The increase in births within cohabitation in the United States and across Europe suggests that cohabitation and marriage have become more similar with respect to childbearing. However, little is known about additional childbearing after first birth. Using harmonized union and fertility histories from surveys in 15 countries, this study examines second conception risks leading to a live birth for women who have given birth within a union. Results show that women who continue to cohabit after birth have significantly lower second conception risks than married women in all countries except those in Eastern Europe, even when controlling for union duration, union dissolution, age at first birth, and education. Pooled models indicate that differences in the second conception risks by union type between Eastern and Western Europe are significant. Pooled models including an indicator for the diffusion of cohabitation show that when first births within cohabitation are rare, cohabiting women have significantly lower second conception risks than married women. As first births within cohabitation increase, differences in second conception risks for cohabiting and married women narrow. But as the percent increases further, the differentials increase again, suggesting that cohabitation and marriage are not becoming equivalent settings for additional childbearing. However, I also find that in all countries except Estonia, women who marry after first birth have second conception risks similar to couples married at first birth, indicating that the sequence of marriage and childbearing does not matter to fertility as much as the act of marrying itself. The increasing percent of births within cohabitation across almost all of Europe and the United States indicates that cohabitation is becoming more common as a setting for childbearing Kiernan . Family all cohabiting unions, or selection into having a first birth within cohabitation, it provides an important piece of the puzzle on how similar cohabitation and marriage are with respect to childbearing.This study investigates how second birth risks differ between married and cohabiting parents across Europe and in the United States. Previous studies have focused on union status at entrance into parenthood . Together, the countries cover a substantial proportion of Europe’s population, including North–South family patterns described by Reher . The data for Austria, Belgium, Bulgaria, Estonia, France, Italy, Lithuania, Norway, Romania, and Russia come from the Generations and Gender Surveys (GGS), which interviewed nationally representative samples of the resident population in each country. Because the GGS is not available for all countries (or the retrospective histories were not adequate for our purposes), I also relied on other data sources. The Dutch data come from the 2003 Fertility and Family Survey (FFS). The data for the UK are from the British Household Panel Survey (BHPS), including the panels from 1991 to 2006. The Spanish data come from the survey of fertility and values conducted in 2006, and the Polish data are from the employment, family, and education survey conducted in 2006. The U.S. data are from the national survey of family growth, conducted between 2006 and 2008. Note that each survey suffers from specific limitations, such as biased response rates or missing data , or when their unions dissolve.In the second set of analyses, I employ competing risk hazard models to examine second conception differentials by union type net of union dissolution. I use a discrete-time framework to estimate multinomial logistic regression using the sample of all person months when respondents were at risk for having a second conception or union dissolution. By defining no event as the reference category, the model is able to estimate the net hazard of either second conception or dissolution.The final set of models pools all of the country datasets to examine differences in second conception risks across countries. Although it would be useful to try to explain differences through contextual variables such as family policies or cultural attitudes toward cohabitation, these variables are not available for all countries. Therefore, I examine whether differences in fertility patterns or the diffusion of cohabitation can explain the variation. In the first set of pooled models, I include interactions between country and other parameters to account for country-specific patterns. In the second set of pooled models, I estimate the association of the percent of first births within cohabitation on second conception differentials by union type.The primary variable of interest is the type of union after the birth of the first child. Union status is a time-varying covariate with three possible states: continuously married, continuously cohabiting, and currently married having previously cohabited. Cohabitors who marry after the first birth move from “currently cohabiting” to “married, but previously cohabited.” I also tested transitions from cohabitation to marriage between first conception and first birth, but only three countries had significant results . Given the inconsistent results and different theoretical implications for “shot-gun marriages,” the focus here is on changes in union status after first birth.It is important to control for mother’s age at first birth in all models, because of the implications for the timing of fertility on subsequent fertility and union behavior, and because the age pattern of childbearing differs substantially across the countries in our study. Mother’s age at first birth may impact second birth risks, since women who delay childbearing may compress second births to have them before the end of the reproductive age  except for Norway, France, Russia, Bulgaria, and Romania, where cohabiting and married women would have similar risks (H1a). Table However, in the Eastern European countries –Bulgaria, Romania, Russia—and Estonia, cohabiting and married women have no significant differences in second conception risks. This confirms the expectations for Bulgaria, Romania, and Russia (H1a), but not for Estonia, where I expected cohabiting women to have lower second conception risks (H1b). In Bulgaria and Russia, conception risks for cohabitors are slightly lower than for married people, while in Estonia and Romania, conception risks are slightly higher for cohabiting couples, but the lack of significance in these countries suggests that the childbearing patterns for married and cohabiting mothers are relatively similar. The lack of difference, however, may be because both groups have very low-fertility risks in general; second conception risks may be so low in these countries that neither type of couple is having children, thus rendering the difference between the two union types negligible.In all countries except Estonia, women who were in a cohabiting relationship at first birth and married afterward have second conception risks that were not significantly different from women who were continuously married, confirming Hypothesis 2. In Estonia, cohabiting women who married have second birth risks 77 % higher than their continuously married counterparts. Note, however, that in Austria, the Netherlands, Poland, and Spain, the odds ratios are above 1.2, implying that if the results were significant, women who marry after first birth speed up the timing of their second conceptions, relative to their continuously married counterparts. Only in Belgium, Italy, Lithuania, and the U.S. are the odds ratios below one, suggesting that those who marry after birth may have lower second conception risks than those who were married at first birth. In any case, the results do not show strong differences between those who marry before first birth and those who marry afterward, although the lack of significance may be due to small sample size. In general, the similar second conception risks suggest that cohabiting couples who have a first birth and then marry may have similar levels of commitment and ideas about family size to those married at first birth. The findings may also indicate that couples who marry after a first birth planned both events jointly and happened to have a first birth before marriage , indicating that the educational differences in second conception rates do not differ by union status. Thus, unlike in other studies, which found a significant educational gradient for first births within cohabitation . Most countries had significantly lower second conception risks for cohabiting women compared to married women, and the same four former socialist bloc countries had no significant difference between second conception risks for cohabiting and married couples. The similar results may be because union dissolution directly after first birth is relatively rare: Perelli-Harris et al.  found thThe difference in second birth risks by union type between the Eastern and Western European countries plus the U.S. raises many questions, particularly about the former socialist countries. As discussed above, these countries went through major upheaval after the collapse of the Soviet Union, and their fertility risks plunged to extreme lows, primarily due to the postponement or elimination of second births , I ran additional models with the pooled data (Table a and H3badditional childbearing. However, in the long run, the meaning of cohabitation and marriage may change substantially, leading to greater similarity again.Figure In this study, the findings show that in the U.S. and most countries of Europe, cohabiting mothers with one child have significantly lower second conception risks than married mothers with one child. For these countries, the results are remarkably consistent, with cohabitors having between 40 and 50 % lower second conception risks than married women, even when controlling for duration of union before first birth. The results are also robust when controlling for union disruption; a competing risk analysis distinguishing between unions that dissolved and remained intact shows that cohabitors who stay in a union have lower conception risks than married women who stay in a union. In general, the results suggest that cohabiting mothers are different from married mothers, perhaps due to different fertility preferences as posited by Second Demographic Transition theory (Lesthaeghe However, the findings also show that in the former socialist countries of Estonia, Romania, Bulgaria, and Russia, cohabiting and married mothers had no significant differences in second conception risks. Controlling for union dissolution does not change these results; marriage and cohabitation were still not significantly different in these former socialist countries. Our pooled models showed that the Eastern European pattern of second conceptions was distinct from that in Western Europe; second conception risks were very low in the 1990s. The pooled models also showed that the association between union status and fertility in France was significantly different than in Estonia, Bulgaria, Romania, and Russia. This was not the case for all low-fertility countries, including Italy and Lithuania, suggesting that cohabitation and marriage may have different meanings in Western and Eastern Europe, especially regarding childbearing and rearing. In Western Europe, relationship instability, lack of commitment, and socio-economic disadvantage may prohibit additional births. In Eastern Europe, cohabiting women may be disadvantaged or beset by poverty (Perelli-Harris and Gerber In all countries, women who cohabited at first birth and then married had no significant differences in second conception risks than continuously married women, except in Estonia, where women who marry after first birth have much higher risks of a second conception. Although the lack of significance may be due to small sample size, in most countries, the risks for those who marry after first birth are higher, suggesting that women who marry speed up the timing of second births. In general, this finding suggests that the most committed couples marry and then conceive at similar or higher risks than those married at first birth. The results are consistent with studies which find that couples with plans to marry have similar relationship satisfaction as already married couples (Wiik et al. I also tested to what extent the diffusion of cohabitation could explain any differences across countries and time. The expectation was that cohabitation and marriage would become more similar as the percent of first births within cohabitation increased, as has been found in studies of subjective well-being (Soons and Kalmijn The findings point to implications for the meaning of cohabitation which are different than those found in Liefbroer and Dourleijn . LiefbroIn any case, the relationship between the diffusion of cohabitation and changing behavior is not straightforward. Country-specific explanations, including the cultural, socio-economic, and policy environment, may be better at explaining differences than a simple model of diffusion. In addition, even though countries may have similar outcomes, the reasons underlying the outcomes may differ. For example, although second conception risks may be lower for cohabiting couples than married couples throughout Western Europe, different cultural factors may be operating. The Catholic Church may play a role in countries such as Poland and Lithuania, but in more secular countries like Austria, state policies favoring the breadwinner model may encourage marriage. Therefore, it is important to acknowledge how different cultural, economic, and social forces have produced unique contexts for family formation.Despite entrenched cultural differences, however, this study shows that in most countries of Western Europe and the United States, cohabiting and married couples do have different fertility behaviors after having had one child together. Second conception risks within cohabitation are much lower, indicating that cohabitation should not be considered “an alternative to marriage” or “indistinguishable from marriage” (Heuveline and Timberlake


