Mediastinal cysts account for 20–32% of all mediastinal lesions. Complete surgical excision is the standard therapy for mediastinal cysts. Translucent cysts containing crystal-clear fluid are called “spring water cysts.” We experienced a case of mediastinal spring water cyst fenestrated under video-assisted thoracoscopy with a miniaturized endoscope (mini-VATS) as an alternative to excisional resection.A 49-year-old woman presented with back pain. Chest CT revealed a posterior mediastinal mass measuring 4.2 × 1.8 × 3.2 cm closed to the tenth thoracic vertebra. Chest MRI demonstrated hypo-intensity on T1-weighted images and hyper-intensity on T2-weighted images. It was estimated that the posterior mediastinal mass did not contain a tumor component. The tumor was growing and symptomatic; therefore, we performed surgical cyst fenestration without excision of the cyst under mini-VATS. The patient experienced complete relief of symptoms. Fluid accumulation in the cyst was not observed on CT images 12 months postoperatively.Kozu et al. reported that all 108 primary mediastinal cysts were resected completely and were recurrence-free after a mean follow-up of 41 ± 26 months. In the case of a functional hydrocele such as spring water cyst, we believe that even if fluid is produced, the thoracic pleura is capable of absorbing the fluid, and the cyst wall might not recur even if the wall is left in place. Fluid drainage through fenestration may prevent recurrent fluid collection.Fenestration of non-neoplastic mediastinal cysts under mini-VATS might be a less invasive radical procedure compared to complete resection. •Translucent cysts containing crystal-clear fluid are called “spring water cysts.”•Complete surgical excision is the standard therapy for mediastinal cysts.•Fenestration of the cyst has lower risk of bleeding or injury to the adjacent normal structures than complete resection.•Fenestration of non-neoplastic mediastinal cysts might be a less invasive radical procedure compared to complete resection. She had no particular medical history, but she has suffered from lumbago since she was young. And she had no surgical or drug consumption history. There was no family history associated with this disease. Chest computed tomography (CT) revealed a posterior mediastinal mass measuring 4.2 × 1.8 × 3.2 cm closed to the tenth thoracic vertebra A, while The patient underwent surgery under general anesthesia. The patient was placed in a lateral decubitus position and fixed with a fixing mattress  on the operating table. An artificial pneumothorax for scope introduction was produced by needle thoracentesis under atmospheric pressure. Two ports were created at the seventh and eighth intercostal spaces; each skin incision was 2–5 mm long. A mini thoracoscope  was used. The mediastinal semilucent cyst existed at the anterolateral portion of the tenth thoracic vertebra. The fluid in the cyst (10 mL) was absorbed using a 16G needle; rapid cytology of the fluid showed no malignancies. The fluid was watery and crystal-clear without cell particles. A coin-sized fenestration was created using a pair of scissors and electrocautery. There was a risk of hemorrhage at the anterior surface of the vertebral body when the whole cyst was dissected due to the exposure of blood vessels on the luminal surface of the cyst. Surgical cyst fenestration without excision of the cyst was performed under mini-VATS A, B. At The thoracic catheter was removed on postoperative day 1, and the patient was discharged on postoperative day 4. The postoperative course was uneventful. Histopathologic evaluation of the resected specimen revealed a mesothelial cyst A, B, and33.1The appearance of the thin-walled, translucent cysts containing crystal-clear fluid gave rise to the name “spring water cysts.” Greenfield and colleagues introduced the new term into the medical literature when they encountered a cyst filled with “crystal-clear fluid of watery consistency” in 1943 3.2In this case, surgery was performed under general anesthesia as a complete resection with unilateral lung collapse was predicted. Fenestration may not require lung collapse during the procedure. Fenestration under mini-VATS is a relatively simple and less invasive procedure; local infiltration anesthesia or intercostal nerve block 3.3Complete resection of the cyst has the risk of bleeding or injury to the adjacent normal structures. In this case, the cyst made contact with the vertebral column, and there was the risk of bleeding from the segmental artery and rupture of the vertebral foramen. Kozu et al. reported that all 108 primary mediastinal cysts were resected completely and were recurrence-free after a mean follow-up of 41 ± 26 months 4Fenestration of non-neoplastic mediastinal cysts under mini-VATS might be a less invasive radical procedure compared to complete resection.No funding sources.No approval is required for this case report.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.Not applicable.Not commissioned, externally peer-reviewed.Soichiro Kiya, MDKembu Nakamoto, MD, PhDSoichiro Kiya, MD: Surgeon performing the operation, writing of original article.Kembu Nakamoto, MD, PhD: Revision and final approval of the manuscript.Toshiyuki Fujii, MD, PhD: Revision of the manuscript.Eriko Sakka, MD, PhD: Anesthesiologist of the operation, and revision of the manuscript.Yousuke Tsutsumi, MD, PhD: Anesthesiologist of the operation, and revision of the manuscript.Kazuya Yoshida, MD, PhD: Revision of the manuscript.None.


Birthweight has been declining consistently for more than 30 years in Japan. This rapid rise in low birthweight is one of the worst among the countries of the Organization for Economic Co-operation and Development. We examined potential determinants of birthweight decline in Japan.We used population-based birth certificate data from vital statistics records and retrieved 40,968,266 birth certificates of neonates born between 1980 and 2004. We analyzed time trends using linear regression analysis in examining whether the decline in birthweight could be explained by obstetrical variables such as gestational age and multiple gestations.From 1980 to 2004, we observed a decline in mean birthweight with a yearly effect of − 8.07 g, which became steeper after 1985, persisted until 1999, and plateaued thereafter. After adjusting for gestational age, gender, birth order, multiple gestations, and fathers’ age, the yearly effect between 1980 and 2004 persisted at − 5.13 g.Recent decreases in birthweight among Japanese neonates were not fully explained by trends in gestational age, gender, birth order, multiple gestations, and fathers’ age. Thus, additional factors such as pre-pregnancy maternal body mass index (BMI) and maternal diet should be considered. Reducing the rate of induced deliveries and improving the BMI or diet of young women should be a public health priority. Birthweight has been declining consistently for more than 30 years in Japan . The meaConcomitantly with this declining birthweight, the proportion of infants with low birth weight, defined as birthweight less than 2500 g, is high and has been increasing , while t2) [Factors associated to low birthweight include short gestational age , 12, mat2) , 18, and2) , 11.Birth weight decline in Japan began in 1975 and continued for 30 years. In 2000, the Ministry of Health, Labour and Welfare (MHLW) promulgated a national campaign named Healthy Parents and Children 21, in which improvement of birth weight was an important target of the campaign. Meanwhile, in 2006, MHLW established guidelines regarding optimal gestational weight gain of expectant mothers based on pre-pregnancy BMI to guarantee that neonates have an adequate and healthy birthweight of approximately 3000 g . AdditioIn the final assessment of the first stage of the Healthy Parents and Children 21 campaign in 2014, birthweight decline had not recovered, indicating that low birthweight is a persistent and severe issue. For the second phase, which began in 2015, the improvement of birthweight is remaining a priority. To contribute to the campaign, it is necessary to clarify the modifiable factors affecting birthweight. Hence, we aimed to examine the period in which the birthweight rapidly decreased and clarify factors contributing to the marked decline.Exhaustive national database such as birth certificates were used in the analyses. Since birth certificates are gathered from all births occurring in Japan under the Family Register Act and include data on birthweight and other demographic information, we used this information to examine the potential determinants of the national birthweight decline.In Japan, birth certificates are stored systematically by the MHLW on electronic data files. These certificates are filled by obstetricians or midwives following obstetric recordings in the hospitals or clinics and are filed in the municipalities’ health departments into the MHLW database. This database is anonymous and includes information related to neonates’ gender, birthweight, birth length, gestational age, multiple gestation, parity, fathers’ and mothers’ age, and birthplace.With permission from the Statistics and Information Department, Minister’s Secretariat, MHLW, a total of 40,968,279 birth certificate files were retrieved between 1980 and 2004. Before filling in the birth certification form, parents were informed about privacy protection and the use of public welfare data. National registration of vital records such as birth certificates is exhaustive, based on the Law. Since this study was considered of public interest, it was approved by the MHLW. We used the data from this specific time frame (1980–2004) because the mean birthweight showed an apparent decline during this period , live birth number, newborn gender, year of birth, prefecture code.The exact values for father’s and mother’s age, prefectural number, and delivery number codes were reported. For gestation codes, 1 stands for singletons and 2 stands for multiple births. For gender, 1 stands for male and 2 stands for female.First, we calculated Pearson’s correlation coefficients between birthweight and independent variable. Then, we calculated means and standard deviations of the variables in 1980 (the beginning of the observation) and in 2004 (the end of the observation).Low birth weight and preterm delivery are both strongly associated with birthweight declines. Therefore we stratified the independent variables into low birthweight or non-low birthweight groups , and preterm delivery or non-preterm delivery groups . The mean value of each independent variable and its standard deviation were calculated for the two birth weight categories and the two term categories, for the years 1980 and 2004.To clarify the factors affecting birthweight decline, we used the multiple linear regression analysis , 19 for P-value of less than 0.05 was considered statistically significant. All analyses were performed using SAS version 9.1 .The effect of time on birthweight was analyzed for each year, first without adjustment (crude effect), then in adjusting for explanatory variables added one by one in the model. We analyzed through total period (1980–2004) and among five-year periods . A The study protocol was approved by the Ethics Committee of the National Institute of Public Health. This study was conducted in accordance with the ethical principles established by the Declaration of Helsinki, 2008.From 1980 to 2004, we observed a decrease in birthweight, which became steeper after 1985, persisted until 1999, and slowed down thereafter , and during the steepest periods .As expected, the birthweight decline was mainly associated with gestational age. After adjusting for all variables, the decrease in birthweight was 5.13 g/year, and adjusting for gestational age solely 5.63 g/year decrease, compared to a crude reduction of 8.07 g/year. This demonstrates that gestational age is not the only factor responsible for the entire birthweight decline.The fact that birthweight decline