Incidences of unassisted home birthing practices have been increasing in Malaysia despite the accessibility to safe and affordable child birthing facilities. We aimed to explore the reasons for women to make such decisions.Twelve women participated in in-depth interviews. They were recruited using a snowballing approach. The interviews were supported by a topic guide which was developed based on the Theory of Planned Behaviour and previous literature. The interviews were audio-recorded, transcribed verbatim and analysed using thematic analysis.Women in this study described a range of birthing experiences and personal beliefs as to why they chose unassisted home birth. Four themes emerged from the interviews; i) preferred birthing experience, ii) birth is a natural process, iii) expressing autonomy and iv) faith. Such decision to birth at home unassisted was firm and steadfast despite the possible risks and complications that can occur. Giving birth is perceived to occur naturally regardless of assistance, and unassisted home birth provides the preferred environment which health facilities in Malaysia may lack. They believed that they were in control of the birth processes apart from fulfilling the spiritual beliefs.Women may choose unassisted home birth to express their personal views and values, at the expense of the health risks. Apart from increasing mothers’ awareness of the possible complications arising from unassisted home births, urgent efforts are needed to provide better birth experiences in healthcare facilities that resonate with the mothers’ beliefs and values. The World Health Organisation (WHO) aims to reduce maternal and neonatal mortality in all countries by 2030 as one of the targets for the Sustainable Development Goals 3 (SDG 3) . The preHowever, some women prefer birthing at home, as they believe it is safer and provides a better outcome for the mother and baby as compared to birthing at a hospital . In the Planning for birth at home based on risk stratification is also practised in some high-income countries such as the United Kingdom and Australia. These births are planned and only offered to women with uncomplicated pregnancies , 6. ThesWhile the role of skilled health personnel for assisted home births is well established, there is a trend of mothers employing “doulas” or birth companions for their unassisted home births. A doula is a woman who is trained and experienced in childbirth and provides continuous physical, emotional, and informational support to a woman during labour, birth, and the immediate postpartum period . The douWomen choose home birth without skilled birth attendance for various reasons. Physical distance and financial limitation were the two significant constraints in Indonesia . While iHistorically, home birthing in Malaysia was conducted by traditional birth attendants (TBAs) who learned from experience and knowledge passed down from one generation to the other . These tIn Malaysia, there has been a drastic reduction in the rate of maternal mortality, from 540 deaths per 100,000 births in the 1950s to 28 deaths in 100,000 births in 2016. This reduction is observed following a drastic improvement in access to health services and universal health coverage. However, there has been an increasing trend of pregnancy-related deaths outside the health facilities over the past decade. There was an increase of homebirth deaths; unassisted birth or attended by an unskilled person, from 7 in 2008 to 13 in 2014 , 18. ThiNewspapers have reported that women took the risk to give birth at home without the presence of skilled health personnel when their wishes to have home birth were turned down by health care personnel. They resorted to home birth support groups to obtain confidence and support to give birth at home . The extTo the best of our knowledge, there has not been any published literature on reasons why women choose unassisted home birth in Malaysia. Our study aims to explore the reasons why women choose unassisted home births in Malaysia.We used a qualitative approach to explore women’s views and perception of their decision for an unassisted home birth. This approach enables a deeper understanding of their perceptions, perspectives and understandings on the phenomenon . The intThis study was conducted in Kuala Lumpur, the capital city of Malaysia, where health facilities including hospitals (public and private) are easily accessible. According to the Malaysia National Health Morbidity Survey 2015, the mean distance to the government health clinic is about 9.8 km . Access Purposive sampling was used to recruit women who were above 18 years old with intentional unassisted home birth experience. We used a snowballing method to recruit the women as it is suitable to find an unattainable population . We initThe women were interviewed individually using a semi-structured topic guide . We condThis study was conducted using a semi-structured topic guide based on the theory of planned behaviour. Thematic analysis was conducted in an iterative manner and started during the data collection . NAAT, SA deductive approach was used to link generated coding to the theory of planned behaviour. Following this, the researchers used an inductive approach to generate categories and themes. The initial codes which shared similar meanings were collated and categorized together. Categories with similar meanings were further collapsed together into meaningful themes. Overlapping themes were combined and grouped into overarching themes. NAAT, JS, SNR, AIAB, KA, IAI, NHS and SO met up to identify the codes throughout each transcript. Figure Any discrepancies were discussed, and disagreements were resolved. Data reached saturation by the 10th interview when no new theme emerged, and interviews were stopped after the 12th interview when saturation has been confirmed. All authors contributed in writing the manuscript. All authors read and approve the final manuscript.The authors are all primary care physicians in public universities in Malaysia. We believe that birthing should be conducted in a manner that is clinically safe to protect the health and life of both mothers and the new-born. The findings described in this study reflect our personal perspectives and our biases as individuals, mothers and primary care doctors, which we may or may not be conscious of. Finally, we acknowledged the challenges in fully capturing the meanings of the interactions during the interview sessions, which may not be reflected in the written word.In total, 17 women who had unassisted home birth were approached to participate in this study. There were a few women who refused participation. Although the snowballing method was used and a few potential participants were suggested, we assumed that the potential fear of backlash from their information-sharing hindered them from becoming participants or they may have an unfavourable outcome from unassisted home birth. The authors have tried their best to invite potential participants.Table In exploring the reasons for choosing unassisted home birth, four themes emerged from the interviews; being able to have their preferred birthing environment, the belief that birthing itself is a natural and safe process, expression of autonomy and faith.Women in this study repeatedly highlighted the value of home births, for it provided them with the comfort of home and the much-needed privacy during birthing. For some, perceived instrumental and chemical intervention within the hospital setting steered them towards unassisted home birth.“The birthing place; where the mother feels most safe, most comfortable, most secure would be at home and birth is a very personal, very intimate act”IDI 1“It’s (birth) usually is not to be observed. It’s just like lovemaking, it is very intimate, it’s not meant to be observed (by others)”IDI 6For some women, birthing was described as a very personal and intimate process, almost mirroring the act of lovemaking. They perceived unassisted home birth as a conduit to the privacy and comfort that they aspired for. All women unanimously indicated the importance of a comfortable environment during delivery to attain their intimate needs. This became an important influencing factor in choosing home birth.“I want a place that I can feel safe and comfortable. I can relax and give birth easily. That’s how I gave birth at home easily. I’m affected easily by noise and hospital environment. I am very scared of the hospital environment. So I know if I couldn’t give birth at the hospital, I need to get ready to give birth at home. The sterile environment of the hospital...there is a lot of needles, sharp instruments, glaring lights. Those are very intimidating to me. I feel very insecure. When I go to the hospital, I feel like …” God, I’m going to die “ So I don’t like it”IDI 4“...so once I get into the labour room, I feel scared and stressed. It’s going to be cold. I fear the cold... it’s too cold. I’ve been telling people that I was in pain, but I have to deal with the coldness of the labour room. And then even the steel bar that I have to hold on to during pushing, it’s too cold.”IDI 10Their need for intimacy shaped their delivery preference for home-based over hospital setting. The hospital environment was described as a stressful, cold and uncomfortable place to experience the birth of their child. They felt unsafe, scared and had difficulty being at ease when they had their previous births at the hospital.Some women were traumatised by their previous experience of birthing in the hospital and this experience had very much influenced their decision to seek a comfortable environment for their subsequent delivery.“There must be a different way. I’m not going to go through that  again... all I remember was it’s not a very good experience...because I didn’t know what to expect. I didn’t really read up so I just trusted the doctor...you are like most probably dehydrated and so hungry and cold and I am just lying down there on my side …. it was really painful. Now I talk about it and I cringe. I had such a huge cut, and going to toilet is like.. It was horrible, horrible”IDI 8“I was admitted at 8.00 am. 8.00 am until 7.00 pm, I didn’t get to drink even one glass of water, did not eat. I was so restless and tired and was just lying on my back. It wasn’t really a labour ward because it was full and I was like in an extra room with people walking by and going in and out”IDI 2These women were initially introduced to the concept of unassisted home birth by either a close relative, friends or acquaintance. Further reading from home birth books, magazines and online materials that featured topics such as ‘painless childbirth’ or ‘hypnobirthing’ further convinced them regarding the positive side of home birthing and the ability to perform this. Following this, they went through an active phase of learning and information gathering to familiarize themselves with the delivery practices and routines. They received support by attending home birth group classes, online networking and information from online materials or books. The knowledge and support helped to solidify and further strengthened their decision making for a home birth.“... this yoga teacher educated us on the process of giving birth-what happens during your caesarean (section). And then, the mother who just gave birth naturally at home shared with me what happened and things like that. So, I’m like “Oh, pretty interesting eh?” so that’s how I shifted my mind.”IDI 12“I wanted to know more so I read more about pregnancy and all that. So when I read about that hypnobirthing...it just say “this is what I want”. The article is really good. It’s about removing fear, the joy of being pregnant, the joy of giving birth. So, I looked up to the internet, found out more and I called hypnobirthing practitioners. I called two of them, so I choose one of them and I bought the book, I read the book and finished the book before I went to the course. Then it was just like “okay this is what I want to do””.IDI 5The women perceived birthing as an effortless process with minimal or rather lack the risk of harm to mother and the unborn child. They were convinced of their ability for normal birth. Information from the resources on unassisted home birth further strengthen their confidence. They perceived birthing as a physiological process, and one woman explained the process of birthing philosophically as the blooming of a flower.“This (unassisted home birth) is a piece of cake. I gladly want to birth any day or every day because it is easy due to the techniques”IDI 3“Where is the danger? They talk about baby suffocating, drowning or having bacterial infection. There is no injury! Birthing is not an injury and your baby is not here to hurt you”IDI 6“You have to smile while giving birth. You have to breathe and you imagine blooming flower opening. The crowning of the head is actually clear rose is opening like that. And something beautiful and not to be scared...these videos, hospital birth and home birth that uses hypno-birthing techniques in which we saw how calm the women was, the wife, the mother was, and the husband have their roles”IDI 3The women refused any kind of medical interventions such as instrumental or invasive deliveries as they tried to experience as natural birth as possible. Investigation procedures such as monitoring with CTG and augmentation of labour were not preferred as well. All these medical interventions were perceived to increase unnecessary risks to their unborn child.