The development of head shape and volume may reflect neurodevelopmental outcome and therefore is of paramount importance in neonatal care. Here, we compare head morphology in 25 very preterm infants with a birth weight of below 1500 g and / or a gestational age (GA) before 32 completed weeks to 25 term infants with a GA of 37–42 weeks at term equivalent age (TEA) and identify possible risk factors for non-synostotic head shape deformities. For three-dimensional head assessments, a portable stereophotogrammetric device was used. The most common and distinct head shape deformity in preterm infants was dolichocephaly. Severity of dolichocephaly correlated with GA and body weight at TEA but not with other factors such as neonatal morbidity, sex or total duration of respiratory support. Head circumference (HC) and cranial volume (CV) were not significantly different between the preterm and term infant group. Digitally measured HC and the CV significantly correlated even in infants with head shape deformities. Our study shows that stereophotogrammetric head assessment is feasible in all preterm and term infants and provides valuable information on volumetry and comprehensive head shape characteristics. In a small sample of preterm infants, body weight at TEA was identified as a specific risk factor for the development of dolichocephaly. Long-term neurodevelopmental outcome is a key determinant for quality of neonatal care. Neurodevelopment is particularly not only affected by intracerebral lesions such as leucomalacia or hemorrhage but also by brain growth.1, which has been utilized as a clinical endpoint in contemporary trials investigating nutritional support in very preterm infants2. However, measuring the outer circumference of a newborn’s head is a rather crude two-dimensional (2D) surrogate parameter to assess brain volume.Head circumference (HC) has been established as a marker reflecting brain development3. For deformational plagiocephaly and brachycephaly for example, an—not necessarily causal—association between the degree of deformity and poorer neurocognitive performance has been shown. This suggests that assessment of head shape deformity may help to identify children at risk for developmental delay3. Further issues include asymmetry of the temporomandibular complex with ear shifting, facial asymmetry and malocclusion, the latter being a risk factor for dental caries, traumatic dental injuries and problems of the temporomandibular joint6. Notably, there is no evidence that HC is a trustworthy parameter in infants with head shape deformities.Symmetry of a head’s morphology is presumably a more comprehensive measure reflecting head development during early life. Both symmetrical and asymmetrical non-synostotic head shape deformities do not only represent a cosmetic problem but may also cause functional impairment such as developmental delay7. Known risk factors include pre-, peri- and postnatal parameters as well as male sex, multiple birth, and being a firstborn infant8. Moreover, preterm infants have been shown to feature a particular risk for the development of microcephaly9 and head shape deformities during the first weeks of life11 and infancy12. These findings have been associated with an impaired neurodevelopmental outcome13.Recent research projects in both preterm and healthy term infants shed a light on important aspects such as the detection of risk factors, standardized classification, prevalence and assessment tools for head shape deformities14. To overcome this gap, we recently reported the feasibility of a portable and non-invasive stereophotogrammetric head shape assessment device in preterm infants that serves as a translation of this imaging technology from orthodontics into neonatal care15. Before our report, to the best of our knowledge, stereophotogrammetry has been used in head assessment in infants from four months of age16. As the present knowledge is still very limited in newborns and infants, our study aims are to present data on head shape and volume analyses obtained by stereophotogrammetry in very preterm infants compared to term infants at term equivalent (TEA) age.Currently, head shape quantification is still not standardized, and deformities are often only assessed by visual impression or simple—but non-comprehensive—manual cephalometric methods such as calipers. Reference values for non-synostotic symmetrical and asymmetrical head shape deformities have been proposedAs part of a longitudinal observational study, 25 very preterm infants and 25 sex-matched term infants underwent stereophotogrammetric three-dimensional (3D) head imaging at TEA. Written informed parental consent was obtained prior to study image acquisition. The study had been approved by the ethics committee of the Georg-August-University medical centre  and was performed in accordance with the amended Declaration of Helsinki.Inclusion criteria into the study group were birth weight of below 1500 g and / or gestational age (GA) below 32 completed weeks. Patients of the control group had any body weight and a GA of 37–42 weeks.Exclusion criteria for all patients were palliative care or any critical / deteriorating clinical health condition. For the healthy term control group, syndromal appearance or confirmed disease, clinically apparent cephalic or (sub-) galeal hematoma, other head / scalp lesions and any condition with an impact on head shape or neurological development were defined as additional exclusion criteria. Syndromal appearance or disease and birth trauma were assessed by at least one board certified neonatologist.17. Analysed perinatal characteristics included birth presentation, mode of delivery and presence of asphyxia. At the time of image acquisition, postmenstrual age, body weight (including percentiles) and HC were recorded. Neonatal morbidity was determined by the presence of bronchopulmonary dysplasia (BPD), necrotizing enterocolitis (NEC), intracerebral hemorrhage (ICH) III-IV°, culture-proven or clinically determined sepsis18, retinopathy of prematurity (ROP) III-IV°, periventricular leucomalacia (PVL) and respiratory support. Respiratory support was subclassified into total duration of respiratory support, days of nasal continuous positive airway pressure, days of nasal high-flow therapy and days of invasive mechanical ventilation. Independent of the applied mode of respiratory support, all patients were equally placed in their incubators in prone and supine positions.In preterm infants, 3D images were acquired at corrected TEA (between 37 and 42 weeks) and in term infants during the first week of life. The following data were obtained for each infant: Sex, multiple birth, GA, body weight (including percentiles) and HC at birth . Small for gestational age (SGA) was defined as body weight < 3rd percentile15. During the procedure, the infant’s head was covered with a soft nylon cap that contains textured applications to reduce hair artifacts and to facilitate subsequent 3D image reconstruction. To protect the infant’s eyes from potential irritation due to camera flashlight, a neonatal phototherapy eye protector  was used in all infants. All image acquisitions were performed on the neonatal ward during patient care while the infants were placed in their incubator or bed or while being held by one of their legal guardians  was used. As previously described in detail, a 3D head imaging protocol with ten images from various angles was appliedFor the 3D image reconstruction, VECTRA Analysis Module (VAM) software version 6.2.3  and the MeshLab software version 2016.12  were used.Digital measurements of the reconstructed 3D head model were performed using the Cranioform software version 4.0 . Technical details and definitions are displayed in Table 19. For this purpose, we applied mean reference values for female and male infants at zero to three months of age.Non-synostotic head shape deformities were classified based on the described normative percentiles for cranial index (CI) and cranial vault index (CVAI) and analysed in light of the previously published reference valuesThe CI was used to define symmetrical head shape deformities. Brachycephaly (i.e. increased head width related to head length) was classified as either mild , moderate , or severe , while dolichocephaly (i.e. increased head length in relation to head width) was classified as mild , moderate , or severe .Finally, asymmetrical head shape deformity plagiocephaly  was classified using the CVAI as mild , moderate , or severe .Patient data was handled using Microsoft Excel version 1906 . Numerical variables are expressed as median (interquartile range), categorical variables as percentages. Statistical analyses were conducted using SPSS Statistics version 26 . All data were assumed as non-normally distributed. Comparisons between the study and control group were performed using the Mann–Whitney-U-Test for independent samples. Correlations were assessed by Spearman's rank correlation coefficient. Relationship between head shape deformities and risk factors was analysed by Fisher’s exact test and multiple hierarchical regression. Finally, association between head shape and risk factors was analysed using multiple hierarchical regression. For all statistical tests, the level of significance was set to 0.05.Clinical characteristics of the preterm and the term infant group and data at time of image acquisition are displayed in Table p < 0.001; term infants r = 0.797, p < 0.001) was found. Further, even in moderately to severely plagiocephalic and dolichocephalic preterm and term infants, digitally measured HC and CV exhibited a statistically significantly positive correlation . A similar trend was observed in brachycephalic infants. Given the small sample size, respective correlation of HC and CV was not statistically assessed. In preterm infants, weight at TEA showed a statistically significant positive correlation with CV . In contrast, in term infants, only a trend but no significant correlation of body weight and CV  was found.A statistically significant correlation between the digitally measured HC and the CV in both study groups  as reflected in a highly significantly lower CI when compared to controls . In contrast, CV was not significantly different between the two groups Table . Brachycp = 0.006). This