was not fully explained by the variable in the regression analysis suggests that other factors than those included in the regression analysis played some role. Especially in the specific period where birthweight decline was rapid, the effect of adjustment for all variables was limited, and gestational age effect was also relatively small. This means that other determinants are associated with rapid birth weight decrease.Similarly, based on data from the US , gestatiThe strength of the present study comes from the large, nationally representative dataset that would not change for decades and from the use of information on potential factors associated with trends in birthweight. The limitations of our study come from the lack of detailed information such as comparing birthweight decline among subgroups classified by gestational age, fetal growth and mode of delivery .Indeed, one of the limitations of this study was gestational age estimation. Gestational age was entered in the birth certificate by doctors or midwives. Some used the date of the last normal menstrual period, while others the age estimate based on the early fetal ultrasonography results. This might have introduced variability and affected the validity of our gestational age estimation. Schonberg et al.  determinMany factors affect birthweight; however, the following factors could not be analyzed in the present study: medical conditions during pregnancy, childbirth, and other modifiable factors, such as pregnancy diabetes, pregnancy hypertension, placental abruption and abnormal obstetric bleeding. Considering obstetrical practice, gestational age is affected by the mode of delivery. The induction of labor has also steadily increased in Japan . Based oAnother limitation of this study is the lack of data likely associated with birthweight, such as maternal smoking status, pre-pregnancy weight, and maternal diet during pregnancy. Our data did not provide information on pre-pregnancy medical conditions such as diabetes and hypertension, which affect birthweight by causing large gestational age neonates and fetal growth restrictions, leading to low birthweight. Maternal smoking restricts fetal growth and increases obstetrical complications and the risk of preterm birth; these factors are likely to induce low birthweight and even stillbirths . In Japa2 in the age group of 20–39 years is increasing concomitantly with a decline in the mean birthweight (Fig. Pre-pregnancy BMI and gestational weight gain are other important factors that affect birthweight . BMI disAn increase in maternal age  has beenAlthough socioeconomic status is a well-known factor affecting birthweight , birth cIt is well-known that birth size influences not only short-term conditions but also long-term prognosis . FactorsIn conclusion, our study based on data from birth certificates showed that infants’ birthweight has decreased over the decades. These findings might partially be explained by the decline in gestational age, considered to result from a change in the delivery mode. Thus, further studies are needed to determine the clinical and social significance of these findings.


Descriptive analyses were run to examine SILC participation and household wealth. Multiple binary logistic regression models were fit to assess the unadjusted and adjusted relationship between (1) SILC participation and household wealth, (2) SILC participation and financial preparedness for birth and (3) sex and financial preparedness for birth. The results show that SILC participation led to an average increase of 7.32 items of the 13 household wealth items. SILC participants who had their most recent childbirth after joining SILCs were more likely to be financially prepared for birth  than participants who had their most recent childbirth before joining SILCs. Females were more likely to be financially prepared for birth than males if they had their most recent birth before joining an SILC . SILC participation is shown to increase household wealth and financial preparedness for birth for both men and women. SILCs are a promising intervention that can help poor and rural populations by increasing financial resources and financially preparing parents for birth.Savings and Internal Lending Communities (SILCs) are a type of informal microfinance mechanism adapted in many low- and middle-income countries (LMICs) to improve financial resources for poor and rural communities. Although SILCs are often paired with other health and non-health-related interventions, few studies have examined SILCs in the context of maternal health. This study examined the association between SILC participation, household wealth and financial preparedness for birth. The study also examined the association between sex and financial preparedness for birth. A secondary analysis was conducted on individual survey data collected from SILC participants in two rural districts of Zambia between October 2017 and February 2018. A convenience sample of 600 participants (Lundazi:  Lack of financial resources is a significant barrier for women in low-income countries to deliver at a health facility.Savings and Internal Lending Community (SILC) is a type of microfinance mechanism that can improve household wealth for poor people living in rural areas.Participants who had (or their wife/partner had) the most recent delivery after joining an SILC had higher odds of being financially prepared for birth than participants who had their most recent delivery before joining an SILC.Females had higher odds of being financially prepared for birth than males among the participants who delivered their most recent child before joining SILCs.Of the 295 000 maternal deaths that occur around the world every year, 99% occur in low-income countries and 66% in sub-Saharan Africa . Nearly There are numerous reasons why women in low- and middle-income countries (LMICs) are not seeking, reaching and receiving appropriate care in time .While the lack of financial resources makes it challenging for rural and poor women in low-income countries to access facility-based delivery, sociocultural factors can exacerbate these issues. In many low-income countries in sub-Saharan Africa, spouses and older family members strongly influence a woman’s ability and decision to deliver at a health facility (A study examining household savings during pregnancy showed that 90% of the women who reported saving any money for their most recent birth had either husbands or parents contribute to their savings (Savings Groups (SGs)—low-risk, self-managed, self-financed and informal forms of microfinance—have been recognized for their ability to reach the extremely poor (those earning <1.90/day) in rural areas. They show great potential as a type of intervention that can financially empower both women and husbands or partners to prepare for birth . There aFormed by community members, SGs also function as a social group for the participants to share ideas and stories during meetings, generating a sense of community . StudiesThis study specifically examines the impact of the Savings and Internal Lending Communities (SILCs), an SG model developed by Catholic Relief Services, one of the most widely implemented models of SGs in Zambia . Like otThe purpose of the article is to examine the association between SILC participation, household wealth and financial preparedness for birth. Furthermore, the study also examined the association between sex and financial preparedness for birth. Financial preparedness for birth is often defined as saving money for birth-related expenses, assessed by asking the woman and/or her husband or partner whether she/he was able to purchase required supplies  for the woman to deliver at health facilities , but this change occurred after the implementation of the SILC and does not affect the results. The authors partnered with a local non-governmental organization (NGO) to implement SILCs as part of the Maternity Waiting Home (MWH) project in rural Zambia. The MWH project aimed to understand the impact of MWHs on reproductive health service access and maternal outcomes for women living far (>10 km) from health facilities (n = 297) and five in Mansa (n = 303).A convenience sample of 600 participants was sought from a total pool of 6711 participants from the 10 different communities SILC groups were implemented. Five of the communities resided are located in Lundazi , as well as from the ERES Converge Research IRB, a private local ethics board in Zambia.The purpose of the SILC impact survey was to understand how loan and share-out funds from SILCs were used, how the funds affected the members’ livelihood and how SILC members perceived SILCs. The SILC impact survey included three domains: (1) demographics, (2) economic outcomes and (3) non-economic outcomes and financial preparedness for birth.The demographic domain included information such as participant’s age, sex, district of residence, month and year of the participant’s most recent childbirth , and the month and year when they joined the SILC.The economic domain included information on the amount of the first loan, usage of the loan and share-out funds, and engagement in agriculture, business and/or animal husbandry. Furthermore, data about the specific amounts of investments and gain from agricultural, business and animal husbandry before and after joining the SILC were gathered. The survey information regarding what materials comprised house and roofing structures before and after joining the SILC were also included. These questions were included in the economic domain because they are used to create a wealth index by many low-income countries’ Demographic and Health Surveys .The non-economic domain included variables such as the ability to pay for child school fees, uniforms and shoes; food security and the ability to purchase all the required supplies for the most recent delivery. The survey ends with open-ended questions asking for examples of how membership in the SILC has helped the participant or their family, whether they would recommend SILC to their family and why they would or would not recommend the SILC membership.Last, the financial preparedness for birth was assessed by asking the participants whether he/she was able to purchase all the required supplies—plastic sheet, gloves, baby hat, baby clothes, wrap and so on—for the most recent delivery. The participants who answered ‘yes’ to the question were categorized as financially prepared birth and those who answered ‘no’ were categorized as not financially prepared for birth.Because many people in low-income countries like Zambia often lack regular income, household wealth is frequently assessed by counting assets and assessing the quality of housing, sanitation facility and/or water supply . Similarα ≥ 0.7 = acceptable; 0.9 > α ≥ 0.8 = good and α ≥ 0.9 = excellent).Using these variables from the economic and non-economic domains, a total of 13 new discrete indicators were created. Each indicator was compared across two time points—before and after joining SILCs. Post-SILC participation improvements were coded as ‘1’. No change or post-SILC participation decline/decrease were coded as ‘0’. The ‘increase of wealth index’ was then created by summing the 13 new indicators. According to the United States Agency for International Development’s guideline for housing conditions , brick aTo understand the impact of SILC participation on financial preparedness for birth, all SILC participants were divided into two groups: those who had (or their wife/partner had) their most recent childbirth before joining an SILC and those who had (or their wife/partner had) their most recent childbirth after joining an SILC. The sample was dichotomized by the most recent childbirth date and SILC initial join date to assess how income earned through SILCs influence financial preparedness for birth.t-tests were conducted to examine the differences between participants who were financially prepared and participants who were not for the overall and