SUMMARY Antenatal care from a trained health care worker provides the opportunity to promote favourable outcomes for both the woman and her unborn infant. The greatest benefit of antenatal care is seen when the first visit is initiated early in the pregnancy and continued with at least four antenatal visits throughout the pregnancy. In Papua New Guinea (PNG), 66% of women attend for antenatal care at least once during their pregnancy and 51% attend four antenatal visits. We conducted a maternal and infant health survey among 482 women in three sites in PNG, Hiri, Karkar and Asaro, to explore uptake and provision of antenatal care from women’s perspectives. Most women attended for antenatal care (95%; 459/482) at least once and 73% (313/431) attended the recommended minimum four antenatal visits. Women in Hiri (77%) and Asaro (78%) were more likely to attend four or more antenatal visits than women in Karkar (66%). No woman in any site reported receiving the full range of antenatal care, as indicated in the PNG national guidelines. Coverage for tetanus toxoid, malaria prophylaxis and provision of iron supplements were similar in all sites. Women in Asaro were more likely to report being advised about a supervised birth (91%) than women in Karkar (86%) or Hiri (68%). Our findings suggest that the opportunity to monitor for risk factors in pregnancy were missed, including the opportunity to provide messages relating to the importance of supervised, health facility births. There is a need for renewed commitment and resources to enable optimal antenatal care to be provided in accordance with established guidelines if PNG is to make significant improvements in maternal and newborn health.

Summary Poor women in remote areas in many countries remain the least likely to receive adequate health care during pregnancy and childbirth for various reasons. In Papua New Guinea (PNG) there is some documentation regarding why women do not attend for supervised births, but less is known about women’s perceptions and experiences of childbirth in the community or about newborn care practices in the first few hours following childbirth. As part of a wider maternal and infant health survey among 482 women in three sites in PNG, in this paper we describe women’s experiences relating to supervised and unsupervised births and newborn care practices. Among respondents, the majority (95%) reported attending for antenatal care at least once during their most recent pregnancy and almost two-thirds (65%) gave birth in a health facility. Among the health facility births, 88% were assisted by a trained health care worker. Among the women who gave birth in the community, 44% chose to do so. Primiparous women, those aged 15-24 years and women with secondary or tertiary education were significantly more likely to give birth in a health facility than multiparous women, those aged more than 24 years and women with none or only primary education. There were 489 live births, 93% of whom were breastfed. Overall 60% of women knew any danger signs in a newborn infant. Fever was the most frequently mentioned danger sign (81%). Knowledge of danger signs was significantly associated with giving birth in a health facility, being multiparous and having secondary education, compared with village birth, being primiparous and having none or only primary education. Our findings highlight the importance of using the opportunity at antenatal clinic to provide women with information and knowledge, not only on the importance of attending for a health facility birth, but also on the importance of planning and seeking transfer to the health facility early.

In many low-resource settings an estimated one-third of all births take place unsupervised with traditional and non-traditional villager birth attendants the only providers of care during pregnancy and childbirth. The training of village birth attendants (VBAs) in Milne Bay Province began in 1991, and has continued during a period of significant shifts in national and international public health policy. As part of a wider provincial-wide review of the VBA program we undertook 6 focus group discussions, 13 in-depth interviews and 8 key informant interviews in three districts in Milne Bay Province in 2014. In this paper we describe the role, responsibilities and function of VBAs, and the challenges facing both VBAs and those involved in their training and in supporting their work in the community. In this setting, VBAs continue to assist women during childbirth, and are frequently having to try and manage difficult obstetric complications with little or no support from their communities or local health facilities. Some VBAs reported being called too late by the community, with insufficient time to refer women on to a health facility, resulting in maternal deaths. Many VBAs continued with their practice, motivated by a heartfelt desire to serve, despite feeling ‘neglected’ and ‘overlooked’, while others continued because of their religious convictions and dedication to help their communities. There is an urgent need to better define what VBAs can and should do in this setting, what communities can realistically expect of their VBAs, and how professional health care workers can work more constructively with this long-standing cadre of lay health workers. There is a need for all health facilities and VBA trainers to support their VBAs, and to fully recognize the often difficult situations VBAs are required to work in while continuing to advocate for supervised, health facility births.