Low birth weight is a public health problem in Africa with the cause attributable to malaria in pregnancy. World Health Organization recommends the use of intermittent preventive treatment in pregnancy (IPTp) with sulfadoxine-pyrimethamine to prevent malaria during pregnancy. The objective of this study was to evaluate the prevalence and trajectories of birth weight and the direct impact and relationship between sulfadoxine-pyrimethamine and birth weight in Ghana since 2003.This study used secondary data obtained from the Demographic and Health Survey conducted in Ghana since 2003. Low birth weight was defined as weight < 2500 g irrespective of the gestational age of the foetus, while normal birth weight was between 2500 g to < 4000 g and macrosomia was =  > 4000 g. In all the analysis, we adjusted for clustering, stratification and weighting to reduce bias and improve precision of the estimates. Analysis was performed on each survey year as well as the pooled dataset. The generalized ordered partial proportional odds model was used due to violations of the parallel regression model assumptions. Efforts were made to identify all confounding variables and these were adjusted for. Predictive analysis was also executed.The overall prevalence of low birth weight was 9% while that of macrosomia was 13%. The low birth weight for 2003 was 12% while in 2008 it was 21% and then 68% in 2014. The mean birth weight of the children in 2014 was 3.16 , 2008 was 3.37  and 2003 was 3.59  while that of the pooled data was 3.28 . The adjusted model  showed that non-uptake of SP could result in 51% odds of giving birth to a low-birth-weight compared with normal birth weight child. An insignificant result was observed between macrosomia and low birth weight.There is higher probability that low birth weight could increase over the next couple of years if measures are not taking to reverse the current trajectories. The uptake of sulfadoxine-pyrimethamine should continue to be encouraged and recommended because it has a direct beneficial effect on the weight of the child. Malaria remains a major public health threat to people in the African continent. In 2018, 213 out of 228 million cases of malaria recorded worldwide, occurred in the African Region, World Health Organization (WHO) . The harmful effects of malaria in pregnancy on the morbidity and mortality of foetuses and newborns have been of grave concern to many. Studies have shown maternal anaemia , 4 and pBirth weight can be classified into three: Low birth weight, normal birth weight and high birth weight (macrosomia). Low birth weight has been defined as weight less than 2500 g irrespective of the gestational age of the foetus while normal weight is between 2500 g to less than 4000 g and macrosomia is weight greater than or equal to 4000 g .Birth weight is a serious public health problem in sub-Saharan Africa based on which a number of interventions have been rolled out to mitigate if not eradicate it completely and one of such interventions is the uptake of sulfadoxine-pyrimethamine in pregnancy. Intermittent preventive treatment of malaria in pregnancy (IPTp) with sulfadoxine-pyrimethamine is an antimalaria medication which is among a package of interventions recommended by the WHO for controlling malaria and its effects during pregnancy irrespective of whether the pregnant woman is infected or not. The recommended IPTp drug is sulfadoxine-pyrimethamine (WHO) . AccordiThere have been a number of studies conducted to look at the causes and variables associated with birth weight, some of which include preterm birth and intrauterine growth restriction –21. A stGhana started full implementation of IPTp policy in 2005 after its adoption in 2003. After more than a decade of IPTp policy implementation, evidence-based analysis of the accumulated data is critical to inform the need to scale-up the programme. This has informed the current study with the objective to predict the direct effect of sulfadoxine-pyrimethamine uptake among pregnant women on birth weight in Ghana using the Demographic and Health Survey data.This study is conducted using data obtained from the Demographic and Health Surveys (DHS) program that implements population and health surveys in several countries across the world. These are nationally representative household surveys which provides information on a number of indicators in maternal and child mortality, reproductive health, HIV, family planning and others. A data request was submitted to the official DHS website. The request was approved and dataset was provided via email within two working days. Data for the standard DHS was obtained and on three survey years .Demographic and Health Surveys employ a stratified two-stage sampling design. The first stage involves the selection of clusters also referred to as primary sampling units which in some cases may be the same or a number constituting an enumeration area usually drawn from the most recent census data. These clusters are systematically selected based on probability proportionate to size. At the second stage, a sampling frame made up of listing of all households within a cluster is obtained. This is to allow for equal chances of selection and to make the data obtained nationally representative. Households to be included in the survey are then selected systematically from the sampling frame. In the selected households, only women between the ages of 15–49 years who were either permanent residents or stayed over the night before the survey were eligible to be interviewed. The variables for this analysis were extracted from the 2003, 2008, and 2014 Ghana Demographic and Health Survey’s (GDHS) structured questionnaires.The DHS used a structured questionnaire as an interview guide for data collection. Different types of questionnaires classifications were used to collect the data namely household, women, men, children and biomarker. This study utilised the women’s survey in which data was collected from all eligible women between the ages of 15 and 49 concerning topics such as socio-demographic characteristics, women characteristics, birth history, IPTp-SP uptake, birth weight amongst others.The dependent variable for this study is birth weight (at birth) which is defined and categorised as follows: low birth weight (birth weight < 2.5 kg), normal (birth weight ≥ 2.5 kg < 4.0 kg) and high (macrosomia—birth weight ≥ 4.0 kg) birth weight. It was coded as an ordinal outcome. A code of “1” was assigned to children who were classified as low birth weight, “2” as normal birth weight and “3” macrosomia.The primary exposure of interest was the uptake of sulfadoxine-pyrimethamine (fansidar). The World Health Organization recommends that sulfadoxine-pyrimethamine (SP) be given to all pregnant women starting as early as possible in the second trimester . In this study, the uptake of SP was defined as pregnant women who took at least one dose of sulfadoxine-pyrimethamine. Pregnant women who received at least one dose of SP or fansidar were categorized as “yes” and assigned “1” and those who did not at all were classified as “no” and assigned “2”.All other independent variables (confounders) were grouped into four. These were maternal factors . Child factors . The third category was socio-economic . The fourth was the combination of maternal factors, child factors and socio-economic factors.The generalized ordered partial proportional odds model is used to estimate the odds ratios of the predictor on the predicted of interest controlling for identified confounding variables for each survey year and that of the pooled dataset. The model can be specified as follows:M represents the number of categories of the ordinal variable, in this case three (3), that is, low birth weight, normal and macrosomia birth weights. It can therefore be deduced from Eq. . A type I error of 5% was specified and used for variables significance and interpretation.All analyses were based on complete cases, where any observation with missing variable(s) was dropped. This was adopted because the samples were large enough to show any differences between groups if it indeed exists. All analyses were carried out with Stata version 17.The DHS surveys have been reviewed and approved by International Classification of Functioning, Disability and Health (ICF) and Ghana Health Service Institutional Review Boards (IRB). The ICF IRB approved the study protocol, survey instruments and materials prior to the study commencement. This ensures that the survey complies with the U.S. Department of Health and Human Services regulations for the protection of human subjects. Verbal informed consent was sought from DHS respondents to all the questionnaires as well as drawing of blood in surveys. Further to that was a verbal informed consent sought by the interviewer reading a prescribed statement to the respondent and recording in the questionnaire whether the respondent consented . Interviewer then signed his or her name attesting to the fact that he/she read the consent statement to the respondent and they agreed to participate.The overall prevalence of low birth weight is 9% while that of macrosomia is 13% Fig. p-value < 0.001 with a corresponding test statistic of 42.52. This indicates highly significant evidence that the parallel regression assumption has been violated. The main primary exposure variable (SP uptake) failed the parallel regression assumption. Other variables included child sex, preceding birth interval and mother’s BMI. As a result of the violation, we used the generalized ordered partial proportional odds model.We used the brant test as provided by Long and Freese’s “spost” routines to first of all determine whether there was any violation of the parallel regression assumption that made it impossible to apply the standard ordered proportional odds model . The tesThe results as presented in Table Presented in Tables Figure This is the first study of its kind to have looked at the three main birth weights in Ghana using a nationally representative survey (DHS) from 2003 to 2014 with an approximately five years interval. The study examines the prevalence of birth weight  and their projected trajectories by the end of 2030. The study goes further to establish a relationship between birth weight and SP uptake during pregnancy by controlling for all relevant and available confounders. In this study, we established the need to apply a generalized ordered partial proportional odds model due to violations of the parallel regression model assumptions using the brant test.The findings show that over the three survey years, the prevalence of macrosomia is higher than that of low birth weight. Specifically, there was a higher prevalence of macrosomia in all the survey years  than there was low birth weight. We observed a higher projection of low birth weight taking into consideration the previous year’s prevalence to 14.89 percentage increase while that of macrosomia will decrease to about zero (0) percentage points. The higher projection of low birth weight maybe as a result of the increase in prevalence observed in the 2008 and 2014 over 2003 survey years. The higher prevalence of low birth weight may be attributed to poor socioeconomic status, maternal malnutrition and inadequate antenatal care as reported elsewhere –31. ThisThe high prevalence of macrosomia as observed in this study confirm findings of other studies in some developing countries such as Nigeria, Uganda and Algeria that report a prevalence of 7.5, 8.4 and 14.9 percentage points respectively . AnotherThis study further reveals the importance of pregnant women taking sulfadoxine-pyrimethamine during pregnancy to help improve the weight of their new born. It shows that pregnant women who took SP during pregnancy were more likely to give birth to normal weight children than to low-birth-weight children when the two were compared. We moved further to look at predictive probabilities of pregnant women who did not take sulfadoxine-pyrimethamine and realized that taking SP decreases the probability by about 7.4 (1.1 – 13.8) percentage points of giving birth to normal weight children. The predictive probability of giving birth to a low-birth-weight child for those who did not take SP increased by about 7.4 (1.07 – 13.8) percentage points while that for macrosomia increases at a lower point of 0.06%. Both were evaluated with the full model (where confounders were controlled for) at their means and statistically significant. These findings confirm what was observed elsewhere, where increased birth weight was significantly associated with an increase SP uptake . Quakyi There is higher probability that low birth weight could increase over the next couple of years if measures are not taking to reverse the current trajectories. The uptake of sulfadoxine-pyrimethamine should continue to be encouraged and recommended because it has a direct beneficial effect on the weight of the child. Overall, the average body weights of children in Ghana are majorly within the WHO recommendation. Interpretation and conclusion of the findings should be made with caution due to our inability to adjust for other important variables that have the potential to influence the final results.One of the major strengths of this study is the use of a nationally representative sample across Ghana over a 15-year period. The second one is the use of a more robust and appropriate statistical model called generalized ordered partial proportional odds model when the parallel regression model assumption is violated. There are a number of limitations, the first is our inability to model the primary exposure variable with the outcome of interest for the year 2003 due to insufficient sample size. In addition, the sample size used for the overall analysis was inadequate due to the proportion of women who respondent to whether they have used SP during their last pregnancy. Therefore, there were a number of missing observations and so this has the potential of affecting the conclusions. Due to the 5-year retrospective nature of the survey, the probability of recall bias affecting the data collected and subsequently the analysis and interpretation is very high. Important variables such as Neonates born with congenital defect or genetic conditions and also gestational diabetes which are more likely to affect birth weight were not obtained and therefore not adjusted for.


