Even though digitization is widely recognized as one of the most imperative trends in achieving effective urban governance, digital infrastructure remains far from the global trend in many African countries. This paper proposes a novel, resilient data manipulation architecture model called the Birth Notification Verification Model (BNVM) using blockchain and smart contracts. The proposed solution was evaluated in a real-world use case scenario in Ghana. The model, which is based on the Ten Civil Registration and Vital Statistics (CRVS) Framework, focuses on the initial inputs for birth registration at the birth notification level. The approach presented in this study paves the way for the creation of decentralized, secure, transparent, and automated systems for civil registration. The application of a smart contract architecture that blends a centralized design with an on-chain and off-chain architecture is further supported by this, providing more evidence of its viability. It offers a safe verification framework for the Ghana Birth and Death Registry based on smart contract technology and can guarantee a birth notification as proof of birth certificate registration in accordance with international standards. The findings provide insight into the use of blockchain technology in public registry institutions. Furthermore, exploring its adoption and implementation in Sub-Saharan Africa contributes to the growing field of blockchain technology research and demonstrates how the concept will address long-standing issues with corruption and security in developing countries. Digitization governance is one of the most significant current discussions in the urban governance field. Especially, with the spreading of Blockchain Technology (BCT), researchers have shown an increased interest in the application of the technology in solving birth registration challenges as a digital infrastructure in developing countries. According to , BlockchHowever, there is little advice for urban governance at present as to how to manage existing or emerging technology pressures or guidance on cross-system coordination and interoperability for efficient and effective Civil Registration and Vital Statistics (CRVS) . In theiThis study provides an exciting opportunity to make an important contribution to the growing area of urban digitization governance research by exploring the BCT adoption and implementation from the perspective of Sub-Sahara African challenges. The study further evaluates the extent and application of smart contract implementation in a real use case scenario. A blockchain-based system would lead to credible social identity, prevent identity fraud and ease the registration processes. From a broader perspective, robust civil registration and vital statistics systems will propel pursuits towards the achievement of sustainable governance by providing security, facilitating inclusion and access to social services.It does not seem too difficult to register births with Ghana’s Birth and Death Registry (BDR) even after many years when only an affidavit and a weighing card are required for registration to be completed. This poses a risk and opens the way for fraud . Cases oTo investigate the current birth registration processes at the Ghana BDR.To identify key pain points as well as relevant blockchain features that can be implemented.To propose a new block-chain based solution to tackle identified pain points.To test the application of a smart contract solution in the blockchain architecture.The main objective of the research is to develop a design model that implements the concepts of BCT to improve processes in birth registration at the Ghana Birth and Death Registry. Specifically, this study aims at achieving the following:As a basic infrastructure of Urban Governance, civil registration involves the legal notification and recording of individual vital events, including births and deaths, by the government . The offPeer-to-PeerNetwork infrastructure—In a P2P network, there is no centralized server, and each user is a node with server functionality. This layer embodies decentralization and network robustness [bustness Cryptography—Blockchain employs cryptography for authentication, permission enforcement, integrity verification, and other areas. It makes use of a variety of cryptographic techniques including cryptographic one-way hash functions, Merkle trees and public key (private-public key pairs) [y pairs) .Consensus Mechanism—In a blockchain network, a consensus is used to prevent dishonest actors from writing potentially invalid information to the database [database .Timestamp—The process of ‘trusted timestamping’ is an established approach for claiming that particular digital information existed at a particular ‘point in time’ in the past. It is assumed that the time-stamped information is not changeable by anyone in the future. The digital information can be time-stamped by using secure cryptographic methods [ methods .Ledger—The ledger represents a list of bundled (data) transactions in cryptographically linked ‘blocks’. Once the transaction data is verified a ‘block’ will be created. The ‘blocks’ in the chain are groups of transactions posted sequentially to the ledger by using a cryptographic signature—that is, added to the ‘chain’ [ ‘chain’ .Validity Rule—Common set of rules of the network  [d, etc.) .The characteristics of blockchain made it an important technology to solve many urban governance problems. Blockchain is a technology that makes the shared registry concept from distributed systems a reality for several application domains, from the cryptocurrency one to potentially any industrial system requiring decentralized, robust, trusted and automated decision-making in a multi-stakeholder situation . EnsurinZheng et al. classified significant smart contract applications into six groups based on their generalizations . When thDeth et al., introduced a free-to-use time-stamping service for online news articles. His proposed system uses secure technologies for saving the results of the time-stamped content for example embedding hashes into the Bitcoin blockchain  . Thus, iFor the first research question, an explorative approach is used to identify the current business process of the institution. This involved the use of documents and previous research detailing the process of the current CRVS System. De Savigny recommends a set of documents required for such enquiry . Based oReports from previous comprehensive assessmentsStrategic documents containing vision and mission statements, as well as aims and goals of the CRVS systemRelevant laws and regulationsStandard operating procedures and workflow diagrams.Grant and Booth argue that, a qualitative systematic review is a method for integrating or comparing the findings from qualitative studies . The expMegel and Heermann explained that secondary qualitative data collected can be analyzed using different theories  etc . All theProcess mapping can be used to describe, compare and visualize an organization, processes, workflows and functionality of a CRVS system . We usedInspired by the Ten CRVS Framework, the model focuses on the initial inputs for birth registration at the birth notification level. A robust architecture that allows birth events to be automatically authenticated prior to birth registration is critical to ensuring a more secured registration system .Within this model, a birth event is requested by an applicant to the Service Provider (SP) who could be a health professional at a hospital. The service provider registers the notification on the blockchain system that automatically triggers two smart contracts (1) Creation of a Timestamp and (storage of data). After a successful blockchain transaction, the service provider issues a notification confirmation receipt to the applicant for birth registration. Subsequently, a birth registration request is made at the Registration office that represents the authentication or registration party (ARP). They verify the notification receipt on the blockchain with an automatic trigger of the timestamp verification smart contract. After the necessary consensus and verification protocols execution on the blockchain, the verification results are produced for the final internal birth certificate registration processes. Feedback is then given to the applicant. Fundamentally, the blockchain component serves as the verification architecture for the Authenticating and Registration Parties prior to the actual birth registration. Without a successful authentication of the birth notification, the registration party cannot proceed with the issuance of a birth certificate. The model presupposes a dependent relationship between the blockchain, the registration party’s systems and the service provider system.The model functionality is given in The process is represented visually in the BPMN model. The procedure is divided into three steps: notification, validation/verification, and registration and storage (or archiving). A parent notifies a healthcare institution of a birth event and, under the current system, obtains a child welfare/weighing card for their kid. When a parent or informant takes their child to the registry to register for new birth, the registration process starts. A child’s welfare or weighing card is required, and the Registration officer fills up Form A when the client provides the necessary information. Because this form is only accessible in English, the registration officer will translate any information submitted to the client into another language. The information on the form is then manually put into a local register, which is subsequently scanned, compiled, and sent to the central register in soft copy. As soon as the birth is recorded for free by the local registrar, the newborn is immediately awarded a birth certificate. The term “late registration” refers to the fact that birth is not documented until the kid reaches the age of 1. Late registrations are handled in the same way as early registrations, with a few exceptions. As with early registrations, the registration process begins at the district level and is overseen by the regional office; however, certificates are only issued in Accra, at the central registry/head office, and are then delivered to the location of registration for collection, unlike early registrations. The process is represented visually in the BPMN model. The procedure is divided into three steps: notification, validation/verification, and registration and storage (or archiving).The methodology presented above is used to establish and analyze the process’s pain points by comparing them to the Ten CRVS Framework. Using this method, much more clarity and depth may be gained than a general explanation of the process’s pain points. Additionally, by visualizing the present process, it’s simple to understand how the suggested solution fits into it. The framework defines the numerous stages necessary for civil registration. This comparison demonstrates that the whole process is now encountering birth notice and data exchange challenges. The aforementioned pain points are crucial when it comes to confirming and verifying birth events before issuing birth certificates. In the absence of enhanced digitization of birth event notification and data exchange, there is a risk of oversight, as well as unlawful data collection and insertion. Additionally, information processing would be carried out manually, resulting in lengthy delays and inconsistencies throughout the process.An undefined method and documentation for birth notification with separate notification information.Inadequate integration of notification and registration procedures results in the lack of a centralized record of weighing cards.As a result, there are no effective means to validate an individual’s assertion that a weighing card provided as proof for late or delayed birth registration is authentic and correct.Illegal modification of weighing card data is neither traceable nor verifiable.As seen in the preceding Birth notification, as defined by Cobos Muoz et al. is the collection and subsequent transmission of critical information about the fact of birth or death by a designated agent or official of the CRVS system via a CRVS-authorized notification form (paper or electronic), with the information transmitted being sufficient to support eventual registration and certification of the vital event .Another key problem faced by the system is seen in According to the highlighted pain points throughout the registration process, the significant