The aim of the study was to evaluate the relationships between intake of mother's own milk (MOM), compared with intake of pasteurized donor milk (DM), and postnatal growth, incidence of retinopathy of prematurity (ROP) and bronchopulmonary dysplasia (BPD), in extremely preterm infants.z-score (Δ) from birth to 32 weeks PMA for weight, length, and head circumference (HC). Secondary outcomes were incidence of ROP and BPD. Mixed models adjusting for confounders were used to investigate the association between exposures and outcomes.Swedish population-based cohort of surviving extremely preterm infants born 2004 to 2007. Exposure to MOM and DM was investigated from birth until 32 weeks postmenstrual age (PMA) in 453 infants. Primary outcome variables were change in −1 · day−1) was associated with Δweight and ΔHC with beta estimates of 0.03 z-score units  and 0.03 z-score units , respectively. After adjustment for predefined confounders, the association remained significant for Δweight and ΔHC. A similar pattern was found between Δweight and each 10% increase of MOM. Unadjusted, a higher intake of MOM (mL · kg−1 · day−1) was significantly associated to a lower probability of any ROP and severe ROP; however, these associations did not remain in the adjusted analyses. No associations were found between MOM (mL · kg−1 · day−1) and BPD. Moreover, no associations were found between DM and growth or morbidity outcomes.Infants’ mean gestational age (GA) was 25.4 weeks. Unadjusted, MOM , was associated with improved postnatal weight gain and HC growth from birth until 32 weeks PMA in extremely preterm infants. Interventions aiming at increasing early intake of unpasteurized MOM for extremely preterm infants should be encouraged. What Is KnownA predominant intake of mother's own milk, as opposed to pasteurized donor milk, is associated with improved postnatal growth in preterm infants.Some studies suggest that in preterm infants, a predominant intake of mother's own milk compared with a predominant intake of pasteurized donor milk may prevent neonatal morbidities, such as infections, retinopathy of prematurity, and bronchopulmonary dysplasia.What Is NewThe first study performed in a large national population-based cohort of extremely preterm infants where the effects of unpasteurized mother's own milk and pasteurized donor milk on postnatal growth and morbidities has been evaluated.The advancement of medical, nursing, and nutritional care of extremely preterm infants continues to improve the survival of these vulnerable infants –3. The iPostnatal growth is a complex and multifaceted process influenced by factors, such as degree of immaturity, ability to assimilate nutrients, the nutritional composition of feeds, and presence of neonatal morbidities. In spite of the improvement of parenteral nutrition (PN) solutions and infant formulas, it remains clear that human milk is the optimal nutrition for the preterm infant provided that it is fortified to meet nutritional requirements.Unpasteurized mother's own milk (MOM) is recommended as the primary choice and pasteurized donor milk (DM) as the secondary alternative ,10. BeneIn the last decade, there has been an increase in studies reporting beneficial outcomes of postnatal growth and incidence of neonatal morbidities, for preterm infants receiving a greater proportion of MOM compared with DM –20. To fExtremely Preterm Infants in Sweden Study (EXPRESS), which included all infants born before 27 completed weeks of gestation between 2004 and 2007 in Sweden  to be performed without informed parental consent.both energy and protein) was summarized as the proportion of days (%) with any human milk fortifier from birth through 32 weeks PMA. All retrieved data was registered in the computer-aided nutrition calculation program Nutrium . Potential nutrients from blood products were not included in the current analyses.Prenatal-, neonatal- and postnatal data, including morbidity, mortality, and growth measurements of weight, length, and HC, were prospectively collected for the first 180 days of hospitalization or until discharge or death ,25. In tz-scores for the gestational age (GA) and sex-specific Fenton preterm infant growth reference  together with the proportion of MOM of total breast milk (MOM%), constituted the exposure variables. Due to the breast milk data being recorded with different time intervals, the mean area under the curve (AUC) was calculated as a proxy for the mean intake of MOM and DM from birth until 32 weeks PMA for each infant. For interpretation of univariable and multivariable models, these variables were rescaled into increments of 10 mL · kg−1 · day−1 or 10% by dividing the mean AUC by 10.In Sweden, extremely preterm infants are offered pasteurized DM as a complement to MOM until at least 32 weeks PMA after which DM is replaced by preterm formula. Our objective was to study differences in outcome based on respective intakes of MOM and DM, hence the exposure period was defined as beginning at birth and ending at 32 weeks PMA. Intake of MOM and DM  from birth to 32 weeks PMA for weight, length, and HC. The secondary outcome variables were any and severe ROP, ROP treatment, and any and severe BPD. We chose to focus on these morbidity outcomes as they are diagnosed after the exposure period  as opposed to other neonatal morbidities, such as sepsis and necrotizing enterocolitis, which often occur before 32 weeks PMA.The primary outcome variables were change in The data was analyzed in IBM SPSS Statistics for Windows, version 26.0  and SAS software version 9.4 . Descriptive data are presented by mean (SD) and median  for continuous variables, and number and percentage for categorical variables.Associations between exposure and outcome variables were examined with univariable and multivariable linear mixed models for continuous outcomes and generalized linear mixed models with binomial distribution and logit link function for dichotomous outcomes. The assumptions of normal distribution and homogeneity of residual variance in linear mixed models were examined through diagnostic plots and found fulfilled.z-score  and birth weight z-score , days with mechanical ventilation, days with postnatal steroid treatment, proportion of the volume of PN of the total volume of nutritional intake from birth through 32 weeks PMA (hereafter referred to as PN%) and health care region. Health care region was analyzed as a random effect. The proportion of days with any human milk fortifier was identified as a mediator, and therefore not adjusted for in the models.The following confounders were identified for both growth and morbidity outcomes: GA at birth, respective birth anthropometry z-score/birth weight z-score, mechanical ventilation, postnatal steroid treatment, and health care region. In addition to these, the second model also included the confounder PN%, which in this cohort represents both an additional source of nutrition (to MOM and DM) and degree of neonatal morbidity.Statistically significant associations in univariable analyses were further analyzed in multivariable analyses. Adjustment for confounders was performed in 2 different models for each of the studied outcomes of which the second model was considered to be the main analysis. The first model included the nonnutritional confounders GA, birth anthropometry For all analyses, the tests were 2-tailed and an alpha less than 0.05 was considered significant. Missing data was not imputed. Beta estimates and odds ratios are presented with 95% confidence intervals (CI).z-scores from birth until 32 weeks PMA were −1.2 (0.7) for weight, −1.5 (0.7) for length, and −1.5 (0.9) for HC.Prenatal- and neonatal characteristics as well as postnatal outcomes for infants surviving to at least 32 weeks PMA (n = 453) are presented in Table The average (mean AUC) of energy and macronutrients originating from enteral, parenteral, and total nutritional intakes, human milk intakes and PN%, as well as the proportion of days for which the infants received any human milk fortifier, from birth until 32 weeks PMA are presented in Table z-score, mechanical ventilation, postnatal steroid treatment, health care region, and PN%  z-score units for Δweight and 0.02  z-score units for ΔHC from birth through 32 weeks PMA.The univariable associations between MOM and the growth outcomes are depicted in Figure P = 0.001); OR 0.93 ; and OR 0.96 , respectively , but not after inclusion of PN% as a confounder  of MOM, DM, and PN according to PMA for infants with and without severe ROP. There were no univariable associations between MOM and either any BPD or severe BPD . Each increase of 10% MOM of the mean AUC estimated from birth through 32 weeks PMA would yield an increase of 0.03  z-score units for Δweight from birth through 32 weeks PMA. There were no univariable associations between MOM% and any of the ROP or BPD outcomes.There was a positive association between MOM% and Δweight in the univariable models, but not for Δlength and ΔHC . The association between MOM% and Δweight remained significant in both multivariable models after adjustment for GA, birth weight No univariable associations were present between DM and either Δweight, Δlength, ΔHC, any ROP, severe ROP, ROP treatment, any BPD or severe BPD .