Although childhood undervaccination among single mother families is a concern for child healthcare, their association is still under debate. This study aimed to investigate the association between maternal marital status and the risk of childhood undervaccination and determine the mediating effect of household income.We utilised prospective birth cohort from the Japan Environment and Children’s Study (JECS). Of 104,062 foetal records (children) from 97,413 mothers, 82,462 that included mothers recruited between 2011 and 2014, were analysed. Childhood undervaccination was defined as not having been vaccinated with at least one routine vaccine. A log-binomial regression analysis was used to estimate the risk ratio (RR) for the association between maternal marital status and the risk of childhood undervaccination. A causal mediation analysis was further performed to investigate the proportion of the association mediated by household income.Among 82,462 children, 3188 and 79,274 had unmarried and married mothers, respectively. Childhood undervaccination was observed in 1053 (33.0%) and 16,901 (21.3%) children of unmarried and married mothers, respectively. Maternal marital status was associated with a higher risk of childhood undervaccination . Compared with married and older mothers, both unmarried and older  and unmarried and younger  mothers were associated with a higher risk of childhood undervaccination. The causal mediation analysis showed that the proportion mediated by household income was 10.5% .This nationwide, prospective, large-scale birth cohort study found that a household with a single mother was associated with an increased risk of childhood undervaccination, and 10% of this association was explained by household income. These findings underscore the importance of improving the social environment among single mother families, including not only poverty but also working conditions.The online version contains supplementary material available at 10.1186/s12889-022-12511-7. Vaccination is a major contributor to improved public health, especially among children, preventing 2–3 million deaths every year . The thrThe association between a single parent family  and childhood undervaccination has been under examination since the 1980s . A studyIn this study, we investigated the association between maternal marital status at pregnancy and childhood undervaccination at age 2 years. Most recommended vaccines in Japan are administered before age 2 years . Thus, cThis cohort study, which utilised data from the Japan Environment and Children’s Study (JECS), was based on the jecs-ta-20190930 dataset released in October 2019. The JECS is a large-scale, nationwide, multicentre, prospective birth cohort study funded by the Ministry of the Environment of Japan. The detailed study design and baseline characteristics of the JECS cohort were described elsewhere , 24. Motn = 3739); 2) withdrew consent (n = 19); 3) at least one questionnaire was not completed ; 4) child vaccination data were missing or logically incorrect (n = 2205); and 5) maternal marital status data at pregnancy were missing (n = 318).JECS participants who met the following criteria were excluded from this analysis: 1) mothers with stillbirths, miscarriages, or unknown birth outcomes (Haemophilus influenzae type b (Hib), Streptococcus pneumoniae, diphtheria, pertussis, tetanus, polio, Bacille de Calmette et Guerin (BCG), measles, and rubella. The following vaccine types were categorised into the “vaccinated” group: combination (such as measles-rubella [MR]) and single vaccines; oral live and inactivated polio vaccines; and multiple vaccines that are administered before age 2 years (such as the Hib vaccine), if they were administered at least once. Childhood undervaccination was defined as not having been vaccinated at age 2 years with at least one or more of these vaccines.The primary outcome was childhood undervaccination at age 2 years. Two types of vaccines are currently available in Japan. One is a routine vaccine that can be administered at no cost to an individual, and the other is a voluntary vaccine that can be administered at the individual’s expense . Among vThe exposure variable, maternal marital status at pregnancy, was obtained from a questionnaire sent in the first trimester of pregnancy and was categorised as being married (defined as being lawfully or de facto married) or unmarried .The characteristics of participants included in our analyses were as follows: maternal age at pregnancy, maternal educational level , annual household income , maternal job at pregnancy , presence of siblings, maternal smoking status during pregnancy, maternal alcohol intake status during pregnancy , maternaThe DAG was used to represent the causal directions among factors and to identify potential confounding factors , 28. MatA causal mediation analysis was performed with annual household income as a mediator. Household income was analysed as a continuous variable, with the median income for each category considered as the income for that category. The ≥6 million JPY income category was set to 8 million JPY. The total effect, average causal mediation effect (ACME), average direct effect (ADE), and proportion mediated were estimated , 30.Since the variables used in this study were based on responses to the questionnaires, the occurrence of missing data was predicted. Therefore, multivariate imputation by chained equations (MICE) was performed to create and analyse 200 datasets each for imputing the missing data. The results of analyses using each dataset were combined based on the Rubin’s rule . AnalyseSensitivity analyses were conducted to examine the robustness of the aforementioned analyses. In the sensitivity analysis of the log-binomial regression analysis, E values were calculated for the adjusted RR . That isp-values of less than 0.05 were considered statistically significant. For the interaction test in the subgroup analysis, p-values of less than 0.05 were also considered significant.All analyses were conducted using R software . The package “mice (version 3.11.0)” was used to impute missing data by MICE , and theFigure P-value for interaction, 0.02).Supplementary Fig. Figure Table The E value for the adjusted RR of unmarried versus married mothers and the lower limit of the 95% CI were 2.01 and 1.86, respectively. The log-binomial regression analysis with cluster-robust standard errors, considering the mother as a cluster, showed that the adjusted RR for childhood undervaccination among unmarried mothers to married mothers was 1.34 , similar to the main analysis shown in Fig. This nationwide, prospective birth cohort study investigated the association between maternal marital status and childhood undervaccination at age 2 years. Unmarried mothers were approximately 1.3 times more likely to have childhood undervaccination than married mothers. Furthermore, although the social backgrounds of younger and older unmarried mothers may be different, our findings suggest that both are at risk of childhood undervaccination. We subsequently conducted the causal mediation analysis using household income as the mediator. Approximately 10% of the association between maternal marital status and childhood undervaccination was explained by household income.Clarifying the association between the two can provide an evidence-based justification for social support. The vaccines surveyed in this study were provided at no cost to the individuals. The result of the mediation analysis, which showed that the mediating effect of household income was low, was consistent. Another possible barrier to childhood vaccination is the lack of time for child healthcare among households with single mothers. Compared to the Organisation for Economic Co-operation and Development (OECD) countries, single mothers in Japan have higher poverty rates despite higher employment rates . Our stuSupplementary Table Several previous studies had similar findings. A US cross-sectional study of 14,810 children aged 24 to 35 months suggested an association between maternal marital status and severely delayed childhood vaccinations  after adjusting for covariates, including maternal age and maternal educational level . AnotherSome previous studies have also examined the association between household income and childhood vaccination status. However, regardless of the timing of the studies, they did not find an association between the two. A US study of 4431 children conducted in 1994 indicated no association between household income and up-to-date childhood vaccination . AnotherThe key strength of our study was its large-scale and prospective birth cohort data. Previous studies were mostly designed as cross-sectional studies . Our stuOur study had some limitations. First, the characteristics of the JECS cohort may not accurately reflect those of Japanese pregnant women. The JECS participants were recruited through Co-operating health care providers and government agencies. Mothers who have negative views on vaccination  may avoid visiting them. Hence, the JECS cohort may have underestimated the frequency of VH. However, the JECS recruited sufficient participants nationwide. Since the coverage for each vaccine was not largely different from those reported previously , the effPoverty in single mother families as well as VH are serious problems. The average poverty rate in OECD countries, including Japan, has been 9.8% for families with two parents. In contrast, for single mother families, it has been 32.5% . AlthougVaccination system issues, such as supply and geographical accessibility, have been identified as reasons for undervaccination in low and middle-income countries . In contWe investigated the association between maternal marital status and childhood vaccination status in a Japanese nationwide birth cohort. Furthermore, we examined the mediating effect of household income on this association. When mothers were unmarried, childhood undervaccination increased by approximately 1.3 times. Moreover, 10% of this association was explained by household income. Our study suggests both an effect of financial support and the problem of balancing work and child healthcare among single mothers. The focus needs to be directed towards the main problems of maternal working conditions and poverty.Additional file 1.Additional file 2.Additional file 3.


