Each ethnic group has its own cultural values and practices that widen inequalities in child health and survival among ethnic groups. This study seeks to examine the mediatory effects of ethnicity and socioeconomic position on under-5 mortality in Nigeria.Using multilevel logistic regression analysis of a nationally representative sample drawn from 7620 females age 15 to 49 years in the 2003 Nigeria Demographic and Health Survey, the risk of death in children younger than 5 years (under-5 deaths) was estimated using odds ratios with 95% confidence intervals for 6029 children nested within 2735 mothers who were in turn nested within 365 communities.The prevalence of under-5 death was highest among children of Hausa/Fulani/Kanuri mothers and lowest among children of Yoruba mothers. The risk of under-5 death was significantly lower among children of mothers from the Igbo and other ethnic groups, as compared with children of Hausa/Fulani/Kanuri mothers, after adjustment for individual- and community-level factors. Much of the disparity in under-5 mortality with respect to maternal ethnicity was explained by differences in physician-provided community prenatal care.Ethnic differences in the risk of under-5 death were attributed to differences among ethnic groups in socioeconomic characteristics (maternal education and to differences in the maternal childbearing age and short birth-spacing practices. These findings emphasize the need for community-based initiatives aimed at increasing maternal education and maternal health care services within communities. Exceptions to this include Nigeria and pre-war Rwanda, where economically disadvantaged groups held a monopoly on government leadership after independence.16,17The association between ethnicity and health is well established.16 Cultural values and practices unique to these different ethnic groups influence child health outcomes.18,19 Yoruba and Igbo girls tend to marry in the third decade of life, while early marriage, before age 16 years, is common among the Hausa/Fulani/Kanuri ethnic groups.19 This commonly results in younger age at first birth, prolonged labor, and increased child mortality within these ethnic groups.20 The Hausa/Fulani/Kanuri ethnic groups also have a higher proportion of illiterate adults and less access to healthcare.16Nigeria is situated in West Africa and is bordered by Niger in the north, Chad in the northeast, Cameroon in the east, Benin in the west, and 850 kilometers of the Atlantic Ocean in the south. With a population of over 140 million people, Nigeria is the most populous country in Africa. It is geographically, culturally, and ethnically heterogeneous, with about 374 identifiable ethnic groups, of which the largest and politically dominant ethnic groups are the Hausa and Fulani of the north, the Yoruba of the southwest, and the Igbo of the southeast. These ethnic groups collectively account for 68% of the population. The Kanuri, Edo, Ijaw, Ibibio, Ebira, Nupe, and Tiv make up 27%, and other minority ethnic groups make up the rest.This study investigated whether the effect of ethnicity on under-5 mortality is fully mediated by socioeconomic position. If there remain significant ethnic differences in under-5 mortality that are not explained by socioeconomic position, then socioeconomic position only partially mediates the association between ethnicity and under-5 mortality, and factors related to ethnicity can then be hypothesized as determinants. The objectives of this study were to assess whether under-5 mortality varies across socio-geographical contexts, to examine the individual-level relationship between ethnicity and under-5 mortality, and to determine whether contextual explanatory factors account for variation in under-5 mortality.21 From these households, data were collected from 3725 females aged 15 to 49 years who had a total of 6029 live-born children within 5 years before the survey. Birth history data were used to compute under-5 mortality rates.The data used in this study were from the 2003 Nigeria Demographic and Health Survey (DHS), which is a nationally representative survey that allows assessment of child health in a national context. The survey used a stratified 2-stage sampling procedure to select a probability sample of 7620 females according to a list of Standard Enumeration Areas from the 1991 Population Census sampling frame. A more detailed description is reported elsewhere.The outcome variable was the risk of under-5 death (0–59 months), defined as the probability of dying between birth and the fifth birthday.Ethnicity: Ethnicity of the mother was based on the answer to the question “What is your ethnic group?” in the DHS questionnaire, and was categorized as: (1) Hausa/Fulani/Kanuri, which were analyzed as group because these ethnic groups either speak a common language or dialect; share a common sense of identity, cohesion, or history; or have a single set of customs and behavioral rules, as in marriage, clothing, diet, taboos; (2) Igbo; (3) Yoruba; and (4) Others .(1)sex of the child(2)birth order and interval between births, created by merging “birth order” and “preceding birth interval,” which were classified as: first births, birth order 2 to 4 after a short birth interval (<24 months), birth order 2 to 4 after a medium birth interval (24 to 47 months), birth order 2 to 4 after a long birth interval (≥48 months), birth order ≥5 after a short birth interval (<24 months), birth order ≥5 after a medium birth interval (24 to 47 months), and birth order ≥5 after a long birth interval (≥48 months). The variables birth order and preceding birth interval were merged because preceding birth interval, which is the interval between the previous birth and the birth of the child in question, excludes first births from the analysis since they are not preceded by another birth. Thus, the merger of these variables enables the analysis to include first births, which were merged with children born after a birth interval of 24 months or longer;(3)maternal age, grouped as: 15 to 18, 19 to 23, 24 to 28, 29 to 33, and 34 years or older;(4)maternal age at first birth, categorized as: 18 years or younger and 19 years or older;(5)religion, categorized as: Christian, Muslim, and Traditional indigenous religion. Religion was included in order to examine the role of belief systems on ethnicity, as compared with other factors that might affect the influence of ethnicity on child survival;(6)maternal education, categorized as: none, primary, and secondary or higher education; and(7)maternal occupation, categorized as: professional/technical/managerial, clerical/sales/services/skilled manual, agricultural self-employed/agricultural employee/household or domestic/unskilled manual occupations, and not working.Seven individual-level variables of interest were examined:22,23 PSUs are small and designed to be fairly homogeneous with respect to population socio-demographic characteristics, economic status, and living conditions. They comprise one or more enumeration areas, which are the smallest geographic units for which census data are available in Nigeria. Each cluster consists of a minimum of 50 households. If there were fewer than 50 households, a contiguous enumeration area was added.21 Two community-level variables were assessed here. The first was community maternal education , which was categorized as low and high. This was assessed because maternal education is an important determinant of child survival in low- and middle-income countries23,24 and is associated with improved child survival and immunization rates.25,26 The second community-level variable was physician-provided community prenatal care, which was categorized as low and high based on the percentage of mothers who received prenatal care by a doctor. This was assessed because prenatal care directly increases mothers’ subsequent utilization of healthcare, such as institutional delivery and immunization.27–30Community or contextual-level variables were analyzed at the level of the primary sampling unit (PSU), which are administratively defined areas used as proxies for neighborhoods or communities.31The ethnic distribution of the children and mothers was estimated, and Pearson’s chi-square test was used to examine statistically significant differences, using Stata version 10.0 (StataCorporation).32 Children (level 1) were nested within mothers (level 2) who were in turn nested within communities (level 3). Five models were fitted. Model 0 (null model) contained no explanatory variables and only focused on decomposing total variance into its individual and community components. Model 1 contained maternal ethnicity as the only variable. Model 2 added child-level variables . Model 3 included mother-level variables . Models 4a and 4b included sequentially added community-level variables ; one variable was added at a time in order to identify the community-level variable to which inequalities in under-5 mortality among the ethnic groups could be attributed.A 3-level multilevel logistic regression model was used to account for the hierarchical structure of the DHS data.33 and P values were calculated. MLwiN software 2.0.2 (Center for Multilevel Modeling)34 was used for the multilevel analyses, with binomial, predictive quasi-likelihood (PQL), and first-order linearization procedures, using Markov Chain Monte Carlo (MCMC) techniques.35 The Bayesian deviance information criterion (DIC) was used to estimate the goodness of fit of consecutive models; a lower DIC value indicates a better fit of the model.36The fixed effects (measures of association) were expressed as odds ratios (ORs) and 95% confidence intervals (95% CIs). The random effects (measures of variation) were expressed as variance partition coefficient (VPC) and percentage change in variance (PCV). The VPC is a measure of the extent to which siblings resemble each other more than they resemble children from other families in relation to under-5 mortality. A large VPC would indicate that mother and community factors are important in understanding the risk of under-5 mortality, while a VPC close to 0 would indicate that individual- and community-level factors exert only a small influence on under-5 mortality. Precision was evaluated by using the standard error (SE) of the explanatory variables. Parameters were tested in an approximate manner using the Wald statistic, ie, the ratio of the estimated variance to its standard error,The survey procedure and instruments for the 2003 Nigeria DHS were approved by the Ethics Committee of the Opinion Research Corporation (ORC) Macro International, Incorporated, Calverton, USA and by the National Ethics Committee of the Federal Ministry of Health, Nigeria. This study is based on analysis of secondary data; all participant identifiers were removed. Ethical permission for use of the data in the present study was obtained from ORC Macro Inc.The data were from 6029 children of 3725 mothers from 365 communities. The largest ethnic group was the Hausa/Fulani/Kanuri (43%), while the “other” composite ethnic group made up 35% of the sample. With respect to birth order/interval, maternal age, maternal education, and maternal age at first birth, the largest groups were children born in birth order 2 to 4 after an interval of 24 to 47 months (26%), age 24 to 28 years at child birth (30%), no maternal education (50%), and maternal