Aims. We aim to evaluate the association of maternal gestational oral glucose tolerance test (OGTT) glucose concentrations with anthropometry in the offspring from birth to 12 months in Tianjin, China. Methods. A total of 27,157 pregnant women underwent OGTT during 26–30 weeks gestation, and their children had body weight/length measured from birth to 12 months old. Results. Maternal OGTT glucose concentrations at 26–30 gestational weeks were positively associated with Z-scores for birth length-for-gestational age and birth weight-for-length. Compared with infants born to mothers with normal glucose tolerance, infants born to mothers with gestational diabetes mellitus (impaired glucose tolerance/new diabetes) had higher mean values of Z-scores for birth length-for-gestational age  and birth weight-for-length , smaller changes in mean values of Z-scores for length-for-age  and weight-for-length  from birth to month 3, and bigger changes in mean values in Z-scores for weight-for-length  from month 9 to 12. Conclusions. Abnormal maternal glucose tolerance during pregnancy was associated with higher birth weight and birth length, less weight and length gain in the first 3 months of life, and more weight gain in the months 9–12 of life. Gestational diabetes mellitus (GDM) is increasingly common worldwide . In ChinChildhood obesity is a global problem. The prevalence of childhood obesity is 6.7% in 2010 worldwide, and 70% of obese adolescents become obese adults . HillierTianjin is the fourth largest city with over 12.9 million residents in Northern China, and 4.3 million residents live in central urban districts. The prenatal care and children health care in central urban districts are a routine of a three-tier care system consisting of approximately 65 primary hospitals, 6 district-level Women's and Children's Health Centers, and a city-level (Tianjin) Women's and Children's Health Center . In Tianjin, all pregnant women are registered at the primary hospitals, and in the 32nd gestational week, they are referred to a secondary hospital or a tertiary hospital for management till delivery. All children are given the health examinations in the newborns (<3 days after birth), postnatal period (42 days after birth), infancy (<3 years old), and preschool (3–7 years old). Tianjin Women and Children's Health Centre is the leader of the 3-tier care system and responsible for organization, coordination, and implementation of women and child health care, research, and promotion projects.Health care records for both pregnant women and their children have been collected and available in electronic form since 2009 . Pregnann = 1262)/IFG (n = 14) or new DM (n = 144) during 2 h OGTT.A universal screening for GDM has become an integral part of the antenatal care in urban Tianjin . A totalMothers' anthropometric data were collected during the pregnancy by obstetricians in the primary hospitals. Weight and height were measured in light clothing and no shoes using a beam balance scale . Blood pressure was measured using a standardized mercury sphygmomanometer . Children's weight and length were measured at birth, 3 months (<4 months), 6 months (≥4 and <7 months), 9 months (≥7 and <10 months), and 12 months (≥10 and <13 months). Weight was measured to the nearest 0.01 kg using a digital scale . Length was measured to the nearest 0.1 cm using a recumbent length stadiometer . We have done a validity study to compare the electronic data of measurements of birth weight and hospitals' measurements of birth weight among 454 children in six major hospitals. The correlation between two measurements is 0.991. We have also done a validity study to compare the electronic data of measurements of height and weight with the same visit's measurements of height and weight by trained health workers among 200 pregnant women and 160 children aged ≤2 years in four different local health centers. The correlations between electronic data and measurement data for body weight are 0.998 for pregnant women and 0.999 for children and for height/recumbent length are 0.997 for pregnant women and 0.999 for children.2), overweight (BMI 24–27.9 kg/m2), and obese (BMI ≥ 28 kg/m2) using the Chinese BMI classification standard [Body mass index (BMI) was calculated by dividing weight in kilograms by the square of height in meters. Prepregnancy BMI was classified as normal weight  Z-scores for birth length and birth weight-for-length; (2) Z-scores for length-for-age and weight-for-length at months 3, 6, 9, and 12; and (3) changes in Z-scores for length-for-age and weight-for-length for each three months and from birth to month 12, according to different maternal glucose concentrations at 26–30 gestational weeks. We included 3 multivariable models in the analyses. Model 1 was adjusted for maternal characters including maternal age, prepregnancy BMI, weight gain during pregnancy, family history of diabetes, education, and family income. To explore the potential mediating effect, in model 2 we additionally adjusted for infant feeding status; and in model 3 we additionally adjusted for birth variables for gestational age Z-score. All statistical analyses were performed with PASW for Windows, version 20.0 .The general characteristics of both mothers and children according to different maternal glucose concentrations at 26–30 gestational weeks are presented in P < 0.001) and birth weight-for-length , and lower mean values of Z-scores for length-for-age at months 3 , 6 , 9 , and 12  (http://dx.doi.org/10.1155/2014/516980). We also compared mean values of Z-scores for weight-for-age from birth to months 3, 6, 9, and 12, and the results were similar to Z-scores for length-for-age and weight-for-length  , especiar-length .P < 0.001) compared with those infants born to mothers with normal glucose tolerance. From month 9 to 12, changes in mean values of Z-scores for weight-for-length were bigger among infants born to mothers with GDM  compared with those infants born to mothers with normal glucose tolerance (0.02). After additional adjustment for birth variables for gestational age Z-score (model 3), the smaller changes in mean values were still significant for length-for-age Z-score (P < 0.001) but were not significant for weight-for-length Z-score (P = 0.056) from birth to month 12 among infants born to mothers with new DM compared with those infants born to mothers with normal glucose tolerance. We did not find significant differences in changes in Z-scores for body length and weight-for-length from months 3 to 9 according to maternal OGTT glucose concentrations at 26–30 gestational weeks. Considering the effect of previous weight or length, we analyzed percentage change of Z-scores (change in Z-score between present and previous Z-scores accounting for previous Z-score) for weight-for-age and length-for-age for each three months from birth to month 12 according to maternal OGTT glucose concentrations at 26–30 gestational weeks . The percentage change in Z-scores for weight-for-age from month 3 to 6 and from month 6 to 9 and the percentage change in Z-scores for length-for-age after month 6 were bigger among infants born to mothers with new DM compared with those infants born to mothers with normal glucose tolerance.The present study indicated that abnormal maternal glucose tolerance at 26–30 gestational weeks was associated with larger birth weight and birth length, less weight and length gain in the first 3 months of life, and more weight gain in the months 9–12 of life.Previous studies have suggested that exposure to the intrauterine diabetic environment causes larger offspring size and more fatness at birth and higher risk of childhood obesity and young adult IGT and diabetes in the offspring , 20. TheThe present study is, to our knowledge, the first large prospective study to assess the associations of maternal glucose tolerance during pregnancy with changes in Z-scores for length-for-age and weight-for-length each three months from birth to month 12 in China. We firstly explored the potential mediating effects of fetal growth on the associations between maternal OGTT glucose concentrations and changes in Z-scores from birth to month 3 and found that abnormal maternal glucose tolerance during pregnancy was associated with slower weight gain and length gain in the first 3 months of life, which was consistent with earlier findings from the Project Viva that GDM predicted a slower gain in weight-for-length Z-scores in the first 6 months of life . In addiIt is noteworthy that our study found the trend of rapid gain in weight-for-length Z-scores only among infants born to mothers with GDM after 9 months of birth. This phenomenon may relate with complementary food supplements for infants more than 6–9 months old. In animal models, maternal hyperglycemia resulted in perinatal hyperglycemia and increased hypothalamic insulin levels, followed by findings of permanent dysplasia of hypothalamic nuclei regulating food intake and metabolism in the offspring . These aWe found that there was less breastfeeding among infants born to mothers with GDM than infants born to mothers with normal glucose during pregnancy, and offspring of mothers with GDM had more weight gain in the months 9–12 of life. One study with data from a retrospective cohort study conducted in Colorado  reported that the BMI trajectory was slower among infants in the adequate breastfeeding category (≥6 breast milk-months) than those infants in the low breastfeeding category (<6 breast milk-months) between birth and 9 months of age and between 4 and 6 years of age, and in both the offspring of diabetic pregnancies and offspring of nondiabetic pregnancies . Many stThere are several strengths in our study, including the large sample size of more than 27,000 mother-infant pairs in which OGTT was performed, repeated direct measures of maternal weight during pregnancy, repeated direct measures of the growth and development of infants at birth and each 3 months until 1 year old, and a wide range of potential confounders. Our main outcomes included both infant growth from birth to months 3, 6, 9, and 12 and infant growth each 3 months from month 3 to 12. A limitation of our study is that we only followed infant growth to 12 months old. Thus we cannot assess the effect of maternal OGTT glucose concentrations on offspring's growth and development after 12 months. However, we will get the children's later growth and development information in the near future.In summary, our study indicated that abnormal maternal glucose tolerance during pregnancy was associated with higher birth weight and birth length, less weight gain and length gain in the first 3 months of life, and more weight gain in the months 6–12 of life. Intensified intervention of GDM during pregnancy should be taken to reduce abnormal glucose metabolism to decrease the risk of infants who are born to women with GDM becoming overweight or obese in later life.Compared with boys and girls born to mothers with normal glucose tolerance, boys and girls born to mothers with GDM had higher mean values of Z-scores for birth length and birth weight-for-length (online Table 1).Click here for additional data file.


