To examine temporal trends of NICU admissions in the U.S. by race/ethnicity, we conducted a retrospective cohort analysis using natality files provided by the National Center for Health Statistics at the U.S. Centers for Disease Control and Prevention. A total of 38,011,843 births in 2008–2018 were included. Crude and risk-adjusted NICU admission rates, overall and stratified by birth weight group, were compared between white, black, and Hispanic infants. Crude NICU admission rates increased from 6.62% (95% CI 6.59–6.65) to 9.07% (95% CI 9.04–9.10) between 2008 and 2018. The largest percentage increase was observed among Hispanic infants (51.4%) compared to white (29.1%) and black (32.4%) infants. Overall risk-adjusted rates differed little by race/ethnicity, but birth weight-stratified analysis revealed that racial/ethnic differences diminished in the very low birth weight (< 1500 g) and moderately low birth weight (1500–2499 g) groups. Overall NICU admission rates increased by 37% from 2008 to 2018, and the increasing trends were observed among all racial and ethnic groups. Diminished racial/ethnic differences in NICU admission rates in very low birth weight infants may reflect improved access to timely appropriate NICU care among high-risk infants through increasing health care coverage coupled with growing NICU supply. Delivery of very low birth weight (VLBW) or very preterm (VPT) infants at hospitals with a Level III/IV NICU is now a standard of care in the United States2. As increasing hospital competition motivated hospitals to expand the scope of care and retain high-risk patients, the proliferation of NICU units and beds in a higher proportion of hospitals with maternity services and provision of neonatal intensive care extended beyond regional or academic centers5. Recent U.S. trends show that NICU admissions have increased, particularly in larger and less premature newborns6. Expanding the NICU admitted newborn population to less acutely ill newborns suggests that some NICU utilization may be unnecessary. At the same time, some very premature newborns were still not admitted to Level III/IV NICUs. Furthermore, there is evidence that greater bed supply is associated with high NICU admissions, particularly among low-risk newborns10.In the past 50 years, remarkable advances in the neonatal intensive care units (NICUs) have improved the survival and reduced the morbidity of premature and sick newborns11, infants born to racial minority could suffer disproportionally more from less-than-optimal NICU care access. For example, VLBW infants usually required to be admitted to a NICU and the percentage of VLBW infants is three times as high among non-Hispanic black infants compared to non-Hispanic white infants (2.92% vs 1.02% in 2018)11. Race and ethnicity are important factors when assessing health risks and access to health care. While studies on racial/ethnic differences among children address a wide range of areas12, researches on racial/ethnic differences among infants have focused mostly on birth outcomes and infant mortality13. In this study, we examined temporal trends of NICU admissions by race/ethnicity in the U.S. for all birth weight ranges at the national level and conducted subgroup analyses birth weight group.These raise important concerns regarding access to NICU care. Given that birth outcomes determining the need for NICU care tend to be worse among infants who are non-WhiteAll methods were carried out in accordance with relevant guidelines and regulations. The study protocol was approved by the Committee for the Protection of Human Subjects (CPHS) at the University of Texas Health Science Center at Houston and the need for informed consent was waived by ethics committee because of the deidentified nature of our data.14. Since information on NICU admission was exclusive to the 2003 revision of the U.S. birth certificate, we excluded births recorded using the earlier version (12.1%). We also excluded those weighing less than 500 g (0.1%) or born before 23 completed weeks of gestational age (0.1%) as they are generally not considered viable with current technology16. Finally, we excluded births with unknown NICU information (0.3%), birthweight (0.1%), gestational age (0.1%), or Apgar score (0.4%).This is a population-based retrospective cohort study using restricted natality files provided by the National Center for Health Statistics (NCHS) at the U.S. Centers for Disease Control and Prevention (CDC). All births to mothers whose state of residence was U.S. states and the District of Columbia between January 1, 2008, and December 31, 2018 were included17. This definition of NICU care is comparable to Levels III and IV of neonatal care as established by the American Academy of Pediatrics (AAP)2. The primary exposure of interest was maternal race/ethnicity as reported separately on birth certificates. We used the bridged race for responses that included more than one race and combined the bridged race and Hispanic ethnicity into the following categories: non-Hispanic white (“white”), non-Hispanic black (“black”), Hispanic, and other.The primary outcome-of-interest was a NICU admission rate, which was measured as the proportion of live births who were admitted to a NICU. According to the CDC’s guideline for completion of the 2003 U.S. birth certificate, NICU admission is defined as “admission into a facility or unit staffed and equipped to provide continuous mechanical ventilator support for a newborn”22. Although these factors were mostly validated among VLBW infants for neonatal mortality, we considered them to be relevant to an infant’s health status beyond VLBW and associated with NICU admission22. Among known risk factors, gestational age using the obstetric estimate of gestation at delivery (OE), small for gestational age (SGA), large for gestational age (LGA), 5-min Apgar, plurality, cesarean delivery, and sex were associated with NICU admission and included in the risk adjustment23. Details of the modeling strategy are presented in the supplemental materials.We risk adjusted NICU admission rates to account for the differences in the infant health status by race/ethnicity over the study period. Neonatal characteristics indicating an infant’s health status from well-established severity illness and mortality risk scores were assessed to identify risk factors associated with NICU caremargins based on marginal standardization method and adjusted rate ratios (ARRs) for black and Hispanic infants compared with white infants were estimated using Stata command nlcom24. Stata command margins produces the adjusted predictions that are expected values of a dependent variable computed from the results of a regression where all other covariates are held at means. The nlcom takes nonlinear transformations of a parameter estimate from a fitted model to estimate the risk ratio and construct the confidence interval using the delta approximation method, an approximation appropriate in large samples.Analyses were conducted overall and stratified by birth weight group as VLBW (< 1500 g), moderately low birth weight  and normal to high birth weight . Univariable analyses were conducted to assess association between each of risk factors -gestational age, SGA, LGA, 5-min Apgar, plurality, cesarean delivery, and sex- and NICU admission. Multivariable logistic regression models were specified with NICU admission as the dependent variable and race/ethnicity as a primary independent variable while adjusting for birth year and risk factors that were statistically significant in univariable analysis. To assess differential temporal trends for NICU admission across race/ethnicity, we included interaction terms between birth year and race/ethnicity in the models. The model-adjusted NICU admission rates were estimated with predicted probabilities using Stata command We assessed the representativeness of our study cohort by comparing birth cohorts recorded with the 2003 revision to total U.S. birth cohorts for 2008–2015 before the 2003 revision had been implemented in all U.S. states and the District of Columbia. We conducted sensitivity analyses for temporal trends limiting analysis to births that occurred in the 27 U.S. states where the 2003 revision had been used throughout the entire study period (2008–2018). All statistical analyses were performed using Stata, version 16.0 .From 2008 to 2018, there were 43,872,185 live births. Of these, 38,011,843 births were included in the study sample  in 2008 to 9.07% (95% CI 9.04–9.10) in 2018, a 37% growth. Increases were observed regardless of race/ethnicity: 6.58% (95% CI 6.54–6.62) to 8.50% (95% CI 8.46–8.53) among white infants, 9.09% (95% CI 8.99–9.18) to 12.03% (95% CI 11.94–12.11) among black infants, and 5.70% (95% CI 5.65–5.75) to 8.63% (95% CI 8.57–8.69) among Hispanic infants  among black infants compared to white infants in the MLBW group but may also imply unmet need for black MLBW infants.Most differences in overall NICU admission rates by race/ethnicity disappeared after risk adjustment. This could indicate that crude racial/ethnic rate differences were justified by different risks or needs. These average findings, however, obscure important differences revealed in stratified analyses. In the VLBW group, compared to white infants, black infants had similar NICU admission rates while Hispanic infants had much lower NICU admission rates that were catching up by 2018. Only 77% of Hispanic VLBW infants were admitted to a NICU in 2008 while 84% of white and 82% of black VLBW infants were admitted to a NICU. But 90% of white and black VLBW infants and 89% of Hispanic VLBW infants were admitted to a NICU in 2018.This may reflect improved access to timely appropriate NICU care among high-risk infants through increasing health care coverage coupled with growing NICU supply27. The growth in NICU bed supply has outpaced measured need25, and the greater availability of NICU beds is known to be associated with greater utilization28. Possible overuse of NICU care by race and ethnicity is an important area of future research. Freeman demonstrated that available NICU beds increased additional NICU utilization among those less ill or in the range of birth weights in which admission decisions are likely to be more discretionary28. Shulman et al. found that among infants born at GA of 34 weeks or more, inborn admission rates for specific GA strata correlated strongly with overall inborn admission rates and did not significantly correlate with percentage of admissions with high illness acuity7. Similarly, Ziegler et al. found significant between-hospital variation in NICU admission rates that cannot be explained by infant health condition among infants born 35 to 42 weeks' gestation8. Harrison et al. found that non-VLBW infants were more likely to be admitted to a NICU in regions with the highest NICU bed supply, indicating possible overuse9. In our study population, almost 50% of the black and Hispanic mothers compared with 28% of white mothers resided in a large central metro area where they were likely to be close to large hospitals with NICU beds30. Increased capacity, payments that reward NICU care, perhaps disproportionately to its value in lower risk newborns, and weak state regulation may cause potential overuse of NICU among NHBW infants32. The U.S. has significantly greater neonatal clinicians