Tracts with median housing age values before 1975 with a poverty level of 20% or more were considered to be neighborhoods with a high risk of exposure to deteriorating lead-based paint. We estimated multilevel models to examine the relationship between neighborhood housing age/poverty level and each dependent variable . The odds of adverse birth outcomes were significantly higher for mothers living in high-poverty neighborhoods with median housing built before the lead-based paint ban. Increased awareness of—and improved methods of alleviating— ubiquitous lead-based paint exposure in Texas may be necessary interventions for positive developmental trajectories of children. Allocating federal funds for place-based interventions, including universal lead paint mitigation, in older, high-poverty neighborhoods may reduce the disproportionate risk of adverse birth outcomes. The purpose of this study was to determine whether housing age in combination with neighborhood poverty, as a proxy for fetal exposure to heavy metal lead, is associated with adverse birth outcomes. We linked population-level birth certificate data for Black, Hispanic, White and Other women, stratified by nativity, from 2009–2011 in Texas ( Negative birth outcomes in the United States of America are common and consequential. In 2018, 1 out of every 10 infants was born preterm (less than 37 weeks), and 1 in 12 exhibited low birth weights . In receResearchers have investigated a number of potential causes for negative birth outcomes. Maternal infection, hypertension, pre-eclampsia, maternal stress, and multiple pregnancies are significant predictors of preterm birth and low birth weight, though this list is non-exhaustive ,7. Of inInhalation of lead from leaded gasoline was the primary source of elevated blood lead levels in the past, but exposure via gasoline plummeted after the U.S. ban on leaded gasoline . CurrentAlthough there is an indistinct relationship between many environmental metals and adverse birth outcomes, that is not the case for the relationship between lead exposure and adverse birth outcomes ,19,20. TDespite the relationships between ubiquitous lead exposure and adverse birth outcomes, studies looking at lead exposure from house paint have become less common since the ban on lead-based paint in the mid-1970s . HoweverHypothesis 1 (H1).Living in an older, high-poverty neighborhood increases the odds of preterm birth, low birth weight, and small-for-gestational age compared to living in a newer and/or low poverty neighborhood in Texas.Hypothesis 2 (H2).High-poverty neighborhoods with median housing built before the lead-based paint ban will be concentrated in rural areas.Hypothesis 3 (H3).The urban/rural status of a census tract will significantly moderate the relationship between at-risk neighborhoods and the odds of preterm birth, low birth weight, and small-for-gestational age.Hypothesis 4 (H4).There will be racial/ethnic disparities, extenuated by nativity status, in the prevalence of preterm birth, low birth weight, and small-for-gestational age for Black and Hispanic women compared to White women.In this study, we use population-level data from Texas to document associations between living in pre-1975 housing and high-poverty neighborhoods and negative birth outcomes. Furthermore, we present geospatial information on these neighborhoods. Our study is the first to link negative birth outcomes in Texas using comprehensive birth certificate data linked to geographic census tract-level housing and poverty data, and to examine racial/ethnic groups by nativity.n = 1,128,679) [n = 1,040,642).We obtained restricted individual-level birth certificate data from natality files for all singleton births to non-Hispanic Black, Hispanic, non-Hispanic Other, and non-Hispanic White women from 2009–2011 in Texas 128,679) . To arri,679 . ToCensus tract-level median housing age data were obtained from the American Community Survey, 2007–2011, and census tract-level poverty data were obtained from the American Community Survey, 2006–2010 ,30. TracWe linked individual-level birth certificate data to census tract-level data and ERS Rural–Urban Continuum Codes based on residential geocodes, provided with the birth certificate data from the Department of State Health Services. These mothers lived in 99.0% of census tracts in Texas , with an average of 200 mothers per tract (range = 1–1873). Nearly 97% of the census tracts had at least 30 births, indicating substantial clustering by census tract.Our dependent variables were preterm birth, low birth weight, and small-for-gestational age. The three dependent variables were each binary coded into 0 and 1, with 1 indicating the presence of preterm birth, low birth weight, or small-for-gestational age. Preterm birth was defined as fewer than 37 weeks gestation, low birth weight was defined as <2500 g, and small-for-gestational age was defined as <10th percentile of birth weight-for-gestational age using published national reference guidelines . Other iThe median housing age at the tract level was first coded into a dichotomous variable, with 1 as a median age before 1975 and 0 as a median age of 1975 or after. Next, census tract poverty level, representing the percentage of census tract residents living below the federal poverty line, was divided using the American Community Survey cutoff score for census tracts designated as “poverty areas”  . Then, tUrban and rural status for neighborhood tracts was created from the ERS Rural–Urban Continuum Codes for counties across Texas. The county codes are available in three metropolitan groupings  and six non-metropolitan groupings , resulting in a nine-part county classification. Census tracts were matched with their corresponding counties and then the codes were dichotomized into metropolitan and non-metropolitan based on the two metropolitan and non-metropolitan groupings provided by ERS. Tracts coded as 1 were considered urban (comprised of the three metropolitan codes) and tracts coded as 0 were considered rural (comprised of the six non-metropolitan codes).00 = 0.04 to 0.05, p < 0.0001). Although the ICCs are low, high clustering and significant variance between neighborhoods implied that our decision to use multilevel modeling was appropriate. The confidence level was set at 95% (p < 0.05) to determine the statistical significance. We first examined the distribution of the variables and prevalence of the dependent variables  overall and by individual-level characteristics and neighborhood-level housing age with and without poverty level. Next, we examined preterm birth stratified by housing age/poverty level and race/ethnicity/nativity. Finally, we estimated three sets of hierarchical generalized linear models (HGLM) to examine the relationship between neighborhood housing age and each dependent variable. Multilevel models were built sequentially: (a) bivariate models, (b) a demographic model, (c) a full model, and (d) an interaction model. The HGLM was estimated using Laplace based on a binomial distribution and logit link function which allowed us to assess model fit by examining the change in the negative two log-likelihood (-2LL) between models and comparing AIC and BIC values [The pseudo intra-class correlations (ICC) were 1.1–1.5%, depending on the birth outcome, and the variances between neighborhoods were all significant . Stratified by nativity status, about 33% of births were to U.S.-born White mothers and about 10% were to U.S.-born Black mothers. There were very few births to immigrant Black or White women and 80% of births to “Other” race/ethnicity were immigrants (and likely to be mostly women of Asian descent given Texas demographics). About 58% of the births were to unmarried women, and about 40% were first births. About 52% of the women had a high school degree or less education, and approximately 22% were college graduates. About 15% of the births were missing father’s education, and about 46% of the fathers had a high school degree or less education. About 39% of the women started prenatal care after the first trimester  or had no prenatal care, 66% of them lived in neighborhoods classified as urban, about 32% of them lived in neighborhoods where the median age of housing was before 1975, about 39% of them lived in neighborhoods where the poverty level was 20% or higher, and about 20% of them lived in neighborhoods where the median age of housing was before 1975 and the poverty level was 20% or higher .Ten percent of births were classified as preterm birth, 7% were low birth weight, and 11% were small-for-gestational age. The prevalence of adverse birth outcomes was highest for 11-to-19-years-old mothers, Black U.S.-born mothers, unmarried mothers, parents who were less educated (or missing information on father’s education), mothers with delayed or no prenatal care, mothers living in rural neighborhoods, mothers living in neighborhoods with older housing, mothers living in neighborhoods with a poverty level of 20% or higher, and mothers living in at-risk neighborhoods (both older housing and a poverty level of 20% or higher). The prevalence of adverse birth outcomes was lowest among White immigrant mothers, married mothers, parents who were college graduates, mothers without delayed/no prenatal care, mothers living in urban neighborhoods, mothers living in neighborhoods with newer housing (1975 or newer), mothers living in neighborhoods with a poverty level less than 20%, and mothers living in neighborhoods with newer housing and/or a poverty level less than 20%. The lowest prevalence of adverse birth outcomes differed among age groups, with preterm birth and low birth weight being lowest for 20-to-34-years-old mothers, and small-for-gestational age being lowest for mothers aged 35 or higher. The prevalence of birth outcomes varied by parity status where preterm birth was most prevalent for mothers with five or more births, whereas low birth weight and small-for-gestational age were most prevalent for mothers with their first births.In support of the primary hypothesis, the odds of giving birth to a preterm, low-birth-weight, or small-for-gestational-age infant were all significantly higher for Texas mothers living in areas with greater concentrations of housing built before the ban on lead-based paint with high neighborhood poverty from 2009 to 2011. Individual-level sociodemographic characteristics explained much of the variation in the odds of experiencing negative birth outcomes, especially mothers’ race/ethnicity/nativity, but could not fully diminish the association between living in an at-risk neighborhood and inauspicious births.Many studies document the relationship between heavy metal lead and increased risk of adverse birth outcomes ,20,21,22The secondary hypothesis, that Texas rural areas would have more at-risk neighborhoods than urban neighborhoods, was not supported by the study results. Instead, across the state of Texas, high-poverty neighborhoods with median housing built before the ban on lead-based paint (at-risk neighborhoods) were concentrated in urban census tracts. This coincides with previous literature on other states. For example, one study in South Carolina found a higher prevalence of blood lead levels in urban areas and that older housing age is a major factor in increasing blood lead levels . In thisThe third hypothesis, that the urban/rural status of a census tract would moderate the relationship between at-risk neighborhoods and the odds of the adverse birth outcomes, was not supported. These study findings may indicate that older, high-poverty neighborhoods have higher risk regardless of urban/rural status, or perhaps that other structural patterns exist. The geospatial analysis of at-risk neighborhoods often matched maps of historically redlined neighborhoods in major Texas cities. Given that historical redlining is associated with higher rates of preterm birth in cities such as New York City , the potIn support of the final hypothesis, U.S.