issue was the absence of a digital verification method for the registration system’s main stakeholders, namely the health care workers responsible for birth notification and the BDR Official. As a result, Family-The family will be responsible for notifying a health facility of the birth event and obtaining a notification certificate with a signature code instead of a weighing card as documentation of the event for birth registration purposes.Health Facility-Certified Health Practitioners will be responsible for completing an online notification form and issuing notification certificates that include all pertinent information about the birth event. Unlike the previous procedure, digital records of the notice will be stored on a central server (GHS node) that acts as a node on a blockchain network.Registration Office—In addition to a valid notification certificate (instead of a weighing card), birth registration will need an affidavit (when necessary). The notification data and signature code are entered, which results in automated verification of the data and timestamp, while background investigations are necessary to confirm the validity of an affidavit.The approach evaluates two distinct scenarios: at-home delivery and birth in a health centre. Due to the lack of health facilities nationally, several births occur at home and so go unrecognized. In such cases, families must get notification certificates from a health provider within the appropriate birth registration time .Families are required to attend a local registration centre and provide notification certificates as proof of birth in addition to completing a registration form (Form A). Occasionally, campaigns for birth registration require volunteers from the BDR to travel directly to people’s homes, particularly in remote regions, to register them.Local Registration Center and Health Facility- Currently, local registration centres are located in a variety of places, including certain health facilities. In contrast to the existing approach, the BDR will use the blockchain network to share a database among hospitals. This will enable the verification of notification certificates before registration to be automated.The suggested system is structured in such a way that it addresses the institution’s notification and sharing challenges. As depicted in A parent or informant must first seek registration at a local registration facility. A BDR official will be needed to access the site using their given ID/login credentials and complete a birth registration request form that requires just the event notification ID. The smart contract will be invoked in this situation to validate the record and timestamp. After approval, the record is updated to reflect the registration, and a birth certificate may be printed and stamped.When the HO fills a notification form, it is called to save the information on the blockchain network;This is executed when the LRO inputs the timestamp ID and clicks on verify. It is called to authenticate the timestamp ID on the blockchain network;To ensure that the contract executes smoothly, it divides the entire process into two states, corresponding to two events:The contract code snippet above will be executed whenever a registration or verification event is triggered from the front end. This is made possible via the Meta Mask chrome plugin, which links the front end and back end Ethereum networks and provides access to information through the web3.js API.To further address the shortcomings of the process, we present an approach that automatically generates a publicly verifiable, tamper-proof timestamp for each registration record. This code snippet initiates the off-chain database system to allow the information to be saved. Following this initiation, then call for the execution of the smart contract as the variables within the contract. As long as the time values for the creation of the notification form match, a notification of a Successful Registration Pops Up.To further assess the proposed model, a privacy analysis is carried out on the proposed architecture overview, and a comparative analysis is carried out with the traditional registration process.Participants in the public Blockchain are free to enter and leave, so the on-chain data are visible to everyone. The privacy of the data cannot be protected. For the model proposed in this paper, consortium Blockchain can be used to authenticate all the participants, and the encryption function of the storage contract and the decryption function of the reading contract can be used to protect the data privacy stored in Blockchain. The multichain structure can protect the privacy of the data. At the same time, no one can view others’ data without permission.Based on the Novel BNVM, the proposed architecture used to ensure the privacy of patients or applicants and verification of notification records can strengthen the trust between the GBDR and GHS and reduce the running costs of registration and maintain the security of the whole system. It has the following advantages in terms of privacy and security.Good fault tolerance. The decentralized system does not depend on a single service node and can effectively solve the single-point failure. Multiple service nodes depend on each other to reduce the possibility of errors. Decentralized, autonomous, and distributed nature will bring spontaneous innovation and new ways to coexist with efficiency.Attack protection. The centralized system is easily attacked by a third party or becomes an attacker, while the decentralized system has no centralization. If malicious nodes attack all nodes on the whole system, they will pay a high cost, so the possibility of evil is very low.It was preventing monopoly. Compared with the centralized system, it is difficult to use the information asymmetry to collude with each other in the decentralized system. A decentralized system allows all nodes to participate in the decision-making, ensuring the system’s security and transparency. At the same time, it also can audit malicious behaviours.They are improving the trust between participants. The decentralized system has no unified third party, so all participants do not have to bear the risk caused by trusting the third party. The system can automatically facilitate cooperation between the two parties.The proposed architecture combining blockchain and smart contract technology is different from the current system. In light of the blockchain solution deployment lifecycle proposed by , this stAs introduced in The deployment of smart contract is the key to gurantee the data security and privacy. Core requirements for deployment will involve considerations for technologies like cloud computing as demonstrated by ,34. The This research provides additional evidence of the applicability of a smart contract architecture that combines an Ethereum-based blockchain platform with a centralized database design . It provA large and growing body of literature has investigated the broad application of blockchain technology to solve different private and e-government challenges of reliability and traceability of data to ensure security ,6,18,26.The findings and proposals from this study suggests several courses of action for practitioners. Government database architectures can now move closer to implementing a blockchain based system by offering a safe verification framework for the Ghana Birth and Death Registry based on smart contract technology. Additionally, by connecting civil registration with other government systems like identification and health, it will be possible to improve CRVS quickly and facilitate interoperability across all industries.The limitations of this research are inherent in its scope. The goal of this study is to optimise Ghana’s civil registry’s birth registration process. Although the proposed blockchain approach addresses the process’s current pain points and difficulties, the study’s depth is constrained. For instance, the data sources are restricted to published empirical research. An empirical inquiry could be conducted to affirm the validity of the processes discovered. Additionally, research on technical and legal subjects is not included in this study. These issues are left out of scope due to the author’s insufficient knowledge of them. As is the case with all emerging technologies, the majority of research on blockchain technology is focused on designing frameworks.Future researchers could repeat this study by assessing the applicability of the framework in international settings. As the first study to concentrate on civil registry optimization using a blockchain framework, more study is required to test the concept using an application. Additionally, investigations into the legal and technical aspects of implementations could be conducted.


Navigating a health system which differs considerably from one’s own can be a challenging process. Navigating this in seeking maternal health care can be additionally daunting. This article explores how immigrant women from diverse countries and ethnic backgrounds experienced and navigated the Norwegian maternal health service during pregnancy and childbirth.Eleven semi-structured interviews collected between 2019 to 2020 and analysed thematically informed this analysis.Principles of universalism underpinning all social and health policy in Norway, expect equality of service provision and access. These principles result in less individual choice. The women in this study found these contrary to their expectations of care but responded differently, with some experiencing the health provision as liberating while others distrusted that they were receiving the best care. A focus of concern was the expectation of more medicalized services. While some of these women used their own resources to circumvent the Norwegian health provisions, the implications for the health system extend beyond these women’s experiences.The analysis suggests a need to encourage those whose expectations of care differ to build trust in institutions providing care. This article contributes to knowledge on the implications of diversity on Norway’s universal health system. This article explores the experiences of immigrant women from diverse cultural backgrounds with the Norwegian maternity health care during their pregnancies and births. The women immigrated to Norway for various reasons from countries including China, Germany, Indonesia, India, Israel, Iran, and Serbia. In the interests of ensuring promised anonymity, no further details about the background of the participants are provided.When mothers encounter a new maternity care system that is culturally and organizationally different from what they are used to, it may affect their interaction with the health professionals and result in undesirable experiences  or hospital. Maternal health care in Norway is offered at two organizational and professional levels; “specialized doctors at hospitals and general practitioners in municipalities perform maternity care services in cooperation with midwives on both care levels”  in this study refers to the health services provided to a woman during pregnancy and childbirth by a doctor, midwife, and/or nurse at a community health centre , purposive sampling was used to recruit eleven immigrant women. The interviewees were recruited from public kindergartens and community health centres in two Norwegian municipalities with a high population of people with immigrant backgrounds.The eventual sample comprised women from nine different ethnic and cultural backgrounds who had carried out their pregnancy and birth in Norway. The women had different reasons for immigration to Norway, length of residence in Norway, education level, and language proficiency in Norwegian and English. All interviewees were university educated and communicative in English despite being from different countries. This sample is therefore not representative of the most vulnerable population of immigrant women in Norway.Once written and verbal consent to participate were obtained from the immigrant mothers, semi-structured interviews were conducted by the first author between October 2019 and March 2020, in person, by telephone, and online via Skype. The in-person interviews were conducted at the place of the interviewee’s liking, which was mostly in public kindergartens with their attending children, in their homes, or in cafes. The interviews ranged from thirty minutes to two hours in length and were carried out in three languages—nine in English and two in the participants’ own