Whether only low-grade blastocysts should undergo freeze–thaw transfer during the in vitro fertilization/intracytoplasmic sperm injection cycle remains controversial; however, high-quality embryos cannot be obtained from some patients. Therefore, we aimed to identify factors that may affect the live birth.A total of 662 couples with only low-grade blastocysts who voluntarily accepted freeze–thaw blastocyst transfer at a single reproductive center over a 7-year period were followed-up. According to the outcome after transfer, they were divided into live birth group and failed pregnancy group. A nomogram was constructed for predicting live births.Baseline information and clinical treatment characteristics of patients in the two groups were comparable. Fifty-two of the 662 cycles (7.9%) resulted in live birth. Paternal age, maternal basal luteinizing hormone level, endometrial preparation scheme, and blastocyst development days were independent factors that affected low-grade blastocyst freeze–thaw transfer outcomes. The predictive model constructed based on these four factors presented favorable calibration and discriminatory abilities .For patients who exclusively underwent low-grade blastocyst freeze–thaw transfer, advanced paternal age and a high level of maternal basal luteinizing hormone adversely affected low-grade blastocyst freeze–thaw transfer outcomes. Artificial cycle preparation of the endometrium and day 5 blastocyst selection may improve the probability of live birth. Infertility is defined as no clinical pregnancy after 12 months of unprotected sexual intercourse. In the recent reports, infertility affected 8–12% of couples of childbearing age worldwide  and the Despite improvements in embryo culture methods, certain insurmountable challenges regarding the quality of available embryos persist. Embryo quality depends on various factors; however, irreversible factors, such as the advanced age of the couple, decreased reproductive organ function, and poor response to ovarian stimulation, among others, have resulted in the acquisition and transfer of poor-quality embryos in certain couples. It is already clear that poor-quality embryos are associated with lower clinical pregnancy rates and poorer pregnancy outcomes than high-quality embryos, whether at the cleavage stage or the blastocyst stage , 5. NoneHigh-quality single-embryo transfer has always been considered the optimal scheme for achieving favorable pregnancy outcomes of IVF embryo transfer , whereasIn clinic practice, the necessity for LGB transfer has been controversial, and most LGBs have been discarded; however, high-quality embryos cannot be obtained from some patients. To our knowledge, no study has focused on patients who underwent embryo transfer with only LGBs. Therefore, this study aimed to determine the independent factors influencing the live birth rate of LGB frozen–thawed transfer by analyzing the relevant factors involved in IVF/intracytoplasmic sperm injection embryo transfer and construct a predictive model that provides beneficial information regarding clinical treatment to improve the confidence of affected patients.We retrospectively screened 735 LGBs (score < 3 BB) , 13 tranThe entire cohort of embryos was cryopreserved on day 5 (D5) or day 6 (D6) and vitrified using an open system that allows for direct contact with liquid nitrogen and the embryo, which results in a high cooling rate. At our center, we use the Gardner blastocyst score  to evaluRegarding natural frozen–thawed embryo transfer cycles, the development of the dominant follicle and endometrium was monitored from day 10 using regular transvaginal ultrasound, urine luteinizing hormone (LH) tests, and serum LH, estradiol, and progesterone levels until ovulation. To prevent luteal phase defects, luteal phase support was provided by dydrogesterone tablets from the day of ovulation . Regarding artificial frozen–thawed embryo transfer cycles, patients received estradiol valerate  from day 3, three times daily, to prepare the endometrium for embryo transfer. Endometrial thickness was monitored using transvaginal ultrasound from day 10; when the endometrium reached or exceeded 8 mm, progesterone was provided . On embryo transfer day, required endometrial patterns were type B, type C, or type B–C according to the classification of Gonen and Casper . Type B The serum human chorionic gonadotropin level was measured 14 days after transfer. When serum β-human chorionic gonadotropin (hCG) exceeded 20 IU/L, the diagnosis was hCG positive and luteal support therapy was continued. Transvaginal ultrasonography was performed on day 35 after transfer. Clinical pregnancy was diagnosed based on the presence of an intrauterine pregnancy sac, fetal pole, and original cardiac beat. Positive fetal cardiac activity at 12 weeks of gestation, defined as a persistent pregnancy, and live birth after 28 weeks of gestation were the primary outcomes of this study. Patients with live births were assigned to the live birth group (Group 1), and other patients were assigned to the failed pregnancy group (Group 2).t test was used for normally distributed continuous variables, and the Mann–Whitney U test was used for non-normally distributed continuous variables. Categorical variables are expressed as numbers or percentages and were assessed using the Chi-square test. Variables with significant differences (P < 0.25) according to univariate analysis were included in the multivariate logistic regression analysis. Independent factors influencing LGB frozen–thawed transfer outcomes were screened out and a nomogram was established. The predictive ability of the nomogram was evaluated using the receiver-operating characteristic (ROC) curve and area under the ROC curve (AUC). The higher the AUC value , the higher the resolution of the nomogram. Furthermore, the calibration curve of the nomogram was used to evaluate the predictive accuracy. Finally, we used a decision curve analysis and clinical impact curve to evaluate the net benefit and clinical applicability of the model. A P value < 0.05 was considered statistically significant in all tests.SPSS  and R (version 4.0.3) software was used for statistical analyses. Continuous data are presented as mean ± standard deviation. Student’s According to the B-ultrasound results, 52 and 610 cycles were assigned to the live birth and nonpregnancy groups, respectively. Basic clinical characteristics of the patients are shown in Table To determine the effect of treatment methods on outcomes, based on the results of single-factor analysis, we divided all cycles into two groups according to different endometrial preparation methods Table . The twoThe 662 cycles were then grouped according to the transfer of blastocysts from different developmental days (D5 or D6). Patient characteristics and outcomes are shown in Table P = 0.012), basal LH , endometrial preparation protocol , and days of blastocyst development  were independent factors that influenced LGB frozen–thawed transfer. To ensure the objectivity of the model, we constructed ROC curves  were included in the multivariate logistic regression model. Figure To test the reliability of the model, we constructed a ROC curve for the predictive model Fig. A with anTo our knowledge, this is the first study to report the outcomes and influencing factors of patients who undergo only LGB frozen–thawed transfer. Clinical pregnancy was achieved with 55 of 662 cycles (8.3%), and live birth was achieved with 52 cycles (7.9%); these rates were considerably lower than those of high-quality blastocyst transfer. We observed that older paternal age, increased maternal basal LH levels, endometrial preparation protocols, and longer blastocyst development days were significantly associated with poor frozen–thawed LGB transfer outcomes. Furthermore, based on these findings, a live birth model for LGB was constructed for the first time.In our prediction model, paternal age was the greatest contributing factor affecting transfer outcomes; however, this has been rarely reported. Couples worldwide are having children at older ages, which is associated with fertility challenges. Although maternal age appears to have a greater influence on assisted reproductive technology outcomes, a previous study  revealedThe day of blastocyst development was a significant factor affecting the live birth rates associated with LGBs in our model. The influence of the embryonic development stage on transfer outcomes has been controversial. With the application of vitrification freezing technology, the selection of frozen embryos has evolved from the earlier cleavage stage to the blastocyst stage. When evaluating multiple randomized, controlled trials, Glujovsky et al.  observedThe preparation method of endometrium is one of the key factors to determine the success of frozen– thawed blastocyst transplantation, including natural and artificial cycles. Several studies , 28 haveAs a significant physiological regulator in women, LH not only participates in the menstrual cycle but also has a critical role in reproductive function. Previous studies on the effects of basal LH levels of IVF have predominantly focused on populations with polycystic ovary syndrome (PCOS). The generally high LH levels during the follicular phase of patients with PCOS potentially lead to decreased pregnancy continuation rates and early pregnancy losses . A recenThis study had some limitations. First, our nomogram is based on the retrospective data of 7-year follow-up of a single center. Although strict screening methods are used to reduce the inherent bias, the decisions of clinicians may also affect our results. In the future, it is necessary to verify the discovery that paternal age is the largest contributor to the nomogram in prospective studies. Second, this study focused exclusively on the transplant outcomes of frozen–thawed blastocysts. Therefore, our analysis may not be applicable to fresh transplanted LGBs. Third, the factors we evaluated were limited. The data regarding certain life factors, such as smoking frequency and alcohol consumption of the couple, were not collected. Therefore, we intend to incorporate these aspects in future studies.This single-center retrospective analysis is the first to assess the factors influencing frozen–thawed LGB transfer for patients with only poor-quality embryos and establish a prediction model of live birth. Our results suggest that older paternal age and increased maternal basal LH levels are associated with lower live birth rates. However, the artificial cycle as the preimplantation endometrial preparation approach and day 5 blastocyst transfer may increase live birth rates when conducted using only LGBs.