-born Black mothers had the highest risk for all of the adverse birth outcomes compared to U.S.-born White mothers, and U.S.-born Hispanic women also had higher risk compared to U.S.-born White mothers; these findings add support to a growing body of literature that highlights structural racism as a key determinant in birth outcomes . Racial Since a large portion  of the population resided in at-risk neighborhoods, the primary implication is support for place-based interventions that reduce poverty and inequalities in the built environment, particularly for high poverty neighborhoods with median housing age built before the ban on lead-based paint. First, further examination of environmental factors, including the presence of lead-based paint, lead-contaminated water, pollution, and other known correlates of adverse birth outcomes can identify the best points of intervention for the individual at-risk neighborhoods ,18,52. ORehabilitation efforts have been implemented across cities in the U.S.A. to decrease exposure to lead . For exaThe racial/ethnic/nativity disparities in adverse birth outcomes and the overlap of urban at-risk neighborhoods with historically redlined neighborhoods may indicate that funding for place-based interventions should especially be allocated to older, high-poverty communities of color. In Texas, addressing structural racism in low-income historically redlined neighborhoods may mean allocating funding to mitigate existing environmental injustices linked to adverse birth outcomes, including air pollution, and lead-contaminated water . FurtherOther pathways, such as risks associated with structural racism  , may alsCurrently, the regulatory body in charge of monitoring lead levels in the U.S.A. is the Environmental Protection Agency, which directs its lead-monitoring and enforcement efforts through its office of Enforcement and Compliance Assurance. Most of the strength of the agency and office is exercised through the Lead Renovation, Repair, and Painting rule (LRRP) , which rWhile notifying potential residents of the presence of lead and regulating building renovations may lessen some lead exposure, these sources of mitigation will mostly benefit individuals and families who possess the resources to have choices when deciding where to live, and those who can afford to live in renovated properties. Ideally, federal funds would be set aside to institute a universal lead paint testing program for older buildings and to properly contain the lead in affected buildings.This study is limited by short-term, cross-sectional, census-tract level housing and poverty data, as well as a limited set of socioeconomic factors. Longitudinal studies using individual-level housing characteristic indicators are needed to obtain more precise estimates of the association between living in pre-lead-ban housing and adverse birth outcomes. Despite these limitations, this study is bolstered by a large, population-level sample of over 1 million births; utilization of all eligible birth certificate data in Texas; comparison by nativity for Hispanic, Black, and White mother subgroups; objective measures of birth outcomes from the birth certificate data; objective rather than subjective median housing age and poverty level for census tracts; an appropriate multilevel modeling strategy; and fairly recent data.This study adds to the evidence that housing age in combination with neighborhood poverty is still a significant predictor of adverse birth outcomes; areas with older median housing ages and high poverty appear to be most at risk of these birth disparities. More broadly, findings identify older housing and high-poverty neighborhoods as potential structural determinants of adverse birth outcomes. Additionally, structural racism likely plays an important factor as U.S.-born Black and Hispanic women face disproportionate odds of these adverse birth outcomes compared to U.S.-born White women. Furthermore, poor families, families living in high-poverty neighborhoods, residents in older neighborhoods within urban or historically segregated areas, U.S.-born Black and Hispanic mothers, and those subject to other choice-limiting vulnerabilities will likely continue to face disproportionate rates of adverse birth outcomes without place-based interventions.This study points to the need for increased awareness of the prevalence of lead-based paint in older, high-poverty neighborhoods in Texas and broadly across the U.S.A. Despite the ban on lead-based paint, the measure of risk of exposure to lead was associated with increased adverse birth outcomes. Integrated surveillance of housing characteristics, neighborhood poverty, sociodemographic characteristics of mothers, and birth outcomes will be critical for future investigations of whether living in low-income neighborhoods and older housing plays a lasting role in children’s developmental trajectories.


Globally, Low Birth Weight (LBW) prevalence is estimated to be 14.6%. It is a major cause of neonatal mortality in developing countries including Ethiopia. Despite extensive institution-based studies in Ethiopia, there is no comprehensive study using countrywide data. Thus, this study aimed to investigate trends and determinants of Small Birth Weight (SBW) among under-five children in Ethiopia.Under-five children data from 2000, 2005, 2011, and 2016 Ethiopian Demographic and Health Surveys (EDHS) were used. However, only 2787 children were weighed at birth and used for analysis in this study. Descriptive statistics and the logistic regression model were used to determine trends and determinants of SBW respectively.The prevalence of SBW increased from 7.0%  to 13.2%  between 2000 and 2016. The odds of SBW increased by being a female child , mother's with partner occupation of agriculture  and mothers who did not know their partner's occupation . However, infants born to mothers with primary , secondary  and higher  educational status versus no education and grandmultiparous mothers  versus primiparous had lower odds of SBW.In Ethiopia, during the survey period, there was an increment in prevalence of SBW, and maternal related factors were significant determinants. Therefore, empowering mothers through education and improving the socioeconomic status of the household can be one strategy to reduce SBW. Low Birth Weight (LBW) is defined as weight at birth of less than 2,500 grams (5.5 pounds). At birth, the weight of the baby can be low either due to preterm birth or fetal restricted intrauterine growth ,2. A babLBW can predict the child's health throughout life and may result in a wide range of chronic diseases in future life such as ischemic heart disease, stroke, hypertension, diabetes, metabolic syndrome, malignancies, dementia, osteoarthritis, and poor cognitive development –9. BesidGlobally, in 2015 an estimated 20.5 million live births were LBW with a prevalence of 14.6%. However, a considerable variation was observed across regions and within countries on the prevalence, and 91% of the number is contributed by low- and middle-income countries, mainly Southern Asia (48%) and sub-Saharan Africa (24%) ,13.LBW can be caused by both direct factors related to pregnancy complications and indirect factors such as economic development . StudiesLBW is a key indicator of progress towards global nutrition target achievement set by WHO to reduce LBW by 30% in 2025. Therefore, monitoring LBW trend is an essential component of the Global Nutrition Monitoring Framework approved by member states at the World Health Assembly (WHA) in 2015 ,17. AlthIn Ethiopia, including the national survey, there is variation in prevalence of LBW between 9.9% to 28.3%(18–21). However, majority of the studies conducted were facility-based and no study reported about trends of LBW from nationally representative data. Thus, this study planned to investigate trends and determinants of small birth weight among under-five children in Ethiopia from nationally representative data. So, the finding of the study will be able to provide effective health policies to reduce infant mortality and change the directions of interventions.Ethiopian Demographic and Health Survey (EDHS) is a nationally representative cross-sectional survey conducted every five years. In Ethiopia, the first Demographic and Health Survey (DHS) was conducted in 2000 and consequently, in 2005, 2011, and 2016. In the survey, a stratified, two-stage cluster design was used to select a sample. Each region was stratified into urban and rural areas. In the first stage, samples of Enumeration Areas (EAs) were selected independently in each sampling stratum with probability proportional to EA size. In the second stage of selection, households per cluster were selected. Details of sampling design have been mentioned elsewhere ,23.www.dhsprogram.com after a written request explaining the purpose of the study was communicated.Different sets of validated questionnaires containing different unit of analysis were used to collect information from different levels. Those questionnaires were eventually converted into different datasets. In this study, childrecode dataset which contained information about all children who born in the previous five years preceding the survey was used. During the four-survey period from the total births recorded, only 2787 children were weighed at birth and used for analysis in this study. The 2000, 2005, 2011, and 2016 EDHS data were used for trend analysis and the recent, 2016, EDHS data was used for determinants study. These data was obtained from the DHS data website at The following operational definitions are used for this study.Outcome variable: In this study, birth weight of the infant was the outcome variable and classified into normal if weight is greater than or equal to 2500 grams, and SBW if below 2500 grams.Explanatory variables: The explanatory variables included in the study were selected based on epidemiological information, prior studies, a review of the relevant published demographic studies, and the available information in the DHS datasets  group; did not work, agricultural, and don't know.Wealth index was a composite indicator of a household's economic status which was used by DHS surveys globally . EDHS caParity was derived from total children ever born to the mother and categorized into (i) primiparous, (ii) multiparous (2–5), and (iii) grand multiparous (>5).The number of Antenatal Care (ANC) visits was a continuous variable and categorized based on the minimum WHO antenatal visit recommendation: No ANC visit, 1–4 visits, and more than 4 visits.Yes”, if she took at least for one day, and “No” if no iron supplement was