Purpose: The objective of this study was to analyze the birth methods  predominant in the Malopolska province, to describe the risk factors for non-physiologically normal births, and to characterize the demographics of women who give birth and selected parameters of maternity care. Methods: The retrospective analysis was conducted on data collected in 2013–2014 in the framework of the current activity of the Polish National Health Fund and encompassed 68,894 childbirths from 29 hospitals in 21 towns in the south of Poland. Results: In the study period, 38,366 (56.5%) of the births in Malopolska were vaginal, and only 22,839 (22.9%) of births were considered ‘normal’, without an episiotomy. The remaining were births by CS . Factors increasing the chances of having a normal childbirth in comparison with birth by CS were as follows: days free from work, living in a village, woman’s age > 35 years, and the hospital’s referral level (primary or secondary). Women aged 18–34 years and those living in a village/town were more frequently admitted directly into the birth room without a stay in the maternity units. There was a high level of medicalization of births in Malopolska: natural labour and childbirth were rare. It seems that efforts to increase natural birth rates should be directed toward both reducing the CS rate as well as increasing vaginal birth without an episiotomy. According to the World Health Organization (WHO), a normal birth is defined as one that starts spontaneously and bears a low risk of complications, with the child being born between the 37th and 42nd week of pregnancy in a vertex position . It is aPolish maternity care  is obstetrician-led and it is considered relatively highly-medicalized. Generally available data point to a trend towards a lower and lower proportion of natural births. According to the reports on hospital morbidity published by the National Public Health Institute (NPHI) , in 2013The analysis was carried out on archival data collected in 2013–2014 in the framework of the current activity of the Malopolska Regional Branch of the Polish National Health Fund (NFZ). The analysis encompassed 29 hospitals in 21 towns in southern Poland. One hospital was a teaching institution , 16 were secondary care centers , and 12 were primary hospitals . The studied group comprised only births funded by the NFZ. We analyzed demographic data of the pregnant women  and information on the conditions of childbirth . Additional information included the mode of admission for the birth and the postpartum length of stay (LOS) in hospital.During the period covered by the study, there were 68,894 childbirths in Malopolska. We excluded those women whose data were improperly entered into the database (897 cases), those who gave birth at home  , and thoThe variables have been categorized into groups based on maternal age  and place of residence . Each healthcare facility was assigned a referral level . Childbirth type was defined by the birth method as normal birth or Caesarean Section (CS) and by the mode of admission for the birth as (1) childbirth, defined as direct admission to the birth room or labour unit (without pre-birth stay), birth at term, delivering one child; (2) as a multiple  or preterm birth involving direct admission to the birth room or labour unit with a preterm birth and/or multiple birth; or (3) as a pre-birth hospitalization preceded by the patient’s stay at the maternity unit (department of high-risk pregnancy). An entirely normal childbirth was assumed to entail spontaneous labour without the need for an episiotomy.p < 0.05. We used IBM SPSS statistics  for all statistical analyses.We compared the incidences of particular types of birth depending on the demographic features of the women in labour as well as the characteristics of the places of childbirth, using the Chi-squared test of independence. Individual groups were described using the occurrence of a given feature. There was also an analysis of post-childbirth LOS, considering the birth type and the mode of admission for the birth. For this purpose, mean values and standard deviations were calculated. Two-way analysis of variance (ANOVA) was applied to evaluate the relation between post-childbirth LOS and the birth type or mode of admission. A multinomial regression model was used to assess the odds of vaginal labour both with and without episiotomy compared with CS births. The results are presented as the odds ratio (OR) along with 95% confidence interval (CI). Statistical significance was assumed at This work was approved by the Bioethics Committee of Jagiellonian University . The study was based on the data gathered during routine patient care and the analysis did not include any individual participant’s data. As a result, no consent statements were required from participants. The study in this form was approved by the local Bioethics Committee of Jagiellonian University.The study covered 9.1% of all births in Poland in 2013–2014. According to the Polish Central Statistical Office, Malopolska’s proportion of women in the population does not differ from the national proportion . The province accounts for 8.75% of the Polish population, 51.38% of whom live in rural areas (compared with 39.66% in the entire country). In all, 54.9% of the women covered by this study lived in the countryside, which is the largest proportion considering all the birth-giving women in Poland 42.1%, . In the The highest proportion of normal births was observed in women aged <18 years of age; however, in all women delivering naturally, those over 35 years of age most often gave birth without an episiotomy. Taking into account the mother’s place of residence, living in a small town can be considered a predictive factor in that women living in a village gave birth naturally much more often, and usually with perineal protection. CS births were mostly performed in cities, and on weekdays (from Monday to Friday). On the weekends, women delivered naturally significantly more often with perineal protection .Pre-birth hospitalization at the maternity unit applied to over 20% of women in the study. Women aged 18–34 and those living in a village or small town were more likely to be admitted directly to a birth room  . The higPatients hospitalized in primary and secondary referral hospitals were the most likely to undergo a vaginal birth with perineal protection . This also applied to those living in the countryside or giving birth on a work-free day. In women aged <18 years, the percentage of vaginal births with an episiotomy was double that in women aged 18–34, whereas women aged over 35 were more likely to deliver vaginally with perineal protection .The LOS in hospital significantly correlated with the mode of admission for childbirth and with the birth method. Patients delivering naturally were hospitalized for the shortest time, as well as those admitted to hospital directly for labour. In the group with episiotomy, the trend was similar: the women delivering prematurely or those previously hospitalized had a longer stay in hospital .Medicalization, by definition, is not a negative development. In certain situations, it has had tremendous benefits. In developed countries, until the mid-1930s, maternal mortality rates were high, at about 400 deaths per 100,000 births. The major determinants of the high levels of maternal mortality were the standard of care at birth or a total lack of healthcare . At the Nonetheless, it seems that in Poland medical solutions are used too often and the answer to the question posed in the title of our study is obvious. Natural labour and birth were rare in Malopolska: only one in five women gave birth vaginally without additional intervention.Episiotomies help ease births that are complicated by shoulder dystocia, prevent severe perineal tears , and shorten the second stage of labour, and also more commonly occur in obese women ,15. HoweUnfortunately, almost half of the women studied here underwent a CS. In the USA, such births constitute almost 30% of all births, but in many countries, especially in Europe, it is much less, such as 14.7% in Finland and 16.2% in Sweden ,22,23. IFactors that can be associated with the course of labour and the degree of its medicalization are the length of childbirth and the time that the medical staff can devote to the woman giving birth. A slow and controlled birth is fundamental for protection of the perineum . Our resWhat is striking about our data was the higher proportion of normal childbirths in facilities with lower referral levels and among women from rural areas. Similar observations were described by Swift . The reaIt is difficult to expect entirely natural births in a medicalized environment. Data from Europe show that a friendly environment is conducive to normal childbirth, without intervention and with good obstetric results . This waThe high level of medicalization of childbirth in Poland and the high proportion of CS births are also associated with adverse economic effects and negative influences on public health; for example, CS involves a longer LOS (on average 1.2 days), which of course raises the cost of hospitalization. Furthermore, the use of CS increases antibiotic consumption  and thisThis retrospective study had some limitations. Demographic information for the study population was limited; thus, data on the characteristics of childbirth and the patients , as well as information regarding differences in the type of care received by the patients, were unavailable. Despite the large population constituting the study group, another limitation of the study is also the fact that it only covers one province. Comparing the data on the number of spontaneous vaginal births vs. others from NPHI reports with the ones obtained in this study suggests a possibility of considerable distinctions between different regions in Poland. On the other hand, a strength of the study is the method of data collection, which guaranteed its comprehensive nature.Births in Malopolska are highly medicalized—a natural labour with no episiotomy is a rarity. Efforts to increase natural birth rates should be directed at both increasing vaginal birth with no episiotomy and reducing the CS rates. The data presented in this study is definitely different from the trends in other developed countries, but consistent with trends across Poland. Further well-controlled research studies are urgently needed.


