This study aimed to explore both mothers’ and fathers’ lived experiences of the birth environment. Objectives were set to explore how the physical, psychosocial, spiritual and cultural environment during labor, influence the parents’ birth experience, and to delve into the similarities and differences between mothers’ and fathers’ views and experiences of the birth environment.The study adopted an interpretive phenomenological research design. A purposive homogenous sample of seven couples was recruited from the main local public hospital in Malta. Data were collected using one-time, face-to-face, semi-structured interviews with each couple. The birth territory theory by Fahy guided this study and interpretive phenomenological analysis was used to analyze, interpret and elicit the meanings that participants attributed to their experiences of the birth environment.Three super-ordinate themes emerged from the data: ‘The home–hospital gap’, ‘Midwifery care’ and ‘Movement in labor’. A conflict between the comfort of home and home-like aesthetics, and the reassuring, but foreign, clinical environment and medical equipment, was felt by mothers and fathers. The midwife was a fundamental part of the birth environment for the parents, taking precedence over the physical environment. Movement in labor was important to mothers while fathers became more involved when mothers were mobile during labor. The birth environment consisted of facilitating and impeding factors to movement, which made an impact on the parents’ experiences.Mothers and fathers experienced the birth environment from different perspectives. However, they have indicated similar needs and desires from the birth environment, creating a shared experience. Where a mother gives birth is crucial to her experience, health, wellbeing and progress in labor2. We often forget that fathers also have their own needs from the birth environment, which will influence their ability to support the mother and impact their own experience of childbirth3. Following a literature review, it became clear that, evidence on mothers’ and fathers’ joint experience of the birth environment, as couples, is scarce. To address this gap in the literature, this study aimed to explore both mothers’ and fathers’ lived experiences of the birth environment. The literature review also presents a clear consensus that birth environment goes beyond the physical space, and is influenced by those present, the institution and holistic setting6. Hence, this study goes beyond the physical perspective of the birth environment to include all aspects.The birth experiences of both mothers and fathers, have long lasting effects on themselves and their familiesThe study objectives were to explore how the physical, psychosocial, spiritual and cultural environment during labor, influence the parents’ birth experience and to delve into the similarities and differences between mothers’ and fathers’ views and experiences of the birth environment. Couples’ experiences of the birth environment during early labor when at home, and experiencing labor at an obstetric-led public hospital for those having a normal vaginal birth, were studied.7. The birth territory theory guided this research study throughout, from its design through to the interpretation of the results. The birth territory theory is made up of two main components: the physical terrain, and jurisdiction. The physical terrain is described using two opposites: the ‘surveillance room’, and the ‘sanctum’. The ‘surveillance room’ lacks privacy and optimizes professionals’ supervision. The ‘sanctum’ birth space provides a home-like and private environment, optimizing physiology8. Jurisdiction refers to the use of power, by mothers or others within the birth space. Redesigning the birth territory to enhance a mother’s integrative power improves satisfaction and empowers mothers. This power can be facilitated by the midwife through midwifery guardianship. In contrast, disintegrative power separates the mother from her inner power to birth intuitively. This theory takes a holistic approach towards the birth environment and embraces the individuality of each mother and her labor, as well as the importance of the midwife as part of the birth environment9.The research study sought to elicit meaning to couples’ experiences of the birth environment. The study adopted an interpretive phenomenological research approach, using interpretative phenomenological analysis (IPA) to analyze the data6. Participants for this study were recruited from the main tertiary general public hospital in Malta. This hospital has one obstetric-led maternity unit, with midwives attending all normal vaginal births, and obstetricians called when complications arise. The unit consists of individual birthing rooms with ensuite facilities and a bed at the center of the room. Home birth and midwife-led units are not available as part of the national health services in this setting. This was the first study which explored couples’ experiences of such a birth environment in this hospital.The birth environment is a culturally and geographically sensitive area of researchA purposive homogenous sample allowed for focus within the study, data saturation was used to guide the number of couples in the sample, which led to a sample of seven couples. Parents meeting the eligibility criteria were approached with an information letter for recruitment by an intermediary person, a midwife, who was not involved in this research project. Data were collected in early 2017 and written informed consent was obtained prior to each interview from participants.First-time parents were included in this study, to exclude the influence of previous birth experiences. The researchers were interested to know about the complete experience of the birth environment, to include both the home environment in early labor and the hospital environment where labor progressed and birth occurred for the participants. Therefore, only couples who came to the hospital in spontaneous labor were included in the study. To better understand the parents’ experience of the home environment during early labor, only couples who lived in the same household were included in the study, as the home environment was a shared environment for each couple. Additionally, only couples whose child was born at term by normal vaginal birth were included. Couples experiencing induction of labor, instrumental delivery or cesarean section were excluded from the research study. Couples whose infant required neonatal intensive care and mothers who experienced complications during or after birth were excluded. Couples where both mother and father were over 18 years of age were included in the study. Couples where either mother or father were unable to communicate in Maltese or English, were not included in the study.One-time, face-to-face semi-structured interviews were used for data collection in this study. The interview schedule consisting of four open-ended questions, asked couples about their experiences of the physical, psychosocial, cultural and spiritual birth environment and how the environment made them feel. Participants were also asked what they would change from the birth environment they experienced. Such questioning allowed participants to reflect on the various aspects of their birth environment and not only on the physical dimension. Demographic data collected included the participants’ age, nationality, attendance to antenatal education and age of the baby at the time of the interview. The interview schedule was self-designed by the researchers, following a thorough review of relevant literature.Interviews were carried out by one researcher (RM), following the mothers’ and their babies’ discharge from the hospital, within the first four weeks postpartum. Each couple participated in a joint interview, to capture their joint experience of the birth environment.A pilot study of two interviews was carried out and no necessary changes to the interview schedule were deemed necessary. The main study consisted of seven coupled interviews. Interview schedules were designed in both Maltese and English, allowing participants to choose their preferred language. Interviews were held in the participants’ home as this was preferred by the participants. Interviews were audio-recorded with the participants’ permission. Audio-recordings of interviews were transcribed verbatim for analysis.7 , allowing dwelling in the data and eliciting the meanings participants attributed to their experiences. Descriptive, linguistic and conceptual comments were analyzed for their meanings to the participants. Emergent themes were then developed from the exploratory notes, moving from a descriptive process to interpretation of the data. Connections across emergent themes were identified to produce a structure, recognizing the most important and essential aspects of the data. The above steps were repeated for each transcript. Patterns across the different cases were identified, which lead to a reconfiguration of themes and super-ordinate themes. Researcher triangulation was adopted by both researchers to validate the emergent themes7 .Ethical approval to carry out the research study was granted by the Faculty of Health Sciences Research Ethics Committee of the University of Malta, after obtaining the necessary institutional permissions allowing access to the participants.Mothers’ ages ranged from 27 to 38 years. Fathers’ ages ranged from 27 to 41 years. All participants were of Maltese nationality and had given birth between one and four weeks prior to the interview. All participants had attended antenatal education sessions together as a couple. This is relevant to the study as the antenatal education program provided by the hospital includes a visit to the birthing unit and birth rooms which were later used by the participants.Data analysis led to three super-ordinate themes. ‘The home–hospital gap’ which reflects what the home and hospital environment meant to the participants. ‘Midwifery care’, where midwives were considered to be fundamental to the birth environment and ‘Movement in labor’ which takes a holistic approach to facilitating and impeding factors for movement and what these meant for the couples .The participants’ narratives started with the ‘comfort of home’ theme . Home wa‘At the same time you need that stuff ... there's always going to be that gap, between having a delivery at home and a delivery at hospital, you're giving up your personal space for equipment that will be there to help you in case of an emergency.’ A conflict between the medicalized surroundings providing reassurance and a safe environment for birth, yet at the same time being unfamiliar, was felt by the participants. There was a contrast between functionality and personalizing the birth space as seen in the theme ‘functional vs personal’. The heavy presence of equipment such as the neonatal resuscitaire, added to the clinical and functional feel of the birth room. However, the birth space was personalized by some of the participants, with the use of music and dimming the lights. Being able to personalize the environment provided familiarity and psychological reassurance particularly for mothers. Mothers and fathers felt differently about personalizing the birth space. This was more important and achievable for mothers, while fathers felt that the space was more about functionality.A physically, but also psycho-social private space was of prime importance to both mothers and fathers. The theme ‘privacy for an intimate moment’ relates to participants’ psycho-social and spiritual need for intimacy during birth. Both the room design and professional attitudes were reflected on in this theme. The couples felt there were positive aspects, like individual birthing rooms and ensuite facilities. However, having swinging-style doors compromised privacy. Experiences of professionals’ attitudes varied greatly around maintaining privacy. Entering the room with prudence was greatly appreciated by couples:‘A midwife came in to talk to the midwife taking care of me, not immediately coming in, she sort of stayed by the door and when she saw that everything was OK she came in.’ Midwifery care was considered to be more important to the couple than the physical environment, emphasizing the holistic nature of the birth environment . The midThe couples felt that the midwife’s main concern should be the mother and baby. However, when midwives encouraged fathers to be involved during labor, both mothers and fathers benefitted, as revealed in the theme ‘midwives for both parents’:‘I was just standing there close to her waiting for the midwife to tell me what to do and every time she said go in front of her and she will hold on to you and I did what she said, then when she was getting tired I was telling her just last few pushes.’ (Ben)‘The midwife was asking him to be more encouraging.’ (Claire)‘…but she got me really involved like.’ (Ben) (Couple 1)Mothers and fathers differed in that fathers observed closely how the midwives worked, which put them at ease. On the other hand, for mothers it was more about how the midwife made them feel, in what was considered to be a sacred time for the mother as she focused on her labor and trusted her midwife. Mothers felt positively about how the midwives made them feel during labor with their warmth making up for the cold and clinical environment. Midwives were viewed as being calm, with the participants and their colleagues. The theme ‘midwives for midwives’ reflects upon how couples felt there was team work between midwives which made couples feel comfortable and safe within the birth environment:‘They stay calm between themselves and don't make you feel any pressure. There is a nice environment, they work really well together.’ Movement in labor was related to various facilitating and impeding physical and sociocultural factors within the birth environment . The midMost of the couples felt that mobility and upright postures kept birth as natural as possible, in the theme ‘facilitating a natural birth’:‘…what I found out was the more you move the more you make it natural, despite everything, the better it was for me.’ The participants felt that the size and spaciousness of the delivery room facilitated movement, a positive aspect of the physical environment, together with the availability and use of birthing aides, such as the birthing ball. Participants perceived that these aided spontaneous labor and reduced the sensation of pain.Mothers and fathers recognized how comfort and mobility are interrelated in the theme ‘feeling constrained’. Cardiotocography and pharmacological analgesia, although deemed necessary, were not desirable aspects of the birth environment. One of the mothers used epidural analgesia, and she felt that epidural analgesia consequently constrained her movement, despite being pain-free she was not particularly comfortable. However, limited movement was not related to epidural analgesia alone, as another mother felt one fixed entonox port in the room limited her mobility:‘…had the gas been portable, that, because even to go to the bathroom I felt uncomfortable, because as I started to take it and started to rest as I was getting up, you have to take it beforehand so I didn't want to stand in any way and leave it behind, I was afraid to leave it behind, had it been portable you could move, as I didn't want to stand up and move because of it.’ The theme ‘the bed and alternatives’, explored the availability of birthing aides and the culture of a bed-centric birthing room. All participants felt that avoiding the bed and making use of birthing aides was advantageous in the first stage of labor. However, the bed still played a central role during the second stage of labor, with five out of the seven participants giving birth on the bed. The midwife’s suggestions and practices played an important role in adopting upright postures throughout labor. Staying on the bed for the second stage of labor was a sociocultural norm and doing anything alternative was seen as being unusual. The use of water-immersion was considered by two of the participating couples. However, the apparent lack of facilities and hospital policy did not give them the possibility to use water for birth.10. Participants’ narratives of events reflected the shared experiences between couples, however, similarities and differences across mothers’ and fathers’ perspectives became evident and were further explored.The super-ordinate themes: ‘the home–hospital gap’, ‘midwifery care’ and ‘movement in labor’ are discussed in relation to the holistic perspective of the birth territory theory as described by Fahy and colleagues10. The cold and clinical environment provided cleanliness, but was not comforting to the participants. The couples made reference to a sanctum-like birth environment as described by the birth territory theory when they refer to home-like and warm features, which would have been a desirable aspect of the birth environment11. However, equipment and medical assistance, despite being foreign and not aesthetically pleasing, were considered to contribute towards having a safe birth. The hospital environment was seen as being a foreign environment, yet providing reassurance. In contrast, according to the birth territory theory, the more a birth space is similar to the sanctum terrain, the safer and more confident the mother feels to give birth9. The findings suggest that certain aspects of the surveillance environment such as equipment, although daunting, were perceived as being necessary for a safe labor and birth. Similarly in the Sheehy et al.12 study of women’s expectations and experiences, and in the study of Davis Harte et al.13 on birth partner’s experiences, both report a foreign and clinical environment as providing reassurance. The conflicting meanings given to the hospital environment, in this study, are also reported in both of these Australian studies. Both the Hodnett et al.14 Cochrane systematic review and the Overgaard et al.6 prospective cohort study, found mothers were more satisfied in midwifery-led birth centers as opposed to obstetric-led units. Provision of a birth center, with sanctum-like aesthetics, could be one way to bridge the gap between home and hospital settings, as well as offering choice to expectant parents.A contrast between the clinical and functional delivery room and the personal and comfortable setting of their own home emerged throughout the study. The clinical appearance and presence of equipment experienced by the participants relates to Fahy and colleagues’ birth territory theory’s description of a surveillance room2 large scale National Childbirth Trust (NCT) survey to be desirable aspects of the birth environment for mothers. The findings of the present qualitative study suggest similar improvements to the clinical hospital setting, with some of the participants feeling that the aesthetics reflected ill-health and did not fit the joyful experience of birth. Some mothers managed to create their own sanctum terrain with the help of their midwife. Mothers and midwives attempted to create more of a sanctum birth space, by personalizing their surrounding with the use of music and dimming the lights. For the fathers, the environment was perceived to be purely functional and not capable of being personalized. This could be related to the fact that personalizing the environment was directed at improving the mother’s comfort in labor and not the father’s wellbeing. The findings center around the mothers’ physical comfort and wellbeing. In contrast, the phenomenological delivery-room design study of Hyldgaard Nielsen and Overgaard15, based in Denmark, found the birth environment providing space, comfort and personal touches for the birth partner’s comfort, an important element in birth room design for mothers.Home-like features, access to music, adjustable lighting and comfort aides, were reported in the Singh and Newburn10. For both mother’s and father’s psychosocial and spiritual wellbeing, depended upon the provision of privacy to share this intimate time together, privacy needed to be maintained by the physical environment and the staff at the delivery suite. Privacy was as important to fathers as it was to mothers. This resonates with Davis Harte et al.12 findings, which recognized privacy as essential for birth partners. However, the culture of a hospital, which is not the participants’ own space, can never be completely private. The design of the hospital room meets the hospital’s needs, allowing hospital staff to enter and exit as needed. A change in the design of the room and presence of a screen for privacy, as recommended by a father in this study, is also a recommendation of the BUDSET  designed by an expert panel of midwives and architects16. Mothers and fathers were content when their birth space was treated as a private space. Unfortunately, privacy had been invaded for some of the couples when staff, not involved in their care, entered the room without prior warning. During labor, couples wished to be surrounded only by those directly involved in their care.Maintaining the parents’ privacy in the intimate moments of labor and birth is a defining aspect of providing a sanctum birth space10. Building a rapport with the midwife was important to all participants in the present study. Most participants felt that the manner in which they were cared for was more important than the physical environment they experienced. When the midwife caring for the couple was welcoming and caring, the cold and clinical aesthetics of the birth environment did not remain as daunting. Hyldgaard Nielsen and Overgaard15 found that an alternate hospital birth room, with warm, healing features amplified the psychosocial and emotional support provided by midwives, who were considered an integral part of this type of environment. In the present study, with a ‘cold and clinical’ environment, the midwife still provided warmth and wellbeing towards both mothers and fathers. Likewise, Goldkuhl et al.4 ethnographic study found that the midwife enhancing a mother’s integrative power through her care, increases control, safety and satisfaction, beyond what the physical environment alone can provide.The midwife was recognized to be of paramount importance in the holistic birth environment. Likewise, in the birth territory theory, midwifery guardianship optimizes the mother’s safety and respect within the birth terrain, empowering the mother for birth9. The study findings demonstrate that couples preferred to be given unbiased information and explanations to facilitate making their own choices. Those couples who were not involved in decision-making were not as content with the midwifery care they received. These findings resonate with two large longitudinal studies: Rudman et al.17 found that not being involved in decision-making negatively impacted mother’s satisfaction in labor. Hildingsson et al.18 found that fathers’ experience of midwifery care was dependent on information giving and decision-making.Participants formed a relationship with their midwife based on trust, the midwife’s attitude, their confidence in her skills and the information she provided them. Conforming to the birth territory theory, midwifery guardianship, which facilitates the mother’s integrative power during labor and birth, is highlighted in these findings. Decision-making is an intrinsic part of midwifery guardianship19. Therefore, when the father was guided by the midwife on being supportive towards the mother, both mother and father had a positive experience. When midwives did not provide fathers with support, fathers felt helpless. The present study, in accordance with the mixed-methods study of Johansson et al.3, found that midwives need to include fathers for them to become involved during labor. The uniqueness of the present study is that exploring the couples’ joint perspectives, emphasizes how meaningful it was for the mother, when the midwife involved the father, and this facilitated a shared experience of birth.In the present study, midwifery care, although still primarily