highly disadvantaged settings in Memphis, Tennessee. The home participants were primarily African-American women and their first live-born children living in highly disadvantaged urban neighbourhoods. The intervention of transportation plus pre-natal/post-partum home visiting by nurses reduced maternalmortality from 3.7% to 0.4%., which was significant. Interestingly, adding screening to this in another treatment resulted in maternalmortality of 2.2%. A new initiative, the National Partnership for Maternal Safety, was formed in the USA to address the recent rise in MMR against the global decreasing trend (D'Alton et al., 2014). Three priority bundles were identified for collaborative broad-based implementation programmes for the most common preventable causes of maternal death and severe morbidity: obstetric haemorrhaging, severe hypertension in pregnancy, and peripartum and venous thromboembolism. In addition, three unit-improvement bundles for obstetric services were identified. One, a structured approach for the recognition of early warning signs and symptoms, including structured internal case reviews to identify system improvement opportunities. Two, support tools for patients, families, and staff that experienced an adverse outcome. According to De Brouwer and Van Lerberghe, in their publication ‘Safe Motherhood Strategies: a Review of the Evidence’ (2001), the USA did not achieve a reduction in maternalmortality at the same rate as Sweden and other European countries due to a lack of information, lack of public pressure, the down-rating of midwifery by obstetricians over a long period of time, and insistence on institutional delivery over home delivery without providing basic access and care facilities. The USA achieved better results only after these barriers were removed.
This paper investigates the impact of SAB, GFR and GDP on maternalmortalityrate in SouthSudan. How- ever, as highlighted in the introduction, factors impact- ing the maternalmortalityrate include socio-economic factors, macro-economic factors and physiological fac- tors [ 1 ]. Lack of access to health care facilities is also a major factor due to lack of roads and transportation sys- tem [ 7 , 10 ]. More than 50% of the population walks three miles or more to the nearest primary health care unit. All of factors affect the total health care system and in particular high maternalmortalityrate problem. Kruk et al. have investigated the impact of the community perceptions on the quality of care provided by the local health system on pregnant woman’s decision to deliver in a clinic. They have suggested that improving the qual- ity of care at first level clinics may assist the efforts to increase facility delivery in sub-Saharan Africa [ 2 ].
SouthSudan has one of the world ’ s worst population health indicators; for instance, the maternalmortality ra- tio stands at 789/100,000 live births , less than 30% of women are attended to by a skilled health worker; and the rate of institutional delivery assisted by a skilled birth attendant is less than 20% . In post-conflict con- texts, healthcare provision and improving population health outcomes is particularly difficult because of poor infrastructure, limited human resources, and weak stew- ardship [3 – 5]. In SouthSudan too, the long drawn con- flict has weakened the health system, and there are severe shortages of health workers and few well- functioning health facilities [2, 8]. De Francisco A et al. , drawing on the International Covenant on Eco- nomic, Social and Cultural Rights , argue that for public health programs to be useful to and to be used by the people they mean to serve, one “ requires location- specific investigations ” (, pg.19 – 20). In a recent re- view of maternal and child health policies in SouthSudan, Mugo et al.  noted that “ Informing policy with evidence requires acute sensitivity to local context ” ; in a subsequent paper, they further emphasize the need to “ address the socio-economic factors that prevent women from using maternal health services ” in SouthSudan . This paper presents the findings of such an investigation from SouthSudan; it complements the recent work by Mugo et al. , Wilunda et al. , Lawry et al.  on barriers to maternal health in SouthSudan.
The authors would like to thank WHO (World Health Organisation), and UNICEF (United Nations International Children ’ s Emergency Fund), SouthSudan Country Offices and SouthSudan National Bureau of Statistics (NBS) and Juba Teaching Hospital for providing the dataset. The authors appreciate the Australian Government for financially supporting this study through Australian Government Research Training Program Scholarship. We also express our gratitude to the Higher Degree by Research (HDR), RMIT University for financial support, Melbourne, Australia. Furthermore, our appreciation and thank to the RMIT University Learning Centre for their language advisory review in particular Dr. Ken Manson. The contents are solely the responsibility of the authors and don ’ t necessarily represent the official views of the supporting offices.