age 18 years or younger at first birth (55%), respectively.Among the Hausa/Fulani/Kanuri, children of birth order 2 to 4 born after an interval of 48 months or longer, and those of birth order 5 or higher born after an interval of 24 to 47 months were most common. The Hausa/Fulani/Kanuri mothers were most frequently 24 to 28 years of age, had no education, and were age 18 years or younger at the birth of their first child. Children of Igbo mothers were most commonly birth order 2 to 4 born after an interval of 24 to 47 months. The most common Igbo mothers were age 34 years or older at child birth, had a secondary or higher education, and were 19 years or older at first birth. Yoruba children were most commonly birth order 2 to 4 order born after an interval of 24 to 47 months, while Yoruba mothers were most commonly age 24 to 28 years at child birth, with a secondary or higher education, and were 19 years or older at first birth.P = 0.021) and communities , thereby justifying the use of multilevel models in this analysis. The intraclass correlations between mothers and communities, as indicated by the VPC, were 7% and 8.2% respectively, indicating that the variations in under-5 mortality were mostly due to child-level factors.The null model (Model 0) indicated a significant variation in under-5 mortality across mothers  and communities . The slightly increased intraclass correlation of 7.4 between mothers and the decreased intraclass correlation of 5.3 between communities indicate that controlling for ethnicity slightly increases the proportion of variance in under-5 mortality existing between mothers, but decreases the proportion of variance existing between communities. As indicated by the PCV, 11.1% and 20.2% of the variance in the odds of under-5 mortality across mothers and communities, respectively, was explained by ethnicity.Ethnicity was included in Model 1 to investigate whether its effect was different across contexts. Crude ORs showed that, as compared with children of Hausa/Fulani/Kanuri mothers, children of Igbo mothers had a 40% lower risk of dying , children of Yoruba mothers had a 57% lower risk of dying , and children of mothers in other ethnic groups had a 19% lower risk of dying . In comparison with the null model, the variation in under-5 mortality in Model 1 remained significant across mothers . The intraclass correlation between mothers decreased to 3.7%, while the intraclass correlation between communities remained basically unchanged at 5.4%. In this model, 57.3% and 22.5% of the variance in the odds of under-5 mortality across mothers and communities, respectively, was explained by birth order/birth interval.Adjusting for sex of the child and birth order/birth interval in Model 2 attenuated the risks of dying for children of Igbo  and Yoruba mothers , as compared with the Hausa/Fulani/Kanuri ethnic group. In comparison with Model 1, the mother-level variation became nonsignificant, while the community-level variation decreased further, but remained significant . The intraclass correlation between mothers decreased slightly to 4.5%, while the intraclass correlation between communities decreased to 3.0%. The decreased variance in the odds of under-5 mortality of 3.0% and 4.5% across mothers and communities, respectively, was explained by mother-level characteristics.Maternal age, maternal age at first birth, maternal religious affiliation, maternal education, and maternal occupation were introduced in Model 3. The risk for children of Igbo mothers remained basically unchanged, the risk for children of Yoruba mothers became nonsignificant, and the risk for children of mothers from other ethnic groups was attenuated . In comparison with Model 2, the community-level variation decreased further while remaining significant , the point estimates remained basically the same. However, with the introduction of physician-provided community prenatal care (Model 4b), the differences in the risks of under-5 mortality between the ethnic groups became statistically nonsignificant, indicating that the association between ethnicity and under-5 mortality could be attributed to differential access to prenatal care provided by doctors within communities. In addition, model 4b showed that the risk of dying was 59% higher for first births  and 2-fold for children of birth order ≥5 after a short birth interval (<24 months) , but 41% lower for children of birth order ≥5 after a long birth interval (≥48 months) . The risks were 33% higher for children of mothers who were age 34 years or older , as compared with children of mothers age 24 to 28 years. The risks of dying were 63% and 80% higher for children of mothers with primary  or no education , respectively, as compared with children of mothers with secondary or higher education.P = 0.022). The intraclass correlation between communities remained at 4.5% in Model 4a and 3.9% in Model 4b, while the intraclass correlation between mothers was 3.0 in Model 4a and 2.9 in Model 4b, in comparison with the previous models. This means that differences in the under-5 mortality between ethnic groups are partly due to community-level characteristics in Models 4a and 4b. Community-level and mother-level factors explained 15.4% and −84.7% of the variance in the odds of under-5 mortality, respectively. The decrease in DIC value with each successive model indicates a good fit between the model and the data.In comparison with Model 3, community-level variation in Models 4a and 4b decreased further while remaining significant Under-5 mortality was highest among children of Hausa/Fulani/Kanuri mothers and lowest among children of Yoruba mothers.(2)Under-5 mortality varied significantly across contexts, thereby justifying the use of multilevel modeling in the analysis.(3)There was significant variation in under-5 mortality by ethnicity, much of which was explained by differences in individual-level explanatory factors  and community-level explanatory factors .The findings of this study indicate that much of the association between maternal ethnicity and under-5 mortality was mediated by differences in individual-level socioeconomic characteristics, especially maternal education and maternal age. Ethnicity is thus an explanatory factor for differences in health-seeking behavior, since it was significantly associated with maternal education even after controlling for socioeconomic factors. Similar findings have been reported in other studies in Nigeria37 and elsewhere.38,39 The proportions of individual-level characteristics in this study showed that Hausa/Fulani/Kanuri mothers were most commonly uneducated, younger, and age 18 years or younger at first birth; this supports the association found in this study between socioeconomic position and under-5 mortality.With respect to the objectives of the study, the findings were as follows:40,41 This finding reflects the influence of cultural beliefs and practices in childbirth fertility-related behaviors most commonly associated with the Hausa/Fulani/Kanuri ethnic group of Northern Nigeria. The culture of early marriage, young age at first birth, high order births with short birth intervals, and low literacy and educational attainment among females of the Hausa/Fulani/Kanuri ethnic group significantly contributes to under-5 mortality differences among the ethnic groups, a point that has also been stressed in a recent study in Nigeria.42 Furthermore, maternal education is also known to influence the chance that mothers will access health care services, such as physician-provided prenatal care, hospital delivery, and child immunization. Thus, ethnicity may have an indirect effect on under-5 mortality by influencing physician-provided community prenatal care, as was the case in this study and other studies.40,41The results also showed that ethnic differences in under-5 mortality were associated in part with birth order/birth interval, which in turn supports hypotheses suggesting that ethnic differences in health-seeking behavior explain health disparities.24,25,43 first births and higher order births were significantly associated with higher risks of under-5 deaths. As discussed earlier, this is more commonly associated with health behaviors of individuals from the Hausa/Fulani/Kanuri ethnic group, and is also linked with the socioeconomic level of the mothers. It was expected that higher maternal age (34 years or older) would be associated with a lower risk of under-5 mortality, as this association had been reported.26 It is believed that older mothers are more educated, have better jobs, and may be better empowered to partake in household decision-making and fertility-related decisions. Lower maternal education (primary education or less) was significantly associated with an increased risk of under-5 death, which is in line with results from other studies.27,37 The reason for this is that higher education enables mothers to acquire modern and improved perceptions of disease causes and treatment, improves the health and welfare of their child, and enhances decision-making power.As in previous studies,Physician-provided community prenatal care was significantly associated with under-5 mortality in this study: the risk of dying was lower for children of mothers residing in communities with high levels of physician-provided prenatal care, as compared with children of mothers residing in communities with low levels of such care. Physician-provided community prenatal care is also an indication of the access and quality of care received by the mother and infant during delivery. Moreover, it reflects how socioeconomic position at the community level affects health outcomes and parallels the associations seen at the individual level. The presence of significant community-level variation after controlling for individual- and community-level characteristics indicates a need for further exploration of community-level effects on under-5 mortality risks.This study showed that ethnic differences in the risks of under-5 deaths were attributable to differences in socioeconomic characteristics among the ethnic groups and to differences in the health-seeking behavior of the different ethnic groups. This reflects the need for interventions to reduce economic inequalities among women, both at individual and community levels. There is a need for community-based initiatives aimed at increasing the proportion of mothers with higher education in communities and the proportion of mothers who receive maternal health care services  in communities. Furthermore, attempts must be made to change health-damaging cultural norms and behaviors that are more common among certain ethnic groups, such as short birth-spacing intervals . Interventions aimed at eliminating ethnic disparities in child health in Nigeria should be incorporated into public health objectives and program planning at the national level.This study has some limitations. First, the administratively defined boundaries used as proxies for neighborhoods may nondifferentially misclassify individuals into inappropriate administrative boundaries, which can generate information biases and reduce the validity of the analyses. Second, other individual- and community-level factors not addressed in the present study, such as cultural beliefs, may also be important determinants of full immunization; these were excluded because of the absence of relevant data.


