Objective: Data published from the United States have demonstrated that the use of cervical cerclage has fallen in the period 1998–2013. This is in contrast to recommendations in Australia. We examined this trend using data from the Australian Institute of Health and Welfare (AIHW). Study design: Retrospective population-based study. Methods: Data from the Australian Institute of Health and Welfare procedural database were used to determine the total number of cervical cerclage sutures inserted during the period 2004 to 2013. Population datasets were used to calculate age-stratified incidence rates of cerclage. Findings: There was a significant increase in the rate of cervical cerclage in women aged 25 to 34 years and in the 35 years and older age group. The incidence of preterm birth was stable for gestations of 32 to 36 weeks, but slightly increased in the 20 to 27 week and 28 to 31 week gestational age groups. Further research into cervical cerclage and the use of vaginal progesterone for the prevention of preterm birth would be valuable. Preterm birth is the leading cause of perinatal death, complicating more than 10% of births internationally . In addiThere is evidence that cerclage is superior to no treatment in the prevention of preterm birth and that its use might be associated with a reduction in the risk of perinatal death . However2 (aR2) values, and p-values. This study received prospective approval from the Australian National University Human Research Ethics Committee (protocol 2015/347).Data regarding pregnancy-associated cervical cerclage were obtained from the Australian Institute of Health and Welfare (AIHW) national procedural dataset, collected through the Australian National Health Information Agreement under the auspice of the Australian Health Ministers’ Advisory Council (AHMAC). This is specified in the National Minimum Data Sets relating to hospitals and day procedure facilities, and comprises pooled data supplied by Australian state and territory health authorities. It provides information about procedures performed on admitted patients in hospitals and day surgery facilities. To ensure no pre-pregnancy  cerclage data were included , data was extracted based on the ICD-10-AM  in the procedure chapter XIII, using the ICD specific codes 16511-00 . The data was collected in age bands and extracted to an Excel™ spreadsheet for analysis. To obtain denominators, the total numbers of term and preterm births for each year of the study were obtained from the AIHW Australia’s Mothers and Babies series [2 = 0.47; p = 0.03) and the 28 to 31 week group , but no observed change in the 32–36 week group   over the study period , but, after 2007 (coincident with publication of the RANZCOG guidance), there were significant increases in the 25 to 34 year age group  and the 35 years and older age group   . The incy period . When th< 0.005) .This study of national trends in Australia demonstrates that, since the release of the RANZCOG guideline for the prevention of preterm birth in 2007, there has been a significant increase in the incidence rate of cervical cerclage in Australia, in women 25 years of age and older. This is a direct contrast to data from the United States which shows a fall in the use of cerclage . DespitePreterm birth occurs in about 6%–8% of all births in Australia and up to 10% of all pregnancies worldwide, with no evidence of any decrease in the rate in recent years ,10. PeriVaginally-placed cervical cerclage continues to be an intervention of choice in Australia. The Australasian Society of Ultrasound in Medicine (ASUM) recommends that cervical length should be assessed at the time of the mid-trimester morphology ultrasound . At presPreterm birth is closely linked to cervical shortening; however, this shortening is likely to be one factor in an obstetric complex or syndrome that contributes to preterm labour and birth . CervicaPrematurity is the single most important cause of perinatal mortality and morbidity. Women with documented shortening of cervix in mid trimester and those with a history of previous preterm delivery, recurrent cervical dilatation or previous cervical procedures are at particular risk of preterm labour. There is also consensus data to suggest women who have low progesterone levels are also at risk of preterm birth. Identifying women at risk of preterm delivery and working towards the prevention of preterm birth is topical in current international obstetric literature. Reducing the rate of preterm birth nationally and globally will significantly reduce social and economic costs. To date, no single strategy has been proven to have significant efficacy over another as the aetiology of preterm labour is often multifactorial.Our study demonstrates that the use of cervical cerclage for the management of women at risk of preterm birth has increased in the study period (2007–2013) for women aged over 25 years. This is in a setting where the rates of preterm birth in Australia for babies 20–27 weeks and 28–31 weeks have actually increased, by a small but significant amount. This trend contrasts with the published trend in the US, which demonstrates a movement away from cerclage in favour of vaginal progesterone supplementation to reduce the rate of preterm birth. Cerclage has been the mainstay of management for women at risk of preterm birth for many years. In Australia the RANZCOG guideline supports the use of cerclage. With an awareness and counselling of the risks associated, cerclage clearly still has a place in practice, however in order to challenge and reverse the statistics, comparison between vaginal progesterone supplementation and cerclage would be helpful, in addition to further investigation of the pathophysiology and aetiology of preterm birth and its risk factors.


Rates of normal birth have been declining steadily over the past 20 years, despite the evidence of the benefits to mother and baby. This is most obvious in steadily increasing caesarean section rates across countries and studies of the factors involved suggest it may be more to do with the organization of maternity care and the preferences of healthcare providers than changes in maternal or demographic conditions. The proportion of women in British Columbia (BC) receiving care from a midwife continues to grow and there is a particular focus on promoting and supporting normal pregnancy and birth in the midwifery philosophy of care. In BC, women receiving care from a midwife are less likely to have a caesarean section and other birth interventions.An interpretive approach, based on interpretive phenomenology was used to explore the experiences of midwives in BC of normal birth and the strategies that they use to keep birth normal. Fourteen experienced midwives were purposively selected from across the range of practice, geographical, and rural/urban contexts to participate in depth interviews. Data were analyzed using Thematic Network Analysis.Seven key themes were identified in the data: working with women from the early pregnancy, informing choice, the birth environment, careful watching and waiting, managing early labour, helping the woman to cope with labour, and tools in the tool kit.Midwives in BC work closely with women from early pregnancy to prepare them for a normal birth, and as “instruments of care” they adopt a range of approaches to support women to achieve this. The emphasis on continuity of care in the BC model of midwifery care plays a vital role in this.The online version of this article (doi:10.1186/s12884-017-1323-7) contains supplementary material, which is available to authorized users. In Canada, the World Health Organization’s definition of normal birth see Fig.  has beenWhile CS will be essential in some cases to achieve a safe outcome, the real concern is about the growing rate of unnecessary CSs and its impact on women and their infants. For example, CS is associated with higher rates of maternal mortality, morbidity, infection, hemorrhage, thrombosis, and complications in subsequent pregnancies. For the infant, it is associated with increased mortality and morbidity, admission to neonatal unit, respiratory distress syndrome, and difficulty bonding and breastfeeding . More reA taskforce established in British Columbia (BC) in 2006 to investigate the increasing rates of CS concluded that although the factors that are often blamed on increases in CS rates such as older maternal age, hypertension, diabetes, obesity and multiple pregnancy had increased, “the rate of caesarean birth is rising faster than medical or demographic conditions would justify” . In the Midwifery was established as a regulated profession in BC in 1998 and demand for care from a midwife continues to grow—in 2015, 21% of women had care with a midwife . MidwiveContinuity of care is a key and deliberate feature of the model of midwifery care in BC and to achieve this, midwives work as solo practitioners or in teams of up to four midwives, each midwife can provide care for a caseload of up to 60 women each year, and each midwife is compensated per “course of care” through the province’s universal health insurance . Each woman will see her midwife several times before the birth at visits that last for about 45 min. Most women who have care with a midwife will know the midwife who attends them for the birth and women have the choice of place of birth—hospital, home, or another appropriate setting. Women receiving midwifery-involved care (a midwife was involved in their care but may not have been the delivery provider) in BC in 2014/15 were more likely to have a vaginal birth  and less likely to have a caesarean section  [This study set out to examine the experiences of midwives in BC of normal birth, the challenges that they experience to keeping birth normal and the strategies that they themselves use in their practice.An interpretive approach based on interpretive phenomenology and involving in-depth interviews, was used to explore midwives’ experiences of promoting and supporting normal birth , and between those working as solo, midwifery group and collaborative practitioners (midwives and family doctors sharing a caseload). Following approval from the university Behavioural Research Ethics Board, 16 midwives were approached, provided with verbal and written information on the study and 14 consented to participate.TM and two were conducted by telephone. Interviews lasted for between 45 min and an hour and were recorded digitally. Recordings were transcribed for analysis. Interviews began by exploring what midwives understood by the term normal birth, participants’ experience of normal birth in their daily practice as midwives, any particular challenges they experience and the strategies that they use to maintain normal birth. The focus of this paper is on the strategies that midwives used to maintain normal birth.Interviews provide “a unique access to the lived world of the subjects, who in their own words describe their activities, experiences and opinions”  (p.10). global themes. In this way, the data were explored, thematic networks were constructed and explored, and patterns were summarized and interpreted.Thematic network analysis  was usedBerger  describeThe 14 midwives who participated in the study were from across the range of practice types, urban, rural and remote contexts, and geographical locations in BC and nine participants had more than 10 years experience as midwives see Fig. .Fig. 3Panormal birth. Eleven of the fourteen midwives interviewed raised concerns with the term normal, suggesting the term was academic, only classified after the fact, or culturally defined. Eight midwives preferred the term physiologic, and seven midwives referred to normal birth as an outcome and spoke about working towards