Perinatal mortality and maternal health in rural China

Background and context Since the economic reforms of 1978, China has been acclaimed as a remarkable economy, achieving 9% annual growth per head for more than 25 years. However, China's health sector has not fared well. The population health gains slowed down and health disparities increased. In the field of health and health care, significant progress in maternal care has been achieved. However, there still remain important disparities between the urban and rural areas and among the rural areas in terms of economic development. The excess female infant deaths and the rapidly increasing sex ratio at birth in the last decade aroused serious concerns among policy makers and scholars. Decentralization of the government administration and health sector reform impacts maternal care. Many studies using census data have been conducted to explore the determinants of a high sex ratio at birth, but no agreement has been so far reached on the possible contributing factors. No study using family planning system data has been conducted to explore perinatal mortality and sex ratio at birth and only few studies have examined the impact of the decentralization of government and health sector reforms on the provision and organization of maternal care in rural China. Objectives The general objective of this study was to investigate the state of perinatal health and maternal care and their determinants in rural China under the historic context of major socioeconomic reforms and the one child family planning policy. The specific objectives of the study included: 1) to study pregnancy outcomes and perinatal health and their correlates in a rural Chinese county; 2) to examine the issue of sex ratio at birth and its determinants in a rural Chinese county; 3) to explore the patterns of provision, utilization, and content of maternal care in a rural Chinese county; 4) to investigate the changes in the use of maternal care in China from 1991 to 2003. Materials and Methods This study is based on a project for evaluating the prenatal care programme in Dingyuan county in 1999-2003, Anhui province, China and a nationwide household health survey to describe the changes in maternal care utilization. The approaches used included a retrospective cohort study, cross sectional interview surveys, informant interviews, observations and the use of statistical data. The data sources included the following: 1) A cohort of pregnant women followed from pregnancy up to 7 days after birth in 20 townships in the study county, collecting information on pregnancy outcomes using family planning records; 2) A questionnaire interview survey given to women who gave birth between 2001 and 2003; 3) Various statistical and informant surveys data collected from the study county; 4) Three national household health interview survey data sets (1993-2003) were utilized, and reanalyzed to described the changes in maternity care utilization. Relative risks (RR) and their confidence intervals (CI) were calculated for comparison between parity, approval status, infant sex and township groups. The chi-square test was used to analyse the disparity of use of maternal care between and within urban and rural areas and its trend across the years in China. Logistic regression was used to analyse the factors associated with hospital delivery in rural areas. Results There were 3697 pregnancies in the study cohort, resulting in 3092 live births in a total population of 299463 in the 20 study townships during 1999-2000. The average age at pregnancy in the cohort was 25.9 years. Of the women, 61% were childless, 38% already had one child and 0.3% had two children before the current pregnancy. About 90% of approved pregnancies ended in a live birth while 73% of the unapproved ones were aborted. The perinatal mortality rate was 69 per thousand births. If the 30 induced abortions in which the gestational age was more than 28 weeks had been counted as perinatal deaths, the perinatal mortality rate would have been as high as 78 per thousand. The perinatal mortality rate was negatively associated with the wealth of the township. Approximately two thirds of the perinatal deaths occurred in the early neonatal period. Both the still birth rate and the early neonatal death rate increased with parity. The risk of a stillbirth in a second pregnancy was almost four times that for a first pregnancy, while the risk of early neonatal deaths doubled. The early neonatal mortality rate was twice as high for female as for male infants. The sex difference in the early neonatal mortality rate was mainly attributable to mortality in second births. The male early neonatal mortality rate was not affected by parity, while the female early neonatal mortality rate increased dramatically with parity: it was about six times higher for second births than for first births. About 82% early neonatal deaths happened within 24 hours after birth, and during that time, girls were almost three times more likely to die than boys. The death rate of females on the day of birth increased much more sharply with parity than that of males. The total sex ratio at birth of 3697 registered pregnancies was 152 males to 100 females, with 118 and 287 in first and second pregnancies, respectively. Among unapproved pregnancies, there were almost 5 live-born boys for each girl. Most prenatal and delivery care was to be taken care of in township hospitals. At the village level, there were small private clinics. There was no limitation period for the provision of prenatal and postnatal care by private practitioners. They were not permitted to provide delivery care by the county health bureau, but as some 12% of all births occurred either at home or at private clinics; some village health workers might have been involved. The county level hospitals served as the referral centers for the township hospitals in the county. However, there was no formal regulation or guideline on how the referral system should work. Whether or not a woman was referred to a higher level hospital depended on the individual midwife's professional judgment and on the clients' compliance. The county health bureau had little power over township hospitals, because township hospitals had in the decentralization process become directly accountable to the township government. In the township and county hospitals only 10-20% of the recurrent costs were funded by local government (the township hospital was funded by the township government and the county hospital was funded by the county government) and the