The primary outcome was parent-reported speech problems in early childhood adjusted for clinical and demographic confounders in SGA and LGA infants compared with AGA infants. Secondary outcomes measured were parent-reported early childhood learning, behavioural, hearing, movement and hand problems.Median age at the time of study was 5 years, range 2–10 years. Although the adjusted OR was 1.19 (0.92 to 1.55) for SGA infants and OR 1.11 (0.88 to 1.41) for LGA infants, this failed to reach statistical significance that these subgroups were more likely to have parent-reported speech problems in early childhood compared with AGA infants. This study also found parent-reported evidence suggestive of potential learning difficulties in early childhood (OR 1.51 (1.13 to 2.02)) and behavioural problems (OR 1.35 (1.01 to 1.79)) in SGA infants.This study of 7004 infants in Wales suggests that infants born SGA or LGA likely do not have higher risks of parent-reported speech problems in early childhood compared with infants born AGA. To further ascertain this finding, studies with wider population coverage and longer-term follow-up would be needed. This study has a relatively large sample size, although this represents around 26% of all eligible invitees to Respiratory and Neurological Outcomes of Children Born Preterm Study (n=26 722).Major domains of early childhood developmental outcomes were explored.Potentially using parent-reported questionnaires may introduce some degree of recall bias.Like most cohort studies, missing data in those enrolled, particularly in confounders, were present.Data were collected between 2003 and 2011.Birth weight is a complex product of intrinsic and extrinsic influences on the feto-maternal interaction and is an important predictor of perinatal morbidity and mortality.Outcomes for certain subgroups such as prematurity and small for gestational age (SGA) have been well explored but remains unclear for large for gestational age (LGA) infants particularly mid-term to long-term outcomes. LGA is associated with birth complications and indirect effects persisting into adulthood.9et al found an increased risk of autism in term infants born SGA between 23 and 31 weeks, whereas being born large may have conferred some protective effect.11Overall, data on the mid-term to long-term effects of being LGA across all gestational ages are lacking, and little is known about neurodevelopmental outcomes. A retrospective cohort study by Moore To assess if preterm and term SGA or LGA infants have more parent-reported speech problems in early childhood compared with infants with birth weights appropriate for gestational age (AGA).To assess if preterm and term SGA and LGA infants have more parent-reported learning, behavioural, hearing, movement and hand problems in early childhood compared with AGA infants.This study was conducted using data collected from the Respiratory and Neurological Outcomes of Children Born Preterm study (RANOPS), a cross-sectional population study conducted in Wales in 2013. This study recruited equal numbers of preterm (n=13 361) and term-born children (n=13 361) in years 2003, 2005, 2007, 2009 and 2011 to complete questionnaires on respiratory and neurodevelopmental outcomes if their child has ever had any active or resolved problems .10.1136/bmjopen-2022-065587.supp1Supplementary data10.1136/bmjopen-2022-065587.supp2Supplementary dataTerm infants were selected to be comparable with the preterm infants, for date of birth, sex and locality. A total of 7129 responses were received including consent for data usage and access to health databases. Characteristics between those who enrolled and those that did not are shown in 10.1136/bmjopen-2022-065587.supp3Supplementary dataParent-reported answers on neurodevelopmental outcomes were collected in 2013 for all ages. For example, ‘Does your child have any problems with their speech?’; followed by a yes, or no, option. In the event neither option was selected, the response was recorded as unsure. Baseline demographics, including birth and maternal characteristics, were collected from national health databases.11–13The primary neurodevelopmental outcome was parent-reported early childhood speech problems.The eligible population were all children enrolled in RANOPS, born from 23 weeks of gestation to mothers from 18 to 50 years of age with available speech outcomes (n=7004). Exposure measures were gestational age at birth and birthweight centile by category. Birthweight centiles were calculated for each sex and gestation (in weeks) using the LMS Growth programme .Covariates included neonatal and maternal influences known a priori to influence birth weight in-utero. Neonatal factors are singleton or multiple births, gestational age at birth and sex. Maternal factors accounted for, included smoking during pregnancy, the Welsh Index of Multiple Deprivation (WIMD) score  and their age.Evidence suggests that active smoking is associated with increased risk of low birth weight and preterm birth, and prevalence of smoking is associated with socioeconomic status.26 28–312 test and maternal age at delivery using the analysis of variance test.Duplicates and infants with missing exposure or primary outcome data were removed. Initially, neonatal and maternal characteristics at birth for all infants were compared across their birthweight centile category. Comparisons were performed using the Kruskal-Wallis equality of populations ranks test for birthweight centile category, gestational age and WIMD score at birth. Sex, number of births, mode of delivery and maternal smoking during pregnancy were compared using the χNext, the proportion of children with speech problems between birthweight centile categories was compared. Using a logistic regression model, the unadjusted and adjusted for potential confounders, ORs for speech problems, comparing SGA and LGA infants to those born AGA were derived. Stratifying by preterm and term infants and using a logistic regression model, the ORs for speech problems were also derived for SGA and LGA infants compared with AGA infants. In view of a single primary outcome, p values corresponding to each statistical test were not corrected.Six sensitivity analyses were performed. First, we repeated the logistic regression using a random-effects model to cluster by week of gestational age, and second by the age of the child at time of the survey. We then repeated using the 5th and 95th centile cut-offs, and then again removing all responders where ‘unsure’ was coded for the primary outcome.10.1136/bmjopen-2022-065587.supp4Supplementary dataPatients or the public were not involved in the design, conduct, reporting, or dissemination plans of this research.Four thousand two hundred and eighty-four preterm and 2865 term infants were enrolled in RANOPS (n=7149).Stratifying by birthweight centile categories of SGA, AGA and LGA infants, baseline neonatal and maternal characteristics of the study cohort are shown in Distribution of early childhood speech problems in preterm and term infants by birthweight centile is as shown in Logistic regression adjusted for neonatal and maternal features of the primary outcome (parent-reported speech problems in early childhood) showed that SGA and LGA infants were not more likely than their AGA counterparts to have problems, OR 1.19 (0.92 to 1.55) and OR 1.11 (0.88 to 1.41), respectively. Analysis of parent-reported secondary outcomes found evidence that SGA infants have an increased risk of learning difficulties in early childhood compared with those born AGA, OR 1.51 (1.13 to 2.02). There was also some evidence that SGA infants were more likely to have early childhood behavioural problems, OR 1.35 (1.01 to 1.79). This study did not find that infants born SGA or LGA were more likely to have hearing, movement or hand problems in comparison to AGA infants .interaction=0.999)  .Multilevel regression model of SGA and LGA babies compared with those born AGA across each gestational age category (using child age as the clustering variable) also showed compatible results ; LGA, OR 1.11 (0.87 to 1.41)) with the main analysis. When ‘unsure’ responses excluded from analysis, logistic regression repeated showed no increased likelihood in primary neurodevelopmental outcome, parent-reported early childhood speech problems in babies born SGA, OR 1.20 (0.92 to 1.56) or LGA, OR 1.13 (0.90 to 1.44) compared with those born AGA. Repeat of the analysis using the 5th and 95th centiles as cut-offs for SGA showed that babies born SGA were not more likely than babies born AGA to have parent-reported early childhood speech problems, OR 1.35 (0.98 to 1.86).The literature supports that parents’ perceptions on their child’s development have shown significant consistency with standardised developmental objective measures in preterm-born and term-born infants, and are increasingly used in developmental screening for at risk infants.The production of speech is complex, relying on not only intact cognitive, motor and sensory functions but also complicated by hearing loss, particularly the child’s age at time of hearing loss.Evidence from this study suggest that SGA infants may have higher risks of parent-reported learning difficulties and behavioural problems in early childhood but not hearing, movement or hand problems. A single-centre cohort study of term infants in Australia born to women presenting antenatally between 1981 and 1984 showed that children born SGA had significantly more learning difficulties when followed up at 14 years of age using a parent-reported survey and academic achievement test. This study reported a comparable 19.8% and 20.5% incidence for those who completed psychometric testing and behavioural questionnaires, respectively. This study also demonstrated long-term attention difficulties in extremely SGA (3rd centile and below) term-born female adolescents.6 48We also saw that the proportion of all parent-reported early childhood disorders showed a strong relationship with gestational age at birth seen in . This apAnalysis of baseline characteristics noted a significant difference in maternal age, and demographics at birth between birthweight centile categories. While this study was not designed to explore the relationship between maternal age and birthweight centile categories, previous studies have reported significant findings of higher maternal age in LGA infants.26 52 53There was also a significant difference in the mode of delivery across birthweight centile categories likely due to clinical practice managing high-risk pregnancies.23Findings from this work, on a subset of 7004 infants in Wales suggest that infants born SGA or LGA may not have higher risks of speech problems in early childhood when compared with AGA infants. While enrolment was achieved on only a subset of less deprived infants, important differences may still exist, and we found that some infants being born SGA may have increased parent-reported learning difficulties and behavioural problems compared with AGA infants. Further longer-term studies on infants born SGA and LGA would be of value to better understand the association of birth weight on neurodevelopment.


