N 371). Data were collected through face-to-face interviews with the mother in a waiting room after the delivery of the child at the hospital. Newborn length and weight were measured and converted to length-for-age Z-score using WHO standards. The prevalence of stunting at birth (35⋅6 %) and low birth weight (24⋅6 %) were high. In the adjusted model, factors significantly associated with stunting were birth interval <2 years, low birth weight, inadequate dietary diversity and food insecurity (P < 0⋅01) mid-upper arm circumference (MUAC) of mother <23 cm (P < 0⋅05). The high magnitude of stunting and low birth weight calls all stakeholders and nutrition actors to work on preventing maternal undernutrition and improving their dietary practice through nutrition education. It is also recommended to mitigate food insecurity with evidence-based interventions using a combination of measures. Additionally improving maternal health services including family spacing was recommended to reduce stunting and low birth weight among newborns in the study area.On a global basis, 144 million people are stunted, and in Ethiopia, it remains a major public health problem. A limited number of studies have been conducted at the national level and in the study area to generate information on stunting at birth. The present study investigated the magnitude and predictors of stunting among newborns delivered at the Public Hospitals of Hawassa City, Ethiopia. A facility-based cross-sectional study was conducted between August and September 2021 among mothers and newborns ( Globally, more than one in four children under the age of 5 years are stunted and Sub-Saharan Africa and South Asia suffer the heaviest burden. Stunting is one of the most common indicators of long-lasting undernutrition, which is a true growth failure or inability to reach potential height for a particular age. World Health Organization (WHO) defined stunting as a height-for-age (HAZ) Z-score below 2 sd of the median of WHO standards. It is also an indicator of chronic malnutrition resulting from a lack of adequate dietary intake over a long period and/or recurrent illness. These primary causes of undernutrition are negatively affected by lack of food access, availability and healthcare services. According to the estimates from UNICEF, the WHO and the World Bank, more than half of all stunted children <5 years old were reported to live in Asia, and more than one-third lived in Africa. It is evidenced that Africa and Asia were regions highly affected by child stunting where they accounted for more than nine out of ten of all stunted children globally.Child undernutrition is a global problem with several concerns of survival, the incidence of acute and chronic diseases, healthy development and economic productivity of individuals and society. The same survey reported the national prevalence of stunting, among under-five children as 37 % and out of which 17⋅1 % were below 6 months of age. Other studies noted that nearly half of the children were stunted in the Northwest, Southern and Eastern parts of Ethiopia–13.In Ethiopia, stunting remains a major public health problem–17. But the first 1000 days of life from conception, the age of 2 years is the most critical period in newborn growth–20. It is less likely that stunted children regain the height lost as a result of stunting; consequently, most children will never gain the equivalent body weight for height.The aetiology of stunting is varied but recognising the causal factors in the prenatal period including maternal height, weight gain, anaemia and infection, as well as the postnatal period such as infant and children's feeding practice, and infections becomes vital. Prenatal causes of child stunting are directly associated with maternal undernutrition. As a result, poor maternal nutrition during pregnancy can lead to a stunted newborn–25; even though the effect of prenatal undernutrition may be addressed during the postnatal period through proper child-feeding practices.For stunting occurring at birth, maternal nutritional status plays a major role. Achieving so by helping women of reproductive age is in good nutritional status at conception is the best preventive measure,22,23. Hence, stunting at birth is considered the overall best indicator of maternal nutritional, medical, obstetric and socioeconomic status,26–28. It is also considered a simple and useful marker for assessing intergenerational linkages in health and malnutrition.Safeguarding proper nutrition of pregnant women is an essential measurement to minimise stunting at birth–33. It is believed that evidence of stunting at birth is quite crucial to reaching the global target of reducing stunting by 40 % by 2025, and also relevant to playing a role in the plan of the government of Ethiopia to end stunting. Therefore, the primary aim of the present study was to assess the magnitude of stunting at birth and associated factors among those delivered at the Public Hospitals of Hawassa City. The magnitude of low birth weight and its coexistence with stunting was also investigated.In Ethiopia, even though the prevalence and associated factors of stunting among under-five children were addressed well, the nutritional status among newborns has been overlooked, while the burden is presumed to be high. Lots of efforts are focusing on mitigating undernutrition among children under 5 years age. The other is Hawassa Referral Hospital which is a comprehensive specialised and teaching Hospital under Hawassa University. Presently, the Hospital has 400 total beds and an average monthly delivery flow of 540.A facility-based cross-sectional study was conducted between August and September 2021. The study was conducted among mothers who gave birth at Hawassa City Public Hospitals. Hawassa City is the capital of Sidama National Regional State, which is found 275 kilometres South of Addis Ababa. The City is subdivided into eight sub-cities of which seven are urban having 21 kebeles and one rural with 12 kebeles. According to the 2007 population census, the total number of people living in the city administration was 386 773 of which 195 320 are males and 191 453 are females. There are two public Hospitals in the city. Adare General Hospital is one of the Public Hospitals of Hawassa City established in 2015 G.C. and has an average monthly delivery flow of 490, a 97 % confidence level and a 10 % non-response rate. The number of mother–child dyads to be selected was proportionally allocated to each Hospital according to the number of delivery flow reports of the same time interval of the preceding year. The K-value for each Hospital is distinctly calculated. Accordingly, the K-value for Hawassa Referral Hospital is K = 540/195 = 3, and for Adare General Hospital, K = 490/176 = 3. The first participant's mother was randomly selected by the lottery method. Since the K-value for both Hospitals is 3, every third newborn was selected using a simple random sampling technique until the required sample size is attained.The sample size of 381 was calculated using the single population proportion formula with of 30⋅5 % prevalence of stunting at birthData were collected through face-to-face interviews with the mother in a waiting room after the delivery of the child at the hospital. The socio-demographic variables were adapted from the Ethiopian Demographic Health Survey (EDHS) and others from similar previous studies. Basic socio-demographic data such as the age of the mother, marital status, estimated household's average monthly income, religion, educational status, occupation and data concerning household economic status were collected. Data collectors used interviewer-administered structured questionnaires to interview mothers by cross-checking their maternal medical cards when necessary..The dietary diversity was calculated based on the number of food groups consumed by the mother women in the previous 24 h of the survey. We assigned a score of 1 to each food group if the subject had consumed it or 0 if not. The scores of the ten food groups were summed up to calculate the total dietary diversity score of women was used to assess household food insecurity during the 4 weeks preceding the survey. The households were categorised into four groups: food secure, mildly food insecure, moderately food insecure and severely food insecure. Finally, these were merged into two groups: food-secure and food-insecure households.The Household Food Insecurity Access Scale (HFIAS)The anthropometric measurement was done immediately after birth. The weight of the newborns was measured by using a balanced digital Seca scale (Germany) to the nearest 100 g. The reading on each scale was taken to zero level before weighing each newborn.The length of the newborn was measured when the newborn lay in a supine recumbent position. Two persons, one supported and secures the head of the newborn and the other took measurements of the newborn's length from the top of their head to the heel of their foot. The measurement was completed three times using an infantometer the average length of three measurements was recorded to the nearest 0⋅1 cm to ensure accuracy.The height of the mothers was measured using a height board while the mother was in a standing position. Each height was taken to the nearest 1 cm. The MUAC of the mother was measured with non-stretchable standard tape to the nearest 0⋅1 cm.. WHO Anthro software was used to convert the anthropometric measurements into WHO Z-scores. Stunting was defined as HAZ <−2⋅0 and categorised using WHO definitions. Low birth weight was determined according to WHO standard birth weight below 2500 g.Data were checked, coded and entered into SPSS, v. 20, for analysis. HAZ was calculated using the WHO Child Growth Standardssd), were used to describe the characteristics of the study population. The normal distribution of the data was checked with the Kolmogorov–Smirnov test.Descriptive statistics, including percentages as well as means and standard deviation  was found to be less than 1⋅12 and the tolerance test was found to be 0⋅89. The final model fitness status was checked by Hosmer and Lemeshow's goodness-of-fit chi-square test .Bivariate logistic regression analysis with crude odds ratio at 95 %CI was used to assess the association between dependent and independent variables. Multivariate logistic regression analysis with an adjusted odds ratio at 95 %CI was conducted to determine predictors of undernutrition and associations were declared significant at Among the 381 recruited mother–newborns pairs, 362 participated in the study giving a response rate of 95 %. Forty-six (12⋅7 %) of the study mothers were in the age group of <20 years old, while 284 (78⋅5 %) mothers were in the 20–34 years range and 13 (3⋅6 %) had no formal education .Table 1The majority of 300 (82⋅9 %) mothers was multipara and only 50 (13⋅8 %) was primipara. Two hundred seventy-six (76⋅2 %) had a birth interval of ≥24 months. About 323 (89⋅2 %) had antenatal care (ANC) during pregnancy, and 234 (71⋅3 %) had taken iron supplementation during their recent pregnancy. About 59 (16⋅3 %) women had pregnancy-induced hypertension (PIH), while 77 (21⋅3 %) women gave birth with gestational age <37 weeks .Table 2Two hundred eighty-seven (79⋅3 %) mothers’ MUAC is measured at ≥23 cm. About 281 (77⋅6 %) mothers had adequate dietary diversity, and 212 (58⋅6 %) mothers were food insecure .Z-score below −2 sd, and 89 (24⋅6 %) newborns were low birth weight. Twenty-one (5⋅8 %), 61 (16⋅9 %) and 68 (18⋅8 %) newborns were only low birth weight, only stunted and stunted and low birth weight, respectively (One hundred twenty-nine (35⋅6 %) newborns had a length-for-age ectively .Fig. 1.P < 0⋅001), age of mother <20 years (P < 0⋅05), not getting iron supplements during pregnancy (P = 0⋅004), presence of PIH (P = 0⋅141), giving birth before <37 weeks (P < 0⋅05), mothers MUAC <23 cm (P < 0⋅01), inadequate dietary diversity, being in food-insecure household (P < 0⋅01) and low birth weight (P < 0⋅01) predicted stunting at birth  and Ethiopia (30⋅5 %),38. Even though an association between gestational age and the short stature of mothers with stunting at birth has been reported in the previous study, our study did not show significant associations of this variable. In the present study, birth interval between two consecutive births had a statistically significant association with stunting at birth. According to WHO technical consultation group on birth spacing after having live birth, the recommended interval before attempting the next pregnancy is at least 24 months which can reduce the risk of adverse maternal, perinatal and infant outcomes. Consistently, the present study revealed an increased likelihood of stunting at birth among newborns delivered with a birth interval of <24 months compared with those delivered with a birth interval ≥24 months. Unlike the findings of previous studies,44, our findings did not show a significant association between being delivered from a short-stature mother as a determinant of stunting at birth. Similarly, there was a lack of significant association between stunting with not having ANC in the present study but reported in previous studies to have a significant association for children born from mothers who did not have ANC,45,46. Possibly this might be due to the majority of mothers in the present study being multipara and they may get adequate nutrition information during their previous pregnancies. Additionally, the present study was conducted in an urban area for the study participants to access mass media and get adequate health and nutrition information.The high prevalence of stunting at birth 35⋅6 % (30⋅7–40⋅6 %) among newborns in the present study suggests severe public health significance of problems needing evidence-based intervention. The findings on the prevalence of stunting at birth are consistent with previous studies from Guatemala (33 %)–50, the present study revealed a significant association between maternal dietary diversity and food insecurity in newborn stunting. The possible explanation might be food access and diversification during pregnancy enable to nourishing of the fetus for better growth and development during fetal life. This is because an inadequately diversified diet lacks some essential nutrients which would be essential for fetal growth and development consequently leading to newborn growth failure.Consistent with the findings of previous studies,51–53. Due to this, pregnant women might not eat adequately, thus, being exposed to undernutrition and can give stunted newborns.Inline, the present study indicated that the likelihood of stunting was increased for newborns delivered from mothers with poor nutritional status (MUAC < 23 cm) compared with their counterparts. This may be related to a lack of access to a nutritional diet, knowledge deficit of good maternal dietary practice or mistaken perception of women that frequent and much diet consumption during pregnancy could lead to excessive fetal growth which they perceive would be beyond tolerance of the birth canal and result with difficulty during childbirth,53–55. The plausible reason behind this might be low birth weight is an indicator of premature birth or intrauterine growth restriction, and hence, low birth weight is a predisposing factor to child growth failure resulting in stunted birth.Low birth weight is one of the crucial factors in our model which had a significant association with newborn stunting, and a similar finding was reported in previous studiesThe present study has limitations that need to be considered including the cross-sectional nature of the study does not allow causal inferences to be made. A certain level of recall bias should be taken into consideration concerning the last menstrual period, dietary practice and medical history of the mother.Additionally, the causal factors behind the high proportion of stunting at birth are not thoroughly addressed from intergenerational malnutrition perspectives. Future studies can help understand the causal factors leading to stunting at birth and help design effective interventions to reduce the problem. However, the present study is one of a few studies in Ethiopia and elsewhere that assess the prevalence and predictors of stunting at birth.Despite the above limitations, our data provide important information on the prevalence and potential predictors of stunting which is important for policy makers and funders. Our data also highlighted the prevalence of stunting at birth and low birth weight is high, needing critical attention by all nutrition actors. Newborns delivered with low birth weight are more stunted. Similarly, stunting is widely witnessed among newborns delivered with a birth interval between two consecutive births <24 months, undernourished mothers, inadequate dietary diversity of women during pregnancy and household food insecurity. Preventing maternal undernutrition through nutrition education is emphasised. It is also crucial to give due emphasis to improving maternal health services including family planning and interventions to minimise low birth by providing all necessary services for all pregnant women during pregnancy.It is also recommended to strengthen the existing community-level interventions for improving access to food, particularly for the most vulnerable groups of the community, women during pregnancy and lactation. The present study is conducted in only Public Hospitals; women who gave birth in private clinics/Hospitals were not considered. Consequently, this may underestimate or overestimate the rates. The estimate might be better represented if it includes all health institutions, and longitudinal follow-up data were used.


Human hydatidosis is a parasitic infection by the larval stages of the Echinococcus (E.) that rarely occurs in pregnancy . Canines are the definitive host while humans are the accidental host. They most often affect the liver (60%) and lungs (30%). E. granulosus causes cystic echinococcosis and is the most frequent form. E. multilocularis causes alveolar echinococcosis and is becoming increasingly more common. E. infections often remain asymptomatic for years before the cysts grow large enough to cause symptoms. Hepatic and pulmonary signs and symptoms are the most common clinical manifestations. There is no consensus on their management in pregnancy. We report two pregnancies complicated by hydatid disease of the liver and lung, discuss their problematic management, and review the recent literature. Hydatid cyst (hydatidosis) is a zoonotic disease that occurs throughout the world, particularly in those areas where people are involved in the cattle-rearing profession. The two types are Echinococcosis (E.) granulosus and multicularis. In humans, hydatid cysts are more commonly caused by the larva of the tapeworm E. granulosus while infection with E. multicularis is less frequent but is more serious. The life cycle of E. granulosus alternates between carnivores and herbivores like dogs and sheep and humans are accidental intermediate hosts where the liberated ova burrow through the intestinal mucosa and are carried by the portal vein to the liver to develop into adult hydatid cysts. The liver is the most common site of the infection and most cysts are found in its right lobe. Some ova pass through a capillary sieve and become lodged in any part of the body, including the lung, peritoneum, kidney, brain, mediastinum, heart, bone, and other parts of the body . In adulCase 1: hydatid cyst of the liver in a pregnant patientA 22-year-old female, Afghani refugee, G4P2A1, presented at 34 weeks + 5 days of pregnancy to our emergency department, complaining of a few months’ history of chronic epigastric and right upper quadrant abdominal pain associated with vomiting. She gave a history of exposure to farm animals in her home country. Abdominal ultrasound showed multiple lobulated cystic masses in the liver, suggestive of hydatid cysts (the largest measured 7.7x7.5x6.8cm).Magnetic resonance imaging (MRI) confirmed the presence of a large hydatid cyst in segment 6 of the liver that was very likely communicating with the intra-biliary tree Figure . The serCase 2: lung hydatid cyst with desaturationA 26-year-old Pakistani female G2P1A0 at 21+3 weeks of gestation presented to our emergency department with chest pain of three days duration. She had a persistent cough since 2016 that was worsening and was now associated with shortness of breath for the past three months. Additionally, she reported vomiting after coughing and had a low oxygen saturation on arrival (84%). The investigation included a chest X-ray that revealed a 14x13 cm cystic lesion with fluid level in the mid and lower aspect of the left lung, which resulted in a remarkable mediastinal shift to the right side. Serology was positive for E. antibodies. A computerized tomography (CT) scan of the chest showed a 16x10 cm left lower lobe cystic lesion with an internal layering membrane causing a right-sided mediastinal shift consistent with a hydatid cyst  on oxygen and was started on praziquantel (dose 20 mg/kg twice daily). She had ultrasound-guided drainage of the cyst. Albendazole (400 mg twice daily) was then added to praziquantel. Two weeks following antihelminthic therapy, she underwent thoracic surgery with excision and decortication of the cyst to remove the cyst  cyst and the surrounding lung showed chronic organizing inflammation with foreign body granuloma Figures -6. The bThe pregnancy progressed without complications until 40 weeks when she had a normal vaginal delivery of a healthy male baby.Hydatid cysts in pregnancy are, nowadays, exceedingly rare. Management is controversial and consists of a combination of medical treatment followed by surgical excision. However, medical treatment, including albendazole or mebendazole and praziquantel are not safe in pregnancy, especially in the first trimester. Initial treatment by albendazole followed by praziquantel is advised in order to avoid possible weakening and rupture of the hydatid cyst. Preoperative rupture of the hydatid cyst wall may lead to a host of reactions, including fever, urticaria, eosinophilia, potentially anaphylactic shock, and possible dissemination of other cyst contents.Table One patient with a hydatid cyst of the kidney was managed by the termination of pregnancy in the first trimester . Very feAlbendazole is the drug of choice for hydatid disease and is a useful adjunct to surgery. Perioperative drug therapy with albendazole (or mebendazole) reduces the risk of recurrent disease. It also softens the cyst, facilitating removal but may increase the risk of spontaneous rupture . All patThe postoperative follow-up consists of clinical examination, liver function tests, and chest X-ray once a month for the first three months, which is then continued every three months till the end of the first postoperative year . PregnanHydatid disease very rarely occurs in pregnancy. The lungs and liver are the two most commonly involved organs. The management of patients remote from delivery involves a combination of medical and surgical treatment. The use of albendazole is the mainstay and concerns about its safety have not been reported in humans.


