Gestational age (GA), birth weight (BW) and length (BL) and head circumference (HC) were collected from birth records. The associations between measured pollutants, and pollution surrogates, were analysed using general linear models, controlling for maternal age, parity, maternal health, and season of birth. Only HCHO was associated with any of the birth outcomes. There was a 0.044 decrease in BW z-score (p = 0.033) and 0.05 decrease in HC z-score (p = 0.06) for each unit increase in HCHO. Although HCHO concentrations were very low, this finding is consistent with other studies of formaldehyde and poor birth outcomes.There is a growing body of research on the association between ambient air pollution and adverse birth outcomes. However, people in high income countries spend most of their time indoors. Pregnant women spend much of that time at home. The aim of this study was to investigate if indoor air pollutants were associated with poor birth outcomes. Pregnant women were recruited prior to 18 weeks gestation. They completed a housing questionnaire and household chemical use survey. Indoor pollutants, formaldehyde (HCHO), nitrogen dioxide (NO Exposure to toxicants during pregnancy has the potential to affect foetal growth and development . There iMuch of the research has examined the implications of exposure to outdoor air pollution. There has been limited research into the impact of indoor air pollution (IAP). Studies on IAP have tended to focus on the detrimental impacts of the burning of biomass for cooking and heating in low to middle income countries . HoweverFor pregnant women the majority of time is spent indoors at home ,16,17,182) and volatile organic compounds (VOCs) were monitored at 34 weeks gestation. Data on traffic near the women’s home address as well as exposure to environmental tobacco smoke (ETS) was also collected. Standard demographic variables, including gestational age (GA), length , weight (BW) and head circumference (HC) were obtained from birth records. Ethics approval for this was obtained from both the Princess Margaret Hospital (Registration number 1611/EP) and Murdoch University (Project number 2007/238) human research ethics committees.Non-smoking pregnant women were recruited from within a larger birth cohort study of the effect of maternal stress responses to physical, biological and emotional stressors on foetal and child health outcomes. Women were recruited prior to 18 weeks of gestation. At initial recruitment, non-smokers were approached and asked if they wished to participate in the IAP component. Those that agreed completed a number of validated questionnaires, including a housing inventory and chemical usage survey, at recruitment. Indoor air concentrations of formaldehyde (HCHO), nitrogen dioxide  solution [3) for formaldehyde; 0.42 ppb (0.8 µg/m3), and 0.5 ppb for individual VOCsEach of the indoor pollutants, HCHO, NOsolution . Formaldsolution . Samplinsolution . For allData was collected for exposure to ETS and traffic, as well as maternal health status. Exposure to ETS was determined by questions on whether there were smokers in the home and if the mothers were exposed to 2 or more hours of ETS at home and/or at work. Distance from home to main roads was used as a proxy for traffic pollutant exposure. This was obtained by geocoding each woman’s home address and mapping these on road maps obtained from Western Australia Main Roads Department using a specialised computer software package . Details of current and past health of the women were collected from questionnaires filled in by the mothers at 18 and 34 weeks of gestation. Data was collected on current asthma, current and gestational diabetes, and current and gestational high blood pressure. These were all self-reported. Maternal age at birth of the child, parity and season of birth were also recorded.Birth outcomes: Gestational age was normally distributed so the raw data was used in the analyses. All other birth measures, BW, BL and HC, were transformed to z-scores based on birth centile charts from the WHO [ the WHO . The z-sExposure data: Pollution concentrations could not be transformed to normal so raw values were used. For HCHO, the average of bedroom and living room concentrations was used. For VOCs, a suite of 31 compounds were monitored but most were not detected. The most commonly detected compounds were the BTEX compounds  so a BTEX score was calculated by summing up those compounds. A total household chemical use score  score) was calculated. This score was calculated as a sum of reported usage frequencies of each category of the 11 household products. The scoring guide to each product based on frequencies of used were as follows: rarely (0); monthly (1); fortnightly (2); weekly (3); most days (4) or daily (5) [aily (5) . A scoreOther variables: Maternal age was normally distributed. Maternal health conditions  were classified as binary variables (present/not present). For both diabetes and hypertension, current and gestational conditions were combined for a single variable. There were three categories for parity: nulliparous, primipara, and multipara.de novo in models. Distance from main road and exposure to ETS were included in each of the models of measured pollutants but removed if they were not significant at the level of 0.5. All analyses were conducted using SPSS The relationship between IAP exposures and each of the four birth outcomes  were analysed using general linear models. Separate models were constructed for each indoor air exposure variable, as well as distance from main road and exposure to ETS. All models included maternal age and parity as both of these factors are known to affect birth outcomes . MaternaThree hundred and seventy-three non-smoking women (373) were approached and 305 (81.7%) agreed to participate in the IAP sub-study. Of these participants, birth data were available for 266 births. Furthermore, four women were found to be active smokers and were excluded from the analyses. Therefore, the final analyses included 262 live births . Most births were full term with only 6 babies born <37 weeks, but all born after 36 weeks. The age range for mothers was 18 to 41 years (mean 29.6 years) and most were healthy with very few reported health issues . Details2 and VOCs. There were no significant correlations between measured IAPs (data not shown). Fifty-eight women reported significant (>2 h) daily exposure to ETS. Only 9 homes were within 50 m of a major road, while a further 14 were within 100 m. Indoor air data, as well as the distance of homes (by categories) from main roads, are presented in Indoor air pollution concentrations were low with a large number of samples below the LOD, particularly for NOGestational age: None of the environmental pollutants, monitored and surrogates, were associated with GA.Birth weight: Average household HCHO was associated with reduced BW. After controlling for parity, maternal age and maternal health, there was a decrease of 0.044 z-score in birth weight for every 1 µg/m3 increase in HCHO (p = 0.033) (= 0.033) . No othe= 0.033) .Birth length: There was no association between BL and any of the exposure variables.Head circumference: Of all the exposure variables, only HCHO was associated with HC. There was a decrease of 0.056 z-scores for every 1 µg/m3 increase in average household HCHO, but this was not statistically significant (p = 0.06).2 and VOCs, nor the pollution surrogates, CHCE, distance from main roads and ETS, were associated with any birth outcomes. Although HCHO concentrations in homes were low, the results are consistent with other data on HCHO and birth outcomes.There are only a few studies on the associations between maternal exposure to IAPs on birth outcomes. In this study there was a significant association between HCHO concentrations in homes and reduced BW. Neither of the other measured pollutants, NOAlthough pregnant women in high-income countries spend most of their time indoors, particularly toward the end of pregnancy ,18, therOf the pollutants measured only HCHO was associated with any of the birth outcomes. Although HCHO is a constituent of outdoor air it is generally found in higher concentrations indoors  and indo3), well below occupational exposures and residential concentrations that have previously been associated with, mostly respiratory, health effects [3) and reduced BW [The concentrations of HCHO in the current study are low  that may explain the effects of HCHO on the developing foetus are not known but may include genotoxicity, oxidative stress, disruption of the protein, enzyme and hormonal activity and DNA methylation . Formald2 (46.6%) and VOCs (19.4%) below the limit of detection. Exposure to ETS was self-reported and there was no objective measure of exposure, such as cotinine, obtained in this study. Outdoor air pollution was assessed by proxy using distance from roads. The study was conducted in a small city, and its surrounding rural areas, with a population of about 80,000. There is no major industry in the area and the main contributor to outdoor air pollution is traffic. However, traffic is only relatively heavy during the holiday season and very few homes of the pregnant women were within 100 m of roads that could get intermittent heavy traffic flows.There were no associations with other pollutants, measured directly or as surrogates, and birth outcomes. The lack of associations in this study may be due either to the low levels of those pollutants, limitations of the exposure assessment, or an association does not exist. Indoor concentrations of measured pollutants were low, with many samples for NO2 [2 and VOCs, however, may vary considerable both spatially and temporally, and are dependent on sources. For example, NO2 concentrations can increase rapidly with the use of gas appliances [Both NO2 ,46,47,482  as outdo2 . Gavin e2  recommen2 ,50,51,522 ,50. The pliances  and therpliances . Indoor pliances .n = 266), although this is a similar size to other pregnancy exposure studies, such as studies conducted in the USA (n = 263) [n = 362) [n = 273) [There are a number of limitations to this study. The sample size was small (n = 263) , Poland n = 362)  and Frann = 273) . Monitorn = 273) ,33 and pn = 273) ,18. Datan = 273)  found onn = 273) . TrimestThis study provides evidence that indoor exposures, even at low levels, may be associated with adverse birth outcomes. Formaldehyde, which is predominantly an indoor air pollutant, was associated with reduced birth weight. These findings are consistent with other research, albeit mostly involving much higher exposures. Further research is required to attain a better understanding of how low-levels of HCHO exposure may influence foetal development.