Measuring the maximum occipitofrontal circumference only once at birth or within 24 h after birth may lead to misclassifications of microcephaly. This study compared the head circumference (HC) of newborns at birth or within 24 h after birth to their third day of life (DOL3) as well as evaluated maternal- and infant-specific factors associated with increased HC by DOL3.This prospective study included 1131 live births between February and May 2019 with a gestational age > 27 weeks. All newborns had their HC measured at birth or within 24 h after birth as well as on DOL3 before discharge. HC measurements were performed by trained personnel using non-elastic tape measures. The World Health Organization (WHO) and Fenton Growth Charts were used as reference ranges for interpretation of full-term and preterm neonates, respectively.P < 0.001). The mean ± standard deviation HC within 24 h of birth and at DOL3 were 33.58 ± 1.53 cm and 33.75 ± 1.37 cm, respectively. Thirty-two newborns had HCs less than the third percentile (< P3) at birth, 25 of which had HC ≥ P3 at DOL3. After adjusting for mode of and presentation at delivery, newborns whose mothers experienced labor pains  and were either symmetrically  or asymmetrically small-for-gestational age  had significantly increased HC at DOL3. On average, newborns whose mothers experienced labor pain had 0.31 cm increases in HC at DOL3. Symmetrical SGA newborns also had an average 0.59 cm increase in HC at DOL3. Parity and gestational age were not associated with changes in HC.Paired sample t-test analyses found a statistically significant increase in HC measured on the DOL3 compared with HCs of the same newborns at birth or within 24 h of birth. The mean HC increase was 0.17 cm (95% confidence interval , Serial HC measurements on DOL3 or before newborns’ discharge is crucial to classifying congenital microcephaly. Microcephaly in neonates is defined by a maximum occipitofrontal circumference greater than 2 standard deviations (SDs) below the mean (less than the third percentile [< P3]). While performing head circumference (HC) measurements are simple, the results can be mismeasured. Despite standardization efforts, HC measurements are not always accurate due to technical errors – even after training .The delivery process itself can also introduce anthropometric changes to newborns’ head size at birth. Skull molding during vaginal delivery may reduce head size while caput succedaneum, cephalhematomas, and subdural hematomas may increase it , 3. ThesThis study assessed the difference in HC measured at birth or within 24 h of birth to the third day of life (DOL3) for the same newborns. It also assessed maternal- and infant-specific factors that may impact differences in HC. The researchers hypothesized that repeated HC measurements on DOL3 would differ from HC measured at birth, highlighting the importance of serial measurements to accurately classify microcephaly.This prospective study was conducted at Siriraj Hospital – the largest public quaternary care medical center in Bangkok, Thailand with a capacity of more than 2000 beds and 7000 deliveries annually. Live births at a gestational age > 27 weeks between February and May 2019 were included in the study. Infants referred to other hospitals earlier than DOL3 and neonatal deaths within 24 h after birth were excluded. This study was approved by the Research Ethics Board at Siriraj Hospital (Si 650/2018) and performed per the International Council on Harmonization’s Good Clinical Practice, Belmont Report, and Declaration of Helsinki. All newborns were enrolled after parents provided written informed consent.All newborns had their HC measured soon after delivery by nursing staff at one of the following delivery units: common or private labor rooms, septic labor room, or caesarean section (C-section) room. Twenty nurses from these units participated in in-person training sessions held by one of the authors (C.S.). Intraclass correlation coefficients (ICC) for inter- and intra-observer reliabilities were examined in 15 out of 21 participants. The results confirmed highly reliable measurements .Maximum occipitofrontal circumference was measured thrice (with the largest number of the three measures being recorded) using non-elastic tape measures at birth or within 24 h of birth as well as on DOL3 before newborns were discharged.All data were recorded while mothers and infants were admitted at Siriraj. Assessed maternal variables included: age; parity; past medical history; prenatal and birth history ; cigarette, alcohol, and drug use; as well as laboratory results. Assessed infant variables included: gestational age; birth weight and length; HC; as well as the date and time HC measurements were performed. Gestational age was calculated based on the mother’s last menstrual period (LMP). For mothers who were uncertain about their LMP, gestational age was estimated using an ultrasound report (if available) or Ballard score. Percentiles for each HC were performed using the WHO and Fenton Growth Charts as references for interpreting data of full-term and preterm neonates, respectively.® .Descriptive statistical methods (Pearson’s Chi-square or Fisher’s exact test) were used to analyze categorical data. Paired sample t-tests were used to compare HCs at birth or within 24 h of birth and by DOL3. Factors associated with changes to HC  were analyzed using an analysis of variance. Multiple linear regression was performed to analyze the relationship of these factors towards predicting changes in HC at DOL3. All analyses were performed using a Statistic Package for Social Science in SPSSOf 1131 enrolled newborns, 550 (48.6%) were female, and 995 (88.0%) were at term (37–42 weeks gestation). Thirty-two (2.8%) newborns had HCs < P3 at birth while 1099 (97.2%) had HCs ≥ P3 . The mean ± standard deviation (SD) HC within 24 h of life and at DOL3 were 33.58 ± 1.53 cm and 33.75 ± 1.37 cm, respectively. Upon assessing the impact of this difference between the two measurements, only seven of 32 newborns with HCs < P3 at birth remained so by the time of discharge. After following up on these seven infants, the researchers found that: three had delayed cognitive development and continued to display microcephaly at 18 months of age; one was normocephalic, but had delayed speech; another was normocephalic and had normal cognitive development; and two were lost to follow-up. Three newborns had been normocephalic at birth but were identified as microcephalic at DOL3 . Of these three newborns, one was diagnosed with congenital cytomegalovirus (CMV) infection while the other two had normal HC and development at subsequent follow-ups. No congenital Zika infections were identified within this study’s cohort.A statistically significant increase in HC measured at DOL3 was observed compared with measurements of the same newborns at birth or within 24 h of birth. This mean HC increase was 0.17 cm  and who were either symmetrically  or asymmetrically  SGA had significantly increased HC at DOL3  were factors significantly associated with increased HC at DOL3 Table . After aParity and gestational age were not associated with HC changes Table . The resThis study compared HC measured at birth or within 24 h of birth to DOL3 as well as assessed mother- and infant-specific factors that affected HC differences between these two time points. The researchers found that the mean HC on DOL3 was significantly greater than HC at birth or within 24 h of birth. In this study’s cohort of 1131 newborns, 32 had microcephaly at birth or within 24 h of birth, but only seven (22.0%) were classified as microcephalic by DOL3. This supports the use of serial HC measurements to accurately classify congenital microcephaly.Minimal changes in HC can lead to misclassifying infants as microcephalic instead of normocephalic. While a difference of 0.17 cm in HC may not appear like much, the clinical impact associated with the ability to classify whether a newborn is microcephalic is far greater for neonates and their families. The mean increase of HCs between DOL3 and at birth was lower than the mean increase of 0.39 cm reported in a previous study , which cInterestingly, while SGA was an associated factor with increased HC by the time of newborns’ discharge, being SGA also was associated with persistent microcephaly at discharge among those with microcephaly at birth. The researchers postulated that these results were related to underlying causes of SGA in newborns. The etiologies of SGA are multifactorial and affected by maternal factors  as well as fetal factors or genetic disorders. Some factors may cause different in-utero fetal environments and postnatal growth catch-up abilities while others influence underlying genetics and cause persistent microcephaly. Compared with appropriate-for-gestational age (AGA) and large-for-gestational age (LGA) newborns, SGA newborns were found to have different body composition  as well as different anthropometric changes . The researchers hypothesized that postnatal HC in SGA may follow the same catch-up pattern. However, newborns’ body weight on DOL3 was not collected. Thus, the researchers were unable to describe and compare these postnatal changes , 8. In aAnother factor associated with increased HC at discharge was labor pain. This change resulted from a natural adaptation of skull molding for smooth vaginal delivery. A photographic study demonstrated that newborns of primiparous mothers had significantly higher degrees of molding than those born by multiparous mothers . This stth percentiles by DOL3. All were classified as normocephalic at discharge. These findings may be from the unmolding process after birth or measurement errors. The researchers attempted to minimize such errors through standardized training. As noted previously, regardless of the simplicity of HC measurements as well as training and standardization efforts, technical errors may still occur. In a rigorously standardized INTERGROWTH study, HC measurement errors ranged from 0.3–0.4 cm [The HC at birth was lower than the cut-off for gestational age among the 25 infants classified as microcephalic, but later normocephalic by DOL3 – with a mean increased HC of 0.55 (range: 0.1–1.2) cm. Upon remeasurement, four newborns had HCs in the third to tenth percentiles and 21 had HCs in the tenth to 503–0.4 cm . Another3–0.4 cm . This agThis study had some limitations. First, the researchers were unable to classify microcephaly based on prenatal fetal ultrasound reports. The Royal Thai College of Obstetricians and Gynecologists recommends that all pregnant Thai women have at least one fetal ultrasound performed during their second trimester (18–22 weeks of gestation) . Most ofIt is general practice to have only a single HC measurement at birth or within 24 h after birth. This study demonstrated that 78.1% of newborns initially classified as microcephalic at birth were later normocephalic by DOL3 and 30% of newborns microcephalic on DOL3 were initially normocephalic at birth or within 24 h after birth. These newborns could have been misclassified as microcephalic or normocephalic had the decision been based solely on HC measurements at birth. This would have hindered subsequent evaluations and therapies.Serial HC measurements at birth and DOL3 or discharge are crucial to ensure accurate assessments of changes in anthropometry of newborns and avoid unnecessary investigations, misclassifications, and parental distress. This further highlights the importance of postnatal serial HC measurements in low- and middle-income countries, where prenatal diagnosis of microcephaly is not always feasible during real-life practice.


