Protein intake did not correlate with the changes in wt.pc in either sex. Despite a similar intake of calories and protein during the TP, we found a significant decrease in wt.pc only in girls. More extensive studies are needed to understand the sex-based differences in caloric needs and metabolic rate in ELBW infants.We sought to determine whether there are sex-based differences in the requirements for calories or protein for optimal growth during the transition phase (TP) when an extremely low birth weight (ELBW) infant, defined as a preterm infant with a birth weight of < 1000 g, is progressing from parenteral to enteral feeds. A retrospective review of ELBW infants born from 2014 to 2016 was performed at a tertiary NICU. Infants with necrotizing enterocolitis, short bowel syndrome, or chromosomal anomalies were excluded. TP was defined as the period when the infant’s enteral feeds were increased from 30 up to 120 ml/kg/day while weaning parenteral nutrition (PN). Effects of sex and protein-calorie intake on the change in growth parameters from the beginning to the end of TP were analyzed. Pre-TP growth percentiles and calorie and protein intake were similar in both sexes. There was a significant ( Optimal early nutrition in preterm infants has been associated with better growth and neurodevelopmental outcomes. The total energy intake during the first 7 days of life is positively correlated with improved growth parameters until the corrected age of 2 years . CoviellThe transition phase (TP) of nutrition is an important stage in the progression towards optimal nutrition in ELBW infants , 5. All The evidence that the establishment of early nutrition in preterm infants is associated with sex-specific differences in the outcomes is still evolving. A recent study showed that higher amino acid intake during the first week of life in preterm infants was associated with greater weight gain during the first 5 weeks of life in males compared to females . InteresSex-related differences in anthropometric parameters and growth are well established in infants and adults. Postnatal growth characteristics are also sex-specific; hence, distinct anthropometric standards for male and female preterm infants, such as Fenton growth chart 2013, are needed . One migThe study design was a retrospective cohort analysis of ELBW infants born from 2014 to 2016 at a level 4 NICU at the University of Mississippi Medical Center (UMMC). The study was conducted in accordance with the Declaration of Helsinki, and the protocol was approved by the Ethics Committee of UMMC and was approved by the UMMC institutional review board on August 16, 2017 (IRB file# 2017-0120). The inclusion criterion was ELBW infants born between the years 2014 and 2016 at UMMC. The exclusion criteria were (1) Infants with short bowel syndrome and/or dependence on total PN, (2) infants who were nothing per os (NPO) for 10 days or more in the first 30 days of life, (3) infants with severe chromosomal anomalies known to interfere with postnatal growth and survival, (4) infants with prostaglandin-dependent cardiac lesions, (5) infants with hydrocephalus, and (6) infants diagnosed with necrotizing enterocolitis (NEC).There were 123 ELBW infants that remained in the study after exclusion. Of these, there were 28 (22.7%) small for gestational age infants who were excluded from the analyses as their growth rates were expected to be very different from appropriately grown ELBW infants. We analyzed 95 ELBW infants, 59 females and 36 males, who were appropriate for gestational age at birth in our study cohort.z scores before, during, and after the TP. The following comorbidities were evaluated as potential confounders—chronic lung disease, culture-positive infections, retinopathy of prematurity, intraventricular hemorrhages, use of postnatal steroids, and patent ductus arteriosus.Data related to the following variables were collected from a review of databases and patient charts: demographic data including gestational age, birth weight and head circumference percentiles, sex, and race were obtained. Nutritional data such as type of enteral feeding , caloric density  during TP, weaning, discontinuation of intralipids, mean calories/kg/day and protein in g/kg/day during TP and enteral phase, day of life birth weight regained, day of life TP initiated, and the duration of the TP were collected. Growth data included weight and head circumference percentiles, growth velocity, and All ELBW infants were started on a total daily fluid intake of 100 ml/kg/day that included 4 g/kg/day of protein as parenteral nutrition after birth. Dextrose was initiated as 7.5 to 10% in PN to provide an initial glucose infusion rate of 4 to 6 mg/kg/min and subsequently increased to provide a glucose infusion rate of up to 11 mg/kg/min. The current standard of care for parenteral nutrition fluids as recommended by the American Academy of Pediatrics includes vitamins, electrolytes, and trace elements in standard doses for all ELBW infants . IntraliTP was defined as the period when the infant’s enteral feeds were increased from 30 ml/kg/day up to 120 ml/kg/day while PN was gradually reduced, with a goal total protein intake of 3.5 to 4 g/kg/day and calorie 100 to 120 kcal/kg/day. Human milk feeds were gradually increased by 10 to 20 ml/kg/day as tolerated. PN was correspondingly reduced when enteral feeds were increased to > 50 ml/kg/day to give at least 150 ml/kg/day of total fluids. Human milk was fortified to 24 cal/oz with human milk fortifier (Enfamil® Human Milk Fortifier Powder) when the volume of the enteral feed was > 50 ml/kg/day. Human milk fortification optimizes caloric content, protein, fat, vitamins, and various other micronutrients . IntraliThe nutritional composition of the PN and enteral feeds were obtained from the nutritional calculator within EPIC’s electronic medical record. A daily measure of total calories and protein from both PN and enteral nutrition was obtained for each ELBW infant. A reference standard was used for calculating calories and protein in breast milk .z scores for weight and head circumference [Fenton 2013 sex-specific growth charts were used for determining the percentiles and mference .Chronic lung disease was defined as oxygen requirements at 36 weeks of corrected gestational age. Retinopathy of prematurity was defined as any stage of retinopathy from stages 1 to 4 diagnosed by the pediatric ophthalmologist. Intraventricular hemorrhage (IVH) was defined as any grade of IVH from 1 to 4 as diagnosed by the radiologist with a head ultrasound. Infection was defined as any culture-positive infection from blood, urine, or cerebrospinal fluid specimens. Patent ductus arteriosus was defined as the presence of a patent ductus arteriosus on an echocardiogram as diagnosed by the pediatric cardiologist.t tests for continuous variables and chi-square test for nominal variables were done. Non-parametric tests were done for samples that did not show normal distribution. We performed the Pearson correlation tests in males and females to evaluate the association of weight change during the TP for the given number of calories and protein. Subsequently, multivariable backward logistic regression analysis was done to confirm this correlation in males and females while accounting for the effect of potential confounders. We used TP calories, protein, duration, and day of life of TP initiation along with the weight percentile before TP as confounders. Statistical significance was determined for inferential statistical tests when p value was ≤ 0.05.Univariate analyses using independent Of the 123 ELBW infants that remained in the study after the initial exclusions, there were 28 (22.7%) small for gestational age infants who were further excluded from the analyses as their growth rates were expected to be very different from appropriately grown ELBW infants. The final analysis was based on a total of 95 ELBW infants, 59 females and 36 males, who were appropriate for gestational age at birth in our study cohort.Sex-specific anthropometric data of the study population is shown in Table Table As expected, females weighed significantly less than males, and the percentiles of birth weight, length, and head circumference based on the sex-specific Fenton growth charts did not differ between sexes.p = 0.46) and protein intake , were not different between the sexes.Sex-specific nutritional characteristics of the study population are shown in Table r = 0.22, p = 0.026) correlation of total calorie intake with a change in weight percentiles for the whole group. The pre-TP growth percentiles did not differ between sexes.There was a significant (p = 0.14)    Fig. . This cor = − 0.15, p = 0.23) and females  was not statistically significant. Similarly, the correlation between protein intake and weight change during TP in males  and females  was not statistically significant.Correlation of protein intake and head circumference change during TP in males  infants can have sex-specific outcomes. A deficit of fat-free mass in preterm infants at discharge is associated with neurological impairment at 2 years of age . PoindexOur study results are confined to the TP of nutrition and growth outcomes during the TP. In contrast, other studies have focused on the higher protein (2-3 g/kg/d) versus lower protein (2 g/kg/day) provided in the parenteral nutrition and evaluate for long-term outcomes. Another distinct feature in our cohort of infants was that they received 4 g/kg/day of protein immediately after birth in their parenteral nutrition fluids. To our knowledge, there are no sex-specific short-term growth outcome studies during TP of nutrition, and our study results may provide unique preliminary findings.We consider our study precursory in reporting sex-based differences in the growth effect of protein and calorie intake during the TP of nutrition in ELBW infants. The strength of our study is that the nutritional management of all infants was standardized based on well-enforced unit guidelines. Breast milk fortification between the groups was similar, which reduces the possibility of micronutrient intake differences between the sexes. Our study provides preliminary evidence that nutritional requirements may be different between the sexes in preterm infants during the TP of nutrition. The main limitations of our study are that this is a single-center retrospective pilot study and that it is based on a relatively small sample size. Comorbidities such as patent ductus arteriosus, postnatal steroids, and intraventricular hemorrhage may affect anthropometric measurements during the TP of growth, but there is no current evidence in the literature on this subject. However, in this current study, the comorbidities were not significantly different between sexes. Moreover, the initial respiratory status, ventilatory support, or the severity of illness in the first few days of life were also not available for analyses. Nevertheless, these are the prime factors for the occurrence of chronic lung disease and the use of postnatal steroids after the transition phase is complete in this population. As the incidence of chronic lung disease and the use of postnatal steroids are not different between the sexes Table , the aboDespite similar intake of calories and protein during the TP of nutrition in ELBW infants, there was a significant correlation of caloric intake with weight percentile changes only in girls but not in boys. Larger prospective studies are needed to confirm our findings, as well as to understand the biochemical and physiological basis for such sex-related differences.


