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Blog

Choose Your Workshops

The pre-conference workshop programme on 30th & 31st August 2022 has something for every health professional. 

It has long been the tradition that prior to the formal Biennial General Meeting there is a two-day programme of technical workshops aimed at improving hands-on skills, learning new techniques and networking with peers from across the Pacific, and the 14th Biennial Conference in Samoa 2022, is no exception to the rule. 

This year we have a number of excellent options for you to consider, and we’re certain the hard part will be choosing only two workshops. 

PEMNet will be operating over two days with a specific emphasis on Training the Trainer. These workshops are an introduction to the newly revised second edition of the popular PEMNet programme, aimed at those who will be tasked with rolling out the programme in their own country in the near future. 

The OASIS workshop is also a very practical workshop programme focused on developing surgical skills and working through the importance of the WHO’s OASIS checklist. This workshop is most appropriate for those who regularly perform surgical duties as it will involve polishing suturing skills and practising other surgical skills. 

For midwives the excellent Midwifery Leadership Workshop presented by Professor Caroline Homer from the Burnet Institute will be as inspirational as it is practical. 

For more information and to select before the workshops sell out, please click through – 

PEMNet 

OASIS

Midwifery Leadership

 

BlogWebinars

Webinar – Learning the lessons from COVID in the Pacific

Register Now!

Thursday 28th April 2022 

An interactive talanoa style discussion on experiences of and lessons learned during the COVID outbreak in the Pacific. 

Panelists will include medical specialists from across the Pacific, including representatives from Fiji, Samoa, American Samoa, and Niue. 

Learn from the experiences of other teams operating during the COVID epidemic.

  • What did they do to safeguard patients’ health? 
  • How did they manage the drain on human resources? 
  • What would they do differently in future outbreaks?
  • How would they prepare their teams for non-COVID times, directly after the intensity of a COVID outbreak?

Panelists Include

Dr Ulai Tapa Fidow

Based in TTM Hospital, Apia Samoa, Dr Fidow graduated with a Postgraduate Diploma in O&G 2012 and a Masters in O&G 2016 from FNU in Fiji. He has been working as a O&G Specialist in Samoa since 2018 andis currently spearheading the development of O&G Guidelines and clinical response, in managing maternal Covid cases in Samoa.

Dr Atropa Belladonna Potoi

Dr Potoi is working at LTP Medical Clinic , Matafele, Samoa. She works as a GP, as a NZ Panel physician and serves on the Samoa Medical Association, and is the current President of the Samoa Medical Council & a Secretary Medical Officer at USP.

Dr Jason Tautasi

Dr Tautasi is a FSM graduate (2014) and has worked in Niue for 5 years as a rural generalist. He is the lead O&G doctor in Niue (past 3 years) and the Lead TB Doctor. He is currently undertaking Postgraduate Diploma in Rural and Provincial Hospital Practice (Otago University).

Dr Folototo Leavai

Dr Leavai is a Gold Medalist Masters of Medicine ( FNU), a School of Medicine part time lecturer, and the Head of Internal Medicine

Dr Bethel Muasau Howard

MBBS, Dip O&G, MMed O&G, Dr Muasau Howard is Chief of OBGYN department at the LBJ Tropical Medical Centre in American Samoa.

Dr Amanda Noovao Hill

Dr Amanda Noovao-Hill

MBBS, DipO&G, MMedO&G, GCMed Dr Noovao-Hill was until recently, a generalist and clinical academic living and working in Fiji. As she winds down her career with the FNU, she intends to continue contributing towards improving Sexual and Reproductive Health in the Pacific through her networks such as the PICCSI project and the Pacific Society for Reproductive Health. .

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Call to Action – Towards the Elimination of Cervical Cancer in the Pacific Islands



Delegates from the following countries and organisations met in Suva, Fiji on 5-6
December 2019 and agreed the Call to Action below:

Delegates from Papua New Guinea, Vanuatu, Solomon Islands, Kiribati, Federated States
of Micronesia, Fiji and Samoa together with representatives of the Pacific Society for
Reproductive Health, Papua New Guinea Obstetrics and Gynaecology Society, Fiji
Obstetrics and Gynaecology Society, Papua New Guinea Institute of Medical Research,
Cervical Cancer Prevention in the Pacific, The Pacific Community (SPC), VCS Foundation,
Royal Australian and New Zealand College of Obstetricians and Gynaecologists, Kirby
Institute at the University of New South Wales, Family Planning Australia, Australian
Cervical Cancer Foundation, Fiji Cancer Society, Fiji National University, University of
Otago, National University of Samoa and Victoria University. Also present were
representatives of the United Nations Population Fund and the United Nations Children’s
Fund.
We agreed to the following principles:

