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July 2013, Volume 42, Issue 1-2, pp 69-87
Date: 16 Nov 2012
Multiplicity of solutions for second-order Hamiltonian systems with impulses
- Huiwen Chen,
- Zhimin He
- … show all 2 hide
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In this paper, we study the existence of infinitely many solutions for second-order Hamiltonian systems with impulses. By using an infinitely many critical points theorem and Fountain theorem, we obtain some new criteria for guaranteeing that the impulsive Hamiltonian systems have infinitely many solutions. No symmetric condition on the nonlinear term is assumed. Some examples are also given in this paper to illustrate our main results.
This work is supported by the Fundamental Research Funds for the Central Universities of Central South University (2012zzts004).
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- Izydorek, M., Janczewska, J. (2005) Homoclinic solutions for a class of second order Hamiltonian systems. J. Differ. Equ. 219: pp. 375-389 CrossRef
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- Yang, J., Zhang, F. (2009) Infinitely many homoclinic orbits for the second-order Hamiltonian systems with super-quadratic potentials. Nonlinear Anal.: Real World Appl. 10: pp. 1417-1423 CrossRef
- Yu, J.S. (2008) Subharmonic solutions with prescribed minimal period of a class of nonautonomous Hamiltonian systems. J. Dyn. Differ. Equ. 20: pp. 787-796 CrossRef
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- Qian, D., Li, X. (2005) Periodic solutions for ordinary differential equations with sublinear impulsive effects. J. Math. Anal. Appl. 303: pp. 288-303 CrossRef
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- Sun, J., Chen, H., Nieto, J.J. (2011) Infinitely many solutions for second-order Hamiltonian system with impulsive effects. Math. Comput. Model. 54: pp. 544-555 CrossRef
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- Willem, M. (1996) Minimax Theorems. Birkhäuser, Boston CrossRef
- Liu, S.B., Li, S.J. (2003) Infinitely many solutions for a superlinear elliptic equation. Acta Math. Sin. Chin. Ser. 46: pp. 625-630
- Qian, A. (2005) Existence of infinitely many nodal solutions for a superlinear Neumann boundary value problem. Bound. Value Probl. 2005: pp. 329-335 CrossRef
- Qian, A., Li, C. (2010) Infinitely many solutions for a Robin boundary value problem. Int. J. Differ. Equ. 2010:
- Title
- Multiplicity of solutions for second-order Hamiltonian systems with impulses
- Journal
Journal of Applied Mathematics and Computing
Volume 42, Issue 1-2 , pp 69-87
- Cover Date
- 2013-07-01
- 10.1007/s12190-012-0621-5
- Print ISSN
- 1598-5865
- Online ISSN
- 1865-2085
- Publisher
- Springer-Verlag
- Additional Links
- Topics
- Keywords
- Hamiltonian systems
- Variational methods
- Critical points
- Impulses
- Industry Sectors
- Authors
- Huiwen Chen (1)
- Zhimin He (1)
- Author Affiliations
- 1. Department of Applied Mathematics, Central South University, Changsha, Hunan, 410083, People's Republic of China


text:
Re-pipe & tub
Thinking about hiring a copper re-pipe job and then replacing the tub myself, wondering how I can find out where the pipes enter the house?
I can see the water meter for instance, and if the pipes ran straight (on a 90 degree from the city line,) then they must make a left turn beacuse there's about four feet offset, I'd just like to have some idea before calling for bids. I guess I could just start digging, Would the city permit dept have drawings?
Fred 23
don't dig.
if city has anything on record i'd be shocked. ask the plumbers when they get there. breid
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MSU's G. Robert Vincent Voice Library houses over 40,000 hours of spoken word recordings. Voices in the collection range from everyday people to cultural and political figures. Over 100,000 voices are captured in the collection, which includes audio dating back to 1888.
Current State's Peter Whorf spoke with John Shaw, supervisor of the Vincent Voice Library.


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yeah stay away from the real 155'ers in the UFC. Good job Gilbert ! lol.
Two-time STRIKEFORCE World Lightweight Champion (155 pounds), Gilbert "El Nino" Melendez (18-2), has signed a new, multi-year agreement with the San Jose, Calif. based world championship Mixed Martial Arts (MMA) promotion.
"STRIKEFORCE is my home, they've always been like family to me and I'm looking forward to continuing my career with them," said the talented, exciting, 5-foot-9, 27-year-old protégé of Brazilian Jiu-Jitsu master Cesar Gracie and Muay Thai legend Jongsanan Fairtex. "There are a lot of great fights out there for me — lots of challenges. I can't wait to get back into the cage, do my thing and show the world that I'm still at the top of my game.''
Universally recognized as one of the top 155-pounders in the world, Melendez has won four in a row and five of six.
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The impressive, one-sided triumph over the highly regarded Aoki came in Melendez' first title defense since he regained the STRIKEFORCE crown with a hard-earned, hard-fought unanimous five- round decision over the fighter that had dethroned him, Josh Thomson, on Dec. 19, 2009, at HP Pavilion San Jose, Calif.
Melendez, who turned pro on Oct. 18, 2002, and won his initial 13 starts, owns other notable victories over MMA standouts Aoki, Clay Guida
"I'm healthy again and excited about fighting again real soon,'' the personable, charismatic Melendez said. "It doesn't matter who I fight. I just want to get back in there and rip.''
yeah stay away from the real 155'ers in the UFC. Good job Gilbert ! lol.
Would you rather be first in the minors or just another struggling fighter in the Pro's?
They probably offered him more money…he would without a doubt be the UFC champ.
Coulda, woulda, shoulda
without a doubt, we'll never know cause he's hiding in the Minor League. What a fuking CHICKEN
just keep crushing cans in strikeforce and pretend your testing yourself. You have beaten every guy in the division. what a joke.
Flying armbar say chicken to his face. Why dont you go run a mile in 6 minutes and do 50 push ups and than get back on the keyboard and talk more crap
Imagine if Anderson Silva signed with Bellator, so he "Could face anyone they put in front of him"


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Israeli occupation: settlers burn crops in Hebron, bulldozers uproot trees in Salfit
- Details
- Published on Thursday, 22 May 2014 13:39
PNN/West Bank
Rateb al-Jbour, Coordinator of the Popular Committee against the wall and settlements in the south of Hebron, said that a group of settlers from the Evi Gal and Mtsaby Yaear illegal settlements burnt crops this morning in Eqwywes, in the south of the West Bank.
He added that the residents are putting out the fire in the fields, which belong to Khaled Mousa al-Najar. Al-Jbour called on all the human rights organizations and international institutions to stop the Israeli army and the settlers from attacking the Palestinians of south Hebron hills.
He mentioned that in the southern area of the Hebron governorate, the residents are always suffering from settlers and IOF activities, which are aimed to expel the residents by demolishing their homes and seizing their lands.
Additionally, Israeli bulldozers are damaging agricultural lands and uprooting trees in the area of Thaher–Sobeh, west of Salfit, in the north of the West Bank.


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The Blue Room (La Chambre bleue)
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Like most of the documentaries that have emerged to recount and reflect on the revolutionary events of the Arab Spring, Uprising is sure to note, in its final moments, that the struggle for democracy continues. In his concise, accessible oral history of Egypt's 2011 revolution, director Fredrik Stanton stitches together voices of the activists and organizers at the center of the events that led to the end of President Hosni Mubarak's 30-year reign; their stories tell of a determination matched only by surprise at the movement that took shape. Stanton offers some context before moving into a day-by-day chronology of a revolution so unexpected and chaotic that, as one protester observes, those at the center of it had little sense that they were making history. Heavy on smartphone and news footage, Uprising offers but a few slivers of new light on its subject, though it takes a hard look, through the general tone of afterglow, at the American government's tacit and explicit support of the Mubarak regime. Egypt's recent constitutional referendum is a reminder that though an uprising lends itself to neatly structured myth, and certainly to documentary, a revolution is a many-chaptered epic and a democracy, ideally, a story without end.
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Qi wireless power specification to standardize wireless charging
The finalization of the Qi low power standard means products sporting the Qi logo could soon be appearing in stores
As the number of portable electronic devices we carry around has multiplied, so too have the chargers we need to keep them running. Over the last couple of years wireless chargers such as the PowerDisc and Powermat have started popping up to save users the hassle of dealing with a mass of charger cables, but these require specific adapters for the different devices being charged. A business alliance of 20 firms has banded together to form the Wireless Power Consortium (WPC) to develop open standards for wireless charging and has just finalized its Qi low power standard that is aimed at delivering wireless charging stations that can charge a range of compatible devices.