“If you don’t disturb the birth, it’s safer that way. If you don’t disturb, the baby will come out fine. The body will most of the time keep the baby safe”IDI 6“The dilation drugs (referring to medications given increase uterine contraction) actually creates stress on the baby. It’s an artificial way of surges (referring to uterine contractions). That’s why the CTG shows the baby is in stress...There were like 14 procedures or something like that, done systematically upon caesarean section, all of which shocks the baby, who for the past 9 months is safe and sound.”IDI 3“I think it matters how your birth is and the birth itself will affect the child. How the baby comes out, by forceps or by vacuum. It actually affects the spine of the baby”IDI 8“...when you were in labour and then you had meconium, the doctor said its either vacuum or caesarean section. I don’t think it’s the most necessary at that time. Because I don’t feel there was any danger”IDI 6The women in this study expressed wanting to be the decision-maker regarding treatment and care, including the choice of birthing place. They believed medical personnel should not be the one who decides the next step of management during childbirth. Any interference by medical staff during the birthing process takes away the exclusivity and control of their birthing experience.“I’m able to give birth wherever I want... people respect and acknowledge the right that I have, and acknowledge the autonomy that I can choose wherever place that I want (to give birth)”IDI 1“...the freedom for the mothers is to deny or to refuse whatever that she is uncomfortable because all is about the mothers. The mother is battling with life and death battle. “So why are you  telling me what to do?””IDI 3“So, the rhythm of this labour, why is it important and how can you be involved in this labouring process. Because one of the time doctor will tell you “Okay, you come here, then you listen to me.” Hey, now it becomes the doctor’s birth not my birth”IDI 6Before giving birth, some women in this study would develop birth plans which are used to convey their desired birth experience. It generally includes information such as where she wishes to give birth, who will attend a birth, and what forms of medical intervention and pain relief will be used. Their experience of healthcare providers rejecting their birth plan, specifically on home delivery was one of the strong pushing factors to divert against hospital delivery.We discussed the birth plan. But it was not well accepted. You know the first thing doctor said like “Oh! This is very western.” That was his comment. And then like “Oh, we don’t know about this”. Things like that.”IDI 6““He (the doctor) just look at my birth plan and said “okay.. alright,.” It’s like very sarcastic and very like “yeah, right whatever.” You know. So, when he said “Yeah okay I’ll sign it.” But there are a few things he put like a question mark. Like can I move about (during labour) -he put question mark. I could sense that he is not going to change his ways. I found out that he never not did episiotomies. Which is scary. It is a standard procedure for him.”IDI 8Some expressed that by giving the doctors permission to perform intimate physical examinations for example, vaginal examination equates to losing control of their own body. This led to a fear of giving birth in the hospital as they felt their rights were violated once they were in the labour room.“..once when I am in the hospital, they are going to do something that even I won’t do to myself. For example vagina examination. Your husband won’t do to you, even I won’t do it to myself. But, you give up your autonomy to this stranger.”IDI 1“... I didn’t have to be checked all the time (when giving birth at home). Somebody putting their fingers in me and all that.”IDI 3Generally, the women felt that giving birth at home gave them a sense of empowerment. They were able to do normal activities at home during labour, unlike in the hospital where they would be confined to bed for foetal monitoring. They believed that being in control of their body will eliminate fear, thus making birth safer as mothers were more in tune to what was happening in and around them.“It gives me some kind of empowerment. I was able to go about, go upstairs, downstairs, drink water and watch television. I was being relaxed at home. Doing normal things in between the contractions”IDI 3“Eliminate fear and then the women will have confidence. They feel empowered and are more in tuned with their body. That will make birth safer.”IDI 6The women described the birthing process to be partly driven by their feeling of security, being in control of the birthing process and knowing exactly what to do to ease themselves. These feelings combined made them confident in giving birth unassisted at home.“I knew what was going with my body, I’m not insecure or afraid because I know what was going on and I know what it takes to relief myself. All I had to do was to do deep breathing and my husband had to do that light massage to release the hormone” IDI 5“I really wanted to give birth at home.. I will do it myself. Maryam  (peace be upon her) did it herself. I’m going to birth myself...whether I’m at home, in the hospital, in the car, on a tree.. I know what my body does.”IDI 1Women proceeded with unassisted home birth as they have confidence in their ability to continue with the delivery of the newborn naturally as they submit totally to any outcome determined by the Almighty.The women allowed their bodily instincts to lead the birthing process with a trust that an undisturbed birth would most likely to confer into a positive outcome. Total belief and submitting their body and mind wholeheartedly to God gave a sense of calmness to the women.“My level of confidence to God, at that time, I knew you (referring to God) created me to give birth naturally because you (referring to God) are the Fairest, Most Loving. You are not subjecting me to the pain. Because of that, I am relaxed about giving birth at home.”IDI 3“It’s a very spiritual experience. There are many people who felt during the birth … spiritual presence or whatever. Feel connected”IDI 6These women believed their pregnancy itself was a gift from God, and God also drove the process of birthing. This stance provided the courage to overcome the fear of labour as they surrendered to any outcome that might occur.“You see, that’s why our five ... The first one is Trust in God, right? Basically that helps to remove fear because when you remove fear you can hear your instinct clearer. Because when you are scared your body tensed up. Then you, actually create the complication” IDI 6“It’s so magical because I surrendered to God. ... Not doctors, not nurses, not my mother or mother-in-law, or my dad. Ultimately it’s you and God... between life and death”IDI 3These women believed that by total submission to God, they do not need medical advice, and they are fully responsible for their decisions. With this firm belief, they are free to choose their birthplace and whatever consequences that may happen is because of fate.“Fate and destiny isn’t it? There will be risks wherever you give birth, either in hospital or at home.”IDI 2“I’m a perfect creation of my God and why do I doubt my creation? We (humans) are perfect. We can give birth; we can be pregnant.”IDI 12One woman reported a critical situation when her baby was born, and there was suspicion of a complication from the birth process. She reflected the miracle of total submission to God even though her baby was born lifeless with the umbilical cord encircling around the neck.“You know the transition of the “spirit” coming in …. because when my baby was born she did not cry. There was no sign of her at all. This is scary ... and the next thing you know...she cried right after the adzan  and you’ll be in awe”IDI 12Birth should be a positive life-changing experience, but it is also a significant life event that could have profound effects on a woman’s physiological and psychological wellbeing. This study seeks to find reasons for women to choose unassisted birth at home. Not many women had chosen to do this, and among those who had, most were quite reserved to discuss the topic outside of their inner-circle.In this study, none of the women was pregnant at the time during the period of the interview, and the women had unassisted homebirth a few years ago. Only one woman had unassisted home birth during her first pregnancy. The other women only resorted to unassisted home birth following their previous hospital births. Hence, the mean age of women in this study is comparatively older compared to the local, national mean age of childbearing, at 30.74 years old . SimilarThe four themes that emerged from the interviews strongly relate to the needs of these mothers; having a beautiful and natural birthing experience while still maintaining the autonomy to decide what they perceived best for them. Our study concurs with a review that reported about first-time mothers who wished that their needs to be respected during labour, ‘to feel involved in the care’ and to have their partners supporting them in their journey . The setIn this study, privacy is one of the main reasons for mothers to choose unassisted birth. The hospital environment was perceived as exposing the mothers to strangers, namely hospital staff. However, maintaining privacy is a challenge in any hospital settings . The medThe United Nation Global Strategy for Women’s, Children’s and Adolescents’ Health acknowledges the need to address not only the clinical requirements for a safe labour and childbirth but also the psychological and emotional needs of the women involved . The womTo materialise the concept of maintaining a good psychological and emotional wellbeing of mothers, one needs an adequate number of trained, skilled health care personnel. At the current state, midwives (or nurses with post-basic midwifery training) in the Malaysian public healthcare setting are overwhelmed with their clinical duties. The 2010 local statistics highlighted that there are about 400,000 deliveries in Malaysian public hospitals, and they are conducting about 200 births per person . The recQuaternary prevention is a concept that emphasizes on “first, do no harm”. It is developed by a Belgian family physician, Marc Jamoulle. It is a set of activities employed to identify people who are at risk of over-medicalisation and to reduce unnecessary or excessive interventions to minimise iatrogenicity . This coThe medicalization of birth has created a division between “natural” and “medical/hospital” birth. Antenatal and intrapartum care has improved tremendously over the past decade, and this has resulted in the increasing ability to recognise and address possible complications arising from pregnancy and birth. Some women in our study strongly believed that birthing is easy, safe, and God had created their body capable of giving birth naturally and independently. Perceived competency could be a motivator to their decision making for unassisted home birthing –42. HaviThe technology of modern medicine is synonymous to images of drug-induced births and instrumentation during delivery, which leads to fear of the interventions being given during the hospital birthing process. The “no intervention” during home birth may contribute to the perception that unassisted home birth is safer than the hospital . A localThe women in our study had a few misconceptions regarding interventions during birthing, which were perceived as unnecessary risks to them and their unborn child. In particular, the medical interventions to hasten delivery such as augmentation of labour and assisted delivery when there is a sign of foetal distress. A meta-analysis comparing outcomes of women who had planned home births and planned hospital births in 2010 showed a doubling of the neonatal mortality rate in planned home births (regardless of assistance) . The womOn the other hand, a systematic review and meta-analysis of planned place of birth among low-risk pregnancies in high incomes countries showed no significant differences in early neonatal death between planned births at home (assisted births) and in hospital . AnotherBeing involved in decision making and wanting to be in control in their birth plans gives the women in this study a sense of control which concurs with previous studies , 40, 49.Shared decision making (SDM) is an important element in healthcare as it empowers the patient in the management of their condition and promotes good doctor-patient relationships. SDM is already a common practice in Malaysian healthcare settings in general. In the SDM model, doctors use their professional expertise to present and explain options to patients, and patients use this information to develop preferences based on their values and priorities. Both parties then negotiate a final shared decision. This model assumes that the patient can participate in decision making; however, doctors will need to know when good decisions are not being made and how to intervene appropriately . It is aIn our study, women were seen to be surrendering themselves in total to God. Compared to previous studies, this emerging theme of “faith” plays a strong role in their decision making, and it