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

Almost Stable Matchings by Truncating the Gale–Shapley Algorithm

We show that the ratio of matched individuals to blocking pairs grows linearly with the number of propose–accept rounds executed by the Gale–Shapley algorithm for the stable marriage problem. Consequently, the participants can arrive at an almost stable matching even without full information about the problem instance; for each participant, knowing only its local neighbourhood is enough. In distributed-systems parlance, this means that if each person has only a constant number of acceptable partners, an almost stable matching emerges after a constant number of synchronous communication rounds. We apply our results to give a distributed (2 + ε)-approximation algorithm for maximum-weight matching in bicoloured graphs and a centralised randomised constant-time approximation scheme for estimating the size of a stable matching.

Lunch eating patterns during working hours and their social and work-related determinants : Study of Finnish employees

Work has a central role in the lives of big share of adult Finns and meals they eat during the workday comprise an important factor in their nutrition, health, and well-being. On workdays, lunch is mainly eaten at worksite canteens or, especially among women, as a packed meal in the workplace s break room. No national-level data is available on the nutritional quality of the meals served by canteens, although the Finnish Institute of Occupational Health laid out the first nutrition recommendations for worksite canteens in 1971. The aim of this study was to examine the contribution of various socio-demographic, socioeconomic, and work-related factors to the lunch eating patterns of Finnish employees during the working day and how lunch eating patterns influence dietary intake. Four different population-based cross-sectional datasets were used in this thesis. Three of the datasets were collected by the National Institute for Health and Welfare (Health Behaviour and Health among the Finnish Adult Population survey from 1979 to 2001, n=24746, and 2005 to 2007, n=5585, the National Findiet 2002 Study, n=261), and one of them by the Finnish Institute of Occupational Health (Work and Health in Finland survey from 1997, 2000, and 2003, n=6369). The Health Behaviour and Health among the Finnish Adult Population survey and the Work and Health in Finland survey are nationally representative studies that are conducted repeatedly. Survey information was collected by self-administered questionnaires, dietary recalls, and telephone interviews. The frequency of worksite canteen use has been quite stable for over two decades in Finland. A small decreasing trend can be seen in all socioeconomic groups. During the whole period studied, those with more years of education ate at worksite canteens more often than the others. The size of the workplace was the most important work-related determinant associated with the use of a worksite canteen. At small workplaces, other work-related determinants, like occupation, physical strain at work, and job control, were also associated with canteen use, whereas at bigger workplaces the associations were almost nonexistent. The major social determinants of worksite canteen availability were the education and occupational status of employees and the only work-related determinant was the size of the workplace. A worksite canteen was more commonly available to employees at larger workplaces and to those with the higher education and the higher occupational status. Even when the canteen was equally available to all employees, its use was nevertheless determined by occupational class and the place of residence, especially among female employees. Those with higher occupational status and those living in the Helsinki capital area ate in canteens more frequently than the others. Employees who ate at a worksite canteen consumed more vegetables and vegetable and fish dishes at lunch than did those who ate packed lunches. Also, the daily consumption of vegetables and the proportion of the daily users of vegetables were higher among those male employees who ate at a canteen. In conclusion, life possibilities, i.e. the availability of a canteen, education, occupational status, and work-related factors, played an important role in the choice of where to eat lunch among Finnish employees. The most basic prerequisite for eating in a canteen was availability, but there were also a number of underlying social determinants. Occupational status and the place of residence were the major structural factors behind individuals choices in their lunch eating patterns. To ensure the nutrition, health, and well-being of employees, employers should provide them with the option to have good quality meals during working hours. The availability of worksite canteens should be especially supported in lower socioeconomic groups. In addition, employees should be encouraged to have lunch at a worksite canteen when one is available by removing structural barriers to its use.