Gaps exist between internationally derived clinical guidelines on care at the time of birth and realistic best practices in busy, low-resourced maternity units.In 2014–2018, we carried out the PartoMa study at Zanzibar’s tertiary hospital, United Republic of Tanzania. Working with local birth attendants and external experts, we created easy-to-use and locally achievable clinical guidelines and associated in-house training to assist birth attendants in intrapartum care.Around 11 500 women gave birth annually in the hospital. Of the 35–40 birth attendants employed, each cared simultaneously for 3–6 women in labour. At baseline (1 October 2014 to 31 January 2015), there were 59 stillbirths per 1000 total births and 52 newborns with an Apgar score of 1–5 per 1000 live births. Externally derived clinical guidelines were available, but rarely used.Staff attendance at the repeated trainings was good, despite seminars being outside working hours and without additional remuneration. Many birth attendants appreciated the intervention and were motivated to improve care. Improvements were found in knowledge, partograph skills and quality of care. After 12 intervention months, stillbirths had decreased 34% to 39 per 1000 total births, while newborns with an Apgar score of 1–5 halved to 28 per 1000 live births.After 4 years, birth attendants still express high demand for the intervention. The development of international, regional and national clinical guidelines targeted at low-resource maternity units needs to be better attuned to input from end-users and the local conditions, and thereby easier to use effectively. Around 11 500 women give birth annually in the hospital, with the great majority being self-referrals. At baseline (1 October 2014 to 31 January 2015), there were 59 stillbirths per 1000 total births and 52 newborns with an Apgar score of 1–5 per 1000 live births.Guidelines for managing complications in pregnancy and childbirth,When starting the study in October 2014, different clinical guidelines on intrapartum care, including the World Health Organization’s (WHO’s) –The aim was to create locally achievable and easy-to-use guidelines to assist birth attendants in providing best possible intrapartum care with the constrained resources available. We adapted existing international guidelines,Box 1We considered how birth attendants could allocate more time to attend to women with labour complications, such as slow labour progress, while still providing essential monitoring and care for women with uncomplicated labour. Following the World Health Organization (WHO) 2017 recommendations,,Blind titration of intravenous oxytocin during labour may cause uterine hyperstimulation with risk of fetal death, uterine rupture and bleeding after birth. Cautious augmentation of labour with oxytocin is thus warranted, but is often hampered in busy, low-resource maternity units by lack of one-to-one care and electronic drip-count devices. WHO recommendations from 2017https://publichealth.ku.dk/about-the-department/global/research/sexual-and-reproductive-health-and-rights/partoma/dokumenter/PartoMa_Pocket_Guide_2_22062018.pdf.Note: The PartoMa pocket guide is available online at In addition to everyday use, training on the use of the pocket guide and partograph was provided during quarterly in-house seminars.In response to birth attendants’ comments, we launched an expanded second version of the pocket guide in 2018. Though the official work language is English, we are currently translating the guide into Swahili, which might strengthen use further.We evaluated the PartoMa intervention using Kirkpatrick’s four-level framework.Level 2 was birth attendants’ knowledge and partograph skills, which we evaluated during December 2017 to June 2018. Paired comparisons before and after seminars showed significant improvements in knowledge and partograph skills among 143 seminar participants, of whom 24 were followed through an additional seminar round where further significant improvements were found .,Levels 3 and 4 were clinical practice and birth outcomes. We conducted a pre–post-intervention study, comparing case files at baseline (October 2014 to January 2015) and one year later (October 2015 to January 2016). As previously published,Training 80 people over 2 days of the seminars costed approximately 800 United States dollars (US$), including laminated pocket guides (US$ 4.80 each), refreshments, photocopies and stationery. The same four whiteboard partographs were used at each seminar (US$ 45 each). A mannequin was already available when a neonatal resuscitation station was added in 2017. The intervention development and evaluation were led by a doctoral fellow and not included in these costs. We have not estimated opportunity costs for voluntary time spent by facilitators, seminar participants, study team members and external reviewers.Introducing locally-tailored clinical guidelines, with quarterly repeated training on their use, improved intrapartum care and birth outcomes in Zanzibar’s tertiary hospital, which appears to have been sustained for 4 years . These changes occurred despite no improvements in staff numbers and staff turnover, no additional medical technology, no other training interventions and continual shortages in supplies. We found high motivation among many birth attendants to learn and to improve care, without additional financial compensation .Box 2Locally adapted clinical guidelines for intrapartum care, co-created with birth attendants, were associated with improvements in knowledge, skills, quality of care and perinatal outcomes.Evidence-based clinical guidelines produced at the international, regional and national levels may not lead to change if they cannot be easily adapted at facility level, taking into account resource constraints of particular settings.Short, repeated in-house training was highly acceptable among birth attendants, even without financial compensation for attendance outside working hours. Nevertheless, developing the PartoMa guidelines was demanding on resources, requiring staff time and capacities, project funding and robust coordination of partners.,,,Maternal health guidelines targeting low-resource settings have typically relied on top-down development by experts, often without end-users’ feedback or pilot testing, followed by inflexible cascade implementation and no post-implementation evaluation.–,When comparing multiple international clinical guidelines in maternal health, inconsistencies have been found across apparently high-quality, evidence-based guidelines.,,,Supported by the study team, a steering group of volunteer birth attendants in Zanzibar have distributed guides and organized seminars since 2016. We have observed signs of ownership of the programme within the steering group, although there are particularly challenges to sustainability due to high staff turnover. In June 2018, the Zanzibar health ministry, with support from the United Nations Population Fund, took over the continuation and scaling-up of the intervention. The PartoMa seminars are now conducted quarterly in both of Zanzibar’s main islands. We are currently setting up a study in five maternity units in Dar es Salaam, United Republic of Tanzania, 'to assess whether the intervention can be easily context-adapted and effectively implemented at similar low-resource maternity units, and whether the process can serve as a model for other areas of health care. The PartoMa study has grown into a valuable single-setting analysis of the applicability of international guidelines targeting maternity care in low-resource settings. We acknowledge the ethical dilemmas of producing achievable guidance for use in settings with inadequate human and economic resources. However, we argue for decision-making support that assists birth attendants in saving lives, rather than best-evidence guidelines that are not used. The global community has called for context-appropriate implementation strategies with clinical guidelines formulated to facilitate understanding and use.