US$ was estimated at 12,409 billion US$ in 1990, declined to 12,257 in 2000, tremendously increase to 65634 in 2010 6 and further increased to 97,156 billion in 2015. Poverty is wide spread as 46.5% of Sudanese live under poverty line with considerable variations between and within states (Central Bureau of Statistics, 2009). Secession of SouthSudan in 2011 resulted in an immediate economic downturn in Sudan in 2012, with significant decline of government revenues and soaring inflation rates, which affected the welfare of a growing number of poor people among them morbidities and mortalities are high. Total health expenditure has been the lowest amongst the countries of the Eastern Mediterranean Region Office (EMRO) of the WHO. Out of pocket health expenditure is high and increasing at a rate higher than the rate of increase of public expenditure on health and can be deemed as impoverishing and catastrophic. Contraceptive is use is just around 10 percent (Paul G. and D., de Walque, 2012). These factors have caused Sudan to witness slow progress in achieving all health related millennium development goals (MDGs), namely reduction of maternalmortality ratio (MMR) and under-five mortality rates. In such socioeconomic and health sector situation all of the underlying causes of maternal deaths identified by the WHO are expected to prevail ((Paul G. and D., de Walque, (2012) and Sophie W., (2010)). It has been well understood that factors lead to maternal death include pregnancies with abortive outcome, hypertensive disorders, obstetric hemorrhage, pregnancy-related infection, other obstetric complications, unanticipated complications of management, nonobstetric complications, unknown or undetermined and coincidental causes (Black, R.E., et al. (2016).
In Butajira, which is in south central Ethiopia, the MMR was estimated to be 665 per 100, 000 LB in 1996 using the sisterhood method . The Butajira study might have been methodologically more robust than the current study as it was linked to demographic surveil- lance and probably had a more precise age estimation. However, Butajira also had better access to health ser- vices, and this could also explain the differences in MMR compared with Bonke. Shiferaw et al.  reported a MMR of 570 per 100,000 LB from Illubabor in western Ethiopia in 1991; however, both studies reported MMR rates below the international estimates for Ethiopia at that time.
Given the country’s rich land and water endowment, the potential for irrigated agriculture is large. With its substantial water resources, SouthSudan can, though irrigation, increase agricultural production by converting into cropland, some parts of its land cover that is currently not under cultivation or is cultivated only periodically. Th e MWRI has identifi ed irrigation as means for attaining food security and improvement of water management for agriculture and as a remedy to the dual problems of recurrent droughts and periodic fl oods. Th e locations for potential development include the following: (i) the lowlands, where farmers make use of fl ooding to supplement water for growing rice; (ii) areas adjacent to river fl oodplains, where farmers cultivate short-maturing varieties of sorghum; (iii) areas around swamps/marshes where extension of the growing season is possible by planting in moist soils left by receding fl oods; (iv) drought-prone eastern mountainous semiarid areas with low water storage and infi ltration capacity; and (v) southwest and western (Green Belt zone) whose agricultural output usually exceeds subsistence level and where modern irrigation techniques can further increase agricultural production, enhance food security and supply agro-industries.
