The influence of the birthplace and models of care on midwifery practice for the management of women in labour

This paper will examine how the settings in which midwives practice (the birthplace) and models of care affect midwives’ decision making during the management of labour. One-hundred-and-four independent, team and hospital based midwives and 100 low obstetric risk nulliparous women to whom labour care was provided were surveyed. These midwives and women resided in the Auckland metropolitan area of New Zealand. The majority of midwives who participated worked in models of care which provided women with continuity of carer and care, however, this was not found to influence the way the midwives provided labour care. Instead, practice was found to be relatively homogenous regardless of whether the midwives worked in independent, team, or hospital-based practice. The birthplace setting in which the labour care took place did influence midwifery practice. The majority of midwives provided labour care in large obstetric hospitals and identified practices dominated by the medical model of care. Practice was described as being influenced by intervention and the need for technology, however, this did not prevent the majority of women from perceiving they were actively involved in the decision making process and that they worked in partnership with their midwives. Closer examination of the midwives’ decision making processes whilst providing the labour care revealed that the midwives’ individual decisions were influenced by the needs of the women rather than the hospital protocols. What became evident was that the midwives in this study had adopted a humanistic approach to care whereby technology was used alongside relationship-centred care.     

The role of a provincial hospital: The Norfolk and Norwich hospital, 1771–1880

Up to the mid-1950's most economic and social historians accepted that improved medical measures, notably the expansion of hospital facilities, made a significant contribution to population growth in the late eighteenth and early nineteenth centuries by helping to reduce mortality rates. In an article which first appeared in 1955, T. McKeown and R. G. Brown criticized what had become the ‘traditional’ view. Though the number of hospitals increased, and though there were advances in medical education and knowledge, such developments, McKeown and Brown suggested, were of little value to the population until reflected in improvements in the standards of treatment available. ‘In assessing the contribution of hospitals to the reduction of mortality’, they argued, ‘we are less concerned with the number of beds than with the results of treatment of the patients who occupied them’.     

Latin American hospitals improve postabortion care. Maternal health

Approximately 4 million women undergo illegal abortions each year in Latin America and the Caribbean, and hundreds of thousands of women with postabortion medical emergencies or incomplete abortions seek hospital care. Once in an emergency ward, a woman may await treatment for 24 hours, bleeding, frightened, and in pain. A woman in such a situation may also experience nurses who chastise her for becoming pregnant or committing a sin, be examined with several staff members observing, undergo unexplained treatment without anesthesia, and/or leave the service facility without knowing whether she is still fertile or how to avoid pregnancy. INOPAL, Population Council's operations research program on family planning and reproductive health in the region, is working to find the best ways, medically and financially, for hospitals to deliver high-quality, comprehensive services to postabortion patients. Most maternal deaths and injuries could be prevented by access to family planning services and information about contraceptive use. The Population Council and colleagues from hospitals, governments, and nongovernmental organizations are conducting studies in Guatemala, Peru, and Mexico on the emergency treatment of incomplete abortions with the goal of improving and standardizing postabortion services.     

The politics of midwifery education and training in New South Wales during the last decades of the 19th Century

This paper focuses on the introduction and development of midwifery education and training in Sydney during the last decades of the 19th century. The aim of the training, it is argued, was to displace the lay midwives by trained midwifery nurses who would work under medical control. The lay midwives were one of the largest occupational groups among women and two-thirds of births in NSW were being delivered by them in the late 19th century. It was a period of professionalisation of medicine and medical men laid claim to midwifery as a legitimate sphere of their practice and saw it as the gateway for establishing a family practice. The lay midwife stood in the way of their claim. The training programs were established purportedly to control maternal mortality. From the beginning in 1887 medical men were in control of midwifery nurse training. In addition to training at the Benevolent Society Asylum, three more women's hospitals were established in the 1890s in Sydney making it possible to train a stream of midwifery nurses. The midwifery nurses were charged exorbitant fees for their training; the fees contributed substantially towards running the new hospitals that delivered birth services to the poor and destitute women mostly in their homes. The midwifery nurses worked hard in miserable conditions under the guise of clinical experience required for training. When a critical mass of poorly trained midwifery nurses were in the offing, a Bill was introduced into the Parliament in 1895, restricting registration to midwifery nurses and this would have eliminated the lay midwife if passed. It took more than two decades to get a Registration Bill passed in the NSW Parliament.     

