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

Dynamic security assessment of power systems using structure-preserving energy functions

An application of direct methods to dynamic security assessment of power systems using structure-preserving energy functions (SPEF) is presented. The transient energy margin (TEM) is used as an index for checking the stability of the system as well as ranking the contigencies based on their severity. The computation of the TEM requires the evaluation of the critical energy and the energy at fault clearing. Usually this is done by simulating the faulted trajectory, which is time-consuming. In this paper, a new algorithm which eliminates the faulted trajectory estimation is presented to calculate the TEM. The system equations and the SPEF are developed using the centre-of-inertia (COI) formulation and the loads are modelled as arbitrary functions of the respective bus voltages. The critical energy is evaluated using the potential energy boundary surface (PEBS) method. The method is illustrated by considering two realistic power system examples.

Actuarial report 2011: Social security schemes administered by Kela 2010-2060

Projections concerning the long-term outlook of the social security schemes administered by the Social Insurance Institution of Finland (Kela) are made regularly by the Institution’s Actuarial Section. The report at hand was compiled with the help of an aggregate model devised by the Actuarial Section. In the model, various universal factors influencing benefit trends are consolidated and the interactions between individual benefits are taken into account. The demographic forecasts underlying the report have also been made by the Actuarial Section. Estimates of income and administrative costs have been made in cooperation with the Financial Planning Section.

Filter Optimization for Grid Interactive Voltage Source Inverters

Higher order LCL filters are essential in meeting the interconnection standard requirement for grid-connected voltage source converters. LCL filters offer better harmonic attenuation and better efficiency at a smaller size when compared to the traditional L filters. The focus of this paper is to analyze the LCL filter design procedure from the point of view of power loss and efficiency. The IEEE 1547-2008 specifications for high-frequency current ripple are used as a major constraint early in the design to ensure that all subsequent optimizations are still compliant with the standards. Power loss in each individual filter component is calculated on a per-phase basis. The total inductance per unit of the LCL filter is varied, and LCL parameter values which give the highest efficiency while simultaneously meeting the stringent standard requirements are identified. The power loss and harmonic output spectrum of the grid-connected LCL filter is experimentally verified, and measurements confirm the predicted trends.

A Resonant Integrator Based PLL and AC Current Controller for Single Phase Grid Connected PWM-VSI

Grid connected PWM-VSIs are being increasingly used for applications such as Distributed Generation (DG), power quality, UPS etc. Appropriate control strategies for grid synchronisation and line current regulation are required to establish such a grid interconnection and power transfer. Control of three phase VSIs is widely reported in iterature. Conventionally, dq control in Synchronous Reference Frame(SRF) is employed for both PLL and line current control where PI-controllers are used to track the DC references. Single phase systems do not have defined direct (d) and quadrature (q) axis components that are required for SRF transformation. Thus, references are AC in nature and hence usage of PI controllers cannot yield zero steady state errors. Resonant controllers have the ability to track AC references accurately. In this work, a resonant controller based single phase PLL and current control technique are being employed for tracking grid frequency and the AC current reference respectively. A single phase full bridge converter is being operated as a STATCOM for performance evaluation of the control scheme.

Analysis of grid connected induction generators driven by hydro/wind turbines under realistic system constraints

Results of an investigation dealing with the behaviour of grid-connected induction generators (GCIGs) driven by typical prime movers such as mini-hydro/wind turbines are presented. Certain practical operational problems of such systems are identified. Analytical techniques are developed to study the behavior of such systems. The system consists of the induction generator (IG) feeding a 11 kV grid through a step-up transformer and a transmission line. Terminal capacitors to compensate for the lagging VAr are included in the study. Computer simulation was carried out to predict the system performance at the given input power from the turbine. Effects of variations in grid voltage, frequency, input power, and terminal capacitance on the machine and system performance are studied. An analysis of self-excitation conditions on disconnection of supply was carried out. The behavior of a 220 kW hydel system and 55/11 kW and 22 kW wind driven system corresponding to actual field conditions is discussed

Relaxation system based sub-grid scale modelling for large eddy simulation of Burgers' equation

An implicit sub-grid scale model for large eddy simulation is presented by utilising the concept of a relaxation system for one dimensional Burgers' equation in a novel way. The Burgers' equation is solved for three different unsteady flow situations by varying the ratio of relaxation parameter (epsilon) to time step. The coarse mesh results obtained with a relaxation scheme are compared with the filtered DNS solution of the same problem on a fine mesh using a fourth-order CWENO discretisation in space and third-order TVD Runge-Kutta discretisation in time. The numerical solutions obtained through the relaxation system have the same order of accuracy in space and time and they closely match with the filtered DNS solutions.

