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

Doing marriage and parenthood: The division of household labour across two life course events

The current study is a longitudinal investigation into changes in the division of household labour across transitions to marriage and parenthood in the UK. Previous research has noted a more traditional division of household labour, with women performing the majority of housework, amongst spouses and couples with children. However, the bulk of this work has been cross-sectional in nature. The few longitudinal studies that have been carried out have been rather ambiguous about the effect of marriage and parenthood on the division of housework. Theoretically, this study draws on gender construction theory. The key premise of this theory is that gender is something that is performed and created in interaction, and, as a result, something fluid and flexible rather than fixed and stable. The idea that couples 'do gender' through housework has been a major theoretical breakthrough. Gender-neutral explanations of the division of household labour, positing rational acting individuals, have failed to explicate why women continue to perform an unequal share of housework, regardless of socioeconomic status. Contrastingly, gender construction theory situates gender as the key process in dividing household labour. By performing and avoiding certain housework chores, couples fulfill social norms of what it means to be a man and a woman although, given the emphasis on human agency in producing and contesting gender, couples are able to negotiate alternative gender roles which, in turn, feed back into the structure of social norms in an ever-changing societal landscape. This study adds extra depth to the doing gender approach by testing whether or not couples negotiate specific conjugal and parent roles in terms of the division of household labour. Both transitions hypothesise a more traditional division of household labour. Data comes from the British Household Panel Survey, a large, nationally representative quantitative survey that has been carried out annually since 1991. Here, data tracks the same 776 couples at two separate time points - 1996 and 2005. OLS regression is used to test whether or not transitions to marriage and parenthood have a significant impact on the division of household labour whilst controlling for host of relevant socio-economic factors. Results indicate that marriage has no significant effect on how couples partition housework. Those couples making the transition from cohabitation to marriage do not show significant changes in housework arrangements from those couples who remain cohabiting in both waves. On the other hand, becoming parents does lead to a more traditional division of household labour whilst controlling for socio-economic factors which accompany the move to parenthood. There is then some evidence that couples use the site of household labour to 'do parenthood' and generate identities which both use and inform socially prescribed notions of what it means to be a mother and a father. Support for socio-economic explanations of the division of household labour was mixed although it remains clear that they, alone, cannot explain how households divide housework.

Model projections for household energy use in India

Energy use in developing countries is heterogeneous across households. Present day global energy models are mostly too aggregate to account for this heterogeneity. Here, a bottom-up model for residential energy use that starts from key dynamic concepts on energy use in developing countries is presented and applied to India. Energy use and fuel choice is determined for five end-use functions (cooking, water heating, space heating, lighting and appliances) and for five different income quintiles in rural and urban areas. The paper specifically explores the consequences of different assumptions for income distribution and rural electrification on residential sector energy use and CO(2) emissions, finding that results are clearly sensitive to variations in these parameters. As a result of population and economic growth, total Indian residential energy use is expected to increase by around 65-75% in 2050 compared to 2005, but residential carbon emissions may increase by up to 9-10 times the 2005 level. While a more equal income distribution and rural electrification enhance the transition to commercial fuels and reduce poverty, there is a trade-off in terms of higher CO(2) emissions via increased electricity use. (C) 2011 Elsevier Ltd. All rights reserved.

Herbal medicines used in the treatment of diabetes mellitus in Arunachal Himalaya, northeast, India

Ethnopharmacological relevance: Medicinal plants have played an important role in treating and preventing a variety of diseases throughout the world. Khampti tribal people living in the far-flung Lohit district of the Eastern Arunachal Himalaya, India still depend on medicinal plants and most of them have a general knowledge of medicinal plants which are used for treating a variety of ailments. This survey was undertaken in Lohit district in order to inventory the medicinal plants used in folk medicine to treat diabetes mellitus. Materials and methods: Field investigations were conducted in seventeen remote villages of Lohit district starting from April 2002 to May 2004 through interviews among 251 key informants who were selected randomly during our household survey. To elucidate community domains and determine differences in indigenous traditional knowledge of medicinal plants with anti-diabetic efficacy, we repeated our field survey starting from April 2008 to May 2010 with one hundred traditional healers locally called as ``Chau ya'' in Khampti of Lohit district. ``Chau ya'' traditional healers who know and use medicinal plants for treating diabetes mellitus were interviewed using a semi-structured questionnaire. Results: This study reports an ethnobotanical survey of medicinal plants in Lohit district of Arunachal Pradesh reputed for the treatment of diabetes mellitus. Forty-six plant species were identified in the study area to treat diabetes mellitus by the Khamptis ``Chau ya'' traditional healers. Comparative published literature survey analysis of this study with other ethnobotanical surveys of plants used traditionally in treating diabetes mellitus suggests that eleven plant species make claims of new reports on antidiabetic efficacy. These plant species are Begonia roxburghii, Calamus tenuis, Callicarpa arborea, Cuscuta reflexa, Dillenia indica, Diplazium esculentum, Lectuca gracilis, Millingtonia hortensis, Oxalis griffithii, Saccharum spontaneum, and Solanum viarum. Some of the plants reported in this study have an antidiabetic effect on rodent models but none have sufficient clinical evidence of effectiveness. Conclusions: The wide variety of medicinal plants that are used to treat diabetes mellitus in this area supports the importance of plants in the primary healthcare system of the rural people of Lohit district of Arunachal Pradesh. The finding of new plant uses in the current study reveals the importance of the documentation of such ethnobotanical knowledge. (C) 2012 Elsevier Ireland Ltd. All rights reserved.