made them choose unassisted home birthing as they strongly believe that God will assist with the birthing process, even if it happens to be a difficult one. This is similar to another report that patients’ belief in God and prayer were so strong that they believe they no longer need conventional medical care . The womtawakkal”. However, according to the teachings of Islam , apart from having the concept of “tawakkal”, there is also the need to seek professional medical help as part of their effort to ensure a safe pregnancy and birth [It is important for health professionals to acknowledge women’s beliefs and at the same time, to treat the women holistically, regardless of their religious beliefs. These women made their decision to birth at home without medical assistance, with the strong belief that God will be there to help them; a concept of “nd birth . The offnd birth . This isnd birth .Some women in this study still receive their antenatal care from either the public or private healthcare facilities and their reason was to ensure that they are free of any kinds of diseases like gestational diabetes or hypertension in pregnancy that may interfere or impair their pregnancy and its outcome. This highlights the crucial role antenatal care may have in identifying potential women who may plan to have unassisted home births. The antenatal team may be able to intervene unassisted home birth plans by providing individualized care with good interpersonal and clinical skills in a respectful manner at every contact. Obstetric risk stratification and availability to have trained and skilled healthcare personnel are crucial to determine suitability to have assisted home births.The strength of this study is this is the first paper to explore the phenomena of unassisted home birth in Malaysia, a middle-income country with a good and accessible health system. This study included mothers who had personal experience of unassisted home birth, and they are of variable backgrounds . However, our limitations are that only women who had a favourable outcome and positive unassisted home birthing experience participated in this study. Thus, their reasons for choosing unassisted home birth discussed here may not represent other women who have given birth at home. The authors did not analyse the maternal age at the time of their unassisted birth; thus the women in this study may falsely be labelled as “older mothers”.This qualitative study observed that the need to keep the birthing comfortable and private, the belief that birthing itself is a natural and safe process, wanting autonomy and faith as reasons for choosing unassisted home birth. The findings highlighted that the current maternal healthcare is less appealing to some women. More resources are needed in creating a more personalised birthing within the hospital setting without compromising safety matters. The current issue of lack of workforce (trained midwives) needs to be addressed so that we can provide more women-friendly services in the hospitals as well as providing services for low risk assisted home births.


A total of 370 (39%) subjects completed a survey on reproductive rate, fertility problems, pregnancy complications, and perinatal outcomes of their offspring. We tested differences in these parameters between the VPT/VLBW subjects and their peers from Dutch national registries. POPS-35 participants had less children than their peers in the CBS registry. They reported more problems in conception and pregnancy complications, including a three times increased risk of hypertension during pregnancy.Evidence suggests that increased survival over the last decades of very preterm – and very low birth weight –born infants is not matched by improved outcomes. The objective of our study was to evaluate the reproductive rate, fertility, and pregnancy complications in 35-year-old VPT/VLBW subjects. All Dutch VPT/VLBW infants born alive in 1983 and surviving until age 35 (Conclusion: Reproduction is more problematic in 35-year olds born VPT/VLBW than in the general population, possibly mediated by an increased risk for hypertension, but their offspring have no elevated risk for preterm birth. Preterm birth is the major cause of neonatal deaths in the Western world. Over a third of the estimated neonatal mortality is associated with preterm birth complications, such as respiratory distress syndrome, intraventricular hemorrhages, necrotizing enterocolitis, and sepsis . The estAdvanced perinatal technology and improved neonatal care greatly increased the survival rate of VPT and VLBW infants over the last decades. Current evidence suggests that increased survival is not always matched by an improved outcome –7. ThereIn the Netherlands, consequences of VPT/VLBW birth have been extensively studied in the Project on Preterm and Small for Gestational Age (POPS) which comprises a nationwide multicenter birth cohort, born in 1983 . The POPThe population consisted of all VPT and/or VLBW infants born alive in the Netherlands in 1983 . The ProWe compared the reproduction rates of our POPS-35 sample to those available from the Dutch National Population Registry (CBS) . Total nThe incidence of pregnancy and delivery complications in POPS-women regarding their first live-born child was compared with data from the Dutch National Perinatal Registration PeriNed . PeriNedIt was not possible to isolate POPS participants from the registry data, due to strict privacy protection regulations. The Medical Ethics Committee of the Leiden University Medical Center had approved previous POPS study protocols and the Medical Ethics committee of TNO approved the subsequent amendment concerning the POPS-35 study.Self-reported reproductive outcomes included in the online questionnaire were as follows: relationship , infertility , conception , pregnancy complications -eclampsia, gestational diabetes), delivery mode , placental pathology , number of children , and offspring perinatal outcome .The choice for these outcome measures was based on data available from national population registries and from a questionnaire study about pre-eclampsia . Gestatin = 370) and eligible non-participants (n = 585) in distributions of gestational age, birth weight, sex, disability (derived from the HUI questionnaire at age 14), and parental level of education (at POPS’ age 14) could be evaluated. Differences between participants and non-participants in the distributions of continuous variables were tested by means of independent samples two-sided t tests for equal variances, categorical variables by Pearson’s chi-squared tests, and ordered categorical variables by linear-by-linear association tests. Differences between the POPS cohort and the data of their peers from the CBS and PeriNed registries were tested with one-sample two-sided t tests for continuous variables and Pearson’s chi-squared tests for categorical variables. A difference was considered statistically significant if the p value was below 0.05.POPS participants are generally very willing to contribute to follow-up assessments, but in cohort studies, attrition always occurs. Fortunately, the POPS cohort is well documented and potential selection characteristics were available from several assessments in the past. Thus, differences between participants  agreed to participate in the study. The characteristics of the participants in the POPS-35 study and eligible non-participants are presented in Table Data presented in Table Table Table A quarter of the 141 POPS-35 females who had ever tried to conceive reported problems in getting pregnant (tried for > 1 year) and 16% of POPS-35 males reported such problems with their partner. A quarter of both POPS-35 females and partners of males went through a miscarriage in one or more pregnancies. Twenty POPS females visited a fertility clinic, nine of whom had fertility issues; in three cases, this concerned their male partners, while in eight cases, no medical cause was found. Six POPS males visited a fertility clinic, of whom two had fertility issues; in two cases, this concerned their partner and in two cases, the cause remained unknown.In Table Data from Table In 28 pregnancies (24%), the mother experienced hypertension during pregnancy, which is higher than the 9% reported in PeriNed. Furthermore, 17 (14%) women had a pregnancy complicated by (pre-)eclampsia, compared to 0.4% in PeriNed. Six women (5%) had gestational diabetes, which is not significantly different from the 3% in PeriNed.POPS-35 females did not differ from PeriNed females regarding delivery mode or placenta pathology during delivery. Their first child had a similar mean birth weight to those in PeriNed, but POPS-35 children were born after a longer pregnancy duration and were more often admitted to the NICU.The firstborns of nine POPS-35 females (8%) were born preterm, namely before 37 weeks of gestation, which is comparable to 9% preterm births in PeriNed. Thirteen POPS-35 females who had children (11%) gave birth to a preterm born infant in one or more of their pregnancies.p = 0.36) and mean birth weight .Of the 118 females who had given birth to any child, 45 were born small for gestational age (SGA), 72 appropriate for gestational age (AGA), and for 1 female this was unknown. Neither pregnancy complications nor perinatal outcomes of their firstborn child differed between SGA and AGA women. The pregnancy of the first child of the females born SGA was not more often supported by ART (both SGA and AGA 13% ART) and a comparable percentage of females experience hypertension during pregnancy (24% for SGA and 23% for AGA), but the numbers were small. Furthermore, the first child of females born SGA did not differ from those of females born AGA with respect to mean GA at birth  . We founWe found much higher rates of gestational hypertension and (pre-)eclampsia in pregnant POPS-35 females than reported in PeriNed. It should again be noted that PeriNed warns for potential under-reporting of (early) pregnancy complications, but such under-reporting probably also occurred in POPS-35, since concordance between self-report and care professional-report has been documented , 39. TheThe study by Boivin also showed more pregnancy complications within females born SGA . The curPOPS-35 females reported higher rates of NICU admissions among POPS-35 offspring than in PeriNed, possibly because of higher rates of pregnancy complication and higher rates of instrumental and caesarian deliveries (not significant). However, the self-reported reasons for NICU admissions included neonatal problems that usually require admission to a high/medium care unit in a general hospital, and not so much a NICU, such as a late preterm birth. This might suggest that the difference between these levels of neonatal care was not so clear for some parents, which may have confounded the results.www.recap-preterm.eu) and in addition to a worldwide research collaboration on adult outcomes of VPT/VLBW birth (www.apic-preterm.org). Such collaborations may be helpful in consolidating all European and worldwide data available on VPT-/VLBW-born children and adults, in order to develop more effective, evidence-based, and personalized interventions.Due to the fact that the POPS-35 participants will be in their reproductive age for at least five more years, one last follow-up is needed in order to draw final conclusions about the reproductive outcomes of the POPS cohort and to be able to identify which extra care is needed. To obtain sufficient statistical power—a well-known and inconvenient issue in studies of VPT/VLBW birth cohorts—POPS is cooperating in a European Union–funded RECAP-preterm platform (Research on European Children and Adults born Preterm; A major strength of the study is the variety of detailed reproductive outcomes that could be measured, providing a comprehensive overview of influential factors on the reproductive outcome of preterm born adults. Another strength is the possibility to look far back in time , enabledOne of the limitations was the relatively small number of women who had been pregnant in our POPS-35 study and who had experienced problems. That might have nullified smaller differences in fertility or pregnancy complications. Moreover, because of this, we made no differentiation between POPS participants who were spontaneous or iatrogenic VPT born, both of which have different underlying pathophysiology, or born small for gestational age.There were no differences in mean gestational age nor birth weight between POPS-35 participants and non-participants. Therefore, selection bias by biological variables that are hypothesized by DOHAD to be related to these parameters  probablyAnother limitation is that no matched control group is available for the POPS cohort. Fortunately, national registries were available for comparison, which is second best to a matched control group. However, the PeriNed registry is completed by physicians, while the collected data is self-reported, both of which show under-reportage of early pregnancy complications .We found lower rates of reproduction, and higher rates of sub-/infertility problems and pregnancy complications in VPT/VLBW females at the age of 35 years than in the general population. Personalized pre-conception counseling and close pregnancy monitoring may help VPT/VLBW females to beat the odds and complete their pregnancies with healthy outcomes for both mother and child.


