Childhood Gender Nonconformity and Parental Maltreatment as Mediators of Sexual Orientation Disparities in Childhood Emotional and Behavioral Difficulties.

The mechanisms underlying sexual orientation differences in psychopathology originating in childhood remain understudied since sexual orientation does not directly manifest in childhood. This study tested whether childhood gender nonconformity and parental maltreatment before age 6 years 9 months partly explained sexual orientation disparities in the developmental trajectories of emotional and behavioral difficulties from age 6 years 9 months to 11 years 8 months. The Avon Longitudinal Study of Parents and Children was used (2182 boys and 2422 girls, Mage = 15.5, 90% White). After controlling for early life factors, non-heterosexual boys and girls displayed significantly greater emotional and behavioral difficulties than their heterosexual counterparts at all three ages. There was a sex difference in the mediating effects. For girls, sexual orientation disparities in childhood emotional and behavioral difficulties were partially explained by childhood gender nonconformity. For boys, sexual orientation disparities in childhood emotional and behavioral difficulties were partially explained by a path through greater childhood gender nonconformity, leading to increased risk of being the targets of parental maltreatment. Childhood gender nonconformity, parental maltreatment, and other early life factors only partially explain sexual orientation disparities in childhood emotional and behavioral difficulties. The mediating effects of childhood gender nonconformity and parental maltreatment on the association between sexual orientation and childhood emotional and behavioral difficulties differ between the sexes.

Bidirectional Causal Associations Between Same-Sex Attraction and Psychological Distress: Testing Moderation and Mediation Effects.

Only one study has examined bidirectional causality between sexual minority status (having same-sex attraction) and psychological distress. We combined twin and genomic data from 8700 to 9700 participants in the UK Twins Early Development Study cohort at ≈21 years to replicate and extend these bidirectional causal effects using separate unidirectional Mendelian Randomization-Direction of Causation models. We further modified these models to separately investigate sex differences, moderation by childhood factors (retrospectively-assessed early-life adversity and prospectively-assessed childhood gender nonconformity), and mediation by victimization. All analyses were carried out in OpenMx in R. Same-sex attraction causally influenced psychological distress with significant reverse causation (beta = 0.19 and 0.17; 95% CIs = 0.09, 0.29 and 0.08, 0.25 respectively) and no significant sex differences. The same-sex attraction → psychological distress causal path was partly mediated by victimization (12.5%) while the reverse causal path was attenuated by higher childhood gender nonconformity (moderation coefficient = -0.09, 95% CI: -0.13, -0.04).

Psychological and Developmental Correlates of Paraphilic and Normophilic Sexual Interests.

The classification of sexual fantasies and behaviors (here referred to as 'sexual interests') has historically been divided into 'paraphilic' and 'normophilic'. However, studies on paraphilic interests are often limited to clinical or forensic samples and normophilic interests are rarely assessed in tandem. Previous research has found mixed results for psychological and other correlates of sexual interests, potentially due to inconsistency in operationalism and measurement of fantasies and behaviors. The aim of the current study was to quantify correlates of sexual interests via the Sexual Fantasies and Behaviors Inventory, containing factors related to general fantasies/behaviors, normophilia, power dynamics, sadomasochism, and courtship paraphilias, using a large (N = 4280) non-clinical sample. Psychological, developmental, sexual, and demographic correlates were investigated via bivariate correlations, mean difference testing, and multiple regression. Sexual interest domains were largely unrelated to psychopathology and developmental factors. Sociosexuality and more accepting attitudes towards sadomasochism was generally related to more arousal to/engagement in normophilic and paraphilic domains. More autism spectrum disorder traits were related to decreased normophilic interests. Psychopathic traits, sexual sensation seeking, and sexual compulsivity were related to paraphilia dimensions, especially courtship paraphilias and domination/sadism; the former was also associated with negative attitudes about establishing consent. Men, non-monogamous, and non-heterosexual participants indicated greater sexual fantasies and behaviors compared to women (except in the case of submission and masochism), monogamous, and heterosexual participants, respectively.

Sexual orientation disparities in the developmental trajectories of emotional and behavioral difficulties from childhood to early adolescence.

