Although effects of weather changes on human health have been widely reported, there is limited information regarding effects on pregnant women in developing countries.We investigated the association between maternal exposure to ambient temperature and the risk of preterm birth (< 37 weeks of gestation) in Guangzhou, China.We used a Cox proportional hazards model to estimate associations between preterm birth and average temperature during each week of gestation, with weekly temperature modeled as a time-varying exposure during four time windows: 1 week (the last week of the pregnancy), 4 weeks (the last 4 weeks of the pregnancy), late pregnancy , and the entire pregnancy. Information on singleton vaginal birth between 2001 and 2011 was collected. Daily meteorological data during the same period were obtained from the Guangzhou Meteorological Bureau.A total of 838,146 singleton vaginal births were included, among which 47,209 (5.6%) were preterm births. High mean temperatures during the 4 weeks, late pregnancy, and the entire pregnancy time windows were associated with an increased risk of preterm birth. Compared with the median temperature (24.4°C), weekly exposures during the last 4 weeks of the pregnancy to extreme cold  and extreme heat  were associated with 17.9%  and 10.0%  increased risks of preterm birth, respectively. The association between extreme heat and preterm birth was stronger for preterm births during weeks 20–31 and 32–34 than those during weeks 35–36.These findings might have important implications in preventing preterm birth in Guangzhou as well as other areas with similar weather conditions.He JR, Liu Y, Xia XY, Ma WJ, Lin HL, Kan HD, Lu JH, Feng Q, Mo WJ, Wang P, Xia HM, Qiu X, Muglia LJ. 2016. Ambient temperature and the risk of preterm birth in Guangzhou, China (2001–2011). Environ Health Perspect 124:1100–1106; http://dx.doi.org/10.1289/ehp.1509778 Preterm birth, defined as birth < 37 completed weeks of gestation, is a complex syndrome and remains a major global public health problem . It is eSeasonal weather changes have extensive effects on human health outcomes, especially for overall mortality, infectious diseases, and cardiovascular diseases . As a spThe most biologically relevant time period for effects of temperature on preterm birth is not known. Previous studies focused mainly on the short-term exposure, which was defined as a few days or weeks before delivery . BecauseAnimal studies have suggested that high temperature exposure could lead to dehydration, reduce uterine blood flow , and incGuangzhou is the largest metropolis in Southern China with a population of 12.9 million . It has All singleton vaginal births at the gestational age of 20–43 weeks were included in the present study. Because the data were collected by the birth date, short pregnancies from the earliest possible conception dates that terminated before the start date of the study (1 January 2001) were not included in the analysis; similarly, long pregnancies from the latest possible conception dates that terminated after the end date of the study (31 December 2011) were also not included in the analysis . Thus, wThis study was approved by the institutional ethical committee board of Guangzhou Women and Children’s Medical Center. Data used in this study were anonymous, and no individual identifiable information was available for the analysis.Preterm birth was defined as birth < 37 completed weeks of gestation. Gestational age at birth was determined according to an ultrasound examination in the first or second trimester . If the 10; micrograms per cubic meter), sulfur dioxide , and nitrogen dioxide . Air pollution data were measured at a fixed environmental monitoring station located in the center of Guangzhou. The monitoring station providing meteorological and air pollution data follows the quality assurance and quality control programs that were mandated by the Chinese government. These data on temperature and air pollution have been widely used to explore their effects on mortality in Guangzhou  and relative humidity (percent), were collected from the Guangzhou Meteorological Bureau. The meteorological data were recorded at a meteorological station in Guangzhou. Daily values for temperature and relative humidity were calculated by averaging four measurements taken at 6-hr intervals over each 24-hr period. Daily air pollution data from 2006–2010 were obtained from Environmental Monitoring Center, including particulate matter with an aerodynamic diameter ≤ 10 μm  1-week (the weekly mean temperature during week t); b) 4-week ; c) late pregnancy  and d) cumulative   .We modeled time-varying weekly temperatures during each time window as a cubic spline with 3 degrees of freedom (df) to allow a nonlinear relationship with preterm birth, and plotted the resulting hazard ratios (HRs) and 95% confidence intervals (CIs) to show the relationship over the entire temperature distribution. In addition, we calculated specific HRs relative to the local median temperature (24.4°C) for locally extreme cold  and moderate cold , and for locally extreme heat  and moderate heat  . In addiMaternal age was categorized into three groups  and included in the model as a stratified variable , because10, SO2, and NO2 as time-varying covariates, using time windows corresponding to those used for temperature. However, because air pollution exposures might be causal intermediates between temperature and preterm birth, adjustment may block part of the total effects of temperature ] = α + βtTemp,l + NS + NS + γtDOW + δLog(tZ),Log[t represents the day of the observation; tY is the observed number of preterm births on day t; t,lTemp is a matrix representing the two-dimensional relationship of mean temperature and lag days; l denotes the maximum lag days; NS is a natural cubic spline with 5 df for relative humidity; NS is a natural cubic spline with 5 df/year for long-term trend and seasonality; and tDOW is the day of the week . tZ is a daily expected count of preterm births on day t:where jtZ is the number of pregnancies at risk during gestational week j (ranging from 20 through 36 weeks) on day t, and jW is the conditional probability of birth during gestational week j, as proposed by where All statistical analyses were performed using SAS statistical software version 9.3  and the R statistical environment (version 2.15)  with theA total of 1,420,348 singleton births at the gestational age of 20–43 weeks were recorded during the study period. After exclusion of 582,202 cesarean section births (with preterm birth rate of 5.2%), 838,146 singleton vaginal births were included in this study. Among them, 47,209 (5.6%) were preterm births, with a daily average of 11.8 preterm births. The demographic characteristics of the study population are shown in sr = 0.098). The median daily mean temperature and relative humidity were 24.4°C and 74% during the study period. The Spearman’s correlations showed a weak correlation between mean temperature and relative humidity  and 32–34  compared with preterm births during weeks 35–36 , though estimates for later preterm births were more precise, at least in part due to larger numbers of observations  after adjustment for weekly average PM10, SO2, and NO2 concentrations during time windows corresponding to those for temperature were similar to those for overall study population, although HRs were slightly attenuated and less precise after adjustment. However, these differences may be attributable at least partly to the use of a different population (2006–2010 vs. 2001–2011), rather than to effects of adjustment for air pollutants per se .In the sensitivity analyses, we included the month as a spline with 3–6 df, and the effect estimates for temperature remained similar (see Table S1). HRs for temperature and preterm among pregnancies during 2006–2010 . Associations with extreme cold and extreme heat both were strongest for temperature on the same day of preterm birth (lag 0) and null after 4- and 6-day lags, respectively. The association with extreme cold was strongest for the longest cumulative lag (lag 0–27), whereas HRs for extreme heat were > 1 at lag 0–6 but < 1 for longer cumulative lags (see Table S2).In the present study, both low and high temperatures during pregnancy were associated with an increased risk of preterm birth. Extreme cold temperatures were associated with the risk of preterm birth during all time windows examined , and extreme heat was associated with preterm birth risk during all but the shortest time window of exposure. Furthermore, extreme heat was more strongly associated with preterm births during 20–31 and 32–34 weeks of gestation than with preterm births during weeks 35–36.To our knowledge, this study may be the first one to investigate the effects of ambient temperature on the risk of preterm birth in developing countries . Air conThe prevalence of preterm birth among singleton in the study area  was similar to those of previous reports in Guangzhou (5.1% to ~ 6.4% from 2002 to 2012) , Korea , and JapFew studies have explored the effects of ambient temperature on the rate of preterm birth with inconsistent results . Two larThere were several potential reasons for differences between our findings and those of previous studies. First, the range of climatic conditions, socioeconomic level, and population susceptibility may vary across areas. In addition, we speculate that the study design, statistical methods, exposure windows, and sample size are important factors . For exaBiological mechanisms that might contribute to the association between ambient temperature and preterm birth are unclear. Previous studies proposed several hypotheses. High temperature exposure causes dehydration and reduces uterine blood flow in pregnant women, which can induce the uterine contraction and onset of labor . In addiSeveral limitations should be mentioned. First, we used data from one meteorological station to define the exposure for all women in Guangzhou. This could cause exposure misclassification. Second, we were unable to distinguish spontaneous preterm birth from iatrogenic preterm birth, although we restricted the study population to those with vaginal delivery. Exposure to temperature might have different effects on these subtypes of preterm birth. We have no data on the percentages of identification method of gestational age  and their changes during the study period, which might influence the incidence of early preterm birth and late preterm birth. In Guangzhou, it is a routine practice to confirm gestational age using ultrasound examination in the first or second trimester . HoweverExposure to both low and high temperatures during pregnancy was associated with an increased risk of preterm birth in our study population. These findings might have important implications in preventing preterm birth in Guangzhou as well as other areas with similar variations in weather conditions.(1.7 MB) PDFClick here for additional data file.