In-utero weight gain can be achieved in very preterm infants through rapid advancement of enteral feeds without increasing risk of necrotizing enterocolitis. There are concerns, however, that such rapid weight gain may lead to an increased childhood adiposity risk, although long-term data are sparse.n = 84, born in 2006/2007) vs. 25–30 ml/kg  and growth up to 5 years of age.This retrospective observational study included two well-characterized cohorts comprising 145 infants born at < 28 weeks or with < 1000 g birth weight. We investigated associations between advancing enteral feeding volumes in daily increments of 15–20 ml/kg  weight and SDS BMI at the age of 5 years remained lower than in the reference population. SDS weight decreased from discharge to about 10–12 months postnatal age and returned to birth values by age 5 years. There was a catch-up for SDS length/height from discharge to 5 years; SDS head circumference decreased from birth to 5 years. Multiple regression analyses revealed that for all anthropometric parameters SDS at birth was the most important predictor for SDS at 5 years. Early parenteral protein intake may be another important factor, at least for head growth.Growth was similar in both cohorts without benefit from more accelerated feeding advancement in cohort 2. In both cohorts, early enteral nutrition was associated with in-hospital weight gain as in utero, a drop in weight SDS post discharge and catch-up to birth SDS until age 5 years, remaining below the reference population. Length showed catch-up form discharge to 5 years, whereas head circumference progressively deviated from the reference population. Increased parenteral protein supplementation may be needed to accompany early enteral feeding advancements. Intensive nutritional support for preterm infants improves growth and thereby potentially neurodevelopment –3. ThereReaching this goal may require intensified enteral nutrition and faster feeding advancements, thereby also reducing time with intravenous access and parenteral nutrition, and the risk of sepsis and cholestasis . The optEspecially after rapid advancement of enteral feeding volumes, there is concern that preterm infants’ growth could be impaired by the variability in protein and energy content of human milk or insufficient enteral macronutrient absorption immediately after birth . In a reWe studied the effect of accelerated enteral feeding advancements in infants born at < 32 wk. gestation or with birth weights < 1500 g . Time toWe now aimed to investigate the effects of accelerated enteral feeding advancements on growth between hospital discharge and age 5 years in extremely preterm or extremely low birth weight infants previously described including details on postnatal nutrition .This was a retrospective, single center observational study of extremely premature infants (< 28 0/7 weeks gestation age or with birth weight < 1000 g) born between January 2006 and December 2007 or between January 2010 and December 2010 at Tuebingen University Women’s and Children’s Hospital, Germany, limited to infants who survived to discharge home. In cohort 1, eight infants died before and three after discharge and in cohort 2, seven infants died before and no infant died after discharge. Infants who died were not included in this study. The initial course of both cohorts has been extensively described [Clinical and anthropometric data between birth and discharge were determined daily. Furthermore, exact nutritional intakes were evaluated daily for the first 28 days after birth. Children’s growth data between hospital discharge and age 5 years were collected during routine in-house follow-up and additionally by means of a parental questionnaire collecting data from the child’s routine developmental screening examinations designated by German law. The time intervals for these screening examinations are at 6 to 7 months of postnatal age (S1), 10 to 12 months (S2), 21 to 24 months (S3), 46–48 months (S4) and 60–64 months (S5).The Institutional Review Board approved the study protocol and written informed parental consent was obtained (project number: 210/2018BO2).The previously established feeding protocol was replaced by a revised version in 2009 to allow for an even faster advancement of enteral feeding volumes, changes to our feeding protocol are described in Table Feeding own mother’s milk was encouraged; if no breast milk was available, formula was fed . In both cohorts, enteral feeds started within 4 h and parenteral nutrition immediately after birth. Full enteral feeds were defined as ≥140 ml/kg/d administered for 24 consecutive hours. To calculate macronutrient supply, we assumed a protein content in human milk of 1.4 g/100 ml and 67 kcal/100 ml.http://www.healthforallchildren.com/?product=lmsgrowth). The reference population was the British 1990 growth reference [Anthroprometric parameters were computed using LMSgrowth  if normally distributed, or as median and interquartile range if not. In case that within a table a minority of parameters were normally distributed, the data are still presented as median (interquartile range) to improve clarity of presentation. Comparisons between groups were performed using a two-sided t-test or ANOVA and post hoc Tukey’s multiple comparison test for normally distributed variables or Wilcoxon test in non-normally distributed data and Chi-square test for categorical outcomes. Multiple linear regression analysis was performed to identify important influencing factors on SDSanalysis  cumulatiA total of 163 premature infants with gestational age < 28 weeks or birth weight < 1000 g were admitted to our hospital during the two study periods; 18 (11.0%) died before age 5 years and were thus excluded from analysis (11/95 (11.6%) in cohort 1, 7/68 (10.3%) in cohort 2). No infant had a severe congenital malformation of the gastrointestinal tract. Demographic data of the study population are shown in Table p < 0.0001, and 26.1 vs. 27.0 wk., p = 0.037, respectively). Full enteral feeds were established significantly later in cohort 1  in cohort 1 and − 1.40 (− 2.24 - -0.61) in cohort 2. 23/84 infants (27%) in cohort 1 and 20/61 (33%) in cohort 2 were born small for gestational age with a weight less than 2 standard deviations below the mean (Table W decreased post discharge with a nadir for SDSW at S2 (10–12 months after birth or 6–8 months post discharge) and a recovery towards birth values by 5 years. By contrast, there was a steady decline in SDSHC and a continuous catch-up of SDSL from discharge to age 5 years  was 9 days and 7 days in these extremely preterm or extremely low birth weight infants.W, SDSL and SDSHC at birth. There were no differences in SDSW between the two cohorts throughout the observational period. In Cohort 1, with slower daily feeding increments and higher parenteral protein intake during the first postnatal week, a better early postnatal head circumference growth was observed until discharge [HC was no longer evident. Nevertheless, cumulative parenteral protein intake after birth remained significantly associated with SDSHC at 5 years in multiple linear regression analysis and SDSHC progressively decreased up to age 5 years. As a consequence of this finding we have increased parenteral protein supplementation during the postnatal transition to full enteral feeds, but additional nutritional interventions  should also be considered [L in both cohorts, showing values within the reference range at age 5 years.Overall, no differences in growth pattern up to 5 years of age were found between the two cohorts with different feeding regimens. Compared to the reference population, the preterm infants studied here had a significantly lower SDSischarge . At age nsidered –20. CatcHC at birth was − 1.30 (0.71) and − 1.11 (1.06) at 11 years of age.A Swedish follow-up study of 83 extremely preterm infants came to similar results: weight showed a sharp decrease in z-scores from birth to 3 months’ corrected age, followed by catch-up growth up to age 11 years, but weight remained lower than in term-born controls (mean (SD) z score: at birth − 0.57 (0.98), at due date − 1.62 (0.76), at 3 months − 2.27 (1.38), at 5 years − 0.77 (1.35) and at 11 years − 0.15 (1.22)) . Z-scoreContrary to our and the Swedish findings, many studies reported that preterm infants with postnatal growth retardation up to discharge regain weight in the following months, with catch up to their peers by the time of reaching school age , 21.W from birth to discharge of close to zero; likewise the change in SDSW from birth to age 5 years was close to zero. The SDSBMI at age 5 years was significantly lower than at discharge and lower than that of the reference population, but again not different between cohorts. Presumably, there were no differences in growth pattern up to age 5 years between the two cohorts because time to establish full enteral feeds was similarly short and cumulative protein intake until d28 was similarly high and higher than in most previous studies reporting increased weight gain with increased protein intake [As currently recommended , both stn intake , 11. Recn intake , 23.In contrast to our findings, most studies report that preterm infants fail to achieve near in-utero weight gain during their NICU stay , 21, 24.Beyond neurocognitive development, it has been suspected that disturbances in intrauterine growth can have long-term effects on adult health, e.g., an increased risk for hypertension and insulin resistance, likely based on mechanisms of fetal programming and epigenetics , 26. HowLimitations of our study include its retrospective and single-center design and up to 35% loss to follow-up until age 5 years. Potentially, the latter could introduce attrition bias and thus affect the validity of our observations, however, mean GA at birth of those followed to age 5 years and of the initial cohorts were similar. For this study, we deliberately did not contact parents whose children had already died before age 5 years, consequently our data only apply to infants who survive to 5 years. Furthermore, this study is obviously limited to survivors, the growth data of the sickest preterm infants, who died before discharge, have not been included. Although this is a retrospective cohort study in two periods 3–4 years apart, there were no significant changes in management between the two cohorts described, apart from modifying the feeding protocol. Remarkably, however, in cohort 1 the proportion of multiple births and gestational age were lower than in cohort 2, although we did not find an explanation for this increase.Strengths include our well-described nutritional regimen and detailed information on nutritional support during the first 28 postnatal days, and that both cohorts included an unselected population of extremely low birth weight (ELBW) infants with intensified and very early enteral nutrition resulting in an early postnatal growth along their intrauterine percentiles during their NICU stay.Both cohorts attained full enteral feeds much earlier than previously reported and weight gain as in utero was achieved. There was no significant difference in anthropometric parameters after discharge between both cohorts, but there was catch-up for SDS length/height from discharge to age 5 years. SDS weight and SDS BMI at age 5 years remained lower than in the reference population, SDS weight decreased from discharge to about 10–12 months and returned to birth values at age 5 years. SDS head circumference decreased from birth to 5 years, thus higher parenteral protein supplementation may be necessary during transition to full enteral feeds.In summary, there is no evidence of an increased risk of obesity up to age 5 years following intensified nutritional support with rapid enteral feeding advancement and percentile-parallel weight gain during their NICU stay. Further follow up into adulthood is desirable.


