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An
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M
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a
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ifi
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K
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C
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allen
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Hea
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v
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Ma
ter
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ea
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Ma
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R
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T
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is
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a
rticle
u
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CC
BY
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SA
li
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.
C
o
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r
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s
p
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A
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:
Sas
tr
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Po
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Gr
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u
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Stu
d
y
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Hea
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Ad
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in
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Un
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Qam
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Hu
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T
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B
ar
at,
I
n
d
o
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esia
E
m
ail:
s
astra
wan
@
g
m
ail.
co
m
1.
I
NT
RO
D
UCT
I
O
N
Ma
ter
n
al
an
d
n
eo
n
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m
o
r
tali
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in
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d
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ican
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co
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tality
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177
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r
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r
ate
of
12
p
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1
,
0
0
0
liv
e
b
ir
t
h
s
[
1
]
.
A
co
n
s
i
d
er
ab
le
n
u
m
b
er
of
t
h
ese
d
ea
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s
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in
a
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s
to
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tim
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Ma
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p
r
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ted
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r
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co
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be
s
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tan
tially
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[
2
]
.
T
h
is
h
ig
h
lig
h
ts
p
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ess
in
g
c
h
allen
g
es
r
elate
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th
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m
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Ma
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Evaluation Warning : The document was created with Spire.PDF for Python.
I
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2252
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8
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6
A
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lysi
s
o
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tern
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p
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m
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e
[
3
]
.
T
h
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m
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ity
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r
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s
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s
tem
is
a
cr
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if
ican
tly
to
m
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[
4
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.
T
h
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m
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ity
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tem
is
d
esig
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r
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[
5
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It
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b
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y
c
a
r
e
g
i
v
e
r
s
f
o
r
m
a
n
y
p
r
e
g
n
a
n
t
w
o
m
e
n
,
w
o
r
k
in
t
a
n
d
e
m
w
i
t
h
o
b
s
t
e
t
r
ic
i
a
n
s
,
n
u
r
s
e
s
,
a
n
d
o
t
h
e
r
s
p
e
ci
a
li
s
ts
to
p
r
o
v
i
d
e
c
o
m
p
r
e
h
e
n
s
i
v
e
a
n
d
c
o
n
t
i
n
u
o
u
s
c
a
r
e
.
In
r
ec
en
t
y
ea
r
s
,
th
er
e
h
as
b
ee
n
r
en
ewe
d
f
o
cu
s
on
t
h
e
r
o
le
of
m
id
wiv
es
as
k
ey
co
n
tr
i
b
u
to
r
s
to
m
ater
n
al
h
ea
lth
,
an
d
th
e
m
ater
n
ity
r
ef
e
r
r
al
s
y
s
tem
h
as
g
ar
n
er
ed
in
cr
e
ased
atten
tio
n
[
3
]
,
[
6
]
.
As
th
e
g
lo
b
al
co
m
m
u
n
ity
s
tr
iv
es
to
ac
h
iev
e
th
e
s
u
s
tain
a
b
le
d
ev
elo
p
m
en
t
g
o
als
(
SDGs
)
,
p
ar
ticu
lar
l
y
th
o
s
e
r
elate
d
to
m
ater
n
al
h
ea
lth
a
n
d
well
-
b
ein
g
,
u
n
d
er
s
tan
d
i
n
g
th
e
n
u
an
ce
s
of
th
e
m
ate
r
n
ity
r
e
f
er
r
al
s
y
s
tem
h
as
b
ec
o
m
e
im
p
er
ati
v
e.
C
h
a
l
l
e
n
g
e
s
s
u
c
h
as
v
a
r
i
a
ti
o
n
s
in
r
e
f
e
r
r
a
l
p
r
o
c
es
s
es
,
c
o
m
m
u
n
i
c
a
ti
o
n
g
a
p
s
,
a
n
d
d
i
s
p
a
r
i
t
i
es
in
r
e
s
o
u
r
c
e
al
l
o
ca
t
i
o
n
n
e
c
e
s
s
i
ta
t
e
a
t
h
o
r
o
u
g
h
e
x
a
m
i
n
a
t
i
o
n
of
t
h
e
e
x
i
s
ti
n
g
s
y
s
t
e
m
s
to
i
d
e
n
t
i
f
y
a
r
e
as
f
o
r
e
n
h
a
n
c
e
m
e
n
t
.
Ma
ter
n
al
m
o
r
tality
co
n
tin
u
es
to
be
a
m
ajo
r
is
s
u
e
in
C
en
tr
al
L
o
m
b
o
k
,
with
5
3
%
of
m
ater
n
al
d
ea
th
s
in
h
o
s
p
itals
in
v
o
lv
in
g
ca
s
es
r
ef
er
r
ed
v
ia
th
e
B
A
K
S
OK
UDA
r
ef
er
r
al
s
y
s
tem
[
7
]
.
T
h
is
co
n
ce
r
n
i
n
g
f
ig
u
r
e
p
o
in
ts
to
p
o
s
s
ib
le
s
h
o
r
tco
m
in
g
s
or
f
ailu
r
es
with
in
th
e
r
ef
er
r
al
p
r
o
ce
s
s
,
h
ig
h
lig
h
tin
g
co
n
ce
r
n
s
ab
o
u
t
s
y
s
tem
ic
p
r
o
b
lem
s
th
at
m
ay
h
in
d
e
r
th
e
p
r
o
m
p
t
a
n
d
ef
f
ec
tiv
e
m
a
n
ag
em
e
n
t
of
m
ater
n
al
h
ea
lth
em
er
g
en
cies.
T
h
e
B
A
K
S
OK
UDA
r
ef
er
r
al
s
y
s
tem
is
u
s
ed
to
e
n
s
u
r
e
th
at
wo
m
en
an
d
n
ew
b
o
r
n
s
r
ec
eiv
e
th
e
ca
r
e
t
h
ey
n
ee
d
d
u
r
i
n
g
m
a
n
y
r
eg
e
n
cies
in
I
n
d
o
n
esia,
in
clu
d
in
g
th
e
C
en
tr
al
L
o
m
b
o
k
R
eg
en
cy
.
T
h
e
s
y
s
tem
is
n
am
ed
af
ter
th
e
a
cr
o
n
y
m
f
o
r
b
id
a
n
(
m
id
wif
e)
,
a
la
t
(
eq
u
ip
m
e
n
t)
,
k
elu
a
r
g
a
(
f
am
ily
)
,
s
u
r
a
t
(
letter
)
,
obat
(
m
ed
icin
e
)
,
ke
n
d
a
r
a
a
n
(
v
eh
icle)
,
an
d
d
a
r
a
h
(
b
lo
o
d
)
.
T
h
e
B
A
K
S
OK
UDA
s
y
s
tem
is
an
im
p
o
r
tan
t
to
o
l
to
en
s
u
r
e
th
at
wo
m
en
a
n
d
n
ewb
o
r
n
s
r
ec
eiv
e
th
e
ca
r
e
th
ey
n
ee
d
,
ev
en
in
r
em
o
te
ar
ea
s
.
T
h
is
h
elp
s
en
s
u
r
e
th
at
p
atien
ts
ar
e
r
e
f
er
r
ed
to
th
e
r
ig
h
t
f
ac
il
ity
on
tim
e
an
d
th
at
th
ey
h
av
e
ac
ce
s
s
to
th
e
r
eso
u
r
ce
s
th
ey
n
ee
d
to
r
ec
eiv
e
th
e
b
e
s
t
p
o
s
s
ib
le
ca
r
e
[
8
]
.
P
r
e
v
i
o
u
s
s
t
u
d
i
e
s
h
a
v
e
e
m
p
h
a
s
i
z
e
d
t
h
a
t
an
e
f
f
e
c
t
i
v
e
r
e
f
e
r
r
a
l
s
y
s
te
m
is
c
r
u
c
i
al
f
o
r
r
e
d
u
c
i
n
g
m
a
t
e
r
n
a
l
m
o
r
b
i
d
i
t
y
a
n
d
m
o
r
t
a
l
i
t
y
by
e
n
s
u
r
i
n
g
t
i
m
e
l
y
a
c
c
e
s
s
to
h
i
g
h
e
r
-
l
ev
e
l
h
e
a
l
t
h
c
a
r
e
f
a
c
il
i
ti
e
s
.
T
y
p
i
c
al
l
y
,
r
e
f
e
r
r
a
l
s
y
s
t
e
m
s
o
p
e
r
a
t
e
a
c
r
o
s
s
m
u
lt
i
p
l
e
l
e
v
e
ls
of
c
a
r
e
,
r
a
n
g
i
n
g
f
r
o
m
p
r
i
m
a
r
y
h
ea
l
t
h
c
e
n
te
r
s
to
t
e
r
ti
a
r
y
h
o
s
p
it
a
ls
.
H
o
w
e
v
e
r
,
e
x
is
ti
n
g
r
e
s
e
a
r
c
h
h
a
s
p
r
i
m
a
r
i
l
y
i
d
e
n
ti
f
ie
d
g
e
n
e
r
a
l
c
h
a
l
l
e
n
g
e
s
a
n
d
b
a
r
r
i
e
r
s
w
it
h
i
n
m
a
t
e
r
n
a
l
r
e
f
e
r
r
a
l
s
y
s
t
e
m
s
,
s
u
c
h
as
poor
c
o
m
m
u
n
i
c
a
t
i
o
n
b
e
t
w
e
e
n
r
e
f
e
r
r
in
g
a
n
d
r
e
c
e
i
v
i
n
g
f
a
c
i
l
i
ti
e
s
,
i
n
a
d
e
q
u
a
t
e
t
r
a
n
s
p
o
r
t
at
i
o
n
,
a
n
d
i
n
s
u
f
f
i
c
i
e
n
t
p
r
e
-
r
e
f
e
r
r
a
l
s
t
a
b
il
i
z
at
i
o
n
.
A
d
d
i
ti
o
n
a
l
l
y
,
t
h
e
l
i
m
it
e
d
s
k
i
l
ls
a
n
d
c
a
p
ac
i
t
y
of
h
e
a
l
t
h
c
a
r
e
p
r
o
v
i
d
e
r
s
at
l
o
w
e
r
-
le
v
e
l
f
a
c
il
i
ti
e
s
h
a
v
e
b
e
e
n
f
o
u
n
d
to
r
e
s
u
l
t
in
u
n
n
e
c
es
s
a
r
y
r
e
f
e
r
r
al
s
.
D
e
s
p
i
t
e
t
h
es
e
f
in
d
i
n
g
s
,
m
o
s
t
s
t
u
d
i
es
h
a
v
e
not
e
x
p
l
o
r
e
d
how
t
h
e
s
e
c
h
a
l
l
e
n
g
e
s
m
a
n
i
f
es
t
wi
t
h
i
n
s
p
ec
i
f
i
c
c
u
lt
u
r
a
l
a
n
d
h
e
al
t
h
c
a
r
e
c
o
n
t
e
x
t
s
.
T
h
is
r
es
e
a
r
c
h
a
d
d
r
es
s
e
s
t
h
i
s
g
a
p
by
p
r
o
v
i
d
i
n
g
an
in
-
d
e
p
t
h
e
x
a
m
i
n
a
t
i
o
n
of
t
h
e
B
A
K
S
OK
UD
A
r
e
f
e
r
r
a
l
s
y
s
t
e
m
w
i
t
h
i
n
t
h
e
u
n
i
q
u
e
c
u
l
t
u
r
a
l
a
n
d
s
y
s
t
e
m
i
c
f
r
a
m
ew
o
r
k
of
C
e
n
t
r
a
l
L
o
m
b
o
k
,
I
n
d
o
n
e
s
i
a.
By
d
o
i
n
g
s
o
,
t
h
is
s
t
u
d
y
o
f
f
e
r
s
n
o
v
e
l
i
n
s
i
g
h
t
s
i
n
t
o
how
l
o
c
al
p
r
a
c
t
i
c
es
,
c
u
lt
u
r
al
b
e
l
i
e
f
s
,
a
n
d
h
e
a
l
t
h
c
a
r
e
i
n
f
r
a
s
t
r
u
c
t
u
r
e
i
m
p
a
c
t
t
h
e
r
e
f
e
r
r
a
l
p
r
o
c
ess
,
c
o
n
t
r
i
b
u
t
i
n
g
v
a
l
u
a
b
l
e
k
n
o
w
l
ed
g
e
to
t
h
e
f
i
e
l
d
a
n
d
h
i
g
h
l
i
g
h
t
i
n
g
t
h
e
i
m
p
o
r
t
a
n
c
e
of
c
o
n
t
e
x
t
-
s
p
e
c
i
f
i
c
s
o
l
u
t
i
o
n
s
f
o
r
im
p
r
o
v
i
n
g
m
a
t
e
r
n
a
l
h
e
a
l
t
h
o
u
t
co
m
e
s
.
