The term “Lotus Birth” identifies the practice of not cutting the umbilical cord and of leaving the placenta attached to the newborn after its expulsion until it detaches spontaneously, which generally occurs 3–10 days after birth. The first reported cases of Lotus Birth date back to 2004 in Australia.Supporters of such a procedure claim that the newborn is better perfused, endowed with a more robust immune system and “less stressed”.However, it should be pointed out that histopathological study of the placenta is increasingly being requested in order to investigate problems of an infective nature or dysmaturity affecting the foetus, and situations of risk affecting the mother. Moreover, from the legal standpoint, there is no uniform position on the question of whether the placenta belongs to the mother or to the newborn. Lastly, a proper conservation of the embryonic adnexa is very difficult and includes problems of a hygiene/health, infectivological and medico-legal nature.The authors analyzed all these aspect in the Italian legislative framework, reaching the conclusion that Lotus Birth is inadvisable from both the scientific and logical/rational points of view. Cutting the umbilical cord is a medical act which – first by tradition and then on scientific bases – is routinely implemented in obstetric centres in all western countries. In recent years, however, a school of thought that is opposed to this tradition has emerged.According to this opposing view, birth is seen from the standpoint of the foetus, and it is claimed that clamping the cord while it is still pulsating could be harmful to the newborn. In this regard, some authors  maintainThe term was coined in 1979 to identify the practice of not cutting the umbilical cord and of leaving the placenta attached to the newborn after its expulsion until it detaches spontaneously, which generally occurs 3–10 days after birth . AccordiFrom the practical standpoint, this technique requires the mother to take her newborn baby home and to procure a sieve of appropriate size, which will be placed in a bowl and in which the placenta will be kept.The placenta will be preserved in this way for a minimum of two days up to a maximum of two weeks, during which time it will be treated with sea salt and ginger in order to improve its conservation and, at the same time, reduce the unpleasant smell that a decomposing organ inevitably produces.The first reported cases of Lotus Birth date back to 2004 in Australia . In ItalThis paper aims at providing an analysis of clinical risks, bioethical issues and medico legal aspects concerning such a procedure, in the Italian legislative framework.Embryo-foetal adnexa are defined as all those structures of the product of conception that are not part of the embryo or of the foetus. Among these, the most important in terms of its functional and morphological complexity is undoubtedly the placenta, which consists of the funiculus, the chorial disc and free membranes. The human placenta is a highly differentiated organ, which is essential for the oxygenation, hydration and nutrition of the foetus, in addition to carrying out a complex endocrine activity.With regard to its structural aspects, the chorial disc comprises the cotyledons (made up of villous branches), the chorion and part of the amniotic sac . On the maternal side, at the apex of the cotyledons, there are more or less extensive flaps of basal decidua that remain attached at the moment of expulsion.In the gravid uterus, the basal decidua is composed of a spongy layer that borders on the myometrium and a compact layer made up of decidualised stromal elements and a few cells of trophoblastic origin (extra-villous intermediate trophoblast). The basal decidua is separated from the cotyledons that make up the chorial disc by a fibrinoid layer, called Nitabuch’s stria . The vasThe placenta is therefore an organ of a “haemochorial” villous nature . in whicSituated above the chorial layer, the amnion lines the foetal side of the placenta and folds back on the funiculus, enveloping it up to its insertion at the umbilicus of the foetus, where it is in continuity with the skin. A thin layer of decidua modified by the extra-villous intermediate trophoblast remains, instead, adherent to the maternal side of the chorial disc .As mentioned above, the placenta is composed of the amniotic sac, the funiculus and – predominantly – the chorial disc, and accompanies the foetus up to the time of birth. Only then does the newborn become separated from the placenta, thus abandoning that part of himself that was previously indispensable, and with which he constituted an inseparable unit – the foeto-placental unit .First of all, it should be pointed out that histopathological study of the placenta is increasingly being requested in order to investigate problems of an infective nature or dysmaturity affecting the foetus, and situations of risk  affecting the mother . Indeed,This adaptability and the functional modulations of the chorial disc largely depend on the action of the extra-villous intermediate trophoblast, which develops in the basal decidua and modifies, among other things, the structure of the spiral arteries and of the blood lacunae.The close intermixing between the extra-villous component of the trophoblast and the maternal decidual structures  has given rise to the idea that the basal decidua  is part of the placenta.This long-standing notion is erroneous and is rooted not only in medical-scientific and obstetric thinking, but also, and even more so, in the popular perception, where it has even influenced the world of culture, art and literature.products of conception”  and the “products of abortion”  are considered to be “part of the mother” and not separate individuals with their own biological-human and personal dignity. Thus, the placenta is generally regarded as a maternal organ, from which the foetus detaches only when it is capable of autonomous life, i.e. when it acquires a potential juridical personality (de facto after the first spontaneous breath) and, therefore, the right to its own individuality.This erroneous conviction is strengthened by the fact that, from a legal standpoint, under the provisions of art. 7 of Italian D.P.R. 285/90 , up to the 28th week of gestation the so-called “This means that the newborn is not granted possession of an organ which belongs to him and which can actually influence his postnatal development, so much so that foetal pathologies related to severe placental alterations, regardless of the condition of the mother, have an impact on the development and growth of the newborn and, later, of the child . Thus, tThis ambiguity means that the human placenta, once expelled, is not usually considered to be of pertinence to a human organism . It therefore becomes extraneous to the juridical property of the puerpera, and is entrusted to the healthcare facility for destruction or utilisation for diagnostic purposes.res.From the juridical point of view, this issue has been addressed by several authors. One of these, Mantovani , claims res has detached, in that this very detachment constitutes a mode of origin of ownership whereby body parts are not rendered res nullius. Moreover, according to the author, it seems that this property right should be granted with regard to any part of the body, in that there is no reason to distinguish one body part from another on the basis of either its functional importance or the way in which it is separated from the body. Only the individual subject has the freedom to regard a body part as his or her own, and hence either to keep it and to exercise the right of property over it or else to abandon it. In the case of abandonment, detached parts of the human body become res derelictae and therefore res nullius; at this point, they will either be destroyed – if they are of no scientific or diagnostic interest – or accrue to the property right of the healthcare facility, if they are of diagnostic, scientific, therapeutic or pharmaceutical interest. Thus, for what concerns the embryonic adnexa, the following considerations can be made:such anatomical parts, at the moment of detachment from the puerpera, become the property of the puerpera herself, perhaps also because she is the guardian of a minor over whom she exercises parental responsibility (together with the father);the parents are entitled to receive the adnexa from the healthcare facility or to have them examined elsewhere at their own expense (e.g. in a private clinic);if the mother and father abandon them, the adnexa become the property of the healthcare facility, of which they are at the complete disposal.This notion, however, immediately raises the question of the property right of the subject from whose body the proper conservation of the embryonic adnexa;the absence of contraindications to conservation itself, as the adnexa do not constitute a biological product falling within the provisions of article 184 of the unified body of Italian health legislation .Should the parents request that the embryonic adnexa be consigned to them for some need of their own or of the newborn, the adnexa would become a specific good which, as such, cannot but constitute an object of their property right. Thus, the problem lies rather in the real possibility to exercise this right at the practical level; it follows that the achievement of this objective requires at least two presuppositions:In the light of what has been said, there necessarily emerge problems of a hygiene/health, scientific, infectivological . and medIt should be pointed out that, from the standpoint of the law and hygiene/health, there is no reference legislation that may suggest any conceivable use of the placenta, other than consignment to the healthcare facility . LikewisFrom the medico-legal point of view, objections inevitably arise, in that, before consenting to this practice, it is necessary to create a specific model of information – one which can reconcile the needs of the mother (and father) with the juridical norms and the scientific, hygienic and deontological demands.Today, with the progressive modification of relationships between the hospital facility and the patient – to the extent of creating a so-called “social contact” – two opposing sets of rights have emerged; on the one hand, patients have the right to expect not only that their health be safeguarded, but also that their will be respected; on the other hand, the healthcare facility is entitled to safeguard its own interests and its employees. In the light of this consideration, it would be necessary to draw up a document, to be signed by the mother and father before delivery of the baby, in which they express the wish to follow the Lotus Birth protocol, on condition that the healthcare facility decides to endorse the request and is able to ensure proper execution of the technique.Nevertheless, it must be borne in mind that – once the possibility to adopt this protocol has been agreed upon – if the need arises to carry out a diagnostic investigation regarding any condition whatsoever of the newborn or of the mother (previous or emerging pathology), the healthcare facility would be totally unable to perform any histopathological diagnostic examination of the placenta, notwithstanding the fact that any such examination would be right and proper and implicit in the above-mentioned contractual relationship between the hospital and the patient. Thus, it clearly emerges that, in such situations, another document would need to be signed, again before the birth of the baby, in which the parents express their wish to forgo any possible diagnostic examination, even if there is a concrete risk to the health of the newborn or the mother.post-partum period.In this regard, the need has been felt in recent years in Italy to create new procedures for monitoring the quality of the healthcare services provided and the risks connected with them. In the field of neonatology, for instance, the Ospedale Policlinico San Martino-IST in Genova, Italy, as part of its routine evaluation of clinical risk, has adopted the practice of adequately conserving the placenta until the newborn is discharged; in this way, it is possible to carry out any histological investigation that may be deemed necessary in the event of the emergence of any unforeseeable neonatal symptoms in the immediate If the principles dictated by the Lotus Birth protocol were to be applied, it would no longer be possible to carry out such investigations, owing to the inadequate conservation of the placenta. Thus, in order to avoid any conflict between the hospital’s policy of clinical risk management and the will of the baby’s mother and father, a third document would need to be signed by the couple; this would exonerate the hospital from responsibility for any untoward consequences that might arise – especially in terms of damages – should any failure to diagnose any neonatal pathology be attributable to the non-examination of the placenta.Finally, in addition to the issues of responsibility evoked by implementation of the Lotus Birth protocol, it must also be noted that the scientific bases on which the practice is founded are scant, indeed almost non-existent.The issue of performing the Lotus Birth, on maternal request, also solicits ethical considerations.The motivation towards choosing the Lotus Birth is the achievement of a natural birth. Cutting the umbilical cord is, indeed, seen as a violent act.Moreover, a woman may request the Lotus Birth practice in order to exercise her right to individual