What are the patterns and differences in preterm birth rates among US counties from 2007 to 2019?In this cross-sectional study, small area estimation models were applied to birth registration records from the National Center for Health Statistics and demonstrated increases in preterm birth rates in 15.4% of counties between 2007 and 2019. The absolute difference between the 90th and 10th percentile counties was stable during the study period with a gap of 6.4% in 2007 and 6.1% in 2019.From 2007 to 2019, geographic disparities persisted, with increases in preterm birth rates in nearly 1 in 6 counties. This cross-sectional study examines US county-level variation and trends in preterm birth rates from 2007 to 2019. Preterm birth is a leading cause of preventable neonatal morbidity and mortality. Preterm birth rates at the national level may mask important geographic variation in rates and trends at the county level.To estimate age-standardized preterm birth rates by US county from 2007 to 2019.This serial cross-sectional study used data from the National Center for Health Statistics composed of all live births in the US between 2007 and 2019. Data analyses were performed between March 22, 2022, and September 29, 2022.Age-standardized preterm birth (<37 weeks’ gestation) and secondarily early preterm birth (<34 weeks’ gestation) rates by county and year calculated with a validated small area estimation model  and percent change in preterm birth rates using log-linear regression models.Between 2007 and 2019, there were 51 044 482 live births in 2383 counties. In 2007, the national age-standardized preterm birth rate was 12.6  per 100 live births. Preterm birth rates varied significantly among counties, with an absolute difference between the 90th and 10th percentile counties of 6.4 . The gap between the highest and lowest counties for preterm births was 20.7 per 100 live births in 2007. Several counties in the Southeast consistently had the highest preterm birth rates compared with counties in California and New England, which had the lowest preterm birth rates. Although there was no statistically significant change in preterm birth rates between 2007 and 2019 at the national level , increases occurred in 15.4%  of counties. The absolute and relative geographic inequalities were similar across all maternal age groups. Higher quartile of the Social Vulnerability Index was associated with higher preterm birth rates , which persisted across the study period. Similar patterns were observed for early preterm birth rates.In this serial cross-sectional study of county-level preterm and early preterm birth rates, substantial geographic disparities were observed, which were associated with place-based social disadvantage. Stability in aggregated rates of preterm birth at the national level masked increases in nearly 1 in 6 counties between 2007 and 2019. A large body of research has documented significant county-level variation in a variety of other health outcomes . However, less is known about county-level rates, trends, and correlates of geographic variation in preterm birth. Although prior data are limited, studies have examined geographic variation in preterm birth rates at the county or state level,16 but these studies have not included trend analyses with contemporary data or applied small area models to generate robust and stable estimates, particularly in counties with small numbers of preterm births. Furthermore, the correlation of social vulnerability with patterns in preterm birth have been examined in health system data sets or only in a single calendar year.18 To examine the evolving epidemiology and county-level variation in preterm birth rates and trends, we leveraged nationwide data to (1) generate robust small area level estimates of preterm birth rates, (2) examine associations between county-level differences in social disadvantage and preterm birth rates, and (3) quantify trends from 2007 to 2019 in county-level preterm birth rates.The national US preterm birth rate increased modestly between 2014 and 2019 after a period of relative stability between 2007 and 2014.19 The institutional review board at Northwestern University determined this study was exempt from review and the need for informed consent due to the use of deidentified data. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.For this cross-sectional study, we obtained restricted birth registration data from the National Vital Statistics System of the National Center for Health Statistics (NCHS), which includes details on all live births in the US, including maternal age, gestational age at delivery, year, and county of residence from 2007 to 2019. Data on race and ethnicity were not included in this analysis given that this was a place-based and not an individual-level analysis. County-level data on social disadvantage were obtained from the Centers for Disease Control and Prevention with the Social Vulnerability Index (SVI).The primary outcome was preterm birth (<37 weeks of gestation), and the secondary outcome was early preterm birth (<34 weeks of gestation). Preterm, early preterm, and total live births were tabulated by county, 5-year maternal age groups between 15 and 44 years, and delivery year. The 5-year maternal age groupings were used consistently as recommended by the National Vital Statistics System for standard reporting. We excluded pregnant individuals younger than 15 years or 45 years or older given small numbers at the county level.21 This model, whose details have been previously published, has been used extensively for estimating county-level CVD mortality rates to describe patterns and trends in county-level vital statistics.26 Briefly, this model is based on the Besag-York-Mollié conditional autoregressive model for spatially referenced count data.27 By iteratively estimating parameters within a Markov chain Monte Carlo algorithm and incorporating correlation across space, time, and age group, these models generate more precise rates, even in the presence of small case counts and populations.17 However, it is possible that the advantage of greater precision of rates with this modeling may make smaller differences in rates more difficult to observe. Specifically, temporal trends for each county will be smoother; thus, observing significant differences will require a larger magnitude of difference . In addition, temporal trends in adjacent counties will require greater magnitude of differences to identify geographic disparities in nearby counties. These aspects of the modeling result in greater robustness, producing a more conservative approach to statistically significant differences when identified. Preterm birth rates were estimated as the medians of the posterior distributions defined by the Markov chain Monte Carlo iterations and were age standardized to the age distribution of individuals with live births in 2007, the first year included in the current analysis.We used a bayesian multivariate space-time conditional autoregressive model to estimate annual county-level preterm and early preterm birth rates by age group. Additional detailed descriptions of the methods and the reliability of rates calculated are in the eMethods in 19 Themes are expressed as percentiles , which are in turn summed and expressed as an overall percentile , with a higher percentile indicating higher vulnerability. We classified counties based on quartile of the overall SVI and then used negative binomial regression to calculate rate ratios for estimated preterm and early preterm birth rates by SVI quartile for each year, with a time-varying SVI . Specifically, for county i, age group k, and year t, the model was iktY = 0ikβ + 1ik SVIβ + ikt)ln and language, and housing and transportation.For 2019, we described the differences between the 10th and 90th percentile counties for the overall SVI and for each of the 4 themes. In secondary analyses, we also performed a series of ordinary least-squares regression models with the estimated rate as the dependent variable and SVI as the independent variable(s) to examine county-level variation in rates associated with SVI.i, age group k, and year t, the model was ln(iktλ) = 0ikβ + 1ikβ·t. The total percent change was then calculated as 100(12β1ike – 1). Using the estimated percent change, we calculated the percentage of counties with increasing birth rates for each age group.We measured temporal trends nationally and in each county by estimating percent change in preterm and early preterm birth rates using log-linear regression on estimated rates from 2007 to 2019. Separate regression models were run for each county using estimated rates for all years. Specifically, for county To further examine geographic patterns, we calculated rates at the national, state, and combined statistical area (CSA) levels by aggregating crude, unsuppressed county-level data. As defined by the US Census Bureau, CSAs are combinations of metropolitan and micropolitan census areas that have economic and social linkages; CSAs may cross state lines. Counties within each state that were not included in a CSA were also aggregated. Age-specific and age-standardized rates were then calculated using these crude values. The corresponding trends were then calculated as defined earlier. No additional analyses were performed for these national-, state-, and CSA-level results.We performed secondary analyses to calculate age-specific preterm birth rates for women aged 20 to 44 years in 5-year intervals in each county with available data on more than 100 births in each age range given age-specific risks of preterm birth. The primary analysis included all pregnant people, because each birth has the potential to be preterm. However, given the deidentified nature of the National Vital Statistics System data set, multiple live births to the same pregnant individual could be included, so we performed a sensitivity analysis restricted to nulliparous individuals with a singleton live birth. All analyses were conducted using R software, version 4.2.1 . Data analyses were performed between March 22, 2022, and September 29, 2022.Between 2007 and 2019, there were 51 044 482 live births in 2383 counties included. In 2007, the national age-standardized preterm birth rate was 12.6  per 100 live births, and the early preterm birth rate was 3.6  . There wR2 of 0.27  , and health behavior counseling .29 However, monitoring of reliable county-level estimates of rates is needed to inform the design, implementation, and evaluation of community-based interventions. The robust small area models presented here may also provide an opportunity for evaluating and comparing effects of policies implemented in some, but not all, localities .30 Additionally, obstetricians, midwives, community workers, and programs, such as federally funded