Pyloroduodenal duplication is the rarest alimentary tract duplication known so far. A 1-year-old female patient presented with abdominal pain, lump in the epigastrium and occasional vomiting. On ultrasound and CT scan of abdomen suspicion of duplication cyst was made. Operation revealed a duplication cyst along pylorus and first part of the duodenum. Excision of free part and mucosal stripping of the attached part of the duplication was done.  Alimentary tract duplications commonly occur along ileum. Pyloroduodenal duplications are extremely rare variety of duplications with only 5 cases reported to best of our knowledge on literature search. These duplications present with abdominal mass and vomiting. In neonates, pyloroduodenal duplication can simulate pyloric stenosis [1-4]. A case of pyloroduodenal duplication is being reported. A 1-year-old female was admitted with abdominal pain, abdominal lump and infrequent episodes of vomiting. The patient was born to a multi-gravida with no perinatal problem. The patient had infrequent episodes of non-bilious vomiting since birth for which occasionally medical treatment was sought.However, for the last 3 months the parents had noted an epigastric lump associated with abdominal pain. On examination, a vague mass was palpable in the epigastrium with no visceromegaly. There was tenderness on deep palpation. Ultrasound of the abdomen showed a 5 cm x 4 cm sized thick walled cyst in the epigastrium. CT scan of the abdomen also revealed a 5 cm x 5 cm sized cyst between the duodenum and the liver with wall enhancement, suggestive of duplication cyst .Laboratory parameters were within normal limits. At operation, a cyst along the pylorus and first part of the duodenum was found . The cyst was opened that showed a mucosal lined cavity having mucus in it . As the cyst was not separable from the gut therefore, excision of the free part of the cyst and mucosal stripping of the rest was performed. The patient recovered well postoperatively. She is doing well at one year follow-up. The histopathology of the specimen showed a gastric mucosal lined tissue having smooth muscles in the wall.Alimentary tract duplications are rare congenital anomalies. The duplications are named after the part of alimentary tract, to which these are intimately attached. Few cases of alimentary tract duplications may contain ectopic mucosa and pancreatic tissue [4]. Most of the alimentary tract duplications are cystic and non-communicating. Pyloroduodenal duplications are mostly non-communicating  as in our case; however a case of communicating pyloroduodenal duplication has also been reported [3]. Pyloroduodenal duplications present with symptoms of gastric outlet obstruction and abdominal mass. Similarly, our patient presented with abdominal mass and occasional emesis. The alimentary tract duplications, in this location, can mimic other cystic lesions like mesenteric cyst, pseudopancreatic cyst, and choledochal cyst etc. Plain abdominal radiograph may show a mass effect in the epigastrium surrounded by displaced gas shadows. Ultrasound, contrast study, endoscopy, and CT scan are important diagnostic tools. Thick wall of the cyst as appreciated on the CT scan, can give a clue of duplication cyst as wall enhancement is not featured by the most of other cystic lesions in the vicinity [1-3].The Pyloroduodenal duplication has been managed by complete excision of the duplication with pyloroduodenal enterectomy and end to end pyloroduodenal anastomosis [2], or by excision of the free part of the duplication cyst along with mucosal stripping of the remaining portion which is intimately attached to the pyloro-duodenum [1]. The second approach was considered safe and was used in the index to which she responded well. Source of Support: NilConflict of Interest: None declared


Introduction. Tongue base cyst is an uncommon but potentially dangerous cause of stridor in neonates and infants. Case Presentation. We report a case of a 2-month-old Arabic male infant with a congenital tongue base cyst revealed by inspiratory stridor and recurrent respiratory distress. Diagnosis of cyst was suspected at endoscopy and confirmed by MRI imaging. The cyst was marsupialized with CO2 laser. One year later, the child remains asymptomatic without recurrence of the mass. Conclusion. Tongue base cysts should be considered in differential diagnosis in new borns with stridor, respiratory difficulties, or swallowing problems. Definitive therapy requires large marsupialization under general anesthesia. Congenital tongue base cysts are an uncommon cause of airway obstruction , 2. An a2 marsupialization was done. One year after surgery, the patient was in perfect health without any airway problems and had gained weight.A 2-month-old male infant of Arabic origin and average socioeconomic statusliving inan urban area with a history of recurrent respiratory distress was referred to pediatric emergency for inspiratory stridor and sever dyspnea. Clinical examination found an apyretic child with polypnea and features of respiratory collapse, so he was intubated and transferred to pediatric intensive care. Biological analysis showed normal complete blood values, with no inflammatory syndrome, also the chest X-ray was normal. The diagnosis of laryngomalacia was suspected. The endoscopic laryngobronchoscopy was performed and disclosed a normal appearing larynx with no major inspiratory collapsus. The digital tongue base palpation revealed a submucosal soft midline mass . MRI sho2 laser. Sometimes, preintubation aspiration becomes necessary before the insertion of the endotracheal tube. Simple aspiration of the cyst is not advised because of its high recurrence rate [In medical literature, a variety of terms have been used for tongue base cysts, such as epiglottic cyst, lingual cyst, vallecular cyst, or laryngeal cyst –8. Two mnce rate –6. Spontnce rate –8. In co


Environmental alternations leading to fetal programming of cardiovascular diseases in later life have been attributed to maternal factors. However, animal studies showed that paternal obesity may program cardio-metabolic diseases in the offspring. In the current study we tested the hypothesis that paternal BMI may be associated with fetal growth.We analyzed the relationship between paternal body mass index (BMI) and birth weight, ultrasound parameters describing the newborn's body shape as well as parameters describing the newborns endocrine system such as cortisol, aldosterone, renin activity and fetal glycated serum protein in a birth cohort of 899 father/mother/child triplets. Since fetal programming is an offspring sex specific process, male and female offspring were analyzed separately. Multivariable regression analyses considering maternal BMI, paternal and maternal age, hypertension during pregnancy, maternal total glycated serum protein, parity and either gestational age (for birth weight) or time of ultrasound investigation (for ultrasound parameters) as confounding showed that paternal BMI is associated with growth of the male but not female offspring. Paternal BMI correlated with birth parameters of male offspring only: birth weight; biparietal diameter, head circumference; abdominal diameter, abdominal circumference; and pectoral diameter. Cortisol was likewise significantly correlated with paternal BMI in male newborns only.Paternal BMI affects growth of the male but not female offspring. Paternal BMI may thus represent a risk factor for cardiovascular diseases of male offspring in later life. It remains to be demonstrated whether this is linked to an offspring sex specific paternal programming of cortisol secretion. Low birth weight is an independent risk factor for cardiovascular disease and glucose intolerance in later life. This was first elucidated in a study investigating thef the geographical distribution of heart disease in Great Britain Meanwhile other maternal mechanisms leading to an increased risk of diabetes, renal diseases and cardiovascular diseases in later life have been described such as maternal genes modifying offspring physiology in early life without being transmitted to the offspring However, in very recent animal studies evidence emerged that paternal factors may influence fetal growth (assessed by measuring birth weight) and the risk of cardiovascular diseases in later life. Especially paternal obesity may cause long-term effects on the metabolism of the offspring. A recent study demonstrated that a chronic high-fat diet in male rats programs β-cell dysfunction in female rat offspring Participants from this study came from the Guangzhou birth cohort We invited a total of 932 Chinese women who delivered their babies at the obstetric department of the first affiliated hospital of Jinan university between March 2010 to October 2010 to participate in the study. Inclusion criteria were as follows: (1) the newborn was born without congenital anomalies; (2) singleton pregnancy; (3) no hepatitis B, C and D, no HIV and no syphilis. After exclusion of cases that did not fulfill the inclusion criteria or were not willing to participate, we finally included 889 remaining cases. After obtaining written consent, a structured medical history was taken. Chinese guidelines for medical follow-up in pregnancy comprise a perinatal health manual which contains essential data about the pregnancy. The data in the ‘Perinatal health manual’ were also used to judge whether the women fulfilled all inclusion and exclusion criteria. The following data were extracted into our database: nationality/ethnic background, age, body height, body weight before and during pregnancy, gravidity, parity, gestational age at delivery, smoking before/during pregnancy, and alcohol consumption during pregnancy and blood pressure readings at all follow-up visits. The criteria for diagnosis of pregnancy-induced hypertension were based on the definition of the Chinese hypertension society: systolic blood pressure of ≥140 mm Hg and/or a diastolic blood pressure of ≥90 mm Hg after 20 weeks gestation, measured at least at two occasions with a break of 4 to 6 hours in-between. Gestational age was calculated from the first day of the last normal menstrual period and confirmed by either first or early second trimester ultrasound scans. Biometric data of the newborns were routinely measured immediately after delivery.Fetal blood was collected from the umbilical cord  within 10 minutes after delivery. Midwives collected maternal blood from a cubital vein in the delivery room or on the ward before delivery immediately after the pregnant women were hospitalized for giving birth. Mothers were asked to stop eating when being hospitalized for giving birth. Food intake prior to hospitalization was not recorded. Samples were processed immediately. The resulting plasma samples were stored at −20°C until analysis.Total cortisol was measured by Fluorescence Polarization Immunoassay (FPIA)  on the AxSYM System , as performed previously Ultrasound measurements during pregnancy were done as described previously Data were analyzed with SPSS version 19.0. Results are presented as mean ± standard deviation. When examining the correlation between paternal BMI with birth weight or ultrasound parameters describing fetal growth, factors that are known to influence intrauterine growth and showed a significant bivariate correlation or association with birth weight or ultrasound parameters in our cohort, respectively, were used as co-variables. Multivariable regression analysis, see also references 24 and 25. was used to adjust for confounding variables known to independently influence birth weight and intrauterine growth.To ensure that the findings are robust, we tested the effect of paternal BMI on fetal growth in different two-sided multivariable regression models. Model A considered – besides maternal BMI – maternal and paternal age, hypertension during pregnancy, maternal glycated serum protein, parity and either gestational age (for birth weight) or time of ultrasound investigation (for ultrasound parameters) as confounding factors. Model B was calculated excluding cases of paternal hypertension but considering maternal BMI, paternal and maternal age, hypertension during pregnancy, maternal glycated serum protein, parity and either gestational age (for birth weight) or time of ultrasound investigation (for ultrasound parameters) as confounding factors. Model C considered maternal