and NICU beds per capita than other developed countries with provision of neonatal intensive care extended beyond regional or academic centers33. Yet, there lacks of clear criteria for designating levels of risk-appropriate neonatal care and capability across states31.In contrast, black infants maintained higher risk-adjusted NICU admission rates in the NHBW group. Black infants in this group had about 15% higher NICU admission rates compared to white infants even though differences became half (7%) after risk adjustment. Hispanic infants in this group had lower NICU admission rates compared to white infants in 2008 but similar rates in 2018. Their risk adjusted rates were similar to those of white infants in 2008 but became higher in 2018. Traditional risk factors might have under-adjusted health risk in the NHBW group even though we included large for gestational age. However, opposite directions of risk adjustment in black (crude RR 1.15 vs adjusted RR 1.07 in 2018) and Hispanic infants (crude RR 0.99 vs adjusted 1.07 in 2018) led us to look for other explanation. The higher use of NICUs in this low risk group may also indicate overutilization of NICUs29. The literature is rich in evaluating the quality of care across providers or hospital characteristics, but it is often limited to VLBW or VPT infants. When race/ethnicity is included, it is usually as a covariate in statistical modeling rather than as a primary study exposure35. Understanding racial/ethnic differences in NICU admission is particularly relevant given that racial/ethnic differences in birth outcomes are persistent36.This study is one of few that compares NICU utilization by race/ethnicity and evaluates the effect of race/ethnicity on NICU admission rate as a primary interest across all birth weights2, but there is a wide variation among states in the definition and criteria of a NICU and accuracy of coding may improve over the years37. However, increasing NICU admission trends were observed also in hospital discharge data28 and validation studies on the accuracy of birth certificate data report a good agreement on NICU admission between birth certificates compared to hospital medical records38. A validation study assessing the quality of medical and health data from the birth certificate from two states found levels of agreement or sensitivity for most checkbox items were substantial or moderate and the sensitivity for NICU admission from a state using the stratified systematic sampling methodology was over 95%38. Second, our study may have underestimated NICU admissions. Since birth certificates are required to be filed within 5 days of the date of birth by the birth hospital, late NICU admissions in a prolonged hospitalization occurring after the filing or NICU admissions occurring at the transferred hospital may not be included40. Also, the infants staying at the NICU for observation without being admitted to NICU are not counted as NICU admission according to CDC’s guideline17. A recent study examining the concordance of hospital-level NICU admission rates between birth certificate data and hospital reported NICU data by all hospitals with an accredited NICU in California finds that birth certificates tends to underreport NICU admissions but the study suggests that good agreement between hospital ranks that are based on NICU admission rates from birth certificates and the gold standard reflects the relative performance of a hospital on NICU admissions40. In an additional sensitivity analysis assuming transferred infants were all admitted to NICU, we found NICU admission rates in 2018 changed from 8.5 to 8.9% in white infants, from 12.0 to 12.3% in black infants, and from 8.6 to 8.9% in Hispanic infants. When limited to VLBW infants to be considered NICU admitted with transfer, we found a little changed: 89.8–91.5% in white infants, 90.0–91.7% in black infants and 88.6–90.3%. Given that our study focus was to measure relative use of NICU by racial/ethnic minority compared to white infants and changes in temporal trend in a population level rather than the exact rate of NICU admissions, our findings should provide reasonable information to assess racial/ethnic differences in NICU admissions and temporal trends.This study has some limitations. First, even though the birth certificate form defines NICU admissions, differences in coding may have occurred across states and hospitals. A 2012 policy statement by the AAP defines a NICU as a level III and IV facilities, where ongoing assisted ventilation for 24 h or more is availableFrom 2008 to 2018, there was little difference in overall risk-adjusted NICU admission rates by race/ethnicity. However, birth weight-stratified analysis revealed that racial/ethnic differences diminished in the VLBW and MLBW groups while risk-adjusted NICU admission rates remained higher among black and Hispanic infants in the NHBW group. The increasing trend in NICU admission rates among the NHBW group appear to continue and further study is needed to identify the reasons for this trend and prevent possible overuse of NICU care.Supplementary Information.


The study aims to investigate the changes in the socio-economic and demographic status of young mothers of age 15–24 years and to examine the association between mothers’ nutrition, i.e., Body Mass Index (BMI) and anaemia with child low birth weight for almost two decades during 1998–2016 in India.National Family Health Survey (NFHS) round II and IV were used. The sample of this study included 3405 currently married young mothers from NFHS II and 44,742 from NFHS IV who gave birth at least one child in the last three years preceding the surveys. Logistic regression and Blinder-Oaxaca decomposition analysis have been used in this study to examine the corresponding association between the concerned variables.p-value = 0.000; 95% CI: 1.05, 1.65) for mothers with low BMI and 1.55  with severe anaemia. Over the decade, the association of LBW babies with mothers’ nutrition has decreased. The odds of LBW with mothers with low BMI decreased from 1.63  to 1.41 . Similarly, mothers with severe anaemia, the odds of LBW child decreased from 2.6  in 1998 to 1.3  in 2016.The analysis showed that the prevalence of low birth weight (LBW) babies has decreased from 26.1 to 22.8 for the 15 to 19 age group and from 20.4 to 18.7 for the 20 to 24 age group over time. Young mothers with low BMI or severe anaemia have shown higher odds of having LBW babies. For instance, the odds of having a LBW child was 1.44 (The maternal and child health improvement in India has been moderate over the decade. Still, a significant proportion of the women are suffering from poor health and young mothers are at more risk to deliver LBW babies. It is highly recommended to integrate maternal and child health programmes with the ongoing health policies to improve the situation while taking additional care of the young pregnant mother and their nutritional health. Young mothers in India are disadvantaged in terms of their nutritional health and co-morbidities associated with their reproductive health , 2. Biol2—ranges from 10 to 19% in most of the countries from this region [2.Maternal undernutrition is prevalent in many regions, especially in south-central Asia, and in some countries, more than 10% of the women are shorter than 145 cm. Maternal undernutrition i.e., body-mass index (BMI) of less than 18·5 kg/ms region . SimilarIn India, the prevalence of low BMI among women is 40% which is higher than in many developing nations. Studies revealed that the low BMI of mothers along with poor nutrition and maternal short stature are the potential risk factors for adverse birth outcomes and child’s LBW in particular . AnotherStudies have confirmed that the nutritional status of Indian women is inadequate. For instance, at least 20% of women are thin BMI < 18.5) and an equal proportion are overweight (BMI ≥ 23), 53% anaemic and 8% enter pregnancy as adolescents .5 and an. AccordiPoor nutrition is one of the known facts behind the LBW of children in developing countries. Several other factors also affect the birth weight such as the age of the mother, economic status, birth order of the child, birth gap, smoking and drinking behaviour of the mother, antenatal care utilization . LBW hasThe data sources that have been used in this study are the NFHS round II (1998–99) and the NFHS round IV (2015–16). Respective “Kids” files for the two different rounds were compiled for analysis. NFHS is a nationally representative Demographic and Health Survey (DHS) of India, which provides data on population, health, nutrition and other important indicators of population health. Data on BMI, anaemia level and birth weight were taken from both rounds. This study is carried out only for the currently married woman within the age of 15 to 24 years and who had delivered at least one child in the last three years preceding the date of the respective surveys. The following control variables have been considered from these two rounds viz. levels of highest education of the mother, wealth index, religion, caste, age group, place of delivery, birth order, type of delivery, place of residence, smoking chewing tobacco, alcohol consumption.2), normal (18.51 to 24.99 kg/m2) and high (> 25 kg/m2).The data from two rounds were pooled to calculate the change in BMI and anaemia and the corresponding change in the odds of LBW babies with the same set of control variables. Although NFHS 2 has a smaller sample than NFHS 4, it does not lack the strength in terms of sample size (except for some socio-economic covariates where the sample size was less than 30 and the estimates were not provided for them) to provide national level estimates. Additionally, the distribution of birth weight variables from the two rounds have been studied and the skewness was examined. Dummies were created for each category of the independent variables and for each of the two time periods 1998–99 and 2015–16. Birth weight has been taken as a dependent variable which is divided into two categories i.e., LBW (< 2.5 kg) and normal or high birth weight (> = 2.5 kg) . According to WHO classification, BMI is categorized as low , different rounds of NFHS for India provides detailed information on socio-economic and demographic characteristics of the respondents/children. Taking care of the nature of the dependent variable, we chose a multivariate logistic regression analysis with the underlying assumptions of a logistic regression in this study. Essentially, the dependent variable is a dichotomous variable, the observations are independent, there are no multicollinearity among the explanatory variables, no extreme outliers are present in the dataset. Hence, this study also assumed a linear relationship between the logit of the response variable and the sum of the explanatory variables.Logistic regression was run to regress the birth weight with the given set of independent variables. The pooled regression analysis was run with the prior identification of all the categories of BMI and anaemia which were eventually the time specified dummies. To show the association between birth weight with BMI, anaemia and socio-demographic variables, a binary logistic regression model was fitted. The model used is-β0 represents the intercept term of the model, βi is the coefficient of i-th variable Xi . The independent