choice and self-governance. However, the ethical principle of autonomy also requires that the woman  is/are adequately informed and aware of the implications underlying such a choice.First of all, the physicians will inform the mother about the fact that the Lotus Birth requires the primary caregiver remaining close to a bag of decomposing flesh, and it keeps her homebound as she cares for the newborn until the umbilical cord detaches.In addition, physicians should caution that in the literature there is no compelling evidence that the baby benefits from having a discarded organ attached to him/her for days, while, there is a lack of research regarding its safety .As a matter of fact the newborn is at a very delicate stage and he/she is very prone to diseases as his/her immune system is not developed so far. By keeping the umbilical cord attached, the environmental micro-organisms have a big chance of affecting the dead tissue.Accordingly, the control over one’s own body and individuality, expressed in the increasing appreciation of the ethical principle of autonomy, cannot separate itself from the careful evaluation of the principles of non-maleficence and beneficence . These pFurthermore, the prudent assessment of benefits, burdens, and harms in health care decision-making impose the exclusion of the application of this procedure in the hypothesis in which the child is at high risk .In fact, if it is true that certainty is not always valid in the medical field, in the hypothesis of certainty of risks to the health of the child, this procedure appears ethically inadmissible.In this sense a thorough, rigorous and responsible information to the community can help to promote a culture based on scientific evidence, removing uncritical beliefs.post-partum period, care must be taken to manoeuvre the baby correctly in relation to the position of the placenta, which, immediately after delivery, is still an integral part of the newborn’s blood circulation. Indeed, brusquely lifting the baby up (for the mother to see) will cause a rush of blood towards the placenta, which, at that moment, is in a lower position. This may result in rapid anaemia of the newborn. Indeed, it is for this very reason that great care has always been taken to clamp the funiculus while maintaining the placenta on a higher plane than the newborn, so that the baby will not be deprived of foetal blood;given that the placenta is a reservoir of blood for the newborn, at the moment of delivery and in the early that said, inappropriate mobilisation of the newborn, or of the placenta, without clamping, could cause deficient neonatal perfusion.In conclusion, in the light of what has been expounded above, it can be claimed that the practice of Lotus Birth is inadvisable from both the scientific and logical/rational points of view. If, however, we wish to underline the only meritorious principle of this procedure, i.e. the emphasis placed by its advocates on the importance of safeguarding the blood supply of the newborn, we may mention the following aspects:post-partum could facilitate the formation of clots. Similarly, cases of idiopathic neonatal hepatitis following Lotus Birth have been described in the Literature [at present, the practicee of lotus birth is new to the UK and there is a lack of research regarding its safety” [On the other hand, it must also be pointed out that, if the Lotus Birth “guidelines” are followed to the letter, the lack of clamping could give rise to a potential thrombotic risk, in that the establishment of a low-flow, low-resistance circulation, like that of the foetus-placenta terature . These a safety” .Regulation governing the management of medical waste pursuant to Article 24 of the Law of 31 July 2002, n. 179”). In this regard, it should be borne in mind that non-compliance with hygiene/health provisions is a penally prosecutable offence under the terms of article 650 of the Italian Penal Code regarding provisions of public authorities. This may constitute a compelling disincentive for expectant mothers to pursue the logic of Lotus Birth.Nevertheless, regardless of the above-mentioned risks, it would seem that the healthcare facility cannot refuse to consign the placenta to the mother if she explicitly requests it, unless doing so were to engender a risk for the hygiene of the hospital environment and for public health (according to Italian D.P.R. 254/03: “Lastly, the importance of adopting informed forms is crucial, and a mutidisciplinary group is working on it.


The aim of the study was to identify the risk factors for preterm birth in public hospitals of the central zone, Tigray, Ethiopia 2017/2018.A total of 88 neonates who born preterm (cases) and 176 neonates who born term (controls) with their index mothers were included making a response rate of 100%. About 84/88 (95.5%) mothers in cases and 173/176 (98.3%) in control had antenatal care follow up. Among them, 33 (39.3%) cases and 102 (58%) controls were had antenatal care follow up four times and above. In multiple logistic regression at P-value < 0.05, mothers with ANC follow up less than four [AOR 95% CI 2.15 ], mothers with pregnancy-induced hypertension , multiple pregnancy , fetal distress  and birth defect  were independent risk factors of preterm delivery. Preterm birth is demarcated as a delivery which occurs at less than 37 completed weeks of gestation or fewer than 259 days . It is cWorldwide approximately 15 million babies are born too soon every year as a preterm birth and more than 60% of them were in sub-Saharan Africa and South Asia where health systems are weak in access and minimum health services utilization . Even thPreterm birth is the biggest cause of neonatal mortality worldwide and the second leading cause of underage five child deaths following pneumonia , 7, 8. TThere is an intense survival gap for premature babies depending on where they are born , 10. PreBeing born preterm is a risk factor that put infants at higher risks of chronic diseases and death later in life . Babies Socio-demographic factors, obstetric and gynecological-related factors, maternal medical disorder and common medical problems in neonates were some of them , 14–16. Global progress for child survival and health cannot be achieved without addressing preterm birth . This paDespite the increase in ANC coverage and recommended guidelines for maternal and neonatal care, the number of preterm birth is increased through time. Even if there are limited studies which show the risk factors of preterm birth through the card review in some part of Ethiopia, the risk factors are different in different settings because of the difference in the healthcare system and demographic features. Consequently, this study was aimed to identify the risk factors for preterm birth in the central zone of Tigray.The study was carried out in public hospitals of central zone Tigray, which has three hospitals named as St. Marry Hospital, Adwa Hospital, and Abyi Adi Hospital. We include 25 cases and 50 controls in Abyi Adi Hospital, 30 cases and 60 controls in Adwa Hospital and 33 cases and 66 controls in St. Marry Hospital. Data collection period was undertaken from December 2017 to February 2018.A hospital-based un-matched retrospective case–control study design was employed.All mothers who gave birth in public hospitals of the central zone of Tigray.For cases All mothers with alive PTB (28 to < 37 weeks) in public hospitals of the central zone of Tigray.For controls All mothers with full-term birth (≥ 37 weeks) at the same hospitals.A double population proportion formula  was used with 95% confidence level, 80% power and proportion of controls with exposure of previous history of preterm birth 36.36% , odds raData was collected using interviewer-administered pretested semi-structured questionnaires and data recorded. The questionnaires were taken from different related studies , 16–18 aTraining was given for data collectors and the questionnaires were pretested on 5% of the sample size at Suhul Hospital prior to the data collection period. Continuous follow-up and supervision were made by the supervisor and principal investigator. All participants were interviewed privately.Preterm birth.Maternal socio-demographic factors, gynecologic and obstetric related factors, maternal medical history of disorders, maternal emotional stress, infant’s characteristics. Those information was obtained by face to face interview and record files.Preterm birth Those who born in < 37 weeks.Gestational diabetes mellitus Fasting plasma glucose ≥ 126 mg/dl.Pregnancy-induced hypertension Systolic blood pressure ≥ 130 mm Hg and/or Diastolic blood pressure ≥ 90 mm Hg.Anemia Hemoglobin < 11.0 g/dl.Oligohydramnios Amniotic fluid index < 8.The data was cleaned, entered and edited using EPIDATA version 3.1 statistical software, then exported to SPSS Version 22.0 for analysis. Results were presented using tables and texts. Hosmer–Lemeshow test was used to check the appropriateness of the model for analysis. Variables which were show statistical significance during bivariate analysis at P-value ≤ 0.25 were entered to multivariable logistic regression. Adjusted odds ratios (AOR) with 95% CI, were estimated to assess the strength of associations and statistical significance was declared at a P-value < 0.05.In this study, all the study participants were accepted to be part of the study which includes 88 preterm neonates (cases) and 176 term neonates (controls). The mean (± standard deviation) age of mothers was 27 ± 6 years’ ranges from 17 to 45 years. Most of the respondents 80 (90.9%) cases and 166 (94.3%) controls were orthodox. Regarding marital status, 79 (89.8%) cases and 161 (91.5%) of controls were married. About 60 (68.2%) of cases and 131 (74.4%) of controls were housewives by occupation and 25 (28.4%) cases and 46 (26.1%) of controls were not able to read and write (Table In our study 84 (95.5%) cases and 173 (98.3%) were had ANC follow up. Among them, 33 (39.3%) cases and 102 (58%) controls were had ANC follow up four times and above. Moreover, 64 (72.7%) newborn from the cases and 139 (79%) controls were born through Spontaneous vaginal delivery. About 50 (56.8%) cases and 50 (28.4%) of controls had one or more of pregnancy-related complications. Regarding the maternal emotional stress about 3 (3.4%) cases and 9 (5.1%) controls had maternal emotional stress, and 35 (39.8%) mothers in cases and 59 (33.5%) mothers in controls had lack of social support. About 13 (14.8%) cases and 19 (10.8%) of controls had one or more maternal medical problems. About 30 (34%) cases and 17 (9.7%) controls had fetal distress. All preterm neonates and 13 (12.9%) of term neonates had a birth weight of < 2.5 kg. Regarding the fetal presentation, 72 (81.8%) cases and 151 (85.8%) controls were in vertex presentation. From the total study participant, about 15 (17%) cases and 9 (5.1%) of controls had a birth defect . Mothers with pregnancy-induced hypertension were about three times higher to give preterm birth than those who had no hypertension . The odds of a mother with multiple pregnancies were about two times more to give preterm birth than mothers with single pregnancy . Neonate with fetal distress during labor and delivery were about four times higher to be preterm than those who had no fetal distress  and those who have birth defect were about three times higher to had a chance of preterm birth  (Table .85. MothThe study was aimed to assess the risk factors for preterm birth in order to tackle the burden of the disease and its associated problems.The lack of ANC diminishes the chance of identifying risks and provide appropriate interventions towards prevention of preterm delivery. Our finding revealed that women who follow ANC less than four times were about two times more to give preterm delivery as compared to women who attended ANC four times or more. This is consistent with the study done in Tanzania , DebremaOur study revealed that mothers who had pregnancy induced hypertension had three times increased the risk of having a preterm birth than those mothers without pregnancy-induced hypertension. This finding is in line with studies conducted in Gondar , DebremaWe found that mothers with multiple pregnancies had more than twofolds increasing the likelihood of having preterm delivery as compared to mothers with singleton delivery. This is consistent with the study done in Tanzania , south-wIn our finding the likelihood of preterm delivery among birth defect neonate were three times more significant than those who had no any birth defect. This could be due to the interaction of genetic and environmental risk factors contribute to preterm delivery. Identification of specific modifiable risk factors should be an important research and public health priority.In this study, we find that fetal distress was about four times more significantly associated with preterm delivery. This finding is consistent with the study done in Jakarta . Fetal dThe commonest obstetrical risk factor for preterm birth was hypertensive disorders of pregnancy and multiple pregnancies. Regarding to neonates, fetal distress and birth defect were the significant variables with preterm delivery. Early detection and treatment of diseases or disorders among pregnant women as well as the improving health care quality delivered to pregnant women may reduce risk factors for preterm delivery.Our study is limited to hospital-based quantitative study. It would be better if qualitative approach study was triangulated to investigate further factors on preterm birth.


