In this issue of the newsletter, we congratulate three ladies on their retirements. They have dedicatedly volunteered and invested immense amount of time and effort in the development of PSRH, in the midst of their professional duties required by their respective employers in the area of women’s health in the Pacific region. Aliote, Carmel and Rufina have now retired as of end June 2018.  For many years, they worked with dedication, commitment and leadership in promoting reproductive health, maternal and newborn care in the region. PSRH and the Pacific families wish them well and a fulfilling retirement.

• Matron Aliote Galuvakadua retired from Fiji Government as Matron of the CWM Hospital
• Ms Carmel Walker, Senior Coordinator for the Global Health Unit, retired from the Royal Australian and NZ College of Obstetricians & Gynaecologists
• Dr Rufina Latu retired from the World Health Organisation as Medical Officer for MCH, Papua New Guinea

Matron Aliote Galuvakadua Retires

After providing 33 years of professional duties in nursing and midwifery, Matron Aliote retires from Fiji civil service. Aliote graduated from nursing in 1985, a profession she had committed her life to. In 1995 she completed her midwifery training, she worked in CWMH hospital and its Anderson maternity unit for these 33years and in July 2009, Aliote became the maternity unit Matron. Anderson maternity unit is the maternity unit of Fiji’s largest hospital, the Colonial War Memorial Hospital in Suva. In this position, she was a midwifery leader, a supervisor, a manager, and a mentor for midwives.

Matron Aliote had the honour to serve as 3rd President of the Fiji Midwifery Society. In this role, she dedicated 9 years of professional guidance and leadership to benefit other midwives in Fiji and the Pacific. In May this year at the occasion of the International Day of Midwives, she handed over the President’s role to the Society in anticipation of her retirement in early June.

Matron Aliote’s passion for midwifery extended to reach other Pacific countries through her involvement with the Pacific Society for Reproductive Health. She was elected into the PSRH Board in 2011 at the BGM held in Honiara, Solomon Islands. Aliote moved up to become the first Pacific midwife to hold the position of vice president (midwifery) for PSRH for six years.  

At her farewell she remarked, “I am assured that my co-workers will continue the work we have established together, setting midwifery standards in our main hospital. They have the knowledge and the skills and I trust that all will go well. It has been a fulfilling and rewarding experience to service my country as a midwife.”

Carmel Walker Retires

Ms Carmel Walker is retiring from The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) in June 2018, after 32 years of service, most of those years providing support to the Pacific region through development of the human resources capacity of Pacific O&G specialists, midwives and reproductive health workers.  Carmel was an integral player in the establishment of our Society, originally named the South Pacific Regional Obstetrics and Gynaecology Society (SPROGS) in 1995 but renamed to PSRH in 1997.  She was the Executive Assistant until 1999 when the secretariat moved from Melbourne to Fiji and continued to take a senior role in arranging and sourcing funds to support the attendance of Pacific doctors and midwives at our PSRH Biennial Meeting since then.   Within RANZCOG, as Senior Coordinator of the Global Health Unit, Carmel was involved in the establishment of Associate Membership and the CPD Program for Pacific O&G Specialists which today boasts 60 Pacific Associate Members, and is the envy of colleagues in other specialties in the Pacific, and she has continued to manage and improve this area.  She has also managed the Brian Spurrett Fellowships since 2004 and the RANZCOG Pacific Midwifery Leadership Fellowship Program through Australia Awards, since 2010 until now – a total of 120 Fellowships for midwives.   In 2011, Carmel was awarded the inaugural PSRH President’s medal in acknowledgement of her contribution to training and development of reproductive health workforce.

“I am blessed that my position at the College has allowed me to make a real contribution to the Pacific reproductive health workforce.  Working with Pacific doctors, midwives and College colleagues has taught me resilience and patience, but it has also given me great joy in seeing the results of development opportunities for my Pacific colleagues.  I’ve learnt over the years that little changes can make a big difference, that empowering people to be their best will bring out the best in them, and that by working together we can achieve more than we ever can by ourselves.  

Observing the growth in the O&G workforce over the past thirty years has been inspiring, given an ever-changing environment with ongoing health, system and resource challenges, as well as natural disasters that can, and do, strike at any time.  However, our Pacific O&G and midwifery workforce is well connected and supportive of each other.  They are aware of their leadership responsibilities, and are committed to developing their own knowledge and skills, finding solutions to challenges and thinking of new ways to improve women’s health in their settings.