home visiting programs, may use these estimates to increase awareness, communicate the risks of preterm birth in the populations in which they work, and inform local strategies for prevention.Data on preterm birth rates have long been available at the national level, are a key indicator of population-level health, and have been widely used for public health planning. Reducing the preterm birth rate represents one of the key goals of Healthy People 2030,31 A previous study found relationships between neighborhood-level characteristics and birth outcomes that persist after adjustment for individual-level factors.31 Hypothesized mechanisms through which local environments may influence birth outcomes include structural racism and its consequent ramifications, including environmental stress , availability of resources , and the built environment .33 Moreover, the geographic patterns in preterm birth mirror those observed for CVD,34 which not only shares upstream social drivers of health but also is more likely after preterm birth. This finding demonstrates how multilevel interventions at the community level that financially invest in disadvantaged communities and address systemic barriers have the potential to improve outcomes across the life course. The SVI, particularly the socioeconomic theme or component, may therefore be a useful tool to implement to identify vulnerable communities and pregnant individuals who are at highest risk of preterm birth.The present analysis demonstrated consistent and graded associations of preterm birth rates with county-level social disadvantage. Although all 4 themes that comprise the SVI were associated with preterm birth, county-level differences in preterm birth rates were predominantly explained by differences in the socioeconomic theme, which includes measures of income, employment, and education. The SVI thus provides potentially valuable information to contextualize variation among counties and to identify structural and policy-level opportunities for prevention of preterm birth, particularly among prevalent and emerging geographic “hot spots.” Beyond individual-level risk factors , there is a large and increasing body of evidence for the importance of broader place-based contextual factors on adverse pregnancy outcomes.This study has several strengths. First, the use of innovative modeling with well-validated small area models allows for more precise estimation and ranking of county-level rates in preterm births. Second, this study examined both preterm and early preterm births. Third, this study considered both age-standardized and age-specific preterm birth rates.35 Second, the use of small area models may, in some cases, lead to oversmoothing; in addition, exclusion of the counties with the lowest number of births, which are more likely to be rural and have greater social disadvantage, may result in underestimation of relative differences across counties. In addition, there is the potential of bias toward recording urban residences in the data set, which may lead to further underestimation of rural-urban disparities. However, the use of small area models provides the most robust and stable estimates for modeling at the geographic scale when small numbers may be present as has been used in other publications for vital statistics.38 Third, the rates presented may underestimate overall rates of preterm birth because of the focus on birthing individuals aged 15 to 44 years, which was necessary given the small sample sizes for extreme ages. In addition, the aggregate rates and trends presented here differ from those published by the NCHS39 because we used age standardization to account for spatial and temporal changes in the age of birthing individuals. Fourth, the primary analysis uses deidentified data and therefore cannot exclude repeated individuals in the primary analysis. However, sensitivity analyses limited to nulliparous individuals resulted in the same patterns as the primary analysis. Fifth, this analysis used a composite score, the SVI, to represent county-level disadvantage, which may not fully represent social disadvantage at a smaller geographic scale (census tract) or at the individual level, which may have led to an underestimation of the importance of social factors in county-level patterns in preterm birth. Specifically, analysis at the county level may still mask significant heterogeneity within counties: census tract or neighborhood-level factors, such as residential segregation, which are well-established drivers of health inequities, might merit analysis in future studies. However, county-level SVI has been widely used in many other health outcomes as a proxy for social disadvantage and represents an important geographic scale that is relevant for policy makers.41 Sixth, the present data set does not differentiate between medically indicated and spontaneous preterm births, which limits the ability to examine how changes in clinical practice over time may influence preterm birth rates . However, the aggregate of both medically indicated and spontaneous preterm birth rates is an important metric to monitor and modify.This study also has several limitations. First, there is the potential for miscoding of gestational age in birth records. However, high concordance between gestational age reported on the birth record and the medical record has been reported, and the NCHS represents the most robust national data source available for the surveillance of preterm births in the US.In this nationwide cross-sectional analysis, substantial variations in preterm birth rates were observed among US counties. These differences were associated with county-level variation in social vulnerability. Stability of age-adjusted preterm birth rates at the national level masked significant increases in nearly 1 in 6 US counties between 2007 and 2019. Policy makers, researchers, and clinicians may use these county-level prevalence and trend estimates to inform the development and evaluation of interventions to reduce place-based disparities in preterm birth and thus improve health for both the birthing individual and offspring.


Preterm birth accounts for nearly 15 million births annually worldwide and constitutes a considerable risk factor for atypical development. This birth context is a source of stress for the parents and often leads to an early separation between their child and them. Research on the influence of the birth status on the infant’s attachment style has shown no systematic link between preterm birth and the development of insecure attachment in children born preterm. This has opened up research perspectives in understanding the role of environmental factors. A literature review was conducted to present an overview of the current findings on parental representations (PR), particularly maternal ones, and their role in the context of preterm birth. PR quality appears to be associated with specific dyadic interaction patterns, thus exposing vulnerability factors. Studies exploring PR have pointed out the importance of considering parental mental elaboration mechanisms and contextual moderators in supporting socio-emotional development among children born preterm. We discussed the challenges of investigating PR in the context of preterm birth for future studies and emphasized the need for research studies to be conducted according to a developmental and non-deterministic perspective. This narrative review also aimed to highlight the importance of family centered care interventions in the context of a public policy focused on the child’s “First 1,000 days” of life. Defined by the World Health Organization as a live birth occurring before 37 completed gestational weeks (GW), preterm birth accounted for 13.4 million births annually worldwide in 2020, or approximately 10% of births in the world . PrematuParental representations (PR) consist of parents’ subjective experiences of how they perceive their infant, their role as a parent, and their relationship . PR thusThe integration of the child’s own characteristics into the parents’ internal representations depends on the parent’s ability to understand and attend to the child’s mental state . PR can A literature review was conducted to identify the extent to which parental representations can be a vulnerability factor in the context of preterm birth, and a challenge for early intervention programs. The aim of this article was to present an overview of the current findings on PR after premature birth. Here, we will focus on parents’ internal working models about their child and not the social representations of preterm birth.We selected articles in the last two decades relating to parental  representations after preterm birth. We used PubMed, Science Direct, and EBSCOhost as academic search engines, with the following terms in titles, abstracts, and main texts: “representations,” “perceptions,” “mentalization,” “reflective functioning,” and “parental,” or “mother,” “father,” “maternal,” and “preterm,” or “prematurity,” “low-birth weight,” or “premature”. This allowed us to identify 297 unique peer-reviewed articles published between January 2000 and October 2022, 30 of which we reviewed here. A woman’s self-image as a “mother” has been shown to be dependent on the woman’s attachment style . We therAmong the articles, we selected those that were related to the review’s topic: (1) the assessment and evaluation of the quality of PR in the context of preterm birth, (2) the link between PR and the attachment style of children born prematurely, (3) the influence and role of PR on the development of early parent-child interactions, and (4) the mechanisms underlying the construction of PR after preterm birth. It is important to note that this narrative review only highlights a portion of the literature as other related articles could be added by expanding search criteria. However, we believe that this review may help in the understanding of apparent contradictions and challenges involved in studying parental representations within the context of preterm birth.First, we will present the comparative findings on the quality of PR after preterm birth and the assessment tools used in this specific birth context. Then, we will examine the link between PR and the attachment style of children born prematurely. Next, we will approach the influence of PR, on and through early interactions, according to the transactional model. We will then consider the role of parental constructs as either risk or protective factors before examining the influence of the mechanisms underlying the construction of PR. Finally, we will discuss clinical and research challenges faced when studying the role of PR after preterm birth in the context of a public policy centered on the child’s “First 1,000 days of life.”The present review