Children born preterm (<37 completed weeks’ gestation) have a higher risk of infection-related morbidity than those born at term. However, few large, population-based studies have investigated the risk of infection in childhood across the full spectrum of gestational age. The objectives of this study were to explore the association between gestational age at birth and infection-related hospital admissions up to the age of 10 years, how infection-related hospital admission rates change throughout childhood, and whether being born small for gestational age (SGA) modifies this relationship.Using a population-based, record-linkage cohort study design, birth registrations, birth notifications and hospital admissions were linked using a deterministic algorithm. The study population included all live, singleton births occurring in NHS hospitals in England from January 2005 to December 2006 . The primary outcome was all infection-related inpatient hospital admissions from birth to 10 years of age, death or study end (March 2015). The secondary outcome was the type of infection-related hospital admission, grouped into broad categories. Generalised estimating equations were used to estimate adjusted rate ratios (aRRs) with 95% confidence intervals (CIs) for each gestational age category  and the models were repeated by age at admission . An interaction term was included in the model to test whether SGA status modified the relationship between gestational age and infection-related hospital admissions. Gestational age was strongly associated with rates of infection-related hospital admissions throughout childhood. Whilst the relationship attenuated over time, at 7–10 years of age those born before 40 weeks gestation were still significantly higher in comparison to those born at 40 weeks. Children born <28 weeks had an aRR of 6.53 (5.91–7.22) during infancy, declining to 3.16 (2.50–3.99) at ages 7–10 years, in comparison to those born at 40 weeks; whilst in children born at 38 weeks, the aRRs were 1·24 (1.21–1.27) and 1·18 (1.13–1.23), during infancy and aged 7–10 years, respectively. SGA status modified the effect of gestational age (interaction P<0.0001), with the highest rate among the children born at <28 weeks and SGA. Finally, study findings indicated that the associations with gestational age varied by subgroup of infection. Whilst upper respiratory tract infections were the most common type of infection experienced by children in this cohort, lower respiratory tract infections (LRTIs) ) and invasive bacterial infections ) were the most strongly associated with gestational age at birth. Of LRTIs experienced, bronchiolitis ), and pneumonia ) were the most common causes.Gestational age at birth was strongly associated with rates of infection-related hospital admissions during childhood and even children born a few weeks early remained at higher risk at 7–10 years of age. There was variation between clinical subgroups in the strength of relationships with gestational age. Effective infection prevention strategies should include focus on reducing the number and severity of LRTIs during early childhood. Children born preterm (<37 completed weeks’ gestation) are typically born with an immature immune system, leaving them vulnerable to infection . HoweverA number of record linkage studies conducted in Australia reported an inverse association between gestational age at birth and gastrointestinal infections ,8, otherResults from a recent population-based record linkage study that we conducted—the TIGAR study —indicateA population-based record linkage study was conducted by linking data from four different sources:Office for National Statistics (ONS) birth registration records, which contain information regarding every live birth and stillbirth within England.ONS death registration records, which contain data related to each death within England.Birth notification records (previously known as NHS Numbers for Babies [NN4B]), which assign each baby born in England with a National Health Service (NHS) number at birth, and also contain information relating to the birth, recorded by the attending clinician.Hospital Episode Statistics Admitted Patient Care (HES APC) records, which contain details of all inpatient hospital admissions to NHS hospitals within England. When a baby is born, two HES APC records are created: a HES delivery record for the mother and a HES birth record for the baby. Both records contain the same information as a standard inpatient HES APC record, but additional fields relating to the mother’s delivery and baby’s birth are also collected.Birth registration, notification and death registration records were linked to HES Birth records and HES APC records  by NHS Digital, in collaboration with the ONS and City, University of London, using a six step deterministic algorithm, as part of a previous National Institute for Health Research (NIHR) funded study. A full description of the datasets, linkage algorithms and quality assurance methods has been published elsewhere ,12. Thisst January 2005 and 31st December 2006, and children were followed up from birth to 10 years of age, death or end of the study (31st March 2015). A number of exclusions were made to the study cohort, including: (1) Families who had registered with the NHS national data opt-out service ; (2) children born at home, in military or private hospitals or elsewhere (excluded as most did not have HES birth records); (3) children born to women who normally reside outside of England as it is possible these children would be admitted to hospitals in other countries during childhood; (4) children for whom gestational age or birthweight were missing; (5) children were born before 23 weeks [The study population included all live, singleton births occurring within England between 123 weeks  or after23 weeks ; and (6)th percentile were defined as SGA and a binary variable was created . In models with interaction terms and in subgroups of infection with low counts, gestational age at birth was analysed using the following standard categories: <28, 28–31, 32–33, 34–36, 37–38, 39–41, and 42 weeks.The primary exposure of interest was gestational age at birth, which is estimated using either the date of the mother’s last menstrual period (LMP) or an ultrasound during early pregnancy and the baby’s date of birth, and was analysed in weeks using the following categories: <28, 28–29, 30–31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, and 42 weeks, with 40 weeks selected as the reference group. Because of lower numbers of births at each gestational age at earlier gestations (23–31 weeks gestation), some weeks were combined into broader groups to ensure sufficient statistical power for estimating rate ratios. The secondary exposure of interest was small for gestational age (SGA) status. Gestation and sex specific birthweight z-scores were generated and then categorised into centiles. Children with a birthweight that was <10The total number of infection-related hospital admissions throughout childhood was the primary outcome of interest. Infection-related hospital admissions were defined as an admission that met the following criteria:The hospital admission occurred at least one day after discharge from the initial birth-related hospital admission . For a full list of transfer codes and further details on how a hospital admission was defined, please see The hospital admission record contained at least one infection-related diagnosis code. Each hospital admission record contained up to 20 International Classification of Disease version 10 (ICD10) diagnosis codes and whilst the primary diagnosis code is often the main reason for admission, in practice, often the diagnosis code associated with most expensive care is listed first. Therefore, all 20 diagnosis codes were searched for relevant ICD10 codes.Using ICD10 codes, infection-related hospital admissions were categorized into the following broad subgroups of infection, based on work from a previous study conducted in Western Australia : invasivFurther details on how variables were derived can be seen in st March 2015), multiplied by 1000.Key characteristics of the study population were presented as frequencies and percentages, and chi-squared tests were used to compare characteristics between those with and without at least one infection-related hospital admission during childhood. Crude hospital admission rates per 1000 person years were generated for each week of gestational age, age band  and for each subgroup of infection , which was defined as the total time from the date of discharge from the birth-related admission to death , 10 years of age or study end  with a negative binomial distribution and log link were used to estimate unadjusted and adjusted rate ratios (RRs) and 95% confidence intervals (CIs) for each week of gestational age. To explore whether the association between gestational age and infection-related hospital admissions was consistent over time, the model included an interaction term between gestational age  and age at admission . The Wald test was used to identify if this interaction was statistically significant. Negative binomial regression models were then used to estimate RRs and 95% CIs for each gestational age week within each age band. All analyses were repeated for specific subgroups of infections. To ensure sufficient statistical power to detect differences in cases where counts were low, gestational age was grouped into broader categories  with 39–41 weeks as the reference group. To assess whether being born SGA modified the relationship between gestational age and infection-related admissions, an interaction term was included between gestational age at birth and SGA status. The Wald test was used to assess the significance of the interactions and a stratified analysis was performed where deemed appropriate.a priori based on existing literature: maternal age at time of baby’s birth [All models were adjusted for the following covariates, which were chosen ’s birth   was conducted as it was likely that some of the data was missing not at random (MNAR). For example, until May 2012 parity was only reported for births within marriage on the birth registration record, therefore missing parity was due to being unmarried. A number of strategies were undertaken to recover missing parity, which have been described in To explore the stability of estimates, a number of sensitivity analyses were performed:Children with a congenital anomaly were excluded. A congenital anomaly was defined as a relevant ICD10 code (Q) recorded in any position of diagnosis code (1–20). To exclude minor congenital anomalies that may not impact a child’s health, only those diagnosed within the first year of life were counted.th, 10-<25th, 25th-75th, 75th-90th, >90th).The relationship between gestational age and birthweight was explored in more depth by: (a) adjusting models for gestation and sex specific z-scores instead of SGA; and (b) including an interaction term between