Steroid‐induced femoral head necrosis (SIFHN) is a serious clinical complication that is caused by prolonged or excessive use of glucocorticoids (GCs). Osteoblast apoptosis and osteogenic differentiation dysfunction caused by GC‐induced oxidative stress and mitochondrial impairment are strongly implicated in SIFHN. Apocynin (APO) is a kind of acetophenone extracted from an herb. In recent years, APO has received much attention for its antiapoptotic and antioxidant properties. This study aimed to investigate whether APO could protect against SIFHN and explore the mechanism. In our study, low‐dose APO had no toxic effects on osteoblasts and restored dexamethasone (Dex)‐treated osteoblasts by improving survival, inhibiting OS and restoring mitochondrial dysfunction. Mechanistically, APO alleviated Dex‐induced osteoblast injury by activating the Nrf2 pathway, and the use of ML385 to block Nrf2 significantly eliminated the protective effect of APO. In addition, APO could reduce the formation of empty lacunae, restore bone mass and promote the expression of Nrf2 in SIFHN rats. In conclusion, APO protects osteoblasts from Dex‐induced oxidative stress and mitochondrial dysfunction through activation of the Nrf2 pathway and may be a beneficial drug for the treatment of SIFHN. Apocynin (APO) is a naturally occurring acetophenone that has been shown to alleviate various diseases such as diabetes, stroke, hypertension and acute pancreatitis.22.1Apocynin (purity ≥99.96%), dexamethasone (purity ≥97%) and ML385 were acquired from MedChemExpress (MCE). The Cell Counting Kit‐8 (CCK‐8) kit, Annexin‐V/7‐AAD Apoptosis Detection Kit, DCFH‐DA Detection Kit, Mitochondrial Superoxide (Mito‐Sox) kit and JC‐1 Kit were obtained from Beijing Solarbio Science & Technology . Primary antibodies against 4‐hydroxynonenal , 8‐hydroxy‐2′‐deoxyguanosine , cleaved caspase 3 , BAX (ab3191), BCL‐2 (ab241548), alkaline phosphatase , osteoprotegerin , RUNX2 (ab76956), Nrf2 (ab137550) and HO‐1 (ab302671) were supplied by Abcam .2.22 environment. To establish the SIFHN cell model, osteoblasts were cultured in medium containing 1 μM dexamethasone for 24 h. For APO treatment, osteoblasts were exposed to 1, 10 and 100 μM APO for 24 h. In the Dex + APO group, osteoblasts were pretreated with diverse concentrations of APO  for 2 h and then conditioned with Dex for 24 h. In the Dex + APO + ML385 group, osteoblasts were pretreated with ML385 (5 μM) for 24 h, followed by APO (100 μM) treatment for 2 h, and then stimulation with Dex for 24 h.MC3T3‐E1 cells were purchased from Procell  and maintained in α‐modified essential medium (α‐MEM) supplemented with 10% fetal bovine serum  and 1% penicillin–streptomycin (Gibco) at 37°C in a 5% CO2.3The CCK‐8 kit was used to investigate the cytoprotective effects of APO on osteoblasts. When the cells reached 80% confluence, the osteoblasts were treated with different concentrations of APO  for 24 h. To explore the cytoprotective effect of APO on osteoblasts, MC3T3‐E1 cells were pretreated with various concentrations of APO  for 2 h with or without 1 μM Dex treatment. Subsequently, CCK‐8 (10 μL) working solution was added dropwise to each well and incubated for 4 h. Finally, the optical density  was recorded with a microplate reader.2.4Flow cytometry was used to estimate the apoptosis rate and reactive oxygen levels in osteoblasts in each group. The cells were harvested after centrifugation and resuspension. Subsequently, the cells were stained with 5 μL of Annexin‐V and 7‐AAD solution and incubated for 20 min at room temperature. Then, we performed flow cytometry (BD Biosciences) to detect apoptosis. To detect intracellular ROS levels, different interventions were implemented when the cells reached 80% confluence. Osteoblasts were labelled with DCFH‐DA and incubated for 20 min at 37°C. Then, ROS levels were detected by flow cytometry .2.5The MMP and the levels of mitochondrial superoxide (Mito‐Sox) in each group of MC3T3‐E1 cells were measured using a JC‐1 Assay Kit and Mito‐Sox Red fluorescence assay probe.2.6Total protein was extracted from osteoblasts by RIPA lysis buffer. The protein concentration was determined by a BCA reagent, and then equal amounts of samples were added to each lane. The proteins were separated in 10%–15% SDS–PAGE gels and then electrotransferred to polyvinylidene fluoride  membranes. Subsequently, the membraned were blocked in 5% skim milk for 1 h and then incubated with antibodies against BAX (1:1000), BCL‐2 (1:2000), ALP (1:2000), OPG (1:1000), RUNX2 (1:1000), Nrf2 (1:1000), HO‐1 (1:1000) and β‐actin (1:1000) overnight at 4°C. After the blot was incubated with secondary antibodies (1:5000) for 1 h, the specific bands were detected and quantitatively analysed by a chemiluminescence system.2.7The activity of alkaline phosphatase (ALP) was determined to evaluate whether APO could reduce Dex‐mediated osteoblast damage. Cells (5 × 104 each well) were inoculated in 12‐well plates and supplemented with osteogenic induction medium after the different drug interventions. After 1 week, the cells were lysed with 100 μL of working solution, and ALP reagent kits  were used to measure ALP activity.Alizarin Red S staining was employed to detect calcium deposition in osteoblasts by complexing calcium ions with Alizarin Red S. After osteogenic induction in the different treatment groups, the cells were stained with ARS on Day 21 .2.8https://ctdbase.org/), and then the Amigo2 database (http://geneontology.org/) was searched for genes involved in OS using the words ‘oxidative stress’. Finally, we searched for potential targets of APO in the SuperPRED database (https://prediction.charite.de/). The intersection was determined by constructing Venn diagrams and was used to identify potential targets by which APO regulates OS in femoral head necrosis. To understand the biological process (BP), cell component (CC), molecular function (MF) and pathways in which these targets were involved, enrichment analysis of these targets was performed using the R package clusterProfiler with the minimum gene set to 5 and maximum gene set to 5000. A p‐value of <0.05 and a false discovery rate (FDR) of <0.1 were considered statistically significant. Protein–protein interaction (PPI) network maps of the targets were built from the STRING database (https://cn.string‐db.org/). The results were imported into Cytoscape software, and the significant nodes in the PPI were calculated using the BottleNeck algorithm of the cytoHubba plugin.To further explore the mechanism by which APO attenuates OS in osteonecrosis of the femoral head, we used bioinformatics tools to search for therapeutic targets of APO. First, genes associated with femoral head necrosis were collected from the CTD database , HO‐1 (dilution 1:200), 4‐HNE (dilution 1:200), 8‐OHdG (dilution 1:200) and cleaved caspase 3 (dilution 1:200) primary antibodies and then incubated then with rabbit anti‐rat secondary antibodies for 2 h in the dark. The mean fluorescence intensity (MFI) was analysed using a fluorescence microscope.2.10n = 8/per group). The Dex group received daily intramuscular injections of 21 mg/kg Dex for 28 days following to the previous protocol.Twenty‐four 12‐week‐old Sprague–Dawley rats  were obtained from the Tianjin Medical University Experimental Animal Center and maintained under specific pathogen‐free (SPF) conditions at 23°C. According to the experimental requirements, after 1 week of adaptation, the animals were grouped as follows: negative control (NC) group, Dex treatment group (Dex) and APO pretreatment group (Dex + APO), Four weeks later, the rats were sacrificed under isoflurane anaesthesia, and the femurs were extracted and preserved in 4% paraformaldehyde for 48 h.2.11MRI was performed on bilateral femurs using a 9.3 T small‐animal scanner  after isoflurane euthanasia, and image analysis was conducted using ImageJ software as previously described.2.122).Micro‐CT  was used to assess the microstructure of the rat femoral head. The following parameters were analysed using CT Analyzer software (Bruker): the bone volume fraction , trabecular thickness , mean trabecular number , trabecular spacing  and bone mineral density . To examine apoptosis, 1 × 104 cells were seeded on coverslips for 24 h before the various treatments. Then, the cells were subjected to fixation and permeabilization. After dewaxing and rehydration, the paraffin sections were incubated in TUNEL working solution, and 4′,6‐diamidino‐2‐phenylindole (DAPI) was added to counterstain the cell nuclei. Images were acquired using a fluorescence microscope.2.15OS levels in serum and MC3T3‐E1 cells were detected by reduced glutathione (GSH), catalase (CAT), glutathione peroxidase (GPx) and superoxide dismutase (SOD) assay kits .2.16Tianjin Medical University General Hospital's Animal Research Ethics Committee authorized all animal experimentation protocols in accordance with the US National Institutes of Health's guidelines for the care and use of animals.2.17t‐test for mean differences or one‐way analysis of variance with a Bonferroni/Dunn post hoc test for multiple comparisons. Statistical analysis was conducted using GraphPad Prism 8.0.2 (United States) .All experiments were repeated at least three times. The data are expressed as the mean ± standard deviation (SD). Comparisons between the two groups were assessed by Student's 33.16H3(OCH3)COCH3, and its chemical structure is illustrated in Figure The molecular formula of APO is HOC3.2The osteogenic differentiation and mineralization abilities of osteoblasts were examined. Figure 3.3Many studies have revealed that ROS are critical in the proapoptotic signalling cascade3.4Mitochondria are the main sites of ROS production, and mitochondrial dysfunction is a major cause of apoptosis. Therefore, we examined the effects of APO on MMP and mitochondrial ROS in Dex‐treated osteoblasts using the probes JC‐1 Figure  and Mito3.5To further explore the mechanism by which APO attenuates OS in osteoblasts, we identified therapeutic targets of APO by using bioinformatics tools. The Venn diagrams showed six intersecting genes related to osteonecrosis of the femoral head, OS and APO targets: NFE2L2 (Nrf2), ERN1, PDGFRB, PDGFRA, KEAP1 and CDK1 Figure . PPI net3.6Nrf2 plays a critical role in cellular sensing of ROS and antioxidant defence.3.7We used ML385 (an inhibitor of Nrf2) to block the Nrf2 pathway to examine the role of Nrf2 in the protective effect of APO against oxidative stress. Compared with those in the Dex + APO group, the levels of Nrf2 and HO‐1 were significantly inhibited in the Dex + APO + ML385 group after ML385 (5 μM) treatment Figure . In the 3.8To investigate the therapeutic effects of APO, we established a rat model of SIFHN. After 4 weeks of treatment, we used MRI, histological and micro‐CT evaluations to assess the protective effect of APO on bone. The T2‐weighted MRI (T2WI) results showed that the femoral head oedema signal was markedly higher in Dex‐treated rats than in the NC group, and the rats in the Dex + APO group had significantly reduced oedema signals in the femoral head Figure . In the 3.9We investigated the effect of APO treatment on the expression of Nrf2, HO‐1 and antioxidant enzymes in a rat model of SIFHN. As shown in Figure 4The incidence of SIFHN is increasing year by year and accounts for the largest proportion of non‐traumatic femoral head necrosis. Cumulative or high‐dose shock therapy with GCs is the most important risk