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

A role for calcium in gonadotrophin-releasing hormone (GnRH) stimulated secretion of chorionic gonadotrophin by first trimester human placental minces in vitro

In vitro studies using first-trimester human placental minces have shown that stimulation of human chorionic gonadotrophin (hCG) secretion by gonadotrophin-releasing hormone (GnRH) is dependent upon the presence of extracellular calcium. Addition of GnRH to first-trimester placental minces in vitro was found to stimulate 45Ca2+ uptake into placental minces, and the process was associated with an increase in immunoreactive hCG in the medium. Addition of GnRH to placental minces preloaded with 45Ca2+ stimulated the efflux of 45Ca2+ within one minute. The calmodulin inhibitors chlorpromazine andtrifluoperazine inhibited the basal uptake and efflux of 45Ca2+ suggesting the involvement of calmodulin in the mobilization of calcium in the placenta.

Leisure-time physical activity, health related functioning and retirement : a prospective cohort study among middle-aged employees

Physical inactivity has become a major threat to public health worldwide. The Finnish health and welfare policies emphasize that the working population should maintain good health and functioning until their normal retirement age and remain in good health and independence later in life. Health behaviours like physical activity potentially play an important role in reaching this target as physical activity contributes to better physical fitness and to reduced risk of major chronic diseases. The aim of this study was to examine first whether the volume and intensity of leisure-time physical activity impacts on subsequent physical health functioning, sickness absence and disability retirement. The second aim was to examine changes in leisure-time physical activity of moderate and vigorous intensity after transition to retirement. This study is part of the ongoing Helsinki Health Study. The baseline data were collected by questionnaires in 2000 - 02 among the employees of the City of Helsinki aged 40 to 60. The follow-up survey data were collected in 2007. Data on sickness absence were obtained from the employer s (City of Helsinki) sickness absence registers and pension data were obtained from the Finnish Centre for Pensions. Leisure-time physical activity was measured in four grades of intensity and classified according to physical activity recommendations considering both the volume and intensity of physical activity. Statistical techniques including analysis of covariance, logistic regression, Cox proportional hazards models and Poisson regression were used. Employees who were vigorously active during leisure time especially had better physical health functioning than those physically inactive. High physical activity in particular contributed to the maintenance of good physical health functioning. High physical activity also reduced the risk of subsequent sickness absences as well as the risk of all-cause disability retirement and retirement due to musculoskeletal and mental causes. Among those transferred to old-age retirement moderate-intensity leisure-time physical activity increased on average by more than half an hour per week and in addition the occurrence of physical inactivity reduced. Such changes were not observed among those remained employed and those transferred to disability retirement. This prospective cohort study provided novel results on the effects of leisure-time physical activity on health related functioning and changes in leisure-time physical activity after retirement. Although the benefits of moderate-intensity physical activity for health are well known these results suggest the importance of vigorous physical activity for subsequent health related functioning. Thus vigorous physical activity to enhance fitness should be given more emphasis from a public health perspective. In addition, physical activity should be encouraged among those who are about to retire.

Tuning and stability of a singly resonant continuous-wave optical parametric oscillator close to degeneracy

Wavelength tuning and stability characteristics of a singly resonant continuous-wave optical parametric oscillator (cw OPO) in the proximity of signal-idler degeneracy have been studied. The OPO is made singly resonant by using a Bragg grating as a spectral filter in the OPO cavity. The signal-idler frequency difference can be tuned from 0.5 to 7 THz, which makes the OPO suitable for cw THz generation by optical heterodyning. The operation of the OPO within this singly-resonant regime is characterized by a strong self-stabilization effect. A gradual transition to an unstable, doubly-resonant regime is observed for a signal-idler detuning smaller than ~ 0.5 THz.

A Case Study in Matching Service Descriptions to Implementations in an Existing System

A number of companies are trying to migrate large monolithic software systems to Service Oriented Architectures. A common approach to do this is to first identify and describe desired services (i.e., create a model), and then to locate portions of code within the existing system that implement the described services. In this paper we describe a detailed case study we undertook to match a model to an open-source business application. We describe the systematic methodology we used, the results of the exercise, as well as several observations that throw light on the nature of this problem. We also suggest and validate heuristics that are likely to be useful in partially automating the process of matching service descriptions to implementations.

