The costs of 'free': Experiences of facility-based childbirth after Benin's caesarean section exemption policy.

: As one of many similar policies in the region, in 2009 Benin launched a free c-section policy in publicly funded hospitals intended to decrease the barriers to facility delivery and the heavy financial burdens on women and their families. We conducted a qualitative study for eight months between 2012 and 2014 to understand women's experiences of care in maternity wards. We carried out semi-structured interviews with 30 women who had delivered via c-section at five hospitals. Two of these hospitals became case study sites where in-depth research was undertaken that consisted of participant observation in each maternity ward and 32 further interviews with women who had complicated, vaginal and c-section deliveries. Overall, women continue to pay for care, both in the form of under-the-table payments to health workers and prescribed payments for services not covered by the policy, though they consider the costs reasonable compared to what the charges were before. Lifting the fees has facilitated conditions for midwives to alert doctors that the procedure might be needed. Partly because c-sections are still feared by most women, in one hospital this led to some women perceiving them as a threat if their labour was progressing more slowly. Implementation of the policy differed greatly between the two case study hospitals. We conclude that some burdens on women's access to care have been addressed but deterrents remain to the improved perception of quality of care on the part of women. Findings detail how important context is to the implementation of the policy, and suggest that similar user-fee removal policies should be accompanied by other measures addressing staff management and quality of care.<br/

Strengths and weaknesses in the implementation of maternal and perinatal death reviews in Tanzania: perceptions, processes and practice.

OBJECTIVES: Tanzania institutionalised maternal and perinatal death reviews (MPDR) in 2006, yet there is scarce evidence on the extent and quality of implementation of the system. We reviewed the national policy documentation and explored stakeholders' involvement in, and perspectives of, the role and practices of MPDR in district and regional hospitals, and assessed current capacity for achieving MPDR. METHODS: We reviewed the national MPDR guidelines and conducted a qualitative study using semi-structured interviews. Thirty-two informants in Mara Region were interviewed within health administration and hospitals, and five informants were included at the central level. Interviews were analysed for comparison of statements across health system level, hospital, profession and MPDR experience. RESULTS: The current MPDR system does not function adequately to either perform good quality reviews or fulfil the aspiration to capture every facility-based maternal and perinatal death. Informants at all levels express differing understandings of the purpose of MPDR. Hospital reviews fail to identify appropriate challenges and solutions at the facility level. Staff are committed to the process of maternal death review, with routine documentation and reporting, yet action and response are insufficient. CONCLUSION: The confusion between MPDR and maternal death surveillance and response results in a system geared towards data collection and surveillance, failing to explore challenges and solutions from within the remit of the hospital team. This reduces the accountability of the health workers and undermines opportunities to improve quality of care. We recommend initiatives to strengthen the quality of facility-level reviews in order to establish a culture of continuous quality of care improvement and a mechanism of accountability within facilities. Effective facility reviews are an important peer-learning process that should remain central to quality of care improvement strategies.<br/

Cost and impact of policies to remove and reduce fees for obstetric care in Benin, Burkina Faso, Mali and Morocco.

BACKGROUND: Across the Africa region and beyond, the last decade has seen many countries introducing policies aimed at reducing financial barriers to obstetric care. This article provides evidence of the cost and effects of national policies focussed on improving financial access to caesarean and facility deliveries in Benin, Burkina Faso, Mali and Morocco. METHODS: The study uses a comparative case study design with mixed methods, including realist evaluation components. This article presents results across 14 different data collection tools, used in 4-6 research sites in each of the four study countries over 2011-13. The methods included: document review; interviews with key informants; analysis of secondary data; structured extraction from medical files; cross-sectional surveys of patients and staff; interviews with patients and observation of care processes. RESULTS: The article finds that the policies have contributed to continued increases in skilled birth attendance and caesarean sections and a narrowing of inequalities in all four countries, but these trends were already occurring so a shift cannot be attributed solely to the policies. It finds a significant reduction in financial burdens on households after the policy, suggesting that the financial protection objectives may have been met, at least in the short term, although none achieved total exemption of targeted costs. Policies are domestically financed and are potentially sustainable and efficient, and were relatively thoroughly implemented. Further, we find no evidence of negative effects on technical quality of care, or of unintended negative effects on untargeted services. CONCLUSIONS: We conclude that the policies were effective in meeting financial protection goals and probably health and equity goals, at sustainable cost, but that a range of measures could increase their effectiveness and equity. These include broadening the exempted package (especially for those countries which focused on caesarean sections alone), better calibrated payments, clearer information on policies, better stewardship of the local health system to deal with underlying systemic weaknesses, more robust implementation of exemptions for indigents, and paying more attention to quality of care, especially for newborns

Recombination dynamics of a human Y-chromosomal palindrome:rapid GC-biased gene conversion, multi-kilobase conversion tracts, and rare inversions

