Assisted vaginal birth is a vital health intervention that can result in better outcomes for mothers and their babies when complications arise in the second stage of labour. Unfortunately, instruments for assisted vaginal birth (forceps and ventouse) are often not utilised in settings where there is most clinical need, resulting in maternal and neonatal morbidity and mortality which could have been prevented. The BD Odon Device is a new device for assisted vaginal birth that may be able to address this unmet need. However, before dissemination, the device requires evaluation in robust clinical trials. A feasibility study to investigate the clinical impact, safety, and acceptability of the BD Odon Device for assisted vaginal birth is therefore planned. This will provide further information on acceptability, recruitment, and the outcome data required to design a future randomised controlled trial of the BD Odon Device versus Kiwi ventouse.Forty women who require an assisted vaginal birth for a recognised clinical indication will have the birth assisted with the BD Odon Device. The primary outcome is successful vaginal birth completed with the BD Odon Device. Secondary clinical outcomes include maternal and neonatal outcomes, and maternal and practitioner satisfaction. Safety data will be reviewed following every birth.A future randomised controlled trial of the BD Odon Device versus the current standard instrument (the Kiwi ventouse) is planned. The findings of the ASSIST Study will inform the randomised controlled trial design.ISRCTN10203171. Prospectively registered on 27 July 2018.ISRCTN, The online version of this article (10.1186/s13063-019-3249-z) contains supplementary material, which is available to authorized users. Complications of the second stage of labour  remain a major cause of maternal and neonatal mortality and morbidity across the world. Such complications are responsible for 4% to 13% of maternal deaths in Africa, Asia, Latin America, and the Caribbean . This buIn addition to widespread low levels of utilisation, earlier surveys report significant regions where AVB was not used at all—in 2006 this was the case in 74% of Latin American and Caribbean countries, as well as 30% of countries in sub-Saharan Africa and 40% of countries in Asia –7, the mForceps are less likely to fail in achieving an AVB when compared to a ventouse; however, they are associated with increased maternal perineal and vaginal trauma. The ventouse is less likely to achieve a vaginal birth and its use is associated with an increased risk of neonatal cephalohaematoma and retinal haemorrhage . Both deThe BD Odon Device is a new device for AVB Fig. . The useThis feasibility study will investigate the clinical impact, safety, and acceptability of the BD Odon Device and assess the feasibility of recruiting women and data collection. It will provide vital information on acceptability, recruitment, and the outcome data required to design a future RCT of the BD Odon Device versus the Kiwi ventouse.The ASSIST Study  is a non-randomised feasibility study of 40 women who require an assisted vaginal birth for a recognised clinical indication and who will all have their birth assisted with the BD Odon Device. A CONSORT diagram of the feasibility study is shown in Fig. The ASSIST feasibility study will utilise only one of the devices intended for use in the eventual randomised controlled study (BD Odon Device). This is to establish the safety, acceptability, and efficacy of the BD Odon Device prior to moving to a full RCT. The intended comparator (the Kiwi ventouse) will not be evaluated in this study since published evidence on its acceptability and success rate at the intended primary site already exists .Participants will be pregnant women aiming for a vaginal birth who plan to give birth at North Bristol NHS Trust (NBT), Bristol, UK. Recruitment is projected to continue for 8 months (due to the AVB rate within the department) after which time it is estimated that 40 sets of primary outcome data will have been recorded.Prospective participants will receive information on the study in early pregnancy (12 to 28 weeks) via the NBT Maternity ‘App’  and paper information leaflets given to women at any hospital admission. Members of the study team will then approach women after 28 completed weeks of pregnancy during antenatal appointments or antenatal admissions to discuss the study and offer women the opportunity to watch a video explaining the study. Women who are willing to take part (should they require an AVB) will then be invited to provide informed written consent. Figure When a woman who has previously consented to participate in the study arrives on the labour ward, her eligibility to participate in the study will be re-checked by a midwife and obstetrician that have been trained in Good Clinical Practice (GCP), and verbal re-confirmation of her consent to take part in the study will be sought by a GCP-trained midwife or obstetrician. Case report forms can be found in Additional file Women will be able to participate in the ASSIST Study if all of the following apply at initial consent: the woman is ≥18 years of age; the woman has a singleton pregnancy of at least 36 weeks gestation; there is a negative antenatal screen for HIV and hepatitis B; the woman is in labour and requires an assisted vaginal birth for a clinical indication  Greentop Guideline 26 [Women will not be able to take part in the ASSIST Study if: there is a diagnosis of a fetal skull abnormality precluding AVB ; there is a known osteogenesis imperfecta affected pregnancy; there is suspicion of a fetal bleeding disorder , haemophilia); there is an intrauterine fetal death in the current pregnancy; the woman is sensitive to latex; the woman is currently serving a prison sentence; or the indication for AVB is a fetal bradycardia which is present, ongoing, and has not recovered.If the obstetrician attending an eligible woman during the second stage of labour, and who has previously provided informed written consent to take part in the study, determines that an AVB is indicated, they will explain this to the woman as per standard practice. If the woman agrees to an AVB, an accoucheur who has had specific training in using the BD Odon Device ;Third- or fourth-degree tear;Cervical tear requiring suturing;Requirement for general anaesthesia;Shoulder dystocia;Use of emergency caesarean section to achieve birth;Maternal death.The maternal safety outcomes are:Apgar score <7 at 5 min;Pressure necrosis of fat or skin;Neonatal soft tissue trauma ;Neonatal vascular injury ;Neonatal skeletal injury (bone fracture);Neonatal intracranial injury ;Neonatal neurological injury still present at 28 days after birth;Neonatal seizure;Phototherapy for jaundice contributed to by bruising;Death within 28 days after birth.The neonatal safety outcomes are:Failure of a component of the BD Odon Device;Number of applications of device;Number of pulls with the BD Odon Device.The device safety outcomes are:Failure to achieve a vaginal birth with the assistance of the BD Odon Device and mode of birth thereafter;Method of infant feeding ;Time from ‘decision to perform assisted birth’ to ‘birth’ (minutes);Time from ‘device application’ to ‘birth’ (minutes);Time to achieve regular respirations (minutes);Episiotomy and perineal trauma;Umbilical arterial and venous pH and base excess;Other neonatal injury;Neonatal pain  at 2 and 6 h after birth);Time spent in neonatal intensive care unit (hours);Anaemia requiring transfusion;Neonatal encephalopathy requiring therapeutic hypothermia within 28 days after birth;Organ failure within 28 days after birth;Failure to establish a normal feeding pattern, defined as ≤1 feed at 10 h of age.The clinical secondary outcomes are:Maternal health-related quality of life data ;Maternal satisfaction with birth experiences ;Maternal perception of pain ;Health service utilisation will be collected ;Maternal continence at 90 days.The women-reported secondary outcomes are:Willingness to use the BD Odon Device;Perceived overall ease of use of device;Ease of device set-up;Ease of device application to the baby’s head;Ease of withdrawal of the applicator after application;Comfort with the level of force required to assist the birth of the baby;Ease of deflation of the air chamber prior to crowning.The practitioner-reported secondary outcomes are:A comprehensive assessment of the safety of the BD Odon Device will be undertaken following every attempted birth within the ASSIST Study. Outcome measures and data collected will ensure capture of any potential adverse events associated with the BD Odon Device at the time of birth by the operator and/or a member of the research team  panels have reviewed the proposed study design, patient-facing documentation , and have supported both the general and specific aims of the study. The Trial Steering Committee (TSC) of the ASSIST Study includes a lay patient representative.A complete sample size of 40 women will enable the estimation of the rate of successful assisted vaginal birth of 80% to within a 95% confidence interval of ±12%. The sample size will also demonstrate AVB requiring use of a secondary instrument of 50% to within a 95% confidence interval of ±15%.The primary, secondary, and safety data will be reported as the frequency and proportion, mean (and standard deviation), or median (and interquartile range) depending on their nature and distribution. The overall rate of successful AVB birth will be reported and the frequency of unsuccessful births will be reported by the six criteria defined for success. Appropriate outcomes will be presented and broken down into subgroups by operator experience (>10 years or <10 years), indication for assisted vaginal birth , participant analgesia , fetal station (0 and +1 cm to spines or +2 and +3 cm to spines), and fetal position (OA or OT or OP). The overall number of safety events will be reported, as well as the number of events by the main reason for adverse events. Events related to device failure and/or mis-use of the device will also be described.The recruitment and process outcomes will be reported as frequencies and percentages. Completion rates of the clinical outcomes will also be reported. Reasons for ineligibility, refusal, loss to follow-up, or missing data will be categorised and described as frequencies.Data on numbers screened, those identified as eligible and approached, those consenting to participate both in advance of labour and again during labour where applicable, those included in follow-up and those providing questionnaire and outcome data and successful birth rates will all inform the sample size calculation of the main trial. During the trial, there will be a continuous review of mother and baby safety from the Sponsor and TMG, and a decision will be made as to whether to continue, revise, or stop the trial.Women and their babies will be followed up at 1 day, 7 days, 28 days, and 90 days following the birth. A woman and her baby will be deemed to complete their participation in the study at 90 days after the birth.Alongside the primary clinical study, an integrated qualitative study (IQS) within the feasibility study will be undertaken. This will investigate: the practitioners’ use of the device to ensure that an appropriate training package is developed for the trial; enable the intervention to be described and refined to optimise its use; and to investigate the woman’s, obstetrician’s, midwife’s, and neonatologist’s perspective of the birth and what they consider to be characteristics of a ‘good birth’. This will enable the research team to incorporate these findings into any subsequent RCT, as well as iteratively altering the ASSIST Study plan if required.The qualitative study will combine observational and interview data collection and analysis. AVBs involving successful or attempted use of the BD Odon device will be observed wherever possible. Successful or attempted births will be followed up with interviews with obstetricians, midwives, and women to triangulate their experiences and views with what has been observed.A TMG consisting of all investigators and co-investigators will be responsible for the day-to-day running of the study.The study will be overseen by two committees, the Independent Data Monitoring Committee (IDMC) and the Trial Steering Committee (TSC). The IDMC will sit after 20 and 40 births have been completed and will have no direct involvement in the running of the trial. Following both reviews, the IDMC will generate a report on the performance of the device and the safety of participants. These reports will be reviewed by the TSC and the Sponsor. The TSC will consist of an independent clinical expert, statistician, and a lay representative, together with the investigators and representative. The TSC will review all reports produced by the IDMC and make a recommendation to the Sponsor following every review to continue, modify, or halt the study. The TSC will provide oversight of the progress of the study and ensure the study is conducted according to the principles of GCP. Auditing will take place when requested by the Sponsor.Study results will be published within 1 year of completion of data collection in an appropriate peer-reviewed, open-access