected by grand multiparity (≥4) and short interpregnancy interval (b12 months) for the same time periods. Data were analyzed using interrupted time series and Poisson regression. Results: CBR was stable until 2012 and then declined from 2014 (pb.0001). Following introduction of the implant, the annual rate/1000 births of selected adverse birth outcomes decreased between 56% and 74% (pb.0001). The number of women with parity ≥4 who gave birth decreased by 59% (pb.0001), and the number with interpregnancy interval b12 months decreased by 64% (pb.0001). Conclusions: Introduction of the contraceptive implant was associated with reductions in CBR, maternal and neonatal morbidity, and the number of women with high-risk pregnancies giving birth. Implications: These results encourage efforts to increase knowledge and availability of the contraceptive implant in low-and middle-income countries such as PNG. In cases where it reduces the CBR and the number of women with high-risk pregnancies birthing, the implant may have a beneficial impact on maternal and neonatal morbidity.

Maternal and perinatal mortality in resource-limited settings

The Lancet Global Health, Nov 1, 2015

e672 with maternal mortality, we did not fi nd this in our setting (p=0•10; fi gure). This result... more

Maternal near-misses at a provincial hospital in Papua New Guinea: A prospective observational study

Australian & New Zealand Journal of Obstetrics & Gynaecology, Jun 5, 2017

Background: Maternal near-miss indices are World Health Organisation (WHO) recognised indicators ... more Background: Maternal near-miss indices are World Health Organisation (WHO) recognised indicators that may improve our understanding of factors associated with maternal morbidity and mortality. In Papua New Guinea (PNG) where maternal mortality is among the highest in the world, only one study has documented near-miss indices in a tertiary-level hospital, but none from provincial hospitals where the majority of underprivileged women access healthcare services. Aims: To determine the near-miss ratio, maternal mortality index (MMI), and associated maternal indices for Modilon Hospital in Madang Province of PNG. Methods: All women attending Modilon Hospital who met the WHO maternal near-miss definition and/or a WHO-modified (PNG-specific) near-miss definition, were prospectively enrolled. Results: There were 6019 live births during the audit period; 163 women presented with life-threatening conditions (153 near-misses and 10 maternal deaths). The maternal near-miss ratio was 25.4/1000 live births and the maternal mortality ratio (MMR) was 166/100 000 live births, with a maternal death to near-miss ratio of 1:15.3. The severe maternal outcome ratio was 27.1/1000 live births and the total mortality index was 6.8%. Higher proportions of near-miss women were aged ≥30 years, nulliparous, illiterate, from rural communities, lacked formal employment, referred from peripheral health facilities, unbooked, had history of still births and were anaemic. Conclusion: Sociodemographic factors such as women's rights, education level and status in society, in addition to appropriate health reforms with greater financial and political support are urgently needed to ensure underprivileged women in rural PNG have access to family planning, supervised deliveries and skilled emergency obstetric care.

Causes of neonatal admissions and in-hospital mortality at Modilon Hospital, Madang Province: A 5-year retrospective study

Papua and New Guinea medical journal, Mar 1, 2016

Community attitudes and gendered influences on decision making around contraceptive implant use in rural Papua New Guinea

Reproductive Health, Sep 5, 2020

Background: Despite targeted interventions to improve contraceptive implant acceptability and upt... more Background: Despite targeted interventions to improve contraceptive implant acceptability and uptake in rural Papua New Guinea (PNG), ongoing use of this method remains limited. Previous literature has suggested community attitudes and intrinsic factors within the decision-making process may be negatively impacting on implant uptake, however these elements have not previously been studied in detail in this context. We set out to explore community attitudes towards the contraceptive implant and the pathways to decision making around implant use in a rural community on Karkar Island, PNG. Methods: We conducted 10 focus-group (FGD) and 23 in-depth interviews (IDI) using semi-structured topic guides. Key sampling characteristics included age, exposure or non-exposure to implants, marital status, education and willingness to participate in discussion. Four FGDs were held with women, four with men and two with mixed gender. IDIs were carried out with five women (current implant users, former implant users, implant never users), five men, five religious leaders (Catholic and non-Catholic), four village leaders and four health workers. Two indepth interviews (four participants) were analysed as dyads and the remaining participant responses were analysed individually. Results: Men were supportive of their wives using family planning but there was a community-wide lack of familiarity about the contraceptive implant which influenced its low uptake. Men perceived family planning to be 'women's business' but remained strongly influential in the decision making processes around method use. Young men were more receptive to biomedical information than older men and had a greater tendency towards wanting to use implants. Older men preferred to be guided by prominent community members for decisions concerning implants whilst young men were more likely to engage with health services directly.