a normal vaginal birth.Interviews began by exploring midwives understandings of the term To be honest I feel like I had a really clear definition at one point. It was really clear to me that normal birth was no intervention, healthy woman, healthy baby … I feel like my definitions are shifting quite significantly in terms of what is a normal length of birth, what is the normal length of pushing … why if everything is going well and baby and mum, mum and baby are doing fine, then can we stretch those meanings of normal a little bit more?Two midwives described how what they considered to be normal shifted over time:work against normal labour. They also spoke about the benefits of their experience in terms of developing a range of skills to deal with different situations and in terms of being more tuned into what is happening in particular scenarios.Six midwives spoke about the importance of experience and confidence in their ability to support a normal birth. They talked about how, over time, they became more confident to work to keep the birth normal and to question procedures and protocols that Participants identified and discussed the particular strategies that they used to keep birth normal. Seven key organising themes were identified relating to: 1. Working with women from the early pregnancy, 2. Informing choice, 3. Managing early labour, 4. The birth environment, 5. Careful watching and waiting, 6. Helping the woman to cope with labour, and 7. Tools in the tool kit  for labour:you know a lot of it is attitude like I say and going through the positive part of pain in labour and, and using your rest periods really effectively, not getting ahead of yourself, trying to just stay in one contraction at a time and I teach them that prior to labour but I also reinforce that a lot in labour and then comfort measures like water, we have great showers in our hospital, we don’t have tubs which is unfortunate but it is true the hot water never stops running so lots of my clients spend long times in the shower and different position changes and heat and ice and all of those things that we can use. I definitely like to use all of them—the ball, going up and down the stairs.… Participants talked about the ways in which they help women to cope with labour. These included ensuring women attend prenatal classes, answering women’s questions candidly, being honest with women—I always have held this in my heart—don’t sacrifice the relationship between the mother and baby because you want the woman to have a completely unintervened birth. I’ve seen that many times where a mom is so miserable by the time she has her baby and so exhausted and so out of it that she’s not even happy to see her baby when, you know as you become more and more experienced you realize there are ways that you can help that to be avoided.Midwives also spoke about the need to consider the woman’s ability to cope and that sometimes it is too much to expect the woman to go without interventions:cannot do it anymore, or where the woman has crossed the line between pain and suffering:But then the other situation is really straight up for pain relief when I, most of the time, when I would recommend an epidural is when I see, and am I wondering if that woman is crossing the line between pain and suffering. And so I, when I do offer that I could offer it very judicially and very gently but I would say something like “what I’m seeing here is this, I’m wondering if you might benefit from some pain relief” and basically either they jump on it or they’re like “no, no, I can manage”.Two midwives talked about offering a woman an epidural if she gets to the point where it appears she It’s like tools in your toolkit and you’re filing that away and it’s like that idea of lifelong learning, you’re always going to be adding tools to your toolkit, you shouldn’t let it get full of cobwebs like you need to keep adding to it because there’s always something that’s going to work and make it a little change and for me the mechanics of it … and understanding all of those mechanics and bringing that to the mechanics of the pelvis and how babies come down and all of that and so there is a part of me that kind of, I can think it’s very cool that there are ways that this baby can come down and the more experience you get the more you realize yeah we can nudge this a little bit. Change that position, tilt, do this, do that.The final cluster of themes related to different tools that midwives gather as they become more experienced and that they use in different scenarios to keep birth normal:wisely to keep birth normal:we can run into little obstacles on our way and  there are tools available and mostly they are my clinical skills but occasionally I suggest an epidural or maybe the patient really demands one and I have not enough to offer that she can do without, yeah of course, interventions need to be used wisely in order to achieve that goal … So I’m open to anything … I use a lot of alternative, I pretty much use any tool that is available, hopefully in the right situation to achieve that goal.… Midwives referred to a number of interventions that they used I only have basic training in acupuncture so I sometimes do some, I sometimes send them to a practitioner … so I just do routine things like birth preparation if, induction points, turning the baby if it’s a breech baby so I just do basic things … we have some really good acupuncturist in town so I can send them out. I might use it in labour if her contractions slow down. If she’s not letting go and just I go again a little bit by my feelings and say okay this would benefit her in this situation.Tools also included referring women for acupuncture and one midwife had basic training in acupuncture:And a lot of that is about cervical ripping and stuff so with people who have a history of going postdates, I really encourage them to do stretch and sweeps and acupuncture and we do like cervical ripping tea and stuff like that. So we try to help them get ready at least to help their cervix ripen before we have to do something more serious and then if they don’t have a history, like I would say we do the same, basically the same thing. We just maybe leave it up to them a little more.One midwife referred to approaches she used for cervical ripening for women with a history of post-term birth. Three other midwives referred to using labour cocktail or Verbena cocktail  for the induction of labour:we have a high water birth rate here, mostly because we have this water birth room, which is available with tons of hot water and a big beautiful tub and so essentially if I get them in the room, I get them in the water, I’m listening to the baby, I shut the curtains around the tub, I turn the lights down and I just give them that hour, like 1 to 2 h of kind of privacy where I’m sneaking in to listen to the baby.… Several midwives mentioned using water to help women to cope with pain and discomfort in labour:One midwife referred to rupturing membranes to rotate babies or to move the labour along. Other tools in the toolkit that midwives also referred to included ensuring the woman has adequate nutrition and hydration in labour, keeping the woman active, and homeopathy and hypnotherapy to help the woman to relax and to reduce anxiety.The demand for midwifery care in BC is growing year on year. The promotion of normal birth is a key part of the midwifery philosophy of care and women who have their maternity care provided by a midwife are less likely to have a CS and other interventions. Recent research suggests care with a midwife is as safe as that provided by a family physician or obstetrician, regardless of whether the woman chooses to give birth with a midwife at home or in the hospital –19. The A key theme running throughout midwives’ accounts was continuity of care and the importance of the relationship between the woman and her midwife and of the midwife working with the woman from early in her pregnancy towards achieving a normal birth. In the BC model of midwifery provision, the emphasis is on the woman seeing the same care provider (midwife) for most of her care. A woman may also see mostly the same provider if her care is provided by a family doctor, but women attending for obstetrician-led hospital-based care may see different members of the multidisciplinary team providing that care. In BC in 2014/5, 51% of all women received their care from an obstetrician . A syste®) to help women to rest. In BC midwives may administer Gravol® under Midwives Regulations [A key theme in the data was the importance of managing early labour. Early labour is a time of considerable uncertainty and it can be a very anxious time for women. Women may not know what to expect and they may need and seek reassurance about whether labour has started and when to attend the hospital . Midwiveulations , for itsMidwives also reported encouraging women to stay at home for as long as possible in early labour in order to avoid the interventions associated with hospital. Cheyne and Hundley  suggest The findings also emphasise the importance of women having a supportive birth environment and although midwives suggested that the optimal place of birth to facilitate normal birth is at home, they also described how they were able to adapt a hospital birthing space to facilitate normal birth and suggested that it is the responsibility of the midwife to protect the birth space, regardless of where the birth takes place. A qualitative study in Australia  highlighFahy and Parratt  refer toreally present”. This further highlights the importance of the relationship that is developed between the woman and her midwife. A study of women’s negative experiences in labour [The findings of this study also highlight that in the birth space the midwife needs to be “n labour  found thn labour  found woPerhaps the most significant finding in this study is that midwives judiciously employ a spectrum of interventions to “nudge” labour and birth towards positive outcomes. This study highlights a number of interventions that midwives use to keep birth normal, dispelling the notion of normal labour and birth being free of interventions. Midwives clearly use interventions but these may not be regarded as medical or technological interventions. A study with exemplar midwives  describeThe strengths of this exploratory study lie in the insight generated from the detailed accounts provided by midwives. This is the first study on this topic to be conducted in BC and the findings support to-date anecdotal accounts of midwives’ commitment to promoting and supporting normal birth, some of the challenges they face, and identify a number of topics for further exploration. The limitations of the research include the small sample size overall, and that although the design aimed to allow for likely contextual and practice differences across BC, the very small numbers of midwives within each stratum further limits the applicability of the findings. In qualitative research, decisions about the generalizability or transferability of findings must be made by the reader, but this relies on the researcher providing adequate information on the methods and contexts used in the research . The detMidwives in BC have an important role in promoting and supporting normal birth as “instruments of care”. This begins early in pregnancy, working closely with women to prepare them for a normal birth, ongoing education, informed choice discussions and the management of expectations. Midwives use a range of midwifery skills and midwifery interventions across the course of care to “nudge” the pathway of pregnancy, labour and birth to the normal. The model of midwifery care, which emphasizes continuity of care, is a vital foundation for this.