In the article titled “Is IVF/ICSI an Independent Risk Factor for Spontaneous Preterm Birth in Singletons? A Population-Based Cohort Study” , the acr


The goal of our study was to explore the combined effects of kidney damage biomarkers previously associated with birth outcomes. To do this, we generated kidney biomarker indices using weighted quantile sum regression and assessed associations with length of gestation or birth weight. A decile increase in each kidney biomarker index was associated with 2-day shorter gestations  and 59-gram lower birth weights , respectively. Weights highlighting the contributions showed neutrophil gelatinase-associated lipocalin (NGAL) (60%) and osteopontin (19%) contributed most to the index derived for gestational age. NGAL (66%) and beta-2-microglobulin (10%) contributed most to the index derived for birth weight. Joint analyses of multiple kidney biomarkers can provide integrated measures of kidney dysfunction and improved statistical assessments compared to biomarkers assessed individually. Additionally, shorter gestations and lower birth weights may contribute to subclinical kidney damage measurable in childhood.Infants born prematurely or with low birth weights are more susceptible to kidney dysfunction throughout their lives. Multiple proteins measured in urine are noninvasive biomarkers of subclinical kidney damage, but few studies have examined the joint effects of multiple biomarkers. We conducted an exploratory study of 103 children in the Programing Research in Obesity, Growth, Environment, and Social Stressors (PROGRESS) longitudinal birth cohort, and measured nine proteins selected  As nephron development is typically complete around 36 weeks of gestation , infantsi.e., albumin and cystatin C) [i.e., alpha-1-microglobulin (A1M) and beta-2-microglobulin (B2M)) [i.e., neutrophil gelatinase-associated lipocalin (NGAL), osteopontin (OPN), kidney injury molecule-1 (KIM-1), clusterin, and trefoil factor 3 (TFF-3)) [Multiple proteins represent validated or emerging biomarkers of renal damage in children that can be obtained noninvasively, through analysis of spot urine , 7. Thestatin C) , 8, failn (B2M)) , 10, or (TFF-3)) –15. We a(TFF-3)) , 17.Multiple kidney proteins can be measured in urine noninvasively, and there is interest in investigating their individual utility as biomarkers to detect renal damage , especiacombinations of nine kidney biomarkers selected a priori and two birth outcomes: length of gestation and birth weight. To our knowledge, no prior study has reported the combined effects of multiple kidney damage biomarkers, examined in early childhood, and the association with length of gestation and birth weight. This work is also the first, to our knowledge, to examine kidney biomarker proteins prospectively among a generally healthy population of children. In this work, we selected weighted quantile sum (WQS) regression [In this work, we set out to improve upon existing studies of individual kidney damage biomarkers by examining the association between gression  to accouThis study included a subcohort of 103 Mexican children, 4 to 6 years of age, participating in the Programing Research in Obesity, Growth, Environment, and Social Stressors (PROGRESS) longitudinal birth cohort in Mexico City. There were 948 women who delivered a live child into the cohort. For this pilot study, 103 children with residual spot urine samples were randomly selected for retrospective kidney biomarker analyses. The children were healthy and free of kidney or cardiovascular disease assessed by maternal questionnaire. The full details regarding enrollment for the parent cohort have been previously published . Briefly2). For regression analyses, BMI was analyzed as a continuous variable due to limited numbers of subjects that were overweight/obese at 4–6 years of age  at urine collection as well as maternal report of indoor smoke exposure during pregnancy. Maternal report of indoor smoke exposure was recorded during the second trimester and indicated whether anyone in the household smoked inside the home. BMI was calculated as weight divided by the square of height (kg/mht/obese ). Gestatht/obese . Capurroht/obese , where Srcentile . The Fenrcentile . A spot n μmol/L .Levels of urinary proteins were determined from spot urine samples. Protein levels were analyzed at the Mount Sinai Human Immune Monitoring Center. The urine soluble kidney biomarkers included: albumin, NGAL, OPN, KIM-1, clusterin, A1M, cystatin C, B2M, and TFF-3. These proteins were selected due to their role as validated or emerging non-invasive biomarkers of renal damage , 34 as wUrinary creatinine concentration was measured at the Mount Sinai Clinical Chemistry Laboratory. Concentrations of creatinine were determined using enzymatic assays as per the manufacturer’s instructions using an Abbott Architect c16000 clinical chemistry analyzer and the ARCHITECT System Software . Quality control was performed using the Bio-Rad Liquid Unassayed Multiqual Control and the Bio-Rad Unity Real Time software . Conversion to concentrations was performed using the ARCHITECT System software.qij, and an outcome of interest, y, the general form of the WQS model isg(μ) is the non-linear link function, in this case the identity function, β1 represents the effect of the mixture, z is the set of covariates with corresponding regression coefficients represented by ϕ, and wi are the weights of each protein, estimated using the mean weights across 1,000 datasets composed of bootstrapped samples and constrained to both be non-negative and sum to 1 [Detailed explanation of the WQS technique has been published previously . Brieflysum to 1 . Due to sum to 1 . Despitesum to 1 –38. A sei.e., poorer) birth outcomes, we constrain the model to estimate weights such that the association between the index and the birth outcome are nonpositive. Models generated where the direction of the association was constrained to be nonnegative were not significant and are therefore excluded from the results.In this application of WQS, we treat the birth outcome, gestational age or birth weight, as the dependent variable and the set of proteins as the component variables comprising the mixture. This method is a reasonable way to assess the impact of birth outcomes on kidney biomarkers in childhood, since an estimate of an association captures the relationship between two variables, here a birth outcome and the kidney biomarker index, regardless of which variable is specified as the response or predictor . Since wOur primary analyses considered gestational age and birth weight as continuous variables. However, in secondary analyses, we performed logistic WQS regression to investigate the renal effects of birth outcomes based upon clinical definitions such as preterm birth  and low birth weight . We used logistic WQS regression to determine whether the mixture of kidney biomarkers was related to the odds of preterm status or the odds of low birth weight status. The covariates in the secondary analyses were identical to those in the primary analyses .In addition to the models estimated using WQS to assess the biomarker mixture, we also performed a linear regression to estimate the association between each individual protein with continuous gestational age or birth weight. In these models, individual protein levels grouped into deciles served as the predictors and covariates were identical to above . Further, Pearson correlation between each protein and the birth outcomes are reported in i.e., those with Fenton birth weight percentiles less than the 10th percentile [i.e., restricted fetal development in utero) or shorter gestations. We performed linear WQS regression identical to those above.Due to the association between length of gestation and birth weight, we also analyzed our data excluding the 19 SGA infants, rcentile . The SGAThe demographics of the 103 participants in this study are presented in In adjusted models, the kidney biomarker index was associated with shorter gestations . SpecifiIn adjusted models, we found that a one decile increase in the kidney biomarker index was associated with 59-gram lower birth weights  . The topIn secondary analyses where the birth outcomes were dichotomized based upon the clinical definitions of preterm birth and low birth weight, kidney biomarker indices estimated for each outcome using logistic regressions showed significant associations. Specifically, an increase of one decile in each corresponding index was associated with a 53.5% increased odds of being born preterm  and a 67.7% increased odds of being born low birth weight   Tables. i.e., excluding the 19 SGA infants, the association remained similar. A one decile increase in the index was associated with 50-gram lower birth weights   . Also in7, -4.8) .After excluding the 19 SGA infants, we re-analyzed the association between the kidney index biomarker and length of gestation. We found that a one decile increase in the index was associated with 2-day shorter gestations  . In agrei.e., NGAL, OPN, and B2M) that are associated with shorter gestations as well as lower birth weights [joint effects are related to shorter gestations and lower birth weights. Higher levels of all of these proteins have previously been shown to be indicative of kidney damage or dysfunction [subclinical renal damage that is measurable in childhood as early as 4 to 6 years of age. Longitudinal studies are needed to determine whether these changes lead to later life clinically apparent renal disease or dysfunction.In a sample of Mexican children free of clinical kidney disease, we report associations between kidney biomarker indices, composed of nine proteins and derived using WQS, and continuous gestational age and birth weight. We identified similar combinations of these proteins associated with increased odds of being born preterm and low birth weight. Our study supports existing literature in identifying higher levels of specific biomarkers of kidney damage  or effective renal plasma flow, were not collected in this healthy population of children; however, they may not be practical for large population-based studies. Although difficult to disentangle, lower birth weight and shorter gestation may share similar pathophysiology in some cases [Our study had limitations. We measured and constructed our indices using nine biomarkers selected me cases , 60; theIn this study, we demonstrated the utility of applying WQS, an ensemble machine learning method for mixtures analyses, to determine indices, composed of kidney biomarkers measured in children’s urine at 4 to 6 years of age, and assessed their association with gestational age and birth weight. Joint analyses of multiple kidney biomarkers provided an integrated measure of kidney damage and improved statistical assessments compared to biomarkers assessed individually. Our results also suggest that the renal impact of shorter gestation as well as lower birth weight, observed through biomarkers of tubular damage, may be measurable later in childhood. The goal of this work was to expand upon the idea of a single “gold standard” biomarker to detect renal dysfunction and instead demonstrate that biomarker indices formed from multiple urinary proteins may be more effective than individual proteins. As we would anticipate the index components and weights to change depending on population characteristics and exposure/outcome of interest, similar computational approaches rather than the specific combinations of biomarkers highlighted in this study may contribute to improved evaluations of non-invasive renal diagnostic techniques.S1 Table(XLSX)Click here for additional data file.S2 Table(XLSX)Click here for additional data file.S3 TableModels were adjusted for child sex, age, BMI, indoor smoking, and urinary creatinine. Larger weights indicate greater contribution of the protein to the index.(XLSX)Click here for additional data file.S4 TableModels were adjusted for child sex, age, BMI, indoor smoking, and urinary creatinine. Larger weights indicate greater contribution of the protein to the index.(XLSX)Click here for additional data file.S5 TableModels were adjusted for child sex, age, BMI, indoor smoking, and urinary creatinine. Effect sizes are in the units of kilograms. Larger weights indicate greater contribution of the protein to the index.(XLSX)Click here for additional data file.S6 TableModels were adjusted for child sex, age, BMI, indoor smoking, and urinary creatinine. Effect sizes are in the units of weeks. Larger weights indicate greater contribution of the protein to the index.(XLSX)Click here for additional data file.