factor for SIFHN.APO is a naturally occurring acetophenone found in rooibos and black walnut roots. Initially, APO was primarily reported to be a NOX inhibitor. However, it has now been demonstrated that APO can alleviate a wide variety of conditions, including diabetes‐related complications, neurodegenerative disorders, cardiovascular diseases, cancer and ischaemia–reperfusion injury.OS and mitochondrial dysfunction‐mediated apoptosis in osteoblasts play a pivotal role in GC‐induced bone metabolism abnormalities.Weakened mechanical strength in bone trabeculae and reduced osteogenic differentiation in the subchondral bone region of the femoral head are important factors in the development of collapse during SIFHN.The Nrf2 pathway plays a crucial antioxidant role in cells.In the present study, APO treatment inhibited osteoblast apoptosis induced by OS and mitochondrial dysfunction via the Nrf2 signalling pathway. However, the in‐depth mechanism needs to be further explored. The potential mechanism of Nrf2 activation by APO may be as follows: (1) APO treatment may weaken the binding ability of GCs to GC receptors (GRs) and inhibit downstream gene transcription. (2) APO may attenuate GR activity. (3) In the physiological state, the binding of Keap1 and Nrf2 is the main mediator of Nrf2 ubiquitination and degradation. APO inhibits the degradation of Nrf2 by facilitating the dissociation of KEAP1 and Nrf2.5In summary, APO inhibits apoptosis in Dex‐treated osteoblasts. APO protects osteoblasts from Dex‐mediated oxidative stress and mitochondrial impairment by activating Nrf2 signalling. In addition, APO mitigates the occurrence and progression of SIFHN in rats. These results provide theoretical support for the pharmacological treatment of SIFHN. APO may be a promising targeted medicine for the management of steroid‐induced necrosis of the femoral head.Xinglong Zhang: Conceptualization ; methodology ; writing – original draft . Ran Pang: Methodology (supporting). Kai Zhang: Methodology (supporting); writing – original draft (supporting). Qian Xu: Writing – review and editing . Chunlei Xu: Methodology (supporting). Wei Shi: Data curation . Xinyu Liang: Methodology . Dong Li: Data curation . Wenhao Cui: Writing – review and editing . Shucai Bai: Data curation . Zhijun Li: Writing – review and editing . Hui Li: Conceptualization ; project administration . Huafeng Zhang: Conceptualization (lead); project administration (lead). Xinglong Zhang, Ran Pang, and Kai Zhang contributed equally to this work and should be considered co‐first authors.There is no funding to report.There are no conflicts of interest to declare.


Controversy exists in clinical practice regarding optimal initial enteral feeding (EF) for moderately premature and low birth weight (BW) infants. We included 96 infants stratified into 3 groups . The protocol recommended starting with minimal EF (MEF) in infants weighing <1800 g. On the first day of life, 5% of the infants in group I did not follow the protocol mandating MEF, but started with exclusive EF instead, compared to 36% and 44% of the infants in groups II and III, respectively. The median number of days until exclusive EF was achieved was 5 days longer for infants receiving MEF than for infants who had received normal portions of EF from birth onward. We observed no significant differences in feeding-related complications. We advocate omitting MEF in moderately premature infants with a BW of 1600 g or higher. Controversy exists in clinical practice regarding optimal initial enteral feeding (EF) for moderately premature and low birth weight (BW) infants. The definition used for minimal EF is inconsistent and varies between 5 and 25 mL/kg/d. In healthy infants with a birth weight of 1600 g or higher we advocate to start with 20 mL/kg/d or higher EF from birth onwards. To start with EF for infants while on continuous positive airway pressure support.Controversy exists in clinical practice regarding initial optimal nutritional and total fluid management in preterm and low birth weight (BW) infants during the first week of life . This isTo add to the knowledge bank, we herewith report our experiences in nutritional and fluid management for infants born with a BW between 1600 and 2200 g. The local protocol recommended starting with MEF in infants with a BW <1800 g and with slightly larger-sized portions of EF in infants with a BW >1800 g. For this study, we were interested in compliance with our feeding protocol, the time until exclusive EF, thus without any intravenous fluids, was met, and the frequency of feeding-related complications during clinical practice.A single-center, retrospective, observational cohort study was conducted at Tergooi MC in Blaricum, Netherlands. This study was approved by the scientific review committee of Tergooi MC in May 2021 (study number: 21.26). This study was not subject to the Dutch Medical Research in Human Subjects Act.All infants with a BW between 1600 and 2200 g who were admitted to the neonatology ward of our hospital on the first day of life were included. In our hospital the neonatology ward is a 10-bed unit. Infants and mothers are hospitalized in separate locations. The included infants were stratified into three subgroups depending on BW: infants with a BW between 1600 and 1799, 1800 and 1999, and 2000 and 2200 g, respectively. The inclusion period was between January 2017 and March 2020 because an updated nutritional protocol was implemented in April 2020.http://links.lww.com/PG9/A99. It is noteworthy that every attending physician had the option to choose clinical management, not strictly according to the feeding protocol. Briefly, for infants with a BW <1800 g, the protocol recommended starting with MEF on the first day of life. MEF was defined as small portions of EF with a total volume of 15 mL/kg/d or less. The local feeding protocol recommended that EF be increased daily with small steps up to 12 times a day 14 mL on day 7, approximately 95–105 mL/kg/d. Total fluid requirements were achieved by providing intravenous glucose or full PN, which was increased stepwise during the first 3 days of life and decreased if, together with enteral nutrition, total fluid requirements were exceeded. PN was stopped if the EF exceeded 100 mL/kg/d.The feeding and total fluid protocols during the first 8 days of life are presented in Supplemental Digital Table 1, z-score for weight < −2.5 SD), sepsis, asphyxia, or if the infant received continuous positive airway pressure (CPAP) respiratory support, only MEF was started after birth in these infants in combination with PN and/or glucose drip, possibly continued for several days.For infants with a BW of 1800 g or higher, it was recommended to start after birth with normal portions of EF, defined as 8 times a day, 5–10 mL. The total fluid requirement was also achieved by providing additional intravenous glucose. EF was increased in steps to approximately 150 mL/kg/d on day 7 and the rates of intravenous fluids were decreased accordingly to attain total fluid requirements. However, in cases of severe dysmaturity  incidence, birth mode, Apgar scores, and maternal incidence of diabetes gravidarum were collected. For the first 7 days of life, the need for respiratory CPAP support and antibiotic therapy for (suspected) infection were recorded. Data on EF-related disorders including gastric residuals, vomiting, and necrotizing enterocolitis were collected. Finally, data on the number of central venous line placements for PN administration were obtained. The data were entered in castor electronic data management system (EDS).SGA was defined as a BW below the 10th percentile for matching gestational age according to the specified growth curve. Exclusive EF was defined as an EF without intravenous fluid administration.P <0.05.The Statistical Program of the Social Sciences  was used for analysis. Statistical analyses were performed using the Kruskal–Wallis test. Statistical significance was set at During the study period, 132 infants admitted to our neonatal high care ward had a BW between 1600 and 2200 g. We excluded 36 infants, of whom 16 were not born at Tergooi MC and 20 not admitted on the first day of life but thereafter from the maternity ward. The remaining 96 infants were included and stratified into three groups: 22 infants with a BW between 1600 and 1799 g, 42 infants between 1800 and 1999 g, and 32 infants between 2000 and 2200 g. Demographic data and number of infants who received CPAP and antibiotic therapy are presented in Table On the first day of life, one infant (5%) with a BW between 1600 and 1799 g started with exclusive EF, despite the local feeding protocol mandating only MEF together with intravenous fluids. In the higher-weight groups, exclusive EF from birth onwards was achieved in larger proportions: 36% of the infants with a BW between 1800 and 1999 g and 44% of the infants with a BW between 2000 and 2200 g  Table . For infWe found no differences in the occurrence of feeding-related complications among the three groups. Necrotizing enterocolitis did not occur in any of the infants. The requirement for a central venous line to administer PN occurred only in one infant in the 1600–1799 g group.This study evaluated during clinical practice nutritional and fluid management during the first seven days of life in moderately premature or low-BW infants hospitalized in a level 2 neonatal ward in a teaching hospital. We observed that the percentage of infants who started immediately after birth with exclusive EF, without any additional intravenous glucose or PN, increased with higher BW. In turn, providing only MEF after birth also resulted in a longer median duration of achieving exclusive EF compared with infants who received slightly larger portions of EF from birth onwards. The occurrence of feeding-related complications did not differ between infants who started after birth with MEF and those who started with slightly larger portions of EF.Initially, this feeding and fluid management protocol was established for all premature infants with a gestational age between 32 and 36 weeks and a BW between 1200 and1800 g. For these infants, the protocol recommends starting MEF combined with PN to achieve fluid requirements. The lower BW limit was based on the fact that infants in our hospital were only admitted with a minimal BW of 1200 g, whereas an upper BW limit of 1800 g was arbitrarily chosen. The results of our study, however, show that for infants with a BW between 1600 and 1800 g, this is a very conservative approach. If this protocol is strictly applied, these infants are still in need of PN and/or intravenous glucose 7 days after birth to meet their fluid requirements. Consequently, infants are frequently exposed to achieve vascular access, and may eventually require a central venous line, which is the case in a single infant. In clinical practice, adherence to the protocol was moderate. Although the majority of infants in the different BW groups started with MEF or EF according to the protocol, not all infants received additional PN and/or intravenous glucose to meet their fluid requirements. One reason could be that several attending physicians found the protocol to be too conservative.To ensure uniform clinical practice, we advocate abandoning only MEF after birth in these patient groups but start with slightly larger portions of EF on the first day of life. This is in line with the results of a randomized controlled