Mapping Road Infrastructure in Developing Countries Applying Remote Sensing and GIS - The Case of the Taita Hills, Kenya

Road transport and infrastructure has a fundamental meaning for the developing world. Poor quality and inadequate coverage of roads, lack of maintenance operations and outdated road maps continue to hinder economic and social development in the developing countries. This thesis focuses on studying the present state of road infrastructure and its mapping in the Taita Hills, south-east Kenya. The study is included as a part of the TAITA-project by the Department of Geography, University of Helsinki. The road infrastructure of the study area is studied by remote sensing and GIS based methodology. As the principal dataset, true colour airborne digital camera data from 2004, was used to generate an aerial image mosaic of the study area. Auxiliary data includes SPOT satellite imagery from 2003, field spectrometry data of road surfaces and relevant literature. Road infrastructure characteristics are interpreted from three test sites using pixel-based supervised classification, object-oriented supervised classifications and visual interpretation. Road infrastructure of the test sites is interpreted visually from a SPOT image. Road centrelines are then extracted from the object-oriented classification results with an automatic vectorisation process. The road infrastructure of the entire image mosaic is mapped by applying the most appropriate assessed data and techniques. The spectral characteristics and reflectance of various road surfaces are considered with the acquired field spectra and relevant literature. The results are compared with the experimented road mapping methods. This study concludes that classification and extraction of roads remains a difficult task, and that the accuracy of the results is inadequate regardless of the high spatial resolution of the image mosaic used in this thesis. Visual interpretation, out of all the experimented methods in this thesis is the most straightforward, accurate and valid technique for road mapping. Certain road surfaces have similar spectral characteristics and reflectance values with other land cover and land use. This has a great influence for digital analysis techniques in particular. Road mapping is made even more complicated by rich vegetation and tree canopy, clouds, shadows, low contrast between roads and surroundings and the width of narrow roads in relation to the spatial resolution of the imagery used. The results of this thesis may be applied to road infrastructure mapping in developing countries on a more general context, although with certain limits. In particular, unclassified rural roads require updated road mapping schemas to intensify road transport possibilities and to assist in the development of the developing world.

Paradox between democracy and security- case study on Pakistan

Pro gradu-tutkielma tutkii demokratian ja turvallisuuden paradoksia Pakistanissa esitellen kuusi tekijää, jotka vaikuttavat kyseiseen paradoksiin. Näitä tekijöitä ovat historiallinen kehitys; eliittihallinto; taloudellinen kehitys; Pakistanin poliittisten tekijöiden demokratian eri määritelmät; opetuksen puuttuminen; ja valtataistelu hallituksen, armeijan, tiedustelupalvelun, oikeusjärjestelmän, poliittisten puolueiden sekä eri heimojen, uskonnollisten ja etnisten ryhmien välillä. Tutkimus tarkastelee myös sitä miten nämä tekijät vaikuttavat demokratian kehitykseen Pakistanissa. Keskeinen argumentti on, että länsimainen demokratia ei esiinny eikä toimi Pakistanissa vallitsevissa oloissa, etenkin historiallisen kehityksen ja ulkoisen turvallisuuden takia. Pro gradu-tutkielma käyttää sekundäärisiä lähteitä, kuten kirjoja, artikkeleita, maaraportteja, kommentaareja sekä omiin kokemuksiin perustuvia havaintoja Pakistanin matkalta 2010-2011. Keskeiset teoriat gradussa ovat Guillermo O’ Donnelin delegaattidemokratia sekä Duncan McCargon eliittihallintoteoria, jotka yhdessä selittävät historiallista kehitystä ja eliittihallinnon dynamiikkaa, mitkä johtavat paradoksiin. Kautta historian armeija on hallinnut Pakistania, ja siviilihallinto on ainoastaan neljä kertaa onnistunut olemaan vallassa, mutta silloinkin siviilihallinto päättyi korruptioväitteisiin tai armeijan vallankaappaukseen. Armeijahallinnoille on luonteenomaista hyvät suhteet USA:n, positiivinen taloudellinen kehitys ja vakaus, kun taas siviilihallinnot ovat epävakaita ja korruptoituneita. Tämä kehitys on paradoksin tausta, joka rakentuu turvallisuuspoliittisen tilanteen pohjalle eli hallitusten ja muiden tekijöiden yritykseen löytää vastapaino Intian uhalle. Tämä on ollut keskeinen huoli kelle tahansa poliittiselle päättäjälle itsenäisyydestä lähtien. Loputon valtataistelu eri poliittisten tekijöiden kesken sekä eliittihallinto pitävät yllä paradoksia, koska eliitit ovat kiinnostuneempia oman valtansa säilyttämisestä kuin kansan tahdon huomioonottamisesta. Koska valtaosa ihmisistä ei ole koulutettuja, he ovat paljolti kiinnostuneita omasta selviytymisestään, ja tämän takia sekä kansa että eliitit suosivat armeijahallintoa, koska se tuo vakautta ja taloudellista kehitystä. Sen vuoksi vallitsevissa oloissa demokratian tulevaisuus Pakistanissa näyttää huonolta, koska liberaalidemokratian vaatimukset eivät täyty puoliksi vapaan oikeussysteemin, puoliksi vapaan lehdistön, valtavan korruption ja monien ihmisoikeusloukkauksien takia unohtamatta armeijan ja tiedustelupalvelun sekaantumista siviilihallintoon.