Increasing skilled attendance during childbirth is well established in literature to play a significant role in averting the many preventable maternal deaths that occur in developing countries such as Ghana. Inadequate utilisation of skilled birth care services in Ghana is believed to be a major hindrance to efforts aimed at improving the health of women, especially during delivery. The purpose of this study was to explore and describe the experiences of rural women regarding the utilisation of skilled birth care provided in the rural areas of Northern Ghana.The study adopted a qualitative, exploratory, descriptive research approach, whereby individual interviews, observations and field notes were used to obtain a thick description of women’s experiences regarding the utilisation of skilled birth care services in the rural areas in Ghana. A purposive sampling approach was used to select 20 women who utilised skilled birth care in the rural areas of Bongo District of Ghana. Data collected from the interviews were transcribed verbatim and analysed to identify themes.The study identified three themes: The women had negative interactions with skilled birth attendants during delivery; women lacked confidence in skilled birth attendants’ abilities; skilled birth attendants disrespected the traditional beliefs of the women.Most of the participants had negative experiences regarding the utilisation of skilled birth care. There is thus a need to develop strategies that could help address the above concerns of women to facilitate utilisation of skilled birth services in the rural areas in Ghana where there is low utilisation of skilled birth care. One of the strategies identified by the World Health Organisation as being crucial for saving the lives of pregnant women and as an indicator for progress in the reduction of maternal mortality is provision and utilisation of skilled birth care . SkilledGhana as a middle-income country within the Sub-Saharan African region although the skilled birth attendance has improved over the years, more than 20% of women still give birth at home without the assistance of a skilled birth attendant . AdequatIn Sub-Saharan Africa, many women deliver their babies at home in rural areas and are usually attended by various untrained family members, or the woman delivers alone unattended . In GhanPrevious studies indicate that, lack of financial or economic resources, transportation, and delivery of supplies, lack of coordination and referral between traditional birth attendants at the community level and facilities can all inhibit women from using facility-based services –10. HoweIn spite of several efforts by the government and other stakeholders such as the introduction of free maternal healthcare policy to facilitate the use of skilled birth care in Ghana, low utilisation of maternal health services especially making use of skilled birth care still persists in the rural areas of Bongo District in Northern Ghana. The researchers observed that women, especially those from rural and deprived communities in the Bongo District of Ghana continue to deliver at home without the assistance of skilled birth attendants. The purpose of this study is to describe women’s experiences regarding the utilisation of skilled birth care in the Bongo district in the Upper East Region of Ghana.A qualitative, explorative and descriptive research approach was employed whereby individual interviews, observations and field notes were used to obtain a thick description of women’s experiences regarding the utilisation of skilled birth care services in the rural areas in Ghana. Qualitative explorative and descriptive research is focused on understanding human’s experiences as it is lived, usually through the careful collection and analysis of qualitative materials that are narrative in nature . This deThe research was carried out in the Bongo District in the Upper East Region of Ghana. The Bongo District was selected as the setting for conducting the study because Bongo District is one of the most rural and deprived districts in Ghana and has all the characteristics of a typical rural area in Ghana . Also, tThe health care delivery system is built around one district hospital in the district capital serviced by four reproductive Health Clinics, seven completed Community Health-based planning Services (CHPS) compounds, 62 outreach points, 10 feeding centres and one rehabilitation centre. According to Bongo District Health Directorate there is one doctor in the district, the District Medical Superintendent who oversees the District Hospital and 65 nurses in the entire district . In the The research population for this study comprised of twenty (20) women who gave birth within 6 months in a health facility. To understand women’s experiences regarding the utilisation of skilled birth care services from their own perspective, a purposive sampling technique was utilized to select 20 participants who gave birth within 6 months period in a health facility.Bongo District is sub-divided into six sub-districts or zones according to Bongo District Health Directorate. Two Zones were randomly selected for the study. These two zones were believed to have performed poorly in skilled birth care attendance in the Bongo District over the years prior to data collection. Nurses and Community Key Informants (CKIs) provided a list of potential respondents (women) who delivered within 6 months utilising skilled birth care in each of the selected zones who were willing to participate in the study and met the inclusion criteria after the purpose of the study was explained to them. In order to maximize the variability of the sample and get diverse experiences, participants were purposively selected taking into consideration respondents’ age, parity, educational status, employment status, marital status and type of delivery, that is whether delivery was vaginal, assisted or caesarean section.Mothers who delivered live babies in health facilities assisted by skilled attendants within 6 months’ period and whose babies at the time of the study were still alive and well.Women who were above 18 years of ageData was collected by means of a semi-structured interview approach, which afforded the researchers flexibility. Prior to beginning data collection, the purpose of the interview was explained to participants. Confidentiality was assured and informed consent was obtained. The consent form was read in the Grune, a language spoken in the study area to participants who could not read or write and provided a thumbprint. Participants were informed they could decline to answer any question or stop talking at any time they wished during the interview process for any reason. They were also informed they could request the audio-recorder be turned off at any time.Please, tell me all about your experiences during the antenatal care of this current baby?Please tell me all about your experiences during the labour and birth of this current baby?Please tell me what informed your decision to choose your place of birth?Please tell me what kind of childbirth care you would have liked to have had at where you gave birth to your child?A semi-structured interview approach was utilised to gain a full understanding of women’s experiences regarding the utilisation of skilled birth care services. The registered midwives and community health nurses working at the antenatal and child welfare clinics were the gatekeepers as they assisted the researchers in choosing 20 participants from amongst the sample group of 110 women attending the child welfare clinics in two zones that had low levels of skilled birth attendance were selected for the study. Interviews were conducted by one of the researchers who worked in the study area for 5 years and could speak the Grune language fluently. The interviews took place at the community social centres perceived as convenient and comfortable and in a Grune language, preferred by participants. The participants suggested the community social centres in the communities as the most preferred venues for the individuals because those venues were free from interruptions. A voice recorder was used to capture data during sessions. Each interview took between 40 to 60 min. The audio-taped interviews were transcribed within 24 h of the interview while the information was still fresh in the researchers’ mind. A language expert translated the interviews into the English Language to enable the promoters of the study and the independent coder to understand the content of the interviews. The transcribed interviews formed the database of the study. The same questions were posed to all participants in the preferred language which was Grune. The following questions were posed to women who utilized a skilled birth care:Data collected from the semi-structured interviews were transcribed verbatim and analysed according to the steps suggested by Tesch, to identify themes and sub-themes relevant to the development of case studies . The app(H14-HEA-NUR-30). The researcher also requested permission in writing from the Bongo District Assembly and the Bongo District Directorate of Health Services to conduct research in the communities in the Bongo District. The researcher then requested permission from the community opinion leaders namely, the chiefs and the assemblymen, who were approached by means of a formal written request so that they become personally informed about the researchers presence in the communities under their direct jurisdiction. Informed consent was obtained from the research participants by issuing each participant with a letter that explained to them in full what the purpose and objectives of the research study were. Translation and interpretation of the information concerning the purpose and objectives into the Grune language was done for those who could not read in the English language. Each participant was given time to read the letter. The consent forms were signed by each participant who could read, and thumb printed by participants who could not read.The research had ethical approval from the Faculty Post Graduate Studies Committee at Nelson Mandela University n = 19) of the participants, belonged to the Frafra ethnic group whilst one (5%) participant belonged to the Builsa ethnic group. Twelve (60%) of the participants were married, six (30%) were single parents and two (10%) were widowed. The parity of participants ranged from one to six children. The youngest participant was 18 years and the oldest was 40 years. The majority  of the participants were within the age range of 15–20 years. The majority  of the women who participated in the study had no formal education. Only 20% (n = 4) of the participants had formal education up to primary or Junior High School level or dropped out at various stages of Junior High School. Also, the majority  of the participants were engaged in farming activities of various kinds to earn a living.The characteristics of the participants show 95 % .“Some of the nurses these days are just there for the money, but they don’t know the job. When you are in labour and you go to give birth, sometimes they would just be struggling with you without knowing what they are doing and if you are lucky they will eventually manage to help you give birth”.The participants reported they lacked confidence in skilled birth attendants’ abilities to conduct safe childbirth. Women’s confidence in skilled birth attendants’ abilities to conduct labour and childbirth safely and successfully is a determining factor in the utilisation of skilled birth care. The participants indicated that they experienced certain attitudes and behaviours from skilled birth attendants during their recent childbirth, making them doubt their competency and ability. The lack of confidence in skilled birth attendants were expressed by women as follows:“I have realised that it is the small, small girls (referring to young midwives) who don’t even know the work well, and yet they don’t respect us at all. For instance, in my own case that I narrated to you about my previous delivery at Bongo Hospital, the nurse examined me and told me I was not due for labour, so I should go back and be roaming, but that was not the true picture about the stage of the labour. I eventually delivered less than 30 minutes”.The women also indicated that they had no trust in the abilities of the younger midwives and nurses. Some of them indicated that, although the young midwives do not know their work well, they are the ones who usually misbehave towards women in labour. This is evident by a quote from a participant below:“…I must say that some of the nurses are unable to recognise the signs of labour because when you are in labour and go them they are unable to tell whether you are due to give birth or not…”.“...As for some of the nurses they can’t recognise labour and are not sometimes able tell you whether what you are experiencing is as a result of true labour or not”.Additionally, some of the participants indicated that some of the skilled birth attendants were unable to recognize true labour signs. Participants did not have the needed confidence in the abilities of skilled birth attendants because they are not able to identify where they were in labour and went to the health facility to give birth. The participants expressed concerns that the inability to recognize labour has often resulted in poor birth outcome for the mother and the child as indicated below:“The midwives wouldn’t just tell us what to do at each stage of the labour especially those of us delivering for the first time, so that you are able to follow their instructions and yet when you don’t follow their instructions during labour, they would speak to you as if we are trained about the delivering process. Communication is what is always creating the confusing between us the women and the nurses during childbirth”.The participants also felt that the skilled birth attendants were supposed to provide them with the right information regarding the labour process but they failed to provide or teach them but expected them to know the process. This issue is highlighted in the statement below:Disrespect for the traditional beliefs of the women was one of the experiences of women’s utilisation of skilled birth care in the study area. Women reported significant disrespect of their traditional beliefs during childbirth by skilled birth care attendants in the health facilities, even though those cultural or traditional beliefs are not harmful to the life of the mother and the unborn baby.