Introduction: birth size is affected by diverse maternal, environmental, social, and economic factors. Aim: analyze the relationships between birth size—shown by the indicators small for gestational age (SGA) and large for gestational age (LGA)—and maternal, social, and environmental factors in the Argentine province of Jujuy, located in the Andean foothills. Methods: data was obtained from 49,185 mother-newborn pairs recorded in the Jujuy Perinatal Information System (SIP) between 2009 and 2014, including the following: newborn and maternal weight, length/height, and body mass index (BMI); gestational age and maternal age; mother’s educational level, nutritional status, marital status and birth interval; planned pregnancy; geographic-linguistic origin of surnames; altitudinal place of birth; and unsatisfied basic needs (UBN). The dataset was split into two groups, SGA and LGA, and compared with adequate for gestational age (AGA). Bivariate analysis (ANOVA) and general lineal modeling (GLM) with multinomial distribution were employed. Results: for SGA newborns, risk factors were altitude (1.43 [1.12–1.82]), preterm birth (5.33 [4.17–6.82]), older maternal age (1.59 [1.24–2.05]), and primiparous mothers (1.88 [1.06–3.34]). For LGA newborns, the risk factors were female sex (2.72 [5.51–2.95]), overweight (1.33 [1.22–2.46]) and obesity (1.85 [1.66–2.07]). Conclusions: the distribution of birth size and the factors related to its variability in Jujuy are found to be strongly conditioned by provincial terrain and the clinal variation due to its Andean location. Birth size is affected by diverse maternal, environmental, social, and economic factors, including maternal health problems that can develop during pregnancy. Among the maternal factors, ethnicity, age, parity, and education level stand out ,2,3. AmoBirth weight is the universal indicator for evaluating newborn (NB) size, although SGA, appropriate for gestational age (AGA), large for gestational age (LGA), weight-length ratio, body mass index (BMI), and ponderal index at birth are also used. There is no consensus in neonatal anthropometry on available growth charts because the charts differ in their criteria for inclusion and exclusion, measuring techniques and instruments, precision in the evaluation of gestational age, and methods for calculating percentiles . The pubOne of the best indicators for capturing the Gaussian distribution of birth size with birth weight at vertex, “optimal birth weight”, is the classification of newborn infants based upon gestational age and birth weight proposed by Battaglia and Lubchenco , which dThe province of Jujuy, in northwestern Argentina, is located on the eastern flank of the Andes and spans foothills ranging in altitude from about 500 m to over 4000 m. This altitudinal cline has conditioned the placement of human settlements within four well-defined ecological regions: (1) Puna (>3500 m), (2) Quebrada (about 2500 m), (3) Valleys (about 1500 m), and (4) Ramal (<500 m). Jujuy populations—particularly those located in highlands (>2500 m)—show a cultural and ethnic affinity with other peoples of the Andean world, which is manifested in onomastics and genetic traits. A significant percentage of individuals  ,10. On tPrevious studies of Jujuy populations indicate an association between high altitude and lower birth weight. Compared to infants born at lower altitudes, highland infants are more likely to present stunting, reduced height and body surface area, and ectomorphy, as well as increased BMI, ponderal index scores, and body surface area/mass ratios ,16,17,18This study’s goal was to analyze the maternal, social, and environmental factors that affected birth size of SGA and LGA newborns in Jujuy between 2009 and 2014.This was an observational, analytical, and retrospective study of consecutive births registered by the Perinatal Informatics System (SIP) of Jujuy’s Ministerio de Salud. SIP is a tool developed by the Centro Latinoamericano de Perinatología, Salud de la Mujer y Reproductiva for collecting data on mothers and newborns in neonatal and obstetric centers. SIP is used in all of the provincial public health system’s maternity wards. In this paper, data collected between 2009 and 2014 was analyzed. The original SIP database (without applying exclusión criteria) covers 70% of births in Jujuy province .This study followed the bioethical guidelines issued by Argentina’s health ministry , which The following exclusion criteria was used: (1) gestational age < 24 + 0 weeks and > 42 + 6 weeks; (2) simultaneous lack of data on weight, height, gestational age, sex, and maternal place of residence during pregnancy; (3) twin pregnancy; (4) congenital malformation; and (5) birth weight and height > P97 of INTERGROWTH-21st standard for gestational weight and height , age, and percentage of homes with unsatisfied basic needs (UBN) in the mother’s place of residence were analyzed.Fetal variables were the indicators for SGA and LGA, calculated using the 10th and 90th percentiles of the INTERGROWTH-21st standard . For neThe prevalence of SGA, AGA, and LGA newborns was analyzed in relation to various categories. Altitude of the maternal place of residence was divided between highlands (HL) > 2500 m, and lowlands (LL) < 2500 m. Regarding parity, two categories were established: primiparous and multiparous. Three groups of birth intervals were defined: <18 months, 19 to 60 months, and >60 months. The pregnancy planning variable was divided into two groups, with and without planning. Pregnant women were grouped according to their levels of education: without schooling, primary, secondary, and university. The following categories of maternal marital status were defined: married, stable union, single, and other. Given that surname-based ethnicity classification systems have proven highly efficient and congruent within northwest Argentine populations, ethnicity was established from the two maternal surnames, which were classified, according to their geographic-linguistic origins, in two large categories: native, that is to say, of indigenous or American origin, and foreign, arising in other parts of the world . Using BWith regards to the variable for the home or locality of the pregnant woman, as recorded by SIP, covariables of altitude and percentage of the population with UBN were established. The latter, an indicator of critical shortcomings and populational poverty, uses information directly related to four areas of basic human needs . Data for UBN came from the 2010 national census .Category variables were expressed as percentages, and statistics differences were calculated with a Chi-squared test using SPSS software . For continuous fetal and maternal variables, means ± standard deviation (SD) were calculated. Comparisons of these variables for SGA and LGA infants were assessed using ANOVA.A spatial autocorrelation analysis of the incidences of SGA and LGA newborns—according to maternal municipal residences, using Moran’s Index—was carried out. Spatial association patterns were estimated by calculating local indicators of spatial association  and locTo integrate the relationship between the presence/absence of SGA or LGA infants as a function of newborn, maternal, and socioeconomic variables, general lineal modeling (GML) with a multinomial distribution was used, with AGA infants as the reference category. By means of regression selection, a minimum adequate model was attained, taking into account variations in the AIC (Akaike information criteria) values of the model when each variable that makes up the fixed effects was individually removed. The variables originally used were the following: sex, gestational age, altitude, surname, maternal age, parity, birth interval, planned pregnancy, educational level, marital status, unsatisfied basic needs, and BMI. Odds ratios (ORs) and confidence intervals of 95% are reported. R software , the RSAfter applying exclusion criteria in percentage terms of the SIP registers chosen for this study, they represent 60% of live births in Jujuy province, 49,185 mother-child pairs—25,014 boys, 24,180 girls . Table 1The study found 1965 SGA newborns; 38,192 AGA newborns; and 9028 LGA newborns. Their distributions are presented in Greater prevalence of SGA newborns was observed in mothers with at least one of the following characteristics: highland residence, primiparity, long birth-interval (>60 months), optimal pre-conception nutritional status, and preterm birth, with statistically significant differences only for the last three variables. AGA newborns were, in comparison with SGA newborns, more prevalent among the remaining variables, but the differences were only significant in lowland mothers, multiparous mothers, and mothers that did not have preterm births .The prevalence of LGA newborns, in comparison with AGA newborns, was significantly greater in mothers with at least one of the following characteristics: lowland residence, multiparity, planned pregnancy, married, stable partner, foreign surname, overweight, and obese. In contrast, significantly higher prevalence of AGA newborns was found in mothers with at least one of the following characteristics: highland residence, primiparity, unplanned pregnancy, single, and indigenous surnames . MaternaAccording to GLM with multinomial distribution and Akaike’s criteria, newborns had a significantly greater risk of being born SGA when they were born preterm and when their mothers were older, highland residents, or primiparous. The only protective factor for SGA newborn was the female sex. On the other hand, the risk of being born LGA was double in the female sex, and it was confirmed that increases in maternal BMI also raised the chance of being born with this phenotype. The factors that acted as protection against LGA