  1. We support the global target to achieve elimination of cervical cancer as a public
    health problem, noting the current high burden of cervical cancer in the Pacific
    and the current lack of adequate vaccination, screening and treatment.
  2. In line with the World Health Organization (WHO) draft targets for 2030, in the
    Pacific our targets are:

    1. a. 90% of girls are fully vaccinated against human papillomavirus (HPV) by
      15 years of age.
    2. b. 70% of women have had an HPV screening test between 30 – 39 years of
      age and a second HPV test between 40 – 49 years of age1.
    3. c. 90% of women identified with cervical pre-cancer and cancer have
      received appropriate treatment and care
  3. We support the principles of equity in striving for the elimination of cervical
    cancer in the Pacific so that no woman or community is left behind.
  4. We support the principle of meaningful collaboration between Pacific Island
    nations in planning, procurement and knowledge sharing.

We are committed to the following actions:

  1. Raising awareness of cervical cancer in the Pacific and its impact on families and
    communities and strengthening advocacy for elimination.
  2. Vaccination
    Exploring funding options including public-private partnerships for ongoing HPV
    vaccination in the Pacific.
    These two tests should be 10 years apart. Clinically validated PCR based tests should be used.
  3. Urging Pacific Island governments to include HPV vaccination against HPV onto
    existing immunization schedules.
  4. Screening
    Urging Pacific Island governments to transition to the delivery of effective cervical
    cancer screening with HPV testing and pre-cancer treatment services.
    Consideration should be given to self-collection of vaginal samples in order to
    facilitate scale up and acceptability.
  5. Treatment:
    Urging cooperation between Pacific Island Governments to establish a treatment
    centre for cervical cancer, including radiotherapy, to act as a referral hub within
    the Pacific.
  6. Workforce:
    Assisting Pacific Island governments and training agencies to develop an essential
    workforce for the delivery of HPV vaccination, cervical cancer screening and the
    management of cervical cancer.
  7. Registry establishment:
    Assisting in establishing an adequate registry to record information about
    vaccination, screening and treatment for the prevention of cervical cancer; and
    with potential linkage to a cancer registry. This will facilitate follow-up of the
    young with incomplete vaccination and women through the screening pathway. It
    will also enable robust monitoring and evaluation of vaccination and screening
    program performance.

For more information, please email/call any of the following:
Professor Alec Ekeroma, HOD, Department of Obstetrics and Gynaecology,
University of Otago, Wellington, New Zealand. E: alec.ekeroma@otago.ac.nz; M:
+64212767975.
Professor Diana Sarfati, Head of Department, Public Health, University of Otago,
Wellington, New Zealand. diana.sarfati@otago.ac.nz
Professor Marion Saville, Executive Director, VCS Foundation, Melbourne, Australia.
E: msaville@vcs.org.au

Blog

Flashback – PSRH in 25 years

The concept of a Pacific Society emerged in 1993 in Suva, Fiji by a group of reproductive health professionals who met at an educational meeting organized by the Fiji School of Medicine and the Royal Australian and New Zealand College of Obstetricians and Gynecological (RANZCOG).  Their vision was to establish a Society that fosters continuing medical education and ongoing support for reproductive, maternal and newborn health among Pacific health professionals. The Society would support various forms of capacity building, partnerships, conferences, meetings and networking.  The name South Pacific Regional Obstetrics and Gynaecology Society (SPROGS) was given at that time. RANZCOG through the commitment of Professor Brian Spurret supported the initiative and made it possible for the Secretariat to be located at the College House in Melbourne during its early development.
1995 – The first inaugural meeting of the Society was held in Port Vila, Vanuatu. A structured executive committee was established to run the affairs of the Society. Dr Wame Baravilala (Fiji) was elected the first President. He was the Dean of the Fiji School of Medicine and Head of Obstetrics and Gynaecology.
1997 – At the biennial meeting in Apia, Samoa the name changed to Pacific Society for Reproductive Health (PSRH), a change put forward by country members to reflect the inclusiveness of country membership.  The term “Reproductive Health” in the Society name also broadens the core business of the Society so that other health professionals become members including midwives, nurses, non-O&G doctors, researchers and academics.
Thereafter, PSRH conferences have been held every two years, preceded by a series of technical skills building workshops on specific topics to respond to the needs of both doctors and midwives. Locations of biennial conferences are listed below:
1999 – Suva, Fiji. The Secretariat was moved to Fiji School of Medicine.
2001 – Madang, Papua New Guinea
2003 – Nadi, Fiji. The Secretariat moved to the Secretariat of the Pacific Community, SPC
2005 – Nadi, Fiji
In April 2006 the Secretariat moved to the Pacific Women’s Health Research & Development Unit which was set up by Dr Alec Ekeroma. The Unit was under the auspices of the University of Auckland and the Counties Manukau District Health Board, New Zealand. The PSRH became registered for the first time as a Charitable Trust with the NZ Charities commission in August 2008 when Salausa Dr John Ah Ching was President and Dr Ekeroma was instrumental in realising that move. The Secretariat was moved to Aiono Dr Alec Ekeroma’s private practice at 525 Remuera Rd, Remuera, Auckland in 2012 as the University no longer had office space for the Trust.
2007 –  Apia, Samoa
2009 – New Zealand hosted (Auckland)
2011 – Solomon Islands hosted (Honiara)
2013 – Samoa hosted (Apia)
2015 – Fiji hosted (Suva)
2017 – Port Vila, Vanuatu
2019 – Port Moresby, Papua New Guinea
 