−1 · day−1) improved weight gain and HC growth from birth until 32 weeks PMA and reduced the probability of any ROP and severe ROP development as well as treatment of ROP. After adjustment for predefined confounders, the associations between MOM (mL · kg−1 · day−1) and postnatal weight gain and HC growth remained significant. Similarly, the association between the proportional intake of MOM (MOM%) and postnatal weight gain remained significant in adjusted models. These results are in line with some previous studies that have shown beneficial growth outcomes for preterm infants fed predominantly MOM compared with DM  and postnatal growth or neonatal morbidities. Notably, the infants in our cohort received significantly less DM than MOM and this may have affected the statistical power to determine relationships between DM and the outcomes.We did not find any associations between DM  from birth through 32 weeks PMA had a greater proportion of days with any human milk fortifier, a higher total intake of human milk as well as a slightly higher total energy intake than infants receiving predominantly MOM . The total protein intake was similar between the groups. This implies that other factors present in human milk, and not only the nutritional intake −1 · day−1) compared with infants with any ROP . In a more contemporary cohort, we have previously shown that those infants with no ROP had a higher intake of MOM , the inability to determine potential differences in the actual amount of fortification used in MOM and DM, which is an important factor to consider when evaluating postnatal growth, the relatively old age of the data (infants born 2004–2007), and finally the observational design, which renders potential residual confounding in spite of our best efforts to identify and adjust for confounders.The effect of the association observed between MOM and improved weight gain and HC growth in this cohort, although significant after adjustment for all identified confounders, was relatively small as indicated by the beta value, and thus the clinical significance of this finding could be questioned. It is, however, important to keep in mind that postnatal growth is a multifactorial phenomenon influenced by several factors, some of which are probably still unknown. Elucidating the respective effects of MOM compared with DM on postnatal growth would require a randomized clinical trial, which for ethical reasons is impossible.We found that MOM, as compared with DM, was associated with improved postnatal weight gain and HC growth in this national population-based cohort of extremely preterm infants. In regards to morbidity, we found associations between MOM and ROP, although not independent of other factors. No corresponding associations were observed for BPD. Notably, during the time of data collection, the nutritional care of extremely preterm infants in Sweden differed from the nutritional care received by infants born today. Thus, it seems relevant to further investigate the impact of MOM on both short- and long-term outcomes in a more contemporary large cohort of extremely preterm infants with equally detailed nutritional data. It is essential for neonatal health care professionals to include interventions that aim to increase the early intake of unpasteurized MOM in the care of extremely preterm infants.


In contrast, the same probability of rupture is obtained for changing the electric field from 410 to 630 Vcm-1 by varying the cholesterol mole fraction in the membranes from 0 to 0.40. These results suggest that the required electric field for the rupture decreases with the increase of surface charge density but increases with the increase of cholesterol. We also quantify the electric field for the rupture of GUVs containing anionic mole fraction of 0.40 under various osmotic pressures. In the absence of osmotic pressure, the electric field for the rupture is obtained 430 Vcm-1, whereas the field is 300 Vcm-1 in the presence of 17 mOsmL-1, indicating the instability of GUVs at higher osmotic pressures. These investigations open an avenue of possibilities for finding the electric field dependent rupture of cell-like vesicles along with the insight of biophysical and biochemical processes.Electropermeabilization is a promising phenomenon that occurs when pulsed electric field with high frequency is applied to cells/vesicles. We quantify the required values of pulsed electric fields for the rupture of cell-sized giant unilamellar vesicles (GUVs) which are prepared under various surface charges, cholesterol contents and osmotic pressures. The probability of rupture and the average time of rupture are evaluated under these conditions. The electric field changes from 500 to 410 Vcm Biomembranes are selectively permeable barrier which separates the interior and exterior of an organism ,2. Variosn-glycero-3-phospho-(1′-rac-glycerol)  (DOPG) and 1, 2-dioleoyl-sn-glycero-3-phosphocholine (DOPC) were purchased from Avanti Polar Lipids Inc. . Bovine serum albumin (BSA), 1,4-Piperazinediethanesulfonic acid (PIPES), Ethylene glycol-bis(2-aminoethylether)-N,N,N′,N′-tetraacetic acid (EGTA) and calcein were purchased from Sigma-Aldrich (Germany). Cholesterol  was purchased from WAKO pharmaceuticals (Japan).1,2-dioleoyl-2 gas for producing thin and homogeneous lipid films. By keeping the vial in a vacuum desiccator for 12 hours, the residual chloroform in the film was removed. Then, 20 μL MilliQ water was added into the vial and pre-hydrated at 45–47°C for 8 minutes. After pre-hydration, the sample was incubated with 1 mL of buffer containing 0.10 M sucrose for about 3 hours at 37°C. To prepare water-soluble fluorescent probe  containing GUVs, vesicles were incubated in the buffer with 0.10 M sucrose containing 1 mM calcein. The incubated GUV suspension (unpurified) was centrifuged at ~ 13,000×g (here g is the acceleration due to gravity) for ~ 20 minutes at ~ 20°C for removing the multilamellar vesicles and lipid aggregates as these elements were sedimented at the bottom of eppendorf tubes. After centrifugation, supernatant was collected and purified by the membrane filtering method [The anionic charged GUVs were prepared in a physiological buffer  and the neutral GUVs were prepared in MilliQ water using the natural swelling method . Here, tg method ,53.XDOPG) were considered 0.60, 0.40, 0.20, 0.10, 0. Hence, the samples were DOPG/DOPC , DOPG/DOPC (40/60), DOPG/DOPC (20/80), DOPG/DOPC (10/90) and DOPG/DOPC (0/100)-GUVs. To prepare cholesterol (Chol) containing membranes, the samples DOPG/DOPC/Chol (60/40/0), DOPG/DOPC/Chol (46/39/15), DOPG/DOPC/Chol (43/28/29) and DOPG/DOPC/Chol (40/20/40)-GUVs were prepared in the same buffer. The corresponding cholesterol mole fraction in these samples were 0, 0.15, 0.29 and 0.40. By considering the surface areas of DOPG and cholesterol [-2). For performing the osmotic pressure experiments, DOPG/DOPC (40/60)-GUVs were prepared in the buffer under various osmotic pressures (Π). The osmolarity of the sucrose solution inside the GUVs was -1, whereas the osmolarities of the glucose solution outside the GUVs were Cout = 388, 375 and 371 mOsmL-1. Hence, the corresponding osmolarity difference between the inside and outside of GUVs were -1. Due to the osmolarity difference between sucrose and glucose solutions, vesicles became swell as water molecules of glucose solution passed into the inside of GUVs through membranes. The osmotic gradient creates lateral tension in the membranes of GUVs. The detail procedure to apply the Π in GUVs has been described in our recent paper [To prepare the GUVs with different surface charges, the DOPG mole fractions  is the gradient of electric potential (V), i.e., E = -∇V.To estimate the electric potential gradient and the distribution of current density on a vesicle, the finite element method-based software COMSOL Multiphysics was used. The simulation was used to investigate transport processes in various model systems . The parThe time dependent electric current module was used in the simulation where the parallel gold electrodes were selected. The numerical model demonstrated the importance of contact and angle between GUV and electrodes. For a certain value of electric potential with current density, the transmembrane voltage shows its threshold value for the rupture of targeted