In Western countries, active maternal smoking during pregnancy is recognized as the most important preventable risk factor for adverse birth outcomes. However, the effect of passive maternal smoking is less clear and has not been extensively studied. In Japan, there has been only one epidemiological study which examined the effects of active smoking during early pregnancy on birth outcomes although the effects of passive smoking were not assessed.Study subjects were 1565 mothers with singleton pregnancies and the babies born from these pregnancies. Data on active maternal smoking status in the first, second, and third trimesters and maternal environmental tobacco smoke (ETS) exposure at home and work were collected with self-administered questionnaires.P for trend = 0.048). No significant association was found between active maternal smoking during pregnancy and the risk of low birth weight. There was a significant inverse relationship between active maternal smoking during pregnancy and birth weight; newborns of mothers who had smoked throughout pregnancy had an adjusted mean birth weight reduction of 169.6 g. When classifying babies by gender, a significant positive association between active maternal smoking throughout pregnancy and the risk of SGA was found only in male newborns, however, the interaction was not significant. Maternal ETS exposure at home or work was not significantly associated with any birth outcomes.Compared with children born to mothers who had never smoked during pregnancy, children born to mothers who had smoked throughout their pregnancy had a significantly increased risk of small-for-gestational-age (SGA) . However, active maternal smoking only in the first trimester and active maternal smoking in the second and/or third trimesters but not throughout pregnancy were not significantly associated with SGA. With regard to the risk of preterm birth, the adjusted ORs for the above-mentioned three categories were not significant; however, the positive linear trend was significant (This is the first study in Japan to show that active maternal smoking throughout pregnancy, but not during the first trimester, is significantly associated with an increased risk of SGA and a decrease in birth weight. Thus, women who smoke should quit smoking as soon as possible after conception. Growth-restricted infants are at increased risk for perinatal mortality and morbidity, short stature, cognitive delays, and neurologic disorders . A meta-Many studies conducted in Western countries have found a significant inverse relationship between active maternal smoking during pregnancy and birth weight and/or significant positive associations between active maternal smoking during pregnancy and the risk of LBW, preterm birth, and/or small-for-gestational-age (SGA) -24. To tThe current prebirth cohort study was performed to address the paucity of epidemiological information regarding the relationship between active and passive maternal smoking during pregnancy and birth outcomes in Japan using data from the Kyushu Okinawa Maternal and Child Health Study (KOMCHS).The KOMCHS was a prospective prebirth cohort study performed to examine risk and preventive factors for maternal and child health problems. Eligible women were those who became pregnant and lived in seven prefectures on Kyushu Island in southern Japan and Okinawa Prefecture. Between April 2007 and March 2008, we requested that 131 obstetric hospitals in Fukuoka Prefecture, the largest prefecture on Kyushu Island with a total population of approximately 5.04 million, provide as many pregnant women as possible with a set of leaflets explaining the KOMCHS, an application form to participate in the study, and a self-addressed and stamped return envelope. Between May 2007 and March 2008, we also requested that 40 obstetric hospitals in Okinawa Prefecture, an island chain in the southwest of Japan with a total population of nearly 1.37 million, provide as many pregnant women as possible with the same documents. Between August 2007 and March 2008, pregnant women living in six prefectures on Kyushu Island other than Fukuoka Prefecture, with a total population of approximately 8.22 million, were also provided with the same documents at 252 obstetric hospitals. Pregnant women who were willing to participate in the study returned the application form containing a written description of their personal information to the data management center. Based on the personal information, research technicians gave them a detailed explanation of the KOMCHS by telephone and sent them a set of two self-administered questionnaires after obtaining their agreement. In total, 1757 pregnant women between the 5th and 39th weeks of pregnancy gave their full informed consent in writing to participate in the KOMCHS and completed the baseline survey. Of the 1757 women, 1590 mother-child pairs took part in the second survey, which was carried out after delivery: 73.5% of the mothers completed the second survey at less than 1 month of giving birth, while 12.9%, 7.4%, 3.3%, and 2.9% completed the second survey at 1, 2, 3, and 4–11 months of giving birth, respectively. Excluded from the current analysis were 23 mothers with multiple births and 2 mothers in which the gender of the baby was not known due to incomplete data reporting. The final study group thus consisted of 1565 mother-child pairs. The ethics committee of the Faculty of Medicine, Fukuoka University approved the KOMCHS.Two questionnaires were administered to each participating mother. The first questionnaire, which consisted of two parts, was filled out by mothers during pregnancy (between the 5th and 39th week of pregnancy). The second questionnaire was filled out by mothers after giving birth. Participants mailed these questionnaires to the data management center conducting each survey. Research technicians clarified or completed missing or unclear data by telephone.The first questionnaire, completed during pregnancy, elicited information about maternal age; region of residence; number of children; family structure; maternal education; maternal employment status; and maternal ETS exposure at home and at work. Employment status in the year when the first questionnaire was conducted or in the previous year was also elicited and women were classified as being unemployed if they were unemployed both in the year the questionnaire was completed and the preceding year. The second part of the first questionnaire was a semi-quantitative, comprehensive dietary history questionnaire that assessed dietary habits during the month preceding the time when the mother completed the questionnaire. Body weight and height were self-reported in this questionnaire. Body mass index was calculated as weight (kg) divided by the square of height (m).In Japan, generally, an obstetrician’s estimate of gestational age at the time of delivery is based on early ultrasound examination and/or the first day of the last menstrual period and birth weight is measured right after birth. Data such as birth weight and gestational age at birth are recorded by staff at the birth hospital or clinic in a booklet called the Maternal and Child Health Handbook. These booklets are provided to every pregnant woman by the municipality in which the woman resides when the women become pregnant and they contain data pertaining to prenatal checkups, postnatal health condition of both mother and baby, and growth of the child.The second self-administered questionnaire elicited information on active maternal smoking status in the first (≤ 15 weeks’ gestation), second (16–27 weeks’ gestation), and third (≥ 28 weeks’ gestation) trimesters; gestational age; birth weight; and baby’s gender. With regard to gestational age and birth weight, mothers were advised to refer to their Maternal and Child Health Handbook.With regard to outcomes, low birth weight was defined as a birth weight less than 2500 g. Preterm birth was defined as a birth occurring at a gestational age of less than 37 weeks. SGA was defined as a birth weight below the 10th percentile of the Japanese neonatal anthropometric norms for babies of the same gestational age, gender, and parity published by Itabashi et al. in 2010 . These na priori potential confounding factors; however, gestational age at birth was removed when the associations with the risk of preterm birth were examined. Marital status was not taken into consideration because 96.3% of the mothers lived with their husbands and there was only one single mother in the study. Active maternal smoking was classified into four categories: 1) never smoked during pregnancy, 2) smoked only in the first trimester, 3) smoked in the second and/or third trimesters regardless of smoking status in the first trimester but not throughout the pregnancy, and 4) smoked throughout pregnancy. Maternal ETS exposure at home was classified into two categories: 1) no one smoked in the mother’s home at the time of the first questionnaire, and 2) someone smoked in the mother’s home at the time of the first questionnaire. Maternal ETS exposure at work was classified into two categories: 1) no one smoked in the mother’s workplace at the time of the first questionnaire, and 2) at least one person smoked in the mother’s workplace at the time of the first questionnaire. Region of residence was classified into three categories: 1) Fukuoka Prefecture, 2) prefectures other than Fukuoka Prefecture on Kyushu Island, and 3) Okinawa Prefecture. Number of living children previously born to the same mother  was classified into three categories: 0, 1 or 2 or more. Family structure was classified into nuclear or extended. Maternal education was classified into three categories: 1) < 13 years, 2) 13–14 years, and 3) ≥ 15 years. Maternal employment was classified as yes or no. And, finally, alcohol consumption during the month preceding the filling out of the first questionnaire was classified as yes or no. Maternal age, body mass index, and gestational age at birth were used as continuous variables.Maternal age at the time of the first questionnaire; region of residence; number of children; family structure; maternal education; maternal employment status; maternal alcohol consumption during the preceding month; body mass index; gestational age at birth; and baby’s gender were selected as Multiple logistic regression analysis was used to estimate adjusted odds ratios (ORs) and 95% CIs for birth outcomes according to active and passive maternal smoking status. Analysis of covariance was used to calculate adjusted means of birth weights according to active and passive maternal smoking status with allowance for confounding factors. Trends of an association were assessed with a multiple logistic regression model or a multiple linear regression analysis assigning consecutive integers to the categories of the exposure variables. All statistical analyses were performed using the SAS software package version 9.2 .The analysis of the effects of ETS exposure at home and at work on birth outcomes was based on the 1427 mother-child pairs who had never smoked during pregnancy.Maternal mean age at the time of the first questionnaire was 31.3 years (Table P for linear trend = 0.04). An exposure-response relationship between active maternal smoking and