Abstract: The idea of introducing extra parameters into the existing model in enhancing more flexibility is a giant stride in research. Transmutation map technique is one of the recent methods of introducing additional properties such as skewness, kurtosis and bimodality into the baseline distribution. In this article, a new exponentiated exponential distribution is developed using transmutation map. This model is referred to as exponentiated cubic transmuted exponential distribution (ECTED). The mathematical properties of the model which include survival function, hazard function, central and non- central moments, moment generating function and order statistics are established. The inherent parameters in the model are estimated using method of maximum likelihood estimation (MLE). The system of equations obtained is non-linear in parameters therefore non-linear optimization algorithms are implemented in R package. The distribution is used to model data on infant mortalityrate in Nigeria. The performance of the subject model is compared with its baseline exponential distribution (ED), transmuted exponential distribution (TED), exponentiated transmuted exponential distribution (ETED) and cubic transmuted exponential distribution (CTED) using Akaike Information criterion (AIC), Corrected Akaike Information criterion (AICC) and Bayesian Information criterion (BIC). It is hope that this will serve as an alternative distribution in modelling complex real life data arising from various fields of human endeavors.
The experience of the CMs themselves appears to have been overwhelmingly positive, even in the face of heavy responsibility and severe constraints. CMs fill an important place in reproductive health care in Afghanistan. Their access to medical treatment distinguishes them from TBAs with more childbirth experience. However, their ties to the community keep these services, often perceived as “foreign” or “Western,” more local and less threatening. Their education and growing expertise represent significant movement away from a society where women have limited education or professional opportunities. It is hoped that as CMs confer benefits to their community there will be other opportunities for women to be trained as local professionals, building the capacity of the community through women’s education. As role models for women’s education and empowerment, CMs will contribute further toward their goal of improved maternal health.
In some of the reviewed papers, total deliveries were used in place of live births (LB) to calculate MMR. Errors in MMR estimations and their interpretations are inherent problems. Generally MMR estimates are subject to high levels of uncertainty and not intended to serve as precise estimates. Caution is required in interpreting small numerical differences in countries as representing real differences in maternalmortality because the estimated uncertainty margins are extremely wide. However, the estimates are indicative of the extent of the maternalmortality problem, and should draw attention to the need for both improved action for maternalmortality reduction and increased efforts for the generation of robust data for estimating maternalmortality levels (4). To achieve a three-fourth decline in MMR by 2015 as set by MDG, efforts has to be strengthen to address the underlying causes of maternal deaths. Among the major five obstetric causes of maternal deaths, the proportion of maternal deaths due to eclampsia/ severe preeclampsia shows increasing trend while that of abortion is decreasing. No grossly notable reduction in the proportions of MD after ruptured uterus/ obstructed labor and sepsis are indicated.
assets are only liquidated when necessary. A large herd is also a critical for risk management, because in most contexts, larger herds survive events such as droughts or disease outbreaks better than small herds, i.e. there is a higher chance of some animals surviving to enable herd recovery. Similarly, many pastoralist groups use complex systems of social support that involve loans, gifts and other exchanges of livestock, and the notion of reciprocal support. In SouthSudan, these social aspects of livestock – especially the payment of bridewealth – are central to maintaining and developing social connectedness and reducing vulnerability. These issues were described for the Bor Dinka in SouthSudan 20 years ago (Harragin and Chol, 1998), and more recently for Nuer pastoralists in Upper Nile (Vistas, 2015). In the humanitarian aid sector in general, social networks are increasingly being recognized as a critical aspect of surviving disasters and famine (e.g. Maxwell et al., 2015).
The MMR in our study is higher than the national averages. Most of the deaths could have been avoided with the help of early referral,quick, efficient and well equipped transport facilities, availability of adequate blood and blood components, and by promoting overall safe motherhood. Analysis of every maternal death through maternal death audit, either at community level (verbal autopsy) or at the institutional level should be carried out. It will help in identifying the reasons and deficiencies in health care delivery system that might contribute in causing pregnancy related deaths.
