However, the risk of common adverse outcomes related to labour, such as shoulder dystocia and post-partum haemorrhage for those delivering at this advanced gestation, remains poorly characterised. The objective of this study was to examine the risk of adverse, labour-related outcomes for women progressing to 42 weeks gestation or beyond, compared with those giving birth at 39 completed weeks.Post-term gestation beyond 41We performed a state-wide cohort study using routinely collected perinatal data in Australia. Comparing the two gestation cohorts, we examined the adjusted relative risk of clinically significant labour-related adverse outcomes, including macrosomia (≥ 4500 at birth), post-partum haemorrhage (≥1000 ml), shoulder dystocia, 3rd or 4th degree perineal tear and unplanned caesarean section. Parity, maternal age and mode of birth were adjusted for using logistic regression.The study cohort included 91,314 women who birthed at 39 completed weeks and 4317 at ≥42 completed weeks. Compared to 39 weeks gestation, those giving birth ≥42 weeks gestation had an adjusted relative risk (aRR) of 1.85 (95% CI 1.55–2.20) for post-partum haemorrhage following vaginal birth, 2.29 (95% CI 1.89–2.78) following instrumental birth and 1.44 (95% CI 1.17–1.78) following emergency caesarean section; 1.43 (95% CI 1.16–1.77) for shoulder dystocia (for non-macrosomic babies); and 1.22 (95% CI 1.03–1.45) for 3rd or 4th degree perineal tear . The adjusted relative risk of giving birth to a macrosomic baby was 10.19 (95% CI 8.26–12.57) among nulliparous women and 4.71 (95% CI 3.90–5.68) among multiparous women. The risk of unplanned caesarean section was 1.96 (95% CI 1.86–2.06) following any labour and 1.47 (95% CI 1.38–1.56) following induction of labour.Giving birth at ≥42 weeks gestation may be an under-recognised risk factor for several important, labour-related adverse outcomes. Clinicians should be aware that labour at this advanced gestation incurs a higher risk of adverse outcomes. In addition to known perinatal risks, the risk of obstetric complications should be considered in the counselling of women labouring at post-term gestation. The NICE guidelines in the UK state that induction of labour should be recommended to women with uncomplicated pregnancies between 41+0 and 42+0 weeks [Post-term gestation is defined as a pregnancy advancing beyond 41estation . As a co+0 weeks , the WHO+0 weeks , in line+0 weeks  and the +6 weeks of pregnancy without labouring [The US-based ARRIVE trial, published in 2018, randomised 6000 low-risk nulliparous women to induction of labour or expectant management at 39 weeks gestation. This landmark trial demonstrated a reduced risk of caesarean section and severe perinatal complications following elective induction of labour in low-risk women at 39 weeks and thus provided reassurance to many women and clinicians about the safety of elective delivery at this gestation . Many wo+0–43+6) with those who gave birth at 39 completed weeks (39+0–39+6). The aim of this study was to determine labour-related risks of progressing to 42 weeks of pregnancy or beyond, compared with those giving birth at 39 completed weeks of pregnancy. Thirty-nine weeks completed gestation was chosen as a reference due to the evidence of favourable perinatal outcomes at this gestation and the findings of the ARRIVE trial which identified this as a viable birth choice that does not increase obstetric risk and avoids the risk of progressing to a significantly advanced gestation undelivered [Our study compared labour-related outcomes among women who gave birth at 42 completed weeks and beyond  for all births in Victoria . CCOPMM +0 weeks) and delivered a liveborn neonate between 1st Jan 2009 and 31st Dec 2014. Both comparison groups included parous and nulliparous women, spontaneous and induced labours, spontaneous and assisted vaginal birth and unplanned, emergency caesarean section (elective ceasarean sections were excluded). Given the structure of the dataset, it was not possible to identify maternal clusters (children born to the same mother). Cases were excluded if they had missing or incomplete gestational age data. Completed week of gestational age was the primary exposure in this analysis with gestation in days calculated using the date of birth of the baby relative to the estimated due date.We examined singleton pregnancies that reached term gestation , shoulder dystocia  or obstetric anal sphincter injury (documented 3rd or 4th degree tear) following vaginal birth. We also examined the risk of unplanned (emergency) caesarean section following any labour and following induction of labour.The distribution of covariates between exposures, gestational age at birth (39 vs ≥42 completed weeks), was examined using univariable logistic regression for categorical data and non-parametric Wilcoxon rank-sum test for continuous data. Potential confounding variables were selected based on a priori evidence of likely confounding between these variables and the outcomes examined, and the results of univariate analysis demonstrating significant variation between the gestation cohorts. Potential confounders included in the regression model to produce adjusted risk estimates for each outcome of interest were parity (defined as the number of previous births over 20 weeks gestation and modelled as binary (nulliparous/multiparous)), maternal age  and mode of birth .Interactions were assessed between exposure  and all covariates included in the adjusted models. Where an interaction was identified, stratified risk measures were determined and presented accordingly. Unadjusted and adjusted relative risk (RR) and 95% confidence intervals (95% CI) were computed using predicted probabilities derived from logistic regression, with 95% CI calculated using natural logarithms and back transformed to the standard metric . AdjusteStatistical analysis was performed using Stata v15 statistical software. The two-sided significance level was set at 0.05 and not adjusted for multiple comparisons. An a priori decision was made not to impute missing outcome data unless outcome missingness was different across exposure status and to only perform multiple imputation of covariates used in adjusted analyses if missingness exceeded 1%. By design, missingness did not occur for the exposure, gestational age at birth (39 vs ≥42 completed weeks).At a two-sided significance level of 0.05 and a referent rate of 5%, this study has a power greater than 90% to detect a RD of 1% or a RR of 1.22 given a cohort size of 100,000 and 5000 in exposure arms and a RD of 1.75% or RR of 1.41 for outcomes with 20,000 and 1500 in comparison arms.Following exclusions, the study cohort included 332,413 births during the period 2009–2014. This comprised 91,314 births at 39 completed weeks and 4317 at ≥42 completed weeks  or grand-multiparous . They were also more likely to have an emergency, unplanned caesarean section  than a vaginal birth. Missingness for covariates was minimal: parity (0.02%), mode of birth (0.03%) and maternal age (0.08%), and therefore, covariate imputation was not used. Based on the whole cohort, missingness was low for emergency caesarean section (0%), shoulder dystocia (0%), macrosomia (0.14%) and post-partum haemorrage (0.8%), whilst for those who delivered vaginally, missingness was slightly higher for 3rd or 4th degree perineal tear (7.6%). There was no clinically important difference between missing outcomes among the two exposure cohorts.Table p<0.001), post-partum haemorrhage across all modes of birth , shoulder dystocia  and 3rd or 4th degree tear  (Table p<0.001) and following induction of labour   were found between gestational age and the following: parity for macrosomia, mode of birth for post-partum haemorrhage and macrosomia for shoulder dystocia . Results were therefore stratified by the relevant interaction for these outcomes. There was no evidence for an interaction between gestational age and parity (unadjusted RR model: p = 0.57) for 3rd or 4th degree perineal tears.We next determined the relative risk and risk difference of these obstetric outcomes after adjusting for parity, maternal age and mode of birth Table . InteracThe adjusted relative risk (aRR) for those giving birth at ≥42 weeks compared with women giving birth at 39 weeks was 10.19 (95% CI 8.26–12.57) for macrosomia among nulliparous women and 4.71 (95% CI 3.90–5.68) among multiparous women; 1.85 (95% CI 1.55–2.20) for post-partum haemorrhage following spontaneous vaginal birth, 2.29 (95% CI 1.89–2.78) following instrumental vaginal birth and 1.44 (95% CI 1.17–1.78) following emergency ceasarean section; 1.43 (95% CI 1.16–1.77) for shoulder dystocia (non-macrosomic babies); and 1.22 (95% CI 1.03–1.45) for 3rd or 4th degree perineal tears . The aRR risk of shoulder dystocia for those giving birth at ≥42 weeks compared with 39 weeks for women with macrosomic babies was RR 0.70 (95% CI 0.49–1.01).Following any labour, women giving birth at ≥42 weeks had an aRR of unplanned caesarean section of 1.96 (95% CI 1.86–2.06) and a risk difference (excess risk greater than those at 39 weeks) of 12.7% (95% CI 11.4–14.0). Following an induced labour, women giving birth at ≥42 weeks had an aRR of 1.47 (95% CI 1.38–1.56) of unplanned caesarean and a risk difference of 9.9% (95% CI 8.2–11.7) compared with women giving birth at 39 weeks  and a 96% increased risk of an unplanned caesarean section.For all outcomes, unadjusted and adjusted RR point estimates were similar. The evidence for an interaction between macrosomia and parity, post-partum haemorrhage and mode of birth and shoulder dystocia and macrosomia is evident in the raw stratified tables and was confirmed as highly statistically significant for all metrics.The risk of shoulder dystocia was increased to 1.43 (95% CI 1.16–1.77) at 42 completed weeks for non-macrosomic babies only, with borderline evidence of a reduced risk for macrosomic babies . It is possible that this represents a lack of power due to smaller numbers of macrosomic babies overall and very small numbers experiencing a shoulder dystocia. However, it is also plausible that babies identified antenatally as macrosomic are delivered earlier than 42 weeks, and only those where the risk of shoulder dystocia for the mother is considered to be low are allowed to progress to advanced gestation.We examined a large, state-wide cohort in Australia over a 5-year period and selected specific adverse outcomes that are likely to be regarded as significant and impactful by both patients and clinicians. Whilst many risk factors for these common complications have been characterised, post-term gestation is not widely reported as a risk factor for post-partum haemorrhage –16, shouWhilst clinicians may have suspected that births ≥42 weeks gestation entail increased risk, the relative magnitude of this increase (>40% for multiple adverse outcomes) is likely to have been under-appreciated in the clinic. Our findings have clinical relevance. Clinicians should be aware that those in labour at 42 weeks gestation and beyond represent a cohort at significant risk for a number of common obstetric complications. Furthermore, knowing that a safe alternative management option exists , thIn order to investigate our hypothesis, it was