Cardiovascular disease (CVD) is the major cause of mortality in industrialized countries. Atherosclerosis is characterized by a long lag time between onset and clinical manifestations. There is evidence that CVD initiate before birth by developmental changes in utero. Genetic and environmental factors may interact in specific periods of life , giving rise to altered developmental plasticity and epigenetic modifications with abnormal phenotypic expression of genetic information without altering DNA sequence. Nutritional imbalances and other environmental clues may cause intrauterine growth delay, decreased gestational age, low birth weight and postnatal catch-up growth. Fetal exposure to maternal hypercholesterolemia has been associated with increased risk and progression of atherosclerosis. Oxidative stress seems to play a major role in the atherosclerotic process by activating both platelets and monocytes forming proinflammatory and proaterogenic substances, resulting in endothelial dysfunction, decreased flow-mediated dilation, and increased carotid intima-media thickness ,2. CVD p


American Journal of Medical Genetics Part A Published by Wiley Periodicals, Inc.The aim of this study was to determine if syndrome‐specific birth weight charts were beneficial for babies with Down syndrome in England and Wales. Birth weights of 8,825 babies with Down syndrome born in England and Wales in 1989–2010 were obtained from the National Down Syndrome Cytogenetic Register. Birth weight centiles for 30–42 weeks gestation by sex were fitted using the LMS method and were compared to those for unaffected babies from the UK‐WHO growth charts. For babies born with Down syndrome the median birth weight from 37 to 42 weeks was 2,970 g  for boys and 2930 g  for girls, and the modal age of gestation was 38 weeks, 2 weeks earlier than for unaffected babies. At 38 weeks gestation they were only slightly lighter than unaffected babies (159 g for boys and 86 g for girls). However at 40 weeks gestation the shortfall was much greater . In neonates with Down syndrome there is little evidence of growth restriction before 38 weeks gestation, so up to this age it is appropriate to use the UK‐WHO birth weight charts. Thereafter birth weight is below that of unaffected babies and it should be plotted on the UK Down syndrome growth charts. © 2015 The Authors.  Growth charts show that early in life babies with Down syndrome gain weight more slowly than unaffected babies [Piro et al., The NDSCR was set up on January 1st 1989, and currently holds anonymous data on over 33,000 ante‐ or postnatal diagnoses of Down syndrome obtained from all clinical cytogenetic laboratories in England and Wales [Mutton et al., Virtually every baby with clinical features suggesting Down syndrome, and any antenatal diagnostic sample from a pregnancy suspected to have Down syndrome, receives a cytogenetic examination because the definitive test for the condition is the finding of trisomy 21. The data in the register are obtained from all clinical cytogenetic laboratories in England and Wales, which are requested to send a completed form for each such diagnosis and its variants. The form contains details of the date, place of birth, and indications for referral, maternal age, and family history. Most laboratories send a copy of this form to the referring physician for confirmation and completion. The gestational age was estimated from the date of the last menstrual period (LMP), and was usually confirmed by ultrasound.Comparisons with other congenital anomaly registers and the http://www.R-project.org/) using the gamlss package [Rigby and Stasinopoulos, 100α were derived using the formulaα is the standard deviation for tail area α under a Normal distribution. This leads to approximate 2nd, 9th, 25th, 50th, 75th, 91st, and 98th centiles using the two‐thirds of a standard deviation spacing proposed by Cole [Centiles were fitted to the birth weight data with the LMS method [Cole and Green,  by Cole .The birth weight centiles were compared with those for unaffected babies from the revised UK‐WHO growth charts [Cole et al., The secular trend in birth weight was examined using linear regression of birth weight SD score on year of birth. The association between gestational age and missing birth weight was estimated using logistic regression.33,767 diagnoses of Down syndrome were recorded in the register from January 1st 1989 to December 31st 2011, from which 8,825 live births with free trisomy 21 and complete information on birth weight and gestational age were extracted  were lighter than unaffected babies Fig. . This coThere is a relatively high rate of spontaneous fetal loss in Down syndrome pregnancies [Savva et al., The birth weight charts for US babies with Down syndrome derived by Boghossian et al.  gave simHeart anomalies are also relevant, as 44% of babies with Down syndrome have a heart anomaly [Morris et al., Smith and McKeown  questionIn unaffected babies, slowing of intrauterine growth after the modal gestational age of 40 weeks is considered a surrogate marker for incipient postmaturity and signals a need for enhanced obstetric vigilance and possible intervention. For babies with Down syndrome, slowing of intrauterine growth appears to occur from the modal gestational age of 38 weeks, hence there may be an earlier onset of incipient postmaturity in this population and enhanced vigilance may be necessary from this time.P = 0.2). Mode of delivery was also unavailable and it may be that growth restriction was an indication for induced delivery before 38 weeks. However this is unlikely because mean birth weight was similar to that for unaffected babies up to 38 weeks. Detailed information on other associated anomalies  was not available.Direct measures of intrauterine growth in late pregnancy are not available for babies with Down syndrome. Hence in our study and those of others [Clementi et al., Marlow has recently challenged the accepted view that for the general population the optimum time for delivery is 37–41 weeks gestation (full term) Marlow, . He provThere is a need for information about the associations between gestational age at delivery and short and long‐term outcome measures in babies with Down syndrome. Some of this might be available by linking existing cohorts and registers.http://www.dsmig.org.uk/publications/growthchart.html). The distribution of birth weight in this study was similar to that of Styles et al (medians 3.06 and 3.00 kg respectively).The widely used UK‐WHO growth charts include a birth weight chart for 32–42 weeks gestation [Cole et al., The modal age at delivery in babies with Down syndrome is 38 weeks. For gestations up to 38 weeks their median birth weight is similar to that for unaffected babies, but after 38 weeks their median birth weight rises less fast than for unaffected babies. This may have implications for perinatal clinical practice.TJC was funded by UK Medical Research Council grant MR/M012069/1.


In Tanzania, there is currently a paucity of BD data necessary to develop data informed prevention activities.A cross-sectional analysis was conducted of deliveries identified with BD in the labor ward registers at four Dar es Salaam hospitals between October, 2011 and February, 2012. The birth prevalence of structural BD, case fatality proportion, and the distribution of structural defects associated deaths within total deaths were calculated.A total of 28 217 resident births were encountered during the study period. Overall birth prevalence of selected defects was 28.3/10 000 live births. Neural tube defects and indeterminate sex were the most and least common defects at birth . Among stillbirths (66.7%) and deaths that occurred within less than 5 days of an affected live birth (18.5%), neural tube defects were the most frequently associated structural defect.Structural BD is common and contributes to perinatal mortality in Dar es Salaam. More than half of perinatal deaths encountered among the studied selected external structural BD are associated with neural tube defects, a birth defect with well–established evidence based prevention interventions. By establishing a population–based BD surveillance program, Tanzania would have the information about neural tube defects and other major structural BD needed to develop and monitor prevention activities. A birth defect is an abnormality of structure or function which originates during intrauterine life and is evident before birth, at birth or manifests later in life . Major sBirth defects may be mild or severe. Major structural birth defects include congenital heart disease (CHD), neural tube defects (NTDs), orofacial clefts, and limb reduction defects; these defects are considered severe, having adverse effects on the well-being and survival of children born with those anomalies ,2. AlmosIn Tanzania, it is estimated that the prevalence of birth defects is 60.5 per 1000 live births . StudiesThis study included all newborns delivered from October, 2011 through February, 2012 in Dar es Salaam from Muhimbili National Hospital (MNH) and all three Municipal hospitals . Ninety percent of births to Dar es Salaam residents occur in a health facility, and 72% of Dar es Salaam residents deliver at Muhimbili National Hospital or at one of the three municipal hospitals ,7. TheseA case was defined as any live birth or stillbirth identified at delivery with a selected external major birth defect in any of the four hospitals during the study period. Study data came from a review and abstraction of labor ward registers during the study period (October 2011 to February 2012). Data were abstracted daily by trained midwives. Labor ward admission and discharge procedures were similar in all study sites. Every pregnant woman who was in labor pain was admitted and registered. Her particulars like name, age, place of residence, gravity and parity are recorded. After giving birth, a complete clinical evaluation of the infant is done by the Medical Officer and if he/she had any medical problem including birth defects, he/she is sent to the neonatal unit for further care and treatment. If he/she has no problem, the baby is given to his/her mother, which will stay at least 24 hours before being discharged.The international classification of diseases version 10 (ICD10) was used to code selected external major structural defects . The selData were entered, cleaned, and analyzed using Epi Info Version 3.5.1. . The birth prevalence of selected major structural defects was calculated by dividing the total number of newborns (live and stillbirths) with selected structural defects  delivered during the study period (Numerator) by the total number of live births delivered at participating hospitals during the same time period (Denominator) . The disThe protocol for this study was approved by the Internal Review Board of Muhimbili University of Health and Allied Sciences (MU/PGS/SAEC/Vol.VI/2011) and Muhimbili National Hospital (No. 150 2011/2012). Names of respondents were not recorded in the data collection form and measures were taken to ensure confidentiality and security of the information collected.During the study period, a total of 28 217 deliveries occurred in the four participating hospitals of which 27 230 were live births. Seventy seven newborns (28.3 per 10 000 live births) had one of the selected external major structural defects. Of the 77 newborns with selected structural defects, 38 (49.3%) were males, 36 (46.8%) females and 3 (3.9%) had undetermined sex , while19.5% had multiple anomalies and 6.5% had syndromes. Overall, 76.6% of deliveries (live births + stillbirths) with selected external structural defects survived at least 5 days, with 15.6% dying prior to delivery (stillbirth), and 7.8% dying within 5 days of delivery (In the diverse birth population of Dar es Salaam, we observed that NTDs, one of the selected external structural defects with the greatest opportunity for prevention, were the most prevalent structural defect followed by musculoskeletal defects. This finding is in contrast to other studies conducted in different parts of the world – Uganda, Nigeria, South Africa and Israel– where musculoskeletal defects were the most common birth defects –14. ThisWe did not identify a significant birth defect prevalence difference when considering only live births and total deliveries as denominators. Isolated birth defects were more common than multiple and syndrome birth defects, a finding similar to a prospective neurosurgical observational study done in Nigeria to assess central nervous system congenital anomalies . Among NEvidence shows that preconceptional use of folic acid helps prevent NTDs, and many countries are implementing mandatory fortification of folic acid in cereals –28. In tInterpretation of these study findings need to be considered in relation to several strengths and weaknesses. One of the major strengths of this study is that all births were thoroughly evaluated during the study period by clinical professionals. This made it possible to capture birth defects among stillbirths or births that survived less than 5 days, which would not have been possible if our study ascertained birth defects by either retrospective review of data from neonatal units or collecting data from either neonatal admission units or birth defects clinics alone. These alternative approaches would have resulted in underestimating the burden of structural birth defects included in this study. An additional strength of this study is the involvement of multiple public hospitals, representing the majority of deliveries to Dar es Salaam residents and covering people with a diversity of demographic characteristics and health related behaviors.This study was limited by the duration of follow–up. Newborns with structural birth defects were followed up for only 5–days, and so the contribution of the selected structural defects to early mortality is a likely underestimate, though there is no evidence that the distribution of selected defects among deaths would differ at 2–weeks or 1–month after delivery. Also only selected major external birth defects were included during the study period to facilitate identification and avoid under reporting. Internal major birth defects were not included due to limitations in technology to diagnose them. Another limitation of this study was that it only included hospital deliveries, which could have either led to underestimation or overestimation of birth prevalence; however, 90.2% of births to Dar es Salaam residents occur in health facilities . Our stuThis study demonstrates that structural external major birth defects are frequent in clinical practice in Dar es Salaam. NTDs were the most common occurring, followed by musculoskeletal defects and orofacial clefts. The majority of stillbirths with selected external structural defects were associated with a neural tube defect which has a well–established evidence based prevention interventions. We can therefore lower perinatal mortality through preventing neural tube defects particularly spina bifida and anencephaly.By establishing a population based birth defects surveillance program, which can provide accurate and reliable estimates of the prevalence and risk factors for NTDs and other major birth defects, Tanzania will have the information necessary for the effective development and monitoring of birth defects prevention activities, including folic acid fortification.


Previous studies have reported decreased birth weight associated with increased air pollutant concentrations during pregnancy. However, it is not clear when during pregnancy increases in air pollution are associated with the largest differences in birth weight.Using the natural experiment of air pollution declines during the 2008 Beijing Olympics, we evaluated whether having specific months of pregnancy  during the 2008 Olympics period was associated with larger birth weights, compared with pregnancies during the same dates in 2007 or 2009.n = 83,672 term births to mothers residing in four urban districts of Beijing, we estimated the difference in birth weight associated with having individual months of pregnancy during the 2008 Olympics (8 August–24 September 2008) compared with the same dates in 2007 and 2009. We also estimated the difference in birth weight associated with interquartile range (IQR) increases in mean ambient particulate matter ≤ 2.5 μm in aerodynamic diameter (PM2.5), sulfur dioxide (SO2), nitrogen dioxide (NO2), and carbon monoxide (CO) concentrations during each pregnancy month.Using 2.5 (19.8 μg/m3), CO (0.3 ppm), SO2 (1.8 ppb), and NO2 (13.6 ppb) concentrations during the 8th month of pregnancy were associated with 18 g , 17 g , 23 g , and 34 g  decreases in birth weight, respectively. We did not see significant associations for months 1–7.Babies whose 8th month of gestation occurred during the 2008 Olympics were, on average, 23 g larger  than babies whose 8th month occurred during the same calendar dates in 2007 or 2009. IQR increases in PMShort-term decreases in air pollution late in pregnancy in Beijing during the 2008 Summer Olympics, a normally heavily polluted city, were associated with higher birth weight.http://dx.doi.org/10.1289/ehp.1408795Rich DQ, Liu K, Zhang J, Thurston SW, Stevens TP, Pan Y, Kane C, Weinberger B, Ohman-Strickland P, Woodruff TJ, Duan X, Assibey-Mensah V, Zhang J. 2015. Differences in birth weight associated with the 2008 Beijing Olympics air pollution reduction: results from a natural experiment. Environ Health Perspect 123:880–887;  In a mestation) . Howeverstation) .10 concentrations were reduced by about 43% (from 90 μg/m3 to 51 μg/m3)  , we prev1 μg/m3) . Althoug2.5 exceeding 100 μg/m3 , carbon monoxide (CO), sulfur dioxide (SO2), sulfate, elemental carbon, organic carbon] monitored between June and October of 2008 decreased during this Olympics/Paralympics period by 18–59% from pre-Olympics levels  with at least 1 month of pregnancy during the Olympics/Paralympics period would have higher birth weights than pregnancies with those same gestational months during 8 August–24 September 2007 or 8 August–24 September 2009 (hypothesis 1). Further, using our air pollution data from 2 June to 30 October 2008, we hypothesized that increased air pollution concentrations would be associated with decreased birth weights among term births in pregnancies with at least 1 month of pregnancy (months 1–8) occurring between 2 June and 30 October 2008 (hypothesis 2). Our first goal was to evaluate whether short periods of pregnancy during the time of lowered overall air pollution levels would be associated with increased birth weight. Our second goal evaluated whether specific air pollutants were associated with these birth weight changes.Study population and birth data. Records of Beijing births are created and maintained by the Beijing Obstetrics and Gynecology Hospital. Using this birth registry, we included all singleton live births of infants who had ≥ 28 completed weeks of gestation occurring between 1 January 2007 and 31 December 2010 to mothers who resided in one of four adjacent Beijing districts  at the time of birth . Gestational age was calculated as the number of complete weeks since the end of the last menstrual period. For each birth/pregnancy, we also obtained the following variables: birth weight (grams), maternal age at birth (years), gestational week of first medical checkup during pregnancy, maternal occupation, maternal education level, pregnancy complications , and whether the pregnancy resulted in a live birth or stillbirth. Gestational hypertension was defined as systolic blood pressure ≥ 140 mmHg, diastolic blood pressure ≥ 90 mmHg, or both, on two or more occasions at least 4 hr apart in normotensive women after 20 weeks gestation. Preeclampsia was defined as new-onset hypertension, in addition to new-onset proteinuria, or in the absence of proteinuria, new-onset end-organ dysfunction after 20 weeks gestation . Eclampsia was defined as preeclampsia with grand mal seizures. Fetal macrosomia was defined as a birth weight > 4,000 g regardless of gestational age. Fetal distress was defined as the presence of signs or symptoms that the fetus was not well, including decreased movement felt by the mother, meconium in the amniotic fluid, a nonreassuring fetal heart rate pattern, or fetal acidosis. Placental abruption was defined as premature separation of a normally implanted placenta from the uterus after 20 weeks gestation. Threatened preterm labor was defined as documented uterine contractions without evidence of cervical change. Preterm labor was defined as documented uterine contractions associated with evidence of cervical change, with the delivery ended before 37 weeks gestation. Polyhydramnios was defined as excess amniotic fluid volume (AFV) or index (AFI) , whereas oligohydramnios was defined as amniotic fluid volume less than expected for gestational age (AFV ≤ 2 cm or AFI ≤ 5 cm). Premature rupture of membranes was defined as rupture of the amniotic sac before labor began.n = 73), and those with a gestational age at birth of > 41 weeks , so as to avoid errors in gestational age and birth weight. We did not have data on the infants’ sex or mode of delivery . After deleting 5,809 births with dates of last menstrual periods before 19 June 2006 and after 31 March 2010 to avoid fixed cohort bias (because we were studying both preterm birth and birth-weight effects of air pollution) , leaving 127,904 term births  available for analysis. This study was approved by the Research Subjects Review Board at the University of Rochester Medical Center and the Ethics Review Committee of Peking University Health Sciences Center in Beijing, China.We then excluded births with weights more or less than 5 standard deviations above or below the mean (llution) , we thenAir pollution and weather. First, we obtained daily PM10, NO2, and SO2 concentrations averaged across the air pollution monitoring stations located in the same four Beijing districts  in which our study subjects lived from 8 August to 24 September in 2007, 2008, and 2009. We then used these daily Beijing-average concentrations to describe the differences in mean pollutant concentrations observed in 2007, 2009, and 2008 during the Olympics for descriptive purposes only (hypothesis 1).2.5 and CO (2·5) using a tapered element oscillating microbalance (TEOM) from 2 June to 30 October 2008. We also measured gaseous pollutants  during these same times using monitors that were calibrated and maintained following manufacturer’s protocols . We measured ambient temperature and relative humidity (RH) at the same site. All the samplers and monitors were collocated on the rooftop of a seven-story building in the center of the Peking University First Hospital campus, located in central Beijing. The First Hospital pollutant concentrations were well correlated with the