PSRH Presidents
1995-1999:    Dr Wame Baravilala (First president, Fiji)
1999-2001:    Dr Emosi Puni (Samoa)
2001-2003    Prof Glen Mola (PNG)
2003-2007:      Dr Rufina Latu (Fiji)
2007-2011:    John Ah Ching (Samoa)
2011-2015:    Dr Alec Ekeroma (NZ)
2015-2017:    Ms Kathleen Gapirongo (Sol)
2017-current:    Dr Pushpa Nusair (Fiji)
 
PSRH has gained new heights in the last 25 years of development. It is the only Society in the Pacific whose membership includes doctors, midwives and nurses. It has a unique organization that engages both doctors and midwives in maternal and reproductive health, and has maintained its relevance in the Pacific.

  • Its biennial conferences have been successfully conducted in the last 20 years
  • It has conducted numerous up-skilling training activities for health professionals, inclusive of midwifery and specialist doctors
  • Expended its membership for building a stronger Society
  • Engaged new partners for joint efforts towards common goals
  • Developed stronger links with UNFPA, who has the global mandate for reproductive health
  • Conducted various types of capacity building in collaboration with RANZCOG and other partners
  • Reaffirmed its commitment for a regional initiative and moving together to shape the direction of Reproductive Health in the Pacific.

As PSRH enters its 25th year, we salute the dedicated members of the Secretariat and Board for keeping the organizational affairs afloat.  Appreciation goes to RANZCOG who contributed significantly in the early development of PSRH and continues to assist. We also thank the members across the Pacific, NZ and Australia for your dedication and support; and to the professional partners and donors for believing and trusting in the work that PSRH does.
The future of PSRH depends on a strong Secretariat, an effective Board and dedicated members and partners to work jointly in supporting organizational growth and development.
 

Blog

Message from the President

Dr Pushpa Nusair
Pacific Greetings to our Readers of the PSRH newsletter.
Through this issue of the PSRH newsletter, I am honoured to highlight a number of important PSRH events, on behalf of the Board. First and foremost, I am delighted to share with you that plans are on-track for the 2019 PSRH Biennial Meeting scheduled to take place in Port Moresby in July next year. I was privileged to have visited the O&G Society of PNG a few weeks ago and held discussions with the local organizing committee under the capable hands of Dr Mary Bagita, President of the O&G Society. One of the amazing things I found was the joint collaborative efforts by both the O&G Society and the Midwifery Society in planning next PSRH conference. The launch of the 13th PSRH Meeting was held in Port Moresby on 11th September 2018. The launch was successfully organized by the local committee.
The biennial conference is a major activity of the Society, a unique occasion that allows members and maternal and reproductive health professionals to network, share experience, debate, discuss and agreeing to actions.  This is a meeting not be missed and I encourage you to start planning your mission to Port Moresby ahead of time. The committee reassured me that intending visitors and participants need not be overly concerned about security issues in Port Moresby. We will be taken care of by our local counterparts.
Following the election of the new Board at the last biennial BGM in Port Vila in July 2017, the Board has been kept busy discussing issues on emails and skype. The membership of the Board includes both doctors and midwives and this is particularly important, noting the complementary roles of the two professions when it comes to maternal and newborn care in Pacific settings. In August this year, we held a face to face meeting in Nadi, Fiji which coincided with the conduct of a number of PSRH workshops and the Fiji O&G Society annual symposium.
In February 2018, I was invited by RANZCOG President Dr Steve Robson to hold a meeting in Melbourne. Much to my delight, it was a meeting that led to the establishment of stronger professional ties between RANZCOG and PSRH. An MOU was signed between the two organisations to seal the partnership and to allow for more functional engagements and collaboration that can strategically lead to improved maternal and newborn care in the Pacific.
We do remember that the PSRH conference in 2017 in Vanuatu called for a focus on prevention and management of cervical cancer in the Pacific. Related to this agenda, I was privileged to participate at the Cervical Cancer Meeting in Samoa in May this year. This was a high level meeting organized by the government of Samoa whose invitation extended to international and regional speakers and participation. At this meeting, I facilitated a discussion on developing a Regional Pacific Policy on Cervical Cancer Screening, Management and Prevention.  The discussion was positive and well received but we need to keep the momentum for policy dialogue and even moving towards initial steps for action. At the upcoming PSRH conference in Port Moresby, we will need to revisit this agenda and aim to arrive at some action plans at regional and national levels. We are banking on our partners to assist us with resources, both technically and financially. I call on you all to start taking a thorough country analysis about this subject before the next PSRH conference. Country voices are important in the discussion of what is feasible and what is not for the management and prevention of cancer of cervix.
Urogynecology is often a forgotten topic in health services for women. In Pacific settings, it is often not talked about. Nevertheless, this year PSRH has engaged Dr Jackie Smallbridge to carry out a feasibility study for urogynecology services in Fiji. Results will be shared and if services can be strengthened in Fiji, it is possible to model in other Pacific Island countries.
PSRH worked with Fiji O&G Society to deliver a series of pre-conference workshops. With support of the PSRH Secretariat, Board members and Partners namely RANZCOG, Ministry of Health (Fiji), Fiji National University, UNFPA, SPC and RACs. We organized and successfully ran six workshops. The six workshops were:
 