Home birth is very common in the Peruvian Amazon. In rural areas of the Loreto region, home to indigenous populations such as the Kukama-Kukamiria, birth takes place at home constantly. This study aims to understand the preference for home births as well as childbirth and newborn care practices among Kukama-Kukamiria women in rural Loreto. Following a case study approach, sixty semi-structured, face-to-face interviews were conducted with recent mothers who experienced childbirth within one year prior to the interview, female relatives of recent mothers who had a role in childbirth, male relatives of recent mothers, community health workers, and traditional healers. We found that for women from these communities, home birth is a courageous act and an intimate (i.e. members of the community and relatives participate in it) and inexpensive practice in comparison with institutional birth. These preferences are also linked to experiences of mistreatment at health facilities, lack of cultural adaptation of birthing services, and access barriers to them. Preparations for home births included handwashing and cleaning delivery surfaces. After birth, waiting for the godparent to arrive to cut the cord can delay drying of the newborn. Discarding of colostrum, lack of skin-to-skin contact as well as a range of responses regarding immediate breastfeeding and immediate drying of the baby were also found. These findings were used to tailor the educational content of the Mamas del Rio program, where community health workers are trained to identify pregnancy early, perform home visits to pregnant women and newborns, and promote essential newborn care practices in case institutional birth is not desired or feasible. We make recommendations to improve Peru’s cultural adaptation of birthing services. According to Peru’s 2018 Demographic and Family Health Survey (ENDES), the most populated region in the Peruvian Amazon, Loreto, has the lowest percentage of institutional births in the country: 74.5%  66.9–80.9)1. This rate is below the national average (92.6%) . In ordeThe World Health Organization recommends promoting the use of institutional health services in order to ensure safe childbirth and prevent both maternal and neonatal mortality . During The Peruvian government has issued protocols and health policies aimed at making the country’s institutional birthing services culturally sensitive –14. The In a context of slow cultural adaptation of health facilities, community-based interventions can substantially reduce neonatal mortality through the incorporation of clean birth and newborn care practices to home births , 17. In Given the high neonatal mortality and home birth rates in rural Peruvian Amazon, the slow cultural adaptation of institutional birthing services, and the efficacy of community-based interventions aimed at promoting both clean birth and newborn care practices, this study aims to understand the preferences for home births and investigate childbirth and newborn care practices among an indigenous group from the Peruvian Amazon. Results were used to develop a community-based intervention that trains community health workers to improve maternal and newborn care practices during home birth and could contribute to the cultural adaptation of institutional birthing services in the Peruvian Amazon.Our study was conducted within the territory of the Kukama-Kukamiria indigenous group community with an estimated population of 69,822 people . The vasThe Kukama-Kukamiria people depend mainly on a subsistence economy based on fishing and horticulture. Some of them engage in small-scale commercial activities such as the sale of fine woods and agricultural products  . More thMost of the Kukama-Kukamiria people speak Spanish, but usually the elderly also speak their indigenous language which belongs to the Tupi Guarani language family . There aOur qualitative design was an interview-based case study . This tyWe conducted face-to-face semi-structured interviews in two phases. During the first phase in May 2017, we explored the general beliefs, customs, and healthcare seeking practices regarding pregnancy and childbirth. The second phase took place in July 2017 with the aim of corroborating findings from the first phase and exploring home birth and newborn care practices in more depth. Interviews were conducted in six villages located in the districts of Nauta and Parinari.vegetalistas–local experts in the medical use of herbs and vegetables, and sobadoras–women who give massages to pregnant women to accommodate the baby in the womb.Our sample size is 60 participants and was the result of data saturation. The target population consisted of: (1) recent mothers who had experienced childbirth within one year prior to the interview (n = 19), (2) female relatives of recent mothers who had a role in childbirth (n = 12), (3) male relatives of recent mothers (n = 7), (4) community health workers (n = 12), and (5) traditional healers (n = 10). The latter included traditional birth attendants, healers, A fieldwork team comprised of authors R.P., an expert in qualitative methods, and Y.S., a professional midwife, were in charge of data collection. Before entering the communities for the first time, the fieldwork team sent letters of introduction to the authorities. Once at the community, the fieldwork team approached the community’s leaders to introduce themselves and ask for permission to conduct research. In these meetings, the fieldwork team explained the objectives of the study. After gaining the community leaders’ approval and support, the fieldwork team presented the research project to the rest of the community and announced that they would invite people to participate in interviews. Our key informant, a community health worker, helped the fieldwork team identify potential participants based on the inclusion criteria. These participants were approached by the team at their houses where they received an explanation of the purpose of the study, the risks and benefits of participation and who to contact in case they had questions or concerns.Interviews were conducted in Spanish by R.P. who was supported by Y.S. taking notes. This method was designed based on previous research with the targeted population –10 and wDuring the second phase of data collection, we used the same interview guides but we spent more time on questions related to traditional practices and newborn care during home birth.All audio records were professionally transcribed and pseudonyms were assigned to each participant. We conducted a thematic analysis by following both an inductive and deductive approach since some themes were based on the structure of the interview guide (themes we wanted to explore) and other themes emerged from the data . The firAuthors I.D.M. and P.T. shared the coding book and the main themes that had emerged with the rest of the research team. In this meeting, the research team collectively decided to organize the themes for this paper into two parts–home birth preferences and childbirth and newborn care practices–and to focus the rest of the coding on those sections of the interview guide. Other sections, such as Attitudes and Practices during Pregnancy, Attitudes and Practices in Postnatal and Maternal Care, and Perceptions about Community Health Workers were excluded from the rest of the analysis process because these topics are beyond the scope of this paper. I.D.M. then coded the rest of the interviews and created an Excel database to serve as an analytic framework consisting of codes in rows and participants in columns with each cell containing quotes. Finally, I.D.M. looked for trends and dissenting positions and analyzed them while also highlighting the most representative quotes of each theme and translating them into English. To ensure translations were accurate, other bilingual members of the research team and a professional English editor revised them.The Institutional Review Board from Universidad Peruana Cayetano Heredia approved this project´s protocol with code 63631 on April 18, 2017. Written, informed consent was obtained from all participants before interviews.Over 27 days, we visited six communities and recruited 60 participants. On average, we stayed in each community for 5–6 days. We conducted interviews with 33 participants during the first phase and 27 during the second.The female relatives group (FR) was diverse in age since it was comprised of mostly sisters, mothers, and grandmothers of the recent mothers. The youngest female relative was 18 years old and the oldest was 74. The median number of children for female relatives was 8. A total of seven male relatives (MR) of recent mothers were interviewed. They were either their fathers or partners and their median age was 34. Ten participants were traditional healers (TH) and five of them were older traditional birth attendants. We also interviewed 12 community health workers (CHW), five women and seven men, whose median age was 49.5 years old. Community health workers are trained to monitor new pregnancies. Their role is to conduct home visits to pregnant women and newborns to check on any signs of health complications and report them to the health facility.Study participants reported that most women in their communities prefer to give birth at home instead of a health facility. Feeling safe and supported are the main reasons to stay at home for childbirth. This is contrasted with a fear of mistreatment and inadequate care at health centers. Other related factors include home birth being perceived as brave and partners’ and social expectations that support home birth. Access barriers such as financial and transportation constraints and long wait times are other complementary factors that limit the use of birthing services.Most participants from all groups indicated that home birth is a traditional practice in which women feel safe and supported by relatives and traditional healers. On the contrary, institutional birth is associated with mistreatment and inadequate care, which was emphasized mostly by community health workers, recent mothers, and female relatives. During home birth, relatives and traditional healers provide emotional care and practical support through food, drinks, and traditional medicine. María, a 23-year-old recent mother, shared her preference for home birth after having three children at home:I [prefer to give birth] at my house. I feel safer here than at the health center because people say that at the health center, you are not treated like when you are at your house. They do not let you take [traditional] medicine, those that you take here [at home]. They [traditional birth attendants and relatives] give you a lot of hot beverages, and there [at the health center] they do not, people say. And if you cannot have your baby, if your baby does not dilate well, they take you to the