used during pregnancy.Maternal history of taking iron supplements during pregnancy was derived from the number of days a mother took the pills and categorized into “Birth order was categorized into three categories: (i) first, (ii) second or third, and (iii) fourth and above. Birth interval was categorized into (i) no birth interval for primiparous mother and (ii) less than 24 months and (iii) greater than or equal to 24 months for multiparous mother.Statistical analysis: Before any statistical analysis, standard EDHS sample weight was applied on the data to account for the unequal probability of selection in the sample and nonresponse. The weighting variable used was women's individual sample weight since the study unit of analysis was women. Descriptive analysis and line graphs were performed to examine trends of SBW. Due to their known high risk of SBW, multiple births were excluded from the analysis. Region, partner education, and history of taking iron supplements during pregnancy were excluded from determinant analysis due to small cases per cell. Backward stepwise regression method was used for model building. To identify candidate variables, bivariate logistic regression at p-value <0.05 was considered, and those variables significant on bivariate analysis were further examined using multiple logistic regression. P-value <0.05 and confidence interval were used to declare the significance of the variable. Model fitness was checked by Hosmer and Lemeshow test, and the result  indicated that the model is a good fit. The statistical analysis was conducted by using IBM SPSS statistics version 20. All figures and tables in the report depict weighted percentages.Ethics: Ethical clearance for the EDHS was provided by the Ethiopia Health and Nutrition Research Institute (EHNRI) Review Board, the National Research Ethics Review Committee (NRERC) at the Ministry of Science and Technology, the Institutional Review Board of ICF International, and the United States Centers for Disease Control and Prevention (CDC). For this specific analysis, the data was requested; the analysis was approved and permitted.Population characteristics: During the four survey periods, a total of 46,318 births were recorded in Ethiopia. Five years prior to each survey in 2000, 2005, 2011, and 2016; 12, 260, 11,163, 11,872 and 11,023 live births was born respectively. From the total births recorded, only 2787 children was weighed at birth, and information about birth weight was obtained either from maternal recall or health card. Based on the source of birth weight information, only 29 (0.2%) in 2000, 49(0.4%) in 2005, 52(0.4%) in 2011 and 109(1.0%) in 2016 was obtained from written card.Socio-demographic and Economic characteristics: Variations in the occurrence of SBW were observed among nine regions and two administrative towns of Ethiopia. Across regions, there is an increment in the number of cases from time to time. In Afar, Benishangul Gumuz, and Harari regions, there is no reported SBW baby in 2000 and 2005 EDHS. During 2016, relatively more cases were reported in all regions and the three top regions with SBW were Afar (28.6%), Amhara (22.4%), and Southern Nation and Nationalities (13.2%) ( (13.2%) .Though there is variation in the number of SBW across maternal educational status, SBW most commonly occurs among mothers who did not attend any formal education. During 2000, 2005, 2011, and 2016 EDHS, respectively 11.1%, 27.7%, 13.5%, and 18.2% of SBW were born to mothers who did not attend any education. Similarly, 9.2%, 17.4%, and 20.2% of SBW babies were reported from mothers whose occupation was agriculture in 2000, 2005, and 2016 EDHS respectively .Partner educational status and occupation are the other important variables for SBW. According to EDHS 2005, 2011 and 2016 SBW is more common among mothers whose partners did not attend any education, and there is no trend between the prevalence of SBW and educational status. Regarding partner occupation, in 2000 and 2005; 9.1% and 16.4% of SBW babies respectively born to mothers whose partners' occupation was agriculture. However, surprisingly in 2016, 40% of SBW babies were born to mothers who did not know their partners' occupation .Maternal obstetrics and child characteristics: Prevalence of SBW increased from time to time based on maternal age at first birth, and the prevalence is more common among youngsters. In 2016, 14.9% of SBW occurred among mothers in the age group of 20 to 29 years  and (8.9%). However, during the 2011 and 2016 survey period, SBW was greater in those with birth intervals less than 24 months compared to those whose birth intervals were greater than or equal to 24 months .Trends of small birth weight: The number of SBW infants increased from 22 in 2000 to 198 in 2016. The prevalences of SBW were 7.0% , 13.5% , 10.8% , and 13.2%  in 2000, 2005, 2011 and 2016 respectively , secondary  and higher  educational level were less likely to have SBW infants compared to those who did not attend any education. Mothers whose partners' occupation was agriculture  and who did not know their partners' occupation  were more likely to deliver SBW infants compared to mothers whose partners participated in paid work. The odds of having SBW infant were less likely in grand multiparous mothers  compared to primiparous mothers. Female infants were more likely  to be SBW compared to male infants .LBW is a major public health problem worldwide especially in developing countries including Ethiopia. It is a major contributor to adverse pregnancy outcomes ,15. TherIn Ethiopia, the prevalence of SBW was increasing except slight reduction from 2005 to 2011. This national prevalence of SBW in 2016 was below that of Bangladesh (20%). This miEducational status was one of SBW determinants. In this study, mothers who attended primary, secondary, and higher educational levels less likely deliver SBW babies compared to illiterate mothers. This finding is consistent with a study conducted in Cambodia using DHS data, further analysis of 2011 EDHS, and cohort studies conducted in southern Ethiopia –29. HaviBesides, in developing countries deprivation of socio-economic status including educational status, occupation and others are risk factors for SBW ,7,30. ThIn this study, partner occupation is the other determinants for SBW. Mothers who do not know their partners' occupation and those whose partner occupation was agriculture were more likely to experience SBW. Evidence suggests that individual-level socioeconomic status (SES) is a risk factor for Small for Gestation Age (SGA) births, and low SES influence the risk of SGA birth due to residential, lifestyle, or occupational-related exposure to harmful agents ,34. AvaiNewborn sex had gestational age-independent effects on birth weight, and female neonates had lower average birth weights than male neonates at each specific week of gestation ,38. SimiMaternal parity is one of the well-known predictors of infant birth weight; the lowest birth weights were found in infants born to primiparous women . Also, iGenerally, in Ethiopia, SBW prevalence is increasing and maternal education, partner occupation, parity, and sex of the baby were determinants for SBW. Therefore, there is a need to empower mothers through education which might indirectly contribute to the reduction of SBW by improving household economic status.As a limitation, only factors that were found on the data were retrieved and the analysis was not controlled for other genetic or biological factors. Thus, given that the etiology of SBW is complex, further research is required to address the interaction of genetic or biological factors with social and environmental factors.In addition, possible biases like social desirability bias due to sensitiveness of the issues, recall bias due to longer recall time and measurement bias because of obtaining birth weight data from maternal subjective evaluation during the survey might affect the study finding.


This study aimed to derive a maternal dietary pattern to explain the variation in B vitamins during pregnancy and to investigate this pattern in relation to birth outcomes. A total of 7347 women who gave birth to live newborns less than one year were included. Their dietary pattern during pregnancy was derived using the reduced-rank regression method with six B vitamins as response variables. Associations between dietary pattern score and birth weight, gestational age at delivery, birth weight Z score, low birth weight, preterm, and small-for-gestational-age (SGA) were estimated using generalised linear mixed models. We identified a high B-vitamin dietary pattern characterised by high intakes of animal foods, vegetables, fungi and algae, legumes, and low intakes of oils and cereals. Women in the highest quartile of this pattern score had newborns with a 44.5 g  higher birth weight, 0.101  higher birth weight Z score, and 27.2%  lower risk of SGA than those in the lowest quartile. Our study suggested that adherence to the high B-vitamin dietary pattern during pregnancy was associated with a higher birth weight and a lower risk of SGA. Birth outcomes, which commonly refer to birth weight and gestational age, are not only closely related to the morbidity and mortality of infants and young children ,2, but aThe aetiology of most types of adverse birth outcomes is complex. As a modifiable risk factor, maternal nutrition during pregnancy has been widely discussed for its potential to prevent adverse birth outcomes . B vitamRecent nutritional epidemiological studies have shifted the focus from single nutrients to dietary patterns, which describe the overall diet and better reflect the interactive or synergistic effects of different nutrients . Of noteTherefore, based on the cross-sectional data in northwest China, we aimed to identify a maternal dietary pattern that maximally explains the variation in B vitamins using the RRR method. Furthermore, we sought to assess the associations of this pattern with birth outcomes after controlling for covariates.n = 87) or implausible energy intake (<4500 or >20000 kJ/d) (n = 316) [The present study used data from a cross-sectional study conducted in Shaanxi Province of northwest China. The design and methodology of the cross-sectional study have been described previously in detail ,20. Brien = 316) . ConsequThe dietary intakes during pregnancy were estimated retrospectively using a semi-quantitative food frequency questionnaire (FFQ). Since dietary intakes did not change to a great extent throughout pregnancy ,23,24, aNeonatal outcomes, including sex, gestational age at birth, and birth weight were obtained from the Medical Certificate of Birth. Birth weight was measured to the nearest 10 g. Gestational age at birth was the number of weeks from the first day of the last menstrual period to the date of delivery. The sex- and gestational age-adjusted birth weight Z score was calculated based on the International Fetal and Newborn Growth Consortium for the 21st Century (INTERGROWTH-21st) standards . LBW refThe covariates selected based on previous studies can be categorised as maternal socio-demographic characteristics and health-related behaviours during pregnancy ,35,36. SMaternal dietary pattern during pregnancy was obtained by the reduced rank regression (RRR) method using the PLS procedure