Safety and effectiveness of oral misoprostol for induction of labour in a resource-limited setting: a dose escalation study

BMC Pregnancy and Childbirth, Sep 8, 2017

Background: Oral misoprostol as an induction of labour (IOL) agent is rapidly gaining popularity ... more Background: Oral misoprostol as an induction of labour (IOL) agent is rapidly gaining popularity in resource-limited settings because it is cheap, stable at ambient temperatures, and logistically easier to administer compared to dinoprostone and oxytocin. We aim to investigate the safety and effectiveness of a regimen of oral misoprostol in Papua New Guinean women undergoing IOL. Methods: As part of a prospective dose escalation study conducted at Modilon Hospital in Papua New Guinea, women with a singleton pregnancy in cephalic presentation and an unfavourable cervix who gave written informed consent were administered oral misoprostol, commencing at 25mcg once every 2 h for 4 doses and increased to 50mcg once every 2 h for 8 doses within 24 h. The primary outcomes studied were i) the proportion of women delivering within 24 h of oral misoprostol administration, and ii) rates of maternal and perinatal severe adverse events. Results: Of 6167 labour ward screened admissions, 209 women (3%) fulfilled the study inclusion criteria and underwent IOL. Overall, 74% (155/209 [95% confidence interval 67.6-79.9]) delivered within 24 h. Most women (90%; 188/209; 95% CI [84.9-93.5]) delivered vaginally with 86% (180/209) having a good outcome for both the mother and baby. Of the 10% (21/209) who failed IOL and underwent caesarean section, a significant proportion of their babies were admitted to special-care nursery compared to babies delivered vaginally (20/21 [95%] versus 8/ 188 [4%]; Fisher Exact test P < 0.001), but their perinatal mortality rate was not significantly higher (1/21 [5%] versus 2/188 [1%]; P = 0.30). The only maternal death was not study related and occurred in a patient with post-partum haemorrhage, 15 h post-delivery. Conclusion: The oral misoprostol regimen for IOL described in the present study is safe, effective and logistically feasible to administer in a resource-limited setting.

Improving maternal and newborn health and reducing stillbirths in the Western Pacific Region – current situation and the way forward

The Lancet Regional Health - Western Pacific

Point-of-care HPV DNA testing of self-collected specimens and same-day thermal ablation for the early detection and treatment of cervical pre-cancer in women in Papua New Guinea: a prospective, single-arm intervention trial (HPV-STAT)

The Lancet Global Health

Background WHO recommends human papillomavirus (HPV) testing and same-day treatment for cervical ... more Background WHO recommends human papillomavirus (HPV) testing and same-day treatment for cervical screening in low-income and middle-income countries (LMICs); however, few published data exist on the validity of the strategy. We aimed to evaluate the clinical performance, treatment completion rates, adverse events profile, and acceptability of a fully integrated strategy, comprising point-of-care HPV DNA testing of self-collected specimens and same-day thermal ablation, for screening of cervical cancer in women in Papua New Guinea. Methods HPV-STAT was a large-scale, prospective, single-arm intervention trial conducted at two clinical sites in Papua New Guinea. Cervical screening clinics with an on-site consultant gynaecologist were selected in consultation with national and provincial health authorities, church health services, and local stakeholders. Eligible participants were women aged 30-59 years attending cervical screening services at the two clinics, who were willing to comply with study procedures and able to provide written informed consent. Women self-collected vaginal specimens for point-of-care GeneXpert testing (Cepheid, Sunnyvale, CA, USA) for oncogenic HPV types. Women testing positive for HPV underwent pelvic examination followed by same-day thermal ablation or referral for gynaecology review. All HPV-positive women and a 15% random sample of HPV-negative women provided a clinician-collected cervical specimen for liquid-based cytology. The primary outcome was clinical performance (ie, sensitivity, specificity, positive predictive value [PPV], and negative predictive value [NPV]) of the strategy for the detection of high-grade squamous intraepithelial lesion (HSIL) or worse. This trial is registered with ISRCTN, ISRCTN13476702.