Petromyzon marinus in free-flowing streams. Non-target mortality was rare and impacts to non-target migration were minimal; likely because pulsed direct current only needed to be activated at night (7 hours of each day). The system was completely portable and the annual cost of the trapping system was low . Use of the technology is poised to substantially advance integrated control of sea lamprey, which threaten a fishery valued at 7 billion U.S. dollars annually, and help restore sea lamprey populations in Europe where they are native, but imperiled. The system may be broadly applicable to controlling invasive fishes and restoring valued fishes worldwide, thus having far reaching effects on ecosystems and societies.A novel system combining a trap and pulsed direct current electricity was able to catch up to 75% of tagged invasive sea lamprey  Invasive species cost the global economy billions to trillions of U.S. dollars annually147891112Resource managers are often mandated to protect valued fishes while providing water for human use15172022Control of invasive fishes and restoration of valued fishes could be improved if a technology existed to guide their migration; in some cases invasive fishes could be guided into traps for removal and in other cases valued fishes could be guided to safe passage around dams. Many tactics already exist to guide fishes, but most are ineffective, costly, difficult to modify after construction, or cause an undesirable change in the waterway25Petromyzon marinus during their upstream spawning migration. The sea lamprey is highly invasive in the Laurentian Great Lakes3134We tested our conceptual model on adult sea lamprey We deployed the trap and electric lead under completely natural conditions in the Chocolay River, MI, USA , and opeA limitation of the experiment conducted in the Chocolay River was that the electric lead was not operated every night and sea lamprey escaped upstream when it was off. To determine the percentage of sea lamprey that could be removed if the electric lead was operated daily, the portable trap and electric lead was deployed in Bridgeland Creek, ON, Canada , during 955 = 5.11, p < 0.001), potentially resulting from the addition of a 25 cm fiberglass wing to the trap during year two (see methods). During both years, sea lamprey that were longer than the median length (48 cm) were more likely to be captured , and sea lamprey were more likely to be captured when discharge was higher than the median observed discharge . However, sea lamprey length and discharge interacted  such that at high discharge, long and short sea lamprey had nearly the same probability of being captured . PIT-tagged sea lamprey were about 20% more likely to be captured in the trap with an electric lead during the second season . Julian date was not included as a possible predictor because all sea lamprey released were sexually immature. Sex was evaluated, but removal of the sex effect reduced AIC by 2, whereas removal of any other effect resulted in an AIC higher than the full model. Therefore, results from the model without sex were reported. Interactions of length and discharge with sex were not considered because sex was not significant as a main effect in the model. All models evaluated and the final model reported here showed no evidence of overdispersion or nonlinearities.An effective invasive species trapping device is most likely to be useful if it minimally impacts non-target species. Therefore, at Bridgeland Creek we also evaluated the capture of non-target species in the trap with electric lead and a standard sea lamprey trap that was operated 40 m upstream to determine what non-target species were moving through the site. During the first season at Bridgeland Creek, the trap with electric lead captured 511 non-target fishes representing 12 different species, while a standard sea lamprey trap captured 1,354 non-target fishes representing 11 different species . During Oncorhynchus mykiss) were captured at expected levels based on previous years, although only about five rainbow trout were captured on average per year. Most non-target fishes were removed from the trap and released alive, except during the first season, when overcrowding of sea lamprey and non-target fishes in the trap with electric lead caused significant mortality during nine nights  to determine if non-target fishes captured in the standard sea lamprey trap upstream passed the electric lead while off or on (during the day or night). Rock bass were the most abundant non-target species observed in our experiment. Other non-target fishes were tagged, but not in great enough numbers to reveal their migratory patterns . During the second trapping season, we tracked movement of PIT-tagged rock bass  to operate the trap with electric lead at Bridgeland Creek was calculated. The average annual cost to staff a sea lamprey trap currently ranges between $5,000 and $15,000 (U.S. Dollars). Here, we specifically calculated the annual cost of the trapping device; comparing the cost of the trap with electric lead to traps traditionally used to catch sea lamprey. The trap with electric lead cost $45,000 and dividing the cost by the estimated life expectancy (15 years), yielded an annual expense of $3,000. Multiplying the hours required to seasonally deploy, clean, and seasonally decommission the trap with electric lead (90 hours) by a technician hourly pay rate ($20) yielded an average yearly staff cost of $1,800. Taken together, the total annual cost for the trap with electric lead was $4,800, not including staff costs for operating the trap itself.The current study builds on previous work which showed that the electric guidance system was effective at increasing sea lamprey encounter rates with traps in laboratory and small-scale stream experiments over short time scales (single nights)2, chemosensory cues, can alter fish behavior without obstructing a waterway, and can be deployed where physical devices would cause an unacceptable change in a waterwayHere, by pairing a non-physical electric lead with a portable trap, we were able to remove up to 75% of the tagged invasive sea lamprey in a natural stream using a single device that was seasonally deployed and cost effective relative to most traditional physical structures used to catch sea lamprey. Physical devices such as screens or concrete devices have been used to direct fishes to passage devices or traps, but they physically alter the waterway, can accumulate debris, are difficult to modify after construction, and can be prohibitively expensive37The electric field used here overcame many of the challenges of previous electric systems used to modify fish behavior. The first electric barriers to block sea lamprey in the Great Lakes used 110 V alternating current actuated through vertical electrodes suspended above the stream42Ameiurus nebulosus likely passed through the electric field during the night when it was activated. The voltage transferred to a fish depends in part on the voltage gradient in the water and fish lengthSander vitreus; in the Great Lakes region) may be guided by the electric field similar to sea lamprey, but this has not been explicitly tested. Recently, a similar electric guidance system induced avoidance responses in several downstream migrating European fishes in laboratory environmentsHypophthalmichthys sp., northern pike Esox lucius, rainbow trout, and valued fishes such as Pacific lamprey Entosphenus tridentatus, Pacific salmon Oncorhynchus sp., and walleye.The trap with electric lead captured most sea lamprey in the stream, while also allowing passage of non-target species, unlike many other physical and non-physical barriers. As sea lamprey are primarily nocturnalThroughout the world, lampreys are valued for the ecological services they provide as well as their value as foodIn the case of sea lamprey control in the Laurentian Great Lakes, removing adult sea lamprey using traps with electric leads may be sufficient to achieve ecosystem restoration goals. To reduce lake-wide adult sea lamprey abundance to levels sufficient to achieve ecosystem restoration goals, removal of 59% of the Great Lakes spawning stock each year is suggested46Integration of electric leads with other tactics could improve efficiency and reproductive suppression. The trap with electric lead could remove more sea lamprey if the trap was baited with synthesized sex pheromone483/sec during the spring (3/sec), the width was 11 m and the depth and water velocity across the channel averaged 0.86 m (SD = 0.22 m) and 0.24 m/sec (SD = 0.09 m/sec), respectively , the width was 12 m and the depth and water velocity across the channel averaged 0.39 m (SD = 0.13 m) and 0.59 m/sec (SD = 0.35 m/sec), respectively  and plotted on a stream map . Electroth and continuing until June 24th, 2015. The electric lead was only operated during the night to minimize the impact to non-target fish migration, while still targeting most migratory sea lamprey. The electric lead was not operated and the trap was not checked during a flood event (May 26th through June 3rd) because the trap could not be accessed . During 2015, the electric lead was operated only at night during the entire operational period regardless of water temperature to determine if high sea lamprey exploitation rates observed during 2014 could be achieved with presumably less impact to non-target species. All traps used in the study were checked daily (except during the Chocolay River flood). Captured animals were sorted according to species. Captured sea lamprey were sexed and inspected for passive integrated transponders (PIT tags). Non-target catch was also inspected for PIT tags during 2015, counted, and immediately released. Experimental protocols involving the handling of fishes were carried out in accordance with United States federal guidelines for care and use of animals and were approved by the American Fisheries Society through the “Use of Fishes in Research Committee, 2014”At the Chocolay River, the trap with electric lead was operated from 2200 to 0500 hours every other night starting April 29accessed . At Brid3) located 0.5 km and 1.5 km downstream of the trap on Chocolay River and Bridgeland Creek, respectively. Cage entrances were opened at 1600 hours for each release event. In Bridgeland Creek, the number of PIT-tagged sea lamprey (1) approaching within 20 m of the trap with electric lead, (2) moving downstream from the trap, and (3) escaping upstream of the trap was determined by placing two PIT tag detection antennas 20 m below and above the trap. A similar approach was used at Chocolay River except that one of the upstream PIT-tag detection antennas was not deployed and instead was placed at the trap entrance to quantify encounters with the trap entrance. Sea lamprey to be PIT-tagged were sourced from multiple streams because at times sea lamprey availability was limited. At the Chocolay River, PIT-tagged sea lamprey were initially captured in the Chocolay River and the Rock River, MI. At Bridgeland Creek, nearly all the PIT-tagged sea lamprey were sourced from the Cheboygan River, MI, except during the first year when sea lamprey were also sourced from the Bridgeland Creek and the Echo River during the first release date. See At least 12 hours prior to release, sexually immature sea lamprey were weighed and measured and then uniquely-encoded PIT tags 32 mm) were inserted in the abdomen through a 3 mm incision. Tagged sea lamprey were placed in release cages  where the probability of capture was explained by biological, chemical, and physical variables: (1) sex, because male and female sea lamprey may respond differently to electric fields, (2) length, because voltage change across a long sea lamprey would be greater than voltage changed across a short sea lamprey, (3) stream discharge, because at high stream discharges sea lamprey would be exposed to the electric lead longer because progress upstream would be slower and (4) the interaction between length and stream discharge, because short sea lamprey may be more likely to escape through the field, but they also have poorer swimming ability. The Akaike Information Criterion (AIC) based stepwise procedure described in Faraway (2005)In Bridgeland Creek, capture of non-target species in the standard trap fished upstream of the trap with the electric lead during 2014 and 2015 were compared to historic captures of non-target species (1999–2013). For each species that was captured in the upstream trap in at least 11 of the past 13 years (1999–2013), the 95% confidence interval (α = 0.05) was calculated for the number of individuals from each species expected to be captured in the upstream trap in a given year. We determined if the number of individuals captured in the upstream trap by species during 2014 and 2015 was within the 95% confidence interval of the historic number captured. Captures of non-target species in the trap with electric lead were also recorded and a survey for injured or dead animals was conducted daily by walking from the trap with electric lead downstream 200 m.During 2015, nets were deployed downstream of the trap with the electric lead to capture non-target species moving upstream. Any non-target species greater than 120 mm received a 23 mm PIT tag  through How to cite this article: Johnson, N. S. et al. A portable trap with electric lead catches up to 75% of an invasive fish species. Sci. Rep.6, 28430; doi: 10.1038/srep28430 (2016).