Algorithms for Exact Structure Discovery in Bayesian Networks

Bayesian networks are compact, flexible, and interpretable representations of a joint distribution. When the network structure is unknown but there are observational data at hand, one can try to learn the network structure. This is called structure discovery. This thesis contributes to two areas of structure discovery in Bayesian networks: space--time tradeoffs and learning ancestor relations. The fastest exact algorithms for structure discovery in Bayesian networks are based on dynamic programming and use excessive amounts of space. Motivated by the space usage, several schemes for trading space against time are presented. These schemes are presented in a general setting for a class of computational problems called permutation problems; structure discovery in Bayesian networks is seen as a challenging variant of the permutation problems. The main contribution in the area of the space--time tradeoffs is the partial order approach, in which the standard dynamic programming algorithm is extended to run over partial orders. In particular, a certain family of partial orders called parallel bucket orders is considered. A partial order scheme that provably yields an optimal space--time tradeoff within parallel bucket orders is presented. Also practical issues concerning parallel bucket orders are discussed. Learning ancestor relations, that is, directed paths between nodes, is motivated by the need for robust summaries of the network structures when there are unobserved nodes at work. Ancestor relations are nonmodular features and hence learning them is more difficult than modular features. A dynamic programming algorithm is presented for computing posterior probabilities of ancestor relations exactly. Empirical tests suggest that ancestor relations can be learned from observational data almost as accurately as arcs even in the presence of unobserved nodes.

Water content - void ratio swell-shrink paths of compacted expansive soils

This paper addresses the behaviour of compacted expansive soils under swell-shrink cycles. Laboratory cyclic swell-shrink tests were conducted on compacted specimens of two expansive soils at surcharge pressures of 6.25, 50.00, and 100.00 kPa. The void ratio and water content of the specimens at several intermediate stages during swelling until the end of swelling and during shrinkage until the end of shrinkage were determined to trace the water content versus void ratio paths with an increasing number of swell-shrink cycles. The test results showed that the swell-shrink path was reversible once the soil reached an equilibrium stage where the vertical deformations during swelling and shrinkage were the same. This usually occurred after about four swell-shrink cycles. The swelling and shrinkage path of each specimen subjected to full swelling - full shrinkage cycles showed an S-shaped curve (two curvilinear portions and a linear portion). However, the swelling and shrinkage path occurred as a part of the S-shaped curve, when the specimen was subjected to full swelling - partial shrinkage cycles. More than 80% of the total volumetric change and more than 50% of the total vertical deformation occurred in the central linear portion of the S-shaped curve. The volumetric change was essentially parallel to the saturation line within a degree of saturation range of 50-80% for the equilibrium cycle. The primary value of the swell-shrink path is to provide information regarding the void ratio change that would occur for a given change in water content for any possible swell-shrink pattern. It is suggested that these swell-shrink paths can be established with a limited number of tests in the laboratory.

A Convex Optimization Framework for Almost Budget Balanced Allocation of a Divisible Good