has allowed us to identify the different tools used or presented in the literature to assess parental representations about the child, two of which are specific to premature birth . While oWorking Model of Child Interview (WMCI) developed by Reflective Function Scale  had secure attachment representations, compared to 53% of mothers of children born at term (57% at 18 months) . HoweverMaternal experience reported from the first hours of the newborn’s life provides a better understanding of the influence of the child’s preterm birth, especially the degree of prematurity on the maternal reaction in the postnatal period . MothersHowever, it should be noted that at 18 months of age, a greater proportion of balanced maternal representations are expressed about the toddler . This suPremature birth is often perceived as a stressful context for the parents. Yet, premature birth in itself cannot be considered as the only source of stress. The actual trauma associated with this complex situation is more related to the way in which this mostly unexpected event is experienced and apprehended by the parents. According to Given the complexity of the processes involved, prematurity appears to be a context of vulnerability that is likely to impact the development of balanced parental representations about the child and optimal early affective parent-infant interactions. In this regard, the potential link between PR and attachment quality in children born preterm has been explored.Previous studies focusing on the factors impacting the quality of PR after preterm birth have shed light on the need to take into account the possible role of PR on the attachment quality of the preterm child. For instance, Several studies have examined the impact of preterm status on mother-infant interactions and, more precisely, the link between the type of maternal representations and specific dyadic patterns. For instance, In addition, . Mothers of moderately preterm children displayed more sensitivity than mothers of very preterm infants, but no other differences were found when comparing maternal interactive behavior among mothers of full-term, moderate, and very preterm infants , whether with children born at term or prematurely . Hall et infants . However infants . More po infants . On the  infants .The studies reviewed above have suggested that maternal representations were associated with specific dyadic interactive patterns, particularly disruptive ones. However, Parental representations of the child consist of the exploration of current and past expectations and fears experienced by the parent but also tend to integrate elements of the actual parent-child relationship, particularly through the care provided by the parent to the child . In thisAs presented earlier, the experience of premature birth can generate exaggerated anxious concerns in the parent, who will be engaged in more frequent intrusive behaviors, or conversely, withdrawal behaviors translated by the avoidance and minimization of actual difficulties . DisturbAccording to Studies investigating the influence of preterm birth on the quality of PR have identified cumulative vulnerability factors. Recent research is now focusing on the role of specific PR elaboration mechanisms in the context of preterm birth. Maternal mentalization contributes to the mother’s sensitive response during mother-infant interaction . HoweverIn a recent study conducted by Similarly, It is noteworthy that recent studies have included both fathers and mothers when investigating the influence of preterm birth on mental elaboration mechanisms among parents of preterm children. Taken together, the studies reviewed above highlight the importance of assessing both the fathers’ and mothers’ parenting concerns in the context of preterm birth and providing support specific to each parent’s needs. Parental elaboration mechanisms (notably PRF) also play a key role in the parenting experience, especially as a moderator in the link between preterm birth and parenting stress .In this review, we discussed the singularities and the role of PR following preterm birth regarding the dynamics of early parent-infant interactions. Studies investigating the social representations of prematurity among caregivers or children born prematurely are not addressed in this review.After reviewing the aforementioned studies, we were able to establish that: (1) most of the studies we reviewed assessed maternal representations after preterm birth with a notable lack of data on paternal representations; (2) research studies did not find a direct link between preterm birth and the quality of PR but rather address the various risk factors associated with preterm birth which may be linked to distorted or disengaged PR following a child’s preterm birth; (3) assessing maternal representations provide insight into the future development of the mother-infant relationship and specific dyadic patterns; (4) early interactions are also part of the co-construction of PR which in turn can influence maternal and child interactive behaviors; (5) recent research has examined the mechanisms underlying the construction of PR in the case of preterm birth, which has been shown to be impacted by stressful contexts (such as preterm birth) and parental gender. Those mechanisms could then constitute long-term vulnerability factors for the parent-preterm dyad .Additionally, findings stress the need for the early identification of vulnerable dyads by identifying markers found in parental narratives in order to provide targeted interventions on both parents’ experience of preterm birth. Parents’ experience of prematurity reveals that fathers and mothers react differently : fathersThis review also emphasizes the complexity and multiplicity of factors influencing child development. Consequently, no direct causal link between the child’s premature birth and the risk of insecure attachment was evidenced, which constitutes a reassuring and destigmatizing message for professionals and parents.On the other hand, preterm birth remains a source of vulnerabilities regarding the child’s developmental outcomes . MultiplIn light of the aforementioned results and issues, it seems relevant to question the modalities by which the role played by PR in early parent-preterm infant interactions could be investigated to identify specific interactive models. The influence of the degree of prematurity on the quality of maternal representations identified by For future research, it would be pertinent to rely on the assessment of PR after a premature birth in order to highlight the extent to which this “mediating variable” could serve as a protective or vulnerable factor regarding parent-child attachment bonds and the children’s outcomes. This could be achieved by exploring the interactive dynamics of the parent-child dyad. The longitudinal study conducted by The parent-infant dyad is organized as “an intersubjective meeting space that expands during the first year of life” , p.133. In addition, findings regarding the influence of maternal mentalization abilities on the abilities of the previously premature 11-year-old child , highligWe encourage future studies to investigate these research questions from a developmental perspective. Indeed, the attachment development of children born preterm is not solely the consequence of maternal interactive behavior  . For insTo conclude, it is of high importance to not only focus on considering the causal pathways between PR and attachment style but also prioritize examining the precursors of the construction of intersubjective bonds and the parent-preterm infant interactive dynamic. The study of both elements will determine protective and risk factors regarding the transmission of parental vulnerability during the child’s early development. Further studies aimed at exploring paternal representations; especially, the role played by fathers’ mentalizing in the case of preterm birth should be promoted. These are the new challenges of early prevention embedded in the policy of the “First 1,000 days.”All authors contributed to the manuscript revision, read, and approved the submitted version.


Globally, increasing rates of facility-based childbirth enable early intervention for small vulnerable newborns. We describe health system-level inputs, current feeding, and discharge practices for moderately low birthweight (MLBW) infants (1500-<2500g) in resource-constrained settings. The Low Birthweight Infant Feeding Exploration study is a mixed methods observational study in 12 secondary- and tertiary-level facilities in India, Malawi, and Tanzania. We analyzed data from baseline facility assessments and a prospective cohort of 148 MLBW infants from birth to discharge. Anthropometric measuring equipment , key medications , milk expression tools, and human milk alternatives  were not universally available. MLBW infants were preterm appropriate-for-gestational age (38.5%), preterm large-for-gestational age (3.4%), preterm small-for-gestational age (SGA) (11.5%), and term SGA (46.6%). The median length of stay was 3.1 days ; 32.4% of infants were NICU-admitted and 67.6% were separated from mothers at least once. Exclusive breastfeeding was high (93.2%). Generalized group lactation support was provided; 81.8% of mother-infant dyads received at least one session and 56.1% had 2+ sessions. At the time of discharge, 5.1% of infants weighed >10% less than their birthweight; 18.8% of infants were discharged with weights below facility-specific policy . Based on descriptive analysis, we found constraints in health system inputs which have the potential to hinder high quality care for MLBW infants. Targeted LBW-specific lactation support, discharge at appropriate weight, and access to feeding alternatives would position MLBW for successful feeding and growth post-discharge. Globally, nearly 20 million infants are born with low birthweight (LBW) (<2500g) each year. LBW infants represent a heterogeneous group who may be preterm (<37 weeks gestation) and/or small-for-gestational age   stayed longer than preterm-SGA [2.4 days ], preterm-LGA [1.3 days ], and term-SGA [2.3 days ] infants (p = 0.02). Infants born in secondary-level facilities were discharged earlier than those in tertiary facilities.The median length of stay, which varied by site (p = 0.01), was 3.1 days ; 75% of infants were discharged within 7 days  infants were separated from their mothers during their time in the facility. Occurrence of separation significantly varied across sites, occurring most often in the African sites  compared to the Indian sites . Out of 100 mother-infant dyads separated, 52 (52.0%) were separated within 30 minutes postpartum and the vast majority were separated within 6 hours postpartum (93/100). Mothers reported the predominant reasons for separation were