An estimated >2 million babies stillborn around the world each year lack visibility. Low- and middle-income countries carry 84% of the burden yet have the least data. Most births are now in facilities, hence routine register-recording presents an opportunity to improve counting of stillbirths, but research is limited, particularly regarding accuracy. This paper evaluates register-recorded measurement of hospital stillbirths, classification accuracy, and barriers and enablers to routine recording.The EN-BIRTH mixed-methods, observational study took place in five hospitals in Bangladesh, Nepal and Tanzania (2017–2018). Clinical observers collected time-stamped data on perinatal care and birth outcomes as gold standard. To assess accuracy of routine register-recorded stillbirth rates, we compared birth outcomes recorded in labour ward registers to observation data. We calculated absolute rate differences and individual-level validation metrics . We assessed misclassification of stillbirths with neonatal deaths. To examine stillbirth appearance (fresh/macerated) as a proxy for timing of death, we compared appearance to observed timing of intrauterine death based on heart rate at admission.23,072 births were observed including 550 stillbirths. Register-recorded completeness of birth outcomes was > 90%. The observed study stillbirth rate ranged from 3.8  to 50.3 /1000 total births and was under-estimated in routine registers by 1.1 to 7.3 /1000 total births (register: observed ratio 0.9–0.7). Specificity of register-recorded birth outcomes was > 99% and sensitivity varied between hospitals, ranging from 77.7–86.1%. Percent agreement between observer-assessed birth outcome and register-recorded birth outcome was very high across all hospitals and all modes of birth (> 98%). Fresh or macerated stillbirth appearance was a poor proxy for timing of stillbirth. While there were similar numbers of stillbirths misclassified as neonatal deaths (17/430) and neonatal deaths misclassified as stillbirths (21/36), neonatal deaths were proportionately more likely to be misclassified as stillbirths (58.3% vs 4.0%). Enablers to more accurate register-recording of birth outcome included supervision and data use.Our results show these routine registers accurately recorded stillbirths. Fresh/macerated appearance was a poor proxy for intrapartum stillbirths, hence more focus on measuring fetal heart rate is crucial to classification and importantly reduction in these preventable deaths. Every Newborn Action Plan (ENAP), more than 80% have a target for neonatal mortality rate reduction, while 32% have for stillbirths  will see whether it has been recorded or not … If one is writing and she finished properly but also other staff will come and check is it done […] but mostly if there are stillbirths then they will exactly record it properly”.“-Data collector, Pokhara NPData demand was an enabler for accurate recording of birth outcomes as health workers understood the importance of tracking this information.It is valuable because of this, how many patients are admitted in hospital, and how well those patients get service, and how many people are healthy, how many leaving alive, how many leaving dead. This document is very important in determining a rate. Again, the documentation is very important for those who come to the hospital whether they are getting proper service or not”.“-Data collector, Kushtia BDIt must be done for the mother and child’s documentation because if anyone wants to know the cause of death information as well as their complications, how we managed these cases, delivery complications, referral information, outcome information (live/still birth) we can understand from here. […] if we do not keep documentation on outcomes how do we identify the success rate and treatment quality?”“-Health worker, Kushtia BDParticipants associated register completion with broader aims of improving treatments and care for women and babies, which motivated their behaviours:The perceived need to document serious events such as stillbirths was recognised, but participants also expressed a hesitancy to record “more negative” outcomes such as neonatal deaths. This hesitancy could lead health workers to record neonatal deaths as stillbirths or abortions:“They always want us to record something good … avoid bad things […] Suppose, everything that I have is positive or good. That is the baby is well and also the mother, and everything is well. But, if there is anything bad within it, they do not want to record it. […] a child was born just with the arrival of the patient (mother), but the child was alive […] when the patient is taken to the ward, after some time it is reported that the baby has died. In that case, to do the report well, they take it as a problem. That’s why they have recorded it as 'abortion'.”-Data collector, Azimpur BDEvery Newborn target of ending preventable stillbirths by 2030 [Despite the magnitude of the issue, stillbirths lack visibility and accountability, often not counting in measurement systems. Valid data on stillbirths that is more widely and frequently available is essential to track the  by 2030  and impr by 2030 . All thrThe register-recorded stillbirth rate in Pokhara, NP only under-estimated the observed rate by 1.7 per 1000 total births (ratio 0.9), despite being recorded in a non-specific column, being comparable with hospitals using registers with specific columns. The Pokhara hospital had a much smaller register, collecting 31 data points compared to 58 in Bangladesh and 45 in Tanzania . AdditioFor international comparison, stillbirth rates are measured using specific cut-offs of gestational age or birthweight . Most stAlthough there were a small number of neonatal deaths on the labour ward, we found more than half were misrecorded as stillbirths 21/36). This is in contrast to a much smaller percentage of stillbirths being misclassified as neonatal deaths (17/430) Fig. . Researc. This isWe found stillbirth appearance (fresh/macerated) was not a good proxy for observed timing of stillbirth, resulting in underestimation of intrapartum stillbirths, consistent with another study which found provider description of fresh/macerated to be inaccurate compared to actual time since fetal death . This reTo capture true intrapartum stillbirth rates, standard of care must be to measure, record, and use the presence of fetal heart sounds on admission. Accountability for deaths after admission to labour ward requires a culture shift across all health system building blocks. Frontline health workers need supportive supervision, protocols, training and equipment such as fetal dopplers. A study in Tanzania showed that programmatically relevant timing of stillbirth data can be collected in routine registers with widespread use of Doppler devices to assess fetal heart rate on admission to maternity services . ImportaDrying, wrapping, and weighing of stillbirths may be a marker of respectful care for families with stillbirths where stillborns are handled gently and treated like babies. Whether the family were given the option to hold their stillborn baby and how the child was wrapped was not captured in EN-BIRTH. In high-income settings, families are usually given opportunity to spend time grieving with their stillborn child . HoweverEvery Newborn-INDEPTH multi-country study similarly investigated survey-reported data on stillbirth, including the feasibility of capturing information on timing of stillbirth [While the EN-BIRTH study included surveys of women’s report on exit from facility to explore survey-reported validity of measurement for maternal and newborn indicators, women were not asked about birth outcome. The EN-BIRTH tablet custom-built software was programmed to skip sensitive questions to minimise risk of further emotional trauma during interviews with women who experienced stillbirth . In the illbirth , 53.A strength of this study is the size, including over 23,000 births across five hospitals in three countries, and using observation as a gold standard to compare to register-recorded indicators. A user-friendly tablet with a custom-built data collection application was used to reduce delays or omissions in recording events. We looked at overall stillbirth recording, details for intrapartum stillbirths, and coverage of care for stillborn babies. Limitations of the present study should be noted. The stillbirths in this study are not representative of all stillbirths in these hospitals, selectively excluding sicker women unable to consent and specifically excluding antepartum stillbirths due to the study’s inclusion criteria of presence of a presumed positive fetal heart rate on admission. Our assessment of stillbirth classification (fresh/macerated) was only of observed intrapartum stillbirths and we were not able to assess classification in antepartum stillbirths. The gold standard used to identify stillbirths was observation of signs of life by trained clinical observers, but a true gold standard requires heart rate assessment immediately after birth . The estOur results show the validity and utility of facility register-recorded data to capture birth outcomes, however, we highlight challenges with identifying timing of stillbirth from appearance. Capturing stillbirths happening after facility admission using presence of fetal heart rate needs to be the standard of care. On admission to hospital in labour, every woman and her baby have the right to be assessed, including knowing if the baby is alive. Health workers require this information in order to provide appropriate care during labour and birth, especially given the unique medical, obstetric and psycho-social needs of women and families experiencing stillbirth. Every woman who experiences stillbirth has the right to know her stillborn baby’s weight and information about what happened, as well as the opportunity to see her baby. Leadership is needed to use data at all levels of the health system, including locally, to drive change in improving care to prevent stillbirths as well as count them.Additional file 1. EN-BIRTH study sites—National mortality rates and hospital context.Additional file 2. STROBE checklist of items that should be included in reports of observational studies.Additional file 3. Respondents for focus group discussion and in-depth interviews for EN-BIRTH Study.Additional file 4. EN-BIRTH data quality assurance for gold standard – double observation and data entry.Additional file 5. Validity measures  by hospital and mode of birth for EN-BIRTH Study.Additional file 6. Two-way tables for observer-assessed and register-recorded birth outcome by hospital/mode of birth, EN-BIRTH study.Additional file 7. Barriers and enablers to routine recording of birth outcomes in the EN-BIRTH study.Additional file 8. Ethical approval of local institutional review boards, EN-BIRTH study.


