About 1.6% of planned births in the United States occur out of hospitals. Studies indicate that planned out-of-hospital birth (OOHB) is safe and satisfying for women; however, there is great variation among ethnic groups, and Black women are underrepresented. A recent phenomenon is the choice to have an unassisted birth (UAB) with no midwife or other professional maternity care attendant. The purpose of this study is to fill a gap in understanding reasons for choosing OOHB or UAB for two clinically important sub-groups of women: Black women, and women who have experienced childhood physical or sexual abuse.This study recruited 18 women who had an OOHB or UAB and who identified as either Black or survivors of trauma to participate in in-depth qualitative interviews concerning their choice to give birth out of hospital. A grounded theory approach was utilized that involved a discursive process of data collection, coding textual passages to identify focused themes, memo writing to document analytic decision-making, and eventual conceptual modeling.All 18 participants endorsed a history of trauma. Focused coding to identify inherent concepts led to the emergence of a theoretical model of the arc of decision-making around choice of place of birth and birth attendant, or lack thereof. Women may choose OOHB or UAB because of a previous trauma, or because they feel discriminated against by healthcare professionals, either because of skin color, age, pregnancy, weight, or some other health condition. Women may choose OOHB or UAB because it affords more control during the process of giving birth.Previous trauma and experiences of discrimination were influential factors for women in the study sample in their choice of birthplace setting and choice of provider. These findings can inform clinical understanding for birth professionals, including doctors, midwives, doulas, nurses, social workers, and psychologists, and contributes more broadly to the national conversation about birth choices in the USA. This study shares information from qualitative interviews with Black women and women who are survivors of abuse regarding their choice to have a planned out-of-hospital birth, or to choose an unassisted birth (UAB) with no midwife or other professional birth attendant. Black women are less well represented among those who choose OOHB, and little is known about the reasons that they may choose OOHB. Previous studies show that women who have experienced childhood physical or sexual abuse may prioritize having a sense of control and autonomy during their birthing experiences; however, little is known about their specific choice for OOHB. Our study recruited 18 women who had an OOHB or UAB and who identified as either Black and/or survivors of trauma to participate in in-depth interviews concerning their choice to give birth out of hospital. Through qualitative research methods, we analyzed transcripts of these interviews and developed a theoretical model about women’s decision making related to OOHB or UAB. We found that women may choose OOHB or UAB because of a previous trauma, or because they feel discriminated against by healthcare professionals, either because of skin color, age, pregnancy, weight, or some other health condition, and that choosing OOHB or UAB allowed them to have more control during the process of giving birth. Understanding the role that previous trauma and experiences of discrimination play in birthplace choice may help birth professionals to consider bodily autonomy, physical and emotional safety, anti-racism, and independence as important factors in their clinical interactions with birthing women. About 1.6% of births in the United States are “community births” that occur out of hospitals, including births in a residence , freestanding birth center, clinic, doctor’s office, or other location . More unThe experiences of Black women are noticeably absent from the literature about community birth. One of the few qualitative studies considering why women choose attended OOHB included a participant sample which was 87% white . StudiesAlso missing are the voices of women survivors of abuse. Stress has long been known to adversely affect the physiological processes of labor . Women wAlthough planned OOHB has been shown to be safe in multiple studies, especially when guidelines for hospital transfer are well-developed , 16, OOHAlthough the literature suggests that planned unassisted births are on the rise , we do nThere is no data to portray how demographic characteristics might influence the choice for UAB. For OOHB more broadly, researchers have found that there was a clear relationship between birth attendant and ethnicity; nurse-midwives and other midwives almost exclusively attended community births to white mothers . OverallChoice of provider and place of birth may also be influenced by women’s previous experiences of trauma; qualitative studies to date have shown that for survivors of trauma, birthing choices are informed at least in part by the perceived control a survivor may have over her environment and experience , 25, andMore information is needed to better understand how situated racial identities and past negative experiences, trauma, and discrimination may be contributing to birth choices that trauma survivors and Black women are making. This article presents findings from in-depth interviews with women who have chosen community birth, including unattended birth, and provides evidence of decision-making regarding their birth choices. It does not shed light on the relative safety of UAB, but instead provides insight into lived experiences and social determinants of health that affect a woman’s choice of birthplace and whether or not to hire a trained birth attendant.A convenience sample of women who self-identified as survivors of trauma and/or Black and who were either interested in OOHB and/or achieved OOHB were recruited to participate in qualitative interviews. Sample recruitment began with contacting past participants to the University of Michigan STACY study. The STACY study obtained a waiver of documentation of written consent from University of Michigan IRBMED and used a phone consent process to recruit a total of 1581 women. These participants were asked about their willingness to be contacted for future participation in follow-on studies during the first phone interview.Our study obtained separate approval from University of Michigan Health Sciences and Behavioral Sciences Institutional Review Board to expand the study beyond the STACY project. Women who had indicated they desired OOHB (whether or not they achieved OOHB) were recruited to participate in qualitative interviews. Two women were interviewed from the STACY study; both women had in fact achieved OOHB. After that, recruitment followed standard anthropological "snowball" sampling. We also distributed fliers to southeast Michigan locales frequented by childbearing women, such as community centers, social service agencies, and grocery stores. One of our first interviewees recruited via snowball sampling indicated she had given birth out of hospital unattended and provided us with information leading to an online listserv. This listserv, led by Laura Caplan Shanley, serves women interested in unattended OOHB, a phenomenon often referred to as “freebirth.” We contacted Ms. Shanley, and she distributed our flier to the listserv. This led to the recruitment of the remainder of the 16 women interviewees, who were recruited from 2009 to 2011.After initial phone or Internet contact and screening to verify a history of trauma and/or self-identified race/ethnicity, each participant was mailed a hard copy of our IRB-approved informed consent agreement. Once the agreement was returned, interviews were scheduled in person at the participant’s home, at a coffee shop, at our office, or via phone, responsive to the participants’ choice. Although participants had the option to waive audiotaping, all 18 participants agreed to be audiotaped. Subject identifiers were stored separately from the interview data, and each participant was invited to provide a pseudonym by which to be identified. Study participants who completed interviews were compensated $40 for their time.Did you “choose” to give birth there, or did it “just happen”?Why did you make that choice?Is there anything from your past that influenced your decision of where to have your baby?Many women have fears about having their first baby—did you? Did your fears influence your decision?What informed your decision to have unassisted childbirth this time around?Interviews lasted between one to two hours in length. The interviews included open-ended questions and assessment for trauma, via the Life Stressor Checklist (LSC); the LSC assesses for 29 potential trauma exposures including behaviorally-specific inquiry into childhood and adult physical abuse and sexual abuse . As the grounded theory approach  whiplash, and it was really not fun, and I've got this calcified knot in my neck. And so I went in and I was like, “You know, this is really bad. It really hurts. I'd really like to deal with this somehow.” And she [a doctor] reached back, “Oh no, you're fine.”... I was just so stunned. Wow, it doesn't exist. Yeah, I was just like, ok, um. I need to find another doctor now.Several women related instances of negative experiences interfacing with healthcare providers that did not involve birth itself. These included a car accident, terminal cancer care of a child, emergency room care for a multiple sclerosis relapse, and other events. Garden Lady recounted her story of being in a motor vehicle accident:[…] kind of on hospital overload, I think, and just overwhelmed with watching her go through cancer and the different medications and just different things and different practices at the hospital that we just weren’t pleased with and the way things went.For Sally, a previous negative experience with the medical community was a four-year period spent interfacing with hospital personnel while her daughter was dying from brain cancer. She recounted that she wasIt crippled us, emotionally, financially, everything. We ended up having to go on public services, having to get MediCal, different stuff. When we got on MediCal, we got treated like we were on MediCal. Let’s just put it like that. Literally. We felt like they didn’t care. We felt like they had no sense of ownership for our daughter’s care or her outcome…In addition to dealing with medications and procedures, Sally and her family also experienced financial hardship which led to the experience of feeling discriminated against based on socio-economic status:I wear head wraps and one day my head wrap came off and she said, “Oh, you look like the Bride of Frankenstein.” I have pretty nappy hair and I don’t appreciate the comments about my hair. …and not even that she was intending to be disrespectful, because she thought it was a joke, but she couldn’t understand the connotation of what that means because she wouldn’t understand my background. (Renee)I had a horrible, horrible MS [multiple sclerosis] attack. My doctor was out of the state. So I went to the doctor that was on call for her. I was going blind, I couldn’t feel anything from the waist down, I was incontinent. He (the doctor) told me, “It’s obviously a back injury because you’re not a small woman.” And I said, “Why am I going blind? Is fat growing over my eyeballs? Why am I going blind?” (Angelina)In addition to medical care that felt disrespectful or even traumatic, many participants related that they felt discriminated against because of their young age, skin color, weight, or socioeconomic status, or intersecting aspects of their identity. Here are two stories from Renee and Angelina, both of whom are Black, that exemplify these experiences, though