were that the mother resided in the highlands and the low preconception weight. .Birth size is an important outcome of a healthy pregnancy that reflects critical aspects of fetal and maternal health, is strongly associated with perinatal mortality and morbidity, and influences long-term health of the individual . The disThis study verifies that in Jujuy the distribution of birth size and the factors related to its variability are strongly conditioned by provincial orography and the altitudinal cline that are characteristic of the Andean foothills. Based on these considerations, it can be argued that the spatial distribution of SGA newborns in Jujuy is generally a mirror image of the distribution of LGA newborns, and therefore that the explanations and interpretations of both phenotypes are, at the same time, complementary and opposite.The interpretation of the three indicators of birth size should be undertaken while considering variations in birth weight according to Jujuy’s geographic regions evidenced in these studies ,18,27. TIn summary, this study confirms previous findings which show that increased altitude lowers birth weight and raises the incidence of SGA newborns ,31. AlthMaternal height, pregestational maternal weight, and weight increase during pregnancy have been identified as the main maternal capital components  which deThe kurtosis and symmetry in the distribution of birth weight as a function of altitude could also explain differences by sex in the prevalence of SGA and LGA newborns in bivariate analysis. Independently of any biological or environmental factor, average birth weight is significantly greater for the male sex than for the female sex. Therefore, the distribution of birth weights for the female sex is expected to be more skewed to the left in the highlands and that P10 values will be lower. The opposite would be expected to occur for the male sex in the lowlands, thus explaining the greater incidence of SGA newborns in the female sex and of LGA newborns in the male sex that were observed in bivariate analysis. Nonetheless, GLM shows that the female sex has a significantly greater odds ratio for LGA. There is no reasonable explanation, nor precedents in the literature, for this finding.Compared with AGA newborns, the mean gestational age for SGA newborns was significantly lower . This trBivariate analysis indicates that, in relation to AGA, the prevalence of SGA—excluding altitude, sex, and preterm birth—is likely associated with a few relevant maternal and obstetric conditions, or ones that are commonly attributed as risk factors for SGA , highlighting multiparity, longer birth intervals, and optimal maternal nutritional status. According to Kozuki et al. , even ifThe relationship between longer birth intervals and risk of SGA is debatable. While Cass et al.  contend n = 17,031,005) by the National Vital Statistics System in the United States apparently shows that the frequency of SGA newborns was significantly higher in nulliparous women ≥ 30 years old and in all women ≥ 40 years old, when compared to women aged 20 to 29 [GLM indicates that older mothers constitute a risk factor for SGA newborns. Pregnancy at later ages is a condition that has grown in recent years. In the United States, during the decade 1991–2001, the number of pregnancies among women aged 35 to 39 rose 36%, and among women aged 40 to 44, pregnancies rose 70% . In deve20 to 29 . The autRegarding the bivariate analysis of LGA with respect to AGA, significant differences associated with maternal nutritional status, marital status, parity, and ethnicity are found. Excessive maternal adiposity (obesity and overweight) constitute a risk factor for LGA, while deficient adiposity (underweight) exerts a protective effect. According to Chiavaroli et al. , greaterDifferences in the prevalence of SGA and LGA newborns according to type of surname (indigenous or foreign) in Jujuy populations are probably related to ethnic variations, altitude, and maternal BMI. Jujuy populations with indigenous surnames, particularly populations in the highlands, have lower average weights and heights, lower BMIs, and are less mixed ethnically than populations in the lowlands ,14,15,36One of the strengths of this study is its contribution to public health by increasing knowledge about the diverse factors—and their prevention—that affect birth size when evaluated with indicators that relate birth weight with gestational age in high-altitude environments, such as in the province of Jujuy. Both SGA and LGA are related to an increase in infant mortality. Non-macrosomic LGA newborns (birth weight < 4000 g) are likely to show an increase in mortality and morbidity, even with non-diabetic mothers. On the other hand, in low- and middle-income countries, about one in five infants are SGA, and one in four neonatal deaths are among such infants .The study’s main limitation is that the data come only from the public health system and does not include deliveries that occurred in privately managed institutions. Information on maternal health during pregnancy, such as the occurrence of eclampsia or diabetes, could not be analyzed due to the lack of availability of appropriate data. These health conditions have been observed to affect birth size. This is particularly true for mothers located in the most remote areas of the province of Jujuy, which makes laboratory access and consultation with specialists impossible. Using surnames as an indicator of ethnicity may lead to misclassification. However, studies on the association of surnames with genetic markers reveals that there is a reasonable agreement of ethnic classification of individuals by surname and phenotype data on genetic markers ,45.The relationship between birth size—evaluated by the indicators for SGA and LGA—and maternal, social, and environmental factors in the province of Jujuy show that these factors differ according to the indicator. For SGA, the risk factors are altitude, preterm birth, later maternal age, and primiparity, while for LGA, the risk factors are female sex and higher BMI.


Breastfeeding and factors influencing breastfeeding are essential when considering the association between parity and neonatal and maternal morbidity risks when mothers are discharged within 24 hours after birth. However, there is a lack of studies examining the effect of parity and breastfeeding in a setting where all healthy mothers are recommended discharge four hours after birth. Therefore, this study examined the association between parity and the time for discharge, breastfeeding, and factors influencing breastfeeding.The study was designed as a prospective cohort study. Data were obtained from questionnaires at one and at six weeks after birth, and combined with registered data. All 147 included mothers were healthy, with an uncomplicated birth and a healthy newborn, discharged within 24 hours after birth.This study documented that primiparous women had a higher relative risk  of having doubts about infant feeding after discharge than multiparous women. Furthermore, 54% of primiparous women contacted the maternity ward after discharge compared to 27% of multiparous women. Twice as many primiparous than multiparous women felt anxious or depressed at one and at six weeks after birth. Finally, the study documented that 13% of primiparous women and 5% of multiparous women discharged within six hours after birth perceived the time before discharge to be too short.Primiparous women differ from multiparous women regarding breastfeeding, insecurity, and anxiety. Special attention towards primiparous women and a follow-up strategy that allows the mothers to contact the maternity ward after early discharge is recommended. Thus, studies found that up to 28% of primiparous women left the hospital within 24 hours after birth3. In comparison, up to 84% of multiparous women were discharged within 24 hours after birth3. However, concerns have been raised regarding early discharge and an increase in neonatal and maternal morbidity4. Healthcare professionals recommend breastfeeding to prevent neonatal infections and protect against overweight and diabetes later in life6. Furthermore, breastfeeding might reduce the mothers’ risk of diabetes, breast cancer, and ovarian cancer5. However, problems with breastfeeding in the first week after birth increases the risk of neonatal jaundice, dehydration, weight loss, and readmission6. Symptoms of neonatal morbidity due to problems with breastfeeding usually do not occur until after the first day in the newborn’s life9. Thus, paying attention to detailed information on morbidity symptoms to the parents may be crucial. A study from the US in 2015 found that 35% of primiparous women had problems with breastfeeding during a 48 hours hospital stay after birth compared to 20% of multiparous women10. Another study observed no difference in breastfeeding incidence, six to eight weeks after birth, in two groups of primiparous women leaving the hospital 24 and 48 hours after birth, respectively11. Further, mothers feeling anxious or depressed after birth are at greater risk for discontinuing breastfeeding12, and primiparous women have been found to have a higher postpartum anxiety and depression rate than multiparous women13. However, another study observed no difference in depression incidence in women discharged before and after 72 hours after birth14. In addition, mothers’ insecurity and readiness for discharge might influence breastfeeding14. Therefore, breastfeeding and factors influencing breastfeeding are essential when considering the association between parity and neonatal and maternal morbidity risks when mothers are discharged within 24 hours. Two systematic reviews compared early discharge with the standard length of hospital stay after birth and