As well as our O&G workforce, I am inspired by and proud of our Pacific midwifery network, and in particular, those with whom I have worked through the RANZCOG Brian Spurrett Fellowships since 2004, and since 2010, the Pacific Midwifery Leadership Fellowship Program held in Sydney and Auckland.

Working with our team of program facilitators at the Nepean and Liverpool Hospitals, we have enabled many Pacific midwives to raise their status as seen through the eyes of their colleagues, and to make a higher level of contribution to their maternity and reproductive health care services.  Each group of midwives who come to Sydney for the midwifery leadership program excite me with their potential and enthusiasm for returning as motivators for change on their return home.

But for now it’s time for me to step back – chill out – and take a break to do some travelling around Australia.  My plans are to relocate to Queensland, not far from Cairns, where I can move onto new challenges and projects where I can help other people with their lives.

It has been an enormous pleasure and joy to work with my PSRH colleagues and my strong ties and love for the Pacific won’t be diminished, that’s for sure.  I will continue to keep in touch with so many friends and colleagues well into the future.   I wish you all the very best as you continue to provide quality care to families across the Pacific, and be the best you can be.”

Dr Rufina Latu Retires 

Dr Latu retires after working with WHO for nine years.

“What a rewarding feeling to have contributed to health and development in the Pacific during the past 37 years. It has been a fulfilling experience of delivering health services, managing health programs, providing peer support; and facilitating capacity building, networking, strategic engagement, leadership and professional growth.”  

Prior to retirement, Dr Latu was Team Leader for Maternal and Child Health programme with the World Health Organization based in Port Moresby in Papua New Guinea.  In this position, she worked with PNG government at national and provincial level, UN agencies, international and national NGOs, health training institutions, and professional bodies such as the O&G Society, Paediatric Society and Midwifery Society of PNG. She has wide Pacific experience and worked for more than 25 years in the Pacific countries in the areas of health systems strengthening, service delivery, public health, non-communicable disease, family planning, reproductive health, maternal-newborn, child and adolescent health, and primary health care. On longer-term technical advisory role, she has worked in PNG, Fiji, Vanuatu and Tonga, providing support to governments in the development of programmes and services.

Dr Latu has been a pioneer member of PSRH and contributed to its growth and development since its inception in 1995. She attended all PSRH biennial conferences except the Madang meeting (PNG) in 2001. The most recent one was in Port Vila, Vanuatu in 2017 where she was chair of the scientific committee and assisted the PSRH Secretariat in the preparation of the conference agenda. She also carried out a number of key voluntary contributions to the work of PSRH and included taking on the role of President, a member of the PSRH committee, and also volunteered to undertake the editorial functions for the PSRH newsletter over the last four years.

Papua New Guinea:  Bachelors Program in Midwifery – rural attachment
Ms Paula Puawe, Midwifery Coordinator, University of Goroka
The University of Goroka offers a Bachelor of Midwifery program for nurses who have completed a three-year nursing diploma at a school of nursing affiliated with a university. Graduates of the 18 months degree course are awarded a Bachelor of Midwifery. The curriculum links theory and practice to the competency standards of the Nursing Council of PNG. Students must spend 16 weeks in labour ward, four weeks in antenatal clinic, three weeks in special care nursery, five weeks in the obstetrics and gynaecology ward, and eight weeks in a rural health setting.
At the end of the midwifery course, graduates may work in urban hospitals, rural hospitals or health centres in urban, rural in remote settings. Most of the clinical practice is taught in urban hospitals and clinics. In order to prepare students to work in rural environments, eight weeks of clinical practice is conducted in a rural setting. While this allows them to experience resource-scarce environments, they have more contact with the community.  A broader range of skills beyond clinical midwifery is needed in rural primary care setting.
The internship program helps trainee midwives develop community health skills to better respond to the needs of people. It was an opportunity to work in a community setting to understand traditional practices and beliefs about health and maternal and neonatal issues and how they manage at the community level. As most of the students return to work in rural and remote locations after graduation, rural placement is a crucial component of the program. It ensures that students are theoretically and practically prepared to work as midwives in any setting.
A total of 38 midwifery students were divided into five groups and each group was assigned an educator to a rural health centre in Eastern Highlands Province. The rural attachment was conducted for 8 weeks. Each group was to carry out a project in addition to the usual clinical practice in the rural health centre. The five project activities were postnatal home visits, clinical audit, community engagement, newborn care and rural staff capacity building and mentoring. Students gained additional skills especially in the areas of research, clinical audit, community engagement and postnatal home visit as this were all new innovative activities.
Rural health internship is part of the bachelor of midwifery program. The internship provides an opportunity for students to experience rural health practice and to be exposed to challenges and opportunities for improving maternal and newborn health. Both students and educators were positive of the program as it helped to build knowledge and skills in community health and provided rural experience in caring for women, newborns and families.  The project recommended that the internship program becomes a mandatory part of the midwifery course.
 
