Preterm birth is the leading cause of death in children under five. A recent Cochrane review found a 42% reduction in early preterm birth (< 34 weeks’ gestation) and 11% reduction in preterm birth (< 37 weeks’ gestation) with omega-3 fatty acid supplementation. To assist in the development of implementation strategies to increase pregnant women’s omega-3 fatty acid intake, we assessed the awareness of Australian pregnant women about preterm birth, their nutrition and supplementation behaviours during pregnancy, and intentions to increase omega-3 fatty acid intake.A ten-minute survey was conducted online to assess the knowledge, attitudes, behaviours, and intentions of Australian pregnant women across three domains: (1) preterm birth; (2) nutrition and supplementation during pregnancy; and (3) omega-3 fatty acid consumption to prevent preterm birth. Participants were recruited from Survey Sampling International’s research panels.Of the 763 women who completed the survey, less than two-thirds had heard of preterm birth. Over 55% of respondents had changed their diet during pregnancy and a prenatal dietary supplement was consumed by 82% of the women surveyed. Respondents’ main source of information about preterm birth and nutrition during pregnancy was from a health professional. When asked about their intentions to increase their omega-3 fatty acid intake following a health professional’s recommendation, the vast majority of participants indicated they would increase their omega-3 fatty acid intake (90%). When a hypothetical scenario was presented of an omega-3 fatty acid supplement being offered from a health service at no cost, the number of respondents who selected they would increase their intake through supplementation increased from 54 to 79%.The main information source for women about preterm birth and dietary supplementation recommendations during pregnancy is their health professional. Therefore, informing women about ways to prevent preterm birth, including the role of omega-3 fatty acids, should occur during antenatal visits. The results from our study are useful for clinicians caring for pregnant women and for the next stage of translation of the Cochrane review findings – the design of implementation strategies to increase the intake of omega-3 fatty acids during pregnancy where needed. Preterm birth is a pregnancy complication that can result in short- and long-term consequences, including problems with respiratory, gastrointestinal, and immune system function; vision and hearing; and cognitive and behavioural problems , 2. PretA number of studies have investigated omega-3 fatty acids for their potential to prevent preterm birth, stemming from findings that, compared to their Danish neighbours, Faroe Islanders had longer gestations and heavier babies, and a significantly higher fish intake . A CochrThe key omega-3 fatty acids in the Cochrane review were the marine-based long-chain polyunsaturated fatty acids, docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA). The main natural dietary source of DHA and EPA are oily fish, such as salmon, mackerel, sardines, and trout. To obtain the dose of DHA that was highlighted as effective for reducing preterm birth in the review, a pregnant woman would need to eat at least two serves (~ 150 g per serve) of salmon each week. A study of fish consumption in Australian women found that intake during pregnancy was, on average, less than 200 g of total fish (oily and non-oily) per week . PregnanGiven the potential to reduce preterm birth highlighted in the recent Cochrane review, we assessed the current awareness of Australian pregnant women about preterm birth, and their nutrition and supplementation behaviours during pregnancy. Additionally, we presented women with information about the possible prevention of preterm birth through omega-3 fatty acid supplementation, and then asked their intentions to increase omega-3 fatty acid intake during pregnancy.A cross-sectional research design was performed among Australian pregnant women (or those who had given birth within the previous six months). A 43-item survey was developed based on best practice principles  and evalEthical approval for this study was granted by the Women’s and Children’s Health Network Human Research Ethics Committee in Adelaide, Australia (HREC/17/WCHN/155). An information sheet outlining the purpose of the survey was provided with the link to the survey. Completing the online survey implied consent.Respondents were recruited through Survey Sampling International’s (now Dynata) research panels and responses to the online survey were collected between August 2018 and January 2019. Women were eligible for the survey if they were currently pregnant or had given birth within the last six months, were over the age of 18 years, living in Australia, and willing to participate in the study. Women were excluded if they indicated at the screening question that they were currently pregnant but answered “0” when asked their gestational age.U test was used for continuous variables and Fisher’s exact test (chi-square) was used for categorical variables. All analyses were two-sided and statistical significance was set at a P-value less than 0.05. Subgroup analyses were performed on relevant questions to investigate differences in responses between nulliparous and multiparous women.Data coding and analyses were performed using SPSS . Descriptive statistics were reported as frequencies and percentages; or medians and lower and upper quartiles. The distributions of continuous variables were assessed for normality using the Shapiro-Wilk test. As data were not normally distributed, non-parametric tests were conducted when testing for differences between groups; the Mann Whitney n = 763) completed the survey. Demographic characteristics are displayed in Table 2 (20.8–29.0), respectively. Overall, 87.9% of respondents indicated that they had completed high school; 84.8% of those completing high school had completed further education. Women expecting their first baby were significantly younger than those who had previously given birth, and were more likely to have completed high school.Seven hundred and sixty three women . Overall, 52.7% indicated they were most familiar with the term “premature birth” out of the four synonyms presented . Only 37.9% of the respondents correctly defined premature birth as “birth before 37 weeks of gestation”, when provided with eight response options . Multiparous women were significantly more likely to correctly answer the definition of premature birth than nulliparous women .Only 61.6% of respondents had heard of preterm birth, whereas 84.0% had heard of premature birth. Multiparous women were significantly more likely to have heard of preterm birth than nulliparous women . The next most common source was the internet , followed by family  and friends .Of the women who had heard of preterm birth (or its synonyms) before commencing the survey, the main source of information about preterm birth was through a health professional (P < 0.001).Of the 763 women surveyed, 432 (56.6%) expressed that they had changed their diet for this pregnancy. Nulliparous women were significantly more likely to indicate they had changed their diet . The nutrient supplement most commonly consumed by respondents was a pregnancy multivitamin (73.4%), followed by folic acid (48.3%). The main motivation for deciding to consume a nutrient supplement during pregnancy was “for the health of the baby” (71.7%), closely followed by the influence of an external recommendation (68.8%), and “for maternal health and well-being” during pregnancy (60.0%) (Table A dietary supplement was consumed during their current pregnancy by 625 (81.9%) of the women surveyed and nulliparous women were more likely to be consuming a dietary supplement than multiparous  and information from friends and family members (45.3%). When asked about who has the greatest influence on their decision to take or not take nutrient supplements during pregnancy, respondents nominated health professionals, and friends and family members . Although pregnancy blogs and the general internet were selected by respondents as sources of nutrition information, they were much less likely to indicate these sources as key influencers in their decision to take supplements in pregnancy Fig. .Fig. 1CA high proportion of respondents (90.6%) had heard of omega-3. Omega-3 fatty acid containing supplements had been consumed by 37.7% of respondents in the 12 months prior to conceiving and 30.4% indicated that they had consumed an omega-3 fatty acid containing supplement during their current pregnancy. Less than a third of the women surveyed (32.1%) were eating at least two serves of fish a week and 19.3% indicated they never ate lean or fatty fish during their pregnancy.n = 80) who indicated they would not make any changes to their omega-3 intake, about a third felt they already had a good diet/were getting enough omega-3 fatty acids . However, only two (7.7%) of the respondents who felt they were already getting enough omega-3 fatty acids ate two or more serves of fatty fish per week.When asked about their intentions to increase their omega-3 fatty acid intake following a government guideline and health professional’s recommendation, a high proportion indicated they would increase their omega-3 fatty acid intake (89.5%), with 53.7% preferring to take an omega-3 fatty acid supplement and 35.8% preferring to increase their omega-3 fatty acid intake from food sources  of respondents indicated they would increase their omega-3 fatty acids by taking an omega-3 fatty acid supplement during pregnancy, if an omega-3 fatty acid supplement were offered at no cost from a health service, 78.8% of respondents indicated they were likely or highly likely to do so Table .Table 4In this study, we assessed the current knowledge of Australian pregnant women regarding preterm birth, their nutrition and supplementation behaviours during pregnancy, and their intended behaviours to supplement with omega-3 fatty acids to reduce the risk of preterm birth. A key finding was the low level of awareness of preterm birth, its definition, and its consequences. This was an unexpected finding in a cohort of well-educated pregnant women. This suggests that preterm birth awareness needs to be increased in Australia.Once presented with information on the consequences of preterm birth and the evidence – that the risk of preterm birth may be reduced by increasing omega-3 fatty acid intake – a high proportion of respondents indicated they were willing to increase their omega-3 fatty acid consumption during pregnancy. While about a third of women said they would prefer to increase their omega-3 fatty acid intake through food sources, less than a fifth of the women were eating the amount of fatty fish required to meet the recommended omega-3 fatty acid intake to prevent preterm birth. These low levels of fish intake in Australian pregnant women are in line with the findings of Taylor, Collins, & Patterson . The disOver half of the respondents reported they had already changed their diet during pregnancy and a substantial majority indicated they had consumed a dietary supplement during their current pregnancy. Similarly high rates of supplement use during pregnancy have been reported in a previous study conducted in Melbourne, Australia (91%) . NullipaThis survey captured novel information which will contribute towards the design and implementation of strategies to increase the intake of omega-3 fatty acids in pregnant women. Health professionals were identified by respondents as their main source for information on preterm birth, nutrition during pregnancy, and influencing their decision to take a nutrient supplement. This strong link with health professionals in antenatal care as a trusted source of information and guidance highlights antenatal visits as a promising avenue to deliver information on preterm birth and evidence-based strategies to reduce the risk of preterm birth. An effective implementation strategy might include updating the clinical practice guidelines and educating health professionals in antenatal care to encourage an increase in omega-3 fatty acid consumption during pregnancy.A key strength of this research was the large number of Australian women included in the study. As with any self-reported data, there are some risks of bias influencing the women’s responses to some of the questions in the survey. In particular, social desirability bias and recall bias might have affected the survey results, though this is difficult to assess.The results from our study have uncovered important factors that could be addressed to increase the intake of omega-3 fatty acids by pregnant women. These findings can be used to inform the design and implementation of any strategies seeking to increase the intake of omega-3 fatty acids during pregnancy in order to reduce preterm birth. We found that the main information source for women about preterm birth and dietary supplementation recommendations during pregnancy is their health professional, emphasising the need to inform women about ways to prevent preterm birth, including the possible role of omega-3 fatty acids, during antenatal visits.Additional file 1. Survey items included in the online survey.


