Puppy mortality is a widespread problem in small animal medicine. Apgar scoring, adapted for puppies performed by trained veterinary staff, was previously shown to be useful in identifying newborn puppies with an increased risk of mortality. The majority of puppies, however, are born in a home or kennel environment. In most whelpings, early evaluations and interventions are performed by the breeder. Therefore, we wanted to evaluate if a modified Apgar protocol for neonatal monitoring would be usable by breeders in a home environment. Our aim was to evaluate potential associations between neonatal scores, delivery times, birth weights, growth rates, and puppy mortality. Twenty-one bitches gave birth to 113 puppies by vaginal delivery. Neonatal scores were related to puppy mortality. Puppies with low neonatal scores had a longer expulsion interval and lower viability. Mortality was higher in puppies with a low relative birthweight. Puppies with a negative growth rate the first two days after parturition did not have a significantly higher risk of mortality in this study. Our results indicate that a modified and simplified neonatal scoring, performed by breeders approximately 5 min after birth, could be useful to identify puppies at risk of mortality.p < 0.0013). The viability and expulsion time of each puppy were significantly related . Viability was significantly related to relative birthweight (p < 0.01). Puppies with a negative growth rate the first two days after parturition did not have a significantly higher risk of mortality. In conclusion, a modified and simplified Apgar scoring performed by breeders approximately 5 min after birth was associated with puppy mortality.Mortality of neonatal puppies is a widespread problem in small animal medicine. Neonatal monitoring, according to standardized protocols, can be useful for identifying puppies that are at risk of mortality. Prompt intervention on weak puppies could increase survival rates. Apgar scoring adapted for puppies has been demonstrated to be associated with mortality and is usually performed by trained veterinary staff. The majority of puppies, however, are born in a home or kennel environment and not at a veterinary clinic. Our aims were, therefore, to evaluate if a modified protocol for neonatal monitoring would be usable by breeders in a home environment. We wanted to evaluate potential associations between modified Apgar scores, birth weights, delivery times, growth rates, and puppy mortality. Modified Apgar scores were related to the viability of live-born puppies ( Neonatal mortality is a widespread problem in small animal medicine ,2,3,4 anDifferent prognostic risk factors for poor neonatal survival have been identified. Puppies with low birth weights were more likely to die within the first 24 h after birth ,12. HighThe growth rate is an indication of the puppy’s ability to ingest colostrum and milk. Breeders commonly evaluate growth rates by weighing puppies daily. Although some degree of weight loss is not uncommon after birth, growth curves should be positive within the first few days . A growtApgar scoring was first described in human medicine and has been widely used ever since. Veronesi et al.  presenteOur aims were to evaluate a protocol for neonatal evaluation adapted for use by breeders and to identify factors indicating an increased risk for puppy mortality. Therefore, we evaluated potential associations between modified Apgar scores, birth weights, delivery times, growth, and puppy mortality.Data were collected prospectively. Questionnaires were sent out by e-mail to breeders who had reported an interest in participating in the study. Participating breeders were recruited through advertisements on social media channels and mailings sent out by Royal Canin to their national network of breeders in Sweden. Dog breeds included in the study were Affenpinscher ; Belgian Shepherd Dog/Tervueren ; Cane corso ; Chihuahua, long-haired ; Chinese Crested Dog ; Dachshund miniature, wire-haired ; Danish-Swedish Farmdog , English Cocker Spaniel ; German Spaniel ; Griffon Fauve de Bretagne , Icelandic Sheepdog ; Irish Red Setter ; Maltese ; Norfolk Terrier ; Pomeranian ; Poodle, miniature ; Portuguese Podengo, (Warren Hound) smooth-haired/miniature ; Schipperke ; and Weimaraner, long-haired . A total of 19 dog breeders with 21 bitches, giving birth to 21 litters with a total of 113 puppies born by vaginal delivery in Sweden from May to September 2018, were included. Bitches of the same breeds belonged to the same breeders.Participating breeders were instructed to evaluate neonatal scores (NS) according to a modified Apgar protocol. According to instructions, puppies were evaluated five minutes after birth. The protocol used in our study was a modified version of the Apgar protocol designed by Veronesi et al.  to be usBreeders were instructed to record the birth weight of the puppies and their daily weight until day 14. Thereafter, weights were recorded every week until 8 weeks of age. The bitche’s body weight (BW) before pregnancy was recorded; the sire’s BW was also recorded but was not considered further in the analysis because of collinearity with the mothers’ body weights.Viability was divided into five categories: (0) puppies that were stillborn, (1) puppies that were born alive but died within 2 h, (2) puppies dying between 2 and 24 h after birth, (3) puppies dying between 24 h and one week, and (4) puppies that were still alive after one week.The relative birth weight of the puppy was calculated as a proportion of the mother’s body weight. The growth rate was calculated as the increase in weight from birth divided by birth weight. The percent daily growth rate was calculated as the increase in weight from the previous day/weight the previous day. Neonatal scores were divided into three categories: scores 0–3, (1) scores 4–6, and (2) scores 7–8 (3). The BW of the mothers was divided into four groups: <10 kg, 10–19.9 kg, 20–30 kg, and >40 kg.On a puppy level, Fisher’s exact test was used to evaluate NS in relation to the viability of live-born puppies and to evaluate the risk of mortality in relation to a negative growth rate. A mixed model was used with relative birth weight as the outcome (logarithmic transformation) and with litter as a random factor and gender, the BWgroup of mother, and birth order as fixed factors. A mixed model was also used to evaluate relative growth after 7 weeks (log10 of BW /birthweight and BW/mother BW) in relation to adult the BWgroup and gender, with litter as a random factor. The goodness-of-fit was tested by plotting residuals vs. fitted data and by checking the normal distribution of the residuals.Ordinal regression was used with viability as an outcome and expulsion time , birth order, and a group of relative birth weight as fixed factors. The ordinal regression was calculated both for all born puppies, including stillborn, and for only live-born puppies. The relative birth weight was divided into two groups: (1) the lowest quartile of each BW group of mothers and (2) puppies from quartiles 2–4. The effect of relative birth weight on expulsion time for each puppy was evaluated with the non-parametric Kruskal–Wallis test because normal distribution could not be achieved. https://www.minitab.com, accessed on 1 September, 2023) and in R  [On a litter level, Spearman’s correlation was used to evaluate the relation between litter size and maternal BW, and the mean and total birthweight/litter, total length of parturition, mean relative birth weight, and the total relative birth weight/litter. Statistical analyses were made with Minitab 21.4.1  . Litter m, 2022) .Pregnancy lengths, calculated from first mating, ranged between 58 and 65 days, and maternal age between 2 and 8.5 years. A total of 10 out of 21 bitches were primiparous (47.6%). Median litter size was 5.0 (range 3 to 9) puppies. No medication was used at the time of delivery except for one bitch to stimulate contractions after signs of placental detachment; the medication used was not specified. The sex ratio was 55.7% females . Five puppies were stillborn (4.4%). Four out of five stillborn puppies belonged to the same litter. Nine puppies were born alive but died within the first week, resulting in a total neonatal puppy mortality of 12.4%. After the first week, only two more puppies died, one unexpectedly on day 12 and one Pomeranian puppy that was euthanized after three weeks due to suspected hydrocephalus. This was the only reported congenital defect in this study (0.9%). The distribution of viability and Apgar scoring are presented in p > 0.05). Puppies that were still alive after more than one week after birth were born with a median of 40 min after the previous puppy . Three puppies were reported to have been born 0 min after the beginning of stage 2. Excluding these three, the range was 6–900 min with a median of 48.5 min. For live-born puppies, the range was 0–250 min. The median time interval between expulsions of each puppy was 41.5 min (range 0 to 285) minutes. For live-born puppies, the median interval between puppies was 40.0 min (range 0 to 165 min). The time in stage 2 for each puppy was not affected by relative birth weight . The median total length of parturition, calculated as the time from the observed onset of stage II until delivery of the last puppy in each litter, was 285 min (range 30 to 1545 min). The total length of parturition was significantly and positively associated with litter size    and ranged between 6.8 and 18.7% of the mother’s body weight. Litter size was significantly correlated with the mother’s BW . Puppy gender had a significant effect on relative birth weight (p = 0.001), with males being heavier than females. Birth order did not affect relative birth weight (p = 0.18).Birth weight ranged between 45 and 535 g. Relative birth weight ranged between 0.55 and 4.0% . The meactively) a. The me= −0.83) b. Howevep = 0.0013), indicating that the NS could predict post-partum mortality . Puppies in the lowest quartile of relative birth weight had lower viability both with all puppies , as well as with only live-born puppies included in the model  (p > 0.05). Of 28 puppies in the lowest quartile, 11 (39.3%) died before the first week.The neonatal score group was related to viability  b. Birth p = 0.10). Thirteen puppies had not increased in weight two days after birth, of which none died within the first week, and 12 survived until weaning. One week after birth, the puppies had, on average, almost doubled their birth weight  but with no effect of gender (p = 0.21). In contrast, the puppies’ relative BW in relation to the mother’s BW was still higher for smaller breeds at 7 weeks of age .Seven weeks after birth, the puppies were, on average, 10.9 (range 4.97–21.29) times heavier compared with their birth weight a. RelatiAccording to our data, standardized neonatal surveillance according to a modified Apgar scoring can be performed by breeders. There was a significant relationship between the NS and the viability of live-born puppies. This indicates that the scores were useful in identifying puppies that were at higher risk of mortality. It remains to be elucidated if such puppies can be rescued with more intense monitoring. It cannot be ruled out that the instructions for monitoring the puppies could have contributed to a higher puppy survival because of closer observation of the neonates. The stillbirth rate in our study (4.4%) was, however, in the lower range of previous studies, with 3.4–10.9% of puppies being stillborn ,9,18,27.Scoring performed by breeders may give a larger variation compared with scoring performed by trained veterinary staff. We used a simplified Apgar score to standardize the breeders’ evaluations of neonatal scores. Instructions were made as simple as possible to reduce operator-dependent variation. In order to simplify the protocol, scoring of heart rate was excluded, as this parameter is difficult to evaluate for a nonprofessional. A reduced heart rate in neonatal puppies is closely related to asphyxia . TherefoThe absolute and relative birth weights of the puppies in this study were within ranges previously reported for breeds of similar sizes ,32. As pPrevious studies have demonstrated that puppies with a low birth weight have a higher probability of neonatal mortality ,31. Low In contrast to a previous study , there wThe median growth rate on the day after birth was 2.9%. Although three of four puppies with known growth rates that died in the first 24 h had a decrease in body weight after birth, the majority of the puppies with negative growth on the first day of life survived until weaning. Puppies with a negative early growth rate in the first 2 days of life may be at a higher risk for mortality , but it In conclusion, our data suggest that instructing breeders to perform a modified and simplified neonatal scoring approximately 5 min after birth could be of value for systematic surveillance of neonatal puppy health in a home environment. Data collected by breeders are likely not as precise as data collected by scientists. However, the protocols were simplified to standardize the data as much as possible. The modified Apgar scores and relative birth weights were related to puppy survival. Puppies with lower Apgar scores had significantly longer inter-pup intervals during parturition. By instructing breeders to routinely evaluate breathing, mucous membranes, reflexes, and vocalization, more at-risk puppies can be detected. It remains to be elucidated if systematic neonatal monitoring by breeders can also contribute to reducing puppy mortality.