Analysis of 3.9 million birth records reveal spillover effects of police killings on the health of black infants. Police use of force is a controversial issue, but the broader consequences and spillover effects are not well understood. This study examines the impact of in utero exposure to police killings of unarmed blacks in the residential environment on black infants’ health. Using a preregistered, quasi-experimental design and data from 3.9 million birth records in California from 2007 to 2016, the findings show that police killings of unarmed blacks substantially decrease the birth weight and gestational age of black infants residing nearby. There is no discernible effect on white and Hispanic infants or for police killings of armed blacks and other race victims, suggesting that the effect reflects stress and anxiety related to perceived injustice and discrimination. Police violence thus has spillover effects on the health of newborn infants that contribute to enduring black-white disparities in infant health and the intergenerational transmission of disadvantage at the earliest stages of life. On 9 August 2014, Officer Darren Wilson of the Ferguson Police Department fatally shot Michael Brown Jr., an 18-year-old African American man, in the city of Ferguson, Missouri, a suburb of St. Louis. The event and other well-publicized cases in 2014 brought renewed and national attention to police killings and police use of force more broadly. Recent data show that police kill about a thousand individuals each year in the United States and approximately 100,000 are admitted to hospital emergency rooms for nonfatal injuries inflicted by law enforcement officers . The detailed geographic information on mothers’ residential location, together with the comprehensive dataset on police killings, makes it possible to study the effect of police killings during pregnancy in the residential environment on infant health. The analysis restricts the sample to singleton, in-state births to California residents and excludes cases with missing information on key variables. Restricting the sample to singleton births is important considering that twins and other multiples have lower birth weight and worse health at birth. Tables S1 to S3 show summary statistics for the sample of births. Materials and Methods includes further details on the data.Estimating the effect of police killings on infant health is challenging because police killings are not random. They are linked to crime and other neighborhood characteristics, which might also affect birth outcomes. To overcome this challenge, this study relies on a preregistered, difference-in-difference (DD) approach with and without sibling comparison , redefining the time periods for exposure before and after pregnancy to cover 3 instead of 6 months (table S8) and addressing posttreatment selection bias related to residential mobility, miscarriage, and abortion (see Supplementary Text). The results confirm the main conclusions discussed here.The results provide causal evidence suggesting that extreme forms of police violence have broader consequences and spillover effects on the health of newborn infants. In utero exposure to police killings of unarmed blacks in the residential environment markedly reduced the health of black infants but not for other groups. Exposure to a single police killing of an unarmed black individual during pregnancy accounts for as much as a third of the black-white gap in birth weight. This finding indicates that police violence is an environmental stressor that contributes to the stark and enduring black-white disparities in infant health and therefore the intergenerational transmission of disadvantage at the earliest stages of life. Birth weight and gestational age are not only related to infant death in the short term  with information about birth weight and gestational age at birth as key measures of infant health, the date of birth, exact information on mothers’ residential location, and key maternal demographic characteristics such as race and ethnicity. For the geocoding of addresses on birth records, the ArcGIS Desktop geocoder was used. To identify full siblings in the sample, the study followed the procedure used by Liu The second data source is incident-level data on police killings in California between 2005 and 2017. These data rely on Fatal Encounters  estimator for multiple high-dimensional categorical variables based on the lfe package in R . The model includes a stable neighborhood effect πcj that controls for mean differences in birth outcomes across census tracts and a year-by-month time effect ηt that captures differences in birth outcomes over years and months  that are constant across all births such as seasonal fluctuations or general time trends. In addition, the model includes county-specific, linear time trends γcyear that captures different temporal trends in birth outcomes across California’s 58 counties. The vector Xicjt consists of maternal and child characteristics. It includes sex of child coded as 0 for male and 1 for female, mother’s age , mother’s education , and child parity .The DD approach leverages millions of birth records from California to compare changes in birth outcomes for black infants in exposed areas born in different time periods before and after police killings of blacks to changes in birth outcomes for control cases in unaffected areas. In particular, the models distinguish nine time periods for mothers exposed to a police killing 18 to 13, 12 to 7, and 6 to 1 months before pregnancy; those who are exposed during pregnancy by first, second, and third trimesters; and those who are exposed 1 to 6, 7 to 12, and 13 to 18 months after pregnancy. The regression models use clustered standard errors on the neighborhood level to address potential serial correlation problems , and exposure during different time periods after pregnancy. All nine indicator variables are binary and coded as 1 if at least one police killing occurred during the specific time interval and within k kilometers of mother’s residence and 0 otherwise. Multiple of the nine indicator variables can be coded as 1 if multiple police killings occurred within k kilometers.The second is a set of nine indicator variables that measures the timing of maternal exposure to police killings of unarmed blacks within a specific distance jD, where j ranges from −3 to −1. While birth outcomes might be affected by exposure to police killings before pregnancy, infants are not exposed in utero.The three indicators for exposure before pregnancy are the time periods 18 to 13, 12 to 7, and 6 to 1 months before pregnancy. They are designated as k kilometers of mother’s residence. They are defined as exposure during the first trimester D0, second trimester D1, and third trimester D2 of gestation. The three terms are the key treatment indicator and estimate the effect of maternal exposure to police killings by trimester of gestation. Trimesters are defined as consecutive 12-week intervals before the date of birth. This definition deviates from the medical definition based on the LMP. It ensures that the lengths of the third trimester and therefore the likelihood of exposure to police killings do not depend on gestational age, introducing a mechanical correlation between the treatment and outcome in the data  and after (r > 2) pregnancy make it possible to evaluate the common trend assumption indirectly. However, time-specific, neighborhood-level factors that are related to police killings and birth outcomes still threaten the identification strategy. Unobserved trends in crime rates or policing may account for both police shootings and changes in birth outcomes. From this perspective, a potential effect on birth outcomes is not caused by exposure to officer-involved killings but instead by changes in crime rates that increase police activity and officer-involved killings. While the model accounts for county-specific linear trends in birth outcomes and the specification of the exposure variable focuses on the 9 months of pregnancy, local crime waves  that coincide with police killings are a potential threat to the identification strategy particularly because previous research links crime with birth outcomes . The estimates δTo address this concern, I compare the effect of maternal exposure to police killings of unarmed blacks to the same effect for exposure to police killings of armed blacks. This falsification test rules out alternative explanations related to crime and other confounders (