Preterm birth, defined as birth occurring before 37 weeks gestation, is one of the most significant contributors to neonatal mortality and morbidity, with long-term adverse consequences for health, and cognitive outcome.The aim of the present study was to identify risk factors of preterm birth (≤36+6 weeks gestation) among singleton births and to quantify the contribution of risk factors to socioeconomic disparities in preterm birth.A retrospective population–based case-control study using data derived from the Finnish Medical Birth Register. A total population of singleton births in Finland from 1987−2010  was reviewed.n = 1,390,742), 4.6%  were preterm (<37 weeks), of which 0.3%  were classed as extremely preterm, 0.4%  very preterm and 3.8%  moderately preterm. Smoking alone explained up to 33% of the variation in extremely, very and moderately preterm birth incidence between high and the low socioeconomic status (SES) groups. Reproductive risk factors  and fetal sex) altogether explained 7.7−25.0% of the variation in preterm birth between SES groups.Among all singleton births (Smoking explained about one third of the variation in preterm birth groups between SES groups whereas the contribution of reproductive risk factors including placental abruption, placenta previa, major congenital anomaly, amniocentesis, chorionic villus biopsy, anemia, stillbirth, SGA and fetal sex was up to one fourth. Preterm birth, defined as birth occurring before 37 weeks gestation, is one of the most significant contributors to neonatal mortality and morbidity, with long-term adverse consequences for health, and cognitive outcome as well as financial implications for health care The aim of the present study was to identify risk factors of singleton preterm birth (<37 weeks gestation) and to quantify the contribution of the risk factors to the observed socioeconomic gradient or disparity in preterm births using the total population of singleton births  for the years 1987–2010 in Finland with around 5.5 million residents and mainly publicly funded health services.The source of data used in this study was the Finnish Medical Birth Register (MBR), which is a compilation of the clinical records from all the obstetric care units in Finland. The data for the years 1987 to 2010 were obtained from the National Institute for Health and Welfare (THL), the current register keeper. The MBR includes information on maternal and neonatal birth characteristics and perinatal outcomes covering all live births or stillbirths delivered after the 22nd gestational week or weighing 500 g or more collected from all delivery units in Finland. For each infant, an electronic form, or rarely a paper form, has to be completed by the hospital covering the first seven postnatal days. The reporting units and register controller actively collaborate to guarantee the validity of the data. For example, information submitted to the MBR is checked and missing or apparently, incorrect information is confirmed by contacting the treating hospitals before correcting. Less than 0.1% of newborns are missing from the MBR, and therefore it was supplemented with data compiled by the Population Register Centre on live births and data compiled by Statistics Finland on stillbirths and deaths during the first week of life. After these additions, the data covered 100% of birth events.Preterm birth was defined as birth before or at 36+6 gestational weeks, being further divided by gestational age to moderately preterm (32+0–36+6), very preterm (28+0–31+6) and extremely preterm (≤27+6). Estimation of the gestational age was based on data for the last menstrual period, unless there was a discrepancy of more than seven or 14 days at the first- or second-trimester ultrasonography measurements, respectively. Information on gestational age was missing in 8,754 (0.6%) cases, which were therefore excluded from the data. Information on in-vitro fertilization (IVF) that included also intracellular sperm injection (ICSI) and frozen embryo transfers (FET) was only available from 1991 onwards. However, only 170 IVF children were born in Finland prior to 1991. Maternal smoking was recorded as either non-smoking or smoking, and after 1991, information on women who had quit smoking during the first trimester was also used. Data on maternal height and weight were available from 2004, and body mass index ) was adjusted only for the years 2004−2010. Small for gestational age (SGA) was defined as fetal growth more than 2 SDs below the sex- and gestational age-specific reference mean (Unpublished MBR data). Socioeconomic status (SES) groups were based on maternal occupation at the time of birth and categorized as upper white-collar workers, lower white-collar workers, blue-collar workers, and others as described elsewhere Information on congenital anomalies was taken from the national Congenital Malformations Register established in 1963 and currently maintained by the THL. The register includes data on major congenital anomalies. The two data sources were linked together using encrypted unique personal identification numbers.The data included all singleton births  for the years 1987–2010 in Finland.The permission to use the confidential register data in this study was approved February 16th in 2012 by the National Institute for Health and Welfare (THL) in Finland. (Reference number 1749/5.05.00/2011). We used only anonymized data, and thus informed consent of the registered individuals was not needed.Statistical differences in frequencies  between the preterm birth groups were evaluated by the Chi Square test. Differences between continuous variables were evaluated by Student’s t and Mann Whitney’s U tests as appropriate. Multivariable logistic regression analyses were used to model the risk factors separately for each preterm birth group . In the multivariable analyses, the reference population included women who delivered at term . Possible independent variables were selected based on bivariate analyses (p<0.05). Differences were deemed to be significant if p<0.05. 95% confidence intervals (CI) were also calculated.Furthermore, to examine the contribution of reproductive risk factors  and obstetric interventions  to preterm birth incidence between SES groups, we measured the percentage reductions for each preterm birth group by using logistic regression. Reproductive risk factors and obstetric interventions were added separately to model 3 , and the percentage reduction in the odds ratio (OR) of each preterm birth group was measured. The formula used was: (OR Model 2– OR Model ×)/(OR Model 2–1) The study population corresponded to all singleton births  in Finland from 1987–2010, of which 4.6%  were preterm (≤36+6 weeks). Of all the preterm births, 0.3%  were classed as extremely preterm, 0.4%  were very preterm and 3.9%  moderately preterm, as shown in The risk factors of preterm birth appeared to fall into two groups: those contributing to the incidence over the entire range of preterm birth and those contributing to the incidence of only the most extreme class preterm births. Risk factors placing women at a high risk (adjusted odds ratio (aOR) >2.0) of extremely, very and moderately preterm births were SGA, placenta previa, placenta abruption, stillbirth and major congenital anomaly, whereas IVF, amniocentesis and anemia were only associated with a high risk of extremely preterm birth .Risk factors placing women at a moderate risk (aOR<2.0) of extremely, very and moderately preterm births were advanced maternal age, primiparity, obesity (BMI≥30), smoking, being single, of low socioeconomic status, prior miscarriages, prior terminations and male fetal sex . FurtherThe contribution of reproductive risk factors of preterm birth and obstetric interventions to socioeconomic disparities in preterm birth were studied by using logistic regression and comparing the percentage reductions in the ORs, as shown in www.thl.fi). Our data did not include late terminations of pregnancies, since the Finnish ICD-10 classification excludes them from perinatal mortality rates. The main finding of the present study was that smoking alone made the largest contribution and explained in the order of up to 33% of the difference in extremely and moderately preterm incidence and very preterm incidence between SES groups, whereas the contributions of reproductive risk factors  explained about 8−25% of the difference in preterm birth incidence between SES groups.The aim of the present study was to identify risk factors of singleton preterm births, and to quantify the contribution of risk factors to the socioeconomic gradient in preterm birth incidence using the total population of singleton birth for the years 1987–2010 in Finland. The secular trend of preterm births was decreasing and the total rate of preterm births (4.6%) for the years 1987–2010 was low compared with the rates of 5–7% reported for other developed countries The results of the present study confirmed the multifactorial etiology of prematurity and showed that SES plays a substantial role in preterm births, even after adjustment for numerous birth characteristics and reproductive risk factors. The incidence of preterm births was mostly higher among blue-collar compared to white-collar workers, which may be due to differences in occupational exposures, lifestyle factors and health-promoting behavior between the groups. However, a possible limitation of the study is that the SES groups were based solely on the maternal occupation at time of birth and no information on the father’s occupation was available. Further, cases with missing SES information were close to the general population, not outliers, implying that the bias brought about by the missing data was unlike to affect the results significantly.Our results also suggested an association between preterm births and several reproductive risk factors, such as primiparity, advanced maternal age, congenital anomalies, IVF, and obesity, which have also been identified in previous studies A novel finding was that amniocentesis, a common invasive prenatal diagnostic procedure, was associated with preterm births. However, amniocentesis may be a risk factor, suggesting causal association, or a non-causal indicator of high risk pregnancy. Previous results have only identified an association between pregnancy loss and amniocentesis; the total post-amniocentesis pregnancy loss rate was reported to be 1.9% in a previous systematic review The most important strength of our study was that the data derived from the mandatory, national Finnish Medical Birth Register (MBR) covered the entire population, and therefore offered a comprehensive insight into the trends and risks of preterm births. The content of the MBR is extensive, and thus it offered a unique opportunity to use numerous birth characteristics, perinatal outcomes and socioeconomic factors as exposures. To the best of our knowledge, the present study population is one of the largest studied to date, and the main outcome measure was adjusted for numerous background information such as socioeconomic factors and birth characteristics. Further, unlike previous studies, we quantified the contribution of risk factors to preterm birth incidence. Further, the MBR has been shown to have excellent data coverage and quality We conclude that our most important finding was that smoking as a marker of lifestyle contributed the most, explaining about 10−30% of the differences in extremely, moderately and very preterm birth incidence between SES groups. This is a clearly recognizable risk group, and therefore an ideal target for interventional attempts to reduce the incidence of preterm birth. Further, smoking is a modifiable risk factor, and thus advocating smoking cessation for pregnant women and women attempting to become pregnant seems to be advisable. It is, however, unknown how much of this risk is causal and how much of the risk remains after quitting smoking since the cluster of the risks brought about by lifestyle is probably present without smoking.Identifying preventable causes of prematurity is one of the most significant challenges in perinatology and health research. Similar to previous studies, the etiology of prematurity appeared to be multifactorial and the risk profile included several reproductive risk factors, lifestyle factors and socioeconomic status. However, up to 78% of the incidence of preterm birth remained unexplained and the reasons were variable, maybe even specific for each case.


