Whether certain birth positions are associated with perineal injuries and severe perineal trauma (SPT) is still unclear. The objective of this study was to describe the prevalence of perineal injuries of different severity in a low-risk population of women who planned to give birth at home and to compare the prevalence of perineal injuries, SPT and episiotomy in different birth positions in four Nordic countries.A population-based prospective cohort study of planned home births in four Nordic countries. To assess medical outcomes a questionnaire completed after birth by the attending midwife was used. Descriptive statistics, bivariate analysis and logistic regression were used to analyze the data.Two thousand nine hundred ninety-two women with planned home births, who birthed spontaneously at home or after transfer to hospital, between 2008 and 2013 were included. The prevalence of SPT was 0.7 % and the prevalence of episiotomy was 1.0 %. There were differences between the countries regarding all maternal characteristics. No association between flexible sacrum positions and sutured perineal injuries was found  or SPT . Flexible sacrum positions were associated with fewer episiotomies .A low prevalence of SPT and episiotomy was found among women opting for a home birth in four Nordic countries. Women used a variety of birth positions and a majority gave birth in flexible sacrum positions. No associations were found between flexible sacrum positions and SPT. Flexible sacrum positions were associated with fewer episiotomies. Perineal injuries and severe perineal trauma involving the anal sphincter complex (SPT) are associated with short- and long-term morbidity, such as perineal pain , 2, dyspKnown risk factors for perineal trauma, including SPT are primiparity , 13, higWomen who choose home birth are a selected and highly motivated population. Generally they are multiparous, are older, and tend to have a higher socioeconomic status . Fewer aThere is still controversy around whether upright or recumbent birth positions are beneficial or harmful with regard to SPT as well as less severe perineal injuries. Giving birth in the lateral and all-fours position has been associated with a higher prevalence of intact perineum –33 but tAnother possible definition is to classify birth positions in which the body weight is on or off the sacrum. Positions that take the weight off the sacrum and allow the pelvic outlet to expand might be favorable to facilitating spontaneous birth . Birth pThe objective of this study is to describe the prevalence of perineal injuries of different severity in a low-risk population of women who planned to give birth at home in four Nordic countries and to compare the prevalence of perineal injuries, SPT and episiotomy in flexible and non-flexible birth positions.This is a prospective cohort study collecting data from planned home births in Norway, Denmark, Sweden and Iceland between 2008 and 2013. All midwives attending home births were asked to recruit their clients to the study. The women were given information about the study during pregnancy, and signed a form agreeing to participate. The method and data collection has been described previously by Blix et al. st 2008 to December 31st 2012 in Norway, in Sweden from January 1st 2009 to December 31st 2013, in Denmark from March 1st 2010 to May 15th 2013 and in Iceland from January 1st 2010 to December 31st 2013.The data collection lasted from January 1The questionnaire included information about women’s background characteristics  Table  and was 2 and ANOVA tests were used to present the background characteristics and compare data between the Nordic countries. The outcome variables were sutured perineal and vaginal injuries, SPT, episiotomies and total posterior trauma. Crude and adjusted odds ratios with a 95 % confidence interval were calculated between the outcome variables and flexible sacrum positions. Potential confounders were adjusted for using logistic regression. The IBM SPSS software package version 22.0 was employed for the data analysis.Descriptive statistics, ChiFor the purpose of this study, a selected sample of 2992 of the original cohort of 3068 women with a planned home birth was included. A total of 76 women who had a caesarean section or an instrumental delivery after transfer to hospital were excluded. Instrumental deliveries were excluded since they are performed in a supine or recumbent birth position. Of the 2992 women, 2796 (93.4 %) successfully gave birth at home and 196 (6.6 %) gave birth spontaneously after transfer to the hospital. The most common reason for transfer was slow progress of labor.n = 1799), followed by Norway (n = 468), Sweden (n = 438) and Iceland (n = 287). The mean age for the total sample was 32 years (range 18–47). There were significant differences between the countries regarding all maternal characteristics. The Icelandic mothers were the youngest and the Swedish mothers were the oldest. The highest proportion of planned home births for women expecting their first baby occurred in Iceland (21.7 %) and in Denmark (18.5 %). Most women irrespective of country were married or cohabiting, did not smoke and were expecting their second baby. Among the multiparous women in the cohort, 140 (4.7 %) women attempted a planned home birth after a caesarean section (VBAC). The vast majority (85 %) of these planned VBAC home births occurred in Denmark.Table The prevalence of SPT was 0.7 % for the total study population, 2.3 % among primiparas and 0.3 % among multiparas Table . The oveWomen gave birth in a variety of positions Table . The majThe major finding of this study is a low prevalence of SPT and episiotomy which did not differ between the countries. The women in this cohort used a variety of birth positions and one third of them gave birth in water. No association was found between flexible sacrum positions and SPT or sutured injuries. Episiotomy was associated with giving birth in a non-flexible sacrum position.The prevalence of SPT and episiotomy in this study is in line with previous research , 24, 38 The women in this study used a variety of birth positions and the majority used flexible sacrum positions. A recent review of the literature reports physical and psychological benefits for women when they give birth in an upright position of their choice  but the Flexible sacrum positions were associated with fewer episiotomies. To our knowledge and according to the midwifery literature , 45, midOne limitation of this study is the lack of information regarding midwifery practices during the second stage to prevent perineal injuries, as well as midwives’ experience and training in assessing and suturing perineal injuries. There is evidence that perineal injuries are often misclassified  by both Another limitation is that midwives in four different countries entered the data. However, using the same protocol limits the classification bias. Midwives who assist women at home births are usually employed within the health care system and are used to recording this type of data, which is similar to the data entered in hospital records. The strength of this study is that the majority of women opting for a home birth and all the midwives assisting with home births on a regular basis in Norway, Sweden, Denmark and Iceland were identified and agreed to participate in this study. According to Blix et al.  the origIt is important to evaluate perineal outcome in relation to birth setting, since perineal injuries are associated with short- and long-term morbidity for women . Home biA low prevalence of SPT and episiotomy was found among women opting for a home birth in four Nordic countries. Women used a variety of birth positions and a majority gave birth in flexible sacrum positions. No associations were found between flexible sacrum position and SPT. Further studies are needed to assess the long-term consequences related to perineal injuries for women giving birth at home.


The 2006 WHO growth charts were created to provide an international standard for optimal growth, based on healthy, breastfed populations, but it has been suggested that Northern European children fit them poorly. This study uses infant weight data spanning 50 years to determine how well-nourished preschool children from different eras fit the WHO standard, and discuss the implications of deviations.Four longitudinal datasets from the UK and one from Finland were used comprising over 8000 children born between1959 and 2003. Weights from birth to 2 years were converted to age–sex-adjusted Z scores using the WHO standard and summarised using Generalized Additive Models for Location, Scale and Shape.Weights showed a variable fit to the WHO standard. Mean weights for all cohorts were above the WHO median at birth, but dipped by up to 0.5 SD to a nadir at 8 weeks before rising again. Birth weights increased in successive cohorts and the initial dip became slightly shallower. By age 1 year, cohorts were up to 0.75 SD above the WHO median, but there was no consistent pattern by era.The WHO standard shows an acceptable, but variable fit for Northern European infants. While birth weights increased over time, there was, unexpectedly, no consistent variation by cohort beyond this initial period. Discrepancies in weight from the standard may reflect differences in measurement protocol and trends in infant feeding practice. Infants in high-income countries tend to fit the WHO 2006 growth standard well for length.Infants do, however, become heavier than the standard after 6 months.Northern European infants demonstrate a largely adequate fit to the WHO weight standard after the first 2 weeks.Infants born recently fit the WHO standard at birth and in the early weeks better than earlier cohorts.All the cohorts were heavier than the WHO standards by age 12 months, with no trend over time, suggesting that this cannot be explained by increasing rates of population obesity.should grow, whatever their ethnic origin. However, weights by country for the WHO dataset have never been published. Since the publication of the standard, studies in unselected, healthy, non-deprived populations such as the UK,5Growth charts are widely used in child health to identify undernutrition and overnutrition.is due to obesity, it ought to be less evident in historic datasets from eras when obesity was less common. Conversely, if it reflects the nature, prevalence and duration of formula feeding, the fit should be better in more recent cohorts as breastfeeding has increased.If the mismatch Our aims are to explore a portfolio of weight datasets from the past 50 years (i) to determine how well real populations of well-nourished preschool children from different eras fit the 2006 WHO growth standard at different ages during infancy; and (ii) to explore how trends differ by era of the cohort and associated infant feeding patterns.Data came from existing longitudinal growth studies, retrieved mainly from routine records. They had already been cleaned, checked and analysed for other purposes, with four studies already published. Details of the five studies are as follows:In a study set up by Dr Elsie Widdowson, routine weights of 1094 babies born in 1959–1965 were obtained contemporaneously from the records of 10 Cambridge Child Welfare Clinics. Weights were measured by clinical staff approximately monthly in the first year of life, with a maximum of 13 weights per child. Of the possible 14 222 measurements all but 864 (6%) were collected. Although the data were cleaned and analysed at the time of collection the results were never published.Cambridge Infant Growth Study (CIGS) was a research cohort of 255 babies recruited in 1984–1987. Infants were sampled in