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

Origin of the plateau in the low-temperature thermal conductivity of silica

Thermal conductivities of glasses at low temperatures show strikingly similar behavior irrespective of their chemical composition. While for T<1 K the thermal conductivity can be understood in the phenomenological tunneling model; the ‘‘universal plateau’’ in the temperature interval 15>T>2 K is totally unexplained. While Rayleigh scattering of phonons by structural disorder should be the natural cause for limiting the mean free path of phonons in this temperature range, it has been concluded before that in glasses a strong enough source of such scattering does not exist. In this study we show by a proper structural analysis in at least one material (namely, silica) that a strong enough source of Rayleigh scattering of phonons in glasses does exist so that the ‘‘universal plateau’’ can be explained without invoking any new mechanism. This may be for the first time that the low-temperature property of a structural glass has been correlated to its structure.

Synthesis and characterization of metal substituted AlxCr1-x(acetylacetonate)(3) single-source precursors for their application to MOCVD of thin films

A detailed study, involving the synthesis of a single-source precursor containing two metal ions sharing the same crystallographic site, has been undertaken to elucidate the use of such a single-source precursor in a CVD process for growing thin films of oxides comprising these two metals, ensuring a uniform composition and distribution of metal ions. The substituted complexes Cr1-xAlx(acac)(3), where acac = acetyl-acetonate, have been prepared by a co-synthesis method, and characterized using UV-Vis spectroscopy. TGA/DTA measurements, and single crystal X-ray diffraction at low temperature. All the studied compositions crystallize in the monoclinic space group P2(1)/c with Z = 4 in the unit cell. It was observed that the ratio (Al:Cr) of the site occupancy for the metal ions, obtained from single crystal refinement, is in agreement with the results obtained from complexometric titrations. All the solid state structures have the metal in an octahedral environment forming six-membered chelate rings. M-O acac bond lengths and disorder in the terminal carbon have been studied in detail for these substituted metal-organic complexes. One composition among these was chosen to evaluate their suitability as a single-source precursor in a LPMOCVD process (low-pressure metal-organic chemical vapour deposition) for the deposition of a substituted binary metal oxide thin film. The resulting thin films were characterized by X-ray diffraction, scanning electron microscopy, and infrared spectroscopy. (C) 2010 Elsevier Ltd. All rights reserved.

Performance Optimization of Induction Motor-Pump System Using Photovoltaic Energy Source

The optimization of a photovoltaic pumping system based on an induction motor driven pump that is powered by a solar array is presented in this paper. The motor-pump subsystem is analyzed from the point of view of optimizing the power requirement of the induction motor, which has led to an optimum u-f relationship useful in controlling the motor. The complete pumping system is implemented using a dc-dc converter, a three-phase inverter, and an induction motor-pump set. The dc-dc converter is used as a power conditioner and its duty cycle is controlled so as to match the load to the array. A microprocessor-based controller is used to carry out the load-matching.

Optimization of ion energy spread in inductively coupled plasma source designed for focused ion beam applications

The ion energy distribution of inductively coupled plasma ion source for focused ion beam application is measured using a four grid retarding field energy analyzer. Without using any Faraday shield, ion energy spread is found to be 50 eV or more. Moreover, the ion energy distribution is found to have double peaks showing that the power coupling to the plasma is not purely inductive, but a strong parasitic capacitive coupling is also present. By optimizing the various source parameters and Faraday shield, ion energy distribution having a single peak, well separated from zero energy and with ion energy spread of 4 eV is achieved. A novel plasma chamber, with proper Faraday shield is designed to ignite the plasma at low RF powers which otherwise would require 300-400 W of RF power. Optimization of various parameters of the ion source to achieve ions with very low energy spread and the experimental results are presented in this article. (C) 2010 Elsevier Ltd. All rights reserved.

Management of bushland vegetation using rainwater harvesting in eastern Kenya.