the risk of preterm birth was significant (P for linear trend = 0.048) although the adjusted ORs for the above-mentioned three categories were not significant. No significant association was found between active maternal smoking and LBW. There was a significant inverse relationship between active maternal smoking and birth weight: newborns of mothers who had smoked throughout their pregnancy had adjusted mean birth weight reductions of 169.6 g (P for trend = 0.005).Table P for interaction = 0.34; Table When classifying babies by gender, a significant positive association between active maternal smoking throughout pregnancy and the risk of SGA was found only in male newborns, however, the interaction between active maternal smoking throughout pregnancy and infant gender with respect to SGA was not statistically significant (Results for maternal ETS exposure at the time of the first questionnaire in the sample of 1427 mother-child pairs in which the mother had never smoked during pregnancy are given in Table The current study demonstrated that active maternal smoking throughout pregnancy poses a statistically significant increased risk for SGA, especially in male newborns. However, in this study, we found that active maternal smoking only in the first trimester, or active maternal smoking in the second and/or third trimesters did not pose a statistically significant risk for SGA. The abovementioned three categories in relation to active maternal smoking were not significantly related to the risk of preterm birth, although the positive linear trend was statistically significant. There was no significant relationship between active maternal smoking and LBW. Active maternal smoking throughout pregnancy was significantly associated with a decrease in birth weight, with an adjusted mean reduction in birth weight of 169.6 g. No significant associations were found between maternal ETS exposure at home or work and any of the birth outcomes we studied.A prebirth cohort study in Greece showed that active maternal smoking at 12 weeks of gestation was significantly positively related to the risk of LBW and SGA, but not preterm birth, while smoking cessation before 12 weeks of gestation was not associated with the risk of preterm birth, LBW, or SGA . In a prThe difference we found in the effect of maternal smoking on male and female babies differs from the findings of a study in Germany that found that, particular in heavy smokers, the adverse effect of maternal smoking during pregnancy on the mean birth weight and risk of SGA was greater in girls than in boys .With respect to maternal ETS exposure during pregnancy among mothers who never smoked during pregnancy, the current results are consistent with those of some previous studies that showed no relationship between passive maternal smoking during pregnancy and birth outcomes ,18,26. IAccording to a review by Jauniaux and Burton, tobacco toxins interfere with the trophoblastic and biological functions of fetal cells that regulate protein metabolism and enzyme activity, leading to an impact on fetal growth, with a reduction of weight, body fat, and many other anthropometric parameters . We haveSeveral weaknesses of the present study warrant mention. Information on tobacco exposure was obtained with self-administered questionnaires and was not validated by objective measurements such as cotinine levels. However, Pickett et al. reported that urinary cotinine measures and self-reported number of cigarettes were highly correlated at any given time point in pregnant women in the USA . AlthougIn the first questionnaire, we could not estimate the participation rate because we do not have exact figures for the number of pregnant women who were provided with a set of leaflets explaining the KOMCHS, an application form, and a self-addressed and stamped return envelope by the 423 collaborating obstetric hospitals. This situation made it impossible to assess the differences between participants and non-participants, because no information on personal characteristics such as maternal age and socioeconomic status was available for non-participants. Our subjects were probably not representative of Japanese women in the general population. For example, a population census conducted in 2000 in Fukuoka Prefecture found that the percentages of women aged 30 to 34 years with < 13, 13–14, ≥ 15, and an unknown number of years of education were 52.0%, 31.5%, 11.8%, and 4.8%, respectively . At baseThe current study did not have substantial statistical power although significant associations were detected. Although adjustment was made for several confounding factors, residual confounding effects could not be ruled out.To the best of our knowledge, this is the first study in Japan to show that active maternal smoking throughout pregnancy is significantly associated with an increased risk of SGA and a decrease in birth weight while maternal smoking only in the first trimester was not related to these outcomes. Taking the results of the present study together with those of previous epidemiological studies, women who smoke should quit smoking as soon as possible after conception.CI: Confidence interval; ETS: Environmental tobacco smoke; KOMCHS: Kyushu Okinawa Maternal and Child Health Study; LBW: Low birth weight; OR: Odds ratio; SGA: Small-for-gestational-age.All authors declare that they have no competing interests.YM, KT, and MA contributed to the study concept and design and the acquisition of data. YM was responsible for the analysis and interpretation of data and the drafting of the manuscript. All authors participated in critically revising the manuscript and approved the final version of the manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2393/13/157/prepub


Epidermoid cyst is a frequent benign cutaneous tumor. The pelvic localization does not occur very often. The literature that taps into such cases is very limited in scope. Here is a report of a 27-year-old woman with a giant pelvic retroperitoneal epidermoid cyst. The use of ultrasound exploration and computed tomography has indicated ovarian origins. The surgery also revealed a retroperitoneal epidermoid cyst, uterus and ovaries were all intact. The evacuation of a cyst was found to contain lamellas of keratin. Histology permitted us to confirm the diagnosis. The patient was faring well after two years of followup. Epidermoid cyst is a common cutaneous benign tumor developed from ectodermal inclusion. Patients with an age ranging from 19 to 45 are most likely to be contaminated with this tumor [The most common locations of epidermoid cysts are the face followed by the trunk and the neck, in that order . However The pelvic retroperitoneal cysts are rare to come across . We repoA 27-year-old single woman, G0P0, showed the following symptoms: steadily growing swelling in the abdomen for 6 months, compounded by pelvic pain, and coupled with intermittent constipation and dysuria as a sign of compression.  The patient had her menarche at the age of 14, and the menstrual cycles were regular without abnormal uterine bleeding. The physical examination revealed the firm, mobile and insensitive abdominal pelvic mass reaching the umbilical point; whereas the rest of examination revealed no abnormalities.The abdominal ultrasound showed a giant abdomino-pelvic well-circumscribed hypoechogene mass separated from the uterus. The ovaries could not be visualized.The computed tomography showed a well-circumscribed mass, measuring 20 cm, with fluid density not taking the contrast, without walls or vegetations, displacing the uterus forward with the left ureterohydronephrosis respecting the cortex; the ovaries could not be visualized and the diagnosis pointed to a giant ovarian cyst . LaboratMedian laparotomy was performed and a 25 cm retroperitoneal cyst was found. Ovaries and uterus were normal . After oThe histology was compatible with an epidermoid cyst .  The postoperative course was uneventful and the patient was doing well enough after two years of followup. Epidermoid cyst is a frequent benign cutaneous tumor. It can occur anywhere on the body, and the most frequent sites involved are the face, the scalp, the neck, and the trunk .Only a few cases (fifteen cases) were reported in the pelvic whose location is retroperitoneal, retrorectal, presacral –16, one  Epidermoid cysts are usually small; however, sometimes they can reach significant volumes, displacing or damaging nearby organs .The pathogenesis is still unclear: congenital or posttraumatic theories are discussed .Because of the rarity of epidermoid cyst, this diagnosis is rarely evoked, and is difficult in the preoperation stage. Clinical examination including pelvic examination revealed a well-limited cyst. Ultrasound and computed tomography (CT) often lead to ovarian cyst diagnosis; CT identifies better epidermoid cysts which are characterized by the absence of homogeneous fluid density, which can easily remove lipomas, fibromas, and desmoid tumors that are differential diagnosis with epidermoid cysts. Magnectic resonance imaging (MRI) is more specific: epidermoid cyst appears generally as hypointense on T1-weighted RM imaging, and hyperintense on T2-weighted imaging .The treatment of the pelvic epidermoid cyst is a surgical ablation: the discovery of a cyst during surgery should prompt us to search for the organ on which it depends. The macroscopic appearance can eliminate a hydatid cyst. Because of the rarity of developmental cysts, they are very frequently misdiagnosed and so inappropriate surgery ensues. If a gynecologist initially finds a retrorectal cyst, most cases will be misdiagnosed as an ovarian tumor. Retrorectal epidermoid cyst contains fatty elements such as desquamated debris, cholesterol, keratin, and water. A gynecologist confuses these elements in the epidermoid cyst with those of mature cystic teratoma, which is a common ovarian tumor. However, if we have knowledge of the developmental cysts, by careful digital examination and image diagnosis, it would be possible to make a differential diagnosis since developmental cysts exist between the presacral and retrorectal space, not in the Douglas pouch like an ovarian tumor . When there is a high suspicion of giant pelvic cyst, dissection must be done in a cleavage plane between pseudocapsule of the cyst and adjacent structures. If this dissection becomes dangerous to adjacent organs including rectum, it would be wiser to open the pseudocapsule, drain the cyst, and proceed to resection of the hull if it involves no risks what so ever for adjacent organs. The residual cavity is drained by a Redon to remove a possible hematoma collected at this level. The post-operative course is usually simple . A successful laparoscopic excision of a retrorectal epidermoid cyst was described , 19. In the literature, no case of recurrence has been reported in followed up patients operated for a pelvic epidermoid cyst with a period ranging between 5  to 26 moEpidermoid cyst is a frequent benign cutaneous tumor. The pelvic location of this entity is rare and difficult to diagnose preoperatively, and so should be considered in the differential diagnosis of ovarian tumors. The treatment consists of a surgical ablation using a cleavage to avoid any damage for other organs.