Infant mortality is one of the most sensitive and commonly used indicators of the social and economic development of a nation. Ethiopia is among the African countries with high infant mortality rates. This study aimed to understand and identify correlates of infant mortality in Ethiopia.The data, used in this study, were drawn from 2019 Ethiopian Demographic and Health Survey data. The multivariable Cox proportional hazard analysis was done to identify the correlates of infant mortality.Infant mortality rate was high in the earlier age of months. Males, higher birth order and rural residences were at higher risk of dying before first birthday compared with respective reference groups whereas health facility deliveries, single births, rich wealth indices and older maternal age were at lower risk of dying before first birthday compared with respective reference groups.The study found that age of mother, place of residence, wealth index, birth order, type of birth, child sex and place of delivery were statistically significant in affecting the survival of the infants. Thus, health facility deliveries should be encouraged and multiple birth infants should be given special care. Furthermore, younger mothers should better care of their babies to improve the survival of infants in Ethiopia. HighlightsThis study aimed to identify the correlates of infant mortality in Ethiopia based on 2019 Ethiopia Mini Demographic and Health Survey data.The mortality rate of infants was very high in the earlier age of months.Infants from rural areas had higher risk of death than infants from urban areas.Infants with higher birth order were more likely to die compared to those with first birth order.Infants born in health facilities were more likely to die compared with those born at homes.The infant mortality rate, defined as the risk for a live born child to die before its first birthday, is known to be one of the most sensitive and commonly used indicators of the social and economic development of a nationGlobally, about 67% of under-five deaths are accounted by the infant mortalityInfant mortality rate in WHO African region (52 deaths per 1000 live births) which is over six times higher than infant mortality rate in the European region (8 deaths per 1000 live births)Infant mortality is correlated with the resources accessible to mothers. For instance, the lack of convenient access to clean drinking and sanitary water leads the women to walk considerable distances while carrying pitchers of water. They may find it simple to use electric washing machines and get drinking and sanitary water, which could enhance their health and allow them to land better employment and devote more money to their kids’ healthPrevious study identified different correlates of infant mortality like sex of child, breastfeeding status, size of child at birth, place of delivery, mother’s age at first birth, child’s birth order, type of birth, mother’s age, religion, maternal anaemia, maternal HIV, wealth index, mother’s educational level, diarrhoea, family size, residence, mother’s marital status, pregnancy type, region, mother’s educational level, ANC visit, source of drinking water, toilet facility, sex of householdUnderstanding and identifying the correlates of infant mortality is important for strategy planners to set effective interventions to reduce infant mortality, which could help to attain the sustainable development goal goal by 2030. Therefore, this study aimed to explore the correlates of infant mortality taking into consideration various demographic and socioeconomic factors based on the 2019 Ethiopia Demographic and Health Survey (2019 EMDHS) data.This study was conducted in Ethiopia. Ethiopia is the country in East Africa bordered by Sudan and south Sudan in the west, Somalia and Djibouti in the east, Eritrea in the north and Kenya in the south. The country covers 1 112 000 square kilometres. The country has two City administrations, namely Addis Ababa and Dire Dawa, and nine administrative regions, namely Tigray, Amhara, Afar, Oromia, SNNPR, Somalia, Harari, Gambela and Benshangul-Gumuz when the 2019 EMDHS data were collected.The data for this study were obtained from the 2019 EMDHS which was conducted by Central Statistical Agency (CSA) under the auspices of Ministry of Health. The 2019 EMDHS is national representative cross-sectional survey. The survey was nationally conducted among the nine Regional States and the two City Administrations of the country from 21 March to 28 June 2019. A total of 8663 households were interviewed with a response rate of 99%. From the total interviewed households, all women of reproductive age fulfilling the selection criteria were eligible for the survey and selected for individual interviewsThe response variable was survival time of an infant measured in months from birth until death/censored. The independent variables were classified into two groups: demographic factors  and socioeconomic factors .In this study, the data were analyzed by statistical software STATA 14. Survival analysis was done to identify the correlates of infant mortality. The use of survival analysis is most important when some subjects are lost to follow up or when the period of observation is finite and certain patients may not experience the event of interest over the study period. In the latter case one cannot have complete information for such individuals. These incomplete observations are referred to as being censored. In essence, censoring occurs when we have some information about individual survival time, but we do not know the survival time exactly.The distribution of survival time is characterized by the survivorship function, the probability density function, and the hazard function. Let Then the survivor function, From The hazard function The hazard function The hazard function can be expressed in terms of the underlying probability density function and the corresponding cumulative hazard function A total of 5753 children were included in this study. Of the total children include, 314 of them were died before celebrating their first birthdays. Out of the total of 314 deaths, 183 (58.3%) of them occurred among male infants and remaining 131 (41.7%) of them occurred among female infants. About 236 (75.2%) infant death were from mothers aged less than 25 years, 23 (7.3%) were from mothers aged 25–34 years and 55 (17.5%) were from mothers of age above 34 years  and 0.694 (95% CI: 0.556–0.867) for 25–34 and 35 and above, respectively. These suggest that infants born from mothers aged 25–34 years had 34.4% lower mortality rate than those infants born from mothers aged below 25 years. The 95% confidence interval indicates that the hazard rate goes to a maximum of 0.868 and a minimum of 0.495. Whereas infants born from mothers aged 35 years and above had 30.6% lower mortality rate than those born from mothers aged below 25 years. The 95% confidence interval indicates that the hazard rate goes to a maximum of 0.867 and a minimum of 0.556. On the other hand, the estimated hazard ratio of infants born from mothers aged 35 years and above compared with those born from mothers aged 25–34 years was This study aimed to identify the correlates of infant mortality. Of the total of 5753 live births included in the study, 314 of them were died before celebrating their first birthdays. Among the total of 314 deaths, 183 (58.3%) occurred among male infants while remaining 131 (41.7%) occurred among female infants. About 75.2% infant deaths were observed among mothers aged less than 25 years, 7.3% were among mothers aged 25–34 years and 17.5% were among mothers of age above 34 years. Infant mortality rate was high in the earlier age of months. The study revealed that age of mother, place of residence, wealth index, birth order, type of birth, sex of child and place of delivery were significantly correlated with infant mortality.This study revealed that infants born from mothers aged 35 years and above had lower risk of mortality than those born from mothers aged below 25 years. This finding is consistent with the result of studyOur study also revealed that an infant born in rural area had higher risk of death than an infant born in urban areas. This finding agrees with the results of the studiesOur study also revealed that infants born at health facilities were less likely to die before first birth day than infants born at home. This result is consistent with the previous studiesMoreover, the study revealed that children born from the rich families were less likely to die before celebrating their first birthdays than those born from poor families. This is consistent with the studyThe Kaplan–Meier survival function was used to estimate the survival time of infants. The result indicated that the mortality rate of infants were very high in the earlier age of months. The study found that age of mother, place of residence, wealth index, birth order, type of birth, sex of child and place of delivery were statistically significant in affecting the survival of the infants. Thus, health facility deliveries should be encouraged and multiple birth infants should be given special care. Furthermore, younger mothers should better care of their babies to improve the survival of infants in Ethiopia.As this study was secondary data analysis on 2019 EMDHS, some of variables with high number of missing values like breastfeeding status of child, and father’s educational level were not included.The data used for this study were secondary data and publicly available and have no personal identifiers. We got permission to use the EDHS data from Measure DHS international program.Not applicable.This research did not receive any funding.K.L.A.: conceptualization, data curation, formal analysis, investigation, methodology, software, validation, visualization, writing—original draft. S.K.W.: formal analysis, investigation, methodology, software, validation, visualization, writing—review and editing. S.D.Y.: formal analysis, investigation, methodology, software, visualization, writing—review & editing. K.B.G.: data curation, formal analysis, methodology, software, visualization, writing—review and editing. G.G.M.: formal analysis, investigation, methodology, software, visualization, writing—review and editing. T.S.W.: formal analysis, investigation, methodology, software, visualization, writing—review and editing. T.B.: formal analysis, investigation, methodology, software, visualization, writing—review and editing. B.H.R.: Formal analysis, Investigation, Methodology, Software, Visualization, Writing—review and editing. A.G.: data curation, formal analysis, investigation, methodology, software, visualization, writing—review and editing. K.D.Y.: formal analysis, investigation, methodology, software, visualization, writing—review and editing.Authors declare that they do not have conflict of interest.All data used for the current study are available upon reasonable request from corresponding author.Not commissioned, externally peer-reviewed.The authors are grateful to DHS Program for providing the data for the study.


