Low birth weight has been consistently associated with adult chronic disease risk. The thrifty phenotype hypothesis assumes that reduced fetal growth impacts some organs more than others. However, it remains unclear how birth weight relates to different body components, such as circumferences, adiposity, body segment lengths and limb proportions. We hypothesized that these components vary in their relationship to birth weight.We analysed the relationship between birth weight and detailed anthropometry in 1270 singleton live-born neonates  from the Mater-University of Queensland Study of Pregnancy . We tested adjusted anthropometry for correlations with birth weight. We then performed stepwise multiple regression on birth weight of: body lengths, breadths and circumferences; relative limb to neck-rump proportions; or skinfold thicknesses. All analyses were adjusted for sex and gestational age, and used logged data.Circumferences, especially chest, were most strongly related to birth weight, while segment lengths  were relatively weakly related to birth weight, and limb lengths relative to neck-rump length showed no relationship. Skinfolds accounted for 36% of birth weight variance, but adjusting for size , this decreased to 10%. There was no evidence that heavier babies had proportionally thicker skinfolds.Neonatal body measurements vary in their association with birth weight: head and chest circumferences showed the strongest associations while limb segment lengths did not relate strongly to birth weight. After adjusting for body size, subcutaneous fatness accounted for a smaller proportion of birth weight variance than previously reported. While heavier babies had absolutely thicker skinfolds, this was proportional to their size. Relative limb to trunk length was unrelated to birth weight, suggesting that limb proportions at birth do not index factors relevant to prenatal life. Neonatal characteristics such as birth weight, ponderal index, or relative length and head circumference may be considered proxies for prenatal environmental quality and are associated with the risk of developing various non-communicable diseases  in later life Many studies concerned with the thrifty phenotype hypothesis use the same basic indicators of prenatal growth , but the relationship between birth weight and other neonatal anthropometry is not well characterised.For example, the relative contribution of adiposity to variation in birth weight is uncertain. One often-cited study reported that total fat mass of neonates explained 46% of the variance in birth weight even though adipose comprises only around 12% of total birth weight It is also unclear how limb lengths and proportions relate to birth weight. This may be relevant as shorter limbs relative to trunk length in adulthood are associated with elevated NCD risk e.g.  and postThe purpose of this study is to investigate the relationship between birth weight and detailed anthropometric measurements in a large sample (n = 1270) of neonates from Brisbane, Australia, including skinfold measurements, limb segment and trunk lengths, and body breadths and circumferences. We aimed to understand the proportionality between birth weight and these different neonatal measurements, and test the hypotheses based on existing literature that shorter segment lengths, especially smaller skinfolds and absolute and relative limb lengths, are associated with lower birth weight.Data on neonatal birth weight, anthropometry, gestational age and sex from the Mater-University of Queensland Study of Pregnancy (MUSP) The following measurements were recorded: birth weight; neck-rump, upper arm, forearm, thigh, and lower leg lengths; head, chest, abdominal, upper arm (MUAC), lower arm, thigh and lower leg circumferences; biparietal, face, shoulder and hip width; and subscapular, triceps, abdominal and anterior thigh skinfold thicknesses. All measurements were taken by the same trained research nurse following standard techniques As birth weight (which relates to volume) may scale allometrically with the other anthropometry (linear measurements), natural logarithms of all anthropometry were used in analyses, although results changed little whether log transformed or raw data were used. The relationship between different neonatal measurements was first assessed using Pearson's correlation. Correlations were performed for the sexes separately, adjusting for gestational age, and for the sexes combined, adjusting for gestational age and sex. Multiple regression of each measurement on birth weight, adjusting for gestation and sex and including a sex*anthropometry interaction term indicated no sex differences in the relationships between birth weight and the various measurements (results not shown). The sexes were therefore pooled for subsequent analyses.To further investigate the relationship between birth weight and neonatal anthropometry, gestational age- and sex-adjusted standardised residuals were first derived for the variables using multiple regression, given evidence for differences in birth weight, body composition and body size/proportions along these lines To analyse the relationship between birth weight and relative limb proportions, a gestational age- and sex-adjusted ratio of upper or lower limb length to trunk length /neck-rump length) was regressed on the standardised residual for birth weight, with and without adjusting for head circumference .Finally, reduced major axis (RMA) regression of the sum of 4 skinfold thicknesses or each of the individual skinfolds on birth weight was performed, adjusting for sex and gestational age, to assess whether skinfold thicknesses scale proportionally with weight. RMA regression was selected as the dependent-independent relationship between the variables is unclear, allometric relationships were under investigation, and the purpose of the analysis was not to derive predictive equations The ethics committees of the Mater Hospitals and the University of Queensland approved the study. Oral informed consent was obtained at recruitment to the study, as approved by the ethics committees and in line with standards for human research at the time (early 1980s). Informed consent was documented on a specific form for this purpose.Mean (standard deviation) birth weight in the sample was 3446 (450) g, and mean gestational age was 39.7 (1.3) weeks. Summary statistics for all raw anthropometry are given in Correlations between birth weight and anthropometry  show minor differences between the sexes . PoolingThe stepwise multiple regression analysis highlighted a similar pattern of relationships between birth weight and body lengths and circumferences . Neonata2 attributable to skinfolds = 0.36). However, adjusted for indicators of overall size , abdominal skinfold was no longer significant in the regression model .The multiple regression of birth weight on the four skinfold measurements showed a significant relationship between each of the skinfolds and birth weight , a result that did not change when head circumference was added to the model .The RMA regression slope of the sum of the 4 skinfolds on birth weight  was 1.00, indicating isometry in the relationship between skinfold thickness and birth weight . Plots oOur study shows that neonatal anthropometric traits vary in the strength of their associations with birth weight. Body circumferences were most strongly related to birth weight and while heavier babies had absolutely larger skinfolds, this relationship was markedly attenuated once we accounted for overall size. Limb segment lengths showed weak associations with birth weight, and relative limb to trunk lengths showed no relationship to birth weight.The fact that body circumferences, particularly those of the chest and head, show the strongest relationships with birth weight is perhaps unsurprising. The trunk and head form, by volume and weight, the greatest part of the neonatal body Our results support a previous study showing that heavier babies have greater fat mass (represented here by skinfolds), and that neonatal fat mass explains approximately 46% of the variance in birth weight Our support for Catalano et al.' s findings comes, however, with a caveat: our results also further highlight the potential misconception that fat mass alone explains this proportion of the birth weight variance. Numerous studies cite Catalano et al.'s result that while fat constitutes 12% of neonatal mass, it accounts for 46% of the variance in birth weight The relatively weak associations between limb length measurements and birth weight, as well as other anthropometry including body breadths and neck-rump length, suggest a considerable degree of independence between limb segment lengths and other neonatal dimensions. The lack of association between relative limb to trunk lengths and birth weight is consistent with previous arguments that relative lower limb length indexes postnatal, not prenatal, environment The results, however, contrast with several studies that report reduced relative limb or limb segment lengths due to exposure to specific prenatal stressors such as maternal smoking It is particularly relevant that distal limb segment lengths show weak associations with birth weight and other anthropometry. Distal limb segment length is argued to be especially sensitive to postnatal environment compared with total limb length in the lower Body composition, rather than birth weight, is likely to be a more relevant means of assessing neonatal nutritional status. This is particularly important given that populations differ systematically in body composition. For example, South Asian infants of a given birth weight have a similar fat mass but reduced lean mass compared with Western populations  A limitation of this study is that it did not directly assess the relationship between anthropometry and markers of prenatal environment. Birth weight has limitations as a marker of foetal environmental stress exposure, and assessing relative limb proportions in relation to other prenatal environment indicators may be more appropriate for assessing the use of limb proportions as markers of prenatal environment. Furthermore, skinfolds measure only subcutaneous fat, and do not consider deeper fat deposits, which could relate differently to birth weight. Finally, this relationship between relative limb proportions, subcutaneous fat and birth weight may not apply in other populations with different environmental exposures or ancestry, and this needs to be investigated. For example, one study showed that heavier neonates from Bangalore, India, had proportionally thicker skinfolds (and so greater percentage fat mass) than normal or low birth weight infants While the maternally-reported ethnicity of the parents in the sample was overwhelmingly ‘White’ , body size, composition and proportions throughout life are known to be affected by ancestry Finally, we note that this sample comprises infants born in 1982–3 in a small region of Australia. Thus it is uncertain whether the relationships reported here between different neonatal measurements remain the same in contemporary birth cohorts, or babies from other regions. Nevertheless the results provide an important first insight into the relationships between different aspects of neonatal anthropometry, and question which few datasets have the required anthropometric detail to address.In conclusion, our study shows that different body measurements at birth show varying relationships to overall birth weight. Head and chest circumferences show the closest associations with birth weight, while relative limb proportions at birth are unrelated to birth weight and therefore do not appear to act as markers of prenatal environment. The results also suggest that subcutaneous fat explains less of the variation in birth weight than previously argued. Rather, in our sample, subcutaneous fat appears to increase proportionally with birth weight. This finding supports arguments that body composition, rather than birth weight or fat mass, may be more appropriate for assessing newborn nutritional status.Table S1Correlation between anthropometry .(DOC)Click here for additional data file.Table S2Results of stepwise multiple regression of anthropometric variables on birth weight . Variables listed in the order they entered the model in the stepwise procedure. Variables excluded from the model (p>0.10): biparietal and hip widths, lower arm length, thigh and lower leg lengths. SE = standard error. Anthropometry log transformed prior to analysis. MUAC = mid upper arm circumference.(DOC)Click here for additional data file.Table S3Results of multiple regression of birth weight on skinfolds and body size . Variable excluded from the model (p>0.10): abdominal skinfold. SE = standard error. Anthropometry log transformed prior to analysis.(DOC)Click here for additional data file.