To determine the association of season of birth and refractive error in very young Chinese children in China.We conducted a population-based study of Chinese children aged 0 to 3 years residing in eastern China. Refraction was determined by non-cyclopegic autorefraction using a hand-held autorefractor. Date of birth was retrieved from birth certificate of the individual subjects. A generalized linear regression model was fitted to estimate the regression coefficient and 95% confidence interval (CI) of refractive error for season of birth, adjusting for confounders.Of the 1385 children eligible to participate, 1222 (88.2%) were examined. Refractive error data were available for 1219 children. The mean spherical equivalent were 1.21 diopters (D) in children born Spring, 1.24 D in those born in Summer, 1.23 D in those born in Autumn, 1.15 D in Winter. After adjusting for age, sex, father's educational level, birth weight and the number of summers between birth and examination date the children have been exposed to, children born in winter had a 0.12 D more myopic refraction compared with those born in summer . The association between season of birth and cylinder power was not statistically significant.In China, children born in winter had a more myopic refraction compared with those born in other seasons. The observed association between season of birth and refractive error was independent of parental educational level and birth weight, suggesting that light level may have a small impact on refractive development in early life. Refractive error, especially myopia, is a major health concern throughout the world due to its increasingly high prevalence in the past few decadesUnderstanding the relationship between season of birth and refractive error may provide further insights into how light levels could affect refractive status in early life. In the northern hemisphere, day lengths are relatively longer in summer and shorter in winter. Therefore, infants born during summer might be exposed to relatively higher levels of light compared with those born during winter. Up till now, only 2 studiesIn this study, we assessed the relationship between season of birth and refractive error in Chinese children aged 0–3 years in urban city in eastern China.The study was approved by the Ethics Committee, Medical College of Soochow University and followed the tenets of the Declaration of Helsinki. Written informed consent was obtained from all parents after the nature of the study was explained.The study site was located in the Child Health Service Center in Xiangcheng District, Suzhou city, China, which provided free health screening for local children aged 0–3 years residing in this town. Before the health screening, an invitation letter was sent to each family in the town and nature of the health screening was explained in the letter. Based on the official records, there were 1385 children aged 0 to 3 years residing in the town in 2013 and 1222 (88.2%) children were screened in 2013.Non-cyclopegic autorefraction was performed by a trained optometrist with a hand-held autorefractor . Sex, date of birth and birth weight were retrieved from birth certificate of the individual subjects. Date of examination was recorded and age at examination was calculated. Information on parental educational level was collected using questionnaires. Months of birth were also grouped together to divide the year into 4 seasons: winter (December–February), spring (March–May), summer (June–August), and autumn (September–November). Cover tests were performed by using fixation targets at both distance (6 m) and near (30 cm) and the presence of strabismus were recorded. Spherical equivalent (SE) was defined as sphere plus half cylinder. Myopia was defined as SE of −0.50 diopter (D) or less. Hyperopia was defined as SE of 0.50 D or more and astigmatism was defined as cylinder power less than −0.50 D.As the Spearman correlation coefficient for SE in the left and right eye was high , only right eye data were used for analyses. SE and cylinder power were analyzed as continuous outcome variables and season of birth was investigated as categorical explanatory variables, respectively. Generalized linear regression models with data of right eyes were fitted to estimate the regression coefficients and 95% CIs of refractive error and cylinder power for season of birth, adjusting for age and gender. In multivariate analysis, we further adjusted for father's educational level, birth weight and the number of summers between birth and examination date the children have been exposed to. Statistical analyses of the data were carried out using SPSS 16.0 . P<0.05 indicated statistical significance.Totally 661 boys and 561 girls were screened in the health service center in 2013. Three of them refused to participate in the eye screening and therefore 1219 children aged 0 to 3 years were included in the analysis. The mean age of the study subjects were 14.12±9.80 months. The mean SE were 1.26±0.73D in the left eye and 1.22±0.74D in the right eye. The prevalence of myopia was 0.3% in boys and 0.5% in girls. The prevalence of hyperopia was 91.2% in boys and 93.5% in girls. The prevalence of astigmatism was 74.3% in boys and 74.8% in girls. The prevalence of strabismus was 0 in the overall study sample. Table 1The mean SE were 1.21D in children born Spring, 1.24D in those born in Summer, 1.23D in those born in Autumn, 1.15D in Winter. In this study of very young Chinese children, we found that children born in winter had a more myopic refraction compared with those born in summer. The observed association between season of birth and refractive error was independent of parental educational level and birth weight. Considering that the magnitude of difference in refraction between children born in summer and winter was only about 0.1D, the results indicated that light level may have a small impact on refractive development in early life.The association between season of birth and refractive error has been investigated in two adult cohorts and one children cohort. In Israeli-born conscripts aged 16 to 22 years, it was found that birth during summer was a risk factor for moderate and high myopia, but not low myopiaThe biological mechanism linking season of birth to refractive error needs to be further discussed. Experimental and clinical results suggested that refractive development may be related to ambient light exposureIn addition to the variation in time outdoors, season of birth reflects other population-wide changes in environmental variables including temperature, humidity, diet, sleeping time and so on. Up till now, there have been few data addressing the potential roles of these changes as risk factors for refractive error, one can only speculate which of these variables, if any, might be related to refractive error. For example, Lin et al found that higher saturated fat and cholesterol intake are associated with longer axial length in Chinese childrenMcMahon et al also suggested that the association between season of birth and refractive error may be confounded by prenatal or postnatal development such as birth weight or parental socioeconomic statusThe participants of our population-based study were very young, which reduced potential biases compared with previous adult studies on this research topic. There are also some limitations of our study which should be considered. First, non-cyclopegic refraction was performed as the study subjects are too young and most parents refused the cyclopegic refraction. Non-cyclopegic refraction might have possibly overestimated the prevalence of myopia in our study but we feel that its effect on the association between refractive error and season of birth is minimal. The use of the Retinomax may cause a significant negative shift in refraction, even with cycloplegia. Secondly, we only adjusted parental educational level and birth weight in multivariate analysis. There may be other residual confounders which were not captured by our study such as parental myopia and time outdoors.In conclusion, Chinese children born in winter had a more myopic refraction compared with those born in summer in eastern China. The observed association between season of birth and refractive error was independent of parental educational level and birth weight. These findings support that ambient light exposure may have a small impact on refractive status in early life.