Microenvironmental factors, including microbe-induced inflammation and immune-checkpoint proteins that modulate immune cells have been associated with both cervical insufficiency and preterm delivery. These factors are incompletely understood. This study aimed to explore and compare interactions among microbiome and inflammatory factors, such as cytokines and immune-checkpoint proteins, in patients with cervical insufficiency and preterm birth. In particular, factors related to predicting preterm birth were identified and the performance of the combination of these factors was evaluated.A total of 220 swab samples from 110 pregnant women, prospectively recruited at the High-Risk Maternal Neonatal Intensive Care Center, were collected between February 2020 and March 2021. This study included 63 patients with cervical insufficiency receiving cerclage and 47 control participants. Endo- and exocervical swabs and fluids were collected simultaneously. Shotgun metagenomic sequencing for the microbiome and the measurement of 34 immune-checkpoint proteins and inflammatory cytokines were performed.Moraxella osloensis  and chemokine CC motif ligand 2 levels higher than 73 pg/mL  in endocervical samples were associated with preterm birth. Combining M. osloensis and chemokine CC motif ligand 2 yielded excellent performance for predicting preterm birth .First, we demonstrated that immune-checkpoint proteins, the key immune-regulatory molecules, could be measured in endocervical and exocervical samples. Secondly, we identified significantly different microenvironments in cervical insufficiency and preterm birth, with precise cervical locations, to provide information about practically useful cervical locations in clinical settings. Finally, the presence of Multiple relationships between microbiomes, immune-checkpoint proteins, and inflammatory cytokines in the cervical microenvironment were identified. We focus on these factors to aid in the comprehensive understanding and therapeutic modulation of local microbial and immunologic compositions for the management of cervical insufficiency and preterm birth. ApproxiThe cervix, located between the microbe-rich vaginal environment and the presumably sterile intrauterine space, provides a mechanical barrier for preventing ascending infection by remaining closed during pregnancy . The cer22.1Subjects were pregnant women prospectively recruited at the High-Risk Maternal Neonatal Intensive Care Center in Kangnam Sacred Heart Hospital. Samples were collected between February 2020 and March 2021. All participants provided written informed consent and the study protocol was approved by the Institutional Review Board of Kangnam Sacred Heart Hospital (HKS 2019-11-024 and 2022-06-010). The inclusion criteria for patients with cervical insufficiency undergoing cerclage were as follows: length < 25 mm or internal os dilation of at least 1 cm, effacement of at least 50%, membranes visible at or beyond the external os, and gestational age between 16 and 24 weeks. The exclusion criteria were less than 18 years of age, multifetal gestations, major fetal malformations, ruptured membranes, vaginal bleeding, clinical chorioamnionitis, or persistent, regular contractions. Outpatients visiting our clinical center for the observation of normal pregnancy or for prophylactic cerclage due to history of previous preterm birth during the study period were included. For normal pregnant women as a control group, only gentle swab sampling without cerclage was performed during routine colposcopic examinations. Endo- and exocervical swabs and fluids were collected simultaneously and stored for analysis. The location of the endocervix is around the internal cervical os and the exocervix is near the vaginal fornix. A uniconcave balloon was used for cerclage , 14. Aft2.2The OMNIgene OMR-130 kit  was used to analyze swab samples. DNA extraction was performed using the Maxwell 16 LEV Blood DNA Purification Kit  within four weeks of sampling, based on the manufacturer’s instructions. After assessing DNA quality using PCR and electrophoresis, libraries were prepared as per standard Illumina protocols. The TruSeq Nano DNA Library Prep kit was used for library preparation, and the quality of the sample pool was confirmed. Libraries were paired-end sequenced 2 × 150 bp) using the Illumina HiSeqXten platform . After trimming, reads aligned to the human reference genome (GRCh38) were removed using BBDuk software. Finally, clean reads mostly derived from microorganisms were used for metagenomic analyses using Kraken2  were used to take samples from the endo- or exocervix. Soluble immune-checkpoint proteins were quantified using the MILLIPLEX Human Immuno-Oncology Checkpoint Protein Premixed 17-plex Panel . The measured immune-checkpoint proteins were soluble cluster of differentiation 28 (sCD28), soluble T-cell immunoglobulin and mucin-domain containing-3 (sTIM-3), soluble herpes virus entry mediator (sHVEM), sCD40, lymphocyte activation gene 3 (sLAG-3), soluble Toll-like receptor 2 (sTLR-2), soluble programmed death-ligand 1 (sPD-L1), soluble cytotoxic T-lymphocyte-associated protein 4 (sCTLA-4), sCD80/B7-1, sCD86/B7-1, soluble programmed cell death protein 1 (sPD-1), sPD-L2, and soluble B- and T-lymphocyte attenuator (sICOS). Inflammatory cytokines were assayed using the Human XL Cytokine Luminex Performance Panel Premixed Kit . The measured cytokines were chemokine CC motif ligand 2 (CCL2), CCL3, CCL4, C-X-C motif chemokine ligand (CXCL10), granulocyte-macrophage colony-stimulating factor (GM-CSF), interferon (IFN)-α, IFN-γ, interleukin (IL)-1α, IL-1β, IL-4, IL-6, IL-8, IL-10, IL-12, IL-13, IL-17A, and tumor necrosis factor-α (TNF-α). All assays were conducted using Luminex-based multiplex technology according to the manufacturer’s protocols on a Bio-Plex 200 instrument .2.4P-values for normality, are presented in P-values. Multivariate logistic regression analysis was performed, using the factors having a P value less than 0.05 in the univariate analysis as co-variables. A receiver operating characteristic (ROC) analysis was conducted to assess the performance of combined factors found to be significant in multivariate analyses to predict preterm birth. The area under the curve (AUC) of combined markers was classified as follows: acceptable (between 0.7 and 0.8), excellent (between 0.8 and 0.9), and outstanding (over 0.9) (http://web-r.org/).Principal component analysis (PCA) was conducted to reduce the number of observed variables to a smaller number of principal components accounting for most of the variance in the observed variables. For pre-processing data, the pcaMethods R package was utilized for row scaling . The valver 0.9) . Spearmaver 0.9) ; Analyse33.1A total of 220 samples (n = 110 for endocervix and n = 110 for exocervix) from pregnant women were analyzed  and Lactobacillus spp. (41178.5 versus 21109.5) in exocervix samples were two-fold greater than in endocervix samples . Four immune-checkpoint proteins, TIM-3, LAG-3, PD-1, and CD86/B7-2, showed differences. For the inflammatory cytokines, CCL2, CCL3, CCL4, GM-CSF, IFN-γ, IL-4, IL-6, IL-13, and TNF-α were significantly different . Age, gestational age at sampling, and body mass index did not reveal differences. The outcomes for normal participants and patients receiving cerclages with uniconcave balloons were not different . In terms of exocervical samples, V. atypica and CD80/B7-1 revealed significant differences  and CCL2 levels higher than 73 pg/mL  in the endocervical samples were associated with preterm birth. When factors independently related to preterm birth after multivariate analyses were subjected to ROC analysis, the AUC was 0.846   for preterm birth when compared to those with L. crispatus dominance . The patients/participants provided their written informed consent to participate in this study.SJ and K-YL conceived the study. WC and YJ analyzed the microbiome data. SC and K-YL led the sampling and clinical data generation. SJ, NL, and KJ generated immunologic data and performed the analyses. SJ wrote the manuscript. M-JP, WS, and K-YL reviewed and edited the manuscript. All authors contributed to the manuscript and approved the submitted version.


