Analyze if in utero exposure to economic downturns is associated with worsened birth outcomes.We used birth records from all live singleton births in the 27 Brazilian state capitals between October 2012 and December 2016  and linked them to local unemployment rates according to the mother’s residence. We estimated the association between different birth outcomes and the local unemployment rate in the three trimesters before birth. We included maternal characteristics and month, year and municipality fixed effects as covariates. We also estimated the association for different groups of mothers, based on marital status, educational level, age and race.A 1 p.p. increase in the local unemployment rate in the trimester before birth is associated with 2.68% higher odds of being born with very low birthweight (< 1500 grams) . That result is pushed by the effect among newborns from mothers younger than 24 , from mothers with 11 years of schooling or less , and from brown or black mothers . The associations among children born from younger, less educated and black or brown mothers are robust to the application of a procedure to control for multiple testing, albeit the results considering the whole sample are not.Our study shows that there is an association between in utero exposure to higher unemployment rates during the last gestational trimester and the odds of being born with VLBW among children born from mothers younger than 24 years old, with less of 11 years of education and black or brown. These results suggest that children born from women of low socioeconomic status are more vulnerable to in utero exposure to economic downturns. Determinants of health at birth have been an important concern in biomedical sciences and epidemiology for a long time . More reDifferent kinds of socio-economic and environmental aggregate-level shocks during gestation have been proven to have a significant effect on birth outcomes, e.g. armed violence , air polth percentile of the weight for gestational age distribution) are the main causes of neonatal death among children born without congenital anomalies [Most frequently studied birth outcomes are birthweight, gestational age and intrauterine growth restriction. Low birthweight , preterm birth , and the newborn being small-for-gestational-age  . That result is pushed by the effect among newborns from mothers younger than 24 , from mothers with 11 years of schooling or less , and from brown or black mothers . The association among children born from younger, less educated and black or brown mothers are robust to the application of a procedure controlling for multiple testing, albeit the results considering the whole sample are not. These results suggest that children born from women of low socioeconomic status are more vulnerable to in utero exposure to economic downturns.Sistema Unico de Saúde, i.e., the Brazilian National Health Service. Data are open access and available in: http://datasus.saude.gov.br/informacoes-de-saude/servicos2/transferencia-de-arquivos (last accessed: 13/08/2018). Data are duly anonymized before being released. Each observation corresponds to one live birth and provides information on the pregnancy, newborn, and maternal characteristics. Registration of birth information on the system is mandatory for all births in the Brazilian territory.In order to assess the birth outcomes, we used microdata from the SINASC-DATASUS, the System of Information on Live Births from the Department of Informatics of the We first selected data from all births between 2012 and 2016 from mothers residing in the 27 state capitals , because those are the years for which both unemployment rates at the subnational level and data from live births are available. We kept data only from singleton births , because birth outcomes in multiple births, specially birthweight, are significantly different. We then merged the data with the estimated unemployment rates in the mother’s city of residence. Information of unemployment at the municipality level is only available with quarterly frequency for the capitals of the 27 states, which are the units of the Federative Republic of Brazil. As data on local levels of unemployment are available from January 2012, we had to drop all births previous to October 2012 to have the local unemployment rate in the 9 months before the month of birth. Our final sample consisted on data of 2,952,430 live singleton births from mothers residing in any of the 27 Brazilian state capitals, born between October 2012 and December 2016.th percentile of weight for gestational age, according to the “International Newborn Size Standards” of the INTERGROWTH-21st Project [We used data on the following outcome variables: birthweight, gestational age, and sex. We considered sex as an outcome variable because there is evidence of a link between stress inducing events and a decline in the proportion of male births –19. We k Project ).Contínua), for the 27 state capitals. Data are available on the website of the Brazilian Institute for Geography and Statistics (IBGE): https://sidra.ibge.gov.br/tabela/4099#/n6/all/v/4099/p/first%2020/d/v4099%201/l/v,p,t/resultado (last accessed: 10/04/2019).Our explanatory variable is the mean local unemployment rate in the city where the mother resided during the pregnancy. We constructed that variable as the mean unemployment rate in the 9 months before the month of birth in the city  where the mother resided. We used the quarterly unemployment rate estimated by the Brazilian Institute of Geography and Statistics (IBGE), using the Continuous National Household Sample Survey , the second and third quarter of 2014 , and the fourth quarter of 2014 . We did the same for the months 1 to 3, 4 to 6, and 7 to 9 before birth to approximate the unemployment rate in the mother’s city of residence during each trimester of gestation.We included as covariates several maternal characteristics, namely: race , years of education , marital status . All missing values in these categorical variables were categorized with the pre-existing category “ignored” to avoid losing those observations in our regressions. In two different robustness checks, we tried both recoding all values originally categorized as “ignored” as missing values and keeping data exactly as original.Some clarification about the race variable in the Brazilian context is needed. “Brown” is the literal translation of the “pardo” category, which is used to refer to individuals of multiracial background. According to official estimations for the last quarter of 2016, 43.8% of Brazilians were white, 47.2% brown, and 8.2 black. White Brazilians tend to be from higher socioeconomic status. This is reflected on inequalities in the labor market. Among working population, in the last quarter of 2016, mean monthly income was approximately $817 American dollars for white individuals, $449 for black, and $455 for brown. Unemployment rates were also divergent: 9.5% among white people, 14.4 among black people, and 14.1 among brown people .We recoded the age of the mother  and created four different binary variables: 19 years old or less, 20 to 24 years old, 25 to 34 years old, 35 years old or more. We also recoded the variables indicating the number of children dead or alive into two binary variables indicating if the mother had at least one other child dead or alive. In the Brazilian vital registration system, miscarriages are recorded as dead children.We included also 12 fixed effects for the month of birth, 5 for the year of birth, and 27 for the mother’s municipality of residence, as well as the full set of interactions between fixed-effects.To estimate the association between the unemployment rate in the mother’s city of residence during pregnancy and birth outcomes, we used a fixed-effects model of the following form:yicma is one of the dependent variables described above, indicating birth outcomes for newborn i, born in the state capital c, in month m, and year a. Ucma is the estimated mean unemployment rate in the city c during the 9 months before the month m in the year a. The coefficient β, which measures the association between birth outcomes and unemployment rate during pregnancy, is the one of interest. Xi is a vector of maternal characteristics  for newborn i. Mm is a month-of-birth fixed effect to account for seasonal patterns in neonatal health. Aa is a year-of-birth fixed effect to account for possible shocks at the aggregate level. Cc is a fixed effect for each state capital city of residence of the mothers to control for underlying time-invariant differences among municipalities. θca is an interaction term between the city of residence and the year fixed effects to account for time varying factors at the local level. νma is an interaction term between the month and the year of birth fixed effects to account to time varying factors from month to month at the national level. ηmc is an interaction term between the month-of-birth and the city of residence fixed effect to account for local seasonality.Where To analyze the timing of the association between variations in the unemployment rate during pregnancy and birth outcomes, we estimated also a fixed-effects model of the following form:logit model) when the outcome variable was binary . Standards errors were clustered at the municipality level to correct for autocorrelation, as is recommended when working with data from repeated cross-sections [Where T = 1 indicates the months 7 to 9, T = 2 the months 4 to 6, and T = 3 the months 1 to 3 before the month of birth, and serves as proxy for the first, second and third gestational trimester, respectively. In all cases, we estimated the model by Ordinal Least Squares when the outcome variable was continuous  and by logistic regression , the coefficients can be interpreted as the marginal effect of a 1 percentage point increase in the local unemployment rate. For the cases estimated by In state capitals, mean birthweight is smaller, and there is a higher proportion of newborns with LBW and VLBW. Mean gestational age is shorter and there is a higher proportion of VPTB. The proportion of PTB and newborns SGA is smaller.Mothers in state capitals are comparatively older and more educated, and the proportion without a partner  is higher. Among them, the proportion of black and brown mothers is higher than in the rest of the country; and the proportion of white mothers is smaller.Among newborns from mothers younger than 24, a 1 p.p. increase in the mean unemployment rate in the mother’s city of residence during the months 9 to 7 before birth is associated with 5.23% higher odds of being born with VLBW . The mean unemployment rate in the last trimester before birth is associated with 6.84% higher odds of being born very underweighted . No significant association was found among newborns from mothers 25 or older.Considering level of education, among newborns from mothers with 11 years of schooling or less a 1 p.p. increase in the local unemployment rate during the months 1 to 3 before the month of birth was associated with 4.77% higher odds of being born with VLBW . No significant association was found among newborns from mothers with 12 or more years of education.We also analyzed the association between in utero exposure to fluctuations in the local unemployment rate and the odds of being born with VLBW separately for children born from white and for black or brown mothers. The rationale for that separation is that, during our period of analysis, mean income from work and unemployment rates among the black and brown population were similar and notably worse than among the white population . ChildreUnemployment rates could differentially affect the fertility decisions made by women and, therefore, introduce a selection bias. If that were the case, the odds of the mother having a certain characteristic would change in response to changes in the local unemployment rate. We regressed different maternal characteristics on the local unemployment rate in the months 10 to 18 Click here for additional data file.S2 Table(PDF)Click here for additional data file.S3 Table(PDF)Click here for additional data file.S4 Table(PDF)Click here for additional data file.S5 Table(PDF)Click here for additional data file.