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Putin visits West Bank, tours key Christian shrine
Russia is also one of Syrian President Bashar Assad's closest allies. Assad has drawn international condemnation for his bloody crackdown on the country's armed uprising.
In the meeting, Abdullah called for a "political solution to the crisis in Syria that would protect the unity and stability of the country and end the violence and bloodshed," a Royal Palace statement said. He said that a solution must have an "Arab and international consensus."
Putin and the king met in a conference hall on the shores of the Dead Sea. Later, Putin inaugurated a Russian guesthouse in the baptismal site in the nearby Jordan River, where tradition says Jesus was baptized by John the Baptist.
Jordan's banned Tahrir, or Liberation Party, condemned Putin as an "enemy who is not welcome in Jordan."
It called Putin "an arch enemy of Islam and Muslims," citing his close ties with Assad. "His visit to Jordan is an arrogant challenge to the feeling of Muslims and a disdain of innocent blood shed in Syria."
On Monday, Putin met Netanyahu, who urged Russia to step up pressure on Iran to curb its suspect nuclear program.
At a state dinner Monday, Israeli President Shimon Peres pressed Putin further, asking that he "raise his voice" against a nuclear Iran. Putin responded by saying that Russia has a "national interest" to secure peace and quiet in Israel but did not elaborate further.
Additional reporting by Jamal Halaby in Amman, Jordan.
The Associated Press


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An investigation of the effects of medication and the use of computerized feedback in task performance of AD/HD children
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Primiparous timed-pregnant Wistar dams were administered a single daily subcutaneous injection of diazepam (1.0 or 5.0 mg/kg) or vehicle over Gestation Days 14-20.
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Wall Blades (Revision 320)
Edit Page Last Edit: 2 years 9 months ago
Wall Blades[1] are a powerful, offensive wall based trap that reset at a fairly fast pace. The downfall to this trap is its short range. They are best placed in small, compact areas where they will hit many enemies at once. They work best in unison with floor traps that will slow or stop your enemies so that the Wall Blades have a chance to do their maximum damage to the foe.
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Albany Police Dispatchers Reject Contract Settlement
By Tim O'Brien, Albany Times Union, N.Y.
Jul. 25–ALBANY — Police dispatchers rejected a proposed contract settlement with the city, their union president said today.
The 35 dispatchers have been without a contract for almost three years. The city offered 3 percent raises retroactive for 2006 and 2007 and 4 percent raises for this year and 2009.
Christian Mesley, president of the Albany Police Officers Union, said the dispatchers were frustrated because they had been told early on they would get an increase in base pay as well as the percentage increase.
The dispatchers start with a salary of about $30,000, he said, and the maximum they get is around $35,000 while their suburban counterparts make up to $50,000.
"They are one of the lowest paid in the area, and they are the busiest," Mesley said. "These guys were demoralized and frustrated. They waited two years and eight months to get offered what everybody else got offered."
Police Chief James Tuffey said the city has pulled the offer off the table, and the dispatchers won't get a better one.
"The agreement was very, very fair to the members of that unit," he said.
The agreement also called for increases in longevity pay, the uniform allowance and lineup pay, the chief said, and the city sought the ability to randomly test the dispatchers for drug use.
Tuffey said the members may have wanted an additional base pay increase, but the city has to decide what it can afford.
"They can ask for anything they want," he said. "It's what the city feels it can pay its employees."
The contract dispute may end up with a fact-finder making a recomendation to the Common Council. The council could then impose a one-year agreement. Mesley said in his 16 years in the union, he has never seen a contract taken to that step.
To see more of the Albany Times Union, or to subscribe to the newspaper, go to http://www.timesunion.com.
Copyright (c) 2008, Albany Times Union, N.Y.
Distributed by McClatchy-Tribune Information Services.
For reprints, email firstname.lastname@example.com, call 800-374-7985 or 847-635-6550, send a fax to 847-635-6968, or write to The Permissions Group Inc., 1247 Milwaukee Ave., Suite 303, Glenview, IL 60025, USA.


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Home Pretty Home ChenOne Home collection targets all those looking for sophistication in both apparel and furnishings under one roof. More... (0)
Ladies, Know Your Rights Inner Wheel Club Karachi Metropolitan has launched a handbook that provides information on rights, laws and support on issues faced by Pakistani women. More... (0)
Classic meets contemporary Copper and Steel's collection offers a refreshing range of contemporary pieces. More... (0)
Another Desi Edition Five million rupees and a cookbook contract is what awaits the very first winner of MasterChef Pakistan. More... (0)
Life After Death The evening centred on the first screening of the Hum TV-produced docudrama, Zindagi, about Pakistan's very first deceased organ donor – Naveed Anwar. More... (0)
And We Have a Winner! The Pakistan Idol journey comes to an end, but what a ride it has been. More... (0)
Celebrating Excellence The 21st Century Business and Economics Club hosted its first get together for Karachi's elite business community earlier in September. More... (0)
Ayesha Somaya launches her Cruise Collection at Brands Just Pret.
Fashion designer Aeisha Varsey's Av Dé Salon is a welcome addition to her boutique in Karachi.
Islamabad Fashion Week Autumn/Winter showcased clothes by both veteran and emerging designers.
Try Okra if you're in the mood for seafood.
Try this innovative and delicious crab dish at the newly remodeled Cafe Aylanto.
Pantene Bridal Couture Week, held earlier in April, showcased bridal and evening wear by both emerging and established designers.
Try this moist, delicious cake at the Espresso Coffee House if you're a fan of the ever popular combination of chocolate and peanut butter.


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today 17°
Ein Wechselspiel aus Sonne und Wolken, die Schauerneigung ist gering.
tomorrow 12°
Ein trüber und verregneter Tag, mitunter kann es kräftig regnen.
Mountain Edge
Biking centre Kitzbuehel
Kitzbuehel is still a secret among mountain bike fans. There is something for everyone: Hundreds of kilometres of well serviced and safe cycling and mountain biking routes.
Up to 15 different gondolas are available to carry the cyclists up the mountain. The routes range from simple routes in the valleys (ideal for families with children) to a variety of cross-country trails and demanding freeride trails in the woods. Further up the trails are rocky. On the slopes down to the valley the cyclists pass by the tree line and then there is the increasing possibility to ride on steep paths through the pine forest also over challenging sections of rocks, stones and roots, especially! For all cyclists, there are always alternative routes on forest roads, where you can enjoy the view and get back to the valley.
Our small team loves life here in the mountains of Tyrol. Our goal is to continue to offer our guests an unforgettable stay in Kitzbuehel, especially on a bicycle, as well as hiking, rafting, canyoning and paragliding you are supported by our team. Enjoy with us the best trails and the best views and find out why our guests keep coming back.
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Q Is For Quantum And 'Q-life'
As the world celebrates Charles Darwin, who was born 200 years ago, physicists can be forgiven a certain jealousy at the spotlight being placed on his profound legacy. But physicists have in fact had a huge impact on biology "" no more so than in helping to discover the structure of DNA and in developing medical-imaging techniques like MRI. The July issue of Physics World marks those achievements and examines at some of the ways in which current ideas in physics are still changing biology.
Features in this issue include a close look at how physics is informing our understanding of cells and of the brain, while Paul Davies, a physicist, astrobiologist and director of BEYOND: Center for Fundamental Concepts in Science at Arizona State University, suggests there are tentative signs that life itself may have arisen as a result of physicists' long-cherished theory of quantum mechanics.
Many of the pioneers of quantum mechanics, such as Niels Bohr, Werner Heisenberg, and Erwin Schrödinger, hoped that their theory, which proved so successful in explaining non-living matter, could one day explain living matter too. But although quantum mechanics can explain the sizes and shapes of molecules — and how they are bonded together — no clear-cut "life principle" has emerged from the quantum realm.
Still, Davies points to increasing, albeit controversial, evidence that suggest that fundamental quantum processes like quantum tunnelling and quantum superpositions can play a fundamental role in biology.
