Training in neonatal resuscitation has been shown to reduce deaths related to intrapartum asphyxia. Helping Babies Breathe (HBB) is a simulation-based program focusing on training healthcare providers (HCPs) in immediate neonatal care including stimulation, initiating bag mask ventilation (BMV) in the absence of breathing by 1 min of life, and delayed (30–60 s after birth) umbilical cord clamping (DCC). Data on implementation of HBB posttraining are limited.To determine time from birth to spontaneous breathing, cord clamping, and initiation of BMV in a setting where the majority of HCPs are HBB trained.Two research nurses observed deliveries conducted in two referral hospitals. Timing included the onset of breathing, cord clamping, and initiation of BMV. Deliveries were grouped according to the mode of delivery.p = 0.009). Complete data were available in 58/61 (95%) neonates receiving BMV, which was initiated in 54/58 (93%) cases within 60 s of life (the “Golden Minute”). Median time to cord clamping was 74 s, with 414 (83.5%) and 313 (63.0%) having cord clamped at ≥ 30 and ≥ 60 s, respectively. Factors associated with BMV were CS delivery , low birth weight (LBW)  , and 1 min Apgar score < 7 . DCC (≥ 60 s) was less likely following CS delivery  and being LBW .In total, 496 neonates were observed; 410 (82.7%) neonates cried or had spontaneous breathing (median time 17 s) soon after birth, 25/86 (29%) of neonates not breathing responded to stimulation, 61 (12.3%) neonates required BMV, and 2 (0.4%) neonates required chest compression and/or adrenalin. Neonates delivered by cesarean section (CS) took longer to initiate first breath than those delivered vaginally . HBB implementation followed guidelines, suggesting that knowledge and skills taught from HBB are retained and applied by HCP. Approximately 85% of newborns breathe spontaneously at birth and another 5–10% will start breathing with just physical stimulation (drying and rubbing) . This imAt the time of birth, the umbilical cord is clamped thereby removing the placental circulation. The clamping of the cord is considered to be delayed, if it occurs at or more than 30–60 s  from theThe Helping Babies Breathe (HBB) program is a simulation-based training program. It trains the healthcare providers (HCPs) on the resuscitation of the neonate focusing on ensuring that babies who are not breathing are assisted with BMV by the first minute of life. The steps of resuscitation in the HBB program include suctioning if there is meconium, drying the infant, checking if the baby is crying or breathing, delaying clamping of the cord, keeping the baby warm, and starting BMV, if the baby is not breathing within the first minute of life (Golden Minute) , 17. TheSeveral hospitals in the Eastern Cape, South Africa, escalated training of their HCP on immediate care of newborns at birth using HBB from 2016. But for any program to be successful, it needs proper implementation. Training on a certain skill using simulation requires that a follow-up is made to assess whether the individual is applying the skill appropriately in a real-life situation. The objective of this study was to assess the condition of newborn infants at birth and the implementation of skills or procedures recommended in the HBB training program, in a setting where the majority of HCP were trained in this program.This was a prospective, observational study. It was conducted at two referral hospitals adjacent to one another in the city of Mthatha, Eastern Cape, South Africa. These hospitals are Mthatha Regional Hospital (MRH) and Nelson Mandela Academic Hospital (NMAH), a tertiary public hospital. Both the hospitals are referral centers for the clinics, district, and regional hospitals in the Oliver Reginald (OR) Tambo region, Eastern Cape, South Africa. MRH and NMAH conduct about 6,000 and 4,000 deliveries per annum, respectively. The majority of vaginal deliveries are conducted by midwives, with doctors mainly delivering those who require cesarean section.Deliveries conducted at the two hospitals during weekdays, daytime (08:00–16:00 h) from January to December 2017, were observed. Two research nurses observed deliveries and HBB-related activities conducted by HCP at the time and soon after delivery. Maternal characteristics, pregnancy, and labor details of deliveries observed were recorded. The research nurses timed the onset of breathing and clamping of the cord from the time of complete delivery of the body using a stopwatch. Interventions (stimulation and initiation of BMV) and time of their implementation among infants who were not breathing spontaneously at birth were also observed and recorded. Delayed cord clamping was defined as clamping the cord at 30–60 s or longer to cater for both the preterm and term infants.p-values < 0.05 were included in the multivariate analysis. Difference with p-values < 0.05 was considered as statistically significant. This study was conducted after getting approval from the Human Research Ethics Committee of the Walter Sisulu University.Time to spontaneous breathing was categorized in 10 s epochs from 0 to 60 s. Comparisons were made between those who were delivered vaginally and those by cesarean section in terms of time to first cry, breath, and clamping of the cord. Factors associated with the need for BMV and for delayed clamping of the cord (for both ≥ 30 and ≥ 60 s definition) were assessed using the univariate and multiple logistic regression reported as odds ratios and 95% CI. Only variables with A total of 496 deliveries were observed. Maternal (pregnancies and labor events) and infants’ characteristics of deliveries observed are shown in In total, 410 (82.7%) infants started breathing spontaneously soon after birth. Among the 86 (17.3%) not breathing spontaneously, 25 (29.1%) started breathing after physical stimulation, leaving 61 (12.7%) requiring BMV . Among tp < 0.001)  . At 1 mip = 0.009 and 31.5 vs. 28 s to start crying, p < 0.001) (p = 0.376). Infants born by cesarean vs. vaginal took longer to first breath even after grouping babies according to gestational age (term vs. preterm) with median time for those following cesarean section 17 vs. 13 s (p = 0.004) in term and 22 vs. 13.5 s (p < 0.001) in preterm infants. On the univariate analysis, neonates requiring BMV were more likely to have been born by cesarean section , being born preterm (37 weeks) , be of low birth weight  , and to have Apgar scores < 7 at 1 min  and 5 min  compared to those who started breathing spontaneously or responded to stimulation. On the multivariate analysis, only neonates who were born by cesarean section, of low birth weight, and had an Apgar score < 7 were associated with the need for BMV  . The med for BMV .p < 0.001). This difference was observed for both the preterm and term infants (The proportion who had clamping of the cord delayed was 83.4% (414/496) using a definition of delayed cord clamping as ≥ 30 s and 63.1% (313/496) using the definition of ≥ 60 s. There were no differences in the proportion who had delayed cord clamping between term and preterm infants for both ≥ 30 s (83.2 vs. 83.8%) and ≥60 s (63.7 vs. 62.5%). The umbilical cord was clamped at a median time of 74 s, with neonates delivered by cesarean section having their umbilical cords clamped earlier than those delivered vaginally  (p = 0.041) of having delayed cord clamping was an infant being delivered by cesarean section.In using the definition of delayed cord clamping as ≥ 30 s, the median time to first breath was not different between those with early (<30 s) and delayed cord clamping  . On the p < 0.001 , having low birth weight , and Apgar score lower than 7 at 1 min and 5 min and need for BMV.The main findings in this study are that 83% of neonates started breathing spontaneously soon after birth and this increased to 87% with physical stimulation. Approximately a third (29%) of neonates who were not breathing at birth started breathing spontaneously after physical stimulation. Less than 1% required advanced resuscitation . The median time for neonates to start breathing spontaneously from the time of birth was 17 s. Deliveries conducted in this setting where HCPs were trained in the HBB program resulted in 98% of neonates breathing spontaneously or receiving BMV by 1 min of life. Neonates who were born by cesarean section and those with low birth weight were more likely to require BMV and, therefore, were less likely to have delayed cord clamping.The time to onset of spontaneous respiration in this report was longer than the 10 s observed in a study by Ersdal et al. . The proThough not all the neonates who were not breathing by 1 min received BMV, it was encouraging that 98% of babies were breathing or being ventilated by the “Golden Minute.” This suggests that HBB training enhanced the knowledge and skills of healthcare workers on immediate care of newborn babies and that the goal of making sure that each neonate should be breathing or being assisted to breathe by 1 min was achieved in most deliveries. An association between retention of skills from the HBB training and a positive result in terms of starting BMV within the Golden Minute for those newborns who fail to initiate spontaneous breathing has been reported previously . The AmeThe ILCOR guidelines suggest that cord clamping should be delayed in neonates who do not require resuscitation , 24. TheThe strength of this study is that the settings in which the study was conducted managed high-risk pregnancies and, therefore, presented HCPs with opportunities to implement all the steps taught in the HBB program, as they got exposed to different clinical scenarios. This allowed the study to have a high number of events where HCPs could be assessed. The limitations of the study are that not all the deliveries were observed, as there were limited resources to provide research nurses to observe deliveries at night and during the weekends. Secondly, there is no data on the performance of the interventions taught in HBB before the implementation of this training in order to assess the impact of training on HBB in performing these interventions.In a setting where training in the immediate care of the newborn was implemented using the HBB program, HCPs implemented the interventions in immediate care according to the steps of the HBB training program. This highlights that knowledge and skills taught during HBB were retained by most HCPs. More than 10% of neonates required some form of assistance soon after birth highlighting the importance of training in HBB, since not providing the necessary basic interventions such as physical stimulation and BMV may have resulted in the deaths of these neonates. It is known that training in basic neonatal resuscitation can reduce neonatal mortality by a third; therefore, the HBB program should be implemented globally especially in low- and middle-income countries where the rate of intrapartum deaths is high.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation on request.This study was reviewed by the Walter Sisulu University Human Ethics Research Committee. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements instead verbal consent was obtained.All authors listed have made a substantial, direct, and intellectual contribution to the work, and approved it for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