The electric dipole moment of Zr2Fe is symmetrical to the axis of The present work is devoted to the study of the electric properties: electric dipole moment, electric quadrupole moment, electric field gradients and electric dipole polarizability of molecule Zr Duereactors ,5,6. At reactors ,8 is verreactors ,10. The reactors (1)Qqk=ek = 0, 1, 2, 3, ...., it is called electric monopole moment, electric dipole moment, electric quadrupole moment, electric eight pole moment, etc.k = 1, it is the electric dipole moment, and its q = 1, 0, −1, which are respectivelyWhen For the diatomic molecule, the molecular axis is the z-axis, and the electric dipole moment vector coincides with the molecular axis. Therefore, only the z component  and their developed real-space scheme by Helena M. Petrilli and Sonia Frota-Pessoa [2O is a C2V group, and in the theory of relativity, it is replaced by a double group C’2V, and a new element 2V is called the boson irreducible representation.The time differential perturbed angular correlation study of electric field gradients and their temperature variation were performed at a K-1173 K  and foun methods . The elea-Pessoa . The nona-Pessoa . However2Fe are studied by the theory of Dirac equation based on fully symmetric group.In the four-component theory of relativity, if the time reversal operator entation ,17,18,19Equivalent definition of time reversal operator: We use another type, that is, Kramer’s theorem to define the time reversal operator, such as r, then there isTime reversal operator: a time reversal operator or Kramer operatorThis means that the state is invariant to time reversal, orIt can be proved that the time reversal operator is the inverse operator ,21, i.e.Kramer’s theorem : It can For the stationary Dirac equation, the operator isHere, single electronic operator ,22,23,24That is to say, A is Hermitian, that is, after it is used, the wave function is not inverted; B is anti-Hermitian, that is, after it is applied, the wave function is reversed. At this time, there are two sets of Kramer pair base sets, and the Dirac operator It is easy to prove that essed as ,23,24 method of the DIRAC10 program, and the basis set is 3–21G. The calculation results are listed in In this paper, the electrical properties of the molecular ZrThe axis of symmetry−19 C and C is Coulomb. The quadrupole moment is a second-order tensor, which represents the two-dimensional  is It is now also necessary to discuss the electric field gradient (/a.u.) of the nuclear Zr as 2Fe is a 2Fe as an example. In the vicinity of its equilibrium point, there is 0.270302 electrons move from the Zr atom to the Fe atom. The second-order force constant for each ZrFe bond axis isIt can be proved that in the direction of the molecular bond, that is, in the z-axis direction, there is one atomic unit electron charge, that is, 1 a.u. charge. And the electric field gradient is 1 a.u., then the second-order force constant = 1 au electron charge * 1 au electric field gradient, that is2Fe are calculated using the relativistic configuration interaction (DIRRCI) method of the DIRAC10 program, and the basis set is 3–21G. The dipole moment of the molecule along the symmetry axis In this paper, the electrical properties of the molecular ZrThe approximations of present calculations based on DIRAC10 software can be discussed here. Relativistic quantum chemistry is related to solve Dirac equation, whose wave function has four components. The results can be regarded as strict and reliable when the basis set is large enough and omission and selection is suitable during the solving process. Unlikely, the other approximation methods, i.e., nonrelativistic Schrodinger equation including the relativistic effect and inclusion of the relativistic effect in the selected basis sets, are seriously dependent on the systems, which yield much lower reliability ,21,22,23


The association of the Great East Japan Earthquake and the subsequent Fukushima DaiichiNuclear Power Plant disaster of March 11 and 12, 2011, in Fukushima, Japan, with birthrates has not been examined appropriately in the existing literature.To assess the midterm and long-term associations of the Great East Japan Earthquake andthe Fukushima Daiichi Nuclear Power Plant disaster with birth rates.Cohort study in which interrupted time series analyses were used to assess monthlychanges in birth rates among residents of Fukushima City, Japan, from March 1, 2011, toDecember 31, 2017, relative to projected birth rates without the disaster based onpredisaster trends. Birth rates from January 1, 2007, to December 31, 2017, in FukushimaCity were determined using information from the Fukushima City government office.The Great East Japan Earthquake and the Fukushima Daiichi Nuclear Power Plant disaster,expressed via 5 potential models of the association with birth rate: level change, leveland slope changes, temporal level change, and temporal level change with 1 or 2 slopechange(s).Birth rate, calculated from monthly data on the number of births and totalpopulation.The mean birth rate before the Great East Japan Earthquake and the Fukushima DaiichiNuclear Power Plant disaster was 69.8 per 100 000 people per month; after thedisaster, the mean birth rate was 61.9 per 100 000 people per month. Compared withbirth rates before the Great East Japan Earthquake and the Fukushima Daiichi NuclearPower Plant disaster, there was an estimated 10% reduction in monthly birth rates inFukushima City  in the first 2 years after thedisaster. After that, the birth rate trend was similar to the predisaster trend. Thepredisaster trend suggested a continuous decrease in birth rate . This gap model was optimal and parsimonious compared withothers. A similar association was found when trimonthly averaged data were analyzed.The Great East Japan Earthquake and the Fukushima Daiichi Nuclear Power Plant disasterwere followed by significant reductions in birth rates for 2 years. There wasinsufficient evidence to indicate that the trend in the 3 to 7 years after the disasterdiffered from the predisaster trends. The recovery from the reductions in the birth ratemay be indicative of the rebuilding efforts. The continuing long-term decrease in birthrates observed before the Great East Japan Earthquake and the Fukushima Daiichi NuclearPower Plant disaster suggests that continuing measures to support birth planning shouldbe considered at the administrative level. This cohort study uses interrupted time series analyses to examine the midterm andlong-term associations of the Great East Japan Earthquake and the Fukushima DaiichiNuclear Power Plant disaster with birth rates. What was the long-term association of the Great East Japan Earthquake and the FukushimaDaiichi Nuclear Power Plant disaster with birth rates in Fukushima City, Japan?In this cohort study using interrupted time series analyses, the birth rate decreasedby 10% in the 2 years after the Fukushima Daiichi Nuclear Power Plant disaster. However,there was insufficient evidence to indicate that the trend in the 3 to 7 years after thedisaster differed from the predisaster trend.After the Great East Japan Earthquake and the Fukushima Daiichi Nuclear Power Plantdisaster, birth rates in Fukushima City decreased temporarily and then returned topredisaster levels after 2 years. Onthe other hand, to our knowledge, there has been very little work describing birth rates inthe Fukushima Prefecture both before and after the disaster.The Great East Japan Earthquake and the subsequent tsunami that occurred on March 11, 2011,led to the Fukushima Daiichi Nuclear Power Plant (FDNPP) disaster. This disaster forcedthose who lived within 20 km of the FDNPP to evacuate, according to the DisasterCountermeasures Basic Act. The disaster increased stress levels among women of childbearingage, making them especially anxious about the potential effects of radioactive materialreleased from the FDNPP on conception and fetuses. Previous literature has addressed theissue of stress associated with the disaster, with some studies reporting the elevatedincidence of cardiovascular diseases, such as congestive heart failure3 On the other hand, mass media reported that, while there was a slightrecovery in the number of births in Fukushima Prefecture 2 years after the disaster (in2013), the numbers decreased again in 2016 based on vital statistics in theprefecture.5 However, whether or how the trend in birth rates in theFukushima Prefecture changed after the disaster has not been examined thoroughly in theextant literature. In addition, the trend after the disaster has not been considered both inthe context of disaster and in the context of decreasing birth rates in Japan.One previous study showed that the number of births decreased in the 13 prefecturesaffected by the Great East Japan Earthquake and the FDNPP disaster (including Fukushimaprefecture) between December 2011 and June 2012.Fukushima City (hereafter simply referred to as Fukushima) is the capital of theprefecture, located in the northern part of the prefecture. It faces a decreasing birthrate, although it is approximately 60 km away from the FDNPP and was exempt from forcedevacuation. This study analyzes the long-term associations between the Great East JapanEarthquake and the FDNPP disaster and the birth rates in Fukushima. Understanding theseassociations may help clarify how local governments can face similar disasters in thefuture.6 This study is exempt from theevaluation of an institutional review board, because Japanese ethical guidelines do notmandate ethical review for studies analyzing publicly available data. In addition, becausethis study used anonymized aggregated data, informed consent was not mandatory according tothe ethical guidelines. Although this was an epidemiologic study, its interrupted timeseries analysis study design could not be categorized as a cohort, case-control, orcross-sectional study. Thus, no reporting guideline was applicable.This study used data on birth numbers and the population in Fukushima from January 1, 2007,to December 31, 2017, to examine the associations between the FDNPP disaster and birthrates. Data were extracted from available data from the Fukushima City government.The main outcome in this study is birth rate, defined by the number of births registered inFukushima per month divided by the city’s population at the beginning of the samemonth. The birth number is counted based on data on birth registration submitted to localgovernments in Fukushima. Birth registration is mandatory for all live births in Japan, andrequires a date of birth and an address clarification for resident registration. If theaddress for resident registration is in Fukushima, then the case is included for theoutcome. Month of birth is determined by the date written on the birth registration.2 statistic,divided by the residual df. The logarithm of monthly population numbers inFukushima was used as an offset parameter. Five models of the association between the GreatEast Japan Earthquake and the FDNPP disaster and birth rates were used: (1) a change in thelevel, (2) a change in both the level and the trend, (3) temporal level change ,(4) gap plus a change in the trend after the gap period, and (5) gap plus a change in thetrends after the disaster and after the gap period  Second, since the gestation period for humans is 9months after conception, the period extended to March 2013. Furthermore, 2 additional modelscorresponding to each outcome model were fitted, to specify the seasonal component in 2ways. In the seasonality-adjusted models, the following variables were added to thevariables used for the original outcome model: (1) indicator variables corresponding to thecalendar month or (2) sine and cosine pairs expressing the secular trends, namely,sin (2π × t/12),cos (2π × t/12),sin (4π × t/12), andcos (4π × t/12), where tindicates secular 12 months. To compare the impact models, both the Akaike informationcriterion and the Bayesian information criterion were reported. From the fitted outcomemodel, the predicted birth rate trend before the disaster, the predicted birth rate trendafter the disaster, and the projected trend of the predisaster period were plotted. Inaddition, rate ratios (RRs) and their 95% CIs were estimated from the outcome models.Sensitivity analyses were also conducted. All the analyses were repeated after using themonthly birth rates to calculate a mean quarterly birth rate. One exception was seasonaladjustment, which was accomplished by adjusting the quarter as an indicator variable. AllP values were from 2-sided tests and results were deemed statisticallysignificant at P < .05.All statistical analyses were conducted using Stata/SE, version 15 (StataCorp). Monthlybirth rates during the study period were plotted and the mean birth rates before and afterthe disaster were calculated. Interrupted time series analysis was used to estimate changesin the level or trends of birth rates by fitting a series of Poisson regression models withthe overdispersion parameter estimated using the Pearson χThe plot of birth rates is shown in the Values of the Akaike information criterion and the Bayesian information criterioncalculated from a series of time-interrupted series analyses are presented in the A series of sensitivity analyses corroborated the results presented above  was examined. In contrast, the present study examined a period of 11 years andidentified long-term trends in birth rates using an interrupted time series design.The decreased number of births from December 2011 to June 2012 in the 13 prefecturesaffected by the Great East Japan Earthquake and the FDNPP disaster (including Fukushimaprefecture) was reported by a previous study.9 were helpful for pregnant women to minimize radiationexposure for their fetus and near future infants. Furthermore, proactive announcements ofthe operating status of perinatal care facilities available for pregnant women would also behelpful. The more immediate and accurate these governmental responses are, the morereassured and confident that pregnant women will be about remaining in Fukushima.This study has several implications for governments of and residents in local communitiesthat have nuclear power plants but are distant from them. First, timely measurement of thearea’s radioactive materials in the environment is essential for reasonable decision making, as is providing the results and accurateprobabilities of reproductive effects to the residents. The decrease in the birth rateimmediately after the FDNPP disaster can be explained by the decision of pregnant women torelocate further away from the FDNPP than Fukushima, for fear of potentially hazardouseffects from radiation. The regular measurement of the radioactive materials enabled theestimation of a cumulative dose and allowed the governments to reasonably decide thatFukushima was exempt from being a forced evacuation zone. In addition, simultaneousmeasurement of radioactive materials in food and water and timely interventions such asregulating the water supply corporation and reasonable instructions for the residents onwhether or not they could use tap water, such as the instruction provided jointly by theJapanese Pediatric Society and other related societies,10 and perinataloutcomes were also helpful for women of childbearing age. The proceedings of the SeventhExploratory Committee on Fukushima Health Management held in June 2012 revealed that ratesof abortion and miscarriage did not differ between the predisaster and postdisasterperiods.8 The recovery afterthe sustained decrease in birth rates observed in March 2013, a period of 9 months after thecommittee met, may be partially explained by the recovery from the lack of or decrease inpregnancies since the report of the committee, considering the approximately 9-monthgestation period. Thus, immediate reporting of perinatal outcomes may contribute toshortening the duration of the decrease in birth rates.Second, continuous monitoring and timely reporting of radiation exposure of theresidents11Third, continuing measures to support birth planning should be considered at the localgovernment level in the long term, as these findings support the notion that the decrease inbirth rates in recent years can be explained by a long-term trend of decreasing birth ratesobserved before the disaster, owing to an aging population, a decrease in the rate ofmarriage, an increase in mean age at marriage, and/or a decrease in desire for childbearing.Thus, the local government may have to address these problems. Previous research suggeststhat an increase in the availability of childcare was associated with an increase in thefertility rate among young adult women living in certain regions of Japan.This study has some limitations. First, it potentially underestimates birth rates severalyears after the FDNPP disaster. If some mothers gave birth after relocation to othermunicipalities but left their resident registration unchanged, they might write“Fukushima” on their birth registration documents. Further investigation maybe warranted regarding whether this practice was common or not. Second, this study was notable to analyze the total fertility rate because of the lack of detailed data. Comparedwith the birth rate, the total fertility rate may not be affected by an agingpopulation.The FDNPP disaster was associated with a 2-year decrease in birth rates in the nearby cityof Fukushima. The recovery from this decrease in birth rates may be indicative of therebuilding efforts. After recovery, the city still seems to be facing a decreasing trendwithout sufficient evidence to indicate a difference from the predisaster trend. Furtherstudies on birth rates at the prefectural level are warranted to explore how the associationbetween the FDNPP disaster and birth rates differs by residents’ distance from theFDNPP.