Every Women Every Child strategy, a target was set for 50% reduction in preterm deaths by 2025. Three analyses informed this target: historical change in high income countries, recent progress in best performing countries, and modelling of mortality reduction with high coverage of existing interventions. If universal coverage of selected interventions were to be achieved, then 84% or more than 921,000 preterm neonatal deaths could be prevented annually, with antenatal corticosteroids and Kangaroo Mother Care having the highest impact. Everyone has a role to play in reaching this target including government leaders, professionals, private sector, and of course families who are affected the most and whose voices have been critical for change in many of the countries with the most progress.Preterm birth complication is the leading cause of neonatal death resulting in over one million deaths each year of the 15 million babies born preterm. To accelerate change, we provide an overview of the comprehensive strategy required, the tools available for context-specific health system implementation now, and the priorities for research and innovation. There is an urgent need for action on a dual track: (1) through strategic research to advance the prevention of preterm birth and (2) improved implementation and innovation for care of the premature neonate. We highlight evidence-based interventions along the continuum of care, noting gaps in coverage, quality, equity and implications for integration and scale up. Improved metrics are critical for both burden and tracking programmatic change. Linked to the United Nation's Reproductive Health's standard process for supplements and may feature some variations in content when compared to the original report. This co-publication makes the article available to the community in a full-text format.This article is part of a supplement jointly funded by Save the Children's Saving Newborn Lives programme through a grant from The Bill & Melinda Gates Foundation and March of Dimes Foundation and published in collaboration with the Partnership for Maternal, Newborn and Child Health and the World Health Organization (WHO). The original article was published in PDF format in the WHO Report "Born Too Soon: the global action report on preterm birth" (ISBN 978 92 4 150343 30), which involved collaboration from more than 50 organizations. The article has been reformatted for journal publication and has undergone peer review according to  Born Too Soon report, published in 2012, drew global attention to the issue of preterm birth and reported that more than 1 in 10 of the world's babies are born too soon each year, 15 million each year . Fo. Fo30]. Improved and consistently applied epidemiologic definitions and methods, with clearly defined preterm phenotypes, are the foundation for improved understanding of the burden of preterm birth ,32 and aDiscovery research focuses on better understanding the causes and mechanisms of preterm birth and elucidating factors that regulate uterine quiescence, initiation of labour, and the multiple host, agent, and environmental factors that cause aberrations in these normal processes of pregnancy. Understanding the reasons for racial and ethnic disparities in preterm birth will advance the field of pregnancy health broadly, as well as accelerate solutions for those populations most in need. A multi-disciplinary approach is needed to identify women at risk and discover new strategies for prevention including potential biomarkers, such as genomic, microbial, immunologic, and hormonal factors.Although infectious and inflammatory processes contribute to a high proportion of early spontaneous preterm births , antibioEquipment and commodities are considered essential for neonatal care units in high-income countries, yet for many such units in low-income settings, basic equipment and essential medicines are not available or functional. Development of robust, fit-for-purpose equipment, is a critical next frontier for referral care for premature babies in the settings where most die, especially for care in hospitals . Some exDelivery or implementation research addresses how interventions can be best implemented, especially in resource-constrained settings where coverage inequalities are more pronounced so that all families are reached with effective care. Implementation research and program evaluation evaluates how best to achieve wide scale coverage of interventions, including prevention particularly family planning and such as care of women with infectious diseases such as malaria, HIV and STIs; improved nutrition; smoking cessation; and reducing maternal workload. In many high-income countries and those with emerging economies, there is evidence of an increase in late preterm deliveries due to elective inductions and caesareans without clear medical indication . More inThe vast majority of published studies on neonatal care relate to high-technology care in high-income settings . ImplemeUnderlying this entire research agenda is the development and implementation of the capacity to advance the science of prevention of preterm birth, manage preterm labour and improve care of premature babies. Standard case definitions of the types and causes of preterm birth are being developed ,32 and wTo understand the impact of evidence-based interventions on deaths due to complications of preterm birth, we considered analyses including historical data from high income countries Figure , recent The historical data from the United States and United Kingdom Figure  shows thBasic care and infection case management interventions have an effect on neonatal deaths and on deaths amongst moderate and late preterm births, which account for over 80% of preterm births.More targeted care is necessary for reducing deaths among babies 28 to <32 weeks and this reduction could be accelerated as higher-impact interventions are now known, such as antenatal corticosteroids, surfactant, KMC and other enhanced methods of infant warming and feeding which were not available in the mid-20th century in the United States and United Kingdom.Intensive care may be necessary to reduce deaths among extremely premature babies (< 28 weeks), who account for 5% of all premature babies though a larger proportion of deaths.LiST) analysis examining projected lives saved with interventions for preterm birth was conducted for 75 Countdown to 2015 priority countries . LiST is a free and widely used module in a demographic software package called Spectrum, which allows the user to compare the effects of different interventions on the numbers of maternal, neonatal and child deaths and stillbirths, as well as stunting and wasting [A Lives Saved Tool  could be saved in 2025 if these interventions were made universally available (95%). Full coverage of antenatal corticosteroids alone resulted in high mortality reductions, a 41% decrease from 2010 [Table Born Too Soon report initiated a process towards achieving goals for preterm birth prevention and presented a new goal for the reduction of deaths due to complications of preterm birth   ensuring that every woman and child who needs an intervention receives it, then, according to the is Table  and the is Table , countriBorn Too Soon is sobering in the news of a large burden and in the personal stories of loss behind that burden. Yet this is also a story of hope in the significant opportunities for change, especially as we approach the final sprint for the MDG 4 target and aim to maintain momentum beyond 2015. These first-ever country estimates of preterm birth leave us without the excuse of ignorance [gnorance . In 2010gnorance . AdditioEvery Woman Every Child [A number of specific actions, pursued by all partners and applied across the RMNCH continuum of care, will help prevent preterm birth and associated mortality, and have an immediate, profound and sustained impact on human capital. The seven constituencies, as identified by ry Child , have foBring both financial and other resources to address maternal and newborn health and the burden of preterm birth.• Adapt integrated packages of care, considering contexts, and tailored to local health service delivery channels.• Increase reach of existing preventive interventions in the preconception period, especially family planning, and including adolescent-friendly services.• Ensure that every woman receives the high-quality care she needs during pregnancy, birth and postnatally, especially if she is at risk of preterm birth. There should be greater emphasis on the universal provision of antenatal corticosteroids, building on the work of the UN Commission on Life-Saving Commodities for Women and Children as an opportunity to accelerate progress.• Undertake immediate action to scale up KMC as a standard of care for all preterm babies under 2,000 grams, regardless of resource setting.• Improve methods for diagnosing and treating prematurity-related impairment in childhood.• Ensure that every family has the support they need, immediately after birth of a premature baby, following its loss, or living with a child with prematurity-associated disability.Parents, advocates and civil society have captured the attention of governments and monitored progress in the United States through support of an annual Premature Birth Report Card. The Report Card, a familiar means of assessing progress for school-age children, has been a powerful tool used in the United States to prevent preterm birth and its serious health consequences. These grades, used as a rallying point, have helped bring visibility and promote change. Issued by the March of Dimes every year since 2008, the Report Cards assign a letter grade to the United States and to each of 50 state governments. In addition, they summarise the actions that must be taken to fund prevention programs, address health care access and bring about needed change in health care systems.Transparency and objectivity of the data and analysis are important factors in the success of the Report Cards. Each year, great care is taken to explain the methodology for grade determination and the basis of comparison to other states. Use of the Report Card grades by state governments has grown since the Report Cards were first launched in 2008, and coverage by local media is consistently strong.One southern U.S. state, with the second highest preterm birth rate in the country, has received an "F" on its Report Card every year since 2008. The failing grade mobilised state health officials in early 2012 to launch a statewide initiative with the goal of reducing rates. In this state and many others, media events featuring prominent public officials are held to announce Report Card grades or report on state progress to address preterm birth. The U.S. Surgeon General has also participated in media outreach to publicise the Report Cards and their recommended actions.Sustained effort by healthcare leaders and advocates at all levels, inside and outside of government, has elevated the issue of preterm birth on the nation's health agenda, contributing to an announcement of new federal resources to test promising practices in February 2012. Soon after, the Association of State and Territorial Health Officials (ASTHO) joined with the March of Dimes to ask state health officials to pledge to reduce preterm birth rates in their states, and the pledge was incorporated into Report Cards. Top health officials in every state, along with Puerto Rico and the District of Columbia, signed the pledge.As federal and state governments devote attention and resources to the problem, the Report Cards will continue to mobilise stakeholders and mark progress.http://www.marchofdimes.com/mission/prematurity-reportcard.aspxMore information is available at Improve the data for preterm birth rates, mortality, impairment and their causes, with regular tracking of coverage, quality and equity gaps, as is done through Countdown to 2015 and linked to the work of the Commission for Information and Accountability using the data for action and accountability, including the establishment of national birth registrations.Conduct multi-country collaborative research on the:• Etiology of preterm birth, advancing the understanding of strategies to prevent and treat maternal health conditions associated with preterm birth  and improving identification of diagnostic markers and related screening tools.