A dentigerous cyst encloses a crown of an unerupted tooth by its follicle and is attached to the neck of the tooth. They may be of developmental or inflammatory origin. Dentigerous cyst of inflammatory origin occurs in immature tooth as a result of inflammation from preceding non-vital deciduous tooth or from other source spreading to involve the tooth follicle. These are diagnosed in the first and early part of second decade either on routine radiographic examination or when patient complains of swelling and pain. They generally involve mandibular premolars.This article presents a case report of an 11-year-old male patient with a dentigerous cyst of inflammatory origin in the left mandibular premolar region with radiographic feature of a large unilocular radiolucency involving unerupted second premolar. The treatment rendered in this patient comprised of surgical enucleation of cyst under local anesthesia along with extraction of mandibular first and second primary molars. Pain may be present only when they are secondarily infected.An 11-year-old male patient reported with a complaint of swelling on the lower left side of the face which was present since one month. The patient gave history of pain in that region since one week on mastication.Extraoral examination revealed swelling in the left mandibular region which extended laterally 2 cm away from the corner of the mouth to 2 cm prior to the angle of the mandible and inferiorly to the lower border of the mandible. The swelling was firm in consistency and tender on palpation.Intraoral examination revealed a swelling extending laterally from distal surface of the mandibular left permanent canine to the distal surface of the mandibular left first permanent molar, superiorly up till the gingival margin and inferiorly obliterating the vestibule. Mandibular left primary first and second molars showed deep carious lesions . On percThe panoramic radiograph showed a coronal radiolucency involving pulp with the mandibular left second primary molar. A large unilocular, well-circumscribed radiolucency enveloping the unerupted mandibular left second premolar, attachment being at the cervical margin of the premolar was also seen. Radiograph also showed furcation radiolucency along with external root resorption of the second molar and apical displacement of the unerupted second premolar . AspiratWith above findings, it was preliminarily diagnosed as dentigerous cyst with a differential diagnosis of radicular cyst and odontogenic keratocyst. The two treatment options considered were marsupialization of the cyst into the oral cavity or enucleation of cyst.Treatment procedure was started with administration of local anesthesia by giving an inferior alveolar nerve block on the left side. Sulcular and relieving incisions were given using a number 15 BP blade. Mucoperiosteal flap was raised by periosteal elevator and the cystic lesion with primary molar roots was exposed.It was decided to surgically enucleate the cyst because of the extensive size of the lesion. This was done along with extraction of mandibular left primary first and second molars . The mucMacroscopically the specimen measured 3 × 2.5 cm, which was attached to the neck of the left mandibular second premolar and the apical view showed the apical displacement of the tooth bud  and B. MOn the basis of clinical, radiographic and histo-pathological findings, the present case was diagnosed as dentigerous cyst of inflammatory origin involving the unerupted left mandibular second premolar.5 The dentigerous cysts are mostly discovered by routine radiographic examinations or by enlargement of affected region in the jaw.Dentigerous cysts are benign odontogenic cysts associated with crowns of unerupted permanent teeth.2 They proposed that developmental dentigerous cyst might form a dental follicle and might become secondarily inflamd, a source of inflammation being a non-vital tooth. The second mechanism they proposed was formation of a radicular cyst at an apex of a non-vital deciduous tooth followed by eruption of its permanent sucessor into the radicular cyst resulting in a dentigerous cyst of extrafollicular origin.The pathogenesis of dentigerous cyst is still controversial. Three feasible mechanisms have been proposed for histogenesis of the cyst by Benn and Altini:6 Available evidence in our case indicated that infection of the predecessor (second primary molar) could have been the source of inflammation of the dentigerous cyst.They also suggested that follicle of permanent successor might get secondarily infected from either periapical inflammation of a non-vital predecessor or other source leading to a dentigerous cyst formation. Earlier reports of dentigerous cysts associated with non-vital predecessors support this mechanism.7 In the case presented here, the unerupted premolar did not show enamel hypoplasia and it may be inferred that the cyst may have developed after the crown was fully formed.Unerupted tooth enveloped by a dentigerous cyst may or may not show enamel hypoplasia depending on the time of commencement of a dentigerous cyst. Enamel hypoplasia is seen when a dentigerous cyst commences at an early stage of development of the involved tooth whereas in cases where the cyst originating after the completion of tooth development, enamel hypoplasia is not a significant factor.11Dentigerous cysts are usually single lesions as presented in this case. Bilatral and multiple cysts have been reported in patients with syndromes, such as basal cell nevus syndrome, mucopolysaccharidosis and cleidocranial dysplasia.12 as dentigerous cysts are known to recur rarely.13 Enucleation of a dentigerous cyst along with removal of the associated permanent tooth is recommended if it shows arrested development, is extensively displaced,14 or if the lesion is extensive.Recommended treatment for dentigerous cyst is marsupialization, if there appears to be a reasonable prospect that the involved tooth might be brought into its normal position in the arch,In the case presented here, enucleation of the cyst along with the involved tooth was preferred because of the extensive size of the lesion and apical displacement of the unerupted second premolar.


A receptor is likely to counteract the effects of glutamate excitotoxicity – actions that may protect the preterm and term fetal brain from the effects of birth hypoxia. In this review we discuss the development of creatine synthesis during fetal life, the transfer of creatine from mother to fetus, and propose that creatine supplementation during pregnancy may have benefits for the fetus and neonate whenever oxidative stress or feto-placental hypoxia arise, as in cases of fetal growth restriction, premature birth, or when parturition is delayed or complicated by oxygen deprivation of the newborn.While the use of creatine in human pregnancy is yet to be fully evaluated, its long-term use in healthy adults appears to be safe, and its well documented neuroprotective properties have recently been extended by demonstrations that creatine improves cognitive function in normal and elderly people, and motor skills in sleep-deprived subjects. Creatine has many actions likely to benefit the fetus and newborn, because pregnancy is a state of heightened metabolic activity, and the placenta is a key source of free radicals of oxygen and nitrogen. The multiple benefits of supplementary creatine arise from the fact that the creatine-phosphocreatine [PCr] system has physiologically important roles that include maintenance of intracellular ATP and acid–base balance, post-ischaemic recovery of protein synthesis, cerebral vasodilation, antioxidant actions, and stabilisation of lipid membranes. In the brain, creatine not only reduces lipid peroxidation and improves cerebral perfusion, its interaction with the benzodiazepine site of the GABA Two areas in obstetric and neonatal medicine that lack effective prophylactic treatments are premature birth and neonatal hypoxic-ischemic encephalopathy (HIE). It is well known that morbidity and mortality are higher for babies born pre-term . Infantsnd and 3rd trimester of pregnancy for the purpose of preventing birth-related hypoxic-ischemic encephalopathy.Systematic reviews show that maternal administration of corticosteroids for impending preterm birth significantly reduce the risk of neonatal death, respiratory distress, cerebroventricular haemorrhage, and necrotising enterocolitis, and clearly reduces the requirement for neonatal respiratory support and intensive care . Antenatrd world settings  CK - as has been suggested for placental creatine kinase . Thus, tIn healthy women muscle creatine content increases from [pre-pregnant] 200 mmol/kg alkali-soluble protein (ASP) to 223 mmol/ kg ASP at 18 weeks and 233 mmol/ kg ASP at 36 weeks gestation . This muafter birth [While it is likely that the ‘dietary’ source of creatine for the fetus is the maternal circulation, it is presently unclear when the capacity for creatine synthesis develops in the fetus. Studies in the precocial spiny mouse suggest that the reno-hepatic axis of creatine synthesis develops late in gestation , and if er birth ,110 sugger birth . As discer birth . Urine cer birth , but theNgal), a marker of tubular injury, is significantly up-regulated after birth hypoxia. These changes in kidney structure, and markers of injury are completely prevented by maternal dietary creatine supplementation.Our studies in the spiny mouse have shown that maternal dietary creatine supplementation prevents hypoxic injury to multiple organs including the brain , diaphraThe potential roles of creatine may be relevant to an array of pregnancy conditions leading to preterm birth, and therefore to high risk of HIE. One such condition is preeclampsia, a common syndrome of pregnancy that manifests after 20 weeks gestation with new-onset hypertension alongside maternal end-organ dysfunction and/or intrauterine fetal growth restriction , and is In addition to pre-eclampsia, other obstetric conditions that must be managed conservatively include cervical incompetence, preterm premature rupture of the membranes (PPROM), partial placental abruption and placenta praevia, and fetal growth restriction. Fetal hypoxia, hypoglycaemia and activation of the fetal hypothalamic-adrenal axis arise as consequences in many of these conditions, leading not only to fetal growth restriction and preterm delivery but also, potentially, to fetal death or stillbirth ,123. IntCreatine is considered a safe nutritional supplement for adult humans and has been shown not only to increase muscle mass and performance, prevent disease-induced muscle atrophy and improve rehabilitation, but also to strengthen cellular energetics in general . By mainThere are no conflicts of interest. None of the listed authors received any payment for their participation in writing this manuscript.DWW, HD, RJS, and ZI wrote the original draft; SE and DL contributed significantly to redrafting and to the final manuscript. All listed authors were involved in revising the draft and producing the final manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2393/14/150/prepub