Background. Patterns of fetal growth are largely influenced byenvironmental, nutritional, and socioeconomic factors more than differences inpopulations. The aim of this study was to assess anthropometric measurements ofEthiopian preterm infants at birth and compare the results with theinternational INTERGROWTH-21st data. Patients and methods. Weanalyzed anthropometric data on live-born singleton preterm infants enrolled ina hospital-based multicenter study of illness in preterm infants (SIP). Eligiblenewborns with gestational age of 28-36 weeks were included. Gestational age (GA)and sex-specific mean and standard deviations (SD), 10th, 50th, 90th, centilevalues for birth weight, length and head circumference (HC) were calculated andcompared with INTERGROWTH-21st data. Result. A total of 2763preterm infants were included in the study, 54% were male. The prevalence ofsmall for GA (SGA) (<10th percentile) and large for GA (LGA) (>90thpercentile) were 10.8% and 9.9%, respectively. In all 3 parameters, the meanvalues of boys were higher than of girls. Birth weight centiles were comparableto international averages at lower GA, then after GA of 32 weeks the 10th, 50th,and 90th centile values were 100-500 g less than the international averages. Thehead circumference centiles were mostly comparable, and the 90th centile valueswere greater than the international averages across the GA and in both sexes.Conclusion. The infants’ birth weights were smaller athigher GA, which may indicate maternal undernutrition in the third trimester ofpregnancy. Strengthening antenatal nutrition counseling and providing nutritionsupplementation might improve the birth weight. Fetal growth depends on genotype, sex, maternal health status, obstetricconditions, environmental factors, and geographic location3; however, only <3.5% of skeletal growth is attributed to differences in populations.4 Newborns are classified based on their weight, gestational age (GA) andweight adjusted for GA, to identify high risk infants such as those small forgestational age (SGA), and large for gestational age (LGA), often in need ofspecific interventions.5Intrauterine growth measured by size at birth is one of the important determinantfactors for neonatal survival.6 LBW contributes to most of neonatal and post neonatal mortality. Beyondinfancy, survivors are at increased risk of growth failure and developmentalproblems at younger ages, and hypertension, type 2 diabetes, and heart diseaseduring adulthood.7 Likewise, several studies from Ethiopia have reported a range of 9.1% to28.3% prevalence of LBW in different parts of the country.811Normal birth weight according to WHO, is from 2500 to 4000 g, while low birth weight(LBW) is defined as weight at birth <2500 g, very LBW (<1500 g) and extremelyLBW (<1000 g).12 The first 1000 days of life is a critical period, which determines thegrowth, immunologic, metabolic and neurodevelopmental outcome of individuals insubsequent years.14 The rate of undernutrition in under 5 children in Ethiopia isone of the highest in the world.15 Ephrem et al reported larger HC averages of Ethiopian children from birth to24 months of age compared to WHO standards and recommended a different nationalreference range as the first choice of screening for hydrocephalus in Ethiopia.16 Data on the anthropometric parameters of preterm infants in most low-incomecountries are scarce, where the risk of neonatal death is very high.18Nutritional deficiency could be experienced in utero due to poor maternal diet thatinfluences fetal nutrition, which results in smaller birth size and otherdetrimental birth outcomes and long term complications.7 Birth size is largely determined by the maternal health, maternal nutritionand socioeconomic conditions than genetic differences.4 Comparison of the anthropometric values of the preterm infants withinternational data will reveal the status of intrauterine growth of Ethiopianpreterm infants.There is a large gap between birth outcomes of low income countries and high income countries.The aim of this study was to assess anthropometric measurements of Ethiopian preterminfants at birth and compare the results with the international INTERGROWTH-21stdata.20This was a hospital-based multi-center descriptive clinical study; using datafrom a study on causes of illness and death of preterm infants in Ethiopia(SIP). This study was undertaken in 5 government university hospitals inEthiopia; Gondar University hospital (north Ethiopia), Jimma University MedicalCenter (south-west Ethiopia); and 3 hospitals in Addis Ababa, Black LionHospital, Saint Paul Millennium College Hospital, and Ghandi Memorial Hospital.The methodology paper of the protocol and the paper on major causes of death ofpreterm infants in Ethiopia have been published previously.Live-born, singleton preterm newborns, <7 days of age born during the studyperiod between 2016 and 2018, and whose parents gave informed consent, and wereenrolled in the primary study. Both the healthy preterm infants and those whowere admitted to neonatal intensive care units (NICUs) were included foranalysis. For the purpose of this analysis, newborns who were older than48 hours at time of enrollment and those with major/gross congenital anomaliesand dysmorphic features were excluded as these conditions may affectanthropometric measurements. We have also excluded those infants with GA of<28 weeks as they were few in numbers.The assessment of GA was done based on 3 methods ,physical examination using the Ballard Score, and ultrasound). When thedifference between GA assessed by Ballard and that calculated from an accurateLMP was not greater than 2 weeks, the LMP GA was assumed to be correct. GAassessment was performed by trained physicians and anthropometric measurementswere done according to the standard procedures. Birth weight was measured withcalibrated digital weighing scales to the nearest 10 g. Head circumference andlength were also measured to the nearest 0.1 cm. Data was collected using studyspecific forms.The study was conducted after ethical approval was obtained from Addis AbabaUniversity College of health Sciences institutional review board (Ethics ID:AAUMF 03-008), and LMU Institutional Review Board (Ethics ID: 19-649).21Data analysis was done by R software. Percentiles of anthropometric measurementswere calculated. Con-tinuous variables were presented as means and standarddeviations. Results are presented as mean differences, standard deviations (SD),and as means with 95% confidence interval (CI). The prevalence of SGA (<10thpercentile) and LGA (>90th percentile) in this study was calculated based onWHO standards.A total of 4919 were enrolled in the SIP study. Exclusions included those with majorcongenital anomalies (N = 24), those with GA <28 weeks (N = 74), those withincomplete anthropometric measurements (N = 196), postnatal age older than 48 hoursat admission (N = 104) or a multiple pregnancy (N = 1659) . All 3 aThe mean (SD) of the mothers’ age was 26 years (SD 5.4), and half of the mothers wereyounger than 25 years of age. More than one third 1048 (38%) were not able to reador write, while half had a formal education. Two fifths of the infants were latepreterm 1082 (39%), while the rest were very preterm and moderate preterm, 896 (32%)and 785 (28%) respectively. More than one quarter 818 (32%) of the infants had abirth weight of <1500 g. The main reasons infants were brought to NICU were forprematurity, breathing problem and being cold to touch .GA and sex-specific means and standard deviations (SD) for birth weight, length andhead circumference are shown in thcentile values were found to be consistently higher than the international standardsat all GAs in both sexes  infants.27 In 2010 about 1.2% to 3.0% of the preterm births in low- and middle-incomecountries were estimated to be SGA, the SGA percentage in the current study isconsiderably higher (10.8%), however the this study was hospital based, and mightnot represent the prevalence of SGA in the general population.28We used the definition of SGA suggested by a 1995 WHO expert committee as infantsbelow the 10th centile of a birthweight-for-gestational-age, sex-specific reference population.Limitations of this study include the fact that the data were hospital-based, ratherthan population-based, and infants <28 weeks of GA were excluded, because theywere few in numbers. And the international growth standard (INTERGROWTH 21st) hadexclusion criteria of mothers living at altitude greater than 1600 m. All the studysites in the current study have altitudes greater than 1600 m, which might have aninfluence on birth size. In addition, and INTERGROWTH data had fewer infants of GA<33.Birth weights of the infants in this study were comparable with the internationalaverages at lower GA; however at later GA, the infants’ measurements were generallysmaller. The finding that the infants were smaller at higher GA may indicatematernal undernutrition in the third trimester of pregnancy. Strengthening antenatalnutrition counseling and providing supplementation might increase the birth weight.Improving birth weight may have a positive impact on neonatal survival. Mostly, thelengths of the infants were smaller than international averages across the GAs; HCmeasurements were comparable, the 90th centile values were higher than internationalaverages consistently in all GAs and in both sexes, which could indicate the need todevelop a population-based HC charts for unbiased interpretation in clinicalpractice. The need for specific anthropometric standards for those who live athigher altitude might be a question worth investigating. The percentage of pretermSGA in this study was higher than the estimate in low- and middle-income countries,population based study is required to assess the burden of preterm SGA in thissetting.


A birth dose of the hepatitis B vaccine will prevent most perinatally acquired infections and offers early protection from horizontal transmission. This article assessed the prevalence of the hepatitis B birth dose and associated factors among children in the District 2 Hospital.  A prospective cross-sectional study between June and December 2017 recruited parents/caregivers of children aged 12–59 months who were randomly selected at the vaccination department in the District 2 Hospital. The structured questionnaire applied was to collect the characteristics of participants and check the vaccination schedule. The birth dose was defined as the hepatitis B vaccine, which was given to children within 24 hours after birth. Additionally, a semistructured questionnaire was used for interviews and focus group discussions (FGDs) to assess the risk perceptions and barriers to vaccination. P < 0.05). In-depth interviews and FGDs found that most participants did not know that hepatitis B could be transmitted through childbirth, and barriers that affected the birth dose vaccine included children being sick, premature infants, or reason relating to physicians.  A total of 292 parents/caregivers had a mean age of 32.7 ± 6.8 years; among them, 88.7% were females. Their children had a mean age of 30.3 ± 13.9 months and 71.6% of these children received the hepatitis B birth dose, which correlated with the age of gestation ( The rate of hepatitis B birth dose was low, which resulted from associated factors such as premature birth, likely to be linked with false contraindications and beliefs that, potentially, the 2013 incident is still fresh in people's minds. Therefore, strategies to implement policies around the hepatitis B birth dose should be in line with current World Health Organization recommendations and strategies to modify current beliefs about vaccination. Hepatitis B virus (HBV) infection is considered a public health issue in Vietnam with 8.6 million people being HBV positive. The rate of infection in women is lower than men, being 8.8% and 12.3%, respectively . The prord child for sampling (k = 3). After that, a purposeful sampling strategy was carried out on a total of 30 parents/caregivers whose children did not receive the birth dose within 24 hours. The participants were invited to an interview or focus group discussion (FGDs).All parents/caregivers who directly take care of children and whose children are between 12 and 59 months of age, who had the vaccination cards, were eligible. A cross-sectional study was performed between June and December 2017. Systematic random sampling was based on the daily registered list to select children at the vaccination department. We selected every 3The structured questionnaire included two sections. The first depicted the demographics of the parents/caregivers, such as age, gender, residence location, occupation, education, and information about hepatitis B vaccination, and the demographics of children included age, gender, birth weight, place of birth, and the period of delivery and birth order of the child in the family. The second assessed the hepatitis B birth dose vaccination by checking their children's vaccination records (paper records). If no vaccination card was available, the next child on the list was contacted. Additionally, a sample of 30 parents/caregivers, whose children did not receive the hepatitis B birth dose within 24 hours, undertook an in-depth interview or FGDs. A semistructured questionnaire designed for our in-depth