The challenge of world health

2 development specialists have expounded on the demands world health has placed on public health. Striking declines in infant and child mortality occurred with the advent of biomedical and technical interventions in developing countries after World War II. At the same time, these interventions promoted longer lives by curing and/or treating chronic diseases in developed countries. In the 1970s, however, it was apparent that the hospital based, curative approach could not meet health needs and was very costly. In developed countries, biomedical and social sciences showed that chronic diseases did not occur due to modernization but from unhealthy behaviors, diet, and lifestyle. In fact, in 1975, the US Centers for Disease Control announced that unhealthy lifestyles contributed to 50% of all deaths while the medical system was responsible for only 11%. The US and other developed countries then began to promote healthy lifestyles, and in the 1980s, considerable improvements in health occurred, especially among adults. Developing countries which depended on the Western medical model did not experience health gains in the 1970s. Yet developing countries where health systems concentrated on carrying essential services to all people and promoted basic hygiene and sound dietary practices continued to achieve considerable health gains. In 1978, WHO an UNICEF hosted the International Conference on Primary Health Care in Alma Ata, the Soviet Union to hold these developing countries with community based health systems as models of primary health care (PHC). The 1980s witnessed the spread of PHC especially in the form of child survival which focused on oral rehydration therapy and breast feeding. The biomedical and social sciences are needed to move this health policy and program strategy forward. Governments must see to policies that promote healthy people. Political will is needed to make human welfare a high priority.     

Education and the Gender Gaps in Health and Mortality

The positive associations between education and health and survival are well established, but whether the strength of these associations depends on gender is not. Is the beneficial influence of education on survival and on self-rated health conditioned by gender in the same way, in opposite ways, or not at all? Because women are otherwise disadvantaged in socioeconomic resources that are inputs to health, their health and survival may depend more on education than will men??s. To test this hypothesis, we use data from the National Health Interview Survey-Linked Mortality Files (NHIS-LMF). We find that education??s beneficial influence on feeling healthy and on survival are conditional on gender, but in opposite ways. Education has a larger effect on women??s self-rated health than on men??s, but a larger effect on men??s mortality. To further examine the mortality results, we examine specific causes of death. We find that the conditional effect is largest for deaths from lung cancer, respiratory disease, stroke, homicide, suicide, and accidents. Because women report worse health but men??s mortality is higher, education closes the gender gap in both health and mortality.     

家庭电子健康档案——公民健康权利的重要载体，人口与健康科学数据的重要来源

一、“人”是健康的核心、科研的落脚点 健康是人类发展所必须关注的一个永恒的基本的主题,但绝不仅仅是单纯的医学问题。长期以来,随着诊疗技术的不断发展,健康领域越来越为医院、医务工作者和医学科研人员所主导,患者的地位越来越被动,“未病”者的生存与健康状况更是难以得到及时、有效和持续的制度性监测、研究和干预,导致突发公共卫生事件频发,社会危害严重。     

The fertility,mortality and nuptiality of the Rungus Dusun

One of the authors, when holding the position of medical officer in Borneo carried out an intensive medical survey of the Rungus Dusun. The present paper records the results of analysing demographic data collected during this survey. The number involved was very small ; for instance, only 55 of the women were aged 15 years or over, and thus the findings are subject to considerable sampling error. In the circumstances, it is remarkable that the levels of fertility and mortality estimated to apply to different cohorts should be as consistent as they are.

Sterility amongst the Dusun is shown to be reasonably low and fertility adequate. Such doubt as has been expressed as to their ability to survive is shown to derive from high mortality in infancy and early childhood.

It is hoped that this study may make some contribution to the creation of an adequate body of techniques for studying the demography of such people.     

Midwives’ views of caseload midwifery – comparing the caseload and non-caseload midwives’ opinions. A cross-sectional survey of Australian midwives.