relation was determined as moderate (Cramer V = 0.432). Dolichocephaly was the most present head shape deformity in preterm infants. Specifically, dolichocephaly was mild in 8 / 25 (32%), moderate in 4 / 25 (16%), and severe in 5 / 25 preterm infants (20%), respectively.Occurrence and severity of specific head shape deformities at TEA are displayed in Table To assess potential risk factors for head shape deformities, all preterm and term infants were analysed regarding the presence of common clinical characteristics and risk factors including sex, multiple birth, abnormal birth presentation other than cephalic, mode of delivery and body weight at TEA. These parameters were not associated with brachycephaly, dolichocephaly or plagiocephaly.p = 0.049). However, there was no significant correlation between CI and GA . Likewise, there was no correlation of the severity of dolichocephaly with other risk factors such as total duration of respiratory support, days of nasal continuous positive airway pressure, nasal high-flow therapy or invasive mechanical ventilation, respectively.Dolichocephaly was detected predominantly in preterm infants (36% vs. 4% in term infants). Within the preterm infant group, GA was significantly different between patients with dolichocephaly and without dolichocephaly , total duration of respiratory support and body weight at TEA. On multiple hierarchical regression analysis, the only variable that accounted for a statistically significant effect on CI was body weight at TEA Table , Fig. 4.20 to address these issues. Yet to date, none of these techniques have been implemented into clinical routine. In this clinical study, a hand-held stereophotogrammetry device was successfully used in preterm and term infants at TEA allowing to create a database with the 3D parameters of the entire head. Metric and volumetric values as well as proportions and indices could be evaluated for all study participants.Despite an increasing interest in the 3D head assessment with focus on non-synostotic head shape deformities, imaging of newborn heads still is only a small research field and reliable data remains limited. The main reasons for this shortcoming include technical limitations and the challenging need for a non-invasive, fast and accurate method that requires neither patient cooperation nor the use of sedatives in the newborn. Besides 2D methods, superior 3D techniques such as a laser shape digitizer have been described22. However, the exact circumstances determining the more frequent abnormal head shape development in preterm infants are unclear. Moreover, the timely evolution of head shape abnormalities in the first weeks to months after birth remains elusive.Premature birth has been previously described as a risk factor for non-synostotic head deformities20. Unlike Ifflaender and colleagues, however, who found a significant difference in median duration of total respiratory support, nasal continuous positive airway pressure (nCPAP) and invasive mechanical ventilation in dolichocephalic infants compared to controls, we identified body weight at TEA to be an independent outcome variable with a potential effect on the CI.To overcome this gap, here, we identified differences between preterm and term infants and aimed at characterizing general risk factors for head shape deformities for our entire patient cohort as well as specific risk factors for preterm infants. This is in accordance with results of Ifflaender et al., who used a laser shape digitizer to obtain 3D head images of preterm infants at TEA and who were able to determine differences when compared to term infants23. In the neonatal period, HC is—despite being only a 2D parameter—the current gold standard parameter for CV, and indirectly reflecting brain volume9. Accordingly, HC is considered a predictor for neurological outcome in neonates13.Early head and weight growth have been found to be associated with improved neurodevelopment in mid-childhoodIn the present study, we analysed both HC and CV to determine whether the easy manual measurement of HC is equally applicable as the digital measurement of CV. In our patient cohort we found a high correlation between HC and CV. CV is estimated to be more comprehensive and therefore likely to be superior. Our data, however, supports the current clinical practice, that manually measured HC is a good instrument to determine CV.9. Interestingly, and contrary to our expectations, HC mirrored CV even in patients with symmetrical as well as asymmetrical head deformities. However, since in our study cohort only a few patients had a severe head shape deformity, a larger number of patients needs to be studied to strengthen this statement.Our findings are in agreement with results from a magnetic resonance imaging study by Cheong and colleagues who assessed head growth in preterm infants at TEA. In this study, microcephaly correlated with reduces brain tissue volumesIn preterm infants, a highly significant correlation of body weight and CV could be identified. In contrast, in term infants this tendency was also present but did not reach statistical significance. It may be presumed, that differing chronological age and time-dependent factors between preterm and term infants account for this discrepancy. Examples for time-dependent factors could be the overlap of cranial sutures which is common in the first days after birth or physiological postnatal weight loss which is usually up to 7–10% of body weight at birth within the first days of life. Therefore, especially in term infants, weight might not be a reliable parameter to affect HC or CV at TEA.Between preterm and term infants at TEA, no clinically relevant differences were found for HC and CV. Applying the paradigm that a normal increase in HC and CV reflects physiological neurological development until TEA, this is a rather reassuring observation. Importantly, our patient cohort did not feature a high neonatal morbidity which may have influenced the favorable outcome in this study.19 and Willis et al.10, a lower CI—indicating the displaced relationship between head length and width—was found to be a discriminant characteristic between premature and term infants at TEA. Presence of a narrow and so-called “preemie head” is impressive for parents and caregivers but its biological impact still requires further evaluation. Plagiocephaly played a subordinate role in our study.In accordance with the results by Ifflaender et al.For various reasons, preterm infants are susceptible for developing dolichocephaly. Theories for the underlying pathogenesis include preterm birth leading to exposure to gravitational forces at a very early age. Further, the cranial bone structures are more impressionable and therefore at higher risk to result in a sustained deformation of the head; neck muscle tone is reduced but still needs to hold a relatively larger head in place; and during hospitalization the head is regularly placed in a lateral position even more often when the baby is critically ill.Interestingly, our multiregression analysis demonstrated that weight at TEA accounted for almost a third of all variance found in CI. In other words, a greater weight at TEA was associated with a greater risk for dolichocephaly. One possible explanation for this observation might be, that—according to Newton's law of gravity with mass being directly proportional to gravitational forces—larger infants are exposed to greater gravitational forces with the result of increased head shape deformation. A detailed head shape description of the only three preterm infants with a birth weight < 1000 g and body weights at TEA at < 1st, 2nd and 17th weight percentiles support this hypothesis: Only one baby had moderate dolichocephaly (CI 72.5%), the two others were measured within the upper normal range . With an average CI of 77.7%, these three lightest preterm infants  were less dolichocephalic than the average preterm infant in our study group (median CI of 76.0%). This is rather surprising, as we expected an increase in severity of head shape deformities among the SGA—as well as in the failure to thrive-infants, who are generally known to carry a greater risk for neonatal morbidity.In our study, GA differed significantly between patients with dolichocephaly and without dolichocephaly but surprisingly not with duration of respiratory support or any other factors of neonatal morbidity. Although reliable evidence is sparse to support this assumption, one would expect a correlation between dolichocephaly and duration of nasal continuous positive airway pressure (nCPAP) support in particular, because the head cap which holds the nCPAP system fits rather tight around the infant´s head and might potentiate head deformation. Our data could not support these assumptions, and moreover, we did not find any difference between nCPAP and other invasive or non-invasive ventilatory modes.The principle limitation of this study was the relatively small sample size. The reason for this was the pilot character of the study. However, the size of the preterm infant cohort was potentially too small to observe significant effects. Further, we did not define a specific hypothesis  to be proven wrong or right. Hence, the here described differences cannot be regarded statistically significant but rather hypothesis generating and descriptive in nature.For our study, infants with known risk factors for head shape deformities such as multiple birth or birth presentation were not excluded which may have biased the results. Potentially, due to the small number of participants we did not find a correlation between any known risk factor and the presence of head shape deformities. In addition, the cohort was relatively healthy and neonatal morbidity was low. These factors may explain rather normal measurements in terms of HC and CV. Despite this, a significant number of infants showed relevant head shape deformities. The hypotheses generated in this study should be used to design adequately powered trials in the future.Instead of focussing on single measurements, it would be interesting to assess head shape and volume development over time in order to identify potential confounders at different stages during infants´ growth as spontaneous improvement of head shape deformities often occurs during infancy.