• Implementation research to develop and deliver innovations to reach the poorest.Table Born Too Soon movement see the report and this supplement as important next steps towards a world where every woman, every newborn and every child is given the best chance to survive and thrive.All of the partners, donors and contributors involved in the Over the last decade, the world has changed. Just as it is no longer acceptable for people with HIV/AIDS to remain untreated because they live in poor countries, it is no longer acceptable for women to die while giving birth. Likewise it should be unacceptable for almost 3 million newborns, to die, including those who are born too soon. Over three-quarters of premature babies who die could be saved if basic care reached them and their mothers. Rapid progress is possible. At the same time, research and innovation for preterm birth prevention is urgent. These actions would reduce disability and chronic disease, improve reproductive and maternal health, and build sustainable health systems. We need more frontline health workers who are skilled and confident in newborn care. We need facilities equipped with life-saving commodities, and girls, and women who are educated, and enabled, can protect their own health, and that of their babies.KMC: Kangaroo Mother Care; PMNCH: Partnership for Maternal, Newborn and Child Health; pPROM: Prelabour premature rupture of membranes; RMNCH: Reproductive, Maternal, Newborn and Child Health; STI: Sexually Transmitted Infection; WHO: World Health Organization.The authors declare that they have no conflict of interestThe chapter was coordinated by JEL with MVK; drafted by JEL, MVK, CPH, EL and all other authors reviewed and contributed.The time of JEL and MVK was funded by a grant from Bill & Melinda Gates Foundation to Save the Children's Saving Newborn Lives programme. The Born Too Soon report was funded by March of Dimes, the Partnership for Maternal, Newborn and Child Health and Save the Children. The Born Too Soon series in Reproductive Health was funded by March of Dimes and Save the Children. Funding from Save the Children is provided by a grant from Bill & Melinda Gates Foundation to Save the Children's Saving Newborn Lives programme.In line with the journal's open peer review policy, copies of the reviewer reports are included as additional file Click here for file


EHP 120(12):1739–1745; Pedersen et al.].Many commonly eaten foods contain acrylamide, a known neurotoxicant and suspected human carcinogen. Previous animal studies have suggested acrylamide may also cause reduced birth weight in prenatally exposed offspring. Investigators now report an association between higher concentrations of acrylamide and glycidamide hemoglobin adducts in umbilical cord blood and reduced birth weight in children of women who ate diets rich in acrylamide [Acrylamide forms during frying or high-temperature baking of carbohydrate-rich foods such as fried potatoes, potato chips, cookies, and breakfast cereals. Within the body, acrylamide and its metabolite glycidamide form adducts, or chemically joined products, with proteins and DNA. These adducts can potentially disrupt genetic and biological functions.Pregnant women at 11 locations in Denmark, Greece, Norway, Spain, and England participated in the study during 2006–2011, and the investigators used information on 1,101 mother–child pairs. Demographic and detailed dietary information was collected from all the women, umbilical cord blood samples were obtained at birth, and birth information was extracted from medical records.Acrylamide and glycidamide hemoglobin adducts were found in all cord blood samples, and levels tended to be higher if the mother smoked. Subsequent analyses accounted for maternal smoking as well as other potentially confounding factors, such as length of pregnancy, child’s sex and country of birth, and mother’s age, prepregnancy weight, and ethnicity.The investigators found an association between decreasing birth weight and increasing levels of adducts. In a comparison of the highest and lowest quartiles of exposure among children of nonsmoking mothers, acrylamide and glycidamide were associated with average birth weight decreases of 107 and 103 g (3.8 and 3.6 oz), respectively. These decreases are comparable with those attributed to moderate smoking during pregnancy. Reduced birth weight is linked with adverse health effects such as impaired growth and development early in life and increased incidence of cardiovascular disease, diabetes, and osteoporosis in adulthood.The availability of adduct measurements and the large, well-characterized study population are key strengths of the study. However, there remained the potential for unmeasured or uncontrolled factors to influence the results. Furthermore, it was not possible to precisely characterize dietary acrylamide intake, because even in the same types of foods, levels can vary depending on manufacturing and preparation methods. If confirmed by further research, the results of this study suggest that pregnant women may benefit from reduced consumption of acrylamide-containing foods.


Birth defects are defined as those conditions that are substantially determined before or during birth and which are recognizable in early life. They are an important cause of morbidity and mortality in infants. The main objective of the study was to determine the association of certain risk factors with birth defects occurring in pediatric patients seeking care in Civil Hospital, Karachi.This was a prospective, cross-sectional study conducted at Department of Pediatrics: Units I, II and III of Civil Hospital Karachi, which is a tertiary care hospital located in the city center. These units provide care to pediatric patients from all over the country, with majority belonging to a low socioeconomic background. All infants with at least one birth defect were approached and their mothers interviewed. Demographics of both the mother and the infant were noted. Questions regarding possible exposure to risk factors were asked. Infants who were not accompanied by their mothers were excluded from the study.A total of 587 out of 669 infants completed the study successfully. Of these, defects related to urogenital system (19.9%) were the commonest, followed by those related to eye (16.9%), musculoskeletal system (12.9%), body wall defects (12.3%), oral cavity (12.1%), central nervous system (10.9%), gastrointestinal tract (3.2%), cardiovascular system (2.7%) and those related to ear, nose and throat (1.2%).669(4.1%) out of a total of 16,394 pediatric patients visiting the hospital during our study were identified as having at least one birth defect. The commonest ones were those related to the eye and the urogenital system. The main factors that influence the occurrence can be grouped into maternal, socioeconomic, nutritional and educational. Birth defects are defined as ‘those conditions that are substantially determined before or during birth and which are, in principle, recognizable in early life’ . Some ofThus, a broad definition of birth defects includes not only anatomical defects but also molecular and cellular abnormalities present at birth . A WHO dBirth defects usually occur during organogenesis (between 3rd and 8th week of gestation). They may result in complete or partial absence of an anatomical part or alteration of its normal configurations. Mostly, these are caused by environmental or genetic factors acting independently or in concert. Major structural anomalies occur in 2% to 3% of live born infants. An additional 2% to 3% are recognized in children by age 5 years, for a total of 4% to 6% [Some of these disorders are obvious at birth, for e.g. cleft palate; some, such as congenital dislocation of the hip (CHD), may escape early detection, while others may not become apparent until much later in life, for e.g. patent ductus arteriosus (PDA). Internal defects, when they are not lethal, may often go unrecognized. However, in any case, these defects are a major cause of morbidity and mortality in infants worldwide, accounting for as many as 260,000 deaths  in the year 2004 alone [Many studies have been conducted to determine the association of various risk factors with the incidence of birth defects. For example, folic acid supplementation has long been implicated in the prevention of neural tube defects and other major defects . SimilarThe prevalence of birth defects varies widely, depending on the geographical locale. It was found to be 2.07% in Turkey, 2.39% in Europe, 1.5% in Japan and 1.96% in the United States . These nThe aim of our study was to assess the risk factors associated with various birth defects in pediatric patients seeking care in Civil Hospital, Karachi.This was a prospective cross sectional, interview-based study conducted during a three year period from 20th February, 2009 to 15th March, 2012 at Pediatrics I, II and III wards in Civil Hospital, Karachi, which is a public sector, tertiary care hospital. This hospital is a host to visitors from all parts of the country.Information regarding patients was obtained from patient records at the beginning of each session of study. Those found to have at least one birth defect were approached and their attendants (mothers) were interviewed. Those, whose mothers were not available at the time of interview, were checked at the end of the next session for a maximum of 5 times. The type of defect was noted down from the patient files along with other parts of the questionnaire.All infants who were diagnosed with having at least one birth defect were included. Those subjects, whose mothers were not available for interview after 5 attempts, were excluded from the study.The Ethical Review Board of Dow University of Health Sciences approved the study. Subjects’ attendants were informed of their right to refuse and of the respect of the confidentiality of their answers. Informed, written consent was obtained from all attendants.The questionnaire was divided into four sections. The first section dealt with demographic data of the child, which consisted of age, sex, birth weight, ethnicity, religion, residence and socioeconomic status. The second section was concerned with data regarding the child’s mother. It included questions regarding maternal comorbidities, gestational age, gestational period, occupation and education level of the mother. The third section contained a series of Yes/No questions regarding exposure to various risk factors. The fourth section involved noting down the name of the specific defect from the patient file.A pretest of the interview questionnaire was conducted on a sample of 13 infants to determine its effectiveness. The questionnaire was edited in order to overcome the shortcomings encountered in the pretest.Data from the questionnaire was entered in SPSS  version 14 for analysis.A total of 16,394 pediatric patients visited the hospital during our study period out of which 669(4.1%) were classified as having at least one birth defect. A total of 587 patients out of 669 were evaluated completely during the course of study (response rate 87.7%). The decrease was due to non-availability of child’s mother, or due to failure to give consent.Data regarding patients’ demographics is illustrated in Table Maternal Characteristics are elaborated in Table Table Table This is only the first study of its kind in Pakistan that aims to assess the risk factors for certain birth defects at a tertiary care center. It is also, according to our knowledge, the first prospective, interview-based study conducted on this topic. The percentage of affected individuals in our study (4.1%) is also quite high compared to studies from other parts of the world. This could be due to the fact that the study was conducted in a hospital setting, where only those infants are admitted who need special care.A higher percentage of males was found to be affected compared to females. This finding is consistent with that of Shaw et al. who observed an increased risk for most systems even after adjusting for confounders . The malA large percentage of our subjects (38.7%) was born before 37 weeks. Kase et al. reported a reciprocal relationship between being born preterm and the presence of birth defects, which is consistent with our findings . HoweverMaternal factors have been found to play an important role in the presentation of birth defects. Most mothers, in our study group, were over the age of 30. A high incidence of defects has been observed for both extremes of ages in multiple studies -23. MateMaternal Education also has an indirect effect on the incidence of birth defects . In our Certain maternal comorbidities have been linked with an increased incidence of birth defects. Mothers with preexisting or gestational diabetes generally have a higher incidence of birth defects, with the cardiovascular, musculoskeletal and central nervous systems being the most affected -30. HoweAmong maternal risk factors, folate supplementation, cigarette smoking and exposure to x-rays occupy a significant position. Neural tube defects, which include spina bifida and encephaloceles, have long been linked to folic acid supplementation -33. In oAmong social factors, consanguineous marriage has been repeatedly found to have an association with birth defects ,44. In oIn conclusion, the percentage of affected individuals in our setting has been found to be greater than in other similar studies. The main factors that influence the incidence can be grouped into maternal, socioeconomic, nutritional and educational.The most important limitation of our study was that we included only live infants, who had their mother available to answer the questions. Secondly, stillbirths were not included in the study. The study was conducted in a hospital setting which does not truly represent the percentage throughout the country.This is one of the first studies on the epidemiology of congenital malformations in Pakistan. In our effort to make it as extensive as we possibly could, we included even those malformations, whose classification as congenital was debatable, or which although predominantly found after birth, also occurred as birth defects.Certain malformations, such as congenital heart defects, have been underrepresented in our study. Their low percentage finds its roots in the prospective nature of the study. Although all attempts were made to ensure the maximum number of cases were included, a certain percentage could not be reached and thus not included in the study. Furthermore, although such malformations affect a significant percentage of Pakistani infants, a large percentage of them either dies, or is referred to special centers (eg NICVD) for emergency treatment, with only few remaining in tertiary care centers. Since our study was conducted in just one tertiary care center, many cases could not be included. This has led to a significantly low percentage of these relatively common birth defects in our sample.The authors declare that they have no conflict of interests.AS, MZR and SSA conceived the idea and were involved in data collection, analysis and drafting of the manuscript. SA and SMAN were involved in data collection and critically revising the manuscript. All authors have read and approved the manuscript.


A 27 year-old- lady was evaluated due to recurrent ventricular tachycardia. After performing echocardiography and cardiac MRI, she was found to have large pericardial cyst. Pathologic examination confirmed it as mesothelial pericardial cyst. Up to our knowledge it is the first presentation of simple pericardial cyst as ventricular a tachycardia. A 27 year-old lady was evaluated due to repeated episodes of ventricular tachycardia . She wasMesothelial pericardial cysts are benign intrathoracic lesions, usually found incidentally on chest X- ray in an asymptomatic patient or during investigation for common complaints such as chest pain and dyspnea . Cyst atSimple pericardial cyst usually manifests as a non-enhanced, well defined mass in the pericardium with low intensity on T1-weighted and high intensity on T2 weighted. Rarely, as was our case, due to high protein content of the cyst, high signal intensity is seen on T1-weighted images [This article emphasizes on the role of multi-imaging modality for accurate diagnosis in rare diseases esp. with uncommon presentations.


Achieving Millennium Development Goal 4 is dependent on significantly reducing neonatal mortality. Low birth weight is an underlying factor in most neonatal deaths. In developing countries the missed opportunity for providing life saving care is mainly a result of failure to identify low birth weight newborns. This study aimed at identifying a reliable anthropometric measurement for screening low birth weight and determining an operational cut-off point in the Uganda setting. This simple measurement is required because of lack of weighing scales in the community, and sometimes in the health facilities.This was a hospital-based cross-sectional study. Two midwives weighed 706 newborns and measured their foot length, head, chest, thigh and mid-upper arm circumferences within 24 hours after birth.Data was analysed using STATA version 10.0. Correlation with birth weight using Pearson’s correlation coefficient and Receiver Operating Characteristics curve analysis were done to determine the measure that best predicts birth weight. Sensitivity and specificity were calculated for a range of measures to obtain operational cut-off points; and Likelihood Ratios and Diagnostic Odds Ratio were determined for each cut-off point.Birth weights ranged from 1370–5350 grams with a mean of 3050 grams (SD 0.53) and 85 (12%) babies weighed less than 2500 grams. All anthropometric measurements had a positive correlation with birth weight, with foot length showing the strongest (r = 0.76) and thigh circumference the weakest (r = 0.62) correlations. Foot length had the highest predictive value for low birth weight (AUC = 0.97) followed by mid-upper arm circumference (AUC = 0.94). Foot length and chest circumference had the highest sensitivity (94%) and specificity (90%) respectively for screening low birth weight babies at the selected cut-off points. Chest circumference had a significantly higher positive likelihood ratio (8.7) than any other measure, and foot length had the lowest negative likelihood ratio. Chest circumference and foot length had diagnostic odds ratios of 97% and 77% respectively. Foot length was easier to measure and it involved minimal exposure of the baby to cold. A cut-off of foot length 7.9 cm had sensitivity of 94% and specificity of 83% for predicting low birth weight.This study suggests foot length as the most appropriate predictor for low birth weight in comparison to chest, head, mid-upper arm and thigh circumference in the Uganda setting. Use of low cost and easy to use tools to identify low birth weight babies by village health teams could support community efforts to save newborns. Globally neonatal mortality is 23/1,000 live births and it contributes to 60% and 40% of infant and under 5 mortality respectively. A third of all neonatal deaths occur in Sub-Saharan Africa, where neonatal mortality rate (NMR) is 35/1000 live births. While infant and child mortality have decreased over the last 20 years, neonatal mortality has almost remained unchanged and this has resulted in an increase in the proportion of infant and child deaths that occur in the neonatal period [Low birth weight (LBW), defined as a weight less than 2500 grams, is an underlying factor in up to 70% of neonatal deaths in developing countries . Low birStudies have been conducted in various settings to identify anthropometric surrogates for low birth weight. The anthropometric measurements that have been studied include; body length, foot length, head, chest, thigh, calf and mid-upper arm circumference -12. GeneThe study was carried out in Iganga-Mayuge Health and Demographic Surveillance Site, Eastern Uganda. Iganga and Mayuge Districts are predominantly rural, with 70% of the population living within five kilometres of a health facility. The area is served by one hospital and several lower level health centres. Preliminary results of the Uganda Demographic and Health Survey 2010/11 indicate that neonatal and infant mortality rates are 22.3 and 77.5 per 1000 live births respectively in the Eastern region of Uganda.This was a hospital-based cross-sectional study carried out in Iganga General Hospital. Two hospital-based midwives and one doctor  were trained by the principal investigator for three days, on how to measure the newborns’ foot length, head, chest, thigh and mid-upper arm circumferences. Informed written consent was obtained from the mothers before their babies were measured. A sample size of 512 was obtained using Buderer’s formula with the following assumptions: sensitivity – 80%, LBW prevalence – 12% , absolute precision of sensitivity – 10% and α – 5% . Data weFor each recruited baby, the following measurements were done within 24 hours after birth: 1. Head circumference was measured between the glabella anteriorly and along the occipital prominence at the back of the head; 2. mid-upper arm circumference (MUAC) was measured at the midpoint between the tip of the acromion process and olecranon process of the left upper arm; 3. chest circumference was measured at the nipple level at the end phase of expiration; 4. thigh circumference was measured at the lowest furrow of the gluteal region using a flexible non-elastic measuring tape; 5. foot length was measured from the heel to tip of the big toe using hard transparent plastic ruler.t-test. Correlation with birth weight was determined using Pearson’s correlation coefficient. Receiver operating characteristics (ROC) analysis was conducted separately for each measure and the area under the curve (AUC) calculated to explore which measure best predicted birth weight. Sensitivity and specificity were calculated for a range of measures to obtain operational cut-offs that could be used to identify small babies in the community. This operational cut-off was taken as the value with the highest average value for sensitivity plus specificity i.e. the lowest total misclassification error rate. Positive likelihood ratio (+LR), negative likelihood ratio (-LR) and diagnostic odds ratio (DOR) were determined at each cut-off point. This study was approved by Makerere University School of Public Health Institutional Review Board and Uganda National Council of Science and Technology.The measurements were taken in centimetres to one decimal place. Birth weight was measured with a digital salter scale to the nearest 10 grams. The scale was calibrated before each use using a bottle weighing 1000 grams. The midwives and a clinical supervisor, who is a medical doctor, were trained for three days on how to