In response to rising rates of medical intervention in birth, there has been increased international interest in promoting normal birth . However, there is limited evidence for how best to achieve increased rates of normal birth. In this study we examined the role of modifiable and non-modifiable factors in experiencing a normal birth using retrospective, self-reported data.N = 5840) were analysed using multiple logistic regression models to identify associations with four aspects of normal birth: onset of labour, use of anaesthesia, mode of birth, and use of episiotomy. The probability of normal birth was then estimated by combining these models.Women who gave birth over a four-month period in Queensland, Australia, were invited to complete a questionnaire about their preferences for and experiences of pregnancy, labour, birth, and postnatal care. Responses , had continuous electronic fetal monitoring during labour, and knew only some of their care providers for labour and birth. Women had a higher probability of normal birth if they lived outside major metropolitan areas, did not receive private obstetric care, had freedom of movement throughout labour, received continuity of care in labour and birth, did not have an augmented labour, or gave birth in a non-supine position.Our findings highlight several relevant modifiable factors including mobility, monitoring, and care provision during labour and birth, for increasing normal birth opportunity. An important step forward in promoting normal birth is increasing awareness of such relationships through patient involvement in informed decision-making and implementation of this evidence in care guidelines.The online version of this article (10.1186/s12884-018-1871-5) contains supplementary material, which is available to authorized users. Making Normal Birth a Reality, called for a standard definition of normal birth to increase confidence in the auditing and monitoring of practice trends [process of birth and does not extend to outcomes of birth such as vertex presentation and intact perineum.The term ‘normal birth’ in academic literature and health policy has more generally come to refer to a birth without, or with limited, clinical intervention. A 2007 consensus statement by the Maternity Care Working Party, e trends . The resCampaign for Normal Birth within the UK, now continued as part of the Better Births Initiative [Joint Policy Statement on Normal Birth to support, promote and protect normal birth for women [National Maternity Services Plan: 2010) [Towards Normal Birth in New South Wales policy directive required all birthing facilities in that Australian state to have a written policy for normal birth by 2015 [The 1990s and 2000s saw a steady increase in rates of medical intervention during labour and birth across a number of developed countries . While sitiative . Care pror women . In Austn: 2010)  is basedn: 2010) . Additio by 2015 .Despite increasing international interest there is relatively limited evidence for how to best facilitate normal birth as a multi-dimensional construct. To date, very few studies have examined determinants of normal birth in this way  . The BirOther research on factors that may reduce intervention during birth has focused on individual procedures, such as induction of labour or caesarean section. In regards to modifiable factors, characteristics of care are one source of variation. There is greater use of intervention in private birthing facilities than in public facilities, including induction of labour, epidural anaesthesia, episiotomy, instrumental vaginal birth, and caesarean section –21. ThesLess modifiable characteristics have also been associated with increased intervention during birth. Rates of intervention are typically increased for women with obstetric conditions such as gestational diabetes, pre-eclampsia or placenta praevia , 32, 33.The aim of this study was to expand current evidence for factors which may promote or inhibit women achieving a normal birth. We examined a range of both modifiable (e.g. continuity of care) and non-modifiable (e.g. parity) factors, using secondary analysis of retrospective, self-reported, population-level survey data of women’s maternity care experience. Additionally, we aimed to expand on the methods used in previous studies by providing the probabilities of achieving normal birth as a singular construct among all women, irrespective of their risk status.Behavioural & Social Sciences Ethical Review Committee. Completion of the anonymous survey was taken as evidence of consent to participate.All women who gave birth in Queensland, Australia, across a 4-month period  were invited by the Queensland Registry of Births, Deaths and Marriages to complete the 2012 Having a Baby in Queensland Survey; a cross-sectional evaluation of women’s experiences of pregnancy, labour, birth, and postnatal care . Women wFor women who had a live birth, the usable response rate was 30.4% . The respondent sample was approximately representative of the 2011 birthing population of Queensland for mode of birth, previous caesarean section, plurality of pregnancy, area of residence, infant birthweight and gestational age at birth , 44. TheNormal birth was defined according to the Werkmeister and colleagues definition . Women wDid you have an epidural or spinal (anaesthetic injection in your back) for pain relief during labour?’. For women who did not use anaesthesia during labour we assessed mode of birth by asking ‘How was your baby born?’ with five response options: an unassisted vaginal birth, a vaginal birth assisted with a vacuum, a vaginal birth assisted with forceps, a vaginal birth assisted by forceps and a vacuum, a caesarean birth. Women who had an unassisted vaginal birth were then further categorised using the item, ‘During your birth, did you have an episiotomy  to enlarge your vaginal opening?’, according to whether they had an episiotomy. The remaining women who did not have an episiotomy were those who had a normal birth.Onset of labour was assessed through a series of questions about whether women had experienced medical or surgical procedures to induce labour, and whether women had experienced any labour at all. Women were coded as having a spontaneous labour if they did not have prostaglandins, artificial rupture of membranes, synthetic oxytocin, or a balloon catheter for the purposes of inducing labour. Women who had a spontaneous labour were coded according to whether they used anaesthesia during labour using the item ‘Based on previous literature we selected a range of independent variables, including demographic and obstetric characteristics, antenatal and intrapartum care, experiences during labour and birth, and organisational factors. These variables are detailed in Additional file Multiple logistic regression models were used to estimate the associations between the independent variables and the four binary outcomes: onset of labour, anaesthesia, mode of birth, and episiotomy. Results are presented as probability ratios. As a simple example, if the probability of a normal birth was 0.2 for women in the reference group and 0.1 in another group then the probability ratio would be 0.5 (0.1 divided by 0.2), meaning that the probability was halved compared with the reference group. These probability ratios are used instead of odds ratios (the ratios of odds) which are often less intuitive and prone to misinterpretation – particularly with highly prevalent outcomes.4 = 0.41.To estimate the probability of a normal birth we multiplied the estimated probabilities from the four logistic models . For example, if a woman had a 0.80 probability at each of the four stages than her probability of a normal birth would be 0.80We used a Bayesian paradigm to fit the logistic models so that we could multiply together the four probabilities and create a mean and 95% credible interval for the probability of normal birth. Ninety-five per cent credible intervals are like 95% confidence intervals but have the simpler interpretation of having a 95% probability of containing the true value.all women birthing in water experiencing a normal birth. This variable was excluded from the analysis as it is likely a proxy for an intervention-free birth rather than a predictor. Continuous variables were centred and scaled to help with the interpretation of the regression models.Relationships between the independent variables were checked for co-linearity using variance inflation factors. Type of facility (public or private) and place of birth were found to have too much overlap with model of care, and were excluded for this reason. For water immersion during birth there was perfect prediction, with Analyses were conducted using R version 3.0.2 (2013–09-25) software combined with JAGS to run the models , 46. We Of the total sample, 53.1% had a spontaneous labour, 47.5% birthed without an epidural, spinal or general anaesthesia, 53.7% had an unassisted vaginal birth and 53.2% gave birth vaginally without an episiotomy. Combining these four outcomes, the overall rate of normal birth was 28.7% and was 44.3% among women who had a vaginal birth. Descriptive information relative to the independent variables is provided in Additional file Women had higher probability of experiencing spontaneous labour if they had completed secondary education. Relative to private obstetric care, women had a higher probability of having a spontaneous labour