Since studies show that an unfavorable environment during intrauterine development predisposes individuals to several diseases in adulthood, our objective is to assess the relation between fetal growth restriction and chronic renal disease in adults. We searched four different electronic databases through November 2017: CENTRAL, EMBASE, LILACS and MEDLINE. We selected studies with longitudinal or transversal designs associating kidney function in adulthood with low birth weight. Two reviewers evaluated the inclusion criteria and the risk of bias and extracted data from the included papers. Thirteen studies were selected for the systematic review and meta-analysis. We observed increased risks of presenting end-stage renal disease , a lower glomerular filtration rate (ml/min) , microalbuminuria  and a small increase in the albumin/creatinine ratio  in the low birth weight patients, compared with control group. These findings suggest that low birth weight is associated with renal dysfunction in adults. Low birth weight may increase the probability of developing decreased renal function in adulthood. The investigations to date have been heterogeneous with respect to age, associated diseases, population, and definitions of outcomes; few studies have tried to synthesize all available data, but the populations evaluated were heterogeneous and were not restricted to adulthood because children and individuals with a history of extreme prematurity were also considered A reduced nephron number is critical in the progression toward chronic renal failure, and the remaining nephrons exhibit increased glomerular filtration, hyperperfusion, compensatory hypertrophy, microalbuminuria, arterial hypertension, glomerulosclerosis, overt proteinuria, and progressive fibrosis Therefore, our objective was to evaluate the current literature on the influence of IUGR on renal disease in adulthood.This study was conducted following the recommendations of the Cochrane Handbook for Systematic Reviews of Interventions, The Cochrane Collaboration, Version 5.1.0 The protocol for this review was registered at PROSPERO (CRD42017040019).The electronic search was conducted through November of 2017 using the following electronic databases: Cochrane Central Register of Controlled Trials (CENTRAL), Latin American and Caribbean Health Sciences (LILACS), Medical Literature Analysis and Retrieval System Online (MEDLINE), and EMBASE. The terms used in the Pubmed/MEDLINE search were (“Kidney Diseases” [Mesh]) AND “Fetal Growth Retardation” [Mesh] with no filters for species, sex or languages. The same terms were applied in EMBASE and CENTRAL, but with their extended trees. In LILACS, the search strategy was  AND . Initially, no filters were applied for the study design, date, or language. The authors also conducted manual searches in the included studies and reviewed the references available on the subject to identify other potentially eligible articles.th percentile when the article provided these data. The search included publications in English, Portuguese, French, and Spanish.The inclusion criteria were as follows: studies evaluating low birth weight (different classifications but with possible correspondences) and kidney function in adulthood. The evaluation of kidney function could include the glomerular filtration rate, albumin-creatinine ratio, presence of microalbuminuria, or end-stage renal disease. Subjects had to be over 18 years old, and the control group was limited to subjects with a birth weight up to the 90The exclusion criteria were as follows: studies involving kidney function evaluation in children, animals, or a group with a specific disease ; studies analyzing only kidney volume; and reviews. Furthermore, we excluded studies involving very premature births (<32 weeks), birth weights less than 1500 grams, and birth weight analyzed in quartiles; studies with missing data; and studies with different outcomes, such as the rate of low-normal creatinine clearance.consensus after discussion. Any other uncertainties were resolved by email contact with the original authors.Two reviewers (JCS and MAC) independently read the titles and abstracts of the papers retrieved using the pre-defined search strategy and applied the inclusion criteria. Then, the remaining articles or the articles that did not have abstracts were obtained in full and read again, with the same eligibility criteria applied. Any selection conflicts were solved by Then, data were extracted from the selected studies, including information on the author, date of publication, study design, number and characteristics of the participants, age, predictors, outcomes, and definitions of low birth weight, small for gestational age, IUGR, end-stage renal disease, and microalbuminuria, if applicable.The data were analyzed using Review Manager (RevMan) 5.3. Using the Mantel-Haenszel statistical test, we compared dichotomous outcomes using the OR with the 95% CI. For continuous data, we used both the average difference (MD) and 95% CI and the statistical test of the inverse of the variance.2 statistic. A difference was statistically significant if the chi-square result was p<0.10 and/or I2>50%. In such cases, we applied a random effects model. However, for the opposite result, we used a fixed effects model. In those cases, we assumed that each study estimated the same amount of effect (homogeneous) and that the results were different only due to chance.The heterogeneity of the data extracted from the included studies was assessed using the chi-square test and the IThe methodological quality of the cohort and case-control studies included in the meta-analysis was assessed according to the Newcastle-Ottawa Scale (NOS). Each study was judged from three broad perspectives: group selection, group comparability, and detection of the outcome or exposure of interest for case-control or cohort studies. As the evaluation of the NOS is currently in progress, we classified the studies as having a high risk of bias when they received between 0 and 4 stars, having a moderate risk of bias when they received between 5 and 7 stars, and having a low risk of bias when they received ≥8 stars. Cross-sectional studies were evaluated according the National Institutes of Health (NIH) Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies, which comprises 14 criteria.Sensitivity analysis was performed by excluding each study individually and performing a new statistical analysis of the remaining studies. A funnel plot was not used due to the small number of studies included in each outcome.The search identified 901 articles, 858 of which were found through four electronic databases  and 43 of which were found by manual search. After duplicates were removed and articles were deleted based on titles and abstracts, 129 articles remained. The full versions of these articles were evaluated. A total of 116 articles were excluded for several reasons . Finallyth percentile . The control group included individuals whose birth weight was greater than the 10th percentile but lower than the 90th percentile . Neither Ruggajo et al. A total of 100466 subjects who had low birth weight or were small for gestational age were compared with 914602 controls with respect to the end-stage renal disease outcome. Fan et al. th percentile, mean: 2230 g), while Li et al. To evaluate microalbuminuria, we compared 1956 subjects who had low birth weight or were small for gestational age with 10125 controls. Only Laganovic et al. For the quantitative outcome, the ACRs of 255 low birth weight or small for gestational age individuals were compared with those of 312 controls. Only Laganovic et al. 2), 322 cases were compared with 366 controls. The formulas selected by each author to calculate the GFR were as follows: Gielen et al. Finally, to analyze the glomerular filtration rate (GFR) (ml/min), 490 low birth weight or small for gestational age individuals were compared with 893 normal birth weight or adequate for gestational age individuals. For the analysis of GFR  of 52%  and 3.Considering the 5 studies evaluating end-stage renal disease included in this analysis, increased risk was observed in the low birth weight group (risk ratio (RR) 1.31, 95% confidence interval (CI): 1.17, 1.47) . The sen2) was found between the cases and controls . The sensitivity analysis also presented the same positive results with respect to the GFR (ml/min), but when the Al Salmi et al. study was excluded, the results became insignificant  (An increased risk of a lower GFR (ml/min) was observed in the low birth weight group . However, no statistically significant difference in the GFR   and 4.Considering the 3 included studies that used microalbuminuria as an outcome, an increased risk of microalbuminuria was identified in the low birth weight group  . The senA small increase in the albumin-creatinine ratio (mg/mmol) was identified in the low birth weight group compared with the controls  based on the 3 relevant included studies. According to the sensitivity analysis, when either Hoy et al. According to our review, having a low birth weight or being small for gestational age during intrauterine development interferes with renal function in adulthood. We observed that these conditions are related to the development of microalbuminuria  and end-stage renal disease , a decreased glomerular filtration rate (ml/min) , and a slightly increased albumin-creatinine ratio (mg/mmol) .The decrease in renal function likely occurs because the reduction in the nephron number in IUGR fetuses is not completely compensated for during the postnatal period Another possible mechanism of injury is fetal exposure to glucocorticoids, a growth inhibitory factor that may be a cause of structural and physiological alterations in blood pressure regulation th percentile for weight The finding that low birth weight is associated with renal damage in adulthood indicates the need for follow-up for individuals born below the 10In contrast to previous meta-analyses versus previous studies was the exclusion of high birth weight subjects among the controls when possible, which allowed better interpretation of the results because of the U-shaped relation between birth weight (low or high) and increased urinary albumin discharge due to diabetic end-stage renal disease The initial objective of our group was to select only longitudinal prospective cohorts; however, the literature is limited, and no results from longitudinal prospective cohorts are available. Consequently, our study was limited to cross-sectional, case-control studies and retrospective cohorts. Another important difference of our study The selection of specific minorities to establish the study participants is an important source of bias in the literature and hinders the reproducibility of the results in the general population because low birth weight is suggested to be more common in some specific communities To study the effects of birth weight on the incidence of decreased renal function and kidney disease later in life, larger cohorts with longer follow-ups are recommended. Currently, considering the finding that renal function is impaired in adults born small for gestational age, societies must observe this population closely to determine a better follow-up strategy to reduce renal damage.In conclusion, a positive correlation exists between low birth weight or small for gestational age and renal dysfunction in adulthood. This study provides the best evidence for this correlation based on the most homogeneous adult population available. However, well-designed prospective cohorts are needed to better understand the causality of this association and to identify possible interventions that will allow better recuperation of kidney glomerular capacity after intrauterine injury.Senra JC, Carvalho MA, Rodrigues AS, Krebs VL, Gibelli MA, Francisco RP, Bernardes LS participated in the study conception and design, collecting and synthesizing the data, and in drafting or revising the manuscript.