In New South Wales (NSW) Australia, women at low risk of complications can choose from three birth settings: home, birth centre and hospital. Between 2000 and 2012, around 6.4% of pregnant women planned to give birth in a birth centre (6%) or at home (0.4%) and 93.6% of women planned to birth in a hospital. A proportion of the woman in the home and birth centre groups transferred to hospital. However, their pathways or trajectories are largely unknown.The aim was to map the trajectories and interventions experienced by women and their babies from births planned at home, in a birth centre or in a hospital over a 13-year period in NSW.Using population-based linked datasets from NSW, women at low risk of complications, with singleton pregnancies, gestation 37–41 completed weeks and spontaneous onset of labour were included. We used a decision tree framework to depict the trajectories of these women and estimate the probabilities of the following: giving birth in their planned setting; being transferred; requiring interventions and neonatal admission to higher level hospital care. The trajectories were analysed by parity.Over a 13-year period, 23% of nulliparous and 0.8% of multiparous women planning a home birth were transferred to hospital. In the birth centre group, 34% of nulliparae and 12% of multiparas were transferred to a hospital. Normal vaginal birth rates were higher in multiparous women compared to nulliparous women in all settings. Neonatal admission to SCN/NICU was highest in the planned hospital group for nulliparous women (10.1%), 7.1% for nulliparous women planning a birth centre birth and 5.1% of nulliparous women planning a homebirth. Multiparas had lower admissions to SCN/NICU for all thee settings .Women who plan to give birth at home or in a birth centre have high rates of vaginal birth, even when transferred to hospital. Evidence on the trajectories of women who choose to give birth at home or in birth centres will assist the planning, costing and expansion of models of care in NSW. In Australia, as in many high-income countries, women can choose to give birth at home, in a birth centre or in a birth unit. In New South Wales (NSW), the most populous state in Australia, there are over 97,000 births a year . Annual There is now strong evidence that for women with a healthy pregnancy, especially those having their second or subsequent baby, giving birth at home or in a BC is a safe option –12. The n = 832) were made by women and maternity care providers [The Australian National Review of Maternity Services released in 2009 sought perspectives from a range of stakeholders regarding maternity services in Australia in order to inform priorities for the development of the National Maternity Services Plan (The Plan) which was released in 2011 . As a reroviders . Consistroviders , 14.According to the 2016 NSW Mothers and Babies Report [While women usually choose where they would like to give birth at the beginning of pregnancy, the process is dynamic due to complications or risk factors that may develop, making the pathway or trajectory for women who plan to give birth at home or in a birth centre difficult to predict at a service level. A woman intending a homebirth, for example, may commence her pregnancy with no significant history of illness or pathology only to find her plans changed as the pregnancy continues and a complication arises. This may result in a change of birth setting, either during the pregnancy or in labour; the latter made sometimes more difficult due to a lack of integration between the providers of homebirth and hospital services . In counTransfer rates from planned homebirth to hospital vary by country as well as by parity, with predictably lower rates in multiparous women. The rates of intrapartum transfer from home to hospital in studies over the past 10 years from a number of high-income countries varied from 8.8 to 21.0% overall , 20–22. While transfer rates in NSW have been reported overall, little is known about what happens to women who commence labour in their planned place of birth, and their babies during and after transfer. Anecdotally, support for the expansion of homebirth and birth centre services has been hampered by a belief that this intrapartum change of venue adds a layer of unnecessary risk to women and their babies , 29. ThiThe aim therefore was to investigate the birth trajectories of women at low risk of complications who at the end of pregnancy plan to give birth at home, in a birth centre or a hospital labour ward. The development of this decision tree framework was also undertaken to inform a future costing of these birth settings.A retrospective population-based cohort study using linked health data was undertaken. The study draws on the framework of decision analytic modelling to construct a decision tree. Typically, a decision tree model provides a simplified framework of decisions that are made at different points in a treatment schedule depending on outcomes or events at a given time, “under conditions of uncertainty” and are mutually exclusive , 31. TheA decision tree is interpreted left to right, on the left is the decision node representing the planned place of birth at the onset of labour for women with a healthy pregnancy at low risk of complications. The pathways or trajectories represent the events that occurred for these women and their infants and are defined at each ‘chance’ node moving right, from which a branch emanates. The alternative trajectories are mutually exclusive and the probability of each branch is calculated. While decision tree analysis is used for modelling options in terms of end-points and costs, we are using the framework to depict and quantify the trajectories of women by their planned birth setting. We populated the decision tree in this study with data analysed from a linked population-based data set obtained from NSW Ministry of Health.This study investigates the trajectories of women in New South Wales who planned to give birth in the birth settings described above. During the study period (2000–2012), there were six alongside BCs and three freestanding BCs in NSW. Freestanding BCs accounted for approximately 15% of BC births between 2000 and 2012. The data did not permit separate analysis by type of BC.The number of maternity hospitals in NSW has remained constant over the period. The majority of homebirth services were and still are provided by midwives in private practice who are employed directly by women. There are a small number of publicly funded homebirth services which are staffed by midwives employed by public hospitals , 33.NSW Perinatal Data Collection (PDC): Midwives and doctors collect data routinely on all women who give birth in NSW, at the point of care, most often through electronic medical record platforms. Maternal and infant data is collected on all births greater than 20 weeks gestation or 400 g birthweight.NSW Admitted Patient Data Collection (APDC): This is a record of all NSW hospital inpatient services including public and private hospitals, public psychiatric hospitals, and private day procedure centres. Clinical data is recorded using the International Classification of Diseases- Australian Modification (ICD-AM) codes.NSW Registry of Births, Deaths and Marriages (NSWRBDM): Data on all registered births and deaths.Australian Bureau of Statistics (ABS) mortality data including primary cause and date of death.Data for all women who gave birth in NSW between January 2000 and December 2012 and all babies born between January 2000 and December 2012 of greater than 400 g and 20 weeks gestation were included. Four datasets were linked:were 37 to 41 completed weeks of pregnancyhad a singleton pregnancy in the cephalic presentationhad no known medical or pregnancy complications (low-risk) including previous caesarean section and breech presentationhad a spontaneous onset of labourAged between 17 and 40 (inclusive)The cohort was derived from the Perinatal Data Collection (PDC) which records all births in NSW from public and private maternity service providers, including homebirths . Women wGiven that this study aimed to examine the trajectories of women who planned to give birth in the three available settings in NSW, we classified the women according to planned place of birth as recorded in the PDC. This dataset was obtained for the Birthplace in Australia Study, a national data linkage study of maternal and perinatal outcomes by place of birth  . A detaiWe stratified the decision tree by parity to investigate the impact and events related to planned birth settings, as the demographic details are significantly different for nulliparous women compared to multiparous women. Women who have an unplanned homebirth ) and those who free-birthed  were not included in this cohort. The age range indicated here corresponds with the age range categorised as ‘A’ in the Australian College of Midwives Consultation and Referral Guidelines . CategorData were received and analysed in SPSS V24. Groups were established according to the women’s intended place of birth as recorded in the PDC. The trajectories were determined using descriptive statistics to map the events that occurred throughout the labour, birth and postnatal period. These events represent the intended place of birth at the onset of labour, transfer to hospital (in labour or post-partum), mode of birth, and neonatal events including admission to special care nursery and neonatal intensive care. Data indicating mode of birth were missing in both nulliparous (120 cases) and multiparous (110 cases) hospital groups, therefore these cases were not included in the trajectories. Demographic data were stratified by parity; we used Chi Square test to compare grouped categorical data and univariate general linear model analysis of variance (ANOVA) to determine the differences in the means.When allocating women who “transferred to HLW” from a BC for the decision tree, interventions such as epidural analgesia and instrumental birth were taken into account as some women who were recorded in the PDC to have given birth in a birth centre had received one or more of these interventions. These women were considered to have had a planned birth centre birth but were transferred to a hospital labour ward. Given these rooms are commonly adjacent to or near the labour ward for an alongside BC, the ‘transfer’ is assumed in this analysis. Freestanding BCs in NSW are not located near obstetric and neonatal services