variables are as follows: age , location , caste , religion , education , wealth index , time , birth order , place of delivery , delivery by caesarian section , smoking , drinking alcohol  and chewing tobacco .where Yi is the log odds ratio of P, the probability of LBW (1 if the baby has LBW otherwise 0), The decomposition method outlined in this part of the study, known as the Oaxaca decomposition, which is also known as Blinder-Oaxaca decomposition , 21, expTable It has been found that with an increase in BMI levels, the mean birth weight of the child has also increased. It is lowest for a woman having low BMI for both the age group of mothers (2.67 kg for 15–19 age group and 2.7 kgs for 20–24 age group). But over the years, we found that the changes in mean birth weight are not conspicuous in any of the groups, which is expected. Similarly, it has been found that the anaemia level of mothers and mean birth weight of their child followed an inverse relationship. Mothers with severe anaemia showed the lowest mean birth weight for both age groups. For instance, it was 2.4 kgs for both age-group in 1998–99 and 2.6 kgs and 2.7 kgs in 15–19 and 20–24 age group respectively in 2015–16.Table Table Table For anaemia, the association with birth weight has decreased over the years. During 1998–99, the chances of having LBW babies was 2.6 times likely to occur to a woman with severe anaemia and 39% more likely to occur to a woman with moderate anaemia. Whereas during 2015–16, we can observe that the association has decreased over time. Women with severe and moderate anaemia are 30% and 11% more likely to have LBW babies. The likelihood of LBW babies among women with anaemia seemed to have decreased during 2015–16.Table However, we also observed that the difference in mean birth weight with respect to anaemia is 0.14 units. Out of which only 35.71% (coefficient = 0.05) of the difference can be explained by anaemia and the rest of it remained unexplained due to other factors affecting Birth Weight.This paper examined the association of young mothers’ nutritional status with childbirth weight. In this study, those mothers were considered who became pregnant quite early between 15 to 24 years of their age and were exposed to deliver LBW children. The major findings of this study are as follows.First, the prevalence of low BMI and severe anaemic mothers have decreased over the decades. Second, the birth weight of the infants is directly related to BMI but inversely related to the anaemia level of the mothers. Third, over the decade, the prevalence of LBW babies has decreased and a higher reduction has taken place for mothers within the age of 15 to 19 years. Fourth, the odds of having LBW babies was significantly higher for mothers with low BMI, moderate and severe anaemia. However, mild anaemic mothers do not show any significant association. Moreover, the association between BMI, anaemia and child birth weight has decreased over the decade. Fifth, BMI can explain about one-fifth of the difference in child birth weight between mothers with low and normal BMI whereas more than one-third of the difference can be explained by anaemia between mothers with severe and non-severe anaemia.Some possible explanations of these findings have been provided. Women with abnormal BMI are at risk of LBW outcomes . The decSince the implementation of the National Health Mission (NHM) in 2005, the improvement in maternal and child health has been accelerated . The effThis study has the following limitation. As the data was taken from a cross-sectional survey which provides only a snapshot of any current situation, the BMI and anaemia level of the mother was captured at the time of interview and not during their pregnancy period.


The article presents the results of a study of psychological factors of consumer loyalty concerning electric vehicles. An electric scooter was used as an example of an electric vehicle. The study involved a total of 165 people in China and 150 people in Russia. The study aimed to compare the psychological characteristics of Russian and Chinese consumers based on their attitudes toward an innovative product such as the electric scooter.(1) The identity of Russian and Chinese consumers and the perceived individuality of the product (electric scooter) differ significantly; (2) The proximity of the consumer's identity and the image of the product (electric scooter) enhances the positive attitude toward the product; (3) Risk strategies of consumer behavior of Chinese and Russians differ.The questionnaire included the scales: (1) “Measuring brand personality” by J. Aaker, (2) “Measuring consumer identity” elaborated by Morozova and Antononva, (3) The risk behavior scale by Vasilenko, Tkachenko.(1) The first hypothesis was confirmed: there were revealed differences in the consumer behavior of the respondents of these two groups concerning in their self-perception, as well as in the perception of electric scooters. The Russians perceive an electric scooter as energetic, young, extravagant, modern, and unusual; the Chinese are down-to-earth, family-oriented, real. (2) The hypothesis that the correlation of the consumer's identity and the individuality of the product is one of the psychological factors that determine the consumer's loyalty to a product is also confirmed. (3) The Chinese consumers' identity is more close to the product individuality and their loyalty to the product is higher. (4) Risk strategies of consumer behavior of Chinese and Russians significantly differ in terms of satisfaction with choosing of vehicle, the frequency of its use, and the importance of family approval of the choice of vehicle. The results can be used in the marketing strategy development. From the scientifical perspective, these results contribute to an understanding of the consumer loyalty mechanisms associated with consumer identity. Modern post-industrial society is such a set of social relations in which individual consumption occupies a key place Ilyin, . RegardlThe ideology of consumption pleasure stimulates uncontrolled consumption, which negatively affects various spheres of society. One of these areas is the transport sector and the problem of mass motorization. In many countries, the apparent failure of car-centered transport systems is driving the development of new urban mobility concepts. There are three business models for road transport and urban mobility .Personal identity as a concept which is actively developed in many social sciences, including psychology. It is a system of ideas about oneself, life goals and values, which gives a feeling of identity and constancy of personality  There are psychological characteristics of Chinese and Russian consumers that affect their attitudes to electric scooter:- The image of the product (electric scooter) is different for Chinese and Russian consumers.- The identity of Chinese and Russian consumers has different characteristics.(2) The proximity of the consumer's identity and the image of the product (electric scooter) enhances the positive attitude toward the product.(3) Risk behavior among Chinese and Russian consumers differ.www.wjx.cn) was conducted and the respondents were cross over China mainland. The study involved 165 people living in various localities of the People's Republic of China. The following sample characteristics were taken into account: gender (65 men and 100 women), age , 77% of the respondents are students. Most of the participants in the study were young people, since the problem of using electric scooters is more relevant for them.The Chinese part of the sample. In China in June 2021, the online survey through one 3rd party survey agency (The Russian part of the sample. The collection of data (Google questionnaire) by online survey through Facebook, Instagram, Vkontakte, WhatsApp, Telegram in Moscow and Moscow region, Russia was conducted in March 2021. The study involved 150 people living in Moscow and the Moscow region. The following sample characteristics were taken into account: gender (74 men and 76 women), age , 62.7% of the respondents are students.The representativeness of the sample was ensured by the diversity of participants. In Russia, the listed social networks have their own target audiences, and the coverage of users of various social networks provided the necessary diversity. In addition, people who came from various parts of Russia live in Moscow and the Moscow region. The sample size is determined by the methodology and is considered sufficient for this design of a psychological study.The methodological basis of this research is the concept of brand identity proposed by N. Kapferer in 1986 Yanenko, . Based oThe study used a questionnaire developed while studying personal factors of preference toward electric scooters among consumers. The questionnaire includes:(1) A socio-demographic block of questions that allows analyzing consumer groups based on such parameters as gender, age, and social status.(2) A block of questions for analyzing the features of brand identity and consumer identity. This section includes the following methods: (1) The method of “Measuring brand identity” by Aaker . The tec(3) The method “Measuring consumer identity” [the method of J. Aaker with the modification by Antonova and Morozova ]. Since (4) Questionnaire for identifying indicators of risk-taking consumer behavior. The questionnaire was developed on the basis of risk models of consumer behavior proposed by Vasilenko and Tkachenko .A block of questions for analyzing the characteristics of brand personality and consumer identity  were tested for reliability. Alpha-Cronbach coefficient are 0.78 and 0.86, respectively, which allows to analyze the internal consistency of the methods.Both Chinese and Russian groups noted the Ruggedness of an electric scooter. This product is perceived as sporty, dynamic, which is logical, given the purpose of this type of transport. The second significant characteristic of the image of an electric scooter in the Russian sample was Excitement, in the Chinese sample—Sincerity. Russians perceive an electric scooter as energetic, young, extravagant, modern, unusual. The Chinese perceive it as down-to-earth, family-oriented, real. This result highlights how different the perception of an electric scooter is in China and in Russia: for the Chinese consumers this product is a practical, useful thing, and for Russians it is an unusual, extravagant accessory.t test (Mann-Whitney U test for independent samples), statistically significant differences were revealed on the scales of Sincerity, Competence, Sophistication and Ruggedness. This is because Chinese consumers perceive the electric scooter much more emotionally than Russian consumers, correlating it with their personality, accepting it as part of their image. On the dimension of Excitement, the respondents of both samples rate the electric scooter approximately the same.When comparing the images of the electric scooter of the Russian and Chinese samples using the Student's Hypothesis 1 has been partially confirmed: the image of an electric scooter represented in the minds of Russian and Chinese respondents is significantly different. Russians perceive the electric scooter as energetic, young, extravagant, modern, unusual. The Chinese perceive it as down-to-earth, family-oriented, real.The self-perception of