Cyst hydatid in the lung is still a health problem for many countries. It develops in the lung and can grow into the lung parenchyma. When it is diagnosed as a giant cyst, surgery should be performed. In the surgery, capitonnage is necessary to protect the lung parenchyma. Echinococcus granulosusand humans are the intermediate hosts. Many countries are endemic, especially the Middle East, South America, and eastern and southeastern region of Turkey.Echinococcosis is an infestation caused by theA 12-year-old boy admitted to the hospital with right chest pain and shortness of breath. He had no other complaints such as cough, fever, or hemoptysis. During the examination, the right hemithorax respiratory sounds were diminished and the other side was normal. He had shortness of breath during exercise. On posteroanterior chest radiograph, there was a huge well-circumscribed opacity in the right hemithorax. Magnetic resonance showed a 15 × 16-cm cystic lesion which was filling the right hemithorax totally. Mediastinum and the heart had deviated to the left hemithorax . SurgerCyst hydatid is found in the form of eggs in the feces of carnivorous animals such as dogs, wolves, foxes, and jackals, and it enters the human system as an embrion. If the cyst manages to reach the lung, four scenarios may happen: (1) the parasite dies, the cyst is lost spontaneously, and the cuticle undergoes fibrosis; 2) cystic fluid is expectorated with a bronchial drainage; 3) the cyst dies because of infection between the cyst wall and cuticle, and the infection occurs in the cystic cavity; and (iv) the cyst continues to grow according to the compliance of the lung parenchyma. cystic f the cystCysts may reach very large dimensions as the lungs have more elasticity. Lamy et al describes cyst over 4 cm as a giant cyst, while Halezeroglu et al and Karaoglanoglu et al define cyst over 10 cm as a giant cyst.As we added the giant lung hydatid cysts to our experience through video-assisted thoracoscopic surgery (VATS), morbidity and hospitalization time significantly decreased. We believe that VATS should be performed instead of thoracotomy as the latter induces atelectasis and pneumonia in hydatid cysts.


Retinopathy of prematurity (ROP) is a vascular proliferative disorder of the developing retina and a significant cause of childhood blindness around the world. The incidence of ROP is affected by many factors, and the incidence rate varies from country to country. The purpose of this study is to report the incidence and risk factors of ROP in neonatal intensive care unit (NICU) of Guangzhou First People’s Hospital in China.A retrospective review was performed on 436 premature infants who were consecutive ROP screened in the NICU of Guangzhou First People’s Hospital from March 2013 to October 2017. The single-factor analysis and the logistic multivariate regression analysis were used to detect risk factors of ROP.Total 436 premature infants were consecutive ROP screened, 138 (31.65%) were found ROP, and 61(13.99%) were treated. The single-factor analysis revealed that the incidence of ROP was associated with multiple births, gestational age, birth weight, mechanical ventilation, intravascular hemolysis, the number of operations and blood culture results. The logistic multivariate regression analysis revealed that gestational age; birth weight, mechanical ventilation, minimum SaO2 and daily weight gain were independent risk factors for ROP onset. Forty-nine patients underwent retinal laser photocoagulation with recurrence 20 patients. Twelve patients underwent anti-VEGF drug (Ranibizumab) via intraocular injection with 5 patients of recurrence.The incidence of ROP in NICU of Guangzhou China will match those in middle-income countries, but higher than high-income countries. Anti-VEGF drugs could be preferred as a good treatment method for zone 1 ROP and aggressive posterior ROP. Retinopathy of prematurity (ROP) is one of the major causes of blindness in children and is the most common cause of retinal vasculopathy in premature or low-birth-weight infants . The phyIn recent years, with the development of neonatal medical technology, an increasing number of severe premature infants have survived, including cases of prematurity associated with in vitro fertilization (IVF), multiple births and infants with very low birth weight, very low gestational age, congenital dysplasia, immaturity, septicemia, severe infections and multiple surgeries after birth. The survival rates of extremely immature premature infants < 26 weeks and < 1000 g worldwide have continuously increased, and the incidence of ROP has been increasing in parallel –8.This study retrospectively analyzed the screening and treatment of ROP in severe premature infants who were admitted to the Neonatal Intensive Care Unit (NICU) of Guangzhou First People’s Hospital from March 2013 to October 2017. The results revealed that ROP was common in severe premature infants with risk factors and that anti-VEGF treatment of ROP produced a curative effect. Guangzhou First People’s Hospital is a comprehensive Grade 3A hospital in economically developed regions of China with advanced neonatal care. The purpose of this study was to analyze the prevalence and risk factors of ROP in advanced neonatal care hospitals in a single centre of China.The medical ethics committee of Guangzhou First People’s Hospital approved this study. The patient-related data collected in this study include the following: name, age, and clinical diagnosis. The names were replaced by numbers, and the relevant data of the patient was encrypted and stored in the main study. We had obtained the written informed consent of the parents of the children.A retrospective analysis was performed on premature infants who underwent ROP screening in the NICU of Guangzhou First People’s Hospital from March 2013 to October 2017.According to the 2004 and 2014 China ROP screening guidelines , ROP scrThe first fundus examination was performed at 4 to 6 weeks after birth or at 32 weeks of postmenstrual age (PMA). The following methods and procedures were used: (1) the primary screening was performed by binocular indirect ophthalmoscopy with appropriate mydriasis. Infants with suspected ROP were examined with Retcam (retina camera). (2) The surgeon determined the use and method of treatment based on the results and images got from the Retcam examination. (3) Examination results and treatment recommendations were recorded in detailed electronic medical records. They are location of the disease into zones , the circumferential extent of the disease based on the clock hours (1–12), the severity of the disease (stage 1–5) and the presence or absence of “Plus Disease”. And screen or treatment information, which included follow-up, treatment methods. (4) Follow-up treatments and condition progression were recorded in detailed electronic medical records according to the international staging and classification standard for ROP . They arLaser photocoagulation and anti-VEGF drug (Ranibizumab) were used in 61 premature infants with ROP who reached the therapeutic threshold. Forty-nine with ROP in zone 2 or zone 3 underwent retinal laser photocoagulation, and 12 with ROP in zone 1 or aggressive posterior ROP (AP-ROP) were given anti-VEGF drug (Ranibizumab 0.25 mg) via intraocular injections. All patients with ROP recurrence were retreated with laser photocoagulation. Infants with ROP were monitored until 54 weeks of PMA as the study endpoint.Data related to the objectives were collected from the electronic medical record. Data included the following: (1) birth data , (2) relevant data obtained within 30 days after birth  and congenital dysplasia, etc.), (3) long-term follow-up data for infants with ROP .2 test. A multivariate logistic regression analysis was used to determine independent risk factors for ROP. P < 0.05 was defined as the threshold for a statistically significant difference.SPSS 17.0  was used for all statistical analyses. A single-factor analysis was used to analyze correlations with ROP and identify a normal fundus (ROP (−) or ROP (+). All measurement data are presented as percentages (%) and were measured with the χThe total number of newborns was 11,275 in Guangzhou First People’s Hospital from March 2013 to October 2017. Four hundred thirty-six severely premature infants met the ROP screening criteria and completed a first ROP ophthalmological examination at which their general condition was recorded. Among these patients, 256 (58.72%) were boys, and 180 (41.28%) were girls. The incidence of all stages ROP was 31.25% (80) girls and 32.22% (58) boys. The treatment of ROP was 12.89% (33) girls and 15.56% (28) boys. There are 286 (65.60%) were single births, 116 (26.60%) were twin births, and 34 (7.80%) were gestations births. The incidence of ROP was 33.57% (96) in single births, 23.28%(27) in twin births, and 44.12%(15) in gestations births. The treatment of ROP was 12.24%(35) in single births, 13.79%(16) in twin births, and 44.12%(29.41) in gestations births. The average gestational age was 33.84 weeks (min 26 max 39 weeks). Overall, 342 of the patients (78.44%) had a gestational age ≤ 32 weeks, and 94 patients (21.56%) had a gestation age > 32 weeks. The incidence of ROP were 31.56% (117) in gestational age < 32 weeks and 22.34% (21) in gestational age > 32 weeks. The treatment of ROP were 16.4%(56) in gestational age < 32 weeks and 5.3%(5) in gestational age > 32 weeks. The mean birth weight was 2160.23 g (min 1015 max 3690 g). Birth weights ≤1500 g were recorded in 251 cases (57.57%), weights 1501–2000 g were recorded in 109 cases (25%), and weights > 2000 g were recorded in 76 cases (17.43%). The incidence of ROP were 46.61% (117) in birth weights ≤1500 g, 16.51% (18) in birth weights 1501-2000 g, and 3.95% (3) in birth weights > 2000 g. The treatment of ROP was 21.51%(54) in birth weights ≤1500 g, 6.42% (7) in birth weights 1501-2000 g, and 0 in birth weights > 2000 g. One hundred forty-two of the patients (32.57%) were mechanical ventilation > 96 h group, and 294 patients (67.43%) were mechanical ventilation < 96 h group. The incidence of ROP were 54.22% (77) in mechanical ventilation > 96 h group, and 20.75%(61) in mechanical ventilation < 96 h group. The treatment of ROP were 28.17% (40) in mechanical ventilation > 96 h group, and 7.87%(21) in mechanical ventilation < 96 h group.)According to the screening results and treatment, all children were divided into two groups: ROP (−) and ROP(+). Four hundred thirty-six severely premature infants, 298 patients (68.35%) were ROP (−), and 138 patients (31.65%) were ROP (+). In ROP(+) group, 61 patients (44.20%) received treatment (12 patients revieved anti-VEGF drug treatment and 49 patients received laser treatment). The ROP (+) and ROP (−) groups were included in a univariate analysis. The results showed that the incidence of ROP was correlated with many factors including multiple birth, gestational age, birth weight, mechanical ventilation, IVH, number of operations, and positive blood culture (Table 1P < 0.05), which were introduced into a logistic regression equation for a multi-factor unconditional logistic regression analysis. The independent risk factors that were introduced into the logistic regression model included gestational age, birth weight, mechanical ventilation, oxygen saturation, and average daily weight gain  via intraocular injections. Ranibizumab was injected into the vitreous with 0.25 mg per dose. In the laser photocoagulation treatment group, 21 patients (42.86%) exhibited recurrence of ROP. In the Ranibizumab treatment group, 5 patients (41.67%) had recurrence of ROP. All infants with ROP recurrence were retreated with laser photocoagulation. The conditions of all infants were controlled after retreatment until 54 weeks of PMA. No serious complications such as retinal detachment occurred in any patient in our study. The results of the analysis showed that both the number of gestational weeks and birth weight were significantly lower in the Ranibizumab treatment group than in the laser photocoagulation treatment group and the untreated ROP (+) group , and 13.99% (61 cases) of premature infants with ROP required treatment. These values are similar to those in many Chinese reports (from 10.8 to 17.6%) –28; HoweROP is a disease involving multiple factors, and its exact etiology is not known. According to many reports, gestational age and birth weight are currently recognized as the primary risk factors for ROP . Our resWe also analyzed the correlation between ROP and individual factors in this study; the results showed that the factors significantly associated with the incidence of ROP include IVH, invasive examinations, and positive blood culture. However, the mechanisms by which these factors cause ROP are not clear. We speculate that these factors may lead to vital signs instability, and long-term, high-flow oxygen absorption is usually given as a treatment method.In a logistic regression analysis, gestational age, birth weight and unmonitored supplemental oxygen were indicated as the primary risk factors for ROP . Our stuWith the rapid development of perinatal medicine and continuous improvements in treatment facilities, the survival rate for premature and low-birth weight infants has substantially improved, and the incidence of ROP has also significantly increased in China. Many studies have suggested that the up-regulated expression of VEGF plays an important role in the development of ROP , and antIn report of the developed countries, the ROP that need treatment includes zone 1, any stage with plus disease; zone 1, stage 3, with or without plus disease; and zone 2, stage 2 or 3, with plus disease. The ROP that need watch and wait includes zone 1, stage 1 or 2 without plus disease and zone 2, stage 3 without plus disease. However, there is no uniform treatment threshold for ROP in China , 43. DueRetinal laser photocoagulation is a standard treatment for ROP. However, it can result in many problems, such as a wide range of retinal damage and the loss of vision in the photocoagulation area, and is not suitable for some patients, such as those with ROP in zone 1 or AP-ROP –46. AntiIn our study, children with ROP in zone 2 or 3 were treated with traditional retinal laser photocoagulation, whereas children with ROP in zone 1 and posterior polar invasion ROP were given Ranibizumab via intraocular injections. The recurrence of ROP in the laser treatment and anti-VEGF treatment groups were 42.86 and 41.67%, respectively. Because anti-VEGF drugs may induce systemic risks in premature infants, all infants who had ROP recurrence were retreated with laser photocoagulation.The conditions of all children were controlled after retreatment was given until 54 weeks of PMA. No serious complications such as retinal detachment occurred in any patients in our study. We speculate that may be related to the fact that children with a very low birth weight (< 1000 g) and gestational age (< 26 weeks) were not included in this study. An analysis of the two groups showed that the gestational age and birth weight were significantly lower in the anti-VEGF treatment group than that in the laser treatment group. This result is similar to other reports , 53–57.In conclusion, in this study, we systemically analyzed the incidence of and risk factors for ROP in severely premature infants treated in the NICU at Guangzhou First People’s Hospital. The results of our study suggest that the incidence of ROP is 31.65% which will match those in middle-income countries, but higher than high-income countries. Anti-VEGF drugs could be preferred as a good treatment method for zone 1 ROP and aggressive posterior ROP.