and as such, these women would have physically changed location. The proportion calculated in each branch are conditional on the number in the previous event (to the immediate left), adding up to 100%.n < 5, which meant they could not be reported due to ethical restraints regarding potential identification) and did not alter the conditional probabilities of the corresponding trajectory.Neonatal transfer to higher-level care is reported in the NSW PDC as admission to Neonatal Intensive Care Unit (NICU) OR Special Care Nursery (SCN). Given the levels of care differ significantly in these two areas, this provides a crude measure of neonatal outcome. We calculated the length of stay of these babies and identified those who stayed in the NICU/SCN for greater than 48 h as a measure of more serious morbidity. Cases of intrapartum stillbirth and early neonatal death were retained in the trajectories . These numbers were very small  had their intended place of birth recorded as hospital, 29,951 (6.0%) intended a birth centre birth and 1824 (0.4%) intended a homebirth. There were differences in the demographic characteristics of the three groups with women intending a homebirth being older  4.7) than those in the birth centre group  and hospital group . A higher proportion of women in the hospital group were giving birth to their first baby (nulliparous) (45.1%) compared to the birth centre and homebirth groups (42.7 and 29.9% respectively) and the highest proportion of women with a gestational age of 40 weeks and over were women in the homebirth group (67.1%) compared with women in the birth centre (59.1%) and the hospital group (54%) . Of the 23% of women who transferred to hospital during labour, more than half (55.0%) went on to have an NVB. The rates of instrumental birth and caesarean section for nulliparous women planning a homebirth who were transferred to hospital were 22 and 23% respectively see Fig. . These rMultiparous women planning a homebirth had a 92.5% rate of NVB compared with 88.0% in a BC and 93.6% in the planned hospital group. Even following transfer, over 88% of women planning a homebirth had an NVB in hospital. In total, the vaginal birth rate in the multiparous birth centre group was 98.3%. Instrumental birth and CS rates were in the planned homebirth group were 12 and 1% respectively, following transfer . The smallest proportion of neonates admitted to SCN/NICU were admitted following a homebirth (1.7%). Of the planned BC group overall, 7.1% of neonates were admitted to the SCN/NICU. Infants of women who were transferred from home to a hospital in labour had a 16.7% NICU/SCN admission rate however as a proportion of all planned homebirths, the overall SCN/NICU admission rate was 5.1%.Overall, fewer infants of multiparous women were admitted to the SCN/NICU with total SCN/NICU admission rates as follows: planned homebirth 1.6%, planned BC birth 3.6% and planned hospital birth 6.3%. The highest proportion of infants of multiparous women who were admitted to SCN/NICU were in the planned hospital group, following a CS birth (21%).This study has used a decision tree framework to map the trajectories of women at low risk of complications planning birth at home, in a birth centre and in a hospital labour ward. Whilst there are options of birth setting for some women in NSW, the options do not meet demand. Women who would like to give birth at home are required to pay a private provider in the most part, and anecdotally, reports of waiting lists for birth centre care are common. This study aimed to illustrate the trajectories of healthy, low risk women to provide evidence on the rates of transfer and intervention in this group. This information is important to assist in planning of birthing services, and can also be used to inform estimates of costs of different places of birth. Overall, a greater proportion of women who planned a homebirth remained at home and had an NVB, followed by women who planned birth in a BC regardless of parity. Women choosing to give birth in a hospital received a higher level of intervention in both parity categories. Nulliparous women in both the homebirth and BC groups had higher transfer rates than their multiparous counterparts, however they had higher normal birth rates than the planned hospital group. These results demonstrate similar trends in NVB and instrumental birth rates for women at low risk of complications to international studies of place of birth , 6.Transfer rates were lower compared to international evidence in both parity groups, particularly in the homebirth group. This could be attributed to a number of factors including the small number of women choosing a homebirth and careful planning and screening by the midwives who care for these women. In NSW, the majority of women who choose to give birth at home do so under the care of a midwife in private practise (MPP) which also requires personal funding, however there are a small number of publicly funded homebirth programs. The option of homebirth needs to be researched by the individual woman and extra effort required to find and engage a midwife who provides homebirth care. Women who choose a homebirth have confidence in the physiology of labour and birth, aspiration for a deeper relationship with her caregiver and a desire to be in a safe and familiar environment –37.For women who planned birth at home or in a BC, those who required any intervention, including an epidural block or instrumental birth, were transferred to the hospital as these interventions are beyond the scope of care delivered in a BC. The majority of women who choose a BC used facilities that were within or adjacent to a hospital, as freestanding BC births account for around 15% of BC births during this time. This close proximity to medical intervention may influence the woman’s and the midwife’s ‘threshold for intervention’. However, a study in Sweden of adjacent birth centre facilities governed by the same hospital guidelines found that women had lower rates of intervention than their hospital labour ward counterparts , as seenConsidering the women included in this analysis had a spontaneous onset of labour, it is not surprising that a largest proportions of the admissions to SCN/NICU were following instrumental and caesarean births, which could be related to either the need for an expedited delivery or the admission was as a result of an injury incurred during the birth. Similar rates of admission to SCN/NICU were shown in international studies of place of birth including a lower rate in multiparous women and women who planned a homebirth , 40. VerWhile data linkage is a powerful means to examine perinatal outcomes at a population level, there are limitations to the granularity of the data making close investigation of specific events challenging. Transfer from a birth centre to hospital is a good example. This study intended to highlight the trajectories of healthy women who could be reasonably compared across the three birth settings. Transfer from one setting to another is sometimes not recorded in the PDC, particularly when a BC is located within a maternity unit. For this reason, we used interventions such as epidural block and instrumental birth to indicate a transfer from BC to hospital. The numbers of women choosing a homebirth in NSW is very small and the probabilities associated with each trajectory in this group are less certain. With the benefit of linking data from across health datasets from one state, we were able to develop a cohort of women with comparable observable characteristics. It is difficult, however, to account for the unmeasurable or unobserved characteristics of women which fundamentally influence their choice of place of birth. Cases of stillbirth and neonatal death have been retained within the corresponding trajectories as these eventualities contribute to the trajectory of the mother and baby. This framework forms the foundation of a future cost analysis of place of birth using Australian Refined Diagnosis Related Groups. Closer investigation of morbidity and mortality was not within the scope of this paper. However, these outcomes have been reported on a national level in the Birthplace in Australia Study .This study has depicted the birth trajectories for women at low risk of complication and addresses the assertion that birth planned at home or in a birth centre results in a high rate of transfer, therefore adding an element of complication to an already delicate process. We have shown that a large proportion of women who begin labour at home or in a birth centre, stay in their chosen setting and indeed, even when transferred, have a high rate of normal vaginal birth. It is possible that the higher rates of intervention in hospital labour wards, even in a very low-risk group of women, could be avoided if women were given a greater choice of birth setting. Given this is the first time the trajectories of women choosing a birth outside hospital has been mapped, this evidence will assist the planning, costing and expansion of models of care in NSW.


Journal , an error appeared in the Discussion section, which stated that there were no significant differences in regard to IQ between the preterm and control groups. The sentence as published reads: “Although an association between preterm birth and lower mean IQ scores has consistently been reported,56 our finding of a preterm birth–specific impairment is unlikely due to lower general cognitive ability, because our preterm group did not differ significantly from the control group on IQ scores, and including IQ as a covariate had no effect on the results.” The sentence should instead read: “Although an association between preterm birth and lower mean IQ scores has consistently been reported,56 our finding of a preterm birth–specific impairment is unlikely due to lower general cognitive ability, because including IQ as a covariate had no effect on the results.”In the research article “Association of Preterm Birth With Attention-Deficit/Hyperactivity Disorder–Like and Wider-Ranging Neurophysiological Impairments of Attention and Inhibition” by Anna-Sophie Rommel, Sarah-Naomi James, Gráinne McLoughlin, Daniel Brandeis, Tobias Banaschewski, Philip Asherson, and Jonna Kuntsi, published in the January 2017 issue of the In addition, in Table 3 on page 44, all group comparisons are currently incorrectly indicated as significant by asterisks. A revised table can be found below. The authors regret the error.


