Our findings indicated that observed associations between birth weight and future PCOS risk are more likely to be attributable to genetic pleiotropy driven by the fetal genome rather than a causal mechanism.Associations between lower birth weight and higher polycystic ovary syndrome (PCOS) risk have been reported in previous observational studies, however, the causal relationship is still unknown. Based on decomposed fetal and maternal genetic effects on birth weight , we conducted a two-sample Mendelian randomization (MR) analysis to assess potential causal relationships between fetal genome predicted birth weight and PCOS risk using a large-scale genome-wide association study (GWAS) including 4,138 PCOS cases and 20,129 controls. To further eliminate the maternally transmitted or non-transmitted effects on fetal growth, we performed a secondary MR analysis by utilizing genetic instruments after excluding maternally transmitted or non-transmitted variants, which were identified in another birth weight GWAS . Linkage disequilibrium score regression (LDSR) analysis was conducted to estimate the genetic correlation. We found little evidence to support a causal effect of fetal genome determined birth weight on the risk of developing PCOS . In addition, a marginally significant genetic correlation (r Polycystic ovary syndrome (PCOS), affecting 6% – 9% of women of reproductive age, is the most common endocrine condition . Based oMendelian randomization (MR), which is a causal inference technique using genetic variants randomly allocated during conception as instrumental variables, is less prone to residual confounding or reverse causation bias . In a prRecently, two large-scale genome-wide association study (GWAS) meta-analyses on PCOS released their summary statistics , 33, whihttp://egg-consortium.org) and the Icelandic birth register to construct two sets of instrumental variables (IVs) for the primary and secondary MR analysis, respectively. GWAS of birth weight conducted by the EGG Consortium included 406,063 individuals of European ancestry (-8) single nucleotide polymorphisms (SNPs) identified into 5 groups based on the effects of maternal and/or fetal genotypes on offspring birth weight: 1) fetal effect only, 2) maternal effect only, 3) fetal and maternal effects with the same direction, 4) fetal and maternal effects with the opposite directions, and 5) unclassified  .-8) genetic variants were selected from summary statistics of birth weight GWAS conducted by the EGG Consortium  was used for LD clumping, with the European subsample of 1,000 Genome Project data as reference panel . After that, data harmonization was performed to combine SNP-birth weight and SNP-PCOS associations using the “harmonise_data” function in the TwoSample MR package  and the PhenoScanner database . After excluding associated SNPs, 12 and 11 SNPs were retained as genetic instruments in each set of IVs, respectively  of PCOS risk for one SD change in birth weight.The multiplicative random-effects inverse-variance weighted (IVW) method was used as the main analysis , 39. WalTo test the MR relevance assumption , the F statistic was calculated for each genetic instrument in our study . FurtherGiven that the IVW method provides a biased estimate in the presence of unbalanced horizontal pleiotropy , we carried out sensitivity analyses by using several pleiotropic-robust methods, including MR-Egger , weighteA secondary MR analysis was conducted using the fetal genetic associations extracted from the birth weight GWAS by Warrington et al. , after eLDSR analysis was conducted to assess the genetic correlation between offspring birth weight and PCOS risk by using the fetal genetic associations with birth weight after adjusting for maternal genotypes. First, we conducted LDSR analysis based on summary statistics from birth weight GWAS conducted by Warrington et al.  and PCOShttps://github.com/bulik/ldsc) . LDSR analysis was performed using the LDSC software, version 4.0.0 (ik/ldsc) , 35.The main analysis by IVW suggested little evidence to support a causal relationship between fetal genome determined birth weight and PCOS risk. Causal effect estimates of fetal genome determined birth weight on PCOS risk in the primary MR analysis equated to an OR of PCOS of 0.86 (95% CI: 0.52 to 1.43) for one SD increase in birth weight  and the secondary IVs set , respectively. The proximity of the intercept to the origin in the scatter plot  between birth weight and PCOS on a genome-wide scale. Although the result of replication LDSR analysis showed a non-significant genetic correlation between birth weight and PCOS , the effect directions and magnitudes were consistent with one another.There was a marginally significant genetic correlation  alleles. Our findings provided little evidence for a causal effect of the fetal genome-determined birth weight on offspring developing PCOS in later life. These findings were consistent with previous observational studies that there was no difference in birth weight between women with PCOS and controls , 23, 48.MIR146A and ADIPOQ, both of which were related to PCOS, were associated with birth weight  to select genetic variants as IVs, and the outcome data were also extracted from the latest or largest GWAS meta-analyses on PCOS . Second,www.trialregister.nl) were included in both GWASs  may not be causally associated with the risk of PCOS in later life, the potential non-linear causal associations between low/high birth weight and PCOS development need to be further investigated. Further, strong evidence for the genetic pleiotropy between fetal-genome predicted birthweight and later life PCOS risk not only suggests a shared genetic basis but provides novel insight into the common intervention and treatment targets for these two phenotypes.The original contributions presented in the study are included in the article/Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. Written informed consent to participate in this study was provided by the participants’ legal guardian/next of kin.DL, YG, JuZ, and JiZ initiated the study. DL, YG, and JiZ undertook statistical analyses and drafted the manuscript. All authors contributed to the interpretation of analysis results and critical revision of the manuscript. All authors contributed to the article and approved the submitted version.


Such an unprecedented high number of samples in the context of in vitro gut microbiota modelling allowed a coverage of clinically relevant interpersonal differences in gut microbiota composition and function. A key finding was that cRG-I supplementation  lowered interpersonal compositional differences due to the selective stimulation of taxa that were consistently present among human adults, including OTUs related to Bacteroides dorei/vulgatus and Bifidobacterium longum (suspected keystone species), Bacteroides thetaiotaomicron, Bifidobacterium adolescentis and butyrate-producing taxa such as Blautia sp., Anaerobutyricum hallii, and Faecalibacterium prausnitzii. In contrast, both IN and XA treatments increased interpersonal compositional differences. For IN, this followed from its low specificity. For XA, it was rather the extremely high selectivity of XA fermentation that caused large differences between 15 responders and 9 nonresponders, caused by the presence/absence of highly specific XA-fermenting taxa. While all test compounds significantly enhanced acetate, propionate, butyrate, and gas production, cRG-I resulted in a significantly higher acetate (+40%), propionate (+22%), yet a lower gas production (–44%) compared to IN. cRG-I could thus result in overall more robust beneficial effects, while also being better tolerated. Moreover, owing to its remarkable homogenization effect on microbial composition and metabolite production, cRG-I could lead to more predictable outcomes compared to substrates that are less specific or overly specific.The human gut microbiota is characterized by large interpersonal differences, which are not only linked to health and disease but also determine the outcome of nutritional interventions. In line with the growing interest for developing targeted gut microbiota modulators, the selectivity of a carrot-derived rhamnogalacturonan I (cRG-I) was compared to substrates with demonstrated low  and high selectivity , at a human equivalent dose (HED) of 1.5 g/d. The high throughput of the ex vivo SIFR Prevotella, Bacteroides and Ruminococcus are three main contributors to the microbiota variation in healthy subjects [Over the past decades, the human gut microbiota has been related with human health and, when aberrant, to metabolic disorders  , inflammsubjects . Even ifAmongst strategies that aim to improve human health by targeting the gut microbiota, dietary fibres such as pectin-derived polysaccharides  and preb® technology , a high-throughput, bioreactor-based gut model, was shown to generate, within 24–48 h of incubation, insights down to species level that are predictive for outcomes of clinical studies where prebiotics are repeatedly dosed over 2–6 weeks [While a large number of test subjects is indubitably necessary to obtain representative insights in the human gut microbiota, it is particularly important when the aim is to assess the tentative selectivity by which a substrate affects the microbiota that can greatly differ among human subjects. In this context, a main disadvantage of the commonly used in vitro models is their low throughput. Moreover, current in vitro models may also be biased by substantial alterations between the in vivo derived microbiota and the microbiota that is establishing itself in the laboratory systems, both for short-term ,29,30,31–6 weeks .