Background: Preterm birth, defined as infants born before 37 weeks of gestation, is the largest contributor to child mortality. Despite new evidence highlighting the global burden of prematurity, policymakers have failed to adequately prioritize preterm birth despite the magnitude of its health impacts. Given current levels of political attention and investment, it is unlikely that the global community will be adequately mobilized to meet the 2012Born Too Soon report goal of reducing the preterm birth rate by 50% by 2025.Methods: This study adapts the Shiffman and Smith framework for political priority to examine four components contributing to policy action in global health: actor power, ideas, political context, and issue characteristics. We conducted key informant interviews with 18 experts in prematurity and reproductive, maternal, newborn, and child health (RMNCH) and reviewed key literature on preterm birth. We aimed to identify the factors that shape the global political priority of preterm birth and to describe policy opportunities to increase its priority moving forward.Results: The global preterm birth community  lacks evidence about the causes of and solutions to preterm birth; and country-level data quality is poor with gaps in the understanding required for implementing effective interventions. Limited funding compounds these challenges, creating divisions among experts on what policy actions to recommend. These factors contribute to the lack of priority and underrepresentation of preterm birth within the larger RMNCH agenda.Conclusion: Increasing the political priority of prematurity is essential to reduce preventable newborn and child mortality, a key target of the 2030 Sustainable Development Goal for health (target 3.2). This study identifies three policy recommendations for the preterm birth community: address data and evidence gaps, clarify and invest in viable solutions, and bring visibility to prematurity within the larger RMNCH agendas. Premature infants that do survive are more likely than infants born at term to suffer from a range of morbidities, including respiratory distress, sepsis, difficulty feeding, and cerebral palsy, among other conditions1. Although preterm birth occurs across communities and geographies, 80% of preterm births occur in south Asia and sub-Saharan Africa1.Preterm birth, which refers to infants born before 37 weeks of gestation, is a significant contributor to child and newborn mortality worldwide. An estimated 14.8 million newborns were born premature in 2014, and in 2016, 18% of child deaths were attributed to complications of preterm birth, making prematurity the leading cause of death for children under five years of ageBorn Too Soon: The Global Action Report on Preterm Birth, led by the March of Dimes, the Partnership for Maternal, Newborn & Child Health (PMNCH), Save the Children, and the World Health Organization (WHO), provided the first ever estimates of the global burden of preterm birth3. It also introduced a global action agenda to reduce the preterm birth rate by 50% by 2025.In 2012, a seminal report,1. Similarly, theEvery Woman Every Child Global Strategy for Women’s, Children’s and Adolescents’ Health (2016–2030) has a strong focus on newborns and preventing stillbirths, but not prematurity4. In addition, most countries do not report national data on preterm births and the World Bank’s Global Financing Facility for Women, Children, and Adolescents (GFF) does not monitor preterm birth rates5.However, progress has been slow and preterm birth remains largely hidden on the global policy agenda. Reducing preterm birth is essential to achieve the Sustainable Development Goal (SDG) for health (SDG 3), including the key targets on newborn and child mortality, yet prematurity is not measured in the indicators or monitoring frameworks6.In order to reduce preterm births, prematurity must gain increased political priority – that is, “the degree to which international and national political leaders actively give attention to an issue, and back up that attention with the provision of financial, technical, and human resources that are commensurate with the severity of the issue”This study examines the actors, ideas, political contexts, and characteristics that have shaped the visibility of preterm birth, and identifies opportunities and challenges for prematurity to gain greater political priority moving forward. We focus on the global level because preterm birth is a worldwide health challenge, not limited to a particular geography.The University of California San Francisco (UCSF) Committee on Human Research certified this study, IRB number 15-15752, as exempt. We obtained written, informed consent from all key informants. Informants were assigned a unique identifier  to maintain anonymity.7. According to this framework, a global health issue achieves political priority when: (1) international and national political leaders publicly and privately express sustained concern for the issue; (2) the organizations and political systems they lead enact policies to address the problem; and (3) these organizations and political systems provide resources to address the problem that are commensurate with its severity7. The framework has been applied to several underrepresented health challenges, including safe motherhood, newborn survival, mental health, and surgical care to understand the factors contributing to or hindering policy action10. Shiffman and Smith propose that there are four key determinants of political priority in the context of a particular health issue: actor power, ideas, political context, and characteristics of the issue; and 11 sub-factors, summarized in7. The collective impact of these factors determines the degree of prioritization or neglect of a given health challenge, which in this instance is preterm birth7.We applied a conceptual framework developed by Shiffman and Smith to assess the political priority of preterm birth 7. Accor12. SK contacted prospective KIs by email asking if they would be interested in participating in our study. If they expressed interest in participating in the study, we set up a time to connect by phone, Skype, or in-person using email correspondence. Our sample included basic scientists, epidemiologists, and representatives from major bilateral and multilateral organizations, academic research groups, advocacy groups, and the largest research funders in the preterm birth arena11.We conducted 18 semi-structured interviews with key informants (KIs) from May 2015 to September 2015. We purposively selected KIs based on their expert knowledge of preterm birth as researchers, practitioners, advocates, and policymakers at the global level and in lower-income countries (LICs) and middle-income countries (MICs). We identified KIs by reviewing peer-reviewed and grey literature on preterm birth and on reproductive, maternal, newborn, and child health (RMNCH), consulting professional networks, and asking KIs for other relevant professionals 12.Interviews were conducted until our study reached theoretical saturation, i.e., no new themes were emerging in our interviewsExtended Data13). Interviews were conducted in English in-person, by telephone, or on Skype, with the average interview lasting about one hour. Interviews were audio recorded and transcribed. The audio recordings from the interview were deleted after the de-identified transcripts were created. The de-identified transcripts are secured on a password protected and encrypted computer.We used the Shiffman and Smith framework to develop the semi-structured interview guide, which informed the interviewing process and analyses  (SeeExtended Data13). Each interview was coded by two researchers SK and SF to ensure consistency15. Each interview was summarized to identify key themes, as were codes across all interviews. This process was documented with internal memos and matrices to check bias and maintain transparency. All authors discussed the summary data to identify findings and ensure the interpretations were sound and replicable.Interview transcripts were analyzed usingPubMed andGoogle for the relevant literature. This literature was identified by searching for articles about preterm birth and political priority, using search terms such as “prematurity” or “preterm birth” and “advocacy”, “priority”, “politics”, and “leadership”. In addition to providing context and verification to key informant remarks, this literature allowed us to track policy changes for preterm birth from 2015–2019 to see whether the early years of the SDGs affected attention to the issue.The interview data was supplemented with a review of published and grey English language literature on preterm birth from 2015–2019. SK searchedOur study found that the global preterm birth community consists of academic researchers, multilateral organizations, government agencies, and civil society organizations that are well connected in part because of a shared history of collaboration and group decision-making.Born Too Soon report in 2012, the report authors and supporting organizations collectively decided to expand the group’s focus from addressing preterm birth as a single cause of newborn death to addressing newborn survival more broadly 17. This expansion aligned with the report’s call for partners across the RMNCH continuum of care to work collaboratively to address preterm birth . In 2014, core partner institutions behindBorn Too Soon joined child health institutions to create the Every Newborn Action Plan (ENAP) to end preventable newborn deaths and stillbirths by 2035 . ENAP has become the main organizing body for preterm birth, within the larger newborn survival network.After publishing theAn agreement of those partners at that moment was that we needed to broaden this action plan to include not just preterm birth, but other main causes of newborn death. (KI15)Informants described a high degree of collaboration under the ENAP platform . A variety of institutions helped guide the ENAP’s strategy , with thI think that one of the things that people would say about the newborn health community is that it's a very collaborative and quite a highly networked group. (KI3)18. Academics have played a leadership role in advancing research on preterm birth and shaping the newborn survival community . Some