The current study tested whether the reported lower wellbeing of parents after preterm birth, relative to term birth, is a continuation of a pre-existing difference before pregnancy. Parents from Germany  and the United Kingdom  reported their new-born’s birthweight and gestational age, subsequently categorised as very preterm or very low birthweight , moderately/late preterm or low birthweight , or term-born (≥ 37 weeks and ≥ 2500 g). Mixed models were used to analyse life satisfaction, an aspect of wellbeing, at four assessments-two years and six months before birth and six months and two years afterwards. Two years before birth, satisfaction of prospective term-born, MLP/LBW, or VP/VLBW mothers did not significantly differ. However, mothers of VP/VLBWs had lower satisfaction relative to mothers of term-borns at both assessments post-birth. Among fathers, satisfaction levels were similarly equivalent two years before birth. Subsequently, fathers of VP/VLBWs temporarily differed in satisfaction six months post-birth relative to fathers of term-borns. Results indicate that parents’ lower life satisfaction after VP/VLBW birth is not a continuation of pre-existing life satisfaction differences. Relatedly, VP/VLBWs’ average stay in neonatal intensive care units (NICU) is two months3, which is associated with reduced wellbeing among their parents9. Subsequently, at up to 12 years after birth, parents of preterms show decreased wellbeing and increased stress levels11, with mothers more affected than fathers7. Furthermore, in a follow-up study of mothers of VP/VLBWs especially, increased distress was reported at two, seven and 13 years after birth6. Parents may therefore struggle to overcome the initial adversity associated with preterm birth as they are at a higher risk for having post-traumatic stress symptoms12, however research findings here are somewhat inconsistent13. In addition, taking care of a VP/VLBW child, who has a higher risk of developmental delay14, may increase the reported long term burden felt by parents15. Thus, for parents of MLP/LBWs or VP/VLBWs, and in particular for mothers of VP/VLBWs, research indicates reduced levels of wellbeing during their offspring’s childhood.Both moderately to late preterm birth or low birthweight , and very preterm birth or very low birthweight especially , are associated with increased risk of mortality and morbidity16, which has been consistently shown to have a high correlation with fewer mental health problems19, and better physical health16. As a general trend, a transient increase in general life satisfaction has been reported for parents in Britain and Germany in the years directly before and after childbirth, before returning back to pre-pregnancy levels21. Although potentially true for the majority of the population, research also suggest that this transition to parenthood may differ depending on the parent’s sex, age, education level, or whether the parent has a migrant background22. What is currently unknown, is whether the course of life satisfaction differs for parents of children born VP/VLBW or MLP/LBW. Due to the aforementioned studies showing mental health differences post-birth, parents of VP/VLBWs or MLP/LBWs may differ from parents of term-borns by showing a transition to parenthood with either a smaller rise, no rise, or even a deterioration in life satisfaction surrounding birth. Alternatively, it has been hypothesised that increased stress and lower life satisfaction may be a precursor of preterm birth23, that is prenatal stress and financial hardship increases the risk of preterm birth occurring25. It is therefore possible that life satisfaction is already low before pregnancy for future parents of preterm children. Thus, any subsequent association found between preterm birth and parents’ lower life satisfaction would not be due to preterm birth per-se but rather a continuation of pre-existing lower life satisfaction. Similarly, many factors that have been associated with lower life satisfaction, such as higher age, lower income, lower education, and migrant background27, have also been associated with increased risk of preterm birth29. Overall, the idea of a stable difference between parents of preterms or term-borns, before and after the birth, would be in line with results of general population studies showing postpartum depression is highly associated with pre-partum depression30.An important aspect of subjective wellbeing is general life satisfactionThere will be a difference in life satisfaction two years before birth between future parents of VP/VLBW, MLP/LBW and term born infants, tested separately in mothers and fathers.The changes in life satisfaction of parents before and after birth will differ depending on whether the infant is born VP/VLBW, MLP/LBW, or term born, tested separately in mothers and fathers.This study aims to answer two main research questions. First, do future parents of MLP/LBW or VP/VLBWs already have lower life satisfaction than parents of term-borns, up to two years before birth? Second, is the course of life satisfaction from two years before till two years after birth different for parents of MLP/LBWs or VP/VLBWs when compared to parents of term-borns? To answer these questions, data from two large population representative panel studies from Germany and the United Kingdom are studied. These studies both include repeated assessments of parental life satisfaction before and after birth, which allows to check the robustness of our findings. This resulted in the following hypotheses:31 and (2) the combined datasets of the British Household Panel Study and the Understanding Society study (BHPS/USS)32. The SOEP is a random sample of representative households in Germany. While initiated in 1984, it has been annually asking parents about gestation and birthweight of new-borns since 2003, meaning the included infants ranged in birthyear from 2002 to 2019.This study used data from two international panel studies (1) The German Socio-Economic Panel 32. Further information about the SOEP can be found in Goebel et al.31 and in Buck and McFall for the BHPS/USS33.Analyses were also performed on data from the United Kingdom. The BHPS is a nationally representative study which started in 1991, collecting information about gestation and birthweight for newborns from 1999 until the final wave in 2008. In 2008, the BHPS was absorbed into the USS study, which has released ten data waves. For this analysis, all results are simply referred to as BHPS/USS data and are the combination of waves 9–18 of the BHPS and waves 1–10 of the USS, meaning the included infants ranged in birthyear from 1997 to 2019In each study, all births with valid data on either birthweight or gestational age were identified. We then categorised births into three groups—VP/VLBW (VP < 32 weeks and/or VLBW < 1500 g), MLP/LBW (MLP < 37 weeks and/or LBW < 2500 g) but not VP/VLBW, or term born (birthweight ≥ 2500 and gestation ≥ 37 weeks). When a parent had multiple children, just one birth was considered for how it influenced life satisfaction. The decision of which birth was made by ranking the births by whether they (1) had valid data for both birthweight and gestation, (2) were VP or VLBW, (3) were MLP or LBW, and finally (4) by birth year. This meant that just one birth would be chosen per parent, with preference given to those with full data, born with lower gestational age or lower birthweight, or if they were the first child reported to the parent.34. In the BHPS/USS data, the question was “how dissatisfied or satisfied are you with your life overall?” and answers ranged from one (completely dissatisfied) to seven (completely satisfied). In SOEP, the question was “How satisfied are you with your life, all things considered? ” and it ranged from zero (completely dissatisfied) to ten (completely satisfied). To harmonize life satisfaction, scores were Z standardized separately in each study and separately for mothers and fathers, so that over the four assessments the mean was zero and had a standard deviation of one .The outcome variable of self-reported life satisfaction was measured annually in each study, with the exception of the 11th wave of BHPS. For each parent, life satisfaction assessments were only eligible for inclusion if they fell within a certain timeframes relative to the birth and were binned into four specific assessment points. Assessment points were ideally two years before birth (life satisfaction before the pregnancy of the selected birth), six months before birth (life satisfaction during the pregnancy of the selected birth), six months after birth , and two years after birth (long term life satisfaction post birth). Due to births occurring at any time during annual assessments, the first and fourth assessment were eligible for inclusion when they were at most 36 months and at minimum 12 months away from the birth. Similar restrictions were applied on the second and third assessments, being no more than 12 months away from the birth. As the first assessment was before the pregnancy of the child, it was determined that this would reflect “baseline life satisfaction”. Life satisfaction was measured using a single item, which has been found to perform very similarly to multiple item measures of life satisfactionA number of covariates were considered. Time invariant binary variables were the child’s sex, whether the child was a singleton or not, whether the child had a known long-standing health condition, whether the child was the first birth reported for the parent, and whether the parent reported a migrant background. Time varying covariates were whether a sibling was born within any of the four assessments, the age of the parent in years, the z standardized net household income for the parent, marital status, and the parent’s highest education level  levels of low (levels 1–2), medium (3–4) and high (5 +).For SOEP, ethical permission was granted by the Scientific Advisory Board of DIW Berlin in Germany, and by IRB review at Vanderbilt University (IRB #180737). For BHPS and USS, ethical permission has been repeatedly granted by the University of Essex, with the most recent ethical approval number ETH1920-0123. All studies were performed in accordance with the relevant guidelines and regulations with participants providing informed consent before data collection.35, with mixed models performed using the package lme436. Main analyses used all valid data, which was defined as valid life satisfaction data surrounding the sole birth selected per parent and falling within the specifically defined timeframes. Main analyses combined data from the studies but analysed data separately for fathers and mothers while sensitivity analyses in the SOEP specifically removed certain sub-samples (e.g. the refugee specific subsamples), as their transition to parenthood may be particularly stressful22. Two between subjects ANOVAs initially analysed parents’ baseline life satisfaction by the child’s birth group variable . A power analysis was conducted on the two ANOVAs with a desired power of 0.8, with an expected moderate standardized mean difference of 0.30 and an expected small difference of 0.15 between the parents of term-borns and the VP/VLBW and MLP/LBW groups respectively. For the baseline satisfaction ANOVAs, life satisfactions scores were Z standardized based solely on the mean and standard deviation of assessment one, two years before birth. For the linear mixed models, as previously noted, scores were Z standardized based on all four assessments as to investigate longitudinal changes. Longitudinal analyses were performed as unbalanced panels, allowing for parents to vary in their number of life satisfaction assessments. Parents may not have all four assessment points due to not being interviewed in the specific timeframes that were subsequently imposed, due to not being recruited before the birth of their child, or due to not taking part in the study at a