Electron microscopy and diffraction of ordering in Ni---W alloys

Electron microscopy and diffraction studies of ordering in stoichiometric Ni-20%W and off-stoichiometric Ni-15%W alloys have been carried out. The specimens of Ni-20%W were first disordered at 1398 K for 4 h and then quenched rapidly into water. Short range order (SRO) spots were observed at {1 1/2 0}* positions. Two hitherto unknown metastable phases: D-2h(25)-Ni2W and DO22-Ni3W were observed in the diffraction patterns. Long range order (LRO) transformations were studied at 1103 and 1213 K. Kinetics and mechanism of transformations have been identified. Ni-15%W specimens were solution treated at 1523 K for 1 h followed by quenching in water. SRO spots similar to those found in Ni-20%W were observed in this alloy as well. The transition to LRO was studied at 1093 K. Distinct Ni4W precipitates could be observed after 5 h of annealing at this temperature. After 100 h of annealing precipitates were found to grow into faceted shape coherent with the disordered matrix. After prolonged annealing for over 150 h the Ni4W precipitates began to lose coherency by the generation of misfit dislocations. The microstructural observations have been compared for the stoichiometric and off-stoichiometric alloys.

Phase transitions in the anchored organic bilayers of long-chain alkylammonium lead iodides (CnH2n+1NH3)(2)PbI4; n=12, 16, 18

The single perovskite slab alkylammonium lead iodides (CnH2n+1NH3)(2)PbI4, n = 12, 16, 18, display two phase transitions, just above room temperature, associated with changes in the alkylammonium chains. We have followed these two phase transitions using scanning calorimetry, X-ray powder diffraction, and IR and Raman spectroscopies. We find the first phase transition to be associated with symmetry changes arising from a dynamic rotational disordering of the ammonium headgroup of the chain whereas the second transition, the melting of the chains in two dimensions, is characterized by an increased conformational disorder of the methylene units of the alkyl chains. We examine these phase transitions in light of the interesting optical properties of these materials, as well as the relevance of these systems as models for phase transitions in lipid bilayers.

Effective Mass-Driven Structural Transition in a Mn-Doped ZnS Nanoplatelet

Mn doping in ZnS nanoplatelets has been shown to induce a structural transition from the wurtzite to the zinc blende phase. We trace the origin of this transition to quantum confinement effects, which shift the valence band maximum of the wurtzite and zinc blende polyrnorphs of ZnS at different rates as a function of the nanocrystal size, arising from different effective hole masses in the two structures. This modifies the covalency associated with Mn incorporation and is reflected in the size-dependent binding energy difference for the two structures.

A nearly constant switching frequency current hysteresis controller with generalized parabolic boundaries using 12-sided polygonal voltage space vectors for IM drives

In this paper, a current hysteresis controller with parabolic boundaries for a 12-sided polygonal voltage space vector inverter fed induction motor (IM) drive is proposed. Parabolic boundaries with generalized vector selection logic, valid for all sectors and rotational direction, is used in the proposed controller. The current error space phasor boundary is obtained by first studying the drive scheme with space vector based PWM (SVPWM) controller. Four parabolas are used to approximate this current error space phasor boundary. The system is then run with space phasor based hysteresis PWM controller by limiting the current error space vector (CESV) within the parabolic boundary. The proposed controller has simple controller implementation, nearly constant switching frequency, extended modulation range and fast dynamic response with smooth transition to the over modulation region.

Direct hexagonal transition of amorphous (Ge2Sb2Te5)(0.9)Se-0.1 thin films

Ge2Sb2Te5 (GST) is well known for its phase change properties and applications in memory and data storage. Efforts are being made to improve its thermal stability and transition between amorphous and crystalline phases. Various elements are doped to GST to improve these properties. In this work, Se has been doped to GST to study its effect on phase change properties. Amorphous GST film crystallized in to rock salt (NaCl) type structure at 150 degrees C and then transformed to hexagonal structure at 250 degrees C. Interestingly, Se doped GST ((GST)(0.9)Se-0.1) film crystallized directly into hexagonal phase and the intermediate phase of NaCl is not observed. The crystallization temperature (T-c) of (GST)(0.9)Se-0.1 is around 200 degrees C, which is 50 degrees C higher than the T-c of GST. For (GST)(0.9)Se-0.1, the threshold switching occurs at about 4.5V which is higher than GST (3 V). Band gap (E-opt) values of as deposited films are calculated from Tauc plot which are 0.63 eV for GST and 0.66 eV for (GST)(0.9)Se-0.1. The E-opt decreases for the films annealed at higher temperatures. The increased T-c, E-opt, the contrast in resistance and the direct transition to hexagonal phase may improve the data readability and thermal stability in the Se doped GST film. (C) 2014 AIP Publishing LLC.