Background: Plasma albumin (ALB) reflects protein nutritional status in rats, but it is not clear whether it is associated with dietary protein insufficiency in pregnant women and/or their risk of low birth weight delivery. This study aimed to investigate whether maternal serum ALB redox state reflects maternal protein nutritional status and/or is associated with infant birth weights. Methods: The relationship between the serum reduced ALB ratio and infant birth weight was examined in an observational study of 229 Japanese pregnant women. A rat model simulating fetal growth restriction, induced by protein-energy restriction, was used to elucidate the relationship between maternal nutritional status, maternal serum ALB redox state, and birth weight of the offspring. Results: In the human study, serum reduced ALB ratio in the third trimester was significantly and positively correlated with infant birth weight. In the rat study, serum reduced ALB ratio and birth weight in the litter decreased as the degree of protein-energy restriction intensified, and a significant and positive correlation was observed between them in late pregnancy. Conclusions: Maternal serum reduced ALB ratio in the third trimester is positively associated with infant birth weight in Japanese pregnant women, which would be mediated by maternal protein nutritional status. LBW delutrition ,4,5,6,7,utrition ,8. LBW dutrition , and fetutrition . This lautrition , which hutrition ,12,13, outrition ,15,16,17utrition , which iutrition . Specifiutrition .Albumin (ALB) is the most abundant circulating protein . ALB canWe hypothesized serum maternal ALB redox state during pregnancy would be correlated with infant birth weight, which could be mediated by maternal nutritional status. The aim of this study was to investigate whether maternal serum ALB redox state is associated with maternal nutritional status and/or infant birth weights. We conducted an observational study on Japanese pregnant women to examine the association between serum ALB redox state and infant birth weight. We also executed an animal experiment that simulated FGR, by maintaining pregnant rats on an AIN-93G diet  ad libitThis study was conducted in accordance with the principles of the Declaration of Helsinki and with the approval of the Institutional Review Board of Hokkaido University Hospital (Protocol No. 017-0281). Pregnant women that were scheduled to give birth between October 2018 and April 2019 were recruited at Obihiro Kosei General Hospital, Hakodate Central General Hospital, and JCHO Hokkaido Hospital, all of which are located in Hokkaido prefecture, Japan. Women were eligible if they (1) were aged 18 or older at recruitment, (2) intended to receive medical examinations during pregnancy and to give birth at any of the above three hospitals, and (3) were well informed of, in full understanding of, and in agreement with their participation in the study. Exclusion criteria were the women (1) had their first medical examination at 14 weeks of gestation or later and (2) were judged as inappropriate to participate in this study by the physicians. A total of 379 women participated in this study, and written informed consent was obtained from all of them. The participants visited the hospitals for medical examinations during the first (<14 weeks of gestation), the second (between 24 weeks and 27 weeks + 6 days of gestation), and the third trimester (around 36 weeks of gestation) of the gestational period. During the visits, demographic information was collected; blood was drawn from the antecubital vein and the serum fraction was obtained after centrifugation and stored at −80 °C. Demographic information was also collected at delivery.This study was a part of a larger study; it was conceived and the approval was obtained again after the remaining part was completed. All the analyses were thus conducted retrospectively. Among the 379 participants, 270 completed all three medical examinations during pregnancy, and gave birth. For the analyses of this study, 4 subjects were excluded as they had multiple pregnancies, 8 subjects were excluded as they had missing data on blood biochemistry, and 29 subjects were excluded as they were diagnosed with diabetes mellitus or gestational diabetes mellitus (DM/GDM); DM is a risk factor for large for gestational age rather than premature delivery , and DM/n = 6), being fed the AIN-93G diet ad libitum, or given the same diet reduced by 20%, or 40% of the average amount of ad libitum feeding. These groups were designated as the control (CTRL), 20% energy restriction (20% ER), and 40% energy restriction (40% ER) groups, respectively, and were maintained on this dietary regimen from PD10 until delivery (PD22). On PD9, PD16, and PD19, body weights of the dams were measured, and blood was collected from the lateral tail vein on the same days. The blood samples were then centrifuged, and the serum fraction was obtained after centrifugation and stored at −80 °C. On the delivery day (PD22), body weights of all of the pups were measured. The sum of birth weights in each dam was designated as “litter weight”, and the litter weight was then divided by the litter size (number of pups) to obtain the “birth weight in the litter”. All of the dams and pups were finally euthanized by deep anesthesia with sevoflurane .The design of this animal experiment was proposed by the authors, and then approved by the Animal Research Committee of Morinaga Milk Industry Co., Ltd. (Protocol No. 18-026). The experiment was performed between September 13th and October 4th, 2018, in accordance with the committee’s guidelines. Eighteen pregnant Wistar rats (dams) on pregnancy day1 (PD1) were commercially obtained . The dams were acclimated to the facility condition for 8 days ,24,25, dSerum ALB redox state was expressed by the ratio of reduced to total ALB, designated as serum reduced ALB ratio; it was determined by applying serum samples to HPLC as described previously ,29. As sp < 0.05. As for the animal experiment, a wild type animal model was selected in this experiment and statistical analyses were conducted based on the assumption that the dietary groups had normal distributions and homogeneity of variance. As for multiple linear regression analyses vs. infant birth weight, the serum reduced ALB ratio in the third trimester, pre-pregnancy body weight, pre-pregnancy BMI, gestation period, and body weight at delivery, as reported in the Results section, were selected as independent variables as they were found to be significantly correlated with infant birth weight in single linear regression analyses (p < 0.05).Data were analyzed by one-way ANOVA followed by a Tukey–Kramer HSD test, simple linear regression analyses, and multiple linear regression analyses using JMP software . Significance was demonstrated at Characteristics of the participants are summarized in Serum reduced ALB ratios differed significantly between the trimesters; the ratio in the second trimester was the highest and that of the third trimester was the lowest A. Serum p = 0.138), presumably because of the small sample size.Simple linear regression analyses were conducted to examine the relationships of maternal serum parameters vs. infant birth weight . Serum rMultiple linear regression analyses were then conducted for combinations of the above five parameters vs. infant birth weight . Serum rThe average energy and protein intakes of the dams were 196.2 kJ/d and 2.2 g/d in the CTRL group, 143.1 kJ/d and 1.6 g/d in the 20% ER group, and 107.7 kJ/d and 1.2 g/d in the 40% ER group, respectively. Body weights of the 40% ER group were significantly lower compared with the CTRL group on PD16 and PD19, whereas weight gains were different between all the three groups on PD16 and PD19 in the same directionality as the energy/protein intakes . When thSerum reduced ALB ratios of the 20% ER and 40% ER groups were significantly lower compared with the CTRL group on both PD16 and 19 A. In conSimple linear regression analyses were conducted to examine the relationship of the serum reduced ALB ratio or ALB concentration vs. birth weight in the litter; the analyses were conducted for all the animals in the three dietary groups together . Serum rWhen serum samples on PD19 were incubated at 4 °C for 5 weeks, the means ± SDs of reduced ALB ratios were down to 36.3 ± 6.7% in the CTRL group, 33.1 ± 5.4% in the 20% ER group, and 28.5 ± 3.9% in the 40% ER group, respectively, and significant differences in the serum reduced ALB ratio seen between the groups before the incubation was dissolved after the incubation. Still, the significant and positive correlation between the serum reduced ALB ratio and birth weight in the litter was persistent after the incubation .Protein-energy undernutrition is considered potentially prevalent in Japanese pregnant women ,20, and In the human observational study, LBW delivery comprised 3.9% of all the participants, which is lower than previously reported for Japanese pregnant women (9.4%) . Among tThe relationship between serum ALB redox state and birth weight of the offspring was also examined in an FGR model in rats. In order to simulate FGR, pregnant animals are normally placed on low-protein diets ,12,13, oThe largest limitation of this study was that, when considering the fact that serum reduced ALB ratio is normally >70% , albuminIn conclusion, maternal serum reduced ALB ratio in the third trimester is associated with infant birth weight in Japanese pregnant women, which is also substantiated by a rat model simulating FGR by protein-energy restriction, as we hypothesized. According to the rat model and with reference to previous literature ,24,25, p


In this study, we determine if differences in DNAm exist between women who reported a preterm birth in the last 3–5 years compared to those who had full-term births by using two different approaches: epigenome-wide association study (EWAS) and genome-wide co-methylation analyses.Preterm birth (< 37 weeks’ gestation) is a common outcome of pregnancy that has been associated with increased risk of cardiovascular disease for women later in life. Little is known about the physiologic mechanisms underlying this risk. To date, no studies have evaluated if differences in DNA methylation (DNAm) among women who experience preterm birth are short-term or if they persist and are associated with subsequent cardiovascular sequelae or other health disorders. The purpose of this study was to examine long-term epigenetic effects of preterm birth in African American mothers (Though no significant CpG sites were identified using the EWAS approach, we did identify significant modules of co-methylation associated with preterm birth. Co-methylation analyses showed correlations with preterm birth in gene ontology and KEGG pathways. Functional annotation analysis revealed enrichment for pathways related to central nervous system and sensory perception. No association was observed between DNAm age and preterm birth, though larger samples are needed to confirm this further.We identified differentially methylated gene networks associated with preterm birth in African American women 3–5 years after birth, including pathways related to neurogenesis and sensory processing. More research is needed to understand better these associations and replicate them in an independent cohort. Further study should be done in this area to elucidate mechanisms linking preterm birth and later epigenomic changes that may contribute to the development of