informants noted that the prominent role of academics has created barriers to communicating with advocates and policymakers . In addition, some informants expressed concern that donors invested $100 million in a UCSF research initiative on preterm birth, as opposed to funding an institution such as the WHO .Informants highlighted the strength of the global newborn network’s technical capacity A notable weakness within the preterm birth community was the lack of political and civil society champions from LICs and MICs. Whereas the March of Dimes has mobilized civil society on preterm birth in the United States, grassroots advocacy in LICs and MICs has been insufficient . Informants mentioned several barriers to civil society engagement in LICs and MICs, including stigma toward mothers of preterm infants and women’s disempowerment ; lack of awareness of the problem of prematurity ; perceptions of feebleness of the infant or death of premature infants as fate ; and a lack of external development funding for preterm birth .Frankly, to think of a grassroots movement would imply that there is knowledge of the nature of the problem. And, frankly, people are not aware that prematurity can be prevented. Again, the vast majority of the population has a sense of inevitability. You lose a baby [then] it was God's will. It was Mother Nature, it was not meant to be. And that is not true. (KI12)This study found that a lack of evidence on the causes of and solutions to preterm birth has created divisions on how to prioritize prevention and care agendas, which in turn hinders how preterm birth is framed externally to policymakers.3. Many informants also described a shared understanding of the best care practices for preterm infants, such as essential newborn care and emergency services for mothers 16.There are some signs of cohesion within the preterm birth community. For instance, the field follows the WHO’s definition of preterm birth as any baby born before 37 completed weeks of gestation However, informants described weak metrics on the effectiveness of existing interventions at the local level  and noted knowledge gaps on how to best implement effective care interventions in LICs and MICs . They called for a coordinated effort around discovery and implementation science .23.Furthermore, there was disagreement on how to allocate constrained resources, namely between prevention and care strategies . Informants referenced a range of different prevention strategies, such as family planning, prenatal care, and nutrition interventions, as a means to address the range of risk factors associated with preterm birth. However, informants warned that because the underlying etiology of preterm birth is still largely unknown, the mechanisms for preterm birth prevention are complex and not well understood Informants agree there is an urgent need for more evidence on prematurity, but there was a lack of consensus as to what types of prevention research should be the first priority . Suggestions included scientific discovery for new prevention methods  and improving the scale-up of existing prevention interventions, such as the safe administration of antenatal corticosteroids for mothers at risk of preterm delivery .Informants reported that the limited evidence around preterm birth prevention has stalled progress in engaging policymakers on prevention strategies . While some KIs warned that the prevention agenda has been neglected too long, others were hesitant to promote interventions without more evidence . Two informants reported that the Public-Private Partnership to Prevent Preterm Birth encountered resistance because researchers felt it was presumptive to create a prevention initiative when there is a lack of scientific clarity .When we started to launch the prevention partnership, there were a lot of, sort of knee-jerk reactions to ‘Oh where's the hard evidence around prevention? What can you really say about the evidence around prevention?’ (KI 5)Informants worried that the community’s lack of internal consensus has created fragmented advocacy messages, with some focused on safe motherhood and pregnancy, and others focused on newborn survival . Informants urged that there should be one consistent, high-impact advocacy message . . Addressing preterm birth is essential to achieving the SDG and ENAP targets. Integrate available preterm birth interventions into maternal and child health programs and leverage this approach in advocacy messaging.(1)Sometimes it’s better to have an advocate that is focused on one issue, like preterm birth, but I think in terms of the ultimate impact it is a much better strategy overall to highlight [preterm birth] within the broader continuum. (KI 8)Leverage evidence about the severity of the burden of prematurity as the leading cause of child death . Unlike other high-burden conditions, such as HIV/AIDS or malaria, preterm birth is often blended with other factors contributing to newborns deaths (KI10). The importance and impact of investing in preterm birth risks getting lost.(2)We need to make it simple [for political leaders]. And I would say point one, frame it as a very important problem in terms of burden of disease. (KI12)Adopt a universal frame that shows how preterm birth impacts families of all geographies, races, and socioeconomic statuses . Improve data and messaging on the economic burden of prematurity and articulate the cost-saving potential of preterm birth interventions for policymakers, particularly Ministers of Finance 24.(3)Preterm birth can happen to anybody, and I think that's an important message for politicians and policymakers to hear. So that people understand that it's not just in somebody else's backyard, it's in their own. It's their mothers, their daughters, and their grandchildren that are at risk for preterm birth, just like anywhere else in the world. (KI11)I think the challenge is that the preterm birth community is not unified, and I don't know if it could be unified, but the differences between the care camp and the prevention camp, I think, impedes our ability to speak with one voice and move forward together as a community. (KI15)Born Too Soon report and ENAP helped create policy windows and provided platforms to advance the visibility of preterm birth. However, there is a need to better leverage the RMNCH agenda and to mobilize political attention to prematurity in LICs and MICs.This study found that theBorn Too Soon report was an important policy window to bring worldwide attention to prematurity 7. To mark the report’s launch, more than 30 organizations made new or enhanced commitments in support of the UN Secretary General’s Every Woman Every Child initiative25. A dedicated launch disseminated the report’s findings to political leaders and received significant media coverage 26. Later that year, more than 50 countries recognized World Prematurity Day 2012 and several governments made commitments to reduce preterm mortality27.The release of theBorn Too Soon brought attention to preterm birth as a single condition, ENAP helped advance and maintain attention to the issue as part of a larger newborn survival agenda . In 2014, researchers working within ENAP published the Every Newborn series in theLancet, which found that efforts to reduce preventable deaths among newborns have been slow, in spite of existing solutions28. At the 67th World Health Assembly (WHA) in May 2014, evidence from theLancet series was highlighted and Melinda Gates gave a keynote address urging action on newborn health 29. The WHA passed Resolution 67.10, with 194 member states endorsing the ENAP30. As of 2017, 48 countries have established national newborn survival plans or given newborns a platform in national health plans31.While32. Informants described the United Nations International Children’s Emergency Fund (UNICEF) as historically weak on issues of prematurity and newborn survival . In addition, collaboration between the maternal and newborn survival communities has historically been challenging, largely due to competition among RMNCH institutions for limited resources 17. Informants warned that this fragmentation presents significant barriers to collective action impacting the infant mortality agenda 6. There are some signs of improvement (KI5). For instance, the 2015 Global Maternal Newborn Health Conference focused on the integration of maternal and newborn health along the continuum of care, and included a session on management of preterm birth and care of the preterm newborn35.Informants explained that the preterm birth community has struggled to build strong linkages with the RMNCH community and leverage the larger RMNCH agenda for increased political support . For example, informants reported that the wider community largely failed to respond when data in 2014 showed preterm birth as the leading cause of death among children under five years of age – the first time an infectious disease was not the leading cause of child mortality 36. Informants also noted that the GFF might have influence over whether LIC and MIC decision-makers prioritize newborn health at the country-level .Efforts are also underway to raise political attention to prematurity in LICs and MICs. Informants noted that World Prematurity Day advocacy efforts have been slow, even stagnant, in some high-burden settings . Also, newborn health groups such as ENAP and the USAID-led Every-Preemie-SCALE consortium are partnering with high-burden countries to develop country-specific plans to reduce preterm birth rates and improve survival outcomesThe bad news is I don’t believe there’s anyone in these countries, at the moment, when they’re writing their plans, actually in the room, saying “preterm birth, preterm birth.” (KI10)Data weaknesses present barriers to how well prematurity is understood and how aware policymakers are about the severity of preterm birth. These weaknesses include poor quality of country-level data and gaps in the evidence needed to guide implementation.3. There was some progress as of May 2019: of the 90 countries that adopted the Every Newborn tracking tool, 41% adopted birth registration and 53% had a perinatal death review policy37. Informants noted a need for more granular data on preterm birth among sub-populations in high-burden settings, in order to understand the effectiveness of interventions