Risk factors for cerebral palsy in Moldova

Risk factors for cerebral palsy in Moldova | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Help Center Sign In Submit a Preprint Cite Share Download PDF Research article Risk factors for cerebral palsy in Moldova Ecaterina Gincota Bufteac, Reidun Jahnsen, Larisa Spinei, Guro L. Andersen This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-39000/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background This is the first study assessing risk factors for cerebral palsy (CP) among children born in Moldova. Methods We identified 351 children with CP born during 2009 and 2010 in state hospitals, maternity wards, orphanages and rehabilitation centres in Moldova. Detailed information on 417 children without CP (of the total number of 81,277 children) served as a reference group. Logistic regression analyses were applied to calculate crude and adjusted odds ratios (OR) with 95% confidence intervals (CI) in addition to attributable risk (AR). Results Among children with CP (40.5% girls), 26% had unilateral, 54% bilateral, 13% dyskinetic, and 5% ataxic CP, with 2% unclassified. Almost three quarters of children with CP were from rural areas and 101 (29%) were prematurely born. Significant risk factors for CP included low Apgar score at five minutes (OR 6.187, 95% CI 2.059–18.59), hyperbilirubinemia (OR 6.3, 95% CI 4.1–9.6), breech delivery (OR 3.5, 95% CI 2–6.01), assisted vaginal delivery (OR 47, 95% CI 11–194), birth out of maternity (OR 6.591, 95% CI 1.904–22.81), low education level (OR 3.889, 95% CI 2.8–5.248), alcohol consumption (OR 1.903, 95% CI 1.269–2.885) and hypertension (OR 2.264, 95% CI 1.5–5.417). For singletons born at term, significant risk factors were low Apgar score (OR 2.115, 95% CI 1.22–3.808), hyperbilirubinemia (OR 5.854, 95% CI 3.648–9.393), breech delivery (OR 6.48, 95% CI 3.1–13.7), fundal pressure (OR 3.268, 95% CI 1.398–7.642), maternal hypertension (OR 2.248, 95% CI 1.55–3.997) and alcohol consumption (OR 2.105, 95% CI 1.315–3.369). Hyperbilirubinemia, Apgar score (0–3), birth out of maternity and breech delivery had the highest AR for CP both in the total and term singleton groups. Chronic diseases among mothers also had a high AR for CP. Conclusions A combination of factors related to the child, the delivery and the mother were risk factors for CP among children born in Moldova, many of them possibly avoidable. The results may indicate a need for better maternal and perinatal childcare. A national CP register in Moldova is recommended as an opportunity to follow up these findings. Pediatrics Cerebral palsy Moldova risk factors breech presentation hyperbilirubinemia asphyxia quality register Figures Figure 1 Background This is the first study assessing the risk factors for cerebral palsy (CP) among children born in Moldova. CP is the most common physical disability of childhood, describing a group of permanent disorders of movement and posture attributed to non-progressive disturbances in the developing foetal or infant brain [1]. Potential risk factors have been studied in depth in many developed countries since the 1970s [2–4]. Preterm birth (<37 gestational weeks, GW), multiple birth, infection in pregnancy, and low birth weight are factors associated with an increased risk for CP [3–5]. In a systematic review conducted in 2016 by Pascal Van Liesholt et al. [5], included studies indicated that lower gestational age, maternal medical diagnoses, preeclampsia, low birth weight, and the combination of male gender with preterm birth or low birth weight were found to be positively associated with CP [6]. A 2013 systematic review of risk factors for CP among children born at term in developed countries found that 10 risk factors were statistically significant in each study: placental abnormalities, major and minor birth defects, low birth weight, meconium aspiration, instrumental or emergency Caesarean delivery, birth asphyxia, neonatal seizures, respiratory distress syndrome, hypoglycaemia and neonatal infections. Instrumental deliveries (compared with spontaneous vaginal or elective Caesarean deliveries) were associated with increased risk of CP, as was breech delivery. However, the study concluded that there is a need for more in-depth investigation of the associations [7]. A study from the Australian Collaborative Cerebral Palsy Research Group in 2011, including 587 individuals with CP and a large control group, concluded that preterm birth, intrauterine growth retardation, perinatal infections and multiple births were the largest risk factors for CP [8]. A study from Botswana in 2017 showed that significant risk factors for CP included serious neonatal infections, complications during delivery, and maternal human immunodeficiency virus (HIV). The study concluded that the major risk factors for CP in Botswana differ from those described in high-resource settings [9]. A 