® technology was used to assess the selectivity by which cRG-I affects the composition and metabolite production of the human adult gut microbiota. The high throughput of the ex vivo SIFR® technology enabled the inclusion of 24 human adults in the study design, which was crucial for addressing this central hypothesis. The specificity of cRG-I was compared with IN and XA as examples of low-specificity and very high-specificity fibres.In this study, the SIFR®, Nutrileads, Wageningen, The Netherlands). Inulin is a polymer of β-bond-linked fructose residues with a chain-terminating glucose with a fructose:glucose ratio of 20:1. Xanthan is constituted of repeated pentasaccharides of β glucose moieties decorated with trisaccharide side chains comprising 2 mannose and 1 glucuronic acid units. cRG-I is a polydisperse pectic polysaccharide derived from carrot pomace and highly enriched (80%) in the RG-I domain. The monosaccharide composition of cRG-I is (% mol/mol): rhamnose, 14.3; arabinose, 34.8; galactose, 19.6; fucose, 0.8; glucose, 4.3; mannose, 0.9; xylose, 0.7; galacturonic acid, 25 (25). The schematic structures of the compounds are illustrated in The test compounds evaluated were IN from chicory , XA , and cRG-I  [The SIFRubjects) . BrieflyFive experimental conditions were tested for 24 human adults: a no-substrate control (NSC), a 0.3 g/d low dose of cRG-I (cRG-I_L), a 1.5 g/d high dose of cRG-I (cRG-I_H), 1.5 g/d inulin (IN), and 1.5 g/d of xanthan (XA) A. For eaFresh faecal samples were collected according to a procedure approved by the Ethical Committee of the University Hospital Ghent (reference number BC-09977). This procedure required participants to sign an informed consent in which they donated their faecal sample for the current study. The selection criteria for the 24 donor samples used herein were as follows: 25–65 years of age, no antibiotic use in the past 3 months, no gastrointestinal disorders , no use of probiotic, nonsmoking, alcohol consumption <3 units/d and BMI < 30. For this specific study, 13 male and 11 female donor samples were assessed. The age of the test subjects ranged from 28 to 61 years and was on average 37.8 years .SCFA  and branched-chain fatty acids  were extracted from the samples with diethyl ether, after addition of 2-methyl hexanoic acid as an internal standard. Briefly, 0.5 mL samples were diluted in distilled water (1:3), acidified with 0.5 mL of 48% sulfuric acid, after which an excess of sodium chloride was added along with 0.2 mL of internal standard (2-methylhexanoic acid) and 2 mL of diethyl ether. Upon homogenization and subsequent separation of the water and diethyl ether layer, diethyl ether extracts were collected and analysed using a Trace 1300 chromatograph  equipped with a Stabilwax-DA capillary GC column, a flame ionization detector, and a split injector using nitrogen gas as the carrier and makeup gas. The injection volume was 1 µL and the temperature profile was set from 110 °C to 240 °C. The carrier gas was nitrogen, and the temperatures of the injector and detector were 240 and 250 °C, respectively. The sample pH was measured using an electrode .g. DNA was extracted via the SPINeasy DNA Kit for Soil , according to the manufacturer’s instructions. Subsequently, library preparation and sequencing were performed on an Illumina MiSeq platform with v3 chemistry. The 16S rRNA gene V3-V4 hypervariable regions were amplified using primers 341F (5’-CCT ACG GGN GGC WGC AG-3’) and 785Rmod (5’-GAC TAC HVG GGT ATC TAA KCC-3’). Results were analysed at different taxonomic levels . The α-diversity (species richness) was estimated via the Chao1 diversity index. As compared to other indices, this index estimates the number of missing OTUs (and thus “counts the uncountable”) [Quantitative data were obtained by correcting abundances  with total cell counts , resulting in the estimated absolute cell counts per mL of different taxonomic groups. Initially, a bacterial cell pellet was obtained by the centrifugation of 1 mL sample for 5 min at 9000× ntable”) . Furtherwww.graphpad.comm, accessed on 23 November 2022), while the regularized canonical correlation analysis (rCCA) was executed using the mixOmics package with the shrinkage method for the estimation of penalisation parameters (version 6.16.3) in R  [p-values were corrected with Benjamini–Hochberg’s method [10-transformed values. Second, a value of a given taxonomic group below the limit of detection (LOD) was considered equal to the overall LOD according to the procedure elaborated by Van den Abbeele et al. (2023) [p-values corrections.All univariate and multivariate analyses were performed using GraphPad Prism  . Treatmes method  (FDR = 0. (2023) . FinallyPrevotellaceae, Bacteroidaceae, and/or Ruminococcaceae  increased the cell numbers significantly compared to the NSC A, indicaBacteroidaceae stimulation, the increase of the same phylum with XA was due to increases in Porphyromonadaceae. Further, IN mildly increased both aforementioned families along with the Rikenellaceae family. Likewise, the Firmicutes increase upon cRG-I and IN supplementation was due to increases in Acidaminococcaceae, Lachnospiraceae, and Veillonellaceae, while XA markedly increased unclassified families. Further, cRG-I_H and IN both increased the Actinobacteria phylum  upon cRG-I supplementation was marked and remarkably consistent across the 24 adults. This was already significant at the five-time lower HED of 300 mg/d cRG-I (cRG-I_L).Interestingly, the increased abundance of Bacteroidetes (and Bacteroides dorei/vulgatus and Bifidobacterium longum (Porphyromonadaceae members (OTUs related to Parabacteroides distasonis and P. merdae) and particularly an OTU4 related to Hominilimicola fabiformis  thus providing insights in less abundant taxa. A striking observation was that cRG-I significantly increased a broad spectrum of OTUs  belonging to Bifidobacteriaceae (2), Bacteroidaceae (4), Acidaminococcaceae (1), unclassified Clostridiales (1), Lachnospiraceae (18), Ruminococcaceae (3), and Veillonellaceae (1); including OTUs of health-related species such as Bifidobacterium longum, Bifidobacterium adolescentis, Anaerobutyricum hallii, and Faecalibacterium prausnitzii. In contrast, while a broad spectrum of OTUs tended to also increase upon IN supplementation, the large interpersonal differences of IN-related treatment effects resulted in only eight OTUs being significantly affected by the IN treatment. Finally, XA did not impact any low abundant OTUs suggesting a highly specific fermentation by the aforementioned Hominilimicola fabiformis and Parabacteroides species in donors harbouring a microbiota containing OTUs related to these species.All significantly affected OTUs (among the 100 most abundant) were also presented in a heat map  thus proR) and XA non responders (XANR) positioning in the middle and to the left, respectively  for each analyte, XA had the highest CVs for total SCFA, acetate, and propionate as well as gas production compared to other test compounds . The IN B. dorei/vulgatus and B. thetaiotaomicron correlated with acetate and propionate, while butyrate production was associated with the presence of OTUs related to Blautia species (OTU24/41), A. hallii (OTU33), and F. prausnitzii (OTU5). Further, for XA, marked correlations were established for XA-fermenting taxa: while OTU4/77 correlated with acetate production, the OTU related to P. merdae more strongly correlated with propionate . Of note, the striking decrease in interindividual variation had earlier been observed in a mouse model of enteric infection as well (manuscript in preparation). This confirms the remarkable homogenization effect of cRG-I, the coherence of the effect even across models and host species, and further confirms the predictivity of the SIFR® technology for the impact of fibre supplementation in (human) intervention studies [The high-throughput, ex vivo SIFRerotypes ,17,18,19 studies .Bacteroidaceae (B. dorei/vulgatus and B. thetaiotaomicron) [Bifidobacteriaceae (B. longum and B. adolescentis) [Anaerobutyricum hallii [Blautia sp. [Faecalibacterium prausnitzii [B. dorei/vulgatus and B. longum, suggesting that these species are likely keystone species for cRG-I fermentation, as previously suggested [Bacteroides species are generally known to possess a broad range of carbohydrate-active enzymes (CAZymes) within their polysaccharide utilization loci (PUL) [B. dorei/vulgatus seems to be the most competitive amongst Bacteroides species to ferment cRG-I. The initial fermentation of large cRG-I polymers by Bacteroides species likely releases cRG-I fragments that are then consumed by Bifidobacteriaceae, known degraders of arabinans and galactans, the main side chains of cRG-I [Bacteroides and Bifidobacterium species in the fermentation of complex polymers have been described before [Bifidobacteriaceae and Bacteroidaceae, but also to Acidaminococcaceae, unclassified Clostridiales, Ruminococcaceae, Veillonellaceae, and particularly Lachnospiraceae, all significantly increased upon cRG-I treatment. As demonstrated for other complex polysaccharides [The specific taxa that increased upon cRG-I treatment included, amongst others, acetate/propionate-producing omicron) , acetatescentis) , and butm hallii ,42, Blauutia sp. ,44, and usnitzii . The marusnitzii , correlauggested ,28. Whilci (PUL) ,47, B. dof cRG-I ,49. Suchd before . Moreovecharides , the higcharides ,22, cRG-Parabacteroides merdae, Parabacteroides distasonis, and particularly Hominilimicola fabiformis, a species recently isolated by Afrizal et al. via single-cell dispensing [H. fabiformis was characteristic of the microbiota of nonfermenters. This is in line with recent findings of Ostrowski et al. (2022) [Ruminococcaceae species (R. UCG13) to be the keystone degrader of the xanthan gum backbone via a novel glycoside hydrolase family 5 (GH5) enzyme. Interestingly, the 16S rRNA gene sequence of R. UCG13 revealed a >99% sequence similarity with H. fabiformis . While unable to ferment the high molecular weight polymer, Bacteroides/Parabacteroides species were shown capable of consuming oligosaccharides generated by the keystone H. fabiformis species. As XA thus classifies as a very high specificity fibre, it depends on the presence of keystone species capable of initiating its colonic fermentation to potentially lead to health benefits. Very high specificity fibres solely fermented by keystone species that are not consistently present among the gut microbiota of individuals (as is the case for XA) may thus lead to poorly predictable outcomes in human studies, as they increase the overall interpersonal differences upon supplementation.While XA also significantly decreased pH and boosted SCFA production , these changes were less pronounced compared to cRG-I, given that 9 of the 24 donors were nonfermenters to XA treatment. XA fermentation related to markedly increased levels of a very narrow spectrum of OTUs related to spensing . The abs. (2022) , who demCollinsella aerofaciens, Bifidobacterium adolescentis, Bacteroides ovatus, Bacteroides caccae, Ruminococcus faecis, and Coprococcus comes. Another example of the low specificity of IN was the marked correlation of the increase in Faecalibacterium prausnitzii and butyrate levels upon IN treatment in some but not all donors. Such a strong donor-dependent microbiota modulation is in agreement with recent studies that describe IN as a low specificity fibre used by a wide array of gut microbes [Bifidobacteriaceae is the most pronounced microbiota change commonly induced by IN in clinical studies [Bifidobacteriaceae in contrast to Bacteroides species that thrive better at higher pH [Bifidobacteriaceae. Overall, while low-specificity fibres (such as IN) offer the advantage that there are no or less nonfermenters, the outcomes of such interventions are less predictable as the baseline interindividual differences will be maintained or even enhanced.IN treatment also markedly enhanced the intersubject β-diversity. This resulted from donor-dependent increases of a variety of OTUs related among others to microbes ,25,35. A studies . In the  studies . Such a igher pH . The lowBifidobacterium species, albeit in a specific manner. The health benefits attributed to Bifidobacterium species are numerous and include antipathogenic effects, immune modulation, the prevention of gut disorders, and the production of beneficial metabolites and vitamins [B. longum and B. adolescentis strains as probiotics [Bacteroides and Bifidobacterium spp. acting as primary and secondary degraders, respectively, further promoting the cross-feeding of key anti-inflammatory species such as F. prausnitzii [A. hallii [Bacteroides spp., on the other hand, have been associated with health or diseased situations depending on the species, their intestinal location, and the host health status [As described above, inulin and cRG-I both stimulate vitamins ,57,58,59obiotics . While iusnitzii  and A. h. hallii . Bacteroh status ,64,65 buWhen focusing on changes in fundamental fermentation parameters, cRG-I resulted in significantly higher acetate (+40%), propionate (+22%), and thus also total SCFA levels (+32%) compared to IN, both dosed at an equivalent of 1.5 g/d. Nevertheless, gas production was significantly lower for cRG-I compared to IN (−44%). A strong gas production upon intake of IN (or other fructans such as FOS) due to a rapid colonic fermentation has been observed before and could result in limited tolerance at high doses ,67. InteBifidobacterium and Bacteroides spp. and this could lead to consistent health outcomes in humans.In conclusion, unlike IN, cRG-I and XA were shown to be high and very high specificity fibres, respectively, possessing chemical characteristics that likely allow them to be utilized by a selected or only a narrow group of intestinal commensals, thus supporting the need for developing more selective or targeted gut microbiota modulators with more predictable outcomes ,24,25. T


In European countries, postpartum depression (PPD) occurs in 13–19% of women. The statistics indicate that postpartum depressive disorders affect up to 300,000 women in Russia annually. There is still an extremely acute lack of psychological comfort provided to women during labor in Russia. To our knowledge, ours is the first study that examines the association between childbirth experience and the risk of PPD in Russia.We collected data from 190 Russian-speaking mothers, ages 19 to 46, (M = 32 ± 4.3) two months after their delivery. Birth satisfaction and physical well-being two months after delivery were significantly inversely associated with PPD. Birth satisfaction negatively correlated with the perceived severity and unpredictability of labor, and positively correlated with physical well-being two months after delivery. The presence of a partner and a personal midwife or doula at birth was associated with higher birth satisfaction. Our results emphasize the significance of childbirth satisfaction in the context of PPD and suggest the importance of individual professional support during labor. Postpartum depression (PPD) occurs in 13–19% of women globally , with anHigher rates of PPD have been observed in nations with significantly higher rates of income inequality, maternal and infant mortality, and women of childbearing age working more than 40 hours a week . In RussAn extensive World Health Organization (WHO) report in 2003 indicated a number of risk factors for PPD . The authors showed that a history of psychopathology before and during pregnancy, maternal neuroticism and difficult child temperament, lack of social support, and obstetric difficulties among others, present risk for development of PPD. While obstetric