The PNG Midwifery Leadership Buddy Program: An evaluation.

PROBLEM: Papua New Guinea (PNG) has a high rate of preventable maternal and neonatal deaths. BACKGROUND: Developing midwifery leadership is vital to addressing the current deficits in health outcomes for women and their babies. The PNG Midwifery Leadership Buddy Program responds to this need through leadership training and partnering of midwives across PNG and Australia. Participants in the program undertake a workshop in Port Moresby and commit to a 12-month peer support relationship with a midwife 'buddy'. AIM: To evaluate participants' experiences of the Buddy Program and the impact of the program on leadership skills. METHODS: All 23 midwives who had completed the program were invited to participate in the evaluation. The study used a concurrent mixed methods approach. Qualitative data were collected via interviews and then thematically analysed. Quantitative data were collected via a survey and analysed with descriptive statistics, then findings were triangulated. FINDINGS: Participants reported increased confidence for leadership, action and advocacy. Numerous quality improvement projects were implemented in health services in PNG. Challenges to the success of the program included technological limitations, cultural differences and the COVID-19 pandemic. DISCUSSION: Participants reported the PNG Midwifery Leadership Buddy Program was successful in increasing their leadership skills and collaborative opportunities, as well as strengthening midwifery more broadly. While there were barriers, most participants valued the experience and believed it benefited them professionally and personally CONCLUSION: The Buddy Program provides a practical model for building midwifery leadership capacity that may be transferrable to other contexts.

Emotional responses in Papua New Guinea show negligible evidence for a universal effect of major versus minor music.

Music is a vital part of most cultures and has a strong impact on emotions [1-5]. In Western cultures, emotive valence is strongly influenced by major and minor melodies and harmony (chords and their progressions) [6-13]. Yet, how pitch and harmony affect our emotions, and to what extent these effects are culturally mediated or universal, is hotly debated [2, 5, 14-20]. Here, we report an experiment conducted in a remote cloud forest region of Papua New Guinea, across several communities with similar traditional music but differing levels of exposure to Western-influenced tonal music. One hundred and seventy participants were presented with pairs of major and minor cadences (chord progressions) and melodies, and chose which of them made them happier. The experiment was repeated by 60 non-musicians and 19 musicians in Sydney, Australia. Bayesian analyses show that, for cadences, there is strong evidence that greater happiness was reported for major than minor in every community except one: the community with minimal exposure to Western-like music. For melodies, there is strong evidence that greater happiness was reported for those with higher mean pitch (major melodies) than those with lower mean pitch (minor melodies) in only one of the three PNG communities and in both Sydney groups. The results show that the emotive valence of major and minor is strongly associated with exposure to Western-influenced music and culture, although we cannot exclude the possibility of universality.

Associations of maternal iron deficiency with malaria infection in a cohort of pregnant Papua New Guinean women.

BACKGROUND: Iron deficiency (ID) is common in malaria-endemic settings. Intermittent preventative treatment of malaria in pregnancy (IPTp) and iron supplementation are core components of antenatal care in endemic regions to prevent adverse pregnancy outcomes. ID has been associated with reduced risk of malaria infection, and correspondingly, iron supplementation with increased risk of malaria infection, in some studies. METHODS: A secondary analysis was conducted amongst 1888 pregnant women enrolled in a malaria prevention trial in Papua New Guinea. Maternal ID was defined as inflammation-corrected plasma ferritin levels < 15 µg/L at antenatal enrolment. Malaria burden (Plasmodium falciparum, Plasmodium vivax) was determined by light microscopy, polymerase chain reaction, and placental histology. Multiple logistic and linear regression analyses explored the relationship of ID or ferritin levels with indicators of malaria infection. Models were fitted with interaction terms to assess for modification of iron-malaria relationships by gravidity or treatment arm. RESULTS: Two-thirds (n = 1226) and 13.7% (n = 258) of women had ID and peripheral parasitaemia, respectively, at antenatal enrolment (median gestational age: 22 weeks), and 18.7% (120/1,356) had evidence of malaria infection on placental histology. Overall, ID was associated with reduced odds of peripheral parasitaemia at enrolment (adjusted odds ratio [aOR] 0.50; 95% confidence interval [95% CI] 0.38, 0.66, P < 0.001); peripheral parasitaemia at delivery (aOR 0.68, 95% CI 0.46, 1.00; P = 0.050); and past placental infection (aOR 0.35, 95% CI 0.24, 0.50; P < 0.001). Corresponding increases in the odds of infection were observed with two-fold increases in ferritin levels. There was effect modification of iron-malaria relationships by gravidity. At delivery, ID was associated with reduced odds of peripheral parasitaemia amongst primigravid (AOR 0.44, 95% CI 0.25, 0.76; P = 0.003), but not multigravid women (AOR 1.12, 95% CI 0.61, 2.05; P = 0.720). A two-fold increase in ferritin associated with increased odds of placental blood infection (1.44, 95% CI 1.06, 1.96; P = 0.019) and active placental infection on histology amongst primigravid women only (1.24, 95% CI 1.00, 1.54; P = 0.052). CONCLUSIONS: Low maternal ferritin at first antenatal visit was associated with a lower risk of malaria infection during pregnancy, most notably in primigravid women. The mechanisms by which maternal iron stores influence susceptibility to infection with Plasmodium species require further investigation.

