Preterm birth continues to be a leading cause of death for children under the age of 5 globally. This issue carries significant economic, psychological, and social costs for the families affected. Therefore, it is important to utilize available data to further research and understand the risk factors for preterm death.The objective of this study was to determine maternal and infant complications that influence preterm deaths in a tertiary health facility in Ghana.A retrospective analysis of data on preterm newborns was conducted at the neonatal intensive care unit of Korle Bu Teaching Hospital (KBTH NICU) in Ghana, covering the period January 2017 to May 2019. Pearson's Chi-square test of association was used to identify factors that were significantly associated with preterm death after admission at the NICU. The Poisson regression model was used to determine the risk factors of preterm death before discharge after admission to the NICU.n = 84) had normal birth weight (>2.5 kg), 3.3% (n = 40) had congenital anomalies and 30.5% (n = 367) were born between 34 and 37 gestational week. All 29 preterm newborns between the 18–25 gestational week died. None of the maternal conditions were significant risk factors of preterm death in the multivariable analysis. The risk of death at discharge was higher among preterm newborns with complications including hemorrhagic/hematological disorders of fetus , fetus/newborn infections , respiratory disorders , fetal growth disorders/restrictons  and other complications .Of the 1,203 preterm newborns admitted to the NICU in about two and half years, 355 (29.5%) died before discharge, 7.0% (This study demonstrate that maternal factors are not significant risk factors of preterm deaths. Gestational age, birth weight, presence of complications and congenital anomalies at birth are significantly associated with preterm deaths. Interventions should focus more on child health conditions at birth to reduce the death of preterm newborns. Preterm birth, since 2016, has been identified as the leading cause of under 5 mortality globally . This shPrematurity not only contributes directly to neonatal deaths globally but also increases the risk of death from other causes . These cRisk factors of preterm births, which also contribute to a large proportion of preterm deaths , have beA retrospective analysis of secondary data on preterm infants was conducted at the neonatal intensive care unit of the Korle Bu Teaching Hospital (KBTH NICU) in Ghana. Data extraction forms were used to collect data from folders from the pediatric department, the admission and discharge book at the nurse's desk, including copies of death certificates covering the period January 2017 to May 2019. All medical records of preterm infants pronounced dead on arrival at KBTH NICU, and those on preterm infants with incomplete data were excluded. Korle Bu Teaching Hospital NICU is a tertiary referral centre that is equipped with 20 incubators, 20 cots, and 10 radiant warmers. The unit manages ~2,500 newborns annually with about 10 new admissions each day. Preterm babies account for 50–60% of all new admissions. About 80% of the newborns admitted at the unit are referred from the KBTH labor wards and obstetric theatre. The rest are referred from peripheral hospitals. Data extraction span over 5 weeks with the support of five research assistants.The primary dependent variable for this study was the discharge outcome at NICU among preterm births, that is whether the preterm infant was dead or alive before discharge from NICU. Preterm infant deaths before discharge were confirmed from the duplicates of death certificates kept at NICU.Exposure variables were subdivided into maternal, delivery-related, and infant factors. Maternal factors included sociodemographic characteristics of the preterm infant's mother such as age, occupation, marital status, educational status, religion, parity, and HIV status of mother as well as maternal medical conditions. The place of delivery (whether at KBTH or other facilities), mode of delivery , and whether any resuscitation was done in an attempt to stabilize the newly delivered preterm infant, constituted delivery-related factors. Infant factors including sex of infant, gestational age in weeks at birth, birth weight, as well as the presence or absence of congenital anomalies and complications were also assessed.Birth complications in the preterm newborns were categorized using the WHO's International Classification of Diseases (ICD-11) for Mortality and Morbidity Statistics (Version: 04 / 2019) . The catThe data extracted from the medical records were cleaned, coded, and entered into a Microsoft excel 2016 spreadsheet and exported into Stata IC version 16  for final analysis. Descriptive statistics including frequencies, proportions, mean, and standard deviation were were used to describe the maternal and child characteristics by gestational age at bith. The line plot was also used to describe the preterm outcome after admission at NICU by the completed gestational age at birth in weeks.p-values of 1.000 indicating the model is appropriate. The statistical significance for the study was set at a p-value of 0.05.Pearson's Chi-square test of association was used to identify factors that were significantly associated with preterm outcomes after admission at the NICU. The Poisson regression model was used to determine the risk factors of preterm death before discharge after admission to the NICU. The variance inflation factor (VIF) was used to assess multicollinearity. The final multivariable model had a average VIF of 2.66 (range: 1.07–7.08) below the threshold of 10. The deviance and Pearson's goodness of fit test were both non-significant with n = 387, 30.4%), 2018 , and 2019  were reviewed. Due to missingness on some very important variables in the study, a total of 1,203 observations with complete information were used for the analysis of this study, 359 (29.8%) from 2017, 577 (48.0%) from 2018, and 267 (22.2%) from 2019 records  of them in the age range 30–39 years. A few 3.9% (n = 47) had no formal education whilst 18.7% (n = 225) of them had a tertiary level of education. One thousand and six (83.6%) were married and 54.0% (n = 650) of them had given birth to only one child. Fifteen (1.25%) of the mothers were HIV positive. The majority  of the preterm newborns were delivered at Korle-Bu Teaching Hospital, with over a third  of the births through cesarean section. About half  of the mothers had no maternal medical conditions. Among the 38 with maternal infectious diseases, hepatitis B was the common with 17, followed by syphilis with 12, urinary tract infection with 5 and 4 with candidiasis. About 50.5% of the preterm infants were males. Of the 1,207 preterm newborns admitted to the NICU, 15.9% (n = 192) of them had no complications and 42.8% of them required resuscitation. Less than a tenth  were born with normal birth weight (>2.5 kg), 3.3% had congenital anomalies and about a third  were born at 34 to 37 weeks  years with most (37 weeks .n = 355) died before discharge. Marital status  was significantly associated with outcome at discharge with higher mortality among single mothers (40.5%) compared to co-habiting (23.0%) and married mothers (29.3%). Also, place of delivery  was a significant factor with higher mortality among mothers who delivered elsewhere (41.1%) compared to those who delivered in Korle-Bu (27.9%). Mode of delivery  was associated with outcome at discharge with higher mortality among vaginal delivery (32.4%) compared to caesarean section delivery (27.1%). Death at discharge from NICU was also higher among preterm newborns who were resuscitated (38.8%) compared to the non-resuscitated (22.5%) . Mortality at discharge from NICU was higher among preterm births newborns with lower birthweight . Also, mortality at discharge from NICU was higher among newborns with congenital anomaly . Gestational weeks at birth was also associated with moratlity at NICU discharge  were the factors that significantly influenced the outcome of preterm infants at the KBTH NICU  of the newborns during the 28th gestational week survived. On the other hand, mortality were 17.1% and 15.9% among the newborns on the 35 and 36th week, respectively. The proportion of preterm newborns surviving at each gestational age increased steeply between 27 and 28th gestational weeks (from 14.7 to 43%) then increased steadily to 32nd gestational weeks before levelling from 34 to 36th gestational weeks. Proportionately more preterm before the 29th gestational weeks died than survive (57% of preterm die at 28 weeks). Half of the preterm newborns born between the 29 and 30th gestational week survived.p = 0.002), fetus/newborn infections , respiratory disorders , fetal growth disorders  and other complications .p = 0.010) and those with extreme low birth weight .Compared to those with normal weight at birth, the risk of death at discharge was significantly higher among those with very low birth weight . Compared to late/moderate preterm newborns, the adjusted risk of death was significantly higher among the very preterm newborns  and the extreme preterm newborns   .Three out of every ten preterm newborns (29.5%) admitted to the NICU died before discharge. The risk of death among these preterm newborns decreases as their gestational age increases. Those who were born extremely preterm (< 32 weeks gestation), had a higher risk of death compared to those born late preterm. Risk of mortality was higher among preterm new-borns with birth weight below 1.5 kg. The risk of death before discharge among preterm babies admitted at NICU was higher for babies with neonatal co-morbidities such as Haemorrhagic /haematological disorders of foetus, foetus/new-born infections, Respiratory disorders, Fetal growth disorders. The existence of complications and congenital anomalies at birth among preterm newborns increased the risk of death. The study, however, found that maternal conditions were not significant risk factors of death at the NICU.Preterm birth remains a major cause of perinatal, neonatal, and infant mortality , 18, 24.Neonatal mortality has long been known to be associated with gestational age, with decreasing mortality in infants as gestational weeks approach full-term , 29–31. Birth weight was also negatively associated with death in NICU. A very low birth weight (1.0 to < 1.5 kg) and extremely low birth weight (< 1.0 kg) significantly increased the risk of preterm death. Earlier findings have also indicated low birth weight (LBW) as a predictor of death in the first 24 hours after birth . ExtremeWhile birth weight is highly correlated with gestational age, studies that controlled for body size have reported a consistent relationship between prematurity and increased risk of morbidity and mortality . More roKangaroo mother care (KMC) is another intervention is being explored to improve the survival of low birthweight and preterm infants though the uptake is slow in low-to-middle-income countries –49. TherMaternal factors and delivery conditions were not significant risk factors of preterm death before discharge from NICU in the current study. This supports the earlier findings of Iyoke et al. that survival was not dependent on maternal risk factors in a retrospective review of singleton preterm and term births from 2009 to 2013 in a teaching hospital in Nigeria . ContrarThere is the need for further research into interventions that are safe, effective, and scalable in limited-resource settings, where most preterm-associated infant mortality occurs . It mighAlthough the study design adequately answered the study objective, the retrospective record review employed did not allow for some relevant clinical indicators of preterm birth implicated in literature, such as maternal lifestyle factors including smoking and alcohol intake, medications used by mothers during pregnancy, and record of antenatal care among others to be assessed. For the same reason, a very important predictor of preterm outcome such as single/multiple birth was not extracted. Furthermore, authors are unable to report on other method of determining gestational age and its possible impact on preterm classification.the data used in this study was obtained from just one tertiary facility. Hence the sample is not nationally representative and findings cannot be generalized for the country.Since the data was extracted from hospital records, issues of missingness of information on specific characteristics was common. This was evident from the flow chart in This study demonstrate that maternal factors are not significant risk factors of preterm deaths. Gestational age, birth weight, presence of complications and congenital anomalies at birth are significantly associated with preterm deaths. Interventions delivered during labour and birth including kangaroo mother care and the use of antenatal corticosteroids should be scaled up to ensure nationwide coverage so as to reduce preterm deaths. Additionally, further research involving national level data on preterm deaths and associated causes is recommended.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.The studies involving human participants were reviewed and approved by Korle Bu Teaching Hospital, Institutional Review Board, IRB No: KBTH-IRB/00010/2019. Written informed consent from the participants' legal guardian/next of kin was not required to participate in this study in accordance with the national legislation and the institutional requirements.HT conceived the study, prepared the data collection guide, and collected the data. HT and DOA researched the literature. SKA and YA were involved in the data analysis and result interpretations. SKA wrote the first draft of the manuscript. All authors reviewed, proofread, and approved the final version of the manuscript.