BACKGROUND: Lesbian, gay, bisexual, and asexual adolescents are at increased risk of poor mental health outcomes but it remains unknown whether this disparity emerges from early childhood and through to adolescence. This study tested sexual orientation disparities in the developmental trajectories of emotional and behavioral difficulties from ages 5 to 14 years, and the influence of early life adversities upon them. METHODS: The Millennium Cohort Study, a British birth cohort, was used (4,838 boys and 5,016 girls). Parent-report emotional and behavioral difficulties at ages 5, 7, 11, and 14 were measured using the Strength and Difficulties Questionnaire. Sexual orientation was measured via sexual attraction at age 17. Early life adversities in the first 5 years of life, including parental age at birth, birthweight, duration of breastfeeding, parent-child relationship quality, and parental absence, were collected prospectively. RESULTS: Latent growth modeling suggested that, for both sexes, sexual orientation disparities in emotional and behavioral difficulties increased from age 5 to 14 years. Homosexual and bisexual girls displayed significantly greater emotional and behavioral difficulties than heterosexual girls at ages 7, 11, and 14. Homosexual and bisexual boys displayed significantly greater emotional and behavioral difficulties than heterosexual boys at ages 11 and 14. Asexual boys and girls displayed significantly greater emotional and behavioral difficulties than their heterosexual counterparts at all four ages. For both sexes, sexual orientation disparities in emotional and behavioral difficulties only reduced slightly in magnitude after controlling for early life adversities. CONCLUSIONS: Sexual minority disparities in emotional and behavioral difficulties increased from childhood to early adolescence, possibly due to the accumulation of susceptibility to minority-related stressors. Sex and early life adversity may contribute to these developmental disparities.

Neuroticism and Sexual Orientation-Based Victimization as Mediators of Sexual Orientation Disparities in Mental Health.

This study tested whether elevated risk of poorer mental health outcomes among nonheterosexual adolescents compared with heterosexual adolescents is plausibly explained by neuroticism and sexual orientation-based victimization. The Millennium Cohort Study, a large British prospective birth cohort, was used (4566 heterosexual boys, 77 bisexual boys, 129 homosexual boys, 96 asexual boys, 4444 heterosexual girls, 280 bisexual girls, 158 homosexual girls, and 182 asexual girls). We analyzed the following measures assessed at age 17 years: sexual orientation based on sexual attraction, neuroticism, sexual orientation-based victimization, self-harm attempts, and psychological well-being. Mediation analysis was undertaken separately by sex and yielded the following statistically significant findings: for both sexes, we found that bisexual and homosexual adolescents scored higher than heterosexual adolescents on neuroticism; for both sexes, bisexual and homosexual adolescents reported more negative psychological well-being scores and self-harm attempts compared with heterosexual adolescents, with total effects (standardized regression coefficients) ranging from .58 to .91; those associations were mediated through sexual orientation-based victimization and neuroticism scores, with the indirect effects (standardized regression coefficients) through sexual orientation-based victimization and neuroticism scores ranging from .09 to .26 and .16 to .55, respectively. Asexual adolescents did not differ significantly from their heterosexual counterparts in psychological well-being and self-harm attempts, with the total effects ranging from - .02 to .21. Sexual orientation-based victimization and neuroticism may both contribute to the sexual orientation-related disparities in psychological well-being and self-harm attempts. However, neuroticism appears to the more powerful factor.

Childhood Gender Nonconformity and Recalled Perceived Parental and Peer Acceptance Thereof, Internalized Homophobia, and Psychological Well-Being Outcomes in Heterosexual and Gay Men from Poland.

The link between gender nonconformity and psychopathology may be due in part to negative childhood experiences resulting from other people's reactions to gender nonconformity. The aim of this study was to test whether recalled perceived levels of parental and peer acceptance of childhood gender nonconforming behaviors and play mediate the relationship of childhood gender nonconformity with depression and social anxiety in adulthood. We also tested whether this relationship was moderated by sexual orientation and, among gay men, whether internalized homophobia was an additional mediator. All variables were measured in a large sample of male participants using self-report (n = 449 gay men, age: M = 27.8 years, SD = 6.69; and n = 296 heterosexual men, age: M = 27.4 years, SD = 6.57) in Poland. Gay men reported more childhood gender nonconformity than heterosexual men. The relationship between gender nonconformity and depressive symptoms as well as social anxiety symptoms was significant in both gay and heterosexual men. Among gay men, this relationship was partially mediated by peer but not parental acceptance of the measured aspects of gender nonconformity and internalized homophobia. Among heterosexual men, recalled perceived parental acceptance of gender nonconformity partially mediated the relationship between gender nonconformity and depressive and social anxiety symptoms. Our findings were partially in line with those found in Western European and North American samples. Although the two groups differed in their recalled perceived gender nonconformity, they did not differ in their depression or social anxiety scores. Nevertheless, childhood gender nonconformity may be an indirect risk associated with mental health symptoms, irrespective of sexual orientation. Its higher prevalence among nonheterosexual individuals makes it a particular risk for this group.