languages, Farsi and Kurdish, in which the first author is fully proficient. Biographic details were collected before the immigrant women were asked to recount their experiences of navigating and negotiating the NMHS during their pregnancies and births. Despite their diversity, there was a notable commonality in their experiences.Participants were recruited by contingent purposive sampling Hood, , wherebyThe interviews were audio-recorded and transcribed verbatim by the first author. To protect the participants’ confidentiality, all were given pseudonyms, and identifying details were anonymized after transcription. The data were analysed using thematic analysis , Zara went to a private clinic in Norway and paid for the scan at 8 weeks. She continued:I had very heavy vomiting, so I consulted the doctor and asked for tablets, but here they said no tablets … so I got the medicine from my sister in-law in India to subside the vomiting. That was helpful.Zara from India explained how she handled uncertainty during pregnancy. She consulted her sister-in-law, who is a doctor in India, and stated that “This mother’s experience illustrates her proactivity in bridging the gap between her expectations of maternal health care, which was not only shaped but continually influenced by medical practice and advice from her social network in her home country.Birth was described as a challenging event by all the mothers. The two main contributing issues were linked to the degree of medical intervention and communication with health care professionals. These are presented in order. Excerpts from the interviews illustrate how discrepancies between the women’s ideal birth plans and the standard Norwegian birth approach were managed.The degree of birth medicalization in the NMHS posed dilemmas for some mothers in their birth plans. Many of the participants came from cultures where they described birth by C-section as a more common elective option in private health care settings compared to Norway. Although some of the mothers expressed a desire for more medical intervention during their pregnancy and labour, some acknowledged a developing confidence in the Norwegian system. Consultations with midwives contributed to their acceptance about their body’s capability in the birth process.see monitors and wires” to put her mind “at ease”. But she formed a trusting relationship with her midwife, who gained her confidence in the NMHS and encouraged her to consider a natural birth.I had researched caesarean birth, but I can say that it was my [Middle Eastern] midwife’s reassurance about my ability to give birth naturally because I had wide hips etcetera, that convinced me to go through with it. So that’s why I decided to forget about caesarean. Of course, this was against my mom’s advice, because she believed that I was physically too weak to push a baby out - and she was right, I have never been athletic or strong - but because research has shown that natural birth is better for the baby and the mom, I decided to accept the risk and do it.Melika from Iran illustrates this growing confidence. At first, she wanted a highly medicalized birth, stating it was important for her to be able to “I have prepared myself for natural birth and will only do an operation if I can’t handle it. The hospital contacted me to ask what I wanted to do, and I explained that I wanted to go through with natural birth and only have a caesarean birth if there were complications.When her birth was delayed, she was told that baby’s head had grown too big and that natural birth may be too difficult, but she insisted on going through with it, saying:Melika perceived pregnancy and birth as a risky period that needed constant monitoring. Consequently, she thought of technology as a safe and reassuring way of handling risk during childbirth, which would give her a sense of security. Her shift in mindset was facilitated by trust in her health care provider who had a similar cultural background as her but was working in the NMHS, as well as her own research into the topic.they have experience with all sorts of complications during natural birth, and so they are confident that even if the baby is breech, they will do a better and safer job birthing the baby rather than doing a C-section. So, their confidence is quite high in this regard”. Her perceptions of the NMHS were influenced by her friends’ negative experiences with complicated births in Norway. Parisa would have liked the opportunity to choose her birth plan rather than be convinced to trust the natural birth process. Parisa interpreted the Norwegian model as less medicalized and as such more prone to risk, yet was convinced that because of the emphasis on this more natural approach, care providers would be more skilled in managing complications than performing a more medical birth. Hence, she compromised her wish for a medicalized birth with more trust in the capability of professionals.Another mother, Parisa from Iran, also faced conflicting expectations between having a heavily medicalized birth and encouragement to have a natural birth. She felt pressured by the standardized Norwegian approach to birth, and doubted her ability to give birth naturally, while the emphasis on a natural birth in this system made her doubt its competency in performing caesareans and managing complicated births. Her pregnancy experience caused alarm as there was the possibility of a breech birth, which at the end did not occur. This enabled her to regain some confidence in the NMHS, stating: “Communication rather than language, played an important role in shaping the women’s experiences during labour and birth. Several of the mothers experienced poor communication from their health care providers.I wanted to keep the baby inside. They [maternal health care providers] had something else in their mind … I didn’t know they were preparing me to give birth for two days until I was transferred to give birth … I even let my husband leave the hospital not knowing I was going to be induced soon. He didn’t know what was happening either, even though he is Norwegian.‘Where [are] you take[ing] me? Where is the doctor?’ That’s what I was saying to the nurses. ‘Don’t worry … you just need to relax’ [the nurses said] … They didn’t tell me that I was going to give birth we didn’t know what was happening … Oh, now I’m emotional … that was hard.Natasha from Israel had a difficult pregnancy and gave birth prematurely. When she went to the hospital, she was given medication to stop the labour; however, this was ineffective. She went into labour at 24 weeks, which is considered an extreme preterm birth that would require lifesaving support (Syltern et al., Implicit in this Israeli mother’s description of the birth is the lack of meaningful communication. She felt that she was not informed about decisions that were made about her and that she was treated as a passive participant. What is experienced as inadequate communication here is possibly related to the perceived locus of expertise, which resides with the medical practitioners, not the mother, father, or other patients. This is a consequence of increased medicalization of the pregnancy and birth process. This experience contrasts with the perceived under-medicalization of the NMHS by the other interviewees.it’s a nice idea to think you have one person who follows you before the pregnancy, is there for your birth and follows you after”. She assumed that the communication between the woman giving birth and midwives would be better if they had already established a relation before the birth, as had Melika, the Iranian mother, and that the midwife at birth would be better acquainted with the patient. In Norway, several different midwives may be involved during a woman’s pregnancy and birth. One of Shania’s aims for her labour was to manage without epidural pain relief. She found that because she had not asked for it at the beginning of her labour, it was not provided to her when she eventually asked for it. She reflects: “I would advise any future women giving birth in Norway who are apprehensive, if they want an epidural, they better ask for it right away!” She identified part of the issue as the poor interaction and communication between her and the changing midwives during her labour about the labour process.Shania from Canada also experienced challenges with communication during labour. She was surprised that she would not have one constant midwife who would follow her throughout pregnancy and birth, as was common in her country. She said, “The women’s narratives raise several issues. The expectations the women had of their interactions with the professionals and the provisions of the health services were largely influenced by their knowledge of the systems and practices in their home countries. The interviewees in this study came from different countries and had diverse cultural backgrounds. They brought with them knowledge and ideal expectations of the types of care they wanted to receive during maternity which were shaped by their backgrounds and sociocultural positions. All the women had little knowledge of the NMHS. They were also coming into a system shaped by the principles of universalism which differed considerably from the guiding principles for the provision of health care in their own countries. For some women, having additional resources such as material wealth as well as professional and family networks that could be marshalled made a difference to their experiences. These were used to either enhance or bypass the Norwegian provisions. Some of the women experienced significant tension related to their expectations of highly medically supported or directed pregnancies and births. While the medical profession is central to maternity care in Norway, it is also expected that birth should be as natural as possible. The idea of pregnancy and birth as carrying unacceptable risk without medical intervention was paramount for some women who sought certainty and control. For some, this influenced the extent of their satisfaction with the Norwegian health system. Therefore, how these women experienced the Norwegian maternity care varied. While some were able to compensate for the discrepancies between what they perceived to be on offer of the NMHS and their expectations of maternity care, others had to adapt. The differences in the Norwegian approach to maternity care subsequently caused positive responses as well as anxiety, frustrations, and even changes in these women’s perceptions of maternity care. These experiences are analysed as consequences of medicalization, membership in and use of social networks, their participation in decision making and what implications these have for Norwegian maternity care in its universalist model. These discussions are presented in order.th century, creating a shift from the home to the hospital (Riessman, Peter Conrad  defines Unlike the medical model, the midwifery model  consistently sees the needs of the mother and the fetus as being in harmony, the two as one “organic unit” and posits that both pregnancy and childbirth are “health and entirely normal condition[s]” (Simonds et al., as cited in Brubaker & Dillaway, In this study, some participants such as Parisa expressed the push towards the more natural and midwifery-oriented model of birth in Norway as disconcerting. There is evidently a tension between the medical and more natural model of birth which has been debated among researchers in this field.This model of maternity care is “woman centered and holistic” (Brubaker & Dillaway, Additionally, the participants expected more frequent surveillance to control for and perhaps respond to possible abnormalities in the foetus early in the pregnancy, as the Chinese and the Indian mothers pointed out. Cindy compared the limited antenatal care in Norway to the rigorous one in China, emphasizing that detecting abnormalities during pregnancy was a priority in China because of the serious implications it would have for the family in the absence of state support. The German mother, who had experienced several miscarriages in Norway, was particularly dissatisfied with the quality of maternity care in Norway, and care she received in Germany reinforced her view that the NMHS was not only under-medicalized, but also outdated. The medicalization of maternity care is therefore a wider reflection of the state and its policies on family and health care. As such, the medicalization of pregnancy and birth varies across different maternity care models. For example, “whilst the UK and USA are