Maternity histories provide a means of estimating fertility and mortality from surveys.The present analysis compares two types of maternity histories—birth histories and pregnancy histories—in three respects: (1) completeness of live birth and infant death reporting; (2) accuracy of the time placement of live births and infant deaths; and (3) the degree to which reported versus actual total fertility measures differ. The analysis covers a 15-year time span and is based on two data sources from Matlab, Bangladesh: the 1994 Matlab Demographic and Health Survey and, as gold standard, the vital events data from Matlab’s Demographic Surveillance System.Both histories are near perfect in live-birth completeness; however, pregnancy histories do better in the completeness and time accuracy of deaths during the first year of life.Birth or pregnancy histories can be used for fertility estimation, but pregnancy histories are advised for estimating infant mortality. Population-based surveys such as the Demographic and Health Surveys (DHS) play an important role in generating evidence for decision-making, particularly in countries where population-level data are either scarce or of poor quality. DHS always include a module known as a maternity history. A maternity history is used to gather information that is needed to estimate fertility and child mortality, as well as to identify currently living children in order to assess various aspects of child health and nutrition.There are two types of maternity histories: birth histories and pregnancy histories. A birth history collects information from mothers on pregnancies that resulted in a live birth, whereas a pregnancy history collects information on both live births and pregnancy losses . Each type of history can be either backward or forward in time orientation. A backward history starts with the collection of information on a woman’s most recent birth or pregnancy and goes back in time to her first birth or pregnancy. In contrast, a forward history starts with a woman’s first birth or pregnancy and ends with her most recent. In the World Fertility Survey project carried out between 1974 and 1981, pregnancy histories were collected from representative samples of women in over 40 countries . Both prGiven the importance of DHS data in macro-level health planning, it is important to determine the validity of maternity history data. Two types of errors affect the validity of such data: (1) event omission and (2) event displacement in time. Event omission leads to underestimation of demographic indicators derived from the data. Event displacement occurs when the mother inaccurately reports a child’s date of birth, age, or date of death. An event whose timing is incorrectly pushed further back in time than it actually occurred is called “backward displaced,” whereas an event whose timing is incorrectly pushed closer to the date of the interview is called “forward displaced.” Characteristics of the questionnaire, the mother (respondent), the interviewer, and the vital event itself can all contribute to the likelihood of omission or displacement .There have been a number of data-quality assessments involving birth and/or pregnancy histories –18. The Previous assessments have also documented reporting problems such as age heaping and digit preference. However, only two of these assessments , 8 were Completeness of live births, early neonatal deaths, neonatal deaths, and infant deathsDifferences between reported and actual “total fertility”Accuracy of the time placement of live births, early neonatal deaths, neonatal deaths, and infant deathsIn this study, we compare birth and pregnancy histories in terms of the validity of fertility and infant mortality information at the individual level. We test three hypotheses regarding the two questionnaire types—specifically that both types of histories have the same:Testing of the first and third hypotheses is based on individual matching of a woman and her live births, early neonatal deaths, and infant deaths between two data sources described below. The second hypothesis is based on aggregate-level fertility measures.The analyses involve two data sources from Bangladesh: (1) census and vital event data from the Matlab Demographic Surveillance System (DSS) and (2) birth and pregnancy history data from the 1994 Matlab Demographic and Health Survey (MDHS). Each is now described.Matlab, a rural sub-district in southeastern Bangladesh, is home to a DSS that has been operational since 1966. The International Centre for Diarrhoeal Disease Research, Bangladesh  manages the DSS, which covers 149 contiguous villages that are divided into two areas: (1) the Maternal and Child Health Family Planning area (henceforth referred to as the “program area”), where intensive public health interventions have been in existence since 1978 and (2) a comparison area (henceforth referred to as the “non-program area”), where villages are almost exclusively dependent upon government-sponsored programs.The hallmark of the DSS is longitudinal surveillance of the population. At the time of the fieldwork for this study in 1994, Community Health Workers (CHWs) were visiting households bi-weekly in their assigned areas, inquiring about vital events and changes in family composition  and making entries in a notebook. Field supervisors made monthly visits to each household with the CHW and completed event registration forms as indicated: pregnancy outcome, death, marriage, in-migration, out-migration, and divorce .In 1982, ICDDR,B created a DSS Database that consolidates all vital information on each DSS resident. A 10-digit registration number is assigned once to an individual and is permanent. There is a minimum residency of 6 months in the DSS in order to be included in the Database. Although completeness of the DSS data has not been assessed formally, it is a good assumption that vital event ascertainment is near 100 % due to the timely nature of the data collection and quality control. Thus, the DSS is a viable “gold standard” data source for validation of vital event reporting by women in the Matlab population.MDHS Sample: A stratified random sampling design was used, with each of the 149 DSS villages as a stratum and a fixed sampling fraction of 22/300 = 0.073 within each village in order to yield a desired sample size of approximately 3000 women. With this schema, 3,225 households were selected from DSS villages. Of the households selected, 3,037 were occupied dwellings and had persons present and 3009 had completed household interviews. Of 3,480 women age 15–49 in these households, 3039 had completed interviews (a 97.4 percent response rate).Also selected were 250 households from 12 neighboring villages just outside of the DSS area. These non-DSS villages were chosen because they were comparable to the adjacent DSS villages in terms of their geographic, economic, social, and religious characteristics. The comparison of the survey data from respondents in the non-DSS villages with data from respondents in the adjacent DSS villages provides insight on the generalizability of the validation results. In particular, we wanted to test for possible biases of survey responses of DSS women since they have been asked about vital events for so long that they may give more accurate responses than would otherwise be the case. Such a bias is referred to as a ‘contamination effect’ below.Questionnaires: One-half of the MDHS questionnaires contained a standard birth history module (as was used in the 1993–94 BDHS) and the other half contained a pregnancy history module. Both types of maternity history were forward histories and had similar formats, with the exception of three pregnancy history questions on non-live birth pregnancies. (See below.)Data collection: Thirty-two of the 48 interviewers who were involved in fieldwork for the 1993–94 BDHS were engaged to conduct the interviews in the MDHS. Having the same interviewers in both the BDHS and MDHS effectively controlled for interviewer effects. Interviewers administered a birth history or pregnancy history questionnaire by random assignment within each village, i.e., about half received each type.The MDHS took place from April to May 1994, immediately after the 1993–1994 Bangladesh Demographic and Health Survey (BDHS) . The ratData processing: The original MDHS data were entered into the Integrated System for Survey Analysis , and stAn area-level validation study of fertility, infant mortality, and contraceptive prevalence estimates from the MDHS compared to the DSS has been published, noting some discrepancies between MDHS- and DSS-derived estimates . Survey-For the analysis of possible contamination, first, we compared background characteristics of women in the 12 non-DSS villages with those of women in the 17 adjacent DSS villages, and another comparison was with the characteristics of all women in the DSS sample. Second, we compared levels of three indicators of data quality between the DSS and non-DSS samples. If contamination exists, we would expect data quality to be superior for women in the DSS villages. The three indicators were (1) heaping of women’s ages on ages ending in 0 or 5 , (2) the percentage of women who gave a complete birth date (month and year) for all births, and (3) heaping of birth interval lengths on multiples of 12 months.Various pregnancy outcomes  are recorded in a pregnancy history; therefore, mothers who were interviewed using a pregnancy history questionnaire were first asked: “What was the outcome of the pregnancy ?” The following questions further helped to classify the pregnancy outcome based on the mother’s responses: “Did the baby cry or show any sign of life after its birth?” and “How many months did the pregnancy last?”In both the pregnancy and birth history questionnaires, the interviewer identified deaths by asking the mother the following for each live birth reported: “Is (NAME) still alive?” If the mother reported that the child was not alive, the interviewer then asked: “How old was he/she when he/she died?” Deaths occurring before the second birthday were recorded in months, and deaths occurring within the first month of life were recorded in days. (Deaths at 2 years and above were recorded in years.)Early neonatal deaths—live births that die within the first week (0 to 6 days) of lifeNeonatal deaths—live births that die within the first month (0 to 29 days) of lifeInfant deaths—live births that die within the first year (0 to 11 months) of lifeThe analysis focuses on four demographic outcomes: (1) live births, (2) early neonatal deaths, (3) neonatal deaths, and (4) infant deaths. We used the following definitions for the analyses:Validation indicators: The match rate, more specifically, the proportion of vital events of a certain type  documented in the DSS that were also reported in the MDHS, was the main indicator of the completeness of event reporting. Because the DSS was the “gold standard” data source in the analysis, the denominator was the total number of events identified in the DSS during a given time period.The accuracy of time placement can obviously be assessed only for matched events. Date of birth was recorded in the MDHS using either the western calendar or the Bengali calendar.  For each matched live birth, the date of birth was converted to the completed number of months preceding the survey . Time displacement was defined as the difference between the DSS date of birth/death and the MDHS date of birth/death, with both of these dates converted to “months ago”. Given the slight differences in the calendars, the “correct” time placement was defined as the actual minus reported difference equal to zero or within ±1 month.Indicators of displacement for live births were the proportion of matched live births with dates reported: (a) too early , (b) correctly , and (c) too late . The mean number of months backward or forward displaced was also calculated. Another indicator was the mean absolute overall error in months. Key indicators pertaining to the time placement of deaths were the proportion of actual infant deaths reported to have occurred after the first year of life in the MDHS; the proportion of actual neonatal deaths reported to have occurred after the first month of life in the MDHS; and the proportion of early neonatal deaths reported to have occurred after the first week of life in the MDHS.The phenomenon of heaping—or the tendency to report ages or dates ending in certain digits more than others—was explored by calculating the proportion of DSS infant deaths that were heaped on 12 months in the MDHS, and the proportion of DSS neonatal deaths heaped on 1 month in the MDHS. The rationale for examining those two heaping measures was that deaths heaped on 12 months or on 1 month would be excluded from the numerator when calculating infant mortality rates and neonatal mortality rates, respectively.Reference periods: Individual-level validation indicators are presented for a 15-year reference period . Aggregate-level fertility and mortality measures (as described below) are validated for a 10-year reference period (June 1984 to May 1994) and are presented in a manner comparable to that of standard DHS surveys .This analysis examined both individual-level and aggregate fertility measures. As mentioned previously, our study used strict inclusion criteria . Consequently, aggregate-level fertility measures have been calculated for this specific subset of women, not for all women residing in the DSS during the time frame in question. The validity of 3-year (36-month) “total fertility” estimates for this group of women was assessed by first calculating age-specific birth rates (5-year age groups) for the 36-month period before the survey, summing these and then calculating the actual (DSS) minus (MDHS) “total fertility” estimate. We also examined cumulative fertility from age 15 to age 39 for these women. The latter measure was examined because, beyond the most recent 36-month period, it was not possible to calculate age-specific rates for the entire reproductive span (15–49 years) using the MDHS data.  