city. Here [at home], it is not like that; here they [traditional birth attendants and relatives] see how to make it work, they make your baby dilate fast with vegetables.Relatives of recent mothers also expressed their preference for home births. Being able to take care of the relative giving birth was the main reason reported:Interviewer (I): How do you feel about your daughter giving birth at home?Participant (P): Oh, I feel calm because I see her next to me, I am looking after her, I am taking care of her. She asks me for something and I give it to her. Maybe [she asks] for a stew that maybe she wants to drink. Maybe she asks me: “Mom, I want to drink” and I give it to her, I boil it for her. I take care of her here.While women feel safe and supported having a home birth, community health workers, recent mothers, and their female relatives shared secondhand and personal stories of women being told off for not pushing during labor and receiving unnecessary procedures such as C-sections:Here [at home] I am motivated by my father-in-law and my mom when they tell me: “Daughter, walk, walk, have courage, if you do not have courage, who is going to have it for you? Nobody.” At the health center, you are told off; they are yelling at you.Recent mother                              - Well, some [women] say they do not want to go to the hospital because at the hospital, they perform C-sections on them, they cut them. Because of that, they are afraid to go to the hospital; they prefer to give birth in their houses with the traditional midwife instead of getting cut. That is what I hear many women who have children saying because that is the fear they have, to be cut.Community health worker                              - [Women don’t go to the health center] because they [health providers] grope them, they do things like that to them so it is better to be at home. Sometimes, they [health providers] give them [women in labor] cuts, cuts so they dilate faster so they have their kids more quickly.Female relative                               - Along with perceived mistreatment, many interviewees were concerned about inadequate care at the health centers. The woman being left alone during labor or forced to wait to receive care were salient themes when participants described why women prefer to give birth at home. Participants from all groups reported these themes. For example, a male relative explaining why his wife does not trust the health center said, “She is suspicious that they might leave her there alone [during labor] and she could die. That is where her mistrust comes from. [At the health center], they leave them all alone.” A recent mother emphasized the long wait saying that the health providers “take us to the health center, then the [nurse] technician leaves us there alone, and they treat us only when we can’t walk anymore.”Participants’ perceptions of inadequate care also stemmed from a series of restrictions to their traditional childbirth practices at the health center such as having a relative or community member cut the umbilical cord, the consumption of traditional beverages, and having a standing–or any position except horizontal–birth. These restrictions contribute to women’s preference for home birth.ubos–a slightly alcoholic beverage made out of fermented hog plum. For instance, a participant said, “[Health providers] do not let you take your medicine, those that we take at home.”Participants from all groups reported that during home birth, women drink hot beverages that are not provided or allowed at health centers such as cotton leaf tea, milk, coffee, and Some recent mothers and their female relatives shared that they decided not to give birth at the health center because if they did, their babies could not have a godmother. It is a common practice among Kukamas that a godparent chosen by the parents cuts the umbilical cord. Silvia, a 29-year-old recent mother, explained why she did not go to the health center to give birth: “because I wanted her [my baby] to have a godmother, because at the hospital they do not want [the godmother to cut the umbilical cord], it is not possible.” A father of two children born in health centers who did not have their cords cut by a godparent said that he feels “kind of weird because you should have a godfather at birth.”Although standing birth is starting to be offered at some health centers across the country, many women are not aware of this or do not live close to a center that offers this option. The lack of this service discourages women from having an institutional birth. For example, Flavia, a 21-year-old woman who has had three pregnancies, says that she and other women from her community prefer to give birth at their houses because: “Here [at home] you have [birth] in your normal way, they [health providers] are not touching you. And here [at home] you have [birth] in the position you want, there you don’t.”Most participants from all groups reported that women who have home births are brave and have a lot of courage whereas women who go to health centers are weak or “dejadas.” For example, a father of six said that his partner’s last birth was at home because “she had courage.” Romina, a grandmother and a mother of eight, shared what she was told by her closest female relatives when she was pregnant the first time:Back in the time when my grandma was alive, she would tell us that we [had to] give birth there [at home]. If we were brave, we could give birth in our house; if we were not, we would be taken to the health center, she said.A traditional healer also emphasized the contrast between having a home birth and being brave and having an institutional birth and being weak:Not everyone can give birth. Especially the first time. Many of them scream: “Ay, ay.” They talk nonsense. Those things sometimes intimidate the husband, it intimidates the family, the mother, the grandmother. Then, they take her [the pregnant woman] to the health center.The perception of women who go to health centers as weak or “dejadas,” however, was contested by a few participants from each group. These participants considered that during emergencies, giving birth at the health center is not a sign of weakness. For some of them, women giving birth are always brave regardless of where it happens: “Both of them are brave, those [who give birth] at the health post and those [who give birth] at home. Women are always brave when they have to bring a child into the world” .Regardless of their group, some women from the study reported having a home birth because it was their partner’s/husband’s decision. Nadia, an 18-year-old recent mother, said that she wanted to give birth to her child at home because “that is what my husband said.” A similar dynamic was described by a community health worker when she was asked who decided the place for the birth: “The pregnant woman decides and her role is to tell her husband so he can accept or not because some [husbands] do not accept.”Women’s preference for home birth is also informed by gender when the health provider in charge of the woman’s health is a man. Participants, most of them recent mothers and community health workers, reported that women feel ashamed showing their bodies to male health providers. When Martín, a community health worker with 22 years of experience was asked why women do not go to the health center during pregnancy or labor, he said, “I mean, for one, the [professional] midwife is a man. They are embarrassed by that.”Besides the cultural and interpersonal aspects of home birth, participants from all groups mentioned features of health centers that contribute to preference for home birth. Long distance, cost, and waiting time were main reasons for not having an institutional birth.Community health worker Martin explains the economic reasoning:I mean, I think that [they do not have institutional births] because of their finances. Okay, I am going to tell you, sometimes there is no money, not even for a gallon of gasoline. Mainly that, that is why mothers are used to giving [birth] at home. They do not want a hospital nor a health center. They [women] are used to giving birth at home.Julia, whose daughter recently gave birth, explains that distance is another reason she prefers giving birth at home:Of course [it is easier to give birth at home]. If I go to the health center and I am in a hurry, for example, maybe I cannot get a towel or a diaper for the baby. Look how far away I live [from the health center]. It would take too long to come here to pick up something from the health center. If it is at home, it is easier, and I do not have to move around with my daughter.In addition to distance and transportation barriers to health centers, once they are there, the people in these communities also have to deal with long waits to receive care. Marlene, a 22-year-old mother of three, shared why she decided to have all her kids at home:I like it [giving birth at home] because, well, at the hospital, they take too long to take care of you, they ask you for so many things ; they delay you actually. At my house, well, that is where I had [my children]. There [at home], my mom, they give you everything hot, they give you, so you drink and you have [your children] fast. That is how I had all my children.After exploring the main reasons why most women in these communities prefer to have home births, we analyzed how these births happen. We focus on aspects directly related to newborn health such as clean birth procedures and newborn care.Regarding safe childbirth practices, all participants who were asked about handwashing said that the traditional midwife or relatives attending the home birth do wash their hands with soap before labor. This information came from traditional birth attendants reporting about their own practices as well as community health workers and recent mothers and their female relatives.Despite the male relatives group who reported not knowing about the cleaning practices before childbirth, all participants mentioned that babies are delivered to a blanket on a previously swept wood floor. The blanket is washed either with rain or river water before the birth takes place. There was only one participant, a recent mother, who did not know if the blanket used during her labor was washed before or not because her mom was in charge of that. A piece of plastic was used by a few participants which goes under the blanket or it replaces it. The next excerpt represents these findings:P (recent mother): We had put the mattress in one side of the room and the plastic. I had plastic and I put some blankets. It was all clean. Always the room [has to be] clean. It was like this, first plastic, right? Then my sheets so they could get dirty.I: How were the sheets washed?P: They are washed with rain water.After the baby is born, it is not always dried immediately. Although most of our participants who commented on this said that the baby is dried immediately after being born, a few community health workers revealed that the newborn can wait