trial, in which SGA infants of gestational age 32–36 weeks and BW >1499 g were randomly allocated to receive either a proactive feeding regime, starting with 100 mL/kg/d and gradually increasing to 200 mL/kg/d by day 4, or a standard feeding regimen, starting at 60 mL/kg/d and gradually increasing to 170 mL/kg/d by day 9 (Another conservative approach in our protocol is to start with MEF when CPAP is applied. However, since recent experiences and literature suggest that even the controlled introduction of oral bottle feeding for infants on CPAP can be safe, adjustments to our protocol are justified to start with and increase nasogastric tube feeding more rapidly than providing only MEF for infants while on CPAP support .9 In addition, to assess guidelines in clinical practice we also advocate to develop a core outcome set. Key outcomes that might be included could be avoidance of hypoglycemia, time to feeds, breastfeeding success, or growth. This will also increase comparison between studies and improve the management of these infants.A major strength of our cohort is that this is a study that reports compliance to and suggestions on how to improve a feeding protocol for these groups of infants. Evidence-based nutritional guidelines for moderately preterm infants and low-BW infants are notably absent, despite being the largest population of preterm infants. A recent review confirmed this . The autOur study is a retrospective cohort that is always dependent on accurate record keeping, and is therefore a limitation. However, our study mostly covers requested feeding and intravenous glucose and PN parameters, which were recorded digitally in electronic patient files, and therefore, most likely none of these parameters could be missed. Another limitation is that our feeding protocol was only loosely followed; therefore, it was difficult to interpret the clinical tolerance of our feeding protocol in each weight class. Finally, it is a single-center study and this limits the generalizability of this study.In conclusion, based on this observational study and the existing literature, we recommend starting with 20 mL/kg/d or higher EF from birth onward in moderately premature healthy infants with a BW of 1600 g or higher. Furthermore, we recommend the development of international evidence-based guidelines for this group of moderately premature and low-BW infants and to develop a set of core outcome parameters. This may help achieve uniform clinical practice as well to assess the guidelines in clinical practice.


Providing care to a woman after a Life-Limiting Fetal Conditions (LLFC) diagnosis is a difficult experience for midwives. This study’s aim is to describe the experience of midwives assisting in births following an LLFC diagnosis. It is a qualitative study using Interpretative Phenomenological Analysis (IPA). Semi-structured in-depth interviews were conducted with 15 midwives with experience in caring for women giving birth following an LLFC diagnosis. The data was analyzed through coding using the MAXQDA tool. The main theme emerging from the experience of midwives concerned difficulty in interacting with the woman giving birth. The analysis singled out four subthemes containing the most significant issues arising from the experience of midwives in caring for a woman giving birth to a lethally ill child: in relation with the woman giving birth; in relation with the child and the family; in relation with oneself; and in relation with the workplace. Midwives should have access not only to solid knowledge about this question, but also to courses developing skills in dealing with difficult situations, in coping with stress, in expressing compassion and, most importantly, in communicating with women and their families in such difficult circumstances. The development of prenatal diagnosis has led the fetus being seen as a patient who can receive specialized palliative care from the moment of diagnosis until birth. The pregnant woman who continues with her pregnancy following an LLFC  diagnosis (in connection with her baby) is also a patient. This particular group of patients requires professional maternity care focused on the life, not the death, of the lethally-ill patient (the fetus) .Obstetric and neonatal teams care for women who give birth to babies with a lethal prognosis. Exact statistics are not available due to difficulties with defining and prenatal diagnosis of fetuses with a potentially lethal prognosis. Data from the European Register deaths from the 20th week on due to congenital anomalies amounts to 42 births out of 100,000, and early neonatal deaths or infant deaths (in the 1st week after birth) amounts to 47 out of 100,000 births, producing a general perinatal mortality incidence of 92 out of 100,000 births (Eurocat website). Other studies suggest figures on the order of 1/11,000 and 2% of all pregnancies in which parents receive diagnoses that limit the life of the developing fetus ,4,5.In their practice, midwives and obstetricians must face various situations involving perinatal loss, intra-uterine fetal death or stillbirth. Caring for families affected by these traumatic circumstances is one of the most difficult experiences for health professionals ,7,8. EacEach family experiences the death of a fetus or newborn infant differently. Upon receiving devastating news that her baby may die, a pregnant woman must go through a birth experience which is most often emotionally arduous for her (and for the baby’s father or support person). Midwives who are directly involved in caring for this group of parents can learn about their needs with sensitivity, and support them in giving birth and saying goodbye to their dying child . Studies have shown that a philosophy of care focused on the paradigm of ‘being with’ the woman giving birth and her family can enhance the family’s healing process after the event and strengthen family bonds ,12. ‘MidThere is a lack of qualitative research describing the experiences and emotions of midwives assisting women giving birth with an LLFC diagnosis. The purpose of our study was to learn about and analyze the experiences of midwives assisting in births involving an LLFC diagnosis (intra-uterine death (IUFD), stillbirth or neonatal death). In it, the authors sought to determine how the midwives who take part in such births describe this experience in the context of the difficulties associated with caring for this particular group of birthing women.Considering the varied emotional reactions of the midwives who form the target group, a methodology was sought that would reflect the subtle differences in the way they communicate their experiences. Interpretive Phenomenological Analysis (IPA) was chosen because it provides the researcher with an opportunity to describe how participants understand their life and the role they play, and how they feel in a particular situation . The maiRecruiting of midwives began in May 2022 when information about the study was sent by email to 12 hospitals in Poland (with second and third degrees of reference). Eighteen midwives from seven Polish hospitals agreed to participate in the study. Two midwives withdrew from the study before being interviewed, and one interrupted the interview five minutes into it due to the difficult emotions raised by the topic. In the end, 15 midwives took part in the study, after which all had the opportunity to see a psychologist. The participating midwives were provided with thorough information about the study’s objectives and its course. The study was conducted on a voluntary basis, with each person agreeing to take part in the study before it began. The youngest midwife was 30 years old, the oldest was 62, and all had a higher education. In addition, 12 midwives declared that they had completed various specializations. The shortest a participant had worked as a midwife was 7 years, the longest was 38 years. Eleven participants declared that they had personally experienced maternity. Each of the interviewees attended at least five births involving an LLFC diagnosis, with one claiming to have attended 30 such births. The experience of midwives conducting the labor of women with an LLFC diagnosis included stillbirth, intra-uterine fetal death (IUFD) and the live birth of babies who died immediately after birth. The characteristics of the study group are shown in the table below .The interviews were conducted between May 2022 and January 2023. Seven interviews were recorded using the Zoom platform at the participants’ home at the most convenient time for the interviewee. Eight interviews were conducted using a voice recorder during a face-to-face meeting at a location suggested by the midwives. The recordings were conducted by the first author of this article, who is an experienced midwife. The research was based on a pre-arranged set of topics. The preparation of broader research questions made it possible to gather extensive research material. The author’s many years of professional experience allowed her to empathically feel for the world of the participants to the extent possible. The importance of empathy in this type of research is especially important . The parAs Smith points out, the IPA standards are strongly idiographic . It was The central part of the analyses focused on the experience of the difficult relation between the midwife and the woman giving birth involving an LLFC diagnosis. In connection with the central theme, four subthemes of analysis of the research material were established: in relation with the woman giving birth; in relation with the child and the family; in relation with oneself; and in relation with the workplace. On the one hand, a key aspect of our approach is the use of the preposition ‘in’ to better reflect the dynamics of events and feeling experienced by the midwives; on the other hand, while analyzing the research material, this allowed us to formulate/establish a specific interpretive argumentation track, which is mandated by the choice of the specific methodological approach (IPA). In the midwives’ descriptions of their experiences, the focus on the woman giving birth comes to the fore. These births were described by the midwives in terms of the needs of the woman in labor, rather than their own experiences. Twelve midwives stated the most common way to cope while conducting a difficult labor was to meet the laboring woman’s expectations about the course of the birth: For me, the hardest part was to respond to their expectations, because somewhere deep inside I didn’t agree with them. I think that I would have acted differently in their place. But, at the same time I didn’t want to judge them and I wanted to help. So, in order to help them I had to get a feel for how they perceived the situation. And that was probably the hardest thing for me to do. To set aside what I felt in that situation and switch, in a moment, to their point of view’ (Interview no. 7).‘In responding to the expectations of the parturients, midwives need to recognize their needs, and this is difficult in this group of women because it involves asking questions that evoke emotions. Eleven midwives found it stressful to speak with parturients during the first period of labor about various formal issues . They were concerned with not burdening the parturient with additional suffering:What is probably the most difficult is the first meeting with this woman—when I have to sense what she needs, begin speaking, establish contact. And I don’t know what kind of mental state she is in, whether my questions about listening to her pulse, dressing the baby after birth, saying farewell, etc., will trigger a wave of tears or increase her pain. Whether she will go into a total block, in which I will have no contact with her. Seeking not to add to this woman’s suffering while, and at the same, finding out what her needs are so that I can meet them at least in some small way is very stressful. (Interview no. 12).