We address the problem of allocating a single divisible good to a number of agents. The agents have concave valuation functions parameterized by a scalar type. The agents report only the type. The goal is to find allocatively efficient, strategy proof, nearly budget balanced mechanisms within the Groves class. Near budget balance is attained by returning as much of the received payments as rebates to agents. Two performance criteria are of interest: the maximum ratio of budget surplus to efficient surplus, and the expected budget surplus, within the class of linear rebate functions. The goal is to minimize them. Assuming that the valuation functions are known, we show that both problems reduce to convex optimization problems, where the convex constraint sets are characterized by a continuum of half-plane constraints parameterized by the vector of reported types. We then propose a randomized relaxation of these problems by sampling constraints. The relaxed problem is a linear programming problem (LP). We then identify the number of samples needed for ``near-feasibility'' of the relaxed constraint set. Under some conditions on the valuation function, we show that value of the approximate LP is close to the optimal value. Simulation results show significant improvements of our proposed method over the Vickrey-Clarke-Groves (VCG) mechanism without rebates. In the special case of indivisible goods, the mechanisms in this paper fall back to those proposed by Moulin, by Guo and Conitzer, and by Gujar and Narahari, without any need for randomization. Extension of the proposed mechanisms to situations when the valuation functions are not known to the central planner are also discussed. Note to Practitioners-Our results will be useful in all resource allocation problems that involve gathering of information privately held by strategic users, where the utilities are any concave function of the allocations, and where the resource planner is not interested in maximizing revenue, but in efficient sharing of the resource. Such situations arise quite often in fair sharing of internet resources, fair sharing of funds across departments within the same parent organization, auctioning of public goods, etc. We study methods to achieve near budget balance by first collecting payments according to the celebrated VCG mechanism, and then returning as much of the collected money as rebates. Our focus on linear rebate functions allows for easy implementation. The resulting convex optimization problem is solved via relaxation to a randomized linear programming problem, for which several efficient solvers exist. This relaxation is enabled by constraint sampling. Keeping practitioners in mind, we identify the number of samples that assures a desired level of ``near-feasibility'' with the desired confidence level. Our methodology will occasionally require subsidy from outside the system. We however demonstrate via simulation that, if the mechanism is repeated several times over independent instances, then past surplus can support the subsidy requirements. We also extend our results to situations where the strategic users' utility functions are not known to the allocating entity, a common situation in the context of internet users and other problems.

Computation of thermodynamic properties of quaternary and higher order systems from binary data using shortest distance composition paths

Equations for the computation of integral and partial thermodynamic properties of mixing in quarternary systems are derived using data on constituent binary systems and shortest distance composition paths to the binaries. The composition path from a quarternary composition to the i-j binary is characterized by a constant value of (Xi − Xj). The merits of this composition path over others with constant values for View the MathML source or Xi are discussed. Finally the equations are generalized for higher order systems. They are exact for regular solutions, but may be used in a semiempirical mode for non-regular solutions.

Adiabatic eigenfunction-based approach for coherent excitation transfer: An almost analytical treatment of the Fenna-Matthews-Olson complex

We suggest a method of studying coherence in finite-level systems coupled to the environment and use it for the Hamiltonian that has been used to describe the light-harvesting pigment-protein complex. The method works with the adiabatic states and transforms the Hamiltonian to a form in which the terms responsible for decoherence and population relaxation are separated out. Decoherence is then accounted for nonperturbatively and population relaxation using a Markovian master equation. Almost analytical results can be obtained for the seven-level system, and the calculations are very simple for systems with more levels. We apply the treatment to the seven-level system, and the results are in excellent agreement with the exact numerical results of Nalbach et al. Nalbach, Braun, and Thorwart, Phys. Rev. E 84, 041926 (2011)]. Our approach is able to account for decoherence and population relaxation separately. It is found that decoherence causes only damping of oscillations and does not lead to transfer to the reaction center. Population relaxation is necessary for efficient transfer to the reaction center, in agreement with earlier findings. Our results show that the transformation to the adiabatic basis followed by a Redfield type of approach leads to results in good agreement with exact simulation.

Closed-form nonlinear sectional analysis of pretwisted anisotropic beam with multiple delaminations

Fiber reinforced laminated composite open-section beams are widely used as bearingless rotor flex beams because of their high specific strength and stiffness as well as fatigue life. These laminated composite structures exhibit a number of different failure modes, including fiber-matrix debonding within individual layers, delamination or separation of the layers, transverse cracks through one or more layers and fiber fracture. Delamination is a predominant failure mode in continuous fiber reinforced laminated composites and often initiate near the free edges of the structure. The appearance of delaminations in the composite rotorcraft flexbeams can lead to deterioration of the mechanical properties and, in turn, the helicopter performance as well as safety. Understanding and predicting the influence of free-edge delamination on the overall behavior of the laminates will provide quantitative measures of the extent of the damage and help ensure their damage tolerance.