INTERGROWTH-21st Newborn Cross-Sectional Study (NCSS) charts were established and recommended for global application. However, whether one international reference is appropriate for all populations is still unclear. We aim to compare the updated Chinese birth size charts by gestational age with INTERGROWTH-21st NCSS charts.+0 to 42+6 weeks were measured in 13 cities in China from 2015 to 2018. Growth charts were constructed. The measurements of all these infants were evaluated by the methods of calculating their Z scores using the INTERGROWTH-21st standards. The prevalence of small for gestational age (SGA) and large for gestational age (LGA) based on birth weight was analyzed using Chinese charts and INTERGROWTH-21st charts.A cross-sectional survey was carried out, and the birth weight, length and head circumference of 24,375 infants born after uncomplicated pregnancies at gestational age ranging from 24Z scores were 0.10 for birth weight, 0.35 for length and − 0.02 for head circumference. Compared to the INTERGROWTH-21st charts, the Chinese birth weight percentile curves were higher except for the 90th percentile at 29–37 weeks gestational age, and the length percentile curves were higher after 33 weeks gestational age, while the 10th percentile of the head circumference was lower and the other percentiles were similar. The prevalence of SGA was 10.1% [95% confidence interval (CI) = 9.7%–10.5%] using the Chinese birth weight chart and 6.5% (95% CI = 6.2%–6.8%) using the INTERGROWTH-21st birth weight chart. The prevalence of LGA was 9.9% (95% CI = 9.5%–10.2%) and 8.2% (95% CI = 7.9%–8.6%) using the Chinese and INTERGROWTH-21st birth weight charts, respectively.The mean Chinese birth size charts based on infants born after uncomplicated pregnancies were different from the INTERGROWTH-21st charts. Differences in the classification of newborns by the two charts should receive attention, and whether the application of INTERGROWTH-21st in Chinese newborns will lead to misclassification needs to be validated in future clinical practice. The effective identification of high-risk newborns with abnormal growth plays an important role in health risk prediction, prognosis assessment and early intervention . Birth sBirth size charts by gestational age are usually established based on birth registration data –11. It iIn China, existing growth standards for the assessment of birth size were established in 1988 . Due to The cross-sectional survey was prospectively conducted in nine cities, which included Beijing, Harbin, Xi'an, Shanghai, Nanjing, Wuhan, Fuzhou, Guangzhou and Kunming, from June 2015 to November 2018. In addition, the other four cities  surrounding the nine cities were included after July 2017 to add the number of early preterm newborns. Some maternal and child health hospitals or general hospitals in these cities that met the following conditions were selected: (1) the number of annual deliveries was > 1000; (2) there were both obstetrics and neonatal pediatrics departments; and (3) medical equipment in neonatal pediatric departments was adequate. A total of 69 hospitals from the 13 cities were selected.+0 to 42+6 weeks’ gestational age and their exclusion criteria were: (1) twins or multiple births; (2) unclear gestational age; (3) in vitro fertilization; (4) congenital malformation, limb defects, fetal edema or chromosomal abnormalities; (5) both or one of the parents is of non-Chinese origin; (6) mother's height < 145 cm; (7) mother's age < 18 or > 40 years old; (8) mothers who smoked, consumed alcohol or abused substances at three months prepregnancy or during pregnancy; (9) mothers who continued to take corticosteroids or other immunosuppressants during pregnancy for more than one month; (10) full-term newborns  whose mothers had some risk factors for fetal growth restriction, including severe anemia (hemoglobin ≤ 60 g/L), gestational diabetes, preeclampsia, eclampsia, hyperthyroidism or hypothyroidism, cardiorenal insufficiency, chronic hypertension; (11) preterm newborns  whose mothers had some significant risk factors for fetal growth restriction, including severe anemia (hemoglobin ≤ 60 g/L), gestational diabetes that was not effectively controlled by diet or exercise intervention, severe preeclampsia, eclampsia, severe cardiorenal insufficiency , hyperthyroidism or hypothyroidism that could not be effectively controlled by drug therapy. It should be noted that the exclusion criteria of preterm infants were not as strict as those of full-term infants because of the limitation of the number of preterm infants who met these strict inclusion criteria, especially for those early preterm infants, as well as the fulfilling requirements on the sample size for constructing the growth charts as much as possible.Subjects were live newborns from 24The gestational age was calculated in exact weeks combined with the mother's last menstrual period (LMP) and pregnancy ultrasound assessment within the first trimester. The LMP assessment was used when the two methods estimate differed by < 1 week; otherwise, the early pregnancy ultrasound assessment was used. Those subjects were divided into 19 groups in complete weeks from 24 to 42 weeks of gestation.According to the statistical accuracy requirements for establishing growth charts, the sample size of each gestational age group should be generally at least 200 . In thisFull-term newborns aged 37–41 weeks of gestation were sampled by stratified cluster sampling according to sex and gestational age group in the selected hospitals of each city. Moreover, those full-term newborns were evenly distributed by season by random sampling from each season. Because the number of newborns born at 42 weeks of gestation and preterm newborns who met the inclusion criteria was limited, all newborns born at these gestational ages in selected hospitals of each city during our survey period were included when they met the inclusion criteria to meet their sample size requirements. A total of 24,375 newborns were investigated.Birth weight was measured within 12 hours of birth using a neonatal electronic weighing scale to the nearest 10 g. Birth length was measured within 24 hours of birth using an Infantometer to the nearest 0.1 cm. Head circumference was measured within 24 hours of birth using a flexible, nonstretchable plastic tape to the nearest 0.1 cm. All indicators were measured twice by two trained investigators according to the same standardized method , and theMeasuring equipment for length and head circumference at all sites was uniformly equipped, and the neonatal electronic weighing scales of all the sites were qualified by the unified standardized weights before investigation. Standardized weights  and steel rulers (accurate to 0.1 cm) served to calibrate the measuring equipment every week. It was required that the error not exceed 10 g for the electronic scale and 0.5 cm for the infantometer or nonstretchable plastic tape. Equipment whose error exceeded the range was corrected or replaced in a timely manner. All investigators had participated in rigorous specialized training and passed an examination before the investigation. Intraobserver and interobserver measurement errors were no more than 10 g for weight and 0.5 cm for length or head circumference. The same protocols and quality control methods were adopted across sites.t (BCT) distribution with cubic spline smoothing for birth weight and Box‒Cox power exponential (BCPE) distribution with cubic spline smoothing for birth length and head circumference according to the minimum value of global deviance, Akaike information criterion and Bayesian information criterion of the GAMLSS model among Box‒Cox Cole-Green, BCPE and BCT. The Z scores of measurements were calculated using the INTERGROWTH-21st standards (INTERGROWTH-21st-Newborn-tool-win20170217) [t test method of Z scores of measurements was used to compare the difference between Chinese newborns and the INTERGROWTH-21st standards. The 10th and 90th percentiles of birth weight were taken as the cutoff points for defining small for gestational age , appropriate for gestational age , or large for gestational age . The proportions of SGA and LGA and their 95% confidence intervals (CIs) were calculated using both Chinese charts and INTERGROWTH-21st charts, and the consistency in the classification of newborns using the two charts was analyzed.Baseline data were analyzed using descriptive statistics in SPSS 21.0. The Generalized Additive Model for Location, Scale and Shape (GAMLSS) –29 was e0170217) , 15, andTable The smoothing fitted centile curves for birth weight, length and head circumference from 24 to 42 weeks of gestation for males and females and their fitness with the actual observation values are presented in Fig. Z scores of measurements in Chinese newborns in each gestational age group are shown in Table Z scores of birth weight and length of Chinese newborns were higher than 0, especially the Z scores of newborns at 37–40 weeks of gestation, which were up to 0.14–0.25 for birth weight and 0.54–0.74 for birth length. The Z scores of head circumference were not statistically significant in most gestational age groups.The Figure using the INTERGROWTH-21st chart. The prevalence of LGA was 9.9% (95% CI = 9.5%–10.2%) using the Chinese charts and 8.2% (95% CI = 7.9%–8.6%) using the INTERGROWTH-21st charts. The prevalence of SGA and LGA using the two charts in different gestational age groups is shown in Fig. The prevalence of SGA was 10.1% (95% CI = 9.7%–10.5%) using the Chinese chart and 6.5% (95% CI = 6.2%–6.8%) Table New birth size charts were established based on infants born after uncomplicated pregnancies from various geographical regions of China. These sites are all located in provincial capitals or municipal cities, whose altitude is in the range of 3–397 m above sea level except for Kunming (1891 m above sea level). The per capita GDP of these provinces where all the sites are located in 2018 is higher than the national average , and the perinatal mortality rate of these provinces was 2.38–5.74 per thousand births, and their low birth weight rate was 2.45%–5.51% . The aven = 408), especially the sample size of each gestational age group under 28 weeks, which was even less than 10. Correspondingly, this study had a relatively large sample size (n = 4839) at 24–32 weeks. Due to the difference in the sample size, we still cannot confirm whether this difference in birth size at 24–32 weeks of gestation reflects the actual population difference. Additionally, the inclusion criteria of preterm infants and the model selection  in our study were not the same as those in the INTERGROWTH-21st project, which may cause slight differences between them.The INTERGROWTH-21st project has established birth size charts based on low-risk populations in eight countries, which are considered to represent ideal intrauterine growth , 15. SubIn clinical practice, the 10th and 90th percentiles of birth weight charts are generally used as the screening threshold for SGA or LGA. To further understand the significance of the difference in birth size between the Chinese population and the INTERGROWTH-21st NCSS population, we analyzed the centile curves of birth weight. The 10th percentile of the Chinese birth weight chart was higher than that of the INTERGROWTH-21st chart, while the 90th percentile at most gestational ages was lower than that of the INTERGROWTH-21st chart, especially at 29–37 weeks of gestational age. Using the two charts, we also found that the prevalence of SGA and LGA by the Chinese chart was higher than that of the INTERGROWTH-21st chart. In addition, almost all