if they were receiving GP shared care, standard public care, public midwifery continuity care, or private midwifery care.The probability of experiencing spontaneous labour was lower for women with gestational diabetes, high blood pressure, other risk factors, or a multiple pregnancy. Women who were primiparous, multiparous with a history of caesarean, older, of higher BMI, or of later gestational age were also at a lower probability of having a spontaneous labour. The mean probability ratios and 95% credible intervals are presented in Table The probability of not using anaesthesia during labour was higher for women living in inner and outer regional areas, receiving GP shared care, standard public care, or public midwifery continuity care, not receiving augmentation of labour, experiencing freedom of movement throughout labour, or who had continuity of carer for labour/birth , were at an earlier gestational age, or lived in a major city relative to an inner or outer regional area. These characteristics align with findings from previous studies of normal birth  and the Perhaps of greater clinical utility in the promotion of normal birth are the modifiable factors  we found to change women’s likelihood of normal birth. The probability of normal birth was higher for women who received care in a model other than private obstetric care, had continuity of care during labour and birth, knew none rather than some of their care providers, had freedom of movement during labour, did not have continuous fetal monitoring or augmentation, or birthed in a non-supine position. Despite the sample and methodological differences in this study, these findings are largely consistent with those of Miller and colleagues .The higher rate of obstetric intervention in private facilities is well-established –21. By uWe also found that normal birth was less likely when women knew some rather than none of their care providers. It is possible that this may relate to differences in the organisation of labour and birth care between private and public models of care . As we have demonstrated, models of care provided in public facilities  increase the probability of achieving a normal birth, and may be less likely to provide a known care provider at the time of labour and birth care. However, having previously known care providers for labour and birth may be less relevant than having continuity of carer throughout this time. We found that women with continuity of carer for labour and birth (after accounting for known care providers and model of care) were 24% more likely to have a normal birth. Having continuous support during labour is argued to provide emotional support and comfort, information and advocacy, enhancing women’s sense of control and reducing the need for medical intervention . While cOur findings for a greater probability of normal birth among women who didn’t have continuous electronic fetal monitoring, had freedom of movement, or who birthed in a non-supine position are consistent with previous studies about normal birth . Other rIn contrast to a previous study of normal birth , we did A strength of this study is that it appears to be the first to have examined probabilities of normal birth as a multi-dimensional construct for a wide range of predictors and with a non-restricted sample of women. The study also used population-level sampling to invite participation and was uniquely able to use a combination of clinical and experiential factors due to the self-reported nature of the data, which has not been possible using clinical reporting alone. A high level of concordance between maternal self-report and medical records has been repeatedly demonstrated for clinical information pertaining to birth –58.While the respondent sample was representative of the Queensland birthing population on many key clinical characteristics, some characteristics were under-represented. We could have used sampling weights to provide a closer match to the Queensland birthing population; however such weights are generally more important for estimating prevalence, whereas our study was concerned with the association between variables which we assumed were generalisable from our sample to the wider population. We also did not examine the inter-relationships between different predictors of normal birth. While we identified certain groups of women at a reduced likelihood of achieving a normal birth, such as primiparous women or those with a history of caesarean section, we did not examine how the chances of normal birth may be increased for such groups. Future research may wish to consider potential interactions between modifiable and non-modifiable characteristics to determine how intervention could be reduced among particular groups of women.Despite increasing interest in normal birth, actual rates remain low and research for how to facilitate this is minimal. Models of care with a more natural philosophy of birth, not limiting women’s freedom of movement and position during labour and birth, and continuity of care provider throughout labour and birth are shown to increase the likelihood of achieving a normal birth. To support the desired promotion of normal birth, care providers and women must be made aware of existing evidence for how care and treatment related factors influence normal birth outcomes. Pragmatic evaluation research is needed for how policies that relate to facilitating factors affect women’s experience of normal birth.Additional file 1:Comparison of Respondent Sample and Population Characteristics. This file contains two tables comparing maternal and infant characteristics of the sample population with those of the Queensland, Australia, birthing population in 2011. (PDF 642 kb)Additional file 2:Measurement of independent variables examined for associations with normal birth. This file contains a table detailing the independent variables used in the analysis, describing how they were measured in the Having a Baby in Queensland 2012 Survey. (PDF 484 kb)Additional file 3:Sample characteristics of women as frequencies and percentages. This file presents a table outlining the characteristics of women in the study sample. Means and standard deviations, or frequencies and percentages where relevant, are provided. (PDF 486 kb)


Capillary rarefaction (CR) is an established hallmark of essential hypertension (EH). The aim of this study was to examine early changes in capillary density (CD) and blood pressure (BP) in low birth weight (LBW) infants who are at risk of developing EH in later life.We studied 77 LBW infants and 284 normal birth weight (NBW) infants, all born to mothers with normotension, in a longitudinal multicenter study. Intravital capillaroscopy was used to measure functional basal capillary density (BCD) and maximal capillary density (MCD) at birth, 3, 6, and 12 months.We found that LBW infants, born preterm and at term, had a significantly higher CD at birth, then underwent significant CR in the 1st 3 months culminating in a CD similar to that seen in NBW infants. NBW infants showed a gradual reduction in CD between birth and 12 months. Non-Caucasian ethnicity and preterm birth were significant predictors of a higher CD at birth. Systolic BP in NBW infants increased significantly from birth to 3 months, and we identified a significant negative correlation between systolic BP and MCD.This study has identified a process of early “accelerated capillary remodeling” in LBW infants, which corrects their higher CD at birth. This remodeling is unlikely to explain the CR seen in adult individuals with, or at risk of developing EH. Further follow-up studies are required to determine the timing and mechanisms involved in CR, which is likely to occur after the 1st year of life but before early adulthood. Individuals with EH are known to have significant structural and functional microcirculatory abnormalities when compared with normotensives. Capillary rarefaction (CR), defined as a reduction in spatial capillary density (CD), is an established hallmark of EH and is evident before the development of the disease.2–5 The consistent finding of CR in adult individuals with normotension destined to develop hypertension,6 as well as in borderline hypertensive cohorts,3 invites this pertinent question: how early in life does pathological CR occur and could such knowledge provide pointers as to how the growing EH pandemic could be prevented?Essential hypertension (EH) is a major risk factor for cardiovascular disease7–9 The mechanism(s) for these associations is not known. We have previously reported that LBW infants born at term or preterm to mothers with normotension do not have CR: instead, these infants have a significantly higher CD at birth compared with their normal birth weight (NBW) counterparts.10 Our findings appeared to contrast with reports that functional and structural microcirculatory abnormalities, including CR, are already present in childhood and young adulthood, respectively, in individuals born with LBW.11–16 We, therefore, conducted a longitudinal study of a large cohort of infants from birth over a 1-year period.A strong body of evidence indicates that low birth weight (LBW) <2.5 kg is associated with vascular abnormalities, the development of hypertension, stroke, and increased mortality in adult life.G-CROS is a British Heart Foundation-funded, prospective cohort study that was approved by the National Research Ethics Service—Dulwich (14/LO/0690). Recruitment was carried out at St George’s University Hospitals NHS Foundation Trust and Kingston Hospital NHS Foundation Trust, London, UK. Infants were recruited across all birth weight categories, gestations, and ethnicities over a 33-month period between August 2014 and April 2017 following written informed parental consent. Each infant was studied on 4 occasions: at birth, 3, 6, and 12 months. Both preterm  and term  were included. All participants across all study groups were given a 1-month window either side of their expected follow-up visit to schedule an appointment. The follow-up time points were therefore 3, 6, and 12 months (± 1 month at each stage). The control group was defined as NBW infants born at term. Infants born to mothers with hypertension and/or type 1 diabetes mellitus were retrospectively excluded.capillaries18 by applying a size-appropriate neonatal blood pressure (BP) cuff around the calf muscle. The cuff was then inflated and maintained at 30 mm Hg for 2 minutes to determine the maximal CD (MCD), which represents the structural  CD.17 BCD was counted on the running video and all capillaries were counted; including continuously and intermittently perfused capillaries. MCD was counted on stills of the video during venous congestion. Skin and room temperatures were monitored during the study using Tele-Thermometers . The total number of capillaries was counted offline using the CapiScope 4.35.0.0 computer software .Two independent observers, M.G. and R.R., used the CapiScope Handheld Video Capillaroscopy System  to measure the CD on the plantar surface of each infant’s big toe. Four microscopic fields were recorded continuously for 30 seconds. Basal CD (BCD), which represents functional CD, was calculated as the mean of these 4 microscopic fields. We then used venous congestion to maximize the number of visualized perfused skin We used the Welch Allyn VSM 300 monitor to measure the infants’ BP in a temperature-controlled room (22–24°C). A neonatal and appropriately sized BP cuff was used on the calf with the infant in a resting state.We collected maternal details including ethnicity, maternal age, body mass index, BP, smoking, and alcohol history. We measured postnatal growth by measuring the infants’ birth weight (BW), head circumference, body length, mid-arm circumference, and foot width and length. The birth centile was manually plotted for each infant on a “UK-WHO growth chart 0–4 years”. A BW below or equal to the 10th centile was classified as small for gestational age (SGA). Appropriate for gestational age (AGA) was defined as a BW above the 10th centile.The reliability of CD measurements was assessed by estimating the intraclass correlation coefficient (ICC) for the intra- and interobserver reliability, between 2 independent observers: M.G. and R.R. The intraobserver reliability of our method was found to be moderate for MCD measurement (ICC = 0.73) and good for BCD measurement (ICC = 0.86). The interobserver reliability of our method was found to be excellent for both MCD and BCD measurements .P values are 2-sided and a P value of <0.05 was considered statistically significant. All statistical analyses were carried out by using the Statistical Analysis System, version 9.3 .The primary end points were defined as the BCD and MCD at the following time points: 3, 6, and 12 months. Between-group and within-group differences in BCD and MCD were analyzed using a mixed model in which BW category/prematurity (preterm vs. term), measurement time point, and interaction between BW category/prematurity and measurement time point were treated as fixed effects, and the subject was treated as a random effect. In addition, mixed models with time-varying covariates were employed to assess the effects of these covariates on the BCD, MCD, percentage change in BCD and percentage change in MCD. The estimated between-group and within-group differences from the mixed models are reported together with their 95% confidence intervals. Correlation coefficients between BP and MCD at different time points were also calculated. Reported P < 0.0001), followed by a smaller reduction between 3 and 6 months . Similarly, the greatest reduction in MCD occurred between birth and 3 months . Although BCD continued to reduce after 6 months, MCD did not show a significant reduction between 6 and 12 months  Similarly, a significant reduction in MCD was found during this same period of time . Although the NBW cohort demonstrated further smaller reductions in BCD and MCD in the period between 3 and 6 months; the LBW cohort did not show any further significant reductions in CD after 3 months.P < 0.0001 and MCD MD = 12.83, 95% CI [8.77 to 16.88], P < 0.0001). LBW infants also demonstrated a significantly higher percentage reduction in BCD  and MCD  between birth and 3 months when compared to the NBW group  had a higher BCD and MCD at birth when compared to term infants  and , respectively. Similar to LBW infants, preterm infants underwent a significant capillary remodeling in the 1st 3 months of life . After 3 months, there was no significant difference in BCD or MCD between preterm and term infants (n = 80) had a higher BCD and MCD at birth when compared to AGA infants (n = 255), . This was followed by a significant reduction in both parameters so that by 3 months, there was no significant difference between the 2 cohorts.Preterm infants ( infants . SimilarP < 0.001) and MCD  at birth and a more significant percentage reduction in BCD between birth and 3 months . A lower gestational age predicted a significantly higher BCD at birth , 3 months , and 6 months  but only predicted a higher MCD at birth  and 6 months . All other maternal parameters or predefined measures of infants’ growth , maternal age at time of baby’s birth, and smoking history before pregnancy) were not found to be statistically significant predictors of CD changes.Non-Caucasian ethnicity predicted a higher BCD (regression coefficient (RC)= –11.32, 95% CI [–17.75 to –4.89], P = 0.0281; P = 0.0001) and remained relatively constant thereafter . Furthermore, the change in CD predicted the change in BP  and , respectively. BP did not change significantly in the LBW between birth and 12 months.At birth, LBW infants had a significantly lower diastolic BP than NBW infants , have a significantly higher CD at birth when compared to NBW infants.19 Thus, previous studies have suggested that the capillary network in the conjunctiva is structurally extensive and “disorderly” at birth before it matures into a more effective network between 14 and 17 weeks.20 It makes teleological sense to accept that our findings in the 1st 3 months of life represent a period of plasticity during which a normal physiological phenomenon of “pruning” or “remodeling” of capillaries is seen in NBW infants. Top et al. 15, for instance, examined the capillary microcirculation in the buccal mucosa in term neonates and found higher BCD in infants less than 1 week old compared with older children, confirming that BCD decreases progressively from as early as 1 week following birth. Suichies et al. showed that NBW infants born at term undergo a significant reduction in skin blood flow in the 1st 5 days of life, and they suggested that this is due to morphological and regulatory changes in the microcirculation of the skin.21 Alternatively, it could be postulated that this physiological process of remodeling could be initiated antenatally. In keeping with this, LBW infants who are generally born prematurely may not have undergone the same extent of capillary loss as their NBW counterparts born at term. This would explain the higher CD at birth found in LBW infants and in preterm infants. It would also explain our finding that lower gestational age predicts a higher capillary density at birth.Infants have a vast and dense capillary surface area available for fluid, oxygen, solute, and protein exchange, most notably in the peritoneum, muscle, and skin.22 CR, which is known to increase peripheral vascular resistance and has been confirmed to antedate the onset of hypertension,2–6 has specifically been identified in the microvasculature of the retina23 and the dermal microcirculation of prepubertal children.25 However, very few studies have investigated CR in newborn infants with LBW. Goh et al.26 examined skin CD in 17 LBW infants and 21 high BW infants at 1 postnatal time point (3 months of age) and found no difference in BCD between the 2 groups. As CD was only measured once, at 3 months, they were unable to observe the significant accelerated capillary remodeling that we found in our study. Therefore, our new findings provide an explanation for the results of Goh et al.26; as we too found no difference between NBW and LBW infants at 3 months and suggest that LBW infants, having undergone an accelerated capillary remodeling, bring their CD to a level equivalent to that of NBW infants. van Elteren et al.27 studied the microcirculation in infants and found that both preterm (<32 weeks’ gestation) and term neonates undergo a significant reduction in their total vessel density (TVD) in the 1st month of life and that preterm infants have a consistently higher TVD than term infants.27 The authors suggested that this is an adaptation of the cutaneous microcirculation at birth and that differences in antenatal oxygen exposure may explain differences in the way the microcirculation develops in the early