hospitals collected user fees to balance their budgets. Also the staff salaries depended on fee incomes by the hospital. The hospitals could define the user charges themselves. Prenatal care consultations were however free in most township hospitals. None of the midwives made postnatal home visits, because of low profit of these services. The three national household health survey data showed that the proportion of women receiving their first prenatal visit within 12 weeks increased greatly from the early to middle 1990s in all areas except for large cities. The increase was much larger in the rural areas, reducing the urban-rural difference from more than 4 times to about 1.4 times. The proportion of women that received antenatal care visits meeting the Ministry of Health s standard (at least 5 times) in the rural areas increased sharply from 12% in 1991-1993 to 36% in 2001-2003. In rural areas, the proportion increase was much faster in less developed areas than in developed areas. The hospital delivery rate increased slightly from 90% to 94% in urban areas while the proportion increased from 27% to 69% in rural areas. The fastest change was found to be in type 4 rural areas, where the utilization even quadrupled. The overall difference between rural and urban areas was substantially narrowed over the period. Multiple logistic regression analysis shows that time periods, residency in rural or urban areas, income levels, age group, education levels, delivery history, occupation, health insurance and distance from the nearest health care facilities were significantly associated with hospital delivery rates. Conclusions 1. Perinatal mortality in this study was much higher than that for urban areas as well as any reported rate from specific studies in rural areas of China. Previous studies in which calculations of infant mortality were not based on epidemiological surveys have been shown to underestimate the rates by more than 50%. 2. Routine statistics collected by the Chinese family planning system proved to be a reliable data source for studying perinatal health, including still births, neonatal deaths, sex ratio at birth and among newborns. National Household Health Survey data proved to be a useful and reliable data source for studying population health and health services. Prior to this research there were few studies in these areas available to international audiences. 3.Though perinatal mortality rate was negatively associated with the level of township economic development, the excess female early neonatal mortality rate contributed much more to high perinatal mortality rate than economic factors. This was likely a result of the role of the family planning policy and the traditional preferences for sons, which leads to lethal neglect of female newborns and high perinatal mortality. 4. The selective abortions of female foetuses were likely to contribute most to the high sex ratio at birth. The underreporting of female births seemed to have played a secondary role. The higher early neonatal mortality rate in second-born as compared to first-born children, particularly in females, may indicate that neglect or poorer care of female newborn infants also contributes to the high sex ratio at birth or among newborns. Existing family planning policy proved not to effectively control the steadily increased birth sex ratio. 5. The rural-urban gap in service utilization was on average significantly narrowed in terms of maternal healthcare in China from 1991 to 2003. This demonstrates that significant achievements in reducing inequities can be made through a combination of socio-economic development and targeted investments in improving health services, including infrastructure, staff capacities, and subsidies to reduce the costs of service utilization for the poorest. However, the huge gap which persisted among cities of different size and within different types of rural areas indicated the need for further efforts to support the poorest areas. 6. Hospital delivery care in the study county was better accepted by women because most of women think delivery care was very important while prenatal and postnatal care were not. Hospital delivery care was more systematically provided and promoted than prenatal and postnatal care by township hospital in the study area. The reliance of hospital staff income on user fees gave the hospitals an incentive to put more emphasis on revenue generating activities such as delivery care instead of prenatal and postnatal care, since delivery care generated much profits than prenatal and postnatal care . Recommendations 1. It is essential for the central government to re-assess and modify existing family planning policies. In order to keep national sex balance, the existing practice of one couple one child in urban areas and at-least-one-son a couple in rural areas should be gradually changed to a two-children-a-couple policy throughout the country. The government should establish a favourable social security policy for couples, especially for rural couples who have only daughters, with particular emphasis on their pension and medical care insurance, combined with an educational campaign for equal rights for boys and girls in society. 2. There is currently no routine vital-statistics registration system in rural China. Using the findings of this study, the central government could set up a routine vital-statistics registration system using family planning routine work records, which could be used by policy makers and researchers. 3. It is possible for the central and provincial government to invest more in the less developed and poor rural areas to increase the access of pregnant women in these areas to maternal care services. Central government together with local government should gradually provide free maternal care including prenatal and postnatal as well as delivery care to the women in poor and less developed rural areas. 4. Future research could be done to explore if county and the township level health care sector and the family planning system could be merged to increase the effectiveness and efficiency of maternal and child care. 5. Future research could be done to explore the relative contribution of maternal care, economic development and family planning policy on perinatal and child health using prospective cohort studies and community based randomized trials. Key words: perinatal health, perinatal mortality, stillbirth, neonatal death, sex selective abortion, sex ratio at birth, family planning, son preference, maternal care, prenatal care, postnatal care, equity, China