stratified samples. The financially prepared sample was further stratified by sex.The aim of this analysis was to describe SILC participation and household wealth for birth and to examine the association between (1) increase of wealth and financial preparedness for birth and (2) sex of the participants and financial preparedness for birth. Descriptive statistics were analysed with means and standard deviations (SD) provided for the overall sample as well as the stratified sample between those who were financially prepared for birth and those who were not. A set of chi-square tests of independence and two sample Means and SD were calculated for the overall and stratified samples from Lundazi and Mansa. Several binary logistic regression models were fit to assess the unadjusted and adjusted relationship between increased wealth index and financial preparedness for birth. Adjusted logistic regression models included age, sex, district of residence and the period of the most recent childbirth as covariates. All logistic regression models provided adjusted odds ratios (AORs) and 95% confidence intervals (95% CIs).To understand the relationship between sex and financial preparedness for birth, logistic regression models were fit between those who had their most recent childbirth before and after joining SILCs. The data were analysed using Stata 15.0 .n = 388) than males were included in the sample. Approximately 30% of the sample was between 26 and 35 years of age (n = 183), closely followed by 36-year-olds to 45-year-olds . About one-fifth (19.88%) of the overall sample had their most recent childbirth after joining SILCs. On average, the increase of wealth index was 7.32, which means that, on average, SILC participants had ∼7.32 of the 13 economic and noneconomic indicator increase after SILC participation.P < 0.001), sex distribution (P = 0.009), the time point at which the most recent childbirth occurred (P < 0.001) and increase in wealth (P = 0.002). Samples that were financially prepared for the most recent birth had a higher percentage of participants from Mansa (51.01%) compared with 32.09% of those not financially prepared. The financially prepared sample also had more female (68.12 %) and more participants delivering a child after joining SILCs (25.57%) compared with 56.68% female and 12.20% participants delivering after joining SILCs from the not financially prepared sample. The financially prepared sample had, however, a lower increase of wealth, with an average increase of 7.54 wealth index compared with 8.52 from the not financially prepared. While we find no evidence that increase of wealth is significantly different between financially prepared and not financially prepared SILC participants from Lundazi, a large gap existed in the increase of wealth index between the two districts, with participants from Lundazi (10.49) exhibiting a greater increase of wealth index in the sample that were financially prepared compared with those from Mansa (2.04).Of the 600 participants, 64.85% were considered financially prepared for the most recent birth. When comparing the two groups—financially prepared for birth and not financially prepared for birth—the result showed a significant difference in the district of residence  and financial preparedness for birth. Furthermore, being a female was positively associated with financial preparedness for birth only if they had their most recent birth before joining an SILC.The results show that SILC participation was positively associated with household wealth as evident in the increase of wealth index (average 7.32). This finding is congruent with the general literature, which suggests SGs are able to reach poor people living in rural areas to provide them the means to access basic financial services such as loans, social funds and share-out funds . HoweverCompared with the participants who had their most recent childbirth before joining SILCs and those who had their or their wife/partner had the most recent childbirth after joining SILCs were almost three times more likely to be financially prepared for birth, determined by the participants’ ability to purchase all the required supplies for the most recent delivery. Out-of-pocket costs relating to childbirth can range up to one-third of the monthly household income for the poorest Zambian households  are especially prone. Social desirability could have also impacted the outcomes, given that the survey data were collected through face-to-face interview with the local NGO’s programme evaluators rather than anonymously filled by participants. Thus, the participants may have overreported on the gain from the SILCs. However, the interview format was unavoidable due to the overall limited literacy in rural Zambia.Second, the increase of wealth index is limited in its ability to capture wealth. Since responses were not recorded according to a specific unit for the investments and gain from agriculture, business and animal husbandry, the answers varied across participants. Some answered in Kwacha, while others responded in number of bags, kilograms, gallons and other units for indicators such as amount of crops harvested before and after joining SILCs. Therefore, while the study showed the overall increase of wealth in all SILC participants, it is unclear what the magnitude of increase was for each variable. Moreover, the survey did not capture other information that could have also shown an increase such as healthcare expenses. However, for many people in Zambia that lack regular income, assessing household wealth via counting the assets and quality of housing and water supply is a common methodology .Last, the lack of additional variables such as expenditure on different birth supplies, transportation, drugs and diagnostic tests was not included in the survey. These variables would have provided deeper insights to assess the range of financial preparedness for birth. Because the type of supplies needed to deliver at a health facility may differ by health facility or woman , financial preparedness for birth was captured by asking the participants to report their perception whether they were able to purchase ‘all’ the necessary birth supplies. This may have caused the participants who were only partially prepared for birth to either overreport or underreport their financial preparedness for birth.The study found that participating in SILCs increased household wealth and the likelihood to be financially prepared for birth. In addition, female SILC participants were more likely to be financially prepared for birth only for the participants who had their most recent childbirth before joining SILCs. This finding suggests that SILCs may be functioning as a social platform for females to share their concerns regarding childbirth, which allowed both males and females to prioritize gains from SILCs to financially prepare for birth. In sum, the study suggests that SILCs are a promising intervention not only to increase wealth for the poor and rural populations but also to help participants be financially prepared for birth. As such, the present study holds important implications for improving maternal health by helping poor males and females living in rural areas to overcome financial barriers to access fundamental reproductive health services.


Caenorhabditis elegans spermatocytes was the Major Sperm Protein (MSP), a nematode-specific cytoskeletal element. Earlier studies in the pig parasite Ascaris suum had identified accessory proteins that facilitate MSP polymerization and depolymerization within the pseudopod of crawling spermatozoa. In this study, we show that C. elegans homologs of the two Ascaris accessory proteins MFP1 and MFP2 co-localize with MSP in both the pseudopods of C. elegans sperm and the FBs of C. elegans spermatocytes.Until recently, the only verified component of Fibrous Bodies (FBs) within  C. elegans, MSP additionally functions as the extracellular signaling molecule for triggering both ovulation and oocyte maturation . MSP is highly abundant in sperm, where it reaches 10-15% of total and 40% of soluble cellular protein (Roberts 2005). Within developing spermatocytes, MSP is packaged into fibrous body–membranous organelle (FB-MO) complexes . By assembling into paracrystalline FBs, MSP is both sequestered away from the critical meiotic processes of chromosome segregation and cytokinesis while also being packaged for efficient segregation into spermatids during the post-meiotic partitioning process . Following the meiotic divisions and sperm individualization, FBs disassemble, and MSP disperses as dimers throughout the spermatid cytoplasm . When sperm activate to form motile spermatozoa, MSP polymerization within the pseudopod drives the motility of the crawling sperm . Thus, MSP exists in at least three distinct molecular states: 1) in highly organized paracrystalline FBs within developing spermatocytes 2) as unpolymerized dimers within spermatids, and 3) in dynamically polymerizing filaments and fibers within crawling spermatozoa.During the process of cell differentiation, specific cytoskeletal proteins can sequentially assemble into a wide variety of diverse molecular superstructures. Nematode spermatogenesis provides a powerful system for studying these transitions since sperm-specific transcription ceases prior to the meiotic divisions and translation ceases shortly thereafter . Therefore, structural transitions that follow the meiotic divisions must be carried out by the remodeling of already synthesized proteins. The Major Sperm Protein (MSP) is a nematode-specific cytoskeletal element whose polymerization dynamics drive the pseudopod-based motility of the activated sperm . In Ascaris suum identified MSP fiber proteins 1 and 2 (MFP1/2) as key regulators of MSP polymerization . MSP assembly dynamics within pseudopods requires the opposing forces of MFP1 and MFP2; MFP1 acts antagonistically to slow polymerization whereas phosphorylated MFP2 enhances MSP polymerization by serving as a nucleation site for polymer extension . However, because these studies focused on MSP dynamics within crawling sperm and in vitro biochemical assays, the localization of these proteins within developing spermatocytes remained unknown. Would they be packaged along with MSP in FBs? Would the homologs of these proteins exhibit similar localization patterns during C. elegans spermatogenesis?Because MSP neither binds nucleotides nor assembles into polar filaments, its assembly and disassembly dynamics require accessory proteins. Previous biochemical studies in the pig parasite C. elegans, we compared protein sequences between the two species. We globally aligned Ascaris MFP2 with the predicted protein sequence of the two highest scoring C. elegans matches ZK265.3 and C04G2.9 . These are two spermatogenesis-expressed members of a larger MFP2 domain containing nematode specific peptide family, group H , and will be hereafter referred to by their C. elegans gene prefix nsph. Ascaris MFP2 exhibits 51.4% identity and 66.7% sequence similarity with ZK265.3 (nsph-2) and 38.0% identity and 52.3% similarity with C04G2.9 (nsph-3.2). ZK265.3 and C04G2.9 have 41.0% identity and 52.6% sequence similarity with each other. Ascaris MFP1 has two isoforms, MFP1-a and MFP1-b, which when aligned with C. elegans MSD-1 (Major Sperm protein Domain containing), show 52% identity and 70.8% sequence similarity, and 51.9% identity and 66.0% sequence similarity, respectively . The sequence similarity between A. suum and C. elegans motility proteins suggests that they may have similar functions and binding properties.To confirm that the Ascaris proteins MFP2 and MFP1 have homologs in C. elegans spermatocytes and spermatozoa, we performed immunocytology experiments. For our analysis, we generated a rabbit polyclonal antibody against a unique NSPH-2 peptide  and obtained a polyclonal antibody against C. elegans MSD-1, from David Greenstein . To test the specificity of the new anti-NSPH-2 antibody, we used high-efficiency genome