postnatal period. However, when we investigated the effects of oxygen therapy on CD and BP in LBW infants in a recent study, we found that oxygen therapy was associated with higher BP levels at 40 weeks postnatally, but had no effect on CR.28Multiple studies have established that various micro- and macrovascular markers of hypertensive risk such as CR, increased intima–media thickness, arterial stiffness, and endothelial dysfunction are present in children and young adults with a history of LBW.12 studied 39 school children (aged 7–12 years) with a history of very preterm birth and LBW. They found that their subjects had a significantly lower BCD, but not MCD, when compared with 21 NBW infants born at term.12 Similarly, Lewandowski et al.29 recently studied young adults (aged 20 –30 years) with a history of preterm birth and LBW and found that these individuals had significant rarefaction of their BCD and MCD, a higher BP, and a relatively exaggerated antiangiogenic state when compared with their term-born counterparts.29 Irving et al.30 studied young adults (mean age 24 years) with a history of LBW and found no difference in BCD or MCD. It must be stressed here that both studies of Bonamy et al.12 and Lewandowski et al.29 included individuals born to mothers with hypertensive disorders of pregnancy that has been shown to affect microvascular remodeling through the release of antiangiogenic factors such as soluble endoglin and sFlt-1 into the maternal circulation and potentially into the fetal circulation.31 Our study is, therefore, unique in that we only included LBW infants born to mothers with normotension to eliminate any effects of maternal hypertension or antiangiogenic factors on the neonatal microcirculation. Recent studies have suggested that preterm birth, more so than LBW, is the predominant factor associated with an adverse vascular profile, but this issue is still debated. However, our results show that LBW infants born at term or preterm show significantly higher CD profile at birth and parallel accelerated capillary remodeling in the 1st 3 months of postnatal life.Conversely, studies investigating LBW and its association with CR in older children and young adults have provided inconsistent results. For instance, Bonamy et al.32 We and others have previously demonstrated that adult South-Asian individuals with normotension have a reduced BCD and MCD when compared to Caucasian controls with normotension.33–35 Larger studies conducted in infancy and throughout life in these individuals are warranted to define the independent effect of ethnicity on the postnatal microcirculation and future CVD risk.Our novel finding that infants of South Asian and Black ethnicity had higher BCD and MCD at birth and a more significant percentage reduction in CD between birth and 3 months than their Caucasian counterparts is very intriguing and requires further investigation. It is well known that Black and South Asian individuals are at a higher risk of cardiovascular morbidity and mortality that cannot be explained by the traditional CVD risk factors.36 who published a study on perinatal predictors of newborn BP and showed that LBW is associated with low BP in newborns. Interestingly, Launer et al.37 showed a direct association at age 1 week and an inverse association at age 3 months, suggesting that the direction of the LBW and BP association reverses at some point between these 2 ages. We speculate here that the accelerated capillary remodeling we observed in the 1st 3 months of life possibly mediates the reversal of the association between LBW and BP.Our finding of an inverse association between systolic BP and MCD at 3 months is novel and suggests that capillary remodeling may induce the rise in BP at 3 months of life. Our finding of a lower diastolic BP in LBW infants confirms the results of Gillman et al.16 is likely to occur after the 1st year of life but before adolescence. Identifying the exact timing of CR may provide an opportunity to prevent or reverse these microcirculatory abnormalities and thereby prevent future hypertension.We have shown that LBW infants born to mothers with normotension have a significantly higher CD at birth compared to NBW infants. NBW infants showed a gradual reduction in CD in the 1st 12 months of life with the greatest reduction occurring between birth and 3 months. More interestingly, LBW infants underwent a process of accelerated capillary remodeling in the 1st 3 months life, by the end of which they had a CD similar to that of NBW infants. We also found a significant negative correlation between systolic BP and MCD at 3 months, which may provide a strong evidence for the role of CR in the causation of hypertension. This process of accelerated capillary remodeling is unlikely to explain the CR observed in adult individuals with a history of LBW. We, therefore, postulate that another process of “capillary hyper-pruning”


Plant collections are, by their very nature, records of phenology—the study of cyclical events in an organism's life cycle including growth and reproduction phases that occur over the course of the year. These phases, which are called phenophases, are represented in plant collections with such features as young flower buds, senescing leaves, and even bare branches on a herbarium sheet. In combination with the collection date and locality information present on the specimen label, collections provide valuable data about plant phenology.Phenology is not a new science, but it has taken on additional importance in recent decades as a metric for studying the impacts of global climate change on species. As the climate warms and weather patterns are altered, it becomes increasingly vital to quantify the effects of these changes on plants and animals. Certain taxa, of plants in particular, are quite sensitive to temperature, precipitation, and other environmental variables, with the timing of their growth, reproduction, and senescence advancing or becoming delayed depending on the conditions to which they are exposed.Shifts in phenology can have cascading effects through the ecosystem. For example, the timing of when a forest leafs out signifies the start of the growing season and with it the progression of nutrient and water cycles. Likewise, if plants flower earlier in warmer springs but their insect pollinators have not yet emerged, plant and pollinator populations themselves can be negatively impacted. At the landscape scale, even small changes in phenology can have substantial consequences.Long‐term data that capture the variability inherent to plant phenophases are foundational to phenological studies. Systematic records of phenology are rare, however, so researchers have been creative in using records that were collected for purposes other than phenological research. Herbarium specimens have proven to be especially robust sources of historic and recent phenological data, and, thanks to global efforts to image specimens and create digital records for information that was previously available only in analog format, more and more of these data are freely available online.The urgency of biodiversity research relating to environmental change, the ready availability of phenological data, along with continually improving computational capabilities, make this an ideal time to be conducting phenological research. In this special issue, “Emerging Frontiers in Phenological Research,” nine research groups have come together to present innovative phenology projects, all of which make use of, or can be applied to, herbarium specimens.Acer rubrum L. (red maple) from across eastern North America. They analyzed climate variables and combinations of these data to evaluate the effect of phenological coarseness on the strength of the models. As with Pearson, Ellwood et al. found that more precise estimates of phenophase make for slightly stronger models. However, in certain research applications, the effort required to produce accurate, fine‐scale phenophase annotations may not be worth the small statistical advantage.Digitized herbarium specimens most often require the addition of phenological classification to be useful for phenological research, and this can be resource‐intensive and time‐consuming. Lorieul et al.  describeProtea L., in a phenologically understudied part of the world—subtropical Africa. Importantly, they found that even these botanically unique Protea species respond phenologically to temperature in ways that are similar to northern temperate species. This suggests that some phenology–climate relationships are generalizable across at least certain plant groups. Panchen et al.'s (To date, the majority of phenological research has involved individuals making extensive observational records, annotating herbarium specimens, and/or conducting experimental work. Most of this work has been done with temperate plant species in the Northern Hemisphere (Willis et al., et al.'s  researchRichardson et al.  present This suite of articles represents work at the cutting edge of phenological research. We anticipate that these articles will provide even the most experienced phenological researcher new insights into research methods, software packages, and foundational standards and practices. Likewise, we are hopeful that this work will inspire new and experienced researchers to continue to push the boundaries of what is possible when using herbarium specimens in phenological research.