GUV.A MOSFET based IRE device was used for generating the pulsating DC (direct current) electric field with pulse width 200 μs and frequency 1.1 kHz. The detail circuit diagram was published in the earlier papers ,63. The Vm) is defined as the difference between the values of the homogeneous electric potential on both sides of the membrane. In the presence of pulsed electric field to a vesicle, when Vm exceeds ~ 1.0 V, the structural rearrangement of the lipid bilayer occurs, creating permanent aqueous pathways or pores in the membranes. The induced Vm at each membrane point is defined as follows [R is the radius of vesicle, θ is the angle between the electric field and surface potential and τcharg is the membrane charging time constant. The expression for fm is defined as follows [σm, internal medium is σin, external environment is σex, and h is the thickness of membrane. Assuming σm = 0 , then fm = 1.5. Hence, Eq where, θ = 0. The rupture of GUVs occurs in that membrane site where transmembrane potential has a maximum value. The maximum value of Vm (= Vc) is called the ‘critical transmembrane voltage for breakdown’ of vesicle. Then Eq  with a 20× objective. All experiments were performed at 25 ± 1°C. The images of GUVs were found from the recorded video using a charge-coupled device camera  with exposure time 111 ms. The frames per second (fps) of the camera was 25. A mercury lamp was used to acquire images of vesicles using the fast-digital camera. Phase contrast images were acquired using the cellSens Entry (Ver. 1.16) PC software . The fluorescence intensity in the inside of GUVs was found from the active gray scale video using cellSens Dimension (Ver. 3.20) PC software .Vc) for the rupture of GUVs. It was simulated the value of Vc for R = 12 μm GUV using Eq  is shown in θ. Moreover, all these values of E are responsible for rupturing of GUVs by creating pores in the membranes. If θ = 0, the rupture occurs at E ~ 450 Vcm-1, while higher values of E are required for the rupture of GUVs if θ changes from 0 to 90°. The value of electric field required for the rupture of GUVs is also dependent on the sizes of GUVs for a particular value of θ. As for example, E varied from 350 to 540 Vcm-1 for R = 10 to 15 μm at θ = 0. The 1/R dependent electric field required for vesicle rupture is shown in θ = 0. The value of E increases almost linearly with 1/R. This simulation work provided an important information on how much electric fields are needed for the rupture of GUVs in various experimental conditions.Before going to quantify the electric field required for the rupture of vesicles, it was important to perform the simulation using the similar condition as used in the experimental study. It is mentioned earlier (see section 2.4) that the finite element-based software COMSOL Multiphysics is used to conduct the simulation. using Eq . The valE = 390 Vcm-1 was applied on a ‘single DOPG/DOPC (60/40)-GUV’ (DOPG mole fraction XDOPG = 0.60) for a maximum time 60 s. At time t = 0 s , the GUV shows spherical structure in an inverted phase contrast image . We calculated the average time (tr_avg) of the stochastic rupture by fitting the data. The solid red line  data is fitted using a linear equation, and we obtain tr_avg ~ 0 s when E ~ 420 Vcm-1. These investigations give us the information that how applied electric field influences the average time of the vesicle rupture. Interestingly, the values of external electric fields required for rupture of GUVs are very much consistent with the result as obtained in COMSOL simulation (see section 3.1).The Prup_t) until different times (tEF) during the application of E. Prup_t of DOPG/DOPC (60/40)-GUVs for E = 330 Vcm-1 (◼) until the time, tEF = 10, 20, 40 and 60 s. The probability of rupture is defined as the number of ruptured GUVs divided by the total number of observed GUVs. Suppose a number of 20 GUVs are investigated in 20 individual microchamber till a particular time after applying a specific electric field. If 10 GUVs are ruptured, Prup_t = 10/20 = 0.5. At first, we observe the results of E = 330 Vcm-1 in which the value of Prup_t increases with the increase of tEF. At 10 s, Prup_t = 0.10 ± 0.01 and at 60 s, Prup_t = 0.38 ± 0.07. Similar experiments were done for E = 350 Vcm-1  at 162 mM salt concentration in buffer. Electric field E = 420 Vcm-1 was applied on DOPG/DOPC (40/60)-GUV (here XDOPG = 0.40) for a maximum time 60 s. The phase contrast image of a spherical shaped GUV is shown in t = 15 s and then ruptured at t = 15.5 s. The same electric field was also applied on DOPG/DOPC (10/90)-GUV (here XDOPG = 0.10) and rupture occurred at t = 32.5 s  for XDOPG = 0.60 -GUV’  for a maximum time 60 s. In this case, the inside of vesicle was 1 mM calcein with 0.10 M sucrose. Prior to apply the pulsed electric field, the inside of GUV shows white color in a fluorescence microscopic image  for Chol = 0 , osmotic pressure is induced in the GUV, which increases the radius of the membrane at swelling equilibrium. The osmolarity difference at an initial condition between the inside and the outside of GUV becomes Cout = 375 and 371 mOsmL-1, and hence the corresponding ΔC0 = 13 and 17 mOsmL-1. The detail description of maintaining the osmolarity difference is reported earlier [E = 300 Vcm-1 under 17 and 13 mOsmL-1 are shown in Prup_60s for ΔC0 = 0 -GUVs under different osmotic pressures (Π). The osmolarity of the inside sucrose of GUVs,-GUVs und mOsmL-1 .tr_avg for ΔC0 = 0 , that is, when the externally applied electric field is above the electroporation threshold value. Electric field distribution, which is established in lipid membranes when electric current passes through the GUV, is difficult to predict, especially when the targeted vesicle has different conditions. For effective prediction of electric field strength and distribution, we performed the simulation study using the similar experimental condition  is connected with transmembrane voltage (Vm) [Vm∞E, hence σe∞E2. Osmotic swelling creates lateral membrane tension (σos) in the GUVs [σt = σos + σe . With the increase of osmotic pressure, the value of σt increases, and therefore, the stability of membranes decreases. Again, the probability of rupture is defined as follows [kp is the rate constant of vesicle rupture. Generally, the rate constant for any reaction can be expressed by the following well-known Arrhenius equation [A is a constant whose unit is s-1, kB is the Boltzmann constant and T is the absolute temperature. According to the classical theory of pore formation in lipid bilayers, the energy barrier of a prepore at a critical radius is defined as follows [B is the electrostatic term for charged lipids in membranes [r is the prepore radius.The electroporation in GUVs under various osmotic pressures was reported earlier , where wage (Vm) ,76 by σethe GUVs ,78. Ther follows :Prup_tequation :kp=Aex follows ,81:Ub(embranes , Γ is thB and decreases the value of Ub (see Ub, which eventually decreases the probability of rupture as found in σos in σt increases. With the increased σos, the value of Ub decreases, and consequently increases the rupture probability. This explanation is consistent with the result mentioned in As the anionic lipid in membranes increases, the repulsive force between the anionic lipids becomes stronger. Such stronger effect increases the value of f Ub see , which uf Ub see  and 8 asWe quantify the pulsed electric field required for the rupture of GUVs along with the behavior of such vesicles exposed to electric field. The optically detectable rupture is identified in the phase contrast and fluorescence images due to the disruption in membrane integrity. The amount of electric field required for vesicle rupture depends on the surface charges, cholesterol contents and the osmotic pressures. Addition of anionic lipid in membranes requires relatively lower electric field for the rupture of GUVs. In contrast, higher cholesterol content requires relatively higher electric field for vesicle rupture. Again, the value of applied electric field for vesicle rupture is greatly influenced by the osmotic gradient, indicating that higher gradient required lower electric field. Such differences are well explained by the mechanical stability of membranes of vesicles. The pore formation in the membranes of vesicles and consequently the rupture of vesicles are explained by the well accepted classical theory of pore formation in lipid bilayers. These investigations provide quantitative and valuable information on the electric field dependent rupture of GUVs under various conditions. This study serves as a guideline for further experiments in this area and offers an entrancing biophysical description of the phenomenon of electroporation in vesicles together with the insight of biological consequences.