Low birth weight (LBW) has been associated with subsequent risks of obesity and certain chronic diseases, but evidence for the associations is limited for the Chinese population.In this study we analyzed data from two population‐based prospective cohort studies, the Shanghai Women's Health Study and the Shanghai Men's Health Study, to examine the associations between LBW and the risk of obesity and chronic diseases. Birth weight was self‐reported at baseline; anthropometric measurements were made at study enrollment. Type 2 diabetes mellitus (T2DM) diagnoses were self‐reported, whereas hypertension diagnoses were based on self‐report and blood pressure measurements at baseline and follow‐up surveys.P < 0.05 for non‐linearity), and LBW was linked with lower BMI, smaller WC, and larger WHR and WHtR. An excess risk of T2DM was observed for LBW (<2500 g) versus birth weight 2500–3499 g since baseline  and since birth , whereas the HRs for hypertension since baseline and birth were 1.13 (95% CI 1.01–1.27) and 1.20 (95% CI 1.11–1.30), respectively. The risk of the diseases decreased as birth weight increased up to ~4000 g; further increases in birth weight did not convey additional benefits.Birth weight was available for 11 515 men and 13 569 women. Non‐linear associations were observed for birth weight with baseline body mass index (BMI), waist circumference (WC), waist:  hip ratio (WHR), and waist:  height ratio (WHtR; The results suggest that LBW, an index of poor intrauterine nutrition, may affect health risks later in life in the Chinese population. HighlightsLow birth weight was linked with lower body mass index, a smaller waist circumference, and larger waist:  hip and waist:  height ratios in the Chinese population.The non‐linear pattern of associations between birth weight and body size in adulthood in this population, as well as the higher risks of type 2 diabetes mellitus and hypertension in men and women with low birth weight, suggest that nutrition in early life is of considerable importance to health in later life. Epidemiologic studies conducted in both developed and developing countries, including Scandinavia,China has been experiencing an extremely rapid nutritional transition and has witnessed a sharp rise in the prevalence of obesity, T2DM, and hypertension over past half century, particularly during the past two decades.In this study we used the data from two large prospective cohort studies conducted in China, the Shanghai Women's Health Study (SWHS) and the Shanghai Men's Health Study (SMHS), to evaluate associations of birth weight with multiple anthropometric measurements and estimate the relationship between birth weight and subsequent risk of T2DM and hypertension. The results may help us understand the causes and challenges of obesity, diabetes, and hypertension in China, and develop preventative strategies for the diseases as high priority for population health in low‐ and middle‐income countries.The SWHS and the SMHS are both population‐based prospective cohort studies conducted in Shanghai, China. Details of the study methodologies have been reported previously.At baseline, each participant completed an in‐person interview that collected information on demographics, birth weight, whether participants were breastfed as infants, lifestyle habits, dietary intake, physical activity habits, occupational history, and history of chronic diseases. The study protocols were approved by the relevant institutional review boards of all institutes involved, and written informed consent was obtained from all participants.2). The waist:  hip ratio (WHR) and waist:  height ratio (WHtR), which have been shown to be better anthropometric indicators for adult cardiometabolic risk than BMI,At baseline, blood pressure, standing height (cm), body weight (kg), and waist and hip circumference (cm) were measured by trained health professionals according to standard protocols. Blood pressure was measured on the right arm using a standard mercury sphygmomanometer after participants had rested for at least 5 min. The first and fifth Korotkoff sounds were recorded. Standing height was measured to the nearest 0.1 cm without shoes. Body weight was measured to the nearest 0.1 kg using a digital scale that had been calibrated every 6 months. Waist circumference (WC) was measured 2.5 cm above the umbilicus and hip circumference was measured at the level of maximum protrusion of the gluteal muscles. Each measurement was taken twice with a tolerance of 1 mmHg for blood pressure, 1 cm for height and circumferences, and 1 kg for weight. If the difference between two measurements was greater than the tolerance, a third measurement was taken. The mean value of the two closest measurements was used in the present analysis. Body mass index was calculated as weight (kg) divided by height squared  were considered to have prevalent hypertension.Cohort members were followed‐up for incident T2DM and hypertension, with blood pressure measurements taking place every 2–3 years after baseline. The follow‐up surveys for both cohort studies were organized by local health authorities. Therefore, home visits could be performed by trained retired nurses, which guaranteed high response rates of cohort members. For the SWHS, the response rates for the first (2000–2002), second (2002–2004), third (2004–2007) and fourth (2008–2011) in‐person follow‐up surveys were 99.8%, 98.7%, 96.7%, and 92.0%, respectively. For the SMHS, the response rates for the first (2004–08) and second follow‐up surveys (2008–2012) were 97.7% and 91.9%, respectively.Both prevalent cases at baseline and incident cases since baseline were regarded as incident cases since birth. The vital status of participants was updated by annual record linkages to the Shanghai Vital Statistics Registry and the Shanghai Resident Registry.In all, 13 569 women and 11 515 men provided information on birth weight at the baseline survey and were included in the analyses. Participants were categorized into four groups according to birth weight , with the 2500–3499 g group used as the reference category. Entry time was considered as time since birth or age at enrollment, which were used to calculate incidence since birth and since baseline, respectively. Exit time was defined as age at death, age at diagnosis of T2DM or hypertension, or last follow‐up contact date, whichever came first. We did not observe significant heterogeneity between men and women in associations between birth weight and subsequent risk of metabolic disorders; thus, we combined the two databases in the analysis.The potential curvilinear relationships of birth weight with risk of adult obesity, T2DM, and hypertension were evaluated using restricted cubic splines functions (RCS)All analyses were performed by using SAS version 9.1 , and all tests of statistical significance were based on two‐sided probabilities.The prevalence of low birth weight (<2500 g) was 5.3% in men and 6.9% in women Table . Men witPtrend < 0.0001). However, the age‐adjusted mean WHR increased as birth weight increased, but only among men. The prevalence of T2DM and hypertension at baseline showed a U‐shaped relationship with birth weight.As indicated in Table P‐value for overall significance of <0.0001, a P‐value for linearity of 0.0043 and a P‐value for non‐linearity of <0.0001. After adjusting for BMI, WC increased as birth weight increased , whereas WHR  and WHtR  increased until birth weight reached approximately 2750 g, after which WHR and WHtR decreased as birth weight increased. In addition, WHR increased further as birth weight increased past 4000 g.Figure P‐value for overall significance <0.05), but not for that defined by WC . Moreover, the association was linear for central obesity defined by WC  and WHR , but non‐linear for that defined by WHtR .Table P‐value for non‐linearity <0.05 for the prevalence and incidence of T2DM and hypertension since birth, but P > 0.05 for incidence since baseline).As indicated in Fig. We further evaluated the associations of birth weight groups with the risk for T2DM and hypertension, and the results are presented in Table Using data from two prospective cohort studies of Chinese women and men, namely the SWHS and SMHS, we found non‐linear associations of birth weight with adult body size and risk for T2DM and hypertension. Low birth weight was generally associated with lower BMI, smaller WC, larger WHR and WHtR, and a higher risk for T2DM and hypertension. These findings are in agreement with most previous studies and indicate an important role of intrauterine nutrition in the etiology of subsequent metabolic disorders.Low birth weight has been consistently associated with lower BMI but a higher risk of central obesity and metabolic syndrome in adults.In the present study we found a J‐shaped relationship between birth weight and BMI at baseline, when participants were aged 40–74 years. Our finding of the lower birth weight–lower BMI relationship is in agreement with most previous studies conducted in Western populations,It has been suggested that adverse exposures in early life can “program” short stature and a predisposition to abdominal adiposity, as well as an insulin resistance and other cardiometabolic risk factors in adult life.Accumulating evidence suggests that poor growth in utero, and thus low birth weight, is associated with an increased risk of developing diseases such as T2DM and hypertension in later life.The present study found no heterogeneity between sexes for associations of birth weight with adult body size and related chronic diseases. This result is not consistent with a previous study in which only women exposed to famine conditions in utero or during infancy were observed to have a greater risk of developing hypertension.The strengths of the present study include the relatively large sample size and directly measured height, weight, and circumferences. However, several limitations should be acknowledged. First, birth weight was based on self‐report. We included only approximately one‐third of cohort members who answered the question on birth weight. Thus, both recall bias and selection bias are of concern. Second, a diagnosis of T2DM was also self‐reported. It is estimated that approximately half of all people with T2DM in China remain undiagnosed.In conclusion, in the present study we found that low birth weight was associated with subsequent obesity and the prevalence and risk of T2DM and hypertension in Chinese men and women. The results suggest that nutrition in early life is of considerable importance to health in later life. Low birth weight should be considered as an important risk factor for obesity, diabetes, and hypertension in the general population and can be used to identify high‐risk individuals. Moreover, the government should pay more attention to maternal health to reduce the number of babies born with a low birth weight and thus to decrease the prevalence of obesity, diabetes, and hypertension in the general population in the long run.The authors declare no potential conflicts of interest.