Microphthalmia is considered to be the most common congenital malformation of the eye after congenital cataract. However, its association with intraorbital cyst is considered to be very rare. Most of the lesions are still misdiagnosed as orbital tumor and teratomas as there is a general paucity of data reported in literature. Herein, we report a rare case of congenital microphthalmia with intraorbital cyst in an eight-month-old male patient. Congenital microphthalmia with intraorbital cyst is a rare condition occurring due to defective closure of the embryonic fissure as well as over-growth of the inner layer of the optic cup . The fisCysts associated with microphthalmia and anophthalmia represent two points on the spectrum of the colobomatous eye disorder and may create difficulty in clinical distinction .An eight-month-old male was presented by the parents with the chief complaints of inability to open the right eye since birth and gradual progressive swelling underneath the right lower lid for three months.The past medical history revealed that the patient was taken to the local eye hospital one week after birth with the chief complaints of inability to open the right eye (RE) since birth. The medical reports revealed that the right globe was not visible and the left eye (LE) was normal with no developmental anomalies at that time. The USG A+B scan showed chorioretinal coloboma with cystic (hyperechoic) space behind the chorioretinal surface and a small optic nerve stump on the RE with normal LE findings.Three months later, cystic swelling appeared from the inferior orbit that was gradually increasing in size and was more prominent during coughing. This lead to the right lower lid ectropion and exposure of the palpebral conjunctiva associated with redness and occasional discharge. Swelling gradually increased in size with mild keratinization of the exposed surface . The LE At eight months, when the child was brought to our center, multidetector computed tomography (MDCT) was advised which showed non enhancing right intraorbital cyst with small right globe and dysplastic optic nerve . There wMicrophthalmia is considered to be the most common congenital malformation of the eye after congenital cataract. Its association with the intraorbital cyst is considered as a rare developmental anomaly of the globe that can affect one or both the eyes . StudiesIn some cases, cysts associated with microphthalmia can be diagnosed clinically, whereas in others, it can be doubtful. Studies have shown that additional imaging can be valuable in these cases. Orbital ultrasound A+B scan is of great importance in identifying orbital cysts [The detection of microphthalmia can be done in early neonatal period. It typically presents as a protruding mass in the inferior orbit associated with microphthalmic eye. The globe may be completely surrounded by the cyst in some cases, while others may present with very rudimentary displaced microphthalmic eye, thus creating difficulty in identifying the eye clinically as in our case .In some al cysts . In our al cysts . In our Although it is clearly a defined entity, sometimes it becomes difficult to differentiate it from some lesions such as congenital cystic eye, meningocele, arachnoid cyst, primary optic nerve sheath cysts, and teratomas of the orbit. Lieb et al. has mentioned the importance of imaging techniques in ruling out these differentials .Histopathologically, cyst in a microphthalmic eye is similar to the congenital cystic eye. Nevertheless in congenital cystic globes, the cyst is located centrally or slightly upward in the orbit and histologically it lacks normal ocular structures and shows the presence of the cyst lined with neuroglial tissue. However, in micropthalmos with cyst, there is bulging of the lower eyelid as the cyst is attached to the inferior portion of the globe along with evidence of ocular development in conjunction with a small cornea, iris, ciliary body, lens, vitreous cavity, retina, and choroid .The treatment strategy for patients with microphthalmos and orbital cyst depends on several factors such as visual potential, age at presentation, and volume of the orbital content . ClinicaIn this case report, we tried to report a rare case of congenital microphthalmia with intraorbital cyst. Several studies are still required to understand the spectrum of this complex condition, which is considered as one of the cause for childhood blindness. Advanced ultrasound technology using three dimensional image and computed tomography can be helpful in early diagnosis of the lesion which in turn provide great help in counseling the parents and provide appropriate treatment options in early neonatal life.


The World Health Organization recommends a minimum of 33 months between two consecutive live births to reduce the risk of adverse maternal and child health outcomes. However, determinants of short birth interval have not been well understood in Ethiopia.The aim of this study was to assess individual- and community-level determinants of short birth interval among women in Ethiopia.A detailed analysis of the 2016 Ethiopian Demographic and Health Survey data was performed. A total of 8,448 women were included in the analysis. A two-level multilevel logistic regression analysis was used to identify associated individual- and community-level factors and estimate between-community variance.At the individual-level, women aged between 20 and 24 years at first marriage , women aged between 25 and 29 years at first marriage , having a husband who attended higher education , being unemployed , having an unemployed husband , being in the poorest wealth quintile , being in the poorer wealth quintile , being in the middle wealth quintile , being in the richer wealth quintile , increased total number of children born before the index child  and death of the preceding child  were associated with increased odds of short birth interval. At the community-level, living in a pastoralist region , being a city dweller , high community-level female illiteracy  and increased distance to health facilities  were associated with higher odds of experiencing short birth interval. Random effects showed significant variation in short birth interval between communities.Determinants of short birth interval are varied and complex. Multifaceted intervention approaches supported by policy initiatives are required to prevent short birth interval. A preceding birth interval is defined as the amount of time between the birth of the child under study (index child) and the immediately preceding birth , 2. It hTo reduce the risk of adverse maternal and child health outcomes, the most recent World Health Organization (WHO) recommendation for a healthy pregnancy interval is at least two years 24 months) or a birth-to-birth interval of 33 months, assuming nine months gestation  months o, 6, low Worldwide, birth interval practices differ widely . ParticuA variety of factors influences a woman’s birth interval, including her personal characteristics and the health status of her previous child . TraditiIn Ethiopia, the prevalence of short birth interval ranges from 21.7%   to 57.6%Taking into account changing demographics, such as high fertility  in EthioWoredas. Each Woreda is further subdivided into the lowest administrative unit, called Kebeles. During the 2007 census, each Kebele was subdivided into census enumeration areas (EAs), which were convenient for the implementation of the census.An in-depth secondary data analysis was conducted using the 2016 Ethiopian Demographic and Health Survey (EDHS) data. The EDHS is carried out every five years to provide health and health-related indicators at the national and regional levels in Ethiopia. The 2016 EDHS is the fourth national survey conducted in all parts of Ethiopia , Gambella, and Harari] and two administrative cities [Addis Ababa and Dire Dawa]). Administratively, regions in Ethiopia are divided into Zones, and Zones into administrative units called The 2016 EDHS was cross-sectional by design. It employed two-stage stratified cluster sampling based on a sampling frame of the 2007 Population and Housing Censuses in which EAs were the sampling units for the first stage and households for the second stage . The detThe outcome variable for this study was short birth interval. Short birth interval was defined as an interval less than 33 months between two successive live births (33 months = 24 months of birth to conception period + 9 months duration of pregnancy). Preceding birth intervals exceeding 33 months were defined as non-short birth interval, which is consistent with the WHO recommendations Reviewers' comments:Reviewer's Responses to QuestionsComments to the Author1. Is the manuscript technically sound, and do the data support the conclusions?The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: YesReviewer #2: Yes**********2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: YesReviewer #2: Yes**********3. Have the authors made all data underlying the findings in their manuscript fully available?PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.The Reviewer #1: YesReviewer #2: Yes**********4. Is the manuscript presented in an intelligible fashion and written in standard English?PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.Reviewer #1: YesReviewer #2: No**********5. Review Comments to the AuthorPlease use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. Reviewer #1: The paper by author(s) presents an exhaustive analysis of statistical tools for the analysis of individual and community level determinants of short birth interval in Ethiopia.This work may be accepted, it is recommended to go through a minor review.i. Methods: Study area and setting: An in-depth secondary data analysis was conducted using the 2016 Ethiopian Demographic and Health Survey (EDHS) data. and Study design and sampling: the study used data from the 2016 Ethiopian Demographic and Health Survey (EDHS). This may be presents similar meaning.ii. Why authors used Akaike’s Information Criterion (AIC), Schwarz’s Bayesian information criteria (BIC) and Log-likelihood tests to assess goodness of fit and inform the selection of nested models ? Why not R2 or adjusted R2 or Mallows Cp or mean sum square error (MSE) or others tools? If authors used any references I think it will be more reliable.iii. I think authors used fully/mutually adjusted Odds Ratio. If authors describe shortly about this it will be more reliable.Reviewer #2: Comments on “Individual and community level determinants of short birth interval in Ethiopia: a multilevel analysis” (ID: PONE-D-19-21556)This paper covers a relevant question: what are the factors associated with short intervals? There is a large body of work examining the effects of short intervals on various outcomes, but we have much less research on the determinants of those intervals in the first place. The paper takes a novel and informative approach to addressing this question by implementing a multilevel mixed effects logit model. I feel that the paper is not ready for publication, as there are a number of issues that need to be addressed.General comments:1) The most important overarching weakness of the paper is the lack of any framework to motivate the study and to interpret the results. The