“When I delivered at the hospital, my mother requested for the placenta to be taken home for burial according to my tradition, but the nurse refused to give it to her. My mother even pleaded with the nurse for about 30 minutes and she still refused to give it to us”.“One thing that annoyed me and my family was the refusal by the nurses to allow us to take the placenta home for burial”.The participants in this study indicated that certain cultural practices such as taking the placenta home by relatives or mothers to be buried according to their tradition were denied by skilled birth attendants after childbirth and instead, decided to dispose thereof according to the hospital protocol and policies. The sentiment of one of the women was expressed below:“The health personnel refused to give the placenta to us to take home but rather took it themselves and went and burnt it. I don’t know where they burn them in the hospital, but I am told they always burn it. But you see burning the child’s placenta, means you’re burning his destiny for life”.The participants indicated that they perceived that midwives refused to release the placenta to family members because they wanted to burn the placenta which was unacceptable. They indicated that such practice of burning the placenta could have dire consequences on the destiny of the child. The participants indicated that the placenta is usually supposed to be buried outside the house at a place called “Tampugre” and not to be burnt.zoomkom”  or “puusakoom” . A participant expressed her sentiment in the quote below:“When I gave birth at Namoo clinic my mother brought me “Zoomkom” but the midwife refused to allow me drinks it. She rather asked my mother to go and buy tea for me. But, I couldn’t take it well because I didn’t have an appetite for a tea. I wanted zoomkom or pusakoom”.“I don’t understand why the midwives wouldn’t always allow us to take our zoomkom or puusakoom after giving birth, but they would rather recommend a tea for us as if as we are white people”.The participants in this study reported that some of the skilled birth attendants refused to allow family relatives or mothers give certain food they believed to be culturally accepted according to the tradition of women. Women reported that normally when a woman gives birth newly, the first thing they give to her according to their tradition was hot “The aim of this study was to explore and describe rural women’s experiences in the utilisation of skilled birth care. The findings of this study show that labouring women in rural areas in the Bongo District of Ghana had negative experiences utilising skilled birth care. The participants based their opinions regarding the use of skilled birth care on their experiences of childbirth.The results of this study show that most of the women attended the antenatal clinic when they were pregnant and that influenced some of women decision to give birth in a healthcare facility. The findings of this study confirm a report from the 2014 Ghana Demographic and Health Survey (GDHS) which shows that due to women’s awareness of the importance of ANC, 87% of pregnant women in Ghana attended ANC at least one to four times prior to giving birth .Also, the findings of this study revealed that some of the participants in this study had negative interactions with skilled birth attendants during childbirths. Interviews with women indicated that they had negative interactions with skilled birth attendants during childbirths. Participants reported that skilled birth attendants such as nurses and midwives used abusive language against women who utilised health facilities for childbirth in the study area. The attitudes of some of the midwives have made some of the women to regret having taken a decision to give birth utilising the services of skilled birth attendants. Similarly, it is reported in literature that an important factor expectant mothers consider in utilising skilled birth care is the quality of the patient-provider interaction and communication . In a reFurthermore, this study found that during childbirth women did not trust the confidence of skilled birth attendants’ abilities. It was reported by most of the participants during the interviews that they did not trust the abilities of the skilled birth attendants especially the younger ones. Women’s confidence in skilled birth attendants’ abilities to conduct childbirth safely and successfully is a determining factor in the utilisation of skilled birth care. Previous researchers have reported similar findings that some women did not have confidence in the abilities of skilled birth attendants which usually influences birthplace decision-making of mothers –22. YounAdditionally, lack of cultural sensitivity or respect for women’s traditional beliefs was one of the experiences of women’s utilisation of skilled birth care in the study area. Some of women reported significant lack of cultural sensitivity or respect for traditional beliefs such as not allowing relatives to take home the placenta to be buried according to their tradition, not allowing certain foods, birthing position as well allowing their mothers-in-laws to stay with labouring women during childbirth by skilled birth attendants in the health facilities, even though those cultural or traditional beliefs are not harmful to the life of the mother and the unborn baby. In general, although giving the placenta to women or their family members to take home has no health implication, midwives do not usually give the placenta to the woman or her family members after childbirth to take home but are rather disposed of by themselves with the reason it was against the facility policy to give placenta to a woman’s relatives to take home. There have been several calls in Ghana, urging skilled birth attendants to integrate certain cultural practices that are held in high esteem by women and do not cause any problem to the expectant mother and unborn baby into the healthcare delivery system, to promote the utilisation of skilled birth care . DespiteAlthough this study provides important insights to experiences of women utilising skilled birth care provided by skilled birth attendants in the rural areas of Bongo district in the Upper East of Ghana, there are some limitations that need to be acknowledged. This study selected only women who gave birth utilising skilled birth care services. The inclusion of women who gave birth without utilising skilled birth care in the study would have enriched the findings of this study. It is therefore recommended that further studies be conducted to explore the experiences of both mothers who utilised or did not utilised skilled birth care during birth in order to compare their experiences. Also, it was observed that the majority of the participants in this study were from the same ethnic group and that might have influenced mothers experience in utilising the skilled birth care. Notwithstanding the limitations highlighted above this study achieved its objective of exploring and describing the experiences of women utilising birth care provided skilled birth attendants in in the rural areas of Bongo district in the Upper East of Ghana.This study gives a unique insight into women’s experiences of utilisation of the services provided by skilled birth attendants. The findings of this showed that most the women who utilised skilled birth care during childbirth in study had negative experiences as women experienced verbally abusive words and rude behaviors and lack of cultural sensitivity or respect for traditional beliefs by skilled birth attendants. This study also showed that some women did not have confidence in the abilities of skilled birth attendants to provide safe childbirth care. There is the need for maternal healthcare managers to address the poor attitudes and lack of cultural sensitivity or respect for traditional beliefs by skilled birth attendants to facilitate utilisation of the services provided by skilled birth attendants in the rural areas in Ghana where there is low utilisation of skilled birth care.The results of this study point to the fact that there is the need for healthcare managers in rural communities in Ghana to develop policies and strategies that will make skilled birth attendants such as nurses and midwives in rural areas to be culturally sensitive to the cultural beliefs and practices of women during labour and birth in the health facilities.Newly qualified nurses and midwives should be given orientation training as well as supportive supervision and mentoring by senior and experienced midwives to enhance their knowledge and skills in childbirth careThe Nursing and Midwifery Council of Ghana should organise specialized short courses covering all areas of maternity care to update the knowledge and competencies of maternity care providers. It should be made compulsory for all midwifery practitioners to attend.A further research study could be conducted to assess stakeholders’ perspectives on the barriers to skilled birth care in both rural and urban communities in Ghana to enable the development of good strategies and policies that could be used by skilled birth care providers to facilitate the use of skilled birth care by women. A research study should be conducted on how to integrate traditional birth attendants into the orthodox health care practice.


This study uses the machine vision method to develop an on-machine turning tool insert condition monitoring system for tool condition monitoring in the cutting processes of computer numerical control (CNC) machines. The system can identify four external turning tool insert conditions, namely fracture, built-up edge (BUE), chipping, and flank wear. This study also designs a visual inspection system for the tip of an insert using the surrounding light source and fill-light, which can be mounted on the turning machine tool, to overcome the environmental effect on the captured insert image for subsequent image processing. During image capture, the intensity of the light source changes to ensure that the test insert has appropriate surface and tip features. This study implements outer profile construction, insert status region capture, insert wear region judgment, and calculation to monitor and classify insert conditions. The insert image is then trimmed according to the vertical flank, horizontal blade, and vertical blade lines. The image of the insert-wear region is captured to monitor flank or chipping wear using grayscale value histogram. The amount of wear is calculated using the wear region image as the evaluation index to judge normal wear or over-wear conditions. On-machine insert condition monitoring is tested to confirm that the proposed system can judge insert fracture, BUE, chipping, and wear. The results demonstrate that the standard deviation of the chipping and amount of wear accounts for 0.67% and 0.62%, of the average value, respectively, thus confirming the stability of system operation. The quality of mechanical parts is dependent on the accuracy of the machining tools and the abrasion conditions of cutting tools. For instance, Fernández-Valdivielso et al.  analyzedThere are two types of insert condition inspections in turning processes: one is indirect inspection, where the external sensors feedback the analytical machine data ,10, and Direct inspection analyzes the problems in machining by directly observing the practical situation of the cutting tool. Some documents use sound, light, or a probe to build a cutting tool model to observe the status of the cutting tool ,31,32. Hdevelopment of an on-machine insert condition monitoring system that can be used to one-time identify the four insert conditions—fracture, BUE, chipping, and flank wear.development of a mountable visual system with different light sources to on-machine capture good-quality insert images that can be exactly analyzed under different lighting conditions.development of a contour and texture fusion inspection method to reduce environmental problems and to accurately identify insert conditions during inspection.Differing from existing research findings, this study analyzes insert statuses and uses fusion contour and texture inspection methods to build a more accurate evaluation and judgment system, which is applicable to on-machine automatic inspections and eliminates the environmental problems during inspection. A visual inspection system that can be used in CNC turning machine tools is constructed, which consists of a CCD camera and a lens for capturing insert images, a protection box to protect the photographic equipment, and a peripheral circuit and components, to avoid scrap splashes and cutting fluids during the cutting processes. The visual inspection system has a cleaning air tube, which jets air toward the insert to clean the surface of the inspected insert, thus, reducing the problems of subsequent image processing and increasing the accuracy of the insert condition judgment. The visual inspection system designed in this study has a surrounding light source and a fill-light for the tip of the insert to ensure that the insert condition can be analyzed under changing lighting conditions. When the light source is adjusted to determine the location of the blade and the tip of the insert, it is applicable to insert condition monitoring if onsite tool alignment is not accurate, thus enhancing the feasibility of image recognition in the machine. The light source intensity is adjusted and the insert image is captured under varying intensities for inspection analysis. The effect of any external environment changes on the insert condition monitoring result can be reduced and the system designed in this study can obtain accurate results in different environments. Image underexposure or solarization that generally result from changes in the insert condition are also improved. This study analyzes captured insert images with different features and the common insert conditions of an external turning tool, including fracture, BUE, chipping, and wear, can also be inspected. The analysis of the results can be quantized according to the texture feature distribution. This study conducts on-machine