Birth weight has a vital role in determining newborns survival in vulnerable conditions. Low birth weight is associated with fetal and neonatal morbidity and mortality, impairment of growth and development and also chronic disease later in life. This study was aimed to assess the magnitude of low birth weight and its determinants in Wolaita Sodo University teaching and referral hospital, southern Ethiopia. Institution based cross-sectional study was conducted from November to December 2018. Systematic random sampling technique was used to select study participants. Data was collected by interviewing mothers through structured questionnaire and reviewing neonates' medical records using a checklist. Multivariable binary logistic regression analyses were employed to identify factors associated with neonatal jaundice. The proportion of low birth weight in the study area was found to be 15.8% (95% CI 11.7-19.9). Being primiparity , anemia during pregnancy , pregnancy induced hypertension , intake herbal medication during pregnancy , drinking alcohol during pregnancy  were predictors of low birth weight. The proportion of low birth weight among newborns delivered at Wolaita Sodo University teaching and referral hospital was comparable with the global prevalence of low birth weight. Parity, anemia, alcohol, herbal medication, and pregnancy-induced hypertension were significantly associated with low birth weight. Low birth weight has a vital role in determining of newborns survival in a vulnerable condition. It tells fetal exposure to risk factors such as maternal unfavorable socioeconomic conditions, smoking habit, malnutrition, and diseases as well as lack of attention to prenatal care and delivery –3. It alAccording to the world health organization (WHO) definition, babies with a birth weight of less than 2500g regardless of their gestational age are considered as low birth weight newborn .Low birth weight (LBW) is still an important public health problem worldwide. Prevalence of Low birth weight across the globe accounts for 15.5%, which means that each year from 130 million annual births, 20 million is low birth weight . AlthougStudies tested that various Socio-demographic, obstetrics and fetal factors are predictors of low birth weight. An institutional study in the northwest part of Ethiopia revealed being a preterm, absence of antenatal care, and malarial attack during pregnancy, anemia during pregnancy and lack of iron supplementation were the independent predisposing risk of low birth weight .Though Wolaita Sodo University teaching and referral hospital is the only public referral hospital in the zone study on magnitude of low birth weight and its predictors were not available, studies in other parts of Ethiopia cannot represent a current study area due to a difference in socio-cultural, lifestyle and health-seeking behavior across the country.Therefore, this study was aimed to assess the magnitude of low birth weight and its determinants irrespective gestational age and types of pregnancy in Wolaita Sodo teaching and referral hospital. Furthermore, the study will have input for program managers and policymakers in program designing, implementing and evaluating regarding neonatal mortality and also on improving childhood health care.A hospital-based cross-sectional study was conducted in Wolaita Sodo University Teaching and Referral Hospital from December 1 to November 30. The hospital is found in Sodo town which is an administrative capital for the Wolaita zonal administration in South Ethiopia. The town is located at 380 km south from Addis Ababa. WSUTRH is the only public teaching and referral hospital in Wolaita Zone which provides a broad range of medical services to both in and outpatients of all age groups in its catchment area for about two million people. Based on a medical director report for 2017/18, around 3830 deliveries were attended in Wolaita Sdod university teaching and referral hospital in a single year.The sample size was determined by using single population proportion formula with the assumption of 14.9% prevalence of low birth weight in North West Ethiopia , 95% conThe source populations were all neonates with their index mother who were delivered at Wolaita Sodo University teaching and referral hospital and the study populations were all neonates their index mother who were delivered at Wolaita Sodo University teaching and referral hospital during the data collection time.All newborns delivered at Wolaita Sodo University teaching and referral hospital were eligible irrespective of their gestational age and parity except those delivered in other health institution or home but admitted into the hospital.The data were collected through interviewing of a mother using a structured questionnaire, measurement of birth weight and review of medical records. The questionnaire was adapted from previous similar literature –15. It hData were collected by three BSc nurses who had experience of data collection and one-day training was given. The overall supervision was carried out by the principal investigators. A pre-test was conducted on 10% of the similar study population and appropriate modifications were made.The collected data were checked manually for completeness and entered into Epi-data version 3.1 and then exported to SPSS version 20. Univariate analysis was done using frequency and percentage. In bivariate analysis, candidate variables were recognized for multiple binary logistic regressions at a p-value of < 0.05. In multivariable logistic regression, odds ratios and 95% CI were computed and variables with p-value less than 0.05 were considered as significant.Birth weight: the first weight of the newborn which is measured before dischargeLow birth weight: neonate born with a birth weight of ≤2499g . Similarly, maternal co-morbidities during pregnancy, i.e., anemia and hypertension, had shown significant association with low birth weight. Low birth weight among anemic mothers was three times more likely compared with non-anemic mothers . Mothers who had a history of hypertension during current pregnancy were six times higher risk of getting low birth weight newborn compared to those no history of hypertension during current pregnancy.Furthermore, intake of traditional or herbal medication and alcohol during pregnancy has a significant association with low birth weight. Mothers who took traditional medication during pregnancy were thirty-five times more likely to get low birth weight baby than mothers who did not take traditional medication . Newborn from a mother who drinks alcohol current pregnancy was eight times more likely be low birth weight compared to a mother who did not drink alcohol during current pregnancy  .World Health Organization (WHO) defines low birth weight as a birth weight of an infant 2499 gram or less irrespective of gestational age (5). The prevalence and risk factors of low birth vary across ethnicity, geography and economic status of countries. The study was aimed to assess the proportion and associated factors of low birth weight in order to reveal the burden of the problem and the possible local contributing factors. It was supposed that this study provided important information and created an overall image on the magnitude and associated factors of low birth weight at Wolaita Sodo University teaching and referral hospital.The finding of this study revealed that the proportion of low birth weight in the study area was found to be 15.8% (95% CI 11.7-19.9). This finding was consistent with previous studies done in southern Ethiopia 17.88%), northwest Ethiopia (14.9%), Tigray region (14.6%), and Gondar town (17.4%) , 15–17. .88%, norAxum (9.9%), Maichew (6.3%) and Jimma (11.01%) , 18, NigOn the other hand, this finding was lower than a finding in Debre Markose referral hospital Ethiopia (26.3%) . This miMultivariate analyses of this study showed that the odds of low birth weight among primiparity mothers were 5.8 times more likely compared to multipara mothers. This study was in line with the study conducted in Nigeria and India , 25. HowHypertensive mothers were at high risk of getting a low birth weight baby. The study showed that mothers who had a history of hypertension during current pregnancy were 6.9 times higher risk of getting low birth weight newborn compared to those mothers with no history of hypertension during the current pregnancy. This finding was supported by studies done in northwest Ethiopia and Nigeria , 27. ThiThis study also assesses whether traditional  medications have an effect on birth weight of newborn since there is a cultural issue in the study area in which many more traditional malpractices are carried out. This study revealed that low birth weight among mothers who took traditional or herbal medications during the current pregnancy was 35.7 times more likely compared to mothers who did not take herbal medication. This might be due to the harmful effects of traditional medications. Using the traditional or herbal medicine during pregnancy might result in malnutrition, congenital anomaly, tumor or renal failure that had a direct effect on intrauterine growth restriction .The finding revealed that the odds of low birth weight among mothers who had a habit of alcohol drink during the current pregnancy were 8.1 times more likely compared to those who did not drink alcohol during the current pregnancy. This finding was consistent with a study done Axum, Ethiopia . This miMoreover, this study showed that anemia was one risk factor of low birth weight. Low birth weight among anemic mothers was 3.8 times more likely compared with non-anemic mothers. This finding was supported by studies done in northwest Ethiopia and Sudan , 32. ThiThe proportion of low birth weight among newborns delivered at Wolaita Sodo University teaching and referral hospital was comparable with the global prevalence of low birth weight. Primiparity, anemia during the current pregnancy, traditional medication intake during pregnancy, pregnancy-induced hypertension and alcohol drink during pregnancy were predictors of low birth weight. Furthermore, this study recommends for all concerned body troublesome work on perinatal care to achieve sustainable development goal in Ethiopia since the low birth weight has an important role in neonatal mortality.