BMI, hypertension during pregnancy, maternal glycated serum protein and either gestational age (for birth weight) or time of ultrasound investigation (for ultrasound parameters) as confounding factors. A p-value of less than 0.05 was considered significant.2, whereas the mean age of the mothers was 28.49 years and the mean BMI prior to pregnancy was 20.20 kg/m2.Demographic data describing the participating couples and their offspring are given in Since fetal programming is an offspring gender dependent process Gestational age at delivery was 274.44±9.79 days; the ultrasound examination was done at gestational day 266.8±15.1. We used these data to describe the newborns body shape, since the birth process is known to affect certain anthropometric parameters (e.g.: head circumference) immediately after birth When analyzing cases including male offpspring only, all tested models revealed that paternal BMI correlated significantly with birth weight, biparietal diameter, head circumference, abdominal diameter, abdominal circumference and pectoral diameter .However, when analyzing cases only including female offspring, all tested models revealed that paternal BMI did not correlate with birth weight, biparietal diameter, head circumference, abdominal diameter, abdominal circumference and pectoral diameter . Key finThese analyses uniformely showed that the effect of paternal BMI on birth weight as well on parameters describing offspring intrauterine growth are highly dependent on offspring gender.In order to detect effects of paternal BMI on the newborns endocrine system, we measured renin activity, aldosterone-, cortisol- and fetal glycated serum protein (as a parameter of glycemic control) concentrations in fetal blood taken right after delivery. Renin activity, aldosterone- and glycated serum protein concentrations of newborn boys and girls in the fetal blood right after delivery cortisol, aldosterone, renin activity and fetal glycated serum protein (as a parameter of glycemic control). Aldosterone, renin activity and glycemic control as analyzed by measuring fetal glycated serum protein were not related to paternal BMI in newborn boys and girls (data not shown). However, the cortisolCortisol concentration of newborn male offspring in newborns, however, was was significantly associated with paternal BMI in male offspring . This asThe present study demonstrated that paternal BMI during conception is associated with fetal growth of the male offspring but not female offspring. This was shown by analyzing birth weight and ultrasound parameter describing the body size of the newborn prior to birth. In addition, we could demonstrate that fetal cortisol at delivery is associated with paternal BMI in male offspring only.Anthropometric parameters, especially head circumference, of newborns may be influenced by labor The fetal programming hypothesis suggests that environmental factors in early life may alter the risk of cardiovascular diseases in later life. It is thought that environmental factors like maternal nutrition or maternal exposure to toxins like cigarette smoke lead to epigenetic alterations of the offspring which influence the activity of key cardiovascular regulatory systems like insulin resistance, blood pressure and lipid metabolism in later life Increasing evidence emerging mainly from animal experiments indicates an important biological role of fathers in fetal programming as well. Recent studies demonstrated that high-fat diet in fathers programs β-cell dysfunction in female rat offspring via epigenetic mechanisms Independent groups worldwide demonstrated that both maternal under-nutrition as well as maternal over-nutrition during pregnancy lead to a gender specific phenotype in the offspring A recent study also indicated that paternal obesity seems to affect the offspring in a gender dependent manner To the best of our knowledge, this is the first study showing that paternal BMI during conception is associated with growth of the male but not female offspring. The underlying mechanisms still are unknown. Since we also saw a moderate association between paternal BMI and fetal cortisol in newborn boys, paternal programming of the hypothalamus-hypophyis-adrenal axis in a gender dependent manner (see above) might be possible. It was already shown that this endocrine system is subject to fetal programming


The aim of this study was to compare maternal labour and birth outcomes between women who gave birth on a birth seat or in any other position for vaginal birth and further, to study the relationship between synthetic oxytocin augmentation and maternal blood loss, in a stratified sample.A re-analysis of a randomized controlled trial in Sweden. An on-treatment analysis was used to study obstetrical outcomes for nulliparous women who gave birth on a birth seat (birth seat group) compared to birth in any other position for vaginal birth (control group). Data were collected between November 2006 and July 2009. The outcome measurements included perineal outcome, post partum blood loss, epidural analgesia, synthetic oxytocin augmentation and duration of labour.The major findings of this paper were that women giving birth on the birth seat had shorter duration of labour and were significantly less likely to receive synthetic oxytocin for augmentation in the second stage of labour. Significantly more women had an increased blood loss when giving birth on the birth seat, but had no difference in perineal outcomes. Blood loss was increased regardless of birth position if women had been exposed to synthetic oxytocin augmentation during the first stage of labour.The results of this analysis imply that women with a straightforward birth process may well benefit from giving birth on a birth seat without risk for any adverse obstetrical outcomes. However it is important to bear in mind that, women who received synthetic oxytocin during the first stage of labour may have an increased risk for greater blood loss when giving birth on a birth seat. Finally it is of vital importance to scrutinize the influence of synthetic oxytocin administered during the first stage of labour on blood loss postpartum, since excessive blood loss is a well-documented cause of maternal mortality worldwide and may cause severe maternal morbidity in high-income countries.http://register.clinicaltrials.gov)Unique Protocol ID: NCT01182038 ( Interventions in the childbirth process can, in both high- and low-income countries, save the lives of mothers and infants and in some cases reduce the occurrence of serious sequelae,2. HowevIt is more than 20 years since Waldenström and Gottvall publisheChildbirth and Authoritative Knowledge” edited by Davis-Floyd and Sarget[The randomized controlled trial is considered to be the most reliable method for empirical research and has in recent decades played an important role in producing evidence for midwifery and obstetric practice-14. Johnd Sarget, that thd Sarget,16. Whend Sarget,18. Neved Sarget,11 and id Sarget,11 mightThe aim of this re-analysis was to compare maternal labour and birth outcomes between women who gave birth on a birth seat or in any other position for vaginal birth and further, to study the relationship between synthetic oxytocin augmentation and maternal blood loss, in a stratified sample.The present article is based on data collected in an RCT by Thies-Lagergren et al.,11 and iThis is an OT analysis of an RCT that was originally powered to detect differences in instrumental vaginal births, based on an arbitrary reduction of instrumental births from 15% to 9% . Of the 1002 births analysed, fifty-two births were excluded due to emergency caesarean section, leaving 950 for analysis according to the OT principal. Analyses include 253 nulliparous women, referred to as the birth seat group, who gave birth on the birth seat compared to 697 nulliparous women, here referred to as the control group, who gave vaginal birth in any other position.The participants spoke Swedish sufficiently well to receive information and give informed consent or refusal for participation in the trial. Inclusion criterion were a healthy woman with an uncomplicated pregnancy exclusive of any medical diagnosis, a singleton foetus in cephalic presentation, a Body Mass Index (BMI) less than 30 and a spontaneous onset of labour occurring between gestational weeks 37 + 0 and 41 + 6. Women diagnosed with gestational diabetes not requiring medical treatment were included. Also included were women with a history of caesarean section who now planned a vaginal birth (VBAC) and women induced because of spontaneous rupture of membranes without spontaneous contractions for longer than twenty-four hours.Midwives working in antenatal clinics invited women to join the study and provided oral and written information. Eligible women who accepted participation gave written consent and this was documented in the women’s case notes. The women were at liberty to withdraw their consent throughout the whole trial. The included women gave birth at two hospitals in Sweden, which were chosen for convenience. The assisting midwife, who checked that the inclusion criteria were met, confirmed eligibility for participation in the trial on admission to the delivery ward.Data collection sheets contained the woman’s date of birth, personal identification number and randomization number. In case of non-compliance to randomization, the midwives were asked to record any reason for this on the data collection sheet. All other outcome measurements were available from the electronic case notes.The principal outcome measurements were post-partum blood loss and perineal outcome (episiotomies/lacerations/oedema).Secondary outcomes were epidural analgesia, synthetic oxytocin for augmentation of first and second stage of labour and overall duration of labour. Infant outcomes are not reported in this paper since results of the previous analyses showed that very few infants (3.0 %) were transferred to the NICU.The data were analyzed using PASW  version 20.0. Due to diversion from the original randomisation, a statistical comparison between the groups for demographic variables was carried out. We calculated odds ratios (OR) with a 95% confidence interval, for epidural analgesia, augmentation of labour, duration of labour, blood loss and perineal outcome between women who gave birth on the birth seat versus those who did not. Step-wise logistic regression analysis was used to examine the net effects of birth position and synthetic oxytocin for augmentation on blood loss greater than 500 ml. In the analysis the odds ratios were adjusted for maternal age, BMI, smoking, cervix status at admission, for epidural analgesia, fetal head circumference, fetal weight, gestational age, oxytocin augmentation and duration of first and second stage of labour.All participants included in the analysis were given standard midwifery care during birth. There is no evidence suggesting that giving birth on a birth seat should involve increased pain or medical risks for the birthing mother or her infant. There is an increased risk for blood loss between 500–999 ml, however, this has been shown to be without clinical relevance for participants. The stuThe group of 253 women in this analysis who gave birth on the birth seat comprises 246 (49.2%) of the 500 who were originally allocated to the experimental group and 7 (0.1%) from the control group who gave birth on the birth seat. All women who did not give birth on the birth seat, irrespective of allocation, are included in the control group. None in the birth seat group had an instrumental vaginal birth.Table p = <0.01) and second (p = <0.01) stages of labour than the control group. These findings remain significant after adjustments. There was no difference between the groups for duration of the third stage of labour.Table p = <0.01) and the second stage (p = 0.05) of labour. However after adjustment only augmentation in the second stage of labour remained statistically significant.A comparison between the groups for labour augmentation initiated during the first and second stages of labour showed that less women in the birth seat group were given synthetic oxytocin for labour augmentation during both the first stage .Among the total number of participating women, 14.7 % had a documented blood loss more than 1000 ml. In order to more fully understand the relationship between blood loss and