To assess the relationship between body surface area (BSA) at birth and future risk for gestational diabetes mellitus (GDM).This is an observational cohort study from Vantaa, Finland. The cohort included 1548 Finnish primiparous women, aged 15–28 years, without pre-existing diabetes, who gave birth 2009–2015. All women were born full-term and had complete information about their birth weight and length, from the Finnish Medical Birth Register. Additional data for the study were provided by individual patient health records and Statistics Finland. Study participants were divided into five levels (I–V) according to BSA at birth, based on normal distribution.p = 0.015 for linearity, after adjustments for age, educational attainment, pre-pregnancy BMI and smoking). The odds ratio (OR) for GDM in level V, with the largest BSA at birth, compared with level I, with the smallest BSA at birth, was 0.43 [95% confidence interval (CI) 0.22–0.83]; adjusted for age, educational attainment, pre-pregnancy body mass index and smoking. The OR for GDM was 0.8  for each one standard deviation increase in BSA at birth, adjusted for the same confounders. BSA at birth correlated with adult anthropometry: correlation coefficients were r = 0.16 (95% CI 0.11–0.21) for weight, r = 0.31 (95% CI 0.26–0.35) for height, and r = 0.06 (95% CI 0.01–0.11) for BMI.There was an inverse association between BSA at birth and risk for GDM (Body surface area at birth is inversely associated with future risk for GDM in primiparous women. Gestational diabetes mellitus (GDM) is a common pregnancy disorder and has long been defined as any degree of abnormal glucose metabolism, first detected or with first onset, during pregnancy . The preGestational diabetes mellitus has adverse short- and long-term effects on the pregnant woman and her child, both during pregnancy and later in life , 5, withAccording to the Developmental Origins of Health and Disease (DOHaD) hypothesis prenatal environmental conditions might have long-lasting effects and affect an individual´s morbidity in adulthood , influenIn 2016, we initiated a long-term follow-up study in the city of Vantaa, Finland, to assess both short- and long-term consequences of glucose metabolism on pregnant women and their offspring’s health. The relationship between body size at birth and future risk for GDM has previously been studied using primarily birth weight as a measure of body size at birth. Body surface area (BSA) is an anthropometric measurement used to make a more accurate evaluation of metabolic mass and body size. The aim of this study is to evaluate how BSA at birth affects the future risk for GDM.This is an observational cohort study from the city of Vantaa, which is part of the Helsinki metropolitan area and the fourth biggest city in Finland, with around 220,000 inhabitants. During a 7-year follow-up, between January 1st 2009, and December 31st 2015, 13,530 women from Vantaa gave birth. Of these, 1548 primiparous women were Finnish (born in Finland with Finnish or Swedish as native language), without previously diagnosed diabetes mellitus, born at term after the year of 1987 , and aged 15–28 years during the follow-up period. All these women had complete data from the birth register and thereby formed the study cohort.http://www.thl.fi/en/statistics/parturients). The register started to collect information on deliveries on a nationwide basis from the year 1987. Therefore, only women born 1987 or later were included in this study. The following information about the women was obtained from this source: their own birth weight and birth length, pre-gestational weight in adulthood, adult height, previous pregnancies , infertility treatments, information about current pregnancies and deliveries, smoking during pregnancy, and hospitalization due to hypertension during pregnancy. Information about GDM, height, and weight was further completed by information from Vantaa Health care patient records.Data on maternal-fetal characteristics and pregnancy outcomes were obtained from the Finnish Medical Birth Register, which is administrated by the National Institute for Health and Welfare in Finland and receives the information about all live and stillbirths, from 22 gestational weeks or an offspring weight of at least 500 g onwards, from all Finnish maternity hospitals , or use of oral corticosteroids. In these high-risk patients GDM screening is performed earlier in pregnancy between gestational weeks 12 and 16, and if OGTT is normal, it will be repeated between gestational weeks 24 and 28 .Educational attainment was defined according to years of schooling, as obtained from Statistics Finland  for pre-pregnancy weight, r = 0.31 (95% CI 0.26–0.35) for adult height, and r = 0.06 (95% CI 0.01–0.11) for pre-pregnancy BMI  years. Baseline characteristics of the 1548 women, divided into five levels, according to body surface area (BSA) at birth is shown in Table p = 0.015 for linearity, after adjustments for age, educational attainment, pre-pregnancy BMI and smoking). The highest prevalence of GDM, 18.1%  was observed at level I; whereas, the lowest prevalence of GDM, 9.5% was observed at level V   for each one SD increase in BSA at birth, and the OR for GDM was 0.95  for each one SD increase in ponderal index at birth, after adjustment for the same confounders . BSA at birth was inversely associated with GDM , among those with the smallest BSA at birth, and lowest (9.5%), among those with the largest BSA at birth. Similarly, the OR for GDM in the group with the largest BSA, compared to the group with the smallest BSA was 0.46. We also used another marker of body size at birth, i.e., ponderal index to evaluate the relationship between body size at birth and risk for GDM. Ponderal index at birth did not predict future risk of GDM. Further, BSA at birth and adult anthropometry correlated, although weakly, with the strongest correlation observed between BSA at birth and adult height.The GDM prevalence in our study cohort was 12% and the mean age of the primiparous women was 22 years. The mean age of primiparas in Finland during the study period between 2010 and 2015 was 29 years . The natTo the best of our knowledge, this is the first study to investigate the relationship between BSA at birth and later risk for GDM in primiparous women. We aimed to investigate the relationship using BSA at birth as a more accurate estimate for body size at birth than for example birth weight, in order to approximate the metabolic tissue and body size as a whole. Further, we assessed the relationship between both BSA and ponderal index as parameters on risk for GDM. Comparisons between our findings and previous publications are based on studies that have assessed the relationship between birth weight only or ponderal index, and risk for GDM.Similar to previous studies that have shown birth weight to be inversely associated with risk for GDM , 29, 30,The conflicting results between former studies with regard to a linear inverse versus a U-shaped relationship between birth weight and risk for GDM have, at least to some extent, been thought to reflect differences in study settings, with some studies lacking a big enough comparison group of macrosomic infants. In addition, the relationship has also been explained by ethnic differences; as Williams showed in 1999, women of African-American ethnicity showed a U-shaped relationship between birth weight and risk for GDM, while women of other ethnicities, showed an inverse linear relationship . MoreoveThere are several factors affecting fetal growth such as gestational age, parity, infant sex, in utero metabolism, and genetic factors , 35. FurA small birthweight has been thought to affect morbidity in adulthood and has formed the basis for the DOHaD hypothesis —the concWhy did we think it was important to assess the relationship between maternal body size as a whole, also taking birth length into account, and risk for GDM? Compared to birth weight, birth length has been considered to be an even stronger predictor of adult height , 43, andIn 2005, Eide et al. concluded that as birth length predicts adult stature and adult stature is associated with several non-communicable disorders—birth length might be a better predictor of adult health than birth weight . Adult wThe strength of the study is that it encompasses all primiparous Finnish women from Vantaa city, the fourth biggest city in Finland, who delivered during a 7-year follow-up period and of whom we had complete data about their own birth length and weight based on register data. To avoid the confounding effect of previous GDM or parity, we included only primiparas in the study. The diagnosis of GDM is based on a standardized 2-h 75-g OGTT and the diagnostic criteria have remained the same during the whole study period. Finally, the Finnish Medical Birth Register is considered to be of high quality .The study also has some limitations. We missed information about some well-known risk factors for GDM; such as family history of diabetes, gestational weight gain, dietary habits, and physical activity. All study participants had Finnish background, and therefore the generalization of the results globally can be restricted. Most importantly, it was only in 1987 when the Finnish Medical Birth Register started to collect information on a nationwide basis, thereby, this cohort consisted only of rather young primiparas and the results cannot be generalized to older pregnant women.In conclusion, BSA at birth is inversely associated with future risk for GDM in primiparous women. Special attention should be paid to pregnant women who have been born small, in order to follow-up and if possible reduce the risk for GDM. Likewise, to encourage a healthy and nutritious pregnancy diet and to aim for an optimal fetal growth are important in any pregnancy to reduce transgenerational transmission of GDM and to prevent an infant’s risk for being born small and thereby at risk for future metabolic disturbances.


Efforts to understand the pathophysiology of bone fragility must focus on bone traits during growth. We hypothesized that variance in individual trait ranking in the population distribution is established by genetic factors and is reflected in foetal trait ranking in early pregnancy, but intrauterine factors modify trait ranking in late pregnancy, followed by the reinstating of this ranking during the first postnatal year. Thus, relations with paternal factors are present in early pregnancy but are then lost and subsequently reinstated postnatal. We recruited 399 healthy pregnant women aged 20–42 years from The Mercy Hospital for Woman in Melbourne, Australia. Foetal femur length (FL) and knee-heel length (KHL) were measured by ultrasound during gestation, and FL, KHL, body length and weight were measured in neonates, infants, and parents. The z-scores were calculated using Royston models. Pearson correlation was used to assess tracking and linear mixed models to test the associations. Correlations between FL and KHL z-scores of the same trait at 20 and 30 weeks gestation, at birth, and at 12 and 24 months of age (r = 0.1–0.3) and of body length and weight at birth, and 6, 12 and 24 months (r = 0.3–0.5) became more robust after 6–12 months (r = 0.4–0.8). FL and KHL z-scores at 20 weeks gestation accounted for 4–5% of total variance, while FL, KHL, body length and weight z-scores at birth accounted for 13–26% of total variance in the same traits at 24 months. Maternal FL and KHL were associated with foetal FL and KHL at 20 and 30 weeks, but there were no such associations for paternal FL and KHL with foetal traits during gestation. Both maternal and paternal traits were associated with infant traits. Tracking in traits is not established antenatal but is robustly established at 6–12 months of age. Low birth weight and poor growth in infancy are associated with increased rates of chronic disease and osteoporosis in adulthood –3. Efforin utero growth. There is considerable evidence that the velocity of foetal length and weight growth slows down from approximately 30–34 weeks gestation [There are few longitudinal studies of antenatal and postnatal growth, and birth weight is often used as a proxy