Studies have revealed associations between preceding short and long birth-to-birth or birth-to-pregnancy intervals and poor pregnancy outcomes. Most of these studies, however, have examined the effect of intervals that began with live births. Using data from Bangladesh, we examined the effect of inter-outcome intervals (IOI) starting with a non-live birth or neonatal death, on outcomes in the next pregnancy. Pregnancy spacing behaviors in rural northeast Bangladesh have changed little since 2004.We analyzed pregnancy histories for married women aged 15-49 years who had outcomes between 2000 and 2006 in Sylhet, Bangladesh. We examined the effects of the preceding outcome and the IOI length on the risk of stillbirth, neonatal death and spontaneous abortion using multinomial logistic regression models.Data included 64,897 pregnancy outcomes from 33,495 mothers. Inter-outcome intervals of 27-50 months and live births were baseline comparators. Stillbirths followed by IOI’s <=6 months, 7-14 months or overall <=14 months had increased risks for spontaneous abortion with adjusted relative risk ratios (aRRR) and 95% confidence intervals = 29.6 , 1.84  and 2.53 , respectively. Stillbirths followed by IOIs 7-14 months had aRRR 2.00  for stillbirths.Neonatal deaths followed by IOIs <=6 months had aRRR 28.2  for spontaneous abortion. Neonatal deaths followed by IOIs 7-14 and 15-26 months had aRRRs 3.08  and 2.32 , respectively, for stillbirths; and aRRRs 2.81  and 1.70 , respectively, for neonatal deaths.Spontaneous abortions followed by IOIs <=6 months and 7-14 months had, respectively, aRRRs 23.21  and 1.80  for spontaneous abortion.In rural northeast Bangladesh, short inter-outcome intervals after stillbirth, neonatal death and spontaneous abortion were associated with a high risk of a similar outcome in the next pregnancy. These findings are aligned with other studies from Bangladesh. Two studies from similar settings have found benefits of waiting six months before conceiving again, suggesting that incorporating this advice into programs should be considered. Further research is warranted to confirm these findings.The online version of this article (10.1186/s12884-019-2203-0) contains supplementary material, which is available to authorized users. Several studies have shown that short intervals between pregnancies are associated with subsequent poor pregnancy outcomes, including spontaneous abortion, stillbirth, preterm birth, low birth weight (LBW), congenital malformations, small for gestational age (SGA), and early neonatal death –16. SimiGlobally, 122 million live births occur annually and of these, 2.7 million result in neonatal deaths. In addition, women experience an estimated 28 million spontaneous abortions and 2.6 million stillbirths , 19. In To date, researchers have focused little attention on the effect of intervals after non-live birth outcomes. In Matlab, Bangladesh, research on the effect of the interval between a live birth, or a non-live birth, and a subsequent outcome showed that the risk of under-five mortality varied by the type of outcome that started the interval . AnotherAcross Bangladesh, intervals after live births have generally improved over time but Sylhet has been lagging behind other districts , 24. It Underscoring the need to counsel women who have experienced a neonatal death, the 2014 Bangladesh Demographic and Health Survey observed that “the length of the birth interval is closely associated with the survival status of the previous sibling.” In Bangladesh, among various sub-groups identified in the 2014 DHS, the highest percentages of very short interval births (defined as less than 18 months since the preceding birth) occurred in the group in which the preceding sibling had died 23%), compared to short interval births which occurred when the sibling was alive (3%), or in the group of women in the lowest income quintile (5%) or rural women (5%). Having a preceding death was associated with short IPIs reflecting the fact that parents who have lost a child wish to have another one shortly thereafter to replace the one who has died %, compar.Risk factors for adverse perinatal outcomes and the clustering of neonatal deaths in the Sylhet cohort studied in this analysis have been described , 26 but The data were drawn from a study known as ‘Projahnmo I’ which was a community-based, cluster-randomized trial conducted in the Sylhet district of Bangladesh. Its aim was to evaluate the effect of an integrated maternal and newborn care program on neonatal mortality, and the results have been reported elsewhere . BrieflyClinicalTrials.govNCT00198705.The Projahnmo I trial was registered with Data on intervals between non-live birth outcomes in low income countries are not widely available. For example, the Demographic and Health Surveys (DHS) do not routinely gather information on birth intervals, or pregnancy outcomes, after miscarriage, stillbirth, or newborn death as a separate category. DHS data are available by survival status of the preceding sibling, a category that includes siblings of all ages who died.Using Projahnmo data on pregnancy histories, we studied the following outcomes: stillbirth, neonatal death, and spontaneous abortion. In these data, we only had self-reported dates of pregnancy outcomes and thus we used the term inter-outcome interval (IOI), following DaVanzo et al. , who defWe considered the following categories of the IOI which have been used in studies of IPI: <6, 7-14, 15-26, 27-50, and 51-74 and 75+ months, with 27-50 months used as a baseline comparator , 28 17,, 22, 29.This analysis included pregnancies with self-reported outcomes and IOIs. We excluded women with only a first pregnancy in order to focus on the impact of the interval following an adverse pregnancy outcome. Neonatal deaths were defined as live births that subsequently resulted in mortality within the first 28 days after birth. The denominator for neonatal mortality included all live births. Stillbirths are clinically defined as those babies born with no signs of life at or after 28 weeks' gestation   and in tOur analysis was stratified by the type of outcome that started the interval . Thus, we fitted three separate models so that, conditional on the interval being preceded by an adverse outcome, we evaluated the effect of the length of IOI on the subsequent outcome. Analogous to the analysis by DaVanzo et al 2007, we fitted multinomial logistic regression models where the 4-category multinomial outcome comprised live birth (the reference outcome), stillbirth, neonatal death and spontaneous abortion. The measures of association were thus risk ratios of the different IOIs (with 27-50 months taken as a reference) for adverse outcomes, relative to the risk ratios of these intervals for a live birth outcome. Hence they are relative risk ratios. Covariates adjusted for included multiple/single pregnancy; mother’s education, parity at current birth, and maternal age at current birth; household socio-economic status (SES) index; Projahnmo study arm; whether the mother attended at least one antenatal care visit, and place of birth (home versus facility). The SES index was derived from the household variables using principal components analysis . The houOur data included 64,897 pregnancy outcomes from 33,495 mothers. Table Table Short (<=6 months) IOIs that began with a spontaneous abortion, were associated with relatively higher risks of another spontaneous abortion versus a live birth, compared to intervals of 27-50 months [aRRR 23.21 ]. The interval 7-14 months was also associated with an increased risk of another spontaneous abortion [aRRR 1.8 ]. When the intervals <=6 months and 7-14 months were merged to increase the sample size and to improve reliability of the estimates, the relative risk for spontaneous abortion versus a live birth remained strong in this IOI category versus 27-50 months [aRRR 2.70 ]  intervals that began with stillbirths, were associated with higher relative risks for a spontaneous abortion than a live birth, compared to births following IOIs of 27-50 months [aRRR 29.6 ]. The estimated aRRR for the 7-14 months category was 1.84. When using the combined <=6 months and 7-14months intervals, the aRRR was 2.53  for spontaneous abortion and 1.91 for stillbirth.Having had a neonatal death was associated with a higher risk of all three adverse outcomes versus live outcomes, for the IOIs shorter than 24 months relative to the 27-50 months reference IOI. The aRRR for spontaneous abortion was 28.2  for <=6 months compared to 27-50 months IOI. When the first two intervals (<=6 and 7-14 months) were combined, the associations remained strong with an aRRR of 2.82 .IOIs beginning with a neonatal death were associated with increased risks of stillbirth , and neonatal death .This study demonstrates that the highest risk for a spontaneous abortion was following another spontaneous abortion, or after a short IOI <=14 months irrespective of the preceding outcome. After a stillbirth, the IOIs <=14 months were associated with a higher risk of another stillbirth or a spontaneous abortion. Having a prior neonatal death was associated with an increased risk of another neonatal death or a non-live outcome for intervals up to 26 months relative to 27-50 months. The risk of a stillbirth after a neonatal death was also significantly higher for IOI’s >72 months, suggesting a U-shaped relationship where the risk decreased up to 27 months, but then increased again after 72 months. Overall, following an adverse outcome, a short IOI was associated with a risk of another adverse outcome in the subsequent pregnancy. Further research that appropriately measures gestational age and IPI is needed to help guide family planning interventions.A recent study from rural Bangladesh has demonstrated that incorporating post-partum family planning into the maternal and newborn care packages can significantly improve birth spacing and reduce the risk of preterm birth  . Given tMost of the available literature on the recommendation for how long to wait after an adverse event before conceiving again come from high income countries and focus on waiting time after a miscarriage. Some results from high income countries suggest that conception within a short interval (6 months) after an abortion does not result in adverse pregnancy outcomes –38. A reIn contrast, results from low- and middle-income countries  and ourAnother Bangladesh study, based on 10,453 pregnancies found that, compared with inter-pregnancy intervals (IPIs) of 6-12 months, pregnancies that were conceived <3 months after a miscarriage were more likely to result in a live birth . HoweverSomewhat in contrast to these findings, a study from Bangladesh, based on 66,759 pregnancy outcomes, found that “if the preceding pregnancy ended in a miscarriage or stillbirth, there is an elevated risk that the index pregnancy will end with the same outcome, regardless of the amount of time since the previous pregnancy ended” . The difMost of the studies in the literature have investigated the effect of intervals defined as inter-pregnancy or inter-birth depending on the available data , 42, 43.Evidence of effect modification of the interval by maternal age has been found where the risk of preterm delivery for older mothers (aged >34 years) was lower at shorter IPIs (<11 months) but higher at longer IPI’s (11-23 months) in comparison to mothers aged 25-34 years . In our We identified two possible mechanisms that might explain how short intervals may affect pregnancy outcomes: folate depletion and vertical transmission of infection. We discuss these mechanisms because there is evidence in the literature regarding these mechanisms’ effects on perinatal outcomes (not just infant child outcomes) and there is also evidence on Bangladeshi women’s health conditions as they relate to these mechanisms.Folate depletion has been hypothesized as a mechanism through which short IPIs are associated with adverse perinatal outcomes. If pregnancy occurs three to four months after a birth, before sufficient repletion of folate resources, the risk of another miscarriage may increase. A review of seventeen studies in low, middle and high income countries concluded that “strong evidence exists that folate depletion occurs in women during the first three to four months postpartum.”