A preterm birth is the leading cause of death in both neonatal and children under five years of age every year throughout the world, particularly in Sub-Saharan Africa. The causes of a preterm birth are complex and multifactorial; many risk factors that contribute it are not fully understood. The aim of this study was to identify predictors of a preterm birth among mothers who gave birth in Silte Zone Public Hospitals, Southern Ethiopia (2019/20). th to October 30th, 2019, by assigning mothers who gave preterm births as cases and those with term births as controls. A total of 365 respondents (91 cases and 274 controls) were selected by a consecutive simple random sampling until the required sample size was achieved. For each case, three consecutive controls were included. Data were collected using a structured interview questionnaire complement with record reviewing. The data were entered into Epi Info 7 and exported into SPSS 25 for analysis. Descriptive analysis was computed to obtain summary values for cases and controls separately. All candidate variables in bivariate analysis were entered into the multivariable logistic regression model by using the backward likelihood ratio selection methods. Finally, variables with p value ≤ 0.05 were considered as potential determinants of a preterm birth and reported in the form of adjusted odds ratio with 95% confidence interval.  A hospital-based unmatched case-control study design was carried out from July 15 Among a total of 365 mothers who gave live birth, 91 (24.9%) were cases compared to 274 (75.1%) which were controls. The final multivariable logistic regression analysis results showed that having history of a previous preterm birth , having shorter interpregnancy interval , experiencing obstetric complication , and having infant born with low birth weight  were found to be independent predictors of a preterm birth.  According to this finding, mothers having previous history of a preterm birth, experiencing obstetric complication, having shorter interpregnancy interval, and having infant born with low birth weight were reported as the independent predictors of a preterm birth. Improving the quality of antepartum and intrapartum, counseling on birth space, creating awareness on family planning, and early screening of preterm determinants are mandatory. A preterm birth is a syndrome with a variety of causes and underlying factors, usually divided into spontaneous and provider-initiated preterm births. A doctor recommends premature childbirth at the initiative of a health professional and suggests early childbirth if the baby or mothers have a health problem. A spontaneous preterm birth is a birth that begins on its own and that happens when a woman enters premature labor or when her water breaks too early. Most preterm births occur spontaneously, but some are caused by the early induction of labor or caesarean section, whether for medical or nonmedical reasons , 2.Ethiopia is also one of the major countries with the highest number of under-five deaths and newborns worldwide in 2016. It represents 3.3% and 3.4% respectively of all under-five and newborn deaths in the world. From 320,000 babies born prematurely in Ethiopia each year, an estimated 24,400 7.6%) deaths of children under five years of age are caused by the direct effects of a premature complication . Again t.6% deathIn developing countries, the attention given to a preterm birth is less. In Ethiopia especially, little is known about determinants that contribute to a preterm birth and also previous studies were focused mainly on the magnitudes, rather than its determinants. Despite the burden of a preterm birth, few effective strategies or approaches are available to prevent a preterm birth and reduce related deaths. In some parts of Ethiopia, limited studies show that premature childbirth is critical, while those in Southern Ethiopia, particularly in the current study area, are not being studied.Therefore, the aim of this study was to identify determinants of a preterm birth at Silte Zone Public Hospitals, Southern Ethiopia. This will help health providers to have adequate knowledge and intervene early in the antenatal care visit and also might have an input to programmers and policy makers.th to October 30th, 2019. Cases were defined as all selected mothers who gave a live preterm birth (<37 0/7 weeks), whereas controls were also defined as all selected mothers who gave live from 37 weeks and above of gestation (≥37 0/7weeks). However, gestational age was used to determine both cases and controls based on either by last menstrual period (LMP) or early ultrasound (before 24 weeks of gestation) assessments. All selected mothers who gave live (<37 0/7 weeks) for case and term birth (≥37 0/7weeks) for control were considered as the study population.A facility-based unmatched case-control study was conducted at Silte Zone Public Hospitals, Southern Ethiopia from July 15Mothers who have multiple births, postpartum psychosis, seriously ill, unable to communicate, and referred immediately to other health institution did not know their LMP and have no early ultrasound assessment, and mothers referred to the facility without antenatal information were excluded.Zα/2 = 1.96), 80% power of the study (Zβ = 0.84), and ratio of control to case 3 : 1 (r = 3). Different exposure variables that have high contribution for a preterm birth were selected from related previous studies and the main exposure variable that gives highest sample size was taken. Based on this, place of rural residence was chosen as an independent variable since it gave maximum sample size as compared to other exposure variables. 31.8% of mothers gave live full-term births (assuming the control group was exposed), when rural residence was a risk factor for a preterm birth (AOR = 2.13) [The sample size was determined by two population proportion formulas and it calculated using Stat Calc Epi Info 7.1.4 software considering the following statistical assumptions: 95% confidence level  report in 2018/19 year prior to the data collection period. Once a mother with a preterm birth was recruited as a case group, the next three consecutive mothers were selected as the control groups at the same condition in respective hospital and recruitment was continued until the required sample size is fulfilled. In case a selected mother did not fit the criteria or declined to consent, the next mother was selected.Eight data collectors and three supervisors qualified in diploma and BSc midwife, respectively, were assigned for each of the selected hospitals after two consecutive days of training was given. Data were collected through a face-to-face interview by using pretested structure questionnaires, and also review maternal and neonatal medical charts were checked to take and confirm for some important variables within 48 hours after they gave birth. The interview, document review, and physical measurements were conducted by trained midwife nurses working in each hospital. Data were collected from participants after they were fully recovered from delivery process, who are ambulant, stable, and fit for interview and measurements almost within 48 hours after giving birth. The overall estimated time to take information from each mother was needed for almost 25-30 minutes.Physical measurements were obtained by using anthropometric measurement equipment following standardized techniques for each mother and newborn infant after birth. Maternal weight was measured using weight scale with height rod . The instrument was calibrated each time before use with a standard one-kilogram weight material. A mother puts still in the middle of scale stand without touching anything and with the body weight equally distributed on both feet. The weight was taken to the nearest 100 g (0.1 kg). Maternal height was also measured using scale with height rod , while the mother was in standing position, barefooted with heels together, arms hanging naturally at the sides, legs straight, and shoulders relaxed. The maternal mid-upper arm circumference (MUAC) was measured using a flexible nonstretchable standard tape to the nearest 0.1 cm. The circumference was measured at the midpoint between the tip of the acromion process of the scapula and olecranon process of the ulna. Similarly, newborn weight was also measured using a balanced digital SECA scale (Germany) which is a nonhanging type. The scale was always calibrated using a standard one-kilogram weight material, and the reading on each scale was taken to zero level before weighing each newborn. The measurements were taken to the nearest 100 grams. All measurements were taken twice with the same measuring instrument, and the average was computed. Gestational age in weeks was estimated either by LNMP or early ultrasound assessment through interview and taking from documentation to the nearest of 0/7 week birth expressed date of completed weeks.The questionnaires were checked in the field manually for completeness and consistencies before data entry. Data were entered into Epi Info 7.1.4 software and exported to Statistical Package for Social Sciences (SPSS) version 25 software for analyses after editing, coding, and cleaning. Descriptive statistics were employed to describe the characteristics of the study participants in relation to outcome variable by using crosstabulation expressed as frequency and percentage for the case and control groups, respectively.Both bivariate and multivariate analyses were employed by using logistic regression model to identify determinants of a preterm birth that are statistically significant. Since the interest is in identifying determinants of a preterm birth, the dependent variables are coded as 1 if the mother is with a preterm birth and coded as 0 if not.p value ≤ 0.25 with 95% CI and crude odds ratio (COR) were considered for the final multivariable analysis. Subsequently, those identified candidate variables in bivariable analysis were incorporated into the multivariable logistic regression model by using the backward stepwise elimination likelihood ratio (LR) selection methods in order to identify the independent predictors of a preterm birth among the study participants.First, simple binary logistic regression analysis was run to identify crude association between dependent variable and each of independent variables that were statistically significant at p value = 0.407) to check the appropriateness of model for analysis. The final findings of the model were reported by using AOR with 95% CI at p value ≤ 