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

The impact of FSC certification on timber tree regeneration and floristic composition in Honduran community forests

Forest certification has been put forward as a means to improve the sustainability of forest management in the tropical countries, where traditional environmental regulation has been inefficient in controlling forest degradation and deforestation. In these countries, the role of communities as managers of the forest resources is rapidly increasing. However, only a fraction of tropical community forests have been certified and little is known about the impacts of certification in these systems. Two areas in Honduras where community-managed forest operations had received FSC certifications were studied. Río Cangrejal represents an area with a longer history of use, whereas Copén is a more recent forest operation. Ecological sustainability was assessed through comparing timber tree regeneration and floristic composition between certified, conventionally managed and natural forests. Data on woody vegetation and environmental conditions was collected within logging gaps and natural treefall gaps. The regeneration success of shade-tolerant timber tree species was lower in certified than in conventionally managed forests in Río Cangrejal. Furthermore, the floristic composition was more natural-like in the conventionally managed than the certified forests. However, the environmental conditions indicated reduced logging disturbance in the certified forests. Data from Copén demonstrated that the regeneration success of light-demanding timber species was higher in the certified than the unlogged forests. In spite of this, the most valuable timber species Swietenia macrophylla was not regenerating successfully in the certified forests, due to rapid gap closure. The results indicate that pre-certification loggings and forest fragmentation may have a stronger impact on forest regeneration than current, certified management practices. The focus in community forests under low-intensive logging should be directed toward landscape connectivity and the restoration of degraded timber species, instead of reducing mechanical logging damage. Such actions are dependent on better recognition of resource rights, and improving the status of small Southern producers in the markets of certified wood products.

Electrical treeing in polyethylene: effect of nano fillers on tree inception and growth

Treeing in polyethylene based nanocomposite samples as well as unfilled polyethylene samples were studied using 50Hz ac voltage. The tree inception voltage was observed for different types of samples. The tree initiation time as well as the tree growth patterns at a fixed ac voltage have also been studied. The results show that there is an improvement in tree inception voltage with nano filler loading in polyethylene. Different tree growth patterns for both the unfilled polyethylene and the polyethylene nanocomposites have been observed. A slower tree growth was observed in polyethylene nanocomposites. The partial discharge characteristics of unfilled and nano filled polyethylene samples during the electrical tree growth period was also studied. Decrease in PD magnitude as well as in the number of pd pulses with electrical tree growth duration in polyethylene nanocomposites has also been observed. The possible reasons for the improvement in electrical tree growth and PD resistance with the addition of nano fillers are discussed.

Decision tree design and applications in speech processing

The design and operation of the minimum cost classifier, where the total cost is the sum of the measurement cost and the classification cost, is computationally complex. Noting the difficulties associated with this approach, decision tree design directly from a set of labelled samples is proposed in this paper. The feature space is first partitioned to transform the problem to one of discrete features. The resulting problem is solved by a dynamic programming algorithm over an explicitly ordered state space of all outcomes of all feature subsets. The solution procedure is very general and is applicable to any minimum cost pattern classification problem in which each feature has a finite number of outcomes. These techniques are applied to (i) voiced, unvoiced, and silence classification of speech, and (ii) spoken vowel recognition. The resulting decision trees are operationally very efficient and yield attractive classification accuracies.

Growth, mortality, and exploitation of the Engraulidae, with special reference to the anchoveta, Cetengraulis mysticetus, and the colorado, Anchoa naso, in the Eastern Pacific Ocean

ENGLISH: Growth and mortality data for Cetengraulis mysticetus, Anchoa naso, Engraulis mordax, E. ring ens, E. anchoita, E. encraslcbolus, E. japonicus, and E. australis were assembled and compared. Estimates of the coefficients of natural mortality, M, of E. anchoita and Ancboa naso were made from the maximum age of the former and from data for the other species. The relative yields per recruit at different fishing mortality rates and lengths at entry into the fishery were calculated for each species, using what are considered to be the best estimates and other likely values of K, a constant of growth, and M. The maximum yields per recruit are theoretically obtainable at very high fishing mortality rates, except when the length at entry is low relative to the asymptotic length. K and M may be positively related to the temperature and to each other, and if such is the case at higher temperatures greater fishing effort would be needed to attain the maximum yield per recruit. The applicability of the yield-per-recruit approach to the data is discussed, and suggestions for further research are made. SPANISH: Se reunieron y compararon los datos sobre el crecimiento y mortalidad correspondientes a Cetengraulis mysticetus, Anchoa naso, Engraulis mordax, E. ringens, E. anchoíta, E. encrasicbolus, E. japonicus y E. australls. Los estimativos de los coeficientes de la mortalidad natural, M, de E. anchoita y Anchoa naso se obtuvieron según la edad máxima de E. anchoita y según los datos de las otras especies. Se calculó para cada especie el rendimiento relativo por recluta a diferentes tasas de mortalidad por la pesca y a diferentes longitudes de entrada a la pesquería, empleándose lo que se considera que son los mejores estimativos y otros valores probables de K, una constante de crecímíento, y M. El rendimiento máximo por recluta se obtiene teóricamente a tasas muy altas de la mortalidad por la pesca con excepción de cuando la longitud a la entrada es baja en relación a la longitud asintótica. K y M pueden estar relacionadas positivamente a la temperatura y mutuamente, y si este es el caso a temperaturas más altas se necesitará un esfuerzo superior de pesca para obtener el rendimiento máximo por recluta. La aplicabilidad del enfoque a los datos rendimiento-por-recluta es discutido y se hacen sugerencias para otras investigaciones. (PDF contains 66 pages.)