Maternal, perinatal and newborn outcomes among women enrolled into the WANTAIM trial, Papua New Guinea

Women and Birth

Causes of neonatal admissions and in-hospital mortality at Modilon Hospital, Madang Province: A 5-year retrospective study

Papua and New Guinea medical journal, Mar 1, 2016

“This is really something: same place, same day result, same day treatment” Women’s experiences of testing positive for HPV and receiving same-day treatment in Papua New Guinea: an interpretative phenomenological analysis

Introduction: Human papillomavirus (HPV) testing is transforming cervical screening globally. The... more Introduction: Human papillomavirus (HPV) testing is transforming cervical screening globally. The World Health Organization (WHO) now recommends same-day HPV screen-and-treat for primary cervical screening in low- and middle-income countries (LMIC) but there is a lack of evidence on women’s lived experience of testing positive for oncogenic HPV and receiving same-day treatment. This study aimed to address this knowledge gap among women participating in a same-day HPV screen-and-treat (HPV S&T) program in Papua New Guinea. Methods As part of a larger qualitative study, this paper explores the lived experiences of 26 women who tested positive for oncogenic HPV and were treated the same day. We analysed the data using the interpretative phenomenological analysis method. All data were managed using Nvivo 12.5. Results The interpretative phenomenological analysis led to three superordinate themes: 1) alleviating initial worries, (2) transforming the disclosure process, and (3) connecting...

Towards the elimination of cervical cancer in low-income and lower-middle-income countries: modelled evaluation of the effectiveness and cost-effectiveness of point-of-care HPV self-collected screening and treatment in Papua New Guinea

BMJ Global Health, Mar 1, 2022

Women’s acceptability of a self-collect HPV same-day screen-and-treat program in a high burden setting in the Pacific

Background: A field trial to evaluate a self-collect point-of-care HPV screen-and-treat (HPV S&T)... more Background: A field trial to evaluate a self-collect point-of-care HPV screen-and-treat (HPV S&T) program was implemented in two Well Women Clinics in Papua New Guinea (Papua New Guinea). Assessing the acceptability of a health intervention is a core element of evaluation. In this study, we examined women’s acceptability of both self-collection and HPV S&T intervention in Papua New Guinea. Methods: Sixty-two semi-structured interviews were conducted with women who had undergone cervical screening in the same-day self-collected HPV screen-and-treat program in Madang and Western Highlands Provinces, Papua New Guinea. Data were thematically analysed using the Theoretical Framework of Acceptability (TFA) and managed using NVivo 12.5. Results: Self-collection was highly acceptable to women as it meant they could forgo what was deemed a culturally embarrassing cervical examination. The provision of same-day results, and treatment if indicated, was particularly valued by the women because ...

Acceptability and sustainability of a point-of-care HPV ‘self-collect, screen-and-treat’ for cervical cancer prevention in Papua New Guinea: A qualitative exploration of key informants’ perspectives

medRxiv (Cold Spring Harbor Laboratory), Sep 27, 2023

Maternal Near-misses at a Provincial Hospital in Papua New Guinea: A Prospective Observational Study