The claimed advantages of home deliveries, including fewer medical interventions, are potentially counter balanced by the small additional risk on perinatal adverse outcome compared to hospital deliveries in low risk women. Homelike birth centres have been proposed a new setting for low risk women combining the advantages of home and hospital, resulting in lower intervention rates with equal safety. This paper addresses whether the introduction of a midwife-led birth centre adjacent to the hospital combines the advantages of home and hospital deliveries. Additionally, we investigate whether the introduction of a midwife-led birth centre leads to a different risk selection of women planning their delivery either at home, at the hospital or at the birth centre.Anonymized data, between January 2007 and June 2012, was collected from the four participating midwife practices. Women (n = 5558) were categorized according to intended place of birth. Women’s characteristics and pregnancy outcomes were compared between the period before and after its introduction using Chi square and Fisher’s Exact tests. Direct and indirect standardized rates were calculated for different outcomes , taking the period before introduction as reference.After the introduction of the birth centre a different risk selection was observed. Women’s characteristics were most unfavourable for intended birth centre births. Additionally, an higher neonatal risk load was seen within these women. After its introduction neonatal morbidities decreased (5.0 vs. 3.8 %) and maternal morbidities decreased (8.3 vs. 7.3 %). Interventions were about equal. Direct and indirect standardization provided similar results.Neonatal morbidity and maternal morbidity tended to decrease, while overall intervention rates were unaffected. The introduction of the midwife-led birth centre seems to benefit the outcome of midwife-led deliveries. We interpret this change by the redistribution of the higher risk women among the low risk population intending birth at the birth centre instead of home. There are considerable variations in organization of Perinatal Care. In the Netherlands, approximately 50 % of women start delivery under supervision of a community midwife. Dutch community midwives are independent health care professionals who provide care for low risk and medium risk pregnant women. Dutch guidelines define low, medium and high risk pregnant women CVZ. CV . A low rOne of the concerns raised regarding the Dutch Perinatal Care System is whether the small additional risk on adverse perinatal outcome  of home deliveries is of fact by the claimed advantage of lower intervention rates compared to planned hospital births , yet with its own entrance and home-like interior. The unit is staffed by local community midwives. The unit fits to the UK National Perinatal Epidemiology Unit report description of a ‘midwife-led birth centre adjacent to the hospital’, i.e. “An alongside midwifery care unit offering care to women with straightforward pregnancies during labour and birth in which midwives take primary professional responsibility for care. During labour and birth diagnostic and treatment medical services, including obstetric, neonatal and anaesthetic care are available, should they be needed, in the same building, or in a separate building on the same site. Transfer will normally be by trolley, bed or wheelchair”  complications arise, obstetrical and neonatal expertise and clinical facilities are directly available.A regional study in the north of Rotterdam was designed comparing outcomes before and after the introduction of the midwife-led birth centre in October 2009, using direct and indirect standardization. The four largest local community midwife practices in the region were approached, whose women are allowed to choose place where to deliver . Anonymized data were collected from each of these registries. If women deliver in the birth centre, the data registration is still the midwife’s responsibility through internet entry. Data were collected between January 2007 and June 2012. We selected the records of all singleton pregnancies supervised by a community midwife at the onset of labour (5953 women). The onset of labour was defined as spontaneous contractions or the spontaneous rupture of membranes. Excluded were 62 women with so called ‘medium risks’ [e.g. women with a history of postpartum haemorrhage or obesity (BMI > 35)] and another 333 women since their planned place of birth was unknown. The remaining 5558 were divided into two groups, the period before the introduction of the birth centre (n = 1834) and the period after its introduction (n = 3724).Within each period women were categorized by intended place of birth , which usually is concordant with the true place of birth.The retrospective use of anonymized medical records exempted institutional review of the Medical Ethics Committee.Four primary outcomes were chosen: (1) intrapartum and early neonatal mortality (up to 24 h), (2) a composite outcome of intrapartum related neonatal morbidities , neonatal hospital admission, or other trauma related to birth), (3) a composite outcome of intrapartum related maternal morbidities (third/fourth degree rupture or postpartum haemorrhage >1000 cc), and (4) the presence of a medical intervention .Of the 27 selected variables, the variable education level had ≥30 % missing values and was therefore excluded from analysis. For all other variables missing values were <30 % and were replaced by mean, median and mode, for respectively, numeric , ordinal and nominal values.First, we compared women’s characteristics between the period before and after the introduction of the midwife-led birth centre, using Chi square tests and Fisher’s Exact tests. We compared women’s profiles before and after the introduction of the birth centre, according to the intended place of birth , intrauterine growth restriction , or preterm birth (<37th week of gestation) .To increase the validity of our results of the comparison before and after the introduction of the birth centre, we applied direct as well as indirect standardization. The index population (i.e. the population of interest) consisted of the women who could plan their birth the midwife-led birth centre . The standard or reference population consisted of 1834 eligible women who could not plan their birth in the birth centre .In our analysis the index population was standardized according to the strata of the standard population. The index populations of planned birth centre births and planned hospital births were standardized using the standard populations of planned hospital births, since women’s profiles were similar. The index population of planned home birth was standardized using the standard population of planned home births.Populations were stratified for parity (nulliparous vs multiparous), age , ethnicity (Dutch vs non-Dutch) and the presence of Small for Gestation Age . In our analysis the presence of SGA represented an objective estimate of the risk challenge at birth  of women planned a home delivery and 1391 (67 %) planned a hospital delivery. After the introduction of the birth centre, 470 (12 %) women planned a delivery at home, 1583 (41 %) at the hospital, and 1671 (44 %) at the birth centre.In the period after the introduction of the birth centre, women who planned birth at home were significantly more likely to be multiparous or had taken more often preconceptional folic acid  compared to the women who planned birth at home in the period before the introduction (see column A). A similar pattern was seen in the women who planned their birth at the hospital. In the period after the birth centre introduction, these women showed more favourable characteristics compared to women in the period before the introduction. This group was significantly more often multiparous, older, married or living together, had taken preconceptional folic acid, and had received antenatal care before 14 weeks of gestation (see column B).In the period after the introduction of the birth centre is was observed that women who planned birth at the birth centre showed more unfavourable characteristics compared to home as well as hospital birth .An higher neonatal risk load was seen in women with a planned birth at the birth centre; the total prevalence of Big3 was higher .After the introduction of the birth centre, the intrapartum and early neonatal mortality decreased combining all deliveries regardless place (4/1834 = 2.2 ‰ vs. 2/3724 = 0.5 ‰).Intrapartum related neonatal morbidities were significantly more common in the period before the introduction of the birth centre , as described in Table Intrapartum related maternal morbidities were also lower in the period after the introduction (153/1834 = 8.3 % vs. 270/3724 = 7.3 %). After the introduction of the birth centre they were highest among planned hospital births. Interventions were about equal in both periods (14.9 vs. 14.3 %). In the period after the introduction, interventions occurred significantly more often in birth centre deliveries compared to planned home or planned hospital births (16 vs. 11 vs. 14 % respectively)..Figure After the introduction of the birth centre, standardized intrapartum and early neonatal mortality rate decreased for all the different planned places of birth  birth centre led to a redistribution of intended place of midwife-led births. Low risk women planning their delivery in the midwife-led birth centre have a higher risk profile compared to low risk women who planned their pregnancy at home or in the hospital, all under supervision of the midwife. This was confirmed by the birth weight distribution. Although the study did not have sufficient power to interpret the observed change in intrapartum and early neonatal death after the introduction of the birth centre (0.22 vs. 0.05 %), the decreasing trend observed in planned home, hospital and birth centre births, suggests on average better care through more adequate selection. A similar trend was observed in intrapartum related neonatal morbidities, decreasing from 5.0 to 3.8 %. Standardized rates showed the largest decrease in intended planned hospital births compared to planned home and birth centre births. A similar trend was observed in intrapartum related maternal morbidities (decreasing from 8.3 to 7.3 %). Standardized rates showed the largest decrease in the planned birth centre births. The rate of interventions in our entire study population was 14.5 %. Intervention rates appeared unaffected by the introduction of the birth centre. Standardized rates of interventions were higher in planned home births, lower in planned hospital births and at the expected rate in birth centre births.Our cohort study showed some strengths. We used an intention-to-treat-like approach without ex post exclusion of unsuitable midwife cases to create a fair, unbiased comparison of planned home, hospital and birth centre births in this observational context. These unsuitable cases show poorer outcomes, and should therefore be included  gives greater comparability but requires more data. Indirect standardization (weights taken the standard population) requires fewer data but provides less comparability .As our results show the complete experience of the introduction of a midwife-led birth centre adjacent to the hospital on maternal and perinatal outcome in the north side of Rotterdam, its generelizability is mainly for urban areas. Some study limitations merit discussion. A randomized controlled trail would be the superior design to address our research question. However when homebirth was part of a trial, participation hampered Tyson  and intrSecondly, the study did not have sufficient power to assess intrapartum and early neonatal death.Thirdly, while the presence of SGA was used as additional case mix adjustment, our case mix adjustment could be further improved by detailed risk factors. We cannot rule out remnant confounding by indication as little is known on the factors underlying choice of setting. In addition, we categorized women into Dutch and non-Dutch women for reasons of power, where adverse outcomes may differ among the different ethnic groups [e.g. the increased prevalence of postpartum haemorrhage  care factors, such as decisions for intervention, transferal data .Lastly, this study largely neglects the emotional aspects and the aspect of autonomy when comparing places of birth. The choice of the place of birth is largely upon the pregnant woman. The current growth of the share of birth centre and hospital births suggests overall positive balance of these effects, in particular since the economic incentive is in favour of home delivery. Studies assessing the mother’s opinion show that any increase of medical safety easily outweighs other benefits, i.e. emotional aspects  should be interpreted with caution due to small numbers. If this, however, truly represents a decrease, it may in part be explained by the beneficial effect of local and national initiatives to lower perinatal mortality, in particular improved risk selection across all delivery options . The decreasing trend observed in planned home, hospital and birth centre births, may suggest on average better care through more adequate selection of women and/or more adequate management, e.g. exact measurement of blood loss and early use of intramuscular oxytocin.Overall intervention rates were not affected by the introduction of the birth centre. While the underlying pattern suggests better fit of risk profile to setting and a better fit of risk profile to the choice for interventions, the introduction of an extra hospital-based facility did not represent an up- or downward pressure towards intervention rates in general. Previous studies on birth centres showed lower intervention rates combined with an equal, or even better, performance (Gottvall et al. The introduction of a midwife-led birth centre led to a redistribution of women planning their midwife-led delivery at home, at the hospital, or at the local birth centre. Women opting for a delivery in the midwife-led birth centre had the most unfavourable risk profile.Intrapartum and early neonatal mortality and intrapartum related neonatal and maternal morbidities tended to decrease, while overall intervention rates were unaffected. The introduction of the midwife-led birth centre seems to benefit the outcome of midwife-led deliveries. We interpret this change by the redistribution of the higher risk women among the low risk population intending birth at the birth centre instead of home.