. StudiesWith respect to pregnancy intervals, one study found that mean erythrocyte and serum folate levels were significantly lower among women with short IPIs (6 months or less) compared to women with longer intervals of 18-24 months  . A seconA review of causal mechanisms concluded that there is evidence to support the hypothesis that folate depletion constitutes a hypothetical mechanism that explains the increased risk of adverse perinatal outcomes in women with short pregnancy intervals (43). However, this review focused on birth weight and small for gestational age outcomes, rather than neonatal death, stillbirth, and miscarriage.With respect to vertical transmission of infections, women infected with bacterial, fungal, or viral organisms may harbor the organisms at a site from which the newly-conceived fetus can be infected. One study noted that, in theory, the risk of infection of the fetus could be higher for women with short intervals because they have less time to recover between pregnancies . Studiess are based on a large sample size and the pregnancy history survey was conducted as part of a household survey rather than in a hospital setting. Thus, our study was not likely to suffer from selection bias resulting from sampling only those who seek care at formal institutions. Per criteria set forth for assessing the quality of observational studies on pregnancy spacing [The first strength of our study is that our result spacing , we examThe main limitation of our study is that CHWs relied on pregnancy history recall rather than obtaining data from medical records. Thus there were no gestational ages which would have enabled us to investigate the inter-pregnancy interval effect. The errors in the recall of timing of events may explain why there are reported outcomes other than spontaneous abortion within the 6 months IOIs, which is not possible. There may also be some misclassification bias where early neonatal deaths were reported as stillbirths and the other way round, and similarly for spontaneous abortions and induced abortion. However, to reduce errors in recall of dates, the CHWs in our study carried a list of dates for historical events that happened in recent previous months or years and they asked mothers to use those dates as reference as well. Furthermore, a conversion calendar was used so that if women reported a date using a local calendar, a corresponding western calendar date could be recorded.Using pregnancy history recall and outcome dates, our findings address a significant gap in the literature on the combined effect of an adverse pregnancy outcome and the length of an interval between pregnancies or pregnancy outcomes, on the risk of another adverse outcome in a subsequent pregnancy. Our data suggest that, in rural northeast Bangladesh, the six-month pregnancy interval following any of three adverse events  was associated with the highest risk of a spontaneous abortion in the next pregnancy. Following a stillbirth, a less than 14 month inter-outcome interval  was associated with another stillbirth or spontaneous abortion, and following a neonatal death, an inter-outcome interval less than 26 months  was associated with all three adverse outcomes.Studies from other low-income settings have found benefits of waiting six months before conceiving again. This suggests that incorporating this advice in programs should be considered, but further research is needed. A recent study from rural Bangladesh has demonstrated that incorporating post-partum family planning into the maternal and newborn care packages can significantly improve birth spacing and reduce the risk of preterm birth. Formative research in Sylhet, Bangladesh, has shown that even though there is an understanding of the benefits of healthy spacing, women are not able to make their own pregnancy spacing decisions . InterveThere is also a need for additional research to identify genetic and other bio-markers that are associated with clustering of adverse outcomes within mothers as has been established in other settings , 58–62, Additional file 1:Table S1. Adjusted Relative risk ratio : combining <6 months and 7-14 months. (DOCX 19 kb)


Supplemental Digital Content is available in the text Progestin-primed ovarian stimulation (PPOS) is a new ovarian stimulation regimen for in vitro fertilization (IVF), with the advantages of an oral administration route and more control over preovulatory luteinizing hormone (LH) levels. Assessing the safety of this novel regimen is an important premise for its routine practice.We conducted a large retrospective cohort study for infants born between August 2014 and April 2017 from IVF and embryo transfer cycles after either PPOS and the conventional gonadotropin-releasing hormone-agonist (GnRH-a) short protocol at our center. Around 1589 live-born infants were finally enrolled, corresponding to 1258 frozen-thawed (FET) cycles, which led to 855 live-born infants from PPOS (659 FET cycles) and 734 live-born infants from the short protocol (599 FET cycles).Birth characteristics regarding gestational age, birth weight and length, infant sex, and early neonatal death were comparable between the 2 groups. The incidence of live-birth defects in the PPOS group (1.52%) was similar to that in the short protocol group (1.63%) and was not statistically significant. For birth defects, the risk significantly increased for multiple births, and the adjusted odds ratio was 3.14 . No associations were found between congenital birth defects and maternal age, body mass index (BMI), the duration of infertility, method of insemination, infant sex, embryo stage at transfer, the number of embryos transferred or ovarian stimulation regimen.Our study shows that the neonatal outcomes and risk of congenital malformations were similar between the PPOS and conventional GnRH-a short protocol. However, multiple pregnancy led to a higher likelihood of birth defects. Since the birth of the first IVF-conceived infant in the United Kingdom in 1978, the number of pregnancies and births due to the use of this technology has risen exponentially.,5 Great efforts and innovations, such as the use of gonadotropin-releasing hormone-agonist (GnRH-a) instead of human chorionic gonadotropin (hCG) as the ovulatory trigger and the adoption of a freeze-all strategy, have been made to optimize the ovarian stimulation regimens and treatment strategies.,7Several studies have focused on ART-related side effects in women and the potential impacts of ART on their offspring. Although IVF complication rates are low, concern about the risks of some nonphysiological treatment procedures and the effects on the internal environment, such as ovarian stimulation regimens, high estrogen levels, and ovarian hyperstimulation syndrome (OHSS), continues to increase.,9 Additionally, an internal LH surge could be induced by using GnRH-a to trigger ovulation. Together with the freeze-all strategy, 150 women who received PPOS had a satisfactory clinical pregnancy rate of 47.8%, and an implantation rate of 31.9% was obtained at that time. Compared with conventional COS regimens, the application of PPOS has the advantages of an oral administration route, more control over LH levels, and a lower risk of OHSS.,11In 2015, we reported a new regimen for controlled ovarian stimulation (COS), namely progestin-primed ovarian stimulation (PPOS), and oral progestin was first introduced into the COS procedure to prevent a premature LH surge in this novel regimen.,13 Thus, a concern that accompanies the desire to incorporate this new regimen into routine practice regards whether the PPOS regimen is safe to the baby. In our previous preliminary study, more than 200 infants born from the PPOS regimen were followed up, and similar neonatal outcomes between the PPOS protocol and the traditional protocol were found. However, the relative small sample size and lack of an analysis of risk factors on congenital malformations limited the findings in our previous study. To date, this unique PPOS regimen has resulted in more than 800 infants born after embryo vitrification. Therefore, a larger cohort study is needed to systematically assess the safety of this new ovarian stimulation regimen.The health of a child born following ART using any new procedure or compound is paramount. Any ovarian stimulation protocol for IVF/ICSI should not compromise the health of the mother during pregnancy or that of the infant born to the mother.,16 In consideration of their safety statistics for offspring, we selected the standard GnRH-a short protocol as the control group to evaluate the safety for offspring born from IVF-ET after PPOS.Routine IVF procedures—using GnRH agonists or antagonists for the prevention of a premature LH surge—have become accepted as safe. This acceptance was based on the initial reassuring results of most follow-up studies, either prospective or retrospective.22.1This retrospective cohort study was conducted in the Department of Assisted Reproduction of the Ninth People's Hospital of Shanghai Jiao Tong University, School of Medicine. The study was approved by the ethical review committee of the Ninth People's Hospital of Shanghai and the Shanghai Jiaotong University Medical Centre, China.