Russian and Chinese respondents also revealed both similarities and differences. The leading dimensions for characterizing self-images in both groups are Ruggedness and Sincerity. Another essential characteristic of the Russians is Competence, and of the Chinese—Excitement. The Chinese celebrate their openness, while for the Russians, success is more important. In addition, the Chinese are more categorical in assessing their self-images, while the Russians are more inclined to average assessments.t-test (Mann-Whitney U-test for independent samples), statistically significant differences were found on the Sincerity and Ruggedness dimensions. The distribution for the variable “Evaluation of oneself on the dimension of Excitement” in the Chinese sample differs from the normal, therefore, the differences between the groups for this variable were identified using the Mann-Whitney U test. The null hypothesis was rejected: the images of Russian and Chinese consumers differ significantly in terms of the Excitement dimension.When comparing the images of an electric scooter in the Russian and Chinese samples using the Student's Based on primary statistics, we can conclude that respondents from China consider themselves sincerer, more emotionally vivid, and more courageous. On the one hand, this may be associated with greater self-confidence, better self-knowledge, which is a characteristic of the Chinese respondents. On the other hand, it certainly reflects the ethnic characteristics of self-perception.The difference in self-image and the electric scooter among Chinese consumers is significantly lower see . The ManThe image of oneself and the image of a product (electric scooter) is significantly closer among Chinese consumers than among Russian ones.We can conclude that the hypothesis 2 is confirmed: the proximity of the consumer's identity and the image of the product (electric scooter) enhances the positive attitude toward the product.t test, it was found that there is a statistically significant difference between the attitudes of Russian and Chinese consumers toward public transport. This is probably due to the financial status of Russian youth . It means, that they have no money for personal car or car-sharing.The transport preferences of the Chinese and the Russians are different. While most residents of Moscow and the Moscow region (over 90%) use public transport, the sympathies of the Chinese are distributed between public transport (41.8%), private cars (34.5%) and car-sharing (20.6%). When comparing the groups using the Student's We compared the Russian and Chinese samples using the criteria of risk behavior using the risk behavior scale . Using Student's t test, assessments of images of oneself and an electric scooter were compared according to the dimensions of J. Aaker's method, given by respondents of both genders: no significant differences were found between the groups. The groups of men and women also do not differ significantly in terms of adherence to electric scooters.When evaluating one's image using the dimensions of the J. Aaker most respondents mentioned their Sincerity (97%), Excitement (83%) and Ruggedness (90.9%). That means that the most respondents perceive themselves as open, friendly, energetic, modern, freedom-loving, and persistent people. Since the number of women in the sample of Chinese respondents significantly exceeds the number of men, it is checked whether this result is related to the gender of the respondents. At the tendency level, it can be noted the tendency of women to give themselves higher marks on the Sincerity dimension : in men, the image of oneself and the image of an electric scooter on the Sophistication dimension is more consistent than in women.Correlations between self-images and the electric scooter are weak, but it is interesting, the highest correlation was found on the Sophistication dimension—the dimension that has the lowest values when respondents characterize the personality of the electric scooter. That is, respondents who feel refined, charming, endow these qualities and an electric scooter. Correlation analysis showed a weak negative relationship between gender and the difference between oneself and electric scooter images on the Sophistication dimension (0.29 at Testing the hypothesis about the correlation between the image of oneself and the image of a product as a factor of its preference.*), Excitement (−0.16*) at p < 0.05, and Competence (−0.22**) at p < 0.01. Interestingly, in addition to the Sincerity and Excitement dimensions, on which most respondents gave themselves high marks, the Competence dimension is also important. This suggests that the perceived similarity between themselves and the electric scooter in terms of Intelligence, Reliability, and Success is related to the loyalty to this type of transport.To test the hypothesis about the correlation between the difference in self-image and the electric scooter with the loyalty to this type of transport, the delta was calculated for each of the dimensions of J. Aaker's methodology . Then these values were taken modulo, and the Spearman criterion was used to check the correlation with the loyalty and actual use of the electric scooter. Loyalty to an electric scooter, which is understood as a desire to purchase it in the future, is weakly negatively associated with the difference in images on the dimension Sincerity  gave high marks to the electric scooter. Sophistication and Competence are the least characteristics for this sample—high marks for these parameters were given by 26 and 28.6%, respectively. These data indicate that the electric scooter is perceived by Russian consumers as a modern, bright vehicle that gives a feeling of freedom and independence. Low scores on the Sophistication dimension are probably because the electric scooter is not yet a fashionable accessory for Russians.When assessing their own image on the dimensions of J. Aaker's methodology, most of respondents noted their Sincerity (74%), Competence (76%) and Ruggedness (77.3%). That is, most of respondents recognize themselves as people who are practical, friendly, successful, and freedom-loving.As can be seen from the initial analysis of the data, there is no contradiction between the identity of the respondents and the perceived identity of the electric scooters, however, they differ. This suggests that the respondents do not perceive the electric scooter as a product close to them, reflecting their identity.This assumption was also confirmed by statistical analysis: no statistically significant correlations were found between the identity of the respondents and the individuality of electric scooters.Testing the hypothesis about the connection between the image of oneself and the image of a product as a factor of its preference.p < 0.01. Ruggedness is the only dimension that is significant both for the identity of the respondents and for the personality of an electric scooter. Accordingly, the discrepancy on this dimension leads to a lower adherence to this mode of transport.To test the hypothesis that the similarity between the image of oneself and the perceived individuality of the product as a factor of the consumer's loyalty to this product, the delta between these two dimensions was calculated for each of the variable of the J. Aaker methodology . Then we took these values to build modulo, and used the Spearman test, to check the relationship between this delta and actual use of the electric scooter. Loyalty to an electric scooter, which is understood as a desire to acquire it in the near or distant future, is weakly negatively associated with the difference in images on the ruggedness dimension (−0.28) at Thus, the hypothesis about the correlation between the difference in the images of oneself and the electric scooter with the adherence to this type of transport was partially confirmed in both the Chinese and Russian samples.This allows us to conclude that the approach proposed by N. Antonova to the study of psychological factors that determine consumer loyalty to a brand or product is highly heuristic. The assumption that the consumer's identity is related to the product's personality, as well as that the consistency of these images affects the consumer's loyalty to this product, was confirmed in this study.Thus, based on the results of this study, the following conclusions can be drawn:(1) The consumer behavior of Russians and Chinese when choosing transport is different. The Chinese are more likely to use private transport, while the Russians are more likely to use public transport. Chinese consumers are characterized by a higher level of satisfaction with their choice and a pronounced focus on family approval, that is not the same for Russians.(2) The self-image of Russian and Chinese consumers is different. At the same time, the Chinese perceive themselves as sincere, courageous, and emotionally bright people. Russians' self-image is less differentiated, and they tended to give themselves an average score when evaluating themselves. Along with ruggedness, Russian respondents noted their competence.(3) The image of an electric scooter represented in the minds of Russian and Chinese consumers is different, and the respondents from China have this image significantly closer to their self-image than the respondents from Russia. Chinese consumers perceive the electric scooter much more emotionally than Russian ones, correlating it with their personality, accepting it as part of their image. However, the differences in the emotional component of the attitude toward an electric scooter are not related to the behavioral component—the level of loyalty to this type of transport does not significantly differ among Chinese and Russian consumers.The influence of cultural context on consumer attitudes is undeniable. However, the nature of this influence and its intensity will be different depending on a variety of external factors. This study attempted to cross-culturally analyze the consumer attitudes of Russians and Chinese using the example of their attitude to an electric scooter. The individuality of the product perceived by consumers is considered through the prism of personal identity.One of the objectives of the study was to identify the correlations between the consumer's identity and the perceived individuality of the product, as well as to analyze cross-cultural differences that affect this correlation. Based on the results obtained, one can say that the correlation between the consumer's identity and a product's personality is one of the factors of the cognitive and emotional components of consumer loyalty to a product. Having carried out a cross-cultural analysis of the data, the self-image of Russian and Chinese respondents differs both in the set of leading personality traits and in the intensity of their expression was found. Differences in self-images are related to differences in the perception of a product.The original contributions presented in the study are included in the article/supplementary materials, further inquiries can be directed to the corresponding author.www.hse.ru). Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.The studies involving human participants were reviewed and approved by Ethics Committee of Doctoral School of Psychology, HSE University (Moscow, Russia, FZ conducted the collection of data and wrote the paper. The author confirms being the sole contributor of this work and has approved it for publication.The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


