The effect of birth timing manipulation around carnival on birth indicators in Brazil.

This paper studies the patterns and consequences of birth timing manipulation around the carnival holiday in Brazil. We document how births are displaced around carnival and estimate the effect of displacement on birth indicators. We show that there is extensive birth timing manipulation in the form of both anticipation and postponement that results in a net increase in gestational length and reductions in neonatal and early neonatal mortality, driven by postponed births that would otherwise happen through scheduled c-sections. We also find a reduction in birthweight for high-risk births at the bottom of the weight distribution, driven by anticipation. Therefore, restrictions on usual delivery procedures due to the carnival holiday can be both beneficial and detrimental, raising a double-sided issue to be addressed by policymakers.

Neonatal mortality rate and determinants among births of mothers at extreme ages of reproductive life in low and middle income countries.

Neonatal mortality, which refers to the death of neonates during the first 28 completed days of life, is a critical global public health concern. The neonatal period is widely recognized as one of the most precarious phases in human life. Research has indicated that maternal extreme ages during reproductive years significantly impact neonatal survival, particularly in low- and middle-income countries. Consequently, this study aims to evaluate the neonatal mortality rate and determinants among neonates born to mothers at extreme reproductive ages within these countries. A secondary analysis of demographic and health surveys conducted between 2015 and 2022 in 43 low- and middle-income countries was performed. The study included a total sample of 151,685 live births. Researchers utilized a multilevel mixed-effects model to identify determinants of neonatal mortality. The measures of association were evaluated using the adjusted odds ratio within a 95% confidence interval. The neonatal mortality rate among neonates born to mothers at extreme ages of reproductive life in low- and middle-income countries was 28.96 neonatal deaths per 1000 live births (95% CI 28.13-29.82). Factors associated with higher rates of neonatal mortality include male gender, low and high birth weight, maternal education (no or low), home deliveries, multiple births, short preceding birth intervals, lack of postnatal checkups, and countries with high fertility and low literacy rates. This study sheds light on the neonatal mortality rates among neonates born to mothers at extreme ages of reproductive life in low- and middle-income countries. Notably, we found that neonatal mortality was significantly higher in this group compared to neonatal mortality rates reported regardless of maternal ages. Male babies, low and high birth-weighted babies, those born to mothers with no or low education, delivered at home, singletons, babies born with a small preceding birth interval, and those without postnatal checkups faced elevated risks of neonatal mortality. Additionally, neonates born in countries with high fertility and low literacy rates were also vulnerable. These findings underscore the urgent need for targeted interventions tailored to mothers at extreme ages. Policymakers and healthcare providers should prioritize strategies that address specific risk factors prevalent in these vulnerable populations. By doing so, we can improve neonatal outcomes and ensure the survival of these newborns during the critical neonatal period.

Racial and ethnic differences in the risk of recurrent preterm or small for gestational age births in the United States: a systematic review and stratified analysis.

BACKGROUND: The risk of recurrent adverse birth outcomes has been reported worldwide, but there are limited estimates of these risks by social subgroups such as race and ethnicity in the United States. We assessed racial and ethnic disparities in the risk of recurrent adverse birth outcomes, including preterm birth, low birthweight, fetal growth restriction, small for gestational age, stillbirth, and neonatal mortality in the U.S. METHODS: We searched MEDLINE, CINAHL Complete, Web of Science, and Scopus from the date of inception to April 5, 2022. We identified 3,540 articles for a title and abstract review, of which 80 were selected for full-text review. Studies were included if they focused on the recurrence of any of the six outcomes listed in the objectives. Study quality was assessed using the NIH Study Quality Assessment Tool. Heterogeneity across studies was too large for meta-analysis, but race and ethnicity-stratified estimates and tests for homogeneity results were reported. RESULTS: Six studies on recurrent preterm birth and small for gestational age were included. Pooled comparisons showed a higher risk of recurrent preterm birth and small for gestational age for all women. Stratified race comparisons showed a higher but heterogeneous risk of recurrence of preterm birth across Black and White women. Relative risks of recurrent preterm birth ranged from 2.02 [1.94, 2.11] to 2.86 [2.40, 3.39] for Black women and from 3.23 [3.07, 3.39] to 3.92 [3.35, 4.59] for White women. The evidence was weak for race and ethnicity stratification for Hispanic and Asian women for both outcomes. CONCLUSIONS: Disparities exist in the recurrence of preterm birth, and race/ethnicity-concordant comparisons suggest race is an effect modifier for recurrent preterm birth for Black and White women. Due to the small number of studies, no conclusions could be made for small for gestational age or Hispanic and Asian groups. The results pose new research areas to better understand race-based differences in recurrent adverse birth outcomes.