editing to generate CRISPR-Cas9 knockout (KO) lines through insertion of multiple premature termination codons in all three frames for both ZK265.3 (nsph-2) and CO4G2.9 (nsph-3.2) . Although neither knockout strain on its own exhibited a phenotype, they were useful for determining the specificity of our anti-NSPH-2 antibody. In control nsph-3.2 KO hermaphrodites, the anti-NSPH-2 antibody labelled distinct structures within late-stage spermatocytes  as well as the pseudopods of spermatozoa within the spermatheca . In nsph-2 KO hermaphrodites, only background labelling was observed. We then compared the localization of anti-NSPH-2 and anti-MSD-1 with the well characterized anti-MSP pattern in male gonads . In spermatozoa, both NSPH-2 and MSD-1 antibodies localize to the pseudopod, matching the known pattern in Ascaris spermatozoa. Within prophase and meiotically dividing spermatocytes, NSPH-2 and MSD-1 antibodies labelled discrete structures throughout the cytoplasm in a pattern strongly resembling FBs labelled by MSP antibodies . To verify that NSPH-2 and MSD-1 localized to FBs, we co-labelled male germlines with anti-MSP and either anti-MSD-1 or anti-NSPH-2 antibodies (To determine where NSPH-2 (MFP2) and MSD-1 (MFP1) localize within tibodies -I. Withitibodies . In contC. elegans. Our discovery that MSD-1 and MFP2/NSPH-2 are packaged together with MSP in the FBs of developing spermatocytes supports a model in which the FBs function to gather, concentrate, and sequester proteins that will ultimately drive or regulate pseudopod motility. While early studies of MSP dynamics in Ascaris capitalized on its assets for biochemical approaches, parallel genetic approaches in C. elegans were stymied by the fact that many key factors, including MSP, MFP1 (MSD), and MFP2 (NSPH) are encoded by multigene families. Our own individual knockout strains of nsph-2 and nshp-3.2 exhibit no obvious phenotypes. This result does not mean that MFP2/NSPH is non-essential, but that exploring its function may require knocking out combinations of up to five of non-identical, sperm-related NSPH genes. Similarly, the four MSD genes encode identical proteins that may need to be deleted to generate a mutant phenotype. CRISPR technologies give us the ability to knockout multiple genes and explore MSP dynamics in new ways. Beyond MSD and NSPH, will other proteins first identified in Ascaris as regulators of MSP dynamics and sperm motility  also localize to the FBs of developing spermatocytes? Alternatively, are there more proteins like the intrinsically disordered protein SPE-18 that localize to FBs and facilitate their growth and shaping but then are degraded shortly after the meiotic divisions ? Further studies will reveal whether MSD-1 and NSPH-2 function together with SPE-18 to facilitate FB assembly, or if they are just conveniently packaged in FBs alongside MSP.Until recently, it was thought that Major Sperm Protein (MSP) was the only component of Fibrous Bodies (FBs) in Worm cultureet al., 1995) and inoculated with the E. coli strain OP50, using methods similar to those described by Brenner (1974).Worms were cultured on MYOB plates . Briefly, C. elegans strain N2 was gene-edited by the insertion of a 43-base-pair sequence that includes multiple stop codons in all three reading frames to disrupt translation . A BamHI site was included 3’ to the stop codons to facilitate genotyping. Strains JDW307 nsph-3.2(wrd56[C04G2.9::exon 1 STOP]) and JDW308 nsph-2(wrd57[ZK265.3::exon 1 STOP]) were generated by CRISPR injection of an RNP complex  that was first incubated at 37°C for 15 minutes, then mixed with the co-injection marker pRF4 (50 ng/µl) and the relevant repair oligos (110 ng/µl) before being injected into wild-type L4 + 1 day worms grown at 20°C. After 4 days, rolling worms were plated individually, allowed to lay eggs, and the parental animal was genotyped by PCR and BamHI digestion. For candidate knock-ins the extrachromosomal array was removed by selecting non-roller progeny. Genotyping primer sequences can be provided upon request. The tracrRNA and crRNAs were obtained from Integrated DNA Technologies (IDT).CRISPR/Cas9 mutagenesis was performed as previously described (Paix C04G2.9 crRNA: 5’-TACCGGGCTCGGCGGGAAGG-3’ZK265.3 crRNA: 5’-AAAGGAAAACTGGATTTGGG-3’Repair oligos (BamHI sites in bold)C04G2.9/NSPH-3.2 AAGATACTTGGGCATTCCAGCCAATCGGAGCCCCCTGGGAAGTTTGTCCAGAGCAGAGGTGACTAAGTGATAAGGATCCTCCCGCCGAGCCCGGTAAAATGTATGGGTGAGCAZK265.3/NSPH-2GGATCCGGGTGGACAGATTCAAATTCTTCAGTACAAGGGATACAACAAAGCGGAGTTGAAAGGAAAACTGGATTTGGGAAGTTTGTCCAGAGCAGAGGTGACTAAGTGATAAAntibodies and immunocytochemistryet al., 2009). Primary antibodies included: 1:1500 4D5 mouse anti-MSP monoclonal  and 1:200 rabbit anti-MSD-1 rabbit polyclonal . Affinity purified rabbit antiserum against MFP2/NSPH-2 (ZK265.3) was generated by YenZym Antibodies using the peptide 92-108 EWLPLKQRHENNEGIRE. In experiments, the antibody was used at a 1:200 dilution. All samples were incubated with primary antibodies for 2 hours at room temperature. Affinity-purified secondary antibodies included 1:400 Alexa Fluor Plus 555 goat anti-rabbit IgG  and 1:300 Alexa Fluor 488 goat anti-mouse IgG (H+L) . Final slides were mounted with Fluoro Gel with DABCO (Electron Microscopy Sciences #17985-02) containing DAPI.Sperm spreads were obtained by dissecting 8-15 male worms per slide in 7.5 microliters of egg buffer  on ColorFrost Plus slides  coated with poly-L-lysine . Light pressure was applied to coverslips to flatten the samples. Samples were then freeze cracked in liquid nitrogen and fixed overnight in −20°C methanol. Specimen preparation and antibody labeling followed established protocols , image exposures were kept constant with no further image processing. For others, image exposures were optimized for individual gonads. The levels adjust function in Adobe Photoshop was used to spread the data containing regions of the image across the full range of tonalities.


Objective: Preterm birth is a leading contributor to childhood morbidity and mortality, and the incidence tends to increase and is higher in developing countries. The aim of this study was to analyze the potential impact of preterm birth in different etiology groups on neonatal complications and outcomes and to gain insight into preventive strategies.Methods: We performed a retrospective cohort study of preterm infants less than 32 weeks' gestation in the Third Affiliated Hospital of Zhengzhou University from 2014 to 2019. Preterm births were categorized as spontaneous or iatrogenic, and these groups were compared for maternal and neonatal characteristics, neonatal complications, and outcomes. All infants surviving at discharge were followed up at 12 months of corrected age to compare the neurodevelopmental outcomes.Results: A total of 1,415 mothers and 1,689 neonates were included, and the preterm population consisted of 1,038 spontaneous preterm infants and 651 iatrogenic preterm infants. There was a significant difference in the incidence of small for gestational age between the two groups. Infants born following spontaneous labor presented with a higher risk of intraventricular hemorrhage, whereas iatrogenic preterm birth was associated with higher risk of necrotizing enterocolitis and coagulopathy and higher risk of pathoglycemia. There was no difference in mortality between the two groups. Follow-up data were available for 1,114 infants, and no differences in neurologic outcomes were observed between the two preterm birth subtypes.Conclusions: Preterm births with different etiologies were associated with some neonatal complications, but not with neurodevelopmental outcomes at 12 months of corrected age. Preterm birth is the leading cause of neonatal mortality and morbidity and is a major risk factor of neurodevelopmental impairment , 2. It iPreterm birth can result from many possible etiologies, but the two major clinical etiologies of preterm birth are iatrogenic and spontaneous preterm birth . IatrogeGestational age (GA) at birth is the strongest predictor of neonatal complications and outcomes , and allThere is a growing awareness of the role of pathologies in preterm mortality and morbidity. Given the heterogeneity within clinical etiologies of preterm birth, it is helpful to examine the etiologies separately. In addition, identifying the specific characteristics of each clinical etiology is essential for developing effective methods for preventing preterm birth . There aThis was a retrospective, hospital-based cohort study carried out at the Third Affiliated Hospital of Zhengzhou University between 1 July 2014 and 30 June 2019. This study included all preterm infants born in this hospital with a GA < 32 weeks. Infants delivered at other hospitals and transferred to the NICU at the Third Affiliated Hospital of Zhengzhou University within 7 days after birth were also included if the detailed pregnancy and delivery records were available. Exclusion criteria included stillbirths, delivery room deaths, malformed fetuses, and infants for whom the pregnancy information was not fully recorded. This study was approved by the ethics committee of Third Affiliated Hospital of Zhengzhou University and was exempt from the requirement for informed consent.Newborn infants at GA < 32 weeks were included. The study cohort was classified into spontaneous preterm delivery  and iatrogenic preterm delivery  . IndicatAll survivors were assessed at 3, 6, and 12 months of corrected age by trained specialists. Development was evaluated using the Bayley Scales of Infant and Toddler Development-Chinese version, including the psychomotor developmental index and the mental developmental index. Developmental delay was indicated by scores <70 on either scale. The criteria for the diagnosis of cerebral palsy included permanent movement and posture disorders caused by non-progressive disturbances that occurred in the developing fetal or neonatal brain . Adversep < 0.05 was considered statistically significant.Data were analyzed using the SPSS 26.0 software . Descriptive statistics are presented using absolute and relative frequencies for categorical variables, and continuous variables are presented as means ± standard deviations. Categorical data were compared using either Fisher's Exact Test or the chi-square test, and continuous data were analyzed with ANOVA for normally distributed variables and by Kruskal–Wallis tests for non-normally distributed variables. The multivariate analysis was adjusted for GA, birthweight, gender, and delivery model, with the reference group being spontaneous labor onset. All tests were two-tailed, and n = 1,038; 61.5%) or iatrogenic . The ratio of gender, incidence of asphyxia, percentage of erythropoietin treatment, and duration of mechanical ventilation showed no differences between the two groups. GA and birth weight were significantly different between the groups, with the iatrogenic group having the higher GA and lower birth weight. The overall prevalence of SGA was 10.0%, which was much higher in the iatrogenic group than that in the spontaneous group . In addition, the cesarean section rate in the iatrogenic group was more than twice that in the spontaneous group , which indicates that vaginal delivery is not an option for most iatrogenic very preterm infants . The preterm infants were classified as spontaneous ( infants .p < 0.001). There were also relatively more multiple gestations in the spontaneous group (27.4%) compared to the iatrogenic group (11.3%). As expected, hypertensive disorder was the most common indication for early pregnancy termination in the iatrogenic group (72.8%), followed by fetal distress (40.9%) and placental abruption (11.8%). Meanwhile, women who underwent a spontaneous preterm delivery were more likely to have received antibiotics (10 vs. 3.0%) compared to the iatrogenic group for the treatment of ureaplasma urealyticum infection, chorioamnionitis, and streptococcal infection. The use of magnesium sulfate to prevent eclampsia was higher in the iatrogenic group (21.8%) than