The impact of antenatal depression on pregnancy outcomes has been well investigated in developed countries, but few studies have been conducted in low-income countries. As depression is significantly affected by socio-economic and cultural factors, it would be difficult to generalize evidence from high-income countries to low-income countries. We conducted a community-based cohort study to estimate the incidence of adverse birth outcomes and the direct and indirect pathways via which depression and other psychosocial risk factors may impact such birth outcomes within Gondar town, Ethiopia.The study followed 916 pregnant women who were screened for antenatal depression using the Edinburgh Postnatal Depression Scale (EPDS). We also assessed the incidence of preterm births, Low Birth Weight (LBW) and stillbirths. Modified Poisson regression was used to estimate the relative risk of predictors on adverse birth outcomes and a Generalized Structural Equation Model (GSEM) was used to estimate the direct and indirect effect of antenatal depression and other psychological risk factors on adverse birth outcomes.The cumulative incidence of stillbirth, LBW and preterm was 1.90%, 5.25%, and 16.42%, respectively. The risk of preterm birth was 1.61, 1.46, 1.49, and 1.77 times higher among participants who identified as Muslim, reported being fearful of delivery, were government employee’s, and who had no antenatal care services, respectively. Partner support moderated the association between depression, preterm birth, and LBW. Depression had no direct effect on birth outcomes but indirectly affected preterm birth via partner support. Religion had both direct and indirect effects on preterm birth, while occupation and fear of delivery had direct effects. The risk of LBW was 9.44 and 2.19 times higher among preterm births and those who had exposure to tobacco, respectively. Stress coping was indirectly associated, and preterm birth and tobacco exposure were directly associated with LBW. The risk of stillbirth was 3.22 times higher in women with antenatal depression and 73% lower in women with higher coping abilities.There was a high incidence of all adverse birth outcomes in Gondar Town. Depression and psychosocial risk factors had important indirect negative effects on risk, while partner support provided a positive indirect effect on the incidence of adverse birth outcomes. Interventions that focus on increasing partner engagement and participation in antenatal support may help reduce adverse birth outcomes by enhancing maternal resilience. Women with depression during pregnancy produce a higher level of cortisol hormone that can affect fetal growth and subsequently lead to adverse birth outcomes including preterm birth, low birth weight (LBW), and stillbirth , 2. ‘PreLBW (birth weight less than 2500gm) is the main cause of perinatal mortality and morbidity  and alsoAntenatal depression leads to the production of a high level of cortisol, a stress hormone, associated with discontinuation of the proper functioning of the placenta and reduced oxygen supply to the fetus which can ultimately result in fetal death or miscarriage . AntenatA review of studies conducted in developed countries reported maternal depression as a risk factor for poor infant growth . FurtherStudies from Ethiopia have previously reported a lack of association between stillbirth and LBW and maternal common mental disorders (CMD) –29; howeA community-based cohort study was conducted, and pregnant women in their second or third trimester were followed up until one month after birth. Participants recruitment occurred between June 1, 2018, and March 20, 2019, in Gondar Town. Gondar Town is one of the administrative zones of Amhara Regional State that is located in the Northern part of the region at a distance of 747 km away from Addis Ababa . Gondar town has 12 kebeles , and in 2017/2018, there were 6,450 pregnancies , 31. TheThe primary exposure variable  and all other covariates were assessed during the second or third trimester of pregnancy. The birth outcomes  were collected during the first month of delivery. A face-to-face interview was conducted at both times of data collection. Data collectors used a structured and pre-tested electronic-based questionnaire aided by an online Open Data Collection Kit (ODK) application tool . The preThe main exposure variable was antenatal depression, which was assessed using the Edinburgh Postnatal Depression Scale (EPDS). Cox and colleagues developed this scale , and it The primary outcome was the incidence of adverse birth outcomes, which was determined by the occurrence of at least one of the three conditions of preterm birth, Low Birth Weight (LBW), or stillbirth. Birth weight was obtained from medical records or measured at their home  within 24 hours of delivery using a digital SECA scale to the nearest 0.1gm. LBW was classified as a birth weight of less than 2500grams . GestatiThe Oslo Social Support Scale (OSSS-3)  was usedPartner support was assessed by the statement “My husband helps me a lot” with five possible responses, “Always”, “Most of the time”, “Some of the time”, “Rarely”, and “Never”. The maternal Middle-Upper Arm Circumference (MUAC) tape was used to measure the nutritional status of the women. The MUAC is a validated and recommended measurement for nutritional status during pregnancy, with a cutoff score between 18 and 22cm as underweight and 22.5 to 31cm as normal .Pregnant women were asked if they participated in moderate-intensity physical activity such as brisk walking, dancing, gardening, and usual housework for two to three hours/week  and theiThis analysis forms part of a larger mother-child health cohort study designed to explore the extent of perinatal depression and its effect on birth and infant health outcomes in Gondar Town. The required sample size for the whole cohort was calculated using an Epi Info version 7 . This caAs the occurrence of adverse birth outcomes was rare, it was necessary to estimate risk using an appropriate model for rare outcomes. Therefore, we estimated relative risk using a Generalised Linear Model (GLM) with an identity log and binomial link function  . HoweverA mediation analysis using Generalized Structural Equation Modeling (GSEM) was conducted to look at the direct and indirect relationships between the identified covariates and each of the birth outcomes. A GSEM with logit link function was used to allow estimation with the categorical outcome and mediator variables , 54. RelEthical clearance was obtained from the Social and Behavioral Research Ethics Committee (SBREC) of the Flinders University  and the During the survey, 960 pregnant women were contacted in the six selected districts, and 44 were excluded because of refusal, absenteeism, and ethical issues. Finally, a total of 916 participants were followed to the postnatal period. During the follow up there were four women who refused to participate, eight were lost to follow up, and nine were excluded because of their high risk of severe depression  score of ≥17). Finally, 895 participants were included in the analysis. The survey response rate was 97.7%, and the loss-to-follow up rate was 2.3%.From the 895 pregnancies, 17 resulted in stillbirth , 47 in LBW , and 147 resulted in preterm births . There was a significant difference in the proportion of preterm births across the six districts (p = 0.001). The highest proportion of preterm birth (55.7%) was in the Abiygzi district and the lowest (4.0%) was in the Kirkos district. The proportion of LBW and stillbirths was not statistically different in selected districts .The results of the mediation analysis are reported in In multivariate analysis, the risk of preterm birth was 1.61  times higher among participants who identified as Muslim. Similarly, in the path analysis, religion had both a direct effect  and an indirect effect  on preterm birth with the effect being mediated by maternal stress coping ability and partner support. Participants who expressed fear about the delivery had an increased risk of preterm birth  compared to their counterparts. A similar relationship was found in the path analysis where fear of delivery had a direct effect on preterm birth . Tables Participants who were government employees had an increased risk of preterm birth  relative to those who performed home duties only. Similarly, the occupation had a direct positive effect on preterm birth in path analysis . The risk of preterm birth was 1.77 times higher  in participants who did not have antenatal care visits during pregnancy, although there was no significant relationship in the path analysis. Tables In multivariate Poisson regression modelling, the risk of having a LBW infant was significantly increased in women with preterm birth and maternal tobacco smoke exposure during pregnancy. The adjusted model is presented in There was a significant indirect effect of stress coping ability on LBW  through preterm birth. Despite significant paths from antenatal depression to LBW through both partner support and tobacco exposure, antenatal depression had no direct  or indirect effect  on the risk of LBW. The indirect effects of partner support on LBW through preterm birth and tobacco exposure were also not significant .  & Fig 2As anticipated, the multivariate-adjusted risk of LBW was 9.44  times higher among preterm births compared to full-term births. This increase in risk was also observed in the path analysis in which preterm birth had a direct positive effect on the risk of LBW . Preterm birth also mediated an effect of stress coping ability  and partner support  on the risk of LBW. In multivariate analysis, women with tobacco exposure during pregnancy had an increased risk of LBW , an association that was confirmed in the path analysis, in which exposure to tobacco had a direct positive effect on the risk of LBW . Tables The adjusted risk of stillbirth was 3.22  times higher among study participants with depression during pregnancy. The path analysis showed a small direct positive effect of antenatal depression on stillbirth . However, the risk of stillbirth was decreased by 73% in study participants with good stress coping ability . However, this effect was also slightly attenuated in the path analysis . Tables The short and long-term undesirable effects of maternal depression on the newborn and their women have been well established, and the impact is highest in low-income countries , 60. WhiIn the current community-based cohort study the incidence of stillbirth in Gondar town was 19 per 1000 live births, a finding consistent with a systematic review of studies in Ethiopia , EthiopiIn this study, the risk of stillbirth was 3.22 times higher in study participants who had depression. Risk of stillbirth was 0.27 time lower among study participants with good stress coping ability. However, in the path analysis, both depression and stress coping ability were not statistically significant, most likely as a result of insufficient power due to a relatively low number of stillbirths. While a lack of association between antenatal depression and stillbirth has been reported in high-income countries , 73 as wThe estimated incidence of LBW in our study was 5.2% (21.0% in preterm and 2.1% in term births), lower than in other community  and healBoth partner support and a higher stress coping ability modified the association between antenatal depression and LBW, although the effect for stress coping was relatively small. The risk of LBW was 3.4 times higher among study participants with depression and poor partner support relative to those without depression and good partner support. Besides, partner support and preterm birth mediated indirect effects of antenatal depression on LBW. A similar mediating effect for antenatal depression of social support on low birth weight has been reported in other cohort studies , 79. TheAs expected, the risk of LBW was 9.44 times higher among preterm births (21.1% among preterm births and 2.1% among term births). The association between LBW and preterm birth was also observed in similar studies conducted in Gondar  and DangThe risk of LBW was 2.19 times higher among study participants who had tobacco smoke exposure during pregnancy. Tobacco exposure as a risk factor for low birth weight has been reported in studies from developed countries , 89, 90.Within Ethiopia, an estimated 320,000 (10.0%) babies are born prematurely each year , similarPreterm birth is a major cause of death and long-term loss of human potential and its complication is a direct cause of neonatal death . PretermUnlike other recent studies –106, theLow and preterm births are associated with restricted fetal growth , 70, 103Consistent with other studies , 97, 121Participants identifying themselves as Muslim had 1.61 times higher risk of preterm birth than those identifying as Orthodox Christian. A slightly higher proportion of those identifying as Muslim also reported receiving less support from their partner, had poor stress coping ability, fewer ANC visits, and more minor depression compared to those identifying as Orthodox Christian, and this might be a reason for Muslims to had higher preterm as these factors independently increased the risk of preterm birth.This study presented the incidence of major adverse birth outcomes and highlighted how psychosocial risk factors play an important role in determining such outcomes. Psychological science in pregnancy  is an emThe study had few limitations, including the exclusion of women with a high probability of depression. In addition to reducing the overall sample of the study, this exclusion may have either underestimated or overestimated the effects of antenatal depression on the risk of adverse birth outcomes. A further limitation was the non-measurement of few possible confounders, mediators and outcomes that might have additional light on the proposed mechanisms. These variables include information on abuse, pregnancy complications , history of infections, and levels of inflammation during pregnancy. However, a modified Poisson regression approach is theoretically robust to omitted covariates. The other limitation is associated with the usual challenges of measuring preterm birth and low birth weight due to the accuracy of the last menstrual cycle and weight in places other than health facilities, respectively.Our study also had several strengths. The cohort was community-based, and the study population was created using a stratified cluster-based random sampling approach. Our results are, therefore, likely to be representative of the incidence and factors that predict adverse pregnancy outcomes within the region. The sample size was also relatively large, although power was reduced due to the low frequency of some outcomes. Besides, we used two different approaches to assessing the associations. A regression approach allowed us to assess the overall independent effects of each risk factor, while the path analysis allowed us to assess both the direct and indirect effects of each risk factor, as well as potential mediators of the indirect effects. Finally, the use of a modified Poisson regression approach increased the precision of our estimates and allowed the reporting of relative risks rather than odds ratios, thereby increasing interpretability.The incidence of preterm birth, low birth weight, and stillbirth in Gondar Town in Ethiopia was high, suggesting the need for improved surveillance, particularly for those women with risk factors for adverse outcomes. Maternal occupation, religious identity, antenatal care service uptake, and fear of delivery were independent predictors the risk of preterm birth. Similarly, preterm birth and smoking during pregnancy both increased the risk of low birth weight. The positive association and between depression and preterm birth, and between depression and low birth weight was attenuated by partner support and increased stress coping ability. As such, interventions that focus on increasing partner engagement and participation in antenatal support, thereby enhancing maternal resilience, may reduce the risk of adverse birth outcomes in Gondar Town. 13 Apr 2020PONE-D-19-29080Effect of Antenatal Depression on Adverse Birth Outcomes in Gondar Town, Ethiopia: A community-based cohort studyPLOS ONEDear Dr. Abel Fekadu,Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.We apologize about the delay in the review process. We invite you to resubmit as the paper received favorable reviews.https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.We would appreciate receiving your revised manuscript by May 28 2020 11:59PM. When you are ready to submit your revision, log on to If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter.http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocolsTo enhance the reproducibility of your results, we recommend that if applicable you deposit your laboratory protocols in protocols.io, where a protocol can be assigned its own identifier (DOI) such that it can be cited independently in the future. 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If eligible, we will contact you to opt in or out.We look forward to receiving your revised manuscript.Kind regards,Anna Palatnik, M.D.Academic EditorPLOS ONEJournal Requirements:When submitting your revision, we need you to address these additional requirements.1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found athttp://www.journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and http://www.journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdfAdditional Editor Comments (if provided):Reviewer 1:This paper was well conceived and well-written. The authors conducted a large survey of pregnant women (n~900) in Gondar town, Ethiopia. The main exposure in the study was antenatal depression and the main outcome was incidence of adverse birth outcome . Information on a range of risk factors  was also collected and including in the data analysis . The authors report on the main risk factors for each adverse birth outcome. The main findings in relation to the incidence of still birth indicates that Ethiopia is lagging behind other countries in reducing still births. Depression was not a risk factor for still birth in this study (perhaps due to low power); neither was is associated with low-birth weight or pre-term labour. The main findings suggest that perceived partner support and ability to cope with stress were moderated the relationship between depression and low-birth weight  - and the effect was stronger when considering preterm birth. There was no main effect for experiencing depression and low-birth weight or preterm birth. So the main take-home message appears to be that interventions efforts might be better focused on increasing partner support and the woman's ability to cope with stress.The authors neatly report on the study strengths and limitations in the discussion. The survey response rate was extremely high (97.7%).Comments/queries:Please provide more information on the collection of data during the second trimester. How regularly were women assessed between the second trimester and the outcome assessment (one month after birth). The data collection and the questionnaire section is somewhat confusing because it suggests that many of the study variables  were assessed at the one-month post birth interview, as opposed to during the second trimester (i.e. during the pregnancy and before the birth outcome data was collected). Please clarify.There is a bit of confusion in the discussion about the need for studies with larger sample sizes, although the large sample size of the study is listed as a study strength. It appears the authors mean that larger sample sizes are required to study rare outcomes (i.e. still birth) in future.There appears to be a mix-up in the measurement section re the cutoff score for MUAC .Reviewer 2:Abstract“The impact of psychosocial factors on pregnancy outcomes has been investigated in developed countries but few studies have been conducted in low-income countries.” This sentence does not look really important. If the authors have to report this, how can the outcome differ across culture? Why the HIC findings is not generalizable to LICs?IntroductionThe authors argued that the moderating effect of depression was not studied in Ethiopia. If this is known in other countries, is it not generalizable to other countries like Ethiopia?MethodsThe authors argued that preterm birth was not controlled in previous studies. it is understood that measurement of preterm birth is very problematic as women cannot remember the LMP which might have affected the results. The challenges related to assessment of preterm birth and low birth weight were not stated in limitations. There is also stigma related to reporting stillbirth. How could the authors managed to reduce bias related to such stigma.The grave limitation of previous studies on the association of depression and LBW were linked to low sample size which was also the case in the current study. How different is the current study from previous studies?