To investigate the rates of hospitalisation for anaemia and depression in women in the six-year period (3 years before and after birth). To compare hospital admissions for depression in women with and without anaemia.This is a population-based cohort study. Women’s birth records  Perinatal Data Collection) were linked with NSW Admitted Patients Data Collection records between 1 January 2001 and 31 December 2010, so that hospital admissions for mothers could be traced back for 3 years before birth and followed up 3 years after birth. Setting: NSW Australia. Subjects: all women who gave birth to their first child in NSW between 1 January 2004 and 31 December 2008.Hospital admissions for both anaemia and depression were increased significantly in the year just before and after birth compared with the years before and after. Women with anaemia were more likely to be admitted to hospital for depression than those without .Depression was associated with anaemia in women before and after birth. This finding highlight the important role of primary care providers in assessing for both anaemia and depressive symptomatology together, given the relationship between the two. Treating or preventing anaemia may help to prevent postnatal depression. Depression in the postnatal period is a major health problem –3, with Poor physical health is a risk factor for postnatal depression (PND). A prospective cohort study in1,507 nulliparous women in Melbourne of Australia showed that women with five or more physical health problems had a six-fold increase in the risk of depressive symptoms at 3 months postpartum and a three-fold increase in the risk of subsequent depressive symptoms at 6–12 months postpartum . Women en = 511,938) in Finland between 2002 and 2010 reported that anaemia is a predictor of depression during pregnancy [n = 729) found that mothers with low levels of the iron marker, ferritin, at 48 h post-partum were 3.73 times more likely to have PND at 32 weeks [One of these physical health risk factors is anaemia, a common problem for women  , particuregnancy . A prosp32 weeks . Another32 weeks . HoweverDescribe the rates of hospitalization for anaemia and depression in mothers in the 3 years before and after giving birth.Compare the association of hospital admission of depression in women with and without anaemia.Given the wide-reaching impact and costs on the individual, parent-child dyad and community, we sought to investigate whether there is an association between anaemia and depression in Australia. These findings could inform public health policy, including highlighting a potential link between preventable physical and mental health problems in the perinatal period. Specifically, we used population-based linked data in Australia to:We hypothesized that anaemia is associated with an increase in hospital admissions for depression.This is a population-based cohort study, including all women who gave birth to their first child in New South Wales (NSW) between 1 January 2004 and 31 December 2008. Mothers who had subsequent births in 4 years after the first birth were excluded. Data were linked using the NSW Perinatal Data Collection (PDC) and the NSW Admitted Patients Data Collection (APDC). Women’s hospital admissions for anaemia and depressive disorders were identified by APDC records. Mother’s birth records were linked with APDC records between 1 January 2001 and 31 December 2010, so that hospital admissions for mothers could be traced back for 3 years before birth and followed up 3 years after birth. The study population and data linkage are detailed in Figs. The PDC is a data collection of births of at least 20 weeks gestation or at least 400 g birthweight in NSW of Australia. It includes all births in hospitals (public and private) and home births. The database includes information on maternal characteristics and outcomes of pregnancy, labour and birth. The APDC is a routinely collected census of all hospital separations in NSW hospitals including public, private and psychiatric hospitals and day procedures. It covers all patient hospitalisations and includes information on patient demographics, diagnoses and clinical procedures. The diagnoses for admissions have been coded according to the 10th revision of the International Statistical Classification of Diseases and Related Health Problems, Australian Modification (ICD-10-AM) .Data linkage was carried out by the NSW Department of Health Centre for Health Record Linkage (CHeReL). Each record from PDC and APDC datasets was assigned a Person Project Number to allow records for the same individual to be linked. In the 1000 randomly selected sample of records, the false positive rate of the linkage was 0.3% and false negative < 0.5%.anaemia or depressive disorders was used for the analysis of the rate, odds ratio (OR) and adjusted OR.The diagnoses in each hospital admission record in APDC data include 55 diagnoses . Principal diagnosis refers to the one which was chiefly responsible for hospital admissions . The staDescriptive statistics were used to summarise the rate and proportion of hospital admissions. The proportion was calculated by women’s 1st hospital admissions for the diagnosis of anaemia or depression as nominator and overall hospital admissions as denominator. Logistic regression models were used to estimate the odds ratio (OR) of anaemia on hospitalisation for depression. The dependent variable is the first hospital admission for depression (yes/no) in the study period (3 years before birth and 3 years after the birth). The independent variable is the first hospital admission for all diagnoses of anaemia in the study period. The adjusted factors for the OR include maternal age, maternal country of birth, maternal diabetes mellitus and hypertension, gestational diabetes, smoking status during pregnancy, remoteness of living area,, method of birth, gestational age, baby’s death and place of birth and the Index of Relative Socio-economic Disadvantage Quintile . The anaCharacteristic of the study population and the rate of the first hospital admissions for anaemia are detailed in Table There were 236 hospital admissions with principal diagnosis of anaemia and 2569 admissions with all diagnosis of anaemia in the study periods (3 years before birth and 3 years after birth) (Table The rates of anaemia in women in the year just before and after giving birth were significantly higher than the 2 years before (the second and third year before birth) and 2 years after (the second and third year after birth) the period, especially for all diagnoses of anaemia Table .The hospThe proportion of women’s anaemia in the year just before and after birth were also significantly higher than the 2 years before (the second and third year before birth) and 2 years after (the second and third year after birth) this period for all diagnoses of anaemia Table . For theFigure Table To consider the impact of the increase of overall hospital admissions during pregnancy and perinatal period, the proportion of depression was analysed Table . SimilarFigure Table This study showed that the hospital admissions for depression increased significantly in the first year after birth compared with those before birth. The increased trend after birth is consistent with our previous study  and otheThis study also showed that hospital admissions for anaemia with all diagnosis were significantly increased in the year of pregnancy  and the first year after birth . To consider the impact of increased overall hospital admissions before and after birth, the proportion of anaemia was also analyzed. Similar to the hospital admission rate, the proportion of anaemia was also significantly increased in the year of pregnancy and the first after birth. A systematic analysis of population-representative data from 107 countries between 1995 and 2011 showed that global anaemia prevalence was between 29%  = 24–35) and 33% (95% CI = 29–37) in non-pregnant women, 38% (95% CI = 34–43) and 43% (95% CI = 39–47) in pregnant women [Majority of anaemia (91%) was diagnosed as a non-principal diagnosis rather than principal diagnosis, as many women with anaemia were not diagnosed until they were admitted into hospital to give birth or for other medical reasons. Thus the greater the number of hospital admissions for other principal diagnoses, the greater the number of anaemia cases that will be found as an additional diagnosis. In New South Wales, 99.5% women gave birth in hospitals, this provided a good opportunity to identify women with anaemia. To adjust the impact of overall hospital admissions, the proportion of hospital admissions for anaemia  was calculated.Women in the pre- and postnatal periods are particularly vulnerable to the effects of iron deficiency on mood through both direct and indirect pathways . FactorsThis study showed that women with anaemia were more likely to be admitted to hospital for depression than those without. The finding are consistent with the results based on population-based cohort studies from Finland  and SpaiPotential mechanisms of effect for the relationship between anaemia and depression may associated with the role of iron in mood regulation. Iron contributes to myelination in the brain, as well as the development and functioning of the monamine system, which are key neurotransmitters involved in mood such as serotonin, dopamine and noradrenaline , 30. IroIn addition to this proposed direct pathway, iron deficiency and depression may be associated via an indirect, stress-induced inflammatory pathway. The individuals with depression experience chronic psychosocial and physical stressors. The stress lead to an overactive hypothalamic–pituitary–adrenal (HPA) axis, which triggers stress-induced elevated levels of pro-inflammatory cytokines –38. Pro-The strengths of this study include the population-based methodology, and data spanning a 6 year period to offer a richer understanding of mental and physical health in Australian women. Our findings present a baseline period from which to monitor the association between anaemia and depression in Australian women.These findings also need to be considered within the context of study limitations.This study shows that, for the principal diagnosis of anaemia, the proportion in the year just before the birth was lower than the third year before birth and the third year after birth. This was because women’s hospital admissions increased significantly in the pregnancy year (more than four times than the second and third year before birth and the second and third years after birth), however the absolute hospital admissions were still higher than the 2 years before and the 2 years after the year of birth. This study further showed that the proportion of depression for both principal and all diagnosis decreased significantly in the first year before birth Fig. . This waThe ‘other anaemia’ diagnosis included the cases without clear diagnosis such as unspecified anaemia. As a result, the diagnosis for D60-D64 (aplastic and other anaemia) included relatively more cases. For women before and after birth, unspecified common anaemia such as anaemia complicating pregnancy, childbirth and the puerperium (O99.0) may be included in this group.Some researchers mentioned that hospital admissions for PND might be over-enumerated because hospital admission could occur for other medical reasons in the postnatal period , 46. FurTemporal order between anaemia and depression could not be investigated by this study because majority of anaemia were diagnosed later than its occurrence. Majority of anaemia did not be found until women were admitted to hospital for giving birth or other reasons.This is the first population-based study to demonstrate a possible link between anaemia and depression in Australia, and emphasizes the importance and inter-relationship of both mental and physical health in the period before and after birth. Current clinical care practice guidelines recommend psychoeducation on the importance of iron during pregnancy and iron screening for women at risk of anaemia , as wellAnaemia was associated with postnatal depression for women. This finding highlight the important role of primary care providers in assessing for both anaemia and depressive symptomatology together, given the relationship between the two. Treating or preventing anaemia may help to prevent postnatal depression.