Food Systems Development: The Necessary Paradigm Shift for a Healthy and Sustainable Agrarian Transition, a Case Study from Bougainville, Papua New Guinea.

Classical agricultural development paradigms prioritise basic requirements such as agronomic, caloric and economic needs for the target environment and for beneficiaries. As challenges associated with climate change, globalisation, and population growth compound and amplify one another, project scope must be broadened to take a holistic food systems approach that includes sociocultural and historical contexts, as well as climate impacts as underpinning project design. In this paper, we illustrate the importance of adopting a food systems development paradigm rather than a classical agricultural development paradigm through a case study in Bougainville, Papua New Guinea. The case uses Rich Picturing, targeted and focus-group interviews, and garden visits in remote Bougainville; it provides a poignant illustration of the importance of this more holistic perspective given the historical inefficacy of food systems development, as well as Papua New Guinea's exposure to a plethora of compounding environmental, social, economic, and political stresses and shocks that demonstrate the important linkages between ecosystem services and health. The study aims to demonstrate how including localised gender dynamics, climate vulnerability, rapidly morphing social norms, and climate analogue environments is critical in building food systems resilience and is key to designing policies, programs, and development projects that more effectively address environmental, sociocultural, and health considerations. Building on the inadequacies in agricultural development efforts previously documented for Papua New Guinea, we propose an improved framing for food systems development and identify areas for future research.

Living with thalassaemia in Papua New Guinea, the experience of children, adolescents and their families.

AIM: Thalassaemia, the commonest genetic blood disorder in Papua New Guinea (PNG) presents daunting challenges for the affected children, their parents and families, and the health system. We aimed to describe the quality of life of affected children and adolescents and the experience of and difficulties faced by their parents in the setting of a tertiary referral hospital in PNG. METHODS: A mixed-methods longitudinal study involving baseline questionnaire, then serial interviews with parents, children and adolescents living with ß-thalassaemia attending Port Moresby General Hospital. RESULTS: Twenty-one patients and their families were interviewed over a 6-month period. Most families originated outside the National Capital District and had migrated to be near the Port Moresby General Hospital and its blood bank services. Thirteen patients had at least one affected sibling and four families had experienced the death of at least one other affected child. No child was receiving chelating agents, and most had clinical evidence of iron overload. There were important impacts of thalassemia on quality of life, including very poor school attendance and some aspects of children's self-perception. Families faced significant burdens and made genuine sacrifices to care for their children. CONCLUSION: Regular blood transfusions increase the life-span of children with thalassaemia but there is a need to achieve a hyper-transfusion regimen coupled with chelation therapy. As for all chronic illness, a focused and holistic approach is needed to improve the quality of life for affected children and their families.

Language and ethnobiological skills decline precipitously in Papua New Guinea, the world's most linguistically diverse nation.