found that it was safe for healthy mothers and term infants to be discharged early after birth if accompanied by one home visit by a midwife15. However, the definition of early discharge in the reviews varied from six to 72 hours after birth. Therefore, this study examined the association between parity and the time for discharge, breastfeeding, and the factors influencing breastfeeding among mothers discharged within 24 hours after birth.Studies since 2016 from developed and developing countries document that early discharge after birth is becoming more common among mothers16. The study was a prospective cohort study among women giving birth vaginally in an urban hospital and being discharged within 24 hours after birth. Participants were recruited between 20 September 2020 and 16 April 2021 from the Department of Gynecology and Obstetrics at North Denmark Regional Hospital, with has approximately 1400 births annually. A midwife invited the mothers to participate in this study at a routine biochemical screening of the newborns 48 to 72 hours after birth. Inclusion criteria were: mothers with vaginal birth, gestational age of 37+0 to 42+6 weeks, reading and understanding Danish, and discharged within 24 hours. Exclusion criteria were: caesarean section, stillbirth, and homebirth. The standard recommendation was a discharge of all healthy mothers, with an uncomplicated vaginal birth and healthy newborns, four hours after birth. See the labor wards criteria and contraindications for discharge four hours after birth in Supplementary file Table S1. All mothers received information about the mothers’ vaginal bleeding, fever, and signs of neonatal jaundice before discharge. Furthermore, all mothers were handed out a schedule of how often the newborn needs to urinate, breastfeed and how the feces change color day-by-day within the first week after birth. The labor wards follow-up strategy is presented in Supplementary file Table S2. We define early discharge as discharge within 24 hours after birth.This article follows the checklist according to the ‘Strengthening The Reporting of Observational Studies in Epidemiology’ (STROBE) statement18. A link to the questionnaire was sent to the mother’s security mail one week after birth, and by e-mail, six weeks after birth.A self-administrated online questionnaire was used to collect data and contained 44 questions. Seven questions from the questionnaire were used for this study (see questions and answer possibilities in the study in Supplementary file Table S3)®) hosted by the Region of Northern Denmark was used to manage the questionnaires20. REDCap is a secure web-based software platform designed to support data capture for research studies. Data from the local register were combined with the questionnaire using the unique personal identification number given at birth to all Danish individuals by the Danish Civil Registration system21.If the mother did not respond to the questionnaire, she was contacted by phone 10 to 11 days after birth and encouraged to fill in the questionnaire. A reminder was sent by phone if there was a lack of contact after two calls. If the mother was contacted by phone with no response after four days, another reminder was sent by phone. Baseline characteristics were retrieved from the regions local department of data management. The software program Research Electronic Data Capture  with a 95% confidence interval (CI). Time-to-event curves were calculated by the Kaplan-Meier method to visualize the difference in hours to discharge between parity groups accompanied by a log-rank test. We adjusted for potential confounders selected a priori based on existing literature, supplemented by directed acyclic graphs for each outcome22. Missing data were reported in the tables. We performed an analysis of the selection process and loss to follow-up between one and six weeks after birth (Supplementary file Tables S4 and S5). Furthermore, we conducted a sensitivity analysis, assuming a best-case and a worst-case scenario (Supplementary file Tables S6 to S8). The data were analyzed using STATA/MP version 16.123. A p<0.05 was considered statistically significant in all analyses.We performed a sample size calculation based on the available literature with a significance level of 0.05 and a power of 80. Our sample size calculation based on the literature found that a minimum of 384 mothers were required to detect a difference between parity and breastfeedingA total of 373 mothers met the inclusion criteria from 20 September 2020 to 16 April 2021. However, 226 women (60.6%) did not participate in the study, either because they did not receive an invitation, refused to participate, or did not respond to the questionnaire. A total of 147 (39.4%) answered the first questionnaire one week after birth, and 109 (74.1%) of these mothers answered the second questionnaire six weeks after birth . We obseThe characteristics of mothers and newborns discharged within 24 hours after birth and differences between parity groups are presented in 3.This study examined the association between parity and time for discharge, breastfeeding, and factors influencing breastfeeding. The study showed that primiparous women had a higher risk of having doubts about infant feeding after discharge than multiparous women. In addition, more primiparous women reported adverse outcomes than multiparous women. Finally, this study illustrated that primiparous women were consistently discharged later than multiparous women throughout the first 24 hours after birth. The consistency of each outcome will be discussed by comparing our results to the findings of other studies. We chose to divide the mothers into discharged within six hours and between seven and 24 hours. These cut-off values have been used in other studies, making our results comparable to those24. However, the study did not report the time interval between giving birth and being discharged after birth. The study was conducted in the US, where the Newborns’ and Mothers’ Health protection Act ensures coverage for a 48-hour length of hospital stay after birth if the mothers have health insurance26. Therefore, we assume that most mothers in the study were discharged later than 24 hours after birth, thus making it difficult to compare the results with our findings. Some studies have compared parity and factors related to breastfeeding among mothers discharged within 24 hours after birth27. One study documented that maternal characteristic rather than the duration of hospital stay postpartum seemed to be essential predictors according to the duration of breastfeeding2. For example, low level of education and smoking were associated with a short breastfeeding duration2. On the other hand, the study showed that multiparity and a positive experience of initiating breastfeeding were associated with a long breastfeeding duration2. Nilsson et al.3 documented that breastfeeding experiences and breastfeeding knowledge were associated with discharge within 12 hours after birth. Therefore, parity, positive breastfeeding experience, breastfeeding knowledge, smoking, and a low educational level should be considered when developing policies for postpartum care.Only 2.8% of the mothers did not breastfeed one week after birth, indicating that most mothers had enough support to initiate breastfeeding. However, this study observed that more primiparous women discontinued breastfeeding six weeks after birth than multiparous women. This was an expected result since multiparous women with previous breastfeeding problems were offered hospitalization longer than 24 hours. Our findings correlate to a study, including 20694 mothers that documented primiparous women to have a shorter mean duration of breastfeeding than multiparous women13 findings of more primiparous women being anxious and depressed than multiparous women within the first five days after birth measured on the Edinburgh Postnatal Depression Scale. We did not use a diagnostic tool to measure if the mothers were anxious or depressed in this study, but the results illustrate if the mothers felt anxious or depressed after birth. Furthermore, Nakamura et al.13 showed that the number of supporters at home is more strongly associated with maternal depression than mothers’ satisfaction with the support. Therefore, healthcare providers should consider the larger proportion of primiparous women feeling anxious or depressed when organizing the postpartum care after early discharge and consider the mother’s support at home when planning the follow-up strategy.This study did not find an association between parity and mothers feeling anxious or depressed one or six weeks after birth. However, twice as many primiparous women felt anxious or depressed than multiparous women at one and at six weeks after birth. The larger proportion observed in our study correlates with the findings of Nakamura et al.28. In this study, parental education in pregnancy was converted into a 1-hour online video due to the national restrictions during the COVID-19 pandemic. This might have been reflected in our results and contributed to the doubts about infant feeding shown among the primiparous women.An association between parity and the mothers’ doubts about infant feeding after discharge was documented in this study. Primiparous women’s risk of having doubts about infant feeding was 162% times as high as multiparous women’s risk. A randomized controlled trial confirmed that an educational program improved the parents’ knowledge of taking care of a newborn and improved the mothers’ self-efficacy29. The midwives offered these mothers as many home visits as needed29. In comparison, the mothers in this study were offered one home visit, which might explain the difference in the number of mothers contacting the