Adansonia digitata L.) is an integral component of many dryland farming systems in sub-Sahara Africa. Such traditional agroforestry systems can foster a variety of benefits; besides positive livelihood implications baobab can particularly address food security objectives due to its highly nutritious fruits. However, many bottlenecks persist inhibiting the broader potential of indigenous trees in farming systems and their increased utilisation and commercialisation. We suggest that traditional farming systems with baobab trees can be advanced by stimulating the emergence of local markets for baobab products while promoting businesses and innovations aimed at meeting the arising market demand. Increasing the perceived value of local agroforestry products in combination with facilitating additional commercialisation pathways will in turn lead to food security and livelihood benefits. Using a multi-stakeholder approach such considerations were put into practice in Kilifi, Kenya, by initiating a community-based enterprise development producing high-quality baobab powder and oil. Initial results demonstrate behavioural changes, an improved practical knowhow with regard to baobab management and utilisation, and an increased consumption of baobab, which may already contribute to food security objectives. Baobab is increasingly seen as a valuable resource as opposed to ‘food for the poor’ and a tree possessed by evil spirits. This may lay the groundwork for further value addition activities and enterprise development in the communities. With baobab being a common, yet so far underutilised feature of local farming systems in Kilifi, activities based on its increasing commercialisation can be complementary and easily integrable to prevailing livelihood strategies.The baobab tree ( Natural or traditional agroforestry systems created by purposeful retention of indigenous trees on farmers’ land can foster a variety of benefits, including the provision of ecosystem services or positive livelihood impacts  is an ideal candidate to study indigenous tree species in traditional farming systems. For such reasons it has also been identified as a priority species for domestication  and community-based enterprise (CBE) development to strengthen applicability for agroforestry products using indigenous tree species in rural areas. NPD covers processes necessary to bring a new product to the market, including developing a product strategy, developing the business case, designing the product and process, testing the product and ultimately production and market launch  ranges from 21 to 30 °C (900 mm to 1300 mm) at the coast and 30 °C and 34 °C (300 mm to 900 mm) in the hinterland  were selected and primary data collected using a semi-structured, previously tested questionnaire. In addition, key informant interviews were conducted targeting people already engaged with baobab processing as well as NGOs and county agencies active in natural resource utilisation, identified via snow-ball sampling. Descriptive statistics were applied to analyse quantitative data, whereas qualitative data was subjected to content analysis to reveal further information on perception and knowledge levels about baobab and current utilisation and management practices.The baseline assessment enabled identification of knowledge gaps concerning baobab and the development of a tailor-made capacity building strategy, including the establishment of customised training manuals for farmers and community extension agents. Involved scientific and private partners provided input to ensure information on nutrition, food technology, and marketing was not only scientifically sound but also reflecting practical realities. In total 60 community extension agents and 60 farmers were trained between December 2017 to September 2019. Participating farmers were purposefully selected through village leaders and networks of extension agents based on whether they possessed baobab trees and their willingness to become involved in baobab processing activities. Farmer trainings covered aspects such as baobab nutritional value, post-harvest management, product preparation and marketing. Four additional community members were also trained in operating the central processing facility. Trainings for community extension agents intended to not only strengthen their capacity, but also enable them to distribute knowledge further into the communities to ensure that, once demand of baobab increases, further farmers can be linked to the CBE operation. Alongside these activities novel baobab products, developed by food and process technologists, were showcased and sensory evaluations conducted. This intended to a) demonstrate the versatile use of baobab in both sweet and savoury food preparations to stimulate home consumption and subsequently demand and b) give ideas for future product diversification and small-scale business opportunities based on baobab.Simultaneously with the capacity building initiative the actual establishment of the CBE was initiated. Results from the baseline assessment coupled with the expertise of the different actors involved informed the overall strategic outline of the CBE, taking into account the local conditions. The BAOFOOD research project consortium formed the basic partner network, however, over time links to other initiatives working on high-quality baobab processing in neighbouring countries  were established for further advice. Private sector players were particularly important to establish a detailed business plan and standard operation procedures (SOPs), whereas research partners provided guidance on aspects such as baobab resource base, value chain setup or product development and nutritional implications. CBE development activities continuously informed and were closely linked to the capacity building activities, e.g. by focussing on product handling skills and food hygiene practices to be fulfilled during operation. All farmers having participated in the trainings were registered as contact farmers enabling them to supply pre-processed baobab to the central processing facility in Kilifi, where production of baobab powder and oil takes place. Pre-processing entails the selection and correct storage of high-quality fruit, as well as extracting the pulp-on-seed after a defined timeframe in the communities. Construction activities of the central processing facility, including both the actual premises as well as the commissioning of processing machinery such as oil mill and powder extractor were concluded in September 2019, enabling the CBE to be operational for the subsequent baobab harvesting season. However, additional activities are needed in future particularly regarding empowerment of community members and generation of a self-sufficient operation.To assess effects to date of the CBE development and the capacity building program, a further survey was conducted in April/May 2020. All community members who were involved in the intervention were interviewed, including both the 60 baobab suppliers as well as the 4 processors at the CBE. Furthermore, 59 farmers from the same region acted as a control group, identified via a simple random sampling approach. Semi-structured interviews were used to gain insights on changes in baobab utilisation and management as well as potential benefits community members may have already gained. Descriptive and comparative analyses were conducted using the Statistical Package for the Social Sciences program (SPSS) to gain a better understanding of changes which have occurred during the intervention. Data from the survey was complemented by expert interviews of key stakeholders involved in the CBE.mabuyu”) was identified, consisting of the dry baobab pulp and seed prepared in a mix of sugar and food colouring, targeting mainly children as consumers and sold in village kiosks or by the road side. Besides these and a use in juice or porridge, known to 93.3%, 40.0%, and 39.2% of respondents, respectively, awareness for other baobab products and their nutritional value was very low. In regional markets a few non-food baobab products were identified, including drums and lampshades made from shells, paper from bark, or soap from oil, targeting mainly tourists or middle to high income earners. No organised community group was found dealing with baobab either for value addition or selling raw material.The baseline assessment demonstrated low education levels , main livelihood activity was crop farming and temporary food shortages a regular problem (70% of respondents). The majority (69%) owned naturally occurring baobab trees on their land. Approx. 1/3 of respondents had been involved in making a baobab product, yet only a minority was engaged in any tree management activities other than harvesting. Farmers more likely to harvest baobab included ones with larger farms, of younger age, and with more knowledge concerning baobab products and management practices. Knowledge levels were generally low and closely correlated to prevailing practices. On a commercial level, one processed food product (“p < 0.05). Thus, sensitising farmers about the commercial potential of the tree, the variety of uses, and its nutritional benefits may promote its utilisation, change attitudes and beliefs about the tree, and increase household uptake of baobab products.Overall, the results pointed to a basic, yet expandable baobab utilisation. Reasons cited for a not more widespread use and management included negative perceptions associated with the baobab tree in coastal Kenya (hosting of evil spirits), or the lack of information concerning utilisation practises and benefits. Nevertheless, 68.8% of respondents expressed interest to engage in more intensive and/or improved management and utilisation of baobab in the future. Information needs identified were particularly high with regard to storage, processing both for sale and home consumption, marketing, as well as nutritional and health benefits. Temporary food shortage was significantly linked to higher information needs regarding processing for sale . To ensure hygienic conditions the central processing facility consists of several closed structures for storage, processing as well as changing rooms for staff. By partnering with existing regional microenterprises further local value addition should be generated and innovation and business development stimulated. This may be aided by the strategic location of the central facility in a tourist hot-spot and supporting activities by the involved NGO, in which hands the CBE currently lies. The target was set to initially focus on local and regional markets as well as gradual growth—allowing to perfect the production model, supply chain and quality assurance along the way and ensuring a stable base for production easily expandable with growing demand, including the integration of more farmers. Experience from other countries showed that early concentration on export had a high risk of creating a boom-bust situation and opportunities from local markets are—despite the opportunities arising from a growing middle class . As demand increases, the CBE will expand the radius of the targeted area or replicate baobab processing activities in other Kenyan regions.With regard to governance, a clear shareholding structure is envisaged, whereas community members will hold part of the shares and profits will be distributed in line with shareholdings. The board of directors, comprising partnering shareholders, will oversee the realisation of the business plan in a democratic fashion and maintain an active advisory oversight role to offer expertise in areas such as factory operations, marketing and supply chain development, commercial operations and certification. At present, however, the CBE can dominantly be regarded a research-private sector initiative. Community members have, nevertheless, expressed interest for further involvement and already committed land and materials for the construction of local storage shelters. Further participation was inhibited by lack of business experience as well as the financial risk this would entail. As of now, the CBE has survived from donor funding, in total approx. 