authors need to spell out a theoretical argument for how birth intervals are determined. What is the decision-making process? What kinds of factors affect those decisions? How do the major elements included in the analysis  ultimately determine the durations of birth intervals? This will help the authors to interpret their results in some kind of a structured way that can guide the reader. As it is now, the reader is bombarded with many coefficients of varying magnitudes and signs with only brief post hoc arguments justifying them. It would be much more helpful to have an understanding of why we should care about the variables chosen for the model, why the effects are predictable or surprising, and what kind of policy recommendations are called for.2) The analysis should be restricted to only women with a partner. These make up the great majority of multiparous women (95% in your sample) and these are the individuals which can be realistically targeted with policy interventions. This is because women who have multiple births out of wedlock in a culturally conservative society are unlikely to be planning these births in the same way . Furthermore, the marital status category (unpartnered) must necessarily be collinear with categories of other variables indicating that the woman is not married. For example, the category for husband’s education indicating ‘not partnered’.3) The continuous variables  should probably be operationalized in a non-linear way. This can be done either through polynomial transformations (e.g. age at marriage ^2 or higher) or through categorization. Categories are probably a better choice for the presentation of the results. I recommend that the authors examine the data to see if this is appropriate.4) Does maternal age at birth refer to her age at the birth of the index child or the previous child? If it is her age at the birth of the index child, this variable does not make sense to include in the model. This is because her age at birth is determined by the length of the interval (i.e. your outcome variable). If it is her age at the birth of the previous child, you need to spell this out in the text. Likewise, children ever born should refer to the number of children born prior to the birth of the index child (i.e. not including the index child). It was not clear from the paper or supporting documentation.5) If I have understood the results correctly, it seems like community-level factors actually have very little influence on birth interval length once individual-level characteristics are controlled for. The ICC for the full model with individual and community factors was only 2.9%. In the conclusion and policy implications, however, you have interpreted community-level factors as a major concern. Is this justified given the low ICC?6) The paper will benefit greatly from language editing for clarity and precision.Specific comments:Line 46: The definition of birth intervals is not quite right. First, the interval is not defined as the number of months between births, but the amount of time. Months are simply the unit that some authors express that time in. It can equivalently be expressed in years (in continuous form) or days. Second, the authors are defining a preceding birth interval here. That is fine, because that is what the paper is about. I would simply suggest that they rephrase the definition as the definition of a preceding interval instead of birth interval in general. This is because there can also be a succeeding birth interval, which would be the interval following the birth of the index child.Line 70: How can the prevalence range from 21% to 57.6%? Does this mean across specific sub-populations or over time?Line 223: Age at birth should be reported in more meaningful categories than the ones provided here. The age group 18-34 is enormous and captures the large majority of births. Why not present these as standard 5-year age groups?Line 228: ‘Magnitude’ should really be ‘prevalence’.Line 302 – 314: If you are using the same data as the EDHS, I do not think there is a need to explain why your estimates of the prevalence of short intervals differ from the report. It is clear that you use a different definition of ‘short intervals’ than the DHS program, and that this is the reason why your prevalence is higher. The comparisons to Tanzania, DR Congo, and Bangladesh are not really relevant here. I would recommend dropping this paragraph entirely, and earlier in the paper when you present the prevalence you estimate, just add a line stating that the definition you use is different from the DHS definition, and this is why your estimates are higher.Table 1: Age at first marriage is not included in the table.Table 3: Where is model 1? The columns start from model 2. I would also set the reference category of education as ‘No education’. Only 2.5% of women had higher education.**********what does this mean?). If published, this will include your full peer review and any attached files.6. PLOS authors have the option to publish the peer review history of their article  digital diagnostic tool,  14 Nov 2019http://www.journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and http://www.journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdfEditorial comments: When submitting your revision, we need you to address these additional requirements. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at Response: Our manuscript has been revised to meet PLOS ONE's style requirements.Reviewer #1 comments: The paper by author(s) presents an exhaustive analysis of statistical tools for the analysis of individual and community level determinants of short birth interval in Ethiopia.Response: Thank you.Reviewer #1 comments: Methods: Study area and setting: An in-depth secondary data analysis was conducted using the 2016 Ethiopian Demographic and Health Survey (EDHS) data. and Study design and sampling: the study used data from the 2016 Ethiopian Demographic and Health Survey (EDHS). This may be presents similar meaning.Response: We agree with the reviewer and we removed the repetition from the ‘study design and sampling’ section.Reviewer #1 comments: Why authors used Akaike’s Information Criterion (AIC), Schwarz’s Bayesian information criteria (BIC) and Log-likelihood tests to assess goodness of fit and inform the selection of nested models ? Why not R2 or adjusted R2 or Mallows Cp or mean sum square error (MSE) or others tools? If authors used any references, I think it will be more reliable.Response: Thank you. Generally, R-squared (R2), Mean Squared Error (MSE) and other tools , Mean Absolute Error (MAE)) are sensitive to the inclusion of additional variables in the model, even if those variables don’t explain significant variation in the outcome. For instance, including additional variables in the model will always increase the R2 and reduce the MSE. In contrast, Akaike’s Information Criterion (AIC), and Schwarz’s Bayesian information criteria (BIC) penalise the deviance for models with a larger number of parameters, and thus provide more protection against overfitting the model to the data, relative to approaches based on hypothesis testing . Therefore, using a more robust metric to guide the model choice is recommended. Adjusted R2, AIC, BIC, and Mallows Cp are among the most commonly used metrics for measuring regression model quality and for comparing models. It is because of the above-mentioned reasons, we used AIC and BIC. In this revised version, we removed Log-likelihood tests. Therefore, in this revised version of the manuscript, we restricted the model fit statistics based on Akaike’s Information Criteria (AIC) and Schwarz’s Bayesian Information Criteria (BIC). We have added a brief statement explaining the robust nature of AIC and BIC under the ‘model fit statistics’ section of the manuscript (Line 230-236).Reviewer #1 comments: I think authors used fully/mutually adjusted Odds Ratio. If authors describe shortly about this it will be more reliable.Response: We agree and have mentioned that ‘adjusted odds ratio’ was used to express the fixed effect sizes of the individual- and community-level factors on short birth interval (Line 197)Reviewer #2 comments: This paper covers a relevant question: what are the factors associated with short intervals? There is a large body of work examining the effects of short intervals on various outcomes, but we have much less research on the determinants of those intervals in the first place. The paper takes a novel and informative approach to addressing this question by implementing a multilevel mixed effects logit model. I feel that the paper is not ready for publication, as there are a number of issues that need to be addressed.Response: We have carefully edited the manuscript to address the issues raised by you and other reviewersReviewer #2 comments: The most important overarching weakness of the paper is the lack of any framework to motivate the study and to interpret the results. The authors need to spell out a theoretical argument for how birth intervals are determined. What is the decision-making process? What kinds of factors affect those decisions? How do the major elements included in the analysis  ultimately determine the durations of birth intervals? This will help the authors to interpret their results in some kind of a structured way that can guide the reader. As it is now, the reader is bombarded with many coefficients of varying magnitudes and signs with only brief post hoc arguments justifying them. It would be much more helpful to have an understanding of why we should care about the variables chosen for the model, why the effects are predictable or surprising, and what kind of policy recommendations are called for.Response: The socio-ecological model of health behavior provides the theoretical foundation of the current study. We have now incorporated detail about this theoretical foundation into the manuscript (line 126-139). In addition, as mentioned in the method section (line 165-170), the assumption of independence of observation has been taken as a basis to determine which variables are to be analysed at the individual- and community-levels.Reviewer #2 comments: The analysis should be restricted to only women with a partner. These make up the great majority of multiparous women (95% in your sample) and these are the individuals which can be realistically targeted with policy interventions. This is because women who have multiple births out of wedlock in a culturally conservative society are unlikely to be planning these births in the same way . Furthermore, the marital status category (unpartnered) must necessarily be collinear with categories of other variables indicating that the woman is not married. For example, the category for husband’s education indicating ‘not partnered’.Response: The variable ‘Marital status’ in Demographic and Health Survey data describes the marital status of the women at the time of the survey not their marital status in the last five years. In our previous version of the manuscript, the ‘not married’ category included women who had never been married, as well as women who were separated, divorced, and widowed. In light of your feedback, in this revised version, ‘marital status’ is now categorized into ‘married’ and ‘separated/divorced/widowed.With the