A urachal cyst has a rare incidence that has been reported as 1/5,000 live birth.We report two patients with a complicated urachal cyst, a 5-year-old female who presented to the emergency department with severe abdominal pain and a 3-year-old female presenting with abdominal pain and constipation. Upon laparoscopic exploration both patients had complicated urachal cysts which were adherent to the urinary bladder.Complicated urachal cysts can present with acute abdominal pain. A urachal cyst has a rare incidence that has been reported as 1/5,000 live births . SymptomA 5-year-old girl presented to the emergency department with severe persistent abdominal pain. Her physical examination revealed pain and tenderness below the umbilicus.Her abdominal ultrasound showed a picture of a well-defined thick-walled intraperitoneal cystic lesion in the supra-pubic region. The cyst measured 41 × 38 × 29 mm in its maximum diameters, contained dependent debris level, and was surrounded by multiple mildly thickened bowel loops suggestive of complicated duplication, mesenteric cyst, or even infected torsion of ovarian cyst. Computed tomography (CT) scan of the abdomen and pelvis with IV and oral contrast was performed and revealed a thick-walled cyst in the lower abdomen as seen in Fig. Laparoscopic exploration revealed a normal appendix and ovaries. Extraperitoneal swelling and inflamed omentum adherent to the small bowel and pyogenic membranes led to conversion to open exploration. No mesenteric cyst or duplication were noted.Pathology was an infected thick-walled cyst filled with pus , adherent to the anterior abdominal wall and connected to obliterated urachus as well as being firmly adherent to bladder fundus as seen in Fig. We performed a complete excision of the cyst as well as the involved bladder. Afterwards, we repaired the urinary bladder using 3/0 Vicryl in two layers. Then, a 12 French urinary catheter was placed. The excised urachal cyst is shown in Fig. The second patient was a 3.5-year-old pediatric female patient who presented to the emergency department with severe abdominal pain, abdominal distention, as well as constipation, and vomiting. A general examination was performed revealing a generally ill appearance with body temperature of 38℃. Her abdomen was moderately distended, lax and tender upon palpation around the umbilicus in addition to a mass that was felt infra-umbilical.Following admission, the patient was resuscitated placing a catheter and administering intravenous bolus fluids 20 ml/ kg until urine output established 1.5 ml/kg urine output followed by administration of maintenance fluids at the same time IV antibiotics ceprofloxacin, gentamicin and metronidazol. Lab findings were relevant for a total leukocytic count TLC of 11.6. Abdominal postro-anterior view erect x-ray showed moderate dilated bowel loops with an air-fluid level with no specific findings. An abdominal pelvic ultrasound was carried out showing a cyst filled with turbid fluid related to the urinary bladder and no abnormalities of urinary tract. This was followed by a CT scan of the abdomen and pelvis with oral and IV contrast which showed patent dilated urachus extending down to the superior aspect of the urinary bladder with inflammatory process measuring 3.8 × 2.9 × 2.7 cm as well as ileo-ileal intussusception.Upon exploration, there was no evidence of intussuception as stated in CT and an infected urachal cyst was found between the umbilicus and the urinary bladder, but it was not connected to the bladder. Evacuation and excision of the cyst were done and it was separated from the bladder. Urinary bladder mucosa was intact Repair of sero-musculosa of the urinary was performed in two layers of 3/0 Vicryl with insertion of a 12 French urinary catheter. The patients were discharged with a scheduled follow-up in the outpatient clinic. The patient was admitted for 6 days post-operatively till clinical improvement.The specimens from both patients were sent to pathology and shown no evidence of malignancy and confirmed inflammatory nature of the specimens.There are five subtypes of congenital urachal anomalies: patent urachus, umbilical-urachal sinus, vesicourachal diverticulum, urachal cyst, and alternating sinus . A urachPrevious literature showed that when a cyst develops on this remnant, it seldom causes any symptoms unless it is accompanied by a secondary infection. The majority of patent urachal findings are incidental when patients present with other problems as they are frequently asymptomatic. Urachal anomalies were reported to be most common in infants between the ages of 1 day to 2 years of age and the incidence rate in males was found to be twice that of females . And wheThe presentation of these anomalies varies drastically in the clinical setting. Urachal cysts may present as an abdominal mass and develop into an abscess if infection occurs. Symptoms then may range from generalized abdominal pain, fever, to periumbilical pain, redness, or drainage . Rather,In order to diagnose the urachal cysts in our patients, abdominal ultrasound and CT scan were needed. Once a thick-walled cyst was noted on CT, a laparoscopic exploration was performed, which is noted in the literature to be the preferred method of exploration as it is a minimally invasive, safe, and effective method, with a better cosmetic outcome and ideal for pelvic exploration –14. HoweThese cases show the presence of urachal anomalies, which could be patent, cyst, or sinus, and is often not associated with signs or symptoms needing intervention. In the case of complications, such as infection of the urachal cyst, surgical intervention is indicated. Previous studies found that only those presenting with complicated urachal cysts, larger-sized cysts, or cysts with no signs of regression should undergo surgical excision through laparoscopic means –14. Howe


Short birth interval remains a major reproductive health problem, especially in the developing world. It is associated with maternal, neonatal, infant and under-five morbidity and mortality. This study identifies the risk factors of short birth interval among women in Cameroon. Women in early postpartum (with at least one previous live birth) from four health facilities in the Nkongsamba Health District were consecutively included in the study from September 2021 to December 2021. All data were collected by interview, using a semi-structured questionnaire, and analysed in Epi-Info version 7.2.3.1. With a statistically significant threshold of 5%, the adjusted odds ratio was used in multiple logistic regression to measure the association between short birth interval and potential factors. This study included a total of 679 participants with an age range of 18 to 47 years. Short birth interval was recorded in 46.10 [95%CI: 42.38–49.86]% of these women. A little more than half (56.72%) had at most 4 pregnancies already, while only 06.35% had at least 8 pregnancies in their reproductive life. Maternal age ≤ years (AOR = 2.66[1.80–3.93]), less than or equal to 10 months of breastfeeding of the previous child (OR = 2.48[1.80–3.41]), use of modern contraception before conception (AOR = 0.62 [0.43–0.89]), and the number of household occupants below 5 (AOR = 0.60[0.40–0.92]) were significantly associated with short birth interval. Short birth interval remains a significant call for concern in Cameroonian women. The likelihood of short birth interval is affected by maternal age, duration of breastfeeding, use of modern contraception and number of household occupants. Interventions to promote effective breastfeeding and postpartum family planning uptake are indispensable in the fight against short birth interval in Cameroon. Adequately spacing births offers a chance for the woman to recover from the effects of the previous pregnancy. Short and long birth intervals have been described to be associated with a significantly higher risk for adverse maternal, perinatal and child outcomes. According to current World Health Organisation recommendations, the gap between the previous live birth and the subsequent delivery should be at least 33 months . This imShort birth interval constitutes a major health problem, especially in low- and middle-income countries. According to the results of the 2018 Cameroon demographic and health survey, 50% of deliveries took place 31.2 months after the previous delivery. Up to 24% of deliveries occurred 24 months after the last pregnancy .According to an analysis from an Ethiopian study, neonatal mortality is about 85% higher among women with short birth intervals compared to women without short birth intervals. The odds of infant mortality and under-five child mortality were doubled in women with short birth intervals compared to their counterparts without short birth intervals –12. It hMultiple studies have been conducted in Africa to identify factors associated with short birth interval among women. These factors include duration of breastfeeding, socioeconomic level, level of education of the woman, use of contraception, parity, gender of the preceding child, religion (being a Muslim), age of the woman, age of the woman at her first delivery, number of living children, employment status of woman and husband, place of residence , and the level of education of the husband –5,14–22.With the low level of modern contraceptive use and the high level of unmet need for family planning in Cameroon –26, the We conducted a hospital-based cross-sectional study targeting women with at least one previous live birth who delivered in four health facilities of the Nkongsamba Health District. All data were collected through interview using a semi-structured questionnaire and analysed using the statistical software Epi-info version 7.2.3.1 .Our study was conducted in Nkongsamba city, the capital city and major city of the Moungo Division, in the Littoral Region of Cameroon. Nkongsamba is located some 149.5 km from the economic capital of Cameroon, on the national highway number 5. It is characterised by a cosmopolitan population dominated by the Mbo’os. The Nkongsamba Health District constitutes one of the largest health districts of the Moungo Division. Based on patient turnover, four major health facilities including the Nkongsamba Regional Hospital, the Catholic Medicalised Health Centre, The Bon Samaritain Medicalised Heath Centre and the Fultang polyclinic. These health facilities receive and deliver 70–90% (depending on the year) of the pregnant women in the health district. Our study was conducted between September 2020 and December 2021.Our study population was made up of women of childbearing age from the Nkongsamba Health District who have a history of at least one previous live birth. We included all women with at least one previous live delivery who had just delivered in the maternities of the four health facilities chosen for this study.This study’s minimum required sample size was estimated using the single proportion sample size formula. The expected prevalence of short birth interval was 56%, with the absolute precision on either side of the proportion set at 0.038 and an acceptable two-sided alpha error of 5%. This was used to estimate a minimum required sample size for this study of 656 participants. Participants were consecutively included as they delivered in the maternities of the four health facilities included until the required sample size was reached.Administrative authorisations were obtained from the District Medical