100,000 USD, of which 28% were construction, 5% equipment, 44% training, and 23% consultancy costs. To date, the operation is not yet economically self-sustainable, although it is anticipated that after the first year of operation profits will be generated. Direct operating costs have been kept low by maintaining relatively short supply chain and logistics, whereas an emphasis has been put on marketing costs as this has been considered particularly important since dealing with novel products.p < 0.05) were observed in terms of baobab tree number on farms, age and education. This may be explained by the purposive selection of farmers.Table Differences with regard to baobab between the two groups are illustrated in Table Although the long-term effectiveness of the undertaking remains to be seen and the CBE is still a work in progress, the initial results are encouraging. Baobab subsistence use has increased locally, which due to its nutritional profile can directly contribute to food security objectives. Behavioural changes and an improved practical knowhow indicate that the overall perception is changing towards baobab being a valuable resource as opposed to ‘food for the poor’ and a tree possessed by evil spirits. Thus, the first step of the conceptual framework developed has been reached, laying the groundwork for an increased future demand for baobab products, and, ultimately, for the success of the CBE. Detailed effects on income, employment and market creation are, however, yet uncertain with the CBE not fully having started operation. Experiences from other countries with an already higher degree of baobab commercialisation show that annual mean income from baobab pulp and seed sales was in the realm of USD136 ± 14 (Venter and Witkowski An increasing baobab commercialisation, however, may also lead to overharvesting of the resource or threaten subsistence use and livelihoods (Buchmann et al. The comparison with other CBE initiatives in natural resource management, although complicated by the variety of business models, demonstrated that challenges are often similar. Issues such as financial challenges, including the dependence on external investments or lack of management or marketing skills on the ground are common problems (Ambrose-Oji et al. Illustrated approach also shares many similarities with innovation platforms, as these should provide opportunities for local innovations while nourishing introduced ones (Tenywa et al. Overall, the following lessons learnt can be derived from the case study and the underlying approach. It was possible to enhance appreciation of the local farming population with regard to baobab, inducing more intense consumption and change in management practices. The developed CBE strategy benefited strongly from experiences of baobab-processing initiatives from other countries as well as academic and non-academic collaborators engaged in the initiative, providing scientific, local, and business knowledge and experience. By careful management of expectations of farmers it was possible to sustain their engagement despite the long timeline, which was necessary to thoroughly develop underlying strategies and management principles. Although arising benefits will be supplemental, these nevertheless can be an important contribution as marginalised groups, women were targeted. Baobab is an ideal candidate for product development activities due to its versatile use as an ingredient for both sweet and savoury foods while holding a nutritional profile which can contribute to food security. The approach may be more cost-efficient and sustainable than other initiatives targeting innovation, although more research is required in this regard. However, it has to be acknowledged that without external funding the implementation would not have been feasible. Due to prevailing market failures such as environmental externalities or information asymmetries, particularly since the baobab sector in Kenya is still in early stages, further investments into its market and value chain development are necessary. The CBE alone is not in a position to take these investments and private-sector contributions may not be easy to find due to potential risks—however, the associated social benefits justify further public investments.With the complexity involved in agricultural research for development being increasingly recognised, there has been a shift from linear to more complex, integrated approaches to foster innovation in resource-poor environments. The approach developed in this piece of work, integrating CBE and NPD principles in a framework based on innovation systems and multi-stakeholder collaboration, fits right in here. It features many characteristics associated with successful commercialisation of underutilised plant species, in particular capacity building of communities, strategic partnerships with a variety of stakeholders, using simple, scalable technologies, and taking into account the local context. The practical implementation in Kilifi demonstrated, that it was possible to increase local demand and the value seen in baobab, laying the groundwork for further value addition and enterprise development in the communities. This may also contribute to maintaining or even increasing baobab agroforestry and conservation of baobab trees on farms. With baobab being a highly nutritious food source the increased consumption may already contribute to food security. Effects on income, livelihoods, or empowerment of communities, however, will probably only be seen further down the line. Nevertheless, with baobab being a common, yet so far underutilised feature of local farming systems in Kilifi, the approach offers the possibility to be complementary and easily integrable to prevailing livelihood strategies. Although projections show that additional income would only be supplemental, this can help marginalised communities diversify livelihood strategies—focussing solely on baobab as an income source would be too much a risk. The strategy on developing high quality raw material baobab powder and oil via the CBE processing operation enables additional local marketing pathways for baobab products—considering both the input as well as output resources. Thus, CBEs and the developed approach can be a promising model for the sustainable local rural development of poor populations and—being more streamlined—possibly more cost-effective than comparable initiatives, although this should be more thoroughly addressed in future research.


In recent years, there have been many reports on the pregnancy outcomes of fresh blastocyst transfer (BT) and frozen-thawed BT, but the conclusions are controversial and incomplete. To compare the pregnancy outcomes, maternal complications and neonatal outcomes of fresh and frozen-thawed BT in the context of in vitro fertilization or intracytoplasmic sperm injection (IVF/ICSI) cycles, we conducted a meta-analysis.A meta-analysis was conducted by searching the PubMed, Embase, and Cochrane Library databases through May 2020. Data were extracted independently by two authors.Fifty-four studies, including 12 randomized controlled trials (RCTs), met the inclusion criteria. Fresh BT was associated with a lower implantation rate, pregnancy rate, ongoing pregnancy rate, and clinical pregnancy rate and higher ectopic pregnancy rate than frozen-thawed BT according to the results of the RCTs. The risks of moderate or severe ovarian hyperstimulation syndrome, placental abruption, placenta previa and preterm delivery were higher for fresh BT than for frozen-thawed BT. The risk of pregnancy-induced hypertension and pre-eclampsia was lower for fresh BT; however, no significant differences in risks for gestational diabetes mellitus and preterm rupture of membrane were found between the two groups. Compared with frozen-thawed BT, fresh BT appears to be associated with small for gestational age and low birth weight. No differences in the incidences of neonatal mortality or neonatal malformation were observed between fresh and frozen-thawed BT.At present there is an overall slight preponderance of risks in fresh cycles against frozen, however individualization is required and current knowledge does not permit to address a defintive response. As cryopreservation technology has developed during the past few decades, the proportion of individual undergoing frozen blastocyst transfer (BT) has increased . There hWith regard to maternal complications, Maheshwari et al. showed that frozen-thawed BT was associated with lower risks of postpartum haemorrhage (PH), placental abruption (PA), placenta previa (PP) and preterm delivery (PTD) than fresh BT and that the pregnancies arising from frozen-thawed BT seemed to have lower risks of maternal complications . Shavit Regarding the neonatal outcomes, an early review demonstrated that there were no significant differences in incidences of perinatal death or low birth weight of infants between fresh BT and frozen-thawed BT . HoweverThere is growing concern regarding whether children born after frozen thawed BT have higher risks of congenital malformations than those born after fresh BT via IVF/ICSI. A register-based cohort study suggested that the risk for congenital malformation of the children born after frozen thawed BT was not higher than that of children born after fresh BT; in addition, no increased risks regarding the affected organ system were found between the two groups .Due to limited sample sizes, past meta-analysis conclusions are controversial. With the emergence of new reports, there is an urgent need to perform a meta-analysis to compare the outcomes following fresh BT and frozen-thawed BT to provide guidance for clinical practice. The purpose of this meta-analysis was to examine pregnancy outcomes, maternal complications and neonatal malformations after frozen thawed BT versus those after fresh BT in an IVF/ICSI cycle and assess whether frozen thawed BT is a better choice than fresh BT.We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines when performing the systematic review and meta-analysis , pre-eclampsia (PE), PTD, PP, PA, PH, and preterm rupture of membrane (PROM). PTD was defined as a liveborn or stillborn infant with a gestational age at birth of at least 28 weeks but less than 37 weeks. Very preterm delivery (VPTD) was defined as a liveborn or stillborn infant with a gestational age at birth of at least 28 weeks but less than 32 weeks. The neonatal outcomes included gestational age at delivery, birth weight, stillbirth, perinatal mortality and neonatal mortality. Large for gestational age (LGA) was defined as a birth weight above the 90th percentile. SGA was defined as birth weight below the 10th percentile. Very small for gestational age (VSGA) was defined as weighing below the 3rd percentile. High birth weight (HBW) was defined as a weight of > 4000 g at birth. Very high birth weight (VHBW) was defined as a weight of > 4500 g at birth. Low birth weight (LBW) was defined as a weight of < 2500 g at birth. Very low birth weight baby (VLBW) was defined as a weight of < 1500 g at birth. We also analysed neonatal malformations (NM), including congenital anomalies, chromosomal aberrations, and different organ system malformations.2 statistic. I2 > 50% was considered to indicate marked heterogeneity [p < 0.05 was considered statistically significant.All statistical analyses were conducted using RevMan software. For the included studies, the results of dichotomous data for each of the studies eligible for meta-analysis were expressed as a risk ratio (RR) with the 95% confidence interval (CI). Although we analysed the data using both fixed effect models and random effect models, the results in the text are only from random effect models due to underlying heterogeneity in the studies. These results