necessary to select a reference gestation to compare the risk of adverse outcomes. We selected 39 weeks gestation for two important reasons: it is the gestation when foetuses are most commonly born and a gestation where there is a justifiable clinical option to induce labour . In lighWe believe our data has a number of strengths. The first is the size of the cohort and our capacity to capture data from an entire state. Second, our dataset included very little missing data for the confounders of interest (<0.08%), which meant that imputation techniques to account for missing data were not required for adjusted analysis. The amount of missing outcome data was less than 1%, except for vaginal tears. The magnitude of missing outcome data for obstetric anal sphincter injury is consistent with that reported in the literature. This outcome is notoriously poorly reported , 21. TheThe limitations include that this was a retrospective study, that we only demonstrate associations not causal effects and that the dataset did not allow for identification of clustering by birth mother which will lead to 95% CI that are too narrow. Standard error underestimation is reduced when the number of clusters is large (our data) and when within-cluster correlation is low (unknown in this setting); however, it can persist even at cluster sizes of 2 to 5 (likely in birth cohorts) . Despite+0–40+6), there is clearly a balance to be found between the risks and benefits at different gestational ages for both mother and baby. The risk of adverse neonatal outcomes such as neonatal death, respiratory compromise, hypoglycaemia, sepsis and admission to the Neonatal Intensive Care Unit is known to be lowest among uncomplicated pregnancies delivered between 39+0 and 40+6 weeks of gestation [Within the range of term gestation (37estation , 24, 25.We are not suggesting that our findings should lead to prescriptive advice to women about avoiding pregnancies reaching post-term gestation. And we acknowledge that our cohort, whilst representative of an entire Australian state, is derived from a high-resource setting and our findings and recommendations may not be applicable in low- or middle-income settings where resources are scarce. However, we believe our findings may enhance shared decision-making in settings similar to our own, where women choosing to await spontaneous labour beyond their expected date of birth should be informed of significantly increased risk of many labour-related adverse outcomes should they progress beyond 42 weeks gestation without having given birth.It is well-established that for mothers progressing beyond 42 weeks gestation, their babies are at considerably increased risk of stillbirth and perinatal mortality. Our study demonstrates that labour-related risks for these women are also high and should be considered as part of clinical planning and counselling.


Is the legacy of structural racism in the housing market associated with disparate outcomes in a contemporary obstetric cohort?In this cohort study including 64 804 live births in 17 zip codes, historically redlined zip codes were associated with increased risk of preterm birth and periviable birth.These findings suggest that historic discriminatory policies remain associated with poor obstetrical outcomes, suggesting intergenerational discrimination and disinvestment continue to have a role in modern health disparities. This cohort study examines the associations of the historic racially discriminatory home loan policy of redlining with modern obstetric outcomes in a US city. Despite much higher health care expenditure than comparable countries, striking racial and ethnic disparities exist in obstetric outcomes in the United States. A multifaceted exploration of the factors influencing these disparities, including the legacy of structural racism, is important to improve health outcomes for all.To characterize the association of the historic racially discriminatory home loan practice of redlining with disparities in modern obstetric outcomes.the redline map). Patients with a live birth recorded in the data system with a recorded home zip code within the historic HOLC categories were included. Data were analyzed from July to December 2019.In this retrospective cohort study of a 9-county birth certificate database in the Finger Lakes region of New York state from 2005 to 2018, modern obstetric outcomes were matched with regions classified by the federal government for mortgage loan servicing based on racially discriminatory criteria from the 1940 Home Owners’ Loan Corporation map  in the zip code historically defined as “Best” or “Still Desirable” and the highest overall preterm birth rate of 427 of 3449 births (12.38%) in the zip code historically defined as “Hazardous.” These associations with preterm birth remained significant in logistic regression controlling for poverty levels and educational attainment  and parental race .In this cohort study, the linkage of historic and modern community data sets with an obstetric data set offered the opportunity to characterize modern obstetric disparities associated with a system of historic inequity. The persistence of these findings after correcting for contemporary community socioeconomic characteristics suggest potential influences of a system of profound structural inequity that ripple forward in time, with impacts that extend beyond measurable socioeconomic inequity. Additionally, risk of death in pregnancy is higher for Black women with at least a college degree than for White women who have not completed a high school diploma.7The US has higher infant and maternal mortality rates than nearly any other Organization for Economic Cooperation and Development nation despite also having the largest health expenditures.8These disparities remain pronounced across the spectrum of obstetric experiences. Preterm birth demonstrates particularly prominent racial and ethnic disparities in the US, with non-Hispanic Black women experiencing a preterm birth rate at least 50% higher than non-Hispanic White women.11 The cumulative effect of structural racism is one driver of the disproportionate negative outcomes faced by Black women.3 This is the factor that likely gives rise to the so-called immigrant paradox, in which immigrant women have better health outcomes on arrival to the US than after multiple years of living within the US.12 The legacy of structural racism is extensive in the US13; one historic vehicle of discrimination and disinvestment was the practice of redlining: a formal practice of the federal government’s Home Owners’ Loan Corporation (HOLC) beginning in the 1930s to delineate areas where mortgages could be insured based on overtly racially discriminatory criteria.14Increasing focus of the medical community on health care disparities has revealed a wide array of contributions to the inequity of health outcomes, ranging from the physical environment to socioeconomic factors, individual health behaviors, stress, and genetic factors.15 This structure of disinvestment, which formally stretched forward into the 1960s, has far reaching impacts. Owing to a range of sequelae of community disinvestment, as well as the critical role of home ownership in intergenerational wealth-building, the legacy of historic redline racial discrimination correlates with modern social and health inequities.17 We conducted this study to evaluate our hypothesis that the legacy of racial discrimination measured by historic redlining is associated with modern obstetric outcome disparities.From the 1930s into the 1940s, the federal government created thousands of area descriptions for cities across the US. First created by the HOLC, redline policies were then adopted by the Federal Housing Administration and the Department of Veterans Affairs, all of which ostensibly used these classifications to guide where it was financially “safe” to issue mortgages, although “safety” frequently represented a categorization for the racial composition of neighborhoods, with predominantly White neighborhoods categorized in lowest risk categories .STROBE) reporting guideline.This cohort study was approved by the University of Rochester Research Subjects Review Board, including a waiver of informed consent consistent with institutional review board approval for use of deidentified data. This study is reported following the Strengthening the Reporting of Observational Studies in Epidemiology  and periviable birth (births at 22-25 weeks), as these births impart the greatest risks for neonatal morbidity and mortality and are thus of particular focus. Secondary outcomes of interest included maternal diagnoses of pregnancy-related hypertension, severe depression, and substance use and additional pregnancy-related outcomes, including neonatal intensive care unit admission, 5-minute APGAR score less than 7, and exclusive breastfeeding in the immediate postpartum period.18 Median gross income of community members, percentage of community members with a high school diploma, and percentage of community members living below the US poverty level were tabulated for each zip code.The data set then was merged with publicly available community data from the US Census Bureau. Zip code cohorts were linked to income, poverty, and educational attainment data, as described by the US Census Bureau based on the 2017 American Community Survey.14 to classify them according to the classification by the federal government as A, “Best”; B “Still Desirable”; C, “Definitely Declining”; and D, “Hazardous” for mortgage loan servicing based on racially discriminatory criteria  and maternal and paternal race.P values were 2-sided, and statistical significance was set at P = .05. Data were analyzed from July to December 2019.Stata statistical software version 16.0 (StataCorp) was used to collapse the obstetric data set into zip code cohorts to describe geographic distribution of outcomes as well as to perform the statistical analyses. Graphic representations of the distributions of obstetric, and community socioeconomic data were generated in ArcGISPro version 2.5.0 (Esri). From 2005 until 2018, the birth data system contained detailed information for 210 984 live births. A total of 199 088 live births were eligible for inclusion as being associated with a zip code containing more than 100 deliveries in the study period with resulting 120 zip code cohorts.Of these births, there were 64 804 within the 15 zip codes that were redlined and had HOLC grades in Rochester, New York. One contemporary zip code overlapped with the historic D “Hazardous” designation, and 1 contemporary zip code overlapped with historic regions characterized as A “Best” or B “Still Desirable.” Ten zip codes were distributed in 1 or 2 categories between these extremes, and 3 contained 3 or more of the historic designations and thus were tabulated but not included in the statistical analysis.P = .001) to 1.38  for “Hazardous” (P < 001)  in the zip code historically defined as “Best” or “Still Desirable” and the highest overall preterm birth rate of 427 of 3449 births (12.38%) in the zip code historically defined as “Hazardous.” Overall preterm birth, extreme preterm birth, and periviable birth by HOLC designation are presented in P < 001) .Geographic disparities in