Background: Antibiotics are widely prescribed by obstetricians, which exposes a large number of infants to antenatal antibiotics (AAB). The effect of AAB on various aspects of neonatal development of preterm infants remains unclear.Methods: In this retrospective study, infants born with gestational age (GA) between 22 +0 and 36 +6 weeks at our unit from 2017 to 2019 were included. Multivariable analysis was adopted to examine the associations between AAB exposure and various outcomes related to enteral feeding process, body growth, and neonatal infection after adjusting for potential confounders. Further subanalysis on the exposure level of AAB and stratified analysis by GA (<34 vs. ≥34 weeks) were also conducted.Results: In this cohort comprising 2,543 preterm infants, AAB was associated with decreased risks of feeding intolerance  and neonatal infection . Higher AAB exposure level was associated with higher Z scores of birth weight , but lower Δbodyweight Z-scores . AAB was positively associated with the parameters related to body growth in infants with GA <34 weeks but negatively associated in those with GA ≥34 weeks.Conclusions: AAB exposure affects the enteral feeding process and neonatal infection. The effects on body growth vary by the exposure level of AAB and GA of infants. A well-designed prospective and preferably multi-centre study with predefined parameters is required to confirm our findings. Up to 40% of women receive antibiotics during pregnancy  mainly fThus far, most studies on AAB affecting offspring development have focused on the general neonatal population, with only few studies being conducted in preterm infants, where AAB likely exacerbated the risk of prematurity on development. A report has shown that AAB exposure is associated with higher risk of gut-related morbidities in preterm infants, including necrotising enterocolitis (NEC) , 7. AAB Herein, we evaluated the relationship between AAB exposure and enteral feeding, body growth, and infection in preterm infants born between 2017 and 2019 at our hospital.This retrospective cohort study was conducted at the Shenzhen Bao'an Women and Children's Hospital, Shenzhen, China. The research ethics committees of the School of Public Health, Sun Yat-sen University, and the study hospital approved the study .+0 and 36 +6 weeks from January 1, 2017, to December 31, 2019, at the study hospital were included. The exclusion criteria were death before hospital discharge, major congenital anomalies, admission to the neonatal department later than 24 h after birth, and incomplete neonatal information or maternal information.Preterm infants born with gestational age (GA) between 22 Indications for antibiotic treatment in pregnant women included cesarean section, preterm premature rupture of membranes (PPROM), and GBS infection of the lower genital tract. Local practice of prepartum AAB treatment is attached as supplementary information . AAB exp9/l in the first 3 days of life, ≥20 × 109/l after 3 days since birth, or <5 × 109/l on any day) (9/l)  , 23; decy) (9/l) ; elevatey) (9/l) ; and eley) (9/l) . The timFor confounder adjustment, maternal infection was defined as chorioamnionitis and/or PPROM during pregnancy. A composite parameter, adverse neonatal condition, was defined as at least one of the following: gastrointestinal tract (GIT)-related diseases ; respiratory distress syndrome (RDS); bronchopulmonary dysplasia (BPD); retinopathy of prematurity (ROP); sepsis; and brain injury . Detailed diagnostic criteria of these conditions and diseases are listed in t-test for normally distributed continuous variables, Wilcoxon rank-sum test for continuous non-parametric variables, and Chi-square test for categorical variables.Maternal and neonatal characteristics were compared between the AAB and No AAB groups using Student's p-value from the F test were reported for each outcome. Time-to-event data including TIEF, TFEF120, TRBW, and the time to the first infection were tested with the Cox proportional hazard model. A hazard ratio (HR) was reported together with 95% CIs and a p-value calculated using the Wald test. Incidences of feeding intolerance, attainment of full enteral feeding, regaining birth weight before discharge, sepsis, and clinical infection were tested with logistic regression. Odds ratio (OR), 95% CIs, and p-value using the chi-square test were calculated. Clinical infection episode was tested as recurrent time-to-event data with the Prentice, Williams, and Peterson total time (PWP-TT) model , and a T) model . The lenp-values for both analyses were calculated as described above.Further subanalysis was conducted in the AAB group according to the days of treatment (DOT), ≤ 3 vs. >3 days, with the ≤ 3-day subgroup as reference. DOT was calculated as the sum of the days of antenatal exposure for each antibiotic used . A stratFor confounder adjustment, only GA, sex, and delivery mode were adjusted in Model I. Maternal factors, adverse neonatal condition, and proportion of OMM were further adjusted in Model II based on Model I. Refer to each table for the factors included in different models.survival  and with higher bodyweight Z-scores . The AAB infants had a trend toward higher incidence of feeding intolerance than the No AAB ones , significantly slower advancement of enteral feeding , and higher incidence of attaining full enteral feeding before discharge . Significantly higher bodyweight Z-scores were found in the AAB infants than in the No AAB ones, at birth , while no significant difference was found in the bodyweight Z-scores on discharge or in Δbodyweight Z-scores. No significant difference was found in the incidence of neonatal infection between the AAB and No AAB infants, but the AAB infants had longer time to first infection .A total of 3,105 preterm infants were identified during the study period, and 2,543 of them were included in the study . Charactp < 0.001) and in the subgroup with GA ≥34 weeks , but not in the subgroup with GA <34 weeks. No association between AAB DOT and the incidence of feeding intolerance was found (p < 0.001) and in the subgroup of GA ≥34 weeks . No significant association was found for the advancement rate of enteral feeding, the incidence of attaining full enteral feeding, or TFEF120 in the whole study population or in either GA subgroup. No significant association was found for AAB DOT with these parameters in the whole population or in the GA subgroups.Results of the multivariable analyses are listed in as found . Enteralp < 0.01) if only delivery mode, sex, and GA were adjusted (p < 0.001) and on discharge , and lower Δbodyweight Z-score  (p < 0.001). Only in the subgroup of GA ≥34 weeks was AAB associated with increased Δbodyweight Z-score  before the adverse neonatal condition and the proportion of OMM were included in the model.At birth, AAB exposure was associated with larger bodyweight Z-score  . In the < 0.001) . AAB expp = 0.03) and longer time to the first infection , but not with the incidence of sepsis or the number of neonatal infection episodes in the whole study population , suggesting that the effect of AAB is dependent on conditions included in this composite parameter.The aim of assuring fast increment of enteral feeding is to provide sufficient nutrients and energy for preterm infants to meet their increasing nutritional needs. Few studies have examined how AAB affects neonatal body growth. In this study, AAB did not affect the parameters related to body growth adopted in the whole study population, which is unlike the neonatal antibiotic exposure. The disappearance of significance on the bodyweight Z-score at birth after the adjustment for maternal factors suggests that AAB affecting birth weight was dependent on other maternal factors. Further, the exposure level of AAB, shown as AAB DOT, affected body growth. High exposure level of AAB (DOT >3 days) conferred benefits to the body growth of fetuses but limited their neonatal body growth; this effect was independent of other maternal and neonatal factors. Preterm infants with different GAs responded to AAB differently in terms of body growth. AAB was associated with lower incidence and longer time of regaining birth weight in infants of GA ≥34 weeks, while higher incidence and shorter time were seen in infants of GA <34 weeks, suggesting that AAB could confer benefits to the infants with small GA possibly n = 86). Early preterm infants are assumed to be more seriously affected by AAB, but few studies have focused on this group, possibly because of the limited number of cases and the complicated condition of these infants and the treatments received by them and their mothers. A much larger cohort would render an opportunity for a more focused assessment of the infants of smaller GA (<28 weeks). The DOT of AAB did not affect neonatal infection in the AAB infants, suggesting that the overall exposure level of AAB might only have limited effect. However, how different types of antibiotics affect neonatal infection remains unclear, despite the ORACLE trial suggesting erythromycin over amoxicillin–clavulanic acid therapy. Although our results suggest that AAB only affects neonatal infection to a limited extent, a population-based cohort study showed that AAB exposure could increase the risk of infection in childhood  to P-PJ from Sun Yat-Sen University, China and the Science, Technology and Innovation Commission of Shenzhen Municipality, China (JCYJ201908809183601667) to LM.