Papua New Guinea is home to >10% of the world's languages and rich and varied biocultural knowledge, but the future of this diversity remains unclear. We measured language skills of 6,190 students speaking 392 languages (5.5% of the global total) and modeled their future trends using individual-level variables characterizing family language use, socioeconomic conditions, students' skills, and language traits. This approach showed that only 58% of the students, compared to 91% of their parents, were fluent in indigenous languages, while the trends in key drivers of language skills (language use at home, proportion of mixed-language families, urbanization, students' traditional skills) predicted accelerating decline of fluency to an estimated 26% in the next generation of students. Ethnobiological knowledge declined in close parallel with language skills. Varied medicinal plant uses known to the students speaking indigenous languages are replaced by a few, mostly nonnative species for the students speaking English or Tok Pisin, the national lingua franca. Most (88%) students want to teach indigenous language to their children. While crucial for keeping languages alive, this intention faces powerful external pressures as key factors (education, cash economy, road networks, and urbanization) associated with language attrition are valued in contemporary society.

Balancing it out: A grounded theory of how midwifery students at a faith-based university in Papua New Guinea provide care to women following stillbirth.

Providing care to women following stillbirth affects the well-being of midwifery staff. In this grounded theory study, the authors used focus groups and individual interviews to explore the experiences of midwifery students at a faith-based university in Papua New Guinea. Balancing it Out is the process students used to balance social, cultural and professional factors to achieve their aim of providing the best possible care to women following stillbirth. Provision of holistic care to women following stillbirth and cross-sector health promotion are crucial to attain the best outcomes for women and the midwifery staff who provide their care.

Effects of biochar, compost, and biochar-compost on soil total nitrogen and available phosphorus concentrations in a corn field in Papua New Guinea.

Replenishing soil nutrient particularly total nitrogen (TN) and available phosphorus (P) is important to sustain soil health for food production. Organic amendments such as compost and biochar are commonly applied to improve soil nutrient retention especially N and P. In farms, biochar is usually applied once followed by applying other organic amendment applied in their full rates. Both form and rate of organic amendments can affect soil nutrient concentrations particularly in short term. This study aimed to examine the effects of compost and mixture of compost with biochar (both at full rates) on soil nutrient concentrations in short term. A randomised complete block filed experiment with eight replicates was used for this study. The effects of biochar (5 t/ha) only, compost (at the rates of 10 t/ha, 25 t/ha and 35 t/ha) and biochar mixed with compost (5 t/ha and 10 t/ha, respectively) on soil nutrient concentrations compared with control were explored in a corn field. Compost treatment at the rate of 35 t/ha had significantly higher TN, available P, calcium (Ca) and iron (Fe) compared with other treatments and control. Soil potassium (K) levels remained unchanged among all treatments. Biochar only treatment had significantly higher available P and Ca concentrations compared with biochar mixed with compost treatment. Compost application at higher rate (35 t/ha) proved best practice to significantly increase TN and available P concentrations in short term. Significantly higher available P concentration in biochar only treatment compared with the biochar mixed with compost treatment could have been associated with stimulation of P immobilisation when biochar was mixed with compost. Our results indicated that the form and rate of organic amendments in short term cropping systems are important to be considered while applying to a volcanic soil to ensure N and P availability for plants are not compromised.

Estimating Child Mortality at the Sub-national Level in Papua New Guinea: Evidence From the Integrated Health and Demographic Surveillance System.

BACKGROUND: Child mortality is an important indication of an effective public health system. Data sources available for the estimation of child mortality in Papua New Guinea (PNG) are limited. OBJECTIVE: The objective of this study was to provide child mortality estimates at the sub-national level in PNG using new data from the integrated Health and Demographic Surveillance System (iHDSS). METHOD: Using direct estimation and indirect estimation methods, household vital statistics and maternal birth history data were analysed to estimate three key child health indicators: Under 5 Mortality Rate (U5MR), Infant Mortality Rate (IMR) and Neonatal Mortality Rate (NMR) for the period 2014-2017. Differentials of estimates were evaluated by comparing the mean relative differences between the two methods. RESULTS: The direct estimations showed U5MR of 93, IMR of 51 and NMR of 34 per 1000 live births for all the sites in the period 2014-2017. The indirect estimations reported an U5MR of 105 and IMR of 67 per 1000 live births for all the sites in 2014. The mean relative differences in U5MR and IMR estimates between the two methods were 3 and 24 percentage points, respectively. U5MR estimates varied across the surveillance sites, with the highest level observed in Hela Province (136), and followed by Eastern Highlands (122), Madang (105), and Central (42). DISCUSSION: The indirect estimations showed higher estimates for U5MR and IMR than the direct estimations. The differentials between IMR estimates were larger than between U5MR estimates, implying the U5MR estimates are more reliable than IMR estimates. The variations in child mortality estimates between provinces highlight the impact of contextual factors on child mortality. The high U5MR estimates were likely associated with inequality in socioeconomic development, limited access to healthcare services, and a result of the measles outbreaks that occurred in the highlands region from 2014-2017. CONCLUSION: The iHDSS has provided reliable data for the direct and indirect estimations of child mortality at the sub-national level. This data source is complementary to the existing national data sources for monitoring and reporting child mortality in PNG.