Fast- and drift-ice communities in the Bothnian Bay and the impact of UVA radiation on the Baltic Sea ice ecology

The aim of this thesis was to study ecology of Baltic Sea ice from two perspectives. In the first two studies, sea-ice ecology from riverine-influenced fast ice to drift ice in the Bothnian Bay was investigated, whereas the last two studies focus on the sensitivity of sea-ice bacteria and algae to UVA examined in situ. The seasonal sea ice cover is one of the main characteristics of the Baltic Sea, and despite the brackish parental water, the ice structure is similar to polar ice with saline brine inclusions, the sea ice habitat. The decreasing seawater salinity from the northern Baltic Sea to the Bothnian Bay translates to decreasing brine volumes along the gradient, governing the size and community structure of the food webs in ice. However, the drift and fast ice in the Bothnian Bay may differ greatly in this sense, as drift ice may have been formed at more southern locations. Rafting and the formation of snow ice are common processes in the ice field of the Bothnian Bay. As evidenced in this thesis, rafting altered the vertical distribution of organisms and snow-ice formation provided habitable space in the better-illuminated, nitrogen-rich surface layer. The divergence between fast and drift ice became apparent at the more advanced stages, and chlorophyte biomass decreased from fast to drift ice, while the opposite held true for protozoan and metazoan biomass. The brine volumes affected the communities somewhat, and a higher percentage of flagellate species was generally linked to lower brine volumes, whereas chain-forming diatoms were mostly concentrated in layers with larger brine volumes. These results add to knowledge of the ecological significance of the ice cover lasting up to 7 months per year in this area. Sea-ice food webs are generally light-limited, but while increasing light irradiances typically enhance the primary production and further, the secondary production in sea ice, any increase in solar radiation also includes an increase in harmful UVA radiation. The Baltic Sea ice microbial communities were clearly sensitive to UVA and the responses were strongly linked to the earlier light history, as well as to the solar irradiances they were exposed to. The increased biomass of chlorophytes and pennate diatoms, when UVA was excluded, indicates that their normally minor contribution to the biomass in the upper layers of sea ice might be partly dictated by UVA. The effects of UVA on bacterial production in Baltic Sea ice mostly followed the responses in algal growth, but occasionally the exposure to UVA even enhanced the bacterial production. The dominant bacterial class, Flavobacteria, seemed to be UVA-tolerant, whereas all the Alpha-, Beta- and Gammaproteobacteria present in the surface layer showed UVA sensitivity. These results indicate that changes in the light field of ice may alter the community structure and affect the functioning of ice food webs, and are of importance when the effects of thinning of the ice cover are assessed.

Pre-harvest measurement of pine stands for sawing production planning.

To enhance the utilization of the wood, the sawmills are forced to place more emphasis on planning to master the whole production chain from the forest to the end product. One significant obstacle to integrating the forest-sawmill-market production chain is the lack of appropriate information about forest stands. Since the wood procurement point of view in forest planning systems has been almost totally disregarded there has been a great need to develop an easy and efficient pre-harvest measurement method, allowing separate measurement of stands prior to harvesting. The main purpose of this study was to develop a measurement method for pine stands which forest managers could use in describing the properties of the standing trees for sawing production planning. Study materials were collected from ten Scots pine stands (Pinus sylvestris) located in North Häme and South Pohjanmaa, in southern Finland. The data comprise test sawing data on 314 pine stems, dbh and height measures of all trees and measures of the quality parameters of pine sawlog stems in all ten study stands as well as the locations of all trees in six stands. The study was divided into four sub-studies which deal with pine quality prediction, construction of diameter and dead branch height distributions, sampling designs and applying height and crown height models. The final proposal for the pre-harvest measurement method is a synthesis of the individual sub-studies. Quality analysis resulted in choosing dbh, distance from stump height to the first dead branch (dead branch height), crown height and tree height as the most appropriate quality characteristics of Scots pine. Dbh and dead branch height are measured from each pine sample tree while height and crown height are derived from dbh measures by aid of mixed height and crown height models. Pine and spruce diameter distribution as well as dead branch height distribution are most effectively predicted by the kernel function. Roughly 25 sample trees seems to be appropriate in pure pine stands. In mixed stands the number of sample trees needs to be increased in proportion to the intensity of pines in order to attain the same level of accuracy.