the SGA and LGA newborns classified by INTERGROWTH-21st were also SGA or LGA newborns classified by Chinese charts. Similar results were reported in another study from Guangdong Province of China, which showed that the rate of SGA and LGA by INTERGROWTH-21st was lower than that of the local birth weight curve  . It poinUnquestionably, whether a growth chart is appropriate requires a comparison of the occurrence of short- or long-term adverse health outcomes of newborns who are screened by different charts. A study on the relationship between neonatal birth size and adverse perinatal outcomes found that the risk of adverse outcomes of SGA newborns classified by only the race-based birth weight customized standard but not the INTERGROWTH-21st standard was still significantly higher than that of non-SGA infants. This suggests that the INTERGROWTH-21st standard may not identify SGA newborns with a high risk of adverse outcomes, especially in a population with a larger maternal body size. It is thought that local population correction is necessary to avoid misclassification when applying the INTERGROWTH-21st standard . SubsequThere were some limitations: (1) due to the strict inclusion criteria and the limitation of the number of premature births and time of the special investigation, the sample size of early preterm newborns was small, which may have a certain impact on the extreme percentile; (2) the exclusion criteria of newborns in this study were determined based on the common causes of abnormal intrauterine growth as well as other similar international studies , 15. TheIn conclusion, new birth size charts established based on infants born after uncomplicated pregnancies living in developed economic-social environments reflect the growth of Chinese infants born after pregnancies free from major complications. These growth charts were different from the INTERGROWTH-21st charts. Differences in the classification of newborns by the two charts should receive attention, and whether the application of INTERGROWTH-21st in Chinese newborns will lead to misclassification needs to be validated in future clinical practice.


Lipids are a complex group of molecules in the body, essential as structural, functional and metabolic components. When disbalanced, they are regarded as a cardiovascular risk factor, traditionally in cholesterol level evaluation. However, due to their complex nature, much research is still needed for a comprehensive understanding of their role in atherosclerosis, especially in the young. Several new lipid biomarkers are emerging, some already researched to a point, such as lipoproteins and apolipoproteins. Other lipid molecules are also being increasingly researched, including oxidized forms due to oxidative inflammation in atherosclerosis, and sphingolipids. For many, even those less new, the atherogenic potential is not clear and no clinical recommendations are in place to aid the clinician in using them in everyday clinical practice. Moreover, lipids’ involvement in atherogenesis in children has yet to be elucidated. This review summarizes the current knowledge on lipids as biomarkers of cardiovascular risk in the paediatric population. Cardiovascular diseases (CVD) are still the leading cause of morbidity and mortality worldwide . The undAtherosclerosis has already begun in childhood . Early aLipids are hydrophobic molecules playing key roles in cellular membranes, cell signaling and cell metabolism . They caThis review highlights the role of lipids in cardiovascular risk assessment in children. First, the systematic search approach, with comparison of previous similar review papers, is described. Next, the relevant lipids in cardiovascular risk assessment in children have been divided into three groups according to their evidence-based meaning in clinical practice. For each, the physiological function, as far as it is known, has been described along with current evidence in the context of cardiovascular risk in the paediatric population. We conclude by emphasizing the need for further research of lipid biomarkers in cardiovascular risk assessment in children.We searched for studies reporting on lipid-based metabolites  and their association with cardiovascular risk in children. Several layers of keyword search criteria were used in the PubMed, Web of Science and Google Scholar databases in the years from 2000 to 2022: children, paediatric, lipids, biomarkers, cardiovascular risk. The results were filtered according to their significance and association with the paediatric population. None of the reviews found presented lipid biomarkers as cardiovascular risk factors in the paediatric population, which makes our review unique. Therefore, reviews pertaining to adults were analyzed in association with a manual search of the relevant mentioned biomarkers in children. The most important good-quality studies are presented in Countless other lipid biomarkers are being researched; however, only the most clinically relevant, promising and established in children were included. For the purpose of this review, lipid biomarkers have subsequently been divided into traditional, newer and research biomarkers, as shown in The most common lipid determination methods include nuclear magnetic resonance and tandem mass spectrometry. The first provides a method for distinguishing and quantifying a wider range of lipoprotein subclassess. On exposure to a magnetic field, distinct lipoprotein subclasses emit a unique signal that is directly proportional to their concentration . It provTotal cholesterol is the most known cardiovascular risk factor among lipids. The molecular structure of cholesterol is lipoprotein, and it has a central hydrophobic core (primarily cholesterol esters and triglycerides) surrounded by a hydrophilic membrane , as presented schematically in Lipoproteins belong to the group of sterol lipids, with the exception of triglycerides, which are fatty acids. Measuring total cholesterol includes measuring chylomicrons, chylomicron remnants, very low-density lipoproteins (VLDL), intermediate-density lipoproteins (IDL), low-density lipoproteins (LDL), high-density lipoproteins (HDL) and lipoprotein (a) (Lp(a)). Triglycerides are major lipids located in chylomicrons (and their remnants), VLDL and IDL; meanwhile, cholesterols are abundant in LDLand HDL, but are also present in IDL and chylomicron remnants . Chylomicrons are made in the intestine by the dietary lipids, and their size depends on the amount of fat ingested. They are rich in triglycerides and are transported to the liver and peripheral tissues. Chylomicron remnants are the result of the removal of triglycerides from chylomicrons in the peripheral tissues. They have more cholesterol and are pro-atherogenic. VLDL are produced by the liver; meanwhile, the IDL are the result of the removal of triglycerides from VLDL by muscle and adipose tissue. They are pro-atherogenic. LDL are derived from IDL and VLDL and contain even more cholesterol, carrying the majority of the cholesterol in the circulation. HDL perform the reverse cholesterol transport from peripheral tissues to the liver and are regarded as anti-atherogenic . The relHypercholesterolemia is one of many cardiovascular risk factors in childhood, and it is indisputable that it can be identified from early years on as a prediction of future cardiovascular risk . It is oTotal cholesterol and LDL in children with obesity have been associated with fatty deposits in the aorta and coronary arteries with an onset in childhood ; additioAlthough CVD seem to be rare in childhood, the atherosclerotic process begins in childhood. Early and prolonged exposure to cardiovascular disturbance, such as dyslipidemia, contributes to premature CVD in ever-yonger adult populations . PaediatObesity in childhood presents an increased risk for many cardiovascular risk factors in young adulthood, among which dyslipidemia plays an important role. However, the risks of adverse outcomes among overweight or obese children who became nonobese by adulthood were similar to those among individuals who were never obese , emphasiIn this group we included Lp(a) and apolipoproteins, which play a crucial role in lipoprotein metabolism. They include apolipoprotein A-I (APO-AI), apolipoprotein A-II (APO-AII), apolipoprotein A-IV (APO-AIV), apolipoprotein A-V (APO-AV), apolipoprotein B-48 (ABO-B48), apolipoprotein B-100 (APO-B100), apolipoproteins C (APO-C), apolipoproteins E (APO-E) and apolipoprotein(a) (apo(a)) . Not allLp(a) is a lipoprotein that is very similar to LDL but that has a unique apolipoprotein—apo(a). Its genetic sequence is highly variable, resulting in a protein with molecular weight ranging from 300 to 800 kDa . Apo(a) Anyway, subclinical atherosclerosis seems less problematic in children with higher Lp(a) levels, demonstrated by their similar cIMT and pulse wave velocity (PWV), another marker of subclinical atherosclerosis , to chilApolipoproteins are a part of lipoproteins present in the hydrophilic membrane surrounding the hydrophobic core , as alreThey have a structural role and also act as ligands for lipoprotein receptors, guiding the formation of lipoproteins and serving as activators or inhibitors of enzymes involved in the metabolism of lipoproteins .Apolipoproteins A are a diverse group of apolipoproteins with different functions. Four molecules are discussed in the literature  .APO-AI is a major structural protein of HDL, accounting for more than two thirds of HDL protein. It is also an activator of lecithin cholesterol acyltransferase (LCAT), which converts free cholesterol to cholesteryl ester. High levels of APO-AI are considered anti-atherogenic . InverseAPO-AI is the most abundantly researched apolipoprotein A, mostly in a ratio with apolipoproteins B, which was shown to have a better predictive role in cardiovascular risk assessment in adults , with elAPO-AII is the second most abundant protein in HDL protein. Its role is unclear but it seems to be a strong predictor for CVD . Higher APO-AIV is associated with HDL, chylomicrons and lipoprotein-free fractions. Its precise physiological role is not yet determined; however, studies indicate that it might be involved in the regulation of food intake . APO-AV Apolipoprotein B is a product of a single apolipoprotein B gene expressed in the liver and intestine. It is later modified with mRNA editing, resulting in APO-B48 and APO-B100. APO-B48 is a major structural protein in chylomicrons and chylomicron remnants; meanwhile, APO-B100 is a major structural protein in VLDL, IDL and LDL. It is also a ligand for LDL receptors and thereby plays an important role in clearing lipoprotein particles. Elevated levels of APO-B100 are associated with a pro-atherogenic state . UnderdiMore commonly, the ratio between apolipoproteins B and APO-AI is researched, as has already been discussed above, emphasizing the proatherogenic effect of high APOB values, usually associated with obesity and subclinical atherosclerosis ,51,52. AAs other apolipoproteins present a possible therapeutic target, so does APOB, and a clinical trial with mipomersen, an antisense oligonucleotide inhibitor of APOB, was conducted. A double-blind, placebo-controlled study showed significant reductions of LDL, APOB and Lp(a) in adult patients with hypercholesterolemia at risk of coronary heart disease not controlled by existing therapies .APO-C lipoproteins are associated with chylomicrons, VLDL and HDL. APO-CI is an LCAT activator. APO-CII is a cofactor for LPL and therefore enhances triglyceride hydrolysis. Loss of its function results in marked hypertriglyceridaemia. APO-CIII is on the other