health disorders and maternal mood and well-being.The online version contains supplementary material available at 10.1186/s12863-021-00988-x. Preterm birth, defined as the delivery of a neonate born prior to 37 weeks’ gestation , is a coPreterm birth is often categorized as spontaneous or indicated. Spontaneous preterm birth refers to birth resulting from preterm labor, preterm spontaneous rupture of membranes, preterm premature rupture of membranes (PPROM) or cervical weakness. Indicated preterm birth occurs in response to maternal or fetal distress. The etiology of spontaneous preterm birth is multifactorial and often difficult to causally determine for an individual patient. Factors such as maternal infection, premature rupture of membranes, and medically indicated induction for pre-eclampsia or intrauterine growth restriction are common reasons for preterm birth . While tEpigenetics, the interplay between genetic and environmental factors, have been a generally understudied area to understand the long-term outcomes of preterm birth . More spPreterm birth and other pregnancy complications have been associated with increased risk of cardiovascular disease later in life , 12, indThe purpose of this study was to examine the long-term epigenetic effects of preterm birth on African American mothers. In this study, we determine if differences in DNAm exist between women who reported a preterm birth in the last 3–5 years compared to those who had full-term births by using two different approaches: EWAS and genome-wide co-methylation analysis.n = 250) enrolled with a biological child aged 3–5 years old (n = 250) for this longitudinal study (N = 500). Women were eligible to participate in the study if they were ≥ 21 years old, self-identified as African American or Black, spoke English, had no mental illness that could interfere with reliable response to self-reported psychological measures, and enrolled with a biological child (3–5 years old). There was a total of four study visits, each 6 months apart. Baseline data were collected at the Time (T) 1 visit, including demographic information, smoking status, clinical measurements , and salivary DNA. The purpose of the InterGEN study was to examine Gene (G)- Environment (E) interactions on blood pressure for mothers and children. DNAm of genes associated with blood pressure (G) and environmental factors (E)  were studied. A diagnosis of high blood pressure was not a requirement for study participation. Audio Computer Assisted Self-Interview (ACASI) software was used for self-reported data collection. Mothers reported gestational age at birth for the enrolled child at the T2 interview by answering “How many weeks pregnant were you when your (enrolled) child was born?” They indicated length of gestation by choosing from a list ranging from 20 to 42 weeks. Preterm births were categorized as those occurring before 37 weeks gestation. A sample (n = 77) of the responses for gestational age were objectively validated by medical record abstraction. Recruitment, psychological measures, and genetic methods are discussed elsewhere [The Intergenerational Impact of Genetic and Psychological Factors on Blood Pressure (InterGEN) Study was conducted between 2014 and 2019 in Connecticut. Mothers -500 format tubes according to established study protocols. Saliva samples were transported to the research laboratory and refrigerated at 4 °C until processed. DNA extraction and purification were carried out using ReliaPrep kits, and the Illumina Infinium Methylation EPIC (850 K) BeadChip was used for epigenome-wide DNAm measurement. Sample processing and methylation analyses were conducted at the Yale Center for Genome Analysis. The resulting genetic data contained methylated (M) and unmethylated (U) signals used to calculate β values, where β = M/(M + U) and varying from 0.0 to 1.0.p-value > 0.001, and located in sex chromosomes. The batch effect correction was conducted using the ComBat method from the ‘sva’ R package (version 3.34.0) [Quality control was performed using the ‘minfi’ R package (version 1.32.0) . Subsequ 3.34.0) . Normali 3.34.0) . Princip 3.34.0) . After qAssociation analysis to detect differentially methylated CpGs associated with preterm birth was conducted using the ‘cpg.assoc’ function from the ‘minfi’ R package. The linear regression model examined the association between preterm birth and DNAm, adjusting for maternal age, cell proportions , the top three principal components (PCs), and smoking status. Multiple testing correction was conducted using False Discovery Rate (FDR) of less than 0.05.p-value for the association with preterm birth. Genes within modules with correlation ≥ |0.13| and p-value ≤ 0.05 were selected for functional annotation and interactome analysis. The gene significance and module membership were evaluated for the two modules with biological significance.Co-methylation analysis was performed using the ‘WGCNA’ R package (Version 1.69) . The netThe CpG annotation for the EWAS and co-methylation analysis was conducted using the ‘IlluminaHumanMethylationEPICanno.ilm10b4.hg19’ R package (Version 0.6.0) . FunctioThe interactome analysis was performed with the STRING database (Version 11.0) . We set DNAm age acceleration is defined as the residual term of a univariate model regressing estimated DNAm age on maternal chronological age. We used 353 age-related biomarkers identified by Horvath –29. Horvn = 64), had a multiple gestation (n = 2), and if they had missing/insufficient DNA (primary outcome) for analysis (n = 2). This resulted in a final sample of 182 women contributing data for the present analysis. Participant characteristics are summarized in Table 2) (46.1%) and were non-smokers (78.3%). Approximately a quarter of women (25.2%) had a preterm birth with their enrolled child. Validation of a subsample of preterm births was completed using medical record abstraction, and self-report was found to be highly correlated to objectively ascertained gestational age.A total of 250 women were enrolled at the T1 InterGEN visit, however, only 191 completed the T2 visit where preterm birth status of the enrolled child was assessed. Participants were excluded from analyses if they: did not complete the T2 visit or were missing data on preterm birth (the primary exposure)  mapped to the DOC2A gene. Functional annotation of the top 500 CpG sites associated with preterm birth found no significant GO and KEGG enrichment at FDR < 0.05. The top three nominal associations for GO pathways include vasopressin receptor binding, maternal aggression, and positive regulation for cellular pH reduction. The top three nominal associations for the KEGG pathways include vascular smooth muscle contraction, cGMP-PKG signaling pathway, and vasopressin-regulated water reabsorption.The Manhattan plot depicting the association between DNAm and preterm birth in African American women is presented in Supplemental Figure p-value < 0.05. Functional annotation for all the 45 modules showed two modules enriched for GO terms (cyan and darkred) and one for KEGG pathways (cyan). Functional annotation and protein-protein interaction (PPI) analysis are depicted in Fig. A total of 302 significant modules were identified, of which 45 had a correlation ≥|0.13| and p-value = 0.04) and age . The GO enrichment . Negatively correlated sites did not show significant GO enrichment. PPI analysis . For this module, we did not identify a correlation with age or smoking. The functional annotation to the cyan module identified olfactory transduction pathway enriched in the KEGG analysis , olfactory receptor activity (FDR = 0.022), and transmembrane signaling receptor activity (FDR = 0.031). In the negative subgroup of cyan modules, we found the same GO terms that those detected in the whole module.The cyan module showed a negative correlation with preterm birth  and preterm birth  groups.We observed a strong correlation between DNAm age and chronological in the InterGEN cohort. There was a significant association between hypertension and DNAm age; however, no association was identified between DNAm age and preterm birth Table . Figure In this study, we identified epigenetic changes associated with preterm birth history among African American women 3–5 years after delivery. Though no significant CpG sites were identified using the EWAS approach, we did identify significant modules of co-methylation associated with preterm birth. Co-methylation analyses showed a negative correlation of darkred with preterm birth, and a positive correlation with the cyan module. Functional annotation analysis revealed enrichment for pathways related to central nervous system and sensory perception. No association was observed between DNAm age and preterm birth, though larger samples are needed to confirm this further.n = 48). These changes were localized in genes associated with cellular regulation and metabolic processes. Another study carried out in an Asian cohort (N = 1019) of term and preterm infants reported differential methylation in cord tissue and blood among infants born preterm, in sites associated with fetal growth and development, and immune response pathways, respectively [n = 16) and at term (n = 24). They identified differential methylation of genes associated with metabolic, cardiovascular and immune pathways among women who delivered preterm compared to those who delivered at term.Previous studies have examined the epigenomic effects of preterm birth on both mothers and their newborns, however, none have focused on the epigenetic effects on the mother after having a child born preterm –32. Wangectively . One stuIn this study, we identified several co-methylation modules associated with preterm birth. The darkred module showed enrichment for cell development, neurogenesis, and central nervous system. The cyan module was enriched for olfactory signaling, sensory perception, synaptic transmission, calcium ion binding, and transcription regulation. Interestingly, previous research has found women with preterm birth history are at increased risk for cardiovascular disease, mood disorders, and perceptions of their baby . Little Strengths of this study include that this is a secondary analysis of data from a cohort study comprised of African American women, a group that is underrepresented in epigenomic studies, as well as a focus on the understudied topic of effects of preterm birth on mothers in the 3 to 5-year time period after delivery. Limitations include the potential for residual confounding, cross-sectional design, and lack of baseline DNAm levels for women in the perinatal period. The rate of preterm birth reported by women in our study was higher than reported in nationally representative data for African Americans , and thiIn summary, we identified differentially methylated gene networks associated with preterm birth in African American women 3–5 years after birth, including pathways related to neurogenesis and sensory processing. More research is needed to understand better these associations and replicate them in an independent cohort. Further study should be done in this area to elucidate mechanisms linking preterm birth and later epigenomic changes that may contribute to the development of health disorders and maternal mood and well-being.Additional file 1: Supplemental Figure 1. Manhattan Plot of epigenome-wide associations with preterm birth, InterGEN. Supplemental Figure 2. Quantile-Quantile Plot for association between DNA methylation and preterm birth, InterGEN.