in SAS . Before n (%) and means ± SDs, respectively. Linear trends across the quartiles of dietary pattern score were estimated using Cochran-Armitage tests for maternal characteristics and univariate linear regression models for nutrient intakes. Given the significant within-group homogeneity for most birth outcomes at the county level, the generalised linear mixed model with a random intercept at the county level was employed to estimate the associations of maternal dietary pattern score with birth outcomes. The dietary pattern score was analysed both as a continuous variable (per 1-SD increase) and a categorised variable (the lowest quartile as the reference). To assess the robustness of these associations, a total of three models were constructed in sequence. Model 1 included no covariates. Model 2 included socio-demographic characteristics. Model 3 included all covariates in Model 2 plus health-related behaviours. The link functions of continuous and binary dependent variables were “identity” and “logit”, separately. Linear trends for birth outcomes across the quartiles of dietary pattern score were assessed by putting the quartile number into models as an ordinal variable. Since multivitamins usually contain B vitamins, stratified analyses by folic acid and multivitamin supplementation were performed to test whether these supplements modified the associations of dietary pattern score with birth outcomes. Potential effect modifications were examined by including interaction terms in the fully adjusted models.Binary and continuous variables were presented as p < 0.05 was considered statistically significant.All statistical analyses were performed using SAS software . A two-sided A total of six RRR factors were identified. The first RRR factor explained 42.27% of thiamin, 68.34% of riboflavin, 20.92% of niacin, 59.00% of vitamin B6, 56.16% of folate, 41.50% of vitamin B12, and 48.03% of the total variation of six B vitamins. The subsequent five RRR factors explained only 12.73%, 4.71%, 1.67%, 1.45%, and 1.01% of the total variation, separately. Therefore, only the first RRR factor was regarded as the dietary pattern of interest. Since the dietary pattern score was moderately to highly positively correlated with the intakes of six B vitamins , this paThe factor loading values of the food groups in the high B-vitamin dietary pattern are shown in Maternal socio-demographic characteristics and health-related behaviours differed by quartiles of the high B-vitamin dietary pattern score . Women iptrend = 0.012) higher birth weight, 0.101  higher birth weight Z score, and 27.2%  lower risk of SGA.Associations of the high B-vitamin dietary pattern score with birth outcomes are presented in Pinteraction = 0.056). Among the women who did not use multivitamins, per 1-SD increase in the high B-vitamin dietary pattern score was related to 14.2%  lower risk of SGA. In contrast, the association was not significant among users (p > 0.05)  .This population-based study conducted in northwest China identified a high B-vitamin dietary pattern, which was characterised by high intakes of animal foods, vegetables, fungi and algae, legumes, and low intakes of oils and cereals. A higher score for the dietary pattern corresponded to higher birth weight and Z score as well as a lower risk of SGA.To our knowledge, only one other study examined the associations of maternal dietary patterns characterised by B vitamins with neonatal outcomes . In a moIn the present study, it seemed that the high B-vitamins dietary pattern exerted protective effects against SGA only among pregnant women who did not take multivitamins. A plausible explanation for this finding was that multivitamins provided adequate B vitamins to meet the needs of fetal growth. Owing to the variation in the brands of multivitamins, the content of B vitamins in supplements cannot be directly compared with the dietary pattern. Based on a double-blind randomised controlled trial in rural Shaanxi Province, we previously reported that antenatal multiple micronutrients with a recommended allowance of B vitamins resulted in a 44 g increase in birth weight and a 0.19 week increase in gestational age in comparison with folic acid alone . OverallThis study found that neither the continuous nor binary variable of gestational age was relevant to the high B-vitamin dietary pattern. On the contrary, birth weight-related outcomes, including crude birth weight, gestational age- and sex-specific birth weight, and SGA, were all associated with the high B-vitamin dietary pattern. These results suggest that birth weight rather than length of gestation is susceptible to the dietary pattern. Birth weight is the most widely used anthropometric indicator for newborns, in which an increase indicates the promotion of growth and development . In 2012Mechanisms that relate antenatal B vitamins and birth weight are still unclear. Almost all B vitamins are involved in one-carbon metabolism and related pathways. Folate is the main carrier of one-carbon units, while riboflavin, vitamin B6, and vitamin B12 act as essential cofactors or precursors of key enzymes . ImportaIt is noteworthy that although our dietary pattern was driven by the variability of B vitamins, the highest quartile was accompanied by the highest intakes of other nutrients, such as protein, vitamin A, vitamin C, calcium, and zinc. We cannot exclude the potential effects of these nutrients on birth weight. Rather than single out individual nutrients that could account for the benefits of the dietary pattern studied, it may be more realistic to explore the synergy of multiple nutrients or food groups.The present study has some strengths. First, because of the stratified multistage random sampling method, our findings can be generalised to the whole Shaanxi Province. Second, in contrast with previous studies that investigated the role of individual B vitamins in neonatal outcomes, our study explored the beneficial effect of the B vitamins-related dietary pattern using the RRR method, which provides a better foundation for the development of dietary recommendations for pregnant women. Nevertheless, several limitations should be noted. First, temporality and causality cannot be demonstrated from this cross-sectional study. Second, residual confounding cannot be ruled out due to unmeasured or unknown socio-demographic or health-related factors. Third, women were asked to recall pregnancy characteristics within 0–12 months after delivery in our study. Although many studies have shown that pregnancy is a major event during which many features can be recalled well even after years ,52, the In the cross-sectional study in northwest China, we derived a maternal dietary pattern that was rich in B vitamins using the RRR method and found that greater adherence to this dietary pattern during pregnancy was related to higher birth weight and a lower risk of SGA. Based on these findings, obstetricians should pay more attention to the B-vitamin status of pregnant women and advise women to increase the proportion of animal foods, vegetables, fungi and algae, and legumes in their diets to prevent adverse birth outcomes.


Leymus chinensis) was superior in terms of rumen degradability characteristics, chemical composition and feeding value.Limited studies have been reported so far on the rumen degradability characteristic of low-quality forage. In the current study, three low-quality forages  were selected. Various nutritional parameters such as rumen degradation characteristics, chemical composition and feeding value of three roughages were studied in detail. Among the three roughages, the Chinese rye grass (p < 0.001) than in the BG. The effective degradability (ED) values of NDF were the highest in the CRG and lowest in the NO (p < 0.001). In addition, the ED values of ADF were the highest in the CRG and lowest in the BG (p < 0.001). The ED value of CP in the CRG was significantly higher than that in the BG and NO (p < 0.001). The estimated total digestible nutrients (TDN) (54.56%) and DM degradation rate (DDM) (60.06%) of the CRG were higher than those of BG and NO. In addition, the expected DM intake (DMI), estimated relative feed value (RFV), and estimated relative feed quality (RFQ) of the BG were lower than those of the CRG and NO. Altogether, based on our findings, we concluded that the nutritional quality, feeding value and effective rumen degradation rate of CRG were better than of BG and NO.The current study was designed to investigate the chemical composition, rumen degradation characteristics, and feeding value of three roughages commonly used in Asia as ruminant feed, including Chinese rye grass (CRG), barley grass (BG), and naked oat straw (NO). Four Holstein Friesian cows equipped with permanent rumen fistulas were chosen for experimental trials in the current study. The nylon bag method was carried out to measure the crude protein (CP), acid detergent fiber (ADF), ruminal degradability of dry matter (DM), and neutral detergent fiber (NDF). Our analysis revealed that the contents of CP in the CRG (9.0%) and BG (8.9%) were higher than in the NO (5.94%). The contents of NDF in the CRG (64.97%) and NO (63.83%) were lower than in the BG (67.33%), and the content of ADF in the CRG (37.03%) was lower than in the BG (37.93%) and NO (38.28%). The ED values of DM in the NO and CRG were significantly higher ( The CRG is widely distributed in the eastern Inner Mongolian plateau and Songnen plain in China [Urtica cannabina L. and CRG at the rate of 50:50 had shown greater in vitro digestibility of neutral detergent fiber (NDF) than at the ratio of 0:100, 30:70, 70:30, and 100:0 [High-quality forage is essential for the production performance and health of ruminants . At presin China . The feein China ,5,6. Thend 100:0 . Conseqund 100:0 , while 3nd 100:0 . The palHordeum violaceum Boiss) mainly grows in high altitude areas and is planted in two distinct seasons. A study reported that the content of CP in Barley grass (BG) was 5.8%, which is the protein level of low-quality roughage [Barley grass (roughage . Fay et roughage  demonstrroughage . Consistroughage . Consistroughage . At presroughage . TherefoAvena nuda L.) is an annual grass species native to China that is different from hull oat (Avena sativa L.) in terms of morphology and nutritional value. According to the survey by Food and Agriculture Organization in 2017, the annual production of naked oat straw (NO) was approximately 1.4 million tons in China [Naked oat  have been given in Four Holstein Friesian cows  equipped with permanent rumen fistulas were used to measure the ruminal degradability of nutrient of three forages by nylon bag method. The cow’s basic diet and nutrient levels are provided in Three different forage raw materials were selected, and each of forage was sampled in triplicate. Furthermore, the nine samples were oven-dried at 65 °C for 48 h to a constant weight to analyze the DM contents, and then ground in a hammer mill to pass a 1 mm sieve for chemical analysis. The crude protein (CP), crude ash (Ash), and starch content of the samples were analyzed using the procedures recommended by AOAC (1984) . The conThe nylon bag method  was perfAfter removal from the rumen, the nylon bags were rinsed quickly under the water to prevent fermentation. Consequently, the