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Most maternal deaths, intrapartum-related stillbirths, and newborn deaths in low income countries are preventable but simple, effective methods for improving safety in institutional births have not been devised. Checklist-based interventions aid management of complex or neglected tasks and have been shown to reduce harm in healthcare. We hypothesized that implementation of the WHO Safe Childbirth Checklist program, a novel childbirth safety program for institutional births incorporating a 29-item checklist, would increase delivery of essential childbirth practices linked with improved maternal and perinatal health outcomes.
Methods and Findings
A pilot, pre-post-intervention study was conducted in a sub-district level birth center in Karnataka, India between July and December 2010. We prospectively observed health workers that attended to women and newborns during 499 consecutively enrolled birth events and compared these with observed practices during 795 consecutively enrolled birth events after the introduction of the WHO Safe Childbirth Checklist program. Twenty-nine essential practices that target the major causes of childbirth-related mortality, such as hand hygiene and uterotonic administration, were evaluated. The primary end point was the average rate of successful delivery of essential childbirth practices by health workers. Delivery of essential childbirth-related care practices at each birth event increased from an average of 10 of 29 practices at baseline (95%CI 9.4, 10.1) to an average of 25 of 29 practices afterwards (95%CI 24.6, 25.3; p<0.001). There was significant improvement in the delivery of 28 out of 29 individual practices. No adverse outcomes relating to the intervention occurred. Study limitations are the pre-post design, potential Hawthorne effect, and focus on processes of care versus health outcomes.
Citation: Spector JM, Agrawal P, Kodkany B, Lipsitz S, Lashoher A, Dziekan G, et al. (2012) Improving Quality of Care for Maternal and Newborn Health: Prospective Pilot Study of the WHO Safe Childbirth Checklist Program. PLoS ONE 7(5): e35151. https://doi.org/10.1371/journal.pone.0035151
Editor: Philippa Middleton, The University of Adelaide, Australia
Received: January 24, 2012; Accepted: March 8, 2012; Published: May 16, 2012
Copyright: © 2012 Spector et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: This work was supported by grants from World Health Organization (WHO) and the Children's Investment Fund Foundation (CIFF). WHO provided input on study design, data analyses, decision to publish, and preparation of the manuscript. WHO had no role in data collection. CIFF had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: AAG receives royalties for books and essays focused on patient safety and medicine. CL receives royalties for a book focused on healthcare management. All other authors have declared that no competing interests exist. This does not alter the authors' adherence to all the PLoS ONE policies on sharing data and materials.
Reducing childbirth-associated mortality is a top global health priority but simple, effective methods to achieve it are severely lacking. Most of the 350,000 maternal deaths, 1·2 million intrapartum-related stillbirths, and 3·1 million neonatal deaths that occur each year could be avoided through the delivery of timely interventions proven to be effective and affordable [1], [2], [3], [4], [5]. Shifting place of delivery from home to hospital is a key strategy for improving childbirth outcomes and has led to unprecedented increases in institutional births in several countries [6], [7], [8]. But even as institutional birth rates rise, morbidity and mortality rates have been slow to fall [7], [9], [10]. Poor quality care in institutional births is recognized to be a major contributing factor to childbirth-related harm [11], [12], [13]. Improving facility-based care is a critical necessity yet no widely applicable, effective method currently exists.
In recent years checklist-based interventions have been adopted with increasing frequency in health to aid management of complex or neglected tasks that risk serious human harm. Integration of checklist programs into clinical practice has been shown to reduce deaths and complications in intensive care medicine and surgery [14], [15], [16], [17]. Several features of childbirth make a checklist-based strategy promising: the major causes of maternal and perinatal mortality are well described; most deaths occur within a narrow time window (twenty-four hours after birth); international guidelines for best practices exist but are not followed; and proven interventions are relatively inexpensive and easy to perform, but can be difficult to remember and execute in proper sequence [18], [19], [20].
In 2008, the World Health Organization (WHO) established a checklist-based childbirth safety program with the goal of determining whether a simple, low-cost, scalable intervention with potential for broader testing could be devised. A 29-item bedside WHO Safe Childbirth Checklist was developed according to previously established methodology and tested for usability in ten countries in Africa and Asia [21]. An implementation program was designed to maximize the likelihood of successful checklist adoption into clinical practice. We hypothesized that this program would increase the rate of delivery of essential childbirth practices linked with improved maternal, fetal, and neonatal health outcomes in a low income setting.
Study Design
We conducted a prospective, pre-post-intervention study observing childbirth practices of health workers at a sub-district level hospital in Karnataka, India. Our plans were to observe health workers attending to a minimum of 300 birth events before the intervention; introduce the checklist program; and then monitor health workers attending to a minimum of 300 birth events after the intervention. The total study was anticipated to last 6 months. The pilot hospital was selected on the basis of sufficient birth volume (minimum 250 births monthly), general availability of supplies, motivated leadership, and absence of other ongoing interventions. Basic emergency obstetric care and caesarean sections are offered at the facility [22]. Nurses provide care during most births. Other staff includes two obstetricians, one surgeon who performs caesarean sections, and an anesthetist. There are no pediatricians on staff. A co-investigator (BK) led the project locally and the hospital administration endorsed the intervention. Five data collectors were trained by the investigators to observe and document health worker practices. Data collectors were student nurses previously unknown to hospital staff with no clinical responsibilities. Inclusion criteria were health workers at the study site who cared for women and newborns from the time of admission for childbirth to discharge. Health workers providing care to mothers not involved in childbirth, including those being managed for abortions, miscarriages, and antenatal problems were excluded. Written informed consent was obtained from health workers and patients. The study was approved by ethics committees at JNMC Medical College in Karnataka, WHO, and the Harvard School of Public Health. The Indian Council of Medical Research also approved the study.
The intervention was a four-step checklist-based childbirth safety program designed and implemented using methods adapted from previous programs; in particular, CUSP and TeamSTEPPS [23], [24]. It involved (1) Engagement of local administrative and clinical leaders and identification of facility-based implementation leads; (2) Education about childbirth safety principles, deficiencies in current practice, and how to use the WHO Safe Childbirth Checklist during a one-day learning session; (3) Execution beginning with one week of simulation and supervised practice; and (4) Evaluation and ongoing monitoring [25].
The hospital-based implementation leads (an administrator, a senior physician, and a senior labor nurse) were selected by the facility and trained by the investigators. They introduced the checklist program to staff during the one-day learning session and monitored its ongoing use. Learning was supported by written materials, lectures, an instructional video, and hands-on simulation. Following introduction of the program, the implementation leads supervised use of the checklist and offered strategies for improvement in performance and learning when their full-time clinical schedules allowed. An outside physician "coach" visited the facility fortnightly to provide additional support to help staff improve adherence to the checklist program.
The WHO Safe Childbirth Checklist consists of succinct reminders of essential steps for safe childbirth care (see Table S1). Items on the checklist address the major causes of maternal deaths (i.e., hemorrhage, infection, obstructed labor, and hypertensive disorders), intrapartum-related stillbirths (i.e., inadequate intrapartum care), and neonatal deaths (i.e., intrapartum-related events, infection, and complications of prematurity) in lower income countries [18], [26], [27], [28]. Checklist items are organized for use at four critical junctures in care during birth: at the time the woman is admitted, when the woman begins to push or before cesarean, within one hour after birth, and before discharge. Modifications to the checklist are encouraged to align content with local practice. Adjustments made by the pilot site's review committee were the following: change from "does mother need referral" to "does mother need review by obstetrician," minor change to maternal antibiotic administration criteria (specifying labor >24 hours in a primigravida or labor >12 hours in multipara as indications), minor change to maternal magnesium sulfate administration criteria (specifying diastolic blood pressure threshold at 100 mmHg instead of 110 mmHg), inclusion of ASHA (Accredited Social Health Activist) workers as satisfactory birth companions, requirement that nurses introduce themselves by name to laboring women, removal of the newborn special care and monitoring item (all ill newborns were referred to other facilities since there was no pediatrician on staff), and removal of the follow-up after discharge item (the existing follow-up process was felt by local staff to be sufficient). No additional equipment, supplies, or medications were provided. Checklist use was not mandatory; individual health workers could decide for themselves whether or not to use the checklist during any given patient encounter. Completed checklists were attached to the mothers' charts.