journal. The results will be presented at local, national, and international meetings. Summaries will also be distributed using existing parent networks. A summary of results will also be sent to all women who participated in the study, unless they express their wish not to receive such information. Results will be communicated to a lay audience by social media activities of North Bristol NHS Trust, the University of Bristol, and the research team.An appropriately conducted AVB, performed when clinically indicated, is associated with improved maternal and neonatal outcomes when compared with caesarean section in the second stage of labour or compared with no action . AVB is The BD Odon Device is the first new device for AVB since the introduction of ventouse into clinical practice in the 1950s . ExtensiIf found safe by the TSC, IDMC, and Sponsor, findings from this feasibility study will inform the design of a randomised controlled trial that may produce evidence that supports the introduction into clinical practice of a new device for AVB. If this were able to address the unmet need for AVB around the world it would have a major impact on the management of complications in the second stage of labour and maternal and neonatal outcomes worldwide.The ASSIST Study is scheduled to commence on 8 October 2018, using version 16.10. The study will cease after 40 complete sets of primary outcome data are received. This is projected to be in May 2019.Additional file 1:Case report forms. Copies of the case report forms for the ASSIST Study. (ZIP 830 kb)Additional file 2:Operator training for the ASSIST Study. Details of the training programme operators received prior to study start. (DOCX 73 kb)Additional file 3:Schedule of review of data collected in the ASSIST Study. Details of the Sponsor/TSC/IDMC reviews. (DOCX 96 kb)Additional file 4:Grant agreement. Summary agreement and signature page from funder. (PDF 147 kb)Additional file 5:SPIRIT 2013 checklist: recommended items to address in a clinical trial protocol and related documents. (DOC 120 kb)Additional file 6:Ethics Committee Approval for the ASSIST Study format. Letter from the South Central Berkshire Ethics Committee. (PDF 372 kb)


Maternal and cord blood were collected immediately after birth. Levels of micronutrients and heavy metals were quantified. Pregnancy outcomes (gestation age (GA), birth weight (BW), and chest and head circumference) were also measured. Mean (± standard deviation (SD)) age of mothers in kerosene and LNG groups were similar (p = 0.734). Mean (±SD) BW of newborns of LNG users was significantly higher compared to newborns of kerosene users . Mean GA (in weeks) was similar between the two groups (p = 0.532). Women in the kerosene group had significantly higher cord blood levels of zinc, lead, mercury, iodine and vitamin B6 and lower levels of folic acid compared to LNG users (p < 0.05). Newborns of kerosene users had reduced levels of zinc, lead, mercury, iodine, vitamins B6 and B12, folic acid, and homocysteine compared with LNG users (p < 0.05). Also, cooking with kerosene was significantly associated with reduced birth weight after adjusting for potential confounders (β ± standard error (SE) = −0.326 ± 0.155; p = 0.040). Smoke from kerosene stove was associated with reduced birth weight and micronutrients imbalance in mothers and newborns.Cooking with kerosene emits toxic pollutants that may impact pregnancy outcomes. Sixty-eight women in their first trimester of pregnancy, kerosene users ( Kerosene remains one of the most widely used domestic cooking energy in low- and middle-income countries (LMICs) of Africa, Asia, and Latin America . It is eExposure to high concentrations of heavy metals such as lead and cadmium during pregnancy increases the likelihood of miscarriages, premature deliveries, low birth weight (LBW), and impaired cognition in growing children . AlthougWe investigated the relationships between HAP from kerosene and pregnancy outcomes as well as micronutrient levels in cord blood of mothers and newborns. We hypothesized that exposure to HAP from kerosene will negatively affect pregnancy outcomes as well as micronutrient levels in mothers and newborns.This is a cross-sectional study where 68 pregnant women (30.2 ± 5.6 years of age) were recruited from three health centers  in Ibadan, Nigeria between May and December 2015 . The EthQuestionnaires were administered at study entry to obtain socio-economic and demographic information. One hundred and fifty-one consecutive pregnant women who cooked with either kerosene, LNG, wood, electricity or a combination of these cooking fuel for the past 10 years were recruited at first presentation to the health center (during first trimester of pregnancy). Among these women, 42 cooked primarily with kerosene; 26 cooked with LNG; 3 cooked with electricity; 3 cooked with firewood; 30 cooked with a combination of kerosene and LNG; 14 cooked with a combination of electricity and LNG; 11 cooked with combination of kerosene, electricity, and LNG; and 5 cooked with combination of kerosene and electricity. Forty-two women who cooked, primarily, with kerosene and 26 who cooked, primarily, with LNG for the past 10 years were considered for this study. The LNG group was used as the reference group for comparability of outcomes. As part of the socio-economic and demographic information, additional variables obtained at study entry included dietary patterns that could impair micronutrient status and nutritional supplements. Exclusion criteria for participation in the study included high-risk pregnancy, poorly controlled hypertension, diabetes mellitus and human immunodeficiency virus (HIV) infection.All newborns were weighed at birth with an electronic digital scale. The gestational ages of all live births (in weeks) were also estimated within hours of delivery as well as head circumference, crown-to-heel length, chest circumference and placenta weight.Venous blood (10 mL) samples were obtained from the ante-cubital vein of the participating mothers immediately after delivery. Blood samples from the newborns’ umbilical cords were also obtained at birth into vacutainer tubes that did not contain anticoagulant. Samples were allowed to clot, retract, and were spun at 4000 rpm for 5 min using the MSE Table Centrifuge . The sera were collected and stored in sterile cryoprecipitate tubes at −20 °C until analysis was performed.Analyses for zinc, lead and mercury were performed using atomic absorption spectrophotometry. For the analyses of trace metals, serum and standards were appropriately diluted with deionized water. The serum was deproteinized, spun, and supernatant was obtained. This was aspirated into an atomic absorption spectrophotometer (AAS)  for the analysis of trace metals based on the principle that when atoms in the aspirated vapor are excited, they return to ground state by emitting light of the same wavelength. The amount of light absorbed by the metal is proportional to its concentration, which is determined by specific wavelength in the AAS .Vitamins B6 and B12, folic acid, and homocysteine levels were determined using enzyme-linked immunosorbent assay (ELISA) method as previously described . The ELIAll field and laboratory personnel were blinded to the exposure status of the women to minimize bias in the measurements of pregnancy outcomes and levels of maternal and fetal cord blood micronutrients.t-test. Pearson’s correlation coefficients (r) were used to determine correlations between parameters in maternal and cord blood sera with pregnancy outcome measures like birth weight (BW), placenta weight (PW), crown-to-heel length (C2H), head circumference (HC), chest circumference (CC), and gestational age (GA). Linear regression analysis was performed to assess the relationship between micronutrients and heavy metals and birth weight. Multivariate linear regression analysis was used to examine association between HAP from kerosene and birth weight while adjusting for potential confounders. The variables were included in the final model based on statistical significance, clinical/biological importance, and potential confounding. The Hosmer–Lemeshow test was used to assess model goodness-of-fit. The strength of the associations were assessed using β coefficients with standard error. Statistical significance was assigned at p < 0.05.Data analysis was performed using SPSS version 17 Statistical package . Results were expressed as mean ± standard deviation (SD). Mean serum levels of the micronutrients and vitamins were compared using Student’s p < 0.05).p = 0.082).Gestational age (GA), head circumference, chest circumference, chest-to-head length of newborns was similar and not statistically different between kerosene and LNG users . Placentp < 0.001; The mean birth weight of newborns of kerosene-using mothers was significantly lower compared to the birth weight of newborns of LNG-using mothers  and heavy metals (lead and mercury) are presented in We also examined associations between maternal blood micronutrients and heavy metals levels and birth weight in the two cooking fuel groups . Overallβ ± standard error (SE) = −0.326 ± 0.155; p = 0.040). The reduced birth weight of newborns was also evident when micronutrients and heavy metals in cord blood were included in a separate model adjusting for socio-economic characteristics, mother’s age, and multivitamins consumption during pregnancy .To confirm that the observed significant difference in birth weight between groups was not explained by socio-economic characteristics that were statistically significant between fuel groups  and differences in the levels of maternal micronutrients and heavy metals , we performed multiple linear regression analysis adjusting for these variables in addition to mother’s age and multivitamin consumption during pregnancy. The association remained consistent with newborns of kerosene-using mothers having significantly reduced birth weight  . Zinc, fLead and mercury are cumulative toxicants that are particularly harmful to young children. Childhood lead exposure is estimated to contribute to about 600,000 new cases of intellectual disabilities in children every year and no known level of lead exposure is considered safe . We posiThe limitation of the study is the low sample size. Due to some cultural beliefs and religion preferences, it was difficult to convince participants to deliver their babies at health care facilities. However, since we observed statistical significance in pregnancy outcomes and many of the micronutrients, we feel that the sample size was adequate to assess our hypothesized effects. In Nigeria, there is no free or subsidized healthcare policy, which may suggest that only participants with moderate to high socio-economic status participated in the study. Therefore, the results of the study may be generalized to pregnant women attending healthcare centers during pregnancy in the study area. We suggest that caution be observed when comparing the results of this study to other studies that might have recruited pregnant women from both government-established healthcare centers and local traditional delivery centers. The two fuel groups in this study were distinct. LNG users were women that used primarily LNG for cooking. Similarly, kerosene users were women that used primarily kerosene for cooking. While we ensured the two fuel groups used kerosene and LNG predominantly, the women might have used other additional cooking methods or were exposed to other cooking fuel types during the study period due to communal lifestyles that are typical of women in this setting. Finally, we did not determine whether the women in this study cooked by themselves and how long they stayed in the kitchen cooking during the follow-up period. This would have enabled us to determine the degree of exposure during the pregnancy period. However, with the cultural etiquette in Nigeria, and similar African countries, where women are responsible for domestic cooking, we are confident that the majority of women in this study participated in cooking during the follow-up period. Also, our previous study in the settings where the current study was performed showed that 61% of women cooked approximately 3–5 h, on average, per day .The strength of the study is the objective measures used in all outcomes assessed which limits or greatly minimized the misclassification of outcomes. Also, we limited participants to pregnant women using kerosene or LNG predominantly for 10 years. While this might have reduced the number of participants and limited our sample size, it helped to minimize exposure misclassification and cross effects of firewood smoke exposure, which has been reported to be associated with adverse pregnancy outcomes .The study showed that pregnant women who cook with kerosene experienced more adverse pregnancy outcomes with their infants weighing less compared to mothers using LNG for cooking. We also observed micronutrient imbalance in mothers and newborns exposed to HAP from kerosene. The results of the study underscore the need to improve nutrition during pregnancy and to strengthen and formulate policies to replace kerosene as cooking and household fuel with much cleaner fuels like LNG and ethanol.