nylon bags were washed with tap water till the water ran clear. Furthermore, the nylon bags were oven-dried at 65 °C for 48 h to constant weight and regain moisture for 24 h and then ground using a ball mill to pass through a 1 mm screen. Then, they were thoroughly mixed, and the DM, CP, NDF, and ADF of samples were analyzed using the method previously described. The degradability value at time 0 was obtained by rinsing four bags per sample. The real-time degradation rate is calculated by the difference subtraction method, and the calculation formula is: the real-time degradation rate of a certain nutrient component of the feed sample (%) = 100 × (the nutrient content before degradation − the nutrient content after degradation)/the nutrient content before degradation.The degradation data were fitted to the following exponential equation : P = a +P is the nutrient disappearance rate in the rumen at a time “t”; “a” is a rapidly degradable fraction; “b” is the potentially degradable fraction; “c” is the constant rate of degradation of “b”(%/h); and “e” is the base of natural logarithms. “a + b” is the total degradable fraction. The NLIN program in SAS (9.2) was used to calculate the values of a, b, and c. Each cow is regarded as a duplicate; there were two parallel bags in each cow.Then, the effective degradability (ED) of DM, CP, NDF, and ADF of forage samples were calculated by applying the following equation :ED(%) = s 3.1%/h . The NLIThe quality and expected feed intake of roughage—RFV% = DMI × DDM/1.29—was measured according to the relative value of roughage . The uniData on chemical composition and feed value were analyzed by mean value. Real-time degradability was analyzed using repeated measure data of a MIXED procedure of SAS (9.2) with the model (1).p < 0.05. Differences among the three forages were evaluated using a multiple comparison test following the Tukey–Kramer method.For all statistical analyses, significance was declared at The chemical compositions of the three forages are shown in p < 0.001) higher than of the CRG at 4 h, 8 h, 12 h, 24 h, and 36 h in rumen (p < 0.001) and 48 h (p = 0.002) in the BG was highest. The rapidly degradable fraction (a) of the BG was significantly higher (p < 0.001) than of the CRG and NO, and no difference was found between the CRG and NO (p > 0.05). The constant rate (c) (p = 0.005) of the potentially degradable fraction and the potentially degradable fraction (b) (p < 0.001) of DM in the BG was significantly lower than in the CRG and NO. The effective DM degradation (ED) of the BG forage was lowest (p < 0.001) compared with the CRG and NO, and there was no significant difference (p > 0.05) between the CRG and NO.The DM degradations of the BG and NO were significantly (in rumen . All thep < 0.001) compared to BG and NO (p = 0.031) and 48 h (p < 0.001) in the CRG and BG was significantly higher than in the NO, and no difference was found between the CRG and BG (p > 0.05). The NDF degradation of 72 h in the BG was highest (p < 0.001) compared to the CRG and NO. Compared with the CRG and NO, the potentially degradable fraction (b) of NDF in the BG was highest (p < 0.001). The constant rate (c) of potentially degradable fraction (b) of NDF in the CRG and NO were significantly higher (p = 0.01) than in the BG, and no difference was found between the CRG and NO. The effective NDF degradation (ED) was the highest in the CRG and lowest in the NO (p < 0.001)The NDF degradation at 8 h, 12 h, and 24 h in the CRG was the highest (G and NO . The NDFp < 0.05) than in the BG and NO (p > 0.05). The ADF degradation of 30 h, 36 h, 48 h, and 72 h in the CRG and BG was significantly higher (p < 0.05) than in the NO, and no difference was found between the CRG and BG (p > 0.05). The ADF potentially degradable fraction (b) was the highest in the BG and lowest in the NO (p < 0.001). The effective ADF degradation (ED) was the highest in the CRG and lowest in the BG (p < 0.001).The ADF degradation at 4 h, 12 h, and 24 h in the CRG was significantly higher  compared with the NO and BG (p < 0.001), and no difference was found between the CRG and NO (p > 0.05). The potentially degradable fraction (b) of CP in the CRG and BG was significantly higher (p = 0.002) than in the NO, and no difference was found between the CRG and BG (p > 0.05). The effective degradation (ED) of CP in the CRG was significantly higher (p < 0.001) than in the BG and NO, and no difference was found between the BG and NO (p > 0.05).The CP degradation at 4 h, 30 h, and 72 h in the CRG was the highest (O and BG . CompareThe TDN (54.56%) and DDM (60.06%) of the CRG were higher than of the BG  and NO . The DMI (1.78%), RFV (82.02%), and RFQ (78.09%) of the BG were lower than of the CRG  and NO . The estimated feeding value of three forages  has been summarized in Chinese rye grass (CRG) is an ideal pasture for grazing and hay production due to its good palatability, strong resistance to trampling, and high protein content . The CP The CP content in forage is the most limiting nutrient parameter , and somDry matter intake (DMI) is essential for dairy cows’ production performance. A critical factor affecting the DMI of dairy cows is the ruminal DM degradability, which is positively correlated with DMI . The rumFeed value was used to evaluate an important economic characteristic of roughage. The RFV  is a comprehensive reflection of NDF and ADF, and it was used to measure the quality of roughage. The RFV value and the nutritional value of the roughage were positively correlated. The RFV value of general high-quality roughage is assumed to be higher than 100 . In the Altogether we concluded that there were differences in the nutrient contents of the three forages. The CRG had the highest CP and the lowest NDF and ADF contents. At the same time, the CRG had the highest effective degradation rate of DM, NDF, ADF, and CP in the rumen, and the values of TDN and DDM were higher than those in the BG and NO. The RFV and RFQ of the CRG and NO straw were higher than of the BG. Based on the present study, the CRG had the highest ruminal degradability and is, therefore, a promising alternative to utilize for feeding high yielding dairy cows.


Background: Bronchopulmonary dysplasia (BPD) has multifactorial origins and is characterized by distorted physiological lung development. The impact of nutrition on the incidence of BPD is less studied so far.Methods: A retrospective single center analysis was performed on n = 207 preterm infants <1,000 g and <32 weeks of gestation without severe gastrointestinal complications to assess the impact of variations in nutritional supply during the first 2 weeks of life on the pulmonary outcome. Infants were grouped into no/mild and moderate/severe BPD to separate minor and major limitations in lung function.Results: After risk adjustment for gestational age, birth weight, sex, multiples, and antenatal steroids, a reduced total caloric intake and carbohydrate supply as the dominant energy source during the first 2 weeks of life prevailed statistically significant in infants developing moderate/severe BPD (p < 0.05). Enteral nutritional supply was increased at a slower rate with prolonged need for parenteral nutrition in the moderate/severe BPD group while breast milk provision and objective criteria of feeding intolerance were equally distributed in both groups.Conclusion: Early high caloric intake is correlated with a better pulmonary outcome in preterm infants <1,000 g. Our results are in line with the known strong impact of nutrient supply on somatic growth and psychomotor development. Our data encourage paying special attention to further decipher the ideal nutritional requirements for unrestricted lung development and promoting progressive enteral nutrition in the absence of objective criteria of feeding intolerance. Bronchopulmonary dysplasia (BPD) is a chronic lung disease of the preterm infant characterized by distorted physiological lung growth , 2. The Inflammatory processes in the immature lung caused by mechanical ventilation and oxygen toxicity are the main contributors to the disease . Pre- anThis gap of knowledge in the context of BPD pathogenesis is surprising, as the short-term benefits of high caloric nutritional supply on somatic growth and psychomotor development are reasonably well-established. Therefore, current nutritional guidelines and recommendations are mainly derived from the scientific data obtained for motor function measures and cognitive outcomes. The recommended high protein intake and the proper distribution of carbohydrates, proteins, and lipids reduce the risk for lifelong sequelae following preterm birth. The evaluation of lipid composition and adequate supply of micronutrients demonstrates the opportunity to further optimize nutritional supply and the effect size on these outcome measures , 18. On In our retrospective single center cohort study, we aimed to correlate the nutritional supply within the first 2 weeks of life and the occurrence of moderate/severe BPD in more than 200 preterm infants with a birth weight <1,000 g. Datasets were analyzed before and after risk adjustment for important clinical confounders. Further detailing of the nutritional supply was intended to specify the contribution of macronutrients and supplements with known impact on the preterm infant's outcomes.a priori power calculation was not performed. The aim was to correlate the nutritional supply and the pulmonary outcome. From n = 295 available patients, n = 88 preterm infants were excluded due to death before 36 weeks of gestation (n = 56), severe congenital malformation of the lung, heart, brain, gut, or kidneys (n = 9), presence of severe gastrointestinal complications of necrotizing enterocolitis  or focal intestinal perforation (n = 6), infection with cytomegalovirus (n = 1), and severe aspiration pneumonia (n = 1). Furthermore (n = 9) preterms had to be excluded due to the transfer to another NICU before 36 weeks (n = 6), outborn status (n = 2), or missing data (n = 1). We decided to exclude deaths that were mostly related to death in the delivery room (n = 10), death during unrestricted NICU therapy independent of the pulmonary status (n = 20), decision to cessation of NICU therapy independent of the pulmonary status (n = 18), and severe congenital malformations (n = 6), while only two deaths were due to respiratory failure during intensive care therapy . Furthermore, infants with NEC were excluded due to the high impact of NEC pathology on BPD.Based on the results from a population-based cohort study in 10 European regions including our region of Hesse, we focused on infants at highest risk for moderate/severe BPD with a birth weight <1,000 g and gestational age <32 + 0 weeks . NutritiThe study was conducted following the rules of the Declaration of Helsinki of 1975, revised in 2013, and was approved by the ethics committee of the Justus-Liebig-University Gießen (AZ 98/14).All parameters were obtained from the electronic data management systems and the paper file records. Data were entered into a SPSS Statistics databank version 23.0.0.3 for Microsoft Windows . Baseline maternal and infant parameters included gestational age, birth weight, sex, birth as singleton, or multiples, and antenatal steroid application. Percentiles for weight, length, and