62957 RePRodUctive HealtH at a GLAnce April 2011 PAPUA new GUineA country context PnG: MdG 5 Status Papua New Guinea (PNG) is a small country with a total MdG 5A indicators population of 6.6 million people. PNG’s economy is weath- Maternal Mortality Ratio (maternal deaths per 100,000 live 250 ering the impact of the global economic crisis well, with a births) UN estimatea robust pace of economic growth.1 Despite its vast natural Births attended by skilled health personnel (percent) 53.0 and mineral wealth, poverty remains a growing concern MdG 5B indicators with nearly 40 percent of the population still subsists on less than US $1.00 per day.2 Contraceptive Prevalence Rate (percent) 32.4 Adolescent Fertility Rate (births per 1,000 women ages 15–19) 65 PNG’s large share of youth population (40 percent of the Antenatal care with health personnel (percent) 78.8 country population is younger than 15 years old2 provides a window of opportunity for high growth and poverty reduc- Unmet need for family planning (percent) 29.8 tion—the demographic dividend. For this opportunity to Source: Table compiled from multiple sources result in accelerated growth, the government needs to in- a The 2006 DHS estimated maternal mortality ratio at 733. vest more in the human capital formation of its youth. Gender equality and women’s empowerment are impor- MdG target 5A: Reduce by three-quarters, between tant for improving reproductive health. Higher levels of 1990 and 2015, the Maternal Mortality Ratio women’s autonomy, education, wages, and labor market participation are associated with improved reproductive PNG has made insufficient progress over the past two decades on health outcomes.3 In PNG, the literacy rate among females maternal health and is not yet on track to achieve its 2015 targets.5 ages 15 and above is 56 percent.2 Nearly three-quarters of adult women participate in the labor force2 that mostly in- Figure 1 n Maternal mortality ratio 1990–2008 and 2015 target volves work in agriculture. Gender inequalities are reflected 400 340 in the country’s human development ranking; PNG ranks 350 300 300 290 124 of 157 countries in the Gender-related Development 270 250 250 Index.4 MDG 200 Target 150 Greater human capital for women will not translate into 85 100 greater reproductive choice if women lack access to repro- 50 ductive health services. It is thus important to ensure that 0 health systems provide a basic package of reproductive 1990 1995 2000 2005 2008 2015 health services, including family planning.3 Source: 2010 WHO/UNICEF/UNFPA/World Bank MMR report world Bank support for Health in Papua new Guinea The Bank’s current Country Assistance Strategy is for fiscal years to 2008 to 2011. current Project: None Pipeline Project: P109323 PG-Health Appraisal date 9/19/2011 Previous health project: None Analytic and Advisory Activities: HIV Integrated Bio-behavioral survey (P109084)—that will result in key data such as prevalence, incidence, trends of HIV/AIDS to inform policy making and effective interventions. A Study on the demand and supply side barriers/constraints of Adolescent sexual and reproductive health in the pacific (1 of the 3 countries being PNG) (P120712). THE WORLD BANK n Key challenges Figure 3 n Use of contraceptives among married women by residence 40 36.7 High fertility 24 overall 30 Fertility has not changed much since 1996 and is still high 22.3 20 among the poorest. Total fertility rate (TFR) dropped slightly from an average of 4.8 births per woman in 1996 to 4.4 births per 10 woman in 2006.6 0 Urban Rural However, urban-rural disparities exist with women in urban Source: DHS Final Report, PNG 2006. areas (3.6) having lower TFR than rural women (4.5) (Figure 2). Similarly, TFR among women in the Highland region (3.9) is en citing lack of knowledge as the main reason for not intend- lower than among women living in the Islands regions (4.6). ing to use contraception. Lack of knowledge (28 percent) and wanting more children (26 percent) are the predominant reasons Figure 2 n total fertility rate by residence women do not intend to use contraception in the future.6 Further, 5 9 percent of women expressed husbands’ or religious opposition 4.4 overall 4 3.6 4.5 while another 9 percent cited health concerns or fear of side- 3 effects. While five percent indicated contraceptives are hard to 2 get, cost is a lesser concern, indicating further need to strengthen 1 family planning services. 