factors were reported to make a small but significant contribution to the development of PPD, the subjective experience of childbirth was not examined in this literature review.Newer evidence, however, suggests that a traumatic childbirth experience plays a major role in the development of PPD ; our preIn Russia, modern evidence- and ethics-based obstetric practices are still in their infancy, while the maternity healthcare system largely follows the conservative Soviet approach  a higher level of PPD symptoms was associated with a lower level of childbirth satisfaction, poorer physical well-being after delivery, and delivery mode ; and 2) a higher level childbirth satisfaction was associated with delivery mode , better physical well-being after delivery, and mode of birth support .Data collection took place from June 2018 to February 2019. The women received an invitation to take part in the study through thematic communities and training classes for moms-to-be and new parents. Questionnaires were sent to respondents via e-mail after their written consent to participate was received. The participants were interviewed two months after delivery (the average age of the children was 1.9 ± 0.22 months). The inclusion criteria were 1) being at least 18 years old, and 2) giving birth no more than two months ago.Table 1).One hundred ninety (190) women participated in the study. All participants spoke Russian and lived in big cities . The characteristics of the sample are presented in the 48.7% of the participants gave birth in Moscow and the Moscow Region; 14.4% in other regions of the Russian Federation; 18.2% in European cities; 9.6% in Israel; and 9.1% in former USSR countries.The Russian version  on a 5-point Likert scale . We also asked the participants to assess the perceived severity of their birth experience (“How hard was the birth experience for you?”) on a 5-point Likert scale (1 = "easy" to 5 = "extremely hard").We used the Russian version  of the Birth Satisfaction Scale Revised Indicator (BSS-RI), a short 6-item self-report questionnaire, to assess birth satisfaction . A 3-poiWe also asked the participants to assess their health condition at the moment of the screening (two months after delivery) on a 5-point Likert scale (1 = "very poor" to 5 = "very good"). Finally, we collected data on the participants’ socio-demographic characteristics, such as the number of children, the mode of delivery, gestational age, place and time of delivery, and type of delivery support.The main variables of the study were: PPD (based on EPDS scores); physical well-being after delivery; birth satisfaction (based on BSSR-RI scores); and the subjective severity and unpredictability of labor.Spearman’s correlation coefficient was used to estimate the relationship between PPD, birth satisfaction, physical well-being, and the predictability and subjective severity of labor.Multiple linear regression analysis examined the factors predicting PPD, where PPD was a dependent variable, and birth satisfaction, physical well-being after delivery, perceived severity of birth experience, and predictability of birth were entered in the model as the independent variables. The data met the assumptions for multiple regression analyses; the residuals were normally distributed after the square root transformation of the dependent variable. Model 1 explored unadjusted associations; Model 2 was adjusted for maternal age, gestational age at birth, and the number of children.We used the Kruskal-Wallis test to assess the differences in the levels of PPD, physical well-being, and childbirth satisfaction between the groups with different kind of labor support  and mode of delivery.We analyzed the differences in individual support depending on the country of birth by the chi-square test.All analyses were performed using IBM SPSS Statistics 22.Table 2). Women with higher PPD scores more often perceived their labor as severe . A serious discrepancy between the reality and expectations of childbirth was negatively associated with satisfaction with childbirth .The level of childbirth satisfaction correlated negatively with PPD  , emergency caesarean (ECS), or elective caesarean section (ELCS)), and the level of PPD. Neither did these groups differ in the quality of physical well-being after childbirth.Satisfaction with childbirth was significantly lower in women who had emergency caesarean sections than in those who gave birth vaginally . VB and ELCS women did not significantly differ in their levels of childbirth satisfaction. ECS mothers perceived their delivery as being more difficult than VB and ELCS mothers did . Similarly, the ECS mothers’ expectations about the childbirth tended to differ more often from the reality than those of VB mothers  and ELCS mothers .Table 1). Women who were accompanied by a midwife and a partner during childbirth showed the highest average level of childbirth satisfaction (Table 1). Significantly higher birth satisfaction scores occurred in the group with doula/midwife and partner support, compared to unaccompanied birth .In our study, 36.1% (n = 69) of the participants gave birth unaccompanied, while 69.3% (n = 121) had individual support .Childbirth satisfaction and well-being after childbirth did not significantly differ based on the country in which the delivery took place. However, there were significant country differences in the support given at the time of delivery, so that in Russia, women gave birth to a child without the support of her partner, a personal midwife or a doula more often than in Europe and Israel (ΧTable 3).Multiple linear regression analysis showed that levels of birth satisfaction, physical well-being after delivery, perceived severity of the birth experience, and the predictability of labor process contributed significantly to the regression model F  = 8.80; p< 0.001, and accounted for 26% of the variance in PPD. Significant predictors of PPD were physical well-being after delivery  and birth satisfaction . Controlled for maternal age, gestational age at birth, and the number of children the model explained 25% of variance in PPD  did not directly correlate with the risk of developing PPD. However, an emergency cesarean section seems to be harder for a woman, as this delivery mode was associated with lower childbirth satisfaction and the realities that fell short of the expectations. Subjectively, such childbirth is perceived as being more difficult.There are contradictory findings in this regard, with some studies reporting elevated risk of PPD following emergency cesarean section , while oOur study’s findings indicate that the level of childbirth satisfaction in Russia does not significantly differ from that in European countries and Israel. Specific to childbirth in Russia were lower rates of partner and doula support during the childbirth . This is the legacy of the Soviet system of obstetrics . The presence of a partner or other family member during labor was only allowed in state hospitals beginning in 2012; nowadays there is a growing trend for an increased number of deliveries with the partner present .Current Federal legislation in Russia does not establish woman’s right to have more than one companion during labor. However, our study shows that childbirth with a doula or individual midwife and a partner’s support is associated with higher levels of birth satisfaction and physical well-being after delivery. These results are consistent with the research data on the positive impact of doula assistance on the psychological well-being of women in childbirth . Thus, aOur study showed that birth satisfaction and physical well-being two months after delivery were inversely correlated with PPD. Perceived severity of labor and worse well-being after delivery were associated with lower birth satisfaction. The presence of a partner and a personal midwife or doula at birth was associated with higher birth satisfaction, which indicates the importance of the individual professional support during labor as a possible avenue for PPD prevention.We used self-report methods to assess the levels of depression. Clinical interviews would supplement the results and make them more valid. A more detailed questionnaire about the woman’s birth experience or a qualitative study would enrich the results about the association between birth satisfaction and perinatal affective disorders. Further research with the larger group with doula or midwife support is needed.