Beijing average pollutant concentrations . These pollutant and weather data were used in our statistical analyses for hypothesis 2 described below.Second, we used our previously collected air pollution and weather measurements, which included PM5 and CO , in our Statistical analyses. Hypothesis 1. First, using the date of birth and gestational age included in the data set, we calculated the beginning and end of each month of pregnancy. We then included only those pregnancies ending in a term birth with at least 24 days of pregnancy in a given month  occurring in the 47 days between 8 August and 24 September in 2007, 2008, or 2009. This definition ensures that any subject has at most 1 month of pregnancy in the Olympics period in our analysis. For simplicity of presentation, we defined the 1st month of pregnancy to begin with the 1st day after the last menstrual period. No attempt was made to correct for the date of conception. Using these 71,803 births, we calculated descriptive statistics for subject characteristics by year. In preparation for model fitting, using all 71,803 term births, we fit a semiparametric additive model , in which birth weight was modeled as a smooth function of maternal age with 4 degrees of freedom. We then re-ran these analyses including the covariates described above. The smooth function was estimated by a smoothing spline, using the gam package in R. We used results from these models to estimate the difference in birth weight among term births (with 95% CI) associated with having a specified month of pregnancy during the 2008 Olympics period, compared with having that same month of pregnancy during the same dates in 2007 or 2009.2.5 concentration in the 1st month of pregnancy for each study subject. We also included indicator variables for gestational age (complete weeks) at delivery, residential district, maternal education , linear terms for the mean temperature and relative humidity levels during the same 1st month of pregnancy, and a smooth term for maternal age (smoothing spline with 4 degrees of freedom). We repeated this same model to estimate the difference in birth weight associated with the mean 1st month SO2, NO2, and CO concentrations. We then repeated these analyses for the 2nd, 3rd … 8th month mean pollutant concentrations in the same manner.Hypothesis 2. Starting from the 127,904 births, we included only term births with at least 1 month of pregnancy (months 1–8) occurring between 2 June and 30 October 2008 (time period for which we measured the air pollutants described above), leaving 32,506 births  available for analysis. We calculated descriptive statistics for air pollutant concentrations, weather conditions, and subject characteristics for these births. We then calculated mean pollutant concentrations, temperature, and relative humidity for each gestational month for all months where at least 75% of the measured values were not missing. Again using semiparametric additive models, we regressed birth weight on the mean PMSensitivity analyses. To examine whether our findings were limited to pregnancies with one or more pregnancy complications , we restricted our analyses to those without a pregnancy-related hypertensive disorder  and then again to those without a fetal placental condition . We did not have data on preexisting hypertension. We then re-ran the same set of models described above. Next, for each year separately, we generated Q-Q plots of residuals from our hypothesis 1: 8th month model described above. In these plots, residuals were sorted, and the sorted values were plotted against the expected sorted birth weight values from a normal distribution with the same mean and variance. If the model residuals had an exact normal distribution, the points would fall on the diagonal 1:1 line. We were interested in deviations from normality in the extreme values . If deviations from normality at the upper or lower tails differed for 2008 compared with 2007 or 2009, this would suggest differences in birth weight associated with the 2008 Olympics period were restricted to either small or large for gestational age babies. Last, we examined whether our findings were limited to pregnant women residing in only one Beijing district or only to women who were college graduates . We estimated the difference in birth weight associated with having a specific month of pregnancy during the 2008 Olympics period compared to the same calendar dates in 2007 or 2009, for pregnant women living in each district separately, by adding interaction terms  to these models. Similarly, we estimated these same birth weight differences for women with a bachelor’s degree or more, some technical school, or high school or less, separately adding interaction terms to the models . We used SAS version 9.32  to construct all datasets and conduct descriptive analyses, and R (version 2.15.1) to perform all semiparametric additive model analyses.Hypothesis 1. Characteristics of the study subjects included in hypothesis 1 analyses  are shown in 10, NO2, and SO2 concentrations were substantially lower in 2008 during the Olympics than during the same dates in 2007 or 2009  and increase  in birth weight, respectively . After an = 189) of pregnancies with a pregnancy-related hypertensive disorder and then the 12.9%  of pregnancies with a fetal placental condition, having the 8th month of pregnancy during the 2008 Olympics period instead of the same dates in 2007 or 2009 was still associated with significant 24-g  and 22-g  increases in birth weight, respectively. Further, Q-Q plots revealed similar patterns of residuals in the upper and lower ends of the birth weight distribution across all 3 years , or to small or large birth weight babies. When excluding the 2.0%  are shown in 2.5 concentrations were highly correlated with both their SO2 (r = 0.86) and CO mean concentrations (r = 0.71), but slightly negatively correlated with NO2 concentrations (r = –0.25) (2 concentrations were highly inversely correlated with both temperature (r = –0.96) and relative humidity means (r = –0.70). Monthly mean PM2.5 concentrations were moderately correlated with temperature (r = 0.41), but monthly mean SO2 and CO concentrations were not (r ≤ 0.10). Monthly mean PM2.5, SO2, and CO concentrations were only weakly correlated with monthly mean relative humidity levels (r ≤ 0.28).= –0.25) . Monthly2.5, SO2, and CO concentration in the 8th month of pregnancy were associated with significant decreases in birth weight, after adjustment for gestational age at delivery, residential district, maternal education, and mean temperature and relative humidity in the same month . However, our findings are inconsistent with those of Our finding of greater birth weight associated with lower air pollution levels during the natural experiment of the Beijing Olympics is consistent with recent work by in China . SimilarPotential mechanistic explanations. Our finding of increased birth weight associated with decreased pollutant concentrations in the 8th month of pregnancy may suggest potential mechanisms acting during that time of pregnancy, including those mechanisms that affect maternal, placental, or fetal health. Maternal factors associated with poorer fetal growth include maternal hypertension and cardiopulmonary disease. Though exposure to air pollution in pregnancy has been associated with an increased risk of hypertensive disorders later in pregnancy , as well as an increased risk of placental notching during the third trimester . 10 concentrations during the last month of pregnancy were associated with decreased placental mitochondrial DNA content, which have been associated with increased oxidative stress and inflammation. Increased maternal C-reactive protein levels have also been associated with increased pollutants concentrations during pregnancy . . . Furtherarbons). , these pThis estimated increase in birth weight associated with having the 8th month of pregnancy during the 2008 Olympics period, compared with the same dates in 2007 and 2009, could be due to residual confounding by socioeconomic status. If women of lower socioeconomic status , who are also at higher risk of adverse pregnancy outcomes  moved out of the study area during the 2008 Olympics, this could explain the estimated increase in birth weight associated with the 2008 Olympics. However, we do not feel this was the case, because women in 2008 had a larger proportion with a bachelor’s degree (54.7%) than women in 2007 (50.8%). Residual confounding by other factors such as maternal stress and noise associated with living near the Olympics venues or Olympics traffic could also affect the estimated birth weight difference.We did not have data on several potential confounders, including parity, prepregnancy body mass index, smoking, attendance at prenatal care visits, and race/ethnicity. However, China’s Family Planning Policy , enacted in 1979, restricted the number of children married couples in Beijing could have during the study period to one, with exceptions for those living in rural areas, ethnic minorities, and for couples where each partner had no siblings. Therefore, one can assume that almost all of the pregnancies included in this study are the first child for each pregnant woman. Second, smoking rates in women living in Chinese cities are generally low. A recent letter reported that in 2010, an estimated 28.1% of adults in China (52.9% of men and 2.4% of women) were current smokers, and that the prevalence was significantly higher among rural residents than urban inhabitants , such asThis 47-day reduction in ambient air pollutant concentrations during the Beijing Olympics and Paralympics may be too short a time period for beneficial reproductive health effects to be observed if this air pollution reduction occurred early in pregnancy. For example, for pregnancies with their 1st, 2nd, or 3rd months of pregnancy during the Olympics, it is possible that any beneficial fetal growth effect of an Olympics air pollution reduction during these times was then masked by adverse fetal growth effects of air pollution increases in months 4–9 when air pollution returned to the normally elevated levels after the Olympics. Our estimate of a 23-g bigger baby associated with having the 8th month of pregnancy during the Olympics period is a small increase relative to the median birth weight in our study population (< 1%). However, this size increase in birth weight may have been larger if the air pollutant concentration reductions lasted for several months or lasted the entire pregnancy.We did not have residential addresses during pregnancy, only the residential district at the time of delivery. However, air pollution reductions were observed across Beijing, and as long as subjects remained in Beijing, the substantially lower air pollutant concentrations in the summer of 2008 compared with 2007 and 2009 would be comparable proxies for subjects’ ambient air pollution exposures during these time periods. Because we did not have district-specific air pollutant measurements, we could also not assess whether pollutant/birth weight associations were different for each district.Last, China’s Family Planning Policy restricted the number of children married couples in Beijing could have during the study period to one, with few exceptions. This likely resulted in healthier pregnancies in this Beijing study population compared with the U.S. population , as evidence shows a lower preterm birth rate in Beijing in 2008 (3.3%) compared with that of the United States in 2008 (12.3%)  and 20122.5, SO2, and CO concentrations that we report should not suggest associations of individual pollutants with any health effects. Rather, the entire air pollutant mixture or specific components correlated with PM2.5, SO2, NO2, and CO concentrations in Beijing during this time may be responsible for these estimated improvements in birth weight late in pregnancy. Further work should replicate this finding, examine potential mechanistic explanations, and study health effects of specific pollutant mixtures .In summary, reductions in late-pregnancy ambient air pollution exposures were associated with increased birth weights among pregnant women living in Beijing during the 2008 Summer Olympics. However, the associations of birth weight with PM(164 KB) PDFClick here for additional data file.