Birth centres are regarded as settings where women with uncomplicated pregnancies can give birth, assisted by a midwife and a maternity care assistant. In case of (threatening) complications referral to a maternity unit of a hospital is necessary. In the last decade up to 20 different birth centres have been instituted in the Netherlands. This increase in birth centres is attributed to various reasons such as a safe and easy accessible place of birth, organizational efficiency in integration of care and direct access to obstetric hospital care if needed, and better use of maternity care assistance. Birth centres are assumed to offer increased integration and quality of care and thus to contribute to better perinatal and maternal outcomes. So far there is no evidence for this assumption as no previous studies of birth centres have been carried out in the Netherlands.The aims are 1) Identification of birth centres and measuring integration of organization and care 2) Measuring the quality of birth centre care 3) Effects of introducing a birth centre on regional quality and provision of care 4) Cost-effectiveness analysis 5) In depth longitudinal analysis of the organization and processes in birth centres.Different qualitative and quantitative methods will be used in the different sub studies. The design is a multi-centre, multi-method study, including surveys, interviews, observations, and analysis of registration data and documents.The results of this study will enable users of maternity care, professionals, policy makers and health care financers to make an informed choice about the kind of birth location that is appropriate for their needs and wishes. The Dutch maternity care system is based on the notion that pregnancy, birth and the puerperium are primarily physiological processes. Most pregnant women are initially considered as ‘low risk’ and in 2012 85 % of them initially received antenatal care from an independently operating community midwife. The remaining 15 % of pregnant women received antenatal care from a secondary or tertiary obstetrician from the beginning of pregnancy onwards, mostly due to a history of medical or obstetrical problems [One important aim of the Dutch model is to ensure safe midwifery-led care under the responsibility of an independent community midwife for women with low risk pregnancies, regardless whether they prefer to give birth at home, in a birth centre or in a hospital. The percentage of home births in the Netherlands is high compared to other developed countries but is decreasing rapidly. In 2012, 15.7 % of all births in the Netherlands took place at home compared to 30.3 % in 2000 .These trends led to a substantial increase of births in obstetric hospital units. To accommodate the growing number of low-risk women who do not want to deliver at home several birth centres were established in the Netherlands with a large variation in their philosophies, characteristics and service delivery –7. StudiTo determine process, structure and outcome quality indicators enabling the assessment of the quality of birth and postpartum care in a birth centre, in collaboration with the various care providers and clients involved;To develop a typology of birth centres based on the level of integration of organisation and care, also making use of the quality indicators mentioned;To assess the effect of birth centre care in relation to the different types of birth centres in terms of optimality and adverse outcomes;To study the impact of the introduction of birth centre care on the local adjacent birth and postpartum care system by comparing process indicators and perinatal and maternal outcomes before and after the introduction of a birth centre;To study the cost effectiveness of birth centre care compared with usual care ;To assess experiences of both clients and care givers (working either within or in collaboration with a birth centre);To perform a longitudinal multiple case study investigating the organizational processes in a limited number of selected birth centres from an operational, medical, behavioural and administrative perspective;To translate results of this study into recommendations for future birth and postpartum care in the Netherlands;The effect of the introduction of a relatively large number of birth centres on the quality and the effectiveness of the Dutch maternity care system have not been studied up to now. The objectives of the Dutch Birth Centre Study can be summarized as follows:In this paper we introduce the Dutch Birth Centre Study and its design.Inventory of birth centres, development of quality indicators, definition of Birth Centre, measuring integration of organization and careMeasuring the quality of birth centre careEffects of introducing a birth centre on regional quality and provision of careCost-effectiveness analysisIn depth longitudinal analysis of the organization and processes in birth centresThe Dutch Birth Centre Study consists of five sub studies which are linked to one another:Different qualitative and quantitative methods will be used in the sub studies. Data collection includes observations, interviews , questionnaires , standard registered data and additional registrations. Data collected in one sub study will be shared with other sub studies as much as possible to make sure that the birth centres and other professionals involved in birth and postpartum care are minimally burdened by participating in the various evaluations. This study will be conducted in the period 2013–2015.To characterize all Dutch birth centres the Dutch Birth Centre questionnaire will be developed based on the questionnaire of Laws et al. to characterize Australian birth centres . This quClient-experiences will be assessed by using the postnatal part of the Repro-Q . The Rephttp://www.perinatreg.nl). The Netherlands Perinatal Registry (PRN-foundation) is a joint effort of the four professional organisations that provide perinatal care in the Netherlands: KNOV , LHV , NVOG (Dutch Association of Obstetrics & Gynaecology) and NvK (Paediatric Association of the Netherlands). All professional organisations have their own voluntary based medical registry. Those registries are linked to one combined PRN-registry. The participation rate of obstetric caregivers (gynaecologists and midwives) is almost 100 %. All Dutch paediatricians working in a hospital with a neonatal intensive care unit (NICU) participate, as well as 60 % of the paediatricians working in hospitals without NICU [Individual baseline and outcome data are collected from the Netherlands Perinatal Registry  date, time of day and dilatation at first and last visit at home before the actual birth and referral. We will also collect the time of start of continuous support by midwife and birth attendant, transport and arrival at birth centre or hospital, time of first action by secondary caregiver, time of arrival in birth centre postpartum and of the return home postpartum and number of hours of maternity care assistance at home. Furthermore data are collected about place of referral, type of transport in case of referral, discipline of the birth attendant and if the situation occurred that the preferred hospital or birth centre was fully booked.Serious adverse outcomes are expected to be very low as the study population consists of women with an uncomplicated pregnancy who will start labour under midwifery-led care. Therefore the two main outcome measures will be composite measures: the Optimality Index (OI) and a composite measure of adverse neonatal and maternal outcomes .The Optimality Index is a composite score combining background and outcome data based on a simple scoring system: optimal or not optimal. The optimal score is maximal perinatal outcome with minimal intervention placed against the woman’s health status. The OI is very suitable to compare groups with comparable risk profile or to correct group comparisons for differences in risk profile , 18. BacThe composite adverse outcome score will include maternal and neonatal outcome indicators. Adverse maternal outcome indicators are maternal death (within 42 days of giving birth), third or fourth degree of perineal trauma, placental retention, postpartum haemorrhage (>1000 ml), and admission to an intensive care unit or obstetric high care unit. Adverse neonatal outcome indicators are stillbirth after presentation in labour, early neonatal death (<7 days), Apgar score <7 after 5 min, neonatal encephalopathy, meconium aspiration, admission to neonatal unit within 48 h of birth and birth weight below 5th percentile.The aim is to study the way birth centres are organised, what services are provided, who is responsible, and to measure the level of integration of care of birth centres.Inclusion criteria participants: all locations in the Netherlands that could be considered a birth centreMethod: systematic inquiriesExpected outcome: identification of all potential Dutch birth centres (reference date August 2013)Birth centres in their current presentation are relatively new in the Netherlands. Therefore no clear definition and no list of birth locations that can be considered a birth centre is currently available. To examine the large variety of possible birth centres criteria for inclusion are selected: birth settings where out-of-home community midwifery led care is provided in a home-like environment to women at low risk of medical complications at the onset of labour. Every birth location that can be included will be invited to participate in this part of the study. Based on the characteristics birth centres are examined by three independent researchers and a selection of all potential Dutch birth centres is made.A comprehensive set of structure and process quality indicators will be developed to evaluate birth centre care using a multi-staged approach. The development process consists of three phases: 1) identification of existing structure and process quality indicators in birth care (literature study); 2) translating indicators for maternity care in general into determinants for measuring structure and process quality of birth centre care; 3) determinant selection of relevant structure and process quality indicators (two-step web-based Delphi consultation) . The webInclusion criteria participants: professionals working with or in a birth centre, representatives of health insurance companies, policymakers and advisorsMethod: two-step web-based Delphi consultationInstrument: web-based questionnaireExpected outcome: a list of potential structure and process quality indicators for birth centres in the NetherlandsThis procedure will result in a list of potential structure and process quality indicators for birth centres in the Netherlands. In order to test whether these quality indicators actually can measure the quality of birth centres, they will be validated within the presumed selection of birth centres.Inclusion criteria participants: management representatives in all birth locations identified previouslyMethod: surveyInstrument: Dutch Birth Centre questionnaire (adjusted Laws questionnaire)Expected outcome: preliminary classification/typology of birth locations into birth centres and other birth settingsThe Dutch Birth Centre questionnaire will be sent to a (management) representative of each birth location as identified in the first step of the study. A definition for different types of birth centres in the Netherlands will be developed based on internationally used definitions and the information obtained through our questionnaire. The characteristics of all Dutch birth centres will be described.Inclusion criteria participants: all birth locations identified preliminary as birth centreMethod: survey and interviewInstruments: Dutch Birth Centre questionnaire, interview topic list, conceptual framework on integrated careExpected outcome: level of integration for each birth centreTo construct a typology of birth centres we will use the concept of integrated care. This concept was developed first for the increasing number of people with a chronic disease. Different  disciplines are involved in the continuous care for persons with a chronic disease. For instance, care for a person with diabetes mellitus type II may involve a general practitioner, a dietician, and a physiotherapist, but also an endocrinologist. The essence of integrated care is a continuum of care for service users which crosses the boundaries of primary, secondary, tertiary and public health care –22. The The aim is to study the process and outcomes of birth centre care, compared to birth at home and birth in a hospital, for pregnant women under the responsibility of the independently operating community midwife at the start of labour. Client experiences and provider satisfaction are included in the outcome measures. At the end of the total study all different outcomes will be linked with each other.Inclusion criteria participants: all low risk women starting labour while in care with a participating community midwife for a period of 3 monthsMethod: standard and additional health care registrationInstruments: Optimality Index and a composite measure of adverse neonatal and maternal outcomeExpected outcome: quality of care in birth centres versus home or hospital birth for low risk womenMidwifery practices in the area of all birth locations in this study will record the data for each birth under their care during 3 months: data routinely recorded in the Netherlands Perinatal Registry and additional process indicators not available from the Netherlands Perinatal Registry.Inclusion criteria participants: all women in their postpartum period under care of participating community midwives for a period of 3 monthsMethod: SurveyInstrument: Repro-Q with added questionsExpected outcome: women’s experiences with perinatal careTo assess client experiences the postnatal part of the Repro-Q will be used. Especially for this study, questions about facilities and transfer are added for women who received care in a birth centre. The same midwifery practices as in sub study 2.1 will be asked to distribute information of this part of the study and a acceptance paper form to each woman that receives care in their postpartum period regardless who gave natal care to them. These women will be approached 6 to 8 weeks after they give birth by the way they preferred to answer the questions on client experiences i.e. by email, by post or by telephone. A reminder will be sent after 4 weeks.Inclusion criteria participants: all care providers working in and with birth centres in the NetherlandsMethod: SurveyInstruments: Care provider questionnaireExpected outcome: providers’ experiences and satisfactionTo assess the experiences of professionals working within and with a birth centre a questionnaire will be developed based on earlier questionnaires used in workforce planning , 26. TheThe aim of the evaluation is to gain insight into the effect of the introduction of a birth centre in a region on planned place of birth and the outcomes of the provided birth and postpartum care.Inclusion criteria participants: all low risk women starting labour while in care with a participating community midwife for a period of at least 3 months before the start of the birth centre and a minimum of 3 months afterwardsMethod: standard and additional health care registrationInstruments: case record form, Optimality Index and a composite measure of adverse neonatal and maternal outcomeExpected outcome: effect of the start of a birth centre on regional quality of care for low risk womenIn May 2011 a baseline assessment was performed in areas where a birth centre was intended to start before June 2013. Ten regions collected data for more than 3 months. Midwifery practices in the area of an intended birth centre recorded the following data for each birth under their care: data routinely recorded in the Netherlands Perinatal Registry and additional process indicators not available from the Netherlands Perinatal Registry (see sub study 2). The follow-up measurement has been conducted in the second half of 2013. Data collection has resulted in around 3000 births for the pre-test period and will result in 3000 births for the post-test period. These numbers are sufficient to describe changes in the region between the period before the birth centre started and afterwards. Logistic regression analysis will be performed to study the difference in planned place of birth between the period before and after the start of the birth centre. Linear regression analysis will be performed to test the mean differences in the Optimality Index between the period before and after the birth centre started. All analyses will be adjusted for potential confounders such as maternal age, parity and gestational age.The costs and effects of women with planned place of birth at a birth centre will be compared to women with a planned place of birth home and hospital under midwifery led care.Inclusion criteria participants: all low risk women starting labour while in care with a participating community midwife and living and having a birth centre as an option for planned place of birthMethod: standard and additional health care registrationInstruments: case record form, Optimality Index and a composite measure of adverse neonatal and maternal outcomeExpected outcome: effect of planned place of birth  on regional quality of care for low risk womenThe outcome measure for the effect study will be the Optimality Index. At least three midwifery practices in the area of each birth centre in this study will record data for each birth that started under their care during 3 months: data routinely recorded in the Netherlands Perinatal Registry and additional process indicators not available from the Netherlands Perinatal Registry (see sub study 2). A sample size of nine birth centres per level of integration  with 66 women per centre achieves 80 % power to detect an effect size of 0.2 .For the births included in the effectiveness part the costs will be assessed. Costs of birth in this study include the health care costs from the start of labour until 7 days after birth. These costs consist of a) medical interventions during birth such as: referral, augmentation, pharmaceutical and non-pharmaceutical pain relief, continuous foetal monitoring, intra partum antibiotics prophylaxis, continuous support of labour, birth by caesarean section, instrumental vaginal birth, manual placenta removal and blood transfusion, b) use of hospital facilities such as: hospital admission and length of stay, and c) staffing such as: attending midwife or obstetrician or both, maternity care assistance during childbirth and in the days thereafter.Volume of health care resource use will be registered prospectively on the case record form used by the attending midwife. Costs of birth and postpartum care are estimated by a detailed cost price analysis. Other resource use  will be translated into costs using standard prices .Inclusion criteria participants: all low risk women starting labour while in care with a participating community midwife and living and having a birth centre as an option for planned place of birth for a period of at least 3 monthsMethod: measurement of quantities and assignment of unit costs by detailed cost price analysis and use of standard pricesInstruments: case record formsExpected outcome: effect of planned place of birth on costsTotal costs per woman according to planned place of birth will be calculated. Mean differences between the groups and their 95 % confidence intervals will be estimated using non parametric bootstrapping due to the skewed nature of cost data.The aim of the economic evaluation is to study the cost-effectiveness of the care provided by different types of birth centres compared to home birth and hospital birth under midwifery led care. The economic evaluation will be performed from a health care perspective. The time horizon of the economic evaluation is from the start of labour until 7 days after birth. Due to this short time frame no discounting will take place.Inclusion criteria participants: all women starting labour while in care with a participating community midwife during a period of 3 monthsMethod: incremental net benefit methodInstruments: case record form and Optimality IndexExpected outcome: cost-effectiveness of birth centre care compared to home or hospital birth for low risk womenCosts and effects  will be transformed in a net-monetary benefit (NMB) estimate. Using the net benefit regression approach cost-effectiveness acceptability curves will be generated which show the probability of being cost-effective for the different planned places of birth: at home, the different types of birth centres and hospital birth for all acceptable levels of the willingness to pay .InclusioThe aim of this study is to assess to what extent different degrees of organizational integration  lead to differences in performance.This longitudinal qualitative research focuses on arriving at a deeper level of understanding of the process of care and cooperation and its development over time. The research design for this study is that of a process study using the grounded theory methodology . Seven bData will be collected through investigating from a so-called engaged scholarship/quasi-ethnographic perspective, in which from a variety of data sources over a substantial period of time conclusions will be drawn. This means that observations will take place in each of the birth centres for a number of days at a time, during daytime and during night-time, to observe ongoing activities and to interview care providers as well as clients.Inclusion criteria participants: birth centres selected by theory-drive selectionMethod: observations and interviewsInstruments: fly-on-the-wall observations, topic list for interviews, member checks and peer reviewsExpected outcome: improved understanding how different aspects of organizational design, care processes and collaboration (a) interrelate and (b) how they affect  outcomesData will be analysed using the constant comparative method. The purpose