Age-specific birth rates could, however, be calculated for the age range 15–39 for each 36-month period within the 10-year study period.z tests and t tests. These statistics were also used to test for differences between birth and pregnancy histories in the actual minus reported differentials for “total fertility”. The significance of differences in event coverage and time placement was also determined using independent two-sample z tests and t tests. Multivariate logistic regression was used to estimate differences between birth and pregnancy histories in live birth omission while adjusting for other identified determinants of such omission. Children born to the same woman were regarded as being part of the same “cluster.” As a result, the conventional regression assumption of independent observations does not hold so we used regression with generalized estimating equations (GEE) to account for the correlation of events within the same cluster. The analyses were conducted using SPSS and Stata [The significance of differences in event coverage and time placement was determined using independent two-sample nd Stata , 25.Maternal variables: age, years of schooling, parityEvent variables: child’s sex, child’s survival status at the time of the interview; number of months the event occurred before the survey (according to DSS data)Interviewer variables: age, years of schooling, marital statusThe following variables were considered for inclusion in the multivariate model:p < 0.25 were retained. In the multivariate model, variables that did not significantly (p < 0.05) contribute to the model were excluded, and a final model was fit.In the univariate analysis, we used the Wald statistic to determine whether or not a variable would be included in the multivariate model; those with The analysis was based on 1925 MDHS respondents  who were matched with their records in the DSS and who had at least one birth or pregnancy during the 15-year period before the 1994 MDHS . Thus, any observed differences in the validation study outcomes were likely due to the type of maternity history, not to those socio-demographic factors.The DSS women were older, had more years of schooling, and were of lower parity than the women in the adjacent, non-DSS villages. However, only the age difference was statistically significant (top panel of Table p < 0.01), which could be attributed to contamination due to the continuous questioning of women about vital events in DSS households. However, surprisingly, women in the DSS were more likely to report an age ending in 0 or 5 than women in the non-DSS villages , although the difference was not statistically significant. It is interesting to note that a similar “reverse contamination” was documented as part of the 1980 validation study in Matlab [Regarding the indicators of potential contamination, there was virtually no difference between areas in heaping of birth intervals (bottom panel of Table n Matlab . In summResults are now described for each hypothesis in turn.p = 0.07). Among mothers with no formal education and older mothers (30+ years), statistically significant differences exist between the two types of histories, with birth histories having a higher proportion of omitted live births than pregnancy histories (data not shown).Birth and pregnancy histories had virtually identical completeness of live birth reporting at 99 % Table . A childPregnancy histories performed slightly better than birth histories in terms of the completeness of infant death reporting Table ; infant Among infant deaths, the completeness of death reporting was lower for deaths that occurred earlier during the first year of life. For the 10 years preceding the survey, 83 and 81 % of neonatal deaths were captured by pregnancy and birth histories, respectively. Completeness rates were even lower for early neonatal deaths: 82 % of those deaths were captured by pregnancy histories compared with 79 % by birth histories (Table p < 0.25) for inclusion in the multiple logistic regression predicting omission: current survival status of the child, mother’s age, parity, interviewer’s years of schooling, and interviewer’s marital status. These variables, along with a variable on questionnaire type (birth history versus pregnancy history) were included in the logistic regression model. Three covariates remained in the final model: child’s survival status, maternal age, and parity (Table p = 0.050).From the univariate analysis, the following variables were deemed appropriate  and reported (MDHS) “total fertility” for the 36-month period before the survey were small. Cumulative rates to age 39 were also similar for the periods 3–6 years and 6–9 years before the survey Table . Birth hBirth and pregnancy histories performed identically in terms of the correct placement of live births . There was also a strong and significant relationship between displacement and the number of months since the child was born. Twenty-eight percent of live births that occurred 0–59 months before the survey were displaced, compared with 63 and 76 % of live births occurring 60–119 and 120–179 months before the survey, respectively (p < 0.05).Differentials in displacement of births in time were explored according to the sex of the live birth, survival status at the time of the survey, and number of months before the survey. Birth and pregnancy histories performed similarly with respect to displacement according to each of those characteristics. Overall, female births were more likely to be displaced than male births; however, this differential was not statistically significant (not shown). There was, however, a striking observation in terms of displacement according to survival status Table . The datp = 0.015). Corresponding estimates for neonatal deaths were 94 and 90 % in the pregnancy history and birth history samples, respectively; for early neonatal deaths, the corresponding values were 93 and 89 %, respectively . The two types of maternity history were virtually identical with respect to the percentage of matched neonatal deaths heaped on month 1 (3.6 vs. 3.7 %) (not shown).Regarding heaping of age at death , birth histories had a higher percentage of infant deaths heaped on month 12 than did pregnancy histories . Very few such tests can actually document the validity of the collected data. Thus, demographic surveillance systems offer a unique opportunity to assess the validity of birth and pregnancy history data collected in the manner of a typical DHS survey, the primary source of national fertility, and child mortality estimates in many less-developed countries.Our three study hypotheses concerning comparable validity of birth and pregnancy histories were generally supported by the data. The “total fertility” measures calculated after matching cases on an individual level were accurate for both birth and pregnancy histories, and the small differences between the survey and gold standard estimates are fairly consistent with what was observed in a previous area-level validation  that alsWhen calculating woman years for the age-specific birth rates, the present analysis used the DSS maternal date of birth for women less than 28 years of age, not the reported (MDHS) date of birth. Only younger women born in the DSS area had known date of birth, so we could not assess the effect of misreporting of women’s ages for all women. Our analysis of a possible contamination effect was based on women’s reported ages and dates of birth and suggests that there are some inaccuracies in age and date of birth reporting. However, we expect that inaccuracies of maternal age reporting would only have a minor effect on the results.Both birth and pregnancy histories were close to perfect in terms of the completeness of live birth reports; completeness rates were 99 %. The regression analysis showed, however, that when adjusting for the survival status of the child, maternal age at the time of interview, and parity—three factors observed to have a strong, statistically significant association with live birth omission in this analysis—the odds of a missed live birth were two times higher if a birth history was used rather than a pregnancy history. Also for infant deaths, use of a birth history led to significantly more of these being reported at 12 months  than was true for the pregnancy history. Therefore, for estimation of infant and child mortality, a pregnancy history is preferred.Although a pregnancy history is a natural, chronological account of all pregnancies, it will take longer to administer than a birth history because of the additional level of information being asked and recorded. Also, a pregnancy history is more delicate to administer than a birth history since women may not want to discuss pregnancy losses. For example, in contexts where abortion is illegal and/or stigmatized, such pregnancy terminations may be difficult to disclose to an interviewer.Because no previous individual-level validation studies have included both birth and pregnancy histories within the same study, there is no frame of reference against which our findings can be compared. The previous validation study conducted by Becker and Mahmud  in MatlaThere is no significant advantage of one type of maternity history over the other in terms of the time placement of live births. For births that were not correctly placed in time, displacement was symmetric; that is, equal proportions of live births were backward displaced and forward displaced. This finding is contrary to results of previous assessments in which there was a documented greater tendency for backward displacement of live births , 27, 28.Completeness was lower for deaths earlier during the first year of life. In addition, unlike the comparability of birth and pregnancy histories in terms of fertility estimation, when the priority is on measuring mortality within the first year of life, a pregnancy history is the better instrument to use. Deaths are more likely to be omitted in surveys than are surviving children, and this study shows this pattern with the lowest completeness rates for children who died in the early neonatal period. The poorer performance of both types of histories in capturing deaths that occurred during the first month of life is particularly salient given the increased global attention being paid to neonatal health and survival –32.Regarding generalizability of this study’s findings, a number of factors need to be considered. First, long-term exposure of DSS residents to demographic surveillance and public health interventions could render the DSS population quite different from other populations in terms of the recall and reporting of information in a survey. However, in our analyses, only one of three indicators of such potential “contamination” showed evidence of such an effect—98 % of births had complete date information in the DSS area versus 91 % in the adjacent non-DSS villages. Though significant, this is not a major difference that would render the DSS population unique relative to other populations. As a result, the study’s findings are likely to be applicable to other contexts, at least within rural Bangladesh. It is important to note that validation studies like this can only be done where demographic surveillance has been in place for a number of years.Migration is another consideration. This analysis excluded all out-migrants from the DSS including those who returned at a later time. This is not customary for standard analyses of fertility and mortality using population-based surveys. Although one may argue that this exclusion introduces a selection bias, 88 % of all MDHS respondents with any DSS records met the criterion of no out-migration from the DSS area during the 15-year reference period for the analysis. (Note that migration between villages within the DSS area did not pose a problem because of the unique identification numbers that are used.) Thus, migration probably does not pose a significant threat to the generalizability of our findings.It is now possible to conduct validation studies like this one in other sites. In particular, any of the INDEPTH sites with complete and continuous registration of births and deaths for 15 or more years could undertake a similar study . The NavThe ideal data collection system for estimation of fertility and mortality is a vital registration system, but the cost of such a system is prohibitive for many developing countries. The alternative in many countries is a DHS, which includes a full birth history questionnaire that can produce data to estimate fertility and infant and child mortality. There has been a recent movement toward demographic data collection with faster turnaround than the typical DHS. In this vein, mobile phones are now being used by local enumerators to collect questionnaire data in some countries; this platform has been shown to provide results in a much more timely fashion than a DHS .Birth and pregnancy histories are comparable in terms of their completeness of live-birth reports. However, because birth histories are associated with a higher degree of age of death heaping at 12 months, resulting in the exclusion of deaths that should be included in infant mortality calculations, a pregnancy history is the preferred tool for estimating infant mortality. The lower completeness of neonatal and early neonatal death reporting in both types of histories is salient given the importance of neonatal survival as a global priority. Our study’s findings are likely to be applicable to other contexts, at least within rural Bangladesh, although validation studies of this nature can only be done where demographic surveillance has been in place for a number of years.