maternity ward in the two studies. However, in this study, twice as many primiparous women contacted the maternity ward after discharge than multiparous women (54.1% vs 27.5%). The mother’s contact with the maternity ward can be interpreted as feeling insecure after early discharge and needing professional support. However, it also illustrates the will among primiparous women to ask for help from healthcare professionals when they have doubts about their or their newborn’s well-being, which might prevent neonatal and maternal morbidity.More primiparous women than multiparous women contacted the maternity ward in the first seven days after discharge in this study. In total, 35% of the mothers contacted the maternity ward after discharge. Another study documented that 14% of mothers discharged within 12 hours called the maternity ward for advice after discharge31. However, the studies were from respectively 1987 and 1997. Thus, more updated research is needed to examine how primiparous and multiparous women differ in their need for information before early discharge after birth.There was no significant association in the adjusted analyses between parity and mothers having no knowledge about the signs of the newborn’s well-being. However, 11% of primiparous women reported not knowing the signs of the newborn’s well-being in this study, which indicates that primiparous women might need more information before discharge. Two studies documented that primiparous women wanted more information about caring for the baby, and multiparous women wanted more information about caring for themselves before discharge after birth2. We did not find any apparent reason for the difference in the proportion of mothers who perceived the length of hospital stay as too short. Thus, there is a lack of consistency in the literature regarding the mothers’ perception of the length of stay. However, twice as many primiparous women perceived the time before discharge after birth to be too short when discharged within six hours after birth compared to multiparous women. Furthermore, no mothers perceived the time before discharge too short when discharged seven to 24 hours after birth. The above mentioned indicate that some mothers might need more time before being ready for discharge, especially primiparous women. In this study, primiparous women were offered a home visit around 24 hours after discharge, which might impact their perception of the length of stay since they were asked at one week after birth. If a midwife offered all the mothers one or more home visits, fewer mothers might have perceived discharge within six hours as too short.No association between primiparous and multiparous women’s perception of the length of hospital stay was documented in this study. Only 5.5% of the mothers perceived the hospital stay too short when discharged within 24 hours after birth. In comparison, 13.5% found the hospital stay too short in a study from 2004 when mothers were discharged within 24 hours after birth32. The larger number of readmitted newborns in this study than the average in the Region of North Denmark indicates that discharge within 24 hours might increase the risk for neonatal readmission. A large retrospective cohort study based on data from 1992–1995 in California included more than 1.2 million newborns delivered vaginally and examined the risk of newborns’ being readmitted when discharged on the day of birth27. The study documented that newborns of primiparous women had an increased odds ratio of 1.21 of being readmitted than newborns of multiparous women27. However, there was no description of the labor ward recommendation for the time of discharge, prenatal education, or the follow-up strategies after discharge in the study. Thus, more updated research is needed with a more detailed description of the setting.Neonatal readmission is a rare event, and a more extensive study population is needed to find any significant association between parity and the risk of neonatal readmission. Data from The Danish Health Data Authority show that in the Region of North Denmark, a total of 2.4% newborns of primiparous women and 2.9% newborns of multiparous women were readmitted within 30 days after discharge in 2018There is a risk of selection bias caused by a loss of follow-up, and there is a risk of the results in the analyses at six weeks after birth being underestimated. In addition, this study did not have enough power to find a significant difference between the parity groups and breastfeeding at one and at six weeks after birth. This study is strengthened by using rigorous methods based on prespecified criteria in a protocol for cohort studies. Furthermore, the study was prospective, and there was only a minor risk of differentiated selection bias or information bias.The findings in this study indicate that differentiated postpartum care after early discharge might be needed, and special attention to primiparous women should be considered. Healthcare professionals should include the parents’ readiness for discharge before discharging mothers within six hours after birth to avoid mothers’ perceiving the time before discharge to be too short. Moreover, more individualized information about infant feeding and signs of the newborn’s well-being should be considered when developing policies for early discharge. Healthcare professionals might pay more attention to the mothers’ anxiousness or depression when developing postnatal care policies after early discharge. The results indicate that a follow-up strategy could be to allow the mothers to contact the maternity ward in the first seven days after discharge. The mothers’ doubts about infant feeding and the reasons for the mothers contacting the maternity ward after discharge need to be further examined to optimize postpartum care.


Young adults born preterm at very low birth weight exhibited smaller RV dimensions compared to term-born peers. Standard echocardiographic measures of RV function did not differ, but mildly reduced function was detected by RV longitudinal strain. This difference was related to birth weight and gestational age but not lung function or left ventricular function. Echocardiographic strain imaging may be an important tool to detect differences in RV function preterm and VLBW.Being born preterm  or at very low birth weight  is associated with increased rates of cardiopulmonary disorders in childhood. As survivors age, late cardiac effects, including right ventricular (RV) remodelling and occult pulmonary hypertension are emerging. In this population-based study, we aimed to investigate right heart structure and function in young adults born PT at VLBW compared to normal-weight term-born controls. The New Zealand VLBW Study has followed all infants born in 1986 with birth weight <1500 g. All were born preterm from 24 to 37 weeks. A total of 229 (71% of survivors) had echocardiograms aged 26–30 years which were compared to age-matched, term-born, normal-weight controls ( Advances in neonatal care over the last 30 years have led to significantly increased survival rates for infants born preterm (<37 weeks gestation), especially in those born very preterm (<32 weeks gestation) or very low birth weight VLBW <1500 g) [500 g 1,,5. The fAdults born very prematurely or with VLBW experience increased rates of health and neurodevelopmental problems compared to term-born, normal-weight peers, particularly cardiopulmonary disorders ,7,8,9. ETo date, evaluation of preterm/low birth weight cohorts has mostly focussed on left heart structure and function. The right ventricle (RV) has been less studied but may be particularly vulnerable to maladaptive responses as the immature heart transitions early from the fetal to neonatal circulation and due to the impact of the chronic lung disease of prematurity and pulmonary vascular disease .The population-based New Zealand VLBW Study comprises a unique cohort that included all VLBW infants born in New Zealand in 1986 . All werThe New Zealand Very Low Birth Weight Study is a prospective, population-based cohort study that included all 413 VLBW (<1500 g) infants born in New Zealand in 1986 who were admitted to a neonatal unit . The 338Perinatal and demographic information was collected at birth for the preterm cohort and in young adulthood for control. This included incidence of bronchopulmonary dysplasia (BPD)—defined at that time as persistent oxygen requirement at 36 weeks post-menstrual age. For this evaluation, participants underwent comprehensive assessment including health and social functioning history, anthropometry, pulmonary function testing and transthoracic echocardiography.Echocardiography was performed using an iE33 machine  by an experienced cardiac ultrasonographer blinded to study group. Image acquisition and measurements were performed in accordance with American Society of Echocardiography guidelines . IndicesRight ventricular systolic function by myocardial deformation was assessed using TomTec 2D Cardiac Performance Analysis . If images were of insufficient technical quality for strain assessment , strain was not analysed. For adequate images, end systolic endocardial and epicardial borders of the right ventricle were traced manually. After software speckle tracking, automated end-diastolic borders were reviewed and adjusted if appropriate. Endocardial strain measurements were recorded for the freewall alone and for the whole RV including interventricular septum . Images were analysed by a single assessor blinded to study group. For intraobserver variability, intra-class correlation coefficient was 0.95 indicating excellent reliability.Lung function data have been reported previously and showed that the PT/VLBW young adults had a higher incidence of airflow obstruction with significantly