Price transparency is a vital factor in consumers’ judgements and decisions. When selecting a bundled vacation package, travelers are often influenced by transparency in the prices of individual elements of the package. However, because of the diversity of elements bundled in a vacation package, it is a challenge to research the impact of price transparency. To try to overcome this challenge, our study used five experiments to examine the primary impact of element price transparency on travelers’ purchases, along with the moderating effects of consumer involvement and the vertical position of element prices in product descriptions. For the primary effect, we found that tourists preferred vacation packages with low transparency in element prices. We also found that the primary effect of price transparency remained consistent and robust across both revised and actual vacation packages. For moderating effects, we found that tourists with low involvement attached greater importance to price transparency than those with high involvement when the element price was presented higher in the product description of the travel package. The findings of the five experiments have theoretical implications for price transparency and Heuristic-systematic Model and practical implications for tourism professionals designing and marketing vacation packages. China Snow Town and the problem of different charges for the same package. The root cause of the above issues is closely related to the price transparency of vacation packages. The tourism enterprises attempt to benefit from information asymmetry by concealing the element prices in packages.In the past two decades, China’s tourism industry has progressed rapidly, and the number of tourists travelling with guided tour has also increased year by year.Tourism enterprises usually strategically manipulate  the element prices within a bundled vacation package. To make the best purchasing decision, tourists attempt to find relevant prices until they have formed some judgments . They maThe existing research confirms the impact of price transparency on consumers’ positive responses. Above all, this paper explores the following questions through five experiments: (1) Under the circumstances of different levels of price transparency, how will consumers purchase travel packages? (2) How does consumer involvement affect the relationship between price transparency and consumer purchase intention, and will it play a moderating role? (3) How does the vertical position of an element price moderate the impact of price transparency on consumers’ purchase intention? Experiments 1, 2 and 3 mainly studied consumers’ willingness to purchase vacation packages under different levels of price transparency by changing experimental materials and participants. The main effects were verified through three experiments to ensure the external validity and robustness of the primary effect of price transparency, which lays the foundation for the subsequent tests of the moderating factors; Experiment 2 mainly examined how consumer involvement affected consumer responses to price transparency; Experiment 3 mainly investigated how the vertical position of an element price moderated the impact of price transparency on consumer decision-making. The conclusion of these experiments will provide some reference for travel agencies to make more effective price marketing strategies.Price transparency is an important dimension of information transparency and an extension of the core concepts of availability and accessibility . Price twhether the price should be transparent and how the price should be made transparent. The first is mainly based on the accessibility and availability of price information, and the academic community has not reached a consensus on the impact. Some research shows that revealing the price of each component of the product would destroy the balance of information due to the spillover effect, and cause distortion to both parties of the transaction  is a theoretical model of the dual-processing of individuals when processing information . The moddisease risk ,computer and information technology ,information security ,food safety ,crisis management ,decision-making marketing field .HSM is a framework and behavioral paradigm for studying behavioral decision-making. It can explain individual processing, evaluating, using information and decision-making in different situations . It is wFrom research in the field of marketing, heuristic factors such as the reliability of information sources, and individual perception of information quality  can stimIn tourism, HSM has served as the theoretical support for a number of studies, such as online reviews , online The research above suggests that HSM provides a sound research perspective for the study of consumer decision-making. However, the impact of heuristic cues on sales performance, consumer decision-making and purchase intention has received relatively little attention from researchers . The impWe predicted that the transparency of element prices in a bundled vacation package might influence travelers’ purchase intentions. The framework of HSM strongly bolstered our prediction.HSM argues that individuals are likely to process heuristic cues to save cognitive efforts in the decision-making process. This follows the principle of “minimum cognitive effort” . As a heH1: Bundled vacation packages with low transparency of prices will increase travelers’ purchase intention compared with those with high transparency prices.Our research suggests that the factor of involvement affects the impact of price transparency. According to HSM, the choice of individual information processing mode  depends on individual motivation and ability level. Only when individuals have strong motivation will they adopt systematic information processing . MotivatPrior studies have shown that involvement can significantly affect people’s cognitive processes such as attention and memory, behavioral characteristics such as searching for product information and responses when processing information . ResearcH2: Consumer involvement will moderate the impact of price transparency in a bundled vacation package on their purchase intention. Specifically, the positive effect of low transparency on purchase intention will be heightened when consumer involvement is low (vs. high).Our study proposed that the impact of price transparency would be moderated by the vertical position of element prices in sales descriptions. Vertical position is a critical factor to arouse consumer’ attention in product selection both in conventional  and in oH3: The vertical position of prices in a vacation package will moderate the impact of price transparency on travelers’ purchase intentions. Specifically, the positive effect of low transparency prices on travelers’ willingness to purchase will be heightened when these prices are presented at the higher vertical position (vs. lower).China Snow Town in a local travel agency—chosen because it had been criticized for its price opaqueness. Although the destination had dealt with the price issue, the negative impact still exists and consumers are more sensitive to the package price. The product description and price information in the original material were revised. The second, used in Experiment 2, was from the vacation package of Yalong Bay as presented on a tourism website. This was chosen because it had a good reputation in terms of price and other aspects among tourists. Therefore, consumers were less sensitive to the price of this product. The original product description and price information were revised. The third material was China Snow Town, but in its original form rather than revised. This was chosen to ensure the external validity of the impact of price transparency. To minimize country-specific effects, only Chinese participants were recruited for the studies. We conducted five experiments to empirically examine our hypotheses, and to guarantee internal and external validity and methods of measurement and manipulation. Three different experiment materials were used. The first, used on Experiments 1 and 4, was from the travel package Study 1 examined the main effect of the transparency of element prices in a vacation package on tourist purchase intention.163 Chinese adult subjects  recruited from an online panel in March 2021, were randomly appointed to the two experimental conditions. (price transparency: high price transparency in Package A vs. low price transparency in Package B).China Snow Town. They were then required to read a revised vacation package description. We manipulated the presentation of different prices representing high and low transparency such that in one condition, Package A presented the tickets to resorts inside China Snow Town. In contrast, in another condition, Package B presented the prices of two amenities in it.Subjects first imagined as requested that they were planning to take a packaged tour to Then, subjects were demanded to indicate their purchase intention of the vacation package on three-item measurement rated using a five-point scale , compared with considering Package B less transparent when the package showed prices of amenities  = 6.377, p < 0.05, 2η = 0.038).First, the manipulation of price transparency was successful, such that Package A was perceived as being highly transparent when it showed tickets to resorts  than n Package A with high transparency, where the tickets to resorts were presented  = 4.902, p < 0.05, 2η = 0.030).Second, the participants’ purchase intention was significantly influenced by price transparency. Specifically, participants were more likely to purchase Package B with low transparency, where the prices of amenities were presented, , the vacation package displaying the element prices of low transparency increased consumers’ likeliness to purchase the package.Study 2 set out to reproduce the result of the first experiment in the context of evaluating a coastal vacation package. The hypothesis of the main effect of price transparency was examined in a between-subjects design.Subjects in the second study were 306 Chinse Adults  recruited from an online panel in July 2021.They were randomly appointed to one of the two experimental conditions (price transparency: high transparency in Package A vs. low transparency in Package B).First, participants were provided information concerning how difficult they feel to discover the price of tickets to resorts and amenities by rating their perceived price transparency on a five-point scale  in order to activate their perceived price transparency. Subjects were then asked to imagine that they were considering a package tour to a coastal city. The manipulation of price transparency was used the same way as that in the first study. Specifically in the high transparency scenario, Package A was described with the presentation of ticket to resorts, whereas in low transparency scenario, Package B was depicted with the presentation of prices of amenities. Subjects were then requested to answer questions to evaluate their likeliness to purchase.M = 3.95, SD = 0.859), compared with considering Package B less transparent when the package showed prices of amenities  = 7.274, p < 0.01, 2η = 0.023).First, we successfully manipulated price transparency in this study, such that Package A was perceived as being highly transparent, where tickets to resorts were displayed  than Package A considered high transparent by displaying the tickets to resorts  = 8.204, p < 0 0.01, 2η = 0.026).Second, in the context of coastal vacation package, the impact of price transparency on consumers’ purchase intention was similar to that in study 1, that is, the participants’ purchase intention was significantly influenced by the price transparency manipulated in Packages A and B. To be specific, in Package B considered less transparent, where the prices of amenities were presented, consumers’ purchase intention was higher  than Package A presenting the element prices of high transparency .First, respondents were recruited from a local panel company to measure the perceived level of difficulty of acquiring prices in the given context. Then we concentrated on duplicating the results of the first two experiments to improve the generalizability of the findings. We also excluded the alternative explanation of consumers’ risk aversion.Participants for manipulation check were 76 Chinese adults  recruited from a local panel company for a nominal payment in October 2021. Participants attended the study in a marketing laboratory room with computers. Respondents were asked to read the actual vacation package only with total price information of the vacation package listed as most of vacation packages do in China. Then respondents were asked to search for prices of ticket to resorts and amenities by using computers in order to activate their perceived price transparency. Finally, we measured their perceived level of difficulty of searching for price information by a five-point scale .China Snow Town. After finishing the above tasks, participants were asked to evaluate their likeliness to buy the package by rating their purchase intention on a 5-point scale  and to rate their risk aversion by responding to three 5-point items revised from The experiment recruited 298 Chinese adults  from a local panel company. Subjects were appointed to two different experimental conditions (price transparency: high transparency in Package A vs. low transparency in Package B).First, we required the subjects to imagine that they were travelling to M = 3.51, SD = 0.997) compared with Package B in which prices of amenities were displayed  = 4.117, p < 0.05, 2η = 0.053).First, we successfully manipulated price transparency. Package A was perceived as high transparency where tickets to resorts were presented  than high transparency  = 5.847, p = 0.016, 2η = 0.20).Then, we conducted a main effect test by using one-way ANOVA with price transparency as the independent variable and consumers’ purchase intention dependent variable. The findings indicated that price transparency negatively influenced consumers’ purchase intention. Specifically, low transparency activated higher purchase likeliness  = 0. 