Obstetric Anesthesia Digest, Sep 1, 2018

Background: Maternal near-miss indices are World Health Organisation (WHO) recognised indicators ... more Background: Maternal near-miss indices are World Health Organisation (WHO) recognised indicators that may improve our understanding of factors associated with maternal morbidity and mortality. In Papua New Guinea (PNG) where maternal mortality is among the highest in the world, only one study has documented near-miss indices in a tertiary-level hospital, but none from provincial hospitals where the majority of underprivileged women access healthcare services. Aims: To determine the near-miss ratio, maternal mortality index (MMI), and associated maternal indices for Modilon Hospital in Madang Province of PNG. Methods: All women attending Modilon Hospital who met the WHO maternal near-miss definition and/or a WHO-modified (PNG-specific) near-miss definition, were prospectively enrolled. Results: There were 6019 live births during the audit period; 163 women presented with life-threatening conditions (153 near-misses and 10 maternal deaths). The maternal near-miss ratio was 25.4/1000 live births and the maternal mortality ratio (MMR) was 166/100 000 live births, with a maternal death to near-miss ratio of 1:15.3. The severe maternal outcome ratio was 27.1/1000 live births and the total mortality index was 6.8%. Higher proportions of near-miss women were aged ≥30 years, nulliparous, illiterate, from rural communities, lacked formal employment, referred from peripheral health facilities, unbooked, had history of still births and were anaemic. Conclusion: Sociodemographic factors such as women's rights, education level and status in society, in addition to appropriate health reforms with greater financial and political support are urgently needed to ensure underprivileged women in rural PNG have access to family planning, supervised deliveries and skilled emergency obstetric care.

Improving maternal and newborn health and reducing stillbirths in the Western Pacific Region – current situation and the way forward

The Lancet Regional Health - Western Pacific, Mar 1, 2023

Effects of Plasmodium falciparum infection on umbilical artery resistance and intrafetal blood flow distribution: a Doppler ultrasound study from Papua New Guinea

Malaria Journal, Jan 19, 2017

Background: Doppler velocimetry studies of umbilical artery (UA) and middle cerebral artery (MCA)... more Background: Doppler velocimetry studies of umbilical artery (UA) and middle cerebral artery (MCA) flow help to determine the presence and severity of fetal growth restriction. Increased UA resistance and reduced MCA pulsatility may indicate increased placental resistance and intrafetal blood flow redistribution. Malaria causes low birth weight and fetal growth restriction, but few studies have assessed its effects on uteroplacental and fetoplacental blood flow. Methods: Colour-pulsed Doppler ultrasound was used to assess UA and MCA flow in 396 Papua New Guinean singleton fetuses. Abnormal flow was defined as an UA resistance index above the 90th centile, and/or a MCA pulsatility index and cerebroplacental ratio (ratio of MCA and UA pulsatility index) below the 10th centile of population-specific models fitted to the data. Associations between malaria (peripheral infection prior to and at ultrasound examination, and any gestational infection, i.e., 'exposure') and abnormal flow, and between abnormal flow and birth outcomes, were estimated. Results: Of 78 malaria infection episodes detected before or at the ultrasound visit, 62 (79.5%) were Plasmodium falciparum (34 sub-microscopic infections), and 16 were Plasmodium vivax. Plasmodium falciparum infection before or at Doppler measurement was associated with increased UA resistance (adjusted odds ratio (aOR) 2.3 95% CI 1.0-5.2, P = 0.047). When assessed by 'exposure' , P. falciparum infection was significantly associated with increased UA resistance (all infections: 2.4, 1.1-4.9, P = 0.024; sub-microscopic infections 2.6, 1.0-6.6, P = 0.051) and a reduced MCA pulsatility index (all infections: 2.6, 1.2-5.3, P = 0.012; sub-microscopic infections: 2.8, 1.1-7.5, P = 0.035). Sub-microscopic P. falciparum infections were additionally associated with a reduced cerebroplacental ratio (3.64, 1.22-10.88, P = 0.021). There were too few P. vivax infections to draw robust conclusions. An increased UA resistance index was associated with histological evidence of placental malaria (5.1, 2.3-10.9, P < 0.001; sensitivity 0.26, specificity 0.93). A low cerebroplacental Doppler ratio was associated with concurrently measuring small-for-gestational-age, and with low birth weight. Discussion/conclusion: Both microscopic and sub-microscopic P. falciparum infections impair fetoplacental and intrafetal flow, at least temporarily. Increased UA resistance has high specificity but low sensitivity for the detection of placental infection. These findings suggest that interventions to protect the fetus should clear and prevent both microscopic and sub-microscopic malarial infections.