Common Infrastructure for Finite-State Based Methods and Linguistics Descriptions

Finite-state methods have been adopted widely in computational morphology and related linguistic applications. To enable efficient development of finite-state based linguistic descriptions, these methods should be a freely available resource for academic language research and the language technology industry. The following needs can be identified: (i) a registry that maps the existing approaches, implementations and descriptions, (ii) managing the incompatibilities of the existing tools, (iii) increasing synergy and complementary functionality of the tools, (iv) persistent availability of the tools used to manipulate the archived descriptions, (v) an archive for free finite-state based tools and linguistic descriptions. Addressing these challenges contributes to building a common research infrastructure for advanced language technology.

Evaluation and improvement of generators reactive power margins in interconnected power systems

The amount of reactive power margin available in a system determines its proximity to voltage instability under normal and emergency conditions. More the reactive power margin, better is the systems security and vice-versa. A hypothetical way of improving the reactive margin of a synchronous generator is to reduce the real power generation within its mega volt-ampere (MVA) ratings. This real power generation reduction will affect its power contract agreements entered in the electricity market. Owing to this, the benefit that the generator foregoes will have to be compensated by paying them some lost opportunity cost. The objective of this study is three fold. Firstly, the reactive power margins of the generators are evaluated. Secondly, they are improved using a reactive power optimization technique and optimally placed unified power flow controllers. Thirdly, the reactive power capacity exchanges along the tie-lines are evaluated under base case and improved conditions. A detailed analysis of all the reactive power sources and sinks scattered throughout the network is carried out in the study. Studies are carried out on a real life, three zone, 72-bus equivalent Indian southern grid considering normal and contingency conditions with base case operating point and optimised results presented.

Controlled synthesis of CuO nanostructures on Cu foil, rod and grid

CuO nanowires are synthesized by heating Cu foil, rod and grid in ambient without employing a catalyst or gas flow at temperatures ranging from 400 to 800 degrees C for a duration of 1-12 h. Scanning electron microscopy (SEM) investigation reveals the formation of nanowires. The structure, morphology and phase of the as-synthesized nanowires are analyzed by various techniques such as X-ray diffraction (XRD), transmission electron microscopy (TEM), X-ray photoelectron spectroscopy (XPS), thermogravimetric analysis (TGA) and Fourier transform infrared spectroscopy (FTIR). It is found that these nanowires are composed of CuO phase and the underlying film is of Cu2O. A systematic study is carried out to find the possibilities for the transformation of one phase to another completely. A possible growth mechanism for the nanowires is also discussed. (C) 2011 Elsevier B.V. All rights reserved.

OPSM - Opportunistic Power Save mode for Infrastructure IEEE 802.11 WLAN

We focus on the energy spent in radio communication by the stations (STAs) in an IEEE 802.11 infrastructure WLAN. All the STAs are engaged in web browsing, which is characterized by a short file downloads over TCP, with short duration of inactivity or think time in between two file downloads. Under this traffic, Static PSM (SPSM) performs better than CAM, since the STAs in SPSM can switch to low power state (sleep) during think times while in CAM they have to be in the active state all the time. In spite of this gain, performance of SPSM degrades due to congestion, as the number of STAs associated with the access point (AP) increases. To address this problem, we propose an algorithm, which we call opportunistic PSM (OPSM). We show through simulations that OPSM performs better than SPSM under the aforementioned TCP traffic. The performance gain achieved by OPSM over SPSM increases as the mean file size requested by the STAs or the number of STAs associated with the AP increases. We implemented OPSM in NS-2.33, and to compare the performance of OPSM and SPSM, we evaluate the number of file downloads that can be completed with a given battery capacity and the average time taken to download a file.

A fixed-grid finite element based enthalpy formulation for generalized phase change problems: role of superficial mushy region

The enthalpy method is primarily developed for studying phase change in a multicomponent material, characterized by a continuous liquid volume fraction (phi(1)) vs temperature (T) relationship. Using the Galerkin finite element method we obtain solutions to the enthalpy formulation for phase change in 1D slabs of pure material, by assuming a superficial phase change region (linear (phi(1) vs T) around the discontinuity at the melting point. Errors between the computed and analytical solutions are evaluated for the fluxes at, and positions of, the freezing front, for different widths of the superficial phase change region and spatial discretizations with linear and quadratic basis functions. For Stefan number (St) varying between 0.1 and 10 the method is relatively insensitive to spatial discretization and widths of the superficial phase change region. Greater sensitivity is observed at St = 0.01, where the variation in the enthalpy is large. In general the width of the superficial phase change region should span at least 2-3 Gauss quadrature points for the enthalpy to be computed accurately. The method is applied to study conventional melting of slabs of frozen brine and ice. Regardless of the forms for the phi(1) vs T relationships, the thawing times were found to scale as the square of the slab thickness. The ability of the method to efficiently capture multiple thawing fronts which may originate at any spatial location within the sample, is illustrated with the microwave thawing of slabs and 2D cylinders. (C) 2002 Elsevier Science Ltd. All rights reserved.