modern preterm birth rates across the entire region remained statistically significant in multivariable regression controlling for community-level poverty levels and educational attainment and patient-level maternal race and paternal race in rates of all preterm births . Thus, eWhen comparing secondary outcomes between the extremes of HOLC grades, there was a significant difference in all measured secondary complications and outcomes (eTable in the This cohort study found associations between modern obstetric outcome disparities and historic policies driving intergenerational inequity based on race. Our findings provide further evidence of the influence of a legacy of structural racism on the disproportionate burden of adverse pregnancy outcomes for Black women in the US.In our study population of a single midsized US city, historic redlining was associated with increased risk of preterm birth in the modern day. This association between historic redlining and contemporary preterm birth rates is striking across the gestational age range. The historic redlining was associated with contemporary increased odds of any preterm birth that did not resolve when factoring in community or patient-level characteristics, particularly in the regions historically designated with the greatest “Hazard.” The persistence of the association of any preterm birth with increasing “Hazard” designation by the HOLC, even when accounting for contemporary community income levels, poverty levels, and educational attainment, suggests that current community resource distribution alone does not explain these disparities in outcome. Potentially, the overarching influence of a system of profound structural inequity ripples forward in time with impacts that extend beyond measurable socioeconomic inequity.In contrast, when analyzing the most extreme forms of preterm birth, the unadjusted risk of periviable birth with decreasing HOLC grade ceased to be statistically significant when we controlled for patient-level racial characteristics but not when we controlled for community-level economic characteristics. This finding may generate new hypotheses surrounding the relative association of social and environmental factors across the spectrum of preterm birth, including the roles that income, insurance access, and life stressors may play in the pathogenesis of preterm birth. Moreover, future studies may have the opportunity to explore the potentially differential associations of these factors with preterm births that occur spontaneously vs those that are iatrogenically created owing to medically indicated deliveries.When we compared secondary outcomes between the extremes of historic HOLC designation, giving birth when living in the regions historically designated with the greatest “Hazard” was associated with contemporary increased odds of experiencing a range of pregnancy-related comorbidities, as well as increased odds of adverse obstetric outcomes. Odds of severe maternal depression and a diagnosis of substance use disorder were markedly increased among women delivering from the historically “Hazardous” area. By the time of their delivery, these women then also experienced increased odds of maternal complications, such as pregnancy-related hypertension, and neonatal complications, such as low APGAR scores and higher rates of neonatal intensive care unit admission. These associations underscore the echoes of the past—imparting higher morbidity for members of communities impacted by a legacy of disinvestment.This study has some limitations. Our study characterized the modern impacts associated with historic, racially discriminatory policy in a single, midsized US city. Given the size of the region, the extremes of HOLC designation included only 1 zip code each, which limits our power and may introduce additional unidentifiable confounders in our multivariable regression. Findings from this single region may also not be applicable to other regions in the US.These data have the possible limitations of all large data sets, including the potential for inaccurate data and residual confounding, although the extensive training and codification of birth certificate data in our system lessens these risks. Moreover, owing to the fact that this is a registry of live births, the impact of the assessed factors by definition did not include stillbirths.19 and also adds the opportunity to integrate zip code–level economic and educational attainment data into the regression models, independent of patient-level socioeconomic data.While limited in scope, our study design provides the opportunity to perform an in-depth analysis that integrated community-level data into a data set of patient-level obstetric outcomes, superimposed on historic HOLC designations. This reinforces the findings of a 2020 study delineating associations between historical redlining and birth outcomes in a modern cohort of deliveries in CaliforniaThis cohort study integrated historic and modern community data sets into obstetric data sets, offering the opportunity to analyze the contemporary health legacy of historic inequity. Given the sweeping impacts of disproportionate burden of adverse pregnancy outcomes on Black women and their families associated with historical racially discriminatory housing policy, attempts to dismantle these disparities must be multifaceted and informed by increasingly integrated analysis of previously disparate data sets. The observation that racially discriminatory home lending patterns of the 1940s were associated with contemporary preterm birth rates can inform us that the legacy of government-sanctioned discrimination persists today.


The surgical management of esophageal atresia in extreme-low-birth-weight infants (< 1000 g) is challenging. We report on an extreme-low-birth-weight infant who was extremely preterm  and of prenatally unknown Gross type C esophageal atresia.After resuscitation and intubation, the tracheoesophageal fistula was closed on the first day of life in the neonatal intensive care unit via an extrapleural approach using a titanium clip. On the sixth day of life, the Caucasian child was extubated. To minimize the operative trauma in the initial neonatal period, we prolonged gastrostomy placement until the 22nd day of life (weight 725 g). At the age of 3 months (weight 2510 g), thoracoscopic esophageal anastomosis was performed. The postoperative course was unremarkable. During the further clinical course, eight esophageal dilations were necessary. Currently, the patient swallows without difficulties at the age of 4 years and thrives well .Our case shows that minimized postnatal surgical trauma with primary tracheoesophageal fistula closure at the bedside, delayed gastrostomy, and minimally invasive esophageal repair after substantial weight gain (> 2.5 kg) is a good strategy for esophageal atresia/tracheoesophageal fistula in extreme-low-birth-weight infants.The online version contains supplementary material available at 10.1186/s13256-021-02951-x. The percentage of esophageal atresia (EA) with tracheoesophageal fistula (TEF) in extreme-low-birth-weight (ELBW) infants < 1000 g) is low 3%) 000 g is . The sur% 000 g iA 510 g Caucasian female infant without prenatally diagnosed anomalies was delivered to a previously healthy 37-year-old mother  at 25.7 weeks gestation via cesarean section after pathological findings on cardiotocography and growth retardation. Apgar scores were 3, 6, and 7. The patient was intubated immediately after birth, and broad-spectrum antibiotics (ampicillin + cefotaxime) were started. EA/TEF (Gross type C) was diagnosed via chest x-ray after a nasogastric tube was unable to pass the esophagus. A Replogle tube was placed in the upper pouch with continuous suction, and an umbilical vein catheter was established. Cardiac and renal ultrasound were normal; no additional malformations were diagnosed. The three older siblings of the patient do not have any congenital anomalies and are all healthy.On the first day of life (DOL) (10 hours after birth) open TEF clipping was performed via an extrapleural approach in the incubator at the neonatal intensive care unit using a titanium clip (operation time 36 minutes). To reduce the operative trauma in the initial neonatal period and enable extubation after 6 days, we decided to postpone the placement of a gastrostomy. Therefore, we applied total parenteral nutrition (TPN), which resulted in a constant elevation of direct bilirubin (maximum of 200 mg/dl). At 22 DOL (weight 725 g), we created an open gastrostomy (operation time 58 minutes). After steady weight gain (2510 g), we performed a thoracoscopic primary esophageal anastomosis (operation time 93 minutes) at 3 months of age, without tension and without any perioperative adverse events ; 100 cm (Percentile 24)].et al. reported staged repair in an infant born with 445 g at of 36 weeks gestation that survived [et al. reported a case with 540 g of 24 weeks gestational age with initially diagnosed pure EA (based on bronchoscopy findings). [The optimal surgical treatment for EA/TEF in ELBW infants < 1000 g) remains controversial  , 10. Nevet al. suggested that neonates with a short-gap EA that are cardiopulmonary stable and weigh more than 2000 g at birth with less than one major associated malformation are good candidates for TR [Thoracoscopic repair (TR) of EA/TEF is an ongoing controversy. Dingemann s for TR . Others s for TR , 13. Ones for TR .et al. report on three cases with birth weights and gestational ages of 490, 790, and 800 g and 25, 26, and 27 weeks, respectively [Reports on delayed TR for EA/TEF in ELBW infants are rare. Margain ectively . They weExtremely preterm and low-birth-weight infants of EA/TEF can benefit from a staged repair with primary open ligation of the fistula followed by gastrostomy and delayed thoracoscopic anastomosis.Additional file 1. Summary of surgical treatment for EA/TEF in ELBW infants (< 1000g)


