In the UK, 1–2% of infants are born very preterm (<32 weeks of gestation) or have very low birth weight (<1500 g). Very preterm infants are initially unable to be fed nutritional volumes of milk and therefore require intravenous nutrition. Milk feeding strategies influence several long and short term health outcomes including growth, survival, infection (associated with intravenous nutrition) and necrotising enterocolitis (NEC); with both infection and NEC being key predictive factors of long term disability. Currently there is no consistent strategy for feeding preterm infants across the UK. The SIFT trial will test two speeds of increasing milk feeds with the primary aim of determining effects on survival without moderate or severe neurodevelopmental disability at 24 months of age, corrected for prematurity. The trial will also examine many secondary outcomes including infection, NEC, time taken to reach full feeds and growth.Two thousand eight hundred very preterm or very low birth weight infants will be recruited from approximately 30 hospitals across the UK to a randomised controlled trial. Infants with severe congenital anomaly or no realistic chance of survival will be excluded. Infants will be randomly allocated to either a faster (30 ml/kg/day) or slower (18 ml/kg/day) rate of increase in milk feeds. Data will be collected during the neonatal hospital stay on weight, infection rates, episodes of NEC, length of stay and time to reach full milk feeds. Long term health outcomes comprising vision, hearing, motor and cognitive impairment will be assessed at 24 months of age (corrected for prematurity) using a parent report questionnaire.Extensive searches have found no active or proposed studies investigating the rate of increasing milk feeds. The results of this trial will have importance for optimising incremental milk feeding for very preterm and/or very low birth weight infants. No additional resources will be required to implement an optimal feeding strategy, and therefore if successful, the trial results could rapidly be adopted across the NHS at low cost.ISRCTN76463425 on 5 March, 2013.ISRCTN Registry;  In the UK, 1–2% of newborn infants are very preterm or have very low birth weight. Preterm birth is the major risk factor for infant mortality, with 73% of neonatal deaths in the UK occurring in infants born before 37 completed weeks of gestation  versus slower increase [18 ml/kg/day]) in very preterm (<32 weeks) or very low birth weight infants (<1500 g) infants has any effect on survival without moderate or severe disability at 24 months corrected age.Two thousand eight hundred infants from approximately 30 neonatal units will be recruited within the UK and Ireland over 3 years.Gestational age at birth is <32 completed weeks, or birth weight <1500 gReceiving ≤30 ml/kg/day of milk at randomisationWritten informed parental consent is obtainedSevere congenital anomalyIn the opinion of the treating clinician, have no realistic chance of survivalUnlikely to be traceable for follow-up at 24 months of age Moderate/severe visual impairment Moderate/severe hearing impairment Moderate/severe gross motor impairment Moderate/severe cognitive impairment assessed using the Parent Report of Children’s Abilities–Revised (PARCA–R), a parent report measure of non-verbal cognitive and language development. Total PARCA–R scores <44 will be used to identify children with moderate/severe cognitive impairment . This quThe primary outcome will be the proportion of infants surviving without moderate or severe neurodevelopmental disability at 24 months of age corrected for prematurity. This composite outcome will be determined by confirming that the child is alive or dead using records held and maintained by The Health and Social Care Information Centre and other central UK NHS bodies. For live infants, a parent report questionnaire will be used to assess sensory and gross motor impairment and standardised measures to assess cognitive function in order to identify children with:A child who has any one or more of these impairments will be classified with a moderate/severe disability. Definitions for motor and sensory impairments described above are as defined in the report published by British Association of Perinatal Medicine (BAPM) in 2008 .Survival to discharge home.Microbiologically-confirmed or clinically suspected late-onset invasive infection from trial entry to discharge home.NEC (Bell stage 2 or 3) from trial entry to discharge home.Time taken to reach full milk feeds (tolerating 150 ml/kg/day for 3 consecutive days).Growth  from birth to discharge home.Duration of parenteral feeding.Length of time in intensive care.Length of hospital stay to discharge home.Secondary outcomes to be assessed when infants are discharged home for the first time are:In addition, the separate components of the composite primary outcome at 24 months of age corrected for prematurity will be analysed individually as secondary outcomes. The diagnosis of cerebral palsy by a doctor or other health professional will also be a secondary outcome assessed at this age.Written consent will be sought from parents only after they have been given a full verbal explanation and written description of the trial via a parent information leaflet. Consent will be obtained by means of dated parental signature on a study consent form and the signature of the person who obtained informed consent. Recruitment will be conducted by a health professional with delegated authority. Parents who do not speak English will only be approached if an interpreter is available.Parents will not be given any financial or material incentive or compensation for enrolling their babies in this trial.Randomisation will take place at the time the clinician is ready to start increasing the feed volume. This will be performed through a secure website hosted by the NPEU CTU with telephone back-up available 24/7, 365 days a year.A minimisation algorithm will be used to ensure balance on important prognostic factors: hospital, multiple birth, gestational age ranges, and birth weight <10th centile for gestational age. Multiple births will be given the same allocation.This is an open trial; blinding of the clinicians, nursing staff, and parents is not possible. A blinded endpoint review committee will examine the relevant data collection forms and clinical notes of infants with possible sepsis and NEC and classify them systematically according to predefined criteria.Deviations from the scheduled speed of increase may be made at the discretion of the treating clinician if the infant appears unable to tolerate the allocated speed of milk feed increase.At all stages it will be made clear to the parents that they are free to withdraw their infant from the trial at any time, without the need to provide explanation. If parents choose to withdraw, they will be asked for permission to complete data collection and/or follow-up.The attending clinician may also withdraw the infant from the allocated treatment if they consider this to be in the best interest of the infant’s health and well-being.All outcome data are routinely recorded clinical items that can be obtained from the clinical notes or local microbiological laboratory records. No additional blood or tissue samples are required for this trial. Clinical information will be collected using specially created data collection forms.A parent questionnaire will assess neurodevelopmental outcomes and health care costs when the infant is 24 months of age (corrected for prematurity).Data will be processed using validated data management systems to ensure consistency, viability and quality of data. It will be stored in line with the Data Protection Act 1998.Result in deathAre life-threateningRequire inpatient hospitalisation or prolongation of existing hospitalisationResult in persistent or significant disability/incapacity, orAre a congenital anomaly/birth defectAdverse events are defined as serious if they:The term “life-threatening” refers to an event in which the child was at risk of death at the time of the event; it does not refer to an event which hypothetically might have caused death if it were more severe. SAEs are to be reported from randomisation until discharged home.Safety reporting will be carried out in accordance with the NPEU Clinical Trials Unit standard operating procedures and clinical regulations.The primary comparison will be the difference in the proportion of infants surviving without moderate or severe disability at 24 months of age corrected for prematurity. Based on previous trials, it is estimated that 80% of the infants will survive to 2 years, and that 11% of these will have a moderate or severe disability . Hence iWith the same level of significance, a sample size of 2500 infants will have 90% power to detect an absolute risk difference of 5.4% (from 25.0% in control group to 19.6%) in the incidence of sepsis  and an aAn inflation factor of 1.12 was applied to the sample size to allow for multiple births, expected to have correlated outcomes, receiving the same allocation. This was based on an estimate of 25% for the proportion of multiple births and an intraclass correlation coefficient of 0.9 for the primary outcome at 2 years, based on a similar outcome in a preterm population . The totDemographic factors, clinical characteristics and outcomes will be summarised with counts (percentages) for categorical variables, mean (standard deviation) for Normally distributed continuous variables, or median (interquartile or entire range) for other continuous variables. Infants will be analysed according to allocation regardless of the speed of milk feed increase they actually receive.The two groups will be compared using generalised estimating equations, adjusting for the minimisation factors to account for the correlation between treatment groups. This method of analysis will also account for the correlation in outcomes between twins and siblings born in a subsequent pregnancy during the trial period. For the primary outcome, an adjusted risk ratio with 95% confidence will be calculated using log binomial regression, or log poisson regression with a robust variance estimator if the binomial model fails to converge . Linear The consistency of the effect of advancing milk feeds across specific subgroups of infants will be assessed using the statistical test of interaction. Pre-specified subgroup analyses include: (i) week of gestation at birth, (ii) birth weight  type of milk (breast milk only/formula only/mixed). Subgroup analysis will be performed on the primary outcome, and the incidence of sepsis and NEC.Relevant resource use data collection will be undertaken prospectively from centres participating in the trial. Private out of pocket costs to parents will be collected via a questionnaire sent at 24 months of age corrected for prematurity. Unit costs will be obtained from published sources and centres participating in the trial and applied to resource use. Published sources will include Unit Costs of Health and Social Care  and NHS The main economic analysis will be in the form of a cost-effectiveness analysis from the perspective of the health care provider , based on an intermediate outcome of cost per neonatal sepsis avoided when discharged home and on the outcome of disability-free survival at 24 months of age corrected for prematurity . A secondary analysis will extend the perspective to include private out of pocket costs to families associated with travel and time off work during the period of follow up.The analyses will adopt an incremental approach in that data collection will concentrate on resource use and outcome differences between trial arms. A bootstrapping approach will be undertaken in order to calculate confidence intervals around the mean costs , 28. CosResults will be presented using cost-effectiveness acceptability curves. The robustness of the results will be explored using deterministic and probabilistic sensitivity analysis.Preterm infants are at significant risk of poor long-term neurodevelopmental problems with almost 12% having moderate or severe disability , with boInfection and NEC remain highly predictive factors for neurodevelopmental disability. Any reduction in either problem may therefore be expected to reduce long-term disability in this population.Overall lifetime financial costs of disability are significant, and so preventing even a few cases and reducing cognitive problems at the population level would reduce the financial burden of long-term care for the NHS and society. No additional resources will be needed to implement the optimal feeding strategy, which, if successful, could be adopted rapidly across the NHS at low cost.