for antenatal growth . Howeverestation . Maternaestation . This inestation . This meestation . Rapid gestation . The weaestation ,13. Thatestation . If mateHowever, it is plausible that the ranking of a trait in adulthood is largely determined by genetic factors, and this notion would be supported if trait ranking in the second trimester (20 weeks) does not predict trait ranking at birth  but does predict trait ranking at 6, 12 and 24 months. If this is the case, then an individual’s trait ranking in the population distribution could be largely determined by genetic factors. If this is not the case, then intrauterine and postnatal environmental factors could be more important in determining the variance in an individual’s trait ranking.While the maternal influence on foetal growth is well known, the role of paternal factors in foetal growth is not known . MoreoveThe aims of this study were to determined femur length (FL) and knee-heel length (KHL) prenatal (20 and 30 weeks gestation), at birth and postnatal  to investigate whether trait ranking in the second trimester and at birth predicts trait ranking of offspring and the contribution of parents to the variance in antenatal and postnatal trait ranking of offspring. We hypothesized that the variance in individual trait ranking in the population distribution is established by genetic factors, as reflected in foetal trait ranking in early pregnancy, but that intrauterine factors modify trait ranking in late pregnancy due to maternal constraints, although it is reinstated during the first year of postnatal life. Thus, the relations with paternal dimensions are present in early pregnancy, lost and then reinstated only after six months of postnatal life.Between July 2008 and June 2009, 399 healthy pregnant women aged 20–42 years with a single normal foetus were recruited at their 20-week-gestation routine ultrasound scan at The Mercy Hospital for Women in Melbourne, Australia . Among tGestation was determined based on the last menstrual period unless the gestational age based on the first ultrasound measurement (crown-rump length (CRL) before 12 weeks or biparietal diameter (BPD) at 12–20 weeks) differed by more than 7 days; in such cases, gestational age was based on ultrasound assessments. Foetal growth was monitored using 2D ultrasound assessments of FL and KHL at 2 occasions; at 20 (range 17–23) and 30 (range 27–34) weeks gestation. Measurements were obtained by two experienced ultrasonographers using a Philips IU22, Philips HDI-5000 or a Philips HDI-300 ultrasound machine. We excluded foetuses who had major malformations detected by ultrasound scan or who were delivered preterm before 37 weeks gestation. A questionnaire included maternal lifestyle such as current smoking and alcohol use, parity, and country of birth to classify their ethnicity. Of the 370 women who completed the questionnaires, 279 (75.4%) reported that they were Caucasians, while 24.6% were of different multi-ethnic origins, mainly from Asian countries.2 (kg/m2). FL was determined to the nearest 0.5 cm as the distance from the greater trochanter to the lateral condyle [Following birth (1 to 7 days of age) and at 6, 12 and 24 months of age, the weight, crown-heel length (CHL), KHL and FL were measured by two trained researchers. CHL was measured to the nearest 0.1 cm using a lengthboard , and KHL and FL were measured using a hand-held BK5 infant knemometer  . Birth w condyle , and KHL2 before and after inclusion of each of the factors in the models. The SAS software version 9.4  was used for data analyses.All variables were checked for normality by visual inspection of the histograms. We performed non-response analysis and compared the characteristics of those with and without measurements at 24 months of age. Royston models were fitted to foetal and infant growth measurements to create z-scores for size measurements during growth . PearsonCharacteristics of the participants are shown in Correlations between FL z-scores at 20 weeks gestation with those at birth, 6, 12 and 24 months were between 0.1 and 0.3 . SimilarMaternal FL was associated with foetal FL at 20 and 30 weeks gestation , but paternal FL was not  . SimilarWhen the offspring were classified according to quartiles of FL and KHL at 20 weeks gestation (A), at 30 weeks gestation (B), and at birth (C) the resulting ranking of FL and KHL quartiles converged and overlapped a lot . When clThe foetal FL z-score at 20 weeks gestation did not predict the infant FL z-score at 12 months  but did predict the FL z-score at 24 months of age  . The foeGenetic factors determine most of the variance in height and bone dimensions in adulthood, and tracking is well documented during childhood and adulthood ,11. HoweThere have been few longitudinal studies relating antenatal growth to postnatal growth ,22,23. TOunsted et al. suggested that maternal constraints slow foetal growth, even in normal pregnancies . They coGrowth restriction can be identified early and late during gestation using ultrasound. Foetal FL in the first trimester, predicts antenatal and postnatal length, but the associations are stronger before birth than after birth . SmallerCooper et al. reported positive associations between birth size and bone mass and fracture risk in later life ,31–33. HTo the best of our knowledge, this is the first study of antenatal and postnatal growth of FL and KHL to include measurements of the same traits in both parents. Both maternal and paternal proportions are known to influence offspring proportions during postnatal growth . This stThe strength of this study is the standardized research setting for obtaining measurements of both parents and offspring rather than using self-reported measurements of height and weight. However, there are some limitations to our study. The best way to assess age in the prenatal period, based on the first day of the last menstrual period, is prone to error because the interval from menstruation to fertilization varies from 8 to 20 days . AlthougIn conclusion, there was a small effect of foetal traits in the second and third trimesters and a larger effect of neonatal traits on traits at 2 years of age. These findings did not confirm our hypothesis that ranking is established early during antenatal growth, lost as a result of maternal constraints and reinstated during postnatal growth, thus ranking must be established later. Maternal, not paternal, influences were apparent during gestation, but both maternal and paternal parameters influenced the traits at 2 years of age as previously shown. Additional longitudinal studies of antenatal and postnatal growth are needed to obtain a better understanding of maternal constraints, the mechanism behind this phenomenon, and the long-term effects on offspring. Greater knowledge of the biological determinants of variation in foetal growth may be advantageous for decision-making regarding the need for intervention in clinical practice.S1 Dataset(SAS7BDAT)Click here for additional data file.


The burden of maternal and neonatal mortality remains persistently high in Nigeria. Sepsis contributes significantly to both maternal and newborn mortality, and safe delivery kits have long been promoted as a cost-effective intervention to ensure hygienic delivery practices and reduce sepsis. However, there is limited evidence on the effectiveness of home birth kit distribution by community health workers, and particularly the impact of this intervention on health outcomes. This paper reports a secondary analysis of data from a cluster randomized trial in rural northern Nigeria in which birth kits were distributed by community health workers to pregnant women in their homes, analyzing non-experimental variation in receipt and use of birth kits. More specifically, associations between pregnant women’s baseline characteristics and receipt and use of birth kits, and associations between birth kit use, care utilization and maternal and newborn outcomes were assessed.Baseline, post-birth and endline data related to 3,317 births observed over a period of three years in 72 intervention communities in Jigawa state, Nigeria, were analyzed using hierarchical, logistic regression models. In total, 140 women received birth kits, and 72 women used the kits. There were no associations between baseline demographic characteristics, health history, and knowledge and attitudes and receipt of a kit, suggesting that community health workers did not systematically target the distribution of birth kits. However, women who used the kit reported reduced odds of past pregnancy complications  as well as significantly higher odds of feeling generally healthy at baseline , of exposure to radio media , and of perceiving themselves as having a low-risk pregnancy . While there were no significant associations between birth kit use and facility based delivery, skilled birth attendance or post-natal care, women who used a kit exhibited significantly lower odds of completing four or more ANC visits  and significantly higher odds of reporting prolonged labor , and post-partum bleeding .This evidence suggests that use of birth kits is low in a rural population characterized by minimal baseline utilization of maternal and neonatal health services, and the use of birth kits was not associated with reductions in maternal or neonatal morbidity. While further research is required to understand how the effectiveness of birth kits may be shaped by the mechanism through which women access and utilize the kits, our findings suggest that the provision of kits to women outside of the formal health system may be associated with increased risk of adverse outcomes. Despite increasing attention and commitments by policymakers globally to the goal of reducing maternal and neonatal mortality, both have remained stubbornly high in sub-Saharan Africa. In Nigeria, the neonatal mortality rate  was roughly stagnant between 1990 and 2013, and the burden of neonatal mortality remains higher in Nigeria vis-a-vis other sub-Saharan African countries [In addition, both MMR and NMR show geographical variation, and the highest levels are observed in the northern part of the country. The MMR in Jigawa state, a rural state in northern Nigeria that is the focus of this analysis, is estimated to be around 1,012 per 100,000 live births . The NMRSepsis contributes significantly to both maternal and neonatal deaths. The World Health Organization (WHO) estimates that 10.7% of maternal deaths  and 30% Despite these recommendations, there is limited evidence around the impact of clean delivery kits on health outcomes, including neonatal sepsis and neonatal mortality –12. The Two recent studies presented non-experimental evidence that women who used birth kits distributed by a primary health center in Egypt were significantly less likely to experience puerperal sepsis, and their neonates were less likely to develop cord infection , 14. A qConceptually, there are at least two important factors that may limit the effectiveness of birth kits. First, utilization rates of the kits themselves may be low outside of formal health care settings; the existing evidence almost exclusively focuses on interventions in which birth kits are distributed to health facilities or skilled birth attendants , 12, altThe objective of this paper is to examine associations between baseline characteristics and birth kit use and receipt, as well as birth kit use and care utilization and maternal and neonatal outcomes, by conducting a secondary analysis of data from a cluster-randomized controlled trial (cRCT) implemented in Jigawa, Nigeria. In the main trial, birth kits were distributed by community health workers to pregnant women in their homes in one experimental arm. Given that the experimental design entailed the assignment of pregnant women to receive a birth kit independent of their interactions with the health system, their planned delivery location, or their desire to use the birth kit, we are able to assess whether women in a low-resource context with limited access to care use a birth kit, use it effectively, and demonstrate any improvement in health outcomes. Importantly, the paper fills a significant gap in the literature by