Homocysteine (Hcy) is a critical factor for cardiovascular injury, and the elevation of Hcy in children will inevitably increase the risk of cardiovascular disease in adulthood. This study explored the effect of very low-mineral water on children’s Hcy and cardiovascular health.t-test. The relationships between Hcy metabolism biomarkers and key factors, cardiovascular biomarkers, serum Ca, and mineral intake were analyzed with linear regression.This was a retrospective cohort study that recruited two groups of 10–13-year-old children who had consumed direct drinking water (DDW) in school for 4 years. The control group (NW)  consumed normal DDW (conductivity 345 μs/cm). The very low-mineral water consumption group (VLW)  consumed very low-mineral DDW (conductivity 40.0 μs/cm). Serum Hcy, Hcy metabolites, cofactors of Hcy metabolism, and cardiovascular biomarkers were assessed and standardized by age- and sex-specific Z-scores, and the differences between the two groups were analyzed with independent 2D3, vitamin B6 and B12, 5-methyltetrahydrofolate, and Apo-A1. Serum Hcy was positively associated with serum Apo-B and Apo-B/A1, and negatively associated with Ca intake from water and serum 1,25,(OH)2D3.Compared with the NW group, the VLW group had significantly higher serum Hcy, Apo-B, Apo-B/A1, and oxLDL, and lower serum 1,25,(OH)2D3, and disordering of calcium metabolism might play important roles. This study first established an association between demineralized drinking water and cardiovascular health in children, suggesting a new environmental concern risk to cardiovascular health.This study suggested that drinking very low-mineral water may increase Hcy level and oxidative stress, worsen lipid profile, and threaten the cardiovascular system in children. Reducing 1,25,(OH) Although CVD usually happens in adulthood, there is evidence that these diseases may start in childhood and adolescence , 2. ReceThere are two pathways of homocysteine metabolism . First, In our previous study, drinking very low-mineral water could increase blood homocysteine, high-sensitivity C-reactive protein (hs-CRP), and arginase levels compared with drinking tap water, and induce cardiovascular pathological lesions including interstitial edema, localized higher acidophily of cytoplasm, focal fiber dissolution, and fracture in the heart, mucoid degeneration, localized endothelial cell exfoliation, scattered foam cells, and localized intimal thickening in the intima of the aortic arch in rabbits . Drinkin3 2D3) in children in our previous study (2D3 is a cofactor in the transsulfuration of homocysteine by directly upregulating cystathionine β-synthase and is negatively associated with serum Hcy (Our previous study found that direct drinking water (DDW) on many primary school campuses are very low-mineral water resulting from the wide use of the reverse osmosis technique . Drinkinus study . 1,25,, including sleep, socioeconomic status, outdoor exercise time outside class, medication, lifestyle factors, medical history, family history of development-associated diseases, and consumption history of mineral or vitamin supplements. Total outdoor exercise time was calculated by adding the outdoor exercise time outside class and the time for morning exercises and physical education. Participants with the following conditions were excluded: had bone fracture or transferred from other schools during 2009–2013, absented themselves from annual health examinations or summer remedial in 2013 (which lacked exposure to DDW from August to September 2013), consumed mineral or vitamin supplements, had cardiovascular disease, digestive system disease, metabolic syndrome, or development-associated diseases , which had been investigated twice (in March and August 2013). They were calculated according to China Food Composition . What isThe developmental parameters, including systolic blood pressure (SBP), diastolic blood pressure (DBP), and cardiovascular and development-associated disease information, were obtained from annual health examination records in 2009 and 2013. Ten milliliter of blood was obtained in the annual health examination in 2013 (September 2013) for the blood test.2.2.2D3 were cited from our previous study , soluble thrombomodulin (sTM), Resistin, OxLDL, Malondialdehyde (MDA), and 3-nitrotyrosine (3-NT)], were assessed by commercial ELISA kits . The ratio of Apo-B to Apo-A1 (Apo-B/A1) was calculated by Apo-B/Apo-A1.Serum Ca, Mg, and 1,25,(OH)us study . Serum H2.3.Water samples (including tap water and DDW) were collected twice (October 2012 and May 2013). Their minerals were measured according to our previous study , 17, 27.The mineral intake from drinking water and total mineral intake was calculated as follows:Mineral intake from drinking water  = mineral content in DDW (mg/L) × daily consumption of DDW (L/d) + mineral content in tap water (mg/L) × daily water consumption at home (L/d).Total mineral intake (mg/L) = mineral intake from drinking water (mg/L) + dietary mineral intake (mg/L).2.4.t-test was used to compare the difference in socio-demographic characteristics, lifestyle factors, blood pressure, and mineral intake between the two groups. Differences in the sexual distinction between the two groups were analyzed using the Chi-square test.All statistical analyses were performed with SPSS for Windows version 18.0 . The independent-sample 2D3, Apo-A1, Apo-1, Apo-B/A1, hs-CRP, VCAM-1, sTM, Resistin, OxLDL, MDA, and 3-NT 2D3, z-Apo-A1, z-Apo-1, z-Apo-B/A1, z-hs-CRP, z-VCAM-1, z-sTM, z-Resistin, z-OxLDL, z-MDA, z-3-NT) were computed . Vitamin B6, B12, 5-MTHF, and Cys were divided by their Z-scores . The effects were assessed by binary logistic regression. Effects of mineral intake and serum Ca and Mg (age- and sex-specific Z-score) on z-Hcy, z-vitamin B6, z-vitamin B12, z-5-MTHF, z-Apo-A1, z-Apo-1, z-Apo-B/A1, and z-OxLDL were assessed by single linear regression, and their combined effects were by multiple linear regression. The independent effect of serum Hcy (age- and sex-specific Z-score) on z-Apo-A1, z-Apo-1, z-Apo-B/A1, and z-OxLDL and their combined impact on mineral intake were assessed by single linear regression and multiple linear regression, respectively.To avoid the influence of age and sex, standardized age- and sex-specific Z-scores of the mineral intake from drinking water and total mineral intake, serum Ca, Mg, Hcy, Cys, Met, vitamin B6, vitamin B12, 5-MTHF, 1,25,(OH)computed . The dif3.3.1.As we described in our previous paper , the min3.2.p ≥ 0.05, p ≥ 0.05, p < 0.05, p ≥ 0.05, p ≥ 0.05, As we described in our previous article , all thep ≥ 0.05, p < 0.01, p ≥ 0.05, There was no difference in daily dietary mineral intake, including Ca, Mg, Na, K, and Zinc, between the two groups in 2013 , children in the VLW group showed significantly higher z-Hcy, and lower z-Cys, z-vitamin B6, z-vitamin B12, z-5-MTHF, and z-1,25,(OH)3.4.p < 0.05, p < 0.01, After drinking DDW for 4 years (during 2009–2013), children in the VLW group showed significantly higher z-Apo-B, z-Apo-B/A1, and z-oxLDL, and lower z-Apo-A1 than children in the NW group   was negatively associated with serum Hcy, and positively associated with serum vitamin B12 and 5-MTHF (age- and sex-specific Z-scores)  positively associated with serum Apo-A1 (age- and sex-specific Z-score), and negatively associated with Apo-B/Apo-A1 and oxLDL (age- and sex-specific Z-scores) (3.6.2D3 was negatively associated with z-Hcy . The z-Hcy was positively associated with z-Apo-B and z-Apo-B/A1  was negatively associated with z-oxLDL 4.via dampening the excessive Na intake.In our previous study, we reported that children had seriously insufficient Ca intake from diets, which was in line with other studies . Drinkinvia consuming VLW might be associated with the lower Ca intake, as Tanaka reported in postmenopausal women 2D3 can directly upregulate cystathionine β-synthase, an enzyme involved in the transsulfuration of homocysteine, which is mediated by vitamin D receptor via binding together with the retinoid X receptor and acetylated histone H4 in the intergenic region of the cystathionine β-synthase gene 2D3 in this study, the disturbing of bone metabolism, which increased serum Ca when Ca intake was insufficient, was associated with serum 1,25,(OH)2D3. Therefore, serum 1,25,(OH)2D3 can disturb either homocysteine metabolism or Ca metabolism, and then played a key role in cardiovascular risk by consuming very low-mineral water.Dyslipidemia and lipid oxidation are risk factors for cardiovascular diseases –40. BothSome limitations to this study were reported in our previous paper . For exa5.2D3 disorders induced by insufficient Ca intake might play a key role. Although further studies are required to confirm this finding, we still suggest that children drinking very low-mineral water or reverse-osmosis purified water are exposed to many health risks besides retarded bone development.This study was the first trial to evaluate the association between long-term consumption of very low-mineral water and cardiovascular health in children. We found that consumption of very low-mineral water, even though it is not the only source of daily drinking water, might disturb homocysteine and lipid metabolism, increase oxidative stress, and then threaten cardiovascular health in children. Calcium and 1,25,(OH)The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by The Ethics Committee of Army Medical University, Chongqing, China. Written informed consent to participate in this study was provided by the participants’ legal guardian/next of kin.WS conceived the investigation and designed the exposure estimates. YH designed the exposure estimates, performed the experiment and statistical analyses, and drafted the manuscript. LL made substantial contributions to the data collection. YT and LW made substantial contributions to performing the experiments. JL and HZ performed the statistical analyses. JW assisted with and checked the statistical analyses and modified the manuscript. All authors contributed to the article and approved the submitted version.This work was supported by the National Key R&D Program of China (2021YFC3100100), the Military Major Program of People’s Liberation Army of China (Grant No. AWS18J004), and the Project of Chongqing Municipal Health Bureau (Grant No. 2012-2-447).