By
i
d
e
n
t
i
f
y
i
n
g
t
h
e
b
e
s
t
p
r
a
ct
i
c
es
a
n
d
a
r
e
a
s
f
o
r
i
m
p
r
o
v
e
m
e
n
t
,
t
h
is
s
t
u
d
y
ai
m
s
to
p
r
o
v
i
d
e
i
n
s
i
g
h
t
s
t
h
a
t
can
i
n
f
o
r
m
p
o
l
i
c
y
d
e
ci
s
i
o
n
s
,
g
u
i
d
e
h
e
a
l
t
h
c
a
r
e
p
r
a
c
t
it
i
o
n
e
r
s
,
a
n
d
e
l
e
v
a
t
e
t
h
e
q
u
a
li
t
y
of
m
at
e
r
n
i
t
y
c
a
r
e
d
el
i
v
e
r
e
d
t
h
r
o
u
g
h
t
h
e
c
o
l
l
a
b
o
r
a
t
i
v
e
e
f
f
o
r
t
s
of
m
i
d
w
i
v
e
s
a
n
d
o
t
h
e
r
h
e
a
l
t
h
c
a
r
e
p
r
o
f
e
s
s
i
o
n
a
ls
.
In
d
o
i
n
g
s
o
,
we
hope
to
a
d
v
a
n
c
e
t
h
e
d
i
s
c
o
u
r
s
e
on
m
i
d
w
i
f
e
r
y
c
a
r
e
a
n
d
it
i
s
i
n
t
e
g
r
a
l
r
o
l
e
in
s
h
a
p
i
n
g
t
h
e
m
a
t
e
r
n
a
l
h
e
a
lt
h
l
a
n
d
s
c
a
p
e
.
2.
M
E
T
H
O
D
2
.
1
.
Resea
rc
h
des
ig
n
T
h
is
s
tu
d
y
em
p
lo
y
s
a
ca
s
e
s
tu
d
y
d
esig
n
to
ex
p
lo
r
e
th
e
B
A
K
S
OK
UDA
r
ef
er
r
al
s
y
s
tem
in
C
en
tr
al
L
o
m
b
o
k
,
I
n
d
o
n
esia.
T
h
e
ca
s
e
s
tu
d
y
ap
p
r
o
ac
h
allo
ws
f
o
r
an
in
-
d
ep
t
h
ex
am
in
atio
n
of
r
e
al
-
wo
r
ld
ch
allen
g
es
with
in
th
e
lo
ca
l
h
ea
lth
ca
r
e
an
d
cu
ltu
r
al
co
n
tex
t.
T
h
is
d
esig
n
alig
n
s
with
th
e
s
tu
d
y
’
s
aim
of
id
en
tify
in
g
s
p
ec
if
ic
b
ar
r
ier
s
an
d
g
ap
s
in
t
h
e
r
ef
er
r
al
p
r
o
ce
s
s
,
p
r
o
v
id
in
g
d
etailed
in
s
ig
h
ts
th
at
can
in
f
o
r
m
tar
g
et
ed
im
p
r
o
v
em
en
ts
in
m
ater
n
al
h
ea
lth
ca
r
e
o
u
tco
m
es.
2
.
2
.
P
a
rt
icipa
nts
T
h
e
s
t
u
d
y
i
n
v
o
l
v
e
d
e
l
e
v
e
n
p
a
r
t
i
c
i
p
a
n
t
s
w
h
o
d
i
r
e
c
t
l
y
e
n
g
a
g
e
d
in
t
h
e
m
a
t
e
r
n
i
t
y
r
e
f
e
r
r
a
l
s
y
s
t
e
m
in
t
h
e
d
i
s
t
r
i
c
t
of
C
e
n
t
r
a
l
L
o
m
b
o
k
.
T
h
e
p
a
r
t
i
c
i
p
a
n
t
s
i
n
c
l
u
d
e
d
m
i
d
w
i
v
e
s
r
e
s
p
o
n
s
i
b
l
e
f
o
r
r
e
f
e
r
r
i
n
g
m
o
t
h
e
r
s
f
r
o
m
p
u
b
l
i
c
h
e
a
l
t
h
c
e
n
t
e
r
s
to
h
o
s
p
i
t
a
l
s
,
r
e
f
e
r
r
a
l
r
e
c
e
i
v
e
i
n
g
m
i
d
w
i
v
e
s
,
d
o
c
t
o
r
s
,
n
u
r
s
e
s
,
a
n
d
h
o
s
p
i
t
a
l
m
a
n
a
g
e
r
w
h
o
o
v
e
r
s
a
w
m
a
t
e
r
n
i
t
y
s
e
r
v
i
c
e
s
.
T
h
e
s
e
l
e
c
t
i
o
n
of
p
a
r
t
i
c
i
p
a
n
t
s
was
a
i
m
e
d
at
c
a
p
t
u
r
i
n
g
d
i
v
e
r
s
e
p
e
r
s
p
e
c
t
i
v
e
s
w
i
t
h
i
n
t
h
e
r
e
f
e
r
r
a
l
s
y
s
t
e
m
.
T
h
e
n
u
m
b
e
r
of
p
a
r
t
i
c
i
p
a
n
t
s
(
s
a
m
p
l
e
s
i
z
e
)
in
t
h
e
s
t
u
d
y
w
a
s
d
e
t
e
r
m
i
n
e
d
b
a
s
e
d
on
t
h
e
p
r
i
n
c
i
p
l
e
of
d
a
t
a
s
a
t
u
r
a
t
i
o
n
[
9
]
.
D
a
t
a
c
o
l
l
e
c
t
i
o
n
t
e
r
m
i
n
a
t
e
d
o
n
c
e
no
n
e
w
i
n
f
o
r
m
a
t
i
o
n
or
c
a
t
e
g
o
r
i
e
s
w
e
r
e
i
d
e
n
t
i
f
i
e
d
f
r
o
m
t
h
e
i
n
t
e
r
v
i
e
w
s
.
In
t
o
t
a
l
,
11
p
a
r
t
i
c
i
p
a
n
t
s
w
e
r
e
i
n
t
e
r
v
i
e
w
e
d
f
o
r
t
h
i
s
r
e
s
e
a
r
c
h
.
T
h
e
p
a
r
t
i
c
i
p
a
n
t
s
p
r
o
f
i
l
e
is
d
e
p
i
c
t
e
d
in
T
a
b
l
e
1.
Evaluation Warning : The document was created with Spire.PDF for Python.
I
SS
N
:
2
2
5
2
-
8
8
0
6
I
n
t J Pu
b
lic
Hea
lth
Sci
,
Vo
l.
1
4
,
No
.
2
,
J
u
n
e
20
2
5
:
74
0
-
7
48
742
T
ab
le
1
.
T
h
e
p
ar
ticip
a
n
ts
p
r
o
f
i
le
P
a
r
t
i
c
i
p
a
n
t
s
N
u
mb
e
r
of
p
a
r
t
i
c
i
p
a
n
t
s
R
e
f
e
r
r
i
n
g
mi
d
w
i
v
e
s
4
R
e
c
e
i
v
i
n
g
m
i
d
w
i
v
e
s
2
D
o
c
t
o
r
s
2
N
u
r
ses
2
H
o
sp
i
t
a
l
ma
n
a
g
e
r
1
To
t
a
l
11
2
.
3
.
Da
t
a
c
o
llect
io
n
Data
wer
e
co
llected
th
r
o
u
g
h
s
e
m
i
-
s
tr
u
ctu
r
ed
i
n
ter
v
iews
co
n
d
u
cted
b
etwe
en
J
u
ly
an
d
Sep
te
m
b
er
2
0
2
3
.
T
h
e
in
ter
v
iews
wer
e
g
u
i
d
ed
by
an
o
p
e
n
-
en
d
ed
q
u
esti
o
n
n
air
e
th
at
allo
wed
p
ar
ticip
an
ts
to
f
r
ee
ly
e
x
p
r
ess
th
eir
v
iews
an
d
e
x
p
er
ien
ce
s
.
All
in
t
er
v
iews
wer
e
au
d
io
-
r
ec
o
r
d
e
d
a
n
d
tr
a
n
s
cr
ib
ed
with
th
e
co
n
s
en
t
of
th
e
p
ar
ticip
an
ts
to
en
s
u
r
e
ac
cu
r
ate
ca
p
tu
r
e
of
i
n
f
o
r
m
atio
n
.
2.
4
.
Da
t
a
a
na
ly
s
is
T
h
em
atic
an
aly
s
is
[
1
0
]
was
em
p
lo
y
ed
to
s
y
s
tem
atica
lly
an
aly
ze
th
e
in
ter
v
iew
d
ata.
T
h
e
p
r
o
ce
s
s
in
v
o
lv
ed
m
u
ltip
le
s
tag
es,
in
clu
d
in
g
f
am
iliar
izatio
n
with
th
e
d
ata,
g
en
er
atin
g
in
itial
co
d
es,
s
ea
r
ch
in
g
f
o
r
th
em
es,
r
ev
iewin
g
an
d
r
ef
in
in
g
th
em
e
s
,
an
d
d
ef
in
in
g
an
d
n
am
in
g
t
h
em
es.
T
h
e
an
aly
s
is
was
p
er
f
o
r
m
ed
iter
ativ
el
y
,
th
er
eb
y
e
n
ab
lin
g
t
h
e
id
en
tific
a
tio
n
of
p
atter
n
s
an
d
p
r
o
v
id
in
g
v
alu
ab
le
in
s
ig
h
ts
.
2.
5
.
Rig
o
r
a
nd
t
rus
t
wo
rt
hin
ess
We
e
n
s
u
r
e
d
t
h
e
v
a
l
i
d
i
t
y
of
t
h
e
r
e
s
e
a
r
c
h
by
e
m
p
l
o
y
i
n
g
s
e
v
e
r
a
l
s
t
r
a
t
e
g
i
e
s
t
h
a
t
a
l
i
g
n
w
i
t
h
q
u
a
l
i
t
a
t
i
v
e
r
e
s
e
a
r
c
h
r
i
g
o
r
.
We
f
o
c
u
s
e
d
on
c
r
e
d
i
b
i
l
i
t
y
,
d
e
p
e
n
d
a
b
i
l
i
t
y
,
c
o
n
f
i
r
m
a
b
i
l
i
t
y
,
a
n
d
t
r
a
n
s
f
e
r
a
b
i
l
i
t
y
.
T
r
i
a
n
g
u
l
a
t
i
o
n
was
a
c
h
i
e
v
e
d
by
i
n
c
l
u
d
i
n
g
a
d
i
v
e
r
s
e
r
a
n
g
e
of
p
a
r
t
i
c
i
p
a
n
t
s
i
n
v
o
l
v
e
d
in
t
h
e
m
a
t
e
r
n
a
l
r
e
f
e
r
r
a
l
s
y
s
t
e
m
,
s
u
c
h
as
m
i
d
w
i
v
e
s
,
d
o
c
t
o
r
s
,
n
u
r
s
e
s
,
a
n
d
h
o
s
p
i
t
a
l
m
a
n
a
g
e
r
s
.
T
h
i
s
a
p
p
r
o
a
c
h
a
l
l
o
w
e
d
f
o
r
c
a
p
t
u
r
i
n
g
m
u
l
t
i
p
l
e
p
e
r
s
p
e
c
t
i
v
e
s
a
n
d
e
n
h
a
n
c
i
n
g
t
h
e
c
r
e
d
i
b
i
l
i
t
y
of
t
h
e
f
i
n
d
i
n
g
s
.
D
e
p
e
n
d
a
b
i
l
i
t
y
was
m
a
i
n
t
a
i
n
e
d
by
d
o
c
u
m
e
n
t
i
n
g
t
h
e
e
n
t
i
r
e
r
e
s
e
a
r
c
h
p
r
o
c
e
s
s
a
n
d
d
e
c
i
s
i
o
n
t
r
a
i
l
,
w
h
i
c
h
a
l
l
o
w
e
d
o
t
h
e
r
r
e
s
e
a
r
c
h
e
r
s
to
f
o
l
l
o
w
t
h
e
s
t
e
p
s
t
a
k
e
n
.
F
u
r
t
h
e
r
m
o
r
e
,
m
e
m
b
e
r
c
h
e
c
k
i
n
g
w
a
s
u
s
e
d
to
v
a
l
i
d
a
t
e
t
h
e
d
a
t
a
,
e
n
s
u
r
i
n
g
t
h
a
t
p
a
r
t
i
c
i
p
a
n
t
s
c
o
n
f
i
r
m
e
d
t
h
e
a
c
c
u
r
a
c
y
of
t
h
e
c
o
l
l
e
c
t
e
d
i
n
f
o
r
m
a
t
i
o
n
a
n
d
i
n
t
e
r
p
r
e
t
e
d
r
e
s
u
l
t
s
.
2.
6
.
Ref
le
x
iv
it
y
T
h
e
r
esear
ch
er
s
ac
k
n
o
wled
g
e
d
th
eir
r
o
le
in
s
h
ap
in
g
th
e
r
ese
ar
ch
p
r
o
ce
s
s
an
d
th
ey
r
em
ain
e
d
r
ef
lex
iv
e
th
r
o
u
g
h
o
u
t
th
e
s
tu
d
y
.
R
ef
lex
i
v
ity
was
ess
en
tial
to
ac
k
n
o
wled
g
e
an
y
p
o
ten
tial
b
iases
an
d
en
s
u
r
e
a
tr
an
s
p
ar
en
t
an
d
eth
ical
r
esear
ch
p
r
ac
tice
.