up to 30 minutes to be dried. This usually happens because the baby is placed on a blanket until the godparent arrives to cut the cord: “[The baby waits] like 30 minutes, until we find the godfather” . It is not until that procedure is done that the baby is dried.We found that scissors were the tool used to cut the cord according to the vast majority of participants from all groups. These scissors were either bought specifically for the birth, previously owned or, in fewer cases, brought by a health provider. In any case, they were always disinfected with boiling water.Another key aspect of newborn care is breastfeeding. Although responses regarding whether or not breastfeeding was immediate–within one hour of birth–varied, the majority of participants agreed that the first breastfeeding took place after the baby was cleaned and dressed. According to our participants, this can occur between 15 to 120 minutes after the baby is born. In one extreme case, breastfeeding occurred 13 hours after birth because the baby “did not ask for it” according to the mother.Regarding skin-to-skin contact between mother and baby, according to most participants, this first direct contact is not immediate since it happens once the baby is cleaned by the traditional midwife or the relative helping with childbirth. For instance, Vilma, a 53-year-old mother of eight, said that her daughter carried her baby “after the traditional midwife cleaned him, that is when she gives it to the mom.” When this contact occurs, the baby is already dressed. For example, a community health worker, clearly stated that the baby’s first contact with the mother was after she was dressed: “The baby was in the blanket, then we cleaned and dressed her, and once she was well covered, the mother carried her.” There was only one participant, a traditional birth attendant, who reported skin-to-skin contact when she explained the procedures after birth. According to her, the baby is placed naked on the mother’s naked belly until the godparent arrives to cut the cord.As for the colostrum, our results show that discarding it is a common practice. Whereas male relatives did not show much understanding about the colostrum, the majority of female participants mentioned that the first breast milk, the colostrum, is discarded. This happens because people think that the colostrum makes the baby sick because it is old and stored milk. Laura, a 74-year-old mother of 11, explained that she discarded the colostrum because “the baby gets infections in his stomach.” Sofia, a traditional midwife with 20 years of experience said that she “throws out the yellow milk [colostrum]” because it makes “the baby throw up.”Although the majority of participants reported the practice of disposing of the colostrum, a few of them keep it and give it to the newborn. Rafaella, a mother of four who gave birth eight days before the interview, shares how she breastfed all of her children without discarding the colostrum:I. Did you wring out that milk [colostrum] and throw it away? Or did you give it to the baby?P: No, I gave it to them directly, they [the professional midwife] did not explain anything to me. They told me to breastfeed him and I did.I: How was it with your other children?P: The same.I: You have never wrung out the yellow milk.P: Never.This study explores the Kukama-Kukamiria people’s preference for home births and their childbirth and newborn care practices. Our findings show that women prefer home births over institutional births because it is a culturally charged practice that they cannot reproduce at a health center. Home birth makes women feel safe and supported. It is also a sign of bravery and a way to comply with traditional gender roles such as following their partner’s decisions. These preferences are also linked to experiences of mistreatment at health centers, lack of cultural adaptation of birthing services, and access barriers. Regarding newborn care, there are practices that contribute to hygienic childbirth such as handwashing and clean delivery surfaces. However, the discarding of the colostrum, the lack of skin-to-skin contact, and the range of responses regarding immediate breastfeeding and immediate drying are findings that show opportunities to improve the newborn care practices in these communities.We found barriers to both health facility access and quality care. In relation to access, studies in the Peruvian Amazon and other low and middle-income countries have also found that distance and financial constraints limit people’s options to home birth , 23–26. malva or mallow, ginger, coffee, hot milk, tea, and hot water among Kukama-Kukamiria, Yaguas, and Awajun people Reviewers' comments:Reviewer's Responses to QuestionsComments to the Author1. Is the manuscript technically sound, and do the data support the conclusions?The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: YesReviewer #2: Yes**********2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: N/AReviewer #2: Yes**********3. Have the authors made all data underlying the findings in their manuscript fully available?PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.The Reviewer #1: YesReviewer #2: Yes**********4. Is the manuscript presented in an intelligible fashion and written in standard English?PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.Reviewer #1: NoReviewer #2: Yes**********5. Review Comments to the AuthorPlease use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. Reviewer #1: 1. Summary of the researchThis study presents a compelling qualitative analysis of home birth preferences and practices among the Kukama-Kukamira people of rural Amazonas. These findings have significant implications for maternal and infant health as they elucidate the cultural meaning ascribed to home birth, the rationale for its preference over institutional delivery, and homebirth and newborn practices among indigenous communities in the Amazonas. The authors propose that these findings can be used to promote evidence-based maternal and newborn care practices during home birth and inform the integration of cultural practices in institutional birthing facilities.2. Examples and Evidencea. Major IssuesIt is unclear whether the authors are ultimately recommending improving home birth practices (as is intended with the community-based intervention) or integrating cultural practices into hospital systems to increase institutional births. Even so, health systems must first address the structural barriers impacting access to institutional deliveries, namely distance from facility and cost of transportation. The authors should more clearly indicate what the ultimate implications of their findings are.The phenomenological and case study approach is appropriate to address the proposed research questions and the theoretical framework was adequately applied. The process of conducting a second round of interviews ensures deeper exploration of the processes being examined.Authors should state whether the interviews were conducted in Spanish and if so, how they were translated.I am concerned about how conducting the interviews in participants’ homes may have impacted responses, especially in relation to discussions of partners’ decision-making and gender roles in relation to institutional deliveries as participants may have felt uneasy with speaking openly if their partners were present or nearby.Please elaborate on the data analysis methodology – were all transcripts (besides the first two that were double-coded) coded by I.D.M and P.T.? What do the authors mean by “we collectively decided how to organize the themes of this paper” in line 168?The results are comprehensive and the quotes illustrative of the identified themes. One way to improve this section would be to tease apart discrepancies between ideas from different types of respondents – what were the differences in perspectives from mothers, partners, traditional healers, community health workers, and female relatives. For example, did postpartum women mention cost or distance as deterrents to institutional births? If there were no differences in responses, this should be noted.The findings are contextualized appropriately within the broader literature on home birth practices and barriers to institutional deliveries. Some review of the literature on provider perspectives may further illuminate why women prefer home births instead of institutional deliveries, and how providers view these populations and the services that they deliver.Are there any illustrative quotes demonstrating mistrust or perceived low quality of care by women toward health center staff? This is a key point in the discussion (lines 418-426) yet the data presented in the results does not sufficiently support this.Regarding the section on bravery, do the authors have recommendations on how to leverage this information to promote institutional births? What is it about home births that signifies bravery and would it be possible to recreate this within a healthcare setting? This may be beyond the scope of this paper.Are there any studies related to partner influence on birth decisions that can be referenced to further support the authors’ discussion of partner decision-making and gendered factors?In making recommendations for clean home birth practices, authors should acknowledge the importance of structural factors such as access to water and sanitation as necessary resources for implementation of hygienic birth practices.Finally, please proofread for grammatical mistakes throughout.b. Minor IssuesLine 35: I recommend revising “birth represents a meaningful…practice” to more specific phrasing Line 81: Please briefly explain how cultural birthing practices differ in the Peruvian Andes as compared to the Amazon, and why cultural integration policies implemented by the Peruvian government have been unsuccessful in the Peruvian Amazon.Lines 87-88: Who would be the target of clean birth and newborn care interventions – mothers, relatives, traditional birth attendants?Lines 127-131: How might the exclusion of health center staff perspectives impacted study findings?Lines 325, 328, & 329: The word “gloves” is misspelled.Lines 416-417: Can you cite evidence to support this claim?Line 442: The authors describe the role of the godmother as a “barrier for institutional birth.” Is this cultural practice a barrier in itself or, is the barrier the health center’s reluctance to integrate cultural practices into their delivery services? I recommend reconsidering the language used in this sentence.Line 499: Do you mean primary care services? Or obstetric services?Reviewer #2: This is a well-crafted research study on the home birth preference and practices among women in the rural Peruvian Amazon. Due to the general lack of research in this area and the critical need to include indigenous people's voices in questions surrounding their own health care, the qualitative methodology was an appropriate research strategy. The authors clearly described their use of standard approaches for recruiting and engaging participants, for gathering data (interviews), and for their analysis. The results revealed important insights into the barriers that prevent rural Peruvian women and their families from obtaining care in institutional facilities as opposed to their homes, and the discussion contained useful recommendations for community- and institutionally-based care providers. For revision, I would suggest: 1) include a table with descriptive characteristics of the sample, as it was heterogeneous and could be made clearer in table form; 2) include a bit more comparison/contrast from the different participant subgroups  as the sample heterogeneity raised questions about possible differences; 3) consider discussing how the impact of your efforts could be extended by future research that included health care officials' responses to these and related study findings.https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool,  12 Feb 2021We are again grateful to the Reviewers and the Editor of PLoS One for their suggestions, which we are confident have strengthened our paper. Below, we detail the changes we made in response to the comments we received from each reviewer.Editor:- Line 29 . Is “every second” literal?No, it is a figure of speech. We replaced it.