Parturition is a complex process involving changes at the hormonal, physiological, morphological, immune, and metabolic levels. Worldwide, preterm birth (PTB), defined as parturition occurring between 20 and 37 weeks of gestation, is a major determinant of neonatal mortality and morbidity, often with long-term adverse effects on the health of both mother and child.In recent decades, the incidence of PTB has continued to rise in most countries. According to the World Health Organization, the rate of PTB across 184 countries is reported to be 5~18% of all births. Therefore, it is urgent to find ways to prevent preterm labor, and for this, a better understanding of the mechanisms behind it and those associated with parturition is necessary.In this Research Topic we bring together important papers that carefully disclose the mechanisms of parturition and preterm birth and provide potential technologies and biomarkers to understand and predict them. This will definitely help us find more effective clinical interventions to prevent preterm birth and improve the outcome of parturition in the future.Romero-Morales et al. enhanced classification of preterm-term birth using continuous wavelet transform and entropy-based methods of electrohysterogram (EHG) signals, and Qi et al. reported two fetal membrane indicators derived from Magnetic Resonance Imaging that can predict premature rupture of membranes (PROM) and preterm premature rupture of membranes (PPROM). Olmos-Ramírez et al. have also found that uterine activity modified responses of the fetal autonomic nervous system at preterm active labor using a novel time-frequency analysis of fetal heart rate variability (FHRV). Besides this significant progress, Hussein et al. reported lowered expression of soluble Fms-like tyrosine kinase 1 (sFLT-1) and placental growth factor (PlGF) with high ratio of sFLT-1/PlGF in extracellular vesicles of preterm birth and suggested that could be used as potential biomarkers for preterm birth.Innovation of instrumentation and methods remains the major step in an understanding of the processes involved in birth. The use of electromyography (EMG) for parturition and preterm birth prediction has been found to have higher specificity and sensitivity , 2. ReceWith the progress of technologies, H Liu’s group also published a series of papers in Frontiers using transcriptome sequencing (RNA-seq), mass spectrometry detection of proteome (LC-MS/MS), single cell transcription sequencing (scRNA-seq), and spatial transcription (ST). In addition, they verified the involvement of inflammation and hypoxia in laboring myometrium and that gives some important hints for future studies –6.Vidal et al. submitted a significant review about the multiple feto-maternal organ systems, differing mechanisms, and pathways involved in spontaneous preterm birth. They also stressed the need for biological models that permit concomitant observation and analysis of organ interactions, rather than focusing on these tissues as single entities.In this Research Topic, In summary, the papers in this Research Topic help us to better understand the mechanisms of parturition and preterm birth and shed new light into more effective clinical predictions and interventions in the future.JB wrote the first draft of the manuscript, and RG revised the manuscript. All authors read and approved the final version.


There are few medicines in clinical use for managing preterm labor or preventing spontaneous preterm birth from occurring. We previously developed two target product profiles (TPPs) for medicines to prevent spontaneous preterm birth and manage preterm labor. The objectives of this study were to 1) analyse the research and development pipeline of medicines for preterm birth and 2) compare these medicines to target product profiles for spontaneous preterm birth to identify the most promising candidates.Adis Insight, Pharmaprojects, WHO international clinical trials registry platform (ICTRP), PubMed and grant databases were searched to identify candidate medicines  and populate the Accelerating Innovations for Mothers (AIM) database. This database was screened for all candidates that have been investigated for preterm birth. Candidates in clinical development were ranked against criteria from TPPs, and classified as high, medium or low potential. Preclinical candidates were categorised by product type, archetype and medicine subclass.Prevention: Omega-3 fatty acid, aspirin, vaginal progesterone, oral progesterone, L-arginine, and selenium; Treatment: nicorandil, isosorbide dinitrate, nicardipine and celecoxib) and seven were medium potential . 107 candidates were in preclinical development.The AIM database identified 178 candidates. Of the 71 candidates in clinical development, ten were deemed high potential (This analysis provides a drug-agnostic approach to assessing the potential of candidate medicines for spontaneous preterm birth. Research should be prioritised for high-potential candidates that are most likely to meet the real world needs of women, babies, and health care professionals.The online version contains supplementary material available at 10.1186/s12884-023-05842-9. Preterm birth  is the leading cause of death in children under five and a major cause of newborn morbidity –3. Up toThe lack of innovation in medicines for spontaneous preterm birth/labour can be attributed to the broader, long-standing lack of investment in research and development (R&D) for new medicines for obstetric conditions . A 2014 The Accelerating Innovation for Mothers (AIM) project was initiated to catalyse the development of new medicines for obstetric conditions . Within Development of the AIM medicine pipeline database has been previously described –25. BrieTo identify high-potential candidates in the pipeline, we applied a systematic, stepwise approach to assessing all 178 candidates for preterm birth prevention and preterm labour management. First, we excluded candidates that were: 1) approved and already available on the market for this indication; 2) recommended by WHO, or otherwise in routine clinical use for this indication; 3) already recommended or widely used to treat a subgroup of women within the condition of interest ; 4) inactive due to negative trial outcomes ; 5) indicated as inferior to current treatments based on currently available evidence; and 6) under investigation for other conditions related to labour/birth, such as labour induction, and not preterm birth.We previously developed TPPs to guide development of novel medicines for prevention of spontaneous preterm birth and management of preterm labour – the first TPPs developed for preterm birth . These TPreclinical candidates were assessed descriptively, including categorisation by product type, new or repurposed, and medicine subclass. Comparison of preclinical candidates to the TPPs was not performed, given the lack of data for most of the TPP-based criteria.For each variable, candidates were assigned a numerical score representing the level of matching for a given variable of the TPP Table  and S2, Of the 178 candidates in the pipeline, seven (3.9%) were approved and on the market for the prevention or management of preterm birth . An additional 11/178 (6.2%) candidates are approved for other clinical conditions and have been used off-label for preterm birth  or to promote fetal well-being following preterm delivery .In total, 68 38.2%) candidates were currently active and 110 (61.8%) were inactive  . Meta-anp = 0.02) [Lactoferrin was ranked as medium potential Fig. c, and th = 0.02) . HoweverThere were four candidates assessed for management of preterm labour in Phase III Fig. a, 13 in No Phase III candidates were identified as high potential. Retosiban, a selective oxytocin antagonist and glyceryl trinitrate, a nitric oxide donor were ranked medium potential Fig. a. A piloNicardipine, nicorandil, isosorbide dinitrate and celecoxib were all ranked high potential and are all from the same drug class as tocolytics in clinical use Fig. b. NicardHuman chorionic gonadotropin and relcovaptan were ranked medium potential Fig. b. A placBryophyllum pinnatum extract, a herbal succulent that contained phenolic constituents was ranked medium potential  were active and 64 (69.6%) were inactive , nitric oxide donors , oxytocin receptor antagonists (retosiban) and calcium channel blockers  . Our anaIn contrast, there are currently few medicines that are recommended for the prevention of preterm birth. A significant amount of active R&D concerns progestin medicines for preterm birth prevention. Studies have investigated different formulations and routes of administration , as well as aiming to identify which sub-population of women will benefit most from progesterone . RecentlDietary supplements represented 18% of the candidates under investigation for preterm birth. Trials of some of these supplements, including vitamins A, C and E, have been conclusively shown not to be effective at preventing preterm birth –61. In cThe large number of candidates in development for preterm birth/labor suggests comparatively high R&D interest for this condition. However, 62% of all candidates and 72% of candidates in preclinical development for preterm birth/labor are inactive, with no updates or published progress since 2018. For example, the promising oxytocin receptor antagonist retosiban developed by GSK was halted in Phase III trials due to difficulties with trial recruitment . The comWe have developed a novel, drug-agnostic approach for analysing the R&D pipeline for medicines for spontaneous preterm birth and preterm labor. Our analysis provides the most extensive mapping of the historic and current R&D pipeline for preterm birth/labor and identified ten high priority candidates currently in clinical development, as well as significant gaps in R&D. This approach may be useful for prioritising research for other maternal conditions, as well as other fields of drug development, particularly where TPPs already exist . HoweverOver the last 20 years R&D for preterm birth/labor medicines is an active area compared to other maternal conditions. However, many candidates, including promising new therapies, are currently inactive. Development of alternative tocolytics, new formulations of progestins and dietary supplements are areas of high research activity. We identified six high priority candidates for preventing spontaneous preterm birth and four high priority candidates for the management of preterm labor that best meet real-world requirements. This novel method of matching drug candidates to TPPs can help better direct research funding towards the most promising candidates and ensure new and effective therapies become available.Additional file 1: Appendix A. Supplementary tables. Table S1. Scoring of target product profile comparison, for quantification of potential of candidates. Table S2. Threshold for ranking of potential at each phase of the R&D development pipeline.Additional file 2: Appendix B. Low rank candidates.