focused on the mother and baby, also incorporates the father. Mothers and fathers were content when the midwives involved the fathers during labor. However, not all fathers in the study had the same experience of midwifery care. When fathers were guided by the midwives, on how to be supportive, and were made to feel included in the labor, their experience was better. For the mothers this was also beneficial, as their partner offered a unique supportive role. The father’s physical, psychological and spiritual support facilitates the release of oxytocin and hence results in a physiological and satisfying birth experience20 also took on an observer role, which was associated with being vigilant of all that was going on for the sake of the mother and baby. Midwives supporting each other put couples at ease and created a safe environment.Midwives were viewed as being calm and serene with the participants and with each other. This calm attitude influenced the environment, including the parents, to remain calm. Fathers took on an observer role during labor, whereas mothers were more concerned about how the environment made them feel on a psychological and spiritual level. Consumed in their labor, mothers did not observe much. Fathers on the other hand, were very observant of the physical and psychosocial environment. This pertained especially to midwifery care. Fathers watched how the midwives worked, especially the interactions and the team work between midwives. Likewise, fathers in the phenomenological study of Longworth and Kingdon21 and Singh and Newburn2. However, perceived spaciousness was not just related to the size and layout of the room, but also to the care given, which influenced the mother’s ability to utilize the space. Similarly, in the present study, factors influencing movement in labor included the midwife’s practice and the mothers’ choices.A spacious birth room with birthing aides available to use, facilitates freedom to mobilize, improving mothers’ experiences, as seen in this study and previous research across various birth units in the United Kingdom carried out by Symon et al.8. CTG was a reassuring and prevalent part of the birth environment for the participants. However, CTG interfered with a mothers’ ability to move around freely and to be comfortable. For this reason, telemetric CTG was preferred to facilitate movement. This reflects the participants’ expectations and compliance to a surveillance terrain. Additionally, pharmacological analgesia was for some participants a constraining factor for mobility in labor. Dependence on pharmacological analgesia restricted the mothers’ movement and these participants would have preferred to use their chosen method of analgesia and be able to move freely, for a more comfortable labor and improved experience.Movement was associated with keeping labor as natural as possible. The knowledge acquired prior labor, the midwife’s advice and the participants’ own experiences during labor led them to firmly believe that mobilizing kept labor natural. For mothers, listening to their own bodies, by moving as they felt was right for them at the time, facilitated a natural birth. The findings of this study present a relationship between comfort and movement in labor. Being constrained for movement diminished a mother’s comfort in labor. Fathers encouraged mothers to mobilize in labor, particularly when the midwife also encouraged the mother to mobilize. In accordance with the birth territory theory, midwifery guardianship was present when the midwife facilitated the mother’s own inner power to listen to her body and mobilize. Disintegrative power may also be exerted with the midwife undermining the mother’s ability to listen to her body to move around freely as when cardiotocography (CTG) monitoring led midwives to tell mothers to stay in a particular position, which limited mobility. Interestingly, couples did not associate the CTG with the rest of the medical equipment, contrary to the birth territory theory which includes the use of CTG as part of the surveillance terrain22 also found that fathers had a more positive experience when their partner used an upright birth position. As seen in the present study, this was related to having a more useful role during birth as opposed to other birth positions. Involving the father with the mother’s upright postures and mobility was also meaningful to the mothers.The benefit for fathers, in the present study, was that upright postures gave them an active role in the labor. The mixed-methods study of Johansson and Thies-Lagergren16. On the contrary, the present study found that the presence of birthing aides in the room, as well as midwives’ suggestions to use birthing aides, encouraged their use. An important facility in the BUDSET, as well as in the birth territory theory’s sanctum birth terrain, is a deep bath or birth pool16. None of the mothers in the study made use of water for analgesia or for birth. Two of the participating couples expressed frustration that these facilities, which they thought could be advantageous for comfort and having a physiological labor, were not available to them.Mobility and upright postures were very popular with the participants during the first stage of labor. However, the bed remained a prominent part of the second stage of labor. Not all mothers were comfortable with adopting different positions during the second stage, as the supine position was seen as the sociocultural norm. The BUDSET tool also acknowledges the influence of culture and healthcare practices on the use of the bed and supine position for birth. The presence of birthing aides such as the birthing ball, birthing stool and mats, in the delivery room, encouraged participants to make use of these facilities for movement in labor. The BUDSET tool recommends birthing aides being available, but does not recommend keeping such equipment available in each roomThe use of a qualitative phenomenological design offered depth to the findings and allowed the individual experiences of participants to be voiced in the study. The small homogenous sample included couples whose labor started spontaneously and did not encounter complications during labor. However, the experiences of couples undergoing medical interventions, would likely lead to varying results. Participants were Maltese nationals, therefore findings are influenced by the Maltese culture, and so may not be representative of the culturally diverse population giving birth in Malta. Participants were informed that they were being interviewed by a clinical midwife (RM). This may have influenced the information they felt comfortable to divulge during the interviews, especially when talking about the role of the midwife. The interpretive phenomenological approach recognizes the researchers’ pre-understandings of the phenomenon and in this study, the researchers were familiar with the midwifery practices in the same hospital environment being studied. Exploring the shared experience of the couple, added depth and meaning to the study. Carrying out semi-structured interviews with the couple together gave them the opportunity to remind each other, and contribute to each other’s birth stories and experiences of the environment. However, participants may have felt more comfortable to disclose certain information without the presence of their partner. Therefore, varying results and other valuable data, could have emerged had they been interviewed separately.Exploring the birth environment from the aspect of both parents, as a couple, presented a shared experience, giving an understanding of what each other’s presence in the birth environment meant to the participants as well as the meaning of the birth environment to both parents’ experiences. The findings highlight how fathers wish to be more involved, how important their presence and involvement is to their partner and how this can be facilitated or inhibited by the birth environment. The cultural and psychosocial aspects play a crucial role in the birth environment, as seen in this study’s findings. Hospital birth was experienced as a sociocultural norm. The hospital environment, equipment and personnel, offered reassurance despite being a foreign and daunting environment. Despite the clinical setting, the parents related the birth environment to keeping birth as natural as possible, this was especially evident in the ability to mobilize freely and make use of birthing aides. The midwife played an essential role within the birth environment, in relation to facilitating movement and upright postures in labor and creating the right psychosocial, emotional and spiritual environment.Recommendations for improvements in practice for the physical environment include home-like features, birthing aides and telemetric CTG monitoring or intermittent fetal heart monitoring. To improve the psychosocial and spiritual environment, the researchers recommend improved privacy and continued involvement of the father. Further research into the shared experiences of mothers and fathers during childbirth as well as a mixed-methods study on the birth environment are recommended where the perspectives of midwives could also be explored.


This study investigated whether the timing of birth of the younger siblings was associated with the risk of the older siblings’ developmental vulnerability in early childhood.th percentile on an individual AEDC domain ; and Communication Skills and General Knowledge) were classified as developmentally vulnerable. Modified Poisson Regression was used to estimate relative risks (RR) for associations between post-birth interpregnancy intervals (IPIs) and developmental vulnerability.Linkage of population-level birth registration, hospital, and perinatal datasets to Australian Early Development Census (AEDC) records (2009–2015), enabled follow-up of a cohort of 32,324 Western Australia born singletons. Children with scores <10Relative to post-birth IPIs of 18–23 months, post-birth IPIs of <6 and 6–11 months were associated with an increased risk of children being classified as DV1  and DV2 ; and DV1  and DV2 , respectively. Post-birth IPIs of <6 months were associated with an increased risk on four of the five AEDC domains. Post-birth IPIs of 48–60 months were associated with an increased risk of developmental vulnerability; however, the risk was statistically significant for DV1, DV2 and the domains of Emotional Maturity and Language and Cognitive Skills (school-based).Developmental vulnerability was associated with having a closely spaced younger sibling (<12 months post-birth IPIs). Optimising birth spacing should be further investigated as a potential means for improving child development outcomes. Given the relatively short birth intervals and relatively long dependency periods of human offspring, there is an increased need to understand the impact that siblings may have on each other’s learning and development , 2. Studthe resource dilution hypothesis, which states that a family’s resources are finite, and thus, children’s cognitive, educational, emotional, and physical development will be compromised with increasing sibling numbers .