due to policies related to premature birth (50.0%), LBW (80.0%), facility standard practice (20.0%), infant illness (21.0%), or maternal illness (13.0%). Across the duration of admission, separation lasted an average of 21.0 hours  and did not vary by sex, but varied significantly by site (p<0.0001), with the longest in Tanzania and shortest in India-Odisha . Term-SGA infants had the shortest duration of separation, but this was not significant . Percent of time separated, calculated by dividing the total separation in hours by total hours of facility stay, demonstrated that mother-infant dyads spent more than one-third of their admission separated (37.3% (SD: 37.6%), n = 86).Over the entire length of stay, 32.4% (48/148) of infants were admitted to the NICU, primarily in tertiary facilities . NICU admission was most common in Tanzania  and Malawi , followed by India-Karnataka  and India-Odisha , depending on policy standards and facility availability. Admission to the NICU was most prevalent among preterm-AGA infants (50.9%) followed by term-SGA (21.7%), preterm-LGA (20.0%) and preterm-SGA infants (17.7%). In crude binomial regression models adjusting for clustering by facility, there was no significant association between preterm-SGA and term-SGA infants and NICU admission compared to preterm-AGA infants ; conversely, preterm-LGA infants were significantly less likely to be admitted to the NICU compared to preterm-AGA infants . In addition, infants with the lowest birthweights [(1500-<1800g) and (1800 -<2200g)] had a higher prevalence of admission to the NICU (54.6% and 31.8%) compared to those infants born with higher birthweights bands (2200-<2500g: 25.4%). However, this was not significant after adjusting for clustering by facility . Infants ever admitted to the NICU had a significantly longer length of stay compared to non-NICU admitted infants. Infants admitted to the NICU had a median length of stay of 6.0 days  compared with 2.1 days  among infants in the postpartum ward (p<0.0001). In addition, the length of stay varied significantly by site (p<0.0001). NICU admission duration did not vary by infant sex or LBW type.Infants in the NICU were primarily fed breastmilk unless clinical complications impacted the infants’ ability to feed. Oxygen/CPAP was initiated for 43.8% (21/48) of NICU admitted infants. Feeding intolerance occurred among 22.9% (11/48) of the NICU-admitted infants, which led clinicians to stop oral feeds. These infants were then given parenteral nutrition, fed breastmilk via nasogastric tube, and/or were administered intravenous fluids. Of all the NICU-admitted infants, 4.2% (2/48) were given parenteral nutrition, 8.3% (4/48) had a nasogastric tube, and 54.2% (26/48) were given fluids intravenously.Fig 1).Of the 148 enrolled infants, one infant in Malawi did not have any feeds prior to discharge at two days postpartum; the remaining 147 infants had feeding observed from birth to discharge. The majority, 93.2% (137/147), were exclusively fed human milk [mom’s own milk or DHM], 6.1% (9/147) were given mixed milk feeding [formula and breastmilk], 2.0% (3/147) were given other liquids (no specific information available), and 0.7% (1/147) was given only formula. Mixed milk feeding was more common in India-Odisha  compared to Tanzania , Malawi , and India-Karnataka . Provision of feeds other than human milk and formula  were not observed. Based on maternal report, three infants were given other unknown liquids. Otherwise, feeding information , obtained from direct observations was highly correlated with maternal self-report  initiated breastfeeding within 1 hour of birth. Early initiation varied by infant LBW type: 90.0% of preterm-SGA, 59.1% of preterm-AGA, 25.0% of preterm-LGA, and 95.7% of term-SGA infants. This variation was likely related to mother-infant separation and infant prematurity with preterm-AGA and preterm-LGA infants averaging 33.5 and 30.1 weeks gestation respectively, preterm-SGA infants at 35.6 weeks and term-SGA at 38.9 weeks. Among infants separated, 69.0% (29/42) initiated early breastfeeding, whereas 95% (38/40) of non-separated infants initiated early breastfeeding. After adjusting for clustering by facility in a crude binomial regression model, infants who were separated from their mothers were significantly less likely to initiate early breastfeeding compared to those infants who were not separated .Figs S1) followed by expressed breastmilk . Provision of expressed breastmilk, unfortified and fed immediately after expression, varied by site . Direct observation of milk expression was conducted with 62/64 mothers. Nearly all expressed milk by hand ; a manual pump was used by three mothers , and electric pumps by two  at private facilities.Direct breastfeeding was the predominant feeding type observed  (Formula was fed to 6.1% (9/147) of infants with a cup/spoon/paladai, primarily in India-Odisha and Tanzania; bottles with a nipple were not used. Unfortified DHM fed by cup/spoon/paladai was given to 10.5% (4/38) of infants born in India-Karnataka, representing 2.7% of the whole cohort. Supplementation, only given in India-Karnataka, included iron and vitamin D  or zinc and multivitamins .Table 4). Two or more sessions were provided to 56.1% of dyads, typically in a group setting. Support was primarily provided by healthcare providers (90.1%) or family members (27.3%). Type of support varied by site, including help with positioning of the infant, latch, milk expression, and feeding with a cup/paladai (Table 4). Counseling, as reported by mothers, did not vary by infant sex , LBW type , or NICU admission . Mothers reported being the primary decision-makers for breastmilk feeding. Clinicians played an important role in influencing the mother to feed infants expressed breastmilk (68.1%), DHM (100.0%), and infant formula (100.0%). For the three infants whose mothers reported to feed ‘other’ unknown liquids, the mothers (n = 2) or family members (n = 1) made the decision.Overall, 81.8% of mothers reported receiving at least one lactation support and counseling session; yet, the frequency, provider, and type of counseling varied by site (. The average PIBBS score at baseline was 11.9 (±4.3) and increased to 14.2 (±3.3) within 24 hours prior to discharge; 58.6% of infants were discharged with low feeding competency (PIBBS score ≤15). There were no significant differences in the mean discharge PIBBS scores by lactation support, sex, LBW type, size-for-gestational age, or GA.Feeding competency assessments showed significant improvement from baseline to facility discharge across all sites (Table 5). On average, infants lost 2.4% (± 5.8%) of their birthweight, varying by length of stay. Overall, 5.1% (7/138) lost >10% of their birthweight at the time of discharge. However, 18.8% of infants were discharged with weight below the site specified discharge criteria: 20.6% (7/34) of infants in India-Karnataka and 5.7% (2/35) with weights <1800g; 40.0% (16/40) in Tanzania had <2000g; (3.5%) (1/29) in Malawi <1500g. All infants were stable at the time of discharge.Based on national and facility policy, infants met certain criteria around feeding, stability, and weight to be discharged. Of the 140 infants assessed at discharge, 97.1% were fed only breastmilk , 2.7% fed formula only, and 0.7% fed a mix of formula, direct and expressed milk. Weight change between birth and discharge was minimal , yet notable levels of mother-infant separation and gaps in universal and repeated lactation support or counseling –24.Uptake and adherence to EBF was high, aligning with global recommendations and facility standard protocols , 25. MorWhile uptake of EBF was excellent, health system constraints  likely led to misalignment of practice and policy and limited optimization of in-facility care, demonstrated by <60% receiving 2+ lactation support sessions, >66% of dyads experiencing maternal-newborn separation, and discharge of 18.8% of infants below minimum weight thresholds. Nurse-to-patient ratio guidelines from medical and nursing societies range from 1:3 for the lowest acuity care (level 1) to 1:1 for the highest acuity care (level 5) –33. OnlyLack of universal and hands-on provision of lactation support and counseling was possibly driven by the high levels of mother-infant separation, staff shortages, and lack of specialized training on LBW lactation support among providers, which are well-documented barriers to support of EBF –41. UnreFurther, breastmilk alone may be insufficient to meet the nutritional needs of MLBW infants , 44–46; Our study addresses key knowledge gaps as the majority of published research focuses on very LBW/preterm infants in high-income settings despite the predominance and risk of MLBW infants . We presWe do have some notable limitations. We focused on MLBW infants, which preselected a preterm-AGA population that is less mature than a preterm-SGA group, . In addition, our study population included infants born at secondary and tertiary facilities and thus cannot be generalized to infants born at lower-level facilities or at home. The study sample size allowed for a deep understanding of the feeding experiences and care of LBW infants and resulted in a rich descriptive data at each site. However, this sample does not represent all LBW infants and, since this was intended largely as a descriptive paper, our modeling analyses are limited. Statistically significant findings should be interpreted cautiously as we could not control for potential confounders, and observed associations may be spurious. Further studies need to confirm our findings. Additionally, GA source differed by site which could cause LBW type misclassification; however, we use prioritization criteria for choosing the source of GA, namely ultrasound at first trimester when available over other sources followed by LMP in medical charts. Finally, observation by study staff may have altered participant behaviors; however, we had multiple observations over time and had specific research nurses gather information rather than clinical staff.health systems improvements to increase human capacity, staffing and training, to improve breastfeeding alternatives availability, and to support adherence to discharge policies, which would improve mother-infant experience of care by reducing mother-infant separation, initiating breastfeeding early, and providing lactation support and counseling specialized for MLBW.With increases in facility-based childbirth, critical opportunities exist to set up MLBW infants, their mothers, and families to thrive post-discharge. Given the renewed investment and recent guidelines in the care of small and sick newborns , 50, theS1 Fig(TIF)Click here for additional data file.S2 Fig(TIF)Click here for additional data file.S1 File(DOCX)Click here for additional data file.