Officer of the Nkongsamba Health District and the Directors of the four health facilities included. When the protocol and data collection tools were ready, a pre-test of the questionnaire was conducted among 15 women of the Kekem District Hospital (West Region of Cameroon). After confirming the capacity of the questionnaire to meet research objectives while remaining participant friendly, we deposited the file to solicit an ethical clearance of the study. Data collectors who were holders of a degree in midwifery working in the respective maternities were trained in a working session which lasted for 5 hours. Key issues addressed were the steps to obtaining participant consent and how to collect the data required for the study.Data was collected using a semi-structured interviewer-administered questionnaire. This questionnaire collected data on the sociodemographic, economic, and obstetric characteristics of the participants. After presenting the study information, verbal consent from the participants was obtained. This was followed by a one-to-one interview of each participant during which the data was collected. Only willing and consenting participants were included in the study. The questionnaire evaluated the duration between the actual birth and the last live birth. It also collected data on sociodemographic characteristics  and obstetric characteristics like the total number of pregnancies, abortion history, and stillbirth history.Short birth interval: This study adopted the World Health Organisation’s definition of short birth interval, which considers at least 33 months between the previous live birth and the next delivery.Use of modern contraception before conception: This included any woman who declared to have used a modern method of contraception between her last live birth and pregnancy.Data from questionnaires was keyed into a predesigned data entry sheet developed on Epi-Info version 7.2.3.1 and analysed. Selected quantitative variables were transformed into categorical variables. The prevalence of short birth interval was calculated as a proportion with its 95% confidence interval, while other characteristics of the population were presented as proportions. For normally distributed continuous variables, the mean age with its standard deviation was estimated. Potential risk factors of short birth interval reported in similar studies in other settings were selected and tested for their association with a short birth interval in our context. The strength of the association between short birth interval and the selected potential risk factors was measured using the odds ratio in simple logistic regression. All potential factors with p-values ≤0.25 were jointly included in a multiple logistic regression model, with one controlled for the effect of the others. The statistically significant threshold was set at 5%.This study was approved by the Cameroon Bioethics Initiative/Ethics Review and Consultancy Committee. For potential participants who could read and understand English, a copy of the information sheet was provided to them, and for those who could not read, the information sheet was read and explained to them. The information sheet contained the objective of the study, process of data collection, data confidentiality and expressly invited them to participate in the study while ensuring them of their liberty to accept or refuse participation and that their decision would not have any consequence on the healthcare they seek no or in the future. All participants were given enough time to ask questions and all their questions answered by the team. For this study, participants consent was verbal either given by them in case of an adult or by their parents or guidance in case of minors. This consenting process and the verbal consenting were approved by the ethics review board in the approved study protocol. Only participants who consented were included in this study.This study included a total of 679 participants with an age range of 18 to 47 years. The mean age of the participants was 30.32±5.68 years. A little more than half (56.72%) had at most 4 pregnancies already, and only 06.35% had at least 8 pregnancies in their reproductive life. History of at least one miscarriage was reported in 27.26% of the participants.Short birth interval was recorded in 46.10 [95%CI: 42.38–49.86]% of these women. Following multiple logistic regression in which seven variables with p-value ≤ 0.25 were controlled, the four abovementioned variables persisted with a statistically significant association with short birth interval. Women aged ≤ 30 years had a 2.66-fold higher odd for short birth interval compared to their older counterparts . Also, women who breastfed their previous babies for ≤ 10 months had 2.18-fold higher odds for short birth interval compared to their counterparts who breastfed for a longer period.On the other hand, women from households with less than 5 occupants had 0.60-fold lower odds for short birth interval compared to those from households with a higher number of occupants . Also, women who reported modern contraceptive use before pregnancy had 0.62-fold lower odds for short birth interval compared to women who did not .This study aimed to identify factors associated with short birth interval among women in the Nkongsamba Health District, Cameroon.In this study, short birth interval was recorded in 46.10 95%CI: 42.38–49.86]%. This implies that 4 to 5 women in a group of 10 in this population were at risk of having a short birth interval. The findings concord with the results of the 2018 demographic and health survey in Cameroon, which reported 50% of deliveries to have taken place 31.2 months after the previous delivery .38–49.86. In UganOn the other hand, some studies have found this prevalence to be significantly lower than our findings. Still, in Ethiopia (Northern Ethiopia), a prevalence of short birth interval as low as 23.3% has been recorded . In NigeIn this study, younger age (≤ 30 years) was significantly associated with higher odds of short birth interval. Similar findings have been reported in Uganda, where younger maternal age was found to be associated with higher odds of short birth interval . A similShort duration of breastfeeding in the previous live birth was found to be associated with a short birth interval. This has been a consistent finding in multiple studies carried out in different settings ,22,28,34The use of modern contraception in the past before pregnancy was associated with lower odds of short birth interval. This association has been recorded in several other studies ,17,38,39Women from households with less than 5 occupants had significantly lower odds of short birth interval compared to their counterparts with a larger number of occupants. In our search, we did not find this studies evaluating this association. Contrary to expectations that short birth intervals characterise households with fewer persons , we found out that households with more than 4 persons had higher odds of short birth intervals. We feel that the number of household occupants might not be a predictor but an outcome associated with short birth interval. More studies need to be carried out on the relationship between the number of household occupants and short birth interval.Contrary to findings reported in other settings, which state that level of education ,34 and sCross-sectional studies fail to create cause-effect relationships and might even identify temporal associations. The factors presented in this study should therefore be interpreted carefully. However, our study was designed following adequate methodology with a control for confounding effects of other variables and presents a picture of the prevalence and risk factors of short birth interval in a sample of women in the Nkongsamba Health District, Cameroon.The proportion of women with a short birth interval in the Nkongsamba Health District, Cameroon, remains unacceptably high. The likelihood of short birth interval among women significantly depends on maternal age, duration of the previous breastfeeding, use of contraception before conception and the number of household occupants. Encouraging postpartum family planning and effective breastfeeding will go a long way to reduce the prevalence of short birth interval and its consequences on maternal, neonatal and child health.S1 Database(MDB)Click here for additional data file.


This review examined the impact of mode of birth on sexual function in the medium- (≥6 months and <12 months postpartum) and longer-term (≥12 months postpartum). (2) Methods: Literature published after January 2000 were identified in PubMed, Embase and CINAHL. Studies that compared at least two modes of birth and used valid sexual function measures were included. Systematic reviews, unpublished articles, protocols and articles not written in English were excluded. Quality was assessed using the Newcastle Ottawa Scale. (3) Results: In the medium-term, assisted vaginal birth and vaginal birth with episiotomy were associated with worse sexual function, compared to caesarean section. In the longer-term, assisted vaginal birth was associated with worse sexual function, compared with spontaneous vaginal birth and caesarean section; and planned caesarean section was associated with worse sexual function in several domains, compared to spontaneous vaginal birth. (4) Conclusions: Sexual function, in the medium- and longer-term, can be affected by mode of birth. Women should be encouraged to seek support should their sexual function be affected after birth. Birth can have profound effects on women’s lives, including on their sexual function in the longer-term. Decreased sexual functioning is an important indicator of maternal morbidity , and detThe American Psychiatric Association defines sexual function as “a person’s ability to respond sexually or to experience sexual pleasure” . Up untiAn important aspect that may impact sexual function is mode of birth, which can be categorised into spontaneous vaginal birth, vaginal birth with an episiotomy, assisted vaginal birth, planned caesarean section or emergency caesarean section. Data from the Euro-Peristat study 2016) indicated that 66.2% of all births in the EU were spontaneous vaginal births, 7.5% were assisted vaginal births, 10.7% were planned caesarean sections, and 12.9% were emergency caesarean sections . More re indicateDespite the significant amount of literature surrounding the impact of mode of birth on postpartum sexual functioning in the short-and longer-term, there is no consensus on the association between mode of birth and sexual functioning. Several cohort studies have shown that women who have a spontaneous vaginal birth (with an intact perineum) are more likely to resume vaginal sex by six to eight weeks postpartum compared to women who have an episiotomy, an assisted vaginal birth or a caesarean section ,19. AnotSystematic reviews on the association between mode of birth and postpartum sexual function have been undertaken in 2004, 2010, 2020 and 2022 ,34,35,36Sexual dysfunction that continues beyond six months postpartum is more likely to have an impact on maternal wellbeing: women with impaired sexual function are more likely to score worse in all quality of life domains; and women at six months postpartum with worse sexual functioning scores are more likely to have worse scores for general health and physical functioning ,4. ThereRelevant studies were identified using PubMed, Embase