Objective: The potential of magnetic resonance imaging (MRI) as a technical biomarker for cerebral microstructural alterations in neurodegenerative diseases is under investigation. In this study, a framework for the longitudinal analysis of diffusion tensor imaging (DTI)-based mapping was applied to the assessment of predefined white matter tracts in amyotrophic lateral sclerosis (ALS), as an example for a rapid progressive neurodegenerative disease.Methods: DTI was performed every 3 months in six patients with ALS (mean (M) = 7.7; range 3 to 15 scans) and in six controls  with the identical scanning protocol, resulting in a total of 65 longitudinal DTI datasets. Fractional anisotropy (FA), mean diffusivity (MD), axonal diffusivity (AD), radial diffusivity (RD), and the ratio AD/RD were studied to analyze alterations within the corticospinal tract (CST) which is a prominently affected tract structure in ALS and the tract correlating with Braak’s neuropathological stage 1. A correlation analysis was performed between progression rates based on DTI metrics and the revised ALS functional rating scale (ALS-FRS-R).Results: Patients with ALS showed an FA and AD/RD decline along the CST, while DTI metrics of controls did not change in longitudinal DTI scans. The FA and AD/RD decrease progression correlated significantly with ALS-FRS-R decrease progression.Conclusion: On the basis of the longitudinal assessment, DTI-based metrics can be considered as a possible noninvasive follow-up marker for disease progression in neurodegeneration. This finding was demonstrated here for ALS as a fast progressing neurodegenerative disease. The hypothesis of this study was that DTI metrics alterations in ALS related tract systems correlate to parameters of clinical progression and thus might be used as an additional marker for disease progression.The aim of this study was to correlate Sixty-five longitudinal DTI data sets from six ALS patients and six healthy subjects were recorded with the identical scanning protocol after informed consent; the average time interval between the scans was 3 months (interquartile range 3–4 months). Patients were assessed only if they felt capable for MRI examination. The mean follow-up time was 26 months (range 9–48 months). Patients were 5 males and 1 female , and controls were 5 males and 1 female . All ALS patients were diagnosed according to revised El Escorial criteria , representing 20 gradient directions (GD) and one scan with gradient 0 (b0); repetition time (TR) was 3500 ms, echo time (TE) was 83 ms, and the b-value was 1000 s/mm2, acquisition time was 7 min.Scanning was performed on a 1.5 Tesla clinical scanner . The DTI protocol consisted of 3 × 21 volumes  were aligned to that b0 template. Thus, the bias of the baseline scan  stereotaxic standard space  algorithm , an averaged DTI data set was calculated from control data sets by arithmetic averaging of the MNI transformed data while preserving directional information of individual data sets  bys is the elevation obtained by fitting a regression line. The progression rate (in % per year) for ALS-FRS-R was defined bywhere 0.365 is the mean FA value of controls in the CST and In order to provide an estimation of the reproducibility, the coefficient of variation was determined for the different DTI metrics of controls.The ALS patients showed ALS-associated white matter alterations in general agreement with previous studies . Therefore, this study provides a framework for the analysis of longitudinal DTI data in order to map progressive neurodegeneration. ALS was chosen as an example for a neurodegenerative disease with a generally rapid progression in which a prominent tract structure, i.e., the CST, is affected in the early course of the disease, corresponding to neuropathological stage 1 (Braak et al., In the small sample of subjects, different progression trends could be identified, i.e., controls showed DTI metrics alterations that were in line with standard ageing-related alterations (Salat et al., The present study is limited by the number of subjects but can be considered as an indicator for the potential of the methodology. As an advantage, the identification of tract structures by DTI techniques can be considered rather operator independent in contrast to a region-of-interest analysis. Further, the methodological approach is independent of age so that age-related changes of the DTI metrics (Salat et al., There are some limitations in the acquisition protocol. The examination was done at 1.5T with 20 directions, 1 b-value, and 5 mm slice thickness. The slice thickness was relatively large for FT. However, we have identified the CST with straightforward superior-inferior directionality with sufficient accuracy. If more subtle fronto-dorsal or lateral tract structures or a mixture of the three directions are to be analyzed, a slice thickness of 5 mm might be too large. However, it could be demonstrated that DTI metrics could be assessed as a technical marker even with such a restricted DTI protocol, which should be available at each clinical scanner and could be run in any routine data acquisition. Moreover, the protocol with a short acquisition time of 7 min was well tolerated by ALS patients also in an advanced clinical condition so that it was possible to acquire this higher number of follow-up scans.in vivo biomarker of neurodegeneration which correlates with clinical progression. Potentially, these results will encourage future longitudinal studies in neurodegenerative diseases. Here, the applied methodology might be used to study other tract structures that are specific for the given neurodegenerative disease, e.g., Braak stages in Alzheimer’s Disease (Braak and Braak, This longitudinal DTI-based analysis of structural tract changes addressed the identification of a straightforward, non-invasive, quantitative DB and AK: substantial contribution to the conception of the study, data acquisition, data analysis, critical revision of the manuscript, final approval of the version to be published. IK: substantial contribution to the data acquisition, critical revision of the manuscript, final approval of the version to be published. UB: substantial contribution to the conception and design of the study and the interpretation of the data, critical revision of the manuscript, final approval of the version to be published. MG: substantial contribution to the data analysis, critical revision of the manuscript, final approval of the version to be published. JK: substantial contribution to the design of the study and the interpretation of the data, critical revision of the manuscript, final approval of the version to be published. H-PM: substantial contribution to the conception of the study and the data analysis, critical revision of the manuscript, final approval of the version to be published.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.


As labor may mask a symptom of the rupture of ovarian cyst and delivery is a risk factor of its rupture, the possibility of rupture of ovarian cyst should always be considered during delivery. In recent years, ovarian endometrial cyst during pregnancy has been on an increasing trend, rising to 0.52% Our patient, a 33‐year‐old primigravid, was introduced to our hospital with spontaneous pregnancy complicated by an ovarian cyst. At the initial examination at our hospital, we observed a single 9‐cm cyst in Douglas' pouch that was subsequently diagnosed as an endometrial cyst. As there were no malignant findings, surgery was not performed during the pregnancy Fig. . There wThe oxytocin infusion was discontinued in the evening because no effective labor was achieved despite rupture of the membranes 5 h after labor induction. After the oxytocin infusion was stopped, the uterine contractions continued at 2‐min intervals. The patient had difficulty walking on her own, but this was diagnosed to be due to the labor pain.μL and C‐reactive protein level of 14 mg/dL, indicating a high inflammatory response suspected to be due to an intrauterine infection for which cefmetazole sodium was administered at 1 g every 12 h. As the delivery arrested for 2 h after uterine dilation of 9 cm was achieved, the oxytocin infusion was restarted. The baby was delivered the same day. Because the patient complained of lower abdominal pain even after delivery, nonsteroidal anti‐inflammatory drugs were administered. Thereafter, the patient could walk on her own but complained of intermittent nausea and had poor dietary and water intake, so fluid replacement was required from the second day after birth. Three days after birth, the nausea continued, abdominal pain was aggravated, and upper left abdominal tenderness and rebound pain were observed. Ultrasonography revealed ascites retention and reduction in the ovarian cyst (5.1 cm × 2.2 cm) (Fig. The following morning, delivery progressed to 9 cm of uterine cervix dilation. The patient's body temperature was 36.3°C, but blood sampling revealed a white blood cell count of 26,660/The rupture of ovarian tumors during pregnancy reportedly occurs in 0–5% of the cases During labor, the fetus descends and places pressure on the tumor. In addition, the uterus contracts after delivery, and when there is adhesion between the tumor and the uterus, the tumor is towed with the contraction. Manual compression and fundal massage in the case of postpartum hemorrhage could also lead to tumor compression, increasing the risk of tumor rupture during or immediately after delivery. Therefore, if there are strong complaints of abdominal pain in cases of pregnancy complicated by ovarian cysts, ultrasonography should be performed to evaluate whether the cyst has ruptured. To our knowledge, there were no previous reports comparing the frequency of rupture of the ovarian cyst between its types. However, adhesion is more likely in endometrial cysts than other types of ovarian cyst It is possible that the primary symptom of rupture of ovarian cyst, sudden lower abdominal pain, may be masked during delivery. The clinical symptom of rupture of endometrial cyst is often lower abdominal pain without signs of infection In conclusion, delivery is a risk factor of rupture of ovarian cyst. As lower abdominal pain is a primary symptom of rupture of endometrial cyst, there is a tendency to overlook it as a symptom of labor pain and delay diagnosis as in this case. As a delay in diagnosis may result in severe progression, the possibility of rupture of ovarian cyst should always be considered during delivery.TK: contributed to the finalization of the manuscript. NO and SO: wrote the first draft of the manuscript. AH and YO: performed the surgery. SA and EM: supervised the case report.None declared.