To examine how physical and psychological childbirth experiences affect maternal perceptions and experiences of early infant behavioural style (temperament).Unnecessary interventions may disturb the normal progression of physiological childbirth and instinctive neonatal behaviours that facilitate mother–infant bonding and breastfeeding. While little is known about how a medicalised birth may influence developing infant temperament, high impact interventions which affect neonatal crying and cortisol levels could have longer term consequences for infant behaviour and functioning.A retrospective Internet survey was designed to fully explore maternal experiences of childbirth and her postnatal perceptions of infant behaviour. Data collected from 999 mother–infant dyads were analysed using Pearson’s correlations and multiple analyses of covariance, employing the Bonferroni method of correction to establish initially significant variables. Multiple linear regressions were conducted to determine major perinatal contributors to perceived early infant temperament.p = 0.000) was the most significant predictor of Alert-Responsive infant behaviour, followed by maternal Postnatal Positive experience . In contrast, depression (EPDS) scores  were the most significant predictor of Unsettled-Irregular infant behaviour, followed by Anxious-Afraid Birth Emotions  and infant age . Mothers also perceived their infants as more Alert-Responsive  and Easier overall  after a Supported birth experience.Multiple regression analyses on each of the eight Mother and Baby Scales outcome variables indicated that early infant behavioural style (0–6 months) was largely predicted by subjective maternal states during and post-childbirth, postnatal depression scores, maternal personality traits and infant age. For example, infant age . Social support enhanced the mother’s childbirth experience, benefitting her perceptions of her baby’s early temperament. These findings provide further support for current World Health Organisation intrapartum guidelines (2018) on the importance of making childbirth a ‘ Rising levels of childbirth interventions have become a major concern in recent years . The tervia postnatal maternal mood.Therefore, we know that a negative birth experience can have an impact on postnatal maternal mood. Postnatal depression in turn may lead to emotional and behavioural problems in the infant and young child , 2018. AIt is also possible that there are direct links through the inter-connected maternal–infant neurohormonal systems during childbirth . Furthera quality that varies among individuals, is moderately stable over time and situation, is under some genetic influence, and appears early in life—a coherent profile of behavior, affect , and physiology (neurochemistry of the brain)’ ’ , p. 38. onment’. , p. 26. Assessing infant temperament independently is an intensive activity and therefore research often relies on maternal self-report, although the mother’s mental health post-birth might affect actual or perceived infant temperament. The potential disruptive impact of maternal PPD on normal mother–infant interactions  may distAs well as the finding that newborn infants up to 8 weeks are more likely to be unsettled after an assisted birth (using forceps or ventouse extraction) or emergency C-section , some auNevertheless, research exploring how childbirth may (directly or indirectly) affect early infant behaviour and developing temperament is sparse. Our previous qualitative research explored maternity care providers’ perceptions of how this might occur . Our finThis suggestion led to the current study, which aimed to examine whether mothers’ physical and psychological experiences of pregnancy, childbirth and the early postnatal period are associated with perceptions of their infants’ behavioural style, while also considering broader maternal demographic factors, personality and postnatal mood.A retrospective online survey examining physical and psychological experiences of childbirth, maternal mental health and infant behaviour.Mothers were eligible to participate if they were over 18 years of age, had an infant aged 0–30 weeks from a singleton pregnancy, resided in the United Kingdom and had no major health problems. Exclusion criteria were: any major health problems in mother or infant; premature birth (<37 weeks); multiple birth (>1 infant) or low birthweight (<5.5 lb) .Participants completed an anonymous online survey about their physical and psychological experiences of pregnancy, childbirth and the early postnatal period, alongside a validated measure of perceived infant behavioural style. The survey included items examining the following criteria.Maternal age, ethnicity, education, postcode, monthly household income and relationship status were reported by mothers, as well as parity (number of children), infant age, gender, gestational age and birthweight (if known).Birthplace , how labour commenced (e.g. induction or spontaneous) and progressed (e.g. acceleration), timings for each labour stage (hours/minutes), birth interventions , birth mode , pain ratings, pain relief methods  and pre/postnatal complications  . Items avia five-point Likert scales (1 = strongly disagree to 5 = strongly agree). Many validated psychological tools, such as the Edinburgh Postnatal Depression Scale . Responses were captured on Scale  and the on Scale , use fouoperative birth experience, no one tool covered the period with the breadth required. Furthermore, while maternal satisfaction with the birth, including operative birth experiences and the care she receives, are very important, we were specifically interested in the wider potential impacts of the mother’s physical and psychological responses to her pregnancy, birth and postnatal experiences on her baby. Consequently, we developed our own questions with a focus on how the mother felt during each stage of her journey, which we could then compare with her perceptions of her baby’s early behavioural style.The subjective measures of pregnancy, birth and postnatal experiences were based on the literature around women’s psychological responses to childbirth and the perinatal period. To the best of our knowledge, at the time of designing this survey, there was no single validated tool that could measure the mother’s actual experience and emotional responses to her experience throughout the perinatal period. Indeed, although there are some validated tools relating to maternal interpretations of the birth experience, such as the Birth Satisfaction Scale , which evia six-point Likert scales  to items, such as ‘My baby has settled quickly and easily’ and ‘During feeds my baby has tended to fuss and cry’. The scale contains eight sub-scales: Alert-Responsive (A-R); Unsettled-Irregular (U-I); Easiness (E); Alertness during Feeds (ADF); Irritable during Feeds (IDF); Lack of Confidence in Caretaking (LCC) and Breastfeeding (LCBF); and Global Confidence (GC) . Maternal personality was measured using the Ten Item Personality Inventory (TIPI). The TIPI  is a shoI have been able to laugh and see the funny side of things’), with check box answers on a four-point Likert scale . Mothers with scores of 13 or above are considered high risk. The sensitivity, internal consistency, validity and reliability of the EPDS as an effective screening instrument for postnatal depression are well established, and it is widely used in both research and clinical practice in the United Kingdom and elsewhere  on a four-point Likert scale . Positive items are reverse scored and therefore higher scores are indicative of higher anxiety levels. This tool is considered a reliable and valid measure of anxiety states  and social media (e.g. Facebook and Twitter). The study took place on SurveyMonkey®. On accessing the anonymous online survey, participants were presented with an information page outlining the purpose of the study and eligibility criteria, as well as data protection and confidentiality arrangements. Following electronic consent, participants were asked to complete standard demographic information before beginning the survey. Participation took approximately 15–30 min. Afterwards, participants were thanked and presented with a debrief page outlining where to seek further information and professional support if needed.Participants were recruited between June 2014 and March 2017 via the associated tools for analysis: correlations and ANOVAs to establish similarities, differences and interactions of infant behaviour in relation to the birth experience and surrounding factors. Finally, multiple linear regressions were used to establish predictors. Our analysis plan is further detailed below.Raw data were imported from SurveyMonkey™ into SPSS version 26 (SPSS United Kingdom Ltd). Each of the four questionnaires incorporated in the survey was first scored according to their individual instructions. Multiple statements concerning pregnancy or postnatal complications were summed and included as continuous scores rather than individual items. Continuous, nominal and ordinal data could then be quantified and interpreted How did you feel during pregnancy/your birth’). Principal components analyses (PCA) were conducted using Direct Oblimin rotation methods, as recommended by To begin, factor analyses were carried out on participant-rated statements concerning their subjective perceptions of the perinatal experience. This technique was applied where multiple statements rated on a five-point Likert scale had the potential for reduction to fewer items: subjective maternal physical and psychological experiences of pregnancy, childbirth and the early postnatal period and overall maternal perceptions of the birth experience (e.g. positive/supported/directed). Mothers had responded to questions and a list of potential answers concerning their personal perceptions of the perinatal period  and Multivariate Analyses of Variance (MANOVAs) were first performed on the sociodemographic and infant characteristics data. Thus, infant characteristics  and sociodemographic variables  were considered. Significantly associated maternal and infant factors were subsequently controlled for in all further statistical analyses.a priori Bonferroni correction method of analysis, with all means comparisons chosen in advance  were created in SPSS where required. Pearson’s partial correlations, controlling for covariates and excluding cases listwise, were conducted where independent variables reflected either ratio or interval data. MANCOVAs were carried out for categorical independent variable data, using the  advance , 2016. TMonthly household income was categorised using the five income brackets taken from the Office for National Statistics (ONS) division of quintiles from 2014 to 2016, corresponding with the survey design and data collection period . For mulCertain factors had the potential to be bi-directional in causality. However, placing perceived infant behaviour and maternal confidence as the speculated outcome variables was integral to the overall study aims: to explore how physical (objective) birth events, psychological variables and the subjective maternal experience of childbirth may influence