were combined for meta-analysis with the use of the Mantel/Haenszel model along with the random effects model. We assessed whether there was sufficient similarity between the eligible studies in regard to their design and clinical characteristics. Statistical heterogeneity was assessed with a chi-squared test and quantified with the Iogeneity . p < 0.0A total of 3985 available publications were identified in our search. Of these, 3783 were excluded after reading the title and the abstract. Finally, 54 articles, including 12 randomized controlled trials (RCTs) and 42 nonrandomized controlled trials (NRCTs), were considered eligible by one or both reviewers      , MPR  and LBR  showed no statistically significant differences between fresh BT and frozen-thawed BT (Appendix 4)  was lower in the fresh BT group than in the frozen-thawed BT group  Fig. . CompareIn conclusion, our meta-analysis showed that fresh BT was associated with lower IR, PR, OPR, and CPR and higher EPR than frozen-thawed BT. There were no differences observed in the MR, MPR or LBR between fresh and frozen-thawed BT.P = 0.0002, heterogeneity: I2 = 57%)      (Appendix 5)  and PROM  did not differ significantly between fresh BT groups and frozen-thawed BT groups (Appendix 5)     (Appendix 6)   were found (Appendix 6)  Fig. a and VHB0%) Fig. b associaIn conclusion, fresh BT tends to lead to SGA and LBW, while frozen-thawed BT has the opposite effect. The stillbirth, perinatal mortality and neonatal mortality risks showed no statistically significant differences between the two groups.P = 0.009, heterogeneity: I2 = 0%)  Fig. a. Furthe0%) Fig. b, respir0%) Fig. c, nervou0%) Fig. d, gastro0%) Fig. , revealep-value on IR, PR, EPR, PIH &PE, GDM, PTD, LGA and SGA was more than 0.05 and which indicated the absence of publication bias. Egger’s tests yielding statistical evidence of publication bias at a p-value of OPR and CPR less than 0.05. In considering publication bias trim and fill meta-analysis was done. However, based on this analysis, no significant change was seen as compared with the main meta-analysis.The publication bias could be assessed by using either a funnel plot subjectively and Eggers regression test objectively in Additional file Subgroup analysis was performed according to the design of the origin trials, cryopreservation method, endometrial preparation method    in 1983 . This teWith respect to pregnancy outcomes, frozen-thawed BT was associated with higher IR, PR, OPR and CPR than fresh BT. There was no difference in MR, MPR, or LBR. Recently, Zeng et al. showed that there was no difference in IR, CPR, MR, or MPR, but an increased LBR was found for fresh BT compared with that of cryopreserved thawed BT . Roque eFrom the perspective of maternal complications, our research demonstrated that the risks of PA, PP and PTD are lower for frozen-thawed BT than for fresh BT. In contrast, the risks of PIH and preeclampsia associated with frozen-thawed BT are higher than those associated with fresh BT. Blazquez et al. suggested that FET pregnancies carry a higher risk of PIH and pre-eclampsia than fresh ET pregnancies, possibly indicating that the protocols currently used for endometrial reception of embryos have a deleterious effect on placentation, perhaps due to the long exposure to hormone replacement . OHSS isIn regard to neonatal outcomes, our study suggested that there were lower risks of SGA and LBW in singleton pregnancies after frozen-thawed BT than in those after fresh BT, which was consistent with the previous meta-analysis . HoweverThe major strength of this systematic review is the comprehensive literature search, identifying study subjects from a substantial number of relevant publications; another strength is the many pregnancy outcomes, maternal complications and neonatal outcomes the study evaluated between frozen and fresh BT to explore which method is better for mothers and infants. In addition, we conducted RCT and NRCT meta-analyses separately to improve the quality of evidence. However, the present meta-analysis also has some limitations, one of which was the significant heterogeneity in the pregnancy outcomes in the meta-analysis. We tried to find the source of heterogeneity by performing a subgroup analysis to examine the source of heterogeneity but were not able to identify the source. In addition, the baseline characteristics of patients differed among the included studies, including country, age, smoking status, duration of infertility, type of infertility, endometrial thickness, and cryopreservation type.In summary, considering the higher IR, PR, OPR, and CPR; lower EPR; and decreased risks of OHSS, PA and PTD, as well as the incidences of SGA and LBW associated with frozen-thawed BT, there is an overall slight preponderance of risks in fresh cycles against frozen. However, frozen-thawed BT also has potential risks, such as LGA, PIH and pre-eclampsia. During the freezing process, there is a trade-off between the risk of pre-eclampsia hypertension and all other higher risks of fresh tranfers. In conclusion, the present review assessed the risks and magnitudes associated with fresh or frozen-thawed transfers, however it could not provide a final answer on the research question in object in the title. Therefore, individualization is required in order to choose the best procedure for each specific case according to the clinical needs.Additional file 1: Appendix 1. PRISMA checklist.Additional file 2: Appendix 2. Sample search strategy used for PubMed.Additional file 3: Appendix 3. Risk of bias graph.Additional file 4: Appendices 4–7. Supplemental Figures.Additional file 5: Appendices 8–18. Publication bias.Additional file 6: Appendix 19–34. Subgroup analysis.Additional file 7: Appendix 35. Women with high ovarian response.Additional file 8: Appendix 36. Single blastocyst transfer.Additional file 9: Appendix 37–49. Sensitivity analysis.Additional file 10: Appendix 50. Meta regression.


Mothers’ reports about pregnancy, maternity and their experiences during the perinatal period have been associated with infants’ later quality of attachment and development. Yet, there has been little research with mothers of very preterm newborns. This study aimed to explore mothers’ experiences related to pregnancy, premature birth, relationship with the newborn, and future perspectives, and to compare them in the context of distinct infants’ at-birth-risk conditions.A semi-structured interview was conducted with women after birth, within the first 72 h of the newborn’s life. A total of 150 women participated and were divided in three groups: (1) 50 mothers of full-term newborns  ≥ 37 weeks; FT), (2) 50 mothers of preterm newborns  and (3) 50 mothers of very preterm newborns .Mothers of full-term infants responded more often that their children were calm and that they did not expect difficulties in taking care of and providing for the baby. Mothers of preterm newborns although having planned and accepted well the pregnancy  and while being optimistic about their competence to take care of the baby, mentioned feeling frightened because of the unexpected occurrence of a premature birth and its associated risks. Mothers of very preterm newborns reported more negative and distressful feelings while showing more difficulties in anticipating the experience of caring for their babies.The results indicate that Health Care Systems and Neonatal Care Policy should provide differentiated psychological support and responses to mothers, babies and families, taking into account the newborns’ GA and neonatal risk factors. Generally, in the third trimester of pregnancy, women develop a clear and rich representation of their infants , 2, infl“real baby”, in contrast to the “idealized baby” and, as such, prenatal representations are subject to change as a result of the interactions with the “real baby” [“real newborn” [castles in the sand” [Birth reveals the al baby” , 8. Shornewborn” . For mothe sand” , 9.In a preterm birth, the experience of pregnancy, childbirth and early childbearing can be considerably altered due to the associated risks and danger of survival but also health risks  and possible developmental sequelae  . ConcomiIndeed, mothers of premature infants exhibit higher levels of post-traumatic stress and depressive symptoms compared with controls, without recovery even 14 months after birth , 18, 20.Maternal representations have been defined as mothers’ own mental and subjective representations of their experiences interacting with their infants, even before their infant’s birth, which may influence the parents’ interpretation of infant behavior and their later behavioral responses to their infant . SeveralIt is well documented that mothers’ balanced and positive maternal representations of early pre- and postpartum experiences are positively associated with later secure mother-infant attachment in normative samples –32. For “characterized by narratives that convey coherence, openness to change, richness of detail, and a sense of the mother as engrossed in her relationship with her infant, as they value and enjoy their relationship with their infant and are aware that this relationship affects their child’s behavior and development” [In the case of a very preterm birth, due to the extreme and traumatizing circumstances, mothers are even less likely to develop balanced maternal representations lopment” . Howeverlopment” . Availablopment” , 41; (2)lopment” , 43; (3)lopment” , 45 and lopment” , 47. Morlopment” .As a contribution to the body of knowledge concerning maternal representations and to the development of psychological tailored interventions to promote maternal early adjustment and later secure mother-infant relationship in the context of different neonatal birth conditions , we aimed to explore prenatal and early maternal representations concerning pregnancy, birth, maternity and future perspectives. Furthermore, we aim to compare these representations among three groups: (1) mothers of full-term newborns ; (2) mothers of preterm newborns  and (3) mothers of very preterm newborns . This study uses qualitative methods, which are best suitable to explore individuals’ idiosyncratic experiences. To our best knowledge this is the first study comparing maternal reports of pre- and postpartum experiences between these three groups.A total of 150 mothers participated in this study, divided in 3 groups: (1) 50 mothers of FT newborns , (2) 50 were mothers of PT newborns , and (3) 50 mothers of VPT newborns . Mothers’ eligibility criteria included: (1) Portuguese language fluency; (2) admission in a maternity hospital following delivery ; (3) with no known drug/alcohol addiction problems; and (4) with no history of mental illness.The total number of eligible mothers, in the three participating hospitals, was 177, among which 27 mothers in the preterm group refused to participate, resulting in 150 participants.Table n = 15), intrauterine growth restriction (n = 11), placental abruption (n = 9), early dilation (n = 3), preeclampsia (n = 2), uterine contractility (n = 3), baby’s bradycardia (n = 2), elevated urinary levels of the amino acid lysine (n = 2), and other non-specified causes (n = 3). In this group, 6 mothers used In-Vitro Fertilization (IVF) to conceive. The preterm births were due to: rupture of the membrane (n = 13), intrauterine growth restriction (n = 13), infection (n = 6), preeclampsia (n = 5), loss of amniotic fluid (n = 6), hypertension (n = 3), placental abruption (n = 3), and baby’s bradycardia (n = 1). Similarly, in this group, 17 mothers were enrolled in the infertility consultation to become pregnant and 6 of them used IVF to conceive. Although a small number, in the group of very premature infants, parents (n = 6) did not cohabit at the time of the baby’s birth  and it was also in this group that we found a higher frequency of emigrant mothers (n = 12). In the full-term and in the preterm groups, the number of primiparous mothers was equally or approximately the