gestational age and birthweight centiles  births remained for analysis  with a tCrude admission rates per 100 person years were highest during infancy and for children born the most preterm. Rates declined over time, with the sharpest decline seen after the first year after birth. Children born extremely preterm (<28 weeks) had an infection-related admission rate of 1195/100 person-years during infancy. This means that if 100 children were followed up for one year, there would be 1195 infection-related hospital admissions expected during this period, indicating that some children were admitted more than once in the year see .This relationship remained in the adjusted regression models and estimates were stable in all versions of the adjusted models . The assSimilarly, in models based on age-specific analyses , there wth centile) appeared to be protective in those born extremely preterm (There was evidence of effect modification by SGA status (interaction P<0.0001). The effect of gestational age was stronger in those born SGA compared to those not born SGA . When bi preterm . In all  preterm . There wThe 473,041 infection-related hospital admissions included 507,437 infection-related ICD10 codes, of which: 37%  were URTIs; 21.8%  were LRTIs; 10.2%  were gastro-intestinal infections; 1.6%  were invasive bacterial infections; 4.5%  were genitourinary infections; 2.8%  were skin and soft tissue infections; and 22.2%  were other viral infections. Approximately 93% of infection-related hospital admissions had only one infection-related ICD10 code. Of those records with more than one infection ICD10 code, URTI (62.7%) and viral infections (66.7%) were the most common codes to appear .Crude admission rates by types of infection overall and by age at admission are presented in Rates of infection-related admissions for genitourinary, gastrointestinal, skin and soft tissue, and invasive bacterial infections decreased over time and were very low later in childhood. Models with interaction terms indicated that the effect of gestational age was not consistent across age groups for the three most common types of infection: LRTIs, URTIs, and other viral infections . For allThis study revealed that gestational age at birth was strongly associated with rates of infection-related hospital admissions during childhood. Adjusted rate ratios decreased with each additional week of gestational age and children born even a week or two early had higher infection-related admission rates than those born at 40 weeks’ gestation. Whilst the relationship attenuated over time, rates persisted at 7–10 years of age, rates for children born before 40 weeks of gestation were still significantly higher than those for children born at term. SGA status modified the effect of gestational age, with the highest rates of infection-related hospital admissions occurring among children born preterm and SGA. Finally, the findings indicated that the effects of gestational age varied by subgroups of infection. Whilst URTIs were the most common type of infection experienced by children in this cohort, LRTIs and invasive bacterial infections were the most strongly associated with gestational age at birth.Whilst there are many studies exploring gestational age at birth in relation to specific infections during childhood, few have studied infection more broadly, particularly in a UK context. Three similar, large, population-based studies conducted in Australia all reported inverse associations between the risk of infection-related hospital admissions and gestational age at birth ,7,9. HowThe higher risk of infection associated with earlier gestational age at birth is most likely due to the baby’s immature immune system. Babies born preterm have deficiencies in both their innate and adaptive immune functions, and these systems may be further compromised by other factors related to preterm birth: perinatal infection is a major cause of preterm birth and is associated with increased intrauterine inflammation ; the useThe rates of infection-related admission markedly decreased after two years of age. However, our findings indicated that nevertheless an excess risk remained at 7–10 years in children born before 40 weeks’ gestation. Whilst all babies, regardless of gestational age at birth, develop their adaptive immune systems throughout infancy and childhood, there is evidence that even at eight years of age children born preterm have reduced lymphocyte subpopulations , which mWhilst there was an inverse association between gestational age at birth and infection-related admissions for all types of infection, there was variation in the strength of this relationship by subgroup. Similar findings have been reported elsewhere. A large study followed 6.6 million children for one year in California and also reported increased odds of hospital admission for bacterial infections and respiratory infections, with odds increasing with each decreasing week of gestation. Interestingly, the relationship between gestational age and non-specific infections  was not as clear; only late preterm babies were at higher risk of hospital admission than those born at full term . A studyThe findings in this study also suggest a particularly strong relationship between gestational age at birth and LRTIs, with bronchiolitis accounting for the majority of these admissions during infancy. Similar findings have been reported elsewhere ,5. The aGestational age at birth was also found to be strongly associated with pneumonia-related hospital admissions during childhood, with the highest risk seen under the age of two, particularly for those born at <28 weeks’ gestation. Similar findings have been reported in other studies. A study conducted in Wales reported a hazard ratio for admissions related to pneumonia and influenza that was three times higher in children born <33 weeks’ gestation compared to those born between 39 and 42 weeks’ gestation.The relationship between preterm birth and respiratory conditions is well established ,31,33,34Paranjothy et al. 2013) also reported an independent effect of SGA on infection rates 013 also . TargetiTo our knowledge this is the largest study conducted in England that investigates gestational age at birth in relation to all infection-related hospital admissions during childhood. The key strength of this study is the total population studied, which has enabled us to explore gestational age largely week-by-week, identifying significant differences in rates even in children born at 38 and 39 weeks’ gestation. In addition, the ten years of follow up data also enabled us to explore how rates differed by clinical subgroup and how they changed over the course of childhood. Finally, the use of routinely collected data means that it is largely unaffected by recall and social-desirability bias, which can often lead to issues in several epidemiological designs [However, there are a number of limitations that must also be considered. There was variation in the quality and completeness of variables recorded within the different datasets. In addition to this, multiple imputation was not used as a method for dealing with missing data due to some of the data being potentially missing not at random (MNAR). This meant a complete case analysis was undertaken instead, and whilst the estimates remained stable in the fully adjusted model and in sensitivity analyses, we cannot rule out any potential bias being introduced through excluding those with missing data. Moreover, this study only captures the most severe cases of infection that require hospitalisation; it will underestimate rates of all infections in this population as we did not have access to data for primary care settings, where the majority of childhood infections will be managed. Additionally, we were unable to adjust for the following factors: maternal antibiotic use in pregnancy and underlying maternal conditions, which may have contributed to preterm labour and potentially the long term health of the child ; maternaOverall, the findings from this study have highlighted the need for effective infection prevention strategies to help protect children born preterm and close to full term. This is particularly relevant as the past two decades have seen increases in childhood hospital admissions in England for bronchiolitis , throat Gestational age was strongly associated with LRTIs, in particular, bronchiolitis and pneumonia. Whilst there is an effective vaccination programme for bacterial pneumonia across England , there Whilst the severity of respiratory infections may be greatest in those born extremely preterm, the burden of infection-related hospital admissions is largely due to those born early term and term. Since the beginning of the Covid-19 pandemic, hospital admissions for infectious diseases that are transmitted via respiratory droplets have declined ; most liThe findings from this study have highlighted the heterogeneity that exists within categories of gestational age. Future research should investigate gestational age at birth as a continuum, exploring it week-by-week. In addition to this, it remains unclear whether the high rates of hospital admission in children born most preterm are influenced by parents’ and clinicians’ perceptions of the child being more vulnerable due to prematurity . FurtherThe findings in this study have shown that preterm birth is strongly associated with severe infection-related morbidity, particularly during the first two years after birth. Those born the most preterm had the highest rates of infection-related hospital admission, but even children born a week or two before their due date were consistently at higher risk of infection-related hospital admissions during childhood than children born at term. Whilst the magnitude of harm is small for children born between 37–39 weeks gestation, they represent a large number of births worldwide each year. The findings further show that gestational age groups commonly investigated are not homogenous and there should be a move towards investigating the effects of gestational age at a granular level. Effective infection prevention strategies are particularly important during the current covid-19 pandemic and could include a focus on reducing the number and severity of LRTIs during early childhood.S1 Fig(DOCX)Click here for additional data file.S2 FigNote: Bronchiolitis and pneumonia are subgroups of the LRTI category.(DOCX)Click here for additional data file.S3 FigNote: Bronchiolitis and pneumonia are subgroups of the LRTI category.(DOCX)Click here for additional data file.S1 Table(DOCX)Click here for additional data file.S2 Table(DOCX)Click here for additional data file.S3 Table(DOCX)Click here for additional data file.S4 Table(DOCX)Click here for additional data file.S5 Table(DOCX)Click here for additional data file.S6 Table(DOCX)Click here for additional data file.S7 Table(DOCX)Click here for additional data file.S8 Table(DOCX)Click here for additional data file.S1 File(DOCX)Click here for additional data file.