‘with this patient this was the more difficult [...] as I had the impression that she simply had no need for such contact from me’ (Interview no. 3). Meeting such expectations was especially difficult in the case of women who avoided contact with medical personnel. The absence of contact and conversation made it difficult to find out what a woman’s needs related to childbirth are: Establishing a relationship with a woman during labor is also difficult given the strong emotions that arise in both the parturient and the midwife. The tension and anxiety of the parturient are amplified by the midwife’s performance of midwifery procedures: Listening to the heartbeat, following the progress of labor. I think that, yes, all this is difficult, especially for this woman. But also for me, because she most often takes any new information with anxiety in the 1st period, while in the 2nd period of labor it is the same. When she feels that the resolution is approaching, she tries to suppress it, as if to delay it, to postpone it in time’ (Interview no. 5). ‘Five midwives believe that professional experience (birth room staff seniority) can help them establish a relationship with the woman . Three note that the peculiarities involved in assisting during a birth of this type do not allow the midwife to prepare for it adequately, especially when the midwife does not know the woman giving birth .Midwives held the view that, if possible, physical pain relief should be provided to the parturient during labor. One midwife additionally stressed the importance of an individual approach, even in this question: It seems to us that the psychological pain is sufficient enough and we wish to relieve the physical pain [...]. But I think that we should still inquire about this, because some people are psychologically structured in such a way that they like to shift psychological pain onto physical pain and somehow this brings them relief, so I am not sure we should treat everyone in the same standard way’ (Interview no. 4). ‘‘Let’s not take these moments with the child away from them, let them hold it in their arms as long as they need to’ (Interview no. 10).The midwives considered it important for parents to say goodbye to their child after death with dignity, and with this in mind, they tried to give the family as much time together as possible: The midwives in charge of the birth tried to do their best to prepare the newborn baby to be shown to the woman and the family. One of the issues identified from the data was the difficulty in dealing with what the baby looked like, as sometimes the newborn was macerated. The midwives were keen to manage the second period of labor in such a way as to cause as little damage as possible to the baby’s delicate tissues. Sometimes they chose to make a perineal incision, mainly so that the baby body would be born with as little damage as possible: We also try to make sure that this baby suffers as little as possible during the course of the birth, so that visually it shows as little bruising and deformities as possible; so that later, after it has been born and wrapped in tetra cloth or a blanket [...], they can see this child [...] and so that this image, which will remain with them for the rest of their lives, causes as little trauma for them as possible’ (Interview no. 6). ‘− to ensure that memories of childbirth are positive (Interview no. 3); − to make them feel secure (Interview no. 5); − to support them emotionally (Interview no. 6); − to spare them additional suffering (Interview no. 7). The statements of the midwives reveal an evident concern to provide a sense of security, for the father/support person who was present at the birth as well. This motivation was inextricably linked to the awareness that this type of event causes major suffering for the family. The midwife’s main tasks:‘We often are aware that this person will be there only for a moment’ (Interview no. 11). It seems like the need to accept reality helps the midwives focus on their duties. During such births, the midwives’ attention if most often focused on making the birth as gentle as possible: An interesting aspect that emerges from this analysis is the account about the baby, in relation to whom all the applicable procedures and solutions are carried out in support of life and health. However, these are births with a lethal prognosis, and it was evident in the midwives’ narratives that in these situations they are primarily concerned for the woman and her well-being. In such a situation, the midwives were aware of their limitations and of the need to live up to their responsibilities at a time when the baby is already dying, or will die soon: they really wonderfully say goodbye to these children and I am full of admiration and very touched, and in part full or joy that we managed to have a wonderful birth in silence in such a marvelous atmosphere’ (Interview no. 13).‘Five midwives who have experience in assisting during births with women who had been prepared, along with their husband/partner, to give birth to a child with a lethal prognosis say that the presence of the child’s father during the birth has therapeutic value:It seems to me that some couples come to the maternity ward and decide to give birth together without having given it much thought, and they must come to face with various things, while patients who come from the hospice have discussed many things with their partner, with a companion, or with a loved one’ (Interview no. 11). ‘‘This was a really difficult birth mentally, because all the time the father made me responsible for [the actions of] someone else (Interview no. 2), or ‘froze’ (Interview no. 2). In the above scenario, the midwife being interviewed showed the researcher two different perspectives on the conduct of childbirth: the first being when the decision that the father would be present during the birth is taken thoughtlessly and leads to greater hardship during the birth; and the second being when parents duly prepared in a suitable place embark on the birthing process fully aware of what will take place. As they observed the relationship between the parents, eight other surveyed midwives also saw closeness, tenderness and mutual support. Two midwives had experiences of births in which the baby’s father even obstructed the course of labor: It should be said that midwives chose different strategies in dealing with women, taking into account firstly the needs of the woman, but also those of the child’s father.The midwives’ responses describing their experiences with conducting births of women during whose pregnancy a lethal fetal/baby diagnosis was made contain references to their own emotional difficulties and to their high level of stress and discomfort. Although midwives believe that, in terms of care, these births do not differ much in handling from physiological births, they definitely require a different sort of emotional commitment. As some midwives noted:Technically, the second stage of birth is really no different than in the case of a woman who gives birth to a healthy baby, because vertical positions are also used. Also, the patient can choose the position in which she is most comfortable’ (Interview no. 1). ‘The key to interpreting the midwives’ statements is the word ‘technically.’ For a midwife with many years of experience in the birth room, the management of childbirth, understood as the performance of specific midwifery procedures, is not difficult. As one midwife noted, the difficulty is related to the need for emotional support when providing care at the same time to women giving birth to a healthy and a lethally diagnosed baby:I know what I can expect when meeting such a patient, any patient, actually. Because, in fact, whether that patient is giving birth to a sick baby, or a stillborn baby, or a normal baby, she pretty much requires the same thing. [...] one speaks one way with a patient who has a physiological pregnancy and a physiological birth, and differently to this [other] type of patient. It is obvious that you have to switch gears here. The worst thing is when one is conducting two births at once, that is, a physiological and a pathological one.’ (Interview no. 2). ‘‘I felt blamed [...] with all that happens to me and with my feelings I have to deal myself’ (Interview no. 2). The midwives show that managing two labor processes which take place in neighboring rooms and have different courses and prognoses represents a big challenge in their job, especially when they have to assume the burden of feelings felt as negative by the woman giving birth: These difficult emotions, the stress and discomfort that arise during LLFC births are aggravating, and midwives do not have the space and the time to deal with them. The inability to ‘stop’ for a while and ‘cool off’ is due to the need to go on working on call and caring for other women or to fill out medical forms after the birth: I will sit down and think for a moment, […], for a minute or two. And I have to deal with the documentation because my shift will end in a moment, or else I have to go see a patient, because just because I assisted during a birth doesn’t mean that I can sit down for an hour, but I need to go see her, to check that she isn’t bleeding, and find out how she feels’ (Interview no. 2). ‘‘are consciously prepared for the birth of their child. Preparation for a stillbirth is not always possible, however.’ (Interview no. 10).Midwives found it emotionally easier to conduct childbirth with women who had prepared for the situation a few weeks earlier. Such preparation was organized by an experienced midwife either at the hospice or during the course of the pregnancy. As the midwives noted, such parents Most midwives said that it is difficult to care for a parturient who unexpectedly learns about the intra-uterine death of her previously healthy child. Three midwives  said that, with this group of parents, the most difficult aspects involve unpredictable reactions in the birth room and communication difficulties. The parents, in their despair, do not want to see the child and blame the midwives for what happened to them. As one midwife related it:We spend the entire night in the birth room… it is a difficult experience to assist people in this situation... In her despair the mother even denied the humanity of her child and called on us to take “this” away from her…. Having carefully worked with their emotions all night, having overcome this anger, they said farewell to their child; they spend time with it and did everything they possibly could for the child. During the night, they came to terms with being parents to their stillborn child’ (Interview no. 15).‘On the other hand, a loud call for psychological support to be organized for midwives as well emerges from the interviewees’ statements: I was taught how to receive a birth from a woman who is expecting a healthy baby from the technical point of view, but I was not prepared to receive births from women who give birth to stillborn babies, or babies who will die in their arms. This isn’t easy, no one taught me how to deal with this, I need help to deal with these emotions’ (Interview no. 12).