The place of birth has been rapidly changing from home to health facility in Lao People’s Democratic Republic (Lao PDR) following the strategy to improve the maternal and neonatal mortality. This change in the place of birth might affect the mother’s satisfaction with childbirth. The objective of this study was to assess whether the place of birth is related to the mother’s satisfaction with childbirth in a rural district of the Lao PDR.A community-based survey was implemented in 21 randomly selected hamlets in Xepon district, Savannakhet province, between February and March, 2016. Questionnaire-based interviews were conducted with mothers who experienced a normal vaginal birth in the past 2 years. Satisfaction with childbirth was measured by the Satisfaction with Childbirth Experience Questionnaire. Using the median, the outcome variable was dichotomized into “high satisfaction group” and “low satisfaction group”. Logistic regression was performed to assess the association between place of birth and satisfaction with childbirth. Three models were examined: In Model 1, only the predictor of interest  was included. In Model 2, the predictor of interest and the obstetrical predictors were included. In Model 3, in addition to these predictors, socio-demographic and economic predictors were included. A mixed-effects model was used to account for the hierarchical structure.Among the 226 mothers who were included in data analysis, 60.2% gave birth at the health facility and the remaining 39.8% gave birth at home. Logistic regression analysis showed that the mothers who gave birth at the health facility were significantly more likely to have a higher level of satisfaction compared to the mothers who gave birth at home . This association remained even after adjusting for other predictors .Facility-based birth was significantly associated with a higher level of satisfaction with childbirth among the mothers in the study district where maternal and neonatal mortalities are relatively high. The findings of the present study support the promotion of facility-based birth in a rural district of the Lao PDR. Satisfaction with childbirth has a powerful effect on the mother’s health and her baby’s well-being. High satisfaction with childbirth can enhance the mother’s relationship with their babies , and canBased on Subjective Well-being Theory, satisfaction with childbirth is conceptualized as a cognitive evaluation of whether the birth experience matches the mother’s personal preferences , 10. ParWhile home-based birth is still common among rural areas in developing countries –15, faciThe place of birth is an important component for childbirth because it is deeply related to the physical, emotional, cultural, and social aspects of childbirth . TherefoPrevious studies conducted in Lao PDR investigated mother’s satisfaction with delivery care and satisfaction with services provided to women who gave birth at a health facility , 25. TheStudies comparing the satisfaction with childbirth in terms of place of birth are rare, particularly in developing countries. Therefore, this study aims to assess whether the place of birth is related to the mother’s satisfaction with childbirth in a rural district of the Lao PDR.We conducted a cross-sectional study in Xepon district, Savannakhet province. Xepon district is a rural district that is located along the Vietnamese border, approximately 500 km from the Vientiane capital. According to the Xepon district health office, 75% of the residents belong to ethnic minorities, such as Tri and Makong ethnic groups. The present study selected Xepon district as a poor and rural district of Lao PDR . MoreoveXepon district has one district hospital and 14 health centers; all are public healthcare facilities. Xepon district includes 235 hamlets  according to the classification of the Xepon district health office. The district hospital covers 37 hamlets, and each health center covers between 6 and 43 hamlets.The present study used a stratified cluster sampling to select the study participants. First, the public healthcare facilities in Xepon district were stratified into three strata: Stratum I, which is represented by the district hospital; Stratum II, which is consist of a total of five health centers located along the main road; and Stratum III, which is composed of a total of nine health centers that are not along the main road Fig. . Second,In each hamlet, surveyors continued to recruit mothers until the target number of participating mothers  had been reached. In one hamlet where the number of the eligible mothers who gathered did not reach the target number, the surveyors met the target number by inviting eligible mothers from a neighboring hamlet. Ultimately, 253 mothers participated in the study. We excluded six mothers based on the exclusion criteria . We excluded 18 mothers with missing information in the questionnaire. Three mothers who referred from home to hospital during birth were excluded because the transfer to facility during labour was likely to confound results relating to maternal satisfaction with childbirth . This reA public health research expert (KP) trained the surveyors on the ethical issues and data collection method for 2 days. The surveyors, who were health workers from the Xepon district health office and the Savannakhet provincial health office, collected data between February and March 2016. They conducted interviews with study participants in the selected hamlets, using a semi-structured questionnaire. A day prior to the scheduled visit to the selected hamlets, the surveyors requested eligible and willing mothers through the health volunteers of the hamlets to gather at a designated place of the hamlet to participate in the study. The surveyors then visited the hamlets and interviewed the mothers who were gathered. When the surveyors had difficulty in communicating with participating mothers in the Lao language, they asked the health volunteers of the hamlet to translate the Lao language into the ethnic language.The satisfaction with childbirth of mothers was measured using the seven question items obtained from the Satisfaction with Childbirth Experience Questionnaire (SWCh) . SWCh isTo validate the SWCh for use in a rural Lao setting, a native Lao speaker who is engaged in public health research did the forward translation while a native English speaker who is an expert in maternal and child health and understands the Lao language, conducted the back translation. The research team compared the original and the back-translated English versions to ensure that semantic equivalence has been maintained and that words are appropriate for rural mothers. The questionnaire translated to ethnic language involving SWCh was not prepared for this study because the ethnic groups of the study participants do not have written language system . The resAs a result of excluding the two items, the present study used the following five items: 1) In most ways, my childbirth experience was close to my ideal; (2) The conditions of my childbirth experience were excellent; (3) If I could do it over, I would change some things about my childbirth experience; (4) I am satisfied with the experience of my baby’s birth; (5) I got what I wanted out of my childbirth experience. The following two items were excluded during the analysis; My baby’s birth did not go the way I wanted it to go; If I could do it over, I would change almost nothing about my childbirth experience. In the five-item scale, the total score ranged from 5 to 35. The factor loadings of each item were above 0.5  and house types . By the wealth index, households were ranked and divided into quartiles.Based on previous studies which examined the predictors of childbirth satisfaction , 32–34, Frequencies and medians with interquartile ranges were computed to summarize the data. The outcome variable was measured continuously. However, the present study did not use linear regression for multivariate analysis because the data did not meet the assumption for using linear regression: the residuals were not normally distributed. Therefore, the outcome variable was dichotomized into “high satisfaction group” (28 points or above) and “low satisfaction group” (fewer than 28 points), using the median (28 points) for logistic regression. Bivariate analyses were performed to assess the association between the outcome variable and each of the predictor variables using Fisher’s exact test.Multi-level modeling was used to account for the hierarchical structure of the data: mothers (at level 1) are nested within hamlets (at level 2), and the hamlets are nested within health center catchment areas (at level 3). Thus, a three-level, mixed-effects logistic regression model was used for the multivariate analysis. Three models were examined: In Model 1, only the predictor of interest  was included. In Model 2, the predictor of interest and the obstetrical predictors were included. In Model 3, in addition to these predictors, socio-demographic and economic predictors were included. Stata 14.1 was used for performing the mixed-effects logistic regression analysis. Significance level was set at < 0.05 for all tests.Additional analysis was performed to confirm if the association between place of birth and satisfaction with childbirth would change after adding two items that had been excluded in the present study analysis.Tok Tok (two-wheel-tractor with trailer).Nearly three-quarters (73.0%) were aged between 20 and 34 years old, with a median age of 25 year old  of the participants were multiparas Table . More thNo socio-demographic and economic characteristics were significantly associated with satisfaction with childbirth Table .Table 4p < 0.001). Being the decision maker of the birth place was significantly associated with satisfaction with childbirth (p < 0.001). Receiving antenatal care was significantly associated with satisfaction with childbirth (p = 0.035). The participants who did not have pregnancy complications were significantly more likely to have a higher level of satisfaction with childbirth compared to the participants who had pregnancy complications (p = 0.026).The participants who gave birth at a health facility were significantly more likely to have a higher level of satisfaction with childbirth Table  comparedLogistic regression analysis showed that mothers who gave birth at a health facility were significantly more likely to have a higher level of satisfaction compared to the mothers who gave birth at home  in Model 1 Table . In ModeThe additional analysis using SWCh’s seven original items also showed that mothers who gave birth at a health facility were significantly more likely to have higher level of satisfaction compared to the mothers who gave birth at home    and remaOne possible reason for the higher satisfaction among women who gave birth at a health facility is their exposure to delivery-related policy and programs, such as ‘Free Maternal Health Service Policy’  and ‘SkiOur main finding concurs with several studies conducted in Lao PDR and other developing countries. Two studies conducted in Xiengkhuang province and Oudomxay province described that more than 80% of mothers who gave birth at the hospital were generally satisfied with the maternity health care, especially with the attitude