Data Collection
Data were collected through observation of health workers' practices and review of birth registers. Observation data were recorded on standardized data sheets by data collectors who directly observed health workers. Observation took place 24 hours daily for a minimum of six days weekly; unobserved days were selected at random. Practical limitations precluded continuous observation of each woman from the time of admission until discharge. Observation therefore took place at three specific periods: on admission, continuously from the time of pushing until one hour after delivery, and before discharge. Checklist use was observed during the post-intervention period. Data collectors did not interact with patients or health workers during their observations. For ethical reasons, they were instructed to notify health workers if they observed a potentially harmful condition or practice. Data quality was assured through periodic assessment of data collector skills (confirming they achieved 100% concordance on a sample of three observations), parallel observations by the local study coordinator once weekly, and on-site review of all observation forms within 72 hours. The data management system had range, plausibility, and cross-validation checks confirming all data were logical. Double data entry was performed for a sample of the observation forms.
The primary outcome was the average rate of successful delivery of essential childbirth practices by health workers at each birth event. A birth event was defined as the period from admission for childbirth to discharge. Twenty-nine practices were evaluated. Successful delivery of individual practices was defined by completion of a predetermined set of process indicators (see Table S2). For several practices this required proper assessment of the mother or baby, recognition of abnormal signs or symptoms, and execution of appropriate action. Essential childbirth practices relating to maternal care were referral when indicated, partograph use, periodic assessment of infection risk and antibiotic administration when indicated, periodic assessment of hypertensive-disease risk and magnesium sulfate administration when indicated, assessment of HIV risk and anti-retroviral administration when indicated, presence of a birth companion, good hand hygiene, periodic danger sign counseling, presence of an assistant for birth, oxytocin administration within 1 minute after birth, periodic blood loss estimation and bleeding risk, and family planning discussion. Essential childbirth practices relating to newborn care were use of a sterile blade to cut the umbilical cord, proper thermal and resuscitation care, referral when indicated, assessment of HIV risk and anti-retroviral administration when indicated, breastfeeding within one hour, periodic assessment of infection risk and antibiotic administration when indicated, assessment of adequate feeding before discharge, and periodic danger sign counseling.
Observed rates of in-facility maternal deaths, newborn deaths, and stillbirths were analyzed as secondary outcomes. The frequency of medication administration before and after the intervention was also measured.
Statistical Analysis
We aimed to collect data on a minimum of 300 consecutively enrolled birth events during each phase of the study. The sample size was calculated to detect a 20% absolute increase in the average rate of essential childbirth practices successfully delivered by health workers after introduction of the checklist program, with a statistical power of 80% and an alpha value of 0.05, using a generalized estimating equations (GEE) test accounting for clustering by provider [29], [30].
Each of the 29 individual childbirth practices were quantified in terms of the proportion successfully delivered, and GEE methods were again used to adjust confidence intervals to account for clustering by provider. Rao-Scott Chi-Square tests were used to test whether possible categorical confounders (categorical patient characteristics) had different distributions before and after the intervention, accounting for clustering by provider. If covariates were found to be imbalanced over the two phases, regression analyses were conducted to adjust for possible confounding due to patient characteristics.
Using the Bonferroni approach to adjust the overall 5% Type I Error rate for the 30 before versus after comparisons (each of the 29 individual childbirth practices plus the average rate of practices delivered), a P-value less than 0.05/30 = 0.0017 would be declared significant.
Our secondary outcome was the change in observed rates of in-facility maternal deaths, newborn deaths, and stillbirths, although the study was not powered to detect a difference in mortality. Secondary outcomes were exploratory and the Type I error rate was not adjusted.
Analyses were performed with SAS version 9·2 (SAS Institute Inc, Cary, North Carolina).
We observed health workers attending to 499 birth events during the baseline period (July–September, 2010) and 795 birth events after introduction of the checklist program (September–December, 2010). All hospital staff involved in childbirth were invited to participate and agreed to do so, and there was no staff turnover during the study. The pre- and post-intervention periods did not overlap and data was not collected during the brief period when the program was introduced. Table 1 lists the number of observations made at each period in the flow of care. Demographic characteristics of women and newborns are shown in Table 2; there were no differences in the two phases of the study. The checklist was observed to be used by health workers at least 95% of the time at each of the four checklist pause points in the post-intervention period.
The rate of successful delivery of essential practices at each birth event increased from an average of 10 of 29 practices at baseline (95%CI 9.4, 10.1) to an average of 25 of 29 practices afterwards (95%CI 24.6, 25.3; p<0.001)(Figure 1). The Bonferroni correction did not affect the outcomes that were declared significant since all P-values less than 0.05 were also less than 0.0017. Figure 2 shows the rates of successful completion of individual practices before and after introduction of the checklist program. There was significant improvement in the delivery of every practice except maternal referral.
Figure 3 shows the frequency of initiation of medication therapy at each period of care. The use of medications increased at some periods and decreased at others. There were no differences in observed maternal and neonatal deaths in the two study periods, though the study was not powered to detect significant differences in mortality (Table 3). The stillbirth rate showed a declining trend after introduction of the checklist program.
In this pilot study, a novel checklist-based childbirth safety program led to a marked increase in delivery of essential childbirth practices linked with improved maternal, fetal, and newborn outcomes. Overall, there was an average 150% increase in adherence to accepted clinical practices at any given birth event, and 28 of 29 individual practices were delivered with significantly greater frequency. Strategies for achieving quality improvements in institutional births in low income settings are lacking. These results suggest the potential for this approach to improve maternal and perinatal care.
While these results were found in just a single hospital, research in this area has not previously demonstrated interventions that are comprehensive (to capture sufficient behaviors to have a chance of saving lives) and simple (to be scalable and sustainable). Moreover, facilitating behavior change to increase adherence to evidence-based healthcare practices is known to be challenging [31], [32]. In this initial work we aimed to prove that such methods could be devised and produce measurable change.
The ways by which a checklist-based approach improves care during childbirth warrants exploration to better understand how this intervention produced such promising results. We believe the intervention had three primary mechanisms of effect: (1) as a checklist instrument that reinforced for health workers a core set of essential practices that must be completed at each and every birth; (2) as a reminder to complete these practices at the most crucial period – at the bedside at the moment of care; and (3) as a tool that highlighted gaps in the existing system of care at the facility which enabled local staff to take steps to effectively strengthen their own health system to ensure adherence to checklist practices. No additional investments in equipment or supplies were made, and no incentives were given. The local team seemed inspired by the checklist program and developed a personal interest in helping it to succeed.
There were changes in behavioral patterns that were individual in nature, for example improvement in health workers washing their hands with soap and water and wearing clean gloves (by comparison, before the intervention soap was not used routinely). Other improvements resulted from system changes. For instance, after introduction of the program it became apparent that no structure was in place to adequately monitor women and newborns immediately after delivery, which brought to light the difficulty in reliably completing crucial assessments and practices at that time. In response, the local staff took the initiative to convert an underutilized room adjacent to the labor ward into a postpartum bay where women and newborns were observed for at least one hour after delivery. The checklist program also helped to identify similar deficiencies in the discharge process, which was subsequently systematized by the local staff. The program reinforced the importance of ensuring that medicines and supplies were readily available to health workers on the labor ward and not kept remotely in the hospital store. Finally, the intervention appeared to improve communication and teamwork. Nursing staff used the checklist as a framework for communicating patient information at shift changes as well as conducting daily safety rounds to discuss complicated cases as a team.