Hypertensive disorders during pregnancy (HDP) increase the risk of offspring with a low birth weight, preterm birth and small-for-gestational age; however, evidence of the anthropometric measurements during early childhood remains limited. We aimed to understand the associations between maternal HDP and anthropometric measurements of children aged up to seven years in a Japanese cohort. In total, 20,926 mother–infant pairs participated in the Hokkaido Study on Environment and Children’s Health, Japan, from 2002 to 2013. Medical reports were used to confirm HDP exposure, while weight, height, height z score, and weight z score were the outcomes. The prevalence of HDP in the study population was 1.7%. The birth height of male children born to HDP mothers was smaller as compared to those born to non-HDP mothers. When adjusted with covariates, the linear regressions showed significant changes in birth weight , birth height , weight at seven years , and weight gain between four and seven years  of male children exposed to HDP. Differences were more significant in male children than female. Our study showed that despite low birth weight, male children exposed to HDP caught up with their growth and gained more weight by seven years of age compared with male children not exposed to HDP, whereas no such differences were observed in female children; however, this finding requires replication. Hypertensive disorders during pregnancy (HDP) are defined as hypertension (blood pressure ≥140/90 mmHg) with or without proteinuria ≥300 mg/24 h), emerging after 20 weeks of gestation. HDP has been classified into four types: preeclampsia, gestational hypertension, superimposed preeclampsia, and chronic hypertension, excluding eclampsia in the previous disease type classification 4 h, emer,6. HDP, The Developmental Origins of Health and Disease (DOHaD) hypothesis may be appropriate for children’s long-term development. Barker’s hypothesis, along with the DOHaD hypothesis, have explained the patterns of the life course in detail, and state that poor fetal nutrition, indicated by small birth size, might lead to fetal adaptations altering the propensity for diseases in adulthood ,12. TherCatch-up growth refers to the “a height velocity above the statistical limits of normality for age or maturity during a defined period, following a transient period of growth inhibition; the effect of catch-up growth is to take the child towards his/her pre-retardation growth curve” . Catch-uEarly postnatal growth is strongly affected by genetic factors, and infants genetically predisposed to a large size, but born to small mothers, show fast natal growth . In deven = 10,329), two years (n = 9014), four years (n = 7211), and seven years (n = 6198), and assessed the associations between HDP and anthropometric measurements.The Hokkaido Study on Environment and Children’s Health is a prospective birth cohort that was started in 2002; further information about this cohort can be found elsewhere ,28,29. FParticipants completed a self-administered questionnaire comprising information on parental characteristics. Baseline data on maternal age, height, weight, education, socioeconomic status, smoking, alcohol consumption before and during pregnancy, and use of artificial reproductive technology were obtained. The medical record provided information on gestational days at delivery, sex, birth height and weight of the infant, and history of HDP of the mother. The exposure variable was HDP. We used the Japanese standard definition of HDP and classified the symptoms based on severity. Mild HDP (h) was defined as a blood pressure ≥140/90 mmHg but <160/110 mmHg after 20 weeks of gestation, and proteinuria (p) ≥300 mg/24 h without exceeding 2.0 g/24 h or a score of 3 + on the dipstick. Severe HDP (H) was defined as a blood pressure of ≥160/110 mmHg and proteinuria (P) exceeding 2.0 g/24 h or a score of 3 + on the dipstick )  . Similar, 1.11]) . No othep < 0.05) while no association was observed in females (p < 0.1). HDP can cause adverse effects, resulting in several maternal and neonatal complications leading to fetal distress, preterm birth, stillbirth, low birth weight, and IUGR as suggested by our previous as well as other different studies [In the present population-based cohort study, we attempted to understand the association between HDP and anthropometric measurements of children from birth to seven years of age. Intrauterine exposure to HDP was negatively associated with height during birth in male children p < 0.0 while no studies ,33.The prevalence of HDP in our study was 1.7%, which is less than that reported in the Japan Environment and Children’s study (3.1%) . The difOur study did not show any significant difference in the birth weight of children, regardless of HDP. This might be owing to the mild effect of HDP. Patients with non-severe HDP generally have a favorable prognosis, and most studies report that birth weight, incidence of fetal growth restriction, and preterm birth are similar to those of normal pregnancies ,38,39,40Our study did not show any association between HDP and anthropometric measurements at different ages in female children. From birth till adolescence, linear growth, weight and BMI trajectories differed between the sexes according to the severity of exposure to HDP. In general, HDP and preeclampsia are negatively associated with linear growth. A cohort study from Norway showed that differences in anthropometric measurements were limited to male children . AnotherMale children exposed to HDP had a lower weight at birth. The vast majority of low-birth-weight infants will show postnatal catch-up growth, and most of this catch-up occurred in the first 6–12 months of life, regardless of the height or weight at birth ,48,49. MA Japanese study also showed multiple developmental patterns in boys and girls, suggesting that maternal BMI and some unfavorable behaviors during early pregnancy impacts a child’s pattern of body mass development . AlthougThe strength of this study includes its prospective birth cohort design, comprising 20,926 mother–infant pairs. Owing to the nature of its cohort, we were able to follow up the participants until different years of age. We obtained information on HDP from medical records, which is a highly reliable source. Anthropometric measurements were obtained from the MCH handbook, which is one of the essential records for tracing the health of Japanese children. However, this study has some limitations. The prevalence of HDP was 1.7% in the total participants, which might have led to an underestimation of the results. The data on pre-pregnancy BMI, smoking, and alcohol consumption habits were self-reported by the participants, which might have caused recall biases. Although paternal obesity is also known to accelerate growth in children, we did not have paternal BMI data to compare. Preterm infants with maternal hypertension may have worse outcomes than full-term infants, which could not be assessed in our study due to fewer preterm infants, adding to other limitations. Additionally, the risk of gestational diabetes, type 2 diabetes mellitus, thyroid disorders, and dietary factors were not assessed in this study.Our study showed that despite lower weight at birth, male children exposed to HDP had accelerated catch-up growth and gained more weight by seven years as compared to children born to mothers without HDP; however, this finding needs replication. HDP can cause adverse birth outcomes. Hence, identifying risk factors and assessing risk during pregnancy, along with monitoring medical history and proper health education by medical personnel, and public health community interventions can reduce the complications associated with pregnancy. As intrauterine exposure to hypertensive disorders can affect the neurodevelopmental and cardiometabolic health of children in the long run, our study recommends further studies on Japanese mothers to strengthen the evidence provided by our findings.


The COVID 19 pandemic represents a major stress factor for non-infected pregnant women. Although maternal stress during pregnancy increases the risk of preterm birth and intrauterine growth restriction, an increasing number of studies yielded no negative effects of COVID 19 lockdowns on pregnancy outcome. The present study focused on pregnancy outcome during the first COVID 19 lockdown phase in Austria. In particular, it was hypothesized that the national lockdown had no negative effects on birth weight, low birth weight rate and preterm birth rate. In a retrospective medical record-based single center study, the outcome of 669 singleton live births in Vienna Austria during the lockdown phase between March and July 2020 was compared with the pregnancy outcome of 277 live births at the same hospital during the pre-lockdown months of January and February 2020 and, in addition, with the outcome of 28,807 live births between 2005 and 2019. The rate of very low gestational age was significantly lower during the lockdown phase than during the pre-lockdown phase. The rate of low gestational age, however, was slightly higher during the lockdown phase. Mean birth weight was significantly higher during the lockdown phase; the rates of low birth weight, very low birth weight and extremely low birth weight were significantly lower during the lockdown phase. In contrast, maternal gestational weight gain was significantly higher during the lockdown phase. The stressful lockdown phase in Austria seems to have no negative affect on gestational length and newborn weight among non-infected mothers. We are currently confronted with first global pandemic since the “Spanish flu” in 1918. COVID 19 represents a major socio-economic-political-emotional stress factor (SEPE) .This was especially true of pregnant women during the first and second wave the of pandemic in 2020. Pregnant women suffered from a twofold stress situation: on the one hand, there is the awareness that COVID 19 infections may be deadly diseases, and the uncertainty as to whether the infection can be transmitted to the fetus and whether it has unknown consequences for the course of pregnancy and the birth and the development of the child. Furthermore, a vaccination was not available until January 2021 and is still not available on a large scale. On the other hand, the dramatic collapse of the world economy led to a state of emergency, triggered by fears, worries and suddenly occurring economic problems ,5,6,7,8.Birthweight represents a sensitive indicator for the intrauterine growth process, and it is well documented that stress phases during pregnancy may result in low birth weight ,10. EverIn-utero exposure to the “Spanish flu”, which was seen as a quasi-experiment for studying the influence of a pandemic on fetal development, had adverse effects on intrauterine growth such as lower birthweights ,16,17. SConsequently, an adverse effect of the COVID lockdowns on pregnancy outcome might be assumed. Interestingly, the opposite was found in several studies. While few studies reported increased stillbirth rates associated with COVID lockdowns in Italy , Israel In the present study we focused on the situation in Austria, where a nationwide hard lockdown started in mid-March 2020, with severe effects on social life and the economic situation such as social distancing, loneliness and dramatically increasing unemployment rates. The main focus of the present study was pregnancy outcome during this first lockdown phase in Vienna, Austria. Based on the results of the studies mentioned above, we tested the following hypothesis: the first national lockdown in Austria from March 16 to June 15 had no negative effects on mean birth weights and the prevalence of low birthweight and pre-term birth among non-infected women in Vienna, Austria.On 25 February 2020, the first two cases of COVID 19 infection were detected in Austria. Later, it emerged that infections had already taken place in Tyrol on 8 February. The Austrian government advised people in Austria to follow strict hand hygiene rules and to practice social distancing. The first death caused by COVID 19 was confirmed on 12 March in Vienna. On 16 March, the first complete lockdown began in Austria, which in its strict form lasted until 20 April. Schools and universities were closed and had to change to distance learning. Occupational activities (if possible) were carried out in home office. Shops, with the exception of groceries and pharmacies, were completely closed. Nationwide, homes were to be left only for necessary professional activities, necessary purchases (food or medication), assisting