augmentation, a stratified analysis was performed between the birth seat group and the control group and results are shown in Table p = 0.04) and significantly more who had a blood loss over 1000 ml (p = 0.003) when they had received synthetic oxytocin during first stage of labour.In the control group there were significantly more women who had a blood loss between 500 – 999 ml (p = <0.01). There were no statistically significant differences for any degree of perineal lacerations. Oedema was measured on a visual analogue scale (VAS) between 24–36 hours after birth and no difference was demonstrated between the groups.Perineal outcomes are also shown in Table The major findings in this paper were that women giving birth on the birth seat had shorter duration of labour and were significantly less likely to receive synthetic oxytocin for augmentation in the second stage of labour. There were no differences in perineal outcomes between the groups. Significantly more women had an increased blood loss when giving birth on the birth seat. Blood loss was increased regardless of birth position if women had been exposed to synthetic oxytocin augmentation during the first stage of labour.These findings altogether reveal the complexity of interventions used in contemporary obstetric practice; one might ask: what came first, the chicken or the egg? It may be speculated that women who gave birth on the birth seat had a more straightforward labour, were less tired and experienced less pain, making them less exposed to interventions. It is known that upright birth positions improve contractions, make pain easier to handle and enhance shorter duration of labour, and should therefore be used as an intervention to facilitate a straightforward birth-23. ExpeAccording to the ITT analysis the second stage of labour was significantly shorter for women who gave birth on the birth seat and when the OT analysis was applied, it was disclosed that the overall duration of labour for those women was shorter and duration of the second stage of labour was even shorter (ITT = 6 min vs. OT = 12 min).Analysis by ITT found no statistically significant difference between the groups for blood loss above 1000 ml but according to the OT analysis, significantly more women who gave birth on the birth seat had a blood loss of ≥1000 ml. In accordance with earlier research, the present analysis suggests that upright position facilitated by the birth seat may cause a greater blood loss, however the increased blood loss was of little clinical relevance for the women, as reported earlier-10. The Regarding perineal lacerations and perineal oedema this analysis is consistent with the ITT analysis. There were no increased incidences in first, second or third degree perineal lacerations for women giving birth on a birth seat, which is in contrast to earlier findings from a systematic Cochrane-review,22. MoreIn hospitals, trust in medical guidelines rather than the physiological process of birth is common. Some reIt is a great challenge to conduct and achieve high compliance in RCTs carried out in an intrapartum care setting. The priIt is important to bear in mind that the women who participated in the trial probably had a positive attitude towards the birth seat when they initially agreed to join the study. The results from the OT analysis might also have pin-pointed those women who were motivated to give birth without interventions and who wanted to and actually gave birth on the birth seat. Further research to understand the negotiation process between the midwife and the birthing woman will be of great interest.Our results indicate that it may be relevant to combine the two methods of analysis when compliance is reduced. In a letter to the editor of the journal “Infection Control and Hospital Epidemiology”, Herigon & Newland suggesteWe have illustrated that non-compliance in intra-partum studies remains a problem and that choice of method of analysis has a considerable impact on results obtained. This fact leads us to reflect on cause and effect: the chicken or the egg? Results of this analysis imply that women with a straightforward birth process may well benefit from giving birth on a birth seat without risk for any adverse obstetrical outcomes. However it is important to bear in mind that women who receive synthetic oxytocin during the first stage of labour, may have an increased risk for blood loss ≥ 1000 ml, regardless of birth position. Finally it is of vital importance to scrutinize the influence of synthetic oxytocin administered during the first stage of labour on blood loss postpartum, since excessive blood loss is a well-documented cause of maternal mortality worldwide and may cause maternal morbidity even in high-income countries.The authors declare that they have no competing interests.LTL conducted the trial and drafted the manuscript. LJK made substantial contribution in planning the trial, drafting the manuscript and analysing data. KC revised the manuscript critically and gave final approval for the version to be published. IH made substantial contribution in analysis and interpretation of data. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2393/12/135/prepub


Severe perineal trauma occurs in 0.5-10% of vaginal births and can result in significant morbidity including pain, dyspareunia and faecal incontinence. The aim of this study is to determine the risk of recurrence, subsequent mode of birth and morbidity for women who experienced severe perineal trauma during their first birth in New South Wales (NSW) between 2000 – 2008.All singleton births recorded in the NSW Midwives Data Collection between 2000–2008  linked to Admitted Patient Data were analysed. Determination of morbidity was based upon readmission to hospital within a 12 month time period following birth for a surgical procedure falling within four categories: 1. Vaginal repair, 2. Fistula repair, 3. Faecal and urinary incontinence repair, and 4. Rectal/anal repair. Women who experienced severe perineal trauma during their first birth were compared to women who did not.2,784 (1.6%) primiparous women experienced severe perineal trauma during this period. Primiparous women experiencing severe perineal trauma were less likely to have a subsequent birth (56% vs 53%) compared to those not who did not , however there was no difference in the subsequent rate of elective caesarean section , vaginal birth   or normal vaginal birth  . Women were no more likely to have a severe perineal tear in the second birth if they experienced this in the first . Women who had a severe perineal tear in their first birth were significantly more likely to have an ‘associated surgical procedure’ within the ≤12 months following birth  . Women who gave birth in a private hospital compared to a public hospital were more likely to have an ‘associated surgical procedure’ in the 12 months following the birth , regardless of parity, birth type and perineal status.Primiparous women who experience severe perineal trauma are less likely to have a subsequent baby, more likely to have a related surgical procedure in the 12 months following the birth and no more likely to have an operative birth or another severe perineal tear in a subsequent birth. Women giving birth in a private hospital are more likely to have an associated surgical procedure in the 12 months following birth. Severe trauma to the perineum during vaginal birth can occur spontaneously or as a result of obstetric intervention ,2. SeverWhile approximately two thirds of Australian women will experience some trauma to the perineum during a vaginal birth , around Risk factors associated with an increased incidence of severe perineal trauma include parity (primiparous), maternal age (very young and old), nutritional status, previous experience of perineal trauma, fetal weight, abnormal collagen synthesis and gender of the fetus ,8,9. WhiIt has been suggested that women who have experienced severe perineal trauma may be fearful of experiencing a subsequent pregnancy and birth; this fear is reported to be based upon the risk of sustaining subsequent perineal trauma, and that these women may require an episiotomy or a caesarean section ,17. SomeThe aim of this study was to determine the risk of recurrence, subsequent mode of birth and morbidity for women who experienced severe perineal trauma in a first birth in NSW between 2000–2008.Birth data for the time period July 1st 2000 until June 30th 2008 of all singleton births was provided by NSW Department of Health as recorded in the NSW Midwives Data Collection (MDC). This legislated, population based surveillance system contains maternal and infant data on all births of ≥400 grams birth weight or ≥20 weeks gestation.The recording of perineal status was altered on the MDC in 2006. Prior to 2006, perineal status was recorded as intact/graze, 1st degree tear, 2nd degree tear, 3rd degree, 4th degree tear, episiotomy and combined episiotomy and tear. Post 2006 combined episiotomy and tear was removed. The two versions of the data were merged for the purpose herein. The data item ‘Episiotomy Yes/No’ was also utilised. The accuracy of the recording of perineal status has previously been shown to have a kappa of 0.84 and 0.82 in two separate and individual studies ,23. The Data on all hospital admissions was provided by the census data collection, the Admitted Patient Data Collection (APDC). The clinical data component of the APDC utilises the International Classification of Diseases – Australian modification (ICD-10-AM). Probabilistic linkage of the two datasets was undertaken by the Centre for Health Record Linkage. The validity and accuracy of this process has been examined and these datasets have low rates of missing data when compared to medical records and high levels of agreement ,23.Seven thousand APDC codes related to all patient admissions over the period from 2000–2008 in NSW were sorted individually by the first author, and coded under sixteen sub headings. The purpose of sorting these codes was to determine the reason for, and frequency of, admission for women within a 12 month time period following birth for procedures related to perineal/pelvic floor trauma. The identified subheadings were: Nervous System; Skin; Skeleton; Renal/Ureter/Bladder; Fertility/Pregnancy; Miscellaneous (this included such codes as oncology related therapies); Eyes; Ears; Respiratory; Cardiac; Gastrointestinal; Pelvic/Sphincter/Urethral; Lymphatics; Breast; Psychiatric and Male Specific Codes. Any procedural codes relating to diagnosis and repair of the initial trauma were not included in the final coding categories. A list of potential Medicare Benefit Schedule (MBS) procedural codes was identified by the first author. This initial sorting of codes was completed and independently reviewed by two of the co-authors for accuracy. This list was then reviewed independently by three specialists in fields related to perineal trauma and outcomes including: 1. A midwife running a postnatal specialist perineal trauma clinic, 2. An obstetrician, and 3. A colorectal surgeon. Through this consensus process a refined list of codes that were specifically associated with therapies and treatment for morbidities potentially occurring as a result of severe perineal trauma from subheadings Renal/Ureter/Bladder, Fertility/Pregnancy, and Pelvic/Sphincter/Urethral was agreed upon. These codes were then grouped into the following four categories related by procedure and physiology: 1. Vaginal repair, 2. Fistula repair, 3. Faecal and urinary incontinence repair, and 4. Rectal/anal repair. There were 34 subgroups/diagnostic codes for vaginal repair, eight for fistula, eight for faecal and urinary incontinence and 11 for rectal/anal repair.The first pregnancy recorded in the MDC with vaginal birth documented as the mode of birth was considered the index pregnancy for this dataset regardless of parity. For this reason, sub-analyses were undertaken according to parity.Ethical approval was obtained from the NSW Population and Health Services Research Ethics Committee, Protocol No.2010/12/291.Descriptive analyses of short and long term morbidity associated with all types of perineal trauma was produced utilising SPSS v.19 (IBM). Frequency distributions were used to classify the population and descriptive statistics the morbidity outcomes. Relative risk was calculated between factors and events, Odds Ratios (OR) are