‘The vast majority of midwives participating in the study called for such support. Three midwives shared their experience of seeking psychological support on their own. Relations with the workplace are understood primarily as ways for the midwife to cope with difficult experiences at work. The most common of these is talking to someone about what took place: What I need, I think, is to be able to tell someone about it. And that brings relief. And I think, unfortunately I have to admit it, that it’s important that this person be a woman, and it’s wonderful if she is a midwife, that is, someone who walks in the same shoes as me’ (Interview no. 4). ‘Such a person has to meet specific requirements; it has to be a trusted person from work, preferably someone with experience in receiving difficult births: I find it very helpful to talk to someone else, if it happens to be another midwife from the same shift, after work we go for an hour to sit in some quiet place to talk and I tell her about my emotions from the difficult shift’ (Interview no. 1). ‘The need to support and exchange experiences with other midwives motivated one midwife to organize periodic meetings at her hospital: I myself started going to such counseling. Some colleagues from various hospitals and I, five midwives in all, are going to such counseling with a psychologist once a month, so I suggested to the girls that we sit down sometimes, at least once in a while, to discuss our experiences and for each to tell what her approach was because I’m also learning different reactions, so to speak, from them’ (Interview no. 13). ‘Eight midwives also shared experiences of creating mutual support groups from the bottom up; most often such support is not formalized. This lack of support procedures may be due to the particularly sensitive subject matter we are dealing with. What was clear from the statements of those interviewed was the need for help from someone who had experienced something similar. Such networks form naturally and bottom-up, as can be seen from the statements of the midwives themselves.Our research has shown that childbirth following an LLFC diagnosis is a difficult experience not only for the parents, but also for the midwife who conducts them. The main theme that emerged in the midwives’ narratives was difficult relationships. These relationships referred to the woman giving birth, the baby/family, themselves and the work they do.In this study, we have shown that it was important for the midwives to focus on the expectations of women giving birth to a child with a lethal diagnosis. These expectations concerned the course of birth and, especially, ensuring that it was as gentle as possible. This is consistent with previous studies, which showed that the course of birth and the memories associated with the death of the child long remain in the woman’s memory, and are an important and significant event in her life .Providing empathetic care focused on the needs of a mother of a lethally ill child in labor is emotionally arduous for the midwife. For many years, research has shown that midwives working in the birthing room empathize emotionally with those giving birth ,24. The Showing empathy and providing good care to their parturients in a way that went beyond the guidelines of standard maternity care was indicated as important by the midwives interviewed. It was also important for them to show a particularly sensitive approach to the family by, for example, extending the mother and father’s stay with their child after death and making a dignified farewell possible. The importance of such an approach is also highlighted in the literature .In our study, the midwives stated that the risk of experiencing dissatisfaction decreases when the mother and father are adequately prepared for the birth. The study shows that in a situation when the child is lost, the midwives and other hospital staff play a role in reducing the affected family’s pain and suffering. This is also borne out by research conducted to date . PreviouIn our study, midwives stressed that the most difficult thing is to assist in a birth when the parturient is surprised by the unexpected situation of stillbirth. The opportunity for the family to prepare in advance and come to terms with the inevitable death of their child leads the parents in the birth room to welcome their child and to celebrate the last moments of their prenatal parenthood in an atmosphere of peace and quiet. The parent’s acceptance of this tragic situation has an impact on the working comfort of the midwives in the birth room and defuses the additional stress load connected with having to deal with the despairing parents’ negative emotions. This is consistent with the research conducted by Denise Côté-Arsenault and Erin Denney-Koelsch, which shows that the parents’ prognostic certainty allows them to take full advantage of the time spent with their child, to prepare for its birth and imminent death and for a life without it . In theiThe midwife is an important member of the medical team and provides direct care to a woman who gives birth to a child with a lethal prognosis. Perinatal palliative care is a challenging experience, as it is a practice in which the emotional support for the woman giving birth and her family is also necessary . StudiesThe midwives’ emotional involvement in the parents’ experience of illness, death of the newborn and bereavement can not only contribute to emotional problems, but also to somatic symptoms such as, for example, headaches and stomach aches, palpitations, and sleep problems ,34,35. SIn our study, midwives shared various strategies for coping with the experience of perinatal death. Their years of professional experience helped them to establish a relationship with the parturient and conversations with colleagues at work helped them to reduce their level of stress. This is consistent with research conducted by Garcia-Caterina et al., which shows that empathetic listening to the women/families under their care and communicating their feelings to their peers, combined with institutional support, are factors that protect midwives from the negative impact of stressful work .Those midwives who are experienced in conducting births of babies with a lethal prognosis say that those are unique events. Each of these births is different, requires an individual approach and to a certain extent escapes the defining framework of procedures and regulations. To that same extent, knowledge of such births is gained through experience, as senior midwives pass their experience and the ‘culture of practice’ to their younger colleagues ,40. On tAmong the strong points of this study is the fact that, as a qualitative study, it has enabled us to learn about the experience of midwives in detail and in-depth. It also made it possible to capture a wide variety of experiences, opinions and beliefs that had previously gone unnoticed in the literature, leading to the uncovering of subtleties and complexities that might have been missed in quantitative studies. Moreover, while admittedly conducting a questionnaire-based interview, the authors were able to adapt their questions depending on the course of the study.This study’s limitations are largely due to the qualitative nature of the research. The first has to do with the relatively small sample, which meant that the results obtained cannot be generalized. Another one is the selection bias factor—the possibility that the study may only reflect the views of those midwives who, for reasons unknown to the authors, wished to share their experiences and came forward to take part in it, but not of those who did not. Thus, such a sample may not reflect the experiences of the entire population of midwives. Importantly, we do not know the opinions of those midwives who declined to take part in the study or who interrupted the interview on account of their strong emotions connected with this subject. Presumably, their opinions may differ considerably from those of the participating group. The presence of the interviewer may also have influenced the course of the study. Ultimately, it should be said that our study is focused on the experiences of midwives who cared for parturients after a prenatal diagnosis with a lethal prognosis for the baby (LLFC). Therefore, it is important to conduct further studies related to loss (miscarriage) and other types of perinatal deaths , stillbirth or neonatal death) faced by midwives.Our research shows that the level of stress and work comfort experienced by the midwife assisting in the birth of a lethally ill child is related to the quality of preparation of the parturient and the child’s father for birth. There is a need for psychological support for midwives, but also for women facing a lethal prognosis concerning their child ,43,44,45


This study investigated whether parental SES moderates the effect of birth health on Developmental Coordination Disorder (DCD) in preschool children.n = 23) or typically developing (TD) group  based on the testing results. All children in the DCD group were further confirmed to meet other diagnostic criteria of the DSM-V using the intellectual test and parental questionnaires. Moderation analysis was conducted using the PROCESS macro for SPSS, and 95% confidence intervals with a bootstrap procedure were calculated to identify the significant moderating effect.One hundred and twenty-two children aged 4 to 6 years were enrolled in the study. The Movement Assessment Battery for Children --2nd Edition (MABC-2) test was used to assess the motor coordination of children. They were preliminarily categorized into either the DCD  and maternal employment status  were found to moderate the relationship between birth length and the probability of having DCD. Moreover, the relationship between birth weight and the probability of having DCD was moderated by the annual household income .Maternal education (unstandardized coefficient = 0.6805, SE = 0.3371, The lower maternal education level and maternal unemployment strengthened the negative relationship between birth length and the probability of having DCD. Additionally, the negative relationship between birth weight and the probability of having DCD was statistically significant in high annual household salaries. DCD is A recent systematic review has shown that children born very preterm (before 26 weeks of gestation) and/or have very low birth weight  have the probability of having DCD 6 to 8 times higher than the term-born peers –12. In aIn spite of the strong correlation between parental growth and child growth patterns , other cThe literature has indicated that families with low SES are more likely to have children who are uncoordinated, compared to their peers , 28. SpeIn order to early identify and intervene children with DCD, an enormous number of studies have investigated the potential perinatal or postnatal predictors for DCD to better understand the underlying mechanism . HoweverBy investigating this issue, our findings may help raise parental awareness toward DCD, formulate the diagnostic strategies for preschool children at risk of DCD, and identify the modifiable factors which may buffer the adverse effect of poor birth health on the