other people and short recreational activities in nature. According to the analysis of phone mobility records, the mobility of Austrian people dropped down drastically during the lockdown in March. Data from the Google Covid 19 Community Mobility Reports revealed that mobility was reduced by 80 percent compared to the months of January and February and remained low until the end of April. In May, there was an increase in mobility, but it was still below the comparison period before the pandemic .Starting on 6 April, everyone entering a shop had to wear a face mask. On 14 April, wearing face masks became mandatory on public transportation. By late April, new cases had stabilized to around 20–50 per day on average. A slight relaxation of the lockdown measures began on 20 April, and phase two of the lockdown started. The lockdown in Austria was not over until 15 June; however, social distancing remained, as did the awareness that COVID 19 diseases are still not treatable and represent a deadly danger.n = 945) taking place between 1 January and 31 July at the Viennese Danube Hospital. In this group, maternal age at birth ranged from 17 to 47 years . A total of 669 of these births took place during the months March and July 2020 during the lockdown phase in Austria. A total of 277 births took place during the pre-lockdown months January and February 2020. The Danube Hospital is one of the largest public birth clinics in Vienna [Data set 1 comprised all singleton life births  and by two consecutive ultrasound examinations performed before the twelfth week of gestation. Preterm birth was defined as ≤36 weeks of gestation. Moderate to late preterm birth (MlPB) was defined as 32 to 36 gestational weeks. Very preterm (VPB) was defined as 28 to 32 weeks of gestation, extremely preterm (EPB) as less than 28 weeks of gestation . In the All newborns were measured immediately after birth. The following parameters were directly taken from the newborn: birth weight in grams using a digital infant scale, birth length in centimeters using a standard measurement board for infants and head circumference in centimeters using a tape. A low birth weight (LBW) was defined as 1500–2500 g, a very low birth weight (VLBW) as 1000–1500 g, and an extremely low birth weight (ELBW) as <1000 g according to the recommendations of the World Health Organization (WHO) .2).The following maternal parameters were collected: age at giving birth, body height, pre-pregnancy weight, end of pregnancy weight and gestational weight gain. Body height was measured to the nearest 0.1 cm using a standard anthropometer. Pre-pregnancy weight was obtained by interview using the retrospective method. Body weight was measured again to the nearest 0.1 kg on a balance beam scale, at the first prenatal visit around the eighth week of gestation. Additionally, maternal weight was measured before delivery . The weight gain during pregnancy was calculated by subtracting pre-pregnancy weight from body weight before delivery. Pre-pregnancy body mass index (PPBMI) was calculated ((body weight in kg)/(body height in m)Since no personal socioeconomic data of the mothers, such as employment, income or educational level, were available, the unemployment rate in Austria, published by Statistics Austria , was useThe study design corresponds to a retrospective medical record-based single-centre study. In a first step, pregnancy outcome , Caesarean section rate and maternal somatic parameters  at the Danube hospital during the lockdown months March to July 2020 were compared to pregnancy outcome during the pre-lockdown months January and February 2020. Furthermore, pregnancy outcome during the lockdown months was compared with pregnancy outcome between 2005 and 2019 at the Danube hospital in order to provide a long-term perspective of the pregnancy outcome at this medical center. In addition, low birthweight rate and Cesarean section rate at the Danube hospital between 2005 and 2019 were compared with low birthweight rate and Caesarean section rate in Austria using data from Statistics Austria. In a second step, association patterns between pregnancy outcome and maternal parameters as well as lockdown phase were tested. Furthermore, the unemployment rate during the lockdown phase is presented.t-tests and χ2 were calculated to test differences between the births during the lockdown phase and those during pre-lockdown period. Additionally, linear regression analyses were calculated to analyze the associations between maternal parameters as well as the lockdown and gestational age at birth and newborn weight. p < 0.05 was considered statistically significant.Statistical analyses were carried out using SPSS for Windows . The Kolmogorov–Smirnov test indicated the normal distribution of most metric variables. Therefore, parametric tests were performed exclusively. After computing descriptive statistics, Student’s Examining the individual months of 2020, the VPB rate was lower during the lockdown months of March to June than during January/February. The MLBP rate, in contrast, was highest during the lockdown months of May and June 2020, but dropped during July 2020 .According to the Statistics Austria dataset, the prevalence of low birthweight among singleton births in Austria ranged between 4.7 and 5.2% from 2005 to 2019. The prevalence of low birth weight at the Danube Hospital during this time span was higher, ranging between 4.8% in 2005 and 7.9% in January/February 2020 .p = 0.049) of LBW in January/February (54.2/1000) than during the lockdown period of March to July (38.9/1000). The risk of giving birth to a LBW newborn was significantly higher during pre-lockdown period (OR 1.66 CI 0.98–2.81). The rates of extremely low birthweight (<1000 g), very low birthweight (1000–1500 g) and low birthweight (1501–2500 g) at the Danube hospital are listed in Comparing the rate/1000 LBW between the pre-lockdown months of January/February 2020 and the lockdown months of March to July 2020 showed a significantly higher rate  occurred in 2017. The highest mean birth weight occurred during the lockdown phase (3381.7 g). A similar trend was evident for birth length, with the highest values (50.8 cm) also reported for the lockdown period. Mean head circumference (34.3 cm) did not differ markedly between the years 2005 to 2020 .The comparison of newborn size between pre-lockdown and lockdown months in 2020 yielded insignificantly higher birthweight and insignificantly higher birth lengths during the lockdown months. Newborn head circumference was only slightly higher during the lockdown months.During the last fifteen years, the Caesarean section rates at the Danube hospital were always markedly lower than the Caesarean section rate of Austria as a whole. . During p = 0.021).Age, body height, body weight and pre-pregnancy BMI did not differ significantly between mothers giving births during the pre-lockdown months January/February 2020 and mothers giving birth during the lockdown months. Gestational weight gain, however, differed significantly . During p = 0.049). Nearly 39% of the pregnant women showed a weight gain of more than 15 kg between March and July 2020, while this was true of only 33.8% of the mothers during the pre-lockdown months , but not with maternal age and the lockdown phase. The same associations could be observed for gestational length. Gestational length was significantly positively associated with maternal gestational weight gain , while no significant association with the maternal age and the lockdown phase could be observed. Consequently, gestational weight gain seems to be a key factor for pregnancy outcome in this sample.Linear multiple regression analyses yielded that birth weight in 2020 was significantly positively associated with maternal gestational weight gain  a Public Health Emergency of international concern on 30 January 2020 and, subsequently, a pandemic on 11 March 2020. COVID 19 not only represents a pandemic and global health crisis but is also a psychosocial and economic disaster ,45,46,47In the present study, pregnancy outcome during the first hard lockdown phase in Austria was focused on. In particular, the following hypothesis was tested: the first national lockdown in Austria from March 16 to June 15 had no negative effects on mean birth weights and the prevalence of low birthweight and pre-term birth among non-infected women in Vienna, Austria. Exclusively non-infected mothers were examined in order to exclude effects of COVID 19 infections on the fetus. The comparison of births during the lockdown months March to July with the pre-lockdown situation (January and February 2020) and the database from the last 15 years supported the unexpected results of previous studies ,37,38,39Mean weight and length at birth were highest during the lockdown months, whereas the rates of low birthweight (1500 to 2500 g), very low birthweight (1000 to 1500 g) and extremely low birth weight (<1000 g) decreased during those months. These findings are in contrast to the observations during the financial crisis 2008 ,52,53, bAlthough the results of the present study are in accordance with those of some previous studies ,37,38,39In the present study, the lockdown related stress could have affected the fetuses mainly during the third trimester of pregnancy. Previous studies suggested that maternal and intrauterine environments affect fetal growth in weight mainly during the third trimester . This isOur study contains the following limitations. A main issue is the retrospective design, which does not enable including standardized stress inventories or questionnaires to obtain information concerning economic parameters and the individual perception of the lockdown by the pregnant women. Furthermore, we have no information regarding the family situation, the perceived social support or the cultural and ethnic background of the mothers. The study design did not allow testing causalities or even associations between stress factors, behavior life style and pregnancy outcome of the study population. The focus group—deliveries during the lockdown months—was relatively small. Only 669 singleton births took place during the lockdown phase at the Danube Hospital. Although the hospital is one of the largest public birth clinics in Vienna, the study population is not representative for whole Austria, and the findings should not be generalized. Nevertheless, the study also has strengths. This is the first study analyzing pregnancy outcome among uninfected women during the first hard COVID 19 lockdown in Austria. This gives it a pilot study character, and its design made a comparison with the rates of low birth weight and preterm births over the last 15 years.Neither the extremely preterm births rates nor the prevalence of low birth weight increased during the lockdown months. On the contrary, both parameters were lower during the lockdown months than in the years before. Gestational weight gain, however, was significantly higher during the lockdown months. Furthermore, gestational weight gain was significantly associated with birthweight and gestational length. The stressful lockdown phase in Austria seems to have no significantly negative effect on extremely preterm birth rates and newborn weight among non-infected mothers.


