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Maternal mortality remains exceptionally high in Papua New Guinea (PNG) at 733 per 100,000 live births. There has been little, if any, improvement in maternal mortality or maternity services since the 1980s. In 1992-1993 a survey of 550 women in rural coastal areas of Madang Province was undertaken to investigate the prevalence of maternal risk factors and parous women's utilization of and attitudes towards the existing health services. Women were classified as at risk on the basis of previous obstetric complications, parity, stillbirths and neonatal deaths. On this basis 67% of women were classified as being at risk in a future pregnancy. High rates of obstetric complications were reported, with only 42% of women delivering their most recent child in a health facility. There was no statistical difference between those not at risk and those at risk in terms of their use of antenatal care or having been referred for a health centre delivery. The most common reason given for not utilizing the existing health services was lack of access. Most commonly expressed positive perceptions of a health centre delivery were the availability of medical help (59%) and the physical comfort of the health centre (48%). Most common negative views expressed were lack of physical comfort (29%) and the attitudes of staff (11%). Women's opinion on village births was divided. Many (47%) thought that there was nothing good about a village birth and the same percentage cited lack of medical care if problems arose. On the other hand 36% of women thought there was nothing wrong with a village delivery, and 30% cited the care and respect received from relatives as a positive aspect. When asked for suggestions on how services could be improved only a minority of respondents expressed an opinion. Those who did wanted better access, more information on family planning and improved care and respect from staff.

The prevalence of typhoid in the Papua New Guinea (PNG) highlands region increased rapidly in the mid-1980s, and now remains endemic. In this study ribotyping has been used to examine the number and types of Salmonella enterica serovar Typhi strains present during the 1977-1996 period. The ribotyping banding pattern results were based on Cla I and Eco RV digests. The 57 PNG isolates were divided into 11 different ribotypes. Comparison of ribotypes using coefficient of similarity values revealed a diverse group of ribotypes. Several strains appear to be endemic in PNG For instance, ribotypes 1, 2 and 3 were most commonly found among PNG isolates and isolates with these ribotypes have been cultured over a period of at least 11 years (1985-1996). Ribotype 3 was also observed in isolates from Malaysia and Thailand. Also found in PNG were ribotypes 4, 5, 6, 7, 8, 9, 16 and 17. The ribotyping suggests that serovar Typhi strains present in PNG include unique strains of serovar Typhi and also strains that are common to other countries.

This paper outlines three important issues in the clinical management of sexually transmitted diseases (STDs) in Papua New Guinea which have, until now, gone unrecognized or been neglected. Suggestions for possible solutions are made. The high prevalence of both chlamydial and trichomonal infections in women cannot be ignored. Both of these infections have been shown to increase the transmission of HIV. The current algorithm for the treatment of vaginal discharges does not include treatment for trichomonal infection in the first instance, yet trichomoniasis has been shown to be the most common STD in community studies both here and elsewhere. Trichomoniasis is usually asymptomatic in men, but still increases the risk of HIV transmission; furthermore, it causes illness in their female partners and thus needs to be treated. The current recommended regimens for the treatment of gonococcal and chlamydial infection are complex due to the number of drugs recommended for gonorrhoea to combat the problem of drug resistance, and the length of therapy for chlamydia. Compliance with such a regimen is likely to be poor, particularly in asymptomatic partners. We need to consider the relative advantages provided by a drug which could be given as a single oral dose for chlamydia, and perhaps for both infections. Azithromycin is one possibility, as it has been shown to be effective for chlamydial infection in numerous studies, and has been found satisfactory for gonorrhoea where local isolates were susceptible. Testing of a small number of isolates from Papua New Guinea has shown that azithromycin may be suitable for use here, but further susceptibility testing needs to be performed. Utilization of services for STDs, particularly by women, is extremely low. This is due to a combination of factors involving limited knowledge of symptomatology and its significance, the asymptomatic nature of many infections, the structure of the services, health worker behaviour, and social attitudes. To address these issues we must make modifications to STD service provision, as well as provide widespread information about the potentially serious consequences of contracting STDs, including both infertility and AIDS. Possible modifications to the services are discussed, and include making routine screening available for women through currently existing services such as family planning and antenatal clinics and considering the possibility of establishing Women's Health Clinics which would provide all primary reproductive health services in an integrated manner.