2017 study from China indicated 20 significant risk factors for CP, among which the most important were maternal age >30 years, maternal alcohol consumption during pregnancy, rural residence, paternal occupational exposure to harmful substances, and multiple births. This study concluded that maternal habits during pregnancy and rural residence had an important role and that the CP incidence could probably be further lowered if these factors were considered [10]. A population-based cohort study from 1999 to 2010, performed in 2014 in Sweden, concluded that vacuum-assisted delivery was associated with an increased risk of neonatal intracranial haemorrhages compared to Caesarean section [12]. In 2015, a study on the influence of high bilirubin levels in newborns showed that advances in the care of neonatal hyperbilirubinemia have decreased the incidence of kernicterus. However, neonatal exposure to high levels of bilirubin continues to cause CP. New categories of bilirubin-induced neurological dysfunction, either independent or characterised by subtle bilirubin encephalopathy following moderate hyperbilirubinemia, have been implicated in long-term motor function [13]. A particular interest for us was to examine the existing literature regarding the consequences to the newborn of fundal pressure manoeuvres. Both the Kristeller manoeuvre and inflatable belts are still frequently used in obstetric practice in Moldova. A 2017 systematic review in the Cochrane Database [9] concluded that evidence from randomised controlled trials was insufficient to show whether manual fundal pressure or fundal pressure by inflatable belt have a severely harmful impact on the baby. However, some of the studies showed a decrease in the five-minute Apgar score. The findings being uncertain, the authors advised that “in the future studies should be of good quality, clearly describe how fundal pressure was applied, and focus on safety of the unborn baby” [11]. The present study aimed to identify and describe potential risk factors for CP among children born in Moldova. Data from the birth years 2009–2010 were linked with data from the National Agency for Public Health in Moldova to investigate risk factors for CP. Methods The recruitment area of the present study covered both rural and urban localities in Moldova. To perform this study, we first conducted a cohort study that allowed us to describe the characteristics of total births for two years (2009–2010): total number of births, neonatal mortality, gestational age, birth presentation and the total number of children diagnosed with CP versus those without CP. Based on the findings, and because no detailed information on other variables was available, a second case-control study was performed, with two groups of children: one with a confirmed diagnosis of CP and one without. A cohort of 417 children without CP born in Moldova between the 1 st of January 2009 and 31 st of December 2010, who survived the early neonatal period (first seven days of life), were included. This group was randomly selected by place of residence and place of birth (rural or urban), to have a reference group that was as representative as possible. The Institute of Mother and Child provides services to children from all over the country and University Clinics to children from the capital. The group number is comparatively small in both subgroups because the complete pre- and perinatal data were only available for these children. The second group comprised 351 children with a confirmed CP diagnosis born in the same period. The CP diagnoses were ascertained by studying the medical records of all children born during the two birth years at the maternity wards, state hospitals for children, orphanages and rehabilitation centres across the country. Each ascertained diagnosis was tracked backwards from the age of seven years, when the diagnosis was confirmed, to the neonatal period, using the medical records from all the relevant departments of the hospitals, such as child neurology, neonatal intensive care units and maternity wards. In this way, we succeeded in covering approximately 95% of the population. In the first article on CP in Moldova from 2018, we described a cohort based on 75% population coverage, with subtypes, severity and prevalence of CP diagnosed in children [14]. Data on maternal health, pregnancy, delivery and the early neonatal period were obtained from the National Agency of Public Health, Chisinau, Moldova. Detailed data on preconception, antenatal and intrapartum risk factors, as well as CP subtypes and the physical and intellectual development of children with CP born during the outlined period, were collected from hospital medical records. The clinical information on CP was collected between 1 st of July 2016 and 20 th of December 2017, when the children were at least seven years old, with the following inclusion criteria: children (1) born exclusively in Moldova, (2) meeting the criteria for CP defined by Surveillance of Cerebral Palsy in Europe (SCPE) [2] and (3) without a genetic diagnosis. Orphanages and habilitation centres in Moldova also provided summary and detailed perinatal and clinical data. SCPE criteria for the diagnosis of CP were applied based on detailed neurological descriptions in the medical records [2,14]. Only those children with CP with complete perinatal information were included in the present study. Study population The total number of births in 2009–2010 was 81,670, of which 393 children died during the neonatal period (0–7 days after birth). CP was diagnosed in 396 children. Twenty-seven children were abandoned at orphanages with no medical records, and thus perinatal data were missing. Eighteen children had a post-neonatal cause (i.e. traumatic brain damage took place more than 28 days after birth) and were excluded. Thus, the study population comprised 351 children). The reference group of 417 children with complete pre- and perinatal data was randomly selected from the total of 81,277 children using the medical records of the Institute of Mother and Child and the University Clinics, Chisinau, Moldova (Figure 1). Variables Exposure variables Registration of obstetric and perinatal data at birth is compulsory in Moldova. Data recorded in the hospital medical records include gender, pre-labour rupture of membrane (any rupture of membranes persisting for more than 24 hours and occurring before the onset of labour), plurality (twins or triplets) and gestational age (GA) in weeks. GA was calculated from the first day of the last menstrual period and classified into term-born (37 weeks or more) or preterm-born (any birth before 37 completed weeks of gestation). Birth weight (BW) was recorded in grams, and being small for gestational age (SGA) was defined as BW below the 10th percentile for the GA. GA was also analysed as a continuous variable. Children with missing GA data were excluded. Birth presentation (vertex, breech or transverse) and mode of delivery were recorded as either vaginal birth (vertex or breech) or Caesarean section (but without specification of planned or emergency delivery). Deliveries outside a maternity ward were considered home births. Home births also included deliveries at rural general practitioners’ offices with no specialised medical assistance and/or ambulance available. Maternal age at delivery was retrieved from the National Agency for Public Health and recorded in three age groups (a: 14–18 years; b: 19–34 years; and c: ≥35 years). Place of birth was recorded as urban or rural; maternal highest education was recorded as low (primary school), medium (high school) or high (university or college); and maternal employment was recorded as yes or no. Assisted vaginal delivery (AVD) included instrumental implication (using forceps or vacuum extraction) and fundal pressure, defined as physical manipulation during the second stage of labour (Kristeller manoeuvre and/or inflatable belt). All variables, for a better understanding, were classified into three categories: Child-related variables: gender, birth year, GA, birth presentation, Apgar score at five minutes, multiple gestation, plurality, SGA, BW. Delivery-related variables: breech delivery, fundal pressure (Kristeller manoeuvre and/or inflatable belt), Caesarean section, place of birth, birth out of maternity, AVD, premature rupture of membranes (PROM), meconium waters aspiration, and umbilical cord around neck. Mother-related variables: maternal age categories, socioeconomic status, educational level, parity (number of previous births), alcohol consumption during pregnancy, and chronic diseases (hypertension, hepatitis, diabetes, intellectual disability, epilepsy and pyelonephritis) [15]. Outcome variables According to the SCPE recommendations, all children diagnosed with CP were classified with spastic, dyskinetic, ataxic or not classified subtypes [16]. Ethics The study was approved by the National Committee for Ethical Expertise of Clinical Trials (number 266), the Center of Early Intervention ‘Voinicel’ Ethical Committee (number 01/17) and the National Centre for Personal Data Protection. A statement of agreement of collaboration between the State Medical and Pharmacy University and the Institute of Mother and Child was signed, and permission to conduct the study was obtained from the Ministry of Health (12th of July, number 08/88), the Municipality Council of Social Protection, (13th of July 2016, number 070117/957) and the Ministry of Labour, Social Protection and Family of the Republic of Moldova. Parents or primary caregivers of patients treated at all the hospitals sign an informed consent form stating that medical data collected as part of the admission process may be used for research purposes. The use of this regularly collected medical information in the present study