lower mean forced expiratory volume in 1 s (FEV1), FEV1/FVC  ratio and decreased diffusing capacity of the lung for carbon monoxide (DLCO) . In thist-tests and Chi-square tests as appropriate. Sex differences in echocardiographic indices are well described, therefore comparisons were adjusted for sex with analysis of variance (ANOVA). The differences between controls and VLBW, gestational age groups and birth weight groups, and the RV indices or strain, were assessed using ANCOVA with sex included in the models. To further assess the impact of birthweight and gestational age on RV indices and strain, subjects were grouped according to World Health Organization defined sub-categories of prematurity: extremely premature (<28 weeks) very premature (28–31 weeks) and moderate to late preterm (32–37 weeks), and birthweight: VLBW (<1500 g) and extremely low birthweight (<1000 g) [t-tests were used to explore the effect of perinatal factors, antenatal steroid use and a diagnosis of BPD, within the study group. The relationships between strain and adult lung function and previously reported left ventricular (LV) indices of ejection fraction (EF), LV volumes and LV mass index were explored using Pearson’s correlation coefficients. Statistical analysis was carried out with IBM SPSS version 25.0, Armonk, NY, USA. A two-tailed p-value < 0.05 was taken to indicate statistical significance.Dichotomous variables are summarised as frequencies and percentages. The distributions of continuous variables were assessed by visual assessment of density and quantile-quantile plots and are summarised as the mean +/− standard deviation for normally distributed data. Differences in demographic and perinatal data between controls and VLBW groups were explored using independent Student’s <1000 g) . IndepenYoung adults born at VLBW had smaller right atrial area and volume, smaller RV end-diastolic area and smaller ventricular dimensions . Right v3/m2)  .A gradient of difference in RV dimensions and in longitudinal strain was observed when individuals were grouped according to WHO categories of gestational age  Figure .A similar gradient of difference was also observed across groups categorised by birth weight  Figure .p = 0.025). No difference was found in any other parameter between VLBW with BPD compared to those without BPD ; FEV/FVC ; or DLCO  z-scores.Data regarding lung function have been previously published . There wp = 0.045), LV end-diastolic volume , LV end-systolic volume  or LV mass index No significant association was found between RV strain and left ventricular ejection fraction (r = 0.15, In this study, involving a unique population-based cohort of young adults born preterm at VLBW, we have identified measurable differences in right heart structure and function as compared to normal-weight, term-born controls. We confirm the decreased right ventricular end-diastolic chamber size previously reported in existing literature. In addition, we report for the first time, relatively decreased myocardial deformation in VLBW/preterm young adults compared to their peers as determined from evaluation of echocardiographic strain. This was associated with gestational age and birth weight, but not with BPD in infancy or adult lung function.Smaller end-diastolic RV chamber size in this analysis is consistent with our previously published left heart data from this cohort, which showed smaller LV volumes when indexed to BSA . Using RAlthough right ventricular systolic strain has previously been reported using CMR, we report for the first time decreased RV strain measured by echocardiography in a population-based cohort of preterm or VLBW young adults. Our finding of subtly altered strain in VLBW vs. controls is in agreement with the CMR findings of Lewandowski et al. albeit to a lower degree of magnitude. Further analysis of strain and structural measures revealed that differences were greater in those born earlier or at lower birth weight, consistent with data published from other cohorts regarding both RV and LV function ,32.We did not demonstrate differences in RV function when assessed using conventional methods with the exception of lower FAC observed in those VLBW participants with a history of BPD. Echocardiographic assessment of RV function can be challenging due to the complex morphology and conventional measures are limited by image and angle dependence . Strain Due to improved survival, the long-term consequences of preterm birth are gaining increased recognition with emerging evidence of cardiovascular effects ,20,22,36All infants undergo extensive remodelling of the right ventricle after birth as the patent ductus arteriosus closes and the right ventricle changes from a high to low pressure circulation. Being born prematurely disrupts normal cardiac development and this remodelling must occur earlier. In addition cardiac remodelling in preterm infants may also be affected by accompanying abnormal lung development, characterised by a paucity of pulmonary vasculature, dysmorphic and dysfunctional vessels leading to occult pulmonary vascular disease in adulthood . Goss etlower birth weight and gestational age, and smaller chamber volumes. We therefore believe that these differences in the strain-analysable group are more likely to have resulted in the under rather than overestimation of reduction in strain in our VLBW cohort, if at all. Our cohort was recruited based on being born VLBW rather than gestational age as was accepted practice at the time. This means the cohort likely represents all the very preterm infants born in New Zealand in 1986. There was unsurprisingly, an association between gestational age and birth weight within the very low birth weight cohort with approximately 2/3rds of the <1 kg group born at less than 28 weeks gestation but the cohort also includes some moderately and late preterm infants with growth restriction and so findings related to gestational age can only be interpreted in this context.Our study has limitations. Not all images were suitable for strain analysis—due mainly to the post hoc nature of this analysis and the LV focussed echo protocol that inadequately captured the RV. Suboptimal acoustic window also limited some strain analysis. Although participants with analysable strain images exhibited demographic characteristics similar to the PT/VLBW cohort as a whole, it is possible, that reduced acoustic windows may have excluded some subjects with RV dysfunction related to pulmonary disease. The strain-analysable group also had slightly higher birth weight and gestational age, and larger LV volumes. However, cardiac dysfunction associated with preterm birth has thus far been associated with Strengths of our study include comprehensive cardiovascular assessment in a population-based cohort of PT/VLBW individuals, with a high retention rate. Although secular changes in clinical practice may impact the generalisability of our findings, the cohort were cared for with modern strategies, including antenatal steroids and total parenteral nutrition, and as a population-based cohort are representative of the generation of young adults who are now in their fourth decade and at increased risk of cardiovascular disease. It will be valuable to see if our findings are replicated in population-based cohorts from other countries and settings. Although it is somewhat reassuring that strain values remain in the normal range in PT/VLBW individuals in our study, existing data on cardiovascular function in preterm-born young adults provide strong evidence that there are cellular, structural and functional differences in such individuals leading to a ‘cardiac phenotype of prematurity’  includinYoung adults born preterm at very low birth weight have smaller right ventricular dimensions and subtle differences in function measured by echocardiographic strain. Although the changes in function are small by young adulthood, this growing population warrant further research as they age to determine the trajectory of their cardiac function and understand the mechanisms of these differences and evaluate impact on clinical outcomes.


Background and Objective: To correlate the intraocular pressure with the postconceptional age and identify a statistically significant connection between congenital glaucoma and prematurity. Materials and Methods: The current paper is a retrospective, comparative, case-control study. Data collection featured maternal age, gestational age at birth, birth weight, and intraocular ocular pressure (IOP) measurements. Results: Forty-two eyes of 21 children underwent examination. The participants were assigned into two groups. The Preterm-Glaucoma (PG) group included eight preterm-born children diagnosed with glaucoma, whereas the Preterm (P) group was comprised of premature newborns without the aforementioned condition. There was no statistically relevant difference in birth weight (p = 0.691078) nor in mean gestational age (p = 0.752623) between the two groups. The mean IOP in the PG group was 23.813 ± 4.5493, whereas in the P group, it ranged around 13.231 ± 1.0699, p < 0.0001. Using mixed-effects models, we obtained a reduction in IOP of 0.45 mmHg per week in the first month of life. A further weekly reduction of 0.36 mmHg was achieved in the next two months. Conclusions: The mean IOP of prematurely born children decreased with age. Our findings correlate with previously conducted studies, however, the drop in IOP values exceeded any data published so far. We found no correlation between prematurity and the incidence of congenital glaucoma. Gestational age is a universal variable used to describe fetal maturation. It is defined by the number of weeks that have passed from the first day of the mother’s last menstrual cycle up until delivery .An ‘at term’ infant is born alive