Environmental factors during early life alter the hypothalamus-pituitary-adrenal (HPA) axis regulation and increase the risk of diseases in later life. However, adrenal function at each developmental stage has not fully been investigated in relation to pathological antenatal conditions. Cortisol levels of newborns with intrauterine growth restriction (IUGR) are elevated during the neonatal period; however, when studied during early childhood, cortisol levels are reduced compared with their peers, suggesting that the HPA axis regulation might be altered from activation to suppression, the timing of which remains uncertain.The aim of this study was to assess the presence of an interaction between intrauterine growth and postnatal age on cortisol levels in newborns hospitalised at a neonatal intensive care unit.We performed a secondary analysis using a dataset from saliva samples of 62 newborns collected between 30 and 40 weeks corrected age. Interactions between postnatal age and clinical variables with regard to cortisol levels were assessed.z-score of the birth weight and IUGR showed significant interactions with postnatal age on cortisol levels; cortisol levels were higher ≤5 days of birth and lower >14 days of birth than those in their peers without IUGR.The The adrenal function of newborns with IUGR might be altered from activation to suppression within the first several weeks of life. Longitudinal studies need to address when/how IUGR alters adrenal functions, and how these responses are associated with diseases during adulthood. During pregnancy, plasma cortisol levels markedly change with gestational stage . HoweverSeveral studies have shown associations between perinatal physiological stress and attenuated adrenal function during childhood. For example, IUGR and preterm birth are associated with attenuated cortisol secretion at ages between 6 months and 7 years . In contUsing a cohort of newborns hospitalised in a neonatal intensive care unit (NICU), we have previously reported that lower cortisol levels were associated with clinical events suggestive of unfavourable foetal/postnatal conditions such as exposure to maternal pregnancy-induced hypertension (PIH), caesarean delivery, and preterm birth . Using tThis study was conducted in compliance with the Declaration of Helsinki and with the approval of the Ethics Committee of Kurume University School of Medicine (13142). Written informed consent was obtained from one parent of each participating newborn.This cross-sectional observational study was conducted as part of a project that investigated the independent variables of cortisol levels and their diurnal patterns , 2018. IDetailed data on patient recruitment, sample collection, and cortisol assays have been reported previously , 2018. ISaliva was collected before and 1 h after regular feeding at 10:00 and 19:00 using an absorbent swab . A cortisol assay was performed using an enzyme immunoassay kit . The limit of detection of this assay in our laboratory was 0.19 nmol/L, and the intra- and inter-assay coefficients of variation were 5.43% and 6.41%, respectively.Clinical information was obtained from electronic patient records, including maternal age, maternal body weight, and body-mass index at the time of delivery, gestational age, delivery mode, intravenous tocolysis, premature rupture of membranes, histopathologically confirmed chorioamnionitis, PIH, multiple gestations, antenatal glucocorticoid administration, birth weight, and its standard score calculated against the standard Japanese birth weight for gestational age , IUGR lep < 0.003, after correcting for multiple comparisons of 18 variables. For combinations of categorical variables with significant interactions, the simple effect test was performed for cortisol levels among three postnatal ages of ≤5 days, between 6 and 14 days, and >14 days (defined by the upper and lower quartile) for better clinical translation.Values are presented as mean (standard deviation), unless otherwise specified. In the current study, only saliva samples collected before (but not after) feeding at 10:00 and 19:00 were considered because of the known influence of feeding on the cortisol levels . Interacn = 55), maternal hyperthyroidism or hypothyroidism (n = 2), or maternal gestational diabetes mellitus (n = 5) were considered  who were hospitalised because of low birth weight (nsidered .p < 0.001), and postnatal age and IUGR   . Signifi= 0.002) .p < 0.001).When the simple effect test was performed for newborns with/without IUGR, the cortisol levels were associated with postnatal age in newborns with (but not without) IUGR; cortisol levels at >14 days were lower than those at ≤5 days and between 6 and 14 days . SubsequOur study suggested that foetal growth is associated with the relationship between postnatal age and cortisol levels in NICU newborns; cortisol levels of newborns with IUGR were higher soon after birth and lower after two weeks compared to those in their peers without IUGR. These findings build on our previous observations from the same dataset, that maternal PIH, caesarean delivery, and preterm birth are associated with lower cortisol levels in newborns hospitalised in the NICU .Intrauterine growth restriction is associated with an increased incidence of both short-term and long-term morbidities . In newbStudies involving children and adults found associations between low birth weight and increased basal cortisol levels . HoweverBecause of the observations suggesting accelerated organ maturation of IUGR newborns , the rapWe did not serially obtain multiple saliva samples; temporal changes in cortisol levels were only extrapolated from cross-sectional findings. Because newborns were recruited when their feeding was established, preterm newborns had older postnatal ages than did their near-term/term peers at the time of the study. Our findings need to be re-assessed in future studies, which serially collect saliva samples from the first day of life to at least four weeks. IUGR newborns in the current study cohort exclusively had asymmetrical IUGR, presumably because symmetrical IUGR was excluded from the study cohort when newborns with major congenital anomalies were excluded.Cortisol levels of newborns were associated with both postnatal age and intrauterine growth. Cortisol levels of newborns with IUGR were higher soon after birth and lower after two weeks than their peers without IUGR. It is possible to speculate that intrauterine growth may alter age-specific cortisol levels via deactivation of the HPA axis within first weeks of life. Future studies should address the impact of IUGR and other perinatal physiological stressors (and their level and duration) on the adrenal function and the development of diseases during adulthood. The potential benefits of care designed to minimise perinatal physiological stressors in these vulnerable newborns also need to be evaluated.10.7717/peerj.6368/supp-1Supplemental Information 1Clinical data used in the current study are shown as raw values.Click here for additional data file.


Benshangul Gumuze region is one of the regional states in Ethiopia, with highest rate of neonatal mortality rate. The trend increased at alarming rate from 42/1000 live birth in 2005 to 62/ 1000 live birth in 2011. Hence, identifying predictors of neonatal death and implement evidence based interventions at community level is crucial to reduce the mortality. Therefore, the purpose of this study was to identify predictors of neonatal mortality in Assosa zone, Western Ethiopia.A community based matched case control study was conducted from February 1, until December 30, 2013. The study included 114 cases who died during the first 28 completed days after birth from September 1, 2010 till September 1, 2013. For each case, one alive control matched approximately by the same date of birth (−/+ 2 days) was identified from the preliminary data collected. Finally, multivariate conditional logistic regression analysis was performed; and goodness of fit of the final model was tested using likely hood ratio test. All analysis was done using EPI Info version 7 and SPSS version 16 statistical softwares.Model households in health extension packages , age at first pregnancy < 20 years old ,pregnancy complication , delivery complication , antenatal care visit , primipara mothers , small size neonate at birth [AmOR = 3.40: 95%CI: 1.05–11.55], gestational age < 37 weeks , and home delivery  were found statistically significantly associated with neonatal mortality.Model households in health extension package and antenatal care visit were associated with reducing risk of neonatal mortality. However, age at first pregnancy < 20 years old, primipara mothers, pregnancy complication, delivery complication, small size neonates, gestational age < 37 weeks, and home delivery were associated with increasing risk of neonatal death. Therefore, promotion of model household in health extension package, anti natal care visit, institutional delivery, family planning to prevent early age pregnancy; and improve access to basic emergency obstetric care and intensive newborn care centers are effective interventions to reduce risk of neonatal mortality at community level.The online version of this article (10.1186/s12884-019-2243-5) contains supplementary material, which is available to authorized users. According to World Health Organization definition, neonatal mortality (NM) is death among live births during the first 28 completed days of life . This maSix million nine hundred thousand children died before reaching their fifth birthday globally in 2011; about 43% of this deaths was NM .According to 2011 Ethiopian demographic and health survey (EDHS) report, national NMR in 2000, 2005 and 2011 were 49, 39 and 37 per 1000 live birth respectively , 7.Benshangul Gumuze region is one of the regional states in Ethiopia with highest rate of NM; it was 62 per 1000 live birth in 2011 . The ratThe conceptual framework of this study was adapted from Mosley and Chin framework for the study of child survival in developing countries . It has Socio demographic and economic factors –20, mateIn Ethiopia, there were few studies conducted at community level. However, they were only confined to demographic study areas , 38. MorA matched case control study was conducted in Assosa zone, Western Ethiopia from February 1 until December 30, 2013. Assosa zone is located 667 km to West of Addis Ababa. It has a population of 342,287; male 188,258 and female 154,029 (2007 census projected). The zone has 7 woredas (districts) and 72 kebeles (villages). The study population was sample of neonates who died during the first 28 completed days after birth and sample of neonates who survived the first 28 completed days after birth, from September 1, 2010 until September 1, 2013. Cases were neonates (index birth) who died during the first 28 completed days after birth and controls were neonates (index birth) who survived the first 28 completed days after birth and alive during data collection. Neonates, match the definition of case and control were eligible for the study. However, neonates born outside Assosa zone and neonates mothers who were sick or unable to communicate were excluded from the study.1) was 48.5%, and proportion of preterm birth among controls (P0) was 8.2%  were found associated with NM at 5% level of significance. However, marital status, ethnicity, religion, occupation, type of roof of the house, presence of separate kitchen, type of water source, and presence of toilet facility were not significantly associated with NM , ANC visit , pregnancy complication  vaccination were not statistically significantly associated   and unskilled birth attendant  were statistically significantly associated with NM. Despite of the above, distance of health facility from home were not shown statistically significant association , small size neonates at birth, gestational age < 37 weeks, and home delivery were found statistically significantly associated with NM Table .Table 6MRisk of NM was 68% lower  in model HHs of HEP compared with those not model HHs in HEP.Neonates born to mother’s age at 1st pregnancy < 20 years old were 4.3 times at higher risk of death  than those neonates born to mother’s age at first pregnancy > = 20. Neonates born to mothers who had complication during pregnancy were 4.59 times more likely at risk of death  compared with those neonates born to mothers who had no complication during pregnancy. Mothers who had complication during delivery were 2.8 fold at higher risk of having NM  compared with those mothers who had no complication. Primipara mothers were 3.37 fold at higher risk of having neonatal death  than those mothers with parity of two to four. Neonates born to mothers who had received ANC were 66% lower risk of death  compared with those neonates born to mothers who had not received ANC.Neonates who were small size at birth were 3.4 times more likely at risk of death  compared with those average size neonates at birth. In