[Note: HTML markup is below. Please do not edit.]Reviewers' comments:Reviewer's Responses to QuestionsComments to the Author1. Is the manuscript technically sound, and do the data support the conclusions?The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: YesReviewer #2: Yes**********2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: YesReviewer #2: Yes**********3. Have the authors made all data underlying the findings in their manuscript fully available?PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.The Reviewer #1: YesReviewer #2: Yes**********4. Is the manuscript presented in an intelligible fashion and written in standard English?PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.Reviewer #1: YesReviewer #2: Yes**********5. Review Comments to the AuthorPlease use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. Reviewer #1: Abstract“The impact of psychosocial factors on pregnancy outcomes has been investigated in developed countries but few studies have been conducted in low-income countries.” This sentence does not look really important. If the authors have to report this, how can the outcome differ across culture? Why the HIC findings is not generalizable to LICs?IntroductionThe authors argued that the moderating effect of depression was not studied in Ethiopia. If this is known in other countries, is it not generalizable to other countries like Ethiopia?MethodsThe authors argued that preterm birth was not controlled in previous studies. it is understood that measurement of preterm birth is very problematic as women cannot remember the LMP which might have affected the results. The challenges related to assessment of preterm birth and low birth weight were not stated in limitations. There is also stigma related to reporting stillbirth. How could the authors managed to reduce bias related to such stigma.The grave limitation of previous studies on the association of depression and LBW were linked to low sample size which was also the case in the current study. How different is the current study from previous studies?Reviewer #2: This paper was well conceived and well-written. The authors conducted a large survey of pregnant women (n~900) in Gondar town, Ethiopia. The main exposure in the study was antenatal depression and the main outcome was incidence of adverse birth outcome . Information on a range of risk factors  was also collected and including in the data analysis . The authors report on the main risk factors for each adverse birth outcome. The main findings in relation to the incidence of still birth indicates that Ethiopia is lagging behind other countries in reducing still births. Depression was not a risk factor for still birth in this study (perhaps due to low power); neither was is associated with low-birth weight or pre-term labour. The main findings suggest that perceived partner support and ability to cope with stress were moderated the relationship between depression and low-birth weight  - and the effect was stronger when considering preterm birth. There was no main effect for experiencing depression and low-birth weight or preterm birth. So the main take-home message appears to be that interventions efforts might be better focused on increasing partner support and the woman's ability to cope with stress.The authors neatly report on the study strengths and limitations in the discussion. The survey response rate was extremely high (97.7%).Comments/queries:Please provide more information on the collection of data during the second trimester. How regularly were women assessed between the second trimester and the outcome assessment (one month after birth). The data collection and the questionnaire section is somewhat confusing because it suggests that many of the study variables  were assessed at the one-month post birth interview, as opposed to during the second trimester (i.e. during the pregnancy and before the birth outcome data was collected). Please clarify.There is a bit of confusion in the discussion about the need for studies with larger sample sizes, although the large sample size of the study is listed as a study strength. It appears the authors mean that larger sample sizes are required to study rare outcomes (i.e. still birth) in future.There appears to be a mix-up in the measurement section re the cutoff score for MUAC .**********what does this mean?). If published, this will include your full peer review and any attached files.6. PLOS authors have the option to publish the peer review history of their article  digital diagnostic tool,  17 Apr 2020The response to reviewers document has been attached.AttachmentRebuttal letter.docxSubmitted filename: Click here for additional data file. 6 May 2020PONE-D-19-29080R1Effect of Antenatal Depression on Adverse Birth Outcomes in Gondar Town, Ethiopia: A community-based cohort studyPLOS ONEDear Mr Fekadu,Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.Please explain how did you achieve such high response rate on the survey, Thank youhttps://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.We would appreciate receiving your revised manuscript by Jun 20 2020 11:59PM. When you are ready to submit your revision, log on to If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter.http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocolsTo enhance the reproducibility of your results, we recommend that if applicable you deposit your laboratory protocols in protocols.io, where a protocol can be assigned its own identifier (DOI) such that it can be cited independently in the future. 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If eligible, we will contact you to opt in or out.We look forward to receiving your revised manuscript.Kind regards,Anna Palatnik, M.D.Academic EditorPLOS ONE[Note: HTML markup is below. Please do not edit.]https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email us at figures@plos.org. Please note that Supporting Information files do not need this step.While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool,  7 May 2020Response for editor comment has been included in journal submission portal.AttachmentRebuttal letter two.docxSubmitted filename: Click here for additional data file. 2 Jun 2020Effect of Antenatal Depression on Adverse Birth Outcomes in Gondar Town, Ethiopia: A community-based cohort studyPONE-D-19-29080R2Dear Dr. Fekadu,We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.Within one week, you’ll receive an e-mail detailing the required amendments. 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For more information, please contact Kind regards,Anna Palatnik, M.D.Academic EditorPLOS ONEAdditional Editor Comments :Reviewers' comments: 5 Jun 2020PONE-D-19-29080R2 Effect of Antenatal Depression on Adverse Birth Outcomes in Gondar Town, Ethiopia: A community-based cohort study Dear Dr. Fekadu:I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. onepress@plos.org.If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact plosone@plos.org. 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Background: Preterm birth contributes to the morbidity and mortality of newborns and infants. Recent studies have shown that maternal exposure to particulate matter and extreme temperatures results in immune dysfunction, which can induce preterm birth. This study aimed to evaluate the association between fine particulate matter (PM2.5) exposure, temperature, and preterm birth in Seoul, Republic of Korea. Methods: We used 2010–2016 birth data from Seoul, obtained from the Korea National Statistical Office Microdata. PM2.5 concentration data from Seoul were generated through the Community Multiscale Air Quality (CMAQ) model. Seoul temperature data were collected from the Korea Meteorological Administration (KMA). The exposure period of PM2.5 and temperature were divided into the first (TR1), second (TR2), and third (TR3) trimesters of pregnancy. The mean PM2.5 concentration was used in units of ×10 µg/m3 and the mean temperature was divided into four categories based on quartiles. Logistic regression analyses were performed to evaluate the association between PM2.5 exposure and preterm birth, as well as the combined effects of PM2.5 exposure and temperature on preterm birth. Result: In a model that includes three trimesters of PM2.5 and temperature data as exposures, which assumes an interaction between PM2.5 and temperature in each trimester, the risk of preterm birth was positively associated with TR1 PM2.5 exposure among pregnant women exposed to relatively low mean temperatures (<3.4 °C) during TR1 . Conclusions: When we assumed the interaction between PM2.5 exposure and temperature exposure, PM2.5 exposure during TR1 increased the risk of preterm birth among pregnant women exposed to low temperatures during TR1. Pregnant women should be aware of the risk associated with combined exposure to particulate matter and low temperatures during TR1 to prevent preterm birth. Preterm birth is defined as labor and delivery at less than 37 gestational weeks. Preterm birth is associated with stillbirths and premature infant complications, resulting in substantial economic costs and impairments that persist into adulthood . The hig2.5, or particles with an aerodynamic diameter of 2.5 µm or less) is more uniformly distributed in air compared with other pollutants. PM2.5 exposure is a useful indicator of overall exposure to outdoor particulate matter (PM) and can be used to study the health effects of such exposure [2.5 is strongly associated with adverse health effects [2.5 enters the body and accumulates in various compartments of the respiratory tract, interacting with epithelial and immune cells [2.5, it is important to elucidate the impact of air pollutants on human immune