Medication use, which increased in some periods and decreased in others, was a partial contributor to improved practices. Improved assessment of mothers and newborns was often the most significant factor in health workers' successful adherence to essential practices. We suspect that increased medication usage reflected improved awareness of appropriate indications for administration (for instance, increased antibiotic administration to at-risk newborns in the postnatal period) and that decreased medication administration reflected a decline in overuse practices (for instance, a reduction in the traditional practice of administering antibiotics after birth for all episiotomies).
We recognize that a simple paper checklist alone is unlikely to result in lasting behavior change [33]. In this study the WHO Safe Childbirth Checklist was the central component of an implementation program based on a well-described change model carried out by hospital administration and clinical leaders [23]. The program involves engaging and empowering the local team; providing education on best practices and existing deficiencies; discussing potential barriers and introducing the checklist through focused training; and establishing a mechanism for ongoing monitoring and evaluation [34]. This is a comprehensive behavior change strategy facilitated by a checklist program. We found that this approach was associated with rapid uptake by the local team and low implementation costs.
This study has several limitations. A risk of the pre-post-intervention design is confounding by secular trends. The study period was, however, limited to six months and no difference was observed in the characteristics of the women and newborns in the two phases of the study. No other interventions took place during the study period and there were no changes in hospital staffing. For these reasons, secular trends alone were unlikely to be responsible for the observed differences.
A potential Hawthorne effect, in which subjects' behavior is influenced by an awareness of being observed, is another methodological limitation given that independent observers conducted the evaluation of health workers' performance [35]. This methodology was selected for its obvious advantages over self-reporting and for practicality (for instance, video cameras in this setting would have been infeasible). We worked to minimize Hawthorne effect by employing the same data collectors before and after the intervention, by having the health workers observed in the same way for both periods of observation, and by structuring nearly continuous periods of observation from the start of the study so that health workers had the opportunity to become accustomed to the presence of observers.
Additional concerns relate to the study's generalizability and sustainability. The pilot facility is representative of first-level referral centers in India albeit with a motivated local team and general accessibility to childbirth equipment and supplies. These factors undoubtedly contributed to implementation success. The potential efficacy of this approach in other settings is unclear and merits further study. Regarding sustainability, there is evidence from other disciplines to suggest that checklist programs remain to be associated with sustained health improvements and positive attitudes toward the programs up to at least 18 months after the initial introduction and evaluation periods [36], [37], [38]. A follow-up to this pilot study is now being organized to assess checklist use and adherence to essential practices more than 12 months after the initial investigation.
Lastly, this pilot study focused on processes of care as indicators of quality. Though the observed stillbirth rates showed a declining trend, the sample size in this pilot investigation was insufficient to detect significant differences in mortality. A multi-center study in north India is currently underway to measure the impact of the program on a composite measure of severe maternal, fetal, and newborn harm. Enrollment for this prospective randomized trial is anticipated to begin in late 2012.
Most maternal and newborn deaths, and many stillbirths, are avoidable. Assuring the delivery of key evidence-based interventions during childbirth is critical to optimizing care for women and newborns and helping priority countries to achieve progress toward Millennium Development Goals Four and Five. In this study, implementation of a novel checklist-based childbirth safety program led to improved quality of care delivered by health workers attending to institutional deliveries. Future study is required to determine whether a checklist-based approach to promoting safety in childbirth also reduces harm and saves lives.
Supporting Information
Table S1.
Elements of the WHO Safe Childbirth Checklist.
Table S2.
Definitions of childbirth practices used in the WHO Safe Childbirth Checklist program pilot study.
We are indebted to the individuals who contributed to the development the WHO Safe Childbirth Checklist program including: Sabaratnam Arulkumaran, Chris Barnes, Angela Bader, Dr Benachinamaradi, William Berry, Shereen Bhutta, Zulfiqar Bhutta, Ann Blanc, Dan Boorman, Waldemar Carlo, Susan Crowther, Gary Darmstadt, Louise Day, Ambassador Mark Dybul, Lizzie Edmondson, Barbara Farlow, Zhao Gengli, Kathleen Hill, Justus Hofmeyr, Narayan Honnungar, Julia Hussein, AK Jana, Cate Kamau, Grace Kodindo, Barbara Kwast, Rashad Massoud, Claudia Morrissey, Elizabeth Morse, Susan Niermeyer, Padmanaban Packirisamy, Vinod Paul, Robert Pattinson, Amit Revankar, Harshad Sanghvi, Susan Sheridan, Youssef Tawfik, Phommady Vesaphong, Wilson Were, Jean-José Wolomby, Blair Wylie, and Juliana Yartey. We also deeply thank the individuals that conducted early study of the checklist program for practical usability in their own hospitals, including Shereen Bhutta, Zulfiqar Bhutta, Jane Machira, and Leonard Okoko.
Author Contributions
Conceived and designed the experiments: JMS AAG. Performed the experiments: JMS PA BK AL GD AAG. Analyzed the data: PA SL JMS AAG. Wrote the paper: JMS PA AAG BK SL AL GD RB M. Merialdi M. Mathai CL.
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- 28. Lee AC, Cousens S, Darmstadt GL, Blencowe H, Pattinson R, et al. (2011) Care during labor and birth for the prevention of intrapartum-related neonatal deaths: a systematic review and Delphi estimation of mortality effect. BMC public health 11: Suppl 3S10.AC LeeS. CousensGL DarmstadtH. BlencoweR. Pattinson2011Care during labor and birth for the prevention of intrapartum-related neonatal deaths: a systematic review and Delphi estimation of mortality effect.BMC public health11Suppl 3S10
- 29. Zeger SL, Liang KY (1986) Longitudinal data analysis for discrete and continuous outcomes. Biometrics 42: 121–130.SL ZegerKY Liang1986Longitudinal data analysis for discrete and continuous outcomes.Biometrics42121130
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- 31. Althabe F, Buekens P, Bergel E, Belizan JM, Campbell MK, et al. (2008) A behavioral intervention to improve obstetrical care. The New England journal of medicine 358: 1929–1940.F. AlthabeP. BuekensE. BergelJM BelizanMK Campbell2008A behavioral intervention to improve obstetrical care.The New England journal of medicine35819291940
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- 34. Pronovost PJ, Weast B, Rosenstein B, Sexton JB, Holzmueller CG, et al. (2005) Implementing and validating a comprehensive unit-based safety programme. Journal of Patient Safety 1: 33–50.PJ PronovostB. WeastB. RosensteinJB SextonCG Holzmueller2005Implementing and validating a comprehensive unit-based safety programme.Journal of Patient Safety13350
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Mayo E (1933) The human problems of an industrial civilization. New York: Macmillan. E. Mayo1933The human problems of an industrial civilization.New YorkMacmillan
- 36. Pronovost PJ, Goeschel CA, Colantuoni E, Watson S, Lubomski LH, et al. (2010) Sustaining reductions in catheter related bloodstream infections in Michigan intensive care units: observational study. BMJ 340: c309.PJ PronovostCA GoeschelE. ColantuoniS. WatsonLH Lubomski2010Sustaining reductions in catheter related bloodstream infections in Michigan intensive care units: observational study.BMJ340c309
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The Debt Ceiling Approacheth
Now that the fiscal cliff has been turned into various cliffs over the entirety of 2013 (should be a fun year, gang...), we can turn our attention the the next one coming up.
In February, we face the sequester cliff, followed shortly by the debt ceiling.