–26.24–26n = 27,265) of the study population. To minimise bias attributable to missing data [Overall, complete covariate information was available for 84.3% , to the results based on the analysis of the complete cases only . Overall, a total of 13,902 (43.0%) children had a short post-birth IPI (<18 months), whilst 12,799 (39.6%) of children had a long post-birth IPI  were classified as DV1, and 3,577 children (11.4%) were classified as DV2. The proportion and relative risk of children classified as DV1 and DV2 followed a reverse J-shaped distribution across post-birth IPIs; children with the shortest post-birth IPIs had the greatest proportion and risk of developmental vulnerability .unadjusted model). Children with short IPIs of 6–11 months had an increased risk of being classified as DV1 and DV2 compared to children with post-birth IPIs of 18–23 months, 1.19 (95% CI: 1.11–1.27) and 1.34 (95% CI: 1.21–1.50), respectively (unadjusted model). Children with long IPIs of 24–35 months had an increased risk of being classified as DV2 only, relative to the reference group . Children born with longer post-birth IPIs of 36–47 and 48–60 months were associated with an increased risk, relative to the reference group, of being classified as DV1 and DV2, with a greater risk with increasing post-birth IPI category (unadjusted model). Adjustment for the sex and age at AEDC completion resulted in slightly elevated RR of children being classified as DV1 for all post-birth IPI categories and of children being classified as DV2, for all post-birth IPI categories, except 24–35 and 36–47 months (Model 1). Adjustment for pregnancy- and birth-related variables attenuated the RR of children being classified as DV1 and DV2 for all post-birth IPI categories (Model 2). Furthermore, adjustment for sociodemographic variables further attenuated the RR of children being classified as DV1 and DV2 for all post-birth IPI categories (Model 3). In the fully adjusted models, children with short post-birth IPIs of <6 and 6–11 months had an increased RR of being classified as DV1, 1.21 (95% CI: 1.11–1.31) and 1.10 (95% CI: 1.03–1.17), respectively and DV2, 1.31 (95% CI: 1.15–1.49) and 1.21 (95% CI: 1.09–1.34), respectively (adjusted model). Children with post-birth IPIs of 48–60 months had an increased risk, relative to the reference group, of being classified as DV1  and DV2 .Children with short post-birth IPIs of <6 months were at an increased risk of being classified as DV1 (RR: 1.68 95% CI: 1.54–1.83) and DV2 , relative to the reference group; post-birth IPIs of 18–23 months (7 months : Model 1tegories : Model 2tegories : Model 3Model 2). Further adjustment for sociodemographic variables further attenuated the RR as developmentally vulnerable for all five AEDC domains for all post-birth IPI categories (Model 3). Post-birth IPIs of 48–60 months for the domains of Emotional Maturity  and Language and Cognitive Skills  (school-based), only , only .Sensitivity analysis revealed that the overall associations between post-birth IPIs and developmental vulnerability at age five were not substantially different between complete cases and the imputed cases .We found the risk of developmental vulnerability for all five AEDC domains, and the aggregated measures (DV1 and DV2) of child development followed a reverse J-shaped relationship with respect to post-birth IPIs. The risk of developmental vulnerability was highest for children with a post-birth IPI of <6 and 6–11 months. Our results provide support for the theoretical assumptions of the negative effect of sibling births spaced closely together  on older siblings. Furthermore, we reported that for long post-birth IPIs, the risk of developmental vulnerability generally increased–the risk of developmental vulnerability was statistically significant for children with post-birth IPIs of 48–60 months for DV1, DV2 and for the domains of Emotional Maturity and Language and Cognitive Skills (school-based). Adjustment for pregnancy, birth and sociodemographic variables accounted for a substantial proportion of the risk associated with sub-optimal post-birth IPI durations.Only a handful of studies have examined the associations between pregnancy spacing and school readiness or academic performance –41. One Our results are further supported by the findings of a larger cohort study of approximately 5,000 sibling pairs, aged between 14 and 22 years, from a representative US sample that aimed to assess the relationship between birth spacing and educational attainment . The stuthe resource augmentation hypothesis, or the pedagogic experience associated with the no-one-to-teach hypothesis may be lost due to the interval between siblings being too large to be beneficial. It should be noted that a wide range of biological factors [Albeit generally statistically non-significant, we observed that post-birth IPIs longer than the reference category were associated with an increased risk of developmental vulnerability, with a greater risk for each increasing post-birth IPI category for each AEDC domain. Specifically, we reported that post-birth IPIs of 48–60 months were associated with an increased risk of developmental vulnerability for the domains of Emotional Maturity and Language and Cognitive Skills (school-based). These results provide some preliminary evidence to suggest that perhaps any potential benefits of sibling interactions associated with  factors , 43, inc factors , the use factors , and breOther important social risk factors, including parenting experience or technique, stability and quality of housing, the total number of people residing within a household, and availability of learning resources within the household, could not be controlled . Total household size and household composition may have both positive and negative effects on household recourse–multigenerational households may be beneficial to improving child development outcomes via grandparental investment . LikewisVery short post-birth IPIs of <6 and 6–11 months were associated with an increased risk of children being classified as developmentally vulnerable on aggregate measures (DV1 and DV2) and four of the five AEDC domains. Long post-birth IPIs of 48–60 months were also associated with an increased risk of developmental vulnerability on the aggregate measures. The results of this study expand on the current evidence base and suggest that associations between birth spacing and early child development outcomes are observable at school starting age. Although further studies are required, optimising birth spacing between siblings may be a potential means to improve child development outcomes.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.


The incidences of early term and late preterm birth have increased worldwide during recent years. However, there is a lack of prospective study about the influence of early term and late preterm birth on infants’ neurodevelopment, especially at the early stage. Therefore, we conducted this cohort study to investigate the impact of early term and late preterm birth on infants’ neurodevelopment within 6 months.This cohort study was conducted in Wuhan, China, between October 2012 and September 2013. A total of 4243 singleton infants born within 34-41 weeks of gestation at Wuhan Children’s Hospital were included. The Gesell Developmental Scale (GDS) was utilized to evaluate the neurodevelopment of infants.β = − 17.42, 95% CI: − 21.15 to − 13.69), fine motor , adaptability , language  and social behavior . There was a significant negative trend for early term birth in DQ of fine motor . Late preterm infants had a significantly elevated risk of neurodevelopmental delay in domains of gross motor , fine motor , and adaptability , whereas early term birth was significantly associated with neurodevelopmental delay of fine motor .Among the 4243 included participants, 155 (3.65%) were late preterm infants, 1288 (30.36%) were early term infants, and 2800 (65.99%) were full term infants. After adjusted for potential confounders, significant negative relationship was shown between late preterm birth and development quotient (DQ) in all domains of neurodevelopment: gross motor (This study suggested that late preterm birth mainly elevated the risk of neurodevelopmental delay of gross motor, fine motor, and adaptability, whereas early term birth was associated with the developmental delay of fine motor within 6 months. Further research is needed to determine the effectiveness and necessity of the interventions at the early stage for early term and late preterm infants who had suspected neurodevelopmental delay. Risks that have been revealed in previous studies include respiratory morbidity, diabetes, obesity-related disorders, long-term developmental outcomes, and even mortality in infancy, childhood, and young adulthood [+ 6 weeks of gestation) is also under-recognized, while previous studies are mainly focused on health outcomes of extremely preterm infants (less than 28 weeks of gestation) [Preterm birth (less than 37 weeks of gestation) is generally recognized as a major cause of neonatal morbidity and mortality . Howeverstation) .Notably, early term and late preterm births have been prevalent worldwide in recent years. It is estimated that early term and late preterm births account for 15 to 31% and 3 to 6% of all live-born infants, respectively , 12. DesGiven the limited reports and the existing inconclusive results on the impact of early term and late preterm birth on neurodevelopment during early infancy, this study aimed to investigate the effect of early term and late preterm birth on infants’ neurodevelopment within 6 months through a cohort study in Wuhan, China.+ 6 weeks of gestation at Wuhan Children’s Hospital between October 2012 and September 2013, without congenital anomalies, were eligible for inclusion in this study.Participants of this study were derived from a prospective birth cohort study conducted in Wuhan, China, which was designed to investigate prenatal and postnatal risk factors related to child health. Live singleton infants born within 34–41n = 8). In the statistical analysis stage, 4243 infants were incorporated after excluding 196 participants who had incomplete demographic information or health records within 6 months. The Medical Ethics Committee of Wuhan Children’s Hospital  approved the research protocol, and all the procedures involved in this study were executed following the approved guidelines. Informed consent was obtained from the mothers of infants at their first antenatal examination.Initially, a total of 4439 infants met the eligibility criteria after excluding those who refused to accept this routine neurodevelopmental survey  was extracted from the delivery record, calculated by the date of delivery and the last recorded menstrual period, and was ascertained by ultrasound examination. According to the GA, infants were categorized as late preterm birth (34 weeks 0 day to 36 weeks 6 days gestation), early term birth (37 weeks 0 day to 38 weeks 6 days gestation), and full term birth (39 weeks 0 day to 41 weeks 6 days gestation) .In this study, the Gesell Developmental Scale (GDS) was conducted to evaluate the neurodevelopment of the infants. The GDS, developed by Gesell and Amatruda, is widely used for child neurodevelopmental diagnosis and intellectual evaluation worldwide . The ChiThe score in each domain is expressed by developmental quotient (DQ), calculated as below: children’s estimated developmental age/ chronologic age× 100. According to the Chinese norm, the neurodevelopmental delay of each domain was defined as the DQ score below 85 . Four stInformation about the number of prenatal examinations, parity, mode of delivery, infant’s gender, birth weight, and neonatal asphyxia situation were derived from the delivery record. The socioeconomic factors such as maternal and paternal education level and infant’s feeding pattern were attained by questionnaire.ORs) and 95% confidence intervals (CIs) for the associations between GA and neurodevelopmental delay in each domain. In GLM and logistic regression analyses, we adjusted for the potential confounders, including parental education level, number of prenatal examinations, parity, mode of delivery, gender of infants, birth weight, neonatal asphyxia, and feeding pattern. In the further stratified analyses by infant’s gender, we evaluated the potential interactions between gender and GA by supplementing the relevant cross-product terms in the logistic regression models. All statistical analyses in this study were conducted using SAS, version 9.4 , and P-value < 0.05 was considered statistically significant.Mean and standard deviation or frequency and percentage were used to describe the characteristics of the study participants. For each infant, the DQ of the five domains was calculated, and neurodevelopment of each domain was classified into delay (DQ < 85) and normal (DQ ≥ 85) accordingly. One-way analysis of variance (ANOVA) was conducted to compare the mean of DQ of each domain