function [2.5 can deposit in other compartments of the respiratory tract and interact with epithelial and immune cells. Consequentially, exposure to PM2.5 can cause local or systemic inflammatory responses [According to a World Health Organization (WHO) report, maternal exposure to air pollution increases risk of preterm birth and low birth weight (LBW) WHO, 2018). Fine particulate matter . The MDIS system is a national statistical site containing sectorwide household and population data, including birth outcomes in the database.We used birth data from the MicroData Integrated Service (MDIS) system of the Korea National Statistical Office  before 22 weeks or after 42 weeks of gestation and (ii) as part of multiple pregnancies , 581,239 infants were included in our main analysis.We used data from birth surveys, which included data on sex, birth weight, birth date, gestational age at birth, parity, season of birth, parental age, parental education status, parental occupations, and residential area.2.5 levels were measured using the Community Multiscale Air Quality (CMAQ) Modeling System [2.5 concentrations were estimated using the Weather Research and Forecast —Sparse Matrix Operator Kernel Emission  Community Multiscale Air Quality  Modeling System [2.5 exposure data because PM2.5 monitoring data has many missing values.PMg System . Betweeng System . We usedThe CMAQ modeling data were generated using meteorological research and forecasting models comprising three overlapping weather data sources at 27, 9, and 3 km for a specific period of time . The datwww.kma.go.kr). The daily mean temperatures of each TR were divided into the following groups according to the quartile values: group 1 (−14.5 to 3.4 °C), group 2 (3.4–14.5 °C), group 3 (14.5–22.8 °C), and group 4 (22.8–31.8 °C).The temperature data from 2009 through 2016 were obtained from the Korea Meteorological Administration , range 2 (3.4–14.5 °C), range 3 (14.5–22.8 °C), and range 4 (22.8–31.8 °C).In the analysis, the mean PM2.5 and extreme temperature with risk of preterm birth. Model 1 included PM2.5 and temperature exposures of each trimester. Model 2 included PM2.5 and temperature exposures of all three trimesters and assumed the interactions between PM2.5 and temperature in each trimester. All models included child sex, mother’s age, mother’s educational level, parity, and season of birth as covariates. The models were calculated as follows:Logistic regression models were used to evaluate the associations of prenatal exposure to PM2.5 in the ith trimester, i = 1, 2, or 3.Model 1: logit(π) = β0 + βTR1i + covariates. TRi: PM2.5 in the first trimester. TR2: PM2.5 in the second trimester. TR3: PM2.5 in the third trimester.Model 2: logit(π) = β0 + βTR11 + βTR22 + βTR33 + covariates. TR1: PMp < 0.05.SAS version 9.4  was used to perform all statistical analyses. The significance level was set at 2.5 from March 2009 through February 2016 in Seoul.The characteristics of the full-term and preterm births are presented in 2.5 (10 µg/m3) exposure in each trimester is presented in The risk of preterm births by PM2.5 exposure is shown in p < 0.001). On the other hand, the risk of preterm birth was lowest when the temperature was 14.5–22.8 °C during TR1.The risk of preterm birth due to the combined effect of extreme temperature and PM2.5 and low temperatures during TR1. We found that the risk of preterm birth was associated with combined exposure to PMAccording to a recent study, the risk of spontaneous preterm delivery increased following exposures to temperatures between 0 and −6 °C . Tempera2.5 particles induces oxidative stress and inflammation in pregnant women, which can contribute to the onset of preterm birth [2.5 during pregnancy, has also been associated with poor fetal growth [Inhalation of PMrm birth . Air polrm birth . As a rel growth . Our resl growth . Regulatl growth .In our study, exposures between 22.8 and 31.8 °C were relatively lower than the range of high temperatures classically associated with premature birth. The high temperature range in Korea is 22.8–31.8 °C. The U-shaped dose–response relationship was observed between ambient temperature and risk of preterm birth in this study. Our results for high temperature exposure may be explained as follows. First, temperature represents the value of the average exposure temperature. Therefore, temperature exposure might not be constantly high, and the temperature may be lower than the data values presented. Second, the high temperature range consists of measurements higher than 30 °C. Third, in obstetrics and gynecology, “maintaining normothermia” refers to the comfortable and healthy environmental temperature ranging between 23 and 25 °C, which is associated with a lower risk of fetal death due to hypothermia. In our study, the range of 22–31 °C was relatively warm. In our study, if the temperature range was relatively narrow and the average exposure temperature was between 30 and 40 degrees, our results may be different.It is important to explain not only the effect on premature birth of high temperatures but also the influence on premature birth of low temperatures. Many previous studies have demonstrated a U-shaped relationship between temperature and birth outcomes, reflecting a higher risk of premature births at extreme temperatures and a lower risk of premature births at moderate temperatures. Some relevant studies have focused on high temperatures above 40 °C. Our study’s main observation was that maternal exposure to low ambient temperatures during pregnancy could influence the timing of parturition. Additionally, we showed a protective effect of moderate ambient temperatures. Other studies have also reported that low temperatures increased the risk of preterm birth as much as high temperatures. Moderately warm temperatures have also been shown to be helpful for both the pregnant woman and her fetus , which iOur study accounted for both environmental epidemiological considerations and gynecological considerations. We also considered extreme temperatures on both ends of the scale. We investigated about 600,000 pregnancies from 2009 through 2016 using national data. This was not a cohort study observing detailed factors, but it was a study that comprehensively observed an association between human health and specific environmental determinants using national statistical data.2.5 exposure can be vastly different from their outdoor counterparts; the use of air conditioners and air purifiers indoors, for example, can contribute to such differences. These uncertainties about exposure settings should be considered when interpreting the study results.Since this was a retrospective study using national data, one limitation was that we were unable to control some factors that might have affected outcomes concurrently with the variables of interest. However, with this study of about 600,000 pregnant women from 2009 through 2016, we were able to comprehensively observe an association between human health and specific environmental determinants. Our study adjusted for sex, maternal age, maternal education level, parity, birth season, and temperature, but could not adjust for exposure in the working environment and outdoor activity time. Another limitation was related to the context of exposure assessment. Indoor temperatures and indoor PM2.5 during TR1 had a significantly increased risk of preterm delivery. This indicates that pregnant women should avoid very low temperatures and exposure to high concentrations of air pollutants simultaneously, particularly during TR1. Appropriate temperature control and fine particle management during TR1 could be an important measure to prevent preterm births. We need to consider not only extremely high temperatures but also the impact on premature births of extremely low temperatures.We found that pregnant women exposed to low temperatures and PM


The tendency of the three modelLewis acidic sites A–C to releaseneutral Al fragments  or transientaluminum cations  has been investigatedboth in the absence and in the presence of neutral N-donors. Sites C are most likely responsible for the activation capabilitiesof TMA-rich MAO, but TMA depletion destabilizes them, possibly inducingstructural rearrangements. The remaining sites A and B, albeit of lower Lewis acidity, should be still able torelease cationic Al fragments when TMA-depleted modified MAOs aretreated with N-donors (e.g. [AlMe(bht)]+ from MAO/BHT).These findings provide tentative interpretations for earlier observationsof donor-dependent ionization tendencies of MAO and MAO/BHT and howTMA depleted MAOs can still be potent activators.Theestablished model cluster (AlOMe) tert-butyl-4-methylphenol). Albeit only sites of lower Lewisacidity are found in TMA depleted modified MAOs, they can releasecationic Al fragments when treated with certain N-donors. This showshow TMA depleted MAOs can still be potent activators.A model cluster for methylaluminoxane (MAO) was used tostudy the tendency of model Lewis acidic sites to release neutralAl fragments or transient aluminum cations both for unmodified MAOand TMA-depleted MAO/BHT (TMA = trimethylaluminum; BHT = 2,6-di- The crystal structure of its higher homologue tert-butylaluminoxane (TBAO), obtained by controlled hydrolysisof tri-tert-butylaluminum, has been determined, featuringwell-defined (AlOtBu)n cages with four-coordinate Al and three-coordinate O centers atthe edges of four- or six-membered rings.10 Experimental and computational studies have shown that similar cagesof pure (AlOMe)n are not stable enough.In the absence of the bulky tBu groups, rearrangementsmaximize the number of the less strained six-membered faces.25Since its serendipitousdiscovery in the 1980s,26 likely servesa structural, stabilizing role in MAO clusters. It is generally acceptedthat hydrolysis of TMA yields a complex and dynamic distribution of(AlOMe)n(AlMe3)m cages.25 The formula accounts indiscriminately for formal AlMe3 that is actually incorporated into the cage backbone and for properAlMe3 molecules that are reversibly associated with theAl-clusters. The latter serve to stabilize residual unsaturated Aland O atoms  and areknown to undergo exchange equilibria with residual “free”TMA molecules.28Besides, some residual TMA from the