Maternal and newborn health indicators in Papua New Guinea – 2008–2018

Sexual and reproductive health matters, 2019

Papua New Guinea (PNG) is the most populous country in the Pacific with more than 9 million peopl... more Papua New Guinea (PNG) is the most populous country in the Pacific with more than 9 million people. Difficult terrain, poor roads and limited infrastructure mean providing effective health careespecially in rural areas, where most people liveis challenging. Women and newborns in PNG experience high rates of preventable morbidity and mortality; however, reliable data are often limited or unavailable. The aim of this paper is to provide an overview of research on key maternal and neonatal health (MNH) indicators conducted approximately over the past 11 years in PNG comparing research findings to global MNH estimates of the indicators. There was considerable variation in mortality indicators (maternal mortality ratio, neonatal mortality rate and stillbirth) reported across studies in PNG. Mortality was generally higher in rural areas. Rates of sexually transmitted infections (STIs) in pregnancy were consistently high, while anaemia in pregnancy, preterm birth and low birth weight varied widely between studies and settings. Breastfeeding seems to have been under-researched. There was a lack of data available on other indicators such as the adolescent birth rate, postnatal care provided to women and newborns, intermittent preventative treatment to prevent malaria in pregnancy and treatment to prevent mother-to-child transmission of HIV. Studies demonstrate the high burden of preventable maternal and newborn morbidity and mortality across PNG. Efforts to improve MNH outcomes need to be escalated.

Point-of-care testing and treatment of sexually transmitted infections to improve birth outcomes in high-burden, low-income settings: Study protocol for a cluster randomized crossover trial (the WANTAIM Trial, Papua New Guinea)

Wellcome open research, Nov 20, 2019

Background: Chlamydia trachomatis Neisseria gonorrhoeae and bacterial vaginosis have been associa... more

Twelve month follow-up of a contraceptive implant outreach service in rural Papua New Guinea

Australian & New Zealand Journal of Obstetrics & Gynaecology, Apr 1, 2017

Background: Poor access to contraception contributes to persistently high maternal mortality rate... more Background: Poor access to contraception contributes to persistently high maternal mortality rates in Papua New Guinea (PNG). Since 2012 contraceptive implants have been provided to women in rural areas of PNG through outreach services but follow-up data in these communities on continuation and acceptability is lacking. Objective: To gain insight into women's experience with contraceptive implants by assessing the acceptability, satisfaction, 12 month continuation rates and efficacy of contraceptive implants among women in rural PNG. Material and methods: We undertook a cross-sectional survey of women in two rural provinces who had received a contraceptive implant at least 12 months prior using a structured questionnaire. We sought information on device continuation rates, satisfaction scores, side effects and failure rates. Results: Of the 860 women surveyed, 97% (n = 836) still had the device in situ after 12 months and 92% (n = 793) were very happy with it. Seventy-six percent of women (n = 654) reported no side effects. Irregular bleeding was the most commonly reported side effect (n = 178, 20.6%) but only 7% (n = 13) said the bleeding was bothersome. Documented failure rates were 0.8% although pregnancy at the time of insertion could not be excluded in any of these cases. Conclusion: Twelve month implant follow-up data in this study showed high continuation rates and high levels of satisfaction among a rural population in PNG. Implants have the potential to lower maternal morbidity and mortality and simultaneously address the unmet need for contraception in these communities.