interview questionnaire and FGDs was used in assessing risk perceptions (risk of getting the disease and transmission) and to identify barriers to receiving the vaccination (reasons that children did not receive the birth dose on time or difficulties in getting the hepatitis B vaccine) . It tookWe evaluated the hepatitis B vaccination based on the vaccination cards, whereby the period of time for the birth dose was calculated by the date of vaccination minus the date of birth; however, if the period of time falls within one day (24 hours), it is considered as a timely birth dose, and the reverse applied for vaccinations that were defined as delayed. The children were recorded as “complete and timely” when they were vaccinated with the timely birth dose, followed by the three additional doses of pentavalent vaccine, recommended at 2, 3, and 4 months .t-test were used to analyze the relationship between the dependent (demographic characteristics of participants) and independent variables (the birth dose of children). Logistic regression was performed in the multivariate analysis. All the significant differences of variables were considered if the P value showed <0.05. While data from the transcripts were coded using NVivo10, which was used to record our themes, tally code frequencies, and trace code relationships. We used a constant comparison method, by which we tested and applied our coding categories to each new transcript.We analyzed participants' demographics and the prevalence of the birth dose using Stata 13.0 software. Descriptive analysis was described as frequency, percentage, and mean scores. The chi-square or Fisher's exact test and the All participants agreed and signed informed consent forms before taking part in our study and were able to stop participating at any time. Also, they were assured that their responses would be kept confidential, and transcripts were anonymous. The proposal was approved by the Ethics Council of the University of Medicine and Pharmacy at Ho Chi Minh City (protocol number 196-UMP-BOARD).A total of 688 eligible participants, with 292 (42.4%) of them agreeing to take part in completing the questionnaire. Demographics of the study population are presented in There were 94.9% of children that received three doses of pentavalent vaccine, while only 71.6% of them got the birth dose within 24 hours, and children who had complete and timely hepatitis B vaccine, including the birth dose and three doses of pentavalent vaccine on time, were recorded as 71.2% .P < 0.05). Adjusting for other variables, the gestation period of more than 37 weeks had a 1.2 times higher prevalence of receiving the birth dose within 24 hours compared to the age of gestation less than 37 weeks .The comparisons of participants' characteristics in groups with and without the hepatitis B birth dose vaccine within 24 hours are presented in The characteristics of participants who attended in-depth interviews and FGDs are presented in   “I think the children's immune system is weak; so, they are susceptible to hepatitis B” .  “Hepatitis B is spread via the respiratory; so, we kept our distance” .  “Transmitted by contact with an infected person” .A sample of 30 parents/caregivers of the 292 participants, whose children did not receive the timely hepatitis B birth dose, participated in an in-depth interview or the FGDs. We identified several common opinions where it suggested that participants knew the risks of hepatitis B and ways of transmission, with a majority of parents/caregivers being aware that anybody could get HBV, which included their children. However, they seldom mentioned that HBV could be transmitted through MTCT, sexual contact, and blood.Some participants in the FGDs had some opinions about issues relating to the birth dose. These included the side effects after vaccination  in premature infants.One woman said, “If children are premature, they should not get the hepatitis B birth dose vaccine within 24 hours” .One man in the FGDs said, “After getting a vaccination, children can get a fever, convulsions, or die” .The effect of the HBV birth dose is found in some surveys in Vietnam, whereby the rate of HBsAg positive in children vaccinated with 4 doses of the HBV vaccine including a birth dose is lower than those who did not receive the birth dose or were not vaccinated  . Within Some limitations of our study include the small percentage of the study population that agreed to participate and only children with vaccination cards were eligible. Additionally, events over a long time interval are being asked about, and they may happen recall bias. Also, the study has not collected variables including antenatal visits, BCG vaccine, and vaccination barriers among healthcare workers. Future studies should be concentrated on these issues. Although not generalizable, it provided insights into the local sociocultural context of parents to design appropriate intervention and an outreach plan.The rate of hepatitis B birth dose was low, which resulted from associated factors such as premature birth, likely to be linked with false contraindications and beliefs that, potentially, the 2013 incident is still fresh in people's minds. Therefore, strategies to implement policies around the birth dose HBV should be in line with current WHO recommendations and strategies to modify current beliefs about vaccination.


The presence of motor signs and symptoms in Parkinson’s disease (PD) is the result of a long-lasting prodromal phase with an advancing neurodegenerative process. The identification of PD patients in an early phase is, however, crucial for developing disease-modifying drugs. The objective of our study is to investigate whether Diffusion Tensor Imaging (DTI) of the Substantia nigra (SN) analyzed by machine learning algorithms (ML) can be used to identify PD patients.Our study proposes the use of computer-aided algorithms and a highly reproducible approach  to increase the reliability and accuracy of DTI metrics used for classification.The results of our study do not confirm the feasibility of the DTI approach, neither on a whole-brain level, ROI-labelled analyses, nor when focusing on the SN only.Our study did not provide any evidence to support the hypothesis that DTI-based analysis, in particular of the SN, could be used to identify PD patients correctly. Diffusion tensor imaging (DTI) has been proposed for analyzing microstructural integrity not only of white but also grey matter. However, the use of DTI to observe, e. g., subcortical grey matter changes is currently under debate . Whether3, 72 slices, 64 gradient directions with a b-value of 1000 s/mm2). In addition, a non-gradient volume (b = 0 s/mm2) was acquired as well. Further details of the PPMI image acquisition protocol can be seen online . We performed pre-processing by using the PANDA-toolbox (v1.3.1) in Matlab 2018b, including normalization to standard space  [DTI datasets of 162 PD patients  and 70 age and gender-matched healthy controls (HC)  were analyzed. This study used human subject recordings chosen from the Parkinson’s Progression Marker Initiative (PPMI) database. The PPMI dataset was published open-access with a positive ethics statement of the responsible authorities. Therefore, additional ethics committee approvals do not apply to this study. DTI-MR sequences were acquired on a Siemens 3 T TIM Trio scanner using a 12-channel matrix head coil and a two-dimensional echo-planar DTI sequence  . To furtThe application of the bSVM on the various types of diffusion metrics revealed that there are no significant differences concerning the BA or the ROC-AUC for voxel-wise whole-brain or AAL-based ROI-labeled analyses (data not shown here). As most studies suggest, diffusion metrics are most likely altered in the SN of PD patients, making the SN the region of highest interest to increase the signal-to-noise ratio for classification . TherefoIn this study, we demonstrated a standardized and systematic approach to potentially attain the individual discrimination of PD patients from healthy controls using DTI datasets. This approach comprised the pre-processing of the data, the automatized selection of appropriate features, and the subsequent classification. Atkinson-Clement, Pinto, Eusebio, and Coulon  already Our findings are well in line with previous publications using conventional analyses. Further studies without substantial methodological improvements  will most likely not result in potentially translatable advancements in improving diagnostic accuracy or patient care.


Echinococcus multilocularis larval tapeworm infections in humans that severely impairs the health of affected patients in the northern hemisphere.Alveolar echinococcosis (AE) is a zoonotic parasitic disease caused by The expression levels of 20 cytokines associated with AE infection were measured by enzyme-linked immunosorbent assay, and the correlations between these cytokines were analysed in the R programming language.Serum cytokine levels differed among individuals in both the AE patient and healthy control groups. The results of the correlations among the cytokines showed obvious differences between the two groups. In the AE patients group, Th1 and Th2 cytokines formed a more complicated network than that in the healthy control group.The altered correlations between Th1 and Th2 cytokines may be closely associated with AE infection, which may provide a new explanation for the essential differences between AE patients and healthy individuals. Echinococcus multilocularis larval tapeworm infection in humans that is fatal if left untreated [E. multilocularis in a pastoral region of Qinghai province [Alveolar echinococcosis (AE) is a severe parasitic disease caused by ntreated , 2. The ntreated , 3. AE cntreated , 5. Thisntreated , 7. Epidhttp://whqlibdoc.who.int/hq/2012/WHO_HTM_NTD_2012.1_eng.pdf). To date, surgery is the only potentially curative option for the treatment of AE; however, AE recurrence after hepatectomy is high, and many patients present with inoperable disease [The World Health Organization (WHO) has listed echinococcosis as one of the 17 neglected diseases targeted for control or elimination by 2050  cells can selectively differentiate into the Th1 or Th2 subtype in response to an nfection , 10. AE nfection . In micenfection , 12. Thenfection , 12.In this study, 20 cytokines, including Th1 and Th2 cytokines, were selected according to the related literature –15. The The participants consisted of 45 AE patients  and 45 healthy people . The mean age of the AE patients was 38 years , and the mean age of the healthy controls was 39 years . All the recruited participants were Tibetan and lived in the Guoluo Tibetan Autonomous Prefecture of Qinghai Province, and 91% were herdsmen. The diagnosis of AE was according to the People’s Republic of China Health Industry Standard—Diagnostic Criteria for Hydatid Disease (WS257–2006) by a professional doctor. The classification of AE patients in different clinical stages of AE was accomplished according to the World Health Organization- (WHO-) PNM , detailed in Table Five millilitres of peripheral venous blood was harvested from each participant after an 8- to 12-h fast under strict precautions in sterile tubes containing EDTA anticoagulation, and 1 mL of serum was immediately separated from the blood and preserved at − 80 °C for the measurement of cytokines.The serum levels of 20 cytokines in AE patients and healthy controls were measured by an enzyme-linked immunosorbent assay (ELISA) kit (Thermo Scientific) according to the manufacturer’s protocols. All samples were measured three times for each cytokine, and the mean value was taken for analysis. The 20 analysed cytokines are listed in Table We searched related studies in the PubMed database using the keywords “cytokine” and “alveolar echinococcosis” to explore data on cytokine expression in previous studies associated with AE from 1990 to 2019. After a literature review, a total of 56 studies were identified, 16 of which reported cytokine levels in human AE.The relationships between the AE patient group and the healthy group were analysed by a principal component analysis (PCA) performed based on the Bray-Curtis distance matrix across the samples using the vegan package in R (version 3.4.4). Student’s t-test was performed to compare PC1/PC2 between groups using the stats package in R. Spearman’s correlations between cytokines were calculated using the Hmisc package in R. The correlation networks between cytokines were constructed using the GeneNet package in R and were further visualized using Cytoscape 3.4.0 .The expression levels of 20 cytokines were compared between the AE patient group and the healthy control group, while the ELISA results showed that cytokine expression levels differed among individuals in both the AE patient and healthy control groups.P < 0.001).The PCA showed that most samples in the AE patient group had obviously different cytokine compositions than those in the healthy control group, while a few samples showed similarity Fig. . The difThe correlations among some cytokines were obviously different between the two groups. In the healthy control group, there was no correlation between MIP-1α and IL-13 or among MCP-1, MCP-1α and MIP-1β  as controls, with prospective follow-up and involving large sample sizes.