same as the number of multiparous mothers , while in the very preterm group the number of primiparous mothers was lower (VPT: n = 10 vs. n = 40).In what concerns birth characteristics, the number of instrumental births , was higher in the group of preterm infants (72%) and very preterm infants (68%). In the sample of full-term infants, the distribution of the two types of delivery was equally distributed. The occurrence of a very preterm birth was caused by: rupture of the membrane , before conducting any assessment or data collection. All procedures involving human subjects in this study were approved by the Ethics Commission at the Mothers’ eligibility to participate in the study was determined through data collected from clinical files. Two female research assistants contacted personally eligible mothers after delivery and explained the study’s purpose and procedures. In this contact, their free participation was guaranteed in accordance with the American Psychological Association ethical research conduction guidelines. Eligible, consenting parents gave their written informed consent to participate. Once consent was obtained, mothers participated in an interview to collect: socio-demographic information , prenatal, perinatal and postnatal information  and post-discharge situation . Through the hospital medical record, additional clinical information regarding the prenatal and perinatal conditions, of both mother and baby, relevant to the study, were obtained.Within the first 72 h after birth, a semi-structured interview was conducted face-to-face, at a time and date that were convenient for mothers, in Portuguese maternities of three hospitals in Porto and Lisbon, where the newborns were admitted with their mothers. Interviews were audio-recorded and transcribed verbatim for qualitative analysis. The temporal window of 72 h to conduct the maternal interview was decided because: (1) it was intended to evaluate the maternal experiences in the immediate postpartum period, which is generally defined as the period between the first 48 and 96 h of postpartum hospital stay ; (2) in During design, data collection, and analysis, we adhered to the consolidated criteria for reporting qualitative research (COREQ) when possible as outlined in pregnancy ; (2) reaction to early birth and prematurity ; (3) maternal experience and relationship with the newborn child ; (4) baby’s temperament ; and (5) future perspectives . The interviews were audio-recorded and lasted approximately 1 h. The validity of the interview was tested and confirmed in past research  future perspectives. Several subthemes, discussed below, emerged in the data further describing how mothers viewed both their pre- and perinatal experiences.Overall, five main themes were discerned in the data: (1) pregnancy; (2) early birth and prematurity; (3) maternal experience and the relationship with the newborn; (4) babypregnancy and the subtheme of planned pregnancy, most mothers of PT infants (80%) and VPT infants (62%) planned their pregnancy, in contrast with 36% in the group of FT mothers . Non-acceptance of pregnancy was found in 8% of FT mothers, 4% of mothers of PT infants and 2% of mothers of VPT infants. Moreover, 4% of mothers of VPT infants reported feeling ambivalent about their pregnancy: “I did not want a baby, I was on a diet. My eldest son is fourteen, and now I wanted to have my own life. My husband was so happy that it irritated me. It was only when I started reviewing my son’s baby pictures, that I started liking her” (M70)  or totally (96%) supported during pregnancy, both by health professionals and/or by closed ones such as family/friends. Likewise, 92% of mothers of PT infants felt fully supported and only one mother said she felt she had no support (2%). As for the group of mothers of VPT infants, 60% reported feeling totally supported, while 14% mentioned not having received any support. For instance, one mother noted: “The pregnancy was complicated. I was very nervous; my husband was arrested. I was alone and pregnant; I had another child and I still had to work because there was no one who could help me financially and someone had to pay the bills” (M21) . Interestingly, 30% of mothers of PT newborns and 14% of mothers of VPT newborns said that they were not afraid for the baby’s life. As an example: “They  reassured me that there are a lot of babies like him that turn out okay. I believe in them because I have cousins who were born premature who are now big and strong adults” (M46).As for the second theme of maternal experience and relationship with the newborn child, and in the subtheme feeling love for the baby for the first time . Other mothers only described the emergence of this feeling later, namely, at birth (14% of mothers of FT babies and 22% of mothers of VPT babies), when they saw the “real” baby, as one mother explained: “As soon as I saw him it was clear to me how much I loved him!” (M19).In the third theme of first separation from the baby . In the same group, this feeling was followed by detailed descriptions that revealed a lot of suffering and pain as well as the emergence of feelings of fear/guilt (34%), as in the following case: “My first thought was: I did something wrong, I failed! I felt ashamed and scared” (M60). In both groups (FT and VPT), three mothers did not know how to describe their experience or “how to translate into words” (M14) what they felt when they were first separated from their babies (6%): “I do not know what to say … sure I wanted to go with my baby, but I could not” (M14).In the subtheme of baby’s temperament , as in “she is very peaceful, silent and quite, observant and attentive … she is so calm that sometimes I think that she believes she is still in my belly … she is loving, sometimes I cuddle her in the nose and she smiles. I thought that she would be bossy because she was electric while on my belly, she moved a lot during the pregnancy but actually she is a doll and I just feel like cuddling her” (M22), while 10% considered their baby to be agitated and constantly weeping, pointing for instance, “she has quite a temper! She has a strong personality and she only does what she feels she wants to do … she is also very nervous, agitated … she is a difficult baby, very demanding, she cries a lot and does not sleep well, she can’t even stop at night, at least she could let me sleep so that I could rest in order to meet her needs during the day, she does not make things easier” (M15). The responses of mothers of VPT babies were more diverse, fluctuating between agitated/weeping (40%), calm (26%), and not knowing how to describe them (32%).In the fourth theme of future perspectives ; “It will be very good, to finally take care of her, not being dependent on any medical equipment” (M34). Contrary, some mothers  mentioned that it would be difficult, but that they were willing to learn.In the fifth theme of by Table , 60% of expecting difficulties in the future . Beyond the difficulty revealed in the process of anticipating the future, 22% of these mothers preferred not to think about it: “I have started to think about it, but I do not want to think about it too much because those kind of thoughts do not help me and I feel like I have to focus on the present moment and live day-by-day, one day at a time” (M31).Regarding the subtheme of In this study, we explored maternal early experiences related to pregnancy, early birth, maternity and the relationship with the newborn, and future perspectives regarding parenting. Furthermore, we compared them in the context of distinct infants’ at-birth-risk conditions, by including in our sample mothers of full-term, preterm, and very preterm newborns. A semi-structured interview was conducted 72 h after delivery and results allowed to distinguish both similarities and differences among these groups.full-term (FT) mothers, most mothers did not plan their pregnancy, but the majority mentioned they had accepted it. The larger part of mothers reported to have felt love for their baby when they found they were expecting. Almost all mothers felt supported by both health professionals and/or family/friends during gestation. During their hospital stay, most mothers described their baby’s temperament as calm and only about a quarter described them as restless or difficult. Anticipating the future, these mothers felt that it would be good to take care of their babies, but the majority expected to find difficulties to be overcome with the help from family support (which they anticipated having).In the group of mothers of preterm (PT) babies planned and accepted well their pregnancies. In fact, a large part of mothers in this group was enrolled in the infertility medical consultation (assisted reproduction) to become pregnant. These mothers reported having felt love for their child as soon as they learned they were pregnant. Despite these positive aspects, when birth occurred prematurely, mothers felt concern or great concern and guilt. As in previous studies, mothers of PT infants described feelings of distress and despair regarding the experience of pregnancy and birth [Most nd birth . Howevernd birth  with motnd birth , 53 repomothers of very preterm (VPT) infants. The pregnancy and early postpartum experience reported by mothers of very preterm infants is equally accepted, but compared to the other two groups, the feeling of love for the newborn occurs much less frequently at an early stage, for instance, when mothers first are informed about their pregnancy. Worryingly, in this group, the first feeling of love is described as occurring only after birth by about one-third of the mothers and, even more serious, three mothers did not express this affection for their baby at all. Regarding this dimension it is important to note that we did not present mothers with any definition of the expression “feeling love”. In fact, some mothers expressed having doubts about the meaning of “feeling love” and were not sure about having ever felt that sensation while others defined “feeling love” as the “urgency” of being close, to care, to hold, to love, to protect and as a complex, confusing and to some extent scary but positive and strong bonding feeling. To our best knowledge, no previous study found differences between the three groups of mothers concerning the moment when these feelings arouse for the first time.The most striking results of this study concern the narratives of Furthermore, since several studies found that the prevalence of depression is higher in mothers of very or extremely preterm infants , we wondActually, not only did the life scripts of these mothers carry more risk indicators  but, also, they reported more cumulative risk situations at that present moment. For example, some of them had not received any personal support during pregnancy or clinical/health follow-up, which is rare in the Portuguese context . These mWhen asked to describe their babies’ temperament a large group of mothers of VPT infants reported perceiving their infant as agitated, and a significant number of mothers showed difficulties in characterizing the baby’s temperament. These results may be explained by both (1) the mothers’ emotions and their main focus on their newborn struggle for survival in the immediate moment which prevent them from being sensitive to other characteristics of their baby; and (2) by the physical immaturity of the very preterm newborn which, as reported in other studies, results in greater difficulty for parent-newborn interaction .When asked to reflect upon their perceptions and expectations for the future, mothers of VPT infants were so focused on their newborn struggle for survival in the immediate moment that they showed reluctance in looking into the future. Again, these findings may be due to the frightening uncertainty about their baby’s survival in this phase. Uncertainty and grief usually prevent mothers from being able to perceive and to reflect about potential difficulties in the