Objective: The aim of this study was to study growth patterns of children born after suspected fetal growth restriction (FGR) at term and to compare the effect of induction of labor (IoL) and expectant management (EM), also in relation to neurodevelopmental and behavioral outcome at age 2.Methods: We performed a 2 years' follow-up of growth of children included in the Disproportionate Intrauterine Growth Restriction Trial at Term (DIGITAT) study, a Randomized Controlled Trial (RCT) comparing IoL with EM in pregnancies with suspected FGR at term. We collected data on child growth until the age of 2 years. Standard deviation scores (SDSs) for height and weight were calculated at different ages. We assessed the effects of IoL compared with EM and the effects of a birth weight below or above the 3rd or 10th centile on catch-up growth. Target height SDSs were calculated using the height of both parents.Results: We found a significant increase in SDS in the first 2 years. Children born after EM showed more catch-up growth in the first month [height: mean difference −0.7 ] and weight [mean difference −0.5 ]. Children born with a birth weight below the 3rd and 10th centiles showed more catch-up growth after 1 year [mean difference −0.8 SDS ] and after 2 years [mean difference −0.7 SDS ] as compared to children with a birth weight above the 3rd and 10th centiles. SDS at birth had the strongest effect on adverse neurodevelopmental outcome at 2 years of age.Conclusion: After FGR at term, postnatal catch-up growth is generally present and associated with the degree of FGR. Obstetric management in FGR influences postnatal growth. Longer-term follow-up is therefore needed and should be directed at growth and physical health.Clinical Trial Registration:www.ClinicalTrials.gov, identifier SRCTN10363217. Catch-up growth is considered to be a process of compensatory accelerated growth after a period of poor growth intrauterine. Many studies have shown that growth-restricted children show catch-up growth in the first years after birth –6. CatchLong-term consequences of fetal growth restriction (FGR) and catch-up growth have been studied extensively in the last two decades. It is now generally accepted that low birth weight as a consequence of growth restriction is a risk factor for cardiovascular disease later in life –9. It hocomplete or incomplete  trial —a multicP < 0.001) when compared to the expectant monitoring group. Despite this difference in (absolute) weight in favor of the children in the group with expectant monitoring, more babies in the expectant group were severely growth restricted, with a birth weight below the third percentile   .At 2 years of age, a neurodevelopmental and behavioral follow-up study was performed and showed that children with low birth weights, especially if the birth weight was below the 3rd centile, had a greater risk [adjusted OR 3.6 (95% CI: 1.5–8.8)] for abnormal scores on the Ages and Stages Questionnaire (ASQ). The prevalence of these abnormalities was directly related to the severity of growth restriction .The objective of the present study was to (1) analyze whether obstetric management (IoL vs. EM) policy influences catch-up growth, (2) assess whether children born in the DIGITAT trial (participants and nonparticipants) exhibit catch-up growth until age 2, and (3) assess long-term behavioral and neurodevelopmental outcomes in relation to catch-up growth.The study population consisted of children born to mothers who participated in the DIGITAT trial . During Baseline characteristics of the mothers and children were collected at study inclusion and at birth and have been described elsewhere .Z scores were calculated for height, weight, and weight for height at different ages based on, respectively, calculated target height- and population-based growth curves  of their child until the age of 2 years and to report the height of the father. Maternal height was already recorded at baseline. Standard deviation scores (SDSs) or h curves . Head ciNeurodevelopmental and behavioral outcomes of these children were also assessed at 2 years of age using two standardized parental questionnaires: the Ages and Stages Questionnaire (ASQ)  and the We found no commonly used or accepted definition of catch-up growth, and different studies use different definitions. We defined “complete catch-up growth” of height if the measured height SDS minus the target SDS was above −1.6. For weight and for weight for height, an SDS above −2 was used as an indication of complete catch-up growth .SDSs at birth were calculated using birth weight and height centiles, corrected for gestational age, using the formula of Niklasson . “Growtht-test or the nonparametric Mann–Whitney U test. The chi-square test and the Fisher's exact test were used for categorical variables.Continuous variables were presented as means with standard deviations (SDs), or medians with interquartile ranges (IQRs). Differences between groups were presented as differences in means or percentages with 95% confidence intervals (CIs). Continuous variables were compared using the Student's We assessed whether catch-up growth was influenced by the following factors: IoL compared with EM (only for children included in the randomized study), the effects of birth weight below the 3rd or 10th centile, adverse neonatal outcome at birth , birth weight centile, maternal smoking, breastfeeding, and gestational age at birth. Parents of the children included in the trial completed two questionnaires, the Ages and Stages Questionnaire (ASQ) and Child Behavior Checklist (CBCL), for presence of neurodevelopmental and behavioral problems, respectively.t-test. Changes in SDS scores between different time points were calculated and compared between subgroups using non-paired t-tests. Repeated SDS measurements were analyzed using a linear mixed model, which accounts for missing values during follow-up with random person and age effects and fixed group effects. Since the relation between age and SDS scores was expected to be nonlinear, we used quadratic spline functions with knots on 1, 3, 6, 9, 12, and 18 months to model this relation. The results of these analyses are presented graphically.The target height SD score was compared to the actual SD score using a paired We performed a logistic regression analysis to study the effect of gestational age and birth weight SDS. In a second analysis, we studied the additional effect of catch-up growth on the outcome. Multiple imputation was used to handle missing observations.Analyses were carried out in Statistical Package for the Social Sciences (SPSS) 20. The repeated-measures analyses were carried out in R, version 3.02.p < 0.05).Baseline characteristics of respondents (completion of questionnaires) and non-respondents are shown in n = 526) (The response rate was 53% (n = 526) . Of thesA significant increase in SDS in the first 2 years of life was seen . At birtp10) were born with a mean SDS of −1.8 for height (n = 171) and −2.4 for weight (n = 382), and at 2 years of age, the SDS was −1.1 for height (n = 67) and −1.2 for weight (n = 69). For children who were born with a birth weight that equals or was above the 10th centile (>p10), the mean SDS at birth was −1.1 for height (n = 63) and −1.2 for weight (n = 141), and at 2 years of age, −0.4 for height (n = 30) and −0.6 for weight (n = 30). Children born with a birth weight <p10 showed significantly more catch-up growth in weight at age 1 [mean difference −0.8 SDS ] as well as at age 2 [mean difference −0.7 SDS ] when compared to children born with a birth weight >p10 ] and show more catch-up growth in weight particularly in the first month compared to boys ] and weight [mean difference 0.5 ] during the first month after birth. Thereafter, the growth patterns of the two groups were similar , Table 4Children with adverse neonatal outcome had lower SDS birth weight. We did not observe significantly more catch-up growth in this group, but numbers were low . Smokingn = 311) of children, and 84% (n = 335) complete catch-up in weight after 1 year. The mean target height SDS for the entire group was −0.3 SDS; the mean observed SD height score at 2 years of age was −0.9 SD, which is still significantly lower than the expected target height SD (p = 0.000).Complete catch-up growth in height was seen in 86%  .At 2 years of age, the majority of children of the DIGITAT cohort have height higher than 1.6 SD below their target height range and weight above −2 SDS, indicating that catch-up growth is, for the greatest part, complete . HoweverOur study is the first study to compare the effects of IoL with EM on postnatal catch-up growth in FGR. Previous studies have shown that children born after FGR exhibit catch-up growth in height and weight , 9, 12, A weakness of our study is a possible response bias as data were obtained through postal inquiries and data were completed by the