162, p = 0.872). In addition, we find that there was no significant correlation between risk aversion and consumers’ purchase intention either at the overall level (r = −0.126， p = 0.069) or in high-transparency group  as well as low-transparency group .As far as the alternative explanation of risk aversion is concerned ，the findings indicated that price transparency did not have impact on risk aversion .222 Chinese adult subjects in the experiment were  recruited from an online panel. Generally, the procedure of study 4 replicated study 1 but made some alternations. Subjects were asked to seek for the price information of tickets to resorts and amenities in order to activate their different perceptions of price transparency. After that, they were told to imagine that they were planning to travel to Finally, subjects were required to rate their involvement in four items revised from the study of M = 3.94, SD = 0.877) than Package B displaying price of amenities in the vacation package  = 6.390, p < 0.001). It provided evidence for the successful manipulation of price transparency.After measurement, Package A displaying tickets to resorts was higher in price transparency . Specifically, when participants’ involvement was relatively high (+1SD measurement), we found no significant impact of price transparency on consumers’ purchase intention . In contrast, when participants’ product involvement was relatively low (− 1SD measurement), there was a significant impact of price transparency on consumers’ likeliness to purchase the package . The result confirms the existing conclusion that the evaluation of an advertised information are significantly higher for low-involved consumers  from an online panel. Though the procedure of study 5 shares similarities with that of study 3, there were the following alterations. In this study we utilized a 2 (price transparency: high vs. low) × 2  between-subject experimental design. We presented participants with an actual vacation package of We manipulated price transparency in the same manner as Study 3. Vertical position was manipulated in the way that the prices of tickets and amenities were placed at the top and at the bottom in the product description. After reading the experimental stimuli, subjects were requested to evaluate their willingness to buy the vacation package using a 5-point scale .p = 0.016).We successfully manipulated price transparency. Package A which presents the tickets to resorts was perceived as being highly transparent (M = 3.78，SD = 0.952) compared to Package B which presents prices of amenities in the vacation package perceived as less transparent  = 2.415, t = −4.690, p = 0.00, 95% confidence level: ). H1 was supported. Moreover, the overall moderation was significant . To be specific, When the price was positioned vertically higher, the purchase intention was higher when the price transparency was lower  versus higher .When the price was positioned vertically lower, it was demonstrated that there was no significant impact of price transparency on purchase intention  as shown in A moderation test was implemented using In study 5, the researchers adopted a two-way between-subject experimental design by manipulating the variables of price transparency and vertical position to investigate the moderating effect of vertical position on the impact of price transparency on purchase intention. The results of study 5 supported H3 and demonstrated that vertical position of prices moderated the impact of price transparency on consumer intention to purchase vacation packages. Specifically, when the price of amenities (low transparency) was displayed higher in the package description, the impact of price transparency on consumer purchase intention was significant. When the price of amenities (low transparency) was displayed lower in the package description, there was no significant difference in the impact of price transparency on consumers’ willingness to buy. Therefore, the vertical position of prices moderates the impact of price transparency and H3 was supported.China Snow Town, choosing between vacation packages of high and low transparency. The result of the second experiment, conducted for a coastal destination, was consistent with that of Experiment 1. Given the generalizability of the primary prediction, Experiment 3 found that the main effect of price transparency on consumer judgement was consistent and robust across revised and actual vacation packages, and the study excluded the alternative explanation of consumers’ risk aversion. Experiment 4 replicated Experiment 1 for packages to China Snow Town but with different price transparency. This supported the moderating effect of involvement on the previous findings. Experiment 5 replicated Experiment 3, showing the moderating role that vertical position played. Consumer likeliness to purchase a package with low-transparency price information increased significantly for participants whose involvement was low and when the price was presented vertically higher.This paper explored how the price transparency of a bundled vacation package influences travelers’ decision-making. We predicted that tourists would be less likely to buy a package when price transparency was high. Experiment 1 examined the main effect of the impact of price transparency (high vs. low) on purchase intention. Participants imagined travelling to These results make contributions to the development of related theories. The study contributes to the stream of literature on price transparency. Our findings also contribute to the literature on the heuristic-systematic model (HSM). In past literature, HSM has often been used in information system and marketing research to explain how individuals process information . In our Our research also extends the literature concerning the impact of price transparency on behavioral pricing. It has long been debated whether price transparency is a disadvantage or an advantage for firms. On the negative side, previous research has argued that price transparency can harm an organization because it weakens customer loyalty and stimulates perceptions of price unfairness , 2004. KChina Snow Town package, a package to a coastal destination and an actual vacation package presented by a local travel agency. Our findings from the experiments also revealed that the construct of price transparency could be manipulated by presenting ticket prices for scenic destination (high price transparency) and the cost of amenities (low price transparency) in a vacation package.By extending these investigations to the decision-making process under different price transparency situations, we found that individual purchase intention increased in the case of low transparency of element prices in a bundled vacation package. We thoroughly investigated these impacts through the This research offers practical and managerial implications. First, most studies have reached the consensus that transparency of element prices in packages can have a critical and positive influence on consumers’ evaluations . Our stuSecond, online and offline travel agencies need to be aware that the position of price information in descriptions of bundled vacation packages can play an important role in changing consumer behavior. Our research found that when the element prices were positioned at the higher place, the impact of price transparency was significant and thus suggests marketers should place the price information of low transparency higher in the marketing information to enhance purchase intentions.Third, presenting the element prices of low transparency in a vacation package would be useful for potential consumers with little or no knowledge or prior experience of the package. Experiment 4 demonstrated that travelers’ involvement significantly changed the impact of price transparency on their choices. Specifically, travelers’ preference for packages with low transparency of prices was reinforced when their involvements were low. Our research suggests that tourism managers and marketers should attract low-involved travelers by taking advantage of prices of low transparency.Fourth, the Covid-19 Pandemic has dealt a heavy blow to China’s tourism industry . The domvertical position on the impact of price transparency. Since the horizontal placement affects consumer’s attitude , Social Science Found of Heilongjiang Province (grant number: 20GLH028), 2021 Harbin University of Commerce Teaching Staff “Innovation” Support Project (grant number: 20GLH028) and Philosophy and Social Sciences project of Heilongjiang Province (20GLE389).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Globally, the estimated recurrent childbirth of one forth of women happens every two years or fewer. Next to Nigeria, Ethiopia is the second populist country in Africa and the first populist country in sub-Saharan Africa which consists of over 114 million population. There are prevalent short successive birth intervals problems in underdeveloped nations such as Ethiopia that contributes to adverse effects on mother and child health. However, studies that explore recurrent birth events and associated factors are very limited. Thus, this study aimed to explore and model the recurrent birth event by considering its subsequent within a mother and identifying its important determinants. As a result, the research findings of this study will be one of the preliminary research papers on the recurrent birth events that take into account the subsequent event and enable to be input for the policymakers, health institutions, and future researchers.th event since the entry time, kth event since the time from the previous event, respectively.A total of 4676 mothers with their 16833 corresponding children were involved in this study. The data was obtained from the 2019 Ethiopian Mini Demographic and Health Survey (EMDHS). In this study, extended cox regression models such as Andersen-Gill (AG), Prentice, Williams, and Peterson total time (PWP-TT) model, PWP-gap time (PWP-GT) model, and Frailty model were employed. These all models are used to consider recurrent events within mothers and determine the potential determinants. AG, PWP-TT, and PWP-GT estimate the effect of covariates by considering the correlation between event times for a person can be explained by past events given the covariates, kAmong mothers who have first and ninth recurrent birth events, 75.5% and 80.1% of them respectively were rural residents while 57.6% and 70.6% of them respectively were a place of delivery in the health sector. The highest prevalence of first recurrent births (44.3%) was obtained from Muslim mothers. Mothers' education level , mothers' age at first birth , household wealth index , child mortality , household size  and sex of child  were important determinants of recurrent birth event. This indicates mothers’ education level and household size were positively associated with recurrent birth events. Whereas mothers’ age at first birth, household wealth index, child mortality, and sex of the child was negatively associated with recurrent birth events.The WHO recommends a minimum of 33 months between two consecutive births, which is longer than the Ethiopian recurrent birth intervals observed in this study. The highest recurrent birth occurred during the age of fewer than twenty years old of mothers at first birth as compared to mothers whose age was older at first birth. Mothers, children, and household characteristics had significant effects on recurrent birth events. We authors would like to