after 37 weeks of gestation. Any birth taking place before this date will result in a preterm-born child .Extremely preterm: <28 weeks.Very preterm: 28–32 weeks.Moderate/late preterm: 32–37 weeks [Preterm births are classified in:Every year, approximately 15 million children are born prematurely (more than 1 in 10 newborns) , and oveAlthough more than 60% of preterm births occur in Africa and South Asia, prematurity is truly a worldwide issue. Nevertheless, low-income countries have higher preterm birth rates when compared to more developed ones (12% versus only 9%), and within each country, poverty is one of the leading factors to influence prematurity .Preterm labor is now regarded as a syndrome initiated by multiple mechanisms, including infection or inflammation, uteroplacental ischemia or hemorrhage, uterine overdistension, stress, and other immunologically mediated processes . NeverthCongenital glaucoma is an uncommon ocular condition and one of the main causes of blindness in children. It commonly occurs among communities that encourage consanguinity  and may A surgical approach is the only feasible treatment and should be carried out as soon as possible after a diagnosis has been established. However, the available procedures are some of the most difficult and complex in glaucoma surgery ,12. ChilIn this regard, other systemic abnormalities that may accompany preterm births only add a further burden to the surgical and postoperative strategy. One study carried out by Zertsalova et al. stated that the majority of congenital glaucoma patients were, in fact, preterm-born . This seHowever, these findings contradict the trend that we noticed in our practice, hence we decided to further study this dissimilarity.In the already published retrospective studies ,8 conducWe enrolled another 13 prematurely born infants without congenital glaucoma, who required at least 3 months of ophthalmologic follow-ups for retinopathy of prematurity (ROP) screening (group P).The study received approval from the local ethics committee.Written consent was obtained from all subjects’ parents and/or legal guardians after receiving thorough explanations for possible benefits and potential risks.Inclusion criteria encompassed the following: Preterm-born children, with (PG group) or without (P group) primary congenital glaucoma, aged 1 day to 3 years, and followed-up for a minimum of 1 year ,8.The sought-out exclusion criteria were secondary congenital glaucomas and any ocular or facial traumas, as stated in the already published studies ,8.We assessed the general ocular appearance and the patients’ visual behavior. All examinations were performed under low-dose inhalation anesthesia by the same team. The intraocular pressure (IOP) was measured using a Perkins tonometer in both groups. The PG group underwent further corneal diameter and axial length measurements, whereas the P group was assessed for retinopathy of prematurity via indirect ophthalmoscopy. Gonioscopy could not be properly performed  in all cases, hence we did not include it in our study.All patients in the PG group underwent surgery for congenital glaucoma the following day after examination ,15, whilSubjects in the PG group underwent measurements at the time of their referral for congenital glaucoma suspicion, with no prior data available. In the P group, the IOP was assessed at birth, with follow-up visits after one and three months, respectively.The aim of this study is to identify a statistically significant connection between congenital glaucoma and prematurity, as well as to correlate the variation of intraocular pressure with postconceptional age.All the cases were distributed into two groups: Eight premature patients diagnosed with congenital glaucoma (PG) and 13 preterm subjects without congenital glaucoma (P) .The number of weeks of gestation ranged between 28 and 35 weeks in both groups. In the PG group, the mean value was 31.625 ± 2.56 weeks, whereas in the P group, it arrayed around 31.308 ± 1.974 weeks .p = 0.75, >0.1 .The difference between weeks of gestation in the two groups is without statistical significance, t-test  p = 0.691 (>0.1), however, without being statistically relevant (The birth weight was higher in the PG group (1659.375 ± 420.53 g) than in P group (1586.923 ± 386.83 g), with a relevant .In what concerns sex dispersion, 11 boys and 10 girls were assigned to the two groups: Three boys (37.5%) and five girls (62.5%) in the PG group, respectively, eight boys (61.54%) and five girls (38.46%) in the P group. .p > 0.1, thus without any statistically significant differences.Comparing the values in each group, we have a Fischer test of p values were not statistically significant between groups > 0.99 (Fischer’s Exact Test). The cause that led to premature birth was specified in each subject’s hospitalization form .Maternal age at birth was assessed as well, with a mean of 29.625 ± 6.631 years in the PG group (ranging from 16 to 39 years) and around 31.076 ± 5.361 years in the P group (19 to 41 years). However, differences were not statistically significant, with a Subjects in the PG group underwent measurements at the time of their referral for congenital glaucoma suspicion, with no prior data available. Thus, the variable used for time positioning of the IOP values was the mean age at the moment of diagnosis (expressed in months) = 3.875 ± 1.125 months.p = 0.063924,), employing an independent t-test. As the mean age was akin, without any statistically important dissimilarities between the two groups, we proceeded to analyzing the mean IOPs.In the P group, the IOP was assessed at birth, with follow-up visits after one and three months, respectively. To evaluate the differences in IOP between the two groups, we used the mean IOP in the PG group and the mean IOP at three months from the P group. In order to ensure a relevant outcome, the mean ages of the groups were tested for any significant differences : 14.858 ± 1.985, range = (11–21).IOP RE : 14.743 ± 1.697, range = (11–18).IOP LE : 14.974 ± 2.253, range = (11–21).Two values (2.56%) have been bigger than 20 (21 mmHg) at birth, decreasing in the next period.Dividing IOP in percentiles (P10–P90) by age, in P group, we obtain :p-value = 0.000010, 95% CI, −2.487959, −1.127426) between birth and one month,1.807692  between birth and three months,3.346154 , birth—one month1.307692 , birth—three months2.923077, birth—one month2.307692 , birth—three months3.769231(And for LE:p < 0.001).Thus, an important decrease in IOP values can be noticed over time. This observation is statistically significant . This finding was also suggested by one study  using anThere is currently only a handful of studies addressing this issue, all of which have a shorter follow-up period. To our knowledge, this is the longest study assessing the IOP trend in prematurely born children. IOP measurements were performed at birth and after one and three months, respectively. The mixed-effect model was employed in order to evaluate the IOP shift, which turned out to have a statistically significant decrease with age.Ricci  evaluatep = 0.752623), variables having a higher value, but without statistical importance. The birth weight values also exceeded those of Ng et co.: 1659.375 ± 420.530596 g in the PG group, 1659.375000 ± 420.530596 g in the P group (p = 0.691078). In the aforementioned study, a mean IOP reduction of 0.11 mmHg (p < 0.001) was observed with each week of postconceptional age. In contrast, we noticed a reduction of 0.45 mmHg per week in the first month of life, and a mean reduction of 0.36 mmHg per week in the following two months.Ng et al.  measuredp = 0.047; 95% CI: −0.58 to −0.0035, decreasing from 16.3 mmHg (10.52–22.16) at 26.3 weeks to 13.1 mmHg (7.28–18.92) at 37.6 weeks [Lindenmeyer et al.  examined.6 weeks . Thus, tIt should also be stated that all of the above-mentioned studies do not take into account other variables, such as sex distribution, maternal age at birth, the type of delivery procedures, causes of premature birth, and other associated disorders.On a separate note, our study was comprised of two groups, and in one of them the preterm infants were diagnosed with congenital glaucoma (the PG group).In regards to this aspect, the current literature is still deficient. In one study, Thiagarajah et al. , stated Senthil et al.  assessedt-test p value of <0.0001. Thus, obtaining a statistically significant difference between the two values, we can state that, to our knowledge, there is no correlation between prematurity and the incidence of congenital glaucoma in this population.These studies suggest that there can be a correlation between prematurity and congenital glaucoma, justifying our search in the current paper. However, comparing the mean IOP values in our groups, 23.813 ± 4.5493 in PG group and 13.231 ± 1.0699 in the P group , we obtained a When discussing limitations, we are aware of the bias induced by the small number of patients encompassed in this start-point article and the necessity of a future, more ample study based on this research idea. Although the number of subjects included in our study may raise questions about the relevance of our statistics, it is of importance to state that most, if not all the congenital glaucoma cases in Romania are referred to the Clinical Emergency Eye Hospital in Bucharest for treatment. To our knowledge, there is no other hospital or private practice to address this illness in our country. Therefore, the current study should be regarded as an overview of the annual trend in congenital glaucoma in communities and regions similar to Romania.No correlation was found between preterm birth and the incidence of congenital glaucoma. Furthermore, it appears that in the preterm-born population, the IOP tends to decrease with age.