One of the major aims of marriage is to procreate or give birth to a child. Childbirth is so crucial in marriage that it often determines the happiness of the couple. Too much delay in childbirth after marriage or the likelihood that one cannot give birth after marriage can lead to divorce. However, causes of delay in childbirth are often difficult to detect by both the Gynaecologist and the couple involved. This makes proposing solutions to issues related to childbirth usually unsuccessful.  It is against this background that we conducted this study to identify factors that determine childbirth within 10 months or after 10 months of marriage (birth length) among women in Ghana. This was achieved by using a logistic regression model for the dichotomous birth length variable, adjusting for risk factors/predictors of birth length. The data used for the study were obtained from the 2014 Ghana Demographic and Health Survey, consisting 6,525 complete cases with 18 predictor variables. Statistical analyses were carried out using STATA version 14.1.  The results show that respondents who have ever terminated pregnancy are more likely  to deliver after 10 months, wives whose husbands have higher education are less likely  to give birth after 10 months of marriage, wives who reported that beating is justified if she goes out without her husband's notice are more likely  to give birth after 10 months, wives who reported that beating is justified if she neglects the child are more likely  to give birth within 10 months, and wives who reported that beating is justified when she argues with her husband are less likely  to give birth after 10 months of marriage. Every unit increase in the age of the respondent at marriage increases the likelihood of giving birth after 10 months of marriage, and a unit increase in the age of the respondent at first sex decreases the likelihood of giving birth after 10 months in marriage.  For conception within 1 month of marriage, wives and husbands should/are encouraged to have frequent sex, any negative social behaviour or policies must be discouraged, experts' advice on contraceptive use must be sought, and women are encouraged to desist from termination of pregnancy at any time of their life. Husbands should openly express their desire and love for their children since this increases the likelihood of wives' desire to give birth. This leads to frequent sex, which then reduces conception time, and hence childbirth within the shortest possible time. In Vitro Fertilization (IVF) in 1979 [It is known that procreation or childbirth is one of the main aims of marriage, and childbirth is so crucial in marriage that it often determines the happiness of the couple. Research on improving birth rates has received much attention following the success of  in 1979  and IVF  in 1979 , 4. ThesOne may hypothesize that pregnancy and parenthood experienced after infertility and assisted conception will be very appealing. However, it has been shown that past infertility and ART conception are likely to be associated with higher anxiety about pregnancy loss, delayed mother-infant attachment, reduced maternal confidence, hypervigilant and overprotective parenting, and idealized expectations of parenting capacity and the infant . ClinicaThe implication is that too much delay in childbirth after marriage or when it is likely that one cannot give birth after marriage can lead to divorce . HoweverHammarberg and colleagues  study reIn Ghana, the increase in the level of contraceptive use is one of the main causes of reduced fertility . Other fIn this paper, we explored the effects of sociocultural and socioeconomic factors that are likely to influence conception time among women after marriage in Ghana. Hence, we structured the paper into four main sections as follows. We have already given the background of the study in In this section, we introduce the study setting and the source of data. We also introduce the outcome variable of interest in this study, as well as factors that determine the value or the status of this outcome variable. Finally, we discuss statistical approaches used in this study.http://dhsprogram.com/What-We-Do/Protecting-the-Privacy-of-DHS-Survey-Respondents.cfm, approved by the ICF International Institutional Review Board (IRB). We will now introduce the outcome variable and the risk factors of birth length status.This study is conducted in Ghana, and the data used for the study are obtained from the Ghana Demographic and Health Survey for 2014. This is a cross-sectional study, where the outcome variable of interest and its associated risk factors were measured at a single time point. In this study, we focused on individual birth record data, obtained from the respondents during the survey. We observed that some of the individual records have missing values –17, and In this study, the outcome variable of interest is birth length status .The status of the outcome variable, introduced in the previous section, depends on certain risk factors. These risk factors predict the status of the outcome variable. In this section, we introduce the risk factors for the birth length status. These risk factors will be used in the data analyses section to account for their influence on the status of the outcome variable.The study adjusted for the effect of partner's educational attainment on birth length status . We also adjusted for the effect of pregnancy termination birth length status, where respondent was asked if she ever terminated pregnancy . Other risk factors included in the birth length status model are geographical location , oral contraceptive usage , anaemia status , husband stays at home , and beating justified if refuses to have sex, if burns food, argues with husband, neglects child, or goes out without informing husband . We also adjust for the effect of some continuous risk factors such as age at marriage, haemoglobin level, and weight.In this section, we discuss some selected statistical approaches/tools that will allow us to investigate the relationship between the outcome variable (birth length status) and the predictors of birth length status.In this study, we used two statistical approaches to analyse the data on birth records. First, we used the Chi-Square test statistic\citep{ chi} to X1, ⋯, Xp are the risk factors/predictors; β0, ⋯, βp are parameter estimates representing the effects of their corresponding risk factors on the dichotomous response variable (birth length status); yi is the outcome which equals to 1 if respondent i gives birth to her first child after 10 months of marriage and 0 if within 10 months; X is a design matrix for the predictors; and β is a vector of the parameter estimates. Also, p is the probability that a respondent gives birth after 10 months of marriage and p/(1 − p) is the odds of the outcome variable among those who exposed to the predictors relative to those who are not exposed to the same predictors. So in effect, the β  is the log odds ratio of the birth length status for those who are exposed to the predictors relative to those who are not exposed.In the further analyses, we used the logistic regression model , 19–23 tβ1, ⋯, βp, respectively. These predicted probabilities are used to classify individuals into either those who actually give birth to their first child within 10 months after marriage or after 10 months of marriage. This approach is known as classification \citep{van2004methodology,collett2002modelling}. Thus, to assign an individual to one of the two groups on the basis of the predicted response probabilities, we need to identify a “threshold” value, π0 , in such a way that if π0 = 0.5$ if the two groups are symmetrical. Also, π0 can be determined from the observed data, where π0 is chosen so as to either minimize the overall proportion of misclassification or to compromise between the minimization of the 2 misclassification probabilities .We use this model (1) to predict the response probability for an individual for which the values of the predictors in the model are observed. In order to determine the predicted probability, we need to back-transform usingb/(b + d) × 100 [b/(b + d) = 1 − SPEC (expressed as proportion), which represents the probability of positive prediction given that an individual gives birth to the first child within 10 months of marriage and (2) a/(a + c) = 1‐$SEN (expressed as proportion), which represents the probability of negative prediction given that an individual gives birth to the first child after 10 months of marriage. These methods are often used in disease status prediction and classification, and depending on the nature of the disease, one of these misclassifications may be more serious than the other. More often, the focus is to minimize the probability of false negative, which is equivalent to maximizing sensitivity.When our two groups refer to those who give birth to their first child within 10 months and those who give birth to their first child after 10 months of marriage, we can summarize the relationship between the true situation and the prediction as shown in d) × 100 . We defiπ0varies. Since we classify an individual as one who gives birth to their first child after 10 months of marriage if π0 and 1-specificity will increase with decreasing π0. On the other hand, when sensitivity is equal to 1-specificity, the probability of positive prediction given that an individual gives birth to their first child after 10 months is comparable to the probability of positive prediction given that an individual gives birth to a child within 10 months. In this situation, the model has no predictive power. For a highly predictive model, we want sensitivity to be much bigger than 1-specificity (we want sensitivity to increase much faster than 1-specificity) as π0 goes from 1 to 0. Statistical analyses in this study were carried out using the STATA version 14.1 software  curve , 25 to doftware  and the various predictors. We also present and provide interpretation of the results from the logistic regression model (1).Χ2 = 4.61, p value = 0.032), (2) partner's educational level 2 = 10.19, p value = 0.017), (3) beating justified if wife neglects child 2 = 9.63, p value = 0.002), (4) beating justified if wife argues with the husband 2 = 13.94, p value = 0.001), (5) beating justified if wife burns food 2 = 8.37, p value = 0.004), (6) age of the respondent , and (7) ever terminated pregnancy 2 = 5.08, p value = 0.024) are significantly associated with the outcome variable and hence are potential predictors of the status birth length. However, predictors such as (1) contraceptive use 2 = 2.10, p value = 0.148), (2) anaemia status 2 = 1.84, p value = 0.18), (3) husband at home status 2 = 2.10, p value = 0.15), (4) beating justified if wife goes out without husband's notice 2 = 3.24, p value = 0.072), (5) beating justified if wife refuses to have sex 2 = 3.11, p value = 0.078), (6) weight , (7) age at first sex , and (8) haemoglobin level  of the respondent are not statistically significant, and hence, they are not reported in the results of our further analyses (using the logistic regression model).In In this section, we build a logistic regression model to estimate effects and to assess the significance of the predictors on the status of the outcome (birth length). We select the best predictors/model by going through the following four steps. However, this can also be done using an automatic stepwise variable selection procedure given in the STATA code attached.p value = 0.651), beating justified if wife refuses to have sex with husband , and weight  are removed in the subsequent analyses. In the second analyses, we fitted a logistic regression model (Model B) without the highly statistically insignificant predictors in Model A. In this model, the predictor, beating justified if wife burns food was highly insignificant  and was removed in the subsequent analysis. So, in the third model (Model C), we fitted a logistic regression model to the birth length status data without the highly insignificant predictors in Models A and B. However, predictors such as geographical location , primary  and secondary education , and haemoglobin level  of the respondents were still insignificant in analyses under Model C and hence were removed in the subsequent analyses. In the fourth model, Model D, all the insignificant predictors under Models A, B, and C were removed.First, we fitted a logistic model (Model A) with all the predictors in We stored/saved