and CINAHL databases, and searches were limited to studies published between January 2000 and February 2023. Keywords in the search included: mode of birth , episiotomy, postpartum, and sexual function. A detailed search strategy is presented in the Both quantitative and mixed method studies were eligible for inclusion in this review, including cohort studies, cross-sectional studies, case–control studies and randomised controlled trials. Systematic reviews, unpublished results or studies, protocols, studies not written in English or written prior to 2000 were excluded. In order to be included, studies must have compared at least two different modes of birth. To facilitate clinical usability of this review, as well as provide a useful framework for this review and other studies in the future, specific modes of birth were the main focus of the review. Therefore, studies that compared data on spontaneous vaginal birth, vaginal birth with episiotomy, assisted vaginal birth, planned (elective) caesarean section and emergency caesarean section were included. The secondary focus of this review were comparisons that incorporated multiple modes of birth in each category, as some studies combine multiple modes of birth into one group. Therefore, studies that compared non-specific mode of birth groups such as vaginal birth , vaginal birth with breech presentation, and caesarean section (without differentiation between planned and emergency caesarean section) were included. Only episiotomy was considered, rather than other perineal trauma, as it is an intervention performed (or not) by a health care professional during birth, whereas other perineal trauma happens as a result of birth. In order to ensure comparability of the studies, only studies that used a validated sexual function measure were included.All of the measures of sexual function used in the studies included in this review are self-reported measures. The measures contain questions/statements, to which women report on their sexual function, by rating their sexual function using a numeric/Likert scale. A measure was considered to be a valid measure for sexual function if it has undergone psychometric evaluation and its psychometric properties were found to be acceptable.The Female Sexual Function Index (FSFI) consists of 19 items embedded in six domains . The theoretical range is 2.0 to 36.0, with higher total FSFI-scores indicating better sexual functioning . A cut oThe Golombok Rust Inventory of Sexual Satisfaction (GRISS) for women consists of 28 items embedded in seven subscale domains . The raw score is converted into a transformed score ranging between one and nine, which can be used to produce a diagnostic profile. A transformed score greater than or equal to 5 indicates sexual dysfunction ,41,42. TThe Sexual Health Outcomes in Women Questionnaire (SHOW-Q) has 12 items embedded in four subscales . It was designed to be used on a diverse range of women, including women in same sex relationships, women who are sexually active without a partner, and sexually inactive women. All items are scored on a scale from zero to 100. For three of the subscales , higher scores represent better sexual function. For the final subscale (pelvic problem interference), higher scores indicate worse sexual function. After reversal of the pelvic problem interference scores, all items are totalled for an overall score with a theoretical range of zero to 400 . Lower tThe Sexual Activity Questionnaire (SAQ) has 21 items embedded in three scales . Each question has weighted loadings to create factor scores, with high scores in the pleasure domain representing high pleasure, and low scores in the discomfort domain representing low levels of discomfort. The habit domain is a single question and the value given as the answer is the score for this domain, with more habitual regular sexual activity resulting in higher scores. Each question is rated using a four-point Likert scale from 0 to 3, with the total score ranging from 0 to 30 ,46. The The Sexual Function Questionnaire (SFQ28) has 28 items embedded in eight domains , arousal (lubrication), arousal (cognitive), orgasm, pain, enjoyment, partner ). Lower scores indicate increased probability of sexual dysfunction. Overall total score has a theoretical range of 14 to 170. Each domain is scored separately, with different ranges of scores indicating sexual dysfunction. For all domains, lower scores indicate worse sexual functioning ,50. The The Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) is a 12-item questionnaire that measures three domains: behavioural–emotive, physical and partner/related . Each item is graded on a five-point Likert scale from always (zero) to never (zero). The behavioural–emotive items are reversely scored. Higher scores indicate better sexual functioning, with a maximum total score of 48 ,53. The Results from the sexual function measures were categorised into medium- and longer-term: studies that collected data at beyond or equal to six months postpartum and at less than 12 months postpartum were classified as medium-term, whereas those that collected data at beyond or equal to 12 months postpartum were classified as longer-term.Studies that were identified as potentially eligible for inclusion were exported to Rayyan, a systematic review reference management tool. Duplicates were removed. When deciding which studies to include, two researchers  independently screened the titles and abstracts. From there, full texts were evaluated for their eligibility by the two researchers, based on inclusion and exclusion criteria. Any inconsistency between researchers on whether studies should be included or not were discussed further in order to come to an agreement. If agreement could not be reached, a third author (LP) was involved in the discussion. Information on study design, location of study, descriptive characteristics of participants, types of modes of birth, the measure of sexual function, and the results of those studies related to mode of birth and sexual function was then extracted.Quality of the included studies was assessed by two researchers  independently using the Newcastle Ottawa Scale (NOS) . The NOSA scoring system developed by Sharmin et al. (2017) was used to group the included studies by quality score: a study was rated good quality if it scored three or four stars in selection, one or two stars in comparability, and two or three stars in outcomes. A study was rated fair quality if it scored two stars in selection, one or two stars in comparability and two or three stars in outcome. A study was rated poor quality if it scored zero or one star in selection, or zero stars in comparability, or zero or one star in outcomes ,57. TabuData from the included studies was extracted and reported using the Population, Exposure, Comparator and Outcomes (PECO) framework . ExtractIn total, 6509 studies were identified in database searches. After removing the duplicates, screening of the titles and abstracts against the inclusion and exclusion criteria was carried out, as well as checking references and similar articles, 112 studies remained. These studies were further evaluated based on the full texts, of which 31 were included in the review. A detailed overview of the search, screening and selection process is presented in a PRISMA flowchart . A list Of the 31 included studies, 9 were cross-sectional studies , 3 were case–control studies , 5 were retrospective cohort studies  and 14 were prospective cohort studies . The studies were published between 2005 and 2022, originating from 17 countries including Turkey ,62,63,64In the included studies, six different measures were used to assess sexual functioning. The FSFI was used in 25 studies ,87,88,89Of the 31 studies, 18 measured sexual function in the medium-term at ≥six months and <12 months postpartum  ,87,88,89When comparing studies in terms of parity, 16 studies included only primiparous women (3901 primiparous women) ,84,86,89There were 17 different modes of birth comparisons; the most common comparison was between vaginal birth  and caesarean section (without differentiation between planned and emergency caesarean section) . None ofOf the included studies, 21 were of a good quality, nine studies were rated as having a fair quality and one study was rated as being of a poor quality .Three studies showed three statistically significant associations between mode of birth and sexual function in the medium-term  64,77,8,877,80.One study showed a statistically significant adjusted association between mode of birth and sexual function in the medium-term. Planned caesarean section was associated with better total sexual functioning scores and better scores for arousal, lubrication and orgasm when compared to assisted vaginal birth .Two studies showed two statistically significant crude associations between mode of birth and sexual function in the medium-term. Spontaneous vaginal birth was associated with better total sexual functioning scores when compared to assisted vaginal birth . PlannedSix studies that showed no statistically significant associations between mode of birth and sexual function in the medium-term ,83,87,88Six studies showed 25 statistically significant associations between mode of birth and sexual function in the longer-term ,82,86,88Two studies showed two statistically significant adjusted associations between mode of birth and sexual function in the longer-term. Assisted vaginal birth was associated with increased odds of pain at 12 months postpartum, in comparison with spontaneous vaginal birth . PlannedFour studies showed 23 statistically significant crude associations between mode of birth and sexual function in the longer-term. Spontaneous vaginal birth was associated with better scores pain when compared to assisted vaginal birth . VaginalFour studies showed no statistically significant associations between mode of birth and sexual function in the longer-term ,75,78,83Seven studies showed 12 statistically significant associations between mode of birth and sexual function in the medium-term  67,71,7,80,81,89Four studies showed five statistically significant adjusted associations between mode of birth and sexual function in the medium-term. Vaginal birth with episiotomy was associated with worse total sexual functioning scores and worse sexual functioning scores for desire, compared to caesarean section (without differentiation between planned and emergency caesarean section) . AssisteFour studies showed seven statistically significant crude associations between mode of birth and sexual function in the medium-term. Spontaneous vaginal birth was associated with better sexual functioning scores for arousal, compared to vaginal birth  and caesarean section (without differentiation between planned and emergency caesarean section) . CaesareSix studies showed no statistically significant associations between mode of birth and sexual function in the medium-term  63,68,7,78,85,88Four studies showed 6 statistically significant associations between mode of birth and sexual function in the longer-term  66,70,7,73.Two studies showed four statistically significant adjusted associations between mode of birth and sexual function in the longer-term. Caesarean section (without differentiation between planned and emergency caesarean section) was associated with increased satisfaction with vaginal tone when compared to spontaneous vaginal birth and assisted vaginal birth . AssisteTwo studies