Measuring unmet need for contraception among women in rural areas of Papua New Guinea.

Located in the South West Pacific region, with a population of 7.5 million, Papua New Guinea (PNG) is among a group of Pacific countries with sub-optimal health status. The maternal mortality ratio is 171 per 100,000 live births. Unmet need for contraception and family planning services, although poorly understood in PNG, may be one of the underlying causes of poor maternal health. This study set out to measure the prevalence and trends in unmet need for contraception and the identified socioeconomic factors associated with contraceptive use among women of reproductive age (15-49 years) in PNG. Data available from the Integrated Health and Demographic Surveillance System (IHDSS) were used in this study. A sub-population data set was extracted of 1434 women who gave birth in the preceding two years and resided in four rural surveillance sites: Asaro, Hides, Hiri and Karkar. Analyses of unmet need for contraception were performed with respect to birth spacing and limiting the number of births. Unmet need for contraception was 34% for the previous birth, 37% for the current pregnancy, and 49% for future family planning. The total unmet need for contraception was 35%, of which 49% was for spacing births and 51% for limiting births. Women's age, education and household wealth are the most significant determinants of unmet need for contraception. The high level of unmet need for contraception may contribute to women's poor health status in PNG. Urgent programming responses from the health sector for supporting effective interventions to increase availability and utilisation of contraceptives are required.

Limits to commercially iodized salt to address dietary iodine deficiency in rural Papua New Guinea.

BACKGROUND AND OBJECTIVES: Fortifying commercial table salt with iodine is the principal strategy used globally to prevent dietary iodine deficiency. However, the costs of providing fortified salt to remote communities may result in it not being locally available or too expensive for many households. This study shows that barriers to consuming adequately iodized salt remain significant for remote rural households in Papua New Guinea (PNG). METHODS AND STUDY DESIGN: Using data from a rural household survey conducted in four areas of PNG in 2018, two issues are examined. First, we contrast the characteristics of households that reported consuming or not consuming iodized table salt, respectively. Second, the adequacy of the iodine content of samples of table salt consumed was assessed in the laboratory. RESULTS: Nine percent of the 1,026 survey households reported not consuming iodized table salt. These households tend to live in remote communities, are among the poorest households, have received no formal education, and have experienced recent food insecurity. Second, 17 percent of the 778 salt samples tested had inadequate iodine. The brand of salt most commonly consumed had the highest share of samples with inadequate iodine levels. CONCLUSIONS: Particularly in remote communities, ensuring that individuals consume sufficient iodine will require going beyond salt iodization to use other approaches to iodine supplementation. To ensure that the iodine intake of those using commercial table salt is adequate, closer monitoring of the iodine content in table salt produced or imported into PNG and enforcement of salt iodization regulations is required.

Papuan mitochondrial genomes and the settlement of Sahul.

New Guineans represent one of the oldest locally continuous populations outside Africa, harboring among the greatest linguistic and genetic diversity on the planet. Archeological and genetic evidence suggest that their ancestors reached Sahul (present day New Guinea and Australia) by at least 55,000 years ago (kya). However, little is known about this early settlement phase or subsequent dispersal and population structuring over the subsequent period of time. Here we report 379 complete Papuan mitochondrial genomes from across Papua New Guinea, which allow us to reconstruct the phylogenetic and phylogeographic history of northern Sahul. Our results support the arrival of two groups of settlers in Sahul within the same broad time window (50-65 kya), each carrying a different set of maternal lineages and settling Northern and Southern Sahul separately. Strong geographic structure in northern Sahul remains visible today, indicating limited dispersal over time despite major climatic, cultural, and historical changes. However, following a period of isolation lasting nearly 20 ky after initial settlement, environmental changes postdating the Last Glacial Maximum stimulated diversification of mtDNA lineages and greater interactions within and beyond Northern Sahul, to Southern Sahul, Wallacea and beyond. Later, in the Holocene, populations from New Guinea, in contrast to those of Australia, participated in early interactions with incoming Asian populations from Island Southeast Asia and continuing into Oceania.