In particular, researchers think that quantum mechanics could lie at the heart of the mechanism by which the European robin can navigate over spectacularly long distances by means of the Earth's magnetic field. Others, meanwhile, think that quantum mechanics is essential to the process of photosynthesis.
Davies also asks whether some form of "quantum replicator", or "Q-life", could provide a solution to the challenge of understanding the origin of life itself. Most researchers suppose that life began with a set of self-replicating digital-information-carrying molecules or a self-catalyzing chemical cycle but, Davies argues, they key properties of life — replication with variation and natural selection — does not logically require structures to be replicated. "It is sufficient," writes Davies, "that information is replicated, which opens up the possibility that life may have started with some form of quantum replicator."
The advantage of copying information is that it would be much faster than building duplicate molecular structures, while quantum fluctuations provides a natural mechanism for variation and coherent superpositions could let life Q-life evolve rapidly by exploring an entire "landscape" of possibilities at the same time.
As Davies writes, "Life has had three and a half billion years to solve problems and optimise efficiency. If quantum mechanics can enhance its performance, or open up new possibilities, it is likely that life will have discovered the fact and exploited the opportunities."
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Attending home vs. clinic-based deliveries: perspectives of skilled birth attendants in Matlab, Bangladesh.
Keywords: childbirth, safe motherhood, midwifery, qualitative research, Bangladesh
Afin de faciliter l'acces a une assistance qualifiee pendant l'accouchement, certains pays d'Asie encouragent la naissance/a domicile en presence d'une sage-femme. Pourtant, rares sont les donnees empiriques qui indiquent que les soins domicile sont aussi stirs et efficaces que les soins dans des centres de sante dans cette region. Une recherche qualitative, avec la participation d'informateurs cles, des entretiens approfondis et des discussions de groupe, a ete realisee en 2003 et 2004 a Matlab, region rurale du Bangladesh, pour examiner les avantages de l'accouchement domicile par rapport h l'aecouchement en milieu hospitalier dans la perspective de 13 accoucheuses qualifiees. Les conclusions recensent des obstacles majeurs reneontres pendant les accouchements h domicile, notamment les transports mediocres, l'environnement inadapte l'insuffisance des foumitures et de l'equipement, le manque de securite et l'inadequation de la formation et de l'encadrement medical, qui peuvent contrarier la prestation de soins qualifies. La principale difficulte etait de resister aux pressions des familles demandant d'adherer aux normes traditionnelles et de convaincre les familles d'accepter le transfert de la parturiente. Un environnement propre et stir, la disponibilite de fournitures, la capacite de mener d'autres activites professionnelles et d'assurer une prise en charge rapide, et la couverture elevee figuraient au nombre des avantages cites pour l'accouchement en milieu hospitalier. L'etude cerne les questions pratiques, culturelles et medicales dom il faut tenir compte lors du choix entre des strategies a domicile tu hospitalihres et de la conception d'interventions de maternite sans risque.
En un esfuerzo por ampliar el acceso a una atencion competente durante el parto, algunos paises asiaticos han emprendido importantes iniciativas para promover la opcion de dar a luz en el hogar con una partera. No obstante, poca evidencia empirica indica que los cuidados hogarenos son tan seguros o eficaces como la atencion medica recibida en un establecimiento de salud en la region. En 2003 y 2004, se llevo a cabo una investigacion cualitativa con informantes clave, entrevistas a profundidad y discusiones en grupo, en Matlab, una zona rural de Bangladesh, a fin de examinar la viabilidad del parto en el hogar o en un servicio de salud, desde la perspectiva de 13 parteras calificadas. Los resultados esclarecen las principales limitaciones encontmdas durante los partos en el hogar, como transporte deficiente, un ambiente inadeeuado para dar a luz, insuficientes suministros y equipo, falta de seguridad, y capacitacion y supervision medica inadecuadas, lo cual podria impedir el suministro de atencion competente. Lt mas dificil file la presion de las familias para observar las normas tradicionales referentes al parto y convencer a las familias de aceptar la necesidad de remitir a la mujer a otros servicios. Entre las ventajas de atender el parto en un establecimiento de salud se meneionaron: un ambiente seguro y limpio, la disponibilidad de suministros, la capacidad de realizar otras actividades laborales y hacer referencias rapidas, y mas cobertura. El estudio destaca los aspectos practicos, culturales y medicos que deben tomarse en cuenta al escoger entre estas dos estrategias y al disenar intervenciones para una maternidad sin riesgos.
IN an effort to make skilled attendance at birth more accessible, some countries in Asia have recently begun major initiatives to promote the option of delivery at home with a skilled attendant. (1,2) Yet there is little empirical evidence to suggest that home-based strategies are as effective as those in medical facilities. Research into home-based strategies has largely focused on the training of traditional birth attendants (TBAs), (3,4) whereas home birth with a skilled attendant has received little attention.
In Bangladesh, a national level initiative is underway to post skilled birth attendants in rural communities (5) in response to persisting high rates of maternal mortality, now reported at 320 per 100,000 live births. (6) Currently, 91% of births still take place at home with only 13% attended by a health professional. (7) The strong preference for home birth is commonly associated with restrictions on female mobility and cultural norms. (8,9)
A critical element of delivery care relates to the ability of skilled attendants to perform effectively. Key aspects of safe delivery practices include the physical setting, availability of supplies and equipment, level of skill and self-confidence of the provider and a supportive environment. (10) While the constraints faced by women living in developing countries in accessing professional birthing care and quality of care issues are well researched, (11-15) the views and experiences of skilled attendants assisting childbirth in women's homes have not been available.
This paper examines the experiences of skilled birth attendants carrying out home-based deliveries in a rural setting in Bangladesh, in comparison with deliveries attended by the same attendants in health facilities. The research raises critical questions and concerns about the feasibility of a professional home-based delivery approach in this part of the world.
The Matlab Maternity Care Programme was initiated in 1987 at a time when the majority of maternal deaths in Bangladesh occurred at home and were directly related to complications during labour or the post-partum period, which could have been prevented. (16) These findings led to the hypothesis that posting skilled birth attendants at the community level would have the best potential for saving lives, provided these workers were trained and equipped to treat obstetric complications and were backed by an effective chain of referral. The aim was for skilled birth attendants to live near pregnant and delivering women to facilitate rapid intervention at the onset of a complication.
The programme was designed so that two skilled birth attendants were based in each of the four health facilities that exist in the ICDDR,B International Centre of Health and Population Research service area of Matlab and would be available to respond to calls 24 hours a day for deliveries at home. Each health centre served a population of approximately 25,000 with 90% of households living within 3 km of the facility. Two additional skilled birth attendants provided care in the ICDDR,B maternity clinic, and three attendants were on standby to fill in for absence on leave or sickness, if the attendant(s) had spent the previous night assisting a delivery or were out of the health centre when a delivery call came. Periodic transfers were made so that the attendants rotated posts.
The attendants were nurse-midwives who typically had four years of training (three years of basic nursing and a fourth year devoted to childbirth) or lady family planning visitors (LFPVs), who were paramedics with at least six months midwifery training. Both types of attendants were instructed to provide skilled obstetric care, including management of normal labour, medical treatment of problem pregnancies (including iron and antihypertensive drugs) and neonatal care, but excluding assisted deliveries. Attendants were also responsible for organising referrals and accompanying patients when a home birth was deemed unsafe, first to the ICDDR,B basic emergency obstetric care (EOC) clinic in Matlab or, if needed, to a comprehensive EOC facility (public or private) in Chandpur, the district headquarters. Other primary responsibilities included antenatal and post-natal visits in women's homes. Additional safe motherhood activities involved visiting families to encourage the use of the midwifery services and training TBAs on safe delivery practices and referrals.
These attendants relied heavily on women community health workers (CHWs), who were local residents engaged in maternal and child health and family planning activities. The CI-IWs played a critical role in establishing social connections between the skilled birth attendants, who were comparatively better off and better educated than their patients, and community members. In order to avail themselves of delivery services offered by the skilled birth attendants, families were instructed to inform the CHW about the pregnant woman's condition first. The CHW would fill out a form that the family member subsequently delivered to the skilled attendant stationed in the health centre. The attendant was then required to travel by whatever means available--boat, rickshaw or on foot--to the household of the delivering woman.