Objective. To use cortical bone thickness (CBT) of the humerus to identify risk factors for the development of metabolic bone disease in preterm infants. Methods. Twenty-seven infants born at <32 weeks of gestational age, with a birth weight of <1,500 g, were enrolled. Humeral CBT was measured from chest radiographs at birth and at 27-28, 31-32, and 36–44 weeks of postmenstrual age (PMA). The risk factors for the development of osteomalacia were statistically analyzed. Results. The humeral CBT at 36–44 weeks of PMA was positively correlated with gestational age and birth weight and negatively correlated with the duration of mechanical ventilation. CBT increased with PMA, except in six very early preterm infants in whom it decreased. Based on logistic regression analysis, gestational age and duration of mechanical ventilation were identified as risk factors for cortical bone thinning. Conclusions. Humeral CBT may serve as a radiologic marker of metabolic bone disease at 36–44 weeks of PMA in preterm infants. Cortical bones of extremely preterm infants are fragile, even when age is corrected for term, and require extreme care to lower the risk of fractures. Metabolic bone disease (MBD) has been identified as one of the health problems associated with prematurity and results from mineral deficiency –3. RadioBMD measurements using dual-energy X-ray absorptiometry (DXA) are generally used to diagnose MBD and to assess the risk for fracture. The determination of measurements obtained by DXA tends to be variable, however, as they are influenced by the type of device, the measurement mode, and the analysis software. Moreover, preterm infants cannot easily undergo DXA measurement without sedation. Therefore, DXA may not be useful for the measurement of BMD of premature infants, especially during the early postnatal period when respiration and circulation are unstable.The radiographic measurements of cortical bone thickness (CBT) have been used to evaluate osteoporosis in adults , 7, withPreterm infants born at <32 weeks of gestational age and with a birth weight of <1,500 g, who were admitted to the Neonatal Intensive Care Unit (NICU) at the University of Fukui Hospital, between December 2008 and June 2015, were enrolled in this study. Infants with congenital malformations, chromosome abnormalities, and metabolic disease were excluded. The study was approved by the Institutional Ethics Committee at the University of Fukui. Parents provided written consent for their infants to participate in the study.2. Enteral feeding was initiated as soon as possible within the first postnatal week. Mother's milk was preferred; when each mother's milk volume reached 100 mL/kg/day, breast milk was fortified with 1.3 g/100 mL of HMS-1 , which contains 78 kcal, 2.0 g of protein, 99 mg of Ca, and 57 mg of P/100 mL, as well as 10–30 mg/kg/day of P supplements. When mother's milk was insufficient or unavailable, Meiji LW preterm formula was used , which contains 70 kcal, 2.0 g of protein, 65 mg of Ca, and 41 mg of P/100 mL. During the study period, we adjusted the daily intake of Ca, P, and vitamin D2 to maintain the serum Ca levels between 8.2 and 9.8 mg/dL, serum P levels between 5.0 and 7.0 mg/dL, urinary Ca/creatinine (Cr) between 0.3 and 0.5 mg/mg Cr, and urinary P/Cr between 0.5 and 1.0 mg/mg Cr.In our NICU, parenteral nutrition (PN) was initiated in preterm infants within the first day of life. Calcium  was routinely added to PN solutions, with phosphate  subsequently added within a week. PN solutions were also supplemented with 40–80 IU/kg/day of vitamin DCBT measures were calculated from chest radiographs routinely obtained to assess lung condition at birth at 27-28, 31-32, and 36–44 weeks of PMA and a body weight >2,000 g. Chest radiographs were retrospectively retrieved from the radiology database of the University of Fukui Hospital. Radiographs were obtained using a Siemens Mobilett XP Eco system , with a tube voltage of 60 kV and current time product of 1.6 mAs.M1). The width of the intramedullary canal on the same line was determined (M2). CBT was calculated by subtracting M2 from M1 and dividing by 2. All measurements were made by observers who were blinded to the infants' background.The medial and lateral CBTs of the humeral diaphysis were calculated by adapting the methods previously reported by Tingart et al.  and MathDemographic and clinical data regarding the infants' perinatal and postnatal courses were extracted from the medical records. Serum Ca, P, and alkaline phosphatase (ALP) levels, and urinary Ca/Cr, P/Cr and tubular reabsorption of P levels were determined at a PMA of 36 to 44 weeks.The independent variables were gestational age; birth weight; small for gestational age (SGA) status; sex; prenatal steroid use; duration of mechanical ventilation; duration of intravenous sedation; postnatal complications, such as respiratory distress syndrome, patent ductus arteriosus (PDA), intraventricular hemorrhage, cystic periventricular leukomalacia, necrotizing enterocolitis, early and late hemoculture positive for sepsis, bronchopulmonary dysplasia (BPD), retinopathy of prematurity, and fracture; treatments administrated, such as total dosage of hydrocortisone, diuretic drug use, number of days with enteral feeding >100 mL/kg/day, and Ca/P/vitamin D supply at that point; PMA; and body weight at the time of radiographic evaluations. PDA was defined as a requirement for indomethacin treatment and/or surgical closure. BPD was defined as oxygen dependence at 28 days of life.U and Fisher exact probability tests were used to analyze the data. Correlations were evaluated using the nonparametric Spearman rho test. The data are presented as medians (ranges). A p value < 0.05 was denoted to be a statistically significant difference. Stepwise logistic regression analysis was performed using SPSS software, version 14.0 . To establish a final regression model, a stepwise downward selection model was used, starting with a prespecified set of candidate variables. An entry criterion of p < 0.05 was used for statistical significance during this process.The Mann-Whitney During the study period, 555 infants were admitted to our NICU and 70 infants had a gestational age of less than 32 weeks and a birth weight of less than 1,500 g. Twelve infants were excluded from our study because of death, chromosomal abnormality, or hospital transfer before 36 weeks of PMA. In 27 out of the remaining 58 infants, eligible chest radiographs, including the whole length of right or left humerus, had been obtained at 36–44 weeks of PMA and at the time point of body weight >2,000 g. Among this group, 25 infants also had adequate chest radiographs obtained at birth. In addition, some infants had undergone radiographic evaluation at two different times, namely, at 27-28 and 31-32 weeks of PMA. The demographic data of the 27 infants included in our analysis are listed in ρ = 0.51, p < 0.05) and birth weight  and negatively correlated to duration of mechanical ventilation , lower birth weight , and longer mechanical ventilation period . Bone fractures occurred in two infants in the decreasing CBT group. These infants were born at a gestational age of 22 weeks and their fractures were recognized at 87 and 103 days of age.For the majority of infants, CBT increased as with PMA. In six infants, however, the CBT gradually decreased by 20% or more, from birth to 36–44 weeks of PMA . ComparaSerum ALP levels and urinary P/Cr levels of infants in the decreasing CBT group were significantly higher than those in the nondecreasing CBT group. There were no significant between-group differences in serum Ca and P levels or urinary Ca/Cr levels at 36–44 weeks of PMA .p = 0.017, odds ratio (OR), 0.27) and duration of mechanical ventilation  were identified as significant risk factors, but not birth weight or total dosage of hydrocortisone (The risk factors for decreasing CBT were evaluated by univariate logistic regression analysis. Gestational age (ortisone . FinallyIn the present study, we demonstrated that the risk factors of MBD, a younger gestational age, lower birth weight, and longer duration of mechanical ventilation, are also associated with decreasing humeral CBT. As CBT values at birth were comparable across all infants in our study group, our findings underline the importance of continued monitoring of CBTs in preterm infants, regardless of gestational age and birth weight.MBD is diagnosed by radiological changes and its severity classified by the radiological characteristics observed in rickets . HoweverThe incidence of bone fractures in preterm infants has been reported to be between 1.2% and 10.5% –11. MostFetal bone mineralization occurs during the last trimester of gestation, with deposition of 80% of the mineral contents of term newborns . TherefoCatache and Leone demonstrated that increased urinary Ca concentration reflected the development of MBD . UrinaryA possible limitation of this study is the small sample size. Since chest radiographs were retrospectively analyzed, one-third of the preterm infants failed to undergo chest radiography that included the whole length of the humerus. Additionally, we could not assess the correlation between the BMD measured by DXA and cortical bone thickness.In conclusion, our data indicate that humeral CBT gradually increases after birth and that it may be a reliable predictor of ongoing MBD in very premature infants. Attention is needed in handling very early premature infants with decreasing CBT to reduce the risk for fractures. It is also imperative that doses of Ca, P, and vitamin D supplementation are adjusted for each infant to optimize bone development over the early postnatal period and likely beyond.