Association between high-risk fertility behaviors and neonatal mortality in Ethiopia: A multilevel mixed-effects logit models from 2019 Ethiopian mini demographic and health survey.

Objectives: This study aimed to explore the association between high-risk fertility behaviors and neonatal mortality in Ethiopia. Study design: A community-based cross-sectional study was conducted using data from the 2019 Ethiopian Mini-Demographic and Health Survey. Methods: Mixed-effects logit regression models were fitted to 5527 children nested within 305 clusters. The definition of high-risk fertility behavior was adopted from the 2019 EMDHS. The fixed effects (the association between the outcome variable and the explanatory variables) were expressed as adjusted odds ratios (ORs) with 95 % confidence intervals and measures of variation explained by intra-class correlation coefficients, median odds ratio, and proportional change invariance. Results: The presence of births with any multiple high-risk fertility behaviors was associated with a 70 % higher risk of neonatal mortality (AOR = 1.7, (95 % CI: 1.2, 2.3) than those with no high-risk fertility behavior. From the combined risks of high-risk fertility behaviors, the combination of preceding birth interval <24 months and birth order four or higher had an 80 % increased risk of neonatal mortality (AOR = 1.8, (95 % CI, 1.2, 2.7) as compared to those who did not have either of the two. The 3-way risks (combination of preceding birth interval <24 months, birth order 4+, and mother's age at birth 34+) were associated with approximately four times increased odds of neonatal mortality (AOR (95 % CI:3.9 (2.1, 7.4)]. Conclusions: High-risk fertility behavior is a critical predictor of neonatal mortality in Ethiopia, with three-way high-risk fertility behaviors increasing the risk of neonatal mortality fourfold. In addition, antenatal follow-up was the only non-high fertility behavioral factor significantly associated with the risk of neonatal mortality in Ethiopia.

National chlorhexidine coverage and factors associated with newborn umbilical cord care in Bangladesh and Nepal: a cross-sectional analysis using household data.

BACKGROUND: Preventable newborn deaths are a global tragedy with many of these deaths concentrated in the first week and day of life. A simple low-cost intervention, chlorhexidine cleansing of the umbilical cord, can prevent deaths from omphalitis, an infection of the umbilical cord. Bangladesh and Nepal have national policies promoting chlorhexidine use, as well as routinely collected household survey data, which allows for an assessment of coverage and predictors of the intervention. METHODS: We used data from the 2017-2018 Bangladesh Demographic and Health Survey and the 2016 Nepal Demographic and Health Survey, two large-scale nationally representative household surveys. We studied coverage of single application of chlorhexidine to the umbilical cord of newborns born in the past year using descriptive, bivariate and multivariable analyses. Key predictors of newborns receiving chlorhexidine cleansing, including socio-economic factors, healthcare related factors and the application of harmful and nonharmful substances, were explored in this study. RESULTS: Coverage of chlorhexidine cleansing was 15.0% in Bangladesh and 50.7% in Nepal, while the application of a harmful substance was 16.9% in Bangladesh and 22.6% in Nepal. Results from the multivariable analyses indicated that delivery in a health facility was strongly associated with a newborn's receipt of chlorhexidine in both countries (Bangladesh: OR = 2.23, p = 0.002; Nepal: OR = 5.01, p = 0.000). In Bangladesh, delivery by Cesarean section and application of another non-harmful substance were significantly and positively associated with the receipt of chlorhexidine. In Nepal antenatal care was significantly and positively associated with chlorhexidine, while application of a harmful substance was significantly and negatively associated with receipt of chlorhexidine. Maternal education, urban/rural residence, religion and sex were not significant in the multivariable analysis. Wealth was not a significant factor in Bangladesh, but in Nepal newborns in the two highest wealth quintiles were significantly less likely to receive chlorhexidine than newborns in the lowest wealth quintile. CONCLUSION: As Bangladesh and Nepal continue to scale-up chlorhexidine for newborn umbilical cord care, additional focus on newborns born in non-facility environments may be warranted. Chlorhexidine cleansing may have the potential to be an equitable intervention, as newborns from the poorest wealth quintiles and whose mothers had less education were not disadvantaged in receiving the intervention in these two settings.