To explore birth companions’ experience of the birthing room and how it influences their role supporting the woman during labor and birth.Although support from a birth companion positively affects the outcome of labor and birth, limited research explores how the birthing room influences the companion. This study identifies elements of the birthing room essential for the birth companion to offer optimal support to the woman during labor and birth.Fifteen birth companions were individually interviewed 2 weeks to 6 months after birth using a semi-structured interview guide. Transcribed interviews were analyzed based on reflexive thematic analysis.The findings are captured by one overall theme: creating a supportive birth space in an unfamiliar environment. This creation process is further described by three subthemes: not being in the way, finding one's role, and being close to the birthing woman.The findings illustrate how the birthing room was an unfamiliar environment for the birth companions, but one that they needed in order to give the required support. With slight changes in physical design, the birthing room can become calmer and more private and better help the birth companion fulfill the supportive role. This article examines birth companions and their roles supporting women during labor and birth. A birth companion should be chosen or accepted by the birthing woman and can be the father to be or a partner, relative, friend, doula, or healthcare professional. Support from a birth companion includes providing information, advocacy, practical and emotional support, and being continuously physically present . A systeBirth is a neurohormonal physiological and psychological process, particularly influenced and controlled by oxytocinergic mechanisms. This process is influenced by sensory stimuli, for example, from the uterus and by one-to-one support offered by a birth companion. Also, the external environment might influence these neurohormonal processes. A stressful and unfamiliar environment activates the sympathetic nervous system and inhibits the release of endogenous oxytocin, leading to weakened or ceased labor contractions, while a calm, private, and safe environment reduces stress and increases the release of endogenous oxytocin . HoweverIn the Swedish Room4Birth research project, we found that the birthing room, through its design, could support either a salutogenic physiological birth process or a pathological treatment of childbirth . We alsoThere is limited research exploring birth companions’ experience of the birthing room design. A video ethnographic single-case study in Australia found childbirth supporters to be in a physical space that did not facilitate their presence and roles .There is limited research exploring birth companions’ experience of the birthing room design.https://www.gu.se/en/research/room4birth).This study explores the birth companions’ experience of the birthing room and how it influences their role supporting women during labor and birth. The knowledge gained is intended to identify design elements of the birthing room essential for birth companions to offer optimal support to women during labor and birth. The study is part of the Room4Birth research project, which aims to expand evidence-based knowledge of the design of the maternal healthcare environment and how it influences maternal and newborn health and care outcomes , and those consenting were contacted by H.N. 1 week after birth by email or phone. They were informed that participation was voluntary, that they could withdraw consent at any time, and that the data would be handled confidentially. All participants signed a consent form before an individual interview scheduled according to the participant’s availability.A total of 15 birth companions were individually interviewed: eight fathers of the child being born, four doulas , two relatives, and one friend. Characteristics of the study participants are presented in A total of 15 birth companions were individually interviewed: eight fathers of the child being born, four doulas , two relatives, and one friend.The interviews were based on a semi-structured interview guide  tested and developed in two pilot interviews with birth companions. The interviews were informal with the companions first being asked to describe how they perceived the birthing room with follow-up questions such as how the room affected them, if they felt comfortable and if there was a space for them. Thereafter, questions were asked to cover topics such as if they felt free to adapt the room to their and the birthing woman’s needs, parts in the environment that were important for them, and elements of the birthing room that facilitated or distracted them in their supportive role. All interviews were conducted by H.N., one in a secluded room at the researchers’ office and all others using a video communication tool (zoom.us). All were audio-recorded and lasted 36 min on average; an independent agency transcribed the recordings.Reflexive thematic analysis is a flexible method comprising several steps , 2021a. In reflexive thematic analysis, the subjectivity and reflexivity of the researcher are important tools in the research design, enabling the analysis to be richer and more insightful . Both ofThe study was designed and conducted in line with the Declaration of Helsinki: Ethical Principles for Research Involving Human Subjects For some birth companions, the medico–technical equipment in the birthing room engendered a feeling of safety. It ensured that the room was a safe place where any medical complication that might arise during the birth process could be handled. For other birth companions, the medical equipment signaled that birth was not a normal physiological process that the woman’s body could handle, prompting worrying questions concerning when and how the equipment might be used and what types of emergencies could happen:There were a lot of tubes. It really looked like a hospital environment. Everybody says, “You are not sick—this is health care [to have a baby].” But it did not feel like that. Or at least the room didn’t say so. The room instead said, “Here we can resuscitate you, in case you die,” sort of. (ID 3)The size and furnishings of the birthing room indicated planning for the presence of only one birth companion. So as not to be in the way, the companions needed their own space where they could put their belongings without hindering staff in their jobs. The windowsill, sofa, and/or chair were such spaces, whereas the areas around the computer, cabinets, and wall with medical equipment were spaces the birth companion avoided so as not to hinder the labor ward staff in their work. When settled in a dedicated chair, the companion could feel more relaxed:It felt like it  was my place, this is where I belong. You are so lost as a partner. What should I do? How am I not in the way of all these important people who will do all these important things so that my baby doesn’t get hurt, etc. (ID 8)The birthing bed was usually placed in the center of the birthing room, indicating that this was where the main event would happen: It was to be used by the woman during labor and was where the baby would be born. The bed was technical and difficult for the birth companion to adjust, and it was covered with plastic, indicating that the birth could become messy:It  was like the centerpiece of the room. It’s what catches your eye when you enter the room. You look at the bed and you see the list behind it with all the pipes, tubes, and regulators. You understand someone is going to lie there, and it probably won’t be nice. (ID 3)It was important for the birth companion not to disturb the labor ward staff unnecessarily, as they seemed very busy and stressed. It was considered logical that the staff would not be continuously present but generally only come into the room as needed and then leave. When help was needed, the birth companions had to call using the buzzer, which was a secure link to the staff:I felt we could manage here. And then there was the buzzer, so I didn’t feel alone, which was nice. (ID 3)The theme finding one’s role describes the birth companions’ attempt to find their role in an unfamiliar environment and culture, with the risk atmosphere signaled by the birthing room and the whole labor ward. This made them feel lost and uncertain about how to behave. As expressed by one birth companion, being in the birthing room gave a feeling of being abroad in a foreign country:It is sort of like visiting another country—you don’t really know the culture and how to behave, because you haven’t been to this country before…. I didn’t know, what were my rights as a partner? Do I get something to eat, or do I need to go and buy it myself? And in that case, how do I get back in, as it  was locked. I, who had never been there before, had no clue. Where do I go to the toilet? Can I sleep somewhere? Can I even stay? (ID 8)While caught up in the labor and birth process in this unfamiliar environment, the birth companions tended to neglect their own needs, such as resting, eating, and using the toilet. They were often caught up in the birth process, and prioritizing their own needs was difficult as the birthing woman was central. On the other hand, they needed to fulfill their basic needs to have energy for the supportive role, but it was difficult to do this in the birthing room. One birth companion described how, during a longer labor, she rested in an armchair, covering her head with a scarf to ensure privacy, but still could not get needed rest. Eating was also difficult or almost forgotten, or they just grabbed convenient food such as a banana. Another birth companion expressed:It worked for me as I knew it was a temporary thing. I wouldn’t be there for more than 1 or 2 days. I knew my wife would have a much more difficult time, so I shouldn’t complain about a mattress [on the floor]. I was happy just to have a place to sleep. (ID 7)Another example of how the birth companion’s needs were marginalized was the lack of opportunity to use the toilet in privacy. The toilet in the birthing room could be occupied by the birthing woman and be messy, and, if not shielded by a door, it did not invite the birth companions to use it:It was a toilet without a door, just partitioned off with a room divider. So, it wasn’t a private situation to use the toilet. After a brief “knock, knock,” someone could come into the room and just stand there. Hm, so it felt a bit uncomfortable for us both if you needed to use the toilet. (ID 10)When caught up in the birth process, one could lose awareness of time and space. The birth companions could perceive themselves as confined in the birthing room. Looking through a window could give them a sense of time and space, as it reminded them of the world outside the birthing room. Rain spattering on the window, a sunset or sunrise all helped them relate to the outside world. More space and a window with a view could mitigate the experience of the birthing room as a bunker:Well, it was sort of like a bunker. There were a lot of things in the room, hence the strained feeling. And the window, there was a building directly outside of it. It felt very crowded. (ID 12)The subtheme being close to the birthing woman captures the closeness to the birthing woman the birth companions needed in their supportive role. Being close was important so that the woman could feel that the companion was there for her, and this entailed both mental and physical closeness. Physical closeness could, for example, entail holding a hand, giving a massage, and having eye contact, while mental closeness implied creating an atmosphere of intimacy in the room:I believe that distance can feel very great when giving birth. Even if it is just half a meter, it can sort of feel like “Where are they?” So I try to be as close as possible. With good eye contact to show “you are doing well.” And by using my hands a lot, through touch, I need to be close. (ID 4)The theme It gave some control [the electronic fetal monitor]. You