This cohort study examines the association of preterm birth with risk of mortality and morbidity among infants born in China from 2010 to 2019. What are the rates of mortality and major morbidity among infants born extremely preterm in China?In this multicenter cohort study across mainland China from 2010 to 2019, which included 8514 infants with gestational age less than 28 weeks, there was an improved rate of survival to discharge and an increased rate of major morbidity over the decade.These findings suggest that infants born extremely preterm are at increased risk of mortality and morbidity in China and that more active and effective treatment strategies are needed, especially for infants born at gestational age 25 to 27 weeks. Extreme prematurity is associated with a substantial burden on health care systems worldwide. However, little is known about the prognosis of infants born extremely preterm in developing countries, such as China.To describe survival and major morbidity among infants born extremely preterm in China over the past decade.This retrospective cohort study was conducted from January 1, 2010, through December 31, 2019. Included individuals were infants with gestational age less than 28 weeks discharged from 1 of 68 neonatal intensive care units located in 31 provinces in China. Data were analyzed from August through October 2020.Extremely preterm birth.Survival to discharge and major morbidity  were measured.P < .001), without a significant change for infants born at less than 24 weeks. Major morbidity was found in 5999 of 8281 infants overall, for a rate of 72.4%, which increased from 116 of 223 infants  to 1363 of 1656 infants  from 2010 to 2019 . Regional variations in survival were identified, with an almost 2-fold increase  from 188 of 474 infants (39.7%) in northwest China to 887 of 1153 infants (76.9%) in north China. Gestational age , birth weight , premature rupture of membranes , and antenatal steroids  were associated with improved survival, while being born SGA , being male , multiple birth , having a mother with gestational diabetes , and low Apgar score  were found to be risk factors associated with decreased chances of survival.Among 8514 eligible infants, 5295 (62.2%) were male and 116 infants (2.0%) were small for gestational age (SGA). Overall, 5302 infants (62.3%) survived to discharge. The survival rate was 1 of 21 infants (4.8%) at 22 weeks, 13 of 71 infants (18.3%) at 23 weeks, 144 of 408 infants (35.3%) at 24 weeks, 480 of 987 infants (48.6%) at 25 weeks, 1423 of 2331 infants (61.0%) at 26 weeks, and 3241 of 4692 infants (69.1%) at 27 weeks. Survival increased from 136 of 241 infants  in 2010 to 1110 of 1633 infants  in 2019 for infants born at 24 to 27 weeks (mean difference, 11.5%; 95% CI, 4.9%-18.2%; This study found that infants born extremely preterm were at increased risk of mortality and morbidity in China, with a survival rate that improved over time and a major morbidity rate that increased. These findings suggest that more active and effective treatment strategies are needed, especially for infants born at gestational age 25 to 27 weeks. This study primarily aimed to evaluate mortality and major morbidity among infants born extremely preterm in China over the past decade.In China, the lower cutoff point for reporting preterm birth had long been set at 28 weeks until the latest guideline was published by the National Health Commission in 2017, removing this lower gestational threshold.STROBE) reporting guideline.This cohort study was approved by the research ethics board of the Children’s Hospital of Fudan University with a waiver of informed consent from this ethics board because of the retrospective and observational design of the study. This study is reported following the Strengthening the Reporting of Observational Studies in Epidemiology  from January 1, 2010, through December 31, 2019. These study sites are located in 31 provinces, autonomous regions, and municipalities throughout 7 geographical areas, accounting for approximately 10% of the tertiary NICUs in mainland China  capable of logical consistency check and data verification. Meanwhile, submitted data were double checked for accuracy and completeness by the research center. All authors vouch for quality assurance.18 Infants with a birth weight below the 10th percentile for their GA were considered small for gestational age (SGA).19 Elderly pregnancy was considered to have occurred in pregnant women aged older than 35 years. Maternal complications included hypertensive disorder complicating pregnancy, gestational diabetes, chorioamnionitis, placental abruption or placenta previa, and premature rupture of membranes (PROM). Hypertensive disorder complicating pregnancy and gestational diabetes were diagnosed according to national guidelines.21 Chorioamnionitis was confirmed clinically or histopathologically.22 We used PROM to refer to spontaneous rupture of membranes before the onset of labor. Fetal distress was diagnosed based on a rapidly deteriorating or abnormal cardiotocograph or a fetal scalp pH less than 7.2.23 Antenatal steroid was defined as any corticosteroid used to accelerate fetal lung maturity, regardless of doses and timing of administration. We diagnosed BPD as oxygen dependency for at least 28 days.24 The Papile criteria were used to grade IVH.25 We used WMI to refer to cystic and diffuse periventricular leukomalacia.26 Diagnosis of IVH and WMI was done by cranial sonography, magnetic resonance imaging, or computed tomography with the most severe findings during hospitalization. Diagnosis and grading of NEC were performed according to modified Bell criteria.27 Sepsis was defined by clinical symptoms and positive culture from blood or cerebrospinal fluid samples.29 Individuals who had ROP stage 3 to 530 or were receiving treatment  for ROP were considered to have severe ROP.Estimates of GA were obtained, in descending order of preference, from ultrasonography, last menstrual period, or New Ballard Score.Study main outcomes were survival to discharge and major morbidity, which was defined as the presence of BPD, IVH (grade III-IV), WMI, NEC (stage II-III), sepsis, or severe ROP. We further evaluated the proportion of deaths that occurred after withholding or withdrawing life-sustaining intensive care, including ventilation, chest compression, circulatory support, and parenteral nutrition.Results were presented as mean with SD, median with interquartile range (IQR), or numbers with percentage, as appropriate. We used modified Poisson regression models with robust variance estimation to examine the association between GA and short-term outcomes, adjusting for birth weight, study site, and discharge year. Regression models assessing yearly changes in survival and morbidity rates were adjusted for GA, birth weight, and study site.Perinatal risk factors associated with survival were evaluated using multivariable modified Poisson regression, with adjustment for the fixed effect of study sites and discharge year. Infants who died after treatments were withdrawn were excluded from the analysis. Pearson correlation coefficient and variance inflation factor were used to detect collinearity between variables. Maternal and neonatal variables, but not collinear variables, were entered into the model, including GA (in weeks), birth weight , SGA status, male sex, elderly pregnancy status, use of in vitro fertilization (IVF), multiple pregnancy status, cesarean delivery status, maternal complications, fetal distress, 5-minute Apgar score of 7 or less, and antenatal steroid use. Data were missing for fewer than 10% of individuals in almost all measures  , and valP values were 2-tailed, and P < .05 was considered statistically significant. Data analyses were performed using SPSS statistical software version 24.0 (IBM) from August through October 2020.We identified 8514 eligible infants born at 21 weeks and 4 daysto 27 weeks and 6 days of gestation with a mean (SD) birth weight of 967 (181) g, of whom 5295 (62.2%) were male and 116 individuals (2.0%) were SGA. Over the 10-year period, there were more infants in the lower GA categories, with the proportion of infants with GA less than 26 weeks increasing from 33 of 241 infants  in 2010 to 323 of 1656 infants  in 2019. Moreover, the proportion of enrolled infants out of all infants discharged from NICUs, which was calculated excluding infants from hospitals without available data for total number of discharged infants in the corresponding study year, increased from 158 of 107 985 infants in 2010 (0.15%) to 1398 of 201 877 infants in 2019 (0.69%). , 159 of 8110 mothers with chorioamnionitis (2.0%), 729 of 8110 mothers with placental abruption or placenta previa (9.0%), 680 of 8208 mothers with hypertensive disorder complicating pregnancy (8.3%), and 885 of 8208 mothers with gestational diabetes (10.8%). A rising trend was found for all these complications except hypertensive disorder complicating pregnancy from 2010 to 2019.The administration rate of antenatal steroids ranged from 10 of 25 mothers (40.0%) at 21 to 22 weeks to 2211 of 4539 mothers (48.7%) at 27 weeks and increased from 54 of 233 mothers  in 2010 to 957 of 1650 mothers  in 2019. Regional variations existed, with the highest use rate in the south (639 of 1060 mothers [60.3%]) and the lowest in the northeast (100 of 372 mothers [26.9%]) . Among 6277 infants receiving ongoing active treatment, 975 infants (15.5%) died, and among 2237 infants for whom a decision was made to limit or withdraw life-sustaining care, all infants died. Among all deaths, 414 deaths (13.5%) occurred within the first day of life and 1944 deaths (63.3%) occurred in the first week. The median (IQR) length of stay for infants who survived was 68 (53-85) days, increasing from 58 (22-81) days in 2010 to 72 (58-88) days in 2019  at 22 weeks, 13 of 71 infants (18.3%) at 23 weeks, 144 of 408 infants (35.3%) at 24 weeks, 480 of 987 infants (48.6%) at 25 weeks, 1423 of 2331 infants (61.0%) at 26 weeks, and 3241 of 4692 infants (69.1%) at 27 weeks . There