Timing of infant mortality in French Guiana: The persistence of high post neonatal mortality.

BACKGROUND: Infant mortality in French Guiana, a French overseas territory, is 2.7 times greater than in mainland France. Given the importance of better understanding infant mortality we aimed to describe the early & late neonatal, and postneonatal mortality in French Guiana between 2007 and 2022. METHODS: We used data from the Institut National de la Statistique et des Etudes Economiques to describe trends and performed survival analysis. RESULTS: Overall, there were 1 073 deaths before one year of age, of which 297 (27.7 %) occurred on the first day of life. The overall proportion of early neonatal deaths was 47.1 %, late neonatal deaths was 17.3 %, and post-neonatal deaths was 35.6 %. The overall incidences were 4.6 per 1,000 for early neonatal mortality, 1.4 per 1,000 for late neonatal mortality, and 3.1 per 1,000 for post neonatal mortality. The incidence for infant mortality for French Guiana residents was thus 9.1 per 1,000. CONCLUSIONS: We show that post neonatal deaths in French Guiana are proportionally greater than in mainland France and they do not seem to decline, as they did in France. The relative proportions of post-neonatal mortality can thus help to identify important areas for action to correct excess infant mortality. Although poor pregnancy follow-up remains a problem we show that follow-up of infants is also a pressing problem that warrants increased efforts.

Evaluating the Clinical Risk Index for Babies (CRIB) II Score for Mortality Prediction in Preterm Newborns: A Prospective Observational Study at a Tertiary Care Hospital.

INTRODUCTION: Neonatal mortality is an issue that affects both the developed and developing world. It is very important in the neonatal intensive care unit (NICU) to do the assessment of the severity of neonatal illness, which in turn helps in estimating and preventing mortality in the NICU by improving healthcare control and by rational use of resources. This research was carried out to evaluate how effectively the Clinical Risk Index for Babies (CRIB) II score can predict mortality rates among newborns treated in our NICU.  Methodology: This prospective observational study spanned one year, commencing in October 2021 and concluding in September 2022, within the confines of our NICU. The CRIB II score calculation was performed for included newborns, and the outcomes of the newborns were compared. A receiver operating characteristic (ROC) curve was obtained to ascertain the optimal CRIB II cut-off score for predicting mortality. RESULTS: Within the designated research timeframe, 292 neonates were admitted to the NICU. Forty-four newborns were enrolled in the study. Preterm neonates who died had higher CRIB II scores than those who survived, and their median (IQR) was 6 (1-12) vs. 9.5 (5-14) (p=0.0003). The estimate for the area under the curve was 0.83 (95% CI 0.68-0.92), and the odds ratio of 2.56 suggests neonates with a higher CRIB II score have higher chances of mortality. CONCLUSION: The CRIB II score is very good at predicting mortality in preterm newborns.

Caesarean delivery and neonatal mortality: evidence from selected slums in and around Dhaka city, Bangladesh- A prospective cohort study.