was approved as described and did not require a new individual consent form to be completed. Statistical analyses Data analyses were performed using SPSS for Windows version 22.0 (SPSS Inc., Chicago, IL, USA). A significance level of 0.05 was chosen. Descriptive statistics with frequencies, proportions and Chi-square tests were used to compare the children with and without CP. Odds ratios (ORs) with 95% confidence intervals (CIs) were used to calculate the risk for CP among children using the three categories of variables (child-, delivery- and mother-related). We calculated the attributable risk (AR) to identify the excess risk attributed to each of the exposure variables. A variable was considered a confounder if it was associated both with exposure and outcome (CP). Thus, gender, plurality, GA, maternal age, birth out of maternity and SGA were assessed as possible confounders. Following the proposed hierarchical model of Victora et al. [17], several confounders were explored using logistic regression analyses. Singletons born at term were assessed separately for possible confounders to identify whether they had different risk factors for CP. Results Over the study period, there were 81,670 births and 81,277 (99.5%) children survived the neonatal period. Among those who survived, 3,770 (4.6%) were born preterm (22–36 GA) and 77,507 (95.4%) at term (≥37 GA; Figure 1). Among the 81,277 children, 351 (4.3 per 1,000 live births) were diagnosed with CP, and we successfully identified complete information on the variables of interest in 417 children without CP, used as a reference group. Table 1 presents a comparison of the two groups regarding child-, delivery- and mother-related characteristics. Of the 351 children diagnosed with CP, 209 (59.5%) were boys, 26% had unilateral, 54% bilateral, 13% dyskinetic, and 5% ataxic CP, with 2% unclassified. The proportion of preterm children (29%) was higher among those with CP than among those in the reference group (17%), giving an OR for CP among those born preterm of 1.162 and 95% CI 1.073–1.258. Low Apgar score (<4) at five minutes also showed an increased risk of CP, with OR 6.187 and 95% CI 2.059–18.59 (Table 2). We also found an increased risk of CP among children born SGA, with OR 1.407 and 95% CI 1.01–1.962. Children with hyperbilirubinemia had an overall greater risk of CP, with OR 6.304 and 95% CI 4.112–9.671 (Table 2). Hyperbilirubinemia and Apgar score at five minutes (0–3) had an 84% AR of CP, multiple gestation almost 75%, and BW >1,500 grams had a 58% excess risk of CP (Table 2). When we examined potential risk factors during delivery, we found that children born in breech delivery had an increased risk of developing CP, with an OR of 3.48 and 95% CI 2.01–6.02 compared to the reference group (Table 2). Other factors that could lead to traumatic hypoxic events during delivery also increased the risk for CP: fundal pressure (OR 15.529, 95% CI 3.573–64.909), birth out of maternity (OR 6.591, 95% CI 1.904–22.81), umbilical cord around the neck (OR 2.751, 95% CI 1.293–3.936) and PROM (OR 0.197, 95% CI 0.088–0.438; Table 2). The AR was 87% for birth out of maternity, 80% for PROM and 67% for breech delivery (Table 2). Mother-related variables showed that 251 children (72%) were born to mothers living in rural areas (Table 1), with an overall OR for CP of 1.961 and 95% CI 1.628–2.363 (Table 3). Other mother-related variables that showed an increased risk for CP were age above 35 years (OR 1.7, 95% CI 1.096–2.638), low education level (OR 3.889, 95% CI 2.8–5.248), alcohol consumption during pregnancy (OR 1.903, 95% CI 1.269–2.885), and chronic diseases such as hypertension (OR 2.264, 95% CI 1.5–5.417) and epilepsy (OR 1.133, 95% CI 1.075–1.194; Table 3). Other severe conditions among mothers, such as diabetes, intellectual disability and pyelonephritis, did not increase the risk for CP (Table 3). Epilepsy had an AR of 78%, hypertension 60% and parity 53% for CP (Table 3). Multiple logistic regression analyses left only two child-related risk factors for CP: male gender and hyperbilirubinemia in the newborn (Table 4). Among delivery-related variables, breech delivery showed an OR for CP of 2.982 and 95% CI 1.498–5.939, birth out of maternity an OR of 7.646 and 95% CI 1.868–31.303, and PROM an OR of 4.895 and 95% CI 1.956–12.249. Umbilical cord around the neck gave a 28% increased risk of developing CP (Table 4). Multiple regression analysis also showed that the AR for CP was 82% for hyperbilirubinemia, 87% for home births, 80% for PROM and 64% for the mother coming from a rural area (Table 4). Analysis of mother-related variables showed that hypertension (OR 0.240, 95% CI 0.126–0.457) and age above 35 years (OR 1.995, 95% CI 1.254–3.174) remained statistically significant (Table 4). Mothers from rural areas had a 64% AR for CP, and those older than 35 years had a 50% AR (Table 4). Table 5 shows that among