synthesis 31 or by addition of suitablescavengers like 2,6-di-tert-butyl-4-methylphenol.34 In all cases, “free” TMA is likelyremoved/scavenged first, consequently inducing a partial release of“structural” AlMe3 molecules. This dissociationexposes unsaturated Al and/or O atoms on cage edges, destabilizingthe cluster and inducing structural rearrangements. Formation of largerAl-cages, upon TMA depletion, has been observed experimentally bydiffusion NMR spectroscopy33 and cryoscopy.27These dynamicequilibria are particularly relevant in MAO modificationsinvolving TMA depletion. This can be achieved, for instance, by vacuumdrying (bp of TMA = 125 °C)3 molecules are proposed to serve functional roles.In particular, they are thought to be responsible for the Lewis acidityof MAO via generation of transient [AlMe2]+ speciesrelevant for precatalyst activation .43 Bipyridine (bipy), for instance, extracts[AlMe2]+ from MAO with high chemoselectivityin the form of the donor stabilized adduct [AlMe2(bipy)]+.41Importantly, in addition to their stabilizingrole, “structural”AlMetivation 1.18,26,3py), can generate the corresponding[AlMe2(py)2]+ adduct, but concomitantformation of neutral AlMe3(py) is also observed.41Similarly,pyridine (44 It has been proposed that additionof the Brønsted acidic BHT to MAO leads to (a) conversion of“free” TMA and a fraction of “structural”AlMe3 into the relatively inert AlMe(bht)2 complexvia methane generation46 and (b) conversion of the remaining“structural” AlMe3 in analogous “structural”AlMe2(bht) molecules, resulting in [(AlOMe)0.87(AlMe2 bht)0.13]n cages (bht = BHT phenolate).44 Addition of bipy to MAO/BHT leads to the formationof [AlMe(bht)(bipy)]+, while py selectivelygenerates neutral AlMe2(bht)(py).44Recently, analogous reactionshave been reported for the phenol-modifiedMAO/BHT.py has been studied alsoforMAO supported on silica;47 Brønsted acidicSi–OH groups of silica are known to scavenge TMA similarlyto BHT.49 However, the complexity of theseheterogeneous systems hampers straightforward connections with thestructure and reactivity of unmodified MAO in solution.50The interaction with 19 have proposed that the cage 16,6  studies, for example, identifying C type sites as those being more prone to release [AlMe2]+ and AlMe3.55In extensive computational studies, Linnolahtiand co-workers16,6 was considered for MAO, along with its bht-decoratedanalogues representing MAO/BHT. The thermodynamics of [AlMeR]+ and/or AlMe2R dissociation (R = Me or bht) wasinvestigated both in the absence and in the presence of neutral N-donorslike py and bipy, providing a close comparisonwith previously reported experimental studies.44In the present paper, a systematic computational study is reported,aiming to provide further insights in the functional roles carriedout by the Lewis acidic Al-sites. The representative model cluster 57 and widely used for modelingof Al-species relevant to olefin polymerization59 and otherresearch fields,60 and it has been shownto be suitable for studies related to MAO activators.61 Additionalinclusion of Grimme-type long-range dispersion corrections63 does not affect computational results significantly (see Supporting Information).The computational protocol M06-2X/TZ(PCM)//TPSSTPSS/DZ has beenpreviously benchmarkedC siteas representative example (see Supporting Information for the corresponding schemes for A and B):3 with the analogous AlMe2(bht)  2a+ or AlMe2R in the absence of donors  species44Formation of [AlMeR] like py 2c or bippy  are predicted for the two inequivalent C-type sites of 16,6 studied here.It should be noted here, that the experimentallyfound MAO anionwith the highest detected abundance is also a GR) are reported in 64 Furthermore, reactions are modeled assuming naked ions in a solventcontinuum, rather than the ion pairs typically formed in the low polaritysolvents used (see below for further discussion on this point).66DFTestimated reaction Gibbs free energies , upon addition of BHT to MAO, clearly indicatea highly exergonic process for all the various types of acidic sites is quite small and comparable to the dimerization energyof TMA ;67 appreciably higherΔGR are estimated for sites A and B , instead.The peculiarity of sites C lies in the “structural”AlMe3 molecules being bound to the Al site of the cagevia two bridging methyl groups (similar to the TMA dimer), leadingto a more labile interaction compared to sites A and B with one bridging methyl and a proximal two-coordinate Oatom on the cage edge (Schemes S1b and S2b).37The resultsconcerning the generation of neutral or ionic fragmentsare reported in A, in which the Aland O atoms involved in the interaction with AlMe3 areadjacent but not bound to each other  is bound slightly weaker than AlMe3 to B and C . As shown in Table S3 and Figure S1, the bht fragments of “structural”AlMe2(bht) are rotated out of the optimal Al–O–Cbht binding geometry, likely due to steric congestion. Thisdistortion is most prominent for site A and might be(co)responsible for the particularly weaker binding of the bulky Al-phenolatefragment to this site.AlMe2R are calculatedfor formation of cationic [AlMeR]+, that is, ionizationshould occur more easily for C than for A and B. [AlMe(bht)]+ should be released somewhatmore easily than [AlMe2]+ from each site . Charge dissipationis known to be crucial for generating weakly coordinating anions and,consequently, highly active catalysts.7 The abilityof MAO to generate large anions with a delocalized negative chargehas been proposed as one of the origins of the excellent cocatalyticproperties of this aluminoxane.71 In the presence of a neutralmonodentate donor like py, all reactions are predictedto be significantly easier and particularly for C , and nearlyenergetically neutral for A. Release of AlMe2(bht) is again favored with respect to that of AlMe3 foreach site . The exergonicity is enforced by two main contributions.First, py stabilizes the leaving molecular species AlMe2R by forming coordinately saturated AlMe2R(py)complexes. Second, py can bind also to the three-coordinateAl atoms on the cage edge generated by the dissociation, thereforepreventing cage destabilization . The appreciably lower ΔGR in the former case is due to the formationof the aforementioned Al–O bond ]+)but not for sites A  and B . Here, four-coordinate Al atoms are generatedonthe cage, and only the stabilization of the [AlMeR]+ fragmentsby two py molecules provides an increased driving force]+ more easily than [AlMe2]+.Also ionization is facilitated by the presence of bipy  without being released by the Al cages.Sites strongly3. TherefA and B, and ionizationis predicted to be similarly thermodynamically unfavorable in bothcases . Toprove this concept, the representative ion pair [AlMe(bht)(bipy)]+− has been modeled (fullyrelaxed) for B, assuming that the cation remains in theproximity of the Al site it was generated from. Calculated ΔGR drops from 15.0 kcal/mol for the isolatedions to only 2.2 kcal/mol for the contact ion pair ]+ should be similarly easy. However, as discussedin the previous sections, sites that release [AlMe2]+ in MAO (C) should not be of the same type asthose releasing [AlMe(bht)]+ in MAO/BHT (A/B). The latter type is appreciably less prone to undergo ionizationionization of MAO but not MAO/BHT.44 Thedifference between the two cocatalysts and the different Lewis acidicsites becomes experimentally less evident with the bidentate donor bipy, which is a more effective ionizing agent.Computational resultsindicate that,for a given site, generation of C sites should be those releasing[AlMe2]+ and AlMe3 most easily. Thisimplies that (a) they are likely responsible for the activating capabilityof MAO and (b) the “structural” AlMe3 moleculesbound to these sites are largely released upon TMA depletion . Theconsequent liberation of unsaturated three-coordinate Al-atoms onthe cage can lead to structural rearrangements that “annihilate”these sites.In unmodified MAO, type 2R molecules should therefore be bound primarily tothe remainingsites A and B. In the case of MAO/BHT, calculationsindicate that the two sites have similar tendencies to release [AlMe(bht)]+ and AlMe2(bht). Sites A and B should therefore be responsible for the properties of MAO/BHT,even though their reactivity is appreciably lower than that of sites C in unmodified MAO. These computational results explain thelower propensity of MAO/BHT with respect to MAO to undergo ionizationupon interaction with py:44 this depends not only on the different stability/electrophilicityof [AlMe(bht)]+ vs [AlMe2]+ cationsbut also on the reactivity of B vs C-typesites they originate from.In TMA-depleted MAOs, “structural”AlMeA–C sites should be rather independentof the size of cage they belongto, since their properties are mainly determined by their local structures.Importantly, the apparent diversity of Lewis acidic sites in MAO andits TMA depleted counterparts indicates that strongly Lewis acidicAl-sites like C are not necessarily a prerequisite foran effective abstractor.The reactivity trends of type 75 in combinationwith the OPTIMIZE routine of Baker77 and the BOptsoftware package.78 All relevant structureswere fully optimized at the TPSSTPSS level79 of theory employing correlation-consistent polarized valence double-ζDunning(DZ) basis sets 81 from the EMSL basis set exchange library.82 All calculations were performed at the standard Gaussian 09 qualitysetting [Scf = Tight and Int(Grid = fine)]. Final single-point energiesand natural bond orbital83 analyses werecalculated at the M06-2X level of theory84 employing triple-ζ Dunning (TZ) basis sets .80 Solvent corrections where included at this stageby the polarized continuum model (PCM);85 a typical solvent used in olefin polymerization, namely toluene,was considered. The density fitting approximation (resolution of identity)was used at the optimization stage as well as for final energy calculations.89 Enthalpies and Gibbs free energies were then obtained from TZ single-pointenergies and thermal corrections from the TPSSTPSS/cc-pVDZ-(PP) vibrationalanalyses; entropy corrections were scaled by a factor of 0.67 to accountfor decreased entropy in the condensed phase.92 The structureof 16,6, optimized by Linnolahti and co-workers, wasused as starting the geometry.19 Electrostatic potentialmaps of cubegen routineof Gaussian using the formatted checkpoint files of M06-2X singlepoint energy calculations.Following the protocol described in ref , all geo