BackgroundPerinatal asphyxia is one of the main causes of death in term newborns. During the past two decades, no significant progress has been made in reducing neonatal deaths in developing countries. This study was aimed to determine various factors associated with birth asphyxia in term newborns at a tertiary care hospital of Multan, Pakistan.MethodsThis case-control study was conducted at the Neonatal pediatrics Department, The Children’s Hospital, Multan in collaboration with the labor room of Nishtar Hospital Multan from April 2020 to September 2020. Newborns delivered in the labor room with a low Apgar score of five or less at the first minute were recruited as cases and newborns with an Apgar score of more than five in the first minute were recruited as controls. The demographic information of neonates and mothers was noted. A Performa was used to collect all information. All data were analyzed through SPSS 26.0 .ResultsA total of 426 newborns (213 cases and 213 controls) were enrolled. In cases, there were 132 males and 81 females whereas there were 115 males and 98 females in the control group (P=0.09). Majority 132 (62%) mothers of cases were primiparous compared with 110 (52%) mothers of control. The difference in parity of mothers of cases and control (P=0.03) was significant. Prolonged labour was noted in cases 123 (58%) vs. controls 55 (26%) (P=0.001) while fetal distress was found in 120 (56%) cases and 45 (21%) controls (P=0.001). Meconium was found in the amniotic fluid in 171 (80%) cases and 86 (40%) controls (P=0.001). All other risk factors turned out to be insignificant between cases and controls (P>0.05).ConclusionMeconium stained liquor is a major risk factor for birth asphyxia. Prolonged labor of more than 24-hour period, as well as fetal distress, is also a major risk factor of perinatal asphyxia. Involving obstetricians in the present research give more reliability and reproducibility of the data collected. Perinatal asphyxia is one of the main causes of death in term newborns . During Risk factors of birth asphyxia have been divided into antepartum and Intrapartum factors. Antepartum factors include high or low maternal age, Primigravida or grand multipara birth, and eclampsia. Intrapartum factors are meconium-stained liquor, fetal distress, and prolonged labor ,6.The objective of this study was to detect various factors responsible for asphyxia in the term newborns. Recognition of these factors before birth and early commencement of preventive measures can reduce neonatal mortality and brain injury due to birth asphyxia.This case-control study was conducted at the Department of Neonatology, The Children’s Hospital, Multan, Pakistan, in collaboration with the labor room of Nishtar Hospital Multan. Approval from The Ethical Committee of The Children's Hospital & Institute of Child Health, Multan, Pakistan, references number ECP/2021/249 was acquired. Written and informed consent was taken from all mothers. The data was collected during the six-month period from April to September 2020. Mothers of newborn pairs who were delivered in the labor room were included in the study.A total of 426 newborns (213 cases and 213 controls) with gestational age more than or equal to 37 weeks to 42 weeks and delivering a single live-birth weighing between 2,000 and 4,000 grams were recruited. Babies with a low Apgar score of five or less at the first minute after birth were recruited as cases and babies with an Apgar score of more than five at first minute after birth were recruited as control. Apgar score at one minute after birth was calculated according to the standard criteria by attending neonatal physicians in the labor room. All mothers with gestational age less than 37 weeks were excluded.EPI INFO was used to calculate sample size according to double population formula considering the proportion of Primigravida in case group 59% and control group 45% from the previous study conducted in Nigeria . By consA special proforma was used to collect study data. The basic demographic information included the age of the mother, gender of baby, birth weight, and mode of delivery. Dubowitz method was used to determine the gestational age of all the newborns . InformaAll the data were analyzed through SPSS version 26.0 . Mean and standard deviation were calculated for the age of the mother, gestational age, and weight of the baby. Frequency and percentages were calculated for the gender of the babies and mode of delivery. Confounding factors like the age of the mother, weight of the baby, and gestational age of the baby were controlled by stratification. A Chi-square test was applied to compare the occurrence of study variables  in cases and controls. P-value equal to or less than 0.05 was taken as significant.The majority of the newborns, 247 (58.0%) were male. The mean birth weight of the cases was 2,823.47+478.37 grams whereas the mean birth weight of control was 2,848.36+438.26 grams. There were 252 (59.2%) mothers who had a mode of delivery as spontaneous vaginal birth while the remaining 174 (40.8%) delivered by cesarean section. The mean age of the mothers in the case group was 26.35+6.79 years range (15-42 years) while the mean age of controls was 25.76+6.46 (15-42 years). Table Table This study was conducted to identify the various factors leading to perinatal asphyxia in term newborns delivered at Nishtar Hospital Multan, Pakistan. In the present study, 62.0% of cases were male in comparison to 54.0% controls but the difference was not statistically significant. A study from the Children Hospital Lahore, Pakistan, found a male to female ratio of 2:6:1 in newborns with asphyxia . Our stuThe Primigravida are often being deprived of the demands of pregnancy like early booking and regular antenatal visit therefore they are unaware of their responsibility to themselves and their unborn fetus . This maMeconium-stained liquor was seen in 80.3% cases in comparison to 40.4% controls (P<0.0001). The presence of meconium provides an additional criterion for the determination of fetal distress. Grade III or grade IV meconium staining is considered to be a maker of more prolonged or severe asphyxia episodes ,8,15,16.Although we did not find any significant association of gestational age with the risk of birth asphyxia, some studies have shown increasing trend of birth asphyxia with an increase in gestational age ,22. Our Being a case-control study is one of the strengths of this research. There were some limitations in our study as this was a single-center study and findings cannot be generalized. We were unable to collect information regarding maternal diabetes, hypertension, or the presence of anemia, which could have given us further insight. We could not evaluate cord blood gases in diagnosing perinatal asphyxia. Moreover, Apgar scores at 2, 5, and 10 minutes would have further given us very useful information.Meconium-stained liquor is a major risk factor for birth asphyxia. Prolonged labor of more than 24-hour period, as well as fetal distress, is also a major risk factor of perinatal asphyxia.Involving obstetricians in the present research give more reliability and reproducibility of the data collected. The incidence of perinatal asphyxia in any community is too large magnitude dependent on main risk factors; these, in turn, being influenced by the effect of literacy level, ethnic and customary views, health education, and resourceful application of health care facilities as well as the quality of obstetric, gynecological, and newborn care.


In recent years, newborns born to immigrant mothers have accounted for about 10% of the total births in Taiwan. However, little is known about whether there are differences between newborns of immigrant and native-born mothers regarding the prevalence and the possible causes of birth defects. By combining four nationwide databases and assessing all newborns between 2005 and 2014 in Taiwan as research subjects, this study determined the prevalence of birth defects stratified into nine categories  in the newborns of immigrant mothers and native-born mothers. We found that the prevalence of any birth defects in newborns of immigrant mothers (ranging from 0.98 to 1.24%) was lower than that of native-born mothers (2.86%). Skeletomuscular system defects are the most common among newborns of women from the main immigrant countries (0.24–0.42%), while circulatory system defects were the most common among newborns of Taiwanese women (0.92%). The risks of all defects remained lower for newborns of immigrant mothers (AORs ranged from 0.37 to 0.47) after controlling for possible confounding variables. The higher rates of birth defects among newborns of native-born mothers may be attributed to an older maternal age at childbirth and a higher prevalence of diabetes than that of immigrant mothers. The findings from this study imply that the prevalence of birth defects between newborns of immigrant and native-born mothers is not similar, as evidenced by a decade of population-based data. Birth defects are complex conditions caused by a variety of genetic and environmental factors and are the main cause of mortality and morbidity in the neonatal period ,2. It haTaiwanese ethnic groups span diverse races and cultures. Since the 1980s, a large number of Southeast Asian women have immigrated to Taiwan through marriage and have contributed a considerable proportion of newborns. From 2005 to 2014, immigrant women gave birth to about one in eight newborns . These rIn addition to ancestry, most immigrant women in Taiwan form families with men of lower socio-economic status, and thus face multiple difficulties and challenges, including language, food, beliefs, culture, living habits, parenting, economic deprivation, and lack of social support ,12. MoreHowever, it is worth mentioning that immigrant women are a highly select group who demonstrate strong resilience . On averIn this study, the data of newborns and their mothers were concatenated and analyzed from four national population databases between 2005 and 2014 in Taiwan. The databases include the National Health Insurance program in Taiwan, birth certificate applications, the birth certificate registry, and cause of death data. The health insurance database is part of the National Health Insurance program, which is a compulsory health care system that launched in 1995. The program has a coverage rate of more than 99% of Taiwan’s total 23 million population, making the information from the health insurance database representative for medical and public health research. The birth certificate application covers all live births in Taiwan  or stillbirths of 20 weeks and older and/or birth weight of 500 g and more. The statistical items include maternal background , pregnancy conditions , spousal data , newborn data  and other variables. The birth certificate registry information was obtained from the Ministry of the Interior of Taiwan. The data used contained basic demographics including ID number, gender, date of birth, gravidity and parity, place of birth (city/county), gestational age, birth weight, and location of birth . Additionally, parents’ ID numbers, education level, marital status, occupation, etc., were also included. The cause of death data compiled information from the cause written in the database or on the death certificate of Taiwanese nationals with a registered household. These data included the ID number, date of birth, date of death, place of death, location of death, and any details recorded by the International Classification of Disease (ICD) code on the death certificate.n = 465,569). Those with complete data  were divided by maternal nationality of origin and further categorized into groups with and without birth defects.This study used data from 2005 to 2014 based on the following two considerations. (1) Prior to 2005, there were a considerable number of people listed as marriage-based immigrants but were in fact illegal work immigrants. This increased the complexity of the data cleaning process and may expand the number of samples and dilute the estimated disease rate. (2) After 2014, the number of immigrant women in Taiwan dropped significantly, and the number of children born also fell sharply. Because birth defects have a relatively low prevalence rate, an insufficient number of newborns made the estimation of the disease rate unstable. Therefore, this study stratified independent experimental groups using the top three countries of origin for marriage immigrants, which are mainland China, Vietnam, and Indonesia. New immigrants from other countries of origin are merged as “Others”, making up a total of four different groups of new immigrant women. The difference in birth defects were assessed through a comparison to newborns of native-born Taiwanese mothers. The detailed sampling and grouping processes are shown in Based on diagnoses using the ICD system, this study classified birth defects into nine categories as the research outcome. The nine categories were the nervous system ; the eye, ears, face and neck ; cleft lips