exception of ‘never married’ women, we assumed that all other unpartnered women  who were eligible for the birth interval question at the time of the survey conceived their multiple births from with their late/ex-husband. Since data regarding birth interval were collected from their childbirths in the five years preceding the survey, women may become widowed or divorced or separated shortly (or any time) before the time of the survey but after they already become eligible for providing birth interval information. Therefore, separated, divorced, and widowed women were retained for the analysis. In addition, while separated, divorced, and widowed women were with their late/ex-husbands, there were likely factors present that limited them from achieving an optimum birth interval and these factors should be investigated. Moreover, since some of separated/divorced/widowed women were among those who contributed to the magnitude of short birth interval in the country, including them in the analysis could help to inform policy and health programmers. However, as you hypothesized that ‘women who have multiple births out of wedlock in a culturally conservative society may be unlikely to be planning their births in the same way’, we excluded ‘never married’ (i.e. 12 (0.14%)) women from the analysis in this revised version of the manuscript. Thank you for your careful review. We have described the exclusion of ‘never-married women’ from the analysis (line 115 to 117). In addition, the reasons for retaining separated/divorced/widowed women are described under the exposure variable section (line 147-148). Regarding your concern regarding collinearity among ‘Not partnered’ categories and not married women:In our previous version of the manuscript, since separated, divorced, and widowed women (i.e. 371 women) were not eligible to answer for their polygyny status, their husband/partner’s education, and their husband's/partner’s occupation, there was systematic missingness for these variables. To address the missing values, we replaced them with a ‘Not partnered’ category values. However, your concern regarding collinearity led us to consider the variable as it is (i.e. with the systematic missingness). Thank you for that. Now, we performed a complete case analysis (CCA). Evidence has shown that CCA provides unbiased results when the chance of being a complete case does not depend on the outcome  . Therefore, we believe the concern of collinearity has been addressed. In addition, the results of multicollinearity analysis are annexed as supplementary material ).Reviewer #2 comments: The continuous variables  should probably be operationalized in a non-linear way. This can be done either through polynomial transformations (e.g. age at marriage ^2 or higher) or through categorization. Categories are probably a better choice for the presentation of the results. I recommend that the authors examine the data to see if this is appropriate.Response: We agree with the reviewer and have presented ‘maternal age at first marriage’ in 5-year age categories. However, the highest category is restricted to maternal age at marriage of 30 years and above since the number of observations after 30 years of maternal age becomes small.Reviewer #2 comments: Does maternal age at birth refer to her age at the birth of the index child or the previous child? If it is her age at the birth of the index child, this variable does not make sense to include in the model. This is because her age at birth is determined by the length of the interval (i.e. your outcome variable). If it is her age at the birth of the previous child, you need to spell this out in the text. Likewise, children ever born should refer to the number of children born prior to the birth of the index child (i.e. not including the index child). It was not clear from the paper or supporting documentation.Response: Thank you. Previously, we considered maternal age at the birth of the index child. In this revised manuscript, we used maternal age at the birth of the preceding child. Since it does not fulfill the linearity assumption, we presented it in 5-year age categories.Reviewer #2 comments: If I have understood the results correctly, it seems like community-level factors actually have very little influence on birth interval length once individual-level characteristics are controlled for. The ICC for the full model with individual and community factors was only 2.9%. In the conclusion and policy implications, however, you have interpreted community-level factors as a major concern. Is this justified given the low ICC?Response: We appreciate your observation. However, an ICC value of 2.9% while small, it is not zero. It indicates that the experience of short birth interval among women still depends on community contexts despite controlling individual- and community-level factors in the final model. Moreover, in this revised of the manuscript, the magnitude of ICC in the final model increased (from 2.9% to 9.5%). This change could be attributed to the changes made in coding some of exposure variables such as maternal age at first marriage, maternal age at birth of preceding child and total number of children born before the index child. Keeping this change in mind, even though individual- and community-level factors were controlled in the final model, 9.5% of the total variance in the odds of short birth interval was accounted for by between-cluster variation of characteristics. This implies that experience of short birth interval among women still depends on community contexts. As it is known, an ICC of 0 or closer to 0 would suggest that the clusters/community are similar to random samples taken from the country and suggests that clusters/community are not relevant to understand the variation in short birth interval. Whereas a high ICC value informs us that clusters/community are very important in understanding the individual differences in short birth interval :443-9.). In line with this, our interest is to show that nearly 10% of the total individual differences in short birth interval were due to cluster/community variation. In the manuscript (line 404-407), the statement was presented as follow: “The random-effect analysis result had also revealed that community-level random effects remained significant after controlling for both individual- and community-level variables, indicating that the experience of short birth interval among women depends on community contexts.”Reviewer #2 comments: The paper will benefit greatly from language editing for clarity and precision.Response: The paper has been carefully revised by native English speakers.Reviewer #2 comments: Line 46: The definition of birth intervals is not quite right. First, the interval is not defined as the number of months between births, but the amount of time. Months are simply the unit that some authors express that time in. It can equivalently be expressed in years (in continuous form) or days. Second, the authors are defining a preceding birth interval here. That is fine, because that is what the paper is about. I would simply suggest that they rephrase the definition as the definition of a preceding interval instead of birth interval in general. This is because there can also be a succeeding birth interval, which would be the interval following the birth of the index child.Response: The definition has been corrected accordingly. Reviewer #2 comments: Line 70: How can the prevalence range from 21% to 57.6%? Does this mean across specific sub-populations or over time?Response: The variation of the magnitude was observed across sub-populations. The 21% prevalence of short birth interval is based on the 2016 Ethiopia Demographic and Health Survey while 57.6% prevalence was based on the 2010 study conducted in one district; Lemo district. For clarity, it is rewritten as follows (line 74-75): ‘In Ethiopia, the prevalence of short birth interval ranges from 21.0%  (17) to 57.6% (district level estimate) (18).’Reviewer #2 comments: Line 223: Age at birth should be reported in more meaningful categories than the ones provided here. The age group 18-34 is enormous and captures the large majority of births. Why not present these as standard 5-year age groups?Response: Age at birth is presented in the 5-year age categories as per your recommendation.Reviewer #2 comments: Line 228: ‘Magnitude’ should really be ‘prevalence’.Response: Corrected accordingly.Reviewer #2 comments: Line 302 – 314: If you are using the same data as the EDHS, I do not think there is a need to explain why your estimates of the prevalence of short intervals differ from the report. It is clear that you use a different definition of ‘short intervals’ than the DHS program, and that this is the reason why your prevalence is higher. The comparisons to Tanzania, DR Congo, and Bangladesh are not really relevant here. I would recommend dropping this paragraph entirely, and earlier in the paper when you present the prevalence you estimate, just add a line stating that the definition you use is different from the DHS definition, and this is why your estimates are higher.Response: This paragraph is entirely dropped from the paper. The reason for the difference is also described as follow (line 325-329):‘The difference in the prevalence of short birth intervals between the current study and the one reported in the 2016 EDHS (21.7%) (17) is due to the different definitions used for short birth interval. The EDHS considered a birth interval of less than 24 months a short birth interval, whereas our study defined it as less than 33 months, which is in accordance with the WHO recommendations (4).’Reviewer #2 comments: Table 1: Age at first marriage is not included in the table.Response: It is incorporated in this revised manuscript.Reviewer #2 comments: Table 3: Where is model 1? The columns start from model 2. Response: As it is mentioned in the method section, under the heading ‘multivariable multilevel analysis’ (Line 190-193), Model I (Empty model) was fitted without explanatory variables to estimate random variation in the intercept and the intra-cluster correlation coefficient (ICC). Table 3 presents quantities based on fixed effects only. That is why column describing model 1 was not included in table 3. The finding of model 1 is presented in table 4. However, for the sake of clarity, the reason for not including ‘Model I’ in table 3 has been added as a footnote (line 608).Reviewer #2 comments: I would also set the reference category of education as ‘No education’. Only 2.5% of women had higher education.Response: The reference category of education has been changed as per your suggestion.AttachmentResponse to Reviewers.docxSubmitted filename: Click here for additional data file. 31 Dec 2019Individual and community level determinants of short birth interval in Ethiopia: a multilevel analysisPONE-D-19-21556R1Dear Dr. Shifti,We are pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it complies with all outstanding technical requirements.Within one week, you will receive an e-mail containing information on the amendments required prior to publication. 