Obtaining a nutrient-rich diet during pregnancy is a challenge for pregnant women living in low-income countries. This randomized, controlled trial was designed to determine if a freshly prepared food supplement from local animal-source foods and dark-green leafy vegetables given prior to and/or during pregnancy improved birth outcomes in rural Vietnamese women. Primiparous women, 18 to 30 years of age, who participated in the study were assigned to one of three groups: PC-T women received the supplement from pre-conception to term, MG-T women received the supplement from mid-gestation to term, and the RPC women received routine prenatal care. Supplement intake was observed and quantified. Infant anthropometry was measured at birth and/or within seven days of delivery. The effect of the intervention on maternal and birth outcomes was determined using linear regression modeling. Of the 460 women enrolled in the study, 317 women completed the study. Those not completing the study had either moved from the area, did not conceive within 12 months of study enrollment, or miscarried. The food-based supplement increased protein, iron, zinc, folate, vitamin A and B12 intakes in the PC-T and the MG-T groups. However, it failed to alter infant anthropometric measurements at birth. In the entire cohort, maternal gestational weight gain was greater in women with a low pre-pregnancy BMI (<18.5) and in women with a higher educational attainment. Working as a farmer reduced gestational weight gain but it did not affect birth weight or length. In summary, a nutrient-rich, food-based supplement given to rural Vietnamese women from pre-conception to term or mid-gestation to term did not affect maternal or infant outcomes. The low weight gains, possibly due to demanding farm work done throughout the reproductive cycle, may have obviated any effects of the low energy, nutrient-rich food supplement on birth outcomes.Trial registration : Registered Clinical Trials.gov: NCT01235767. Poor maternal nutrition is linked to both prematurity and fetal growth retardation. Indicators of maternal malnutrition before pregnancy, such as short stature, account for about one third of low weight births  -6.5  -6.5 .12  were measured by microbiological assay using a chloramphenicol resistant strain of Lactobacillus casei and a colistin sulphate resistant strain of Lactobacillus leichmannii for folate and B12, respectively [The collected blood was processed immediately in the field laboratory. EDTA-preserved whole blood was collected to measure hemoglobin by the cyanmethemoglobin method using a Drew D3 auto analyzer . Anemia was defined as a hemoglobin concentration below 12 g/dL for nonpregnant women and 11 g/dL for pregnant women . Twenty-ectively , 22. Serectively . Serum vectively .The head of the communal health station contacted all women twice a month for a morbidity interview and to check the menstruation data. Urinary pregnancy tests were done monthly using the dipstick analysis. Gestational age, in weeks, was calculated from the first day of the last menstruation period (LMP date) and the date of birth (DOB): (DOB–LMP date)/7.The hospital staff in the delivery room measured infant birth weight immediately after the baby was cleaned. The baby was wrapped in a towel when weighed and then the towel weight was subtracted from the total. Study staff used standard weights to check the scale before using. The study staff measured the infant weight, length, head and mid-upper arm circumference in 199 infants (63% of the cohort) within seven days of delivery using standard WHO procedures . InfantsThe study aimed to enrolled 460 eligible women under the initial assumption that 95% would become pregnant within 1 year and 85% would be retained during follow-up. This sample size was based on a desired 80% power to detect a 135 g difference in mean birth weight between any two trial arms  in a population with a 380 g SD in birth weight (based on a prior survey of 1200 births in the Cam Khe district in 2005).In all analyses, categorical variables are presented as percentages, and continuous variables are presented as means and standard deviations. Continuous variables that were not normally distributed are presented as medians and interquartile ranges. Baseline maternal characteristics  and primary outcomes  were compared across the assigned treatment groups using analysis of variance , chi-square , and Kruskal-Wallis  tests. If the global test over the three treatment groups was statistically significant (p<0.05), pair-wise tests were performed . The primary outcomes of the trial were compared between trial arms without adjustment for baseline characteristics. Dietary recall data were compared using a model-based approach  to account for intra-participant variation, given that most participants had 2 recalls per time-point. Blood markers of maternal nutritional status were compared separately at each time point . The statistician was masked to trial group assignments when the statistical analyses were performed.To examine the impact of the intervention on birth outcomes while adjusting for maternal characteristics, as well as to explore potential associations between maternal characteristics and birth outcomes, we fitted separate univariable and multivariable regression models for birth weight , birth length, and GWG. Adjustment variables included infant gender, gestational age, and maternal characteristics at baseline  and during pregnancy . Covariables were checked for collinearity and variable inflation factors . Missing values (5% of covariable data) were multiply imputed .All statistical analyses were conducted using SPSS statistics 24  and STATA version 14 ; associations reaching p<0.05 were considered statistically significant.Two separate analyses were conducted for birth weight: one was based on the weights made at the District Hospital (N = 315) and the second was based on weights measured by study staff (N = 199) within a week of birth. In total, 317 infants had birth weight measured from at least one source. The women for whom study-measured weights were available had largely remained in contact with the study staff throughout pregnancy and complied with the assigned diet supplements . The hospital-measured weights included 118 women who stopped attending study visits and, therefore, were no longer receiving the food supplements. Thus, while not planned a priori, the two birth weight sources allowed for analyses that approximated intention-to-treat  and per-protocol (study staff-measured) approaches.. More than 3,300 women  were excluded for the following reasons: 60% had plans to work outside of the study area, 33% were already pregnant or had a child previously, 5% did not meet the inclusion criterion of planning to have a baby within one year, did not live with their husband, or had a health problem, such as heart or kidney disease, and 2% declined to enroll without giving a reason. The 460 eligible women were randomly assigned to either the pre-conception to term (PC-T) food supplementation group, the mid-gestation to term (MG-T) group, or the routine prenatal care (RPC) group. Of those 460 women, 143 women (31%) did not finish the study for various reasons: they withdrew, moved from the village, did not conceive within 12 months, or had health problems that prevented continuing in the study . Of the 317 women who finished the study, as defined by having a recorded infant birth weight, the study team completed infant anthropometric measurements in 199 (63%) and hospital measures were available for 315 (99%). Actual losses to follow-up were higher than anticipated , leaving the final sample with 84% power to detect a difference of 150 g between any two trial arms for the 315 hospital-measured infants and 64% power for the 199 study-measured infants.Of the 3,764 women who were initially identified as eligible for the study, 460 were enrolled Table 2. On average, the participants were 21 years old at enrollment; about 40% had education beyond middle school. As is typical in rural Vietnam, about 70% of the women lived with their husband’s parents and 78% worked as farmers. Approximately one-fourth of the women had a body mass index (BMI) below 18.5 kg/m2. Women dropping out of the study (Table 3) were less likely to live with their parents-in-law (59% vs. 71%) and to work as farmers (70% vs. 78%), had lower upper arm muscle area  and greater arm fat areas (17.3 cm2 vs. 16.4 cm2) than the dropouts; however, only upper arm muscle area differences were statistically significant after accounting for multiple hypothesis tests (Table 3).Characteristics of the participants are shown in Table 4. At baseline, the nutrient intakes did not differ among the three groups. Protein, iron, zinc, vitamin A, folate, and vitamin B12 intakes were higher in the PC-T and MG-T groups compared to the RPC group (p<0.001) at mid-pregnancy. At late pregnancy, the nutrient intakes of the PC-T and MG-T groups exceeded the controls (p<0.001) except for energy . The food-based supplement increased iron and folate intakes by about 60–80% and the protein and zinc intakes by about 30%. Vitamin A and B12 intakes were increased more than two-fold by the supplement.Maternal dietary intakes and nutritional status biomarkers of the women for whom such measures were available are shown in  were numerically lower in the PC-T group (35 μg/L) compared to the RPC group (56 μg/L), and by mid-pregnancy, the serum ferritin values of the PC-T (48 μg/L) and MG-T (58 μg/L) groups were lower than that of the RPC group (69 μg/L), but differences were not statistically significant. Serum ferritin levels were markedly lower at late pregnancy than at baseline in all three groups, and no group differences were evident. Despite the differences in intakes, biomarkers of the other iron status indicators as well as zinc, vitamin A, folate, and B12 did not differ among the three groups at any time point . Also, the incidence of anemia and inflammation among the three groups did not differ at baseline, mid or late pregnancy in the full cohort of 317 women or