Seasonality of food availability, physical activity, and infections commonly occurs within rural communities in low and middle-income countries with distinct rainy seasons. To better understand the implications of these regularly occurring environmental stressors for maternal and child health, this study examined seasonal variation in nutrition and health care access of pregnant women and infants in rural South Africa.We analyzed data from the Venda Health Examination of Mothers, Babies and their Environment (VHEMBE) birth cohort study of 752 mother-infant pairs recruited at delivery from August 2012 to December 2013 in the Vhembe District of Limpopo Province, the northernmost region of South Africa. We used truncated Fourier series regression to assess seasonality of antenatal care (ANC) attendance, dietary intake, and birth size. We additionally regressed ANC attendance on daily rainfall values. Models included adjustment for sociodemographic characteristics.Maternal ANC attendance, dietary composition, and infant birth size exhibited significant seasonal variation in both unadjusted and adjusted analyses. Adequate frequency of ANC attendance during pregnancy (≥ 4 visits) was highest among women delivering during the gardening season and lowest during the lean (rainy) season. High rainfall during the third trimester was also negatively associated with adequate ANC attendance . Carbohydrate intake declined during the harvest season and increased during the vegetable gardening and lean seasons, while fat intake followed the opposite trend. Infant birth weight, length, and head circumference z-scores peaked following the gardening season and were lowest after the harvest season. Maternal protein intake and ANC ≤ 12 weeks did not significantly vary by season or rainfall.Seasonal patterns were apparent in ANC utilization, dietary intake, and fetal growth in rural South Africa. Interventions to promote maternal and child health in similar settings should consider seasonal factors. Seasonal food insecurity is a widespread yet overlooked phenomenon that particularly affects rural communities in low-and middle-income countries (LMIC) . The annA small but growing number of studies have demonstrated seasonality of birth size in LMICs, attributing these patterns to “seasonal energy stress” from concurrent food shortage, strenuous physical activity, and illness –9. HowevWe analyzed data from the Venda Health Examination of Mothers, Babies and their Environment (VHEMBE) study conducted in the Vhembe District of Limpopo Province, the northernmost region of South Africa. Many households in this area engage in subsistence crop production as a source of food, growing primarily maize, fruits, and vegetables in backyards or on small plots of land . The cliThe VHEMBE study is a prospective birth cohort that aims to evaluate the determinants and impacts of environmental exposures on child growth, health, and development. This analysis used data collected at the time of delivery, including abstracted medical records that were recorded throughout the pregnancy. Participants were recruited among women who presented for delivery at Tshilidzini hospital, in the town of Thohoyandou, between August 2012 and December 2013. All women delivering or still in the hospital on a weekday were screened . Women were eligible for inclusion if they were at least 18 years old, had contractions at least five minutes apart, spoke primarily TshiVenda (the most commonly spoken language in the area), lived within 20 km of the hospital and intended to remain in the area for at least two years, had not been diagnosed with malaria during the pregnancy and gave birth to a viable singleton. Of 920 eligible women, 152 declined to participate and 16 were lost to follow-up before full enrolment data were collected, yielding a study sample of 752 mother-infant pairs. For this analysis, sample sizes ranged from 605 to 751 due to missing outcomes data including first ANC visit date (n = 147), total number of ANC visits (n = 140), birth length (n = 6), head circumference (n = 6), birth weight (n = 1), and dietary intake (n = 1).Following recruitment at the time of delivery, trained bilingual Venda interviewers administered a structured questionnaire to collect sociodemographic characteristics and abstracted medical records. Participants were also visited at home one week after delivery, where Global Positioning System (GPS) coordinates were captured using a Garmin Etrex30 device outside the front door of the building where the mother slept. Coordinates were taken in duplicate (midway through the visit and at the end) and averaged to assign the final coordinates of each home.The University of California, Berkeley, the University of Pretoria, the Limpopo Department of Health and Social Development, Tshilidzini Hospital and McGill University granted ethics approval for the VHEMBE study. The Committee for Protection of Human Subjects at the University of California, Berkeley further approved the use of these data for the present study.Antenatal care (ANC) attendance records were collected at delivery from the mother’s ANC card, a form of medical record which women carry with them to all visits to any ANC clinic during pregnancy. We characterized ANC attendance by adequate frequency (≥4 visits) and early initiation (≤12 weeks), according to WHO recommendations at the time of the study . RecordsDuring the interview at the time of delivery, mothers completed a detailed quantitative food frequency questionnaire designed and validated in a population residing in the study area, which asked about food consumption in the previous month . Total ast or below the 99th birthweight-for-age percentiles) replaced by gestational age indicated in medical records for 10% of participants. Birth size measurements were complete for all but one missing birth weight and six missing length and head circumference measurements.Child birthweight was assessed by hospital nurses immediately after delivery—with a Tanita BD-815U neonatal scale  provided by the study which measured grams to two decimal places—and was retrospectively abstracted from hospital records. Study nurses measured birth length and head circumference within the first 24 to 48 hours of birth. Birth length was measured using a Seca 417 portable infantometer , with the infant laid on his or her back, legs aligned and fully extended, and toes pointing directly upward. Head circumference was assessed to the nearest 0.1 cm using a tape measure positioned just above the eyebrows, above the ears, and around the largest part of the back of the head. Measurements were taken in triplicate and averaged. For each size outcome, growth z-scores for gestational age and sex were constructed according to WHO Child Growth Standards . Gestatip is the number of Fourier term pairs assessed and θi is the point in the annual cycle when the ith infant is born, calculated in radians . Seasonality is modeled by adding the first p pairs of Fourier terms to the regression model, parameterized by βr and γr. Separate models for each ANC attendance, dietary intake, and infant birth size outcome were fitted with an increasing number of Fourier pairs. Seasonality was assessed using likelihood ratio (LR) tests or F tests for multiply imputed data to compare models and select the model with the best fit for each outcome. For each outcome, we selected the model that satisfied α = 0.10 for both comparison to the null model (no Fourier terms) as well as to the nested model with fewer Fourier terms.We used logistic regression to model ANC outcomes (adequate attendance and early initiation) and linear regression for dietary intake  and birth size outcomes  in relation to season. Seasonal trends in ANC attendance, dietary intake, and birth size were examined using truncated Fourier series terms , a methoAs a secondary analysis, we explored the role of rainfall in ANC attendance. Rainfall during each pregnancy was constructed with the Climate Hazards Group InfraRed Precipitation with Station (CHIRPS) daily data at 0.05° resolution . CHIRPS a priori from the literature [All regression models were adjusted for covariates identified terature ,6,24,25.terature ); and duTo limit potential bias from missing ANC data, we used inverse probability of censoring weighting (IPCW) to adjust for the propensity of missing ANC records . We geneAll statistical analyses were conducted using Stata 14.2 . Rainfall variables were constructed using MATLAB Release 2018b  and road distance was calculated using R Version 3.5.1 .Among 752 singleton births, 52% of infants were male and the mean gestational age at birth was 39.3 weeks (SD: 2.3). The mean age of mothers at delivery was 26.4 years (SD: 6.3), 43% were primiparous, 55% had not completed secondary school, and 14% were HIV-positive. Maternal characteristics varied by categorical season of delivery, including lower reported typical monthly household income and taller stature among women giving birth during the lean, rainy season .Overall, 16% of women initiated ANC in the first 12 weeks of pregnancy and 73% attended at least four total ANC visits during pregnancy . The avest order), maternal carbohydrate  and fat  intake, and birth weight , length , and head circumference . Early ANC initiation and protein intake did not vary by date of delivery; in other words, no combination of Fourier terms provided a better fit than the null model without Fourier terms. The seasonal associations for each outcome from adjusted models were somewhat stronger than from unadjusted models  = 0.59, 95% CI: 0.40 to 0.86; a = 0.89, 95% CI: 0.82 to 0.96; a = 0.83, 95% CI: 0.54 to 1.30) or continuous  rainfall characterizations.Pregnant women exposed to above average daily rainfall during the third trimester (after week 26) had lower odds of attending ≥4 ANC visits during pregnancy than those exposed to lower rainfall  attendance, maternal dietary intake, and infant birth size. Truncated Fourier series models for seasonality showed that adequate ANC attendance (≥4 visits) was lowest among mothers delivering during the “lean” season when food insecurity, agricultural labor, and rainfall typically occur. This trend corresponded with another finding that higher average daily rainfall during the third trimester correlated with a decline in adequate ANC attendance. We also identified seasonal trends in the composition of maternal diets, including a trade-off of carbohydrates for higher fat intake during the harvest season, when food prices are generally lower. Additionally, we found that birth weight, length, and head circumference decreased during the lean season and increased during the post-harvest vegetable gardening season. This study adds to previous research on birth size and seasonality, and to our knowledge is the first to model the influences of seasonality or rainfall on ANC attendance in a low- to middle-income country (LMIC) setting.th percentile) among 1,916 live births over 26 years in rural Gambia, with the highest incidence at the end of the annual lean season and rates varying inversely with maternal weight changes across the year. In a prospective cohort including 633 full-term births rural India, Rao et al. [A review of birth size and seasonality in LMICs concluded that such patterns are likely due to seasonal variation in food security, agricultural labor, and infectious disease . For exao et al. –31—theseRecent work suggests that seasonality of pregnancy outcomes may be partly attributable to seasonal variation in the characteristics of pregnant women, confounding potential causation by seasonal environmental conditions. A study among U.S. women demonstrated that differences in socioeconomic status by pregnancy timing contributed to seasonal variation in the gestational age distribution . HoweverPromising interventions to mitigate seasonal declines in fetal growth are suggested by randomized controlled trials in rural Gambia  and BurkOur finding of an association between rainfall and adequate ANC attendance is supported by qualitative studies in similar settings, such as the following quote from a study in rural Indonesia:“It is really hard when it is raining. We are afraid we will fall over because the road is so slippery and we are pregnant. The health centre is far and you can see that the road is poor.”Women experiencing hunger during the lean season may have little energy to attend ANC, particularly for women who must walk far in wet conditions to reach the clinic or a road where they can take public transportation. Travel costs or other fees may also be particularly burdensome during the lean season when household resources are limited. Other seasonal barriers may include the opportunity cost of time away from household resource generation, particularly during critical times in the subsistence farming cycle when missed labor could imperil the household food supply ,39,40. TThis study was not designed to identify specific causal pathways that may operate between seasonal factors and ANC, nutrition, or birth size. As mothers were enrolled at the time of delivery, some variables of interest including maternal health and activity levels were not measured prospectively during the pregnancy. While a handful of other studies have documented changes in maternal caloric intake, physical activity, and illness that may explain seasonality in birth size, further research is needed to disentangle the factors contributing to seasonality of ANC.Our results are also limited by a relatively short observation period of 17 months, which may not represent long-term seasonal patterns in the community. Additionally, given the adolescent fertility rate (ages 10–19) of 65 per 1,000 births in Limpopo Province , this stMisclassification of gestational age may have occurred from calculation based on mothers’ recollection of last menstrual period at the time of delivery. However, we attempted to reduce measurement error by cross-referencing with medical records of gestational age based on earlier reported LMP or fundal height. Finally, missing ANC data for 19% of participants likely reduced the precision of our estimates and introduced potential bias due to differing characteristics of participants missing ANC records. We addressed this issue using inverse probability of censoring weighting, however it is possible that this approach did not fully account for systematic differences.Despite these important limitations, our analysis strengthens the evidence for seasonality of birth size and maternal nutrition while contributing to a dearth of knowledge about seasonality of ANC attendance, especially in LMIC settings. These results have implications for the potential effects of climatic events—including increasing frequency and magnitude of extreme events such as flooding and drought —on healtS1 Fig(A) As an example, CHIRPS data for the study area are shown for January 20, 2013 and (B) values within a 0.25° radius from the participant centroid are identified; (C) the mean value within the buffer for each day over the study period is shown. This process was completed for each participant using her home GPS coordinates to calculate rainfall for each day of her pregnancy.(PNG)Click here for additional data file.S1 TableData are presented as mean (SD) or geometric mean (×/geometric SD) for continuous measures, and n (%) for categorical measures.(DOCX)Click here for additional data file.S2 TableData are likelihood ratio test statistics comparing generalized linear models regressed on Fourier terms for date of birth. Four models were compared for each outcome: (1) intercept only (Null model); (2) including the first order Fourier pair ; (3) including the first and second order Fourier pairs ; and (4) including the first through third order Fourier pairs . Likelihood ratio tests were used to compare nested models.(DOCX)Click here for additional data file.S3 TableData are odds ratios (OR) and 95% confidence intervals (CI) from logistic regression models of binary antenatal care (ANC) attendance outcomes regressed on average daily rainfall (continuous mm/day) for each trimester. Inverse probability of censoring weights were applied to all models to account for missing outcomes data. Adjusted models include maternal parity, HIV status, education, marital status, and pregnancy desire; father’s supportiveness of the pregnancy; and household income and distance to a main road.(DOCX)Click here for additional data file.