head circumference were derived from the German perinatal registry . Small f2O or higher was attained and the fraction of oxygen provided by nasal cannula was determined as published  did not fulfill any BPD criterion according to the NICHD consensus definition. The majority of n = 94 infants (45.4 %) was assigned to mild BPD which are known to have a lung function close to preterm infants not fulfilling the criteria of BPD (n = 63 infants with moderate or severe BPD and considerably restricted pulmonary outcome constituted about one third (30.4%) of the total cohort (p = 0.578) in-line with the published literature , the analyses did not reach statistical significance . In line, the enteral intake of calories, macronutrients and supplements tended to be higher in the no/mild BPD group, however without statistical significance . The durFinally, the observed differences in enteral supply between both groups were analyzed in the context of breast milk supply, milk fortification, and for the clinical item “feeding intolerance.” Rates of breast milk supply (49.3 vs. 47.6%) and milk fortification (72.2 vs. 71.4%) were equally distributed between both groups. The number of cases fulfilling the objective criterion of feeding intolerance on day 1 (22.2 vs. 20.5%) and within the first 14 days of life (97.9 vs. 100%) did not differ between the two groups, but enteral nutrition was paused more frequently in the moderate/severe BPD group .Taken together, the total energy supply during the first 2 weeks of life prevailed as the main criterion separating infants with better and worse pulmonary prognosis, and the detected differences in enteral nutrition were not due to objective criteria of feeding intolerance.Early and progressive enteral nutritional supply has beneficial effects on somatic growth and psychomotor development. Our results are in line with the sparse literature available on this topic in the context of BPD. Our retrospective analysis demonstrates that even slight differences in early nutritional supply during the first 2 weeks of life can have consequences for the lung. Lower total caloric intake can mainly be attributed to a lower increase in enteral nutrition. Of clinical importance, the overall slower increase in enteral nutrition in the moderate/severe BPD group was not hampered by objectifiable clinical criteria and the prevalence of documented feeding intolerances. Instead, the individual subscribers' subjective assessment of feeding tolerance without a documented objectifiable reason in the patient records was responsible for the differences in enteral nutritional supply. The trend toward increased total fluid intake observed in infants with no/mild BPD is probably due to the fluid volume required to achieve the higher caloric intake. In line with many publications, the immediate period after birth represents an especially vulnerable period for distortion of further lung development that cannot only be assigned to fetal predisposition, infections, mechanical ventilation, and oxygen toxicity , 35. Thep-value of p = 0.044. Vice versa, the slight differences in caloric intake of ~10% during the first 2 weeks of life encourage future studies to address the potential of an even more progressive nutritional approach. Fittingly, one recent study on this topic demonstrated the benefit of reaching a higher caloric intake even in week 3 and 4 of life . Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin.HE initiated the retrospective analysis. TT, AW, JN, SS, and TL collected the data, performed the validity data checks, and provided valuable intellectual contributions. TT and HE drafted the manuscript and prepared the figures and tables. K-PZ and GE revised the manuscript for important content. All authors have read and approved the final version of the manuscript.https://dzl.de/en/dzl-data-warehouse/).This work was supported by von-Behring-Röntgen Stiftung (63-0009) and Clinical Research Unit KFO 309-2. Datasets are deposited in the DZL data warehouse (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.


Spontaneous preterm birth is a global issue that contributed to perinatal morbidities and mortalities worldwide. The study aimed to describe the experience at UKM Medical Center in managing women at high risk for spontaneous preterm birth using the Arabin pessary.This is a retrospective observational study involving 58 pregnancies from 1st January 2013 to 31st December 2019. Inclusion criteria were previous mid-trimester miscarriage and/or preterm birth, previous cervical surgery or short cervical length on routine sonogram. The demographic data, characteristics of each pregnancy and details of outcomes and management were described.2 respectively. The most frequent indications for Arabin pessary insertion were previous mid-trimester miscarriage (46.4%) and early preterm birth (17.2%). A total of 73.4% of these women had the pessary inserted electively at a mean cervical length of 31.6 ± 9.1 mm at median gestation of 15.0 weeks. They were managed as outpatient (56.9%), inpatient (24.1%) or mixed (19.0%) with combination of progestogen (81.0%) and 53.4% received antenatal corticosteroids. Spontaneous preterm birth at or more than 34 weeks gestation occurred in 74.1% with birthweight at or more than 2000 g (82.4%). Despite cervical funneling in 12 women (20.7%), 66.7% delivered at or later than 34 weeks gestation and 2 (16.7%) resulted in miscarriage.The majority of women were Malay with mean age and body mass index of 32.9 ± 4.2 years and 27.1 ± 6.3 kg/mInsertion of the Arabin pessary is beneficial to prevent spontaneous preterm birth in pregnant women who are at high risk. In particular, early insertion and close monitoring allows the best possible outcomes.NCT04638023) on 20/11/2020.This study was retrospectively registered with ClinicalTrials.gov ( Preterm birth is defined by delivery before 37 completed weeks and is a major cause of perinatal morbidity and mortality . ConsequPreterm birth can either be iatrogenic due to severe preeclampsia and fetal growth restriction or spontaneous caused by vaginal infection, and cervical incompetence –9. SpontCervical insufficiency is a condition believed to be caused by congenital deficiency of collagen in the cervical tissue or from cervical trauma. Consequently, the cervix is unable to withstand the pressure from the growing fetus in utero causing the cervix to shorten and open creating a funnel. Traditionally cervical cerclage is recommended in this group of women based on either history alone and/or cervical assessment in the present pregnancy . HoweverThe aim of this study was to describe the experience of managing women who were at high risk for spontaneous preterm birth using Arabin pessary.This was a single tertiary center retrospective analysis which included 66 pregnancies that underwent Arabin pessary insertion  between 1st January 2013 until 31st December 2019 in UKM Medical Center. Ethics approval had been obtained through the Institutional Ethics and Research Board (FF-2017-372). No consent was required by the ethics committee as this was a retrospective study. Administrative permissions and/or licenses were not required by our team to access the data used in our research.+ 0 weeks or previous cervical surgery such as large loop excision of transformation zone (LLETZ) or loop electrosurgical excision procedure (LEEP) with their gestational age confirmed via dating scans in the first trimester. Patients were excluded if the details of the pregnancy were incomplete, had Arabin pessary inserted in other centers or delivered elsewhere.This study had been performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki. The women included in this study had singleton pregnancies who were high risk for spontaneous preterm birth based on previous spontaneous preterm birth before 34Patients who were identified to be high risk for spontaneous preterm birth based on the obstetrics history were identified. Screening for vaginal infections was performed by taking vaginal swab samples which were sent for microscopic, cultural and sensitivity analysis (HVS C&S). Women with candidosis were treated with antifungal pessary according to our routine protocol. If the diagnosis of cervical insufficiency was highly suggestive, the Arabin pessary was inserted electively at 14 to 16 weeks gestation regardless of the cervical length measurement. If the diagnosis of cervical incompetence was doubtful, the patients’ cervical length was monitored via transvaginal sonogram initiated from 14 weeks. It was performed every 2 weeks until 28 to 30 weeks gestation. The pessary was inserted if there was cervical length shortening irrespective of whether there were any symptoms. The decision to insert the pessary and subsequent management such as additional progestogen therapy, in- or out-patient management and antenatal corticosteroids were based on the attending obstetricians. The progestogen therapy was administered either parenterally (250 – 500 mg weekly) or vaginally (200 mg daily before bedtime) based on the physician’s choice. Transvaginal sonogram to measure the cervical length was performed using a 7-MHz transducer  according to the Fetal Medicine Foundation (FMF) guideline. All the patients were followed up 2 to 4 weekly after pessary insertion in the antenatal clinic until delivery. Progestogen therapy was stopped at 34 weeks gestation and Arabin pessary was removed at 36 weeks or more or when the patients were in established labor.All of the records were traced and scrutinized including the sociodemographic variables which consist of maternal age, race, pre-pregnancy body mass index (BMI), parity, number of miscarriages, indication for Arabin pessary insertion, and intervention for previous preterm birth. The clinical characteristics included cervical length and gestational age at insertion, presence of funnelling, whether pessary was inserted electively or as emergency, continuity of management post insertion as inpatient, outpatient or mixed, addition of progestogen therapy, presence of antenatal complications such as diabetes, hypertension, anemia, threatened preterm labor and preterm prelabor rupture of membranes, administration of corticosteroids, pathological smear and gestational age at removal. Primary outcome measured was birth at or more than 34 weeks gestation. Secondary outcome measured were type of labor, mode of delivery, neonatal birthweight and neonatal intensive care unit (NICU) admission.Miscarriage was defined as pregnancy loss at 22 weeks and less . Early np value of < 0.05 was deemed significant.Data were analyzed using SPSS software package version 23 . Simple descriptive analyses were used to describe the demographic data and clinical characteristics of the study group. Comparisons between groups were made with Fisher’s exact test or contingency coefficient for dichotomous data and Student’s t-test and non-parametric test for normally and not normally distributed data respectively. A total of 66 pregnancies were identified whereof eight were excluded as they were either transferred to another center for delivery due to financial constraint or the data was incomplete. The remaining data of 58 pregnancies were analyzed.2 respectively. The most common indication for insertion of an Arabin pessary was previous mid-trimester miscarriages  