in the spontaneous group  and coagulopathy  was observed in the iatrogenic group, while the spontaneous group had a greater frequency of IVH . In addition, the ratio of pathoglycemia was relatively low, but it occurred more frequently in the iatrogenic group  compared to the spontaneous group. There was no difference in neonatal mortality between the two groups for infants < 30 weeks. For infants born at 30–31+6 weeks' gestation, the risk of death was greater in the iatrogenic group than the spontaneous group  during the follow-up period, and 250 infants were completely lost to follow-up . Follow-up information was therefore available for 1,114 infants, and no differences in poor outcomes were observed between the two preterm birth subtypes either for GA < 28 weeks or for GA 28–31+6 weeks .Preterm delivery is one of the most important causes of perinatal morbidity and mortality. This retrospective study showed that iatrogenic preterm births with GA < 32 weeks were more vulnerable to some complications.The rate of iatrogenic preterm birth in this study was slightly higher than that described previously , which mWhen comparing neonatal complications, 13 parameters were selected for descriptive analysis. Although there was no difference between the two groups regarding the incidence of pneumonia, the incidence was over 60% in both groups, which indicated that preterm neonates with GA < 32 weeks were more likely to have had pneumonia diagnosed. Lung inflammation in the neonate may be initiated by events that occur before birth or as a result of respiratory therapies used to treat lung disease. Premature infants are particularly vulnerable because they under-express protective factors like the anti-inflammatory cytokine IL-10 and Clara cell protein  and beca+6 weeks' GA, the risk of death was greater in the iatrogenic group, which indicated that the underlying causes of iatrogenic preterm birth might be diverse at this GA. This reflects the fact that these infants were induced due to severe pregnancy complications, which might have increased their risk of death. For infants with lower GA, there were no differences between the two groups, and it is likely that the shorter GA diminished the significance of the differences in mortality between the groups. We also observed no significant difference in neurological outcome between the spontaneous group and the iatrogenic group. One explanation for this might be that only neonates still alive at follow-up were included in this study, and aggressive medical care was beneficial to the children's outcomes. Whether infants received rehabilitation therapy depended on parental attitudes and socio-economic factors. The small number of children with adverse neurological outcomes in the follow-up cohort, particularly children with cerebral palsy, might also explain this lack of difference between the two groups. In addition, the rate of infants lost to follow-up was not negligible. Therefore, conclusions should be drawn with caution because unknown confounding factors might have accounted for this observation.Numerous studies have evaluated the relationship between preterm birth subtypes and neonatal death risk, but these have reported inconsistent results , 30, 36.Some limitations of this study should be noted. First, our results were restricted to very preterm infants (GA < 32 weeks) in a single maternity hospital, which might limit generalizability. Second, the rate of lost to follow-up was 18%, and it is possible that children with poor outcomes were not followed up, which might have biased the results. Finally, multiple factors are associated with the neurodevelopment outcomes, and not only preterm birth itself and its subtypes, but also medical care and socio-economic factors might affect the outcomes. Despite these limitations, this study has several strengths. This study chose to classify the etiologic types of preterm birth according to the reason for delivery by consulting obstetric records and collecting neonatology records, which ensured the accuracy of the data to the greatest extent possible. The assessment of both neonatal and infancy period outcomes in very preterm infants was another strength. This investigation might provide guidance for future research.In conclusion, some neonatal complications were associated with etiologic types of very preterm birth. However, we evaluated only the neonatal and infancy period outcomes of the preterm infants in this study. Thus, further research is needed on the long term consequences of preterm birth subtype. Outcomes beyond survival are also important, especially long-term neurological, cognitive, and behavioral consequences. Finally, we strongly support the view that it is the understanding of the association between neonatal complications and preterm birth clinical subtypes that will pave the way to the prevention of adverse outcomes.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.The studies involving human participants were reviewed and approved by the ethics committee of Third Affiliated Hospital of Zhengzhou University. Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin.CZ designed the study. XC, XZ, WenhL, WendL, YW, and SZ were involved in data collection. XC and XZ analyzed the data and wrote the paper. All authors read and approved the final manuscript.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.


Background: The global coronavirus (Covid-19) pandemic concerns all people, but has a specific effect on those who are expecting a baby during this time. The advice in the UK changed rapidly, with 14 different sets of national guidance issued within 1 month. Individual NHS Trusts released various guidance relating to the withdrawal of homebirth services, the closure of birth centers, restrictions on the number of birth partners (if any) allowed during labor, and whether any visitors were allowed to attend after birth. With the landscape of maternity care changing so rapidly, research was carried out to provide real-time data to capture the lived experiences of expectant families.Methods: A mixed methods online survey was carried out over 2 weeks between 10th and 24th April 2020. The survey was open to those in the third trimester of pregnancy, those who had given birth since the beginning of the “lockdown” period in the UK, and the partners of pregnant women and people who were in these circumstances. The survey asked questions about how respondents' holistic antenatal experiences had been affected, whether their plans for birth had changed, and the effect of these changes on respondents' emotional wellbeing. Of the 1,700 responses received, 72 mentioned that they had seriously considered “freebirthing” .Findings: An analysis of the respondents' reasons for considering freebirth was conducted, finding that reasons for considering freebirth were complex and multifaceted. Lesbian, bisexual, pansexual, and queer women were more likely to have considered freebirth than heterosexual people (p < 0.001).Conclusions: Considering giving birth without a healthcare professional present is unusual in the Global North and represents an emerging field of study. The literature examining the reasons that people consider freebirth shows a variety of underlying motivations. A global pandemic represents a new factor in such considerations. The findings from this research can help inform maternity service planning in future crises. The global coronavirus (Covid-19) pandemic concerns all people but has a specific effect on those who are expecting a baby during this time. Perinatal care, like emergency medical care, is time-sensitive, and cannot be delayed and then accessed later. In the first days of the lockdown in the UK, rapid response research was planned to understand the real-time social and cultural impact on the lived experience of people accessing maternity care in the UK. Our research question was:What are the experiences of perinatal care of those who are due to have a baby in the first months of lockdown in the UK, and how do they feel about these experiences?Our article is drawn from this wider research project, which used an online survey of parents. The survey comprised of three main elements: capture of demographic information; a psychometric tool that was administered to those who had given birth; and a series of open-ended questions. The survey opened on 10th April 2020 and closed on 24th April 2020.One of the themes that emerged from the open-ended questions was that 72 respondents had given serious consideration to freebirthing. This paper specifically discusses the experiences of those respondents, examining both why they considered this option, and their feelings about freebirth.Freebirth occurs when someone:“intentionally giv[es] birth without health care professionals (HCPs) present in countries where there are medical facilities available to assist them .”Although legal in the UK, freebirth is typically viewed as a non-mainstream and stigmatized birthing decision. The subject is under-researched and there is a paucity of academic literature on the phenomenon. Existing studies are largely qualitative and focus on the motivations of women in Western nations such as USA , UK 3),,3), IrelSuch studies highlight that women decide to freebirth for a range of reasons. These include a previous traumatic birth , dissatiIn the first weeks of lockdown in the UK, the advice for expectant parents changed rapidly. On the 9th March 2020 the Royal College of Obstetricians and Gynecologists (RCOG) issued guidance suggesting pregnant women were not at greater risk from coronavirus that the general population. However, a week later, the UK Government guidance stated pregnant women were one of the most vulnerable groups. Within a few days, RCOG advised NHS Trusts to consider closing smaller maternity units .Despite the proven safety of out of hospital settings for low-risk births , 12, in The uncertainty and confusion around this advice meant that pregnant people became concerned as to how these restrictions would impact their rights and experiences during labor and birth. As a result, national human rights charities such as the Association for Improvements in the Maternity Services (AIMS) and Birthrights, published a range of literature to support people impacted by these restrictions e.g., , 14]. Fu. Fu14)].Quantitative data about freebirth is almost non-existent. It is unknown, for example, how many people per year freebirth their babies in the UK. Demographics relating to freebirthers' socio-economic background, ethnicity, age, and parity do not exist. In short, within the UK context, there has never been a quantitative study undertaken that attempts to collect such data. Given this lack of statistical data relating to freebirth, the rates of increased interest in freebirthing due to the COVID-19 pandemic remain unclear. However, communities such as the Freebirth and Emergency Childbirth Support Group—a UK fee-based Facebook group—have been created on social media during the pandemic. This group provided information to almost 300 expectant parents, healthcare professionals and birth supporters. The emergence of groups such as this during lockdown suggests a genuine interest from a range of people in learning more about freebirth.An online survey was undertaken to capture the experiences of those in the UK who had given birth, or were due to give birth, between the 9th March 2020 and the 3rd July 2020, or whose partners had given birth or were due to give birth between these dates. The dates chosen ensured participants had either recently become parents or were in the third trimester of pregnancy at the time of the research. The survey collected demographic data, used a psychometric tool to measure support in labor and birth, and included a large number of open-ended questions about respondents' experiences.Participants were asked to indicate whether they or their partner was pregnant, their baby's date of birth or due date and their local healthcare service trust. Participants