Each of the attendants had a male porter to carry supplies and assist with transport, who also assumed the role of security guard when deliveries occurred at night. A speedboat was available 24 hours a day for emergency transfers.
This strategy continued until 1996, when there was a shift in approaches in Matlab. Home deliveries were gradually phased out and replaced by facility-based care. Between 1996 and 2000, all four health centres were upgraded and equipped to perform obstetric care. The same midwives were asked to stop attending home births and to perform deliveries in the health facilities.
Research methods
The research was carried out between September 2003 and June 2004 in the Matlab sub-district of Bangladesh. Matlab is located in the delta region 30 km southeast of Dhaka. The population in this rural area is generally poor, with farming and fishing the primary source of income; literacy rates are low, particularly among women. (17) The majority of inhabitants are Muslim, with a minority Hindu population, and female mobility is restricted. Typical of this region of Bangladesh, the area is flooded several months during the year.
The sampling frame was exhaustive, including all 13 skilled birth attendants who attended home deliveries. As three of them requested a transfer before 1996, when the facility-based approach was introduced, only their input relating to home deliveries was included in the research. The manager, who played a key role in the development and implementation of the programme, was also included as a respondent.
The research strategy included key informant interviews with four of the skilled attendants and the programme manager on an ongoing basis throughout the study. They were selected based on seniority and their ability to describe the experiences of the skilled attendants more broadly. In-depth interviews involving a series of repeat visits were carried out with the other nine skilled attendants. These interactions generated an additional set of research questions, which guided group discussions. Respondents were divided into two groups of six and seven, and a series of six group sessions were held until we were satisfied that all pending questions were addressed. A final set of interviews, designed to validate the findings and provide additional insights and interpretations, were carried out with key informants.
Two senior research investigators with extensive experience in qualitative data collection administered the interviews. Informed consent was taken from all respondents before the interview. The researchers took notes during the interviews and expanded upon the information immediately afterwards. Interviews were conducted in Bangla and translated into English.
For the analysis, a coding system was developed, capturing the main themes and concepts. Data triangulation identified only those concepts that could be validated through a combination of data sources, such as multiple interviewees, key informants, and group discussions.
Findings: home-based deliveries
The findings reveal a broad set of difficulties that the attendants confronted when assisting home deliveries. From their perspective, the health facility offered an environment more conducive to effective skilled attendance at births.
Respondents uniformly complained that transport was extremely difficult, especially in the dry season when the only option was to go by foot or rickshaw. Due to the poor roads, particularly at the initiation of the programme, the use of the rickshaw was limited and a good deal of travel on foot was required to reach households. In the monsoon season a boat was used which, at the height of the rains, made access easier. However, in the early and late monsoon season travel by boat was often not possible.
Delays in obtaining the speedboat for emergencies were also common. One of the midwife informants recounted a story about a woman who suffered a uterine prolapse after a TBA attempted to remove the placenta manually. The midwife was summoned and the woman's life-threatening state made evident the need for immediate hospital care. The midwife notified the boat service, but the woman died before the boat arrived more than an hour later.
Lack of a proper environment for delivery
In village settings, families typically allocated a dirty, private corner of the house to serve as the place for delivery.(8,18,19) In addition, as families placed a strong emphasis on removing the woman from the prey of evils spirits, a dark area was preferred. The lighting was generally poor, as most rural households did not have electricity. When the delivery occurred at night, there was only the light from a kerosene lamp, which was insufficient, especially if an episiotomy was needed.
As childbirth is traditionally considered to be polluted by Bangladeshis, the delivery bed materials had to be discarded after the birth. Hence, an old blanket or jute sack was placed on the floor, covered by a plastic sheet. The attendants found it arduous to deliver from the floor, which they felt compromised their skills.
In households, bamboo screens commonly divide rooms. During labour, groups of female relatives and neighbours would gather on the other side of the screen, peering through the slits of bamboo, conversing about the progress of the labour and delivery, laughing amongst themselves, and frequently questioning the skilled attendant about the delivery. These interruptions disturbed the attendants' concentration and interfered with their work. At times, this was so disruptive that the attendants said they were tempted to leave.
The delivery environment in Hindu households, where a temporary, separate room (aus ghor) was constructed for the delivery at minimal cost, was described as particularly problematic. The room typically had adequate space only for the mother and baby, forcing the skilled attendant to position herself partially outside the structure when assisting the delivery. During the monsoon season, the attendant was unprotected from the rain. Due to the association of the blood and fluids with pollution, the structure was typically constructed in a "dirty" area.
"My head was drenched by rainwater and my bottom was soaked with cow urine because the aus ghor was built just beside the cow shed." (Midwife)
Hindus also subscribe to choa-chuee, a belief system which teaches that anything an impure person touches is also impure and must be avoided. As a result, during delivery family members would refuse to provide assistance or materials to the attendant because she was regarded as impure. She was even required to pump the tubewell herself if she needed water, or somebody from the family would pour water into her cupped hands, invariably maintaining a distance while doing so. These practices caused frustration for respondents, who expected cooperation and respect from the delivering woman's family.
Both Hindu and Muslim families were said to show disdain towards midwifery and its association with impurity. Religious differences also caused conflict between the attendants and the families.
"In the morning I heard the husband of the woman loudly order one of the maidservants, 'Give that Charal (one of the lowest castes) woman some puffed rice.' I felt so bad that I could not drink even a sip of water there." (Hindu midwife attending a birth in a Muslim household)
Lack of acceptability of procedures: delivery position and episiotomies
Traditionally, women deliver in a kneeling position with the genitals covered, which meets cultural norms. TBAs would not visually examine the birth canal or cervix; rather, they frequently placed their hands in the birth canal to feel the position of the baby and assess the progress of labour. In contrast, the skilled attendants were trained to perform deliveries with the woman lying on her back which, for them, had the advantage that it allowed the midwife to assess the progress of labour more easily and ease the baby out to avoid tearing. Women often objected to using the supine position for delivery or spreading their legs, and resisted if the attendant tried to lift their clothes during delivery, as causing extreme shame. While some of the respondents allowed the delivering woman to choose her position, others were uneasy and unwilling to compromise. In the latter case, extended negotiations between the attendant and the woman's family would be required. The attendants faced problems particularly with the older women who were commonly present and were the primary decisionmakers regarding childbirth.
Fears about episiotomy created tremendous barriers to any willingness to seek skilled assistance for horne-based delivery, and convincing families about the need for an episiotomy was difficult. Older women held many misconceptions about episiotomies and were frequently opposed, maintaining that they had delivered babies without this invasive practice and that tears were a natural outcome of delivery that healed on their own. They additionally expressed concerns that the procedure would have a negative effect on sexual relations. Stories of women who developed infections after episiotomy or suffered from pain associated with the procedure were apparently circulated in the community, creating much resistance.
A widespread traditional practice during the post-partum period was for women to expose the opening of the birth canal to heat, by squatting over hot coals for long periods several times a day; this was believed to heal the area, particularly if a tear had occurred. Even after episiotomy this practice was followed, and the attendants reported cases when the stitches melted, leading to additional problems. It was also difficult for women to maintain appropriate hygiene following an episiotomy, as recommended by the birth attendants. Women did not have sanitary pads but used pieces of cloth to absorb post-partum discharge. These cloths were generally re-used without being washed with soap, and due to the association with pollution, they were typically dried in a hidden, dark and damp corner of the house away from men's view. This put women at risk of infection.
Lack of necessary supplies and equipment
The skilled attendants always kept two bags containing instruments and supplies in the health centre ready to attend a normal delivery. This included a blood pressure machine, stethoscope, fetoscope, two pairs of disposable gloves, one safe delivery kit, a thermometer, scissors, disposable syringes and a flashlight, which was needed for night calls. Basic drugs were ampicillin, diazepam, paracetamol, gentian violet, tetracycline eye ointment, metronidazol and saline. Respondents often required additional equipment and supplies but due to the limitations of transport, were forced to restrict what they carried. If an unforeseen need arose, they frequently found that their supplies were inadequate and they would have to return to the health centre for them. At times, when the newborn required special care, they were forced to carry the infant back to the health facility as well.