This birth cohort study investigated longitudinal infant growth and associated factors in a multiethnic population living in a low‐resource district surrounding the town of Paarl in South Africa.Between March 2012 and October 2014, all mothers attending their second trimester antenatal visit at Paarl Hospital were approached for enrolment. Mother–infant pairs were followed from birth until 12 months of age. Comprehensive socio‐demographic, nutritional and psychosocial data were collected at birth, two, six and 12 months. Infant anthropometry was analysed as z‐scores for weight and height. Linear regression was used to investigate predictors of birthweight, and linear mixed‐effects models were used to investigate predictors of infant growth.Longitudinal anthropometric data from 792 infants were included: 53% were Black African, 47% were mixed race, and 15% were born preterm. Stunting occurred in 13% of infants at 12 months. Maternal height, antenatal alcohol and tobacco use, ethnicity and socioeconomic status were significant predictors of birthweight. In the adjusted mixed‐effects model, birthweight was a significant predictor of growth during the first year of life.Birthweight was an important predictor of growth trajectory during infancy. Birthweight and growth were influenced by several important modifiable factors. AGAAppropriate for gestational ageBMIBody mass indexBMIZBody mass index for age z scoreHFAZHeight‐for‐age z‐scoreIPVIntimate partner violenceIQRInterquartile rangeLBWLow birthweightLMICLow and middle‐income countriesSESSocioeconomic scoreSGASmall for gestational ageWFAZWeight‐for‐age z‐scoreWFHZWeight‐for‐height z‐scoreWHOWorld Health OrganizationThis large cohort study investigated the factors associated with birthweight and longitudinal infant growth in a resource‐poor setting.Birthweight was a major predictor of growth trajectory during infancy, after adjusting for socioeconomic status, ethnicity, prematurity and intra‐uterine growth restriction.Alcohol or tobacco consumption during pregnancy was high in this population and was associated with both poor birth outcomes and poor postnatal growth during infancy.Childhood malnutrition, which encompasses both undernutrition and overweight or obesity, is highly prevalent in low‐ and middle‐income countries (LMIC) South Africa comprises multiethnic populations, with varying socioeconomic circumstances, psychosocial factors, disease exposures and cultural practices. Differences in child growth patterns may occur in such population groups, and these reflect genetic or environmental factors or a combination of these Few cohort studies from LMIC have investigated child growth longitudinally, and no longitudinal studies of growth patterns in South African infants from different ethnic backgrounds have been carried out. The aim of this study was to describe patterns of growth and factors that had an impact on growth in South African infants enrolled in the Drakenstein Child Health Study.The primary aim of the Drakenstein Child Health Study birth cohort was to investigate the epidemiology, risk factors, aetiology and long‐term impact of respiratory illness on child health, including investigations into growth and nutrition in early childhood Pregnant women living in a resource‐poor area surrounding an agricultural town were enrolled during their second trimester of pregnancy at two primary healthcare facilities serving different ethnic communities: TC Newman serving a mixed race community and Mbekweni serving a Black African community. This means that the two clinics were synonymous with ethnicity. Women who were less than 18 years of age, those who were unable to provide informed consent or those who intended to leave the area within a year were excluded. All the infants that were born to mothers enrolled into the study were included in the analysis. All pregnant women who were enrolled into the study received standard antenatal care at a single district level hospital.Socio‐demographic and health information were obtained from questionnaires administered to the mothers during antenatal and postnatal study visits. Four socio‐demographic variables were used to generate a relative socioeconomic score (SES): education, employment, household income and assets. Participants were stratified into quartiles based on their SES score. These quartiles were labelled as low, low‐to‐moderate, moderate‐to‐high or high SES, to enable comparisons within the study population All births occurred at a single public hospital, Paarl hospital, which provides general hospital and emergency care for a population of more than 600 000 people living in a vast geographical area of approximately 22 500 square kilometres. It is based in a predominantly semirural region 60 kilometres from Cape Town in the Southern tip of South Africa.Birthweight and length were measured at the hospital. Gestational age at birth was estimated based on an antenatal ultrasound carried out in the second trimester (68%), and if this was unavailable, then fundal height (28%) or maternal recall of the last menstrual period (4%) was used. Trained study staff collected serial anthropometric measurements on the infants at two, six and 12 months. The infant's length was measured in centimetres to the nearest completed 0.5 cm, and their weight was measured in kilograms to the nearest completed 10 g, according to standard operating procedures. Maternal height was measured to the nearest 0.1 cm at enrolment, using a wall‐mounted stadiometer. The birth anthropometrical measurements were conducted by trained labour ward staff, and the birthweights and lengths were obtained from the patients’ folders. When we compared the labour ward staff measurements of infant anthropometry with study staff measurements in a subgroup of patients, we found no significant differences.Weight was measured, in the light or no clothing, using the TAN1584 digital platform scale  and recumbent length using the seca210 length‐measuring mat . The latter was performed on a firm surface by two staff members. The equipment was calibrated weekly. All anthropometric measurements were carried out twice for each child, with a third measurement if the difference between the first and second measurement differed by more than 0.5 cm for length or more than 0.5 kg for weight. Study staff underwent regular anthropometric training and assessment every three months, and this was conducted by the lead anthropometrist.Four time points were used for the purposes of this analysis: birth, two, six and 12 months of age. A valid anthropometric measurement was within four weeks before or after that time point.With regard to nutritional information, the infant feeding practice was categorised based on the World Health Organization's (WHO) Infant and Young Child feeding indicators, namely exclusive breastfeeding or bottle feeding, which included infant cows’ milk‐based formula with or without breastmilk or semisolids Validated questionnaires were administered to mothers antenatally and six weeks postpartum to assess psychosocial factors Birthweight and length were converted to z‐scores for gender and gestational age using the INTERGROWTH‐21st standards The weight and length measurements following birth were converted to z‐scores based on age and gender, using Anthro software  t‐tests or Wilcoxon rank‐sum tests (Mann–Whitney tests) for continuous variables.Growth patterns in the study population were analysed at each time point by calculating the median WFAZ and HFAZ as well as between the time points by calculating the difference in WFAZ and HFAZ. At each time point, indicators of malnutrition were calculated so that infants with an HFAZ <−2 were classified as stunted, those with a WFAZ <−2 as underweight for age, those with a WFHZ <−2 as wasted and those with a BMI for age >2 as overweight and >3 as obese. Growth patterns and indicators of malnutrition were stratified by study site, in other words ethnicity. Significant differences in WFAZ and HFAZ, indicators of malnutrition, and changes in WFAZ and HFAZ between time points were identified using chi‐square or Fisher's exact tests for categorical variables and a priori interest. For all models, regression coefficients with 95% confidence intervals (95% CIs) were calculated to determine the strength of these associations.Variables significantly associated with infant WFAZ at birth were explored. Two linear regression models were built to investigate maternal height and antenatal smoking, based on urinary cotinine levels, as independent predictors of Based on the literature, known variables associated with infant growth during the first year of life were explored using linear mixed‐effects models. Ethnicity and SES were included as fixed effects and WFAZ at birth and age at time of study visit were included as random effects. Three models were built. The first adjusted model (model one) included all variables that were significant in the unadjusted model. The final model (model two) only included the variables that remained significant in model one.The statistical analysis was conducted using Stata 12 .Ethical approval was obtained from the University of Cape Town, Faculty of Health Sciences Human Research Ethics Committee and the Provincial Child Health Research committee. Written informed consent was obtained from all the participants.From March 2012 to October 2014, we enrolled 789 mothers with a median age of 25.7 (21.8–30.7) years who had given birth to 792 infants, including three pairs of twins Table . We exclThe study population had a predominantly low income, with 43% of households earning below the minimum wage of 5000 South African Rands per month The median gestational age at birth was 39 weeks, but 15% of babies were born preterm Table . Of the Malnutrition, either under or over nutrition, occurred consistently throughout infancy Table . StuntinIn the unadjusted models of infant WFAZ at birth, ethnicity, household income, gravidity, maternal alcohol and tobacco use, recent IPV and maternal height were significantly associated with lower WFAZ at birth Table . Only vaIn the univariate analysis, birthweight, ethnicity, SES, antenatal and postnatal IPV and antenatal and postnatal maternal substance use – specifically alcohol or tobacco – were significantly associated with infant growth, as measured by repeated WFAZ measurements over the first year of life Table . HoweverIn this South African birth cohort, we found a high prevalence of LBW and SGA infants and a mean WFAZ at birth below the WHO reference population. Despite some catch‐up growth, a substantial prevalence of childhood stunting was observed in this sample. Black African children had better nutritional status from birth that persisted throughout infancy compared to mixed race infants. We also demonstrated an emerging group of overweight and obese infants, with a higher prevalence among black African infants. Antenatal maternal smoking and alcohol consumption and maternal height were important independent predictors of infant birthweight. Birthweight, SES, ethnicity and maternal antenatal alcohol and tobacco consumption were important determinants of the infant's longitudinal growth during the first year of life.Our results were consistent with studies that showed that birthweight was a strong determinant of longitudinal infant growth in the first year We demonstrated the independent negative effects that smoking and alcohol consumption during pregnancy had on both birthweight and postnatal infant growth, which persisted after controlling for SES and ethnicity. This may have been partially mediated through the effects of alcohol and tobacco on foetal growth Socioeconomic score (SES) was an important determinant of infant growth. Consistent with other studies in LMIC, higher SES promoted infant growth We found a high prevalence of stunting in this sample, particularly at two months of age, with a marginal decline by 12 months of age. These results were consistent with cross‐sectional South African studies that have reported a similar high prevalence of stunting in children In contrast, we also found a concerning prevalence of overweight or obese infants. To the best of our knowledge, no previous studies have documented the prevalence of overweight and obese infants in South Africa. These findings may reflect changes in lifestyle, diet or poor feeding practices The strengths of this study included the prospective design with good cohort retention, the longitudinal measurements of multiple parameters of infant growth by trained study staff, the inclusion of two ethnically distinct South African population groups and the collection of comprehensive SES, maternal and nutritional information. In addition, using mixed‐effects modelling of growth enabled us to model individual growth trajectories, which are by nature comprised of repeated, dependent measurements over time, in a single model. This added to the quality of our results. Some limitations also need to be noted and these were that these findings may not be generalisable to other African or LMIC populations. However, many of the factors explored in this analysis are highly prevalent in LMIC.This was the first study of this magnitude to evaluate longitudinal growth in a developing county during the first year of life, including multiple maternal, infant, psychosocial and environmental risk factors that have been associated with poor infant growth. It highlights some of the adversities that children in developing countries face, which arise as early as intra‐uterine life.Our findings of the predictive nature of birthweight on growth trajectory during infancy emphasise the importance of maternal health and antenatal care on infant growth. Simple, cost‐effective interventions that focus on maternal health, such as programmes to reduce alcohol consumption and smoking and improve nutrition, may improve birthweights and subsequent postnatal growth, thereby promoting child health. Further studies are required to investigate environmental and genetic determinants of infant growth in LMIC.The Drakenstein Child Health Study is funded by the Bill and Melinda Gates Foundation (OPP 1017641), The Discovery Foundation, South Africa, The South African Medical Research Council, GlaxoSmithKline (GSK)/South African Thoracic Society, The Harry Crossley Foundation and The Hamilton‐Naki FoundationThere authors have no conflicts of interest to declare.Figure S1 Flow chart of infants included at each study visit between March 2012 and October 2014.Figure S2 Longitudinal infant WFA z scores stratified by prematurity and weight.Table S1 Mixed effects model of variables associated with infant weight‐for‐age z‐scores  at 2 months, 6 months, and 12 months; infants born preterm and/or SGA excluded.Table S2 Mixed effects model of variables associated with infant weight‐for‐age z‐scores  at 2 months, 6 months, and 12 months; restricted to infants born preterm and/or SGA.Click here for additional data file.