reported for rare outcomes. Due to the number of associations examined, the level of statistical significance was set at <0.001.Between July 1st 2000 and June 30th 2008 there were 510,006 vaginal births. Nearly all of these births occurred in hospital (95%) and 71% of the women were born in Australia. Of the women giving birth vaginally 14.2% had an instrumental birth and 0.6% had a vaginal breech birth  for primiparous women  compared to women who did not have a severe perineal tear (4.1% vs 0.6%). In the second pregnancy following the index birth where the primary severe perineal trauma occurred, 12 women following a vaginal birth (1.1%) and one woman following a caesarean section (0.85%) had an admission ≤12 months following the second birth for an ‘associated surgical procedure’.Overall, both primiparous and multiparous women admitted for an ‘associated surgical procedure’ ≤12 months post birth were more likely to be older 29.7 vs 30.8), primiparous (49.5% vs 40.6%), not to smoke (11.9% vs 15.8%) and have a private hospital admission for the procedure (34.5% vs 20.7%) . Similar findings have been reported by Baghestan et al. (2011) and Elfaghi et al. (2004). Elfaghi et al. (2004) reported this finding as concerning, and therefore suggested that providing women with the option of elective caesarean sections may result in increased subsequent pregnancies for women who had experienced previous birth trauma . Whilst A prospective cohort study conducted by Gottvall and Waldenstrom (2002) investigated whether the experience of the first birth impacted upon women choosing to experience subsequent pregnancies and births . The autThe findings of this study report that for women who experience third and/or fourth degree perineal trauma there is no difference between elective caesarean section and normal vaginal birth rate for subsequent deliveries. For women who are symptomatic for urinary, flatus or faecal incontinence, or have findings that deviate from normal via manometric or endoanal ultrasonography associated with severe perineal trauma, it is suggested that an elective caesarean section should be recommended by the health care professional . HoweverConcerns exist as to the ongoing integrity of the pelvic floor and anal sphincter function if a woman is to experience a subsequent vaginal birth . In a stThere is also some evidence to suggest that following traumatic birth experiences, women may choose a vaginal birth over a caesarean section for subsequent births, and it is suggested that these choices may occur as a result of an understanding of the physiological and psychological benefits for both themselves and their newborns ,29,30. WIn this study, in comparison to women who had not sustained severe perineal trauma during birth, women who experienced a third of fourth degree perineal tear were no more likely to experience severe perineal trauma in a subsequent pregnancy. Studies investigating the risk of recurrence of in subsequent births for women who have experienced severe perineal trauma vary widely in findings -20. StudIn a previous study we found that women who gave birth in a private hospital compared to a public hospital were at greater risk of SPT compared to women who had no perineal trauma or minor perineal trauma ; however they were at no increased risk when compared to all women who did not experience SPT (9). Other studies have shown a protective effect of private hospital care on SPT rates  but haveIt has been suggested that best practice models of care for women who sustain severe perineal trauma include a referral for an endoanal ultrasound and consultation with a colorectal surgeon in locations where specialist perineal care clinics are operational, and women can access supportive, collaborative care within the one facility .There are significant advantages of using population based datasets such as the MDC, including the size of the dataset, a well validated dataset and the anonymous nature of the results therein. The limitations are the limited number of variables that are included and the scarcity of specific information on potential confounders, specifically information regarding maternal weight and pregnancy weight gain and pre-existing medical conditions. This paper has reported that older age is associated with admission for an associated surgical procedure (30 years versus 31 years); whilst these findings are statistically significant the clinical significance is questionable. We are reassured by previous validation studies that perineal status is very accurately recorded ,39,40. TIn this study we found primiparous women experiencing severe perineal trauma compared to those who did not were less likely to have a subsequent birth, no less likely to have a normal vaginal birth in a subsequent pregnancy and no more likely to have a repeat SPT. Women who had a severe perineal tear in their first birth were however significantly more likely to have an ‘associated surgical procedure’ in the ≤12 months following birth and women who gave birth in a private hospital are also more likely to have an ‘associated surgical procedure’ in the 12 months following the birth. More research is needed to explore with women and health providers their decision making following a SPT to determine whether women are making the choice of a vaginal birth following a SPT or if health practitioners are influencing this choice. There is also an urgent need to explore the experiences of women who experience a SPT and the impact of the morbidity observed in this study on their wellbeing. There is also limited information available about the ideal construction of health services for women experiencing SPT from the perspective of women and health providers.The authors declare that they have no competing interests.HP participated in data review, design and drafting of manuscript as a component of a doctoral study. HD conceived of the study design, participated in design and drafting of manuscript. VS assisted with review of data. CT conducted statistical analysis and helped review the manuscript draft. CB advised and assisted with statistical analysis. AS, CK and MG provided expert review of coded data and assisted with writing the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2393/13/89/prepub


To study the incidence of congenital anomalies and the associated risk factors in Department of Pediatrics at Mahatma Gandhi Institute of Medical Sciences, Sevagram, Wardha, a rural medical college hospital in central Maharashtra.All the intramural deliveries between 1 January 2005 and 31 July 2007 comprised 9386 births and their 9324 mothers (62 mothers gave birth to twin babies). The newborns were examined and assessed systematically for the presence of congenital anomalies, system wise distribution of anomalies and risk factors attributable.Out of the total 9386 deliveries, 9194 were live births and 192 were stillbirths. The total number of babies with congenital malformations was 179 (1.91%). Out of the 9262 singleton births, 177 (1.05%) were malformed, whereas 2 of the 62 pairs of twins had birth defects. Nine of the 179 malformed babies (5.02%) were still born. Prematurity, increased maternal age, increasing birth order and low birth weight were found to have a higher risk of congenital anomalies. Cardiovascular malformations were most common in live births, followed by musculoskeletal and genitourinary anomalies.Congenital anomalies are a major cause of stillbirths and infant mortality. Evaluation of cardiovascular system to rule out congenital heart disease in high-risk mothers’ babies is the important factor to be considered. Congenital malformation represents defects in morphogenesis during early fetal life. According to the World Health Organization (WHO) document of 1972, the term congenital malformations should be confined to structural defects at birth.2 PatientsThis study was conducted in Department of Pediatrics at Mahatma Gandhi Institute of Medical Sciences, Sevagram, Wardha, a rural medical college hospital in central Maharashtra. All the intramural deliveries between 1 January 2005 and 31 July 2007 comprised the study material. There were a total of 9194 live births and 192 stillbirths during this period. The study material comprised 9386 births (live and still) and their 9324 mothers (62 mothers gave birth to twin babies). All the newborns were looked for congenital malformations soon after birth and everyday during routine ward rounds. Relevant information regarding maternal age, gestational age, sex, community, birth weight, birth order and consanguinity was documented. Significant antenatal history like maternal illness, ingestion of drugs, exposure to radiation and complications of labor was recorded. Antenatal ultrasonography (USG) findings were noted. Relevant radiological, histo-hematological and genetic tests were carried out. Autopsy was done on stillbirth and neonatal death, whenever parents consent could be obtained. Karyotyping was done. A meticulous general and systemic examination was carried out by a consultant at the time of birth to detect any malformations. Ultrasound was employed routinely to detect multiple congenital anomalies and to rule out majority of the internal congenital anomalies. 2D echocardiography was also used for all congenital heart diseases, along with the routine X-ray chest and electrocardiogram. Other investigations were intravenous pyelonephrography and retrograde cystourography. Computed tomography (CT) scan and magnetic resonance imaging (MRI) were advised only for certain special cases and these cases were followed up for a period of 1 year. During the follow-up, the babies were re-examined to detect any other malformations. Malformations were divided into major and minor; major malformation interferes considerably with the function of all or part of the infant, minor malformation gives no serious medical or cosmetic consequences to the patients. The major malformations were divided into central nervous system (CNS), musculoskeletal, gastrointestinal, genitourinary, cardiovascular system (CVS), syndromes and miscellaneous disorders. Statistical analysis was done using Z test and Chi-square test.P < 0.01) as compared to live births, the frequency being 4.68% and 1.84%, respectively. Nine of the 179 malformed babies (5.02%) were still born. Out of the total 9386 deliveries, 9194 were live births and 192 were stillbirths. The number of babies with congenital malformations diagnosed at birth or within the first week of life was 164, while the total number of malformations was 179 (1.91%).History of parental consanguinity was present in 14 cases of congenital malformations in our study. Babies with congenital anomalies were of the first order (34.63%), and second order to third order (51.95%). More than four or fourth birth order was associated with 13.40% of the anomalies. There was a history of oligohydramnios in 13/179 (7.26%) cases and polyhydramnios in 7/179 (3.91%) cases. Also, 19/179 mothers (10.61%) had a history of previous abortions, 6/179 (3.35%) were diabetic mothers and 5/179 (2.79) had a history of congenital heart disease in previous child or malformed babies. et al.[et al.,[Congenital anomalies are important causes of still births and infant mortality, and are contributors to childhood morbidity. The number of birth defects in infants is increasing antenatally and during the neonatal period due to advanced diagnostic technology, especially USG. The incidence of congenital malformation in the present study was 1.90%, which is comparable with the earlier studies from the same hospital, which reported an incidence of 2.72 and 1.24% subsequently.4 When aut54et al. reportedet al.[et al.[et al.[The annual report of Indian Council of Medical Research says thaet al. reportedl.[et al. reportedl.[et al. reportedl.[et al.–16 The il.[et al. conducteCongenital anomalies are a major cause of stillbirths and infant mortality. By thorough clinical examination, the life-threatening congenital malformation must be identified, as early diagnosis and surgical correction of the malformed babies offer the best chance for survival. The incidence of congenital heart disease is much higher than that previously reported from the other parts of the country and from the same area also. Evaluation of cardiovascular system to rule out congenital heart disease in a high-risk mother’s baby is the important factor to be considered.