mother-reported infant behaviour. A predictive form of analysis was chosen to establish the strongest independent variables and to indicate which factors might explain the greatest proportion of the total variance in infant behavioural scores and maternal confidence when all other factors were held constant. Multiple linear regression was used with the forced entry method, excluding cases pairwise to maximise data retention.R2 is reported throughout.Finally, therefore, multiple linear regressions were performed for each of the eight MABS items. In line with SD = 4.2; range 19–44 years); mean infant age was 15.31 weeks . Initially, 1,152 mothers completed the survey although 153 did not meet the inclusion criteria, leaving 999 in the analysis. Mean maternal age on completion of the survey was 32 years —999 mothers who met all the inclusion criteria completed the scale, although only 855 completed the breastfeeding section, corresponding to the breastfeeding data. The MABS data were analysed and coded according to instructions .Associations between the MABS scores, infant characteristics and maternal demographic background were explored. Infant Age, Infant Gender, Gestational Age, Birth Weight, Maternal Age, Maternal Education and Number of Children were significantly associated with MABS scores and therefore controlled for in all further analyses.The number of complications experienced by mothers during pregnancy and postnatally were computed. Altogether, 37% experienced at least one pregnancy complication  and 50.3% at least one postnatal complication . Partial Pearson’s correlations identified significant positive associations between the number of pregnancy complications and Unsettled-Irregular infant behaviour as well as Lack of Confidence in Caretaking and Breastfeeding. Similarly, Number of Postnatal Complications had significant positive relationships with Unsettled-Irregular and Irritable during Feeds and negative associations with maternal confidence measures . TherefoM = 39.07, SD = 5.26; MLU M = 39.70, SD = 4.70; Home M = 39.83, SD = 4.75 . Additionally, infants were rated as more Unsettled and Irregular after a hospital or MLU birth than after a homebirth: Hospital M = 50.58, SD = 12.57; MLU M = 50.60, SD = 12.56; Home M = 45.06, SD = 10.13 . Finally, mothers reported lower Lack of Confidence in Breastfeeding after homebirths rather than hospital or MLU births: Hospital M = 17.06, SD = 6.61; MLU M = 16.43, SD = 5.66; Home M = 13.58, SD = 4.09 .Mothers were asked where they had given birth . A MANCOVA was conducted to highlight any significant differences between birth settings. Bonferroni tests highlighted that infants were rated as less Alert and Responsive after a hospital birth compared to a MLU or home birth: Hospital N = 489) than by any means of induction: Yes Spontaneous Labour M = 49.43, SD = 12.67; No Spontaneous Labour M = 50.67, SD = 11.99 . Infants were also less Alert-Responsive after a Sweep (N = 179) than after No Sweep: Yes Sweep M = 38.64, SD = 5.50; No Sweep M = 39.43, SD = 5.00 .A series of MANCOVAs were conducted for each start of labour method in relation to MABS. Notably, infants were significantly less Unsettled-Irregular after Spontaneous Labour  = 16.87, p = 0.000]. Equally, mothers reported greater Lack of Confidence in Breastfeeding after a Membrane Sweep: Yes Membrane Sweep M = 17.98, SD = 7.00; No Membrane Sweep M = 16.13, SD = 6.01 . Similarly, they reported greater Lack of Confidence in Breastfeeding when Induced by Pessary and Drip (N = 60): Yes Pessary and Drip M = 19.45, SD = 8.01; No Pessary and Drip M = 16.30, SD = 6.07 .Mothers reported Pearson’s partial correlations were conducted to assess associations between the length of each labour stage  and MABS scores. Length of Latent Stage was inversely associated with Alert-Responsive infant behaviour, while lengths of Active Stage and Second Stage were positively associated with Unsettled-Irregular infant behaviour and Lack of Confidence in Caretaking and Breastfeeding. Overall, infants were generally less alert, more unsettled and mothers less confident, after a longer labour see .Mothers responded to a series of questions about interventions that may have occurred during labour. These included whether they had experienced Artificial Rupture of Membranes (ARM), (continuous) Electronic Foetal Monitoring (EFM), Foetal Scalp Electrode (FSE) or a Foetal Blood Sample (FBS). A series of MANCOVAs assessed differences in perceived infant behaviour and maternal confidence according to Birth Mode. Infants were most likely to be Unsettled-Irregular after Assisted Birth see . In addiPearson’s partial correlations found that Pain Ratings during labour were positively associated with Unsettled-Irregular infant behaviour and inversely associated with overall infant Easiness. Pain Ratings were also associated with lower maternal confidence ratings—both globally and in relation to caretaking .In terms of pain relief, nitrous oxide (Entonox) was positively associated with Unsettled-Irregular infant behaviour and Lack of Confidence in Breastfeeding; Pethidine was positively associated with Irritable during Feeds and Lack of Confidence in Caretaking and inversely associated with Global Confidence; Spinal Block was associated with Lack of Confidence in Breastfeeding; while Epidural was associated with less perceived infant Easiness, more Unsettled-Irregular behaviour and lower maternal Confidence in Caretaking and Breastfeeding .r (234) = −0.068, p = 0.033. Reflexology during labour was positively associated with perceived infant Easiness  and Acupuncture during labour was inversely associated with Alert during Feeds . Thus, infants were reported as ‘easier’ after Reflexology and as more ‘relaxed during feeds’ after Acupuncture. However, both Acupuncture  and Reflexology  had small sample sizes, undermining the reliability of these findings. Therefore, Reflexology and Acupuncture were excluded from further analyses.Partial correlations highlighted significant associations between certain natural methods of pain control and infant behaviour. Hypnobirthing was inversely associated with Unsettled-Irregular, n = 4, 0.4%). Although there were no significant differences in perceived infant behaviour, differences in maternal Global Confidence were seen between ‘No Tear’ (n = 187) and ‘Tear or Episiotomy’ (n = 812): No Tear M = 18.20, SD = 1.76; Tear or Episiotomy M = 17.63, SD = 1.86 .A MANCOVA employing the Bonferroni correction explored differences between mothers who had or had not experienced a ‘Tear or Episiotomy’. Notably, Episiotomy was too small a group to include as a stand-alone item . This factor was then transformed into a dichotomous variable: ‘Gentle Birth of Head’ or ‘Other’ (a non-gentle birth of the head). Infants were perceived as more Alert-Responsive, less Unsettled-Irregular and Easier overall after a Gentle Birth. In addition, Gentle Birth of Head led to an increase in Global Confidence scores alongside a decrease in Lack of Confidence in Breastfeeding scores .M = 49.63, SD = 12.39; No Skin to Skin M = 54.30, SD = 11.88 . Infants were also reported as Easier overall: Yes Skin to Skin M = 24.25, SD = 2.29; No Skin to Skin M = 23.55, SD = 2.21 .MANCOVAs were conducted to differentiate between infants who did or did not have immediate skin-to-skin contact with their mother post-birth. Infants who experienced immediate ‘Skin-to-Skin’ contact were reported as less Unsettled-Irregular: Yes Skin to Skin M = 31.96, SD = 8.55; No Skin to Skin M = 34.96, SD = 7.72 . They also reported less Lack of Confidence in Breastfeeding after immediate skin-to-skin contact with their baby: Yes Skin to Skin M = 16.37, SD = 6.16; No Skin to Skin M = 18.90, SD = 7.43 .Overall, mothers reported less Lack of Confidence in Caretaking if they had experienced immediate skin-to-skin contact with their baby post-birth: Yes Skin to Skin M = 49.56, SD = 12.27; Other M = 54.06, SD = 13.26 .The sample consisted of 882 (88.3%) mothers who initiated breastfeeding and 117 (11.7%) who began feeding by any other method, such as syringe fed, formula or expressed bottle fed. Therefore, to facilitate further analyses, First Feed was dichotomised into two groups: Breastfed (‘breastfed’) and Other . In a MANCOVA for First Feed and MABS, perceptions of Unsettled-Irregular infant behaviours increased if the First Feed was ‘Other’: First Feed Breastfed M = 16.73, SD = 4.36; Other M = 20.05, SD = 5.37 . Mothers also understandably had lower Lack of Confidence in Breastfeeding if they were currently breastfeeding their baby: Currently Breastfed M = 16.45, SD = 6.20; Other M = 20.33, SD = 8.64 .Current Feed responses were likewise dichotomised: ‘Currently Breastfed’ and ‘Other’. The sample consisted of 850 participants (85.1%) who were currently breastfeeding, while 146 (14.6%) were feeding by another method (e.g. formula). A MANCOVA was conducted for Current Feeding Method and MABS. Infants were less Alert during Feeds if currently breastfeeding: Currently Breastfed As outlined in the Data Analysis section, PCA with Direct Oblimin rotation methods were used to analyse multiple subjective statements regarding mothers’ personal experiences of pregnancy, childbirth and the postnatal period, as well as her overall perceptions of the birth experience.As there was no one validated scale that covered individual maternal responses to the whole perinatal period, subjective statements around the mother’s sense of her own physical and psychological wellbeing during the three major stages  were derived from the literature. Questions relating to women’s subjective birth and perinatal experiences were analysed using principal components analysis (PCA) and explained 62%–68% of the variance for each period, as well as for maternal overall perceptions of her birth experience. This compares well to Subjective pregnancy states included ‘felt happy and excited/anxious and fearful about the birth’ (labelled Positive Pregnancy Emotions) and ‘had plenty of energy/felt tired and drained’ . In both cases, a higher score indicated a more positive subjective experience. Subjective birth states included: Positive ; Neglected (‘abandoned’ or ‘ignored’); Aware-Alert ; and Anxious-Afraid  Birth Emotions.These subjective pregnancy and childbirth factors in relation to MABS are presented in Next, Pearson’s partial correlations were conducted between subjective maternal postnatal states, the mother’s overall perceptions of her birth experience and her baby’s temperament. Feeling physically and mentally positive post-birth and having an overall positive, supported experience were associated with maternal perceptions of easier and more settled infant behaviour. Equally, feeing distressed postnatally and having a more directed birth experience overall were associated with more difficult, unsettled infant behaviour see . NotablyMaternal personality (TIPI), postnatal mood (EPDS) and current state (STAI State) were significantly associated with MABS items. For example, a more positive mood, feeling calm and traits, such as Openness to new experiences and Emotional Stability, were associated with easier infant behavioural style see .As described above, multiple physical and psychological factors were associated with MABS. The next section examines the factors that best predicted infant behaviour and maternal confidence when all other