This paper reports on women's understanding of diseases believed to be sexually transmitted in the Asaro Valley of the Eastern Highlands Province. Sexually transmitted diseases (STDs) seemed to be a new category of disease as there were no local language terms for them. Women did not associate STDs with infertility. Although some symptoms were recognized and known to be sexually transmitted, STDs sometimes went untreated for years. STDs were thought of as milder than AIDS because they could be treated. Those informants who had good knowledge of AIDS claimed to have known an AIDS patient. It was interesting that those who knew an AIDS patient reported a change in sexual behaviour among people who saw the deteriorating state of their relative who was dying of AIDS.

Community health education played a major role in a study of sexually transmitted diseases (STDs) and other reproductive tract infections which we conducted in rural and periurban communities of the Asaro Valley near Goroka in the Eastern Highlands Province of Papua New Guinea. We found that most women had little knowledge about STDs, which they often did not realize were sexually transmitted. Even major signs and symptoms were thought to be normal and many women had not sought treatment until irreversible damage was done. Knowledge of the complications of STDs, such as infertility and stillbirth, was also slight in these women. It is apparent that there is a desperate need for more reproductive health education at the community level. In developing our health education methods, we found that simple line drawings of male and female reproductive organs and of people with different signs of STDs proved useful. These were quick and easy to produce from readily available materials. It was important to separate men and women into different groups with educators of the same sex, and to create a very informal atmosphere, encouraging free-ranging discussion. Following health education and sensitive interviewing, almost all the women selected for the community-based study of the prevalence of reproductive tract infections consented to vaginal examination, even if they were asymptomatic. Additionally, many nonselected women requested examination.

We conducted a community-based study of the prevalence of sexually transmitted diseases in rural and periurban communities in Eastern Highlands Province. We interviewed a stratified random sample of women and men, examined the women for evidence of sexually transmitted diseases (STDs) and collected specimens for diagnosis of syphilis, by serology and dark-field microscopy, gonorrhoea, by Gram stain and culture, chlamydial infection, by polymerase chain reaction (PCR) and direct immunofluorescence (DIF), trichomoniasis, by wet mount, and bacterial vaginosis, by wet mount and Gram stain. The men were tested for chlamydial infection only (first void urine tested by PCR and DIF). 201 women and 169 men were tested. Additionally, adults in the same communities who had not been randomly selected were offered the same services. An extra 243 women and 85 men were tested in this way. The laboratory results confirmed the clinical impression of an extremely high prevalence of STDs in this population. Among those randomly selected, 46% of the women had trichomonal vaginal infections and 26% had Chlamydia trachomatis infections detected by PCR, while 25% of the men had chlamydial infections. Other infections were much less common. 58% had one or more STDs. The prevalence of infection in self-selected adults was similar to that found in those randomly selected.

This paper reviews some of the issues relating to typhoid fever in Papua New Guinea. Before the mid-1980s only sporadic cases of typhoid were reported but it is now one of the greatest public health problems in the highlands and some urban areas. In one study near Goroka an annual incidence rate of 1208 per 100,000 people was found, with settlers from other areas at greater risk than the local landowners. Problems relating to management included differentiation from other diseases, the limitations of the Widal test and poor compliance among outpatients. In Papua New Guinea it appears that transmission is largely from person to person, with little evidence for water-borne transmission. The prolonged convalescent excretion of Salmonella typhi and the difficulties this poses for control of the disease are discussed. Prevention will only be achieved in the long term by improvements in hygiene and sanitation, though more immediate control could be achieved by vaccination with an appropriate vaccine.