BackgroundPreterm birth (PB), defined as birth occurring at less than 37 weeks of gestation, is a leading cause of perinatal mortality and morbidity in the world.ObjectivesThis study aimed to evaluate the socio-demographic characteristics and etiological factors associated with preterm birth and consequent adverse perinatal outcomes retrospectively at a tertiary care hospital. MethodsA single-centre retrospective observational study was conducted in the department of Obstetrics & Gynaecology, Fakir Mohan Medical College & Hospital, Balasore, Odisha, India, from April 2019 to March 2020. Data were retrieved from the antenatal ward admission register, case files, theatre records, and neonatal care unit records and reviewed. Descriptive statistics were used to describe data. Chi-square test and student’s t-test were used to find significance of difference between variables.ResultsThe incidence of preterm birth in the study population was 5.52%. The mean gestational age of preterm deliveries was 34.39 ± 1.92 weeks. The bulk of the women hailed from a rural background and belonged to the lower socioeconomic strata. About 47.29% of the women were nulliparous and spontaneous preterm birth was noted in 70.40%. Premature rupture of membranes (PROM), anaemia, intrauterine growth restriction (IUGR), preeclampsia, and eclampsia were the most common adverse pregnancy conditions prevalent in these women. Preterm deliveries comprised 31.21% of all neonatal intensive care unit (NICU) admissions. Respiratory distress syndrome, birth asphyxia, neonatal sepsis, and jaundice were the most common complications. Neonatal death occurred in 51 (9.21%) preterm infants with birth asphyxia being the commonest cause of such deaths. Maternal factors and adverse neonatal outcome variables were compared between the spontaneous and iatrogenic/medically indicated preterm birth groups. Preeclampsia, IUGR, and cesarean section were more significantly associated with the iatrogenic group.ConclusionOur study provides a general overview of the associated etiological factors and perinatal health concerns associated with preterm birth in a rural/semi-urban setting in Eastern India. The findings might provide essential data for taking steps toward the prevention and management of preterm birth from a developing country’s perspective. Preterm birth, defined as birth occurring at less than 37 weeks of gestation, is the leading cause of perinatal mortality and morbidity in the world ,2. With The etiology of preterm birth is multifactorial and in the majority, an idiopathic cause is still attributed . There aThis study was, hence, undertaken with the aim to retrospectively evaluate the socio-demographic characteristics and etiological factors associated with preterm births along with the consequent adverse perinatal outcomes at a tertiary care hospital in Eastern India. A single-centre retrospective observational study was conducted in the department of Obstetrics & Gynaecology, Fakir Mohan Medical College & Hospital, Balasore, Odisha, India, for one year, from April 2019 to March 2020. The procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation  and with the Helsinki Declaration of 1975, as revised in 2000. The study was approved by the Institutional Ethics Committee of Fakir Mohan Medical College & Hospital, Balasore . Consent from the patients was waived off by the ethical committee of the institute because of the retrospective design of the study.All deliveries between 28+0 and 36+6 weeks of gestation that occurred during the one-year period were included in the study. Only live births were included in the study. We excluded stillbirths, multiple pregnancies, and pregnancies complicated by congenital malformations. Data were retrieved from the antenatal ward admission register, case files, theatre records, and neonatal care unit records and then reviewed. Information sought was socio-demographic characteristics, complete obstetric profile including antenatal maternal high-risk factors, the onset of labour, mode of delivery, and adverse perinatal outcome variables.The basic socio-demographic variables that we studied were maternal age, residence, socioeconomic class and education. Detailed obstetric profile of the women such as parity, gestational age, previous abortions, prior preterm birth, booking status, and regularity of antenatal care (ANC) visits was recorded. The prevalence of preeclampsia, eclampsia, intrauterine growth restriction (IUGR), antepartum haemorrhage, gestational diabetes mellitus (GDM), prediabetes, anaemia, abnormal fetal heart rate (FHR) pattern, malpresentation, premature rupture of membranes (PROM), oligohydramnios, polyhydramnios, and medical illnesses  in the study population was noted. The parameter of management considered was the administration of antenatal corticosteroids and magnesium sulphate for neuroprotection. The onset of labour was either spontaneous or iatrogenic and accordingly, the women were grouped into two subtypes. The adverse perinatal outcome variables retrieved were low birth weight, neonatal intensive care unit (NICU) admission, respiratory distress syndrome (RDS), birth asphyxia, neonatal sepsis, neonatal hypoglycemia, hypothermia, jaundice requiring phototherapy, duration of NICU stay, and neonatal death.Length of gestation was estimated based on the date of the last menstrual period or from the first-trimester ultrasound. Socio-economic status was derived using the modified Kuppuswamy scale . SpontanAll pregnant women symptomatic of coronavirus disease 2019 (COVID-19) or with a history of exposure who were admitted to our facility from February 2020 onward underwent COVID-19 testing as per Government of India and Indian Council of Medical Research (ICMR) guidelines 2020. In this first wave of the pandemic, our protocol was to test those neonates for COVID-19 who were born to positive mothers, had contact history with positive cases, or were symptomatic with pneumonia or severe acute respiratory illness. Testing was done by nasopharyngeal swab reverse transcriptase-polymerase chain reaction (RT-PCR). Statistical analysisData analysis was done using Microsoft Excel  and IBM SPSS Statistics for Windows, Version 20.0 . Descriptive statistics were used to describe data. Continuous variables were expressed as the mean and standard deviation, whereas discrete variables were expressed as frequencies and percentages. Association between variables was analyzed using the Chi-square test with or without Yates’ correction and student’s t-test. P-value <0.05 was considered statistically significant.During the research period, there were 12,567 total deliveries at our institution, of which 222 were stillbirths and excluded from the study. Of the 12,345 live births, 682 were preterm deliveries. Thus, the incidence of preterm birth in the study population was 5.52%. Among 682 deliveries, 554 met the eligibility criteria of the study after excluding multiple births and pregnancies complicated by congenital malformations. The mean maternal age of women with preterm delivery was 24.27 ± 4.42 years. The socio-demographic profile of women presenting with preterm birth is outlined in Table The frequency of antepartum complications is shown in Table The mean birth weight of preterm neonates in our study was 2205.76 ± 701.33 grams. Out of 1365 admissions to the NICU, 426 were preterm births. Thus preterm deliveries comprised 31.21% of all NICU admissions. Neonatal sepsis, jaundice requiring phototherapy, birth asphyxia, and RDS were the most frequent complications observed among preterm neonates requiring NICU admission  predispose to preterm birth ,15. This+6 weeks group and rest were in the <34 weeks group. In an African study, the mean gestation was 33 ± 3 weeks and 62% were late preterms (34-36 weeks) [Gestational age at birth is the strongest predictor of neonatal complications and outcomes. The mean gestational age of preterm deliveries in our study was 34.39 ± 1.92 weeks. About 54.15% deliveries were in the 34-366 weeks) . In the 6 weeks) . There i6 weeks) , a Belgi6 weeks) . In our Major factors associated with preterm birth include hypertensive disorders of pregnancy and preeclampsia, premature rupture of membranes, scarred uterus, IUGR, and placenta previa ,22. FactA preterm baby is prone to develop birth asphyxia due to an insufficient amount of surfactant in the lungs, which prevents atelectasis and maintains alveolar stability. The average birth weight of preterm babies tends to be significantly lower as compared to the term babies. The mean birth weight of preterm neonates in our study was 2205.76 ± 701.33 grams, which is similar to another Indian study in which the average preterm birth weight was 2.1 ± 0.6 kg . The effPreterm birth has two major clinical etiologies: iatrogenic and spontaneous preterm birth. Iatrogenic preterm birth, including labour induction and CS delivery without labour, constitutes about 30-40% of all preterm births, and preeclampsia/eclampsia and severe intrauterine growth restriction are the common causes . SpontanPreeclampsia/eclampsia and IUGR were more significantly associated in the medically indicated group as compared to the spontaneous group. A Chinese study too revealed hypertensive disorder as the most common indication for early pregnancy termination in the iatrogenic group (72.8%), followed by fetal distress and placental abruption . There wThe limitations of our study included the retrospective study design. Also, the study did not include the subset of preterm births <28 weeks and lacked a control of term births for comparative analysis. However, we compared the two subtypes of preterm birth as the iatrogenic variety is on the rise due to recent advances in the management of high-risk factors. The first wave of the COVID-19 pandemic occurred during the last month of the study period, but it did not affect our research as none of the women or their neonates was found to be positive during the said period in our facility. Although larger multicentric prospective longitudinal studies can better define the association of maternal factors and perinatal outcomes with preterm birth, they are difficult to conduct in resource constraint settings. Further research is needed to analyze the long-term consequences on infant health and childhood neurodevelopment, explore the biochemical mechanism and genetics of preterm birth, and study the effects of screening and preventive strategies.Preterm birth causes a remarkable increase in adverse perinatal outcomes in terms of neonatal morbidity and mortality as compared to term birth. The burden of preterm birth on the health system of the developing world is particularly substantial. A regular goal-oriented population-based clinical audit into sociodemographic profile, risk factors, and perinatal morbidity and mortality associated with this condition might improve the clinical outcomes by unravelling the pathogenesis specific to that population. The findings of this study provide a general overview of the associated etiological factors and perinatal health concerns associated with preterm birth in a rural cum semi-urban setting of Eastern India and the influence of management in a tertiary hospital. Our study might provide health care providers and policymakers with essential data for taking steps toward the prevention and management of preterm birth from a developing country’s perspective.