in the 199 women who complied with supplementation . Using micronutrient supplements at 16 and 32 weeks significantly increased serum folate levels at both time points (p<0.001), but taking those supplements was not associated with birth weight, birth length, or GWG.Table 5. Birth weight measured immediately after delivery by hospital staff averaged 3006 g, and it did not differ among the three diet groups. Birth weight measured by the study team during the first week of life were similar to the hospital measurements (2972 g), and it also did not differ among the three groups. The prevalence of low birth weight babies tended to be higher when evaluated by the study team rather than from hospital records, 8.0 vs 3.2%. This may reflect the practice of rounding birth weight to the nearest 100g by the hospital staff as well as the usual water loss by infants during the first few days of life causing a decrease in body weight [th percentile for the gestational age. Maternal gestational weight gain averaged 7.4 kg in the entire cohort during the first 32 weeks of gestation and it did not differ among the treatment groups. On average, the women gained 0.40 kg/week between 16 and 32 weeks of pregnancy.Birth outcomes of all of the women and of the three intervention groups are summarized in y weight . Water ly weight . Birth ly weight . In the Tables 7). In our multivariable model, for each standard deviation increase in gestation age (approximately 2 weeks), there was a statistically significant increase in team-measured birth weight (129 g) and birth length (0.5 cm), but not in hospital-measured birth weight after accounting for multiple hypothesis tests.After adjustment for infant and maternal variables, there were no statistically significant associations between the food supplement intervention and birth outcomes. However, infant gestational age at delivery as measured at the hospital and by study staff was positively associated with birth weight and birth length (Table 7). A low pre-pregnancy BMI (< 18.5) was also associated with greater GWG, with lower BMI women gaining about 2.3 kg more than higher BMI women after adjustment for other variables. Several socioeconomic variables were associated with GWG. Working as a farmer compared to other professions was associated with lower GWG , while higher educational attainment compared to below high school level was associated with greater GWG . GWG gain itself was positively associated with hospital-measured birth weight (not shown in tables). For each standard deviation of greater GWG (approximately 3.6 kg), the corresponding increase for hospital-measured birth weight was 89 g  and 51 g ; for study-measured birth weight the increase was 42 g  and 25 g .Maternal height was positively associated with gestational weight gain   or were equal to the Estimated Average Requirements  [In this randomized-controlled trial, provision of a small  nutrient-rich, food-based supplement five days/week from prior to conception to term did not alter pregnancy outcomes as measured by birth weight, length, the prevalence of preterm births, or the occurrence of small-for-gestational babies. Although the supplement significantly increased energy, vitamin A, Band B12) . AbsenceIn a study of non-pregnant, rural Vietnamese women done 10 years earlier, about 15% were anemic and about 40% had a BMI below 18.5 , 36. Sev12 recommended intakes, circulating concentrations of these nutrients did not differ among the three groups at either mid or late pregnancy. There are several reasons why the increased intake of animal source foods with good nutrient bioavailability failed to increase serum nutrient levels. One explanation is the lower nutrient absorption when it is consumed either from or with food compared to taking a supplement in the fasting state. Several studies have shown that more zinc is absorbed from a supplement taken without food rather than with a meal [Although our nutrient-rich, food-based supplement provided about half of the iron and zinc RDA and more than doubled the vitamin A, folate, and Bh a meal , 41. Alsh a meal . FinallyTables  and 6. In our model, birth weight increased about 50 g and length increased about 0.3 cm (p<0.05) for every cm increase in maternal height. These positive effects of maternal height on birth weight and length maybe related to the higher gestational weight gains (about 0.8 kg) by the taller women (p<0.01). However, the anatomical factors of taller women, i.e. a larger uterus or pelvis, may allow more fetal growth [In a secondary data analysis, we studied the maternal characteristics associated with birth outcomes in the entire cohort of 317 women l growth , 44. An l growth , 46.Although the prevalence of underweight women has declined in Vietnam over the past 10 years, the median birth weight is unchanged . The lowAmong the three treatment arms, the mean birth weight in the routine prenatal care (control) group was about 68 g higher than that in the PC-T group. Of the maternal characteristics measured, only the baseline arm muscle area differed between the RPC and the supplemented groups; it tended to be higher in the RPC group . Others have reported that pregnant women in lower income countries with larger upper arm muscle areas tend to have heavier infants , 50. ThiA serious limitation of this study was the high rate of attrition prior to conception and during the first trimester of pregnancy that significantly reduced our power to find an effect of the food supplement on newborn size. Nearly 90% of the eligible women did not qualify because they were already pregnant, had plans to move out of the area, did not meet our inclusion criteria, declined to participate, or were prohibited from participating by family members. Of the 460 women who consented, only 68% completed the study, potentially reflecting the participant burden of the coming to the feeding site five days/week. Since the drop-outs were slightly less likely to work as farmers, they were probably better economically and, therefore, more likely to take jobs outside the study area. However, it is important to note that the direction of the observed effect did not favor the intervention. Another limitation was the lack of full compliance with the study. Many women did not eat all of the scheduled supplemental meals. However, among the 199 women with team-measured infant anthropometric values, the vast majority (191) had consumed at least 75% of the provided supplements, and no main effect of the intervention was observed. Although not planned, this “complier” sample served as an estimate of the efficacy of the intervention whereas the larger sample of 315 women, who had hospital-measured birthweights, was more analogous to an effectiveness study population . Both samples resulted in the same conclusion, no main effect on birth weight.In conclusion, a small nutrient-dense supplement provided to rural Vietnamese women prior to conception did not improve birth outcomes. The study is unique in that nearly 80% of the participants worked as farmers and gained only about 7.5 kg during their pregnancies. Performing heavy agricultural work during pregnancy, which is not uncommon in low or middle income countries, has been associated with lower birth weights . Future S1 Checklist(DOCX)Click here for additional data file.S1 File(CSV)Click here for additional data file.S1 Table(DOCX)Click here for additional data file.S1 Protocol(DOC)Click here for additional data file.


Alterations in the immune system can result in alanine aminotransferase (ALT) flares either during pregnancy or after delivery in women with chronic hepatitis B virus (HBV) infection. The aim of this study was to prospectively assess changes in serum biochemical and virological markers of HBV infection during and after pregnancy in a large North American cohort of pregnant women with chronic HBV.Adult pregnant women enrolled in the Hepatitis B Research Network between 2011 and 2016 were included. Serum ALT values and HBV DNA viral levels were obtained at <28 weeks and >28 weeks of gestation and <16 weeks, 16–31 weeks, and 32–48 weeks postpartum. Outcomes of ALT flares included severity, duration, and initiation of antiviral therapy.8 vs 343 IU/mL), but serum ALT levels at their first study visit were similar. Among untreated pregnant women, there was a very mild increase in serum ALT postpartum among both HBeAg-positive and HBeAg-negative women (P < 0.001). Serum ALT flares (range 107–513 U/L) developed in 3.4% (5/149) during pregnancy and in 4.3% (4/92) after delivery. Twenty-two percent were initiated on antiviral therapy. After withdrawal of prophylactic anti-HBV therapy, 17.2% (5/29) developed serum ALT flares (range 107–208 U/L)within 14 weeks ofdrug discontinuation, and 3 additional women had flares despite continuous anti-HBV therapy during pregnancy or postpartum. Many ALT flares were not associated with significant changes in HBV DNA levels. No flares were severe with elevations of bilirubin or clinical decompensation.Amongthe 158 pregnant women with chronic HBV, the median age was 33 years, 73% were Asian, and 63% were hepatitis B e antigen (HBeAg) negative. The median HBV DNA level was substantially higher in the HBeAg-positive vs HBeAg-negative women (1.3 × 10Spontaneous ALT flares in untreated pregnant women with chronic HBV are infrequent, mild, and self-limited both prepartum and postpartum. Although flares after the withdrawal of antiviral therapy postpartum are more common, they were also mild and self-limited. Further studies of the immunopathogenesis of pregnancy-related flares are needed, as well as effects on long-term outcome of the mother and infant. Pregnancy and the postpartum period are associated with unique changes in the immune system that may impact the natural history of autoimmune diseases and immune-mediated infections . AlthougIn the postpartum period, ALT flares have been reported in 25%–44.7% of untreated women  and wereThe Hepatitis B Research Network (HBRN), sponsored by the National Institute ofDiabetes and Digestive andKidneyDiseases, comprises 20 adult liver centers in the United States and 1 center in Toronto, Canada . The HBRa priori as a transient rise of serum ALT up greater than ≥5 times the ULN (20 U/L). Flares were graded as