BACKGROUND: This study examined the neonatal mortality for newborn of women who delivered by caesarean section or vaginally using a prospective cohort. METHODS: A total of 6,989 live births registered from 2016 to 2018, were followed for neonatal survival from the selected slums of Dhaka (North and South) and Gazipur city corporations, where icddr,b maintained the Health and Demographic Surveillance System (HDSS). Neonatal mortality was compared by maternal and newborn characteristics and mode of delivery using z-test. Logistic regression model performed for neonatal mortality by mode of delivery controlling selected covariates and reported adjusted odd ratios (aOR) with 95% confidence interval (CI). RESULTS: Out of 6,989 live births registered, 27.7% were caesarean and the rest were vaginal delivery; of these births, 265 neonatal deaths occurred during the follow-up. The neonatal mortality rate was 2.7 times higher (46 vs. 17 per 1,000 births) for vaginal than caesarean delivered. Until 3rd day of life, the mortality rate was very high for both vaginal and caesarean delivered newborn; however, the rate was 24.8 for vaginal and 6.3 per 1,000 live births for caesarean delivered on the 1st day of life. After adjusting the covariates, the odds of neonatal mortality were higher for vaginal than caesarean delivered (aOR: 2.63; 95% CI: 1.82, 3.85). Additionally, the odds were higher for adolescent than elderly adult mother (aOR: 1.60; 95% CI: 1.03, 2.48), for multiple than singleton birth (aOR: 5.40; 95% CI: 2.82, 10.33), for very/moderate (aOR: 5.13; 95% CI: 3.68, 7.15), and late preterm birth (aOR: 1.48; 95% CI: 1.05, 2.08) than term birth; while the odds were lower for girl than boy (aOR: 0.74; 95% CI: 0.58, 0.96), and for 5th wealth quintile than 1st quintile (aOR: 0.59, 95% CI: 0.38, 0.91). CONCLUSION: Our study found that caesarean delivered babies had significantly lower neonatal mortality than vaginal delivered. Therefore, a comprehensive delivery and postnatal care for vaginal births needed a special attention for the slum mothers to ensure the reduction of neonatal mortality.

Determinants of Neonatal, Infant and Child Mortalities in Iran: A Systematic Review.

Background: Children mortality is considered as one of the main indicators of population development and health, while most of the children's deaths are preventable. This study systematically reviewed the determinants of children mortality in Iran. Methods: This systematic review was conducted to summarize all the factors associated with children mortality in three age groups; Neonate (0-28 d), Infant (28 d-1 yr old) and children (<5 yr old), based on the PRISMA guideline. Many of the electronic international and national databases, in addition to hand searching of reference of selected articles, grey literature, formal and informal reports and government documents were screened to identify potential records up to Jan 2022. We included all studies that identified determinants of child mortality in any province of Iran or the whole country, without any restriction. Results: Overall, 32 studies were included, published between 2000 and 2022, of which 23 were cross-sectional and 15 published in Farsi language. The associations between several risk factors (n=69) and the child mortality were examined. Among the identified factors, 'birth weight', 'mother's literacy', 'socioeconomic status', 'delivery type', 'gestational age', 'pregnancy interval', 'immaturity', 'type of nutrition', and 'stillbirth' were the most important mentioned determinants of child mortality in Iran. Conclusion: Appropriate interventions and policies should be developed and implemented in Iran, addressing the main identified associated factors, resulting from this review study, with the aim of minimizing preventable child deaths, based on their age categories.

Overview of the Global and US Burden of Preterm Birth.

Preterm birth (PTB) is the leading cause of morbidity and mortality in children globally, yet its prevalence has been difficult to accurately estimate due to unreliable methods of gestational age dating, heterogeneity in counting, and insufficient data. The estimated global PTB rate in 2020 was 9.9% (95% confidence interval: 9.1, 11.2), which reflects no significant change from 2010, and 81% of prematurity-related deaths occurred in Africa and Asia. PTB prevalence in the United States in 2021 was 10.5%, yet with concerning racial disparities. Few effective solutions for prematurity prevention have been identified, highlighting the importance of further research.

Why do women choose home births.

In recent years, the US has seen a significant rise in the rate of planned home births, with a 60 % increase from 2016 to 2023, reaching a total of 46,918. This trend positions the US as the leading developed country in terms of home birth prevalence. The American College of Obstetricians and Gynecologists (ACOG) suggests stringent criteria for selecting candidates for home births, but these guidelines have not been adopted by home birth midwives leading to poor outcomes including increased rates of neonatal morbidity and mortality. This paper explores the motivations behind choosing home births in the US despite the known risks. Studies highlight factors such as the desire for a more natural birth experience, previous negative hospital experiences, and the influence of the COVID-19 pandemic on perceptions of hospital safety. We provide new insights into why women choose home births by incorporating insights from Nobel laureate Daniel Kahneman's theories on decision-making, suggesting that cognitive biases may significantly influence these decisions. Kahneman's work provides a framework for understanding how biases and heuristics can lead to the underestimation of risks and overemphasis on personal birth experiences. We also provide recommendations ("nudges according to Richard Thaler") to help ensure women have access to clear, balanced information about home births. The development of this publication was assisted by OpenAI's ChatGPT-4, which facilitated the synthesis of literature, interpretation of data, and manuscript drafting. This collaboration underscores the potential of integrating advanced computational tools in academic research, enhancing the efficiency and depth of our analyses.