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If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.The Reviewer #1: Yes**********5. Is the manuscript presented in an intelligible fashion and written in standard English?PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.Reviewer #1: Yes**********6. Review Comments to the AuthorPlease use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. Reviewer #1: (No Response)**********what does this mean?). If published, this will include your full peer review and any attached files.7. 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Interpersonal discrimination experience has been associated with adverse birth outcomes. Limited research has evaluated this relationship within multicultural contexts outside the United States where the nature and salience of discrimination experiences may differ. Such research is important in order to help identify protective and risk factors that may mediate the relationship between discrimination experience and adverse birth outcomes.N = 1653).Evaluated the relationship between perceived discrimination, as measured in pregnancy, with birth weight and gestation length among Māori, Pacific, and Asian women from Aotearoa New Zealand  and in acquiring housing (β = − 146 g) were associated with lower birth weight when compared to Māori women not experiencing these types of discrimination, while an ethnically motivated physical attack (β = − 1.06 week), and unfair treatment in the workplace (β = − 0.95 week), in the criminal justice system (β = − 0.55 week), or in banking (β = − 0.73 week) were associated with significantly shorter gestation.Despite a high prevalence of discrimination experience among women from all ethnic groups, discrimination experience was a strong predictor of lower birth weight and shorter gestation length among indigenous Māori women only. Additional research is needed to better understand the risk and protective factors that may moderate the relationship between discrimination experience and adverse birth outcomes among women from different ethnic groups. Aotearoa New Zealand, like many other developed countries, has substantial inequities in health, with lower rates of morbidity and mortality among white New Zealanders , compared particularly to those of indigenous (Māori) ethnicity , 2. One In addition to experiences of discrimination shaping individual health, there is increasing evidence that experiencing discrimination in prior generations can impact biology and health in subsequent generations –23. For Maternal experiences of discrimination may influence fetal development and timing of parturition through impacts on stress physiology functioning. For example, we have previously reported that the stress hormone cortisol is higher in pregnant women reporting discrimination experience in Aotearoa New Zealand . MaternaGiven this background, the purpose of this paper is to understand whether maternal experience of ethnic discrimination predicts birth outcomes among a large and ethnically diverse cohort of women in Aotearoa New Zealand, where measures were collected longitudinally – both before and after birth. The results of this analysis are important for understanding whether the previously documented relationship between interpersonal discrimination experience and adverse birth outcomes may differ based on cultural context of those experiences.n = 6822) and the resulting main cohort of their 6853 children are generally comparable to New Zealand national birth statistics in relation to maternal age, ethnicity, parity and indicators of socioeconomic position [Data for this paper come from the Growing Up in New Zealand (GUINZ) longitudinal cohort study. Using multiple strategies, pregnant women were invited to participate in GUINZ if they had an estimated birth date between 25 April 2009 and 25 March 2010, and were living within a geographic area defined by the Auckland, Counties-Manukau, or Waikato District Health Board regions in the North Island of Aotearoa New Zealand . The recposition . The samIn the antenatal questionnaire .In the antenatal questionnaire, women were asked “which ethnic group or groups do you belong to?” Those women that identified more than one ethnic group  were the2), yearly household income ; 2 = 20,000–29,999NZD; 3 = 30,000–49,999NZD; 4 = 50,000–69,999NZD; 5 = 70,000–99,999NZD; 6 = 100,000–149,999NZD; 7 ≥ 150,000NZD), maternal education , mother’s relationship status in pregnancy (with or without partner), and smoking in pregnancy (yes/no) were assessed during the antenatal questionnaire and were included as covariates in our multivariate regression models. Offspring sex  was collected at the 6 week questionnaire and was also included as a covariate in multivariate models. Women with incomplete data for any covariates were excluded from the analysis, resulting in a final sample size of 1653.Maternal age in pregnancy (years), maternal body mass index (BMI) (kilograms/meterWe first performed a univariate analysis to describe sample characteristics, both within the entire sample and stratified by ethnicity. We next evaluated bivariate associations between all study variables by calculating Pearson correlation coefficients. We then used multivariate regression to evaluate the relationship between each of the discrimination variables and birth weight and gestation length, respectively, while adjusting for covariates. Multivariate models were run separately for each of the three ethnic groups.Summary statistics are provided in Table Bivariate analyses of the entire sample Table  demonstrWomen who had more education and higher income were significantly more likely to report having experienced a verbal attack, and higher education was associated with being significantly more likely to report any unfair treatment. Physical attack in pregnancy was associated with significantly shorter gestation length in the entire sample.Table The relationships between ethnic discrimination measures and gestation length after adjusting for covariates are presented in Table In this study we aimed to understand the association between maternal experience of ethnic discrimination and birth outcomes among a large and ethnically diverse cohort of women and their children in Aotearoa New Zealand. We find that a very high prevalence of women reported experiencing discrimination. Women with higher education and income were more likely to report having experienced verbal attacks. While there was an overall association between physical attack experience and shorter gestation weight, multivariate analyses stratified by ethnicity demonstrated that lower birth weight and shorter gestation length were associated with discrimination experience only among Māori women. Specifically, Māori women reporting discrimination in response to unfair treatment at work and in acquiring housing were more likely to have lower birth weight babies than Māori women who did not report experiencing these types of ethnic discrimination. In addition, Māori women reporting a physical attack or experiencing unfair treatment because of their ethnicity in the workplace, in the criminal justice system, or in banking all had significantly shorter gestation length than Māori women who did not report these experiences. The effect sizes were also relatively large, with unfair treatment at work predicting a 243 g reduction in birth weight, and physical attacks in pregnancy being associated with a week shorter gestation length among Māori women. These effects were independent of maternal socioeconomic status and individual health behaviors that impact birth weight, such as smoking. Interestingly, this relationship did not exist for women within the broad Pacific ethnic group, and among Asian women those reporting discrimination because of their ethnicity in the housing market actually had higher birth weight infants.The finding of discrimination experience being associated with adverse birth outcomes among Māori women is consistent with prior research that has predominately been conducted among African Americans in the United States . ConsistThe inverse relationship between housing discrimination and birth weight among Asian women was unexpected. Since women of Asian ethnicity had the lowest birth weights overall, higher birth weight within this group may reflect a less healthy birth weight. In addition, many studies find a j-shaped relationship between discrimination experience and health outcomes, with individuals who do not report having experienced discrimination actually having worse outcomes than those reporting moderate amounts of discrimination , 44, 45.In addition to suggesting that the impacts of discrimination on birth outcomes may differ depending on ethnicity and cultural context, these results also suggest that discrimination may impact birth outcomes through pathways beyond the commonly described impacts on stress physiology. For example, increased birth weight associated with discrimination experience could reflect differences in diet or physical activity levels in pregnancy. These results highlight the need to evaluate the relationship between discrimination and birth outcomes in diverse cohorts in order to understand both how the context of discrimination experience affects internalization of these exposures, as well as the different physiological and behavioral pathways that mediate these effects.Our analysis adjusted for several confounders, including smoking in pregnancy. Smoking is strongly associated with a reduction in fetal growth . SmokingDespite the strengths of this study, which includes a large sample size and longitudinal study design, there are several limitations to consider. While the sample is ethnically representative of the New Zealand population, there is nevertheless a potential for bias with respect to women for whom all data are available for analysis. In particular, a large number of women were missing information for pre-pregnancy weight, and therefore were excluded from the analysis due to the inability to adjust for maternal size. Another potential limitation of this study is that there were no follow up questions that asked about how women perceived their discrimination experiences. While many women were able to describe and recognize having had a discriminatory experience, it would be informative to know their affective responses to such experiences, such as whether or not it elicited anger or made them feel upset. Differences in affective responses could affect internalization of these experiences . Future We found the expected relationship between discrimination experience and adverse birth outcomes, but only among Māori women. The results of this analysis suggest that ethnic discrimination can have important impacts on health for Māori, particularly since lower birth weight offspring and infants born with shorter gestational age are more likely to experience adverse health outcomes across the life course. Since this finding was not present for Pacific and Asian women it suggests that it is important to understand the cultural context within which discrimination experience is taking place, as there could be differences in additional risk or protective factors that moderate the relationship between discrimination and health. More research in multi-ethnic contexts is therefore needed to fully understand the pathways through which discrimination may impact health.Additional file 1. Antenatal Questionnaire; Description: Questionnaire instrument.