hand an inhibitor of LPL, and it also inhibits the ligation of triglyceride-rich lipoproteins with their receptors. Loss of its function leads to hypotriglyceridemia and a reduced risk of CVD. Furthermore, inhibition of APO-CIII leads to a decrease in serum triglycerides, also observed in patients with LPL deficiency indicating another mechanism of triglyceride modulation independently of the regulation of LPL . AccordiAPO-E acts as an exchanger between lipoprotein particles and is associated with chylomicrons, chylomicrons remnants, VLDL, IDL and HDL. There are three common genetic variants: APO-E2, APO-E3 and APO-E4. APO-E3 and APO-E4 are ligands for LDL receptor, while APO-E2 only poorly binds to it; patients who are homozygous for this variant can develop familial dysbetalipoproteinemia. APO-E4 has also been associated with an increased risk of both atherosclerosis and Alzheimer’s disease . The latAs in the adult population, the genetic variant of APO-E in the setting of nervous function and brain injury has also been questioned and is also associated with the function of cell maintenance and repair . HoweverIn this group, we present biomarkers differing from traditional cholesterols and triglycerides as well as from their attached apolipoproteins that could present novel biomarkers for cardiovascular risk in children or even a therapeutic target in the future.Oxidized lipid molecules have been modified by lipid peroxidation, with the modification of both lipid and protein components promoting inflammatory and immunological mechanisms that lead to the formation of macrophage foam cells. The concept that the oxidation of lipoproteins is central in the pathogenesis of atherosclerosis was reported decades ago, and new reports of the relationship between oxidized lipids and subclinical atherosclerosis have since been incoming in the form of both in vitro and in vivo studies . In favoThe most commonly researched oxidized lipoprotein is oxidized LDL (Ox-LDL), which has already been associated with subclinical atherosclerosis, coronary and peripheral arterial disease, acute coronary syndrome and vulnerable atherosclerotic plaques in human studies in the adult population . It has Other factors might contribute to Ox-LDL levels, such as bilirubin levels, which can prevent lipid oxidation in vitro; it has been shown that lower levels of bilirubin contribute to increased Ox-LDL in obese children and adolescents . SimilarOther lipoproteins are being oxidized in the process; however, research on the paediatric population is scarce. With higher myeloperoxidase levels, higher oxidized HDL (Ox-HDL) was observed, reflecting higher oxidative stress in children . To some2ɑ, have also been associated with severe obesity in children [Lipid peroxidation byproducts, such as thiobarbituric acid reactive substances (TBARS), malondialdehyde (MDA) and 8-isoprostane Fchildren  and coulLipoprotein X (Lp-X) is an abnormal cholesterol-rich lipoprotein particle that can be found in familial lecithin:cholesterol acyltransferase deficiency, a rare genetic disease, and several hepatic disorders  with cholestatic liver disease . Cases wLipoprotein-associated phospholipase A2 (Lp-PLA2) is a platelet activating factor acetylhydrolase, which is found to be involved in atherosclerosis as an established and independent risk biomarker of atherosclerosis-related CVD. It is associated with LDL, HDL and Lp(a) , presentIts function has been researched more thoroughly—it hydrolyzes oxidized phospholipids that are further formed into lysophospholipids and oxidized non-esterified fatty acids. Lysophospholipids promote the expression of adhesion molecules, stimulate cytokine production and attract macrophages to the arterial intima , therefoIn children, similar trends have been observed, where Lp-PLA2 concentrations are elevated in children with hypercholesterolemia and associated with other markers of atherosclerosis, such as cholesterol levels and cIMT, suggesting its potential use in identifying early atherosclerotic changes in children . AdditioCeramides are components of all cell membranes, and, in addition to their structural function, they are also involved in immune cell function and inflammation . IncreasCeramides belong to sphingolipids. Among these, sphingosine-1-phosphate and sphingomyelin may play an important role in atherogenesis as they were found in atherosclerotic plaque. Furthermore, the inhibition of the de novo ceramide synthesis reduces the development of atherosclerosis . AdditioIn the adult population, ceramides have been recognized as significant predictors of cardiovascular death among patients with coronary artery disease or acute coronary syndrome, surpassing currently used biomarkers, and have been independently associated with adverse cardiovascular events ,123. In A specific disease, known in paediatric age, is Farber disease, which was first described in 1957; it is a rare, fatal, inherited metabolic disorder caused by mutations in the lysosomal acid ceramidase. The enzyme is responsible for ceramide degradation, and consequently ceramides accumulate in most tissues in these patients, leading to a spectrum of joint, cardiac, pulmonary and central nervous system defects and death by the age of 2 in the classical form of the disease. In the milder, although rarer, forms, some can survive into young adulthood .Lipids are a complex group of metabolites; traditionally, when disbalanced, they are regarded as a cardiovascular risk factor. However, due to their complex nature, much research is still needed for a comprehensive understanding of their role in atherosclerosis, especially in the young. Several new lipid biomarkers are emerging; however, for many, even ones that are not so new, the atherogenic potential is not clear and no clinical recommendations are in place to aid the clinician in using them in everyday clinical practice. Additional research to evaluate and to develop practical recommendations is encouraged.According to our knowledge, our review is the first to provide a comprehensive foundation for further research in lipid biomarker evaluation in the context of CVD in the paediatric population; however, due to the abundance of lipid molecules, not all could be included, which is the greatest limitation of this review. Our proposed list of lipid biomarkers should be further extended according to potential biomarkers found in the future along with their clinical assessment in cardiovascular risk stratification in children. Furthermore, proposed lipid biomarkers should be tested in a larger paediatric cohort with atherosclerosis assessment.


Preterm birth and its complications and the associated adverse factors, including brain hemorrhage, inflammation, and the side effects of medical treatments, are the leading causes of neurodevelopmental disability. Growing evidence suggests that preterm birth affects the cerebellum, which is the brain region involved in motor coordination, cognition, learning, memory, and social communication. The cerebellum is particularly vulnerable to the adverse effects of preterm birth because key cerebellar developmental processes, including the proliferation of neural progenitors, and differentiation and migration of neurons, occur in the third trimester of a human pregnancy. This review discusses the negative impacts of preterm birth and its associated factors on cerebellar development, focusing on the cellular and molecular mechanisms that mediate cerebellar pathology. A better understanding of the cerebellar developmental mechanisms affected by preterm birth is necessary for developing novel treatment and neuroprotective strategies to ameliorate the cognitive, behavioral, and motor deficits experienced by preterm subjects. Preterm birth is a significant medical condition that is the leading cause of neonatal mortality and infant morbidity worldwide . The WorPreterm birth is associated with a wide range of long-lasting adverse health outcomes, particularly neuropsychological deficits that include impairment of cognitive, behavioral, language, socialization, or motor-coordination functions. It is estimated that one or more of such neuropsychological problems develop in 25–50% of preterm infants .Due to their high social and medical importance, the origin of neurological problems associated with preterm birth has been extensively investigated in clinical and preclinical settings. At least some such deficits result from disruption of the cerebellum, the brain region involved in motor coordination, cognition, learning, memory, and social communication . NumerouIn light of the aforementioned confounding factors that accompany preterm birth and the limited availability of human cerebellar tissue samples, it was difficult to identify the origin and developmental mechanisms of cerebellar pathologies that were directly attributable to preterm birth based solely on human patient analysis. In recent years, however, the problem has been alleviated by the use of animal models, especially large animal models, whose cerebellar developmental programs are particularly similar to those in humans. In this review, we will first briefly describe cerebellar anatomy and development. Then, we will discuss experimental approaches and models used to analyze the effects of preterm birth on the cerebellum. Finally, we will describe specific developmental mechanisms disrupted by preterm birth and some adverse factors commonly associated with preterm birth.Neuroanatomy and development of the cerebellum have been most studied in the mouse but appear to be sufficiently conserved across mammalian species . Thus, wAnatomically, mouse cerebellum is divided into two lateral hemispheres and a vermis that is located between the hemispheres. Both vermis and hemispheres are subdivided by fissures into distinct folia, forming species-specific foliation patterns  Chizhik. The cerAlthough many of the aforementioned aspects of mouse cerebellar neuroanatomy also apply to the human cerebellum, certain species-specific cerebellar features exist in humans. For example, the human cerebellum has a surface area that is 750-fold larger than that of the mouse cerebellum. In addition, the human cerebellum exhibits greater folial complexity than the mouse cerebellum, and the human cerebellar hemispheres are enlarged relative to the vermis. Finally, the cerebellum contains approximately 80% of all neurons in the human brain, while it contains only 60% of the neurons in the mouse brain .Cerebellar development has been most extensively studied in mice. Thus, we will summarize cerebellar development, primarily based on mouse studies. Then, we will discuss developmental features unique to the human cerebellum.In both mice and humans, during embryonic development, the cerebellum originates from rhombomere 1, the most anterior segment of the hindbrain . The istA typical mouse pregnancy lasts 19 days. Excitatory neurons that populate adult mouse cerebellar nuclei arise from the rhombic lip between embryonic days (e) 10.5 and 12.5. Granule cell precursors (GCPs) migrate from the rhombic lip between e13 and e18.5, when the rhombic lip regresses in the mouse  Figure . After eIn the mouse, postmitotic Purkinje cells arise from the cerebellar ventricular zone between e10.5 and e13.5. By e17.5, these cells have migrated radially to form a cell cluster below the EGL that becomes refined into the monolayer several days following birth . Murine Although many aspects of cerebellar neurogenesis are conserved across mammalian species, notable differences exist between the cerebellum of humans and mice. These include significant differences in the cerebellar