recommend communities, governmental and non-governmental stakeholders consider the associated factors of frequent recurrence of birth noticed in this study. Besides, we would also like to recommend women start birth while they got mature in age to reduce frequent recurrent birth and its corresponding adverse effects. Recurrent birth is defined by the WHO as two or more consecutive births of women . GloballAccording to United Nations (UN) projections from 2019, Sub-Saharan Africa's total reproduction rate, at 4.7 births per woman in 2015–2020, is more than double that of any other world area. As a result, Africa's population is predicted to increase from 1 billion in 2015 to over 2 billion in 2050 and approximately 4 billion in 2100. This upward population expansion causes the economy to become incompatible with the population, even for fundamental requirements. This has a variety of negative consequences for human well-being and the environment .Next to Nigeria, Ethiopia is the second populist country in Africa and the first populist country in sub-Saharan Africa which consists of over 114 million population , 4. BehaStudies , 2, 7 reA study in Uganda revealed that most of the short recurrent birth intervals occurred among rural women as compared to women in the urban area. The study also reported that the younger maternal age and lack of husband influence on the duration of the next baby are the most influential factors . Beyond Though numerous studies on overall fertility, as far as the researchers’ knowledge is concerned there is very limited study on the recurrent birth events in Africa and Ethiopia in particular. Sometimes the event of interest can occur more than once in a subject the so-called recurrent events. In our case recurrent birth events. However, several studies in –11 focuswww.dhsprogram.com. Providing up-to-date estimates of key demographic and health indicators by collecting high-quality data for maternal and child health are the primary objectives of EDHS among its multidisciplinary objectives [In this study, a total of 4676 women who have delivered at least one live birth were considered. The data was obtained from the 2019 EMDHS. This secondary data was downloaded from the DHS website jectives . The samjectives .The sample data consists of mothers' identification number, children's birth order, start and stop time of birth, event, and gaps (in years) revealed in Table th, 110th, 220th, 320th, and 420th) with their corresponding recurrent birth and duration of birth (in years) was depicted in Fig. A sample of five mothers  covariates.AG model is formulated in terms of increments in the number of events along the timeline. The outcome of interest is time until an event occurs or time since study entry also known as the total time scale . It usesth event since the time from the previous event. Both PWP approaches are conditional models as an individual is not considered in the risk set for the kth event until experiencing the (k − 1)th event. The baseline hazards vary from event to event, the hazard function for the kth event for the ith subject with the PH of PWP-TT model is given by:The PWP model analyses ordered multiple events by stratification, based on the prior number of events. The stratification PWP models are i) PWP total time (PWP-TT), which evaluates the effect of a covariate for the kth event since the entry time in the study; ii) PWP gap time (PWP-GT), which evaluates the effect of a covariate for the kk−1).λk(t)0 is the common baseline hazard function.The PWP—GT model describes an intensity process from the occurrence of an immediately preceding event, with the gap time defined as  of mothers in each recurrent birth.Table As compared to mothers who are living in the urban area and home place of delivery, the proportion of mothers in the rural area and health sector place of delivery was higher respectively at each recurrent birth event. Among mothers who have first and ninth recurrent birth events, 75.5% and 80.1% of them respectively were rural residents while 57.6% and 70.6% of them respectively delivered at home. The highest prevalence of first recurrent births (44.3%) was obtained from Muslim women. Frequently, as compared to mothers whose education levels were primary and above, illiterate mothers have a higher proportion per each recurrent birth event. The proportion of children's death at each recurrent birth was greater than 8.1% of the total children in the corresponding recurrent birth. As compared to poorer, middle, richer, and richest households, the proportion of mothers from the poorest household was the highest at each recurrent birth event. For instance, in the first recurrent birth, the proportion of poorest mothers (28.4%) was higher compared to poorer (17.4%), middle (16.2%), richer (15.5%), and richest (22.5%) mothers. Mothers from the SNNPR region had a higher proportion of first (12.9%) and second (14.0%) recurrent birth while the proportion of mothers in the Oromia region was higher from third (14.5%) to ninth (23.3%) recurrent birth.Figure The estimated effects of mothers, household, and child characteristics on recurrent birth events using the AG model, PWT-TT model, PWP-GT model, and frailty model were fitted, see Table Using the AG model, the age of mothers at first birth, place of delivery, mothers' education level, region, religion, household size, sex of the child, and child mortality have significant effects on the recurrent birth. The estimated hazard of recurrent birth of mothers who have a primary education level was 1.210 times the estimated hazard of recurrent birth of mothers who have no education . The estimated hazard of recurrent birth of mothers whose ages were between 20 and 34 years old was lower by 28.7% than the estimated hazard of recurrent birth of mothers whose ages were less than 20 years old . The hazard ratio of recurrent birth of the hazard of Muslim to Orthodox households was 1.260 indicates that the estimated hazard of recurrent birth in Muslim households was higher by 26.0% than the estimated hazard of recurrent birth in Orthodox households. Mothers whose place of delivery was in the health sector had a lower estimated hazard of recurrent birth as compared to mothers whose place of delivery was at home.The parameter estimates obtained from PWP-TT, PWP-GT, and Frailty models were closer to each other for characteristics of household size, household wealth index, and child mortality. The household size, household wealth index, and child mortality have a significant effect on recurrent birth. The estimated hazard of recurrent birth in households that had a middle wealth index was 0.776 times the estimated hazard of recurrent birth in a household with the poorest wealth index. This refers to the estimated hazard of recurrent birth in the household that had a middle wealth index was lower by 22.4% of the risk of recurrent birth in the household who have poorest wealth index  which indicates that the poorest household was more likely to have higher recurrent birth as compared to the household with middle wealth index. The estimated hazard of recurrent birth of mothers who haven’t died children was 0.673 times the estimated hazard of recurrent birth of mothers who have died children . This means the estimated hazard of recurrent birth of mothers who haven’t died children was lower by 32.7% of the estimated hazard of recurrent birth of mothers who have died children. Households with medium (5–9) and large (10 and more) family sizes had a higher risk of recurring birth as the estimated hazard ratio was greater than one .Results from the PWP-TT model and PWP-GT model point out the sex of child have a significant effect on the recurrent birth in which mothers who have female children had a lower risk of recurrent birth as compared to mothers who have male children. The estimated hazard of mothers who have female children was 0.836  times the estimated hazard of mothers who have male children and it is almost the same in the case of the PWP-TT model and PWPGT model. Based on the PWP-GT model, the effect of place of residence and age of mothers at first birth was not null . Besides, results from the frailty model was also shows the age of mothers at first birth had a significant effect on recurrent birth in which the risk of recurrent birth of mothers aged 20–34 and 35–49 years was lower by 27.0%  and 27.5%  respectively of the estimated risk of recurrent birth of mothers whose age less than 20 years old.th, 12th, and 14th recurrent birth events indicate a women successive birth within a gap of less than a year. Over 51 percent of women had greater than or equal to three recurrent births. The term recurrent birth was defined as two or more successive deliveries of mothers [In this study, the exploratory data analysis of recurrent birth events and important mothers, household, and child characteristics that are associated with recurrent birth in Ethiopia were identified using the extended cox model such as the AG model, PWP-TT model, PWP-GT, and frailty model. The median follow-up time for 3rd, 4th, 5th, 6th, 7th, 8th, 9th, 10th, 11th, 12th, and 13th recurrent birth was two years. The minimum duration of birth (0.95 years) from 4Ethiopia is one of the countries with a high fertility rate in Africa . In thisPlace of delivery and residence, age of mothers at first birth, mother’s current marital status, mothers and husband/partner education level, region, religion, household size, household wealth index, and child mortality was independently associated with recurrent birth events. The highest recurrent birth occurred during the age less than twenty years old of mothers at first birth as compared to mothers whose age older at first birth. This is in line with findings in , 20 statIn the AG model, the effects of mothers' education level, place of residence and place of delivery, age of mothers at first birth, region, household size, sex of the child, and child mortality had a significant effect on recurrent birth. As a lack of studies on recurrent birth events and associated factors, mostly our study findings were compared to a study related to birth intervals and recurrent preterm birth. The risk of recurrent birth of mothers whose ages were below twenty years old was higher as compared to mothers whose ages were 20–34 and 35–49 years old. This was in line with a study on early marriage in Ethiopia , 20. TheThe estimated hazard of recurrent birth of mothers who have female children was lower by 11.12% than the estimated hazard of recurrent birth of mothers who have male children. In Ethiopia, commonly women who have a child of the same sex successively are eager to deliver a child of different sex, and hence the actual number of children in the family becomes higher than the desired number of children. It is also reported in a study in Uganda , that whLikewise in the AG model, household size, sex of the child, and child mortality had also a significant effect on recurrent birth using PWP-TT, PWP-GT model, and frailty model. Mothers from the poorest Wealth index had higher recurrent birth than mothers from the middle wealth index. This was consistent with analysis results obtained from 2018 NHDS  in NigerThe findings of this study are limited to data obtained from a survey EDHS 2019. It would be better if a further study can be conducted on previous surveys EDHS2016, EDHS 2011, etc. to assess the progress in detail. Many different studies related to recurrent birth have used different predictor variables and some of them arrived at different results. Therefore we recommended that further studies on this topic include other important covariates that were not included in this study which could have a potential confounding effect.The recurrent birth interval of Ethiopian mothers was less than the minimum birth interval set by WHO, a minimum of 33 months between two successive live births is recommended. The highest recurrent birth occurred during the age less than twenty years old of mothers at first birth as compared to mothers whose age was older at first birth. The effects of mothers' education level, place of residence and place of delivery, age of mothers at first birth, region, household size, sex of the child, and child mortality had a significant effect on recurrent birth. Besides, mothers from the poorest economic status and the rural area had higher recurrent birth than mothers from middle economic status and urban areas, respectively. We authors would like to recommend communities, governmental and non-governmental stakeholders consider the associated factors of frequent recurrence of birth noticed in this study. The age of 70.5% of mothers in this study was less than twenty years old at their first birth. Thus, we would also like to recommend women start birth while they got mature in age to reduce frequent recurrent birth and its corresponding adverse effects.