Cognitive and behavioural factors contributing to distress in LGBTQ+students: a prospective mediation study.

We applied a cognitive behavioural therapy (CBT) model of psychological distress and examined cognitive and behavioural predictors and mediators of depression, anxiety and suicidality among lesbian, gay, bisexual, trans, queer and other sexual or gender minority (LGBTQ+) students. LGBTQ + university students (N = 385) completed questionnaires at baseline, 1 and 2 months. Structural equation modelling (SEM) was used to test the relationship between baseline negative beliefs (about the self, others and the future) and depression, anxiety and suicidality 2 months later, via cognitive and behavioural response mediators (perseverative thinking, avoidance and self-compassion) assessed at 1 month. The final model demonstrated acceptable fit: χ2 (16) = 73.36, p < .001, comparative fit index (CFI)=0.96, Tucker-Lewis index (TLI)=0.93, root-mean-square error of approximation (RMSEA) = 0.09 (90% CI [0.07-0.12]), standardized root-mean-square residual (SRMR) = 0.04, accounting for significant variance in depression/anxiety (48%) and suicidality (27%). For depression/anxiety, negative beliefs had a direct effect and an indirect effect via perseverative thinking and avoidance. For suicidality, negative beliefs had a direct effect. A cognitive behavioural conceptualization may improve our knowledge of the psychological mechanisms involved in depression, anxiety and suicidality in LGBTQ + students. Negative beliefs about the self, others or the future, perseverative thinking, and avoidance are promising targets for prevention and treatment.

Crystal Structure, Topology, DFT and Hirshfeld Surface Analysis of a Novel Charge Transfer Complex (L3) of Anthraquinone and 4-{[(anthracen-9-yl)meth-yl] amino}-benzoic Acid (L2) Exhibiting Photocatalytic Properties: An Experimental and Theoretical Approach.

Here, we report a facile route to the synthesizing of a new donor-acceptor complex, L3, using 4-{[(anthracen-9-yl)meth-yl] amino}-benzoic acid, L2, as donor moiety with anthraquinone as an acceptor moiety. The formation of donor-acceptor complex L3 was facilitated via H-bonding and characterized by single-crystal X-ray diffraction. The X-ray diffraction results confirmed the synthesized donor-acceptor complex L3 crystal belongs to the triclinic system possessing the P-1 space group. The complex L3 was also characterized by other spectral techniques, viz., FTIR and UV absorption spectroscopy, which confirmed the formation of new bonds between donor L2 moiety and acceptor anthraquinone molecule. The crystallinity and thermal stability of the newly synthesized complex L3 was confirmed by powdered XRD and TGA analysis and theoretical studies; Hirshfeld surface analysis was performed to define the type of interactions occurring in the complex L3. Interestingly, theoretical results were successfully corroborated with experimental results of FTIR and UV absorption. The density functional theory (DFT) calculations were employed for HOMO to LUMO; the energy gap (∆E) was calculated to be 3.6463 eV. The complex L3 was employed as a photocatalyst for the degradation of MB dye and was found to be quite efficient. The results showed MB dye degraded about 90% in 200 min and followed the pseudo-first-order kinetic with rate constant k = 0.0111 min-1 and R2 = 0.9596. Additionally, molecular docking reveals that the lowest binding energy was -10.8 Kcal/mol which indicates that the L3 complex may be further studied for its biological applications.

Lessons from behaviorism: The problem of construct-led science.

Yarkoni makes a number of valid points in his critical analysis of psychology, but he misses an opportunity to expose the root of its problems. That root is the poor practice around the derivation of explanatory constructs. We make comment on this with an example from behaviorist history and relate this to the recent discussion of scientific understanding in the philosophy of science.

Vitamin D Supplementation in Pregnancy and Lactation and Infant Growth.