developmental trajectory, with mouse cerebellar development appearing “delayed” relative to that of human . For exaAlthough each cerebellar cell type employs a unique molecular program, it is essential to note that the development of different classes of cerebellar neurons depends on each other in both humans and mice. For example, Purkinje cells secrete the sonic hedgehog (Shh) protein that non-autonomously promotes proliferation of both GCPs in the EGL and inhibitory interneuron progenitors in the white matter . Thus, PHuman brain imaging studies were instrumental in revealing the adverse effect of preterm birth on cerebellar development, and analysis of postmortem human cerebellar tissue has begun identifying candidate cerebellar populations and the developmental mechanisms affected by preterm birth. However, interpretation of the results of human cerebellar postmortem tissue studies is complicated by numerous confounding factors, including hemorrhage, inflammation, and medical treatments, thereby necessitating the use of more controlled experimental animal models.Mouse models provided important insights into the mechanisms of neural pathology caused by adverse factors associated with preterm birth. However, the mouse is not best suited to study preterm cerebellar neurogenesis because of the considerable natural variation of gestational length between dams, the difficulties in accurately assessing gestational length, extremely poor survival of preterm pups, and the discussed above differences in the cerebellar developmental trajectories in humans and mice . Thus, min utero , doublecortin (DCX), and β-tubulin . Nor wasin utero in relatively hypoxic conditions and arterial oxygen tension sharply increases upon birth (Hes1)  . These oMultiple lines of evidence indicate that preterm birth negatively affects Purkinje cells. While analysis of postmortem cerebellar tissue from preterm infants and preterm pigs showed no difference in the overall density of Purkinje cells, the number of glutamate decarboxylase 67 (GAD67)—positive Purkinje cells was specifically reduced in the posterior cerebellum of preterm guinea pigs of both sexes . Consideex utero environment relative to in utero conditions, as hyperoxia was reported to inhibit the maturation and dendrite branching of Purkinje cells  in the vermis of preterm pigs relative to newborn term controls . HoweverThe different glial cell types that comprise the cerebellum are also affected by preterm birth. Particularly, preterm human infants exhibited a reduced density of Bergmann glial fibers in the cerebellar molecular layer . Since SPreterm birth also affected the development of oligodendrocytes, which are myelin-forming glial cells residing in the white matter of the cerebellum . ImmaturIn addition to directly affecting the cerebellar developmental program as described above, preterm birth is also associated with various complications or other factors that may adversely affect cerebellar development. Some of the most common of these adverse factors are cerebellar hemorrhage, inflammation, and the side effects of medical treatments. Although these factors are not uniquely applicable to preterm subjects and not all preterm infants experience one or more of these factors, preterm babies have a much higher chance of experiencing these factors than term infants. Thus, adverse effects on cerebellar development of hemorrhage, inflammation, and side effects of medical treatments are discussed briefly below.Cerebellar hemorrhage is a common complication of preterm birth that affects up to 37% of preterm babies . The immSimilar to human patients, cerebellar hemorrhage induced by collagenase injection in the mouse resulted in reduced cerebellar growth and persistent neurobehavioral abnormalities . The autin utero or after delivery. Maternal intrauterine infection with systemic fetal inflammation can trigger preterm delivery. On the other hand, the risk of postnatal neonatal infections is increased in subjects born preterm (Preterm subjects have a higher chance of experiencing infection/inflammation while still  preterm .Necrotizing enterocolitis with sepsis correlates with a reduced cerebellar diameter and white matter lesions in humans .Escherichia coli lipopolysaccharide (LPS) led to an increased number of microglia, cerebellar white matter injury, and loss of oligodendrocytes  and glial (such as Bergmann glia and oligodendrocytes) cells and to affect the maturation of neurons (Purkinje cells) and glia (oligodendrocytes). It is likely that premature exposure to an extrauterine environment, including its higher oxygen concentration relative to In addition to the early exposure to the extrauterine environment, preterm human subjects may also experience the adverse effects of hemorrhage, inflammation, and the side effects of medical treatments. The common association of preterm birth with other deleterious influences makes it challenging to identify which molecular pathways are specifically affected by preterm birth and which are affected by the confounding factors that frequently accompany preterm birth. Highly controlled studies utilizing large animal models that recapitulate the developmental trajectory of the human cerebellum are particularly needed to dissect the molecular mechanisms compromised by preterm birth and each of its associated factors. A better understanding of the mechanisms of preterm cerebellar pathology will help to develop therapeutic strategies to treat or prevent neurological deficits in babies that are born preterm.


Fear can impact childbirth experiences, yet most birth stories women hear portray birth as unfavourable, and women must actively seek out positive birth stories.We aim to explore how women feel when sharing positive birth stories and the socially constructed motivations for or against sharing. Research question: What are the experiences of women who share positive birth stories?A qualitative descriptive approach was adopted, adhering to Standards of Reporting Qualitative Research (SRQR) guidelines, and underpinned by an interpretivist research philosophy. Participants were recruited via Facebook using a non-probability, voluntary-response, purposive sampling method. Twelve English-speaking Western Australian women aged 24–38 years identified as having had a positive vaginal birth experience within the past 5 years. Semi-structured interviews were transcribed verbatim and analysed using thematic analysis.The theme Not Safe to Share and sub-themes The Perils of Sharing and Changing the Narrative explores how participants repeatedly felt unable to share their birth stories because society’s dominant view of childbirth was negative. It describes the experienced or anticipated reactions that contributed to feeling unsafe and how participants withheld or altered their stories to feel accepted. The theme Safe Spaces and sub-theme The Joys of Sharing, explored participants’ love of sharing their birth stories in safe spaces, allowing re-access to feelings of elation, validation of their stories, and opportunity to empower others.Women often feel reluctant to share their positive birth stories. Findings may help understand the lack of availability of positive birth stories in our society. Normalising the positive birth experience may improve the experience of sharing positive birth stories, potentially improving society’s view of childbirth. Birthing a baby is one of the most varied, unique, and life-changing experiences a woman may encounter in her lifetime. A woman’s experience of labour and delivering a baby can be influenced by her perceptions of childbirth, informed by things such as antenatal education , media eAvailable research has found that many women fear childbirth, afraid of complications for self or baby, inadequate or absent care by midwives or doctors , experieFear can be incited by the negative representation of childbirth, portrayed on television shows as excruciating, terrifying, and often depicts a woman, covered in sweat, screaming, laying on her back in a hospital bed, being tended to by an obstetrician . The topThe medicalisation of childbirth began in the seventeenth century with the introduction of educated doctors outranking midwives, whose knowledge from experience had been passed on from other midwives . Women wFear of childbirth can impact birth outcomes by increasing the rate of elective and emergency caesarean-section , or incrAn experimental study by Ucar and Golbasi , assesseThe term “positive birth” is subjective and may mean different things to different women, from the birth of a healthy baby through to feelings of euphoria, it is an appraisal made by the mother regardless of mode of birth and can include (but is not limited to) homebirths, caesarean sections, and medically managed births. Caregiver support is a significant contributor to a positive evaluation of childbirth, and women need to feel connected to their care provider through being heard, supported, and through continuity of care . To achiA Swedish study on positive births by Karlstrom et al , also fo, to understand the shared challenges of motherhood  be an empowering, amazing experience.” (Milena).“I think an initial mothers group going around in a circle and hearing everybody’s horrible experiences. I kind of felt that I couldn’t be too excited for myself because I didn’t want to hurt anybody else’s feelings, as silly as that sounds. But I guess that was, and because you don’t really know the group initially. So, you don’t want anyone to hate you straight away!” (Milena).Holding this positive view of birth appeared to thwart their ingroup membership with other parents, making them feel like a minority outgroup member. The vulnerability of sharing was strikingly evident in Mother’s Groups , where that connection to other new mothers was vital to forming new relationships based on shared experiences. One participant explained:Mother’s groups also provide an opportunity for new parents to validate their birth experiences and feel normal in this pivotal life event, an opportunity participants felt they were denied, not solely based on the views of the other parents, but also the child health nurse facilitating the group, “I was just getting a little bit of blankness from other people and child health nurse, nurse was like facilitating it, she was like smiling and I mean it looked a little bit strained” (Helen). Participants explained this was a common experience with health providers, including some doctors and obstetricians. Having specialists in the field consider their experiences outside the norm provides authority to beliefs of being abnormal, potentially impacting participant’s well-being.The sub-themes The Perils of Sharing and Changing the Narrative further explore situations when participants find themselves in situations deemed Not Safe to Share.The perils of sharing were the adverse reactions of others that shaped participants’ experience of sharing their stories and contributed to feeling ostracised when speaking about birth. Participants were concerned about other’s feelings when sharing their birth stories, worried about being perceived as judging the experiences of others, “People seem defensive or when I was sharing my positive experience with her, she was very defensive and made out that I was trying to criticise her for having a caesarean when that’s not what I was doing at all” (Bronwyn). Birth stories are so unique and varied, and there seems to be a constant comparison and evaluation when sharing. People try to reconcile the differences between their stories and others to feel justified and validated in their own experiences. It appears that when stories are too different to reconcile nuances, women must attribute these differences by classifying people as outgroup members.Participants were concerned sharing their birth stories would sound like bragging, “Oh, it makes you feel uncomfortable, like if I had been too, so that tall poppy syndrome stuff that’s like don’t be too big or too positive or too… because then you potentially look insensitive to someone else’s journey” (Simone). We argue that our Australian culture is a barrier to celebrating our achievements and feeling proud of ourselves. It is more accepted in Australian culture to focus on the negatives and challenges in stories than to revel in positivity and achievements, a sentiment captured by this participant, “Like you’re telling it because you know you had a lovely experience. It’s kind of like ‘Oh, I’ve got great hair today.’ Like yeah, yeah, good for you” (Stacey).Participants found others to be disinterested in hearing their stories and found it stunted conversations. Reactions included awkward shock and eye rolls, being labelled as “hippie”, “radical”, or “crazy”, and many participants found people would directly challenge elements of their stories, attributing them to inaccurate recall or luck. These reactions highlight how participants were at risk of being stereotyped by their positive birth story. One participant declared, “I’m not radical. I’m not extreme or anything. I’m not going underground to give birth” (Alison). Another participant felt she was perceived as “Someone who lived outside society” (Sarah). The notion of being radical or living outside society is language indicative of someone with outgroup membership, but what does that mean for mothers when they feel they do not belong to motherland? Participants spoke about how they altered or withheld their stories to avoid this, discussed further in Changing the Narrative.“It depends on the person and depends on what experiences they’ve had, because you sometimes have to temper what you say to people if they have not necessarily had a vaginal birth, or a positive birth… So, with people who are a lot more like pro-natural birth and stuff, I’m much happier to talk at-length, to use words like elated and amazing and remarkable and those kinds of things” (Stacey).Participants were discerning about sharing their stories, to protect themselves and their experience, whilst being accepted by others; “It’s just like [a] positive pivotal point in your life. And like the last thing you want to do is for anyone to put a dent in it. You know you’re just, you’re so protective of that experience” (Sarah). Participants would choose not to share, or omit positive descriptors from their stories, merely describing the mechanics of the birth, offering a brief description without going into any detail. One participant described:Changing the narrative allows participants to tell their stories in a way that aligns with the dominant view of birth, potentially allowing them access to ingroup membership and the opportunity to bond with other women over shared storytelling.“I said that like “Oh it was really beautiful” and then I immediately backed it up with “But unfortunately, even though like the birth went really smoothly, she’s been like, she’s been quite a colicky baby, so the, like it’s been really hard”, like I felt like I needed to put in that, like negative, to balance out things” (Helen).Participants spoke about justifying their stories by offering disclaimers or caveats. This gave participants the power of reconciling the differences in their stories, thus eliminating the need for others to attempt it. One participant felt compelled to include a negative aspect from parenting for balance:By adapting their stories to fit the dominant view, participants compromise their own authentic identity, potentially impacting their well-being. Participants who could tell their story authentically in a safe space exhibited feelings of excitement and joy explored earlier in the theme Safe Spaces.This study was the first to explore women’s experiences of sharing their positive birth stories to elucidate socially constructed motivations for or against sharing. Despite being open and excited to share their positive birth stories, the sample of 12 women often felt they were unable, as it challenged the dominant view of birth. The experienced and anticipated reactions from others made participants feel vulnerable and unsafe when sharing their stories, highlighting the differences of their experiences to the normative view of birth, making them feel like outsiders. Participants felt others invalidated their experiences by challenging details or attributing the experience to luck and would often protect themselves and their stories by changing the narrative. By withholding their stories, only sharing selected elements of their stories that fit the dominant view of birth or omitting positive descriptors and merely listing the mode of birth, participants mitigated the risk of outgroup membership. Participants enjoyed telling their birth stories in a safe space, which constituted people with similar experiences or views on birth, such as with many midwives, on dedicated Facebook forums, and with some close friends or family. Sharing their stories allowed women to access positive, euphoric feelings from their birth and feel reignited and elated. Sharing in safe spaces permitted participants to feel they belonged, an ingroup membership that created a space for validation of their own experiences. Participants felt motivated to share their stories to connect with and inspire other women to strive for positive birth experiences.Reports that participants felt surrounded by an overwhelmingly negative portrayal of childbirth from others and in the media is supported by existing literature , 6, and Participants’ reports of others challenging or invalidating their stories are consistent with Kay et al , who recParticipants’ motivation to withhold or part-tell their stories is compatible with Need-to-Belong Theory, which posits that people adapt their behaviours to seek approval from, and therefore connection to, others . To achiThe sub-theme The Joys of Sharing aligns with Johnson et al  findingsParticipants were very passionate about sharing their stories to empower future mothers to achieve the same positive experience. They attributed it to being informed, well supported, having autonomy over birthing decisions, trust in their body’s abilities, a positive mindset, and continuity of care, all of which is supported in the literature , 32, 35.From a broader perspective, if women who experience positive births feel silenced, positive birth stories may only ever be considered in isolation, perpetuating a negative view of birth. This may overinflate the negative aspects of birthing, giving prospective mothers the idea that something will inevitably go wrong, driving them to make decisions based on a dependence on technology and medicalisation in pursuit of safety . This moThe unique exploration of the experiences of women telling their positive birth stories and its contribution to the growth of research on positive birth experiences is a strength of this research. A potential response bias may limit findings, as women who feel unable to share their positive birth stories may volunteer to participate to access an opportunity to tell their story. This may mean women with positive birth stories who have many avenues for sharing their stories did not feel the need to contribute. The sample was also relatively homogenous as women were tertiary-level educated Caucasians recruited within a narrow network. This demographic may have greater access to factors that promote a positive appraisal of birth, such as access to information, autonomy of decisions, and adequate support. All participants were from Western Australia and may not be reflective of the experiences of women from areas outside this region. We recommend future studies replicate this research with a diverse sample to strengthen transferability of findings and consider including a quantitative component to capture how many women perceive their births as positive and feel comfortable sharing their stories.The inclusion of modes of birth that deviate from societal norms, such as home birthing, may influence reactions to participants’ birth stories, therefore skewing results and may be considered a limitation of this research. Future research may consider replication with the exclusion of non-hospital modes of birth; however, one could argue that the mode of birth contributes to the overall birth experience and is therefore relevant in sharing positive birth stories. The five participants in this study who delivered their baby at home attribute the calm, relaxed environment and autonomy of timeline and decisions to the positive evaluation of their experience.We acknowledge ZN’s position as the researcher in this study as a potential limitation. ZN’s biases stem from her own positive birth and experiences sharing her birth story. Although efforts have been made throughout the research to mitigate this bias, such as reflexivity, audit trail, member-checking, and researcher consensus, it is impossible to entirely remove this subjectivity. ZN’s experience also enabled her to provide participants with a safe space for sharing their stories, potentially supporting women to feel comfortable enough to provide a rich description of their experiences, which may be deemed a strength of this research.This study explored the experience of women who shared their positive birth stories. Participants often felt that it was not safe to share their birth stories in a society dominated by a negative view of childbirth. When participants were in a safe space, with like-minded people, they experienced the same validation and joys of sharing that many women usually gain from sharing a typical birth story. Participants often had to withhold or part-tell their story to feel they belonged when sharing their stories. This may help to understand the lack of availability of positive birth stories in our society and why women feel they must actively seek them out. Understanding the motivations behind sharing or withholding their positive birth stories may contribute to finding avenues to normalise the positive birth experience, potentially contributing to changing society’s view of birth, which will hopefully improve birth experiences in the future.One application of this research is developing an awareness of these experiences in perinatal care providers such as midwives, doctors, obstetricians, and child health nurses. Promoting a balanced view of childbirth at this authoritative level may encourage acceptance of positive birth stories, and validating stories during debriefing sessions may empower new mothers and facilitate acceptance. Antenatal education classes could also encourage portraying positive birth experiences and focus on educating women about the role of fear in childbirth and the importance of autonomy of decisions, information power, caregiver support, and faith in their body to deliver a baby.At the systemic level, including positive birth experiences in the media may accurately portray childbirth as the varied experience it is, working towards a broader view of childbirth in society. Normalising the positive birth experience may potentially allow women with all experiences the opportunity to share their stories more openly by broadening safe spaces for sharing. It may also illuminate the possibility of a positive birth experience for women, and they may feel empowered to strive towards achieving it for themselves.