insert condition monitoring experiments with inserts in different states and the results show that the insert condition monitoring system designed in this study is applicable to computer numerical control (CNC) turning machine tools for correct and stable identification of insert fracture, BUE, chipping, and wear conditions. Contributions of this study therefore includeThe structure of this paper is as follows. The CNC turning machine tool used in this study, shown in During image capture, the fill-light is used for the inspected insert and the light source intensity is changed to ensure that different inserts have appropriate feature strength. This study uses two light sources in different positions as shown in First, the flank profile feature is determined using the flank exposure image in The horizontal blade line in If the insert condition, as identified by the insert condition monitoring system designed in this study, is not classified as fracture or BUE, the flank wear judgment process begins. First, the grayscale transformation is implemented for the trimmed insert outer profile image in The flank wear or chipping wear status can be classified according to the trimmed flank wear zone image, as shown in To validate the feasibility of the on-machine insert condition monitoring system proposed in this study, the visual inspection system mounted on the turning machine tool for insert condition monitoring experiments is shown in The insert condition monitoring system can identify different insert conditions and its operational stability is a key point of evaluation. Due to the changing external environment and light source intensity, there will be different results for insert condition tests and calculations. This study repeatedly tests the same insert to validate the stability of the insert condition monitoring system and the experimental results are shown in This study developed an on-machine insert condition monitoring system to identify four external turning tool insert conditions; fracture, BUE, chipping, and flank wear. The experimental results demonstrate that the developed monitoring system can successfully identify the four insert conditions. Moreover, as shown in The status of cutting tools used in the cutting processes of machine tools will obviously influence the manufacturing quality of machine parts. Therefore, this study develops an on-machine insert condition monitoring system for the turning tool insert of CNC turning machine tools and uses the machine vision method to inspect the common flank wear, chipping, fracture, and BUE statuses of turning tool inserts. This study differs from the existing research methods and outcomes as it fuses the machine vision method with contour and texture inspections to analyze the insert status. This eliminates the environmental problems in the insert inspection process to build a more accurate on-machine turning tool insert condition monitoring system. To fix the CCD camera and lens in the CNC turning machine tool to carry out the on-machine insert condition visual inspection process, a visual inspection system with a protection box, cleaning air tube, and two light sources is designed. The protection box can avoid the scrap splash and contamination of cutting fluid on the lens during the cutting processes, while the cleaning air tube jets air toward the insert to clean off surface contaminants. A surrounding light source and a fill-light for the tip of an insert with variable light intensities are employed to analyze the effect of change in lighting conditions on the visual inspection of the insert status. In the insert image capture process, the intensity of the surrounding light source and fill-light is changed to ensure that the test insert has appropriate feature strength. The surrounding light source uses strong light to irradiate the insert surface to obtain the surface shape and area features, while the fill-light enhances the tip status feature to facilitate subsequent captured image processing and analysis. An insert condition monitoring classification process designed in this study includes insert outer profile construction, insert status region capture, and wear region judgment and calculation. The insert outer profile construction uses the exposure image to determine the outer profile feature, and then the vertical flank line, horizontal blade line, and vertical blade line are established according to this outer profile feature. The insert image can be trimmed for subsequent insert condition feature recognition. In terms of insert status region capture, the insert fracture zone and BUE zone are identified according to the outer profile feature lines and the insert outer profile image is trimmed to obtain the actual image of the insert wear region. For insert wear region judgment and calculation, the flank wear or chipping wear is identified based on the grayscale value histogram of all pixels of the trimmed flank wear zone image. The wear amount is calculated using the pixel length of the upper and lower boundaries of the wear region image, which are used as the reference index to identify the normal wear or over-wear status of the insert. Finally, inserts in different states are used for on-machine insert condition monitoring experimentation to confirm that the system designed in this study can identify insert fracture, BUE, chipping, and wear statuses. In addition, as the changes in external environment and light source sometimes influence the image processing result, the operational stability of the on-machine insert condition monitoring system is tested in this study. The experiment is conducted repeatedly and the average value and standard deviation of the chipping rate and wear amount in the experimental results are recorded as the basis for evaluating the operational stability of the system. The experimental results show that the light source variation does influence the calculation of chipping rate and wear amount. The standard deviation of the chipping rate is only 0.67% of the average value, while the standard deviation of wear amount is 0.62% of the average value (standard deviation lower than 2 pixels), thus validating the stability of system operation.


Background Warfarin's adverse drug events are dangerous, common, and costly. While outpatient warfarin management tools exist, there is a dearth of guidance for inpatients.Objectives We sought to describe a health system's chronic warfarin quality metrics in older inpatients, defined by international normalized ratio (INR) control, explore associations between INR overshoots and clinical outcomes, and identify factors associated with overshoots.Patients/Methods Data on patients 65 years and older who were prescribed chronic warfarin and admitted during January 1, 2014, to June 30, 2016, were extracted through retrospective chart review. We defined overshoots as INRs 5 or greater after 48 hours of hospitalization. Logistic regression modeling was used to determine risks for overshoots and multivariate analysis for overshoots' association with length of stay (LOS), bleeding, and mortality.Results Of the 12,107 older inpatients on chronic warfarin, most were 75 years or older (75.7%), female (51.2%), and white (70.0%). While 1,333 (11.0%) of patients had overshoots during the admission, 449 (33.7%) of these reached overshoots after 48 hours. When stratified by overshoots versus no overshoots, LOS more than doubled (15.6 vs. 6.8 days) and the bleed rate was significantly higher (27.4 vs. 8.3%) in the overshoot group. While overall mortality was small (0.4%), the overshoot group's mortality was significantly higher (3.12 vs. 0.28%). Black race and weight wereprotective againstovershoots; history of heart failure and antibiotic/amiodarone exposure werepredictive ofovershoots.Conclusion This is the largest study examining warfarin quality metrics for hospitalized adults, specifically older inpatients. Our model may serve as the basis for identifying high-risk warfarin patients to target interventions to reduce adverse drug events. The Agency for Healthcare Research and Quality (AHRQ) labels anticoagulants such as warfarin a high-risk drug. Prior studies have shown that the majority of warfarin-associated bleeds result in serious outcomes, with fatal outcomes reported in up to 10%.Multiple tools exist for warfarin management in the outpatient setting,We now seek to bridge this gap in warfarin management specifically in the inpatient setting. This study aims to (1) describe a large health system's warfarin quality metrics in older inpatients, defined by the international normalized ratio (INR) control, (2) explore the association between inpatient INR overshoots and clinical outcomes, and (3) identify intrinsic and extrinsic patient factors associated with INR overshoots. We hypothesize that poor warfarin control is common in the inpatient setting and is associated with poor clinical outcomes.We conducted a retrospective chart review at a large health system operating in the New York metropolitan area, encompassing seven hospitals . Data were extracted from electronic health records of patients 65 years and older who were admitted and treated with chronic warfarin between January 1, 2014, and June 30, 2016. For this study, we defined chronic warfarin as documentation of warfarin use as a home medication prior to admission . Our local institutional review board approved the study (IRB #16–642).We defined INR overshoots as supratherapeutic INRs of greater than or equal to 5; it has previously been shown that the incidence of adverse events, specifically bleeding events, rises steeply with these INR values.Data points collected included all inpatient INR values, patient-related variables , and presence of comorbid conditions , moderate or severe chronic kidney disease [CKD], hemiplegia/paraplegia, malignancies, HIV, and liver disease). Additional variables included medications administered during hospitalization  and organizational factors .Outcomes included hospital LOS, mortality, and clinically significant bleeding. To capture clinically relevant bleeding, patients needed to meet at least two of the following three criteria: (1) an ICD9 code for bleeding , (2) RBCs transfused during admission, and/or (3) receipt of a reversal agent during the admission . The ICD9 bleeding codes used for analysis were derived from members of the New York State Anticoagulation Coalition and from Leonard et al 2008) and are listed in08 and arLogistic regression modeling was used to determine the risk factors for INR overshoots. Additional multivariate analysis was employed to associate INR overshoots with LOS, bleeding, and mortality. Variability across the health system was evaluated with INR overshoots by type of hospital, tertiary care versus community facility. Additional analysis of the impact of patient weight (kg) on INR overshoots was done through chi square testing at 10-kg intervals to establish safety thresholds.p < 0.0001).There were 17,494 unique admissions across seven acute care facilities for patients 65 years and over on warfarin. Of these, 12,107 were on chronic warfarin with INR data available and 5,387 were initiated on warfarin during the hospitalization (not included in our target population). Of those on chronic warfarin, 1,020 (8.4%) discontinued warfarin on discharge from the hospital. Patients with INR overshoots were more likely to be discharged without warfarin than those without overshoots . While the overall mortality rate for the chronic warfarin group was small (0.4%), there was a significantly higher mortality rate  in the group with INR overshoots. There was no significant difference in either the 30- or 90-day readmission rates between groups.p < 0.0016).In evaluating variability in the quality of warfarin management across the seven facilities, the rates of INRs over 5 after the first 48 hours ranged from 3.0 to 5.9%. While there was no significant difference between hospital types  with regard to INR overshoots, admission to a tertiary hospital was found to be protective against bleeding . When adding the variable for INR overshoots to the logistic regression model, we found that  an INR greater than or equal to 5 was independently predictive of a longer LOS (p < 0.0001), higher bleed rate (p < 0.0001), and higher mortality (p < 0.0001).p < 0.0001); 4.1% of patients less than or equal to 90 kg experienced INR overshoots compared with 2.5% of patients over 90 kg (p < 0.0001). At weights over 120 kg, there is no significant difference in incidence of INR overshoots between weight classes.Chi-square testing at 10-kg intervals for body weight found significant thresholds at both 50 and 90 kg: 7.7% of patients less than or equal to 50 kg experienced INR overshoots compared with 3.5% of those over 50 kg  or the need for reversal due to bleeding. To overcome this barrier, our focus for poor control was on supratherapeutic INRs known to be high risk for acute bleeding episodes rather than on subtherapeutic INRs. On the inpatient setting, the risk of subtherapeutic INRs can be mitigated by using heparin-bridging therapies when appropriate. We did not separate surgical and medical patients who may have different risk factors for adverse events. A final limitation was that the use of antibiotics or amiodarone was not correlated in its timing with the administration of warfarin.Our study findings indicated that (1) INR overshoots are prevalent in the inpatient setting in an older population across our health system and associated with poor outcomes and (2) INR overshoots are independently associated with low weight, heart failure, non-black race, and antibiotic or amiodarone exposure. In the outpatient setting, both intrinsic patient-related and extrinsic factors are integrated into warfarin dosing algorithms. We found that similar factors are also associated with inpatient INR metrics. Yet, no such tool exists in the inpatient setting to determine appropriate warfarin dosing, especially for more frequent (than weekly) assessments. Our model may serve as the basis for identifying high-risk patients and developing interventions for inpatient warfarin dosing strategies. Future studies should focus on the impact of the rate of change of the INR (the delta INR) on predicting INR overshoots when combined with clinical factors identified by our prediction model.