four cohorts from lists of Cambridge city mothers booked to deliver in particular months, with some filtering by midwives. Measurements were taken mainly by one highly trained auxologist every 4 weeks from 4 to 52 weeks, then at 15, 18, 24, 30, 36 and 48 months. Weight, length, head and arm circumferences, triceps and subscapular skinfolds were measured at each visit: 223 (87%) had all 15 measurements from birth to 2 years.12–14This dataset comprises the routine weights of a birth cohort of 3418 children born at term in Newcastle upon Tyne between June 1987 and May 1988. Up to 11 weights measured by clinical staff in infancy were retrieved from baby clinic records, and 3060 of the babies had at least two weights.16Gateshead Millennium Study (GMS) is a birth cohort of 1029 babies (923 term) born in Gateshead in 1999–2000, representing 81% of eligible births during the recruitment period. Routine weights were retrieved from baby clinic records. There was a mean of 13 weights per child in the first year. Research nurses measured 830 infants at 13 months.17–19This dataset comprises the routine heights and weights of 2809 children aged 0–4 years born between October 2003 and September 2004 who attended child health clinics in Tampere. Children were weighed by clinical staff on electronic scales. Up to 16 scheduled events were recorded per child at birth, 1–2 weeks, 6–8 weeks, 2, 3, 4, 5, 6, 8, 10, 12, 18, 24, 36 and 48 months. There was a mean of 12 measurements per child.20The datasets were cleaned and weights converted into Z scores relative to the WHO growth standard. Data beyond 2 years were excluded, when numbers were low and bias was likely. The measurements at birth and 6–8 weeks, 3, 6, 9, 12 18 and 24 months were summarised by age, sex and cohort . The meathis study fit was defined in terms of mean weight Z score, measured in fractions of a centile channel width relative to the WHO median, where one channel width=0.67 SDs.There is no standard definition of what constitutes a good or poor fit to a growth reference. In Mean birthweight Z scores in the five datasets were all positive and close to zero . They weThe smoothed curves of mean Z score versus age from the GAMLSS models were plotted by cohort on separate charts by sex, along with the constant SD (sigma), skewness (nu) and kurtosis (tau) . The curThe depth of the trough, like birthweight, became progressively shallower over time. Mean Z score fell by between 0.2 and 0.5 SDs from birth to 7 weeks, the fall tending to be greater in the earlier cohorts . The earThe strengths of this study are that the five datasets represent weight gain before and during the obesity epidemic. The datasets are of high quality and all but CIGS are representative of their populations, with high recruitment rates. The GAMLSS modelling approach makes maximum use of the available data and controls for potential bias. A weakness is that the most contemporary study is from Finland, not the UK, where growth patterns may differ systematically.Overall, most cohorts were within a channel width of the WHO median and many showed an excellent fit in the early weeks, though less so beyond this point. It seems unlikely that these later differences could be simply genetic, since two of the six WHO datasets were of predominantly Northern European origin and they showed no consistent differences in stature.The increase in birthweight over time is consistent with research in other high-income countries.5Though born heavier, the infants here initially lost weight relative to the WHO standard and then regained it, causing a trough to appear in the Z score growth curve. This has been described in other cohorts,32In contrast, the later rise relative to the standard did not show the same trend over time, suggesting that it may be unrelated to breastfeeding. While observational studies have found an association between use of breast milk substitutes and faster weight gain later in infancyMeasurement error might also play a role, since the MGRS cohorts were measured using the same research protocols, where all clothes were removed or adjusted for.37The overall fit to the WHO weight standard of these cohorts ranged from excellent to adequate, so that use of the WHO standard is unlikely to introduce major bias in the assessment of individual children. Some of the more subtle variation in fit is likely to reflect variations in the levels of breast and formula feeding, as well as the composition of formula milk, in different eras. However, the lack of a consistent trend for weight gain after the initial weeks suggests that the higher average weight gain seen in North European cohorts cannot simply be explained by increasing rates of obesity in later childhood and adulthood.


Newborns from diabetic mothers are more frequently born prematurely, large for the gestational age, with difficult respiratory adaptation and risk of RDS (respiratory distress syndrome) and, subsequently, exposed to a higher risk of perinatal distress, hypoxia, metabolic stress and hematologic alterations. Comparing the status at birth of 120 newborns from mothers with diabetes, with 120 controls from uncomplicated pregnancies, over a period of 4 years, in a specialized tertiary center, no significant differences in the immediate outcome of such newborns and similar incidence of hypoxia at birth were shown, as illustrated by the parameters of the acid-base balance . However, there are significant differences in the route of delivery, with a predominance of C-section deliveries in the diabetic group (4 out of every 5 cases), which might be an important contribution to the relative good status of these newborns at birth. Although balanced at birth, the newborns from diabetic mothers need intensive monitoring and care in the subsequent hours after birth, for important risks such as hypoglycemic episodes. The term “infant from diabetic mother” (IDM) refers to those from pregnancies complicated by diabetes mellitus type 1, type 2, and also gestational diabetes, i.e. any type of glucose intolerance diagnosed for the first time during the current pregnancy . It is estimated that in a population based study, approximately 3-10% of the OGTT  assessed pregnancies after 24 weeks of gestation, present abnormal glucose levels. Of these, 80-90% are gestational diabetes, and the minority remaining are chronic diabetes type 1 or 2 incidentally discovered during pregnancy [2].Newborns from diabetic mothers (IDM-infant from diabetic mother) are known for the relative high-risk of mortality and morbidity [4]. The onset of the metabolic stress is due to the high glucose levels in the maternal blood, transferring to the fetus and inducing fetal hyperinsulinism [5]. The well established high-risk of macrosomia/ large for gestational-age (LGA) fetuses, with estimated fetal growths above the 90th percentile for gestational age-adjusted curves is believed to be insulin-induced, with an incidence of 15-45% in the interval compared to the 5-15% in the general population .Uncontrolled maternal diabetes, especially during the periconceptional period, is the main etiological factor inducing morbidities in the newborn, from congenital malformations such as cardiac malformations and neural tube defects, to altered fetal growth velocities and modified adaptation mechanisms under the metabolic strain that can induce organ-specific modifications such as the hypertrophic cardiomyopathy of the newborn . Most probably, classically described modifications such as myocardial hypertrophy, accelerated growth, polycythemia and modified blood rheology and cerebral perfusion found in the intra-uterine life [8] are due to the chronic effects of adaptation mechanisms to the continuous metabolic stress of hyperglycemia [9].Newborns from diabetic mothers are more frequently born prematurely, large for the gestational age - with newborns identified from mothers with diabetes was compared to a matched group named non-IDm of controls from age-matched uncomplicated pregnancies. Parameters were statistically assessed with a specialized SPSS software vers. 10, and a probability p<0.05 was considered significant. A number of 120 newborns from mothers with diabetes  have been assessed and compared to 120 age-matched controls born during the same 4-year period. Group IDM (n=120): included 30,83% newborns from mothers with diabetes type 1 and 2, from which 31 cases IDD type 1 and 6 cases diabetes type 2. As expected from previous studies, the incidence of gestational diabetes in our group was significantly higher than the pre-existent forms, 69,16% versus 30,83% , ratio 2:1.Fig. 3), BE  and HCO3  sampled at birth were compared between the groups by using Student t TEst and a probability of <0,05 as threshold for significance. Parameters assessed at birth: average values for umbilical blood pH . Values of BE were -4,92 for the IDM group versus -5,04 for non-IDM (p=NS). Values HCO3 at birth were 21,42 for the IDM group versus 21,14 for the non IDM (p=NS).Table 1).Also, the Apgar score assessment at birth did not show any significant difference between the two groups, with the exception of the subgroup with an Apgar score between 5-7 1 minute after birth: 13 IDM cases versus 8 non-IDM cases, but even in this subgroup the scores became similar at 5 minutes . It is important to note that the two groups studied were matched for gestational age at birth, in order to exclude the independent implications of prematurity on the newborn status at birth as a confounding factor. Also, no congenital malformations were identified in the two groups.This prospective monocentric study demonstrated a prevalence of the incidence of infants from diabetic mothers of 120/ 9057 births over a period of four years, a prevalence of 0,01%, most probably due to the lack of systematic diabetes screening in the general population of our geographical region.In our experience, the rate of preexistent diabetes cases over the gestational diabetes pregnancies was of 1: 2, in accordance with the previously published data.When newborns from diabetic mothers were compared at birth with age-matched controls from non-diabetic pregnancies, there were no significant differences of the acid-base balance parameters on cord blood sampling at birth, so no significant incidence of the immediate perinatal hypoxia. What appeared as dramatically different was the C-section rate between the groups, as 4 in 5 children from diabetic mothers, were delivered by C-section, a rate significantly higher than the normal average.Therefore, a discussion over the optimum route of delivery remains open, as the current data support the choice of the C-section route as a probable way of protection from the adaptive effort during the expulsion of these fragile newborn, especially because the possibilities of the prenatal assessment of the reserves of these children were extremely limited. Classical methods such as cardiotocography before and during labor, or fetal Doppler and biophysical score assessment are unreliable and not predictive for perinatal hypoxia and sudden death in metabolic diseases such as maternal diabetes.Comparing the status at birth of newborns from mothers with diabetes with controls from uncomplicated pregnancies showed no significant differences in the incidence of hypoxia at birth, as illustrated by the parameters of the acid-base balance . However, there are significant differences in the route of delivery, with a predominance of C-section deliveries in the diabetic group that might have an important contribution to the relative good status of these newborns at birth.The present study brings arguments that birth by C-section reduces the risk of perinatal hypoxia in newborns from diabetic mothers.