Epidermal inclusion cysts are cysts occurring in intradermal or subcutaneous regions with the cyst wall consisting of the true epidermis. They are slow-growing tumors that occur most commonly on the scalp, neck, face, and trunk. They are common in infancy and childhood or after female external genitalia mutilation. Herein, we report a case of a spontaneously occurring epidermal inclusion cyst of the clitoris, a rare location in a 43-year-old woman which was removed by local excision. Epidermal cysts are usually solitary, asymptomatic, slow-growing tumors that are cystic, round, and elevated . They ocWe present a case of epidermal inclusion cyst of the clitoris in a 43-year-old parity four female who presented to our out-patient department with complaints of swelling in the perineal region for the past 18 years, discomfort and pain during sexual intercourse for the past two to three years which increased in the past two to three months. The swelling when first noticed was initially the size of a pea, which showed very slow growth over time till it reached its present size. The onset of the swelling had no relation to delivery or trauma in the clitoral region during delivery. The swelling was first noticed by the patient four years after her last vaginal delivery. There were no urinary complaints, no history of trauma in the perineal region, no history of genital mutilation, no history of systemic complaints, and no history of hormonal intake. There was no significant obstetric, past medical, surgical, or family history. On examination, vitals were stable. Systemic examination was normal. On local examination, there was a well-circumscribed, mobile, round, soft, cystic, fluctuant, mildly tender swelling of size 6cm×4cm in the clitoral area. The skin above the swelling was pinchable. There was no hyperpigmentation or any presence of punctum. There was no local rise in temperature over the cyst. The urethra was situated very close to the swelling and appeared as if making the floor of the swelling. There were no signs of virilization. Figure Ultrasonography showed an anechoic cyst of size 6cm×4cm×3cm in the clitoral region with echogenic contents and without any vascularity. The cyst seemed to displace the urethra to the right side. However, the space for dissection between the urethra and swelling was just 3-4 mm in around 2cm length posteriorly. The features were suggestive of a clitoral cyst. After taking informed written consent, elective surgery was done and the cyst was excised under general anesthesia. A curvilinear incision was given at the mucocutaneous junction, avoiding neurovascular bundle areas of the clitoris. The urethra was kept catheterized using a metal catheter when the cyst was dissected from the posterior wall. The urethra was safely dissected away from the cyst and the cyst was enucleated. Dead space was obliterated. Hemostasis was achieved. Surgical reconstruction of the clitoris was done for cosmesis. The incision was closed with interrupted 3.0 vicryl in multiple layers. On the cut section, the cyst was filled with dirty greyish yellow material. Figure On histopathology, squamous epithelium was seen in the cyst wall with evidence of keratinous material inside confirming the diagnosis of the epidermal inclusion cyst. No sebaceous gland, sweat gland, or hair follicle was seen on histopathology thus ruling out the other differentials like a sebaceous cyst, pilar cyst, or hidradenitis. The patient had an uneventful post-operative period. On follow-up after three months, the patient was totally symptom-free with no discomfort on sexual activity and no signs of recurrence.A variety of cystic tumors can occur in female external genitalia which may be vaginal, paraurethral, or clitoral . ClitoraIt is not uncommon to encounter clitoral epidermal inclusion cysts after a history of trauma or female genital mutilation. However, it is quite rare to see spontaneous clitoral inclusion cysts in the absence of trauma or genital mutilation. After a thorough and extensive review of the literature, we could find only ten such cases reported in the literature till date. Teague and Anglo 1996) reported a case of a clitoral cyst in a child . Schmidt996 reporAlthough rare, clitoral cysts can occasionally be seen in one’s clinical practice. It is important to determine whether the tumor is benign or malignant by histopathological examination. In the case of a benign clitoral cyst, differentiation should be done from clitoromegaly which has a whole different lot of differential diagnosis. History of trauma or mutilation should be enquired. Surgery should take into account the patient’s symptoms, cosmesis, and the impact on sexual function and psychological status. The patient should be followed up to check for recurrence.


Low birth weight is a global public health problem, with 15–20% of all births globally, described by weight at birth of less than 2500 g ensuing fetal and neonatal mortality and morbidity, poor cognitive growth, and an increased risk of chronic diseases later in life. The prevalence is critical in East Africa where about 11% have low birth weight out of 54% of neonates whose weight was measured at birth. There are many causes of low birth weight, including early induction of labor or cesarean birth, multiple pregnancies, infections, diabetes, and high blood pressure. Moreover, socioeconomic factors and unhealthy dietary habits could contribute to low birth weight in areas with poor intake of a diversified diet. This study has indicated the association between poor dietary diversity and low birth weight in the study area for the first time.An institutional-based cross-sectional study was conducted on eligible 423 pregnant women recruited from Gestational Age of less than 17 weeks until delivery where the birth outcomes were recorded in health institutions in randomly selected five Woredas in East Gojjam Zone, Amhara, Ethiopia from June 2019 to December 2020. Questionnaires were used to collect data on socio-economic-demographic, dietary diversity scores, and food consumption scores.P ≤ 0.042; 0.059  P ≤ 0.007; whereas low dietary diversity score group and low food consumption group increased the risk of low birth weight with AOR 2.425  P ≤ 0.011and 2.983  P ≤ 0.044 respectively.The study found a prevalence of low birth weight of 9.6%, low dietary diversity score of 53.2%, low food consumption score of 19.7%, and preterm delivery of 9.1%. Ever attended school and a higher level of education (diploma and above) decreased the risk of low birth weight with an Adjusted Odds Ratio (AOR) of 0.149  Participants with no formal education, no diploma, and above (no college or university training/degree), low diversity score group, and low food consumption group had an increased risk of low birth weight. Therefore the use of a diversified diet, educating women to a higher educational level, and health education on the intake of a diversified food rich in multiple micronutrients are recommended as strategies that will ameliorate the occurrence of low birth weight.The online version contains supplementary material available at 10.1186/s40795-022-00621-9. Low Birth Weight (LBW) is defined as weight at birth less than 2500 g. It is a major public health problem, with a prevalence of 15 to 20% worldwide. Various studies were conducted to estimate the prevalence and determinants of LBW . FurtherA low dietary diversity score was associated with higher odds of infant LBW whereas healthy dietary patterns  during pregnancy were associated with lower odds of infant LBW. Studies suggest that higher dietary diversity, nutritional status before and during pregnancy, and maternal anthropometric characteristics may be protective of LBW in addition to the socio-economic characteristics. According to the World Health Organization, poor maternal nutritional status during pregnancy confers greater risk for LBW in developing countries . WhereasDietary diversity is recognized as a measure of diet quality (consumed variety of food from different food groups per day or week), nutrient adequacy, and MicroNutrient (MN) utilization with a prominent effect on adverse birth outcomes like LBW, Small for Gestational Age (SGA) and Pre Term Delivery (PTD) –13. ThouThis study determined the prevalence of low birth weight and its associated factors, including low dietary diversity and food consumption score, in East Gojjam Zone, Amhara, Ethiopia.n = (Z1-α/2)2P(1-P)/d2 = 1.96*1.96*0.48*0.52/0.0025 = 383; with the addition of a 10% non-response rate, the total sample size was 423. The sample was collected based on the proportion of pregnant women in the randomly selected Woredas and continued follow-up until birth. The data were collected using a structured questionnaire about participants’ socio-economic-demographic factors, a daily and weekly dietary intake questionnaire [A facility-based cross-sectional study was conducted between June 2019 to December 2020 on eligible consenting 423 pregnant women of GA < 17 weeks in health institutions from five randomly selected Woredas, namely Debre Markos, Dejen, Machakel, Hulet Ej Enese, and Awabel that are present in East Gojjam Zone, Amhara Regional State, Ethiopia. The sample size was determined using single population proportion formula assuming the prevalence of overall MN deficiency or poor DDS in the study area to be either 48 or 55% respectively . Therefoionnaire , 14, andTo determine factors associated with LBW two indexes were developed from the food frequency questionnaires, the Dietary Diversity Score (DDS) and Food Consumption Score (FCS) which were categorized into the Dietary Diversity Score group (DDSg) and Food Consumption Group (FCG) as low and adequate or high. These were done from the ten food groups  who presented for ANC and planned to deliver in the selected hospitals or health centers within the study period were included. Whereas, all women with multiple pregnancies, chronic hypertension, or previous history of pre-eclampsia, severe anemia, chronic renal, liver, and gastrointestinal diseases that are likely to affect MN status, HIV/AIDS, diabetes mellitus, and poor obstetric histories were excluded , 21.Low Birth Weight (LBW) is defined as a birth weight of less than 2500 g regardless of gestational age [onal age .The dietary Diversity Score (DDS) represents the number of different food groups consumed by each pregnant woman within 24 h. It is a qualitative measurement of food consumption, used as a proxy indicator of micronutrient adequacy at an individual level [al level . It is aal level .The dietary diversity score group (DDSg) is a categorical variable derived from the DDS where a DDSg value of less than five is considered inadequate or low and a value of more or equal to five is considered adequate or high DDSg [igh DDSg , 23.Food Consumption Score (FCS) another index developed by the World Food Programme [rogramme and asks rogramme . The weirogramme .Food consumption group (FCG) is a categorical variable derived from FCS where FCG of less than35 is considered as low while a value of more or equal to 35.5% is considered as adequate or high FCG [high FCG .Multiple Micronutrients (MMN) are drug supplements that contain three or more trace elements or vitamins and minerals in a single preparation [paration .P < 0.05 level of significance. Model fitness was