BACKGROUND: It is unclear whether maternal vitamin D supplementation during pregnancy and lactation improves fetal and infant growth in regions where vitamin D deficiency is common. METHODS: We conducted a randomized, double-blind, placebo-controlled trial in Bangladesh to assess the effects of weekly prenatal vitamin D supplementation (from 17 to 24 weeks of gestation until birth) and postpartum vitamin D supplementation on the primary outcome of infants' length-for-age z scores at 1 year according to World Health Organization (WHO) child growth standards. One group received neither prenatal nor postpartum vitamin D (placebo group). Three groups received prenatal supplementation only, in doses of 4200 IU (prenatal 4200 group), 16,800 IU (prenatal 16,800 group), and 28,000 IU (prenatal 28,000 group). The fifth group received prenatal supplementation as well as 26 weeks of postpartum supplementation in the amount of 28,000 IU (prenatal and postpartum 28,000 group). RESULTS: Among 1164 infants assessed at 1 year of age (89.5% of 1300 pregnancies), there were no significant differences across groups in the mean (±SD) length-for-age z scores. Scores were as follows: placebo, -0.93±1.05; prenatal 4200, -1.11±1.12; prenatal 16,800, -0.97±0.97; prenatal 28,000, -1.06±1.07; and prenatal and postpartum 28,000, -0.94±1.00 (P=0.23 for a global test of differences across groups). Other anthropometric measures, birth outcomes, and morbidity did not differ significantly across groups. Vitamin D supplementation had expected effects on maternal and infant serum 25-hydroxyvitamin D and calcium concentrations, maternal urinary calcium excretion, and maternal parathyroid hormone concentrations. There were no significant differences in the frequencies of adverse events across groups, with the exception of a higher rate of possible hypercalciuria among the women receiving the highest dose. CONCLUSIONS: In a population with widespread prenatal vitamin D deficiency and fetal and infant growth restriction, maternal vitamin D supplementation from midpregnancy until birth or until 6 months post partum did not improve fetal or infant growth. (Funded by the Bill and Melinda Gates Foundation; ClinicalTrials.gov number, NCT01924013 .).

Cross-sex shifts in two brain imaging phenotypes and their relation to polygenic scores for same-sex sexual behavior: A study of 18,645 individuals from the UK Biobank.

Genetic and hormonal factors have been suggested to influence human sexual orientation. Previous studied proposed brain differences related to sexual orientation and that these follow cross-sex shifted patterns. However, the neurobiological correlates of sexual orientation and how genetic factors relate to brain structural variation remains largely unexplored. Using the largest neuroimaging-genetics dataset available on same-sex sexual behavior (SSB) (n = 18,645), we employed a data-driven multivariate classification algorithm (PLS) on magnetic resonance imaging data from two imaging modalities to extract brain covariance patterns related to sex. Through analyses of latent variables, we tested for SSB-related cross-sex shifts in such patterns. Using genotype data, polygenic scores reflecting the genetic predisposition for SSB were computed and tested for associations with neuroimaging outcomes. Patterns important for classifying between males and females were less pronounced in non-heterosexuals. Predominantly in non-heterosexual females, multivariate brain patterns as represented by latent variables were shifted toward the opposite sex. Complementary univariate analyses revealed region specific SSB-related differences in both males and females. Polygenic scores for SSB were associated with volume of lateral occipital and temporo-occipital cortices. The present large-scale study demonstrates multivariate neuroanatomical correlates of SSB, and tentatively suggests that genetic factors related to SSB may contribute to structural variation in certain brain structures. These findings support a neurobiological basis to the differences in human sexuality.

Direct sunlight-driven enhanced photocatalytic performance of V2O5 nanorods/ graphene oxide nanocomposites for the degradation of Victoria blue dye.

Herein, we report the synthesis and characterizations of Vanadium pentoxide (V2O5) nanorods/graphene oxide (GO) nanocomposite as efficient direct solar light driven photocatalyst for the enhanced degradation of victoria blue (VB) dye. The nanocomposite was synthesized by sonochemical process and characterized using several analytical methods in order to study the structural, morphological, compositional, optical and photocatalytic properties. The X-ray diffraction studies confirmed the orthorhombic structure of V2O5 while the morphological examinations revealed the growth of V2O5 nanorods and 2D GO sheets. Interestingly, the UV studies ratify that the bandgap of the nanocomposite was reduced compared to pure GO and V2O5. Interestingly, the interaction of the V2O5 nanorods with the graphene oxide substrate and its effect on the electronic properties of the combined system, have been examined by means of theoretical calculations, based on the so called Geometry, Frequency, Noncovalent, eXtended Tight Binding (GFN-xTB) method. Studying the photocatalytic behavior of nanocomposite, we observe an almost complete degradation (97.95%) of Victoria Blue (VB) dye under direct sunlight illumination within just 90 min. The outstanding nanocomposite photocatalytic efficiency was due to the excellent transfer of interfacial charge and the suppressed recombination of charge-carrier. The kinetics of the degradation process was also analyzed by calculating the rate constant and half-life time. Finally, a possible mechanism has also been discussed for the degradation process of VB dye using nanocomposite under direct sunlight irradiation.