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Determinants for women’s care seeking for birth in low-income setting are multifactorial and remain poorly understood. A life course approach can assist to structure the interplay of the different factors that lead to women seeking care or not.In this study we aimed to explore individual women’s reproductive pathways, and increase understanding of how important life events including previous pregnancy and birth experiences can help us to understand individual choices made for care seeking during childbirth.The study took place in Tanzania between 2015 and 2017. 14 women were followed throughout their pregnancy, birth and postpartum period through participant observation and in-depth interviews. In total 94 in-depth interviews were held (between 5–7 interviews per woman). Analysis occurred continuous throughout the data collection period resulting in detailed narratives of crucial events across women’s life course, with specific attention to their current pregnancy.Of the 14 women, seven had a facility birth, six a home birth and one woman gave birth at the home of a local birth attendant. Four different story plots were identified: expected home birth, expected facility birth, unexpected facility birth and unexpected home birth. Birth narratives of four women representative of the different story plots are presented. Narratives illustrate women’s individual reproductive pathways including the various factors influencing women’s expectations and justifications for their actions during their pregnancy and birth.Women’s agency, including women’s perception of self, the self in relation to the social environment and reflection on risks associated with the range of options, influences the final decision made for birth. Women’s narratives suggest that quality of care can function as a primary pull factor for facility birth. As long as home birth is by some perceived to be a better alternative, achieving skilled care for all will be difficult to achieve. Birth with a skilled birth attendant (SBA) has been a measurable target in the effort to reduce maternal mortality, and globally, more women are giving birth in facilities . Althougwhy and how Tanzanian women weigh the range of known factors in their ultimate decision for birth location . Then I just went back. I continued to stay.Paulina started to open up about how she felt about her husband and how challenging it is for her. Paulina complained that her husband does not help her at all. She just tries not to depend on him if she can. She does her own little business from the house – selling soaps, cooking oil, groundnuts to people along the road. One day her husband was violent against her and she had had enough of it. She said:This medication they gave me now for this pregnancy brings me problems. When you take it you feel the earth is turning, your head is painful, the belly hurts, even until the child moves. When I started with this medication I couldn’t even go out. I was really sick inside (the house). […]I went back there [to the health centre] on Monday. […] I went back there to explain the nurse. The nurse explained me, she stated that it is not possible to change the medication, there’s only this one. The nurse refused. She said maybe you go and check for malaria at the (other) dispensary. And then you come back to tell us whether you have malaria […]. I didn’t ask (why), when they refused me, that nurse, I left. When I don’t take this medication I just feel good. […] And the way I understood, we were told ‘if the medication does not agree with you, come and they’ll change it for you’. That’s why I came back again. The nurse says, there’s no medication at all, it is really hard to change the medication.Paulina was diagnosed with HIV during her last pregnancy and was by now accustomed to both the reality of being HIV positive and the required treatment. During her current pregnancy, her HIV medication was changed, which caused her severe physical discomfort, she eventually stopped taking the treatment because the nurse/midwife at the ANC clinic refused to provide her with her old medication.I found her, I told her. She told me: ‘There are no medications to exchange. Sit here and explain me now what is bothering you’. So, I started to tell her now. I explained her and then later she said: ‘Well sit here, I’ll get the medication for you’. I sat, I waited for the medication. She gives me the normal one now.It was not until she was attended by a known and friendly nurse/midwife at one of her last visits that her complains were taken seriously and her medication was changed. As a sign of gratitude, Paulina gave her a chicken.It (labour pains) was there for many days […] a full week […] coming and going. […] Aa! The pains started in the evening; I was called by my sister-in-law, there in the surroundings of (names village name), that Saturday. I left here (home) around 1pm, we went there, we arrived around 3pm. (We) went by bike. That boy, my child, that big one, he rode (the bike). We stayed; we talked there up till around 5pm (and then started the journey home). Aa! I saw I couldn’t stay on the bicycle anymore. I told him (her son who was driving the bicycle); just wait, I take a motorcycle, you just come with the bicycle, I took the motorcycle and then it brought me here, at home around 7pm. Then I saw that the time, to go to  and the transport fee, it’s a lot! These days, to just go to  is 4000 Tsh ($2 USD). If you don’t have, that’s it. Then I thought: the transport fee that I have, it’s better to use it for other expenses. I just stayed home, whatever would happen would happen now. We cooked here, the food was ready and we ate. Then I went to sleep. The others didn’t know. I just knew it myself, they didn’t know, nor did I tell them. They didn’t know, until it was 4am, then I woke them up and told them to go and wake up that neighbour. […] They went to call that neighbour, when she came I had already given birth. There (pointing at the room where she gave birth), on the floor. I arranged clothes and I placed a bag, that’s it. […] I just laid down flat. When I felt the contraction I pushed, I pushed like that, I pushed once, I felt the child was coming. I pushed again, I pushed twice, three times, I then took the child out. When I gave birth, I stayed just a bit […] I pressed the belly, then everything (the placenta) came out.Around her due date she called me to say she had delivered, a baby girl, safely, at home. When we visited her, I congratulated her and asked how she was feeling and how her labour started and progressed.I asked if she had a lot of blood loss this time, she said it was not much but, perhaps two pieces of kitenge full. She had taken some local medicine, which had helped her to stop the bleeding.I (SP) met Diana at the end of October when she was seated in the waiting area of the ANC clinic. It was around 8am and she was waiting for the clinic to start. After her visit, I observed her ANC card and saw that it was written that she was 12 + 6 weeks pregnant, noticing she started early with the ANC. I met Diana again less than two weeks later. Diana had called me several times to ask me when I would come to see her. When I arrived in her village and called her, she told me she was already waiting for me at the health facility. She invited me to her house and we walked there together in 15 minutes.Both Diana and her husband come from different regions of Tanzania. They met in this village town in 2007 where they both had moved for work and had family relations. Diana had finished primary school before moving and started to work in a shop with basic groceries. Now she is running her own business of selling second hand clothing. Her husband Alex works as an electrician.It was three months (the pregnancy) […] the stomach was having pain […] I was bleeding so I decided to go to the hospital […]at the hospital they wrote me medicine to take from the pharmacy […] so they give medicine yet the pregnancy was gone […] I don’t know what happened (too cause this) but I did work when the blood was coming out so even in this pregnancy they (the nurses) told me not to work.During all her previous pregnancies, Diana went to the same health facility, both for ANC and birth. In 2008, Diana became pregnant for the first time. After 3 months of this pregnancy, Diana got a stomach ache and thick blood loss and decided to go to the health facility for checkup because she realized that there was something wrong.I went with my sister in law […] because I was starting to feel the contractions. Then they took me to the hospital at night. I stayed there, when it was morning, at 9, I started to deliver. I