–20 The final data, involving 1589 live-born infants, were stratified into 2 groups according to the method of ovarian stimulation: 855 births after PPOS and 734 births after the short protocol. The study design and participant selection procedure are presented in Supplemental Figure 1.Infertile couples, who underwent IVF or ICSI treatment with frozen-thawed embryo transfer (FET) using PPOS or the standard GnRH-a short protocol, were recruited for the study. These patients underwent the procedures from January 1, 2014 to July 1, 2016, leading to births between August 1, 2014 and April 1, 2017. Mothers with reported maternal diseases, such as gestational diabetes mellitus, hypertension, thyroid disorders, intrahepatic cholestasis of pregnancy or adverse environmental exposure during pregnancy, were excluded from this study because of the possible association of these factors with birth defects.2.2 Briefly, ovarian stimulation was initiated for patients via the intramuscular injection of 150 or 225 IU of human menopausal gonadotropin  and the simultaneous oral administration of 100 mg Utrogestan  daily, starting from day 2 or 3 of the menstrual cycle until the trigger day. The doses of hMG were adjusted after 5 to 7 days according to the patient's ovarian response.The details of the ovarian stimulation regimen for PPOS have been described in our previous publications.In the short protocol, ovarian stimulation was carried out using a daily dose of 0.1 mg of triptorelin , injected subcutaneously, starting on day 2 or 3 of the natural cycle and continuing until the trigger day. This treatment was accompanied by the intramuscular injection of 150 IU or 225 IU of hMG, beginning on the same day as the first triptorelin administration. The doses of hMG were adjusted after 5 to 7 days according to the patient's ovarian response.Monitoring was performed using transvaginal ultrasound scanning of the ovaries and serum estradiol measurements. When one dominant follicle reached 20 mm or when at least 3 follicles reached diameters of 18 mm, final oocyte maturation was induced with 0.1 mg of triptorelin for PPOS or 5000 IU of hCG  for the short protocol. Transvaginal ultrasound-guided oocyte retrieval was conducted 34–36 hours later after maturation induction. All follicles with diameters of more than 10 mm were retrieved. Flushing Medium  was used for oocyte retrieval, and Human Tubal Fluid  with 10% Serum Substitute Supplements  was used as the oocyte collection and insemination medium. Fertilization was carried out in vitro by either IVF or ICSI, depending on the semen parameters. The embryos were cultured in 10%SSS-supplemented Continuous Single Culture medium . Grade I and II embryos, which were regarded as top-quality, were frozen by vitrification. Grades III and IV embryos were placed in extended culture until the blastocyst stage. During this stage, only morphologically good blastocysts were frozen. The freezing and thawing procedure for embryos, embryo and endometrial synchronization procedure, and timing of ET are described elsewhere. In all FET cycles, no more than 2 thawed embryos were transferred according to the patient's intention. Mixed ET cycles from different ovarian stimulation protocols were excluded from the study. Once pregnancy was achieved, progesterone supplementation was continued until 10 weeks of gestation.The day-3 embryos from each IVF/ICSI treatment cycle were examined according to Cummins’ criteria.2.3The couples completed a telephone interview during each stage of pregnancy up to 1 month after delivery. As previously reported, the interview questionnaire included the following information: a wide range of preconception and pregnancy exposures, pregnancy complications, gestational week, mode of delivery, birth date and locality, birth weight and length, infant sex, congenital malformations, and neonatal diseases, if any. For neonates born in hospital, a detailed physical examination was performed at birth and written reports were obtained from the pediatrician. For live-born infants with birth defects, case information was collected by a specially designated nurse to ensure that the infants met the case definition of the Chinese Birth Defects Monitoring Program. “Conception” was defined as a positive serum level of hCG. “Biochemical pregnancy” was defined as any miscarriage without any evidence of a fetal sac on transvaginal ultrasonography, but with a positive serum hCG pregnancy test. “Clinical pregnancy” was defined as the detection of a gestational sac via transvaginal ultrasonography. “Live birth” was defined as the complete expulsion or extraction of the fetus from its mother, followed by breaths or other evidence of life, such as a heartbeat, umbilical cord pulsation, or definite movements of voluntary muscles. “Ongoing pregnancy” was defined as an intrauterine pregnancy with fetal heart motion, with the absence of labor by the end of our research period. “Early neonatal death” was defined as the death of a live-born baby within 7 days of birth. “Congenital anomalies” were defined as all structural, functional, and genetic anomalies diagnosed in aborted fetuses, at birth or during the neonatal period. Congenital malformations were classified according to the International Classification of Diseases Q codes (Q00–Q99), tenth edition.The outcomes were defined based on the International Committee for Monitoring Assisted Reproductive Technology and the World Health Organization revised glossary of ART terminology 2009.2.4t-tests if the normality assumption was true; otherwise, the Kruskal–Wallis test was applied. Proportions were compared using Fisher's exact test or the chi-square test when appropriate.Statistical analysis was performed using SPSS version 17.0 . The normality of continuous variables was tested using the Shapiro–Wilk test. Continuous variables were compared via Student's /ICSI), singleton/multiple pregnancy, infant sex , type of transferred embryo (cleavage-stage embryo/blastocyst), number of transferred embryos per cycle and ovarian stimulation method (PPOS/short protocol). The effects of risk factors on congenital malformations were expressed through an adjusted odds ratio (OR) and 95% confidence interval (CI). Differences were considered statistically significant when the P-value was <.05.A random effects logistic regression model was performed to quantify the effects of related factors on the congenital malformations. The potential factors in the model included maternal age, BMI, infertility duration, method of insemination . The 1657 clinical pregnancies consisted of 1333 live births and ongoing pregnancies, 265 pregnancy losses, 32 ectopic pregnancies, 1 stillbirth, and 28 cases that were lost to follow-up, resulted in a total of 1589 live-born infants (1258 live-birth cycles). Among them, 659 pregnancies led to the births of 855 live-born neonates after treatment with the PPOS protocol; 599 pregnancies led to the births of 734 live-born infants after treatment with the GnRH-a short protocol. The evolution of the pregnancies followed, and the numbers of live-born and stillborn infants are presented in Table P < .001). Other maternal characteristics, such as BMI, infertility duration, and the proportion of nulliparity were not significantly different between the 2 groups . The cause of infertility and the origin of spermatozoa were also comparable between the 2 groups (P>0.05). IVF was applied most frequently in both groups , whereas the rate of blastocyst transfer in the PPOS group was significantly lower than that in the short protocol group .Table P > .05). These results indicated that comparable neonatal outcomes were achieved for both groups.The details of the neonatal outcomes regarding gestational age, birth weight, birth length, and sex are summarized in Table P = .855). Comparisons between the groups regarding birth defects according to singletons, multiples, and neonatal sex were carried out, and the analysis showed no significant difference. Detailed information regarding the detected malformations according to the various organ systems is presented in Table According to the definition in the International Classification of Diseases, a total of 25 cases (1.57%) among all live-born infants qualified as having congenital defects. As shown in Table P = .015).Table 4In this study, the infant follow-up data from the large retrospective cohort study showed that the health of the 855 live-born infants conceived after treatment with the novel PPOS protocol was no different from that of the 734 live-born infants conceived after COS with the conventional GnRH-a short protocol. There were no treatment-related differences in neonatal characteristics or in the incidence of birth malformations. The rates for congenital malformations were not significantly different between the 2 groups, and the overall rate of congenital malformations of 1.57% observed here concurred with the rate of 1.11%-1.58% reported in a Chinese population-based study for birth defects occurring in infants, conceived by IVF treatment, within 7 days after delivery.,28 In the PPOS regimen, progestin was first used in COS during IVF treatment in combination with the freeze-all strategy. Our previous studies have shown that progestin was an effective oral alternative for the prevention of a premature LH surge and could achieve comparable pregnancy outcomes to those of the short protocol in infertile woman. Nevertheless, concerns about the unconfirmed effects of PPOS on oocyte and/or embryo quality when the progestin level is high during COS still exist. Available evidence on this point is sometimes varied and even contradictory.Progesterone soft capsules (Utrogestan), containing natural micronized progestin, are usually used to support luteal function during pregnancy. Studies have shown that Utrogestan use is not associated with an increased risk of congenital malformation. Any procedures or compounds that disturb the oocyte maturation process may damage its developmental competence. Zavareh and Salehnia reported that the addition of progestin to the in vitro maturation media of mouse GV oocytes significantly decreased the maturation rate and that the GV arrest rate increased. Fukui et al also demonstrated that progestin supplementation of IVM culture systems decreased the rate of bovine oocyte maturation. By contrast, Carter et al showed that the addition of progestin to the culture medium did not affect the proportion of in vitro matured/in vitro fertilized zygotes that developed to the blastocyst stage in vitro. In rhesus monkeys, an improvement in in-vitro oocyte development was demonstrated in the presence of progestin and estrogen. Overall, the literatures do not provide clear evidence on this point, and these inconsistent data may be due to differences in the experimental strategies that used.During folliculogenesis, the oocyte gains developmental competence and subsequently becomes a fully mature oocyte with the