imagine you have control, but you actually don’t. But it gave some form of security. It is on 130 now, super, or 120. At some point it went down to 80 and then my partner changed position and it went up again. That felt so good. (ID 1)However, the physical design of the ordinary hospital birthing rooms, with their medico–technical equipment, did not invite such closeness, but rather tended to distance the birth companion from the birthing woman. For example, the electronic monitor of contractions and fetal heartbeats could draw attention away from the birthing woman’s experience of contractions. Observing the baby’s heart rate on the screen of the electronic fetal monitor could contribute to a sense of safety as long as everything was normal, but if the curve became unusual and attracted attention from labor ward staff, it instead became a stressor:I don’t know if it was the room that enabled us to be so very close to each other. Just that we had the couch where everyone could fit, the whole family, and the [birthing] pool where she  could sit towards the side, and everyone could touch each other, and it was natural that we all wanted to be close. (ID 14)The centrally located birth bed was large, but not large enough to be used by two people, such as the woman and her partner. The complex technical design of the bed made the birth companion dependent on the staff to adjust it, so having their eyes at the same height as the birthing woman’s eyes was difficult. They described how they struggled to gain closeness at the right height by leaning over the bed in strange positions, kneeling, and positioning the armchair near the bed. In contrast, the home birth setting enabled closeness and intimacy in a more natural way:I was kind of scared, or worried about it before. But it turned out so well, and it was really because it was such a calm environment, with calm and harmonious people. The two midwives were absolutely amazing. They were low key, staying in the background and acting only when there was a need for support or to do something. One of them was knitting between contractions, and that contributed to the sense of calm. (ID 15)There were no other voices, just the family and me talking. The midwife stayed in the background, so there were no other interrupting features. It felt a bit like we were in a bubble—it was very special. (ID 14)Being close required that the birthing room had an atmosphere of privacy, intimacy, and calm. The birth companions found the labor ward staff to be central to creating such an atmosphere by, for example, respecting the privacy of the birthing woman, protecting her from exposure, not going into and out of the room unnecessarily, and knocking before entering. In a more homely and private environment, it was easier for the birth companions to be and feel close to the birthing woman. A homely environment enabled a more intimate atmosphere, which could be created by adding color, providing dimmable lighting and soft music, and hiding medical equipment. Birth companions with experience of assisting at both hospital births and home births concluded that such an atmosphere was easier to create in the home birth setting:the physical design of the ordinary hospital birthing rooms, with their medico–technical equipment, did not invite such closeness, but rather tended to distance the birth companion from the birthing woman.This study, exploring birth companions’ experience of the birthing room and how it affects their role supporting the birthing woman, shows that it was a challenge to create a supportive birth space in the birthing room, which appeared as an unfamiliar environment. This challenge simultaneously entailed not being in the way of labor ward staff and finding a role in the room that enabled closeness to the birthing woman, which was essential to her support.This study, exploring birth companions’ experience of the birthing room and how it affects their role supporting the birthing woman, shows that it was a challenge to create a supportive birth space in the birthing room, which appeared as an unfamiliar environment.In reflexive thematic analysis as conducted here, reflection on the “information richness” of the data set is recommended . Our datOur finding that birthing rooms of medico–technical design were experienced as unfamiliar is unfortunately aligned with what hospital-based labor wards generally provide . The birnot being in the way captures how the birth companions tried to avoid interfering with the labor ward staff. The technocratic model of medicine has been described as a healthcare paradigm that requires, for example, the following of certain routines during the labor and birth process, which is assessed as inherently risky and in need of control by medical and technological expertise (The theme xpertise . That bixpertise . This mexpertise . Neverthxpertise . The impxpertise . In contfinding one’s role captures how the birth companions felt lost and tended to neglect their basic needs. Previous research has shown that fathers want to be active participants in their partners’ labor, and that being a calm and supportive birth companion can be emotionally challenging (The theme llenging . Howeverbeing close to the birthing woman emphasizes the closeness the birth companions needed as part of their supportive role. However, the birthing room design instead tended to distance them from the birthing woman, not promoting the privacy and integrity that they needed to secure for the birthing woman. A scoping review has described how the birthing room could be perceived as more private and intimate if a small area separates it from the corridor, indicating a gradual transition from outside to inside, and the bed is positioned to create a sense of intimacy (The theme intimacy . In our intimacy . The resbeing close to the birthing woman, which concerns both physical and mental closeness. Mental closeness implied creating an atmosphere of calm intimacy in the room. The labor ward staff were part of the birth environment and could contribute to this atmosphere. In a midwifery model of woman-centered childbirth care, developed in studies in Sweden and Iceland, one of the three central and intervening themes in the model is to create “a birthing atmosphere” that fosters feelings of calm, trust, and safety and that supports a sense of normalcy. The midwife has a central role in creating such a birthing atmosphere, but in a hospital-based birth environment, this is a great challenge (The birthing room, apart from the physical space, is found to be the site of human interactions that affect the atmosphere in the room . This wahallenge  due to thallenge . For midhallenge . The midhallenge . This waThe birth companion’s support is important for the birthing woman and positively influences her childbirth experience as well as the outcome of labor and birth . By explProvide storage space for the birth companion’s and birthing woman’s belongings—This would create a welcoming feeling by showing that both have important roles in the birth.Create sufficient space for the presence of several birth companions—The birthing room needs to be spacious enough for several birth companions.Provide comfortable furnishings so everyone can sit and rest—These should include both a large sofa and movable armchairs to enable closeness to the birthing woman.Hide the medical equipment—Although this equipment can provide a sense of security, it also signals that birth is risky and can raise worrying questions that disrupt the birth companion in their supportive role.Provide a homely environment that is soft and cozy and allows the birth companion to personalize the room—The features should include soft and dimmable light and the ability for individual choice of music.A spacious bed should be positioned carefully to provide privacy—A hospital bed positioned centrally in the room signals to the birth companion that this is where the baby is to be born, discouraging movement during labor and birth. Also requested was a bed large enough for both the birthing woman and her companion, so the companion can provide support through physical closeness.Provide clear descriptions of where the birth companion can conveniently obtain beverages and snacks nearby—This would enable the companion to get refreshments while remaining near the birthing woman.Ensure that there is a window with a view that allows the amount of daylight to be controlled—There is a need for a window that the birth companion can look out to follow the rhythm of the day and changes in weather, so as not to lose track of time. The window should be positioned to ensure privacy but allow the amount of daylight entering the room to be controlled.A small hallway between the birthing room and the corridor would constitute a transitional space for those entering the birthing room, thereby increasing privacy.An additional toilet is needed in the labor ward for the birth companions—The toilet in the birthing room might well be occupied by the birthing woman, and an additional toilet outside of the birthing room would give the birth companion some privacy.A quiet and peaceful space outside of the birthing room where birth companions could briefly rest—This should be separated by a door from the waiting area or day room, as these areas can become crowded and do not provide the privacy needed for rest.Based on our findings, we have made a list of recommendations for aspects of birthing room design that facilitate birth companions in their supportive role during labor and birth. These recommendations can be considered both in adapting existing birthing rooms and constructing new ones.Our study found the birthing room design tending to distance the companions from the birthing woman, not promoting the privacy and integrity that they needed as part of their supportive role. There is a need for a birthing room design that facilitates physical closeness between the birth companion and the birthing woman.The ideal is that the room should be designed so that it can be changed and adapted to personal wishes and needs. Examples are presented of how the birthing room design could be adapted to provide a more relaxing environment for the birth companions in which they can find their role and place, fulfill their needs, and thereby be able to give optimal support.The labor ward staff were part of how the birthing room was perceived and by continuous and calm presence, they can contribute to a sense of safety and calm.Click here for additional data file.Supplemental Material, sj-pdf-1-her-10.1177_19375867231163336 for The Birth Companions’ Experience of the Birthing Room and How It Influences the Supportive Role: A Qualitative Study by Helena Nilvér and Marie Berg in HERD: Health Environments Research & Design Journal