  • PEMNeT Workshop:  focusing on maternal and neonatal safety
  • Research Workshop:  focusing on Fiji obstetric audit
  • Family Planning Workshop: focusing on Key to SDGs
  • Colposcopy Workshop:  focusing on standardizing care to prevent cervical cancer
  • Palliative Care Workshop: focusing on giving life to days rather than days to life
  • Professional Development Workshop: focusing on leadership and safety in health practice

 
Details of these workshops can be accessed from the PSRH website. The success of these workshops is attributed to the PSRH Secretariat, resource persons, Board members and partners. It was also encouraging to have Board members co-facilitating the workshops. PSRH intends to hold similar preconference workshops at the PSRH Meeting in Port Moresby.

Blog

Annual Symposium of FOGS Fiji Society of Obstetricians and Gynaecologists (FOGS), Suva, Fiji

The annual scientific meeting of the Fiji Society of Obstetricians and Gynaecologists (FOGS) took place on 27th-29th August 2018. Six workshops were delivered in the lead up to this meeting.

The Chief Guest was Professor Alec Ekeroma and the key note address was given by Professor Rajat Gyaneshwar. Both have been key influential agents in the on-going development of PSRH. Other international speakers included Dr Roy Watson from RANZCOG, Ireen Manuel from PSRH, Dr Tapa Fidow from Samoa and the Society of Obstetric Medicine of Australia and New Zealand (SOMANZ) President, Dr Angela Makris who was able to offer clinical advice on the difficult clinical cases via video conference.
The main resolutions from the FOGS 2018 were:

  1. Critical Incident Protocol:  there is a need to develop standard protocols to facilitate reviews of critical obstetric incidents such as maternal and perinatal deaths. This tool helps to review case by case events and facilitates positive learning among team members, and eventually leads to improved care and prevention of unnecessary deaths.  A workshop is planned for February 2019 to further address maternal death reviews.
  2. New partners such as the SOMANZ network offer an additional avenue for discussing complex clinical obstetric cases with Pacific specialists.
  3. Increasing numbers of Fetal Anomalies was raised as a common cause of early neonatal deaths. The meeting advocated for diligence in preconception Folic Acid administration to prevent such events.

The FOGS annual general meeting was also held where it elected a new and younger membership of FOGS Executives. Nevertheless, they will need mentoring and development in during their term of 2 years.  The team plans to hold regular quarterly meetings, initiate a membership drive, conduct workshops on Critical Incident Protocol, Intrapartum Care, Perineal Care, Gynecology and Subfertility; sourcing assistance from PSRH, RANZCOG and the Fiji Midwifery Society.
 
The FOGS meeting ended on a high note. Dr Nitik Ram of CWM Hospital in Suva Fiji had his first phase of research published in The Pacific Journal of Reproductive Health, an independent publication of the Pacific Society for Reproductive Health (PSRH) Charitable Trust and administered by the Pacific Women’s Health Research Unit of the University of Auckland. The Journal began publishing in 2015 as a means to increase research evidence from the Pacific region in collaboration with Pacific-rim countries. PSRH has been working with researchers in the Pacific region to help develop research and audit capabilities and drive research in the workplace.
 