0.05 as a cut-off point to be considered statistically significant. Furthermore, results were summarized and displayed using tables, figures, and graphs.Appropriate model diagnostics tests were assessed whether the required assumptions for the application of multivariable logistic regression analysis were fulfilled. Multicollinearity test was performed to see the presence of collinearity among independent variables by using a standard error prior to determining the final model. Results with inflated standard error > 2 were excluded from the analysis. And also the goodness-of-fit test was checked using the Hosmer-Lemeshow test statistics  in Worabe Health Center, which is related to the client visit for maternal care services. Based on the findings and experiences from the pretest modification on logical sequence, simplicity and clarity of the question were done.Furthermore, data collectors checked the questionnaires for completeness before leaving each study participant. Both supervisors and investigators made close follow-up and reviewing each questionnaire regularly to check for completeness, consistency, and clarity in each hospital. Finally, before data analysis editing, coding, cleaning, and data exploration were done.Ethical clearance was obtained from Wachemo University College of Medicine and Health Science ethical review committee to carry out this study. A formal support letter was written from Wachemo University to Silte Zone Health Departments. Also, a formal letter of permission was secured before starting data collection process from Silte Zone Health Departments to each of the selected public hospitals. An informed verbal consent was obtained from the mothers after fully explaining the purpose of the study throughout the data collection period. Participants were informed about the right not to participate in or withdraw from the study at any time through the interviews. All the information obtained were kept confidential at all time by using codes and were collected anonymously.Among a total of 365 mothers who gave single live birth in Silte Zone Public Hospitals, 91 (24.9%) were the case groups compared to 274 (75.1%) which were the control groups; this makes a response rate of 100%.Regarding the sociodemographic characteristics, the majority of mothers (64 (70.3%) of the case groups and 222 (81%) of the control groups) were found in the age range of 20-34 years. About 55 (60.4%) of the case group and 157 (57.3%) of the control group mothers were living in rural area. Again concerning the marital status of mothers, about 74 (81.3%) of the case groups and 248 (90.5%) of the control groups were married. With regard to religious and ethnic status, majority of 78 of the case groups (85.7%) and 251 (91.6%) of the control groups were Muslim and 74 (81.3%) of the case groups and 242 (88.2%) of the control groups were Silte, respectively .Multigravida and multiparous mothers were comprised nearly similar proportion in both the case groups (70 (76.9%) and 68 (74.7%)) and the control groups (210 (76.6%) and 204 (74.5%)), respectively. Concerning history of immediate previous pregnancy outcome, 33 (47.1%) of the case groups and 27 (12.9%) of the control groups had previous history of a preterm birth. Similarly, a proportion of previous history of still birth, abortion, and congenital anomalies in the case groups were 6 (8.6%), 11 (15.7%), and 6 (8.6%), while in the control groups were 14 (6.7%), 25 (11.9%), and 10 (4.8%), respectively .Regarding human immunodeficiency virus (HIV) status, majority (80 (87.9%)) of the case groups and (250 (91.2%)) of the control groups were tested for HIV infection; however, 6 (7.6%) of the case groups and 14 (5.6%) of the control groups were positive for HIV infection. With regard to anemia status, approximately 90% of mothers in both the case and control groups were screened for hemoglobin level, from which majority of mothers (66 (81.5%)) of the case groups and (222 (88.1%)) of the control groups had their hemoglobin level 11 gm/dl and above .Nearly above of the average (50 (54.9%)) of the case groups and (144 (52.6%)) of the control groups were female sex. Regarding the presentation during delivery, infants delivered in vertex presentation were higher among in the control groups (254 (92.7%)) than those in the case groups (81 (89%)). Similarly, about below the half (41 (45.1%)) of the case group and (52 (19%)) of the control group neonates experienced birth asphyxia after birth. Furthermore, the proportion of low birth weight (<2500 gm) was higher among the case group (60 (65.9%)) than that of the control group (55 (20.1%)) .p value ≤ 0.25 and have crude association with the occurrence of a preterm birth and also collectively entered to multivariable logistic regression model using the backward elimination stepwise likelihood ratio selection method to identify determinants.Bivariate analysis showed that monthly family income, history of a preterm birth, interpregnancy interval, ANC visit, mode of delivery in current pregnancy, experiencing obstetric complication in current pregnancy, maternal weight, infant birth weight, and presence of birth asphyxia were candidate variables for multivariable analysis at p value ≤ 0.05.After adjusting for covariate, the multivariable logistic regression analysis showed that having history of a previous preterm birth, having shorter interpregnancy interval (<24 months), having any one or more obstetric complications , and having infants with low birth weight (<2500 gm) were found to be independent predictors for the occurrence of a preterm birth at p value = 0.007). In the same manner, those mothers who had shorter interpregnancy interval (<24 months) were about 4.5 times more likely to develop a preterm birth compared to mothers with recommended interpregnancy interval (≥24 months) .Accordingly, the odds of developing a preterm birth were 3.5 times more likely among mothers who had history of a previous preterm birth as compared to mothers who had no previous history of preterm births . Furthermore, the odds of developing a preterm birth were 5.6 times more likely among newborn who had low birth weight (<2500 gm) as compared to those newborn who had normal birth weight (≥2500 gm)   during the current pregnancy had 4 times higher odds of developing preterm births as compared to those who were not experienced any one or more obstetric complications at all  .This study identified both maternal- and neonatal-related factors had a significant association with the occurrence of a preterm birth among mothers who gave birth in the study area.Accordingly, mothers who had previous history of a preterm birth were more likely to deliver a preterm birth compared to mothers who had no previous history of a preterm birth. This finding is in agreement with previous studies conducted in Northern, Southwest, and Southeast Ethiopia and found that previous history of a preterm birth increases the risk of a preterm birth –10 and aOn the other hand, this study found that mothers with shorter interpregnancy interval (<24 months) had higher odds of bearing a preterm birth than mothers with the recommended interpregnancy interval (≥24 months). This finding is in line with report from different studies done in Axum and Adwa, Northern Ethiopia; Jimma, Southwest Ethiopia; and Amhara Regional State of Ethiopia, in which mothers with shorter interpregnancy interval increase the risk of a preterm birth , 15, 16.Additionally, this study revealed that mothers experienced any one or more obstetric complications  in current pregnancy had high risk of having a preterm birth than those mothers without these obstetric complications. This finding correlates to the finding of studies conducted in Debre Markos, Debre Tabor, and Hosanna Town, Northern and Sothern Ethiopia, respectively, which showed that mothers having obstetric complication increase the risk of having a preterm birth –19. ThisThe odds of developing a preterm birth were more likely to occur among newborn who had low birth weight (<2500 gm) as compared to their counterparts. This result is in agreement with a study carried out in Northern Ethiopia, which revealed that infants with LBW were more likely to have a preterm birth . SimilarThe most important strength of this study includes the following: it is conducted for the first time and done in all public hospitals in the study area to identify determinants of a preterm birth by using a case-control study. However, it is also carried out by using the combination of face-to-face interview and medical chart review for complementation and confirmation of some important variables, which is used to minimize the possible recall bias. This study also has some limitations: it might be a possibility of prone to recall bias because mothers were asked about their previous obstetric historic characteristics such as recall for gestational age based on their last date of menstruation, interpregnancy interval months, number of ANC visit, and months of iron-folate tablet taken, In order to minimize potential recall bias and to complete the interview medical record review for some important variables was used.Again, in this study, it was not possible to enroll mothers who had difficulty to estimate their gestational age with unknown last normal menstrual period (LNMP) and missed the ultrasound result in their chart, which means to estimate gestational age not including other options like clinical assessment. Furthermore, this study is unable to include mothers who delivered at home because there might be a possibility of introducing selection bias.This study showed that the independent predictors of a preterm birth were some maternal and neonatal bases to the occurrence of a preterm birth. Mothers having previous history of a preterm birth, experiencing any one or more obstetric complications, having shorter interpregnancy interval, and having infants delivered with low birth weight were reported as the most important maternal and neonatal predictors of a preterm birth. The essential strategies should be stressed on improving antenatal care services and promoting early detection and clinical managements which are crucial for those pregnant mothers experiencing any obstetric complications during their expected antepartum and intrapartum care service providing times. In addition to this, encouraging mothers to utilize contraceptive and providing health education on a preterm birth and obstetric complications may lead to decline the burden of a preterm birth and its consequences.