Resistance to referrals
Respondents indicated that the most difficult part of their work was convincing families to accept the need for referral. The skilled attendants were instructed to attend normal deliveries and refer complicated cases that could not be managed at home to the Matlab clinic. However, particularly initially, there was an expectation that the attendants could handle all cases; family members could not understand why some deliveries might be beyond their capabilities. A common reaction was that in referring, the attendants were simply avoiding their responsibilities. Many families, mainly the mothers-in-law, expressed grave concerns over transporting a delivering woman to Matlab * or allowing her to be subject to the procedures used in the maternity clinic. The skilled attendants often spent hours or even full days trying to convince families to let them take the woman to Matlab.
The skilled attendants thought referral was the primary reason why they were not called to attend a delivery, particularly women's fear of being sent by ambulance to the EOC facility in Chandpur, accompanied by the attendant, where she would be transferred to the government hospital. This had huge cost implications, particularly with caesarean section, which required at least 10-15,000 taka (approximately US$250-$480 in 1987-96). Moreover, the Matlab and Chandpur hospital staff were not known to villagers and the more urbanised settings were perceived as intimidating.
Working in isolation in these environments, the skilled attendants admitted they frequently lacked the confidence to proceed normally and were quick to refer. When faced with a complicated case, they were often eager to shift responsibility to the medical staff in Matlab as per official policy, while the family often applied overwhelming pressure not to refer. This dilemma caused the attendants a lot of anxiety.
Lack of training for home delivery and medical supervision
Most of the attendants said that lack of training specific to assisting in home deliveries, and being removed from essential supplies and equipment, negatively affected their ability to do their job. Another major limitation was that they lacked medical supervision. Supervision was carried out through monthly meetings where they conferred with other staff in the maternity care programme. This gave them the opportunity to discuss deliveries and stillbirths, complicated cases and referrals, and the conditions under which any deaths occurred. However, they found this system of verbal reporting and indirect supervision inadequate. Many expressed a need for medical supervisors to evaluate their performance directly during field visits and give them advice, thus enhancing their competence and fostering their confidence to cope in difficult conditions. A primary concern was the risk related to home deliveries. In their view, a supervisor would remove the responsibility (and potential blame) from them.
Social pressure
The skilled attendants said they experienced tremendous social pressure during the home delivery period, particularly in life-and-death situations. If anything went wrong, they felt they would be accountable to the family, the community and the ICDDR,B authorities. As a result, they felt vulnerable and were unwilling to make problematic decisions.
"I remember those days when I attended home deliveries. I was so nervous. The fetal heartbeat somehow sounded different in a village setting. Frequently, I referred patients to Matlab because I did not have the courage to maintain full responsibility." (Lady family planning visitor)
They also said that community members had many expectations which they could not necessarily fulfil. For instance, they were often urged to give an injection to increase labour and speed up delivery, because that is what TBAs and village practitioners frequently recommended, particularly in cases where labour was not progressing. The skilled attendants were expected to use the same approach and deliver the baby quickly, to avoid drawing too much attention to the delivery. In contrast, the skilled attendants had been taught to allow labour to progress naturally. When they refused to give an injection, their credentials and credibility were questioned. They were often suspected of wrongdoing and accused of selling the drugs elsewhere. Family members also questioned why the attendant had come to their home if their solution was to refer the patient, and why they were unwilling to respond to the wishes of the community, which embraced different delivery practices.
Inadequate security
At the inception of the programme, most of the skilled attendants were young and unmarried. In a context where high value is placed on female virginity before marriage and women are vulnerable to sexual and physical abuse, (20) the attendants had grave concerns about living and working in the villages, and particularly about travelling at night to attend deliveries. In Bangladesh, female mobility is still restricted and generally unacceptable at night, and women in transit outside the home are considered fair prey to sexual assault. (20) Although a potter accompanied them at night, the women remained anxious about their personal safety. Community members were outraged, and complaints submitted to the programme manager after the following incident:
"During that time I was unmarried. Once my boatman told me, 'Apa (sister), don't attend any calls for the next two to three days after sunset. I've heard that someone is planning to kidnap and marry you.' That night I received a delivery call and I did not go. The patient died." (Midwife key informant)
Scheduling difficulties
The attendants were required to remain in the household of a delivering woman until they were confident that neither the mother nor the newborn needed additional assistance. Hence, when an attendant was called to attend a delivery, she was uncertain when she would return to the health centre. Respondents all felt their irregular schedules negatively affected their work satisfaction and interfered with their personal lives. Problems mentioned included leaving a breastfeeding infant for long periods or missing family gatherings. Many were confronted with ongoing opposition by their spouses, often causing conflict in their marriages.
Comparison with facility-based deliveries
In 1996, a gradual policy shift began from promoting home-based to facility-based deliveries, and midwives and paramedics were made responsible for conducting deliveries in the health centres. (21) The community health workers were said to have played a key role, informing community members through their door-to-door activities that there would be no more home deliveries and that women in labour should be taken to the health centre. During antenatal visits in the health centre, the skilled attendants showed the delivery room and the available instruments to the pregnant woman and anyone accompanying her (e.g. mother or sister-in-law). In the initial phase of the transition, they also showed village leaders the delivery room and asked them to discuss the benefits of health centre deliveries with the community.
The attendants welcomed the change, which from their perspective improved their ability to perform, citing the following positive outcomes:
* more rapid transfer of patients from the health centre to the Matlab maternity clinic
* ability to continue doing other work while monitoring labour
* ability to provide care for more than one woman at a time
* care available 24 hours a day
* secure working environment
* ability to assist with complicated cases
* procedures like episiotomies easier to perform
* assistance available from other skilled attendants if needed
* electricity 24 hours a day
* equipment and medications always available
* controlled, hygienic working environment
* more regularity in the work schedule.
At the same time, some of the attendants admitted that when working in the facility they were less concerned about their relations with the community. This was reflected in their behaviour during one-on-one interactions with women and family members, which we often found through informal observations to be abrasive and demeaning. Specifically, the midwives reprimanded women for arriving late for delivery, taking too long to deliver, screaming during contractions, refusing to expose their genitalia and having too many children.
This study has highlighted a series of difficulties confronted by skilled birth attendants attending home births. A preliminary evaluation of the government's skilled birth attendance programme in Bangladesh had uncovered some of the same constraints, such as inadequate supervision, difficulties travelling to households and lack of support from community members. (5) In-depth, qualitative research allowed us to identify additional factors, many of which were culturally rooted, that need to be taken into consideration if the Bangladesh government continues to invest in home-based delivery care at the national level.
The rationale for instituting skilled attendance for home-based deliveries was associated with cultural norms favouring home births. Yet many of these same cultural values were found to create conflict between the skilled attendants and pregnant women and their families, thus impeding the aim of safe delivery in the home. The attendants expected cooperation from and acceptance of medical practices by families when they were called to assist a delivery. However, in the home environment families expected relative control over the birth, an event that typically is guided by elderly women relatives and encompasses a mix of traditional and modern practices to ensure a successful outcome. Perhaps the starkest incongruity between traditional and medical practice was that the attendants were expected to deliver all births at home irrespective of the woman's condition.
This divergence of opinions and expectations needs to be considered when providing obstetric care, whether in the home or the clinic setting. Other researchers have described similar clashes between nurse-midwives, who tend to align themselves with modernity and clinical approaches, and the recipients of their care. (22,23) Thus it is important to identify which aspects of professional delivery care can be modified to meet cultural expectations without jeopardising the health of the woman. For instance, in Matlab the nonsupine position or adequate cover of the woman to prevent exposure may increase the acceptability of services by women and their families and community support.
Our findings highlight how other constraints found in the home setting could potentially be addressed through improved programmatic strategies. These include training specific to home deliveries and supervision that involves on-site visits by medical personnel. Community education designed to enhance the general understanding of the care and procedures offered by the skilled attendant may alleviate concerns and establish a sense of trust among community members. There remain, however, other obstacles such as difficulties getting to households, security, the time needed to assist a delivery, and conditions within the home, all of which are more difficult to resolve. Another stark issue relates to the conduct of the skilled attendants. We found that in the health facility the midwives often showed disrespect for the pregnant woman and her accompanying family members. Such behaviour was linked to a desire on the part of the attendants to assert their higher social status and the fact that they were in charge. In an ethnographic study of a Bangladeshi hospital obstetric unit, it was also reported that nurse-midwives scolded and humiliated patients to reinforce their dominant status. (24) Presumably, in a culture where hierarchical designations govern relations between individuals and groups, (25) the tendency to subordinate patients also took place in their homes. Thus, in either setting, safe motherhood programmes must recognise this as a problem in need of redress. Efforts aimed at improving the behaviour of midwives will require culturally appropriate training, taking into account societal views on status and adequate supervision.