BackgroundMidwife-led continuity of care has substantial benefits for women and infants and positive outcomes for midwives, yet access to these models remains limited. Caseload midwifery is associated with professional satisfaction and lower burnout, but also impacts on work-life boundaries. Few studies have explored caseload midwifery from the perspective of midwives working in caseload models compared to those in standard care models, understanding this is critical to sustainability and upscaling.AimTo compare views of caseload midwifery – those working in caseload models and those in standard care models in hospitals with and without caseload.MethodsA national cross-sectional survey of midwives working in Australian public hospitals providing birthing services.FindingsResponses were received from 542/3850 (14%) midwives from 111 hospitals – 20% worked in caseload, 39% worked in hospitals with caseload but did not work in the model, and 41% worked in hospitals without caseload. Regardless of exposure, midwives expressed support for caseload models, and for increased access to all women regardless of risk. Fifty percent of midwives not working in caseload expressed willingness to work in the model in the future. Flexibility, autonomy and building relationships were positive influencing factors, with on-call work the most common reason midwives did not want to work in caseload.ConclusionsThere was widespread support for and willingness to work in caseload. The findings suggest that the workforce could support increasing access to caseload models at existing and new caseload sites. Exposure to the model provides insight into understanding how the model works, which can positively or negatively influence midwives’ views.     

Child mortality and reproductive behaviour in German village populations in the past: A micro-level analysis of the replacement effect

Abstract Reproductive histories of couples married during the eighteenth and nineteenth centuries in a sample of 14 German villages are analysed in order to answer several questions regarding the relationship between child mortality and reproductive behaviour. An effort is made through selection of cases and use of multiple classification analysis to eliminate or control non-volitional or otherwise confounding influences on the relationship between a couple's experience with child mortality and their fertility. The results do not provide a decisive answer to the question of whether, under a regime of otherwise presumed natural fertility, previous experience of child mortality affected subsequent reproductive behaviour. The evidence was much clearer in indicating that behaviour consistent with replacement efforts emerged or strengthened as family limitation spread. Finally, the results indicated that though it was not necessary for overall child mortality to decline before family limitation practices were adopted, couples with the most favourable child mortality experience were most likely to practise family limitation and to reduce their fertility. Child mortality appeared at least to impede, if not totally prevent, efforts to reduce the number of children ever born or to cease childbearing at an earlier age or at a given parity.     

人文素质对医患关系影响的调查分析

紧张的医患关系是目前我国医疗卫生领域面临的主要问题,问卷和访谈调查结果显示：影响医患关系的主要因素是医患双方的人文素质、缺乏沟通、媒体的误导等非技术性因素。缓和医患关系,应该从医院、医生、患者、社会等各个层面着手,建议构建仁心仁术的医院,做知性理性的就医者,形成公益公正的社会氛围。具体如医患双方提高法律、道德等人文素养,促进沟通和交流,倡导良好的医德医风,健全和完善医疗纠纷处置机制,发挥媒体的正面引导作用等。     

中国大陆全民医保与台湾地区全民健保福利性之比较

中国大陆的全民医疗保险与台湾地区的全民健康保险在制度覆盖对象、基金给付范围和给付程度、基金实现效率及效果等体现制度福利强度的方面都有明显的差别,这与两地的经济实力、健保观念、健保管理经验和政治环境差异有关。借鉴台湾地区健保经验,大陆欲增强全民医保的福利效果,应把医疗保险发展成统一的全民健康保险,实行门诊和大病统筹保障;加快培育私营医疗服务机构,增加定点医疗机构并让民众自由就诊;建立以病人为中心的医院品质评价机制,引导医院改进服务设施,提高人本服务水平;加快基金按服务质量和病种付费的步伐,加速推行总额预算制;减少对公立医院的非建设性投入,加大对民众医保的投入。     

Infant mortality decline in Malaysia, 1946–1975: The roles of changes in variables and changes in the structure of relationships