Globally, infant mortality has declined considerably but has remained unacceptably high in sub-Saharan Africa, especially Nigeria where infant mortality rate is 67/1000 live births. To facilitate infant mortality reduction in Nigeria, an understanding of the synergistic effect of bio-demographic characteristics of mothers known as High Risk Birth Behaviours (HrBBs) is important. We therefore investigated the influence of HrBBs on infant survival in Nigeria.n = 21,350) who had given birth within the 5 years preceding the survey. HrBBs was measured through integration of information on maternal age at child’s birth, parity, and preceding birth interval with respect to the most recent child. The HrBBs was categorized as none, single and multiple. Data were analysed using descriptive statistics, Log-rank test and Cox proportional hazard model (α =0.05).This cross-sectional study design utilized data from the 2018 round of Nigerian Demographic Health Survey. The study participants were a representative sample of women of reproductive age . Being a male, having small size at birth, failure to receive tetanus injection, non-use of contraceptives and living in the core-north (North West and North East) predisposed children to higher risk of dying before 12 months of age. The hazard ratio of infant mortality was significantly higher among infants of mothers in multiple HrBBs category  compared to their counterparts with no HrBBs.Multiple HrBBs increase the chances of dying among infants in Nigeria. Screening women for HrBBs for special health attention during pregnancy, birth and postnatal period will alleviate infant death in Nigeria. Infant Mortality which is the probability of a child dying between birth and the first birthday is one of the most useful indicators for assessing the general level of health and development of a society. It gives an overview of the functionality of a country’s healthcare system, socioeconomic situation, and the state of maternal and child health. Globally, 85 and 29% of deaths among children occurred in the first 5 years of life and during infancy respectively. More than 50 % of these deaths occurred in Sub-Sahara Africa (SSA) with Infant Mortality Rate (IMR) of 62 deaths per 1000 in 2018 [Nigeria with a population of over 200 million is one of the five countries that accounted for half of global burden of infant mortality occupying a second position after India , 3. In NHigh-risk Birth Behaviours (HrBBs) in the context of this study was defined in terms of three preventable characteristics, namely; mother’s age at delivery which can either be too young (less than 18 years) or too old (greater than 35 years), shorter or longer birth interval, and a high parity , 10. TheThe established relationship between infant mortality and birth interval has been consistent in the literature. Short and longer birth interval increased the risk of infant mortality, often referred to as a U-shape hypothesis , 20, 21 Studies have been conducted in Nigeria based on the independent analysis of maternal age at childbirth, short birth interval, high parity and infant survival . HoweverThe present study utilized 2018 Nigeria Demographic and Health Survey (NDHS) dataset. This cross-sectional and nationally representative sample survey was designed to provide information on population, maternal and child health indicators’ estimates, and fertility-related behaviours . The stuThe two-stage cluster sampling technique was used for the survey based on the sampling frame adopted from the 2006 Nigeria population and housing census. The primary sampling units, referred to as clusters, were the enumeration areas. In all, 42,000 households were sampled from 1400 clusters selected for the survey. A detailed report of the sample design and sampling procedures has earlier been published . The stuThe outcome variable of interest is the infant survival status . The survival time (months) was derived for each child aged 0–11 months using survival status at 12th month, age at death, and date of interview. Children who did not experience death as at the time of the survey were right-censored and were coded 0; otherwise, 1 in the analysis. The main explanatory variable was High-risk Birth Behaviour (HrBBs) derived from mother age at childbirth < 18 years or > 34 years, preceding birth interval < 24 months or > 59 months, and number of children ever born > 4. An indicator variable was generated for each of the three risky behaviours: mother age at childbirth was coded as 1 if age < 18 years or > 34 years, 0 otherwise; birth interval coded as 1 if interval < 24 months or > 59 months, 0 otherwise; children ever born as 1 if parity ≥5 and 0 if otherwise. The sum of the indicator variables was 3, 2, 1 or 0; ≥2 was categorised as multiple, 1 as single and 0 as non-high-risk birth behaviours.Other covariates that were considered important according to literature and were included in the analyses include: household/environmental characteristics , child/mother characteristics , and health service-related characteristics  .Cox proportional hazards (CPH) model: The CPH modelled the hazard function as the dependent variable to determine which combination of explanatory variables significantly affects the hazard. We thus expressed the CPH model with the predictors as:Descriptive statistics and survival analysis were used for the analysis. Data were weighted before use due to the complex sampling design used during data collection in order to adjust for differences in population sizes of each region in Nigeria. Weighting the data will extrapolate the analysis output to other areas not covered during the survey in order to enhance generalizability of the study’s findings. At univariate level, descriptive statistics were used to describe infant mortality by the key variable (high-risk birth behaviours status) and other selected covariates. The log-rank test was used to examine the relationship between survival status and the selected characteristics. The crude Cox PH model was used to explain the relationship between infant mortality and high-risk birth behaviours. bj - vector of the coefficients of the explanatory variables,h0(t) - baseline hazard function andj indicates the changes in the expected time to infant death due to a unit change in the jth predictor. The exponentials of the coefficients suggest the tendency of exposure to infant death; thus, HR > 1 indicates higher exposure, HR < 1 lower exposure and HR = 1 equality.The coefficients bp < 0.20) based on the log-rank test. The HRs and their respective 95% confidence intervals (CIs) were reported. In each of the models, Akaike Information Criteria (AIC) and Bayesian Information Criteria (BIC) values were also reported for model comparison; the model with the least value was adjudged as being more adequate [Amidst other independent variables, four adjusted Cox PH models 1–4 were fitted. Models 1–3 encompassed variables to define household, child/maternal, and health service-related characteristics along with preceding model(s) significant variables, respectively; while model 4 included all the significant factors  was statistically significant.In Fig. Figure p < 0.05). Specifically, the prevalence of infant death was common among mothers who did not use contraceptive (4.6%) relative to contraceptive users (1.9%). Children who were male (4.5%), of small size at birth (5.5%), born via caesarean (6.1%), and did not receive tetanus injection (5.4%) were more prone to infant death compared to their respective counterparts. Similarly, the prevalence of death was higher among infants whose mothers were uneducated (4.7%) and had zero visit to ANC (5.0%). Also, children from the North west (4.7%) and of Hausa/Fulani tribe (4.7%) were more vulnerable to die during infancy  has yielded progress in most parts of the world except in sub-Sahara Africa where infant mortality is still unacceptably high and account for more than 50 % of global infant death. Sadly, Nigeria is one of the five countries of the world that account for this poor statistic. Infant survival has been unduly affected by several preventable factors such as health/environmental related conditions, socio-demographic and biological characteristics of the mothers. Most importantly, the bio-demographic characteristics of mothers which is referred to as High-risk Birth Behaviours (HrBBs) has a strong impact on infant survival. This study therefore examined the influence of the combination of these three risk factors on infant survival in Nigeria.Our findings showed that the higher the number of HrBBs engaged by infants’ mothers, the higher the likelihood of the infant mortality. Similar studies conducted in Nigeria substantiates this finding , 27. A nFurthermore, the effect of a short birth interval of less than 24 months has been shown to affect infant survival, this harmful effects of a non–optimal preceding birth interval are concentrated in early infancy . High paAdditionally, other predictors of infant death found in our study were being a male child, mothers who did not receive tetanus injection, babies with small birth size, delayed breastfeeding initiation and unskilled birth attendant . This is consistent with research findings from similar studies , 30, 31.Other socioeconomic factors that influence infant deaths were; mothers who had primary or no formal education level, region of residence and ethnicity. Research has documented that education offers mothers increased access to health information and connections with resources for infant health; services, healthcare professionals and effective use of the health care system –35. EducOur study also found that non-use of contraceptive commodities among the mothers increased the risk of infant mortality as compared with mothers that used contraceptives. Non-use of contraceptives expose women to the risk of unplanned and undesired births which may account for high parity and subject the infants to neglect and improper care especially in the midst of ravaging poverty . This fuAside the sampling errors that can limit the extent to which the findings from this study can be generalized to the entire population, the cross-sectional nature of the data used for this study inhibits the causal relationship between HrBBs and infant mortality. To attribute infant death to high risk birth behavior, further studies that will use cohort or quasi-experimental design approach are thus recommended. The use of a large nationally representative data remains a strength of this study.HrBBs is an important predictor of infant mortality and multiple HrBBs increase the chances of death among infants in Nigeria. Screening women for HrBBs for special health attention during pregnancy, birth and postnatal period is essential in alleviating infant death in Nigeria. It is important to create awareness and health education for women, men and families on risk factors of infant deaths such as maternal age, short birth interval and high parity . There is also a need to design interventions to improve female education and economic empowerment which could delay age at marriage for woman till 18 years, when they are matured to take decisions and capable of reproductive health events. At the same time, women will benefit from more awareness and counselling on the risks associated with late childbearing.