Kurzinformation zum EU - Projekt: "Mechanisms influencing long term trends in reproductive success and recruitment of Baltic cod : implications for fisheries management"

In July 1994 an internationally coordinated and EU financed multidisciplinary research project about Baltic cod recruitment was started. The primary goals are to identify and describe dominant biotic and abiotic processes affecting the developmental success of early stages and the maturation of cod in the Central Baltic, to incorporate these processes into recruitment models in order to enhance prediction of future stock fluctuations due to environmental pertubations, species interactions and fisheries management directives as a prerequisite for an integrated fish stock assessment in the Central Baltic and to evaluate the feasibility and possible effects of stock enhancement programs on stock and recruitment and providing the biological basis for assessing their economic value.

Age validation, growth, mortality, and demographic modeling of spotted gully shark (Triakis megalopterus) from the southeast coast of South Africa

This study documents validation of vertebral band-pair formation in spotted gully shark (Triakis megalopterus) with the use of fluorochrome injection and tagging of captive and wild sharks over a 21-year period. Growth and mortality rates of T. megalopterus were also estimated and a demographic analysis of the species was conducted. Of the 23 OTC (oxytetracycline) -marked vertebrae examined (12 from captive and 11 from wild sharks), seven vertebrae (three from captive and four from wild sharks) exhibited chelation of the OTC and fluoresced under ultraviolet light. It was concluded that a single opaque and translucent band pair was deposited annually up to at least 25 years of age, the maximum age recorded. Reader precision was assessed by using an index of average percent error calculated at 5%. No significant differences were found between male and female growth patterns (P>0.05), and von Bertalanffy growth model parameters for combined sexes were estimated to be L∞=1711.07 mm TL, k=0.11/yr and t0=–2.43 yr (n=86). Natural mortality was estimated at 0.17/yr. Age at maturity was estimated at 11 years for males and 15 years for females. Results of the demographic analysis showed that the population, in the absence of fishing mortality, was stable and not significantly different from zero and particularly sensitive to overfishing. At the current age at first capture and natural mortality rate, the fishing mortality rate required to result in negative population growth was low at F>0.004/ yr. Elasticity analysis revealed that juvenile survival was the principal factor in explaining variability in population growth rate.

Patterns of growth, mortality, and size of the tropical damselfish Acanthochromis polyacanthus across the continental shelf of the Great Barrier Reef

Age-based analyses were used to demonstrate consistent differences in growth between populations of Acanthochromis polyacanthus (Pomacentridae) collected at three distance strata across the continental shelf (inner, mid-, and outer shelf) of the central Great Barrier Reef (three reefs per distance stratum). Fish had significantly greater maximum lengths with increasing distance from shore, but fish from all distances reached approximately the same maximum age, indicating that growth is more rapid for fish found on outer-shelf reefs. Only one fish collected from inner-shelf reefs reached >100 mm SL, whereas 38−67% of fish collected from the outer shelf were >100 mm SL. The largest age class of adult-size fish collected from inner and mid-shelf locations comprised 3−4 year-olds, but shifted to 2-year-olds on outer-shelf reefs. Mortality schedules (Z and S) were similar irrespective of shelf position (inner shelf: 0.51 and 60.0%; mid-shelf: 0.48 and 61.8%; outer shelf: 0.43 and 65.1%, respectively). Age validation of captive fish indicated that growth increments are deposited annually, between the end of winter and early spring. The observed cross-shelf patterns in adult sizes and growth were unlikely to be a result of genetic differences between sample populations because all fish collected showed the same color pattern. It is likely that cross-shelf variation in quality and quantity of food, as well as in turbidity, are factors that contribute to the observed patterns of growth. Similar patterns of cross-shelf mortality indicate that predation rates varied little across the shelf. Our study cautions against pooling demographic parameters on broad spatial scales without consideration of the potential for cross-shelf variabil