Although there are several organisational models for delivery care, (26,27) the global priority is to ensure skilled attendance for all births (28) and access to emergency obstetric care for complications. There remains an ongoing debate among national and international stakeholders about whether skilled birth attendants should be posted at the domiciliary or facility level. Few rigorous evaluations have been carried out examining skilled attendance in the home setting. Probably the most cited example comes from Malaysia where, under a home-based programme, maternal mortality decreased significantly. (26,27) Explanations for the success of this initiative are attributed to the posting of a sufficient number of well-trained midwives, ongoing access to essential drugs, adequate means of referral to comprehensive care, free care at all levels and recognition of and respect for local customs. (26) In Indonesia, however, a home-based delivery policy brought a dramatic increase in skilled attendance at birth, but failed to improve access to life-saving care for women in need. (29)
There is general agreement that a constellation of conditions is required for professional attendants to function effectively. These include adequate personnel with the appropriate skills to provide maternity care, an enabling physical environment involving sufficient supplies and equipment and efficient referral systems, and ongoing training and supervision. (10,30,31) Less emphasis has been placed on the extent of local acceptability of medical practices and the importance of community support. In a context like rural Bangladesh, the obstacles illuminated in our research raise important questions about whether quality of delivery care can be assured in the home setting.
Whereas in the past it has been assumed that cultural issues would prevent women from utilising clinic-based obstetric services, the experience in Matlab illustrates that a well-organised maternity programme offering comparatively good quality services can help to overcome these barriers. Data collected through the Matlab health and demographic surveillance system suggest that in the health facility the skilled attendants were able to assist more deliveries than in the home setting. During the home-based strategy, the proportion of women seeking skilled delivery attendance at home peaked at 19.6% in 1992, while the rise in facility births was impressive, increasing from 6% in 1996 to 26.8% in 2001, only a year after all the facilities were fully functioning. (21) At the height of the home-based strategy in 1992, each pair of birth attendants assisted on average 133 home births per year, compared to 183 births per year in each facility in 2001. Socioeconomic inequalities in the use of a skilled attendant were substantial for both home- and facility-based care, although inequalities in access were somewhat greater for births in health facilities. (21) Since 2001, there has been a gradual increase in facility-based delivery care, with 35.9% and 40.1% of women giving birth in a facility in 2003 and 2004, respectively.
While some may argue that the long duration of its safe motherhood programme makes Matlab highly unusual in the Bangladesh context, data show that the Matlab service area is not as unique as many people suggest. (32) In fact, over time maternal mortality data from Matlab have been similar to nationwide trends identified through demographic and health surveys. Furthermore, even if Matlab were unique, the conditions would be even more difficult in other parts of the country where safe motherhood programmes and the health infrastructure are less developed.
National governments should be encouraged to clarify what their policies and aspirations are in terms of where women deliver, and either commit to a facility-based strategy or make explicit the rationale for choosing other alternatives. It is generally argued that home births increase coverage with skilled care in rural areas and respond to women's demands for home-based care. However, midwives deployed at the community level may not actually provide much outreach, instead serving those closest to them. (21) Moreover, the basic conditions in homes in rural areas may prevent midwives from delivering skilled care. Home delivery care is also inefficient in terms of the midwife's time and ability to cope with emergencies, and home-based provision is less likely to be sustained in the long term. Before embarking on major initiatives to scale up skilled attendance at home, our results underscore the importance of further examining the safety and effectiveness of home birth strategies to ensure skilled birthing care for women.
This research was funded under Cooperative Agreement #388-A-00-97-00032-00 with the United States Agency for International Development (USAID), ICDDR,B grant number GR-00089. ICDDR,B acknowledges with gratitude the commitment of USAID to the Centre's research efforts. Carine Ronsmans is funded by the Department for International Development, UK. We thank the skilled attendants for the time they gave to share their valuable experiences.
(1.) Huque ZA, Leppard M, Mavalankar D, et al. Safe motherhood programmes in Bangladesh. In: Berer M, Ravindran TKS, editors. Safe Motherhood Initiatives: Critical Issues. London: Reproductive Health Matters, 1999. p.53-61.
(2.) Geefhuysen CJ. Safe motherhood in Indonesia: a task for the next century. In: Berer M, Ravindran TKS, editors. Safe Motherhood Initiatives: Critical Issues. London: Reproductive Health Matters, 1999. p.62-72.
(3.) Sibley L, Sipe TA, Koblinsky M. Does traditional birth attendant training improve referral of women with obstetric complications: a review of the evidence. Social Science and Medicine 2004;59(8):1757-68.
(4.) Bergstrom S, Goodburn E. The role of traditional birth attendants in the reduction of maternal mortality. Studies in Health Services Organisation & Policy 2001;17:77-96.
(5.) World Health Organization. Skilled Birth Attendance: Review of Evidences in Bangladesh. Dhaka: WHO, 2004.
(6.) Bangladesh Maternal Health Services and Maternal Mortality Survey 2001. Dhaka: National Institute of Population Research and Training, 0RC Macro, Johns Hopkins University, ICDDR, B, 2003.
(7.) Bangladesh Demographic and Health Survey 2004. Dhaka: National Institute of Population Research and Training, Mitra and Associates, and ORC Macro, 2004.
(8.) Rozario S. The dai and the doctor: discourses in women's reproductive health in rural Bangladesh. In: Ram K, Jolly M, editors. Modernities and Maternities: Colonial and Postcolonial Experiences in Asia and the Pacific. Cambridge: Cambridge University Press, 1998. p.144-76.
(9.) Blanchet T. Meanings and Rituals of Birth in Rural Bangladesh. Dhaka: University Press Ltd, 1984.
(10.) Graham W J, Bell JS, Bullough CHW. Can skilled attendance at delivery reduce maternal mortality in developing countries? Studies in Health Services Organization & Policy 2001 ; 17:97-130.
(11.) Goodburn EA, Gazi R, Chowdhury M. Beliefs and practices regarding delivery and postpartum maternal morbidity in rural Bangladesh. Studies in Family Planning 1995;26(1):22-32.
(12.) Afsana K, Rashid SF. The challenges of meeting rural Bangladeshi women's needs in delivery care. Reproductive Health Matters 2001 ;9(18):79-89.
(13.) Matthews Z, Ramakrishna J, Mahendra S, et al. Birth rights and rituals in rural south India: care seeking in the intrapartum period. Journal of Biosocial Science 2005;37(4):385-411.
(14.) Thind A, Banerjee K. Home deliveries in Indonesia: who provides assistance? Journal of Community Health 2004;29(4): 285-303.
(15.) Prevention of Maternal Mortality Network. Barriers to treatment of obstetric emergencies in rural communities of West Africa. Studies in Family Planning 1992;23(5):279-91.
(16.) Fauveau V, Stewart K, Khan SA, et al. Effect on mortality of community-based maternity-care programme in rural Bangladesh. Lancet 1991;338: 1183-86.
(17). Van Ginneken J, Bairagi R, de Francisco A, et al. Health and Demographic Surveillance in Matlab: Past, Present and Future. Special Publication No.72. Dhaka: ICDDR,B, 1998.
(18.) Bhatia S. Traditional childbirth practices: implications for a rural MCH program. Studies in Family Planning 1981;12(2):66-75.
(19.) Rozario S. Purity and Communal Boundaries: Women and Social Change in a Bangladeshi Village. Dhaka: University Press Ltd, 2001.
(20.) Amin S, Diamond I, Raved RT, et al. Transition to adulthood of female garment-factory workers in Bangladesh. Studies in Family Planning 1998;29:185-200.
(21.) Chowdhury ME, Ronsmans C, Killewo J, et al. Equity in use of home-based or facility-based skilled obstetric care in rural Bangladesh: an observational study. Lancet 2006;367:327-32.
(22.) Devries RG. The warp of evidence-based medicine: lessons from Dutch maternity care. International Journal of Health Services: Planning, Administration, Evaluation 2004;34(4):595-623.
(23.) Lugina H, Mlay R, Smith H. Mobility and maternal position during childbirth in Tanzania: an exploratory study at four government hospitals. BMC Pregnancy and Childbirth 2004;4(1):3.