of the medical staffs and medical service of the facilities , 25. OthThe low satisfaction of mothers who gave birth at home in the current study might have been influenced by the lack of assistance provided by skilled birth attendants. In the present study, no mothers who gave birth at home were attended by skilled birth attendants, and only 1.8% of them were supported by traditional birth attendants. Many of them were supported by a husband or family members. Skilled birth attendants give appropriate advice, guidance, and support during pregnancy, childbirth, and postnatal period . AssistaThe main findings of the present study are not consistent with the primary findings of similar studies conducted in developed countries. Those studies described that mothers who gave birth at home were more satisfied than the mothers who gave birth at the hospital, and reported that less intervention and having close contact with the baby contributed to increasing the childbirth satisfaction , 46, 47.In the present study, other factors that were positively related to satisfaction with childbirth were: 1) absence of pregnancy complication, and 2) family members’ decisions on birth place. However, the present study could not identify the association because this study did not adjust for these confounding variables. To enhance the mother’s satisfaction with childbirth in developing countries, future studies are recommended to explore the factors that are associated with the satisfaction with childbirth in consideration of high maternal and infant mortality and morbidity.The utility rates of maternal healthcare services found in the present study were similar to those reported in the Lao Social Indicator Survey conducted between 2016 and 2017 . For exaTo the best of our knowledge, the present study is the first to quantitatively study the association between place of delivery and satisfaction with childbirth in Lao PDR or any other Southeast Asian country. Previous studies in Lao PDR have explored the satisfaction with maternal care services in health facilities. This study is original in that it includes hypothesis-based analysis, including not only the mothers who gave birth at a health facility but also the mothers who gave birth at home. The Lao Government’s strategy of promoting facility-based birth might have contributed to the mother’s health and her baby’s well-being, as well as safe birth. The results of this study support the strategy of promoting facility-based birth in Lao PDR.Our study has some limitations. First, the study included mothers who arrived first in the meeting place of their hamlet. This group of mothers might have more interest in healthcare compared to mothers who arrived late. This possible selection bias might have contributed to higher satisfaction among mothers who gave birth at a health facility. Second, the present study used the five-item scale that has not been used in previous studies. The researcher had to eliminate the two items from the original, seven-item SWCh in order to keep the original single factor model and to increase the reliability of the Cronbach’s alpha. However, the five-item scale used in the present study ensured construct validity; the main findings are unlikely to change even if the original seven-item scale had been used in the present study. Third, while the present study found significant association between the place of birth and satisfaction with childbirth, due to the cross-sectional nature of the study, this association does not necessarily mean causation. The fourth limitation is that the present study did not measure the satisfaction of maternal care. Therefore, the present study could not discuss the quality of maternal care provided by health facilities in Lao PDR. To promote facility-based birth and enhance the satisfaction with childbirth, future studies will be needed to evaluate the quality of maternal care and supply-side readiness of facility-based birth , 48, 49.The facility-based birth was significantly associated with a higher level of satisfaction with childbirth among mothers in the study district where maternal and neonatal mortalities are relatively high. There is a possibility that women living in a rural district of Savannakhet province can improve their satisfaction with childbirth if they change the place of birth from home to a facility. The results of the present study support the strategy of promoting facility-based birth in Lao PDR.


A high rate of preterm birth is observed in the Guadeloupe archipelago (French West Indies), raising the hypothesis of harmful environmental exposures, including landfilling. Our aim was to evaluate whether preterm births cluster around the three main open landfills located in this area.The study population consisted of 911 women enrolled in the Timoun mother-child cohort (2004–2007). Home addresses during pregnancy and locations of landfills were geocoded. To test for the presence of preterm birth clusters around each dumpsite, we used a focused cluster test specifically designed to detect spatial clustering around point sources.n = 767) as controls, a significant cluster was identified within 2 km around the Saint-François landfill with a relative risk (RR) of 4.82 (p = 0.04). No clusters were found around the other two landfills .A total of 144 (15.8%) preterm births were observed among 911 births. Using the term births (The paucity of data available on open landfill sites regarding waste quantities, composition, and changes over time precludes any site-specific interpretation because of the variable degree of possible emissions. This result has to be confirmed in other tropical island environments where waste management has become a major concern with the potential to negatively impact the environment and public health. A high rate of preterm birth is observed in the Guadeloupe archipelago (part of the French West Indies): 15.8% 2005–2008) versus 5.5% in mainland France (2010) [005–2008 Waste management has always been a crucial issue in island environments due to limited land space and increased volumes and diversity of solid waste . In this context, landfilling is the major (if not the only) option for waste management. However, landfills can represent a health risk for residents because of exposure to pollutants through different pathways: inhalation of substances emitted by the site, contact with water or polluted soil, and consumption of contaminated foodstuffs or drinking water. In this respect, residential proximity to landfills has been previously linked to preterm births or congenital malformations, although several alternative explanations  cannot be excluded , 4.Spatial epidemiology can give important clues when searching for putative environmental causes of a disease , 6. In pBecause three main open landfills were used for solid waste disposal in the Guadeloupe archipelago, our aim was to evaluate whether preterm births cluster around these predefined locations.2 with a population of 450,000 inhabitants. This study relies on the Timoun mother-child cohort fully described elsewhere [n = 110) to reduce heterogeneity as African ancestry is a strong risk factor for preterm birth [n = 25), severe birth defects (n = 8), and induced pregnancies after fertility treatment (n = 15), resulting in a study population of 911 women (one case involved both fertility treatment and multiple births). Gestational age in weeks was estimated by the obstetricians in charge of follow-ups. It was based on the first day of the last menstrual period and was confirmed or corrected by ultrasound. Preterm birth was defined as a birth before 37 completed weeks of gestational age.Guadeloupe is an archipelago located in the Leeward Islands in the Caribbean. It covers an area of 1628 kmThe three main  open landfills in Guadeloupe  opened as temporary structures in the 1970s  focused cluster test specifically designed to detect spatial clustering around point sources, assuming a Bernoulli distribution and using a grid file with only a single grid point reflecting the coordinates of the focus of interest . The proFor hypothesis testing, we generated 9999 Monte Carlo replications to ensure good statistical power. Focused cluster tests were performed around each landfill in turn using the SaTScan software program  .n = 911), a total of 144 (15.8%) preterm births were observed in as many different locations. Selected socio-demographic and lifestyle characteristics of the study population are reported in Table In the study population (n = 767) as controls, a significant cluster was identified within 2 km around the Saint-François landfill with a relative risk (RR) of 4.82 (p = 0.04) (Table p = 0.26). No risk was highlighted in the vicinity of the Baillif landfill (p = 0.64).Using the term births (4) Table . The numWe found a significant cluster of preterm birth in the vicinity of the Saint-François landfill, which was located in a less densely populated area than the other two landfills (as reflected by the numbers of Timoun newborns and expected cases). Potential socio-demographic confounding factors did not appear to account for this observation.The present study has several strengths. First, because of the absence of heavy industries in the Guadeloupe archipelago, no confounding by their effluents is to be predicted. Moreover, no other pollution sources are documented in the areas that surround the three dumpsites. Second, preterm birth was carefully and uniformly characterized within a cohort framework. Both the residential addresses of the pregnant women and the landfill locations were known with sufficient precision to allow appropriate geocoding. Third, this study benefited from the well-established advantages of the focused cluster test to assess whether cases are closer to the sources than expected. Addressing a specific hypothesis of concern, this inferential method has a higher power compared to other spatial methods .This study is not without limitations. First, only authorized landfills were considered; however, illegal, uncontrolled landfills that receive waste without any selection at the origin may be an additional health concern. Second, the distance from the dumpsite was used as a proxy for exposure as it may reflect and integrate a broad range of contaminants and different routes of exposure . This buffer-based approach considers that emissions from a landfill are uniformly dispersed in all directions. It is worth noting that a 2-km radius, which is within plausible estimates of the range of chemicals dispersed from a site, has been often used to estimate exposure . HoweverTo the best of our knowledge, the current study is the first to report on this topic in a tropical island environment. The available scientific evidence has been recently reviewed by Kihal-Talantikite et al. , revealiWaste management in island environments has become a major concern with the potential to negatively impact development activities (including tourism and trade), food supplies, the environment, and public health. The excess risk of preterm birth observed around one Guadeloupian dumpsite supports these concerns but will need to be confirmed in other tropical island environments. In the meantime, preterm births might be considered in any risk assessment of landfill disposal sites in tropical belt.