wP < .001). The trend in survival varied by GA, as shown in P < .001). However, no significant change was found for infants born at GA less than 24 weeks.The survival rate improved from 136 of 241 infants  in 2010 to 1111 of 1656 infants  in 2019  from 188 of 474 infants (39.7%) in the northwest to 887 of 1153 infants (76.9%) in north China. Improved survival was observed in all regions except northwest and north China  to 652 of 740 infants (88.1%) among study sites. Outcomes for infants from different regions are shown in eTable 4 and eFigure 2 in the Among 5179 infants, BPD occurred in 3835 infants (74.0%); the condition was evaluated in infants who survived more than 28 days. Among 7566 infants examined by cranial imaging, 1262 infants (16.7%) had WMI and 3691 infants (48.8%) developed IVH. Among 8219 infants, NEC occurred in 830 infants (10.1%); of these, 531 infants were diagnosed with stage II to III NEC and 57 developed post-NEC strictures. A total of 2996 of 8259 infants (36.3%) developed sepsis. Ophthalmologic examinations were performed in 4674 of 8281 infants (56.4%), and 3060 of 4674 infants (65.5%) met the diagnostic criteria of ROP. Among 4518 infants, 848 infants (18.8%) had severe ROP.P < .001); the prevalence of severe ROP was 1 of 2 infants (50.0%) at GA 21 to 22 weeks and 358 of 2708 infants (13.2%) at 27 weeks (P < .001). The prevalence increased from 2010 to 2019 for BPD , IVH grade III to IV , WMI , NEC stage II to III , and sepsis , but the prevalence of severe ROP did not change significantly despite increasing rates of ROP screening (As shown in creening .P < .001).(eTable 3 in the P < .001).Overall, major morbidity was present in 5999 of 8281 infants (72.4%), and 780 infants (9.4%) survived without any major morbidity. Major morbidity increased from 11 of 25 infants (44.0%) at 21 to 22 weeks to 3326 of 4552 infants (73.1%) at 27 weeks . AdditioP < .001), birth weight , PROM , and antenatal steroids  were associated with improved survival. However, being born SGA , being male , multiple birth , having a mother with gestational diabetes , and low Apgar score  were found to be risk factors associated with decreased chance of survival (In multivariate analysis of infants with active treatments, we found that GA (adjusted risk ratio [aRR], 1.084; 95% CI, 1.063-1.105; survival . Compari1 Along with social progress, economic development, and medical improvement, the total number of infants born extremely preterm and its proportion among all discharged infants increased steadily over time. Care of these infants has become a critical and urgent issue in China. This cohort study provides valid and detailed information on the short-term outcomes of infants born extremely preterm in mainland China. We found that these infants were at increased risk of mortality and morbidity and that survival rate improved and major morbidity rate increased over time. The strengths of this study are a large number of infants from a nationwide cohort and a long study period spanning 10 years.China, a populous country, ranked second globally in the number of preterm births.8 Researchers have reported improved survival over time for infants born extremely preterm in Canada,31 the US,12 and the Republic of Korea.32 Similarly, we found a significant increase in survival from 2010 to 2019 for infants born at 24 to 27 weeks, but we did not find an increase for infants born earlier than 24 weeks. A study from England5 found that survival increased from 40% in 1997 to 53% in 2006 overall, but without significant improvement for infants born at 22 to 23 weeks. Such variations in trend according to GA may be associated with differences in therapeutic difficulty among infants in different GA groups and decreased willingness to provide active obstetrical and neonatal care for infants at the lowest GA. It could also be a reflection of the biological limit of viability, which cannot be extended easily by medical advances.This study found that several factors were associated with short-term outcomes after extremely preterm birth. We found that survival increased with advancing GA, which was consistent with the results of a 2010 study.34 we found that survival for infants born extremely preterm varied among hospitals and regions. A study from Europe35 found that more than four-fifths of regional variation could not be explained by maternal, pregnancy, or infant characteristics. China has a vast territory with inequities in economic development, medical technology, and quality of health care provision. We found that the lowest survival rate was in the northwest region, which has a subaverage disposable income level per capita for China. Regional disparities in the resources of neonatal medicine, such as experienced professionals and advanced equipment, may be associated with clear differences in outcomes.36 Additionally, such regional variations may be ascribed to different care practices among units and regions owing to a lack of consensus on clinical practices; for example, we found a divergence in use of active treatments, prenatal corticosteroids,37 antibiotics,38 and human milk feeding.39As other studies found,41 while 2 other studies found different results. Blumenfeld et al42 reported no differences in neonatal mortality between those born with and without PROM. Persson et al43 found that maternal diabetes was not associated with increased mortality in high-income countries. However, these studies were performed without considering active treatment. Furthermore, because of the retrospective design of our study and missing data for obstetric interventions, such as maternal antibiotic and tocolysis, associations between these perinatal factors and outcomes should be interpreted with caution.We identified multiple favorable and adverse factors associated with survival, which are largely in keeping with results from 2 previous studies,44 Notably, although the number of infants receiving antenatal steroids has increased over the last decade, the overall administration rate in China was still much lower than in developed countries.12 The present guideline from the Chinese Obstetrics and Gynecology Society recommends use of antenatal corticosteroids between 28 and 34 weeks of gestation without mentioning women who are at risk of preterm delivery at less than 28 weeks’ gestation.14 Practices for extremely preterm birth have not been unified, and large variations were found across different sites and regions. Therefore, it is necessary to reinforce and standardize prenatal management.In line with national trend reports, we observed a significant increase in elderly pregnancy over the study period, which might be associated with the announcement of universal 2-child policy in October 2015.45 In China, the decision to withhold or withdraw care was ethically optional and made primarily by parents. A survey found that the main reasons for parental decision to withdraw care were economic burden and fear of poor or uncertain outcomes.17 Our study could encourage health care professionals and parents to reassess their attitudes toward care at extremely low GA. More active and effective treatment strategies are needed, especially for infants born at later than GA 25 weeks. Certainly, medical decisions should be made in the best interest of each individual by a team discussion among obstetricians, neonatologists, and families, considering not only GA, but also clinical conditions, socioeconomic issues, and other important factors associated with prognosis.We are encouraged by the improved survival of infants born extremely preterm over time, but there are still grounds for concern. First, our study found a high proportion of infants who died after a decision was made to limit or withdraw life-sustaining care. Neonatologists strive to rescue infants with a reasonable likelihood of an acceptable long-term quality of life, but decisions for active treatment, in fact, are complex in clinical scenarios and remain controversial worldwide. In developed countries, there was general agreement to provide comfort care at 22 weeks and active care at 25 weeks, while a wide variation in recommendations was seen for infants with GA from 23 to 24 weeks.6 The observed increase in morbidity in our study may be associated with the higher survival rate of infants with the most premature births. Furthermore, this increase may be associated with a change in practices and advances in diagnostic technology over time, such as improved quality of neuroimaging. Because these major complications have all been associated with neurodevelopmental impairments,46 we suspect that high rates of long-term disorders may exist in infants who survived, calling for continued interventions and updated clinical practice guidelines to improve the outcomes.Second, infants born extremely preterm are still at increased risk of morbidity. In our study, 9.4% of infants survived to discharge without any major morbidity, and the morbidity rate increased over time. By contrast, the rates of NEC, BPD, periventricular leukomalacia, and severe ROP decreased from 1997 to 2011 in France, with an increasing proportion of infants surviving without severe morbidity.47 Second, participating hospitals were not selected randomly, and all were large tertiary centers in urban areas, which may limit generalizability. Third, data were retrospectively collected and long-term outcomes were not available.This study has several limitations. First, our results are not population based. The mortality rate may be underestimated because infants who died in the delivery room were not included, and failure of access to NICUs still exists owing to imperfect transportation systems, especially in less developed regions.This study found that infants born extremely preterm in China were at high risk of mortality and morbidity. Although we found that the survival rate improved over time, major morbidity increased. These findings suggest that more active and effective treatment strategies are needed, especially for infants born at GA 25 to 27 weeks.