Extrauterine Growth Restriction (EUGR) refers to inadequate growth during hospitalization. Current definitions for EUGR are varied and can be classified as cross-sectional (weight at a given t-time <10th centile) or longitudinal (weight loss between birth and a given t-time >1SD). Different t-times are also considered in literature, such as 36 weeks of gestational age (GA) or age at discharge. The aim of this study is to investigate whether EUGR could predict the auxological outcome at 24–30 months, and to evaluate the agreement between cross-sectional and longitudinal definitions. In total, 1589 infants with GA <30 weeks or birthweight ≤ 1500 g and without major congenital anomalies were included in this study. Cross-sectional and longitudinal EUGR were calculated at 36 and 40 weeks of GA, at discharge, and at 28 days. The concordance between the two definitions was estimated by Kappa coefficient. At 24–30 months, 803 infants were measured again. The agreement between the two definitions of EUGR was low. Both EUGR and not-EUGR groups were at lower centiles for weight, but at higher centiles for head circumference at 24–30 months than at birth. Longitudinal EUGR was associated with a poorer growth outcome for weight and height circumference than cross-sectional EUGR. No differences were observed for length. An agreed definition of EUGR is highly desirable in clinical practice to assess medical and nutritional interventions in preterm neonates. Based on the results of this study, we recommend the use of the longitudinal evaluation, that proved to better predict the auxological long-term outcome with respect to the cross-sectional one. Extrauterine Growth Restriction (EUGR) has often been reported in literature following preterm birth and birth with Very Low Birth Weight . The condition of EUGR refers to an inadequate growth that occurs during hospitalization ,3. The gEUGR is influenced by a number of factors. It can be partially explained by periods of inadequate nutrition, feeding intolerance (commonly present in preterm infants), and a range of mild to severe morbidities associated with preterm birth ,6. PrenaCurrent definitions can be classified in two groups: (1) cross-sectional, consisting of having a weight below the 10th centile (or another cut-off) at a given time (t), independently of birthweight; and (2) longitudinal, consisting of a weight loss of more than 1 (or 2) Standard Deviation (SD) between birth and a given t-time. The t-times proposed in literature are three: 36 weeks of GA, age at discharge, and 28 days of postnatal age . The aim of this study was to investigate whether the EUGR (however defined) can predict the auxological outcome at 24–30 months of age, and to evaluate the agreement between cross-sectional and longitudinal definitions at the same t-time.Clinical and growth data were collected for 1887 infants with GA < 30 weeks or weight ≤ 1500 g (according to the Vermont Oxford Network criteria ), born bThe weight was expressed in Standard Deviation Score (SDS or z-score) using the INeS charts  (at birtNeonates were defined asSGA or Large for GA (LGA) if their birthweight was below the 10th or above the 90th centile of the INeS charts, respectively.EUGR was defined in the cross-sectional way if weight was below the 10th centile at a given t-time, whereas it was defined in the longitudinal way if the weight loss was more than one SD between birth and a given t-time. Forty weeks of GA was also considered in addition to the t-times typically considered in the literature , this being, conventionally, the average duration of a physiological pregnancy.The agreement between cross-sectional and longitudinal EUGR definitions at the same t-time was estimated by Cohen’s kappa coefficient.Among 1589 neonates, 803 babies  were followed up until 24–30 months; their data were analyzed to assess the auxological outcome with a general linear model that considers as response the difference of weight-, length-, or head circumference-SDS between 24–30 months and birth (∆SDS), and as covariates the EUGR (defined on weight as above), the population (A or B), and the weight by GA (SGA or non-SGA).The results of the general linear model estimate the effect of EUGR on growth, is reported in The LSmeans represents the estimate of the EUGR effect corrected for Population (A or B) and birth weight by GA (SGA or non-SGA).Both EUGR and non-EUGR groups were, on average, around lower centiles for weight at 24–30 months than at birth (mean ∆SDS < 0). On the contrary, regarding the head circumference, both EUGR and non-EUGR groups were, on average, on higher centiles than at birth (mean ∆SDS > 0).When EUGR was considered as longitudinal, the worsening of weight-SDS at 24–30 months was greater in EUGR than in non-EUGR group at all four times (p < 0.01). Similarly, the improvement of head circumference-SDS was higher in the non-EUGR than in the EUGR group. There were no differences between the EUGR and the non-EUGR in the cross-sectional evaluation, neither for weight nor for head circumference.No differences were observed for length.In the literature, there is no consensus about the definition of EUGR. For this reason, the results of the available studies are difficult to compare. Regarding the cross-sectional definition, many studies available in the literature differ for population and time.Applying the definition of EUGR as weight below the 10th centile at discharge, we estimated a prevalence of 74% of neonates with GA < 30 weeks, and 93% of neonates with GA ≥ 30 weeks and birthweight ≤ 1500 g. Our data are quite different with respect to the previous results described in literature; however, Clark et al. , and KarAccording to the definition of EUGR as weight below the 10th centile at 36 weeks of GA, we classified as EUGR 83% of infants with GA < 30 weeks, and 98% of newborns with GA≥30 weeks and birthweight ≤ 1500 g. Our results are in agreement with the data reported by Lemons et al. , who obsApplying a different definition of EUGR, characterized as weight at 28 days of postnatal life below the 10th centile, we found a prevalence of 53% of EUGR in infants with GA < 30 weeks, and 89% in newborns with GA ≥ 30 weeks and birthweight ≤ 1500 g. Our data agree with the results reported by Martin et al. , who estRegarding the longitudinal definition, in the literature, there are many studies that differ not only for population, but also for the choice of ∆SDS threshold. In our study, we defined the EUGR as the loss of 1SD between birth and discharge and 92% of newborns with GA < 30 weeks, and 55% of babies with GA ≥ 30 weeks and birthweight ≤ 1500 g was classified as EUGR. Franz et al.  defined Marks et al. , ShlomaiConcerning the four times considered, each one of them presents advantages and disadvantages. The time of discharge depends on different criteria and often varies among the Neonatal Units and even among physicians of the same Unit. However, this time is often used because it is considered a proxy of the clinical stability of patient. The reliability of times of 36 and 40 weeks of GA depend on the gestational age at birth, and, when the GA at birth is too close to 36 or 40 weeks, the physiologic weight loss could be confused with EUGR. The time of 28 days of postnatal life does not depend on GA at birth and it is equidistant from birth for all neonates; however, the late preterm babies are likely to be discharged before this time.Using different definitions of EUGR has several clinical implications. The cross-sectional way is an evaluation that does not consider what happened between birth and the t-time. The longitudinal assessment instead reflects changes from birth to a defined t-time. Additionally, for the longitudinal assessment, it is important to choose the right cut-off value to define EUGR  because the probability of exceeding it depends on birthweight: the lower the birthweight centile, the lower the probability to lose 1 or 2 SD. For this reason, and considering the large amount of SGA in our Neonatal Intensive Care Unit, we have chosen weight loss of 1SD as a cut-off of the longitudinal assessment.The benefit of a harmonized definition of EUGR is of the use of this measure in clinical practice for identifying babies with high risk of long-term auxological or neurological negative outcomes ,14,15,16The analysis of the auxological outcome at two years shows that, on average, our study population is lighter and shorter and has a lower head circumference with respect to the CDC-target population at the same age. This means that a delay in growth is experienced between birth and 24–30 months. Similar findings are reported in the literature ,30,31,32When Population A (GA at birth < 30 weeks) and Population B (GA at birth ≥ 30 weeks and VLBW) were considered separately, centile crossing down was observed for all three auxological variables in Population A. In population B, weight centile crossing down (lower than in Population A) was observed; however, head centile crossing up and an almost length centile tracking was observed. This is probably due to GA, which is known to affect the postnatal growth more than other conditions .The longitudinal definition of EUGR  was predictive of growth at 24–30 months, showing that the EUGR babies have a higher delay of growth than non-EUGR ones. Regarding head circumference at 24–30 months, on average, it is of higher centiles than at birth. Additionally, in this case, only the longitudinal assessment of EUGR was predictive of the outcome, showing that, on average, the gain is higher in non-EUGR than in EUGR group. Based on the data reported in our study, we suggest to use the longitudinal definition of EUGR as a better predictor of the auxological long term-outcome. The t-time of choice in our clinical practice is “at discharge” due to the high concordance between operators in the discharge criteria.The present study has limitations inherent to an observational study with retrospective collected data. For this reason, not all variables are available for all subjects at all the t-times considered. Moreover, even if the sample size is quite large, our study is monocentric. Since this is a single center study, the generalization of results to other centers is limited. On the other hand, the homogeneity of samples from a single center may strengthen the validity of the data. Future research should be designed as prospective, multi-center studies, in order to clarify the discrepancy in results across centers.In conclusion, the low agreement between cross-sectional and longitudinal definitions of EUGR is likely due to the fact that they measure different aspects of the growth. For this reason, it is necessary to have a clear and harmonized definition of EUGR allowing to compare different clinical strategies and nutritional care of preterm infants during hospitalization in Neonatal Intensive Care Unit. This definition should be an indicator useful to clinicians in their everyday practice. Based on the results of this study, we recommend the use of the longitudinal evaluation, which proved to better predict the auxological long-term outcome with respect to the cross-sectional one.