- Line 40. How are drying and cord cutting related here? Again on line 443, the question arises again. Delayed cord clamping is actually recommended to increase iron to the baby. Couldn’t the cord be dried even if there was a delay in having it cut?By drying we refer to the drying of the newborn, not the drying of the umbilical cord. Drying the baby and cord-cutting are related because the drying happens after the cord is cut. The cutting is done by a godmother who is not always in the room. Then, waiting for her to arrive delays both the cord-cutting and the drying of the newborn.- Line 41. what are “heterogenous” answers?We meant that there was a range of responses regarding immediate breastfeeding and immediate drying of the bay. We made changes throughout the paper to clarify this.- What is new? Is this an update from a previous study? Is there currently a growing stigma for home births? What do people understand about the risk of maternal mortality?Thank you for your questions, they help us make the Introduction much stronger. This is not an update from a previous study, instead, it was preliminary research for a current community-based intervention that trains community health workers to identify pregnancy early, perform home visits to pregnant women and newborns, and promote essential newborn care practices in case institutional birth is not desired or feasible. This study could also contribute to the cultural adaptation of institutional birthing services in the Peruvian Amazon. What is new is that, despite a growing interest in providing culturally appropriated institutional birthing services, home birth and neonatal mortality are still very high in the Peruvian Amazon. We argue that better information about women’s home birth preferences and their childbirth and newborn care practices in the Peruvian Amazon could contribute to both community-based interventions aimed at improving clean birth and newborn practices and the cultural adaptation of institutional birthing services. As a result, the risk of neonatal mortality could decrease. We have re-structured the introduction to make these arguments more clear. Perceptions about the risk of maternal mortality were not part of the study. We focused on what made women want to stay at home more than their fears of giving birth at home.- Line 55 - is this a rate or a percentage?It is a percentage. We decided to reframe the sentence after re-reading the source. The new version is: “Infections are the main cause of neonatal death in this region, even among newborns with a healthy weight for gestational age and without genetic conditions that might compromise their life [2]”.- Line 74- more details needed on this integration. When was this? How many facilities?We included this information in the new version. The first standing birth protocol was issued in 2005 by the Ministry of Health. In 2016 a more detailed protocol was approved. These measures apply nationwide but there is no evidence of its actual implementation. We removed the study from the Andes because it was a community-based intervention run by a non-governmental organization instead of the State and it was conducted before the national standing birth protocols were issued. - Line 102 – accessible to where?We clarified: “Indigenous communities in this geographic area are widely dispersed; their access to health facilities is time-consuming and by boat only”.- Line 113- were observational data included?No, only interview data was included.- Line 126- please include numbers of respondents and justification for the sample size“Our sample size is 60 participants and was the result of data saturation. The target population consisted of: (1) recent mothers who had experienced childbirth within one year prior to the interview (n=19), (2) female relatives of recent mothers who had a role in childbirth (n=12), (3) male relatives of recent mothers (n=7), (4) community health workers (n=12), and (5) traditional healers (n=10)”.When we revised the data to provide the number of respondents for each group and create the table with demographic characteristics of our participants we realized we miscounted before. The number of participants is 60 instead of 59.- Line 130 – spelling should be midwives (or can keep as parteras?); are sobedoras different than TBAs?We changed traditional midwives to traditional birth attendants throughout the paper. Some sobadoras are TBAs but this is a specific social role so we preferred to make the distinction.- Line 141- please include consent process details“These participants were approached by the team at their houses where they received an explanation of the purpose of the study, the risks and benefits of participation and who to contact in case they had questions or concerns”. - Line 143- please include the languages, and if tools were pre-tested“Interviews were conducted in Spanish by R.P. who was supported by Y.S. taking notes. This method was designed based on previous research with the targeted population [6-10] and was not pre-tested”.- Line 180- why was the stay in each community so short? This would be difficult for a phenomenological studyBudget constraints and difficult living conditions due to limited resources in each village  made a longer stay impossible. We have realized that our study does not comply with all aspects of the phenomenological approach. We have limited our study design to an interview-based case study.- Line 192- what are the roles and training of CHWs?We included the following sentences: “Community health workers are trained to monitor new pregnancies. Their role is to conduct home visits to pregnant women and newborns to check on any signs of health complications and report them to the health facility”.- If available, please include a demographic table or description of the participants.This was also suggested by Reviewer 2. In response to both of them, we included Table 1. We included three variables that had a good rate of response (less than 10 missing cases): sex, age, and number of children. We had to exclude years of formal education because almost one third of participants did not answer to that question. This probably due to the access barriers to schools that that affects many communities living in rural areas in Peru.- Please append the interview guidesThey have been included. - Line 222- were experiences of mistreatment expressed directly or second hand stories?Community health workers and recent mothers and their female relatives shared second hand and direct stories, respectively, of women being told off for not pushing during labor and receiving unnecessary procedures such as C-sections.- Line 266- please spell out SJSSJS is the abbreviation of San Jose de Samiria, one of the three villages where we conducted our study. To maintain our participants' confidentiality, we have decided to not mention the names of the villages and delete the abbreviations we had in the paper. We also did not find salient differences between the villages so that referring to them does not change the analysis.- Line 279- is it only gendered factors, or also intrafamiliar, and other power dynamics?In this subsection, we have focused on gendered factors that happen at both an intrafamilial and an institutional level. In the first case, they are clearly the result of imbalanced power dynamics between men and women. Another power dynamic that we have explored in the paper is the doctor-patient interaction which is marked by mistreatment. There are other intrafamilial factors related to home birth that are not specifically gendered that we mention in other subsections. The feeling of safety and comfort that comes from being surrounded by family members and receiving their help during birth is one example.- Line 281- what is “L”?L is the initial of one of the three villages where we conducted our study. To maintain our participants' confidentiality, we have decided to not mention the names of the villages and delete the abbreviations we had in the paper. We also did not find salient differences between the villages so that referring to them does not change the analysis- Line 313- what types of “things” are asked for?They are asked for identification, paperwork, and to wait and give birth without relatives in the room. We clarified this in the quote. - Lines 325, 328, & 329: The word “gloves” is misspelled.Thank you, we corrected all the misspelling. We deleted the paragraph on gloves use because it is not part of the best practices for clean births. They are also not distributed to traditional birth attendants by the government and are barely used.- Line 329- are TBAs supposed to get gloves from health facilities?No, they are not supposed to get them from the health facilities. In fact, the WHO does not include the use of gloves as part of the procedures for a clean home birth. Because of that, we have decided to remove his part.- Line 351- were responses not clear, or just given in a range?They were given in a range. We clarified this in the new manuscript.- Line 362- is “carried her” the same as skin to skin care?No, it is not skin-to-skin care because the baby has clothes.- Line 374- who is “they”?Professional midwives. We clarified the quote.- It would be helpful, in the results, to understand the weight of various factors that participants describe that help them decide when and where to seek care.Thanks for the suggestion, we included this information in the first paragraph of the Home birth preferences subsection: “Study participants reported that most women in their communities prefer to give birth at home instead of a health facility. Feeling safe and supported are the main reasons to stay at home for childbirth. This is contrasted with a fear of mistreatment and inadequate care at health centers. Other related factors include home birth being perceived as brave and partners’ and social expectations that support home birth. Access barriers such as financial and transportation constraints and long wait times are other complementary factors that limit the use of birthing services.