On the early morning of 26^th February a massive earthquake of magnitude 7.5 struck PNG affecting the provinces of Southern Highlands, Hela and Western Highlands. The affected areas are largely mountainous and remote. The earthquake has claimed many lives with more than 50 deaths reported one week after the disaster. The exact numbers of deaths of those buried alive in landslides and rumbles are not known but estimated to have exceed hundreds.
An estimated 275,000 people live within 50km of the epicentre and experience frightening landslides and falling shelter and buildings. Approximately 325,000 people are estimated to have been displaced due to loss of basic needs for shelter, food and water. Immediate needs for survival include shelter, food and water, sanitation and life-saving health services. At least half of health facilities were damaged and became non-functional. Women, infants and children were the most affected as they struggled to get food, water and sanitation. More than 50% of rural health facilities and staffing homes have been flattened and buried under landslides. Some health workers are reported to be suffering from psychological trauma and post disaster depression.
The massive earthquake and destructive landslides caused severe destruction to homes, plantations, infrastructure, buildings, roads and bridges and cut off water and electricity. People were devastated while numerous strong aftershocks continued for at least a further week. Destroyed mining sites and gas plants posed the risks of potential toxic spills.

The government declared PNG in a state of emergency two days later. The last few weeks saw international aid flowing into the two most severely damaged provinces. Emergency responses to save lives were established but many deaths occurred unnoticed. Choppers are the main only means of transport to reach these remote communities. Villagers and communities are frustrated at the slowness of accessing food, water and essential health services. It will take a long time for people to sustain adequate food supplies and return to their usual routines. Outbreaks of food and water-borne diseases are likely to occur, while malnutrition from lack of food will surely affect small children.

Australia and New Zealand sent helicopters and planes to help deliver food, water and medicine to the remote region, where the government and aid agencies have been scrambling to reach villages stranded by landslides and collapsed roads.

A ferocious Tropical Cyclone Gita crashing with fierce winds of up to 260 km/h was the most intense tropical cyclone to impact Tonga since reliable records began.

After experiencing a fearful night, Tonga woke up to see massive destruction to their homes and belongings following Cyclone Gita’s merciless journey. Winds were forceful and roared angrily for many hours overnight. Many described the event as the most frightening experience they have come across. Some families cramped themselves up in small bathrooms as heavy rain and fearless winds bulldozed into their homes. In the middle of the night, brave doctors and nurses transferred patients to safe rooms as water sipped into the wards.

Severe Tropical Cyclone Gita left a trail of destruction – ripped roofs off houses, uprooted large trees, destroyed buildings and homes. Thousands of residents faced prolonged cut off of electricity and water supplies.
In responding to the aftermath of Gita, Tongans have been resilient to pick themselves up and immediately start clean-up operation and restoration within 24hours post cyclone.
There have been no confirmed deaths from the storm, although there were reports of injuries, a few major but mostly minor injuries.

A/Prof Pushpa Nusair of FNU reports on those who recently graduated with Masters and research topics:
1)Ailsa T.Benati (Kiribati)- Research project –A Retrospective audit of trial of Labour after Caesarean Section (TOLAC) cases at Lautoka Hospital (1st January 2015-31^st December 2016)
2) Mairini Rokovunisei (Fiji)-Retrospective Audit of Antenatal Care of Syphilis in Pregnancy at Colonial War Memorial Hospital (January 2015 to January 2017)
3) Nitik Ram-Post Caesarean Section wound Infection at Colonial War Memorial  Hospital ,Suva ,Fiji (1^st January 2016 to 31^st December 2016). RANZCOG Best Student.
4) Byron Fatiaki-Retrospective Audit of Pregnancy complicated by Intrauterine Growth Restriction diagnosed at Lautoka Hospital from January 1^st 2016 to December 31^st 2016
5) Viliame Mataitolu –Outcomes of Women with Hypertension in Pregnancy at Labasa Hospital (1st March 2016 to 28^th February 2017)

PSRH offers ten Research Awards per annum to assist research capacity building in reproductive health in the Pacific region. Each award is to the value of NZ$500 and can be used to develop a larger research proposal or for paying expenses in performing a clinical audit. Where the awards are over-subscribed, priority will be given to projects that have part-funding from another source.
The criteria are:

1. The Principal Investigator (PI) is a financial member of PSRH
2. The PI has ready access to the internet and a computer
3. The project addresses a priority area/service
4. Have the support of the Head of Unit/Ward/Service/Hospital
5. Sound research/audit application and methods
6. A research team (2-7 members) will perform the project with one member having performed research before
7. Take no more than two years to complete
8. Findings to be published in the Pacific Journal of Reproductive Health
9. The application must be typed with referencing where appropriate

Applications on the linked form close 30th March 2018.
 