The objective of this study was to evaluate whether a 5 to 9 kg weight gain, for obese women, optimized a set of maternal and neonatal health outcomes.Maternal obesity has a wide range of health effects on both the pregnant woman and developing fetus. The clinical significance of these disorders, combined with a dramatically increasing prevalence of obesity among pregnant women has precipitated a major health crisis in the United States. The most commonly used recommendations for gestational weight gain were established by the Institute of Medicine (IOM) in 2009 and have become well known and often adopted. The authors of the IOM report acknowledged that the recommended gestational weight gain of 5 to 9 kg for obese women whose body mass index was greater than 30 kg/mData containing approximately 12,000,000 birth records were obtained from the United States Natality database for the years 2014 to 2016. A Bayesian modeling approach was used to estimate the controlled direct effects of pre-pregnancy body mass index and gestational weight gain.Obese women gaining less than 5 kg during pregnancy had reduced maternal risks for gestational hypertension, eclampsia, induction of labor and Caesarian section. In contrast, maternal gestational weight gain of less than 5 kg was associated with increased risks for multiple adverse neonatal outcomes with macrosomia the exception. Obese women who gained more than 9 kg during pregnancy had increased risk for multiple maternal and neonatal adverse outcomes.Obese women who were observed to gain less than 5 kg during gestation had reduced odds of several peripartum disorders. However, this lower gestational weight gain was associated with an increase in multiple risks for the neonate.The online version of this article (10.1186/s12884-019-2273-z) contains supplementary material, which is available to authorized users. Maternal obesity has a wide range of health effects on both the pregnant woman and developing fetus , 2. The Maternal obesity causes pregnancy-onset metabolic conditions including gestational diabetes mellitus (GDM), gestational hypertension and pre-eclampsia/eclampsia . These p2), Obese II (BMI of 35.00–39.99 kg/m2) or Obese III (BMI of ≥40.00 kg/m2) [In the United States, the most commonly used recommendations for GWG were established by the Institute of Medicine (IOM) in 2009 . GuideliData containing approximately 12,000,000 birth records were obtained from the United States Natality database for the years 2014 to 2016. The entire database was downloaded and the following variables were extracted for analysis: maternal race/ethnicity, plurality, BMI class and gestational weight gain. The BMI classification used the six category WHO classification. The following maternal conditions and events were extracted: GDM, gestational hypertension, pre-eclampsia/eclampsia, occurrences of labor induction and delivery by caesarian section, blood transfusion, perineal laceration, uterine rupture, unplanned hysterectomy and ICU admission. The following fetal conditions and events were extracted: birth weight, obstetrical estimate of gestation length, five-minute Apgar score, admission to NICU, whether the infant was ventilated for at least six minutes, and whether the baby was alive at the time of the birth being recorded.The maternal weight gain was standardized to 40 weeks of gestation using internal standardization. Gestational weight gain was then classified as being in the recommended range or above or below the range according to the cut-points as recommended by IOM. For the purpose of classification, the following definitions were used: Extremely low birth wieht (ELBW) was birth weight less than 1000 g, very low birth weight (VLBW) was birth at less than 1500 g, low birth weight (LBW) was birth at less than 2500 g, very preterm birth (VPTB) was birth before 32 weeks of gestation and preterm birth (PTB) was birth before 37 weeks of gestation.ijk was the count of cases, at birth, and nijk, the count of births. The counts, Yijk were modeled as independent Binomial distributions conditional on an unknown rate parameter (μijk).A Bayesian modeling approach was used to perform a 3-way decomposition of total effects into direct, indirect and interactive effects , 10. Forijk) with a mean = 0 and variance = 100, for each combination of GWG and ppBMI.The logit of the rate parameter was then provided a vague normal prior  and the software OpenBUGS 3.2.3 [p-value of less than 5% for a 2-tailed test. The posterior predictive p value was used to evaluate all odds ratios with a p-value < 0.05 referred to as statistically significant [To aid in identifiability, the RGS 3.2.3 . A burn-nificant . ResultsThe database recorded 11,529,069 singleton births. Incomplete records that were excluded numbered 568,351 that were missing ppBMI, 139,657 that were missing maternal weight gain, 4385 that were missing gestation length estimates and 5171 that were missing birth weights. The study modeled data from 10,811,496 birth records that were cross-stratified into six ppBMI categories and three GWG categories with the number and percent of each combination among obese women reported in Table The overall modeling was performed with the baseline arbitrarily set at the combination of normal weight ppBMI and the currently recommended GWG, for each disorder. These model results are presented in Tables For women who were obese I, GWG less than 5 kg was associated with a significantly decreased risk for gestational hypertension, induction of labor and Caesarian section and a significantly increased risk of gestational diabetes. The neonates born to these women had significantly increased risk for extremely low birth weight, very low birth weight, low birth weight, very preterm delivery, preterm delivery, low Apgar score, admission to Neonatal Intensive Care Unit, ventilation for more than 6 min and neonatal mortality and a significantly reduced risk for macrosomia. For women whose ppBMI was classified as Obese I, gaining more weight than 9 kg was associated with an increased risk for gestational hypertension, eclampsia, induction of labor, Caesarian section and perineal laceration. The neonates born to these women had increased risk for extremely low birth weight, macrosomia, very pre-term delivery, low Apgar score, admission to Neonatal Intensive Care Unit and ventilation for more than 6 min and significantly reduced risk for low birth weight and preterm delivery  , 14. ThiThe current study supports previous studies that have shown maternal health benefits for obese pregnant women who gain less weight than 5 kg or even lose weight –18. SpecThe current study showed that, it is harmful for both the mother and neonate for obese women to gain more than 9 kg, during gestation. With few exceptions, adverse maternal outcomes occurred with greater odds when the limit was exceeded. The exception that was consistent for all ppBMI classes was GDM that occurred with decreased odds at the higher class of GWG. Analyses of adverse neonatal outcomes provided considerable additional support for obese women to gain less than 9 kg, during gestation. With few exceptions, adverse neonatal outcomes occurred with greater odds when the limit was exceeded. The exception was low birth weight and PTD had a significantly sparing effect among obese III women who gained more than 9 kg.Current results showed that GWG was lower among women who developed GDM but the causal relationship remains obscure. Both steps in lowering GWG from above recommended to recommended and from recommended to less that recommended GWG were associated with increased rates of GDM. If the relationship was causal, the conclusion would be that higher GWG prevented GDM. However, the authors of the IOM guidelines predicted difficulties identifying the causal ordering between GWG and disorders that develop during pregnancy, like GDM, and also advised that conditions diagnosed early in pregnancy and managed effectively, may have reduced risk. As predicted, studies evaluating the effect of GWG on GDM has been shown risks to be both increased  and decrThis study is limited by the observational nature of the data. The interaction model implemented in this study only corrects for confounding by variables included in the model not for confounding by unrecorded or omitted variables. The current results on GWG on adverse outcomes are not confounded by ppBMI but may be confounded by treatment variables. More specific causal inferences should be pursued. For example, more specific causal modeling could address how ppBMI and GWG contribute to GDM and adverse effects by GDM causing complicating causes that are certain to include hypertension, eclampsia and macrosomia. Further research could clarify the mediating effect of GDM on the relationships between the components of maternal obesity and adverse outcomes through additional causal factors like hypertension and eclampsia. To this end, the modeling approach implemented in this study can be expanded to include analyses specific to two groups of women, including those who do and those who do not develop GDM. This could be achieved by modeling all possible 3-way interactions among ppBMI, GWG and GDM. When combined with close monitoring for the chance development of GDM, the clinician can be equipped with the most useful nutritional recommendations related to GWG. We anticipate that the recommendations for GWG will vary with both ppBMI and GDM diagnosis and we encourage further research.Obese women who were observed to gain less than 5 kg during gestation had reduced odds of several peripartum disorders. However, this lower gestational weight gain was associated with an increase in multiple risks for the neonate.Additional file 1:Winbugs code and data. This code and these data can be used to repeat the analyses reported here. (DOCX 14 kb)


A 30-year-old woman presenting with hemoptysis followed by acute respiratory distress developed a diagnostic pulmonary radiographic finding, called the sign of the camalote, indicative of ruptured hydatid cyst. Her computed tomography scan demonstrated the characteristic detached parasitic membrane floating on cystic fluid, reminiscent of Amazonian camalote leaves. She was managed successfully surgically. Ruptured hydatid cysts may present as a diagnostic challenge, in which the sign of the camalote may provide an important clue for this serious complication. A 30-year-old woman who spent her childhood summers in northern Iran raising sheep was hospitalized with hemoptysis. Initial chest computed tomography (CT) revealed a right lower lobe cyst, 9 by 11 cm. Several days after admission, she developed respiratory distress with hypoxia. Repeat CT scan demonstrated air within the pulmonary cyst with a floating wavy membrane at the air-fluid level, indicative of the sign of the camalote . She undEchinococcus granulosus, commonly presents radiologically as a round density. Most persons remain asymptomatic for years until cyst perforation, mass effect, or secondary infection. As the hydatid cyst slowly enlarges, it may erode into the bronchial tree with the introduction of air into the cyst wall, causing collapse of the inner endocyst membrane. The collapsed membrane within the cyst forms a serpiginous structure within the cyst  cases of symptomatic hydatid lung disease in Tunisia [% cases o