Dioxin exposure levels remain elevated in residents living around former US Air Force bases in Vietnam, indicating potential adverse impacts on infant growth. In this study, 210 mother–infant pairs in dioxin-contaminated areas in Vietnam were recruited at the infants’ birth and followed up for 4 months. Perinatal dioxin exposure levels were estimated by measurement of polychlorinated dibenzo-p-dioxins/furans toxic equivalent (PCDDs/Fs-TEQ) in breast milk. The infants’ size was measured at birth and 1 and 4 months after birth, and neurodevelopment was evaluated using the Bayley Scales III at 4 months of age. Among 4 dioxin groups , cross-sectional comparisons of body size and neurodevelopment scales and comparisons of longitudinally assessed body size were performed respectively. At birth, head circumference of girls in the ≥75 percentile group was significantly larger than those in the <25 and 50–75 percentile groups. At 4 months of age, the weight and body mass index (BMI) of boys in the ≥75 percentile group were significantly lower than those in the other groups. Increase in weight was significantly lower in the ≥75 percentile group in both sexes from birth to 1 month but only in boys at 1–4 months of age. Estimated marginal mean values in a mixed model of weight and BMI during the first 4 months of life were significantly lower in the ≥75 percentile group in boys. In girls, marginal mean values for head circumference were increased with increase in dioxin levels. Only in boys, cognitive, language, and fine motor scores in the ≥75 percentile group were significantly lower than those in the other groups. These results suggested a considerable impact of perinatal dioxin exposure on infant growth, particularly in boys exposed to dioxins at high level of PCDDs/Fs-TEQ. After several decades of herbicide spraying, the concentrations of dioxins in the environment and in humans residing the sprayed areas remained elevated compared to those in the unsprayed areas During the Vietnam War from 1961 to 1972, herbicides were sprayed in copious amounts in Southern Vietnam, contaminating the area with 2,3,7,8-tetrachlorodibenzo-Infant body size at birth has been suggested as a good marker of fetal development. Growth in the neonatal period is also affected by fetal condition. Previously, in the Netherlands and Japan, small body size at birth and slightly delayed neurodevelopment in early life have been reported in infants exposed to dioxins and polychlorinated biphenyls (PCBs) at background levels during pregnancy Therefore, in this study, we investigated relationships between perinatal dioxin exposure levels, estimated from dioxin levels in breast milk, and infant growth and neurodevelopment. Subjects were infants whose mothers were residing in the “hot spots” of dioxin contamination in Southern Vietnam.The Thanh Khe and Son Tra districts in Da Nang City, located within 10 km of Da Nang airbase, which have been characterized as dioxin-contaminated areas, were selected for study area. In collaboration with Vietnamese government, Hatfield Consultants monitored the areas around the former Da Nang airbase in 2006 and 2009, and reported significant quantities of 2,3,7,8-TetraCDD in the soil samples  from the northern end of Da Nang airport where mixing and loading areas and storage of herbicides were once located. This substance was also found in the sediment samples  from Sen Lake and the drainage system from the north of the airbase to Sen Lake 2, and head circumference/length (HL ratio) was calculated to evaluate infant proportions. A total of 219 mother–infant pairs participated in the survey. However, the data of nine mothers lacked information about body build and socioeconomic factors. Therefore, the data for 210 mother-infant pairs were used for analysis in the present study.One hundred and fifty-nine pregnant mothers who gave birth in the Thanh Khe district hospital  from July 2008 to January 2009 and 80 mothers who gave birth in the Son Tra district hospital  from November to December 2009 were recruited by obstetricians on the bases of the following criteria: the mothers residing in the Thanh Khe and Son Tra districts during pregnancy, they gave birth to full-term babies and the delivery was free of any complications. When the infants were 1 month (30 days) old, nurses from communal health centers visited them and collected breast milk samples from 147 mothers (93%) in Thanh Khe and 80 mothers (100%) in Son Tra. Infant size including weight, length (height), and head and abdominal circumferences were measured by the nurses and doctors at birth and 1 and 4 months after birth. When the infants were 4 months old, their neurodevelopment was evaluated using the Bayley Scales of Infant and Toddler Development, third edition . Body mass index (BMI) was obtained using the formula: weight/(length)Information about the mothers regarding age, history of residency, parity, smoking and drinking habits, job, education, family income and smoking habits, and duration of breastfeeding was collected through interviews. Height and weight of the mothers, information about the infants , and details of complications during pregnancy and delivery were collected from the obstetricians. Seventy percent of the 210 subjects were housewives, and the others were saleswoman, factory workers, and office workers with no occupational history of pesticide exposure. All infants were breastfed until 4 months of age. No significant differences in gestational age and birth weight were observed between the infants who participated in the present follow-up study and those who did not.Written informed consent was obtained from all the mothers. The institutional ethics board of epidemiological studies at Kanazawa Medical University approved the study design (License number: ES-74). The Department of Health and Prevention of Diseases, Da Nang City government in Vietnam reviewed and approved the informed consent process.Breast milk samples from nursing mothers were collected in clean polyethylene containers when the infants were 1 month old. Samples were collected at home by hand pressure with the assistance of midwives or medical workers. Each sample (approximately 20 mL) was frozen, transported in dry ice to Japan, and stored at −30°C until analysis.Approximately 10 mL of breast milk from each sample was used to quantify the levels of seven congeners of PCDDs and 10 congeners of PCDFs; 2,3,7,8-TetraCDD, 1,2,3,7,8-PentaCDD, 1,2,3,4,7,8-HexaCDD, 1,2,3,6,7,8-HexaCDD, 1,2,3,7,8,9-HexaCDD, 1,2,3,4,6,7,8-HeptaCDD, OctaCDD, 2,3,7,8-TetraCDF, 1,2,3,7,8-PentaCDF, 2,3,4,7,8-PentaCDF, 1,2,3,4,7,8-HexaCDF, 1,2,3,6,7,8-HexaCDF, 1,2,3,7,8,9-HexaCDF, 2,3,4,6,7,8-HexaCDF, 1,2,3,4,6,7,8-HeptaCDF, 1,2,3,4,7,8,9-HeptaCDF and OctaCDF. Lipid content in breast milk was extracted and treated in a series of purifying operations, including alkali digestion and hexane extraction. Chromatography was performed on a multi-layered silica gel column. A single-layered column of activated carbon dispersed on silica gel was used to separate and collect PCDDs/Fs fractions. Quantification was performed using a gas chromatograph  equipped with a high-resolution mass spectrometer  operating in the selected ion monitoring mode. The gas chromatograph was equipped with an ENV-5MS column . All samples were analyzed at the Center for High Technology, Kanazawa Medical University, Japan. The established method of analysis has been described previously Lipid-based concentrations of the 17 congeners of PCDDs/Fs were calculated. Toxic equivalent factors (TEFs) for each congener were referenced from the list of WHO 2005 TEF The Bayley III is an individually administered scale for assessment of developmental functioning of infants and young children aged 1–42 months across the cognitive, language, and motor domains. The language and motor domains have two subscales: receptive and expressive communication (language) and fine and gross motor skills. In administering the scales, the examiner observed or used various test materials to interact with the infants, and scored them based on their responses. When the infants were 4 months old, they were tested by one examiner in the presence of the infants’ caregivers. Before starting the survey, the examiner was well trained for evaluation using the scales by a senior examiner. The unique rules of administration were strictly followed, as described in the guidance manual of the Bayley III. A trial survey of a group of 18 Vietnamese infants was performed to assure the feasibility of the Bayley III in the Vietnamese population. Evidence of convergent and discriminant validity of the test was confirmed by checking the intercorrelations among subtests, based on a priori hypothesis that subtests designed to measure similar underlying constructs would have higher correlations than subtests that were designed to measure dissimilar constructs. The results of Bayley III testing in the present study were in agreement with the hypothesis .www.who.int/childgrowth/standards). Before performing multivariable analysis, confounding factors were identified for covariates based on identification of a significant correlation coefficient with at least one aspect of infant development  and with reference to factors with meaningful influence on infant growth and neurodevelopment established in previous reports The SPSS (ver. 11.0) software package for Windows  was used for statistical analyses. Subjects were divided into four groups according to PCDDs/Fs-TEQ levels in breast milk . Means of characteristic factors of mother-infant pairs and dioxin levels in breast milk were compared among the four PCDDs/Fs-TEQ groups using one-way ANOVA, and followed by Scheffé’s test for comparisons between groups. Cross-sectional comparisons of infant body size and scores on the Bayley III among the 4 PCDDs/Fs-TEQ groups at birth and 1 and 4 months after birth were performed using a generalized linear model after adjustment for confounding factors in each gender. To evaluate relationships between PCDDs/Fs-TEQ levels in breast milk and longitudinally assessed growth measurements, multivariate mixed-effects regression models for repeated measures were performed for weight, length, BMI, and head circumference after conversion of z scores consistent with the WHO infant growth standard , educational period (years), alcohol drinking during pregnancy (yes/no), family income, family smoking (yes/no), gestational weeks at birth, infant age (days) on the day of each examination, and location difference  in boys  and in gBecause growth velocity of body size measurements is a good marker for infant growth, we compared estimated increases in weight, height, and head and abdominal circumference per day during the first month after birth and at 1–4 months among the 4 PCDDs/Fs-TEQ groups after adjusting for the same confounding factors that were included in the body size analysis . In boysRelationships between PCDDs/Fs-TEQ levels and adjusted z scores for weight, height, BMI, and head circumference from birth to 4 months were analyzed using a linear mixed model for repeated measures after adjusting for maternal age, weight, parity, educational period, drinking habit, family income, family smoking, gestational weeks at birth, and location difference. ANOVA test results for fixed factors (PCDDs/Fs-TEQ categories) and estimated marginal means for each PCDDs/Fs-TEQ category adjusted for confounding factors are shown in Differences in neurodevelopmental scores, as evaluated by the Bayley III, were investigated among the four PCDDs/Fs-TEQ groups at 4 months of age after adjustment for maternal age, weight, parity, educational period, drinking habit, family income, family smoking, gestational weeks at birth, infant age (days) at examination, and location difference. At this time, weight and BMI at 4 months of age were not included as confounding factors, because no significant relationship was evident between neurodevelopmental scores and anthropometric measurements. The results in both sexes are shown in Dioxin contamination in hot spot areas in southern Vietnam is originated from Agent Orange, a herbicide and defoliant sprayed by the U.S. during the Vietnam War. The high contribution of 2,3,7,8-TetraCDD to the total amount of dioxins (approximately 90%) was due to the fact that Agent Orange contained only 2,3,7,8-TetraCDD, and not other PCDD and PCDF congeners. However, in the subjects living in the hot spot areas of the present study, the most highest TEQ% of 2,3,7,8-TCDD was 