Post‐traumatic stress disorder (PTSD) affects approximately 3% of women in the postnatal period, but less is known about risk factors for PTSD than other postnatal mental illnesses. This review aimed to analyze the literature on the impact of mode of birth on postnatal PTSD.Searches were undertaken of CINAHL, the Cochrane Library, MEDLINE, PsycINFO, and Scopus for studies investigating the link between mode of birth and postnatal PTSD in high‐resource countries from January 1990 to February 2021. Quantitative and qualitative data were collected and synthesized. Meta‐analysis was performed with four of the studies, and the rest were analyzed narratively.P = 0.005), emergency cesarean birth (EmCB) more than elective cesarean birth (ElCB) (P < 0.001), instrumental vaginal delivery (IVD) more than spontaneous vaginal delivery (SVD) (P < 0.001), and EmCB more than SVD (P < 0.001). Women who developed PTSD after EmCB felt less in control and less supported than those who did not develop it after the same procedure. Request for repeat ElCB appeared more common among women with pre‐existing postnatal PTSD, but this may subsequently leave them feeling dissatisfied and their fears of childbirth unresolved.Twelve quantitative studies, presenting data on 5567 women, and two qualitative studies, with 92 women, were included in the review. Most studies found a significant relationship between mode of birth and maternal PTSD symptoms. Meta‐analysis found cesarean birth was more closely associated with PTSD than vaginal delivery (VD) (Modes of birth involving emergency intervention may be risk factors for the development of postnatal PTSD. Ensuring that women feel supported and in control during emergency obstetric interventions may mediate against this risk. Given that childbirth is usually a positive and life‐affirming event, only recently did the scientific community begin to recognize that giving birth could be deeply traumatic for some women. Postnatal PTSD is, thus, one of the lesser‐researched perinatal mood and anxiety disorders (PMAD). In 1997, the phenomenon was recognized widely enough that the first large‐scale study was carried out by a group in Sweden.In recent years, cesarean births have become much more common and, in some countries, for example, Brazil, a planned CB is the most common mode of birth in private health care settings.Given the global increase in the rate of CB,Are women who have a CB more likely to experience PTSD postnatally than women who have a VD?What are the views of women who have postnatal PTSD on the impact of birth mode on their PTSD?What are the views of those who support women  on the impact of birth mode on development of PTSD?SECONDARY REVIEW QUESTIONS:Is an EmCB more likely to trigger symptoms and signs of PTSD than an ElCB?Is an IVD more likely to trigger symptoms and signs of PTSD than an SVD?Does a previous history of postnatal PTSD impact a woman's decision making about her mode of birth in subsequent pregnancies?How do individuals who have PTSD perceive the impact of social/peer support on their mental health outcomes?PRIMARY REVIEW QUESTIONS:22.1This project included quantitative and qualitative studies to provide a holistic review of the literature. Studies from 1990 onwards were included, as research on postnatal PTSD commenced in this decade.For quantitative research, studies of women who had given birth within 6 months before recruitment to a live, term, singleton infant in high resource countries were included.2.2The review protocol was registered on the PROSPERO International Prospective Register of Systematic Reviews (CRD42018089132).2.3Abstract screening was undertaken followed by full‐text assessment by JC and Y‐SC. Papers that met eligibility criteria were included. When a paper did not explicitly state these criteria, authors were contacted via emailA data extraction form was created for quantitative and qualitative studies. From quantitative studies, the data extracted included incidence of postnatal PTSD for women who underwent different modes of birth in the form of odds ratios comparing the mode of birth studied with SVD where possible. For qualitative studies, key findings  were extracted.2.4Quality was assessed independently by JC and Y‐SC using the Newcastle‐Ottawa scale (NOS)2.52.5.1The primary outcome of interest was PTSD status in the six‐month period after birth. The diagnosis of PTSD should have been based on DSM criteria, using the Impact of Event Scale (IES) or another validated scale used by study authors. Data on symptoms of PTSD, which did not meet full criteria for a diagnosis of PTSD, were also included, as not all study participants had undergone a full diagnostic interview. Qualitative data were included which described the attitudes toward and experiences of different modes of birth by individuals who developed postnatal PTSD and those who supported them.2.5.2Secondary outcomes included the impact of a history of postnatal PTSD on subsequent birth‐planning. Research indicates that individuals who experience a traumatic birth are more likely to request an elective cesarean,2.6I2 could not be calculated. Qualitative and quantitative studies not suitable for statistical analysis were reported narratively.The data from the quantitative studies were assessed for suitability in a meta‐analysis. Studies were included if they reported sample size, mean PTSD score, and standard deviation at a relevant follow‐up point. Meta‐analyses were conducted to explore the effect of mode of birth on the score of PTSD symptoms. Because of the range of scales used, it was necessary to convert each to standardized mean difference (SMD) using Hedge's g33.1A systematic search on March 20, 2018 retrieved 602 quantitative studies from the five databases and an additional seven studies from reference searching of appropriate reviews identified by the search . This may be a smaller effect size (ES) than expected, because this analysis pooled SVD and IVD, as well as ElCB and EmCB. Both poolings likely contain distinct groups which may have varying effects on PTSD.Meta‐analysis of three studies3.4.3Emergency cesarean birth is considered to be the most traumatic mode of birth, because of the stress associated with needing emergency surgery, often when a woman is in established labor.P < 0.001).Meta‐analysis of three studiesP < 0.001).Three studiesWith respect to the qualitative studies, Tham et al. interviewed 84 women who had an EmCB, 42 of whom went on to develop symptoms of PTSD.3.4.4Three of the quantitative studies that compared ElCB and EmCB found a significantly lower level of PTSD symptoms in the former.3.4.5P < 0.001).A meta‐analysis of two studiesP = 0.0001; β = 0.135 P = 0.003, respectively).P = 0.5); however, the small study size meant it was unlikely any association would be detected if present.Two studies subdivided instrumental vaginal deliveries into forceps and vacuum extraction deliveries.Five of the other studies combined instrumental vaginal births into one variable. Furuta et al. found PTSD symptoms were more common with IVD than SVD.44.1P = 0.005). Symptoms were also significantly worse in women who had EmCB than in those who had either SVD (P < 0.001) or ElCB (P < 0.001). The significant difference between EmCB and ElCB may have confounded the first analysis, which pooled these two cesarean groups. Women who had cesarean births worried more about the safety of their baby and felt less satisfied overall with their birthing experiences,Although the studies identified by the quantitative search provided varied results, eight out of the 12 studies found that mode of birth was significantly associated with the development of symptoms of PTSD postnatally. Meta‐analysis showed that PTSD symptoms were more severe in women who had CBs compared to those who had VDs (Each of the midwives interviewed by Nyberg et al. reported being asked by women with postnatal PTSD for an ElCB in a subsequent pregnancy but did not believe that this was the optimum mode of birth for this group of women.As health care professionals closely involved with women pre‐, peri‐, and postpartum, midwives are in a unique position to help mitigate the risk of postnatal PTSD and other PMAD.The impact of inadequate support from staff during labor and birth on women with PTSD supports the findings of Nyberg et al. This study reported that many women with postnatal PTSD told specialist midwives that they believed a lack of support and control during their birth had resulted in their PTSD.No studies were found that evaluated the role of support from partners, families, and peers as a potential mitigating factor against PTSD. This is an important avenue for future research.4.2This is the first systematic review and meta‐analysis to combine information from small‐ and medium‐sized studies and present synthesized findings on the association between birth mode and maternal postnatal PTSD. However, there are several limitations. Not all studies included women with clinically diagnosed PTSD, and instead measured PTSD symptoms. There were also issues with the inclusion criterion of “live, term, singleton births.” Six of the included studies did not specify this within their papers, and only three replied to the authors of this review confirming that their paper met this criterion. This left three studies included on a benefit of the doubt basis.For this meta‐analysis, we compiled the most relevant clinical information, using robust statistical methods to synthesize the evidence on birthing methods and PTSD symptoms. A potential limitation was the assumption of equivalence in the measures used in the different studies and follow‐up points. A meta‐analysis of SMDs also assumes the populations of each study contain equivalent variation. The fixed‐effects model does not allow for any variation in the effect of birth mode on PTSD across studies. The violation of any of these assumptions may introduce bias into the estimates of effect or the uncertainty around them. The small number of studies means random‐effects models were unlikely to improve reliability.4.3Although there was variation among the studies, an overall conclusion can be made that mode of birth impacts PTSD in the postnatal period. Women who have emergency CB and instrumental VD might be at an increased risk, although it is important to note that women with all types of birth experiences can go on to develop PTSD, and this disorder is not limited to those who had a birth that would be deemed traumatic from a clinical perspective. Qualitative data indicated that although elective CB may not be associated with postnatal PTSD, they might have a negative impact on women with pre‐existing postnatal PTSD. Support and involvement in decision making from staff during labor may have a protective effect for women who experience emergency obstetric intervention, but more work must be done to confirm the above findings.Appendix S1–S8Click here for additional data file.