line with this, neonatal death was 4.35 times higher among neonates with gestational age (GA) < 37 weeks  compared with those neonates with GA > =37 weeks. Home delivered mothers were 2.8 times at higher risk of having neonatal death  than those health institution delivered mothers.This study was conducted to identify predictors of neonatal mortality. It was employed community based matched case control design. This study revealed that, model HHs in HEP, age at first pregnancy < 20 years old, pregnancy and delivery complication, ANC visit, parity of one (primipara mothers), small size neonates at birth, GA < 37 weeks, and home delivery were found to be predictors of NM.Model HHs in HEP were significantly associated with neonatal mortality. Even though, there were no previous studies done specifically on association of model HHs in HEP and NM; previous reports by United Nations International Children’s Fund and World Bank were indicated model HHs in HEP was major factor in decreasing child mortality in Ethiopia , 15. ThiConcerning maternal biological and obstetric factors, mother’s age < 20 years old at first pregnancy was shown statistically significant association with NM. This finding was congruent with previous studies , 18, 20.Among the neonatal related factors, small size neonates were at higher risk of death than those average size neonates were. This finding was similar with previous studies conducted in Kenya, Ethiopia, Nigeria, and Indonesia , 26–28. Concerning health service and delivery related factors; neonatal death was statistically significantly higher among neonates born to home delivered mothers. This finding was in line with findings from previous studies done in Ethiopia and Vietnam , 34. NeoConcerning physical and psychological factors, heavy work exercise and pregnancy planning were not statistically significantly associated with risk of neonatal death. Conversely, previous studies reported statistically significant association , 36. ThiGenerally, based on the findings of this study, EDHS report, and general situation of the region; there were three suggested reasons for increasing NMR in the region, while the national NMR was decreased between 2005 and 2011. Firstly, health services coverage of the region  were very low compared with health services coverage of the rest regions in the country. Secondly, poor access and utilization of basic emergency obstetric care, and intensive newborn care centers in the region. The third reasons were, early marriage and early pregnancy, and home delivery were wide spread cultural practice in the region. Even though, the rate of NM of the region was increased between 2005 and 2011, it had no effect on the national NMR for the same period; due to small population proportion of the region compared with other regions in country.At last, it is crucial to discuss strengths as well as limitations of this study. The study employed matched case control design, subsequently this could improve efficiency to control cofounders by increasing precision of effect size estimate. Moreover, this study was community based; hence, it gave an opportunity to investigate risk factors present within the community.Despite the above strengths, the study also had limitations. Firstly, majority of the data was three-year recall period self reported data by mothers. Hence, this might introduced recall bias due to differential recall of information among mothers of cases and mothers of controls; this may lead to differential misclassification of study subjects and finally distortion of effect size estimates in any direction from null. Secondly, majority of the socio demographic factors were temporal measurements but taken as proxy indicators of the past and this might not give true measurement of the past. The third limitation was, small size and average size neonates was proxy indicator of birth weight of neonates, due to absence of birth weight record and this might not be accurate measurement. Lastly, nutritional status of the mothers and delivery related factors  were not studied in detail. Therefore, the reader of this article should consider those limitations might have implication on internal validity of the result.Based on the findings of this study, improving coverage of model HHs in HEP will have broad impact to reduce neonatal mortality, since it comprise many health packages directly and indirectly related to maternal and new born health, that are crucial to implement at family level. Secondly, improving access and utilization of basic emergency obstetric and intensive newborn care service to reduce risk of delivery complications and improve newborn survival especially for preterm and LBW neonates respectively. The third interventions are promotion of ANC, institutional delivery, health education and family planning for adolescents to prevent early age pregnancy. Generally, those interventions should be implemented at community level to avert the high neonatal mortality in the region.Nutritional status of the mother and delivery related risk factors, such as: cord cutting material, delivery surface, and cord tie material used during delivery were not investigated in detail and should be studied in future.In summary, model households in health extension packages, mothers age at first pregnancy < 20 years old, complication during pregnancy, complication during delivery, primipara mothers, antenatal care visit, small size neonates at birth, gestational age < 37 weeks, and home delivery were found as independent predictors of neonatal death. Therefore, promotion of model HH in HEPs, ANC visit, institutional delivery, and prevention of early age pregnancy and improve access of basic emergency obstetric care and intensive newborn care are very crucial interventions to avert the high risk of neonatal mortality.Additional file 1:Anonymous data generated and analyzed to study predictors of neonatal mortality in Assosa Zone, Western Ethiopia, 2013. (XLSX 99 kb)


To estimate the completeness of live birth registration through South Africa’s civil registration and vital statistics system between 1996 and 2011.The number of births registered by the civil registration and vital statistics system was compared with independent estimates of the true number of births derived using: (i) the reverse survival method applied to 2011 census data; (ii) the application of estimated age-specific fertility rates to population estimates from censuses and surveys; and (iii) data from the public-sector district health information system.In 1996, an estimated 25% of births were registered within the calendar year of birth and 33% were registered before the end of the subsequent calendar year. By 2008, 76% of registrations occurred within the calendar year of birth, 84% occurred by the end of the following year and 90% occurred before the child’s fifth birthday. These improvements were seen in all provinces and differences in completeness between provinces narrowed markedly. Improvements in the completeness of registration coincided with government efforts to strengthen the system, new legislation on vital registration and the introduction of child support grants, which required birth certificates. Interprovincial migration of children influenced the completeness of registration in affected provinces. There was some terminological confusion among government agencies on defining the timeliness of registration and the year of birth.The completeness of birth registration in South Africa increased rapidly between 1996 and 2004. To allow international comparison, the method for measuring the completeness of birth registration needs to be standardized. Actions taken globally to achieve the millennium development goals highlighted the failure of civil registration and vital statistics systems in some low- and middle-income countries to record vital events accurately and to provide data essential for monitoring key child health indicators. The United Nations Secretary-General's Global Strategy for Women's and Children's Health 2016–2030 further emphasizes the importance of these systems for monitoring maternal and child health.,,Birth registration, which is enshrined in the United Nations Convention on the Rights of the Child,Every child’s birth right,,In the publication Evidently, a standard measure or method for monitoring the completeness of birth registration is lacking. The World Health Organization defines completeness as “a measure of the extent to which births and deaths in a country in a given year are registered by the civil registration system.”To date, no estimate of the completeness of birth registration in South Africa has been based on estimates of the true number of births. The aims of this study therefore were to assess the completeness of birth registration in South Africa’s nine provinces between 1996 and 2011, with particular reference to the SDG’s focus on monitoring and reducing health inequities, and to propose a method for annual assessment.,South Africa, an upper-middle-income country with a population of over 56 million individuals in 2016, has a well-established civil registration and vital statistics system, but still faces challenges in using the data to track births and deaths, and particularly, to estimate child mortality.We used unit record data to create tables of births by year of occurrence and year of registration. The statistical office defines late registration as registration after the calendar year of birth , with the calendar year of registration closing at the end of February of the following year. We regarded births registered before the end of February of the calendar year following the calendar year of birth as being registered in the year of birth and births registered in the following calendar year as being registered in the year of birth + 1, and so on.x. Hence, the number of children aged 0 to 15 years recorded in the 2011 census were projected backward to estimate the number of births for each age cohort using the life table measures, xLis the number of person-years lived between age and age x + 1 (x can vary from 0 to 15) recorded in the cohort life table, of which 0 lis the radix (i.e. the number of births in the age cohort). Estimating the number of births in any year involved the following stages: (i) age cohort survival probabilities to 2011, which were applicable to births over the past 15 years, were derived using the Actuarial Society of South Africa’s 2008 population projection model with the migration assumptions set to zero;x last birthday in 2011 by the number of births these individuals originated from in the year in which they were born; (iii) each survival factor was then used to estimate the number of births in year y (yB) by dividing the number in a particular age cohort recorded in the 2011 census (in the country or province) by the appropriate survival factor. For example, the number of births in the year starting 10 October 2010 (2010B) was derived by dividing the number of children under 1 year of age (born in the area of interest) in the 2011 census  by the survival factor for this age cohort from the model, 2010B plus 0.2274 × 2009B; and (v) the number of births in different provinces in each year was scaled to ensure that the sum of the births in all provinces equalled the national total.First, estimates of the true number of births between 1996 and 2010 were derived using the reverse survival method from the enumerated South African-born population recorded in the 2011 census, allowing for interprovincial migration between 2001 and 2011.Second, an alternative estimate of the number of births against which the completeness of birth registration could be evaluated was derived using estimated total fertility rates. We based these rates on national and provincial fertility research in South Africa between 1996 and 2011.