According to the data as stated in the Profile of the Privinsi Health Office of South Sumatra, there were as many as 165 cases of maternal deaths in 2017 (South Sumatra Health Office, 2017). Data from the East OKU district health office shows that there were 17 deaths in the birth of 17 cases in 2017 (Health Office, OKUT 2017). MMR in East Oku Regency in 2007 was the highest in South Sumatera, Indonesia, in 2017. MMR causes were due to circulatory system disorders (6 mothers), eclampsia (4 mothers), bleeding (1 mother), metabolic disorders (1 mother), and others cause (5 mothers). Because of the high MMR, a system is needed to accelerate the decline in MMR. Efforts to accelerate the reduction of MMR have been carried out, among others, through increasing accessibility and quality of services carried out by bringing health services closer to the community through the placement of midwives and Poskesdes in various corners of the country. While from the aspect of service quality, it is carried out through efforts to increase the ability/competence of health workers and basic health and referral facilities (PONED/ PONEK), as well as other intervention programs (Ministry of Health, 2013). To suppress MMR can not only be done by health workers, but also requires cross- program cooperation, across sectors and participation from the community.
Historically, maternalmortality has been resistant to reduction despite decreases in other prominent causes of death, infection rate and changes in socioeconomic factors. Yet there are case studies of nations that demonstrate remarkable declines in maternalmortality in relatively short-time spans. It is evident that provision of quality services to pregnant women during delivery whether it is in the hospital or in homes in rural communities is the key to saving the lives of mothers. In northwestern Europe in the nineteenth century and in south Asia in the twentieth century, midwives were trained and integrated into the health care delivery system. In Great Britain and the United States in the 1930s, hospital deliveries were made safer and accessible to the majority of women. “Those countries that managed to provide professional obstetric care to cover the whole population, including poor and remote areas, achieved a relatively low level of maternalmortality earlier than the others” . The lessons of the past can direct the efforts of the present to reach the World Health Organization’s Millennium Development Goal of reducing maternalmortality worldwide by 75% by 2015.
The investment environment in SouthSudan currently presents a very high level of risk and volatility for both the South Sudanese government and investing companies. SouthSudan is in the midst of a civil conflict which has destabilised large swathes of the country, fragmented systems of authority, undermined democratic structures and sparked an enormous humanitarian crisis. For governments worldwide, contracts negotiated in times of crisis have often resulted in less favourable terms and, in the long run, have accrued less benefit to citizens from the exploitation of their resources. And for citizens already suffering severe poverty and displacement, upholding their rights under a new contract or the law is extremely difficult. Beyond the immediate risks posed by the ongoing conflict, corruption risk in SouthSudan remains high. This risk is well documented. In May 2012, President Kiir sent a letter addressed to “cor- rupt government officials, current and former”. In it he states that, “An estimated $4 billion are unaccounted for or, simply put, stolen by current
Maternalmortality rates (MMR) are calculated as deaths per 100 000 births, extending from 28 weeks of pregnancy to 6 weeks postpartum. Where there is vital registration with accurate recording of births and deaths it is possible to make assessments of secular changes in MMR and to compare such changes with specific interventions. Unfor- tunately, most developing countries do not have vital registration and alternative techniques have to be used including indirect interview methods such as the `sister- hood' method where women are interviewed about the occurrence of a pregnancy-related death in the family. There are advantages and disadvantages of all these techniques, the greatest problem being under-reporting. A comparison of MMR using three data sources was performed in Matlab, Bangladesh (Ronsmans et al. 1998). The investigators compared maternal deaths identified through a unique demographic surveillance system (DSS), using a previous detailed investigation into the levels and causes of maternalmortality, and deaths identified in a special study of lay reporting. There were important and substantial disagreements between the routine reporting and the special studies, and up to 50 % differences in MMR using the different approaches. This has important implications for any monitoring or evaluation of pro- grammes aimed at reducing MMR (Ronsmans et al. 1997).
We note that, although for pricing purposes insurance companies use the current yield curve, in order to quantify the financial risk for projection purposes, the development of a suitable model for the evolution of the interest rate is of key importance. Hence, we consider two alternative pricing frameworks based respectively on the CIR (Cox et al., 1995) model and the HJM model (Heath et al., 1992) for the term structure of interest rates. The parameters of the models are calibrated using the estimates of the UK yield curves published by the Bank of England. Further, mortality risk is taken into consideration by calculating survival probabilities using a modified version of the stochastic mortality model developed by Cox and Lin (2005), which allows for the possible perturbation by mortality shocks of the UK standard mortality tables used by practitioners (for example, the PA90, the PMA80 and PMA92-C20 mortality tables). The risk margin is then calculated using both the percentile approach and the standard deviation method.