significant variables were held constant. STAI State was highly correlated with EPDS (>0.7). Given that STAI State probably reflected the mother’s current  mood, it was decided that EPDS would remain. Consequently, STAI State was removed in the following analyses to reduce multicollinearity.As multiple physical and psychological factors were associated with MABS, the next section examines the factors that best predicted perceived infant behaviour and maternal confidence. Multiple linear regression analyses were conducted for each MABS item to predict maternal reports of infant behaviour and her own self-reported confidence. Significant perinatal factors for infant behaviour and maternal confidence—as highlighted by the Pearson’s correlations and MANCOVAs described above—were entered into the final regression models.MABS items were split into infant behaviours  and mateThe predominant predictors of maternal confidence were whether she had given birth before, known as parity (Number of Children), her subjective perinatal experience  and psychological factors, such as EPDS and Emotional Stability .In summary, The aim of this study was to examine how maternal physical and psychological experiences of pregnancy, childbirth and the early postnatal period may be associated with the mother’s perceptions of her infant’s behaviour, taking into account broader maternal demographic factors, postnatal mood and personality. The study had several notable findings, and numerous aspects of childbirth and the perinatal period were associated with perceived early infant behaviour. Although certain childbirth interventions, complications, birth mode and types of pain relief were associated with less settled infant behaviour (0–6 months), regression analyses highlighted that subjective and psychological factors, alongside maternal personality traits, largely predicted perceived infant behavioural style and maternal confidence outcomes.In addition, the mother’s sense of wellbeing during and post-birth was reflected in higher levels of reported confidence and self-efficacy alongside her perceptions of easier infant behaviour. The predictability of birth events could play a key role in situations where the mother’s sense of agency and control is increased or diminished, as research shows that agency in relation to free choice is particularly important for unpredicted negative events . More spThese findings support the concept that subjective maternal perceptions of childbirth may contribute to early infant temperament development or to maternal perceptions of her baby’s behavioural style. This could have important implications for maternity and midwifery practice, particularly for more vulnerable mother–infant pairs, or those who experience a challenging birth. The main findings are further discussed under the following headings.Although many of the more objective factors, such as interventions, birthplace, birth mode and gentle birth of the infant’s head, were associated with infant and maternal outcomes, breastfeeding was the only physiological perinatal factor that retained significance in the regression models for perceived infant behaviour. Specifically, ‘currently breastfeeding’ was associated with less Unsettled-Irregular behaviour over the first 6 months. Furthermore, infants were reported as less Alert during Feeds if they were currently breastfeeding, indicating that breastfeeding could be less stimulating and more relaxing for the infant. Breastfeeding is an instinctive newborn behaviour, highly sensitive to external stimuli from emotions, such as anxiety and fear . Its iniThis finding may also be connected to the close skin-to-skin contact that naturally occurs during breastfeeding, regulating hormonal systems after a challenging birth, enhancing oxytocin and lowering cortisol levels, reducing the negative impacts of pain and stress on neonatal and maternal HPA axes and benefitting mother–infant neurobiological wellbeing and synchrony post-birth .via physiological pathways, as discussed. This may result in lower maternal confidence combined with more negative thoughts and feelings. Thus, the relationship between mother and infant states of wellbeing or otherwise is likely to be bi-directional  during childbirth and distressed postnatally, and these negative emotional states were associated with maternal reports of Unsettled-Irregular infants. As speculated by prior research , this mavia an easier birth and maternal recovery, with the mother’s wellbeing during and post-birth encouraging neonatal wellbeing via their inter-connected hormonal systems  scores predicted perceptions of unsettled, irregular and irritable infant behavioural style, supporting previous research identifying a link between postnatal depression and perceptions of more ‘difficult’ infant behaviour . This reEPDS postnatal depression scores were associated with maternal Postnatal Distress, which in turn was associated with both the physical and emotional birth experience, aligning with evidence that negative birth experiences and postnatal psychological states contribute to postpartum depression . MoreoveOxytocin promotes bonding and attachment . ConversAs expected, heritable maternal character traits predicted self-reported infant behavioural style and maternal confidence ratings. The mother’s personality influences outcomes on three levels: how she feels, the way she responds to her newborn baby and the postnatal environment she creates . TherefoA less anticipated finding was that the presence of an extra birth companion alongside the birth partner positively predicted maternal perceptions of infant Easiness. Potentially, having two continuously supportive figures in the birthing room contributes more effectively to a positive birth experience with positive outcomes, including enhanced maternal perceptions of her baby. Furthermore, we know that continuous emotional support from a female companion, such as a doula, may lessen maternal stress levels, boost oxytocin  and encoFinally, sociodemographic variables were associated with certain types of infant behaviour. Mothers who did not attend higher education perceived their infants as more alert, responsive and easier overall. These findings might be explained through examining previous research which shows that mothers with higher education in established careers can find the transition to motherhood more challenging and have lower life satisfaction after having a baby . This geThis study provided an in-depth exploration of a concept previously only alluded to in the research literature on childbirth and infant behaviour: that potentially long-term physiological impacts of childbirth on the infant’s behavioural style and stress response system  could povia check boxes. However, ethnic minority use of the Internet is slightly below average  recorded  average . This ma average . There wThere are drawbacks to employing a self-report retrospective survey linked to the issue of subsequent validity of findings in regard to accurate recall of autobiographical memories . HoweverRetrospective reports of infant behaviour could be affected by biased memories of events and current behaviours during periods involving growth spurts, teething or weaning, all of which may alter the infant’s normal behavioural patterns. They could also be influenced by maternal mood, although this effect is considered small . MaternaAs this was a cross-sectional study, a future prospective longitudinal study could measure the same sample of women and infants at various time points throughout their perinatal experience. Importantly, the sample population was self-selecting. This undoubtedly affected the type of participant who completed the online questionnaire, rendering the recruitment strategy less inclusive. Potentially, however, a more homogeneous sample could help clarify findings in terms of specific impacts of childbirth experience on perceived infant behaviour.Given that these findings provide support for those of a previous qualitative study, with health professional data collected over a similar period , a futurDifficulties in bonding and attachment processes could be a key point in this connection between the mother’s response to childbirth  and interpretations of her baby’s behaviour. via the influences of postpartum maternal mood on mother–infant bonding and attachment—warrants further investigation. To include measures of CB-PTSD symptomology alongside early mother–infant interactions and bonding would therefore add to a more complete theoretical model for future testing (see Despite their possible contribution to infant behavioural outcomes, no direct measures were used here to assess symptoms of CB-PTSD or bonding and attachment behaviours between the mother and her baby. Nevertheless, the suggested pathway in this study between maternal birth experience and perceived infant behavioural style—ting see . In lineOur results add to a large body of research illustrating the complexity of childbirth and its potential outcomes for mother and infant. They highlight how infant and maternal outcomes of childbirth appear to be mutually influenced by one another’s response to birth and by multiple physiological and psychological perinatal variables, such as feeling anxious and afraid or neglected during childbirth. Social and professional support the mother receives during the perinatal period may positively enhance her response to childbirth, in turn benefitting her infant’s behavioural style. This finding is particularly pertinent in light of United Kingdom maternity policies involving restrictions on home births, water births and partner accompaniment in early labour during the COVID-19 pandemic. In some areas, this led to an increase in women opting for ‘free-births’ without any professional care—often to keep their partner with them throughout labour and birth and, for others, to avoid catching COVID . RestricOur findings therefore provide further support for the current United Kingdom maternity and midwifery services’ objective to increase staffing numbers, reduce risk and promote a model of safe, consistent, continuous and emotionally supportive care for all expectant mothers . Overallpre-March 2020, observed that maternity services have been very stretched during the COVID-19 pandemic. These problems arising in maternity care across the United Kingdom are intensifying previous issues of staff shortages and a lack of emotionally supportive care and are leading to increased reports of psychological distress in new mothers (The most recent of these maternity reviews—namely the Welsh review —although mothers . Conside mothers , which i mothers , an urgeMaternity research collaboratives, including The Lancet Midwifery Series  and the positive birth experience’, this should include ‘giving birth to a healthy baby in a clinically and psychologically safe environment with continuity of care and emotional support’. Promoting maternal emotional wellbeing alongside physical safety during and after childbirth is of paramount importance. High-quality one-to-one midwifery care during childbirth may benefit the mother’s physiological and psychological states (As recommended by the l states  and consl states . This coThe raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Swansea University Department of Psychology Research Ethics Committee. The patients/participants provided their written informed consent to participate in this study.CP: design, conceptualisation, methodology, data collection, formal analysis, writing—original draft, writing—review and editing, and project administration. CW and AB: design, conceptualisation, methodology, data analysis support, writing—review and editing, and supervision. All authors gave approval for submission, contributed significantly to the article, and are responsible for its contents.