 

The Health Specialist Centre (HSC) is an innovative social enterprise model which provides private health care. It is a medical centre and a hotel, owned by Aiono Dr Alec Ekeroma and was opened in May 2018.
The HSC has two consulting rooms that will carry out minor/local anaesthetic procedures, a waiting room and a pharmacy/laboratory. The computers in every clinical area links to electronic patient files stored securely in the cloud. The centre is working towards being a paperless operation with specialist entering all data electronically which will assist in discussions with specialists overseas. According to Aiono, the clinical services can be expanded into hotel rooms if there is a demand and a cost-benefit assessment justifies as such in the future. This development has been strategically planned so that as demand grows, expansion of specialist activity to other rooms can occur, as long as new services are justified. Since most specialists are working part time and after-hours, and the clinics structured and rostered, the two rooms currently allocated is sufficient space into the medium term. The specialist centre is in a prime location close to the Tupua Tamasese Meaole (TTM) Hospital and the medical and nursing schools.
The HSC specialists will be credentialed to perform within their scope of practice and will be required to sign a code of conduct that will cover knowledge of patient’s rights, a duty to clinical audit and clinical governance. The contractors will form their own group led by a clinical director and are mandated to develop, sign off and implement clinical protocols and processes such as health and safety, infection control, patient satisfaction. The clinical group will handle all matters of clinical governance.

The Fiji Midwifery Society celebrated International Midwifery Day in a unique way – each health division developed its own event. This allowed the celebrations to take place in three locations at the same time – Central, Northern and Western. Labasa Hospital hosted the occasion in the Northern Division while Lautoka was host for the Western Division. The Central Division celebration was held at Makoi Maternity Unit in Suva.
The theme for the day celebration was “Midwives Leading the Way with Quality Care”, taken from that of the 2018 International Council of Midwives. Our very own Chief Nursing and Midwifery Officer (CNMO), Mrs Selina Waqa Ledua was the Guest of Honour for the day. In her address, she reminded midwives on the concept of Quality Midwifery Care from the clients’ and customers’ perspectives. Quality midwifery care translates to a smiling midwife with compassionate and care when delivering her duties. Student midwives also participated at the occasion and spoke on theme of midwifery-led model. This model will be applied at the new Makoi maternity unit – to showcase innovations in midwifery-led care.
This midwifery event also promoted NCD messages of eating healthy foods, so instead of having a celebration cake, a huge fruit platter was shared. The Hospital Chaplain Rev. Jone Marika conducted the devotion and highlighted the importance of midwives and their biblical roles.
To honour the event, other groups were invited including families of midwives, NGO’s representatives and retired midwives.  The day’s program included a walk through the new Makoi Maternity Unit. This unit will start birthing services by end of June. The CNMO had open talks with midwives to ensure that Makoi Maternity Unit provides quality midwifery care.  Matron Aliote Galuvakadua is the current President of the Fiji Midwifery Society.