Racial disparities in birth outcomes are mirrored in cardiovascular health. Recently there have been calls for more attention to preconception and interconceptional health in order to improve birth outcomes, including as a strategy to reduce black-white disparities.As part of a larger study of cardiovascular and reproductive health , female participants were linked to their children’s birth certificates for Louisiana, Mississippi, and Texas births from 1982 to 2009. Three thousand and ninety-five women were linked to birth certificate data. Birth outcomes were defined as low birthweight (LBW) birthweight < 2500 g; preterm birth (PTB), > 3 weeks early; small for gestational age (SGA), <10th percentile for gestational age (percentiles based on study population); large for gestational age (LGA) >90th percentile for gestational age]. Cardiovascular measures  at the visit closest in time but prior to the pregnancy was examined as predictors of birth outcomes using logistic models adjusted for covariates.Only a few cardiovascular risk factors were associated with birth outcomes. Triglycerides were associated with higher risk of LBW among whites . Higher glucose was associated with a reduction in risk of SGA for black women , but not whites (p for interaction = 0.02). Clear racial disparities were found, but they were reduced modestly (LBW/SGA) or not at all (PTB/LGA) after CVD risk factors were adjusted for.This analysis does not provide evidence for preconception cardiovascular risk being a strong contributor to racial disparities.The online version of this article (10.1186/s12884-018-1959-y) contains supplementary material, which is available to authorized users. In the United States, blacks have roughly double the risk of infant mortality of other ethnic groups , due larRecently there have been calls for more attention to preconception and interconceptional health in order to improve birth outcomes –11, inclStill, few studies have examined preconception cardiovascular health and birth outcomes , and somp = 0.32.The Bogalusa Heart Study is a long-running study of childhood, adolescent, and now adult cardiovascular health, founded by Dr. Gerald Berenson in 1973 . ParticiAs part of a larger study of cardiovascular and reproductive health , female participants were linked to their children’s birth certificates for Louisiana, Mississippi, and Texas births from 1982 to 2009. The 1982–1989 records contained fewer variables for linkage than later years; observations that matched on four variables  were confirmed by visual comparison of addresses. From 1990 to 2009, a three stage linkage process was used, including deterministic record linkage based on maternal social security number (SSN), and probabilistic linkage when SSN was unavailable.Five thousand, nine hundred and- ten women/girls participated in BHS at least once during the study. Of those, 3263 were linked to birth certificate data, representing a linkage of approximately 65% of the likely births (as approximately 10–15% of women do not give birth). Participants linked to birth records were more likely to be black (37% vs. 35%), had more study visits, had a younger average age at first visit (8.8 vs. 10.5), were less likely to smoke (35% vs. 38%), and had statistically lower mean BMIs (19.9 vs. 20.3) and blood pressure (101.8 vs. 102.8) . Among white women, those whose parents had a high school education, rather than more or less education, were most likely to be linked, while among black women, likelihood of linkage fell with increased parental education. Among the smaller group with information about adult education, higher education was associated with increased likelihood of linkage among both black and white women. Three thousand and ninety-five women had at least one screening as a child, which occurred prior to the first pregnancy in the dataset. Two thousand, seven hundred and sixty-three screenings included a fasting blood samples; 2691 of these had data for analysis of lipids, insulin, and glucose. . If a woman had multiple pregnancies, the first linked pregnancy was used, and analysis was limited to singleton births.Blood pressure levels were measured on the right arm of subjects in a relaxed, sitting position by two trained observers (3 replicates each). Systolic blood pressure and diastolic blood pressure were recorded using a mercury sphygmomanometer. The fifth Korotkoff phase was used for diastolic blood pressure. The mean values of the readings were used for analysis.Fasting blood samples were drawn for lipids and glucose analysis. Prior to 1987, serum total cholesterol and triglyceride levels were determined by a Technicon AutoAnalyzer II . From 1987 to 1996, cholesterol and triglyceride levels were determined by enzymatic procedures on the Abbott VP instrument  and on the Hitachi 902 Automatic Analyzer  after 1996. Serum lipoprotein cholesterols were analyzed by using a combination of heparin-calcium precipitation and agar-agarose gel electrophoresis procedures. Both chemical and enzymatic procedures met the performance requirements of the Lipid Standardization Program of the Centers for Disease Control and Prevention, which has routinely monitored the precision and accuracy of cholesterol and triglyceride measurements since 1973. Measurements on CDC-assigned quality control samples showed no consistent bias over time within or between surveys.From 1981 to 1991, plasma glucose was measured by a glucose oxidase method using a Beckman Glucose Analyzer . Since then, it has been measured enzymatically as part of a multichemistry (SMA20) profile.Measurements were made by laboratory technicians blinded to participants’ risk factors. Ten percent blind duplicate samples are selected, prior to blood drawing. The intraclass correlation coefficient for blind duplicate samples ranged from 0.92 for glucose to 0.99 for total cholesterol.Birth outcomes were taken from measures on the birth certificates. Low birthweight (LBW) was defined as birthweight < 2500 g, preterm birth (PTB) as birth < 37 weeks ; small for gestational age (SGA) was defined as <10th percentile for gestational age (percentiles based on study population) and large for gestational age (LGA) as >90th percentile for gestational age. Report of both birthweight and gestational age on birth certificates have been found to be highly accurate . A seconCovariates were chosen a priori based on factors known to be associated with exposure and outcome , 28. RacAge at pregnancy was calculated from participant’s date of birth. Data on parity, weight gain, maternal education, and smoking were taken from the birth certificate data. BMI at time of visit was calculated from measured height and weight: participants were measured in duplicate and the average of the measures was used. Adequacy of prenatal care was assessed using the Kotelchuck index , and catp < 0.20: these varied by outcome but included age, race, smoking, parity, maternal education, adequacy of prenatal care, BMI at time of visit, age at time of Bogalusa screening, and years between Bogalusa screening and birth. Due to the strong correlation between BMI and cardiovascular risk factors, results are presented adjusted for BMI alone, then with adjustment for all factors. In addition to stratified models, combined models were run with an interaction term for race to examine differences between white and black participants. Results are presented stratified by race. As some studies have found non-linear associations between cardiovascular risk factors and birth outcomes [n = 586, 217 black, 369 white for those with a measure within 5 years of pregnancy) and results became too imprecise to judge whether this group differed from the main sample.Cardiovascular measures at the visit closest in time but prior to the pregnancy  were examined as predictors. Logistic regression was used for dichotomous measures. Models were adjusted for variables that were associated with the outcome at outcomes , quadratRacial disparities in birth outcomes were examined, first, unadjusted, then adjusted for the same confounders identified in the previous analysis. Finally, results were presented adjusted for these confounders as well as cardiovascular risk factors identified as predictors of birth outcomes in this or other analyses, including quadratic associations. As the associations found in this analysis were relatively weak, no formal mediation analysis was performed.Participants’ parents provided informed consent for child visits and adult participants provided their own informed consent for BHS measures. The Institutional Review Boards (IRB) of Tulane University (IRB ID#256406), the State Department of Health and Hospitals of Louisiana, and the Texas Department of State Health Services approved the linkage protocol (Mississippi deferred to the Tulane IRB). The linkage was conducted under a waiver of consent, as it was deemed minimal risk and infeasible without the waiver.The study population was approximately one-third black and two-thirds white Table . The majOnly a few cardiovascular risk factors were associated with birth outcomes. Triglycerides were associated with higher risk of LBW among whites .A quadratic association was found with systolic blood pressure, indicating higher risk for LBW and SGA at lower and higher levels


Seasonal infertility manifests in either pregnancy failure, or reduced litter size, or both in sows bred during summer. What is less clear is whether season influences piglet traits important for post-natal survival and growth, such as birth weight variation. Sows fed a diet with dextrose before ovulation gave birth to litters with reduced birth weight variation. Thus, this experiment had two aims: first, to identify if sows bred during summer would give birth to litters with higher birth weight variation, and second, to test if feeding sows dextrose before mating would reduce birth weight variation, especially during summer months. This experiment identified that there is evidence for increased birth weight variation in sows bred during the summer months despite the observed reduced litter size, suggesting that this is another way seasonal infertility can manifest. The 5% inclusion of dextrose in the pre-ovulatory sow diet increased litter size without compromising litter homogeneity at birth and resulted in higher piglet growth rates in those born to sows mated in winter (lactated in summer). Dextrose can be used successfully in a ‘wean to mate’ diet to boost the reproductive performance of sows.p < 0.05). There was a tendency for a higher co-efficient of variation (CV) birth weight in summer than winter , but no effect of treatment or interaction between treatment and season was observed. Piglet average daily gain was unaffected in those born to sows bred in summer, but when born to sows bred in winter, Dextrose piglets grew 23 g per day faster than Control (p < 0.05). This experiment identified evidence for increased birth weight CV in sows bred during the summer months despite the reduced litter size, suggesting that this is another way seasonal infertility can manifest.In this experiment, we proposed two hypotheses: birth weight variation would increase in litters from sows bred in summer, and dextrose supplementation during the wean to mate period would ameliorate this manifestation of seasonal infertility. Five hundred and ninety-one multiparous sows were allocated to Control; standard diet, or Dextrose; control +5% dextrose diets from weaning until insemination during summer and winter. Dextrose sows farrowed 1.0 and 1.4 more total pigs born