T
h
is
r
ef
lex
iv
e
a
p
p
r
o
ac
h
in
v
o
lv
ed
c
o
n
tin
u
o
u
s
s
elf
-
ex
am
in
atio
n
an
d
c
r
itical
r
ef
lectio
n
o
n
th
eir
o
wn
ass
u
m
p
tio
n
s
,
p
r
ec
o
n
ce
p
tio
n
s
,
an
d
in
te
r
p
r
etatio
n
s
o
f
t
h
e
d
ata.
B
y
m
ain
tain
in
g
a
r
e
f
lex
iv
e
s
tan
ce
,
th
e
r
esear
ch
er
s
wer
e
ab
le
to
id
en
tify
an
d
ad
d
r
ess
an
y
p
er
s
o
n
al
o
r
p
r
o
f
ess
io
n
al
in
f
lu
en
ce
s
th
at
m
ig
h
t
h
av
e
af
f
ec
ted
th
eir
d
ata
co
ll
ec
tio
n
,
an
aly
s
is
,
o
r
in
ter
p
r
eta
tio
n
.
T
h
is
p
r
ac
tice
en
h
an
ce
d
th
e
cr
ed
ib
ilit
y
a
n
d
tr
u
s
two
r
th
in
ess
o
f
th
e
s
tu
d
y
.
2.
7
.
E
t
hica
l
c
lea
ra
nce
E
th
ical
ap
p
r
o
v
al
was
o
b
tain
ed
f
r
o
m
th
e
Un
iv
e
r
s
itas
Qa
m
ar
u
l
Hu
d
a
r
ev
iew
b
o
a
r
d
p
r
io
r
to
th
e
co
m
m
en
ce
m
e
n
t
of
t
h
e
s
tu
d
y
(
n
o
.
1
2
/EB/UNI
QHBA/0
1
/2
3
)
.
T
h
e
p
ar
ticip
an
ts
wer
e
p
r
o
v
id
ed
with
in
f
o
r
m
ed
co
n
s
en
t
f
o
r
m
s
d
etailin
g
th
e
p
u
r
p
o
s
e
of
th
e
s
tu
d
y
,
co
n
f
id
en
tia
lity
m
ea
s
u
r
es,
an
d
th
eir
r
ig
h
t
to
with
d
r
aw
at
an
y
s
tag
e.
C
o
n
f
id
en
tiality
was
s
tr
ictly
m
ain
tain
ed
,
a
n
d
p
s
eu
d
o
n
y
m
s
wer
e
u
s
ed
to
p
r
o
tect
p
ar
tic
ip
an
ts
’
id
en
titi
es.
3.
RE
SU
L
T
S
AND
D
I
SCU
SS
I
O
N
E
f
f
ec
tiv
e
f
u
n
ctio
n
in
g
of
th
e
m
ater
n
ity
r
e
f
er
r
al
s
y
s
tem
is
cr
u
cial
to
en
s
u
r
e
th
e
well
-
b
ein
g
of
m
o
th
er
s
d
u
r
in
g
ch
ild
b
ir
th
.
Desp
ite
th
e
g
o
v
er
n
m
en
t
’
s
ef
f
o
r
ts
to
d
ev
el
o
p
an
d
s
tr
ea
m
lin
e
th
e
r
ef
e
r
r
al
s
y
s
tem
,
its
p
r
ac
tical
ex
ec
u
tio
n
h
as
b
ee
n
r
id
d
le
d
with
ch
allen
g
es.
In
v
ar
io
u
s
d
is
tr
ict
-
lev
el
lo
ca
tio
n
s
,
in
clu
d
in
g
C
en
tr
al
L
o
m
b
o
k
,
th
e
m
ater
n
ity
r
ef
e
r
r
al
s
y
s
tem
h
as
b
ee
n
p
u
t
in
to
o
p
er
atio
n
th
r
o
u
g
h
a
m
e
ch
an
is
m
k
n
o
wn
as
“
B
A
K
S
OK
UDA
.
”
T
h
is
in
itiativ
e
was
estab
lis
h
ed
to
p
r
o
m
p
t
m
id
wiv
es
to
th
o
r
o
u
g
h
ly
ass
es
s
an
d
co
m
p
lete
all
th
e
n
e
ce
s
s
ar
y
p
r
o
ce
d
u
r
es
th
r
o
u
g
h
o
u
t
th
e
r
e
f
er
r
al
p
r
o
ce
s
s
.
T
h
e
ac
r
o
n
y
m
“
B
A
K
S
OK
UDA
”
ess
en
tially
s
er
v
es
as
b
o
th
a
ch
ec
k
lis
t
an
d
an
o
p
er
atio
n
al
f
r
am
ewo
r
k
g
u
id
i
n
g
m
ater
n
ity
s
er
v
ices
f
o
r
h
ea
lth
ca
r
e
p
r
o
f
ess
io
n
als.
Up
o
n
ex
am
in
i
n
g
th
e
im
p
lem
en
tatio
n
of
th
e
m
ater
n
ity
r
ef
er
r
al
s
y
s
tem
,
s
ev
er
al
is
s
u
es
h
av
e
em
er
g
e
d
,
h
ig
h
lig
h
tin
g
th
e
ch
allen
g
es
in
it
i
s
p
r
ac
tical
ap
p
licati
on.
3
.
1
.
Adherence
to
pro
t
o
co
ls
Mid
wiv
es
ar
e
r
eq
u
ir
ed
to
co
m
p
lete
a
p
ar
to
g
r
ap
h
,
but
s
o
m
e
do
not
ad
h
er
e
to
th
is
p
r
o
to
c
o
l.
I
n
s
tead
of
cr
ea
tin
g
th
e
p
a
r
to
g
r
a
p
h
d
u
r
in
g
th
e
r
ef
er
r
al
p
r
o
ce
s
s
,
th
ey
o
p
ted
to
co
m
p
lete
it
af
ter
t
h
e
b
a
b
y
was
b
o
r
n
.
So
m
e
ju
s
tify
th
is
by
claim
in
g
th
at
th
e
d
o
cto
r
i
n
s
tr
u
cted
th
em
to
r
ef
er
th
e
p
atien
t
p
r
o
m
p
tly
a
n
d
d
id
not
r
e
q
u
est
th
e
Evaluation Warning : The document was created with Spire.PDF for Python.
I
n
t J Pu
b
lic
Hea
lth
Sci
I
SS
N:
2252
-
8
8
0
6
A
n
a
n
a
lysi
s
o
f th
e
ma
tern
a
l h
e
a
lth
r
eferr
a
l sys
tem:
a
ca
s
e
s
tu
d
y
o
f …
(
S
a
s
tr
a
w
a
n
)
743
co
m
p
letio
n
of
a
p
ar
to
g
r
ap
h
at
th
at
m
o
m
en
t
as
s
tated
by
a
p
a
r
ticip
an
t
“
I
d
i
d
n
’
t
c
r
ea
te
a
p
a
r
t
o
g
r
ap
h
;
I
was
o
n
ly
in
s
tr
u
cted
to
r
ef
e
r
by
th
e
d
o
cto
r
.
We
u
s
u
ally
m
ak
e
t
h
e
p
ar
t
o
g
r
ap
h
af
ter
th
e
b
a
b
y
is
b
o
r
n
”
(
T
T
)
.
A
p
ar
t
o
g
r
ap
h
is
a
g
r
ap
h
ical
r
ec
o
r
d
of
th
e
p
r
o
g
r
ess
of
lab
o
r
u
s
ed
by
h
ea
lth
ca
r
e
p
r
o
f
ess
io
n
als,
p
a
r
ticu
lar
ly
m
id
wiv
es,
to
m
o
n
ito
r
th
e
well
-
b
ein
g
of
b
o
th
t
h
e
m
o
t
h
er
an
d
f
etu
s
d
u
r
in
g
ch
ild
b
ir
th
.
It
is
d
esig
n
ed
to
p
r
o
v
id
e
a
v
i
s
u
al
r
ep
r
esen
tatio
n
of
v
ar
io
u
s
p
ar
am
eter
s
o
v
e
r
tim
e,
aid
in
g
in
th
e
ea
r
ly
d
etec
tio
n
of
p
o
ten
tial
co
m
p
licatio
n
s
.
T
h
e
p
ar
to
g
r
a
p
h
s
er
v
es
as
a
r
ea
l
-
tim
e
r
ec
o
r
d
,
allo
win
g
h
ea
lth
ca
r
e
p
r
o
v
id
er
s
to
id
en
tif
y
d
ev
iatio
n
s
f
r
o
m
th
e
n
o
r
m
al
p
r
o
g
r
ess
io
n
of
lab
o
r
.
T
h
is
ea
r
ly
d
etec
tio
n
en
a
b
les
tim
ely
in
ter
v
e
n
tio
n
if
co
m
p
licatio
n
s
ar
is
e,
p
o
ten
tially
p
r
e
v
e
n
tin
g
m
ater
n
al
an
d
f
etal
h
ea
lth
is
s
u
es.
Hen
ce
,
co
m
p
letin
g
th
e
p
ar
to
g
r
ap
h
a
f
ter
t
h
e
b
ir
th
of
th
e
b
ab
y
is
less
u
s
e
f
u
l.
T
h
e
o
b
s
e
r
v
e
d
t
e
n
d
e
n
c
y
a
m
o
n
g
m
i
d
w
i
v
e
s
to
d
e
l
a
y
t
h
e
c
o
m
p
l
et
io
n
of
t
h
e
p
a
r
t
o
g
r
a
p
h
u
n
t
i
l
a
f
te
r
c
h
i
l
d
b
i
r
t
h
r
a
i
s
es
c
o
n
c
e
r
n
s
r
e
g
a
r
d
i
n
g
t
h
e
ef
f
e
c
t
i
v
e
n
e
s
s
of
t
h
is
c
r
u
c
i
a
l
t
o
o
l.
T
h
e
p
a
r
t
o
g
r
a
p
h
is
s
p
e
c
i
f
i
c
a
ll
y
d
e
s
i
g
n
e
d
as
a
r
e
al
-
t
i
m
e
r
e
c
o
r
d
to
p
r
o
v
i
d
e
a
g
r
a
p
h
i
c
a
l
r
e
p
r
e
s
e
n
t
at
i
o
n
of
l
a
b
o
r
p
r
o
g
r
e
s
s
,
e
n
a
b
l
i
n
g
h
e
a
lt
h
c
a
r
e
p
r
o
f
e
s
s
i
o
n
a
l
s
to
m
o
n
i
t
o
r
v
a
r
i
o
u
s
p
a
r
a
m
e
t
e
r
s
a
n
d
d
e
t
e
ct
d
e
v
i
a
t
i
o
n
s
f
r
o
m
n
o
r
m
a
l
p
r
o
g
r
e
s
s
i
o
n
.
T
h
i
s
t
o
o
l
p
l
a
y
s
a
c
r
it
i
ca
l
r
o
l
e
in
t
h
e
e
a
r
l
y
i
d
e
n
t
i
f
i
c
at
i
o
n
of
p
o
t
e
n
t
i
al
c
o
m
p
l
i
c
a
t
i
o
n
s
a
n
d
f
a
c
i
li
t
at
e
s
t
i
m
e
l
y
i
n
t
e
r
v
e
n
t
i
o
n
to
p
r
e
v
e
n
t
a
d
v
e
r
s
e
o
u
t
c
o
m
e
s
.
T
h
e
p
o
ten
tial
im
p
ac
t
of
n
o
n
ad
h
er
e
n
ce
to
r
ea
l
-
tim
e
r
ec
o
r
d
s
on
tim
ely
in
ter
v
en
tio
n
is
cr
u
cial.
Un
f
o
r
tu
n
atel
y
,
n
o
t
all
m
id
wi
v
e
s
ad
h
er
ed
to
th
e
p
r
o
t
o
co
ls
.
So
m
e
s
tu
d
ies
h
av
e
r
ep
o
r
te
d
poor
ad
h
e
r
en
ce
t
o
p
r
o
ce
d
u
r
es
[
1
1
]
,
[
1
2
]
.
In
th
e
co
n
tex
t
of
th
is
s
tu
d
y
,
if
th
e
p
ar
to
g
r
ap
h
is
co
m
p
leted
a
f
ter
th
e
b
a
b
y
is
b
o
r
n
,
h
ea
lth
ca
r
e
p
r
o
v
id
er
s
m
ay
m
is
s
cr
u
cial
in
d
icato
r
s
of
co
m
p
licatio
n
s
d
u
r
in
g
lab
o
r
.
T
h
is
d
elay
in
r
ec
o
g
n
izin
g
d
ev
iatio
n
s
f
r
o
m
n
o
r
m
al
p
r
o
g
r
ess
io
n
co
u
ld
lead
to
d
elay
ed
in
ter
v
en
tio
n
s
[
1
3
]
,
in
cr
ea
s
in
g
t
h
e
r
is
k
of
ad
v
er
s
e
m
ater
n
al
an
d
f
etal
o
u
tco
m
es
[
1
4
]
.
T
h
e
ju
s
tific
atio
n
p
r
o
v
id
ed
by
s
o
m
e
m
id
wiv
es,
citin
g
d
o
cto
r
in
s
tr
u
ctio
n
s
to
p
r
o
m
p
tly
r
ef
er
with
o
u
t
co
m
p
letin
g
t
h
e
p
a
r
to
g
r
a
p
h
,
u
n
d
er
s
co
r
es
t
h
e
n
ee
d
f
o
r
im
p
r
o
v
e
d
co
m
m
u
n
icatio
n
an
d
alig
n
m
en
t
b
etwe
en
h
ea
lth
ca
r
e
p
r
o
f
ess
io
n
als.