estimate results from Models A, B, C, and D and then compared the performance of these models using their respective AICs shown in The results of the best fitting Model D are presented in We observed that women who reported that beating is justified if she goes out without her husband's notice are more likely  to give birth to their first child after 10 months of marriage. This finding appears to suggest that wives are more likely to violate this order, and hence, there may be frequent misunderstanding between partners, which may subsequently lead to infrequent sexual intercourse which may delay conception among such women. On the contrary, wives who reported that beating is justified if she neglects child are more likely  to give birth to their first child within 10 months of marriage. This finding which may suggest that wives who believe that husbands care much about their children are more willing to give first within the shortest possible time. Wives who reported that beating is justified when she argues with her husband are less likely  to give birth to their first child after 10 months of marriage  relative to wives who reported that beating is not justified if she argues with her husband. This suggests that such wives are more likely to offer sex to their husband without arguing/refusing anytime they demand and hence more likely to conceive within 1 month after marriage. These findings, overall, appear to give an indication that various forms of social violence are key factors in determining how long a woman stays in a marriage before giving birth to the first child and, possibly, the next child and so on.We found that for every unit increase in the age of the respondent at marriage, there is a 0.125 increase in the likelihood of giving birth to the first child after 10 months of marriage. This finding is probably due to a higher proportion (28%) of contraceptive use among older-age (>18 years) wives relative to approximately 26% of contraceptive use among the younger-age (≤18) wives. The results show that for every unit increase in the age of respondent at first sex, there is a 0.029 decrease in the likelihood of giving birth to the first child after 10 months in marriage. This suggests that if a woman stays longer to have her first sex, then such woman is more likely to have more sex in marriage and more likely to conceive within 1 month of marriage. Though not general, but it is more likely that younger wives and those who stay longer to have their first sex may be more willing or have much desire to have sex, hence more likely to conceive within 1 month of their marriage.π0 value using π0can assist in deciding on an optimal value of π0. For instance, when π0 = 0.65 gives higher (70.94%) sensitivity and lower (47.39%) specificity. When π0 = 0.60, sensitivity is higher at 85.16% and specificity is lower at 25.80%. This means that decreasing π0 value leads to increasing sensitivity. Since we want sensitivity to increase much faster, we may use a cutoff value π0 = 0.60$ or π0 = 0.55$ which gives sensitivity as 95.11% and specificity as 12.78%. For instance, using π0 = 0.63$ produces the following classifications presented in Tables In this section, we assess the predictive power of Model D in predicting probabilities for birth length status using the Receiver Operating Characteristic (ROC) curve discussed in s higher 0.94% senWe now assess the predictive power of Model D using the ROC curve to estimate the area under the curve. The ROC curve is a plot of sensitivity versus 1-specificity. This means that when sensitivity = 1 − specificity, the area under the curve is 50%, corresponding to no predictive power. If sensitivity increases faster than 1-specificity, the more bowed is the ROC curve and the bigger is the predictive power of the model. This corresponds to a larger area under the ROC curve. Hence, the shape of the ROC curve and the area under the curve is indications of the predictive power of the model. Hence, the ROC curve displayed in In this paper, we investigated the effects of various risk factors on the first child's birth length after marriage. Birth length in this study is a dichotomous variable coded as 1 if an individual gives birth to her first child after 10 months of marriage, and 0 if an individual gives birth to her first child within 10 months of marriage. The study used birth record data from the 2014 Ghana Demographic and Health Survey (2014 GDHS). Some of the variables have missing values  & , 28, 201We assessed the effects of the various risk factors on the status of the dichotomous birth length variable using the logistic regression model , 21, 23.We build our regression model for the dichotomous birth length variable by fitting four logistic regression Models A, B, C, and D  wives relative to a lower contraceptive use among the younger-age (≤18) wives. Also, for every unit increase in the age of respondent at first sex, there is a decrease in the likelihood of giving birth to the first child after 10 months in marriage, which appears to suggest that if a woman stays longer to have her first sex, then such woman is more likely to have more sex in marriage and more likely to conceive within 1 month of marriage. Though not general, but it is more likely that younger wives and those who stay longer to have their first sex may be more willing or may have much desire to have sex, hence more likely to conceive with 1 month of the marriage.Our study results suggest that for conception within 1 month of marriage or to give birth to the first child within 10 months of marriage, wives and husbands should have frequent sex. The results also appear to suggest that any negative social behaviour or policies, on the part of the husband or society, that will reduce the likelihood of having frequent sex with the wife must be discouraged. Women who wish to have children are encouraged to desist from termination of pregnancy at any time of their life since this act has the likelihood of reducing chances of conception for such women. Based on our results, we also encourage husbands to openly express their desire and love for their children since this increases the likelihood of wives' desire to give birth. This leads to frequent sex, which then reduces conception time, and hence, child birth within the shortest possible time.


Advances in the miniaturization of microelectromechanical systems (MEMS)  are revoAn innovative strategy for continuous microparticle sorting in microfluidics is the use of deterministic lateral displacement (DLD) devices ,5,6. Sevuid flow . DLD devuid flow ,12). Dc A current topic of research is the effect of electric fields on the motion of particles in aqueous suspensions within DLD devices. The first work of electric-field assisted DLD separation was by Beech et al. , who insirection ,15. Thisirection  recently effects ,18. HoweThe physical mechanism behind particle separation at low frequencies has not been clarified yet. The smaller values of the applied electric fields suggest that another phenomenon different from DEP is responsible for this. Recent experimental work has shown the appearance of stationary flow vortices around the pillars for ac signals around hundreds of Hz and below ,19,20. F


Excessive weight is associated with periodontitis because of inflammatory mediators secreted by the adipose tissue. Periodontal impairments can occur during pregnancy due to association between high hormonal levels and inadequate oral hygiene. Moreover, periodontitis and excessive weight during pregnancy can negatively affect an infant’s weight at birth.  This observational, cross-sectional study aimed to evaluate the association between pre-pregnancy overweight/obesity, periodontitis during the third trimester of pregnancy, and the infants' birth weight. The sample set was divided into 2 groups according to the preconception body mass index: obesity/overweight (G1=50) and normal weight (G2=50). Educational level, monthly household income, and systemic impairments during pregnancy were assessed. Pocket probing depth (PPD) and clinical attachment level (CAL) were obtained to analyze periodontitis. The children’s birth weight was classified as low (<2.5 kg), insufficient (2.5–2.999 kg), normal (3–3.999 kg), or excessive (≥4 kg). Bivariate analysis  and logistic regression (stepwise backward likelihood ratio) were performed (p<0.05).2[2]=23.21; p<0.0001). Maternal overweight/obesity was also associated with low/insufficient birth weight . G1 showed lower socioeconomic levels and higher prevalence of arterial hypertension and gestational diabetes mellitus during pregnancy than G2 (p=0.002). G1 showed higher means of PPD and CAL  and therefore a higher prevalence of periodontitis than G2 (p=0.0003). G1 showed lower infants’ birth weight than G2 (p=0.0004). Excessive maternal weight and educational levels were independent variables associated with periodontitis during the third trimester of pregnancy (X The present findings suggest an association between excessive pre-pregnancy weight, maternal periodontitis, and low/insufficient birth weight. The adipose tissue secretes inflammatory mediators that cause a widespread inflammatory state in the body of the obese patients. As a result, these patients may have a significant inflammatory response in the periodontal tissues, even in the presence of a normal amount of dental plaque.2Therefore, with the tooth biofilm formation, the patient’s periodontal condition can worsen during this period.Pregnancy can also negatively affect a patient’s oral condition. During pregnancy hormonal alterations cause physiological and anatomical changes. These changes occur from conception to labor and promote fetal growth and pregnancy maintenance. High levels of progesterone and estrogen cause oral alterations during pregnancy decreasing an individual’s immune response.10 All studies found a positive association between obesity/overweight and periodontal status; however, they did not use the same classifications for periodontitis and body mass index (BMI), and none of the studies analyzed the association of these factors with infants’ health at birth.Studies have reported a triangular association between obesity/overweight and periodontal status during pregnancy.15 In contrast, maternal overweight/obesity is strongly associated with insulin resistance, which, in turn, is related to the gestational diabetes mellitus (GDM), preeclampsia, and macrosomia.19 However, studies that considered maternal overweight/obesity, periodontitis, and birth weight have not been conducted yet. Therefore, this study aimed to evaluate the association between pre-pregnancy overweight/obesity, periodontitis during the third trimester of pregnancy, and birth weight.The scientific literature highlights the association between periodontitis and adverse delivery outcomes, such as preterm birth and low birth weight.20The Strengthening the Reporting of Observational studies in Epidemiology (STROBE) guidelines were used to ensure the accurate reporting of this observational, cross-sectional study.According to the Declaration of Helsinki, this study was approved by the Ethics Committee on Human Research (CAAE 58339416.4.0000.5417). All participants provided written informed consent.2 The participants were recruited from a Brazilian public healthcare system in Bauru City, São Paulo from August 2017 to November 2018. The pre-pregnancy BMI was considered because the main objective of this study was to analyze how overweight/obesity could affect the systemic and oral health during pregnancy. For pre-pregnancy BMI calculations, pre-pregnancy weights were collected from medical follow-up. Heights were obtained during the appointment using a stadiometer . A normal pre-pregnancy weight was defined as a BMI of 18.0–24.99 kg/m2, while pre-pregnancy overweight was defined as a BMI between 25.0 and 29.99 kg/m2 and pre-pregnancy obesity as BMI ≥30.0 kg/m2.21The patient’s weight during the third trimester of pregnancy was recorded to evaluate their BMI during this period.One hundred women in the third trimester of pregnancy were included in this study and subsequently divided into 2 groups according to preconception BMI: pregnant women with obesity or overweight (G1=50) and pregnant women with normal weight (G2=50). The third trimester of the pregnancy was chosen to be evaluated in this study because of its high hormonal levels.2 were assigned to G1 and those with a BMI from 18 to 24.99 kg/m2 were assigned to G2. The exclusion