and there were 15 patients  who had been managed with either Arabin pessary or cervical cerclage in previous pregnancies. There was a total of 12 patients  who had been managed with cervical cerclage in their previous pregnancies.Table Streptococcus  followed by Candida albicans .Table + 4 weeks with birthweight of 620 g following an emergency insertion of pessary at 21 weeks gestation for short cervical length on ultrasound. Majority of the patients had spontaneous labor  and 34/52 (65.4%) delivered vaginally. Emergency caesarean section was performed in 13/18 (72.2%) of pregnancies due to fetal distress, malpresentation and refusal for vaginal birth after a caesarean section.Table Table p < 0.001), median gestation at insertion  and presence of funneling  between those who had elective and emergency pessary insertion respectively. There were no significant differences in mean maternal age, mean pre-pregnancy BMI, pregnancy outcome, birth less than 34 weeks gestation, median gestational age at birth, median birthweight and rate of NICU admission.Table This is the first study that was conducted in Malaysia that showed the experience of a single tertiary center in using Arabin pessary in women at high risk for spontaneous preterm birth. In our center, the pessary has been used as an alternative to cervical cerclage since 2013. Patients with obstetric history that was highly suggestive of cervical insufficiency had elective Arabin pessary insertion at 14 to 16 weeks. Emergency insertion was performed in those who had asymptomatic or symptomatic cervical length shortening on ultrasound.There are only a few studies that recruited the same cohort of patients similar to ours. The rate of preterm birth less than 34 and 37 weeks in our cohort was 25.9 and 50% respectively. Hence, our median gestation at insertion was earlier (15.0 weeks) with longer mean cervical length (31.6 mm) than the studies done by Ivandic et al. and Barinov et al. , 24. LikThe data in this study had demonstrated that majority of preterm births were classified under late with birthweight of 2000 g or more. The results of this study cannot be compared to other published data as the cohort of patients recruited was different. In our center, patients who were identified as high risk for spontaneous preterm labor would undergo cervical length monitoring from as early as 14 weeks gestation. Those with history that was suggestive of cervical incompetence would have the Arabin pessary insertion electively at 14 weeks. On the other hand, those whose histories were not clear, were counselled and options were given for them to choose. Either the Arabin pessary would be inserted electively at 14 weeks or inserted only in the presence of cervical length shortening following 2 weekly cervical length measurements from 14 to 28 weeks gestation.et.al and Saccone et.al both recruited this cohort of women at 18 to 22 weeks gestation. They demonstrated significantly lower rate of preterm birth and higher birthweight as compared to the control group [et.al and Nicolaides et.al recruited similar cohort of women at 20 to 24 weeks and randomized them into control and treated groups. Both studies did not show reduction of spontaneous preterm birth less than 34 weeks as compared to the control group [The protocol of the management of women at high risk for spontaneous preterm birth in our center is unique. Most studies recruited low risk women with shortened cervical length following screening of asymptomatic low risk women via transvaginal sonogram. The results were contradicting. Goya ol group , 26. Huiol group , 28.We are aware that our study was limited by the small sample size and this was not a randomized control trial. We did not include data on the neonatal outcomes in regard to incidence of perinatal morbidities such as necrotizing enterocolitis, intraventricular hemorrhage, respiratory distress syndrome, retinopathy of prematurity, and duration of NICU stay. Additionally, the added use of progestogen might have influenced the outcomes of this study. However, the selected population were highly selective consisting of those who were at high risk of preterm birth which is one of the reasons there was no control group in this study. As this was a single center experience, which targeted a homogenous group of women, the management did not differ much between the obstetricians involved.The results of our observational study suggested that the insertion of the Arabin pessary in women at high risk for spontaneous preterm birth is beneficial if it is inserted electively earlier at 14 weeks gestation. We found that the early elective insertion and close monitoring of the patients are beneficial in the management of this high risk group of women to allow additional steps in management aiming for the best outcome. Arabin pessary is safe with minimal side effects, affordable, simple to use and non-operator dependent. A larger multi-center study is required for further validation of our results.


Associations of interest were obtained using the Cox regression model.the participants were aged 24.9 years old (median) and had 11 years of schooling (median); 82.4% lived with their partners, and gestational age at the birth was 39 weeks (median). Twenty-five percent of the participants scored ≥13 on the Edinburgh scale. Depressive symptoms did not appear associated with low birth weight  or prematurity  in the adjusted analysis. However, premature labor increased the risk of low birth weight  and prematurity . Additionally, each week added to gestational age decreased the risk of low birth weight .the presence of depressive symptoms among women with low-risk pregnancies was not associated with low birth weight or prematurity. According to the World Health Organization (WHO), more than 254 million people of all ages are affected by depression worldwide. Hence, depression is among the primary causes of incapacity and significantly contributes to the global load of illness, especially among women. Depression is a mental disorder characterized by depressive mood, sleep disorders, lack of interest in daily tasks, difficulty concentrating, guilt, lack of or excessive appetite, and occasionally thoughts and suicidal ideation,3-4.Depression is considered a public health problem due to its severity, recurrence, and negative impact on health. The various physical, hormonal, emotional, and psychosocial transformations that occur during pregnancy directly influences these women’s mental health, explaining its prevalence-5.Depression is highly prevalent during pregnancy, affecting one in every five women worldwide-9.The consequences of depression during pregnancy in the short and long terms have been investigated, emphasizing the harm caused to the fetus’s health, including low birth weight and prematurity. Despite the biological plausibility of this association, studies present conflicting results. A recent literature review included seven studies in which increased risk of prematurity was found among women with depression, while another five studies did not find such an association.A systematic review reports an association between prenatal depression and premature birth in less than ¼ of the 50 studies included in the study, and approximately half (53%) of the studies addressing low birth weight found an association with prenatal depression. The cutoff point adopted in the study for the Edinburgh Postnatal Depression Scale (EPDS) was equal to or higher than 10 points. In the same year, a Vietnamese cohort study using the same scale and cutoff point found a risk three times greater for prematurity and a twice greater risk for low birth weight among women with depression.A prospective cohort conducted in 2018 in Kenya, not included in the previous reviews, found an association between depression and premature labor: women with depression during pregnancy were approximately four times more likely to have premature babies, in comparison to women without depressive symptoms. Another cohort study, conducted in a city located in the south of Brazil, addressed women exclusively assisted by the Unified Health System (SUS) during prenatal care and labor and verified that mothers experiencing depression during pregnancy were four times more likely to have an infant with low birth weight.In Brazil, the relationship between depression during pregnancy, low birth weight, and prematurity is seldom addressed. A cohort study addressing women with low-risk pregnancies was conducted in the capital of São Paulo and did not find any association between depression and low birth weight or prematurityThe previous discussion shows no consensus in the international or Brazilian literature regarding the relationship between gestational depression, low birth weight, and prematurity, which justifies this study. This study’s primary objective was to investigate the potential association between depressive symptoms during pregnancy, low birth weight, and prematurity among women with low-risk pregnancies assisted by Primary Health Care services. The secondary objective was to identify the factors associated with both outcomes..This prospective cohort study was conducted in the mid-south region of the state of São Paulo, Brazil. According to data provided by the cities in the state and the Fundação Sistema Estadual de Análise de Dados [State Data Analysis Foundation System], the city’s São Paulo Social Responsibility Index, wealth and longevity dimensions are below those reported by the state of São Paulo. The services sector accounts for 45.3% of the city’s formal jobs.The study was conducted in Botucatu, SP, Brazil, a city with an estimated population of 146,497 inhabitants in 2019.Botucatu has PHC units that work as the entrance door to the health system: 2 PHC units linked to a University and 18 PHC units linked to the city hall: 6 Basic Health Unit (UBS), and 12 Family Health Units (UFS) with 15 teams. The UBS are a reference in pediatrics, gynecology and obstetrics, and general practice within the covered area, providing care to 63.0% of the population. USF have a team composed of family physicians, nurses, dentists, nursing technicians, dental assistants, and community health agents located in the city’s periphery, providing care to 37.0% of the city’s populationThe pregnant women were recruited in all the PHC units in the city between May and December 2018. The following inclusion criteria were used: pregnant women at any gestational age, aged 18+ years old, and literate. Multiple pregnancies were excluded due to the risk of low birth weight and prematurity.This study addressed a convenience sample composed of 193 pregnant women, who were monitored until child delivery and had all data of interest available., was used to collect data concerning depressive symptoms during pregnancy. It was translated into and validated in many countries, including Brazil, and was indicated and validated to be used during pregnancy. A systematic review, addressing instruments designed to assess depression among pregnant women and identify the most appropriate instruments to apply in prenatal care services, reports that the EPDS was the most accurate scale . Its advantages include the fact that it is a self-reported, simple, and easy-to-apply instrument, simple to be interpreted, and any professional