For all intents and purposes, this thread will be used as a repository for both cliffs.
The debt ceiling, of course, has far graver consequences for both the country and the planet. Treasury adopted emergency funding measures about two weeks ago.
Here's a question I have. Hopefully this spurns some discussion:
It's often remarked that Republicans have the upper hand in negotiating over the debt ceiling.
Why is that? Is it because Republicans are seen as more likely to cut the baby in half than the President is?
Lawmakers Gird for Next Fiscal Clash, on the Debt Ceiling
By MICHAEL D. SHEAR and JACKIE CALMES
Published: January 2, 2013
WASHINGTON — With the resolution of the year-end fiscal crisis just hours old, the next political confrontation is already taking shape as this city braces for a fight in February over raising the nation's borrowing limit. But it is a debate President Obama says he will have nothing more to do with.
Even as Republicans vow to leverage a needed increase in the federal debt limit to make headway on their demands for deep spending cuts, Mr. Obama — who reluctantly negotiated a deal like that 18 months ago — says he has no intention of ever getting pulled into another round of charged talks on the issue with Republicans on Capitol Hill.
"I will not have another debate with this Congress over whether or not they should pay the bills that they've already racked up through the laws that they passed," the president said Tuesday night after he successfully pushed Republicans to allow tax increases on wealthy Americans. On Wednesday, he signed the legislation.
The president's position is sure to appeal to his liberal allies, who fear another round of compromises by Mr. Obama. But it once again sets the stage for a nail-biting standoff that economists warn could lead to a damaging financial default and doubt from investors about the ability of the country to pay its obligations.
Moody's, the rating agency, warned on Wednesday that the looming political battles over the nation's debt could lower the group's rating of American debt.
"We're in for another round of brinkmanship and uncertainty," said Mark Zandi, the chief economist at Moody's Analytics, who predicted weeks of "angst, discussion and hand-wringing" in Washington. "I don't think the economy can really find its footing and jump to a higher level of growth until we get to the other side of this."
Joel Prakken, senior managing director of Macroeconomic Advisers, an economics forecasting firm, said bluntly, "This is kind of a mess."
The financial imperative for an increase in the debt limit comes at a time of increasingly sour relations between the president and his Republican adversaries in the House. To secure a deal to avert automatic tax increases and spending cuts on Jan. 1, Mr. Obama was forced into last-minute talks with Senator Mitch McConnell of Kentucky, the Republican leader, after weeks of negotiations with Speaker John A. Boehner in the House collapsed amid acrimony and internal Republican dissension.
Now, the president and Mr. Boehner are signaling a fresh round of take-it-or-leave it stands that are in sharp opposition: The president says increasing the borrowing limit is nonnegotiable, while Republicans say the House is all but certain to pass a bill that raises the debt limit only in exchange for significant cuts — a challenge to Mr. Obama and the Democratic-controlled Senate.
Smarting from the president's victory on taxes over the New Year's holiday, Republicans in Congress are betting that their refusal to raise the $16.4 trillion debt ceiling will force Mr. Obama to the bargaining table on spending cuts and issues like changes in Medicare and Social Security.
But doing so would inevitably reprise the bitter debate over the debt ceiling that took place in the summer of 2011, when the government came close to defaulting on its debt before lawmakers and the president agreed to a 10-year package of spending cuts in exchange for Republican agreement to raise the debt ceiling by about the same amount.
And that is exactly what Republicans want — again.
"If they want to get the debt limit raised, they are going to have to engage and accept that reality," said Brendan Buck, a spokesman for Mr. Boehner. "The president knows that."
Senator Patrick J. Toomey, Republican of Pennsylvania, said flatly that his party should risk the possibility of default — including interruptions in federal benefit checks and paychecks for government workers — if it was the only way to compel the president to support deep spending cuts that will reduce the deficit.
"That's disruptive, but it's a hell of a lot better than the path that we're on," Mr. Toomey said Wednesday on MSNBC. "We absolutely have to have this fight over the debt limit."
The Republican Party's caucus in the House will discuss a debt ceiling strategy at a private retreat in Williamsburg, Va., this month, according to a top Republican aide, who said they were determined to insist again on spending cuts that equal the amount of increase in how much the country can borrow.
"The speaker told the president to his face that everything you want in life comes with a price," the aide said. "That doesn't change here. I don't think he has any choice."
White House officials say Mr. Obama is equally determined to avoid letting the debt ceiling become a regular Republican tool for extracting concessions on spending on programs popular with Democratic constituents.
"It means that he won't negotiate on it," a senior administration official said Wednesday about the president's comments. "He's not entertaining offers about it. We're not having meetings about it."
The official, who asked for anonymity to discuss legislative strategy, said the debt limit "was never used as a policy leverage tool before."
"This is them paying the bills for the spending that they racked up," the official said. "They need to do that."
Some people in both parties questioned why Mr. Obama would so emphatically vow not to negotiate over the debt limit, a promise he may ultimately be forced to break if necessary to avoid economic shock waves.
"It's bizarre," said one veteran Democratic senator who would not be named, citing the proven willingness of Republicans to force a fiscal crisis unless the president makes a deal for additional spending cuts.
Mr. Obama resolved immediately after the 2011 debt crisis, privately and publicly, that he would not be drawn again into negotiations over the borrowing limit. He has said that presidents and Congresses have a fundamental, shared responsibility to ensure that the government pays bills that it owes to its citizens and creditors.
In saying he will refuse to bargain over the debt limit, Mr. Obama is counting on help from the business community, given its traditional ties to Republicans. Recently, for example, the head of the Business Roundtable, John Engler, a Republican and former governor of Michigan, called for extending the debt limit for five years.
"You don't put the full faith and credit of the United States' finances at risk," said David M. Cote, chairman of Honeywell and a Republican member of the 2010 Simpson-Bowles fiscal commission. "The whole idea of using debt ceiling that way or saying 'I'll do this horrible thing to all of us unless you give in' just doesn't make any sense for anybody. It makes me very nervous. It's not a smart way to run the country."
Mr. Obama might also take to the road again, using the power of his office in an effort to convince the public that another fight over the debt ceiling risks another economic crisis. Public polls after the last debt ceiling fight suggested that more people blamed Republicans for the threat of a shutdown.
"If Congress refuses to give the United States government the ability to pay these bills on time, the consequences for the entire global economy would be catastrophic — far worse than the impact of a fiscal cliff," Mr. Obama said Tuesday.
What are you talking about? The federales just generated $60 billion more in annual tax revenue.
The problem is solved. :drool:
The Next Fiscal Cliff
Dont celebrate yetthe next budget crisis is just two months away.
By Matthew Yglesias
Posted Wednesday, Jan. 2, 2013, at 2:04 PM ET
The fiscal cliff is deadbut the era of semi-permanent fiscal policy crisis is still with us. Indeed, if anything, the resolution of the cliff has simply served to set up a quantitatively smaller but qualitatively much more terrifying cliff two months from now. Thats when the country once again reaches a crisis over the lapsing of the Treasury Departments authority to borrow money.
Once upon a time, when Congress wanted to instruct the federal government to spend more money than it was going to collect in taxes, it would specifically authorize bond sales. During World War I this was deemed inconvenient, and Congress instead generically authorized the borrowing of a bunch of money to finance its appropriations. Since this number was specified in nominal dollar terms, inflation and economic growth ensured that over time we would hit this new debt ceiling under any conceivable fiscal policy. So then Congress would raise it. And we would hit it again.