and build strategies for prevention .Informants highlighted limitations with existing data on the global burden of prematurity , noting the very wide variability of country-level epidemiological data . Data quality varies in part due to different methods of recording gestational age and misclassification of live-born newborn babies as stillbirths20.Informants also reported a lack of evidence to guide implementation of effective interventions and ways to address barriers to delivery in different local contexts, highlighting two interventions: (1) administering ACS to women at high risk of premature delivery; and (2) kangaroo mother care (KMC), sometimes called skin to skin contact, to care for preterm infants . As of 2015, coverage of ACS and KMC was below 10% in LICs and MICs38. In light of these findings, at least three organizations stopped or slowed their scale-up of ACS and some researchers called for a complete halt on ACS implementation in low-resource settings until the WHO released new guidelines 39. In 2017, the WHO began a three-year trial on ACS in low-resource settings40. Further, informants underscored the importance of understanding the interaction of local contexts with the planned intervention to ensure that it does not have unintended fatal consequences 40.Informants explained that scale-up of ACS in low-resource settings significantly slowed after a 2015 cluster randomized trial found that administering ACS at all levels of care in rural and semi-urban areas led to a population level increase in neonatal deaths43.Despite consensus regarding the effectiveness of KMC in improving premature infant outcomes – including a Cochrane Review and WHO endorsement – informants described debate about the clinical definition of KMC and how best to implement KMC in all settings . Informants explained that a gap in understanding how KMC works in local contexts slows progress to adapt and bring those interventions to scale . The WHO has initiated several studies to improve evidence on KMC implementationWe are scientifically in agreement that A, B, and C work under a set of ideal circumstances, but those are not immediately applicable and transferable, implementable, in settings where you do not have that set of conditions.(KI12)44.Nearly half of informants felt that policymakers do not yet recognize the severity of prematurity . Despite data challenges, most informants reported that available estimates on the burden and incidence of preterm birth can be used to engage policymakers at the global level and in LICs and MICs . For example, after data showed Malawi with the highest rate of prematurity, the Malawi government launched a national newborn action plan with a strong focus on scaling up KMC and other methods of care for preterm infants (KI15)We know enough to act. It’s not like lack of data should paralyze us or lead to inaction. (KI14)Our study finds that preterm birth has struggled to achieve political priority on the global health agenda. Since 2012, the preterm birth community has made important progress in developing a well-networked group of stakeholders committed to newborn health, developing groundbreaking evidence on the severity of preterm birth, and supporting the development of country-specific Every Newborn action plans. However, several challenges have hindered global action on preterm birth and threatened much needed progress in the SDG era. These are:Limited evidence and a lack of country-level data on the causes of and solutions to prematurity, including prevention strategies and effective implementation in low-resource settings.Lack of consensus on how to allocate limited resources across prevention and treatment interventions.Difficulties integrating prematurity into the RMNCH agenda and uniting the RMNCH community to leverage support for prematurity.45. Although there has been some progress, our study finds that many of the same challenges persist and create barriers in attracting and maintaining policymaker attention to preterm birth. For instance, gaps in evidence and locally relevant data can weaken trust in expert recommendations. Conflicting or confusing guidance on interventions makes it difficult for policymakers to determine how they should invest their limited resources. Additionally, it is not clear to policymakers how focusing on preterm birth can drive improvements across RMNCH indicators.These challenges echo 2010 findings from Sather and colleaguesThe findings of our study point to four main policy options for the global health community to consider in order to advance the priority of preterm birth moving forward: (1) address data and evidence gaps that hamper implementation; (2) clarify the viable solutions to prevent and address preterm birth; (3) invest in strategies to address preterm birth across RMNCH; and (4) develop coordinated strategies to bring visibility to prematurity within the RMNCH agenda.46. Although the substantial data gaps are known, priorities for the research agenda are not clear – a 2016 study found that while preterm birth prevention research is likely to have a high impact, it ranked only as 129th among 205 priority research questions for newborn survival47. The preterm birth community must develop a coordinated research agenda to help facilitate funding and action for research and data improvements. This could in turn help identify opportunities to leverage other data investments for preterm birth, such as efforts to strengthen national health information systems.Informants described a number of data and evidence gaps in understanding the causes, solutions, and effective implementation of interventions in low resource settings. Previous studies have also found substantial gaps in understanding preterm birthInformants described a lack of agreement on strategies to tackle preterm birth, often reflecting false dichotomies, e.g., prevention vs. treatment focus, safe motherhood vs. neonatal health. The preterm birth community must clarify strategies along the continuum of care and develop coordinated recommendations on priority investments, based on robust evidence vetted by the field. Attempting to prioritize preterm birth without clear and viable solutions will discourage policymakers and make it more difficult to hold leaders accountable.Many of the struggles in the preterm birth community can be attributed to limited resources. The preterm birth field faces steep competition for limited resources, from within the RMNCH community and also global health broadly. Internal tension and a lack of consensus within the preterm birth field places the agenda at an even greater disadvantage, because the field lacks a deep network of researchers, policymakers, and other champions when compared with other high-burden health issues that have already been established as clear policy priorities. It is likely that improved evidence and consensus will identify effective preterm birth strategies across the RMNCH continuum of care, which will require increased investment by global and national policymakers. The RMNCH field should identify integrated strategies to sufficiently resource preterm birth prevention and treatment, rather than resorting to former silos and competition for resources that will only hinder progress.The preterm birth community made a strategic decision to broaden its focus to newborn health under the ENAP platform. This pragmatic approach is aligned with the emphasis in the SDGs for an integrated, multi-sector, and multi-stakeholder approach.However, framing preterm birth as one newborn health condition among many has diluted policymaker focus and stalled action on preterm birth. There is a real risk that preterm birth will continue to be overlooked, jeopardizing progress across the RMNCH continuum.The challenge is to leverage the RMNCH platform without hindering efforts to reduce preterm birth. The preterm birth community and partners should recognize preterm birth as essential to achieving RMNCH goals in global and national strategic documents and include specific indicators to reduce preterm birth. The RMNCH community should join in coordinated advocacy efforts and help raise the political priority of preterm birth.To the best of our knowledge, this is the first study of the challenges in assuring global political priority of preterm birth. One major strength is that we interviewed a broad range of stakeholders across multiple types of organizations: researchers, practitioners, advocates, and policymakers at the global level and in LICs and MICs.There are at least four limitations. First, the study did not examine whether the issue of prematurity is or is not a national level political priority, which could be useful, particularly in high burden countries. As mentioned, we deliberately focused our study at the global level, given the worldwide nature of preterm birth, but it will be helpful to conduct future studies at the national level. Second, our study relied upon self-reporting by key informants, who may not have disclosed full and complete information during our interviews and who may have carried personal biases on key issues. We addressed the potential for bias by granting anonymity to study participants, and sought comments from representatives of different organizations. Third, many of our study participants have collaborated on past projects, which is common in global health but could potentially lead to a lack of diverse perspectives. To address these, we probed in our interviews to uncover and understand areas of difference and consensus among respondents.Lastly, our study interviews were conducted in 2015. However, we have reviewed and incorporated current reports and updated literature through the year 2019 to capture the most important policy events and publications related to preterm birth from 2015–2019.The SDGs targets to end preventable newborn and childhood deaths by 2030 will go unmet if deaths from prematurity continue to climb year after year. To reduce prematurity, global policy makers and national leaders must recognize the problem of preterm birth as a priority issue.This study identified actionable ways the preterm birth and newborn health community can increase the political priority of preterm birth on the global health agenda: develop a research agenda to address data and evidence gaps, clarify