Background: Preterm birth (birth at <37 weeks gestation) is the leading cause of death in children under 5-years-old, and prevention is a global public health issue. Seasonal patterns of preterm birth have been reported, but factors underlying this have been poorly described. Sun exposure is an important environmental variable that has risks and benefits for human health, but the effects of sun exposure on pregnancy duration and preterm birth are unknown.Objectives: To determine the association between available sun exposure and preterm birth.Methods: We performed a population-based data-linkage study of 556,376 singleton births  at or after 24 weeks gestation, in Scotland between 2000 and 2010. Maternity records were linked to available sun exposure from meteorological records, by postcode. Logistic regression analysis was used to explore the relationship between available sunshine and preterm birth at <37 weeks gestation. Exploratory analyses included a subgroup analysis of spontaneous and indicated preterm births and a sibling analysis in sib pairs discordant for preterm birth.Results: The rate of preterm birth was 6% . Increased available sun exposure in the first trimester of pregnancy was associated with a reduced risk of preterm birth, with evidence of a dose-response. Compared with the lowest quartile of sun exposure, the highest quartile of sun exposure was associated with a reduced odds ratio (OR) of preterm birth of 0.90  0.88–0.94 p < 0.01) on univariable analysis and OR of 0.91  after adjustment for second trimester sunlight exposure, parity, maternal age, smoking status, and deprivation category. No association was seen between preterm birth and second trimester available sun exposure or combined first and second trimester exposure. Similar patterns were seen on sibling analysis and within both the indicated and spontaneous preterm subgroups.Discussion: Available sun exposure in the first trimester of pregnancy is associated with a protective effect on preterm birth <37 weeks gestation. This opens up new mechanisms, and potential therapeutic pathways, for preterm birth prevention. Preterm birth (birth at <37 weeks gestation) is a leading cause of neonatal morbidity and mortality, and deaths in children under 5-years-old worldwide . The conSunlight is a component of the natural environment that is necessary for human health . VitaminOnly one US-based study has explored preterm birth rates and sunlight exposure; however, this study did not address whether ultraviolet (UV) light exposure influenced preterm birth or low birth weight but aimed to assess whether variation in UV light-induced vitamin D synthesis might contribute to racial disparities in birth outcomes in the US, using statewide estimates. To specifically examine the effects of available sunlight on preterm birth requires consideration of exposure periods and individual level adjustment of other maternal data. Using high granularity environmental data applied to an individual pregnancy allows modeling of overall risk related to sun availability and modeling of exposure periods. As latitude increases, the variation offered by larger alterations in the length of day over the calendar year offers a natural experiment in which to examine the effects of available sun exposure. Scotland has high-quality maternity data, and high latitude with variability in sunshine both across and between years, making it an ideal place to study the effects of available sunshine on pregnancy. The objective of this population cohort study was to determine whether there is an association between available sunlight and preterm birth by linking geographically mapped sunlight data to pregnancy and birth records.The study was approved by the privacy advisory service for National Services Scotland approval number PAC91/147. Data available for analysis were pseudo-anonymized and analyzed within a trusted research environment (the NHS Scotland Safe Haven). Findings are reported in accordance with the RECORD checklist for observational studies using routinely collected health data .We used the Scottish Morbidity Record 02 (SMR02) which records information of all women admitted to Scottish maternity hospitals . It conta priori thresholds of plausibility. Infants were excluded if the gestational length was more than 46 weeks, birth weight was >7,000 g or <350 g, and maternal age was <13 years. Finally, we excluded women with missing gestation at birth, parity, smoking status, or who we could not link with available sunshine exposure.We extracted data from SMR02 record on all liveborn infants born in Scotland between Jan 1, 2000, and Dec 31, 2010, inclusive. We restricted the analysis to singleton births at or beyond 24 weeks gestation as a feature of the SMR02 database . We exclPreterm birth was considered as a categorical variable, defined as birth before 37 weeks gestation. Ultrasound is routinely used in the first trimester of pregnancy in Scotland to determine gestational age . We impuThe mean daily sunlight exposure was calculated for each trimester and during the whole pregnancy for each woman. We did not use data on available sun exposure during the third trimester of pregnancy, because most preterm births occur during the third trimester, which complicates the exposure duration of available sunlight during this period. To represent cumulative sunlight exposure, a value was calculated for the mean of trimester 1 and 2 called “average trimester 1 and 2” exposure.We defined “spontaneous” preterm births as women who gave birth <37 weeks gestation, who did not have an elective cesarean section or an induction of labor. We defined “provider initiated” preterm births as women who gave birth <37 weeks gestation, who had an elective cesarean section or an induction of labor.Postcodes of residence, which are highly geographically specific, were used to link to meteorological data in 5 ×5 km grid squares, generated from two sources, the UK meteorological (Met) office  and EUMEWe took a first-principles approach to identifying confounders of the sunlight and preterm birth relationship utilizing directional acyclic graphs (DAGs) to determine the primary modeling approach . AvailabFor the “trimester 1” and “trimester 2” exposure models, we adjusted for the alternative trimester of exposure, available sunlight exposure in the preceding trimester (for second trimester exposure) or subsequent trimester (for first trimester exposure) for both model 1 and model 2. The “average trimester 1 and 2” exposure was not adjusted for any other exposure variable.P <0·05 were considered statistically significant.For descriptive statistics of continuous variables, we used mean and SD for normally distributed data, and median and interquartile range (IQR) for non-parametric data. Categorical data were presented as percentages with 95% Confidence Intervals (CI). We modeled odds ratios (OR) of preterm birth using logistic regression, before and after adjustment for confounders. We undertook the primary analysis described above and also controlled for within-mother effects using conditional fixed effects regression by using the national identifier [Community Healthcare Index (CHI)] to identify mothers within the dataset. We also modeled available sun exposure with the gestational age at delivery in completed weeks as a continuous variable using linear regression with univariate and multivariate models as described for the primary analysis.We did a sibling analysis as a sensitivity analysis to explore the effect of any potential residual confounding. We identified mothers who had experience both a term birth and a preterm birth and compared the sun exposure between these pregnancies using conditional logistic regression with mother-level fixed effects. In the sibling analysis, we compared available sunlight exposure during pregnancy in sib-pairs discordant for preterm birth. We analyzed the whole group, as well-separate analyses to adjust for the season of conception and maternal age, smoking status, SIMD category, and parity.To explore potential underlying mechanisms, we performed a subgroup analysis of spontaneous preterm births of <37 weeks and indicated preterm births of <37 weeks.All analyses were done with Stata (version 14).Between Jan 1, 2000, and Dec 31, 2010, there were 553,791 live singleton births recorded in Scotland. Of these births, we excluded 81,417 . The anaOver the study period, the mean sunlight exposure hours per day ranged from 1.59 in winter months to 6.71 h in summer months . The annp < 0.01) on univariable analysis with a small attenuation of effect size in the adjusted models but a persistent significant dose-dependent protective effect [model 1 OR 0.91 ] (p 0.12). The average trimester 1 and 2 exposure had a weakened but similar effect to the trimester 1 exposure, confirming the persistence of the trimester 1 effect regardless of trimester 2 with the highest quartile of exposure associated with a reduced OR of preterm birth of 0.95  and in the adjusted model 1 OR 0.96 (95% CI 0.93–1.00 p 0.04). The results were unchanged controlling for within mother effects (p < 0.01) (Available sun exposure in trimester 1 of pregnancy was inversely associated with preterm birth in univariable and multivariable models with evidence of a dose-dependent effect . Compare< 0.01)] . However effects . Using l < 0.01) .The sibling analysis included 9,054 sibling pairs and showed an inverse relationship between preterm birth and sun exposure in the first trimester similar to the full cohort .This outcome was seen in the spontaneous and indicated preterm birth analysis with persistent dose-dependent effect sizes for the inverse relationship between available sunlight in trimester 1 and preterm birth , 5.We found a robust association between available sunlight in the first trimester and a reduction in the risk of preterm birth. This effect appears to be dose dependent and the effect is only minimally attenuated by adjustment of the models. The relationship also persists in the subgroup analyses of the sibling, spontaneous and indicated preterm birth groups