Over time, a tradition of partisan grandstanding emerged. Even though the need to borrow more is driven entirely by the nexus of tax and spending laws Congress has passed, operationally the request for a higher debt ceiling must be submitted by the Treasury secretary. Thats a golden opportunity for opposition members of Congress to castigate the incumbent administration for its irresponsibility, even though everyone knows it ultimately has to be raised. Or at least they did until 2011, when Republicans coalesced around the Boehner rule that every dollar of increased borrowing authority should be offset by a dollar of spending cuts. The Obama administration reacted by taking the bait and trying to entice Boehner into a grand bargain. It didnt work, and instead we got the Budget Control Act and the automatic sequester cuts that became part of the fiscal cliff.
Initially, hopes were high in Washington that the cliff might be averted byagaina grand bargain on the long-term deficit. But this weeks deal doesnt do that. It extends somewhat more of the Bush tax cuts than Obama wanted to extend, offers no new spending cuts, and on the sequester it simply punted. Implementation was delayed two months until the beginning of March, thus creating a brand-new cliff of cuts to domestic and military programs that would hurt the economy and allegedly harm military preparedness.
And while this cliff is much smaller in scale than the full cliff that was narrowly avoided on New Years Day, its much more terrifying because it will arrive in the beginning of March when were hitting the debt ceiling again.
Or, rather, the Treasury Department says we already hit it earlier this week. For now, they can pay the governments bills with a few accounting tricks rather than with more borrowing. But these extraordinary measures can only work for so long. Treasury wont say exactly when the bag of tricks runs out, but past experience tells us its about two months. And this sets up an interesting collision, since the administration has sworn to the press, Senate Democrats, and yours truly that they have no intention of bargaining over the debt ceiling a second time.
Their viewand its a correct oneis that authorizing the executive branch to pay bills that Congress has already legally required the Treasury to pay is not a concession to be bargained over. Even establishing the precedent that there will be bargaining over the point is dangerous since a bargain might always fail and create a disaster scenario in which theres no way to avoid defaulting on legally valid federal obligations.
At the same time, conservative members of Congress have no intention of ditching their Boehner rule. On the contrary, recalcitrant members were induced to allow the cliff deal to pass in part on the promise of future spending cuts to come.
Meanwhile, Obamas negotiation of the fiscal cliff deal has raised grave doubts about his credibility on the debt ceiling. The deal itself is fine on the merits, but it is based on the president violating what seemed like a firm commitment not to extend tax cuts for people earning more than $250,000 a year. White House officials explained, among other things, that it was unlikely moderate Senate Democrats would really hold that line if we went over the cliff. So is the debt ceiling really any different? If House Republicans hold firm on the Boehner rule, are Democratic senators from Arkansas, South Dakota, Alaska, North Carolina, and other red states going to have Obamas back on a no-bargaining stance? Will Obama be willing this time to hold a line that red state Democrats arent? I have my doubts, and House Republicans do, too.
The intersection of the sequester cuts and the debt ceiling may provide a way out. Obama and the GOP could agree on a package of cuts to replace the sequester, and that legislation could also hike the debt ceiling. That would let Republicans say the debt ceiling hike was paired with spending cuts, while Obama can say he negotiated the sequester, not the debt ceiling. But that still leaves the question of what package of cuts the two sides could agree to. House Republicans have been pretty clear that they want to replace the sequesters military cuts with cuts to anti-poverty programs, and Obamas been very clear that hell agree to no such thing. Instead, hes said any further cuts will have to be balanced by further tax increases. Back to the grand bargain in other words, even as that bargain looks no more realistic today than it did three weeks ago.
In other words, the whole exhausting saga is going to go around and around. Welcome to the permanent fiscal emergency.
By 2025, entitlement spending and debt payments are projected to suck up all federal revenue.
Of course, we won't be making it to 2025.
No later than 2016 I figure.
Pretty interesting strategy piece by Marc Ambinder.
Do Republicans really have leverage now?
Marc Ambinder
January 3, 2013, at 3:27 PM
There are two ways to look at the policy fights in Washington. One is that the just-completed fiscal cliff deal is one round of four, with each side emboldened to approach the next round with new wind at their backs. The other is that the fiscal cliff deal sets the tone for the next three battles, and each, while painful and full of theater, will resolve themselves somewhat predictably.
Remember: The debt ceiling expired at the end of the year, but the Treasury can move money around until the middle of February. That's "Round Two." Round Three is the resumption of the sequester spending cuts, which are mandated by the 2011 Budget Control Act; half will come from defense, half will come from domestic spending. The budget deal delayed their implementation by two months, to March 2. Round Four is the budget for 2013; the government's blueprint for obtaining and spending money becomes moot on March 27.
Republicans would seem to have the upper hand, at least somewhat, because the first "round" had nothing to say about spending cuts, which Democrats want to avoid. All the bargaining from here on out will be about what to cut, because, by law, about $110 billion worth of deficit must eliminated budget by the end of the year. Leverage!
But it's hard to see how that works in reality. They've got some leverage, because there will be spending cuts, but not as much as it seems. First, just remember that "deficit reduction" and "spending cuts" aren't the same thing. If a magical new source of revenue is found between now and March 2, like, for example, the government discovers $110 billion worth of gold bars in a bunker somewhere, they can reduce the deficit without cutting anything. That's obviously not going to happen, but there are many, many different ways to close the mandated gap without simply cutting a lot of money from programs.
Now, Republicans are going to insist that Democrats agree to immediate discretionary and entitlement cuts above and beyond anything already budgeted, and it is fair to assume that spending cuts of a certain (and uncomfortable to Democrats) magnitude will be the line in the sand that Speaker John Boehner will draw.
Democrats and President Obama are going to insist that the sequester cuts and any subsequent cuts be accompanied by revenue-raising measures like tax increases, levies, and tax reform. (The money available is limited by deduction limits for those making above $250,000 Obama asked for as part of the first fiscal deal.)
But what Obama really has done is delayed the inevitable. He has a bunch of concessions that he knows he has to make — Medicare cuts among them — that he did not have use up to get Republicans on board with the change in marginal tax rates. One reason why Democrats balked so quickly at the Republican proposal to change the cost-of-living adjustment formula for entitlements is that they'd rather lose that fight later.
Also, Republicans have to specify how they want to cut the budget. Obama doesn't have to do that. He has already suggested a willingness to accept Medicare COLA changes, and he asked Republicans for ideas on revenue-raisers. In appearing to compromise his campaign position that taxes for people earning more than $250,000 would go up — a marker for defining the middle class, something very important to some Democratic activists — he has given Republicans the responsibility for detailing their own "ask."
Here is a thought experiment: Going over the fiscal cliff would have damaged the economy and thrown it back into a recession. Defaulting on the national debt would probably send the economy into a depression. Why would the Republicans, who, after all, were reasonable enough to vote on a tough deal to avert the fiscal cliff, refuse to make a deal on legislation to avert the debt ceiling default, which would imperil the country and anger their donor base even more?
It may be wiser for Republicans to use all of their leverage to insist on deep cuts during the sequester fight without upsetting the financial markets by holding the debt ceiling over the president's head. The president is counting on Republicans to be unreasonable, but if they aren't, then he loses some of the political leverage he has.
2013: Year of the Cliff
How Washington Learned to Love Hostage-Taking
Alec MacGillis
January 4, 2013 | 12:00 am
President Obama's decision to agree to a "fiscal cliff" deal that doesn't address the debt ceiling was premised on the thinking that congressional Republicans will not be as successful at holding the economy hostage in the coming months as they were in the summer of 2011. For one thing, the administration believes the business community, and elite opinion more broadly, will be much more vocal than they were last time around in cautioning Republicans against debt-ceiling hijinx.