have (a lot of pain), I deal with it anyhow, because it is normal […] you don’t have an option […] I knew what was going to happen, people used to tell me […] they told me when the day of delivery, will happen this and this and then you will go to the hospital […] yaah even the pain they told me […] things to go with  they had already bought for me.Three years later, Diana became pregnant for the second time. She was not using any family planning methods and when I asked her if she felt she had to wait a long time before she got pregnant, she said it was just a normal time. During this pregnancy she got malaria, which was diagnosed at a private laboratory. Even though she had already started ANC, when she felt sick she went to the laboratory for a check-up. She remembers that she rested a lot during this pregnancy because of her previous experience. At home people had prepared her for the birth and told her what would happen.Yes. I went and took it out. It really bothered me, up till now it brings me problems […] They told me; ‘just go to check for these diseases’, I checked for STD’s, I checked for pregnancy, I wasn’t pregnant, but that problem kept on coming back. […] It was November and I took it out, then I got pregnant of her.After birth she started using family planning. She went to a private facility close by her house and chose the intra uterine device. After some time, she was experiencing a foul smell and thick vaginal discharge and decided to go back to the private facility. At the private facility they didn’t have an explanation for the side effects and advised her to take it out. In 2012, quickly after she stopped using the family planning, she became pregnant.You have to go (to ANC) to know each and everything what is going on, because when you are not going there you can’t understand what is going on and how the baby is laying in the belly. If you don’t go to the clinic then you don’t know the health of your child.Diana still has the ANC card of her previous pregnancy and I saw that she started ANC when she was 5–6 months (22 weeks) pregnant. She visited ANC 2 times during this pregnancy and she delivered in the same facility. It was all a good experience for her without any complications. She had not been using family planning methods since her birth, so when she missed her period for one month she went to the health facility where a urine test confirmed her pregnancy. Her first ANC visit followed soon after.When I am there, I have to wait for long and (when I arrive) the things (services) are not started, so I have to wait long because they did not already start with the work. Sometimes there is one nurse and the women are with many, so we have to wait for a long time. Then you can start to get problems, like stomach, because you didn’t eat since the morning. Because: I wake up in the morning, early in the morning. I left the kids, I went there to the line (waiting area) and I want to be on time. When I was there I was asking myself “I woke up in the morning, I didn’t even prepare for them at home”. So, I am asking myself, “why is it like this?” I am waiting too long.Like many others she too was confronted with inconveniences and lack of available services at the health facility.The government should be responsible because they provide medicines or treatment, but they (the nurse/midwives) don’t have it there. When they (the nurse/midwives) don’t have the instruments, you have to go somewhere else […] she (the nurse/midwife) is not responsible for these things.But, she expressed sympathy for the working conditions of the nurse/midwives, placing responsibility for their insufficient education and lack of resources with the government.Sometimes you have to go to the laboratory (private) because if you go the clinic you don’t get service early or sometimes they don’t have instrument … You go to test to know your condition about health condition and health condition of your baby …. When you go to normal one (government facility), some of the tests are not there, or there are a lot of people, you can be there with your pregnancy and stay until two or three so I think it’s better to go even if you pay money but you get the service.She knows the limits of the system and if needed seeks care in private laboratories or health centres. During this pregnancy she attended 5 ANC visits. When she was feeling sick, she thought she had malaria and decided to go to a small private laboratory close by her house. There they tested her positive for amoebiasis and a urinary tract infection and wrote her a prescription for medication which she gave to her husband so he could buy it for her.Since Saturday I felt my head was hurting and even the stomach. That night I felt sick, like having a contraction, when I woke up at 6am (on Sunday) I went to the hospital […] I went with my husband […]. When I arrived there  I took the card and wanted to get the form (treatment form for sick patients). […] I didn’t expect to deliver that day; I expect to deliver in April. They (at reception) told me to go direct to labour to get measured. […] I went with him (husband) inside there (at the maternity ward), but labour you cannot enter with someone. […]. When they (nurse/midwives) measured me, they told me it was contraction. After telling me that they told me I have to stay there at the hospital, they give the bed to lie there (in the maternity ward). They told me that the way  is not yet ready, so they told me to do exercise. So, when I was there I started doing exercise of walking since morning up to night. […] All that time I was alone, the nurse/midwives were doing their things, you just keep walking and when you are tired you come to sleep. […]. So when it was 2 am the contraction was ready, then I told them that I want to go to labour, because the contraction was ready. When I went to the labour at 3am they measured me again and they said “not yet”. Then they told me to stay there [at the labour bed] because it  was a little bit ready. So, I stayed there till I delivered at 7am. I was lying, just turning side to the other side. […] I called them when I felt that I have to push. She came and said “not yet, just keep waiting”. That time when the ‘bottle broke’ (water broke) then I started to deliver. When I called her the contraction was read then she started giving me service. (The nurse/midwife told me) the way to lie down, the way to push the baby. After (the baby was born) then she was cleaning the baby then she cut the cord. There is a place they put the baby there. Then they come for me, to clean me. After they finish cleaning me then she gave me the injection.Her strong social network in support of a facility birth made it very likely Diana would give birth again in the health facility also for this pregnancy. She gave birth approximately one month before her due date.They asked me, this is your first pregnancy, I say no, the first pregnancy was twins, then the first child died and the second one died on the next week, so they say ‘pole’ (sorry)I (SP) met Flora for the first time when she entered the ANC room in the health center. Both Flora and Nurse Happy laughed some times while she asked the questions of the ANC card about demographic information and risk factors. Flora answered with a confident and loud voice, made eye contact and looked around to see what was going on. Nurse Jane continued and asked Flora about her previous pregnancies.On foot! […] Because up till the centre in (village name) is 1 hour yes, or maybe and a half […] On foot it’s far, true […] When you don’t have money you walkNurse Jane performed an HIV test and weight measurement. After this, Flora was asked by Nurse Happy to climb on the bed for further examination. Then Flora was invited to sit on the bench. Nurse Happy explained to Flora that she is HIV positive. She spoke with a soft tone of voice, and looked at Flora, explaining about the medication she needed to take, how often and why. She received her medication: a plastic box with HIV medication, the red pills to increase the blood and medication for malaria. Then Flora was told to go the other side of the building to open a file and get registered at the HIV clinic. This took approximately 10 minutes. I asked Flora if I could come with her to her house so I would be able to reach her for an interview since she does not have a phone. She agreed and welcomed me at her house. This time we went with a piki piki (motor cycle taxi) but normally Flora comes by foot to the health facility which takes her up to 1.5 hours.The first born were twins […] I delivered at home; I was with my mom […] yeah, she told me to push, she collects the thing we cut on the placenta […]one of them cried and the other one opened the mouth and died […]one was still alive for one week, after one week he died.After one week I came back to her house for the first interview. Flora is 21 years old. She was born in another district, where she finished standard seven primary education. However, she is unable to read or write. In 2014, when she was 19 years old she became pregnant