Evaluation of Cypholophus macrocephalus sap as a treatment for infected cutaneous ulcers in Papua New Guinea.

Cypholophus macrocephalus sap is used to treat bacterially infected cutaneous leg ulcers in Papua New Guinea. High resolution LC-MS analysis of the sap revealed it to be rich in sulphated flavonoids. We assessed the effects of the sap on the differentiation and pro-inflammatory anti-microbial responses of M1 macrophages using IL-6 and TNF-α ELISAs and found significant increases in M1 macrophage IL-6 expression with concentrations as low as 243 ng/ml sap. Neutrophil IL-6 and TNF-α expression was also significantly increased but to a lesser degree. Matrix metalloproteinases (MMPs) 1, 2, 8 and 9 which are known to contribute to the toxic nature of wound exudates were inhibited by the sap at 24 µg/ml. The sap was tested with several bacterial species known to colonize cutaneous ulcers in Papua New Guinea but proved not to be active. Cypholophus sap stimulates pro-inflammatory, anti-microbial M1 macrophage and neutrophil responses at very low concentrations, whilst also inhibiting MMPs. The combination of an enhanced innate immune response and inhibition of MMPs in ulcer exudate, may contribute to the eradication of bacteria and healing of these infected ulcers. The sap concentrations used in these assays are readily achievable in an in vivo context.

Lepiniopsis ternatensis sap stimulates fibroblast proliferation and down regulates macrophage TNF-α secretion.

The sap of the tree Lepiniopsis ternatensis is used as a topical treatment for cutaneous leg ulcers in Papua New Guinea. This study, which is the first investigation of this medicinal plant, examines the effect of the sap on wound healing biology using human-derived primary cell lines. NMR spectra from 1D and 2D experiments revealed the sap to contain a single major component, identified as the polyphenol, trifucol. The sap significantly increased the proliferation of dermal fibroblasts at just 1.3 µg/ml, without influencing keratinocytes, suggesting a fibroblast-specific mechanism of stimulation. It also significantly inhibited TNF-α secretion by pro-inflammatory M1 macrophages, but not from neutrophils, at 130 µg/ml. The low toxicity of the sap towards dermal cells along with its fibroblast stimulation activity and downregulation of macrophage TNF-α makes it a potentially attractive agent to promote dermal wound healing in chronic non-healing ulcers.

Iodine status of non-pregnant women and availability of food vehicles for fortification with iodine in a remote community in Gulf province, Papua New Guinea.

Adequate iodine status of women of childbearing age is essential for optimal growth and development of their offspring. The objectives of the current study were to assess the iodine status of non-pregnant women, availability and use of commercial salt, extent to which it is iodised, and availability of other industrially processed foods suitable for fortification with iodine. This prospective cross-sectional study was carried out in 2018 in a remote area in Gulf province, Papua New Guinea. Multistage cluster sampling was used to randomly select 300 women visiting local markets. Of these, 284 met study criteria of being non-pregnant and non-lactating. Single urine samples were collected from each of them. Discretionary salt intake was assessed; salt samples were collected from a sub-sample of randomly selected households. A semi-structured, pre-tested questionnaire to assess use and availability of commercial salt and other processed foods was modified and used. Salt was available on the interview day in 51.6% of households. Mean iodine content in household salt samples was 37.8 ± 11.8 ppm. Iodine content was below 30.0 ppm in 13.1% and below 15.0 ppm in 3.3% of salt samples. Mean iodine content of salt available at markets was 39.6 ± 0.52 ppm. Mean discretionary intake of salt per capita per day was 3.9 ± 1.21 g. Median UIC was 34.0 µg/L (95% CI, 30.0-38.0 ppm), indicating moderate iodine deficiency. For women with salt in the household, median UIC was 39.5 µg/L (95% CI, 32.0-47.0 µg/L), compared to median UIC of 29.0 µg/L (95% CI, 28.0-32.0 µg/L) for those without salt. This community has low consumption of iodised salt, likely due to limited access. Investigation of other industrially processed foods indicated salt is the most widely consumed processed food in this remote community, although 39.8% of households did use salty flavourings.