supporting the strength of this relationship.Only one other study has examined sunlight and preterm birth risk. Thayer et al.  investigAs explored in DAG , sunlighWe prefer the approach that the season of conception is not a discrete entity and adjusting for the season in addition to maternal confounders is over adjustment that hypothetically would then attenuate effect. Our data support this hypothesis, with an increasing reduction in effect size with the addition of season of conception into the model and that the effect remains, even if reduced in size, supports the strength of the relationship between first trimester sunlight and preterm birth.Season of conception has been previously associated with preterm birth, and in a London cohort, winter birth was associated with a 10% increased risk of preterm birth . HoweverIt is biologically plausible that higher sunlight availability in trimester 1 has downstream effects on the gestational length and, therefore, preterm birth by improving implantation or early placentation. The determination of gestational length is complex and poorly understood, with maternal age, body mass index (BMI), and previous genetic predisposition interacting with intrinsic pregnancy factors . The essThis large epidemiological study increases the understanding of the protective effect of early pregnancy sunlight on the gestational length in a high latitude country. As preterm birth remains the leading contributor to neonatal death, understanding environmental influences open novel research pathways to investigate strategies to reduce preterm birth and hence childhood morbidity and mortality.In Scotland, higher environmental sunlight availability in the first trimester of pregnancy has significant dose-dependent protective effects on preterm birth that are applicable to the whole singleton pregnancy population. This effect is seen in spontaneous and indicated preterm births, suggesting a likely early pregnancy effect on the maternal vascular and immunological adaptation to pregnancy. This opens novel research pathways to explore both mechanisms and interventions to reduce preterm birth.The original contributions presented in the study are included in the article/This original research idea was developed by SS, LM, CD, and RW with project development and analysis by LM and TC. Input by KD regarding environmental exposure and contribution to development of research methods. Final manuscript prepared by LM with contribution from all authors to development. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Finally, a Bonferroni correction was used and variables with a p-value < 0.0038 at 95% CI were declared statistically significant. A total of 308 (103 cases vs 205 controls) mothers of newborns were interviewed, yielding a response rate of 100%. The mean age (SD) of mothers for the cases and the controls were (25.97 ± 4.47) and (25.52 ± 4.17) respectively. Prolonged duration of labor , non-cephalic fetal presentation , being preterm  and low birth weight [AOR 4.43;  were found to be the determinants of birth asphyxia. Prolonged duration of labor, non-cephalic presentation, prim parous, preterm, and low birth weight were the independent determinants of birth asphyxia. Hence, improving the utilization of parthograph during labor and interventions focusing on this area should give priority to reducing the risk of morbidity and mortality.Birth asphyxia is a leading cause of neonatal deaths, which accounts for about 31.6% of all neonatal deaths in Ethiopia. Despite its being one of the important causes of morbidity and mortality in newborns, its determinants were not investigated according to local context. So, this study was aimed at investigating the determinants of asphyxia at Illu Aba Bor zone public health facilities. An institution-based case–control study was employed. A pre-tested, structured and adapted interviewer administered questionnaire for mothers of newborn interviews and a data extraction tool for chart review were used. The collected data were entered into Epi-data version 3.1 and exported to SPSS version 24 for further analysis. A binary logistic regression was employed, and variables with a  It can be defined as a “failure to initiate and sustain spontaneous breathing at birth2”, and it’s diagnosed in extramural babies per minute or intramural babies with a birth Asphyxia-Apgar score of less than 7 in the first 5 min3. Globally, in 2017 alone, 5.4 million children died before their fifth birthday and 2.5 million of those children died in their first month of life, of which 23% of all deaths were due to asphyxiation, the fifth leading cause of under-5 mortality4.Birth asphyxia is the most common and serious neonatal health problem globally, and it significantly contributes to neonatal morbidity5. For example, in sub-Saharan country, Ethiopia reached its MDG4 child mortality goal. Despite the fact that neonatal mortality remains high, this is mainly contributed by birth asphyxia (31.6%)6.In addition to this, WHO reports indicate that birth asphyxia is the third leading cause of death in newborns after infection and premature birth, which accounts for about 23% in developing countries, mainly Asia and sub-Saharan Africa, 40% & 34% respectively7. Moreover, the proportion of neonatal deaths is high in Sub-Saharan Africa, including, Ethiopia8. In Ethiopia, the neonatal mortality rate decreased from 2005–2016 but, it was slightly increased to 30 per 1000 live births by 201910. Even though the prevalence of birth asphyxia in Ethiopia varies from place to place, for instance, previous studies done in Tigray, Gondar, Dilla and Jimma with 22.1%, 13.8%, 32.8%, and 18%, respectively14, the summary of a pooled umbrella review found to be 22.52%15.The proportion of birth asphyxia is 2 per 1000 live births in developed countries, and it is more than tenfold higher in low-income countries with limited access to quality maternal and neonatal care18.Furthermore, out of worldwide neonatal deaths, 24% were due to birth asphyxia with serious neurological sequels3. The putative maternal-related risk factors, maternal socio-demographic is one which includes age of the mother, educational status of the mother, and marital status25. In addition to maternal socio-demographic, the past maternal obstetric-related risk factors like no or less ANC follow up25, being primiparous27, and child death26 were also determinants of birth asphyxia. Moreover, meconium-stained amniotic fluid29 and other labour complications31 were also risk factors for birth asphyxia.Even though a number of contributing factors to birth asphyxia existed, the main factors were thought to be categorized into maternal, fetal, and materno-fetal factors25. Along with this, most countries have developed guidelines to treat neonatal asphyxia, including Ethiopia32. However, neonatal death is still high, ‘world is failing new-borns’ as quoted by UNICEF21 and it’s challenging to achieve sustainable development goals (SDGs) of 12 per 1000 live births by 203019. So, to reduce the impact of birth asphyxia on neonatal morbidity and mortality, more studies are needed in a variety of settings, including Ethiopia. Hence, studies are needed to identify the determinants of childbirth in order to avert the problem. Therefore, this study aims to identify the determinants of birth asphyxiation, especially in the study area.Despite the high contribution of birth asphyxia to neonatal death, most of the risk factors were preventable and treatable2 away from the capital of Ethiopia, Addis Ababa. The zone includes approximately a total population of 1,197,156, of whom 58, 7134 are men and 610,022 are women; with an area of 16,555.36 square kilometers, Ilu Abba Bor has a population density of 72.31. The zone has two hospitals; one referral and one general hospital actively provide care for the maternal and newborn babies. Monthly, Mettu Karl Comprehensive Referral Hospital provides 320 delivery services and Darimu District Hospital provides about 280 delivery services.A facility-based case–control study was used in the Ilu Abba Bora zone public hospitals. The Ilu Aba Bor zone is bordered to the north by the East Wollega zone, to the south by the nations and nationalities, to the west by Kelem Wollega, to the northwest by the West Wollega zone, and to the east by the East Wollega zone. The zone is more than 600 kmNewborns diagnosed with birth asphyxia by the physician and those eligible for the study during data collection time (cases) and newborns without birth asphyxia and eligible for study during data collection time (control) by excluding newborns with congenital anomalies and birth defects.In this study, the subjects were divided into cases and controls.Cases (asphyxiated): Newborns with an APGAR value of < 7 by the doctor at 5 min.Controls (not asphyxiated): newborns with an APGAR value of > 7 at 5 min.Cases (asphyxiated): Newborns with an APGAR score  value of < 7 by the doctor at first and fifth minute35.Controls (not asphyxiated): Newborns with an ‘APGAR’ score value of ≥ 7 at first and fifth minutes.Prolonged labor: Occurs when labor after the latent phase of first stage of labor exceeds 12 h in primigravida or 8 h for multipara mothers.Prolonged membrane rupture: A condition in which a rupture of membrane of amniotic sac and chorion occurs 1 h before the onset of labour.Anemia: maternal hemoglobin level < 11 mg/dl during current pregnancy.Hypertension during pregnancy: the type of hypertension which occurs after 28th weeks of gestation.Sample size was determined by double population proportion formula, using Epi- info version 7 from factors reviewed by considering 95% CI, 80% power, 1:2 case to control ratio, Odds Ratio = 2.21 which is the ratio of odds of cases among neonates with birth asphyxia to odds of controls among neonates free of birth asphyxia; proportion of controls 22.7% and proportion of cases as 39.3%, preterm, unable to read and write, primiparous and ante partum hemorrhage as a variables and the final sample size was 308(103 cases and 205controls) after adding 5% non-respondent rate(23). For sampling