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Widespread use of benzophenones (BPs), a group of environmental phenolic compounds, is suspected of interfering with human health. The association of prenatal exposure to benzophenone derivatives with birth outcomes including birth weight and length, head, arm and thoracic circumference, abnormalities, corpulence index and anterior fontanelle diameter (AFD) was investigated. Mother-infant pairs of 166 within PERSIAN cohort population in Isfahan, Iran, in the 1st and 3rd trimesters of pregnancy were assessed. Four common benzophenone metabolites including 2,4-dihydroxy benzophenone (BP-1), 2-hydroxy-4-methoxy benzophenone (BP-3), 4-hydroxy benzophenone (4-OH-BP) and 2,2′-dihydroxy-4-methoxy benzophenone (BP-8) were measured in maternal urine samples. The median concentration of 4-OH-BP, BP-3, BP-1 and BP-8 were 3.15, 16.98, 9.95 and 1.04 µg/g Cr, respectively. In the 1st trimester, 4-OH-BP showed a significant correlation with AFD in total infants, decreasing 0.034 cm AFD per a log unit increase of 4-OH-BP. Within the male neonates, 4-OH-BP in the 1st and BP-8 in the 3rd trimester were significantly associated with head circumference and AFD increase, respectively. Among female neonates in the 3rd trimester, increasing 4-OH-BP and BP-3 concentration was correlated with a decrease in birth weight and AFD, respectively. This study demonstrated that all the target BP derivatives can influence normal fetal growth at any age of the pregnancy, nevertheless, to support these findings further studies are needed in a large and different group population. Among them, endocrine-disrupting chemicals (EDCs) that may mimic and alter the function of hormones, have become a particular concern. Benzophenones (BPs) are one of the EDCs3 which are incautiously used as UV filters in personal care products (PCPs) and plastic packaging4. Benzophenones are also applied as flavouring ingredients, for the stabilization of odour, in sleeping tablets as well as in printing factories (IARC 2014)5. These compounds also naturally exist in several fruits and drinks like grapes, papaya and green tea7. BPs can be entered into the body by inhalation and ingestion, and through absorption on the skin. Recent studies have detected different BPs in water bodies and foods, and their metabolites in urine, blood and breast milk10. The main excretion path of the absorbed metabolites is via urine. Therefore, the level of exposure to the BPs can be determined by monitoring their metabolites in the urine11.The advancement of science and technology parallel to the improvement of human welfare has imposed ubiquitous and emerging pollutants on the environment and consumable stuff which raised health concerns of exposure to these pollutants13. According to the results of different studies and IARC reports, these chemicals are carcinogens to animals and potential carcinogens for humans (group B)5. 4-hydroxy benzophenone (4-OH-BP) and 2-hydroxy-4-methoxy benzophenone (BP-3) as derivatives of BP, with estrogenic activity and estrogen disruption properties, can accumulate in the blood, liver and kidneys through penetration from the skin and cause endometriosis and breast cancer18.Some of the potential health impacts of exposure to BP derivatives include carcinogenicity, endocrine dysfunction, eczema, toxicity to the ecosystem, growth, reproduction system and organs19. Many studies on the biological monitoring of BP metabolites have been performed in different countries, however, studies on pregnant women and their neonates are not extensive. It has been reported that BPs can alter the hormonal balance and interrupt the evolution of the reproductive system of the fetus21.Over the last decades, the BPs containing products' widespread usage and the risks associated with them have attracted the attention of researchers. The most vulnerable group to these pollutants is pregnant women and their infants. BPs in a detectable concentration can cross the placenta and enter the mother's amniotic fluid and fetus's blood circulation potentially affecting the fetus's normal development process19. Research has shown that maternity exposure to BP-3 reduces the pregnancy duration and birth weight of girls, but conversely, increases male infants' head circumference and birth weight by up to 0.3 cm25. Furthermore, paternal preconception exposure and maternal exposure to BP-2 significantly increased the chance of a baby girl’s birth, while exposure to 4 -OH-BP during this period increased the chance of a baby boy’s birth26.In China, monitoring the concentration of BP metabolites in pregnant women showed that increasing each logarithmic unit in 2,4-dihydroxy benzophenone (BP-1) and 4-OH-BP concentrations in the 1st trimester led to a 0.06 and 0.08 cm decrease in infant’s birth height, respectively. Reduced birth weight of newborns especially in girls was also associated with BP-1 and BP-327. In evaluating fetus growth, AFD is one of the most important parameters28. The average normal size of AFD at birth is 2.1 cm and usually, its large or small size indicates skull or systemic disorders in the body. The most common symptoms of large and protruding AFD are achondroplasia, congenital hypothyroidism, Down syndrome and rickets29.Considering the presence of BPs in a variety of substances and their adverse health effects on newborn infants and pregnant women, we monitored the most common and dangerous BP metabolites' urinary levels including BP-1, 4-OH-BP, BP-3 and 2,2′-dihydroxy-4-methoxy benzophenone (BP-8), in the first and third trimesters, the critical periods of pregnancy. In addition, we evaluated their association with birth outcomes such as birth length, weight and head, thoracic and arm circumference, anterior fontanelle diameter (AFD), infant sex, birth anomalies and corpulence index (CI). The association of urinary concentration of these metabolites with gestational age and the effects of gestational duration on infant's birth outcomes were evaluated comprehensively in our previous article31, as far as the authors’ knowledge, this study was conducted for the first time in this country, one of the huge cosmetic consumer regions in the world. Furthermore, the impact of some metabolites such as BP-8 on birth outcomes has not been reported by now in the literature. Because very limited studies regarding BP-1 and 4-OH-BP effects on birth outcomes are available, identifying the factors affecting this outcome is very important. Therefore, the results of this study can be helpful for future research and also for healthcare authorities, especially in the case of assessing AFD abnormality which can be a symptom of certain diseases in newborn infants29.Although a few studies have evaluated maternal exposure to other phenolic compounds such as parabens in Iran32.The participants of this study were a number of PERSIAN Cohort  pregnant women of Isfahan residences, the third most populous city and the second industrial hub of Iran. Individuals without any underlying and chronic diseases, having the same address for more than 1 year, and being in the first trimester of pregnancy were included in the study. Hormone therapy or having any hormone-related illnesses and working in occupations such as cosmetics manufacturing, packaging and printing industries and hairdressers that increase the risk of high exposure to BPs, were considered exclusion criteria. In the present study, 170 eligible pregnant women were enrolled in 2019–2020. However, some of them (N = 4) due to miscarriage were excluded from the study before the sampling. Sampling was conducted during the routine pregnancy visits of 166 remaining participants. In the early morning, fasting spot urine samples were taken from the participants. All the participants signed a