Infant mortality in Ghana: investing in health care infrastructure and systems.

Child and infant mortality is a global problem. Almost half of deaths of children under age 5 years occur in the neonatal period, the first 28 days of life, with 2.4 million neonatal deaths globally in 2020. Sub-Saharan Africa has disproportionately high numbers of neonatal deaths. Ghana's neonatal mortality rate is 22.8 per 1000 live births and remains behind targets set by the United Nations Sustainable Development Goals. Quality antenatal care, postnatal monitoring, breastfeeding support, and postnatal family planning are important in preventing neonatal deaths. While Ghana has made progress in making care more financially accessible, it has not been matched with the improvements in the critical infrastructure required to ensure quality health care. The improvements have also not eliminated out-of-pocket costs for care, which have hindered progress in decreasing infant mortality. Policymakers should consider investments in health care infrastructure, including expanding public-private partnerships. Policies that improve workforce development programs, transportation infrastructure, and health insurance systems improvements are needed.

Vayu bubble continuous positive airway pressure is a promising solution with favorable treatment outcomes for respiratory distress syndrome in newborns: a qualitative study in Bangladesh.

Background: According to Bangladesh Demographic and Health Survey (2022), neonatal mortality, comprising 67% of under-5 deaths in Bangladesh, is significantly attributed to prematurity and low birth weight (LBW), accounting for 32% of neonatal deaths. Respiratory distress syndrome (RDS) is a prevalent concern among preterm and LBW infants, leading to substantial mortality. The World Health Organization (WHO) recommends bubble continuous positive airway pressure (bCPAP) therapy, but the affordability and accessibility of conventional bCPAP devices for a large number of patients become major hurdles in Bangladesh due to high costs and resource intensiveness. The Vayu bCPAP, a simple and portable alternative, offers a constant flow of oxygen-enriched, filtered, humidified, and pressurized air. Our study, conducted in five health facilities, explores the useability, acceptability, and perceived treatment outcome of Vayu bCPAP in the local context of Bangladesh. Methods: A qualitative approach was employed in special care newborn units (SCANUs) of selected facilities from January to March 2023. Purposive sampling identified nine key informants, 40 in-depth interviews with service providers, and 10 focus group discussions. Data collection and analysis utilized a thematic framework approach led by trained anthropologists and medical officers. Results: Service providers acknowledged Vayu bCPAP as a lightweight, easily movable, and cost-effective device requiring minimal training. Despite challenges such as consumable shortages and maintenance issues, providers perceived the device as user-friendly, operable with oxygen cylinders, and beneficial during referral transportation. Treatment outcomes indicated effective RDS management, reduced hospital stays, and decreased referrals. Though challenges existed, healthcare providers and facility managers expressed enthusiasm for Vayu bCPAP due to its potential to simplify advanced neonatal care delivery. Conclusions: The Vayu bCPAP device demonstrated useability, acceptability, and favorable treatment outcomes in the care of neonates with RDS. However, sustained quality service necessitates continuous monitoring, mentoring and retention of knowledge and skills. Despite challenges, the enthusiasm among healthcare providers underscores the potential of Vayu bCPAP to save lives and simplify neonatal care delivery. Development of Standard Operating procedure on Vayu bCPAP is required for systematic implementation. Further research is needed to determine how the utilization of Vayu bCPAP devices enhances accessibility to efficient bCPAP therapy for neonates experiencing RDS.

Does oral iron and folate supplementation during pregnancy protect against adverse birth outcomes and reduced neonatal and infant mortality in Africa: A protocol for a systematic review and meta-analysis?