A positive perinatal experience facilitates a smooth transition to motherhood and enhances the development of a strong bond between mother and newborn, contributing to maternal and societal wellbeing. Given the medicalization of childbirth in Cyprus, the examination of mothers’ experiences of perinatal care becomes imperative.To investigate mothers’ experiences of care during the perinatal period and to identify factors related to the provision of maternal care that contribute to the interpretation of these experiences.The study draws on data from the European survey “Babies Born Better”, an online survey utilizing a mixed-methods approach to explore women’s experiences of maternity care across Europe. The study population were women who had given birth in Cyprus over a 5-year period (2013–2018). Quantitative data were analyzed using SPSS v22, while qualitative data were analyzed through inductive content analysis.bad experience”, 11.1% a “good experience”,13.9% a “very good experience”, and 13,3% a “very bad experience”. The top three sub-factors of the overall experience which received positive evaluation were “Relationship with health care professionals” (33.6%), “Birth environment and care” (11.4%), and “Breastfeeding guidance” (10.8%). The qualitative analysis yielded five themes: “Relationship with health care professionals”, “Breastfeeding establishment”, “Childbirth rights”, “Birth environment and services” and “Choice of mode of birth”.A total of 360 mothers participated in the study. In rating their overall experience, 24.2% stated that they had a “Mothers in Cyprus wish to have respectful maternity care. They need maternity health care professionals to respect their dignity and ask for evidence-based information with shared decision making. Mothers in Cyprus expect to have their childbirth rights safeguarded, to have better support from HCP, and to receive humanized care. The perinatal care provided in Cyprus needs significant improvements based on mothers’ needs and expectations. The birth of a child is a pivotal point in the life of a woman and a family . The expp < 0, 0006) and skin-to-skin contact had a positive effect on mothers’ experiences. Staff confidence, adequate analgesia and continuity of care also contributed positively. Deliktas et al. . In% with th4.7% thanPerinatal care in Cyprus is obstetric-led and highly medicalized, characterized by high levels of interventions . Indicathttps://www.babiesbornbetter.org/), with the aim to become a major resource for the improvement of maternal and childbirth care around the world. The data of what works, for whom and in what circumstances, will provide us insights into best practices for childbirth. The present article analyzes data collected in Cyprus during the second phase of the BBB study. Indicatively, this phase was conducted between March and August 2018 with the participation of more than 44 000 mothers worldwide [The present study is part of the Babies Born Better (BBB) online survey which was developed as part of the EU funded COST actions ISO907«Changing childbirth cultures and consequences» and IS1405 «Building Intrapartum Research Through Health – an interdisciplinary whole system approach to understanding and contextualizing physiological labor and birth». The BBB survey involves the participation of researchers from more than 38 countries in Europe and worldwide ; most recent pregnancy information ; childbirth environment ; and, finally, perceptions and feelings of overall birth experience. The survey consisted of both close-ended and open-ended questions in which women were asked to provide their views about their experiences of care , 47.The questionnaire was prepared by a group of researchers, and subsequently reviewed and improved by a wide range of stakeholders, including academics, activists, and people with diverse personal and professional backgrounds. The questionnaire was then translated into 23 languages for use across Europe and beyond. In Cyprus, the original questionnaire was used for English-speaking participants, whereas a Greek version for developed for Greek-speaking participants. The questionnaire was translated by native speakers  into Greek and subsequently verified and refined using back translation to improve its reliability. Some transcultural adaptations were introduced in the items related to the Cyprus health system, birth setting, and birth professionals. The survey ran as an open online survey on SurveyMonkey® platform between March and August 2018.The study utilized convenient sampling. The participants were recruited in two ways during the period of March-August 2018: (a) through social media, and (b) through the researchers’ own social networks. Invitations to participate in the study along with the survey link were extended through various social media channels, as well as personally through leaflets containing the survey link. The inclusion criteria were mothers aged 18 and above who had given birth in the previous 5 years and were residents of Cyprus, regardless of first language. The exclusion criteria omitted mothers who had not given birth in Cyprus and their age were below 18 years old.Ethics approval for this international study was granted by the Ethics Committee of the University of Central Lancashire (UCLAN) in the UK (Ethics Committee BuSH 222 & STEMH 449). All data was stored and handled in accordance with the General Data Protection Regulation, the UK Data Protection Act (1998), as well as the University of Central Lancashire (UK) guidelines. The front page of the survey provided potential participants with information about confidentiality, consent, data protection and the scope and aims of the survey. Based on this information, participants consented to participate by choosing to progress beyond this front page.2) correlation was explored between “Feelings about childbirth experience” with “Type of childbirth”. Qualitative data were analyzed through inductive content analysis, adhering to the following steps: (1) reading the full set of data to obtain an overview; (2) codification of each answer by combining inductive procedures; (3) identification of themes and categorization (4) intra code and intercode comparison and subsequent recodification to ensure the internal consistency of codes and subcategories; (5) merging of subcategories to themes. The same process was followed independently by two researchers and any discrepancies regarding themes were discussed until consensus was reached. This is a systematic and objective method designed to describe in depth a phenomenon in order to make it more understandable [The analysis of the data was carried out using descriptive and correlation statistics methods with the help of the Statistical Package of Social Sciences SPSS 22 . The level of statistical significance was set in all cases at 5%. Chisquare . The detailed demographic characteristics of the participants are presented in Table In the question asking participants to select from a list of options and rank “the three positive experiences of your care (with the first being the most important for you)” it emerged that the most frequently chosen answer, as well as the one most often rated at utmost importance for the women, was “the relationship with health professionals” (33.6%). “Breastfeeding guidance” ranked second in importance, selected at a rate of 10.8%, and of third importance, was the “Birth environment and care”, with 11.4% of participants choosing this as one of the three factors. The least frequently selected positive experience was mode of birth, chosen by only 1.7% of respondents. , “Relationship with Health care professionals” (8.1%), and “Birth environment and care” (6.4%), followed by “Breastfeeding guidance” and “Childbirth rights” The majority of the sample had no specific recommendations to suggest .“Feelings about childbirth experience” correlated significantly with “Mode of birth”, the respondents, 21.7% - of women who experienced a normal birth stated that they had a “very good experience”. By comparison, of mothers who gave birth with a planned cesarean section, 13.6% - said they had a “very good experience”. The mothers who gave birth by emergency cesarean section 10.3% chose the answer “very good experience” to the corresponding question, while of those who gave birth with ventouse intervention 35% had a very good experience in correlation to the women who had an emergency cesarean section .The option “quite a bad experience”, was chosen by 16.9% mothers who gave birth normally, 21.2% of mothers who gave birth by scheduled cesarean surgery, 17.2% of mothers who gave birth by emergency cesarean and 15% of the mothers who gave birth with ventouse intervention. The results indicate that mothers who gave birth normally or with ventouse assistance, had a better experience compared to mothers who gave birth through planned or emergency cesarean surgery, at the level of statistical significance (p = 0.03) and (2) interventions in childbirth, where “very good birth experience” had women with “no intervention” by 26.2%, while 8.3% with “accelerated labor” (p = 0.001).The birth experience was also found to be correlated with (1) the type of birth, where it was shown that mothers who gave birth by vaginal birth more often reported having a “very good experience” (21.7%) than those who gave birth by cesarean section (13.6%) . Some mothers (6.4%) did not recommend birthing in the same venue, also citing the same reason  answered on the question about the birth environment where the 6,9% reported positive comments, the 10,8% rated their experience of birth environment and care as negative. Lastly, 5,3% reported neutral comments.From the inductive analysis of the data on the open-ended questions five broad themes emerged and each theme was divided into sub-themes Table .Table 4TExperience and expertise/ professionalism of HCP.The relationship between mothers and HCP was a key factor, contributing to the overall quality of the childbirth experience. Mothers stressed the importance of the HCP experience, and significantly valued the expertise and the support provided during labour and birth. Patience, courtesy, and politeness shown by HCPs during labour and birth were deeply appreciated.My health care professionals were experienced; they have the necessary knowledge…I feel safe as I trust my doctor and my midwife during pregnancy and especially during childbirth.” (ID 6841158169)“The experience and expertise of the HCPs was also identified as an important for building a relationship of trust, that made mothers feel safe:“Doctors are thinking of money. There is no cooperation between mothers, doctors and nurses and it seems that they do not care much” (ID6890272490)When mothers were asked about potential changes that would improve their care, interesting examples of very poor care emerged:“They didn’t care for me at all and I felt like I was a money machine for them” (ID 6733027836).Another mother said that she would not advise any woman to give birth in the same setting she had given birth because of the unprofessional behavior of some HCPs:“My second birth took place only in the presence of midwives and my husband. Everything was very natural and better than my first baby where the doctor was present…the doctor was anxious, in a hurry and did not provide the same guidance as midwives” (ID 6732499265).Mothers also commented on the different models of care and on the levels of support provided by midwives and obstetricians:Midwives were gentle and helpful during labor and that made me feel comfortable” (ID 6733569197)“One mother made a special reference to the midwives’ behavior:“I appreciate the overnight support from my midwife, in contrast to the brief presence of the doctor at birth” (ID 6781575650).Interestingly, several mothers commented that they were satisfied with the continuity of care offered by midwives during labor and birth, in contrast to the care offered by the obstetrician:Midwives were continuously promoting breastfeeding and were giving advice”(ID 6732232003).