Fibroids are present in approximately one in ten pregnancies and are inconsistently linked with preterm birth. We sought to determine the association between fibroids and preterm birth in a prospective cohort with standardized research ultrasounds for characterizing fibroids in early pregnancy while accounting for the clinical paths that precede preterm birth.Participants who were pregnant or planning a pregnancy were recruited from communities in three states between 2000 and 2012. Members of this prospective cohort had a research ultrasound in the first trimester to establish pregnancy dating and to record detailed information about the presence, size, number, and location of fibroids. Baseline information from time of enrollment and a detailed first trimester interview contributed key information about candidate confounders. Birth outcomes, including clinical classification of type of preterm birth  were cross-validated from participant report, labor and delivery records, and birth certificate data.Among 4,622 women with singleton pregnancies, 475 had at least one fibroid (10.3%) and 352 pregnancies resulted in preterm birth (7.6%). Prevalence of fibroids was similar for women with preterm and term births (10.2% vs. 10.3%). Fibroids were not associated with increased risk of preterm birth after taking into account confounding  nor any clinical subtype of preterm birth. No fibroid characteristic or combination of characteristics was associated with risk.If fibroids increase risk of preterm birth, the effect is substantially smaller than previous estimates. Given lack of effect in a large population of women from the general population, rather than higher risk academic tertiary populations previously most studied, we encourage a reconsideration of the clinical impression that presence of fibroids is a major risk factor for preterm birth. Approximately 10% of women have a uterine fibroid detectable by ultrasound in the first trimester , yet effPreterm birth is commonly treated as a single outcome. However, multiple etiologic pathways contribute to preterm birth, including spontaneous onset of labor, preterm premature rupture of membranes, and medically indicated delivery for maternal or fetal complications , 24. EacWe sought to characterize the association between fibroids and preterm birth in a community-based cohort of women with standardized imaging for fibroid characterization during early pregnancy. We also evaluated the association by clinical subtype of preterm birth with the hypothesis that fibroid status would relate differently to risk of spontaneous versus medically indicated preterm birth.Right from the Start is a prospective, community-based pregnancy cohort that recruited women who were pregnant or planning a pregnancy from three states  between 2000 and 2012 [and 2012 . Study rand 2012 , fibroidand 2012 , fibroidand 2012 , and fiband 2012 .Participants completed a baseline interview upon enrollment and a detailed computer-assisted telephone interview in the first trimester. Interviews collected basic demographic information, maternal medical history, reproductive history, and health-related behaviors during early pregnancy.Participants had a transvaginal ultrasound for fetal viability assessment, gestational age confirmation, and fibroid characterization. Ultrasounds were performed at a median of 57 days’ gestation . Study sonographers with at least five years of obstetric experience followed a detailed protocol for fibroid assessment, which required three sets of caliper measurements for each fibroid’s length, width, and height. Fibroid volume was calculated using the formula for an ellipsoid. Sonographers took multiple images with caliper markings of all fibroids and completed a fibroid map, which indicated fibroid location  and type. Fibroid type was classified as submucosal (distorting or in contact with the uterine cavity without myometrium between fibroid and endometrium), intramural (within the myometrium without distorting the uterine cavity), subserosal , or pedunculated . Obstetrician investigators masked to pregnancy outcome assessed all images. Gestational age was based on self-reported last menstrual period (LMP) if within seven days of ultrasound predicted gestational age, otherwise ultrasound predicted gestational age was used. Maternal height and weight measured at ultrasound appointment were used to calculate body mass index (BMI).Participants were followed until pregnancy outcome, which was self-reported and validated by medical and birth certificate records. We defined preterm birth as live birth at less than 37 weeks’ gestation. We categorized preterm birth into three distinct subtypes using hospital records or vital records. Spontaneous preterm labor was defined as onset of spontaneous preterm contractions leading to a preterm birth. Preterm premature rupture of membranes (PPROM) was defined as preterm birth following spontaneous rupture of membranes with subsequent onset of labor. We defined medically indicated preterm birth as labor induction or cesarean birth in the absence of preterm labor or PPROM for maternal or fetal conditions such as pre-eclampsia, fetal growth restriction, or fetal distress. We used the term spontaneous preterm birth to refer to births resulting from either preterm labor or PPROM.In a secondary analysis, we evaluated preterm birth categories by gestational age. We defined late preterm birth as deliveries occurring for any indication between 34 weeks and 0 days and 36 weeks and 6 days, early preterm birth as deliveries occurring between 28 weeks and 0 days and 33 weeks and 6 days, and very early preterm birth as deliveries occurring prior to 28 weeks.p-value 0.001), were younger , and were more likely to be black  compared with participants observed until pregnancy outcome. A total of 4,622 women were included  . If a woa priori to include maternal race/ethnicity  and age (continuous) in all adjusted models. Other potential confounders  were retained in the final model if their inclusion resulted in a 10% change in the association between fibroids and preterm birth. We tested for effect modification of the relationship between fibroid status and preterm birth by maternal race/ethnicity using the likelihood ratio test. Stratified estimates were reported if the test suggested effect heterogeneity (p<0.15).We used log-binomial generalized linear regression models to calculate crude and adjusted risk ratios (RRs) and 95% confidence intervals (CIs) associated with overall preterm birth risk for fibroid presence, fibroid number, total fibroid volume (quartiles), largest fibroid volume (quartiles), fibroid type, and location. We also quantified the association between fibroid presence and preterm birth subtypes: spontaneous preterm birth as preterm labor and PPROM and medically indicated preterm birth. We decided We did not consider history of preterm birth a confounder in the primary model since fibroid status in prior pregnancies could have impacted prior pregnancy outcome , 36. InsWe performed a series of secondary analyses evaluating the association between fibroid presence, number, type, size, and location with late preterm, early preterm, and very early preterm birth using both chi-squared testing and log-binomial generalized linear regression models. We also evaluated the relationship between fibroids with different combinations of characteristics  and risk of overall preterm birth. We performed all analyses in Stata .p=0.34, Wilcoxon rank-sum test). Among preterm births, 88% were late preterm (n=309), 29 were early preterm, and 14 were very early preterm.Among 4,622 women, 475 had at least one fibroid on research ultrasound 10.3%) and 352 had a pregnancy ending in preterm birth (7.6%). This population included mostly white or black, non-Hispanic women  from a range of household income and education levels. Forty-eight percent of women were nulliparous and 8.2% reported a prior preterm birth. A notable proportion of women were overweight or obese at pregnancy onset (43.4%) and few smoked (3.5%). Women who were older than 35, black, or obese were more likely to have fibroids  and the median volume of the largest fibroid was 4.64 cm3 . Forty-four percent of women with fibroids had at least one intramural fibroid, compared to 42.3% with at least one subserosal and 14.5% with at least one submucosal fibroid. Twenty-one percent of women with fibroids had multiple fibroid types. Fibroid characteristics were similar when comparing women with preterm birth and those who delivered at term . Fibroid number, volume, type, or location were not associated with preterm birth. We did not identify any combination of fibroid characteristics related to increased risk of preterm birth. When compared to women without fibroids, women with multiple intramural fibroids, intramural fibroids >3 cm in diameter, or multiple fibroids >3 cm in diameter were not at increased risk of preterm birth .Prevalence of fibroids in pregnancies ending in preterm and term birth was 10.2% and 10.3%, respectively. Among women with fibroids, 29.3% had more than one. Median total fibroid volume was 4.78 cmPreterm birth clinical subtype was known for 60.0% of cases (n=211). Most commonly, preterm birth was secondary to spontaneous preterm labor n=83, 39.3%), followed by medically indicated delivery for maternal or fetal conditions , and preterm births after PPROM . We did not detect an association between fibroid presence and medically indicated preterm birth  or spontaneous preterm birth (adjusted RR, 1.27; 95% CI, 0.76– 2.11; Table , 39.3%, Fibroid presence or size was not associated independently with late preterm, early preterm, or very early preterm birth. However, the number of women with deliveries prior to 34 weeks of gestation was small, and therefore this cohort is inadequately powered to assess risk for early and very early preterm births.In this prospective, community-based pregnancy cohort with standardized imaging for fibroid characterization in the first trimester, we did not find evidence that fibroid presence, size, location, or number influences risk of preterm birth. Fibroids were not associated with any clinical subtype of preterm birth. If fibroids increase preterm birth risk, the effect is notably more modest than previous literature indicates.Given the null association between fibroids and preterm birth, let us consider the confidence we have in these results. Participants had a research ultrasound to determine fibroid presence, size, location, and type in the first trimester. Imaging was performed by experienced clinical sonographers using a detailed protocol to systematically characterize fibroids. This is an improvement over studies depending on maternal self-report, which fails to capture up to 80% of fibroids , 38, or We used community-based recruitment methods to enroll a cohort more representative of the general population than clinic-based studies ; though We excluded women who used reproductive technologies to conceive from this analysis. The association between fibroids and preterm birth may be underestimated if fibroid characteristics linked to infertility also drive risk of preterm birth. Nonetheless, fibroid presence, size, and type were not associated with time to pregnancy in this cohort . We did In most studies about fibroids and preterm birth –8, 10–18We did not find evidence fibroids contribute to preterm birth risk in this prospective study of more than four thousand women, nor did we detect an association between fibroids and any clinical preterm birth subtype. To abate undue anxiety among expectant mothers, we encourage a reassessment of classifying presence of fibroids as a risk factor for preterm birth among women with normal fertility.