Post-Partum Hemorrhage (PPH) accounts for 34% of maternal deaths in Kenya. Active management of third stage of labour (AMTSL) is a World Health Organization and Ministry of Health of Kenya approved protocol for reducing maternal mortality and morbidity arising from post-partum hemorrhage. Kiambu County in Kenya records an average of six maternal deaths per month, out of which, two are due to PPH. This paper analyses how facility factors influence utilization of this protocol in Kiambu County.This was a cross sectional study among 431 skilled birth attendants in 52 health facilities. Two hundred and three birth attendants were selected using multistage sampling. Data was collected using questionnaires and observation checklists and analyzed using STATA version 11. Chi square, Fisher’s exact and Logistic regressions tests were used.AMTSL was utilized by 31.5% of the birth attendants. Controlled cord traction (96.5%) was the most utilized. Uterine message after every 15 minutes was the least utilized component. Utilization was more in government facilities (37.4%) (Logistic regression p=0.006) and in level four health facilities (49.5%) (p<0.001). Utilization was higher (34.7%) among birth attendants who experienced less frequent stock outs (p=0.027) and in facilities with more than two staff authorized to order supplies (34.9%) (p=0.020). Utilization was higher in facilities with a fridge (44.5%) (p=0.001) and in facilities with standards documents in the labour ward (68.0%) (p=0.001).Health facility factors significantly influence utilization of AMTSL and therefore the county government should put in place strategies to enhance the factors that influence utilization of AMTSL positively. Maternal mortality has remained high despite the fact that most maternal deaths are avoidable. About 1000 women die from pregnancy and childbirth related complications around the world every day. More than half of the deaths occur in sub-Saharan Africa and one third occur in South Asia . DespiteLooking at the main causes of the high maternal mortality, post-partum hemorrhage (PPH) which is bleeding after delivery tops the list accounting for 34% of maternal death . BesidesAccording to the Ministry of Health in Kenya guidelines, AMTSL involves three basic procedures: Administering oxytocin within one minute of child birth, delivering the placenta using controlled cord traction and massaging the uterus immediately after birth of the placenta and after every 15 minutes for the first 1-2 hours after delivery . InternaUtilization of AMTSL is influenced by Health facility factors. This research article examines health facility factors influencing the utilization of AMSTL in Kiambu County in Kenya. According to KDHS 2008/2009, central province of Kenya, from which the county was mapped out, had most deliveries (73%) taking place in a health facility [Study design: this study used cross-sectional design. This design described facility factors influencing utilization of AMTSL at the time of study.Study setting: the study was carried out in Kiambu County located in central part of Kenya. In this county most mothers (74%) deliver in health facilities KDHS (2008/2009). The county has 378,574 women of reproductive age. The study was carried out in maternity units in the county. The county had a total of 52 health facilities offering routine delivery services in the county. These health facilities are owned by the either the government, faith based organizations or are privately owned. In terms of levels these health facilities included level three  and level four facilities .Study population: the study population was skilled birth attendants working in maternity units in the 52 health facilities in Kiambu County. According to the districts health records and staff records in health facilities at the time of the study there were approximately 431 skilled birth attendants working in maternity units in the county.Sampling techniques and sample size: multistage sampling was used. At the first stage, the birth attendants were stratified into six strata based on type (ownership) and the level of health facility. At second stage, the birth attendants in each stratum were clustered according to the health facility where they worked i.e. each health facility was regarded as a cluster. Simple random sampling using ballot method was used to sample the clusters included in the study from each stratum. Clusters were randomly selected until the proportionate number of birth attendants in the respective stratum was reached. A total of 28 clusters  were sampled. All the birth attendants on duty (not on leave) during data collection in each of the 28 sampled clusters were interviewed. Each of the health worker sampled was observed managing third stage of labour and later interviewed. Therefore 203 birth attendants were interviewed and 203 deliveries observed. The Sample size was calculated using the Fisher’s formula when the population is less than 10,000.Data collection: non-participant observation of management of third stage of labour was done using observation check list. Interviews using interviewer administered questionnaires were conducted for birth attendants who conducted the aforementioned deliveries to collect data on health facility factors. The research assistants were trained skilled birth attendants at diploma and degree levels.Variables: the Independent variables were the health facility factors. The Dependent Variable was utilization of AMTSL. The care givers were grouped into two i.e. those who utilized and those who did not utilize. Utilization was determined by observing birth attendants conduct third stage of labour using an observation checklist. A care giver was said to have utilized AMTSL if he/she did all the following: Administered oxytocin within one minute of child birth, delivered the placenta using controlled cord traction, massaged the uterus immediately and massaged uterus after every 15 minutes for the first 1-2 hours after delivery. A care giver who did not perform one or more of the procedures was regarded not to have utilized. The observation check list however, collected information on performance of each of the procedures. This criterion was developed using the Ministry of Health guideline on components of AMTSL [of AMTSL .Validity and reliability: interviewer administered questionnaires were used rather than self-administered questionnaires to ensure validity. The questionnaires and the observation checklist were tested in a similar group and adjusted accordingly to improve their ability to collect appropriate data. To avoid hawthorne effect during observation of deliveries, the birth attendant were not informed of the specific skills being observed. Also observation of a birth attendant conducting third stage of labour was done before interviewing the birth attendant. The research assistants were qualified health workers who had been trained on AMTSL. The data collectors also underwent training on how to use the questionnaires and the checklists to ensure consistency.Data entry and analysis: data was entered into STATA version 11. Descriptive statistics were used to generate frequencies and proportions. The dependent variable was organised as a binary variable with two categories; Utilized and not utilized AMTSL. Chi square and fisher’s exact at 95% confidence interval were used to test the association of the independent and dependent variables. The variables that had statistically significant association using chi square were subjected to logistic regression to generate the odds ratios.Females were 81.8% of all respondents. Ages of the respondents were as follows; 32.0% aged between21-30, 35.0% aged between 31-40 years,25.1% aged between 41-50 years and 7.9% aged between 51-60 years.92.6% of the respondents were nurses and the others (8.4%) were clinical officers. 69.0 % of birth attendants were diploma holders, 27.6% were certificate holders and 3.4% were degree holders.AMTSL utilization status All (100%) the birth attendants utilized at least one of component of AMTSL as follows; 8.3% utilized one component, 27.0 % utilized two components, 33.0% utilized three components while 31.5% utilized all the four components of AMTSL. Controlled cord traction was the most utilized component with 96.5% of the care givers utilizing it. Uterine massage after every 15 minutes for 1-2 hours (subsequent massage) was the least utilized component with only 33.1% of birth attendants utilizing it. The facilities type was determined using ownership (managing authority). The proportion of birth attendants utilizing AMTSL was highest among those working in government health facilities (37.4%) and was lowest was among those working in private health facilities (8.0%). The association between type of health facility and utilization of AMTSL was statistically significant at 95% confidence level (logistic regression p=0.006). 2= 26.6414, DF=1, P<0.001). The proportion of birth attendants utilizing AMTSL was higher among birth attendants working in level 4 and 5 facilities at 49.5% than in level 3 facilities (15.7%). There was a statistical significant association between level of health facility and utilization of AMTSL at 95% confidence interval 2=4.8950, DF=1, p=0.027) of the birth attendants. Birth attendants from faith based (2.9%) and government (7.6%) managed level four facilities are the least likely to have more frequent stock outs. Utilization of AMTSL was higher (34.7%) among birth attendants who had less frequent stock outs compared to care givers who experienced more frequent stock outs (15.1%). The association between supplies stock outs and utilization of AMTSL was statistically significant at 95% confidence interval (Fisher’s Exact p=0.020).Government managed facilities are more likely (93.5%) than other facilities to have more than two birth attendants authorized to order supplies. Most birth attendants (84.7%) worked in health facilities with more than 2 staff authorized to order supplies. Utilization of AMTSL was highest (34.9%) among birth attendants who worked in facilities with more than two staff authorized to order supplies. The association between number of staff authorized to order supplies and utilization of AMTSL was statistically significant at 95% confidence interval (Fisher’s Exact p= 0.100).Availability of needles, syringes and oxytocin in labour ward was observed. The supplies were regarded as ‘not available’ if they were not available at the point of use (in labour ward) irrespective of their available in other places e.g. the store. Most (92.1%) birth attendants had supplies available at the point of use. Government level 4 facilities were more likely to have the supplies for AMTSL available at the point of use than other types of facilities. Utilization of AMTSL was higher (33.2%) among birth attendants working in facilities where supplies were available at the point of use than where supplies were not available at the point of use (12.5%). At 95% confidence interval, there was no statistically significant association between availability of supplies at the point of use and utilization of AMTSL 2=21.1398, DF=1, p=0.001)(χ. Most (63.1%) of the birth attendants worked in facilities with a fridge. Faith based facilities (80.0%) and private facilities (72.0%) are more likely to have a fridge. On the other hand level 4 facilities (85.3%) are more likely than level 3 facilities to have a fridge (43.5%). Utilization of AMTSL was higher (44.5%) among birth attendants who worked in facilities with a fridge than those who worked in facilities without (9.3%). At 95% confidence interval, the association between availability of a fridge and utilization of AMTSL was statistically significant . Availability of standard documents in the maternity unit was observed. Absence of the documents in maternity units was termed as ‘not available’ irrespective of the presence of the documents elsewhere in the facility. Most (73.8%) birth