future.Lastly, although it was not defined in our initial research aims, given the high and unexpected number of births by caesarean section, we decided to analyze the impact of this variable on our findings. Indeed, the type of delivery affected mother’s perception of the baby’s temperament (mothers who gave birth by caesarean section described more often their newborns as agitated) as well as the anticipation of prospective problems or potential future difficulties see . Like inIn summary, mothers’ early perception of their experiences with full-term, preterm and very preterm infants showed some similarities but equally important differences. These results reinforce previous evidence indicating that maternal experiences in these three groups are distinct , especiaIn fact, the growing recognition that parents’ negative emotions  and stress are associated not only with prematurity but also with the quality of their experience during their stay at the NICU contributed to the significant enhancement of Family-Centered Care (FCC) within NICU and to the development of family-centered interventions during NICU hospitalization , 60. TheIn our study, mothers of very preterm newborns showed more negative emotions and more difficulty in facing the future. The fragile clinical conditions of very preterm infants, the incidence of mortality among these babies and the extremely stressful conditions of anxiety and depression may prevent mothers from engaging with their baby . These sFurthermore, mothers of VPT infants face a long stay in the NICU which frequently has repercussions in their personal and family lives. Their specific needs pose new challenges that must be addressed in the NICU, and more generally by the Health Care Systems and Neonatal Care Policy, including government and global maternal and child health care agencies.Our study has both strengths and limitations. The current study was developed within a descriptive and interpretative paradigm, using a qualitative methodology, without generalization concerns. Indeed, one of our limitations it that our results mainly mirror the reality of Portuguese mothers living in urban areas. However, it is noteworthy that our study includes a large sample of 150 mother-infant dyads which, although distributed across three study groups, allows us to deepen our data exploration and the uniqueness of each group experience.Importantly, in our sample, the three study groups are distinct from the point of view of family conditions, history of pregnancy and attempts to conceive , which should be considered when reading our results. In fact, in addition to the risk-factors associated with a preterm birth, the group of very premature infants presents more risk-factors associated with pregnancy and family relationships (support network), compared with the other two groups, which may increase mothers’ sense of insecurity, influencing the nature of their postpartum experiences. Future studies must address questions of diversity, marginalization, and interlocking oppressions in this particular group.Mothers experience in each group, also, varied regarding breastfeeding experiences  and labor . Although the samples vary in these aspects, in fact, they reflect the different experience in these groups. The unexpected and high number of caesarean sections deserves further investigation, namely regarding its causes and consequences.To learn more about the participants’ perspectives, we invited a group of 10 parents (both mothers and fathers) in the preterm group to participate in a videotaped focus group to discuss and reflect about the study findings. The parents confirmed that the identified themes and subthemes reflected their experience, demonstrating an identification with the study results and stressing the need for more effective support responses in the hospital maternity and after discharge. Further research addressing the temporal continuity of these early experiences, namely the impact of parental stress and early relationships on infants’ development, is pivotal. For instance, although it is generally accepted that parental stress is influenced by infants’ gestational age and weight at-birth, and particularly with pre- and perinatal complications , some pa“call to action” has been proposed highlighting the urgent need to understand the etiology and the context of a preterm birth , focusing on the need to use new strategies, namely prevention strategies  to tackle the combined biological and social factors associated with an early birth [At last, it is important to stress that preterm birth is the most common single cause of perinatal and infant mortality, affecting 15 million infants worldwide each year with global rates increasing exponentially . In recely birth –97. For ly birth .We believe that this study contributes to the body of knowledge that describes maternal pre- and perinatal experiences with their newborns in the context of different neonatal risk factors. The exploration and understanding of early life subjective experiences and their causes are fundamental in enhancing successful evidence-based mother-infant intervention strategies and medical-clinical practice, while simultaneously informing theoretical, practical, research, policy-making and public health decisions.


To explore the relationship between parity and macrosomia and provide the necessary reference for the maternal and children health service.A cross-sectional epidemiological survey with the purpose to assess the birth outcomes was conducted in Shaanxi province, China.The incidence of macrosomia in multiparas was higher than that in primiparas. Univariate analysis showed that maternal age < 25 years, peasant/housework, living in rural areas and female infants were the protective factors of macrosomia. The possibility of having a macrosomic infant also increased with gestational age, maternal education level, household wealth index, living in Central Shaanxi and gestational diabetes. The generalized linear mixed models represented the association between parity and macrosomia. After adjusting for statistically significant factors in univariate analysis from model 1 to model 3, the risk of being born macrosomia was 1.26 times higher for a multipara compared to that for a primipara.Present study indicated parity of two children was associated with increased risk for macrosomic births compared with parity of one child. Compared to primiparas, multiparas should far strengthen the pre-pregnancy education and the guidance during pregnancy to control pre-pregnancy body mass index and pregnancy weight, and keep the appropriate exercise and balanced diet. We found that parity was related to the occurrence of macrosomia. The incidence of macrosomia of multipara was higher than primipara, and the difference was statistically significant. Compared to primiparas, multiparas should far strengthen the pre-pregnancy education and the guidance during pregnancy to control pre-pregnancy body mass index and pregnancy weight, and keep the appropriate exercise and balanced diet.After adjusting for statistically significant factors in univariate analysis, analysis based on generalized linear mixed models revealed that the risk of macrosomia was 1.26times higher for a secondborn child compared to a first born.The primary strength of the present analysis is the large sample size , which accounted for ~ 9% of neonates in Shaanxi Province. Therefore, our results can be generalized to the entire province as well as Northwest China.Birth weight (BW) is an important indication of mothers’ and neonates’ nutritional status, and may be the important determinant of infant’s survival and future health, growth, and development . Macrosord-degree perineal tears, thromboembolic events and anesthetic accidents [Maternal complications of macrosomia include prolonged labor, labor augmentation with oxytocin, cesarean delivery, postpartum hemorrhage, infection, 3rd- and4ccidents , 7. Accoccidents . Furtherccidents –14.Maternal parity is a well-recognized predictor of infant birthweight, with the lowest birthweights observed among infants born to nulliparous women –20. BirtThe cross-sectional study was executed in Shaanxi province of Northwest China from August to November 2013. The infants born during 2010–2013 and their mothers were the objects of the research. Because of the different population density and fertility rates between rural and urban areas in the whole province, a hierarchical, polystage, probability-proportional-to-size sampling method was used in the present research. In China, administrative organization was divided into 3-hierarchy frames. Counties, townships and villages constitute the rural areas. Independent of rural areas, districts, streets and communities constitute the urban areas. In the first place, 20 counties and 10 districts were randomly selected from the whole province. Then, six townships and three streets were randomly sampled in the chosen counties and districts. Afterwards we selected six villages from per chosen township and six communities from per chosen street randomly. A random sampling method was used to select 30 babies born during 2010–2013 and their mothers in every chosen village, and, 60 in every sampled community. Expected sample size of our study was approximately 32,400 infants and their mothers. But 2373 subjects were unwilling to join in the study (response rate: 92.68%). Therefore 28,644 single live infants were chosen for this project. And 481 objects were removed for unknown birth weight and childbearing history. Moreover, 812 subjects were removed who had more than 3 children. In the end, a total of 27,351 singleton live infants were selected.All data was stated by the mothers of the chosen children, including socio-demographical information and information on maternal lifestyles during pregnancy. Xi’an Jiaotong University Health Science Center devised all questionnaires. Ten field teams that every team comprised 10–12 members were formed for these counties or districts. As soon as completing every questionnaire, the supervisors were responsible for detecting any errors and/or imperfect information. All data collection was completed in the local village clinics and community health service centers. Our study was sustained by the local hospitals and health administrative departments as well as the Shaanxi province Ministry of Health.Controlling for potential confounding factors was necessary when determining the relationship parity and macrosomia. Based on the currently available body of knowledge and the nature of our data, we selected potential confounding factors from three groups of variables: children, family and mothers. The factors included within the children group were the child’s sex and gestational age. The factors included within the family group were economic conditions, region and residence. The factors included within the mother group were maternal education level, age at the child’s birth, occupation and gestational diabetes.Primipara: A woman who has borne only one living child.Multipara: A woman who has given birth to 2 living children.