- Line 394- “people want to” should be changed to indicate less choice, given constraintsWe replaced that phrase for the following: “In relation to access, studies in the Peruvian Amazon and other low and middle-income countries have also found that distance and financial constraints limit people’s options to home birth .”- Line 400- lack of awareness by who?By health providers. We clarified in the manuscript.- Line 410- who is “their”?Saker and colleagues. We clarified in the manuscript.- Line 416- please see the following publication, showing a large percent of women experience unconsented vaginal exams and other disrespectful care Thank you, we included the results of the suggested paper in the Discussion section.- Line 423- what language is spoken at the health care center?Spanish. We clarified in the new manuscript.- Line 449- this is not clear – what is the link between pushing and having relatives present? We changed the sentences and re-located them in the paragraph where we discuss safety and support. This is the new version: “Qualitative studies of the Kukama-Kukamiria people show that the presence of relatives during childbirth is understood to drive away bad spirits [5]. The baby’s father also has an important role during childbirth because he motivates the mother when she is pushing . According to the current standing birth protocol in Peru [14], pregnant women can choose one companion during institutional birth. This can be the father or any other family or community member. In light of our findings and related literature, this norm is insufficient. To make institutional birth more appealing to Kukama-Kukamiria women, more companions should be allowed in the childbirth room”.- Line 465- are other liquids given when breastfeeding is delayed?No- Line 466- who is this reported by?Moore ER, Bergman N, Anderson GC, Medley N. Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database Syst Rev. 2016 Nov 25;11(11):CD003519. doi: 10.1002/14651858.CD003519.pub4. PMID: 27885658; PMCID: PMC6464366.https://pubmed.ncbi.nlm.nih.gov/27940805/- Line 473- please see recent evidence related to the risk of bed sharing - We appreciate this contribution. After reading the paper, we removed the sentences on bed-sharing since it is not an alternative to skin-to-skin contact and it might even be detrimental for the baby. Instead, we added some recommendations to improve skin-to-skin care. " The lack of skin-to-skin contact that we found should be addressed by health officers. We recommend educational campaigns targeting community health workers, pregnant women, and traditional birth attendants about the importance of skin-to-skin contact. Moreover, we recommend addressing one of the main reasons for the delay of such contact – waiting for the godparent to cut the cord. For instance, recommending that the newborn rest on the mother’s chest even if the cord has not yet been cut, is a possibility". When we revised the data to provide the number of respondents for each group and create the table with demographic characteristics of our participants we realized we miscounted before. The number of participants is 60 instead of 59.- Line 479- the average number of days when colostrum is available is knownYes, we deleted the sentence. - Line 484 – is this maternal or neonatal mortality?Neonatal mortality. We clarified this in the new manuscript.- Line 486- use word like “beneficial” rather than suitable, which is more judgmentalThanks for the suggestion. We changed the word.- Line 500 – please provide some examples of cultural adaptationsWe edited the paragraph. These are some of the examples: “This study shows the limitations of the current standing birth protocol and can inform future changes to ensure the cultural adaptation of birthing services in the Peruvian Amazon. For instance, allowing only one companion might be a barrier to institutional births since women are used to having their close relatives and a birth attendant during childbirth. We recommend increasing the number of companions to at least four people so that the partner, the mother, a childbirth attendant, and a godparent can be present. The cultural adaptation of birthing services should also integrate the role of the godparent in cutting the umbilical cord. The mechanisms to report and hold health providers accountable for mistreatment should also be improved and including community health workers in this process is key”.- The discussion would be strengthened with more references to the other work that has been conducted on maternal and postnatal care and care seeking in Latin America. Please see the following citations.We included the suggested papers in the Discussion, thank you for bringing these papers to our attention.- Please include a strengths and limitations section.We included a Strengths and Limitations section.- Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming.We carefully reviewed the requirements and made the necessary changes. - Please include a copy of the interview guide used in the study, in both the original language and English, as Supporting Information, or include a citation if it has been published previously.We have included the interview guides as supportive materials.- We note that you have indicated that data from this study are available upon request. PLOS only allows data to be available upon request if there are legal or ethical restrictions on sharing data publicly.We made data available. - In your revised cover letter, please address the following prompts:a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail  and who has imposed them . Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent.http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories.b) If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings as either Supporting Information files or to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. For a list of acceptable repositories, please see We made data available. - Please amend either the title on the online submission form (via Edit Submission) or the title in the manuscript so that they are identical.They are identical now, thank you. Reviewer 1:- Line 35: I recommend revising “birth represents a meaningful…practice” to more specific phrasing Changed to specific phrasing suggested by Reviewer 1.- It is unclear whether the authors are ultimately recommending improving home birth practices (as is intended with the community-based intervention) or integrating cultural practices into hospital systems to increase institutional births. Even so, health systems must first address the structural barriers impacting access to institutional deliveries, namely distance from facility and cost of transportation. The authors should more clearly indicate what the ultimate implications of their findings are.Thanks for this input. The primary implications of this study were to inform a community-based intervention aimed at reducing neonatal and maternal mortality through the training of community health workers. They were trained to identify pregnancy early, perform home visits to pregnant women and newborns, and promote essential newborn care practices in case institutional birth is not desired or feasible. This study could also contribute to the cultural adaptation of institutional birthing services in the Peruvian Amazon. This is mentioned in the last sentence of the introduction and the discussion.- Line 81: Please briefly explain how cultural birthing practices differ in the Peruvian Andes as compared to the Amazon, and why cultural integration policies implemented by the Peruvian government have been unsuccessful in the Peruvian Amazon.We removed this part from the article because we found no clear evidence that the cultural birthing practices differ between the Peruvian Andes and the Amazon. Moreover, the evidence we presented of the cultural integration in the Andes was a small intervention project conducted by a non-governmental organization previous to Peru's first standing birth protocol. It was not part of a national policy. We apologize for the confusion.- Lines 87-88: Who would be the target of clean birth and newborn care interventions – mothers, relatives, traditional birth attendants?The paper cited does not specify who would be the target of clean and birth newborn in the community. But we did include more information about the strategies recommended by the authors. We added these sentences: According to the authors, clean birth and newborn care interventions should be promoted through community-based behavioral change interventions, training of health workers and birth attendants, and clean birth kits [16]. It is unclear who the specific targets of these strategies are except for health workers and birth attendants”.- Authors should state whether the interviews were conducted in Spanish and if so, how they were translated.We clarified in the new manuscript that interviews were conducted in Spanish and only the most representative quotes of each theme were translated into English by I.D.M who is bilingual. The entire manuscript has been proofread by a professional English-language editor.- I am concerned about how conducting the interviews in participants’ homes may have impacted responses, especially in relation to discussions of partners’ decision-making and gender roles in relation to institutional deliveries as participants may have felt uneasy with speaking openly if their partners were present or nearbyWe had the same concern about the same so we conducted the interviews with women and men separately. Male relatives were not present or nearby during the interviews with recent women and female relatives.- Please elaborate on the data analysis methodology – were all transcripts (besides the first two that were double-coded) coded by I.D.M and P.T.? What do the authors mean by “we collectively decided how to organize the themes of this paper” in line 168?We edited the text to make it more clear: “Authors I.D.M. and P.T. shared the coding book and the main themes that had emerged with the rest of the research team. In this meeting, the research team collectively decided to organize the themes for this paper into two parts – home birth preferences and childbirth and newborn care practices – and to focus the rest of the coding on those sections of the interview guide. Other sections, such as Attitudes and Practices during Pregnancy, Attitudes and Practices in Postnatal and Maternal Care, and Perceptions about Community Health Workers were excluded from the rest of the analysis process because these topics are beyond the scope of this paper”. - Lines 127-131: How might the exclusion of health center staff perspectives impacted study findings?Rather than excluding health center staff, they were not considered as participants because their perspective did not help answer our research question that aimed at understanding home birth preferences and practices around childbirth and newborn care among the Kukama-Kukamiria people. Their participation could have impacted our study findings by providing an outsider perspective on why women prefer home births and an insider experience of institutional births. The latter we could have contrasted with women's experiences and perceptions of institutional births which came out when they described why they prefer home births.