Adolescent Sexual Behavior Patterns in a British Birth Cohort: A Latent Class Analysis.

This study examined adolescent sexual behaviors patterns, and the consistency between sexual behavior and sexual orientation, in a prospective birth cohort. We used data on 5150 young people from the Avon Longitudinal Study of Parents and Children. Sexual orientation was assessed using a 5-point scale of sexual attraction at 15.5 years. Fourteen sexual activities were assessed using the Adolescent Sexual Activities Index at 13.5 and 15.5 years. Latent class analysis suggested four subgroups of adolescent sexual behaviors at 13.5: a "high-intensity sexual behaviors exclusively with other-sex, no same-sex intimacy" group (3.87%); a "moderate-intensity sexual behaviors exclusively with other-sex, no same-sex intimacy" group (16.57%); a "low-intensity sexual behaviors exclusively with other-sex, no same-sex intimacy" group (34.21%); and a "no sexual behavior" group (45.35%). There were five subgroups at 15.5 where four of them (23.42%, 18.37%, 28.12%, and 24.52%, respectively) were interpreted the same as at 13.5 years and a new "high-intensity sexual behaviors, some same-sex intimacy" subgroup (5.57%). Latent transition analysis showed approximately half the adolescents moved toward greater engagement in higher intensity sexual activities with other-sex at 15.5. Boys and girls who were in groups without same-sex intimacy were predominantly attracted to the other-sex, whereas there were moderate consistencies between same-sex intimacy and same-sex attraction for boys and low consistency for girls. Findings suggest that it may be important to include low-intensity sexual behaviors when assigning adolescents to sexual orientation groupings (via sexual behaviors) in order to reduce selection biases and increase statistical power via the increase in sample size.

Stillbirths including intrapartum timing: EN-BIRTH multi-country validation study.

BACKGROUND: An estimated >2 million babies stillborn around the world each year lack visibility. Low- and middle-income countries carry 84% of the burden yet have the least data. Most births are now in facilities, hence routine register-recording presents an opportunity to improve counting of stillbirths, but research is limited, particularly regarding accuracy. This paper evaluates register-recorded measurement of hospital stillbirths, classification accuracy, and barriers and enablers to routine recording. METHODS: The EN-BIRTH mixed-methods, observational study took place in five hospitals in Bangladesh, Nepal and Tanzania (2017-2018). Clinical observers collected time-stamped data on perinatal care and birth outcomes as gold standard. To assess accuracy of routine register-recorded stillbirth rates, we compared birth outcomes recorded in labour ward registers to observation data. We calculated absolute rate differences and individual-level validation metrics (sensitivity, specificity, percent agreement). We assessed misclassification of stillbirths with neonatal deaths. To examine stillbirth appearance (fresh/macerated) as a proxy for timing of death, we compared appearance to observed timing of intrauterine death based on heart rate at admission. RESULTS: 23,072 births were observed including 550 stillbirths. Register-recorded completeness of birth outcomes was > 90%. The observed study stillbirth rate ranged from 3.8 (95%CI = 2.0,7.0) to 50.3 (95%CI = 43.6,58.0)/1000 total births and was under-estimated in routine registers by 1.1 to 7.3 /1000 total births (register: observed ratio 0.9-0.7). Specificity of register-recorded birth outcomes was > 99% and sensitivity varied between hospitals, ranging from 77.7-86.1%. Percent agreement between observer-assessed birth outcome and register-recorded birth outcome was very high across all hospitals and all modes of birth (> 98%). Fresh or macerated stillbirth appearance was a poor proxy for timing of stillbirth. While there were similar numbers of stillbirths misclassified as neonatal deaths (17/430) and neonatal deaths misclassified as stillbirths (21/36), neonatal deaths were proportionately more likely to be misclassified as stillbirths (58.3% vs 4.0%). Enablers to more accurate register-recording of birth outcome included supervision and data use. CONCLUSIONS: Our results show these routine registers accurately recorded stillbirths. Fresh/macerated appearance was a poor proxy for intrapartum stillbirths, hence more focus on measuring fetal heart rate is crucial to classification and importantly reduction in these preventable deaths.

Birthweight: EN-BIRTH multi-country validation study.