The aim of the study was to determine the effect of short pregnancy interval on perinatal outcomes.The research was a retrospective study. The material consisted of birth records of a state hospital for the last three years in Manisa in the western region of Turkey (2015-2017) (n:8961). The research population included women whose gestational interval was ≤two years and the gestational week was over 22 weeks (n:2089). Perinatal outcomes were assessed through preterm birth, stillbirth, and low birth weight.The mean age of women who are in the research group is 26.7 ± 5.32. According to the perinatal results of women with a pregnancy interval of two years and shorter; 8.2% of women had birth before 37 weeks and 0.3% resulted in stillbirth. It was determined that 4.8% of infants were born with low birth weight. There was no difference between the short pregnancy interval and stillbirth or preterm birth. However, a significant difference was found between the low birth weight and short pregnancy interval. (p>0.05).Pregnancy interval does not affect preterm birth and stillbirth from perinatal outcomes, but has a significant effect on the birth weight of the newborn. The World Health Organization states that the pregnancy interval is time between the delivery date of the preceding live birth and conception date of the index pregnancy in women who have had more than one birth.5Regardless of the gestational age, babies under 2500 grams of birth weight are considered “low birth weight”.9Short pregnancy interval is also a risk factor for preterm birth.13The risk of neonatal death due to short pregnancy interval is high. The perinatal mortality was increased by 3-4 times in patients with an interval of fewer than 12 months between pregnancies, while infant mortality was increased by 2 times.11Different cut-off points have been considered for nonoptimal pregnancy interval in the literature. The optimal pregnancy interval (24 months) was considered as the cut-off point in this study. The aim of this study was to determine the effect of short pregnancy intervals on perinatal outcomes.The research is a retrospective study. The research used the birth records of a state hospital in Manisa in the western region of Turkey for the last three years (2015-2017) (N:8961). All pregnant women who met the criteria for including to the research in the years of 2015 – 2017 (n: 2089) were included. The criteria for including to the research are determined as gestational interval of the pregnant women should be ≤2 years and the gestational week of pregnant women should be over 22 weeks.The data of the study were collected using a data collection form consisting of 21 questions. The data collection form was created by evaluating the data where the records that can be obtained through the system are complete. We evaluated three adverse perinatal outcomes: low birth weight (less than 2500 g), preterm birth (birth at less than 37 weeks’ gestation), and stillbirth. Number, percentage distribution and Chi-square test were used for the evaluation of research data. The study received approval from Medicine Health Sciences Ethics Committee of Manisa Celal Bayar University Faculty and state hospital.The time between two pregnancies in 55.0% of women in the research is shorter than 2 years. The mean age of women is 26.7 ± 5.32. The number of pregnancies for 44.4% of women was 2, and 52.9% had 2 live births. It was determined that 3.7% of the women in the research group had a chronic disease, and 9.8% were smoking .The previous pregnancy of approximately 84.0% of women has resulted in a birth. The gestational age of birth for 0.8% of women (according to the ultrasound) is 33 weeks and below. It was determined that 1.1% of women had a pregnancy-induced disease and 36.7% had anemia  .Looking at the characteristics of infants in the research; 99.7% were born alive, 99.5% of newborns were singular, 48.6% were female. The weight of 0.7% of infants are 2000g and below; 23.8% shorter than normal. The first minute of the APGAR score of 0.9% of the infant was between 0-6, and the fifth minute APGAR score of 0.4% of the infant was determined to be between 0-6. In addition, 8.7% of infants were determined to need intensive care . The shoThe study showed that 55% of women become pregnant in less than two years. In a study of pregnancy interval results in Israel, it was reported that the pregnancy interval short than 24 months was 54.1%.16In the study, 8.2% of the births occurred before 37 weeks. It was found that the short pregnancy interval did not have a significant effect on preterm birth. The short pregnancy interval has been recognized as a risk factor for preterm birth.20The study also found that 0.3% of women had given stillbirth and the pregnancy interval did not have a significant effect on stillbirth. There are almost 3.2 stillbirths per 1000 births all over the world each year. The highest absolute numbers (approximately stillbirth rates are 32 per 1000) of stillbirths occur in Sub-Saharan Africa and South Asia.It was determined that 4.8% of infants were born with low birth weight and that the short gestational interval created a significant difference in terms of baby’s birth weight. According to the data of the Turkish Population Health Survey (2013); 10% of the children whose birth weight are known are at a low birth rate. In this study, where the effect of short gestational intervals on perinatal outcomes is investigated, perinatal results were evaluated in three subheadings. Pregnancy interval does not affect preterm birth and stillbirth from perinatal outcomes but has a significant effect on the birth weight of the newborn. Furthermore, more than half of the women who were included to this study conceived before the optimal pregnancy interval in this study. It supposed that increasing to take proper contraceptive medicines and raising awareness of women for perinatal outcomes are important for both women and children health aspects.


BackgroundGlobally, approximately 14.6% children are born with low birth weight (LBW) annually. In Pakistan, this figure however reaches approximately 16%. Low birth weight infants are vulnerable to develop early morbidities like hypothermia, hypoglycemia, respiratory distress syndrome and hypocalcemia. There is a scarcity of statistics which creates a gap in development of strategies for improving quality of care in developing countries. The aim of our study was to determine the frequency of early morbidities such as respiratory distress syndrome (RDS), hypoglycemia, hypothermia and hypocalcemia in low birth weight neonates.Methodologyst April 2016 to 30th September 2016 at The Aga Khan University Hospital, Karachi. All low birth weight infants, i.e., those with birth weight < 2500 grams were included in this study and observed for early morbidities, including hypothermia, hypoglycemia, hypocalcemia and respiratory distress syndrome. Descriptive analysis was done using SPSS version 22 , mean and standard deviation were determined for quantitative variables, whereas frequency and percentages were calculated for qualitative variables.A prospective descriptive study was conducted via non-probability sampling technique from 1ResultsA total of 2082 neonates were born during the study period, of which 271 (13%) were born with low birth weight. One hundred and eighty-five (68.1%) of these LBW neonates were preterm babies while 86 (31.9%) were born at term. Among LBW neonates 137 (51.0%) were males and 134 (49.0%) females. In the study population, hypoglycemia was seen in 17.3%, hypocalcemia in 13.6%, respiratory distress syndrome in 11%, and hypothermia in 2.5%.ConclusionOur study highlighted major early morbidities of LBW neonates, and their association with birth weight, gestational age and gender. Significant association of birth weight was found with hypothermia and hypocalcemia, whereas hypocalcemia and RDS were significantly associated with gestational age. However, none of the early morbidities had significant association with gender. Keeping in perspective the early morbidities in this population we propose that priority be given to providing adequate attention to low birth weight neonates. Newborns with birth weight less than 2500 grams are called low birth weight (LBW) . NeonataThe United Nations Children's Fund (UNICEF) estimates show that globally approximately 20 million children are born with LBW annually. LBW neonates prevalence is much higher in the developing countries 16.5%) compared to developed countries (7%); with the highest incidence in south central Asia (27%) followed by Africa 13%-15%) [6.5% comp%-15% 6., howeverLow birth weight IUGR newborns are prone to develop early morbidities such as birth asphyxia, hypothermia, hypoglycemia, hypocalcemia and polycythemia ,8, whereLow birth weight neonates often develop hypoglycemia, evident by study conducted on neonatal hypoglycemia in babies identified as high risk, which reported a 27% incidence of hypoglycemia in low birth weight neonates . In a stLimited literature is available from developing countries in this regard, which hinders development and implementation of new strategies for improving quality of care in developing countries. Any step towards establishing such strategies is dependent on availability of data on early morbidities in low birth weight neonates, which can help in determining the neonatal health status at national level.This prospective descriptive study was conducted at Neonatal Intensive Care Unit (NICU) and Well Baby Nursery of The Aga Khan University Hospital, Karachi from 1st April 2016 to 30th September 2016, after approval from the hospital ethical review committee. Our NICU is a Level III NICU with state-of-the-art facilities and a capacity of 24 beds. Neonates after appropriate management in NICU are shifted to mother baby step down unit. A total of 271 neonates born with low birth weight (<2500 grams) were enrolled by non-probability consecutive sampling technique, out of 2082 neonates born at our institute during the study period. Inclusion criterion was neonates with birth weight <2500 grams regardless of gestational age. Exclusion criteria were neonate with any congenital anomalies, discharged before 72 hours of life, those who underwent any surgical procedure. All neonates who fulfilled these criteria were selected for the study after taking informed consent from their parents. Data was collected on a structured proforma which included demographics as well as variables under study including hypothermia, hypoglycemia, RDS and hypocalcemia, for which all neonates were monitored closely. Neonates were monitored during the initial 72 hours for early morbidities. Descriptive analysis was carried out using SPSS version 22 . Mean and standard deviations were calculated for birth weight. Frequency and percentage were calculated for early morbidities such as hypoglycemia, hypothermia, respiratory distress, and hypocalcemia. Chi-square test was conducted to understand the impact of these on result variables. p value ≤0.05 was taken as significant.During the study period, a total of 2082 neonates were born out of which 271 newborn babies fulfilled the criteria. Male to female ratio among these neonates was almost equal with 137 (51%) being males while the rest 134 (49%) were females. Among these neonates 185 (68.26%) were preterm while 86 (31.7%) were term. The mean birth weight of enrolled neonates was 2.055 kilograms ± 0.229 SD and mean gestational age was 35.2 weeks ± 1.99 SD. The frequency of the morbidities under study was as follows: morbidities were present in 44.6% (n = 121) low birth weight neonates, RDS in 11% (n = 30), hypoglycemia in 17.3% (n = 47), hypocalcemia in 13.6% (n = 37), hypothermia in 2.5% (n = 7), while 56.4% (n = 150) LBW neonates had no early morbidities  are antenatal, perinatal and postnatal factors. Present study reflects that there was a gradual decline in morbidity with increasing gestational age and birth weight. Therefore, measures such as provision of adequate antenatal and postnatal care, as well as prevention of complications in pregnancy to achieve adequate weight at birth, as well as to prevent preterm delivery are factors that are significantly important in reducing neonatal morbidity.The frequency of morbidity and mortality among neonates reflects the quality of antenatal, intrapartum and postnatal care, and varies across different institutes and even countries. In developing countries with limited facilities, the survival of high-risk neonates tends to be low, in particular due to inability to address early morbidities in neonatal period. Early morbidities observed in our study were also found in a study conducted by Basu et al., which showed that common morbidities of low birth weight included RDS, apnea, sepsis, hypothermia, hypoglycemia, shock and intraventricular hemorrhage (IVH) .Frequency of hypoglycemia has a wide variability across literature. A study conducted on low birth weight infants found that hypoglycemia occurred in 24% of infants, however, in our study we observed that 17.3% of low birth weight neonates had episodes of hypoglycemia . AccordiOur study highlighted major early morbidities of LBW neonates, and their association with birth weight, gestational age and gender. Significant association of birth weight was found with hypothermia and hypocalcemia, whereas hypocalcemia and RDS were significantly associated with gestational age. However, none of the early morbidities had significant association with gender. In order to minimize early morbidities in low birth weight neonates, adequate consideration should be given to this high-risk population by the health care providers. The data acquired through this study will subsequently be used not only in creating awareness among medical practitioners dealing with neonates, but also in developing protocols for appropriate management and prevention of such morbidities.