parents. We do, however, believe our measurements are reliable, as the children were measured by child health care professionals during routine scheduled child health care visits and parents were asked to provide us with those measurements. Respondents (mothers of the children) were slightly older, smoked less, higher educated, and more frequently Caucasian. Whereas, the percentage of growth-restricted children was comparable between non-respondents and respondents, there might have been more healthy life and feeding styles in respondent families; we do not know, however, to which direction our results would shift if the total sample would have been available. Unfortunately, our response rate was only around 50%, and the number of measurements at the age of 2 years is much lower. Within the group of respondents, we do not expect the group of children of whom we have measurements at age 2 to differ from the group of children without measurements at age 2. We suspect that missing values at 2 years are due to logistical reasons: the questionnaires were sent out around the age of 2 years (22–26 months of age) when a considerable group of parents had not yet been to the child health clinic for the scheduled 2-year visit and therefore did not have the measurements. We, therefore, do not expect a bias in our results, but it does influence our sample sizes.The timing of IoL remains difficult however, as IoL before 38 weeks' gestation increases risks of complications due to late prematurity , 26. TheThe majority of children born after FGR at term exhibit catch-up growth after birth and show complete catch-up growth after 2 years. After an EM policy, more children are severely growth restricted and show more catch-up growth during the first month after birth. A lower birth weight percentile was found as the most important factor influencing adverse neurodevelopmental outcome at age 2.This study has been approved by the ethics committee of the Leiden University Medical Center (Ref. No. P04.210).LW, SC, and KBo performed the analyses, drafted the initial manuscript, and approved the final manuscript as submitted. SS conceptualized and designed the study, interpreted the data, and critically reviewed the manuscript. JP, AW-L, HB, SG, FD, MP, KBl, FR, JL, and BM critically reviewed the manuscript. All authors have seen and approved the final manuscript.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. The handling Editor declared a past co-authorship with one of the authors SS.


Under international law, birth registration is considered a human right because it determines access to important legal protections as well as essential services and social supports across the lifespan. Difficulties related to birth registration and the acquisition of personal identification (PID) are largely regarded as problems specific to low-income countries. For Indigenous people in northern and rural Canada, however, lack of PID, like birth certificates, is a common problem that is rooted in the geography of the region as well as historical and contemporary settler colonial policies. This communication elucidates the complicated terrain of unregistered births for those people living in northern Ontario in order to generate discussion about how the social determinants of health for Indigenous people in Canada are affected by PID. Drawing on intake surveys, qualitative interviews and participant observation field notes, we use the case study of “Susan” as an entry point to share insights into the “intergenerational problem” of unregistered births in the region. Susan’s case speaks to how unregistered births and lack of PID disproportionately impacts the health and well-being of Indigenous people and communities in northern Ontario. The implications and the need for further research on this problem in Canada are discussed. Birth registration is considered a fundamental human right and one that “continues to be overlooked” with regard to its significance as a social determinant of health . AccordiDifficulties related to birth registration and the acquisition of personal identification (PID) are largely regarded as a problem associated with low-income countries with poor civil registration systems ,10,11,12In Canada, a birth certificate is the foundational piece of PID that enables access to most government services and supports like child and family benefits, social housing, social service supports , emergency food supports  and so on. As well, individuals without a birth certificate cannot open bank accounts, which in turn limits one’s ability to receive electronic payments, make significant purchases or establish and build credit. Indeed, the possession or lack thereof, of a birth certificate has cascading and cumulative effects on an individual’s well-being that are all connected with Social Determinants of Health (SDoH) ,15. WhenAccording to the World Health Organization, SDoH are “the environmental conditions in which people are born, grow, live, work and age—conditions that together provide the freedom people need to live lives they value” . For insFor Indigenous people in Canada, settler colonialism and the dispossession of land  have been identified as the most significant of the Social Determinants of Health (SDoH) ,20,21. IThis short communication is an effort to elucidate the complicated terrain of unregistered births and lack of PID for those people living in rural northern Ontario, and is intended to generate discussion about how the social determinants of health for Indigenous people in Canada are affected by PID. We use an illustrative case study as an entry point to share insights that have been generated from a community-based research project, in which we are evaluating the need and effectiveness of an ID services program for the region.Northern Ontario constitutes about 87% of Ontario’s total landmass and is located within the Robinson Superior Treaty and Treaties 3, 5 and 9 , yet theThe size of northern Ontario, particularly the provincial far north, presents unique challenges in regard to health and social services delivery. In northern Ontario, Indigenous people transverse multiple spaces and boundaries when accessing health care services. First Nations residing in northern Ontario live on-reserve, off-reserve and frequently both. In other words, they may live in the city and regularly travel to their home community to visit family, participate in cultural activities and to pursue land and water based food procurement activities .Given the geographic diversity and location of Indigenous peoples throughout the northern portion of Ontario it is impossible for us to definitively count the exact number of individuals whose births were not registered and subsequently do not possess PID. However, an assessment of the challenges and barriers faced by individuals acquiring PIDs and its impact on health outcomes first requires that we hold conversations with community members living in a range of locations: urban, road access reserves (both near and distant from cities and towns) and fly-in access reserves/First Nations. This initial phase of the project is detailed below.During the winter of 2018 we began working with the Kinna-aweya Legal Clinic to evaluate their “Awenen Niin (Who Am I?)” ID Services program. Awenen Niin had received funding through the Local Poverty Reduction Fund to sustain its ID service program. Located in Thunder Bay, the Kinna-aweya Legal Clinic provides “legal advice and assistance to residents of the District of Thunder Bay, particularly Aboriginal people, who need assistance with poverty law issues” . The cliKinna-aweya identified assistance obtaining PID as a pressing and serious gap in service provision and the Awenen Niin Program fills this service vacuum that is not provided by any other agency in Thunder Bay and northern Ontario more broadly, including Service Ontario and Service Canada. Kinna-aweya personnel have specifically identified this problem as situated within a social determinants framework. Our research practice adheres to the principles outlined in “Ownership, Control, Access and Possession (OCAP) or Self-Determination Applied to Research” .This is a community based research (CBR) project that is guided entirely by the needs of our community partner . Our resIt is worth noting that although this issue is largely invisible to non-Indigenous academics and researchers, it has been identified as a serious challenge for Indigenous people and communities for quite some time. It is for this reason that presenting these findings is particularly important and central to using our research for advocacy and raising awareness as part of the community-based research process.N = 116), one-on-one semi-structured interviews with Kinna-aweya personnel and other service providers in Thunder Bay working on ID services (N = 5), informal conversations with Kinna-aweya personnel and health care providers and community organization members (N = 10) and our close involvement with the Thunder Bay “ID Action Group,” which meets monthly to track the progress of local ID services and “ID clinics” and develop advocacy strategies around PID. We have attended and taken field notes at nine of these meetings (N = 9). The ID Action Group consists of health care and social services providers, academics, community organization members, representatives from Indigenous organizations and service providers and other interested stakeholders .Exploration of this issue began in February 2018 when the authors were part of a team invited to serve as independent evaluators for the Kinna-aweya Legal Clinic’s Awenen Niin ID Services program. Qualitative and quantitative data collection began in Thunder Bay, Ontario in June 2018 and is ongoing. Data consist of client ID clinic intake surveys . Without PID people become severely limited in their ability to access health and social services, obtain employment and bank accounts, secure safe housing and enrol in schools to name but a few key services. Significantly, for Indigenous people, a birth certificate that includes parental information is necessary to be legally registered as an Indian under the Indian Act, which in turn enables access to additional health and social services.