purpose, systematic random sampling was used for all delivered neonates in the study as a sampling frame. By exploiting a monthly delivery report from the hospital and accounting for 15.6% of newborns who are asphyxiated. Every second asphyxiated baby was selected as a case, while every third non-asphyxiated newborn was included as a control.36 was used to collect maternal socio-demographic and antepartum characteristics. A pre-tested checklist (extraction tool) was used to collect intra-partum and fetal related factors for both cases and controls. The questionnaire was first compiled in English and translated into the naïve local language, "Afan Oromo," and then translated back into English by the linguist for consistency. Data were gathered by face-to-face interview and reviewed from medical charts by trained BSc nurses after cases were confirmed by physicians (birth asphyxia) and controls were recorded by identification numbers.Primary and secondary (record review) data were used. A pre-tested, structured and adapted questionnairep-value < 0.25 were taken to multi-variable regression. A backward likelihood ratio with a probability distance of 0.1 was used to develop the model. The collinearity diagnosis has been checked. The quality fit of the final model was checked using the Hosmer–Lemeshow test of the quality check, taking into account the good fit at a p-value of 0.05 (0.208), the omnibus likelihood test < 0.05(0.000) and the model classification of the Checked accuracy (77.9%). The odds ratios estimated at 95% CI was used to show the strength of the association. Finally, A Bonferroni correction was used and variables with a p-value < 0.0038(threshold for significance was p = 0.05/13) used to declare statistical significant.Data were collected by trained health professionals and cleaned, coded and entered into Epi-data version 3.1 and then transported into SPSS version 24 for analysis. Frequencies and cross tabulations were used to summarize descriptive statistics. The association between birth asphyxia and each covariate was first assessed by bivariate logistic regression to identify a candidate variable for the final model. Variables with This study was carried out in accordance with relevant guidelines.Letter of ethical clearance was obtained from Institutional Review Board of Institute of Health, Jimma University and letter of cooperation from population and family health department. Informed consent was obtained after the purpose of the study was explained to participants. To ensure confidentiality the participants were informed that their data were coded and no need of writing their name.A total of 308 (103 cases and 205 controls) participants took part in this study, with a response rate of 100%. The mean ages (standard deviation) of the mothers for the cases and controls were 25.97 (SD: 4.47) and 25.52 (± SD: 4.17), respectively. Almost three-quarters (72.5%) of the mothers in the cases and 143 (69.8%) of the controls were married  mothers of the cases and ninety-one (44.4%) controls were primiparous, while 13 (12.6%) mothers of the cases and 17(8.3%) controls have had a history of child death. Regarding the frequency of antenatal care follow-up, 84(81.6%) of mothers in the cases and 173(74.4%) of controls had antenatal care follow-up more than four times  mothers of the cases and 13(6.4%) controls developed prolonged labor. Regarding weight of new born, 21(20.4%) of the cases and 14(6.8%) of the controls had birth weight less 2500 gm. On the other hand, 62(25.2%) of the cases and 15(7.3%) of the controls had gestational age of less than 37 weeks (preterm). Moreover, 98(95.1%) cases and 201 (98.1%) controls had a singleton baby  mothers of the cases and fourteen (6.8%) controls had a history of anemia during pregnancy 0.7% mothHypertension during pregnancy, duration of labor, prolonged rupture of membrane, fetal presentation, parity, gestational age at birth and newborn weight fulfilled the criteria and were potential candidates for the multiple logistic analyses.By multi-variable logistic regression analysis, duration of labor, fetal presentation, gestational age, and weight of newborn were significantly associated with birth asphyxia.Newborns of mothers who had prolonged labour were 4.12 times more likely to develop birth asphyxia as compared to those with normal labour  mothers were not associated with asphyxiation. However, our findings are inconsistent with a study conducted in Kenya36 that reported that the mother's age was a significant risk factor for developing birth asphyxia. This contrast might be due to the different sample sizes or the type of setting in which the study was conducted.Maternal age at delivery was not significant for the birth asphyxia in this study. This might be due to the fact that pregnancy and labor in all age groups cannot predict the occurrence of birth asphyxiation if they are effectively managed. Our study finding is consistent with the study findings in Pakistan21; evidence showed that those who had not had full antenatal follow-up were associated with developing birth asphyxia. The possible explanation was that the majority of women may not be expected to be familiar with or appropriate preventive attitudes with respect to birth asphyxia during their pregnancies (21).In a current study, the amount of antenatal care follow up was not significantly associated with birth asphyxia. This finding is congruent with a study done in Rwanda23, Gondar12, Pakistan25, and Rwanda21, which revealed that the likelihood of developing birth asphyxia was higher in newborns born to mothers with a longer labor time. Moreover, the study from Kenya36 also indicated that duration labour was another important risk factor of asphyxia. This may be because the mother's pelvis is not suitable for the newborn's head or does not have sufficient contraction, or the cervix is obliterated and the newborn is large37. It is also clear that if there is prolonged labor, there is a high chance that the fetus will be afflicted and result in birth asphyxia. In addition, studies in Nigeria31 also showed that prolonged labor is associated with fetal and maternal exhaustion and also with fetal distress, which results in birth asphyxia.In this study, neonates of mothers who had prolonged labor were 4.12 times more likely to develop birth asphyxia than those with normal labor. This finding is similar to studies done in Aksum40 and Iraq41, which revealed that fetal malpresentation was significantly associated with the occurrence of asphyxiation. This might be due to the fact that the fetus experiences oxygen deprivation by changing fetal heart rate, fetal movements, and increasing meconium in the amniotic fluid. In addition, malpresentation of the fetus increases the risk of numerous complications, such as umbilical cord prolapse/compression, which can lead to severe suffocation36.Furthermore, this study found that neonates born with non-cephalic presentation were 4.35 times more likely to develop birth asphyxia than those with cephalic presentation. This finding was similar to studies done in Pakistan42, which indicated the prolonged rupture of membranes (> 18 h) was the most significant risk factor for birth asphyxia, This contradiction might be due to the sample size difference, since the study in Indonesia was a small sample size (70 participants), the setting difference, and the compared participants between the two studies.Contrary to a study conducted in Indonesia23, Pakistan29, Nigeria27 and Kenya36. This discrepancy might be due to hawthorn effect, method difference, and possible cofounder example study in Pakistan. Besides, this finding is inline with the study done in Dessie hospital43 reported that parity had no significant association with birth asphyxia.This study revealed that the probability of developing birth asphyxia was not associated with parity. This finding is contrasting to the studies done in Aksum20, Gondar12, Rwanda20, Pakistan25 and Kenya36. This might be due to low birth weight newborns usually having immaturity of the lungs and impaired respiratory muscles44.The current study showed that newborns weighing less than 2.5 kg were 4.43 times more likely to develop birth asphyxia than newborns delivered with a weight greater than 2.5 kg. This result is similar to that of the studies done in Aksum25 and Kenya36. This may be due to the fact that premature babies face multiple medical conditions, including organ system immaturity, especially lung immaturity, which leads to respiratory failure that causes birth asphyxia30. However, the studies in Gondar12 and Dessie hospital43 evidenced that the age of newborns had no significant association with birth asphyxia. The discrepancy may also be due to the decision of p-value (p ≤ 0.2) which is different from the study (p < 0.25) which might result in losing the important variable, and measurement.Finally, in the current study, newborns with low gestational age were 5.77 times more likely to develop birth asphyxia than their counterparts. Our finding is consistent with the study findings in PakistanThe cases and controls were taken from the same setting except for the outcome difference, the assessment of model fitness using different measures, and the reliability test of the questionnaire. Referral bias was avoided by pooling the results across both referral and general hospitals together, since the study was of an institutional-based nature, it cannot represent the whole community.Predictors were maternal and newborn-related characteristics. Though these predictors were mainly related to prolonged duration of labour, non-cephalic fetal presentation, premature infants and low birth weights were the independent predictors of birth asphyxia. So, improving the utilization of parthograph during labour, dedicating to giving the correct, quick, and accurate diagnosis and proper management of pathological disorders during pregnancy and delivery, more attention to newborns of low birth weights and preterm newborns at birth by providing a good environment for childbirth, can reduce severe birth asphyxia.