Birth registration is a crucial aspect of ensuring that children have access to their rights and benefits, including health care, education, and citizenship. In sub-Saharan Africa (SSA), birth registration rates remain low, with millions of children going unregistered each year. Understanding the predictors of birth registration among children in this sub-region is important for developing targeted interventions to improve registration rates. The study examines the predictors of birth registration among children in SSA.We performed a cross-sectional analysis of secondary data pooled from the Demographic and Health Survey of 17 countries conducted from 2015 to 2021. A weighted sample of 162,500 children was included in the final analysis. We summarized the proportion of birth registration among children in SSA using a forest plot. We utilized a multilevel binary logistic regression analysis to examine the predictors of birth registration. The results were presented using adjusted odds ratios (aOR) with 95% confidence intervals (CIs).We found that 48.32% [48.15–48.49] of births in SSA were registered. The lowest and highest prevalence of birth registration were found in Ethiopia (2.70 [2.38–3.02]) and Sierra Leone (92.93 [92.36–93.50]), respectively. Increasing child’s age was found to be significantly associated with a higher likelihood of birth registrations, with those aged 4 years  having the highest odds of birth registration compared to those aged below 1 year. Children born to mothers with primary , secondary , and higher education  were more likely to be registered than those born to mothers who had no formal education. Also, children born in health facilities were more likely to be registered  than those born at home. The odds of birth registration were significantly higher among children whose mothers received assistance during delivery , those in the richest wealth index , and those in rural areas .There is low childbirth registration coverage in SSA. The predictors of this phenomenon are the child’s age, maternal level of education, wealth index, place of residence, sub-region, maternal age, place of delivery, assistance during delivery, marital status, and sex of household head. Interventions and policies developed to improve childbirth registration coverage in SSA should prioritize mothers with no formal education, those who deliver at home, those with low socioeconomic status, those living in female headed household, and adolescent mothers. As social beings, the identity of every individual is critical to their existence and recognition. Birth registration has long been one of the key conduits through which an individual’s identity is made known. In this context, birth registration refers to the process of recording a child’s birth . This prWorldwide, it is estimated that nearly 166 million children under age five  are not formally registered, with another 237 million children under-five having no birth certificates . In sub-Indeed, there have been some studies conducted in individual sub-Saharan African countries that have identified a combination of demographic , geographic , and socio-cultural  factors that predict birth registrations –11. Howehttps://dhsprogram.com/data/available-datasets.cfm. The data were extracted from the kids recode (KR file) and the household member’s recode (PR file). According to Croft et al.  of 17 sub-Saharan African countries conducted from 2015 to 2021. The dataset used can be accessed via t et al. , DHS is t et al. , 13. DHSt et al. . A weighBirth registration was the outcome variable in the study. It was derived from the question that asked if children aged 0–4 years on the household roster have a birth certificate. The respondents were asked the question: Does (NAME) have a birth certificate? The response options were “has certificate,” “registered,” “neither,” and “do not know.” The “do not know” response option was dropped. Next, we recoded those whose response option was ‘neither’ as “no” and was assigned a value “0.” The remaining two response options: has certificate and registered were added together to generate a new response option “yes = 1”. We utilized the recoded response options: no and yes in the final analysis .Eleven (11) explanatory variables were considered for inclusion into the study based on their availability in the DHS dataset as well their association with birth registration from previous studies , 16–18. p < 0.05. We utilized a multilevel binary logistic regression analysis to examine the predictors of birth registration. The first model (Model O) revealed the variance in birth registration attributed to the primary sampling unit (PSU) by being an empty model with no explanatory variables. Model I only included individual-level variables, while Model II included household/community level variables. Model III contained all the explanatory variables. The results were presented using adjusted odds ratios (aOR) with 95% confidence intervals (CIs). The “melogit” program in Stata was used to execute the multilevel regression models. To account for disproportionate sampling and non-response, the “svyset” command was used, and weighting was done to account for the intricate nature of DHS data.After data cleaning in each country’s dataset, we appended the dataset from all 17 countries in SSA included in the study. We summarized the proportion of birth registration among the children in SSA using a forest plot. We examined the distribution of birth registration across the explanatory variables using cross-tabulations. Next, the Pearson chi-square test of independence was used to determine the association between birth registration and the explanatory variables at We did not seek ethical clearance since the dataset used is already available in the public domain. We complied with all the ethical guidelines regarding the use of a secondary dataset for publication after permission to use the dataset was granted by the Monitoring and Evaluation to Assess and Use Results Demographic and Health Surveys (MEASURE DHS).p < 0.05.Regarding the place of delivery, women who delivered at a health facility (65.5%) had a higher proportion of registered births compared to those who delivered at home (35.5%). Similarly, birth registration was higher among children born to mothers who received assistance during delivery (66.7%). The findings also show that there is a high proportion of birth registration among children from households with richest wealth index (74.2%). A greater proportion of birth registration was recorded among those in urban areas (64.2%) and male-headed households (57.4%). There were significant differences in the proportion of birth registration in the sub-region with the Western sub-region having the highest (74%) while births in the Eastern part recorded the least births registered (35.6%). All the explanatory variables except for the sex of the child were significantly associated with birth registration at In Compared to adolescent girls, older women had a higher probability of registering their children’s birth. Children born to mothers with primary , secondary , or higher education  were more likely to have been registered than those born to mothers who had no formal education. The odds of birth registration was higher among children born to married , widowed , and separated women  compared to women who had never been in a union.Also, children born in health facilities were more likely to have been registered  than those born at home. The odds of birth registration was significantly higher among those who received assistance during delivery  and those in rural areas . Increasing wealth index was associated with increasing likelihood of birth registration with the highest odds among those in the richest wealth index . However, the likelihood birth registration was lower in female-headed households  relative to those in male-headed households. Children in the Western sub-region were more likely to be registered  than those in the Central Africa.2 = 0.289, 95% CI = 0.243–0.344). In the same model, the variation between the clusters contributed to 8.1% of the total variation of birth registration (ICC = 0.081). We observed that the between-cluster variance decreased to 6.1% (ICC = 0.061) in Model I then increased again to approximately 10% (ICC = 0.098) in Model II and finally reduced to 9.1% in the last model. These variations in the ICC value show that the differences in the factors at the household/community level accounted for much of the variations in birth registration relative to the individual level. Additionally, Model III had the lowest AIC (186091.1). Hence, Model III was selected as the best-fitted model.The random effect results show the variations in birth registration attributed to the model compositions. Results in Model O showed that the primary sampling unit clusters accounted for approximately 29% of the birth registration in SSA (σWe examined the predictors of birth registration among children in SSA. We observed a birth registration coverage of 48.32%, which is lower when compared to other jurisdictions such as India that has a coverage of 77.2% . MoreoveOur study found that older children had the highest odds of being registered compared to younger children. This result is corroborated by a study conducted in Zimbabwe that found a higher likelihood of birth registration among older children . We postHaving some level of formal education was associated with higher odds of birth registration. Similar findings have been reported in Ghana , India , and NigContrary to Kumar et al.’s study  which foGiving birth in a health facility was associated with a higher probability of birth registration compared to home birth deliveries. Relatedly, those who received some assistance during the birth delivery were more likely than those who did not receive such assistance to register their children’s births. The results align with earlier reports from Zimbabwe  and SSA The study also shows a positive association between wealth index and birth registration. That is, the higher the wealth index, the greater the odds of birth registration. Analogous findings have been reported in SSA  and IndiRelatedly, our result indicates that rural residency was associated with a higher chance of registering births—a finding that contradicts with a study conducted in SSA . A plausFinally, the study revealed that children born into female-headed households were less likely to be registered. Our result is in contrast to an earlier study, involving 93 countries in low-and middle-income countries that found the sex of household heads as not being consistently associated with the birth registration of children . We posiThis study bears some policy implications. First, the significant differences in birth registration by sub-region imply that a straight jacket approach to resolving the lapses in childbirth registrations in SSA would prove futile. Rather, specific policies must be implemented to meet the needs and contextual environment of the respective sub-regions. The results also underscore a need for women empowerment to help alleviate any challenges they might face in the quest to register their children. Also, encouraging more birth deliveries at a health facility would be relevant in raising parents’ awareness of the need and benefits of registering their child’s birth.Appropriate statistical analyses were conducted to arrive at the results. Nevertheless, there are some inherent limitations pertaining to the methodology. The study design used does not offer the opportunity to establish any sort of causality between the explanatory variables and the likelihood of registering a child’s birth. Due to the reliance on secondary data, important variables such as cultural norms and expectations could not be assessed in relation to their role as a predictor of childbirth registration.There is low childbirth registration coverage in SSA. The predictors of this phenomenon were the child’s age, maternal level of education, wealth index, place of residence, sub-region, maternal age, place of delivery, assistance during elivery, marital status, and sex of household head. Interventions and policies developed to improve childbirth registration coverage in SSA should prioritize mothers with no formal education, those who deliver at home, those with low socioeconomic status, those living in female headed household, and adolescent mothers.http://dhsprogram.com/data/available-datasets.cfm.Publicly available datasets were analyzed in this study. This data can be found at: http://goo.gl/ny8T6X.Ethics approval was not required for this study since the data is secondary and is available in the public domain. More details regarding DHS data and ethical standards are available at: SY conceived the study, supervised the study, and attest that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted. RA, JO, A-AS, BA, EB, and SY contributed to interpretation of data, revised the article critically for important intellectual content, and approved the final version of the manuscript. All authors contributed to the article and approved the submitted version.SY is an editorial board member of this journal. A-AS and BOA were employed by REMS Consult Limited.The remaining 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. 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