BACKGROUND: Globally, one-third of pregnant women are at risk of iron deficiency, particularly in the African region. While recent findings show that iron and folate supplementation can lower the risk of adverse birth outcomes and childhood mortality, our understanding of its impact in Africa remains incomplete due to insufficient evidence. This protocol outlines the systematic review steps to investigate the impact of oral iron and folate supplementation during pregnancy on adverse birth outcomes, neonatal mortality and infant mortality in Africa. METHODS AND ANALYSIS: MEDLINE, PsycINFO, Embase, Scopus, CINAHL, Web of Science, and Cochrane databases were searched for published articles. Google Scholar and Advanced Google Search were used for gray literature and nonindexed articles. Oral iron and/or folate supplementation during pregnancy is the primary exposure. The review will focus on adverse birth outcomes, neonatal mortality and infant mortality. Both Cochrane Effective Practice and Organization of Care and Newcastle-Ottawa Scale risk of bias assessment tools will be used. Meta-analysis will be conducted if design and data analysis methodologies permit. This systematic review and meta-analysis will provide up-to-date evidence about iron and folate supplementation's role in adverse birth outcomes, neonatal mortality and infant mortality in the African region. ETHICS AND DISSEMINATION: This review will provide insights that help policymakers, program planners, researchers, and public health practitioners interested in working in the region. PROSPERO REGISTRATION NUMBER: CRD42023452588.

Income inequality as a determinant of neonatal mortality in the Americas during 2000-2019: implications for the attainment of Sustainable Development Goal target 3.2.

BACKGROUND: The work of the WHO Commission on the Social Determinants of Health has been fundamental to provide a conceptual framework of the social determinants of health. Based on this framework, this study assesses the relationship of income inequality as a determinant of neonatal mortality in the Americas and relates it to the achievement of the Sustainable Development Goal target 3.2 (reduce neonatal mortality to at least as low as 12 deaths per 1,000 live births). The rationale is to evaluate if income inequality may be considered a social factor that influences neonatal mortality in the Americas. METHODS: Yearly data from 35 countries in the Americas during 2000-2019 was collected. Data sources include the United Nations Inter-agency Group for Child Mortality Estimation for the neonatal mortality rate (measured as neonatal deaths per 1,000 live births) and the United Nations University World Institute for Development Economics Research for the Gini index (measured in a scale from 0 to 100). This is an ecological study that employs a linear regression model that relates the neonatal mortality rate (dependent variable) to the Gini index (independent variable), while controlling for other factors that influence neonatal mortality. Coefficient estimates and their robust standard errors were obtained using panel data techniques. RESULTS: A positive relationship between income inequality and neonatal mortality is found in countries in the Americas during the period studied. In particular, the analysis suggests that a unit increase in a country's Gini index during 2000-2019 is associated with a 0.27 (95% CI [- 0.04, 0.57], P =.09) increase in the neonatal mortality rate. CONCLUSION: The analysis suggests that income inequality may be positively associated with the neonatal mortality rate in the Americas. Nonetheless, given the modest magnitude of the estimates and Gini values and trends during 2000-2019, the findings suggest a potential limited scope for redistributive policies to support reductions in neonatal mortality in the region. Thus, policies and interventions that address higher coverage and quality of services provided by national health systems and reductions in socio-economic inequalities in health are of utmost importance.

Prevalence of Bacterial Vaginosis and Its Association With Preterm Birth in a Tertiary Care Hospital in Chennai: A Cross-Sectional Study.

Background The most common preventive cause of premature labour is ascending infections. This study was conducted to evaluate the association between bacterial vaginosis (BV) and preterm labour in antenatal women and determine the significance of using the Amsel criteria to screen for BV. Methods This was a hospital-based cross-sectional study conducted among 100 antenatal mothers in the second trimester attending the antenatal OPD at a tertiary care hospital in Chennai from October 2019 to September 2021 after obtaining clearance from the institutional ethics committee and written informed consent from the study participants. Data were entered in Excel (Microsoft Corporation, Redmond, WA) and analysed in SPSS (IBM Corp., Armonk, NY). Results According to the Amsel criteria, BV was detected in 21 women (21%). Neither maternal age nor parity had an effect on the study group. There was a statistically significant relationship (p < 0.05) between the mode of delivery, preterm labour, and the study group. Of the 21 positive BV cases, 95% were positive for clue cells and only 5% were positive for gram-negative bacteria. Consequently, BV was found to be associated with early labour. There is no association between BMI and BV (p > 0.005). Conclusion In the current study, BV was shown to be associated with preterm labour. Our study underscores the significance of the Amsel criteria as a valuable tool for screening BV in antenatal women.