- The results are comprehensive and the quotes illustrative of the identified themes. One way to improve this section would be to tease apart discrepancies between ideas from different types of respondents – what were the differences in perspectives from mothers, partners, traditional healers, community health workers, and female relatives. For example, did postpartum women mention cost or distance as deterrents to institutional births? If there were no differences in responses, this should be noted.Reviewer 2 had the same suggestion. In response to both of them, we included more contrast between responses, even if they were not differences between types of respondents. For example: "The perception of women who go to health centers as weak or “dejadas,” however, was contested by a few participants from each group. These participants considered that during emergencies, giving birth at the health center is not a sign of weakness. For some of them, women giving birth are always brave regardless of where it happens: “Both of them are brave, those [who give birth] at the health post and those [who give birth] at home. Women are always brave when they have to bring a child into the world.” .We also noted more instances where there were no differences. For example: “Despite the male relatives group who reported not knowing about the cleaning practices before childbirth, all participants mentioned that babies are delivered to a blanket on a previously swept wood floor. The blanket is washed either with rain or river water before the birth takes place. There was only one participant, a recent mother, who did not know if the blanket used during her labor was washed before or not because her mom was in charge of that. A piece of plastic was used by a few participants which goes under the blanket or it replaces it”. We discussed why we found few differences between groups in the Strengths and Limitations section.- The findings are contextualized appropriately within the broader literature on home birth practices and barriers to institutional deliveries. Some review of the literature on provider perspectives may further illuminate why women prefer home births instead of institutional deliveries, and how providers view these populations and the services that they deliver.We included some of the literature on providers’ perspectives in the discussion:1) “Peruvian providers’ perspectives of mistreatment during institutional births is unknown, but studies in other countries suggest that providers are aware of verbally and physically abusing women themselves and observing their peers doing the same [31]. Some of the drivers of mistreatment and abuse are perceiving women as being difficult, lack of accountability, and stress [31]”. 2) “The evidence in Nepal suggests that other barriers to skilled birth care include the limited availability of skilled birth attendants and lack of community awareness regarding the importance of birthing services [27]”.- Are there any illustrative quotes demonstrating mistrust or perceived low quality of care by women toward health center staff? This is a key point in the discussion (lines 418-426) yet the data presented in the results does not sufficiently support this.We addressed mistreatment in the first subsection of the results, "Safety and Support v. Mistreatment and Restrictions". There we included first and second-handed stories of mistreatment. We included an additional quote and a new paragraph explaining other sources of mistrust. We also changed the name of the subsection to "Safety and Support v. Mistreatment and Inadequate Care". Your comment helped us realize that Inadequate Care is a more adequate description for the data we discussed there. - Regarding the section on bravery, do the authors have recommendations on how to leverage this information to promote institutional births? What is it about home births that signifies bravery and would it be possible to recreate this within a healthcare setting? This may be beyond the scope of this paper.We added some recommendations: “Our study not only reinforces these findings but also shows how the association between home birth and bravery can be a barrier to institutional birth. However, the few people we found who also consider women having institutional births to be brave, suggests a potential cultural change that could lead to more institutional births. To reinforce this cultural change and given what we know about the link between home birth and bravery and the perception of the health center as a place where women are powerless (i.e. subjects of mistreatment and unconsented procedures), we suggest that interventions should emphasize that institutional births are for all women, not just those experiencing complications, and that women can decide their childbirth positions during institutional births. We also recommend allowing more companions than the one that is currently permitted during institutional births”.- Are there any studies related to partner influence on birth decisions that can be referenced to further support the authors’ discussion of partner decision-making and gendered factors?We added information from a systematic and a literature review. “In Saker and colleagues’ study [25], the decision to have a home birth was made by the men and elderly members of the family. A systematic review of access barriers to obstetric care at health facilities and a literature review of determinants of institutional births show that women’s decisions are heavily influenced by their partners’ preferences . According to these studies, women need their husbands’ or relatives’ permission to have an institutional birth, and they may lack control over the material resources necessary to afford or access one ”.- In making recommendations for clean home birth practices, authors should acknowledge the importance of structural factors such as access to water and sanitation as necessary resources for implementation of hygienic birth practices.Thank you for noting that. We included it in the discussion: “Our study shows that hygienic birth practices  are common in the community, but structural factors such as access to water and sanitation are necessary to ensure their effectiveness”.- Lines 416-417: Can you cite evidence to support this claim?Although this was stated in one of our references , we decided to eliminate this sentence. We consider that an ethnographic work such as the one by Anderson cannot determine an association between feeling ashamed and maternal death. It is possible that people avoid giving birth in the health center because of those feelings but having birth a home does not necessarily lead to maternal death. Instead, we discussed how home births can be safe for the newborn and the mother if they are clean.- Line 442: The authors describe the role of the godmother as a “barrier for institutional birth.” Is this cultural practice a barrier in itself or, is the barrier the health center’s reluctance to integrate cultural practices into their delivery services? I recommend reconsidering the language used in this sentence.Thank you for pointing this out. We edited the language: “It also contributes to it by showing that not integrating the role of the godparents into birthing services can be a barrier to institutional birth”.- Line 499: Do you mean primary care services? Or obstetric services?Obstetric services.Reviewer 2:- Consider discussing how the impact of your efforts could be extended by future research that included health care officials' responses to these and related study findings.This was great advice, thank you. We included recommendations in the discussion sections. These are some of those:1) “Moreover, the implementation of the protocol is limited [15]. In our complementary formative research for the Mamas del Rio program, we found that none of the 10 health facilities serving Kukama-Kukamiria people had the 13 supplies  required to adapt their services to accommodate the standing birth protocol. Five of those facilities had only two supplies and the other five had none. Since the lack of implementation of such protocols is a barrier to institutional births, a nationwide evaluation of protocol implementation should be conducted. We recommend that the supplies be distributed to every health center, prioritizing those that primarily serve indigenous people, and that communities be informed about the cultural adaptation of birthing services”. 2) “We recommend increasing the number of companions to at least four people so that the partner, the mother, a childbirth attendant, and a godparent can be present. The cultural adaptation of birthing services should also integrate the role of the godparent in cutting the umbilical cord. The mechanisms to report and hold health providers accountable for mistreatment should also be improved and including community health workers in this process is key”.AttachmentResponse to Reviewers.docxSubmitted filename: Click here for additional data file. 13 Apr 2021Home birth preference, childbirth, and newborn care practices in rural Peruvian AmazonPONE-D-20-27331R1Dear Dr. Del Mastro Naccarato,We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.Within one week, you’ll receive an e-mail detailing the required amendments. 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I recommend this article for publication and believe it will make a significant contribution to the field of research on home births among indigenous populations in Latin America.Reviewer #2: I am just filling this in because the system will not allow me to submit my review unless I meet a minimum number of characters to submit it -- I am not sure what the problem is.**********what does this mean?). If published, this will include your full peer review and any attached files.7. PLOS authors have the option to publish the peer review history of their article (If you choose “no”, your identity will remain anonymous but your review may still be made public.Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.Reviewer #1: NoYes: Elizabeth SolidayReviewer #2:  21 Apr 2021PONE-D-20-27331R1 Home birth preference, childbirth, and newborn care practices in rural Peruvian Amazon Dear Dr. Del Mastro N.:I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. onepress@plos.org.If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact plosone@plos.org. If we can help with anything else, please email us at Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staffon behalf ofProfessor Tanya Doherty Academic EditorPLOS ONE