highly medicalized, Scandinavian countries and the Netherlands are less so, and there, where birth is seen as a normal physiological process, rates of clinical interventions such as Caesarean sections are significantly lower” (Nettleton, The data show that the interviewees’ social networks might have contributed to how they encountered the NMHS. They had friends who informed them about what to expect from the NMHS, which can be considered system knowledge, an important type of knowledge for navigating the health care system (Willis et al., Another example of assumed system knowledge evident in the data was linked to a midwife who acted as a cultural bridge builder Næss,  in acquaOther women had transnational ties that helped them compensate for the differences they encountered in the medicalization of antenatal care. This, we argue, is a form of transnational system knowledge used for bridging perceived gaps in a new medical model. One of the interviewees, for example, had a sister-in-law who was a physician in India who told her to get an earlier ultrasound and sent her medications the interviewee could not obtain from her Norwegian physician.System knowledge as a concept is important in the immigration setting because immigrants must transfer, adapt, and sometime relearn this knowledge when encountering a new health care system. Social and cultural capital, such as networks, education, and communication skills, are therefore important assets in the transitioning of system knowledge which can enable the navigation and even the negotiation of a new health care system. The central point is that the interviewees’ social networks, their social capital, and experiences contributed to how they applied system knowledge to navigating and negotiating the NMHS; hence shaping how they experienced and interpreted it.Research shows that the relationship between health care provider and patient plays an important part in generating satisfaction with childbirth (Benyamini et al., The Israeli mother who had a premature birth felt that she had no opportunity to participate actively in decisions around her labour, and she experienced the event as disempowering. What she experienced could be considered as a form of over-medicalization over which she had no control. She was not involved in what, for her, was a critical life event. Although the acuteness of her condition may have led the health care professionals to prioritize intervention over communication, she felt that her involvement in decisions made about her body and her infant was necessary.A common experience for most interviewees in this study was their expectation of a more medicalized service than the NMHS offered. For some of the women, their desires for more medical intervention led them to partially deviate from the universally provided services, seeking services outside the NMHS through private health institutions in Norway or abroad, including from their home countries. The women who were able to seek services outside the NMHS were those with financial resources as well as connections and knowledge about alternative services. Similar to Benyamini et al. , we founThe medicalization of childbirth and pregnancy, however, is one of degree. The Norwegian system has, as much of the western world, embraced a medical framework for the management of pregnancy and birth, albeit not to the degree some of the women desired. This is because a more natural approach to maternity care with fewer unnecessary medical interventions has been emphasized in Norway since the 1970s midwifery reforms, both for better birth outcomes and more positive birth experiences (Dahlberg et al., As pointed out by Rothstein , a univeSome of the interviewees were satisfied with the system and some changed how they perceived it. The Middle Eastern midwife could be interpreted as an agent for the universalism of the Norwegian welfare state by working as a street-level bureaucrat Lipsky,  to make Expectations and demands differ, and they differ with situations. They may be related to culture, social class, social networks, knowledge, and personal experiences. While these women do not represent any group, ethnicity, or culture other than their own, the Norwegian maternity care model differed from their expectations. Some had generally positive experiences, whilst for others, their experiences fell short of their expectations. Although this study was influenced by limitations such as access, time, and language, the findings of this study contribute to understanding the implications of universal maternal health care through the perspective of immigrant service users. This article underscores the issues of diversity and choice within a universal system, contributing to a larger ongoing discussion on universalism in the Nordic welfare system.


Available data on fetal and neonatal neurodevelopment, in particular with reference to retinal light-responsive pathways, will be examined together with the GABA functional switch, and the subplate disappearance, which, at an experimental level, differentiate the neonatal brain from the fetal brain. In this study, we assume how a very rapid activation of retinal photoreceptors at birth initiates a sudden brain shift from the prenatal pattern of functions to the neonatal setup. Our assumption implies the presence of a photoreceptor capable of capturing and transducing light/photon stimulus, transforming it into an effective signal for the activation of new brain functions at birth. Opsin photoreception or, more specifically, melanopsin-dependent photoreception, which is provided by intrinsically photosensitive retinal ganglion cells (ipRGCs), is considered as a valid candidate. Although what is assumed herein cannot be verified in humans based on knowledge available so far, proposing an important and novel function can trigger a broad range of diversified research in different domains, from neurophysiology to neurology and psychiatry.Developmental neuroscience research has not yet fully unveiled the dynamics involved in human birth. The trigger of the first breath, often assumed to be the marker of human life, has not been characterized nor has the process entailing brain modification and activation at birth been clarified yet. To date, few researchers only have investigated the impact of the extrauterine environment, with its strong stimuli, on birth. This ‘hypothesis and theory' article assumes the role of a specific stimulus activating the central nervous system (CNS) at human birth. This stimulus must have specific features though, such as novelty, efficacy, ubiquity, and immediacy. We propose light as a robust candidate for the CNS activation  For instance, the capability to react to external stimuli characterizes humans as it is essential for viability of both preterm and full-term newborns , there must be a common mechanism in place that is at the basis of the beginning of breathing. In order for the first breath to take place, the diaphragm should contract and flatten and the chest cavity enlarge . This coMoreover, central respiratory networks in the brainstem quickly lose their inhibitory function and begin to generate continuous, rather than intermittent, breathing movements  but overlapping spectral responses. In humans, the visible light spectrum has a wavelength ranging from ~400 to 700 nm  are the only retinal output neurons. They receive processed rod/cone input through the retinal circuitry and send this visual information to image-forming brain targets, such as the dorsal lateral geniculate nucleus (dLGN) and superior colliculus (SC), and finally to the primary visual cortex Masland, .However, sight is not the only function of the retina. In addition to standard visual functions, characterized by elevated spatial and temporal contrast acuity, the retina encodes environmental irradiance  to regulate several aspects of our physiology, such as circadian rhythms, pupillary light reflex (PLR), hormone synthesis, and behavioral responses  is more ancient in terms of evolution than rod/cone opsins  responses to light, ‘intrinsically' photosensitive RGCs are called this way because they are capable of responding to light even in the absence of any synaptic input from other retinal neurons  of the hypothalamus  has been identified at 36 weeks of gestation (GW). In addition, results, which have been extrapolated from a primate model (baboon), show that RHT may be functional from 24 GW onward. These results also show that the fetal SCN oscillates prenatally, in the last trimester of pregnancy  , this retinal pathway is formed, thus, it is capable of conveying light signals to the brain with a very broad range of projections. Hence, in humans, in response to light at birth, ipRGCs can determine extraordinary fast signaling to the whole brain.All these data show that, in all mammals, at birth, the retina is light-responsive The subplate (SP) zone is a highly dynamic and transient cytoarchitectonic compartment of the fetal telencephalic wall . SATs correspond to the intermittent delta-frequency activity observed in conventional EEG recordings, in both fetuses and preterm newborns  linked to labor and birth. These ‘back and forth' functional changes indicate the presence of a sudden rearrangement of neurotransmitters' patterns at birth. GABA can play a fundamental role in the modulation of the brain response to bombardment by external stimuli at birth, including stimulations of the retina.Alterations in the polarity of GABA activity have been extensively investigated, as GABA is developmentally regulated and highly susceptible to insults that restore immature excitatory actions. Several crucial events begin before birth, such as the oxytocin-mediated GABA shift. In experimental models, intrinsic alterations in activity and morphology have been shown to occur during delivery , functioning as neuronal markers, have been described in studies on experimental models in mammals. In particular, a dramatic photo-dependent induction of IEG In humans, studies on brain functions are not easy to be performed as they can be invasive and unfeasible, particularly so on pregnant women, fetuses, and newborns. On the other hand, human neurodevelopment has unique and specific features that are associated with extraordinary mental capabilities, including cognitive and affective abilities, which distinguish humans from other primates; hence, they cannot be inferred from animal model studies  nucleus, a pontine reflex blocking center, has been shown to reverse its function abruptly at birth, activating the pontine facial/parafacial complex, which, in turn, triggers the medullary pre-Bötzinger nucleus, thereby determining a ‘neurogenic drive' for the contraction of the diaphragm. This network activation might generate ‘the first and strongest respiratory effort', namely, the first breath  mainly perform functions that occur beyond conscious perception , e.g., they are part of the biological clock that governs the rhythm of life . MoreoveRecent studies show how ipRGCs can be active across a broad range of physiological light intensities including in darkness, i.e., at dim, scotopic light intensities, where a lower amount of photons is present , which are transmitted to the fetus during circadian periods. Instead, after birth, there is a progressive photic regulation of the circadian system outputs, with marked rhythms in sleep-wake phenomena and hormone secretion. This suggests that the human fetal SCN does not have access to the external environment's light-dark cycles  is robust as it is constantly ensured and actively maintained  for the publication of any identifiable images or data included in this article.DP and MLR contributed to the article and its layout to the same extent, searching for literature data, and writing the article. AM, MarF, FF, and PP discussed the background, read, and commented the whole article. MasF who passed away a few years ago, was the first scientist who in his books on Human Birth Theory, conceptualized that human beings' first breath is triggered by the activation of the brain following its reaction to light, formulated the assumption and the relevant theory, agreed on the layout of the article, and supervised all the work done on its first draft. All authors contributed to the article and approved the submitted version.This article was supported by the grant ord. prot. 43/2022 from the Ph.D. funds, Department of Neuroscience, Mental Health and Sensory Organs NESMOS, Sapienza University of Rome, Rome, Italy.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.