BACKGROUND: Accurate birthweight is critical to inform clinical care at the individual level and tracking progress towards national/global targets at the population level. Low birthweight (LBW) < 2500 g affects over 20.5 million newborns annually. However, data are lacking and may be affected by heaping. This paper evaluates birthweight measurement within the Every Newborn Birth Indicators Research Tracking in Hospitals (EN-BIRTH) study. METHODS: The EN-BIRTH study took place in five hospitals in Bangladesh, Nepal and Tanzania (2017-2018). Clinical observers collected time-stamped data (gold standard) for weighing at birth. We compared accuracy for two data sources: routine hospital registers and women's report at exit interview survey. We calculated absolute differences and individual-level validation metrics. We analysed birthweight coverage and quality gaps including timing and heaping. Qualitative data explored barriers and enablers for routine register data recording. RESULTS: Among 23,471 observed births, 98.8% were weighed. Exit interview survey-reported weighing coverage was 94.3% (90.2-97.3%), sensitivity 95.0% (91.3-97.8%). Register-reported coverage was 96.6% (93.2-98.9%), sensitivity 97.1% (94.3-99%). Routine registers were complete (> 98% for four hospitals) and legible > 99.9%. Weighing of stillbirths varied by hospital, ranging from 12.5-89.0%. Observed LBW rate was 15.6%; survey-reported rate 14.3% (8.9-20.9%), sensitivity 82.9% (75.1-89.4%), specificity 96.1% (93.5-98.5%); register-recorded rate 14.9%, sensitivity 90.8% (85.9-94.8%), specificity 98.5% (98-99.0%). In surveys, "don't know" responses for birthweight measured were 4.7%, and 2.9% for knowing the actual weight. 95.9% of observed babies were weighed within 1 h of birth, only 14.7% with a digital scale. Weight heaping indices were around two-fold lower using digital scales compared to analogue. Observed heaping was almost 5% higher for births during the night than day. Survey-report further increased observed birthweight heaping, especially for LBW babies. Enablers to register birthweight measurement in qualitative interviews included digital scale availability and adequate staffing. CONCLUSIONS: Hospital registers captured birthweight and LBW prevalence more accurately than women's survey report. Even in large hospitals, digital scales were not always available and stillborn babies not always weighed. Birthweight data are being captured in hospitals and investment is required to further improve data quality, researching of data flow in routine systems and use of data at every level.

Immediate newborn care and breastfeeding: EN-BIRTH multi-country validation study.

BACKGROUND: Immediate newborn care (INC) practices, notably early initiation of breastfeeding (EIBF), are fundamental for newborn health. However, coverage tracking currently relies on household survey data in many settings. "Every Newborn Birth Indicators Research Tracking in Hospitals" (EN-BIRTH) was an observational study validating selected maternal and newborn health indicators. This paper reports results for EIBF. METHODS: The EN-BIRTH study was conducted in five public hospitals in Bangladesh, Nepal, and Tanzania, from July 2017 to July 2018. Clinical observers collected tablet-based, time-stamped data on EIBF and INC practices (skin-to-skin within 1 h of birth, drying, and delayed cord clamping). To assess validity of EIBF measurement, we compared observation as gold standard to register records and women's exit-interview survey reports. Percent agreement was used to assess agreement between EIBF and INC practices. Kaplan Meier survival curves showed timing. Qualitative interviews were conducted to explore barriers/enablers to register recording. RESULTS: Coverage of EIBF among 7802 newborns observed for ≥1 h was low (10.9, 95% CI 3.8-21.0). Survey-reported (53.2, 95% CI 39.4-66.8) and register-recorded results (85.9, 95% CI 58.1-99.6) overestimated coverage compared to observed levels across all hospitals. Registers did not capture other INC practices apart from breastfeeding. Agreement of EIBF with other INC practices was high for skin-to-skin (69.5-93.9%) at four sites, but fair/poor for delayed cord-clamping (47.3-73.5%) and drying (7.3-29.0%). EIBF and skin-to-skin were the most delayed and EIBF rarely happened after caesarean section (0.5-3.6%). Qualitative findings suggested that focusing on accuracy, as well as completeness, contributes to higher quality with register reporting. CONCLUSIONS: Our study highlights the importance of tracking EIBF despite measurement challenges and found low coverage levels, particularly after caesarean births. Both survey-reported and register-recorded data over-estimated coverage. EIBF had a strong agreement with skin-to-skin but is not a simple tracer for other INC indicators. Other INC practices are challenging to measure in surveys, not included in registers, and are likely to require special studies or audits. Continued focus on EIBF is crucial to inform efforts to improve provider practices and increase coverage. Investment and innovation are required to improve measurement.

Chlorhexidine for facility-based umbilical cord care: EN-BIRTH multi-country validation study.