(24.) Leppard MJ. Obstetric Care in A Bangladesh District Hospital: An Organizational Ethnography. Unpublished PhD thesis. London: London School of Hygiene and Tropical Medicine, 2000.
(25.) Kotalova J. Belonging to Others: Cultural Constructions of Womanhood among Muslims in a Village in Bangladesh: Uppsala University, 1993.
(26.) Koblinsky MA, Campbell O, Heichelheim J. Organizing delivery care: what works for safe motherhood? Bulletin of World Health Organization 1999 ;77(5):399-406.
(27.) Van Lerberghe W, De Brouwere V. Of blind alleys and things that have worked: history's lessons on reducing maternal mortality. Studies in Health Service Organization & Policy 2001 ; 17:7-34.
(28). Starr A. The Safe Motherhood Action Agenda: Priorities for the Next Decade. New York: Inter-Agency Group for Safe Motherhood, Family Care International, 2001.
(29.) Ronsmans C, Endang A, Gunawan S, et al. Evaluation of a comprehensive home based midwifery programme in South Kalimantan, Indonesia. Tropical Medicine and International Health 2001 ;6(10):799-810.
(30.) Safe Motherhood Inter-Agency Group. Skilled Attendance at Delivery: A Review of the Evidence. New York: Family Care International, 2000.
(31.) Travis P, Bennett S, Haines A, et al. Overcoming health systems constraints to achieve the Millennium Development Goals. Lancet 2004;364:900-06.
(32.) Ronsmans C, Vanneste AM, Chakraborty J, et al. Maternal mortality decline in Matlab, Bangladesh: a cautionary tale. Lancet 1997;350:1810-14.
* Pregnant women are believed to be highly vulnerable to evil spirits, one reason why their mobility was restricted. (8,9,11) Susceptibility was considered to be at its pinnacle during labour and delivery, which were to take place in utmost privacy to keep them a secret.
Lauren S Blum, (a) Tamanna Sharmin, (b) Carine Ronsmans (c)
(a) Medical Anthropologist, ICDDR, B, Centre for Health and Population Research, Dhaka, Bangladesh. E-mail: firstname.lastname@example.com
(b) Research Investigator, ICDDR, B, Centre for Health and Population Research
(c) Reader in Epidemiology and Reproductive Health, Infectious Disease Epidemiology Unit, London School of Hygiene and Tropical Medicine, London, UK
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Zinna California Giants Mix
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By father in law thinks I am just an over protective mom, when i ask him not to pick up my son using just his arms. I wanted to know what you guys thought. Is it Ok to pick up a 16 month old using his hands and arms only?
Picking up toddler using only his arms
I have not all the time but I think its more of a concern for infants than toddlers.
Miranda mom to 4 Turdybirds, BFF Clutz-o-Matic
"I shouldn't of came here, I'm allergic to waffles.."
I do. Sometimes when we're walking we'll do the "1.. 2... weeee" thing and lift her up for a little swing. Sometimes just to play. I've only heard negative things when it's done forcefully or whatever.
Kaylie (07/04), Madilyn (05/08), Kevin (04/10) & Michael (08/11)
We do but we are careful not to snatch on them.
It is not a problem if you do with both hands and pick them up gently. If you snatch them, it can hurt their elbows mainly. Shoulders too but the main concern is the elbow...If I am not mistaken.
Molṑn Labé
Flying a Flag for my Army Brother
Give me Liberty, or Give me Death!
I wouldn't--it causes an injury called Nursmaid's elbow, which is a dislocation of the elbow joint. THe elbow is NOT a very strong joint, and lifting a toddler's weight by his forearms or wrists is a good way to do that injury. That being said, it is often more associated with forceful lifting/jerking as if you were yanking an uncooperative child.
Kinsey CrossFitting Mama
Patrick Bailey 05-21-08 ANA to Dairy; Baked Egg OK!
William Burkett 07-02-10 VBAC
My DH does it a lot, DS loves it, my boys love to play rough.It drives me crazy.
Proud wife to James, full time mom/attachment parenting Ethan Alexander 5-10-08
thanks for the website- i have forward it to my father in law.
Married to the greatest man 7-6-02
Noah 5-25-08
Riyah 1-2-10
We also do the: 1, 2, weee, thing. And Dh is always picking her up by her hands/arms. @ first it freaked me out-but she loves it. She's a rough houser with dh so nothing really phases me anymore.
Is it okay to pick them up?
-if you do it carefully
Single mommy to Kennedy(05/08) and Keegan(01/10)
Ok I was just thinking about this. I ahve noticed I do it A LOT and I need to stop.
We do it, more often than we should. He loves it when we swing him between our legs. Damage is caused more often with jerking motions.
" Be who you are and say what you feel, because those who mind don't matter, and those who matter don't mind"� Dr. Seuss


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2640 Space
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2640 Space is a venue for many social events in Baltimore. The venue is the joint venture of Red Emma's Bookstore Coffeehouse and St. John's United Methodist Church and is used for many seminars, lectures, workshops, events for children and so on. Many film screenings, culinary events and local music shows are also held here. So this place is nice to catch up with the happenings of the city.
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Nine Space
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Description: Ethnic Print Terry Beach Peshtemal:
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Material: 100% Turkish Cotton
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Four medieval knights went head-to-head to keep the crowds on their toes at English Heritage event
Four medieval knights went head-to-head to keep the crowds on their toes at English Heritage event
Tributes left for motorcyclist who died after a collision in Bowling Green Lane on Thursday afternoon
Former team-mates of the 24-year-old carpenter join families and friends to raise money for British Heart Foundation
Reginald "Rex" Warneford was awarded a Victoria Cross for shooting down a German Zeppelin
The "Jester from Leicester" played eight exhibition matches at an awards night at Attleborough Liberal Club
Bezzie, lolz, hashtag and twerking are now among acceptable terms
Patrols will be on the look out for offenders in West Midlands-wide operation
He suffers number of injuries in crash in village of Offchurch
Harriet Harman says: 'We need robust hustings which cannot just be held in our Labour heartlands'
She is rescued by fire crews wearing breathing apparatus, as residents are evacuated
My ancestors were related to Nicholas Chamberlaine, Bishop tells youngsters at Founders Day service
One of my wife's relatives knew Nicholas Chamberlaine, says Dr Cocksworth
"There has been a lot of research into the positive affect animals can have on a wide range of people with illnesses"
The retired race dogs will be relocated to the Rugby kennel before finding a permanent home
The new plinths will provide a safer and more stable experience for heavier patients at the hospital
36-year-old remains in a stable condition in hospital after incident in Northampton Lane, Dunchurch, on Tuesday
Male biker airlifted to Coventry University Hospital after collision outside Goodyers End Primary School
The road was closed near Stratford for around 12 hours after smash involving three cars, a lorry, a van and a motorcycle this morning
But Nuneaton and Bedworth councillors vote to 'leave all options on table' after discussing Greater Birmingham Combined Authority
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The Mumbai police have sounded a high alert acting on the information that four members of terror outfit Lashkar-e-Taiba (LeT) have sneaked into the city. ]
On Thursday, they released the photo of one of the terrorists and appealed to the citizens to remain alert during the upcoming Christmas season and New Year.
"The police have received specific input regarding the terrorists," joint commissioner of police (crime) Himanshu Roy said in a hurriedly-called press conference on Thursday evening. The police had no information on their exact plan, but they are likely to target heavily crowded places, he added. He released the photo of Walid Jinnah, one of the infiltrators.
The three others have been identified as Abdul Karim Mussa, Noor Abdul Ilahi and Mafooz Alam.
"The four LeT members plan to carry out terror-related activities. According to our information, all of them are in the age group of 20-30 years," Roy said, adding, "We have formed a special team to trace them and the police are taking major security precautions."
The police have also started a hotline number — 22633333 — dedicated specifically for information related to the terrorists. "We appeal to the citizens to alert the police if they have information," Roy said.
He said the terrorists had entered the city for "extremely dangerous activities". He, however, refused to divulge the source of the information.
Earlier this week, the Union ministry of home affairs had issued an alert regarding possible terror activities in Mumbai and Ahmedabad. Following this, the Mumbai police threw a thick security blanket around the city, especially South Mumbai.