this was a pervasive theme across accounts:[…] the best prenatal care that I received to date, there’s always been just a disconnect between myself and the care providers. Sometimes it’s like […] yeah, a disconnect between myself and the care providers. (Renee)She was a nice enough lady, and she came recommended from a friend of mine. I just felt like, she just wasn’t connecting – we weren’t connecting. (Mariah)I knew that it would be the luck of the draw as to who would actually be there and it might not necessarily be that one of seven, or nine, that we’d really bonded with. So that was my whole worry. And sort of feeling like, “Why are we coming in here?” We could just have robo-midwives, you just walk in and step on a scale and pee in a cup and just leave. (Garden Lady)Some women reported experiencing a lack of alliance with their care provider, or instances of discontinuity of care, regardless of previous negative healthcare interactions or discriminatory or insensitive care experiences. As Dana said, these women described feeling like “the person in the patient is forgotten.”Those previous negative experiences (birth or non-birth-related) led these women to seek out new information and engage in a process of discernment about what was right for them for future birthing experiences. This education and discernment process also strengthened their critiques of the medical model. Out of this process, women made the decision to give birth outside of a hospital either with a homebirth midwife or unassisted (by choice or because of obstacles to hiring a midwife).Women engaged in an extensive process of educating themselves about the birth process and their range of options. These included engagement with popular media, online sources, and print materials.Internet interactions Many women spontaneously criticized mainstream books and media representations of birthing women. They perceived that the media creates a cultural message that birth is a painful emergency. Nightsong describes the way she educated herself before her first birth:I was, unfortunately like so many women out there today are, pretty clueless about how birth really works. I thought I was informed, but I wasn’t in the least bit informed. I went the hospital birthing class and the hospital breastfeeding class - neither one of which were really helpful. I thought they were. Looking back - not in the least. (Nightsong)Unassisted Childbirth, published in 2016  you had a big baby, to try to convince you that the c-section is a better route to go?” And it was at that time that I thought, “You know what – that makes sense.” I put all the puzzle pieces together and I felt like that was right on. It was at that moment in time that I lost complete confidence in her caring for me...I thought, “This is not what I’m doing. I’m not having a c-section.” I’m not having a c-section. She’s not pushing me into having a c-section.Dana describes how interactions in an online parenting forum changed her birth trajectory. She had three vaginal births in hospitals and then gave birth to her fourth child, who had spina bifida, by cesarean. She intended to give birth to her fifth child vaginally in a hospital. Around 36 weeks of pregnancy, her doctor ordered an ultrasound. The ultrasound technician did not think there was anything unusual about her baby’s size. Dana describes the interaction with her obstetrician after that:Reading Scholarly reading also played significant roles in the self-education process for women:Midwifery Today. If I go to my library then I have access to J-Stor. I read old scholarly works. Different things like that really influenced the perception that I had of birth, and the perception that I had on the role of the woman. That all influenced how I felt about my birth. (Renee)I just read a lot! (…) I was reading studies, reading journals, like when I could get The Thinking Woman’s Guide to Giving Birth. I think that was probably a pivotal point. And so my mistrust for the whole process around mistreating women in pregnancy and birth began from my personal experience there and was reinforced through all my reading and research. That decision [to give birth outside of a hospital] was made after doing a lot of reading and research. I feel like I read! Gosh! I had a reading list, I remember. It had like a dozen books on it. I read them all. I read Other experiences also contributed to these women’s growing sense that the medical model was not right for them. For example, Jay worked as a doula and the experience of accompanying women during hospital births made her realize that achieving an unmedicated birth with few interventions was quite difficult in the hospital setting. Instead of being able to concentrate on contractions and physical sensations, Jay says that, “You just have to be on your toes and really working hard to get the birth plan that you want.” Rhiannan related the story of witnessing a friend give birth by herself because labor was too fast to get to the hospital. And Sally began to pursue a degree in Naturopathy.Alternative medicine Twelve out of eighteen participants expressed a general preference for alternative or natural medicines and practices. These included preferences for natural and organic foods, herbal medicines, and vitamin supplements. Participants also shared that they used alternative healing methods like massage therapy or chiropractic care.unsafe in the care of medical professionals or in the hospital environment. Every interviewee made comments that critiqued the dominant model of care and many explicitly connected “feeling safe” with making one’s own choices (“control”) about birth. For example:[…] it bothers me a lot, I’m actually in school to be a nurse right now, it bothers me so much to know that there’s so many women that could have a birth that they may want more than another and they’re not getting it because they’re not educated – they don’t know they have a choice. (Dana)I feel very strongly that women need to give birth where they feel safest. Or where they feel like they can relax the best. So if that's the hospital, then go to the hospital. I think that probably the most important thing is to figure out where you feel safe...I think that the best thing that I learned from this is that my intuition and my instinct is good. I know things. I'm not stupid because I don't have a medical degree. I can do this just fine. And I can learn things and...I don't always need some expert to tell me what to do. (Greta)All the people just coming in. All of the sudden there’s all these people coming in and out and in and out and in and out. And that’s not very conducive to feeling safe and relaxed. (Gracie)The only real fear that I had was giving birth in a hospital. Giving birth itself? No. Giving birth in a hospital? I was terrified of that. (Rhiannan)Previous experiences and self-education existed in a synergistic relationship with the emergence of these women’s critiques of the medical model. As women critiqued the medical model, they were often able to explain to themselves why previous experiences had felt so negative. Much of their critique focused on the issue of “safety” and feeling Critiques of the medical model, coupled with a desire for more control over their own experiences, led these women to decide they wanted something different from the mainstream biomedical approach to childbirth.Some women came out of this period of research and discernment hoping to give birth in a hospital but with more control. Others knew, based on their research and critique of previous care, that they wanted to give birth outside the hospital-based system. A few knew that they preferred an unassisted birth. Women had to balance their own desires with those of their partner and, occasionally, extended family members. Although some were sure they wanted an unassisted birth, others found themselves betwixt and between systems, with one foot in the hospital system and another outside. As they attempted to enact their choices, some ran into obstacles such as financial barriers, lack of available midwives in their area, or interactions with care providers that gave them pause.[…] after the miscarriage, it was totally solidified. There was no way you could pay me enough money, or compel me forcibly enough, to have a baby in a hospital.Maggie is an example of someone who knew that she did not want a hospital birth after a negative hospital miscarriage experience:Well when we found out that we were pregnant with K--, I just kept going over in my head, I can’t possibly go back to these midwives who were the only midwives in the area. There’s no one else who would deliver at home. I refuse to deliver in the hospital and so at that point, what we’re going to do is just be pregnant for nine months and see if something turns up. What turned up was Laura Shanley’s book. I was like, “Oh, look at that. People aren’t just crazy and it happens.” So that was then how it became solidified. (Maggie)However, she did not immediately know what she did want:Ultimately with her [Sally’s daughter] passing away that year and for us to really want it to be like a very close family experience for the birth, and me wanting to have my other children involved and things like that, things that I just knew they weren’t going to do at the hospital period, made me want to have a homebirth. Sally and Angelina also knew that they did not want to give birth in a hospital. They first attempted to hire homebirth midwives, but finally gave birth unassisted:We were going to have a midwife. There’s really only one that was available in my area and she’s like almost two hours away. For the price, because I was already seeing my OB [obstetrician] for my regular visits, and what we would have had to pay for her to just come and strictly do the delivery only, and we didn’t mesh well with her personality-wise that well either, we just decided to go ahead and try the unassisted home birth.Obstacles to a homebirth midwife-attended birth led Sally to choose an unassisted birth, as she explains here:[…] my daughter’s birth really tainted me because I didn’t want anyone to give me permission to do something or not do something. Period. I wanted to be completely in control. And I didn’t want someone saying, “No, I have to put my hand in your vagina first and make sure that you can push or lay down to push.”I started feeling really strongly that I wanted the first person that touched our baby to be my husband. Period. I didn’t want it to be a midwife, I didn’t want it to be someone else. I asked the midwife…how she felt about that and she said, “Well, I have to be there and I have to be checking things during your labor. I have to be there and I might have to catch the baby. You don’t know what will happen.” It just felt wrong to me. It just felt really important to me to have my husband catch the baby. So that’s when we decided not to do homebirth midwives... when we left, we sat and looked at each other across the table at lunch. And I said, “Unassisted?” and he said, “Yeah, unassisted.” And that was it!Angelina worried that she would not achieve the birth she wanted with the homebirth midwife she originally hired:It’s hard to find a homebirth midwife, and then the lay midwife that I did find, her philosophy was in line with mine. She was like, “I’m on hiatus from doing births, but you can have an unassisted birth and I’ll help you. I’ll give you information.”Renee, like one other woman in our study, was unable to find a local homebirth midwife to attend her. She says:[…] at that point, was not totally supportive of the idea of not having a hospital birth anyways. I mean, even if we could have . So the fear of what might happen, all of the complications and whatever.Gracie told us that she had bowed to her partner’s wishes for their first child’s birth, which she described as, “suction, forceps, suction, forceps, finally pulled, yanked out with forceps,” because heI think I didn’t care what people thought the second time. The first time I was weighing in, thinking like, “Maybe they’re right. Maybe it is really too dangerous. And maybe it is a crazy idea.” My family thought it was a crazy idea. [The second time], I knew that it was going to be different. That it had to be different. That this was my opportunity, and it was going to be different.But, going into her second birth experience, she says,As long as being an adult means making decisions and then also dealing with the consequences of whatever decision that you make and as long as you’re making an informed decision and you have weighed the consequences then you know, you have to do what you feel is best for you.Whether women ultimately made the choice to birth within the hospital system, or to go outside the system, considerable discernment was evident related to decision-making and choosing birthplace and providers (or lack thereof). Renee is conscious of this process and its implications:Women overwhelmingly described their community births, including their unassisted births, as positive experiences that generated posttraumatic growth, healing, and feelings of empowerment. This contrasted sharply with the tone and content of stories about mainstream hospital births that they had seen or experienced. Many women spontaneously described these births in spiritual terms.