viable solutions, invest in preterm birth across RMNCH strategies, and elevate the visibility of preterm birth as an important issue within the RMNCH continuum. These actions will help enable greater political priority to preterm birth, which has the potential to spur global and country-level advancements to reduce prematurity and achieve SDG targets.We are unable to share the underlying data due to data protection issues. Interview transcripts are the primary source of data for this manuscript. Data cannot be shared publicly because to do so would be a breach of confidentiality. The participants in the key informant interviews could be identified using the transcripts, which is why the data cannot be made available.The University of California San Francisco (UCSF) Committee on Human Research certified this study, number 15–15752, as exempt.sara.kassabian@gmail.com. If there is interest in secondary analyses of the data, we will review the request and consider purpose, methods, and use of the data.Readers with questions about the data can contact the corresponding author by email atAssociated materials  have also been made available at the UK Data Repository.The semi-structured interview guide and codebook are included in the UK DataService ReShare repository.https://dx.doi.org/10.5255/UKDA-SN-85425113.Repository: Building a global policy agenda to prioritize preterm birth: A qualitative analysis on factors shaping global health policy-making Colchester, Essex: UK Data Service.This project contains the following underlying data:Semi-structured interview guide. Codebook. (The codebook was created to define the meanings behind different codes.)Creative Commons Zero "No rights reserved" data waiver (CC0 1.0 Public domain dedication).Data are available under the terms of the This important paper aims to identify factors that shape the global political priority of preterm birth. It is a well-written and timely paper, and provides new insights to why preterm birth has not received policy priority despite its large burden. These findings are highly relevant for the prematurity and child mortality community, but also in our understanding of agenda setting in global health more generally. The paper helps explain why prematurity is not higher on the global health agenda. Further, the paper highlights relevant suggestions on how to increase its priority. While these contributions are important, I have some concerns with the paper in its current presentation, and in particular the description of the review.Methods:Review: The review of the literature is informative to understanding the policy context and developments after the interviews were conducted. However, the methods used are unclear and the choice of sources seem to miss out on potentially relevant literature. I would recommend addressing these, or if not, being explicit about the limitations of the review:While the academic literature is likely to cover some of the changes in policy priority (2015-2019), I am not convinced that PubMed and Google scholar literature will be up to date on policy development. Given that policy making also is influenced by other developments than new evidence, I wonder if this is captured when the search focused on academic databases. Why were policy documents not included in your review? I think this would have added value, with attention to how prematurity was (or was not) on the agenda in WHO documents, guidelines, etc. This would also align with your attention on the SDG era and provide insights on (other) issues that are prioritized. This could help you explain the hindrances for why prematurity is not high on the agenda.The search strategy conducted is not described in detail, and it is hence difficult for the reader to evaluate whether the search captured relevant elements. While I understand that the manuscript did not aim to conduct a systematic review, a detailed presentation of your scoping review should be included. I would appreciate if the search strategy could be added as a supplement/appendix. The presentation of the review of the manuscript seems more as tool to inform the findings from your qualitative study than a review, and it is not clear in the Results section where you draw upon your findings from the review. I would suggest to either provide more detail about how the review was conducted and demonstrate clearer in the Results section how it informed your study, or to leave out the review part and consider your ‘coping review’ as a way to understand your findings. The key strength of your paper is the qualitative interviews and the rigorous analysis.  Political priority framework: This study adapts the Shiffman and Smith framework, which is a well-chosen framework for this study. The authors write that the framework has been applied to ‘underrepresentative’ health challenges. This normative statement about the framework highlights the relevance of the framework to also understand why certain issues are not on the agenda, but I argue that it is equally useful to understand why some issues do get attention. I would suggest to rephrase (or something similar): ‘The framework has been applied to understand the factors contributing to or hindering policy action in global health, including safe motherhood, newborn survival, mental health, and surgical care’.Interviews and recruitment: Well-described methods used to recruit study participants. The information about using a combination of purposive and snowball sampling could have been presented in abstract.  Results:Issue Characteristics: The last paragraph describes that half of the informants say that prematurity is not perceived as a severe problem. Were they able to say something about why? It seems like there was detailed discussion in specific parts of the prematurity agenda (e.g. KMC), but what is the issue not perceived as severe? This links to your findings on ideas . It would be of great interest to know if they said more that could explain why this is not perceived as an severe issue (by some).The authors also highlight when their claims are supported by multiple (or some) stakeholders, and show that insights are gained from the broader sample. I would suggest to keep the information about who said what.  Discussion:The discussion is well-written and reflects upon the main findings of the study. I have some questions concerning the interpretation of the study findings:Integration difficulties and recommendation to 4 on coordination of strategies to make prematurity visible on the RMNC agenda: How is lack of priority to prematurity a) different from and/or b) similar to attention to newborn health and maternal mortality ? As your paper (and stakeholders) argue, there are reasons to believe that there is an overlap in interventions in this era, but why has there been less attention to prematurity than what has been seen in the increased attention for maternal survival ?On your finding onIncrease visibility to prematurity: You discuss the fine balance between the risks of prematurity becoming less visible and potential benefits if prematurity is incorporated (and/or overlooked) in the broader RMNCH agenda. Can you – based on your interview/findings – say anything about how causes (prematurity) might be seen as different than newborns, children, mothers  that often are core in the messaging on the RMNCH agenda? Is the framing of prematurity as a particular problem (and cause of child deaths) found useful outside the prematurity community? It seems as the collective works well on the inside, but less in its external engagement, which may influence visibility – in particular when there are few low-hanging fruits and solutions. I might be wrong, but it would be helpful if you can reflect upon some of this in more detail in the Discussion section.     Overall, the paper is well-written and of great interest for global health scholars. With the exception of the lack of clarity on review (see comment above), the study design and analysis is rigorous. I hope comments are helpful to improve the manuscript further.Is the work clearly and accurately presented and does it cite the current literature?YesIf applicable, is the statistical analysis and its interpretation appropriate?Not applicableAre all the source data underlying the results available to ensure full reproducibility?NoIs the study design appropriate and is the work technically sound?PartlyAre the conclusions drawn adequately supported by the results?YesAre sufficient details of methods and analysis provided to allow replication by others?PartlyReviewer Expertise:Priority setting and policy making in global health , including policy analysis, qualitative studies (and quantitative studies).I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Congratulations to the authors for this excellent piece of work. The manuscript is very well led right from abstract to the conclusion. The key messages are clear and very crucial to reach out to global health communities. Relating these findings to my own work experience of MNCH in Nepal and Uganda, I am in complete agreement with the key challenges around lack of evidence on and country level data, lack of consensus on use of the limited resources and difficulties in integration of prematurity into RMNCH agenda. The policy options outlined by the authors, particularly to address evidence gaps and clarify the viable solutions to prevent preterm birth also resonates very well with my own experience. Policy call to improve data quality on preterm birth at national level, and investment priority to generate evidence on what causes preterm birth are the most important messages from the manuscript.   