T
h
is
d
is
cr
ep
an
cy
in
p
r
o
to
co
l
a
d
h
e
r
en
ce
r
aises
q
u
esti
o
n
s
ab
o
u
t
th
e
ef
f
ec
tiv
en
ess
of
co
m
m
u
n
icatio
n
ch
an
n
els
with
in
h
ea
lth
ca
r
e
team
s
an
d
th
e
p
o
ten
tial
im
p
ac
t
on
tim
ely
in
te
r
v
en
tio
n
to
p
r
e
v
en
t
m
ater
n
al
an
d
f
etal
h
ea
lth
is
s
u
es.
T
h
e
d
e
v
iatio
n
f
r
o
m
estab
li
s
h
ed
p
r
o
t
o
co
ls
r
ef
lects
a
p
o
te
n
tial
b
r
ea
k
d
o
wn
in
co
m
m
u
n
icatio
n
or
a
lack
of
u
n
d
er
s
tan
d
in
g
am
o
n
g
h
ea
lth
ca
r
e
p
r
o
f
ess
io
n
als
r
eg
ar
d
in
g
th
e
im
p
o
r
tan
ce
of
r
ea
l
-
tim
e
ad
h
er
e
n
ce
to
s
p
ec
if
i
c
p
r
o
ce
d
u
r
es
[
1
5
]
.
J
u
s
t
as
th
e
m
id
wiv
es
in
th
e
s
tu
d
y
ju
s
tifie
d
th
eir
ac
tio
n
s
b
ased
on
d
o
cto
r
in
s
tr
u
ctio
n
s
,
h
ea
lth
ca
r
e
p
r
o
v
id
er
s
in
o
t
h
er
s
ettin
g
s
m
ay
r
atio
n
alize
d
ev
iatio
n
s
f
r
o
m
estab
lis
h
ed
p
r
o
to
co
ls
d
u
e
to
tim
e
c
o
n
s
tr
ain
ts
or
p
er
ce
iv
e
d
u
r
g
en
c
y
.
3
.
2
.
H
u
m
a
n
er
ro
rs
An
o
th
er
co
n
ce
r
n
a
r
is
es
f
r
o
m
h
u
m
an
e
r
r
o
r
s
.
C
er
tain
m
id
wiv
es
m
en
tio
n
ed
th
at,
in
t
h
e
r
u
s
h
an
d
h
ec
tic
n
atu
r
e
of
th
ei
r
wo
r
k
,
t
h
ey
o
cc
asio
n
ally
f
o
r
g
o
t
to
ad
m
in
is
ter
d
u
al
-
lin
e
in
f
u
s
io
n
.
Alth
o
u
g
h
t
h
ese
o
cc
u
r
r
en
ce
s
do
not
o
cc
u
r
o
f
ten
,
th
e
y
s
till
war
r
an
t
atten
tio
n
,
esp
ec
ially
co
n
s
id
er
in
g
th
e
s
ev
er
e
im
p
licatio
n
s
th
at
co
u
ld
ar
is
e
if
th
is
p
r
o
ce
s
s
is
n
o
t
p
r
o
p
e
r
ly
atten
d
ed
t
o
,
in
cl
u
d
in
g
th
e
p
o
ten
tial
f
o
r
f
atal
co
n
s
eq
u
en
c
es.
On
e
in
f
o
r
m
a
n
t
ex
p
r
ess
ed
,
“
...
th
er
e
was
so
m
u
ch
b
lo
o
d
ev
er
y
wh
e
r
e.
I
was
s
o
m
ewh
at
p
an
ick
ed
an
d
ea
g
er
to
tr
an
s
p
o
r
t
th
e
p
atien
t
to
th
e
h
o
s
p
ital
q
u
ick
ly
,
ca
u
s
in
g
me
to
f
o
r
g
et
to
s
et
up
a
d
u
al
-
lin
e
in
f
u
s
io
n
.
.
.
”
(
S).
A
f
ew
m
id
wiv
es
lack
ed
c
o
n
f
id
en
ce
in
a
d
h
er
i
n
g
to
s
tan
d
ar
d
p
r
o
ce
d
u
r
es,
p
ar
ticu
lar
l
y
wh
en
th
e
p
r
o
ce
d
u
r
e
in
v
o
lv
ed
th
e
ad
m
in
i
s
tr
atio
n
of
m
ed
icatio
n
s
,
s
u
ch
as
Mg
SO4
.
T
h
is
h
esit
atio
n
s
tem
m
ed
f
r
o
m
c
o
n
ce
r
n
s
ab
o
u
t
th
e
elev
ated
b
o
d
y
tem
p
e
r
atu
r
e
of
p
atien
ts
,
wh
ich
o
f
ten
b
ec
am
e
a
s
o
u
r
ce
of
co
m
p
lain
ts
d
u
r
in
g
th
e
r
ef
er
r
al
p
r
o
ce
s
s
.
T
h
is
is
r
ef
lecte
d
in
th
i
s
s
tatem
en
t:
“
I
am
af
r
aid
to
ad
m
in
is
ter
Mg
SO4
b
ec
au
s
e
of
th
e
p
o
ten
tial
r
ea
ctio
n
s
it
m
ay
ca
u
s
e,
as
m
an
y
p
atien
ts
co
m
p
lain
of
f
ee
lin
g
h
o
t
af
ter
r
ec
eiv
in
g
Mg
SO4
.
.
.
”
(
T
B
)
.
C
o
n
f
r
o
n
te
d
f
r
eq
u
en
tly
with
co
m
p
lain
ts
f
r
o
m
p
atien
ts
an
d
th
eir
f
am
ilies
r
eg
ar
d
in
g
h
ig
h
f
ev
e
r
,
m
id
wiv
es
ten
d
to
av
o
id
ad
m
i
n
is
ter
in
g
th
e
n
ec
ess
ar
y
m
ed
icatio
n
,
ev
en
if
it
m
ea
n
s
d
ev
iatin
g
f
r
o
m
th
e
p
r
escr
ib
ed
p
r
o
ce
d
u
r
e.
T
h
e
r
elu
ctan
ce
to
ad
m
in
is
ter
Mg
SO4
was
s
o
lely
b
ased
on
th
e
m
id
wif
e
’
s
ex
p
er
ien
ce
an
d
not
f
o
r
m
ed
ical
r
ea
s
o
n
s
.
It
ap
p
ea
r
s
th
at
h
er
e
th
e
m
id
wif
e
(
h
ea
lth
ca
r
e
p
r
o
v
id
er
)
d
o
es
not
co
m
p
r
eh
en
d
th
e
r
ea
s
o
n
wh
y
th
e
p
atien
t,
wh
en
r
ef
er
r
ed
,
s
h
o
u
ld
be
g
iv
en
m
ed
icatio
n
,
in
th
is
ca
s
e,
Mg
SO4
.
I
n
s
t
a
n
c
es
of
m
i
d
w
i
v
es
f
o
r
g
e
t
t
i
n
g
to
a
d
m
i
n
i
s
t
e
r
a
d
u
a
l
-
l
i
n
e
i
n
f
u
s
i
o
n
,
e
v
e
n
if
i
n
f
r
e
q
u
e
n
t
,
p
o
s
e
a
s
i
g
n
i
f
i
c
a
n
t
r
i
s
k
to
m
a
t
e
r
n
al
h
e
a
l
t
h
,
as
e
x
em
p
l
i
f
i
e
d
by
t
h
e
i
n
f
o
r
m
a
n
t
’
s
a
cc
o
u
n
t
of
a
s
i
t
u
a
ti
o
n
in
w
h
i
c
h
th
i
s
c
r
i
ti
c
a
l
p
r
o
c
e
d
u
r
e
was
o
v
e
r
l
o
o
k
e
d
in
a
p
a
n
i
c
-
i
n
d
u
c
e
d
r
u
s
h
.
T
h
e
s
e
h
u
m
a
n
e
r
r
o
r
s
,
o
c
c
u
r
r
i
n
g
a
m
i
d
s
t
c
h
a
o
t
ic
w
o
r
k
c
o
n
d
i
t
i
o
n
s
,
e
m
p
h
a
s
i
z
e
t
h
e
n
ee
d
f
o
r
a
d
d
i
t
i
o
n
a
l
t
r
a
i
n
i
n
g
,
s
u
p
p
o
r
t
s
y
s
t
e
m
s
,
a
n
d
i
n
t
e
r
v
e
n
t
i
o
n
s
to
e
n
h
a
n
c
e
m
i
d
w
i
v
e
s
’
a
b
i
l
it
y
to
e
f
f
e
c
t
i
v
e
l
y
m
a
n
a
g
e
h
i
g
h
-
s
t
r
e
s
s
s
i
t
u
a
ti
o
n
s
.
As
t
h
e
r
e
is
a
p
o
t
en
t
i
a
l
f
a
t
al
i
t
y
r
es
u
l
t
i
n
g
f
r
o
m
s
u
c
h
o
v
e
r
s
i
g
h
t
s
[
1
6
]
u
n
d
e
r
s
c
o
r
e
s
t
h
e
u
r
g
e
n
c
y
of
a
d
d
r
e
s
s
i
n
g
t
h
es
e
i
s
s
u
e
s
to
e
n
s
u
r
e
t
h
e
s
a
f
e
t
y
of
b
o
t
h
m
o
t
h
e
r
s
a
n
d
i
n
f
a
n
t
s
d
u
r
i
n
g
c
h
i
l
d
b
i
r
t
h
r
e
f
e
r
r
a
l
s
.
T
h
e
p
o
t
e
n
t
ia
l
f
a
t
a
l
it
y
r
e
s
u
l
t
i
n
g
f
r
o
m
o
v
e
r
s
i
g
h
t
s
in
a
d
m
i
n
i
s
t
e
r
i
n
g
c
r
i
t
i
c
al
p
r
o
c
e
d
u
r
e
s
[
1
7
]
,
s
u
c
h
as
d
u
a
l
-
li
n
e
i
n
f
u
s
i
o
n
,
u
n
d
e
r
s
c
o
r
e
s
t
h
e
u
r
g
e
n
c
y
of
a
d
d
r
e
s
s
i
n
g
t
h
e
s
e
is
s
u
e
s
.
In
t
h
e
c
o
n
t
e
x
t
of
c
h
i
l
d
b
i
r
t
h
r
e
f
e
r
r
a
ls
,
d
e
l
a
y
s
or
e
r
r
o
r
s
in
ess
e
n
t
i
al
i
n
te
r
v
e
n
t
i
o
n
s
can
h
a
v
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s
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v
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r
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c
o
n
s
e
q
u
e
n
c
e
s
f
o
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b
o
t
h
m
o
t
h
e
r
s
a
n
d
i
n
f
a
n
t
s
.
To
m
i
t
i
g
a
t
e
t
h
e
r
i
s
k
s
a
s
s
o
c
i
at
ed
w
i
t
h
h
u
m
a
n
e
r
r
o
r
s
in
h
e
a
l
t
h
c
a
r
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s
e
tt
i
n
g
s
,
c
o
m
m
it
m
e
n
t
to
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o
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r
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v
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m
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t
is
p
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r
a
m
o
u
n
t
[
1
8
]
.
R
e
g
u
l
a
r
r
e
v
i
ew
s
of
c
r
i
tic
a
l
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n
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t
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r
o
o
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c
a
u
s
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a
n
a
ly
s
e
s
,
a
n
d
p
r
o
a
c
t
i
v
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a
p
p
r
o
a
c
h
e
s
to
a
d
d
r
e
s
s
i
n
g
v
u
ln
e
r
a
b
i
l
i
ti
e
s
can
c
o
n
t
r
i
b
u
t
e
to
a
c
u
l
t
u
r
e
of
p
a
ti
e
n
t
s
a
f
e
t
y
[
1
7
]
,
[
1
8
]
.
H
e
a
l
t
h
c
a
r
e
i
n
s
t
it
u
t
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o
n
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r
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n
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e
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ts
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f
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v
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r
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e
n
t
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w
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h
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ca
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a
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in
t
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.
Evaluation Warning : The document was created with Spire.PDF for Python.
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3
.
3
.
F
a
m
ily
co
ns
ent
cha
lleng
es
a
nd
cult
ura
l
no
rm
s
Mid
wiv
es
p
r
o
m
p
tly
in
itiated
th
e
p
atien
t
’
s
r
ef
er
r
al
u
p
o
n
r
e
ce
iv
in
g
ap
p
r
o
v
al
f
r
o
m
th
e
f
a
m
ily
,
more
s
p
ec
if
ically
f
r
o
m
th
e
h
u
s
b
an
d
.
C
h
allen
g
es
ar
is
e
wh
en
s
ee
k
in
g
f
am
ily
co
n
s
en
t
b
ec
a
u
s
e
of
th
e
h
u
s
b
an
d
’
s
ab
s
en
ce
.
In
s
u
ch
s
itu
atio
n
s
,
th
e
m
id
w
if
e
ty
p
ically
o
b
tain
ed
co
n
s
en
t
f
r
o
m
an
y
f
am
ily
m
em
b
e
r
wh
o
was
cu
r
r
en
tly
ac
ce
s
s
ib
le
f
o
r
th
e
r
ef
er
r
al
p
r
o
ce
s
s
.