We are very proud of Dr Nitik Ram, pictured here (second from the left) with a number of PSRH founders. We hope more young doctors will follow his footsteps. You can read Dr Ram’s research findings at:
https://pacificjournalreproductivehealth.org/…/issue/current

Blog

Midwifery Training in Vanuatu – making excellent progress towards improved maternal and newborn care

by Christine Jackson, Midwifery Technical Advisor
The first ever Graduate Diploma students of Midwifery in Vanuatu completed the studies in June 2017. This has been a great achievement for the government in training their own midwives and taking ownership in future capacity building in maternal and newborn health. Fifteen trained midwives are now deployed and working in rural hospitals and health facilities.
 
The 15 students were selected from all provinces in Vanuatu, many in remote rural settings. Therefore the students have already been exposed to the challenges of maternal and newborn care, and have dealt with many maternal complications while working in rural health facilities.  It has been a rewarding experience for tutors and facilitators to build capacity on experienced health workers. Ms Christine Jackson (NZ) played a major role in supporting the local team in steering the course and providing technical guidance and assistance to achieve this level of qualification.
 
The application of midwifery skills and knowledge in Primary Health care is pivotal to improving community health, especially maternal and newborn care. Midwifery functions as a key component of the health system and facilitates improved basic care when well integrated in primary healthcare settings. The health of a community is profoundly dependent on the health of the mother and her family. To ensure informed healthy reproductive choices birth spacing is essential. Access to quality, and appropriate antenatal care and removing the “three delays” for seeking safe delivery, ensures quality care in pregnancy and delivery.
 
Six months following the graduation of the first batch of midwifery students, a second cohort of 15 students were recruited to take the same Graduate Diploma of Midwifery. This is in line with national plans of government to train enough midwives so that every health centre has a trained midwife and therefore the capacity to provide quality maternal and newborn care at primary level.
 
The 15 midwifery students have just completed a two-week course on Pacific Maternal & Neonatal Emergency Training. PEMNeT (including Early Essential newborn care, EENC) with funds from Australian government sourced to the Ministry of Health and administered by Vanuatu College of Nursing Education (VCNE). The course aims to upskill midwifery students in emergency obstetric and neonatal care, a core component of their formal 18month training programme.  The workshops allowed the students to interact with other primary health providers so that they learn team work with other categories of health professionals and maximize joint efforts in addressing maternal and newborn health. The ultimate result is to have competent graduate midwives who can provide quality reproductive and maternal-newborn services throughout the six provinces of Vanuatu.

Three male midwifery students come from remote rural areas who have a combined nursing experience for over twenty years. Using acquired critical knowledge they will play an important role in the necessary changes required to improve maternal and newborn outcomes, by implementing safe, respectful and expert midwifery care. These 3 men along with other male midwives will be pivotal in changing the attitudes in a male dominated society, to ensure all women have access to maternal reproductive health.
 
The midwifery students are exposed to both clinical and managerial topics that highlight the importance of the midwife who contributes to reviewing and the development of health policies at local and national levels. On completion of the Graduate Diploma the students will return to their provinces and take up multi-skill midwifery role in health centres and hospitals.
 

Blog

Papua New Guinea – Annual symposium of the PNG Society of O&G

Dr Mary Bagita
The annual scientific symposium was held in Madang during 29-31 August. The President, Dr Mary Bagita delivered the opening address and highlighted the theme of the meeting to focus on adolescent health, “Adolescent Health – a growing challenge”.
 
It was pleasing to see large numbers of O&G Specialists, clinicians, health extension officers, nurses and midwives turn up to the meeting. The host team in Madang, Dr John Bolnga and his colleagues extended a warm welcome to the visitors and made special efforts to keep the discussions interesting and dynamic.  The Society also managed to hold its annual general meeting with its members to discuss its business.
 
At its opening session, a moment of silence was observed in remembrance of Dr John Maku who passed on during the course of the last 12 months. Dr Maku was an expert Paediatrician who dedicated his life in serving his people. The President provided an excellent opening speech which highlighted the achievements of the Society despite the many challenges in providing health care in PNG. She paid tribute to two women: Ms Carmel Walker of the Royal Aust and NZ College of Obstetricians and Gynaecologists and Dr Rufina Latu from WHO, both of whom have made significant support and contribution to the work of the PNG O&G Society and overall support in the Pacific region through the Pacific Society of Reproductive Health. Both ladies recently retired from their respective organisations in June 2018.
 
As was the practice in previous O&G annual symposium, Provincial SMOs made presentations on maternal and newborn statistics and described achievements and challenges. The keynote address was given by Mr Koffi Kouame, UNFPA Country Representative in PNG.  Other speakers included representatives from National Dept of Health, WHO, UNFPA, IPPF and Port Moresby General hospital. Mr Moses Sariki from the Madang Provincial Education Office spoke on the need for educating our young people on Adolescent Sexual and Reproductive Health Issues in PNG. Other relevant topics in line with the theme included: update on the HPV Vaccination, mental health and youth-friendly services. One of the main areas for discussion was prevention of adolescent pregnancy and supporting adolescents to use effective contraception. A panel group discussed how to manage minority groups that oppose contraception.
One of the highlights of the conference was the presentation of research projects by postgraduate students attending University of Papua New Guinea medical school.
 