Intrathoracic mesothelial cysts are congenital lesions induced by the abnormal development of the pericardial coelom. There have been a few reports of giant mesothelial cyst of the superior mediastinum, but the preferred treatment remains a controversial topic. We herein report a rare case of successful removal of giant mesothelial cyst that was incidentally detected during a medical checkup.A 53-year-old man with a feeling of mild chest tightness was referred to our hospital for the evaluation of an abnormal shadow of the mediastinum on chest X-ray. Computed tomography showed a multilocular, homogenous, large cyst in the superior mediastinum measuring 18 cm in size without contrast enhancement and with spotty calcification, and magnetic resonance imaging showed a low intensity on T1-weighted images and high intensity on T2-weighted images. Therefore, a cystic thymoma, thymic cyst, lymphangioma, cystic teratoma or pericardial cyst was suspected as the preoperative diagnosis. Despite mild symptoms, the patient underwent total thymectomy under median sternotomy for an appropriate diagnosis and treatment. The pathological diagnosis was giant multilocular mesothelial cyst.Intrathoracic mesothelial cyst is a benign cyst and generally asymptomatic, but can sometimes induce critical chest clinical symptoms if untreated, depending on its size. In our case, complete surgical resection and a detailed pathological evaluation was effective for making the appropriate diagnosis and delivering treatment. In addition, an immunohistological evaluation is effective for diagnosing mesothelial cysts when it is difficult to distinguish the cyst from other cystic lesions. The occurrence of mesothelial cyst of the mediastinum is rare, accounting for 3–6% of all mediastinum tumors. These cysts are usually asymptomatic and are of little clinical importance, being classified as congenital abnormalities . They maWe herein report a rare case of a patient who underwent total thymectomy for a giant cyst of the upper mediastinum and was diagnosed with mesothelial cyst of the upper mediastinum by an immunohistological examination.The patient was a 53-year-old man who was referred to our hospital because of an abnormality at a medical checkup. He did not have a medical checkup for more than 5 years. He sometimes had a feeling of mild chest tightness. Chest X-ray showed an abnormal mass in the right pericardial region Fig. . PhysiolPreoperative computed tomography (CT) showed a large, superior-to-anterior mediastinal, fluid-filled and well-demarcated cyst. The cyst extended from the superior mediastinum caudally on the right atrium to 18 cm in size. The anterior–posterior component measured 5.6 cm. There were septations and spotty calcification, but no solid component in the cyst, which had a slightly greater CT attenuation than water Fig. . The remDespite the mild state of his symptoms, we decided to surgically remove the cyst because of the possibility of the coexistence of varied malignancies or the induction of critical manifestations if it ruptured, including hemorrhaging or compression of the surrounding structures. Total thymectomy under mediastinal sternotomy was performed with the successful removal of the intact cyst. During the surgery, a well-encapsulated and thin-walled cyst filled with serous fluid was observed in the superior-to-anterior mediastinum that adhered to the internal thoracic artery but did not invade it. We did not need to divide any thoracic major vessels because the cyst was separated from them. The tumor was 15 × 8.5 × 2 cm in size with grayish-white discoloration Fig. a. The cuBased on these findings, the pathological diagnosis of intrathoracic mesothelial cyst of the mediastinum was made. The patient was discharged without any post-operative complications 7 days after the operation, and was followed up for 2 months post-operatively without any recurrence.Mesothelial cysts are benign entities that are classified as congenital tumors and usually diagnosed in the fourth to fifth decade of life. They are generally unilocular, small and contain clear fluid within a thin wall. As their classic anatomical location is in the cardio-phrenic angle, they are also referred to as pleuro-pericardial cysts. The incidence of unusual locations, such as the chest wall, mediastinum and diaphragm, is between 8 and 11% . RecentlThe atypical locations of mesothelial cysts have embryological causes, as these cysts are congenital lesions due to an anomaly in the development of the pericardial coelom. During development, incomplete fusion or secondary migration of isolated elements, such as a lacuna, can occur at the level of the parietal pleura, mediastinal pleura or septum transversum, which explains the unusual locations of mesothelial cysts . On occaIn the diagnosis of mesothelial cysts, we cannot easily distinguish preoperatively whether or not a cystic lesion is another type of mediastinal cyst. In our case, since the cyst was located in the right upper pole of the thymus and uncommonly multilocular, it was difficult to distinguish it as another tumor, such as a thymic cyst, which is derived from thymic tissue. Although mesothelial cysts are usually unilocular , CangemiAlthough consensus- and evidence-based guidelines on the management of giant mesothelial cysts are currently lacking, therapeutic treatment, such as puncture or extirpation of the cyst, is occasionally necessary. We recommend removing a cyst surgically when encountering a giant benign mediastinal cyst for which the diagnosis is unclear, for two reasons. First, there is the possibility that the benign cyst may mask other pathological changes of the thymus or other malignant tumors. In some reports, benign mediastinal cysts, such as thymic cysts, which have similar radiological and pathological findings to mesothelial cysts, have been associated with various malignancies, including thymic carcinoma, thymoma and lung carcinoma . SurgicaWe herein report a rare case of an unusual large multilocular mesothelial cyst of the superior mediastinum that was successfully extirpated. For the accurate diagnosis and treatment, asymptomatic large benign cysts carrying a risk of exerting compressive effects in the near future or concealing malignancies should be surgically removed. Furthermore, immunohistological examinations will support the correct diagnosis of mesothelial cysts.