This analysis has identified several factors contributing to the dramatic decline in infant mortality since World War II in Malaysia, as well as one factor that prevented the infant mortality rate from declining even more rapidly. Our main findings are the following: On average, mothers' education more than doubled over the study period, contributing to the decline in their infants' mortality. In addition, the beneficial effect of mothers' education on infant survival appears to have become stronger over the study period. Hence, further advances in education should lead to further improvements in infants' survival prospects. Another analysis of these data (Peterson et al. 1985) found that education is somewhat more influential in affecting child mortality in low-mortality, high-income areas than in the opposite type of areas. Therefore, socioeconomic development may have complemented, instead of substituted for, the the beneficial effect of mothers' education in promoting infant and child survival in Malaysia. Improvements in water and sanitation also contributed to the infant mortality decline, especially for babies who did not breastfeed. However, unlike education, these influences have become less important over time, especially for babies who are not breastfed. Hence, further improvements in water and sanitation, a goal of Malaysia's Rural Environmental Sanitation Programme, may have smaller relative effects on infant mortality than did previous improvements. Targeting such improvements on areas where women breastfeed little or not at all, however, will increase their effectiveness in promoting infant survival. The substantial reductions in breastfeeding that have taken place since World War II have kept the infant mortality rate in Malaysia from declining as rapidly as it would have otherwise. We estimate that, in our sample, the detrimental effects on infant survival of the decline in breastfeeding have more than offset the beneficial effects of improvements in water and sanitation. Unlike some other researchers (e.g., Palloni 1981), we find that changes in fertility levels and in the timing and spacing of births have had negligible effect in explaining the decline in infant mortality within the samples we have considered. We have excluded births to older women from our analysis, however; this exclusion may have led to an understatement of the influence of changes in the age pattern of childbearing.(ABSTRACT TRUNCATED AT 400 WORDS)     

The estimation of mortality at the London Foundling Hospital, 1741-99

The high mortality of foundlings across Europe has long been established by historical demographers but methods of quantification have not permitted comparison with rates in the populations beyond the foundling hospitals. This study investigates mortality rates at the London Foundling Hospital in the eighteenth century in a way that addresses the issue. The study finds that although foundling mortality was extremely high at certain periods in the hospital's history, there is evidence for a decline towards the end of the century, in common with national and local rates. This suggests that the causes of the mortality fall were common even to infants born in disadvantaged circumstances, and brought up away from their mothers. Several possible reasons for the fall in mortality are considered, including improved nutrition among mothers, a shift in the disease environment, and changes in such habits as gin drinking.     

Determinants of Regional Variations in Infant Mortality in Rural India

An analytical framework is specified for understanding the determinants of infant mortality. It distinguishes between factors at three levels – village, household and individual – and arranges them in ascending order with respect to their proximity to infant mortality. Village and household-level factors are assumed to influence infant mortality indirectly by influencing at least one of the six individual-level factors. The present analysis of the data aggregated at the state level clearly demonstrates the importance of both medical and non-medical factors for explaining the observed regional differences in infant mortality in rural India. The percentage of births attended by trained medical personnel and poverty, are the two important determinants of regional variations in neo-natal mortality; and the village-level availability of medical facilities and the extent of triple vaccination are the two important determinants of post-neo-natal mortality. The influence of adult women's literacy on infant mortality is explained by better medical care at birth, and preventive and curative medical care during the post-neo-natal period. Medical factors have been shown to be slightly more important than non-medical factors. This suggests that it might be possible to reduce the high level of infant mortality currently prevalent in many states in India by simple preventive medical interventions.     

The association of childhood socioeconomic conditions with healthy longevity at the oldest-old ages in China

Based on unique data from the largest-ever sample of the Chinese oldest-old aged 80 and older, our multivariate logistic regression analyses show that either receiving adequate medical service during sickness in childhood or never/rarely suffering from serious illness during childhood significantly reduces the risk of being ADL (activities of daily living) impaired, being cognitively impaired, and self-reporting poor health by 18%-33% at the oldest-old ages. Estimates of effects for five other indicators of childhood conditions are similarly positive but mostly not statistically significant. Multivariate survival analysis shows that better childhood socioeconomic conditions in general tend to reduce the four-year period mortality risk among the oldest-old. But after additional controls for 14 covariates are put into the model, the effects are not statistically significant, thus suggesting that most of the effects of childhood conditions on oldest-old mortality are indirect-at least to the point of affecting current health status at the oldest-old ages, which itself is strongly associated with mortality. While acknowledging limitations of the present analyses due to a lack of information on childhood illness, the oldest-olds'recollection errors, and other data problems, we conclude, based on this and other studies, that policies that enhance childhood health care and children's socioeconomic well-being can have large and long-lasting benefits up to the oldest-old ages.     