(I) had such a great time with it, I thought, “Oh, let’s do this again.” (Jay)[…] the birth itself was incredible. It really was. I got to catch my own baby in the pool at home. (Ophelia)I had no idea I was having the baby. If you had told me that I was giving birth at that moment, I would never had guessed. I mean, I felt funny. And so three pushes and the baby came out. And my instant reaction was, “Oh my gosh! I have to do that again!” I mean that was such a different experience. I was just like that was awesome and the very best thing that’s ever happened and I have to do it again. I’m not going to, but that was my feeling. (Gracie)This… birth, it’s just like we knew what to do. We were, front to back, we knew exactly what to do and how to do it, and it was just perfect. It was literally just perfect. The examples of Jay, Ophelia, Gracie and Sally show how positive these stories were:Posttraumatic growth Not only were these birth experiences positive, but women also described them as healing (in relation to their previous traumas). They saw that they had new reactions, feelings, and thoughts about previous sexual abuse and traumatic births:I knew from the moment my husband and I first had sex after the baby was born, the birth itself healed me from sexual abuse. It was amazing! It was clear as day for me. Of course, I love my (first child) beyond words, but the birth itself, how traumatic that process was -- it almost didn’t matter because the second birth healed me from the first birth. Beyond that, the second birth healed me from my sexual abuse. I had always had problems during sexual intercourse with just being able to relax, and it always took a long time for my husband to be able penetrate and that kind of thing, and from the very first time we made love after my son’s birth, there was no problems at all and there hasn’t been since. (Nicole)I didn’t know that I had fears to confront for real. After I gave birth, especially like this last time, I knew, this is strange, but I knew that I had lost fears. I felt absolutely fearless about my ability to get my grown woman on. To be a grown woman and do what I have to do. (Renee)Empowerment In addition to noting these instances of what might be described as posttraumatic growth, women attributed new feelings of empowerment to their birth experiences:The empowerment through giving birth on my own terms has definitely spilled over to all aspects of my life, for sure. I am clearly a different person. Through that, and that I was a few years ago after giving birth and I would not be that same person in the positive aspects if I had given birth [differently]. .I would recommend her to, if she was a spiritual person to see birth as a spiritual journey and to see it as an evolution of herself as a woman. That labor, thinking about labor and delivery, not that labor and delivery that it’s not only a chance for you to meet your child, but it’s a chance for you to get to know a facet of yourself that you wouldn’t otherwise know. (Renee)Incorporating a new narrative Similar to the sentiment expressed by Natalie about feeling like a different person, others also expressed ways they were incorporating a new empowered narrative about themselves based on their experiences giving birth:Since I’ve given birth, when I think of my body, I think whole, capable -- capable is a good word -- and strong. How empowering birth is. Homebirth is unmedicated and you’re in a loving environment, surrounded by encouraging people. You feel so powerful and so, kind of like an Earth Goddess. It’s something that can’t be replicated. (Rhiannan)I just always heard before I birthed the first time that it was this painful, awful thing. It was something you have to go through in order to have a child and it was terrible and tragic and it was Eve’s sin that caused all of this. I remember as a child wanting children – I always wanted to be a mom but I was always terrified of actually giving birth. Now of course, that’s another great learning that came from this – that it doesn’t have to be that way. And it’s only that way if you let it be that way. Like I said, in fact, it can be a completely empowering, wonderful, best experience of your life kind of thing. And it truly was. The day I gave birth to my son was the best day of my life. (Nicole)https://www.theguardian.com/commentisfree/2011/nov/27/barbara-ellen-birth-marilyn-monroe). Even more attacked are women who plan unattended births. The story of “unattended births” has often been told through a “monster mother” lens [When a woman in the United States suggests she is considering a community birth with a trained midwife, she is likely to encounter strong pushback from family, friends, and colleagues based on commonly held beliefs about “safety” and “risk.” Women are told they are “selfish” and “naïve” . The women in this study took their decision to give birth outside of a hospital and/or unassisted extremely seriously and were well-aware of how counter-cultural their choices were. Their descriptions of research and self-education matches the findings of Jackson, Dahlen, and Schmied in 2010 , who fouContrary to mainstream depiction, these women describe themselves as educated and well-informed. In fact, they may see women who follow obstetric advice blindly, without doing their own research, as uneducated. Researchers in Canada found, similarly, that women who made alternative birth choices  felt they were judged as “deviant,” but utilized information management techniques to “present themselves as responsible, competent mothers” .For all of the participants, previous negative experiences played a pivotal role in their decision to give birth outside a hospital, with or without assistance. Instead of feeling safe inside a hospital with medical caregivers, these women felt unsafe and unsupported. This was true at the physical and the emotional level. Physically, women in this study were uniformly clear that they wanted physiologic births, which is difficult to achieve in the United States. Generally, they wanted to maintain control of who touched them, when they were touched, and in what ways. Emotionally, women desired to give birth in conflict-free, supportive environments in which their bond with their baby was respected. Fears that medical interventions would happen without consent (or through coercion), that they would be separated from their babies, or that caregivers would be “cold” or “clinical”  underline these women’s sense that hospital birth is “riskier” than caregivers think it is. Recently, a large quantitative study of 2700 birthing women in the US found that one in six women reported experiencing caregiver maltreatment, including verbal abuse, stigma, and discrimination . It alsoAsking for help and being ignored stands in bas relief to another aspect of maternity care, which is choice concerning the provision of medical interventions, which are ubiquitous and may be hard to refuse. Recent research found that women who declined intervention, especially women of color, were more likely to experience discrimination . ConversWomen in our study began to see their desire to avoid unnecessary medical interventions and to be in charge of their own bodies  as sites of struggle. As Natalie says, “Yeah, it was a leaning-towards-natural-birthing-in-the-hospital initially. Which, as we began to explore what the obstacles were for that and what challenges we’d be facing, we realized we were arming ourselves for battle.”Avoiding unwanted interventions seemed nearly impossible in the hospital setting. When Mariah says, “I just really didn’t want a male doctor there and I didn’t want a c-section and that was about it” to describe her “freebirth” choice, she is implying that she would not have full control over those choices in a hospital. Women who had previously given birth were especially aware that it can be hard to advocate for oneself in labor. These themes were consistent with the findings evident in a 2016 review of fifteen articles about birth outside of medical systems , in whicAs we analyzed these stories, the pattern of negative experiences, subsequent research, and out-of-the-mainstream decision-making, became clear. Their jubilance and sense of triumph at accomplishing birth on their own terms was palpable. These positive experiences led to posttraumatic growth and enhanced self-confidence, which other researchers have also noted .Limitations of this study include the fact that this model is not the only model that could explain community or unassisted birth choices. Women who have not experienced previous negative interactions with medical care providers, who have not experienced discrimination, or who have not been exposed to trauma may also choose community or unassisted birth, but for different reasons. In addition, in these stories, all the mothers and babies were free from medical complication. Their reflections might have sounded quite different if there had been a serious complication. Another limitation is that this is a small sample of women who were motivated to share their intentional and positive experiences of unassisted birth.Our qualitative research showed that previous trauma and experiences of discrimination were influential factors for women in their choice of birthplace setting and choice of provider. Given the ubiquity of racism, gender discrimination and sexual abuse in modern society, and reports of disrespectful care in medical settings, this research should underscore the necessity of trauma-informed, antiracist, culturally congruent, and respectful medical care at all levels, especially in the reproductive health context. Learning from mothers who have rejected the healthcare system as a safe system in which to give birth can help all of us reflect on and improve care.This study reframes the social discourse around what makes a “good mother.” We think opening the definition of “good mother” to include women who have chosen UAB allows a focus on women as autonomous and logical decision makers who are capable of making nuanced decisions, rather than passive “patients” who must listen to medical advice. We invite medical care providers and policy makers to consider bodily autonomy, physical and emotional safety, anti-racism, and independence as equally important factors in high-quality parturient care.