Despite the disproportionate prevalence of gestational diabetes (GDM) and preterm birth (PTB) and their associated adverse perinatal outcomes among Black women, little is known about PTB among Black women with GDM. Specifically, the relationship between PTB by subtype (defined as indicated PTB and spontaneous PT labor) and severity, GDM, and nativity has not been well characterized. Here we examine the risk of PTB by severity  and early term birth (37 to 38 weeks) by nativity among Black women with GDM in California.This retrospective cohort study used linked birth certificate and hospital discharge data for 8609 of the 100,691 self-identifying non-Hispanic Black women with GDM who had a singleton live birth between 20 and 44 weeks gestation in California in 2013–2017. Adjusted odds ratios (aOR) and 95% confidence intervals (CIs) were examine risks for PTB, by severity and subtype, and early term birth using multivariate regression modeling.p = 0.5963). Overall, 14.2% of US- compared to 8.9% of foreign-born women had a PTB .Approximately, 83.9% of Black women with GDM were US-born and 16.1% were foreign-born. The overall prevalence of early PTB, late PTB, and early term birth was 3.8, 9.5, and 29.9%, respectively. Excluding history of prior PTB, preeclampsia was the greatest overall risk factor for early PTB , late PTB , and early term birth . There was no significant difference in the prevalence of PTB by subtypes and nativity (Foreign-born status remained protective of PTB, irrespective of severity and subtype. Preeclampsia, PTB, and GDM share pathophysiologic mechanisms suggesting a need to better understand differences in perinatal stress, chronic disease, and vascular dysfunction based on nativity in future epidemiologic studies and health services research. Nearly 86% of pregnancies impacted by diabetes are the result of gestational diabetes mellitus (GDM) , 2. GDM,In the U.S., maternal country of origin may be a proxy for the impact of structural oppressions and life course experiences of over/chronic exposure to gendered racism, classism, and other forms of discrimination unique to Black women. However, traditional “big data” epidemiological studies that rely on administrative databases tend not to contain structural and neighborhood factors to allow for temporal or spatial contextualization of the data beyond individual behavior or characteristics. Thus, we propose the application of a public health critical race (PHCR) praxis as a methodology to interrogate the racialized social and clinical phenomenon of PTB among Black women with GDM in California in quantitative population health research. In this manner, we hope to avoid the reproduction of “mother blame” narratives  and struTo date, there are limited data that describe the association of nativity and PTB by severity and subtype, and early term birth, respectively, in a high-risk population of Black women with GDM in California. To address this gap, we examined the risk of early PTB (< 34 weeks), late PTB (34–36 weeks), and early term birth (37–38 weeks) by nativity among Black women with GDM.The utilization of the PHCR praxis informs two key study assumptions: 1) structural racism creates a hierarchy of power, domination, and privilege in society that impacts the distribution and expression of illness and health as well as access to and utilization of resources to meet and maintain basic social needs ; and 2)This retrospective cohort study used linked birth certificate and hospital discharge data for 2,096,608 women who had live singleton births between 20 and 44 weeks gestation without chromosomal abnormalities or major birth defects in California from 2013 to 2017. From a population of 100,691 self-identifying Black women in this sample, we identified 8609 non-Hispanic Black women with GDM for this study. Fig. Birth certificates, maintained by California Vital Statistics, were linked to a hospital discharge, emergency department, and ambulatory surgery records maintained by the California Office of Statewide Health Planning and Development. These databases contain detailed information on maternal and infant characteristics, hospital discharge diagnoses, and procedures. Hospital discharge, emergency department, and ambulatory surgery files provided diagnoses and procedure codes based on the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9) and International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10) as reported to the California Office of Statewide Health Planning and Development by the health care facilities.> 39 to 44 weeks, controls, inclusive of full term (39 to 40 weeks), late term (41 to < 41 weeks), and post-term (42 weeks and beyond)]. Best obstetric estimate of gestation at birth was obtained from birth certificate records [> 40 years old), history of PTB among multiparous birthing persons (yes/no), maternal education , participation in women, infant, and children’s (WIC) program (yes/no), diagnosis of preeclampsia in the index pregnancy (yes/no), smoking during pregnancy (yes/no), payer status for birth , self-pay, or other employer based/individual insurance plans), pre-pregnancy body mass index (BMI = weight in kilograms divided by height in meters2) across six categories (< 18.5 (underweight); 18.5 to 24.9 ; 24–29.9 (overweight); > 30 kg/m2 (obese); obesity defined as BMI > 30 across 3 categories (BMI of 30 to < 35 (Class 1); BMI of 35 to < 40 (Class 2); BMI of 40 of higher ), adequacy of prenatal care utilization , between 34 and 36 weeks , between 37 0/7 to 38 6/7 weeks , and term birth [ records . PTB was records . The pretelchuck , and birtelchuck , 49 for telchuck .Three types of PTB were assessed: preterm premature rupture of membranes , spontaneous labor with intact membranes, and provider initiated for maternal, placental, or fetal indications. The birth was identified as spontaneous PTB when medical records demonstrated PPROM or spontaneous labor with intact membranes. PTB was determined by gestational age at birth. As previously described by Jelliffe-Pawlowski et al.  in 2015,Univariate and bivariate comparisons of gestational groups were determined using chi-square analysis between U.S.-born (the referent group) and foreign-born Black women. Bivariate logistic regression was used to calculate the crude odds ratios (cORs) and 95% confidence intervals (CIs) for the associations of nativity and gestational duration adjusted individually by covariates. In addition, odds ratios, adjusted for maternal and obstetric characteristics (aORs) and 95% CIs were calculated to evaluate the relative risk of PTB, by severity and subtype, and early term birth using multivariate regression modeling.p <  0.05. To assess for confounding, the cORs, aORs, and standard Wald 95% CIs were examined for differences in gestational outcome groups by these covariates based on nativity. If the magnitude of adjusted association changed by 10% or greater, the potential confounder was included in the final model.Effect modification was determined by calculating stratum-specific estimates of associations between covariates and each gestational group using the Breslow-Day test for homogeneity of the risk ratios with statistical significance, p < 0.10 to enter the model and p < 0.05 to remain in the model), with inclusion of covariates and interaction terms between covariates and nativity with a significant association with each the three gestational outcome groups as well as confounders between nativity and the gestational groups. Likewise, interaction terms between covariates were assessed that were considered clinically important based on the clinician authors domain knowledge and areas of expertise in high risk obstetrics hospitalist care, public health, and applied epidemiology, and found to be relevant in the literature and clinical practice across all three gestational groups.Backward stepwise regression was used for final model building  was used to analyze data received by the California Preterm Birth Initiative at the University of California San Francisco as of March 1, 2020. Methods and protocols for the study were approved by the Committee for the Protection of Human Subjects within the Health and Human Services Agency of the State of California.n = 7222 of 8609; 83.89%) U.S.-born Black women with GDM, compared to foreign-born, were more likely to give birth under the age of 25 years , obtain 12 or fewer years of formal education , participate in WIC , develop preeclampsia at birth , smoke in pregnancy , use Medi-Cal , have pre-pregnancy obesity class I , class II , and class III , and achieve adequate or adequate plus prenatal care  (Table n = 245).Demographic characteristics of study participants are shown in Table p = 0.0293), preeclampsia*smoking (p = 0.0008), and smoking*obesity (p = 0.0004) (Table There were 328 (3.8%) early PTBs, 820 (9.5%) late PTBs, 2570 (29.9%) early term births, and 4891 (56.8%) full term births in the sample. Compared with U.S.-born Black women with GDM, the odds of early PTB, late PTB and early term birth were reduced by 50, 40, and 30% respectively , cOR 0.6 , and cOR 0.7  (Table p = 0.0037), preeclampsia*smoking (p = 0.0318), and smoking*obesity (p = 0.0081)  and intermediate PNC utilization ) were significantly associated with a lower odds of late PTB. Prior PTB ), preeclampsia ), self-pay insurance status ), education < 12 years ), smoking ), class II obesity ), class III obesity ), and Medi-Cal ) were significantly associated with increased odds of late PTB. No significant associations were observed between late PTB and maternal age, and WIC participation  wep = 0.0282) ) and intermediate PNC utilization ) were also significantly associated with lower odds of early term birth. Prior PTB ) and preeclampsia ) were significantly associated with increased odds of early term birth. In contrast to early PTB and late PTB, pre-pregnancy obesity across all three classifications, class I ), class II ), and class III , was significantly associated with increased odds of early term birth. No significant associations were observed between early term birth and maternal age, education, WIC participation, smoking, payer status at birth, or birth types (Table .5) and pp <  0.0001), with the largest contribution towards PTB burden found among foreign-born Black women in California from Ghana (11.8%), Other (10.3), Nigeria (10.2%), Somalia (8.3%), and Ethiopia (6.9%), respectively (Table p = 0.5913) in the sample population ), late PTB ) and early term birth ) , suggesting that these predictors did not fully explain the protective effect of foreign-born status among Black women with GDM in California. In addition, the association of nativity with early term births remained similar (aOR = 0.73), providing further evidence that these predictors did not fully explain the protective effect of foreign-born status. Thus, the disparity in early term births between U.S.-born and foreign-born Black mothers with GDM based on nativity raises questions and concerns about potential variations in quality of care, patient understanding and autonomy, and glycemic surveillance, reporting, and control mechanisms. As such, further investigation of structural, social, and clinical factors will be critical areas of investigation in follow-up studies.In this study, the most common predictors of PTB among Black women with GDM, regardless of PTB severity, were history of prior PTB, preeclampsia, smoking, and class II obesity. Given the context of structural inequities in perinatal and reproductive health in the U.S., and the American College of Obstetricians & Gynecologists (ACOG) 2013 treatment guidelines for preeclampsia with severe features at > 34 weeks versus < 34 weeks, , where tAdditionally, a subanalysis of birth types by gestational groups revealed high hospital performance of cesarean births among 3 out of 4 Black women with GDM who experienced an early PTB, and nearly every 2 out of 3 Black women with GDM who experienced a late PTB in our sample of Black women across California. Given the most common predictors of PTB among Black women with GDM, regardless of PTB severity, were preeclampsia, smoking, and class II obesity, within the context of provider-initiated births as a result of preeclampsia, and the high hospital performance of early PT and late PT cesarean births, our data raises concern for the increased burden of PPH and its social and clinical sequelae among Black women with GDM in California who experience PTB. A potentially prolonged labor induction with prolonged use of oxytocin and magnesium sulfate, along with the inability to use methergine as a primary uterotonic due to its contraindication in patients with hypertensive disease, increases the likelihood that Black women with GDM, obesity, and preeclampsia will likely experience uterine atony with PPH, requiring administration of blood products, particularly during a cesarean birth. These data suggest a need for different clinical approaches to optimizing the care, experiences, and outcomes for Black women with GDM and obesity, who either present and/or develop preeclampsia at early and late PTB, given the risk of both short- and long-term perinatal morbidity that may impact the woman and child.Additionally, hemorrhage that leads to blood transfusion is a leading cause of severe maternal morbidity (SMM)  and BlacTo the best of our knowledge, as of April 2020, this is the first quantitative population health research study to evaluate the association of nativity, PTB, by severity and subtype, and early term birth, respectively, in a high-risk population of Black women with GDM in California. Other study strengths include: 1) use of a large, population-based sample with a single racial group exclusive to Black women with GDM; 2) sufficient statistical power to adjust for important covariates; 3) delineation between PTB subtypes: PPROM, spontaneous PTB with intact membranes, provider initiated PTBs, and unknown subtype; 4) stratification of PTB subtypes by maternal country of origin for the countries with the largest proportion of foreign-born Black women with GDM in the sample; 5) evaluation of interactions between nativity and all maternal characteristics, and between key maternal characteristics, including preeclampsia, smoking, and obesity; and 6) explicit acknowledgement and utilization of an anti-racist praxis undergirding our study assumptions and methodologies.While we believe that the strengths of the study far outweigh its weaknesses, it is important to acknowledge a number of limitations that will be critical to address in future studies. These limitations include: 1) an inability to diagnose or find a rationale for medically-indicated early term birth; 2) a lack of information available for us to determine and assess patient, provider and systems level factors such as patient knowledge and autonomy, nutritional intake, referrals to paraprofessionals, magnitude of glycemic control, and group GDM and prenatal support; and 3) inability to measure key variables associated with birth and nativity such as pregnancy wantedness, stressors, and supports within the context of the social ecological, life course, and resiliency perspectives, and access to social capital.There is an urgent need for advanced epidemiological and health services research to identify the underlying causes of excess PTB and early term births among U.S.