emerged in the interviews. From the result sections, readers note that actor power, ideas, political contexts and issue characteristics are the themes presented in the paper, which indeeddid not emerge, rather were directedby the framework the authors used.In data collection and analysis, the authors said interviews were conducted until the study reached theoretical saturation, i.e. no new themesanalyzed using Dedoose, version 7.1.3, maybe the authors want to amend the language. Dedoose facilitated coding process, analysis is more about the framework the study was guided by and the actual coding process used.Interview transcripts wereIt would help readers if the authors write a few lines about ‘impression coding’ as they use this term in the analysis section.Each interview was coded by two researchers SK and SF to ensure consistency. As the authors were informed by a very clear Shiffman and Smith framework to direct their analysis, I suppose there is a very less chance of inconsistency among the coders. It might help readers to elaborate a few lines on what were the inconsistencies like if any.In the strengths and weakness section, the authors said they relied on ‘self-reporting by key informants’. It is less clear whether it is a strength or weakness as authors said they used purposively selected KIs as the study participants. The authors might want to check the methodology section for consistency. Regarding the methodological detail, the authors have very well applied Shiffman and Smith framework and adapted this to guide them to interview KIs and the analysis. I have some small comments, which I think would help further to improve the quality of the paper: Overall, the paper is excellently written, and very worthy to go out for indexing.Is the work clearly and accurately presented and does it cite the current literature?YesIf applicable, is the statistical analysis and its interpretation appropriate?Not applicableAre all the source data underlying the results available to ensure full reproducibility?No source data requiredIs the study design appropriate and is the work technically sound?YesAre the conclusions drawn adequately supported by the results?YesAre sufficient details of methods and analysis provided to allow replication by others?YesReviewer Expertise:MNCH, HIV/AIDS, Primary Health Care, Health Systems and PoliciesI confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. This is a well written article, which has highlighted preterm issues at policy level and the report will contribute towards improvements of preterm neonates. The framework used is appropriate and the researchers need to be commended. The method for data collection is also appropriate, however presentation of results lack information about the sample. At least organizations that took part without necessarily describing their post should have been communicated. We depend on the same institutions to push the preterm agenda, as such it is important to hear their views specifically. The authors acknowledge that the study was conducted some years back and are hoping that the literature review will support the findings. There is need to indicate dates for the documents used to ensure that we are indeed using current data. What criteria was used to select these documents? How many did they find? How many were discarded and why were they discarded? It is important to describe the process. Once these comments are addressed the article could be indexed.Is the work clearly and accurately presented and does it cite the current literature?YesIf applicable, is the statistical analysis and its interpretation appropriate?Not applicableAre all the source data underlying the results available to ensure full reproducibility?PartlyIs the study design appropriate and is the work technically sound?YesAre the conclusions drawn adequately supported by the results?YesAre sufficient details of methods and analysis provided to allow replication by others?PartlyReviewer Expertise:NAI confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. The authors state that the interview data was supplemented with a literature review. Did the authors consider doing this as a systematic review, and/or are there previously published systematic reviews on preterm birth policy or advocacy? Was any data abstraction tool developed to abstract information from the literature (particularly the grey literature)?The choice to cite statements in the results with specific key informant IDs is a little unusual and distracting. Unless there is a specific reason to do so, I would encourage the authors to remove these citations.The ID numbers for the quotes are meaningless on their own. I understand that the authors want to indicate that different quotes came from different participants, while also maintaining confidentiality. However, it would be helpful to add a little more information on the participants, perhaps a general description of their role/profession  and perhaps the number of years they have been working in the area.On page 7, please define the acronym ACS.Did key informants or the literature describe any LMICs that were doing better than their peers at leadership and advocacy for preterm birth? Given the many implementation challenges identified, it would be helpful and critical to also discuss those countries or settings that have made progress. Malawi is identified as a country that has been responsive to making changes based on available data, but little information is provided on how they were able to accomplish that.The authors note that one limitation of the qualitative data is that it was collected in 2015, but that the literature review allowed the data to be brought more up to date. However, it was not clear how the literature review was used to supplement the interviews. Specifically, is there more current evidence on the use of antenatal corticosteroids and/or kangaroo care? It would be helpful to be a little more explicit on whether the literature indicates changes or movement on preterm birth since the interviews were conducted.et al., 20201 for a discussion of this). Given limited resources and the many competing demands for reporting that health workers face, what specific recommendations did the key informants (or authors) have on how data collection efforts can be improved?Adequate and comparable data from LMICs is a challenge for child health beyond the perinatal and neonatal period (see Brault I enjoyed reviewing this article discussing the factors that shape leadership and political prioritization of preterm birth. The use of the Shiffman and Smith framework is very successful in this manuscript, as assessing issues like leadership and advocacy can be challenging. The manuscript also provides several helpful recommendations and areas for future research which will be critical for addressing the gaps or challenges identified by the key informants. I have a few specific comments and questions, which would strengthen the manuscript.Is the work clearly and accurately presented and does it cite the current literature?PartlyIf applicable, is the statistical analysis and its interpretation appropriate?Not applicableAre all the source data underlying the results available to ensure full reproducibility?NoIs the study design appropriate and is the work technically sound?YesAre the conclusions drawn adequately supported by the results?YesAre sufficient details of methods and analysis provided to allow replication by others?PartlyReviewer Expertise:I am a medical anthropologist with expertise in qualitative and mixed methods approaches, and maternal, neonatal, child, and adolescent health both in the U.S. and internationally.I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.


This paper pioneers to investigate the endowment effect in the European Union mission Trading Scheme (EU ETS) as well as the impacts of trading experience and compliance pressure on the endowment effect. This study is based on the complete transaction records of the market. In the data set, the records of two consecutive reverse transactions from a same emitting company are selected. The lowest price that the buyer is willing to pay (WTP) and the maximum price the seller is willing to accept (WTA) are evaluated by excluding their risk cost that is used to avoid short-term fluctuations in the price. By distinguishing the difference between WTA and WTP, and long-term fluctuations in the prices during the two transactions, the trader’s endowment effect can be quantitively assessed. The results show that the degree of endowment effect of traders follows the trading experience. In addition, since the EU ETS is a cap-and-trade market, the traders face different levels of compliance pressure; when the pressure of the emission companies increases, the degree of endowment effect will also decrease. The endowment effect is a phenomenon: an agent has an increased preference towards an item, triggered by mere possession of that item . In the In the endowment effect literature, Knetsch and Sinden  opened uTo address the above issue, this paper conducts an empirical analysis on the presence of the endowment effect in the European Union mission Trading Scheme (EU ETS). In addition, the EU ETS is a cap-and-trade market where its participants face compliance pressure of different levels and directions . The influences of compliance pressure on the endowment effect could affect the market liquidity of the EU ETS, and therefore this analysis could provide some implications for the development of the EU ETS. First, the market liquidity can be improved from the perspective of endowment effect, provided that the effect of the compliance pressure on the endowment effect is known. Second, when firms are buying (or selling) allowances, they are facing the corresponding compliance buying pressure (or the compliance selling pressure). By comparing the endowment effects on traders when they face performance pressures in different directions, policy suggestions can be provided from supply and demand aspect, and it will be helpful to promote the development of the market.The selection of the EU ETS as the research object is based on the two following reasons. First, reviewing 76 endowment effects studies, Tuncel and Hammitt  found thThe contribution of this work is threefold. First, the endowment effects of the participants in the EU ETS is quantitively assessed. Based on the transaction prices and fluctuations of carbon prices, this study pioneers to evaluate and compares the WTP and WTA of traders in a real market, i.e., the EU ETS. Second, this work empirically analyzes how the degree of traders’ endowment effects changes with varieties in trading experience, compensating the extant literature which is filled with laboratory experiments. Third, based on the cap-and-trade attribute of the EU ETS, this paper includes the compliance pressure as an influential factor of the endowment effects, and conducts an empirical analysis of the impact of compliance pressure on the endowment