Dear SirA 2800 gram baby boy was born with a prenatal diagnosis of a choledochal cyst; he was admitted to NICU for further evaluation. Clinically he was jaundiced with a palpable abdominal mass in the right hypochondrium. Choledochal and duplication cysts were differential diagnoses. Ultrasonography by an experienced sonographer or a CT scan is usually sufficient for diagnosis. Communicating duplication cyst can easily be diagnosed on barium meal follow through which may show contrast in the cyst; isotope scanning may show areas with ectopic mucosa if lining the cyst.[1-3] In this case, the CT scan with intravenous contrast showed an intraperitoneal cystic lesion (10cm x 7cm x 6cm) in diameter extending from the sub hepatic region down to the pelvic inlet, with a thin non-enhancing wall and fluid attenuation with a significant mass effect on adjacent structures and bowel.At explorative laparotomy a duodenal duplication cyst at the second part was found  and a complete resection and anastomosis was not an option. The cyst content was non-bilious fluid. The cystic wall was opened and excised up to the common wall with stripping of lining mucosa. The baby recovered uneventfully and discharged home at the age of 19 days. Histopathology was consistent with duodenal duplication cyst with an ectopic gastric mucosa. On follow up the infant is doing well and thriving.Treatment of alimentary tract duplication cysts is total surgical excision but it should be tailored according to the site. In difficult sites like in our case, subtotal excision with mucosal stripping should be done.Source of Support: NilConflict of Interest: None


Patent urachus is a rare congenital abnormality. Since its first description by Cabriolus in 1550, few cases have been reported. A 26-year-old Vietnamese primigravida presented at 20 weeks of gestation for evaluation of a cystic mass in the umbilical cord, which was first discovered at week 13 of pregnancy by ultrasound scan. The cystic mass originated from the root of the umbilical cord, connected to the urinary bladder, and no intestinal contents were enclosed within. Doppler ultrasound assessment showed that the single umbilical artery existed within the normal range. The progression of the umbilical cyst continued to be screened, but the mass disappeared on ultrasound images at 27 weeks of gestation. This led to the consideration of the cyst’s rupture. After 38 gestational weeks, the pregnant woman delivered a 3350g male infant via cesarean section because of an obstructed vaginal labor. The following days, a stream of urine was recorded leaking out from the umbilical mass whenever he cried. Seven weeks after delivery, an open surgical approach was successfully performed. The baby is now 43 months of age, growing and developing normally. Since an allantoic cyst with patent urachus is a rare clinical entity, early discovery, close monitoring and accurate diagnosis through ultrasound in the prenatal period may consequently allow clinicians to have suitable attitudes towards management when the infant is born. Failed obliteration of the urachus can lead to various abnormalities: urachal cyst, urachal diverticulum, sinus or patent urachus - the most common type3. Allantoic cysts in infants with patent urachus can be formed due to the drainage of urine into the umbilical cord6, or in uncommon situations, after leakage of hypo-osmotic urine into the Wharton’s jelly8.Patent urachus, which was first described by Cabriolus in 1550, is an extremely rare clinical presentation, occurring in 1 to 2 or 2.5 per 100,000 deliveriesHere we present a clinical case with a diagnosis of patent urachus. The newborn possessed a single artery in the umbilical cord and one allantoic cyst, and underwent a successful surgical resection.A 26-year-old Vietnamese primigravida, with no relevant medical, psychosocial or family history of morbidity, toxic exposure or abnormalities, after 1 year of marriage was informed of pregnancy at 7–8 weeks of gestation. The expected time for labor was October 1st 2011. First ultrasound screening at 12–13 weeks of gestation showed a 1.9mm nuchal translucency thickness. Simultaneously, a double test was also undertaken and demonstrated a trisomy 21 risk of 1/61000 and a trisomy 18 risk of 1/100000. Based on the fetal ultrasound exam, clinicians discovered a small cystic mass on the anterior abdominal wall whose nature remained unknown. No specific interventions were made and clinicians intended to keep observing the cyst. The next ultrasound exam at 16 weeks of gestation demonstrated a well-developing fetus with an enlarging cystic mass. However, its nature still remained unidentified due to lack of experience on image observation. Discrimination between allantoic cyst and pseudo-cyst presented a significant challenge for most of the ultrasonographists as well as clinicians at that time. Therefore, they decided to scrutinize it for one more month before deciding on a therapeutic intervention, especially since the triple test also showed low risk of trisomy 21, 18 and 13.The morphology ultrasound at 20 weeks of gestation on the fetus showed the presence of a single umbilical artery  and a cyAt 23 weeks of gestation, through the second morphology ultrasound, the cyst showed an increase in dimensions to 35mm × 28mm .At 24 weeks of gestation, due to her weight gain reaching 13kg, an oral glucose tolerance test (OGTT) with 75g glucose was performed with a positive result for gestational diabetes. As a result, the patient was instructed to undertake a carbohydrate-restricted diet including 6 small meals plus 2 glasses of unsweetened milk every day. After 2 weeks, her blood glucose level returned to normal.th–90th percentile. A Doppler ultrasound evaluation using the Japan Society of Ultrasonics in Medicine (JSUM) 2001 proposal (More information can be found in the Voluson® E-Series (BT09) Advanced Reference Manual) showed that Resistive Index (RI) and Pulsatility Index (PI) of the umbilical artery and middle cerebral arteries was within the 20th and 50th percentile9.At 27 weeks of gestation, the cyst disappeared on ultrasound images, and a 180-minute echographic recording found no urine in the bladder. From the above findings, clinicians suspected that the cyst was ruptured, forming a fistula by which the urine refluxed into amniotic sac. No interventions were considered at this point. The next serial ultrasonography scan showed a little urine in the bladder but no umbilical cyst. Although there was only one single umbilical artery, the fetus still grew well, which was reflected by the growth chart of Hadlock with an estimated fetal weight (EFW) ranging from 70The patient had obstructed vaginal labor at 38 and 4/7 weeks of gestation with high suspicion of her limited pelvis. As a result, she underwent a cesarean section under general anesthesia and was administered Suxamethonium, Propofol, Esmeron and Sufentanil, after the failure of epidural block. Forty-five minutes later, the mother gave birth to a healthy male infant weighing 3350g. Post-delivery evaluation demonstrated a herniated sac-like mass (dimensions = 3mm × 4mm) at the root of umbilical cord and confirmed that the umbilical cord contained only one artery. The placenta was in normal condition. The umbilical cord was clamped about 5cm from the root.In the following days, we recorded a stream of urine flushing out from the umbilical mass every time the infant cried. The umbilical tape was changed three times a day using normal saline and sterilized gauze. Five days after delivery, the umbilical stump dried and fell off, but the mass still persisted. The umbilical mass was still kept clean and covered by new tapes as described above until the operation at the infant’s seventh week. The open surgical approach was used under general anesthesia. Surgeons made a 2cm incision in the midline below the umbilicus, dissected rectus abdominis muscle and exposed the allantoic duct. They removed the duct, tied surgical knots using absorbable sutures, checked the two ureters and the bladder to ensure there were no further abnormalities and finally, the umbilicus was reconstructed. The patient was discharged 2 days after the operation without any complication.At present, the patient is a 43-month-old boy with weight of 14kg, height of 100cm, and normal psychomotor development. He was re-checked several times at 3, 6 and 12 months of age, as well as every year after that with ultrasound examination and no abnormal structure was shown.th gestational week3. They are divided into two groups: congenital and acquired. Patent urachus, which accounts for 10–15% of all urachal remnant diseases, is usually congenital10. Although newborns with congenital patent urachus have been recognized since the sixteenth century, prenatal diagnosis of this condition has only been carried out since 19882 and our case is one of the first observed in Vietnam. As with other previous patent urachus cases, in our situation the mother underwent a morphology ultrasound examination at 20 weeks of gestation which revealed an extra-abdominal 29mm × 25mm cystoid structure near the umbilical cord root connecting to the fetal bladder. Omphalocele was ruled out because of the absence of fetal bowel contents within the channel. However, remarkably, only one umbilical artery was detected. Next ultrasonography performed at 27 weeks of gestation noticed the disappearance of the cyst. No urine was found in the fetal bladder after 180-minute recording. We suspected a rupture which created a fistula and drained the urine into the amniotic fluid. As the cyst ruptured in its early period, no umbilical cord compression was identified. The fetus developed normally regardless of the cyst and the presence of a two-vessel cord. At about 38 weeks of gestation, the pregnant woman was admitted with uterine contractions, and vaginal delivery was performed. Obstructed labor, however, subsequently took place, which prompted obstetricians to make an emergency cesarean section instead. To the best of our knowledge, only C. Rasteiroet al. has ever mentioned a case of allantoic cyst with patent urachus before11. Unlike ours, in their description, although the cyst grew to 100mm in size, it did not burst and the amniotic fluid volume remained unchanged. Similarly, the bladder was empty but this was because the fetus micturated and urine leaked into the cyst. Although there have been several patent urachus cases reported, our patent urachus case with a ruptured cyst in the setting of single-umbilical-artery fetus is unique.Urachal anomalies are the general name for several abnormal conditions  resulting from the failure of closing the allantoic duct during the 147. Particularly, differentiation between a pseudo- and a true cyst can regularly confound ultrasound diagnosis, despite the fact that very rare cases have been distinguished based on ultrasound imaging. Nevertheless, there are at least three features which can give us important suggestions. A true cyst is always in close contact with the fetal anterior abdominal wall, surrounded by umbilical vessels which can be verified by color flow imaging, and shows an open channel from the cyst to the bladder and the fetal umbilicus12. The gold standard for differential diagnosis between a pseudo- and a true cyst is histopathology. Under the microscope, a true cyst comprises an epithelial lining and originates from remnants of the allantoic duct while the pseudo-cyst is the result of the degeneration or the edema of Wharton’s jelly12. A pseudo-cyst not only makes up a higher incidence but is also more associated with aneuploidy and other chromosomal disorders than a true cyst13. Hence, obstetricians are usually recommended to perform a karyotype once they discover a cystic lesion. In our current case, we assumed that it was indeed a true cyst. A karyotype was executed but no peculiarities were found. This poses another complicated problem - the best and earliest time for authenticating a true cyst. In