“Well, Susan’s case is actually about an entire family. So, originally Susan, who is the mom, comes in with her mother, the grandma. Susan’s daughter had been in the grandma’s care since the child was born but we told them in advance that we needed the mom [Susan] to fill out the forms because she’s the parent who gave birth. So, the mother and grandmother are kind of a team and come in together, which itself was a challenge because they both had to take off time from work and take the bus to get here among other issues.It turns out it’s a delayed birth registration situation because the daughter wasn’t registered at the time of birth. So, to register the little one’s birth, you also need mom’s [Susan] birth certificate because you have to include proof of mother’s maiden name when you do a delayed birth registration. Mom [Susan] doesn’t have her birth certificate anymore, so we have to apply for that first before we can begin to apply for the daughter’s delayed birth registration.So, we apply for mom’s [Susan’s] replacement birth certificate and it’s taking a long time. So I call to make an inquiry and eventually we receive it only to find out that the mother’s [Susan] birth place was listed incorrectly on her birth certificate. Who knows how that happened but we’re finding it’s not an uncommon occurrence among our clients to have records with mistakes or inconsistent details. So now we need to apply to amend the place of birth on the mother’s [Susan] birth certificate, which means we now need the Grandma’s birth certificate. Grandma doesn’t have hers, either. So then we order grandma’s birth certificate, which we’re still waiting on.This means we need to pay a fee to fix a mistake that God-knows-who made twenty years ago [on Susan’s birth certificate]. All of this just to get the daughter’s birth registered so she can attend school and receive benefits. Keep in mind this process takes a long time and costs a lot of money for the client and they’re not able to obtain services until the paperwork is fixed and completed.”To illustrate the scope of the problem of PID in the region and the implication it has for the social determinants of health, we draw on the case of “Susan Waboose” (a pseudonym), a young mother who came to the Kinna-aweya ID clinic for assistance with obtaining PID for her daughter who needed PID to enrol in school and to receive non-insured health benefits. We chose Susan’s case because it illuminates the “intergeneration problem”, which happens when multiple generations of one family either lack birth registration or require a replacement birth certificate that has been lost, incorrectly issued in the first place or was never received from the issuing institution. Details about Susan’s case come from our field notes and interview data. According to interviewees, while it was Susan who first initiated the case file at Kinna-aweya, the case quickly became about mother, daughter and grandmother:This case is ongoing and has yet to see resolution wherein the child would be issued her birth certificate so that she can obtain essential services and supports.The case of Susan begins to shed light on a number of issues underlying the difficulty of obtaining PID in northern Ontario, a problem that disproportionately impacts Indigenous people and, in turn, affects their access to health and social services. What is clear from the case of Susan and her family is that for people whose birth was never registered, obtaining delayed birth registration is a complicated, time-consuming and costly process. Yet without this primary record, getting access to health and social services, vaccines, child benefits, schooling and so forth is difficult if not impossible for already under-serviced people.Susan’s case also illustrates that for many Indigenous people living in northern Ontario, this is an intergenerational problem that affects multiple members of a family and has long-term health consequences. There are many reasons that this has become an intergeneration problem for Indigenous people, ranging from the history of residential schools ,34,35; tAs a result of these structural barriers compounded by settler colonialism and geography, this young girl (Susan’s daughter) cannot access services available to most people living in Canada. Exacerbating the matter, the entire family has also not been accessing many essential supports and services for decades owing to the family members’ missing and invalid forms of PID. Significantly, we need to think about the cumulative effects that these decades have had on the health outcomes of each individual as well as the family unit.Since we began using the ID clinic intake forms to generate a client profile in June 2018, 113 forms have been completed (detailing information on 139 clients as parents often apply for multiple children on a single form). Over half of the individuals seeking to obtain some form of PID or register a birth were women. More than 80 percent of these clients identified as Indigenous and 15.9 percent of the clients sought either a delayed birth registration or their first birth certificate. When we presented these data at the monthly ID Action Group, a representative from Service Canada expressed surprise and, indeed, was alarmed at how high the rates were for delayed birth registration and first birth certificate. Clearly this problem is more serious than anyone anticipated as well as unrealized to people outside of these communities.Susan’s case is indicative of many of the stories and experiences that have been shared with us since we began working with Kinna-aweya. Notably, as a function of our mapping process we have come to understand that ID clinics in southern and urban regions of Ontario tend to be organized around replacement ID services (where the birth was registered), a process that is relatively easier and more expedient and less costly than applying for delayed birth registration. It is also uncommon for PID services in southern Ontario to encounter multi-generation families without birth certificates. Indeed, based on our conversations with select service providers in some southern cities of Ontario, they report that it is rarer for them to perform delayed birth registrations. Hence, the problem of PID in Ontario appears to be more pronounced and unique in the rural north and in Indigenous communities.This case study illustrates that the challenge of obtaining PID is a problem even in G7 nations and that the failure to possess this piece of ID can have cascading effects that can be intimately linked to the social determinants of health. Overall, we argue that this is an issue that has gone largely unrecognized as it relates to larger issues of health and well-being and settler colonialism.It is important to note that there are no good data on unregistered births  in Ontario. We have received reports from key informants that certain fly-in access First Nation communities have anywhere from 50–75% of children whose births are unregistered. It is difficult to document or even know the extent of this problem, though Kinna-aweya ID clinics have found many cases. Our work is underway to further explore the extent of unregistered birth among Indigenous people, the structural challenges they face in trying to obtain personal identification and the long-term health consequences of not having PID. It is also important to note that the problem of PID and unregistered births is likely not confined to Ontario or Canada more broadly but most likely affects other settler states with Indigenous populations like Australia or New Zealand.