is to attain new insights by breaking through standard ways of thinking about phenomena reflected in the data . In thisThe insights of all sub studies will be put together, whereby the various elements of the research will be integrated. The national quantitative results will be combined with the insights from the interviews, the cost effectiveness results, client and professional experiences and the information and mirror sessions of the in-depth study to provide insight in the quality of birth centre care in the Netherlands. The regional quantitative results will provide insight into the development over time in a changing health care setting. Based on the confrontation of the various kinds of information more insight can be gained about birth centre care in general and about the strengths and weaknesses of different ways to organise birth centres in particular.This form of triangulation of information that results from various scientific paradigms is an exciting process that will be carried out by the principal investigators of the participating organizations. It will lead to recommendations for further development of birth centres in the Netherlands.This study will be carried out by an unique collaboration of several organizations, each with their own proven expertise in the field of the organization of health care and perinatal care in particular. Prior to as well as during the study period all organizations will be involved in both the planning and execution of all related sub studies. A broad advisory committee will be formed by representatives of all different kind of maternity care providers, research consortia, professional organizations, health insurance companies, national health department and clients to discuss the process and preliminary outcomes of this study. Design and planning of the study were presented to the Medical Ethics Committee of the UMCU . They confirmed that this study agrees with Dutch legal regulations for the methods used for this study and because of that official ethical approval of this study is not required . The Dutch Birth Centre study will evaluate the effect of birth centre care in the Netherlands from different angles and combining different research methods. In this way the Dutch Birth Centre Study will provide information on the functioning of different birth centres as well as their contribution to the quality of birth and postpartum care and the effect of the level of integration on the organisation of birth centre care; it also will evaluate the quality of birth centre care in terms of process and health outcomes, compared to birth at home or on a maternity ward in a hospital. Client and provider experiences are included in the outcome measures. An economic evaluation will assess cost-effectiveness of birth centre care compared to care as usual . In-depth analysis will provide information on how different degrees of organizational integration on the continuum from partial to fully integrated birth care will lead to differences in performance.In 2009 a steering committee instituted by the Dutch ministry of Health published a report called ‘A good start’ (in Dutch: ‘Een goed begin’) . This ofThe sudden increase in birth centres as integral part of the maternity care system is a relatively new development in the Netherlands. Until now, it seems that each region is developing its own version, based on local preferences, available space, and (lack of) mutual trust. Generally applicable standards for birth centre care are not available and there is no evidence of their added value. This study is designed to fill these gaps in our knowledge, to provide minimum standards for birth centre care and to compare their performance to the traditional care provision at home or in a hospital.The results of this study will enable care providers, policy makers, health care financers, professionals and users of maternity care to make an educated choice about the kind of birth location that is appropriate for their needs and wishes.


Acute gastroenteritis (AGE) is a leading cause of infectious morbidity in childhood. Clinical studies have implicated caesarean section, early birth and formula feeding in modifying normal gut microbiota development and immune system homeostasis in early life. Rates of early birth and cesarean delivery are also increasing worldwide. This study aimed to investigate the independent and combined associations of the mode and timing of birth and breastmilk feeding with AGE hospitalisations in early childhood.Population-based record-linkage study of 893,360 singleton livebirths of at least 33 weeks gestation without major congenital conditions born in hospital, New South Wales, Australia, 2001–2011. Using age at first AGE hospital admission, Cox-regression was used to estimate the associations for gestational age, vaginal birth or caesarean delivery by labour onset and formula-only feeding while adjusting for confounders.There were 41,274 (4.6 %) children admitted to hospital at least once for AGE and the median age at first admission was 1.4 years. Risk of AGE admission increased with decreasing gestational age , caesarean section (20 %), planned birth (17 %) and formula-only feeding (18 %). The rate of AGE admission was highest for children who were born preterm by modes of birth other than vaginal birth following the spontaneous onset of labour and who received formula-only at discharge from birth care (62–78 %).Vaginal birth following spontaneous onset of labour at 39+ weeks gestation with any breastfeeding minimised the risk of gastroenteritis hospitalisation in early childhood. Given increasing trends in early planned birth and caesarean section worldwide, these results provide important information about the impact obstetric interventions may have on the development of the infant gut microbiota and immunity.The online version of this article (doi:10.1186/s12887-016-0591-0) contains supplementary material, which is available to authorized users. Acute gastroenteritis is characterised by viral or bacterial infection causing diarrhea and vomiting and is a leading cause of infectious morbidity in infants and children worldwide even in developed countries including Australia, where the incidence is highest in the first two years of life , 2. ManyE. Coli. in infants delivered by caesarean section or fed formula rather than breastmilk [Bacterial exposures from the birth canal and perianal region during vaginal birth are important precursors for the colonisation of the gut in the first few days of life. To prepare for this, cells of the adaptive immune system are recruited to the fetal intestinal tissue with a transition to adult T-cells occurring in the third trimester . Once boeastmilk .This suggests potential common biological mechanisms by which shortened gestation, delivery by caesarean section and a lack of breastmilk exposure may increase susceptibility to gut infections by disturbing or modifying gut microbiota and immune system homeostasis in early life. Previous population-based studies have investigated the independent associations of vaginal birth and breastmilk feeding with childhood gastroenteritis –11. Few The aim of this study was to investigate the independent and combined associations of the mode and timing of birth and breastmilk feeding with gastroenteritis hospitalisations in early childhood.The study population included all singleton live births of ≥33 weeks gestation from 2001 to 2011 in New South Wales (NSW), Australia. Stillbirths and births to non-NSW resident mothers were excluded as these births have no opportunity for follow-up through record linkage with hospital admissions in NSW. Infants with major congenital conditions, born before 33 weeks gestation, or twins and higher-order births were excluded as they have different risk profiles, outcomes and models of care . Each chth revision of the International Classification of Disease, Australian Modification (ICD-10-AM) [This study used linked birth, hospital and death records from the NSW Perinatal Data Collection (PDC), NSW Admitted Patient Data Collection (APDC) and Registry of Births, Deaths and Marriages Death Registrations (fact of death) respectively. The PDC is a population-based statutory collection covering all live births and stillbirths of at least 20 weeks gestation or, if gestational age is unknown, at least 400 grams birthweight. It contains information on maternal characteristics, pregnancy, labour and delivery factors, and infant outcomes. The APDC includes demographic and hospitalisation related data for every inpatient admitted to any public or private hospital in NSW. Diagnoses for each admission are coded according to the 10D-10-AM) . The datThe study factors of interest were mode of birth, gestational age (timing of birth) and infant feeding status at discharge from birth care. Mode of birth was defined using the combination of labour onset and type of birth  and categorised as vaginal birth following spontaneous onset of labour, caesarean section following spontaneous onset of labour, vaginal birth following labour induction, caesarean section following labour induction, or pre-labour caesarean section. Gestational age is reported in completed weeks of gestation, as determined by the best clinical estimate including early ultrasound and last menstrual period. This was categorised as preterm (33–36 weeks), early-term (37–38 weeks) or term (39–42 weeks) birth. Infant feeding status at discharge from birth care is recorded using one or more of the following three categories: “breastfeeding”, “expressed breastmilk” or “infant formula”. These categories were used to create two independent groups: any breastmilk feeding (breastfeeding or expressed breastmilk feeding without infant formula) and formula-only feeding (infant formula without breastfeeding or expressed breastmilk feeding).The study outcome was hospital admissions for gastroenteritis, which we refer to as acute gastroenteritis (AGE). Primary or additional diagnoses for gastroenteritis (ICD-10-AM: A00-A09 or K52) were used to identify admissions. Inter-hospital transfers were treated as a continuation of an admission and not a new admission. AGE admissions within 7 days of a previous AGE admission were also treated as a single event.The proportion and number of children with none, one, or more than one AGE admission in the study period by maternal and perinatal characteristics were calculated. Cox proportional hazards regression was used to estimate the adjusted Hazard Ratios and 95 % confidence intervals for the independent and combined associations between the study exposures and first AGE hospitalisation with child age as the timescale and age at discharge from birth care as entry into observation. For censored individuals, age was recorded as the earliest of death, sixth birthday, or end of the study period (30 June 2012).The covariates used in the study reflect known risk factors identified in the literature , 12, 22.th and 90th percentiles for gestational age and sex, to women aged 20–34 years without