Microcatchment water harvesting (MCWH) improved the survival and growth of planted trees on heavy soils in eastern Kenya five to six years after planting. In the best method, the cross-tied furrow microcatchments, the mean annual increments (MAI; based on the average biomass of living trees multiplied by tree density and survival) of the total and usable biomass in Prosopis juliflora were 2787 and 1610 kg ha-1 a-1 respectively, when the initial tree density was 500 to 1667 trees per hectare. Based on survival, the indigenous Acacia horrida, A. mellifera and A. zanzibarica were the most suitable species for planting using MCWH. When both survival and yield were considered, a local seed source of the introduced P. juliflora was superior to all other species. The MAI in MCWH was at best distinctly higher than that in the natural vegetation (163­307 and 66­111 kg ha-1 a-1 for total and usable biomass respectively); this cannot satisfy the fuelwood demand of concentrated populations, such as towns or irrigation schemes. The density of seeds of woody species in the topsoil was 40.1 seeds m-2 in the Acacia-Commiphora bushland and 12.6 seeds m-2 in the zone between the bushland and the Tana riverine forest. Rehabilitation of woody vegetation using the soil seed bank alone proved difficult due to the lack of seeds of desirable species. The regeneration and dynamics of woody vegetation were also studied both in cleared and undisturbed bushland. A sub-type of Acacia-Commiphora bushland was identified as Acacia reficiens bushland, in which the dominant Commiphora species is C. campestris. Most of the woody species did not have even-aged populations but cohort structures that were skewed towards young individuals. The woody vegetation and the status of soil nutrients were estimated to recover in 15­20 years on Vertic Natrargid soils after total removal of above-ground vegetation.

The Skill of ECMWF Medium-Range Forecasts during the Year of Tropical Convection 2008

This study uses the European Centre for Medium-Range Weather Forecasts (ECMWF) model-generated high-resolution 10-day-long predictions for the Year of Tropical Convection (YOTC) 2008. Precipitation forecast skills of the model over the tropics are evaluated against the Tropical Rainfall Measuring Mission (TRMM) estimates. It has been shown that the model was able to capture the monthly to seasonal mean features of tropical convection reasonably. Northward propagation of convective bands over the Bay of Bengal was also forecasted realistically up to 5 days in advance, including the onset phase of the monsoon during the first half of June 2008. However, large errors exist in the daily datasets especially for longer lead times over smaller domains. For shorter lead times (less than 4-5 days), forecast errors are much smaller over the oceans than over land. Moreover, the rate of increase of errors with lead time is rapid over the oceans and is confined to the regions where observed precipitation shows large day-to-day variability. It has been shown that this rapid growth of errors over the oceans is related to the spatial pattern of near-surface air temperature. This is probably due to the one-way air-sea interaction in the atmosphere-only model used for forecasting. While the prescribed surface temperature over the oceans remain realistic at shorter lead times, the pattern and hence the gradient of the surface temperature is not altered with change in atmospheric parameters at longer lead times. It has also been shown that the ECMWF model had considerable difficulties in forecasting very low and very heavy intensity of precipitation over South Asia. The model has too few grids with ``zero'' precipitation and heavy (>40 mm day(-1)) precipitation. On the other hand, drizzle-like precipitation is too frequent in the model compared to that in the TRMM datasets. Further analysis shows that a major source of error in the ECMWF precipitation forecasts is the diurnal cycle over the South Asian monsoon region. The peak intensity of precipitation in the model forecasts over land (ocean) appear about 6 (9) h earlier than that in the observations. Moreover, the amplitude of the diurnal cycle is much higher in the model forecasts compared to that in the TRMM estimates. It has been seen that the phase error of the diurnal cycle increases with forecast lead time. The error in monthly mean 3-hourly precipitation forecasts is about 2-4 times of the error in the daily mean datasets. Thus, effort should be given to improve the phase and amplitude forecast of the diurnal cycle of precipitation from the model.