take the measurements. For each measurement, two readings were done by one midwife and the average was taken. The clinical supervisor performed two repeat measurements for each test for 1 in every 30 study participants to check for reliability. Data were analysed using STATA version 10.0. Five babies with missing data were excluded from the analysis. For each anthropometric measure, the mean, standard deviation and difference between the means of normal weight and LBW babies were calculated using Student’s During the 15 weeks period, there were 753 live births, of which 711 (94%) newborns were recruited into the study. Five babies had missing data, so analysis was done for data collected from 706 babies.Three hundred and eighty babies (54%) were male. The birth weights ranged from 1370–5350 grams with a mean of 3050 grams (SD 0.53) with 85 (12%) babies having a birth weight less than 2500 grams.In addition to measurements taken by the midwife, repeat measurements were taken by the supervisor in 24 cases. Inter-observer agreement was tested using the Kappa statistic and the results were as follows; weight-0.46, HC-0.34, FL-0.30, MUAC-0.28, CC-0.22 and TC 0.18 and p < 0.01.t-test (p < 0.001) [Table There was a significant difference in means of the normal weight and LBW groups for all measurements as shown by Students  p < 0.00 [Table 12) for the various measurements are shown in Table All the anthropometric measurements were correlated with birth weight, with Pearson correlation coefficients between 0.62 and 0.76, which are categorised as moderate to strong correlations according to Dancey and Reidy’s categorisation . The corFor each anthropometric measure, sensitivity and specificity for the whole range of values were calculated and operational cut-off points determined by taking the value with the highest average of sensitivity and specificity. At the proposed cut-offs, FL and CC had the highest sensitivity 94%) and specificity (90%) respectively for screening LBW babies. Sensitivity of FL, MUAC, TC and CC were not significantly different except for HC which was significantly lower. Specificity of CC was significantly higher than for all other measurements Table . Likelih% and speThis study shows that LBW newborns in Uganda can be identified using anthropometric surrogate measures on the first day of life. In resource poor settings where neonatal mortality remains high and many births occur at home, the missed opportunities for either providing life saving care at home or referral are mainly a result of a failure to identify high risk LBW newborns. Anthropometric measurements have been found to be reliable in identifying LBW. However, studies show that the measure of choice and its cut-off point is dependent on the context ,14-16, t2, only 58% of the variation in foot length can be explained by the linear relationship between FL and birth weight. Other analysis  indicate that the two most appropriate measurements for identifying LBW in Uganda are FL and CC.Although in this study all the measurements could identify LBW to some degree, FL had a fairly strong correlation with birth weight (r = 0.76 and AUC = 0.97) although from the value of rA foot length cut-off of 7.9cm has a sensitivity of 94% and specificity of 83% for predicting LBW. At a cut-off of 7.9 cm the probability of a baby being low birth weight increases from 12% to 66% when the foot length is less than 7.9 cm  and in Iran (31.2 cm)  cm and i; and thaOn observation during the data collection, the midwives were finding it difficult to determine the exact point to measure the thigh, head and mid upper arm circumferences. Also timing the end of expiration to measure the chest circumference was challenging. This could have implications for use of these measurements by community health workers. However, foot length was practically easier and faster to measure. The ease with which foot length was measured compared to the rest makes it a preferred measure. A problem of accuracy of HC measurements due to moulding of the head especially when labour was prolonged or obstructed was noted by Dhar et al. . AnotherAlthough in this study, we did not test the usefulness of these measures after day 1 in identifying LBW, Marchant et al. demonstrated that foot length was a good predictor of LBW up to day 5 after birth . This woUganda has launched the Village Health Team concept which is compatible with the WHO and UNICEF recommendation to provide extra care for newborns at home . It invoIn using such a tool, we would be more concerned about minimising numbers of false negatives than false positives. This study tested HC, FL, MUAC, TC and CC, and showed that this is well achieved by FL. The potential risk of including babies that are falsely labelled LBW is minimal compared to the consequences of leaving out truly LBW babies.This being a hospital-based study, the estimates of LBW may not reflect what is in the community. The measurements were done by health workers but the tool will be used by community volunteers and their skills are likely to be different. However a validation of this tool will be done in the community with community volunteers. There was potential for bias by having the same midwife perform both gold standard and index measurements, but this was minimised by the investigator not knowing the cut-off points for the index measurements. The exclusion of very small babies could have led to under estimation of the true sensitivity and specificity since these are more likely to be observed by the proxy measurement.This study suggests that foot length is the most appropriate predictor for LBW given its high predictive values and ease of measurement in comparison to head, chest, thigh and mid-upper arm circumference. A FL cut-off of 7.9 cm had the lowest total misclassification error rate.Further research to establish how reliable foot length is when applied by non-medical persons e.g. community health workers and mothers themselves as compared to trained medical staff, as well as its acceptability is recommended. We also recommend further research to prospectively evaluate the foot length cut-off of 7.9 cm to screen LBW babies. Since some babies may not be visited on day one, studies should be done to determine the number of days after birth within which foot length remains useful for predicting LBW.The authors declare that they have no competing interests.NLE was responsible for the conception and design of the study, statistical analysis and interpretation, and drafting the manuscript. OGC contributed to the conception and design of the study, statistical analysis, interpretation, reviewing and revising the manuscript. KP contributed to statistical analysis and interpretation, and reviewing and revising the manuscript. All authors read and approved the final manuscript.NLE is a medical doctor with a Master of Medicine in Public Health. She is currently pursuing a PhD in child health with emphasis on low birth weight and newborn care practices in the community. She is a lecturer at the School of Public Health, Makerere University College of Health Sciences; and her areas of interest are maternal and child health, community health and health promotion.OGC is medical doctor with a doctorate in public health. He is Associate Professor and Head of the department of community health and behavioural sciences at the School of Public Health, Makerere University College of Health Sciences. He teaches maternal and child health and reproductive health including reproductive health care services organisation for populations living in emergency settings.KP is a medical doctor and holds postgraduate degrees in pediatrics, tropical medicine and a PhD in nutrition. He is a Professor at the Institute of Tropical Medicine, Antwerp, Belgium. He works in the field of child health and nutrition.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2431/13/54/prepub


When calculating life expectancy, it is usually assumed that deaths are uniformly distributed within each of the age intervals. As most of the infant deaths are neonatal deaths, this calls for a better assessment for that age group.The Flemish unified death and birth certificates database for all calendar years between 1999 and 2008 was used. A Kaplan-Meier survival analysis on a yearly basis was performed to assess the mean time-to-event and to compare survival curves between both genders.(k1) close to 0.09. Among those who died in the year after their year of birth yet before their first anniversary, no such concentration in time of the deaths is observed. Differences between the gender groups are small and generally not statistically significant.Over the last years, a slight though not steady decrease of the infant mortality rate is observed. In 2008, the probability among live births of dying before their first anniversary is 4.6‰ in boys and 3.5‰ in girls. The large majority (about 85%) of these have died in their year of birth. The mean survival time of deaths in their year of birth was found to centre around 1 month (about 30 days), which results in a 'mean proportion of the calendar year lived' Statistics Belgium, the federal statistics office, imputes a value for k1 equal to 0.1 for infant deaths in their year of birth when calculating life expectancy. Our data fully support this value. We think such refinement is generally feasible in calculating life expectancy. When calculating life expectancy, it is assumed that deaths are uniformly distributed within each of the age intervals, which translates into the imputation of an additional 0.5 years of life for the deceased in their year of death. This generally holds for all ages, except for the youngest age group, and probably for the oldest age group as well (above 80) -3.k notably inferior to 0.5 for the mean proportion of the calendar year lived by infants who die in their first year of life.Looking at infant mortality, the striking feature is indeed that most of the deaths among live births are concentrated in the very first days. This fact urges us to adopt some factor k by analyzing data for the Flemish Region in Belgium. Which kinds of k-factor(s) should be considered, however, depends on the sort of life table used.Our aim is to assess this factor Usually, life expectancies are derived from so-called period life tables in which age-specific mortality risks based on observations that occurred within successive birth cohorts in a given period of time , are applied to one hypothetical birth cohort under the assumption that the risks do not change over time.Two models of period life tables can be distinguished, depending on the kind of age groups that are observed: a) one with the age at the start of the calendar year , and b) one with the age at the last birthday ,4. This Figure st, also in its base triangle a1. In doing so, it is noteworthy that in model (a) with age attained on January 1st, each parallelogram depicting one age group or birth cohort actually covers 2 ages, whereas in model (b) with age at last birthday, each age group covers 2 birth cohorts .To calculate life expectancy (at birth), it is necessary to ascertain correct values for the person-years lived in each of the discerned parallelograms of the hypothetical cohort in both models, and in the case of the model with age reached on January 1t who survive until the end of the year, will on average have lived 0.5 years insofar as births are uniformly spread over the entire calendar year. This can be deduced from the length of the midline connecting the midpoints of the rectangular sides in triangle a1. On the other hand, the newborns of year t who have died in the set time interval depicted by triangle a1, will on average have lived some observed time length equal to k1 years, with k1 less