This study aimed to identify determinants of still birth in selected hospitals of Southwestern Ethiopia.A total 540 charts registered for maternal health services utilization were included in the analysis with proportion of case to control ratio of one to three . Women who attended antenatal care were 40% less risk for stillbirth compared to those who did not attend antenatal care . Those who had labor length ≥ 24 h were 2.4 times at risk to have still birth than ≤ 24 h . Women who developed uterine rupture were about 5 times more likely to have still birth than did not develop the complication . Women who have different antenatal risks were 4.5 times more likely to have still birth . Weight of baby ≥ 2.5 kg were 73% less likely to still birth when compared to counterparts . Still birth is the death of a baby after 28 weeks of gestation based on world health organization (WHO). Around 2.65 million still births come about every single year globally, out of those 1.45 million occur during the antepartum period .WHO survey also showed that the rate of still birth and early neonatal death was 17.7 and 8.4 million respectively across 29 countries .Different studies from different countries showed maternal age greater than 35 years, multiple pregnancies, parity higher than four, educational status, lack of antenatal care follow-up, chronic comorbidities, preeclampsia or APH, intrauterine growth restriction, major congenital anomaly of the infant, and poor maternal nutritional status were the most frequently mentioned factors that influences the outcome of still birth –8.Prevention and cutback of stillbirth is significant in order to go in line with the current memo of the global newborn action plan by the 67 the WHO congress, aimed the global target to achieve stillbirth rate of < 10/100 births by 2035 .In 2011, Ethiopia had an estimated stillbirth rate of 46 per thousand births, while in southern national nationality peoples region state (SNNPR) stillbirth rate were 29/1000 , 18. TheInstitution based case control study was used to analyze the data from maternal charts registered in the logbook at obstetrics and gynecology units for different health services in Mizan-Tepi university teaching and Bonga general hospitals from January 2011–2015, SNNPR, southwest, Ethiopia. The data was extracted from December 20–January 30, 2016.The source population were all charts of mothers registered in the hospitals for maternal health service utilization. The cases are stillbirths, which were make certain based on the status outcome obtained from the charts. Charts of mothers having live birth outcome were considered as controls. Missed charts from the archive but, registered on registration book were excluded from the study.Sample size was determined using Epi info version 7 by taking the following assumptions: 95% CI, and 80% power, odds ratio of 1.83, case to control ratio of 1:3 and the prevalence of exposure among controls were 57% taken from unmatched case control study done in Mbarara regional hospital . A totalRecords of both cases and controls were selected from, all units provided maternal health care service in the hospitals which fulfills the inclusion criteria were included in the study. Cases that are registered on the log book but whose charts’ were missed. Charts that didn’t include the status of new born  were excluded from the study. First cases were identified from logbook or registration book, which were found in the study period, from respective units. After identifying the cases included in the sample the time of admission was identified for each selected cases. For each case 3 controls who were survived births were selected, which were born immediately preceding or following a case.Data extraction checklist was adapted from related surveillance. The checklist consists of relevant information on socio-demographic data, obstetric and delivery history, and birth outcome. Three midwives and three nurses were recruited and trained for 3 days as data collectors.After data collection was completed, each completed checklist was given a unique code by the principal investigator. Data were entered using Epi Data version 3.1 then exported to STATA version 13.1 for analysis. The data were cleaned for inconsistencies and missing values. Simple frequencies were done to see the distribution of the study subject with the outcome variables and to see any missing data. Bivariate binary logistic regression was used to select variables for multivariable binary logistic regression. Multivariable binary logistic regression was used to identify determinants of still birth. Confidence interval of 95% was used to see the precision and the level of significance was taken at p value ≤ 0.05. Thus the crude odds ratio (COR) from bivariate binary logistic regression and adjusted odds ratio (AOR) from multivariable binary logistic regression is reported.Before the data collection, ethical clearance was obtained from research and ethics committee of the college of health sciences of Mizan-Tepi University. Written permission letter was also received from the hospitals administrators. In order to be confidential only the code, not the names of the participant was taken from the chart.A total 540 charts were included in the analysis with proportion of case to control was one to three . The proportion of still birth with age of mother was higher (50%) in age group of greater than 34 years, 24% still birth with age of 20–34 years and 19.4% of still birth with age of less than 20 years. From all, 278 (80%) of women were attending ANC, of those who were attending ANC 69 (19%) had still birth, while the proportion of still birth from those who did not attend ANC were 66 (34.2%). Fifty (58%) of women had length of labor greater than 24 h, of which, 39 (43.8%) of their birth outcome were still birth. From those who had anemia, 4 (36.4%) of them had still birth, while, 134 (24.8%) of still birth were found from those who had not anemia. Around 17 (68%) of stillbirth was associated to uterine rupture. Thirty-two (46.4%) of still birth were related to antenatal risks like placenta previa, abruption placenta and previous cesarean section. Just about 19 (46.3%) of still birth were directly related to obstructed labor (OL) and 17 (47.2%) of still birth was contributed with different undiagnosed APH in direct or indirectly , labour abnormality, length of labor, and the weight of child were found to be significantly associated with still birth. However the result of multiple logistic regression analysis showed that attending ANC, length of labor, uterine rupture, antenatal risks, and weight of the new born were found to be determinants with still birth as clearly depicted in table two.Women who were attending ANC while they were pregnant were 40% less likely at risk for still birth than those who did not attend . And those who had labor length greater than 24 h were 2.4 times more at risk to have still birth than those who had labor length less than 24 h .Mothers who developed uterine rupture were 5 times more likely to have still birth than their counterparts . In addition women who have different antenatal risk  were 4.5 times more likely to have birth outcome of still birth  when compared with their counter parts. This study also showed that weight of baby greater than or equal 2.5 kg were 73% less likely to still birth when compared to those who have less than 2.5 kg  . The finding of this study is in line with the study done inside and outside of the country that showed women who do not have ANC checkups were at higher risk of stillbirth when compared to their counterparts , 13 and This is indicates the fact that ANC helps the mothers to be screened for certain risk factors, so as to take appropriate measure if risks are detected. Or it creates a good opportunity for health care providers to manage immediately or to establish a future care plan. Moreover, they can provide counseling to mothers and families what should be done to minimize the risks.In this study the presence of antenatal and intranatal risks  were significantly associated with still birth . Similarly women who have uterine rupture were an important cause of still birth in this study . This result is in agreement with study finding of Karachi, Pakistan, which strengthen presence of antenatal and intranatal risk and uterine rupture as an important cause to still birth  and findIt also showed that women who had labor length greater than 24 h were 2.4 times more at risk to have still birth than labor less than 24 h . This finding is in agreement with the study findings of Bangladesh and Mozambique which showed that prolonged labor were significant factor for still birth , 16.. BuThe current finding shows that birth weight of baby have significant factor with still birth, means weight of baby ≥ 2.5 kg were less likely to still birth compared than those who have less than 2.5 kg weight . This finding is similar with study finding Hawassa, Karachi Pakistan and Nepal, which shows very low and low birth weight newborns had higher risk of still birth than normal weight newborns –14.Attending ANC, length of labor; uterine rupture, antenatal risks, and weight of the new born were found to be determinant of still birth. The health office of the Bench-Maji and Keffa zones should work hard to improve awareness of the community about attending antenatal care during pregnancy and health professionals should investigate antenatal risk during ANC follow up.Since this is secondary data it has limitation related with missing of information.The study is institution based study that can’t be generalized for the still birth occurred at community level.