At-birth and point-of-care (POC) HIV testing are emerging strategies to streamline infant HIV diagnosis and expedite ART initiation for HIV-positive infants. The purpose of this qualitative study was to evaluate factors influencing the provision and acceptance of at-birth POC testing among both HIV care providers and parents of HIV-exposed infants in Kenya.a priori themes related to environmental context, patient characteristics, and resources.We conducted semi-structured interviews with 26 HIV care providers and 35 parents of HIV-exposed infants  at four study hospitals prior to POC implementation. An overview of best available evidence related to POC was presented to participants prior to each interview. Interviews probed about standard EID services, perceived benefits and risk of at-birth and POC testing, and suggested logistics of providing at-birth and POC. Interviews were audio recorded, translated (if necessary), and transcribed verbatim. Using the Transdisciplinary Model of Evidence Based Practice to guide analysis, transcripts were coded based on Most providers (24/26) and parents (30/35) held favorable attitudes towards at-birth POC testing. The potential for earlier results to improve infant care and reduce parental anxiety drove preferences for at-birth POC testing. Parents with unfavorable views towards at-birth POC testing preferred standard testing at 6 weeks so that mothers could heal after birth and have time to bond with their newborn before–possibly–learning that their child was HIV-positive. Providers identified lack of resources  as a barrier.While overall acceptability of at-birth POC testing among HIV care providers and parents of HIV-exposed infants may facilitate uptake, barriers remain. Applying a task-shifting approach to implementation and ensuring providers receive training on at-birth POC testing may mitigate provider-related challenges. Comprehensive counseling throughout the antenatal and postpartum periods may mitigate patient-related challenges. Early infant diagnosis of HIV (EID) is critical to identify HIV-positive infants and initiate them on antiretroviral therapy (ART). However, inefficiencies along the EID cascade of care ,–4 resultTesting infants at birth with more efficient point of care [POC] HIV diagnostic technology is emerging as a strategy to streamline EID and minimize challenges with traditional central laboratory based HIV DNA PCR testing at 6-weeks of age. POC diagnostic technologies such as GeneXpert HIV-1 Qual and AlerWhile at-birth and POC strategies to expedite infant diagnosis and treatment hold great promise, dissemination of prevention of mother to child transmission (PMTCT) innovations in sub-Saharan Africa, including Kenya, has historically been slow.–26 This This qualitative study was part of the formative component of a pilot study to assess the feasibility and effectiveness of GeneXpert and Alere q for at-birth POC HIV testing. The aim of the formative component was to assess factors that could facilitate or impede acceptance of POC testing and strategies to optimize implementation. At the time of the interviews, POC machines had not yet been introduced to the study hospitals for testing at any time point and no training for POC implementation or study procedures had occurred.This study was conducted at 4 Kenyan government hospitals. The hospitals were located in coastal (n = 1), central (n = 1), and western (n = 2) Kenya and were of varying resource levels , county referral hospital (n = 1) and a provincial referral hospital (n = 1)). Annual EID volumes in 2017 ranged from 159 and 704 and the percentage of HIV-exposed infants testing positive at 6 weeks ranged from 1.3% to 4.1%.At the time of the study, Kenyan National EID guidelines (2016) recommended HIV DNA PCR testing for all HIV-exposed infants at birth, 6 weeks, 6 months, and 12 months, with a final antibody test at 18 months. If at anWe conducted semi-structured interviews with 26 key PMTCT/EID providers at the 4 study hospitals and n = 35 parents of HIV-exposed infants  who accessed EID services at one of the hospitals in February and July of 2017. Provider participants were purposively selected by study staff to represent different departments  and different roles  involved in the provision of PMTCT and EID services. All relevant providers available at the hospital on the days the interviews were conducted were asked to participate; thus, the sample size for provider participants was limited by the number of relevant provider at each site. Parent participants were recruited by each hospital’s mentor mothers and were contacted by phone or in person to participate. Parent interviews were scheduled on clinic days when mothers were already to be at the hospital for their own or their infant’s care. We targeted an initial sample size 10 parent participants per site. After 10 participants, the research team reviewed field notes and preliminary findings during a debriefing session and assessed the level of saturation . At sites where saturation had not been achieved after 10 participants, additional interviews were conducted and discussed until consensus on saturation was reached. Due to a strike, which created logistical constraints related to scheduling parent participants, only two parents were available for interview at one of the hospitals. No participants refused to be interviewed. Hospital, provider, and parent details are outlined in Tables Written informed consent was obtained from each participant prior to the interview and a remuneration of 500 Kenyan Shillings (approximately USD $5.00) was given in appreciation of participants’ time. All study protocols were approved by ethical review committees at the Kenya Medical Research Institute and the University of Kansas Medical Center.ach interview, the interviewer introduced him/herself, explained the purpose of the study, gave each participant an information sheet outlining the best available research evidence for POC testing using the GeneXpert and Alere q machines, verbally described the process of collecting and processing samples, and discussed the sensitivity and specificity of the results. While some providers had experience using GeneXpert for tuberculosis diagnosis, this was the first time that all parents and most providers were learning of the use of POC machines for early infant diagnosis of HIV.Prior to conducting eAll interviews were conducted by on-site research coordinators or the study manager  who received training in qualitative data collection methods. Interviewers had no prior contact with parent participants, but had previously interacted with some providers during the process of funding acquisition, IRB approval, and study start up. The data reported in this manuscript focus on interview question topics related to factors impacting acceptance and perceived benefits and barriers of at-birth POC testing. Interviews lasted approximately 45 minutes and were conducted in a private office at the study hospital. Provider interviews were conducted in English, audio recorded and transcribed verbatim. Parent interviews were conducted in the participant’s language of choice , audio recorded, translated, and transcribed.a priori themes corresponding to the constructs of the Transdisciplinary Model of Evidence Based Practice . So waiting for the results is terrifying.” (Parent 31)During this long waiting time for infant results, most parents felt substantial anxiety, ““…didn’t have too many worries…they had told me that if I tend to the child as advised, the chances of getting sick would go down. So, I knew the child was safe.” (Parent 2)However, a few parents stated that they Despite the long turnaround times for HIV DNA PCR test results, most parents expressed satisfaction with their EID experience, including satisfaction with the quality and efficiency of services provided, comprehensiveness of counseling, and the attitudes of hospital staff:“And then the services down at the maternity are very good. The nurses are cooperative … When they [HIV+ mothers] come to the hospital, they are given priority. They don't have to take time in the hospital. They get what they want, the drugs, the counseling, part of it.” (Parent 14)Overall 30 of the 35 (85.7%) parents held a favorable view towards at-birth POC testing. Most parents expressed a preference for earlier results. Similarly, providers felt that parents would prefer and benefit from getting their infants’ results earlier. Both parents and providers agreed on two primary benefits that earlier results would afford to parents: it would reduce parental anxiety caused by long waiting periods and it would improve infant outcomes by allowing clinicians to provide result-based counseling and services earlier.“Testing for HIV at birth, I think it's a good idea, because it makes someone be relieved of that anxiety. At least you will want to know how is the child, is she positive or negative?” (Parent 11)“When they test that early they will know what they will do. They will evaluate these that were tested and the outcomes of those results to pave a way forward.” (Parent 23)because we can get those babies' status even before they go home. And some of our mothers don't come back for those post-natal clinics we give. So if we can do it during the delivery or just before they go home, it will help capture those babies early.” (Provider 14) This was seen as especially relevant for parents who may have traveled far to reach the hospital because “you don’t know where they come from, specifically … If she or he misses that test at that particular time, sometimes she will not have another opportunity to do that test.” (Provider 4)Several providers noted that mothers were often lost to follow up prior to the six week test. Providers felt that at-birth POC testing, allowing women to get their infant’s test and result on the same day, would reduce the occurrence of missed opportunities “…Parents and providers also noted that it could reduce the rates of loss to follow up by motivating continued engagement in care and adherence to PMTCT recommendations.“For me, I think it will make mothers do a lot of follow up [rather] than defaulting. Because if at birth, if I’m a seropositive mother and I find out immediately after birth—when I think the blood has mixed a bit—my baby turns out to be negative, it will motivate me to continue knowing if it will be continuously negative [at follow up testing].” (Parent 14)While most parents expressed their own preference for earlier testing and same-day results offered by at-birth POC testing and providers agreed that this would be beneficial to parents, both sets of stakeholders offered insights on why parents may reject this method of testing, instead preferring standard infant testing at 6-weeks of age. Fear that an HIV-positive result at birth would preclude parent-child bonding and negatively impact infant care was expressed by several parents:“You can’t accept to raise the baby, and he has a problem ahead. So many might have bad thoughts. So it’s better at six weeks so people know you have a baby, and you have love for the child.” (Parent 25)someone has brought the mother to the hospital and this person doesn’t know the status of the mother then there is a risk disclosure happening” (Parent 32) was expressed by some parents; however, more felt that “disclosure may not happen since they wouldn’t know why blood is being drawn.” (Parent 27). Similarly, providers felt that issues of stigma and disclosure would not pose significant challenges to at-birth POC testing.Fear that at-birth POC testing could risk unintentional disclosure if “some period of time should be given to the mother so that [the mother] can heal” (Parent 1) both physically and emotionally; (2) It may decrease EID retention “because they will opt not to participate in EID since they get the results on the same day” (Parent 27) and, thus, may forego follow up testing; (3) they “think the baby will feel too much pain” (Parent 32) if a sample is taken at birth; and (4) “Some will be scared about the same day results especially those who have not been looking after their children well.” (Parent 5)Other stated reasons that parents may be resistant to birth POC testing were: (1) after delivery “Patients’ need for comprehensive maternal counseling, starting in pregnancy and continuing through delivery and postpartum was mentioned by nearly all parents and providers. Counseling was seen as necessary to support acceptance of at-birth POC testing, acceptance of their infant’s result, and appropriate infant care based on the result of a birth POC test.They should prepare them through having health talk…when they’re pregnant. They should know at the time they are four months pregnant, six, seven like that so they become prepared. (Parent 16)It need a lot of counseling…They will not be happy of the [positive] result. Maybe that one was your first child and, ‘Wow, I have a child and she also sick, what can I do? What will I do with this child?’ So they need just counseling. (Parent 22)The thing that motivated me to do this [receive EID care], through the doctor's instructions, how they encourage people. If you come here, you find so many people, they also testing HIV positive, so that will … It encourages you, so that you see that you are not alone.” (Parent 11)Some parents also discussed how social support provided by the parent’s family/friends, by a mentor mother or other provider, or by other clients at the hospital would facilitate parental acceptance of at-birth POC testing, “Parents and providers discussed how the timing of maternal HIV diagnosis and maternal disclosure status could impact mothers’ acceptance of at-birth POC testing. More resistance was anticipated among mothers newly diagnosed as HIV-positive during their current pregnancy or delivery, compared with mothers who had known their HIV status for some time:“Unless this one is a mother who was tested, maybe, two, three days back, or was tested at delivery, or at maternity. Had never been on care, and fears the baby may be infected. It's the only person who may not want to receive the result.” (Parent 14)she has not disclosed to the husband and testing the baby [at the time of delivery] would make the husband know the situation.” (Parent 26)Similarly, mothers who had not disclosed their own HIV status to family and/or friends were seen as less likely to accept at-birth POC testing for their newborns because if “Despite these qualitative comments from providers and patients that a new diagnosis or nondisclosure may impede acceptance of at-birth POC, review of individual participant data revealed that among the 20 parents with known timing of diagnosis, all newly diagnosed parents (8/8) held favorable views towards at-birth POC testing compared to only 66% (8/12) favorable views among parents who were previously diagnosed. Among those known to have disclosed their status, 73.7% (14/19) held favorable views towards at-birth POC testing, compared to 100% (16/16) with unknown disclosure status.Both providers and parents discussed how parents have a high level of trust in providers and, thus, would be willing to follow provider recommendations for at-birth POC testing.“It depends on what the sisters say, and you follow their advice.” (Parent 14)“Once they have heard themselves that professionals themselves are handling this [birth POC testing], I don’t think it is going to cause any effect to them. Because they trust the clinician.” (Provider 3)“Mentor mothers were very helpful since they prepare you from pregnancy that you baby will be tested so when the time reaches for the baby to be tested one is very confident.” (Parent 33)If they are not trained, then it means you are not competent and you cannot do that work properly to the standard that is needed.” (Provider 5) However, this barrier was seen as easily overcome with staff training.However, providers felt that their current knowledge of both the 2016 guidelines recommending at-birth testing and the use of the POC machines was inadequate to support this initiative. They felt that their lack of expertise in these areas would impact their ability to provide quality at-birth POC testing to clients because, “o majority of the healthcare workers are not aware of the new guidelines, so we need to sensitize these people. They need to be trained so that when they come across a mother, they are able to tackle that mother fully without referring to another section.” (Provider 16)“SNearly all providers  held a favorable view towards at-birth POC testing. Like parents, providers’ enthusiasm for at-birth POC testing was driven by anticipated improvements in clinical management for HIV-positive infants:The benefits are, we'll be able to attend to the child according to their immediate needs. If the result for this baby is positive, you will be able to put interventions immediately. Maybe you start the child on full ART. If this child is negative, the mother will be supported and maybe referred to the MCH for a test again in six weeks. So if it is beneficial to both the mother and the health worker.” (Provider 15)“The two providers who held and unfavorable view of at-birth POC testing misunderstood the mechanism of testing and how it differed from rapid antibody tests. These providers were concerned with mothers and babies “mixing blood,” which, they feared, would cause a false positive POC result.“Previously we used to say that a baby born to a sero-exposed mother may have the, it’s called what, the, the antibodies of the mother in the blood and that can give a false positive result. So what has changed?” (Provider 4)the patients are many. And the workers are few.” (Parent 31) This shortage of adequately trained personnel was seen as the primary resource constraint to at-birth POC testing. Given their current staffing levels, most providers felt that the extra work required to provide maternal counseling and collect and process samples would result in provider burnout and/or inability to manage at-birth POC testing and other responsibilities.While enthusiasm facilitated provider willingness to accept at-birth POC testing, they feared that significant resource constraints would hinder their ability to successfully implement the intervention. Both patients and providers stated that “…“This testing and counseling is also time consuming so it will limit your time on the other activities that you are supposed to do. So I think it [POC testing] will impact on the performance of other activities.” (Provider 4)Insufficient space in maternity was seen as additional resource constraint that would impact the provision and acceptance of at-birth POC testing because it may impede adequate confidentiality during counseling and testing:“I would want to have an office where that specific testing and counseling is done so that it is done within a room to maintain the privacy and confidentiality of the mothers… We don’t have [a room]. That is the challenge.” (Provider 4)this thing, the machine, is of quality and can give great results.” (Provider 5) However, others were more skeptical and questioned if the machine met their standards and insisted on creating their own evidence through machine validation tests, prior to full implementation:Given the novelty of testing at birth and with POC HIV diagnostics for infants, providers were largely unaware of research evidence regarding at-birth POC testing. Prior to the interviews, research staff discussed the machines and gave providers a brief overview of current literature. In the absence of other evidence or personal experience using the machines, some trusted that “…“We need to see if this equipment is validated—can give the same results as the other equipment. So once we validate, and we know the equipment is working again like other equipment, then we will not have the problem. But at first, we do have a concern about the validation.” (Provider 3)you cannot hasten the process of getting the result if that the is the normal time to wait since this is something that they have done research on and they know it should take this amount of time.” (Parent 23)Similarly, a few parents were skeptical that such rapid results would be as reliable as the PCR results. These parents suggested, “Decision-making around the adoption of at-birth POC testing will be influenced by provider and parent preferences in the context of limited resources and limited provider experience with POC. The majority of parents and providers held favorable attitudes towards at-birth POC testing for HIV-exposed infants, stating that the earlier results provided by at-birth POC testing would reduce parental anxiety and improve infant care. This qualitative finding is supported by quantitative studies suggesting that POC testing can result in earlier ART initiation for HIV+ infants and improved viral suppression at 6-months., 11, 13 Despite favorable attitudes, significant structural barriers in terms of insufficient resources  and limited evidence available to clinicians were identified. These findings are consistent with a Malawi study which found that although nurses had average knowledge and positive attitudes towards the evidence based practice in PMTCT, insufficient resources and difficulties accessing new information  hampered efforts and caused low implementation of EBP. If at-biShortage of clinical personnel was seen by providers as the primary constraint to providing at-birth POC testing. Indeed, the shortage of health workers in many African countries is recognized as a crisis and has Evidence related to PMTCT and EID is a rapidly changing field, prompting frequent guideline updates. In AfricGiven some parents’ resistance towards at-birth POC testing, providers will need to engage patients in shared decision-making early (during pregnancy) to ensure that an individual patient’s preference is understood and respected. As noted by both clinicians and patients in the current study, counseling parents on the potential benefits and risks associated with at-birth POC testing will be necessary to help patients make an informed decision. Counseling should be a continuous process, beginning early in pregnancy and continuing throughout the delivery and postpartum periods to support testing uptake and acceptance of results. The rate of facility delivery in pregnant women living with HIV in Kenya is high (97%). While tThis study has at least three limitations, which should be noted. First, all data collection occurred prior to implementing at-birth POC testing and thus represent perceived facilitators and barriers, rather than realized benefits and barriers. Additional data from focus groups conducted throughout the pilot period will help to confirm if the perceived facilitators and barriers identified in this study hold up once the participants experience the process. Second, all parent participants were engaged in EID care for their HIV-exposed infant and were selected by mentor mothers who they have an ongoing relationship with, thus their views towards at-birth POC testing may not be representative of patients who are less engaged in care. This may account for the discrepancy we saw between the perceived impact that timing of diagnosis and disclosure would have on acceptance of at-birth POC testing. These two factors have been found to influence maternal and infant engagement in HIV care.–52 AmongMost HIV-care providers and parents of HIV-exposed infants held favorable views towards at-birth POC testing and felt that earlier results provided by at-birth POC testing would benefit parents and children by reducing parental anxiety and informing infant care. However, a few participants preferred standard testing so that mothers could heal after birth and had time to bond with their newborn before–possibly–learning that their child was HIV-positive. Counseling, starting early in pregnancy and continuing through delivery, and ensuring confidentiality will facilitate acceptance of at-birth POC among parents of HIV-exposed infants. Furthermore, without being addressed, challenges with resources (primarily provider expertise and time), lack of provider experience with POC, and a misunderstanding of the mechanism of testing could limit clinicians’ ability and/or willingness to provide at-birth POC testing. Training for providers and counseling of parents will maximize the acceptance of at-birth POC testing among providers.S1 Checklist(PDF)Click here for additional data file.S1 File(DOCX)Click here for additional data file.S2 File(DOCX)Click here for additional data file.S3 File(DOCX)Click here for additional data file.S4 File(DOCX)Click here for additional data file.