and pigs born alive than Control sows, respectively ( Seasonal infertility can manifest itself in various forms but reports typically concentrate on a reduction in farrowing rate and litter size. This is driven by temperature and photoperiods, which directly impact on reproductive axes and indirectly act through effects on lactation feed intake. These effects can vary across years and are often site-dependent, as climatic conditions and management strategies differ. In herds that suffer reproductive loss during summer months, either through reduced farrowing rates or pigs born per litter or a combination of both, management strategies have been adopted to maintain pig flows. As a rule of thumb, producers will mate more sows during the warmer months of the year to counteract this dip in reproduction and maintain pig numbers on the ground. What producers may be less able to deal with is a dip in piglet birth weight, or, even more importantly, an increase in litter weight variation, as there are currently very few management strategies that can address such an issue. An increased within-litter heterogenicity is associated with increased piglet death and increased variation in weaning weights ,2. This p = 0.068), and, because significance was not obtained, data was not presented. This study also failed to show any seasonal effect on litter size (conception rate was not reported), which may suggest the experimental herd was not susceptible to the impacts of seasonal infertility.Campos, et al.  have sugBirth weight CV appears to be established during the embryonic stage (d35 gestation) , suggestVariation in litter birth weight can affect pork production from the time of birth through to slaughter. There is little published information on the seasonality of variation in litter birth weight, but the science would suggest it is plausible. It would appear that oocyte quality is important, and so nutritional strategies should target this reproductive phase. Dextrose is successful in reducing litter weight variation, and so its effects should be tested during the summer months. The aim of the following experiment was to determine whether CV of birth weight was influenced by season, and to test the effectiveness of dextrose administration at alleviating these effects.All procedures were carried out with approval from Primary Industries and Regions South Australia. The experimental periods were applied over two season replicates; summer, February–March and winter, August–September. Climate data for each of the experimental periods are shown in p < 0.05). There was no difference in season or treatment for any other variables examined.Sow history prior being recruited to the experiment is outlined in 2/sow. Sows were hand fed 3.5 kg of each of the control and treatment diets daily at 0700 h. Diet information is presented in Over four replicates in summer, and six replicates in winter, sows were weaned in groups of 40 to partially slatted pens with a space allowance of 2 mn = 3 to 5 boars) terminal sire dose. After the second insemination, sows were relocated into partially slatted gestation pens in groups of 50 and fed via electronic sow feeder at a space allowance of 1.8 m2/sow. Sows were allocated to gestation pens based on size and mating date and so pens contained both treatments, as well as commercial sows from outside the experiment. Return rate at 21 days of gestation was determined in the presence of a mature boar, and pregnancy rate confirmed via ultrasonography at approximately 28 days of gestation. All sows were fed a gestation diet (13.0 DE MJ/kg) at 2.1 kg/day in summer and 2.4 kg/day in winter.From weaning, sows were moved daily at 0800 h from the large pen into detection mating areas in groups of five, where fence-line contact with two mature boars was used to detect oestrus. If oestrus was not detected, sows were moved back to the large group pens, but, when standing behaviour was observed, the sows were relocated into mating stations. Once in the mating stations, sows received two post-cervical artificial inseminations 24 h apart and were fed as outlined above. All sows were inseminated with a pooled (Sows mated during the summer replicate farrowed during winter (June and July), and winter in summer (December and January). At approximately day 110 of gestation, sows were moved into farrowing accommodation and housed in farrowing crates (1.8 × 2.4 m). All sows were fed a lactation diet (14.2 DE MJ/kg) at 2.4 kg/day until farrowing, and then ad libitum to weaning. On the day of farrowing, the following measurements were recorded: total born (TB), born alive (BA), born dead (BD) and mummified foetuses. Piglets born both alive and dead were weighed individually, and those alive were tagged to allow individual identification. Fostering occurred once daily at 1300 h and all piglet movement involving tagged piglets was noted. Age and reason for piglet mortality was recorded, as well as piglet removal for ill thrift. Tagged piglets were weighed again on day 21 of lactation. Individual piglet weights on day 1 and day 21 were used to calculate the total litter weight, minimum and maximum piglet weight, standard deviation (SD) and co-efficient of variation (CV) weight, and the percentage of piglets within the litter weighing less than 1.1 kg . Piglets were counted at weaning to give number of pigs weaned per sow (NPW).p < 0.05 and tendency at p = 0.1. Normally distributed data were analysed using a general linear mixed model, but generalized linear mixed models were applied to binary data  using binary logistic regression, and to count data  using Poisson regression. All analyses contained parity, season, treatment and the interaction between season and treatment as fixed effects, and mated week as the random term. The number of sows retained for these analyses are outlined in All data were analysed in SPSS v25  and significance established at Separate analyses were conducted for 1764 Control and 2076 Dextrose piglets with the individual being the statistical unit. Linear regression was used for weights at day 1 and day 21, and binary logistic regression for survival to birth, fostering and weaning. The model included birth sow parity, birth litter size group , birth weight group , CV group , sex, season, treatment, and the interaction with main effects and treatment. Birth sow, foster sow and mated week were fit as random terms.p < 0.01; p < 0.001). Similarly, farrowing rate was improved by 25% from summer to winter (p < 0.001), and there was a tendency for a 5.9% improvement in Dextrose compared to Control sows (p = 0.1).No significant interaction between season and treatment was identified for any mating performance measure. Wean to service interval (WSI) was 1.5 days shorter in summer than winter . There was no impact on BD, but mummified was similar between treatment sows in summer, and reduced in Dextrose sows when compared with Control during the winter matings (p < 0.01). Pre-foster deaths were reduced in sows mated during winter than summer (p < 0.05); no difference was observed in post-foster deaths, but piglet removal was less in the winter bred sows (p < 0.05). Piglet removal was also reduced in the Dextrose sows when compared with Control (p < 0.05). There was a tendency for NPW to be improved in sows mated in winter than summer (p = 0.1).TB was higher in Dextrose than Control sows (p < 0.1), but no treatment effect was observed in minimum (0.86 ± 0.02 kg), maximum (1.88 ± 0.02 kg), or SD (0.31 ± 0.01). There was a tendency (p = 0.1) for day 1 CV to be higher in summer than winter (p < 0.001). Both the SD and CV at day 21 was increased in litters born to Dextrose treated sows (p < 0.05). Season also affected the CV weight on day 21, with sows bred during winter having higher variation than those bred in summer (p < 0.05).No significant interaction between season and treatment was identified for litter weight characteristics. A tendency for higher day 1 total litter weight was established in Dextrose sows when compared to Control . More piglets from sows bred in summer survived to weaning (90.7%) than those bred in winter . Birth weight group significantly influenced survival during birth, to fostering and weaning  for more Dextrose female piglets to survive the birth process than both females and males from Control sows. A trend for reduced survival until fostering in male Control piglets, compared with females from the same treatment, and both genders from Dextrose sows, was also established (p < 0.1). A total of 91.2% of females but 83.9% of males survived to weaning in the Control treatment (p < 0.01), but no sex effect was observed in Dextrose litters , but was unaffected by birth sow parity, CV group and treatment . A significant breeding season by treatment interaction was identified, whereby there was no treatment effect in piglets born to sows bred in summer, but in those bred during winter, the weaning weight and growth was improved in the Dextrose piglets .Piglet average birth weight was influenced by litter size, birth weight group and gender (We hypothesised that season would influence litter weight variability, and that when sows were fed a diet supplemented with dextrose before ovulation, this seasonal influence would be ameliorated. Our results support this hypothesis, in part. There was some evidence of increased litter weight variation in litters born to sows bred in summer, however the addition of dextrose failed to reduce this variation both across and within seasons.The first objective of this investigation was to identify whether seasonal infertility impacted on piglet traits such as birth weight, and within-litter weight variation. The experimental site was appropriate for the investigation, as the traditional indicators of seasonal infertility were observed; farrowing rate was 25% lower and litter size reduced by 0.4 pigs during summer, in comparison to the winter matings. Whilst no difference in average birth weight was identified, there was some evidence that day one litter weight CV was increased in sows bred during summer, which is in support of our hypothesis. Reviewed by De Rensis, et al. , reducedInterestingly, litter weight variation at birth had no impact on piglet survival and growth, which contrasts with previous work . It is, 2 = 0.394, Milligan, et al. [Dextrose appears to be a more effective energy source in dietary induced insulin enhancement than starch or fat . This waPerhaps one of the most interesting findings was that pigs conceived in winter and suckled in summer grew 23 g/day faster in Dextrose than Control litters, and as such were half a kilogram heavier at weaning. Lactation growth rates are suppressed during warmer months by poor sow feed intake, and this would be exacerbated under the natural ventilation farrowing shed conditions of this experiment. Given there was no improvement in any of the birth weight characteristics, this is a difficult finding to explain. We can only surmise that the size of effect of treatment on litter size across seasons altered mammary tissue activation in the winter bred, summer suckled Dextrose litters. Litter size is a main contributor to milk production, with more piglets ensuring adequate gland drainage and subsequent improvement in milk output . In summIn conclusion, supplementing dextrose at a 5% inclusion rate to sows in the ‘wean to mate’ period increases litter size without increasing the CV of litter weight. An additional benefit of the dietary treatment was an improvement in suckling piglet growth rate during the warmer, summer months.