The male-specific region of the human Y chromosome (MSY) includes eight large inverted repeats (palindromes) in which arm-to-arm similarity exceeds 99.9%, due to gene conversion activity. Here, we studied one of these palindromes, P6, in order to illuminate the dynamics of the gene conversion process. We genotyped ten paralogous sequence variants (PSVs) within the arms of P6 in 378 Y chromosomes whose evolutionary relationships within the SNP-defined Y phylogeny are known. This allowed the identification of 146 historical gene conversion events involving individual PSVs, occurring at a rate of 2.9-8.4×10(-4) events per generation. A consideration of the nature of nucleotide change and the ancestral state of each PSV showed that the conversion process was significantly biased towards the fixation of G or C nucleotides (GC-biased), and also towards the ancestral state. Determination of haplotypes by long-PCR allowed likely co-conversion of PSVs to be identified, and suggested that conversion tract lengths are large, with a mean of 2068 bp, and a maximum in excess of 9 kb. Despite the frequent formation of recombination intermediates implied by the rapid observed gene conversion activity, resolution via crossover is rare: only three inversions within P6 were detected in the sample. An analysis of chimpanzee and gorilla P6 orthologs showed that the ancestral state bias has existed in all three species, and comparison of human and chimpanzee sequences with the gorilla outgroup confirmed that GC bias of the conversion process has apparently been active in both the human and chimpanzee lineages

Relics of cosmological quark-hadron phase transition

We propose that the amplified density fluctuations by the vanishing sound velocity effect during the cosmological quark-hadron phase transition lead to quark-gluon plasma lumps decoupled from the expansion of the universe, which may evolve to quark nuggets (QNs). Assuming power-law spectrum of density fluctuations, we investigate the parameter ranges for the QNs to play the role of baryonic dark matter and give inhomogeneities which could affect big-bang nucleosynthesis within the observational bounds of CMBR anisotropy. The QNs can give the strongest constraint ever found on the spectral index.Comment: REVTEX, 4 pages, 2 eps figure

Constraints on the Detectability of Cosmic Topology from Observational Uncertainties

Recent observational results suggest that our universe is nearly flat and well modelled within a $\Lambda$CDM framework. The observed values of $\Omega_{m}$ and $\Omega_{\Lambda}$ inevitably involve uncertainties. Motivated by this, we make a systematic study of the necessary and sufficient conditions for undetectability as well as detectability (in principle) of cosmic topology (using pattern repetition) in presence of such uncertainties. We do this by developing two complementary methods to determine detectability for nearly flat universes. Using the first method we derive analytical conditions for undetectability for infinite redshift, the accuracy of which is then confirmed by the second method. Estimates based on WMAP data together with other measurements of the density parameters are used to illustrate both methods, which are shown to provide very similar results for high redshifts.Comment: 16 pages, 1 figure, LaTeX2

Elucidating the mechanism of ferrocytochrome c heme disruption by peroxidized cardiolipin

The interaction of peroxidized cardiolipin with ferrocytochrome c induces two kinetically and chemically distinct processes. The first is a rapid oxidation of ferrocytochrome c, followed by a slower, irreversible disruption of heme c. The oxidation of ferrocytochrome c by peroxidized cardiolipin is explained by a Fenton-type reaction. Heme scission is a consequence of the radical-mediated reactions initiated by the interaction of ferric heme iron with peroxidized cardiolipin. Simultaneously with the heme c disruption, generation of hydroxyl radical is detected by EPR spectroscopy using the spin trapping technique. The resulting apocytochrome c sediments as a heterogeneous mixture of high aggregates, as judged by sedimentation analysis. Both the oxidative process and the destructive process were suppressed by nonionic detergents and/or high ionic strength. The mechanism for generating radicals and heme rupture is presented

Observation and study of baryonic B decays: B -> D(*) p pbar, D(*) p pbar pi, and D(*) p pbar pi pi

We present a study of ten B-meson decays to a D(*), a proton-antiproton pair, and a system of up to two pions using BaBar's data set of 455x10^6 BBbar pairs. Four of the modes (B0bar -> D0 p anti-p, B0bar -> D*0 p anti-p, B0bar -> D+ p anti-p pi-, B0bar -> D*+ p anti-p pi-) are studied with improved statistics compared to previous measurements; six of the modes (B- -> D0 p anti-p pi-, B- -> D*0 p anti-p pi-, B0bar -> D0 p anti-p pi- pi+, B0bar -> D*0 p anti-p pi- pi+, B- -> D+ p anti-p pi- pi-, B- -> D*+ p anti-p pi- pi-) are first observations. The branching fractions for 3- and 5-body decays are suppressed compared to 4-body decays. Kinematic distributions for 3-body decays show non-overlapping threshold enhancements in m(p anti-p) and m(D(*)0 p) in the Dalitz plots. For 4-body decays, m(p pi-) mass projections show a narrow peak with mass and full width of (1497.4 +- 3.0 +- 0.9) MeV/c2, and (47 +- 12 +- 4) MeV/c2, respectively, where the first (second) errors are statistical (systematic). For 5-body decays, mass projections are similar to phase space expectations. All results are preliminary.Comment: 28 pages, 90 postscript figures, submitted to LP0

Search for new phenomena in final states with an energetic jet and large missing transverse momentum in pp collisions at √ s = 8 TeV with the ATLAS detector

Results of a search for new phenomena in final states with an energetic jet and large missing transverse momentum are reported. The search uses 20.3 fb−1 of √ s = 8 TeV data collected in 2012 with the ATLAS detector at the LHC. Events are required to have at least one jet with pT > 120 GeV and no leptons. Nine signal regions are considered with increasing missing transverse momentum requirements between Emiss T > 150 GeV and Emiss T > 700 GeV. Good agreement is observed between the number of events in data and Standard Model expectations. The results are translated into exclusion limits on models with either large extra spatial dimensions, pair production of weakly interacting dark matter candidates, or production of very light gravitinos in a gauge-mediated supersymmetric model. In addition, limits on the production of an invisibly decaying Higgs-like boson leading to similar topologies in the final state are presente