among different GA groups. The generalized linear model (GLM) was used to analyze the prediction of DQ associated with gestational age with adjustment potential confounding factors. Unconditional logistic regression was utilized to calculate the odds ratios (P < 0.01).The distribution of demographic characteristics of participants in this study is shown in Table P < 0.01), and lower than full term infants (P < 0.01). The GLM analysis indicated that late preterm birth was significantly associated with decreased DQ in all domains: gross motor , fine motor , adaptability , language  and social behavior . For early term birth, the statistically significant negative trend was only shown in the DQ of fine motor .Table OR = 3.82, 95% CI: 2.67 to 5.46), fine motor  and adaptability , whereas early term birth was significantly associated with delayed neurodevelopment in fine motor .Results of neurodevelopmental delay in different domains and the association with late preterm birth/early term birth are presented in Table OR = 4.30, 95% CI: 2.75 to 6.71), fine motor , and adaptability ; late preterm girls had a higher risk of neurodevelopment delay in 2 domains: gross motor  and fine motor . As for early term infants, the significant association was only found with fine motor development delay among girls . The crude OR showed that late preterm birth was significantly associated with language delay among girls . However, the association was no longer significant after adjusting for the potential confounding factors.We further explored the associations of late preterm birth and early term birth with neurodevelopment delay of different domains stratified by infants’ gender. As shown in Table Table In this study, we explored the impact of early term and late preterm birth on the neurodevelopment of infants within 6 months. Our results indicated that late preterm birth was associated with decreased DQ in all neurological domains, and early term birth was associated with decreased DQ in the fine motor. Moreover, late preterm birth had an elevated risk of neurodevelopmental delay in gross motor, fine motor, and adaptability domains. In contrast, early term birth only showed an increased risk of developmental delay in the fine motor.0/7 and 400/7 gestational weeks is a critical period for immature brain growth, in which cortical and white matter volumes are multiplied by two and five, respectively [0/7 and 380/7 gestational weeks is included in the critical period, the association between early term birth and neurodevelopmental delay may be also explained [According to the Fetal Origins Hypothesis, the fetal intrauterine environment, associated with gestational length, has profound and long-term effects on children’s health and development . Our curectively . While explained .Additionally, the prior study has shown a linear correlation between gestational age and birth fetal brain volume , supportThe present study found that late preterm birth mainly influenced infants’ neurodevelopmental delay of gross motor, fine motor, and adaptability during the early stage. In contrast, early term birth was associated with neurodevelopmental delay of fine motor. These findings may suggest that there may be different potential mechanisms under the impact of gestational age for different neurodevelopmental domains, and different neurodevelopmental modules may have different developmental critical periods. It has been shown that sensory axons are usually myelinated before motor axons, and myelination generally extends from the center to the periphery, from the dorsal to the ventral . It seemFurther, we investigated the influence of late preterm birth and early term birth with neurodevelopmental delay stratified by infants’ gender. Late preterm birth was associated with a higher risk of delay in 3 domains  in boys. In contrast, adaptability developmental delay was not observed among late preterm girls. Moreover, the association of early term birth with fine motor developmental delay was only detected in girls. Prior studies have shown that fetal gender may play an essential role in regulating the influence of prenatal exposure on neurodevelopment , 42. MalThe main strength of this study is the relatively large sample size compared with previous studies, which included information collected from pregnancy through 6 months after birth. Moreover, we were able to adjust for some potential confounding factors that may impact infants’ neurodevelopment in the present study. Furthermore, the assessment of infants’ neurodevelopment was under strict quality control, making the results more reliable. However, several limitations of this study need to be concerned. First, infants’ neurodevelopment was only assessed within 6 months in this study. As individual neuropsychological development is a long-term process and can be affected by various biological and psychosocial factors, further follow-up is required to identify the neurodevelopmental status of early term and late preterm birth infants in the future. Second, the participants in this study came from a single center of tertiary hospital, limiting our findings’ generalizability to the broader population. Third, although the revised GDS is widely used for neurodevelopmental assessment and diagnosis in China, it is not commonly used in western countries, which increases the difficulty of comparing the results among different studies worldwide.In conclusion, we conducted a prospective cohort study in Wuhan, China to evaluate the impact of early term and late preterm birth on infants’ neurodevelopment at the early stage, and found the evidence that late preterm birth mainly elevated the risk of neurodevelopmental delay of gross motor, fine motor, and adaptability. In contrast, early term birth was associated with an increased risk of fine motor developmental delay within 6 months. We found that longer gestation benefits the infants’ gross and fine motor development at an early stage even among term infants. Further research is needed to determine the effectiveness and necessity of the interventions at the early stage for early term and late preterm infants who had suspected neurodevelopmental delay.


A pre-weaned Zaraibi goat kid’s body weight gain and survival are complex traits affected by the maternal ability of the doe and the kid’s capability for rapid growth and survival, in addition to the management tactics and environmental variables during the postnatal period. In this study, we investigate the effect of some potential maternal, postnatal, and management-related factors, including sex, litter size, birth weight, daily milk yield, parity, kidding year, and kidding season. The effects of these factors on both the daily body weight (ADG) gain and survivability of Zaraibi (Nubian) kids during the suckling period are studied. The body weight gain for kids was influenced significantly by all the aforementioned factors, except for the kidding season. The framework of the survival analysis revealed that the male kids experienced a greater risk of death compared with the female kids. The single-born kids were at a lower risk of death compared with two or more kids born in a litter. Survival rates increased steadily along with the increase in the mother’s daily milk yield and the dam’s parity number. There was a decrease in the probability of mortality with each passing year. In practice, monitoring traits that indicate an imbalance in milk and that could lower the body weight of the kid could promote the identification of kids with a higher risk of death and the inability to achieve the required body weight gain.During the early period of an animal’s life, rapid growth and higher survival rates can provide more profits to producers by minimizing the rearing and replacement costs. The present study aimed to investigate the effect of some maternal, postnatal, and management-related factors , as well as the kidding year and season on both the average daily weight gain (ADG) and survivability of suckling Zaraibi goat kids during the postnatal period. A total of 3005 kidding events were available from the herd of Zaraibi goats raised at El-Serw Experimental Station from 2008 to 2014, which belongs to the Animal Production Research Institute. Data revealed that the overall ADG was 131.14 ± 2.34, 94.22 ± 2.21, and 85.63 ± 2.33 g/day, whereas the survival rates were 94.68%, 91.81%, and 90.62% during the periods from birth to 1, 2, and 3 months, respectively. During all periods considered, the aforementioned maternal, postnatal, and management-related factors significantly affected the ADG. In males, the ADG increased compared with females. Singletons had a higher ADG compared with kids born to a litter of two or more. A higher KBW and DMY were associated with an increase in the ADG. Additionally, increasing the parity order was associated with an increased ADG. The kidding season did not have a significant effect on the ADG, whereas the kidding year showed a significant effect on the ADG. During the pre-weaning period, the hazard of death increased by 23.1% (hazard ratio (HR) = 1.231; 95% CI = 0.972–2.057) in males compared with females in terms of survival rates. A higher LS was associated with an increase in the incidence of mortality, increasing by 51.6%  with each unit increase in the LS. Additionally, the KBW was an extremely important determinant of survivability, as the risk of death decreased by 62.8%  with the increase in the KBW. Likewise, survival rates increased steadily along with an increase in both the DMY and parity number. The risk of death decreased by 52.7%  and 38.2%  with the increase in the DMY and parity number, respectively. The kidding season did not significantly affect the kid’s survivability, but with each passing year, there was a decrease of 2.8%  in the probability of mortality. In conclusion, better growth and survival rates can be achieved by controlling the maternal, postnatal, and management-related factors, as well as upgrading management plans. Goat farms have the potential to flourish when fostered by the systems of an intensive or semi-intensive nature, which work as a stimulus for commercial goat production. Under the organized management of farms, losses occur because of various causes of death. Thus, some economic productive and reproductive traits have to be improved under these systems to sustain the productivity of the herd . Among tZaraibi goats are considered to be one of the well-known native Egyptian breeds, also called Egyptian Nubian goats. This breed is widely kept in Egypt and the Near East region because of their distinguished productive and reproductive traits, such as being highly prolific and producing sufficient amounts of high-quality milk and meat. The average body weight of a Zaraibi goat is 25–50 kg. It produces 150–300 kg of milk each season, and its rate of producing twins is approximately 2.5%. Therefore, the Zaraibi breed of goats has become a target for a genetic improvement scheme. Early growth is an important factor in gaining profits via meat production ,5.Published studies on Zaraibi kids under Egyptian management conditions are scarce, although several studies have identified the factors related to the performance of animal growth and the survivability of suckling kids and lambs. To address this data gap, the present study was devoted to exploring the potential effect of some maternal, postnatal, and management-related factors including sex, the litter size (LS), the birth weight (BW), the daily milk yield (DMY), and the parity number (PA), as well as the kidding season (SE) and the year (Y), on the growth rates and survivability of Zaraibi kids during the pre-weaning period. Moreover, to the best of our knowledge, this is the first study that used the product-limit method of Kaplan and Meier  to estimate the survival rates of Zaraibi suckling goat kids under Egyptian conditions. Usually, the limitation in the analysis of such a variable is related to data availability through the time for each individual. Time progress is the main basis for survival analysis, that is