Low birth weight is an important predictor of maternal and child health. Birth weight is likely to be affected by maternal health, socioeconomic status and quality of health care facilities.To assess trends in the birth weight, the proportion of low birth weight, maternal factors and health care facilities for delivery in villages of Western Maharashtra from the year 2004 to 2016 and to analyze factors associated with low birth weight for total birth data of 2004–2016.Data collected for 19244 births from 22 villages in Vadu Health and Demographic Surveillance System (HDSS), Pune, Maharashtra, India from the year 2004 to 2016 were used for this analysis.There was an overall increase in the annual mean birth weight from 2640.12 gram [95% CI 2602.21–2686.84] in the year 2004 to 2781.19 gram [95% CI 2749.49–2797.95] in the year 2016. There was no secular trend to show increase or decrease in the proportion of low weight at birth. Increasing maternal age (>18 years) compounded with better education, reduced parity and increasing number of institutional deliveries were significant trends observed during the past decade. Low birth weight was found to be associated with female gender, first birth order, poor maternal education and occupation as cultivation.Changes in maternal age, education, occupation, and increased institutionalized deliveries contributed in to increasing birth weights in rural Maharashtra. Female gender, first birth order, poor maternal education and occupation of cultivation are associated with increased risk of low birth weight. Low birth weight (LBW) is defined by the World Health Organization as birth weight of less than 2500 grams (gm). LBW is the single most important cause of neonatal mortality[2]. A hiIn the year 2013, the global incidence of LBW was 16%, whereas in South Asia it was found to be 28% . The proThere is strong evidence to show that the incidence of LBW is affected by multiple factors including genetic, placental, fetal, maternal and social factors 9]10]. [10]. 9][. [10]. 9Although the district and national family health surveys provide statistics of important child health-related indicators, they do not provide a longitudinal analysis of health indicators. Lack of extensive longitudinal community-based studies on birth-related indicators in India makes it difficult to assess trends in birth weights and birth-related indicators15]. Hea. Hea15].The present paper is an analysis of 19244 births captured as part of Vadu HDSS over a period of 12 years (2004–2016). In this paper, we summarize trends in birth weight, proportion of LBW, maternal factors  and health care facilities for delivery (place of delivery and personnel conducting delivery) in Vadu HDSS. Secondly, we have analyzed factors associated with LBW in Vadu HDSS.The Vadu HDSS has received approval from the Institutional Ethics Committee of KEM Hospital Research Centre, Pune (KEMHRC EC Ref No: KEMHRC/VSP/Dir.Off/EC1371). This being a demographic surveillance, a verbal informed consent was taken from an adult member of the household, preferably head of the household during their registration into HDSS 18] and  and 18] We used birth data collected from all the births in Vadu HDSS from the year 2004 to 2016. The Vadu HDSS under the auspices of KEM Hospital Research Centre Pune (KEMHRC) longitudinally monitors a rural population of 171462 (as on December 2016) residing in 22 villages. The analysis was conducted for babies of mothers who were usual residents of Vadu. Data of mother-baby diads who visited Vadu only during childbirth were excluded from this analysis.Vadu has a predominantly agrarian economy. It is a homogenous population in terms of religion and lifestyle. In the last five years, some villages have experienced rapid industrialization. This has resulted in increased land prices which led to a drastic change in the economic condition of landowners who have sold their lands for non-agricultural purpose. The industrialization has provided avenues for newer occupational opportunities 20]. Hea. Hea20].The Vadu HDSS captured data using standard data collection tools widely used by several demographic surveillance sites across the globe. Trained Field Research Assistants (FRA) conducted the house to house surveys biannually using standardized structured interview schedule as a tool for birth, death, marriage, pregnancy, and migration. The respondents included adult family members from each household who were approached for interviews followed by a verbal consent22]23].[23].22][.[23].22]Data on birth weight were based on information using hospital records, vaccination cards or maternal recall. Hospital records were used as the primary source of data; when not available, information based on vaccination card and/or maternal recall was used in this order. Data of all live births reported from the year 2004 till 2016 have been included in this analysis. Apart from birth weight, the following data were extracted from the HDSS database: sex of the baby, birth order, maternal age, maternal occupation, maternal education, place of delivery and health professional conducting the delivery. The data were independently extracted by the database management team from KEMHRC, Vadu.The data underwent dual quality control—quality control related to data collection and quality control related to data management. As a part of the quality control, a team of supervisory cadre (the FRS) repeated data collection for random 10% households. The FRSs also accompanied the 10% randomly selected FRAs on the field at the time of data collection. For the quality control related to data management, there were set of algorithms and programs which were pre-tested and were run on data at regular intervals.The outcome of birth weight was assessed by calculating mean birth weight and the proportion of LBW infants for each year. This included babies that were preterm as well as small for gestational age. The explanatory variables included infant sex, birth order, maternal age, maternal education, occupation, place of delivery and health professional conducting the delivery. These variables were extracted from the Vadu HDSS database. The clean and fully documented datasets from Vadu HDSS are regularly published online as a part of the INDEPTH Data Repository.To address the first objective, we compared the change in mean birth weight and proportion of LBW amongst all live born babies annually from the year 2004 till 2016. We compared the change in birth weight at each quartile over time. Moreover, we assessed trends in birth characteristics such as parity, place of delivery, maternal age, education, and occupation. Birth weight and maternal age were expressed as mean and standard deviation. All other variables were categorical and were expressed as proportions. Regression analysis was used to analyze the trends in continuous data and Pearson’s Chi-square test was used to analyze the trend in the categorical variables.To investigate the association between LBW and the explanatory variables; we used logistic regression analysis on total live birth data from the year 2004 to 2016. Crude odds ratios (ORs) with 95% confidence intervals were estimated for all the explanatory variables. Adjusted ORs were calculated by entering all the significant explanatory variables including the year of birth into the logistic regression model. Each variable entered the model if the likelihood-ratio test for its coefficient was significant (P<0.05). The statistical analyses were carried out using STATA v11 software.A total of 24,116 live babies were born from the year 2004 to 2016 after excluding missing values for gender and maternal indicators and 110 still births from data of 24,363 births. Data of 19,244 babies born to resident mothers in Vadu HDSS from the year 2004 to 2016 were considered for this analysis.th or 25th percentile of the data but there was an increase in the median and 90th percentile by 250 gm and 500 gm respectively [The overall mean birth weight was 2742.56 ± 507.84 gm. There was an increase in the annual mean birth weight from 2640.12 gm [95%CI 2602.21–2686.84] in the year 2004 to 2781.19 gm [95% CI 2749.49–2797.95] in the year 2016 [p for trend using regression <0.001]. The male babies were heavier than the female babies . The mean birth weights for male babies increased by 188.76 gm (7.14%) and for female babies by 87.46 gm (3.32%) from the year 2004 to 2016 . We compectively .There were a total of 3176  babies with a reported birth weight of less than 2500 gm. The prevalence of LBW was significantly higher in females as compared to males .Summary characteristics of the total population of low birth weight are: Mean 1985.76 gm, SD 327.87 gm, Median 2000 gm, Minimum 1800 gm and Maximum 2490 gm. The proportion of LBW infants varied from 10.34% to 22.45% across the duration and there was no secular trend towards an increase or decrease in the proportion of LBW infants . The higThere was a decrease in the parity from the year 2004 to 2016 for particularly babies born with birth order of 3 or more .There was a decrease in the proportion of births at private health care setup from the year 2012 onwards whereas the deliveries conducted at public health set-ups steadily increased from the year 2012 to 2016. Overall, the proportion of institutional deliveries increased to a great extent during the 12 years timespan and the number of home deliveries reduced to approx. 