analyzing the effects of birth kits when distributed by community health workers directly to pregnant women.This study utilizes data from a cRCT of community-based interventions designed to reduce maternal and newborn mortality conducted in Jigawa state, Nigeria. Jigawa is located in northwestern Nigeria and is characterized by extremely poor baseline health outcomes, particularly for women and neonates. The region has also been exposed to ongoing violence linked to the Boko Haram conflict. The cRCT was implemented by the Abdul Latif Jameel Poverty Action Lab (J-PAL) in partnership with the Planned Parenthood Federation of Nigeria (PPFN) and was designed to evaluate three interventions: training local women as Community Resource Persons (CoRPs) to provide health education to pregnant women and their families; deploying the CoRPs in conjunction with the distribution of safe birth kits to pregnant women; and deploying the CoRPs in conjunction with community dramas to change social norms around maternal health. This paper does not report the primary experimental effects of the interventions; these effects are reported in a separate, forthcoming paper.Ethical approvals for the cRCT analyzed here were provided by the Massachusetts Institute of Technology (MIT) and the Operational Research Committee (ORAC) of the Ministry of Health in Jigawa state, Nigeria. ORAC serves as the institutional review board for human subject research conducted within Jigawa state. The cRCT protocol is registered at ClinicalTrials.gov under the registration number NCT01487707. All data collection was conducted in Jigawa, a region with low female literacy.All respondents provided written consent using paper consent forms, and the consent process was documented in the electronic data system by enumerators. In addition, consent was sought from the parents or guardians of any non-emancipated minors included in the sample. These consent processes were approved by the relevant Institutional Review Boards.Jigawa state had a population of 4.3 million during the 2006 census, and includes 27 local government areas (LGAs); 80% of the population lives in rural areas . The staIn northern Nigeria, key stakeholders in the health sector hypothesized that the expansion of the MSS alone might not lead to enhancement of maternal and child health outcomes given the observed low rates of utilization of maternal health care ex ante. Accordingly, our partner organization, the Planned Parenthood Federation of Nigeria (PPFN), proposed to implement three community-based interventions involving health educators deemed community resource persons or CoRPs, designed to stimulate utilization of these newly available maternal health services and thus enhance maternal and neonatal health . These iIn the first experimental arm, CoRPs services were rolled out to sampled villages; CoRPs are local women between 20 and 45 years of age recruited by PPFN in conjunction with local ward health committees. They received a one-week training and were mandated to provide information on antenatal care, nutrition in pregnancy, identification of danger signs, birth preparedness, labor and postnatal care, breastfeeding, immunization, birth registration, and family planning over a series of six home visits to pregnant women. PPFN described CoRPs as serving as “a bridge crucial to foster trust, confidence and acceptance between the midwives and their clients and to ensure effective communication between the two groups”. The CORPs also received a small stipend .In the second experimental arm, CoRPs were provided with birth kits to distribute to pregnant women in their third trimester, in conjunction with the provision of instructions around how to use the kit. The kits included a plastic sheet for the woman to lie on during delivery, surgical gloves for a birth attendant to utilize, a sterile razor and cord clamps to cut and tie the umbilical cord, methylated spirit to clean the umbilical stump, clean gauze, swabs and perineal pads to be used by the mother after birth, a gallipot, a mechanical suction tube to clear secretions from the baby’s airways, and a wrapper and diapers for the use of the mother and baby immediately after birth . All matIn the third experimental arm, in addition to the CoRPs intervention, PPFN also conducted community drama activities in order to promote the importance of safe motherhood at the community level. The fourth experimental arm served as the control arm, in which PPFN did not provide any new services. Women in control communities continued to have access to standard health services provided at MSS clinics.The RCT design entails randomization at the community level, given that all three interventions are subject to significant within-community spillovers. In total, 96 clusters in 24 local government areas (LGAs) were included. All clusters were located within 20 kilometers of a MSS PHC, and each cluster included 75 respondents enrolled at baseline. In addition, neonatal deaths were tracked for the full cluster population .α = .1, K = .2); this is assuming a baseline neonatal mortality rate of 47 per 1,000 and a baseline maternal morbidity rate of 35%, and attrition of less than 5% [k for perinatal indicators in other developing countries as well as methodological guidance for sample size calculation in cluster randomized trials [Baseline power calculations estimated the cRCT had 90% power to detect a 24% decrease in neonatal mortality and a 23% decrease in maternal morbidity using a one-tailed test  was conducted between December 2011 and May 2012 using a 15% random sample of all enumerated households including a woman of reproductive age (between 15 and 49); if more than one woman of reproductive age was present in a sampled household, one woman was randomly selected utilizing an on-the-field randomization protocol. The baseline survey included information about household composition and socioeconomic characteristics, birth history, utilization of health services for pregnancies within the preceding 24 months, contraceptive utilization, the respondent’s health and the health of any infant children, and health knowledge and attitudes. In addition, anthropometric measurements were collected for the respondent’s children under the age of two .Following the baseline, continuous monitoring of pregnancies via a RapidSMS surveillance system was initiated between November 2013 and November 2015. Female community members were recruited and trained to monitor pregnancies and vital events among baseline respondents, and were assigned to send a simple SMS to the survey team when a birth was observed in baseline households, and to report deaths of women and infants in any household. The SMS messages were then redirected to an enumerator who had the responsibility of identifying the household and administering questionnaires within 3 days and at 28 days after birth. For deaths of women of reproductive age, verbal autopsies were conducted to determine the cause of death.The three-day survey included questions about utilization of antenatal care, the mother’s health during pregnancy, the delivery itself, and the mother’s and infant’s health since birth; the infant’s weight and length were also measured. The 28-day survey included questions about attitudes toward utilization of maternal health care, maternal and neonatal morbidity in the first month, and infant health practices; again, infant weight, length and mid-upper arm circumference (MUAC) were measured. In addition, an audit of all baseline households was conducted at the halfway point of continuous data collection in which all baseline households were revisited. The enumerators were mandated to pose a brief series of questions about births in the household, and to collect additional information from any births that had previously been missed. An endline survey with the baseline sample was conducted between February 2016 and July 2016.Attrition in the endline was 9.8%. However, some women who were not surveyed at endline due to migration or divorce had been represented in earlier surveys (post-birth surveys or the audit). Accordingly, the rate of attrition from any follow-up data collection was only 7.8% of the original sample.This paper reports summary statistics on receipt and use of birth kits in the target population, and uses hierarchical logistic regression to analyze associations between baseline characteristics of respondents and receipt and use of birth kits, as well as associations between use of birth kits and outcomes during pregnancy and delivery. The analysis focuses on the sample “as treated” and is complementary to an intention-to-treat analysis analyzing experimental evidence around the primary effects of the intervention, reported in a separate, forthcoming paper. More specifically, an “as treated” analysis is utilized here given that an intention-to-treat analysis cannot provide evidence about the correlations between birth kit use and health outcomes.Receipt and use of birth kits varied at the individual level even within clusters assigned to receive birth kits. Accordingly, individual-level variation rather than cluster-level variation was employed, using data from women who reported a birth during the evaluation period in any of the three intervention arms; this was a sample of 3,317 women. For the analysis of birth kit use, the sample was restricted to women who reported receipt of a birth kit from a CoRP.Given that there is presumably correlation in delivery outcomes within clusters, the analysis accounted for this intra-cluster correlation by estimating logistic regressions including clustered standard errors. Data were analyzed using Stata 14.2 , and the Stata command “logit” was employed, using the “cl” option. More specifically, logit models were estimated iteratively employing maximum likelihood estimation, and sandwich standard errors were employed to conduct inference given an arbitrary structure of within-cluster correlation of errors .Binary variables capturing birth kit receipt and use were constructed as follows: “birth kit receipt” was defined as equal to one if the respondent reported receipt of a birth kit from a PPFN CoRP. “Birth kit use” was defined as equal to one if the respondent reported using the birth kit during her delivery. The baseline characteristics assessed included demographic characteristics, health history, utilization of health services, health knowledge, knowledge of pregnancy-related complications, perceptions of risk in pregnancy and childbirth, and household dynamics, as described in more detail below.Demographic characteristics included variables capturing age, ethnicity, household structure, educational background, birth parity, and a wealth index. Birth parity was defined as the number of births (including stillbirths) reported by the respondent; it was converted to a categorical variable for parity zero, parity one, and parity 2+. The household wealth index was computed by principal component analysis from four binary variables capturing whether the household reports a solid roof, a solid floor, access to a latrine and a house constructed from solid materials.Variables capturing baseline health history and health care utilization included the respondent’s history of miscarriage, stillbirths, infant deaths, and pregnancy complications, and antenatal care utilization, skilled attendance at birth, and utilization of postnatal care as reported for her last birth. Additional variables captured baseline health knowledge, including radio exposure, coded as equal to one for women who report listening to the radio at least once a week, and awareness of tuberculosis, HIV/AIDS, and the importance of exclusive breastfeeding. Variables capturing baseline knowledge of pregnancy-specific complications included the number of labor and delivery complications, danger signs, and postpartum complications identified by the respondent.The respondent’s perceptions of risk in pregnancy and delivery were measured using the following variables: whether she believes maternal death to be preventable, whether she is confident she will not encounter challenges in delivery, and three binary variables representing whether the respondent