BACKGROUND: Umbilical cord hygiene prevents sepsis, a leading cause of neonatal mortality. The World Health Organization recommends 7.1% chlorhexidine digluconate (CHX) application to the umbilicus after home birth in high mortality contexts. In Bangladesh and Nepal, national policies recommend CHX use for all facility births. Population-based household surveys include optional questions on CHX use, but indicator validation studies are lacking. The Every Newborn Birth Indicators Research Tracking in Hospitals (EN-BIRTH) was an observational study assessing measurement validity for maternal and newborn indicators. This paper reports results regarding CHX. METHODS: The EN-BIRTH study (July 2017-July 2018) included three public hospitals in Bangladesh and Nepal where CHX cord application is routine. Clinical-observers collected tablet-based, time-stamped data regarding cord care during admission to labour and delivery wards as the gold standard to assess accuracy of women's report at exit survey, and of routine-register data. We calculated validity ratios and individual-level validation metrics; analysed coverage, quality and measurement gaps. We conducted qualitative interviews to assess barriers and enablers to routine register-recording. RESULTS: Umbilical cord care was observed for 12,379 live births. Observer-assessed CHX coverage was very high at 89.3-99.4% in all 3 hospitals, although slightly lower after caesarean births in Azimpur (86.8%), Bangladesh. Exit survey-reported coverage (0.4-45.9%) underestimated the observed coverage with substantial "don't know" responses (55.5-79.4%). Survey-reported validity ratios were all poor (0.01 to 0.38). Register-recorded coverage in the specific column in Bangladesh was underestimated by 0.2% in Kushtia but overestimated by 9.0% in Azimpur. Register-recorded validity ratios were good (0.9 to 1.1) in Bangladesh, and poor (0.8) in Nepal. The non-specific register column in Pokhara, Nepal substantially underestimated coverage (20.7%). CONCLUSIONS: Exit survey-report highly underestimated observed CHX coverage in all three hospitals. Routine register-recorded coverage was closer to observer-assessed coverage than survey reports in all hospitals, including for caesarean births, and was more accurately captured in hospitals with a specific register column. Inclusion of CHX cord care into registers, and tallied into health management information system platforms, is justified in countries with national policies for facility-based use, but requires implementation research to assess register design and data flow within health information systems.

Electronic data collection for multi-country, hospital-based, clinical observation of maternal and newborn care: EN-BIRTH study experiences.

BACKGROUND: Observation of care at birth is challenging with multiple, rapid and potentially concurrent events occurring for mother, newborn and placenta. Design of electronic data (E-data) collection needs to account for these challenges. The Every Newborn Birth Indicators Research Tracking in Hospitals (EN-BIRTH) was an observational study to assess measurement of indicators for priority maternal and newborn interventions and took place in five hospitals in Bangladesh, Nepal and Tanzania (July 2017-July 2018). E-data tools were required to capture individually-linked, timed observation of care, data extraction from hospital register-records or case-notes, and exit-survey data from women. METHODS: To evaluate this process for EN-BIRTH, we employed a framework organised around five steps for E-data design, data collection and implementation. Using this framework, a mixed methods evaluation synthesised evidence from study documentation, standard operating procedures, stakeholder meetings and design workshops. We undertook focus group discussions with EN-BIRTH researchers to explore experiences from the three different country teams (November-December 2019). Results were organised according to the five a priori steps. RESULTS: In accordance with the five-step framework, we found: 1) Selection of data collection approach and software: user-centred design principles were applied to meet the challenges for observation of rapid, concurrent events around the time of birth with time-stamping. 2) Design of data collection tools and programming: required extensive pilot testing of tools to be user-focused and to include in-built error messages and data quality alerts. 3) Recruitment and training of data collectors: standardised with an interactive training package including pre/post-course assessment. 4) Data collection, quality assurance, and management: real-time quality assessments with a tracking dashboard and double observation/data extraction for a 5% case subset, were incorporated as part of quality assurance. Internet-based synchronisation during data collection posed intermittent challenges. 5) Data management, cleaning and analysis: E-data collection was perceived to improve data quality and reduce time cleaning. CONCLUSIONS: The E-Data system, custom-built for EN-BIRTH, was valued by the site teams, particularly for time-stamped clinical observation of complex multiple simultaneous events at birth, without which the study objectives could not have been met. However before selection of a custom-built E-data tool, the development time, higher training and IT support needs, and connectivity challenges need to be considered against the proposed study or programme's purpose, and currently available E-data tool options.

Uterotonics for prevention of postpartum haemorrhage: EN-BIRTH multi-country validation study.