Does the use of higher versus lower oxygen concentration improve neurodevelopmental outcomes at 18-24 months in very low birthweight infants?

BACKGROUND: Immediately after birth, the oxygen saturation is between 30 and 50%, which then increases to 85-95% within the first 10 min. Over the last 10 years, recommendations regarding the ideal level of the initial fraction of inspired oxygen (FiO2) for resuscitation in preterm infants have changed from 1.0, to room air to low levels of oxygen (< 0.3), up to moderate concentrations (0.3-0.65). This leaves clinicians in a challenging position, and a large multi-center international trial of sufficient sample size that is powered to look at safety outcomes such as mortality and adverse neurodevelopmental outcomes is required to provide the necessary evidence to guide clinical practice with confidence. METHODS: An international cluster, cross-over randomized trial of initial FiO2 of 0.3 or 0.6 during neonatal resuscitation in preterm infants at birth to increase survival free of major neurodevelopmental outcomes at 18 and 24 months corrected age will be conducted. Preterm infants born between 230/7 and 286/7 weeks' gestation will be eligible. Each participating hospital will be randomized to either an initial FiO2 concentration of either 0.3 or 0.6 to recruit for up to 12 months' and then crossed over to the other concentration for up to 12 months. The intervention will be initial FiO2 of 0.6, and the comparator will be initial FiO2 of 0.3 during respiratory support in the delivery room. The sample size will be 1200 preterm infants. This will yield 80% power, assuming a type 1 error of 5% to detect a 25% reduction in relative risk of the primary outcome from 35 to 26.5%. The primary outcome will be a composite of all-cause mortality or the presence of a major neurodevelopmental outcome between 18 and 24 months corrected age. Secondary outcomes will include the components of the primary outcome (death, cerebral palsy, major developmental delay involving cognition, speech, visual, or hearing impairment) in addition to neonatal morbidities (severe brain injury, bronchopulmonary dysplasia; and severe retinopathy of prematurity). DISCUSSION: The use of supplementary oxygen may be crucial but also potentially detrimental to preterm infants at birth. The HiLo trial is powered for the primary outcome and will address gaps in the evidence due to its pragmatic and inclusive design, targeting all extremely preterm infants. Should 60% initial oxygen concertation increase survival free of major neurodevelopmental outcomes at 18-24 months corrected age, without severe adverse effects, this readily available intervention could be introduced immediately into clinical practice. TRIAL REGISTRATION: The trial was registered on January 31, 2019, at ClinicalTrials.gov with the Identifier: NCT03825835.

Association of socioeconomic disadvantage and ethnicity with perinatal neonatal, and infant mortality in Slovakia.

BACKGROUND: Infant mortality rates are reliable indices of the child and general population health status and health care delivery. The most critical factors affecting infant mortality are socioeconomic status and ethnicity. The aim of this study was to assess the association between socioeconomic disadvantage, ethnicity, and perinatal, neonatal, and infant mortality in Slovakia before and during the COVID-19 pandemic. METHODS: The associations between socioeconomic disadvantage (educational level, long-term unemployment rate), ethnicity (the proportion of the Roma population) and mortality (perinatal, neonatal, and infant) in the period 2017-2022 were explored, using linear regression models. RESULTS: The higher proportion of people with only elementary education and long-term unemployed, as well as the higher proportion of the Roma population, increases mortality rates. The proportion of the Roma population had the most significant impact on mortality in the selected period between 2017 and 2022, especially during the COVID-19 pandemic (2020-2022). CONCLUSIONS: Life in segregated Roma settlements is connected with the accumulation of socioeconomic disadvantage. Persistent inequities between Roma and the majority population in Slovakia exposed by mortality rates in children point to the vulnerabilities and exposures which should be adequately addressed by health and social policies.

Preclinical validation of NeoWarm, a low-cost infant warmer and carrier device, to ameliorate induced hypothermia in newborn piglets as models for human neonates.