Valistus suomalaisessa kirjakulttuurissa 1700-luvulla

The dissertation discusses the history of the book and the Enlightenment in Finland by studying the reception and diffusion of eighteenth-century books and by approaching the discourse on the Enlightenment in Finnish source material. The methods used relate to historian Robert Darnton s studies on eighteenth-century print culture and his analyses of the relations between print culture and society. The study is based on diverse eighteenth-century sources: books, pamphlets and dissertations, bibliographies, book auction protocols, parliamentary documents, estate inventory deeds, newspapers, letters, lectures, memoirs and commonplace books. By the end of the eighteenth century, book production had increased and secular literature had begun to challenge the dominance of religious literature. The books of the Enlightenment belonged to the new literature that found its way into Finnish book collections previously dominated by religious literature. Enlightenment literature is not a set selection of books but rather diverse works from different genres. Thus the study introduces a variety of printed material, from philosophical tracts and textbooks to novels and pornography. In the case of books of the Enlightenment, the works of French Voltaire and German Christian Wolff were among the most widely read and circulated books in Finland. First and foremost, the Enlightenment was an era of intellectual debate. These debates carried strong criticism of the prevailing systems of thought. Enlightenment ideas challenged the Lutheran society of Sweden and especially its sense of conformity. Contemporaries saw many of the books of the Enlightenment as vessels of new ideas and criticism. Furthermore, this kind of print material was interpreted as being dangerous for uneducated readers. Belonging to a certain estate and social class had a major impact on individuals reading habits and their acquisition of books. One specific social group stands out in the Finnish source material: the officers at the Sveaborg naval fortress possessed and distributed Enlightenment books more than the members of any other social class. Other essential social groups were scholars, the nobility and the clergy, who took part in debates concerning the ideas and benefits of the Enlightenment. In the Finnish debates at the time, the concept of Enlightenment involved three primary notions. Firstly, it referred to the French philosophers, les philosophes, and to their works as well as to the social changes that took place during the French revolution. It also carried the idea of philosophical light or the light of reason, in a sense similar to Immanuel Kant s writings. Most importantly, it referred to a belief in progress and to a trust in true knowledge that would supercede ignorance and fanaticism. Hence, it is impossible to speak about the Enlightenment era in the Swedish realm without such concepts as reason, benefit or progress. These concepts likewise marked the books of the Enlightenment in eighteenth-century Finland.

CowLog

We have developed CowLog, which is open-source software for recording behaviors from digital video and is easy to use and modify. CowLog tracks the time code from digital video files. The program is suitable for coding any digital video, but the authors have used it in animal research. The program has two main windows: a coding window, which is a graphical user interface used for choosing video files and defining output files that also has buttons for scoring behaviors, and a video window, which displays the video used for coding. The windows can be used in separate displays. The user types the key codes for the predefined behavioral categories, and CowLog transcribes their timing from the video time code to a data file. CowLog comes with an additional feature, an R package called Animal, for elementary analyses of the data files. With the analysis package, the user can calculate the frequencies, bout durations, and total durations of the coded behaviors and produce summary plots from the data.

Source and target enzyme signature in serine protease inhibitor active site sequences

Amino acid sequences of proteinaceous proteinase inhibitors have been extensively analysed for deriving information regarding the molecular evolution and functional relationship of these proteins. These sequences have been grouped into several well defined families. It was found that the phylogeny constructed with the sequences corresponding to the exposed loop responsible for inhibition has several branches that resemble those obtained from comparisons using the entire sequence. The major branches of the unrooted tree corresponded to the families to which the inhibitors belonged. Further branching is related to the enzyme specificity of the inhibitor. Examination of the active site loop sequences of trypsin inhibitors revealed that there are strong preferences for specific amino acids at different positions of the loop. These preferences are inhibitor class specific. Inhibitors active against more than one enzyme occur within a class and confirm to class specific sequence in their loops. Hence, only a few positions in the loop seem to determine the specificity. The ability to inhibit the same enzyme by inhibitors that belong to different classes appears to be a result of convergent evolution

Signal subspace approach in localization of sound source in shallow water

A new algorithm based on signal subspace approach is proposed for localizing a sound source in shallow water. In the first instance we assumed an ideal channel with plane parallel boundaries and known reflection properties. The sound source is assumed to emit a broadband stationary stochastic signal. The algorithm takes into account the spatial distribution of all images and reflection characteristics of the sea bottom. It is shown that both range and depth of a source can be measured accurately with the help of a vertical array of sensors. For good results the number of sensors should be greater than the number of significant images; however, localization is possible even with a smaller array but at the cost of higher side lobes. Next, we allowed the channel to be stochastically perturbed; this resulted in random phase errors in the reflection coefficients. The most singular effect of the phase errors is to introduce into the spectral matrix an extra term which may be looked upon as a signal generated coloured noise. It is shown through computer simulations that the signal peak height is reduced considerably as a consequence of random phase errors.