χ2 test was used to prove differences in proportions between groups. On account of the multilevel hierarchical structure of the data, the generalized linear mixed model approach was used, which is a good method for analyzing data with a hierarchical structure and can be applied in sampling investigations. Ultimately, a 2-level analysis was performed to adjust for the effect of randomization by counties/districts and to analyze the associations between parity and macrosomia with county/districts to level 2 and individual to level 1 by nine potential confounding factors. Model 1 adjusted for gestational age and sex of infants. Model 2 adjusted for the variables in model 1 plus the relevant maternal characteristics, including maternal education level, age at the child’s birth, occupation and gestational diabetes. Model 3 adjusted for the variables in model 2 and the status of family characteristics . All statistical analyses were performed using SAS 9.3 . Two-tailed P < 0.05 was considered statistically significant.A database was designed by EpiData version 3.02, and data entry was duplicated. Firstly, the characteristics of participants were summarized using means±SDs for normally distributed continuous variable. The categorical variables were described using count and proportions. The Of the infants, boys accounted for 53.92% of total infants. Amongst the region of the infants, infants in Central Shaanxi, Northern Shaanxi and Southern Shaanxi accounted for 54.41, 25.06 and 20.53% respectively. The childbearing age of mothers was 26.92 ± 4.65 years and approximately 39.45% of them were educated beyond senior high school. The other details of the sample and distribution of the major demographic variables are shown in Table P < 0.001).The average birth weight of 27,351 newborns was 3267.21 ± 455.90 g. The neonatal average birth weight of the primipara was 3262.18 ± 452.36 g, and that of the multipara was 3275.07 ± 461.29 g. Neonatal birth weight of the multipara was higher than that of the primipara, and the difference was statistically significant. The incidence of low birth weight infants was 3.38%, and the incidence rate of macrosomia was 6.79%. Among the 27,351 women of childbearing age surveyed, 16,677(60.97%) women were primiparas, and 10,675(39.03%) were multiparas. The birth weight status of the children for primiparas and multiparas were shown in Table Univariate analysis results showed that maternal age < 25 years, peasant/housework, living in rural areas and female infants were the protective factors of macrosomia. And the possibility of having a macrosomic infant also increased with gestational age, maternal education level, household wealth index, living in Central Shaanxi and gestational diabetes. Compared with primipara, multipara was also associated with an increased risk of delivering a macrosomic infant Table .Table 3In Fig. We found that parity was related to the occurrence of macrosomia. The incidence of macrosomia of multipara was higher than primipara, and the difference was statistically significant. After adjusting for statistically significant factors in univariate analysis, analysis based on generalized linear mixed models revealed that the risk of macrosomia was 1.26 times higher for a secondborn child compared to a first born.The association between parity and macrosomia has been previously investigated in a few studies conducted elsewhere, and increased parity is associated with higher risk of fetal macrosomia , 24. MulThe present cross-sectional study indicated parity of two children was associated with increased risk for fetal macrosomia. Compared to primiparas, multiparas should far strengthen the pre-pregnancy education and the guidance during pregnancy to control pre-pregnancy body mass index and pregnancy weight, and keep the appropriate exercise and balanced diet in order to reduce the incidence of macrosomia.The primary strength of the present analysis is the large sample size , which accounted for ~ 9% of neonates in Shaanxi Province . TherefoThe present cross-sectional study indicated parity of two children was associated with increased risk for macrosomic births compared with parity of one child. Compared to primiparas, multiparas should far strengthen the pre-pregnancy education and the guidance during pregnancy to control pre-pregnancy body mass index and pregnancy weight, and keep the appropriate exercise and balanced diet in order to reduce the incidence of macrosomia.


Research suggests that some fathers and birth partners can experience post-traumatic stress disorder (PTSD) after witnessing a traumatic birth. Birth-related PTSD may impact on many aspects of fathers’ and birth partners’ life, including relationship breakdown, self-blame and reducing plans for future children. Despite the potential impact on birth partners’ lives there is currently no measure of birth-related PTSD validated for use with birth partners. The current study therefore adapted the City Birth Trauma Scale for use with birth partners. The City Birth Trauma Scale (Partner version) is a 29-item questionnaire developed to measure birth-related PTSD according to DSM-5 criteria: stressor criteria (A), symptoms of re-experiencing (B), avoidance (C), negative cognitions and mood (D), and hyperarousal (E), as well as duration of symptoms (F), significant distress or impairment (G), and exclusion criteria or other causes (H). A sample of 301 fathers/birth partners was recruited online and completed measures of birth-related PTSD, bonding, and demographic details. Results showed the City Birth Trauma Scale (Partner version) had good reliability (α = 0.94) and psychometric and construct validity. The fathers/birth partners version has the same two-factor structure as the original scale: (1) general symptoms and (2) birth-related symptoms, which accounted for 51% of the variance. PTSD symptoms were associated with preterm birth and maternal and infant complications. Overall, the City Birth Trauma Scale (Partner version) provides a promising measure of PTSD following childbirth that can be used in research and clinical practice. Post-traumatic stress disorder (PTSD) is a trauma and stressor-related disorder that may develop following direct or indirect exposure to, or witnessing of, actual or threatened death, serious injury or sexual violence . ChildbiApproximately 97% of women will have their partner or another close friend or family member with them during birth . ApproxiResearch around risk factors for the development of PTSD after witnessing a traumatic birth has mainly focused on fathers, with the exception of The impact on the father/birth partner of birth-related PTSD has not been widely researched but qualitative and case studies suggest in fathers it is associated with social isolation, job loss, mental breakdown, vasectomy and sexual scarring . For theDespite the potential impact of PTSD on fathers and birth partners, it remains under-researched. Lack of research evidence and awareness means it is also not recognized in maternity services. Routine assessment of fathers and birth partners’ mental health is neither conducted nor recommended in clinical guidelines e.g., . One of The City Birth Trauma Scale  is a 29-A cross-sectional psychometric study to assess the reliability and validity of the City BiTS (Partner version) using responses to an online survey.Individuals were eligible for the study if they were present at their partner’s labor or birth within the past 5.5 years (a wide time frame was used to ensure we could recruit an adequate sample size); were 18 years and older; and had a good enough command of English to understand and respond to the questions.n = 82) were excluded because they dropped out before completing the questionnaire , their child was over the age of 5.5 years  or their infant’s date of birth was unreadable or incorrect .A total of 383 eligible fathers/birth partners started the questionnaire, of these 301 (78.6%) fathers/birth partners were included in the final sample. Remaining participants  items are scored on a yes/no scale. DSM-5 symptoms Criteria B to E (Q3–22) are measured using 20 items that measure the frequency of symptoms for these items over the last week, rated on a four-point scale with scores from zero  to three (five or more times). The total symptom scores for Criteria B to E range from 0–60 and symptoms are considered present if an item is rated as one or more. Two questions (Q23–24), scored the same as Criterion B to E, identify a dissociative subtype so are not symptoms of PTSD. The scores for Criteria F (Q26) range from zero (symptoms < 1 month/no symptoms) to two (symptoms lasting > 3 months). Criterion G items (Q27–28) are rated as yes/sometimes/no and the exclusion criteria item (Q29) is rated as yes/maybe/no. The City BiTS can be scored to measure PTSD symptoms  or PTSDThe City BiTS was adapted for use with fathers and birth partners by altering the instructions slightly and ensuring questions for stressor criteria A were phrased to ask whether they thought their partner or baby might be seriously injured or die. Fathers/birth partners were classed as fulfilling Criteria F and G if they scored one or more on symptom duration and for distress or impairment, respectively. Fathers/birth partners who responded to the exclusion criteria question (Q29) as “yes” or “maybe” were considered not to have PTSD and therefore removed from estimates of PTSD prevalence.To evaluate construct validity additional questions were asked which measured: (1) perceived trauma ; (2) maternal complications ; (3) infant complications ; and (4) Father/parent – infant bond .This study was approved by City, University of London Research Governance Ethics Committee. The City BiTS (Partner version) and questions about participants demographic details were hosted on an online survey platform Qualtrics. The survey was available online for 9 months from June 2016 to March 2017. Participants were recruited though adverts placed on social media websites of United Kingdom perinatal charities , Twitter, and a study website created on Facebook. Consent to advertise the survey on charity websites was sought from moderators and research officers of relevant organizations and websites. Social media adverts contained hyperlinks to frequently asked questions and a link to the survey. Recruitment adverts were specifically targeted to fathers; however, the study did not ask participants for their sex or what their relationship was to the baby/child. It is therefore probable the sample was of fathers but possible that other types of birth partners were included. We therefore refer to fathers/birth partners throughout.Participants were given information about the study and had to tick a box to confirm they were 18 years or older and consented to take part in the study. If participants did not tick this box they were unable to progress to the survey. Participation was voluntary and anonymous unless participants chose to give their email address to receive their assessment scores and/or a summary of the study results.Analyses were conducted using the statistics environment R  and SPSSU, and Kruskal–Wallis tests were carried out using birth-related symptoms, general symptoms and total symptoms as the dependent variables, and whether or not the mother or baby had any complications during the labor and birth (yes vs. no), what type of birth the mother had , the partners bond with the baby, and the partners subjective rating of the birth as traumatic (1 = not traumatic – 5 = extremely traumatic) as the independent variables.Further, the readability of the scale was determined using the Flesch readability scale and years of formal education required using the Gunning Fog index. As the data were not normally distributed, to test known-group validity, non-parametric Mann–Whitney r > 0.90 (0 questions) or did not significantly correlate with other questions (0 questions). Eighty four percent of the correlations were between r = 0.20 and r = 0.60 . The highest correlation was r = 0.76 between Q6B (getting upset when reminded of the birth) and Q7B (feeling tense or anxious when reminded of the birth).Initial data screening was conducted to examine whether any questions were not performing well. First, the range of each question was examined to ensure there were no restricted items where participants did not use the full range of the scale. This confirmed all questions used the full range. Secondly, the distributions of the questions were examined through inspection of skewness values and histograms. As with the original City BiTS scale, the majority of the symptom subscale items (B–E) were positively skewed (17 out of 20). PTSD scales are frequently skewed when used in normal populations  and thisn = 301) ranged in age from 21 to 60 years . From those that responded to the demographic questions, the majority of fathers/birth