medical literature, Waldo Sepulvedaet al. reported three cases of patent urachus detection in the first trimester at 11 to 14 weeks’ gestation, based on the findings of megacystis and the large umbilical cord cyst6. In most of the cases, patent urachus was recognized during the second and third trimester. However, clinicians still remained unconfirmed about this condition until the urine dribbles from the umbilicus right after the delivery, and our case was no exception6.A cystoid mass perceived through ultrasound may be involved in different conditions, which makes the prenatal diagnosis questionable3 and non-specific signs and symptoms. Therefore, specialists should be accustomed to it and be prepared for the treatment. Different methods can be used to manage this condition. Complete surgical removal of the urachus is one of the general recommendations with favorable outcome14. Surgical techniques can avoid malignant conversion and other complications occurring together with increasing age whereas conservative treatment (i.e. drainage and antibiotic therapy) sometimes leads to recurrent infection or cyst formation. Apropos of surgical treatment, experts and researchers up to now have still debated on the optimal method and have not come to any conclusion. Prior to the endoscopic era, open excision was the main method for removing the urachus. A large ten-year retrospective study focusing on open surgery conducted by Mesrobianet al. in 1997 did not show any complications or reoperations afterward15. Open surgery also required shorter hospital stays16. However, since the appearance and universal application of laparoscopy in 199517, several studies have suggested that this method could be a safe and effective alternative with minimal morbidity18. Laparoscopic approach not only provides an all-around visualization of the urachal channel and fetal bladder but also improves patient’s general state and reduces post-operative pain more rapidly, as do all endoscopic procedures16. In our case presented here, surgeons and urologists who participated in that operation opted for open excision. The best time to execute a patent urachus surgical removal also remains controversial19.The recognition of patent urachus is not easy due to a very low frequency of 1- 2.5:100000 live births20, which might support our hypothesis. However, no optimal follow-up time interval was accurately proposed. In the past, Sepulvedaet al. reported a case with a three-year follow-up, wherein no abnormalities were ultimately revealed6. Ideally, a randomized, prospective study with larger population should be conducted to achieve a certain conclusion.An open surgical approach was carried out when the neonate was seven weeks old. The operation ended with success and the male baby was discharged after two days. He was observed closely over the following days and no further complications were found. The baby grew up normally. At present, he is a 43-month-old boy with physical and psychomotor development corresponding to his age. Ultrasound examination has again verified his normal anatomical structure. Through this case, we are likely to make a conclusion that patients with isolated patent urachus who already underwent a surgical removal may have a far more optimistic prognosis. Medical literature describes several early-treated patent urachus neonates who then developed well with no anomaliesOur case demonstrates some limitations. We could have diagnosed patent urachus earlier but in reality, we could not reach the confirmation till 20 weeks of gestation. Our lack of experience may be the major reason, since it was the first time we encountered this urachal remnant disease in Vietnam. Regardless of the inevitable limitation detailed above, the main aim of our paper is to present a new case and provide more information about patent urachus, hence contribute partly to a better and safer treatment of this rare congenital anomaly.Briefly, we have described a ruptured allantoic cyst with patent urachus in the setting of single umbilical artery fetus. The majority of patent urachus were discovered in the second and third trimester. Regarding our case, open resection may also achieve optimistic prognosis without any complication, hospital readmission and reoperation. In conclusion, there are still challenges on turning out early diagnosis and better treatment methods.Informed consent for publication of images and information from this case was obtained from the mother of the infant. This is a case report of a very rare congenital anomaly. Its indexation would be of interest to obstetricians and gynaecologists as it outlines methods of diagnosis and treatment.I have read this submission. I believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. The article is well written and descriptive of the likely problems encountered with this rare condition.Whilst the problem was corrected at open surgery, laparoscopic surgical excision represents the contemporary management with its reduced post operative morbidity and length of hospital stay although both methods are equally successful in correcting the defect.I have read this submission. I believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.


Investigators from Children's National Medical Center and George Washington University School of Medicine, Washington, DC, studied the correlation between white matter tract changes and developmental outcomes in a series of infants with hypoxic ischemic encephalopathy (HIE) treated with whole body cooling. Investigators from Children's National Medical Center and George Washington University School of Medicine, Washington, DC, studied the correlation between white matter tract changes and developmental outcomes in a series of infants with hypoxic ischemic encephalopathy (HIE) treated with whole body cooling. Using magnetic resonance imaging (MRI) with quantitative diffusion tensor imaging (DTI), fractional anisotropy, as well as mean, axial and radial diffusivity of the corpus callosum (CC), posterior limbs of the internal capsule (PLIC) and cortical spinal tracts (CST) were calculated in 50 infants at a median age of 8 days of life, and compared with neurodevelopmental outcomes using a Psychomotor Developmental Index (PDI) and Mental Developmental Index (MDI) derived from the Bayley Scales of Infant Development at 15 months (42 patients) and 21 months (35 patients) of age.Controlling for gestational age, birth weight, socioeconomic status and gender, there was a statistically significant correlation p<0.001) between decreased fractional anisotropy of the CST and lower PDI scores as well as decreased fractional anisotropy of the CC and lower MDI scores. Increased axial diffusivity of the CC and lower radial diffusivity of the CST also correlated with lower PDI and MDI scores (p=0.018 and p=0.03respectively). [ between COMMENTARY. HIE is a common cause of mortality and long-term morbidity in neonates. Early assessment of the degree of neurologic injury is important for prognosis and rehabilitation planning, but can be challenging by conventional imaging methods. Evaluation by standard MRI is complicated by observer variability as well as significant differences in imaging findings depending on the timing of the exam , 3.Diffusion Tensor Imaging (DTI) is an advanced magnetic resonance imaging technique that uses the restricted movement of water molecules perpendicular to the long axis of white matter tracts as a measure of axonal integrity and a decrease in fractional anisotropy in HIE patients suggests microstructural injury . DTI may


It is a recognized child right to acquire a name and a nationality, and birth registration may be necessary to allow access to services, but the level of birth registration is low in Nigeria. A household survey about management of childhood illnesses provided an opportunity to examine actionable determinants of birth registration of children in Bauchi and Cross River states of Nigeria.Trained field teams visited households in a stratified random cluster sample of 90 enumeration areas in each state. They administered a questionnaire to women 14–49 years old which included questions about birth registration of their children 0–47 months old and about socio-economic and other factors potentially related to birth registration, including education of the parents, poverty (food sufficiency), marital status of the mother, maternal antenatal care and place of delivery of the last pregnancy. Bivariate then multivariate analysis examined associations with birth registration. Facilitators later conducted separate male and female focus group discussions in the same 90 communities in each state, discussing the reasons for the findings about levels of birth registration.Nearly half (45%) of 8602 children in Cross River State and only a fifth (19%) of 9837 in Bauchi State had birth certificates (seen or unseen). In both states, children whose mothers attended antenatal care and who delivered in a government health facility in their last pregnancy were more likely to have a birth certificate, as were children of more educated parents, from less poor households, and from urban communities. Focus group discussions revealed that many people did not know about birth certificates or where to get them, and parents were discouraged from getting birth certificates because of the unofficial payments involved.There are low levels of birth registration in Bauchi and Cross River states, particularly among disadvantaged households. As a result of this study, both states have planned interventions to increase birth registration, including closer collaboration between the National Population Commissions and state health services. Birth registration of children may be required for access to health, education and other services in some places; it allows accurate estimation of age (for example in relation to military service or marriage); it helps in reuniting separated children and parents; and it can provide important population information for planning of services . Birth rBirth registration levels in developing countries have been reported to be related to demand factors such as socio-economic status, parental education, religion, ethnicity, maternal age and marital status ,4-7, as In Nigeria, the National Population Commission (NPopC) is the body responsible for the national vital registration system, including birth registration . Births Despite birth registration being compulsory, levels in Nigeria remain low. The 2013 Demographic and Health Survey (DHS) reported that 30% of children less than five years old had their births registered . MultiplHausa and Fulani cultures, including polygamy and extended family households, while Cross River State in the South is predominantly Christian with a majority of Efik people and more typically nuclear families.As part of a household survey on childhood illnesses and their management, we examined the level of birth registration and the socio-economic and other factors potentially related to birth registration among children aged 0–47 months old in Cross River and Bauchi states of Nigeria. Bauchi State in the North East region is predominantly Muslim with In 2011, a household survey on childhood illnesses and their management was part of a programme to support evidence-based planning of primary health services in Bauchi and Cross River states of Nigeria ,16. The Trained female interviewers administered a questionnaire to mothers aged 14–49 years of children aged less than four years. In Bauchi it is not possible for males to interview women and in Cross River female interviewers are preferred. The age range of birth to four years was chosen because an aim of the overall work was to examine management of childhood illnesses among children up to three years old. The field teams also collected information from each household about demographics and socio-economic status, and recorded information from key informants in each community about access to services.Three months