Principle of a Dual Current Source Converter for AC Motor Drives

The principle of operation of a dual current source converter is briefly explained. The combination of two single current source converters (SCSC) to form a ``dual (duplex) current source converter'' (DCSC) is proposed. The DCSC is shown to have the following merits: 1) it retains all the advantages of the SCSC; 2) it reduces the harmonic content of the current waveform considerably; and 3) since the load current is shared equally between two current source converters, ratings of the individual components employed in the circuit are considerably lowered. A DCSC can be an attractive choice for sophisticated large horsepower drives where a good performance of the drive rather than cost is a prime factor. An open-loop control scheme employing the DCSC for an ac motor drive has been successfully implemented in the laboratory. Oscillograms of the improved load current waveforms are shown.

Vain hätapua? : Taloudellinen avustaminen diakoniatyön professionaalisen itseymmärryksen ilmentäjänä

Financial Help Alone? Financial help as an exponent of professional diaconal work One essential form of helping people in the Evangelical Lutheran Church s diaconal work is providing economic aid. It can be seen as work which is in accordance with the spirit of the Church Order (4:3). One of the tasks of diaconal work, determined by the Church Order, is to help those whose distress is the greatest and who have no other source of help. This financial support has become a permanent and essential working method, which has also created tension of various kinds. Financial support has been criticized, especially when the support has been used to fill a gap in the social services provided by the government. It has been argued that diaconal work has been forced to take on responsibility for tasks that belong to the welfare state. The tensions involved in the financial support of diaconal work do not only concern the patching up and supplementing of the deficiencies in the welfare state s services but also the question of diaconal workers self-understanding of financial support and how it relates to their professionalism. In this thesis, I examine the experiences and visions diaconal workers have concerning financial support in their work with clients. The viewpoint of my work is the diaconal workers own experiences and interpretations of the meaning of financial support in customer service. In the articles of my thesis, I examined the meanings that diaconal workers gave to financial support in the aspects of work motivation, empowerment, expertise and tensions. The research material of my articles consists of three different data, which are theme interviews from diaconal workers, a survey from diaconal workers of Espoo and a diaconal barometer of 2009. I have analysed the theme interviews and the survey using qualitative content analysis. The results of my articles showed that diaconal workers motivation in tasks concerning economic aid was sustained by the nature and spiritual aspects of support activities. Work that supported empowerment through financial assistance meant influencing the client s personal life, community and local ties and structural circumstances of the surrounding society. Diaconal workers expertise in financial support work can be characterised as horizontal, which means that the expertise was built on acknowledging the client s dignity, the uniqueness of the client s life situation and listening to the client s own voice. Diaconal workers were also experts in community and area-based work. The tensions in financial support work are linked to its unofficial and undefined role in the field of social welfare and the inability of other aiding parties to respond to their duties. The results of my thesis on the experiences and visions of financial support reveal that it is multilateral and multidimensional. Diaconal workers used financial support to help the clients, taking into account their individual, communal, social and spiritual context. The professionalism of this financial support is reflectively related to the client s need of help and the spontaneity and unexpectedness of the situation. Support work was deeply bound to diaconal workers experiences of spirituality as the basic value in their work, the foundation of their idea of humanity and their method of helping others. In different tasks of financial support diaconal workers balanced between traditional, individual client work based on caritas and working methods which are based on supporting the individual s empowerment and active citizenship, as in postmodern social work. Diaconal workers experiences of financial support illustrated the transition or turning point in the professionalism of diaconal work, which involves finding one s own, stronger and clearer professional identity than earlier with respect to other helpers in society. Creating a unique identity is part of the empowerment process of diaconal work, in which it must define its professional role by itself. In postmodern pluralism and the fragmented context of diaconal activities, the question arose as to whether the spiritual traditions and traditional values of diaconal work support the modifications and adaptations needed in new, unpredictable situations. Diaconal work is said to be fast to react, able to predict changes and adapt to those changes. To preserve its sensitive reactive ability, also in the complex postmodern world, it must retain its own views and orientations. Otherwise, the distinctive values and traditions of diaconal work might sustain static diaconal work, employee-centeredness and a smug attitude when defining beneficiaries and needs, which highlights the paternalism of diaconal work. Such paternalism may complicate the progress of working methods which are based on empowerment and citizenship.