Globally, preterm birth is the leading cause of neonatal and under-five children mortality. Sub-Saharan African (SSA) accounts for the majority of preterm birth and death following its complications. Despite this, there is limited evidence about the pooled prevalence and associated factors of preterm birth at SSA level using nation-wide representative large dataset. Therefore, this study aimed to determine the pooled prevalence and associated factors of preterm birth among reproductive aged women.p-value less than 0.05.The recent Demographic and Health Surveys (DHSs) data of 36 SSA countries were used. We included a total weighted sample of 172,774 reproductive-aged women who were giving birth within five years preceding the most recent survey of SSA countries were included in the analysis. We used a multilevel logistic regression model to identify the associated factors of preterm birth in SSA. We considered a statistical significance at a In this study, 5.33%  of respondents in SSA had delivered preterm baby. Being form eastern Africa, southern Africa, rural area, being educated, substance use, having multiple pregnancy, currently working history, having history of terminated pregnancy, and previous cesarean section delivery, primi-parity, and short birth interval were associated with higher odds of preterm birth among reproductive aged women. However, having better wealth index, being married, wanted pregnancy, and having four or more antenatal care visit were associated with lower odds for a preterm birth among reproductive aged women.The prevalence of preterm birth among reproductive-aged women remains a major public health problem in SSA. Preterm birth was affected by various socio-economic and obstetrical factors. Therefore, it is better to consider the high-risk groups during intervention to prevent the short-term and long-term consequences of preterm birth.The online version contains supplementary material available at 10.1186/s12884-021-04233-2. Preterm birth refers to the birth of a baby between 20 and 37 weeks of pregnancy . It is tFrom the 130 million babies born each year in the globe, approximately 15 million born too soon annually .The finding of previous studies in the globe revealed that several factors are associated with preterm birth. These include: maternal age , wealth Despite preterm is associated with both short- and long-term consequences and majorly affects SSA which covers a significant portion of preterm birth global burden, to the best of our knowledge, the pooled prevalence and associated factors of preterm birth were not estimated at regional level that is Sub-Saharan Africa. The previous studies conducted on preterm birth in SSA countries were based on specific countries and were using small samples that are from facilities.Therefore, this study aimed to investigate the pooled prevalence and associated factors of preterm birth among reproductive aged women who had given birth within five years preceding the DHS surveys in SSA countries. Conducting this will help to make decision on neonatal and child health based on best available scientific evidences. Moreover, the result of this study could support policy makers, clinicians, and programmers to design intervention on preventing preterm birth and its complications in the region.We used the most recent Demographic and Health Survey (DHS) datasets of 36 SSA countries conducted from 2006 to 2018 to determine the pooled prevalence and associated factors of preterm birth among reproductive aged women in SSA.The DHS surveys are routinely collected every five-year across low-and middle-income countries using structured, pre-tested and validated questionnaires. The survey also follows similar standard procedure in development of questionnaires, sampling, data collection, and coding which makes multi-country analysis possible. The DHS surveys employs a stratified two-stage cluster sampling technique. In the first stage, clusters/enumeration areas (EAs) that cover the entire country were randomly selected from the sampling frame . The second stage, the systematic sampling was employed on households listed in each cluster or EA and interviews were conducted in selected households with target populations (women aged 15–49 and men aged 15–64). In this study, a total weighted sample of 172,774 reproductive aged women who had given birth within the five years preceding the survey of each country were included. For those women who had given more than one birth within five years preceding the survey, the most recent birth was used. In addition, the reproductive aged women with missing value of the outcome variable were excluded from the study ”. Duration of pregnancy was dichotomized as “Yes” for preterm birth if it ranges or birth was given between 5 to 8 completed months of gestational age, and “No” if it ranges or birth was given after nine or more completed months of gestational age.In this study, individual and community level variables were considered. Women’s age , education , marital status , wealth index , currently working status (no and yes), mass media exposure ), substance use , preceding birth interval in months , number of ANC visit (< four and ≥ four visits), sex of fetus , multiple pregnancy (no and yes), contraceptive use (no and yes), history of terminated pregnancy (no and yes), wanted pregnancy (no and yes), pervious delivery by cesarean section (no and yes) were included as the individual level variables of the study. Whereas residence  and regions of Africa  were included as the community level variables.The variables of the study were extracted, cleaned and recoded using STATA version 14. The data were weighted using sampling weight, primary sampling unit, and strata during any statistical analysis to adjust for unequal probability of selection due to the sampling design used in DHS data. Hence, the representativeness of the survey results was ensured.A two-level multivariable binary logistic regression analysis was used to estimate the effect of explanatory variables on preterm birth among reproductive aged women. The data has two levels with a group of J EAs and within-group j , a random sample nj of level-one units (reproductive aged women). The response variable was denoted by;σμ2 indicates the cluster variance. Whereas PCV measures the total variation attributed by individual and community level factors in the multilevel model as compared to the null model. It was computed as: μ) [So, appropriate inference and conclusions from this data require advanced modeling techniques like multilevel modeling, which contain variables measured at different levels of the hierarchy, to account the nested effect . Four moullmodel . The MOR95 ∗ σμ) . The secp-value ≤0.2 in the bi-variable analysis were considered for the multivariable analysis. In the multivariable multilevel binary logistic model, variables with p value< 0.05 were declared as statistically significant factors of preterm birth. The Adjusted Odds Ratio (AOR) with 95% Confidence Interval (CI) of the best fitted model were reported to identify the associated factors of preterm birth.Variables with a www.dhsprogram.com) after getting approval to access the data. All methods were carried out in accordance with the Declaration of Helsinki.This study is a secondary data analysis from the DHS data, so it does not require ethical approval. For conducting this study, online registration and request for measure DHS were conducted. The dataset was downloaded from DHS on-line archive  were in East Africa. Majority of the participants, 121,224 (70.16%) were rural dwellers. Six thousand sixteen (37.63%) participants were not educated. More than two third of the study participants, 122,256 (70.76%) were in the age range of 20–34 years. Majority of the participants, 151,912 (87.92%) were married. Moreover, 96,962 (56.12%) had not exposure to mass media. Regarding to obstetrics history of the participants, 22,274 (12.89%) participants had history of terminated pregnancy, 118,179 (68.40%) were not using any contraceptive method, 28,300 (18.08%) had short birth interval, 9685 (6.52%) pregnancies were not wanted or planned, and 14,159 (13.94%) participants had no ANC visit  in Sub-Sharan African countries. Central Africa had the lowest prevalence of preterm birth (2.06%) whereas the highest prevalence was founded in South Africa region 11.19%) , the ICC indicated that about 9.9% of the total variability for preterm birth was due to differences between clusters/EA, with the remaining unexplained 91.1% was attributable to the individual differences. In addition, the median odds ratio also revealed that preterm birth was heterogeneous among clusters. It was 1.41 in the first model which implies reproductive aged women within cluster of having higher risk for preterm birth had 1.41 times higher chance of delivering preterm baby as compared with reproductive aged women within cluster of having lower risk if the women were selected randomly from two different clusters (EAs). Regarding to PCV, about 47.22% of the variability in preterm birth was explained by the full model. Model IV was selected as the best fitted model (had the lowest deviance) Table .Table 3Mp-value of < 0.20.In the bi-variable multilevel analysis, all of the explanatory variables  except contraceptive use had shown statistically significant association with preterm birth at a p ≤ 0.05).In the final model, community level variables such as region and residence, and individual level variables like women’s age, education, marital status, wealth index, current working status, substance use, number of ANC visit, multiple birth, history of terminated pregnancy, wanted pregnancy, preceding birth interval, and previous delivery by CS were significantly associated with preterm birth  and 1.83  times for East and South Africa regions as compared to central region, respectively. Besides, the likelihood of having preterm birth was 12%  higher for teenagers as compared to women aged from 20 to 34 years. The odds of delivering preterm baby among reproductive aged women was 13%  higher for women living in rural areas compared to their counterparts. As compared with women in the poorest wealth index, the odds of having preterm birth was 25% , and 31% , 25% , 18%  lower for mothers having poorer, middle, richer and richest, respectively. Regarding maternal education, the odds of having delivering preterm baby was 1.53 , 1.36 , 1.42  times higher for women’s having primary, secondary and higher education as compared to those with no education, respectively. Married women had 11%  lower chance of having preterm birth as compared to single women. This study also revealed that the odds of having preterm birth among women that were currently working was 1.12  times to their counterparts. Female fetus had 8%  higher chance to be preterm birth as compared to male. Besides, babies born from mothers who were using substance had 27%  higher chance of having preterm birth as compared to their counterparts.The odds of preterm birth were increased by obstetrical factors such as multiple pregnancy , history of terminated pregnancy , and previous delivery by CS . As compared to women’s having optimum preceding birth interval, the odds of having preterm birth was 1.88  and 1.21  times higher for women giving their first birth and who had short preceding birth interval, respectively. Moreover, women’s having four and above ANC visits , and the pregnancy was wanted  were the important obstetrical factors that reduce the chance of preterm birth  in SSA. The higher burden of preterm birth in this study was in line with studies conducted in different parts of the world –40. ThisIn this study, we found that the risk of preterm birth was higher for teenager as compared with women aged from 20 to 34 years. This finding was supported by previous study . The higIn consistent with previous studies , 45, womThis study also revealed that the babies from married women had lower risk to be delivered prematurely than from single women. This finding was supported by previous study done on different areas of the world , 37. ThiThis study identified that short preceding birth interval (< 24 months) increases the risk of delivering preterm babies. This finding was in agreement with previous studies , 53, 54.The chance of giving preterm birth was also higher among women delivering multiple pregnancy and women having previous history of CS delivery. This finding was supported by a previous study conducted in Saudi . This coThe chance of delivering preterm birth was higher among women that have history of terminated pregnancy (abortion and stillbirth) compared to their counterparts. The finding of this study was also supported by previous studies done in different parts of the world , 61. TheAccording to this study, the chance