Nev
er
th
eless
,
g
iv
en
t
h
e
cu
ltu
r
al
n
o
r
m
s
in
wh
ich
th
e
h
u
s
b
an
d
is
ty
p
ically
co
n
s
id
er
ed
th
e
m
o
s
t
r
esp
o
n
s
ib
le
in
d
iv
id
u
al
in
s
u
ch
s
itu
atio
n
s
,
o
th
er
f
am
ily
m
em
b
e
r
s
m
ay
h
esit
ate
to
m
ak
e
d
ec
is
io
n
s
,
lead
in
g
to
d
elay
s
in
th
e
r
ef
er
r
al
p
r
o
ce
s
s
.
T
h
ese
o
b
s
er
v
atio
n
s
ar
e
co
n
s
is
ten
t
with
th
e
f
in
d
in
g
s
o
b
tain
e
d
f
r
o
m
th
e
in
te
r
v
iews:
“
.
.
.
So
m
e
tim
es
it
’
s
d
if
f
icu
lt
f
o
r
us
to
in
f
o
r
m
th
e
h
u
s
b
an
d
a
n
d
f
am
ily
t
h
at
th
e
p
atien
t
n
ee
d
s
to
be
r
ef
e
r
r
ed
b
ec
a
u
s
e
th
e
h
u
s
b
an
d
is
f
ar
away
or
ab
r
o
ad
.
So
,
we
in
f
o
r
m
wh
o
ev
er
is
with
th
e
p
atien
t
at
th
at
tim
e
to
ag
r
ee
to
th
e
r
ef
er
r
al.
.
.
”
(
P)
.
In
ce
r
tain
s
ce
n
ar
io
s
,
m
i
d
wiv
es
f
r
eq
u
en
tly
en
co
u
n
ter
c
h
alle
n
g
es
in
co
n
v
in
cin
g
f
am
ily
m
em
b
er
s
,
in
clu
d
in
g
h
u
s
b
an
d
s
,
to
r
ec
o
m
m
e
n
d
tr
an
s
f
e
r
r
in
g
p
atien
ts
to
h
o
s
p
itals
.
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m
e
f
am
ilies
s
tr
o
n
g
ly
ad
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er
e
to
tr
a
d
itio
n
al
p
r
ac
tices
an
d
h
o
ld
o
n
to
th
e
m
y
th
s
s
u
r
r
o
u
n
d
in
g
ch
ild
b
ir
th
.
T
h
er
e
is
a
p
r
ev
ailin
g
b
elief
th
at
ch
allen
g
es
in
ch
ild
b
ir
th
ca
n
be
ad
d
r
ess
ed
th
r
o
u
g
h
tr
a
d
itio
n
al
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eth
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d
s
,
lead
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s
o
m
e
to
p
r
ef
er
th
is
ap
p
r
o
ac
h
b
ef
o
r
e
f
u
r
th
e
r
s
cien
tific
tr
ea
tm
en
t.
T
h
e
r
e
l
i
a
n
c
e
on
t
h
e
f
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m
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l
y
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p
e
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s
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o
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p
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l
in
i
n
i
t
ia
t
i
n
g
r
e
f
e
r
r
a
ls
p
o
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h
e
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t
h
e
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s
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a
n
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t
.
In
s
u
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a
s
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m
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i
b
l
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f
a
m
il
y
m
e
m
b
e
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s
,
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d
e
l
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y
s
m
a
y
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c
c
u
r
due
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h
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l
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p
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.
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r
a
l
s
e
n
s
i
t
i
v
it
y
in
h
e
a
l
t
h
c
a
r
e
p
r
a
c
t
i
ce
s
[
1
9
]
a
n
d
p
o
t
e
n
t
i
a
l
s
t
r
a
t
e
g
ie
s
to
s
t
r
ea
m
l
i
ne
t
h
e
c
o
n
s
e
n
t
p
r
o
c
e
s
s
in
c
a
s
es
w
h
e
r
e
i
m
m
e
d
i
a
t
e
f
a
m
il
y
m
e
m
b
e
r
s
m
a
y
be
u
n
a
v
a
i
l
a
b
le
.
T
h
e
c
h
a
l
le
n
g
e
of
c
o
n
v
i
n
c
i
n
g
f
a
m
i
l
i
es
,
es
p
e
c
ia
l
l
y
t
h
o
s
e
a
d
h
e
r
i
n
g
to
t
r
a
d
i
ti
o
n
a
l
p
r
a
c
t
i
c
es
,
f
u
r
t
h
e
r
h
i
g
h
li
g
h
t
s
t
h
e
im
p
o
r
t
a
n
c
e
of
e
d
u
c
a
t
i
o
n
a
n
d
aw
a
r
e
n
e
s
s
c
a
m
p
ai
g
n
s
to
b
r
i
d
g
e
t
h
e
g
a
p
b
e
t
w
e
e
n
t
r
a
d
it
i
o
n
a
l
b
e
l
ie
f
s
a
n
d
m
o
d
e
r
n
h
e
a
l
th
c
a
r
e
p
r
a
c
t
i
c
es
.
C
u
ltu
r
al
s
en
s
itiv
ity
in
h
ea
lth
ca
r
e
p
r
ac
tices
is
cr
u
cial
f
o
r
en
s
u
r
in
g
eq
u
itab
le
an
d
p
atien
t
-
ce
n
ter
ed
ca
r
e
[
2
0
]
.
In
th
e
co
n
tex
t
of
ch
ild
b
ir
th
r
ef
e
r
r
als,
h
ea
lth
ca
r
e
p
r
o
v
id
er
s
s
h
o
u
ld
be
attu
n
e
d
to
cu
ltu
r
al
n
o
r
m
s
th
at
in
f
lu
en
ce
th
e
d
ec
is
io
n
-
m
ak
in
g
p
r
o
ce
s
s
es
with
in
f
am
ilies
[
2
1
]
.
T
r
ain
in
g
p
r
o
g
r
am
s
f
o
r
h
ea
lt
h
ca
r
e
p
r
o
f
ess
io
n
als
can
in
clu
d
e
m
o
d
u
les
on
c
u
ltu
r
al
co
m
p
eten
ce
,
e
m
p
h
asizin
g
th
e
im
p
o
r
tan
ce
of
u
n
d
er
s
tan
d
in
g
an
d
r
esp
ec
tin
g
d
iv
er
s
e
cu
ltu
r
al
p
e
r
s
p
ec
tiv
es
3
.
4
.
Adm
ini
s
t
ra
t
iv
e
o
v
er
s
ig
hts a
nd
equi
pm
ent
prepa
re
d
nes
s
C
h
a
o
t
i
c
c
i
r
c
u
m
s
t
a
n
c
es
not
o
n
ly
l
e
a
d
m
i
d
wi
v
e
s
to
o
v
e
r
l
o
o
k
ce
r
t
a
i
n
a
d
m
i
n
is
t
r
at
i
v
e
p
r
o
c
e
d
u
r
e
s
but
al
s
o
d
i
s
t
r
a
ct
t
h
e
m
,
c
a
u
s
i
n
g
t
h
e
m
to
f
o
r
g
e
t
t
h
e
p
a
r
t
u
s
s
e
t
.
D
u
e
to
t
h
e
ill
-
e
q
u
i
p
p
e
d
n
at
u
r
e
of
a
m
b
u
la
n
c
e
s
,
m
i
d
w
i
v
es
a
r
e
e
x
p
e
c
t
e
d
to
p
r
o
v
i
d
e
s
p
e
c
i
f
i
c
m
e
d
i
c
a
l
e
q
u
i
p
m
e
n
t
d
u
r
i
n
g
t
h
e
r
e
f
e
r
r
a
l
p
r
o
c
e
s
s
.
A
l
t
h
o
u
g
h
m
o
s
t
m
i
d
w
i
v
e
s
u
n
d
e
r
s
t
o
o
d
t
h
e
s
i
g
n
i
f
i
c
a
n
c
e
of
t
h
is
p
r
o
c
ed
u
r
e
,
s
o
m
e
d
i
d
not
g
i
v
e
it
th
e
a
t
t
e
n
t
i
o
n
it
n
e
e
d
e
d
.
T
h
e
y
u
n
d
e
r
e
s
t
i
m
a
te
d
t
h
e
s
i
g
n
i
f
i
c
a
n
ce
,
b
e
l
i
e
v
i
n
g
t
h
a
t
t
h
e
t
r
a
n
s
p
o
r
t
a
ti
o
n
of
t
h
e
p
a
t
i
e
n
t
to
t
h
e
h
o
s
p
i
t
al
w
o
u
l
d
be
a
q
u
i
c
k
p
r
o
c
e
s
s
a
n
d
n
o
t
h
i
n
g
u
n
t
o
w
a
r
d
w
o
u
l
d
o
c
c
u
r
.
T
h
i
s
s
en
t
i
m
e
n
t
is
r
e
f
l
e
ct
e
d
in
s
t
a
t
e
m
e
n
t
s
s
u
c
h
as
:
”
...
I
d
i
d
n
’
t
b
r
i
n
g
t
h
e
p
a
r
t
u
s
s
e
t;
I
p
r
o
m
p
t
l
y
r
e
f
e
r
r
e
d
t
h
e
p
a
ti
e
n
t
w
h
e
n
s
h
e
was
r
ea
d
y
.
.
.
I
t
h
o
u
g
h
t
t
h
e
m
o
s
t
c
r
u
c
i
a
l
t
h
i
n
g
w
as
r
ea
c
h
i
n
g
t
h
e
h
o
s
p
i
t
al
as
s
o
o
n
as
p
o
s
s
i
b
le
.
I
w
as
n
’
t
o
v
e
r
l
y
c
o
n
c
er
n
e
d
a
b
o
u
t
c
a
r
r
y
i
n
g
a
l
l
t
h
e
n
e
ce
s
s
a
r
y
e
q
u
i
p
m
e
n
t
w
it
h
m
e
.
.
.
”
(
S
S
)
.
R
eg
ar
d
in
g
t
h
e
p
r
ep
ar
atio
n
of
d
o
cu
m
e
n
ts
f
o
r
r
ef
e
r
r
als,
s
o
m
e
m
id
wiv
es
s
till
r
ef
er
r
ed
p
atien
ts
with
o
u
t
th
e
r
eq
u
i
r
ed
p
ap
er
wo
r
k
,
e
x
p
r
ess
in
g
co
n
ce
r
n
s
ab
o
u
t
d
ela
y
ed
r
e
f
er
r
als
an
d
th
e
r
is
k
of
s
ev
er
e
b
lee
d
in
g
.
Ad
d
itio
n
ally
,
s
o
m
e
m
id
wiv
es
n
eg
lecte
d
to
g
en
e
r
ate
a
p
ar
to
g
r
ap
h
,
p
r
esu
m
in
g
th
at
th
e
p
r
ec
ed
in
g
s
h
if
t
’
s
m
id
wif
e
h
ad
alr
ea
d
y
done
s
o
.
T
h
is
lap
s
e
is
attr
ib
u
ted
to
th
e
lack
of
a
f
o
r
m
al
p
atien
t
h
a
n
d
o
v
er
p
r
o
ce
s
s
d
u
r
in
g
th
e
s
h
if
t
ch
an
g
es.
T
h
e
m
id
wif
e
s
u
g
g
ests
th
at
th
e
s
taf
f
on
th
e
p
r
io
r
s
h
if
t
s
h
o
u
ld
id
ea
lly
co
m
p
lete
th
e
p
ar
to
g
r
ap
h
,
allo
win
g
p
er
s
o
n
n
el
on
th
e
s
u
b
s
eq
u
en
t
s
h
if
t
to
p
r
o
m
p
tly
p
r
o
ce
ed
wit
h
th
e
r
ef
e
r
r
al.
T
h
ese
o
b
s
er
v
at
io
n
s
alig
n
with
th
e
in
s
ig
h
ts
g
ath
er
ed
d
u
r
in
g
th
e
f
o
llo
win
g
in
ter
v
iew:
“
…
I
was
on
th
e
ev
e
n
in
g
s
h
if
t.
T
h
e
m
id
wif
e
wh
o
k
n
o
ws
t
h
e
ch
r
o
n
o
lo
g
y
of
th
is
p
atien
t
is
th
e
m
o
r
n
in
g
s
h
if
t
m
id
wif
e.
I
was
in
s
tr
u
cted
o
n
ly
to
m
ak
e
a
r
ef
er
r
al.
T
h
e
r
e
was
no
p
ar
to
g
r
a
p
h
;
p
e
r
h
ap
s
it
h
a
d
not
b
ee
n
p
r
e
p
ar
ed
by
t
h
e
m
id
wif
e
on
m
o
r
n
in
g
d
u
ty
”
(
B
)
.
An
o
th
er
a
d
m
in
is
tr
ativ
e
m
atter
p
er
tain
s
to
d
o
cu
m
e
n
ts
r
eq
u
ir
e
d
f
o
r
h
ea
lth
in
s
u
r
an
ce
claim
s
(
ja
m
p
er
s
al)
.
W
h
ile
less
f
r
eq
u
en
t,
th
er
e
a
r
e
in
s
tan
ce
s
wh
er
e
f
am
ilies
lack
ess
en
tial
d
o
cu
m
en
ts
,
s
u
ch
as
f
am
ily
ca
r
d
s
,
wh
ich
ar
e
co
m
m
o
n
ly
h
eld
d
o
cu
m
e
n
t
s
.