checked using Hosmer and Lemeshow statistic test at p > 0.05.The collected data were coded and entered into Epi-Data cleaned, exported to IBM SPSS, and used for data analysis. Frequency distribution for categorical variables, and mean with standard deviation for continuous variables were determined. A bivariate followed by multivariable logistic regression was used to identify the association between DDS, FCS, and SED factors with LBW at a 2. More than three fourth (83.1%) of study participants lived in urban areas. The vast majority of the pregnant women were Amhara in ethnicity (99%), married (96%), Orthodox Christian in religion (95.5%), 20–29 years of age (73.3%), and with no health insurance (75.6%). Most of the participants (85.5%) attended school from primary to a higher level. Moreover, a larger proportion of the participants can read and write (87.1%), with more than a quarter of the participants (26.1%) holding a Diploma and above. The male-headed household was 38.4% while the female-headed 4.6%. Among the study participants, 47.3% of pregnant women were housewives. The majority (96.6%) of the participants were below the age of 30 years and pregnant for the first time, while 19.4% were adolescents pregnant and 12.5% had low BMI values. Moreover, the low DDSg has a prevalence of 53.2% while low FCG of 19.7% as depicted in Tables A total of 421 study participants were included in the baseline study making a response rate of 99.5%. The prevalence of LBW and PTD were 9.6 and 9.1% respectively. The average age of the participants was 26.3 ± 4.8 years, age at first pregnancy was 22.5 ± 3.8 years, Mid Upper Arm Circumference (MUAC) 24.5 ± 2.2 cm, Body Mass Index (BMI) 21.73 ± 3.0 kg/mRegarding dietary intake, low DDSg 53.2 and low FCG of 19.7% were recorded where pulses 95.7%, and whole grains 90.3%, were the most commonly consumed food items while fish 4.8%, and special dietary requirements 2.6%, are the least consumed as indicated in Table At the end line of data collection, a total of 379 (89.6%) participants' birth outcomes were recorded as indicated in Fig. P ≤ 0.04); 2.43  P ≤ 0.01; 0.15 , P ≤ 0.04and 0.06 , P ≤ 0.01 respectively. There was also an insignificant increase in the risk of LBW due to regular coffee consumption.The multiple logistic regression analysis was conducted between LBW and DDS, FCS, or other associated factors as indicated in Table In this study, the proportion of LBW, low DDSg, and 'poor' FCG have been identified to be 9.6%, 53.2%, and 19.7% respectively. This indicated more than half of the participants have a DDS of less than 5 and 19.7% have an FCS less than or equal to 35. Moreover, almost half of the participants have an age group between 19.9 to 24 years with no health insurance in a quarter of them and low BMI and MUAC prevalence of 12.5 and 6.6% respectively. Previous studies conducted in Ethiopia indicated a LBW between 6% to 29.1% [P ≤ 0.05) in the bivariate analysis. Another study also reported that maternal caffeine consumption association with major negative pregnancy outcomes including LBW [In this study, it was observed that an increase in FCS resulted in a decrease of LBW by 4% and there was a significant increase of LBW in participants with a low FCG. Moreover, lower DDSg and 'poor' FCG were associated with a high risk of LBW owing to low MN and food insecurity as shown by these variables. Another study in Tanzania also indicated higher DDSg and FCG association with lower risk of SGA, PTB, and LBW . A studyding LBW . Though 12, calcium, and iron as indicated in previous studies [Women in the developing world are more likely to have staple diets due to limited variation in available foodstuffs, putting them at the risk of MN deficiencies. Population groups that are most affected by MN deficiencies are those that subsist on refined cereal grain or tuber-based diets. Such diets provide energy and protein but often lack some critical MN, and essential amino acids , 21. Low studies , 23 whic studies . In addi studies  and MN d studies . Similar studies . In addi studies . In a st studies . Previou studies . Another studies .In this study, low DDSg, and low FCG (which are proxy indicators of MN deficiency), frequent coffee consumption, and absence of health education on MMN increased the risk of LBW. However, those participants who ever attended school and a higher level of education reduced the risk of LBW.This study recommends health education about the intake of diversified nutrients from animals, vegetables, and fruits than only grains and pulses as this will help pregnant women to have a sufficient amount of multiple MN from these diets which could reduce the risk of LBW. This has to be done to promote the prenatal, antenatal, and postnatal consumption of the required MNs for healthy birth outcomes. Besides educating the women and encouraging them to attain higher levels of education will also reduce the risk of low DDSg and 'poor' FCG that result in LBW. The household member has to be told also the role of a diversified rather than a repetitive food schedule during pregnancy as there is no single food that can contain all the nutrients.Though the sample size of the study was sufficient enough to draw those conclusions stated above, the study is limited by the less number of participants from rural areas. Moreover, in the majority of study health centers, the investigator couldn't get ultrasound results due to a lack of equipment. This resulted in a sole determination of the gestational age of the patients’ by the recall of the first day of the last menstrual period without confirmatory tests from ultrasound scanning. The COVID-19 virus pandemic also resulted in a loss of follow-up of participants in the end-line data collection of the birth outcomes. Due to resource limitations, the study has failed to measure the nutrient intake from the foods consumed.Additional file 1.Additional file 2.


Bacillus subtilis QST 713 supplementation in gilts on different reproductive criteria. A total of 94 Camborough-48 gilts at day 85 of gestation were randomly allocated into 2 groups: (1) control diet; (2) control diet + 4 × 108 CFU Bacillus subtilis QST 713 per day. Gilts were supplemented until farrowing. At farrowing, litter size, number of piglets born alive, stillbirths, mummies, birth weight, farrowing duration, and birth interval were recorded. Within litter variation of piglet birth weight, depicted as SDBW and CVBW, was also calculated. Results showed that Bacillus subtilis QST 713 supplementation decreased stillbirth rate  and increased birth weight of the piglets . Also, the litter size , number of piglets born alive , and litter weight  in the treatment group were higher than those in the control. Farrowing duration , birth interval , SDBW , and CVBW  were independent of the Bacillus subtilis QST 713 supplementation. Results of the present study indicate that supplementation of Bacillus subtilis QST 713 during late gestation in gilts reduces stillbirth and increases birth weight thereby improving their reproductive performance.Recent studies have shown that probiotic supplementation during late gestation exerts some beneficial effects on reproductive performance of the sows. This study aimed to investigate effects of  During late gestation, the richness of microbiota in intestine of the sows reduced , 2 whileRecently, there is an increase in studies investigating effects of probiotic supplementation at late gestation on reproductive performance of sows –8. Some Bacillus subtilis QST 713 used in this study was isolated from soil in California, USA, in 1995. This strain is reported to be low toxic to mammals and not likely to be a pathogenic agent in human. Supplementation of Bacillus subtilis QST 713 was suggested to be an effective approach to control necrotic enteritis in broilers [Bacillus subtilis QST 713 increased the length of intestinal villi and decreased the number of deep crypts [Bacillus subtilis QST 713 supplementation also suppressed the harmful effect of antimicrobial on beneficial bacteria in the intestine of the weaned pigs thereby working as “a preventative and/or attenuating compound against dysbiosis in piglets” [Bacillus subtilis QST 713 may increase feed digestion and nutrients absorption in animals. Based on available reports in beneficial effects of Bacillus subtilis QST 713 in animals, we hypothesized that this strain might improve reproductive performance of the pig. The reason to this hypothesis was that the increased nutrients absorption might lead to the increased birth weight and subsequently decreased stillbirth rate in newborn piglets. To this end, the present study aimed to evaluate effects of Bacillus subtilis QST 713 supplementation from day 85 of gestation to farrowing on different reproductive criteria including the number of piglets born alive, litter birth weight, stillbirth rate, dead born rate, birth weight, within litter variation of piglet birth weight, farrowing duration, and birth interval.broilers . Furtherp crypts . BacilluThe present experiment was reviewed and approved by the Committee on Animal Research and Ethics of Faculty of Veterinary Medicine, Vietnam National University of Agriculture (CARE-2021/01).Escherichia coli. During the first 84 days of gestation, gilts were fed 1.8–2 kg of a gestation feed . From days 85 to 110, gilts were fed 2.0–2.2 kg of a lactation feed . Between day 111 and farrowing gilts received 1.0–1.5 kg of the lactation feed. The nutrient composition of the gestation and lactation feed was shown in 8 CFU Bacillus subtilis QST 713  in 4 g mixture of the probiotic and dextrose, which was topped to the daily feed . Gilts in the control group received 4 g dextrose. Pregnant gilts were individually housed in gestation crates, and moved to farrowing crates at about day 107 of gestation. All animals were ad libitum accessed to water provided through a bite nipple drinking system.This study was conducted in a commercial pig farm during February and July, 2021 in Bavi, Hanoi, Vietnam, enrolling ninety-four Camborough-48 gilts. Young gilts were vaccinated against porcine reproductive and respiratory syndrome, Aujeszky's disease, classical swine fever, foot and mouth disease, and porcine circovirus during 24–29 weeks of age. At the age of 30 weeks, estrus gilts were bred with diluted semen of PIC®337 boars. Pregnant gilts were vaccinated against classical swine fever, foot and mouth disease, and At parturition, gilts were supervised by two trained veterinarians. Litter size , number of born alive piglets, dead born piglets (stillbirth and mummy), gestation length, birth interval, farrowing duration, and birth weight were recorded. Mummified piglets were those born dead with full brown/black color of skin. Other born dead piglets were classified as stillbirth. Stillborn piglets included intrapartum and prepartum stillbirths. However, postmortem examination was not allowed due to the regulation of the farm then these two types of stillbirth were not distinguished. Birth interval was the time period between the births of two consecutive piglets. Farrowing duration was the interval between the birth of the first piglet and the birth of the last piglet. Piglets were individually weighed with a 5 g precision digital scale before colostrum intake. Mean birth weight (MBW) of each litter was calculated