for the first time. She was still living at her parental home. She was happy with the pregnancy but her parents didn’t like it because she was not married. The boy didn’t want to marry her because he was already married with to another woman.He is a fisherman […] He comes home on Sunday […] I cannot know what he is doing […] I can’t trust him because am not staying with him long time.After one year, in 2015, she met her current husband who came to introduce himself at her parents’ house and they agreed on the marriage. Until now he hasn’t paid the dowry because he is not in a good financial situation and her parents have accepted that. He is originally from this village where they are living now. She moved in with him, together with her younger brother Isaack, who is 5 years as she takes care of him. Her husband works as a fisherman in a town which is 5 hours away by bus. Flora started to work on the land her husband owns and they grow rice and groundnuts. Soon after she moved here she got pregnant with the current pregnancy. Her husband is often away from home but sends money to herYes, you are troubled going to the clinic every month, better when you start when there are just a few months left […] It’s better when you go to the clinic for 2 months and you give birth in the month that follows […] When you skip a month they will start insulting you. They’ll refuse to give you a check-up.During this pregnancy she planned to start ANC at the end of December, when she was around 6 months pregnant. But, the first time she went to the heath facility she was refused and told to come back with her husband. Flora decided to try again one month later in January which is when I met her.I don’t believe if it is true I have to go back and take the test again. […] yeah, they checked me then they didn’t say anything, they kept quiet […] maybe the test is not ok, the equipment to test […] I and my husband should know how to solve it, but the nurses they should stop .Despite repeated information provided to her by the nurse/midwife about her HIV status, Flora refused to accept the result and did not take the recommended treatmentIf you listen to nurses’ rules, you’ll die with your baby […] She was just angry […] I just experienced their behaviour, the nurses, I don’t want it to happen again.Her refusal to accept her HIV status appeared to come from her general distrust of the health services, partly because of inconveniences caused by the long distance to reach the facility, long waiting hours, denial of services and lack of caring behaviour of providers.It (the bag) has rules. You pay a fine even of 10.000 TZS (5 USD) if you use one thing (at home).Flora initially also refused the ‘blue bag’ when this was offered to her. The blue bag was part of a government incentive program to motivate women to give birth at the health facility. Because Flora planned a home birth she did not want to accept the bag.I can’t get people who can help me there  […] because when you are there you cannot get anybody to do my work here (home). When you find the person to go with you at the hospital, you also need to find someone who can cook for you at home then bring food to the hospital. That’s why I need someone to help with that […] she can help to catch the baby and to remove the sheets […]. I will look for someone maybe I can order someone from my home place. […].Despite Flora’s poor adherence to facility ‘rules’, including refusal to visit the HIV clinic, she faithfully went to her scheduled ANC visits. She said this is expected of every pregnant woman and that ‘only the nurse/midwives know what the condition is of the pregnancy’. Flora explained her only option was to give birth at home.I visited Flora on both the Saturday and Sunday after I had seen her for her last visit in the facility. Her due date had passed so I went to her house to see how she was doing. She told me that now, already for three days, the pain started. ‘The pain comes and goes’, she said. I asked her if she already knew who will help her during the birth and she told me that a neighbour is coming to her house, pointing to the other side of the road.That day at midnight I woke up and realized that it was labour pains. […] I walked myself to the neighbours to inform them […] I didn’t have anybody to send there. The neighbour is just close by, he has a pikipiki (motorcycle). We  were dropped there [at the health facility] […]. I asked her (Meki) to see where they (the nurse/midwife) usually sleep […] The man who was driving the pikipiki he knocked (on the door) and then she (nurse/midwife) woke up […]. We went in the room to examine and then she said “the way  is too little”. She said “why you tell this person who take you here to go away because you need to go to ”. Then she just went and woke up the other doctor. She said “come and examine her”. The doctor said that there is enough way, just to go and sleep (lie down) and just wait for the delivery. Now I went to go and sleep and the pain was continuing so I was sometimes sitting, sleeping like this. And then (at 5am) I sent her (Meki) to go and call the nurse/midwife and then she came and she said’ “it’s still not yet”. When she (the nurse/midwife) finished examining, she said to Meki to sit on the chair and to look at me and then to make sure I am just sleeping on the side and then not to push. And then when the nurse/midwife had left then the water broke. […] At 6am. […] I was just going to continue to pushing now. […] She (Meki) called the nurse/midwife. […] She came and said “start pushing now the head is out”. Then when she was cutting the cord, she gave me the baby […] and then she wrapped the khanga (Tanzanian fabric) around him.The following Monday I was surprised to meet Flora at the post-natal ward at the facility, after she had given birth in the hospital.I (SP) met Maria for the first time at the end of April during her first visit. Even though she had welcomed me at her home and explained the directions, I was unable to locate her. When I met her at the health facility during her second visit, I sat down next to her and greeted her. She told me that she was surprised that I had not visited her yet. I told her that I searched for her but could not find her. She laughed and could not believe that is was hard for me to find her house since it is very close to the facility. Around mid-day we walked to her house and it took ten minutes. Maria rents a room on a small compound and lives there by herself.Maybe because mothers were delivering at home and we just copy that […] when you don’t have a problem you just give birth […] I feel it is difficult to go to the hospital […] to be ruled by the nurse.Maria is originally from another district. In 2008, when she was 14 years old, she became pregnant. By that time, she had just finalized primary school. She married the father of her child and he paid her parents 200,000 Tsh ($100 USD) as a dowry. She delivered her daughter at home without complications. It was her mother giving her support and after asking why she stayed home, Maria said:Ya, I was very young […] We we’re married, then we divorced […] Hate, he was accusing me […] he bothered me.Maria told me about her getting pregnant so young and she expressed to me that she made a mistake, that she just wanted to ‘try one time’ and did not expect to get pregnant. After giving birth, Maria stayed home to look after the house and her child. After some years her husband started to drink and mistreat her.Maria decided to leave him in 2014 and brought her daughter to her parents’ home. Maria came to Mwanza ‘to look for life’ and stayed with a lady friend of hers. She followed her friend to the current town where she found work as a cleaning lady.We’re just lovers […] He has a shop […] No, I can’t (marry him) because I was already married so I don’t see it has benefit.In 2016, Maria became pregnant again with her boyfriend, Charles, who has a small shop for daily groceries. They are not married but see each other regularly. Charles helps her with small things during the pregnancy and visits her once in a while.I didn’t plan to get pregnant […] Ya, the nurse told me not to use amoxicillin, because amoxicillin, it reduces the power of the injection for family planning […] Ya, I feel ok (about this pregnancy), because it already happened so I have to accept it.Maria was surprised when she found out that she was pregnant. She was using injections as a family planning method, she explained, it might be that she became pregnant because it had been a long time since her last injection.Due to the unexpected pregnancy, Mariam was not sure how many weeks pregnant she was and when she could expect to give birth. She told me that she expected her due date to be in July but because the nurses had told her August, so she was not sure.There is a job which I am doing, it was interrupting in the same date so I didn’t go […] I am not afraid but they will scream at me. Because I am the one, it is my fault, my laziness.During this pregnancy Maria had gone to 2 ANC visits. The third one was scheduled but