can apply,16.The EPDS, a scale initially developed to investigate postpartum depression-20. The questions address the presence of depressive or dysphoric mood, guilt, sleep disorders, loss of pleasure, decreased performance, and death and suicide ideation-5. The final score ranges from 0 to 30 points; higher scores represent a more severe condition. Similar to other studies, a score equal to or higher than 13 points was the cutoff point used to indicate the risk of depression-22.The EPDS is a questionnaire composed of ten topics with four options of answers, ranging from zero to three, according to the absence or presence and intensity of symptomsThree other forms specifically designed for this study were used. The first collected the participants’ identification information; the second addressed sociodemographic data and information concerning pregnancy planning and acceptance, availability of social support, and the participants’ lifestyle; and the third form addressed data concerning the pregnancy, labor, and childbirth, which were available in the medical records available in the public maternal hospitals located in Botucatu.The exposure variable was a score indicating depressive symptoms.Two outcomes were considered: low birth weight and prematurity, and the covariates included maternal sociodemographic factors and complications in the current pregnancy. A synthesis of the variables is presented in During the recruiting period, all the pregnant women attending prenatal care appointments in the city’s Health Units were invited to participate. The nursing technicians, nurses, and/or physicians working in the Primary Health Care units recruited the participants. The study’s coordinators trained these workers, who were also informed about the study’s objectives and received step-by-step instructions to operationalize data collection. A manual was developed and delivered to each health unit, and the Public Health Research Unit (UPESC) at the Botucatu Medical School remained available to clarify potential doubts.Data were collected in three stages. Stage 1, after receiving clarification about the study, those who consented to participate received a form containing the EPDS and addressing some identification data. The participants were then conducted to a private room to fill in the forms and later returned the complete forms within a sealed envelope.Stage 2 was conducted up to 15 days after the pregnant women were included in the cohort. An interview was conducted via telephone to obtain sociodemographic data, and stage 3 consisted of collecting data concerning complications during pregnancy, birth weight, and gestational age at birth from the mothers’ and infants’ medical records available in public maternity hospitals. These last two stages were conducted by undergraduate students and residents from the nursing and nutrition programs, trained and supervised by the Public Health Research Unit team. Periodical meetings were held with the interviewers and the supervising team to support data collection.Strategies were adopted to avoid a follow-up loss such as asking the participants’ different telephone numbers and those of their partners or relatives; the telephone interview was scheduled on the day the EPDS was applied according to the participants’ convenient day and time, and contact was attempted at least six times before considering it a loss.Association between depressive symptoms during pregnancy and the outcomes (low birth weight and prematurity) and the covariates individually associated with the outcomes presenting a p<0.20 were verified. Once identified, these covariates were included in the Cox regression model for adjustments. A critical p<0.05 was established in the multiple analysis to accept the association between the positive score indicating depressive symptoms and low birth weight and prematurity. The Hazard Ratio (HR) was calculated in the crude and adjusted analyzes with a 95% confidence interval, and goodness of fit was assessed through distribution of residuals. Analyses were performed using Statistical Package for the Social Science (SPSS), version 21.The study was approved by the Research Ethics Board at the Medical School of Botucatu, under protocol No. 2,641,633. The participants signed free and informed consent forms, and whenever depressive symptoms were identified , the participants were referred to medical assessment in the health units where they received prenatal care.Forty-nine (25.4%) participants presented scores indicating depressive symptoms. Regarding the newborns, 17 were pre-term (8.8%), and 12 presented low birth weight (6.2%); median birth weight was 3,220 g.Variables concerning maternal sociodemographic characteristics concerning the current pregnancy are presented in Depression scores did not appear associated with low birth weight (p= 0.530) in the crude analysis . The cov: 27.2%, 21.7%, and 25.4% of the pregnant women with 20, 28, and 36 weeks of pregnancy, respectively presented depression symptoms, corroborating the results reported here.Contrary to the expected, no association was found in this study between depressive symptoms during pregnancy and low birth weight or prematurity. On the other hand, a large number of pregnant women presented a positive score for depression. This result was similar to that reported by a Brazilian study conducted in another city, which adopted the EPDS and considered a cutoff point of 13 pointsA convenience sample, composed of pregnant women assisted by the public Primary Health Care service, was used. Thus, it does not represent the city’s entire population, as this limitation prevents the generalization of results. For this reason, future studies addressing larger probabilistic samples are needed. On the other hand, by including only pregnant women cared for by the public health network, the potential effect of high rates of elective C-sections was minimized. C-sections are more common in private services and may influence the risk of low birth weight and prematurity. Therefore, despite the low population representatives, excluding a potential confounding factor (elective C-sections) possibly benefited internal validity. Another factor supporting the results’ validity is that the gestational trimester in which mothers were at the time the EPDS was applied was not associated with the final score or the two outcomes addressed here. Therefore, the fact that the pregnant women were not all assessed in the same stage of pregnancy did not affect the results., 33.8% in Tanzania, and 7.0% in Australia. Different rates were found in different places within Ethiopia 11.8%, 21.5%, and 24.9% so that only the highest rate found in Ethiopian studies was similar to the one reported here. Depressive symptoms identified with the EPDS among pregnant women in Nigeria were similar to those found in this study, though the cutoff point used was 12, limiting comparisons between results.The depression rates reported by international studies among pregnant women vary among countries and within the same country. Using the same scale adopted here and the same cutoff point, studies conducted in China report 28.5%-8, except for one, so that the question remains, especially in Brazil.Note that the main result found in this study was no association between depressive symptoms during pregnancy and low birth weight or prematurity. Therefore, the hypothesis that depressive symptoms during pregnancy would increase the risk of these two adverse outcomes was not confirmed. This result is in line with some previous studies. Less poor contexts, in which high-energy food is currently accessible even for lowincome populations, such as in the case of Brazil and other countries in Latin America-30, including the city where this study was conducted, depression during pregnancy may not negatively influence infants’ birth weight or the risk of prematurity. Therefore, other studies conducted in different Brazilian and international contexts should be conducted to broaden understanding regarding the role of depression on low birth weight and premature labor, confirming or discarding the hypothesis of this context-modifying effect.Although very plausible, the association between depression during pregnancy and low birth weight and prematurity was not evident in the crude analysis, and other aspects should be considered to explain it. The influence of depression may vary according to the women’s life context. In a situation of extreme poverty, pregnant women with depression tend to experience anorexia, high levels of stress and are less willing to make efforts to obtain proper food and care for their health. This situation may result in low gestational weight gain and a deficiency of nutrients essential for baby growth, consequently leading to low birth weight and prematurity, alcohol, and smoking,33-34. A literature review addressing the repercussion of maternal depression, including studies conducted in low- and middle-income countries, reports a greater risk of psychological disorders among infants, children, and adolescents; deficient growth and postnatal child development; early weaning; and childhood illnesses, such as diarrhea and other infectious diseases.Even though no evidence was found that depression affects birth weight or prematurity, the high number of pregnant women with depressive symptoms is relevant due to the potential consequences of this condition on other outcomes during childhood and adolescence. A study conducted with pregnant women with depression reports that these women less frequently attend prenatal care and are more susceptible to consume poor quality foodThis study also identified that premature labor increased by approximately five and eight times the risk of low birth weight and prematurity, respectively. On the other hand, each week added to gestational age decreased the risk of low birth weight by 24%. These relations are well known and corroborate the validity of the results reported here.. Studies using varied designs, addressing different populations, and conducted in different countries consistently report an association between premature labor and low birth weight-42.Premature labor is a significant complication that determines neonatal morbidity and mortality due to the progression to premature childbirth, with consequences in the long term including neurological, cognitive, respiratory, cardiovascular, and psychosocial disordersThe large portion of women with low-risk pregnancies in this study presenting depressive symptoms indicates that actions should be implemented in health services to identify, manage, and monitor prenatal depression. Considering the vital work of PHC nurses in prenatal care, these professionals are expected to lead actions intended to incorporate routine screening for depression among pregnant women.Many women with depressive symptoms were identified in this study. Slightly more than ¼ of the participants obtained scores equal to or higher than 13 in the EPDS. However, no association was found between depressive symptoms during pregnancy and low birth weight or prematurity. On the other hand, premature labor was confirmed as an independent risk factor influencing low birth weight and prematurity, while increased gestational age was confirmed as a protection factor against low birth weight.