Birth asphyxia, which accounts for 31.6% of all neonatal deaths, is one of the leading causes of such mortality in Ethiopia. Early recognition and management of its contributing factors would modify the problem. Thus, this study aimed to identify the determinants of birth asphyxia among live births at the University of Gondar Referral Hospital, northwest Ethiopia.th non-asphyxiated baby as a control. A pretested structured questionnaire was used to collect data on maternal sociodemographic characteristics. A pretested structured checklist was used to retrieve data on ante-partum, intra-partum, and neonatal factors of both cases and controls. Data were entered using Epi Info 7 and analyzed using SPSS 20. The bivariate logistic regression analysis was used to identify the relation of each independent variable to the outcome variable. Variables with p values of up to 0.2 in the bivariate analysis were considered for the multiple logistic regression analysis. An adjusted odds ratio (AOR) with a 95% CI and p-value of <0.05 was used to identify significant variables associated with birth asphyxia.A hospital-based unmatched case-control study was conducted from April to July 2017.Cases were newborn babies with an APGAR score of < 7at 5 minutes of birth; controls were newborn babies with an APGAR score of ≥7 at 5 minutes of birth. Every other asphyxiated baby was selected as a case and every 6In this study, prolonged labor , cesarean section delivery , meconium stained amniotic fluid , fetal distress , and low birth weight  were factors which significantly increased the odds of birth asphyxia.Prolonged labor, cesarean section (CS) delivery, meconium stained amniotic fluid (AF), fetal distress, and low birth weight were the determinants of birth asphyxia. Thus, efforts should be made to improve the quality of intra-partum care services in order to prevent prolonged labor and fetal complications, and to identify and make a strict follow up on mothers with meconium stained amniotic fluid. The first 28 days of life and neonatal period are the most vulnerable times for a child’s survival. In 2016Birth asphyxia, defined as failure to initiate and sustain default breathing at birth, is one The effect of birth asphyxia is not limited only to death but also has a short and long term neurodevelopment sequelae, including cognitive and motor disabilities which are almost untreatable, 13. DifMany studies have shown that birth asphyxia is influenced by multiple factors stemming from the ante-partum period. However, factors relating to intrapartum are the predominant risk factors, accounting for 91% of asphyxia. DetermiA hospital-based unmatched prospective case-control study was conducted on newborns delivered from April to July 2017, at the University of Gondar Referral Hospital, Maternity Ward. The hospital is located in Gondar city, 727 km to the northwest of Addis Ababa, the capital of Ethiopia. It is one of the largest tertiary public health institutions in Ethiopia, providing preventive, curative, and rehabilitative services to about 5 million people in the catchment. It also provides delivery services 24 hours a day, 7 days a week by mid-wives, interns, residents, and obstetricians who assist about 4000 deliveries annually.All live newborns after 28 weeks of gestation during the study period were screened for eligibility for the study. Though such cases were not found, the authors proposed to exclude newborns with one or multiple malformations and incompatibility with life, such as hydrops and cyanotic congenital heart defects. In this study, subjects were categorized into cases and controls. Newborn babies with APGAR scores of <7 at 5 minutes were defined as having birth asphyxia, while newborns with APGAR scores of ≥7 at 5 minutes were considered as not having birth asphyxia.The sample size was calculated by Epi Info 7 software for the unmatched case-control study. A previous study noted that pre-eclampsia was a key predictor of birth asphyxia. Having taken 95% confidence interval, 80% power, 15.9% proportion of controls with pre-eclampsia, an odds ratio of 2.37, 2:1 conthnon-asphyxiated newborn was enrolled as a control.By taking a monthly delivery report from the hospital and considering a 13.8% proportion of asphyxiated newborns from a previous study conducted in the hospital in 2013, an averBoth primary and secondary data (chart review) were used. A pre-tested structured interviewer based questionnaire was used to collect data on maternal sociodemographic factors, such as age, marital status, ethnicity, religion, residence, educational, and occupational status. Data on ante partum , intrapartum , and neonatal related factors  were abstracted using a pre-tested structured checklist from the medical records of pregnant women who gave birth during the data collection period.The questionnaire was prepared in English and translated to Amharic , heart rate, grimaces (reflexes), activity (muscle tone), and respiration each of which is given a score of 0, 1, or 2. A score of ≥7 indicated a newborn was not asphyxiated and in a good condition, whereas a low score (<7) indicated a new born with asphyxia.Prolonged labor was considered when the labor, after the latent phase of first stage of labor, exceeds 12 hours in primigravida or 8 hours in multipara mothers. Obstructed labor was considered when the presenting part of the fetus could not progress into the birth canal, despite strong uterine contractions. Premature rupture of membranes (PROM) was defined as a rupture of the membrane of the amniotic sac and chorion occurred more than one hour before the onset of labor. Mal-presentation was defined as any fetal presentation other than vertex. Anemia in pregnant women was defined when the hematocrit level (HCT) was< 33%. Birth weight was classified and defined as normal  or low (<2500 gm).Data were entered using EPI Info version 7 and analyzed using SPSS version 20. Descriptive statistics, such as means with a standard deviations, frequencies, and percentages were used to describe maternal sociodemographic, ante-partum, intra-partum, and neonatal related factors.Bivariate logistic regression was conducted to see the correlation of each independent variable to the outcome variable. Variables with p-values of up to 0.20 in the bivariate logistic regression analysis were identified and fitted to the multiple logistic regression analysis to identify the independent effects of each variable to the outcome variable. An Adjusted Odds Ratio with a 95% confidence intervals (CI) was computed to identify the presence and strength of associations, and statistical significance was declared if p < 0.05.A total of 270 (90 cases and 180 controls) participants were involved in this study with a response rate of 98.9%. The mean ages of the mothers of cases and controls were 27.8 (SD = 5.2) and 26.9 (SD = 4.9) years, respectively. Moreover, 39 (43.3%) mothers of the cases and 32 (17.8%) of the controls were rural dwellers. Thirty-five (42.0%) mothers of the cases and 38 (19.3%) of the controls had no formal education, while one-third (33.0%) of the mothers of the cases and half of (54.0%) the controls had secondary and above level of education. Of the participants, 58 (64.5%) mothers of the cases and 77 (42.8%) of the controls were housewives .Among the total participants, 44(48.9%) mothers of the cases and 99(55.0%) of the controls had <4 ANC visits; 49(56.7%) of the mothers of the cases and 113(62.8%) of the controls were multipara; 12(13.3%) mothers of the cases and only 6(3.3%) of the controls had anemia during pregnancy; 9(10.0%) mothers of the cases and 6(3.3%) of the controls had ante partum hemorrhage during pregnancy.Of the total participants, 34(37.8%) of the cases and 29(16.1%) of the controls delivered by induction. Over half, (60%) of the cases and nearly one-third (31.3%) of the controls were born from mothers with history of prolonged labor; 34(37.8%) of the cases and only 15(8.3%) of the controls delivered with CS, and 40(44.4%) of the cases and only one-tenth (10%) of the controls delivered with stained amniotic fluid .Out of the total newborn babies, 147 (54.4%) were male and two-thirds (66.7%) of the cases and nearly half (48.3%) of the controls were male. One-fifth (17.8) of the cases and only 11 (6.1%) of the controls were preterm; 22 (24.4%) of the cases and only 9(5%) of the controls had low birth weight. There were 8 (8.9%) twin newborns among cases and 7 (3.9%) among controls .The bivariate logistic regression analysis showed that residence, maternal education and occupational status, places of ANC visits, number of pregnancies, ante-partum hemorrhage, type of labor, duration of labor, fetal presentation, mode of delivery, meconium stained amniotic fluid, obstructed labor, gestational age, sex of the new born, birth weight, and fetal heart rate were associated with birth asphyxia. After adjustments for possible effects of confounding variables, prolonged labor, CS delivery, meconium stained amniotic fluid, and low birth weight were significantly and positively associated with birth asphyxia.The likelihood of developing birth asphyxia among neonates born from mothers with prolonged labor was 2.75 times  more compared with their counter-parts. Neonates delivered by CS were 3.6 times  as likely to have birth asphyxia as those born by spontaneous vaginal delivery. Neonates born with meconium stained amniotic fluid were 7.69 times  as likely to have birth asphyxia as those born without being meconium stained. Neonates born with low birth weight were 7.7 times  as likely to have birth asphyxia compared to those born with normal weight. Neonates with intra-partum fetal distress had 5.7 times higher risk of experiencing birth asphyxia than those born with normal fetal heart rate .Asphyxia is the leading cause of mortality due to hypoxic-ischemic damage to newborns. Hence, the quality of medical care at birth is crucial to reduce the overall newborn mortality and its long-term consequences. In this study, it was attempted to identify the determinants of birth asphyxia among newborns at the University of Gondar Referral Hospital. Prolonged labor, CS delivery, meconium stained amniotic fluid, fetal distress, and low birth weight were identified as determinants of birth asphyxia.Prolonged labor is most likely to occur if a woman’s pelvis is not large enough for her baby’s head to pass through, or if her uterus does not contract sufficiently, or if there is a slow effacement of the cervix, 26. In Newborns delivered by cesarean section had 3.6times more risk for birth asphyxia. This finding was consistent with those of studies conducted in Gusau, Nigeria, CombineNeonates born from mothers with history of meconium stained amniotic fluid had 7.69 times more risk for birth asphyxia. This finding was consistent with those of previous studies conducted at the University of Gondar Referral Hospital, Mulago Another neonatal factor found to have significantly associated with birth asphyxia was intra-partum fetal distress. Neonates who had intra-partum fetal distress had about 5.74 times higher risk of developing birth asphyxia. A similar result was obtained in a previous study done in this hospital and otheLow birth weight was also an important determinant of birth asphyxia in this study. Neonates who had low birth weight were 7.72 times more likely to have birth asphyxia than those who had normal birth weight. This finding was in line with those of studies conducted at the University of Gondar Referral Hospital, 44, MulIn this study, the determinants of birth asphyxia are mainly related to the duration of labor, fetal conditions and bad fetal outcomes, and the mode of delivery. Prolonged labor, meconium stained AF, CS delivery, fetal distress, and low birth weight were the determinants of birth asphyxia. Therefore, efforts should be made to improve the quality of intra-partum care service in order to prevent prolonged labor and fetal complications, and to identify and make a strict follow up of mothers with meconium stained amniotic fluid.Ethical clearance was obtained from the Ethical Review committee of the Institute of Public Health, College of Medicine and Health Sciences, the University of Gondar. A permission letter was obtained from the Chief Clinical Officer of the University of Gondar Referral Hospital. Informed verbal consent was also obtained from each study participant to review and use their medical records (charts). Participation in this study was voluntary. Confidentiality of information obtained was ensured using code numbers rather than names and keeping the questionnaire and checklist safe throughout.S1 Data(SAV)Click here for additional data file.