specific point . The multiple assessments per parent were treated as a random effect while the assessment point, birth group, and the interaction between these two factors were treated as fixed effects. In the mixed models, the estimated marginal means of birth groups were calculated at each assessment point. Using the R package emmeans, marginal means were tested for significant differences with a false discovery rate adjustment, akin to a post hoc analysis in an ANOVA37. Further sensitivity analyses considered confounding by conducting linear mixed models before and after including the aforementioned covariates or removing specific sub-samples, ran separately in each study and separately for fathers and mothers.All analyses were performed in R version 4.1.1In the German Socio-Economic Panel study (SOEP) data, 8611 births were reported in the study period to 6282 mothers. Once combined with eligible life satisfaction data, there were 4754, 865 and 107 mothers of term-born, MLP/LBW, and VP/VLBW infants respectively. Similarly, when the respective fathers were identified, there were 4079, 750 and 94 fathers of term-born, MLP/LBW, or VP/VLBW infants respectively. Further information regarding data availability and participant demographics is shown in Table In the British Household Panel Study and the Understanding Society study (BHPS/USS) data, 9601 births were reported in the study period to 6670 mothers. Once combined with eligible life satisfaction data, there were 5665, 627 and 105 mothers of term-born, MLP/LBW, and VP/VLBW infants respectively. Similarly, when the respective fathers were identified, there were 4096, 441 and 78 fathers of term-born, MLP/LBW, or VP/VLBW infants respectively. Further information regarding data availability and participant demographics is shown in Table p = 0.31] nor in fathers , for mean scores in each cohort see Tables One-way between subjects ANOVAs were performed on baseline life satisfaction, separately for mothers and fathers. There were no significant differences in baseline satisfaction based on birth group for mothers [F2, 5457) = 1.175, , 5457 = For mothers and fathers separately, mixed models analysed changes in life satisfaction relative to birth. From these models, the estimated marginal means were calculated and contrasted Tables , 4, and p =  < 0.001) but then largely returned to baseline levels for the last assessment at two years post birth , see Fig. 1.1 and Table p = 0.01) but then also returned back to baseline levels at two years post birth. Finally, mothers of VP/VLBWs showed no increase in life satisfaction from baseline to six months post birth but then demonstrated a significant decline in life satisfaction at two years post birth relative to the three other assessments . Regarding contrasts of estimated marginal means by birth groups at the same assessments, mothers of term-borns had significantly higher life satisfaction than mothers of MLP/LBWs at assessments two, three and four, Fig. 1.1/Table The mixed model indicated that relative to their baseline life satisfaction two years before birth, scores for mothers of term-borns rose at assessment two and to their highest at assessment three, those six months prior to and post birth, , see Fig. 1.2 and Table p = 0.02) but then also returned back to baseline levels at two years post birth. Finally, fathers of VP/VLBWs showed no significant increases or decreases in life satisfaction across the four assessment points. Regarding contrasts of birth groups, fathers of term-borns had significantly higher life satisfaction than fathers of MLP/LBWs at assessments two and four. Fathers of VP/VLBWs temporarily had lower life satisfaction than the two other birth groups at assessment three, with the largest difference equalling 0.24, see Fig. 1.2/ Table In the analysis of fathers, relative to baseline life satisfaction, scores for fathers of term-borns significantly rose in the third assessment but then significantly fell in the fourth assessment (differences in Z scores = 0.08 and −0.06, both Analyses were also performed separately by study, after the removal of specific subsamples, and after the inclusion of covariates, see Supplementary Tables This study investigated changes in parents’ life satisfaction prior to and following the birth of term-born, MLP/LBW, or VP/VLBW infants. Consistently, no differences in life satisfaction between birth groups were found at baseline, for both mothers and fathers. Regarding subsequent differences between child birth groups, in mothers’ data, those with VP/VLBW infants showed a significant decline in life satisfaction in both assessments after birth relative to mothers of term borns. Furthermore, mothers of MLP/LBW infants had a smaller rise in life satisfaction in the assessment prior to birth and then remained consistently lower than mothers of term-born infants. Generally, while mothers appeared to be more affected by the birth than fathers, marginal mean differences in all analyses were relatively small, with Z score differences less than 0.25.24, it was plausible that the life satisfaction of the future parents of MLP/LBW or VP/VLBW infants would already be lower than those of future parents of term-borns. This finding would have been in concordance with the finding that postpartum depression is strongly associated with depression prior to pregnancy30. However, no significant differences in life satisfaction before the pregnancy based on future parental birth group were found, indicating that subsequent differences after birth cannot be simply attributed to a long standing, pre-existing difference.The first aim of the current study was to investigate life satisfaction before pregnancy. A major limitation of past cohort studies is that most started their recruitment at birth or later, limiting the ability to determine whether poorer wellbeing for parents of preterms only occurs after the birth happens. As research has linked increased prenatal stress with preterm birth6. SOEP and BHPS/USS are household panel samples that recruit households and subsequently follow all household members annually. This contrasts to birth cohorts of preterm individuals that specifically recruit infants requiring admission to NICU38. Thus, the MLP/LBW or VP/VLBW infants in this analysis may reflect the parental life satisfaction for parents of all preterm/LBW infants, rather than a selective subsample with greater pathology. For example, the average gestation of the VP/VLBW sample was approximately 31 weeks, whereas past studies using cohort data often have lower average gestations, at approximately 27 or 28 weeks10. This may partly explain why our largest standardised difference of 0.24, measured six months post birth when differences between groups may be expected to be particularly pronounced, is somewhat smaller than the 0.34 effect size they reported at ages two, seven, and 13 years post birth6. While our effects were smaller, a noticeable difference in life satisfaction was found for mothers of VP/VLBW and term born infants at both assessments after birth, with VP/VLBW fathers also showing a temporary significant difference relative to other fathers in the assessment after birth. This is particularly important when interventions to support parents of preterms are considered, especially when considered in tandem with the fact that no pre-existing difference two years before birth were found. As the change in life satisfaction is concordant with the birth occurring, and found for both mothers and fathers of VP/VLBW infants, it suggests that support can be specifically focused after the birth occurs. This quantitative analysis therefore supports previous reports based on qualitative interviews of mothers of extremely preterm infants39.The second aim was to investigate parents’ life satisfaction following birth, with our results showing smaller effect sizes when compared to past studies of preterm or LBW children that have used different recruitment strategies20. It was also found that fathers showed only a small increase in the year after the birth while mothers reported a larger increase in life satisfaction in both assessments nearest to birth, corroborating past findings of larger effects for mothers4. Finally, the inclusion of multiple covariates did not consistently change our main findings regarding preterm birth and life satisfaction. These analyses show that, apart from preterm birth, lower education levels and having a child with a long-term illness are also associated with lower life satisfaction. Thus, when considering the targeting of intervention or identifying those most at risk, these parents appear to be more likely to require support.Moreover, we investigated differences between mothers and fathers and consistency of findings across studies. The finding that life satisfaction also rises for UK mothers of term-borns in the years directly before and after birth, supports past findings only using the SOEP dataset23 and life satisfaction17.When considering the strengths of the current study, the longitudinal approach utilising prospective measurements starting before pregnancy until two years after birth is a particular and unique strength. We could determine if differences in life satisfaction according to prematurity or LBW emerged after birth or whether they were pre-existing. Second, we were able to use two large samples, from two different countries but still using very similar methodology. This allowed for the robustness of our results to be considered. Third, the ability to consider a number of covariates demonstrated that the findings were not confounded by socio-environmental factors that have been previously associated with both preterm birth40 or a week of gestation41. While gestation or birthweight are likely to be accurately reported, it may be a proxy measure of a factor that has a greater influence on parent’s life satisfaction, the child’s health. Past research has found that the association between preterm birth and parental wellbeing is mediated by neonatal morbidity and later child functioning42. Thus, future research may investigate the life satisfaction prior to and following childbirth that results in either admission to NICU specifically or results in long term morbidity for the child. In our study, information on morbidity was limited to a binary variable of whether the child had a health problem; more detailed variables could not be harmonized across the samples and for single-cohort-analyses the statistical power was lacking due to insufficient sample size. Another potential limitation is the use of a single-item life satisfaction measure rather than other measures of mental health or wellbeing, as it may be affected by social desirability bias43. However, past research indicates life satisfaction and mental health demonstrate a strong reciprocal relationship44, with mental health problems a larger contributor than income for explaining variance in life satisfaction17.Limitations of the current study were that rather than relying on hospital records, information on birthweight and gestational age were parent reported, which may be subject to error. However, evidence suggests that a year after birth, over 90% of parents can accurately recall their child’s birthweight within 100 gTo conclude, the findings from two panel studies indicate that while parents of term-born infants show a rise in life satisfaction in the year directly before or after birth, this effect is less pronounced for parents of MLP/LBW and VP/VLBW infants. While mothers showed larger changes in life satisfaction surrounding birth, fathers of different birth groups showed less variation over time, with the differences across birth groups largely stable over time. Overall, while effect sizes were small, the relatively lower life satisfaction of mothers of VP/VLBWs infants at six months and two years after birth should be particularly noted and psychosocial support provided.Supplementary Information.