partners were first-time parents  and most were White . The children were aged from 0 to 64 months  and most were born by unassisted vaginal birth  or emergency cesarean birth . See Fathers/birth partners included in the final sample (n = 161) with the mean gestational age of 33.67 weeks . Similarly, over half the sample reported maternal complications during birth  and/or infant complications during birth 56.3% (n = 169). Optional open text responses describing the complications experienced (n = 149) suggested the most common maternal complications were issues with cord/placenta . With regards to infants, the most commonly reported complications were the infant being born unable to breathe and needing resuscitation (n = 55); and pre-term birth (n = 49). Four fathers/birth partners reported that their infant died.There was a high proportion of preterm birth, maternal and infant complications. The majority of fathers/birth partners had a preterm infant . The majority of fathers/birth partners reported at least one symptom . The distribution was positively skewed (skew = 0.75).The sum of the 20 PTSD symptom subscale items  has a possible range from 0 to 60 and the observed range was 0 to 54  = 1.284, p = 0.115].Responses to the stressor criteria A can be found in n = 9, 40.9%), rather than before birth  or within the first 6 months after birth , .Responses to questions about the onset of symptoms, duration, distress, and impairment are shown in 2(190) = 3745.14, p < 0.001]. The exploratory factor analysis which sought two-factor solution with varimax rotation  and correlations between questions were suitably large [Bartlett’s test of sphericity, χrotation  was founrotation .Confirmatory factor analysis showed that both the four-factor  and two-factor  fit similarly  has a reading ease score of 57.8 meaning it should be easily understood by age 16–17 years. The number of years of formal education required to easily read the scale (Gunning Fog index) was 12.9.U 7238, p < 0.001) and birth-related symptoms . Fathers/birth partners who reported maternal complications during birth reported significantly more birth-related symptoms  but not general symptoms . Fathers/birth partners who reported infant complications reported significantly more birth-related symptoms  and general symptoms . Subjective rating as the birth as traumatic was associated with general symptoms  and birth-related symptoms . General symptoms were also associated with poorer bonding with the baby .Results of known groups analyses are shown in The aim of this paper was to adapt the City BiTS to create a version for fathers and birth partners and test the reliability and psychometric validity in a sample of fathers/birth partners. The results suggest the City BiTS (Partner version) has good reliability, is relatively easy to use, and has the same two-factor structure as the original City BiTS. Results showed 26% of fathers/birth partners in this sample met criteria for PTSD after birth on this scale, which reduced to 22% after excluding those whose symptoms could have been due to medication, alcohol, drugs or physical illness. Twenty-two percent of fathers/birth partners reported that their symptoms caused them a lot of distress.This study adds to the evidence that the City BiTS has good internal consistency. Internal consistency in this study (α = 0.94) is similar to that found in the original City BiTS scale and translated into Croatian (α = 0.90–0.92) . This suThe City BiTS (Partner version) also appears to have good validity. Known-group validity showed scores on the City BiTS were associated with partners subjective ratings of birth as traumatic and reporting complications with their partner or baby during the birth. Total and general symptoms were also associated with poorer parent-child bond.Not being able to remember details about the birth’ did not load strongly on either factor suggesting this item has consistently poor loadings in women and men after birth  and they will experience the physiological phenomena of labor and birth, which includes pain and invasive bodily procedures. In contrast, for fathers/birth partners the threat is indirect , they do not have the same physiological phenomena to cope with, but may feel ill-equipped and powerless to help. This is consistent with evidence that many fathers report feeling helpless during the birth of their child  has good reliability, reasonable face validity and the same two-factor structure as the original scale. However, more research is needed to replicate and extend this study. In particular to examine PTSD symptoms, prevalence, and factor structure in more representative samples, as well as the psychometric properties of the City BiTS (Partner version) in more diverse groups of fathers/birth partners. Potential differences in how birth trauma is experienced and expressed by fathers compared to other birth partners needs to be explored. Future research should also include additional measures of reliability  and validity  to establish the utility of the scale for research and clinical practice.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by City, University of London Research Governance Ethics Committee. The patients/participants provided their written informed consent to participate in this study.RW prepared the data for analysis, interpreted the data, and wrote the manuscript and manuscript revisions. AS carried out data collection and provided feedback on the manuscript. SA co-created the measure, overviewed the entire research process, provided feedback, and edited the manuscript. DW co-created the measure, carried out the analysis, and provided feedback on the manuscript. AT co-created the measure and provided feedback on the manuscript. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Birth registration marks a child’s right to identity and is the first step to establishing citizenship and access to services. At the population level, birth registration data can inform effective programming and planning. In Tanzania, almost two-thirds of births are in health facilities, yet only 26% of children under 5 years have their births registered. Our mixed-methods research explores the gap between hospital birth and birth registration in Dar es Salaam, Tanzania.Every Newborn-Birth Indicators Research Tracking in Hospitals (EN-BIRTH) multi-country study (July 2017–2018). We described the business processes for birth notification and registration and collected quantitative data from women’s exit surveys after giving birth (n = 8038). We conducted in-depth interviews (n = 21) to identify barriers and enablers to birth registration among four groups of participants: women who recently gave birth, women waiting for a birth certificate at Temeke Hospital, hospital employees, and stakeholders involved in the national birth registration process. We synthesized findings to identify opportunities to improve birth registration.The study was conducted in the two Tanzanian hospital sites of the Standard national birth registration procedures were followed at Muhimbili Hospital; families received birth notification and were advised to obtain a birth certificate from the Registration, Insolvency, and Trusteeship Agency (RITA) after 2 months, for a fee. A pilot programme to improve birth registration coverage included Temeke Hospital; hand-written birth certificates were issued free of charge on a return hospital visit after 42 days. Among 2500 women exit-surveyed at Muhimbili Hospital, 96.3% reported receiving a birth notification form and nearly half misunderstood this to be a birth certificate. Of the 5538 women interviewed at Temeke Hospital, 33.0% reported receiving any documentation confirming the birth of their child. In-depth interview respondents perceived birth registration to be important but considered both the standard and pilot processes in Tanzania complex, burdensome and costly to both families and health workers.Birth registration coverage in Tanzania could be improved by further streamlining between health facilities, where most babies are born, and the civil registry. Families and health workers need support to navigate processes to register every child. Birth registration is the process by which the event and characteristics of a child’s birth are recorded in a country’s civil registry . At an iAt the population level, birth registration in the Civil Registration and Vital Statistics (CRVS) system provides continuous demographic information for programming and planning , 6. CompDespite its importance, current estimates suggest that nearly a quarter of the world’s children are unregistered . Sub-SahSince facility births are increasing in all regions of the world, new opportunities exist to improve birth registration , 17. TypIn Tanzania, large gaps remain between facility births and birth registration. Nearly two-thirds of births are now in a health facility, and yet only 25% of children under 5 years are registered – one of the lowest rates worldwide . No reseEvery Newborn – Birth Indicators Research Tracking in Hospitals (EN-BIRTH) study. The Every Newborn Action Plan (ENAP), agreed by all United Nations member states, aims to end preventable newborn deaths and stillbirths  reminds about the date of birth of the baby, also it helps in school admission even in the future when she wants to get a job it can be useful.” -Woman, Muhimbili HospitalWomen generally understood the importance of birth certification, and often provided specific reasons for their motivation to obtain a birth certificate for their child. One woman specifically cited:“I am living at Bagamoyo, so there is a distance. And to tell you the truth, from Bagamoyo to the office which provides the birth certificates is too far.” -Woman, Muhimbili HospitalEvery respondent stated they did not understand or remember some aspect of the instructions about the process e.g., where and when to go, how much it would cost, and the distance to RITA. Given Muhimbili is a referral hospital, it is not uncommon for women to travel a long distance to give birth at the hospital, so the need to return to downtown Dar es Salaam twice to register their child at RITA was a concern:Another woman shared her concern that she might lose the birth notification issued to her during the two-month period she was instructed to wait before registration, and a hospital staff also explained:The challenge is ….according to the police, we can’t reissue the notification.” -Health worker, Muhimbili Hospital““Improving the [electronic medical record] system so that all records are available in the computer system to avoid paperwork which is difficult to keep.” -Hospital staff, Muhimbili HospitalHealth workers expressed general satisfaction with the current system, especially with the designated health technician who issues birth notification cards and instructions. The main identified barrier under this process was the inefficiency of a paper-based system. Hospital staff reported the hand-written birth notification system increased burden on staff, potential for error, and difficulty retrieving files. Once the notification form book is delivered to RITA, it cannot be corrected, and copies cannot be given to families who have lost their form. To address these issues, a staff member interviewed recommended:All women interviewed expressed the importance of possessing a birth certificate as a prerequisite for access to school, travel, and work, and approved of the birth certificates being free of charge and provided on the same day.