14.1% in the 75 percentile group which was much less than that documented in previous studies In the present study, maternal dioxin exposure affected infant weight and BMI in boys at 4 months after birth, because significantly low measurements were observed in boys exposed to higher levels of dioxins (PCDDs/Fs-TEQ ≥75 percentile). Incremental measurement of weight and abdominal circumference during the follow-up period resulted in significantly lower values among boys in the ≥75 percentile group, who were thinner at 4 months of age than the boys exposed to lower levels of dioxins. Not only somatic growth, but also neurodevelopment, particularly expressive language, at 4 months of age was relatively poor in boys exposed to higher levels of dioxins. In contrast, longitudinal measurements of weight and BMI for 4 months in girls exposed to higher levels (≥75 percentile) of dioxins were higher than for those exposed to lower levels. However, the increased values for weight and abdominal circumference during the neonatal period were significantly lower in girls exposed to higher levels of dioxins. Moreover, no difference was observed in neurodevelopment among female infants at different TEQ levels.These results suggest that perinatal dioxin exposure, estimated using PCDDs/Fs-TEQ levels in maternal breast milk, significantly affected infant growth, including body size and neurodevelopment, in early life particularly in boys. Similar gender-specific differences (boys are more susceptible to growth restriction than girls) were reported in infants whose mothers were Yusho patients accidentally exposed to rice oil contaminated with PCDDs/Fs and PCB In girls, head circumference at birth significantly increased with increasing dioxin levels, showing a dose–effect relationship. HL ratio was higher, suggesting a larger proportion of head to body. Head circumference is an index for estimating brain weight in newborns 2+/calmodulin-dependent protein kinase II α (CaMKIIα) activity in the limbic system of male rat offsprings which showed deficits in socio-emotional behavior, and increased CaMKIIα activity in female rat offsprings, which showed hyperactivity, but no socio-emotional deficits (unpublished data). Because CaMKII plays a role in regulating neurotransmission of γ-Aminobutyric acid (GABA) by phosphorylation of GABAergic receptors In animal experiments, exposure to 2,3,7,8-TetraCDD which has the highest TEF during pregnancy caused retardation of neurodevelopment in male offsprings In animal experiment, rodents treated using 2,3,7,8-TetraCDD at sublethal dose display a peculiar wasting syndrome characterized by decreased body weight gain, hypophagia, and feed refusal Body size and neurodevelopment scores in the <25, 25–50 and 50–75 percentile groups were similar. Significantly lower value for body size and neurodevelopment scores in the ≥75 percentile group were also found in boys compared with those in the other groups with <75 percentile of PCDDs/Fs-TEQ, suggesting that the threshold value of dioxin exposure for effects on infant growth may be approximately 75 percentile of PCDDs/Fs-TEQ (18.0 pg-TEQ/g fat), with no linear dose–effect relationship between infant growth and dioxin exposure. The upper range of background exposure levels in unsprayed areas was estimated to be 7.4 pg/g fat for PCDDs/Fs-TEQ based on data from a previous study The duration of observation of the effects of dioxins on offspring growth is an interesting and important issue. In a Dutch cohort study The results of the present study must be interpreted within the context of its strengths and limitations. In the area exposed to dioxin from herbicides during the Vietnam War, this was the first birth cohort study carefully designed to clarify the association between perinatal dioxin exposure and health effects in a segment of the Vietnamese population. PCDDs/Fs-TEQ and not total TEQ including TEQ from dioxin like (dl)-PCBs, was used as an exposure marker because this study focused on dioxin contamination related herbicide exposure; thus, the level of dl-PCBs were not measured. However, contamination with PCBs at Da Nang airport has been reported Outcome effects included body size measurements , and neurodevelopment estimated using the Bayley III, which quantitatively and independently assesses various aspects of infant neurodevelopment. Because measurement of body size parameters other than weight is not common in Vietnam, detailed information on infant growth parameters, including BMI and head and abdominal circumference has been unavailable until this study. Because no standard of infant growth in Vietnamese children was available for comparison, the WHO standard was used to calculate z score. In addition, the results of the Bayley III testing in Vietnamese infants may be affected by differences in socioeconomic factors, customs, cultures, and languages because the Bayley III was developed and standardized for use in an American infant population. Therefore, developmental levels of individual Vietnamese infants could not be judged based on the scores of this test. However, in the present study, all testing was performed by the same examiner who was well trained in use of the Bayley III, and the examiner strictly followed the administration guidelines. Therefore, comparison among infants within the population should be reliable.Adverse effects of perinatal dioxin exposure on infant growth, including weight gain and neurodevelopment, were exhibited in Vietnamese residents of dioxin-contaminated areas where herbicides were stored during the Vietnam War. Health effects were gender-specific; boys were more susceptible. No linear dose-effect relationship was observed between PCDDs/Fs-TEQ levels and infant growth. A longer follow-up study of the present cohort in Vietnam is required to clarify health issues in the next generation related to dioxin exposure.


Gestational age and birth weight are the principal determinants of newborn’s health status. Chile, a middle income country traditionally has public policies that promote maternal and child health. The availability of an exhaustive database of live births has allows us to monitor over time indicators of newborns health.This descriptive epidemiological study included all live births in Chile, both singleton and multiple, from 1991 through 2008. Trends in gestational age affected the rate of prevalence (%) of preterm births , term births (37–41) and postterm births (42 weeks or more). Trends in birth weight affected the prevalence of births < 1500 g, 1500–2499 g, 2500–3999 g, and 4000 g or more.Data from an exhaustive register of live births showed that the number of term and postterm births decreased and the number of multiple births increased significantly. Birth weights exceeding 4000 g did not vary.Total preterm births rose from 5.0% to 6.6%, with increases of 28% for the singletons and 31% for multiple births (p for trend < 0.0001). Some categories increased even more: specifically preterm birth < 32 weeks increased 32.3% for singletons and 50.6% for multiple births (p for trend 0.0001).The overall rate of low birth weight infants (<2500 g) increased from 4.6% to 5.3%. This variation was not statistically significant for singletons (p for trend = 0.06), but specific analyses exhibited an important increase in the category weighing <1500 g (42%) similar to that observed in multiple births (43%).The gestational age and birth weight of live born child have significantly changed over the past two decades in Chile. Monitoring only overall rates of preterm births and low-birth-weight could provide restricted information of this important problem to public health. Monitoring them by specific categories provides a solid basis for planning interventions to reduce adverse perinatal outcomes.This epidemiological information also showed the need to assess several factors that could contribute to explain these trends, as the demographics changes, medical interventions and the increasing probability of survival of extremely and very preterm child. Gestational age (GA) and birth weight (BW) are the principal determinants of health status at birth because they are closely linked to neonatal survival, neonatal and infant morbidity, and later, in adults, to potential sequelae and quality of life -4. The WA series of reports from the International Conference on Prematurity and Stillbirths (USA 2009) reports the damage caused by preterm birth in the world and shows that it is a public health problem on a global scale currently increasing in most countries . The ConCurrently, one of the most important issues is the lack of knowledge about the magnitude and impact of PTB in the world. This barrier is also related to the lack of visibility of this problem. One of the explanations to this barrier is the unavailability of data concerning vital statistics, because births are not always routinely registered .In Chile, preterm birth became an important health priority during the recently enacted health reform, because it is the principal cause of perinatal morbidity and mortality as well as of admission to neonatal intensive care units. Premature newborns weighing <1500 g account for approximately 50% to 70% of neonatal mortality and then 25% to 30% of infant mortality  *100). To examine the specific trends, the analyses were performed for all births and separately for singletons and multiple births (with more than one newborn). Analyses of overall trends were performed with Prais-Winsten regression models for times series by year. In this model, the errors are assumed by a first-order autoregressive process. Differences of rates between periods were evaluated by Pearson’s Chi square test.The data management and statistical analyses were performed with STATA SE; Statistics Data Analysis software, version 10.0.Table The overall frequency of records not meeting the definitions that is: births with GA < 22 and/or LBW < 500 g, was very low and concerned only 1584 observations (0.035%), but their number increased over time. Among them, 84% were found at 20 or 21 weeks of GA, between 1991 and 2001; this subgroup subsequently fell to 77%. The trend in GA values ≥ 44 clearly decreased through 2000; the analysis by year (data not shown) indicates that they peaked in 2003 and 2004 (n = 543), but after 2004 reached a frequency = 0. Overall, 92 184 (2%) observations were removed from the initial set, and the population serving as the basis for classification was 4 467 733 births.This proportion of excluded values did not modify the trends for the prevalence of preterm birth or LBW Figure .Despite the very low number, missing values are a specific subgroup and was analyzed separately. In fact, the LBW rate for births with missing GA values was higher than that of the general population Figure , and thoTable In multiple births, the rates of preterm and LBW throughout the three periods were 10 times higher than those of singleton births.Multiple births increased significantly: 1.57% in P1 , 1.62% in P2 , and 1.81% in P3 . The increase involved mainly twin births, because the triplet rate since 2001 has remained stable, around 0.04%, and the quadruplet rate was 0% (data not shown).p for trend < 0.0001) but not among singletons (p for trend = 0.06). This difference may be explained by different trends for the 1500-2499-g category, which fell among singletons until 1996 and increased thereafter, while among multiple births, this category increased during three periods. Nonetheless, the category of babies weighing <1500 g increased substantially both among singletons and multiple births and at a similar rate in both groups. Finally, the proportion of infants in the weight category of 2500–3999 g fell among both singleton and multiple births.Table Although overall trend of the category of birth weights greater than 4000 g remained stable as a whole for all births, the trend by type of birth was also different; since this group increased in singletons between the first and second period and fell after 2001, while among multiple births, this group declined through the three periods.Apparently, there were two types of trends, those for singletons, which were more recent, and those for multiple births, which were present before the observation period.In the overall population, the trends in gestational age and BW show a significant increase in preterm birth and low BW, a reduction in term and postterm births and a stable level of birth weights above 4000 grams.Preterm births increased most among births before 