T
h
is
d
o
cu
m
e
n
t
en
a
b
les
in
d
i
v
id
u
als
to
be
co
v
e
r
ed
by
p
u
b
l
ic
h
ea
lth
in
s
u
r
a
n
ce
(
jam
p
er
s
al)
.
Ho
we
v
er
,
s
o
m
e
in
d
iv
id
u
als
ten
d
to
o
v
er
lo
o
k
th
e
i
m
p
o
r
tan
ce
of
th
ese
d
o
cu
m
en
ts
,
r
esu
ltin
g
in
is
s
u
es
wh
en
th
ey
n
ee
d
to
be
r
ef
er
r
e
d
to
th
e
h
o
s
p
ital.
T
h
is
is
r
ef
le
cted
in
th
is
s
tatem
en
t:
“
T
h
e
p
atien
t
wan
ts
to
u
s
e
J
am
p
er
s
al
but
d
o
es
n
’
t
h
av
e
a
Fam
ily
C
ar
d
,
ma
’
am
.
I
’
ve
alr
e
ad
y
in
s
tr
u
cted
h
er
to
o
b
tain
a
Fam
ily
C
ar
d
d
u
r
in
g
p
r
eg
n
a
n
cy
,
but
s
h
e
d
i
d
n
’
t
p
a
y
atten
tio
n
“
(
M)
.
T
h
is
s
tu
d
y
s
h
ed
s
lig
h
t
on
th
e
c
h
allen
g
es
m
id
wiv
es
f
ac
e
in
e
n
s
u
r
in
g
th
e
co
m
p
leten
ess
of
th
e
n
ec
ess
ar
y
p
ap
er
wo
r
k
d
u
r
in
g
r
e
f
er
r
als.
T
h
e
lack
of
a
f
o
r
m
al
p
atien
t
h
a
n
d
o
v
e
r
p
r
o
ce
s
s
d
u
r
in
g
s
h
if
t
ch
an
g
es
co
n
t
r
ib
u
tes
to
lap
s
es
in
d
o
cu
m
en
t
p
r
ep
a
r
atio
n
,
as
ex
em
p
lifie
d
by
m
id
wi
v
es,
ass
u
m
in
g
th
at
th
e
p
r
ec
ed
in
g
s
h
if
t
’
s
s
taf
f
h
ad
co
m
p
leted
th
e
p
ar
to
g
r
ap
h
.
T
h
i
s
ca
lls
f
o
r
s
y
s
tem
atic
im
p
r
o
v
e
m
en
ts
in
h
an
d
o
v
e
r
p
r
o
ce
d
u
r
es
an
d
r
ei
n
f
o
r
ce
s
th
e
im
p
o
r
tan
ce
of
en
s
u
r
in
g
th
at
all
th
e
r
eq
u
i
r
ed
d
o
cu
m
e
n
ts
ar
e
p
r
ep
ar
ed
b
e
f
o
r
e
i
n
itiatin
g
r
ef
er
r
a
ls
.
T
h
e
ch
a
o
tic
cir
cu
m
s
tan
ce
s
s
u
r
r
o
u
n
d
in
g
ch
ild
b
ir
th
r
ef
er
r
als
not
o
n
ly
lead
to
h
u
m
an
er
r
o
r
s
but
also
co
n
tr
ib
u
te
to
m
id
wiv
es
o
v
er
lo
o
k
in
g
ad
m
in
is
tr
ativ
e
p
r
o
ce
d
u
r
es
[
2
2
]
an
d
n
eg
lectin
g
to
b
r
in
g
ess
en
tial
m
ed
ical
Evaluation Warning : The document was created with Spire.PDF for Python.
I
n
t J Pu
b
lic
Hea
lth
Sci
I
SS
N:
2252
-
8
8
0
6
A
n
a
n
a
lysi
s
o
f th
e
ma
tern
a
l h
e
a
lth
r
eferr
a
l sys
tem:
a
ca
s
e
s
tu
d
y
o
f …
(
S
a
s
tr
a
w
a
n
)
745
eq
u
ip
m
en
t.
T
h
e
s
en
tim
en
t
e
x
p
r
ess
ed
by
s
o
m
e
m
id
wiv
es,
p
r
io
r
itizin
g
q
u
ick
h
o
s
p
ital
t
r
an
s
p
o
r
tatio
n
o
v
e
r
co
m
p
r
eh
e
n
s
iv
e
p
r
ep
a
r
atio
n
,
r
ev
ea
ls
a
p
er
ce
p
tio
n
g
ap
r
eg
ar
d
in
g
th
e
im
p
o
r
tan
ce
of
f
o
l
lo
win
g
estab
lis
h
ed
p
r
o
ce
d
u
r
es.
T
h
is
u
n
d
er
s
co
r
es
t
h
e
n
ee
d
f
o
r
ed
u
ca
tio
n
an
d
awa
r
en
ess
ca
m
p
aig
n
s
to
em
p
h
asiz
e
th
e
cr
itical
r
o
le
of
ad
h
er
en
ce
to
p
r
o
to
co
ls
an
d
th
e
im
p
o
r
tan
ce
of
ca
r
r
y
in
g
th
e
n
e
ce
s
s
ar
y
eq
u
ip
m
en
t
d
u
r
in
g
r
ef
e
r
r
als.
To
m
i
t
i
g
a
te
a
d
m
i
n
is
t
r
at
i
v
e
o
v
e
r
s
i
g
h
t
,
h
e
al
t
h
c
a
r
e
i
n
s
ti
t
u
ti
o
n
s
s
h
o
u
l
d
i
m
p
l
e
m
e
n
t
s
y
s
t
e
m
a
t
ic
i
m
p
r
o
v
e
m
e
n
t
s
in
h
a
n
d
o
v
e
r
p
r
o
c
e
d
u
r
e
s
[
2
3
]
.
T
h
i
s
i
n
v
o
l
v
es
es
t
a
b
l
is
h
i
n
g
c
lea
r
p
r
o
t
o
c
o
l
s
f
o
r
i
n
f
o
r
m
a
t
i
o
n
tr
a
n
s
f
e
r
d
u
r
i
n
g
s
h
i
f
t
c
h
a
n
g
e
s
or
d
u
r
i
n
g
p
a
t
i
e
n
t
t
r
a
n
s
f
e
r
s
.
S
t
a
n
d
a
r
d
i
z
e
d
c
h
e
c
k
l
is
ts
can
s
e
r
v
e
as
t
o
o
ls
to
e
n
s
u
r
e
t
h
a
t
a
l
l
t
h
e
n
e
c
es
s
a
r
y
d
o
c
u
m
e
n
t
s
a
r
e
r
e
v
i
e
we
d
,
u
p
d
a
t
e
d
,
a
n
d
p
a
s
s
e
d
on
to
t
h
e
n
e
x
t
h
e
a
l
t
h
c
a
r
e
te
a
m
.
R
e
g
u
l
a
r
t
r
a
i
n
i
n
g
s
e
s
s
i
o
n
s
a
n
d
d
r
i
lls
can
f
u
r
t
h
e
r
r
e
i
n
f
o
r
c
e
t
h
e
i
m
p
o
r
t
a
n
c
e
of
a
d
h
e
r
e
n
c
e
to
t
h
es
e
p
r
o
c
e
d
u
r
e
s
a
m
o
n
g
h
e
a
l
t
h
c
a
r
e
p
r
o
f
e
s
s
i
o
n
a
l
s
.
3
.
5
.
Sy
s
t
e
m
ic
cha
lleng
es in hea
lt
hca
re
infr
a
s
t
ruct
ure
L
ac
k
of
a
m
b
u
lan
ce
av
ailab
ilit
y
o
f
ten
lea
d
s
to
d
elay
s
in
th
e
r
e
f
er
r
al
p
r
o
ce
s
s
.
Patien
ts
ex
p
er
ien
ce
d
elay
s
as
th
ey
h
a
v
e
to
wait
f
o
r
th
e
r
etu
r
n
of
th
e
am
b
u
la
n
ce
v
e
h
icle
f
r
o
m
a
p
r
ev
io
u
s
r
ef
er
r
al
or
b
ec
au
s
e
th
e
v
eh
icle
s
er
v
es
o
th
er
p
u
r
p
o
s
es
s
u
ch
as
s
u
p
p
o
r
tin
g
in
te
g
r
ated
h
ea
lth
p
o
s
ts
(
p
o
s
ya
n
d
u
).
Acc
o
r
d
in
g
to
a
p
ar
ticip
an
t,
“
I
wait
f
o
r
t
h
e
am
b
u
lan
ce
u
s
ed
to
r
e
f
e
r
g
en
e
r
al
p
atien
ts
;
o
n
ly
th
en
do
I
m
ak
e
th
e
r
ef
er
r
al,
ma
’
a
m
,
b
ec
au
s
e
th
er
e
is
no
o
th
er
a
v
ailab
le
v
eh
icle.
.
.
”
.
In
th
e
co
m
m
u
n
ity
h
ea
lth
ce
n
ter
(
P
u
s
ke
s
ma
s
),
th
e
lim
ited
p
r
es
en
ce
of
am
b
u
lan
ce
v
eh
icles
is
attr
ib
u
ted
to
th
eir
m
u
ltifu
n
ctio
n
ality
.
Am
b
u
lan
c
es
ar
e
not
ex
clu
s
iv
ely
d
esig
n
a
ted
f
o
r
r
e
f
er
r
als,
b
u
t
also
s
er
v
e
v
ar
io
u
s
h
ea
lth
ac
tiv
ities
in
r
em
o
te
ar
ea
s
.
As
a
r
esu
l
t,
r
ef
er
r
als
can
o
n
ly
be
in
itiated
af
ter
a
s
ig
n
if
ican
t
wait
f
o
r
th
e
am
b
u
lan
ce
to
r
etu
r
n
f
r
o
m
f
ield
d
u
ties
.
T
h
e
ill
-
eq
u
ip
p
ed
n
atu
r
e
of
a
m
b
u
lan
ce
s
an
d
th
e
ex
p
ec
tatio
n
f
o
r
m
id
wiv
es
to
b
r
in
g
s
p
ec
i
f
ic
m
ed
ical
eq
u
ip
m
en
t
t
h
em
s
elv
es
r
aise
b
r
o
ad
er
q
u
esti
o
n
s
ab
o
u
t
th
e
h
ea
lth
ca
r
e
in
f
r
astru
ctu
r
e.
I
n
s
u
f
f
ic
ien
t
r
eso
u
r
ce
s
m
ay
h
in
d
er
m
i
d
wiv
es
’
ab
ilit
y
to
c
o
m
p
ly
with
p
r
o
to
c
o
ls
[
2
4
]
,
e
m
p
h
asizin
g
th
e
im
p
o
r
tan
ce
of
ad
d
r
ess
in
g
s
y
s
tem
ic
is
s
u
es
to
en
s
u
r
e
o
p
tim
al
m
ater
n
al
an
d
f
etal
ca
r
e
d
u
r
in
g
r
ef
er
r
als.
Fu
r
th
er
m
o
r
e
,
in
s
u
f
f
icien
t
r
eso
u
r
ce
s
m
ay
also
lead
to
m
id
wiv
es
f
ee
lin
g
o
v
er
wh
elm
ed
an
d
b
u
r
n
t
out
[
2
5
]
,
wh
ich
can
n
eg
ativ
ely
im
p
ac
t
th
eir
ab
ilit
y
to
p
r
o
v
id
e
h
ig
h
-
q
u
ality
ca
r
e
to
wo
m
en
d
u
r
in
g
an
d
af
ter
p
r
e
g
n
an
c
y
[
2
6
]
.
It
is
c
r
u
cial
to
ad
d
r
ess
th
ese
s
y
s
tem
ic
is
s
u
es
to
en
s
u
r
e
th
at
m
id
wiv
es
h
av
e
th
e
n
ec
ess
ar
y
s
u
p
p
o
r
t
an
d
r
eso
u
r
ce
s
to
p
r
o
v
id
e
o
p
tim
al
m
at
er
n
al
an
d
f
etal
ca
r
e
d
u
r
in
g
r
ef
e
r
r
als.
Ad
d
itio
n
ally
,
ad
d
r
ess
in
g
th
ese
is
s
u
es
can
h
elp
r
ed
u
ce
th
e
r
is
k
of
n
eg
ativ
e
o
u
tco
m
es
f
o
r
b
o
th
m
o
th
er
s
an
d
th
eir
b
a
b
ies.
Dela
y
s
in
th
e
r
ef
er
r
al
p
r
o
ce
s
s
attr
ib
u
ted
to
lim
ited
am
b
u
l
an
ce
av
ailab
ilit
y
s
h
ed
lig
h
t
on
b
r
o
ad
e
r
s
y
s
tem
ic
ch
allen
g
es
with
in
th
e
h
ea
lth
ca
r
e
i
n
f
r
astru
ctu
r
e.
So
m
e
s
tu
d
ies
f
o
u
n
d
th
at
in
f
r
astru
ct
u
r
e
ass
o
ciate
d
with
th
e
q
u
ality
of
o
b
s
tetr
ic
an
d
n
e
wb
o
r
n
ca
r
e
[
2
]
,
[
2
7
]
.