–2R = 0.74) between the proportion of rural residents reported in the 1996 census in a province and the proportion of home births recorded in the 1998 Demographic and Health Survey in that province. We used the following regression equation to estimate the percentage of home births in province i (ihb) from the percentage of home births recorded nationally in 2010 (HB):ir is the percentage of the population in province i that was rural, R is the percentage of the national population that was rural in 2010, and a and b are regression coefficients. As far as possible, we followed the Guidelines for Accurate and Transparent Health Estimates Reporting.Third, we estimated the number of births between 2004 and 2012 using routine health statistics collected by the District Health Information System from public sector health facilities in all nine provinces. In 1994, the introduction of free health care for mothers and children up to 6 years of age led to a substantial increase in the number of births taking place in the public sector.Our study illustrates the usefulness of a robust method for assessing the completeness of birth registration that benefits from considering multiple data sets, particularly less frequently used data sets. We found that the completeness of birth registration in South Africa increased rapidly between 1995 and 2004 and that by 2011, 83% of registrations occurred before the end of the year after the calendar year of birth. This improvement was seen in all provinces and the relative difference between provinces narrowed markedly. The increase in birth registration observed after 1995 coincided with the introduction of amendments to the 1992 Birth and Deaths Registration Act that extended it to include former homelands and with efforts to strengthen vital registration. In addition, the introduction of child support grants in 1998 also played a role because the primary eligibility requirement was that the child’s birth had to be registered.Our estimate of the completeness of birth registration differed somewhat from UNICEF’s finding in 2011 that 95% of births in South Africa were registered within the first year of life.The accuracy of the figures we derived for the estimated numbers of births using the reverse survival method was highly dependent on the accuracy of the enumeration of children in the 2011 census. We believe the 2011 census count was accurate because the figures were comparable with subsequent assessments of the number of older children in school and with the number of survivors of children enumerated in previous censuses.Another limitation is that our analysis assessed the completeness of registration according to the number of complete years after the calendar year of birth because the exact date of registration was not available as part of the unit record data. Consequently, estimates of completeness according to the exact age of the child, which are arguably more desirable, were approximate. Second, the migration of young children after birth made it difficult to interpret the completeness of birth registration in individual provinces. Nevertheless, completeness improved in all provinces and we could use data on births collected by the District Health Information System to monitor registration. Finally, because of the complexity of using multiple data sources to arrive at our estimates, we did not quantify uncertainty in completeness estimates or undertake a sensitivity analysis.Despite the concerted effort of the South African government to improve the civil registration and vital statistics system, there remain obstacles that prevent approximately 20% of births being registered by parents within the year of birth. Insight into what these obstacles are and which communities are most affected are needed. In addition, our assessment of the completeness of birth registration identified some terminological confusion among government agencies on definitions of the timeliness of registration and the year of birth. Although any definition of the completeness of birth registration should compare the number of registered births with the actual number of births, definitions generally do not mention the timing of registration, which could be within 30 days or 12 months or before the age of 5 years. Indicators should therefore be clearly described and there should be a general agreement on standard measures.The commendable improvement in birth registration in South Africa can be attributed to the government’s commitment to improving the civil registration and vital statistics system, to changes in legislation around vital registration and to particular policies, such as cash transfers directed at the welfare of children. Evaluating the impact of these interventions would help other countries develop policies and strategies for improving birth registration.


Dentigerous cysts are one of the most prevalent types of odontogenic cysts and are associated with the crown of an unerupted tooth, especially of the mandibular third molar. In this study, the characteristics of a dentigerous cyst developed around a mandibular third molar on panoramic radiographs were investigated. The panoramic images of 257 consecutive dentigerous cyst cases associated with a mandibular third molar were analyzed. The mean age of the patients was 45.9 ± 13.3 years. The size of the cyst did not significantly correlate to the age of the patient. The unilocular type (89.1%) and the crown side type (68.5%) were significant. The associated mandibular third molars had a high frequency of class III (64.6%) and position B (48.3%) in Pell and Gregory classification and of horizontal position (36.3%) in angulation. Dentigerous cysts were thought to originate and grow commonly around deeply impacted third molars. The associated third molar with dentigerous cyst tends to have a mesial inclination. Dentigerous cysts do not appear to develop gradually after the crown formation has finished, but arise at various periods randomly. The jawbones have a high prevalence of cysts in the human body due to the abundant amount of epithelial remnants. Dentists, therefore, frequently encounter cystic lesions within jawbones. Most jaw cysts are lined with epithelium derived from the odontogenic epithelium. These are referred to as odontogenic cysts. They are subclassified into two groups, developmental or inflammatory . DentigeDentigerous cysts are usually asymptomatic and discovered accidentally as radiolucencies on panoramic radiographs taken for general dental treatment or from investigations of the reason for delayed tooth eruption. The panoramic radiograph, therefore, is the first indication of dentigerous cysts in many cases. It is important for the dentist to understand the characteristics of the dentigerous cyst obtained from a panoramic radiograph. This cyst is associated with the crown of an impacted, embedded, or unerupted permanent tooth. The most frequently involved tooth is a mandibular third molar ,4.In this study, we examined the characteristics of 257 dentigerous cysts developed around a mandibular third molar on panoramic radiographs. The shape, position and size of the radiolucent area showing the cyst region were surveyed. It is well known that radiographically, a dentigerous cyst typically presents a unilocular radiolucency with a corticated margin and its radiolucent area surrounds the crown of the associated impacted tooth . This tyThe study included 257 consecutive patients who underwent the enucleation of a dentigerous cyst and extraction of the associated mandibular third molar at the dental hospital of Tokyo Medical and Dental University between 2009 and 2013. The diagnosis of all dentigerous cysts was provided pathologically.All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The present study was approved by the Institutional Review Board of the Faculty of Dentistry, Tokyo Medical and Dental University (No.1247).All digital panoramic radiographs were taken using a Super Veraviewepocs  instrument operated at 79–80 kVp and 9–10 mA with a photostimulated phosphor plate . The plates were processed with an FCR 7000 system , and the images were stored in the DICOM format. This apparatus provides panoramic images with uniform magnification in both vertical and horizontal dimensions.The Clinical features based on the radiolucent area on panoramic radiographs included the site, locular type, and position of the cyst. The locular types were divided into a unilocular type a and a mThe size of the dentigerous cyst or the radiolucent area on panoramic radiograph was examined. We introduced a relative cyst size for a maximum width of the tooth crown. The size of the cyst was evaluated as follows to reduce the individual differences.The relative size of dentigerous cyst = the length of the major axis of the radiolucent area/the maximum width of the tooth crown of the associated third molar.The position of the associated third molar was classified by Pell and Gregory classification  and desc(Relation of the tooth to the ramus of the mandible and second molar)Class I: Sufficient amount of space exists for the accommodation of the mesiodistal diameter of the crown of the third molar.Class II: The space between the ramus and distal side of the second molar is less than the mesiodistal diameter of the third molar.Class III: All or most of the third molar is located within the ramus. (Relative depth of the third molar in the bone)Position A: The highest portion of the tooth is on a level with or above the occlusal line.Position B: The highest portion of the tooth is below the occlusal plane but above the cervical line of the second molar. Position C: The highest portion of the tooth is below the cervical line of the second molar tooth in relation to the long axis of the impacted second molar. (Angulation)The angulation of the associated third molar was determined by the method of Quek et al. . A groupp-value of less than 0.05 was considered significantly different. The values are expressed as mean ± standard deviation (SD). Fisher’s exact probability was used for statistical analyses. A This series included 167 males (65%) and 90 females (35%), a 1.86:1 male/female ratio. Age and gender distribution are shown in p-value < 0.05), respectively . The unilocular (89.1%) in the locular type and the crown side type (68.5%) in the position of the cyst were significant  and crown side position (68.5%) were significantly different. However, the frequencies of the multilocular type (10.9%) and whole tooth position (31.5%), especially the whole tooth position, were higher than our expectations, although it could not be compared with the other data for lack of a previous study. Some large dentigerous cysts have a multilocular image on panoramic radiographs, thought to be due to the persistence of bone trabeculae within the radiolucency, and there are no truly multilocular dentigerous cysts % and cro.New evaluation approaches for the size of dentigerous cysts were introduced to reduce the individual differences in this study. In this new approach, the image distortion in panoramic radiograph was not considered. There, therefore, were some differences caused by the image distortion among each measurement although all digital panoramic radiographs were taken using the same apparatus under the same photographing condition . A dentiThe position of the associated third molars with dentigerous cysts was examined by Pell and Gregory classification. No previous papers examined the position of the associated third molars with dentigerous cysts by using this classification, as far as we knew. In horizontal classification, class III was the highest frequency, followed by classes II and I. In other words, third molars whose crowns are fully covered by bone have the highest frequency, and the frequency increases with the amount of tooth covered by the ascending mandibular ramus. Dentigerous cysts originate from the reduced enamel epithelium and grow by internal pressure generated by fluid drawn into the space between the reduced enamel epithelium and the tooth crown ,17. ConsIn vertical classification, Class B (48.3%) had the highest frequency, followed by Class A (32.1%) and Class C (19.6%). We previously examined the position of the mandibular third molars of 1906 extraction cases that do not have a dentigerous cyst or other pathologies. This result showed that Class A (85.1%) had the highest frequency, followed by Class B (12.9%) and Class C (1.9%) (data not shown). When we think of these two data instances together, dentigerous cysts are thought to originate and grow commonly around deeply impacted third molars.The angulation of an associated third molar was determined by the angle formed between the intersected longitudinal axes of the second and third molars. There has been no previous report on this angulation as with the position of the associated third molar. The horizontal position had the highest frequency (36.3%), followed by inversion (32.5%) and mesio-angular positions (25.4%). This result indicates clearly that the third molar associated with a dentigerous cyst tends to have a mesial inclination. In the original report, which proposed the angular classification of mandibular third molar used in this study, the mesio-angular position (59.5%) is the most common, followed by the horizontal 17.6%), disto-angular (9.8%), and vertical (9.5%) positions [.6%, distThe patients with dentigerous cyst had a mean age of 46.0 ± 13.4 years in this study, although the highest frequency of dentigerous cyst was present in patients in their 30s. The panoramic images of dentigerous cyst developed around a mandibular third molar showed some diagnostics; (1) a unilocular radiolucent area surrounded the crown of associated third molar; (2) the size of the cyst was not related to the age of a patient; (3) the associated mandibular third molars were deeply impacted and had a mesial inclination. These findings lead to the following characteristics of a dentigerous cyst. Dentigerous cysts were thought to originate and grow commonly around deeply impacted third molars. Dentigerous cysts do not appear to develop gradually after the crown formation has finished, but arises at various periods randomly.