attendants worked in health facilities with no AMTSL standards documents. Birth attendants working in government level 4 facilities are the most likely to have AMTSL standards documents in the labour ward (83%) than others. Utilization of AMTSL was highest (68.0%) among birth attendants who worked in facilities with standards documents in the labour ward and the lowest (16.6%) among birth attendants with no standards documents. The association between availability of standards documents and utilization of AMTSL was statistically significant at 95% confidence interval Logistic regression of facility factors at 95% confidence interval Working in private hospitals reduced the likely hood of utilizing AMTSL 0.5 times. Working in level 4 health facilities increased likely hood of utilizing AMTSL 5.2 times. Having more than two staff authorised to order supplies increased the likely hood of utilizing AMTSL 3.6 times. Having a fridge at health increased the likely hood of utilizing AMTSL 7.8 times. Availability of standards document in the labour ward increased the likely hood of utilizing AMTSL 3 times. Most of the birth attendants in Kiambu County do not utilize AMTSL as per the guidelines. In neighboring countries like Tanzania and Ethiopia the utilization of AMTSL is even lower with only (7%) and (4.5%) of the deliveries respectively benefiting from correct use of AMTSL .Oxytocin administration and Controlled cord traction were the most utilized components of AMTSL. This can be explained by the fact that these two components were in the former guidelines of management of third stage of labour. The former guidelines recommended oxytocin to be administered at the birth of anterior shoulder or immediately after the birth of the baby. The current guidelines recommend oxytocin administration strictly within a minute of child birth. This means that birth attendants who followed the second option of the former guideline were correct in regard to the current guideline.Oxytocin administration and controlled cord traction also take less time to perform and they are one off time procedures unlike uterine message after every 15 minutes for 2hrs which was the least adhered to component. A qualitative study done to assess factors influencing nurses compliance to standard procedures identified ‘time consuming procedures’ as reasons behind non-compliance .There was statistically significant association between both type and level of health facility and utilization of AMTSL in Kiambu County. There was more utilization of AMTSL in Government and level 4 facilities. This discrepancy can be attributed to factors such as availability of standards documents in labour, authorization to order supplies and birth attendance factors such as staff training, knowledge on AMTSL and cadre of the birth attendants. These factors were more favorable in Government and level 4 facilities.AMTSL supplies  are available at the point of use for most of the birth attendants in Kiambu County. This relates well with the finding of this study that stock outs for these supplies were not frequent for majority of birth attendants. Other studies in Kenya have reported similar findings for instance a national survey reported that 71% of health facilities in Kenya have oxytocin and 96% of the health facilities have syringes and needles within reach in delivery room . In TanzThe findings of this study that level 4 and 5 facilities are more likely to have AMTSL supplies is similar to a national survey that reported that availability of medicines and supplies for delivery are more likely to be available in hospitals (level 4 and 5) (72 %) . On the Fridges are available in most facilities in Kiambu County. Fridges are important for proper storage of oxytocin. The statistically significant association between availability of a fridge and higher utilization of AMTSL can be explained by findings of a qualitative study done on compliance with standard precautions. This study found out that availability of equipment or storage of such equipment in places far from where care is provided is a barrier to provision of nursing care .In Kiambu county, faith based and private managed facilities are more likely to have a fridge than government facilities. Also Level 4 facilities are more likely than level 3 facilities to have a fridge. This relates well to the findings by the national survey that hospitals, private and faith based facilities are more likely to have power supply than other facilities.Availability of standards documents in health facilities in Kiambu County is low. Other studies have had similar finding, a national survey reported a 27% availability of obstetric care (not AMTSL) standards documents in central province . HoweverStandards documents are more available in level 4 and government facilities compared to other facilities. Kenya Service Provision Assessment Survey also reported higher availability of standards documents in government managed and level 4 facilities. This is likely to be due to the fact that standards documents are generated by the government and this means they are likely to be distributed to government facilities before others.This study did not examine the outcome of the utilization of AMTSL. There is therefore need for further research to find out the outcome of utilization of AMTSL. This study also covered only one county and therefore the results could not be generalized to the whole country, national wide study is therefore necessary.Utilizations of AMTSL was low. Utilization of AMTSL was higher in government health facilities and level 4 health facilities. Factors such as less frequent supplies stock outs, having more than two staff authorized to order supplies, having a fridge and having AMTSL standards documents in the labour ward. The county government and stakeholders in health care should put strategies to accelerate utilization of AMTSL by ensuring that facilitating factors are in place and more so in level three and private health facilities.The effectiveness of Active Management of Third stage of labour in Kenya;Utilization of Active Management of Third stage of labour in Kenya in a few African countries and in Latin America.Information on adherence to active management of third stage of labour guidelines in Kiambu county, Kenya;Information on factors influencing utilization of Active Management of Third stage of labour in Kenya.


First described in 2005, the Mullerian derived cyst in the mediastinum is a rare finding with few subsequent reports. We report a case of Mullerian cyst occurring in the mediastinum of a 49-year-old female that was resected by robot-assisted thoracoscopic surgery. To our knowledge, this is the first report of robot-assisted resection of Hattori's cyst. Histopathologic analysis revealed ciliated Mullerian-type tubal epithelium positive for paired box gene 8 (PAX8), estrogen receptor (ER), and progesterone receptor (PR), confirming Mullerian differentiation. We also review the clinical presentation, pathology, and differential diagnosis of such cysts. The Mullerian mediastinal cyst was first described by Hattori in 2005 . He repoA 49-year-old woman presented to our clinic for the first time in consultation because of an incidental finding of a paraspinal mediastinal cyst. She was a healthy-appearing, obese (BMI 30.6) woman who recently moved from West Virginia. She is gravida 1, para 1, with first child born when she was 18 years old. She currently has an intrauterine device and previously took oral contraceptive pills for 15 years. The patient was status post-C5-C6 anterior cervical discectomy and fusion for spinal compression. She has a strong family history of breast cancer and is Necdin variant positive (NDN). This gene, located in the Prader-Willi syndrome deletion region, facilitates cell cycle arrest, predisposing her to development of breast cancer. The patient has denied prophylactic mastectomy. During workup for migraine headaches and cervicalgia, a magnetic resonance imaging (MRI) scan of her cervical spine was performed, leading to an MRI of the thoracic spine. In this subsequent MRI, a well-circumscribed homogeneous mass with signals compatible with a pure cyst measuring 2.0 × 1.2 × 2.2 cm was found along the right anterolateral aspect of the T5 vertebral body .Though we recommended continued monitoring of the cyst, the patient, given her genetic predisposition and family history of cancer, opted for surgical intervention. The patient underwent robot-assisted thoracoscopic surgery for resection of the cyst for diagnostic and therapeutic purposes.After induction of general anesthesia utilizing a double-lumen endotracheal tube, the patient was placed on the left lateral decubitus position and the da Vinci Si robot was docked. We utilized 4 ports placed along the 7th intercostal space with CO2 insufflation and a 0-degree 10 mm camera. After retracting the lung anteriorly, we located the cyst at the paraspinal T5 level, where it was encompassed by veins draining to the azygos system. Though the cyst was mostly adherent to the body of the spine, we were able to find a distinct plane for complete excision. The cyst wall was inadvertently ruptured during the dissection and drained serous fluid but was excised completely. The patient had a severe migraine postoperatively but otherwise had a good recovery and was discharged on the second postoperative day.Gross pathological examination revealed the paraspinal cyst to be a 1.3 × 1.0 × 0.3 cm previously disrupted pink-red cystic structure which was bisected to reveal a smooth inner and outer lining. Histopathologic analysis revealed a cyst lined by ciliated Mullerian-type tubal epithelium with no evidence of malignancy. Immunohistochemical staining with paired box gene 8 (PAX8), estrogen receptor (ER), and progesterone receptor (PR) was done to confirm a Mullerian origin as was also described by Hattori  Figure .To our knowledge, this is the 19th documented case in the English literature of a Mullerian cyst in the mediastinum and the first reported case of such a cyst resected by robot-assisted thoracoscopic surgery . Of the We considered other differential diagnoses in assessing this posterior mediastinal mass. Neoplasms such as schwannomas, neuroblastomas, ganglioneuroblastoma, gangliomas, and spinal cord lesions often appear in the posterior mediastinum but are not cystic and can be ruled out preoperatively by imaging and lack of clinical manifestation. An anterior spinal meningocele may also present in the posterior mediastinum and will appear cyst-like on imaging due to filling of cerebrospinal fluid. However, the meningocele will communicate with the vertebral column unlike a true cyst.The most common mediastinal cysts include bronchogenic cysts, enteric duplication cysts, pericardial cysts, and thymic cysts, though most of these cysts appear in the middle mediastinum with the exception of thymic cysts in the anterior mediastinum. Bronchogenic cysts can be ciliated and may stain positive cytokeratin (CK7) positive but rarely stain PAX8, WT-1, and ER positive . EntericThe pathogenesis of a posterior mediastinal Mullerian cyst is still not yet completely understood. Previous reported cases of Hattori's cysts have posited that such cysts are the result of remnant Mullerian tissue during embryogenesis as proposed by Ludwig et al. in his study of Mayer-Rokitansky-Kuster syndrome , 8. The In conclusion, we present a patient with a posterior mediastinal mass identified to be a cyst of Mullerian origin. At her one-month postoperative clinic visit she denied any postoperative complications and endorsed only continued migraines and cervicalgia for which she will follow with her neurologist. While rare in presentation we review the diagnosis of Hattori's cysts and present the first documented RATS approach for resection with considerations for such a robotic approach. Lastly, we overview the likely pathogenesis of such cysts as a remnant of Mullerian duct migration.