and cleft palates ; the circulatory system ; the respiratory system ; the digestive system ; the genital and urinary organ systems ; the musculoskeletal system ; and chromosomal abnormalities p < 0.05 was considered to be statistically significant.In this study, the prevalence of birth defects in newborns was calculated based on the number of birth defects and the total number of newborns in the four different ancestry groups. The prevalence of defects was calculated using the method recommended by the European Surveillance of Congenital Anomalies (EUROCAT) shown as the following. Total prevalence = total number of cases  divided by the total number of births (live births and stillbirths). The chi-square test was used to compare the prevalence of birth defects between Taiwanese newborns and the newborns of immigrant mothers. In order to avoid possible confounding variables, we further used a multivariate logistic regression analysis to control for sociodemographic and clinical characteristics and compare the adjusted odds ratios of various defect categories between newborns of immigrant mothers and newborns of native-born mothers. The above analysis was performed using the SAS software (version 9.4) and The basic demographic distributions from the birth certificate registry  showed tp < 0.01). This result indicates that the prevalence rate of birth defects in newborns of immigrant women was significantly lower than that of newborns of native-born women. Additionally, the rates of birth defects in newborns within each nationality group were not significantly different during the 10 years. Therefore, the subsequent analysis used merged data from all 10 years.The percentages of newborns with birth defects from 2005 to 2014 categorized by the mother’s country of origin are shown in p < 0.001). Among children born to Taiwanese mothers, defects in the circulatory system were the most prevalent (0.92%). Similarly, heart defects were the most prevalent in children born to mothers of “other” nationalities (0.27%). However, the most common type of defects in children born to mothers from Mainland China, Vietnam, and Indonesia were those of the musculoskeletal system (0.24–0.42%). Children born to mothers of native nationality had the lowest rate of defects in the eye, ear, face, and neck (0.04–0.08%), and the children born to mothers of Vietnamese mothers had the lowest prevalence rate of defects in the respiratory system (0.03%).In order to examine the influence of the age of the mothers on birth defects of newborns, When controlling for live/still birth, fetal gender, birth year, number of births, birth location, type of delivery method, residing county/city, maternal age, gestational age, birth weight, and maternal comorbidities, the odds ratios of various birth defects in newborns of non-native mothers were all lower than newborns of local mothers . The adjTo explore the interaction with immigration status, stratification analyses by maternal age (≥35 years vs. ≤34 years) and DM status (disease vs. non-disease) were carried out in nine categories of birth defects. We found that newborns born to mothers over 35 years old had significantly higher risks of birth defects in the respiratory system (AORs = 0.34), musculoskeletal system (AORs= 0.54) and chromosomal abnormalities (AORs = 1.61) as compared to those born to mothers under 34 years old . Similarly, newborns of mothers with diabetes had higher risks of any birth defects (AORs = 0.43), cleft lips and cleft palates (AORs = 0.96), defects in the circulatory system (AORs = 0.33), those in the respiratory system (AORs = 0.40), the genital, urinary organs (AORs = 0.39) and the musculoskeletal system (AORs = 0.76) as compared to those of non-diabetes .The results of this study show that regardless of nationality, the prevalence of various birth defects in newborns of immigrant women was lower than that of native-born women. This is consistent with the results of a previous study by Yang et al.  suggestiCongenital heart defects in newborns are the main problem related to birth defects worldwide. The European Surveillance of Congenital Anomalies (EUROCAT) stated that the overall birth defect rate of newborns from 2013 to 2019 was 22.6 (per 1000 births), and circulatory defects accounted for the majority, at a rate of 7.2, and while the rate was 2.0 for nervous system defects, 3.3 for limb defects, and 3.1 for urinary system defects . HoweverBirth defects cover a variety of genetic and environmental factors ,25,26. HFrom the perspective of maternal physiological conditions, it is not difficult to understand why the prevalence of circulatory system defects in Taiwanese newborns was higher than that of all second-generation immigrants. Maternal chronic diseases  have been found to be associated with birth defects from 10 years of data in Taiwan . MoreoveSocio-economic status has always been considered to be related to birth defects. Pregnant women with lower family incomes, lower education levels, or who are unemployed have been linked to a higher risk of coronary heart disease (CHD) in general . HoweverThe lack of data on the length of residency of the immigrants in this study is another consideration in evaluating the environmental effect on congenital defects. Although the longer the new residents stay, the fewer cultural adaptation problems they experience , immigraThis article used the National Health Insurance database and other connecting databases to obtain data from 2005 to 2014 to examine the differences in birth defect rates in newborns of mothers of different nationalities. When controlling for other risk factors of birth defects, newborns of immigrant women, regardless of their nationality, showed a lower prevalence rate of various birth defects compared to newborns of native-born women. It is obvious that immigrants are a highly select group. With the influence of the healthy immigration effect, their children are heathier than those of the locals. On the contrary, high childbearing age and type 2 diabetes led to a higher rate of birth defects in native-born Taiwanese women, who are also participating in higher education and delaying marriage. Furthermore, over-diagnosis caused by accessibility to health insurance services associated with socio-economic status may also be one of the reasons that a high prevalence of birth defects was observed in Taiwanese newborns. These results refute the stereotypes that the second-generation immigrants have a higher birth defect rate and poorer health conditions and emphasize the importance of appropriate childbearing age, control of chronic diseases during pregnancy , and socio-economic conditions to newborn health.


Equitable access to skilled birth attendance during delivery is vital for reducing global maternal deaths to 70 deaths per 100, 000 to achieve the Sustainable Development Goals (SDGs) by 2030. Although several initiatives have been implemented to reduce maternal mortality in Ghana, inequalities in access to skilled birth attendance during delivery still exist among women of different socioeconomic groups. This study assesses the socioeconomic inequalities in access and use of skilled birth attendants during delivery in Ghana.Research was conducted through literature reviews and document reviews, and a secondary data analysis of the 2014 Ghana Demographic and Health Survey (GDHS), a nationally representative survey. A total of 1305 women aged 15–49 years, who had a live birth the year before to the survey in the presence of a skilled birth attendant were analysed using concentration indices and curves. The indices were further decomposed to identify the major socioeconomic factors contributing most to the inequalities.The results found that access to skilled birth attendants was more among women from rich households showing a pro-rich utilization. The decomposition analysis revealed that household wealth index, educational level of both mother and husband/partner, area of residence and mother’s health insurance coverage were the major contributing factors to socioeconomic inequalities in accessing skilled birth attendants during child delivery among Ghanaian women.This study confirms that a mother’s socioeconomic status is vital to reducing maternal deaths. Therefore, it is worthy to focus attention on policy interventions to reduce the observed inequalities as revealed in the study. The Con in 1987 .to improve maternal health and its target indicators, 5A – to reduce maternal mortality ratio by three-quarters by the year 2015 and the proportion of births attended by skilled health personnel” [Following this in 2000, the United Nations organised a Millennium Summit where heads of states adopted eight 8) international development goals knows as Millennium Development Goals to be achieved by 2015. Among them was goal 5 – “rsonnel” . At the rsonnel”  was publrsonnel” . Given trsonnel” . The SDG internatAccess to skilled birth attendance (SBBA) is a key strategy to reduce the global maternal mortality ratio . TherefoSkilled birth attendance is vital in the pregnancy-childbirth continuum because most maternal deaths arise from childbirth complications . TherefoHigh maternal mortality ratioIn Ghana, findings from the 2017 Ghana Maternal Health Survey (GMHS) reported the pregnancy-related mortality ratio (PRMR)Moreover, it has been confirmed that about 16 to 33% of these complications can be avoided by the assistance of a skilled birth attendant at childbirth . Given tAccording to the 2014 Ghana Demographic and Health Survey (GDHS) Report, Ghana has achieved a 74% coverage on skilled birth attendance . DespiteLevesque et al. and Andersen in their conceptual framework of access and utilization of health services have studied the differences in health seeking behavioural patterns and grouped these variations into demand-side factors and supply-side factors , 24. TheStudies have shown the existence of huge gaps in skilled birth attendance during delivery across different socioeconomic groups . Some stIt is in this regard that, the study seeks to examine the extent to which socioeconomic inequalities contribute to access to and use of skilled birth attendants and the underlying factors that contribute to these inequalities in the Ghanaian context.The data used in this study was derived from the 2014 Ghana Demographic and Health Survey, which was collected by the Demographic and Health Surveys (DHS) Program. Information for the analysis was drawn from the DHS Women’s Questionnaire focusing on women who gave birth in the preceding the survey year. A two-stage sampling method was employed. A total of 427 clusters were selected in the first stage. Employing a systematic sampling for the second stage, 30 households were selected from each cluster totalling 12,831 households being selected of which 11,835 households were successfully interviewed. From the 11,835 households that were successfully interviewed, 9656 women aged 15–49 years were eligible for an individual interview at a response rate of 97% . For thiWho assisted in the delivery of (NAME OF CHILD)” in the women’s questionnaire?The outcome variable for this study is whether women who had a live birth the year preceding the interview year had deliveries assisted by skilled birth attendants or not. The outcome variable is a binary outcome where a value of “1” was given if the delivery was assisted by a skilled birth attendant and “0” if the delivery was not. A skilled birth attendant in this study was defined as a trained and licenced health professional i.e., a doctor, nurse/midwife or community health officer who provides basic and emergency healthcare services to women and their new-borns during pregnancy, delivery, and the immediate postpartum period . Information on delivery assisted or attended by a skilled birth attendant was based on the question “Socioeconomic factors are non-medical factors that influence health outcomes. They are social and economic experiences and realities that help mould one’s personality, attitude, and lifestyle. These factors can also define regions and neighborhoods and have an important influence on health inequities - the unfair and avoidable differences in health status seen within and between countries. In countries at all levels of income, health and illness follow a social gradient: the lower the socioeconomic position, the worse the health.Research has shown that social determinants can be more important than health care or lifestyle choices in influencing health –33.Economic status is measured by income. Social status is measured by education, and work status is measured by occupation. Each status is considered an indicator, although they are related, they do not overlap .1), poorer (Q2), Middle (Q3), richer (Q4) and richest (Q5).The household wealth index is a measurement of the cumulative living standard of a household such as ownership of selected assets , sanitation facilities, types of water access, among others using the principal component analysis . The houEducation is a process  and a product , which is considered as one of the most widely