32 weeks, and LBW births in the category with BW < 1500 g. These trends deserve special attention because these groups of live births have higher known risks of mortality, morbidity, and sequelae ,17,18, aThese trends seem to correspond to a real change; they have been obtained from a database where the records of the variables of interest can be considered good and its exhaustiveness has been observed through the three periods, expressed by a very low proportion of missing values. The observed changes were significant and consistent across all three periods, they involved the entire population of births and affecting singletons and multiple births. The measurements recorded are also highly biologically plausible, in terms of the very small proportion of misclassifications and values ≥44 weeks. Similarly, the trend in birth weight was consistent with that of gestational age.Although the aim of this study is descriptive and not explanatory, the principal limitation of our research, like all research from general population databases, was the lack of more precise information to enable us to answer more specific questions .Therefore, we lack more precise information of the method used to asses individual GA. Thus we cannot differentiate between those cases evaluated with one method or the other nor those GA corrected by USN and those not.We miss as well an association with the Stillbirth registry, which prevented us from obtaining complete information about changes in GA and BW for those who die before birth.Despite such limitations, it appears useful to focus the discussion on the possible effects on these trends of changes in obstetric and perinatal management that are capable of modifying the distribution of births at the population scale to shorten the duration of gestation. This focus should help to guide the formulation of basic hypotheses for future research.The World Health Organization explains that the increase in register of live birth is associated to the possibilities of survival where the birth took place . Then weSimilarly, the misclassifications and missing values should have been progressively able to integrate the group of preterm births, but their number always remained low and relatively stable, and most of the births with missing values for GA had a BW corresponding to term births. The births with missing values for weight had more preterm deliveries, but this category of birth has diminished markedly since 2001 and could not contribute to recent trends.The role of other more widespread factors, such as the changes in maternal age signalled in demographic reports , remainsAdvanced maternal age may be a risk factor, both for the rates of multiple pregnancies but also in terms of greater recourse to treatment for infertility. It has been observed in France that from a quarter to a third of multiple births are related to increase of maternal age, and more than 30% to treatment for infertility .Nonetheless, the increase in multiple births does not appear to be linked to procedures of fertilisation or assisted reproduction, for the elevated cost of these procedures makes them still quite rare. According to the reports of the Latin American Network for the assisted reproduction (REDLARA) only 480 births of this type was born in 2008, 23% of them twin births .It is well known that the choice of method for estimating gestational age can influence perinatal outcomes . This shLMP is greatly affected by the individual characteristics of mother and fetus, and the gestational age tends to be greater, while ultrasound classifications consistently skew to younger ages, and tend to predict shorter pregnancies.As for the effect of these two methods on perinatal outcomes, divers studies show that LMP is associated with a higher incidence of adverse outcomes, including preterm, postterm, and growth fetal restriction -29. UltrUltrasound also may diagnose fetuses smaller than the mean or having growth restriction as having less gestational age. Conversely, fetus determined to be oversized for its gestational age may be classified to a more advanced gestational age ,32.In sum, it appears that the use of one single method (US or LMP) has strengths and limitations. We could expect that we can obtain better estimations if the two methods are considered and particularly if there is concordance between their results ,30.In Chile, the studies that have assessed the fetal ultrasound program for the first trimester observed good concordance between the date of the last menstrual period and the ultrasound date, and this concordance has remained relatively stable over time (61.9% in 1994 and 65.6% in 2001) . Other sIn our study it seems that the choice of the one or the other method did not change the increasing trends in the rate of preterm.On the other hand, the increased use of ultrasound estimates could have reduced the incidence of errors and missing values as well as in the values exceeding 41 weeks ,35.Since the 1990s, nationwide clinical guidelines based on high risk approach have been implemented to improve maternal and perinatal health . The larAt the same time, between 1990 and 2000, prenatal care coverage rose from 85% to 91.4%, and the percentage of women who began prenatal care before 20 weeks of gestation rose from 74% in 1994 to 86% in 2000. All these changes probably increased the opportunities for screening for disorders and preventing complications.In this context, the observed trends may also express medical practices that were more active in the face of maternal or fetal risks and led to more frequent recourse to caesarean birth or induction of labour.This is the case for the deliveries that, according to national guidelines, are induced from week 41 to diminish fetal risk; this guideline may also help to explain the very low number of postterm infants, as observed elsewhere, as well as the stability of birth weights exceeding 4000 g .Thus, the underlying reason for these preterm birth trends must be considered in future research that must distinguish between spontaneous preterm deliveries and those considered medically indicated.Observations in 13 European countries show that the countries with the highest rates of induction of labour also have the lowest rates of postterm births . SimilarSeveral authors have shown that even when taking into account the role of other factors including maternal age, plurality ,41 or thAccording to a trend study conducted from the perinatal information system for the countries of Latin America and the Caribbean (SIP), 40% of preterm births were associated with medical interventions . DeliverThe caesarean rates are especially high in Chile ; during The impact of these wide-scale medical interventions on mothers is both visible and cumulative. Accordingly, a woman who has already had a caesarean delivery in Chile has a risk of a second caesarean delivery 22 times higher than a primipara .In America, the largest increase in preterm birth rates from high-income countries has been reported in the United States. Increase is also important in some medium-income countries, including Brazil. The prevalence rate of PTB in both countries is around 12% .This research shows that in Chile, the overall rate of preterm births and low birth weight may be considered relatively low; but there are specific trends to be considered, such as the increase of newborns with less than 32 weeks of GA. This population is at high risk of morbidity and sequelae; might require specialized management and furthermore could have a significant impact on the public health of the country.Changes such as those observed in these two perinatal outcomes over a considerable period of time could provide information that can be used in the short or long term in several domains of public health as follow up care, financial planning etc. Even more when these current trends could be prolonged in the absence of other targeted prevention policies.From an exhaustiveness register of live births, we have observed in the space of 18 years that the distribution of GA and BW in live births has changed significantly, both for singleton and multiple births.Three trends resulting from these changes deserve special attention, because of their perinatal health impact. They are: the significant increase in the preterm birth rate, especially in the group of new born with less than 32 weeks of gestational age, the increase in the prevalence of very LBW, and finally, the sustained increase in multiple births.Although this descriptive study cannot prove the involvement of other factors according to type of birth, trends in preterm birth and LBW were measured with more specificity than previously and the main outcomes raise other challenges for future researches, such as the assessment of obstetrical and perinatal practices and the need to obtain a better profile of maternal population.This epidemiological information allows us to better define the problems we face and might thus be useful to decision-making bodies for attributing priorities. Equally important is the establishment of a periodic surveillance system for preterm delivery and low BW, both overall and by category, to improve the targeting of public policies related to these indicators.The authors declare they have no competing interest in the performance or publication of this research.PL Conceived of the study, made possible the acquisition of data, made analysis and interpretation of data. GB Made substantial contributions to conception and design of this study. Has been involved in drafting the manuscript and revised it giving a critical and important intellectual content. Has revised and approved the final version submitted to publish.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2393/12/121/prepub


The number of children born to foreign-born mothers in Taiwan has significantly increased since the 1990s. These foreign-born mothers are mainly from China and Southeast Asia. Children born to foreign-born mothers, according to media reports, are subject to inferior health. This study sought to determine whether socioeconomic disparities in birth outcomes exist between native and foreign-born mothers in Taiwan.Analysis data were obtained from the Taiwan Birth Cohort Study of 20,090 nationally representative 6-month-old babies, born in 2005. The data on the babies were divided into two groups, those of foreign-born mothers and those of Taiwanese mothers. The health outcome variables that were examined included two adverse birth outcomes: low birth weight and preterm birth. Multiple logistic regression was used to examine the association between income and foreign-born status, as well as birth outcomes among both groups.p < 0.001), and lower odds of preterm birth among families with a monthly family income < NT$30,000 and NT$30,000–69,999 . Having a higher monthly family income  was associated with lower odds of low birth weight  among Taiwanese mothers, but not among foreign-born mothers.Children of native Taiwanese mothers had a higher prevalence of low birth weight (6.9%) than did children of China-born (4.7%) and Southeast Asia-born mothers (5.2%). The prevalence of preterm birth was also higher among children of native Taiwanese mothers (8.4%) than among children of Southeast Asia-born (7.2%) and China-born mothers (6.3%). Foreign-born status was associated with lower odds of low birth weight among families with a monthly family income < NT$30,000 (adjusted odds ratio (AOR) = 0.24, 95% confidence interval (CI) = 0.14–0.42, Foreign-born mothers from China and Southeast Asia did not experience worse birth outcomes than native Taiwanese mothers did, regardless of the disadvantaged socioeconomic position of their families. Cross-border marriages in the Asia-Pacific region have increased significantly over recent decades. In Japan, the percentage of cross-border marriages had increased from 0.9% in 1980 to 4.3% in 2010[The number of children born to immigrant mothers, particularly from China and Southeast Asia, has also increased significantly in Taiwan since the 1990s. AlthougDespite a lack of evidence-based information, children born to foreign-born mothers are portrayed negatively as having inferior health,8. BecauPrevious studies on pregnancy outcomes among immigrant women have yielded heterogeneous results among immigrant groups, as compared to their native counterparts. In the United States, researchers have observed an epidemiological paradox in birth outcomes among foreign-born women of disadvantaged socioeconomic