criteria were: patients with general health impairments; patients with diabetes mellitus and/or arterial hypertension (AH) before pregnancy; patients with a BMI lower than 18 kg/m2; patients with smoking, drug, or alcohol habits; patients with gestational impairments that required absolute rest; and/or patients who were taking medications that could negatively affect their oral health. Furthermore, twin or multiple pregnancies were excluded in this study. Patients who had their infants before the 37th gestational week and after the 40th gestational week were excluded from this study.The inclusion criteria were: women in the third trimester of pregnancy, women with satisfactory systemic health, and women undergoing regular medical visits. Patients with a BMI higher than 25 kg/m22 The diagnosis of GDM was based on the International Association of the Diabetes and Pregnancy Study Group protocol,23 which defined the diagnosis of maternal hyperglycemia as having a fasting blood sugar level of ≥92 mg/dl. Educational level and monthly household income were classified according to a previous study by our research team.4 This study categorized the educational level along these lines: 0, illiteracy; level I, did not complete the primary education; level II, completed the primary education; level III, did not complete high school; level IV, completed high school; level V, did not complete higher education; level VI, completed higher education; level VII, specialization; level VIII, master’s degree; and level IX, Doctor of Philosophy (PhD). This study registered the highest educational level.Data regarding systemic impairments, such as diabetes mellitus and AH during pregnancy, were obtained from medical records and registered as 0 (absent) or 1 (present). AH in pregnancy was established as ≥140/90 mmHg blood pressure levels.Monthly household income was graded into the following levels according to minimum wage (MW): Level I, up to 1 MW; Level II, 1–2 MW; Level III, 2–3 MW; Level IV, 3–4 MW; Level V, 4–5 MW; and Level VI, higher than 5 MW. The minimum wage considered in this study is approved by the Brazilian government as R$ 937.00 (approximately USD 284.00). Moreover, oral hygiene behaviors were assessed such as daily frequency of toothbrushing and use of daily dental floss.4 Gingival recession and hyperplasia were also measured to calculate the CAL. Six sites of each tooth were assessed: mesial, center, distal, both buccal, and lingual.4 The mean values for the PPD and the CAL were obtained. Periodontitis was diagnosed when the patients had ≥2 interproximal sites with CAL ≥3 mm and ≥2 interproximal sites with a PPD≥ 4 mm (not on the same tooth) or one site with a PD ≥5 mm, according to case definitions for surveillance of periodontitis proposed by Page and Eke24 (2007). Furthermore, periodontal disease was categorized as moderate and severe.24A calibrated dentist performed oral assessments to assess the periodontal condition . Before sample recruitment, calibration of the examiner for the periodontal parameters was performed in 10 patients , corresponding to 10% of the total sample. These 10 patients were not included in this study. The periodontal measurements were obtained at different times by a primary examiner and by a gold-standard investigator to obtain the intra- and inter-examiner concordance coefficient, considering the periodontal fiber changes after the first periodontal probing. All teeth present in the mouth were evaluated, excluding the third molars. The periodontal assessment was performed according to the pocket probing depth (PPD) and the clinical attachment level (CAL). The PPD was measured from the free gingival margin to the bottom of the periodontal pocket and the CAL was measured from the cementoenamel junction to the base of the periodontal pocket.27The children’s weight at birth was provided by the patients after the delivery and classified according to the World Health Organization (WHO) into low/insufficient, normal, and excessive .25-2728. Therefore, initially, the dichotomization of periodontitis  and low/insufficient birth weight  was performed, followed by an inclusion of a maximum of 5 independent variables in the logistic models. Thus, a sample size of 100 was considered representative. The Kolmogorov-Smirnov test was applied to verify the normal distribution of the sample. The t-test was used in bivariate analysis to examine the normally distributed quantitative variables. The Mann-Whitney U test was used to examine non-normally distributed quantitative variables and ordinal variables. The chi-squared test was used to examine binomial data. The logistic regression was adapted using the stepwise backward (likelihood ratio) method to analyze the independent variables associated with periodontitis and infants’ birth weight (dependent variables). A significance level of 5% was considered statistically significant. Hosmer-Lemeshow, collinearity, and residual analyses were used to increase our understanding of the logistic regression results.Statistical analysis was performed using the International Business Machines Corporation Statistical Package for the Social Sciences (IBM SPSS) version 25 . Once we ensured that 10 patients were selected for each combination of independent variables, the protocol proposed by Hosmer and Lemeshow for regression logistic analysis was adapted regarding sample sizeInitially, 123 patients were selected for this study; out of these, 23 were excluded due to the following reasons: requiring absolute rest (n=3), history of periodontitis before pregnancy (n=2), more than 40 weeks of gestation (n=9), smokers (n=2), underweight (n=3), and under orthodontic treatment (n=4). Therefore, 100 patients were included in this study.The participants’ average age was 29.5 years . G1 had lower family income (p=0.011) and lower educational level than G2 (p=0.034).G1 also had a lower prevalence of patients who had completed higher education  compared with G2  .G1 showed a higher pre-pregnancy and gestational BMI than G2 (p<0.0001). Furthermore, G1 had a higher prevalence of hypertension and GDM than that of G2 (p=0.002) .The groups did not differ regarding daily toothbrushing frequency (p=0.757) and daily use of dental floss (p=0.392). However, they differed in the mean PPD (p=0.041), in the mean CAL (p=0.049), and in the prevalence of periodontitis, which was higher in G1 than in G2 (p=0.0003), with 48% (n=24) and 24% (n=12) of patients classified as having moderate and severe periodontitis respectively. None of the patients in G2 were classified as having severe periodontitis, but 36% (n=18) of the patients were classified as having moderate periodontitis .The average birth weights for G1 and G2 were 3.06±0.35 kg and 3.33±0.38 kg, respectively. No infants were classified as having excessive birth weight. However, 18 infants in G1 (36%) had a low or insufficient weight, whereas only 4 infants in G2 (8%) had a low or insufficient weight (p=0.0008) .2[2]=23.21; p<0.0001; R2 of Nagelkerke=0.276). The overall percentage accuracy of the final model was 65%. The Hosmer and Lemeshow analysis indicated a chi-squared value for the final model of 2.58 for 8 degrees of freedom (p=0.958). Maternal BMI  and educational level  were significant predictors of periodontitis in the third trimester of pregnancy.Binary logistic regression was applied to determine the independent variables related to periodontitis  during the third trimester of pregnancy . Pre-pre2[1]=7.01; p=0.008; R2 of Nagelkerke=0.104) related to insufficient birth weight. The overall percentage accuracy of the final model was 77%. The Hosmer and Lemeshow analysis established a chi-squared value for the final model of 19.78 for 8 degrees of freedom (p=0.011). The maternal BMI  was a significant predictor of insufficient birth weight.Moreover, the binary logistic regression was performed to determine the independent predictive variables of insufficient birth weight  . The varThis study contributes to the body of scientific evidence by evaluating the association between pre-pregnancy overweight/obesity, maternal periodontitis, and low birth weight. We adapted the standardized protocols for nutritional status classification and periodontitis diagnosis. The main findings of this study suggest pre-pregnancy excessive weight is significantly associated with periodontitis during the third trimester of pregnancy. Moreover, overweight/obesity is associated with a low/insufficient birth weight.29In this study, the overweight/obese pregnant women had a higher prevalence of AH and GMD than that of non-overweight/nonobese pregnant women (p=0.022). The presence of adiposity in the body was associated with the visceral accumulation of the adipose tissue, which directly contributes to insulin resistance and becomes more evident during pregnancy.30 Hypertension, in turn, is related to the vascular inflammation and endothelial disturbance. The vascular inflammation involves the release of inflammatory cytokines and adipokines that increase the vascular permeability and promote cytoskeletal changes in the endothelial cells, which can disrupt the balance between vasodilation and vasoconstriction. Inflammatory mediators secreted by the patients’ adipose tissue are also involved in this process and in the exacerbate vasoconstriction, causing an increase in blood pressure.3Obesity is a chronic and multifactorial disease and an important risk factor for type 2 diabetes, hypertension, coronary heart disease, osteoarthritis, and metabolic syndrome.31 In this study, pregnant women with excessive weight had lower educational levels (p=0.034) and lower monthly household incomes (p=0.011) compared with pregnant women with non-excessive weight . It highlighted that injecting pregnant hamsters with Porphyromonas gingivalis led to intrauterine growth retardation and to smaller fetuses, together with increased levels of pro-inflammatory mediators [interleukin 1 beta (IL-1b) and prostaglandin E2 (PGE2)] in the amniotic fluid.The first study that suggested oral bacteria influenced the pregnancy outcomes was reported by Collins, et al.36 The inflammatory mediators secreted by the adipose tissue in overweight individuals32 may also play a key role in the higher prevalence of underweight infants due to the indirect effect of the pro-inflammatory markers. Future prospective studies with larger samples must be conducted to better understand the association between maternal overweight/obesity, periodontitis, and birth weight based on this indirect effect. This study has some limitations. A longitudinal study with a larger sample size is required to further understand the association between maternal overweight/obesity, periodontitis, and birth weight. Additionally, this study considered obese and overweight patients in the same group. Future prospective studies are required to evaluate the effect of obesity only on periodontitis during pregnancy and the subsequent birth weight. Moreover, future studies should collect the participants’ visual dental plaque data to ensure the comparison between groups regarding the quality of oral hygiene habits.However, studies that evaluate the association of these factors while considering the presence of periodontitis have not been conducted yet. In this study pregnant women with excessive weight had infants with low/insufficient birth weight (p=0.0008), in addition to the higher prevalence of periodontitis. Therefore, periodontitis seems to be significantly associated with infants’ health at birth. Nevertheless, according to the logistic regression related to infant’s weight at birth, overweight/obesity was the independent variable that persisted on the final logistic model, while the presence of periodontitis prevailed until model 4 of the logistic regression p=0.226, . The autDespite the limitations of this study, it is considered relevant to better understand the association between periodontitis, overweight/obesity during pregnancy, and low birth weight. This is notable as no previously published studies consider maternal systemic health, periodontal condition during pregnancy, and infants’ health at birth.These findings suggest an association between excessive pre-pregnancy weight, maternal periodontitis, and low/insufficient birth weight. Additionally, periodontitis seems to be associated with the patient’s socioeconomic status, and this should be considered during the comprehensive and multidisciplinary care of the overweight/obese pregnant women.