Childbirth fear, which has been argued to have an adaptive basis, exists on a spectrum. Pathologically high levels of childbirth fear is a clinical condition called tokophobia. As a chronic stressor in pregnancy, tokophobia could impact birth outcomes. Many factors associated with tokophobia, including inadequate labor support, were exacerbated by the COVID-19 pandemic.N = 993).We used longitudinally collected data from a convenience sample of 1775 pregnant persons in the USA to evaluate the association between general and COVID-19 pandemic-related factors and tokophobia using the fear of birth scale. We also assessed associations between tokophobia, low birth weight and preterm birth when adjusting for cesarean section and other covariates among a subset of participants . Mothers who self-identified as Black (odds ratio (OR) = 1.90), had lower income (OR = 1.39), had less education (OR = 1.37), had a high-risk pregnancy (OR = 1.65) or had prenatal depression (OR = 4.95) had significantly higher odds of tokophobia. Concerns about how COVID-19 could negatively affect maternal and infant health and birth experience were also associated with tokophobia (ORs from 1.51 to 1.79). Tokophobia was significantly associated with increased odds of giving birth preterm (OR = 1.93).Tokophobia increases the odds of preterm birth and is more prevalent among individuals who are Black, have a lower income, and have less education. Tokophobia may, therefore, be an underappreciated contributor to inequities in US birth outcomes. The COVID-19 pandemic likely compounded these effects. Beginning in the 1980s, researchers in Sweden and later Finland began researching the psychological construct that would come to be defined as ‘fear of childbirth’ [Clinically, pathologically high levels of childbirth fear is called tokophobia. Prior diagnosis of depression or anxiety, a general fear of pain, a history of sexual abuse, nulliparity (no prior birth), and traumatic birth experiences are significant predictors of tokophobia . While tWhile inconsistent measurement makes comparing childbirth fear across cultural contexts difficult, there is some evidence to suggest that cultural environment influences childbirth fear. Studies using the Wijma fear of childbirth index, a 33-item instrument that is the most used tokophobia scale, have reported a severe fear of childbirth prevalence ranging from 7.5% to 15.5% among European countries (as defined by Wijma score ≥85) . NotablyTokophobia has not been previously evaluated in the USA using the Wijma scale. In a qualitative study, Roosevelt and Low suggested that the Wijma scale may be inappropriate for use in the US cultural context because the scale did not include all relevant sources of concern in this setting, including fear of abandonment by clinicians during labor. The only published US study utilizing an internationally validated tokophobia scale was conducted among an online convenience sample during the COVID-19 pandemic. The authors used the fear of birth scale (FOBS), a visual analog scale that has been argued to more accurately compare childbirth fear across cultural settings . These aMaternal psychosocial stress in pregnancy is a known predictor of adverse birth outcomes, including lower birth weight and preterm birth . TherefoSince the social context of birth influences childbirth fear, the COVID-19 pandemic—which substantially affected maternity care experiences—likely impacted this measure. Notably, many of the fear loci identified in tokophobia previously, including fear of harm to self or baby, fear of poor emotional support in labor and inadequate pain management, were directly impacted by the COVID-19 pandemic. Specifically, individuals who gave birth in the early weeks and months after the pandemic was declared in the USA on 13 March 2020 were threatened with the possibility of giving birth alone, of not having access to preferred pain management strategies, and of being separated from their infant if they tested positive for SARS-CoV-2 during delivery , 15. SinThe current study assesses what factors  are associated with tokophobia among a sample of US-based pregnant persons, while also investigating the association between tokophobia and birth outcomes. We test three predictions:1) Maternal health , demographics  and provider type  will be associated with tokophobia measured during pregnancy.2) Concerns that the COVID-19 pandemic will affect maternal and infant health and maternity care experience will be associated with tokophobia measured in pregnancy.3) Tokophobia measured in pregnancy will be prospectively associated with low birth weight and preterm birth, independent of cesarean section delivery, high-risk pregnancy or other covariates.Data come from the COVID-19 and Reproductive Effects (CARE) study, an online survey that was administered to a convenience sample recruited using informational flyers shared through social media  and to US-based contacts working in maternal health . Zip codQualitative information was also collected; specifically, participants were asked three open-ended questions during the prenatal survey: (i) ‘What are some concerns you have regarding your pregnancy and/or giving birth? These concerns may be unrelated to COVID-19’; (ii) ‘Have these concerns changed at all due to COVID-19?’, if yes, ‘How have your concerns changed due to COVID-19?’; and (iii) ‘Is there anything else that you think would be helpful for us to understand about what it is like to be pregnant and planning to give birth during the COVID-19 pandemic?’ This information was not used in quantitative analyses but does provide contextual information presented in the study discussion.N = 3). Reference categories for categorical variables were selected according to the groups expected to be least likely to have tokophobia and are specified in the statistical analysis section.Gestational age during the survey was calculated using data on the due date and date of survey completion ; participant age (years); education ; household income (USD) ; previous birth (yes/no); high-risk pregnancy (yes/no), pre-existing health conditions (yes/no), prenatal depression   and provWe created an original survey to evaluate concerns specific to receiving prenatal care and giving birth during the COVID-19 pandemic (see FOBS was used to assess tokophobia  Supplem. While lTokophobia: (see above).Offspring birth weight (in ounces) was collected through self-report in the postnatal questionnaire. We defined low birth weight using the clinical cut-point of 5 pounds 8 ounces .The offspring birth date reported in the postnatal questionnaire was compared to the due date reported in the antenatal questionnaire to generate gestational age at delivery (in days). We then defined preterm birth using the clinical cut-point of 259 days (37 weeks) .N = 19). We also excluded a single participant with a birth weight of 207 ounces that was more than 5 SD above the mean. All continuous variables exhibited normal distributions, with skewness values within approximately ±0.96 and kurtosis values within approximately ±4.45 [Data analyses and visualizations were conducted using Stata 15.1 and R  and RStuly ±4.45 .Prediction 1 and 2: Unadjusted logistic regression models were conducted to evaluate if tokophobia was significantly associated with both COVID- and non-COVID-related risk factors.Prediction 3: Unadjusted logistic regression models were initially used to test whether tokophobia was associated with low birth weight or preterm birth. To measure the association between tokophobia and birth outcomes independent of other confounders, we then ran models that adjusted for maternal ethnicity (ref: white), income (ref: highest income category), education (ref: highest education category), provider type (ref: midwife), trimester of pregnancy when the survey was completed (ref: first), prenatal depression, nulliparity, high-risk pregnancy, pre-existing health conditions, cesarean section delivery and offspring sex. Multicollinearity was not detected in either adjusted model; all VIF values were in an acceptable range of 1.02–1.56.Sample summary statistics are reported in Odds ratios and 95% confidence intervals are presented in Most participants agreed or strongly agreed with a series of statements that they were concerned the COVID-19 pandemic would impact their health, their infants’ health or their maternity care experience .Consistent with our prediction, all reported concerns were significantly associated with tokophobia  and after adjusting for covariates (adjusted odds ratio (aOR) = 1.91, 95% CI = 1.02, 3.76). Individuals who had a high-risk pregnancy  or who were in the third trimester of their pregnancy at the time of the survey  had significantly higher odds of delivering preterm. No other covariates were significantly associated with the odds of preterm birth.Inconsistent with our prediction, low birth weight was not significantly associated with tokophobia in unadjusted  or adjusted  models. Cesarean section  and high-risk pregnancy  were associated with higher odds of low birth weight birth. No other covariates were significantly associated with the odds of low birth weight.Within the fear of childbirth literature, empirical research has mainly focused on fear of childbirth predictors rather than on associated outcomes. This study is the first to demonstrate a positive relationship between childbirth fear and preterm birth, finding that individuals with tokophobia have nearly twice the odds of giving birth preterm. Importantly, this association remains significant after controlling for both elective and emergency cesarean section, which previous research indicates are associated with tokophobia . For conThe prevalence of tokophobia in our sample is much higher than was reported in a review of tokophobia studies in Europe, Canada, Australia and the USA, which found a childbirth fear prevalence ranging from 6% to 14% across studies . Our numThe high prevalence of tokophobia reported in this study is even more notable since our sample was relatively privileged, with self-identified white, highly educated participants over-represented relative to the general US birthing population. Tokophobia may, therefore, be even higher in more nationally representative samples. Additional studies are needed to understand whether the high levels of childbirth fear reported here were driven primarily by the pandemic, aspects of the US maternal health care system, high levels of pre-existing general anxiety that become elevated during pregnancy or other American cultural norms and expectations around birth.Participants with lower income and education in this study were more likely to have tokophobia. In addition, the odds of a Black mother having tokophobia was 90% higher than the odds that a white mother did. This latter finding may reflect the unfortunate experience of obstetric racism that results in poor care delivery for many Black families in US settings . Some pa“We chose our doctor because she was POC (though not black). We wanted a black doula (but there aren’t many in our city and the ones that are present are incredibly expensive). We are deeply aware of how race plays out in care.”-34-year-old nullipara with low-risk pregnancyHigher childbirth fear associated with obstetric racism may therefore be a presently underappreciated contributor to the stark inequities in maternal and infant health in the USA .Our finding that tokophobia is associated with higher odds of preterm birth is consistent with other research suggesting that maternal stress experienced during pregnancy impacts gestation length , 29. PreThe HPA-axis is usually regulated through a negative feedback loop, with cortisol decreasing sensitivity to CRH in the hypothalamus and reducing subsequent ACTH and cortisol release. However, during pregnancy, cortisol stimulates the production of placental CRH, leading to a positive feedback loop of pCRH, ACTH, and cortisol. These peptides/hormones increase exponentially across gestation and play multiple vital roles, including facilitating fetal maturation and influencing the timing of spontaneous labor . ElevateThe COVID-19 pandemic exacerbated existing weaknesses in the US maternity care system , potenti“I’m terrified all the way around as it is my first pregnancy. You name it, I’ve worried about it. The COVID-19 stuff just adds more fear.”-30-year-old nullipara with low-risk pregnancyOne of the specific pathways through which the COVID-19 pandemic has exacerbated childbirth fear is the threat many participants experienced of having to give birth alone. One participant wrote that she was:“…afraid I’d end up with a c-section due to my lack of support from a doula, midwives, or other friends.”-39-year-old multipara with high-risk pregnancyAssisted childbirth is considered a human universal and is regarded as an important component of our evolutionary history , 36. TheChildbirth is an essential component of human reproduction. And yet, many individuals experience severe childbirth fear, clinically defined as tokophobia. We can imagine at least two plausible evolutionary hypotheses that could help explain why pathologically high rates of childbirth fear occur. One explanation is that tokophobia reflects the development of an extreme version of an adaptive response. Specifically, a modest amount of childbirth fear may be adaptive if it promotes a desire for assistance in labor and delivery, thereby reducing maternal and infant mortality . Since cr = −0.20, P < 0.0001; see [A second, and more likely, hypothesis for the presence of tokophobia in cultural contexts like the USA is that it reflects a mismatch between the birth settings we likely experienced for much of our evolutionary history (i.e. familiar environments with known care attendants) and those where many individuals currently give birth (i.e. unfamiliar birth facilities with unknown care attendants) , 38. The001; see  for descNotably, full-term pregnancy in humans  is defined because 39–40 weeks is the most common gestation length and the gestation length associated with the lowest incidence of neonatal mortality . This coThat said, shorter gestation, including preterm birth, may not be a maladaptive response in all instances; for example, Pike argued that shorter gestation length may be adaptive if it increases maternal or offspring survival in the face of compromised maternal or environmental conditions  . Yet, whOur sample consists of a disproportionally high number of participants who self-identify as white, are highly educated, and are from high-income households relative to the general US birthing population. As indicated by our findings, tokophobia is higher among Black mothers, likely due to racism and other inequities in maternity care experienced by this population , 40. AddRecent research has highlighted the strengths of the FOBS in both clinical settings and application across cultural contexts, mainly since there are issues of translation of several instrument items of the Wijma scale into English . A qualiP = 0.04); however, the difference was slight . Nonetheless, the loss to follow-up among individuals with higher childbirth fear has likely biased our results towards the null since we would predict that higher childbirth fear scores would be more strongly associated with adverse birth outcomes.Consistent with other online survey samples conducted during the COVID-19 pandemic, we had substantial attrition between the first and second surveys . SpecifiWhile this analysis has focused on the impacts of tokophobia on birth outcomes, tokophobia has consequences beyond this, including on the process of childbirth and the postpartum experience. For example, tokophobia is associated with prolonged labor, and the use of epidural and obstetric complications . AdditioResearch on tokophobia originated in Scandinavia, with most related studies occurring in this cultural context. The only previous study to find a significant relationship between tokophobia and birth outcomes surprisingly reported that higher childbirth fear was associated with lower adverse birth outcomes . This fiIt is important to distinguish between moderate childbirth fear, which may have an adaptive basis, and tokophobia, which is considered a pathologically high level of fear. Low levels of fear could be adaptive if it motivates individuals to seek care and assistance in labor . HoweverSince tokophobia is more prevalent among individuals who are Black, lower income and who have less education, and tokophobia increases the odds of preterm birth, our results suggest that tokophobia may be an additional and presently underappreciated contributor to ethnic and socioeconomic inequities in birth outcomes in the USA. Cumulatively, these results demonstrate the need to include tokophobia as a measure in future maternal health studies in the USA and elsewhere. Professional medical associations should also recommend screening and treatment for tokophobia, since treatment has been shown to decrease fear and improve maternal self-efficacy , 50. Fineoad006_suppl_Supplementary_FileClick here for additional data file.