The research topics included:
 

  • Reasons for not booking to ANC and comparing with the fetal and maternal outcomes for the booked mothers at Popondetta General Hospital – Dr Thomas Aiyak
  • Prevalence of Gestational Diabetes at Vunapope General Hospital – Dr Christine Tipayamb
  • Socio-demographic factors in IUD users at Kundiawa Hospital – Dr Megan Kona
  • A retrospective analysis of the Primary Indications of Caesarean Sections and the Maternal and Fetal Outcomes over 12 months at Kimbe General Hospital – Dr Samson Vava
  • Factors associated with initial Antenatal Care Visit at Buka General Hospital – Dr Oliver Ketauwo
  • Adolescent Pregnancy: A prospective study demonstrating the demographics and pregnancy outcomes in adolescents at Kavieng General Hospital – Dr Pauline Masta
  • Births before Arrival (BBA): Contributing Factors to BBA and Maternal and Fetal Outcomes at Modilon General Hospital – Dr Wendy Sapau

 
 
The 2018 symposium concluded with a panel to discuss “the Way Forward for Reproductive and Maternal Health in PNG, focusing on Adolescent Health”.  The panel was followed with a session to agree on the Resolutions of the meeting. The 2018 O&G Symposium identified the following Resolutions and proposed that the Society and its members take action in order to improve reproductive and maternal-newborn health, with special emphasis on adolescent health.

  • RESOLUTION 1:  Prevention of Adolescent Pregnancy
  • RESOLUTION 2:  Strengthen Adolescent Reproductive Health Services
  • RESOLUTION 3:  Strengthen Maternal Death Reviews to reduce maternal deaths
Blog

Scientific Meetings and Symposiums – Opportunities for Professional Development and Networking

by Prof Rajat Gyaneshwar
The modern day health professional aspires to be up to date in knowledge and skills to be able to provide the best care for their patients. The public expectation is that they will receive the highest level of care with compassion, respect and dignity. In response to these aspirations and expectations the Pacific Society for Reproductive Health (PSRH), national Obstetrics & Gynaecological (O&G) Societies of Papua New Guinea, Fiji and others have been increasingly involved in organizing biennial and annual scientific conferences, symposiums and workshops which bring together health professionals from the region to learn from each other and network. It is heartening that PSRH brings together different cadres involved in the delivery of Sexual and Reproductive Health (SRH) care, acknowledging that quality care requires a team effort to respond to the different aspects of SRH.
 
Professional development recognizes that all of us have the potential to continue to develop increasing levels of expertise as well as improvements in our approaches to deliver quality care.  It also recognizes that unless we are involved in maintaining our skill sets we tend to lose them. Thus an expert’s skills can be lost due to lack of practice. Additionally, it is important that health professionals keep abreast of evidence based best practices so that changes in management approaches are instituted appropriately. What was once best practice at some point in time may have become unacceptable practice.
 
It is important that we as individual practitioners become life-long learners and recognize that learning is our personal responsibility.  This requires regular reading, literature reviews, consultation and research. In addition, we need to search for opportunities to meet with our colleagues and learn through discussion, debating, sharing and listening. Scientific meetings and symposiums provide wonderful events for this. At these meetings we have the rare opportunity to interact with and listen to invited experts who can update us on evidence based practices.
 
The adult learning literature says that adults learn best by sharing and testing out their learning experiences with each other. The learning context must be respectful with plenty of opportunity to interact and to appreciate the exchange of experience. Our experience in the Pacific is that health professionals are most participatory and responsive to interactive learning opportunities. Conference and symposium organisers need to be cognizant of this and therefore capitalize on settings that use interactive participation.
 
From its early beginning in 1993, PSRH has worked to bring together health professionals so they can network and stimulate their learning through professional dialogue and sharing on a regular basis. Over the years, PSRH has linked up with RANZCOG, national O&G Societies, and national Midwifery Societies to broaden and expand the opportunities for adult learning in the field of maternal-newborn health and sexual and reproductive health. It is now 25 years since PSRH was established. Every 2 years it has held a well-structured scientific conference preceded by a number of technical workshops. The midwifery and O&G Societies have similar meetings at country level. Attendances at these meetings have generally been sponsored through donor contribution to PSRH, but sponsorships are becoming more difficult to negotiate. Therefore, it is logical that health professionals should start moving towards self-sponsored participation in these meetings.
 