4% by 2016 .In parallel with the trend of institutional deliveries, there was an increase in the proportion of deliveries conducted by trained health care professionals  from the year 2004 to 2016. After the year 2013, there was an increasing trend in the number of deliveries conducted by nurses as compared to doctors .The average maternal age increased from the year 2004 to 2016 which but was not statistically significant [p = 0.2586] . ProportCultivation and homemaking were the two major maternal occupations over the 13 year period. There was a reduction in the number of women cultivators and an increase in the number of homemakers. These observations tally with a large number of agricultural lands being sold to real estate developers in the last decade. Amongst the total observations, the majority of the mothers were homemakers irrespective of their education levels. Amongst the cultivators, 5% of mothers were illiterate, 43.14% had primary education and 47.9% had secondary education.th class) had institutional deliveries. Of all the illiterate mothers, 77.30% delivered in hospitals and 20.45% had home deliveries. The illiterate mothers contributed to the maximum number of home deliveries across all maternal education categories. Moreover, 73–85% of the babies with birth order of 3, 4 and 5 or more were born to mothers either illiterate or with primary education.There was no secular trend in the proportion of illiterate mothers over the year 2004 to 2016 , howeverData for total of 19244 babies born between the year 2004 to 2016 were entered in the logistic regression analysis. The crude and adjusted odd’s ratios are shown in In univariate analysis, female gender, maternal age of <18 years and more than 35 years, cultivation as maternal occupation, maternal illiteracy, home deliveries, birth till the year 2010 and birth order of first or third or fifth or more were found to be associated with LBW. All the proposed variables were found to be statistically significant and hence were retained in the model. In the adjusted analysis, female gender, first birth order, poor maternal education, maternal occupation, and birth until the year 2010 were associated with increased odds of having LBW. The birth order of three and five or more, maternal age <18 years and home deliveries were not significantly associated with LBW in the adjusted model.This analysis depicts an increasing trend in birth weight in the rural population of Vadu HDSS over the last 12 years. There was a decreasing trend in the proportion of mothers aged less than 18 years and proportion of cultivator mothers whereas increasing trend was observed in maternal education, which is parallel to the national trend . The aveFemale gender, first birth order, poor maternal education, and maternal occupation were found to be significantly associated with the risk of LBW.Females were associated with lower birth weights than male babies and had a 16% increased risk of LBW. This is consistent with the earlier literature on LBW –30. The rd birth order and decreases thereafter [Babies with first birth order were associated with a 13% increased risk of LBW as compared to the second birth order in the multivariate analysis. This is similar to the previous literature which showed that birth weight increases up to 3ereafter –36. Bothereafter –37. But th class) were shown to have 42% and 21% increased risk of LBW as compared to mothers with secondary education (completion of 10th class). This is in consensus with a meta-analysis conducted by Silverstrin, which shows that high maternal education has a protective effect against LBW [Maternal health and the sociocultural environment has a significant impact on birth outcomes ,13,38. Iinst LBW . The assinst LBW . This coinst LBW ,42. Thisinst LBW –36.The association of maternal occupation with the risk of LBW has been two way. Overall employment during pregnancy has been found to be associated with reduced risk of LBW  but certChildren born after the year 2010 had a 14% reduced risk of LBW as compared to children born till the year 2010. The exact reasons for this improved risk of LBW are not evident. However, this analysis showed that this reduced risk of LBW is associated with an increasing trend in maternal education and an increased rate of institutional deliveries.The year 2012 onwards, there were increased deliveries conducted at public health facilities and there was a drop in the proportion of deliveries conducted at private health care facilities. This coincides with the initiation of free ambulance services by government of Maharashtra  and the The results of this analysis of surveillance data are in agreement with previous studies which showed that maternal age , parity The present paper has several limitations. The data on birth weights are based on the reported data collected by field workers from the medical records of the families, vaccination cards and parental recall and the exact distribution of data across all the data sources is not available. The outcome includes LBW irrespective of the gestational age and thus includes both premature as well as small for gestational age babies. As gestational age data were not available for all the babies, we have not included the risk of LBW due to prematurity in the analysis. Although socioeconomic status is a confounding variable for many of the variables, it could not be included in the current analysis. There are other indicators such as maternal nutritional status, gestational weight gain, antenatal visits, consumption of iron and folic acid, sanitation, consanguineous marriages which are likely to influence birth outcomes ,30,53 whThe longitudinal nature of HDSS has proved to be of immense value in getting demographic trends in Vadu HDSS area. We demonstrate that increasing maternal age (>18 years), decreasing parity, improved maternal education and increased institutionalized deliveries go parallel with increasing birth weights over the study period. Female gender, first birth order, poor maternal education and maternal occupation of cultivation are associated with increased risk of low birth weight.S1 File(PDF)Click here for additional data file.


Paratubal cysts are usually incidentally found due to being small and asymptomatic adnexal structures. Enlargement to more than 15 cm concurrent with late presentation in an adult is rare. We present the case of a 36 cm diameter cyst in a 31-year-old female whose symptoms involved overactive bladder, abdominal bloating, and pressure. Radiologic findings suggested that it extended from the xiphoid and pubic symphysis. Removal was through a minimally invasive technique. A paratubal cyst is a closed, fluid-filled sac that grows near the ovary and often connected to the fallopian tube. Paratubal or paraovarian cysts represent approximately 10% of all adnexal masses, often unilateral, and benign. They usually originate from the mesothelial covering of the peritoneum or from paramesonephric and mesonephric remnants. Thus, they are covered by a single layer of ciliated columnar or flattened cells [In this case, we describe the unique case of a giant paratubal cyst measuring 36 cm in diameter excised in a minimally invasive technique.A 31-year-old woman presented with abdominal distention and discomfort worsening over the past 6 months. Concurrently, she had development overactive bladder symptoms, bloating, and dyspepsia. Her medical history was pertinent for epilepsy controlled with antiepileptic medications. Urine analysis was negative for any signs of infection, and her pregnancy test was negative. Abdominal examination was positive for a firm and distended abdomen, uniformly enlarged from the xiphoid bone to the pubic symphysis. No tenderness was reported on palpation; however, pressure was endorsed. A bedside abdominal ultrasound was performed that revealed an abdomen fully distended with fluid, initially suspected to be ascites. Computed tomography in 2.5 mm helical slices with both IV and oral contrast suggested the presence of an encapsulated cystic mass containing clear fluid (6 Hounsfield units). Dimensions reported were 36 cm in long axis, 28 cm in transverse diameter, and 15 cm in anteroposterior diameter, corresponding to 7 liters in volume, suggestive of a right ovarian cystadenoma (Figures 2. Thereafter, 2 additional 5 mm trocars on each side of the midline were introduced.The patient underwent resection of the mass. The procedure was begun by drainage of the cyst in order to identify the stalk and excise all cyst walls. A 3 cm supraumbilical incision was performed with careful dissection until reaching the peritoneal cavity. An Alexis O™ wound protector/retractor Applied Medical was introduced through the small incision permitting better visualization of the cyst . Three hThe cyst borders were identified . Using tIn our case, we discuss the option of management of a giant paratubal cyst using a minimally invasive technique. Few documented cases report sizes comparable to our patient's case, and thus, management had to be individualized. Furthermore, larger cysts pose a conundrum as there is a concern for malignancy, adequate removal demands, and appropriate excision, ensuring preservation of fertility of certain populations, as well as attempting to offer treatment with the least risk to the patient.Of the larger paratubal cysts reported, sizes have reached 30 cm maximally whereas our patient had a cyst measuring 36 cm in diameter , 3. FluiParatubal cysts arise from embryologic remnants located in the proximity of the broad ligament between the ovary and the fallopian tube. Incidence rates are reported to be 17% to 33% for patients diagnosed with benign adnexal cysts . SmallerUltrasound and CT imaging in this patient helped in the diagnosis and guided the management permitting a minimally invasive approach. However, the definitive diagnosis requires surgical exploration to confirm cyst origin and its pathology. Ultrasound findings that should raise the clinician's level of concern regarding malignancy include cyst size greater than 10 cm, papillary or solid components, cyst wall irregularities, presence of ascites, and intratumoral high-color Doppler flow. There has been significant research on the use of ultrasound scoring systems alone or in combination with serum markers or historical information for predicting malignancy , 8. SeruSimilar to Salem and Vecchio et al., resolution of the cyst was through a minimally invasive technique , 13. MidThis case report delineates the management of one of the largest paratubal cysts reported while offering the patient a safe minimally invasive treatment modality. Accordingly, management of these cysts is possible once malignancy has been ruled out. Imaging and laboratory testing help guide the preoperative planning.