A checklist and coaching intervention to improve facility-based childbirth care and reduce deaths of women and newborns in India achieved significant gains in the quality of care during labor and delivery, but the improvements were insufficient to reduce death rates, according to a new study.The BetterBirth study is one of the largest ever conducted in maternal-newborn health, with more than 300,000 women and newborns. It is also the first study to rigorously demonstrate large-scale, broad-based improvement in care during the 48-hour period of labor and delivery when women and newborns face the greatest risk of death and complications.The study appears in the Dec. 14, 2017 issue of the New England Journal of Medicine.The research was led by Ariadne Labs, a joint center of the Harvard T.H. Chan School of Public Health and Brigham and Women’s Hospital in Boston, in partnership with the Governments of India and Uttar Pradesh; Community Empowerment Lab in Lucknow, India; Jawaharlal Nehru Medical College in Belgaum, India; Population Services International, and the World Health Organization. It was supported by the Bill & Melinda Gates Foundation.The quality of care around the time of childbirth has been recognized globally as a major contributor to the persistently high rates of preventable maternal and infant deaths in childbirth, even though more women are delivering babies at facilities. The WHO’s Safe Childbirth Checklist was designed to target the seven major causes of death by helping birth attendants consistently follow basic practices such as handwashing and use of clean gloves to prevent infection.In this randomized study conducted from 2014 to 2016, birth attendants and managers at 60 rural health centers in Uttar Pradesh were coached on use of the WHO’s Safe Childbirth Checklist … Sixty matched facilities that did not receive the intervention served as comparison sites … After two months of coaching, birth attendants completed 73 percent of the essential birth practices, 1.7 times better than the control arm at 42 percent … At twelve months, four months after the coaching ended, completion of checklist items persisted at 62 percent percent, 1.4 times better than control facilities, which remained unchanged. There was no difference between intervention and control sites, however, in stillbirths, seven-day newborn mortality, and seven-day maternal mortality and morbidity. Perinatal mortality, for instance, was 47 deaths per 1,000 live births in both groups.“Overall, we found that coaching birth attendants and managers to use the WHO Safe Childbirth Checklist produced greater adherence to essential birth practices, representing significant improvements in care for women and newborns,” said BetterBirth Director Dr. Katherine Semrau, an epidemiologist at Brigham and Women’s Hospital, assistant professor at Harvard Medical School, and lead author.“This was the first rigorous study of deploying checklists and coaching at large scale,” said Ariadne Labs Executive Director Dr. Atul Gawande, a Harvard Chan School professor and senior co-author, who helped lead the development of the Safe Childbirth Checklist with WHO. “The results demonstrated impressive behavior change. Now we in public health must identify the additional ingredients required to produce the complete recipe for saving lives at childbirth.” Read Full Story
The true measure of riskThe real problem long-term investors face is not short-term volatility. It is how to deal with the uncertainty surrounding the likely paths asset prices might take over their investment time horizon. This is not volatility. Instead, this is about understanding the range of possible macroeconomic outcomes, judging the likelihood of those outcomes occurring and choosing an asset allocation that best fulfils the investment objective within that context.Investors’ objectives can and should vary widely, based on their particular investment beliefs and characteristics. As such, their measures of risk should also vary widely and, ideally, be bespoke to the individual investor. In identifying their objectives, investors also need to establish the key outcomes they want to avoid and focus on creating the right measure for their risk appetite accordingly.However, more broadly, almost all investors share a balance-sheet problem, which is not confined to assets alone.Generally, investors such as pension funds and insurance companies, have a key balance-sheet metric, which is the discount rate applied to liabilities, or, in the case of endowments and sovereign wealth funds, an ‘inflation-plus’ return target. Both establish the rate of growth the assets need to achieve to keep the balance sheet whole or reach the required target.The true risk for all investors is the extent to which they are prepared to accept sub-optimal outcomes in their efforts to achieve their objective. A sub-optimal outcome is simply one that does not achieve the investment objective. Anything less than the target return is value destructive – anything greater is value creation.Measuring risk in terms of volatility does not help investors understand or effectively manage this problem. Instead, forecasting returns and economic scenarios are key.Investors should be focusing on their individual pension, insurance, endowment or sovereign wealth fund objectives, risk appetites and tolerances. The medium to long-term investment horizon available to most of these investors gives them an edge and should not be ignored because of investment managers and consultants’ short-term appeals to solve long-term problems.Most important, long-term investors should be focusing on forecasting returns, not volatility. They need to better understand the true economic