Every year, there is global advocacy on ending violence against women; 25^th November is recognized as the International Day for the Elimination of Violence against Women and Girls. This day also kicks start the “16 Days of Activism” against Gender-Based Violence up to 10 December, which is globally recognized as “Human Rights Day”.
The 16 Days of Activism provide an excellent opportunity to raise awareness of GBV as a gender and health priority issue. WHO launched a new manual for health managers and policy-makers to strengthen health systems to deliver better quality of care to women who are subjected to violence, “Strengthening health systems to respond to women subjected to intimate partner violence or sexual violence: A manual for health managers”.
Additional information, including existing resources and materials can also be found at:

• HQ: http://www.who.int/life-course/news/events/2017-intl-day-for-elimination-of-violence-against-women/en/
• WPRO: http://www.wpro.who.int/equity_social_determinants/en/

Pacific Associate Members are invited to apply for the following scholarships offered to Associate Members participating in the RANZCOG Pacific CPD.

• CPD Program ASM Scholarship 2018 to be held in Adelaide, 15-19 September 2018
• Brian Spurrett Fellowship to attend the Anatomy of Complication Workshop, Perth, 19-20 October 2018

Applications close 31 January 2018.
For more information contact Ms Carmel Walker on email:  cwalker@ranzcog.edu.au

 
Dr Susan Tutty
GP Liaison for Women’s Health, Counties Manukau, Auckland, New Zealand
Counties Manukau is responsible for providing women’s health services in the Counties Manuka District Health Board boundary. It covers a population of over half a million and has one of the largest populations of Maaori, Pacific Islanders and Asian communities with relatively rapid population growth and high socio-economic deprived status. Therefore family planning is an essential service for these communities.
Improving access to contraception was highlighted as an important intervention in women’s health, and recommended in perinatal mortality meetings. Despite this, there is little data on women accessing contraception of their choice in Counties Manukau.
In an attempt to estimate planned pregnancy rates, an audit of folic acid use prior to pregnancy was undertaken. It found that only 5% of mothers start folic acid prior to pregnancy. Contraceptive data taken from pharmacies in 2015 suggested that approximately 20% of women in Counties Manukau use some form of contraception, but of that 20% only 8% use long acting reversible contraception (LARC). LARC is now considered first line contraception for all women but its uptake is still low. The Beach Study found that if women seeking contraception were given free access to the contraception of their choice, with no barriers, 67% of women would prefer a LARC.
Unplanned pregnancy: In a survey conducted at Middlemore Hospital, 54% of women reported that their pregnancies were unplanned: 62% of Pacifika women and 88% of Maaori women. Of the 16 women in the survey who were under 21, all of them had not planned their pregnancy. This demonstrates the “unmet need for family planning” and suggests inequities in access to contraception with particular disadvantages for Maaori and Pacifika women and young people.
The effect of poverty: Over half of all births in New Zealand in 2015 were to women living in quintile 4 or 5 neighbourhoods. Maori and Pacifika women are clustered in quintile 4 and 5 as shown in the table below.
 
Thirty seven percent of New Zealand’s Pacific Island people live in Counties Manukau and 76% of the Pacific Islanders of them live in the most socio-economically deprived areas in New Zealand. Pacifika women make up the largest proportion of births (30.6%) at Counties Manukau Health.
The women’s story: The stories of our women, collected from focus groups and freely shared in situations where LARCs are being made available, are incredibly moving and suggest there is a huge unmet need for contraception and for LARCs. Anecdotally, one of our midwives who agreed to help with the insertions of Jadelle on the post-natal ward has become a very strong advocate for LARCs after experiencing the appreciation and relief expressed by women who have received this service.
About LARCs
LARCs are described as “fit-and-forget contraception”, as their failure rate is not user-dependent, which makes them very suitable for the young and for women with busy and complex lives. Once Jadelle is removed the woman returns rapidly to fertility; ideal for spacing children and also for family completion. Jadelle have only been available in New Zealand since August 2010. Not all GPs are confident or skilled in the insertion of LARCs which may influence the options they present to women.
 
Postnatal Contraception
The provision of contraception to women whilst on the post-natal ward is the most cost-effective and convenient service delivery model. However, it is difficult to provide a service to reach all women. Currently, here is only a very limited number of staff doing Jadelle insertions on the postnatal ward with no service on weekends or outside normal working hours. Postnatal tubal ligations are occasionally performed on high needs women but frequently cannot be done due to pressures on theatre time. Immediate postpartum IUDs are currently not being inserted in Counties Manukau.
To accommodate the growing number of women requesting postnatal LARC insertions funding has been made available to primary care facilities for these insertions.  Whilst this is providing a more timely service than the previous referral to a secondary care clinic, there is concern over the high DNA rate of these new mums who already have to manage a new baby in a high needs area.
 