Impact of the contraceptive implant on maternal and neonatal morbidity and mortality in rural Papua New Guinea: a retrospective observational cohort study

Contraception, Jul 1, 2019

Using routinely collected birth data, this study sought to measure changes in maternal and neonat... more Using routinely collected birth data, this study sought to measure changes in maternal and neonatal morbidity and mortality after introduction of the levonorgestrel contraceptive implant into a large, rural island population in Papua New Guinea (PNG). Study design: We conducted a retrospective observational study of birth records from 4251 births that occurred between January 2010 and December 2016 on Karkar Island, PNG. The primary outcome was the change in crude birth rate (CBR) before (2010-2012) and after (2014-2016) introduction of the implant. Secondary outcomes were the change in rates (per year/1000 births) of severe postpartum hemorrhage, postpartum infection, hospital readmission, prematurity (b37 weeks), low birth weight (b2500 g) and maternal and neonatal mortality. We also studied changes in the number of pregnancies affected by grand multiparity (≥4) and short interpregnancy interval (b12 months) for the same time periods. Data were analyzed using interrupted time series and Poisson regression. Results: CBR was stable until 2012 and then declined from 2014 (pb.0001). Following introduction of the implant, the annual rate/1000 births of selected adverse birth outcomes decreased between 56% and 74% (pb.0001). The number of women with parity ≥4 who gave birth decreased by 59% (pb.0001), and the number with interpregnancy interval b12 months decreased by 64% (pb.0001). Conclusions: Introduction of the contraceptive implant was associated with reductions in CBR, maternal and neonatal morbidity, and the number of women with high-risk pregnancies giving birth. Implications: These results encourage efforts to increase knowledge and availability of the contraceptive implant in low-and middle-income countries such as PNG. In cases where it reduces the CBR and the number of women with high-risk pregnancies birthing, the implant may have a beneficial impact on maternal and neonatal morbidity.

Maternal and perinatal mortality in resource-limited settings

The Lancet Global Health, Nov 1, 2015

e672 with maternal mortality, we did not fi nd this in our setting (p=0•10; fi gure). This result... more

Maternal near-misses at a provincial hospital in Papua New Guinea: A prospective observational study

Australian & New Zealand Journal of Obstetrics & Gynaecology, Jun 5, 2017

Background: Maternal near-miss indices are World Health Organisation (WHO) recognised indicators ... more Background: Maternal near-miss indices are World Health Organisation (WHO) recognised indicators that may improve our understanding of factors associated with maternal morbidity and mortality. In Papua New Guinea (PNG) where maternal mortality is among the highest in the world, only one study has documented near-miss indices in a tertiary-level hospital, but none from provincial hospitals where the majority of underprivileged women access healthcare services. Aims: To determine the near-miss ratio, maternal mortality index (MMI), and associated maternal indices for Modilon Hospital in Madang Province of PNG. Methods: All women attending Modilon Hospital who met the WHO maternal near-miss definition and/or a WHO-modified (PNG-specific) near-miss definition, were prospectively enrolled. Results: There were 6019 live births during the audit period; 163 women presented with life-threatening conditions (153 near-misses and 10 maternal deaths). The maternal near-miss ratio was 25.4/1000 live births and the maternal mortality ratio (MMR) was 166/100 000 live births, with a maternal death to near-miss ratio of 1:15.3. The severe maternal outcome ratio was 27.1/1000 live births and the total mortality index was 6.8%. Higher proportions of near-miss women were aged ≥30 years, nulliparous, illiterate, from rural communities, lacked formal employment, referred from peripheral health facilities, unbooked, had history of still births and were anaemic. Conclusion: Sociodemographic factors such as women's rights, education level and status in society, in addition to appropriate health reforms with greater financial and political support are urgently needed to ensure underprivileged women in rural PNG have access to family planning, supervised deliveries and skilled emergency obstetric care.