Phylogeography unplugged: comparative surveys in the genomic era

In March 2012, the authors met at the National Evolutionary Synthesis Center (NESCent) in Durham, North Carolina, USA, to discuss approaches and cooperative ventures in Indo-Pacific phylogeography. The group emerged with a series of findings: (1) Marine population structure is complex, but single locus mtDNA studies continue to provide powerful first assessment of phylogeographic patterns. (2) These patterns gain greater significance/power when resolved in a diversity of taxa. New analytical tools are emerging to address these analyses with multi-taxon approaches. (3) Genome-wide analyses are warranted if selection is indicated by surveys of standard markers. Such indicators can include discordance between genetic loci, or between genetic loci and morphology. Phylogeographic information provides a valuable context for studies of selection and adaptation. (4) Phylogeographic inferences are greatly enhanced by an understanding of the biology and ecology of study organisms. (5) Thorough, range-wide sampling of taxa is the foundation for robust phylogeographic inference. (6) Congruent geographic and taxonomic sampling by the Indo-Pacific community of scientists would facilitate better comparative analyses. The group concluded that at this stage of technology and software development, judicious rather than wholesale application of genomics appears to be the most robust course for marine phylogeographic studies. Therefore, our group intends to affirm the value of traditional (''unplugged'') approaches, such as those based on mtDNA sequencing and microsatellites, along with essential field studies, in an era with increasing emphasis on genomic approaches.

Design for sustainability: case of designing an urban household organic waste management system

Beyond product design, if the notion of product `lifecycle design' enforces the consideration of requirements from all the lifecycle phases of products, design for sustainability enforces the consideration of lifecycle design in the context of the lifecycles of other products, processes, institutions and their design. Consequently, sustainability requirements that need to be met by design are very diverse. In this article, we portray the nature of design process to address sustainability requirements. This is done taking an example of designing a urban household organic waste management system that requires less water and reclaims the nutrients.

A systems approach to characterise the dissemination process of household water treatment systems in developing countries

Abstract: Starting in the 1980s, household-level water treatment and safe storage systems (HWTS) have been developed as simple, local, user-friendly, and low cost options to improve drinking water quality at the point of use. However, despite conclusive evidence of the health and economic benefits of HWTS, and promotion efforts in over 50 countries in the past 20 years, implementation outcomes have been slow, reaching only 5-10 million regular users. This study attempts to understand the barriers and drivers affecting HWTS implementation. Although existing literature related to HWTS and innovation diffusion theories proposed ample critical factors and recommendations, there is a lack of holistic and systemic approach to integrate these findings. It is proposed that system dynamics modelling can be a promising tool to map the inter-relationships of different critical factors and to understand the structure of HWTS dissemination process, which may lead to identifying high impact, leveraged mitigation strategies to scale-up HWTS adoption and sustained use.

Beach surveys of South Carlsbad State Beach onshore of Carlsbad artificial reef

(Document pdf contains 9 pages)

Biological surveys of five southern artificial reefs: Oceanside #1, Oceanside #2, Carlsbad, Pacific Beach, and Mission Bay

(Document pdf contains 19 pages)