BACKGROUND: Postpartum haemorrhage (PPH) is a leading cause of preventable maternal mortality worldwide. The World Health Organization (WHO) recommends uterotonic administration for every woman after birth to prevent PPH. There are no standardised data collected in large-scale measurement platforms. The Every Newborn Birth Indicators Research Tracking in Hospitals (EN-BIRTH) is an observational study to assess the validity of measurement of maternal and newborn indicators, and this paper reports findings regarding measurement of coverage and quality for uterotonics. METHODS: The EN-BIRTH study took place in five hospitals in Bangladesh, Nepal and Tanzania, from July 2017 to July 2018. Clinical observers collected tablet-based, time-stamped data. We compared observation data for uterotonics to routine hospital register-records and women's report at exit-interview survey. We analysed the coverage and quality gap for timing and dose of administration. The register design was evaluated against gap analyses and qualitative interview data assessing the barriers and enablers to data recording and use. RESULTS: Observed uterotonic coverage was high in all five hospitals (> 99%, 95% CI 98.7-99.8%). Survey-report underestimated coverage (79.5 to 91.7%). "Don't know" replies varied (2.1 to 14.4%) and were higher after caesarean (3.7 to 59.3%). Overall, there was low accuracy in survey data for details of uterotonic administration (type and timing). Register-recorded coverage varied in four hospitals capturing uterotonics in a specific column (21.6, 64.5, 97.6, 99.4%). The average coverage measurement gap was 18.1% for register-recorded and 6.0% for survey-reported coverage. Uterotonics were given to 15.9% of women within the "right time" (1 min) and 69.8% within 3 min. Women's report of knowing the purpose of uterotonics after birth ranged from 0.4 to 64.9% between hospitals. Enabling register design and adequate staffing were reported to improve routine recording. CONCLUSIONS: Routine registers have potential to track uterotonic coverage - register data were highly accurate in two EN-BIRTH hospitals, compared to consistently underestimated coverage by survey-report. Although uterotonic coverage was high, there were gaps in observed quality for timing and dose. Standardisation of register design and implementation could improve data quality and data flow from registers into health management information reporting systems, and requires further assessment.

Antibiotic use for inpatient newborn care with suspected infection: EN-BIRTH multi-country validation study.

BACKGROUND: An estimated 30 million neonates require inpatient care annually, many with life-threatening infections. Appropriate antibiotic management is crucial, yet there is no routine measurement of coverage. The Every Newborn Birth Indicators Research Tracking in Hospitals (EN-BIRTH) study aimed to validate maternal and newborn indicators to inform measurement of coverage and quality of care. This paper reports validation of reported antibiotic coverage by exit survey of mothers for hospitalized newborns with clinically-defined infections, including sepsis, meningitis, and pneumonia. METHODS: EN-BIRTH study was conducted in five hospitals in Bangladesh, Nepal, and Tanzania (July 2017-July 2018). Neonates were included based on case definitions to focus on term/near-term, clinically-defined infection syndromes (sepsis, meningitis, and pneumonia), excluding major congenital abnormalities. Clinical management was abstracted from hospital inpatient case notes (verification) which was considered as the gold standard against which to validate accuracy of women's report. Exit surveys were conducted using questions similar to The Demographic and Health Surveys (DHS) approach for coverage of childhood pneumonia treatment. We compared survey-report to case note verified, pooled across the five sites using random effects meta-analysis. RESULTS: A total of 1015 inpatient neonates admitted in the five hospitals met inclusion criteria with clinically-defined infection syndromes. According to case note verification, 96.7% received an injectable antibiotic, although only 14.5% of them received the recommended course of at least 7 days. Among women surveyed (n = 910), 98.8% (95% CI: 97.8-99.5%) correctly reported their baby was admitted to a neonatal ward. Only 47.1% (30.1-64.5%) reported their baby's diagnosis in terms of sepsis, meningitis, or pneumonia. Around three-quarters of women reported their baby received an injection whilst in hospital, but 12.3% reported the correct antibiotic name. Only 10.6% of the babies had a blood culture and less than 1% had a lumbar puncture. CONCLUSIONS: Women's report during exit survey consistently underestimated the denominator (reporting the baby had an infection), and even more so the numerator (reporting known injectable antibiotics). Admission to the neonatal ward was accurately reported and may have potential as a contact point indicator for use in household surveys, similar to institutional births. Strengthening capacity and use of laboratory diagnostics including blood culture are essential to promote appropriate use of antibiotics. To track quality of neonatal infection management, we recommend using inpatient records to measure specifics, requiring more research on standardised inpatient records.