of delivering preterm birth was lower for mothers that had wanted pregnancy. This finding was in agreement with previous studies conducted in elsewhere , 64. ThiThis study revealed that the risk of preterm birth was higher for women’s who uses substance as compared to their counterparts. The finding of this study was supported by studies done in different parts of the world –71. ThisCurrently working status was also significantly and independently associated with preterm birth. The odds of delivering preterm baby for currently working mother was higher as compared to their counterparts. The finding of this study was in consistent with previous findings , 78. ThiThe main strength of this study was the use of weighted, pooled national representative large datasets of SSA countries with the use of advanced statistical analysis technique that accounts the correlated nature of DHS data, which enables us more precise estimates and standard errors. However, this study is not free from limitations. Since, the DHSs are cross-sectional surveys, we cannot establish a cause-and-effect relationship between the different independent variables and Preterm birth. Moreover, since the data were collected through interview, there might be a possibility of recall bias because women may forget the exact duration pregnancy. On the other hand, this study had faced misclassification bias because the cut points for preterm births in weeks that ranges from 28 to 37 but the data was collected in moths. This situation leds to categorization of preterm babies as term baby.Delivering preterm baby among reproductive aged women in SSA remains a major public health problem. Residence, education, marital status, wealth index, currently working status, and substance use and obstetrical factors like number of ANC visit, multiple pregnancy, history of terminated pregnancy, wanted pregnancy, preceding birth interval, and previous delivery by CS were the associated factors of preterm birth. Therefore, it is better to consider women with terminated pregnancy, previous caesarian delivery, multiple pregnancy, short birth interval, and giving their first birth during intervention to prevent the short-term and long-term consequences of preterm birth.Additional file 1: Supplementary file 1: Cross-tabulation of preterm birth in different socio-economic and obstetrical factors from 36 Sub-Saharan African countries.


Background: Healthcare systems advocate for quality care and humanized relations in routine birth care, and have therefore created the Birth Plan, a document available to pregnant women to state their preferences in relation to the birth process. Methods: This qualitative research with a phenomenological design was carried out to record the experiences of women who presented a Birth Plan. Sample selection was carried out using non-probabilistic, intentional and convenience sampling, selecting seven participants who were willing to participate and share their experiences. Results: After analyzing the content of the interviews, four categories emerged: “respecting the woman’s wishes: humanizing the birth process”, “information and primary Care”, “expectations regarding the care received” and “results of using the birth plan”, with their corresponding subcategories. Conclusion: Women consider it beneficial to present a Birth Plan, because it informs them about the process and gives them the opportunity to have a better experience, which takes into account their preferences for making the delivery less instrumental. In addition, they state the importance of having trained professionals involved, and call for more attention to be paid to the birth process in general. Labor is a female physiological process, and a major event and experience in the lives of women. Childbirth care has undergone significant changes over the years. Initially attended by traditional midwives at home, it moved to hospitals after the second half of the 20th century, leading to the medicalization of childbirth . With thThe Birth Plan (BP) is a document in which women can express their preferences, needs, desires and expectations regarding the birth process. However, this document in no way replaces the information provided by the medical staff, nor does it convert the mother into the main organizer of the labor process, but rather enables her to influence the aspects that are negotiable. These issues must be respected, provided the health of the mother or baby is not jeopardized .Birth plans appeared for the first time in the United States at the end of the 1970s as a reaction to increasing medicalization, and as a consequence of women’s efforts to assert their preferences . BPs canThe World Health Organization includes the importance of effective communication in the recommendations published in 2018 for a positive birth experience. It focuses on experience of care as a critical aspect for ensuring high-quality labor, and improved woman-centered outcomes  to make it more humane”.Regardless of the extent to which the BP was adhered to, the opinion of the participants was unanimous in that the BP was a tool that encouraged better communication between the midwife and user, and improved the birth experience. Without communication, their wishes could not be fulfilled and, in this, the midwife’s attitude was considered fundamental. Participant 2 expressed this as follows:P2: “In my case, luckily for me, the midwife had read through everything point by point and we went over the BP together”. “If the staff who attend you are empathetic and receptive and have read the BP, then of course the plan facilitates the birth process”.Most of the women valued the prenatal classes highly; however, they expressed the need for the staff to be up-to-date with the latest developments and for the classes to be coordinated well. They also expressed the importance of receiving information from specialized professionals, such as midwives. Although they were informed of the existence of the BP document, they stated that information about it was difficult to obtain, and they affirmed that they had used other sources to guide and inform them . Some participants responded as follows:P3: “The information they give you is more or less okay […] but professional staff like midwives should be involved, as this is their field of work and they have more information”.P6: “I think it was in the health center. Then I researched a lot into it myself”. “I asked in the health center if it was possible to visit the hospital facilities, but I got the impression that they didn’t have much up-to-date information and they didn’t know how to respond to many questions”.In general, the women expressed their satisfaction with the experience and with having presented a BP, and valued positively the fact that the medical staff were interested in their preferences. All the participants, apart from one, expressed a high degree of satisfaction.P6: “For me, honestly, it was very positive […] everything was done in the way I had requested […] I was given a fair amount of freedom. The experience I had was very good”.Some mothers requested a greater quality of care after birth and, in this regard, some participants expressed that they would value positively more guidance regarding breastfeeding or skin-to-skin contact.P5: “Things as simple as skin-to-skin or some quick guidance on breastfeeding would have been appreciated... instead, everyone disappeared from the room. They didn’t help me with the issue of breastfeeding and then I had lots of problems”.For most participants, the BP was useful beforehand as a guide and to give them an initial introduction to the experience of labor. However, two of the participants stated that it was of no use at all, as their expectations were not met.P4: “For me yes. It helped me to know all of the options I had when giving birth, as I didn’t know of all of them […]”.The BP provided these mothers with greater peace of mind. The women were fully aware of their rights, and knew that the BP acted as an authentic ‘informed consent’ form, and that the medical staff were required to respect it as much as possible.P1: “At that moment it gave me peace of mind […]; peace of mind, in the sense that if anything happens, the birth plan is there”.The motives that led the participants to draw up a BP coincided with those posed in the ‘Estrategia de Atención al Parto Normal’, as well as with the recommendations from the WHO and the Spanish Society of Gynecology and Obstetrics (SEGO) regarding attention given in childbirth, which mention improving humane aspects and promoting the respect for the physiological process with minimum intervention ,17. WhitAlthough the prenatal classes included all the aspects related to pregnancy, birth and the postpartum period, the fact that the medical staff involved appeared to be up-to-date with the latest developments and were willing to adapt to the needs of modern women were valued positively .As with our participants, Gibeau stated that women showed greater dissatisfaction if the medical professional giving the classes was not familiar with the practice of making BPs . AndersoMost of the studies link the satisfaction of the birth experience with the women’s previous expectations, and the extent to which these were fulfilled . Many auThe women acknowledged the benefits of the immediate initiation of breastfeeding, with the guidance and support of the medical staff, as well as not bathing, weighing and measuring the baby, etc., immediately, and so giving greater importance to immediate skin-to-skin contact . In a stMost participants found the BP useful as a way of acquiring information about the birth process and as an initial contact with the experience of labor. However, other authors concluded that the BP did not improve the experience of birth, but it had beneficial effects with regard to fear and pain . In a reFernández-Arroyo draws attention to the term “female empowerment”, with which he refers to the increased knowledge and self-confidence acquired by women who completed BPs in different aspects relating to pregnancy and labor . This doMouta et al. also considered the BP as a tool for increasing the empowerment of women in the birth process . AccordiAlthough few studies have examined this issue, the lack of material and personnel resources, crowded hospitals, overworked staff and other limitations due to the COVID-19 pandemic have changed health systems in general and, in particular, the obstetric services with implications for pregnant women and their BPs. Thus, some authors concluded that 45% of women altered some aspect of their birth plans because of COVID-19, and reported a much higher preference for out-of-hospital births . FurtherThe results obtained in our study should be taken with caution, due to the limitations of the study. The most important limitation was the sample size, which was low because some women chose not to take part in the study, although the numbers were sufficient to cover all of the study categories. In addition, the study was limited to women who presented a BP at a tertiary hospital, and adherence to the BP was very low.Having a BP provides women with greater knowledge of the process of labor and birth, and it helps them to express their wishes, which are generally related to humanizing the process and experiencing it in the most natural way possible. It is considered as a good communication tool with the medical staff, although greater involvement of the staff is needed, and they should be better trained and more aware of the issues involved. In primary care, there is little information available regarding BPs, and so mothers find information from sources outside the health environment. The degree of satisfaction of these women is related to the level of fulfillment of their expectations. This compliance is influenced by the circumstances of the labor, and the degree of involvement of the healthcare professionals. The women also requested greater care after the birth: in this survey, skin-to-skin contact and the rapid initiation of breastfeeding were two important sources of dissatisfaction. In general, they experienced an empowerment of their own role within the birth process, were able to enforce their own decisions, and were aware of the legal value of the Birth Plan.Implications for the clinical practice: the BP should be considered a useful document in childbirth care. These authors recommend the active participation of women in the process of childbirth, and believe that BPs improve women’s levels of satisfaction with the experience of giving birth, and the communication between the mother and the health staff. In this regard, it is the responsibility of midwives in all primary care centers to provide mothers-to-be with accurate, up-to-date information about the childbirth process.