after the household survey, after initial analysis of the findings from this survey, trained teams returned to the same communities to conduct separate male and female focus group discussions. In each group of 8–10 parents from the community, a facilitator used a guide to share information from the household survey and to encourage discussion around the findings, while a reporter took notes. The discussions took place in the local language but the final reports from the discussions, agreed between the facilitator and the reporter, were in English.Different operators entered the data twice with validation to minimize keystroke errors using EpiInfo . AnalysiBivariate analysis examined potential associations with birth registration. Subsequent multivariate analysis used the Mantel Haenszel procedure , adjusteWe conducted separate analyses for the two states. There is no intention for the two states together to be representative of the situation across Nigeria, and the data collection and analysis is part of a programme to support evidence-based planning of health services at state level ,16.The analysis included children aged 0–47 months whose mothers had been pregnant within the last two years. We categorized children as having a birth certificate if the mother reported their having one, whether or not she could show it. Potential determinants of birth registration included: sex of the child; education of the mother and father of the child ; whether the mother had any antenatal care visits, and whether she delivered in a government health facility in her last pregnancy; whether the mother had an income of her own and was involved in the decision on how to spend it; and how many children the mother had (two or less v more than two). At household level, potential determinants included whether the household had enough food in the last one week (as an indicator of absolute poverty) and sex of the household head. At community level, potential determinants included urban or rural location and whether there was an active village health committee.Two coauthors, AA and AC, conducted a thematic analysis of the focus group reports to identify common themes of why parents do not register the birth of children and what could help to increase birth registration.The Ministry of Health in each state gave ethical approval for the study. In addition, field team leaders sought consent for the survey from leaders in each community, and interviewers sought verbal consent from the head of each household, as well as from each individual respondent. Interviewers did not record any names or identifying information and were trained not to proceed with any interview unless they could do so without being overheard.Interviewers collected information about 18,439 children aged 0–47 months old: 8,602 from Cross River and 9,837 from Bauchi.Less than one half of the children in Cross River (45%) and about one fifth in Bauchi 19%) had a birth certificate .Many groups said that people did not know about birth certificates or where to get them.“Since we know the child’s birth date, why should we get a birth certificate?” .Others did not see the point in getting a birth certificate.“Some women deliver in the church and it is only bibles and hymn books that are there, so they cannot have birth certificates.” .Participants agreed that women not delivering in government health facilities were unlikely to get a birth certificate for the child.“I took my child to collect a certificate and I was asked to pay Naira 1500 (US $9), I pleaded to pay Naira 1000 (US $6) but they refused.” .“I paid Naira 300 (US $2) to get a certificate for my child. Is it fair?” .A common complaint was that people have to pay to get birth certificates.“Some women do not know the names of their husbands” .Some said women were loath to request a birth certificate if they did not know the father’s name.“Community leaders should tell the men to encourage their wives to go to the health center and deliver so that birth certificates can be obtained easily.” .“The community chief should impose a law.” .Focus group participants agreed people need to be made more aware about the importance of birth certificates. They suggested an important role for community leaders in raising awareness.In this study, the level of birth registration in 2011 among children less than four years old was low in Cross River at 45% and very low in Bauchi at 19%. Despite the higher overall level of birth registration in Cross River, the factors associated with birth registration were similar in the two states. Children were more likely to have their birth registered if they came from urban households, their parents were more educated, and if their mothers had attended for antenatal care and delivered in a government health facility. In Cross River, less-poor households were more likely to register births.A strength of this study is that it is based on quite large representative samples in each of the two states. Also, it includes qualitative data from focus groups in the same sites as the household survey, allowing exploration of the reasons behind the quantitative findings. A weakness of the study is that it did not collect data about some potential determinants of birth registration, in particular about supply factors such as distance to and features of the nearest facility where births could be registered. As it is a cross-sectional study, we can only describe associations rather than draw conclusions about causality.The levels of birth registration in this study can be compared with other surveys providing state-level estimates in Nigeria. The 2011 MICS reported birth registration levels among children less than five years old as 38% in Cross River and 6% in Bauchi . The MICThe demand factors we found associated with birth registration are similar to those reported previously. A UNICEF report, based on data from DHS and MICS from a number of countries, concluded that poverty and low levels of maternal education and knowledge were associated with failure to register births . ReportsThe focus group discussions in this study provided some insights to supplement the quantitative survey findings. Participants in the groups agreed that parents often do not register a birth if it does not take place in a government health facility. They do not see enough reason to make the effort required to go and register the birth. Quite a common complaint in the focus groups was about having to pay for birth certificates, which are theoretically provided free of charge. Demands for such payments may well deter birth registration. Previously, a “fine” was payable for birth registration more than 60 days after birth, although this fine was not charged in practice. Birth registration is now free of charge, by law, up to the age of 17 years. The household survey did not ask about payment for birth certificates, so we do not know how frequently people paid, or how much they paid. Focus group participants mentioned amounts equivalent to several US dollars. This is substantial in a country where over half the population live on less than US $1.25 per day.Birth registration is a function of local government and Nigerian authors have noted important constraints of local government, including lack of financial and human capacities, lack of input into resource allocation decisions, lack of adequately qualified personnel, and widespread corruption .UNICEF has described strategic approaches for strengthening birth registration in Africa . A recomThis study found that low levels of birth registration were related to lack of contact with government health services during pregnancy and childbirth in both Cross River and Bauchi states and that more disadvantaged children  were less likely to have their births registered. Both states have used the findings to put in place measures to increase birth registration, including increased collaboration between the NPopC and health services.


The World Health Organization recommends Bacillus Calmette-Guérin (BCG) vaccination against tuberculosis be given at birth. However, in many developing countries, pre-term and low birth weight infants get vaccinated only after they gain the desired weight. In Kenya, the ministry of health recommends pre-term and low birth weight infants to be immunized at the time of discharge from hospital irrespective of their weight. This paper seeks to understand the effects of birth weight on timing of BCG vaccine.The study was conducted in two Nairobi urban informal settlements, Korogocho and Viwandani which hosts the Nairobi Urban Health and Demographic Surveillance system. All infants born in the study area since September 2006 were included in the study. Data on immunization history and birth weight of the infant were recorded from child’s clinic card. Follow up visits were done every four months to update immunization status of the child. A total of 3,602 infants were included in this analysis. Log normal accelerated failure time parametric model was used to assess the association between low birth weight infants and time to BCG immunization.In total, 229 (6.4%) infants were low birth weight. About 16.6% of the low birth weight infants weighed less than 2000 grams and 83.4% weighed between 2000 and 2490 grams. Results showed that, 60% of the low birth weight infants received BCG vaccine after more than five weeks of life. Private health facilities were less likely to administer a BCG vaccine on time compared to public health facilities. The effects of low birth weight on females was 0.60 and 0.97-times that of males for infants weighing 2000–2499 grams and for infants weighing <2000 grams respectively. The effect of low birth weight among infants born in public health facilities was 1.52 and 3.94-times that of infants delivered in private health facilities for infants weighing 2000–2499 grams and those weighing < 2000 grams respectively.Low birth weight infants received BCG immunization late compared to normal birth weight infants. Low birth weight infants delivered in public health facilities were more likely to be immunized much later compared to private health facilities. The World Health Organization (WHO) recommends Bacillus Calmette-Guérin (BCG) immunization against tuberculosis (TB) at birth or at first clinical contact to all infants  with theWhen immunization is delayed, there is an increased risk or severity of infections during infancy due to the shortening of the duration of the protective effect of the vaccines . StudiesThe study was carried out in two informal settlements of Nairobi (Viwandani and Korogocho) where the African Population and Health Research Center (APHRC) runs the Nairobi Urban Health and Demographic Surveillance System (NUHDSS). The NUHDSS has been in operation since 2002 and had about 81,129 registered inhabitants in nearly 31,977 households as of December 2012. These two densely populated communities have high unemployment, poverty, crime, poor sanitation and generally poorer health indicators when compared to Nairobi as a whole ,16. The This study used maternal and child health data collected at the NUHDSS from two periods of survey: The first period 2007–2010 under “Urbanization, Poverty and Health Dynamics” (UPHD) project funded by Wellcome Trust that recruited all infants born from September 2006 and the second period 2011–2013 funded by Danish Development Agency (DANIDA) through INDEPTH Network and recruited infants born from January 2010. In addition to following up infants from the first period. During both periods, mother-child pairs were recruited and followed up with visits every four months as applicable. The same questionnaire was administered during each visit by trained interviewers. Information on place of delivery, child’s weight at birth was collected during the first visit, while the children’s immunization history including BCG vaccine given at birth collected during the first three visits. A total of 8,756 infants were recruited with 34,969 visits in total