P < .001) and significantly shorter operation times when the cysts ruptured . Whereas there was no significant difference in operation time in the absence of cyst rupture between 2 groups . In patients with cyst rupture, according to the cyst size increase, the operation time was significantly prolonged without-endobag, whereas no significant prolongation was observed in within-endobag cystectomy. Except for operation time, there were no significant differences in cyst length, pain on the first day after surgery, hemoglobin loss, hospital stay, and inflammatory markers (C-reactive protein and white blood cell counts) in both ruptured and unruptured cases between the 2 groups. There were no postoperative complications in the within-endobag group, but 2 cases of perioperative complications occurred in the without-endobag group. No chemical peritonitis due to spillage of the cyst contents was observed in either group. Laparoscopic ovarian cystectomy performed within-endobag can reduce both the spillage rate of cyst contents and operation time regardless of cyst size in patients with ruptured cysts. Therefore, this technique is a good surgical option for the laparoscopic ovarian cystectomy of large dermoid ovarian cysts.This study aimed to evaluate the effect of within-endobag cystectomy during and after laparoscopic ovarian cystectomy in patients with dermoid cysts. We retrospectively analyzed 84 patients with ovarian dermoid cysts who underwent laparoscopic ovarian cystectomy. In 30 patients, the affected ovary was placed in an endobag before cystectomy and cystectomy was performed within an endobag (within-endobag group), while the remaining 54 patients underwent standard cystectomy without this step (without-endobag group). After cystectomy, the cyst wall was placed in an endobag and was removed from the abdomen. Compared with the without-endobag group, the within-endobag group had a significantly lower rate of cyst content spillage (23.3% vs 72.2%,  Laparoscopic ovarian cystectomy is preferred over traditional laparotomy because of less postoperative pain, less adhesion, lower infection rates, and shorter duration of hospital stay.,3 However, despite the advantages of laparoscopic surgery, concerns remain about inadvertent cyst rupture and the resulting spillage of the cyst contents. The release of sebaceous fluid with hair, fat, bone, cartilage, and blood may be related to postoperative chemical peritonitis, pelvic adhesions, infertility, and cyst recurrence.,4Ovarian dermoid cysts are one of the most common benign ovarian neoplasms in women of reproductive age. Although this technique is now considered an essential method in ovarian cyst surgery, it is not a preventative method to reduce spillage of cyst contents that may occur during cystectomy itself. Therefore, to minimize spillage during cystectomy, a surgical technique within the bag has been introduced.–8 However, most studies have used an endoscopic retrieval bag to minimize the risk of intraoperative spillage of the ovarian cyst content during removal of the cyst wall from the abdominal cavity.,8–10 In this study, we evaluated the effects of within-endobag cystectomy that performing the entire cystectomy procedure within an endobag by comparing the surgical and postoperative clinical data with those of a group of patients with ovarian dermoid cysts who did not use an endobag during cystectomy.The use of an endobag to remove the ovarian cyst wall from the abdominal cavity after laparoscopic cystectomy seems to be effective in decreasing the chance of spillage of cyst contents during cyst wall extraction.We retrospectively analyzed 84 patients with ovarian dermoid cysts who underwent laparoscopic ovarian cystectomy between July 2017 and October 2021 at the Department of Obstetrics and Gynecology of Kyungpook National University Hospital, Daegu, Korea. The diagnosis of ovarian dermoid cysts was established preoperatively by pelvic examination, ultrasonography, or computed tomography and was confirmed histologically. Patients were excluded if they had a history of intraabdominal surgery, evidence of malignancy, or a combination of other ovarian tumors. The institutional review board of Kyungpook National University Hospital approved the study and waived the requirement of obtaining informed consent owing to the study retrospective design . All procedures were performed in accordance with the latest version of the declaration of Helsinki.All the patients underwent laparoscopic ovarian cystectomy. A multichannel, single-port trocar was inserted through the umbilicus. One or 2 ancillary trocars were inserted in the lower quadrant of the abdomen depending on the cyst size. Initially, the pelvis and abdomen were examined to assess adhesion or the risk of malignancy. Patients who underwent cystectomy within an endobag comprised the within-endobag group (N = 30). In this group, before starting cystectomy, an endobag was inserted through the umbilical port and the memory wire of the endobag was removed. The affected ovary was placed and fully wrapped in an endobag Fig. a, and cyOperative time was defined as the time from immediately after inspection of the abdomen through removal of the ovarian cyst wall from the abdominal cavity to the end of suction and irrigation. The cyst length was defined as the maximum diameter of the cyst on ultrasonographic examination. Hemoglobin loss was defined as the difference in hemoglobin levels before surgery and on the first day after surgery. C-reactive protein (CRP) and white blood cell counts (WBCs) were examined as acute inflammatory markers. Differences in CRP levels and WBCs were defined as the differences in CRP levels and WBCs before surgery and on the first day after surgery. The pain score on the first day after surgery was measured using a visual analog scale.P < .05. Student t test was used to examine the differences in numerical variables. Categorical variables were described as percentages and compared using the Pearson chi-square or Fisher exact test, as appropriate.Statistical analyses, including logistic regression analysis, were performed using a commercial software package . Statistical significance was set at P = .454). However, compared with the without-endobag group, the within-endobag group had significantly less spillage of cyst contents  and significantly shorter operation times for cystectomy . Neither group experienced intraoperative complications or chemical peritonitis, whereas only the within-endobag group experienced no postoperative complications. The without-endobag group had 1 case of paralytic ileus and 1 case of rehospitalization due to abdominal pain   , whereas in without-endobag group, the operation time was significantly prolonged as the size increased (R2 = 0.221) (P < .001) , the within-endobag group had significantly shorter operation times than the without-endobag group (23.4 ± 8.6 minutes vs 51.2 ± 28.6 minutes; We evaluated the effects of within-endobag cystectomy which is performing the entire cystectomy procedure within an endobag during the laparoscopic ovarian dermoid cystectomy. In this study, it was confirmed that within-endobag cystectomy can reduce both the spillage rate of cyst contents and operation time regardless of cyst size in patients with ruptured cysts.–12 The incidence of chemical peritonitis after rupture or leakage of cystic teratomas is < 0.5%. Surgical techniques such as the use of endobag or purse-string suture have been introduced to prevent complications associated with leakage of cyst contents.–8,14 In cases of cyst rupture, jet-wash irrigation with large amounts of fluid and removal of tiny particles of cyst contents is considered the gold standard procedure to avoid complications, but it has the disadvantage of requiring a long time.,16 Despite the rare incidence of short-and long-term outcomes associated with intraoperative spillage, surgeons should make efforts to prevent intraperitoneal spillages. Therefore, there is a need for a method to avoid spillage and reduce operation time had been raised. In the within-endobag procedure described in this study, the entire affected ovary was placed in the endobag before performing cystectomy. An endobag was inserted through the umbilicus and the memory wire of the endobag was removed. This step allows the endobag to sufficiently envelop the ovary and reduce the collision between the instrument and endobag inserter during cystectomy. To minimize leakage, an endobag of sufficient size was used to contain the ovaries completely. The Trendelenburg position used in laparoscopy increases the likelihood that the cyst contents will enter the upper abdominal cavity, so the entrance of the endobag was raised sufficiently towards the inlet of the pelvis to allow the contents to flow towards the cul-de-sac. The bottom of the endobag was directed to the cul-de-sac and then spread out sufficiently to allow the cyst contents to descend into the cul-de-sac during cyst rupture.Laparoscopic surgery has been widely used for the treatment of benign ovarian tumors because of the many advantages of a minimally invasive approach; however, it can also cause complications such as chemical peritonitis or spread of infection related to the spillage of cyst contents during surgery.In this study, patients who underwent within-endobag cystectomy had significantly reduced spillage rates and operation times compared with those who underwent without-endobag cystectomy. Although patients in the without-endobag group experienced no increase in complication rates or acute inflammatory marker levels when cyst contents entered the abdominal cavity, they required more time for aspiration and irrigation to remove the cyst contents. Moreover, while the operation time did not differ as cyst size increased in the within-endobag group, we observed significantly increased operation times as cyst size increased in the without-endobag group. This probably reflects the increased amount of cyst contents flowing into the abdominal cavity when not using an endobag, with removal of the cyst contents often requiring more time than the cystectomy itself. When cyst rupture occurred during the within-endobag procedure, less time was required to remove the cyst contents from the abdominal cavity, allowing for significantly shorter operation times.Despite observing no significant differences in rupture rates by endobag use, we found that the spillage rate was significantly lower in the within-endobag group than in the without-endobag group. When performing cystectomy without an endobag, spillage into the abdominal cavity occurs as an inevitable consequence of cyst rupture, whereas within-endobag cystectomy can prevent or reduce spillage. Although our sample size was small, there were no reported cases of chemical peritonitis, and it was confirmed that our method reduced the spillage rate and operation time. Our study has some limitations. First, this was not a prospective randomized clinical trial, the sample size was relatively small. Postoperative complications were found in only 2 cases in which the endobag was not used, so no statistical difference could be confirmed. Therefore, additional studies and randomized clinical trials are recommended to confirm the clinical outcomes of this technique. Second, the surgeries were not performed by the same surgeon. The surgeon skills were not the same, which could affect the operation time. Surgeons with less experienced in laparoscopic surgery may have difficulty performing this procedure at first, but they will get used to it after several times and this procedure is easier and less time consuming than removing spilled cyst contents.In conclusion, this study showed that within-endobag cystectomy can reduce both the spillage of cyst contents and the overall operation time during cystectomy, irrespective of cyst size, in patients with ruptured dermoid cysts. As the size of the cyst increased, the operation time of within-endobag group was within a certain range; therefore, it is considered a good surgical option for patients with large dermoid ovarian cysts.Conceptualization: Jisun Lee, Hyun Jung Lee.Data curation: Hee Jeong Kim, Yujin Heo, Hyun Jung Lee.Formal analysis: Hyun Jung Lee.Investigation: Hee Jeong Kim, Hyun Jung Lee.Methodology: Jisun Lee, Yujin Heo, Hyun Jung Lee.Project administration: Hyun Jung Lee.Software: Hee Jeong Kim.Supervision: Hyun Jung Lee.Visualization: Jisun Lee.Writing – original draft: Jisun Lee, Hyun Jung Lee.Writing – review & editing: Hee Jeong Kim, Yujin Heo, Hyun Jung Lee.