A middle range theory of traumatic childbirth was developed using Morse’s method of theoretical coalescence. The scope of this qualitative theory was increased by formalizing the connections between 14 individual studies all conducted by the same researcher on the same topic, with different groups, using different research designs and different types of analyses. Axioms were derived from this research program along with attributes of traumatic childbirth, posttraumatic stress, and secondary traumatic stress. This middle range theory addresses the long-term chronic consequences of a traumatic birth for mothers including its impact on breastfeeding, subsequent childbirth, and the anniversary of birth trauma. The impact on fathers and clinicians present at the traumatic birth is highlighted as secondary traumatic stress comes into play. Troubling glimpses of difficulties in mother–infant bonding are revealed. Health care providers’ acts always have consequences, either positive or negative. These consequences can spread out like ripples when a stone is dropped into a pond. In a U.S. national survey, 9% of new mothers screened positive for meeting all the necessary Diagnostic and Statistical Manual of Mental Disorders . We need to understand ripples because they are the first phase in the growth of bigger ocean waves . TABS is a charitable trust located in New Zealand dedicated to support women who have experienced traumatic childbirths.All eight of the descriptive phenomenological studies and the one narrative analysis were conducted via the Internet. Women were recruited to participate in these studies through Trauma and Birth Stress’ (TABS) website  viewing their breasts as one more part of their body to be violated just as the women had felt violated during the birth, (b) enduring intense physical pain from the birth trauma, such as a shoulder dystocia delivery, (c) perception of insufficient milk supply, (d) intrusive flashbacks of traumatic birth while breastfeeding, and (e) disturbing detachment from their infants.The long-term detrimental effects of traumatic childbirth extended into yet another aspect of women’s lives: subsequent childbirth. To have more children or not. Some women decided that they would not get pregnant again. They refused to take the risk of another traumatic birth. A few women, who did want more children but could not face another labor and delivery, chose to use a surrogate mother. Some women did get pregnant again but it was unplanned, whereas other women did choose to risk another birth trauma because of their desire for more children. No matter whether the subsequent pregnancy was planned or not, the pregnancy was filled with fear, terror, anxiety, panic, denial, and dread as the women prepared to endure the 9 long months to face what they feared the most: another labor and delivery. The following quote captures this: “My 9 months of pregnancy were an anxiety filled abyss which was completely marred as an experience due to the terror that was continually in my mind from the experience 8 years earlier” , p. 245.Exercising to help baby get in the correct positionMapping out their pelvisWriting a detailed birth planPainting birth artAvoiding ultrasoundsResearching birth centers and scheduling tripsInterviewing obstetrical care providersHiring a doula for labor and deliveryMaking preparations for a home birthDeveloping trust with obstetric health care cliniciansDetermining specific roles of supporters during labor and deliveryUsing TABS website for supportPracticing hypnosis for childbirthResearching homeopathic remedies to prepare their body for childbirthFor three fourths of the women in our study, their subsequent birth was a healing one. Women felt empowered and said it brought reverence to the birthing process. As one woman shared, “I wasn’t made to feel like a piece of meat this time but instead like a woman experiencing one of nature’s most wonderful events” , p. 246.Various treatments for PTSD in the general population have been studied for years. Researchers and clinicians are only starting to assess the effectiveness of these treatments for women who are suffering from PTSD due to traumatic childbirth. One study in my program of research focused on mothers’ experiences with EMDR treatment for their posttraumatic stress symptoms due to birth trauma . Ten womEvidence has accrued by researchers documenting the negative effects postpartum depression has on mother–infant interactions, infant’s cognitive and emotional development, and on women’s partners. The assumption I made was that posttraumatic stress in mothers who experienced birth trauma may also have a negative impact on their interactions with their infant and with their partners just as postpartum depression does.after 6 months, my husband and I still hadn’t had sex since before the birth. When we began to try, I had flashbacks to the birth. At the moment of penetration, I would have a flashback to the instant when my body was pulled down the operating table during one of the failed forceps attempts. , p. 219Fear, terror, and helplessness were emotions often recalled by partners who were present during the traumatic birth . One fatIn my sustained research program on traumatic birth, four of the studies, three descriptive phenomenology and one case study, uncovered difficulties in mother–infant bonding and interaction. The impact of birth trauma on mother–infant interaction was not the primary focus of these studies. However, repeatedly insightful, troubling glimpses of the potentially detrimental impact of traumatic birth on infants’ cognitive and emotional development were revealed. In theoretical coalescence, this is one of the valuable advantages of being the researcher who has conducted all of the studies and is privy to all the data. Disturbing detachment from these infants came out loud and clear as some women avoided reminders of their birth trauma. Posttraumatic stress reared its ugly head here. For example, one mother stated that she felt as though her soul left her body leaving her an empty shell: “Mechanically, I’d go through the motions of being a good mother. Inside I felt nothing” , p. 220.The walls that traumatic birth erected separating mother and infant were not always temporary.My child turned 3 years old a few weeks ago. I suppose the pain was not so acute this time. I actually made him a birthday cake and was grateful that I could go to work and not think about the significance of the day. The pain was less, but it was replaced by a numbness that still worries me. I hope that as time passes I can forge some kind of real closeness with this child. I am still unable to tell him I love him, but I can now hold him and have times when I am proud of him. I have come a long, long way. , p. 222The intrusive flashbacks to the birth trauma led some women to experiencing interactions with their infants as a spectator. The “video tape” of the birth was continually on replay creating a bubble in which the mothers did not quite connect with anyone, not even their infants.I wanted to die. I felt nothing for her and found it hard to celebrate the joy of this child that meant so little to me. I took excellent care of her but it was as if I was babysitting, the emotional bond just wasn’t there. , p. 386Detachment from their infants was reignited at anniversary time. The emotional bonding with their infants was missing. When describing her daughter’s first birthday, this mother admitted,Some women described looking in at their child’s birthday party from a window: Mothers felt “empty inside” and like a “total fake.” Traumatic childbirth also permeated mother–infant bonding during breastfeeding . MothersAll the positive, empowering births in the world won’t ever change what happened with my first baby and me. Our relationship is forever built around his birth experience. The second birth was so wonderful I would go through it all again, but it can never change the past. (p. 247)In the descriptive phenomenological study of subsequent childbirth following a traumatic birth , the detSecondary traumatic stress is the “natural consequent behaviors and emotions resulting from knowledge about a traumatizing event experienced by a significant other. It is the stress resulting from helping or wanting to help a traumatized or suffering person” , p. 10.Intrusive flashbacks/nightmaresNumbing detachmentIncreased arousal: anger, difficulty sleepingRetreating from labor and deliveryHelplessness/powerlessnessAgonizing over what should have beenDSM-IV-TR for PTSD due to traumatic childbirth  cesarean section and the wailing of a mother when we were coding her baby in the delivery room. I feel like I will never get these sounds/images out of my head even though they occurred more than 10 years ago. , p. 757As seen in The baby must have been dead for 5 days or so as the skin was peeling badly and blistered. I felt like I was pulling off skin and worried I would pull off the head. For weeks I could not get pictures of that dead baby out of my mind and had difficulty sleeping due to nightmares. , p. 21Difficulty sleeping due to nightmares was also a regular occurrence for CNMs as vividly illustrated by this quote:Anger was another distressing emotion obstetrical nurses experienced. Nurses at times were angry at obstetricians who were “abusive” to laboring women and were unnecessarily rough during vaginal exams and during the deliveries. At other times nurses directed their anger at themselves for not being a stronger advocate for their patients during childbirth. Both labor and delivery nurses and CNMs felt a sense of powerlessness and helplessness when they were not able to protect their patients from a traumatic birth. These obstetric clinicians would agonize over what should have been. Did they do everything that they should have done? What could they have done differently? Numbness was also experienced as nurses described being in shock immediately after a traumatic birth.Avoidance of reminders of traumatic births occurred. For some obstetrical nurses, avoidance took the form of leaving labor and delivery and transferring to the postpartum unit. Others left the clinical area totally and went to graduate school with the goal of working in academia. CNMs also made similar changes in their careers to avoid traumatic birth. Some midwives left full scope practice and no longer did deliveries. Others went into academic or administration while others left midwifery altogether.In conclusion, Using 6 of the 14 studies included in the development of this traumatic childbirth theory, This traumatic childbirth theory extends the findings of my metaethnography . The metDebriefing, cognitive behavioral therapy (CBT), and EMDR therapy are three types of treatments available for