Ectopia cordis is a rare congenital defect where the heart is completely displaced outside the chest wall. Cantrell's pentalogy is an embryologic anomaly with five classic midline deficiencies often associated with ectopia cordis. Here we present a case of thoraco-abdominal ectopia cordis, brief literature review, and possible implications for changes in antenatal care. Thoraco-abdominal ectopia cordis is an uncommon congenital malformation that can present anywhere in the world. It is often associated with Cantrell's pentalogy of anomalies. Treatment usually consists of staged-surgical repair in highly specialized medical centres. The prognosis is historically poor although advances in early diagnosis and surgical technique have led to improved survival. Early diagnosis through obstetric ultrasound would allow for improved informed clinical decision making on the part of the physician and family.A 23-year-old G3P1010 at 41 + 1 weeks presented with spontaneous rupture of membranes and regular contractions. Due to an increasing foetal heart rate and thick meconium, the patient subsequently underwent an urgent caesarean section for foetal distress.The mother's gynaecological history was significant for a spontaneous abortion at 4 weeks and an intrauterine foetal demise (unknown cause) at 27 weeks with a subsequent uncomplicated vaginal delivery of the expired foetus. There was no family history of congenital abnormalities.The mother had no ultrasound during the current pregnancy. She had no known exposure to teratogens. At 25 + 4 weeks she was treated for severe malaria with intramuscular Artemether. She received the normal tetanus vaccinations, sulfadoxine/pyrimethamine malaria prophylaxis, and folic acid + iron vitamins during her pregnancy. Other than mild anaemia (Hb 10.5 g/dl) she appeared to have an uncomplicated pregnancy.The neonate at time of caesarean had a nuchal cord wrapped round his neck and head. His APGARS were 8, 10, & 10 at 1, 5, and 10 minutes, respectively. He weighed 3.5 kilograms with a head circumference of 34 centimetres and a length of 50 centimetres.He appeared vigorous with spontaneous breathing and excellent tone on examination. The sternum was absent and the heart was completely outside the chest, covered with a thin serous membrane. The upper abdominal wall and anterior diaphragm were both absent, presenting an open abdominal wall defect with a three-vessel umbilical cord that inserted into the lower abdominal wall. The chest wall rose symmetrically with respiration. No echocardiography was performed to diagnose any intracardiac defects. Findings were consistent with a thoraco-abdominal ectopia cordis. The infant was immediately referred to a tertiary paediatric hospital in the country's capitol but died en route within hours. No autopsy was performed .Ectopia cordis is a rare congenital malformation. An incidence of ectopia cordis was reported to be 5.5 to 7.9 per 1 million live births by Chandran S. et al . Likely Ectopia cordis is postulated to start early in the embryonic period around the 8th and 9th week of pregnancy . Kumar BCantrell JR, et al. are thought to be the first to describe a pentalogy of malformations in 1958, of which ectopia cordis is often associated. Cantrell's pentalogy consists of (1) midline supra-umbilical abdominal wall defect; 2) defect of the lower sternum; (3) deficiency of the anterior diaphragm; (4) defect in diaphragmatic pericardium; (5) congenital intracardiac defects . Ectopia defect oKumar B, et al. cite that variations of Cantrell's pentalogy can be classified according to the number of defects found: Class 1 composes an exact diagnosis where all five of the defects are present; class 2 is deemed a probable diagnosis when four, including intracardiac and abdominal wall defects, are present; class 3 is termed an incomplete diagnosis when at least two of Cantrell's anomalies are noted where one is sternal . AccordiBoth intracardiac and other associated anomalies have been reported with ectopia cordis. In order of decreasing prevalence, intracardiac defects include ventricular septal defect, atrial septal defect, tetralogy of Fallot, left ventricular diverticulum, and pulmonary hypoplasia . Other rThe prognosis of complete ectopia cordis depends on the degree of intracardiac and associated malformations. Untreated it is fatal . TypicalEctopia cordis is a rare congenital malformation with a complicated prognosis related to associated anomalies and prenatal and postnatal management. Given the increasing availability of ultrasound, this case could have been diagnosed early in pregnancy. Sonographers must remember to be vigilant for rare congenital anomalies. In a limited resource setting with difficulties in transportation and limited skilled facilities to care for complicated surgical cases, an antenatal diagnosis would have allowed the physician and parents to have a frank discussion about the prognosis and their options. An emergency caesarean section may have been avoided if the pregnancy was deemed incompatible with life. The mother could have delivered at the tertiary pediatric hospital if surgical correction was deemed feasible and desired by the parents.


The importance of maternal sanitation behaviour during pregnancy for birth outcomes remains unclear. Poor sanitation practices can promote infection and induce stress during pregnancy and may contribute to adverse pregnancy outcomes (APOs). We aimed to assess whether poor sanitation practices were associated with increased risk of APOs such as preterm birth and low birth weight in a population-based study in rural India.n = 670) in their first trimester of pregnancy was enrolled and followed until birth. Socio-demographic, clinical, and anthropometric factors, along with access to toilets and sanitation practices, were recorded at enrolment (12th week of gestation). A trained community health volunteer conducted home visits to ensure retention in the study and learn about study outcomes during the course of pregnancy. Unadjusted odds ratios (ORs) and adjusted odds ratios (AORs) and 95% confidence intervals for APOs were estimated by logistic regression models. Of the 667 women who were retained at the end of the study, 58.2% practiced open defecation and 25.7% experienced APOs, including 130 (19.4%) preterm births, 95 (14.2%) births with low birth weight, 11 (1.7%) spontaneous abortions, and six (0.9%) stillbirths. Unadjusted ORs for APOs , preterm birth , and low birth weight  were found to be significantly associated with open defecation practices. After adjustment for potential confounders such as maternal socio-demographic and clinical factors, open defecation was still significantly associated with increased odds of APOs  and preterm birth  but not low birth weight . The association between APOs and open defecation was independent of poverty and caste. Even though we accounted for several key confounding factors in our estimates, the possibility of residual confounding should not be ruled out. We did not identify specific exposure pathways that led to the outcomes.A prospective cohort of pregnant women  with these outcomes is independent of poverty. Our results support the need to assess the mechanisms, both biological and behavioural, by which limited access to improved sanitation leads to APOs. Pinaki Panigrahi and colleagues examine the association between adverse pregnancy outcomes and sanitation practices in pregnant women in rural India. Pregnancy is usually a happy time for women and their families. But, for some women, pregnancy ends unhappily. Some women lose their baby during early pregnancy (spontaneous abortion or miscarriage) or during late pregnancy (stillbirth). Others have their baby earlier than expected (preterm birth) or have a baby with low birth weight, two outcomes that adversely affect the baby’s survival and long-term health. The burden of adverse pregnancy outcomes  is substantial across the world but is particularly high in resource-limited settings. More than 60% of all preterm births take place in Asia and sub-Saharan Africa, and in India alone nearly 13 million babies  had a low birth weight in 2010. Many risk factors for adverse pregnancy outcomes have been identified, including infection, diabetes, poor antenatal care, and other socio-economic factors, but a clear causal mechanism for adverse pregnancy outcomes has not been established.One potential risk factor for adverse pregnancy outcomes, particularly in resource-limited settings, is poor sanitation—the inadequate provision of facilities and services for the safe disposal of human urine and feces. The WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation estimates that, globally, 1.1 billion people defecate in the open, a practice that can expose individuals to contact with human feces containing infectious organisms and that can contaminate food and water. Poor sanitation might contribute to adverse pregnancy outcomes by promoting infection or by causing stress during pregnancy. Women might, for example, limit their intake of food and water to avoid having to use inadequate toilet facilities, thereby adversely affecting the health of their unborn child. Here, the researchers assess whether poor sanitation practices are associated with an increased risk of adverse pregnancy outcomes by undertaking a population-based prospective study in two rural areas of Odisha state, India. Odisha has a high infant death rate , only 18.2% of households have access to an improved latrine , and 75% of households practice open defecation.For their study, the researchers enrolled 670 women during the first trimester of their pregnancy. They recorded socio-demographic data , clinical data, weight and height, and toilet access and sanitation practices for each woman at enrollment and followed them through pregnancy until birth. Nearly two-thirds of the women practiced open defecation, and a quarter experienced an adverse pregnancy outcome, most commonly a preterm birth and/or having a baby with low birth weight. After adjustment for potential confounding factors , open defecation was significantly associated with adverse pregnancy outcomes  and with preterm birth, but not with low birth weight (a significant association is one that is unlikely to have happened by chance). Specifically, the adjusted odds ratios  of adverse pregnancy outcomes and preterm birth among women practicing open defecation compared with women with access to a latrine were 2.38 and 2.22, respectively. Notably, these associations were independent of poverty, caste, and religion.These findings indicate that, among women in Odisha, defecation in the open (poor sanitation) during pregnancy is associated with a higher risk of any adverse pregnancy outcome and of preterm birth than the use of a latrine. Counterintuitively, these findings also suggest that the association between open defecation and adverse pregnancy outcomes is not explained by poverty. Although the researchers adjusted for numerous confounding factors in their analysis, the women who defecated in the open may have shared some other unknown characteristic  that was actually responsible for their increased risk of an adverse pregnancy outcome. Further studies are now needed to determine the socio-behavioral and/or biological basis of the association between poor sanitation and adverse pregnancy outcomes. Appropriate public health interventions can then be designed to reduce the burden of adverse pregnancy outcomes among women living in settings where there is limited access to adequate sanitation.http://dx.doi.org/10.1371/journal.pmed.1001828.This list of resources contains links that can be accessed when viewing the PDF on a device or via the online version of the article at March of Dimes, a non-profit organization for pregnancy and baby health, provides information on pregnancy loss, preterm birth, and low birth weightThe Tommy’s, a UK non-profit organization that funds research into stillbirth, premature birth, and miscarriage, also provides information about adverse pregnancy outcomeswater, sanitation, and health The