The number of preterm birth is increasing worldwide, especially in low income countries. Malawi has the highest incidence of preterm birth in the world, currently estimated at 18.1 percent. The aim of this study was to explore the perceived causes of preterm birth, care practices for preterm newborn babies and challenges associated with preterm birth among community members in Mangochi District, southern Malawi.We conducted 14 focus group discussions with the following groups of participants: mothers (n = 4), fathers (n = 6) and grandmothers (n = 4) for 110 participants. We conducted 20 IDIs with mothers to preterm newborns (n = 10), TBAs (n = 6) and traditional healers (n = 4). A discussion guide was used to facilitate the focus group and in-depth interview sessions. Data collection took place between October 2012 and January 2013. We used content analysis to analyze data.Participants mentioned a number of perceptions of preterm birth and these included young and old maternal age, heredity, sexual impurity and maternal illness during pregnancy. Provision of warmth was the most commonly reported component of care for preterm newborns. Participants reported several challenges to caring for preterm newborns such as lack of knowledge on how to provide care, poverty, and the high time burden of care leading to neglect of household, farming and business duties. Women had the main responsibility for caring for preterm newborns.In this community, the reported poor care practices for preterm newborns were associated with poverty and lack of knowledge of how to properly care for these babies at home. Action is needed to address the current care practices for preterm babies among the community members. Recent estimates indicate that there are 15 million preterm newborns annually and the number is increasing each year . ConsequMalawi has the highest incidence of preterm birth in the world, estimated at 18.1 percent . AdditioTo our knowledge, there is a lack of evidence that people at community level in Malawi can easily care for preterm newborns. Information on local perceptions of preterm birth and care practices is important for programs aiming at improving preterm newborn health at the community level. Two studies in Malawi have previously reported on community concepts of preterm birth and knowledge of preterm birth respectively ,11. HoweWe used a qualitative study design  to descrDifferent sampling strategies were used for different groups of participants. Firstly, we used purposeful sampling for recruiting women, men, grandmothers, traditional birth attendants (TBAs) and traditional healers. We introduced the aim of the study to the local leaders in the community and engaged them to help in identifying potential participants to be included in the study. These local leaders were village heads in the catchment areas and because of their knowledge about the population in their communities; they were in a good position to locate the potential participants. For instance, we asked for men who were not yet grandfathers and had at least one infant at home born in the previous year and women who had given birth in the previous year. The criteria for selecting parents with an infant of less than one year was to explore their current care practices and experiences for newborn babies including their knowledge on the care for preterm babies. We included grandmothers who were staying with their grandchildren in the same household for focus group discussions (FGDs) because we assumed that they would have a greater role to support and advise the parents on how to care for a newborn baby including a preterm. We randomly selected the women who had given birth to a preterm newborn baby for in-depth interviews (IDIs) from the existing list of participants enrolled in the on-going randomized controlled trial to specifically explore the preterm care practices. Pregnancy outcomes for participants enrolled in the clinical trial were well documented and preterm newborn babies were defined as those born before 37 weeks gestational age.Chiyao- the common local language in the catchment areas and Chichewa – the national language in Malawi. The same discussion guide was used for both FGDs and IDIs. Topics covered in the discussion guide were: perceived causes of preterm birth, definition of preterm birth, recognition of preterm newborns, care practices of preterm newborns and the associated challenges. We used IDIs mainly with TBAs, traditional healers and mothers of preterm newborns to get individual perspectives on the issues discussed. We conducted ten IDIs with mothers of preterm newborns, six TBAs and four traditional healers. We conducted a total of 14 FGDs, with a total of 110 participants from the following groups: women (four groups), grandmothers (four groups) and men (six groups). Each focus group consisted of 4 to 12 members. FGDs [Data collection took place between October 2012 and January 2013. Focus group discussions (FGDs) and in-depth interviews (IDIs) were used for data collection. A discussion guide was developed in English and translated into two local languages: rs. FGDs  were maiThe interviews were carried out in one of the local languages based on the interviewees’ preference. In FGDs, we encouraged all participants to contribute to the discussions and each session took approximately 40 to 50 minutes. The interviewers briefed the participants on the aim of the study. All the interviews were recorded digitally. One researcher with experience in conducting qualitative studies (AG) and two research assistants (moderator/note taker), fluent in both local languages conducted all the FGDs and IDIs. All the IDIs were held in participants’ homes and FGDs in either a school or a place selected by a group away from disturbances. All participants received two bars of soap to compensate for their time.The recorded interviews were transcribed verbatim and then translated into English because some of the authors were not familiar with the local languages. The transcribed text was then compared with handwritten notes by the note-taker. We manually analyzed data using a content analysis approach . The lea.“Nowadays girls as young as under 16 years have already started child bearing and they are too young and not physically developed. These girls usually give birth to preterm newborns because their body organs are not well developed”.FGD, Men.Participants reported a number of causes of preterm birth, which can be grouped into two aspects: maternal factors during pregnancy and general social factors as detailed in Table “The uterus has weight but when you have given birth so many times, it loses the weight and becomes lighter  failing to hold the pregnancy”.FGD, Women.Furthermore, during FGDs, several women reported that a woman having too many births, especially eight or more times was dangerous because the uterus was much utilized and could lead to preterm birth.(matenda a mtima), anemia (kuchepa magazi), asthma (mphumu) and epilepsy (khunyu). In addition, all participants emphasized that sexually transmitted infections (STIs) (matenda opatsirana pogonana) such as gonorrhea (chinzonono), syphilis (chindoko) and HIV/AIDS were the main cause, if left untreated as the quote below explains:“If a woman has a disease in the her womb and if it is transmitted to the baby inside the womb, then the baby doesn’t stay longer in the womb - move out of place, and eventually the baby comes out too soon before it is ripe. Most of these diseases are sexually transmitted diseases such as syphilis, gonorrhea and HIV/AIDs.IDI, TBA.Participants further reported a number of illnesses during pregnancy that would lead to preterm birth, such as malaria, high blood pressure mwanamphepo explained in Table likango for both women and men that would lead to a preterm birth or miscarriage. The participants also emphasized moto/tsempho in Chichewa language or ndaka/nsanjiko in Yao language that caused preterm birth because the pregnant woman carelessly shared utensils and ate food prepared by a woman who recently had a miscarriage, had a preterm birth and who has frequently engaged in sex with a man. Participants felt that a husband having a sexual relationship outside marriage causes miscarriage or preterm birth because there is contamination of blood through sexual intercourse of the husband with another woman outside marriage believed to be ‘hot’ which is then mixed with the blood of the pregnant wife through sex also believed to be ‘hot’. Participants further reported that a pregnant woman could also give birth to a preterm newborn if having sex outside marriage. The two quotes below help to explain more:“Some of the women could go and sleep with other men (nsanjiko) when their pregnancy is already tired and we happen to know such women because when delivering, they start by pouring out a lot of water and then delivers a preterm newborn …”IDI, TBA.“We know that the man had sex with another woman so that made the wife to lose the pregnancy because the blood from the other woman is different from the wife’s blood and sometimes the woman who slept with the husband had miscarried before”.FGD, Men.Participants also perceived traditional illnesses, i.e. anamutemberedza) her. Mothers with a previous preterm birth commonly reported that it was God’s will. However, one mother of a preterm newborn emphasized that use of the traditional medicine whilst pregnant would also cause a preterm birth because the system in the uterus ‘is disturbed’.The general social factors were heredity, the use of family planning methods, witchcraft and that the pregnant woman might not have spoken respectfully to elderly people who in turn cursed  in the Chichewa language just like a piece of paper.Furthermore, participants reported using physical features ‘see a summary of points on recognition of preterm newborns’ to recognize a preterm baby. Grandmothers and TBAs commonly reported that the skin of preterm newborn is too soft, has many wrinkles, is transparent and weak . Paraffin helps the mother to constantly check on the newborn at night while fetching for the relish and firewood are duties that a woman normally does so that the family can have something to eat. The women agreed with this assessment stating that having a preterm newborn was a burden on women because men did not help much in caring for the newborn. The majority of women further complained that instead of helping, their husbands started seeing other women which disturbed their marriages. The quote below explains more about how a preterm newborn in the family influenced men having sexual partners outside marriage.“A preterm birth is considered like a miscarriage (chitayo); requiring the family to wait for the appropriate time to take local medicine for chitayo before the family resumes sex, failing to do so the husband can die and this waiting time forces some men to go for other women”.FGD, Women.Almost all participants reported that the care of a preterm newborn was demanding, requiring the mother to be available all the time, thereby affecting business, farming and household chores. Men reported that they did not take part in carrying the baby, but provided support by fetching firewood, paraffin (a liquid which is used for a lamp to give light at night), and relish (a dish that is served with the Malawian staple food - “Because of lack of money when your child falls sick, you wait first so that you can do piece work to find money – poverty is a problem here and these kind of babies when they fall sick, it means you have to rush to the hospital but this doesn’t happen because the nearest hospital is a paying one”.FGD, Men.Participants reported challenges of poverty and lack of knowledge on caring for preterm newborns. Because of poverty, parents failed to buy warm materials, lived in cold houses with grass thatched leaking roofs and failed to rush the baby to the hospital because of lack of money for transport and to pay for the hospital bills. In one of the catchment areas, the nearest health facility was a pay for-service hospital and participants complained of lack of money to access the facility.“We find long queues at the hospital and a preterm baby can die whilst waiting to be attended so after giving it local medicine, we then decide to start off for the hospital because even if you go sometimes they tell you that there is no medicine”.IDI, TBA.All participants concurred that many preterm newborns had failed to survive because of lack of proper care in the homes. However, the majority of participants mentioned that they were able to tell that the preterm newborn was sick because the baby would develop a fever, not breath normally, change skin color to yellow, coughing and crying often times when the mother tries to hold the newborn. Grandmothers and TBAs said that they always provided traditional medicine to the preterm newborns before going to the hospital.et al., in a study on ‘perceptions of preterm birth in Malawi’ similarly reported witchcraft, sexual impurity, traditional illnesses such as mwanamphepo and likango as causes of preterm birth and miscarriages [In our study, we used FGDs and IDIs to explore perceptions of preterm birth and care practices for preterm newborns among community members in the Mangochi district in southern Malawi. Some of the perceptions of preterm birth reported in our study, such as maternal factors are similarly reported as risk factors for preterm birth in previous qualitative and epidemiological studies in Malawi and elsewhere ,18-21. Tarriages . Althougarriages . Furtherarriages ,24. AddiWe found that the majority of participants reported the concept of providing warmth as the most common care practice for preterm newborns. Other studies also recommend that simple care practice such as provision of warmth to preterm newborns should be universal ,25-27. H‘moto’ or has died of ‘moto’ - a disease described traditionally to be associated with sexual impurity [Interestingly, we found that grandmothers encouraged mothers to squeeze milk from the breast and feed the newborn using a spoon and a cup in agreement with preterm newborn care recommendations . Howeverimpurity . In Bangimpurity . The simIn the present study participants report diverse challenges, including economic and health system related issues such as the lack of medication in public facilities and long queues. Lack of money was cited as the major challenge as many families are reportedly poor and could not afford to properly care for the preterm newborns including taking them to the hospital in case of sickness. In one of the catchment areas, the nearest health facility is a pay for-service hospital and this delays decision making to access medical care for a sick preterm newborn. This finding is in line with what others have found ,40. ActuThe strength of this study is that we triangulated the data by using both FGDs and IDIs to explore community perceptions and care practices of preterm newborns. In addition, we included male participants in our study in a society which specifies gender roles assuming that men are not expected to know much about caring for newborn babies. The limitation of our study is that we did not include grandfathers who may have different opinions on preterm birth and care practices. Furthermore, the findings of this study cannot be generalized to all communities in Malawi as the study was conducted among a few people within the catchment areas of an active clinical trial. Although the present study was conducted in catchment areas that have had multiple studies, we believe that the response bias was minimized because no similar study had been conducted before. In addition, some of the participants in our present study were not involved in the ongoing clinical trial. Another limitation is that we did not ask for a place of delivery, so those who gave birth at home might have different views from those who delivered in a health facility on care practices. Possibly those who delivered at the facility had different care practices. However, even when mothers deliver at the health facility, they are quickly discharged and most of the newborn care happens at home.In this community, the reported poor care practices to preterm babies were associated with many challenges such as poverty and lack of knowledge on how to properly care for these babies at home. There is a need for action to address the current care practices for preterm newborn babies among the community members in order to improve survival of the increasing numbers of preterm babies in Malawi. These findings add new knowledge to the existing literature on the preterm newborn care which can foster appropriate preterm newborn care practices in the rural communities.


