“It takes a village” to reduce maternal and newborn mortality in Papua New Guinea

"My daughters have no mother. My son has no mother. I have no wife," says Rex, heartbroken after his wife Miriam died during childbirth in a village in Papua New Guinea.

The hard-hitting lines are from the pilot episode of a television and radio drama called It Takes a Village, produced by the World Health Organization (WHO), The Hands of Rescue, a charity dedicated to safe motherhood in Papua New Guinea, and Australian production company Screencraft, with the support of the Australian Department of Foreign Affairs and Trade.

Maternal and newborn mortality is a fact of life in Papua New Guinea, where the rates are the highest in the Western Pacific Region and among the highest in the world: 171 maternal deaths per 100 000 live births and 20 neonatal deaths per 1000 live births, according to the Papua New Guinea Demographic and Health Survey 2016-18. These tragedies come about largely as a result of preventable or treatable conditions because of a lack of knowledge about family planning and contraception, and people seeking help too late for antenatal care and supervised delivery.

In It Takes a Village, Rex, a rising local rugby league star, is excited as Miriam delivers a healthy son. Worry sets in when Miriam suffers complications and becomes critically ill, prompting a gruelling journey by boat to a health centre.

The show uses storytelling, a core principle of WHO's Communication for Health (C4H) approach and deeply ingrained in Papua New Guinean culture, to illustrate the benefits of seeking care early. It aims to encourage men and the community in general to play a more active role in maternal health, including by identifying the risks and danger signs early so that women can be taken to a health facility in time.

C4H initiatives such as It Takes a Village start with an understanding of the social and behavioural drivers of the health issue, then applying communication techniques, including storytelling, to engage target audiences with relevant and actionable information.

Ms Anna Maalsen, acting WHO Representative in Papua New Guinea says, "We wanted to address some of the barriers to pregnant women getting the care they need. There have been a lot of efforts to strengthen the health-care system, but we wanted to look at what is happening in the community. We wanted It Takes a Village to engage men - who often control household decision-making - and shift the norms and traditional cultures of families and communities, so that women and babies receive care at these critical times before, during and after pregnancy."

Following the production of the pilot episode and its nationwide screening in 2020, WHO undertook an evaluation of the programme to determine the efficacy of its messaging and inform future productions. The pilot episode was screened separately to a group of men and a group of women from various parts of Papua New Guinea, who answered questions before and after viewing. The viewing panels were undertaken following all coronavirus disease 2019 (COVID-19) infection prevention and control protocols.

At first, people in the viewing panels did not consider the many maternal and newborn deaths to be one of the most important health issues facing communities in the country. Women were aware of the dire situation at childbirth, yet saw this as a normal part of life. Most of the women had personal experience of complications at childbirth or knew of someone who had died in labour. The women referred to the common lack of support from men or husbands.

Ms Maalsen says, "Hearteningly, though, after watching Rex and Miriam's story, the men in the panel showed a shift in attitudes around maternal care and spoke about supporting women more. And women said they were keen for more support from the men in their lives."

All of the men said they would now take their partner to a clinic and could see themselves having a role in the birth of a baby. One man said: "When a woman is expecting, the men must be always close to her… when it's time for delivery, he must take her to the hospital."

Some men questioned the cultural taboos against fathers being involved when women give birth or in the first few months of a child's life. And they expressed a determination to share what they had learnt.

"[We must] tell the boys, maybe we should let go of some of our customs from before, especially to do with women during pregnancy. The women too must listen, and discuss among themselves, on how we can take care of each other, men and women," one man said.

Lessons from the pilot episode evaluation will be put into practice in a full series of It Takes a Village, including forthcoming episodes on COVID-19 and vaccination.

The Honourable Jelta Wong, Minister for Health and HIV/AIDS in Papua New Guinea, says of the initiative, "After the success of the pilot episode of It Takes a Village, which reached men and women nationwide, we look forward to working with WHO and partners on future episodes. Working together, with the right mix of interventions, we can achieve better health outcomes for Papua New Guineans."