exposure of portfolios and analyse the economic scenarios that are most likely and most worrying in the future.Stefan Dunatov is CIO at Coal Pension Trustees Investment and a member of the 300 Club The emergence of volatilityThe increasing focus on forecasting risk, and the emergence of volatility as a popular measure of that risk, is a disappointing response by the investment industry to the recent difficulties it has faced.Any investment manager would be excused for thinking the last 15 years have been difficult. Since the late 1990s, investors have faced an increase in apparent economic and investment uncertainty, especially in comparison to the preceding two decades.The rising uncertainty stems from several sources, including significant changes in investment and accounting regulations, not least the transition to marked-to-market pension liabilities under IFRS 13, which crystallises moves in asset prices more frequently on balance sheets. Other sources of uncertainty include the impact on liabilities of a prolonged period of falling interest rates and therefore discount rates, and, perhaps most critically, the single largest market panic since the 1930s.In investment terms, uncertainty translates into risk. Deep uncertainty, when we are faced with an unlimited set of possible outcomes, creates fear – the sort of fear seen during the Great Depression of the 1930s and again in 2008 when the banking system in the West teetered at the edge of an abyss. In dealing with that fear, investors analyse uncertainty by identifying potential outcomes, using historical events as guides, trying to judge the likelihood of different outcomes occurring and to envisage the circumstances leading to each outcome and their economic consequences. This process effectively reduces uncertainty to mere risk.In the current period of increased uncertainty, investors are naturally more focused on how to define, measure and manage that risk.In the search for answers, however, the industry as a whole has failed to develop an appropriate definition and measure of risk. Asset owners have allowed the providers of investment services, including investment managers and consultants, to dictate the approach asset owners should adopt. External advisers naturally prefer to work with an easily definable measure common to many clients. Their solution has been to replace the traditional focus on forecasting returns and all its difficulties with a short-term metric of volatility to forecast risk, which appears to be a more tractable measure. This touches on a separate key issue the industry also has to grapple with – a lack of alignment of interests between the asset owners, consultants and asset managers. Using volatility to measure risk is a big mistake for long-term investors, warns 300 Club member Stefan DunatovThe investment industry has two great failings: the inability to identify the right risks when considering investment objectives, and then measuring those risks the wrong way.A long-term investor’s appetite or tolerance for risk should be a direct function of its individual objectives and should not be measured by a short-term metric like volatility. Forecasting returns, not risk, should sit at the heart of long-term investors’ asset allocation strategy. Volatility doesn’t measure real riskVolatility is a crude, poor measure of risk for a long-term investor. Like the assumption that markets are efficient, the assumption that volatility is a good measure of risk is clearly wrong.Volatility forecasting is only helpful in the very short term. Volatility measures typically inform us about the state of the world at the current time, and models that forecast volatility tend to only be able to do so with any degree of accuracy over a very short time frame. Correlation assumptions form a key part of volatility forecasting, and these are even more difficult to predict – so much so that most market participants tend to not forecast them at all (correlations are most often static assumptions). The most confident analysts believe six months is a long-time horizon for forecasting volatility, which is of limited use to a professional investor with a medium to long-term investment horizon.By succumbing to the pressure of providers to focus on short-term measures of risk instead of long-term objectives, investors are giving up their ability to exploit the illiquidity premium. This undermines the premise of being a patient, long-term investor. Long-term investors should be able to absorb short-term fluctuations in risk premiums, yet risk models focus on these short-term fluctuations.
BATESVILLE, Ind. – Indiana will officially mark 200 years of statehood on December 11.The City of Batesville will celebrate the Bicentennial by hosting an event at the Memorial Building on Sunday, December 11 at 11:30 a.m.Mayor Mike Bettice will officiate the ceremony and raise the official Bicentennial flag.Mayor Bettice will also recognize the Torchbearers who were locally nominated to participate in the Bicentennial Torch Relay in September.The city recently received a five-foot fiberglass bison sculpture from Duke Energy as part of the statewide public art project in conjunction with Indiana’s Bicentennial Celebration.The bison was painted by Batesville High School art teachers Mary K Cambron and Kyle Hunteman.Chris Fledderman of Enneking Auto Body oversaw the donated services of priming, base coating and sealing the bison.Tim Weberding led the effort of Weberding Carving Shop, to make the custom Indiana State Seals.During Sunday’s event, the name of Bicentennial Bison will also be unveiled.Community members submitted names to the Batesville Bicentennial Committee during the Tree Lighting Ceremony on December 1.