Ruismallasuute vähägluteenisessa kauraleivonnassa

Tutkielman kirjallisuuskatsauksessa tarkasteltiin kauran leivontateknologisia ominaisuuksia, entsyymiaktiivista leivontaa ja ruismaltaan hyödyntämistä vähägluteenisessa leivonnassa. Kokeellisessa osiossa tutkittiin ruismallashapantaikinasta valmistetun uutteen vaikutusta kaurataikinan viskositeettiin ja kauraleivän ominaisuuksiin. Työn tarkoituksena oli kehittää maultaan ja rakenteeltaan onnistunut rukiinmakuinen kauraleipä. Ruismaltaan entsyymien annettiin pilkkoa keliaakikolle haitallisia rukiin prolamiineja hapantaikinaprosessissa. Hapantaikinasta erotettiin uute sentrifugoimalla. Leivontakokeisiin käytettiin entsyymiaktiivista ja kuumentamalla inaktivoitua uutetta. Uutteella korvattiin taikinavettä 15, 25 ja 30 % (taikinan painosta). Leivonta toteutettiin miniatyyrikoossa, vuokaleivontana 20 g:n taikinapaloja käyttäen. Taikinoiden viskositeetti mitattiin tarkoituksena seurata beetaglukaanin hydrolyysiä. Rukiin makua mitattiin koulutetun raadin avulla. Happaman uutteen lisäys laski taikinan pH-arvoa noin 5,8:sta noin 4,4:ään. Entsyymiaktiivisen uutteen lisäys laski taikinan viskositeettia ja inaktivoitu uute puolestaan kasvatti sitä. Leipien sisus tiivistyi, jolloin mitatut sisuksen kovuudet kasvoivat uutteen lisäyksen myötä. Uutelisäys paransi leipien makua ja aromia. Uutteen vaikutuksesta leipien huokoset olivat pienempiä ja ne jakaantuivat tasaisemmin leipämatriisiin. Jos uutetta käytettiin inaktivoituna, leipien murenevuus kasvoi. Tutkimuksessa kehitetyn teknologian avulla oli mahdollista valmistaa hyvänlaatuinen, rukiinmakuinen kauraleipä myös ilman että uutteen entsyymit inaktivoitiin keittämällä. Tähän vaikutti ilmeisesti taikinan alhainen pH, joka inhiboi alfa-amylaasia, ja kauratärkkelyksen korkea liisteröitymislämpötila, jolloin entsyymien inaktivoituminen paiston aikana tapahtui ennen kuin tärkkelys tuli alttiiksi liialliselle pilkkoutumiselle. Tämä mahdollistaa uutteen käytön osana leivontaprosessia ilman inaktivointia. Hapantaikinafermentaatio osana gluteenitonta leivontaa havaittiin toimivaksi yhdistelmäksi, sillä se paransi leivän väriä, makua ja rakennetta. Myös leivän homeeton aika parani jo vähäisenkin uutelisäyksen vaikutuksesta. Näyttää siltä, että tämän teknologian avulla on mahdollista tuoda esille pitkään kaivattua rukiin makua vähägluteenisten kauraleipien valikoimassa. Laskennallisesti ja aiempiin tuloksiin tukeutuen, voitiin päätellä, että leivän prolamiinipitoisuudessa on mahdollista päästä tasolle 63,5 mg/kg, mutta jatkokehityksen avulla päästäisiin luultavasti vielä parempiin tuloksiin.

Polarization studies in electromagnetic scattering by small Solar-system particles