In clinical practice, spinal extradural arachnoid cysts (SEAC) are relatively rare. The key to the treatment of SEAC is recognize and close the dural defects (fistula orifice), but there is currently no convenient method to locate and identify the fistula. We propose a method for predicting the location of lumbar/thoracolumbar SEAC fistula based on surgical experience, subsequently closing the fistula through posterior unilateral interlaminar fenestration. Evaluating its surgical efficacy and investigated its effect on patient prognosis.A stepped approach based on clinical experience is proposed. A retrospective analysis was performed on 6 patients diagnosed with thoracolumbar SEAC disease and treated with posterior unilateral interlaminar fenestration through the position by pre-estimated fistula orifice in our hospital’s Department of Neurosurgery between January 2017 and January 2022.All patients who received this treatment experienced significantly lower postoperative VAS pain scores and ODI index compared to their corresponding preoperative values (P < 0.01). During the ongoing follow-up after surgery, no unstable vertebral column, adverse effects, or complications were reported.The use of posterior unilateral interlaminar fenestration for the treatment of large SEAC in the adult lumbar/thoracolumbar segment can reduce spinal cord manipulation and enhance spine stability. The disease can be treated by sealing the fistula orifice through a small fenestra, the position of which is assessed before surgery. This surgical method reduces trauma and improves the prognosis of patients with large SEAC. A spinal arachnoid cyst (SAC) is a rare disease that occupies the spinal canal. SAC is typically characterized by increasing paresthesia or radiculopathy . TypicalSEAC symptoms are quite variable. Depending on the location, patients present with neurological compression symptoms . ThoraciWhile surgery has been recommended for the treatment of symptomatic SEAC, there is no consensus on the best treatment option due to the low incidence of SEAC. According to previous case reports, successful therapy should attempt to seal the cyst’s fistula opening to subarachnoid space  . WhetherA retrospective analysis of clinical data for patients with lower back pain or radicular radiating pain was performed. Patients enrolled in this study if diagnosed with lumbar/thoracolumbar SEAC disease between January 2017 and January 2022 at our hospital’s Department of Neurosurgery. Patients with the following conditions were excluded from the study: (1) evidence of intradural mass lesions or malignant lesions; (2) presence of multiple cystic lesions or metastatic lesions on the cross-sectional MR image; (3) infection, instability, or pain caused by lumbar disc herniation or lumbar spondylolisthesis; (4) cyst size less than two spinal segments. A total of six patients  met the study’s inclusion criteria and were treated with interlaminar fenestration. All surgeries were performed by the same senior surgeon, and each patient provided written informed consent.All patients underwent preoperative MRI imaging. SEAC was diagnosed if oval-shaped tissue with a long T1-weighted-image (T1WI) and a long T2-weighted-image (T2WI) signal with a clear spinal canal edge was observed. Moreover, the oval-shaped tissue was in sharp contrast to the surrounding adipose tissues, and its signal was identical to that of the CSF. T2-fat-suppression-imaging (T2FS) revealed a hyperintense signal, whereas T2-fluid-attenuated-inversion-recovery (T2FLAIR) revealed a hypointense signal. Due to the difficulty of correctly locating the cyst fistula orifice (the communication point between the cyst and the subarachnoid space) using MRI images, MRI was only used to determine the size of the cyst, and to correctly identify the affected spinal levels.The patient was positioned in the prone position, and a stepped approach has been planned. As the first step, the cyst’s size was identified based on its precise location on the affected spinal levels as determined by MRI imaging, and the fistula orifice was estimated based on the surgical experience before the surgery: the cyst was accurately positioned and the mid-upper 1/4 to 2/4 (1/2) of the cyst length was marked as the approximate indicated region of the fistula orifice  was used to assess changes in back and leg pain seven days following surgical decompression for all patients. VAS scores were graded on a scale of 1 to 10, with 1 indicating no pain and 10 indicating the worst pain possible. The Oswestry disability index was used to measure functional improvement (ODI). The ODI index (0 ~ 100%) suggested that those with higher scores had a higher level of disability. The paired-samples t-test was used to examine changes in VAS or ODI parameters before and after surgery. P < 0.05 indicated that the difference was statistically significant (significance level = 0.05). The spine stability was measured (hemilaminectomy/laminectomy) using localized anteroposterior curvatures of > 12° or scoliotic curves of > 15° with or without coronal/sagittal plane translation at the operative segment, which was identified as the unstable vertebral column using CT/X-ray image.Six patients had postoperative MRI to confirm the removal of associated cysts. Postoperative pathology showed arachnoid tissue that was definitively identified as an arachnoid cyst Table ; Fig. 3.Seven days following surgery, five patients reported complete alleviation of lumbar or back pain, complete restoration of muscle strength in their lower limbs, and the ability to walk normally. Lumbar pain was considerably decreased in one patient, with a slight numbness in the outer lower limbs, but muscular strength was completely restored, and the patient was able to live a normal life Fig. . The meaSEAC is rare and has been rarely reported in the literature. Therefore, SEAC has been referred to in the previous literature by a variety of names, including arachnoid diverticula, leptomeningeal cysts, pseudomeningocele, meningoceles, diverticula, localized adhesive arachnoiditis, and epidural cyst. Currently, there is a consensus to use the term ‘Spinal arachnoid cyst (SEAC)’ to describe the disease . SEAC caThe use of imaging examination has been successful in diagnosing SEAC. Clinical data indicates that MRI is the preferred diagnostic modality. The cystic content had a signal intensity that was similar to that of the CSF and was characterized as hypointense on the T2FLAIR image and hyperintense on the T2FS image. Following the injection of a contrast agent into the subarachnoid space, Magnetic Resonance Myelography (MRM) and CT Myelography (CTM) may be used to determine the morphology of the cyst. The compression of the spinal cord and subarachnoid space can be seen using these techniques. MRM, on the other hand, is more invasive than MRI, which is why it is not routinely used. In most cases, plain X-ray radiographs can only be used to detect lesions in the spinal canal that are occupying space and growing slowly. Therefore, the diagnostic specificity of the disease determined by X-ray is poor.The optimal treatment of SEAC has not yet been established due to its low incidence. There is a consensus that surgical treatment for symptomatic SEAC can be beneficial. It has been hypothesized that defining and sealing the fistula orifice between the cyst and the subarachnoid space is an effective treatment strategy . RegardiFrom the above analysis, there is no single technique for the precise localization of fistula orifices in SEAC, and each method had its own set of shortcomings. Based on our previous surgical experience and literature review, we propose a stepped approach for SEAC: MRI was routinely performed before the patients underwent surgery. If a fistula orifice failed to be directly displayed on the image, the position of the orifice was estimated. The location of the fistula orifice was estimated to be in the mid-upper 1/4 to 2/4 (1/2) of the cyst length as indicated by MRI sagittal images and on the opposite side of the compressed dural sac of the spinal canal as demonstrated by MRI axial images  of the cyst length and may be identified by opening the estimated location on the vertebral lamina Fig. . Table 3Currently, the most common surgical approach for symptomatic SEAC is the complete removal of the cyst with multi-level laminectomy and repair of any possible dural defects. This invasive surgical technique is associated with a significant risk of kyphotic deformity, particularly in younger patients with large cysts spanning many vertebral levels, which usually results in spinal instability. Although some research suggests that simultaneous spinal fusion might reduce this risk, the operative trauma associated with such procedures is still significant , 28. AltThe fistula orifice was sutured and most of the cyst wall was peeled away to completely decompress the spinal canal space. However, there is no conclusive evidence on whether the cyst wall should be treated. Most scholars recommend resecting the arachnoid cyst wall as much as possible after fully suturing the fistula orifice. This is because some scholars have found that the disease can be treated by removing the entire cyst wall without locating the fistula orifice intraoperatively . Funao eAlthough the proposed surgical technique is less invasive and safe, it does have some limitations. First, the location of the fistula orifice was determined using our extensive surgical experience because fistula orifice sites are not well defined due to a lack of large data and samples to allow extensive research. Second, this method can only estimate the position of the fistula orifice in large  SEAC. Smaller cysts can be located directly without using this predictive fistula orifice technique for direct fenestration. The proposed imaging technology is less sensitive to detecting the fistula orifice. This procedure will be useful in predicting the location of the fistula orifice for the treatment of this disease, however, with the advancement of imaging technology, neuroendoscopy  interventional treatment can be used to close the dural defect on the premise of accurate development of the fistula orifice, thus play an important role in the minimally invasive treatment of this disease. This is because the lumbar/thoracolumbar spinal canal space is larger than that of the thoracic and cervical segments. Furthermore, because there are fewer nerves, it is advantageous to undertake small vertebral lamina fenestration and minimally invasive cyst stripping operations, which causes less trauma to the spinal cord. This surgical method was exclusively used on the lumbar section for safety reasons. When researchers gain more surgical experience, they will be able to broaden the treatment to include thoracic and cervical segments. The dorsolateral side of the spinal canal is exposed during this surgery, but due to the limitation of the medial spinous process and the lateral articular process, the operator usually has a small operating space. This surgical technique requires the operator to adapt to the delicate operation of microsurgery in a small area. Therefore, beginners have to face a steep learning curve.Currently, there is no standard treatment for SEAC due to its low incidence. The classical approach of fully excising the cyst with multi-level laminectomy destabilizes the spine and increases the risk of postoperative complications. The most critical aspect of the surgery is locating and closing the fistula orifice between the cyst and the subarachnoid space. Therefore, to avoid recurrence of SEAC, treatments should not only decompress the spinal canal by removing the cyst but also shut the fistula orifice. In the present cases, unilateral vertebral lamina fenestration was used to treat adults with large SEAC in the lumbar/thoracolumbar segment. This technique minimized manipulation of the spinal cord by the cyst and improve spine stability. The disease was effectively treated by closing the fistula orifice.