during the period of the study. Not all infants were seen during follow up visits due variety of reasons which included deaths, out migration, temporary exits among others. A breakdown of the selected sample for analysis is given in Figure Our outcome variable of interest is age at BCG immunization. The weight at birth of the child  was used as the primary exposure variable. We defined low birth weight (LBW) and normal birth weight (NBW) as a infants weighing less than 2500 grams and more or equal to 2500 grams respectively ,18. For Descriptive statistics, frequencies, proportions and median of all dependent and independent variables of interest were obtained to summarize the data. The main objective was to assess the age when a child is vaccinated with BCG, and compare LBW infants with the normal birth weight infants. Approximately 1% of the infants in the study received their BCG after 90 days; these were censored at 90 days of age. Thus, Survival analysis techniques were used to assess the time to BCG immunization before 90 days. Kaplan-Meier curves were used to describe the age distribution of getting BCG for the three birth weights group. Cox regression was later used to estimate the impact of low birth weight on the timing of the BCG immunization and identify risk factors of delay to BCG immunization; Cox models assumes proportionality of the hazard function over time. The proportionality assumption did not hold for our data, this was deduced using the Kaplan-Meier curves Figure  and testModel 1) and adjusted (Model 2) time ratios (TR) were used to assess the association between birth weight and BCG timing. Time ratio compares the change in the survival time associated with a change in the values of a given covariate. In an AFT model, every subject has the same “baseline” survival curve, the covariates effects serve to accelerate the passage of time.Unadjusted (Model 3 and 4) were fitted to see how the birth weight interacts with child’s gender and place of delivery  respectively.Interaction models  ethical review committee with annual renewals during the second phase of the study. The research assistants were trained on research ethics and obtained written and verbal informed consent from all the study respondents. The NUHDSS, on which the study was nested, also received ethical approval from KEMRI’s Ethical Review Board.A total of 229 out of 3602 infants (6.4%) included in the analysis were LBW  infants received the vaccine eight times later than the normal birth weight infants. Although there have been concerns about administering BCG in pre-term and low birth weight babies , evidencThe tendency for late immunization among infants from the non-Kikuyu ethnic groups in Kenya has been reported previously and is consistent with the lower utilization of health services among non-kikuyu ethnic groups as observed in other studies ,23. EarlWe assessed the effect of gender of the child in association with birth weight and BCG timing; and found a non- significant interaction, but results showed more delays in males as compared to female. The reasons for the gender difference in the timing of BCG immunization among low birth weight infants are not clear. Further studies are required to determine if this delay is related to parent or caregiver choices associated with low birth weight infants. This is important as studies in West Africa have shown beneficial effects of BCG to be more pronounced in female than male infants -28.The interaction between birth weight and place of delivery where low birth weight infant delivered in public health facilities were immunized much later compared to their counterparts delivered from private health facilities. This is in contrast to the normal birth weight infants delivered from the public health facilities who get immunized earlier. This may be due to the better trained health workers in public health facilities intentionally delaying BCG immunization to low birth weight infants as a precaution, but which staff of private health facilities in the slum may not do.This study was conducted in two urban slums in the Nairobi and may therefore be indicative of the BCG status of low birth weight infants in similar settlements in Kenya. One limitation of the study is the large number of infants who had to be excluded due to the absence of documented birth weight or immunization status. The exclusion eliminated the effects of recall bias in cases where there is no documentation on birth weight or BCG immunization date. About 32% of the infants and a further 2% were omitted from the analysis due to lack of documentation of birth weight and/or BCG date respectively. The exclusions is supplemented by the large sample size for the analysis due to the longitudinal nature of the study. In addition, the absence of information from caregivers regarding the reasons for delays in BCG immunization would have clarified the extent of service-related delays.This study shows that low birth weight infants in Nairobi urban informal settlements receive BCG immunization much later than normal birth weight infants with place of delivery as the main factor of influence. This study contributes to addressing the gap in evidence on timeliness of immunization in urban informal settlements in Kenya as well as other similar settings in low and middle income countries. Additional research should be conducted to further evaluate the timing of the other routine childhood immunizations in similar settings as well as rural and formal urban settlements. These studies should evaluate the effects of immunization delays on overall child health.


A negative birth experience has been shown to have a significant impact on the well-being and future choices of mothers. The objective of this study was to assess the prevalence of, and identify the risk factors associated with a negative birth experience for women in Canada.The study was based on secondary data analysis of the Maternity Experiences Survey (MES), a Canadian population database administered to 6,421 Canadian women in 2006. The examined outcome - negative birth experience – was derived from mothers’ self-report of overall labour and birth experience. Independent variables were maternal demographics, health characteristics, pregnancy-related characteristics, and birth characteristics. Multivariable logistic regression analysis was performed to determine the significant predictors of negative birth experience. Adjusted Odds Ratios (AOR) and 95 % Confidence Intervals (CI) are reported.Negative birth experience was reported among 9.3 % of women. The main significant predictors of a negative birth experience included older age , violence experienced in the past two years , poor self-perceived health , prenatal classes attended , unintended pregnancy , caesarean birth , and neonate admission to intensive care .Significant predictors of a negative labour and birth experience were identified through this study, a first in the Canadian context. These findings suggest future research directions and provide a basis for the design and evaluation of maternal health policy and prevention programs. A negative birth experience has been associated with lower quality of life, lower self-rated health, persistent memory of pain, and the development of posttraumatic stress disorder (PTSD) or its symptoms –10. One  < 0.05) . Of the  < 0.05) .A negative birth experience has also been found to be associated with increased likelihood of request for caesarean birth –23. In CNon-Canadian studies have estimated that between 10 and 20 % of women rate their birth experience as negative –31. AccoPrevious studies in the United States and Sweden have examined the association between birth experience and maternal demographics, health, pregnancy-related, and birth characteristics, sometimes with conflicting results , 35, 37.The design of this study was cross-sectional. The analysis of the predictors of a negative labour and birth experience was based on data collected through the Maternity Experiences Survey (MES), designed by the Public Health Agency of Canada in partnership with Statistics Canada as part of the Canadian Perinatal Surveillance System. The survey included over 300 questions on pregnancy, birth, and the postpartum period. The target population consisted of mothers 15 years of age or older who had a singleton live birth between February 15, 2006 and May 15, 2006 in any Canadian province and November 1, 2005 and February 1, 2006 in any territory, and lived with their baby at the time of the survey. Mothers living on First Nations reserves or in institutions were excluded. A stratified random sample of 8,542 women was selected from the 2006 Canadian Census of Population and 6,421 eligible women (75.2 %) provided a response. Where possible, the questionnaire was provided in the mother’s preferred language. These respondents were weighted to represent 76,508 individuals and thought to be representative of the population for all characteristics examined. The survey was carried out through a telephone questionnaire by professional female interviewers with 96.9 % of the interviews held at five to nine months postpartum. The MES research protocol was reviewed by the Health Canada’s Science Advisory Board and Research Ethics Board and the Federal Privacy Commissioner, and approved by the Statistics Canada’s Policy Committee. Ethics approval was not needed as this was based on a secondary analysis of the MES collected by Statistics Canada. Access to the MES database was obtained through the Research Data Centre in Toronto, approved by Social Sciences and Humanities Council of Canada. Additional details on MES methods can be found in Dzakpasu et al. (2008).negative labour and birth experience. Data were analyzed based on responses to one question in the MES that required the mother to rate her overall labour and birth experience. Responses were provided on a 5 point Likert scale which ranged from “very positive” to “very negative” labour and birth experience. For the purposes of this analysis, the labour and birth experience outcome variable was defined by combining responses of “somewhat negative” and “very negative” into one “negative” level, and responses of “neither negative nor positive”, “somewhat positive”, and “very positive” into one “non-negative” level.The outcome variable of interest was self-rated maternal demographics ; maternal health characteristics ; pregnancy related characteristics ; and labour and birth characteristics . All of these variables were self-reported by the mother [Based on data availability and results of previous research, a number of variables were investigated as possible predictors of a negative labour and birth experience. These included: e mother .The prevalence of negative labour and birth experience was investigated at the national level and by province and territory. To assess the relationship between different predictors and negative labour and birth experience, chi-square tests and odds ratio (OR) were calculated using cross tabulations and logistic regression. A multivariable logistic regression model was performed with all potential predictor variables being considered as independent variables and negative labour and birth experience variable as the dependent variable. To account for complex sampling design, bootstrapping was performed where appropriate to calculate all the OR and 95 % confidence interval (CI) estimates. Population weights, normalized weights, and bootstrap weights were all created by Statistics Canada and provided with the MES data set. The sample sizes reported in this manuscript were derived using normalized weights, weighted to represent a larger population. All analyses were computed with Stata Data Analysis and Statistical Software (version 13.0), and set at alpha <0.05 for two-tailed test for statistical significance.n = 3,437), 26.2 % as somewhat positive , 10.7 % as neither negative nor positive (n = 685), 6.2 % as somewhat negative (n = 395), and 3.1 % as very