PTSD. Research on these treatments for PTSD specific to traumatic childbirth, however, is limited.Debriefing is referred to in the literature on a continuum. One end involves non–mental health care professionals, such as midwives, providing mothers an opportunity in an unstructured format to discuss their labor and delivery experience and to offer information and explanations about their birth. On the other end of the continuum is a structured psychological intervention given by trained mental health professions. This intervention is intended to serve as a primary prevention to help minimize symptoms of acute stress reactions. In the general population, CBT is one of the most studied interventions for PTSD . CBT focIn the general population, EMDR has been effective in treating PTSD. Only two studies have been published that investigated this treatment with women with PTSD secondary to birth trauma . These tThree decades ago, when discussing nursing care in a Newborn Intensive Care Unit (NICU), philosiblog.com)How far do your ripples go, and what are you willing to do to make sure those who are influenced by you are influenced in a positive way? It’s your call, it’s your life. But those ripples impact us all. The pond of humanity encompasses us all. Please be careful of your actions. . Partners of women who have had a traumatic birth also need the attention of obstetrical care providers. Often partners who have been present during a traumatic birth are the forgotten ones.Reliable and valid instruments that screen for posttraumatic stress symptoms are available for clinicians’ use. The Post-Traumatic Stress Symptom Scale  is one sWhile women are still on the postpartum unit, it is a perfect opportunity to observe mothers’ interactions with their infants that may indicate the women have experienced a traumatic birth. For example, when a mother is feeding her infant, does she appear distanced and detached? For some women with elevated posttraumatic stress symptoms, their infants can be reminders of their trauma leading to fragile mother–infant dyads that are in need of our help. Further complicating mother–infant bonding can be the numbness some mothers experience due to their birth trauma. Impaired mother–infant interactions may be one of the first indicators of a traumatic birth. Clinicians need to be cognizant that birth trauma can not only negatively affect mothers but can also have damaging impact on the beginning mother–infant relationships. Early intervention is critical.Women who perceived that their birth was traumatic may need intensive one-on-one support as they initiate breastfeeding. It is essential that clinicians always ask the mother’s permission before touching her breasts to help with breastfeeding. Of course, providing support and encouragement to traumatized women to continue breastfeeding is important. Obstetrical care providers, however, also have a responsibility to let these struggling mothers know that it is their right to choose not to breastfeed without any guilt or judgment. If clinicians’ pressure traumatized mothers to continue breastfeeding, this can compound women’s feeling of inadequacy and shame and be detrimental to this already fragile mother–infant relationship.If women go on to have another pregnancy after a previous traumatic birth, obstetrical care providers have a golden opportunity to help these traumatized women to reclaim their bodies and complete their journey to motherhood. The first step in achieving this, however, is to identify these women who have had a previous traumatic birth. During the first prenatal visit multiparas should be asked about their prior labor and deliveries. Giving traumatized women permission and encouragement to share their prior trauma is the beginning to helping them heal and to prepare for their upcoming childbirth. Unresolved trauma issues can be dealt with during this pregnancy. Clinicians can share with the mothers some of the strategies that women in Obstetrical clinicians failed to rescue women who perceived their birth was traumatic and we fail time and time again to rescue these mothers during their chronic struggles during yearly anniversaries and during subsequent childbirth. Often precious opportunities to finally rescue these women are lost. At infants’ well-baby checkups and yearly physical exams, health care professionals can ask mothers how they are doing and how they perceived their childbirth was. Pediatric clinicians are in an ideal position to identify women struggling with elevated posttraumatic stress symptoms and to make those critical referrals for mental health care.There is such a paucity of research on traumatic childbirth that it can take multiple directions. Instruments developed to screen for posttraumatic stress symptoms in new mothers need to have their psychometrics compared. Intervention studies are needed to decrease the posttraumatic stress symptoms not only in mothers but also in their partners and clinicians who were present during the traumatic births. Randomized control trials testing the most effective treatments for PTSD due to childbirth are critical. Another intervention study can focus on improving mother–infant interaction during the time period mothers are struggling with the aftermath of their birth trauma. An example of one specific research question can be, “Does traumatic childbirth have similar disruptive relations in mother–infant dyads as postpartum depression does?” Another line of research can focus on the comorbidity of PTSD following childbirth with depression and other mood and anxiety disorders. Researchers also need to delve into the complex dynamics of traumatic birth on women’s breastfeeding experiences.Being able to assist a woman in one of the greatest tasks of her life—giving birth to and mothering a baby—is a privilege and challenge that touches every nurse who assists in her care. The challenge extends not only to the concrete physical help that the mother needs, but to the subtle consideration and attention which help her maintain her self-control and thus her self-respect. (p.41)In conclusion, there is still much work that needs to be done on this traumatic childbirth theory. I will leave you with a quote from


Birth defects are a major cause of mortality among children under five. In accordance with its mission, the March of Dimes Foundation is dedicated to reducing the toll of birth defects on children, families, and society. Founded in 1938 to fight polio, March of Dimes currently focuses on prevention of birth defects and preterm birth and has had a major influence on surveillance, research, advocacy, awareness, and education related to birth defects prevention and care. In the USA, it has played an active role in promoting and advocating for newborn screening for early diagnosis and treatment of congenital disorders, folic acid fortification of grains for prevention of neural tube defects, and more recently on raising awareness about birth defects related to Zika virus infection. March of Dimes has played a major role in promoting prevention of birth defects globally by publishing data-based reports and papers related to the toll of birth defects and by supporting surveillance and preconception health education programs. March of Dimes birth defects health education materials directed for raising awareness among families are used worldwide. Additionally, March of Dimes had equipped health care workers and policy makers with essential information about birth defects through published materials and sponsoring of conferences that allow for networking and knowledge exchange. March of Dimes remains committed to prevention of birth defects through supporting research related to causes of birth defects, empowering women and girls with health knowledge, and advocating for policies and programs at national and global levels for giving every child an opportunity to attain his or her optimal level of health. Close to eight million babies worldwide are born with a serious birth defect every year and more than three million of them die before age five . Under iThe March of Dimes was established by President Franklin D. Roosevelt in 1938 to combat epidemic polio. Within the first 20 years of its existence, the March of Dimes funded the successful development of both the Salk and Sabin vaccines against this dreaded disease, leading the way to eliminating polio from most of the world.With its longstanding history of influencing major developments to improve public health outcomes, the March of Dimes has committed in recent decades to improving maternal and infant health in the USA and globally by supporting public and professional education, advocacy, community services, and research. In 2016 alone, the March of Dimes provided more than $5 million in funding for investigator-initiated grants for cutting-edge research to identify the leading causes of birth defects and ways to improve prevention and care.Many March of Dimes-funded initiatives for improving the health of mothers and babies in the USA have benefitted populations around the world. For example, during the 1960s, March of Dimes medical director Dr. Virginia Apgar developed the APGAR score, a system to help health professionals evaluate the physical condition of babies at birth. Today, the APGAR score is used worldwide and serves as a universally understood initial assessment tool to determine the health of a newborn. Dr. Apgar also popularized the use of the term “birth defects,” which remains widely used worldwide to describe congenital anomalies. Like Dr. Apgar, numerous other March of Dimes grantees over the years have paved the way to advances in research and care for affected children. Through determining the underlying causes of certain birth defects and identifying the risk factors associated with them, the March of Dimes promotes strategies for birth defects prevention.The March of Dimes believes that every baby should receive the best care possible to help them achieve their best health. It is this belief that led us to become a prominent voice in advocacy for the creation and expansion of uniform newborn screening programs  to detecTwo landmark reports published by the March of Dimes and partners have shown that the burden of birth defects  and premWhen the March of Dimes initiated its mission to prevent birth defects, few people realized the scope or complexity of the problem. However, knowledge rapidly expanded through conferences sponsored by the March of Dimes to foster exchanges among researchers and scientists from diverse disciplines. One such conference, which continued on an annual basis, is the Human and Mammalian Genetics and Genomics Course at Jackson Laboratories in Bar Harbor, Maine, now in its 58th year. The March of Dimes provided support