Fatigue is an important factor for the safety of ships. In order to alleviate fatigue of the seafarers, the STCW Convention  has made many regulations on the working time of seafarers. At present, if a crew member takes only one day off at home before returning to work on the ship, the working time on the ship must be re-calculated again. If the time spent at home is not sufficient to allow the crew to recover, the regulations of only stipulating the working time, not stipulating the home vacation time, cannot guarantee the crew’s fatigue been well controlled. The aim of present study is to explore the relationship between vacation schedule and fatigue of the seafarers.n = 165). Analysis was conducted using the Cross (chi-square) analysis and hierarchical multiple regression analysis methods.In present study, a simplified stress scale developed by the Ministry of Labor of Japan has been used as a measurement tool. The method of stratified sampling was adopted. Data collection mainly came from domestic ocean-going seafarers (p > 0.05). The length of last vacation time and this service time for seafarers of different positions showed obvious differences (p < 0.01). The rank has a significant effect on the length of the last vacation  and the length of this service time . Also, the results showed that there was a significant negative correlation between the duration of vacation and overall fatigue , while there was a significant positive correlation between the length of service time on board and overall fatigue .We found that there was no difference between crew members of different positions in terms of average vacation time and on-board service time (The results indicated that a reasonable vacation schedule was crucial for the relief of the seafarers’ fatigue, and also played a positive role in the state of working on the ship again. The shortage of seafarers, especially of young officers, is a continuing source of concern in the global shipping industry . As a reLess vacation time and more service time on board means greater separation from family. Separation increases loneliness among seafarers and when coupled with fatigue and stress creates mental depression-a cause of suicide among seafarers . BesidesThis paper mainly discusses the relationship between seafarer’s vacation and fatigue through investigation and research. This paper adopts the QSQ simplified scale  developeCrew fatigue has been recognized by the international community as an important factor threatening maritime safety . FatigueIn order to reduce the risk of crew fatigue, modern merchant ships first adopt a large number of modern technologies to reduce human workload . SecondlSeafarers belong to a special class of occupation, where some evidence from neuroscience shows that the seafarers’ special occupational neuroplasticity . The worHowever, there is a growing awareness of the great importance for recovery during non-working hours to protect workers from the adverse effects of work stress . As a loSD = 9.75), 30–39 have the largest number of people . From the perspective of marital status, it can be seen that the numbers of unmarried (29.1%) and married (70.9%) samples. The collected questionnaires cover various regions. Shanghai has the largest number (38.2%), followed by Guangzhou (8.48%)  and container ships . This sample was stratified by rank and composed of 32 cadets (19.4%), 44 support class crews (26.7%), 80 operation class crews (48.5%) and 9 management class crews (5.4%). The age of the seafarers ranged from 18 to 64 years old  see .A simple occupational stress scale has been developed by the Stress Measurement Team of The Japanese Labor Department . This scIn order to reduce the length of the original version, Please circle the point on the scale that applies to your state today.1 = Not at all  2 3 4 = Most or all the time(1)I feel tired.(2)I feel exhausted.(3)I feel lazy.(4)I feel strained.(5)I feel uneasy.(6)I feel anxious.(7)I feel depressed.(8)Everything is burdensome.(9)I’m in a bad mood.The questionnaire contains 17 questions which were mainly divided into three parts. The first four questions were mainly collected as basic information, related to the seafarers’ position, age, marital status, company location (Q1–Q4). In addition to demographics, questions such as “the duration of the last vacation, duration of this service on ship, average time spent on the ship and average vacation time at home” were also designed (Q5–Q8). Vacation refers to the period during which a crew member is on leave at home. The first two items were used as vacation evaluation items, while the second two items could be used for basic statistics of Chinese seafarers’ vacation. The last 9 items are fatigue items of seafarers based on the simplified version of occupational stress scale (Q9–Q17) see .The data used in present study were collected from several ship management companies in different regions of China. Participation was anonymous and voluntary written consent was obtained from all participants. The study was approved by the Ethics Committee of the Shanghai Maritime University. Questionnaires were distributed via email to all 10 of the Chinese companies’ vessels that were at sea. In order to get more precise answers and a higher response rate, the questionnaire was translated into Mandarin prior to distribution to the Chinese seafarers. The translated and reverse translated versions were then compared in order to verify discrepancies and make corrections . QuestioExploratory data analysis showed that, for the majority of the variables, the assumptions for using parametric tests were satisfied . Constru2 = 25.5, p = 0.000), age , and marital status  presents a significant (p < 0.01). This means that the location, age and marriage of different rank samples are different from each other which has good statistical significance.p < 0.05) indicated the sample’s adequacy for this procedure . These indicated that correlation matrix was not an identity one and factor analysis was able to be carried out  and the Bartlett’s test  in Q7 and Q8, implying that there was no difference between crew members of different positions in terms of average vacation time and length of service on board. In addition, for Q5 and Q6 were significant (p < 0.01) in the sample of positions. In recent years, with the loss of seafarers, especially young senior seafarers, the last leave time and the current service time of seafarers in different positions showed significant differences.The chi-square test  was used to study the differences among the four items, including Q5: the duration of the last vacation, Q6: the duration of this service, Q7: how long you work on the ship for each vacation, and Q8: how long you take each vacation. From 2 = 101.560, p = 0.000 < 0.01). Through the percentage comparison, it could be seen that the proportion of management grade and operation grade choosing one month was 77.78%, 65.00% respectively, which was greatly higher than the average level of 50.91%. The proportion of supporting grade choosing 2 months was 40.91%, which was significantly higher than the average level of 35.15%. The proportion of cadets who choose three months or above was 62.50%, which was dramatically higher than the average level of 12.73%. As it could be seen from the above, officers took less time off at home than ordinary crew.The rank had a significant effect on the length of the last vacation . According to the percentage comparison, 62.50% of cadets chose 1–3 months, which was significantly higher than the average level of 15.76%. The proportion of management grade and operation grade choosing 6–9 months was 66.67 and 57.50% respectively, which was significantly higher than the average level of 44.85%. It showed that the officers generally work long hours on the ship and are not easy to change shifts.The rank also had a great effect on the length of this service time . The average fatigue value of the nine items in the questionnaire was between 2.71 and 2.95 . So the crew was indeed in a state of fatigue. There was no denying that the timing of our investigation coincided with the outbreak, which may have exacerbated the fatigue scores to some extent , that was, at least one of the rank, company location, age, and marriage will have an impact on the overall fatigue, and the model formula was: overall fatigue = 1.412 + 0.547* position + 0.116* company location + 0.013* age –0.232* marriage. The regression coefficient of rank was 0.547 and showed a significant value , indicating that rank had a significant positive effect on overall fatigue. The regression coefficient value of the company location was 0.116, and it was significant , which meant that the company location had a significant positive influence on the overall fatigue. This may be related to the company’s human resource policies, such as vacation arrangements, promotions, compensation, and training. The regression coefficient of age was 0.013, which showed no significant difference , The regression coefficient of marriage was –0.232, and there was no significant correlation .From F-value showed significant (p < 0.05), indicating that the length of last vacation and service this time had explanatory significance for the model. In addition, the R-square value increased from 0.418 to 0.779, indicating that the duration of last vacation and the duration of this service could account for 36.1% of the overall fatigue. Specifically, the regression coefficient of the length of last vacation was –0.571, and it was significant , which meant that the length of last vacation had a significant negative influence on the overall fatigue. The regression coefficient of the service length was 0.267, and it was significant , which meant that the service length would have a significant positive impact on the overall fatigue.For Model 2, after the length of last vacation and service this time was added on the basis of Model 1. The change of t = –7.160, p = 0.000 for last vacation time, t = 3.474, p = 0.001 for service time). This result made us know the importance of reasonable vacation arrangement. It could not only strengthen the communication with family members, reduce the degree of separation, and help companies to retain the crew, but also become an effective strategy to alleviate crew fatigue. This point played a vital role in crew’s own life and health safety, and even the safety of the ship, which would cause sufficient attention from the seafarers’ companies, competent authorities and international regulations.Through our study on fatigue, it was found that the crew was indeed in a serious state of fatigue. In the process of vacation statistics, most of the crews were found to have insufficient vacation and overworked on the ship, especially the senior crew. The higher the rank was, the greater the degree of fatigue was. As with most research, the results of the present research must take into account certain limitations. Firstly, few previous studies had investigated effects of vacations on fatigue in the seafaring. Some of the existing studies illustrate the significance of vacation for seafarers from the perspective of crew retention , 2021. MOverall, the fatigue of seafarers is a complex structure that may be manifested by various occupational factors. In this paper, findings illustrated that relatively more vacation time and less work time are important to alleviate seafarers’ fatigue. On the one hand, these results can help shipping companies develop better leave management systems and ensure high-quality work for seafarers on board. On the other hand, the research results have important guiding significance for shipping companies to strengthen the management system of leave and the protection of seafarers’ rights and interests. Factors affecting the well-being and performance of maritime workers exist at various work levels, including task, individual, team, organization and industry . While tThe raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.JA and WG conceived and designed the study and collected and analyzed the data. WG, RL, and ZL wrote the first draft. All authors contributed to later drafts and approved the final manuscript.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.