effect. Considering the fact that low market liquidity is a problem that has plagued the EU ETS  and otheThe structure of this article is as follows: the second part is the framework of the article; the third part is the introduction of transaction data in EU ETS, and the quantitative modeling for endowment effects, and the empirical model for the analyzes of the influences of trading experience and compliance pressure on the endowment effects; the fourth part is the analysis of the models’ results; the fifth part gives the conclusions and policy implications of this article; the last part points out the limitations of this research and potential future works.Based on the identified knowledge gaps, we conduct the research framework see . First, After quantifying the endowment effect of a trader, we conducted an empirical analysis of the effects of trading experience and compliance pressure on the endowment effect. Each emitting company’s trading experience is represented by the accumulated number of transactions before the current transaction, and the start time of the measurement for the number of transactions is May 1st, 2008, i.e., the beginning of the Phase II of EU ETS. The compliance pressure of each company is calculated from the gap of allocation and surrender and the trading volume before the current transaction. Similarly, in order to make the research more comprehensive, this article also conducts an empirical analysis on the endowment effect that is shown in the process of buying allowances after selling allowances, hence the influences of trading experience and compliance pressure on the buying behaviors that follows selling behaviors are analyzed.2 reduction commitment in the Kyoto Protocol, the EU ETS was launched in 2005. The EU ETS is the oldest and the currently largest emission allowance trading system in the world, operating as a market-based scheme with the purpose to reduce of carbon emissions.To achieve the 8% COThe EU ETS has been running for three phases. The first phase  was from 2005 to 2007; the second phase was from 2008 to 2012; and the third phase is from 2013 to 2020. Up to now, the first two phases of the EU ETS have been completed. Due to the over-allocation of allowances during the trial period, the carbon price has approximately dropped to 0 euros by the end of the first period , affectiDuring the Phase II, if a company makes two consecutive direction transactions, the records of transactions are selected. Therefore, two types of records are included: the first one is a selling transaction follows a buying transaction, and the second one is a buying transaction follows a selling transaction. According to this principle, a total of 65,077 transactions records are extracted from the full sample transaction records; 18,120 transactions records are selling follows buying, and 49,657 transactions records are buying follows selling.The endowment effect can be reflected in the gap between WTP and WTA. In a laboratory study of the endowment effect, the reference price of experiment goods is stable. While in the real market, the carbon price changes every day, accompanied by transaction risks. First, with the software of EViews, WTP and WTA are evaluated by excluding the risk cost that used to avoid short-term fluctuations in the trading price. The risk cost is acquisitioned from the VaR of carbon price, and the VaR is calculated based on the volatility item from the Autoregressive Moving Average-Exponential Generalized Autoregressive Conditional Heteroscedasticity (ARMA-EGARCH) model; secondly, the records of the two adjacent transactions by each trader are selected . After the difference value between WTA and WTP is obtained, this study subtracts the effect of the long-term price fluctuations during the two transactions, then the endowment effect of the trader is quantified accordingly. The long-term price fluctuations are calculated through constructing an EMD method on Python 3finally, the impacts of trading experience and compliance pressure on the endowment effect can be analyzed through EViews 10 9 .To generalize the implausible assumption of a constant variance should be existed in a studied period, a stochastic process called Autoregressive conditional heteroskedasticity (ARCH) processes were introduced by Engle et al. . The ARCTo explain the trend and volatility of carbon prices in Phase I, Fan et al.  construcThe mean equation of the ARMA-EGARCH model is shown as followsThe conventional signal processing techniques, including time-domain and frequency-domain analysis, are based on the assumption that the process generating signals is stationary and linear, as both of them depend on the Fourier transform. Huang et al.  proposedThe EMD method is an adaptive and powerful time–frequency signal processing technique. The EMD technique is used as a tool for extracting the required information from a noisy signal ,28 and iStep 1. Identify all local maxima and minima in Step 2. Equation (4) calculates a new sequence Then, whether Step. 3. If Step 4. If the remaining term When the decomposition is completed, the initial sequence of carbon price In the laboratory research on the endowment effects, WTA and WTP can be known directly by asking individuals ,6. TypicIn 1993, the member states of G30 published a report on financial derivatives, suggesting the use of VaR to assess financial risk for the first time. In the financial industry, VaR is the standard measure of risk and has been popular since it was applied in Basel II  as the benchmark for regulatory capital. VaR has been extensively conducted in empirical analysis, and is widely used by investors, investment banks, commercial banks, and market regulators. The current mainstream calculation method of VaR is based on the ARCH models. This is mainly because ARCH models have a very good performance in the field of describing the volatility of financial market asset returns, and thus VaR value can more clearly reflect financial risk. VaR represents the maximum possible loss of a certain portfolio under normal market conditions at a given confidence level and holding period. P’ soon, therefore they are willing to pay risk cost  is the quantile corresponding to the probability level α in the standard normal distribution. In the 5% significance level, the value is 1.645. In this study, When a company needs to buy allowances, it is facing the risk of prices rising in the next moment, and the The actual trading price is the WTP of the trader plus the risk cost (VaR) paid to avoid the risk of prices rising, therefore the calculation method for WTP is shown as follows:When a company needs to purchase allowances, it is facing the risk of prices decrease in the next moment, and the The actual trading price is the WTA of the trader minus the risk cost (VaR) paid to avoid the risk of prices rising. Since the risk cost is a positive, we use (−VaR) to represent that value, and the calculation method of the WTA is shown as follows:First of all, endowment effect analysis is performed on the first type of data, that is, transaction data of selling allowances that follows buying allowances. Next, compare the WTA for selling allowances and the WTP for buying allowances, and then remove the effect of long-term fluctuations in carbon prices between two trading periods, namely, the difference between the trend terms of the EMD model at the two trading times. Finally, the endowment effect is quantified:Due to the comprehensiveness of the used data set, we can perform a robustness test on the endowment effect from another perspective. In the test, the second type of data is selected, that is, the transaction data of buying allowances that follows selling allowances. The robustness test is achieved through analyzing whether the WTP of the buying allowances is much lower than the WTA of selling allowances, and the Equation (14) of robust test is similar to Equation (13):Because the market is a cap-and-trade market, different emitting companies are allocated with unequal allowances in each year and would surrender allowances that are equal to their emissions, therefore different companies could have different gaps between allocation and surrender. If emitting companies have surpluses in allowances, they need to sell those to benefit from carbon reduction; if they do not have enough allowances to surrender, they need to buy allowances to avoid the penalty. Therefore, different companies have different compliance pressure, which is reflected by the gap, this paper also models and analyzes the impact of compliance pressure on the endowment effects.When the traders conducted trading at time t, their trading experience are represented by the accumulated number of transactions before time t, and the start time of measurement for the number of transactions is May 1st, 2008, i.e., the beginning of Phase II of the EU ETS. Traders’ compliance pressure is reflected in their positions, and their initial position is defined as the subtraction value between allocation and surrender in the first year of a phase. When the company makes transactions, the position is adjusted according the trading volume. When the company is allocated allowances for another year, the position of the company will be subjoined the subtraction value of allocation and surrender for the second year. Hence, the empirical research about the effects of trading experience and compliance pressure on endowment effects is conducted:In the robustness test, we also analyze the endowment effect reflected in the second type of transactions, i.e., a buying transaction that follows a selling transaction. The effects of the trader’s trading experience and compliance pressure on the endowment effect are as follows:The results of the ARMA-EGARCH model for the ‘carbon pricing’ are summarized in The volatility persistence of the ‘compliance trading’ power is measured by the parameter The EMD decomposes the original signal data into several clear, periodic IMF components. In economics, each component can be analyzed and explained according to different influencing factors to find the development law. According to the adaptability of the EMD method, this paper directly performs EMD decomposition on the original carbon price and obtains 5 IMF components and 1 residual term. The decomposition results are shown in From the complete transaction data, there are 17,895 records of selling allowances that follows buying allowances, and 46,437 records of buying allowances that follows selling allowances. Calculated by Equation (13), 15,617 records show positive values, accounting for 87% of the total selling transactions that follows buying transactions and indicating the existence of the endowment effect. Calculated by Equation (14), 41,186 records show negative values, accounting for 89% of the total buying transactions that follows selling transactions and further verifies the existence of the endowment effect. Moreover, the 15,617 selling transactions are conducted by 2296 traders, and 41,186 buying transactions are conducted by 2702 companies. Amongst them, there are 1956 traders can be found in both the categories, indicating that the companies have stable performances on the endowment effect, no matter whether they are selling or buying allowances.