capacity to be fertilized and develop into a high-quality embryo. A follow-up study of more than 500 infants born from LPS showed that the differences in birth defects observed between LPS and conventional ovarian stimulations were not significant, demonstrating that a naturally high progestin status in the luteal phase did not increase the risk of congenital malformations.,35 Therefore, data from the LPS provided evidence regarding the safety of progestin for human oocyte development. Even so, compared with the physiological progestin secreted by the corpus luteum during LPS, the effect of exogenous progestin, administered by daily oral administration of 100 mg Utrogestan, which can achieve the serum level of progestin during the luteal phase, on the safety of oocyte development still needs to be examined further. Therefore, we followed up on the neonatal outcomes and live-birth defects of infants born from PPOS, as data on the occurrence of malformations in offspring are the most important standards for assessing potential adverse effects of a new COS regimen.In 2014, we first demonstrated that ovarian stimulation could be started routinely in the luteal phase using letrozole and exogenous gonadotropins, and the regimen was named luteal-phase ovarian stimulation (LPS). This selection approach may explain why women in the short protocol group were older (34.9 ± 3.7 years) than those in the PPOS group  and may explain the higher proportion of single blastocyst transfer cycles in the short protocol group than in the PPOS group . The follow-up data of the 855 live-born infants conceived after treatment with PPOS and the 734 live-born infants conceived after the short protocol showed that the live-birth rates, gestations, birth weights and lengths, infant sexes, congenital malformations, and stillbirths or neonatal deaths were similar between both groups. These findings indicated that there were no obvious differences in the neonatal characteristics or in the incidence of birth defects between the novel PPOS regimen and the classic ovarian stimulation regimen.In this large retrospective cohort study, we selected the classic GnRH-a short protocol as a control to investigate the safety of PPOS treatment for IVF or ICSI. The use of a short protocol has been proposed as a COS regimen in the subgroup of women with advanced age and/or decreased ovarian function.,39 The significantly increased risk of birth defects with multiple births might be explained in several ways. First, multiple pregnancy significantly increases the risk of preterm delivery. Therefore, malformations associated with prematurity, such as patent ductus arteriosus and exomphalos, are increased in twins, and at least a part of the increase is due to prematurity. The second is that the crowded intrauterine space may cause positional defects so that multiple births are more likely to have mechanically induced defects. Finally, mothers with multiple fetuses may lack sufficient nutritional supply, adversely affecting normal fetal development. Therefore, multiple births is unequivocally a risk factor for birth defects. This finding may lead couples to favor elective, single ET, and couples undergoing ART should be made aware of the known increased risk of birth defects associated with a twin birth.The prevalence estimates of birth defects were further adjusted for 9 covariates, as shown in Table ,40 Meanwhile, the latest available review on the outcome of assisted reproduction concludes that some of the risks to infants born following ART do not arise as a result of the applied techniques or treatments but rather from the underlying health risks of being subfertile.,42 Therefore, subfertile couples should improve their health statuses before undergoing ART.Some meta-analyses have suggested that infants, both singletons and multiples, born following ART are at increased risk of perinatal complications and birth defects compared with spontaneous conceptions. Embryos that survive the freeze-thaw process are less likely to be aneuploidal, and therefore are of superior quality. Alternatively, or in addition, developing embryos in FET cycles may be shielded from the excessive ovarian hormonal exposures, which could have various adverse effects on early embryo development.In this study, all infants were born from FET cycles, which have been reported to have better obstetric and perinatal outcomes, compared with fresh ET cycles.As this study is limited to neonatal information extracted from parent questionnaires rather than from direct access to medical records, minor birth defects might have escaped detection, although these issues are unlikely to have altered the infant birth characteristics. Additionally, no association was found between the maternl age and birth defects in the multivariate logistic regression model in this study, however, previous studies have shown that advanced maternal age was associated with higher risks of birth defects. Although the effects of the majority of confounders were controlled, a potential bias cannot be excluded in this retrospective study. Therefore, a more rigorous prospective randomized controlled evaluation trial is necessary in the near future.In conclusion, our available data do not indicate an elevated rate of birth abnormalities after PPOS compared with the classic COS regimen. In addition, long-term follow-up for the health of children born after PPOS is needed to further support the safety of this new treatment option in IVF.We gratefully acknowledge all the staff of the department of assisted reproduction in Shanghai Ninth People's Hospital for their support and cooperation.Conceptualization: Yonglun Fu, Yanping Kuang.Data curation: Ningling Wang, Jiaying Lin, Yong Fan.Methodology: Qianqian Zhu.Project administration: Yun Wang, Yonglun Fu, Yanping Kuang.Writing – original draft: Ningling Wang.Writing – review & editing: Ningling Wang, Yonglun Fu, Yanping Kuang.


In Tanzania, the information on Birth Preparedness and Complication Readiness is insufficiently provided to pregnant women and their families. The aim of this study was to evaluate the maternal and infant outcomes of a family-oriented antenatal group education program that promotes Birth Preparedness and Complication Readiness in rural Tanzania.Pregnant women and families were enrolled in a program about nutrition and exercise, danger signs, and birth preparedness. The cross sectional survey was conducted one year later to evaluate if the participants of the program (intervention group) were different from those who did not participate (control group) with respect to birth-preparedness and maternal and infant outcomes.A total of 194 participants  were analyzed. For Birth Preparedness and Complication Readiness, the intervention group participants knew a health facility in case of emergency ; arranged accompaniment to go to a health facility for birth ; decided the birthplace with or by the pregnant women ; and attended antenatal clinic more than four times . For birth outcomes, the intervention group had less bleeding or seizure during labour and birth ; fewer Caesarean sections ; and less neonatal complications .The four variables were significantly better in the intervention group, i.e., identifying a health facility for emergencies, family accompaniment for facility birth, antenatal visits, and involvement of women in decision-making, which may be key factors for improving birth outcome variables. Having identified these key factors, male involvement and healthy pregnant lives should be emphasized in antenatal education to reduce pregnancy and childbirth complications.No.2013–273-NA-2013-101.Registered 12 August 2013. In Tanzania, the information on Birth Preparedness and Complication Readiness (BPCR) is insufficiently provided to pregnant women and their families. Tanzania has been struggling with reducing its maternal mortality ratio: 556/100,000 live births in 2015. As most deaths were from preventable causes, such as postpartum hemorrhage and high blood pressure-related complications, BPCR is essential to timely and safely arrive in health facility. The family-oriented antenatal group education was provided to pregnant women and their families in rural Tanzania. A Tanzanian midwife taught the program on nutrition and exercise, danger signs, and birth preparedness using a picture drama, and the control group received usual care. The same village was visited one year later to evaluate if the program participants were different from those who did not participate with respect to birth-preparedness and maternal and infant outcomes. A total of 194 participants (50 program participants and 144 who did not participate in the program) answered the survey. As a result, the education positively affected BPCR, such as identifying a health facility for emergencies, family accompaniment for facility birth, antenatal care visits, and involvement of women in decision-making. For birth outcomes, the intervention group had less bleeding or seizure during labour and birth, fewer Caesarean sections, and less neonatal complications. Having identified four key factors in BPCR, male involvement and healthy pregnant lives should be emphasized in antenatal education to reduce pregnancy and childbirth complications.In countries where the maternal mortality ratio remains high, antenatal education to increase Birth Preparedness and Complication Readiness (BPCR) is considered one of the top priorities . BPCR inIn Tanzania, although increasing, only about half of all pregnant women attend an antenatal clinic more than four times . MoreoveIn the resource-poor settings, antenatal group education is a potential approach because of the limited time for individual counseling at antenatal clinics , 8. PatiIn addition, the influence and decision-making power of the family cannot be ignored in Tanzania. Shimpuku et al. identified perceptional gaps among family members who decide the birthplace and stated that many women considered their husbands as the decision-maker . TancredThis study aimed to evaluate an antenatal group education program among pregnant women and their families with respect to birth-preparedness and maternal and infant outcomes in rural villages of Tanzania.The study hypothesis was if Tanzanian pregnant women and their families received a family-oriented antenatal group education, they would (1) have a higher level of BPCR, (2) attend antenatal clinic four or more times, (3) give birth in a health facility, (4) have less complications of women at birth, and (5) have less complications and deaths of infants than those who did not receive the education.This research was a cross sectional evaluation study to identify the effects of an antenatal education program on birth preparedness and maternal-infant outcomes (the second phase). All the participants were convenient