Having worked in the Pacific for more than 40 years, I am humble to say that I am still learning from fellow professional colleagues. I wish to aspire you all to commit yourselves to doing the best for our patients by maintaining clinical competence and adhering to current best practices in all aspects of safe pregnancy and delivery and overall women’s health.  At every stage of the health profession, everyone should take responsibility for one’s own professional development and as we go up the ladder, we should adopt leadership skills and become role models for junior colleagues.

Blog

Cervical cancer screening and prevention in the Pacific

Glen DL Mola,1 Pamela J Toliman,2 and Andrew J Vallely2,3
1School of Medicine and Health Sciences, University of Papua New Guinea, Port Moresby, Papua New Guinea.
2Papua New Guinea Institute of Medical Research, Goroka, Eastern Highlands Province, Papua New Guinea
3Kirby Institute, University of New South Wales (UNSW) Sydney, Australia
Cancer of the uterine cervix is one of the most common cancers to affect women globally. Estimates from the Global Burden of Cancer Collaboration Group reported that in 2013, there were 485,000 cases worldwide and 236,000 deaths resulting from cervical cancer.1-3 Low- and middle-income countries experience 85% of the global burden of cervical cancer. In Papua New Guinea (PNG) and other countries in the Pacific region, cervical cancer is the most common cancer among women4; in PNG alone, an estimated 1000-1500 women die every year from the disease.5
Cervical cancer is caused by a sexually transmitted infection with certain oncogenic types of human papillomavirus (HPV).  When most people get an HPV infection they mount an immune response and eradicate the infection from their bodies within a few months.  In some people however, the HPV infection is not cleared in this way and the infection persists.6 The precise reasons for this are unclear, but persistence appears more likely following infection with certain HPV types, among women who smoke, and among those living with HIV infection.7 Women who experience persistent infection with one or more oncogenic HPV type are at increased risk of developing cervical pre-cancer and cancer, typically many years or decades after they were first infected.7
The epidemiology of cervical cancer would suggest that it should be relatively straightforward to prevent infection and to screen for the disease.  Nothing could be further from the truth.  Over the past several decades Pacific countries have followed various strategies to try and reduce the burden of cervical cancer, and yet the disease remains the commonest women’s cancer in most settings.
The development of safe, highly-effective HPV vaccines has revolutionised primary prevention for cervical cancer and brought the elimination of cervical cancer as a public health priority within our reach.8  The benefits of protective vaccination have so far however been largely conferred in high-income settings: much more needs to be done to accelerate the introduction and roll-out of HPV vaccine in Papua New Guinea and other high-burden countries in the Pacific.9
Secondary prevention (or screening) is a more difficult issue.  The first screening strategy developed was based on microscopic examination of a cells collected from the cervix and either smeared onto a glass slide (the Pap test) or suspended in a liquid preservative (liquid-based cytology). Specimen collection can only be carried out by a health worker and requires a vaginal speculum examination, which many women find uncomfortable and/or embarrassing. Following collection, specimens are sent away to a specialist laboratory for cytological examination and the results communicated back to the health worker at a later date. Women found to have high-grade lesions on cytology (or ‘cervical pre-cancer’) are then asked to return for colposcopy and biopsy, a procedure requiring considerable gynaecological expertise. Biopsy specimens are sent to a specialist laboratory for histological examination, the results of which then enable health staff to decide the best treatment plan for each woman. Screening programs using such multi-step strategies have been the basis of cervical cancer prevention programs in high-income countries for decades and contributed to the steady decline in deaths due to cervical cancer in these settings.10-12 However, the resource requirements of such programs are high and include the need for highly-trained clinical and laboratory personnel and substantial laboratory capacity. Additionally, the follow-up of women with positive cytology by colposcopy and biopsy requires considerable coordination and resources.
For these reasons, establishing and sustaining cytology-based screening programs in low-income settings has been extremely difficult.13,14 For example, in Papua New Guinea, a cervical screening initiative was established in 1999 by a non-governmental charity (the MeriPath program), and provided a service from more than 30 health facilities in 16 provinces.15 The program was able to achieve only modest coverage however, with around 45,000 women screened over ten years (2001-2011), representing less than 4% of the target population aged 20-59 years. Also, as specimens were sent to Australia for testing, more than half of those found to have high-grade disease were lost to follow-up and therefore did not receive treatment, due to the delay between testing and recall. As such it was concluded that this Pap test screening strategy was not an effective one for the prevention of cervical cancer in this setting.5