Bisphenol A (BPA) and phthalates are ubiquitous non-persistent endocrine disrupting chemicals whose relation with infant birth size is not clearly understood.We examined associations between maternal and paternal preconception urinary concentrations of total BPA and 14 phthalate metabolites and birth size for 233 infants. Multiple linear regression models were used to estimate parental quartiles of BPA and phthalates in relation to birth weight, length, head circumference, and ponderal index with separate models run for each parent adjusting for age, smoking, body mass index, education, alcohol, parity, and creatinine. Models also included an interaction term for each chemical and infant sex and were further adjusted to include the other partner’s chemical concentrations.p < 0.05) were observed for the 2nd quartile of maternal monomethyl phthalate, mono-[(2-carboxymethyl) hexyl] phthalate and mono-n-octyl phthalate when compared with the 1st quartiles. The 3rd quartile of monoethylhexyl phthalate (mEHP) was also associated with a 200.16 g  reduction. Similar reductions in birth weight were observed for the 2nd quartile of paternal mEHP . Additionally, select maternal urinary metabolites were associated with decreased head circumference, birth length and gestational age. However, paternal concentrations were generally associated with increased birth length and gestational age.In maternal models adjusted for partner’s exposure and covariates, reductions in birth weight  contains supplementary material, which is available to authorized users. Bisphenol A (BPA) and phthalates are non-persistent endocrine disrupting chemicals (EDCs) found in a variety of commercial products. Specifically, BPA is used in the production of polycarbonate plastics and epoxy resins, e.g., plastic bottles, lining of food cans, and thermal receipt papers . SimilarDespite a suggestive body of animal evidence, current reviews conclude that studies on BPA and human health are limited –8. An evTo date, research has largely relied upon prenatal urinary concentrations and associated fetal/infant outcomes. To our knowledge, there have been no previous efforts focusing on parental preconception exposures to BPA and phthalates, despite the couple dependent nature of pregnancy. Such a study is important for helping to more fully understand the implications of physiological changes during pregnancy that may be associated with the reported variability of chemical exposures during this sensitive window of human development . As suchThe study population comprises 501 reproductive aged couples who were recruited from16 counties in Michigan and Texas between 2005 and 2009 with the explicit purpose of assessing environmental influences on human fecundity and fertility, as previously described . CouplesAmong the 501 enrolled couples, 347 (69 %) had an observed human chorionic gonadotropin confirmed pregnancy of which 90 % occurred within 6 menstrual cycles and the remaining 10 % in cycles 7-12 . FurtherDuring the enrollment home visit, research assistants instructed couples in the proper collection of urine samples for the quantification of BPA, phthalates, and creatinine. Samples were transported on ice for processing and shipment to the laboratory. Chemical analysis was performed at the Wadsworth Center, New York State Department of Health using an established protocol . Specifin = 233); length in -inches (n = 230); head circumference in inches (n = 183); and date of delivery (n = 233). Weight was converted to grams, and length and head circumference to centimeters for analysis. Gestational age was defined as the number of days from the day of ovulation as recorded on fertility monitors that was estimated to be the day of conception and date of delivery. We also estimated ponderal indices (PIs) for 230 infants, which is similar to adult body mass index and derived from the following formula: [birth weight (grams)/birth length (cm3)] × 100. PIs are proxies of infant adiposity and can be further categorized in relation to growth symmetry: normal (2.20-3.00), symmetrical (>3.00) and asymmetrical (<2.20) ,p-values ≤0.01, which is a much smaller chance of falsely rejecting the null hypothesis of no mean change in birth outcomes per quartile increase of urinary chemical concentration, compared with the lowest quartile of preconception chemical. Imputation improved our precision, in that significance was lower in our initial analyses without imputation (data not shown). We also dichotomized chemicals (mCHP and mOP) with a high percentage of concentrations below the LOD at or below the 75thpercentile, and observed similar results as when modeling machine observed concentrations suggesting possible low dose effects. Despite these added analytic steps, cautious interpretation is needed in the interpretation of our findings as the findings await corroboration in light of these and other study limitations such as a relatively small cohort of infants and unknown birth outcomes for couples exiting the study before delivery.Still, cautious interpretation of results is warranted, given the potential for competing risks since this analysis was conditioned on having a live birth and EDCs have also been reported to be associated with couples’ ability to conceive . Howevernd and 3rd quartiles) with birth size may not simply be explained as the result of limited sample size or overestimating the effect of urinary biomarkers of exposure in light of exposure misclassification. A growing body of evidence suggests that the endocrine system is sensitive to low-dose effects of various chemicals. Furthermore, animal studies of EDCs that act as antiandrogens or estrogen have shown that low-dose effects is not only chemical specific but varies by endpoint as well and may have global dynamic effects on cells, tissues and organs [Furthermore, the presence of many low-level chemical associations (2d organs –50.While the biological explanation behind these findings is not clearly understood, early pregnancy maternal exposures to EDCs have been associated with oxidative damage in rats, sheep and humans , and oxiTo our knowledge, this study represents an initial attempt to utilize a couple-based exposure design to assess the relation between maternal and paternal preconception urinary concentrations of BPA and phthalates and infant gestation and birth size. In the context of an observational design and exploratory analytic strategy, we observed some evidence that BPA and some but not all phthalates were associated with shorter gestations and smaller infants in relation to maternal exposure, but longer gestations and larger infants in relation to paternal exposures. Collectively, the findings underscore the importance of couple based designs for assessing the reproductive and/or developmental toxicity of environmental phenols and other endocrine disrupting chemicals.