for research and medical services in previously unexplored areas, such as the study of human chromosomes.In 1953, the March of Dimes gave a grant to James D. Watson who, with Francis Crick, later identified the double helix structure of DNA. The pair won the Nobel Prize in 1962 and paved the way for modern genetic medicine, including the mapping of the human genome. The March of Dimes also established a network of birth defects centers in university and teaching hospitals around the country to provide, for the first time, early diagnosis and comprehensive care for babies born with birth defects.In the early 1960s, March of Dimes grant funding enabled Dr. Robert Guthrie, who had developed the first newborn blood test for PKU (phenylketonuria), to produce a mass screening test for the disorder. The March of Dimes and patient/family groups went on to campaign tirelessly for expanded and standardized state newborn screening programs nationwide. Today, every baby born in every state in the USA receives screening for a uniform panel of conditions that can be treated soon after birth to prevent intellectual disability or death.Birth Defects Atlas and Compendium, which standardized the names and descriptions of 842 birth defects. Also in the 1970s, the March of Dimes initiated a regional system of neonatal intensive care units (NICUs) in which babies with birth defects or born prematurely could receive the best care.In 1973, the March of Dimes published the first Other notable accomplishments by researchers funded by the March of Dimes included the first report showing that drinking alcohol during pregnancy could cause fetal alcohol syndrome and the development of surfactant therapy for babies born with immature lungs that has saved the lives of hundreds of thousands.Also in the early 1970s, the March of Dimes launched a new office of public affairs in Washington, DC, to coordinate advocacy for state and US federal legislation to further prevention, education, and care for babies with birth defects. The March of Dimes has had many advocacy successes over the years, including the passage of the State Children’s Health Insurance Program (SCHIP), ensuring health care coverage for up to five million children; the Birth Defect Prevention Act, establishing a National Center on Birth Defects and Developmental Disabilities; and the Newborn Screening Saves Lives Act. The most recent advocacy achievement was winning the Food and Drug Administration’s agreement to voluntary fortification of corn masa flour with folic acid to further help reduce the incidence of NTD.Babies & You was a prenatal education program delivered in the workplace, with classes taught by March of Dimes staff or volunteers. This program has evolved into other educational offerings for women in the workplace available today.While pursuing a robust national policy agenda for birth defects prevention and care, the March of Dimes sought to raise public consciousness on birth defects and teach known ways of prevention. The organization placed public service announcements in popular magazines and published dozens of informational materials. In the early 1980s, the March of Dimes launched its first program for advancing the overall health of women and babies.  In 1992, US Public Health Service recommended that all women of childbearing age capable of becoming pregnant consume 400 micrograms of folic acid daily to reduce their risk for having a baby affected by an NTD. Following that, the March of Dimes launched its first national campaign urging women to take a multivitamin containing folic acid every day. This important preconception health message evolved into an enhanced Folic Acid Campaign launched in 1999 in collaboration with the Centers for Disease Control and Prevention (CDC), the American College of Obstetricians, the American Academy of Pediatrics, and the Spina Bifida Association of America. Providing education for women, health care providers and the public to urge compliance with folic acid consumption guidelines for reducing risk of NTDs was the main focus of the campaign, which ran from 1999 to 2002. This campaign had a major impact in increasing awareness of the importance of preconception folic acid consumption: In 1995, only 4% of women reported knowing that folic acid can prevent birth defects, and in 2004, 24% of women reported the same . BuildinAfter tremendous successes with campaigns for birth defects prevention, the March of Dimes decided to launch a new campaign to decrease the rate of preterm birth in the USA in 2003. This Prematurity Campaign supports research, education, community service, and advocacy initiatives—the same strategies that yielded so many discoveries and advances for birth defects prevention. One of the signature programs of this Prematurity Campaign is the March of Dimes NICU Family Support Program®, which provides comfort and information to families with a baby in the NICU, whether born preterm or with a birth defect. More than 75,000 families in the USA each year are helped by this program.The New York Times on December 28, 2015, [www.marchofdimes.org/zika and in Spanish on www.nacersano.org/zika. Health information specialists at the March of Dimes answered email queries about Zika infection and promoted prevention messages via social media. The March of Dimes held various media events to raise journalists’ awareness about Zika and its potential impact on babies, and the March of Dimes became a leader in the fight against the spread of the virus. After months of intense advocacy by the March of Dimes and the coalition of more than 90 organizations that we headed, Congress finally passed a $1.1 billion Zika funding bill in September 2016. Working closely with the CDC and many other partners, the March of Dimes continues to promote Zika virus prevention while helping to develop information about services for families affected by Zika.The March of Dimes commitment to birth defects prevention is such that we are always responsive to emerging challenges. For example, after the first article appeared in In 1998, the March of Dimes decided to extend its mission globally through formation of a Global Programs Department. Although the March of Dimes does not have any international offices or staff in any other countries outside the USA, it is well-known and well-respected worldwide for its contributions to prevention of birth defects and premature birth. The March of Dimes conducts its global work mainly through partnerships with international and in-country organizations that work in Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCAH). As a “Non-state Actor in Official Relations” with the World Health Organization (WHO) and with Pan American Health Organization (PAHO), the March of Dimes has engaged in high-level scientific, technical, and policy discussions related to improving the health of mothers and babies globally. Additionally, we have supported and engaged local academic institutions in low-and middle-income countries to advance the health of women and girls through preconception health activities [One of the major contributions of the March of Dimes globally was to bring to light the high worldwide toll of birth defects through the publication in 2006 of the first-ever country-level estimates of serious birth defects of genetic origin with data from 193 countries .Recognizing the need to build capacity in lower-income countries for prevention and care related to birth defects, in 2001, March of Dimes began sponsoring a biennial International Conference on Birth Defects and Disabilities in the Developing World. To date, these conferences have been held in Tanzania (2015), the Philippines (2013), Poland 2011), India (2009), Brazil (2007), China (2005), and South Africa (2001). These conferences are usually attended by 300–400 participants and serve as a platform for discussions, knowledge sharing, and action. For example, the 2015 conference in Tanzania led to the publication of a consensus statement on “Prevention of Congenital Disorders and Care of Affected Children” [, India (The March of Dimes is a world-renowned leader in raising birth defects awareness. On March 3, 2015, March of Dimes joined 11 other organizations to launch the first-ever World Birth Defects Day, providing a platform for governmental and non-governmental agencies to raise awareness about birth defects globally. In 2017, the third annual World Birth Defects Day efforts were formally joined by close to 80 organizations from about 35 countries that officially participated in raising awareness about surveillance, prevention, and care related to birth defects. This effort resulted in over 24 million impressions on Twitter and other key social media indicators related to the event.The March of Dimes has had a critical role in raising awareness of birth defects in the USA and globally, and has played a prominent role in influencing policies and programs for prevention of birth defects around the world. From initially coining the term “birth defects” to advocating for mandatory folic acid fortification for prevention of NTDs, to promoting education for prevention of Zika virus-related birth defects, the March of Dimes has demonstrated its leadership in the field of birth defects.The March of Dimes is focusing today on empowering women of childbearing age with health education. We believe that our mission to prevent birth defects and premature birth can be fully realized only by enabling women to improve their own health and that of their families. This has led us to develop health education information in plain language for women of childbearing age in both English and Spanish. We reach women globally through a variety of media, including print, web, video, and social media. We have trained health information specialists who answer questions and provide information through a variety of online channels. In low- and middle-income countries, we support programs for improving preconception health knowledge of women and girls in schools, workplaces, and communities. And in addition to consumer education, we have created tools and resources for health care professionals, healthcare organizations, and policymakers that are used worldwide.Throughout its nearly 80 years of existence, the March of Dimes has maintained three core values: bringing science into service for people, building the public trust, and harnessing the power of volunteers. These core values continue to guide March of Dimes staff, volunteers, and corporate sponsors to support community service programs, advocacy, research, and education on birth defects prevention and care. Until we find ways to solve these conditions, we will not cease our efforts to improve the quality of life for all those who are affected by them.