occurrence of DCD. Therefore, the purpose of this study was to understand the differences in birth health and parental SES between children with and without DCD. Additionally, this study examined the moderation of parental SES on the relationship between birth health and DCD. It was hypothesized that parental SES would moderate the association between birth health and DCD.2.2.1.One hundred and twenty-two children aged 4 to 6 years were enrolled in the study. All children completed the assessment of motor coordination using the Movement Assessment Battery for Children—Second edition (MABC-2) test. Based on the testing results, 23 children  were categorized into the DCD group (<=16th percentile) and 99 children  in the typical development (TD) group (>16th percentile). Children in the DCD group were further assessed and confirmed based on the diagnostic criteria of the DSM-V. All measures used in this process were described below. Children in both groups had neither intellectual impairment (IQ < 70) nor neurological/movement disorders that may lead to motor deficits. Their caregivers (101 mothers and 19 fathers) were also invited to join the study. Written informed consents were obtained from children's parents.2.2.This study was a secondary data analysis using the baseline data collected from the Stress, Motor coordination, and Activity Relationships in Taiwanese children (SMART) study, which was a prospective study approved by the Institute of Research Board of China Medical University (CRREC-108-021). In the SMART study, twenty-two preschools in Taichung City, Taiwan, were initially invited; eventually, six of them (27.3%) provided permission and agreed to participate in this study. The baseline data collection of the SMART study was conducted in 2020 (Wave 1) and 2021 (Wave 2). Each wave consisted of two phases. During Phase I, children's motor coordination and intelligence were evaluated using the MABC-2 test  and the 2.3.2.3.1.DCD was defined based on four diagnostic criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) . The SMAAs all children who participated in this study were aged between 4 and 6 years, they were in early developmental years based on the UNICEF definition, suggesting that early childhood spans the period up to 8 years of age (Criterion C of the DSM-V) . The Chi2.3.2.Birth health is the health condition of an infant at birth which is typically assessed by medical professionals immediately following delivery. As a variety of indicators could be used to measure birth health, this study retrospectively obtained data on birth weight, birth length, head circumference, gestation age, and the Apgar score at 5 min after birth from children's health booklets. The data on these variables were recorded by an obstetrician when each child was born. We further calculated the percentile of birth weight for gestation age (BWGA) based on the Taiwanese norms .2.3.3.Three main parameters were selected to determine the parental SES, including the annual household income, parental education level, and parental employment status . The par2.3.4.2.3.4.1.For example, the level 1 = /2 = 150,000. As the result, level 2 = 400,000; level 3 = 600,000; level 4 = 800,000; level 5 = 1,000,000; level 6 = 1,100,000; level 7 = 1,500,000; level 8 = 2,050,000; level 9 = 2,550,000; level 10 = 3,050,000; level 11 = 3,650,000; and level 12 = 4,000,000. Subsequently, the amount of the annual household income of each level was divided by 100,000 while conducting the moderation analyses.In order to deal with the potential bias during data analysis, we have made some changes in the category of parental employment status and the annual household income, respectively. In the parental employment status, we combined the situation 1, 5, 6 into the category of “not having a job”, whereas the situation 2, 3, 4 were combined into “having a job”. In terms of the annual household income, we calculated the average income between the lowest and highest number in each level. It is also worth noting that, although there were specific cut-off points for some of birth health variables which were used to differentiate health status  –44, this2.3.4.2.r) was one type of effect size that could be used to indicate small (r = .10), medium (r = .30), or large (r = .50) effect  or N (%). To investigate the differences in sex, parental education level, and parental employment status between the DCD and TD groups, the Chi-square test was performed. In addition, the Mann-Whitney U test was utilized to examine the differences in the age, birth weight, birth length, head circumstance, gestation age, Apgar score at 5 min, and the annual household income between the DCD and TD groups. Furthermore, the correlation analysis between each variable of children's birth health and each variable of parental SES was performed using the Spearman's rank correlation coefficient. According to the Cohen's work , the correlation coefficient  effect , 46. Howectively .2.3.4.3.The moderation analysis was conducted using the PROCESS software macro for SPSS . In the 3.3.1.x2 = 5.231, df = 1, p = 0.022), indicating significantly more boys in children with DCD (boys: girls = 2.83:1 in the DCD group and nearly 1:1 in the TD group). There were also significant group differences in the total test score of the MABC-2, demonstrating that children had significantly poorer motor coordination (p < 0.001).Baseline demographic information was shown in p's > 0.05). In addition, there were no significant differences in parental SES variables between groups .Compared to the TD peers, children with DCD had lower birth weight, shorter birth length, smaller head circumference, lower gestation age, and Apgar score at 5 min, and lower percentile of BWGA; however, there were no significant group differences in these variables , except Apgar score . Birth weight was also significantly, positively associated with BWGA with a large effect  and head circumference with a small effect . There were also significant associations between gestation age and Apgar score at 5 min with a medium effect  and between BWGA and head circumference with a large effect .As shown in r = 0.577, p < 0.01) and the annual household income with a large effect , whereas the maternal educational level was significantly associated with paternal with a medium effect  and maternal employment status with a medium effect , as well as the annual household income with a large effect . Furthermore, maternal employment status was significantly, positively associated with the annual household income with a medium effect . When the associations between birth health and parental SES variables were investigated, only the Apgar score at 5 min demonstrated a significantly positive association with the paternal employment status with a medium effect .In terms of the parental SES variables, the paternal educational level was significantly, positively associated with maternal educational level with a large effect  and Level 3  [unstandardized coefficient = 0.6805, SE = 0.3371, p < 0.05; Similarly, a significant moderation effect was found for the maternal employment status on the relationship between birth length and DCD [unstandardized coefficient = 0.6100, SE = 0.3059, 3.3.2.p < 0.05, As shown in 3.3.3.Parental SES variables were not found to significantly moderate the relationship between head circumference and DCD see .3.3.4.In a similar manner, there were no moderating effects of parental SES variables on the Apgar score at 5 min and DCD see .4.To the best of our knowledge, this is the first study to examine the potential moderating effect of parental socioeconomic status on the relationship between birth health and developmental coordination disorder during early childhood. Our findings lend partial support to our hypotheses, indicating that parental SES may moderate the relationship between birth health and DCD in some specific circumstances. Specifically, the relationship between birth length and the probability of having DCD could be separately moderated by the maternal educational level and employment status. Additionally, the annual household income may moderate the relationship between birth weight and the probability of having DCD. While a limited number of studies could be referenced to support our results, potential interpretation for each significant moderating effect was provided below.4.1.vs. Level 3) on the relationship between birth length and DCD, and this moderating effect showed different patterns for these two levels. Specifically, in a family in which the mother had lower educational level , the shorter birth length was associated with the higher probability of having DCD. A lack of research has investigated how maternal educational level may impact children's birth length. However, a recent cohort study recruiting Canadian mother-father-offspring triads has identified a stronger association of small-for-gestation-age with maternal education than that with paternal education , the relationship between birth length and the probability of having DCD would be reversed, showing that longer birth length is associated with a higher probability of having DCD. Evidence has demonstrated that an increase in parents' schooling, specifically maternal schooling, would result in better infant health . However4.2.herein). Maternal employment status could affect many aspects of the development outcome of a child, including motor development . This may lead to insufficient statistical power and generalizability of our results. Our results could be also biased by the unbalanced sample sizes between the two groups. This was due to the outbreak of the COVID-19 pandemic which hindered us from entering the preschools and conducting data collection. Therefore, we were unable to recruit more young children with DCD. However, as the purpose of this study was to conduct the moderation analysis, our sample size was considered as sufficient and appropriate. Third, the parental employment status used in the study does not measure the aspect of employment stability, such as the consistency in employment over time, the number of job transitions, or length of time in the same job, as the maternal employment instability may be linked with poorer child health outcomes . In addi5.In summary, this study shed a light on the underlying mechanism of DCD. Our results confirm that the shorter birth length is specifically associated with the increased probability of having DCD in preschool children whose mothers have lower educational levels. Similarly, an unemployed mother may strengthen the negative relationship between birth length and the probability of having DCD. Nevertheless, the positive association between birth weight and the probability of having DCD was reversed in families with higher annual household incomes. Moreover, this study also provides an important practical implication for paediatricians who would be able to early identify the child who is at greater risk of having DCD based on their birth health and parental SES, especially mothers. Furthermore, as our finding may help parents be more aware of early characteristics of DCD, they could raise the concerns to their child's pediatrician earlier if the child demonstrates any difficulty in motor coordination. Additionally, our results suggest insight into whether policies should in advance target those high-risk families for having DCD and provide the corresponding intervention based on familial SES.