“Many mothers mentioned that initiating and sustaining breastfeeding was of critical importance and an integral component of their childbirth experience. Skin-to-skin care and the first hours after birth were perceived by mothers as the most important steps for the establishment of breastfeeding. An environment that promotes both breastfeeding and the mother’s involvement in newborn care was a significant factor in overall satisfaction with the childbirth experience:“I asked them to help me with skin-to-skin after birth, but they did not listen… then I asked them for rooming-in but they said to me that for the baby’s best interest the baby must stay in the nursery” (ID 6785652175).On the other hand, some mothers mentioned that there were HCPs who did not support breastfeeding, offered conflicting advice, and interrupted mothers during breastfeeding. Attention to breastfeeding was elaborated on by some mothers who referred to the “10 Steps to Successful Breastfeeding Initiation” , 51. TheMy choice to give birth with VBAC was a battle for me with my doctor because VBAC is not allowed at this maternity clinic.” (ID 6864013384)“Involvement or lack of involvement in decisions surrounding birth mode and care was one of the main issues highlighted by participants through the survey, and, as such, may have a significant bearing on mothers’ overall experience. Mothers emphasized that an important element of their care was that their choices and desires were heard and respected. One mother described how difficult it was for her to give birth in the way she wanted to:“Most of the time they did not allow me to make a simple decision” (ID 6841647617).Another mother described her choices as being only partially met, noting that:“The doctor respected me and always asked for my consent, he was very supportive”. (ID 6785652157)Mothers describe with positive remarks, the respectful care they received:“Midwives explained more than I would expect”. (ID6747664260).A mother commented that the midwives were very supported, but that this was a pleasant surprise, suggesting that this was not an expected situation:“That was a pleasure to have my husband by my side, during labor” (ID 6793222090)It was common for mothers to express satisfaction at being able to choose to have their partner present during birth:the doctor first examined me at birth…she shouted at me that I must follow her orders. I was very shocked, no one ever spoke to me like that… I could not speak between the contractions, and I was alone, and I could not defend myself. I was very hurt and felt myself in a vulnerable position” (ID 6785652175)“When Some mothers mentioned that their childbirth rights were not consistently safeguarded. The lack of respect and non-response towards their expressed wishes regarding birth mode, privacy, and choice of persons present in the labour room, as well as poor communication between mothers and HCPs were among the examples given. One mother characteristically mentioned:“There was exemplary hygiene.” (ID 6924710149).“There were balls that could help me with birth” (ID 6737100934).“The environment in the clinic was very harmonious and modern ” (ID 6733392130).“That it was close to the NICU.” (ID 6732173142).Mothers identified the birth environment as important, commented positively on modern and clean surroundings, single and cozy rooms, access to a private toilet, and close proximity to the NICU. Participants noted:“The equipment was very old” (ID 6746895859).“They could have been less machinery in the room and more privacy” (ID 6781571507)“There should have been better food (which is important after so many hours of birth and considering the cost is very high) and better care to the mother” (ID 6787210803).However, for some mothers the birth environment was a negative aspect of their experience with some commenting on old equipment, lack of private rooms, inadequate room cleanness, and lack of options for labour pain relief. Some women also commented on the lack of choice in birth venues and the unavailability of home birth in Cyprus, while others commented on the lack of provision of prenatal classes or the high cost of childbirth.“If it is possible for a mother to leave Cyprus and give birth anywhere else in the world, then book a trip immediately. It is unbelievable the degree of medicalization of care here” (ID 6787210803)“In case that you want a natural birth without interventions, then you should avoid the hospitals and maternity clinics in Cyprus, including the one where I gave birth” (ID 6781575652)Choice of birth mode was described by mothers as an important element of their care and as one which enhanced their experience. Many women emphasized their wish to avoid unnecessary interventions, including induction and cesarean section in the absence of serious complications. Some women expressed feeling proud of themselves for having given birth naturally, while many mothers mentioned that they chose their birth venue based on the venue’s reputation in promoting and prioritizing normal birth. Some women also reflected on the high medicalization of childbirth in Cyprus, making the experience of childbirth less pleasant:This study provides evidence on how mothers giving birth in the Republic of Cyprus perceive their experiences. Support by HCPs, respect of the mothers’ wishes, and active involvement in childbirth were associated with a positive experience. The expertise and professionalism of HCPs also contributed to a positive experience along with continuity-of-care and implementation of good maternity practices within a friendly, comfortable, and clean environment.The development and nurturing of relationships of trust between HCPs and pregnant women have emerged as highly significant. Positive emotions increased during childbirth if mothers were respected and treated with kindness. These results are congruent with Raboteg-šarić et al.’s An interesting result was the extent to which HCPs’ behavior and the medicalised nature of maternity care in Cyprus created a negative perception of childbirth experience. In particular, the apathetic behavior of some HCPs, as well as the lack of respect, courtesy, and knowledge, did not support the development of a pleasant experience. Insufficient information, failure to elicit consent to any intervention  and lack of respect for women’s values and wishes, including the right to choose how to give birth, were associated with mothers’ dissatisfaction with care, which resonates with the findings of the study by Shabila et al. . The behThe factor least often chosen by participants as contributing to a positive birth experience was birth mode. It is interesting to ask whether this means that overall, women were least happy with their mode of birth. This is a topic which warrants more in-depth examination, particularly given the high levels of medicalised birth intervention in Cyprus. The failure to facilitate and promote normal/physiological childbirth, as well as the high rates of unnecessary cesarean surgery and other interventions, have been found to contribute to negative perceived experiences of care, as evidenced in the research of Pazandeh et al.  on the iMany mothers ask for normal childbirth, for the avoidance of unnecessary interventions, and for the performance of cesarean surgery only when absolutely necessary. The relationship between mothers, HCPs and the birth environment needs improvement. Mothers wish to see improvements in the birth environment, and in particular the development of environments which are friendly, provide options for pain relief, including natural methods such as music, and support the presence of a partner during labor and birth. In addition, access to single rooms with an ensuite toilet and bathtub in a clean and an aesthetically pleasing maternity ward is recommended. The ability to opt for other means of childbirth such as water birth, was also expressed as desirable. The recommendations for improvement reported by Croatian mothers in Raboteg-šarić et al.’s Correlations between type of childbirth and feelings about childbirth experience was found. Women that had natural childbirth had reported a positive childbirth experience in relation to the women that had a scheduled or emergency cesarean section. Similar findings were reported from Carquillat et al. , where tSimilar results were found in the other countries BBB survey was carried out; specifically the Norwegian team reported that women are in need of a more compassionate and respectful maternity care with continuity of care where the socio-cultural and psychological impacts of care are utmost importance for the women during childbirth . In addiThe mothers that participated in the BBB survey study were 39.2% that gave birth by cesarean surgery; while the official published data for Cyprus reported that 53.6% of women had cesarean therefore, it remains unknown whether women that had cesareans were generally under-represented . NonethThe most significant finding from this study is the need for changes in perinatal care in Cyprus. The improvement of the maternal healthcare system and the promotion and facilitation of positive experiences of labor and childbirth are imperative. Women in Cyprus expect to have their rights in childbirth safeguarded, and to receive respectful care and better support from HCPs, as well as evidence-based care during labor, birth, and breast-feeding establishment. The experiences of mothers should inform public and political debates on the quality of maternity care in Cyprus and the findings of the present study provide valuable insight into this topic.