the 217 singletons born at term with CP, 174 (70%) were from rural areas, a larger number in comparison to the 140 (41%) in the reference group. In the term singleton group, the number of boys with CP was 153 (61%), higher compared to the total group of children. Among all singletons, 14 (6%) of those with CP had an extremely low Apgar score at five minutes compared to none in the reference group. Parity among mothers of children with CP was twice as high at 32 (13%) compared to 22 (6%) children in the reference group (OR 2.115, 95% CI 1.22–3.808). Singletons born SGA had an OR 3.941 and 95% CI 2.157–7.203 of developing CP (Table 6). The AR among all singletons for CP was 83% for hyperbilirubinemia, 33% for Apgar score (0–3) and 69% for fundal pressure (Table 6). A higher risk of CP was also discovered among singletons born at term in breech presentation (OR 6.485, 95% CI 3.068–13.707) and among those born with the help of fundal pressure (OR 3.268, 95% CI 1.398–7.642; Table 6). The AR for CP was 85% for breech presentation, 81%for home births, 78% for AVD and 69% for fundal pressure (Table 6). Mother-related risk factors for CP among singletons born at term particularly included maternal chronic diseases, such as hypertension (OR 2.248, 95% CI 1.55–3.997) and epilepsy (OR 4.65, 95% CI 1.68–12.87), and maternal alcohol consumption during pregnancy (OR 2.105, 95% CI 1.315–3.369; Table 7). The hierarchical split of AR was epilepsy 78%, hypertension 60% and parity 53% (Table 7). The multiple regression analysis, presented in Table 8, showed that the highest risk factors for CP among singletons born at term were home births, hyperbilirubinemia, umbilical cord around the neck, and birth presentation. The AR for CP was 79% for hyperbilirubinemia, ,89% for umbilical cord around the neck and 82% for breech delivery (Table 8). Discussion In this first study on risk factors for CP in Moldova, we found that a combination of risk factors related to the child, delivery, and mother was significant and that the potential interdependency of variables should be the base for future in-depth studies. We found that boys had a higher risk for CP, especially among singletons born at term, but the major risk for CP was found among children with hypoxic-traumatic events during delivery and hyperbilirubinemia during the neonatal period. Maternal residence in rural areas, low socioeconomic status, and alcohol consumption during pregnancy all increased the risk of CP. Chronic disease among mothers, an important public health issue in Moldova, was found to increase the risk of CP substantially. These risk factors were significant both in the total number of children with CP and among singletons born at term. The child- and delivery-related risks of hyperbilirubinemia, Apgar score (0–3) at five minutes, multiple gestation, birth out of maternity, and breech delivery all had highAR for CP, both in the total group and in term-born singletons. Assisted vaginal deliveries and fundal pressure manoeuvres, still performed in Moldova, had the highest AR for CP allthough not significant in multiple logistic regression analyses. Strengths and limitations A strength of the study is that in all 351 children with CP, the diagnosis was confirmed based on the medical records and physical examination of the children by the age of seven years. The CP diagnosis was classified in accordance with SCPE recommendations by the first author, based on detailed neurological descriptions from the children’s medical records [2]. However, the cohort for the present study is small, only two birth years (2009–2010), in comparison with other, larger studies [6–8, 21–29]. Therefore, the results should be interpreted with caution. Detailed perinatal data were obtained from the National Agency of Public Health, and we were able to match 351 (89%) of 396 children diagnosed with CP, in addition to obtaining general perinatal data for all children with CP and all live births in Moldova in 2009–2010. Due to the general but not detailed information on child-, delivery- and mother-related factors in all children born in 2009–2010, the reference group is small, and thus the results have to be interpreted with caution. Comparison with other studies Our first study from 2018, on the prevalence and severity of CP in Moldova in comparison to industrial developed countries in Europe, showed an almost two-fold increase in the number of children with severe forms of CP and associated impairments [14]. The present manuscript is a follow-up study to examine in depth the potential risk factors for CP from three presented groups of variables. The present study showed a lower proportion of prematurely born children with CP compared to a Norwegian study, which could be explained by a different structure of risk factors for CP in Moldova, i.e. intra- and postnatal risk factors among children born at term constitute a large proportion