The daily diet plays a role in systematic inflammation and may be one of the causes of preterm birth. We aimed to examine the effect of a daily proinflammatory diet before pregnancy on gestational age and birthweight using a large birth cohort in Japan. We used data of singleton pregnancies in the Japan Environment and Children's Study involving live birth from 2011 to 2014 to calculate the dietary inflammatory index. We used individual meals with 30 food parameters from a semiquantitative food frequency questionnaire, which assessed diet intake before pregnancy. Participants were categorized according to the quartile of dietary inflammatory index. A multiple logistic regression model was used to estimate the risk of a proinflammatory diet on preterm birth (PTB) before 37 or 34 weeks and low birthweight (LBW) less than 2,500 or 1,500 g, accounting for maternal age, body mass index before pregnancy, smoking status, education, and household income. After applying our inclusion criteria, 89,329 participants were eligible for the present study. Multiple regression analysis showed that the proinflammatory diet had an increased risk of PTB < 34 weeks  and <2,500‐g LBW  compared with the control. In conclusion, a proinflammatory diet before pregnancy was a risk factor for PTB < 34 weeks and LBW < 2,500 g. Therefore, proinflammatory diet needs to be controlled to improve perinatal prognosis. Preterm birth, mainly caused by intrauterine infection, is related to neonatal mortality and morbidity.In addition to bacterial infections from the vagina, an inflammatory diet can also cause intrauterine inflammation, causing preterm birth.Our study found that an inflammatory diet before pregnancy was related to preterm birth, low birthweight infants, and hypertensive disorder of pregnancy.aORadjusted odds ratioBMIbody mass indexCIconfidence intervalDIIdietary inflammatory indexFFQsfood frequency questionnairesHDPhypertensive disorder of pregnancyHPChydroxyprogesteroneJECSJapan Environment and Children's StudyLBWlow birthweight infantsPTBpreterm birthSDstandard deviationSGAsmall for gestational age1Preterm birth (PTB), which can result in low birthweight (LBW) infants, is a major cause of neonatal morbidity and mortality. As preterm infants have immature fetal growth, complications such as cerebral haemorrhage and respiratory distress syndrome can occur , a government‐funded birth cohort study started in January 2011, were used. This survey investigated the effect of several environmental factors on children's health ; (2) Self‐reported questionnaire collected during their second/third trimester, including socioeconomic status such as maternal education or household income: (3) Obstetrics outcome which was retrieved from medical records of each subject's institution. (4) Maternal blood sample collected during their first trimester. The FFQ was completed during the first trimester, and diet intake was assessed before pregnancy. This tool, which was used in the JECS, has been validated as a self‐administrated diet questionnaire in previous Japanese epidemiological studies  for this study. This data set consisted of 4 types of information: (1) Self‐reported questionnaire obtained around the 1In the present study, we excluded cases with insufficient data, multiple pregnancies, or delivery before 22 weeks.4The DII score is a comprehensive indicator of daily inflammatory and antiinflammatory meal contents developed by Shivappa et al.  for each parameter included in the DII ; thus, the Z score of each value was converted to a centred percentile score. Then, the centred percentile score for each food parameter was multiplied by the respective food parameter effect score  to obtain a food parameter‐specific DII score, which were all summed to create the overall DII score for each participant. DII = I1·P1 + I2·P2 + … + I30·P30, where I is the food parameter effect score considering the effect of inflammation obtained from reviewed research articles, and P is the food specific centred percentile score derived from food data. The DII minimum/maximum in nonpregnant populations is reported to range from −8.87 to +7.98 , polyunsaturated fatty acids (PUFAs), fatty acids (n–3 and n–6 FAs), niacin, thiamin, riboflavin, iron, magnesium, zinc, selenium, vitamin A, B‐12, B‐6, C, D, E, folic acid, β‐carotene, garlic, ginger, and onion were obtained from each participants' FFQ. The DII score of each participant was calculated according to Shivappa et al. 2014a). First, the dietary data were linked to a worldwide database that provided a robust estimate of the mean and standard deviation  corrected for gestational age and sex according to Itabashi, Miura, Uehara, and Nakayama . Annual household income was categorized into four levels .PTB was classified into two categories: delivery before 37 weeks and before 34 weeks. LBW was also categorized into two categories: <2,500 and <1,500 g. Fetal growth restriction was evaluated using small for gestational age (SGA). SGA was defined as a birthweight below −1.5 standard deviation . Maternal characteristics were summarized according to each group. One‐way analysis of variance and the chi‐square test was used to compare the continuous and categorical variables, respectively. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) for PTB, LBW, SGA, and HDP were calculated using a multiple logistic regression model, accounting for maternal age, maternal BMI before pregnancy, maternal education, maternal smoking status, and household income. We accomplished this by using dummy variables for categorical variables composed of more than three categories. SPSS version 21  was used for the statistical analyses. A 7The total number of fetal records from infants delivered between 2011 to 2014 in the JECS was 104,102. Of these, 3,332 and 982 infants were excluded due to insufficient data for DII and multiple gestation, respectively. Then, 609, 1,085, and 8,775 participants were excluded for the reasons of abortion, unknown gestational age, and insufficient data, respectively. After applying our inclusion criteria, 89,329 participants were eligible for the present study and categorized into four groups according to quartiles . Whereas maternal age <20 years was the most common in the highest DII score quartile (the most proinflammatory group), maternal age >40 years was the most common in the lowest DII score quartile (the most proinflammatory group). The proportion of low maternal education (<10 years) and low household income  increased with increasing quartiles of DII. The ratio of leukocytosis, which was defined as WBC count over 12,000 during the first trimester, also increased with each increasing quartile of DII.Table P = .03 and P = .04, respectively). These occurrences increased with the increase in DII category.With regard to obstetrics outcome, significant differences in the occurrence of LBW < 2,500 g and HDP were seen (9Table 10This is the first study to investigate the relationship between inflammatory diet and obstetric outcomes, using the largest birth cohort study in Japan. Our results suggest that proinflammatory diet before pregnancy was a risk factor for PTB < 34 weeks and LBW <2,500 g, and HDP.Until now, few studies that examined the correlation between DII score during pregnancy and obstetrics outcomes have conducted. Sen et al.  calculatThe mechanism of the association between proinflammatory diet before pregnancy and PTB is unknown. We think that there are two scenarios where proinflammatory diets cause PTB. First, some foods with large amounts of saturated and transfats induce proinflammatory cytokines (Soto‐Vaca, Losso, McDonough, & Finley, The strength of this study is that it is the first large‐scale study conducted in Japan by the Japanese government with meticulous attention to data collection. Therefore, this study is considered to be representative of the general pregnant population in Japan (Yamaguchi et al., In conclusion, we found that a proinflammatory diet before pregnancy was a risk factor for PTB, LBW, and HDP. Our study suggests that dietary habits may affect obstetric outcomes. Therefore, proinflammatory diet needs to be controlled to improve perinatal prognosis.None.The authors declare that they have no conflicts of interest.All authors approved the final manuscript. M. I. initiated the concept and designed the study to which H. K., A. Y., K. F., and K. H. gave advice. M. K., A. S., and Y. O. collected the data. M. I. analysed the data and wrote the manuscript. M. H., K. F., S. Y., M. K., A. S., Y. O., K. H., and the JECS group reviewed the manuscript and gave critical advice.


The Dutch famine birth cohort study was set up to investigate the effects of acute maternal undernutrition of the 1944–1945 Dutch famine during the specific stages of gestation on later health, with a particular focus on chronic cardiovascular and metabolic diseases, ageing and mental health.The Dutch famine birth cohort consists of 2414 singletons born alive and at term in the Wilhelmina Gasthuis in Amsterdam around the time of the Dutch famine (1943–1947) whose birth records have been kept. The cohort has been traced and studied since 1994, when the first data collection started. The cohort has been interviewed and physically examined in several waves of data collection since that time, allowing repeated measures of a wide range of phenotypic information as well as the collection of biological samples , functional testing  and imaging of the brain (MRI) and vasculature (ultrasound). Additionally, genetic and epigenetic information was collected. Through linkage with registries, mortality and morbidity information of the entire cohort has been obtained.Prenatal famine exposure had lasting consequences for health in later life. The effects of famine depended on its timing during the gestation and the organs and tissues developing at that time, with most effects after exposure to famine in early gestation. The effects of famine were widespread and affected the structure and function of many organs and tissues, resulted in altered behaviour and increased risks of chronic degenerative diseases and increased mortality. The effects of famine were independent of size at birth, which suggests that programming may occur without altering size at birth.As the cohort ages, we will be assessing the effects of prenatal undernutrition on (brain) ageing, cognitive decline and dementia, as well as overall morbidity and mortality.The Dutch famine birth cohort is not linked to a clinical trial. The quasi-experimental design of the study provides a unique opportunity to investigate effects of undernutrition in pregnancy that would not be ethically possible to study otherwise.The long period of follow-up allows for unusually long-term consequences to be investigated decades after the exposure of interest.A limitation is the relatively small size of the cohort limiting the statistical power to investigate effects of prenatal famine exposure on outcomes that are rare.Selective survival and participation may have introduced bias in the studies which included physical examinations or measurements, but linkage to registries give insight into the degree of selection that has occurred.No information is available on the time period between discharge from the hospital after birth and age 50 when the cohort was first traced, leaving limitations for adjusting for potential confounders that may have had an influence during this period.The Dutch famine birth cohort study is a historical birth cohort of men and women born around the time of the 1944–1945 Dutch famine in the Wilhelmina Gasthuis (WG) in Amsterdam, the Netherlands. The study was set up to investigate the effects of prenatal exposure to the Dutch famine on adult health in order to semiexperimentally test the developmental origins of adult disease hypothesis in a human setting. Based on this hypothesis, we expected increased rates of chronic diseases such as type 2 diabetes and cardiovascular disease among those who had been exposed to the Dutch famine prenatally.This paper describes the rationale for the Dutch famine birth cohort study, why it was set up, how it was set up, and which unique features of the Dutch famine provided the opportunity to semiexperimentally investigate effects of prenatal undernutrition in a human setting and allow for the long-term consequences to be investigated decades later. We provide an overview of the studies that have been done in the cohort so far, the findings of 25 years of research in this cohort and which insights they provided as well as the implications these insights might have.Epidemiological studies in populations across the globe have consistently shown that small size at birth is associated with increased risks of chronic degenerative diseases and their biological risk factors such as hypertension, type 2 diabetes and cardiovascular disease.The tragic circumstances of the Dutch famine of 1944–1945 created a unique opportunity to assess the effects of prenatal undernutrition on human health in later life. During World War II, part of the Dutch population was exposed to famine during the severe ‘hunger winter’ of 1944–1945. This historical tragedy has provided the unique opportunity to study short and long-term effects of famine exposure during intrauterine development. The Dutch famine can be viewed as a ‘natural experiment’, because of its sudden onset and end in a previously well-nourished population. The famine was acute, relatively short and had an impact on the entire population within the affected regions, minimising confounding by genetic inheritance or other simultaneously occurring risk factors, such as socioeconomic status. Also, throughout the famine, food rations were precisely registered.In 1944–1945, the Dutch famine hit the western parts of the Netherlands towards the end of World War II, only months before its liberation from the German occupier by the Allied forces. Before the war, nutritional standards of the Dutch population were generally adequate.16 17Soon after the war ended, researchers realised the unique setting the Dutch famine had unintentionally created to semiexperimentally investigate effects of famine exposure in pregnancy on offspring’s health. Since, several research groups have investigated the long-term consequences of prenatal exposure to the Dutch famine. These studies have used a variety of different designs; register studies have linked date and place of birth to various outcomes, data from recruitment tests of military conscripts have been used to study links between prenatal famine exposure (based on time and place of birth) and IQ, mental health and body