than 0.5, or even less than the expected value (0.25) for that time interval, given uniform distributions of births and deaths.In model (a), we assume that the newborns of year t who reach their first anniversary, will all have lived 1 year. The infants who died in their first year of life, will either have died before the end of their year of birth (in triangle a1), or else in the next year before their first anniversary (in triangle a2'). The mean proportion of the calendar year lived by the deceased infants is then the weighted average of the mean proportions observed in both discerned periods, that is k = k1*w1 + k2*w2. In this, k1 refers to the mean proportion of a calendar year lived by the deceased in the base triangle (a1) and k2 refers to the mean proportion of a calendar year lived since birth by the deceased in the next triangle (a2') during their imagined passage through parallelogram A' (comprising both triangles). The weights w1 and w2 then refer to the proportion of infant deaths in the year of birth or in the next year before the first anniversary, respectively. From the figure, it should be clear however that k2 and w2 are actually derived from observations made in the former birth cohort .In model (b), parallelogram A' shows on the hypothetical cohort that the newborns of year The data source for this research is the Flemish unified death and birth certificates database, which is operated by the Flemish central administration. This contains data of all live births and all deaths of infants with a legal residence in the Flemish Region, that were registered in either the Flemish or Brussels Capital Regions. It includes births and deaths in the resident refugee population.More particularly, our analyses include the following data for all years of birth between 1999 and 2008:• the number of registered live births for mothers with legal residence in the Flemish Region, by year of birth and by gender;• the number of registered deaths of infants with legal residence in the Flemish Region that died in their year of birth (excluding still births). This is broken down by the number of days lived, by year of birth and by gender;• the number of registered deaths of infants with legal residence in the Flemish Region that died in the year following their year of birth but before their first anniversary. This is broken down by number of days lived, by year of birth and by gender.To examine the time-to-event of interest, i.e. the number of days lived by the deceased either in their year of birth or in the following year before the first anniversary, a survival analysis was performed using SPSS 16.0 for Windows. More particularly the Kaplan-Meier procedure was applied, which makes it possible to compare survival distributions among subgroups. To test the equality of the survival curves, the Breslow chi-square statistic is reported in which time points are weighted by the number of cases at risk at that time point.It is important to note that 'the number of days lived' were recorded as 'completed days', i.e. those who died on their birthday have 0 days on their record, those who died the very next day have 1 day on their record, etc. Assuming a uniform distribution of deaths within the calendar day, this (again) leads to the substitution of an average of 0.5 days lived for those who died on their birthday, an average of 1.5 days for those who died the following day, etc. These averages on a daily basis were duly taken into account.Graphs of the survival functions within the year of birth are pictured, both on a linear scale and a log scale, the latter being more apt to picture small differences between subgroups Figure .k1) was derived from their mean survival time (in days). Likewise, the mean proportion of the calendar year lived by the deceased in the year after the year of birth yet before the first anniversary (k2), was derived from their mean survival time since birth (in days).The mean proportion of the calendar year lived by the deceased in the year of birth .Differences in proportions were tested with the usual independent samples t-test, assuming the validity of the central limit theorem for large samples. Only the Between 1999 and 2008, the number of registered live births per annum for mothers having their residence in the Flemish Region roughly ranged between 60,000 and 70,000, with boys slightly outnumbering girls (sex ratio close to 1.05). The lowest number of births was recorded in 2002 , the highest in 2008 .Figure P = 0.68).In addition, the figure displays (a) the probability of dying in the year of birth and (b) the probability of dying in the next year before the infant's first anniversary. This clearly shows that the large majority of those who died before their first anniversary actually did so in their year of birth. The average share for all observation years is 85% in males and 87% in females (P = 0.0071) and 2002 (P = 0.019).The probability of dying in the year of birth decreases from 4.6 to 4.0 per thousand live births (‰) between 1999 and 2008 in boys and from 3.8 to 3.2‰ in girls, with some fluctuations over that period. Note that a significant difference between both gender groups was found only for the years 2001 (P = 0.34).The probability of dying after the year of birth but before the first anniversary is much lower, with stable mortality rates well below 1 per thousand. The average for all observation years is 0.7‰ in males and 0.5‰ in females  for all observation years by gender. The value of k1 is quite stable over the years, on average 0.085 in males and 0.090 in females. Between the gender groups, no significant differences in survival graphs are reported.Table (k2), fluctuates between 0.43 (year of birth 2006) and 0.55 (2000) in males and between 0.36 (2002) and 0.67 (2008) in females. The average proportion for all observation years approaches 0.5, i.e. 0.502 in males and 0.495 in females.From Table Differences in survival graphs of the gender groups are generally not statistically significant on a yearly basis, the one exception being the year of birth 2000.Infant mortality has reached very low levels. Our figures for the Flemish Region come close to 4.5‰ for boys and 3.5‰ for girls. Recent figures for Belgium show rates below 5‰ , particuLooking at Figure k1) or the infants dying in the following year but before their first anniversary (k2).The main concern for this paper was to find which values are valid for the mean survival time since birth. The survival time is expressed as a proportion of the calendar year, for either the infants dying in their year of birth , we could write: k = 0.1*(0.86) + 0.5*(0.14) = 0.156. From a practical point of view, k equal to 0.15 would do, which is the value adopted by Statistic Belgium [In life tables with age at birth (model (b) in Figure  Belgium .Statistics Belgium, 13/02/2012).There are however some caveats. First, there is no complete coverage of all births and deaths. Indeed, the Flemish registration system does not cover those births and deaths of residents of the Flemish Region that took place in the Walloon Region or abroad, and of which the birth or death certificates were not presented to the Flemish authorities. These are rare events and their absence should normally have no impact on our results. The missed infant deaths might be considered as non-identified right-censored cases (i.e. lost-to-follow-up). To give an idea of its rarity, its share in the total number of infant deaths was 2.1%  for the calendar year 2007 . Considering that about half of the infant deaths occur within the first week after birth, in which time period we do not expect families to migrate much, the impact of the censored cases must be very small indeed. Besides, in population statistics the deaths of persons who officially left the population are generally no longer taken into account.k1 starts to change on the 3-digit precision level (from 0.0795 to 0.0788). The test for 2008 gives similar results (k1 changes from 0.0827 to 0.0825). Obviously, such small changes are negligible in the context of determining life expectancy at birth.Secondly, the calculation in days lived since birth tends to over-estimate the person-years lived by those who died in the very first days of life. If we were to count in hours instead, it would turn out that a) more infants died within the first period of twenty-four hours than recorded within the first calendar day , and b) these infants lived much less than half a day on average. For instance, in the year 2007 we find in our study population that an extra 21% deaths have occurred on the first natural day of life compared to the first calendar day (resp. 86 vs. 71 infants). The mean survival time in hours is 3.5 hours, which makes for 0.15 days instead of the hypothesized 0.5 days of life. As roughly a quarter of the deaths among the infants who died in their year of birth occurred on the calendar day of birth itself, this may have some impact. When putting this to the test for infants that have died in the first three days of life in 2007, we find that the value for Today, there is an important demand within the European Union for benchmarking, often with ranking of Member States  on some policy indicator. Generally, this is an interesting exercise provided equals are being compared with equals. For this reason, the European Demographic Observatory (ODE) of Eurostat published a manual with guidelines designed to harmonize algorithms for demographic indicators , includiODE stresses the fact that in the field of general population statistics both statistical quality and simplicity are key, which may call for a compromise. As births are usually followed up well in the year of birth, we think it feasible that at least for that time period (i.e. the base triangle on the Lexis diagram) a more precise assessment of the mean duration of life of deceased infants be taken into account. Here indeed, most of the infant deaths are concentrated, random variation is low and departure from a uniform distribution over time is largest. In our opinion, an estimate based on observations with a 1-digit precision may therefore meet the compromise.k-factors according to gender.Female babies in our study population show a somewhat better risk profile than their male counterparts, although the differences are minimal and generally not statistically significant on a yearly basis. By the same token, our data do not support the need to specify different values for the This is not to say that other factors have no predictive value. For instance, a study on stillbirths and infant mortality among hospital births by mothers aged 25 years and over in 1999 in the Flemish Region has shown that the educational level of the mother is an important determinant of foetal and, to a lesser degree, early neo-natal infant mortality . For cerInfant mortality in the Flemish Region of Belgium has reached very low levels. It remains to be seen, however, to what extent further progress will be possible.Statistics Belgium imputes a value equal to 0.1 for the mean proportion of the calendar year lived by the deceased in the year of birth (k1) when calculating life expectancy. Our data fully support this value. We think such refinement on the 1-digit precision level is generally feasible in calculating life expectancy.As most of the deaths in the year of birth are concentrated within the first week after birth, The authors declare that they have no competing interests.EP planned the analysis and drafted the manuscript. HC was responsible for the dataset, took part in the analysis and revised the draft paper. EH was responsible for the data processing, took part in the analysis and commented on the draft paper. All authors read and approved the final manuscript.