of the CP population [18]. Another explanation of the low incidence of CP in Moldova among preterm children could be the high rate of neonatal deaths in Eastern Europe. According to a UNICEF report, over the last three decades (1990–2017), neonatal mortality has been decreasing in industrial developed countries in Europe. However, in Eastern Europe, neonatal mortality was three times higher than in western countries in 2019, at 153.240 versus 30.804, respectively [19]. In Moldova, in 2009–2010, the birth years of this study population, the neonatal mortality index was estimated to be 14.8, six times higher than the Norwegian neonatal mortality index (2.6) in the same period [19]. The largest proportion of total neonatal deaths is due to extremely premature babies, as shown in the results of a local study by Paladi et al. [20]. The study included 863 babies born with extremely low BW (500–1,000 grams) between the 22 nd and 28 th gestational weeks during 2008–2012. The authors determined a 3–4 times lower survival of these children compared to those in perinatal centres in developed countries. Due to Ministry of Health perinatology strategies implemented in recent years, neonatal mortality has decreased from 100.2‰ to 56.6‰ [20]. The proportion of children born prematurely or SGA among those who developed CP was significantly higher compared to the reference group. We also found that children born with a low or extremely low Apgar score at five minutes had a six-fold increased risk of developing CP, results in line with a registry-based Norwegian study [18] and a systematic review of risk factors for CP in developed countries [7]. An important finding related to the child was hyperbilirubinemia, which was found to be almost seven times higher among children with CP than in the reference group. This finding is in line with a study conducted in the USA on the total of children born at term from 1995–2011. The authors concluded that CP consistent with kernicterus occurred with an incidence of 0.57 per 100,000 births; all had high total serum bilirubin levels and at least two risk factors for neurotoxicity, such as prematurity, glucose-6-phosphate dehydrogenase deficiency or hypoxia-ischemia [21]. Hypoxic-traumatic events during labour were found to be important delivery-related risk factors for CP among children born in Moldova. We found that in Moldova, children born in breech delivery, after fundal pressure manoeuvres, or in AVD had a greatly increased risk of developing CP. These results are in line with a study performed in Sweden in 2006, where the authors concluded that several obstetric factors and low Apgar scores were associated with CP [22]. A Cochrane review on fundal pressure during the second stage of delivery showed that the existing publications did not prove the importance of these manoeuvres in shortening labour or reducing harmful impacts on the health status of the mother and child, such as foetal distress, failure to progress, and maternal exhaustion. Our study showed that the Kristeller manoeuvre is an important risk factor for developing CP. However, when we performed the multiple logistic regression analyses, both fundal pressure and AVD were not statistically significant [11]. We found that AVD among children born in Moldova also was a statistically significant risk factor for CP. However, the 95% CI is very wide, and thus a more in-depth study should be performed, using a larger group of children diagnosed with CP and a larger reference group. Vacuum extraction and forceps are frequently used in Moldova, so further population-based studies are crucial. Our study identified that home births was an important risk factor associated with insufficient perinatal care for both mothers and newborns. These results are in line with a study from China where the authors concluded that home births were indicators of low socioeconomic status. Such deliveries are likely to have higher risks because they are mostly performed by untrained birth attendants. Rural residence and home birthsbirths were found more commonly in the group with CP in our study. Low levels of births at hospitals have also been found to be related to CP in other studies from China and the USA [10,23]. We found that breech delivery was a significant risk factor for CP, particularly among singletons born at term (>37 GW). The same results were obtained in the 2009 Norwegian study by Andersen et al. and a study from Sweden [22,24]. However, in our study, breech delivery was not described in correlation with other variables because of insufficient available data. Thus, a more detailed study is required in Moldova. The univariate analyses showed that PROM > 18 h was found to have a 20% increased risk for CP among sigletons born at term born in Moldova. This finding may suggest a poor delivery protocol in these cases. A national registry cohort study in Norway on term-born singletons