0 Urban Rural Poor Pregnancy outcomes Source: DHS Final Report, PNG 2006. Majority of pregnant women receive antenatal care from Adolescent fertility rate is high affecting not only young skilled health personnel (doctor, midwife, or nurse).6 Seventy- women and their children’s health but also their long-term nine percent of pregnant women received antenatal care from education and employment prospects. Births to women aged skilled health personnel with 55 percent having the recom- 15–19 years old have the highest risk of infant and child mortality mended four or more antenatal visits. Still, the quality of these as well as a higher risk of morbidity and mortality for the young antenatal services needs to be improved given that 55 percent of mother.3, 7 In PNG, there are 65 reported births per 1,000 women pregnant women are anaemic (defined as haemoglobin < 110g/L) aged 15–19 years.6 Further, over 21 percent of teenagers age 19 increasing their risk of preterm delivery, low birth weight babies, have had at least one child and 6 percent have had two or more stillbirth and newborn death.9 children. Only 53 percent of women deliver with the assistance of One third of married women use contraception, mostly skilled health personnel with wide urban-rural disparities. modern methods. Twenty four percent of married women use While 88 percent of women in urban areas delivered with the modern contraceptive methods.6 Urban-rural disparities still assistance of skilled health personnel, only 48 percent of their arise: married women in rural areas are less likely to use modern counterparts in rural areas obtained such assistance. Similarly, 75 contraceptive methods than their counterparts living in urban percent of women in the Islands region received assistance from areas (24 percent and 35 percent, respectively) (Figure 3). Inject- skilled birth attendants compared to just 39 percent among the ables are the most commonly used modern method (9.1 percent), Momase region (Figure 4).6 followed by female sterilization (8.6 percent) and pill (4.6 per- cent). Use of long-term methods such as the IUD and implants Figure 4 n Birth assisted by skilled health personnel (percentage) are negligible. by place of residence 100 Unmet need for contraception is high at 30 percent.6 indi- 88.0 80 cating that women may not be achieving their desired family 60 53 overall size.8 Unmet need for contraception is highest among women 48.0 40 with no education (34 percent) as opposed to those with grade 7 20 and above (22 percent). 0 Among countries with available Demographic and Health sur- Urban Rural veys, PNG is the country with the highest proportion of wom- Source: DHS Final Report, PNG 2006. Human resources for maternal health are limited with only 0.05 physicians per 1,000 population but nurses and midwives are national Policies and Strategies that have influenced slightly more common, at 0.53 per 1,000 population.2 Reproductive Health The moderately high maternal mortality ratio at 250 maternal the national Population Policy of Papua new Guinea for 2000–2010 deaths per 100,000 live births indicates that access to and quality includes a reproductive health goal of “ensuring that reproductive of emergency obstetric and neonatal care (EmONC) remains a health services, including family planning, are accessible, afford- challenge.5 able, and available in forms in which are consistent with community values and norms”. the national Health Plan 2001–2010 states that health care respon- Stis/Hiv/AidS prevalence is low but a growing public sibilities at the national level include “secure adequate levels of health concern medicines, contraceptives and other supplies”. PNG has a generalized HIV epidemic with a prevalence of 1.5 the national Health Plan 2011–2020 outlines 8 key results area to percent amongst the general population, however, due to limited improve service delivery and health outcomes; resources and inexistent surveillance system, there has been little Key Result #5 is to “improve Maternal Health” through 4 objectives: action so far and knowledge of STIs/HIV/AIDS and its transmis- 5.1 Increase family planning coverage sion routes needs to be strengthened; although many have heard of 5.2 Increase the capacity of the health sector to provide safe and supervised deliveries HIV (87 percent), few have a comprehensive