status-13, wherOne previous study reported more favorable birth outcomes, including reduced odds of preterm birth, low birth weight, and early neonatal mortality among foreign-born mothers in Taiwan. One hosThis study used a nationally representative sample with comprehensive measures to analyze individual data dimensions of the family socioeconomic environment, maternal risk factors, pregnancy complications, prenatal care, and various health variables. Specifically, this study examined the association between family income and disparities in low birth weight and preterm birth among foreign-born and Taiwanese mothers who reside permanently in Taiwan.Data for analysis were derived from the Taiwan Birth Cohort Study (TBCS). The TBCS sample used in this study was a nationally representative cohort of 24,200 live births born between January 2005 and December 2005. The TBCS sample was drawn from the Taiwan Birth Reporting Database, using a two-stage stratification random sampling method, with an average sampling rate of 11.7%. The TBCS survey involved face-to-face interviews with mothers or primary caregivers to acquire information on family socioeconomic circumstances, maternal health conditions during pregnancy, use of prenatal care, and the health conditions and development of the infants. Information including birth weight, gestational age, birth order (first born or subsequent births), family place of residence, and maternal age were obtained from birth reports. Survey questions were prepared in languages most comfortable to the respondents, and informed consent was obtained from all participants. A total of 21,248 mothers (87.8%) completed the first-wave survey when their infants were 6 months old.Births with either parent deceased (n = 21) or those missing information for birth order (n = 17), parent marital status (n = 606), paternal education (n = 175), maternal education (n = 38), family monthly income (n = 73), smoking during pregnancy (n = 25), first-time prenatal care (n = 43), and number of prenatal visits (n = 213) were excluded from this study. Only infants whose fathers were native Taiwanese and whose mothers were either native Taiwanese or immigrants from China or Southeast Asia were included in the study. In total, 1,158 respondents (5.4%) were excluded from this study. The final sample of 20,090 births (94.6%) consisted of 17,441 Taiwan-born (86.8%) and 2,649 (13.2%) foreign-born mothers.The outcome variables of this study were low birth weight and preterm birth. Low birth weight is defined as birth weights less than 2,500 g. Delivery before a gestational age of 37 completed weeks is considered a preterm birth. The data on gestational age were acquired from the Taiwan Birth Reporting Database, from which the sample of the TBCS was drawn. Gestational age is calculated from the first day of the last menstrual period (LMP) to the date of birth with the assistance of obstetric ultrasonography to measure the fetus size.The independent variable  was assessed by asking mothers their country of origin. One crucial limitation identified in the literature on birth outcomes of immigrant women involves using broad ethnic or racial categories, which fail to capture the heterogeneity of immigrant groups. In Taiwr = 0.60), we used family income to represent family socioeconomic position.Other independent variables included infant sex (boy or girl), birth order (first born or subsequent births), plurality (singleton or multiple birth), place of residence , smoking during pregnancy (yes or no), pregnancy complications , first time use of prenatal care , and number of prenatal visits . Maternal education was measured as years of received formal education categorized into three groups . Family socioeconomic status was characterized according to family income  recoded into three groups . Becaust tests were then employed to examine the bivariate relationships among maternal nativity, risk factors, and birth outcomes. Pairwise comparisons were employed to compare family and maternal characteristics and birth outcomes between nativity groups. Bonferroni correction was used to counteract multiple comparisons[The distribution of risk factors associated with low birth weight and preterm birth among Taiwan-born, China-born, and Southeast Asia-born mothers was examined. Prevalence of low birth weight, preterm births, and means of birth weight and gestational age were also calculated. Chi-square and parisons. BecauseThe Taiwan Birth Cohort Study was approved by the IRB of Bureau of Health Promotion, the Department of Health and the Directorate-General of Budget, Accounting, and Statistics, Executive Yuan, ROC (No. 94-C3–0940005257).Table Significant nativity differences in family socioeconomic characteristics were observed. As shown in Table p = 0.99), the distributions of maternal age, birth order, singleton birth, family monthly income, parental education, maternal education, place of residence, smoking during pregnancy, pregnancy complications, and prenatal care use were all statistically significantly associated with maternal nativity (p < 0.05). After Bonferroni correction for multiple comparisons, maternal age, birth order, singleton birth, family monthly income, parental education, maternal education, place of residence, smoking during pregnancy, pregnancy complications such as diabetes, hypertension, pre-eclampsia, placenta previa, and prenatal care use remained statistically significant. A p value of < 0.0167 was regarded as significant .Table Table China-born and Southeast Asia-born mothers were more likely to have family incomes of less than NT$30,000 , as compared to native Taiwanese mothers  and preterm birth  relative to the native Taiwanese group. However, after adjustment for maternal and family characteristics, foreign-born mothers had even lower odds for low birth weight  and preterm birth . Among mothers with a middle monthly income , only the immigrant group had lower adjusted odds of preterm birth than did the native Taiwanese group after adjustment for maternal and family characteristics . Among mothers with a high monthly income , neither adjusted odds of low birth weight nor adjusted odds of preterm birth was associated with the foreign-born status of mothers.Table p < 0.05 and AOR = 0.59, CI = 0.46–0.77, p < 0.001, respectively). However, the association between family income and low birth weight was statistically insignificant among foreign-born mothers. The association between family income and preterm birth is statistically insignificant for income groups among both native Taiwanese and foreign-born mothers.Table We examined two birth outcomes: low birth weight and preterm births between immigrant and native Taiwanese mothers by socioeconomic status using nationally representative data of a 2005 birth cohort. By assessing the interaction between foreign-born status and family income, we were able to examine the role of foreign-born status at different family income levels and whether an income gradient exists in low birth weight and preterm births among native Taiwanese and foreign-born mothers. Our results show that foreign-born status plays a protective role against low birth weight and preterm birth among mothers with lower family incomes, whereas this protective role was not observed among mothers with high family income Table . The infAll foreign spouses are eligible to apply for the National Health Insurance (NHI) 4 months after entering Taiwan. Taiwan's NHI covers at least 10 free prenatal visits (more if necessary), regardless of nationality. As part of Taiwan’s maternal and child care systems, a schedule of prenatal visits and examinations is recommended in multi-language maternal-child handbooks/passports provided to all pregnant women during their first prenatal visit. Although the available prenatal care resources are the same as those offered to native Taiwanese mothers, Chinese and Southeast Asian mothers were less likely to initiate prenatal care during the first 3 months of pregnancy, and also had fewer prenatal visits. In the context of the negative relationship between the use of prenatal care and birth outcomes, adverse birth outcomes were not observed among native Chinese or Southeast Asian mothers of different family income levels  This study was based on data from the Taiwan Birth Cohort Study, the first and the largest longitudinal birth cohort in Taiwan. (2) This study addressed comprehensive explanatory factors of birth outcomes that may not have been available to previous studies, including birth order, maternal age, family income, maternal education, place of residence, smoking during pregnancy, pregnancy complications, and prenatal care use among infants of foreign-born mothers. (3) Future studies could benefit from following up the birth cohort to provide a clearer understanding of the epidemiological paradox of the salutary birth outcomes observed among infants of foreign-born mothers in Taiwan.x2 = 0.74, p = 0.3896), multiple births , birth weight , and gestational age  were not significantly different between the TBSC sample and the population, except for birthing setting . This may be due to the large sample size and additional hospital births in the TBCS sample . Therefore, we conclude that the results in the present study may be generalized to the population.A chi-square goodness-of-fit test used to determine TBCS sample representativeness showed that the TBCS sample was consistent with the population. The distribution of infant sex (This study was limited by the data being collected by using a self-report procedure. The self-report results may be subject to mistakes, exaggeration, or underreporting resulting from recall or social desirability bias. Using LMP to determine gestational age may also lead to miscalculation resulting from recall bias; however, adjusting gestational age by using obstetric ultrasonography should minimize the bias. The rates of maternal complications in the TBCS are higher than the rates of the same complications in the Taiwan Birth Reporting Database. This difference may be due to recall bias in the TBCS, or to underreporting in the Taiwan Birth Reporting Database. Higher rates of maternal complications in clinical reports,30 suggeWe observed an “epidemiological paradox” and “healthy migrant effect” of birth outcomes in Taiwan: The association between family income and birth outcomes is weaker in foreign-born mothers than in native Taiwanese mothers. However, children born in cross-border marriages are more likely to live in socioeconomically deprived environments. The question of whether a healthier status before birth and continuing throughout a child’s entire life remains unanswered. Further longitudinal studies are required to examine the health disparities among children of cross-border marriages.AOR: Adjusted odds ratio; CI: 95% Confidence interval; TBCS: Taiwan Birth Cohort Study; LMP: Last menstrual period; OR: Odds ratio.The authors declare that they have no competing interests.LWS and TLC conceived the design of the study, performed the statistical analysis, and drafted the manuscript. Both authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2393/12/110/prepub