-born Black women with GDM. This study serves as a building block for epidemiologists, clinicians, and clinician scientists, and suggests that PTB and early term birth may be in part due to chronic inflammation or vasculature dysfunction in response to chronic life stressors. New, prospective, and longitudinal research would benefit from a focus on measures of acculturation, life course experience of structural and interpersonal gendered racism and other stressors, biomarkers, and glycemic control in order to gain a fuller understanding of PTB and early term birth drivers. In addition, given the strong associations between PTB, GDM, preeclampsia, and obesity, future studies should examine the relationships between glycemic control intensity and type of medical management for GDM, PTB and early term birth subtypes, including spontaneous and clinically indicated PTB, and development of preeclampsia in U.S - and foreign-born Black women with GDM.Additional studies are needed to explore the interactions between preeclampsia, smoking, obesity, and life stressors and their effect on birth outcomes. Our findings support the need for randomized trials to assess pharmacologic interventions such as baby aspirin for the prevention and reduction of inflammation among women with a history of early onset preeclampsia and prior PTB less than 34 completed gestational weeks, history of early onset preeclampsia, and prior preterm birth less than 34 completed gestational weeks, particularly among Black women with any diabetes, aged > 35 years or older, obese, and other social and clinical co-morbidities. Our data also support evidence-based socio-clinical interventions such as community informed, Midwifery-led, racially concordant group prenatal and postpartum care with wraparound Doula support services , in coll


To describe the long-term socioeconomic and reproductive health outcomes of women in Uganda by adolescent birth history.Cross-sectional study.Uganda.Women aged 40–49 years at the 2016 Uganda Demographic and Health Survey.We compared socioeconomic and reproductive outcomes among those with first birth <18 years versus not. Among those with a first birth <18 years, we compared those with and without repeat adolescent births (another birth <20 years). We used two-sample test for proportions, linear regression and Poisson regression.Among the 2814 women aged 40–49 years analysed, 36.2% reported a first birth <18 years and 85.9% of these had a repeat adolescent birth. Compared with women with no birth <18 years, those with first birth <18 years were less likely to have completed primary education , more likely to be illiterate , to report challenges seeking healthcare  and had higher mean number of births by age 40 years . Among women married at time of survey, those with birth <18 years had older husbands (p<0.001) who also had lower educational attainment (p<0.001). Educational attainment, household wealth score, total number of births and under-5 mortality among women with one adolescent birth were similar, and sometimes better, than among those with no birth <18 years.Results suggest lifelong adverse socioeconomic and reproductive outcomes among women with adolescent birth, primarily in the category with repeat adolescent birth. While our results might be birth-cohort specific, they underscore the need to support adolescent mothers to have the same possibilities to develop their potentials, by supporting school continuation and prevention of further unwanted pregnancies. We used a nationally representative sample of women in Uganda and assessed the extent of differential recall in reporting of adolescent births .The cross-sectional nature of the data and our descriptive analysis did not allow for assessment of causality.The results may largely apply to this cohort due to societal changes and advancements in protection of women but, this is a critical starting point to examine long-term impact of early birth and repeat adolescent birth.The sub-Saharan Africa region continues to have the world’s highest burden of adolescent births, accounting for 95% of the 12 million births occurring to women aged 15–19 years old each year globally.10et al,11Adolescence (ages 10–19 years) is characterised by rapid physical, social, cognitive and emotional development that lays the foundation for an individual’s health and well-being across the life course. As noted by Patton Global evidence shows that childbirth in adolescence, especially before the age of 18 years, is associated with poor social, economic and health outcomes for both the girl and her offspring.26 27repeat adolescent birth following the first birth <18 years, nor did they assess outcomes related to women’s lifelong reproductive health.While the immediate effects are relatively described, there is limited evidence of the long-term socioeconomic and reproductive health outcomes following early initiation of childbearing, including the effects of repeat adolescent birth, in Uganda and other low-income countries.In response to this gap, this paper seeks to investigate the socioeconomic and reproductive outcomes among women in Uganda toward the end of reproductive life course (40–49 years) according to their adolescent birth history . We hypothesise that having an adolescent birth before the age of 18 years leads to lifelong disruption in the acquisition of socioeconomic resources and well-being. Further, we hypothesise that repeat adolescent births (first birth before the age of 18 years and second before the age of 20 years) further worsen these outcomes. Given the link between early marriage and childbirth and its potential influence on later life outcomes,We used data from the 2016 Uganda DHS individual women’s data set. The DHS are nationally representative cross-sectional surveys where multistage cluster sampling is conducted. All the geographical regions of the country were represented. The DHS are conducted every 5 years in Uganda and collect information on population health along with socioeconomic and demographic characteristics. All women aged 15–49 years in sampled households for the individual women’s data set provided self-reported information about their live births. The interviewer-administered questionnaires used were translated into local languages and pretested prior to data collection.The study population included women aged 40–49 years at the time of the 2016 survey, whom we categorised into three adolescent birth histories: (1) no birth <18 years; (2) first birth <18 years and no additional births <20 years; and (3) first birth <18 years and one or more additional births <20 years (repeat adolescent birth). We included live births rather than pregnancies and analysed all women, including those who never gave birth, given that some pregnancies may end in miscarriage/abortion and others in stillbirths and therefore, the later life outcomes may not be impacted by this. To validate women’s recall of adolescent childbearing, we conducted a sensitivity analysis comparing the childbirth patterns of women born in 1967–1976 as reported in the 1995 Uganda DHS to the same birth cohort of women as reported in 2016 . We foun10.1136/bmjopen-2020-041545.supp1Supplementary dataWe assessed two main categories of later life outcomes: socioeconomic and reproductive health related. 10.1136/bmjopen-2020-041545.supp2Supplementary dataWe further analysed outcomes measured only in the subsample of women who were married or in a union at the time of the 2016 survey, including: age difference with husband; husband’s education level (categorised in the same way as for women); and several measures of empowerment based on women’s reports of whether they (1) solely decide on how their own earnings are spent, (2) are part of a marriage with other wives (polygamy) and (3) decide about their own healthcare.Background variables included: women’s area of residence ; geographical region ; religion ; marital status at survey ; and the mean age (years) at survey, first sex, first birth, and at first union (if ever married/in union).We began with exploratory data analysis to assess the distribution in outcomes and background characteristics and examine missingness. Next, we calculated the percentage of women according to their adolescent birth history . Column percentages of the later life outcomes and their 95% CIs for each category of adolescent birth history were presented. We used the two-sample test of proportions to test for differences in the two column proportions for each later life outcome, and linear regression to compare group means for continuous variables. We further used Poisson regression to compare under-5 mortality rates, estimating incidence risk ratios (IRRs) and associated p values. We described later life outcomes by adolescent birth history among all women and among the subsample of women who were married/in a union at time of survey (for whom partner information was available). We further described later life outcomes in a subanalysis among women with and without repeat adolescent birth by marital status at first birth. For this subanalysis, we included variables with p value of <0.05 between women with and without repeat adolescent births. Information on marital status at first birth was missing for N=95 (N=10 with no repeat adolescent birth and N=85 with repeat adolescent birth); these observations were therefore excluded from the subanalysis.We used survey weights, stratification and clustering to adjust for the complex survey design and non-response. All analyses were conducted using STATA V.12.0 .For this study, we used secondary data and there was therefore no direct patient or public involvement. However, the study objectives and design were developed in collaboration with the Reproductive Health Division of the Ugandan Ministry of Health for whom adolescent fertility is a key research priority. The study builds on a previous landscape analysis of adolescent health needs conducted by the Ministry of Health, which indicated information gaps related to the long-term effects of adolescent childbearing, especially for repeat adolescent birth. The results from the study will be disseminated to different stakeholders at the regional and national level.From the analytical sample of 2814 women aged 40–49 years in the 2016 Uganda DHS, 36.2% had their first birth <18 years . Among tLooking at women, all aged 40–49 years (N=2814), results from bivariate analysis indicated that those who had their first birth <18 years had significantly lower mean years of schooling , were less likely to only have completed primary school or higher , and more likely to be illiterate  compared with those without a birth <18 years . FurtherAmong the 1020 women with first birth <18 years, those with repeat adolescent birth were less likely than those without such experiences to have completed at least primary education , to have lower mean years of education , household wealth scores , more likely to be illiterate  and to have higher mean number of live births by age 40 years . Further, the under-5 mortality rate for children born to women with repeat adolescent births was higher than for those born to women with no repeat adolescent birth . Healthcare-seeking challenges and unmet need for contraceptives were, however, similar when comparing women with and without repeat adolescent births.We further conducted analysis among a subsample of women who were married at time of the 2016 survey (N=2022). Compared with women with no birth <18 years, those with first birth <18 years had partners/husbands who were older  and with lower education level  . FurtherWe also conducted analysis of later life outcomes among women with and without repeat adolescent birth by their marital status at first birth, including variables that were significantly associated with repeat adolescent birth (p<0.05) among all women aged 40–49 years . The proWe investigated the socioeconomic and reproductive health outcomes among Ugandan women towards the end of their reproductive life using data from the most recent Uganda DHS collected in 2016. We compared women’s outcomes according to their adolescent birth histories: those with and without first birth <18 years, and among those with first birth <18 