Maternal deaths in PNG – a national health crisis
ChildFund Australia reports
ChildFund Australia is an independent and non-religious international development organisation that works to reduce poverty for children in developing communities. The deeper analysis into maternal deaths in PNG by ChildFund has led to the publication of a report titled “A national health crisis: maternal deaths in Papua New Guinea”. The report, published in May 2018, highlighted the high rates of maternal and infant deaths, documented as worsening, particularly in rural areas.
Large proportions of women do not have access to antenatal care and safe delivery. The coverage rates have been low for decades. In some clinics, the number of women attending a proper clinic where there’s trained support, the numbers have reduced in the last five years. The number antenatal care has declined and the situation seem to be worsening, quite the opposite to most of the other countries in the region.
In past years, the government and development partners jointly support MCH interventions including early newborn care, antenatal and postnatal care, childbirth, family planning and maternal death surveillance and response (MDSR) systems. However, implementation has been slow and weak. The challenges of delivering effective MCH interventions are due to a combination of health systems issues and community factors which hinder progress for intended improvements. Poor access to essential health care is fuelled by lack of skilled human resources, poorly maintained and equipped health facilities, lack of basic medicines, poorly managed financial flows, geographical distance between communities and health facilities, and weak leadership and management. In addition, inadequate community knowledge and motivation, and poor health-seeking behaviour contribute to under-utilisation of reproductive health and MCH services. As a result, maternal-newborn services remain sub-optimal in most provinces.
The ChildFund report indicates there is an urgent need for more midwives and better health facilities, particularly in the rural villages and districts where most women are giving birth. Many women end up giving birth at home. Many rural health facilities are often only staffed by volunteers.
The high maternal mortality rate is mainly due to poor access to health care for the large numbers of rural women. This makes common complications such as postpartum bleeding, infection and prolonged and obstructed labour difficult to manage.
Specialist Obstetrician, Dr Mary Bagita, says gaining access to maternity care is tough for rural women where the road conditions are poor, air transport is scarce and facilities like water supply may not exist at their local health centre. She is based in Port Moresby where the hospital also receives referrals from surrounding provinces. Often by the time women reach the hospital, she often is unable to save them.
Access is an important constraint. When women are referred from rural health centres to hospitals for management of life-threatening conditions, they are often too sick to recover and eventually die.  Complex societal issues contribute to poor pregnancy outcomes. In a culture where male dominance is predominant,  poorly educated women can’t speak up for herself. She doesn’t have much control over what she can do. So that adds to problems of pregnant women. Domestic violence has a very negative impact for both mothers and babies as women don’t seek help and feel like there is nowhere for them to go.
Many development partners are in agreement that the challenges can be overcome with sustained effort and sizeable investment at scale. There are many excellent front line health workers who are committed to making a difference in the lives of women and newborn babies. They need so much more support.
The report indicates that while the national policy and strategies are in place, they need better planning, resourcing and co-ordination to deliver health services to the whole country.
To access online copy of the full report, please contact:
ChildFund Papua New Guinea, PO Box 671, Gordons NCD; Tel (675) 3232544; email: admin@childfund.org.pg
 

Urogynaecology is part of gynaecology that is involved in the assessment and treatment of women with pelvic organ prolapse, urinary and faecal incontinence. It is a common problem but often hidden because of embarrassment and shame and a lack of awareness that there is anything that can be done to help. NZ MFAT has supported a project scoping the extent of the problem in Fiji and doing a needs assessment on how to upskill health professionals in this field. It is a multidisciplinary approach with upskilling of nurses, midwives, primary care doctors as well as O&G specialists.
I recently spent a week at Port Vila in Vanuatu with Drs Harry, Tungu and Damutalau assisting in prolapse surgery and teaching the midwives and student midwives about perineal suturing. I was very impressed with their surgical skills and enthusiasm and look forward to working with them again in the future to expand their services in quantity and quality.
If you are interested please contact meat Jackiesmalldridge@gmail.com

My colleague, Dr Louise Tomlinson, myself and others have been developing a program that we hope to launch at the next PSRH meeting in July 2019. This is in response to a need identified by Pacific midwives particularly from remote areas where referral can be difficult if perineal trauma is severe. We want to extend the scope of the perineal suturing workshops that we usually run at the PSRH meetings and across the Pacific at other opportunities. As well as improving knowledge and practical skills, we wish to provide some tools to help the participant going forward. We have developed a laminated flip chart with step by step information about how to identify and repair perineal trauma that can be practically useful on a day to day basis. We hope to provide a set of instruments and appropriate sutures to use. We are working on how best to evaluate this program as it unfolds and have engaged some partners to support us financially.
We also want to identify “champions” in each country who are interested in perineal suturing and can act as mentors and troubleshoot for the participants in their countries. We also want them to help us collect data on how the program is going and how they can become trainers in the future.
If you are interested please contact meat Jackiesmalldridge@gmail.com