were also asked to indicate their ethnicity, age, disability, sexual orientation, and gender. The main part of the survey consisted of free text boxes which asked when participants became aware of Covid-19, and when they understood that it might impact their pregnancy and birth plans. It also asked about their plans for birth and whether they had changed, whether they were accessing private healthcare providers, whether other elements of perinatal care had changed, and how they felt about becoming a parent during a pandemic. A psychometric scale for those who had given birth was also included, but the results are not discussed in detail here. All questions after the consent and birth/due date were optional. The questionnaire tool is attached at The survey was promoted and carried out entirely online due to the practicalities of the pandemic, and also to allow as many people to respond as possible. An advert with a hyperlink to the survey was shared on Twitter from both the first author's personal account and a King's College account. On Facebook, the advert was shared in generic birth groups, “due in” groups, homebirth groups, cesarean birth groups, parenting groups and locality-based birth groups. Two human rights charities, Birthrights and the Association for Improvements in Maternity Services (AIMS) were involved in helping design the survey, and in promoting it through their online social media. The questionnaire was open from 10th to 24th April 2020, and 1,754 responses were received.This article reports in detail on the responses that related to freebirth. The psychometric scale data was removed, and a textual search of the full responses was carried out in the Excel spreadsheet for the terms:“Freebirth”“Unattended”“Unassisted”“Free [AND] birth”The last search term produced a high number of false positive results such as “stress free birth,” so all results for this search were manually checked before being included. The word “alone” was searched for (in the spreadsheet) but returned too many vague results. The mention of fear related to giving birth alone may refer to freebirthing, but is more likely to refer to giving birth without a partner, a situation many respondents were unhappy with.Responses which included these terms were then read in full by the lead researcher (MG), and included in the freebirth dataset if they indicated that the participant or their partner had considered freebirth at any point, or if they had had a freebirth. This resulted in responses from 72 people who had considered or had a freebirth being included in the dataset. The full responses  from these participants were then uploaded into NVivo. Two responses which mentioned freebirth were excluded from the analysis as these responses mentioned that the participants were too scared to consider freebirth, or that they were concerned other women might choose to freebirth. A second check of the full database was conducted by the second researcher (SPG) to ensure that all cases had been correctly identified.The demographic data from the full dataset were compiled so as to compare with those considering freebirth. The dataset of 72 responses was then thematically analyzed using NVivo. Thematic analysis is a methodology often used within qualitative research in the social sciences, because it can generate rich detail from the data, whilst also providing an overall organizational structure to compare and discuss the data within. It is used for “identifying, analyzing and reporting patterns (themes) within data” .As the aim of this research was to capture the real-time lived experiences of expectant parents during lockdown, we wanted to employ an analytical methodology that would provide a rich description of the dataset rather than a theoretically driven methodology.Six stages of analytic process are described by Braun and Clarke  as part Each theme was then named and described, drawing on the data to ensure that participants' voices remained the center of the analysis. The themes are presented above in The findings above use the themes identified to form the structure of this article. Simple quantitative analysis was also undertaken with the freebirth dataset, firstly to produce descriptive statistics of the demographics of the participants, but also to turn qualitative answers into quantitative ones by turning open-ended answers into closed ones. Turning qualitative data into quantitative data can be one of the purposes of qualitative research .This section begins by identifying the demographic characteristics of the participants who had considered freebirth. We then go on to examine participants' plans for birth before the pandemic.Of the 72 participants who said they had seriously considered freebirth during the pregnancy, 69 were women who were pregnant at the time of the research. Two participants were women who had given birth since the 9th March, and one participant was a man whose partner was pregnant. This division in the types of participant is roughly in line with the total dataset, where 1,385 were still pregnant at the time of the research, 336 had given birth, and 33 were the partner of someone who was pregnant or had given birth.The majority of participants were white, heterosexual women, as is shown in The youngest woman was 19, and the oldest was 41. The man was 42, but his partner's age is unknown. The average age was 31.4 ± 5 years, and the spread of ages are shown in In terms of geographic distribution, participants considering freebirth were not confined to any particular location in the UK. There is representation in England, Scotland, Wales and Northern Ireland see . There ip < 0.001).The demographic characteristics of those considering freebirth were similar to the demographic characteristics of the entire dataset, with the exception of sexual orientation. Bisexual, lesbian and pansexual respondents made up 4.2% of all survey respondents, but 13.9% of the respondents considering freebirth. Sexual minority women were therefore more likely than heterosexual participants to be considering freebirth. Contingency table testing was used to determine if this difference was statistically significant. Fisher's Exact test was applied to the data, comparing the number of LGBQ+ participants in the full dataset with the number of LGBQ+ participants in the subset who had considered freebirth. This test showed that there was a difference between the groups, with LGBQ+ people being more likely to have considered freebirth . It is interesting both that so many people with professional experience in either birth or healthcare were considering freebirth, and that they felt it was important to provide this information in their answers. For those with partners who are in current clinical practice, this also presents a challenge to the definition of freebirth as a birth “without health care professionals (HCPs) present .” We wilInterestingly, only one person who answered the survey had been planning to freebirth before the pandemic. The other participants had a range of birth plans. Many had been intending to birth at home (60). In England and Wales, around 2% of babies are born at home each year, meaning that those who had planned a homebirth are over-represented in this cohort . A signi“If pregnancy remains low risk to go to [named] Birthing Center. Is [sic] any complications developed to go to [named] Hospital.”Although all of the participants had seriously considered freebirth or were currently considering it at the time they completed the survey, there were a mixture of current plans for birth. Only two women had given birth before the survey, and of these, one woman had had a freebirth, whilst the other had seriously considered freebirth, but in the end had been able to obtain the midwifery care that she had been told would not be available. She explained that although the homebirth service was officially withdrawn:“when my husband rang whilst I was in labor, they initially said no one could come, but after my husband asked to speak to the head of Midwifery, they said they could send someone out to do “checks” prior to transferring in. In the end, though, the midwife turned up with all the gear be and was happy to stay. Birth was extremely straightforward and fast (30 min after midwife arrived).”Of the other 70 respondents whose babies had not yet been born, some were definitely intending to freebirth, whilst others remained undecided in their plans, and one woman was clear that she had previously seriously considered freebirth but was currently intending to give birth in hospital. The majority of expectant parents considering freebirth during the pandemic experienced negative feelings. Positive feelings seemed to be more prevalent amongst participants who had made the decision to have a freebirth, whilst those who were still undecided did not seem to share these positive feelings. Once the decision to freebirth had been made, participants described a returning sense of safety and security: “I feel safe in my own home.”This section will use the qualitative data to explore the two remaining themes relating to the birth care and support respondents considered, and the reasons that respondents considered freebirth.Expectant parents in this study had a range of different first choices for birthplace, including homebirths, birth centers and MLUs, labor wards, and elective cesarean births. When expectant parents' plans for birth changed because of lockdown, a freebirth was not always their second choice for birth either. Some women's second preference was to give birth in a different NHS setting, which they had been informed was not available to them. These difficulties are shown by this participant, as she explains why her second choice of birthplace was not available to her, for reasons unconnected to Covid-19:“I have been told that the home birth service has been pulled and I won't be eligible for a midwife unit led birth as my BMI was too high at booking in so I am now planning to freebirth.”Thirteen women in the study had considered using an independent or private midwife. These are fully qualified midwives, who are registered with the Nursing and Midwifery Council in the same way as NHS midwives. Independent midwives are self-employed, whilst private midwives are employed by private companies. Four women had hired an independent midwife, at the time of the survey. However, more women commented that they were unable to hire an independent midwife. For most, this was because they could not “afford it,” whilst for others it was because the independent midwives had no availability. One woman had considered hiring an independent midwife before lockdown, but had spoken to their maternity services who had reassured her they would be supportive of a home vaginal birth after cesarean with the result that she decided not to hire an independent midwife.Unfortunately, the local homebirth service had then been suspended, and the independent midwife no longer had any availability. The participant commented, “I feel the decision has been made too quickly without thorough troubleshooting.” In another case, a respondent recalled that the local NHS Trust had:“[I]n their infinite wisdom decided to cancel indemnity for all independent midwives in the area….Combined with the cancellation of NHS home births, women in my area are left with few choices of any.”This meant that independent midwives were not legally able to attend births at that time.The majority of participants who were considering freebirth because of Covid-19 had considered at least one other option subsequent to the changes in their original birth plans. Freebirth was therefore not a first or second choice for the majority of participants who were considering it.Given that freebirth was the first choice of only one participant and was not even the second choice for many people, understanding the reasons why participants were considering it is important for healthcare services. The reasons given by expectant parents were varied. As These