Analysis of Sample Frames and Subsampling Methods for Reef Fish Surveys

Introduction: The National Oceanic and Atmospheric Administration’s Biogeography Branch has conducted surveys of reef fish in the Caribbean since 1999. Surveys were initially undertaken to identify essential fish habitat, but later were used to characterize and monitor reef fish populations and benthic communities over time. The Branch’s goals are to develop knowledge and products on the distribution and ecology of living marine resources and provide resource managers, scientists and the public with an improved ecosystem basis for making decisions. The Biogeography Branch monitors reef fishes and benthic communities in three study areas: (1) St. John, USVI, (2) Buck Island, St. Croix, USVI, and (3) La Parguera, Puerto Rico. In addition, the Branch has characterized the reef fish and benthic communities in the Flower Garden Banks National Marine Sanctuary, Gray’s Reef National Marine Sanctuary and around the island of Vieques, Puerto Rico. Reef fish data are collected using a stratified random sampling design and stringent measurement protocols. Over time, the sampling design has changed in order to meet different management objectives (i.e. identification of essential fish habitat vs. monitoring), but the designs have always remained: • Probabilistic – to allow inferences to a larger targeted population, • Objective – to satisfy management objectives, and • Stratified – to reduce sampling costs and obtain population estimates for strata. There are two aspects of the sampling design which are now under consideration and are the focus of this report: first, the application of a sample frame, identified as a set of points or grid elements from which a sample is selected; and second, the application of subsampling in a two-stage sampling design. To evaluate these considerations, the pros and cons of implementing a sampling frame and subsampling are discussed. Particular attention is paid to the impacts of each design on accuracy (bias), feasibility and sampling cost (precision). Further, this report presents an analysis of data to determine the optimal number of subsamples to collect if subsampling were used. (PDF contains 19 pages)

Hydroacoustic surveys: a non-destructive approach to monitoring fish distributions at National Marine Sanctuaries

The science of fisheries acoustics and its applicability to resource management have evolved over the past several decades. This document provides a basic description of fisheries acoustics and recommendations on using this technology for research and monitoring of fish distributions and habitats within sanctuaries. It also describes recent efforts aimed at applying fisheries acoustics to Gray’s Reef National Marine Sanctuary (GRNMS) (Figure 1). Historically, methods to assess the underwater environment have included net trawls, diver censuses, hook and line, video, sonar and other techniques deployed in a variety of ways. Fisheries acoustics, using active sonar, relies on the physics of sound traveling through water to quantify the distribution of biota in the water column. By sending a signal of a given frequency through the water column and recording the time of travel and the strength of the reflected signal, it is possible to determine the size and location of fish and estimate biomass from the acoustic backscatter. As a fisheries assessment tool, active hydroacoustics technology is an efficient, non-intrusive method of mapping the water column at a very fine spatial and temporal resolution. It provides a practical alternative to bottom and mid-water trawls, which are not allowed at GRNMS. Passive acoustics, which uses underwater hydrophones to record man-made and natural sounds such as fish spawning calls and sounds produced by marine mammals for communication and echolocation, can provide a useful, complementary survey tool. This report primarily deals with active acoustics, although the integration of active and passive acoustics is addressed as well. (PDF contains 32 pages)

Olympic Coast National Marine Sanctuary Habitat Mapping: Survey report and classification of side scan sonar data from surveys HMPR-114-2004-02 and HMPR-116-2005-01.

The Olympic Coast National Marine Sanctuary (OCNMS) continues to invest significant resources into seafloor mapping activities along Washington’s outer coast (Intelmann and Cochrane 2006; Intelmann et al. 2006; Intelmann 2006). Results from these annual mapping efforts offer a snapshot of current ground conditions, help to guide research and management activities, and provide a baseline for assessing the impacts of various threats to important habitat. During the months of August 2004 and May and July 2005, we used side scan sonar to image several regions of the sea floor in the northern OCNMS, and the data were mosaicked at 1-meter pixel resolution. Video from a towed camera sled, bathymetry data, sedimentary samples and side scan sonar mapping were integrated to describe geological and biological aspects of habitat. Polygon features were created and attributed with a hierarchical deep-water marine benthic classification scheme (Greene et al. 1999). For three small areas that were mapped with both side scan sonar and multibeam echosounder, we made a comparison of output from the classified images indicating little difference in results between the two methods. With these considerations, backscatter derived from multibeam bathymetry is currently a costefficient and safe method for seabed imaging in the shallow (<30 meters) rocky waters of OCNMS. The image quality is sufficient for classification purposes, the associated depths provide further descriptive value and risks to gear are minimized. In shallow waters (<30 meters) which do not have a high incidence of dangerous rock pinnacles, a towed multi-beam side scan sonar could provide a better option for obtaining seafloor imagery due to the high rate of acquisition speed and high image quality, however the high probability of losing or damaging such a costly system when deployed as a towed configuration in the extremely rugose nearshore zones within OCNMS is a financially risky proposition. The development of newer technologies such as intereferometric multibeam systems and bathymetric side scan systems could also provide great potential for mapping these nearshore rocky areas as they allow for high speed data acquisition, produce precisely geo-referenced side scan imagery to bathymetry, and do not experience the angular depth dependency associated with multibeam echosounders allowing larger range scales to be used in shallower water. As such, further investigation of these systems is needed to assess their efficiency and utility in these environments compared to traditional side scan sonar and multibeam bathymetry. (PDF contains 43 pages.)