Background: Birth weight is an important health parameter for obstetricians and gynaecologists. It is a good health indicator of a child-bearing mother and a strong predictor of infant morbidity and mortality. Methods: This paper utilizes data on 28,647 children born between 2003–2008 obtained from the 2008 Nigeria Demographic and Health Survey (NDHS). For a simple epidemiological convenience, the occurrence of a newborn weight can intuitively be considered to be categorical in nature and the thresholds can be put on a continuous scale. In survey reporting, the mothers frequently estimate their infant’s birth weight and make a classification in ordinal category  instead of actual birth weight. The study fits a multinomial regression model to analyze the relationships between the polytomous response and different kind of covariates in a unified manner. We estimate the fixed effects of bio-social covariates parametrically and the non-linear effect modeled using P-spline. The spatial component was modeled using conditional autoregressive error. A penalized maximum likelihood estimation was performed to estimate the model parameters. Results: We found risk factors that are positively associated with low birth weight, which include multiple birth, short birth interval, death of sibling, childhood diarrhea, fever, mother’s smoking, firewood/dung cooking and poor household. Results further showed that iron syrup supplementation, antenatal attendance, mother literacy and household wealth had significant association with low probability of low birth weight. The finding also showed spatial patterns, which are not captured by the underlying determinants, and we produced probability predictive maps of the spatial residual effects. Conclusions: In addition to the statistical relevance of our method, the generated spatial maps identify highly endemic areas of low birth weight that can assist government agency to channel scarce health resources. A comprehensive approach which institutes a combination of interventions to improve the overall health care of the women is needed. Birth weight is the result of fetal growth and a good predictor of infant morbidity and mortality. Birth weight is a strong indicator not only of the mother’s health but also on a newborn’s chances of survival, growth, long term health and psychological development . In the For a simple epidemiological interpretation, low birth weight (LBW) is defined as a birth weight <2500 g and it has remained a significant health problem in many parts of the world due to immediate and long-term consequences . ReportsA number of studies has investigated the impacts of socio-economic characteristics of mothers on their newborns birth weight. Scanty research work has been done that jointly underscores the influence of the geographical variations in mother’s location and the underlying determinants of birth weight. In this study, we propose a structured additive regression model to examine the influence of different covariates on a categorical response variable. The motivation of this study is the ability of our approach to analyze a multivariate natural ordered response and simultaneously handle covariates of different types in a unified framework. We also explore a small area estimation of the spatial residual effects in child birth weight that are not captured by the underlying factors, which would have been neglected in the classical regression approach.The paper is structured into five sections. In One of the reliable sources of national household-level data on fertility, family planing and children nutritional status are the Demographic and Health Surveys (DHS). The 2008 Nigeria DHS (NDHS) was designed to provide, among other things, information on maternal health, prenatal and postnatal care, altitudes and micronutrient supplementation during pregnancy. The survey covers a national representation of women of reproductive age 15–49 years) and NDHS includes data on birth weights measured on their children aged 1–59 months. Other variables relate to information on levels and trends in fertility; sexual partners; fertility preferences; awareness and use of family planning methods; infants and young children feeding practices; nutrition status of mothers and childhood mortality. However, maternal health outcomes such as child birth weight plays a vital role in the understanding the epidemiology of public health problems, children’s growth restriction, infant mortality trend and childhood survival. The detailed information about the sampling techniques of the survey have been published in the final report of National Population Commission and ICF Macro [ years anNigeria is made up of six geopolitical zones and subdivided into 36 states and the Federal Capital Territory (FCT), as the second administrative levels. This study utilizes data obtained from the 2008 Nigeria Demography Health Survey (NDHS). The data set on child birth was generated with the aim of assessing the influence of some covariates on the response (child birth size) as reported in the health surveys. NDHS data set contains several other variables, only those that are related to child birth weight and those similar to the ones considered in the descriptive analysis were selected. The children involved in the survey had ages ranging between 1–59 months and the respondents (mothers) are in reproductive age range 15–49.The response variable of interest (child birth weight) is classified asA multi-categorical representation of the response variable is coded asBayesX 2.0.1 version software for modeling structured additive regression developed by Brezger et al. [M 1M 2M 3We propose a structured additive regression model to examine the impact of different types of covariates on child birth weight. The parameters in the model are estimated in a unified regression model. We employ r et al.  via penaY, say, birth weight, can be written as a categorical ordered response of a continuous latent (utility) variableη is a predictor depending on covariates and parameters and ε is the error term. The two variables Y and Z are linked by ε in  regression analysis was performed using BayesX version 2.1 via a penalized maximum likelihood estimation as suggested by Fahrmer et al. .The selection of explanatory variables was done on the basis of previous empirical studies ,22 amongThe categorical covariates are grouped into two broad categories according to birth sizes. The bivariate analysis that used A four-way classification of the birth weight distribution was presented in In the model B.1, we fit a spatial semi-parametric model for the response category (birth size) distribution of spatial random effects without a covariate. For the model B.3, we fit a spatial semi-parametric model consisting of spatial effects, linear and non-linear covariates. The categorical covariates  as fixed effects and geographical location of the woman were simultaneously estimated on the response variable (birth weight). The outputs of the analysis are presented in the form of Tables, non-linear graphics and spatial maps.In this section, we present the results of model selection criteria values of six fitted models. The model selection criteria and their values for the models are presented in On the binary logit model, we realized the AIC = 22,520.7 for the model without covariates (Model A.1), linear (AIC= 5042.1) and AIC = 6163.13 for the full Model (A.3). On the cumulative multinomial logit model, we obtained AIC = 72,630.0 for the model without the covariates (B.1), and AIC = 23,667.2 for the geoadditive model B.3. In both cases, we conclude that the model with the covariates effects is a better than the one without any covariate. In addition to the Akaike Information Criterion (AIC), we provided the values of Bayesian Information Criterion (BIC), which emphasizes on the model complexity than the simplicity. AIC relies on model likelihood from the data and the number of parameters estimated in the model. However, our Models 1 and 3 include spatial structure of the geographical location of the woman (respondent), and such models are more complex than the linear Model 2. In other words, the Generalized Cross Validation (GCV) criterion emphasizes on the model optimality rather than simplicity and complexity explores by the former two criteria. The researcher is left with varying options in selecting the preferred model.The results of the analysis are presented in form of Tables of fixed  effects, non-linear plots of continuous covariates and the structured residual plots of spatial components for the binary logit and cumulative multinomial model.The results showed that there was evidence of significant association with higher probability of low birth weight in the North East compared with the North Central region. This indicates that women in the North East had higher odds of low birth weight incidence or higher risk of low birth size than the North Central zone. All other geopolitical zones indicate lesser likelihood of low birth size but these were not statistically significant. Marginally, the Southern Zones had lower prevalence of low birth sizes when compared with the Northern parts of Nigeria.The results from In addition, environmental factors include poor household, death of sibling 2 and 4, firewood/ dung method of cooking and mother smoking, childhood diseases (diarrhea and fever 2 weeks before the survey) were found to contribute to the higher risk of LBW, although they were not statistically significant at 5% probability level. A child born of very low birth weight had a high risk of being susceptible (low immune)to child diseases in their early years of life. There was significant association between childhood under-nutrition (wasting) and low birth weight. The result showed that children born of low birth weight would suffer of growth restriction in their early life (infancy).There was evidence that micro-nutrient intervention such as iron syrup supplementation during pregnancy would boost low birth weight. Also, postnatal vitamin A to children would boost the growth of child born of low birth weight, although vitamin A supplementation was not significant. Iron supplementation to pregnant mother was significant and reduced odd of LBW by 21%, i.e., OR = 0.79, 95% CI , compared to those mothers, who did not take iron syrups. Mother, who attended antenatal also had lesser likelihood of giving birth to baby with low birth weight.The result further showed a strong impact of mother characteristics for improving her birth outcome. Maternal literacy (ability to read or write), urban residence mother, mother belong to richer household would likely would reduce their chances of low birth weight. A literate mother would have a lesser probability (reduce odd) of giving birth to baby with LBW by 11%, i.e., OR = 0.89, 95% CI  compared to an illiterate mother.Further, similar influence of covariates variables were observed from the multinomial model as presented in We further explore the estimates on the model B.3 in The non-linear effects components of the metrical (continuous) covariates in the binary logit model A.3 in  are dispObserving from the upper panel, Further results from the binary logistic model, On the lower panel of (left panel) and the maps showing the 95% credible intervals (right panel) are used to determining the significance level. Using 95% credible intervals, states with white (black) colours are associated with significantly high (low) estimates corresponding to regions lie in the positive (negative) sides, while the grey colour depicts the estimates are not significant among states.Spatial effects for the two geoadditive binary logistic models are presented in The 95% credible intervals from This study investigates the social and demographic  impacts on the child birth weight. Our approach also assess the geographical variations in child birth weight across the states and the woman likelihood of having a child birth weight falling in a specific category. Our fixed effect estimates of regression models look reasonable and controlled for all stable characteristics of the mother including household wealth