The age pattern of mortality over the last century has varied by country, however, there are a number of common features: Mortality at birth is relatively high, though has dropped considerably over the century due to improvements in medical care; the highest probability of survival is around ages 8 to 12; mortality increases rapidly to age 18, where there often is a 'hump' associated with automobile accidents and suicide (particularly among males); and there is an exponential increase in mortality from age 30 associated with senescence. (For a comprehensive description of historic mortality patterns see Jain (1994), Lilienfeld (1976) and Tuljapurkar and Boe (1998)). At the top of the age range an interesting phenomenon has been noticed whereby the rate of increase in mortality appears to level out and then decrease, diverting from the exponential pattern. This has been studied in detail by Coale (1996), Horiuchi and Coale (1990), and Horiuchi and Wilmoth (1998). Tuljapurkar and Boe (1998) list the recent literature reporting decelerations in the rate of mortality increase at high ages, and state: " ...the nature o f mortality at ages over 80 is now moving to center stage in discussions o f future mortality c h a n g e ...Causes of this phenomenon have been speculated on, and are discussed in detail in the next section.
This paper expands in a more theoretical approach the methodology developed in  for exploring the dependence between mortality and market risks in case of stress. In particular, we investigate, using the Feller process, the relationship between mortality and interest rate risks. These are the primary sources of risk for life (re)insurance companies. We apply the Feller process to both mortality and interest rate intensities. Our study cover both the short and the long-term interest rates (3m and 10y) as well as the mortality indices of ten developed countries and extending over the same time horizon. Specifically, this paper deals with the stochastic modelling of mortality. We calibrate two different specifications of the Feller process (a two-parameters Feller process and a three-parameters one) to the survival probabilities of the generation of males born in 1940 in ten developed countries. Looking simultaneously at different countries gives us the possibility to find regularities that go beyond one particular case and are general enough to gain more confidence in the results. The calibration pro- vides in most of the cases a very good fit to the data extrapolated from the mortality tables. On the basis of the principle of parsimony, we choose the two-parameters Fel- ler process, namely the hypothesis with the fewer assumptions. These results provide the basis to study the dynamics of both risks and their dependence.
villages, people fled, losing loved ones, and leaving everything behind. Many remained in hiding for days and weeks, without food or assistance. Those who sought protection in sites for internally displaced persons (IDPs) often found dismal conditions. On 12 February, the Under-Secretary General for Humanitarian Affairs declared a Level 3 Humanitarian System-Wide Emergency Response for SouthSudan, the highest level of emergency. On 18 March, the SouthSudan Human Rights Commission released on interim report on the crisis, finding that human rights violations were committed by both parties to the conflict. By 22 April, over 78,000 IDPs were being protected at UNMISS bases, out of an estimated over 1,000,000 displaced across SouthSudan and to neighbouring countries. The humanitarian community has warned that, due to this massive displacement, SouthSudan faces a high risk of famine. 51. The following section provides an overview of the progress of the conflict and the accompanying international humanitarian law and human rights violations that occurred in the four most-affected States, Central Equatoria, Jonglei, Upper Nile, and Unity. Much of the information concerns urban areas where intense fighting has taken place; these are also the areas where the HRD is most concentrated. However, given the movements of the parties to the conflict and the patterns of violations reported, there is strong reason to believe that grave violations have occurred across rural areas. These areas and witnesses with relevant information have often been difficult to access for reasons outlined above. It should also be noted that not all incidents documented or sites visited by the HRD have been included in this report. Finally, as the conflict is on-going, the HRD’s investigations continue.