Surgical resection should be considered for giant adrenal cysts if they are functional, if malignancy cannot be ruled out, or if there is a risk of bleeding. However, preventing cyst damage, including fluid leak, and ensuring a good field of view could be challenging in laparoscopic surgery. We report on our successful use of the SAND balloon catheter in laparoscopic adrenalectomy.The patient was a 40‐year‐old man with a right adrenal cyst that exhibited growth tendency. We performed laparoscopic adrenalectomy using a SAND balloon catheter through a preexisting port. Use of the catheter allowed for not only aspiration of the cyst fluid without leakage into the operative field but also gentle grasping of the cyst wall, which enabled us to easily remove the adrenal gland, including the cyst.Use of the SAND balloon catheter facilitates safe and easy laparoscopic resection of giant adrenal cysts. CTcomputed tomographyAdrenal cysts are rare but when malignancy cannot be ruled out, it would require excisions without leakage of any fluid that may be derived from the potentially malignant neoplasm and with a good operative field. Use of the SAND balloon catheter can address these issues in laparoscopic adrenalectomy.Adrenal cysts are a relatively rare abnormality, but if they exhibit a tendency to grow, the possibility of malignancy and need for surgical removal should be evaluated. However, peeling these cysts from the surrounding organs and securing a good field of view in laparoscopic surgery can be difficult, particularly in cases involving giant cysts. Here, we report on the case of a patient from whom a 10‐cm adrenal cyst was safely and easily removed laparoscopically using a SAND balloon catheter, which allowed for grasping of the cyst wall without cyst fluid leakage.The case patient was a 40‐year‐old man with a cystic lesion on his right adrenal gland, as confirmed by CT, who had been observed in our hospital for several years. We decided to remove the cyst because it exhibited a growth tendency and we could not rule out the possibility of malignancy. The cyst measured 10 cm in diameter on CT just before the surgery was performed  through an assistant port. After puncturing the cyst Fig.  and aspiCystic lesions in the adrenal gland are relatively rare and have been reported to be occasionally found incidentally during physical examinations and evaluations of other diseases.The SAND balloon catheter was developed for laparoscopic resection of ovarian cysts. The SAND balloon is 300 mm long, 5.5 mm in diameter and can be inserted through the laparoscopic port. The price per balloon is about 150 dollars. It has been used in other laparoscopic procedures, including cholecystectomy and surgery for congenital hydronephrosis.In conclusion, use of the SAND balloon catheter in laparoscopic adrenalectomy for giant adrenal cysts is viable. Adrenal cysts that safely suck the internal solution out of the body through a SAND balloon catheter could be retracted in various directions, and the subsequent peeling operation could be performed easily and safely even with a limited surgical field of view.The authors declare no conflicts of interest.This article is not a case series, which does not require an approval of the research protocol by an institutional reviewer board.Written informed consent for publication of this case report was obtained from the patient.Fig. S1. The intraoperative gross findings of the adrenal cyst and the normal adrenal gland. It was clear that the normal adrenal gland was compressed by the cyst and was present at the limbus, so it was possible to puncture the cyst avoiding the normal adrenal gland without intraoperative ultrasound sonography.Click here for additional data file.


To perform fundus examinations of full-term and premature infants to identify common congenital ocular diseases and determine the incidence and additional risk factors in Ningbo, China.  Fundus examinations were performed on newborns between January 2017 and July 2020 in Ningbo using a RetCam3 or PanoCam LT wide-field digital imaging system. The neonates' birth weight, gestational age, gender, delivery mode, oxygen intake, and other conditions were recorded. We compared the incidence of ocular abnormalities in both full-term newborns and premature infants. P < 0.001). Retinopathy of prematurity (ROP) was observed in 617 newborns accounting for 21.1% of all screened premature infants. Logistic analysis showed that gestational age and birth weight were important risk factors for ROP (P < 0.001). For treatable diseases, such as ROP, FEVR, congenital cataract, glaucoma, and RB, early identification allows for active treatment or referral to a specialized hospital for further treatment.  There were 23,861 newborns in this study comprising 12,605 (52.8%) male and 11,256 (47.2%) female infants, 20,938 full-term babies, and 2,923 premature babies. The average gestational age was 37.9 ± 5.6 weeks, and the average birth weight was 3,189 ± 417 g. Overall, we found ocular abnormalities in 6,645 (27.8%). The most common abnormality in full-term newborns was retinal hemorrhage (RH), which we found in 3,827 (18.3%) cases. Other diseases identified included familial exudative vitreoretinopathy (FEVR), retinoblastoma (RB), and congenital cataracts. The delivery method had a significant impact on the incidence of neonatal RH ( Early examination and prompt treatment of ocular disorders in newborns are important to avoid lifelong visual impairment. Eye examinations should be performed during the neonatal period and at regular follow-up visits. Vision is the foundation of children's intellectual and emotional development. A vision defect may influence children's intellectual development and social adaptability and potentially lead to loss of life , 2. CongCongenital eye diseases include neonatal fundus hemorrhage, exudative fundus lesions, retinopathy of prematurity (ROP), retinoblastoma (RB), familial exudative vitreoretinopathy (FEVR), and other congenital developmental abnormalities –7. NeonaThrough a comparative analysis of the studies on neonatal fundus lesions in various geographic regions, the incidence and risk factors of neonatal congenital eye diseases differ by region. Related congenital eye diseases can have different high-incidence areas –10. ThisThis study was approved by the Ethics Committee of Ningbo Women's and Children's Hospital. Before the examination, the parents of the newborns were provided with information on this study, and only those who signed written informed consent were included in this study.From 1 January 2017 through 30 July 2020, we performed eye disease screening for full-term infants within 30 days of birth. For premature infants, we performed this eye examination at 32 weeks of postmenstrual age (PMA) or four weeks after birth, in accordance with the Chinese Medical Association Guild guidelines. The fundus examination was repeated weekly or, if needed, more frequently until the full vascularization of the peripheral retina was observed or until 45 weeks of postmenstrual age. Premature infants with ROP who met the treatment criteria should be treated in a timely manner and followed up closely according to their condition.Before the examination, the ophthalmologist evaluated the newborn's external eyes and checked the conjunctiva, cornea, iris, and red reflex. The neonates were fasted for at least one hour before the examination. We dilated the pupils using tropicamide three times at least 30 minutes prior to examination. The newborn was placed on the examination bed, wrapped in a bag, and their head was fixed with the assistance of the examination nurse. After topical anesthesia, the eyelid was opened by a sterile eyelid speculum and we applied levofloxacin gel on the corneal surface. A few diseases, such as congenital cataracts, can be detected by red light reflection, while most diseases, such as FEVR and early RB, will still be found through screening. RetCam3 or PanoCam LT was used for 130° fundus shots. Photos were taken of the posterior pole, including the optic nerve and macula by Dr. Jiao Zheng and Dr. Yi Lu. The superior, inferior, nasal, and temporal retinal fields were imaged when possible. During the image collection process, we tried to capture the serrated edge as much as possible and focused on the lesion area. For newborns with ocular diseases, such as ROP and FEVR, further binocular funduscopy was performed by Dr. Delin Liu to confirm the diagnosis.We used Egge's classification standard to classify RH  and typiχ2 test, measurement data were expressed as x ± s, and single-factor analysis was used for risk factors of retinal hemorrhage and retinopathy. Logistic regression was also used for risk factors of retinopathy. P < 0.05 was considered statistically significant.The results of examinations were analyzed using SPSS 23 , counting data were expressed as a rate, comparison of rates in each group was expressed by We collected data on 23,861 living newborns. The study involved 20,938 full-term infants and 2,923 premature infants. There were 12,605 (52.8%) male and 11,256 (47.2%) female infants in the study. The average gestational age (GA) was 37.9 ± 5.6 weeks, and the average birth weight (BW) was 3189 ± 417g. Of the newborns who underwent fundus examinations, 6,645 (27.8%) cases were found to have ocular abnormalities .p=0.035). The clear neonatal fundal diseases of full-term and premature neonates were also analyzed in our study . Birth weight and fetal distress were also risk factors for RH (p < 