showed two statistically significant crude associations between mode of birth and sexual function in the longer-term. Caesarean section (without differentiation between pCS and eCS) was associated with better scores for desire when compared to vaginal birth with episiotomy , and betSeven studies showed no statistically significant associations between mode of birth and sexual function in the longer-term  59,61,7,85,86,89Various factors were considered important when comparing the studies included in this review: study design, sample size, parity, adjustment for confounders, longitudinal follow up and study quality. Comparative analyses were performed to evaluate whether associations varied between the studies that differed in these factors.When comparing the study design, a similar proportion of the studies were cohort or longitudinal studies compared to cross-sectional studies, and both categories showed mixed results without any consistent findings. There were more studies with a sample size of less than 500 participants ,81,83,88Based on the existing literature on sexual function, the confounders considered of great importance include: sexual (dys)function prior to pregnancy, (risk of) depression, breastfeeding status, parity and perineal tears ,31,32,33Of the longitudinal studies that were included, some showed no differences in associations between mode of birth and sexual functioning across various time points ,78,83,85When comparing the results based on the quality of studies, no differences were seen in associations between studies that were of poor, fair and good quality.The main focus of our review was to examine the impact of specific mode of birth on medium- and longer-term sexual functioning. Our review shows that there are significant associations between mode of birth and women’s sexual function in both the medium- and longer-term. Adjusted associations showed that: assisted vaginal birth was associated with worse sexual function  when compared to planned caesarean section, in the medium-term (≥six months and <12 months postpartum); in the longer-term (≥12 months postpartum), spontaneous vaginal birth was associated with better sexual function when compared to assisted vaginal birth (pain domain) and planned caesarean section (desire and pain domains). In both the medium- and longer-term, assisted vaginal birth was consistently associated with worse sexual function, compared to other modes of birth.In regard to the secondary focus of this review (multiple modes of birth combined into one groups), no consistent pattern was shown by adjusted associations to reflect that one mode of birth group was associated with better/worse sexual function compared to another, in the medium- or longer-term.The results from both the main and secondary focus of this review suggest that sexual dysfunction does not necessarily resolve in the first year postpartum, and that assisted vaginal birth can have lasting effects on sexual function past 12 months postpartum.Many studies included in this review show that mode of birth is not associated with postpartum sexual functioning in the medium- and longer-term. This supports the findings of Nikolaidou in their systematic review, on the effect of mode of birth on sexual function in the short- and medium-term (up until 12 months postpartum) .The associations shown in this review between assisted vaginal birth, as well as vaginal birth with episiotomy, and worse sexual function can be linked to mechanisms of injury surrounding these operative interventions: assisted vaginal birth is associated with a higher incidence of episiotomy and severe perineal trauma, as well as pelvic floor trauma and nerve damage which can affect sexual function ,93,94,95The included studies varied by study design, sample size, adjustment for confounders, and study quality, however the associations seem not to be affected by these differences.The longitudinal improvement in sexual function could be due to the natural course of recovery after birth . On the The main strength of this integrative review is that only studies using validated measures to assess sexual functioning were included, allowing direct comparison between the studies, as well as increasing the ability to draw clinical implications from the results. Multiple mode of birth and intervention combinations were investigated. Additionally, we focused on the effects beyond six months postpartum, and did not limit the period of interest to a certain time after birth, meaning studies were included that examined associations up to and greater than 10 years postpartum. The majority of studies included in this review were of good quality.Despite the strengths of this review, some limitations should be noted. When calculating associations between mode of birth and sexual function, some of the included studies did not adjust for important confounding factors in the analysis. Sexual function can be influenced by many factors, including postpartum stress and fatigue, managing relationships with partner (if applicable), life stressors , breastfeeding, experiences during previous births, history of sexual abuse and degree of sexual dysfunction before pregnancy and birth ,31,32,33Despite the evidence showing the difference between male and female sexual function, some measures of sexual function are based on dated evidence which suggests that women’s sexual function is equivalent to men’s sexual function , even thAn additional limitation that should be noted is the lack of consensus on reporting standards in the papers: reporting for mode of births, as well as adjustment for confounding, was not consistent across the papers included in this review.Two studies examined sexual function at and beyond six years postpartum and found significant adjusted associations with mode of birth ,73. AlthMany of the included studies did not adjust for important confounders, with only nine of 31 studies adjusting for at least one of the most important confounders. Therefore, this needs to be considered as a limitation and taken into account when interpreting any associations reported in this review.Future studies should take into account pre-existing sexual dysfunction, quality of the relationship between the parents before and after birth, experienced birth trauma and the model of care experienced, in order to elucidate whether these factors can explain the associations found between mode of birth and sexual function.Another avenue of research that should be explored is how the health care a woman receives, if any, during the postpartum period affects sexual function. Given how important sexual functioning can be for a woman ,2,3,4, fAdditionally, studying women who have more complex births and are underrepresented in the current literature should be made a priority: for example, many studies excluded women who did not have a singleton birth despite the fact that the proportion of twin births out of total births (per 1000 births) is 14.4 in Europe . In a siThere is some evidence that incidence of perineal trauma after birth varies between different ethnic groups; a systematic review showed that the majority of studies conducted in Western countries describe women of Asian ethnicity as having increased risk of severe perineal trauma during birth, whereas Asian women living in Asia were not at increased risk. The reasons for this were unknown but could be attributed to differing care that women from different ethnic groups receive, differing birthing techniques, ethnic anatomical differences or cultural differences, and changes in diet when moving to Western countries ,109. TheIt would be valuable to contextualise sexual functioning scores by asking women more in depth, follow-up questions about their postpartum sexual function. This would help to understand why associations exist in the quantitative data, and identify how postpartum care, focused on sexual function, could help women. It is of vital importance that measures are validated in postpartum women. Additionally, it is important that sexual function measures and have undergone cross-cultural validation, for both linguistics and culture, when they are used to measure sexual function in women whose cultural backgrounds differ from those that the measures were originally validated in.This integrative review summarises the existing evidence on the impact of different modes of birth on sexual functioning, in the medium- (≥six months and <12 months postpartum) and longer-term (≥12 months postpartum), published between 2005 and 2023. Assisted vaginal birth has been found to be associated with worse sexual function when compared to spontaneous vaginal birth and caesarean section in both the medium- and longer-term. However, it should also be noted that some studies showed that spontaneous vaginal birth and caesarean section were associated with worse sexual function in comparison to other modes of birth. No mode of birth can be recommended to preserve sexual function in the medium- or longer-term. Therefore, it is important that postpartum sexual functioning is discussed with mothers for all modes of births, in order to encourage women to seek help and support from healthcare professionals should their sexual function be impaired after birth.


Transforming growth factor beta-1 (TGFβ1) is an adipokine secreted from adipose tissue, placental tissue and immune cells with a role in cell proliferation, cell apoptosis and angiogenic proliferation. The role of TGFβ1 in pregnancy and child growth and the source of cord TGFβ1 are yet unknown. In this study, we sought to clarify the correlation of TGFβ1 levels with parameters of intrauterine growth and child growth during the first year of life, and to determine whether their source is primarily of fetal or maternal origin. Serum samples and anthropometric measurements were obtained from the LIFE Child cohort of 79 healthy mother–child pairs. Measurements were conducted using enzyme-linked immunosorbent assays. Statistical analyses including Mann–Whitney U-test, correlation analyses and linear regression analyses were performed using GraphPad Prism and R. TGFβ1 levels were significantly higher in cord than in maternal serum, suggesting a fetal origin. Multivariate regression analyses revealed strong positive associations between cord TGFβ1 levels at birth and child weight at U6. Furthermore, cord TGFβ1 was significantly correlated with child weight at approximately one year of age. An increase of 10,000 pg/mL in cord TGFβ1 concentrations at birth was associated with a higher body weight of 201 g at roughly one year of age when adjusted for sex. Since the discovery of leptin, adipokines and their roles in various metabolic, endocrinological, immunogenic and vascular processes have been the topic of much research. Hundreds of adipokines have been identified and functionally characterized in recent years ,2. EspecThe TGFβ superfamily was first described in 1990 and encompasses several secretory proteins involved in cellular proliferation, differentiation and apoptosis . The firIn this study, we aimed to analyze TGFβ1 levels in maternal serum and in cord blood at birth and assess whether TGFβ1 is of maternal or fetal origin. We also investigated the association of maternal and cord serum TGFβ1 with gestational parameters such as gestational weight gain as well as parameters of intrauterine and child growth in the first years of life.This was an observational, longitudinal study on a cohort comprised of 79 