Pregnant women exposed to traffic pollution have an increased risk of negative birth outcomes. We aimed to investigate the size of this risk using a prospective cohort of 970 mothers and newborns in Logan, Queensland.We examined two measures of traffic: distance to nearest road and number of roads around the home. To examine the effect of distance we used the number of roads around the home in radii from 50 to 500 metres. We examined three road types: freeways, highways and main roads.There were no associations with distance to road. A greater number of freeways and main roads around the home were associated with a shorter gestation time. There were no negative impacts on birth weight, birth length or head circumference after adjusting for gestation. The negative effects on gestation were largely due to main roads within 400 metres of the home. For every 10 extra main roads within 400 metres of the home, gestation time was reduced by 1.1% .Our results add weight to the association between exposure to traffic and reduced gestation time. This effect may be due to the chemical toxins in traffic pollutants, or because of disturbed sleep due to traffic noise. Exposure to air pollution during pregnancy has been shown to increase the risk of negative birth outcomes such as pre-term birth and low birth weight -4. AlthoMany of the estimated associations between air pollution and birth outcomes have relied on the temporal variation in pollution, but pollution also varies spatially . PollutiAnother reason for taking a spatial approach in this study was the public interest created by our previous study showing restricted fetal development due to increased air pollution exposure in Brisbane, Australia . A commoAlthough levels of air pollution in South East Queensland are low compared with industrial cities, the population's exposure is relatively high due to an outdoor lifestyle and buildings that are highly permeable . Many hoWe used data from a prospectively recruited cohort of mothers in Logan, Queensland . The cohMothers were invited to participate in the study if they: i) attended an antenatal class at the Logan Hospital Maternity Unit, ii) registered to give birth in the maternity ward at Logan Hospital, or iii) attended early parenting classes in the Logan-Beaudesert Health Service District. Mothers were recruited between January 2007 and July 2008. The percentage of mothers approached who agreed to participate was 84%.The birth outcomes of gestation length , birth weight, head circumference and birth length were collected directly from mothers soon after the birth. At a follow-up visit the mothers provided information on their smoking during pregnancy, age, education and parity. We excluded twin births from this analysis as it complicates the assessment of the anthropometric measures. A total of 1,008 women were recruited, however there were four neonatal deaths and six women miscarried.All women gave informed consent and the study was approved by the Princess Alexandria Human Research Ethics Committee.We used two measures of traffic: the distance to the nearest road and the number of road segments around the home. A road segment is a section of road occurring between two reference points . We used three road types, which in order of size are: freeways, highways and main roads. A freeway is divided highway without traffic lights or stop signs. A highway is a major road connecting two or more destinations. A main road is smaller than a highway but bigger than a residential street, and may have traffic lights, roundabouts and other junctions. The road data was for 2007, which is within the time period that the mothers were recruited.The participants' addresses were geocoded using MapInfo 9.5 and the Euclidean distance was calculated between participant's residence and the nearest road. Concentric circles with radii 50 to 500 metres in steps of 50 metres were created around each address. The number of road segments in each circle were counted. Figure The addresses for 28 mothers  could not be geocoded because the address information was inadequate . These mothers were excluded from the analyses, leaving 970 mothers in total.Thirty-one women (3.2% of included mothers) moved house at some time during their pregnancy. For these women the traffic measures were averaged for their two addresses.We used multiple regression models with four dependent variables: gestation (weeks), birth weight (grams), head circumference (centimetres) and birth length (centimetres). We adjusted for gestation when examining birth weight, head circumference and birth length. We analysed all variables on a continuous scale, rather than using categories such as low birth weight  or pre-term birth (before 37 weeks), because of the loss of power caused by categorisation .The independent variables were mother's age, mother's smoking during pregnancy (yes/no), household smoking during pregnancy (yes/no), mother's parity (nulliparous/multiparous), mother's education (primary/high school/TAFE/Tertiary), newborn gender, season of birth and the traffic measures (described below). We controlled for season of birth using a cosinor . As a seFor all models we assumed that the residuals followed a Normal distribution. We log-transformed gestation to improve the validity of the Normal assumption, and so present the results for gestation on the scale of percent change. We visually checked the residuals for any patterns or large outliers using scatter plots. We also looked for influential observations using the dfbeta statistic .All analyses were made using the freely available R statistical software package version 2.11.1 .We examined the effect of the distance from the mothers' homes to the nearest road on the four birth outcomes, assuming that distance to road is a proxy for traffic pollution. The concentration of traffic pollutants are spatially non-linear, with the highest levels adjacent to roads and a non-linear decay with increasing distance ,22. To mWe examined the effect of the number of road segments around the mothers' homes as a proxy of traffic pollution that incorporates traffic volume. We counted the number of roads around the mothers' homes in concentric circles of radii 50 to 500 metres. To find the radius which had the strongest association with birth outcomes we fitted separate models for each radii (10 models per road type). As a comparison we fitted a model without any roads. We then selected the best radius using the Akaike information criterion (AIC) . A diffeFor descriptive purposes we calculated the Spearman's rank correlation between the number of roads segments at all radii and for all three road types.Around 10% of mothers had no information on parity, smoking status or education. So as not to lose these women, we randomly imputed any missing responses using the marginal probabilities from the complete sample. For example, 24% of mothers smoked during the pregnancy, so we imputed a positive response to smoking status using a Bernoulli distribution with a "success" probability of 0.24. We repeated the imputation process 10 times (multiple imputation) and combined the results using the R package "mitools" .People who live near a major road or in areas with many roads may have a lower socio-economic status than those who live further away in cleaner and more desirable locations. If this is true then our traffic exposure proxies are likely to be confounded by socio-economic status when estimating their effects on birth outcomes. To investigate this we fitted logistic regression models to examine if there was an association between the dependent variables of smoking (of the mother and the household) and tertiary education, and the independent variables of distance to road and the number of road segments. The best radius for the number of road segments was selected using the AIC as described above.The basic characteristics of the mothers and newborns are in Table Figure Figure Figure Figure Using the dfbeta statistic there was a large influential observation for the analyses of birth length and birth weight analyses dependent on highways. This was the mother with the largest birth weight 6,000 g) and longest birth length (63 cm), and the equal largest number of highways within 50 metres (1 highway). After removing this one mother the changes in the AIC looked quite different as there was no longer a big improvement in model fit at the shortest radii  and decreased B cells and natural killer cells in placental blood [Our results add weight to the association between exposure to traffic pollution and reduced gestation time ,4. A recal blood . Exposural blood  which haal blood .As well as the increased exposure to chemical pollutants caused by traffic, traffic also creates noise which may increase stress and disturb sleep. Disturbed sleep during pregnancy may be a risk factor for adverse birth outcomes . Traffic10 concentrations were higher for homes near busy roads (within 150 metres) compared with roads that were more than 300 metres away [The plot of the AIC indicated that the negative effects of traffic on gestation were largely associated with main roads within 400 metres of the home Figure , with mures away . Our resThe distance that traffic noise can travel is dependent on the frequency of the noise, for example, the low frequency rumbling of heavy goods vehicles compared with the high frequency squeaking of brakes. Noise pollution can be blocked by sound barriers. We were unable to find any studies that gave the maximum distance for the effects of traffic noise. Interestingly the Queensland department of Main Roads is currently installing free air conditioning or mechanical ventilation to homes with 300 metres of the Pacific motorway just to the south of the study area .We failed to find any association with negative birth outcomes and distance to road Figure , but didWe failed to find any association between traffic and the three anthropometric birth outcomes , but these associations were adjusted for gestation. So pollution is still likely to negatively influence birth size, but via the indirect route of a shortened gestation.The effects of the number of roads on gestation were small, with a mean 4.4% decrease in gestation due to 10 more freeways around the home, and a mean 1.1% decrease for ten more main roads. For a gestation of 40 weeks this would be a reduction to 38.2 weeks for freeways and 39.6 weeks for main roads. However, these small reductions in gestation may have big implications for later life, as healthier babies have healthier childhoods and adulthoods [This study was relatively small compared with others in the field, but unlike some of the large retrospective cohort studies we had detailed information on potential confounders such as smoking. Because of the small sample size we did not examine the effects of pollution on spontaneous abortion or stillbirth, but feel that this is an important area for future research.Our measures of traffic exposure were relatively crude, and did not include a measure of the number of vehicles or the types of vehicles. Our method assumes that the effect of each road type is constant across the study area. Other more sophisticated estimates of traffic, that would reduce exposure misclassification, are a weighted road density  or land We found some evidence of confounding by socio-economic status Table , with moWe found one very influential mother who we removed according to the large dfbeta value and noticeable effect on the results (compare Figures Pregnant women should reduce their exposure to traffic. A reduction in traffic emissions, whether through improved vehicle technology or increased public transport use, would have immediate health benefits by giving children a better start to life.AIC: Akaike information criterion; CI: confidence interval; OR: odds ratio; PM: particulate matter.The authors declare that they have no competing interests.AB led the study, ran the statistical analyses and wrote the first draft. KP and WKS designed and oversaw the data collection. LAW created the GIS data. CH provided expertise on the health effects of pollution. All authors contributed to drafts of the paper and approved the final manuscript.