Causes of neonatal admissions and in-hospital mortality at Modilon Hospital, Madang Province: A 5-year retrospective study

Papua and New Guinea medical journal, Mar 1, 2016

Community attitudes and gendered influences on decision making around contraceptive implant use in rural Papua New Guinea

Reproductive Health, Sep 5, 2020

Background: Despite targeted interventions to improve contraceptive implant acceptability and upt... more Background: Despite targeted interventions to improve contraceptive implant acceptability and uptake in rural Papua New Guinea (PNG), ongoing use of this method remains limited. Previous literature has suggested community attitudes and intrinsic factors within the decision-making process may be negatively impacting on implant uptake, however these elements have not previously been studied in detail in this context. We set out to explore community attitudes towards the contraceptive implant and the pathways to decision making around implant use in a rural community on Karkar Island, PNG. Methods: We conducted 10 focus-group (FGD) and 23 in-depth interviews (IDI) using semi-structured topic guides. Key sampling characteristics included age, exposure or non-exposure to implants, marital status, education and willingness to participate in discussion. Four FGDs were held with women, four with men and two with mixed gender. IDIs were carried out with five women (current implant users, former implant users, implant never users), five men, five religious leaders (Catholic and non-Catholic), four village leaders and four health workers. Two indepth interviews (four participants) were analysed as dyads and the remaining participant responses were analysed individually. Results: Men were supportive of their wives using family planning but there was a community-wide lack of familiarity about the contraceptive implant which influenced its low uptake. Men perceived family planning to be 'women's business' but remained strongly influential in the decision making processes around method use. Young men were more receptive to biomedical information than older men and had a greater tendency towards wanting to use implants. Older men preferred to be guided by prominent community members for decisions concerning implants whilst young men were more likely to engage with health services directly.

Safety and effectiveness of oral misoprostol for induction of labour in a resource-limited setting: a dose escalation study

BMC Pregnancy and Childbirth, Sep 8, 2017

Background: Oral misoprostol as an induction of labour (IOL) agent is rapidly gaining popularity ... more Background: Oral misoprostol as an induction of labour (IOL) agent is rapidly gaining popularity in resource-limited settings because it is cheap, stable at ambient temperatures, and logistically easier to administer compared to dinoprostone and oxytocin. We aim to investigate the safety and effectiveness of a regimen of oral misoprostol in Papua New Guinean women undergoing IOL. Methods: As part of a prospective dose escalation study conducted at Modilon Hospital in Papua New Guinea, women with a singleton pregnancy in cephalic presentation and an unfavourable cervix who gave written informed consent were administered oral misoprostol, commencing at 25mcg once every 2 h for 4 doses and increased to 50mcg once every 2 h for 8 doses within 24 h. The primary outcomes studied were i) the proportion of women delivering within 24 h of oral misoprostol administration, and ii) rates of maternal and perinatal severe adverse events. Results: Of 6167 labour ward screened admissions, 209 women (3%) fulfilled the study inclusion criteria and underwent IOL. Overall, 74% (155/209 [95% confidence interval 67.6-79.9]) delivered within 24 h. Most women (90%; 188/209; 95% CI [84.9-93.5]) delivered vaginally with 86% (180/209) having a good outcome for both the mother and baby. Of the 10% (21/209) who failed IOL and underwent caesarean section, a significant proportion of their babies were admitted to special-care nursery compared to babies delivered vaginally (20/21 [95%] versus 8/ 188 [4%]; Fisher Exact test P < 0.001), but their perinatal mortality rate was not significantly higher (1/21 [5%] versus 2/188 [1%]; P = 0.30). The only maternal death was not study related and occurred in a patient with post-partum haemorrhage, 15 h post-delivery. Conclusion: The oral misoprostol regimen for IOL described in the present study is safe, effective and logistically feasible to administer in a resource-limited setting.

Improving maternal and newborn health and reducing stillbirths in the Western Pacific Region – current situation and the way forward

The Lancet Regional Health - Western Pacific

Point-of-care HPV DNA testing of self-collected specimens and same-day thermal ablation for the early detection and treatment of cervical pre-cancer in women in Papua New Guinea: a prospective, single-arm intervention trial (HPV-STAT)