medical conditions), using children with no hospital admissions only as the controls, using only a primary diagnosis of gastroenteritis, restricting to AGE hospitalisations within the first year of life or within the first two years of life (rather than six), and restricting to births from July 2007 onwards .Cox-regression was used to estimate the associations for the study exposures under variations of the study population and design, to assess the robustness of the main findings and for comparability with other studies of associations between birth factors and childhood hospitalisations. The variations investigated were: a sub-population of low risk liveborn singleton pregnancies , with the exception of infant feeding at discharge. Collection of infant feeding status began in mid-2006 and was only available for 51.8 % of births, within which 0.95 % were missing. As the per cent missing across all variables except infant feeding affected only 0.23 % of records, these were excluded. However, as infant feeding was an exposure of interest, it was imputed using a logistic model following recommendations in the literature , 27 % were born before 39 weeks gestation and 12 % were fed only formula in the birth admission , had a 38–52 % and 28–41 % increased rate of AGE admission respectively, regardless of the mode of birth. Previous studies have demonstrated an increased rate of overall pediatric or respiratory hospitalisations for preterm and early term births , 27–29. The increased rate of AGE admission with decreasing gestational age may be explained in part by the under-preparedness of the newborns immune system, particularly in the gut epithelium, to respond to the initial microbial colonisation at birth. Differences in markers of immune function between infants born before and after 37 weeks gestation have been reported previously . This maVariation in gut microbial composition in infants by mode of birth  and feeding status (breastmilk or formula) is well supported by clinical evidence , 31, 32.Previous population-based record-linkage studies of term births and without breastmilk feeding information found, as we did, an increased risk of AGE for children delivered by caesarean section , 10. HowChanges in clinical obstetric practice have seen an increase in rates of planned birth before 39 weeks gestation and caesarean section worldwide –16, and As planned birth before 39 weeks increases the perceptions of women about what constitutes normal birth is also likely to be altered. Recent studies have demonstrated that almost one in four women believed that a baby was full-term at 34–36 weeks gestation, that one in two believed full term was 37–38 weeks and more than 90 % believed it was safe to deliver before 39 weeks , 42. Anop-values were typically < 0.001), so it is unlikely our findings are due to chance. However, some caution is warranted as some of the associations for the study factors are small and by chance a statistically significant association may be found when performing many comparisons. Using available administrative data has some limitations, as not all potentially relevant characteristics such as diet, environment or antibiotic use during pregnancy and early childhood could be investigated. Despite the lack of information on long term breastfeeding outcomes such as the duration of exclusive breastfeeding, previous studies have found in-hospital formula supplementation is associated with early cessation of exclusive or any breastmilk feeding post-discharge [The strengths of this study are that it is a large population-based cohort, using data and variables with demonstrated accuracy and validity , 45. Usiischarge –48. IdenWe have shown using a large population-based record-linkage study that the rate of acute gastroenteritis hospitalisations in early childhood are increased for births by caesarean section or induction of labour, before 39 weeks gestation and for infants fed only formula at discharge from birth care. The combined effects of these factors highlight the benefit of normal birth and early breastmilk exposure, for reducing the risk of gastroenteritis hospitalisation in early childhood. These previously unknown combined effects represent useful information against a backdrop of increasing rates of caesarean section and early planned birth, and their potential impact on gut microbiota and immune system homeostasis.The data used in this study cannot be shared by the Authors due to the use and release of the data being subject to data custodian and ethics approval and conditions that require the data only be used for approved research, by approved persons directly involved in the project and following the completion of a confidentiality undertaking prior to the information being released.


To describe temporal changes in systolic, diastolic, and mean blood pressure  in term and preterm infants immediately after birth.Prospective observational two-center study. In term infants SBP, DBP, and MBP were assessed non-invasively every minute for the first 15 minutes, and in preterm infants every minute for the first 15 minutes, as well as at 20, 25, 30, 45, and 60 minutes after birth. Regression analyses were performed by gender and respiratory support in all neonates; and by mode of delivery, cord clamping time, and development of ultrasound-detected brain injury in preterm neonates.Term infants (n = 54) had a mean (SD) birth weight of 3298 (442) g and gestational age of 38 (1) weeks, and preterm infants (n = 94) weighed 1340 (672) g and were 30 (3) weeks gestation. Term infants’ SBP, DBP and MBP within the first 15 minutes after birth were independent of gender or respiratory support. Linear mixed regression analysis showed that preterm infants, who were female, born vaginally, had delayed cord clamping and did not require positive pressure ventilation nor develop periventricular injury or ventriculomegaly, had significantly higher SBP, DBP, and MBP at some measurement points within the first hour after birth.We present novel reference ranges of BP immediately after birth in a cohort of term and preterm neonates. They may aid in optimization of cardiovascular support during early transition at all gestations. Throughout fetal life pulmonary vascular resistance remains high and the majority of right ventricular output bypasses the lungs through the ductus arteriosus into the systemic circulation This study aims to define reference ranges for systolic BP (SBP), diastolic BP (DBP) and mean BP (MBP) in the first hour after birth in preterm infants and in the first 15 minutes in term infants and to formulate percentile charts for use after delivery. We further examine differences in the temporal patterns of BP with respect to gender, mode of delivery, delayed cord clamping (DCC), gestational age, level of respiratory support, and development of severe cerebral ultrasound abnormalities.This two-center prospective observational study was carried out at the Royal Alexandra Hospital, Edmonton, Canada and the Department of Pediatrics, Medical University Graz, Austria, both tertiary perinatal centers with approximately 6000 and 3000 births per year and admitting approximately 350 and 100 infants with a birth weight of <1500 g to the neonatal nursery annually, respectively. The Royal Alexandra Hospital Research Committee and Health Ethics Research Board, University of Alberta and the Health Ethics Research Board, Medical University Graz approved. Written parental consent was obtained in all neonates: in Edmonton before or after birth (deferred consent) in Graz only before birth, if possible 24 hours before birth.” Term infants born after elective cesarean section (in Graz only) and preterm infants (from both centers) born either vaginally or by caesarean section were included in Graz and in Edmonton between February 2013 and August 2013. Only neonates without history of blood loss or of cardiovascular support within the first hour after birth were included. The same protocol in both institutions was used. The research team, who was not involved in direct clinical care, attended all included deliveries. All preterm infants were stabilized for the first hour in the delivery room before admission to the Neonatal Intensive Care Unit.IntelliVue MP50 monitors  were used to continuously measure heart rate, oxygen saturation, and blood pressure (BP). BP was measured using a non-invasive BP cuff of appropriate size  on the left upper arm. Cuff size diameter was chosen according to the circumference of the infants left arm. The left upper arm was chosen to avoid interference with the pulse oximetery measurements at the infant’s right hand or wrist. In term infants BP measurements were started immediately after birth and performed at each minute until the infants were 15 minutes of age and brought to the father or mother for kangaroo-care. In preterm infants BP measurements were performed at each minute for the first 15 minutes, then at 20, 25, 30, 45, and 60 minutes after birth. In the Edmonton site, DCC was routinely performed for 60 seconds after delivery unless the obstetric team noted contraindications  and clamped earlier. All parameters were stored continuously in a multichannel system “alpha-trace digital MM”  for subsequent analysis.th, 25th, 50th, 75th, and 90th) for SBP, DBP and MBP were calculated by using the LMS-method described by Cole and Green and were fitted by using LMSchartmaker Version 2.54, a program to calculate age-related reference percentiles using the LMS method . Subgroup analyses for term infants  and preterm infants were performed according to gender, gestational age (23+0–27+6 vs. 28+0–31+6 vs. 32+0–36+6), mode of delivery, DCC for 60 seconds versus earlier cord clamping <60 seconds (ECC), level of respiratory support applied with T-piece mask (continuous positive airway pressure (CPAP) vs. positive pressure ventilation (PPV)), cardiovascular support, and ultrasound detected preterm brain injury defined as intraventricular haemorrhage, parenchymal lesions and/or ventriculomegaly seen on cerebral ultrasound , which were defined prior the start of study. The data are presented as mean ±standard deviation (±SD) for normally distributed continuous variables and median  when the distribution was skewed. Data were compared using Student’s t-test and Mann-Whitney U test for parametric and nonparametric continuous variables, respectively, and χ2 for categorical variables. A linear mixed regression model with correction for gender, gestational age, mode of delivery, DCC or ECC, level of respiratory support (CPAP vs. PPV) was used for calculation of overall effects and differences between groups at each minute. p-values are 2-sided and p<0.05 was considered statistically significant. Subgroup analyses were considered in an explorative sense; therefore, no multiple testing corrections were performed. Statistical analyses were performed with Stata .Demographics of study infants were recorded. Centiles (10Fifty-four term (Graz only) and 94 preterm infants  were studied  and theiAll term infants were delivered by cesarean section, none had DCC of 60 sec, and 10 (19%) of 54 required respiratory support . The remaining term infants were given to the mothers for kangaroo care. The first BP measurements were obtained in the third minute after birth, after the baby was brought to the resuscitation table and the BP cuff was applied. There was no significant difference in SBP, DBP and MBP between infants who required respiratory support and those who did not. In addition, no gender differences were observed. Data from all term infants were therefore analyzed together. Median values of SBP, DBP, and MBP for all term infants are presented in +0–27+6 weeks, 33 infants were 28+0–31+6 and 35 infants were 32+0–36+6. Overall values of BP in preterm infants are presented in Of 94 preterm infants, 65 (74%) were born via cesarean section, 56 (60%) received DCC for 60 seconds, and all received respiratory support in the delivery room (54 (57%) PPV and 40 (43%) CPAP). Of the 94 preterm infants 26 infants were 23There were no significant differences in gestational age, birth weight, mode of delivery, DCC or antenatal steroids between male and female infants. We observed no significant difference in SBP, DBP or MBP between male and females except for a significantly higher SBP, DBP, and MBP in female preterm infants at 25 minutes after birth. In female and male infants, SBP at 25 minutes was 51±10 vs. 46±9 mmHg (p = 0.03), DBP was 29±9 vs. 25±7 mmHg (p = 0.05), and MBP was 37±9 vs. 33±8 mmHg (p = 0.04), respectively.