mass index (BMI), and birth records have been used to set up cohorts comparing those exposed to famine prenatally with their unexposed same-sex siblings, or to those born in the same hospital either before the famine or conceived after it. Some of the earliest studies on the Dutch famine were published within a few years after World War II by Smith and Sindram, and showed that babies born during the famine were lighter at birth.18 19In the 70s, data from 19-year old Dutch military conscripts were used to investigate effects of prenatal famine exposure on IQ20 21Using the Dutch Psychiatry Registry, increased rates of schizophrenia,Barkers findings of links between small size at birth and later cardiovascular and metabolic disease and the hypothesis that fetal undernutrition would underlie this associationIn 1994, the Dutch famine birth cohort was set up in the Academic Medical Centre in Amsterdam, the Netherlands. All men and women born as term singletons between 1 November 1943 and 28 February 1947 in the WG in Amsterdam were eligible candidates to be included in the Dutch famine birth cohort. The WG was the main maternity hospital in Amsterdam at the time of the famine and birth records were still kept at the city archive of Amsterdam.The birth ledgers, which contained general information on date of birth, name of the parents and identification number were retrieved from the Obstetrics department of the Academic Medical Center (the former WG) in Amsterdam of individuals born between 1 November 1943 and 28 February 1947. From the 5425 records, all individuals exposed to famine, according to our definition (see below), were considered eligible exposed candidates. A random sample of eligible individuals unexposed to famine during gestation (born before the famine or conceived after the famine) was taken. Twins and stillbirths were excluded. This resulted in 2680 eligible candidates for which the detailed medical records were searched and coded in all detail in the city archive of Amsterdam. Of these 2680 individuals, 27 individuals (1.0%) were excluded because their medical records were missing or incomplete, and 239 individuals (8.9%) were excluded based on their preterm birth . Ultimately, 2414 people were considered eligible .Exposure to famine during gestation was defined as an average maternal daily ration of less than 1000 calories during any 13-week period of gestation.Medical records contained information on maternal characteristics including maternal weight and blood pressure throughout pregnancy as well as a detailed description of delivery and the postpartum period.Maternal characteristics included maternal age, marital status, reproductive and medical history, and occupation of the head of the family. Blood pressure and maternal weight were measured at every prenatal visit. Pelvic measurements were taken, including the interspinous distance (the distance between the anterior superior iliac spines). Maternal weight gain in the third trimester was estimated as the difference between the woman’s weight as close as possible to the start of the third trimester and her weight at the last prenatal visit , multiplied by the ratio of trimester duration (13 weeks) and the time interval between the two weight measurements.2). Placental area was calculated by: π * placental length * placental width * 0.25. At discharge, infant weight and type of feeding (exclusive breastfeeding/exclusive bottle feeding/a combination) were recorded. Besides information from the medical records for each woman the profession of the father/the head of the family was collected using the hospital admission ‘crib cards’ and coded as manual or non-manual work. Birth characteristics included date of birth, sex, birth weight and birth length (crown to heel). Head circumference was calculated by: π *  * 0.5. Ponderal index was calculated by: birth weight/ in Amsterdam, which traced 2155 of the 2414 eligible participants. Of these, 265 persons had died, 199 had emigrated and another 164 refused to share their address, resulting in 1527 (63.3%) of 2155 cases. Power calculations for a study sample to be invited for interviewing and clinical measurements were based on the 120 min glucose concentrations after a 75 g oral glucose load as the main outcome variable, based on pooled data from three previous MRC Southampton studies which had established a link between birth weight and glucose tolerance in adulthood .31Data collection of the Dutch famine birth cohort study has occurred in six study waves from 1994/1996 to 2020, with a seventh wave planned in 2021  permanent effects on human health. The effects of undernutrition (2) depend on its timing during gestation and the organs and systems developing during that critical time window. The effects on later health were most pronounced among those exposed to famine in early gestation. This may not be surprising considering the fact that all organs are formed in early gestation and insufficient food supply during the formation of the organs interferes most with future physiological functions. The effects of famine were independent of size at birth (3) as there were effects of prenatal famine exposure in the absence of effects on body size at birth. This implies that adaptations that enable the fetus to grow can nevertheless have adverse long-term consequences.Below, we describe the findings according to the three main conclusions.54Our findings suggest that famine exposure during periods of rapid organ growth permanently affects organ structure. The majority of adverse effects of prenatal famine on several (precursors of) chronic diseases were observed specifically in those exposed during early gestation.One of the findings of the Dutch famine birth cohort study is that babies born after exposure to the famine in mid  or late  gestation had lower birth weights, whereas babies born after exposure to the famine in early  gestation had higher birth weight compared with controls .58 This www.hongerwinter.nl).Further information, including a list of publications can be found on the cohort’s web page  and poorer health outcomes. This asymmetric loss of adults with poorer health may have led to an under estimation of the true effects of prenatal famine on adult health outcomes.A final limitation to the study is that we have no information on the time period between discharge from the hospital after birth and age 50 when the cohort was first traced, making it impossible to adjust for potential confounders that may have had an influence during this period.Studies in other settings, of famines with different durations and severity support these findings and suggest that the results of studies on the Dutch famine are not uniquely linked to the Dutch famine situation, but rather reflect biologically fundamental processes of human plasticity.Studies of the Dutch and other famines show that those faced with undernutrition during the critical earliest stages of development have increased rates of chronic generative disease in adult life. These findings teach us the fundamental importance of a good start in life. Adequately feeding women before and during the pregnancy will allow future generations to reach their full potential and lead healthier and more productive lives, ultimately leading to a healthier and more equal future.t.j.roseboom@amsterdamumc.nl).The Dutch famine birth cohort study welcomes opportunities for collaboration; Enquiries should be directed to the principal investigator (


Birth registration establishes the existence of a child under law and provides the foundation for ensuring many of his/her rights. Despite its significance, a continuous, effective and comprehensive birth registration system has not been established in Ethiopia until the recent past. This paper examines the status of child’s birth registration and its associated factors in selected districts of Tigray Region, Ethiopia.A community-based cross-sectional study was conducted from April to May 2018 among 383 randomly selected mothers who had given birth to at least one child since August 2016. A structured questionnaire was used to gather the quantitative data. Qualitative data were collected using key informant interviews and focus group discussions. To analyze the data, SPSS version 20 was used. Logistic regression analysis was employed to assess the association between dependent and independent variables.Findings reveal that significant number of the respondents did not have knowhow about birth registration and its uses. As a result, only 117(30%) of them registered the birth of their children and secured certificates. Inaccessibility of the registrar offices, lack of relevant manpower and political will of the government were reported as major reasons for such a gap. Mother’s education was identified to be positively associated with the likelihood of a child being registered. Children born from mothers living in urban areas were found more likely to be registered compared to their rural counterpart . In light of Religion, children from the Muslim community had better opportunity for birth registration and owning birth certificate compared to children from Orthodox Christian parents. Compared to those who have possessed own birth certificates, the likelihood of mothers who did not possess own birth certificates to register the birth of their children was found lower by the factor of 86% .Birth registration of a child and subsequent issuance of certificate should be pursued as a right issue. To make this a reality, extensive awareness raising programs that underscore the need for a birth registration and its significance for rural communities is needless to say critical. Birth registration, the official recording of a child’s birth by a government agency is one of the most important events in a child’s life. As vividly stipulated in various human right instruments including the Convention on the Rights of the Child , all children have the right to the registration of a name, identity and birthdate .Birth registration is fundamental because it establishes the existence of the child under law. However, apart from being the first legal acknowledgement that designates the child, registration of birth is more often than not vital to the realization of a number of rights and practical needs including provision of access to social services; protecting young people from under-age military service or conscription and securing the child’s right to a nationality at the time of birth or at a later stage. Additionally, it is essential for getting a passport, opening a bank account, obtaining credit, voting or finding employments . In shorData on birth registration supplemented by other statistics such as death, divorce, and marriage are indispensable for setting targets, developing indicators and measurement of progress towards national and global human development targets such as Sustainable Development Goals (SDGs) . The meaA survey report disclosed by UNICEF shows that the percentage of self-reported birth registration under the age of five was 65% globally in the year 2013, which was improved to 71% in 2016 , 10. AltIt is a cause to underdevelopment because the absence of complete birth registration has negative repercussions for children and a nation. For instance, it deprives a child of the privileges, rights and protection that a nation offers for its citizens and hampers overall national development process of a nation , 13. It Available sources in Ethiopia show that the formulation and issuance of relevant laws and policies for the enforcement of birth registration as part of a vital registration system dates back to the time of Emperor Menelik in the beginning of the twentieth century , 15. SinCognizant of the importance of birth registration and the problems associated with not doing so, the Government of Ethiopia has reorganized the legal framework and invigorated the national registration system. Proclamation on civil registration and national identification that compels for births to be registered within three months after birth was for example enacted by the Parliament in July 2012 . HoweverA community-based cross-sectional study was conducted from April to May 2018. The study was conducted in four Woredas (districts) of Tigray Region, namely Shire-Endaslassie, Medebay-Zana, Aksum and La’elai-Maichew. Situated at the northern tip of Ethiopia, Tigray Regional State is one of the nine administrative regional states in the nation. According to the estimate made by Central Statistical Agency (CSA) of Ethiopia, the total population of the region in 2017 was 5.2 million of which, 1.4 million and 3.8 million people lived in urban and rural areas, respectively .The target population of this study was all women who had given birth to at least one child since August 2016, the time when the official registration of birth and other vital events was commenced in Ethiopia. Mothers who had given birth prior to the specified time were intentionally excluded from the study. A single population proportion formula was used to determine the sample size for determining the percentage of registered children with birth certificates and associated factors. In sample size calculation, assumed 50% of registered children with birth certificates was taken because of lack of similar study conducted in Ethiopia. Accordingly, the sample size considered for this study is determined taking into account the standard score corresponding to 95% confidence interval, assumed proportion of registered children with certificates at 50% and the margin of error.Accordingly, data were collected from 384 mothers. To select the sample size from the target population, systematic random sampling technique was used. At the beginning, from the seven administrative zones of the region, two zones  were taken using random sample. Following that, identification of the number of districts in each selected zone was made. Then, four districts (two from each zone) were selected randomly. The districts are Aksum town and La’elai-Maichew from central and Shire-Endaslassie and Medebay-Zana from North West Zones. Once the sample districts have been identified, eight Tabias  were considered randomly. Finally, systematic random sampling technique was employed to select the respondents. The list of eligible mothers was taken from the health extension workers of each Tabia. At the time of data collection, the age of the youngest participant of this research was 18 years. To get representative sample from each district, the study sites were initially stratified into urban and rural districts and final sample individuals were taken considering the number