Thyroid functions in preterm newborns may be altered in the first week of life. Hypothyroxinemia has been commonly reported in these babies, which could be due to the immaturity of the hypothalamic pituitary thyroid axis or acute illness. It could have a long-term impact on the developing brain of these babies. We conducted this study to estimate the incidence of transient hypothyroxinemia of prematurity (THOP) and to determine its risk factors.We analyzed thyroid stimulating hormone (TSH) and free T4 levels of 64 preterm neonates admitted in the neonatal intensive care unit. TSH and free T4 levels were measured in the first week and then at 14-21 days of life to estimate the incidence of THOP and determine its risk factors. We also estimated the incidence of congenital hypothyroidism (CH) and delayed TSH elevation in CH. Risk analysis was conducted using simple and multiple logistic regression, and numerical data was compared using the Mann Whitney U test and t test.THOP was seen in 25% of the preterm babies. Caesarean delivery, presence of one or more morbidities, mechanical ventilation, birth weight ≥ 1,500 g, and gestational age ≥ 32 weeks were identified as risk factors for THOP based on simple logistic regression. In multiple regression, mechanical ventilation and gestational age ≥ 32 weeks were significantly associated with THOP. CH was seen in 2 (3.1%) babies, and 1 of these cases had delayed TSH elevation.Thyroid abnormalities are common in preterm admitted neonates. Mechanical ventilation is an independent risk factor for development of THOP. Thyroid function in sick preterm babies is poorly understood. Many of these babies have low thyroxine levels in the first week of life. They can also have congenital hypothyroidism (CH) without any thyroid stimulating hormone (TSH) elevation in the first week, and CH can therefore be missed in the first screen. TSH elevation is delayed in such babies and can be detected only if a repeat screening is done later at 2-4 weeks ,2. AlterTransient hypothyroxinemia of prematurity (THOP) is the most common thyroid dysfunction in preterm infants. This may be due to withdrawal of maternal T4 transfer, impaired production of T4-binding globulin, immaturity of the hypothalamic pituitary thyroid (HPT) axis, impaired synthesis, decreased iodine stores, use of drugs such as dopamine and steroids, inadequate nutrition, and non-thyroidal illnesses . THOP isEvidence from past studies indicates that there is a higher incidence of CH in preterm infants, often detected only upon rescreening at 2-4 weeks of life ,6. The dMany studies have been conducted on THOP and rescreening for diagnosing CH in preterm babies worldwide, but there is a lack of any such data from India. Therefore, we conducted this study to estimate the incidence of THOP and to determine its risk factors. The study also aimed at estimating the incidence of CH with delayed TSH elevation in preterm babies.This was a prospective cohort study conducted in a neonatal intensive care unit (NICU) of a tertiary level teaching institute. Ours is a 20-bed level III unit that caters to extramural babies. The study was conducted over a period of one year from April 2019 to March 2020. The study was approved by the institutional ethics committee (IEC). Informed consent was obtained from the mother and/or father of the baby.primary objective of the study was to estimate the incidence of THOP and to determine the risk factors in the preterm babies admitted to the NICU.The secondary objectives were as follows:The To estimate the incidence of CH with delayed TSH elevation in admitted preterm babies.To determine the correlation between TSH and FT4 with the birth weight and gestational age of preterm newborns.Inclusion criteria: Neonates admitted to the NICU were eligible for inclusion in the study if they fulfilled all the following criteria:Gestational age < 37 weeksAdmitted at ≤ 7 days of lifeHospital stay ≥ 7 daysExclusion criteria: Babies who did not complete the study because of death, leaving against medical advice, or loss to follow-up after discharge were excluded.Sample I) for TSH and FT4 at 48-72 hours of life for all babies admitted within 24 hours of life and on the day of admission for babies admitted after 48 hours of life. A repeat venous sample (Sample II) is sent for TSH and FT4 at 14-21 days of age for all preterm babies. The first samples are TSH (1) and FT4 (1), and the repeat samples are TSH (2) and FT4 (2). The samples are analyzed using the enzyme-linked automated fluorescent immune assay (ELFA) technique .All newborns admitted in the NICU over the period of one year who fulfilled the inclusion criteria were enrolled in the study. Their details were provided in a pro forma that included the demographic profile such as birth weight, gestational age, and gender and medical details such as duration of hospital stay, morbidities, and administration of dopamine. The babies were stratified into appropriate for gestational age (AGA), small for gestational age (SGA), and large for gestational age (LGA) . The newReference values for serum FT4 and TSH in the first week of life are as follows :TSH was considered elevated if the levels were > 20 mIU/L in the first week and > 10 mIU/L after the first week. The FT4 levels were considered low if the values were < 16.7 pmol/L in babies with a gestational age of 31-36 weeks and < 6.4 pmol/L for gestation of 25-30 weeks . THOP waCH was diagnosed as per cutoffs for TSH, and CH with delayed TSH elevation was considered when TSH (1) was normal but TSH (2) was elevated.Statistical analysis: Statistical analysis was performed using Epi info 7 and SPSS version 27. The normally distributed numerical data were analyzed by t test. The Mann Whitney test was used to compare the numerical data, which was not normally distributed. The Wilcoxon rank sum test was used for the paired data, and Pearson correlation was used to assess the correlation. Risk analysis was conducted using simple and multiple logistic regression.A total of 76 babies fulfilled the inclusion criteria. Out of these, 2 babies died, 2 left against medical advice, and 8 were lost to follow-up and could not complete the study. A final analysis of 64 babies was conducted. The comparisons of the demographic and clinical characteristics of the babies with and without THOP are given in THOP was observed in 16 (25%),  babies, and the median TSH values in babies with THOP was significantly lower than in the babies without THOP (p = 0.016) . Out of CH was diagnosed in 2 (3.1%)  babies, 1 baby had elevated TSH on the first sample, and 1 baby was diagnosed on repeat sampling. The baby with CH had normal FT4 levels in the first week, as well as at the second screening. The baby with CH with delayed TSH elevation had low FT4 levels at the first screening, which normalized at the second screening.We did not find any correlation between the birth weight and TSH (1) and FT4 (1) values of the study population, the correlation coefficient r being 0.04 and 0.01, respectively. Similarly, no correlation was found between the gestational age and TSH (1) and FT4 (1) values, the correlation coefficient r being 0.02 and 0.1, respectively. The Wilcoxon rank sum test for the paired values of TSH and FT4 values showed no significant difference, z = −1.8, p = 0.06 for TSH (1) and z = −0.03, p = 0.97 for FT4 (1).The 2 infants diagnosed with CH were started on treatment. No treatment was started for transient hypothyroxinemia.We studied the TSH and FT4 levels in the first and third weeks of life in preterm babies admitted to the NICU. THOP was found in 16 babies, and CH was seen in 2 babies.The strengths of the study are i) it was a prospective study and ii) we screened the babies for both TSH and FT4 levels simultaneously, which is the ideal screening approach. Limitations include i) the babies were all extramural babies, the majority having no antenatal records, meaning we did not have maternal thyroid status details, and ii) we did not measure free T3 levels, which could have added more information.THOP was seen in 16 babies, an overall incidence of 25% among the preterm babies. Studies have reported THOP to be present in 15%-30% of preterm babies ,12. ChunThere are contradictory results from different studies that have been conducted on long-term follow-up of preterm babies with THOP. Many studies have found adverse effects in the later life of these newborns, such as cerebral palsy and impaired cognitive functions ,22. On tA rare scenario of central hypothyroidism might also have similar presentation of low FT4 and normal/low TSH. A thyrotropin-releasing hormone stimulation test might be the only way of differentiating between the two entities .In our study, 2 babies were diagnosed with CH, and one of them had delayed TSH elevation 1.5%). Variable incidences of CH ranging from 1% to as high as 18% have been reported in preterm babies . The stu.5%. VariDelayed TSH elevation, not due to CH, may be seen in some high-risk babies, which occurs at 2-6 weeks and resolves at 6-10 weeks. This has been named atypical hypothyroidism or transient elevation of TSH. This can be due to recovery of illness, induced suppression of the HPT axis, iodine deficiency or excess of iodine levels, maternal antithyroid drug, or maternal autoantibodies .We did not find any significant difference in the median TSH and FT4 values of different groups of the preterm neonates and between the paired samples in each group. Our findings are consistent with the findings of other studies, where the authors did not find any difference in the FT4 and TSH levels of preterm SGA babies ,30. Liu We did not find any correlation between the gestational age and birth weight and the TSH and FT4 levels. Korkmaz and cols. found no correlation between the first TSH level and gestational age and birth weight, but an inverse relationship was found in the second and third samples . A signiThe clinical relevance of THOP, its long-term impact on the neurodevelopmental outcome, and need for replacement of thyroxine require more research, as there is a lack of clarity, despite many studies being conducted in the past. It has still not been possible to implement universal newborn screening for CH in India. Therefore, no universal recommendation can be made regarding rescreening of all preterm/LBW babies. However, high-risk preterm babies, such as those who are extremely LBW and sick preterm babies with prolonged hospital stay, can be subjected to a first screening at 48-72 hours of life, and rescreening can be done at 2 weeks of life.Further studies from India and other lower- and middle-income countries will help in understanding the problem of THOP and CH with delayed TSH elevation in a better way, as the characteristics of the newborn population in such countries differ from those in developed countries.