0.001). However, gender, maternal gestational diabetes, and maternal hypertension during pregnancy had no obvious influence on the incidence of neonatal retinal hemorrhage (p > 0.005). We detected different degrees of retinal hemorrhage  cases. There were 1680 cases of grade 1 hemorrhage (43.9%), 1031 cases of grade 2 hemorrhage (26.9%), and 1116 cases of grade 3 hemorrhage (29.2%). Vaginal birth was a risk factor for RH (morrhage .P < 0.001). The incidence of ROP in premature infants in the 26–28+6 weeks age group was significantly higher than that of other gestational age groups. The older the gestational age, the smaller the detection prevalence of ROP, showing a significant inverse trend (p < 0.001); the incidence of ROP in body weight in the below 1000g group was significantly higher than other groups. The greater the birth weight, the lower the detection rate of ROP (p < 0.001). The incidence of ROP in the oxygen inhalation group was significantly higher than that in the nonoxygen group (p < 0.001). Further logistic regression analysis showed that BW and GA were the most relevant risk factors  recommends the use of red reflex testing (RRT) to screen for eye diseases after birth . HoweverOur study collected data from more than 20000 newborns in Ningbo. We have shown that 27.8% of all screened neonates were found to have ocular diseases, which was higher than previous studies , 15. TheROP is a proliferative vascular disease that affects retinal blood vessel development in premature infants , 18. WitIn full-term infants, we found that in addition to retinal hemorrhage, the most common ocular abnormalities were FEVR and ROP-like retinopathy. FEVR is an inherited vitreoretinal disease of retinal vascular development which can result in retinal detachment and severe visual impairment . In thisIn addition to the above-mentioned common ocular diseases, our study population had some rare ocular defects, such as morning glory syndrome and RB. Although the incidence of these abnormalities is relatively low, early detection and intervention are of great importance to the visual development of infants.Our study had some limitations. First, we did not follow up on some children with serious RH after the absorption of the hemorrhage. Therefore, we cannot evaluate what would influence the vision of these infants in the future. Second, considering the limited treatment technology in our hospital, some newborns with rare ocular diseases were transferred to other hospitals for further treatment and were lost to follow-up. Third, we did not analyze how many severe eye diseases requiring intervention would be missed if only routine examinations were performed.In conclusion, our study reported the fundus examination of neonates in Ningbo through a large sample, and the results we obtained were somewhat different from those reported in other regions. Early examination of ocular disorders in newborns is important. To avoid blindness, aggressive treatment or referral is required. Examination of the eyes should be performed in the newborn period and at regular follow-up visits.


The present study aimed to evaluate reproductive outcomes and determine the predictors of clinical pregnancy and live birth in women with elevated baseline follicle-stimulating hormone (FSH) levels, who have undergone intracytoplasmic sperm injection (ICSI) treatment.This retrospective study included 1011 ICSI cycles of women with high baseline FSH levels (> 10 IU/L), from a tertiary university IVF center between 2010 and 2015. Logistic regression analysis was performed to evaluate the prognostic factors of clinical pregnancy and live birth.p=0.047). Logistic regression analysis indicated that the age categories ≤30y, 36-39y and ≥40y, level of baseline FSH (≥20 IU/L) and the ovarian response (≤3 or >3 oocytes retrieved) were significantly associated with live birth.Among the 1011 ICSI cycles, the clinical pregnancy and live birth rates per oocyte retrieval were 19.5% and 14.3%, respectively. The live birth rates were 21.1% and 1.7% in women aged ≤30 years and those aged ≥40 years, respectively. In addition, the live birth rate was 1.47-fold higher in women from whom >3 oocytes were retrieved, compared to those from whom ≤3 oocytes were retrieved (Our study indicated that age, baseline FSH level, and ovarian response are independent predictive factors for clinical pregnancy and live birth among women with baseline FSH levels >10 IU/L. Women’s age and ovarian reserve are important markers for ovarian response and; therefore, ART treatment outcomes. Pregnancy rates decrease and miscarriage rates increase with advanced age, and age is one of the most important predictors of Ovarian response to stimulation and reproductive potential can be different in women of similar age, according to the individual’s ovarian reserve . Along wAssisted reproductive technologies are economical burden and very stressful for couples. Evaluation of the expected pregnancy rate according to the characteristics of the couple is very important, and provides information on the realistic chance of pregnancy. The present study aimed to evaluate reproductive outcomes and determine the predictors of clinical pregnancy and live birth in women with baseline FSH levels >10 IU/L, who have undergone intracytoplasmic sperm injection (ICSI) treatment.in vitro fertilization (IVF) center between 2010-2015. Each patient was included only once. The Institutional Ethics Committee approved the study (No.: 16-2/15). The cycles that used antagonist protocol matched the inclusion criteria. All baseline FSH measurements were performed at the beginning of the ovarian stimulation. Data on clinical variables and controlled ovarian stimulation (COS)/ICSI treatment outcomes were retrieved from the IVF database and the patient medical records. COS was started on day 2 or 3 of the menses, with recombinant FSH or urinary FSH/human menopausal gonadotropin (HMG). When the lead follicle diameter reached 12 mm, the antagonist was added. Human chorionic gonadotropin (hCG) was used for follicular maturation when the lead follicle reached 18 mm. Oocyte aspiration was performed 34-36 hours after hCG administration. All mature oocytes underwent the ICSI procedure 2-4 hours after aspiration. Embryo transfer was performed on day 2-5 of the culture period. According to the directives of the Ministry of Health, a maximum of two embryos were transferred. Progesterone vaginal gel (90 mg/day) was used for luteal phase support. Additionally, a single-dose hCG injection (5000 IU) was administered after day 4 or 5 of the embryo transfer. A visible intrauterine sac on ultrasound 3 weeks after embryo transfer was considered a clinical pregnancy. All pregnancy outcomes were recorded. Miscarriage was defined as a loss of a clinical pregnancy before 24 weeks of gestation. Live birth was defined as the birth of a viable infant after 24 weeks of pregnancy.This retrospective study included 1011 oocyte retrieval/ICSI cycles of women aged 19-45 years with high baseline FSH (>10 IU/L), and performed in a single tertiary ®, Beckman Coulter, Inc., Brea, CA, USA) and analyzed using the UniCel® DxI 800 Access® Immunoassay System . The range for FSH measurement was 0.2-200 IU/L. Baseline hormone measurements were routinely performed on day 2 or 3 of menses. All measurements were performed at the morning of the start of COS.The serum baseline FSH levels were quantitatively determined using a chemiluminescent immunometric assay , group B (31-35 years old), group C (36-39 years old), and group D (≥40 years old). Additionally, the women were divided into the following groups according to their FSH level: level 1 (10-14.9 IU/L), level 2 (15-20 IU/L), and level 3 (>20 IU/L).p-value <0.05.Continuous variables were compared among age groups by variance analysis or the Kruskal-Wallis test, depending on the homogeneity and normality of the variables. For multiple comparisons we used the adjusted Bonferroni (Bonferroni-Dunn) test. Categorical variables were compared using the chi-square test or the Fischer’s exact test where appropriate. Logistic regression analysis was performed to evaluate the predictors of clinical pregnancy and live birth. All statistical analyses were performed using the SPSS software . Statistical significance was defined as a A total of 1011 oocyte retrieval/ICSI cycles were analyzed. In addition to a decreased ovarian reserve, 7.4% of the cycles were performed for tubal factor infertility and 30.8% were performed for male factor infertility. Of the 1011 cycles analyzed, 826 (81.7%) involved an embryo transfer procedure. In the remaining 185 cycles (18.3%), embryo transfer could not be performed because of the absence of a mature oocyte (8.2%), fertilization or cleavage failure (7.4%), and other reasons (2.6%). A single embryo transfer was performed in 62.3% of the cycles.The clinical pregnancy rates were 19.5% (197/1011) per oocyte retrieval, and 23.8% (197/826) per embryo transfer. Biochemical pregnancy was noted in 1.9% (20/1011) of the cycles, and 0.3% (3/1011) had an ectopic pregnancy, which was considered preclinical pregnancy failure. Miscarriage was noted in 5.1% (52/1011) of the cycles and 26.4% (52/197) of clinical pregnancies. The live birth rates were 14.3% (145/1011) per oocyte retrieval and 17.5% (145/826) per embryo transfer cycle.The ICSI cycle characteristics of the different age groups  are presented in p<0.05). Among women aged ≥40 years, the rate of poor response was significantly high  (p<0.001) and baseline FSH levels .Although the total gonadotropin used was significantly lower in women aged <36 years than in those aged ≥36 years, their peak estradiol level, number of total and metaphase 2 oocytes, and the number of embryos was significantly higher than those who were older. Additionally, an increase in age was significantly associated with a high rate of poor response (0-3 oocytes) (p<0.001) . Additiop<0.05) and baseline FSH level  in this group had a single embryo transfer, the outcomes were acceptable. On the other hand, among women aged ≥40 years, the clinical pregnancy and live birth rates were 5.2% and 1.7%, respectively. The miscarriage rate significantly increased with age  and number of transferred embryos were applied to the model. Categories of age , extreme baseline FSH level (≥20 IU/L) and ovarian response (≤3 or >3 oocytes) were found as independent predictors of live birth .p=0.006). Conspicuously, the live birth rate was 12.48-fold lower in women aged ≥40 years than in those aged ≤30 years (p=0.001). The baseline FSH level was another significant factor for live birth. The live birth rate was 2.68-fold lower in women with baseline FSH levels >20IU/L than in those with FSH levels of 10-14.9 IU/L (p=0.02). The number of retrieved oocytes was another significant factor for clinical pregnancy and live birth. The live birth rate was 1.47-fold higher in women from whom >3 oocytes were retrieved than in those from whom ≤3 oocytes were retrieved (p= .047).As expected, an increase in age was significantly associated with decreased live birth rates in multivariate analyses. The live birth rate was 2.2-fold lower in women aged 36-39 years than in those aged ≤30 years  and response to stimulation (obtaining ≤3 or >3 oocytes) were independent factors affecting live birth in our large cohort of women with high FSH levels. When the retrieved oocyte number exceeded 3, the clinical pregnancy and live birth chances increased 1.84 and 1.47-fold, respectively, in our cohort. These findings indicate that if a woman responds well to gonadotrophin stimulation, the possibilities of a pregnancy and live birth increase. Thus, efforts to obtain additional oocytes are much valuable in this group of women.The prediction of pregnancy after IVF is an important issue in reproductive medicine. Several studies have attempted to develop prediction models for IVF outcomes  with poor ovarian reserve, clinical pregnancy and live birth rates were acceptable at 23.9% and 21.1%, respectively, although the majority of the women had a single embryo transfer. On the other hand, in the present study, not only age but also the extreme baseline FSH level (>20 IU/L) was found to be a significantly independent predictor of pregnancy and live birth. This observation was consistent with the finding of a previous meta-analysis that included pooled data from five studies, which showed that a high baseline FSH level is associated with low pregnancy rates and that FSH is one of the significant predictive factor for pregnancy outcome  evaluated the IVF outcome in women with baseline FSH levels of 10.0-11.9 IU/L, which were considered as “borderline FSH levels.” The authors reported that the number of embryos was the only predictor of clinical pregnancy. The outcomes of low-prognosis patients have been of a special interest in the field of ART. The most important endpoint is the live birth rate of ART treatments. We attempted to analyze the live birth rates and predictive factors for live birth in our large data set of women with baseline FSH levels >10 IU/L. The strength of this study is that it included more than 1000 oocyte retrieval cycles from a single tertiary center. The limitation is the retrospective nature of the study. In addition, we collected the data from patients who underwent oocyte retrieval; therefore, the prior cancellation before the oocyte retrieval procedure was not included in this study.In conclusion, age, baseline FSH level, and the ovarian response as; ≤3 or >3 oocytes retrieved, are significant predictors of clinical pregnancy and live birth among women with high baseline FSH level. These findings can be used to appropriately counsel women undergoing ART in order to ensure that these women have realistic expectations.


While cohabitation and non-marital childbearing have been increasing in Russia since 1990, the share of marital first births that are conceived prior to marriage has changed very little since the Soviet era. The prior findings on the stability of trends in premarital conceptions in Russia have been contradictory and inconclusive. This study aims to extend the existing empirical evidence on premarital conceptions in Russia and to contribute to the discussion on the persistence of marriage as the preferred partnership context for parenthood. We focus on births that occurred within the first two years of marriage, and compare the childbearing patterns of Russian women who married in different historical periods. For our investigation of fertility among marital cohorts who married during the Soviet era (1960–1991), we use individual-level data from the 1994 microcensus. For our examination of fertility among more recent marital cohorts , we draw on data from birth records in civil registers. We also use relevant complementary data sources. Our findings show that there has been a marked shift in the relationship between conception and marriage in Russia. Increasingly, conceptions have been occurring before marriage, and in the most recent marital cohorts, the level of premarital first conceptions has even surpassed the level of marital first conceptions. The average interval between conception and entry into marriage has also been lengthening. We describe this unique pattern of childbearing and discuss some potential explanations for the ongoing association between marriage and childbearing in Russia.The online version contains supplementary material available at 10.1007/s10680-021-09600-5. Over the past three decades in Russia, family formation and fertility patterns have changed substantially. Cohabitation has become more widespread, non-marital births have increased, and people are increasingly postponing marriage and childbearing. As in other post-Soviet countries, these changes in Russia were greatly influenced by the breakup of the Soviet Union (USSR) and by the societal transformations that followed , changes in fertility and family formation occur in sequence, with one event triggering the next .Another explanatory framework that is often employed in non-marital childbearing research is the “pattern of disadvantage”. This concept was initially built on empirical evidence from the USA ,Undesirable forms of family behaviour, including cohabitation, divorce, and childlessness, were not only discouraged by the legal system; they were punished by the KomsomolHowever, these strict measures aimed at stamping out cohabitation and non-marital births were not fully effective. By 1959, the share of out-of-wedlock births in Soviet Russia had risen to 14%  in 2005, and started decreasing thereafter. The decrease was partly caused by a concurrent increase in fertility that resulted mainly from rising numbers of second and third births, which rarely happen outside of marriage  conducted in 2011 showed that 80% of never-married women were using modern and effective contraception, while slightly less than 11% were using traditional methods, and about 10% were not using any contraception  continues to be highly valued and to be seen as the best setting for having and raising children.The main objectives of the empirical part of our study are to examine the distribution of first births by the time elapsed after marriage; to determine the share of premaritally conceived births; and to investigate the changes in this share over time. We look at the first births that occurred within two years of marriage among women who married while under age 35. We selected a two-year follow-up period based on the results of our preliminary analysis of randomly selected marital cohorts, which showed that 75–80% of marital first births occurred during the first two years after marriage.Two different data sources were used for the core part of the analysis. First, to investigate childbearing among couples who married in the Soviet era, we employed (anonymous) individual-level data from the 1994 microcensus. Then, to track the first births of women of the 2000, 2011, and 2016 marital cohorts, we used retrospective information from official (anonymous) individual-level birth record data for three time periods: 2000–2002, 2011–2013, and 2016–2018.The 1994 microcensus was conducted in all regions of Russia, excluding the Chechen Republic, and covered 5% sample of the total population.Turning to our second data source, we note that official data on birth records in civil registers have been collected and stored by the Russian Federal State Statistics Service  since 1998. Anonymous electronic copies of these birth records include information on the date of birth and the date of the mother’s current marriage. For the period from 2000 onwards, the data cover the whole territory of Russia, except for the Chechen Republic, for which data from 2000 to 2003 are missing. Between 1999 and 2010, filling in the birth order field in a birth record in a civil register was no longer compulsory in Russia. Nevertheless, most regions continued collecting this information. Moreover, data on the biological birth order continued to be reported in the medical birth certificate. In 2011, birth