healthy mothers and their healthy offspring. We obtained serum samples of pregnant women taken at the 36th week of gestation as well as serum samples from the umbilical cord at birth and measured TGFβ1 levels present in these samples. Furthermore, we assessed the weight progression of offspring at three checkpoint examinations  and the association of child weight with TGFβ1 levels measured in umbilical serum at birth.All subjects were participants in the LIFE Child Study, a population-based longitudinal study in Leipzig, Germany. It was first established in 2011 with the aim of examining the role of genetic, environmental and lifestyle factors on child health, and the first participants were recruited in that same year . Since tThe respective serum samples included maternal serum samples taken at the 36th week of gestation and cord serum samples taken at birth. In addition, LIFE Child also provided us with both maternal and child biometric measurements and lab values. Maternal parameters included measurements recorded in the pregnancy records of the participating mothers such as weight gain and gestational age at birth. Child parameters comprised of anthropometric measurements and observations recorded in the check-up booklet of children. The check-up booklet encompasses growth and weight development parameters of children measured at standardized assessments (U1-U10) spanning from birth until eight years of age . For our study, we identified 79 mothers recruited during pregnancy and their respective offspring, all of whom met the inclusion criteria and participated in at least three standardized assessments . Of the 79 children included in our study, we had follow-up measures from 79 participants at the U3 and 78 at U6. Measured values at each of these standardized assessments included weight as well as Kromeyer–Hauschild standard deviation scores (SDS) for weight .Blood samples were processed by the Leipzig Medical Biobank team according to standard operating procedures. While samples from pregnant women were processed within about 180 min after blood collection, cord blood samples were prepared for storage during the working hours of the biobank, at the latest in the morning of the next working day. All samples have been stored at −80 °C (2D-barcoded cryotubes (Azenta)) or at temperatures below −150 °C in straws (CryoBiosystems IMV) . CirculaW-test, and variables were logarithmically transformed where deemed necessary. TGFβ1 levels in maternal and cord serum were compared using Mann–Whitney-U Test. The association of both maternal and cord circulating TGFβ1 with various parameters of child growth and maternal gestational parameters was assessed using simple and multiple regression analyses. Regression results were reported as change in the outcome per +10,000 pg/mL TGFβ1. Correlations were assessed with Spearman’s rank correlation analysis. Results were visualized through boxplot, scatterplot and correlation matrix. A p-value of <0.05 was considered statistically significant in all analyses.All statistical analyses were performed using GraphPad Prism 9.5.1 and R 4.2.2. Distribution was tested for normality of variables and residuals using the Shapiro–Wilk Study group characteristics are summarized in U-test showed that TGFβ1 levels in cord blood were significantly higher than in maternal serum at 36 weeks gestation   .No significant correlations were found between maternal TGFβ1 levels at 36 weeks gestation and child weight or BMI at birth, at roughly one month of age, nor at approximately one year of age.p = 0.033). Furthermore, we found statistically significant positive correlations between cord TGFβ1 levels at birth and child weight as well as weight SDS at U3 (1 month) . In line with this finding, child weight at U6 (1 year) also correlated positively and significantly with cord TGFβ1 , although correlation of cord TGFβ1 and weight SDS at this age was not significant. Child sex also correlated significantly and positively with child weight at birth , at U3  and at U6 . All correlations are presented in Spearman’s rank correlation test did not reveal any significant correlations between cord TGFβ and child weight parameters at birth. Furthermore, no significant correlations could be found between cord TGFβ1 and gestational age at birth. However, TGFβ1 in cord serum at birth correlated significantly with biological sex . Further, birthweight was also significantly related to cord TGFβ1 when adjusted for child sex . At U3 and U6, both measures showed significant associations with TGFβ1, that persisted even after adjustment for sex and, in the case of the raw weight measure, birthweight. At U3, we found the following effect sizes after adjusting for sex: weight: β10,000 TGFβ1 = 156, p = 0.003 and weight SDS: β < 10−4, p = 0.02. At U6, we found similar associations between cord TGFβ1 and weight  as well as weight SDS . Accordingly, an increase of 10,000 pg/mL in cord TGFβ1 concentrations at birth was associated with a weight increase of 201 g at roughly one year of age when adjusted for child sex  and U6 (1 year). However, the significance of associations was not consistent across the different measures. At birth, birthweight and the related SDS were only significantly related to TGFβ1 when correcting for GA  at partum in comparison to levels found in maternal serum antepartum, indicating the fetal origin of cord pref-1 . LikewisHigher levels of cord TGFβ1 in comparison to maternal serum have also been reported in recent studies. In a study assessing TGFβ1 levels in maternal serum in the second and third trimesters compared to non-pregnant controls, Power et al. reported elevated maternal TGFβ1 at both trimesters when compared with the non-pregnant state. They found TGFβ1 to reach its highest level in late gestation. One major difference compared to our study, was the use of unrelated mothers and children instead of the respective offspring of the included mothers. Nonetheless, in accordance with our findings, they also reported higher levels of TGFβ1 in cord serum when compared to levels found in maternal serum . FurtherThe origin of fetal TGFβ1 has also been investigated. High expression of TGFβ1 has been reported in the syncytiotrophoblast cells of the placental villi ,30, and In our findings, maternal serum TGFβ1 did not correlate with the pregestational weight nor with the gestational weight gain of mothers. However, TGFβ1 has been associated with obesity and weight gain in adults. Significant associations have been found between TGFβ1 levels and hepatic abnormalities such as steatosis, obesity, and CRP . In addiOur study was the first of its kind to investigate the relationship between cord TGFβ1 at birth and child growth during the first year of life. The longitudinal study design allowed us to assess long term outcomes in addition to immediate outcomes at birth. We found significant associations between cord TGFβ1 at birth and birthweight, as well as birthweight SDS after adjusting for male gender and gestational age.Recent studies have also explored the relationship between cord TGFβ1 and child parameters at birth, albeit not in a longitudinal fashion. In a previous study, infants with intrauterine growth restriction (IUGR) displayed elevated cord TGFβ1 at birth in comparison to a matched AGA group . This inIntrauterine conditions have been shown to shape the health trajectory of offspring through fetal programming ,37,38. WIn our study, no significant associations between maternal TGFβ1 levels and offspring birth parameters, such as weight, length, head circumference or BMI could be described. Nevertheless, several studies investigated maternal TGFβ1 levels and gestational outcomes with some significant findings. Negative associations were found between maternal TGFβ1 concentrations and birthweight as well as head circumference of offspring . MoreoveInterestingly, while cord TGFβ1 levels at birth were significantly associated with child sex in our healthy cohort, a study investigating TGFβ1 gene expression in the placentas of SGA pregnancies found no differences in gene expression between males and females . AlthougWhile our cohort was relatively large with 79 mother–child pairs, this number still restricts the generalizability and creates a higher risk of type II errors. Moreover, we did not perform a sample size calculation, as it is generally difficult to attain a large cohort of pregnant mothers and their offspring without underlying health conditions or complications during pregnancy and at birth as well as follow-up examinations up to a year after birth. Although our cohort was largely homogenous in terms of birth weight and gestational age, further factors that may impact a healthy pregnancy such as maternal diet, environmental factors, or exposure to allergens during pregnancy were not considered. Of over 4500 children recruited by LIFE Child since 2011, we were only able to identify 79 children who met our inclusion criteria. Additionally, although we compared maternal and cord serum samples, there was a gap between maternal serum sampling at 36 weeks gestation and cord serum sampling at birth. This approximate window of four weeks allows a margin for fluctuations in TGFβ1 levels. The slight variance in age between children at the respective examinations renders anthropometric measurements liable to error. Furthermore, the cross-sectional nature of the serum samples we acquired meant that we were unable to assess TGFβ1 longitudinally. Changes in TGFβ1 in maternal serum during pregnancy could provide more explanation on the associations of TGFβ1 with parameters of intrauterine growth. Similarly, measurement of pre-pregnancy and antepartum TGFβ1 levels in maternal serum could have also been useful in investigating the role of this adipokine in metabolic processes during gestation.The findings of our study raise several questions that could be tackled in the future. Future research directions include a longitudinal assessment of maternal serum TGFβ1 levels throughout pregnancy, as well as TGFβ1 levels in the breastmilk of mothers, especially in cases where they choose to breastfeed. Similarly, longitudinal assessment of child serum TGFβ1 levels throughout childhood would also be beneficial to study the association of TGFβ1 with child weight development, however blood samples are rarely drawn from healthy children without therapeutic consequence. Further, our study only considered healthy pregnancies and births; it would be of interest to observe whether cord TGFβ1 levels are also associated with child weight development in SGA or LGA pregnancies, or whether pregnancy diseases such as gestational diabetes or pre-eclampsia affect this association in any way.In summary, our study suggests that TGFβ1 detected in cord serum at birth is most likely of fetal origin. Furthermore, we found a significant relationship between cord TGFβ1 levels at birth and child weight development in the first year of life. These associations were more pronounced at one month of age than at birth. Child weight at approximately one year of age correlated significantly with cord TGFβ1 levels at birth. Accordingly, an increase of 10,000 pg/mL in cord TGFβ1 concentration at birth was associated with an average weight increase of 156 g at one month of age and 201 g at one year of age when adjusted for gender. Further research considering child TGFβ1 concentrations and child growth parameters is needed to elucidate the role of TGFβ1 in growth and weight gain.