Exposure during pregnancy to malaria and sexually-transmitted infections is associated with adverse birth outcomes including low birth weight (LBW). This study aimed at assessing if the adjunction of two doses of azithromycin to sulfadoxine-pyrimethamine for the intermittent preventive treatment of malaria in pregnancy can reduce LBW.A two parallel-groups, open-label randomized controlled trial involving pregnant women  was conducted in rural Burkina Faso. Women were assigned in a 1:1 ratio either to use azithromycin (1 g daily for 2 days) during the second and third trimesters of pregnancy plus monthly sulfadoxine-pyrimethamine (1500/75 mg) (SPAZ) (intervention) or to continue using a monthly sulfadoxine-pyrimethamine (1500/75 mg) (SP) (control). Primary outcome was a LBW (birth weight measured within 24 h after birth < 2500 g). Secondary outcomes including stillbirth, preterm birth or miscarriage are reported together with safety data.A total of 992 pregnant women underwent randomization (496 per group) and 898 (90.5%) valid birth weights were available (450 in SPAZ and 448 in SP). LBW incidence was 8.7% (39/450) in SPAZ and 9.4% (42/448) in controls . Compared with controls, pregnant women with SPAZ showed a risk ratio (RR) of 1.16  for preterm births, 0.75 (95% CI 0.17–3.35) for miscarriage and 0.64 (95% CI 0.25–1.64) for stillbirths. No treatment-related serious adverse events (SAEs) have been observed, and there was no significant difference in the number of SAEs  or AEs .Adequate prevention regimen with monthly sulfadoxine-pyrimethamine given to all pregnant women has been proved to reduce the risk of LBW in malaria endemic areas. Adding azithromycin to the regimen does not offer further benefits, as far as women receive a malaria prevention regimen early enough during pregnancy.Trial registration Pan African Clinical Trial Registry (https://pactr.samrc.ac.za/Search.aspx): PACTR201808177464681. Registered 21 August 2018. Low birth weight LBW, < 2500 g) caused by impaired fetal growth or preterm birth PTB, < 37 weeks) is the biggest driver of neonatal mortality . The glo500 g cau7 weeks iChlamydia trachomatis .After baseline characteristics were recorded, eligible pregnant women were randomized at 1:1 ratio to either use azithromycin (1 g daily for 2 days) during the second and third trimesters of pregnancy plus monthly sulfadoxine-pyrimethamine (1500/75 mg) (SPAZ) (intervention) or to continue using a monthly sulfadoxine-pyrimethamine (1500/75 mg) (SP) (control). Each treatment (SPAZ or SP) was randomly assigned to two different treatment codes, (letters A and B). A block randomization procedure was conducted and each block containing four treatment code were prepared by an offsite trial data management team at the CRUN. Allocation codes were kept in consecutively numbered sealed envelopes and revealed after completion of enrolment and immediately prior to treatment. Although, this was not a blinded study in the field and at patient level, other investigators were unaware of the trial group assignment except for the statistician. The intervention consisted of monthly courses of sulfadoxine-pyrimethamine  starting early in the second trimester until delivery and azithromycin  in the second and third trimesters of pregnancy. The control treatment consisted of monthly sulfadoxine-pyrimethamine . Treatment administrations were supervised by a trained nurse or a trained field worker.Plasmodium species that caused the infection. Parasite densities were calculated by counting the number of asexual parasites per 200 white blood cells (WBC), and parasites per μl calculated by assuming a WBC count of 8000 cells per μl of whole blood. When the number of asexual parasites was less than 100 per 200 WBC, counting was done against at least 500 WBC. A slide was declared negative if parasites were not found after a review of 1000 WBC or 100 fields containing at least 10 WBC per field. In case of discrepant results (discrepant species or count difference of at least 50%), a third microscopist assessed the slides. The final result was the average of the two closest readings.Thick and thin blood smears were stained with 5% Giemsa for 30 min and independently double-examined by two certified microscopists at 100 × magnification using light microscopy. Thick blood smear was used to detect and count malaria parasites, while thin smear was used to discriminate the In accordance with the trial protocol, low birth weight (primary outcome) was assessed by measuring birth weight within 24 h after birth by a trained nurse using a calibrated digital infant scale (Seca). Neonates were weighed when unclothed. Duplicate measurements were recorded to the nearest 10 g. If the two measurements differed by 10 g, a third measurement was obtained and the two closest values were averaged. Low birth weight was defined as birth weight of less than 2500 g .Secondary outcomes were preterm birth , stillbirth (birth at ≥ 28 weeks’ gestation with no signs of life), miscarriage (any pregnancy lost at < 28 weeks ‘gestation). Adverse events and serious adverse events were collected throughout the study.www.OpenClinica.com). All statistical analysis were performed using R software . Intention-to-treat (ITT) analysis was used and included all women with an available valid birth outcome information. Safety analysis was performed for all women who received a treatment regardless of the number of doses. Proportions between the two groups were compared using the Pearson’s χ2 test. Risk ratios (RR) for prospective studies were calculated for secondary outcomes with their 95% confidence interval. The statistical significance level alpha was set to 0.05.Data was collected on paper-based case report forms (CRF), double-entered in electronic-specific OpenClinica CRF  in the intervention group and 448 (90.3%) in the control group)  doses per woman was 4 (interquartile range between 3 and 5) and the proportion of women with one, two, three, four, or five doses of SP was 0.2% (1/448), 4.9% (2/448), 17.2% (188/448), 42.0% (160/448) and 35.7% (160/448) respectively in the control arm. In the intervention arm, the median number of azithromycin doses was two per pregnant woman and that of SP was 4 (interquartile range between 3 and 5). The proportion of women with one, two, three, four, or five doses of SP in the intervention arm was 0.7% (3/450), 4.2% (19/450), 17.3% (78/450), 38.9% (175/450) and 38.9% (175/450). Overall, 93.3% (418/448) of pregnant women in the intervention arm received the required 4 g of azithromycin.Among the 992 pregnant women randomized, 939 women (94.7%) remained in the trial with a known birth outcome. Of these, valid birth weights were collected for 914 neonates, data on birth weight represented 97.3% of those with birth outcome information available (456 in the intervention group and 458 in the control group). A total of 16 neonates’ birth weights (6 in the intervention and 10 in the control) were excluded from the analysis due to twin deliveries, thus data for primary outcomes analysis included 898 birth weights (450 in the intervention group and 448 in the control group). The incidence of LBW was 8.7% (39/450) in the intervention group and 9.4% (42/448) in the control group (p = 0.79). Subgroup analyses according to infant sex, the prevalence of malaria infection at baseline, anaemia at baseline did not show a meaningful difference in the intervention effect on the incidence of LBW. For all the secondary outcomes, there was no substantial difference between the intervention group and the control group with respect to the frequency of preterm births, stillbirths and miscarriages  were reported. A total of 67 adverse events in the intervention group and 83 in the control group were classified as serious but none was deemed drug-related (Table In this randomized controlled trial conducted in three peripheral health centres of the Yako health district in rural areas of Burkina Faso, systematically adding azithromycin to sulfadoxine-pyrimethamine during the intermittent preventive treatment of malaria in pregnancy did not result in a significantly lower incidence of low birth weight among neonates than the use of sulfadoxine-pyrimethamine. This was inconsistent with the expectations based on studies suggesting that a systematic combination of anti-malarials and antibiotics to prevent bacterial sexually-transmitted infections and malaria in pregnancy is associated with lower incidence of adverse birth outcomes , 22. Intpfdhps540E mutation was to date restricted to East and South East Africa, which is reassuring for continued use of sulfadoxine-pyrimethamine for the intermittent preventive treatment of malaria in pregnancy in West Africa to reduce adverse birth outcomes, thus the adjunction of an antibiotic does not offer additional benefits [There are several possible reasons for these finding. First, the overall reduction of the incidence of low birth weight in the control group than that hypothesized to estimate the sample size . Indeed,benefits . Third, benefits , 32, 33,benefits  does notbenefits –18, 35. benefits –38, thatbenefits , the poobenefits , or the benefits . The comDespite that the adjunction of azithromycin to sulfadoxine-pyrimethamine did not offer additional benefits to reduce adverse birth outcomes beyond that of the intermittent preventive treatment of malaria in pregnancy using sulfadoxine-pyrimethamine, the intervention presented a good safety profile. There was no drug related serious adverse events and the frequency of adverse events and serious adverse events did not differ across treatment groups as already noted by several studies , 26, 32.Important study limitations are worth noting as the gestational age was assessed using the last menstrual period or the measurement of the fundal height rather than ultrasounds and this may be subject to misclassification of pregnant women. Also, the investigators and the study participants were not blinded to the treatment and this may have led to selection or information bias. However, these bias effects were mitigated as the main endpoint’s measurements were not subject to a large degree of individual interpretation.The study showed that adequate use of monthly sulfadoxine-pyrimethamine for the intermittent preventive treatment of malaria in pregnancy given to all pregnant women is likely to reduce the risk of low birth weight in malaria endemic areas. Adding azithromycin to the regimen however does not appear to offer further benefits.