by dividing litter weight by litter size. Standard deviation of mean birth weight of each liter (SDBW) was also calculated. Coefficient of variation of birth weight of each litter (CVBW) was derived by dividing SDBM by MBW then multiplying with 100.t-test. All tests were conducted in RStudio Desktop 1.3.1093 . A p value <0.05 was considered significant.To deal with hierarchical data where multiple piglets born from a sow, generalized linear mixed model was used to compare the stillbirth rate and dead born rate of piglets in the treatment and control groups. Similarly, linear mixed effect model was used to compare piglet birth weight and birth interval between treatment and control groups. Litter size, number of piglets born alive, litter weight, SDBW, CVBW, and farrowing duration were compared between treatment and control groups using a Among 94 gilts enrolled in the study, 10 gilts farrowed in late evening, so were not supervised and discarded from the study. Among 84 gilts remained, 41 gilts were in the treatment and 43 gilts were in the control groups. In total, 939 piglets were born from 84 gilts. Among them 910 (96.91%) piglets were born alive, 26 (2.77%) were stillborn, and 3 (0.32%) were born as mummies. The overall incidence of stillbirth at farrowing level was 21.43% (18/84), and the birth weight was 1269.76 ± 154.09 g. The farrowing duration and birth interval were 167.44 ± 44.38, and 16.45 ± 9.14 minutes, respectively.Bacillus subtilis QST 713 supplementation did not influence gestation length (116.12 vs. 116.56 days), farrowing duration (174.39 vs. 160.81 minutes), birth interval (16.32 vs. 16.59 minutes), incidence of stillbirth at litter level (14.63 vs. 27.91%), SDBW (85.07 vs. 94.65 g), and CVBW (6.42 vs. 7.85%). Bacillus subtilis QST 713 supplementation increased litter size , number of piglets born alive , and the litter weight . Supplementation of Bacillus subtilis QST 713 decreased stillbirth rate  and dead born rate , and increased birth weight of piglets  (p=0.007) .Bacillus subtilis QST 713 supplementation both decreased the stillbirth rate and increased the birth weight. Interestingly, the increased birth weight was simultaneously present with a higher litter size and higher number of piglets born alive. Moreover, despite the larger litter size, the within litter variation of piglet birth weight depicted as SDBW and CVBW in the treatment group was numerically lower than that in the control group.The present study revealed that The larger litter size in the treatment group in this study reflected the results of some previous studies , 8. OtheBacillus subtilis QST 713 increased both litter size/NBA and birth weight despite the fact that birth weight is negatively associated with litter size [It is interesting that ter size , 26. Somter size , 20 whilter size , 14. Twoter size  or late ter size . Howeverter size , and in ter size .It is well documented that the litter size positively correlates with within litter variation of piglet birth weight –31. In oBacillus subtilis QST 713 supplementation on farrowing duration and birth interval is diverse from the finding of the solely existed study that evaluated this aspect [Bacillus subtilis QST 713 supplementation on farrowing duration and birth interval resulting in nonsignificant difference in the present study.In the present study, the effect of s aspect . In theis aspect  speculats aspect , 32, ands aspect . TherefoBacillus subtilis QST 713 supplementation on gilt reproductive performance is not totally clear. Previous studies showed that Bacillus subtilis improve the intestinal immune status [Bacillus spp. can produce a wide range of antimicrobial substances which were found to inbibit the growth of many pathogenic bacteria such as Clostridium difficile, Campylobacter jejuni, Streptococcus pneumoniae, Campylobacter coli, Proteus vulgaris, Klebsiella pneumoniae, Pseudomonas aeruginosa, and Salmonella typhi [Bacillus subtilis during the late stage of gestation [Bacillus subtilis QST 713 could also produce some antimicrobials although the names of these products were not specified. In chicken, Bacillus subtilis QST 713 stimulated the development of intestinal mucosa and villi, and the growth of Lactobacillus spp., and inhibited Escherichia coli and Enterococcus spp. [Bacillus subtilis QST 713 prevented the growth of Escherichia coli, and promoted the development of beneficial bacteria such as Bulleidia [Bacillus spp., Bacillus subtilis, and Bacillus subtilis QST 713 lead to the suggestion that supplementation of Bacillus subtilis QST 713 during the late gestation might enhance the intestinal immune status and the health of gut microbiota, increase the digestion and absorption of nutrients in treated gilts. These promoting effects resulted in enhanced nutrient delivery to the swine fetuses which subsequently increased birth weight, and decreased stillbirth rate.The mechanism of action of e status , and imme status , 35. Bacla typhi , 37. Theestation  reportedcus spp. . In the Bacillus subtilis QST 713 on reproductive performance of gilts/sows deserves further investigation in the future.The present study had a limitation. We used commercially industrialized diets in which only some main ingredients are listed without any further information. This led to the difficulty of formulation of such diets in the future studies. Nevertheless, the promising beneficial effect of Bacillus subtilis QST 713 at the dose of 4 × 108 cfu/meal/day from day 85 of gestation to farrowing in gilts could decrease stillbirth rate and increase the birth weight. The increase birth weight and decreased stillbirth rate were simultaneously present with a larger litter size/NBA. Bacillus subtilis QST 713 is a promising probiotic supplement in gilts during late gestation for improvement of reproductive performance.The present study suggested that supplementation of


Autism spectrum disorders is a group of childhood onset neurodevelopmental disorders affecting millions of children across the globe. Characterised by age inappropriate lack of reciprocal social interaction, repetitive behaviours and deficits in communication skills, it has been found to have genetic, epigenetic and environmental contributions. In this work, we wanted to identify the effects of birth related parameters on the disease pathogenesis in an exposed population of West Bengal, India. We have considered age of both parents at birth, difference in parental age, familial history of mental illness, delay in developmental-milestones, birth-weight, birth-order, birth-term, mode of delivery and gestational complications as contributors. We found the parental age and their age difference to be the most important contributors towards ASD in this population. Birth order, sex of the probands, complications during gestation, birth weight, family history of mental illness and birth history also contributed to the condition, although to a lesser extent. Since such types of data are lacking in Indian population, this report adds useful information to the relevant field. Several studies have confirmed significant genetic contributions and heritable nature of the disorders3. Epigenetic modifications have also been found to have significant contributions in the pathophysiology of the same5. In addition, studies have shown that environmental factors and birth related variables play significant roles in the etiology of ASD10. Since ASD is multifactorial disorder, interplay between genetic, epigenetic and environmental factors is quite expected in the disease pathology.Autism spectrum disorders (ASD) are a group of childhood onset neurodevelopmental disorders with multifactorial aetiology. It is characterised by age-inappropriate reciprocal social interactions, repetitive, stereotypic behaviours and communication deficits. ASD includes Asperger’s syndrome, autistic disorders, childhood disintrigative disorders and pervasive developmental disorders not otherwise specified (PDD-NOS)8 examined over 50 prenatal factors that would be associated with autism risk including advanced paternal age, medications used during pregnancy, bleeding, gestational diabetes, previous foetal loss, hypertension and preeclampsia. In another study, in addition to the parental age, grandparental age (when they gave birth to the parents of the affected children), also turned out to be the risk factors for the same9. Too low or too high parental age were found to be risk factors for autism in other studies also10. Assisted reproductive technology (ART) which accounts for about 1–3% of birth in the present days, have been associated with low birth weight and congenital defects due to the stress on the central nervous system11. Iron deficiency of the pregnant mothers have also been associated with impairment in the development of cognitive, motor and language skills and might lead to ASD12. In-utero or early life exposure to environmental pollutants like heavy metals, phthalates, polychlorinated biphenyls (PCBs), air pollutants and pesticides have been also associated with ASD13. Certain medications of the pregnant mothers like antidepressants14 or anti-seizure medications 15 have been linked to ASD as well. Moreover low birth weight16, methods of delivery, familial history of mental disorders17 and maternal immune activation during pregnancy18 have lead to the birth of children who later developed ASD.In a meta-analysis, Gardener et al.In the present work, we have studied the birth related variables in 170 cases of ASD in the children of West Bengal, India. Attempts have been made to identify the risk factors for ASD in these children in terms of age of the parents at birth, difference in parental age, familial history, delay in developmental milestones, birth weight, birth order, birth term, mode of delivery and gestational complications of the mother. Although birth-related variables have been reported to be risk factors for ASD in previous studies, similar findings are rare in the Indian population. So we made an attempt to identify such factors associated with ASD in this population from the demographic data collected during recruitment of the study participants.5. So it might be quite expected that such problems  would exist in their families also. We found that, problems in the family members of the study participants were varied ranging from mental retardation, depression; delay in speech as found in autism, autism, epilepsy, schizophrenia, aggressive behaviours, reclusiveness, hyperactivity etc.  and their parents were recruited as the study participants. These children were chosen on the basis of DSM-IV criteria and had a mean CARS score of 34.68 ± 3.96. Average age of the probands was 6.13 ± 3.67 years with a male: female ratio of 6.39: 1. In this study, 76.47% were first-born children while 21.18% were second-born children and 2.35% were born as the third child. Average age of the mothers at the time of birth was 28.38 ± 4.41 years and that of the fathers was 34.87 ± 5.00 years, with an average parental age difference of 6.48 ± 3.64 years. Mean birth weight of the probands was 2.81 ± 0.58 kg. About 80% were full term babies, 19% were premature babies and 1% were hyper mature babies. Most of the children were born via Caeserean section (68.24%), while the rest were either born by spontaneous vertex delivery (25.3%) or via forceps