Atherosclerosis, which is a result of gradual deposition of lipids in the lower part of blood vessel endothelium, is the leading cause of mortality and morbidity around the world. It has been proved that some inflammatory blood markers such as fibrinogen can predict the risk for cardiovascular disease conditions, not only in cardiovascular patients, but also in those who do not have any manifestations of the atherosclerotic development. In this study, the effect of cornus mas l. was evaluated on fibrinogen of hypercholesterolemic rabbits and it was also compared with lovastatin drug.In this study, 25 New Zealand adult male rabbits were randomly divided into five groups of five. They were treated for 60 days by 5 different diets, namely basic, high cholesterol, regular plus 1 g/kgBW cornus mas L. powder, high cholesterol plus 1 g/kgBW cornus mas L. powder, and high cholesterol plus 10 mg/kgBW lovastatin. At the beginning and at the end of this period, blood samples were collected from the rabbits and their serum fibrinogen levels were measured.Cornus mas L. powder and lovastatin significantly decreased fibrinogen levels in comparison with high cholesterol group (P < 0.05). Furthermore cornus mas L. powder could reduce the fibrinogen level more than lovastatin (P < 0.05).The results indicated that consumption of cornus mas L. might be beneficial in atherosclerotic patients due to its reducing effects on fibrinogen. Iatrogenic femoral artery pseudoaneurysm (FAP) forms when an arterial puncture site fails to seal (inability to apply hemostasis) allowing blood to jet into the surrounding tissues and form a pulsatile hematoma. These lesions lack a fibrous wall and are contained by a surrounding shell of hematoma and the overlying soft tissues. Pseudoaneurysms usually occur in low puncture situations, because there is suitable mass of soft tissue to contain the bleeding. In contrast, high puncture results in free hematoma due to lack of sufficient surrounding tissue. It can present as a new thrill or bruit, pulsatile hematoma, or marked pain or tenderness. Complications of pseudoaneurysms include rupture, distal embolization, local pain, neuropathy and local skin ischemia. Unlike FAPs of a surgical or post-traumatic nature, catheterization-induced pseudoaneurysm has usually a benign natural history and 80% of cases resolve spontaneously. Several therapeutic strategies have been developed to treat this condition. They include ultrasound-guided compression repair (UGCR), compression repair by mechanical devices, surgical repair, and minimally invasive treatments . UGCR of femoral artery pseudoaneurysm has become the first line treatment in many centers. The introduction of this procedure by Fellmeth in 1991 has reduced the need for surgical repair dramatically, and its cost is much lower than that of open and endovascular repair.1Ultrasound probe must be placed on the neck of pseudoaneurysm with the intention of complete obliteration of blood flow to the pseudoaneurysm. Sometimes, if the neck cannot be discerned precisely in ultrasonic evaluation, pressure is applied non-specifically on extraluminal lesion, but precise detection of pseudoaneurysm neck increases procedural success. Pressure is applied for a period of at least 1 minute, with the procedure repeated 10 times. At the end of each period, compression is relieved briefly to assess pseudoaneurysm patency and to reposition the transducer. Care must be practiced to avoid compromising flow within the underlying femoral artery. After successful thrombosis patients should lie supine for a few hours, with the affected leg in the stretched position.4Compression on pseudoaneurysm of neck can be applied by mechanical devices like FemoStop.Pseudoaneurysm of neck must be viewed precisely by ultrasonography and its location should be marked on groin skin. Also, neck compressibility must be tested by ultrasound probe. Then, device should be fixed on the exact location and pressure applied for 20 minutes intervals and each time, FPA neck patency evaluated by ultrasonography. If the neck was still patent, the procedure must be repeated. Some authors reached results comparable to UGCR in terms of feasibility, safety and effectiveness and better results in terms of operator and patient comfort and cost.6Under sonographic guidance, 25–60 ml 0.9% normal saline must be injected in the tissues surrounding the tract connecting pseudoaneurysm to the femoral artery. Tract patency must be examined 24 hours later, sonographically.6Thrombin injection is a more recent way to induce thrombosis in pseudoaneurysms. Thrombin is the active form of prothrombin. Fortunately thrombin that inadvertently leaks to the general circulation will rapidly diluted and antagonized by antithrombin and thrombomodulin.An ultrasound examination is used to define the relationship of pseudoaneurysm of neck and native vessels. The peripheral pulses are then documented. Under sterile conditions, a 22-gauge spinal needle is inserted with ultrasound guidance into the periphery of the pseudoaneurysm. The needle tip should be placed as remote from the pseudoaneurysm neck as possible. Human thrombin at strength of 1000 units/mL should be injected slowly via a 1 mL syringe. The pseudoaneurysm is scanned continuously and injection terminated when color flow ceases .77In most cases, only 200 U (0.2 ml) thrombin is sufficient to induce thrombosis in the pseudoaneurysm. Rarely and especially in multiloculated cases, it becomes necessary to repeat injections. If most of the pseudoaneurysm became thrombosed but the flow in pseudoaneurysm of neck did not cease, it is not necessary to repeat injection. This will raise the risk of distal embolization and in most cases, flow in pseudoaneurysm of neck will cease in the later stages. At the end of procedure, peripheral pulses must be checked to exclude distal embolization. The patient must be in complete bed rest for 4 hours and scanned 24 hours later to confirm flow cessation in pseudoaneurysm. In another technique, thrombin can be injected directly in the pseudoaneurysm under fluoroscopic guidance while it is filled by contrast from the contralateral site. It is recommended to inflate a balloon catheter near pseudoaneurysm of neck to prevent thrombin leakage.Complications of thrombin injection are rare and can be divided into allergic14Coil and Onyx embolization and stent graft implantation are two ways of treating arterial pseudoaneurysm. Due to efficacy of previously mentioned procedures, these procedures are seldom required.16Coil packing can be done from ipsilateral groin and directly in the pseudoaneurysm and rarely from the contralateral route by cross-over technique. In the former, coils are released one by one through a catheter with its tip placed directly in the pseudoaneurysm under fluoroscopic guidance. In another method, PDA coil was not released and remained attached to its delivery system, while thrombus formation was followed in the pseudoaneurysm. After pseudoaneurysm became completely thrombosed, coil, its delivery system and catheter were withdrawn from pseudoaneurysm.15It is beyond the scope of this article to discuss surgical techniques of pseudoaneurysm repair. But, it is worth to mention that surgery is now very seldom required in the management of post-catheterization FAP with its benign course and multiple nonsurgical therapeutic options. It must be reserved for large wide neck pseudoaneurysms which is often the result of trauma and surgery. 7


The epidemiological evidence linking socioeconomic deprivation with adverse pregnancy outcomes has been conflicting mainly due to poor measurement of socioeconomic status (SES). Studies have also failed to evaluate the plausible pathways through which socioeconomic disadvantage impacts on pregnancy outcomes. We investigated the importance of maternal SES as determinant of birth weight and gestational duration in an urban area and evaluated main causal pathways for the influence of SES.A population-based cross-sectional study was conducted among 559 mothers accessing postnatal services at the four main health facilities in Cape Coast, Ghana in 2011. Information on socioeconomic characteristics of the mothers was collected in a structured questionnaire.In multivariate linear regression adjusting for maternal age, parity and gender of newborn, low SES resulted in 292 g (95% CI: 440–145) reduction in birth weight. Important SES-related determinants were neighborhood poverty , low education , studentship during pregnancy  and low income . In causal pathway analysis, malaria infection (6–20%), poor nutrition (2–51%) and indoor air pollution (10–62%) mediated substantial proportions of the observed effects of socioeconomic deprivation on birth weight. Generalized linear models adjusting for confounders indicated a 218%  risk increase of LBW and 83%  of PTB among low income mothers. Low and middle SES was associated with 357%  and 278%  increased risk of LBW respectively. Malaria infection, poor nutrition and indoor air pollution respectively mediated 10–21%, 16–44% and 31–52% of the observed effects of socioeconomic disadvantage on LBW risk.We provide evidence of the effects of socioeconomic deprivation, substantially mediated by malaria infection, poor nutrition and indoor air pollution, on pregnancy outcomes in a developing country setting. The rapid population growth of developing countries urban zones in recent years has led to the emergence and expansion of slum and squatter settlements in large parts of these areas with deplorable environmental conditions and widespread socioeconomic deprivation. Socioeconomic deprivation manifests as poor housing conditions, unemployment, low income and low educational attainment among others in these urban settlements with adverse consequences for human health. There is mounting evidence linking socioeconomic deprivation with adverse pregnancy outcomes. Factors such as area deprivation, unmarried status, low education, low income and low occupational attainment have been associated with low birth weight (birth weight <2500 grams) The evidence linking socioeconomic deprivation with adverse pregnancy outcome has however been conflicting. Shavers The objective of the present study was therefore to (a) ascertain the importance of different socioeconomic measures for fetal growth and gestational duration in Cape Coast, (b) develop a construct of SES that can strongly and consistently predict pregnancy outcomes in this and similar setting of developing countries, and (c) establish the factors mediating socioeconomic differences in pregnancy outcomes in this setting. The SES construct takes into account the population studied, the research questions asked and the outcomes of interest thereby representing a very precise and reliable measure of SES for the source population. Applying this construct and identifying the factors mediating their effects should provide a better understanding of the high burden of adverse birth outcomes in Cape Coast, and similar developing country settings whilst helping to map out appropriate intervention strategies to improve the situation.A population-based cross-sectional study was conducted among mothers and newborns of the postnatal clinic of the four main health facilities in the Cape Coast metropolis - Regional Hospital, Metropolitan Hospital, University Hospital and Adisadel Urban Health Centre. The Cape Coast metropolis covers an area of 122 square kilometers with an estimated population of 169, 894 according to the 2010 census. Cape Coast is the capital of the Central Region of Ghana and the smallest of the six metropolitan areas in Ghana.The source population comprised all nursing mothers residing in Cape Coast. Six hundred and eighty mothers who had singleton births with no gross anatomical deformities at the selected health facilities and accessing postnatal services at these same facilities were randomly sampled from a register provided by the maternity unit of the facilities. Selected mothers who visited the postnatal clinic were interviewed after been satisfied that they resided in Cape Coast and their respective neighbourhood throughout the duration of the pregnancy. The study population included five hundred and fifty nine mothers and their newborns . Of the study population, 141 (25.2%) were from the Regional Hospital, 131 (23.4%) from the Metropolitan Hospital, 139 (24.9%) from the University Hospital and 148 (26.5%) from the Adisadel Urban Health Centre. A weighting procedure based on the size of the facilities and the number of mothers who delivered at the facilities in 2010 was used to determine the number of mothers to be selected from each facility.The outcomes of interest were (1) fetal growth measured as birth weight (in grams) and (2) duration of pregnancy i.e. gestational age (in weeks). Information on birth weight and gestational age was retrieved from hospital records. Birth weight of the newborns was measured immediately after delivery with a regularly calibrated weighing scale which measures birth weight in kilograms. Gestational age was estimated by the health staff using the last menstrual period method.The primary determinant was socioeconomic status which was operationalized as: (1) area of residence, (2) marital status, (3) education, (4) occupation and (5) income. These were assessed on the basis of information collected in a structured questionnaire which was validated in the source population. Area of residence, education and income were combined into an index of SES with four levels - low, middle, upper middle and high. The levels of SES were constructed as follows. Step one involved assigning scores to the three socioeconomic measures in the following ways: (a) for area of residence, scores of 1, 2 and 3 were assigned to poor, middle class and affluent neighborhoods respectively, (b) for