Occupational Health and Safety in the Palm Oil Industry: A Systematic Review.

BACKGROUND: The palm oil industry is the largest contributor to global production of oils and fats. Indonesia and Malaysia are the largest producers of palm oil. More than a million workers are employed in this industry, yet there is a lack of information on their occupational health and safety. OBJECTIVE: To identify and summarize occupational hazards among oil palm plantation workers. METHODS: A search was carried out in June 2018 in PubMed, Web of Science, Scopus, and Ovid. Relevant publications were identified by a systematic search of four databases and relevant journals. Publications were included if they examined occupational hazards in oil palm plantation workers. RESULTS: 941 publications were identified; of these, 25 studies were found eligible to be included in the final review. Of the 25 studies examined, 19 were conducted in Malaysia, 2 in Costa Rica, and one each in Ghana, Indonesia, Myanmar, Papua New Guinea, and Cameroon. Oil palm plantation workers were found to be at risk of musculoskeletal conditions, injuries, psychosocial disorders, and infectious diseases such as malaria and leptospirosis. In addition, they have potential exposure to paraquat and other pesticides. CONCLUSION: In light of the potential of palm oil for use as a biofuel, this is an industry with strong growth potential. The workers are exposed to various occupational hazards. Further research and interventions are necessary to improve the working conditions of this already vast and growing workforce.

Understanding the interactions between iron supplementation, infectious disease and adverse birth outcomes is essential to guide public health recommendations.

Pregnant women are highly susceptible to anaemia and iron deficiency due to the increased demands of pregnancy as well as other factors. Iron supplementation is recommended in pregnancy, yet the benefits on newborn outcomes are variable between populations, most likely due to the heterogeneity in the prevalence of iron deficiency, detrimental birth outcomes and infectious diseases. Furthermore, there are concerns regarding iron supplementation in malaria-endemic areas due to reports of increased risk of malaria in those receiving iron. This is compounded by limited knowledge of how iron deficiency, anaemia, malaria, and other infections may interact to influence birth outcomes. In a recent cohort study in Papua New Guinea, where there is a high burden of infections and iron deficiency, we found that iron deficiency in pregnancy was associated with a reduced risk of adverse birth outcomes. However, this effect could not be wholly explained by interactions between iron deficiency and malaria. We proposed that iron deficiency may confer a degree of protection against other infectious pathogens, which in turn caused improvements in birthweight. We argue that further studies in multiple populations are crucial to elucidate interactions between iron status, iron supplementation and birthweight as well as to understand the context-specific benefits of iron supplementation in pregnancy and inform public policy. Focus should be given to haematological studies on anaemia, haemodilution and iron absorption, as well as investigating infectious diseases and other nutritional deficiencies. This is a particular priority in resource-constrained settings where the prevalence of iron deficiency, poor nutrition, infections and poor birth outcomes are high. While current recommendations of iron supplementation and malaria prophylaxis to reduce the burden of poor pregnancy outcomes should be supported, the strength of evidence underpinning these must be improved and new insights should be garnered in order to maximise improvements in maternal and child health.Please see related article: https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-018-1146-z .Please see related article: https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-019-1375-9 .

Epilepsy in Papua New Guinea: a longitudinal cohort study.