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Phenylalanine hydroxylase (PAH) deficiency is an autosomal recessive disorder that results in elevated concentrations of phenylalanine (Phe) in the blood. If left untreated, the accumulation of Phe can result in profound neurocognitive disability. The objective of this systematic literature review and meta-analysis was to estimate the global birth prevalence of PAH deficiency from newborn screening studies and to estimate regional differences, overall and for various clinically relevant Phe cutoff values used in confirmatory testing.The protocol for this literature review was registered with PROSPERO . Pubmed and Embase database searches were used to identify studies that reported the birth prevalence of PAH deficiency. Only studies including numeric birth prevalence reports of confirmed PAH deficiency were included.From the 85 publications included in the review, 238 birth prevalence estimates were extracted. After excluding prevalence estimates that did not meet quality assessment criteria or because of temporal and regional overlap, estimates from 45 publications were included in the meta-analysis. The global birth prevalence of PAH deficiency, estimated by weighting regional birth prevalences relative to their share of the population of all regions included in the study, was 0.64  per 10,000 births and ranged from 0.03 (95% CI 0.02–0.05) per 10,000 births in Southeast Asia to 1.18 (95% CI 0.64–1.87) per 10,000 births in the Middle East/North Africa. Regionally weighted global birth prevalences per 10,000 births by confirmatory test Phe cutoff values were 0.96 (95% CI 0.50–1.42) for the Phe cutoff value of 360 ± 100 µmol/L; 0.50 (95% CI 0.37–0.64) for the Phe cutoff value of 600 ± 100 µmol/L; and 0.30 (95% CI 0.20–0.40) for the Phe cutoff value of 1200 ± 200 µmol/L.Substantial regional variation in the birth prevalence of PAH deficiency was observed in this systematic literature review and meta-analysis of published evidence from newborn screening. The precision of the prevalence estimates is limited by relatively small sample sizes, despite widespread and longstanding newborn screening in much of the world.The online version contains supplementary material available at 10.1186/s13023-021-01874-6. Phenylalanine hydroxylase (PAH) deficiency is an autosomal recessive disorder that results in elevated concentrations of the amino acid phenylalanine (Phe) in the blood –4. Over Treatment guidelines recommend initiation of treatment as early as possible upon diagnosis of PAH deficiency . TreatmePhenylalanine hydroxylase deficiency is classified into mild HPA, mild phenylketonuria (PKU), moderate PKU, and classical PKU based on blood Phe concentration obtained in the neonatal period Table ; howeverBecause of the severe consequences of untreated phenylalanine hydroxylase deficiency, many countries currently perform routine newborn screening for elevated blood Phe concentration –17. MethThe accumulation of data from newborn screening programs with varied screening methods employed across the world provides an opportunity to evaluate the birth prevalence of HPA and PKU at the regional and global levels. Here, we systematically review the published literature and analyze regional differences in HPA and PKU birth prevalence, overall and for various clinically relevant blood Phe concentration cutoff values used in confirmatory testing.https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=156377; ID 156377).The protocol for this literature review was registered with PROSPERO  framework . When a publication reported birth prevalence by Phe cutoff interval , the sum of all values above the cutoff value was used. Finally, an unstratified meta-analysis was conducted, which additionally included estimates from studies in which Phe cutoff values were not reported, to determine overall  birth prevalence.2 statistic [To provide appropriate weights for meta-analysis, birth prevalence estimates were transformed using the double arcsine method ; meta-antatistic , 27.Searches in PubMed and Embase identified 1112 entries  with strong scores in the diagnostic method used for case confirmation reported birth prevalence (in the format 1:8000), but did not provide the number of cases or screened newborns [A total of 112 birth prevalence estimates (54 publications) scored strong in the quality assessment domain newborns  and was Birth prevalence estimates ranged from 0  per 10,000 births, based on a single estimate [Eleven publications reported birth prevalence estimates (1 estimate per publication) with a confirmatory test Phe concentration cutoff value of 360 ± 100 µmol/L. The regionally weighted global birth prevalence was 0.96 (95% CI 0.50–1.42) per 10,000 births (Table estimate .Ten publications (1 estimate each) reported birth prevalence estimates using a confirmatory test Phe concentration cutoff value of 600 ± 100 µmol/L. The regionally weighted global birth prevalence was 0.50 (95% CI 0.37–0.64) per 10,000 births Table C for thiFor the 1200 ± 200 µmol/L cutoff value for a Phe concentration confirmatory test, 20 publications (1 estimate each) were eligible and the regionally weighted global birth prevalence was 0.30 (95% CI 0.20–0.40) per 10,000 births  per 10,000 births. It is important to weight birth prevalence estimates by region so that the global PAH deficiency birth prevalence reflects both the birth prevalence and population size of each region rather than just the inverse variance (primarily driven by the sample size) of the individual studies . The highest regional birth prevalence in the overall analysis was reported in the Middle East/North Africa, where consanguineous marriages are among the most frequent in the world, with frequencies up to 42% in Saudi Arabia .Among estimates with a confirmatory test Phe concentration cutoff value of 360 ± 100 µmol/L, the regionally weighted global birth prevalence was 0.96 (95% CI 0.50–1.42) per 10,000 births. On the basis of recent European and American College of Medical Genetics and Genomics guidelines  and 0.30 (95% CI 0.20–0.40), respectively, per 10,000 births. Regional variation in the prevalence of PAH deficiency defined by these cutoff values was observed, with higher prevalences in Europe, Latin America, North America, and the Middle East than was observed globally. In a recent analysis of global variations in PAH genotype , genotypAs might be expected, in this meta-analysis we observed decreasing pooled birth prevalence as confirmatory test Phe cutoff values increased Table . The decI2 values, heterogeneity of birth prevalence estimates was generally high, even among estimates stratified by region and Phe concentration cutoff values for case confirmation. Heterogeneity may be partly explained by random variation related to sampling, which is supported by the fact that many included studies were small , and 66% scored moderate on this domain ; 11% did not report the study setting/source population or derived the information from personal communications. In addition, 126 of 238 reported birth prevalence estimates (53%) scored moderate or weak in diagnostic method used for case confirmation. Thirteen percent of the 238 estimates lacked information on the time period assessed, 3% on the assay used for screening, and 38% on the assay used for case confirmation. Although the frequency of BH4 deficiency is very low (1–2% of HPA cases) [We found that data elements that are key to understanding the reported birth prevalence estimates were often missing: 30% of the 238 estimates scored weak on Substantial inconsistencies were observed in the nominal diagnoses reported, even in recent publications, with poor or inaccurate distinction between PKU, moderate PKU, classical PKU, and HPA  for combining estimates from individual studies are not fully described in that paper, nor are the sources fully described; the global estimate included data from countries that the study describes as lacking newborn screening programs in parts of Africa, Asia, South America, and the Caribbean .The current findings confirm that regional differences exist in the birth prevalence of PAH deficiency, with higher frequencies of inheritance of this autosomal recessive disease in areas with higher frequencies of consanguineous marriages, as has also been noted by others , 47.Limitations of this study include incomplete reporting of key data elements in many of the included publications. In addition, the precision of the reported prevalence was low for most of the included estimates due to small sample sizes. No articles were identified reporting on the birth prevalence of PAH deficiency in Sub-Saharan Africa and birth prevalence estimates from countries in Southeast Asia were limited, lacking representation of some of the most populous countries in the region such as India. Absence of estimates could be attributed to absence of newborn screening programs for PAH deficiency in specific countries and regions , or lackIn this systematic literature review and meta-analysis, we estimated the regionally weighted global birth prevalence of PAH deficiency to be 0.64 (95% CI 0.53–0.75) per 10,000 births . The estimated regionally weighted global birth prevalence among newborns with Phe level ≥ 360 ± 100 µmol/L at diagnosis was 0.96 (95% CI 0.50–1.42), which is the population for whom treatment is recommended. Substantial regional variation was observed with an elevated birth prevalence of this autosomal recessive disease in regions with higher frequencies of consanguineous births. Despite the fact that newborn screening has been widely implemented in much of the world for decades, the precision of the estimates is limited by the unavailability of publications on large population samples. This observation underscores the need for more comprehensive and systematic data collection as well as improved standards for reporting results. Only with more widespread availability of data from newborn screening programs from large populations will it be possible to obtain robust estimates and truly understand the magnitude of this serious and treatable condition.Additional file 1. Literature search strategy, quality assessment, and country region classification. Description of the literature search strategy, how quality assessments were calculated for precision, and how country regions were classified.Additional file 2. Data extraction table. 238 birth prevalence estimates from 85 publications.Additional file 3. Meta-analysis forest plot figures. Figure A-2. Meta-Analysis Results by Region: Confirmatory Test Phenylalanine Cutoff Value of 360 ± 100 μmol/L. Figure A-3. Meta-Analysis Results by Region: Confirmatory Test Phenylalanine Cutoff Value of 600 ± 100 μM/L. Figure A-4. Meta-Analysis Results by Region: Confirmatory Test Phenylalanine Cutoff Value of 1200 ± 200 μM/L. Figure A-5. Meta-Analysis Results by Region: Overall Analysis.