income, scores of 1, 2, 3 and 4 were assigned to monthly incomes of <GH¢100 (USD$71 at the time of study), GH¢101–500 (USD$71–357), GH¢501–1000 (USD$357–714) and>GH¢1000 (USD$714 ) respectively, and (c) for education, scores of 0, 1, 2, 3 and 4 were assigned to no, primary, junior high, senior high and tertiary education respectively. Step two involved summing up the scores for each participant with the total SES scores ranging from 2 to 11. Step three involved classification of mothers with total SES scores of 2, 3 and 4 as low SES; 5, 6 and 7 as middle SES; 8 and 9 as upper middle; and 10 and 11 as high SES.Covariates treated as potential confounders included maternal age, parity and gender of newborn. Covariates treated as mediating factors were reported episode of malaria during pregnancy, pre-pregnancy body mass index (BMI) and cooking fuel used during pregnancy.The Research Committee of the Department of Human Biology, University of Cape Coast, Cape Coast approved the study. Approval was also sought from the management of the selected facilities. Informed consent form attached to the questionnaires was used to seek the consent of all participants before inclusion in the study.The relations of interest comprised maternal socioeconomic status and adverse pregnancy outcomes . We applied multivariate methods for assessing the relations of interest. First, we applied multiple linear regression to estimate the independent effects of socioeconomic characteristics on birth weight. Second, we applied generalized linear models (PROC GENMOD) with Poisson distribution and log link to estimate the independent effects of the determinants of interest on the risk of LBW and PTB. All models were adjusted for age of mother, parity and gender of infant. We performed a causal pathway analysis using the difference method All the mothers reported receiving prenatal care with a high proportion (84%) initiating prenatal care early in pregnancy by attending antenatal clinic for the first time during the first trimester. Almost half (48%) of the mothers reported one or more physician-diagnosed episode of malaria during pregnancy. The proportion of mothers found to be underweight prior to being pregnant was 18%. We found 44% of the mothers using biomass fuels  and 18% of the mothers using liquefied petroleum gas (LPG) as cooking fuel during pregnancy. .Low SES was associated with a 292 g  reduction in birth weight with cooking fuel mediating 32% of the observed effect. Middle SES was also associated with a 219 g  reduction in birth weight with cooking fuel mediating 26% of the observed effect. The mediation fraction in the joint models for low SES and middle SES was 47% and 42% respectively. .Low and middle SES was respectively associated with a 357%  and 278%  increased risk of LBW with cooking fuel mediating 42% and 31% of the observed effects in both relationships respectively. The mediation fraction in the joint models for both low SES and middle SES was more than half (64% and 61% respectively). .Monthly income of <USD$71 was associated with 83%  increased risk of PTB with 17% and 22% of the observed effect mediated by pre-pregnancy BMI and cooking fuel respectively. The mediation fraction estimated from the joint model was 30%. .Low and middle SES was associated with a 26%  and 16%  increased risk of PTB respectively; albeit not statistically significant. .Our population-based study of urban Ghanaian women and their newborns provides evidence of the importance of maternal socioeconomic characteristics for pregnancy outcomes. Area of residence, education, occupation and income were independent determinants of birth weight and risk of LBW in this population. The construct of SES was also a strong determinant of birth weight and LBW risk with low and middle SES respectively associated with 357%  and 278%  increased risk of LBW. Income was the only socioeconomic characteristic associated with statistically significant increased risk of PTB in this population. Malaria infection, poor pre-pregnancy nutrition and indoor air pollution substantially mediated observed effects of socioeconomic disadvantage on fetal growth and gestational duration in this population.The study represents a defined catchment area because consecutive mothers giving birth at the main health facilities in the study area were selected. A weighting procedure based on the size of the facilities and the number of mothers delivering at these facilities was applied to determine a representative sample from each of the study sites. The population-based nature of the study together with the high response rate (82.2%) minimizes selection bias. Even though our study was conducted in an urban area it is still likely that there are some mothers who have barriers preventing them from accessing postnatal services such as lack of money for transport to the health facility. Unfortunately we could not track these mothers for inclusion in our study because the delivery registers at the health facilities do not contain information on the exact residential address of the mothers registered. The potential for selection bias due to the exclusion of mothers not seeking postnatal care from the study is nonetheless minimized in our study. This is due to the high patronage of postnatal services in Cape Coast and other urban settings of Ghana as a result of the high level of awareness of Reproductive and Child Health (RCH) service provision and benefits among urban mothers and the ease of access to RCH services. Many mothers in several urban areas of Ghana do not have to travel long distances to access RCH services due to the wide distribution of health services as a whole in most urban areas. Most mothers are even able to walk to these RCH service provision centers without the need for transport. Finally, mothers giving birth at home and possibly not accessing postnatal care should not be a major concern in our study because unlike rural areas of Ghana, very few mothers deliver at home in urban areas. This small number of home deliveries in urban areas of Ghana usually occurs by accident with most mothers immediately checking in at the nearest health facility due to the ease of access to health facilities.The outcomes were measured and recorded independently from the study with negligible measurement error in all the study sites and thus represent an objective variable. There are limitations associated with the use of the last menstrual period method for estimating gestational age and can obviously result in invalid estimates of gestation but as documented by Lynch and Zhang The SES construct combines data on the mothers area of residence; an area-based measure, and their educational attainment and income levels; individual-level measures, and is a context-specific, culturally sensitive objective variable that captures all aspects of social and economic standing in this population. Occupational class which has traditionally been used in constructing SES indices in various settings was not factored in our construct. With the exception of office work, all the other occupational groups are low income generating activities thereby ranking mothers in any of these jobs on a similar scale in terms of relative social position, economic success and actual standard of living. Our findings on the association of the various occupational groups with statistically significant reductions in birth weight in a way confirm this assertion. In such situations therefore, income is an adequate measure as it captures some of the very aspects of SES that occupational class will capture in any construct whilst also accounting for any small differences in the occupational groups with respect to these aspects of SES. We also did not factor marital status into the construct because our lack of data on paternal socioeconomic characteristics meant we were unable to determine how marital status of mothers translates into for example improved household income, better standard of living and social recognition without a complement of their spouses’ data.We applied multivariate methods to adjust for the potential confounding effect of maternal age, parity and gender of neonate. We did not control for smoking during pregnancy because only 0.7% of the mothers smoked during pregnancy. We employed the difference approach which was first proposed by Judd and Kenny Our study shows how socioeconomic deprivation adversely affects fetal development. Area of residence, education, occupation and income were determinants of birth weight and gestational length in this population. Residing in poor neighborhoods was associated with a mean 221 g reduction in birth weight. Previous studies have also found women living in deprived areas delivering the majority of LBW infants Low income was associated with increased risk of LBW and PTB in this population. The adverse perinatal effects of low income levels of mothers and households have been noted in diverse populations; nationwide in the US Petty traders/fishmongers and housewives/unemployed mothers were at particular risk of delivering smaller babies. Petty trading and fish mongering are low income generating activity in the study area. Homemaking and unemployment especially among mothers whose spouses are not in gainful employment obviously translates into poor family income. The adverse perinatal effects of low income has been shown in the present study and previous reviewed, and is not surprising that these group of mothers were vulnerable. The low income levels of these mothers also translates into poor nutritional practices and patronage of biomass fuels which the present study found to substantially mediate the observed effects of low occupational attainment on adverse pregnancy outcomes.Student mothers were also at risk of delivering smaller babies and were a vulnerable group possibly due to the stressful experience of combining studies with pregnancy. Stress in pregnancy is well documented to adversely affect pregnancy outcomes. Also, it is not unusual to find resident student mothers who are married to be anxious about the welfare of their spouse and children back home which can further exacerbates stress levels. Malaria infections, poor pre-pregnancy nutrition and indoor air pollution jointly explained only about 14% of the observed effect in this group of mothers and certainly strengthens our stress hypothesis. Our finding on the association of studentship during pregnancy with reduced birth weight is to the best of our knowledge the first of such report in the epidemiological literature. This certainly underscores the need to further explore the relationship especially in areas where women are not presented with the opportunity to take leave from studies when pregnant to generate the evidence base for public health action to safeguard maternal and perinatal health.In applying our construct of maternal SES, we found low and middle SES to be associated with statistically significant reductions in birth weight and increased risk of LBW in this population. Malaria infection, poor pre-pregnancy nutrition and indoor air pollution jointly explained between 42% and 64% of the observed effects in the models. Indoor air pollution assessed by biomass fuel use during pregnancy however appears to be the most important mediating factor explaining between 26% and 42% of the observed associations in the models. Studies in India In conclusion, our study provides evidence that socioeconomic deprivation is a strong determinant of adverse pregnancy outcomes in this Ghanaian setting. We also show that malaria infection, poor pre-pregnancy nutrition and indoor air pollution which have been associated with adverse birth outcomes in several settings are important pathways through which socioeconomic disadvantage impact on fetal growth and gestational duration in our setting. Improving social status and income levels of women, and addressing household and neighborhood poverty are thus important to curbing the high burden of adverse birth outcomes in Cape Coast and similar deprived zones of developing countries.Table S1Unadjusted and adjusted effect of maternal socioeconomic characteristics on birth weight.(DOCX)Click here for additional data file.Table S2Unadjusted and adjusted risk of low birth weight (LBW) attributable to maternal socioeconomic characteristics.(DOCX)Click here for additional data file.Table S3Unadjusted and adjusted risk of preterm birth (PTB) attributable to maternal socioeconomic characteristics.(DOCX)Click here for additional data file.