World Health Organization (WHO) provides information on WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation monitors progress toward improved global sanitation; its 2014 report on progress in water sanitation is available The water, sanitation, and health The children’s charity UNICEF, which protects the rights of children and young people around the world, provides information on Water Supply and Sanitation Collaborative Council and the non-governmental organization Practical Action provide information on approaches and technologies for improving sanitationThe PLOS Medicine Collection on water and sanitation and a Policy Forum by Velleman et al. on improving water, sanitation, and hygiene for maternal and newborn health are availableA  The burden of adverse pregnancy outcomes (APOs), which includes both preterm births and low birth weights ,2, is suThe World Health Organization (WHO) defines a birth weight of <2,500 g as low birth weight and a delivery before 37 completed weeks of gestation as preterm birth , infectiThe WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation (JMP) defines an improved sanitation facility as a facility that hygienically separates human excreta from human contact, such as a flush toilet, piped sewer system, septic tank, flush/pour flush to pit latrine, ventilated improved pit latrine, pit latrine with slab, or composting toilet . SimilarAt least some of these identified plausible mechanisms linking open defecation to APOs are supported by existing evidence. For example, there is good evidence that poor sanitation can promote hookworm infestation , which iExposure to unsafe water, unimproved sanitation, and poor waste management during pregnancy may increase the risk of infection, causing downstream effects such as low birth weight and preterm delivery. A recent systematic review  and a coTo the best of our knowledge, this is the first rigorous attempt to quantify the risk of APOs with access to improved sanitation and practice using a population-based cohort, with specific aims to quantify the prevalence of open defecation among pregnant women and its association with APOs.Ethical approval for the study was obtained from the Ethical Review Committee of the Asian Institute of Public Health, and the Institutional Review Board at Emory University . Written informed consent to participate in the study was obtained from each study participant at the time of recruitment. Participants were informed about the purpose of the study, and that they were free to withdraw from the study at any point. The survey team also received cultural competency and confidentiality training from a qualified trainer.The state of Odisha, home to 41.9 million people, has one of the highest infant mortality rates  and maternal mortality rates  in India . Odisha Since improved sanitation access and uses are associated with class, caste, and geography ,54, we aFor the current study, we utilised an existing population-based surveillance cohort with a combined population of 360,000, with approximately 60,000 married women of reproductive age (13–49 y). This cohort was established for the recently completed Aetiology of Neonatal Infection in South Asia (ANISA) study , where aWe conducted a population-based prospective cohort study. Assuming a 20.0% prevalence of APOs ,56–58, wThe survey instruments (questionnaires and observation checklists) were developed in three stages. First, a preliminary survey questionnaire was developed after literature review and inputs from key stakeholders. Second, a draft sanitation exposure assessment questionnaire was developed through focus group discussions with selected pregnant women and key informants in the community. Third, a pre-test was conducted using the preliminary questionnaire in nearby non-study villages to prevent contamination. After triangulation, the main survey administered by the trained CHVs addressed specific questions on sanitation and hygiene practices and conditions during recruitment. Visual observations of defecation sites were performed to confirm the interview response. Where a latrine was used, observational checklists were also used to inspect for the presence of a functional water source or water storage container at the latrine, type of latrine, visible faecal contamination on latrine floors, and presence of a hand-washing station with soap, detergent, or ash at or near the toilet. Other information, such as hand-washing practice after defecation and source of bathing water, was also collected. We defined “poor sanitation” according the JMP criteria of unimproved sanitation facilities and latrine use behaviour .We used the WHO definitions for all outcome measures . The priHousehold socio-demographic information, including maternal age at enrolment, education, religion, caste, and previous pregnancy history, was collected by CHVs using a structured instrument in face-to-face interviews. Since most of the pregnant women had limited knowledge on their family’s monthly income, we derived an indirect measure of household economic information from household characteristics and asset data  obtainedThe survey instruments, including the informed consent document, were translated into the local language (Odiya) and administered by the trained female CHVs. A unique study ID was assigned to each participant and used subsequently on all study forms. Surveys were administered inside the home of the participants, and all study forms, including the informed consent document, were transported by supervisors to a field office and then on to the study hospitals for storage in secure, locked metal cabinets. All personal identifiers were removed from the dataset and were kept along with the informed consent documents securely under the custody of the principal investigator. Only trained personnel had access to the rest of the survey documents for data entry and management.The survey instruments were piloted in villages from similar settings that were not included in the study. The quality of the data collected by the CHVs was ensured through direct supervision by respective field supervisors and subsequently by the programme manager. Supervisory visits and standardisation exercise sessions were organised routinely to ensure the quality of the data collected. Every reported outcome of interest was confirmed by a repeat visit to the household by supervisory staff. CHVs submitted data forms to their supervisor, who checked the forms for completeness and consistency. Double entry was done for all study forms into a custom-designed database management interface using the EpiInfo platform. The quality of the primary outcome measures  was ensured through a quality indicator of high gestational age at birth ; all birth weights were abstracted from medical charts at delivery. The quality of key exposure data (latrine access and use) was crosschecked with observational data supporting use of latrine or open defecation. For analysis and reporting purposes, all of the dataset passed the above quality assurance measures.We conducted cross-tabulation to explore frequencies and bivariate associations between key independent variables and the outcomes . The main independent variable (sanitation) was categorised into access to a latrine (private or neighbour’s) versus open defecation.We used principal component analysis with varimax rotation for computing a wealth index  from theWe estimated unadjusted odds ratios (ORs) and adjusted odds ratios (AORs) of the relationship between improved sanitation access and APOs using logistic regression models. Our predefined analysis using a generalized linear model was changed to logistic regression in response to reviewer requests and because of the types of data included in the model .We included a priori covariates—such as materials used to wash hands after defecation, source of bathing water, place of residence, maternal age, maternal parity, BMI, maternal haemoglobin, ANC, poverty, educational level, caste, and religion—for APOs that were thought to be important confounding factors on theoretical grounds . The cov2), 36.1% did not have anaemia (Hb ≥ 110 g/l), 35.4% were primiparous, and 15.1% had no formal education  experienced APOs . Among tducation .Unadjusted bivariate associations of each of these sanitation factors with APOs are presented in a priori criteria, as related to latrine access and APOs. The model estimate in the multivariable analysis for the association of open defecation with APO  was minimally attenuated  were more likely to experience an APO, independent of the established confounding factors of poverty and caste. To our knowledge, this is the first community-based prospective study to demonstrate that practicing open defecation is associated with a higher risk of APOs. Using a large existing population-based cohort, all pregnancies could be enrolled and followed longitudinally from the first trimester to pregnancy. The diverse nature of our study sites also allowed us to enrol a representative rural Indian sample including individuals of different castes, class, religion, and socio-economic status, with a range of sanitation-related practices.Population-based data on the prevalence of APOs as reported here are uncommon in India. Among our cohort, we found that 19.5% of births were preterm and 14.2% of babies had low birth weight during the study period. Studies from south India (Tamil Nadu) have reported a prevalence of low birth weight and preterm birth of 17.0% and 12.3%, respectively, although the prevalence of low birth weight has also been estimated to be as high as 30%–40% in India . The ratGiven the paucity of research linking open defecation to APOs, it is difficult to assess our findings in the context of other study findings. A hospital-based study in sub-Saharan Africa found a higher risk of preterm birth, but not low birth weight, among babies born to mothers using shared sanitation facilities  .p < 0.01) and an increased risk of low birth weight (p = 0.05) [Our study reports a protective role of maternal haemoglobin (Hb ≥ 110 g/l) in regards to the risk of APOs among the study populations which is in line with other findings. A recent systematic review and meta-analysis showed a significantly higher risk of low birth weight  and preterm birth  with anaemia in the first or second trimester . The sam = 0.05) . We obseAnother important finding of our study was that education remained a key determinant of APOs in the multivariable model. We observed higher education to be associated with lower odds  of APOs among women in the multivariable model. This finding is consistent with numerous research findings of higher education being predictive of lower likelihood of APOs ,61. A CaWe adjusted our estimates to account for socio-economic factors by constructing a household wealth index. Poverty is highly correlated with a lack of sanitation access, and both factors have been linked to increased risks regarding maternal health ,32, stuna priori covariates and considered several biological plausibilities, we did not adjust for many potential risk factors for APOs such as maternal smoking, alcohol use, history of sexually transmitted diseases, history of antenatal complications, history of abortions, etc. Whereas each of these factors has been associated with an increased risk of APOs, we are unaware of any data suggesting that these variables are associated with defecation practice. Hence, we considered these variables unlikely to be confounders in our analysis [In our study, although we adjusted our estimates for analysis . SeveralThis study indicates that, in the context of maternal and child health promotion research, sanitation is an important dimension of women’s health and distinct from poverty and caste. Additional research is warranted that addresses the underlying mechanisms of sanitation-related APOs.S1 Data(ZIP)Click here for additional data file.S1 Fig(TIF)Click here for additional data file.S1 Table(DOCX)Click here for additional data file.S1 Text(DOC)Click here for additional data file.S2 Text(DOC)Click here for additional data file.