order reporting was again made compulsory. Importantly, the birth record data include information on the mother’s current marriage, but not on the order of the marriage. Therefore, we analysed all marriages together, irrespective of their order.We used the birth record data in the same way as the 1994 microcensus data. For our investigation of women in the 2000 marital cohort, we used birth record data for 2000–2002, i.e. we looked at first births that occurred within two years of marriage. The electronic copies of the birth records for these years contain the mother’s month and year of birth, the month and year of the mother’s current marriage, the month and year of the child’s birth, and the child’s birth order. For these reasons, information on the birth order was available for only 58.2% of births. For the regions with missing birth order information, births were split according to the birth order distribution in the regions for which birth order information was available. This approach was applied to Russian birth data of the same years in the Human Fertility Database (HFD), and the results were satisfactory , and the length of the interval between the two events (in completed months), we randomly generated an “exact day” of the event by applying the uniform distribution. The large sample size allowed us to produce reasonably accurate results for this purpose.The same analytical approach was applied to data from all of the selected data sources. We analysed the distribution of births that occurred within two years of marriage and split the duration time into months, from zero to 23. We classified children who were born in the first seven and a half months of marriage as having been conceived before the marriage.In addition, we examined the first childbirths of women in the 1960–1991 marital cohorts (the 1994 microcensus data) and the 2000, 2011, and 2016 marital cohorts (the birth record data), while taking into account the urban–rural divide.The main analysis based on the micro-level data was complemented with an analysis of official vital statistics on births and marriages produced by the Rosstat. These data were used to estimate the total number of births conceived outside of marriage and to calculate the relative frequency of non-marital births among the women of the marital cohorts in our sample, including the annual number of live births by age; the marital status of the mother and the birth order for the 1989–2018 period; and the annual number of marriages by age for 2000, 2011, and 2016.When considering the official statistics on marriages, it should be noted that the statistical tabulations of marriage records in the 1999–2010 period were replaced by brief tables. These concise reports provide data on the number of marriages by only four age groups of the groom and the bride , and the total numbers of marriages and remarriages. Therefore, for comparative purposes, we used data for only one year from this period, namely for 2001. To ensure uniformity, we divided the women of all marriage cohorts into these four age groups.Finally, to shed more light on the changes in the characteristics of cohabiting couples in Russia, we examined data from the 2002 and 2010 population censuses and the 2015 microcensus Rosstat, . We alsoOur examination of the frequency of births in relation to the duration of marriage revealed that significant changes occurred over the 1960–2016 period. Figure The changes in the pattern of the distribution of first births were brought about by several processes. The left panel of Fig. One of the most striking findings is that the frequency of first births that occurred in the first five months of marriage was increasing steadily over our study period, with almost no interruptions . Moreover, whereas the increase in the frequency of premarital conceptions was continuous across the marital cohorts among women who married before age 25, this increase did not become evident until the 1990s marital cohorts among women who married at ages 25–34.A comparison of the childbearing patterns in urban and rural areas Fig.  showed tChanges in the timing of the first birth relative to the length of marriage were taking place alongside the shifts in the composition of the female population by marital status. The proportion of women who were married was consistently declining from one population census/microcensus to the other, whereas the proportion of women who were cohabiting was increasing Fig. . The decTo shed more light on the question of how advanced the diffusion of cohabitation has become in Russian society, we investigated the variation in the type of partnership by women’s completed education using data from the 1994 and the 2015 microcensuses and the 2002 and the 2010 censuses , whereas the share of women in this age group with low education remained relatively stable, at around 4–6%. Thus, it should be emphasised that although the proportion of partnered women who are cohabiting is much higher among those with lower than with higher levels of education, quantitatively, the number of cohabiting women with low education is small.To sum up, it is apparent that union formation behaviour continues to be socio-economically differentiated in Russia. At the same time, however, cohabitation has been gradually increasing over time, and, as we described above, it has been increasing across all educational groups of women.As cohabitation has been increasing, non-marital conceptions and non-marital births have been rising as well. As we noted before, the highest non-marital birth level, of 30%, was recorded in 2005 Fig. . When weFigure Our study provides the most comprehensive empirical evidence (that is available for Russia to date) on changes in premarital conceptions and in first birth intervals among couples who married over a period of almost 60 years, i.e. from 1960 to 2016. For our analysis, we drew on data from multiple accessible sources, including individual-level data from the 1994 Russian microcensus and micro-datasets of birth registration records for select years. Our finding that in Russia, the frequency of first premarital conceptions has not only been increasing, but has surpassed the frequency of marital first conceptions, highlights important shifts in sexual behaviour, as well as in union formation and childbearing in Russia. The turning point in these trends—i.e. the point at which the share of first births that were premaritally conceived surpassed the share of first births that were maritally conceived—was in the mid-1990s, which was also the point in time in Russia when abortion rates started declining, and the use of modern contraception started increasing  in the 1990–2005 period, and the decrease in the level (to slightly above 20%) that occurred in the following years can largely be explained by the increase in the share of second and higher order births among all births, which rarely happen outside of marriage , which suggests that the diffusion of cohabitation has been progressing in Russian society. However, the lack of legal protections for cohabiting couples remains an important barrier to cohabitation becoming equivalent to a marital union. The Russian Federation does not provide for the legal registration of cohabitation without marriage. This means that the property and financial arrangements, as well as the obligations of and the disputes between cohabiting partners, are not subject to regulation. Consequently, cohabitation is associated with higher levels of insecurity for the partners if one of the partners commits an indiscretion, and for the child(ren) of the partners in the event of a union dissolution. Therefore, in Russia, marriage continues to provide greater stability and security for family members than cohabitation.Our study is not without limitations, many of which are related to the data we used. First, the birth record datasets we used to examine fertility in the 2000, 2011, and 2016 marital cohorts did not include data on the partnership histories of women. For this reason, we were not able to investigate the risk of premarital conceptions by women’s union status. Moreover, because of a lack of data, we were not able to examine the association between the risk of premarital conception and women’s educational attainment at entry into marriage. We also believe that the phenomenon of premarital conceptions in Moscow, which is a vanguard city by many parameters, deserves a separate investigation. The union formation and childbearing behaviour of women residing in Moscow is likely to differ significantly from that of women living not only in rural areas, but also in other urban areas of Russia. Finally, the limited scope of our study did not allow us to answer the question of why Russian couples prefer to have children within marriage, or of why couples are increasingly postponing marriage in the event of a premarital pregnancy. By using multiple data sources, we were able to cover a long historical period in Russia. Unfortunately, however, the data contain a very limited number of explanatory variables. Nonetheless, we put considerable effort into identifying the main forces that could be responsible for the unique childbearing pattern in Russia and for the continuous preference among expectant parents to marry before their first child is born. We hope that the reasoning and the reflections provided in this study will stimulate and inform further research on this topic.Supplementary file1 (PDF 449 KB)Below is the link to the electronic supplementary material.