reasons were not mutually exclusive, and many participants expressed several reasons for considering freebirth. Some of the reasons were also connected, for example:“I will have to go into hospital alone as my husband doesn't drive and will have to look after our eldest daughter; there is no one else who can take her and she's not allowed to visit either.”This section will explore each of the three main themes for considering freebirth.Thirty-nine participants said they were considering freebirth partly or wholly because they wished to avoid going into the hospital to give birth. For some this was due to past experiences giving birth in hospitals. For others, the potential of catching Covid-19 whilst in hospital felt too much of a risk to take. Rather than hospitals being a place where they and their babies would be safe, they had become places of potential danger and contamination for some women.Some participants feared what would happen if they went to hospital for this birth. Women described being afraid of being coerced into interventions they did not want if they were in hospital or treated badly in other ways. These fears were not unrealistic, as they were often based on their previous experiences of hospital births:“Despite having quick births ‘easy’ births I have been treated awfully during labor and for that reason only feel I have had one positive birthing experience. I was hoping this birth would be healing….”Other women's fears were based on their experiences of care during this pregnancy, where they felt that coercion and “bullying” had already happened to them. These fears were compounded by the idea that they might be in hospital without a partner “to advocate for me.”Hospital policies around the admission of partners to the labor ward were felt to be coercive by some women. Two women explained that their hospitals were only allowing partners in when labor was established. They had been informed that this would be judged by cervical dilation. However, cervical dilation can only be established by a vaginal examination. Two women described that they intended to decline the offered vaginal examinations but were scared that doing so would mean their partners were not allowed into the labor ward. The very fact that the stated policy made a partner's presence conditional on the women accepting an intervention made them feel that coercion was openly advertised as being integral to choosing a hospital birth.For women whose partners or children were in the high-risk groups, going into hospital meant not only a risk to their own health and their newborn baby's health. It also meant that they potentially became contaminated, and a danger to their families. The dual hospital risks of interventions and the risk of contracting the virus were interrelated:“I fear the changes are going to lead to [more] unnecessary interventions. And an increased risk therefore of having to stay in hospital, increasing the chance that me, baby and my husband's will be exposed to the virus. My husband has a heart condition so I fear the worst.”Most NHS Trusts adopted a policy of only allowing one birth partner into labor wards, MLUs and birth centers during established labor. This created fear in some women that they would not have a known person with them for some or all of their labor. As well as wanting partners to be present at the birth to advocate for them, women described needing their support. This was especially the case when the journey to this birth had been difficult:“[M]y partner is a great support for me, we have gone through IVF and a miscarriage together and I couldn't imagine doing any of this without him….”Some NHS Trusts adopted a policy that the sole birth partner had to be someone the woman lived with, ostensibly to reduce the potential for Covid-19 transmission to healthcare professionals ….”Many of the women who were in this position had planned their support carefully. Until just a few weeks before the survey, they had expected to be able to have a birth partner who they did not live with support them during birth—usually a doula , though one participant had intended to have her mother as her birth partner. Some of these women had intended to give birth in hospital or in birth centers and MLUs, with the support of their non-resident birth partner. They were very aware that they suddenly faced the real possibility of giving birth with no-one they knew present to support them.In some NHS Trusts, the rules about who could be present at a birth were extended to homebirths as well. This created an impossible situation for one participant who is a single parent:“Home births so far are still going ahead in my trust, however I wouldn't be allowed my doula or my kids in the room. I have no childcare and no other birthing partner.”This situation had forced her into considering a freebirth, despite the fact that a homebirth service was still available.For three women, access to water as a form of pain relief was an essential part of their birth plan. One participant was clear that she would have considered a waterbirth on the labor ward, but the only room with a pool was reserved for women who were Covid-19 positive or Covid-19 symptomaticThe number of changes and the uncertainty over which services might be available were mentioned by three participants as a factor in their consideration of freebirth. Different NHS Trusts have made changes to the services available at varying times. Service changes impacted expectant parents' plans, as they made new choices depending on the services available. A participant who had changed her plans several times already in response to the withdrawal and reinstatement of birth support by her NHS Trust said she was now considering freebirth because she did “not want to change my birth plans [again].”A sentiment which was repeated by many participants was the feeling that they had been left with no choices by their perinatal services, with 26 participants describing feeling trapped, and forced into decisions that they did not want to make. They characterized the choices that they had, due to a combination of personal circumstances and local Trust policies as being “no choice” or an “impossible choice.” There was a sense that the decision to freebirth was one which the NHS services were making for them: “I feel I am being backed into a free birth.”Some expectant parents were considering freebirth because of practical reasons, which were often multifaceted. Lockdown restrictions, and elderly parents shielding had restricted the childcare options available for older children for some families. If the partner was the only person available to take care of the children, and the homebirth service had been withdrawn, that meant being without known support during birth. For those whose partner could not drive, or without access to a vehicle, simply getting to the hospital could be a logistical problem. This was especially the case if a homebirth service had been withdrawn and local birth centers were closed, or not available because the pregnant person was not “low risk.” In rural areas, some women were faced with a significant journey to the only available NHS support for birth: “hospital 45 miles away.”Even with access to a car and a driver, this is a daunting journey to undertake in labor. Without that access, options were very restricted:“We don't have a car, and the idea of taking a taxi in mid labor, during a virus outbreak, was unthinkable.”Concern about the distance that might need to be traveled whilst in labor was compounded by previous birth history when women had had fast labors. The woman who lived 45 miles from the hospital said one of her main reasons for considering freebirth was that:“My last baby was born in less than an hour and a half so I'm worried I wouldn't make it to the hospital.”In total, eight participants mentioned that a previous history of precipitous labor was a factor in their consideration of freebirth. All of these women had previously planned a homebirth, or a birth in a birth center with close proximity to their home. They did not perceive that they were making a choice between giving birth in a hospital and freebirthing, but rather between freebirthing and “End[ing] up having an accidental unassisted birth.”This is the first large scale study to capture the demographics of people contemplating freebirth within the UK. It is also the first study to identify LGBTQ+ people considering freebirth. Importantly, freebirth was contemplated by people throughout the UK suggesting that this decision was not motivated by the actions of a few restrictive NHS trusts, but rather that the issue was far more widespread. Furthermore, as far as we are aware, this is the first freebirth study to capture data from all four countries of the UK.Notably, this is also the first time that a UK study has shown that NHS health care professionals have contemplated stepping outside of the NHS maternity system in order to freebirth their babies. As no respondent mentioned other, unconnected professions, it appears that respondents may have been justifying their choice to consider freebirth by constituting themselves or their partners as experts. This also raises as yet unanswered questions about NHS staff perception of safety in relation to the service they and their colleagues provide. It also offers a challenge to the definition of freebirth. If either the person who is giving birth or their partner is currently in clinical practice, can the birth be said to be “without health care professionals (HCPs) present ?”We note that participants within our survey have specifically used the term “freebirth,” alongside responses that indicate that they or their partners are healthcare professionals, and we believe it is important that their terminology about their birth choices is respected. The term was also used by most participants in the survey without healthcare training or partners. Using the term “freebirth” is an active, linguistic choice indicating an awareness of it as a social phenomenon. Moreover, those that indicate they or their partners are healthcare professionals, will likely have awareness of the stigma of freebirthing. We do not propose to offer an alternative definition of freebirth here, but instead highlight this as an issue for consideration should further research into health care professionals stepping outside the NHS maternity system be undertaken.It is well-established that pregnant lesbian and bisexual women face routine heteronormativity, invisibility and invalidation in their encounters with perinatal care . ResearcAnyone can legally choose to give birth at home, regardless of whether this would be medically recommended. This is a well-established right, which has been confirmed under European law . Birth c“Women should be able to make decisions about the support they need during birth and where they would prefer to give birth, whether this is at home, in a midwifery unit or in an obstetric unit .”However, in many NHS Trusts there is a policy that only women deemed “low risk” can give birth in birth centers or MLUs. The National Institute of Clinical Excellence (NICE) suggests that only around 45% of pregnancies are considered “low risk” . This meResearch is shortly due to be published that shows which perinatal choices different NHS Trusts were able to maintain, and which they decided it was necessary to remove. These results are welcome, and important for future emergency planning of perinatal services. As these findings show, removal of choice leads to pregnant people who would rather have an attended birth considering freebirth. However, the stories above also show that personal circumstances can mean that the maintenance of choice in birth is not as simple as which of the four places of birth are open. If a birth center is kept open when a homebirth services is closed but is only available to those who are “low risk”, it does not provide choice for most people. If a homebirth service is still running, but children and those