correctly identified the riskier scenario in a series of questions posed about pregnancy, delivery, and the post-partum period. Based on the number of correct responses, women were assigned to one of three categories of risk knowledge . Finally, baseline household dynamics were captured by the husband’s educational and occupational characteristics and household decision-making patterns. It is important to note that the sample for some regressions is more limited if certain variables are not reported at baseline; in particular, respondents who had not reported a birth in the 24 months prior to baseline do not report baseline care utilization.In the final part of the analysis, associations between birth kit use and pregnancy outcomes  were analyzed. The variables of interest are defined in Care utilization variables included whether the respondent utilized antenatal care and additional questions describing her care utilization pattern , whether the respondent delivered in a facility, whether she delivered at home , whether a skilled attendant was present at the birth, and whether she utilized postnatal care. Variables capturing health practices included whether the respondent developed a birth plan, whether the husband was present at ANC and/or delivery, and whether complementary feeding was initiated in the first three days. Variables capturing maternal and neonatal morbidity included a series of questions around whether the respondent experienced enumerated symptoms during pregnancy, delivery or post-partum, and whether the respondent reported symptoms of illness for the infant in the first 60 days of life. In addition, three binary variables were constructed capturing whether the respondent’s children under two at endline are underweight, stunted or characterized by low MUAC-for-age, defined as weight-for-age, height-for-age, or MUAC-for-age more than two standard deviations below the mean of the WHO reference population.For these variables, we preferentially utilized data reported in the surveys conducted three and 28 days after birth; if these surveys were missing, we drew on parallel data reported in the audit survey or the endline. Given the long follow-up period and the challenges posed by data collection in a remote and conflict-affected region, we benefited from utilizing these various complementary sources of data to obtain maximum information about our sample of interest. Again, this analysis was restricted to women who reported they received a birth kit.In these specifications, we also considered variables that may confound or modify these associations. The confounding variables included were dummy variables for age categories, Hausa ethnicity, marital status, polygamous status, ever attended school, literacy, birth parity status , and assignment to the birth kits arm. The specifications examining maternal and neonatal morbidity and under-two anthropometrics also adjusted for variables capturing utilization of maternal health care: whether the respondent utilized antenatal care, whether she delivered in a facility, and whether the delivery was attended by a skilled provider. The confounding variables were chosen based on a review of the literature around demographic variables predictive of birth kit utilization and maternal health outcomes.Conditional on receiving a birth kit, knowledge was relatively high. 74.3% (N = 102) of women who received a kit reported knowing how to use it, and 66.4% (N = 93) could correctly name at least one object included in the kit. Use rates were lower; only 51.4% (N = 72) report they used the kit in their most recent delivery. The majority of respondents who did not use the kit reported they were still in possession of it. Only one woman reported she discarded the kit, while three respondents reported passing the kit to a friend.Tables p < 0.05), of reporting awareness of HIV transmission via breastfeeding , and of having a spouse who completed secondary school , relative to women who did not receive a birth kit. Otherwise, women who received a birth kit were observed to have similar observable characteristics to women who did not receive a kit.When comparing women who do and do not report receipt of a birth kit, women who received a kit exhibited significantly increased odds of receiving more than 50% of available ANC services in their most recent pregnancy  and that they felt generally well , and were less likely to report a complication in a previous pregnancy . Kit users were also significantly more likely to report utilization of antenatal care  and receipt of iron folic pills  in their most recent pregnancy.Tables p < 0.01), and in general kit users demonstrated a higher level of general health knowledge; they were more likely to be aware of HIV transmission via breastfeeding , and more likely to be aware of the birth control pill . Finally, in terms of attitudinal characteristics, we observe a positive association between kit use and a respondent’s confidence that she will not encounter challenges in a future birth  and a medium level of pregnancy risk knowledge .In addition, there was a positive association between kit use and regular radio exposure , as well as decreased odds of utilizing antenatal care at a primary health center or hospital . There was no significant association between birth kit use and facility based delivery, skilled birth attendance or postnatal care. Use of a birth kit was associated with increased odds that the respondent’s husband was present at the delivery , but also significantly increased odds of neonatal complementary feeding within the first three days of life .Panel A of p <.05) and postpartum bleeding . While birth kit use was not otherwise associated with statistically significant differences in morbidity comparing across respondents who do and do not use birth kits, for a number of variables the observed prevalence of complications was higher in the subsample of women who used a birth kit, and thus the odds ratios reported are greater than one. No statistically significant associations were observed between birth kit use and under-two anthropometrics. Given the small sample size, the analysis lacked power to evaluate maternal and neonatal mortality.The evidence presented in this analysis suggests that in a northern Nigerian state characterized by minimal utilization of maternal health services, uptake of an intervention designed to distribute safe delivery kits to pregnant women at home was low, and utilization of the kits is not significantly associated with enhanced maternal or newborn health outcomes. In this evaluation, only 9.7% of eligible women received birth kits, a low level of penetration that presumably reflects a number of factors. Operational data from the CoRPs program and qualitative data suggest that performance of the CoRPs was relatively low, reflecting limited training, limited incentives provided to CoRPs, and weak supervision. A high level of insecurity due to ongoing unrest linked to the Boko Haram rebellion also generated challenges for supervision and implementation. A large number of CoRPs were inactive, failing to conduct educational sessions with pregnant women in their homes, and similarly failing to distribute birth kits to eligible pregnant women in their third trimester.It is challenging to compare the patterns of birth kit receipt and use in this evaluation to previously reported data on birth kit uptake for two reasons. First, previous quantitative studies examining birth kits generally assume that receipt and use of a birth kit are synonymous, and do not report data separately for individuals who received and used kits. Our results suggest that receipt of a kit is not an appropriate proxy for use, as only 50% of women who report receipt of a kit also report use. Second, the existing evidence almost exclusively focuses on interventions in which birth kits are distributed to health facilities, skilled birth attendants, or stores for purchase . There iIn previous literature, reported use of birth kits ranges from 15–100% . HoweverEight qualitative studies have examined women’s experiences with birth kits, the kits’ general acceptability, and recipients’ reasons for use or non-use. This literature has generally reported that delivery and post-natal practices are culturally patterned, and limited knowledge about the kit and perceptions of limited utility are the most important factors constraining use . Other rOur findings generally show no statistically significant differences in baseline characteristics or in previous maternal health utilization among women who received a kit versus those who did not receive a kit. This evidence suggests that the CoRPs did not systematically prioritize women with certain characteristics for receipt of a kit, and the pattern is also consistent when the sample is restricted to respondents assigned to the birth kits arm. However, there is evidence that women who used the kits are characterized by better reported health at baseline; they are more likely to use antenatal care, more knowledgeable about general health questions as well as the risks of pregnancy, and more confident that they themselves face minimal risk. Birth kit users are also less likely to report a previous pregnancy complication, and are more likely to report greater involvement by their husbands in a previous pregnancy.There is some evidence in the literature related to determinants of birth kit use. Evidence from Egypt suggests that women who had higher ANC attendance during the same pregnancy exhibit higher levels of birth kit use . In SoutContrary to other published studies, we find evidence of significant and negative associations between kit use and utilization of formal health care and recommended health practices, as well as maternal health outcomes. Birth kit use was associated with lower odds of receiving four or more ANC visits, but was not significantly associated with utilization of other maternal health services, such as facility based delivery or postnatal care. In addition, there is weak evidence of an association between kit use and increased odds that the husband is present at delivery , and strong evidence of an association between kit use and increased odds of complementary feeding in the first three days. Given that the World Health Organization recommends exclusive breastfeeding in the neonatal period , this evPrevious evidence from Balsara et al. suggests that mothers using a safe birth kit were more than four times as likely to seek ANC . HoweverPrevious authors have suggested that provision of birth kits could potentially encourage utilization of health services, but given our findings, it appears that this may only be the case when the kit is itself tied to care utilization. Further evidence around the influence of birth kit distribution on health services use is needed to understand differences with respect to the distribution mechanism and the recipient’s characteristics in order to assess and minimize unintended consequences.Evidence from this study suggesting there is no association between birth kit use and neonatal morbidity and a strong positive correlation between kit use and prolonged labor and postpartum bleeding also differs from previous literature that generally concludes that birth kit use is correlated with reductions in neonatal morbidity and/or associated risk. A number of papers report that birth kit use is associated with a reduction in the risk of cord infection , 15, 34 There are several mechanisms that may explain the weak or adverse effects of birth kits observed in this study. First, given the low observed penetration rates of the birth kits intervention, community health workers may have chosen women with certain characteristics to receive birth kits. For example, CoRPs may have targeted the distribution of birth kits to women who are unlikely to use the formal health care system, or women who they perceived to be at higher risk of pregnancy complications. However, our data show almost no evidence of significant correlations between these characteristics as measured at baseline and receipt of a birth kit. Second, women who chose to use the birth kit may have had different characteristics from