characterized by a certain relationship between the two events through the time . For this reason, survival analysis is adopted to tackle the lack of data related to a certain event. The survival analysis can efficiently tackle the issue of censoring as its main variable, other than time, and it also addresses whether the expected event happened or not. This advantage is important for studying events such as a mortality rate in livestock farms, which is time dependent. Applying survival analysis allows for the use of records from surviving (censored) and dead (uncensored) animals/kids, as both records can be used jointly and introduced into the analysis, therefore all the available data about the animals/kids are properly used ,7. The oTrifolium alexandrinum) was offered in winter and spring, whereas clover hay was provided in summer and fall, with crop stubble or rice straw as an addition or a substitute. Fresh water and mineral blocks were consistently offered. The nulliparous doe begins mating approximately at 15 months of age with an average body weight of 30–35 kg. A flushing period of 2 weeks premating was applied, during which a 0.25 kg/doe/day concentrate supplement was offered. From pre-parturition to the first week of lactation, the concentrate supplement was offered again for 2–4 weeks. Two breeding seasons were launched every year where half the number of the does were introduced to bucks in autumn and had their kids in the spring and the other half were introduced to bucks in the spring and had kids in autumn. Random selections were conducted to split the does into groups during each breeding season. A group of 25–30 does were given to each fertile buck. To prevent inbreeding, each buck was allowed to mate with the same does for only two seasons. After those two seasons, another buck from the same flock was substituted. Once the kids were born, the newborns instantly received nutrition in the form of the mother’s secreted colostrum, and iodine dye was applied to the wound that remained after the umbilical cord was removed. To establish the mother–kid bond, they were not separated from each other for 3 months postpartum, and the next step was to transfer the dams and young kids to individual pens for 3 to 4 days. Identification numbers were given to the newborn kids who did not die within 2 to 4 h after birth. Cases other than these were categorized as either a stillbirth or neonatal death. Following the complete drying of the body, the live BW of the newborn kids was recorded within a maximum of 6 h after the birth and then at monthly intervals by using a digital balance. The individual milk yield was determined on a weekly basis by keeping the newborn kids in separate pens for 20 h and milking the goats by hand until the udder was empty throughout the suckling period. The milk yield of each goat was recorded and multiplied with a correction factor of 1.2 to obtain the DMY , where FBW is the body weight at the end of each month and IBW is the initial body weight or BW. A MIXED procedure  was useijklmnop is the ADG, μ is the overall mean, Anii is the effect of ith animal ID, Sj is the effect of jth sex , LSk is the effect of kth litter size , KBWl is the effect of lth birth weight of a kid , DMYm is the effect of mth DMY , SEn is the effect of the nth kidding season (two levels: spring and autumn), PAo is the effect of the oth parity , Yp is the effect of the kidding year (2008–2014), and eijklmnop is the random error related to each observation. The differences between the means were detected according to Duncan’s Multiple Range Test [i is the periods considered at any point i, di is mortality till point i, and ni is the number of kids exposed to risk just prior to ti. The Cox proportional hazard model was used in the study through PROC PHREG of the statistical analysis system to study the effects of the potential risk factors on survival rates [The statistical model was incorporated as the following:nge Test . A multinge Test  was usedi1 is the covariate value for covariate 1 for individual i, etc. The mortality rates were calculated as the number of dead kids divided by the total number of kids born, whereas survival rates were calculated as the number of live kids (censored) divided by the total number of kids born. Statistical significance was set at a p-value of <0.05.The previous equation can be fitted as a linear fixed-effects proportional hazard model by taking natural logarithms as follows:function . Β1, β2 p < 0.05) compared with triplets or more. It is noteworthy that the higher the KBW, the higher the ADG during the suckling periods, and the differences in the ADG per day between suckling kids with an average KBW of 1.5 and 2 kg were not significant (p > 0.05) during the first month of life, whereas a significant difference (p < 0.05) was observed during the second and third months that was in favor of the kids with an initial body weight of 2 kg. Additionally, the daily milk yield had a significant effect on the ADG of suckling kids during the postnatal periods until the second month, and the non-significant differences (p > 0.05) were shown between kids born to does with the DMY in the category of 800–1000 g, and those with a milk yield more than 1000 g. Does in their fourth and fifth parities had suckling kids with an ADG significantly higher during all suckling stages than kids who were born to primiparous does. The Y significantly affected the ADG over all suckling periods with a significant increase being observed during the latest years. However, the SE did not have a significant effect on the ADG at any period from birth to weaning.The sex, LS, KBW, DMY, SE, PA, and Y were studied to ascertain their effects on the ADG of Zaraibi suckling kids . The ADGThe relative importance of the maternal, postnatal, and management-related factors is presented in The survival functions related to the three suckling periods according to the Kaplan–Meier method are presented in p = 0.9994 and 0.4175, respectively), but it had a tendency to affect (p = 0.0843) the kids during the third month. Collectively, the probability of male death increased by 23.1% (HR = 1.231) during the whole suckling period compared with females. Similarly, PA did not have significant effects (p = 0.1524) on the hazard of death in kids during the period from birth to 1 month, whereas it tended to affect the hazard of death during the periods from birth to 2 and 3 months . The probability of the occurrence of mortality decreased by 29.8% (HR = 0.702) and 38.2% (HR = 0.618), respectively. The Y significantly affected the hazard rate during all studied periods. There was a decrease in the probability of mortality in kids with each passing year by decreasing factors of 0.976, 0.975, and 0.972 during the periods from birth to the first, second, and third months, respectively. The SE had an insignificant effect on the mortality rate of kids during all postnatal periods until weaning, contrary to the results observed for the kidding year.The two most important economic traits that concern goat holders are the growth performance and survivability of suckling kids ,14. GrowThe studied maternal and prenatal factors including the S, LS, KBW, DMY, and PA had significant effects on the ADG of suckling kids according to the present results. Male kids outgrew the females throughout all of the different life stages ,16. The p < 0.001) from the first lactation onwards. In this study, the highest values were for those born to mothers in later lactation seasons (124 g milk/day), whereas the lowest growth rate was observed for kids born to the youngest does (106.5 g milk/day).During the period from birth to weaning, the growth of neonates mainly depends on the milk yield of their dams. Therefore, the offspring’s growth rate is directly influenced by both the quantity and quality of suckled milk during this period . In the Several studies have shown the significant effects of PA on the early growth performance of kids from different goat breeds , followed by the second 86/282, 30.49%) and third months . Similar results were observed in previous studies conducted on kids and lambs, where approximately 69% of all the pre-weaning mortality of kids  and appr.49% and The present study showed that the LS was associated with a higher risk of death with each unit increase with respect to parity. The lower mortality rate in singletons compared with that in twins and triplets may be attributed to the absence of aggressive behavior and competition between animals for suckled milk ,37. By cp = 0.051) by 38.2% during the whole suckling period with an increase in the parity numbers. These data are in agreement with those obtained by El-Abid and Abu Nikhaila [Regarding the effects of parity order, the results of this study showed that the risk of death in suckling kids tended to decrease  to increase by 23.1% in male kids compared with that in females during the whole suckling period. Similar results were found for Harnali lamb using survival analysis for estimating lamb survival up to weaning [In the present study, the risk of mortality tended ( weaning . Sawalha weaning  reported weaning  found th weaning  did not  weaning . Moreove weaning . Thus, m weaning .Regarding the kidding year and season, our data revealed that with each passing year, there has been a decrease in the probability of 2.4, 2.5, and 2.8% for death in kids during the periods from birth to 30, 60, and 90 days, respectively. These results could be explained by the overall improvement in the administration systems in the later years. Our results agreed with the findings of Chauhan et al. [The information generated from the multivariate analysis and Cox regression model in the present study showed that sex, birth weight, litter size, parity, and milk yield were the most important risk factors for the average daily weight gain and survival rate of suckling Zaraibi kids during the pre-weaning period. The control of these factors early at the first month of a kids’ age might minimize later losses in goat kids related to productive wastes either due to a low average daily weight gain or due to the survivability of neonates, as the highest average daily weight gain and mortality rates were observed at this age. There is a scope for increasing the birth weight and milk yield, e.g., through the improved nutrition of the dam. Moreover, special attention and specific management practices should be given for females at their earlier parties and multi-born kids.