新型农村合作医疗制度自愿保险的困境与出路

面对新型农村合作医疗在实践中普遍存在的逆向选择问题,政府补贴的增加虽能提高农民的参合意愿,但它仍是治标不治本。如果不能很好地解决这个问题,新型农村合作医疗不能可持续发展,要么会因保障水平不够而夭折,要么就会出现财政赤字而难以为续。在短期内,可以在坚持自愿原则下、在自愿性的框架中,通过兼顾门诊补偿、对一年内没有享受住院治疗服务或门诊服务的参合者提供相应的促进健康和预防疾病服务、调整筹资顺序等手段扩大受益面来寻求可持续发展之路;最终通过引入强制性从根本上解决逆向选择的困境。     

The effect of child mortality experience on subsequent fertility: in Pakistan and Bangladesh

Summary This paper presents an empirical analysis of the effects, behavioural and biological, of child mortality experience on subsequent fertility in two South Asian Islamic nations. Data for the investigation came from retrospective pregnancy histories of 2,910 currently married women interviewed in the Pakistan National Impact Survey (1968-69) and from longitudinal vital registration data (1966-2070) of 5,236 women residing in a rural area of Bangladesh collected by the Cholera Research Laboratory. The aim of this study was to assess the importance of the child-replacement motivational response to child death experience after biological effects have been controlled adequately. A common approach employed previously has been to examine cumulative fertility according to child death experience. In Pakistan and Bangladesh, a consistently positive relationship was demonstrated between the number of children ever born and the number of child deaths. This method, however, did not exclude the inverse relationship, the influence of fertility on mortality, nor did it dissect out behavioural from biological effects. Utilizing a measure of subsequent fertility, live-birth-to-live-birth intervals, the study further illustrated another common pitfall. Since the risk of infant death, which leads to shorter birth intervals, is associated with the mother's reproductive history, women with child mortality experience are more likely to experience shorter intervals because of the biological effect of subsequent infant death. Behavioural influences may, therefore, be observed by considering only those birth intervals in which the first-born child survives to the end of the interval. With these limitations controlled, very few, if any, behavioural influences were noted in the Pakistan and Bangladesh data. Median birth intervals in Pakistan varied between 35-43 and 41-42 months, increasing with parity. Within each parity group, no consistent difference was observed between women with and without previous child loss. In Bangladesh, the median birth interval for all women with a surviving infant was 37-2 months. This was shortened to 24-31 months by an infant death. When intervals with infant deaths were excluded, little or no behavioural influence was detected among women of the same parity, but with varying levels of previous child loss. Even without behavioural effects, elimination of infant mortality in Bangladesh would reduce fertility by prolonging the average period of post-partum sterility. In the Bangladesh setting, however, the size of the effect was only about four per cent. This modest effect, more-over, was counterbalanced by an overall increase of net reproduction by seven per cent due to better survivorship of infants.     

The sterile insect release method on species with two-stage life cycles

Summary A continuous-time density dependent model was constructed of a species with a two stage life cycle. This model has a unique stable equilibrium. With the introduction of steriles at constant rate a second positive unstable steady state appears; this condition does not depend on the mode of action within the life cycle of the density dependence or its relative strength. A comparison was made of the effects of having the density dependence in each of larval and adult recruitment and larval and adult losses. It was found that if only adult recruitment is denisty dependent, then adult numbers can actually increase with the release of steriles provided density independent recruitment greatly exceeds density independent losses. Sterile releases were often more effective against larvae than against adults, although in some cases not importantly so. Density dependence in recruitment gives much lower equilibrium values than when density dependence of comparable strength is in the mortality. The release rates needed to cause extinction were generally between 0.1 and 0.5 of the larval equilibrium with no sterile releases except when the density dependence is predominantly in adult recruitment, in which case much higher release rates are required.     

Determinants of temporal and areal variation in infant mortality in Germany, 1871–1933

This article investigates how sociodemographic, economic, medical, and public health factors influence infant mortality by using data about German administrative areas from 1871 to 1933. Marital fertility has the largest impact on infant mortality, followed by illegitimacy, medical care, urbanization, and infant welfare centers. The variables considered here account for most of the variation in infant mortality. Some of the unexplained variance is due to factors associated with regions, such as breastfeeding patterns, and with time periods, such as national health insurance. The analyses found no evidence that advances in medical technology affected infant mortality or that the influence of economic development changed over time.