women who chose not to use the birth kit: for example, kit users may have been higher risk of poor pregnancy outcomes ex ante. However, the observed associations are significant even when adjusted for baseline demographic characteristics. In addition, women who used the birth kits were in general healthier, more informed about pregnancy risk, and perceived themselves to be at lower risk relative to women who did not use the kits. These characteristics are ceteris paribus associated with a higher probability of better health outcomes .A third potential mechanism is that the birth kits may have been viewed as a substitute form of care for women who prefer to avoid utilizing formal care, or who are unable to utilize it. Women who viewed themselves as low risk and women whose spouses were more involved in health care decision-making may have been particularly likely to substitute toward the use of birth kits, assuming that men also have a strong preference to minimize utilization of formal health care. This yields a reduction in the use of formal care, and an increased odds of adverse outcomes. Our data show some evidence that use of birth kits may be correlated with a reduction in use of ANC care, as kit users were less likely to receive ANC via the formal health system or complete four or more ANC visits, but no evidence of substitution away from other types of health services.A fourth mechanism that would be consistent with the absence of any improvement in neonatal outcomes would be improper use of the birth kit and/or the persistence of other unhygienic or unsafe delivery practices. Previous evaluations that have found positive effects of kit use on health outcomes have also reported increased hand washing and other clean delivery practices , 18. UnfThis study has several strengths. First, it utilizes a unique data set collected at multiple points in time from a population characterized by extremely low levels of human capital and poor health outcomes. Second, participants were randomly selected within communities, ensuring a representative sample. Third, separate data was collected about exposure to the intervention (birth kit receipt) and use of the birth kit, as well as intermediate outcomes such as knowledge, allowing us to identify gaps between receipt of the birth kit and use.However, this study also has several limitations. The analysis utilizes a relatively small sample of birth kit recipients, limiting statistical power for the analysis of the effects of use on health outcomes. Data about care utilization during pregnancy and pregnancy outcomes were collected from respondents at different points in time, and recall bias may be a challenge for respondents who were surveyed only at endline.In addition, given that this is a secondary analysis of cRCT data rather than an ITT analysis, the paper presents only correlational evidence related to birth kit use , 41. WhiGiven that the sample was drawn from one state in northern Nigeria, the evidence presented here may have limited external validity for a broader population. However, this evidence may be relevant for other similar populations , as well as for other interventions in which community health workers characterized by low levels of training and/or supervision promote new health technologies or health inputs.Our findings have implications for health programming, policy and research. While further research is needed to understand how the effectiveness of birth kits is shaped by the distribution mechanism and the characteristics of recipients, this evidence suggests that the provision of kits to pregnant women outside of the formal health system may be undesirable. Use of birth kits may encourage substitution away from the formal health system (at least for ANC), and appears to be associated with negative health outcomes. Distribution via skilled health workers or linking distribution to health service utilization may have more positive effects on beneficiaries; however, this choice also has implications for cost-effectiveness.In light of the growing literature suggesting that safe birth kits are effective in enhancing clean delivery practices and reducing maternal and neonatal health risks, it is important to highlight that the benefits of birth kits may not be universal. Future interventions developed for settings where utilization of formal health care is particularly low should take into account the potential risk that birth kits distribution may in fact reinforce a preexisting preference to avoid utilizing care and contribute to poor health outcomes. Further evidence is needed to understand whether birth kit distribution dis-incentivizes facility delivery in different contexts.Our findings suggest that an intervention in rural northern Nigeria designed to distribute safe birth kits widely to all pregnant women in targeted communities resulted in relatively low rates of penetration, and even lower rates of birth kit use. In this setting, the use of birth kits was not associated with reductions in maternal or neonatal morbidity, but rather seems to be associated with an increase in adverse health outcomes. Further research should explore the potential risks of birth kit distribution in reinforcing low utilization rates of formal health care, particularly in contexts where resistance to formal health services is relatively high.


One hundred fifty-three extreme premature infants  born below 28 weeks’ gestation were prospectively recruited. All infants had auxological measurements undertaken and prospective data on pregnancy, maternal factors, perinatal and postnatal data obtained. SGA infants at birth had significantly higher Clinical Risk Index for Babies scores and mortality, lower birth weight, smaller head circumference, smaller mid arm circumference and shorter leg length at time of birth compared with AGA infants. However, at term equivalence, weight and leg length of were not significant between AGA and SGA infants born at extreme prematurity. Our study shows that extreme premature SGA infants have appropriate catch-up growth by the time they reach term equivalence suggesting that postnatal nutrition and care are important determinants of catch-up growth in SGA infants.Recent studies have shown that small for gestational age (SGA) term infants undergo catch-up growth during infancy but there is limited studies on early growth outcomes of extreme premature SGA infants. The aim of this study was to compare factors associated during birth in extremely premature infants less than 28 weeks’ gestation who were born SGA (<10 What is already known on this topic?Small for gestational age (SGA) infants are at risk of impaired postnatal growth. Majority of SGA infants born at term will have catch-up growth by 2 years of age but there are limited studies on extreme premature SGA infants.What this study adds?Extremely premature small for gestational age infants born less than 28 week’s gestation have appropriate catch-up growth by the time they reach term equivalence suggesting that postnatal nutrition and care are important determinants of catch-up growth in these infants.th percentile for their gestational age. Infants born SGA are at increased risk of perinatal morbidity, persistent short stature and metabolic alterations in later life  is a term most commonly used to indicate infants born with a weight below the 10ter life  and thister life . While tter life ,5. SGA iter life ,7 and apdulthood ,9. Intradulthood ,10,11.th percentile for gestational age) with those who were born appropriate-for-gestational age (AGA) (10th-89th percentile) and to determine whether there was catch-up growth at term equivalence, defined in our study at 36 weeks corrected gestational age (CGA).Accordingly, the aim of this study was compare factors associated during birth in extremely premature infants who were born SGA  born less than 28 weeks’ gestation were prospectively recruited from the TIPIT study and the infants were randomised according to trial protocol ,13. The The mini knemometer was used to measure the length of the lower leg of the infants and to determine short term growth in SGA and AGA premature babies. This device has been validated as an accurate device for the detection of small growth spurts that in neonates occur within days . The minThe MAC for each infant was measured using a normal nonstretch measuring tape and measurements were rounded to the nearest 0.1 cm. The measuring point called the mid-point of the upper arm was located in the mid upper arm half way between the tip of the shoulder blade and tip of the elbow. All infants were undressed during these measurements.The occipitofrontal circumference for each infant was measured using a normal non-stretch measuring tape and measurements were rounded to the nearest 0.1 cm.Distributions of continuous outcomes were checked. P values were calculated using a t-test or Mann-Whitney U test as appropriate. Comparisons of SGA and AGA infants were made using univariate analyses. Statistical Package for the Social Sciences 21.0 was used in the data analysis. The study was approved by North West Research Ethics Committee (reference number 07/MRE08/37).The study was approved by North West Research Ethics Committee (reference number: 07/MRE08/37) and by the Medicines for Human Regulatory Agency. The parents of each potentially eligible baby were informed of the study’s objectives and overall requirements after birth when the baby had achieved respiratory and haemodynamic stability. The Investigator explained the study fully to the patient’s parent(s)/guardian(s) using the patient information leaflet. The parent/guardian was then given at least 12 hours to consider the study. If a parent/guardian was willing for the patient to participate in the study written informed consent was obtained.One hundred fifty-three infants were recruited to the study. The median gestational age at birth was 26.2±1.0 and mean birth weight was 893.8±178.1 grams. This study found that SGA infants at birth had significantly higher Clinical Risk Index for Babies scores and mortality, lower birth weight, smaller head circumference, smaller MAC and shorter leg length at time of birth compared with AGA infants. However, at term equivalence 36 weeks’ gestation, weight and leg length of SGA and AGA infants were not significant .SGA is a sign of growth failure due to maternal factors such as poor nutrition, chronic disease and infections ,15, as wGeneral postnatal growth pattern can be divided into three phases: infancy, childhood, and puberty and failure of growth in any of these phases can reduce growth potential and eventually cause adult short stature . StudiesThe thyroid hormones are essential for normal growth and development of the foetus and deficiency of thyroid hormones perinatally can impairs growth of the infant and compromises its adaptation to extrauterine life . Our resIt is generally recognised that children born SGA have a significantly higher risk of short stature in adulthood than children born AGA at normal size, with a possible explanation that the programming of the endocrine axes occurs during critical phases of foetal development affected by intrauterine growth retardation . AccuratLimitations of this study is the small sample size of this cohort of extremely premature infants born less than 28 weeks’ gestation and the lack of data on maternal size or maternal glycaemic indices which could be potential confounding factors. Due to their extremes of viability, we were unable to obtain blood sampling for growth hormone factors and body size measurement of these infants were not feasible. The authors believe that the mini knemometer is a practical and novel method used to measure the length of the lower leg of the infants and to determine short term growth these extremely premature babies. The authors also acknowledge that many of extremely premature infants is unlikely to have appropriate catch-up growth by the time they reach term equivalence and factors associated with growth will require further research in a larger population group, which would be best performed as a multi-centered study.The mechanism of catch-up growth in premature SGA infants remains unclear . Our stu