years, those with and without repeat adolescent births (two or more births before age 20 years). For the latter groups, we also examined differences in later life outcomes by marital status at the point of the first adolescent birth.Our findings highlight three key points. First, women who had their first birth <18 years reported more negative socioeconomic and reproductive health outcomes in later life than those without such experiences. These differences appear to be driven by the largest subgroup of women with repeat adolescent birth, who had poorer educational attainment, lower household wealth and empowerment, as well as higher fertility and under-5 infant mortality compared with the other groups. This finding aligns with previous research highlighting adolescent childbirth as both a risk factor for, and consequence of, poverty and low education.Second, women with an adolescent birth, and especially with repeat adolescent birth, were more likely to be socioeconomically disadvantaged in later life—confirming the limited evidence on poor economic trajectories following early childbearing.We also found that women with first birth <18 years were more likely to report greater decision-making power over their own earnings, underscoring the results from the Population Council and Women Deliver report which found that adolescent birth was associated with more control over own economic assets. This suggests that women with an adolescent birth might learn to be self-reliant and independent, providing a potential avenue for interventions to economically empower these women.Third, our study results suggest that having a large completed family size is driven not only by an early initiation of childbearing, but by repeat adolescent births. Although the adolescent fertility rate has declined in Uganda, it remains high at 132 births per 1000 women aged 15–19 years.53 54The care of a child born to an adolescent girl takes broadly two patterns in Uganda and this cultural position needs to be factored in when viewing outcomes of women with early birth: those in and out of union. When a woman gives birth within marriage, the responsibility of raising the child is usually taken on by the man or his family with the support of the woman.Public health interventions are needed to prevent repeat adolescent birth and potential negative life-course outcomes via improved access to continued schooling and higher education, and effective contraceptive services. Development of a Uganda school continuation policy for adolescent mothers needs to be fast tracked followed by: wide dissemination, sensitisation of the communities and parents, and enforcement at school level.40This study used data from a large nationally representative sample containing a variety of variables. However, the cross-sectional data cannot support causal associations between adolescent childbirth and the outcomes examined. While our assessment of differential reporting of adolescent childbirth did not show variation on a population level, the results may be influenced by reporting and recall bias due to the self-reported data. Women may also have given socially desirable responses regarding the age at first birth.Findings from this study, while not necessarily causal, suggest that among women in Uganda, giving birth before age 18 years is linked to lower educational attainment, household wealth, and higher fertility and under-5 infant mortality outcomes later in life. Further, they tend to have spouses who are older and of low socioeconomic attainment. This pattern is especially strong for women who have repeat adolescent births, and particularly for those who were married at first birth. Women who begin childbearing before age 18 years, but do not proceed to have a repeat adolescent birth—despite being a minority (5%)—appear to have recovered from any negative effects, and in some instances had better outcomes than those with no birth <18 years. This suggests persistence of the negative outcomes thereby underscoring the need to not only prevent early adolescent birth but prevent repeat adolescent births.


Factors associated with low birth weight at term (TLBW), a proxy for intrauterine growth restriction (IUGR), are not well-elucidated in socioeconomically vulnerable populations. This study aimed to identify the factors associated with TLBW in impoverished Brazilian women.Records in the 100 Million Brazilian Cohort database were linked to those in the National System of Information on Live Births (SINASC) to obtain obstetric, maternal, birth and socioeconomic data between 2001 and 2015. Multivariate logistic regression was performed to investigate associations between variables of exposure and TLBW.Of 8,768,930 term live births analyzed, 3.7% presented TLBW. The highest odds of TLBW were associated with female newborns , whose mothers were black , had a low educational level , were aged ≥35 years , had a low number of prenatal care visits  and were primiparous . Lower odds of TLBW were found among infants whose mothers lived in the North, Northeast and Center-West regions of Brazil compared to those in the South.Multiple aspects were associated with TLBW, highlighting the need to comprehensively examine the mechanisms underlying these factors, especially in more vulnerable Brazilian populations, in order to contribute to the elaboration of health policies and promote better conditions of life for poor and extremely poor mothers and children. Birth weight is strongly associated with infant morbidity and mortality, and is considered a predictor of immediate and future health status in newborns –4. In 20Low birth weight, defined as less than 2500 g, may be a consequence of prematurity or associated with intrauterine growth restriction (IUGR), or a combination thereof ; The proEvidence suggests that low birth weight at term (TLBW) (a proxy for IUGR) is associated with: i. maternal characteristics, such as age, and obstetrics history –15; ii. Although several studies have examined the determinants of TLBW, factors associated with TLBW remain unelucidated among socioeconomically vulnerable populations living in low- and middle- income countries, such as Brazil. To further investigate factors associated with TLBW, this study considered data between 2001 and 2015 from the 100 Million Brazilian Cohort linked to the National Live Birth System (SINASC). The 100 M Brazilian cohort contains information on low-income families with monthly per-capita income less than BRL200 (US$50), representing approximately 55% of the total Brazilian population . Thus, tThis study employed data from the 100 Million Brazilian Cohort, a database constructed by the Center for Data and Knowledge Integration for Health (Centro de Integração de Dados e Conhecimentos para Saúde-CIDACS), affiliated with the Oswaldo Cruz Foundation (FIOCRUZ) . This isCohort data were linked to the live birth registry from SINASC according to similarity using the CIDACS Record Linkage algorithm . This noThe study population included live births of women aged 14–49 years who were registered in the 100 Million Brazilian Cohort between 2001 and 2015 , prior to excluding preterm and post-term births. Multivariate logistic regression was conducted to investigate the factors associated with TLBW. A conceptual hierarchy-based approach Fig.  was empl%, prior The initial model was adjusted for the distal factors. In the second model, all variables contained in the previous model were maintained, with the inclusion of the number of prenatal visits (intermediate factor). The final model included, in addition to the variables contained in the two previous models, the mother’s age at the time of delivery, birth order/parity and sex of the newborn. Odds ratio (OR) values and respective confidence intervals (95% CI) were calculated for each variable maintained in the final model. Data analysis was performed using Stata version 15.1 .Large sample sizes provide ample data to conduct analyses on subgroups of interest while maintaining sufficient power to gain insights into the direction and size of the effects. Due to changes in the SINASC registry with respect to gestational age, it was necessary to conduct additional analyses to verify the results of our multivariate regression analysis. From 2001 to 2010, gestational age was recorded as a categorical variable . Beginning in 2011, gestational weeks at birth was recorded as a discrete variable , estimated from the date of the mother’s last menstrual period, physical examination or image results obtained from SINASC records. Due to dynamic aspects of this cohort, such as the differences in the entry time of each woman in the study, as well as changes in 2011 in terms of how information on gestational age was collected/recorded by SINASC, additional analyses were carried out shown in  for veriAmong the 8,768,930 term live births investigated, 3.7% were found to be TLBW. Table With regard to newborn/maternal characteristics, 69.3% of newborns’ mothers were aged 20–35 years, 32.0% had primiparous mothers, 58.8% had multiparous mothers (2–4 previous live births) and 49.0% were female.Figure The present study evaluated factors associated with TLBW in Brazilian populations living in poverty or extreme poverty. The occurrence of TLBW found herein was similar to that estimated in the overall Brazilian population born in 2017 (3.7%) . Of all Previous studies in Brazil –39 have It is worth noting that a demographic transition is well underway in Brazil, as evidenced by increasing fertility trends in women over 35 years of age, mainly in highly urbanized areas. This combined with the late onset of reproductive activity has led to an increase in the proportion of primiparous women in this age group . In addiMany studies have compared the occurrence of LBW among regions in Brazil, which hinders the ability to make comparisons regarding TLBW. A plausible explanation for discrepancies regarding rates of TLBW may be that, as some authors have observed, in locations with poor childbirth care resources and access to perinatal technology, newborns who die shortly after birth are commonly misclassified as “stillborn” or are not even registered , 39, whiOur analysis indicated that TLBW is inversely associated with the level of maternal schooling, i.e. fewer years of formal study leads to a greater chance giving birth to a neonate with TLBW Fig. . These fThe findings of the present study also indicate that black women have a higher chance of giving birth to newborns with TLBW. How race translates into the social and economic environment and affects birth outcomes remains poorly understood . While aMarital status was found to be weakly associated with TLBW. It is possible that bias occurred in the recording of this variable, resulting in the overreporting of single women, since previous versions of the SINASC form used for registering live births did not include “stable union” as an option, rather specifying consensual union, which denotes a legal recognition of status . HoweverThe estimated OR for TLBW was found to increase with reduced numbers of prenatal visits, indicating the importance of prenatal care. The provision of fewer prenatal health services, characterized by lower numbers of visits, has been associated with negative perinatal outcomes, such as TLBW , 11, 14.Older women (between 35 and 49 years) are more likely to give birth to newborns with TLBW. Advanced maternal age, commonly defined as ≥35 years, is considered a risk factor for adverse health outcomes in children, including LBW and TLBW , 53–55, The study has some important strengths. First, the large-scale dataset allowed us to comprehensively investigate known factors associated with TLBW. Second, the SINASC registry has high national coverage (over 90%), which provided a truly representative study population . MoreoveThis population-based study was focused on investigating live births to poor and extremely poor women. With due caution, some of the findings reported herein may be generalized to other populations with similar characteristics. Importantly, these limitations do not greatly detract from the promising potential enabled through research conducted on the “100 Million Brazilian Cohort”.This population-based study reveals important information regarding the frequencies and associated factors relative to TLBW in poor and extremely poor Brazilian women. Inequity in TLBW has persisted in economically vulnerable populations, especially in live births to mothers with lower educational levels who are black and receive insufficient prenatal care. The identification of factors associated with TLBW is essential to contribute to more inclusive health policies and promote improved welfare for poor and extremely poor mothers and children. Our study highlights the need to assess the underlying mechanisms behind these factors and expand on the analysis through the further exploration of the variables considered herein. We observed that a very high percentage of women receive an insufficient number of prenatal consultations, despite living in a country with a nationalized public health system. In sum, it will be important not only to implement social policies designed to protect pregnant women is economically vulnerable situations, such as through conditional cash transfer programs, but also to provide greater coverage of prenatal care as well as educational support regarding health and nutrition, in addition to paying special attention to the occurrence of comorbidities, especially among older women.Additional file 1: Table S1. Adjusted models† used to assess factors associated with term low birth weight by year of birth. Table S2. Adjusted models† used to assess factors associated with term low birth weight by exposure time at birth categorized into quartiles intervals.