Functional gastrointestinal disorders (FGIDs) are defined as a variable combination of chronic or recurrent gastrointestinal symptoms that are not explained by structural or biochemical abnormalities. Their relationship with prematurity has been increasingly studied. To compare the frequency of FGIDs in preterm and term infants and to evaluate whether invasive procedures during the neonatal period in preterm infants are associated with greater likelihood of FGIDs in the first two years of life. Controlled nested cross-sectional study conducted in a Brazilian university hospital. This was a controlled nested cross-sectional study on a retrospective cohort of infants born preterm who were compared with infants born at term regarding the presence of FGIDs. Medical consultations were conducted by a single pediatric gastroenterologist to obtain information on the gestational and neonatal periods and on clinical manifestations of the digestive tract. The Rome IV criteria for the diagnosis of FGIDs were used. A total of 197 infants (< 24 months), including 99 preterm and 98 term infants, were studied. Infant regurgitation was more prevalent in term infants . The frequencies of other FGIDs  in preterm infants did not differ from those of term infants (P > 0.05). No relationship was found between invasive procedures during the neonatal period and development of FGIDs in preterm infants. Infants born preterm did not have higher frequency of FGIDs in the first two years of life. The secondary objective was to evaluate whether there was any association between sociodemographic variables and invasive procedures during the neonatal period and the development of FGIDs in preterm infants during their infancy.This was a controlled nested cross-sectional study in a retrospective cohort of premature infants who were compared with a group of full-term babies, with regard to the presence of FGIDs.All infants in both groups underwent a consultation with a pediatric gastroenterologist. In the consultation, information on the infant’s gestational and neonatal history and any occurrence of gastrointestinal symptoms was obtained, and a complete physical examination was performed. The Rome IV criteria were used to characterize FGIDs.Infants were included after their guardians had agreed to participate in the study and had signed an informed consent statement. The project was approved by the Research Ethics Committee of the Universidade Federal de São Paulo (UNIFESP) under CAAE no. 66233517.0.0000.5505, on May 5, 2017.All preterm infants seen consecutively at the Preterm Outpatient Clinic of the Neonatal Pediatric Division of the Department of Pediatrics of Escola Paulista de Medicina (EPM), UNIFESP, during the study period (2017-2019), were recruited. The following inclusion criteria were adopted: gestational age less than 37 weeks and current corrected age at the time of the study of between 30 days and 24 months.The group of full-term infants (aged 30 days to 24 months) was recruited from a primary care unit and an immunization center, both in the metropolitan region of São Paulo. Infants born at a gestational age greater than or equal to 37 weeks and a birth weight > 2500 g were included.The following exclusion criteria were used for both groups: previous abdominal surgery, presence of past or current gastrointestinal tract disease, cerebral palsy, severe congenital malformations and presence of an alternative feeding route  or tracheostomy.st curve.Records containing information on the cohort of preterm infants since their birth are kept at the Preterm Outpatient Clinic of the Neonatal Pediatric Division of Escola Paulista de Medicina (EPM). Thus, data were collected regarding the gestational period (parity and age of the mother and complications during pregnancy) and neonatal period . The weight-for-gestational age was classified in accordance with the INTERGROWTH-21For the full-term infants, these data were obtained from the maternity discharge summary in the child’s health record or, in the absence of these documents, from information provided by the mother or guardian.Socioeconomic class was evaluated based on the points system of the Brazil Criterion version 2015 of the Brazilian Association of Survey Companies .Pediatric consultations for the infants in both groups were conducted by a single pediatric gastroenterologist. The frequency of regurgitation and its warning signs , daily duration of crying and irritability, presence and duration of efforts to evacuate, frequency of evacuation, stool consistency, presence of pain when evacuating and any history of fecal impaction were recorded. Considering these clinical characteristics, the diagnosis of FGIDs was established in accordance with the Rome IV criteriaDuring the consultation with the pediatric gastroenterologist, the following information was also collected: history of previous infection ; family history of gastrointestinal disorders; current type of breastfeeding ; and current use of medications .Regarding the family history of gastrointestinal disorders, information was collected about any family history (among parents and first-degree siblings) of chronic constipation, abdominal pain or gastroesophageal reflux.A physical examination was performed, and the results, including weight and length, were recorded. Weight was measured using a Welmy digital pediatric scale  among the term infants; and using a Filizola Baby digital pediatric scale  among the preterm infants. Length was measured using a child stadiometer (0-99 cm). Weight-for-age, height-for-age and body mass index-for-age Z scores were calculated using the Anthro software, version 3.2.2 .The qualitative variables and occurrence of FGIDs in both groups (preterm and full-term infants) were compared using the chi-square test or Fisher’s exact test. Regarding the quantitative variables, Student’s t test was used to compare the mean ± standard deviation when the data were normally distributed; otherwise, the median and first and third quartiles were compared using the Mann-Whitney test. When necessary, a logistic regression model adjusted for age was used. The results from the logistic regression were presented as the odds ratio (OR) and respective 95% confidence interval (95% CI).All analyses were performed using STATA/SE 15.1 for Windows . P-values < 0.05 were considered statistically significant.The study included 103 infants who were born preterm. Among these, four were excluded because they had a gastrointestinal tract disease . The group of infants born full term consisted of 99 infants, and one was excluded due to gastroesophageal reflux disease. Thus, 99 infants born preterm and 98 born full term were studied. In the preterm group, the current corrected age was used.The frequency of infant regurgitation was higher in term infants than in preterm infants . Among tFor regurgitation, we also did a separate analysis according to semester for the two groups, with the following results. Regarding regurgitation among infants < 6 months, 7/34 (18.9%) of the premature infants and 25/55 (45.6%) of the term infants had regurgitation. When analyzed using the chi-square test, we found a statistical difference between the groups, with P = 0.032, i.e. those born at term continued to present a higher prevalence of regurgitation even when analyzed according to semester. Regarding regurgitation among infants > 6 months, this was present in 3/30 (10%) of the preterm infants and 1/19 (5.53%) of the term infants. As expected, the prevalence of regurgitation in the second age category was low in both groups.Despite the higher frequencies of infant colic, functional constipation, functional diarrhea and infant dyschezia in the group of preterm infants, the differences were not significant. When the presence of at least one FGID was evaluated, no difference was observed between the groups .In the group of preterm infants, the association between sociodemographic variables and neonatal factors (including invasive procedures) and FGIDs was studied. The factors of sex, method of delivery, gestational age, birth weight, SGA, resuscitation in the delivery room, orotracheal intubation, arterial or venous umbilical catheterization, use of an orogastric tube, blood transfusion, use of parenteral nutrition, presence of sepsis, use of antibiotic in the neonatal period and length of hospital stay did not show any relationships (P > 0.05) with occurrences of infant regurgitation, infantile colic, functional diarrhea, dyschezia or constipation.When necessary, the guardians of infants with an FGID were instructed by the researcher regarding specific therapeutic measures. Infants with more severe clinical manifestations were referred for evaluation and follow-up at the outpatient clinic of the Pediatric Gastroenterology Division of UNIFESP.,,In our study, higher frequency of FGIDs among preterm infants or those with a history of invasive neonatal procedures was not observed. A recent American study,There are few studies in the literature comparing the prevalence of FGIDs among infants born preterm with that of infants born full term. A prospective studyHowever, the multivariate analysis  showed tAlthough there was no significant difference in the frequency of infant colic in our study, it was higher among preterm infants. This was also observed in the Italian study.The higher frequency of infant colic among preterm infants may be related to changes in gastrointestinal motility, lower production of gastric acid and proteolytic enzymes and lower concentrations of secretory immunoglobulin A (IgA) and antimicrobial peptides in the gastrointestinal tract, which increase the risk of dysbiosis.The recent observation that use of antibiotics may cause predisposition to dysbiosis and, thus, to greater odds of developing FGIDs may be included in this context. In our study, we reviewed data on antibiotic use in the neonatal unit: among the 63 preterm infants who used antibiotics during the neonatal period, 21 (33.3%) developed FGID. Neither of the two preterm infants who did not use antibiotics developed any FGID. We used Fisher’s exact test to analyze these data and did not find any relationship between antibiotic use during the neonatal period in the preterm group and future development of any FGID (P = 1.00).We found higher frequency of constipation among preterm infants than among term infants (17.2% versus 9.2%), but the difference was not significant (P = 0.098). It is worth noting that for a significant difference to be achieved , it would have been necessary to include 361 patients in each group, which would have been unfeasible from an operational point of view. A study conducted in DenmarkThe only studyRegarding dyschezia, the findings from our study also contradicted the expectation of higher frequency among preterm infants: the rates found were 9.3% among preterm infants and 7.5% among term infants (P = 0.735). Dyschezia is a functional disorder that has been little investigated, with few studies in the literature. It results from lack of coordination between increased abdominal pressure and pelvic floor relaxation during bowel movements.We also investigated whether neonatal factors in the group of preterm infants, including invasive diagnostic and therapeutic procedures that were experienced during the neonatal period, could contribute to development of FGIDs. Orotracheal intubation, use of venous or arterial umbilical catheters, use of an orogastric tube, parenteral nutrition, length of hospital stay, type of delivery, history of sepsis, gestational age, birth weight and weight for gestational age classification were some of the factors analyzed. Although it has been suggested in the literatureOur study had some limitations, such as the small number of infants included in the independent analysis on each of the five FGIDs, according to the age ranges recommended through the Rome IV criteria. For example, we included a total of 99 preterm infants in our study, but only 64 were analyzed regarding the presence of regurgitation (infants up to 12 months of age). Moreover, the number of preterm infants with FGIDs was small, which may have compromised the analysis on the relationship between invasive diagnostic and therapeutic procedures and the development of FGIDs. Other limitations were the cross-sectional nature of the study, which did not allow characterization of all FGIDs that had occurred or would occur during the first two years of life, and our use of a sample consisting of all patients consecutively treated at the outpatient clinic, which prevented calculation of the prevalence in a probabilistic sample.On the other hand, the strength of our study was that it was the first to compare the frequency of FGIDs among preterm infants with their frequency among full-term infants using a comparative design and face-to-face consultations in which the Rome IV criteria were used. These face-to-face consultations decreased the risk of understanding bias, which can occur in studies that use only questionnaires. A physical examination was also performed on all the infants, which enabled a more complete assessment that, in addition to inclusion of weight and length data, helped establish the diagnosis of FGIDs.We did not find any evidence of higher frequency of FGIDs among preterm infants than among infants born full term, during the first two years of life. In contrast, we found higher frequency of regurgitation among infants born full term than among preterm infants. In addition, there was no relationship between invasive diagnostic and therapeutic procedures performed during the neonatal period among infants born preterm and development of FGIDs during infancy.