used indicators of socioeconomic status . EducatiThere has been growing global recognition of the interdependency between education and health. The World Health Organization (WHO) posits that a person is unhealthy if he/she is unable to conduct him/herself effectively and achieve some level of ‘social well-being’. The Incheon Declaration states that quality education develops skills, values, and attitudes that enable an individual to lead a healthy and fulfilled life and make informed decisions .There is good evidence that education is strongly linked to health outcomes and determinants of health such as healthy lifestyles and behaviours, health service utilization, etc. Therefore, people with higher educational levels may have better economic conditions which help them afford better and quality healthcare services, develop better information processing and abilities required to make better-informed decisions about their health . One majAccording to the 2014 GDHS, education is self-reported which collects the highest level of education attained by both women and their husbands/partners . For thiOccupation is used interchangeably with employment as a measure of socioeconomic status, embodies both income and education hence, its influence on health. Occupation/Employment reflects the educational attainment required to obtain the job and income levels that vary with different jobs and within ranks of occupations. This is used to measure the effect of socioeconomic status on health due to its role in positioning individuals within the social structure .maternal employment status categorized into two groups: employed or unemployed.Employment has social, psychological, and financial benefits to improve one’s health. This implies that having a well-paying job provides an individual with the financial means to access nutritious foods, quality healthcare, safe housing, etc. all of which impacts health directly. The established correlation between employment and health is that having employment leads to income and eventually having the means to seek better healthcare thereby improving health status . For exaperson who usually decides on a mother’s health care. The response options were: (a) mother alone, (b) mother and husband/partner, (c) husband/partner alone and (d) other . However, for this study, the responses were limited to three (3): (1) mother alone, (2) mother and husband/partner, (3) husband/partner alone.Mother’s autonomy is an important predictor variable . A motheOther predictor variables of interest for this study include mother’s age at birth, mother’s marital status, sex of household head, region of residence, area of residence, mother’s health insurance ownership, mother’s educational level, husband/partner’s educational level, mother’s autonomy, household wealth index, and mother’s employment status. The selection of predictor variables in this study was based on existing literature that reported a significant association with different maternal health care services.The study analysed the data using STATA 14 statistical software. The Adept software version 6 was used to calculate the concentration indices and curves of the socioeconomic inequalities in access and use of skilled birth attendants during childbirth, the concentration of the problem in the selected population and the contribution of the socioeconomic factors to the observed inequality among the population.An indicator of the health outcome of interest (dependent variable) i.e., delivery by a skilled health professional.a stratifying factor capturing the socioeconomic status against which the distribution is to be assessed , anda measure of socioeconomic inequality to quantify the degree of inequity in the indicator variable of interest (dependent variable).The study estimated and measured inequality in the health outcome (access and use of skilled birth attendants during childbirth) using the concentration indices (CI) and concentration curves (CC). Before inequity can be measured, the following are essential:.The study used concentration curves and indices to measure socioeconomic status and inequalities that are essential in understanding the risk, burden, and impact of socioeconomic factors in accessing skilled birth attendants in Ghana. A concentration index (CI) is a relative measure − 1 to + 1) of the extent to which a health outcome/variable is concentrated among the poor or the rich groups. The larger the absolute value of the concentration index (CI), the greater concentration of the inequality. A concentration curve (CC) plots the aggregate per centage share of health in a population against the aggregate per centage share of the population ranked according to their socioeconomic status  from the lowest to highest , 45. As  to + 1 o1In this study, concentration indices (CI) were calculated to measure the magnitude of the inequality in the socioeconomic factors. The concentration index is defined as twice the area between the concentration curve and the line of equality (the 45-degrees line check the definition please). This is estimated as twice the covariance of the health care utilization and a person’s relative rank in terms of socioeconomic status, divided by the outcome mean . This ishi is the health variable index; ri is the fractional rank of the individual i in the distribution of socioeconomic position; μ is the mean of the health variable and cov denotes the covariance.Where C is the concentration index; The value of the CI measures the severity of socioeconomic inequality and vary between − 1 to + 1. A negative value implies that the health outcome is concentrated among those with lower socioeconomic status  showing a concentration curve above/to the left of the line of equality. A positive value indicates concentration among the higher socioeconomic status  showing a concentration curve below/to the right the line of equality. A CI value of zero implies no inequality. The larger the absolute value of CI, the greater the concentration of inequality , 47. ForUnderstanding and explaining the extent to which an underlying factor contributes to socioeconomic inequality has become of great interest to researchers and policymakers. The concentration index is commonly used to examine socioeconomic inequality in health , 49.βk) as seen in eq.  using the Ordinary Least Square (OLS) regression model. However, given a situation where the dependent variable is binary like the use of skilled birth attendance during delivery or not as used in this study, the following need to be considered.y is the concentration index (C), α is the y-intercept, β and χ are the predictor variable of health care demand and ɛ is the error term. Since most health outcomes are binary, a few studies have used different methods – Probit analysis [Where analysis  and logianalysis , 50. Givanalysis . Calculaμ is the mean of the outcome variable y in eq. Cκ is the concentration index of determinant k  and GCε is the generalised concentration index for the error term of (ɛ). This equation shows that C is equal to the weighted sum of the concentration indices of the κ regressors, where the weight for y for Where The GDHS 2014 sought ethical approval from the GHS Ethical Review Committee, Ghana and ICF Macro International Review Board, Maryland, USA. Further, written informed consent from each participant before enrolment was sought. For this study, ethical approval was received from the University of Cape Town Human Research Ethics Committee (HREC).We included 1305 women in the analysis who had at least one birth in the past year preceding the survey. We considered women who accessed skilled birth attendants during childbirth in their last pregnancy.Out of 1305 women who had live births in the year before the study, 636 (49%) of the women who gave birth were between the ages of 25–34 years. More than half (60%) of the mothers were living in rural areas while 40% of the women live in urban areas. Eighty-eight per cent (88%) of the women were married. Regarding the household wealth index, 33% of the women were from the poorest quintiles while 11% were from the richest quintile. Forty-seven per cent (47%) of the mothers had secondary education while a third (33%) had no formal education. Considering the partner’s educational level, 52% had had secondary education or higher, however 27% had no education. A majority (71%) of the mothers were employed with only a few (29%) unemployed. Most (78%) of the households were headed by males and only 22% were headed by females. Approximately 77% of the respondents had health insurance coverage but 23% had none. For women autonomy, 605 (46%) of the mothers decided on healthcare together with their husbands/partners. This is presented in Table From a total of 1305 women who had a live birth in the year before the interview, 28% of the deliveries were unassisted by skilled birth attendants. A breakdown by various socioeconomic stratifies is provided in Table The use of skilled birth attendants differed according to the various socioeconomic groups. Major differences were observed with area of residence, household wealth index, mother’s educational level, husband/partner’s educational level, health insurance cover and the region of residence. Regarding the area of residence as seen from Table Figure Table The concentration index for childbirth in the presence of a skilled birth attendant showed that the estimated value of the relative contribution to the concentration index was negative in some socioeconomic factors such as woman’s employment status (− 0.01), mother’s educational level (no education = − 0.48), husband’s educational level , household wealth index (poorer = − 0.34) and the region of residence . This, therefore, implies that individuals who were worse off in socioeconomic status were less likely to use skilled birth attendants during childbirth. The negative concentration indices indicate that the use of skilled birth attendants during childbirth was low and among the poor. In addition, the absolute values reveal a strong correlation between the mother’s educational level, husband/partner’s educational level and wealth and the use of skilled birth attendants during childbirth compared to the other socioeconomic factors.A pro-rich utilization of skilled birth attendants during childbirth among Ghanaian women between the age of 15–49 years old was seen among women who had health insurance coverage; resided in urban areas; had had some form of education; whose husbands had had some form of education (secondary+); from middle and rich households; and who was in the Ashanti, Brong Ahafo, Central and Northern regions.Using data from the 2014 GDHS, the study determined the factors that affect access and use of skilled birth attendants during childbirth among women aged 15–49 years who had at least one live birth the year preceding the year of the survey. Consequently, the study sought to quantify the factors’ contributions to socioeconomic inequalities using decomposition analysis.The study result showed that a pro-rich concentration (0.188) indicating that more rich women accessed and used skilled birth attendants. The finding is consistent with the results of other studies where skilled birth attendants during childbirth was mostly accessed by women from rich households , 51, 52.The study result showed unequal access and use of skilled birth attendants during childbirth regarding household wealth index, area of residence, region of residence, mother’s educational level, husband/partner’s educational level, and mother’s health insurance cover. The study findings revealed that the socioeconomic status of a mother plays a crucial role in the access and use of skilled birth attendants during childbirth.Inequality in access and use of skilled birth attendants was found to be more predominant between the mothers in the poorest (4%) and richest (44.7%) groups within the wealth quintiles. This revealed a significant positive association for mothers in the richest quintiles as compared to women in the poorest quintiles. These findings supported previous studies that demonstrated unequal access and use of skilled birth attendants in childbirth , 53–55. The study also illustrated that area of residence was significant in influencing access and use of skilled birth attendants during childbirth in Ghana where urban dwellers are more likely to access and use skilled birth attendants. This is in line with studies conducted in Mali, Namibia, Sudan, Malawi, Sierra Leone, Niger, and India , 30, 51 Moreover, the study analysis showed that the region of residence was also significantly associated with women’s access and use of skilled birth attendants in Ghana. The Upper West region had the highest percentage (62.2%) of women not using skilled birth attendants during childbirth compared to the Central Region with the least percentage (5.6%) of women not using skilled birth attendants. Other regions that showed a high percentage of women not using skilled birth attendants were Greater Accra Region (36.4%), Eastern Region (31.7%), Brong Ahafo Region (30.1%), Ashanti Region (26.5%), Western Region (24.4%) and Upper East Region (20.1%). The remaining regions, Northern Region, Volta Region, and Central Region had percentages less than 10%, that is, 10, 8.8, and 5.6%, respectively. This finding was supported by a study conducted in Uganda which showed that region of residence influenced access and use of skilled birth attendants .Additionally, the mother’s educational level to access and use of skilled birth attendants was a significant influence on access and use of skilled birth attendants. According to the study analysis, mothers with no education (44.72%) were less likely to use skilled birth attendants than mothers with secondary and higher education (14.97%). Other studies also confirm similar results , 55, 56 Similarly, husbands/partners who had higher educational levels (secondary and higher) were more likely to access and use skilled birth attendants during childbirth than husbands/partners with no/lower educational levels. A husband/partner with a higher educational level is likely to have higher knowledge and awareness of pregnancy complications .Furthermore, the study findings showed a positive impact of health insurance coverage on access and use of skilled birth attendants during childbirth. Health insurance coverage (41.53%) increased a woman’s chance of accessing and using skilled birth attendants during childbirth compared to women without health insurance (24%). This is consistent with previous studies where health insurance ownership increased a mother’s access and use of skilled birth attendants , 58. ThiThe decomposition analysis revealed that household wealth index, area of residence, region of residence, mother’s educational level and husband/partner’s educational level contributed significantly to the inequalities to access and use of skilled birth attendants during childbirth. The educational level of both mother and husband/partner poses major barriers to access and use of skilled birth attendants during childbirth. Therefore, scaling-up of health education by community-based organizations such as queen mothers’ associations, women groups and church groups may have beneficial effects on pregnant mothers accessing and using skilled birth attendants during delivery and hence prevent maternal mortality during delivery. The Ministry of Health together with the Ghana Health Service need to develop strategies that generate demand for skilled delivery services and reduce financial and geographical barriers to those services.


Pregnancy and childbirth are significant events in women’s lives and most women have expectations or plans for how they hope their labour and birth will go. It is possible that strong expectations about labour and birth lead to dissatisfaction or other negative outcomes if these expectations are not met, but it is not clear if this is the case. The aim was therefore to synthesise prospective studies in order to understand whether unmet birth expectations are associated with adverse outcomes for women, their partners and their infants.Searches were carried out in Academic Search Complete; CINAHL; Medline; PsycINFO, PsychArticles, PubMed, SCOPUS and Web of Science. Forward and backward searches were also completed. Studies were included if they reported prospective empirical research that examined the association between a mismatch in birth expectations/experience and postnatal outcomes in women, their children and/or their partners. Data were synthesised qualitatively using a narrative approach where study characteristics, context and methodological quality were extracted and summarised and then the differences and similarities among studies were used to draw conclusions.Eleven quantitative studies were identified for inclusion from nine countries. A mismatch between birth expectations and experiences was associated with reduced birth satisfaction. Three studies found a link between a mismatch and the development of postnatal post-traumatic stress disorder (PTSD). The evidence was inconsistent for postnatal depression, and fear of childbirth. Only one study looked at physical outcomes in the form of health-related quality of life.A mismatch between birth expectations and experiences is associated with birth satisfaction and it may increase the risk of developing postnatal PTSD. However, it is not clear whether a mismatch is associated with other postnatal mental health conditions. Further prospective research is needed to examine gaps in knowledge and provide standardised methods of measuring childbirth expectations-experiences mismatch. To ensure women’s expectations are met, and therefore experience a satisfying birth experience, maternity providers should provide sensitive care, which acknowledges women’s needs and preferences, is based on open and clear communication, is delivered as early in pregnancy as possible, and enables women to make their own decisions about care.Protocol registration: PROSPERO CRD42020191081.The online version contains supplementary material available at 10.1186/s12884-021-03898-z. Pregnancy and childbirth are significant events in women’s lives that can be associated with both positive and negative emotions. Research suggests that childbirth may affect a woman’s sense of self , 2, and Pregnant women may form beliefs about what to expect during labour and birth. These expectations may be developed from antenatal education, books, television, the internet, healthcare providers or family and friends –29. ManyBased on their expectations and beliefs, some women create specific birth plans, which may include preferences for how each stage of labour should be managed, pain relief options and immediate postnatal care, such as skin to skin contact . HoweverCross-sectional research supports the idea that unmet birth expectations can affect birth satisfaction. For example, a survey of 442 postnatal women found that those whose birth plans were followed had significantly higher birth satisfaction levels . On the The summarised research gives an unclear picture about whether having clear birth expectations can be beneficial to women’s birth experiences in terms of improved communication , 37, or Given the adverse impact a negative birth experience can have on women and their infants’ , 19–21, The protocol was registered with PROSPERO (CRD42020191081).Literature searches and study selection were reported according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines . Online Search results were imported into Eppi-Reviewer 4, where duplicates were removed and results were screened by title and abstract by NU based on inclusion criteria . Each study was read in full, and relevant parts of the text highlighted (for example the country of the study) and applied to the relevant code.Data were extracted for the following domains: Study Characteristics ; Sample Characteristics ; Data collection ; and Results .Methodology sections of included texts were assessed for quality using Joanna Briggs Critical Appraisal Tools for Cohort studies . Each poStudies were synthesised narratively by RW using the technique described by Lucas et al., (2007) . First, n = 1; Canada n = 2, USA n = 4). One study [Searches identified a total of 3684 citations. Hand searches of reference lists of included studies identified a further 2 studies. After removing duplicates and screening through abstracts, titles and full texts, 11 studies remained for inclusion in the review . One study was of medium quality (scoring 6) and one was low quality (scoring 3).Three studies –48 used n = 2); psychological outcomes (n = 6); birth satisfaction and psychological outcomes (n = 2); and physical health (n = 1). No studies looked at the impact of a mismatch on women’s partners or baby/children.The outcomes of the mismatch were all measured for women. These were grouped into birth satisfaction , again with mixed results. One study  found thThree studies looked at postnatal PTSD as an outcome of a mismatch between birth expectations and experiences. One study  showed tper se [One study  used a hper se . The autThis review aimed to understand the impact of a mismatch between labour/birth expectations and experiences on postnatal outcomes for the mother, her partner and her infant. The review identified 11 studies for inclusion. The majority of studies measured birth satisfaction or psychological symptoms as outcomes. Most studies were good quality, with only one rated as poor quality. Results from the review suggest that a mismatch between labour/birth expectations and experiences has a negative impact on women’s satisfaction with birth and may increase the risk of women developing PTSD after birth. There was not enough evidence to draw conclusions about postnatal depression, FOC or physical wellbeing.n = 2) [n = 2) [The finding that a mismatch between birth expectations and experiences is associated with lower birth satisfaction is supported by similar research that was not included in this review, due to not meeting inclusion criteria. For example, several studies were excluded because they did not calculate a mismatch between birth expectations and birth experiences, but instead used a correlation (n = 2) , 60, did [n = 2) , 62, or  [n = 2) , 64. TheResults from the review also suggest that unmet expectations may increase women’s risk of developing PTSD after birth. However, all three studies examining this found that multiple other risk factors, such as fear of childbirth, depression, pain severity, feelings of powerless, lack of adequate information provision and previous trauma increased the chances of women developing PTSD , 51, 52.Results about the impact of unmet birth expectations on other psychological outcomes is less clear. Some studies suggested that unmet birth expectations are associated with psychological difficulties, such as depression , and FOCThe results from this review suggest that women should have their desires relating to labour and birth listened to in order to improve birth satisfaction and potentially reduce the risk of PTSD. Birth satisfaction is a complex concept with many factors predicting it, such as time taken to hold baby, perceived threat to self, perceived threat to baby, birth type, perceived control  and the The lack of prospective research carried out in this area makes conclusions difficult to draw. Measuring birth expectations during pregnancy, rather than after birth is more methodologically rigorous than retrospective measurement as it avoids recall bias. Furthermore, studies were variable in the methods used to measure a mismatch which also makes conclusions difficult to draw. Future research should focus on developing a standardised way of measuring this, to make cross-study comparisons easier. No prospective studies were identified that looked at the impact of a mismatch between birth expectations and experiences on birth partners, or women’s children. Additionally, research on physical outcomes was minimal. Therefore, more prospective research is needed in these areas to examine the gaps in this knowledge.There are several limitations of this review that should be taken into consideration. For example, there are very few studies that evaluate the impact of a mismatch between birth expectations and experiences which makes conclusions difficult to draw. Most of the studies included evaluated the impact of a mismatch on birth satisfaction and psychological outcomes. Whilst the evidence is clearest for birth satisfaction and postnatal PTSD, the mixed results of the impact of a mismatch between birth expectations and experiences on other psychological outcomes suggests more prospective research is needed. Arguably, a limitation of the review methodology is the exclusion of studies where birth experiences and expectations were measured at the same time, or where a mismatch was not calculated. This may have meant some studies were missed. However, those studies that were identified and excluded supported the review findings –64. FurtOverall, this systematic review aimed to synthesise more methodologically rigorous evidence to understand whether unmet birth expectations are associated with adverse outcomes for women, their partners and their infants. The review found that the relationship between unmet birth expectations and depression/FOC and physical outcomes is not clear and more research is needed. However, the results from this review did identify that a mismatch between birth expectations and experiences is associated with birth satisfaction and may increase the risk of developing postnatal PTSD. Further prospective research is needed to identify examine gaps in knowledge and provide standardised methods of measuring childbirth expectations-experiences mismatch. To ensure women’s expectations are met, and therefore experience a satisfying birth experience, maternity providers should provide sensitive care, which acknowledges women’s needs and preferences, is based on open and clear communication, is delivered as early in pregnancy as possible, and enables women to make their own decisions about their care.Additional file 1.