However, education differentiated the effect of father acknowledgement across unmarried mothers. BWGA z-scores were significantly lower among the low-educated unmarried group without father acknowledgment (UM-NF) as compared to UM-F . The same effect among the higher-educated group was non-significant (p = 0.72). Higher maternal education can compensate for the negative effect of a lack of father acknowledgement, but it does not help to overcome the effect of out-of-wedlock stress exposure.We evaluated whether the maternal marital status and father acknowledgement  affect birth weight, and if so, whether the maternal educational attainment modifies this effect. The growing tendency of alternative forms of family structure affects maternal well-being and pregnancy outcome. However, it is not known whether poorer birth outcomes of out-of-wedlock childbearing can be overcome or compensated by maternal education. Using birth registry data, we assessed the impact of maternal civil status and child recognition by the father on birth-weight-for-gestational age (BWGA) z-scores, with respect to maternal education, among Polish mothers . After standardization, the effect of being unmarried with father acknowledgement (UM-F) vs. married with father acknowledgement (M-F) reduced the BWGA z-score of 0.05 ( In the traditional, patriarchal model of family, the father’s presence and a trusting relationship between the father and pregnant mother contribute to a mother’s sense of security and ensure access to financial resources. This traditional model has many pros and cons and has lasted for many generations, but in recent decades it has slowly and gradually been turning into a democratic contemporary family as couples voluntarily enter into marriage or partners choose to live together without being legally married to each other . The groStress may be particularly devastating when the father does not acknowledge paternity, indicated by the lack of the father’s name on the birth certificate ,8,9,10. In our work, we hypothesize that one of the factors that can increase stress resilience in vulnerable groups of pregnant women is an enhanced maternal socioeconomic status as determined by economic, occupational, and educational achievements ,17. A hiGiven this knowledge, we aimed to determine whether maternal education can overcome or compensate for the adverse neonatal conditions  z-scores) associated with a mother’s civil status and the acknowledgment of paternity by the father.The study group comprised the singleton live-born infants born at term (between 37 and 42 weeks of gestation) to mothers whose residence at the time of the infant’s birth was the city of Krakow. The anonymized data from the birth registry  included birth records from 1 October 1995 to December 2009, which comprised the following: month and year of birth, birth weight (in grams), infant’s sex, maternal age (in years), gestational age (in weeks), parity, maternal education , maternal employment status (employed vs. unemployed), and maternal marital status . Paternal data, if present, included age (in years), education , and employment status (employed vs. unemployed).Paternal and maternal education (EDU) was divided into two levels: higher education  and lower education .The maternal marital status and father acknowledgement  were defined as the categorical variable with three levels: (1) married—a legal father of the child  (M-F); (2) unmarried—a father voluntarily signs a paternity statement (UM-F); and (3) unmarried—a lack of father acknowledgement of a child on the birth certificate (UM-NF). Father acknowledgement of a child was proxied by the presence or absence of paternal data  on the birth record. The presence of these data indicated the voluntarily acknowledgement of paternity or court-established fatherhood. It is likely that in such circumstances the father is more prone to be in a close relationship with the mother and be involved in taking care of her during pregnancy and thus support her, forming the cohabiting union. Conversely, the lack of a father’s data on the birth record  may indicate that the mother does not know the father or is unwilling to identify him, which may indicate single motherhood. The outcome variable was assessed as the birth-weight-for-gestational age (BWGA) z-scores. We used the formula: z = (observed birth weight—mean birth weight)/SD), where the mean birth weight and SD were based on published population-based standards, and stratified by infant gender and gestational age in the completed weeks . A positOf 88,474 singleton births, we excluded n = 4725 born before 37 and after 42 completed weeks of gestation; n = 129 stillbirths; n = 3794 births categorized as “large-for-gestational age” ; and n = 9134 births categorized as “small-for-gestational age” . The intent of these exclusions was to conduct the study on singleton, live, full-term births and estimate the differences in the rate of fetal growth within a range of appropriate weights for gestational age. Mothers below 25 years of age at delivery  were also excluded. The education levels of the mothers’ study groups were defined according to the International Standard Classification of Education (ISCED) and were restricted to mothers at least 25 years and above in order to ensure that the majority of the population had completed their education. These exclusions left N = 53,528 eligible births for study.t-tests or ANOVA for continuous variables. Then, we used a multiple linear regression model with the BWGA z-score as the dependent variable, and the index of maternal marital status and father acknowledgement , maternal education (lower/higher), infant’s sex (girl/boy), parity (primiparous/multiparous), maternal age , and birth year , as the independent variables. This model allowed us to estimate the main effects of this Index and EDU. Afterward, we added the product term (Index x EDU) into the multiple linear regression model as a way to test for interactions. Using this model with interaction, we also estimated simple effects of the Index of maternal marital status and father acknowledgement at a particular level of education (lower/higher) when other variables were held fixed at 0. The interplay between two factors (Index and EDU) and their influence on an outcome (BWGA z-score) was visualized. All analyses were conducted with Statistica version 13 .First, we compared the characteristics of the study group stratified by maternal marital status and father acknowledgement, on the one hand, and maternal education, on the other hand, using chi-square tests for categorical variables, and All infants were born between 37 and 42 weeks of gestation. Median birth weight was 3440 g (Q1–Q3: 3200–3700 g). Half of the study mothers were less than 30 years of age (Q1–Q3: 27–33 years), with a minimum age of 25 and a maximum age of 54, whilst the median paternal age was 31 years (Q1–Q3: 28–35 years). Among the study group, 54.1% of women were multiparous with 2–15 children. A vast majority of women were married (91%) at the time of delivery. The study group comprised more employed (82%) than unemployed women. Higher educational attainment was much more frequent among mothers than the lower one (85% vs. 15%). About 75% of fathers had a higher educational background and were employed (90%).For n = 951 infants (1.8%), no paternal data, such as his age, employment, and education were found. This group was classified as UM-NF. The group of UM-F comprised 7.5% infants, whilst the rest of them (90.7%) were categorized as M-F.The three levels of the Index mentioned above differed according to maternal age, maternal employment and educational levels, parity, and birth year, but not the sex of the child . Howeverp < 0.01) within the Index levels: women with a higher educational background more frequently gave birth while being married than unmarried: 92% M-F vs. 8% unmarried (UM-F + UM-NF). Whilst among women with a lower education, we found 84% married (M-F) vs. 16% unmarried (UM-F + UM-NF); We found important educational differences (p <0.01), younger (p = 0.03), and with a lower percentage of being employed (p < 0.01) than mothers with a higher education. The paternal age of infants born by mothers with a lower vs. higher education was elevated (p < 0.01). Paternal unemployment was more common among lower educated vs. higher educated mothers (p < 0.01). The same educational levels for both mothers and fathers were found less frequently among lower-educated than among higher-educated parents (p < 0.01); Mothers with a lower education were more frequently multiparous (p < 0.01); p < 0.01), and the highest proportion of unemployed mothers (p < 0.01).An infant’s sex ratio (the ratio of boys to girls) differed according to the Index groups, with the lowest found among UM-NF (p < 0.01), whilst the mean BWGA z-score of the UM-NF was −0.10 below that of the M-F (p < 0.01). The difference of the mean BWGA z-scores between UM-F and UM-NF groups equaled −0.05 (p = 0.04).After descriptive statistics and group comparisons, we assessed the effect of the Index levels on the BWGA z-score. After standardization to infant’s sex, year of birth, parity, maternal employment, education, and age, the mean BWGA z-score of the UM-F was −0.05 below that of the M-F (p < 0.01).Then, we assessed the effect of maternal education on the BWGA z-score. After standardization to infant’s sex, year of birth, parity, maternal employment, Index levels, and age, the mean BWGA z-score of the higher EDU was 0.07 above that of the lower EDU (p = 0.01), whilst the mean BWGA z-score of the UM-NF was −0.16 below that of the M-F (p < 0.01). While comparing UM-F with UM-NF mothers with lower EDU, the difference of the mean BWGA z-scores equaled −0.11 (p = 0.01).An analysis of interaction between the Index levels and EDU, using a multiple linear regression model, indicated that the effect of Index levels varied across categories of education . Among lp < 0.001), and it was not significantly different from the same comparison among lower EDU (p for interaction = 0.79).Among higher EDU mothers, the difference in mean BWGA z-scores between UM-F and M-F was also 0.05 (p for interaction 0.02). Therefore, the total difference between UM-NF and M-F among higher EDU mothers was −0.06 (−0.16 + 0.10).On the other hand, the difference between UM-NF and M-F among higher EDU was not −0.16, as in lower EDU, but was significantly reduced. This reduction amounted to 0.10 (p = 0.72), which was not statistically significant per se, but significantly smaller in comparison to the same difference found in lower EDU mothers, which equaled −0.11 (p for interaction = 0.045). This stronger effect of the Index of maternal marital status and father acknowledgement for lower EDU mothers is also visible in The difference in mean BWGA z-scores between UM-NF and UM-F among higher EDU mothers amounted to −0.01  on birth outcome, but it does not help to overcome the effect of out-of-wedlock stress exposure. Lower-educated women, whose partners offer lower or no support during pregnancy, are a vulnerable group that needs special perinatal care. We recommend addressing father support interventions in lower-educated mothers as one of the most promising areas in alleviating social risk factors and improving birth outcomes. Future research should focus on identifying psychosocial and lifestyle variables that either alone or in combination with other factors explain the differences in fetal growth.Our conclusion would not be valid without a discussion of its limitations. Our study, similar to many studies based on birth records, is cross-sectional, and one must exercise caution when inferring causality. This is especially important when assessing birth outcomes in relation to father acknowledgement, measured by proxy indicators such as lack of paternal data on birth records, because the questionnaire may be filled in by the hospitalized mother after the child is born. Thus, the study measures associations, not consequences. Furthermore, the dataset of birth records does not allow us to assess the extent and quality of a father’s involvement during pregnancy and the type of emotional relationship between the couple, either in married or unmarried couples. We also did not know whether the current partner was the father of the baby. The dataset also lacks information on the cohabitation status among unmarried women, which is an important omission, as cohabitation is likely to be associated with a man’s willingness to invest in the child. Following a birth to an unmarried couple, cohabiting couples are much more likely to marry or remain together than non-cohabiting couples (Fragile Families Research Brief 2007). Among non-residential fathers, cohabiting men pay more child support than men that have never cohabited with the mother . Due to We decided to restrict our analysis to mothers who had passed a school age (in Poland: 25 years) in order to exclude mothers whose graduate education might have been prevented or postponed by the birth. It is likely that their educational aspiration may be sometimes higher than their actual education degree. There is an obvious correlation between maternal age and education originating from the fact that some women give birth (planned or not) while studying, and because of this, some of them decide not to continue their studying. The correlation between age and education might confound the investigated relationships between father acknowledgement, education, and birth weight. After the study group restriction, we expect to see the unbiased, ”true” effect of education on birth outcome. The procedure of restricting the study group according to passing the school age while studying the effect of education on birth outcomes was also adopted by others .We also decided to exclude LGA and SGA infants, because we wanted to conduct the study on homogenous neonates, without problems with fetal growth. LGA may be the result of gestational diabetes, whilst SGA indicates growth restriction. We expected that analyzing relationships between marital status, father acknowledgement, and birth outcomes on such a consistent group will strengthen our results. Finally, we noted that even in the appropriate birth-weight-for-gestational age range, statistically significant relationships were present.Our study group may represent a very specific group of privileged women as regards marital status (91% were married), employment status , and education attainment . Due to this fact, the results are very specific for this population and the role of father recognition and mother’s education might change in other settings.It is important to emphasize that the aim of our study was not to speak for or against a certain family structure. Instead, primary health care providers need to acknowledge the diversity and address the different needs of different families, and provide support for paternity regardless of family structure.