A composition-dependent ``re-entrant'' crystallographic phase transition in the substitutional metal acetylacetonate complex (Cr1-xGax)(acac)(3)

The formation of a complete solid solution between acetylacetonate (acac) complexes of chromium and gallium, (Cr1-x,Ga-x)(acac)(3) for 0.1 to form for each nominal value of x, with thermal analysis confirming each composition to have a congruent melting point, making it a substitutional complex. Whereas the pure complexes (i.e. the end members of the solid solution, x = 0 and x = 1) are both centro-symmetric, a composition-dependent crystallographic phase transition to a non-centrosymmetric structure is found to occur for compositions with 0.4 < x < 0.9. Such a ``re-entrant'' crystallographic transition is interpreted to be due to the drive to overcome the disorder present in certain centrosymmetric chromium-rich compositions, by going over to a non-centrosymmetric structure with a doubling of the unit cell. The substitutional complex is shown to lead to a substitutional oxide with the beta-gallate structure. (C) 2014 Elsevier Ltd. All rights reserved.

A Nearly Constant Switching Frequency Current Error Space Vector Based Hysteresis Controller for an IM Drive with 12-sided Polygonal Voltage Space Vectors

In this paper, a current error space vector (CESV) based hysteresis controller for a 12-sided polygonal voltage space vector inverter fed induction motor (IM) drive is proposed, for the first time. An open-end winding configuration is used for the induction motor. The proposed controller uses parabolic boundary with generalized vector selection logic for all sectors. The drive scheme is first studied with a space vector based PWM (SVPWM) control and from this the current error space phasor boundary is obtained. This current error space phasor boundary is approximated with four parabolas and then the system is run with space phasor based hysteresis PWM controller by limiting the CESV within the parabolic boundary. The proposed controller has increased modulation range, absence of 5th and 7th order harmonics for the entire modulation range, nearly constant switching frequency, fast dynamic response with smooth transition to the over modulation region and a simple controller implementation.

Pressure-Induced Bond Rearrangement and Reversible Phase Transformation in a Metal-Organic Framework

Pressure-induced phase transformations (PIPTs) occur in a wide range of materials. In general, the bonding characteristics, before and after the PIPT, remain invariant in most materials, and the bond rearrangement is usually irreversible due to the strain induced under pressure. A reversible PIPT associated with a substantial bond rearrangement has been found in a metal-organic framework material, namely tmenH(2)]Er(HCOO)(4)](2) (tmenH(2)(2+) = N,N,N',N'-tetramethylethylenediammonium). The transition is first-order and is accompanied by a unit cell volume change of about 10%. High-pressure single-crystal X-ray diffraction studies reveal the complex bond rearrangement through the transition. The reversible nature of the transition is confirmed by means of independent nanoindentation measurements on single crystals.

Texture transition in cold-rolled nickel-40 wt.% cobalt alloy

The micromechanical aspects of rolling texture development in Ni-40 wt.% Co alloy during very large reductions (up to epsilon(t) = 3.9) have been studied. The alloy showed a typical Cu-type texture up to a true strain of epsilon(t) = 3; however, the texture undergoes an abrupt transition to Bs-type on further rolling to epsilon(t) approximate to 4. (The Bs-type texture, here, comprises almost equal fractions of Goss and Bs components.) Microstructural observations, at early stages, show that deformation is accommodated entirely by slip, and very little presence of deformation twinning is observed to explain the texture transition. However, at much higher reduction levels, micrographs show a high fraction of Cu-type shear bands. These bands are predominantly found in Cu-oriented grains and the crystallites inside the shear bands are preferentially oriented towards Goss, which could explain the final texture evolution. (C) 2014 Acta Materialia Inc. Published by Elsevier Ltd. All rights reserved.

Structural transition and enhanced phase transition properties of Se doped Ge2Sb2Te5 alloys

Amorphous Ge2Sb2Te5 (GST) alloy, upon heating crystallize to a metastable NaCl structure around 150 degrees C and then to a stable hexagonal structure at high temperatures (>= 250 degrees C). It has been generally understood that the phase change takes place between amorphous and the metastable NaCl structure and not between the amorphous and the stable hexagonal phase. In the present work, it is observed that the thermally evaporated (GST)(1-x)Se-x thin films (0 <= x <= 0.50) crystallize directly to the stable hexagonal structure for x >= 0.10, when annealed at temperatures >= 150 degrees C. The intermediate NaCl structure has been observed only for x, 0.10. Chemically ordered network of GST is largely modified for x >= 0.10. Resistance, thermal stability and threshold voltage of the films are found to increase with the increase of Se. The contrast in electrical resistivity between the amorphous and crystalline phases is about 6 orders of magnitude. The increase in Se shifts the absorption edge to lower wavelength and the band gap widens from 0.63 to 1.05 eV. Higher resistance ratio, higher crystallization temperature, direct transition to the stable phase indicate that (GST)(1-x)Se-x films are better candidates for phase change memory applications.