Whether parenteral nutrition benefits growth of very low birth weight (VLBW) preterm infants in the setting of rapid enteral feeding advancement is unclear. Our aim was to examine this issue using data from Japan, where enteral feeding typically advances at a rapid rate.th percentile for postmenstrual age) at discharge.We studied 4005 hospitalized VLBW, very preterm (23–32 weeks' gestation) infants who reached full enteral feeding (100 ml/kg/day) by day 14, from 75 institutions in the Neonatal Research Network Japan (2003–2007). Main outcomes were weight gain, head growth, and extra-uterine growth restriction , 95% CI: 0.02, 0.16] and head growth ; lower odds of EUGR by head circumference . No statistically significant difference was seen in the proportion of infants with EUGR at discharge. SGA infants and infants who took more than a week until full feeding had larger estimates.Even in infants who are able to establish enteral nutrition within 2 weeks, deprivation of parenteral nutrition in the first weeks of life could lead to under nutrition, but infants who reached full feeding within one week benefit least. It is important to predict which infants are likely or not likely to advance on enteral feedings within a week and balance enteral and parenteral nutrition for these infants. Guidelines for nutritional support of very low birth weight  and very preterm (<32 completed weeks' gestation) infants often emphasize parenteral nutrition as the main source of nutrition for the first weeks of life The aim of this study was to quantify the growth benefit of parenteral nutrition in VLBW preterm infants who are able to advance enteral feedings rapidly. Our analysis capitalizes on the Japanese experience in which advancement of enteral feeding in the neonatal intensive care unit (NICU) is typically more rapid than in other countries, possibly due to the high rate of breast milk feeding for preterm infants and the low background necrotizing enterocolitis (NEC) rate We used data from the Neonatal Research Network of Japan (NRN), a multi-center registry of VLBW infants cared for in 75 participating level III perinatal centers in Japan and funded by a grant from the Ministry of Health, Labor and Welfare in 2004. All registered hospitals provided individual patient data including obstetric, delivery, in-hospital care, and follow-up data at age 1.5 and 3 years to the central committee. The central committee identified potential data errors and requested that individual institutions correct data by going back to medical charts when needed. A description of the NRN cohort including morbidities, mortalities, and outcomes at age 1.5 and 3 years, has been reported previously Our main exposure was any use of parenteral nutrition during the hospital stay, which the hospitals provided as yes, or no for each subject. No subject was missing this information.th percentile of the reference; EUGR was defined as weight and head circumference at less than the 10th percentile at a given postmenstrual age, as compared with infants born at the same gestational age in the reference.Our main outcome was extra-uterine weight gain and head growth, which we defined as the change in SD score of each measurement from birth to discharge. These SD scores were calculated using sex, parity, and gestational length (by day) specific growth references for birth weight As growth can be affected by different obstetric and pediatric characteristics as well as the wellbeing of the infant, we considered as covariates the following: maternal age, parity, gestational diabetes (GDM), pregnancy induced hypertension (PIH), use of antenatal steroid, multiplicity, route of delivery, gestational length, sex, SD scores of weight and head circumference at birth, Apgar score at 5 minutes, use of mechanical ventilation, diagnosis and stage of intra-ventricular hemorrhage (IVH), diagnosis of bronchopulmonary dysplasia (BPD), periventricular hemorrhage (PVL), and days taken to reach full enteral feeding.In all analyses we categorized these variables as follows: maternal age , parity  multiplicity , route of delivery , Apgar score at 5 minutes , use of ventilation , IVH , and each completed week of gestation at birth (24 to 32 weeks).First, we compared maternal and infant characteristics between infants who received parenteral nutrition (n = 1604) and those who did not (n = 2401). Next, as extra-uterine growth is affected by both gestational age and intrauterine growth, we stratified our sample by each week of gestation and intrauterine growth status (SGA or not) and examined each of the following across strata as well as by use of parenteral nutrition or not: change in SD scores of weight and head circumference at admission and discharge, and length of hospitalization in days.To account for potential confounding by maternal and infant characteristics, and to account for clustering within institutions, we performed generalized linear mixed models (logistic regression with random intercepts) to estimate the effect of parenteral nutrition on our outcomes of interest . For selection of confounders we used parity, GDM, PIH, use of antenatal steroid, multiplicity, gestational length, sex, Apgar score at 5 minutes, IVH stage, use of mechanical ventilation, day of reaching full enteral feeding, as well as birth measurements, due to their clinical relevance and usage in previous papers We performed all analyses using SAS version 9.3 .All information about the infants was collected anonymously, and the stored data were unlinked from individual data. Written informed consent was obtained from the parents or guardians on behalf of each child enrolled in this study before receiving any data. The protocol of this study was approved by the Central Internal Review Board at Tokyo Women's Medical University, where all data were collected and stored. The database was registered as UMIN000006961.In In In Infants who received parenteral nutrition were born earlier and were generally sicker, for example they were more likely to have needed mechanical ventilation, were more likely to have BPD, and took longer to reach full enteral feeding. Those receiving parenteral nutrition also had lower weight and smaller head circumference at birth, but showed higher weight and larger head circumference at discharge.In Effect modification by weeks of gestation (24–27 weeks or 28–32 weeks), intrauterine growth (SGA or non-SGA), and day to reach full feeding (0–7 days or 8–14 days) were not statistically significant, and though estimates differed slightly for each subgroup, as shown in However, point estimates of the effect of parenteral nutrition was largest in SGA infants and infants who took more than one week until full feeding, and smallest in infants who reached full feeding within a week. Point estimates of increase in weight was largest in SGA infants  and infants reaching full feeding after one week , and smallest in infants who reached full feeding within one week . Similarly, point estimates of increase in head circumference was largest in SGA infants  and smallest in non-SGA infants  and infants reaching full feeding within one week . Point estimates for effect on length of stay was also largest in SGA infants and infants born at 28 to 32 weeks of gestation, and nearly null in infants who reached full feeding within a week, were born under 1000 g, or were born at 24–27 weeks of gestation.We observed that among VLBW preterm (24–32 weeks' gestation) infants who reached full enteral feedings within 2 week of birth, those infants provided with parenteral nutrition demonstrated greater weight gain and head growth, and a lower prevalence of EUGR by weight, as compared with those who did not receive parenteral nutrition. To the best of our knowledge, this study is the first to show that parenteral nutrition promotes weight gain even in preterm infants who are able to advance enteral nutrition at a fairly fast rate.Research to inform optimal nutritional care of the preterm infant is important because inadequate nutrition leads to poor growth extrauterine growth, which in turn has been linked with poor later neurocognitive outcomes Historically, clinicians have been hesitant to advance enteral feedings at a rapid rate due to concerns about intestinal immaturity and the associated risk of NEC, a serious and often life-threatening complication of preterm birth. However, in other studies of early parenteral nutrition and growth, enteral feedings were advanced slowly. In the Poindexter study, subjects took on average 32–34 days to reach 110 kcal/kg/day enteral feeding, and were administered parenteral nutrition for on average 32 days Additionally, through subgroup analysis we found that overall, SGA infants and infants reaching full feeding after one week seemed to benefit most from parenteral nutrition in means of growth and shorter stay. Infants who reached full feeding within one week seemed to benefit least. Our findings suggest that it is important to predict which infants are likely or not likely to advance on enteral feedings within a week.Our study has several limitations. First, we did not have data on the timing or duration of parenteral nutrition. Therefore we had to exclude infants who would be receiving parenteral nutrition due to their complications: infants that had NEC, surgery, or died during hospitalization, and thus we could not set these conditions as outcomes. However, we were most interested in the effects of parenteral nutrition in otherwise healthy preterm infants. Second, although a number of maternal and child characteristics were available, residual confounding may occur by characteristics of infants who received parenteral nutrition that could promote their growth, for instance other differences in nutritional practice. Finally, our study was conducted in Japan where neonatal intensive care practices differ from the U.S. and other countries. However, our setting provides a unique opportunity to examine the role of parenteral nutrition for infants who advance quickly on enteral nutrition, and we believe our findings will be relevant for non-Japanese populations of VLBW infants as well.In summary, our results support the use of parenteral nutrition to improve weight gain and head growth, even among relatively healthy VLBW infants who reach full enteral feeding within 2 weeks. For infants reaching full enteral feedings in 1 week or less, the benefit was smaller. These findings will be useful for clinicians weighing the risks and benefits of providing parenteral nutrition to very low birth weight infants, particularly those who are expected to advance enteral nutrition rapidly.