Is this a fair assumption to make? Well, there are already signs that business leaders will in fact be more outspoken (not difficult, given that they were virtually mute in 2011). "You don't put the full faith and credit of the United States' finances at risk," David M. Cote, chairman of Honeywell and a Republican member of the 2010 Simpson-Bowles fiscal commission, told the New York Times yesterday. "The whole idea of using debt ceiling that way or saying 'I'll do this horrible thing to all of us unless you give in' just doesn't make any sense for anybody. It makes me very nervous. It's not a smart way to run the country."
But it's looking as if elite opinion more broadly is more sanguine about another debt-ceiling showdown than the White House had hoped. It is striking to what degree the Washington establishment has come to normalize Republican hostage-taking of the debt limit, to see it as a predictable and almost natural element of the political landscape. Greg Sargent argues convincingly why this is a problem, noting that the debt ceiling must be raised to pay for past spending, and should not be used as a chip in negotiating future budgets: "In the current context, conservatives and Republicans who hold out against a debt limit hike are, in practical terms, only threatening the full faith and credit of the United States — and threatening to damage the economy — in order to get what they want. Any accounts that don't convey this with total clarity — and convey the sense that this is a normal negotiation — are essentially misleading people. It's that simple."
What bears stating even more strongly, though, is how far we've come from 2011, when the Washington establishment viewed the Republicans' threat of credit default as as the utterly brazen and unprecedented step that it was. Even those who supported the gambit recognized it as a newly deployed weapon. "While opposition to raising the debt ceiling is common, using the face-off to extract real concessions is less so," conservative economist Kevin Hassett, of the American Enterprise Institute, wrote in January 2011.
News reports on the threat of default cast it as a truly risky move: "The debt ceiling debate presents some congressional Republicans with an unhappy choice: A vote to raise the ceiling might expose them to primary challenges in the 2012 election, while a vote against it risks a default on U.S. debt obligations that could jeopardize the fragile economic recovery," wrote Peter Nicholas of the Los Angeles Times that May. As the deadline neared, the tenor of the coverage grew even more ominous: "Georgia Republicans today will help decide whether Washington's unprecedented debate over the federal debt ceiling should be pushed closer to the edge of --- or even beyond --- a potentially dangerous Tuesday deadline," the Atlanta Journal-Constitution reported on July 28. Even after the crisis had passed, official Washington looked on the Republican strategy with a mix of awe and horror -- I was part of a major effort at the Washington Post to reconstruct the year-long tale of how the House GOP came to embrace this previously unthinkable approach.
Now? Political convention has successfully been defined down, and the Republicans' stated intent to hold the debt-ceiling hostage again is being viewed as a matter of course. This Politico report on Tuesday is representative of the Beltway establishment's acceptance of the negotiating tactic:
So: a threat to plunge the nation's into default and with it imperil the nation and world's economy, seen only a year and a half ago as the political equivalent of a nuclear option, is now viewed as "better political ground." What to make of this? The shift in mindset is surely in part a function of basic human nature: our remarkable ability -- for good or ill -- to adapt ourselves to new realities. More than that, though, it is a function of that far more Beltway-unique tendency, to report and comment on politics and governance as pure gamesmanship in such a way that conveys savvy but not judgment. And if it's all a sport, who's to object if one side has radically shifted the goalposts? Good for them, if they can get away with it. And after all, the higher the stakes in the clash, the better the story.
It's one thing if this blitheness about the coming hostage-taking is contained within the Beltway. But if this perception starts to percolate out more broadly, the White House is in far weaker position heading into the next round than it would like to believe.
The GOP has said that revenue increases are off the table. Not likely.
The White House has said that they will not bargain over the debt ceiling. Even less likely.
I think the biggest problem coming to a deal here is that the GOP will rightly insist on spending cuts, but will also insist that Obama propose them. They have had a very difficult time coming up with cuts to entitlements they support, and I see no reason Obama will do the job for them, especially when he knows they will attack him for it.
We got a taste of this already, as soon as Obama was considering the change to chained-CPI Senate Republicans were publicly attacking him for wanting to cut benefits. How do you negotiate with a party that doesn't even know what it wants?
This brings up the new GOP strategy, which is to not negotiate with the White House at all anymore. This was discussed in The Hill. They will try to just go through the normal legislative process and negotiate with the Senate in a closed-door conference committee, leave the WH out and basically dare Obama to veto anything that passes both chambers.
I actually think its a pretty canny strategy, and don't know if Boehner has any choice considering the skepticism his backbenchers view these WH negotiations with now, but it puts a big target on what I was just saying. By going this route, the GOP has no way to force Obama to propose the spending cuts. They have to originate it themselves and pass it through the House. As good of a game they talk about wanting spending cuts, they don't have a lot of real ideas in that dept besides wholesale destruction of Medicare replaced by Premium Support, which doesn't stand a chance in the Senate.
I agree it's a cunning strategy, but it's only going to further shield the President from blame if it doesn't work out.
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Introduction to Psychic Development, NYC
introductory course is open to anyone interested in accessing their psychic
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Born and raised in Australia, Calise Simone is an internationally recognized Psychic Medium and Intuitive Consultant. Calise has been featured on FUSE TV and Calling Out Radio for her psychic work and described by celebrity Clairvoyant medium Lisa Williams as "A very gifted medium".
NB: Exact address of workshop will be provided upon registration****
By purchasing a ticket to this workshop you are acknowledging that you understand and agree to the below disclaimer.
All ticket sales are final. Readings provided are for entertainment purposes only, any actions taken based on information received during a reading is down to your own personal responsibility and choice. All readings and questions answered should at no time be regarded as legal, medical, financial, psychological or business fact nor professional advice and are subject to your own interpretation and judgment. Messages provided during a reading are not a substitute for professional services and it is advised that you should seek advice from the relevant qualified expert.
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What does wave-off mean?
Definitions for wave-off
Here are all the possible meanings and translations of the word wave-off.
Princeton's WordNet
overshoot, wave-off, go-around(verb)
an approach that fails and gives way to another attempt
wave off(verb)
dismiss as insignificant
"He waved off suggestions of impropriety"
Chaldean Numerology
The numerical value of wave-off in Chaldean Numerology is: 5
Pythagorean Numerology
The numerical value of wave-off in Pythagorean Numerology is: 6
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Kate Mary wrote:I like the first story very much and I'm even warming to Noddy too.
Gosh, at this rate even Anita may yet be won over! Honestly, I thought "After the Party" was one of the most boring and annoying and obvious Noddy stories I've ever read — well, it is from relatively late in Enid's career. Her earlier Noddy stories, especially the first several of the original books, are much more inventive and full of fun, I've always reckoned. Noddy Goes to Toyland (the first Noddy book) is in some ways remarkably poignant for a story aimed at very young children — I remember reading it at the age of about 7 or 8 (a bit "old" for it, and of course I was very familiar with Noddy by then) and I was amazed at how moved I was by the question of whether Noddy would be accepted as a "real" toy and be allowed to stay in Toyland. It sounds funny, I know, but there it is. Much more thoughtful than this tedious business of Noddy driving off in the wrong car in the dark (duh) and not being recognised because he was wearing a different hat (double duh)!


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The food that the American Pioneers knew was simple and hearty. Often, dishes were cooked in one pot over the fire, using whatever was available. Since they didn't like to waste anything, women often prepared soups and stews for the family because it was an easy way to use up scraps.
Days were long and full of hard physical labor, so meals also had to be filling to keep everyone going.
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Cooking methods may have changed over the years, but you can still bring history to life in the kitchen by recreating some dishes from the American frontier.
Bacon Johnnycakes
Both bacon and corn cakes were eaten by the settlers, so why not combine the two?
- Bacon (as much as you'd like in the johnnycakes)
- 1 ¼ cups cornmeal
- 1 teaspoon sugar
- ½-1 teaspoon salt
- 1½ cups boiling water
- 2 TBSP bacon drippings
- Cook the bacon until crispy. Reserve the grease to use for cooking. Once the bacon has cooled a bit, crumble it up so you can add it to the johnnycake batter.