−5) and −9) are negative, indicating that the trading experience and compliance pressure can weaken the endowment effect, and this is in line with the findings of List (2003). As the endowment is quantified through the difference between WTA and WTP, and WTP is an expected price of the trader in the previous transaction, the trading experience and compliance pressure can lower the WTA of trader. In the Equation (16), −6) and −9) are also the counter evidence to the above findings. The difference is that the trading experience and compliance pressure can higher the WTP of trader, and then weaken the endowment effect.The results of the model for the ‘endowment effect’ are summarized in By comparing the absolute values of the model coefficients In this paper, for the first time, the presence of the endowment effect is analyzed in a real market (the EU ETS) based on the complete transaction data from 2008 to 2012, and whether the endowment effect will be influenced by trading experience is also investigated. In addition, in the cap-and-trade market mechanism, this article studies the impact of compliance pressure on the endowment effect in the EU ETS.This article has two findings in the field of economics. First, the endowment effect is observed and quantified in a real market based on the transaction data, once companies buy carbon allowances, they have a higher valuation of the carbon price. Contrarily, once companies sell carbon allowances, they have a lower valuation of the carbon price; second, in previous laboratory research, due to lack of sufficient experiment time, it is still controversial whether trading experience will affect the endowment effect. This paper conducts an empirical analysis based on 361,432 records of individuals transaction, and it lasted for five years (from 2008 to 2012). It is found that the companies have the endowment effect regardless of trading experience, but when the trading experience increases, the endowment effect will be weakened.This article also has two findings in the field of carbon market. First, this article finds that in this cap-and-trade market, the traders are not only chasing for achieving compliance obligation, but also are seeking to make profits through transactions. When traders conduct selling transaction follows a buying transaction, the WTA of selling is usually greater than the WTP of buying. Similarly, when traders conduct a buying transaction follows a selling transaction, the WTP of buying is often lower than the WTA of selling. Second, the companies’ endowment effect is influenced by the compliance pressure in the EU ETS; the higher compliance pressure they face, the lower level of the endowment effect they perform. Moreover, compared with selling allowances, compliance pressure has stronger influences on buying allowances, and increase their willingness to buy. This is consistent with the finding of Kahneman et al. : the inaBased on the findings, three policy implications that aim at improving the effectiveness of the carbon market can be offered. First, this article finds that endowment effects are pervasively existed in the EU ETS, which is reflected in the gap between WTP and WTA and can affect the liquidity of allowances. While the trading experience can reduce the magnitude of the endowment effects, therefore, market managers can encourage traders to conduct allowance transactions of small volumes, through which traders can accumulate trading experience, thereby weakening the endowment effect and promoting the market liquidity.Second, in this particular cap-and-trade market, the companies generally face varying degrees of compliance pressure according to their volumes of allocation and emission. This study finds that compliance pressure can reduce endowment effects, therefore, the companies can be allocated a little more allowances than their emissions if they actively invest in reducing emissions, on the contrary, the companies can be allocated a little less allowances than their emissions if they do not actively invest in reducing emissions. This can not only encourage enterprises to invest in emission reduction technology, but also form compliance pressure on emitting companies in the EU ETS and to promote the conclusion of transactions.Finally, this research shows that in the EU ETS, endowment effects make transactions difficult to reach, which is mainly owning to the seller’s unwillingness to sell. It means that apart from avoiding the situation of over-allocation in allowances, avoiding the circumstances that traders cannot find a counterparty to buy allowances is also important. According to this finding, when formulating the plan of emission reduction, it is necessary to set the volume of allocation a slightly larger than that of emission, ensuring that companies with shortages of allowances can buy enough allowances to promote smooth market operationsAdmittedly, there is still a shortcoming in this study. Since only the transaction price is recorded in the dataset of the EU ETS, it is impossible to directly obtain the WTA and WTP of traders in each transaction. Therefore, this article can only estimate the WTA and WTP by excluding the risk cost used to avoid short-term price fluctuations from the trading price; this estimation process is flawed. Nevertheless, this research is still a meaningful exploration of the endowment effect of traders in a real market, and it has certain reference significance for future research on endowment effect in the real market.This empirical research is based on the of 361,432 full-sample transaction data of the EU carbon market. It is a preliminary study of the endowment effect in a real market. In potential future research, we will distinguish and quantify the risk appetites of the traders and make more accurate estimations of their WTA and WTP according to the risk appetite of traders, therefore we can quantify the endowment effect more accurately.


Purpose: The aim was to investigate the associations between maternal thyroid parameters within the normal ranges during early pregnancy and birth outcomes, and further to examine whether the associations were modified by gestational weight gain (GWG).Methods: Maternal serum thyroid-stimulating hormone (TSH), free thyroxine (FT4), and free triiodothyronine (FT3) concentrations within the normal ranges during early pregnancy were measured from 8,107 pregnant women in Wuhan, China. The associations between maternal thyroid parameters and birth outcomes  were analyzed using multivariable adjusted regression models, and effect modification by pre-pregnancy body mass index (BMI) category and GWG were further evaluated.Results: Maternal TSH and FT4 concentrations were negatively associated with birth weight, and the latter only occurred in normal weigh women with inadequate and excessive GWG, as well as in both underweight and overweight women with excessive GWG . Moreover, maternal FT4 and FT3 concentrations were associated with increased risk for low birth weight, and the latter only occurred in normal weigh women with inadequate GWG . These associations still persist when maternal thyroid parameters were modeled as quintiles.Main conclusion: Maternal normal thyroid function during early pregnancy with excessive and inadequate GWG may adversely influence fetal growth. Maternal thyroid function plays a vital role in ensuring placentation and regulating fetal organ development and maturation –3. SpeciAccumulating evidence has consistently demonstrated that abnormal maternal thyroid function such as overt hypothyroidism and hyperthyroidism during pregnancy are related with increased risk of adverse obstetrical and offspring outcomes including preeclampsia, gestational diabetes, placental abruption, preterm birth, fetal death, and low birth weight –14. SeveApart from maternal thyroid function, gestational weight gain (GWG) has also been shown to affect fetal growth . The InsIn the present study, we investigated the associations between maternal serum thyroid parameters within the normal ranges during early pregnancy and birth outcomes in a larger population-based prospective study in Wuhan, China. Furthermore, we examined whether the associations were modified by GWG.Pregnant women during the first prenatal visit  were invited to participate in this study in the Wuhan Children's Hospital  between November 4, 2014 and April 17, 2018. A total of 12,544 pregnant women during the study period completed the questionnaires containing the information about demographics, health status and obstetric history. We excluded 2,863 pregnant women who had chronic diseases, thyroid related diseases and pregnancy complications, as well as 415 pregnant women who gave birth to birth defects perinatal death and twins. Additionally, 29 pregnant women reported that they were smokers or alcohol consumers during the pregnancy were further excluded, resulting in 9,237 study subjects in this study. Among them, 8,107 pregnant women who had the serum thyroid parameters within the normal ranges were retained in the final analysis. The authors have obtained both informed consent and ethics committee approval of Wuhan Children's Hospital  for studies on patients, patient records, or volunteers.Five milliliter of blood samples from pregnant women in their first prenatal examination in the hospital were collected and then were centrifuged to obtain