Nutrition practices for preterm infants during the first few weeks of life can be divided into three phases: the parenteral nutrition (PN), enteral nutrition (EN), and transition (TN) phases; the TN phase includes both PN and EN. Our purpose was to analyze nutrition practices for very preterm infants during the TN phase and their association with the infants' growth during the first 28 days of life.Data from 268 very preterm infants <32 weeks old from six neonatal intensive care units were analyzed retrospectively. The TN phase was defined as enteral feedings of 30-120 ml/kg/d. Postnatal growth failure (PGF) was defined as a 28-day growth velocity <15 g/kg/d. Differences in protein and energy intake between the PGF and non-PGF groups during the TN phase were calculated, and risk factors for PGF were identified using multivariate regression analysis.P = 0.007, respectively]. No significant difference was found in energy intake during the TN phase. The variables associated with PGF included a lower total protein  intake, a smaller day of age at the end of the TN phase, and a higher birth weight z-score.The total protein  intake during the TN was 3.16  g/kg/d, which gradually decreased as the enteral feeding volume increased in the TN phase. The total energy  intake during the TN phase was 115.72  kcal/kg/d. The PGF group had a lower total protein intake  than the non-PGF group had [3.09  g/kg/d vs. 3.27  g/kg/d, Increasing the total protein intake  during the TN could reduce the incidence of PGF. Postnatal growth failure (PGF) is prevalent among very preterm infants , 2, and Actual nutrition practices for preterm infants during their first few weeks of life can be divided into three phases: the parental nutrition (PN), enteral nutrition (EN), and transition (TN) phases, with the TN including both the PN and EN . NutritiMartin et al.  reportedThis retrospective multicenter cohort study included six tertiary-care neonatal intensive care units (NICUs). Four NICUs were located in maternal and child health hospitals in Jiangsu, China: Nanjing Maternal and Child Health Hospital/Women's Hospital of Nanjing Medical University, Changzhou Maternal and Child Health Hospital, Nantong Maternal and Child Health Hospital, and Lianyungang Maternal and Child Health Hospital. Two NICUs were in general hospitals: Northern Jiangsu People's Hospital and the Affiliated Suqian First People's Hospital of Nanjing Medical University, both of them in Jiangsu, China.Participants were recruited from January to December 2019. Infants included in the study were those born before 32 weeks of gestation, admitted to the NICU within 24 h of birth, and discharged after at least 28 days in the NICU. Infants who did not achieve full enteral feeding by the 28th day after birth were excluded.Infants received PN within 24 h after birth, and their initial glucose dose of 4-8 mg/kg/min was increased by 1-2 mg/kg/min, up to 11-14 mg/kg/min. Their AA intake was increased from 1.5-2.0 to 3.5-4.0 g/kg/d; lipids were started at 1.0 g/kg/d and increased by 0.5-1.0 g/kg/d, up to 3 g/kg/d.Infants without contraindications to EN support should receive minimal enteral nutrition as early as possible after birth, with human milk or formula (10-20 ml/kg/d for 3-5 days). Full EN is achieved when the EN calorie intake is at least 80 kcal/kg/d. The target caloric value of full PN is 80-100 kcal/kg/d, and the target caloric value of full EN is 110-135 kcal/kg/d . The PN phase before the TN included a minimal volume of EN and a PN-only phase. Full EN was defined as an EN volume > 120 ml/kg/d or the absence of a PN infusion.Data on the nutrient intake of all intravenous and enteral products during the TN phase and daily body weights were collected retrospectively to evaluate the intake of intestinal protein and energy, parenteral AA and energy, and total protein and energy. An EN volume of 30 ml/kg/d, which was considered equivalent to 30-39 ml/kg/d, was fed to the infants. When the feeding amount was the same for more than 1 day, the daily nutrient intake on these days was divided by the infant's body weight of that day, and the average of these nutrients in the feeding volume was calculated as the average nutrient composition of the feeding volume.z-score was calculated using an online preterm growth calculator (available at www.peditools.org.) /standard deviation. The GV (from birth to the 28th day of life) was based on an exponential model of regaining birth weight. The formula was: GV = /(28-D); where W28 = weight on the 28th day of life, W = birth weight, and D = the day (of age) that birth weight was regained . Being small for gestational age was defined as a birth weight less than the 10th percentile for gestational age . The birls.org.) , and theregained . The terregained .Feeding types included human milk and formula; human milk included mother's own milk (MOM) and donated human milk (DHM). When the volume of human milk reached 50-100 ml/kg/d, human milk fortifiers (HMFs) were added as supplements . The for8−24Ve). During the PN-dominant TN phase, the amino acids in the PN were expressed as protein (1 g protein = 1.13 g AA) to calculate the total protein.Energy calculations of parenteral nutrition were as follows: glucose = 4 kcal/g (glucose injection); AA = 4 kcal/g (6% pediatric compound amino acid injection 18AA-I/19AA-I); and lipids = 9 kcal/g , with continuing oxygen requirements at 36 weeks corrected gestational age , necrotiU and Chi-square tests or Fisher's exact test were used to analyze differences between groups. Variables with statistically significant differences in the univariate analysis were entered into the multivariate logistic regression model to determine the factors predicting PGF. P < 0.05 was considered statistically significant. All analyses were performed using SPSS statistical software, version 26 .Continuous variables were expressed as median and interquartile range (IQR), and categorical variables were expressed as frequencies and percentages. The Mann-Whitney In 2019, 742 preterm infants were treated in the six NICUs; 474 were excluded from the study: 294 because their length of stay was <28 days, 10 because complete data were not available, 2 because their admission to the NICU was >24 h after birth, and 168 because they had not completed the TN by the 28th day after birth. Thus, data from the remaining 268 infants were included in this study.z-scores were significantly higher in the PGF group than those in the non-PGF group , but none of the clinical outcomes was significantly different.Participants' demographic characteristics and clinical outcomes are compared in P = 0.029), a smaller day of age at the end of the TN (P = 0.045), a lower AA intake during the PN phase (P = 0.01), and a lower total protein intake (PN + EN) during the TN phase (P = 0.007) than those without PGF. No significant difference was found in feeding types or other nutritional data during the TN phase  g/kg/d vs. 0.84  g/kg/d, P = 0.03, respectively). After the enteral feeding volume reached 80 ml/kg/d, infants in the PGF group had a lower parenteral AA intake . No significant difference was found in the parenteral or enteral energy intake before or after the enteral feeding volume reached 80 ml/kg/d (P > 0.05).Infants in the PGF group had a lower parenteral AA intake throughout the TN phase than those in the non-PGF group. Before the enteral feeding volume reached 80 ml/kg/d, the infants in the PGF group had a lower parenteral AA intake  No. 73). Written informed consent from the participants' legal guardians was not required for participation in this study, in accordance with national legislation and the institutions' requirements.NW, ZY, and JZ contributed to conception and design of the study. NW and SH contributed to the acquisition and analysis of the data. BW, RC, LG, XL, HW, YG, and WH performed the statistical analysis. NW wrote the first draft of the manuscript. All authors contributed to manuscript revision, read, and approved the submitted version.This research was funded by the Nanjing Medical Science and Technology Development Foundation (ZKX19045) and Project supported by special disease cohort of Nanjing Medical University (NMUC2020037).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.