of mothers who had given birth to at least one child since August 2016 in each district.Idir, women and youth associations and parents were included.An interviewer-administered structured questionnaire (see supplementary file_1) was used to gather the quantitative data. This instrument was deployed to collect data pertaining to demographic characteristics, awareness, and practice of birth registration in the study areas. Qualitative data were collected using Key Informant Interviews (KII) and Focus Group Discussions (FGDs). An interview guide was developed to collect qualitative data from the key-informants (Supplementary file_2). Four key informant interviews and two FGDs were held. The key informants interviewed were officers of civil status assigned to register vital events and issue certificates including birth in each study area. The participants of the FGDs were deemed to represent the local community and hence district officials, religious leaders, leaders of community based organizations such as All returned questionnaire were checked for completeness and consistency of responses manually. After such cleaning, the items were coded and entered into Statistical Package for Social Sciences (SPSS) version 20, and the data entered were checked on normality. Analysis of the data was done using univariate, bivariate and multivariate analyses. Univariate analyses such as frequency and summary measures were used to depict the background attributes of the respondents, whereas bivariate analysis was used to examine the relationship between whether mothers have registered the birth of their children and get birth certificate or not with socio-economic covariates. To identify the factors that influence mothers’ propensity to register and get birth certificates for their children, logistic regression model was applied. Odds ratios at 95% Confidence Interval (CI) were also computed and reported. To see the relationship between the outcome variable and each predictor variable, at the outset binary logistic regression was used. Predictor variables that turned out significant (P ≤ 0.05) at this level were considered for further analysis. The set of predictor variables considered were identified from previously conducted researches in different settings. The dependent variable in this study- registration and possessing of birth certificate of a child or not, is a binary variable which took a value one if mother did register the birth of her child and got birth certificate, zero otherwise. At the time of data collection, mothers who did register the birth of their children were asked to show the certificate; because in Ethiopia, the issuance of a birth certificate immediately follows birth registration.From the 384 eligible mothers, 383 respondents (99.7%) fully responded to the interviewer administered questionnaire. The age composition of the respondents shows that 139 (36.3%) of them were 24–28 years old, followed by 29–33 years 89 (23.2%) and less than or equal to 23 years 86(22.3%). The remaining 69(18%) were aged higher than 34 years. The mean age of the women was 28 ± 5.6 years. Out of the total respondents, 239 (62.4%) were living in urban areas at the time of the survey and the remaining 144(37.6%) were rural residents. With regard to the marital status of the respondents, the majority 291(76%) were currently married, while 39(10.2%) were never married. The predominant religion was Orthodox Christianity for 351 (91.6%) respondents, followed by Muslim 32 (8.4%).The educational level of the respondents indicates that 142 (37%) and 119 (31%) of them have completed primary (1–8) and secondary (9–10) education, respectively. Surprisingly, 76(20%) of the respondents have not received formal education. Only 46 (12%) have completed preparatory and above level of education. The finding further uncovers that majority of the respondents were self-employed mainly in agriculture and trade which account 93 (24.3%) and 75(19.6%), respectively. The respondents who relied on agriculture for their means of livelihood are underemployed because of the seasonal nature of the activities. Moreover, 43 (11.2%) of the respondents were housewives virtually responsible for family care and household chores. The proportion for the unemployed was 22.2%. The remaining were government employees, hired in private organizations and daily laborers (Table The reproductive history of the respondents unveils that 241(63%) of the mothers have given birth to less than or equal to two children, and 125 (32.7%) of them had 3–5 children. The average number of birth was 2.4 ± 1.4 children. Here, mothers were inquired to report the birth order of their last child (latest birth). Accordingly, the result pointed out that 121(31.6%) and 120(31.3%) of the respondents reported that the birth order of their last child was 1st and 2nd, respectively. The age at first birth of the mothers indicated that 181(47.2%) of them gave birth to their first child between 20 and 24 years, and followed by less than or equal to 19 years which accounted 111(29%). The median age at first birth was found to be 21 years. The result further showed that 84.6% of the mothers have visited the nearby health center at least once during pregnancy time for their last child to get antenatal care (ANC) service. It was also found that 86.7% of the mothers delivered their last child at health centers but the remaining gave birth at home, in the absence of professional support. The proportion of mothers who got postnatal care service was 308(80.4%)  of the respondents were knowledgeable while 73(42.4%) of them were otherwise  mothers had heard or been aware of birth registration services, only 117(30%) of them did register their children at birth and possessed birth certificates. The majority, 266(70%), did not register their last child and had no birth certificates at all. From the total respondents who registered and secured birth certificates for their last child, 71 (60.7%) registered their children and acquired certificates within 90 days  following the date of live births whereas the remaining 39.3% did it after 3 months. Information from the FGDs and interviews demonstrated that registration of birth as an act of recording and recognizing the birth of a child by the government was largely unknown at the level of community. During the interview with mothers, we frequently witnessed the tendency to equate birth registration and certification with non-birth registration documents or cards acquired from churches and health institutions. More specifically, a significant number of the respondents considered cards or pieces of papers issued for vaccination as birth registration and certification evidences. Whenever we asked mothers to show us the certificate, they proudly revealed us cards issued by health institutions for vaccination purpose or cards acquired from churches for baptism because churches record the birth of a child when it is baptized. Nevertheless, these cards are limited in coverage and quality when they were viewed from the criteria of what birth registration document is supposed to include. Moreover, absence of coordination between the registrar offices and other concerned bodies like health institutions and police, shortage of infrastructure, inaccessibility of the registrar office and lack of commitment on the side of government organs were repeatedly reported by the key informants as major predicaments for the implementation of the system.Table p < 0.05) to determine mother’s probability to register the birth of her child. Compared to mothers aged ≤23 years, mothers aged between 24 and 28 years were 2 times more likely to register the birth of their children and get birth certificate . In addition to this, the likelihood of mothers aged between 29 and 33 years to register the birth of their children was 2.5 higher compared to mothers aged less than or equal to 23 years . Compared to the reference category (≤23 years), mothers aged greater than or equal to 34 years were less likely to register their children by a factor of 23%, though it was not found statistically significant.Age is one of the predictor variables found significant  of the respondents have never heard about birth registration. Even significant proportion of those who had information about it have not been well-informed because they did not know the legal time when to register a child and the legal office in charge of birth registration and related issues. As a result, 57.6% of the respondents who have ever heard about birth registration have knowledge about birth registration and the importance of birth registration and certificates for their child’s future, which is basically lower than the value (69.9%) found in urban communities of Southern Nigeria . Overalllate registration by the decree. In this regard, it is possible to say that the percentage of registered children and received birth certificate is low in the study areas compared to results in Ghana (52.4%) [The result on the level of birth registration depicts that only 30% of the mothers who had given birth to at least one child since August 2016 had registered the birth of their children and secured certificate for it. Here, the legal framework enacted in Ethiopia to execute birth registration and other vital events needless to say stipulates that births shall be registered within 90 days of the occurrence of the event . However (52.4%) , in thre (52.4%) . Neverth (52.4%) . The gen (52.4%) .The results of multivariate analysis demonstrate that Muslim children have higher chances of registering and acquiring birth certificate. This might be due to the fact that in the history of Ethiopia, there has not been practical official registration of births and other vital events despite the enactment of piece of laws and legal frameworks. In this regard, readers have to notice that the dominant group is follower of Orthodox Christianity. The dogma of the church orders that a baby irrespective of sex must be baptized in order to be counted as member of the Christian community. Hence, Christian followers acquire a card or document for their children from their church during the baptism day. This card seems official birth certificate. Owing to this deeply rooted practice, parents affiliated to Christian Religion have the tendency to consider the card obtained from the churches as the official birth certificate. This in turn resulted in abandoning the official registration of their children even official recording of births is in place. However, the flaw of the document given by the church is that it is not official because it fails to recognize and protect personal, and socio-economic and political rights. This needless to say created disparity in the level of official birth registration among the Christian and Muslim Religious followers. This finding is not typical to the study area, however. It is so because similar research findings were revealed in some African countries like Ghana where children from Muslim households had higher likelihood of being registered compared to their Christian counterparts .Education is also found to have its impact on birth registration. The finding that maternal education improves the likelihood of children being registered is not something unanticipated as it is consistent with empirical evidences and general perceptions. For instance, empirical studies in different African countries such as Ghana , Laos 2, Zambia Maternal age was also found as a significant factor for birth registration in the study areas. As indicated in the multivariate analysis, the probability to register birth of their children was found higher among mothers aged 24–28 years and 29–33 years compared to mothers aged less than 24 years. This result is also consistent with findings reported in Laos . This isThe data were collected from mothers who have given live births for at least one child since August 2016 and whose children were alive at the time of data collection. However, mothers who had given live births for their last children but whose children were not alive at the time of data collection were not part of the study. Thus, birth registration may have been over or under reported in this study. The prevalence of the outcome found is relatively high (30%), which could be derived from information bias. Consequently, there might be an overestimation of the relative risk in the model. Moreover, this result cannot be generalized to the entire population of Ethiopia, but only to the population of the study region (Tigray Region).Registration of birth and acquiring certificate promotes not only the protection of fundamental rights of children but also the provision of educational, health, social security, and other social and economic services. However, findings from this study demonstrate that majority of the respondents have never heard about birth registration, significant numbers do not have knowhow about the procedures of birth registration including the legal time when to register their children and the importance of birth registration and certificates for their child’s future.To improve the status of birth registration to the desired level, therefore, organizations working at local level should create awareness among community members. In this regard, organizations engaged in activities related to schools and health centers should play a dominant role in creating opportunity to encourage and implement birth registration. Such organizations should create clear and expansive awareness raising campaigns on the part of the community regarding the difference between official birth registration and documents obtained from churches and other institutions. This can encourage mothers to register their children with reasons. Furthermore, the government has to prioritize birth registration. Intervention programs initiated by the government and other stakeholders should focus on rural areas, an uneducated segment of the community. Doing so is vital because findings of this study seem to suggest that birth registration is more of a privilege for a small number of children whose mothers are educated and live in urban areas. Finally, further nationwide comprehensive research is required to ascertain the institutional arrangements, effects of low birth registration and intervention programs.Additional file 1 : Survey questionnaire used to assess the status and associated factors of birth registration in selected districts of Tigray Region, Ethiopia, may, 2018.Additional file 2 : An interview guide used to assess the status and associated factors of birth registration in selected districts of Tigray Region, Ethiopia, may, 2018.