This study compares subsequent birth outcomes in migrant women who had already had a child before arriving in Norway with those in migrant women whose first birth occurred in Norway. The aim of this study was to investigate the associations between country of first birth and adverse neonatal outcomes  in parous migrant and Norwegian-born women.before immigration to Norway  versus those with a first birth after immigration , and 2) Norwegian-born women with a first birth outside Norway (n = 6205) versus those with a first birth in Norway . Associations were estimated as crude and adjusted odds ratios (aORs) with 95% confidence intervals (CIs) using multiple logistic regression.National population-based study including second and subsequent singleton births in Norway from 1990 to 2016. Data were retrieved from the Medical Birth Registry of Norway and Statistics Norway. Neonatal outcomes were compared between births to: 1) migrant women with a first birth before immigrating to Norway had increased odds of adverse outcomes in subsequent births relative to those with a first birth after immigration: very preterm birth , moderately preterm birth , post-term birth , low Apgar score  and stillbirth . Similar results were found in the sample of births to Norwegian-born women.Migrant women with a first birth and Norwegian-born women who had their first births outside Norway should serve as a reminder of the importance of taking a careful obstetric history in these parous women to ensure appropriate care for their subsequent pregnancies and births in Norway.The increased odds of adverse neonatal outcomes for migrant  The World Health Organization promotes reducing health inequalities for migrant families . With thbefore immigration to Norway had an increased risk of stillbirth in later births compared with migrant women who gave birth to their first baby in Norway [Nearly half of women giving birth in high income countries are parous  and maten Norway . In the The aim was to investigate the associations between country of first birth and adverse neonatal outcomes  in parous migrant and Norwegian-born women in Norway.In this national population-based study, we used individual record data from the Medical Birth Registry of Norway (MBRN) , 13 and In Norway, the health care system is considered of high quality with low maternal and child mortality rates . All womThe main goal of this study was to compare subsequent birth outcomes in migrant women who already had a child before arriving in Norway (defined as the exposure group) with the same outcomes in migrant women with a first birth in Norway (defined as the comparison group). In order to control for possible parity-related differences between exposure and comparison groups, we restricted the exposure group to include women with only one birth before arriving in Norway Fig. .Fig. 1Fn = 87,696). The final sample included the second and any subsequent singleton births to foreign-born women with two foreign-born parents , and Norwegian-born women with two Norwegian-born parents  giving birth in Norway between the years 1990 and 2016 .The country of a woman’s first birth was determined by the woman’s first parity registered in the MBRN dataset. If a parous woman’s first birth was in the dataset, the birthplace of her firstborn baby was classified as Norway. If the woman’s first birth was not in the dataset, the birthplace was classified as other than Norway. Women with permission to stay in Norway prior to 1990 may or may not have given birth in Norway before 1990 (the study period commencement) and were therefore excluded  and therefore could in theory have had previous babies before 1990. The women’s first parity registered in the dataset was then used to identify country of first birth in the Norwegian-born women. The age limit was chosen based on the fact that the youngest mothers in our dataset were 13 years of age.To identify country of first birth we excluded births to any woman 13 years or older in 1990 whose first birth was not available in the MBRN dataset  and term births were used as comparison group. In the analyses of small for gestational age (SGA) and large for gestational age (LGA) we also excluded births with unknown birthweight . For calculating SGA and LGA, we used Norwegian standards combining information on gestational age, birthweight and gender [Gestational age was based on ultrasound estimation or, when such information was lacking, calculated from the first day of the last menstrual period. Very preterm birth, moderately preterm and post-term birth were defined as births in gestational week 22–31, 32–36 and d gender . Low ApgFrom the MBRN, we also obtained data on year of birth, maternal age , single status , parity , smoking in early pregnancy (yes/no) and previous stillbirth .For each birth year, SSB provided data on maternal level of education , mother’s gross income , reason for immigration , and paternal origin . Maternal country of birth from SSB was used to classify women according to seven Global Burden of Disease super regions (GBD) : High inbefore immigration to Norway versus those with a first birth after immigration, and 2) Norwegian-born women with a first birth outside Norway versus those with a first birth in Norway. We also compared births to migrant women with a first birth before immigration to Norway versus Norwegian-born women with a first birth outside Norway.Neonatal outcomes were compared between births to: 1) migrant women with a first birth Logistic regression analyses were used to investigate possible associations between country of first childbirth (Norway/Other than Norway) and adverse neonatal outcomes in subsequent births. Associations were reported as odds ratios with 95% confidence intervals. Adjustment variables were year of birth, maternal age, parity, marital status, maternal education and mother’s gross income. To account for dependency between births by the same mother, we used robust standard errors that allowed for within-mother clustering.To avoid list-wise deletion and potential bias due to missing data in covariates in the adjusted regression models, we used a multiple imputation technique to replace missing values in covariates. Ten imputed datasets were created using the multivariate normal model . SeparatAnalyses were performed using Stata IC version 16  for Windows.before immigration to Norway had more often missing data on education, lower or missing data on income. They also reported higher smoking prevalence in early pregnancy, a higher rate of previous stillbirth, they were more often from Central Europe, Eastern Europe & Central Asia, shorter length of residence in Norway, higher age at migration, a foreign-born father to the baby, or missing information on paternal origin. Further, they were less likely to originate from High income countries or North Africa & Middle East. Compared with Norwegian-born women with a first birth in Norway, Norwegian-born women with a first birth outside Norway were more likely to: be younger, be of single status, have lower levels of education, have higher income, smoke in early pregnancy, have experienced a previous stillbirth, report a foreign-born father to the baby, or have missing information on paternal origin.Table p < 0.001), moderately preterm birth , post-term birth , SGA , low Apgar score , and stillbirth . For the migrant women the prevalence of LGA  and neonatal death  was similar in both groups.The prevalence of adverse neonatal outcomes in second and subsequent births to migrant and Norwegian-born women in relation to country of first birth is shown in Fig. p < 0.001), SGA , low Apgar score  and stillbirth , and lower prevalence of post-term birth  and LGA . For the Norwegian-born women, the prevalence of very preterm birth  neonatal death  was similar in both groups.Compared to those with a first birth in Norway Fig. , Norwegip < 0.001 and 8.5% vs 7.3%; p < 0.001; LGA: 10.8% vs 15.1%; p < 0.001 and 16.5% vs 19.1%; p < 0.001, respectively) (not shown).In second and subsequent births to migrant and Norwegian-born women the prevalence of SGA was higher, and LGA lower, if the father of the baby was foreign-born compared to births where the father was Norwegian-born , and decreased odds of moderately preterm birth , LGA  and low Apgar score , relative to Norwegian-born women with a first birth outside Norway.before immigration to Norway were more likely to experience adverse neonatal outcomes in subsequent births in Norway when compared to migrant women with a first birth after immigration. Likewise, Norwegian-born women with a first birth outside Norway had increased risk for adverse neonatal outcomes in later births when compared to Norwegian-born women with a first birth in Norway.Migrant women with a first birth To our knowledge, this is the first study to investigate a number of adverse neonatal outcomes in subsequent births after a first birth before immigrating to a new country. A first birth before immigration to Norway was associated with increased odds of very preterm, moderately preterm and post-term birth, low Apgar score and stillbirth. Even if the individual’s risk for these adverse neonatal outcomes is small, the conditions are severe with consequences for the family  and highThe higher odds of adverse outcomes in migrant women with a first birth before immigration may partly be attributed to the stress of migration. Maternal stress during pregnancy has been identified as an independent risk factor for preterm birth , also spSomewhat surprisingly, the results related to Norwegian-born women were similar to the ones in the migrant population. A lack of access to information about obstetric history may therefore explain some of the negative outcomes in women with a first birth before immigration. Less attention is often given to parous compared to nulliparous women in antenatal care , and heaBoth migrant and Norwegian-born women with a first birth outside Norway were more likely to report a foreign-born father to the baby compared to women who gave birth to their first child in Norway, and a foreign-born father was associated with an increased prevalence of SGA and a decreased prevalence of LGA in our material. The differences in birthweight between migrant and non-migrant women are difficult to interpret , 39. SucThe main strengths of this study include the large sample size and long timespan of the study allowing us to follow the same mothers and their pregnancy outcomes over time (26 years). The standardized collection of data on adverse neonatal outcomes, and the selection of available covariates adjusted for in the regression analyses, add to the strengths of the study. The differences in background characteristics in the Norwegian-born sample are mainly a result of the age limit set to determine country of first birth in these women, and this may limit the conclusions that can be drawn from the Norwegian-born sample. Additionally, we cannot rule out misclassification of self-reported parity. Finally, the low prevalence of adverse outcomes in both migrant and Norwegian-born women limited us from determining if the increased risk of adverse neonatal outcomes was primarily related to the first birth after arriving in Norway or if it also applied to later births to the same mother.Both migrant and Norwegian-born women had increased odds of adverse neonatal outcomes in subsequent births if they had their first baby outside Norway compared with if they had their first baby in Norway. The results of this study should serve as a reminder of the importance of collecting a thorough obstetric history from parous women who migrate to a new country after their first birth.