Haiti has the highest rate of neonatal mortality in the Latin America and Caribbean region. While the rate of facility births in Haiti has doubled over the past two decades, there have been no comparable reductions in maternal or neonatal mortality. Little data is available on the clinical characteristics of complications and morbidities among newborns requiring hospitalization after birth and their contribution to neonatal mortality. There is a need to better understand the status of newborn clinical care capacity in Haiti to prioritize training and resources.We performed a retrospective observational cohort study of neonates admitted to a large public referral hospital in southern Haiti in the first 2 years of operation of a new neonatal unit that we established. All neonate cases hospitalized in the unit in these 2 years were reviewed and analyzed to identify their clinical characteristics and outcomes. Multivariable logistic regression was used to identify independent risk factors of hospital mortality. We present the outcomes for 1399 neonates admitted to the unit during August 2017 and August 2019.The leading cause of death was prematurity, followed by hypoxia and infection. Inborn neonates had better rates of hospital survival than those born elsewhere; they were also more likely to be born via cesarean section and to be admitted immediately following birth. There were no differences between the proportion of premature or low-birth-weight babies born at the hospital or elsewhere. Mortality in the second year of the unit’s operation was 12%, almost half that of the first year (21%). Multivariable regression analysis showed that mortality was consistently higher among premature and very low birthweight babies.With modest investments, we were able to halve the mortality on a neonatal unit in Haiti. Resources are needed to address prematurity as an important outcome since hospital mortality was significant in this group. To this end, investment in uninterrupted supplies of oxygen and antibiotics, as well as ensuring adequate newborn resuscitation, infection control, laboratory testing, and timely morbidity and mortality reviews would go a long way toward lowering hospital mortality in Haiti. Haiti has struggled with multiple development setbacks over the past few decades, impeding its capacity to respond effectively to the healthcare needs of its people . The couHaiti has a three-tiered health care system designed to improve primary care access at the community level –13. MateThe lack of appropriate prenatal care, the low quality of obstetric care, and high rates of eclampsia, obstructed labor, untreated infection, and preterm delivery are persistent factors behind the high rates of maternal and neonatal mortality in Haiti , 17, 18.Sud, to establish a neonatal care unit for newborns needing medical care after birth. The objective of this study was to conduct a retrospective review of neonatal admissions during the first 2 years of the unit’s operation to identify risk factors for hospital neonatal mortality, determine if survival improved over time, and inform newborn care based on our analysis.To care for newborns requiring hospitalization in Haiti, we worked with the leadership at Hopital Immaculae Conception (HIC), a departmental hospital in Les Cayes and serving a population of 774,976 , located in 976 Fig. . There a7 people . The mat7 people . At the Most women arrived at the maternity ward shortly before birth and after laboring at home. Accurate estimates of gestational age were generally not available. Clinical assessment and the date of the last menstrual period were used to establish the gestational age to determine prematurity at the time of delivery. Approximately 15% of births were through cesarean section . BreastfIn June 2017, a team from Dartmouth and GHESKIO, with funding from the Children’s Prize and the WK Kellogg Foundation, established the first neonatal care unit at HIC. The unit functioned at a Level IIA neonatal capacity, caring primarily for newborns who were ill with problems that were expected to resolve quickly with moderate risk of serious complications and no assisted ventilation . Two pedRenovation and expansion of the space, as well as provision of essential equipment, medications, oxygen, and supplies, were completed sequentially over 2 years. We note that there were two incubators in use but due to inconsistent power supply, these were not always reliable. Additional equipment purchased and provided through our grant included eight warmer-bassinets, three oxygen concentrators, four incubators, and a portable ultrasound (for maternity ward). Toward the end of our project, electricity was regularly supplied on the neonatal ward due to the installation of a new generator at the hospital. There were no ventilators on the ward. Although nursing and administrative staff were later integrated into the hospital’s operating budget, the initial investment and technical oversight were provided by our team. All staff reported to supervisors within the hospital and were integrated into the hospital’s human resource structure.Helping Babies Breathe (HBB) at Dartmouth [Essential Care for Every Baby [The two pediatricians (MC and WJB) received 3 months of supervised neonatal training at Dartmouth-Hitchcock Medical Center in the U.S., and GHESKIO and St. Boniface Hospital in Haiti. This included a master training in artmouth . There wery Baby  curriculPatients were admitted to the neonatal care unit from the maternity ward at HIC or were born at other facilities/homes in the region and transferred to the unit by their families. In a small number of cases, newborns were transferred by ambulance from referring facilities. The admitting staff included both pediatricians and nurses. A daily electronic register documenting the date of birth, date of admission, place of birth, weight at admission, prematurity status, major health issue(s), length of stay, and outcome for all infants admitted to the unit, was maintained by the pediatricians in MS Excel©. Data were reviewed quarterly by the pediatricians and Dartmouth-GHESKIO teams to track progress, review mortality cases, and identify major bottlenecks. The final database for this study was a compilation of all admissions to the unit between August 2017 and August 2019. The outcome of interest was an inpatient neonatal death.Based on the assessment of the pediatricians, primary diagnoses were established based on the International Classification of Diseases and Related Health Problems (ICD-10) maintained by the WHO . Due to n = 12) were excluded from the dataset due to their exceptionally poor survival prognosis. Infants older than 28 days were also excluded (n = 11). All neonates taken home against medical advice or transferred out of the unit were excluded from the multivariable analysis, but we compared their baseline characteristics to identify any patterns among those who left. Parents’ reasons for leaving early were numerous: having other children to care for at home; timing with major festivals; lack/cost of room and board for families; and political unrest and insecurity. We suspected that some parents also wanted the child to receive traditional medicine at home or were not confident that the baby could recover at the hospital.A flow chart shows the derivation of the sample and reasons for exclusion Fig. . Very smNeonates who were born at HIC were compared to those who were born elsewhere (at home or another facility) to identify any observable differences in neonatal characteristics using a Pearson’s chi-squared test for categorical variables and Student’s t-test for mean length of stay. Table . Next, wAs this study was based on retrospective data review, patients were not involved in choosing the methods or agreeing to plans for dissemination of the study results to parents and their communities.Les Cayes, the commune in which HIC is located , and the rest were “outborn,” meaning born at home or another facility (n = 477). There were very few differences in the recorded baseline characteristics of patients by place of birth. The proportions of boy versus girl neonates were similar for those born at HIC and elsewhere. Preterm birth complicated one-fifth of all admissions regardless of the place of birth. Less than 1 in 10 babies were from multiple gestation pregnancies. Differences in the neonates’ weights on admission and mothers’ ages were also insignificant by place of birth. Close to one-third of neonates were low or very low birth weight, regardless of the place of birth. A majority of mothers (79%) were between 18 and 34 years of age and 62 (4.4%) were 18 or under.Table The three factors that were significantly different by place of birth were: survival status, the mode of delivery, and age at admission. Mortality was higher among outborn babies (14.5% versus 11.1% among babies born at HIC) and outborn babies were also more likely to be taken home against medical advice (25.8% versus 18.2% among babies born at HIC). The mode of delivery was vaginal for most births, but more so for outborn babies, which included home births (91.4% among outborn versus 74.8% among inborn). The majority of outborn babies were brought in within 1–6 days of birth (45.9%), compared to those born at HIC where the majority were transferred on the day of birth (62.7%). However, most of the admissions were made in the first week of life for all neonates. A higher proportion of births at HIC were through cesarean section (25%) compared to those born elsewhere (9%). Both sets of neonates had similar lengths of hospital stay (mean = 4.3 days).Triage at birth to identify babies at risk was not consistently followed on the maternity ward