it was on a day she had to work. Maria asked me if I could change the date (for her third visit) on the ANC card to the next month because she expected the nurses to shout at her when they will see that she did not show up on the scheduled date. We agreed to go together on the end of this month and see what will happen.Ya, it’s my task to go there, I have to […] It’s important to go there, because otherwise what do you do when a problem comes up and you don’t attend any clinic; what do you do. […] It depends on the nurses, when you are lucky you have a gentle nurse. There are others you find them they are just rude, that means she is rude and that’s just how she is.When discussing her plans for birth Maria explained to me that it is important to give birth at the health facility, despite possible difficulties she might face in the hospital.It was Monday, I went to (village name) to do cleaning (her work), after cleaning I went back home here and then because the water was running (from the outside tap) again I was fetching water. Then when it was night I slept. I didn’t know it was contractions because I was just used to the … I get used to this condition of pain in the waist. When the condition was changing I didn’t know it was contractions, I thought it was the same problem of waist. That’s why I didn’t want to call anyone, I thought it would be disturbance because I get used to it. I didn’t know if it was contractions because I didn’t, it was not water or blood that came out, so I didn’t know. When it was 1am I was alone in the room, my boyfriend was not here, he went, he had travelled. When the condition was changing then I didn’t call anyone. Then I took the fabric down (on the floor). Then I sit down (squatting) and then I start to push myself. After (the baby was born) I called the neighbours. […] I called that mama and that lady (pointing at the neighbouring houses). Then they came and called the nurse/midwife (a nurse/midwife who lives nearby). She started to give me service. She cut the cord, she closed the belly (tied a piece of fabric around Maria’s stomach), then she took the baby up on the bed. […] She left immediately. I gave her 5.000 TSH  because it’s not good when someone is giving you service and then you don’t give anything. […] She didn’t ask me, I decided myself.When I came back to the health facility at the agreed date, two weeks later, I did not see her. When I visited her at home instead, she laughed out loud and showed me her baby. She said the birth had come unexpectedly, and that she did not manage to go to the hospital.37–39]. However, within the constraints of their lives, women plan and make choices based on the options available to them [Through the collection of narratives of Tanzanian women’s reproductive pathways, this study sought to increase understanding of how women’s ultimate birth location can be understood by their responses to significant life events including previous pregnancy and birth experiences. The four narratives presented illustrate how women’s decision-making for care seeking and the weight which is given to the range of different factors  depends on women’s agency, including their perception of self, the self in relation to its social environment and reflection on risks associated with the decision to seek care or not. Women’s life stories and how these were shared revealed women’s personal values, social networks, motivation and adaptive style, surfacing an implicit theory of action, which helps us understand their different birth locations . Women i to them ,37, as aAll women in this study were born between 1980 and 2000 and had their first pregnancies between 1995 and 2015. The women in this study, therefore, had different exposure to what they could expect during pregnancy and birth, either through their own -, their mothers’-, or other family members’ experiences. For example, home birth seemed to be the default choice for Maria and Flora’s first births, likely because this is how their mothers gave birth, during a time where home birth was accepted practice. Even though facility birth has been actively promoted, in particular since the year 2000 still today many women view facility birth as necessary primarily for when complications occur . Maria’sTiming of women’s pregnancies and the ‘birth order’ is dependent on whether the pregnancy was intended, wanted or just happened . The curIf women have their own access to resources, their decision-making power increases, which could give potential for facility births . HoweverThe stronger a woman’s self-perception of coping skills, the more willing she is to take risks or embark on unusual courses of action . HoweverIf the global community truly strives to ensure skilled care for all, ensuring quality of care in health facilities should be the highest priority. This will function as the primary pull factor for all women. It seems likely that if women believe their efforts are worth it, they will go to a health facility and they will plan for it, no matter the resources, distances or efforts required. As long as health systems favour advantaged groups, be it those who can afford them or those who know how to deal with system constrains, SBA strategies will still result in uneven and inequitable outcomes . In the Women’s narratives illuminated their individual lived experiences throughout their reproductive pathways until their recent birth. Rich narratives combined with description of women’s previous pregnancy experiences and life events provides increased understanding of the complex individual decision-making processes, within the context of the northern part of rural Tanzania. The role of isolated factors, the weight these are given, and the, often tacit, meanings of perceived risks and opportunities helps us to understand why some women in this study have a facility birth and some do not. Women’s agency and their perceived self-efficacy determine if women feel the power to influence their situation or if they choose to rely on external factors to lead the way. Women in this study appeared resilient and made choices based on their perceived realistic capabilities to seek care. Recognizing the legitimacy of such choices can be a starting point for strengthening individual women’s capacity to influence change. Ultimately demanding health systems capable of delivering high-quality care, while recognizing women’s values and needs, which is essential for women to have positive pregnancy and birth experiences. While no study can provide findings that are universally transferable , this st


Intraconal dermoid cysts are very unusual in routine clinical practice. Clinical symptoms depend upon the site and extension of the lesion. Though rare, proptosis, diplopia, and orbital pain are the presenting symptoms encountered in patients with an intraorbital dermoid cyst. Although radiology can be diagnostic, a complete correlation with the final histopathology is always mandatory for its confirmation. Endoscopic excision of the cyst ensures a complete cure for the disease without any intraoperative/postoperative complications. It constitutes approximately 2% of all orbital tumors.A 30-year male presented to the outpatient department with pain and bulging over the right eye for 3 months and diplopia for 2 months . There wAfter informed written consent, the patient was planned for excision of the mass through a transnasal endoscopic approach. Endoscopic orbital decompression was performed, the lamina papyracea was removed by a freer’s elevator. The periorbita was completely exposed. A horizontal incision was given over the periosteum, and the medial rectus muscle was incised horizontally and later retracted to expose the whole cyst. The mass was identified and delineated all around from the extraocular muscles and the optic nerve and later removed completely by gentle blunt dissection and sent for histopathological examination for confirmation. On histopathology, a cyst wall was identified and was lined by keratinized stratified squamous epithelium with the presence of adnexal structures . There w,,,,The occurrence of a complete intraorbital and intraconal dermoid cyst is extremely unusual in clinical practice. Based on the Pub Med database using intraconal and dermoid cyst as the keywords, only 6 case reports have been described in the literature. Three of them involved the intraconal compartment of the orbit,,,,,The intraocular pain could be due to the inflammatory reaction in the dermoid cyst, which could be due to the presence of chronic inflammation, as demonstrated by Abou-Rayyah et al.Intraconal dermoid is very unusual in the routine practice. Clinical symptoms depend upon the site and extension of the lesion. Though rare, proptosis, diplopia, and orbital pain are the presenting symptoms encountered in patients with intraorbital dermoid. Although radiology can be diagnostic, a complete correlation with the final histopathology is always mandatory. Endoscopic excision of the cyst ensures a complete cure for the disease without any intraoperative/postoperative complications.