Compared to their appropriate-for-gestational-age (AGA) peers, small-for-gestational-age (SGA) infants are prone to growth deficits. As the first 6 months of exclusive breastfeeding is generally recommended, it is essential to understand how this intervention might impact SGA infants’ growth. This study aims to assess growth of exclusively breastfed SGA term infants in the first 6 months of life.A prospective cohort study was conducted on term infants born in Dr. Sardjito General Hospital and two private hospitals in Yogyakarta, Indonesia. SGA was defined as birth weight less than the 10th percentile according to Fenton criteria. Weight, length, and head circumference (HC) were measured at birth and monthly until 6 months old.p < 0.001). During the first 6 months, the SGAs grew in weight and length in parallel with the AGAs. At sixth months of age, the weight and length (mean ± SD) of the SGAs were significantly lower compared to the AGAs (p < 0.001). However, HC (mean ± SD) of SGAs grew significantly faster than the AGAs (p < 0.005). At sixth months of age, there were no significant differences in HC between the two groups (p = 0.824).A total of 39 AGA and 17 SGA term infants who were exclusively breastfed in their first 6 months were included and followed. In SGA compared to AGA, birth weight, length, and HC (mean ± SD) were significantly lower (In the first 6 months, exclusively breastfed SGA term infants, in contrast to weight and length, only show catch up growth in HC, leading to HC comparable to their AGA peers at the age of 6 months.The online version contains supplementary material available at 10.1186/s12887-021-03080-6. Small-for-gestational-age (SGA), defined as infants whose birth weight were less than 10th percentile of the reference, was widely known to have higher risk for perinatal morbidity, growth restriction leading to persistent short stature, neurodevelopmental problems such as low intelligence quotient (IQ), and pubertal disorder in later life . Recent In 2012, the prevalence of infants born SGA was estimated to be 23.3 million in low and middle-income countries . South oCatch up growth, defined as body weight reaching the 10th percentile of the corrected age for SGA children, in SGA infant was regarded as advantageous in maximizing neurodevelopment, enhancing immune function, and achieving final adult height . HoweverMaternal characteristics such as age, parity status, educational level, and medical condition  have been variously shown to influence intrauterine and postnatal growth . VariatiExclusive breastfeeding, defined as giving infants only breast-milk without other food or water for the first 6 months age, is the cornerstone of child growth and development as it provides essential and optimal nutrition for child . HoweverThis study aims to evaluate growth of exclusively breastfed SGA term infants in the first 6 months compared to appropriate-for-gestational-age (AGA) term infants. We hypothesized that the exclusively breastfed SGA grew better than their AGA peers to catch up for their intra-uterine growth deficits.This is a prospective longitudinal observational cohort study of exclusive breastfeeding in relation to growth in term newborns from birth until the age of 6 months.Term infants who were born in the Perinatology ward/Neonatal Intensive Care Unit (NICU) of Sardjito General Hospital and two private hospitals  in Yogyakarta were included in this study. Yogyakarta was an urban city located in a province in the middle of Java Island, Indonesia. Based on Indonesia Demographic and Health Survey 2017, the crude birth rate in Yogyakarta was 15.3 .Ninety-one infants were enrolled consecutively between July 2018 to October 2019. Infants were eligible for study participation if they were born with a gestational age of ≥37 until 41 6/7 completed weeks and exclusively breastfed . The excFor all eligible infants, written informed consent was obtained from both parents before enrollment. Ethical approval was obtained from the Medical and Health Research Ethics Committee of Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada.Maternal characteristics consisted of maternal age, parity, delivery mode, education, occupation, and history of cigarette exposure, were obtained using questionnaires collected after delivery. Mothers self-reported cigarette exposure data from whether she smoked during pregnancy (active smoker) or her family smoked inside the house (passive smoker). Passive smoker was a term used to refer to someone who breathes other people’s smoke . A formePre-pregnancy body mass index (BMI) was calculated based on weight of mother before pregnancy divided by square of height measured at antenatal care visit or after delivery (in kg/m2). Assessment of gestational age was based on ultrasound examination in the first trimester and/or dubowitz score in case there was no ultrasound examination. Hemoglobin level of the mother was measured just before delivery.Weight, length, and head circumference (HC) of the infants were measured by trained research assistants within 24 h after birth and then every month (within 1 week after completion of the month) until the age of 6 months. The trained research assistants were tested for interrater reliability to avoid measurement bias. Infant-mother pairs went to hospital or home visited for follow up study.Infants were weighed naked on a digital weighing scale (Seca 272) to the nearest 1 g. Infantometer (Seca 210) was used to measure the infants’ length to the nearest 1 mm. Head circumference was measured to the nearest millimeter using a non-stretch plastic measuring tape encircling the head at the occipital protuberance level posteriorly and supraorbital ridges anteriorly.Intrauterine growth status was classified using PediTools Fenton 2013 . InfantsInformation on the infant’s feeding was documented at monthly visits. We used the 24-h recall to determine breastfeeding status as suggested by the WHO . HoweverContinuous variables were presented as mean ± standard deviation (SD), while categorical variables were presented as numbers (%). Continuous variables were tested for skewedness and kurtosis. Normally distributed groups were compared using independent t-test. Categorical variables were compared using Chi-square test.p-value of ≤0.25 in the univariate analyses [p < 0.05.We used linear regression analyses to assess predictors of the infants’ weight, length, and head circumference at 6 months as the outcome variables. We did the analyses in two steps: (1) univariate linear regression analyses with weight, length and head circumference at birth as the predictors and sex, maternal height, maternal age, maternal pre-pregnancy BMI, cigarette exposure, etc. as the potential confounders and (2) the construction of multivariate models from independent variables with analyses –31 SPSS In the primary analysis, 91 term infants were included. However, only 56  consisted of 39 AGA and 17 SGA infants completed the 6 months follow-up. Six (11.1%) of the AGA and 6 (16.2%) of the SGA were lost to follow up because they did not attend the follow-up session due to move from their former home or could not be reached by their phone number. Nine (16.7%) of the AGA and 14 (37.8%) of the SGA had to be excluded from the study because they were no longer exclusively breastfed. The flow diagram showing the exclusion of subjects during the study was presented in Fig. p = < 0.001). SGA mothers were younger, had lower pre-pregnancy BMI, and had lower height than AGA groups. Most of the mothers in this study were multiparous women. Half of the subjects were born through caesarean section. Mother’s age, parity, education, occupation, pre-pregnancy BMI, height, cigarette exposure, and anemia were not significantly different among the two groups . There was no significant difference in gestational age between the AGA and the SGA. Fenton standard deviation scores of birth weight, length, and head circumference of SGA group were significantly lower compared to the AGA group  imaging study of neonates with medical complications have found significant positive correlations between head circumference and brain size , 35. A sThe human brain’s growth velocity is higher in the postnatal period than in the intrauterine period, particularly during the first 6 months of life . Gale etThe rapid head growth observed in our study might be explained by the fact that all of the infants were asymmetric SGAs. Kaur et al. found that the increase in head circumference was different among asymmetric and symmetric full-term SGA infants. Better growth in head circumference is attained in asymmetric SGA infants than in symmetric SGA counterparts during the first postnatal year of life; this finding may be attributed to the continuation of ‘brain sparing’ experienced by asymmetric SGA babies during prenatal life .The catch up in growth of term SGA infants varied between studies. Some reported catch up growth as early as 3 to 6 months, while others failed to observe catch up growth until the end of the first year , 18, 40.Compared to symmetrical intrauterine growth restriction (IUGR), asymmetrical IUGR has a better prognosis for growth because their cell number is normal. Their only defect is in the cell size . McIntosSeveral possible mechanisms were considered which might result in the better catch-up growth seen in breastfed SGA infants, including higher food intake, specific nutrients in breast milk, better nutrient absorption, non-nutrient factors in breast milk, or a combination of these factors . The mosCatch up growth in SGA infants is also influenced by growth hormone/insulin-like growth factor (GH/IGF-1) that has a major role in fetal growth as well as in infant and child growth . An incrExclusive breastfeeding is recommended for full-term children, regardless of their weight . PreviouThis study observed a high percentage of caesarian section (c-section), a condition that may partly explain the high rate of drop out in exclusive breastfeeding. The rate of c-section in the city of Yogyakarta in 2018 was 23,1%. The average rate of c-section in Indonesia was higher among urban women (22.1%) compared to rural women (12.4%) . Among SIn this study, infant’s gender regardless of being born SGA or AGA is significantly and independently associated with weight, length, and HC at 6 months. Male infants, irrespective of their birth weight, length, and HC, are heavier, longer, and have bigger HC at 6 months than those of female infants. A similar finding was observed from a study in China. Male infants grow faster than females, up to the age of 12 months .A study in the Philippines showed that the growth standard deviation scores (SDS) of male SGA infants are worse than those of female SGA infants when converting weight, length, or HC are to SD Scores of certain growth references. It was supposed that compared to their peers, the growth of male SGA infants might be more seriously affected .Although Fig. This study also showed that in contrast to weight, length at 6 months was independently associated with maternal height. This association is not easy to explain since maternal height might also be related to maternal education or socio-economic status, apart from its possible association with genetic factor , 49.To the best of our knowledge, this is the first observational study describing the role of exclusive breastfeeding in growth of HC in term SGA infants of Javanese origin, Indonesia’s biggest ethnicity. Moreover, the results of this study have to be considered as recommendation for exclusive breastfeeding in term SGA infants, especially in Indonesia as one of the developing countries.However, we do realize that the small sample size and the high number of both lost to follow up and excluded participants were the limitation of our study. It was not easy to convince mothers to exclusively breastfed for a full period of 6 months, especially in the SGA group. Similar situations were also observed in previous studies . CompariFurther follow up is certainly needed because by the age of 6 months, there was not yet any sign of catch up growth in length and weight.In conclusion, in the first 6 months of life, exclusively breastfed SGA term infants only show catch up growth of HC leading to HC comparable to their AGA peers at the age of 6 months. Sex and intrauterine growth are associated with weight, length, and HC at 6 months. Maternal height only shows any influence on the length of their peers at the age of 6 months.Additional file 1: Table S1. Baseline characteristics of infants included in the final analyses vs. those lost to follow up or excluded due to failure of exclusive breastfeeding. Table S2. Weight, length and head circumference measurement from birth to 6 months of age.