Similar experiences globally prompted the World Health Organization (WHO) to recommend alternative approaches to screening in low- and middle-income countries, and in particular, to advocate ‘screen and treat’ strategies based on same-day testing or clinical examination followed by ‘freezing treatment’ of the cervix (cryotherapy) for women who test positive.16 A WHO-endorsed ‘screen and treat’ approach that has been used extensively in low-income settings around the world is visual inspection of the cervix with acetic-acid (VIA) or Lugol’s iodine (VILI). This strategy involves the application of acetic acid or Lugol’s iodine to the cervix and observing aceto-white staining (VIA) or areas where iodine has not been taken up (VILI), that are said to indicate underlying tissue abnormality.  Favourable performance characteristics for the detection of histologically-diagnosed cervical ‘pre-cancer’ (cervical intraepithelial neoplasia (CIN) grade 2 or worse) in research settings17 has led to VIA being advocated as an accurate, low-cost screening strategy, and to its implementation in several low-income settings including Bangladesh, Tanzania and Thailand.18-20 Many countries have however experienced difficulties scaling up VIA while maintaining adequate quality, and have reported much lower sensitivity for the detection of cervical pre-cancer compared to research settings.17-22
In PNG, many of us held out high hopes that this approach would be more successful compared to the earlier Pap test program because it should not be necessary to locate the woman again, as the whole process could be concluded on one day. Pilot testing of VIA in two provincial sites has been disappointing for a number of reasons. First of all the finding that VIA positivity is not associated with HPV infection,23 or with underlying cervical pre-cancer.24 We have also found cervical cryotherapy cumbersome and time-consuming to administer in the clinic; and logistically challenging to sustain due to the need for a continuous supply of carbon dioxide (in our setting, obtained in cylinders transported considerable distances by road from the supplier).
In the last decade, the effectiveness of HPV testing for the detection of cervical pre-cancer and cancer has been demonstrated in large-scale studies,25,26 leading to the introduction of HPV testing for primary cervical screening in many high-income countries. The WHO recently recommended that HPV testing also be integrated into cervical screening programs in low-income settings, and that countries evaluate how best such testing strategies might be introduced and scaled-up.16 In PNG, we are currently evaluating a ‘test and treat’ strategy based on point-of-care HPV testing (using the GeneXpert HPV Test: http://www.cepheid.com/en/cepheid-solutions/clinical-ivd-tests/sexual-health/xpert-hpv) plus same-day treatment using a battery-powered heat probe (the WISAP C3 thermo-coagulator: https://www.thermo-coagulation.com/c3-mobile-coagulator/). The thermo-coagulator is optimised for low-resource settings and can be operated off a standard mains electricity power or via a small battery pack (invaluable for outreach screening activities). Other features of the WISAP C3 thermo-coagulator include a built-in LED examination light, a retractable heat protection safety guard, and a simple easy-to-use handling mechanism for accurate and safe treatment.
We have found that HPV test results using self-collected vaginal specimens (i.e. those collected by women themselves) are as good as test results using clinician-collected cervical specimens.27 We have also found that testing self-collected specimens for HPV infection can be used to identify women with underlying cervical pre-cancer:28 around 92% of women with high-grade disease can be detected and treated if screened by HPV testing alone, compared with less than 50% when screening is based on VIA examination alone (Table 1). This means that HPV testing alone is far more sensitive for detecting women with cervical pre-cancer than VIA examination alone. Only 8% of all women with disease were ‘missed’ (i.e. were not offered treatment) when HPV testing alone was used for screening, compared with 53% of women being missed when VIA examination alone was used to screen. Furthermore, using HPV testing alone to screen resulted in less women being over-treated (13%) compared to VIA examination alone (17%).
Using self-collected specimens means that only those who test HPV positive (around 10-15% of all those screened) require a pelvic examination.  This means that experienced clinical staff can focus their time on providing counselling and treatment for those most at risk of disease. The use of a highly-portable, easy-to-use, battery-powered treatment device that requires 40 – 60 seconds treatment time per patient compared to around 10 minutes treatment time per patient with cryotherapy, has greatly reduced logistical and operational constraints in the clinic, and is also proving highly-acceptable to women. We are now working with colleagues in other Asia-Pacific countries to evaluate our point-of-care ‘test and treat’ approach in other high-burden settings in our region.
We recommend that health policy makers and political decision makers in the Pacific take note of these findings and allocate sufficient funds for HPV vaccination programs to prevent cervical cancer in the next generation, and for HPV testing and pre-cancer treatment in this generation, so that the scourge of cervical cancer can be reduced and eventually eliminated from our communities.
Table 1: HPV testing compared with VIA examination for the detection and treatment of underlying high-grade disease (cervical pre-cancer)

  Women with high-grade disease who were treated appropriately Women with high-grade disease who were not treated (‘missed’) Women without disease who were treated
(‘over-treated’)
HPV testing alone 92% (33/36) 8% (3/36) 13% (64/491)
VIA examination alone 47% (17/36) 53% (19/36) 17% (80/491)

 
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