Preterm births and parity are two medical areas that seem to be entirely different from each other. The aim of this study was to analyze the relationships between parity and maternal and neonatal outcomes associated with preterm birth. This study involved a retrospective analysis of electronic medical records from St. Sophia Hospital in Warsaw (Poland). This study was conducted among women who gave birth to preterm infants between 1 January 2017 and 31 December 2021. A total of 2043 cases of preterm births were included in the final analysis. A higher odds ratio of preterm birth in primiparas was found in women living in a city/town (OR = 1.56) and having secondary (OR = 1.46) and higher education (OR = 1.82). Multiparas who gave birth to preterm infants were more frequently diagnosed with gestational diabetes (19.69%) than primiparas. Multiparas were more likely to give birth to preterm infants who received an Apgar score of ≤7 both at 1 and 5 min after birth (25.80% and 15.34%). The results of our study emphasize the differences between primiparas and multiparas who give birth to preterm infants. Knowledge of these differences is essential to improve the perinatal care provided to mothers and their infants. According to the definition by the World Health Organization (WHO), preterm birth occurs before 37 weeks of pregnancy are completed. Differentiation between miscarriage and preterm birth depends on the country. In Poland, the cut-off is 22 completed weeks of pregnancy .Preterm births are a global problem entailing a number of consequences for the newborn child, their family and the healthcare system ,3. PremaGlobally, the number of preterm births decreased by 5.26%, from 16.06 million in 1990 down to 15.22 million in 2019. The number of deaths in this group decreased by 47.71%, from 1.27 million in 1990 down to 0.66 million in 2019 . In PolaThe multitude of risk factors for preterm birth makes it difficult to precisely predict its occurrence. However, having knowledge of these factors allows for the provision of personalized and professional care to the pregnant woman, thus reducing the number of complications associated with preterm birth . These mHowever, it has been observed that the subject of preterm births has not been extensively analyzed in the context of parity . TherefoThis study involved a retrospective analysis of electronic medical records from St. Sophia Hospital in Warsaw (Poland), which is a tertiary referral hospital competent and licensed to manage the most difficult cases in obstetrics, gynecology and neonatal pathology, including preterm infants with extremely low birth weight. The study was conducted among women who gave birth to preterm infants between 1 January 2017 and 31 December 2021.The study included all women who gave birth to preterm infants , i.e., between 22 and 37 weeks of pregnancy, with a division into groups by parity—control group (primiparas) and study group (multiparas). The exclusion criteria were gaps in medical records and birth after 37 weeks of pregnancy. Medical records comprising 32,937 births given in the study period were analyzed. Of these, based on the eligibility criteria, 2043 cases of preterm births were included in the final analysis. The numbers of primiparas and multiparas were 1078 and 965, respectively .The electronic databases obtained provided the following information: patient age, place of residence, marital status, education, obstetric history, course of pregnancy and delivery and birth data of the infant. The data were collected on the basis of the patient’s medical records from the course of the current pregnancy and the gynecological and obstetric interview as well as the general interview. The data were collected by the hospital staff, i.e., gynecologists and midwives.The study design was submitted to and approved by the Bioethical Committee at the Medical University of Warsaw (AKBE/112/2022). The study was conducted in line with the principles set out in the Declaration of Helsinki (1964) as amended. Database reports were anonymized and did not allow for patient identification at any stage of the study.p-value of <0.05 was considered statistically significant.The obtained data were analyzed using IBM SPSS Statistics 25.0 for Windows . Categorical variables were reported as numbers (n) and percentages (%), whereas continuous variables were reported as medians (Me) and interquartile ranges (IQR). The normality of distribution of the continuous variables was verified using the Kolmogorov–Smirnov test and the Lilliefors test. To compare the baseline data, a chi-square test was used for categorical variables and the Mann–Whitney U test for continuous variables. The odds of a given outcome occurring in the study group vs. the control group were calculated as an odds ratio (OR) with a 95% confidence interval (CI 95%). The p < 0.05). Detailed data are presented in Multiparas who gave birth to preterm infants were older than primiparas (34 vs. 31 years). Multiparas were more likely to live in rural areas (25.70%), have secondary (19.38%) or primary education (5.70%) and be in a relationship (82.38%). A higher odds ratio of preterm birth in primiparas was found in women living in a city/town (OR = 1.56) and having higher education (OR = 1.82), whereas a lower odds ratio was observed in married women. These relationships were statistically significant (p < 0.05). In the primipara group, the odds ratio was higher for twin pregnancy (OR = 1.39) and anti-biotic prophylaxis (OR = 1.35)—The analysis showed that multiparas were significantly more likely to be pregnant for the third time (3 vs. 1) and have a history of miscarriage (35.44%) as compared to primiparas (p < 0.05), which is also reflected by the higher odds ratio. Moreover, in the primipara group, the odds ratio was higher for health problems (OR = 1.45). Detailed data are presented in Multiparas who gave birth to preterm infants were more frequently diagnosed with gestational diabetes (19.69%) than primiparas. Primiparas, on the other hand, were more frequently diagnosed with hypertension (10.20%), pre-eclampsia (10.20%), cholestasis of pregnancy (6.59%) and hypothyroidism (27.46%) as compared to multiparas (p < 0.05).p < 0.05). Detailed data are presented in Multiparas were more likely to give birth to preterm infants who received an Apgar score of ≤7 both at 1 and 5 min after birth . In turn, primiparas were more likely to give birth to infants with lower birth weights (2300 vs. 2400 g). Preterm infants of primiparas (69.02%) had to be transferred to an NICU more often than those born to multiparas. The observed relationships were statistically significant (Given the extensive literature on risk factors, whose management allows for decreasing the preterm birth rate, it seems valid to focus on an in-depth analysis of individual risk factors and their effect on perinatal outcomes ,21,22,23Our study showed that multiparas who gave birth to preterm infants were older than primiparas, which has also been confirmed in studies by Koullali et al. and Alhainiah et al. ,28. FurtOur study revealed that multiparas were more likely to live in rural areas and more frequently declared to have primary and secondary education, which is in line with the findings by Lei et al. . The higGurung et al. found that the risk of preterm birth in primiparas in the Netherlands was higher than that observed in multiparas . This isFurthermore, we observed that primiparas who had a preterm delivery more often received antibiotic prophylaxis due to the colonization of the genital tract by Streptococcus agalactiae. This is consistent with the findings by Szylit et al., who reported that primiparas were more frequently positive for Streptococcus agalactiae . Another aspect analyzed was the association between parity and selected health variables in the women studied. In our study in the primipara group, the odds ratio was higher for health problems, which has also been confirmed in studies by Chen et al. . A studyOur study showed that labor stimulation with oxytocin was more often used in primiparas. This is consistent with the findings by Oladapo et al., who also found that oxytocin was more often administered to women who were giving birth for the first time . A studyAnother variable analyzed was perineal trauma during labor ,49,50,51Our study demonstrated that the duration of the 1st and 2nd stages of labor and the total labor duration was longer in primiparas who gave birth to preterm infants than in multiparas, which corroborates the results obtained by Ashwal et al. in their study on women who had term delivery . In turnNext, we analyzed the effect of preterm birth on neonatal outcomes relative to parity. Our study showed that preterm infants born to primiparas were more likely to receive an Apgar score of >7, both at 1 and 5 min after birth, had lower birth weight and more frequently required transfer to an NICU. Tadese et al. demonstrated that infants of women who had five or more children received lower Apgar scores. Lower birth weight, on the other hand, is more frequently observed in infants of mothers who had given birth to 2–4 children . Kaur etOur study addresses two areas that are essential to the practice of obstetrics, namely parity and preterm birth, including their characteristic features, differences and potential consequences for the mother and her child.The subject of preterm birth in association with parity is rarely described in publications, even though these two areas have much in common. Despite our greatest attention to detail, the study has some limitations. Firstly, it is retrospective in nature. The database analyzed was derived from St. Sophia Hospital’s electronic medical records, which had data gaps. The limitation of the study regarding data collection may be due to the insufficient completion of medical records by hospital staff. Secondly, despite the large sample size, our study was limited to only one facility, which does not reflect the internal standards followed in other obstetric hospitals. Thirdly, we managed to assess a number of parameters significant for the mother and her child, but due to the retrospective nature of the study, we were not able to obtain any additional data that would improve the quality of our results, e.g., indication for admission to an NICU. Therefore, it is necessary to conduct further research on preterm births and parity, as a better understanding of the associations between these two areas may contribute to a reduced risk of complications and improved care of the mother and her child.Our study found that multiparas who gave birth to preterm infants tend to be older, live in rural areas, have secondary education and be in a relationship as compared to primiparas. Multiparas were more often diagnosed with gestational diabetes and primiparas with gestational hypertension, pre-eclampsia, cholestasis of pregnancy and hypothyroidism. In addition, it was observed that the odds ratio of health problems in pregnancy was higher in the primipara group.Labor stimulation, oxytocin administration in the 1st and 2nd stages of labor, epidural anesthesia and episiotomy were performed more frequently in primiparas and perineal tears occurred more often in multiparas. Labor duration was shorter in multiparas than in primiparas.Multiparas were more likely to give birth to preterm infants who received an Apgar score of ≤7 both at 1 and 5 min after birth. In turn, primiparas were more likely to give birth to infants with lower birth weights.The results of our study emphasize the differences between primiparas and multiparas who give birth to preterm infants. Knowledge of these differences is essential to improve the perinatal care provided to mothers and their infants.