Congenital heart defect (CHD) is the most common major malformations in infants. Little is known about the main epidemiologic characteristics of CHD prevalence in Guangdong province, China. Our study was undertaken to investigate the time trends in the prevalence of CHD in Guangdong province from 2008 to 2012.Data were retrieved from the Guangdong Hospital-Based Birth Defects Monitoring System during 2008–2012. All infants more than 28 weeks of gestation and infants up to 7 days of age in monitoring hospitals were monitored. We used prevalence rate to describe the difference in prevalence of CHD between rural and urban areas. Odds ratio (OR) and 95% confidence interval (CI) for CHD were calculated for the rural and urban areas. The CHD rate was calculated on the basis of birth defects per 10,000 births.P < 0.01) and in rural areas (P < 0.01).A total of 1005052 births were reported to the Birth Defects Monitoring Network of Guangdong Province, of which 5268 cases were diagnosed as CHD. The overall prevalence of CHD was 52.41 per 10 000 births (95% CI: 51.00 ~ 53.83) in provincial-wide, 66.08 per 10 000 births (95% CI: 63.77 ~ 68.39) in urban areas, and 40.23 per 10 000 births (95% CI: 38.52 ~ 41.93) in rural areas. The prevalence of CHD increased with maternal age both in urban areas (The increasing trends of CHD prevalence suggest that maternal age and the improvement of diagnosis ability might play a critical role. Birth defects are the main causes of early miscarriage, perinatal death, infant death and child disabilities, which have been a global public health issue . CongeniEpidemiological studies in developed countries have indicated that a prevalence of CHD ranged from 4–10 per 1000 live births ,9,10. ThThe prevalence of CHD has been studied in developed countries for many years ,4, and iData were obtained from the Birth Defects Monitoring Network of Guangdong Province from 2008 to 2012. The monitoring system is hospital-based registry covering 58 hospitals across the province, and the hospitals at the county level or above were selected to participate. The program primarily monitors infants with birth defects who are born in hospitals. The subjects monitored by the network included live births and stillbirths who were delivered in hospital after at least 28 weeks of gestation. The clinical diagnosis of CHD was diagnosed within 7 days after delivery. Within this period, all diagnosed birth defects were required to be reported. The CHD was identified according to the International Classification of Diseases Clinical Modification Codes, tenth edition .CHD was defined as “a gross structural abnormality of the heart or intrathoracic great vessels that is actually or potentially of functional importance . An isolA registration form for birth defect cases was used to collect information for CHD cases. In the monitoring hospitals, the health care professionals examined every infant immediately after birth to screen for CHD. The diagnosis and verification must be completed within 7 days after delivery. For those affected by CHD, an inperson interview with the mother and medical record reviews were conducted to gather information by a trained doctor. The information is collected using a standard birth defects registration form. The data about deliveries, the number of perinatal infants, and sex of infants are collected using the Seasonal Report Form. The county-level staff submits the forms using the web-based data reporting system. The forms are checked by senior who are responsible for data quality in the monitoring hospital. When errors were identified, the form should be returned for verification. The monitors at the municipal and provincial levels should check the forms. Finally, the data was sent to the National Center for Birth Defects Monitoring , where the experts were responsible for the final confirmation of diagnosis, data checking and evaluating, and disease coding, etc. Because our data was obtained from the database of the Birth Defects Monitoring Network of Guangdong Province, and the data was de-identified and analyzed anonymously, our ethics committee waived the need for informed consent. We received permission from the Birth defects Intervention Group of Guangdong Province to use the data.2 test or Fisher exact test. We used Cochran-Armitage trend test for analysis of trend. Odd ratio (OR) was presented. All ORs were calculated relative to rural areas. A probability value of P < 0.05 was regarded as significant. Statistical analysis was conducted using SPSS for Windows version 13.0.Residential areas were categorized into rural and urban areas according to mother’s residence address during the pregnancy. The number of deliveries in the hospital after at least 28 weeks’ gestation was used as the denominator, and the number of infants diagnosed with CHD within 7 days of birth was used as the numerator. Prevalence estimates are reported per 10 000 live births. We used Poisson distribution to calculate 95% CI of CHDs and its subtypes prevalence. Prevalence rate was used to describe the type-specific difference between urban and rural areas. The significance of categorical variables was assessed by a χBetween 2008 and 2012, a total of 1005052 deliveries were reported to the Birth Defects Monitoring Network of Guangdong Province, of which 5268 cases were diagnosed as CHD. Baseline demographic characteristics of infants with CHD and their mothers are presented in Table The overall birth prevalence of CHD was 52.41 per 10 000 births (95% CI: 51.00 ~ 53.83) in provincial-wide, 66.08 per 10 000 births (95% CI: 63.77 ~ 68.39) in urban areas, and 40.23 per 10 000 births (95% CI: 38.52 ~ 41.93) in rural areas.The birth prevalence of CHD in urban areas increased from 59.33 per 10 000 urban births in 2008 to 107.78 per 10 000 urban births in 2012. In rural areas, the birth prevalence increased from 27.24 per 10 000 births in 2008 to 69.40 per 10 000 births in 2012. The results were shown in Table P < 0.01) and in rural areas (P < 0.01). The results were shown in Table Maternal age was divided into five different age groups: <20 years, 20–24 years, 25–29 years, 30–34 years and ≥35 years. The birth prevalence of CHD increased with maternal age both in urban areas (CHD is the most common group of congenital anomalies and a major cause of death in infancy and childhood . They arOur results showed that the prevalence rises in urban and rural populations during 2008–2012. There are might three reasons for that. First, the use of ultrasonic examination makes the rate of congenital diagnosis improved. In the lack of ultrasonic examination, the percentage of CHD was lower . In our The difference of maternal age-specific overall prevalence was observed in our study, and the prevalence in urban and rural areas increased with maternal age. A similar finding has been reported by Miller et al. , who repIn the birth defect registry system, the urban–rural classification depends on the place where the mother lived during the pregnancy, which mainly reflects the combined exposure during the pregnancy ,20. In oThe data of our study is reliable and representative. The study was based on the birth defect registry system of the province of Guangdong, and the system contains 58 hospitals covering districts, which represents the total situation of CHD in Guangdong province well. All data were reported on the network in time. Strict quality control of data collection was taken by county, municipal and provincial experts every year, thus ensuring reliable data. However, several limitations in the study should be addressed. First, according to the surveillance system, the monitoring period was 28 weeks’ gestation to 6 days after delivery, and babies with CHD detected more than 7 days after delivery would be missed. Second, the study did not cover cases of births given out of hospital, although the proportion was small. Third, our study was difficulty in distinguishing between an ASD and a patent foramen ovale in the perinatal period. And because of most of foramen ovale and ductus arteriosus after birth to 6 days is normally patent and will be closed naturally within several months. The exclusion of a patent foramen ovale and patent ductus arteriosus in perinatal infants eliminated perinatal conditions from consideration, thereby improving the prevalence estimates of CHD. Finally, it is possible that hospital-based samples might introduce referral bias. However, our study used the data from the Guangdong Hospital-Based Birth Defects Monitoring System, which is covering 58 hospitals across the province, and our results provide value insights to our understanding of the main epidemiologic characteristics of CHD prevalence in Guangdong province.The findings from our study have some practical implications. High prevalence of CHD indicates that CHD become one of the major public health concerns in Guangdong province, China. A high and increasing rate of CHD among perinatal infants increases the burden on families and health care providers, both in terms of parental anxiety, and of the direct costs of diagnostic examinations, follow-up, and possibly treatment .In conclusion, the birth prevalence of CHD increased from 2008 to 2012 both in urban and rural areas. The increasing trends of CHD prevalence suggest that maternal age and the improvement of diagnosis ability might play a critical role. More comprehensive surveillance among infants would improve prevalence rate for CHD and help assess prevention efforts, and knowing the prevalence and distribution of CHD can help pediatricians and public health professionals better assess health care needs and conduct causal research.The authors have declared that no competing interests exist.QZ and BL designed the study and performed the analysis. SL and YM collected the data. ZL, TC and CJ assisted in the analysis and data interpretation. LW drafted the manuscript. JX and YW reviewed and refined the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/14/152/prepub