Odontogenic cysts (ODCs) originated from odontogenic epithelium are the most common cyst that may exhibit local destructive behavior. Radicular cysts (RCs) and developmental odontogenic keratocysts (OKCs) are the two most commonly encountered types in practice. Infection of necrotic teeth is responsible for the formation of RCs and progresses as apical lesions, whereas OKCs react with an inflammatory response to chronic irritation caused by necrotic teethThrough the years, there have been conflicting reports regarding the presence of microorganisms in odontogenic cysts. Some previous studies demonstrated that bacteria were not found in odontogenic cysts and did not normally penetrate into the lamina, showing no aerobe and anaerobe bacteria with microbiologically sterile cystic fluid ,3. HoweData used in the present study were collected at the Department of Oral Surgery, Shanghai Jiao Tong University. The study population consisted of systemically healthy patients having ODCs with jaw expansions, along with a history of infection and purulent cyst fluid. Only the expansive cysts were chosen because of the easiness in obtaining the cyst fluids. CT scans were used to evaluate the expansion size of the buccal and/or lingual bony corteces. The patients who were under antimicrobial therapy and were receiving antiviral or immunosuppressive therapies, and the patients with an obvious mucosal breach or portal entry for infection via the oral cavity were excluded from this study. The patients who had odontogenic cysts with a diameter of less than 1 cm in size  were also excluded from this study because of the inability to obtain adequate cyst fluid. A total of 35 patients were enrolled in the study. The study group consisted of males and females whose ages ranged from 10 to 55 years. The average age of all patients included in the study was 32.1±11.3 years; the average age of males was 33.6±11.9 years, and the average age of females was 29.5±10.8 years. The Ethical Committee permission was obtained prior to the commencement of the study.The clinical materials of 35 patients with cysts were obtained, cultured and then analyzed microbiologically. Out of the 35 enucleated lesions, 18 samples were OKCs, 11 of them were RCs,0 of them were DCs .TableThe species of bacteria in these odontogenic cysts were identified by 16S rRNA sequence analysis. The cyst fluids were isolated from odontogenic cysts, followed by strain identification using DNA-based techniques.http://www.ncbi.nlm.nih.gov/BLAST/). The 16S rRNA gene sequences of type strains and other strains closely related to our 28 isolates were obtained from the NCBI database.The PCR products of the 16S rRNA gene were eluted from an agarose gel using the Gene JET™ Extraction kit , and the purified PCR products were sequenced commercially by Sangon Biotech . The sequence data were assembled and analyzed using the Lasergene sequence analysis software package . Sequence similarity searches using the Basic Local Alignment Search Tool (BLAST) were performed by comparing the sequences obtained with other microbial sequences in the National Center for Biotechnology Information (NCBI) database . Additionally,Staphylococcus warner ,Streptococcus dentisani ,Streptococcus constellatus , andStreptococcus anginosus  were identified.In 29 (83%) of the studied specimens, five different types of microorganisms were isolated .PseudomPseudomonas positive cyst fluids were in the OKC group. The remaining material (35.3%) were in RCs. No bacteria were detected in 6 subjects . The status of isolated bacteria from the cultures are shown according to the properties of the cyst fluid . Immunohistochemistry (IHC) staining of histological sections confirmed the presence ofPseudomonas at the tissue level -positive cyst, includingStreptococcus constellatus andStreptococcus anginosus.There was a marked difference at the secretion levels of the proinflammatory markers among the groups . The prePseudomonas positive fluids than in bacterial negative fluids were observed. In addition,Pseudomonas positive cyst had about 2-fold increase in the makers over SMG positive cyst.In addition, BCl-2 and Ki-67 proteins, which are predictive indicators closely associated with cell proliferation, were analyzed in cyst fluids. There was a significant difference in the secretion levels of the proliferation markers among the groups . The preS.millerigroup positive sample/total bacteria positive samples=31.0%) were isolated from sample cultures. In addition,Pseudomonas were found to be higher (58.7%) in bacteria and were predominantly isolated from cultures.Pseudomonas are gram negative and facultative anaerobic branched bacteria that are difficult to grow in culture. The pathogenicPseudomonas are considered to be part of normal commensals of the human oral cavityPseudomonas bacteria were not isolated in previous studies. TNF-α and IL-1α are thought to play a role in bone remodeling, bone resorption, and new bone deposition. In this study, the expressions of TNF-α and IL-1α were determined. There are significant differences in the cytokine level among the cyst groups. ELISA results showed that IL-1α and TNF-α were high inPseudomonas-positive cyst fluids, suggesting that the proinflammatory response created by macrophages might be induced in response toPseudomonas bacteria.Furthermore, positive bacteria were determined in 83% of the specimens. SMG bacteria are important pathogenic microorganisms for infections and abscess of the orofacial region, according to literature survey. Here SMG (Pseudomonas positive cyst fluids. According to our results,Pseudomonas exacerbates the pathogenesis by increasing the productions of TNF-α, IL-1α, BCL-2 and Ki-67, suggesting that this facultative anaerobic bacterium may trigger the pathogenesis of cyst formation. However, further studies utilizing a larger sample size and more advanced tools are recommended, and furtherin vitro studies are also required to clarify the role of this bacterium and other cytokines in the pathogenesis of the ODCs.Cyst formation, like the development of neoplasms, involves a dysregulation of balance between cell proliferation and cell death


The composite APO rate was significantly higher in SGA with CPR <10th centile , while in VSGA with CPR <10th centile was not . The composite APO rate was non-significantly higher both in VSGA  and SGA  with mUtA-PI >95th centile. The ROC analysis showed a significantly predictive value of CPR for composite APO in SGA only . A low CPR was associated with composite APO in SGA fetuses. VSGA fetuses were more frequently affected by composite APO regardless of Doppler values. The predictive performance of CPR and uterine artery Doppler was poor.The aim of this study was to evaluate the association between cerebroplacental ratio (CPR), mean uterine artery (mUtA) Doppler and adverse perinatal outcome (APO) and their predictive performance in fetuses with birth weight (BW) <3rd centile  in comparison with fetuses with BW 3rd–10th centile . This was a retrospective cohort study including singleton pregnancies delivered at term (37 + 0–41 + 6) in a single tertiary referral center over a six-year period. APO was defined as a composite of cesarean section for intrapartum fetal compromise (IFC), umbilical artery pH < 7.20, and admission to the neonatal intensive care unit for >24 h. The characteristics of the study population according to BW (VSGA and SGA) as well as the presence of composite APO were assessed. The prognostic performance of CPR and mUtA-PI was evaluated using receiver operating characteristic (ROC) analysis. In total, 203 pregnancies were included. Of these, 55 (27%) had CPR <10th centile, 25 (12%) mUtA-PI >95th centile, 65 (32%) VSGA fetuses, and 93 (46%) composite APO. VSGA showed a