Am
b
u
lan
ce
s
,
s
er
v
in
g
m
u
ltip
le
p
u
r
p
o
s
es,
s
u
ch
as
s
u
p
p
o
r
tin
g
in
teg
r
ated
h
ea
lth
p
o
s
ts
,
co
n
tr
ib
u
te
to
ex
te
n
d
ed
waitin
g
tim
es
f
o
r
r
ef
e
r
r
als.
T
h
is
is
s
u
e
ca
lls
f
o
r
s
tr
ateg
ic
p
lan
n
in
g
an
d
r
eso
u
r
ce
allo
ca
tio
n
to
e
n
s
u
r
e
th
at
d
ed
icate
d
am
b
u
lan
ce
s
er
v
ices
ar
e
av
ailab
le
f
o
r
tim
e
ly
r
ef
e
r
r
als,
th
er
e
b
y
p
r
ev
en
tin
g
u
n
n
ec
ess
ar
y
d
elay
s
th
at
m
ay
im
p
ac
t
p
atien
t
o
u
tc
o
m
es
[
2
8
]
.
E
f
f
ec
tiv
e
r
eso
u
r
ce
allo
ca
tio
n
is
a
cr
itical
a
s
p
ec
t
f
o
r
o
v
er
co
m
in
g
s
y
s
tem
ic
ch
allen
g
es
[
2
9
]
.
Ded
icate
d
f
u
n
d
in
g
an
d
r
eso
u
r
ce
s
s
h
o
u
ld
be
ea
r
m
ar
k
ed
f
o
r
th
e
p
r
o
c
u
r
e
m
en
t
an
d
m
ain
ten
a
n
ce
of
am
b
u
lan
ce
s
s
p
ec
if
ically
d
esig
n
ated
f
o
r
m
ate
r
n
ity
r
ef
er
r
al.
Fu
r
th
er
m
o
r
e,
it
is
ess
en
tial
to
en
s
u
r
e
th
at
th
e
am
b
u
lan
ce
s
ar
e
eq
u
ip
p
ed
with
th
e
n
ec
ess
ar
y
m
ed
ical
s
u
p
p
lies
an
d
eq
u
ip
m
en
t,
s
u
ch
as
o
x
y
g
e
n
tan
k
s
,
b
ir
th
in
g
to
o
ls
,
an
d
n
eo
n
atal
ca
r
e
s
u
p
p
lies
,
to
p
r
o
v
id
e
o
p
tim
al
ca
r
e
f
o
r
b
o
th
th
e
m
o
th
er
a
n
d
t
h
e
n
ewb
o
r
n
d
u
r
in
g
tr
an
s
p
o
r
t.
T
h
is
e
n
s
u
r
es
th
at
ess
en
tial
s
er
v
ices
ar
e
av
ailab
le
wh
en
n
e
ed
ed
,
alig
n
e
d
with
th
e
b
r
o
a
d
er
g
o
al
of
im
p
r
o
v
in
g
m
ater
n
al
a
n
d
in
f
a
n
t
o
u
tco
m
es.
T
h
e
is
s
u
e
of
lim
ited
am
b
u
la
n
ce
av
ailab
ilit
y
o
f
ten
ex
ten
d
s
b
ey
o
n
d
in
d
iv
id
u
al
h
ea
lth
ca
r
e
f
ac
ilit
ies.
R
eg
io
n
al
co
o
r
d
in
atio
n
an
d
c
o
llab
o
r
atio
n
ar
e
ess
en
tial
f
o
r
o
p
tim
izin
g
am
b
u
la
n
ce
s
er
v
ices
ac
r
o
s
s
h
ea
lth
ca
r
e
n
etwo
r
k
s
[
3
0
]
.
E
s
tab
lis
h
in
g
co
m
m
u
n
icatio
n
ch
an
n
els
b
et
wee
n
d
if
f
er
en
t
h
ea
lth
ca
r
e
p
r
o
v
id
er
s
,
am
b
u
la
n
ce
s
er
v
ices,
an
d
co
m
m
u
n
ity
h
e
alth
ce
n
ter
s
can
f
ac
ilit
ate
s
ea
m
less
m
o
v
em
en
t
of
p
atien
ts
d
u
r
in
g
r
ef
er
r
als.
R
eg
io
n
al
p
lan
n
in
g
h
elp
s
to
d
is
tr
ib
u
te
r
e
s
o
u
r
ce
s
ef
f
ec
tiv
ely
a
n
d
e
n
s
u
r
e
s
th
at
am
b
u
lan
ce
s
ar
e
s
tr
ateg
ically
p
o
s
itio
n
ed
to
s
er
v
e
d
iv
er
s
e
co
m
m
u
n
ities
.
3
.
6
.
B
lo
o
d
do
na
t
io
n sy
s
t
e
m
:
re
a
din
ess
a
n
d r
esp
o
n
s
iv
enes
s
Fu
n
d
am
en
tally
,
each
ex
p
ec
ta
n
t
m
o
th
er
s
h
o
u
l
d
h
av
e
a
p
o
ten
ti
al
b
lo
o
d
d
o
n
o
r
to
m
ee
t
th
e
s
ta
n
d
ar
d
s
f
o
r
b
lo
o
d
d
o
n
atio
n
r
ef
er
r
als.
Nev
er
th
eless
,
th
er
e
ar
e
in
s
tan
ce
s
in
wh
ich
th
ese
p
o
ten
tial
b
lo
o
d
d
o
n
o
r
s
ar
e
u
n
av
ailab
le
wh
en
a
m
o
th
er
in
lab
o
r
r
eq
u
ir
es
b
lo
o
d
.
T
h
is
is
r
e
f
lecte
d
in
t
h
is
s
tatem
en
t:
“
…
We
h
av
e
i
n
f
o
r
m
ed
th
em
d
u
r
in
g
p
r
eg
n
a
n
cy
to
p
r
ep
ar
e
a
d
o
n
o
r
,
but
it
’
s
d
if
f
icu
lt
to
co
n
tact
th
em
wh
en
n
ee
d
e
d
…
(
M)
.
Ad
d
itio
n
ally
,
s
o
m
e
p
r
o
s
p
ec
tiv
e
d
o
n
o
r
s
ar
e
n
o
t
p
r
e
p
ar
ed
to
d
o
n
ate
at
th
at
m
o
m
e
n
t
due
to
h
ea
lth
co
n
ce
r
n
s
as
in
th
e
s
tatem
en
t:
“
…
We
h
av
e
p
r
ep
ar
ed
a
d
o
n
o
r
s
in
ce
p
r
eg
n
an
c
y
,
but
th
ey
s
ay
th
e
d
o
n
o
r
is
not
r
ea
d
y
to
d
o
n
ate
b
lo
o
d
,
an
d
s
o
m
etim
es
th
er
e
is
no
b
l
o
o
d
d
o
n
o
r
av
aila
b
le
at
th
e
m
o
m
e
n
t…
”
(
T
B
)
.
T
h
e
lack
of
b
lo
o
d
d
o
n
o
r
s
em
p
h
asizes
th
e
n
ec
ess
ity
of
a
co
m
p
r
eh
en
s
iv
e
an
d
r
ea
ctiv
e
b
lo
o
d
d
o
n
atio
n
s
y
s
tem
.
Similar
ch
allen
g
es
can
be
o
b
s
er
v
ed
in
h
o
s
p
ital
b
lo
o
d
b
an
k
s
,
wh
er
e
u
n
ex
p
ec
ted
s
u
r
g
es
in
d
em
a
n
d
or
s
p
ec
if
ic
b
lo
o
d
ty
p
e
r
e
q
u
ir
em
e
n
ts
m
ay
s
tr
ain
th
e
ex
is
tin
g
d
o
n
atio
n
in
f
r
astru
ctu
r
e
[
3
1
]
,
[
3
2
]
.
An
ef
f
icien
t
b
lo
o
d
d
o
n
atio
n
s
y
s
tem
s
h
o
u
l
d
p
r
o
ac
t
iv
ely
ad
d
r
ess
th
ese
ch
allen
g
es
an
d
en
s
u
r
e
a
s
tead
y
s
u
p
p
ly
of
b
lo
o
d
p
r
o
d
u
cts
f
o
r
m
ater
n
al
h
ea
lth
ca
r
e
a
n
d
o
th
er
m
ed
ical
in
ter
v
en
tio
n
s
.
Evaluation Warning : The document was created with Spire.PDF for Python.
I
SS
N
:
2
2
5
2
-
8
8
0
6
I
n
t J Pu
b
lic
Hea
lth
Sci
,
Vo
l.
1
4
,
No
.
2
,
J
u
n
e
20
2
5
:
74
0
-
7
48
746
C
o
m
m
u
n
ity
en
g
ag
em
en
t
a
n
d
a
war
en
ess
ca
m
p
aig
n
s
p
lay
v
ital
r
o
les
in
b
u
ild
in
g
a
r
o
b
u
s
t
b
lo
o
d
d
o
n
ati
o
n
s
y
s
tem
.
T
h
r
o
u
g
h
th
ese
ca
m
p
ai
g
n
s
,
in
d
iv
id
u
als
can
lear
n
ab
o
u
t
th
e
im
p
o
r
tan
ce
of
b
lo
o
d
d
o
n
a
tio
n
an
d
th
e
v
a
r
io
u
s
way
s
th
ey
can
c
o
n
tr
ib
u
te
to
t
h
is
ess
en
tial
s
er
v
ice.
E
d
u
ca
tin
g
th
e
p
u
b
lic
a
b
o
u
t
t
h
e
co
n
s
tan
t
n
ee
d
f
o
r
b
lo
o
d
d
o
n
atio
n
s
,
th
e
ea
s
e
of
t
h
e
d
o
n
atio
n
p
r
o
ce
s
s
,
an
d
th
e
im
p
ac
t
of
d
o
n
atio
n
s
on
s
av
in
g
liv
es
f
o
s
ter
s
a
cu
ltu
r
e
of
v
o
lu
n
tar
y
b
lo
o
d
d
o
n
atio
n
s
.
C
o
m
m
u
n
ity
-
d
r
iv
en
i
n
itiativ
es,
d
o
n
o
r
r
ec
r
u
itm
en
t
p
r
o
g
r
a
m
s
,
an
d
p
ar
tn
er
s
h
ip
s
with
lo
ca
l
o
r
g
an
izatio
n
s
can
co
n
tr
i
b
u
te
to
a
s
u
s
tain
ab
le
an
d
r
esp
o
n
s
iv
e
b
lo
o
d
-
d
o
n
atio
n
ec
o
s
y
s
tem
[
3
3
]
.
3
.
7
.
L
ess
o
ns
lea
rned
T
h
e
r
esear
ch
u
n
c
o
v
er
e
d
v
a
r
io
u
s
ce
n
tr
al
th
e
m
es,
in
clu
d
i
n
g
p
r
o
to
c
o
l
ad
h
e
r
en
ce
,
h
u
m
an
er
r
o
r
s
,
ad
m
in
is
tr
ativ
e
o
v
er
s
ig
h
ts
,
h
ea
lth
ca
r
e
in
f
r
astru
ctu
r
e,
c
h
allen
g
es
in
o
b
tain
in
g
f
am
ily
co
n
s
en
t,
cu
ltu
r
al
n
o
r
m
s
,
b
lo
o
d
d
o
n
atio
n
s
y
s
tem
,
a
n
d
co
m
m
u
n
ity
s
u
p
p
o
r
t.
E
ac
h
th
em
e
was
th
o
r
o
u
g
h
l
y
ex
a
m
in
ed
,
elu
cid
ated
,
an
d
in
co
r
p
o
r
ated
in
to
t
h
e
b
r
o
ad
er
r
esear
ch
co
n
tex
t.
All
th
em
es
wer
e
th
o
r
o
u
g
h
ly
s
cr
u
tin
ize
d
to
allo
w
h
o
lis
tic
p
ictu
r
es
of
th
e
r
ef
er
r
al
s
y
s
tem
.
I
m
p
licatio
n
s
f
o
r
h
ea
lth
ca
r
e
p
r
ac
tices
wer
e
also
ca
r
ef
u
lly
an
a
ly
ze
d
.
B
ased
on
th
e
f
in
d
in
g
s
an
d
a
n
aly
s
is
of
th
is
s
tu
d
y
,
f
o
u
r
in
ter
co
n
n
ec
ted
elem
e
n
ts
wer
e
id
en
tifie
d
.
T
h
e
elem
en
ts
in
clu
d
e
p
atien
ts
an
d
f
am
ily
,
h
ea
lth
h
u
m
an
r
eso
u
r
ce
s
,
p
r
o
f
ess
io
n
al
en
v
ir
o
n
m
en
t,
an
d
co
m
m
u
n
ity
s
u
p
p
o
r
t.
T
h
ese
elem
en
ts
in
tr
i
ca
tely
im
p
ac
t
th
e
e
f
f
ec
tiv
en
e
s
s
of
th
e
m
ater
n
al
r
ef
er
r
al
s
y
s
tem
.
A
g
r
ap
h
ical
r
ep
r
esen
tatio
n
of
th
ese
elem
en
ts
is
p
r
o
v
id
ed
in
Fig
u
r
e
1
.
Fig
u
r
e
1.