Magnetic resonance imaging (MRI) provides excellent soft tissue visualisation which may be useful in late pregnancy to predict labour outcome and maternal/neonatal birth trauma.To study if MRI in late pregnancy can predict maternal and neonatal outcomes of labour and birth.Systematic review of studies that performed MRI in late pregnancy or immediately postpartum. Studies were included if they imaged maternal pelvic or neonatal structures and assessed birth outcome. Meta-analysis was not performed due to the heterogeneity of studies.Eighteen studies were selected. Twelve studies explored the value of MRI pelvimetry measurement and its utility to predict cephalopelvic disproportion (CPD) and vaginal breech birth. Four explored cervical imaging in predicting time interval to birth. Two imaged women in active labour and assessed mouldability of the fetal skull. No marker of CPD had both high sensitivity and specificity for predicting labour outcome. The fetal pelvic index yielded sensitivities between 59 and 60%, and specificities between 34 to 64%. Similarly, although the sensitivity of the cephalopelvic disproportion index in predicting labour outcome was high (85%), specificity was only 56%. In women with breech presentation, MRI was demonstrated to reduce the rates of emergency caesarean section from 35 to 19%, and allowed better selection of vaginal breech birth. Live birth studies showed that the fetal head undergoes a substantial degree of moulding and deformation during cephalic vaginal birth, which is not considered during pelvimetry. There are conflicting studies on the role of MRI in cervical imaging and predicting time interval to birth.MRI is a promising imaging modality to assess aspects of CPD, yet no current marker of CPD accurately predicts labour outcome. With advances in MRI, it is hoped that novel methods can be developed to better identify individuals at risk of obstructed or pathological labour. Its role in exploring fetal head moulding as a marker of CPD should be further explored.The online version contains supplementary material available at 10.1186/s12884-022-05290-x. Although the physiology of labour is generally well understood, and there are known risk factors for operative birth, the ability to predict the mode of birth for any given woman still evades obstetricians. Obstructed labour due to cephalopelvic disproportion (CPD) is not usually diagnosed until labour is established, and is one of the leading indications for caesarean section (CS) . WorldwiIn 1948, Mengert stated that there were five components of CPD; namely (1) size and shape of the bony pelvis, (2) size of the fetal head, (3) force exerted by the uterus, (4) mouldability of the fetal head, and 5) presentation and position of the fetus. At the time, only accurate measurements of the first component were possible for pelvimetry  presenta and has The study protocol was registered on PROSPERO international prospective register of systematic reviews (CRD42020220563). The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used to conduct the systematic review.All types of study that conducted MRI in the third trimester, labour or immediately postpartum were deemed eligible, including case reports. Studies were included if they imaged any maternal or fetal structures  and studied how the findings correlated with birth outcome. Papers were limited to English. Systematic reviews, meta-analyses, narrative reviews, and conference abstracts were excluded.A clinical librarian conducted the systematic search. Web of Science, Cochrane, Embase, and Medline databases were searched with a combination of MESH terms and free text. Duplicates were removed by the clinical librarian and results were emailed to the team. Search terms included: magnetic resonance imaging, pregnancy, vaginal birth, labour, caesarean section, pelvimetry, breech, fetal position, fetal station, and fetal macrosomia. Please see supplementary material  screened paper titles and abstracts independently. Irrelevant studies were then excluded. Full text articles of selected papers were screened independently. Reference lists of relevant studies were also checked, and studies were selected if they met the selection criteria. Any disagreements were settled by consensus. Full texts were available for all relevant studies. Studies where gestation at birth could not be determined, where imaging took place in early pregnancy, or where mode of birth was not recorded, were excluded. Later studies involving the same patient cohorts that had been previously published by the same authors were also excluded unless different measurements of pelvic/fetal dimensions were performed.SJ and BD independently extracted patient data into a standardised Excel spreadsheet. Disagreements were settled by consensus. Study characteristics included study size, study design, and length of gestation at the time the study took place. Mode of birth was recorded, as well as pelvic measurements , maternal BMI, fetal dimensions, fetal head moulding, and cervical imaging in predicting mode of birth. Where available, the sensitivity and specificity of these were assessed.Study design, type, size, and selection criteria for pregnant women to undergo MRI or MRI with pelvimetry were assessed. Case-control studies, cohort and case reports/series were assessed using the study quality assessment tool provided by the National Institutes of Health. Randomised controlled trials (RCTs) were assessed using the Cochrane Collaboration’s tool for assessing risk of bias.Due to the small number and significant heterogeneity of studies, a meta-analysis was not performed. A narrative synthesis of results has been performed. All tables were made using Microsoft Excel for Mac (Excel Version 16.49).The search produced a total of 2174 papers published between 1980 and 2021  Table  can predIn contrast, a small study concluded that a considerably unfavourable FPI was associated with failed vaginal birth after caesarean (VBAC). Of the 13 patients, 7 had a vaginal birth. Of the six who had a CS, 2 had positive FPIs (both + 0.7) .In the study mentioned above, Sporri et al. concluded that although the CPD index Table  had highThis method was developed by Sporri et al. Woman who had CS for suspected CPD and failure to progress underwent postpartum MRI scans. Maternal pelvis capacity was compared with both fetal head volume from antepartum US and postnatal measurement of head volume within 12 hours of birth. 28 women underwent CS for suspected CPD. CPD was defined as head volume exceeding the smallest pelvic inlet or mid pelvis capacity. When US assessed antepartum fetal head volume was related to the smallest pelvic capacity of the inlet or midpelvis, sensitivity for predicting CPD was 89%. Postpartum measurement of fetal head volume in relation to pelvic volume gave a sensitivity of 96% for predicting CPD . This meObstetric conjugate (OC) measurements have been used to preselect women for trial of vaginal birth. For high-risk patients  selected to have a vaginal birth, a larger OC was selected for breech babies compared to those with cephalic presentation (12.7 ± 0.89 cm vs 12.2 ± 0.98). The OC was not significantly different between women who had vaginal birth and emergency CS (12.5 ± 0.9 vs 12.3 ± 1.1 cm). Vaginal birth rates were similar between women with cephalic and breech cases; 70.3 and 75.0% respectively . An OC mIn women with cephalic babies, the pelvic inlet, including the OC, has been demonstrated to be significantly smaller in women who had CS for dystocia compared with those with vaginal births , 18, 21.In women undergoing induction of labour (IOL), the mid pelvis anterior-posterior diameter and interspinous diameter (ISD) were significantly smaller in woman who had CS for dystocia compared with those with vaginal births; 116.2+/− 8.0 mm vs 124.6 +/− 8.2 mm and 113.0 +/− 9.7 mm vs 119.1+/− 8.4 mm respectively . This isIn women with breech births, ISD was significantly associated with birth outcome. Vaginal birth success rate was 79% with ISD over 11 cm. However, 58% of patients with an ISD less than 11 cm also had a successful vaginal birth, and would have undergone unnecessary CS. These findings reflect a sensitivity of 71%, a specificity of 53%, an an AUC of 67.7% for predicting successful vaginal birth . SimilarThe RCT discussed above proposed midpelvic and pelvic outlet cut-offs for trial of vaginal breech birth  Table 44. With aIn two studies by Sporri et al., the overall shape of the maternal pelvis was studied as the android and platypelloid were considered abnormal due to the known increased risk of CPD . This waFive of 28 women with CPD had either an android or platypelloid pelvis. 50% of women with CPD were diagnosed with having an ‘abnormality of the pelvis’ compared with one woman who had a vaginal birth. Additionally, more cases of malposition were associated with an abnormal shape of the pelvis . The latp < 0.001, 95% CI of 0.676–0.791). Sensitivity and specificity were 56.2 and 84.4% respectively for predicting CPD [Raised BMI could be an indicator for CPD. In the previously mentioned study by Li et al., BMI over 27.6 had an AUC of 0.726  and distance from the vertex to the base of the fetal skull. In an occiput anterior position, FOD was 10.3 cm. During pushing, the fetal skull became elongated and deformed, with the FOD increasing to 11.2 cm during crowning. The distance from the vertex to base of the fetal skull decreased from 6.4 to 5.6 cm at expulsion . In contp = 0.567). Although not significant, 85% of patients where subjective visual estimation of signal intensity was high had a vaginal birth. No patients with visually assessed low signal intensity had a vaginal birth. Visual sensitivity and specificity were 84.7 and 100% respectively [A study on women undergoing oxytocin IOL found that there was no correlation between cervical signal intensities and failed IOL. Only signal intensities of the posterior cervix showed marginal significance in predicting labour  and is a cheaper imaging modality .This is the first systematic review to assess the role of MRI in pelvimetry and predicting labour outcome, and encompasses studies from a wide range of countries. As the search was limited to English, some papers could have been missed. Most studies did not have a control group. Additionally, three of the largest studies were retrospective in nature, and therefore at risk of bias. Due to the small number of studies and substantial heterogeneity in MRI indication, and reporting of outcomes, the results are likely not generalisable. At present, the role of MRI in predicting mode of birth and CPD cannot be recommended until new markers of CPD and potential novel imaging techniques are developed.MRI may be the best imaging modality to explore all aspects of CPD as described by Mengert et al. Its role in exploring the underlying mechanism of fetal head moulding as a marker of CPD should be further explored. No current markers of CPD accurately predicts labour outcome. MRI may however play a role in better selecting patients for trial of vaginal breech birth. Its use remains uncertain with cervical imaging when US is a cheaper and quicker imaging modality. With advances in MRI, it is anticipated that novel, standardised methods can be developed to better identify individuals at risk of obstructed or pathological labour.Additional file 1.Additional file 2.