Introduction: Approximately 1.5 million neonatal deaths occur among premature and small (low birthweight or small-for gestational age) neonates annually, with a disproportionate amount of this mortality occurring in low- and middle-income countries (LMICs). Hypothermia, the inability of newborns to regulate their body temperature, is common among prematurely born and small babies, and often underlies high rates of mortality in this population. In high-resource settings, incubators and radiant warmers are the gold standard for hypothermia, but this equipment is often scarce in LMICs. Kangaroo Mother Care/Skin-to-skin care (KMC/STS) is an evidence-based intervention that has been targeted for scale-up among premature and small neonates. However, KMC/STS requires hours of daily contact between a neonate and an able adult caregiver, leaving little time for the caregiver to care for themselves. To address this, we created a novel self-warming biomedical device, NeoWarm, to augment KMC/STS. The present study aimed to validate the safety and efficacy of NeoWarm. Methods: Sixteen, 0-to-5-day-old piglets were used as an animal model due to similarities in their thermoregulatory capabilities, circulatory systems, and approximate skin composition to human neonates. The piglets were placed in an engineered cooling box to drop their core temperature below 36.5°C, the World Health Organizations definition of hypothermia for human neonates. The piglets were then warmed in NeoWarm (n = 6) or placed in the ambient 17.8°C ± 0.6°C lab environment (n = 5) as a control to assess the efficacy of NeoWarm in regulating their core body temperature. Results: All 6 piglets placed in NeoWarm recovered from hypothermia, while none of the 5 piglets in the ambient environment recovered. The piglets warmed in NeoWarm reached a significantly higher core body temperature (39.2°C ± 0.4°C, n = 6) than the piglets that were warmed in the ambient environment (37.9°C ± 0.4°C, n = 5) (p < 0.001). No piglet in the NeoWarm group suffered signs of burns or skin abrasions. Discussion: Our results in this pilot study indicate that NeoWarm can safely and effectively warm hypothermic piglets to a normal core body temperature and, with additional validation, shows promise for potential use among human premature and small neonates.

Respiratory distress syndrome is associated with increased morbidity and mortality in late preterm births.

BACKGROUND: Respiratory distress syndrome is strongly associated with prematurity, including late preterm births. Respiratory distress syndrome has been shown to be associated with certain neonatal morbidities and mortality, but these associations are not well described among late preterm births. OBJECTIVE: We sought to determine the association between respiratory distress syndrome and adverse neonatal outcomes among late preterm (34-36 weeks) born singleton neonates. STUDY DESIGN: This is a retrospective cohort study using California's linked vital statistics and patient discharge data (2008-2019). We included singleton, nonanomalous births with a gestational age of 34-36 weeks. Outcomes of interest were interventricular hemorrhage, necrotizing enterocolitis, retinopathy of prematurity, neonatal sepsis, length of hospital stay, neonatal death, and infant death. Chi-square and multivariable Poisson regression analyses were used to examine the association of respiratory distress syndrome with outcomes at each gestational age. Adjusted risk ratio and 95% confidence interval values were estimated. RESULTS: A total of 242,827 births were included, of which 11,312 (4.7%) had respiratory distress syndrome. We found that among neonates with respiratory distress syndrome, necrotizing enterocolitis was higher at 35 weeks (adjusted risk ratio, 3.97 [95% confidence interval, 1.88-8.41]) and 36 weeks (adjusted risk ratio, 4.53 [95% confidence interval, 1.45-14.13]). Intraventricular hemorrhage, retinopathy of prematurity, neonatal sepsis, and length of hospital stay were significantly higher at 34-36 weeks of gestation in neonates with respiratory distress syndrome. Neonatal death was significantly higher among neonates with respiratory distress syndrome at 35 weeks (adjusted risk ratio, 3.04 [95% confidence interval, 1.58-5.85]) and 36 weeks (adjusted risk ratio, 3.25; 95% confidence interval, 1.59-6.68). In addition, infant death was significantly higher at 35 weeks (adjusted risk ratio, 2.27 [95% confidence interval, 1.43-3.61]) and 36 weeks (adjusted risk ratio, 2.60 [95% confidence interval, 1.58-4.28]). CONCLUSION: We found that respiratory distress syndrome was associated with intraventricular hemorrhage, retinopathy of prematurity, and sepsis at 34-36 weeks of gestation, whereas respiratory distress syndrome was associated with neonatal death, infant death, and necrotizing enterocolitis at 35 and 36 weeks. Clinicians should keep these outcomes in mind when making decisions about delivery timing, the potential benefits of antenatal steroids in pregnancies in the late preterm period, and the management of respiratory distress syndrome in late preterm neonates.