serum. Maternal serum thyroid hormones including TSH, FT3, and FT4 were measured within 24 h by DxI800 Immunoassay System (Beckman CoulterUniCel). The inter-assay coefficients of variation (CVs) at low and high concentrations ranged from 1.88 to 3.92% for FT3, 1.66–2.58% for FT4, and 2.43–2.80% for TSH. The between-assay CVs were 1.60–2.85% for FT3, 1.70–3.30% for FT4, and 2.50–3.80% for TSH. A total of 8,107 pregnant women who had their serum thyroid hormone concentrations within the normal ranges according to the percentile distribution of serum thyroid hormones  among the whole population. The 2.5th−97.5th percentiles ranges of FT3, FT4 and TSH concentrations were 1.93–3.85 ng/L, 0.55–0.98 ng/dL, and 0.10–3.24 uIU/mL, respectively.Birth outcomes including birth length (in centimeters), birth weight (in grams), gestational age (in weeks), and fetal sex were collected from the Wuhan delivery system and the child care system in the Wuhan Children's Hospital . Gestational age was calculated as the difference between the date of the last menstruation and the date of delivery. Low birth weight was defined as birth weight below 2,500 g.2). The pregnant women were defined as high risk pregnancy if they meet one of the following criteria: pre-pregnancy weight <40 or>80 kg; height ≤ 1.45 m; age <18 or ≥35 years; malformations of the birth canal or narrow pelvis; abnormal uterine development; thoracic spine deformities; abnormal pregnancy history; pregnancy complication; abnormal conditions during the pregnancy such as threatened abortion, placental abruption, preeclampsia, dyspnea, and acute abdominal pain. GWG (in kilograms) was calculated as the difference between the prenatal weight, and the pre-pregnancy weight. According to the IOM guidelines of 2009  was calculated as weight divided by squared height  version 18.0 for the data analysis. Descriptive statistics for demographics, birth outcomes, and maternal thyroid hormone concentrations were conducted. Statistical significance was defined as a n = 114) in our study population was limited, we did not include them into the stratification analysis. We also only conducted the stratification analysis for low birth weight among normal weight women due to the limited cases.Multivariable linear models were used to investigate the associations of continuous maternal thyroid hormones  with birth weight, and birth length. We also categorized maternal thyroid hormones into quintiles to investigate the possible dose-response associations. A test of trend across quintiles of maternal thyroid hormones modeled as integer values (0–4) was examined and the first quintile was considered as the reference. Logistic regression models were applied to estimate odds ratio (ORs) and 95% confidence intervals (CIs) for the associations between maternal thyroid hormones and risk for low birth weight. The above associations stratified by pre-pregnancy BMI category and GWG were further conducted. The cross-product term between maternal thyroid hormones and GWG was used to assess the interactions. Because the number of obese women , maternal age , maternal education , mode of delivery , parity , high risk pregnancy , infant's sex  and gestational age . We did not adjust both of GWG and pre-pregnancy weight in the stratification analysis.Covariates were included in the final regression models based on statistical and biological considerations. Those covariates were entered into the final multivariable adjusted models with 2, respectively. Of the 8,107 women, 1,358 (16.8%) were categorized as underweight, 6,010 (74.1%) as normal weight, 625 (7.7%) as overweight and 114 (1.4%) as obese. More than half of the women were nulliparous (71.2%) and well-educated (65.4%). The mean (SD) birth length, birth weight and gestational age were 50.2 (1.6) cm, 3,327 (413) g, and 39.0 weeks (1.3), respectively. A total of 178 newborns (2.2%) were low birth weight. The mean (SD) maternal TSH, FT4, and FT3 concentrations within the normal ranges during early pregnancy were 1.35 (0.71) uIU/mL, 0.76 (0.09) ng/dL, and 3.00 (0.37) ng/L, respectively.The characteristics of mothers and newborns are described in Multivariable-adjusted associations between maternal thyroid hormones and birth outcomes are summarized in We observed that maternal FT4 and FT3 concentrations were associated with increased risk for low birth weight; the ORs were 8.98  and 1.97  for every unit increase in FT4 and FT3 concentrations, respectively. Significant dose-dependent relationships across increasing quintiles of maternal FT4 and FT3 concentrations with increasing risk for low birth weight were still found (both p for trends < 0.05). We found that maternal TSH concentrations were not significantly associated with increased risk for low birth weight.p for trend =0.01).We observed that maternal TSH and FT3 concentrations were not associated with birth length. However, we found that maternal FT4 concentrations were negatively associated with birth length. The birth length decreased by 0.50 cm  for every unit increase in FT4 concentrations. Significant dose-dependent relationships were still observed across increasing quintiles of maternal FT4 concentrations with decreasing birth length . Written informed consent to participate in this study was provided by the participants and the participants' legal guardian/next of kin.X-JH and BZ contributed to study design, writing, and revision of the manuscript. YC and LL contributed to the assays. W-QC and BZ performed data analysis. All authors contributed to the article and approved the submitted version.YC was employed Wuhan Pengxiang Medical Equipment Co., Ltd. The remaining authors declare that the research was conducted in the absence of any commercial or financial relations that could be construed as a potential conflict of interest.


We report an isolated cardiac hydatid cyst located in the IVS in an 18-year-old man diagnosed incidentally by transthoracic echocardiography. Cardiac magnetic resonance imaging confirmed a mass lesion of 47×74 mm in diameter located at the base of IVS. The cystic content and its germinative membrane were resected and the cavity was applicated under cardiopulmonary bypass. Postoperative course was uneventful and the patient was discharged on the 6 The diagnosis of hydatid cyst can be difficult because of nonspecific variable symptoms depending on the location and the size of the cyst. Cardiac hydatidosis should be suspected in patients with nonspecific symptoms, especially in endemic areas with high occurrence of hydatid infestation. The myocardium of the left ventricle (LV) is more frequently involved, reaching two-three folds more than the right ventricle (RV), with much less involvement of the interventricular septum (IVS)An 18-year-old man was referred to a cardiologist for routine cardiac evaluation before attending to the national army recruitment college. He did not show any symptoms of cardiac pathology and did not have history of any health problem. Physical examination was normal. Chest X-ray and electrocardiogram (ECG) were normal. Laboratory analysis revealed negative indirect hemaglutination test for hydatid cyst. Transthoracic echocardiography (TTE) revealed a normal ejection fraction and normal valvular functions with a huge cystic mass within the IVS, leading to partial outflow obstruction of both ventricles . For detEchinococcus granulosus. Postoperative TTE was normal, without any remnant of the cyst. The patient was discharged on the 6th postoperative day, with oral albendazole treatment.The patient underwent surgery under cardiopulmonary bypass. A bulging mass between the RV and LV on the epicardial surface was observed on every heart beat, which indicated the location of the cyst, as diagnosed by MRI and TTE. Pericardium was packed with sterile clean pads soaked in hypertonic saline solution to reduce the risk of mediastinal contamination. In order to reach the hydatid cyst, a vertical right ventriculotomy incision parallel to the left anterior descending coronary artery was made. Fluid of the cyst was aspirated by an injector, then the cavity was irrigated with hypertonic saline solution. Cystectomy was performed, and the germinative membrane and numerous daughter cysts were evacuated . The cys. Larvae reach the left side of the heart via coronary circulation and the inflammatory response to the presence of parasitic involvement creates an adventitial pericystic layer. Echinococcosis infrequently occupies the myocardium and account for only 0,5%-2% of all hydatid infestations. Hydatid cyst of İVS, which has different characteristics from right-sided cysts, is the one with infrequent location of cardiac involvements. The presentation of hydatid cyst ranges from asymptomatic to sudden death. As it was seen in our case, it may remain silent and is diagnosed incidentally. The clinical picture of the cardiac cyst depends on the location, number of cysts, age, size, and involvement of adjacent structures within the heart. In some cases, left ventricular free wall or pericardial located cysts can be diagnosed easily by simple routine tests, such as an abnormality of the cardiac silhouette on chest X-ray or ECG abnormality imitating left ventricular aneurysmal dilatation. Indirect hemagglutination test is specific and a sensitive serologic diagnostic test for hydatid disease with negative result does not exclude the diagnosis.Hydatic cyst is an endemic parasitic disease, mostly occuring in livestock keeping countries. Ingested parasitic larvae migrate through the intestinal mucosa and are mainly carried to the liver by the portal venous circulation. Total excision of the cyst is the best treatment and complete closure of the cyst cavity by plication is mandatory without leading any structural defect. This surgical closure of hydatid cyst has proven to have good results as reported before,4.Unless the pathology is inoperable, all patients who have cardiac hydatid cyst, including asymptomatic patients, should undergo surgery to prevent life-threatening catastrophic complications, such as rupture, anaphylaxia, systemic or pulmonary embolization, arrhythmias, pericardial tamponade, and cardiogenic shockIn conclusion, early diagnosis and urgent surgical intervention are essential even in asymptomatic patients to prevent possible life-threatening catastrophes.