E
lem
e
n
ts
af
f
ec
tin
g
t
h
e
m
ater
n
al
r
e
f
er
r
al
s
y
s
tem
T
h
e
ef
f
ec
tiv
e
n
ess
of
th
e
m
ater
n
ity
r
ef
er
r
al
s
y
s
tem
s
ee
m
s
to
h
in
g
e
s
ig
n
if
ican
tly
on
th
e
in
v
o
l
v
em
en
t
of
h
ea
lth
ca
r
e
p
er
s
o
n
n
el.
T
h
e
s
u
c
ce
s
s
f
u
l
im
p
lem
en
tatio
n
of
th
e
m
ater
n
ity
r
ef
er
r
al
s
y
s
tem
r
eq
u
ir
es
a
co
m
b
in
atio
n
of
ad
eq
u
ate
k
n
o
wled
g
e,
s
k
ills
,
an
d
p
r
o
f
ess
io
n
al
b
e
h
av
io
r
.
T
h
is
co
n
clu
s
io
n
is
ev
id
en
t
in
th
e
s
tu
d
y
’
s
f
in
d
i
n
g
s
,
p
ar
ticu
lar
ly
in
t
h
e
th
e
m
es
of
a
d
h
er
en
ce
to
p
r
o
to
co
ls
a
n
d
th
e
i
m
p
ac
t
of
h
u
m
an
er
r
o
r
s
,
b
o
th
of
wh
ich
u
n
d
er
s
co
r
e
th
e
cr
u
cial
r
o
le
of
h
ea
lth
h
u
m
a
n
r
eso
u
r
ce
s
in
t
h
e
m
ater
n
ity
r
e
f
er
r
al
s
y
s
tem
.
T
h
is
r
esu
lt
is
also
in
lin
e
with
s
o
m
e
o
th
er
s
tu
d
ies
[
8
]
,
[
1
3
]
,
[
1
7
]
.
Su
f
f
icien
t
h
u
m
a
n
r
eso
u
r
ce
s
s
h
o
u
ld
be
em
p
o
wer
ed
by
t
h
e
p
r
o
v
is
io
n
of
a
p
p
r
o
p
r
iate
an
d
s
u
p
p
o
r
tiv
e
p
r
o
f
ess
io
n
al
s
ettin
g
s
[
2
]
.
T
h
is
p
r
o
f
ess
io
n
al
en
v
ir
o
n
m
en
t
en
co
m
p
ass
es
ess
en
tial
f
ac
ilit
ie
s
an
d
in
f
r
astru
ctu
r
e,
tr
an
s
p
ar
en
t
p
r
o
to
co
ls
an
d
s
tan
d
ar
d
s
of
p
r
o
ce
d
u
r
e,
an
d
a
d
eq
u
ate
s
u
p
er
v
is
io
n
,
en
ab
lin
g
h
ea
lth
ca
r
e
p
r
o
f
ess
io
n
als
to
ca
r
r
y
out
th
eir
d
u
ties
p
r
o
f
icien
tly
.
T
h
ese
asp
ec
ts
ar
e
d
is
tin
ctly
ev
id
en
t
in
th
e
id
en
tifie
d
th
em
es
of
ad
m
in
is
tr
ativ
e
o
v
er
s
ig
h
t,
e
q
u
i
p
m
en
t
p
r
e
p
ar
ed
n
ess
,
an
d
s
y
s
tem
ic
ch
allen
g
es
with
in
h
ea
lth
ca
r
e
in
f
r
astru
ctu
r
e
[
2
7
]
.
T
h
e
is
s
u
es
of
in
ad
e
q
u
ate
h
ea
lth
f
ac
ilit
ies
h
av
e
also
b
e
en
p
r
ev
alen
t
in
m
an
y
o
th
e
r
s
t
u
d
ies
in
d
ev
elo
p
in
g
co
u
n
tr
ies
[
3
]
,
[
4
]
,
[
3
4
]
,
[
3
5
]
.
W
ith
th
e
cu
r
r
en
t
f
o
cu
s
on
p
ati
en
t
-
ce
n
ter
ed
ca
r
e
in
h
ea
lth
ca
r
e,
p
lacin
g
th
e
p
atien
t
an
d
th
ei
r
f
am
ily
at
th
e
co
r
e
of
s
er
v
ices,
th
eir
r
o
l
e
is
d
ee
m
ed
eq
u
ally
s
ig
n
if
ica
n
t
to
th
at
of
h
ea
lth
ca
r
e
p
r
o
f
es
s
io
n
als.
T
h
is
s
tu
d
y
illu
s
tr
ates
th
at
th
e
co
o
p
er
atio
n
b
etwe
en
p
atien
ts
an
d
th
eir
f
am
ilies
can
af
f
ec
t
th
e
ef
f
ica
cy
of
th
e
m
ater
n
ity
r
ef
er
r
al
s
y
s
tem
.
T
h
eir
b
elief
s
,
n
o
r
m
s
,
a
n
d
c
u
ltu
r
al
b
ac
k
g
r
o
u
n
d
m
ay
in
f
lu
e
n
ce
th
e
s
y
s
tem
’
s
o
u
tco
m
es
[
3
6
]
.
T
h
e
m
ajo
r
ity
of
f
ac
to
r
s
ass
o
ciate
d
with
p
atien
ts
an
d
f
am
ilies
s
ee
m
to
act
as
s
o
cial
d
eter
m
in
an
ts
in
en
s
u
r
in
g
th
e
s
u
cc
ess
of
th
e
m
ater
n
ity
r
e
f
er
r
al
s
y
s
tem
[
3
7
]
.
Evaluation Warning : The document was created with Spire.PDF for Python.
I
n
t J Pu
b
lic
Hea
lth
Sci
I
SS
N:
2252
-
8
8
0
6
A
n
a
n
a
lysi
s
o
f th
e
ma
tern
a
l h
e
a
lth
r
eferr
a
l sys
tem:
a
ca
s
e
s
tu
d
y
o
f …
(
S
a
s
tr
a
w
a
n
)
747
L
astl
y
,
th
e
s
u
p
p
o
r
t
of
th
e
b
r
o
ad
er
c
o
m
m
u
n
ity
also
co
n
tr
i
b
u
tes
to
th
e
f
u
n
ctio
n
in
g
of
t
h
e
s
y
s
tem
,
p
ar
ticu
lar
ly
co
n
ce
r
n
in
g
co
m
m
u
n
ity
m
em
b
e
r
s
’
willin
g
n
ess
to
d
o
n
ate
b
lo
o
d
.
E
s
s
en
tially
,
p
r
o
p
er
o
p
e
r
atio
n
of
th
e
b
lo
o
d
d
o
n
o
r
s
y
s
tem
r
elies
on
co
m
m
u
n
ity
in
v
o
lv
em
en
t.
Sin
c
e
p
ar
ticip
atio
n
is
v
o
lu
n
tar
y
,
th
e
co
m
m
u
n
ity
’
s
r
o
le
is
cr
u
cial
f
o
r
th
e
s
u
cc
ess
of
th
e
m
ater
n
ity
r
ef
e
r
r
al
s
y
s
tem
[
3
3
]
.
4.
CO
NCLU
SI
O
N
T
h
is
s
tu
d
y
h
ig
h
lig
h
ts
cr
itical
ch
allen
g
es
in
th
e
m
ater
n
al
h
e
alth
r
ef
er
r
al
s
y
s
tem
in
C
en
tr
al
L
o
m
b
o
k
.
Key
is
s
u
es
in
clu
d
e
d
elay
s
in
co
m
p
letin
g
p
a
r
to
g
r
a
p
h
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RE
F
E
R
E
NC
E
S
[
1
]
U
n
i
t
e
d
N
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s I
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[
2
]
Y
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Y
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[
3
]
M
.
N
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.
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4
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E
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K
.
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y
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2
0
2
1
.
[
5
]
B
.
F
.
D
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.
[
6
]
N
.
N
.
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.
K
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C
.
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1
.
[
7
]
R
.
P
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,
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3
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[
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]
S
.
I
.
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.
[
9
]
S
.
L.
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[
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0
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.
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r
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.
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7
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[
2
8
]
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9
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0
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.
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,
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MC
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3
6
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,
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N
.
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.
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6.
B
I
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RAP
H
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OF
AUTH
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a
str
a
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n
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tu
re
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Dire
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ra
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.
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h
e
a
lt
h
se
rv
ice
m
a
n
a
g
e
m
e
n
t,
p
u
b
li
c
h
e
a
lt
h
,
a
n
d
v
a
lu
e
-
lad
e
n
h
e
a
lt
h
c
a
re
.
S
a
stra
wa
n
h
a
s
a
u
t
h
o
re
d
so
m
e
p
e
e
r
-
re
v
iew
e
d
sc
ien
ti
fic
a
rti
c
les
p
u
b
li
sh
e
d
in
e
ste
e
m
e
d
jo
u
r
n
a
ls,
i
n
c
lu
d
in
g
th
e
J
o
u
r
n
a
l
of
Cli
n
ica
l
Nu
rsin
g
a
n
d
Nu
rsi
n
g
Et
h
ics
.
Ad
d
it
i
o
n
a
ll
y
,
he
p
a
rti
c
ip
a
tes
as
a
re
v
iew
e
r
fo
r
re
p
u
tab
le
in
ter
n
a
ti
o
n
a
l
jo
u
rn
a
ls
su
c
h
as
Nu
rsin
g
Et
h
ics
a
n
d
BM
C
Nu
rsin
g
as
we
ll
as
a
n
u
m
b
e
r
of
n
a
ti
o
n
a
l
sc
ien
ti
fic
j
o
u
r
n
a
ls.
C
u
rre
n
tl
y
,
S
a
stra
wa
n
h
o
ld
s
a
m
a
n
a
g
e
rial
p
o
siti
o
n
at
th
e
u
n
iv
e
rs
it
y
as
th
e
Vic
e
Re
c
to
r
fo
r
Ac
a
d
e
m
ic
Affa
irs.
F
o
r
a
n
y
in
q
u
iri
e
s
or
c
o
m
m
u
n
ica
ti
o
n
.
H
e
can
be
c
o
n
tac
ted
a
t
e
m
a
il
:
sa
stra
wa
n
@g
m
a
il
.
c
o
m
.
La
lu
S
u
l
a
im
a
n
c
u
rre
n
tl
y
h
o
ld
s
th
e
p
o
si
ti
o
n
of
Dire
c
to
r
at
th
e
Dire
c
t
o
ra
te
of
P
o
stg
ra
d
u
a
te
S
t
u
d
ies
at
U
n
iv
e
rsit
a
s
Qa
m
a
ru
l
Hu
d
a
Ba
d
a
ru
d
d
i
n
.
As
a
d
e
d
ica
ted
re
se
a
rc
h
e
r,
he
sp
e
c
ialize
s
in
h
e
a
lt
h
a
d
m
in
istrati
o
n
,
h
e
a
lt
h
sy
ste
m
s,
a
n
d
h
e
a
lt
h
a
n
th
r
o
p
o
lo
g
y
.
His
e
x
p
e
rti
se
is
e
v
id
e
n
t
in
th
e
p
u
b
li
c
a
ti
o
n
of
n
u
m
e
ro
u
s
sc
ien
ti
fic
a
rti
c
les
a
c
ro
ss
v
a
rio
u
s
n
a
ti
o
n
a
l
jo
u
rn
a
ls.
No
tab
ly
,
S
u
laim
a
n
Lalu
re
c
e
n
tl
y
se
c
u
re
d
n
a
ti
o
n
a
l
re
se
a
rc
h
fu
n
d
in
g
fo
r
h
is
wo
r
k
in
h
e
a
lt
h
a
d
m
in
istratio
n
.
He
can
be
c
o
n
tac
t
e
d
at
e
m
a
il
:
su
laim
a
n
lalu
@
g
m
a
il
.
c
o
m
.
Ev
a
Er
a
wa
t
i
is
a
p
ro
fe
ss
io
n
a
l
re
g
istere
d
m
id
wife
with
o
v
e
r
15
y
e
a
rs
of
d
e
d
ica
ted
se
rv
ice
at
th
e
Ce
n
ter
fo
r
M
i
d
wife
ry
S
e
rv
ice
s
at
P
ra
y
a
Distr
ict
Ho
sp
i
tal.
He
r
e
x
ten
siv
e
e
x
p
e
rien
c
e
in
m
id
wife
r
y
h
a
s
h
e
ig
h
ten
e
d
h
e
r
a
wa
re
n
e
ss
of
th
e
m
a
tern
it
y
re
fe
rra
l
sy
ste
m
.
S
h
e
a
c
ti
v
e
ly
e
x
a
m
in
e
s
a
n
d
a
ss
e
ss
e
s
th
e
re
fe
rra
l
sy
ste
m
,
p
lay
i
n
g
a
c
ru
c
ial
ro
le
in
e
d
u
c
a
ti
n
g
w
o
m
e
n
a
n
d
fe
m
a
le
tee
n
a
g
e
rs
on
m
a
tt
e
rs
of
re
p
ro
d
u
c
t
iv
e
h
e
a
lt
h
a
n
d
sa
fe
c
h
il
d
b
irt
h
.
S
h
e
can
be
c
o
n
tac
ted
at
e
m
a
il
:
7
5
e
v
a
e
ra
wa
ti
@g
m
a
il
.
c
o
m
.
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