Preterm birth (born before 37 completed weeks of gestation) is one of the leading causes of death among children under 5 years of age. Several recent studies have examined the association between extreme temperature and preterm births, but there have been almost no such studies in arid Australia. In this paper, we explore the potential association between exposures to extreme temperatures during the last 3 weeks of pregnancy in a Central Australian town. An immediate effect of temperature exposure is observed with an increased relative risk of 1%–2% when the maximum temperature exceeded the 90th percentile of the summer season maximum temperature data. Delayed effects are also observed closer to 3 weeks before delivery when the relative risks tend to increase exponentially. Immediate risks to preterm birth are also observed for cold temperature exposures (0 to –6 °C), with an increased relative risk of up to 10%. In the future, Central Australia will face more hot days and less cold days due to climate change and hence the risks posed by extreme heat is of particular relevance to the community and health practitioners. Preterm birth (born before 37 completed weeks of gestation) is one of the leading causes of death among children under 5 years of age . PretermIn 2013, around 9% of Australian babies were born preterm . Risks fIn addition to the factors above, environmental parameters such as temperature, humidity, ozone, carbon monoxide, nitrous oxide and particulate matter may also be important factors affecting preterm birth and have been the focus of recent studies ,10,11. HGlobal model simulations indicate that the number of comfortable thermal days is likely to decline due to atmospheric warming in many parts of Australia . The heaIn this paper, we evaluated whether high ambient temperature increases the risk of preterm birth in a Central Australian town of the Northern Territory. We hypothesised that extreme heat conditions in Central Australia could exert maternal stress and thus there is likely to be an association between maximum temperatures and preterm births for this region. In the Central Australian region, the majority of communities are classified as “remote” or “very remote” locations mainly due to their distances from essential services. In this paper we focus on Alice Springs, Central Australia’s major town that serves a population of 25,186 people, of which 19% are Indigenous [Alice Springs has a semi-arid climate, with a low and variable rainfall. The annual rainfall and average temperature for the region is around 260 mm and 29.5 °C (average of the past 10 years according to the Bureau of Meteorology Alice Springs airport station data) respectively. Climate projections indicate a rise in temperature for this region in the range of 1.6–7 °C by 2100, as well as an increase in the number of hot days and a decrease in the number of cold nights . The proAll pregnant women living in remote communities  in the Central Australia region are advised to move to Alice Springs from around 34 weeks to ensure safe delivery. The Alice Springs Hospital (ASH) is the only obstetric services provider in Central Australia. Our analysis is confined to Alice Springs  to avoid the effects of spatial variation in temperature within Central Australia. http://www.bom.gov.au/climate/data/) were used for the analysis . Data for the Central Australian region was obtained from the NT Department of Health for the purpose of this study. Ethics approval to access the data and conduct this research was obtained from the Central Australian Human Research Ethics Committee (CAHREC) and the reference number is HREC-15-326. This data collection consisted of 26460 patient records spanning the period from 1 January 1986 to 31 December 2013. Preterm birth was defined as birth before 37 weeks of gestation. Total births considered for the temperature effects analysis were restricted to live singleton births at the Alice Springs Hospital during the period of 1986–2013. Elective caesareans and data records with missing date of births and gestational age were excluded. Emergency caesareans and induced labour were included as the dataset did not contain details on the reasons for these. Data items obtained included information on maternal age, alcohol and smoking status, history of certain diseases such as STI , UTI (urinary tract infection), cardiac disease, anaemia, epilepsy, gestational diabetes, renal disease and syphilis, pre-existing maternal conditions such as diabetes and hypertension, plurality, gestation age, Indigenous status, place of residence and birth, gender of baby and birth weight. A Poisson Generalised Additive Model was used to account for over-dispersion to examine the short-term effects of temperature on the risk of preterm birth . DistribFollowing , a flexiThe pregnancies at risk model , originahe issue ,30. The In this study, a 22-week window  is used to calculate the pregnancies at risk counts. After applying the exclusion criteria to the dataset obtained from the Department of Health, the dataset included 16,870 single natural births that took place during the period of 1986–2013, with a mean daily count of 1.65 births per day see . The datIn the Poisson Generalised Additive Model run with data of both Indigenous and non-Indigenous pregnant mothers, maximum temperature and minimum temperature were statistically significant parameters (significance level of 5%). The same model was run after separating the data for Indigenous and non-Indigenous mothers. Daily maximum temperature and age of mother were significant (significance level of 5%) when the model was run on Indigenous data. Maximum temperature, anaemia, gestational diabetes and maternal age were significant (significance level of 5%) among the data for non-Indigenous mothers. Smoking status and alcohol status were also significant, but these variables were dominated by the option ‘not stated’. The results have been mainly focused on the whole data set, as the sample size is considerably reduced when the data sets are separated, especially for the Indigenous population. The association between both maximum and minimum temperature with preterm birth was modelled for up to 3 weeks before delivery. The relative risks (RR) of preterm birth were assessed against the following temperatures: the median of summer season at 37 °C; the 90th percentile of the summer season (41 °C); the 95th percentile of the summer season (42 °C); the 99th percentile of the summer season (43 °C); and the maximum temperature recorded (45 °C). The median temperature of the whole temperature record (30 °C) is used as the reference temperature. The relative risk of preterm birth was greater than 1 from temperatures 41 °C to 45 °C see . An immeThe lag-specific relative risk estimates  for different temperatures  are plotted in The cumulative effects of exposure to maximum temperatures greater than 40 °C were statistically significant . An effeThe association of minimum temperature with preterm birth is also modelled. The RR of preterm birth is peaked at minimum temperatures at around 0 °C at some lower and higher lags. There seem to be lower RRs at other minimum temperatures see a. FigureLag-specific relative risk estimates  for different minimum temperatures  are plotted in The cumulative RRs for 21 days before delivery for minimum temperature was statistically significant for temperatures between –6 and 0 °C see . An effeIn our study that focused on Alice Springs in Central Australia, a location which has extreme hot weather conditions and a high preterm delivery rate relative to the rest of Australia, we found that extreme hot and cold temperatures increase the relative risks of preterm birth. In the Poisson Generalised Additive Model run with the whole dataset (Indigenous and non-Indigenous), temperature dominates other explanatory variables such as Indigenous status and maternal age. Daily maximum temperatures and age of mothers were significant when the model was run using only the Indigenous population data. Maximum temperatures, anaemia, gestational diabetes and maternal age were significant when the model was run using the non-Indigenous pregnant mother dataset. The significant effect of maximum temperature is of particular relevance to health policy as Alice Springs is projected to become warmer as the climate changes. Our findings are consistent with that of several other studies that have observed an association between temperature extremes (extremely hot and cold days) and shorter gestational deliveries ,15,16,17While the analyses show that cumulative effects of exposure to temperature >40 °C for 3 weeks before delivery can increase the relative risks by around 8%, such extreme temperature events have not yet been recorded for Alice Springs. Recently, i.e., in February 2015, 21 days with a temperature maximum of >35 °C was recorded for Alice Springs. It has to be noted that while temperatures may not stay above 35 °C continuously across all the summer months, the majority of the days during summer have a temperature >35 °C. Consider that a heatwave is defined as days with temperature >40 °C consecutively for 3 days. If we assume linear increment of relative risk across days, then the increased relative risk for such events should be around 1.14%. While such events have not been recorded in historical data, such future events could occur in Alice Springs. The annual average number of days over 35 °C in Alice Springs is projected to increase from a current value of 89 to somewhere between 96 and 125 days by 2030 . If suchImmediate risks to preterm birth is also observed for cold temperatures, with an increased risk of more than 10% observed for extremely cold temperatures such as –6 °C. Lower immediate risks are observed for temperatures between –6 °C and 26 °C. The immediate increase in relative risk due to the extreme cold temperature recorded (–6 °C) is higher than that of the extreme hot temperature recorded (45 °C). The effects of minimum temperatures are likely to be milder for Alice Springs in the future, given that minimum temperatures are projected to increase under climate change. Delayed effects are observed for both minimum and maximum temperature exposures as observed in . The warmer temperature projections for locations in Central Australia would mean that the relative risk of preterm birth is likely to be higher in the future. This is of particular relevance to health practitioners as they need to create awareness among pregnant women to reduce their exposures to extreme heat during the summer months and take necessary precautionary actions. While this study focuses only on Alice Springs, it has relevance internationally as we anticipate similar results in other hot desert towns. The