Vasectomy
Counties Manukau Health funds a vasectomy service for partners of post-natal women within 6 months of birth; services for women requesting termination and those requesting tubal ligation. Funding based on other criteria including family size has recently been withdrawn. This funding has provided vasectomies to men from high deprivation areas twice as often as men from low deprivation areas, but the numbers of Maaori or Pacifika men receiving this service are still relatively low.
 
Health Equity Project
Ko Awatea and CM Health have initiated a Health Equity campaign with the vision of reducing health disparities experienced by Maaori and Pacific communities by December 2020.  Women in high deprivation areas, Maaori and Pacific women need to be offered appropriate contraception. This project has removed barriers related to the cost of LARC insertions for women in Otara and is working on understanding other barriers within the GP practices, and build on women’s awareness or experience of LARCs.
A model for change has been introduced as illustrated by the following figure which highlights some of the change ideas being explored.
 
The future
At a recent focus group discussion with Maaori and Pacifika women who had recently given birth, the women surprised us by saying, “why are you working with doctors and the nurses, let us know what is there for us.” This is a challenge to go out into the community; to discuss, to challenge and inform women.  The social, economic and health benefits of LARCs have been clearly documented; these should be recognised politically, and funded nationally. Our women, and particularly our Pacifika women, are missing out on appropriate contraception and resulting in many unplanned pregnancies. It is inequitable and unjust.  All women should be informed about contraception, and have timely access to the contraception of their choice. Planned pregnancy provides the opportunity to optimise healthcare and address issues prior to pregnancy; and to give babies the best possible start in life.
 

Recommendation 1
Establish a Comprehensive Cervical Cancer Prevention and Control Programme

• Cervical Cancer is the most common female cancer in the Pacific, contributing to disease burden and causing more than 1,500 premature deaths per year in the region. These deaths can be prevented if pre-cancer status is detected and treated early. Primary and secondary prevention that are effective and practical for Pacific island settings should be pursued.
• The Society made strong commitments to develop a Pacific-oriented guideline on Comprehensive Cervical Cancer Prevention to help countries address this problem. PSRH will embark on collaborating with governments and key partners in the region to pursue this agenda.
• A multi-country Technical Working Group on Cervical Cancer Prevention will be coordinated by PSRH to oversee the development of this programme and facilitate its progress.

 
Recommendation 2
Support Health Workforce Development in Obstetrics and Gynaecology

• The shortage of health workforce in midwifery and obstetrics is a long-standing problem in the Pacific and affects the quality of service delivery in maternal-newborn care. The issue needs to be positioned high in the agenda of development and in the discussions among governments and development partners.
• PSRH is well-positioned to engage in advocacy dialogue with donors and development partners to leverage resources and sponsorship for strengthening health institutions (midwifery schools, Fiji National University and UPNG) to produce adequate health workforce for the region.

 
Recommendation 3
Strengthen the Capacity of Midwifery Training Institutions to produce increased numbers of Midwives to meet national targets
3.1 Shortage of midwives has been a long-standing problem that hinder the provision of essential maternal-newborn care at all levels of the health care system. Increasing the numbers of midwives to fill in the large numbers of vacancies is critical to make progress in quality of care especially at primary care level.
3.2 The Midwifery segment of PSRH Board will work with governments and development partners to reassess the situation in the Pacific and develop strategic plans that are practical and affordable in addressing the issues.
Recommendation 4
Increase Contraceptive uptake and Reduce the Unmet Need for family planning in the Region
4.1 Family planning is an effective intervention for reducing maternal deaths and should be strongly promoted to couples and individuals as an essential component of essential maternal health package.
4.2 PSRH will collaborate with countries, donors and development partners on innovative ways to reach more people with effective contraception, with a focus on long-acting methods of contraception.
 
Other important Recommendations
In addition to the above, the conference discussed other recommendations relevant to the needs of the region. The PSRH Secretariat will endeavor to mobilise partnerships with relevant institutions to partner in these areas. These include:

1. Mainstream the prevention of gender-based violence as part of existing services for women and children. More specifically, screening for GBV using simple practical screening tools can be introduced in clinical settings at all levels of the health care system.
2. Strengthen the practice of functional and effective maternal death reviews as an effective intervention for improving quality of care. PSRH can work with other partners to expand the application of standard methods and templates that can be modified, as appropriate.
3. Explore the establishment of a “surgical skills laboratory” at the two main medical training institutions – Fiji National University and University of Papua New Guinea. The aim is to ensure that graduating doctors are well skilled in conducting operations and perineal repairs.
4. Work in partnership with Ministries of Education in selected countries to support the development of a position statement on the need to incorporate Adolescent Sexual and Reproductive Health Education as a compulsory subject in the school system.

Mr Kelwyn Browne