Background: Preterm birth is associated with increased stress of parents that might influence the parental-child interaction, thus potentially having influence on the neurobehavioral development of the preterm infants. However, little is known concerning the age dependency of parental stress after preterm birth.Objective: The aim of the present study was to examine the age dependency of stress in mothers and fathers after preterm birth and neonatal intensive care unit (NICU) admission of their infant.Methods: In a prospective observational pilot study 47 mothers and 47 fathers completed the parental stress scale:NICU (PSS:NICU) questionnaire within 72 h after delivery. This questionnaire measures parental stress after preterm birth with three subscales: “Looks and Behave” of the child, “Parental Role Alteration,” and “Sights and Sounds.” Stress levels of mothers and fathers were compared and correlated to the age of mothers and fathers, respectively.Results: Parental stress experience after preterm birth tended to be higher in mothers compared to fathers. Mothers showed a significant positive correlation of the “Sights and Sounds” scale and age, whereas fathers did not show any significant age dependency of stress.Conclusion: In mothers stress level increases with increasing maternal age after preterm birth and admission of their infant to NICU, whereas fathers did not show any significant age dependency of stress. Preterm birth is frequently associated with increased parental stress, worry, and anxiety, during and after admission to a Neonatal Intensive Care Unit (NICU) –3. MotheMiles et al.  developeReports on the stress experience of fathers after preterm birth vary –7. FrankTherefore, the aim of the present study was to investigate, whether there is an association of the parents' age and the parental stress after preterm birth and admission of their neonate to a NICU and whether there is a difference between mothers and fathers. We hypothesized that there is an age dependency in parental stress after preterm birth in mothers and fathers, which may explain these differences.A prospective observational pilot study was conducted at the Division of Neonatology at the Medical University of Graz. Parents—mothers and fathers—of preterm neonates born before 37 weeks of gestation and admitted to the NICU were eligible for this study. The study was approved by the Ethical Committee of the Medical University of Graz (EK number: 25-529 ex 12/13) and parents were included after giving written informed consent to participate in the study. Participants were given a socio-demographic questionnaire and the PSS:NICU measuring parental stress within 72 h after the birth of their child and were asked to complete it within 24 h. Parents had to be literate in German and over 18 years old. Fathers had joined the birth in the delivery room and parents were allowed to visit their neonate at any time, after the neonates were admitted to NICU.For the present prospective observational study a sample size of 50 mothers and 50 fathers was considered to be convenient .The following socio-demographic data were collected: parental age, educational status, marital status, and mode of delivery.The PSS:NICU measures parental stress after preterm birth and admission of their neonate to NICU. It is a self-report questionnaire, which can be rated on a five point Likert-Scale: 1 = not at all stressful: the experience did not cause you to feel upset, tense, or anxious, 2 = a little stressful, 3 = moderately stressful, 4 = very stressful, and 5 = extremely stressful. Items describing situations that have not been experienced by the parents can also be answered with “not applicable.” The parents should indicate how much experiences were stressful in the subscale “Sights and Sound” consisting of 5 items , the subscale “Parental Role Alteration” consisting of 14 items  and the subscale, “Looks and Behave” of the child   when the distribution was skewed.t-Test or Mann–Whitney U-test, as appropriate. The association between parental age and stress levels in mothers and fathers were analyzed using Spearman's rank correlation coefficient or Pearson's correlation when appropriate. A p-value < 0.05 was considered statistical significant. The statistical analyses were performed using IBM SPSS Statistics 22.0.0 .Parental age and stress levels of mothers and fathers were compared using n = 18), preterm labor (n = 8), vaginal bleeding (n = 7), eclampsia (n = 6), intrauterine growth retardation (n = 3), others (n = 5).One hundred parents (50 mothers and 50 fathers) participated in this prospective observational study. The PSS:NICU questionnaires of 94 parents (47 mothers and 47 fathers) were included into analyses. Six parents were excluded, since the questionnaires were not completed correctly. The mothers stated their highest level of education as following: 16% compulsory education, 32% apprenticeship, 34% higher school certificate, and 18% university degree. The fathers stated their highest level of education as following: 12% compulsory education, 36% apprenticeship, 26% higher school degree, and 26% university degree. Forty four percent of the couples were married. Of the participating women 33 delivered by cesarean section and 14 women delivered vaginally. Ten women gave birth to twins. The neonates were born prematurely due to preterm prelabour rupture of membranes (p = 0.07). The mean gestational age of the preterm infants was 32 ± 2 weeks of gestation and the mean birth weight was 1,714 ± 456 grams. The preterm neonates of 20 pairs of parents received respiratory support, at the time point when the questionnaires were completed.The mean age of mothers and fathers was 31 ± 5 and 33 ± 6 years, respectively (p < 0.001) and “Looks and Behave” (p < 0.001). In addition, the results showed that mothers had non-significant trends to higher stress levels than fathers in the subscale “Parental Role Alteration” (Analyses of the PSS:NICU showed that “Parental Role Alteration” is the most stressful part for parents in the situation of a preterm birth compared to “Sights and Sounds” (eration” .Correlation analyses demonstrated that stress correlated positively with age in mothers, but only within the subscale “Sights and Sounds” correlation was significant. In contrast, in fathers all stress subscales showed a non-significant negative correlation with age .The present study is the first analyzing gender related age dependency of parental stress after preterm birth and admission of the preterm neonate to a NICU. There was a positive correlation of stress levels and age in mothers, whereas we did not observe any significant correlation of stress levels and age in fathers. In contrary, there was a clear trend to negative correlation of stress levels and age in fathers.In recent studies higher stress levels in mothers than in fathers have been demonstrated , 6, 8, 9For parents after preterm birth of their infant “Parental Role Alteration” proofed to be the highest stressor in the present study that is in accordance with the available literature , 9. The Older mothers are facing from beginning of their pregnancy an overall increased risk. Therefore, we can hypothesize that this might be the reason for the present observation of increasing stress levels with increasing age after preterm birth.Main limitation of the present study is the sample size of mothers and fathers at different ages. However, we demonstrated a significant association of age and stress in mothers. Furthermore, the different subscales of the PSS:NICU have to be interpreted with caution due to the psychometric properties and the dimensionality of the PSS: NICU . HoweverIn mothers stress level increases with increasing age after preterm birth and admission of their infant to NICU, whereas fathers did not show any significant age dependency of stress.Previous research showed that parental stress has been associated with differences in neurobehavioral development of preterm infants . FurtherThe datasets generated for this study are available on request to the corresponding author.This study was carried out in accordance with the recommendations of Regional Committee on Biomedical Research Ethics with written informed consent from all subjects. All subjects gave written informed consent in accordance with the Declaration of Helsinki. The protocol was approved by the Ethikkommission, Medizinische Universität Graz, Austria.E-PS, GP, and BU: conception and design. E-PS PU, NB-S, BS, and GP: collection and assembly of data. E-PS, PU, CM, NB-S, BS, and GP: analyses and interpretation of data. E-PS and GP: drafting of the article. E-PS, PU, CM, NB-S, BS, BU, and GP: critical revision and editing and final approval of the article.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.