index and child-specific factors. The descriptive analysis showed that low birth weight delivery decreases with an increase in birth orders of second , third and fourth as compared to first order births, but not to the fifth order (5 or more). The incidence of low birth weight are inversely associated the household wealth index. The bivariate analysis showed that a large proportion of women did not attend antenatal and they did not give postnatal vitamin A supplements to their children.From the binary logit analysis, the findings revealed that mother literate and prenatal iron syrup supplementation had significant association with a lower probability for a low birth weight. Other variables include urban residence and antenatal attendance also had a strong influence with a low chance of low birth weight, but they were not significant in this study.Our findings also revealed that the childhood undernutrition and disease had significant association with higher likelihood for the low birth weight. Evidence had showed that child birth defects may be genetically induced or evironmental inherent. A recent study had reported that an underweight mother had a higher risk of giving birth to an underweight baby. Our result corroborates the recent study by Kodzi et al. . A meta-In addition, poverty and low maternal education contributes significantly to poor birth outcomes. Our report corroborated the study on the adverse effect of poor maternal socio-economic factors on low birth weight in India and Sub-Saharan Africa ,29.This study also revealed that firewood/dung cooking and mother smoking (tobacco) are critical risk factors of low birth weight in Nigeria. This result is complementary to early work conducted in Zimbabwe. They asserted that low birth weight not only caused by lack of socioeconomic resources but by the use of inferior energy sources for indoor cooking and air pollution . Other pOur result gave a strong indication that iron syrup supplementation during pregnancy yields improvement in child birth weight, while postnatal vitamin A intervention would boost the child growth of those children born with low birth weight. There was a wealthy of evidence that zinc supplementation reduces diarrhea morbidity and respiratory infections among children ,34. OtheOur nonlinear of metrical covariates-- show discernible association with the child birth weight. Our findings are consistent with established theory and even strengthened the empirical results from similar studies. Our result revealed that mother body mass index (mbmi <18.5 kg/md et al. . Previoud et al. ,43.In our analysis, we have established a substantial evidence of geographical variations in the birth weight of babies across states using 2008 Nigeria DHS data. This output on regional variation has corroborated the finding in similar research studies. Recent studies had showed remarkable variations in the incidence of low birth weight with geographical patterns ,44. It iThis is cross-sectional data and is self-reported, as is the case for many survey data. Thus, the casual relationship may be difficult to establish with non-response cases. The information provided is also self-reported, so there is tendency of recall-error or bias especially with issues relating to age, birth size or actual birth weight of the children. In spite of these limitations, the authors believe that the findings from this study will facilitate targeting interventions and policy strategies.In this study, we have explored a robust and flexible methodological approach to analyze the birth weights of under-five children in 2008 Nigeria Demographic and health survey data. Our multivariate analysis takes into account the influence of contextual variables on birth weight from individual household health outcomes, which can engender an important health policy making. Having controlled the confounding factors, our approach produced spatial maps of the residual effects that were not captured by the underlying factors, which would have been neglected in a classical regression settings. The statistical significance of the variables discussed in the fixed effect Tables can be used to formulate programmes for interventions and policy. The spatial plots highlight hot-spots that can assist government to channel resources in an efficient manner.


We investigate the electric-field-dependent optical properties and electronic behaviors of GaS monolayer by using the first-principles calculations. A reversal of the dipole transition from E//c to E⊥c anisotropy is found with a critical external electric field of about 5 V/nm. Decomposed projected band contributions exhibit asymmetric electronic structures in GaS interlayers under the external electric field, which explains the evolution of the absorption preference. Spatial distribution of the partial charge and charge density difference reveal that the strikingly reversed optical anisotropy in GaS ML is closely linked to the additional crystal field originated from the external electric field. These results pave the way for experimental research and provide a new perspective for the application of the monolayer GaS-based two-dimensional electronic and optoelectronic devices. As a typical two-dimensional 2D) material, graphene has rather unique and exceptional properties , which eD materia3h symmetry. Advanced applications often require materials with tunable and reversible electronic properties which can be deliberately modulated by external control parameters. Strain engineering has been identified as one of the promising routes to tune the electronic behavior and the electron energy low-loss spectra of GaS monolayer (ML) and other 2D materials [3 cm−1, a factor of 30 smaller than for E//c [Recently, a stable class of 2D metal dichalcogenide (MD) materials, GaX , has attracted much attention due to their exotic physical and chemical properties, with great promise for applications in fields such as solar energy conversion and optoelectronics –11. Layeaterials . As an aaterials , 14. Foraterials , 16, andaterials . Howeverfor E//c . For optTo address this issue, we perform a theoretical prediction on the modulation of optical and electronic anisotropy on GaS ML. Optical absorption spectra for both E⊥c and E//c directions are calculated under various external electric fields. Band structure and orbit contributions are analyzed to explain the dependence of the dipole transition on the external electric field. Spatial distribution of the partial charge and charge density difference are further simulated, which show the interlayer coupling and asymmetry electronic structure induced by the vertical external electric field, and reveal the physical mechanism for the modulation of the optical and electronic anisotropy of GaS ML. The present results are beneficial to supply the theoretical guidance on the tunable electronic and optoelectronic devices based on 2D GaS material.k-point mesh is used to relax the single-layer GaS, and a cutoff energy of 450 eV is taken for expanding the wave functions into a plane-wave basis. The convergence for energy is chosen as 10-5 eV between two steps and the maximum Hellmann-Feyman force acting on each atom is less than 0.01 eV/Å upon ionic relaxation. Gaussian smearing is used to address how the partial occupancies are set for each wave function, and the width of smearing is 0.1 eV. The imaginary part of the dielectric function due to direction interband transitions is obtained using the Fermi golden rule [We perform the density functional theory (DFT) calculations with the Vienna Ab-initio Simulation Package (VASP) code , using tden rule . During a is 3.64 Å, which is slightly larger than that of bulk material due to the lack of interlayer interaction [(1) and Y(2), respectively.Fully relaxed geometric configuration of GaS ML is shown in Fig. eraction . The boneraction . For conE//c) and ordinary light  are quite different, revealing the optical anisotropy in GaS ML. The absorption edge of TM and TE light are labeled by a red and green dash line, respectively. In the absence of an external electric field, the energy difference of absorption edge between TM light and TE light is approximately 0.55 eV S(1) layer but only the pz states of the lower Ga(2)S(2) layer. Compared with that of the interlayer coupling states in the conduction band, the in-plane states in the valence band are even more sensitive to the vertical external electric field. It is found that the px + py states of the upper Ga(1)S(1) and lower Ga(2)S(2) layers possess separate lower and higher energies, respectively, and the energy difference at Γ point is about 3.05 eV. This indicates that the external electric field induces asymmetric electronic structures in GaS interlayers. The uplifted px + py states of the lower Ga(1)S(1) layer surpass the pz states of the S atoms and become the uppermost valence band, leading to a replacement of the VBM, from the original point between Γ and K to the Γ point. This change of the VBM results in the evolution of the dipole transition from E//c to E⊥c preference, which explains the above prediction that the absorption of E⊥c is gradually increased with the vertical external electric field and exceed that of E//c at a critical external electric field of about 5 V/nm.To reveal the evolution mechanism of the optical anisotropy of GaS ML, the decomposed projected band structures with and without an electric field are further calculated, as shown in Fig. s-type state character that is tightly localized around the S atoms in a spherical shape. While at lower electric fields (0~5 V/nm), the VBM is only from a pz state distributing as a dumbbell shape parallel to the z direction. As the external electric field is increased to the critical value and larger, the VBM is derived from the mixture of px and py components, exhibiting another dumbbell shape perpendicular to the z direction. Based on the VB ordering, parity selection rules come into play. Interband transitions under xy polarization are only allowed for the states with the same parity, whereas those under z-polarization are uniquely for states with opposite parities. Therefore, with an external electric field from 0 to 5 V/nm, the lowest transition CBM-VBM in GaS are only available for the TM-polarized light (E//c), while as the external electric field is larger than 5 V/nm, the lowest transition CBM-VBM tunes to be available for the TE-polarized light (E⊥c) only. This phenomenon pronounces a modulation of the electronic and optical anisotropy under a vertical electric field. The origin of the opposite optical anisotropy can be traced back to the additional crystal field induced by the electric field, as evidenced by the charge density difference plotted in Fig. Spatial distribution of the partial charge at CBM and VBM of GaS ML is further calculated without and with an external electric field of 8 V/nm, as shown in Fig. E⊥c and E//c directions are calculated under various external electric fields. A reversal of the dipole transition from E//c to E⊥c anisotropy is found with a critical external electric field of about 5 V/nm. The band structure calculations indicate a reduction of the band gap and a transition from indirect to direct bandgap in GaS ML with an increasing external vertical electric field. Decomposed projected band contributions exhibit the asymmetric electronic structures in GaS interlayers under the external electric field, which explains the evolution of the absorption preference. Spatial distribution of the partial charge and charge density difference suggest that the strikingly reversed optical anisotropy in GaS ML is closely linked to the additional crystal field which originated from the external electric field. These results not only reveal the modulation of the electronic structures and optical properties of GaS ML by the external electric field but also provide some references to its future application in 2D electronic and optoelectronic devices.In summary, based on the first-principles DFT simulations, we investigate the electric-field-dependent optical properties and electronic behaviors of GaS ML. Optical absorption spectra for both