from 1999–2009 concluded that intervals of more than 24 hours between PROM and delivery were associated with CP, but not with neonatal mortality or death during delivery [25]. Regarding mother-related variables, our study showed that mothers above the age of 35 had a higher risk of a baby developing CP. This might be explained both by chronic diseases at older ages, including hypertension, hepatitis and pyelonephritis as described, and by higher parity. However, this effect can be prevented if women receive quality prenatal care and deliver in a healthcare facility well-equipped to care for high-risk pregnancies and neonates. We also found that this category of women had low socioeconomic status, which might indicate poor nutrition and low access to quality medical care. Other studies have also concluded a higher risk of a child with CP among women over 30 years old [10]. However, some studies show that maternal age below 20 years is also associated with an increased risk of CP [26]. Multivariate analyses revealed that rural residence, alcohol consumption and chronic disease among mothers increased the risk of developing CP. Parturient women who had gestational hypertension and other diseases such as pyelonephritis, hepatitis and epilepsy also had an increased risk of children with CP, probably due to premature birth, low BW, foetal distress, SGA infants and other abnormal perinatal outcomes. These risk factors for CP were identified in a 2011 systematic review by Himmelmann et al. [27]. In Moldova, because particular attention is paid to non-communicable diseases (NCD), the largest causes of morbidity and mortality in the local population, these diseases are recorded in detail for parturient women. The Millennium Goals established by the World Health Organization for the end of 2020 in Moldova are to reduce the morbidity of NCD in the population. A more detailed, population-based study is required to identify potential harms to the foetus during the perinatal period [15]. The restricted analyses on singletons born at term in Moldova showed the same variables as causes for CP, with a higher risk among boys, children who had experienced hyperbilirubinemia, children born in breech delivery, and children born to mothers with chronic diseases. These results are comparable with several other international studies both from high- and low-income countries [18–27]. Conclusion and policy implications In this study, we found that a combination of factors related to the child, the delivery process and the mother were risk factors for CP among children born in Moldova. Our findings suggest that improved perinatal care, following protocols in PROM and other potential hypoxic events, better follow-up during pregnancy, avoiding harmful habits and encouraging birth at maternity wards would potentially reduce the risk of CP. Further studies with larger numbers of participants are required in Moldova to be able to draw conclusions at the population level. Thus, we strongly recommend the creation of a national CP registry in Moldova, which should be linked to the National Agency for Public Health Data, to enable studies at a national level. Abbreviations AR: attributable risk, the effect of a risk factor on the exposed group AVD: assisted vaginal delivery BW: birth weight CP: cerebral palsy FP: fundal pressure GA: gestational age GMFCS: Gross Motor Function Classification System BFMF: Bimanual Fine Motor Function NNM: neonatal mortality SCPE: Surveillance of Cerebral Palsy in Europe SGA: small for gestational age Declarations Acknowledgements We express our gratitude to state and private paediatric clinics, as well as the rehabilitation centres across the country and the orphanage administration in Moldova, who provided the clinical data of children diagnosed with CP. We also wish to thank the National Agency of Public Health, who provided us with the database of all live births in 2009–2010 including complete perinatal data. Ethics approval and consent to participate The study was approved by the National Committee for Ethical Expertise in Clinical Trials (number 266) and the Centre of Early Intervention ‘Voinicel’ Ethical Committee (number 01/17). A statement of agreement of collaboration between the State Medical and Pharmacy University and the Institute of Mother and Child was signed. Finally, permission to conduct the study was obtained from the Ministry of Health (12 th of July, number 08/88), the Municipality Council of Social Protection (13 th of July 2016, number 070117/957) and the Ministry of Labour, Social Protection and Family of the Republic of Moldova. Permission to access the children’s data was obtained from the Republican Ethics Committee, the State Medical and Pharmacy Ethics Committee, the Ministry of Health, the Ministry of Labour and Social Protection, and the directors of the Institute of Mother and Child, the main hospital for children in the