Background: Asphyxia is a medical condition in which placental or pulmonary gas exchange is impaired or they cease all together, typically producing a combination of progressive hypoxemia and hypercapnea. Objective: In addition to regional differences in its etiology; it is important to know its risk factors.Materials and Methods: This is a case-control study, all neonates born from May 2002 to September 2005 in Vali-e-Asr Hospital were studied. 9488 newborns were born of which 6091 of the live patients were hospitalized in NICU. 546 newborns were studied as case and control group. 260 neonates (48%) were female and 286 neonates (52%) were male. Among the neonates who were admitted, 182 of them were diagnosed with asphyxia and twice of them (364 newborns) were selected as a control group. The variables consist of; gestational age, type of delivery, birth weight, prenatal care, pregnancy and peripartum complications and neonatal disorders.Results: Our studies showed that 35 (19.2%) patients had mild asphyxia, 107 (58.8%) had moderate asphyxia and 40 (22%) were diagnosed as severe asphyxia. Mean maternal age was 34.23±4.29yr; (range: 23-38 yr); and mean of parity was 2±1.2; (range: 1-8). Risk factors in our study included emergent Caesarian Section, preterm labor (<37w), low birth weight (<2500g), 5 minute Apgar (less than 6), need for resuscitation, nuchal cord, impaired Biophysical Profile, neonatal anemia, and maternal infertility.Conclusion: All risk factors listed above play a role in asphyxia. The majority of these factors are avoidable by means of good perinatal care. Asphyxia is a medical condition in which placental or pulmonary gas exchange is impaired or they cease altogether, typically producing a combination of progressive hypoxemia and hypercopnea . The greStatistical results show that mortality risk is 15-20% in newborn infants with hypoxic-ischemic encephalopathy (HIE). “It was also shown that 25-30% of survivors were left with permanent neuro developmental abnormalities” . The frequency of HIE after birth asphyxia was reported to be 1.4 per 1000 in Iceland , 3.8 perThese include low birth weight, low Apgar score, low pH and hemoglobin level , as wellAsphyxia is a preventable condition and in addition to regional differences in its etiology; it is exceptionally imperative to know its risk factors. For this reason, we have studied risk factors of perinatal asphyxia annually at Imam Khomeini  Hospital in Tehran from May 2002 to September 2005; in live births.This was a case-control study diagnostic criteria of asphyxia (Inclusion criteria) were: umbilical cord pH<7 or 5 min Apgar<6 or 20 minute Apgar score less than 7, multi organs failure in the first 72 hours or convulsion in the first 24 hours of life. Exclusion criteria were neonates suffering from major congenital anomalies or syndromes. Our control group consisted of two live borne; who were born following asphyxiated neonates with no sign of asphyxia or congenital anomalies. They matched with case group for underlying conditions like: maternal age, gravidity and demographic factors. Hypoxic ischemic encephalopathy is an important criterion of asphyxia. The clinical spectrum of HIE  is described as mild, moderate and severe; based on Sarnat and Sarnet stages of HIE . The variables consist of gestational age, type of delivery, birth weight, prenatal care, pregnancy complication such as preeclampcia, eclampcia, oligo hydramious, poly hydramnious, gestational diabetes mellitus, trauma, major surgery, infertility and impaired biophysical profile; maternal systemic diseases ; perinatal complications like premature rupture of membrane, placenta previa, placental abruption and umbilical cord prolapse, nuchal cord and IUGR ; Peripartum complications included prolonged second stage of labor, dystocia, malpresentation of fetus and need for resuscitation and neonatal disorders such as pneumonia, pneumothorax, congestive heart failure, and severe anemia. Pregnancy complication, maternal systemic diseases, perinatal and peripartum complications were approved by perinatologists. Neonatal disorders were approved by neonatologists. In this study preterm delivery was defined as gestational age less than 37 weeks. Likewise birth weights were divided to low birth weight (LBW) (BW<2500g), normal birth weight (2500g ≤ BW < 4000g) and macrosomia (BW>4000 g).Complete prenatal care is defined as greater than 6 prenatal visits during pregnancy. Umbilical cord arterial blood gases were done in all of our suspicious neonates for confirmation of diagnosis. Data was collected retrospectively based on prepared questionnaires. The questionnaire is based on the variables considered in previous studies. In this research period 9488 newborns were born, of which 6091 of the patients were hospitalized in NICU. Among the neonates who were admitted into the hospital, 182 of them were diagnosed with asphyxia and 364 newborns were selected as control group. Throughout delivery the fetus was monitored every 15 minutes by a specialist. Oxytocin infusion and amniotomy were used for some delivery induction. Neonatal resuscitation was done by an expert team with comprehensive and complete equipments. It should be mentioned that this research was under authorization of Tehran University of Medical Sciences Ethic Committee. Statistical analysis2, Anova test, logistic regression and Odds ratio.The recorded data was based on SPSS version 15; furthermore descriptive statistics were extracted with absolute or partial frequency, mean and standard deviation. Analytic statistics were extracted with XIn this research the files of 546 neonates were studied in two groups, 182 neonates had asphyxia (case group) and 364 neonates were selected as the control group. In case group, 35 (19.2%) had mild, 107 (58.8%) moderate and 40 (22%) were diagnosed as severe asphyxia. Mean maternal age was 34.23±4.29 yr; (range: 23-38 yr); and mean of parity was 2±1.2; (range: 1-8). 260 neonates (48%) were female and 286 neonates (52%) were male. Assessments of demographic and underlying features between two groups are shown in Thus two groups were equally matched. In Since diagnosis of mild asphyxia is extremely difficult, the largest part of our study was based on moderate to severe cases. By studying all asphyxiated newborns we surprisingly found that 80% of our cases had moderate to severe hypoxic ischemic encephalopathy. In view of the fact that clinical manifestations of mild asphyxia are quite similar to prematurity, most of the studies were made on term newborns -8. et al reported no co-relation . We showed that in case group the rate of prematurity was significantly higher than the control group, even though Butt relation . Althougrelation , 7, 12, al study  but Badase group , 7. In oet al reported maternal thyroid disorders increase the risk of asphyxia , birth weight lower than 2500g, need for resuscitation, nuchal cord, impaired biophysical profile, neonatal anemia and maternal infertility and its treatment are risk factors of asphyxia. The majority of these factors may be manageable by means of good prenatal care.


The brain of the brown ghost knifefish, which uses electric fields to “see”, processes electrical signals in a way that is similar to how our brains interpret visual and auditory signals. Related research article Metzen M, Hofmann V, Chacron M. 2016. Neural correlations enable invariant coding and perception of natural stimuli. eLife 5:e12993. doi: 10.7554/eLife.12993Image Simulation of the electric fields produced by two weakly electric fish in close proximity to each otherThe question of how animals make sense of their environment is of interest in both neuroscience and computer science. The key challenge is to understand how to categorize events in ways that are useful to the animal, and also practical to implement. Typically, this involves separating information about an event  from information about where the event happened .While much of the research in this area has focused on vision, similar computational principles are involved for other senses, including smell and hearing . In partIn this situation, studying species with exotic senses not used by humans might shed new light on the problem. Now, in eLife, Michael Metzen, Volker Hofmann and Maurice Chacron from McGill University report the results of experiments on fish called brown ghost knifefish . These fA brown ghost knifefish emits an electric field that oscillates at a given frequency and creates an electric field that surrounds the fish. It also uses an array of electroreceptors on its surface to detect changes in this electric field: these changes could be caused by other fish, both electric and non-electric, predator or prey, as well as other objects. Metzen et al. focused on what happens when a knifefish communicates with another knifefish. Each knifefish emits at a slightly different frequency, so when two knifefish come into close proximity of each other, these frequencies interfere to generate a beat pattern. The frequency of this beat pattern is equal to the difference between the two original frequencies.If a knifefish wants to communicate with another knifefish, it produces a “chirp” – a temporary increase in the frequency of its electric field discharge (Metzen et al. studied how the communication signal is represented in three successive stages of neural circuits: circuits formed by neurons that are directly connected to the electroreceptors on the surface of the fish; circuits formed by pyramidal neurons in the hindbrain; and circuits formed by neurons within the Torus semicircularis in the midbrain. Metzen et al. report that neural responses at each successive stage of processing depend less and less on the phase. This process of making the signals 'phase invariant' is similar to how visual signals are processed .Studies of the comparatively simple neural circuits of the weakly electric fish can also provide insights into the neural mechanisms behind invariant responses in other more complex sensory systems. For example, the responses of the individual peripheral neurons in the knifefish are not phase invariant: however, the activity of these neurons is correlated in a way that is phase invariant. This shows that one way to generate a phase-invariant response is to correlate and combine a number of neural responses.A prominent aspect of electrosensation is that the animal has control over the types of signals that it produces. This makes it a rich ground for testing the theory that biological circuits are optimized to transmit maximal information for a given cost . RelevanMore generally, one expects to find many solutions to the problem of information optimization, depending on the characteristics of the environmental niche for a particular animal and the metabolic costs they can afford . The div