“Sometimes [the process] is difficult to follow because there are people who are living far away from here. It may happen that they forgot to come with two cards, so they will be forced to go back to where they are staying to get them because here you cannot receive the birth certificate without those two cards. Since they are staying far away from here, they will be forced to come again on another day.” -Woman, Temeke HospitalThe most consistently reported barrier was incomplete or confusing information on the process: “unclear and inaccurate information on how and where to get the birth certificates”, particularly around the issue of “the right date to get the certificate”. Some women understood after 42 days, others mentioned 40 or 43 days, and several did not remember. Despite the effort to improve access by bringing the new birth certification process to Temeke Hospital, distance was still an issue:One woman expressed an important concern over the nature of the hand-written birth certificates being issued, explaining that the certificates issued at Temeke Hospital are not permanent. To address this, she suggested that Temeke Hospital provide permanent certificates, similar to those issued by RITA, to prevent future inconvenience.Health workers supported the concept of issuing birth certificates free of charge in a district/regional hospital and noted an increased awareness regarding birth certification since the introduction of the new programme. However, several barriers were still reported. First, they described being understaffed and overstretched by the administrative burden of completing the delivery cards and logbooks in addition to responding to a high volume of births. Staff shortage was specifically cited by the health worker in charge of hand-writing birth certificates – when she has a day off, there is no one to cover the work. The second barrier expressed was the need for additional training and support. The new birth registration responsibilities were not included in the job descriptions of health workers responsible for implementing them. One nurse expressed that additional support and training opportunities would improve her motivation, but they are currently only offered to managers.Finally, a lack of resources was expressed by several health workers. Although women are supposed to stay for 24 h after birth, they are forced to discharge more quickly, typically after only 6 h due to high volume of births and limited capacity. Health workers must then provide women with the documentation and instructions within a shorter time, while responding to other duties, and women, soon after birth, are expected to retain these documents and information. Since there was no designated physical space for birth certification services, the nurse issuing certificates expressed difficulty in staying organized. The child’s clinic cards are required as proof of birth, however, occasionally the hospital runs out of cards to issue.“[UNICEF’s hand-written certificate initiative] is not yet owned by the government. You know, we depend on some sort of fund- that’s where the problem is.” -Ministry officialStakeholders reported that the existing birth registration system is highly centralized with a shortage of staff and resources to support timely registration. Several stakeholders cited inadequate funding as a source of constraint for implementing sustainable programs and discussed the system’s current dependence on donor organizations.Another issue with the lack of full government ownership of the birth registration process piloted at Temeke Hospital is that the handwritten birth certificates may not always be recognized as official. Several stakeholders suggested that families would still eventually need to purchase a printed certificate for official use. Another respondent shared that Tanzania planned to scale-up the new system at the administrative ward-level, potentially increasing government ownership, although there were no known plans to replace the existing system in larger hospitals such as Muhimbili.Our study identifies current barriers and enabling opportunities to improve birth registration following hospital birth in Tanzania. We compared the standard registration system with a pilot improvement scheme – the first published study from Tanzania, and among the first in any LMIC setting.We found that women who gave birth in hospital highly value the importance of birth registration, expressing an earnest desire for their child to have a birth certificate and providing examples of how it would benefit their wellbeing. Yet families are often blamed for failure to register births without adequate information and acknowledgement of their intentions . Their sWe found the complex processes of birth notification, registration and certification were the major barriers preventing families from fulfilling their intentions. Respondents were confused by the multi-step process and strikingly nearly half of respondents from Muhimbili reported having received a birth certificate at discharge, which was not currently possible. This alone could be a major contributor to why some families never take the next step to visit the civil registry if they misunderstand the birth notification form received from the hospital as a birth certificate. By contrast, under the pilot scheme in Temeke, 94% of women were clear they had not yet received a birth certificate at discharge, although were unsure about other aspects of process, including when to return and which documents were required.Instructions about the birth registration process in both hospitals are directed at women during the early postpartum period who are typically discharged within 6–24 h of giving birth. During this early postnatal period, women are busy recovering, caring for their newborn baby, preparing to travel home and receiving other information from their health providers. Providing written and pictorial instructions for women to take home could help navigate these complexities. Including the wider family and especially the baby’s father or other primary caregivers in hearing these birth registration instructions would also provide opportunities for clarifying questions to be addressed. Antenatal care visits provide additional opportunity to discuss the process and share information before birth, as over half of women in Tanzania attend four or more antenatal visits , 19, 29.The travel distances twice to the RITA office in Dar es Salaam to obtain the certificate were reported as significant barriers to birth registration. This concern was still expressed for the pilot scheme in Temeke Hospital despite the advantage of only one visit and potential to combine with attending for a postnatal check.Cost of the birth certificates was cited as a barrier by women at Muhimbili Hospital, in addition to opportunity costs of having to travel to the RITA office twice. Although Temeke Hospital was piloting free certificates and only one visit was needed, opportunity costs were still highlighted in terms of travel and waiting time. Women interviewed in Temeke with experience of the standard registration process with their previous children reported preference for the pilot process. Since 70% of the Tanzanian population live on less than $2 USD per day, all financial and opportunity costs associated with birth registration increase hardship for the poorest . This isOvercoming barriers to birth registration goes beyond family considerations. Health workers involved in the birth notification/registration process at both facilities shared their concerns about their high clinical workloads, shortage of staff, and how birth notification and registration was adding to their general administrative burden. Health workers had difficulty filling out the required paperwork while also trying to provide care. These challenges crosscut with the inefficient paper-based records system, and the difficulty of replacing lost birth notifications or clinic cards. This was more pronounced by health workers at Temeke Hospital with additional responsibility for issuing handwritten birth certificates. The lack of consistent physical facility space for birth registration, no colleague cross-cover for absence or leave, and job descriptions not updated to include these new responsibilities were stated. Many staff expressed the need for birth registration-specific training, sharing that current training programs are usually reserved for managers, and not for implementing staff.The strengths of our study include the mixed-method design using a large survey sample (> 8000 women) in addition to qualitative methods. We compared two different processes currently in use in Tanzanian hospitals. Our results detail not only the registration processes but include the experiences of both women and health workers, which are currently underreported in existing literature.However, our study also has limitations. Both hospitals are peri-urban/urban referral facilities within the limits of the country’s most populous region, which may affect generalizability of results. Our sample of women has a higher education level than average in the Tanzanian population, which may account for lack of variation in women’s response by educational level . StudiesThe purposive sampling and timing of the qualitative interviews with women must also be taken into consideration. All women interviewed on the postnatal wards had given birth mostly within 24 h and thus may have very recently received information on the birth registration process.The sample size for the in-depth interviews was relatively small yet many concerns were identified, which notably were not captured by the closed-question exit survey despite much larger sample size. Although data saturation was determined to be reached, the study may have benefited from a larger sample size for further comparison between hospitals.An important gap in our study is that we did not capture whether birth notifications had been provided to the 342 (4%) of women who had experienced stillbirth or neonatal death nor their understanding regarding death registration. This was to avoid further distress immediately after the loss of a child. Worldwide about 4% of neonatal deaths have a death certificate . A multiIn the past, attention has been focused on closing the gap between high immunization coverage and low birth registration coverage. Recent UNICEF reports suggest that similar methods are applicable to closing the gap between high facility birth and low birth registration , 6, 33. To improve coverage of birth registration, current systems require reducing the burden for both families and health workers. The existing system needs additional simplification and greater accessibility for families. Designated staff also need to be motivated by having registration-related duties explicitly stated in their job descriptions and by receiving training and supportive supervision.Whilst improving CRVS systems at the facility level, there are opportunities to ensure these data are linked with routine Health Management Information Systems (HMIS). Digitisation may facilitate interoperability between information systems for data usage . ImproviBirth registration systems in many parts of the world remain highly centralized, cumbersome and costly for both providers and families. Tanzania has strengthened its birth certification process with pilot schemes linked to increasing facility births. Many missed opportunities exist to further lift the burden of responsibility from families and health workers by simplifying the process and testing further innovations, such as giving the birth certificate at the time of discharge or through electronic registration. Context-specific adaptations with evaluation are needed to inform the most effective strategies for each country, including Tanzania, and accelerate progress for birth registration coverage so that every newborn everywhere counts.Additional file 1. EN-BIRTH study sites – National mortality rates and hospital context.Additional file 2. EN-BIRTH study exit survey questions.Additional file 3. Birth registration in-depth interview guides, EN-BIRTH study.Additional file 4. Birth registration thematic content analysis, EN-BIRTH study.Additional file 5. Exit survey-reported birth notification and certificate coverage, stratified by education level and socioeconomic status.Additional file 6. Ethical approval of local institutional review boards, EN-BIRTH study.