The findings of the association of vaginal flora with preterm birth (PTB) or prelabor rupture of membranes (PROM) were conflicts. Moreover, vaginal flora was different by ethnicity and the evidence from China was limited.This study was a nested case control study, based on Yiwu birth cohort. We assessed vaginal microbiota in the second or third trimester, using 16S rDNA Amplicon Sequencing and explored the association between the diversity and composition of vaginal flora and PTB or PROM.P < 0.05). When we further categorized PTB (Preterm birth) into SPB (PTB without PROM) and PPROM (Preterm prelabor rupture of membranes), there was no difference between SPB and full term. In addition, we found that the proportion of PCoA2 in TPROM group was different from that in full term group and preterm group. The difference between groups was significant according to anosim analysis . With LEfSe  analysis, we found that the abundance of Lactobacillus in the vaginal flora of pregnant women with preterm birth was the highest (P = 0.003).We finally included 144 pregnant women. In present study, the alpha diversity of TPROM (Term prelabor rupture of membranes) samples was lower than that of full term samples (Chao1 index: Lactobacillus was the most abundant in preterm birth group. More studies should be conducted to confirm our findings.In Chinese pregnant women, the alpha diversity in TPROM group was significantly lower than that in both PTB and full term group. However, there was no difference between PTB and full term. The online version contains supplementary material available at 10.1186/s12884-023-05564-y. Lactobacillus spp. and polymicrobial colonization of the vagina has been recognized as risk factors for PPROM [Preterm birth (PTB) is defined as birth delivery at less than 37 gestational weeks. In 2019, WHO reported that the incidence of preterm birth in China was 6.9% . Prelaboor PPROM . Howeveror PPROM –23. HoweTherefore, we conducted a nested case–control study in Zhejiang Yiwu to explore the association of maternal pregnancy vaginal flora diversity and composition, determined using 16S rDNA sequence-based methods, with PTB and PROM.Yiwu city is located in the middle of Zhejiang Province, China, east longitude 119°49 ' ~ 120°17', north latitude 29°02 ′13 " ~ 29°33′ 40", the population size is 1,859,390 residents. Yiwu Maternal and Child Care Hospital is a tertiary hospital with obstetrics, gynecology and pediatrics as its specialty and integrating medical care, prevention, teaching and scientific research. The amount of annual delivery in this hospital is more than 10,000 cases. Yiwu Birth Cohort (YBC) is a running prospective cohort study conducted in Yiwu Maternal and Child Care Hospital, since January 2018. Pregnant women were recruited at their first prenatal visit . Inclusion criteria: (1) agreed to participate in the cohort and provided informed consent; (2) would accomplish perinatal examination and deliver birth in Yiwu Maternal and Children Hospital; (3) aged from 18 to 45 years old. Exclusion criteria: (1) serious chronic or acute disease history; (2) any mental disorder before pregnancy; (3) any threatened abortion or embryonic dysplasia; (5) unable to complete the questionnaire due to intellectual issues. Meanwhile, the participants from YBC met the following criteria were included in this manuscript. Inclusion criteria: (1) the biological specimen of vaginal discharge was available. Exclusion criteria: (1) with syphilis, HIV and other reproductive tract transmits diseases; (2) antibiotics or antifungal drugs were administered before sampling within 30 days. Due to February 2021, 2980 pregnant women accepted to participant in the YBC and 848 participants had biological specimen of vaginal discharge. And there was no difference about maternal age and parity between groups , infectious diseases, placenta previa and preeclampsia. Gestational age at delivery was assessed by maternal last menstrual period (LMP) in combination with ultrasound assessments. We defined PTB as gestational age at delivery of < 37 week. Prelabor rupture of membranes (PROM) was defined as the outflow of amniotic fluid from around the fetus before the onset of uterine contractions, according to the American College of Obstetricians and Gynecologists Practice Bulletin  and were categorized into term PROM (TPROM) and premature PROM (PPROM) , 24. SPBVaginal swab was collected by trained research staff. During routine physical examinations of pregnancy at the second or third trimester , the vagina was opened with a speculum, vaginal swabs were collected from the cervix and posterior fornix with a sterile cotton ball, and the cotton ball was placed into a tube preloaded with 1 ml sterile phosphate buffer (PBS) and immediately stored at -80 °C until assayed.Total genomic DNA from samples was extracted using SDS method. DNA concentration was determined by Nanodrop. The purity and integrity could be evaluated through the 1% agarose gel electrophoresis.According to the concentration, DNA was diluted to 1 ng/μl using sterile water. 16S rDNA was amplified used the specific primer with the barcode. Sequencing libraries were generated using TIANSeq Fast DNA Library Prep Kit (illumina) (TIANGEN Biotech). The library quality was assessed on the Qubit@ 2.0 Fluorometer (Thermo Scientific) and Agilent Bioanalyzer 2100 system. At last, the library was sequenced on the Illumina platform using the 2 × 250 bp paired-end protocol.On average, 93,530 records of original data were measured for each sample, 89,888 records of effective data were obtained after filtered, denoised, spliced and removed of chimerism, with an effective rate of 96.11%. After that, it would run the de-duplication operation on the obtained valid data to obtain the de-duplication sequence ASV (Amplicon sequence variant). Then, we removed the Singletons ASVs . Finally, in order to ensure comparability of species diversity between samples, the diversity core-metrics-phylogenetic command in QIIME2 software was used for standardization, and the standardized data depth was set to 95% of the minimum sample sequence amount. The normalized sample sequencing depth was 43,694, and the number of ASV was 6,060. Species annotation was performed using QIIME2 software. For 16S, the annotation database is Silva Database. In order to study phylogenetic relationship of each ASV and the differences of the dominant species among different samples (groups), multiple sequence alignment was performed.www.r-project.org). P value less than 0.05 was considered statistically significant.Alpha diversity was applied in analyzing complexity of species diversity for a sample . Beta din = 48; mean delivery week: 34.83 ± 1.55), TPROM group  and full term group  in gestational week at sample collection, maternal age, parity and pregnancy complications .As shown in Table Based on the rarefaction curve, the sequencing depth was sufficient to describe the diversity of the samples . And the alpha diversity in mothers with TPROM was lower than that in the mothers with full term . Samples from pregnant women with term birth were enriched in bacteria phylum Actinobacteria while samples from pregnant women with TPROM were enriched in bacteria Firmicutes  representative sequence with the microbial reference database, the species classification information corresponding to each ASV/OTU were be obtained, and then the community composition of each sample at each level  were be counted. The distribution of vaginal flora relative abundance composition among PTB, full term and TPROM were presented for taxonomy. To identify the vaginal flora biomarkers during pregnancy associated with the risk of preterm birth and PROM, we used LEfSe on 16S rRNA data. The abundance of  P = 0.00. SamplesLactobacillus was the most abundant in preterm birth group.In current study, we found that the abundance and diversity of vaginal flora were significantly different among PTB, full term and TPROM group. The alpha diversity of vaginal flora among participants with TPROM were significantly lower than that in both PTB and full term group. However, there was no difference between PTB and full term. In terms of beta diversity, TPROM group was different from that in Term group and preterm group. Based on the LEfSe analysis, The composition of the vaginal flora was different among Asian, Caucasian, Black and Hispanic pregnant women and Asian and Caucasian had the lowest alpha diversity .Study from South Korea and London, using a 16S metagenomics approach, showed that pregnant women at risk for PPROM had greater abundance and diversity at the time of admission than those tended to preterm birth without PROM, which indicated the importance of vaginal flora abundance and diversity on PROM , 26. HowSimilar to our findings, Romero et al.  reportedLactobacilli are important for reproductive health [Lactobacillus, compared to vaginal microbiome in non-pregnant women [Lactobacillus abundance was associated with higher risk for PPROM [Gardnerella and low abundance of Lactobacillus had higher risk for preterm birth [Lactobacillus, [Lactobacillus and PTB [Lactobacillus nor the other rare taxa, such as Gardnerella, were significant markers of preterm birth alone. At present, absence or abundance of a specific taxa alone might not be sufficient to predict subsequent PROM or preterm birth. The findings need to be further confirmed.In addition to abundance and diversity, vaginal microbiota composition was also the focus of attention. The vaginal microbiome acts as a barrier to bacteria and pathogens, and the stability and dominance of e health . During nt women . A studyor PPROM . Anotherrm birth . Similarrm birth . Howeveracillus,  which wa and PTB , 22, 23. and PTB  also conPamong three groups = 0.0637; Pfor the comparison of Term and TPROM = 0.0896). Considering the sample size, we kept all preterm birth in main results. Fourth, due to the limited sample size, we did not matched SPB with PPROM, which could lead some confounding in our analysis. Larger sample size and more intensive sample collections should be considered in the future studies.There were some strengths in this study. First, we analyzed the association of diversity and composition of vaginal microbiota and PTB and PROM, using 16S data in Chinese pregnant women, which was not reported to date. Second, although the sample size was limited, we conducted the analysis after further categorized PTB into SPB and PPROM and found the similar trend. However, several limitations should be mentioned. First, we only tested the vaginal flora once during pregnancy, which might lead to different association due to sampling timing. Second, in our analysis, we did not consider the confounding of history of PTB and PROM, diet and lifestyle, because of the limited medical records. But we have considered some important pregnancy complications and basic characteristics and controlled through matching. Third, in this study, we included 21 spontaneous preterm birth and 27 indicated preterm birth (C-Section PTB cases). However, when we only kept spontaneous preterm birth through excluding C-Section PTB cases, we found the similarity results for alpha diversity although it was not statistically significant  or groups (b).Additional file 3: Supplementary Figure 2. The comparison of alpha diversity (Chao 1 index) between groups. a. The comparison of alpha diversity (Chao 1 index) among SPB, Term and TPROM; b. The comparison of alpha diversity (Chao 1 index) among PPROM, Term and TPROM; c. The comparison of alpha diversity (Chao 1 index) between PPROM and SPB.Additional file 4: Supplementary Figure 3. The principal coordinates analysis and the analysis of similarities among groups. a.The principal coordinates analysis among SPB, Term and TPROM groups; b. The analysis of similarities among SPB, Term and TPROM groups; c. The principal coordinates analysis among PPROM, Term and TPROM groups; d. The analysis of similarities among PPROM, Term and TPROM groups; e. The principal coordinates analysis among PPROM, Term and SPB groups; f. The analysis of similarities between PPROM and SPB.