Multivariable logistic regression analysis revealed racial differences in HepB birth dose vaccination rates. Asian Americans had the highest rate of newborn vaccination consistently over the 3-year period. Conversely, African American infants were less likely to have the birth dose than non-Hispanic Whites . Our research indicates that further studies are needed to explore HepB birth dose hesitancy among African Americans. Hepatitis B vaccination protects newborns from contracting the hepatitis B virus that may lead to chronic infection, liver failure, or death. Trends and racial differences in the administration of the hepatitis B (HepB) birth dose in 2018–2020 were examined in the targeted region. A retrospective analysis of electronic birth dose vaccination data of newborns in 2018–2020 was performed. Birth data from six birthing facilities and home delivery records were obtained from the DC Health Department Vital Statistics Division. This data represented 40,269 newborns and included the mother’s race and ethnicity, health insurance type, birthing facility, and administration of the HepB birth dose. Descriptive analysis and multivariable logistic regression analysis were conducted. In addition, subgroup analysis by health insurance type was also conducted with a significant interaction of race/ethnicity and health insurance type. A total of 34,509 (85.7%) received the HepB birth dose within 12 h or before discharge from the facility. The rates of birth dose vaccination have seen an increase over the 3-year period (83.7% in 2018, 85.8% in 2018, 87.7% in 2020,  Universal hepatitis B (HepB) vaccination among newborns is critical to the public health effort to eliminate HepB infection in the United States (US) . HepB vaData were obtained from the Vital Statistics Division of the District of Columbia Health Department (DC DOH). A retrospective analysis was performed using electronic birth dose vaccination entries of newborns in the 2018–2020 cohorts. Six birthing facility and home delivery records representing 40,269 newborns were collected (237 were excluded due to missing race/ethnicity data). Data variables included the mother’s race and ethnicity, health insurance type, birthing facility, and the HepB birth dose administration date, lot number, and manufacturer. Descriptive and logistic regression analyses were conducted. The DC DOH Institutional Review Board waived review because the study did not meet the criteria for human subject research.p < 0.01)  see . Table 1A total of 40,032 newborns made up the sample. Most were African Americans (42%) followed by Non-Hispanic Whites (NHW) (40%), Hispanics (11%), and Asians (6%). Birthing facilities included community hospitals (57%) and university-affiliated hospitals (42%). Less than one percent had a home or birthing center delivery. Two-thirds of mothers had private health insurance see .p < 0.001), while health insurance type was not associated with it. Overall, there were racial/ethnic differences in the HepB birth dose rates. Asian newborns (89.7%) had the highest vaccination rate followed by Hispanics (89.3%), then NHW (86.2%). African Americans (83.9%) had the lowest newborn vaccination rate.p < 0.001); about two-thirds of African Americans (62.9%) had Medicaid followed by Hispanics (38.5%), Asians (6.1%), and NHW (3.7%) (table not shown). Since the interaction between race/ethnicity and health insurance type on HepB birth dose was statistically significant  registry. Timely identification of newborns at risk of Hep B infection and intervention during perinatal care, such as HBV load monitoring, are important steps for reducing the transmission of hepatitis B. By following the Center for Disease Control’s state perinatal hepatitis B prevention program, the District of Columbia (87.7%) is close to reaching the Healthy People 2030 objectives (90%).In our subgroup analysis, the HepB birth dose rates increased for newborns across all racial/ethnic populations except for African Americans. The rate for this subgroup did not change over the 3-year period. After adjusting for the year, birthing facility, and health insurance, African Americans had the lowest rates of receiving the HepB birth dose. In recognition of these findings, exploration of birth dose hesitancy among African Americans is needed.The results of our interaction analyses between race/ethnicity and health insurance type are interesting. Although health insurance type was not associated with HepB birth dose in our bivariate analysis, there was a main effect of insurance type on HepB birth dose after adjusting all the variables. It may be explained by two factors: (1) there was a larger representation of African Americans in our study sample  . (2) AfrThere are some limitations to our study. First, our registry did not have data on mother-related characteristics including age, education, and hepatitis B antigen status, which may be important factors associated with HepB birth dose. Additional studies examining the specific impact of these mother-related variables on HepB birth dose are recommended. Second, our findings are based on a concentrated population within the Washington metropolitan region and may have limited generalizability to the US population in other geographic settings.In conclusion, worldwide, perinatal transmission occurring at birth from infected mothers to their newborns accounts for the majority of hepatitis B virus (HBV) transmissions . In the


This project builds on previous work linking routinely collected data from birth registration, birth notification, death registration and hospital discharges, extending it to six million births in England and Wales from 2005 to 2014. This linkage is creating a new dataset to investigate previously unanswerable questions about variations in time of birth and its outcome which are highly contested in the health service in England and Wales:How do numbers of births vary according to time of day, day of the week and time of year of birth and how does this relate to modes of onset of labour and delivery?How do patterns of birth vary between maternity services in relation to variations in medical and midwifery staffing, patterns of intervention and size of unit?How does the outcome of pregnancy, in terms of mortality and morbidity rates at birth and in the first year of life, vary according to time of birth in relation to gestational age, and intervention in the onset of labour and delivery?Have the patterns changed over the years 2005 to 2014?Routinely collected national datasets for 2005-14 have been linked using patient identifiable data items. They differ in the way data items are recorded. Methods of linkage, quality assurance and data cleaning have been improved, compared with those developed in the original project.This unique approach links clinical data from hospital admissions with more reliable data on birthweight from birth registration and with gestational age and time of birth from birth notification. This enables investigation of the associations between day and time of birth with its outcome.This is also the first study to link mothers' and babies' hospital discharge data for England and Wales and to draw on public and patient involvement to include outcome measures specifically designed to be women-centred. Overall, the linkage has created a fuller range of data.Results will be available by the time of the conference. Initial results already clearly illustrate differences in timings of birth by time of day and day of the week by mothers' age, gestational age and birth setting and for singleton and multiple births. The study has created a valuable linked dataset that will uniquely enable analyses of associations between timing of birth and its outcome. These results will potentially be able to inform and impact NHS service provision.