Papua New Guinea Midwifery Society is a registered professional body established in 2005. The Society’s main function is to support the professional development of its members in terms of regulation, education and association to promote maternal-newborn services. The society has been a member of the International Confederation of Midwives (ICM) since 2011.
The philosophy lies in the Society’s commitment to support national goals to develop adequate competent midwives to be deployed in all 89 health districts of PNG. The Society is committed to enhancing the skills and passion among midwives to provide comprehensive quality services for women and newborns, and promoting access to a safe supervised delivery. Sister Jennifer Pyakalyia is the President of the Society and has worked tirelessly to keep her members motivated and enthusiastic about midwifery issues.
During the 2018 International Day of Midwives, the PNG Midwifery Society held a national symposium to celebrate the occasion. More than 200 midwives came from provinces to share the universal theme of “Midwives leading the way quality care” through presentations, discussions and networking.  The symposium was officially addressed by the Minister of Health, Hon, Sir Puke Temu whose words of encouragement uplifted the morale of the midwives.

Led by Prof Peter Stone, a one-week training workshop was conducted at the Honiara Referral Hospital for local doctors.
Preparations included pre-trip communication and planning, with national counterpart Dr Leanne Panisi identifying training needs and participants. Prof Stone adapted the workshop structure and schedule to suit local situation.
The training included both basic and advanced sessions in line with the experience of health professionals in O&G ultrasound scanning. Participants were very enthusiastic and there was evidence of immediate use of newly gained knowledge and skills. Working in resource scarce settings, it was not surprising that the main challenges with upskilling ultrasound skills revolved around outdated ultrasound equipment and unavailability of tissue diagnoses for abdominal masses identified on ultrasound scans. Procurement of such equipment is something the local team could discuss with the government. A follow up course with a focus on clinical problem-solving ultrasound is being recommended by the visiting team

Saving Mothers and Newborns – a collaboration between MFAT, Kiribati Ministry of Health and Medical Services, Pacific Society of Reproductive Health and Counties Manukau
In the Pacific Region, 3 women die from childbirth related causes and 30 new-born babies don’t survive following birth, EVERY DAY. Preventing the death of mothers and newborns is a key health priority for Kiribati. NZ MFAT has been supporting staff training for Kiribati Health workers to help address this problem, via the Pacific Emergency Maternal and Neonatal Training Course (PEMNeT).  This is a practical hands on course where midwives, obstetric nurses and doctors train together to manage obstetric and neonatal emergencies well. The PEMNeT course was developed by the Pacific Society of Reproductive Health for use throughout the Pacific.
NZ MFAT funded a Pacific midwife/nurse and a doctor from many PICs to attend the inaugural PEMNeT Facilitator Training Workshop in July 2016 in Auckland. Since then MFAT (via the Counties Manukau Health, Pacific Health Development Unit, and Health Specialists NZ Ltd) has funded Dr Sharron Bolitho, Obstetrician at Christchurch Women’s Hospital to facilitate the implementation of this programme in Kiribati.
A PEMNeT Facilitators Training workshop was conducted from 16-18 April 2018, and immediately following this as part of their training, the Kiribati PEMNeT Facilitator team conducted a 2-day PEMNET course for health staff from Tungaru Central Hospital, Betio Hospital, and the health clinics. The facilitator team includes both doctors and midwives and the School of Nursing & Health (SoNH of Kiribati Institute of Technology) staff. The aim was to strengthen and build the local team, which was achieved.
The local team had many innovative ideas on how to increase the impact and effectiveness of the programme including;

• Adapting and localising the course further to make it really appropriate for Kiribati.
• Rolling out the training to the health centres/clinics based medical assistants, and  nurse/ midwives, at the outer islands
• Designing and supplying an emergency box to every health centre/clinic in Kiribati for use in 2 of the birth emergencies which are the biggest killers of mothers worldwide. These are post-partum (post birth) haemorrhage and preeclampsia/ eclampsia (severe hypertension and seizures). Some Kiribati mothers have died from these causes within the last 10 years.

Much has been achieved with rolling out PEMNeT but there is still a lot of work to be done. This work is part of a wider Kiribati health strategy to build health workforce capacity.  This project is a collaboration between MFAT (NZ), Kiribati Ministry of Health and Medical Services, Pacific Society of Reproductive Health and Counties Manukau District Health Board. This worthwhile work will benefit not only the mothers and babies of Kiribati, but the experience in Kiribati will be able to assist other PICs in making this an effective programme throughout the Pacific. Kiribati could be the leaders in the Pacific Region in PEMNeT!