To compare the prognostic value of fetal Doppler in dichorionic twins and singletons by measuring the interval between diagnosis of an abnormal Doppler flow and birth in fetuses who are small for gestational age (SGA).Comparative retrospective study using a prospectively collected database.A level 3 maternity unit in France.th percentile and confirmed by a birth weight below the 10th percentile.Fetuses from singleton and dichorionic pregnancies who are SGA (vascular or unexplained), defined by an abdominal circumference (AC) measurement below the 10Fisher's exact and Chi-2 tests were used to compare frequencies, and the Mann-Whitney-Wilcoxon test was used to compare medians in non-Gaussian distributions.Both neonatal outcomes and intervals between the first Doppler abnormality and birth were compared in the groups of dichorionic twins and singletons.Obstetric and neonatal outcome were similar in the 104 SGA dichorionic twins and 170 SGA singletons. Abnormalities of umbilical artery Doppler, regardless of type, appeared at the same frequency in both groups (52.9%) but were identified earlier in twins . Among fetuses with abnormal Doppler flow, the interval between the finding and birth was significantly longer in the twins than the singletons .The prognostic value of an abnormal Doppler finding for the course of a pregnancy may be different in dichorionic twins and singletons. The management of women carrying SGA twins and the information provided to them should take these results into account. Many studies have examined the pathophysiology and outcome of singletons born small for gestational age (SGA) due to vascular causes. Monitoring procedures in these cases are relatively consensual, as are the factors used to decide upon early intervention for delivery: fetal heart rate (FHR) abnormalities, arrested growth, estimated fetal weight, and Doppler flow abnormalities. In particular, fetal Doppler has proved its value in monitoring these fetuses  and playTwins are more frequently SGA than singletons . Data arWe compared the prognostic value of fetal Doppler in SGA dichorionic twins and singletons by measuring the time interval between an abnormal Doppler finding and birth.This retrospective study was conducted in a level 3 maternity unit in France. The group of twins included all fetuses in twin pregnancies prenatally diagnosed as SGA born between January 1, 2007, and December 31, 2010. When both twins from the same pregnancy were diagnosed as SGA, both were included. The group of singletons included all fetuses in singleton pregnancies prenatally diagnosed as SGA born between January 1, 2008, and December 31, 2009. A longer period was chosen for recruitment of twins in view of the lower incidence of twin pregnancies.www.cngof.asso.fr).The guidelines in our department are based on Clinical Practice Guidelines issued by the French College of Gynecologists and Obstetricians , or femur length) [th percentile according to the curves of Leroy and Lefort [The cases were identified with DIAMM software  from a prospectively collected and recorded database of information about all pregnancies in our hospital. To verify the inclusion and exclusion criteria, we examined the case records of all fetuses who had a measurement at or below the 10th percentile according to the fetal biometry curves used in our maternity ward [rd percentile and moderate if between the 3rd and 10th percentiles [SGA status was defined by at least one ultrasound AC measurement at or below the 10ity ward . It was centiles .th percentile. Cases were also excluded from the analysis when SGA status was associated with a malformation, a karyotype anomaly, fetomaternal infection, fetomaternal alloimmunization, or premature rupture of the membranes before 24 weeks. Because of their specific complications, monochorionic twin pregnancies were excluded, as were multiple pregnancies that resulted in a twin pregnancy after embryo reduction.We excluded fetuses with a birth weight above the 10Monitoring was similar for twins and singletons suspected to be SGA. Ultrasound monitoring included weekly measurements of the umbilical artery Doppler (UAD) and cerebral artery Doppler indices and measurement of the biometric indicators mentioned above every 2 weeks by the same operator. UAD measurements were taken at the level of the perivesical umbilical artery or its abdominal insertion for twins and at the level of the free loop of the umbilical artery for singletons. Depending on the severity of the SGA status and the Doppler abnormalities, FHR was monitored at intervals ranging from weekly to twice daily, with analysis of the short-term variability.The decision about time and mode of delivery was based on the same set of factors in twins and singletons. These included analysis of the FHR, fetal growth, Doppler abnormalities, gestational age, estimated fetal weight, and signs of maternal decompensation.Generally, the basis for decisions about time of delivery was principally arrested growth or FHR abnormalities . DeliverThe general and obstetric characteristics were: maternal age, parity, geographic origin, pre-pregnancy body mass index (BMI), fetal sex, gestational age, and AC measurement (in millimeters and percentiles), as well as abnormalities of the UAD and cerebral artery Doppler observed at SGA diagnosis. The UAD was classified as normal or as abnormal with either positive diastolic flow or absent or reverse diastolic flow. It was defined as abnormal with positive diastolic flow when the resistance index of the umbilical artery (S-D/S) ranged from 0.80 to 0.99, regardless of gestational age. We defined a group with any UAD abnormalities, including the cases that were abnormal with positive diastolic flow and those with absent or reverse diastolic flow. When the abnormalities continued to increase in severity, we analyzed the earliest one. An abnormal cerebroplacental ratio was defined by a resistance index higher for the UAD than for the cerebral artery Doppler. Time between the first Doppler abnormality and birth was the principal outcome measure.The obstetric outcome data collected were mode of delivery and indications for early intervention for delivery, defined as cesarean before labor or induction of labor.In utero fetal death (IUFD) was defined by spontaneous fetal death after the first trimester of pregnancy, i.e., after 14 weeks of gestation. Medically indicated termination of pregnancy occurred in some extremely SGA fetuses. The decision to terminate the pregnancy was based primarily on the parents’ request but also on a set of factors including gestational age less than 24 weeks or estimated fetal weight below 600 grams, arrested growth, and reverse diastolic flow on the UAD especially with an associated risk of serious maternal complications (severe preeclampsia).A composite criterion defining poor neonatal condition was fulfilled by any one of the following criteria: 5-min Apgar score ≤ 7, umbilical cord arterial pH ≤ 7.20, NICU admission, or neonatal death. Other neonatal outcomes were gestational age at delivery, or birth weight , and the Mann-Whitney-Wilcoxon test was used to compare medians in non-Gaussian distributions . Differences were considered significant when p< 0.05.Fisher's exact and Chi-2 tests were used to compare frequencies .The rate of dichorionic twin pregnancies was fairly stable over the study period: 4.0% in 2007, 4.5% in 2008, 3.3% in 2009, and 4.9% in 2010. The electronic database contained 234 potential SGA cases in twins and 643 in singletons. Examination of each case record showed that 89 records of dichorionic twin pregnancies, including 15 in which both twins were SGA, for a total of 104 fetuses, and 170 records of singletons (control group) met the inclusion and exclusion criteria.rd percentile (severe SGA status) at diagnosis was less frequent in twins than in singletons  . Moreover, pregnancy was terminated for 13 very severely SGA fetuses, all in the singleton group. The rate of preeclampsia was 23.0% (n = 24) in women with twins and 46.5% (n = 79) in women with singletons, p<0.01).The mothers of dichorionic twins were older  and had a lower BMI . An AC below the 3 = 0.02) . Eight tThe rate of poor neonatal condition did not differ between the groups , nor did the other neonatal outcomes .The frequency of UAD abnormalities with positive diastolic flow was similar in both groups but was diagnosed earlier in twins than singletons . The interval between the first abnormal UAD finding with a positive diastolic flow and birth was substantially longer in twins than singletons . This longer interval in twins was found both in severely and moderately SGA fetuses .UAD with absent diastolic or reverse flow was found at the same frequency and diagnosed at the same gestational age in both groups. The interval between the UAD finding of absent diastolic or reverse flow and birth was 23 days in twins and 12 days in singletons (p = 0.05); when found between 26 and 34 weeks, the pregnancy continued after 34 weeks for 9 twins and 3 singletons.The frequency of all types of abnormal UAD findings, like that of positive diastolic flow, was similar in both groups and occurred earlier in twins than in singletons . The interval between the first abnormal UAD finding and birth was notably longer in twins than in singletons , even after stratification of fetuses as moderately or severely SGA at diagnosis.The frequency of an abnormal cerebroplacental ratio was similar in both groups and was diagnosed at the same gestational age in twins and singletons . The interval between this finding and birth was longer in twins than singletons .The abnormalities of umbilical artery and cerebral artery Doppler results in SGA fetuses do not appear to have the same prognostic significance for the course of the pregnancy in dichorionic twins and singletons. In particular, the interval between an abnormal Doppler finding and birth is significantly longer in twins than in singletons.Some maternal characteristics were not distributed comparably in the two study groups. As expected, mothers of twins were older and more often of European origin; both factors are explained by the high proportion of twin pregnancies involving assisted reproductive technology. Moreover, older maternal age is associated with a higher frequency of spontaneous multiple pregnancies . Women cBecause our protocols for management in terms of monitoring and medical decision-making once a fetus is suspected to be SGA are the same for singletons and twins, indication bias should be limited. It is nonetheless possible that the health of the co-twin influenced some medical decisions toward an earlier or later intervention for delivery, but we were unable to take this information into account in this analysis. Moreover, in dichorionic twin pregnancies with one severely SGA fetus, no selective terminations of pregnancy were performed, to avoid complications of this invasive procedure for the healthy co-twin.Furthermore, the fact that we used resistance indices for Doppler abnormalities, regardless gestational age, instead of pulsatility indices which varies with gestational age, could be a limitation for the external validity of the study. However there is no proof of the superiority of the IP compared to IR so French guidelines for SGA and FGR do not recommend one over another index .rd percentile and the mean weight were similar in the two groups. Neonatal condition was also similar in both groups.Singletons were severely SGA more frequently than twins. It is possible that the routine monthly ultrasound monitoring of twins enabled earlier SGA diagnoses and detection of Doppler abnormalities, before severe growth impairment could occur. To limit the effect of this bias on the intervals we analyzed, we performed the principal comparisons while stratifying the populations as severe and moderate SGA, which allowed us to confirm that the results for these intervals were the same in both strata. Moreover, both the percentage of newborns with a birth weight below the 3The proportion of Doppler abnormalities, regardless of type, at diagnosis or during the monitoring, was similar in both groups but there was a trend toward more UAD findings of absent diastolic or reverse flow in twins. It is recommended that UAD measurements be taken at the level of the perivesical umbilical artery or its abdominal insertion for twins and at the level of the free loop of the umbilical artery for singletons . AccordiThe objective of the UAD measurement in fetuses suspected to be SGA is to adapt monitoring accordingly, to predict the onset of unfavorable outcome, and finally to improve health, as this measurement has been demonstrated to do in singletons . This exAccordingly, the results from UAD and cerebral artery Doppler examinations should perhaps be used differently in SGA dichorionic twins and SGA singletons for decisions concerning their monitoring and operative intervention. The longer interval we observed between the onset of Doppler abnormalities and birth in twins did not result in an increase in FHR abnormalities, emergency operative intervention, or poor neonatal condition.Abnormalities of umbilical artery Doppler and abnormal cerebroplacental ratios in cases of SGA do not appear to have the same prognostic significance for the course of the pregnancy in dichorionic twins and singletons. The intervals between the abnormal Doppler findings and birth are longer in the twins. These results suggest that methods of monitoring and decision-making following these findings may be different for these two groups. The information provided to women carrying twins about the expected time until birth after such findings should take these results into account, particularly if Doppler abnormalities are involved in the decision for early delivery.