consent form describing the objectives of the study, voluntarily participating and the needed information in the questionnaire. Trained experts recorded the demographic, socio-economic and lifestyle characteristics of the study population through a direct interview. The participants' pregnancy weight was measured in three stages, the first and third trimesters and before giving birth, in the hospital with a calibrated instrument. However, the pre-pregnancy weight was recorded based on their declaration. The birth outcomes of newborns were measured using the standard and calibrated devices and recorded by experienced nurses. The birth data for 166 infants belonging to the studied women were recorded immediately after delivery. The protocol of the current study were approved by the Persian Cohort Ethics Committee (IR.MUI.REC.1394.1.354), and all the methods used in the study were performed in accordance with the relevant guidelines and regulationsAnalytical standards of BP-8, BP-1, BP-3 and 4-OH-BP; MSTFA and β-glucuronidase enzyme were provided from Sigma Aldridge . Analytical grade acetone, methanol and trichloromethane as dispersing and extraction solvents were purchased from Merck . Stock solutions of the target compounds were prepared in methanol and stored in a dark vial at 4 °C until use. For preparing working standard solutions, the stock solution was diluted in synthetic urine and used for GC/MS calibration. An Agilent technology GC/ triple quadrupole MS was used for the quantification of the BP metabolites.Participants were asked to take a fasting urine sample by referring to the designated health centres in the early morning without changing their routine life patterns. The samples in the 1st and 3rd trimesters were taken within 10–14 weeks and 32–36 weeks of pregnancy, respectively. The urine samples were collected and stored at − 20 °C until analysis in polypropylene containers.27. Briefly, 3–5 ml of the urine sample was added to 100 μL ammonium acetate in a falcon tube (pH = 6.8). ß-glucuronidase/arylsulfatase was used to complete enzymatic digestion. For extraction, trichloromethane and acetone were mixed and added to the digested sample to make a cloudy state. After centrifuging the solution, the organic phase dried with nitrogen gas blow-up, and then MSTFA was added and centrifuged for a complete mix. Eventually, 1 μL of the obtained solution was injected into the GC/MS35.For extraction of the analytes, the dispersive liquid–liquid microextraction (DLLME) method was used which was explained in our previous study−1. Perfluorotributylamine was used to calibrate the mass spectrometer. To increase the accuracy and sensitivity, the selected ion monitoring (SIM) mode was set and mother ions of 193, 227, 285 and 343 m/z with the highest frequency were selected for quantification of 4-OH-BP, BP-3, BP-1 and BP-8, respectively. Initially, for separation of the metabolites, the column oven temperature was set at 90 °C for 2 min, then with an 8 °C/min temperature ramp raised to 290 °C, and at this temperature, it was kept for 5 min. Splitless was set for the injection mode and the temperature of the transfer line was kept at 290 °C.Separation was conducted by an HP-5 silica column with 3 m length, 0.25 mm I.D. and film thickness of 0.25 μm. Ultrapure helium was used as a carrier gas with a flow rate of 1 ml/min36. To create calibration curves, 0–100 µg/L of the four target benzophenone metabolites were spiked in the synthetic urine samples. The correlation coefficient (R2) of the calibration curve for BP-1, BP-3, BP-8 and 4-OH-BP were achieved at 0.996, 0.996, 0.993 and 0.993, respectively. For validation and reproducibility of the analytical method, quality control (QC) samples were used. A known amount of BP metabolites solution spiked into synthetic urine to achieve the target concentration of QC samples. All the procedures of the preparation method were applied for the spiked samples. Relative standard deviations (RSD) were calculated as an expression of the method's precision. Also, the accuracy of the method was investigated by the determination of the recovery percentage of known concentration of the target metabolites in synthetic urine samples. The average recovery percentage for the studied metabolites was 86.67%. However, we corrected our data with the correction factor of 1+ the recovery differences percentage achieved from spike samples measurements. Also, blank samples (synthetic urine without any BP metabolites) were used to investigate any possible contamination of samples by the experimental method. The limit of detection (LOD) and limit of quantification (LOQ) for each of the BP metabolites were calculated with 3 and 10 signal-to-noise ratios, respectively. LOD for, BP-1, BP-3, BP-8 and 4-OH-BP were 0.055, 0.045, 0.04 and 0.048 µg/L, respectively.According to the literature, synthetic urine sample was used for calibration, due to the lack of human urine samples without any EDCs and matrix effects on calibrationAnthropometric indicators including weight, height, head, thoracic and arm circumference as well as AFD were recorded at birth, in the hospital by experienced nurses. Newborns' length was measured from crown to heel in a straight position, and they weighed completely naked. The largest diameter of the head, from the back of the head and above the nasal septum, was measured as the babies’ head circumference. Neonatal Apgar score was also assessed and recorded in the 1st and 5th minutes of birth. The infants were also examined by a paediatrician for birth defects, including any type of defect that can be diagnosed after birth.37. Information about gestational diseases such as diabetes and hypertension were achieved through testing in routine pregnancy visits. Gestational age was calculated at the time of delivery considering the date of delivery and the date of the last menstrual period (LMP)38.The socio-demographic characteristics of mothers and infants and their classification are listed in detail in Table 40. In addition, to determine the rate of changes in the birth outcomes per unit increase of BP metabolites, the unstandardized single-linear regression model was applied. For this purpose, the statistically significant variables in the standardized multiple-linear regression model were log-transformed and introduced to the single-linear regression model. The potential confounders including gestational age, weight gain during pregnancy, pre-pregnancy BMI, passive smoking, household monthly income and education were taken into account in the correlation analysis. All of the mentioned statistical analyses were performed once for the total infants and then for sex-stratified male and female infants, in both the first and third trimester of pregnancy.The linear regression models were used to examine the associations between BP metabolites and birth outcomes. The standardized regression model was used to evaluate the effect size of the metabolites on birth outcomesp value < 0.05 was set as statistical significance.The level of BP metabolites that were less than LOD was replaced with LOD values divided by a square root of two. Also, the creatinine level of the samples, due to the possible differences in urine samples' dilution, was analyzed using the Jaffe method with Hitachi 704 auto-analyzer. After analysis, the volume-based concentration (μg/L) of the metabolites divided by the creatinine concentration (g/L) of urine samples, so that, adjusted with creatinine levels (μg/g Cr). However, statistical analysis was performed for both creatinine-adjusted and unadjusted data. The SPSS software, V.26 , based on two-tailed tests, was used for the statistical analyses and a 41, and these substances contain BPs that affect human health especially pregnant women and their neonates, no human studies have been conducted on BPs biomonitoring and their health effects in Iran.In this study, the correlation between maternal exposure to the most common BP compounds and birth outcomes in a population in central Iran was investigated. Although Iran is ranked the second-largest cosmetic consumer in the Middle East3.Table 43. Considering that the study population has resided in a warm and dry region of Iran with a high UV index and intense sunlight, which enhances the consumption of sunscreen, as a health care product containing BP-3, these findings were acceptable. The lowest concentration in the current study was assigned to BP-8, which might be due to the short half-life of this metabolite and being a minor metabolite of BP-344. 4-OH-BP showed a very significant decrease in the 3rd trimester (5.31 µg/g Cr) compared to the 1st trimester (13.43 µg/g Cr). This is a hydroxide metabolite of BP with a lower molecular weight compared to the other assessed metabolites. It can easily cross through the placenta and enter the fetal body. According to the literature, the transmission rate of 4-OH-BP from mother to fetus has been reported to be higher than other metabolites which supports our findings. Probably, this metabolite has a higher estrogenic activity even more than BP-3 which may explain the associations with fetal growth8. Thus, more attention is needed to regulate its use in cosmetic products and to monitor its exposure46.Table 46. In the current study, all metabolites were detected in the samples with a high percentage. BP-1 and BP-3 were detected in 100% of the samples in the first and third trimesters. 