analysis conducted in this paper is limited by (i) the small number of births in Alice Springs; (ii) the availability of data for other confounding variables; (iii) inadequate information in the NT Midwives dataset we had obtained; and (iv) model design. Firstly, the dataset analysed is quite small compared to many recent studies that were conducted in New York , China , Spain , BrisbanIn the NT Midwives Data Collection, there were no details on medications provided to delay labour. Early labour could be prolonged through medication, but the available data set does not account for that, so the potential number of natural pre-term births could be underestimated. The methods used to calculate gestation age  may have different accuracies. The exact methods used for determining the gestational age were unknown. Also, gestational ages were approximated as whole weeks and not available as days and weeks in the dataset. Alcohol consumption and smoking during pregnancy have been found to have an effect on preterm birth in other studies ,33. It iTime of delivery was not available in the dataset. A more accurate analysis would have required time of delivery and hourly temperature data, especially because immediate increase to the RR of preterm birth was observed in the study. Temperature data used in the analysis originates from the Alice Springs airport station, which is around 10 km away from the town and hence may not precisely represent the temperature conditions of the Alice Springs town area.In the absence of any complications, pregnant women from far remote communities are requested to arrive and stay in a resident hostel in Alice Springs around 6 weeks before their due date. This would mean some of the preterm deliveries in Alice Springs Hospital may have been exposed to different temperature and humidity conditions. The model was designed to understand the effect of the temperature variables up to 3 weeks before delivery. The analysis clearly shows that delayed effects are observed within the three week period, and hence examining the effects of temperature beyond three weeks may also provide more insights. However, then spatial variation of temperature will have to be accounted for in the case of pregnant women who travel from remote locations. In conclusion, the study summarises that extreme maximum and minimum temperatures increase the risk of preterm birth and the effects are influenced by the values of the temperature. The effects of pollution, which may be significant, could not be considered due to data unavailability. Air quality monitoring, more precise temperature measurements and analysis on longer term temperature exposures are required. The main finding from this study is that pregnant women may have to reduce exposure to extreme temperatures in Central Australia. Awareness on the potential risks of exposure to extreme hot and cold conditions and recommendations on how to reduce their effect should be disseminated through health care organisations. A range of behavioural responses, environmental modifications and technological adaptation may also be required to reduce the effects of temperature exposure to pregnant women.


Relative to women who had a single childbirth, the adjusted HRs were 1.17 (95% CI = 0.51–2.69) for women who gave birth to two children, and 1.31 (95% CI = 0.56–3.10) for women with three or more childbirths, respectively. These results were not statistically significant. Study results suggests that giving birth at an early age may confer a protective effect on the risk of death from BC.The evidence is limited on the relationship between reproductive factors and bladder cancer (BC). We studied 1,292,462 women who had a first and singleton delivery between 1 January 1978 and 31 December 1987. Each woman in the study cohort was tracked from their first childbirth to 31 December 2009. Vital status of the women was determined by crosswalking records with a computerized mortality database. We used Cox proportional hazard regression models to estimate the hazard ratios (HRs) of death from BC associated with maternal age at first birth and parity. The data showed 63 BC deaths during 34,980,246 person-years of follow-up. BC mortality rate was 0.90 cases for every 100,000 person-years. Compared with women who gave birth under the age of 23, the adjusted HR was 1.24  = 0.66–2.35) for women who gave birth between age 23 and 26 and 2.30 (95% CI = 1.21–4.39) for women who gave birth over the age of 26. Increasing age at first birth ( In Taiwan, bladder cancer (BC) ranked 12th and 11th among leading causes of cancer mortality for men and women, respectively [Tobacco smoking and exposure to industrial chemicals at work are established risk factors for BC ,4,5,6,7.Substantial epidemiologic evidence supports the hypothesis that endogenous hormones affect the etiology of several types of neoplasms, especially for cancers such as cancers of the breast and ovaries, which are hormone-dependent. Ceteris paribus, parous women have reduced risks of breast and ovarian cancers. The younger the age at first birth, the lower a woman’s risk is for developing these cancers, but the association between age and risk is complex . There iLimited data exist as to the relationship between BC and reproductive factors ,24,25,26Taiwan law requires the registration of births. Within 15 days of the childbirth, parents or the family must register infant births at a local household registration office. Since 1978, data on all live births are released by Taiwan’s Birth Registration System, which is managed by the Department of Interior. Physicians attending the birth complete the live-birth registration form, which includes information on maternal age, education, parity, gestational age, date of delivery, infant gender, and birth weight. Most deliveries in Taiwan occur in either a hospital or clinic . As a ren = 100,099), years of schooling (n = 382), marital status (n = 2665), or birth place (n = 4535). After removing data with missing observations, we were left with 1,292,462 women with complete information for the analysis . Using this ID, we tracked the subject from the time of her first childbirth to 31 December 2009, and her vital status was verified via linking with the computerized mortality database, which permitted us to identify the date of any deaths. No subjects had a missing ID number among the 1,292,462 women followed, so we were able to follow all cohort members over time. Because the registration of deaths at local household registration offices is also mandated by law, the death statistics in Taiwan are considered to be highly accurate and complete ,31.p values < 0.05).We calculated the person-years of follow-up for each subject from the date of first childbirth to the date of death or 31 December 2009. We calculated mortality rates by dividing the number of BC deaths by the number of person-years of follow-up. Cox proportional hazard regression models with time-varying covariates were used to estimate the hazard ratios (HRs) of BC death associated with parity  and age at first birth. We also calculated the 95% confidence intervals (CIs) for the HRs. A cause of death resulting from primary BC is defined using the International Classification of Disease, Injury, and Causes of Death (9th revision) (ICD code 188). Age at first birth was divided into tertiles based on the entire cohort . Our final model included the variables age at first birth, parity , marital status , years of schooling , and birth place . Both years of schooling and birth place were used as surrogate measures for socioeconomic status. We assessed the proportional hazards assumption for all of the aforementioned variables, and detected no violations. To test for trends in BC mortality risk with increasing levels (parity and age at first birth), we assigned ordinal numbers to the categorical variables for parity and median for age at first birth, and estimated our risk models with these variables as continuous variables. The statistical significance of the corresponding coefficient were assessed using the Wald test . AnalyseA total of 1,292,462 primiparous women with complete information were included. Our selection criteria resulted in 34,980,246 person-years during the follow-up period from the time of first childbirth to 31 December 2009. We observed 63 BC deaths, representing a mortality rate of 0.18 cases per 100,000 person-years. None of the 63 BC deaths resided in a township where black foot disease was endemic (a surrogate of high arsenic exposure).In p for trend = 0.01).p = 0.58). This may be due to the relatively small number of BC deaths.The HRs adjusted for age at first birth were 1.17 (95% CI = 0.51–2.69) for women who gave birth to two children, and 1.31 (95% CI = 0.56–3.10) for women who gave birth to three or more children, respectively, relative to women who gave birth to only one child. Our results suggest that increasing parity appears to be moderately associated with an increased risk of BC death. However, these results were not statistically significant, and there was no clear trend with parity  and therefore would tend to underestimate rather than overestimate the true association. Access to population-level data and follow-up made possible by the national ID made it likely that selection bias is not a significant confounder in our study. Information bias is also not likely to be significant for parity and age at first birth.In 1995, Taiwan implemented its National Health Insurance (NHI) program, which covers healthcare needs for all citizens of Taiwan. By 2007, the NHI program provided coverage for 22.60 million out of 22.96 million Taiwanese citizens (coverage rate of 98.4%) . Taiwan Several limitations of this study must be noted. First, Taiwan’s vital statistic and birth registration system records only live births and not stillbirths and abortions. It was therefore not possible for us to examine the potential influence of gravidity on BC risk. Secondly, our study focused, by design, solely on mortality among women who had given births, and we were not able to examine the possible role of nulliparity on the risk of BC. Our findings therefore have limited generalizability. Third, two studies have reported that hormone replacement therapy (HRT) was associated with an increased risk of BC ,40. OtheWe conclude that increasing parity may be associated with a moderately increased risk of BC, even if the result was not statistically significant. We also found that BC risk was higher with greater age at first birth. Despite substantial experimental evidence linking hormonal factors with BC, epidemiologic evidence remains inconsistent. More research will be required to better understand the relationship between parity, age art first birth, and BC risk.