The Lancet Global Health

Background WHO recommends human papillomavirus (HPV) testing and same-day treatment for cervical ... more Background WHO recommends human papillomavirus (HPV) testing and same-day treatment for cervical screening in low-income and middle-income countries (LMICs); however, few published data exist on the validity of the strategy. We aimed to evaluate the clinical performance, treatment completion rates, adverse events profile, and acceptability of a fully integrated strategy, comprising point-of-care HPV DNA testing of self-collected specimens and same-day thermal ablation, for screening of cervical cancer in women in Papua New Guinea. Methods HPV-STAT was a large-scale, prospective, single-arm intervention trial conducted at two clinical sites in Papua New Guinea. Cervical screening clinics with an on-site consultant gynaecologist were selected in consultation with national and provincial health authorities, church health services, and local stakeholders. Eligible participants were women aged 30-59 years attending cervical screening services at the two clinics, who were willing to comply with study procedures and able to provide written informed consent. Women self-collected vaginal specimens for point-of-care GeneXpert testing (Cepheid, Sunnyvale, CA, USA) for oncogenic HPV types. Women testing positive for HPV underwent pelvic examination followed by same-day thermal ablation or referral for gynaecology review. All HPV-positive women and a 15% random sample of HPV-negative women provided a clinician-collected cervical specimen for liquid-based cytology. The primary outcome was clinical performance (ie, sensitivity, specificity, positive predictive value [PPV], and negative predictive value [NPV]) of the strategy for the detection of high-grade squamous intraepithelial lesion (HSIL) or worse. This trial is registered with ISRCTN, ISRCTN13476702.

Maternal, perinatal and newborn outcomes among women enrolled into the WANTAIM trial, Papua New Guinea

Women and Birth

Causes of neonatal admissions and in-hospital mortality at Modilon Hospital, Madang Province: A 5-year retrospective study

Papua and New Guinea medical journal, Mar 1, 2016

“This is really something: same place, same day result, same day treatment” Women’s experiences of testing positive for HPV and receiving same-day treatment in Papua New Guinea: an interpretative phenomenological analysis

Introduction: Human papillomavirus (HPV) testing is transforming cervical screening globally. The... more Introduction: Human papillomavirus (HPV) testing is transforming cervical screening globally. The World Health Organization (WHO) now recommends same-day HPV screen-and-treat for primary cervical screening in low- and middle-income countries (LMIC) but there is a lack of evidence on women’s lived experience of testing positive for oncogenic HPV and receiving same-day treatment. This study aimed to address this knowledge gap among women participating in a same-day HPV screen-and-treat (HPV S&T) program in Papua New Guinea. Methods As part of a larger qualitative study, this paper explores the lived experiences of 26 women who tested positive for oncogenic HPV and were treated the same day. We analysed the data using the interpretative phenomenological analysis method. All data were managed using Nvivo 12.5. Results The interpretative phenomenological analysis led to three superordinate themes: 1) alleviating initial worries, (2) transforming the disclosure process, and (3) connecting...

Towards the elimination of cervical cancer in low-income and lower-middle-income countries: modelled evaluation of the effectiveness and cost-effectiveness of point-of-care HPV self-collected screening and treatment in Papua New Guinea

BMJ Global Health, Mar 1, 2022

Women’s acceptability of a self-collect HPV same-day screen-and-treat program in a high burden setting in the Pacific

Background: A field trial to evaluate a self-collect point-of-care HPV screen-and-treat (HPV S&T)... more Background: A field trial to evaluate a self-collect point-of-care HPV screen-and-treat (HPV S&T) program was implemented in two Well Women Clinics in Papua New Guinea (Papua New Guinea). Assessing the acceptability of a health intervention is a core element of evaluation. In this study, we examined women’s acceptability of both self-collection and HPV S&T intervention in Papua New Guinea. Methods: Sixty-two semi-structured interviews were conducted with women who had undergone cervical screening in the same-day self-collected HPV screen-and-treat program in Madang and Western Highlands Provinces, Papua New Guinea. Data were thematically analysed using the Theoretical Framework of Acceptability (TFA) and managed using NVivo 12.5. Results: Self-collection was highly acceptable to women as it meant they could forgo what was deemed a culturally embarrassing cervical examination. The provision of same-day results, and treatment if indicated, was particularly valued by the women because ...

Top Cited Article John W Bolnga