4-OH-BP in the first and third trimesters were identified in 98% and 82%, and BP-8 in 95% and 89% of the samples, respectively  of these metabolites in our study compared with the presented LOD  in that study47. Another study from china detected very lower rates of these three metabolites in both the first and third trimester of pregnancy48. The detection rate of BP-8 in the present study in the first and third trimesters was 95% and 89%, respectively. However, in most studies on pregnant women, the BP-8 has not been analyzed, or it was detected at a very low rate, about 13%46 and 2%42. These contradictory results can be attributed to the low LOD of this compound in the present study or the high median concentration of BP-8 (1.1–1.9 µg/L) in the first and third trimester of pregnancy probably due to the use of high BP-8-containing compounds. While in the mentioned studies the median concentrations were below 0.001 µg/L. Nevertheless, in our study, all the metabolites' detection rates are in accordance with the results of a study that evaluated BPs urinary concentrations in Chinese and American adults and children45.Similar to 4-OH-BP, BP-8, BP-1 and BP-3 can be easily transferred from mother to fetus due to their low molecular weight. Studies have shown that the median concentration of these metabolites in cord serum was higher compared to pregnancy serum. This reveals that the fetus is more likely than the mother to be exposed to these compounds, which may have harmful impacts on the health and normal development of the fetus during pregnancyThe composition profiles of BP derivatives in urine in the first and third trimesters are illustrated in Fig. 2, partly because of the differences in body build and muscularity49. Obesity and overweight cause a delay in the metabolism of BPs, leading to an increase in their levels in blood and urine50. In addition, these areas have very hot summers where people need to use a lot of lotions and sunscreens to protect themselves from the sun's UV rays. However, in Iran, due to cultural restrictions and religious beliefs, outdoor swimming pools or beach areas for swimming and sunbathing, which increase the need to use sunscreen for the whole body, are not used by women, so a small part of the skin comes in contact with BP-3 containing products. This could be proof of the lower concentration of BP-3 in our study compared to the US and Puerto Rico islands. Nevertheless, the concentrations of other metabolites  in our study were significantly higher than those reported in other countries. This can be attributed to the high use of cosmetics in this country, many of which are probably of low quality due to economic problems or the lack of strict rules for the production and use of these chemicals.Table Table 29. Therefore, 4-OH-BP possibly not only reduces the size of the neonatal AFD but also increases the risk of having an abnormal fontanelle size by increasing the size of head circumference. According to Table 8. According to the previous reports, the correlations of maternal exposure to EDCs with infants' birth outcomes could be sex-dependent51. Therefore, to determine the possible sex-specific effects of the BP derivatives additional stratification of the analysis was conducted by neonatal gender.Despite the great importance of AFD on neonatal health, no study examined the effect of benzophenone exposure during pregnancy on offspring AFD. However, a study that evaluated the size of neonatal fontanelle at birth, demonstrated that for each unit increase in neonatal head circumference, the size of AFD increases up to 52%19, of which we found no association. In the EDEN cohort study in France, per 1-unit increase in ln-transformed BP-3 concentration, 26 g of male birth weight and 0.1 cm of head circumference were increased, while in our study, a log-unit increase of BP-3 metabolite decreased by 12.8 g of male birth weight but increased 0.9 cm of head circumference  and thoracic circumference  in male infants, with twice stronger effect size on thoracic circumference than AFD. BP-8 due to the shorter half-life and difficulty in detection was neglected among researchers and we found no study by now that investigate the effects of BP-8 on these birth outcomes.Table ce Table 22. Howev19. Also, the study of American mothers in the third trimester showed that BP-3 reduced the birth weight of females and, conversely, increased the birth weight of males23. In our study, according to the unstandardized regression coefficient (B), BP-1 had the highest impact on birth weight among the other birth outcomes, decreasing male birth weight by 55.58 g  per a log unit increase of BP-1, maybe due to its high estrogenic activity59. In addition, a 1-unit increase in log-transformed 4-OH-BP in the third trimester led to a 10.46 g birth weight decrease in female infants and that in the first trimester led to a 49.69 g decrease in male birth weight  of BP-3 were correlated with a 0.26 decrease and 0.36 increase of standard deviation in the abdominal circumference of male and female infants, respectively52. We did not find any significant association between the BP derivatives and birth defects; this was probably due to the low percentage of neonate birth abnormalities in the study population.In the current study, there was no significant association between the sex of infants and the studied metabolites. However, some studies stated that BP-3 in the growing fetus targets sex hormones and interferes with estrogen and progesterone levelGenerally, the number of studies that examined maternal exposure to benzophenones and their effects on offspring outcomes is very limited. Usually, the conducted studies, have considered only the routine outcomes of birth, such as weight, height, and in some cases, head circumference. In addition, mostly the association of BP-3 with birth outcomes has been evaluated and other metabolites have not been investigated in a wide range. However, we tried to fill this gap by assessing the correlation of BP metabolites especially those suspected to have high estrogenic activity with a wide range of neonatal birth outcomes, which is the strong point of the study. In this regard, the results of this study can pave the way for further studies concerning the birth outcome of maternal exposure to benzophenones. Despite the many strengths of this study, the main limitation of the study was its coincidence with the Covid-19 pandemic, which caused many problems in sampling due to the high sensitivity of the study population. Given the broad pathways of exposure to BPs, including food and PCP products usage behaviour, it was impossible to select individuals without exposure to these chemicals as a control group. Therefore, the study was designed as a cross-sectional and the participant's urinary concentration of the BP metabolites were compared to each other, based on the level of exposure. This may be considered as another limitation of this study, because cross-sectional study cannot show causal relationships properly. However, this study is part of a cohort study which may cover this limitation and provide very useful information for the cohort study.This study evaluated exposure to benzophenone compounds during pregnancy and their possible health effects on birth outcomes including birth defects, arm circumference, corpulence index and anterior fontanelle diameter (AFD) along with other routine outcomes at birth. To the best of our knowledge, this subject has not been already studied in Iran, especially in the susceptible population such as pregnant women. We found very noticeable correlations within BP derivatives in both boys and girls. In total infants, 4-OH-BP in the first trimester showed a very significant correlation with AFD. In the third trimester, BP-8 was strongly associated with arm circumferences. The sex-specific analysis represented that 4-OH-BP in the first trimester and BP-8 in the third trimester had a considerable impact on boys’ head circumferences and AFD, respectively. However, 4-OH-BP, BP-3 and BP-1 had a negative correlation with boys’ birth weight in the first trimester. Within female neonates, in the first trimester no significant association was found, whereas, in the third trimester, the impacts of BP derivatives were more pronounced in girls with a significant converse correlation of 4-OH-BP with birth weight, and BP-3 and BP-1 with AFD. Our findings showed that all evaluated BP derivatives can affect fetus normal growth in the both early and late stages of pregnancy. However, due to the limited studies on this subject, further investigations are necessary to approve the results, especially regarding the scarcely evaluated birth outcomes.