either mild (rise of ALT to ≥5 times ULN but <10times ULN) or moderate (ALT rise to ≥10 times ULN). Flares were considered severe if jaundice was present (bilirubin ≥2.5 mg/dL at the time of the flare) or if there were of symptoms suggestive of liver injury. Each flare was reviewed by the HBRN Adjudication Committee to confirm that the etiology of the flare was pregnancy related and not due to alcohol, drug, gallstones, or other causes of liver injury. The duration of ALT flare was calculated by week of first qualifying ALT elevation to week of fall of ALT into the normal range (<20 U/L or preflare level). Flare type was characterized as (i) spontaneous , (ii) on therapy (if ALT rise occurred on treatment during pregnancy or postpartum), or (iii) after withdrawal of therapy . A rise in HBV DNA with a flare was defined as at least a 10-fold increase from the preflare value.For these analyses, an ALT flare was defined ClinicalTrials.gov (NCT01263587).All protocols were approved by the HBRN Steering Committee and the institutional review boards (Research Ethics Board in the case of the Toronto site) of the participating sites, and all participants provided written informed consent. This analysis is part of the Hepatitis B Research Network Adult Cohort Study and is registered in Data are summarized via frequencies and percentages for categorical variables and via median and range for continuous variables.10 ALT (U/L) in a linear mixed effects model was estimated and then transformed back to a geometric mean of ALT (U/L) through 10× transformation. The covariates in the mixed model include pregnancy stage, HBeAg, pregnancy interval by HBeAg interaction, and log10-transformed HBV DNA (log10 IU/mL). Similarly, we modeled log10-transformed HBV DNA using a linear mixed effects model that includes pregnancy stage, HBeAg, and their interaction.To estimate changes in serum ALT and HBV DNA over time, mixed effects models during gestation and postpartum with data collected after antiviral therapy were initiated or the next gestation excluded. Subjects with outcomes of miscarriage or termination were also excluded. The mean of logWe summarized the frequency of flares during different types of follow-up periods to account for the change in pregnancy stage (during gestation and postpartum) and antiviral treatment status . Besides the raw percentage of flares, we also estimated the incidence rate (IR) using Poisson regression, accounting for the total length of follow-up (in person-months) during different types of periods.A total of 177 women with chronic HBV in the HBRN were enrolled during pregnancy or became pregnant after enrollment between January 2011 and May 2016 . NineteePregnancy outcomes were available for 131 (83%) of the 158 participants , with 12P = 0.001). Moreover, there was a mild increase in serum ALT postpartum among both HBeAg-positive and HBeAg-negative women (P < 0.001). In contrast, HBV DNA levels did not change significantly over time for HBeAg-negative women (P = 0.14) nor HBeAg-positive women (P = 0.68)  .Of 158 pregnant women, 35 (22%) were initiated on antiviral treatment during gestation (N = 33) or postpartum (N = 2). Nearly all who began antiviral therapy during gestation were HBeAg positive , and 29/32 (91%) had HBV DNA ≥200,000 IU/mL. The median gestation week when treatment was started was 29 weeks (range 16–39 weeks). The percentage of women receiving each antiviral was as follows: tenofovir 76%, lamivudine 21%, and lamivudine switched to tenofovir 3%. Treatment was discontinued (the reasons for discontinuation were unknown) in 24: within 7 days of delivery for 13, between 1 and 12 weeks for 9, and between 32 and 48 weeks after delivery for 2. Treatment was continued in 4, and data for 5 were missing.http://links.lww.com/AJG/A167). Of the 177 women, a total of 16 women ever flared during the follow-up. One woman experienced 2 flares. Pregnancy outcomes were recorded for 15, and all were live births. The rates and IRs of flares were low, with higher values observed after the withdrawal of antiviral therapy . The IRof flares was 0.009 per person-month during gestation and 0.004 per person-month postpartum. Of the 5 flares during pregnancy, 4 were moderate (ALT range 222–513), occurred close to or during the third trimester (27–39 gestationweeks), andwere startedon antiviraltherapy. Of the 4 flares in the postpartum period, 3 occurred within the first 3 months, all but 1 were mild flares (ALT range 107–129), and only 1 postpartum flare (mild) was started on antiviral therapy. Duration of flares varied from 15 weeks to >48 weeks.Among untreated women, ALT flares were observed in 3.4% (5/149) during pregnancy and 4.3% (4/92) during postpartum (7 IU/mL (range 3.9 × 104 to 5.2 × 108 IU/mL). Of the 6 HBeAg-positive women with flares, HBV DNA decreased by more than 10-fold for 3 and remained stably high for 2 (1 missing). Only 1 flare was associated with a transient loss of HBeAg. In univariable analysis, associating spontaneous flares with baseline characteristics, only higher HBV DNA attained statistical significance (P = 0.005) (see http://links.lww.com/AJG/A167). The percentage of patients with positive HBeAg was numerically higher in the flare group (67% vs 35%), but the difference was not statistically significant (P = 0.074).Median HBV DNA among those who experienced flares was 3.5 × 10http://links.lww.com/AJG/A167). In all patients, antiviral therapy was continued and the flare resolved. In the 2 women with postpartum flares, antiviral therapy had been started in the third trimester, and the flares occurred at 7 and 13 weeks postpartum. HBV DNA levels were elevated  at the time of the flare and declined postflare in both women. No HBeAg loss was observed.An ALT flare on antiviral therapy was observed in 2% (1/49) during gestation and 5.6% (2/36) postpartum (http://links.lww.com/AJG/A167). The majority of the discontinuations occurred either within 7 days of delivery (50%) or between 1 and 12 weeks postpartum (33%). Twenty-nine had follow-up data after the withdrawal of therapy, and an ALT flare was observed in 17.2% (5/29). The IR of flare was 0.020 per person-month. Four flares were mild (ALT range 107–199 U/L), and 1 was moderate (ALT 208 U/L). HBV DNA levels ranged from 2.2 × 104 to 3.5 × 108 IU/mL at the time of the flare, with an increase noted in 2 and decrease in 1. Flares occurred 7–14 weeks after discontinuation of treatment andwere prolonged (16 to >26 weeks). ALT levels improved without reinitiation of therapy, and 1 woman lost HBeAg.Of all 177 women, discontinuation of antiviral therapy was observed among 30  or moderate (> 10 times ULN) in intensity but without bilirubin elevation and many resolved without need for antiviral therapy. Interestingly, there was no significant change in HBV DNA apparent with some of the flares, although we acknowledge the possibility that changes in HBV DNA may have been missed, given the frequency of monitoring. In terms of important immunologic end points, only 1 patient had a transient loss of HBeAg in the context of a mild flare. Overall, our results are reassuring, both in terms of the frequency of flares and their outcomes without treatment. The rate of spontaneous ALT flares in other retrospective studies varies from 9% to 25%, with higher rates reported postpartum than during pregnancy –5,10, anThere is no generally accepted universal definition of a significant increase in liver disease activity or “flare” during or after pregnancy. We used 5 times the ULN of ALT to define mild flares and 10 times the ULN to define moderate flares. Recent studies have used much more liberal definitions for ALT flares: any ALT > ULN ; an ALT > 2 times the ULN or twice the upper limit of baseline ALT (whichever is higher); and ALT >5 times the ULN or >3 times ULN (whichever is higher) ,11,19. TALT flares on antiviral therapy occurred in 2% during pregnancy and 5.6% postpartum, a frequency not dissimilar to women not on treatment. These 3 flares (2 postpartum and 1 in second trimester) resolved without interruption or change in antiviral treatment. Information on adherence was not specifically captured, but in 2 of 3 women, the HBV DNA levels were low or declined during the flares, suggesting that nonadherence was not an issue. None of these flares were associated with seroconversion. In the limited other reports on ALT flares during antiviral therapy, similar rates are seen. For example, in a randomized clinical trial of telbivudine started at weeks 26–28 of pregnancy, 8% experienced ALT flare (defined as ALT >2 × ULN) . AlthougThe highest rate of ALT flares was seen in women who discontinued antivirals during pregnancy or after delivery. In total, 17.2% of women experienced a mild to moderate flare within 14 weeks of stopping antivirals. Only 1 seroconversion event occurred in association with these flares, and all resolved without need for reinstitution of antiviral therapy. Reported rates of flare after withdrawal of antiviral therapy in women who discontinued therapy shortly after delivery have been highly variable (5%–62%) –12,19–23This study has a number of limitations. First, most women did not become pregnant after enrollment into the HBRN; rather, they were already pregnant at enrollment. Thus, many women did not have data before pregnancy for more robust baseline comparison. In addition, if women were recruited into the study already pregnant, it is not known whether they discontinued treatment before cohort enrollment. Prepregnancy treatment could influence rates of flare during pregnancy and was observed to be 16% in a recent study . FurtherIn conclusion, ALT levels remain stable during pregnancy in most patients with chronic HBV, but mild increases were observed early after delivery, without concomitant changes in HBV DNA. Although ALT flares occurred in 3.4% during pregnancy and 4.3% postpartum among untreated women and in 17% of those who stopped antiviral therapy, initiation of antiviral therapy was rarely required, and no clinically significant decompensating events occurred. Although total published experience with ALT flares during antiviral therapy is still quite limited, the available data suggest that continuing treatment is the appropriate strategy.AJG_2019_03_06_BZOWEJ_AJG-18-2076_SDC1