The objective of this study was to observe mode of delivery among women with a history of prior cesarean birth.After collecting data on a convenience sample of 1,000 women giving birth at 28 weeks gestation or greater at Mizan-Tepi University Teaching Hospital, we reduced the sample to only include women with a history of prior cesarean birth. We wanted to observe mode of delivery among this cohort and determine if any characteristics were associated with elective repeat cesarean birth, as compared to vaginal birth after cesarean.Of 1,000 women in our convenience sample, data on history of prior cesarean birth was missing on 2 women (0.2%). Of the remaining women, 49 (4.9%) reported a history of prior cesarean; 44 (89.8%) reported one prior cesarean and 5 (10.2%) women had two prior cesarean births. Repeat cesarean birth occurred in 65.1% (n = 29/44) of women with one prior cesarean and in 80.0% (n = 4/5) of women with two prior surgeries. Among the total cohort of women with a history of prior cesarean birth, of those who experienced repeat cesarean birth (n = 33), 27.3% (n = 9) occurred pre-labor, 69.7% (n = 23) occurred intrapartum after the onset of spontaneous labor, and 3.0% (n = 1) occurred intrapartum during the course of an induced or augmented labor. Labor onset and cervical exam on admission were statistically significantly different in bivariate comparisons of women who successfully achieved vaginal birth after cesarean as compared to those who gave birth by repeat cesarean birth, and postpartum maternal antibiotics were more common after repeat cesarean birth, p < 0.05. In a multivariable model of factors associated with successful vaginal birth after cesarean, the likelihood of successful vaginal birth was increased 15% for each increasing centimeter of dilation on a woman’s admission cervical exam .Almost one-third of women in our observational cohort attempted trial of labor after cesarean; those that were successful were more likely to have been more cervically dilated on their admission exam. No sociodemographic or obstetrical characteristics were more likely among women who underwent pre-labor repeat cesarean birth as compared to intrapartum cesarean birth. We observed a convenience sample of 1,000 women who gave birth (after 28 completed weeks of gestation) on labor and delivery at MTUTH between May 6 and October 21, 2019. Through a combination of chart review and structured interview at admission, delivery, and discharge, three physicians collected de-identified data, which was entered into REDCap . Bivaria3.In bivariate comparisons, shown in columns 2 – 4 of 4.Our analysis showed that almost one-third of women with a history of prior cesarean birth are attempting a trial of labor after cesarean at MTUTH, including women requiring induction or augmentation. We have conducted a number of other analyses with this dataset on characteristics associated with cesarean birth among subgroups of women and have found that generally, there are clear obstetric complications associated with cesarean birth, such as prolonged labor. In this analysis, however, the characteristic associated with cesarean birth was how dilated (Bishop’s score) the woman was on admission—the more dilated she was, the lower her risk of cesarean birth. Reported indications were maternal, fetal, or a combination of the two, with one woman identified as undergoing repeat cesarean birth for failed trial of labor.According to our analysis, there was no difference in the prevalence of intrapartum or postpartum complications between the study groups. We did test a number of antepartum, intrapartum, and postpartum maternal and neonatal complications, but there was no difference in outcomes between the groups (data not shown). Prior research has found that pre-labor elective research cesarean birth is associated with reduced postpartum hemorrhage and improved neonatal outcomes as compared to vaginal birth after cesarean . Though When we discussed these findings with coauthors and colleagues at MTUTH, the way these women are currently managed is that providers currently screen for any contraindications to vaginal birth after cesarean using a protocol based on national recommendations. If, according to the protocol, the woman qualifies for a safe trial of labor, she will then be offered the option of cesarean birth versus trial of labor after cesarean. She is usually counseled by a physician during her antenatal care in the outpatient setting and given time to consider the choice. No specific protocol is currently used for counseling. If she chooses to labor, she is monitored with electronic fetal monitoring or managed one-on-one by a midwife on service. MTUTH also has a blood bank on site. The current practices at MTUTH appear to be resulting in the safe management of trial of labor after cesarean. An area of research might be into the standardization of the vaginal birth after cesarean counseling women are receiving or use of a decision aid to ensure that all women are receiving similar information under similar circumstances. The one-to-one attention during trial of labor would also be an area of potential research. This analysis is limited by the lack of contextual data surrounding counseling of women and the method women use to decide on mode of delivery after a prior cesarean birth. Further qualitative research on this topic would add richness to the data and assist with disseminating the success that MTUTH has achieved regarding safe trial of labor after cesarean and vaginal birth after cesarean. Prospective research on the process used by MTUTH regarding mode of delivery decision-making and intrapartum management would enable further research on best methods to implement and disseminate these evidence-based practices, elsewhere.


Higher RRP and ERP was each associated with higher continuous birth weight and lower odds for low birth weight and small for gestational age, with evidence for effect modification by maternal race. On average, per interquartile range increase in RRP, the birth weight was 10.0 g  higher among babies born to white mothers versus 6.9 g  higher among those born to black mothers. For ERP, it was 18.6 g  higher among those that were born to white mothers versus 1.8 g  higher among those born to black mothers. Racial and economic polarization towards more privileged groups was associated with healthier birth weight outcomes, with greater estimated effects in babies that were born to white mothers than those born to black mothers.Neighborhood demographic polarization, or the extent to which a privileged population group outnumbers a deprived group, can affect health by influencing social dynamics. While using birth records from 2001 to 2013 in Massachusetts ( The demographic polarization of a neighborhood describes the extent to which a population group outnumbers another ,2. PopulTo date, few studies have investigated the association between neighborhood demographic polarization and health. Of those that are published, demographic polarization towards more privileged groups was associated with better health outcomes, such as decreased risk for hypertension , pretermi represents the number of non-Hispanic white residents, Bi the number of non-Hispanic black residents, and Ti the total number of residents in Census tract i. In other words, it represents the difference between the number of residents that belong to the privileged group and the number belonging to the deprived group, divided by the total number of residents in a given Census tract. For ERP, the calculation is similar: Wi is replaced with the number of households earning ≥ $100,000 per year, Bi with the number of households earning < $25,000 per year, and Ti with the total number of households in Census tract i. These two annual income cut points approximately correspond to the 75th and 25th percentiles of annual household income in Massachusetts in 2010 [We calculated demographic polarization based on race using five-year estimates from the 2010 American Community Survey, which we termed racial residential polarization (RRP), and demographic polarization based on income, which we termed economic residential polarization (ERP) . In each in 2010 . RRP andn = 978,225). We excluded those with missing address information , with a birth weight below 500 g (n = 772), not live births (n = 8621), not singletons , and not full-term . We excluded a further 154,296 births (19 percent) born to mothers of other racial/ethnic groups, as we were interested in comparing birth outcomes in those born to non-Hispanic white and non-Hispanic black mothers. In addition to birth weight, the birth records included information about the pregnancy itself, such as gestational age, as well as maternal characteristics, such as race/ethnicity, smoking, medical conditions before or during pregnancy, and highest educational level attained. After excluding those with missing covariate data , the final sample size was 629,675. The Massachusetts Department of Public Health geocoded each maternal residential address against TomTom Multinet using AccuMail address and Zip code. These geocodes allowed us to link each birth to its residential Census tract. The Massachusetts Department of Public Health approved the use of these data.We obtained records from the Massachusetts Department of Public Health for all births between 1 January 2001 and 31 December 2013 , and small for gestational age . For birth weight, we built linear mixed models; we built logistic mixed models for LBW and SGA. These mixed models included a random intercept for Census tract to account for possible geographical clustering and confounding by unmeasured spatial variables.a priori based on those used in prior birth weight studies [2.5), since maternal exposure to PM2.5 during pregnancy is negatively associated with birth weight [2.5 exposure during the entire pregnancy was estimated by calculating the average of daily PM2.5 predictions while using the maternal residential address and gestational age. The PM2.5 data came from a hybrid prediction model that combined land-use variables and remote sensing measurements from satellites to estimate PM2.5 daily at a 1 km × 1 km resolution. It was calibrated with PM2.5 monitoring measurements and it was performed