Different charts are used to assess premature growth. The Fenton chart, based on prenatal growth, has been used in the neonates’ intensive care unit (NICU) of the Notre Dame des Secours University Hospital to assess premature newborns’ development. Intergrowth21 is a new multidisciplinary, multiethnic growth chart better adapted to premature growth. Our objective was to compare both charts Fenton and Intergrowth21 in order to implement Intergrowth in our unit.We analyzed 318 files of premature babies born who were admitted to the NICU from 2010 till 2017. Anthropometric data  converted to percentiles was filled on both charts from birth till 1 month of age.The results of the linear regression, taking the weight at birth as the dependent variable, showed that the Fenton scale (R2 = 0.391) would predict the weight at birth better than the Intergrowth 21 scale (R2 = 0.257). The same applies for height and cranial perimeter at birth when taken as dependent variables. When considering the weight and height at 2 weeks, the results showed that the Intergrowth 21 scale would predict those variables better than the Fenton scale, with higher R2 values higher in favor of the Intergrowth 21 scale for both weight (0.384 vs 0.311) and height (0.650 vs 0.585). At 4 weeks, the results showed that the Fenton scale would predict weight (R2 = 0.655 vs 0.631) and height (R2 = 0.710 vs 0.643) better than the Intergrowth 21 scale. The results obtained were adjusted over the newborns’ sociodemographic and clinical factors.The results of our study are controversial where the Fenton growth charts are superior to Intergrowth 21 before 2 weeks of age and at 4 weeks, whereas Intergrowth 21 charts showed higher percentiles for weight and height than Fenton charts at 2 two weeks of age. Further studies following a different design, such as a clinical trial or a prospective study, taking multiple ethnicities into account and conducted in multiple centers should be considered to enroll a more representative sample of Lebanese children and be able to extrapolate our results to the national level. Prematurity is becoming more frequent nowadays especially with the development of artificial fertilization methods . In 2016In fact, many charts have been developed, mostly based on intrauterine growth and rarely adapted to preterm newborns. Indeed, preterm babies are not fetuses as they no longer live in-utero  . RegardlWithin that scope, alarming studies have shown an association between prematurity and obesity in adulthood, with question marks raised about the link between “overfeeding” the preterm newborns, obesity and cardiovascular complications later in life . In the st Project” was a prospective multicenter, multi-ethnic study, which included low-risk women, non-smokers, with a normal pregnancy history, and no health problems that could affect fetal growth [The most commonly used chart at the Notre Dame des Secours University Hospital Center-Byblos (CHU-NDS), is the Fenton chart 2003, which has not been updated till now. Between 2009 and 2014, the Intergrowth21 project has emerged as a successful growth chart and underwent rigorous processes that ensured that the data collected in the INTERGROWTH-21st project is of exceptionally high quality . Intergrl growth . All matl growth . These vIn a recent systematic review, 61 longitudinal reference charts were identified and compared to the Intergrowth-21 chart ; assessmBeing in a developing country, a local validation before adapting Intergrowth-21 charts to our new born infants is necessary, especially to avoid the misclassification of their size, which may have an impact on their nutritional support. For these reasons, the objective of this study was to check which method  used in the neonatology department at CHU-NDS would predict height, weight and cranial perimeter of premature Lebanese babies better. This study would help us evaluate the difference between both curves in terms of extra- and intra-uterine growth restriction, reflected by weight, height and head circumference at birth and verify later the convergence between the intergrowth-21 and the WHO curves of the child health record book around the sixth month of life.This was a retrospective study, conducted at CHU-NDS. Medical records of premature newborns admitted to the neonatal unit over a seven-year period 2010 to 2017), were reviewed. The discretion of names and personal information have been respected. All preterm infants born alive before 37 weeks of gestation and admitted to the neonatology department within 24 h of birth, were included in the study. Term infants (born at 37 weeks of gestation or more) were excluded since Intergrowth-21 is a growth chart adapted only to preterm babies. Furthermore, excluded were [0 to 2017Data was collected from files in the medical archive. Weight, height and head circumference of each child at birth, at 37 weeks of gestation, 2 weeks and 4 weeks of life were noted, and then marked on the percentile curves of the Fenton 2003 and Intergrowth 21 charts. Weight and height were measured using a digital baby scale with a rod, whereas head circumference was obtained via a measuring tape; the same measurement method was followed for all children. The follow-up data of each child after discharge were also collected from medical records of each child’s pediatrician.When the measurements fell on the curves between 2 standard lines of percentiles, the value was then approximated to an intermediate value between the two percentiles. Thus, the 5th, 30th, 70th and 95th percentile were considered if the measurements fell between the following brackets 3rd-10th, 10th–50th, 50th–90th and 90th–97th percentile respectively. Values below the 3rd percentile or above the 97th percentile were reported as 2nd and 98th percentile respectively. This approximation was made for both charts in order to avoid any bias.The data collection took into account other variables such as the date of birth of the new born, the length of stay at the hospital, the need for intubation, transfusion, iron supplementation, the cause of admission to the NICU, consanguinity, medically assisted procreation (In-vitro fertilization-IVF) and the delivery method.2 value would predict the dependent variable more.Statistical analysis of data was performed using SPSS version 22 . Comparisons of the same baby’s measures according to both charts were assessed through linear regressions. Multiple linear regressions were conducted taking weight, height and cranial perimeter as dependent variables and taking in each model one of the charts as an independent variable. The model that had a higher Nagelkerke ROut of a total of 492 medical record extracted, 318 (64.63%) newborns aged between 27 and 36 weeks of gestation met the inclusion criteria. The distribution of gestational ages showed that 52.8% of the babies were born between 34 and 36 gestational weeks, whereas the remaining newborns were under 33 gestational weeks  were admitted to the NICU of the CHU-NDS from maternity ward and 1.6% were transferred before birth from another hospital. The mean age of birth was 33.26 ± 2.10 weeks of gestation. Consanguinity was present in 11.6% of the cases and caesarean section accounted for 85.8% of deliveries. Moreover, 29.9% of the babies were intubated and 78.8% received more than 2 blood transfusions during their stay; 49.7% of infants were fed by breast milk and formula milk, 48.1% by formula milk alone and 1.3% were exclusively breastfed. We note that in-vitro fertilization methods accounted for 24.8% of pregnancies.2 = 0.391) would predict weight at birth better than the intergrowth 21 scale (R2 = 0.257)  should be considered to avoid the bias in anthropometric measurements. A more representative sample of Lebanese children recruited from multiple centers is warranted to extrapolate the results to the whole population. Finally, prenatal diseases that could alter the pattern of growth should be taken into consideration.The results of our study are controversial since the Fenton growth charts showed superiority predicting newborn’s growth in terms of weight, height and cranial perimeter at birth and at 4 weeks compared to the Intergrowth-21 ones, whereas Intergrowth 21 charts showed higher percentiles for weight and height at 2 two weeks of age compared to the Fenton charts. The results obtained could have been affected by many factors, including ethnicity that could not be investigated in this study due to its retrospective aspect. Therefore, further studies that take this study’s limitations into account, are needed.