Epilepsy affects up to 1-4% of children living in low income and middle countries, however there are few studies of the problems faced by children with epilepsy in such settings. We aimed to document the situation for children with epilepsy in Port Moresby, an urban area in Papua New Guinea, a low-middle income country in the Western Pacific region. We conducted longitudinal cohort study using mixed methods, with serial data collected over 2 years which assessed seizure control, neurodevelopment, and structured interviews with children and parents. For quantitative data descriptive statistics are reported; for qualitative data common responses, themes, experiences and perceptions were grouped and reported in narrative. Forty-seven children with epilepsy were followed for a median of 18 months. Twenty six (55%) children had some associated neurodevelopmental disability. Children gave detailed and vivid descriptions of their experience of seizures. Most children and parents had a positive view of the future but faced many challenges including financial difficulties, fear of having seizures especially at school, restriction of activity that isolated them from peers, and significant stigma and discrimination. Seizure control improved over time for some children, but inconsistent supply of phenobarbitone hindered better control. Comprehensive care for children with epilepsy requires a good knowledge of the individual patient -including their seizure type and comorbidities, their family, and their strengths and vulnerabilities. Children with epilepsy face many problems that can lead to isolation, discrimination and restricted opportunities.

The effects of tree spacing regime and tree species composition on mineral nutrient composition of cocoa beans and canarium nuts in 8-year-old cocoa plantations.

The selection of shade trees with appropriate spacing is important for minimising their impact on nutrient accumulation by understorey cash crops in agroforestry systems. Cocoa trees may be intercropped with overstorey legume or non-legume shade trees. A legume tree and/or a non-legume timber tree with edible kernels (Gliricidia sepium and Canarium indicum, respectively) are used as shade trees in cocoa plantations particularly in Papua New Guinea. This study explored the nutrient concentrations of cocoa beans in response to both tree-shade species and shade-tree spacing regime. The study also investigated the extent to which C. indicum tree spacing altered the nutrient concentrations of canarium kernels. G. sepium trees in the study had a final spacing of 12 m × 12 m while the spacing regimes of either 8 m × 8 m or 8 m × 16 m used for C. indicum. The calcium (Ca) concentrations of cocoa beans did not differ significantly between plants located next to G. sepium and plants located next to C. indicum. Cocoa beans next to C. indicum trees with spacing of 8 m × 16 m had higher potassium (K) concentrations than those next to G. sepium trees. However, phosphorus (P) concentrations of cocoa beans next to C. indicum trees with spacing of 8 m × 8 m or next to G. sepium trees were significantly higher than those next to C. indicum trees with spacing of 8 m × 16 m. The K concentrations in cocoa beans and soil were not correlated nor were the P concentrations in cocoa beans and soil. Correlations between nutrients in leaves and cocoa beans, or between leaves and canarium kernels, were not strong. Our results suggest that cocoa and canarium trees can be intercropped successfully, and that they do not compete for soil nutrients.

Women's knowledge of maternal danger signs during pregnancy: Findings from a cross-sectional survey in Papua New Guinea.

OBJECTIVE: To explore knowledge of pregnancy related danger signs among women attending antenatal clinics in Papua New Guinea. DESIGN: Cross-sectional survey undertaken as part of a wider integrated health and demographic survey. SETTING: Three sites in Papua New Guinea: Hiri District (Central Province), Karkar (Madang Province) and Asaro (Eastern Highlands Province). PARTICIPANTS: 482 women aged 15-44 years. FINDINGS: Almost all (95.2%; 459/482) women attended for antenatal care at least once; 68.2% attended four or more times. Among women who attended the antenatal clinic, 53.6% (246/459) reported receiving information about danger signs in pregnancy from a health worker. Of these 60.2% (148/246) could recall at least one danger sign. In addition, 16.4% (35/213) of women who did not receive information from the antenatal clinic reported pregnancy related danger signs. Among the 183 women who reported danger signs, 47.5% (87/183) reported fever; 39.3% (72/183) reported vaginal bleeding and 36.6% (67/183) reported swelling of the face, legs and arms. Women who reported receiving information at the antenatal clinic were significantly more likely know any danger signs, compared with women who did not receive information at the antenatal clinic (OR 7.68 (95%CI: 4.93, 11.96); p = <0.001). Knowledge of danger signs was significantly associated with secondary school education, compared with none or only primary education (OR 3.08 (95% CI: 2.06, 4.61); p = <0.001). CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Every antenatal clinic visit should be used opportunistically to provide women with information about key danger signs during pregnancy and childbirth. Recognising maternal danger signs, together with the importance of seeking early transfer to the health facility and the importance of attending for a health facility birth are critical to improving outcomes for mothers and babies especially in low income settings such as Papua New Guinea.