negative (n = 196). In total, 9.3 % of the women surveyed who responded to this question rated their labour and birth experience as somewhat negative or very negative (n = 591).The MES sample size of 6,421 respondents, weighted to represent 76,508 women was analyzed in this study. Of the 6,421 respondents, 6,384 provided a complete response to the MES question asking the mother to rate her overall labour and birth experience. Of the mothers who responded to this question, 53.8 % rated their birth experience as very positive , and negative labour and birth experience. Results of the multivariable logistic regression model showed age to be the only variable among the list of maternal demographic characteristics studied to be significantly associated with negative labour and birth experience. Mothers who were 30-39 years of age and 40 years and older were respectively 1.90 times  and 2.29 times  more likely to experience negative labour and birth experience compared to mothers who were younger than 20 years old after adjusting for other variables.Table The mother’s perceived health, her alcohol use during pregnancy, and whether she experienced violence in the past two years were the three (unadjusted) maternal health characteristics that were significantly associated with negative labour and birth experience. At the multivariable regression level, only the mother’s perceived health and experienced violence remain significant. Women whose perceived health were poor or fair were significantly more likely to report a negative birth experience  than those who reported excellent or very good health. Furthermore, having experienced intimate partner violence in the past two years was associated with a higher incidence of a negative labour and birth experience .The pregnancy-related characteristics that were significantly associated with negative labour and birth experience at the unadjusted level were the number of past pregnancies, attendance at prenatal classes, intended status of pregnancy, and any health problems experienced during pregnancy. At the multivariable level, significance remained for those who attended prenatal classes , those with unplanned or unwanted pregnancy  and those who reported having experienced health problems during pregnancy .Of the birth characteristics considered at the bivariate level, type of birth, not having to travel somewhere else for the birth, and admission of the neonate to an Intensive Care Unit (ICU) predicted a negative labour and birth experience. However, at the multivariable level, only those mothers who had a caesarean birth  and mothers whose babies were interned in an ICU  were significant.The present study aimed to identify the demographic, health, pregnancy, and birth related characteristics associated with negative labour and birth experience among women in Canada. On average, 9.3 % of Canadian mothers rated their birth experience as somewhat negative or very negative, with the highest averages reported in Western Canada. Most notably, negative labour and birth experience among these mothers was significantly associated with older age, poorer perceived health, domestic violence, prenatal classes, and birth by caesarean section. The findings are novel in that this was the first study to identify the risk factors associated with negative birth and labour experience among Canadian mothers using a national database.Based on the analysis of this national sample, the proportion of Canadian women who report a negative birth experience (9.3 %) was similar to findings in non-Canadian studies, which have estimated that between 10 % (Sweden) and 20 % (the Netherlands) of women rate their labour and birth experience as negative –31. MothIn this study, mother’s poor perceived health and intimate partner violence experienced at home were the only significant maternal health characteristics of negative labour and birth experience. The outcomes associated with poor perceived health are in accordance with the findings among primiparous mothers in Sweden, where negative birth experience after operative birth was associated with poor self-rated health soon after birth and up to 1 year after childbirth . AlthougAmong pregnancy-related characteristics, attending prenatal classes was found to be one of the more surprising factors found to be significantly associated with negative labour and birth experience. Indeed, in this sample, attending prenatal classes was found to increase the risk of negative labour and birth experience. However, inconsistencies have been reported in previous research that produced similar results , 51. It The most notable birth characteristic related to negative labour and birth experience was the type of birth . Previous studies have also found a significant relationship between caesarean birth and lower childbirth satisfaction , 13, 30.In the current study, several potentially predictive characteristics did not contribute to negative labour and birth experience. Smoking, alcohol use, and drug use were not found to be predictors of a negative birth experience after adjusting for other variables. In terms of smoking, a similar conclusion was reached in previous research . To our labour and birth experience, were based on self-report of participants. As such, some variability likely exists between how different individuals defined their experience. However, self-report measures have proven to be just as effective in predicting health outcomes as documented in several studies [Interpretation of this study is subject to a number of limitations. All of the variables included in this model, including the outcome variable of  studies –46. Becahow and why they influence the birth experience. This could be accomplished through qualitative studies such as personal interviews and narratives with individual mothers.The findings of this study may be useful in guiding maternal health policy by identifying areas of focus for innovative prevention and intervention programs that focus on perinatal maternal mental health. For example, caesarean sections are increasing among women in Canada , which bThe MES research protocol was reviewed by the Health Canada’s Science Advisory Board and Research Ethics Board and the Federal Privacy Commissioner, and approved by the Statistics Canada’s Policy Committee. Ethics approval was not needed as this was based on a secondary analysis of the MES collected by Statistics Canada. Access to the MES database was obtained through the Research Data Centre in Toronto, approved by Social Sciences and Humanities Council of Canada.http://www.statcan.gc.ca/eng/rdc/mitigationThe MES survey is voluntary. Implicitly, participation in a voluntary survey requires consent. Respondents are informed of the voluntary nature of the survey through a notice prior to the start of the data collection. Interviewers are also instructed to permit respondents to refuse to answer any question or to terminate an interview at any time. Statistics Canada is prohibited by law from releasing any data that relates to any identifiable person without prior knowledge or the consent in writing of that person. The MES database does not include personal identifiers such as name, address, and telephone number. Various confidentiality rules are applied to the MES data that are released or published to prevent the publication of any confidential information. Data are suppressed to prevent direct or residual in order to protect the identity of the participants. For further information, please see: The data will not be made available in order to protect the participants’ identity. This study was based on a secondary analysis of the MES database collected by Statistics Canada, which requires the researcher to submit an application to access the data at a Research Data Centre. Access to the MES database was obtained through the Research Data Centre in Toronto, approved by Social Sciences and Humanities Council of Canada. The data is available through submitting a formal application to the Research Data Centre in Canada.


Here, we present an improved DTI acquisition and reconstruction scheme, capable of generating high-quality and high-SNR DTI data without eddy current-induced artifacts. This new scheme consists of three components, respectively, addressing the three distinct types of artifacts. First, a k-space energy-anchored DTI sequence is designed to recover eddy current-induced signal loss . Second, a multischeme partial-Fourier reconstruction is used to eliminate artificial signal elevation  associated with the conventional partial-Fourier reconstruction. Third, a signal intensity correction is applied to remove artificial signal modulations due to eddy current-induced erroneous T2∗-weighting . These systematic improvements will greatly increase the consistency and accuracy of DTI measurements, expanding the utility of DTI in translational applications where quantitative robustness is much needed.In most diffusion tensor imaging (DTI) studies, images are acquired with either a partial-Fourier or a parallel partial-Fourier echo-planar imaging (EPI) sequence, in order to shorten the echo time and increase the signal-to-noise ratio (SNR). However, eddy currents induced by the diffusion-sensitizing gradients can often lead to a shift of the echo in  Diffusion tensor imaging (DTI) has proven a powerful tool for characterizing alterations of white matter microstructure –4. DTI hSince most of the MRI signal is attenuated by strong diffusion-sensitizing gradients, the signal-to-noise ratio (SNR) is inherently low in DTI data. This issue can be addressed with several approaches. First, the SNR can be improved by averaging multiple magnitude images from repeated DTI scans, at the expense of a prolonged scan time. Second, high-field systems  may be used to generate DTI data with an inherently higher SNR . However k-space echo-shifting effect. It has been shown that the echo-shifting effect caused by intrascan head motion may result in artificial signal variations in DTI [ k-space energy spectrum analysis (KESA) to demonstrate that the echo-shifting-induced artificial signal loss  in partial-Fourier EPI may not be corrected with postprocessing, while the echo-shifting-induced artificial signal elevation  may be corrected with a multischeme reconstruction algorithm [Even though partial-Fourier EPI and parallel partial-Fourier EPI can generate DTI data with a higher SNR, they are susceptible to various types of artifacts related to thes in DTI –34. We hlgorithm .In addition to intrascan head motion, hardware-related factors  also produce a pronounced echo-shifting effect , which iSince the eddy currents vary significantly among different MRI scanners, the presence of uncorrected eddy current-induced artifacts makes it difficult to achieve consistent diffusion measures in multicenter DTI studies. We thus expect that the improved acquisition and reconstruction methods proposed in this report will also improve the quantitative consistency of DTI measures for translational applications independent of imaging hardware and sites. k-space, the echo may, in reality, deviate from the k-space center for different reasons. For example, susceptibility-induced magnetic field gradients may result in an echo displacement or echo-shifting effect in gradient-echo sequences [Even though most pulse sequences are designed such that the echo is expected to appear at the center ofequences –41, wherequences . As showequences . k-space data (with an acquisition matrix size of 96 × 76) obtained from a spherical gel phantom on a 3 Tesla MRI scanner  with 15 diffusion-encoding directions, illustrating the impact of diffusion-sensitizing gradients on the echo-shifting effect along both readout  and phase-encoding  directions. As demonstrated in the subsequent sections, the echo-shifting effect along the phase-encoding direction results in undesirable artifacts. Other scan parameters used in this single-refocused spin-echo DTI scan are listed in Here we will show that, in