+0–31+6 weeks, and 35 (37%)≥32 weeks gestation. Significantly more infants born <32 weeks received antenatal steroids 51/59 vs. 18/35 (p = 0000.1), respectively. There were no significant differences in mode of delivery and DCC between infants born <28, between 28+0–31+6 weeks and ≥32 weeks gestation. Centiles of SBP, DBP, and MBP for preterm infants born <28 weeks are presented in +0–31+6 weeks in +0–31+6 weeks had significant higher SBP at 1, 2, 5, 14, 20, and 25 minutes, MBP at 1 and 20 minutes, and DBP at 1 minute compared to <28 weeks infants (p<0.05). Comparison of infants 28+0–31+6 weeks vs.>32 weeks showed significant higher SBP at 1, 30 and 60 minutes, MBP at 1, 30 and 60 minutes, and DBP at 30 and 60 minutes in infants with >32 weeks (p<0.005).Twenty-six of 94 (28%) infants were born <28 weeks, 33 (35%) infants were born between 28There were no significant differences in gestational age, birth weight, DCC or antenatal steroids between vaginal and cesarean delivery. Regression model showed BP was significantly higher at 7 (SBP), 8 (SBP and MBP), 9 minutes (MBP), and 45 minutes  after vaginal birth compared to caesarean section. SBP of vaginally born infants was 52±11 mmHg at 45 minutes, compared to 46±6 mmHg of those born by cesarean section, p = 0.009. DBP was also significantly higher at 45 min in vaginally born infants than that of infants born by caesarian section . MBP was also significantly higher at 45 minutes in vaginally delivered infants with 39±13 mmHg compared to 32±6 mmHg of infants born by caesarean section (p = 0.008). However, even though there is a statistically significant difference between the premature infants receiving DCC versus ECC, it is important to note that they were assisted at two different centers, with an unknown-and possibly differential-selection criteria and with different standards of care, which is a limitation of the study.DCC for 60 seconds was only performed in one center (Edmonton) with a total of 56 (60%) preterm infants . There were no significant differences in gestational age, birth weight, mode of delivery, gender or antenatal steroids between infants receiving DCC and ECC. At 60 minutes after birth MBP and DBP was significantly higher in infants receiving DCC for 60 seconds with 33±6 mmHg and 26±6 mmHg vs. 28±4 mmHg and 22±5 mmHg, p = 0.01, and p = 0.04, respectively. No significant differences in SBP were observed within the first hour.There were no significant differences in mode of delivery, DCC, gender, or antenatal steroids between groups who required different levels of respiratory support. However, infants receiving PPV had significantly lower gestational age and birth weight compared to infants receiving CPAP 28.5±3.4 weeks vs. 31.3±2.5 weeks (p<0.001) and 1169±667 grams vs. 1567±625 grams (p = 0.041), respectively. Although, regression analysis showed significant higher DBP and MBP (p = 0.0001 and p = 0.001) in preterm infants receiving CPAP at 60 minutes after birth compared to PPV. T-test comparison had similar SBP, DBP and MBP values throughout the first 60 minutes after birth.All preterm infants had cranial ultrasound prior to discharge and 13/94 (14%) had intraventricular hemorrhage grade 3 or 4 or a periventricular ischemic lesion (n = 4). Multiple regression analysis did not show any difference, however t-test comparison showed a significant lower SBP, and MBP at 25, 30 and 60 minutes of age and DBP 25 and 60 minutes in infants who subsequently developed intraventricular hemorrhage during their hospital admission. SBP at 25, 30 and 60 minutes in the infants developing intraventricular hemorrhage was 40±11 mmHg, 41±3 mmHg, and 38±6 mmHg compared to 50±9 mmHg, 49±7 mmHg, and 46±6 mmHg, p = 0.0005, p = 0.0008, and p = 0.001 respectively. MBP was 28±11 mmHg, 30±4 mmHg, and 26±3 mmHg compared to 36±7 mmHg, 36±6 mmHg, and 32±5 mmHg, p = 0.003, p = 0.01, and p = 0.002, respectively. DBP was 22±11 mmHg and 21±2 mmHg compared to 25±6 mmHg and 29±5 mmHg, p = 0.02 and p = 0.02, respectively.To our knowledge this is the first study describing SBP, DBP, and MBP reference values in term and preterm infants immediately after birth. Overall, SBP, DBP, and MBP remained similar within the first 15 minutes after birth in term infants and decreased throughout the first 60 minutes after birth in preterm infants. Preterm infants, who were born vaginally, were female, had DCC for 60 seconds, and required CPAP had significantly improved SBP, DBP, and MBP values at some measurement points. Furthermore, preterm infants developing severe brain injury had significantly lower SBP, DBP, and MBP at 25, 30, and 60 minutes after birth.Although, our results demonstrate that a low BP immediately after birth might requires cardiovascular support, however, the clinical condition of the infant has to be taken into account and this should be investigated in future studies. In addition, we report on physiological changes at birth and their clinical impact has to be defined in randomized studies.Only term infants after elective caesarian section were included and therefore mode of delivery comparison was not possible, which is a limitation of the study. Infants, were not excluded from analyses, who needed cardio circulatory support after the first hour. Exclusion of neonates, in whom we don’t know yet if the blood pressure in the first hour after birth is normal or not, would have caused a bias in overall analyses of data. In addition, ethic approval was only granted for elective caesarian section and therefore we were unable to recruit infants born after vaginal delivery. Furthermore, we only measured for the first 15 minutes after birth as term infants were returned to their parents for kangaroo-care at that time point. Therefore we don’t know if BP changes afterwards.We observed a steady decrease in SBP, DBP, and MBP throughout the first hour after birth. At first glimpse, this contradicts several echocardiography studies reporting a steady increase in stroke volume and CO in term infants within 1 hour after birth Walther et al and Agata et al reported that CO peaked between 30 minutes to 2 hours after birth with a steady decreased to reach a steady state thereafter We observed a significant higher SBP, DBP, and MBP at 45 minutes after vaginal birth compared to caesarian section delivery. Our observations are similar to published data on peripheral oxygen saturation (from 1 until 5 minutes) and heart rate (from 2 to 10 minutes), which reported higher values after vaginal delivery; in comparison published data on cerebral oxygenation was similar regardless of mode of delivery during neonatal transitionSommers et alBhatt et al recently described that ventilation prior to umbilical cord occlusion improved cardiovascular function and stability during the immediate transition to neonatal life after birth in preterm lambs DCC is believed to improve cardiovascular function and stability during the immediate transition to neonatal life after birth. DCC for 60 seconds can increase an infant’s blood volume by approximately 16 mL/kg and reduce rates of intraventricular hemorrhage in premature infants Bhatt et al demonstrated that infants receiving ventilation before DCC had significantly improved hemodynamics Binder et al reported no differences in BP-values within the first 10 minutes after birth Lung aeration at birth results in an 8–10 times increase in pulmonary blood flow, which is essential for both pulmonary gas exchange and maintenance of left ventricular output In the current study we had similar BP values for infants requiring CPAP or PPV. Complicated effects of intrathoracic pressure and cardiopulmonary interaction in the transitional circulation may explain the lack of significant difference between groups who required different levels of respiratory support.Our data show that preterm babies who have severe brain injury on cerebral ultrasound have significantly different cardiovascular adaptation at birth, with lower BP readings at 25 to 30 minutes and at 60 minutes of age. It is difficult to know whether these findings reflect the possibility that injury starts prior to delivery, or that injury may be modified by interventions that occur during early transition, such as DCC or ventilatory support. Since the present study is not designed and powered to answer any causal relationships of blood pressure and brain injury, it would be prudent to choose interventions that improve BP stability.Observational studies such as this are limited by patient selection, however, the bias was mitigated to some extent by our larger patient numbers, more than one delivering institution, and prospective inclusion of potential confounders, such as gender and mode of delivery. Measurement of BP may vary considerably with the underlying methodology and the BP cuff size, which potentially are confounder in measurement of peripheral BP. However, these methodologies for ascertaining BP are in common use in intensive care units around the world, giving our reference ranges clinical generalizability. In addition, the non-invasive BP recording has its limitations and correlates poorly with invasive BP Non-invasive measurements of blood pressure are feasible during immediate neonatal transition and provide important information on the cardiovascular status of the newborn. These are the first reference ranges of BP in a cohort of term and preterm neonates. We have formulated centile charts that may be used to optimization cardiovascular support during immediate transition in both term and preterm infants.