non-significantly higher rate of composite APO in comparison to SGA (52% vs. 43%;  Fetuses with a birthweight (BW) <10th centile are classified as small for gestational age (SGA) ,3,4. MatVery small for gestational age (VSGA) fetuses with BW <3rd centile represent a particular subgroup showing a higher risk of APO ,14. DoppThis was retrospective cohort study performed at the University Hospital rechts der Isar in January 2012 and December 2017. The inclusion criteria were singleton pregnancies, cephalic presentation, mUtA-PI measurements from 32 + 0 weeks of gestation onwards, CPR measurements within one week of delivery, and delivery of an alive newborn between 37 + 0 and 41 + 6 weeks of gestation with a birth weight <10th centile. VSGA and SGA were defined as a BW <3rd centile and a BW in the 3rd–9th centile, respectively . FetusesGestational age (GA) was calculated based on measurements of the crown–rump length in the first trimester. Either a Voluson E8  or a Voluson E10  with 4- to 6-MHz curvilinear abdominal transducer was used. Fetal biometry was performed by measuring the biparietal diameter, head circumference, abdominal circumference, and femur length. The EFW and its centiles were calculated ,16. DoppComposite APO was defined as the occurrence of at least one of the following parameters: CS for intrapartum fetal compromise (IFC), umbilical artery pH < 7.20, or admission to the neonatal intensive care unit (NICU) for >24 h. IFC was defined as a persistent pathological CTG pattern or the combination of a pathological CTG pattern and a fetal scalp pH < 7.20. The CTG pattern was evaluated according to the International Federation of Gynecology and Obstetrics (FIGO) criteria . A pathoThe following parameters were obtained and analyzed: maternal age, body mass index (BMI), parity, ethnicity, nicotine use, pre-existing conditions, GA at ultrasound, amniotic fluid index, mUtA-PI, UA-PI, MCA-PI, CPR, CPR centiles ,21, indup-value < 0.05 was considered statistically significant. We used IBM SPSS Statistics for Windows, version 26  for analysis. Quantitative data were shown as median and interquartile range. Categorical data were presented as absolute and relative frequencies. Differences in the distributions of quantitative variables between groups were tested using the Mann–Whitney U test. Categorical data were compared between groups using Pearson’s chi-square test or Fisher’s exact test. All statistical tests were conducted two-sided and a Characteristics of the study population according to BW (VSGA/SGA) as well as the presence of composite APO were analyzed. Moreover, univariate logistic regression analyses stratified by BW (VSGA/SGA) were carried out using maternal characteristics  and ultrasound parameters  as independent variables with composite APO as a binary outcome. Statistically significant variables in the univariate analysis were considered in a multivariable logistic regression model. Finally, values of CPR and mUtA-PI, both alone and combined (multivariable logistic regression), for predicting composite APO were evaluated using receiver operating characteristics (ROC) analysis stratified by BW (VSGA/SGA).A total of 203 pregnancies were enrolled. Fourteen women had pre-existing conditions . In the whole study group, 55 (27%) fetuses showed a CPR <10th centile, 25 (12%) women had a mUtA-PI >95th centile, and 10 (5%) pregnancies showed a CPR <10th centile and a mUtA-PI >95th centile. Induction of labor was performed in 131 (65%) pregnancies  and the most frequent indications were premature rupture of membranes ≥12 h, SGA with normal CPR from 40 + 0 weeks onwards or with low CPR from 37 + 0 weeks onward, or VSGA from 37 + 0 weeks onwards. APO included 33 (16%) cases of CS for IFC, 48 (24%) newborns with umbilical artery pH < 7.20, and 29 (14%) newborns admitted to NICU >24 h (reasons were hypoglycemia (11/29), respiratory distress (9/29), hypothermia (4/29), infection (3/29) or hyperbilirubinemia (2/29)). Composite APO occurred in 93 (46%) cases. Overall, 65 (32%) newborns were VSGA and 138 (68%) SGA . There wRegarding perinatal outcome within the groups , VSGA prVSGA fetuses with a CPR <10th centile or mUtA-PI >95th centile or CPR <10th centile and mUtA-PI >95th centile showed a non-significantly higher rate of composite APO .SGA fetuses with a CPR <10th centile had a significantly higher rate of composite APO . In addiIn the VSGA group, univariate logistic regression identified a significant association between one variable (nulliparity) and composite APO . NullipaIn the SGA group, univariate logistic regression identified a significant association between three variables  and composite APO. However, multivariable logistic regression showed that only CPR <10th centile and male fetuses were independent predictors of composite APO ; they inIn the VSGA group, a ROC analysis revealed no relevant prognostic value of CPR or mUtA-PI for composite APO, but a significant prognostic value for nulliparity . The comIn the SGA group, the ROC analysis showed a significant prognostic value of CPR for composite APO, while for mUtA-PI or male fetal sex it did not . Both thThis study showed a significant association between CPR and the occurrence of composite APO in SGA fetuses. VSGA fetuses were more frequently affected by composite APO regardless of CPR value. Furthermore, uterine artery Doppler was not significantly associated with composite APO in either SGA and in VSGA fetuses. The prognostic value for composite APO of CPR and/or mUtA-PI was poor.In the last decade, the difference between fetal growth and fetal size has been highlighted. It is important to distinguish between constitutionally small fetuses and fetuses with signs of placental insufficiency, as the latter are often affected by APO such as IFC or stillbirth, whereas the former are not ,22,23,24We found that CPR values were not associated with composite APO in VSGA fetuses. This is in-line with recent data suggesting that at term EFW <3rd centile is a better APO predictor than low CPR or pathological uterine Doppler in growth restricted fetuses . FurtherIn our cohort, mUtA-PI was not significantly associated with composite APO, although there was a trend in the VSGA group. However, we acknowledge that the subgroup of pregnancies with pathological uterine Doppler was small. This result is controversial, as a recently published meta-analysis implicates a similar performance of uterine artery Doppler compared to CPR for the prediction of APO in late-onset SGA fetuses . In partOur findings showed that nulliparity was a significant predictor of APO in the VSGA cohort. An explanation for this finding might be the longer duration of the second stage of labor in nulliparous women, which is associated with APO . As VSGAOur study was limited by its retrospective design. Furthermore, our institution is a tertiary referral center which can lead to selection bias. Moreover, since ultrasound and Doppler examinations were performed by different operators, the internal validity may be limited. Finally, as we routinely recommend induction of labor ≥37 weeks gestation for FGR fetuses , but prolongation for SGA fetuses with normal Doppler parameters, this might distort the results of this study. However, this is a common problem affecting all studies investigating APO prediction in SGA cohorts.In conclusion, low CPR was associated with composite APO in SGA fetuses, but not in VSGA fetuses. VSGA is a condition that requires particularly careful monitoring regardless of the Doppler parameters. Further clinical research is warranted to clarify the role of cerebral blood flow redistribution and uterine artery Doppler in the prediction of APO as well as in the pathophysiology of the underlying placental insufficiency in VSGA fetuses.