To study the effect of the birthing room design on nulliparous women’s childbirth experience up to 1 year after birth.Although it is known that the birth environment can support or hinder birth processes, the impact of the birthing room design on maternal childbirth experience over time is insufficiently studied.n = 406) to either a regular birthing room (n = 202) or a new birthing room designed with more person-centered considerations (n = 204). Childbirth experiences were measured 2 hr, 3 months, and 12 months after birth by using a Visual Analogue Scale of Overall Childbirth Experience (VAS-OCE), the Fear of Birth Scale (FOBS), and the Childbirth Experience Questionnaire (CEQ2).The Room4Birth randomized controlled trial was conducted at a labor ward in Sweden. Nulliparous women in active stage of spontaneous labor were randomized (p = .002) and 12 months (p = .021) after birth compared to women randomized to a regular room. Women in the new room also scored higher in the total CEQ2 score (p = .039) and within the CEQ2 subdomain own capacity after 3 months (p = .028). The remaining CEQ2 domains and the FOBS scores did not differ between the groups.Women randomized to the new room had a more positive childbirth experience reported on the VAS-OCE 3 months (These findings show that a birthing room offering more possibilities to change features and functions in the room according to personal needs and requirements, positively affects the childbirth experience of nulliparous women 3 and 12 months after they have given birth. The experience of childbirth is of significant meaning for women and their families, both short and long term . In the Contextual and psychosocial elements within the birth environment significantly influence childbirth experiences and physiological birth processes . For insContextual and psychosocial elements within the birth environment significantly influence childbirth experiences and physiological birth processes.Having less clinical-like indoor hospital environments with controllable sensory stimuli, aromas, sounds, lights, comfortable furniture, and views of nature are beneficial for the health of persons admitted to hospitals . For birThere is also a lack of research concerning the effect of the built environment on women’s childbirth experience over time . TherefoWe hypothesized that when the physical design supports physiological birth by offering women enhanced freedom of changing features and functions in the birthing room, the likelihood of a positive childbirth experience will increase.ClinicalTrial.gov (NCT03948815), and ethically approved by the Regional Ethics Board (Dnr:478-18). The study procedures for the RCT followed the CONSORT guidelines and are described in detail in a study protocol  in Sweden . Women wprotocol .Randomization was undertaken between January 2019 and October 2020 at a labor ward located in western Sweden and with an annual birth rate of around 4,000 births . All ran>1 cm). Furthermore, only women who understood either Swedish, English, Arabic, or Somali or had access to an interpreter could be recruited. Women in induced or latent phase of labor or with a planned caesarean birth were excluded.Eligible participants for randomization were women aged 18 or more, classified as Robson 1 ; nullipaParticipant recruitment was carried out by the midwives and assistant nurses at the labor ward. Eligible women were asked to participate after labor ward arrival and confirmed active stage of labor, if both a regular room and the new room were vacant. All women gave signed, written consent to participate, and the time interval from labor ward arrival to randomization was set to be as short as possible to ensure an early allocation to the randomized room. The randomly computer-generated allocation list was managed by an independent agency. Information about the allocated room was printed in sealed, opaque envelopes sequentially placed in a study box at the labor ward. The recruiting care provider was not aware of the randomization sequence, and the independent agency ensured that the allocation list was followed. The women were provided with a four-digit ID code, which was printed on the sealed envelope.Follow-Up 1), while they were still in the birthing room. The questionnaire included a Visual Analogue Scale of Overall Childbirth Experience (VAS-OCE 1-10) and a modified Fear of Birth Scale (FOBS 0-100)   and was lication  but wereFollow-Up 2) and 12 months (Follow-Up 3), all participants were asked to complete another online questionnaire (Supplementary Information 2) sent to their email address with two reminders to nonresponders. These questionnaires included VAS-OCE, FOBS, and the Childbirth Experience Questionnaire version 2 (CEQ2) (After 3 (2 (CEQ2) . A data 2 (CEQ2) , 2004. I2 (CEQ2) .Follow-Up 1, since it was in congruence with the linear scales in the other instruments (CEQ2 and FOBS). Since VAS most often is used to measure pain, we chose to name the variable VAS-OCE to clarify that we measure overall childbirth experience.Assessing overall childbirth experience by using a VAS (continuous data) ranging from 1 to 10, where 10 is most positive, is routinely used in Sweden . In the How do you feel right now about the approaching birth? Answers are rated from calm to worried (0–100) and from no fear to strong fear (0–100), and the scales are summed and averaged to calculate a score. Since participants for this study answered the questionnaire after birth, we modified the FOBS to report the question retrospectively and prospectively: How do you rate worry and fear when you think about your completed labor and birth? and How do you rate worry and fear when you think about giving birth again?. Higher scores in the FOBS represent stronger childbirth fear. As suggested by the creators, a cutoff point of 60 and above was used to define the fear of childbirth  concerning the childbirth experience. For 19 of the CEQ2 items, the response format is a 4-point Likert-type scale ranging from 1 = totally disagree, 2 = mostly disagree, 3 = mostly agree to 4 = totally agree. For the remaining three items , answers are assessed on a linear analogue scale (0–100), which are subsequently transformed to categorical variables: 1 = 0–40, 2 = 41–60, 3 = 61–80, and 4 = 81–100. The items produce mean scores in the four domains as well as a total CEQ2 score. Higher scores in the CEQ2 reflect more positive experiences. The few women who chose to answer the self-reported questionnaire at 2 hr in Arabic (two women in the new room and none in the regular room) or Somali (one woman in the new room and none in the regular room) received the questionnaires at 3 and 12 months in Swedish, since there were no validated translations for FOBS and CEQ2 in these languages.The CEQ2  is a val2 test was used for nonordered categorical variables and Fisher’s exact tests for dichotomous variables. For group comparisons of the continuous variables included in the instruments , Mann Whitney U test was used due to nonnormally distributed data. We also estimated effect sizes r, as proposed by r> .1 is considered a small effect, r> .3 medium effect, and r> .5 large effect (n (%), and for continuous outcome variables as mean (standard deviation), median, quartile 1 and 3, and 95% confidence intervals for mean. Cronbach’s α was used to evaluate the internal consistency reliability of the domains included in the CEQ2 questionnaire.To compare differences between the two randomized groups, χe effect . ResultsA linear mixed effects model was used to describe the group differences in childbirth experience over the three time points. This regression model was chosen since it can provide information about the women’s individual change in childbirth experience over time but is also flexible since it has the capability to handle missing observations in the repeated measures data . The modn = 3) answered Follow-Up 2, but two of them answered Follow-Up 3 in Swedish. Of the total study sample, 397 participants were included in the per protocol population. Among the nine not included according to protocol, eight were recruited in latent phase of labor and one was erroneously allocated to neither the regular room nor the new room. The per protocol population included 396 responders to Follow-Up 1, 285 responders to Follow-Up 2, and 286 responders to Follow-Up 3.The study sample consisted of 406 women, where 204 were randomized to the new room and 202 to the regular room . ResponsThe demographic characteristics of the responders to the follow-up questionnaires did not differ between the randomized groups . Respondr = .18, p = .002) and 12 months  after birth, compared to women in the regular room  between the groups were not statistically significant on either of the follow-up questionnaires (p > .05).The women’s overall childbirth experience on a VAS-OCE 2 hr after birth was similar in both randomized groups, as previously presented . Women ilar room . The difown capacity  and in the total CEQ2 score  3 months after birth  at this time point (p > .05). There were no significant differences in any of the domains or in the total CEQ2 score between the groups 12 months after birth. Cronbach’s α coefficients for each of the four CEQ2 domains indicated internal consistency for the 3-month follow-up (new room vs. regular room); own capacity: α = .81 versus .80, perceived safety: α = .85 versus .86, professional support: α = .75 versus .85, and participation: α = .71 versus .74. Internal consistency was also seen for the 12-month follow-up; own capacity: α = .84 versus .84, perceived safety: α = .88 versus .89, professional support: α = .85 versus .82, and participation: α = .73 versus .85.Women in the new room scored higher within the CEQ2 domain er birth . No signB = −0.36, p = .005) and 12 months  after birth among women in both randomized groups (Supplementary Information 3). Women allocated to the new room scored higher in overall childbirth experience over time than women in the regular room  and these levels of fear remained after 12 months. In contrast, the reported fear of a potential future birth increased in the total cohort after 3 months  and remained after 12 months. This increase in reported fear did not differ between the randomized groups , participation , and for the total CEQ2 score . The change over time did not differ between the randomized groups in the total CEQ2 score or in any of the subdomains , but not for oxytocin augmentation . These adjusted analyses also showed slightly reduced B-coefficients considering the effect of the room on the VAS-OCE among all responders randomized to the new room. The difference regarding time and the interaction between time and the randomized group did not change after the subsequent analyses in any of the outcome variables .The significant effect of the new room in the CEQ2 subdomain own capacity and total CEQ2 score 3 months after birth, which additionally indicates more positive overall childbirth experiences. The statistically significant differences between the groups regarding the CEQ2 variables did not remain in the 12-month follow-up.This randomized trial shows that a hospital birthing room designed with person-centered considerations offering women possibilities to change features and functions in the room has a positive impact on the self-reported childbirth experience 3 and 12 months after birth. Women randomized to the new room had a more positive overall childbirth experience as reported on a VAS-OCE, 3 and 12 months after birth, compared with women randomized to a regular room. Study participants in the new room also had significantly higher scores in the CEQ2 domain This randomized trial shows that a hospital birthing room designed with person-centered considerations offering women possibilities to change features and functions in the room has a positive impact on the self-reported childbirth experience 3 and 12 months after birth.To our knowledge, this is the first quantitative evaluation of the effect of a specially designed hospital birthing room on women’s childbirth experience over several time points during the first year after birth. The study findings emphasize that the physical design of the room is one essential contributing factor for subsequent childbirth satisfaction, which supports our hypothesis. This is also in accordance with previous findings about the experiential value of a conscientiously designed birthing room . An explown capacity after 3 months, which indicates that they experienced a greater sense of self-efficacy and control during birth than women in the regular room. This may have been due to women in the new room being provided with more opportunities to modify physical aspects of the birth environment. Women may experience this as being allowed to prepare the environment for giving birth or, when expressing it from a biological perspective, to prepare the nest for the baby via expression of archaic patterns of behavior. This procedure is essential for birthing women and most certainly, in a subtle way, increases the sense of familiarity with the room, thereby enhancing oxytocin release and the experience of positive emotions . Nevertheless, it is challenging to measure experiences quantitatively, since aspects such as context, social support, interpersonal relationships, and physical and emotional senses need to be taken into consideration . A studyThe place and space for birth is not just created through the physical design but also through those who inhabit and interact within the room . AlthougThe findings of this study show the benefit of acknowledging the physical design of hospital-based birthing rooms. Nulliparous women randomized to a birthing room designed with person-centered considerations aimed at supporting the physiology of birth reported more positive overall childbirth experiences 3 and 12 months after birth than women randomized to a regular birthing room. When designing interventions and environments in hospital settings, it is essential to understand the psychological and existential dimensions of childbirth, since the dynamics and changes in labor and birth experiences influence outcomes. It is also essential to understand how remnants of archaic nest-building behaviors and experiences are still present in birthing women of today. The findings of the study confirm that the physical design matters to women in their assessment of childbirth experience, but we were unable to show the actual effect of the new room on the variables explored. Therefore, additional research is needed that qualitatively explores the impact of the birth environment design on women’s long-term childbirth experiences.From a mental health perspective, it is essential to understand the importance of emotional well-being in the transition to parenthood.A birthing room designed with person-centered considerations, where women and companions can adapt features and functions in the room in accordance with personal needs and requirements, positively impacts women’s birth experiences 3 and 12 months after birth.When striving to optimize care during labor and birth, both the physical and the psychosocial environment need to be improved.To value emotions, birth physiology and person-centered perspectives in labor ward design may be one strategy to help reverse the rising trend of medical interventions in labor that is observed in many hospital settings.Click here for additional data file.Supplemental Material, sj-pdf-1-her-10.1177_19375867221124232 for Impact of Birthing Room Design on Maternal Childbirth Experience: Results From the Room4Birth Randomized Trial by Lisa Goldkuhl, Hanna Gyllensten, Cecily Begley, Christina Nilsson, Helle Wijk, Göran Lindahl, Kerstin Uvnäs-Moberg and Marie Berg in HERD: Health Environments Research & Design Journal


For adults, vacations represent a break from daily responsibilities of work – offering the opportunity to re-distribute time between sleep, sedentary behaviour, light physical activity (LPA) and moderate-to-vigorous physical activity (MVPA) across the 24-h day. To date, there has been minimal research into how activity behaviour patterns change on vacation, and whether any changes linger after the vacation. This study examined how daily movement behaviours change from before, to during and after vacations, and whether these varied based on the type of vacation and vacation duration.Data collected during the Annual Rhythms In Adults’ lifestyle and health (ARIA) study were used. 308 adults  wore Fitbit Charge 3 fitness trackers 24 h a day for 13 months. Minute-by-minute movement behaviour data were aggregated into daily totals. Multi-level mixed-effects linear regressions were used to compare movement behaviours during and post-vacation (4 weeks) to pre-vacation levels (14 days), and to examine the associations with vacation type and duration.N = 9778 days) duration. The most common vacation type was outdoor recreation (35%) followed by family/social events (31%), rest (17%) and non-leisure (17%).Participants took an average of 2.6 (SD = 1.7) vacations of 12 (SD = 14) days’  and sedentary behaviour decreased  during vacation. Post-vacation, sleep remained elevated for two weeks; MVPA returned to pre-vacation levels; and LPA and sedentary behaviour over-corrected, with LPA significantly lower for 4 weeks, and sedentary behaviour significantly higher for one week. The largest changes were seen for “rest” and “outdoor” vacations. The magnitude of changes was smallest for short vacations (< 3 days).Daily sleep, LPA and MVPA all increased .The online version contains supplementary material available at 10.1186/s12966-023-01416-2. The demands of paid and unpaid work substantially reduce a person’s ability to freely allocate their time. A standard workday accounts for approximately half an adult’s waking hours , 2. AddiWhen considering movement behaviours, throughout any day a person’s activities may be considered on a movement continuum where they move between three broad behaviours of sleep, sedentary behaviour, and physical activity . FurtherVacations are an extended and relatively uninterrupted break from the usual demands on a person’s time, offering greater freedom in time allocation. Across a calendar year, a person is likely to take several vacations for multiple different purposes . The purHealth-focused vacation research has largely been directed towards physical and mental health and well-being changes associated with taking vacations. Broadly, vacations are associated with positive changes in self-reported health and well-being –11. Convn = 54) who went on vacations of longer than two weeks. Participants self-reported 7.4 h of sleep during vacation compared to 6.7 h pre-vacation. Cooper et al. , p < 0.001, + 1.5% respectively) before returning to near-baseline levels.Sleep increased significantly during vacation compared with pre-vacation . This significant increase persisted into the first and second weeks post-vacation . In contrast, post-vacation sedentary behaviour increased significantly from pre-vacation levels .Sedentary behaviour decreased significantly during vacation compared with pre-vacation  before decreasing relative to pre-vacation levels and persisting across each post-vacation timepoint .During and post-vacation time points were all significantly different to pre-vacation levels of light physical activity, however the direction differed. Light physical activity increased during vacation  before returning to pre-vacation levels immediately afterwards.Movement behaviours across the vacation period according to main purpose of the vacation  were broadly similar to the overall vacation period patterns Fig. . Generalp values are provided in Supplementary Table p < 0.001, -2.8%) from pre-vacation levels. In addition, the longevity of changes seems related to vacation length, with behaviours returning to pre-vacation levels almost immediately after short vacations, whereas changes persisted for several weeks after longer vacations for sleep and light physical activity.Movement behaviour changes over the vacation period appeared to differed by vacation length . The duration of vacation and type of vacation appeared to be associated movement behaviour changes, with vacations of 4 days to 1–2 weeks and outdoor recreation vacations associated with the most favourable changes. The largest significant during vacation changes were seen for vacations of > 1 week duration. Additionally, after vacations of > 1 week duration, sleep remained higher and light physical activity lower than pre-vacation for at least the first week. Finally, participant characteristics did not appear to influence changes in movement behaviours during or after vacation.This study is the first to explore movement behaviours across the 24-h day using a longitudinal design with objective measures. Our findings were consistent with the two previous studies using self-reported measures. For example, de Bloom et al.  reportedThe most consistent favourable changes across movement behaviours occurred in the 4 days to 2-week range, with these changes appearing to persist longer, the longer the vacation. This is consistent with the law of inertia, where people have set patterns of time use which are difficult to perturb . When a When considering the type of vacation, outdoor recreation was the only category where all movement behaviours had significant favourable changes during vacation. This may be because outdoor recreation vacations are ideally suited to physical activity with two important facilitators, the natural environment and free time, available in abundance . FurtherMost participants in this study worked in office-based occupations, on a Monday-to-Friday schedule. The large decrease in sedentary behaviour from weekdays to weekends is consistent with previous literature of office workers  and is aTo our knowledge, this is largest ever study of movement behaviour patterns during vacations, as well as the first study of vacations that captures 24-h objective movement behaviour data. Use of a remote data collection method meant there were minimal barriers to participants’ involvement in the study when away from home.This study explored activity behaviour patterns exclusively, with minimal knowledge of participant motivations, vacation destinations, itineraries or vacation companions. This sample had a high concentration of vacations during the Australian summer (December and January) and it is possible the time of year when a vacation is taken may be associated with movement patterns, however, this was beyond the scope of the current study. The study sample was generally representative of middle-aged Australians. However, as the sampling frame was parents of primary school age children, when compared with national population data there were slight over-representation of people who were married / in de facto relationships, parents, employed persons and those with higher education. It must be acknowledged that the participants were all parents and city-dwellers residing in one major Australian city, and that the generalisability of the findings, especially for adults without children  and those who reside in non-urban areas  is unclear. The statistical analyses used in this study explored the 24-h day using individual models without direct comparison between movement behaviours. An alternative and more complex approach to account for direct interactions would be compositional data analysis. Whilst the sample size is adequately powered for overall analyses, it’s possible sub-group analyses on participant characteristics may be underpowered. Finally, data collection occurred during the COVID-19 pandemic. Importantly, within state travel was minimally impacted in South Australia during the study period. However, interstate and international travel was largely restricted. Australia adopted an elimination approach to the virus with widespread and varied border closures along with strict quarantine rules, adding up to two additional weeks to any cross-border travel. Participant choices of vacation destination, duration and vacation activities are likely to have differed from pre-COVID travel.Whilst the findings of this study suggest there may be an optimal length and type of vacation to yield the greatest favourable changes, the availability of vacation leave will ultimately dictate vacation options. Minimum yearly paid leave entitlements vary widely around the world. In Australia, the minimum is 4 weeks , whereasChanges observed during vacation are likely the result of a combination of factors, specific to each vacation. Whilst it is difficult to replicate this outside of the vacation setting, potential exists for interventions around the vacation. Future research should include experimental study designs, exploring interventions that encourage favourable behaviour change in the lead up to or after vacations. An interesting finding from the current study is the over-correcting of sedentary behaviour and light physical activity post-vacation toward less favourable directions which would suggest interventions aimed at reducing sedentary behaviour and increasing light physical activity at this timepoint may be warranted. There is potential to explore what specific behaviours a person engages with during vacation  that likely produced favourable changes and aim to incorporate these habits into daily life post-vacation. Another important consideration is exploring potential changes in mental health and well-being during vacation and how they are associated with movement behaviours. Exploring sleep changes in chronic under-sleepers would be of interest to observe if the same increases in sleep duration observed in this study are replicated in that population. Finally, a larger sample or a sample followed for a longer duration would allow more in-depth explorations into particular sub-groups identified within this study, i.e. vacation purpose, demographic subgroups.During vacations, favourable changes in movement behaviours  were observed, with these changes most pronounced in vacations of 4 days to 2 weeks long, and during vacation for outdoor recreation. Post-vacation, moderate-to-vigorous physical activity quickly returned to pre-vacation levels whereas sedentary behaviour and light physical activity tended to over-correct. Increases in sleep were apparent for around two weeks post-vacation, particularly after vacations longer than one week, and after outdoor and social vacations. These data provide preliminary evidence of the health benefits of vacations. Findings suggest that interventions timed immediately post-vacation may help combat unfavourable over-corrections observed in sedentary behaviour and light physical activity.Additional file 1:Supplementary Figure 1. Pre-vacation weekdays and weekends as a percent difference from vacation days.Additional file 2: Supplementary Table 1. Coefficients, standard errors and p values of data presented in Figs. Addtional file 3: Supplementary Table 2. During vacation changes in movement behaviours by participant characteristics.