The results showed that statements were generally more strongly endorsed after idiom embodiment than control conditions, indicating that the meaning of idiomatic expressions may not be as disconnected from perceptual and motor experiences than previously thought. These findings are discussed in terms of the mirror neuron system and the necessity of pluralistic contributions from both sensorimotor and amodal linguistic systems to fully account for the representation and processing of idioms and other figurative expressions.Idioms are used in conventional language twice as frequently as metaphors, but most research, particularly recent work on embodiment has focused on the latter. However, idioms have the potential to significantly deepen our understanding of embodiment because their meanings cannot be derived from their component words. To determine whether sensorimotor states could activate idiomatic meaning, participants were instructed to engage in postures/actions reflecting various idioms (e.g.,  Mary's personality is a magnet, or Mary's mind was a whirlpool; whereas idioms are expressions whose meaning cannot be derived from a systematic or literal processing of the component words , with highly non-decomposable idioms resulting in faster processing and greater “direct access” to meaning  as opposed to incongruent images like an eagle with folded wings corresponded to a word in the sentence, again showing that participants' comprehension was perceptually biased. A series of studies by Matlock and colleagues has shown that the reading latencies of sentences with implied or “fictive” motion such as the road runs through the valley were affected by the speed of motion, type of travel or distance conveyed in a preceding story  resulted in somatotopic motor cortex activation in regions corresponding to the body part responsible for that action. In another study of arm- and leg-related words  words, Pulvermüller et al.  proposed in a seminal book by Lakoff and Johnson  induced “warm” judgments about others  . In addition, the proponents of metaphor embodiment do not claim that their findings “necessarily generalize to all kinds of metaphorical language… [and that] embodied simulation is necessarily central to all aspects of metaphor comprehension” Gibbs, . PuttingContrary to the considerable behavioral and neuroscientific research on the embodiment of metaphors, very little work has been done to investigate the extent to which idioms may also be embodied. This is likely because in contrast to the perceptually rich and verbally creative quality of metaphors, idioms seem like the hallmark of fixed amodal expressions whose meaning must be explicitly learned, stored, and retrieved from memory. Idioms therefore appear to present a potential challenge for embodied theories of cognition because it seems improbable that the comprehension of idiomatic meaning would involve the activation of perceptual and/or motor regions rather than simply linguistic information. However, due to the considerable amount of evidence demonstrating the embodiment of cognition across various domains such as literal and non-literal language like metaphors, there have been a small but slowly growing number of studies to investigate whether idioms are embodied.per se, but consisted of behavioral investigations of the extent to which individuals seem to use mental imagery and underlying conceptual metaphors (that appear to be embodied from the evidence above) in the comprehension of idiomatic meaning. The results of this research have generally been mixed, such that some researchers obtained evidence to support that hypothesis  each activated somatotopically corresponding areas of motor cortex  and that the time course of this activation was generally similar and relatively rapid, within 150–250 ms, for both types of stimuli  only approached significance and showed trends toward the expected effects. In both cases the authors argue for a graded account of embodiment suggesting that as the meaning of an expression becomes increasingly more conventional and abstract, as in the transition from metaphoric to idiomatic meaning, the weaker and less likely it is to activate perceptual and motor brain areas. Even though their results for idioms were non-significant, these researchers claim that their overall findings generally support the embodiment of figurative language.Some further but very weak evidence for the embodiment of idioms comes from a couple of recent studies by Desai et al.  and Laurkick the bucket and biting off more than you can chew. In sum, the findings in both the behavioral and neuroscentific literature are contradictory and the extent to which sensorimotor systems contribute to idiomatic meaning remains unclear. Indeed, given that only Boulenger and colleagues have been able to find significant results in the neural domain thus far  they could plausibly be worked into the context of the story, (2) involved sustained positions or actions that could be maintained while participants read portions of the story and responded to the questions, and (3) because pre-testing of potential idioms by 30 students  similar to those participating in the experiment, indicated that were familiar and understood by at least 70% of those individuals. For each part of the story, participants were assigned to one of three conditions , where they either performed the position or action corresponding to the idiom, a different control position or action, or were simply seated in a normal comfortable position, respectively, in a counter-balanced manner. In other words, every participant engaged in each condition at least once across the 4 portions of the story, with each condition occurring an equal number of times across participants.Specifically, they were told that the purpose of the study was to investigate how reading comprehension may be affected by different positions and movements. We developed a relatively long story involving a crime and subsequent courtroom drama. The whole narrative was designed to read and flow as one coherent story, but it consisted of four parts that were each written to relate to the meaning of a particular idiom. Each portion of the story was followed by a set of four questions designed to measure the extent to which the idiomatic meaning was activated, which was the dependent variable (DV). With respect to both the stories and questions, the idioms were never actually mentioned and considerable effort was taken to avoid using words and phrases closely associated to the idiomatic expressions and their meanings, to prevent them from being simply activated by verbal means. Further information will be provided in the method section, but the idioms used were: To our knowledge, the present study thus appears to be the first to investigate the embodiment of idioms by seeing whether having participants simply perform an idiomatic action would be enough to induce their meaning and affect subsequent judgments. It was predicted that embodying the idioms compared to the two types of control conditions, would result in stronger responses to the questions in the direction of the idiomatic meaning. Demonstrating the embodiment of idioms through this relatively novel approach  who participated in this research for course credit. Prior to participating in the experiment, they were asked to complete a survey about their language background(s). This was to ensure that they had sufficient exposure to the English language by 5 years of age, and maximize the likelihood that they would be familiar with the idioms and the ability to read and understand the narrative and questions. Although every participant was exposed to English by the time they were 5 years old, the language history forms indicated that 17 individuals had more familiarity and knowledge of another language in those early years. Since many Brooklyn College students come from recently immigrated families it is almost impossible to find “pure” monolingual native English speakers. In fact, only 18 out of 60 participants reported that they were not exposed to any other language(s) by the time they were 5 years old.each part of the story in a counter-balanced order and mixed design, such that each participant experienced each condition over the course of the study, but were only assigned to one condition for the portion of the story corresponding to a particular idiom. In other words, one participant would have sat normally for the first part of the story , performed the idiomatic action for the next part of the story (embodied idiom condition), engaged in another control action for the third part of the story (embodied control condition), and sat normally again  for the last part of the story. Another participant would have embodied the idiom for the first part of the story, then engaged in a control position, then sat normally, and embodied the idiom again for the final part of the story, and so on, with each condition occurring equally often in all possible orders, and resulting in 20 participants per condition for each portion of the story .As described above, participants were randomly assigned to one of three conditions for strongly disagree, 6 = strongly agree), such that the DV consisted of the mean rating across each set of 4 responses. It is important to note that the actual idioms were not mentioned in any of these materials, and care was taken to avoid using words and phrases strongly related to the idiomatic expressions and their meaning. The complete narrative will be described further momentarily, but an example of one section of the story and corresponding questions is provided in Appendix A/Supplementary Materials As mentioned, the story was written and designed to be administered in four sections, corresponding to different idioms and described in further detail below. Every phase of the story began with a couple of introductory sentences to set the scene, followed by 3–4 substantive paragraphs of roughly similar length, ranging from about 300-400 words. Each portion of the story was followed by a set of 4 questions created to assess the strength of the activation of the idiomatic meaning alluded to in the preceding part of the text, and responded to on a 6-point scale  by getting into a friend's car which ended up resulting in a robbery and accidental murder. This idiom was embodied by having participants literally sit and stick their necks out while reading that part of the story and responding to the questions. An example of one of the risk-related questions that participants had to answer was “Pat was exercising caution as he let Justin drive oddly silent,” which was reverse coded. The next portion of the story consisted of the prosecuting and defense attorneys' explanations of the murder which showed that both sides had good points and the case was not clear cut, to convey the idiom of sitting on the fence , which was embodied