with high accuracy with temporal, spatial, and combined out-of-sample R2 consistently above 0.8 [We started with univariate analyses quantifying the unadjusted association between RRP or ERP and each birth weight outcome. Subsequently, we built multivariate models adjusted for covariates selected  studies ,17,18. T studies , birth mh weight ,21. Eachbove 0.8 . In the P values were two-sided.We evaluated disparities in the estimated effects of RRP or ERP on birth weight outcomes among those born to white mothers when compared to black mothers by including an interaction term between individual maternal race and RRP or ERP in fully-adjusted models. We then computed the point estimate of the explanatory variable  along with its 95 percent confidence interval (95% CI). We were concerned about the modifiable areal unit problem , so we cWe analyzed a total of 629,675 births, of which 89.5 percent were born to white mothers and the remainder to black mothers . RRP hada priori were confounders. In supplementary analyses, we found that maternal smoking, maternal education, clinical gestational age, Medicaid eligibility, parity, and PM2.5 to be of the most substantial sources of confounding (Higher RRP or ERP was each associated with increased continuous birth weight and lower odds for LBW and SGA . The magfounding .p = 0.0004); p for interaction = 0.17), the black-white disparity was 0.98  as compared to 0.96 ; for SGA (p for interaction = 0.29), it was 0.98  compared to 0.97 . There was also strong evidence for an interaction between ERP and maternal race for continuous birth weight (p < 0.0001); P for interaction of 0.0274, and OR for SGA 0.96  as compared to 0.88  with a p for interaction < 0.0001. The observed associations were similar in sensitivity analyses while using the RRP or ERP measures at the Census block group geographical scale . Expectant mothers living in Census tracts with higher RRP/ERP values were likely to have better access to healthcare and other health-promoting activities . These fOur results demonstrate disparity by maternal race in estimated effects of RRP and ERP on birth weight outcomes. The magnitudes of the association between RRP or ERP on continuous birth weight, odds for LBW and SGA were smaller among those born to black mothers than those born to white mothers. This black-white health disparity could stem from differences in social interactions that black mothers experience when compared to their white counterparts. Specifically, black mothers were likely to have experienced higher amounts of negative social interactions than white mothers . The neg2.5, an exposure that has been linked to birth weight detriments [This study had several strengths and limitations. First, our choice to calculate RRP and ERP at the Census tract level could have led to biased estimates due to the modifiable area unit problem since geographic boundaries are arbitrary . Howevertriments . Moreovetriments , to reduWithin full-term, live singleton births in Massachusetts from 2001 to 2013, Census tract racial and economic demographic polarization towards more privileged groups was associated with a higher continuous birth weight and lower odds for low birth weight and small for gestational age. The estimated effects were smaller among those born to black mothers than those born to white mothers, demonstrating a health disparity by race.


VDR) gene and spontaneous preterm birth (SPTB), as well as their effect on clinical characteristics of women with SPTB and their newborns.To evaluate the association between the FokI (rs2228570), ApaI (rs7975232), Bsml (rs1544410), TaqI (rs 731236), and Cdx2 (rs11568820) single nucleotide polymorphisms (SNPs) in the vitamin D receptor , with newborns of FokI TT carriers having the lowest birth weight (P = 0.011). No other VDR SNP was associated with any other clinical characteristic of women with SPTB and their newborns.Patients and controls did not significantly differ in the distribution of genotype or allele SNP frequencies. However, the FokI polymorphism had a significant effect on newborn birth weight in women with SPTB but not in controls (F = 5.17, VDR FokI polymorphism is associated with newborn birth weight in women of European origin with SPTB.The TT genotype of the  Preterm birth (PTB), defined as a birth at less than 37 weeks of gestational age , represein-vitro fertilization, multiple pregnancy, vaginal bleeding, abnormal placental factors, low socioeconomic status, smoking, etc (PTB can be either spontaneous (SPTB) or medically induced. The heterogeneity of SPTB may be attributed to multiple factors, including socioeconomic status, environmental factors, and genetics . The etiing, etc . Consideing, etc ,7.The function of vitamin D metabolism in pregnancy, especially PTB, is currently being intensively investigated ,9. VitamVitamin D deficiency is related to numerous pregnancy complications ,11. In aVDR)  in the vitamin D receptor gene (VDR) ,17. Sixtd region . Availabd region ,17,19-21VDR gene and SPTB, as well as their effect on clinical characteristics of women with SPTB and their newborns.Therefore, the aim of our study was to evaluate the association between the FokI (rs2228570), ApaI (rs7975232), Bsml (rs1544410), TaqI (rs 731236), and Cdx2 (rs11568820) SNPs of the This case-control study enrolled women who gave birth at the Division of Perinatology, Department of Obstetrics and Gynaecology, University Medical Center in Ljubljana, Slovenia between 2010 and 2019. All participants gave written informed consent for study participation. The study was approved by the Slovenian National Medical Ethics Committee and the Ethics Committee for Biomedical Research of the Faculty of Medicine, University of Rijeka.in vitro fertilization, and complications of pregnancy and congenital anomalies or evidence of infection in newborns. Cases’ and controls’ maternal and newborn characteristics are shown in The patient group comprised 118 women with SPTB. Demographic and clinical data of women with SPTB and their newborns, including family history of SPTB, smoking, maternal age, gestational week of birth, and birth weight of newborns, were collected as described in genetic epidemiology studies on PTB  by meansVDR SNPs employed polymerase chain reaction (PCR) and restriction fragment length polymorphism (RFLP). Genotyping conditions, including primer sequences, PCR protocol, and RFLP fragment sizes are shown in TM .Genomic DNA was extracted from peripheral blood leukocytes by standard procedure with Qiagen FlexiGene DNA kit . All samples were stored at -20 °C. The molecular analysis of https://www.dssresearch.com/resources/calculators/statistical-power-calculator-percentage/), and Hardy-Weinberg equilibrium was calculated with Simple Hardy-Weinberg Calculator – Court Lab .Power of the study was calculated with DSS Researcher’s Toolkit  with factorial design and post-hoc Scheffe test was used to compare maternal and/or gestational age and fetal birth weight between genotypes of VDR SNPs . The level of significance was set at 0.05. Statistical analysis was performed with Statistica for Windows, version 12  and MedCalc for Windows, version 14.12.0. .The normality of distribution of the numerical variables was tested with the Kolmogorov-Smirnov test. The Pearson chi square test was used to assess the significance of differences in genotype, allele, and haplotype frequencies between the groups. To assess the genetic association with SPTB we calculated odds ratios (OR) and 95% confidence intervals. The All genotype frequencies in control women were in Hardy-Weinberg equilibrium (data not shown). The statistical power to detect a 1.5-fold increase in the frequency of the FokI (rs2228570) T allele, ApaI (rs7975232) G allele, Bsml (rs1544410) A allele, Cdx2 (rs11568820), A allele, and TaqI (rs731236) C allele was 90%, 99%, 90%, 90%, and 80%, respectively.VDR FokI (rs2228570), ApaI (rs7975232), Bsml (rs1544410), TaqI (rs731236), and Cdx2 (rs11568820) genotype or allele frequencies between women with SPTB and controls  but not in the control group . However, two-way ANOVA with factorial design showed no significant interaction between the FokI and ApaI SNPs and found only a significant effect of FokI had on newborn birth weight in women with SPTB (Post-hoc Scheffe test showed that new-borns of FokI TT carriers had the lowest birth weight (P = 0.011)  . No otheVDR FokI polymorphism was associated with newborn birth weight women of European origin with SPTB.In this study, TT genotype of the VDR gene as a major etiological factor in SPTB. VDR is a mediator of the pleiotropic actions of vitamin D, and its reduced placental expression is implicated in the pathology of complicated pregnancies  and a short form of VDR protein . Variations in the protein sequence significantly affect the protein function. Using a cell line of human fibroblasts, it has been shown that the FokI “f” isoform  exhibits a less active form of endogenous VDR . Baczynska-Strzecha et al (VDR variants and PTB. The effect of these variants on newborn birth weight was also shown in several studies, which is contrary to our results. Rosenfield et al (VDR gene and lower newborn birth weight in non-Hispanic black women (The function of other ha et al  showed tha et al  showed tld et al  showed tld et al  found a ld et al . Swamy eld et al  demonstrck women . The difVDR SNP genotypes and smoking before pregnancy. Nevertheless, previous research indicated that cigarette smoke decreased vitamin D production, which could affect VDR expression levels (Future studies should consider environmental factors for low birth-weight, including smoking. The present study showed no association between n levels ,33.A possible limitation of our study is the analysis of only the mother's genotype. However, previous studies have shown that maternal genotype is the most important factor affecting subsequent PTB . AdditioVDR FokI SNP was associated with SPTB in women of European origin and that it could affect the lower birth weight of their newborns. Nevertheless, other genetic associations and expression studies in different populations are needed to investigate the role of VDR SNPs in SPTB, especially studies assessing maternal vitamin D status.In conclusion, our study showed that the