To assess the association between newborn birth weight and the presence of intra-amniotic infection, presence of sterile intra-amniotic inflammation, and absence of intra-amniotic inflammation in pregnancies with preterm labor with intact membranes.A total of 69 pregnancies with preterm labor with intact membranes between gestational ages 22 + 0 and 34 + 6 weeks who delivered within seven days of admission were included in this retrospective cohort study. Transabdominal amniocentesis to determine the presence of microorganisms and/or their nucleic acids in amniotic fluid (through culturing and molecular biology methods) and intra-amniotic inflammation (according to amniotic fluid interleukin-6 concentrations) were performed as part of standard clinical management. The participants were further divided into three subgroups: intra-amniotic infection , sterile intra-amniotic inflammation , and without intra-amniotic inflammation. Birth weights of newborns were expressed as percentiles derived from the INTERGROWTH-21st standards for (i) estimated fetal weight and (ii) newborn birth weight.p = 0.06). Differences among the subgroups were identified in the birth weight rates, expressed as percentiles derived from the standard for estimated fetal weight, which were less than the 10th percentile  and 25th percentile . No differences among the subgroups were observed when percentiles of birth weight were derived from the birth weight standard.No difference in birth weights, expressed as percentiles derived from the standard for estimated fetal weight, was found among the women with intra-amniotic infection, with sterile intra-amniotic inflammation, and without intra-amniotic inflammation (with infection, median 29; with sterile inflammation, median 54; without inflammation, median 53; The presence of intra-amniotic inflammatory complications in pregnancies with preterm labor with intact membranes prior to the gestational age of 35 weeks was associated with a higher rate of newborns with birth weight less than the 10th and 25th percentile, when percentiles of birth weight were derived from the standard for estimated fetal weight. Preterm labor with intact membranes (PTL), a clinical phenotype of spontaneous preterm delivery, accounts for approximately one-third of all preterm deliveries –3. This Ureaplasma spp. in the cervix e cervix .Escherichia coli) decreased birth weight in a rat animal model  aal model ; (iv) elal model ; (v) sertriction ; and  was conducted with the following goals: (i) to assess the difference in birth weight, expressed as percentiles derived from standards for estimated fetal weight and newborn birth weight, between the subgroups of those with intra-amniotic infection, with sterile intra-amniotic inflammation, and without intra-amniotic inflammation; and (ii) to compare the rates of birth weights that are less than the 1st, 3rd, 10th, and 25th percentiles among the subgroups with intra-amniotic infection, with sterile intra-amniotic inflammation, and without intra-amniotic inflammation.This retrospective study included pregnant women admitted to the Department of Obstetrics and Gynecology of the University Hospital Hradec Kralove, Czech Republic, between March 2017 and November 2021, who met the following criteria: (i) age ≥18 years; (ii) singleton pregnancy; (iii) gestational age between 22 + 0 and 34 + 6 weeks; (iv) PTL with delivery within seven days of admission; and (v) underwent amniocentesis to assess microbial invasion of the amniotic cavity and intra-amniotic inflammation. The exclusion criteria were as follows: (i) pregnancy-related and other medical complications ; (ii) congenital or chromosomal fetal abnormalities; (iii) signs of fetal hypoxia at the time of admission; (iv) significant vaginal bleeding; and (v) preterm prelabor rupture of membranes.Gestational age was determined based on the first-trimester fetal biometry. PTL was defined as the presence of regular uterine contractions (at least two every 10 min) along with a cervical length <15 mm on transvaginal ultrasound or cervical length of 15–30 mm with a positive PartoSure test  . TransabStreptococcus agalactiae or did not have these results available received intravenous benzylpenicillin  during active labor.Women with PTL received an antenatal course of corticosteroids (betamethasone) and tocolytic therapy with either intravenous atosiban  or oral administration of nifedipine for 48 h. Women diagnosed with intra-amniotic inflammation received clarithromycin intravenously for seven days, unless delivery occurred earlier. Antibiotic treatment was eventually modified based on the results of microbial assessments of amniotic fluid. Women with PTL who were positive for the vaginal-rectal presence of The collection of clinical samples and information from women with PTL was approved by the Institutional Review Board Committee . Written informed consent was obtained from all women. All the women in the study were self-reported as Caucasians. Biological samples  from the women included in this study were used in our previous studies , 23.Ultrasonography-guided transabdominal amniocentesis was performed before administration of corticosteroids, antibiotics, or tocolytics. Details of amniotic fluid sampling have been previously described , 23.The concentration of interleukin (IL)-6 in amniotic fluid was assessed using an automated electrochemiluminescence immunoassay method with the immuno-analyzer Cobas e602  . The mea@C. trachomatis/Ureaplasma/M. hominis-FRT kit  was used to detect DNA from Ureaplasma species, M. hominis, and C. trachomatis in the amniotic fluid. The details of this specific PCR run in a single PCR tube have been previously described  and Statistical Package for Social Sciences (SPSS), version 28.0.0.0, for Windows .The demographic and clinical characteristics of the patients were compared using the non-parametric Kruskal-Wallis test for continuous variables and the chi-squared test for categorical variables, and the results are presented as median [interquartile range (IQR)] and number (%), respectively. The normality of the data was tested using the Anderson–Darling test. The percentiles of birth weight were not normally distributed; therefore, the non-parametric Jonckheere-Terpstra test was used for the analyses. The Cochran-Armitage test for trends was used to compare birth weight rates among subgroups. Spearman's partial correlation analysis was performed to adjust the results for a potential confounder (antibiotic administration). Differences were considered statistically significant at n = 17), ii) preeclampsia (n = 4), pregestational diabetes mellitus (n = 2), and gestational hypertension (n = 2). The remaining 69 women were included in the analysis.In total, 94 women with singleton pregnancies complicated by PTL who delivered within seven days of admission were eligible for the study. Twenty-five women were excluded for the following reasons: i) gestational diabetes mellitus (Ureaplasma spp. + Capnocytophaga ochracea + Fusobacterium nucleatum (n = 1), Lactobacillus spp. + Gardnerella vaginalis (n = 1), Ureaplasma spp. (n = 5), Streptococcus spp. (n = 1), Sneathia sanguinegens (n = 1), Lactococcus lactis (n = 1), Haemophilus influenzae (n = 1), Fusobacterium nucleatum (n = 1), Burkholderia cepacia (n = 1), and non-identifiable bacteria by sequencing (n = 2).Microbial invasion of the amniotic cavity and intra-amniotic inflammation were observed in 15 (22%) and 47 (68%) women, respectively. The microbial findings from the amniotic fluid were as follows: Intra-amniotic infection, sterile intra-amniotic inflammation, and absence of intra-amniotic inflammation were found in 15 (22%), 32 (46%), and 22 (32%) women, respectively. None of the women had microbial invasion of the amniotic cavity without intra-amniotic inflammation.The demographic and clinical characteristics of the study population with respect to the presence of intra-amniotic infection, presence of sterile intra-amniotic inflammation, and absence of intra-amniotic inflammation are shown in p = 0.06; p = 0.04 and 25th percentile: p = 0.01, p = 0.04; 25th percentile: p = 0.02).No differences were found among the subgroups of women with intra-amniotic infection, with sterile intra-amniotic inflammation, and without intra-amniotic inflammation in percentiles of newborn birth weight , 81% (26/32), and 100% (22/22) of newborns from pregnancies with intra-amniotic infection, with sterile intra-amniotic inflammation, and without intra-amniotic inflammation, respectively.p = 0.98; No differences among the subgroup of women with intra-amniotic infection, with sterile intra-amniotic inflammation, and without intra-amniotic inflammation were identified in percentiles of newborn birth weight  no difference in percentiles of birth weight, derived from estimated fetal weight standard, was found among the subgroups of women with intra-amniotic infection, with sterile intra-amniotic inflammation, and without intra-amniotic inflammation; (ii) differences in the rates of birth weight that were less than the 10th and 25th percentiles, derived from the standard for estimated fetal weight, were identified among the subgroups of women with intra-amniotic infection, with sterile intra-amniotic inflammation, and without intra-amniotic inflammation; and (iii) no differences among the subgroups were revealed when percentiles were derived from the standard for birth weight.Escherichia coli) at 20 days of gestation (the term is 22 days) led to a 20% and 22% decrease in birth and placental weights, respectively  might have affected fetal growth when compared to the presence of weak intra-amniotic inflammation  or the absence of these conditions. We do not want to overemphasize this observation; however, this hypothesis is further supported by the trend in the rates of newborns with a birth weight less than the 10th and 25th percentiles among the subgroups, with this trend being the highest in those with intra-amniotic infection, lower in those with sterile intra-amniotic inflammation, and the lowest in the absence of inflammation. The difference among the subgroups was revealed only in the cutoff values of the 10th percentile, which is commonly used by clinicians to identify fetuses and newborns with a diagnosis of small for gestational age , and theectively . Intra-aectively –36. In aectively .Since intra-amniotic infection is considered a cause of cervical insufficiency with prolapsed fetal membranes or PTL rather than a consequence, it is likely that the fetal and placental exposure to this complication might be a long-lasting process compared to preterm prelabor rupture of membranes (PPROM), where this intra-amniotic complication is more likely a consequence. Collectively, the observations from this study are in line with those of our previous studies , 21. TheIn this study, aside from the INTERGROWTH-21st standard for estimated fetal weight, the standard for newborn birth weight was also used to derive percentiles for birth weight. When this standard was applied, no differences in percentiles among the subgroups in the rates of birth weight less than the 1st, 3rd, 10th, and 25th percentiles were found. A similar phenomenon was observed in our previous studies , 21. We Ureaplasma spp., Mycoplasma hominis, and Chlamydia trachomatis; and (iii) PCR for the 16S rRNA gene followed by sequencing. The employment of such an extensive approach offered us the opportunity to divide the subset of women with intra-amniotic inflammation into those with intra-amniotic infection and those with sterile intra-amniotic inflammation. Second, there is strong evidence that the latency interval between admission and delivery in pregnancy with PTL depends on the presence or absence of intra-amniotic inflammation  aerobic and anaerobic cultivation; (ii) specific PCR for ammation , 8, 12. ammation , 8, 12. ammation , 40 or oHowever, this study had some limitations. First, the small cohort of women with PTL used in this study was limited. The monocentric design of the study prevented us from using a larger sample size. Second, the population of women used in this study was homogeneous, involving only Caucasian participants. This potential shortcoming prevents the results of the study from generalizing to populations with broader ethnic and racial disparities. Finally, data regarding ultrasonographically estimated fetal weight obtained at the time of admission were not available. Therefore, we could not compare the percentiles of ultrasonographically estimated fetal weight at the time of admission, derived from the standard for estimated fetal weight, among the subgroups.In conclusion, in this retrospective cohort study conducted on pregnancies with preterm labor and intact membranes prior to the gestational age of 35 weeks, the presence of intra-amniotic inflammatory complications was associated with a higher rate of newborns with birth weight less than the 10th and 25th percentile, when percentiles of birth weight were derived from the standard for estimated fetal weight.