by participants straddling a height-adjustable sawhorse such that only the tips of their toes abutted the floor, resulting in an unbalanced state. The set of items to which participants had to respond are listed in the Appendix. The third part of the story involved the judge's comments leading-up to the delivery of the jury's verdict, written in relation to the idiom of sitting on the edge of your seat , which was embodied with participants literally sitting on the edge of their seat. An example question was “I am eager to hear what the verdict will be.” Finally, the last part of the narrative dealt with the convict's life and thoughts after the guilty verdict, particularly with respect to his partner in crime to relate to the idiom burying the hatchet . In the embodiment condition, participants were presented with two large catering trays. The left tray contained a small hatchet (with its safety guard on), the right tray was filled with dirt, and participants had to bury the hatchet with dirt using a 1-cup scoop. An example item to which participants responded was “Pat will probably overlook Justin's offense by the time they meet again.”The entire story described a court room drama starting with the suspect's account and written so that it could be interpreted like the suspect had As explained before, participants were assigned to one of three conditions for each portion of the narrative, either (1) the embodiment conditions described above, (2) a normal control condition where they were comfortably seated in front of desk and read normally, or (3) an embodied control condition that involved engaging in a non-idiomatic position or action while reading the passage and answering the questions. The purpose of this latter embodied control condition was to make sure that the effects obtained were not simply due to participants being slightly distracted or uncomfortable while reading and responding to questions in the embodied idiom condition. For the more “positional,” “sticking one's neck out,” “sitting on the fence,” and “sitting on the edge of one's seat” idiomatic actions, participants in the embodied control conditions stood cross-legged while leaning against a wall. However, since the action of “burying the hatchet” involved moving one's hand to scoop dirt and dump it over a hatchet in a neighboring tray, the embodied control condition involved participants sitting at the same desk, but moving dominoes from one side of the table to the other. These conditions were chosen after testing various options because they were judged to be similar to the embodied idiom conditions in terms of positional awkwardness and motoric action.Participants were instructed that we were investigating the effects of motor information on text comprehension and that they would be required to perform specific positions/actions while reading a story and responding to questions. While giving participants instructions, it is critically important to note that the experimenter never uttered words associated with the idioms and their meaning, let alone the idiomatic expressions themselves, so that they would not be verbally activated. Instead, participants were asked to basically imitate the same position or action demonstrated by the experimenter while they read each part of the story and answered the corresponding questions. Since the study was designed around one continuous and coherent narrative, the participants were all presented with the sections of the story in the same order, but engaged in different positions or actions for each phase based on the conditions to which they were assigned. After the critical idiom embodiment story task, participants completed a distracter task where they read and underlined passages from a text, followed by a questionnaire to assess their understanding of the target idioms (explaining the meaning of example sentences) and their familiarity with the expressions. The entire study took about 75 min to complete.N = 31, 15 females) rated the idioms for decomposability, literality, and transparency on 5-point scales, with 1 = completely non-X and 5 = completely Xwhich idioms are likely to be embodied. The ratings were obtained by embedding our critical items into a larger set of idioms, and the resulting data is presented in Table A separate group of participants  relative to the embodied control  and normal control  conditions, F = 6.981, p = 0.002, η2p = 0.197, with the latter two conditions not significantly differing, p = 0.92. “Sitting on the fence” also induced more ambivalent judgments  relative to the embodied control  and normal control  conditions, F = 7.174, p = 0.002, η2p = 0.201, with the latter two conditions not significantly differing, p = 0.74. Literally “sitting on the edge of your seat” significantly increased judgments of excitement  relative to the embodied control  and normal control  conditions, F = 5.640, p = 0.006, η2p = 0.165, with the latter two conditions not significantly differing, p = 0.94. However, the effect for “burying the hatchet” was not found to be significant, F < 1Results revealed that actually “sticking your neck out” significantly increased risk judgments  = 10.489, p < 0.001, η2p = 0.259 (assumptions of sphericity were met). Post-hoc pairwise comparisons with Bonferroni corrections showed that burying the hatchet was rated significantly less transparent and thus more opaque than the other three idioms, which were not significantly different.These results are displayed in Figure The current research was intended to be an exploratory study about whether embodying idioms could instantiate their meaning to subsequently affect processing and judgments. Recall that previous behavioral and neuroimaging investigations of this issue had produced mixed results . Given human experience about the importance and vulnerability of one's neck, the existence of multiple expressions conveying risk and involving the neck and head is no coincidence and further supports the embodiment of some idioms. Of course there are other idioms like playing with fire, playing Russian roulette, skating on thin ice, and walking into the lion's den that also convey risk. It seems unlikely that they would have been activated by the current procedure, but that is an interesting question for future research. Specifically, would activating the concept of risk by the movement of “sticking one's neck out” generalize and facilitate the processing of other “non-neck” idioms like skating on thin ice. Similarly, with respect to being on the fence, other idioms about indecision also typically convey a similar state of unbalance and sense of going back and forth or side to side . Hence, the extent to which straddling a sawhorse activated sitting on the fence rather than one or more of these analogous expressions is unclear, as is the issue of whether other indecision idioms like being in a quandary, dragging one's feet, or still up in the air, may have been activated.Since participants were never explicitly told or asked about the idioms directly, we also cannot be certain that they were activating the exact intended expressions. There are many idioms conveying risk, some of which would also be compatible with the action of putting one's head and neck forward . Mirror neurons were first identified in macaque monkeys as special cells in area F5 [in the inferior frontal gyrus (IFG) and analogous to Broca's area 44 in the human brain], primary and premotor cortex, inferior parietal cortex, and the superior temporal sulcus  to determine whether a greater degree of embodiment results in idioms that are more easily processed and remembered than less embodied items.The idiom of We thus propose that similar to the embodiment established for other aspects of language including metaphors, the meaning of many idioms is grounded in actual or simulated experiences encoded in the HMNSThe current findings in conjunction with some of the neuroimaging research thus appear to be indicative of a bidirectional connection between the meaning of idiomatic expressions and the actual or simulated experiences encoded into individuals' perceptual and motor regions through the HMNS. If this conceptualization is accurate, then encountering an idiomatic expression should re-activate those systems to some degree, but the only way to conclusively confirm this would be by using TMS or studying patients with damage to their mirror neuron systems to see if they show any difficulty with idiom comprehension relative to controls. Since some of the regions identified as being important aspects of the HMNS either overlap or are in close proximity to IFG language areas like BA44 and 45, the most convincing support for the importance of the HMNS would come from showing that impairment of more purely motor or premotor cortices affects idiom processing. Cacciari et al.  appear tsomething that's the real McCoy, opening a Pandora's box, to get forty winks, kick the bucket, paint the town red, bury the hatchet, or sell someone down the river), a pluralistic approach like Barsalou et al. (Another interesting avenue for future research will be to examine how typically studied features of idiomatic expressions like decomposability and literality relate to the extent of embodiment. Some factors like imageability will undoubtedly be highly correlated with embodiment, but the nature of this relationship for other variables is less clear and should be explored. The linguistic features of idiomatic expressions are an important aspect of their representation and processing, regardless of the degree of embodiment. In addition, since some idioms are most likely either not or very weakly embodied, with their meaning mainly consisting of amodal linguistic symbols (e.g., u et al.  LanguageIn conclusion, the present findings show that the process of embodying idioms simply by engaging in the corresponding actions can activate their meaning enough to significantly influence subsequent processing and judgments. This study therefore makes an important contribution to the mixed results in the literature by suggesting that the representation and processing of idiomatic meaning may be more grounded in sensorimotor experiences than previously thought, providing further support for the fundamental importance of embodiment in language comprehension and cognition. Since the current research was limited to a small number of stimuli, it will be up to future studies to investigate a larger and more variable set of idioms to determine the reliability and validity of these results. In spite of this limitation, it is our hope that the relatively novel approach, interesting findings, and proposed account in terms of the HMNS, will stimulate further research along these lines to more thoroughly understand how idioms are represented and processed, particularly with respect to their embodiment.The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.