delivery (6.47%). About 46.5% of the mothers had gestational complications like anaemia, urinary tract infections, injury due to falling down or domestic violence, fever, bleeding during pregnancy among many reasons  but the sampling adequacy was low (0.502) so, Varimax Rotation model was used for the primary analysis. The extracted communalities by the corresponding models are shown in Table Principal component analysis, or PCA, is a dimensionality-reduction method that is often used to reduce the dimensionality of large data sets that still contains most of the information in the large setty Table  was sign low 0.50 so, Varip < 0.05). Significant negative correlations were found between developmental milestone–relating to people; birth history-relating to people; birth term-listening response, birth order-fear or nervousness and gestational complications and activity levels. Figure Pearson’s correlation test was employed to find correlation between continuous variables and Spearman’s Rank correlation test was done to find the correlation between ordinal variables. Results are shown in Table p = 0.006), General Impression (p < 0.05), Relating to people (p = 0.32), Body use (p = 0.014) and Object use (p = 0.003). From the trait scores (T) scores we find that positive influence of sex was found on the overall CARS score. Lower mother’s age and higher difference in parental age were associated with higher scores for general impression. Here also positive influence of the sex of the probands was found on General impression. Relating to people was negatively influenced by the developmental milestone. Positive influence of difference in parental age was associated with higher trait scores for body use. Other models did not show any significant correlation.Multiple regression analysis was done including all the predictors like father’s age, mother’s age, difference in parental age, birth order, birth history, birth weight, birth term, family history, complications and medications during pregnancy/child birth. Fifteen different models were analyzed based on 15 outcome variables. Significant results are shown in Table ASD is a neurodevelopmental disorder whose frequency is increasing at an alarming rate throughout the world including India. Genetic, epigenetic and environmental factors have found to play significant roles in the disease pathophysiology. In this work, we wanted to find out the role of birth related variables in the aetiology of ASD in our study population, the Indo-Caucasoid population of West Bengal, India. We have taken into account age of both parents at birth, difference in parental age, birth weight, birth term, birth order, mode of delivery, age, sex, familial history of mental illness, gestational complications/medications of the mother, and developmental milestones, for our study.20, advanced parental age was found to be associated with an increased risk of autism in the offspring. In another study, it was found that older fathers contributed to highest severity of autism in the male child, while the mother’s age did not show any significant effect21. Elsewhere, it was found that both advanced parental age and increase in difference of parental age was related to increased risk of autism22. Another study found that in addition to many other factors lower maternal age contributed to significant risk of ASD23. All these are consistent to the findings in our study population. Older fathers are at risk of giving birth to a child with autism which may be due to the accumulation of spontaneous mutations in their sperm, which increases with age. Age of the mother has been found to be a confounding factor for autism also. Both younger mothers22 and older mothers7 are at higher risk of having a child with autism. Increased spontaneous mutation  might be the reason for older age mothers, but for younger age mothers the reasons are not very clear.Principal component analyses of our data showed that age of both the parents’ at birth, difference in parental age, birth order, birth term, sex, complications during pregnancy were more important contributors to autism. Birth weight, developmental milestones and family history of mental illness also contributed to the disease phenotype although to a lesser extent Table . More st24. They found adaptive functioning and intelligence scores and mental retardation decreased with increasing birth order. We found that for increasing in birth order children had more severe phenotypes of autism (CARS ≥ 35), while about the first born children showed less severe phenotypes (CARS < 35). Birth weight, developmental milestone, family history and birth history also contributed but to a lesser extent.Birth order also contributed significantly, being in the second component. Birth order of the child has been previously associated with ASD phenotypes25. For us the ratio was 6.39:1 . We found sex of the probands were positively correlated with the overall CARS score, non-verbal communication, level and consistency, object use and general impression. Interestingly, on separating the males from the females it was found that the males have a lower mean CARS score (34.35) as compared to the females (36.76), indicating disease severity was more in the females than in the males, even though the frequency of occurance is much less in the females. This is similar to a previous observation found in another population of the same state26. They showed that, higher platelet/plasma 5-HT and plasma 5-HIAA in the females could probably increase the threshold level of ASD phenotypes in the females, thereby contributing to more severe phenotypes.As already known that autism has a sex bias and males are almost 5 times more susceptible than the females28. Developmental delay may consist of global delay in reaching all the milestones or speech delay or regression where the children begin to develop normally until a point when regression of speech/other behavioral patterns occur. In our study population we came across all the three types of delay: about 46.47% had over all developmental delay, 18.83% had speech delay and 19.41% had regression. Similarly birth history, birth term, birth order and complications during gestation period had influence on phenotypic traits like relating to people, listening response, fear or nervousness, and activity level. Here, ‘Complications’ consisted of any type of illness of the mother during gestation/child birth including mostly anemia, fever, depression, bleeding, falling from certain height or other accidents, increase or decrease of blood pressure, jaundice, thyroid problem, hypoxia during child birth and medications for any of the above reasons. Some of the mothers had maintained very poor diet because they could not eat/vomited frequently during pregnancy. Our results are in agreement with a meta analysis which showed that the prenatal factors associated with autism risk were gestational hypertension, gestational diabetes, threatened abortion, and antepartum hemorrhage in addition to the parents’ age29. Maternal immune activation and dietary intake were also previously associated with ASD30. In our study, complications in in utero conditions and birth histories  were found to be important contributors as expected. Such complications were also found to be positively correlated with family history of mental illness. Complications were found to have a negative impact on the trait ‘activity level’.In our study, developmental milestone was negatively correlated with ‘relating to people’, indicating that developmental delay is associated with autism as found in previous studiesFrom regression analyses Table  it was fIn conclusion, we can say that our entire data analyses indicated that age of the parents and difference in parental age contribute primarily and most importantly to the disease phenotype in ASD. Birth order, sex of the probands, complications in mother’s health during gestation period and developmental milestones also contribute significantly to the disease severity. Birth weight, family history of mental illness and birth history also contributed to the condition, but to a lesser extent. Further studies involving larger sample size might throw some light on these aspects as well. To our knowledge, this is the first report of its kind in the ASD population of West Bengal, India.31 by an expert psychiatrist and clinical psychologists; symptom severity being assessed using the Childhood Autism Rating Scale (CARS). Informed written consent was obtained from the parent or caregivers. Children with gross chromosomal abnormalities and/or any other developmental, neurological or psychiatric conditions were excluded from the study. Details of birth related variables, including birth weight, birth term, birth order, mode of delivery, age, sex, familial history of mental illness, age of both parents at birth, gestational medications/complications and developmental milestones were noted based on structured questionnaires. The study was approved by the Institutional Human Ethical Committee of Manovikas Kendra. All methods were performed in accordance with the relevant guidelines and regulations.A total of 170 children with ASD , aged 3–15 years were included in the study. They were recruited from the out-patient department (OPD) of Manovikas Kendra, Kolkata based on DSM-IV criteriaFor statistical calculations, male individuals were assigned a score of 1 and female individuals were assigned a score of 2. Order of birth was scored as 1, 2, and 3 for first, second and third child respectively. Score of 1 was assigned for full term delivery and score of 2 and 3 were given to pre-term and post-term deliveries. Spontaneous vertex delivery was scored as 1, caesarean sections were scored as 2 and forcep delivery was scored as 3. Cases with no complications during pregnancy/at birth was scored as 0 and scored as 1 for showing any complication during pregnancy/at birth. Probands without family history of mental illness were given a score of 0 and with family history were given a score of 1. While considering developmental milestones, probands with no developmental delay were in group 0, while those with overall developmental delay were under group 1, those with speech delay were under group 2, and those with regression were grouped under group 3. Age of both parents at birth were sub divided under the following groups: Mother’s age at the time of birth were stratified into 4 groups: group 1: ≤ 25 years, group 2: > 25 to ≤ 30 years, group 3: > 30 to ≤ 35 years, and group 4: > 35 years. Father’s age at the time of birth were stratified in to 6 groups: ≤ 25 years; > 25 to ≤ 30 years, > 30 to ≤ 35 years, > 35 to ≤ 40 years. > 40 to ≤ 45 years and > 45 years. Birth weight of the probands were divided in to 4 groups: ≤ 1.5 kg under group1; > 1.5 kg to 2.5 kg, under group 2; > 2.5 kg to 3.5 kg under group 3; > 3.5 to 4.5 kg under group 4.Statistical analyses was done using the SPSS Software version 20, checking necessary assumptions before running the appropriate program. Principal component analysis was performed extracting important variables (in from of components) from a large set of variables which were available in dataset. Before running this dataset initial check was done for sphericity and adequacy of sampling for the dataset Table .Supplementary Information.