The Baby-Friendly Hospital Initiative’s Step 4 recommends: “support mothers to start breastfeeding as soon as possible after birth”, thus contributing to the reduction of neonatal mortality. The objective of this study is to estimate the prevalence of breastfeeding in the first hour of life in private maternity hospitals participating in the “Adequate Childbirth Project”, a quality-of-care improvement project, and to analyze determinants of this outcome.Secondary analysis of data collected by the cross-sectional evaluative “Healthy Birth Study”, conducted in 2017 in 12 maternity hospitals participating in the Adequate Childbirth Project, where 4800 mothers were interviewed, and hospital records were observed. Conditions that prevented breastfeeding at birth, such as maternal HIV-infection and newborns’ severe malformations, were excluded. Multiple logistic regression was performed according to a hierarchical theoretical model.The prevalence of breastfeeding in the first hour of life was 58% (CI 95% 56.6–59.5%). Lower maternal education , lower economic status , cesarean section delivery , preterm birth  and non-rooming-in at birth  were negatively associated with the outcome. Receiving information during prenatal care about the importance of breastfeeding at birth , being target of the quality-of-care improvement project , skin-to-skin contact at birth  and female newborn  were factors positively associated with the outcome.The private maternities participating in the Healthy Birth Study showed a good prevalence of breastfeeding in the first hour of life, according to WHO parameters. Prenatal guidance on breastfeeding at birth, being target of the quality-of-care improvement project and skin-to-skin contact at birth contributed to breastfeeding in the first hour of life. Breastfeeding reduces deaths of children under 5 years of age by 13% . Even inBreastfeeding at birth prevents the colonization of child’s gastrointestinal tract by gram-negative bacteria in the hospital environment. Colostrum contains immunological factors that protect the newborn and stimulate his active immune response . A studyThe Baby-Friendly Hospital Initiative motivates facilities providing maternity and newborn services worldwide to implement the Ten Steps to Successful Breastfeeding. Step 4 recommends: “Facilitate immediate and uninterrupted skin-to-skin contact and support mothers to initiate breastfeeding as soon as possible after birth”. The skin-to-skin contact should remain after birth for at least one hour, mothers being encouraged to identify whether the baby shows signs of wanting to be breastfed, and help should be offered, if necessary . This waSystematic reviews , 14 poinThe high contribution of the Brazilian private sector to the performance of cesarean sections and consequent neonatal outcomes stimulated the creation of the “Adequate Childbirth Project”, aiming at prenatal and childbirth care improvement and reduction of the number of cesarean sections and hospitalizations in neonatal ICU . The proIn Brazil, 30% of mothers give birth in the private sector, but private maternity hospitals breastfeeding practices, specially at birth, as well the factors associated with these practices, are seldom studied. The present study innovates investigating the prevalence of breastfeeding in the first hour of life in private maternity hospitals participating in a quality-of-care improvement project and analyzed the determinants of this outcome.This study is a secondary analysis of data collected by the Healthy Birth Study, a cross-sectional evaluative investigation carried out in 2017, 18 months after the beginning of the implementation of the Adequate Childbirth Project (ACP).The Healthy Birth Study selected a convenience sample of 12 hospitals from the 23 private hospitals that joined the project to improve prenatal and childbirth care. For the selection of these hospitals, three criteria were considered: location of the hospital by geographic macro-region , type of hospital  and performance of the hospital in the prenatal and childbirth care improvement project  . Among tThe Healthy Birth Study’s sample was calculated to detect a 10% reduction in the proportion of cesarean sections, using a 50% cesarean rate as a reference, with 80% power and a 5% significance level. Overall, the sample size of 4800 women  had an accuracy of 80% in detecting a 2.5% reduction in the prevalence of cesarean sections. Losses and refusals accounted for about 5% of women and were replenished to complete 400 women in each hospital.Electronic forms using the REDCap  applicatTrained interviewers, external from the hospitals, conducted data collection, addressing all women admitted to the hospital who met the eligibility criteria to participate in the study, until 400 participants were included in each hospital. Women who did not speak Portuguese, with hearing loss, whose delivery occurred outside the hospital and who were hospitalized for judicial termination of pregnancy were not eligible for the study. The women were interviewed face to face at least 6 h after vaginal delivery and 12 h after cesarean section, after reading and signing an informed consent form.Three instruments were used: 1. questionnaire applied to the puerperal woman with questions related to maternal characteristics, pregnancy and prenatal care, childbirth care, newborn and infant feeding; 2. form for extracting data from the medical record of the puerperal woman and the newborn about the type of pregnancy, type of delivery, condition of the newborn and feeding of the newborn during hospitalization; 3. form for extracting data from the prenatal card .In prolonged hospitalizations, data were collected from medical records until the 28th day of infant hospitalization and on the woman's 42nd day of hospitalization. In the case of hospital transfer, data were obtained from the medical records of the hospital from which the puerperal woman and/or the newborn were discharged. Data collection was conducted from March to August 2017. Due to the variation in the size of hospitals, the time required for data collection ranged from 1 to 4 months, depending on the total number of births per month in each participating hospital .The present study used as inclusion criteria living newborns with gestational age ≥ 34 weeks (stillborns: n = 19). Newborns or women who met one or more of the following criteria were excluded: newborns with malformations that could disturb or prevent breastfeeding , sons of HIV-infected mothers (n = 6), postpartum women with severe maternal morbidity or transferred to the Intensive Care Unit (ICU) due to complications during delivery (n = 244) and babies transferred to the ICU at birth (n = 527).The excluded malformations were severe congenital heart disease, Down syndrome, craniofrontonasal syndrome, hydrocephalus, cleft lip or soft palate cleft, pulmonary cystic adenomatosis, corpus callosum dysgenesis, gastroschisis, diaphragmatic hernia, vermin hipoplasia, omphalocele and Moebius and Robin sequence.A total of 785 women were excluded, and data from 4,093 binomials were analyzed. Post-hoc calculations showed that, considering a prevalence of exclusive breastfeeding of 60% and a significance level of 5%, the sample after the exclusions used in the present analysis had 90% power to detect 5% differences in the proportion of this outcome.The outcome was breastfeeding in the first hour of life (yes/no), obtained from two questions to the puerperal woman: "After birth, did you breastfeed in the delivery room?" and "How long, more or less, did it take you to breastfeed for the first time?" Breastfeeding in the first hour of life was considered when the answer to the first question was “yes” and/or the second covered up to 1 h. A hierarchical theoretical model was adopted, with maternal and household characteristics as distal exposure variables; pregnancy and prenatal care characteristics as intermediary exposure variables and hospital, delivery, and newborn characteristics as proximal exposure variables , self-reported skin color , having a partner , education . Household characteristics were analyzed based on economic conditions  [Different groups of women were target of the Adequate Childbirth Project, as defined by the hospital manager, such as: 1. primiparous women; 2. pregnant women belonging to Robson Groups 1 to 4  becausehttps://www.Ibm.com/), using data weighting and incorporating the design effect, considering the complex sampling process [All statistical analyses were performed using SPSS software version 17  were obtained with their respective 95% confidence intervals (95% CI). The variables that obtained p ≤ 0.20 in the bivariate analysis were included in the statistical modeling. Finally, multiple logistic regression was conducted, following the hierarchical conceptual theoretical model applied, according to the temporal proximity of each variable with the outcome .The prevalence of breastfeeding in the first hour of life was 58.0% (CI 56.6–59.5%). There was a wide variation between hospitals, five maternities with prevalence rates above 80% and three less than 30%. There was also discrepancy within the regions, as both the highest (93.0%) and the lowest prevalence (6.3%) were found in the Southeast Region.Most of the women had ages between 20 and 34 years, were white, lived with a partner, had a high level of education and belonged to economic class B. The distal factors associated with the outcome (p < 0.20) in the bivariate analysis were age, skin color, marital status, education level and socioeconomic class Table .Table 1PConcerning the intermediate characteristics, more than half of the mothers were target of the Adequate Childbirth Project, almost 60% of the women were primiparous, just over a tenth had some pathology , the majority started prenatal care in the first trimester and was accompanied by 8 or more prenatal visits. About three quarters of women received prenatal guidance on breastfeeding at birth. Being target of the Adequate Childbirth Project, maternal pathology, number of prenatal visits, beginning of prenatal care and receiving prenatal guidance on breastfeeding in the first hour of life were associated with the outcome in the bivariate analysis Table .Table 2PMost women had a companion during delivery and more than three quarters underwent cesarean section. Most newborns were born at term, the sex ratio was similar, about 3% had low birth weight and almost 60% had skin-to-skin contact with the mother at birth. The majority (64.2%) of the newborns did not follow to rooming-in directly after birth, staying for a while in a nursery/heated crib/incubator. In bivariate analysis, among proximal characteristics, type of delivery, sex of the baby, preterm birth, low birth weight, skin-to-skin contact with the mother and rooming-in were associated with breastfeeding in the first hour of life , according to WHO parameters . This prDespite the unfavorable scenario of private maternity hospitals, where the practice of elective cesarean section is very high , the quaOther factors were also associated with the outcome. The prevalence of breastfeeding in the first hour of life in women with less than 15 years of schooling was about 35% lower than those with higher schooling. Probably, higher educational levels allow greater access to information on the benefits of breastfeeding at birth , 28. In Receiving prenatal guidance on breastfeeding in the first hour of life more than doubled the prevalence of the outcome. Guidance on breastfeeding during prenatal care proved to be an important factor to improve breastfeeding at birth in several studies , 28–31, Cesarean section was one of the factors most associated with the outcome, in the present study and in other settings, decreasing the prevalence of breastfeeding in the first hour of life by almost 40%. Cesarean section appears as a risk factor  related Female babies were almost 20% more likely to be breastfed in the first hour of life when compared to male babies. Boccolini et al  found a Late preterm newborns  had 35% less chance of being breastfed at birth when compared to those born at term. Vieira et al  argue thSkin-to-skin contact between mother and child at birth doubled the prevalence of breastfeeding in the first hour of life. In Rio de Janeiro, a similar result was observed, hospital routines being one of the reasons that prevent this early contact with the mother . Lau 3333 in a sMore than half of the newborns did not remain rooming-in since birth, not because of the severity of the babies, since only 3.2% of them went to the semi-intensive neonatal unit, about 80.7% being allocated in a nursery/heated crib/incubator after birth. In a Brazilian study, the prevalence of rooming-in in private maternity hospitals was also low (51.3%) . RoomingThe present study has limitations. Cross-sectional studies not always allow the establishment of a causal relationship between exposure variables and the outcome, however, most of the variables studied have a clear temporality relationship with breastfeeding at birth. Intentionally, a convenience sample of private maternity hospitals was adopted, located in three Brazilian regions, not covering the North and Midwest regions, which impairs their representativeness in relation to the private network.We conclude that the private maternity hospitals participating in the Healthy Birth Study had a good prevalence of breastfeeding in the first hour of life, according to WHO parameters . PrenataWe recommend a greater investment in expanding the practice of breastfeeding in the first hour of life, vital for child's health and wellbeing. Improving quality-of-care models should be encouraged, so that the private sector can be supported to reorganize prenatal and childbirth care in a humanization view. Good hospital care practices for childbirth are necessary, with the creation of mechanisms that stimulate vaginal delivery, skin-to-skin contact and immediate rooming-in, to favor breastfeeding at birth.