The objective of this study was to determine the prevalence and associated factors of preterm births among mothers who gave birth in Axum and Adwa public hospitals, Tigray, North Ethiopia, 2018.This study showed that 13.3% from the total 472 mothers gave a preterm birth. Being a rural resident , short inter pregnancy interval , previous preterm birth , Premature rupture of membrane , induced onset of labor  multiple pregnancy , malaria during pregnancy , Presence of chronic illness  were significantly associated with preterm birth. Preterm birth (PTB) refers to the birth of a baby that occurs before 37 completed weeks of gestation . The comPreterm birth has many long and short term consequences like cerebral palsy, mental retardation, visual and hearing impairments, learning difficulties, poor health and growth , 4.Globally WHO estimates of global rates of preterm births indicate that of the 135 million live births in 2010, 15 million babies were born too early, representing a preterm birth rate of 11.1% and over 60% of preterm births occurred in sub-Saharan Africa and South Asia [About 350,000 under five children die annually due to the complication of preterm birth in Africa including Ethiopia. And the highest rates of preterm morality are in West Africa, particularly in the countries currently being decimated by Ebola, notably Sierra Leone and Liberia .In the previous studies, previous history of preterm birth was the strongest predictor of risk for subsequent preterm delivery and if these risk factors are not correctly identified and adequately managed, they contribute to the increasing incidence of preterm births. So, Identification and timely referral for further evaluation and management of these risky women during early pregnancy, is important in decreasing the consequences of preterm birth .Developing countries like Ethiopia lacks reliable data on preterm birth depending largely on estimates from delivery records but the records lack consistency and completeness. Despite tremendous improvement in newborn care, prevention of preterm birth has remained largely unaddressed. Therefore, this study has gone a long way in providing relevant data regarding the factors associated with preterm birth among women gave birth in Axum and Adwa Town public hospitals.Institutional based cross-sectional study was conducted in Axum and Adwa town public hospitals from February 08-March 08, 2017. There are four health centers, two general hospitals and one referral hospital in Axum and Adwa town and all are governmental hospitals.The sample size was determined using single population proportion formula by considering confidence level (95%), margin of error = 0.04 and 11.6% of prevalence taken from the study done in Debre Markos . By addiFace-to-face interviewer administered questionnaires and mother’s profile card was used to collect the data from postpartum mothers and gestational age was determined by last normal menstrual period and by early ultrasound check up result.Questionnaire was pretested on 5% of the sample size in suhul shire hospital to ensure its completeness. Data entry was done by two data clerks. Finally, multivariate analysis was run in the binary logistic regression model to control the confounding factors.p value less than 20% were considered into the multivariable analysis. Adjusted odds ratio with a 95% confidence interval was calculated to see the strength and significant association. Variables having a p-value less than 0.05 in the multivariable logistic regression analysis were considered as significant.Data was entered in Epi Data 3.1 and exported into SPSS version 22 for analysis. Both bivariable and multivariable logistic regression analysis were carried out to identify factors associated with preterm birth. In bivariate logistic regression analysis, variables with A total of 472 mothers were included in this study with a response rate of 97.9%. The median age of the study participants was 26.00 with interquartile range of ± 8. 75.6% of the study participants were between 20 and 34 years old. Concerning to maternal level of education status of the respondents, 72.8% of the mothers were attended a formal education Table .Table 1SOut of 472 mothers, 264 (55.9%) of them were multipara and the rest 208 (44.1%) mothers were prim Para. Regarding the mode of delivery for recent pregnancy, 367 (77.8%) out of 472 mothers were gave birth via spontaneous vaginal delivery. the rest 32 (6.8%) and 73 (15.5%) of mothers gave birth via assistance of instrumental and caesarean section, respectively  had ANC follow up for the recent pregnancy. Among these mothers who had ANC follow up about 325 (71.9%) of interviewed mothers had four or more visits.Out of 472 interviewed mothers, 461 (97.7%) were tested for HIV and 449 (97.4%) of them were negative. Concerning to the mothers haemoglobin level check-up, 462 (97.9%) of them were checked for their haemoglobin level  mothers gave preterm babies. These preterm babies were diagnosed by calculating the gestational age from the last normal menstrual period/using early ultrasound result.In this study, Mothers who were living in rural area were two times more likely  to have preterm birth compared to those who live in urban area. Concerning to inter pregnancy interval, mothers with inter pregnancy interval less than 24 months four  times were more likely to give preterm births compared to mothers who had inter pregnancy interval greater. Regarding the previous history of preterm birth, mothers who had history of preterm births were four  times more likely to give preterm birth compared to mothers who had no previous preterm births.Coming to the obstetric complications during the pregnancy like PROM, mothers who encountered PROM  during the pregnancy were almost four times more likely to have preterm birth compared to mothers who had no PROM. Mothers with multiple pregnancy outcomes  were six times more likely to have preterm birth compared with mothers who gave birth singleton.Concerning to the medical factors, mothers who had exposed for malaria during pregnancy  and chronic medical disorders  were seven times more likely to have preterm births than the counterpart  and India (2010) which reported with the prevalence of 11.6% and 15% , 9. ThisThe finding of this study was higher than the study conducted in Gondar 2012), Iran Asali Hospital (2007) and Egypt (2014) which reported that the prevalence of preterm birth was 4.4% 6.3% and 8.2% –12, resp, Iran AsThe finding of this study was found to be lower than studies conducted in Nigeria (2010) with the prevalence rate of 24% . This miThe finding in this study was also lower than the study done in Kenya (2013), Brazil (2009) and India (2010) which reported that the prevalence were 18.3% and 21.7% , 15. TheThis study showed that residence was associated significantly with preterm birth. This finding was in line with the study done in Bahirdar . This miShort inter pregnancy (< 24 months) was significantly associated with preterm birth. This finding was in consistence with the study conducted in Debre Markos since 2013 . This isPrevious preterm birth was another factor significantly associated with preterm birth found in this study. Mothers who had previous history of preterm births seven times were more likely to have preterm births compared to mothers who had no previous history of preterm births in the subsequent deliveries. This finding was in consistence with the secondary data analysis report of Malawi (2014): . The posAccording to this study, mothers who had premature rupture of membranes (PROM) during pregnancy were four times more likely to have preterm birth compared to those had no premature rupture of membrane. This finding was in consistence with findings of cross sectional studies conducted in Debre Markos (2013) and Kenya (2013) , 15. ThiMultiple gestations were significantly associated with preterm birth in this study. Mothers with multiple pregnancies were almost six times more likely to have preterm birth compared with mothers who gave birth singleton This finding was in line with the finding of study done in Kenya (2013) . This miChronic medical illnesses are significant variable associated with Preterm birth. Mothers with chronic medical disorders were almost seven times more likely to have preterm births compared to mothers who had not chronic medical disorders. This finding was in consistence with cross sectional study conducted in Debre Markos 2013) . This mi13 . ThisBesides to this, mothers who had malaria during their pregnancy were more and mothers who had exposed for malaria during pregnancy were five times were more likely to have preterm births than mothers who had not exposed to malaria during the pregnancy. This result was in line with the study done in Iran (2011–2013) . This miResidence, short inter pregnancy, previous history of preterm birth, PROM, induced onset of labor, multiple gestation, Presence of chronic medical illness, being exposed for malaria during the pregnancy were statistically significant with preterm birth. Therefore, efforts have to be made to decrease the magnitude of preterm births and further improvements of antenatal care as well as early screening are important recommendations.Being a cross-sectional study design attempt to our work did not establish the possible temporal relationship between dependent and independent variables. Besides, recall bias in finding out the gestational age of pregnant women was not ruled out.Additional file 1: Table S1. Medical related information of women who give birth in Axum and Adwa town public hospitals, Tigray, Northern Ethiopia, February 08–March 08, 2018.Additional file 2: Table S2. Factors associated with preterm births among mothers who gave birth in Axum and Adwa town public hospitals, Tigray, North Ethiopia, February 08–March 08, 2018.