In remote-sensing studies, particles that are comparable to the wavelength exhibit characteristic features in electromagnetic scattering, especially in the degree of linear polarization. These features vary with the physical properties of the particles, such as shape, size, refractive index, and orientation. In the thesis, the direct problem of computing the unknown scattered quantities using the known properties of the particles and the incident radiation is solved at both optical and radar spectral regions in a unique way. The internal electromagnetic fields of wavelength-scale particles are analyzed by using both novel and established methods to show how the internal fields are related to the scattered fields in the far zone. This is achieved by using the tools and methods that were developed specifically to reveal the internal field structure of particles and to study the mechanisms that relate the structure to the scattering characteristics of those particles. It is shown that, for spherical particles, the internal field is a combination of a forward propagating wave with the apparent wavelength determined by the refractive index of the particle, and a standing wave pattern with the apparent wavelength the same as for the incident wave. Due to the surface curvature and dielectric nature of the particle, the incident wave front undergoes a phase shift, and the resulting internal wave is focused mostly at the forward part of the particle similar to an optical lens. This focusing is also seen for irregular particles. It is concluded that, for both spherical and nonspherical particles, the interference at the far field between the partial waves that originate from these concentrated areas in the particle interior, is responsible for the specific polarization features that are common for wavelength-scale particles, such as negative values and local extrema in the degree of linear polarization, asymmetry of the phase function, and enhancement of intensity near the backscattering direction. The papers presented in this thesis solve the direct problem for particles with both simple and irregular shapes to demonstrate that these interference mechanisms are common for all dielectric wavelength-scale particles. Furthermore, it is shown that these mechanisms can be applied to both regolith particles in the optical wavelengths and hydrometeors at microwave frequencies. An advantage from this kind of study is that it does not matter whether the observation is active (e.g., polarimetric radar) or passive (e.g., optical telescope). In both cases, the internal field is computed for two mutually perpendicular incident polarizations, so that the polarization characteristics can then be analyzed according to the relation between these fields and the scattered far field.

Lipeäkäsitellyn vehnän vaikutus lypsylehmien syöntiin ja tuotokseen vapaalla seosrehuruokinnalla

Lipeä on vahva emäs, jonka on havaittu lisäävän hemiselluloosan ja ligniinin hydrolyysiä pötsissä. Näin ollen lipeäkäsittelyllä on mahdollista korvata viljan mekaaninen litistys ja jauhatus. Seosrehuruokinnalla, jonka osana on lipeäkäsitelty vilja, on mahdollista vähentää liiallisesta tärkkelyksestä aiheutuvia metabolisia ongelmia pötsissä. Tämän tutkielman tarkoituksena oli selvittää lipeäkäsitellyn vehnän vaikutusta lypsylehmien syöntiin ja tuotokseen ad libitum seosrehuruokinnoilla. Ruokinnoissa korvattiin kuivaa murskattua vehnää asteittain kokonaisella lipeäkäsitellyllä vehnällä. Kontrollina oli perinteisesti käytetty kuiva, murskattu ohra-kaura seos. Koe tehtiin Ruotsin maatalousyliopiston (SLU) maataloustieteiden laitoksella Uumajassa. Koe alkoi syyskuussa ja päättyi joulukuussa 2010. Kokeessa oli 17 useamman kerran poikinutta lehmää ja 6 ensikkoa (Ruotsin punainen -rotu). Lehmät olivat lämpimässä pihattonavetassa, jossa seosrehun syöntiä mitattiin vaakakuppien avulla. Koekäsittelyt olivat murskattu ohra-kaura seos (1:1), murskattu kuiva vehnä (1:0), murskatun kuivan vehnän ja kokonaisen lipeävehnän seos (1:1) ja kokonainen lipeävehnä (1:0). Ruokintojen kuiva-ainepitoisuudeksi asetettiin 370 g/kg ja raakavalkuaispitoisuudeksi 180 g/kg kuiva-ainetta. Näennäinen ravintoaineen sulavuus määritettiin happoon liukenemattoman tuhkan avulla. Typen hyväksikäyttöä arvioitiin laskennallisen typpitaseen avulla. Koe toteutettiin 4x4 latinalaisen neliön koemallin mukaisesti ja käsittelyjen väliset tilastolliset erot testattiin kontrastien avulla. Kuiva-aineen (PQ=0,02) ja orgaanisen aineen (PQ=0,02) syönnit lisääntyivät, samalla kun niiden sulavuudet paranivat korvattaessa puolet kuivasta vehnästä lipeävehnällä. Ruokintojen välillä ei ollut tilastollisesti merkitsevää eroa maitotuotoksessa eikä energiakorjatussa maitotuotoksessa. Maidon rasvatuotos lisääntyi vähän (PQ=0,04) ja rasvapitoisuus selvästi (PQ=0,004), kun kuivasta vehnästä korvattiin puolet lipeävehnällä. Kun kaikki kuiva vehnä korvattiin lipeävehnällä, maidon valkuaispitoisuus väheni (PL<0,001). Samoin kävi maidon ureapitoisuudelle (PL=0,002). Lipeäkäsittely ei tuottanut tässä kokeessa taloudellisesti kannattavaa tulosta, sillä maidon valkuaispitoisuus väheni ja syönti lisääntyi maitotuotoksen pysyessä samana. Vehnäruokinnoista paras tuotosvaste saatiin kuivan vehnän ja lipeävehnän seoksella.