To examine the incidence of adverse perinatal outcomes and the risk of adverse perinatal outcomes for Indian-born mothers compared to other mothers living and giving birth in Australia.This retrospective cohort study was designed to investigate all births in Australia in 2012 and those in the Monash Health Birthing Outcomes System (BOS) 2014 to Indian-born mothers in Australia. Data sets were analysed involving descriptive statistics using Statistical Package for Social Sciences (SPSS vs. 23).Indian-born mothers in Australia are at increased risk of induced labour, emergency caesarean section, very preterm birth (20–27 weeks), babies with low to very low birth weight, and low Apgar score (0–2) at 5 min, gestational diabetes, hypothyroidism, iron deficiency anaemia and vitamin B12 deficiencies compared to other mothers giving birth in Australia. This is despite a range of protective factors  that would normally be expected to reduce the risk of adverse perinatal outcomes for mothers giving birth in a developed country.In the absence of many of the recognized maternal risk factors, Indian-born mothers continue to face increased risk of adverse perinatal outcomes, despite access to high quality maternity care in Australia. Recommendations arising from this study include the need for an intervention study to identify maternal risk factors for Indian-born mothers in mid to late pregnancy that contribute to the risk for very preterm birth and low birth weight. Australia boasts one of the safest maternity care systems in the world, with very low rates of maternal and perinatal mortality. It is, therefore, unexpected that immigrant Indian-born mothers continue to experience increased risk for adverse perinatal outcomes despite access to world class maternity care. No studies have examined perinatal outcomes for Indian-born mothers in Australia. The findings of this current study will measure the incidence of this increased risk compared to other mothers and identify the risk factors associated. This current study will contribute to existing knowledge on adverse perinatal outcomes, informing maternity care service providers of the specific risks faced by Indian-born mothers.While numerous studies have reported on maternal risk for adverse perinatal outcomes, very few have considered maternal ethnicity and country of birth as a risk in itself. The purpose of this study is to identify the incidence of adverse perinatal outcomes for Indian-born mothers compared to other mothers living and giving birth in Australia. The study will investigate whether internationally agreed pregnancy risk factors for adverse perinatal outcomes used in mainstream maternity care can be usefully applied to predict risk for Indian-born mothers.Developed countries like Australia, with increased migration are challenged by greater risk of adverse perinatal outcomes among Indian-born mothers compared to locally born mothers. Little is known about the impact that maternal country of birth and ethnicity has on perinatal outcomes.This paper fins that adverse perinatal outcomes were more frequent among Indian-born mothers compared to other mothers living and giving birth in Australia in the absence of recognised maternal risk factors.Further intervention study is required to identify maternal risk factors in mid to late pregnancy that contribute to the risk of low birth weight and emergency caesarean section among Indian-born mothers.Maternal country of birth has been identified as a potential risk factor for adverse perinatal outcomes including low birth weight and premature birth . StudiesStudies related to perinatal outcomes in Australia that include immigrant women have an emphasis on specific sub-immigrant populations using smaller sample sizes . Based oAustralia benefits from the best global standards health indicators, reflecting the achievement of the lowest infant mortality rate in the world at 3.1 per 1,000 live births . HoweverThe retrospective cohort study linked routinely collected deidentified data for all mothers giving birth to babies in Australia from January to December 2012, and at Monash Health in the State of Victoria in 2014.The National Perinatal Data Set (NPD) from the Australian Institute of Health and Welfare (AIHW) National Perinatal and Epidemiology Statistics Unit (NPESU) which undertakes national reporting of reproductive and perinatal health information and statistics in Australia was used for this study. The data collected is based on births reported to the perinatal data collection in each state and territory in Australia  and obtaThe second data set came from Monash Health. The Monash Health Birthing Outcomes System (BOS) data set for the year 2014 was obtained as non-aggregated data from Monash Health, which is a part of the Victorian State Perinatal Collection (VPDC). Data regarding mothers’ socio-demographic details, maternal country of birth, health conditions before and during pregnancy, complications during labour and birth, and perinatal outcomes, such as maternal and newborn health status after birth are collected .In 2012, of “the 312,153 national births, of which 2,255 were stillbirths, the average maternal age was 30 years, with the youngest 15 years and the eldest 56 years”. Of women who gave birth in Australia in 2012, 31.2% were born in countries other than Australia. Regarding parity, 42.4% of mothers had their first baby and 33.2% had their second baby. In 2012, 62.7% of women attended at least one antenatal visit in the first trimester (before 14 weeks gestation), and 14.9% did not begin antenatal care until after 20 weeks gestation. Hospitals are the place of birth for almost all mothers (96.9%). Of all the women who gave birth, 19.4% had a caesarean section without labour and 12.9% had a caesarean section with labour. Of women who gave birth in hospitals in 2012, the proportion in private hospitals was 29.0%. Also, 6.2% of live born babies were of low birthweight . In addition, 1.7% of live born babies had a low Apgar score (between 0 and 6) at 5 min.In 2014, the number of mothers who delivered at Monash Health was 3,172. Of these births, 3 were stillbirths. The average maternal age was 30 years, with the youngest at 15 years and the eldest at 56 years. Of women who gave birth at Monash Health in 2014, 61.8% were born in countries other than Australia. Regarding parity, 32.5% of mothers had their first baby and 13.1% had their second baby. In 2014, 19.3% of babies were admitted to special care nurseries, and 2.0% were admitted to neonatal intensive care units. Of all the women who gave birth,15.2% had an emergency caesarean section and 14.4% had an elective caesarean section. Of women who gave birth at Monash Health in 2014, the proportion of mothers who smoked during pregnancy was 10.1%. Also, 3.4% of live born babies were of low birthweight . In addition, 1.6% of live born babies had a low Apgar score (between 0 and 6) at 5 min.Indian-born living in Australia were examined and compared to mothers who were born in other overseas countries, namely other overseas-born mothers, and mothers born in Australia namely, Australian-born mothers, both latter groups also potentially containing mothers with an Indian background. Acknowledging this ethnic limitation, these three groups were used to effect comparisons. The following Fig. Two data sets were used, but there was no information about the population who were of Indian descent but born in Australia. Consequently, it was not possible to identify outcomes for Indian mothers born in India compared to women of Indian descent born in Australia or other overseas countries in both data sets. Thus, the differences between mothers who were The statistical analyses for this study included the use of descriptive and inferential statistics. Descriptive statistics were used to determine the demographic and perinatal outcomes of the study populations . They yielded frequencies, numbers, and percentages for each variable, using graphs as applicable. Inferential statistics, namely both parametric and non-parametric analyses, were employed to examine the association among variables. For categorical variables, cross-tabulations with a Pearson’s Chi-Square test were calculated to assess the association between each variable and a mother’s country of birth. Given the number of analyses performed, a P < 0.001 level of significance was used to minimise the possibility of Type 1 error. Effect size was calculated for all variables and analyses performed. Kruskal Wallis tests were calculated to determine any statistically significant differences, and the individual effect size was also calculated and compared for Indian-born mothers, Australian-born mothers, and other overseas-born mothers. The initial overview of the study results includes demographic characteristics and resource logistics from the overall data sets. Table The Monash University Human Research Ethics Committee (MUHREC) and the Monash Health Human Research Ethics Committee (MHHREC) approved this study. No informed consent was required from any individuals as the study used existing de-identified datasets obtained with approval from the Australian Institute of Health and Welfare (AIHW) National Perinatal and Epidemiology Statistics Unit and from Monash Health for the Birthing Outcomes System (BOS) data set.The largest proportion of mothers aged 25–29 and 30–34 giving birth in 2012 were Indian-born mothers , as compared to Australian-born mothers (27.62% & 30.90%), and to other overseas-born mothers (26.04% & 36.02%)  @ 5 min, prematurity , and low to very low birth weight < 1000 g-1.16% & 2000–2499 g than other mothers. Indian-born mothers also have a slightly larger risk of stillbirths compared to other mothers. Tables  @ 5 min,The largest proportion of blood glucose monitoring was among neonates to Indian-born mothers at 15.0%, with 9.3% for the neonates of Australian-born mothers. The proportion for other overseas-born mothers’ neonates was 10.1%. The rates of neonates with jaundice, undergoing observation, and other issues, were higher among neonates of Indian-born mothers who gave birth during 2014 , when compared to Australian-born mothers’ neonates  and to other overseas-born mothers’ neonates .Specific research into Indian-born mothers’ perinatal outcomes has been limited in the Australian context. In general, most published perinatal research examines general comparisons among immigrant mothers, refugee mothers, and Indigenous Australians . ImmigraIn the current study, a majority of Indian-born mothers gave birth between 24 and 34 years of age, considered to be the optimal age for childbirth . Indian-Australia provides free maternity care for all mothers who give birth in public hospitals . It has In Australia, the prevalence of smoking is highest for Indigenous mothers than for others . PreviouIndian-born mothers have a higher rate of induced labour and caesarean section birth or instrumental birth than in other mothers giving birth in Australia . InductiPotential factors affecting Indian born mothers?This current study reveals that when compared to Australian-born and other overseas-born mothers a largest proportion of Indian-born mothers were found to have iron deficiency anaemia Table  Fig. 3)3). TheseGestational diabetes mellitus is a more common maternal medical condition among India-born mothers in Australia . South AVitamin D deficiency: Vitamin D is important for placental function and necessary for optimal fetal growth and development . Indian-Vitamin B & B12 deficiency: Vitamin B12 is essential for normal growth and development of the fetus during pregnancy . South APolycystic ovary: Polycystic ovarian syndrome affects Indian-born mothers at a greater rate than other women, the cause for which is unexplained [Thyroidism: Indian-born mothers are at increased risk for developing hypothyroidism resulting in maternal thyroid dysfunction and adverse birth outcomes . Adversexplained .There is emerging evidence that implicates maternal ethnicity as a factor associated with premature placental aging . Indian-This current study was unable to identify the proportion of healthy small babies whose weight was in the higher ranges of the low birth weight < 2,499 g. The inclusion of small healthy babies may be responsible for the very high incidence of low birth weight reported for Indian-born mothers. Dahlen et al. measured Indian-born mothers’ risk for low birth weight to be twice that of Australian-born mothers . Indian-The current study makes some unique contributions. The findings reveal that Indian-born mothers possess many protective factors that are expected to minimise adverse perinatal outcomes, such as being married, singleton plurality, access to antenatal care involving qualified maternity care professionals, normal BMI, non-smoking and lack of substance abuse during pregnancy, and giving birth in a public hospital fully equipped to manage complications. Despite all these protective factors, Indian-born mothers giving birth in Australia still face an increased risk for adverse perinatal outcomes. Indian-born mothers are at greatest risk for preterm birth, low birth weight and very low Apgar @ 5 min.Findings from the current study confirm that Indian-born mothers living and giving birth in Australia are at increased risk of adverse perinatal birth outcomes. Placental monitoring from mid to late pregnancy is suggested . VitaminLow dietary vitamin B-12 intake in the presence of high total folate intake is a marker of adverse birth outcomes for Indian mothers . South AThis study analysed routinely collected birth data sets, these data sets were not collected specifically for research questions. Another limitation of this study is that it is restricted to Indian-born mothers who gave birth in Australia in 2012 and at Monash Health hospitals during 2014. Further, the data sets do not report some pre-existing maternal medical, obstetric, and gynaecologic factors necessary to address the research questions. Also, the 2012 National Perinatal Data and 2014 Monash Health (BOS) hospital Data sets were collected for another purpose, unrelated to this study, and were collected in different years. Moreover, only first generation Indian-born mothers could be identified in both data sets.This research is the first of its kind in Australia that investigates Indian-born mothers’ risk for adverse perinatal outcomes as a discrete group. The study makes a significant and timely contribution to the specific risks faced by Indian-born mothers, risks that are not routinely considered. This current research confirms that Indian-born mothers are at an increased risk for adverse perinatal outcomes compared with other mothers having babies in Australia. The Australian maternity service is renowned for the universal provision of high quality maternity care by qualified health professionals , but we