samples of pregnant women and their families in villages. For the first phase, villagers were recruited to receive an antenatal education program. The details of the process were published elsewhere . For theThe study was conducted in Korogwe district, which is one of the eight districts in the Tanga region, located in the North Eastern area of the country. Maternal healthcare in Korogwe is provided at one district hospital, three government health centers, one faith-based organization, six private dispensaries, and 41 government dispensaries. Three villages were purposefully selected as the research sites, which were located at least 5 km away from the closest health facility. The distance of villages from health facilities was important as this study focused on preparation of birth and those who live distant from health facilities needed to prepare for birth to be able to seek healthcare when necessary. Thus, if villages were sufficiently close to health facilities, they could access healthcare even if they were not well prepared.The purpose of this family-oriented antenatal group education program was to promote BPCR and family involvement in pregnancy and childbirth. A picture drama was developed by the research team to convey the story of two pregnant women. The material was first developed in English and then translated by a master-prepared bilingual Tanzanian midwife. The program lasts for approximately 45 min, including explanation of the research, pre-test/post-test, picture drama, and discussion among the participants. The result of the pre-test/post-test was published elsewhere . The TanAs the picture drama unfolds, the story shows one woman who had attended an antenatal clinic more than four times. During the antenatal clinic visit, a midwife provided information on appropriate nutrition and exercise, danger signs, and birth preparedness. This pregnant woman and her family had prepared transportation, money, and an accompanying person, and identified a health facility to give birth. When she started having contractions, her family was ready to support her timely trip to a health facility. With the support of a Skilled Birth Attendant (SBA), she gave birth a healthy baby. The other pregnant woman had a family who did not understand the importance of antenatal clinic visits and facility births. She did not visit an antenatal clinic and expected a home birth. When she started having contractions, a Traditional Birth Attendant (TBA) came to support her, but she was having an obstructed labour at that time. They waited for many hours before birth, and then observed that the baby was not breathing after birth. The mother started bleeding after giving birth, thus both the mother and the baby were brought to the hospital, but it was too late to save either one of them. The story illustrated the importance of BPCR and family support, as most household decisions including the birthplace in Tanzania are made by the family members, particularly the husband, and not by the woman , 14–16.The primary outcome was whether the BPCR variables of pregnant women and their families were higher in the intervention group than in the control group. As the pre-test/post-test results of the education program was published elsewhere , the preTo evaluate the outcomes, the survey items were developed on the basis of the elements of BPCR  in EngliAs for the primary outcome, the BPCR variables included the following elements: desired place of birth; preferred birth attendant; location of the closest facility for birth and in case of complications; funds for any expenses related to birth and in case of complications; supplies and materials necessary to bring to the facility; an identified labour and birth companion; an identified support to look after the home and other children while the woman was away; transport to a facility for birth or in the case of a complications; and identification of compatible blood donors in case of complications. The questions were answerable by yes/no .For the secondary outcome, the birth outcome variables included the following: did they give birth in a health facility, did an SBA assisted their birth, were there any complications, was the birth by Caesarean section, was it a live birth, did the baby have any complications, and did they want to give birth again at a health facility. The related questions were to be answered by yes or no .The sample size of this study was calculated on the basis of the basic formula with two groups, a two-sided alternative and normal distributions with the same variances. The sample size was calculated as 64 for each group to detect a difference (10 points) between groups at a 5% level of significance with 80% power.During the first phase of the study, the family-oriented antenatal group education program was provided to pregnant women and their families in the intervention group to promote BPCR and family involvement in the villages, as we intended to reach people who were neither attending an antenatal clinic nor planned to give birth at a health facility.At the second phase of the study, that is, one year later after providing the education program, we returned to the same three villages and contacted those who attended the education program and those in the control group who did not. Those who agreed to participate answered a survey about their BPCR before childbirth and their behaviors and childbirth outcomes for the most recent childbirth they experienced. For the first phase, the education program was provided in August 2013. For the second phase, the outcome survey was conducted in August 2014.Ethical clearance and permissions were obtained from the 1) Institutional Review Board at St. Luke’s International University, Tokyo, Japan (14–040); 2) Director of Korogwe District Council, 3) National Institute for Medical Research (NIMR), Tanzania (NIMR/HQ/R.8/Vol.IX/1604), and 4) Tanzania Commission for Science and Technology (COSTECH) (No.2013–273-NA-2013-101).For background data, the t-test was used for numerical control of the intervention and control groups . Pearson’s chi-square test was used for other nominal background data. Those who missed values were excluded from the final analysis, so there was no missing data. For BPCR and outcome variables, the odds ratios (ORs) and 95% confidence intervals (CIs) were also calculated with logistic analysis, comparing the intervention group with the control group. As the number of antenatal visits might affect facility delivery , 18, then = 70 in intervention group; n = 190 in control group). Furthermore, after eliminating the participants with missing data related to the main outcome variables , the valid responses were 194 . Table Figure p = 0.006), were more likely to arrange someone to accompany them to go to a health center or a hospital for birth or emergency , were more likely to decide their birth place , and attended an antenatal clinic more than four times .Table p = 0.001) and less likely to have a Caesarean section . The babies in the intervention group were less likely to have complications . Although it was an important birth outcome variable, there was no significant difference in health facility birth .Table As the ‘ANC visit more than 4 times’ is an important factor that affects other outcomes , 16, theThe current study showed that the family-oriented antenatal group education program had a potential significant effect on BPCR, namely, identifying a health facility for emergency, family accompaniment for facility birth, ANC visits, and involvement of women in decision-making as well as maternal/neonatal complications. Firstly, the change in women’s involvement in decision-making for their birthplace had a unique cultural aspect that warrants discussion. In Tanzanian culture, many women lack the decision-making power within the family which hinders their birth preparedness particularly on transportation and birthplace as those require financial preparation , 19, 20.Another important aspect of the study was that the intervention group was more likely to attend ANC clinic more than four times. In Tanzania, the rate of ANC attendance for more than four times was still 51% . The numRegarding improvement of family members’ accompaniment to health facility, the education had been provided for pregnant women to timely and safely reach a health facility, but it might have influenced quality of care they received at the health facility. Although there was no statistical difference in facility delivery, significant differences were found in self-reported birth complications and Caesarean section between two groups. A Cochrane review showed the continuous support during labor reduced Caesarean section . The intIt was also considered that the education could have promoted healthier pregnant lives among the women in the intervention group as the education included nutrition and the appropriate amount of exercise. In fact, the pre-/post-evaluation immediately after the education in the first phase showed significant improvement in understanding nutrition during pregnancy . PromotiThere were several limitations in this study that must be addressed. The convenient sampling might have caused selection bias such that the intervention group participants were more aware of danger signs or healthy pregnant life. As the study was cross sectional, we cannot eliminate potential baseline differences between the groups. The data were all retrieved retrospectively from women and their families, which might have caused recall bias. In addition, as the participants in both the intervention and control groups were from the same villages, cross-contamination of information such as the importance of facility use was possible. In terms of threats to external validity, we collected data in three villages of Korogwe district; therefore, generalizability might be limited when applying the findings to other places.However, it is equally important to emphasize the key finding and the benefits of the study, that is, the family-oriented antenatal group education program is cost-effective compared with individual counseling or home visits. In the era of SDGs, global health projects are exposed to the question of sustainability . As the This study revealed the potential positive effects of our family-oriented antenatal group education on four BPCR variables: identifying a health facility for emergencies, family accompaniment for facility birth, ANC visits, and involvement of women in decision-making. The outcomes related to maternal and neonatal complications and Caesarean section were fewer in the intervention group. With the identification of the above key factors, male involvement and promotion of healthier pregnant lives should be emphasized in antenatal education in rural Tanzania to reduce birth complications during pregnancy and childbirth.