- Combine all of the dry ingredients. Gradually add the boiling water to the dry ingredients, mixing with a spoon until moistened. The consistency should be thick (instead of runny) but should still be able to slide off the spoon. You may need more or less boiling water to achieve this consistency.
- Add the crumbled bacon and mix well.
- Heat bacon drippings in a cast iron skillet or non-stick pan. You don't want the cakes to stick.
- Spoon the batter into the pan, using one large spoonful for each cake. Once the edges begin to brown and become firm, flip over to cook the other side. If needed, you can add a couple of
drops of oil to the top of the cake before turning it over. Cook until the other side is done. You can press them down a bit to keep an even thickness. Move them to a platter.
- Top with butter and syrup (if you'd like) and enjoy!
5 Additional Pioneer Recipes
Apple butter was made by cooking apples in a large pot outside. Today, use your slow cooker to make your own.
For years, people have been salting and curing meat to make it last longer. To get a sense of how they did this, make your own beef jerky. You can dry it in a food dehydrator or right in your oven.
When in season, fruit was picked and either preserved or used in a variety of recipes. One fruit dish was cobbler, which could be made out of many types of fruit. Try this blackberry one.
The settlers made all their own cheese and butter. See what the process was like by making this ricotta cheese.
Pop some popcorn on the stove and use some molasses to turn it in to a delicious, sweet treat.
Pioneer Cookbooks
The Little House Cookbook: Frontier Foods from Laura Ingalls Wilder's Classic Stories by Barbara M. Walker
Log Cabin Cooking: Pioneer Recipes & Food Lore by Barbara Swell
Pioneer Recipes by Bobbie Kalman
Looking for more American Pioneer learning activities?
- 6 Covered Wagon Learning Activities
- 6 Pioneer Crafts for Teens to Make
- American Pioneers: Books & Resources for Middle School
- Lewis and Clark Animal Discovery Journal
- Pioneer Life – 8 Learning Activities for Kids


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There is a lot of confusion concerning crystals used in fashion jewelry today. Most crystals used in this kind of jewelry is man-made, but also some natural semi-precious stones are used. The man-made crystal most resembling natural diamonds is Cubic … Continue reading
Besides beading, my main hobbies are flower arrangements and cooking. It seems that all my hobbies tend to turn into some kind of semi-hobby-business activities requiring more time than I can set aside for these interests. I am a "full … Continue reading
Every one in the world wants to look fashionable. Further, all of us love to look trendy and like to have his / her own identity apart from a crowd of people. We know your appearance and attire speaks louder. … Continue reading
Fine jewelry with gold and diamonds is at the high end of the scale and may be more difficult to purchase due to the high cost. Fashion jewelry is often a good choice instead as the price is significantly lower … Continue reading
Most Fashion Jewelry is created using non-precious materials. Metal parts are often gold- or silver plated and with or without crystals, pearls and stones. Fashion jewelry is nothing new, it has been around since the early ages of humans in … Continue reading


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Battle Camp is a new massively multiplayer online puzzle RPG by Penny Pop. The fun, light-hearted tone of the game masks what is actually one of the better MMO games to come out recently for the Android and iOS platforms, as Battle Camp combines the battling style of Puzzle and Dragons with humor and clan wars aspects that turn it into a great original game in its own right. Read on for some tips and tricks for Battle Camp!
Battles start off easy, then get harder and harder as you gain levels and unlock new stages. Before you go anywhere, try to put at least one rare monster together by battling and collecting the puzzle pieces that you get. Once you get the puzzle pieces for that rare monster, start racking up common monsters that you can then use for fusing.
Once your rare monster is ready for battle, put it into your team, and then use the Fuse option to increase its level. This will enable it to get stronger, and will prepare it for when you are ready to evolve it. Evolution can only happen to rare monsters, and requires some combination of other common monsters, which can be caught by beating battles in areas that you have usually already been to.
Rare monsters aren't the only good ones though. Even some of the common monsters will be more powerful – for example, the ones that you catch in the Teepee Hollow will be more powerful than the ones that you catch in the camp itself.
Normally, the game will automatically target enemy monsters, but if you want to target a specific monster in battle, tap on that monster and a crosshairs will appear above it, indicating that it has been targeted. Use the element chart (the triangle in the upper right corner of the screen) to figure out which elements work best. Rock and Wind are strong against each other. Fire is strong against plant, plant is strong against water and water is strong against fire.
Always try to make the biggest combinations that you can in battle, and make as many combinations in one turn as you can. Early on in a turn, go for one or two matches of five or more in order to target every monster on the screen. If you are fighting only one monster (or two monsters) then go for a bigger combination consisting of matches of 3 or 4 in a row, in order to do larger amounts of damage.
Click here to continue on to part 2 of the Battle Camp tips and tricks guide!


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Home | Indian Newspapers | Lokmat
About Lokmat Newspaper
Lokmat is the largest read & circulated Marathi language newspaper. It is the fifth largest Indian daily and in Marathi, it is the largest selling daily with 1.58 million copies a day. As per IRS 2010 Q3, Lokmat has a total readership of 23.67 million. Its registered and corporate offices are located in Mumbai, Maharashtra and its main administrative center is located at Lokmat Building, Lokmat Square, Nagpur.
Owner of the Lokmat Newspaper is Lokmat Group. Its Daily publishing newspaper. Its circulation of 15,888,099
Lokmat Newspaper Details
Lokmat Publisher : Lokmat Group
Lokmat Language : Marathi
Lokmat Newspaper URL : http://www.lokmat.com/
Lokmat newspaper published from : Mumbai
Click Here to Read More Marathi Newspapers
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Robert Pattinson not dating Riley Keough, confirms rep
Riley Keough's representative has rubbished reports that the actress is dating Robert Pattinson.
A representative of Keough told Just Jared that she is not dating Pattinson and added that he could confirm that she was not photographed at all this weekend, the New York Daily News reported.
The speculations of the pair dating started after the 'Twilight' star was spotted driving to his LA mansion with an unnamed lady in the passenger seat.
The woman in question was later identified as Keough, 24-year-old granddaughter of the iconic singer Elvis Presley, by a photo agency.


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Piper Griffiths wants one thing in life: To become a Consul, a keeper of the peace between humans and daemons. There are precisely three obstacles in her way.
The first is Lyre. Incubus. Hotter than hell and with a wicked streak to match. His greatest mission in life is to get Piper into bed and otherwise annoy the crap out of her.
The second is Ash. Draconian. Powerful. Dangerous. He knows too much and reveals nothing. Also, disturbingly attractive - and scary. Did she mention scary?
The third is the Sahar Stone. Top secret magical weapon of mass destruction. Previously hidden in her Consulate until thieves broke in, went on a murder spree, and disappeared with the weapon.
And they left Piper to take the fall for their crimes
.Now she's on the run, her dreams of becoming a Consul shattered and every daemon in the city gunning to kill her. She's dead on her own, but there's no one she can trust - no one except two entirely untrustworthy daemons...see problems one and two.
©2014 Annette Marie (P)2015 Tantor
"Great story, shame about narration"
The story was very good. Unfortunately, I was seriously distracted by the nasal quality of the narrator. It sounded very much like she had a horrific cold or a peg on her nose and was struggling to breath, could really do with being rerecorded
"Never narrate a book when you have a cold!!!"
I would normally carry on with a series and buy the next book straight away but the narrator has put me off and I've started something else instead
Does this narrator have a cold....I had to speed the book up as it became very annoying...
Such a shame as the book was ok.