addition and similar to intrascan head motion, the eddy currents induced by strong diffusion-sensitizing gradients in DTI also produce a pronounced echo-shifting effect. For example,  k-space echo distribution corresponding to the summed signals from all voxels in an individual slice but does not reveal the spatially dependent echo-shifting effect. In order to quantify the k-space energy displacement corresponding to different voxels, the KESA method should be employed  k-space energy displacement along the phase-encoding direction  obtained from the phantom DTI data. It can be seen that the echo-shifting effect is relatively uniform within each slice but varies significantly with the diffusion-encoding direction. In addition, for a particular diffusion-encoding direction , the echo-shifting effect varies more significantly among the odd slices (which were acquired first in this interleaved acquisition) than among the even slices, likely because the eddy currents have not yet reached a steady-state. Although the echo-shifting effect along the readout direction may also be quantified with the KESA method, it does not result in partial-Fourier DTI artifacts and thus is not quantified in this paper. k-space energy peak  to ensure that the echo peak is located at the center of the central band. Even though the effective spatial resolution along the phase-encoding direction varies spatially as a result of the echo-shifting effect inherent to DTI scans, images obtained from multischeme partial-Fourier reconstruction may be interpolated to the same spatial resolution. For example, the k-space data to be reconstructed with the scheme shown in To address this issue, we propose to integrate thetruction , which cT2*-weighting, which in turn produce undesirable signal variations [T2*-weighting, producing undesirable signal variations. Even though such signal variations may not be very significant in individual diffusion-weighted images, they actually result in severe artifacts when multiple images are combined to derive diffusion measures such as FA maps (as will be shown in the Results section). As schematically illustrated in Sse) of spin-echo EPI-based DTI data depends on the TE as a function of a T2 exponential decay (as indicated by a black dashed line in eff) differs from the targeted spin-echo TE and the generated echoes have both T2- and T2′-weighting , as schematically shown in Sase) can be represented by either eff − TE, depending on the direction of the echo displacement (see It is well known that the echo-shifting effect in gradient-echo EPI results in variations of the effective TE and riations . Similarment see :2)SaseSaseT2*r  ΔTE>0Sase;L=S0Sse to Sase) resulting from the echo-shifting effect in DTI is termed Type 3 artifact and can be corrected by dividing the acquired signal intensity of each voxel by either exp(−ΔTE/T2*) for ΔTE > 0 or exp(−ΔTE/T2−) for ΔTE < 0, where 1/T2* = 1/T2 + 1/T2′  and 1/T2− = 1/T2 − 1/T2′ [ky, which is measured with the KESA method from the human DTI k-space data.The signal reduction  with the following scan parameters: TR = 4 s, TE = 103 ms, acquisition matrix size = 96 × 76 , voxel size = (2.5 mm)ky maps , a k-spa k-space energy-anchored partial-Fourier EPI sequences, with three different acquisition matrix sizes: 96 × 64 , 96 × 60 , and 96 × 56  at TE = 82, 75, and 66 ms, respectively. Other scan parameters were identical to those used in the phantom scan.The proposed DTI acquisition and reconstruction methods were evaluated in three healthy volunteers on our 3 Tesla MRI scanner. Participants gave written informed consent for a protocol approved by the institutional review board of Duke University Medical Center. Six sets of DTI data were acquired from each participant by using both the conventional partial-Fourier EPI and the new k-space energy-anchored EPI data (with Type 1 artifacts inherently eliminated) were reconstructed with the KESA-based multischeme partial-Fourier reconstruction method to correct for Type 2 artifacts, and the signal intensity correction was subsequently performed to minimize Type 3 artifacts. The signal intensity correction assumed average values of  T2 = 80 ms and T2* = 47 ms for white matter at 3 T [T2 and T2* values, the correction factors would only vary by about 3% for the largest eddy current-induced echo shift measured. Even though Cuppen's method was used in the current implementation of the multischeme reconstruction, other types of partial-Fourier reconstruction algorithm  can also be used in our multischeme reconstruction.The conventional partial-Fourier EPI data were reconstructed with Cuppen's algorithm . The k-sr at 3 T . However k-space energy-anchored DTI data sets acquired with different matrix sizes to assess the FA consistency in the improved DTI scheme.The consistency in the FA maps derived from the three conventional DTI data sets acquired with different matrix sizes was assessed by calculating the root mean square errors between all three possible pairs of FA maps  and by subsequently averaging these three values. This procedure was then repeated for the threeWe also acquired conventional partial-Fourier DTI data with a larger matrix size of 96 × 76  at TE = 103 ms. Four repeated scans were performed, so that the reconstructed magnitude data could be averaged to improve the SNR. Note that this data set, with a large number of overscans, has inherently low levels of Type 1 and Type 2 artifacts, even when processed with the conventional partial-Fourier reconstruction algorithm. Type 3 artifacts are also inherently lower in this data set acquired at a longer TE. Nevertheless, the very minor residual Type 2 and Type 3 artifacts were corrected with the multischeme partial-Fourier reconstruction and signal intensity correction, respectively, before averaging the four sets of magnitude images. The FA map generated from this averaged data set was then used as a reference to assess the accuracy of the other FA maps obtained at shorter TEs. k-space data obtained from a representative subject using the conventional partial-Fourier acquisition scheme (top row) and the new k-space energy-anchored partial-Fourier acquisition scheme (bottom row) with different numbers of overscans (shown in three columns). This figure shows that, because of the eddy current-induced echo-shifting effect, the k-space energy peaks can easily be truncated in conventional partial-Fourier EPI, particularly with fewer overscans. Even though such an undesirable k-space energy truncation can potentially be avoided by using many overscans , the resultant SNR would be significantly reduced. On the other hand, by using the proposed k-space energy-anchored acquisition approach, the k-space energy peaks are consistently located at the center of the targeted k-space coverage, so that the k-space energy truncation can be minimized regardless of the number of overscans to avoid signal losses and ensure a high SNR. k-space energy-anchored EPI data with the conventional Cuppen's algorithm, the resulting images are free from Type 1 artifacts but are still susceptible to artificial signal elevation  in several regions, as shown in the orange boxes in the middle row. Both Type 1 and Type 2 artifacts can be effectively eliminated when the k-space energy-anchored EPI data are reconstructed with the recently developed multischeme partial-Fourier reconstruction algorithm, as shown in the bottom row. k-space energy-anchored acquisition and multischeme partial-Fourier reconstruction, respectively. However, there still exist errors in several areas  due to signal intensity variations across different diffusion-encoding directions . After correcting for these residual artifacts, more consistent and accurate FA maps can be obtained from k-space energy-anchored EPI data for all numbers of overscans, based on the following assessments. k-space energy-anchored DTI with Type 1 and Type 2 artifacts removed , but also vary significantly from scanner to scanner, even when using identical scan parameters. As a result, eddy current-induced artifacts always contribute to the variations in diffusion measures across multiple scanners, making it difficult to design a standardized diagnostic DTI protocol that is consistent across multiple centers if only conventional acquisition and reconstruction methods are used. Here, we report an improved DTI acquisition and reconstruction scheme to minimize three distinct types of eddy current-induced artifacts existing in conventional partial-Fourier DTI. As demonstrated in this paper, when using the proposed DTI scheme, more consistent and accurate diffusion measures can be obtained from DTI scans acquired with different levels of eddy currents. We believe that the developed methods should prove highly valuable for generating reliable and consistent DTI data for translational applications and in multicenter trials.Both Type 1 and Type 2 artifacts can inherently be minimized in full-Fourier DTI and conventional partial-Fourier DTI with a large number of overscans, however at the expense of an unavoidably longer TE and thus lower SNR (see Appendix). On the other hand, conventional partial-Fourier DTI data obtained with a smaller number of overscans have a higher SNR but are more susceptible to eddy current-induced artifacts. By using the DTI acquisition and reconstruction scheme presented in this paper, it is feasible to produce high-quality and high-SNR data with minimal eddy current-induced artifacts. Note that the goal of this paper is not to identify a universal set of DTI parameters  that optimizes both SNR and image quality, as the optimal parameters may vary for different DTI applications. The purpose of this paper is to demonstrate that it is feasible to minimize eddy current-induced artifacts in high-SNR partial-Fourier EPI with an improved acquisition and reconstruction scheme, rather than choosing a conventional full-Fourier or near full-Fourier DTI protocol that produces data with a lower SNR. k-space energy-anchored DTI pulse sequence, designed to eliminate Type 1 artifacts, relies on calibration data measured from a phantom scan. Since the eddy currents are relatively reproducible, these phantom calibration scans can be performed very infrequently . Type 2 and Type 3 artifacts, on the other hand, are removed in postprocessing based on the information derived with the KESA method from the human brain DTI data. In addition to Type 1, Type 2, and Type 3 artifacts, eddy currents also result in geometric distortions and blurring artifacts, which we did not address in this work  as the DTI scans to measure the eddy current-induced echo shifts. However, to avoid the need for a protocol-specific calibration and to increase the practical utility of the proposed method, future implementations may potentially use a single calibration to model the eddy currents and to compute the resulting echo shifts for different DTI protocols, as recently proposed for the correction of eddy current-induced distortions , 48.It has been shown that the eddy currents can be reduced with a twice-refocused spin-echo DTI sequence , 50. In  k-space energy-anchored acquisition and improved reconstruction procedures can be readily extended to parallel partial-Fourier EPI, where eddy currents produce the same three distinct types of artifacts.Finally, in this report, we only demonstrate artifact removal in partial-Fourier EPI data as a proof of concept. The proposedIn conclusion, we have developed an improved DTI acquisition and reconstruction methodology to effectively remove three distinct types of eddy current-induced artifacts commonly observed in conventional partial-Fourier DTI. We have also demonstrated that this new methodology can simultaneously achieve high-SNR and high-quality partial-Fourier DTI with a small number of overscans. This method is expected to greatly improve the quantitative consistency of DTI measures across subjects and sites, thereby extending the utility of DTI in translational applications at large.