On Wednesday, the police announced that they had taken stringent security steps to fortify South Mumbai locations, more importantly areas around the Gateway of India and the Taj Mahal hotel.


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25 Characters That Need to Be in 'Injustice: Gods Among Us'After a surprise announcement just prior to E3 2012, Injustice: Gods Among Us is finally being revealed and detailed. But with NetherRealm Studios taking on a universe as full of amazing and powerful characters as the DC Universe, it's shocking that only six have been confirmed. These characters we speak of are too numerous to possibly count, but whether it's a unique personality or promising blend of skills we think could be perfect for Injustice, we've managed to pick out our favorites. Now that we've had a chance to play Injustice for ourselves, there is no doubt that the developers are approaching both heroes and villains with the utmost and respect and commitment to existing lore. With that in mind, here is our list of heroes and villains we think must be brought to life in the game's new aesthetic. We have our own favorites that didn't make the list, but all of our choices represent fantastic fighters who we also think would bring something special to the combat.
Green LanternSavvy Green Lantern fans will notice that Hal Jordan is not pictured in the provided image. While the inclusion of GL is almost a certainty - since he's one of the heroes with a film franchise bearing his name - the feature film did enough damage. The modern-day backup is John Stewart, and while we would be thrilled to see another incarnation of that character, we can't help but hope for Guy Gardner. The man Geoff Johns refers to as the "DCU Sh*tkicker" is the only Lantern whose power ring constantly sparks, due to his eagerness to unleash its power. Anyone familiar with Gardner knows that he's one of the only 'good guys' who would jump at the chance to beat Batman into a pulp. While all Lanterns share the same basic mid-ranged attacks and melee strength, Gardner is undoubtedly the most brutal of the human officers. Add in his wise-cracking, and he'd offer the depth and personality that Hal Jordan never can in video games.
WildcatOnce a world-class heavyweight boxer, Ted Grant, like many superheroes of the Golden Age, turned his unique skill set to stopping crime under the name of 'Wildcat.' Donning a black catsuit and his usual wrappings (sometimes with claws in place) Grant relies on his boxer's agility and fierce striking to punch even the most supernatural enemies into unconsciousness. NetherRealm would have options though, as Grant's son Tom has also taken up the 'Wildcat' moniker, in a more literal sense. His metahuman DNA allows him to turn into a were-panther at will, taking his father's training to more lethal heights. Seeing as Grant trained Bruce Wayne in the 'sweet science,' he packs quite a punch. The character design, speed and all-melee fight style is something we'd love to see in Injustice. Because, let's be honest, every fighting game should have a man in a catsuit.
Green ArrowEven though bows have become the 'it' weapon of late, Green Arrow has been wielding one for decades. Oliver Queen may be known as much for his outfit and moral dilemmas as his potency with trick arrows, he's as deadly as they come. With a new TV series based on the crimefighter, it's also a safe bet that Warner Bros. will push his inclusion. And they'd be right to do so. We've made our case for why Green Arrow deserves his own game, but seeing how Injustice would match Queen's ranged attacks against melee fighters has our interest piqued. He would be dangerous using the bow as a hand-to-hand weapon as well, but seeing what kind of redesign he'd receive alone would be worth including.
Black AdamIt was clear that someone from the Captain Marvel family would make our list, and we're convinced Black Adam is the downright baddest. The man single-handedly brought on World War III, so dealing with the other villains and heroes in the game would be a walk in the park. Using his god-like strength or devastating lightning - brought on by a cry of, you guessed it, 'Shazam!' - Black Adam would be one character who lives up to the game's name. Throw in a Khandaq fighting stage with stone pillars and statues to tear apart, and you're set.
Deathstroke the TerminatorWe don't need to construct a compelling argument: any DC fighting game should include Deathstroke. Slade Wilson, master of guns and swords has long been compared to Marvel's Deadpool, but there's no debate as far as wew're concerned. The ideal of human strength and physicality, a genius in all forms of combat, it goes without saying: nobody is as deadly as Deathstroke. No human anyway. Seeing as he's bested Batman every time they've gone head-to-head, not to mention taken on the entire Justice League, the vast cast of supernatural and magical beings on hand for Injustice might finally offer him some competition. If not a fighter, then Deathstroke must be included as the final boss. Could you imagine how he'd fight with two eyes?
CometAs the reincarnation of the original Captain Comet a.k.a. Adam Blake, Comet possesses all of the Silver Age hero's strengths, and more. One of the first metahumans ever written - a decade before Marvel explored the notion - Comet is the absolute peak of human evolution, gifted with telepathy, telekinesis, and clairvoyance. What this means in terms of combat is that Comet can fly, fire psionic blasts, manipulate objects, create psychic barriers, teleport, and fire bursts of mental energy as electricity or fire. If that fails, he also has a pistol to go along with his strength and endurance, once rivaling that of Superman. While the lackluster ending of Mass Effect 3 only heightened our desperation for Comet's Mystery in Space to be made into a game, we'd settle for a chance to see how well his myriad gifts and attacks would translate into gameplay.
AzraelJean-Paul Valley holds a unique place in the Batman mythology, and serious fans know him as one of the most important. As a member of the Order of St. Dumas, Valley was a genetically modified and brainwashed soldier, living as a normal civilian, who then became the embodiment of angelic vengeance upon donning his ever-changing armor. Mental state aside, Azrael is gifted with the superhuman speed and strength that would measure up against the deadliest heroes and villains of the DC Universe. Equipped with full body armor, flaming swords that detach from his wrists to be propelled at enemies, and a marked interest in firearms, Azrael isn't lacking ordnance. After a brief appearance in Batman: Arkham City, we're convinced he needs to make the transition to playable character.
DarkseidThe sole ruler of Apokolips, Darkseid is the embodiment of evil and totalitarianism in all its forms. As one of Jack Kirby's New Gods, Darkseid enjoys immortality, and has spent his hundreds of thousands of years honing his cruelty and brutality in battle. Capable of increasing in size, traveling at super-speed, and even traveling through space and time, Darkseid is easily among the strongest characters in the DC Universe. His main weapon would inherently be the Omega Beams fired from his eyes and hands, meaning he's dangerous at range and up close. He punches like a god, after all. Darkseid has appeared in previous NetherRealm titles, but the new art style being used for Injustice would certainly do a great deal for one villain whose appearance has remained somewhat... stale for a few decades.
Black Canary
Known as much for her costume as her abilities, Black Canary a.k.a. Dinah Lance is more than a pretty face and impressive physique. A master martial artist and brilliant tactician and combat leader, it's been claimed by some in the DCU that Canary could even best Batman in combat if necessary. Even with this supreme combat training, Canary's namesake powers are her most lethal - and least used - abilities. Canary's sonic scream allows her to shock, deafen, incapacitate and at times even completely destroy her enemies. Whether through directed blast in conjunction with melee attacks, or simply unleashing her voice on her opponents, Canary would prove to be a devastating fighter in video game form.


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The Greater Allentown Fair
A Walk Down the Midway at Dusk
by David L. Rehrig and Frank T. Smith
A photographic essay of the Greater Allentown Fair.
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State Bank of Mysore is to raise Rs.70-80 crore by way of private placement of equity to mutual funds, insurance companies and other bodies approved by the Securities and Exchange Board of India (SEBI), said its Managing Director Sharad Sharma on Tuesday. Addressing the media, Mr. Sharma said equity stake to the extent of 2.33 per cent of the bank's capital base would be divested before the end of the current financial year. "Formal approval of the board is likely next week," he said.
Mr. Sharma said the bank also planned to raise Rs.600-700 crore via a Qualified Institutional Placement (QIP) or a rights issue to bolster the capital base to meet the Basle-III norms. "This is likely to happen in the first-half of 2013-14," he said.
Q3 profit up 40 %
During the third quarter, the bank made a net profit of Rs.155 crore, 40 per cent higher than a year earlier. Net interest income rose 11 per cent, amounting to Rs.461 crore. Observing that advances grew by 16 per cent during the quarter, Mr. Sharma said, "Our experience has been different from other banks, which have complained of poor credit offtake." He said the overhang of non-performing assets, which had increased significantly since 2011, "has been brought under control." Gross NPAs declined from 4.67 per cent in the first quarter of 2012-13 to 3.99 per cent during the third quarter, he said.
Keywords: State Bank of Mysore, SBM profits