"fantastic start to an amazing series"
I have not read the book but I don't think anything could take away the depth and wonder the narrator brings to the story at first i thought she was annoying because of the way she pronounced Deamons but that was my fault as it shows later that she was saying Daemons ,two different things shes amazing all through the series.
the characters develop the beginnings of their friendship and growth in this book.the main story line is the spring board for a very interesting series.Im writing this review after listening to all of the books so I cant pin point anything with out knowing the outcome of the books but it is certainly worth reading.
100% i didn't stop at all, i even started the next
I'd recommend this series whole heartedly.
"One of my new fave series"
I'm leaving this review on all of the books from this series, but no real spoilers here.
I can say that I'm terribly sad that I'm almost done with the 5th book in this series (even if only 3 are on audible), I am worried that I won't be able to find another series that I love quite like this one, not for awhile. But in another way I'm a little bit glad that I am almost done because I can get back to my life afterward!
I read a ton of books. I don't always leave reviews, but I had to leave one for this series because it kept me going and going and going. I never wanted to put it down. I had to force myself to do so. And when I found that the last two books were not on audible I almost cried, not kidding. The narrator, while not my favorite at first, ended up fantastic.
The plot was awesome. Slight spoiler here: the love story is terrific. There wasn't much of the icky-sweet, romantic-puke, "our love is the strongest love that ever existed" crap that I see in other series that always makes me go "Really? C'mon now." This one was so much more realistic.
I like that the characters are strong but faulted. I love how the friendship between the 3 grows so strong. I wish Piper would say "Thank you" once in awhile, but I'll get over it. I like how the twists happen, when you think one thing might happen and then, bam, another thing happens.
This series had me gripped from *literally* (I'm using that with it's intended meaning), the first chapter of the first book. That is my favorite type of book, the kind that just grip you and won't let you go. I haven't had that happen to me for a long time and it was such a pleasant surprise, even if it did keep my up until 3 in the morning a few times. These are going on my faves shelf because...well...they are.
Dear Annette Marie, more please? Pretty please?
"Got past the cover art to enjoy the book"
I avoided this series for awhile because I didn't like the illustrations on the covers. It's strange how much that first impression affects my book selections, but I'm glad I finally gave it a try.
I really enjoyed the three main characters and the relationships they built. The main girl was annoying at times (overreacted to several situations in ways that hurt one of the other characters), but I liked that she made up for her lack of magical abilities with fighting skills and determination. The two guys pulled me in, both with their looks and personalities. You slowly get to know them throughout the book, and there isn't an instant love connection for no reason, but there is attraction which will probably lead to a love triangle.
The book had a lot of action, and there was a new challenge for the characters around every corner. The ending isn't a cliff hanger, but there are lots of things left untold that make me want to continue with the rest of the series right away. Hope Audible publishes the whole series soon!
I know there are a lot of comments about the narrator already, but I'll add my opinion. She did a reasonable job. The things that bothered me are how young/immature she sounds (but I know the main character is young too), and many times she shouted or used a tone of voice that just didn't make sense in the context. Yes, she sounds a bit congested, but I got used to that. Overall, it was ok and didn't ruin the book.
"The narrator needs help!"
I've never written a review before, but I feel I must. The story was fantastic. I loved the book. The narrator? Oh my goodness. First, the good: she has a nice tone, she speaks well and has decent acting skills. The bad: . She sounds like she has a cold for the entire book, and for about 25% of the book sounds as if she's actually plugging her nose. My biggest pet peeve throughout the entire book that was INCREDIBLY distracting is that she doesn't pronounce L's that are preceded by O's. Example: shoulder shoulder very obviously has a L in the middle of it but she pronounces it SHOW-DER. Hold? Pronounced HOAD. Is this a dialect thing? I don't know, but PLEASE SOMEONE! Give her some tips!! She could be very good with some coaching, but then again so could I. It is so bad and so distracting that I'm really debating whether or not to get the second book. I did really enjoy the the story itself, but her narration is so distracting to me I'm not sure if I'm going to purchase book two.
My big question is: why did no one notice this in the proofing/editing/whatever they do with audio books??
"if you can ignore the narrator's cold..."
the story was surprising. I really liked it. Books have gotten so old lately, vampires or warewolves finding themselves in a situation that they have to overcome then they quickly fall in love. BLAH this was very different. I enjoyed the story and the elements of the different world.
What I did not like and what took a lot of getting used to was the narrator's stuffy nose. Sometimes it was so distracting that I had to pause it and come back later. It was like she had a nose full of snot and didn't want to stop to go blow her nose. if she didn't have a cold I bet she would have been awesome! the way she changed her voice for characters was nice. ill try the sequel.
"Had a hard time finishing the book."
The story wasn't bad, but I was not a fan of the female lead. She was suppose to be in training to be a Consul , yet she reacts to every conflict with emotion, drama and makes one stupid choice after another. An immature teenager who is suppose to be a leader, follows everyone around and when she asserts herself, it is always disastrous. After awhile it became too much.
I ended up skipping to the end to see what happened. I will not be continuing with the series.
"HORRIBLE narrator!! Made me return the book"
I have a rule. Give the narrator one hour so they can relax into their role. Ittook everything in me to stick to that with this book, because within that one hour, I cringed over a dozen times and paused it twice. It wasn't the writing... that actually was already interesting to me. It was the narrator. She is dreadful. She slips into this nasally tone frequently, often mid-sentence that makes it sound like the characters are being strangled. Needless to say, I returned this book... and I never return books. I've heard so many good things about this series, so I'll pick up a paperback copy instead. Do not waste your time on this!
"so fast paced, did not want to put it down"
wish I had gotten it a lot sooner. lol Jorjeana Marie does the Narration just right. must go, starting the 2nd one.
"Absolutely Love This Series"
This book is so fun to read/listen. The characters are well defined and the action was non stop. This series has drama, action, adventure, suspense, twists, & romance.
Lyre!!!! It is a good thing I don't know any incubus. Boy is he charming! I loved his easy going personality. I also loved Ash.
The author is just amazing. A great start to a great series.
"Pass the narrator atissue"
The story was good, but OMG, the nasally tone of the narrator was just too much. I kept wanting to tell her to blow your nose. She sounded stuffy... So I had to stop listing to the book....
I just hope the producers and editors read these reviews, and pay better attention on details that ultimately ruins an audiobok... What a waste!!!! Once again, a good story botched by a bad narrator and production company.
"Another Good Paranormal Story"
Piper, Lyre and Ash are young but behave like adults when dealing with the obstacles that they encounter. They are sexy, smart, and funny which when combined with magic and shape changing makes for a great listen/read. My only complaint is that the narrator sounded as if she had a cold. A little nasally. Luckily the problem improved after a few chapters,
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Hello, does anyone have any idea why these little grey bars have suddenly popped up on my text boxes on my blog site? They weren't there yesterday and I'm not sure what has caused them or how to get rid of them. I was working on my social icons today, but didn't touch the other boxes, so I'm not sure why they all have them. Any help is appreciated.
My site is: http://melaniebolke.com and I'm using PaperPunch
The blog I need help with is melaniebolke.com.


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On Thu, 2007-08-02 at 17:26 +0200, Ralf Ertzinger wrote: > Hi. > > On Thu, 02 Aug 2007 17:43:29 +0300, Jonathan Dieter wrote: > > > Packaging it as an rpm would also help in keeping track of what > > "version" of the virtual hard drive is on each real machine. If we > > decide to add a new program to the virtual hard drive, we could bump > > the version and rebuild the rpm. All systems with the old rpm would > > get the new one during their nightly yum update. > > Especially since the virtual machines modify the drive image, thus > an update kills all modifications to the image. > I should probably clarify my previous post. The hard drive images are readonly, and we use qemu-kvm -snapshot, so all changes are lost when the machine is shut down anyway. Jonathan
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