Postnatal care begins immediately after the expulsion of the placenta and continues for six to eight weeks post-delivery. High standard of care is required during the postnatal period because mothers and babies are at risk and vulnerable to complications related to postpartum haemorrhage and infections. Midwives and traditional birth attendants are responsible for the provision of postnatal care in different settings, such as clinics and hospitals, and homes.A qualitative, exploratory, descriptive and contextual research approach was followed in this study. Unstructured interviews were conducted with the traditional birth attendants. An integrated literature review was conducted to identify the Western postnatal care practices. Tesch's process was followed during data analysis.The following main categories were identified: similarities between indigenous and Western postnatal care practices, and differences between indigenous and Western postnatal care practices. Based on these findings, training of midwives and traditional birth attendants was recommended in order to empower them with knowledge and skills regarding the indigenous and Western postnatal care practices.It is evident that some indigenous postnatal care practices have adverse effects on the health of postnatal women and their newborn infants, but these are unknown to the traditional birth attendants. The employment of indigenous postnatal care practices by the traditional birth attendants is also influenced by their cultural beliefs, norms, values and attitudes. Therefore, there is an urgent need to train midwives and traditional birth attendants regarding the indigenous and Western postnatal care to improve the health of postnatal women and their babies. Indigenous practices regarding postnatal care at Sikhunyani village, Mopani District, Limpopo Province of South Africa. The study had two objectives, which were to explore and describe the indigenous practices regarding postnatal care, and to compare the similarities and differences between the indigenous and Western postnatal care practices.This article reports an important part of the study conducted during the principal investigator's Master's degree, entitled: South Africa as a developing country is challenged with increasing rates of maternal and neonatal mortality, despite the fact that the recommended reduction strategies are in place. According to the World Health Organisation's WHO  maternalTo address this challenge, the standard of postnatal care should be improved through the provision of comprehensive postnatal care services that will enable registered midwives and traditional birth attendants to work as a team and identify postnatal care practices that are a threat to the health of postnatal women and babies , Sepsis (9.1%) and HIV- and AIDS-related infections  to detect the risks and benefits that could have occurred during the study.To ensure the right to self-determination, participation in the study was voluntary without any prejudicial treatment or penalty for those who refused to participate or decided to withdraw from participation. The researcher explained the nature of the study to the participants to ensure the right to full disclosure. The participants were treated fairly and equally before, during and after the study, and the researcher adhered to the agreed times of appointments. The researcher kept in confidence all the data collected from the participants  and cultural backgrounds, with Sotho, Venda and Tsonga as the dominant groups. Data were collected in Xitsonga and transcribed and translated into English. Data were analysed following the process of data analysis according to Tesch ‘he yellow colour of the foremilk signifies dirt that is contained within the initial breast milk which causes abdominal discomfort for the baby, so it is safe to squeeze all the yellow milk until the milk is clear before putting the baby to suck from the breast.’ ‘[The study confirmed that the traditional birth attendants do not have adequate knowledge regarding the natural effect of colostrum in the baby's gut. Similar findings were reported in the studies conducted in Nepal where the traditional birth attendants believed that colostrum is not good for the baby because it causes diarrhoea Mother Baby Friendly Initiative strategy recommended and encouraged exclusive breastfeeding through the introduction of rooming-in, skin-to-skin care, human milk banks and breastfeeding rooms to ensure close proximity between the mother and the infant. Rooming-in enables the baby's urge to suck and its hunger to be gratified without delay It is evident from these quotes that the traditional birth attendants are taking precautionary measures to protect the mother from postpartum bleeding and retention of the placenta by delaying cutting the cord until the placenta is expelled. Meanwhile, they are exposing the baby to cold, which might lead to hypothermia, because they wait for the placenta to be expelled before they wrap the baby in a blanket. In contrast to this practice, Nolte :189 indiMethod of contraception emerged as a sub-category under the differences between the indigenous and Western postnatal care practices. This sub-category also produced the practice of delayed resumption of sexual relations. The traditional birth attendants indicated that the postnatal woman is encouraged to delay resumption of sexual relations until the baby is at least two years of age. Delayed resumption of sexual relations serves as the most suitable and reliable method of child spacing:‘I advise her to delay resumption of sexual relations until the baby is at least two years of age; this allows her body to recover completely and her baby to grow without the fear of her becoming pregnant again.’ South African Recognition of Customary Marriage Act, which allows men to marry more than one wife (Republic of South Africa Traditionally, polygamy is used as a method of family planning. For example, a man is encouraged to marry many wives so as to give the breastfeeding woman time to heal and her baby to grow until the age of two years. The husband is not allowed to have sex with a breastfeeding woman. They believe that the man will be seriously ill after sex - the testes will be swollen and he could die if not treated soon enough. It is evident from these quotes that the traditional birth attendants are concerned about the physical health of postnatal women, their husbands and their babies; hence, they take extra precautions to protect them and prevent complications. The issue of polygamy is also supported by the The in-depth literature control was done under each theme and in This part of the discussion focuses on the similarities between the indigenous and Western postnatal care practices. A well-balanced diet is regarded as an effective strategy in production of milk for infant feeding by both the traditional birth attendants and the registered midwives. Breastfeeding of the baby until the age of two years or more was recommended by the traditional birth attendants, whereas the midwives recommend ingestion of colostrum, which protects the baby against illnesses such as HIV. The study also revealed that, similar to the midwives, the traditional birth attendants do know how to differentiate between normal and abnormal postpartum bleeding and, as a result, they are able to seek medical attention before complications arise. The traditional birth attendants are knowledgeable in the prevention of infection, which is evident in their practice of using a new razor for each client and separate bathing basins for the mother and the baby.Differences between the indigenous and Western postnatal care practices were also identified. Cutting the cord and wrapping the baby before the expulsion of the placenta is regarded as a contributory factor to placental retention by the traditional birth attendants. However, by not wrapping the baby immediately, the baby is exposed to the possibility of hypothermia. On the other hand, the midwives recommend clamping and cutting the cord immediately after the delivery of the baby. This confirms the inadequate knowledge of the traditional birth attendants regarding the effect of delayed wrapping of the baby. The traditional birth attendants recommend that the colostrum should be expressed and thrown away because they regard it as dirty, which might cause diarrhoea in the baby, whilst midwives recommend ingestion of colostrum because it helps to expel the meconium, protects the baby's gut from excoriation and protects against illnesses such as HIV. It is clear that traditional birth attendants have inadequate knowledge regarding the importance of colostrum to the health of the baby. The midwives encourage exclusive breastfeeding for the first six months without introduction of solids, whereas the traditional birth attendants believe in giving the baby a light soft porridge before putting the baby to the breast. The study shows that the traditional birth attendants do not know the effects of early introduction of solids on the health of the baby. Delayed resumption of sexual relations until the baby is two years or more and polygamous marriage were confirmed as the most effective and reliable methods of contraception for the breastfeeding women. However, polygamous marriage is discouraged in Western culture and contraception is provided on discharge to postnatal women in preparation for sexual relations without fear of becoming pregnant during the postnatal period. It is evident that the traditional birth attendants are knowledgeable about the benefits of child spacing to the health of the postnatal woman and the baby. Based on the fact that the indigenous practices are not documented in midwifery books, it is concluded that midwives have inadequate knowledge regarding indigenous postnatal care practices.The study was conducted in one village, which limits the comparison and generalisation of results to other settings. The inadequate knowledge of the traditional birth attendants regarding the effect of delayed wrapping of the baby, the importance of colostrum to the health of the baby and the effect of early introduction of solids on the health of the baby, was also confirmed. It was evident from literature that midwives have limited knowledge regarding indigenous postnatal care practices, which might prevent midwives from detecting practices that are a threat to the lives of postnatal women and newborn babies (Ngomane & Mulaudzi The purpose of the study on which this article is based was to compare indigenous and Western postnatal care practices, with the intention to describe the knowledge of traditional birth attendants and midwives regarding postnatal care. Knowledge of similarities and differences between the indigenous and Western postnatal practices amongst registered midwives and traditional birth attendants is of utmost importance in the provision of quality postnatal care. Furthermore, it will also enhance and maintain a working relationship of mutual trust between registered midwives and traditional birth attendants.It is suggested that training of registered midwives and traditional birth attendants regarding the similarities and differences between the indigenous and Western postnatal care practices is important in empowering the two groups with culturally congruent knowledge and skills.Knowledge gained from this study might encourage researchers to conduct further research on how to integrate indigenous practices into midwifery healthcare.Training of traditional birth attendants regarding the importance of wrapping the baby immediately after birth, of giving colostrum and of exclusive breastfeeding to improve the quality of care during the postnatal period.Training of registered midwives regarding indigenous postnatal care practices, so that they are able to identify and address those practices that are detrimental to the health of women and babies.Further research should be conducted to explore and describe more similarities and differences between indigenous and Western postnatal care practices in other areas of South Africa.