as 17.3% of babies born at HIC were only admitted to the neonatal unit a day after birth. These babies were either kept in the maternity ward with their mother, where they deteriorated, or sent home and brought back by family members because of illness. Although we do not show the data, home births were more likely to be admitted later than births from other facilities.23 = 0.45, p = 0.930). There were no differences in the diagnoses of prematurity , infection , hypoxia , or encephalopathy  among the two groups. However, Student’s t-test showed that babies taken home early by their parents went home a day earlier on average (mean = 3.4 days) compared to those who stayed . Mothers who left early with their babies had a higher number of live children at home (mean = 1.3) compared to those who stayed .To analyze survival until discharge, we excluded babies who were taken home early by their parents and only included those who either died during their stay or were discharged by the attending pediatrician. Chi-square comparisons of included and excluded babies showed that there were no significant differences between those taken home early by parents versus those staying until discharge or death. Regarding birth weight, babies who were taken home early matched proportionally to those who remained until discharge or death  died during their stay at HIC Table . In term21 = 110.4, p = 0.000). There were notable differences by weight at admission and place of birth; VLBW and LBW babies were much more likely to die than to be discharged  and babies born elsewhere and transferred to HIC also had higher mortality  than inborn babies. Infants born via cesarean had better survival . We also note that neonates admitted on the day of birth experienced higher mortality rates than those admitted a little later . There was also an indication that babies born to teenage mothers under 18 years of age had higher mortality compared to other ages . Finally, we compared mortality in the first year of the unit’s operation (August 2017 – August 2018) to the second year of the unit’s operation (September 2018 – August 2019) and found that mortality on the neonatal unit decreased by 40%, from 1 in 5 babies dying in the first year to 1 in 8 babies dying in the second year . Other demographic characteristics, such as the neonate’s sex or being a twin were not correlated with mortality. Student’s-test showed that the difference in mean lengths of hospital stay was not significant by survival status but trending toward a somewhat longer stay for those who were discharged  and the number of live children was not a risk factor for hospital mortality.Table p = 0.002). As expected, LBW and VLBW babies had higher odds of death when compared to normal-weight babies (NBW); LBW babies were 1.7 times as likely to die before discharge (p = 0.037) and VLBW babies were five times as likely to die (p = 0.000). The odds of dying were 2.2 times higher for babies referred to the hospital than those born at HIC (p = 0.000). Those born through cesarean section had a survival advantage . Mothers who were less than 18 years of age had higher odds of losing their neonate when compared to mothers who were 18–34 years old ; the age of the mother was not a factor in mortality otherwise. Babies admitted 1–6 days after birth  or more than a week after birth  had less than half the odds of dying compared to babies admitted on the day of birth. Finally, after adjusting for observed risk factors, we established that the odds of a neonate dying in the second year of the unit’s operation was 56% lower than in the first half of the project .Logistic regression models were supportive of our bivariate findings Table . After aThis study assessed the neonatal outcomes at a newly formed neonatal care unit in southern Haiti and showed overall mortality of 12.2% during the first 2 years of the unit’s operation. This mortality rate is midrange compared to mortality rates that have been reported in similar settings elsewhere, including southern Eritrea 6.5%), western Ethiopia (8.8%), north-central Nigeria (13.4%), western Haiti (14.5%), south-eastern Nigeria (19.4%), eastern Ethiopia (20.0%), Ghana (20.2%), and southern Ethiopia (25.0%) .5%, west–36. If wAs seen in other low resource settings, mortality was highest among premature neonates; nearly 40% of all preterm babies died compared to 10% of term babies. Among premature neonates in Burundi, a similar disparity in inpatient mortality rate was observed; among those less than 32-weeks gestational age, 31% died compared to 11% among those who were 32–36 weeks’ gestation (11%) . In IndiSurvival was better among neonates born at HIC, likely due to the higher risks associated with home births or births at facilities without cesarean section or other emergency obstetric services. Lower-level facilities in Haiti are poorly equipped to provide obstetric care, even if they manage labor and delivery . We alsoThroughout the first 2 years, there was considerable variability but overall improvements in the delivery of neonatal care. This was driven in large part by the availability of antibiotics, laboratory testing, oxygen, and electricity; however, political instability, holidays, nursing schedules, and seasonal conditions also contributed to the unpredictability of unit conditions. Hot summer temperatures in a crowded unit were dangerous for infection control and hurricane-season rains often flooded the unit. Power outages were common at night and parents often slept on the floor of the unit by the neonatal beds. During renovations, the beds were moved to different parts of the pediatric ward, which affected the time it took to walk the babies over from the maternity ward. Over time, we were able to improve many of these conditions by renovating the neonatal space, providing better-quality furniture and equipment, as well as air conditioning and a steady supply of antibiotics and oxygen. However, the situation remained precarious due to the lack of adequate financial support from the health authorities. Therefore, it is notable that despite these challenges, survival improved over the first 2 years.Another unexpected challenge was poor communication between the maternity and neonatal units. There was no formal referral system, where critical maternal information about labor and delivery would be communicated to the neonatal team. Additionally, neonatal care providers can have a broad influence in a hospital setting by ensuring that midwives and delivery nurses are properly trained in neonatal resuscitation and that parents are informed about maintaining hygiene, initiating breastfeeding, and recognizing newborn illnesses. This was sporadically done at HIC and limited by the poor communication across the two wards. We believe this was reflective of insufficient staffing across the hospital which led to a culture of siloed care within departments. Communication between doctors and nurses was also stifled and the power to ask questions or ask for materials resources was tied to seniority and tenure. Infrastructure was poor across the hospital due to a piecemeal project-by-project approach to building capacity rather than a strategic plan to improve hospital conditions. Better funded programs, such as HIV/AIDS prevention and treatment, were better staffed, equipped, and more efficient.There are some notable strengths to this work. Hospital neonatal mortality data are difficult to access in Haiti, so our study presents a unique opportunity to learn about mortality risks in this important population. We audited a whole patient database of hospital neonatal mortality and were able to document the outcomes over 2 years – also allowing for an assessment of changes in mortality over time. We benefitted from the tireless effort of the pediatricians to document each data point and to alert us of any discrepancies with due notice. Similarly, we were able to discuss data quality issues and address inconsistencies in real time. While we could not do anything about data that were missing altogether, we do trust that the recorded data were of high quality.This study also had several limitations. Although improvements in infrastructure and service-delivery capacity have been associated with improved neonatal survival in other settings , we coulThe potential to improve the quality of care in dedicated inpatient neonatal units in low- and middle-income countries cannot be ignored. There are many missed opportunities to provide effective interventions to neonates in health facilities. First, triage at birth to identify newborn distress must be prioritized to ensure a timely response, especially when treatment is available at the facility. Improving communication between the maternity and neonatal units, with a pediatrician attending complicated deliveries to identify neonates who are at risk of distress and illness, can improve the potential for recovery with earlier intervention. Second, considering the higher mortality among preterm babies, training for preterm care, especially for nurses, must be undertaken. Essential equipment, supplies, and medications, such as warmers, antibiotics, and an uninterrupted oxygen supply, should be made available in the very least. Culture confirmation capacity for suspected infections would improve care tremendously. And finally, Haiti must invest significant financial resources in the operation of newborn units, staffed with skilled personnel, at any hospital with a high-volume maternity ward or one that that receives referrals for complicated deliveries. With modest interventions, we were able to improve neonatal outcomes which is encouraging as we attempt to lower neonatal mortality in Haiti and beyond.