The impact of birth weight on lung function and risk of asthma remains contentious. Our aim was to investigate the specific association of birth weight with lung function and the risk of asthma in children.We performed cross-sectional analyses of 3,295 children aged 6–15 years who participated in the 2007–2012 National Health and Nutrition Examination Survey (NHANES). After controlling for potential covariates other than gestational diabetes, maternal asthma and obesity, the linear and non-linear associations of birth weight with lung function metrics and the risk of asthma were evaluated by a generalized linear model and generalized additive model, respectively.1 %predicted, FEV1/FVC %predicted and FEF25 − 75 %predicted . Further threshold effect analysis of birth weight on lung function detected the turning point for birth weight was 3.6 kg. When the birth weight was < 3.6 kg, birth weight was significantly positively associated with all pulmonary function metrics. However, negative associations were found in FEV1 %predicted, FEV1/FVC %predicted and FEF25 − 75 %predicted when the birth weight was ≥3.6 kg. These results were consistent in the stratified and sensitivity analyses. Additionally, a possible non-linear relationship was also detected between birth weight and the risk of asthma.We observed a non-linear association of birth weight with FEVAlthough not all maternal factors were accounted for, our findings provided new insight into the association of birth weight with lung function. Future studies are warranted to confirm the present findings and understand the clinical significance. Convincing evidence supports the notion that factors affecting intrauterine and early life could influence subsequent health and disease in later childhood and adulthood . Among tIn the current study, we used the generalized linear models and generalized additive models to investigate the relationship between birth weight and lung function during childhood in a large sample that was representative of the U.S. population. Moreover, we also evaluated whether birth weight was associated with the risk of asthma.The NHANES is designed by the National Center for Health Statistics (NCHS) of the Centers for Disease Control and Prevention, which applies a complex sampling frame to attain a sample representative of the United States population . We collvia the NHANES Early Childhood Questionnaire (ECQ). Birth weight was recorded in pounds and ounces as reported by the adult proxy and later converted to kilograms (kg). Fetal macrosomia was defined as birth weight >4 kg (Participants aged birth to 15 years were eligible for the birth weight ht >4 kg .1), forced vital capacity (FVC), FEV1/FVC and forced expiratory flow between 25 and 75% (FEF25 − 75), and only participants with FEV1 and FVC values grade A to C were included. The above four spirometric values were converted to %predicted according to the Global Lung Function Initiative 2012 equations . Participants were required to repeat the test until the spirogram was acceptable and reproducible. Then the three best spirometry readings were rated A-F in line with ATS criteria and recorded . In thisquations  or NHANEquations , which ca priori according to prior empirical evidence. The participant information on age, gender, race/ethnicity, education level, family income, mother's age at birth of children and mother's smoking status during pregnancy was self-reported via interview questionnaires. The ratio of family income to poverty (PIR) was calculated by dividing family income by the poverty guidelines. PIR is a measure of socioeconomic status and >1 means at or above the poverty level  We rerun all models for the association of birth weight and lung function with the percentage of predicted indicators using the NHANES criteria.To ensure the robustness of the results, we performed the following sensitivity analysis. (1) We rerun all models for the relationship between birth weight and lung function, limiting our analysis to participants with FEVAll models were adjusted for age (continuous), gender (boys/girls), height, race/ethnicity (Mexican American/Other Hispanic/Non-Hispanic White/Non-Hispanic Black/Other Race), mother's age at birth of children (continuous), PIR (≤ 1/>1), education level (≤ 5 grade/6–8 grade or 9–12 grade), asthma (yes/no), maternal smoking during pregnancy (yes/no) and survey cycles .P-values of < 0.05 were considered to be statistically significant.All analyses were performed using R . 1, FVC, FEV1/FVC, and FEF25 − 75 were 98.52% (14.62), 98.97% (13.78), 98.76% (7.15), and 100.38% (29.77), respectively. Additionally, the range of birth weight across 1st−4th quartiles were < 2.95, 2.92–3.32, 3.32–3.66, and >3.66 kg, respectively. There was no substantial difference in demographic and lifestyle characteristics between included and excluded children  were included in the present study. The characteristics of the study participants based on the quartiles of birth weight are shown in children .P for trend < 0.05). When birth weight was treated as a categorical variable, the results of FEV1 %predicted, FVC %predicted and FEF25 − 75 %predicted were similar to those seen in the continuous variable model structure . Compared to the reference group (birth weight < 2.95 kg), the positive association between birth weight and FEV1/FVC %predicted was only found in the fourth quantile of birth weight (>3.6 kg). The linear trend was also found between birth weight and FEV1/FVC %predicted although this was not statistically significant in the adjusted model (P for trend = 0.253). Then, we conducted a generalized additive model to test non-linearity using penalized smoothing regression splines with a degree of 3. The fully adjusted model showed a non-linear association of birth weight with FEV1 %predicted, FEV1/FVC %predicted, and FEF25 − 75 %predicted  (1 %predicted per 1 kg birth weight was 2.43 (95% CI 1.36 to 3.51), in FVC %predicted was 1.80 (95% CI 0.79 to 2.82), in FEV1/FVC %predicted was 0.70 (95% CI 0.09 to 1.31), in FEF25 − 75 %predicted was 4.24(95% CI 2.20 to 6.29). However, when the birth weight was ≥3.6 kg, per 1 kg increase in birth weight was significantly associated with lower FEV1 %predicted , lower FEV1/FVC %predicted , and lower FEF25 − 75 %predicted , respectively. In addition, no significant association was found between birth weight and FVC% predicted when the birth weight was ≥3.6 kg (The linear associations of birth weight with lung function were summarized in ctively) . We furt ≥3.6 kg .P for interaction >0.05) , gender (boys vs.girls), maternal smoking during pregnancy (yes vs. no), PIR (>1 vs. ≤ 1) and asthma (yes vs. no). We did not find any evidence of effect modification for the association of birth weight and lung function by these variables  –4. Moreocriteria , 6.We also investigated the relationship between birth weight and the risk of asthma. When birth weight was treated as a continuous variable, no association was found whether in the crude model or in the adjusted model. After adjustment for all covariates, in comparison with the reference group (birth weight < 2.95 kg), only children in the third quartile (3.32–3.66 kg) had a 24% lower risk of asthma , indicating a possible non-linear association of birth weight with the risk of asthma. No significant non-linear relationship was found in the fully adjusted generalized additive model . HoweverTo the best of our knowledge, this is the first study to examine the non-linear relationship between birth weight and lung function in a large and representative sample of children from the U.S. population. We observed a non-linear relationship between birth weight and lung function in school-age children. Moreover, we also found some evidence for the non-linear association of birth weight with the risk of asthma. These findings refine and extend previous knowledge about the association of birth weight with lung function, and remind us of the need for early lung function assessment not only in children with low birth weight, but also with high birth weight.1, FVC and FEF25 − 75 in children at age 10 and 18 years  higher FVC in adulthood per 1 kg increase in birth weight . In addition, the non-linear trend between birth weight and childhood asthma also existed, although it is not statistically significant. Several studies have illustrated the effects of birth weight on the risk of asthma, but the results are inconsistent. A retrospective cohort study found that low birth weight is not associated with asthma in childhood in the absence of smoking in pregnancy  can be found below: The studies involving human participants were reviewed and approved by data collection for NHANES was approved by the NCHS Research Ethics Review Board. All participants provided written informed consent. Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin.MY performed the statistical analyses, interpreted the data, and drafted the manuscript. HM, JD, and LY contributed to the data acquisition and review for important intellectual content. LH and LY revised the manuscript. HX conceived and designed this study and final version approval. All authors have read and approved the final manuscript.This study was supported by Natural Science Foundation of Hubei Province of China (No. 2021CFB176).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.