from other households are not allowed in the room, it is not a service that can be used by single parents. If a single birth supporter is allowed, but they have to be from the same household, single pregnant women and people face giving birth without support from someone they know. As can be seen in the responses to this survey, it can be the most vulnerable people who are affected by service disruption the most, and who then feel they are left with no choice but to consider freebirth. Choices which are seen as clinically minor choices (such as access to a birth pool on a labor ward) may be of great importance to pregnant people when making decisions about birth. It is therefore important that quantitative research into the choices that NHS Trusts were able to maintain is nuanced to service users' choices and takes into account the ways different personal circumstances may interact with perinatal service availability or restriction.Although this study of freebirth took place during the Covid-19 pandemic it becomes apparent that pregnant people's motivations reflect those noted by previous scholars. Concern about the safety of hospitals, the reduction of homebirth options, the practicalities of attending hospital and previous birth trauma were all important motivations in this cohort. This demonstrates that the Covid-19 pandemic has placed a spotlight on existing problems in maternity care. Data from this study is clear: when pregnant people are presented with a maternity service they deem unsafe or does not align with their needs, desires or world view, they may step outside of that system. If service providers wish to ensure people have access to perinatal maternity care, they must provide a service that is acceptable to those who are using it.This study has also exposed how some pregnant people considered maternity policies as coercive. A fear of being coerced into unwanted medical interventions raises serious issues regarding the under-researched area of informed consent and refusal in NHS maternity care. It must be ensured that policies do not inadvertently subvert informed consent as this could result in those giving birth submitting to interventions they may otherwise have refused. As already highlighted above, a desire to avoid such policies was a motivating factor for some people in this cohort.Freebirth as a subject of academic research has only begun to be studied relatively recently, and the literature pertaining to it is small. The available literature suggests that it is a decision pregnant women make for a variety of reasons, including previous traumatic births , a lack Although the concept of risk typically dominates discussion on pregnancy and childbirth, the Covid-19 pandemic appears to have challenged people's views on where and how it is safest to give birth. Hospitals are generally assumed to be places of safety, however for women who have experienced a traumatic birth, or who are worried about iatrogenic harm in birth, hospitals may feel unsafe . During This project provided a brief snapshot into the thoughts, feelings, and decisions of expectant parents in the first weeks of the Covid-19 lockdown in the UK. There is an immediacy to these qualitative responses that can provide researchers, policy makers, and practitioners with an insight into lived experiences. The numbers considering freebirth, and the reasons that they were considering this could usefully inform reorganization and prioritization of perinatal services in the event of future lockdowns.considered freebirth, and cannot know the numbers of those who eventually decided to do so. A limitation of this real-time survey tool is that the resultant dataset is a convenience sample which may be biased toward those that feel most strongly about their pregnancy experiences. It could therefore be that those expectant parents who were considering freebirth were more likely to complete this questionnaire than parents who felt more sanguine about the available NHS birth choices.The research was intended to capture experiences from a wide range of expectant parents, and freebirth was not a specific area of investigation within the research. Capturing data from so many people considering freebirth was unexpected. Data capturing the number of freebirths are not routinely collected in the UK, apart from in London, where this information can be volunteered by parents . ThroughFurther research into perinatal experiences during the Covid-19 pandemic has already been planned and partially conducted both within the UK and internationally. The results of other studies will fill some of the research gaps within this work. The opportunity to compare these findings on an international level would also create a more nuanced understanding of the circumstances that affect the consideration of freebirth during a pandemic.As mentioned above, it is not currently known how many participants considering freebirth went on to have a freebirth within this study. Follow-up research to determine the actual circumstances of birth, and participants' satisfaction with their decisions could provide useful information, as no freebirth research to date has focused on consideration of freebirth.This research suggests for the first time that specific groups of people may be more likely to have considered freebirth during the Covid-19 pandemic. Further research with LGBTQ+ people and HCPs would be useful to establish whether these groups are more likely to consider freebirth outside of a pandemic, and to understand the reasons why this might be.The data will be made available without undue reservation through the UK Data Service, in accordance with ESRC protocols.The studies involving human participants were reviewed and approved by King's College London, BDM Research Ethics Subcommittee. The patients/participants provided their written informed consent to participate in this study.MG: conceptualization, methodology, formal analysis, writing—original draft, and writing—review and editing. SP-G: formal analysis, writing—original draft, and writing—review and editing. GM: writing—original draft and writing—review and editing. All authors contributed to the article and approved the submitted version.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.


There are few epidemiological studies on the relation between temperature changes and adverse pregnancy outcomes. The purpose of this study was to determine the relation between Physiological Equivalent Temperature (PET) with adverse pregnancy outcomes including stillbirth, low birth weight (LBW), preterm labor (PTL), spontaneous abortion (SA), preeclampsia and hypertension in Ahvaz, Iran.2, SO2 and PM10), and weekdays were adjusted.Distributed Lag Non-linear Models (DLNM) combined with quasi-Poisson regression were used to investigate the effect of PET on adverse pregnancy outcomes. In this study the effect of time trend, air pollutants  caused a significant increase in risk of stillbirth. Also, high levels of PET  and low levels of PET  significantly increased the risk of LBW. But, low levels of PET  reduced the risk of gestational hypertension.The results of this study showed that hot and cold thermal stress may be associated with increased risk of stillbirth, and LBW in Ahvaz. Weather conditions can affect human health and activities . Heat stRecently, several studies have focused on the possible effects of ambient temperature on pregnancy outcomes. For example, Yu et al. 2018) reported mixed effects of temperature on preterm birth, in the tropical island of Puerto Rico. But, other studies have reported a positive relation between exposure to heat waves in all months of pregnancy and preterm birth, while exposure during early pregnancy was more likely to increase the risk of stillbirth, compared with exposure in the last months of pregnancy . Several reportedHuman thermal discomfort can be measured by various indices . Since 1One of the most popular indices used to measure heat stress in outdoor spaces is physiological equivalent temperature (PET), deviated from the Munich Energy Balance for Individuals (MEMI) . PET is According to numerous studies, the dangers of climate change on human health are undeniable. Although pregnant women are a sensitive group, the extent of these changes during pregnancy is still unknown. The present study is the first study about the effects of temperature on adverse pregnancy outcomes in Iran and the Middle East.The aim of the present paper is to study the relation between PET and stillbirth, low birth weight (LBW), preterm labor (PTL), spontaneous abortion (SA), preeclampsia and gestational hypertension in a 10 year (2008–2018) time frame in Ahvaz, Iran.2 and is 12 m above sea level. In the 2016 census, the population of this city was approximately 1,300,000  and reduced birth weight [− 15 g (95 % CI: −17g_−13 g)]. On the other hand, low temperature (≤ 10th percentile) was not associated with SGA [OR = 1.003 ] risk, but a slight decrease in birth weight [− 6 g (95 % CI: −8g_−4 g)] was observed .Grace et al., (2015), conducted a study in 19 African countries, on nearly 70,000 births, over 20 years, and noticed that with increased warm days and reduced rainfall at any point in pregnancy, a significant increase in LBW was observed in sub-Saharan Africa . Also, KOn the other hand, Hartig and Catalano (2013) stated that the risk of very low birth weight < 1500 g) was related to ambient cold temperatures, during the cold summers of Sweden . Contrar0 g was rConcerning preterm labor, the results of our study did not show any significant relation between the effect of PET and PTL. Similarly, two cohort studies suggested that there was no increase or decrease in the risk of preterm birth among those who were exposed to short-term cold temperatures throughout their pregnancy , 58.However, some studies have stated that both hot and cold weather, affect PTL. For example, in Sabzevar, Iran, an increased risk of preterm birth at both very hot and very cold temperatures especially at 0 till 8 lag days was observed . Also, LIn relation to gestational hypertension, the results of this study showed that low levels of PET in the 1st, 5th and 25th percentiles reduce the risk of hypertension. In contrast, the study done by Melo et al., (2014), on 26,125 admitted pregnant women, between 2000 and 2006 in Recife, Brazil, reported that during the cold months, the incidence of hypertension disorders in pregnancy significantly increased, and the lowest mean monthly incidence was in February (9.95 %) and the highest in August (21.54 %) . Some loIn this study, no significant relation was found between temperature changes and preeclampsia. Similar to this a 36-month research on 11,958 newborns in Mississippi, found no association between the incidence of hypertension in pregnancy and seasonal variation . HoweverAlthough, the relation between temperature and some adverse pregnancy outcomes has been studied before in Iran, the present study included abortion and gestational hypertension for the first time. This study comprehensively examined the effect of PET index on six adverse pregnancy outcomes.This study had some limitations, including the lack of some health and individual data such as maternal weight, body mass index, and physical activity. Also, this was an ecological study, which means that these results are at population level and cannot be generalized to the individual level. Air pollution parameters had been measured at population level and we were not aware of the individual exposure status.The results of this study showed that hot and cold thermal stress may be associated with increased risk of stillbirth, and LBW. Increasing our understanding about the link between temperature changes and adverse pregnancy outcomes in societies sensitive to climate change is essential for improving maternal and fetal health. Pregnant women should be aware of the risk of high and low temperatures for unborn babies and should be encouraged to protect themselves from excessive thermal stress.