knowledge of AIDS.6 5.3 Improve access to emergency obstetric care Although 49% of men are aware that using a condom can prevent 5.4 Improve sexual and reproductive health for adolescent HIV transmission, only 35 percent of women do, clearly highlight- ing a knowledge gap and the need for strengthened prevention. n Key Actions to improve RH outcomes • Commodity security—improve in-country commodity distri- Strengthen gender equality bution and supply chain management to ensure timely distri- • Gender inequality in PNG has prevented women not only from bution of commodities especially to rural, hard to reach areas. accessing available services, but also from practicing their RH decision-making rights. Women need to receive more infor- Reducing maternal mortality mation about gender-based violence and how to protect them- selves from GBV. • Focus on rural areas to ensure that women receive adequate number of ANC and PNC visits; ensure women either deliver • Given the importance of the community in the organizational in health clinics or the delivery is assisted by a skilled birth at- setting of PNG, information should be incorporated in com- tendant. munity meetings about women’s rights to reproductive health. Enhanced male involvement and awareness for RH is key to • Due to the shortage of midwife and skilled birth attendant strengthen gender equality and to empower women in achiev- there is a huge need for the government to invest in training ing their RH needs. programs and establish PPPs with NGOs and church centers to ensure the staff is consistently trained and up-to-date with the curriculum. Reducing high fertility • Increase range of family planning (FP) service delivery points Reducing Stis/Hiv/AidS and available providers: increase community based distribu- tion of contraception and improve physical access by “taking • Given the generalized nature of the epidemic there is a need the services to them” through the use of mobile clinics (espe- to invest in information, education and communication activi- cially for long acting permanent methods and long acting re- ties at all ages and for both genders to increase the knowledge versible contraception); related to HIV and reduce the risk of infection. • Improve technical ability and FP skills of staff—develop an ef- • Establish an effective surveillance system and increase PNG’s fective FP training strategy for PNG, establish post-graduate surveillance capacity to improve the national response to the FP education services, and build the FP capacity of providers epidemic. to offer the services according to quality norms and standards. References: 6. Papua New Guinea National Statistical Office. 2009. Papua New Guinea Demographic and Health Survey 2006. Port Moresby, Papua 1. World Bank, country brief. http://go.worldbank.org/2248ALHNB0. New Guinea. Accessed March 10, 2011. 7. WHO 2011. Making Pregnancy Safer: Adolescent Pregnancy. 2. World Bank. 2010. World Development Indicators. Washington DC. Geneva: WHO. Available at http://www.who.int/making_pregnan- 3. World Bank, Engendering Development: Through Gender Equality cy_safer/topics/adolescent_pregnancy/en/index.html. in Rights, Resources, and Voice. 2001. 8. Samuel Mills, Eduard Bos, and Emi Suzuki. Unmet need for contra- 4. Gender-related development index. Available at http://hdr.undp. ception. Human Development Network, World Bank. Available at org/en/media/HDR_20072008_GDI.pdf. http://www.worldbank.org/hnppublications. 5. Trends in Maternal Mortality: 1990–2008: Estimates developed by 9. Worldwide prevalence of anaemia 1993–2005: WHO global da- WHO, UNICEF, UNFPA, and the World Bank tabase on anaemia / Edited by Bruno de Benoist, Erin McLean, Ines Egli and Mary Cogswell. http://whqlibdoc.who.int/publica- tions/2008/9789241596657_eng.pdf. technical notes development Partners Support for Reproductive Health Improving Reproductive Health (RH) outcomes, as outlined in the in Papua new Guinea RHAP, includes addressing high fertility, reducing unmet demand for AUSAid: Health system strengthening, HIV/AIDS contraception, improving pregnancy outcomes, and reducing STIs. prevention, reproductive health funding. The RHAP has identified 57 focus countries based on poor AdB: Rural Enclaves Project, HIV prevention. reproductive health outcomes, high maternal mortality, high fertility and weak health systems. Specifically, the RHAP identifies nZAid: Rural livelihoods improvement, HIV/AIDS high priority countries as those where the MMR is higher than prevention, capacity building for NGOs. 220/100,000 live births and TFR is greater than 3.These countries are eU: Reproductive health. also a sub-group of the Countdown to 2015 countries. Details of the RHAP are available at www.worldbank.org/population. wHo: Health system strengthening, reproductive health, safe motherhood. The Gender-related Development Index is a composite index developed by the UNDP that measures human development in the UnFPA: Reproductive health and rights, FP training, same dimensions as the HDI while adjusting for gender inequality. financial support for emergency procurement of Its coverage is limited to 157 countries and areas for which the contraceptive. HDI rank was recalculated. UniceF: Child protection, under-5 mortality. UnAidS: HIV/AIDS prevention, treatment and care. Marie Stopes: Contraception distribution, HIV/STIs screening, post-abortion care, advocacy. Pathfinder: Gender-based violence, improving RH through community-led efforts, community-based FP project. correspondence details This profile was prepared by the World Bank (HDNHE, PRMGE, and EASHH). For more information contact, Samuel Mills, Tel: 202 473 9100, email: smills@worldbank.org. This report is available on the following website: www.worldbank.org/population. PAPUA new GUineA RePRodUctive HeALtH Action PLAn indicAtoRS indicator Year Level indicator Year Level Total fertility rate (births/woman ages 15–49) 2006 4.4 Population, total (million) 2008 6.6 Adolescent fertility rate (births/1,000 women ages 15–19) 2006 65 Population growth (annual %) 2008 2.4 Contraceptive prevalence (% of married women ages 15–49) 2006 32.4 Population ages 0–14 (% of total) 2008 40.1 Unmet need for contraceptives (%) 2006 29.8 Population ages 15–64 (% of total) 2008 57.5 Median age at first birth (years) from DHS 2006 20.8 Population ages 65 and above (% of total) 2008 2.4 Median age at marriage (years) — — Age dependency ratio (% of working-age population) 2008 73.9 Mean ideal number of children for all women 2006 3.6 Urban population (% of total) 2008 12.5 Antenatal care with health /sonnel (%) 2006 78.8 Mean size of households 2006 5.2 Births attended by skilled health /sonnel (%) 2006 53 GNI/capita, Atlas method (current US$) 2008 1040 Proportion of pregnant women with hemoglobin <110 g/L) 2008 55.2 GDP/capita (current US$) 2008 1253 Maternal mortality ratio (maternal deaths/100,000 live births) 1990 340 GDP growth (annual %) 2008 6.6 Maternal mortality ratio (maternal deaths/100,000 live births) 1995 300 Population living below US$1.25/day — — Maternal mortality ratio (maternal deaths/100,000 live births) 2000 290 Labor force participation rate, female (% of female population ages 15–64) 2008 72.1 Maternal mortality ratio (maternal deaths/100,000 live births) 2005 270 Literacy rate, adult female (% of females ages 15 and above) 2006 55.6 Maternal mortality ratio (maternal deaths/100,000 live births) 2008 250 Total enrollment, primary (% net) — — Maternal mortality ratio (maternal deaths/100,000 live births) target 2015 85 Ratio of female to male primary enrollment (%) 2006 84.3 Infant mortality rate (per 1,000 live births) 2008 53 Ratio of female to male secondary enrollment (%) — — Newborns protected against tetanus (%) 2008 61 Gender Development Index (GDI) 2008 124 DPT3 immunization coverage (% by age 1) 2006 66.8 Health expenditure, total (% of GDP) 2007 3.2 Pregnant women living with HIV who received antiretroviral drugs 2005 1.2 Health expenditure, public (% of GDP) 2007 2.6 (%) Prevalence of HIV (% of population ages 15–49) 2007 1.5 Health expenditure/capita (current US$) 2007 31 Female adults with HIV ( % of population ages 15+ with HIV) 2007 39.6 Physicians (per 1,000 population) 2000 0.05 Prevalence of HIV, female (% ages 15–24) 2007 0.7 Nurses and midwives (per 1,000 population) 2000 0.53 Poorest-Richest Poorest/Richest indicator Survey Year Poorest Second Middle Fourth Richest total difference Ratio Total fertility rate DHS 2006 — — — — — 4.4 — — Current use of contraception (Modern method) DHS 2006 — — — — — 24.3 — — Current use of contraception (Any method) DHS 2006 — — — — — 32.4 — — Unmet need for family planning (Total) DHS 2006 — — — — — 29.8 — — Births attended by skilled health personnel DHS 2006 — — — — — 53.0 — — (percent)