Republic of Moldova. Consent for publication – not applicable. Availability of data and materials section The datasets generated and analysed in this study are not publicly available due to restrictions regarding the sharing of data with third parties. The Management Committee of the Institute of Mother and Child, the hospital that provided the data, has specified that it is forbidden to share the data with third parties. Data are available from the corresponding author upon reasonable request. Competing interests The authors declare that they have no competing interests. Funding This study was supported by a student grant from the Ministry of Foreign Affairs of Norway and AHEAD-Moldova, Norway, within the PhD program at Oslo Metropolitan University, Faculty of Health Sciences, Oslo, Norway. Author contributions EGB designed the study, extracted and analysed the data, performed the statistical analyses and participated in drafting and improving the manuscript. RJ, LS and GA contributed to the design and conceptualisation of the study, provided critical input and oversight of fieldwork and reviewed the final manuscript as submitted. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work. References Rosenbaum P, Paneth N, Leviton A et al. A report: the definition and classification of cerebral palsy April 2006. Dev Med Child Neurol. 2007;49 Suppl 109:8–14. (Erratum in: Dev Med Child Neurol. 2007;49:480.) Surveillance of Cerebral Palsy in Europe. Surveillance of cerebral palsy in Europe: a collaboration of cerebral palsy surveys and registers. Dev Med Child Neurol. 2000;42:816–824. Nelson KB, Ellenberg JH. Antecedents of cerebral palsy. I. Univariate analysis of risks. Am J Dis Child. 1985;139:1031–1038. Stanley FJ, Watson L. Methodology of a cerebral palsy register. The Western Australian experience. Neuroepidemiology. 1985;4:146–160. Cerebral Palsies: Epidemiology and Causal Pathways by Fiona Stanley, Eve Blair, Eva Alberman (Clinics in Developmental Medicine No. 151) London, UK: MacKeith Press, 2000. Van Lieshout P, Candundo H, Martino R, Shin S, Barakat-Haddad C. Onset factors in cerebral palsy: a systematic review. Neurotoxicology. 2017;61:47–53. doi:10.1016/j.neuro.2016.03.021 McIntyre S, Taitz D, Keogh J et al. A systematic review of risk factors for cerebral palsy in children born at term in developed countries. Dev Med Child Neurol. 2013;55:499–508. O'Callaghan ME, MacLennan AH, Gibson CS et al. Epidemiologic associations with cerebral palsy. Obstet Gynecol. 2011;118:576–582. Monokwane B, Johnson A, Gambrah-Sampaney C et al. Risk factors for cerebral palsy in children in Botswana. Pediatr Neurol. 2017;77:73–77. doi:10.1016/j.pediatrneurol.2017.07.014 Gao J, Zhao B, He L, Sun M, Yu X, Wang L. Risk of cerebral palsy in Chinese children: a N:M matched case control study. J Paediatr Child Health. 2017;53(5):464–469. doi:10.1111/jpc.13479 Hofmeyr GJ, Vogel JP, Cuthbert A, Singata M. Fundal pressure during the second stage of labour. Cochrane Database Syst Rev. 2017;3(3):CD006067. Published 2017 Mar 7. doi:10.1002/14651858.CD006067.pub3 Ekéus C, Högberg U, Norman M. Vacuum assisted birth and risk for cerebral complications in term newborn infants: a population-based cohort study. BMC Pregnancy Childbirth. 2014;14:36. Published 2014 Jan 20. doi:10.1186/1471-2393-14-36 Rose J, Vassar R. Movement disorders due to bilirubin toxicity. Semin Fetal Neonatal Med. 2015;20(1):20–25. doi:10.1016/j.siny.2014.11.002 Gincota EB, Andersen GL, Vik T, Jahnsen R. Cerebral palsy in Moldova: subtypes, severity and associated impairments. BMC Pediatrics. 2018;18:332. doi:10.1186/s12887-018-1305-6 http://www.euro.who.int/en/countries/republic-of-moldova/publications/tackling-noncommunicable-diseases-in-the-republic-of-moldova (last accessed 02.06.2020) Cans C, Dolk H, Platt MJ et al. Recommendations from the SCPE collaborative group for defining and classifying cerebral palsy. Dev Med Child Neurol. 2007;Suppl 109:35–38. Victora CG, Huttly SR, Fuchs SC et al. The role of conceptual frameworks in epidemiological analysis: a hierarchical approach. Int J Epidemiol. 1997;26:224–227. Stoknes M, Andersen GL, Elkamil AI et al. The effects of multiple pre- and perinatal risk factors on the occurrence of cerebral palsy. A Norwegian register based study. Eur J Paediatr Neurol. 2012;16(1):56–63. doi:10.1016/j.ejpn.2011.10.004 https://data.unicef.org/topic/child-survival/neonatal-mortality/ (last access 02.06.2020) Paladi G, Bogdan-Moraru A. The Perinatological Journal, 2014, State Medical and Pharmacy University ‘N. Testimitanu’. Wu YW, Kuzniewicz MW, Wickremasinghe AC et al. Risk for cerebral palsy in infants with total serum bilirubin levels at or above the exchange transfusion threshold: a population-based study. JAMA Pediatr. 2015;169(3):239–246. doi:10.1001/jamapediatrics.2014.3036 Thorngren-Jerneck K, Herbst A. Perinatal factors associated with cerebral palsy in children born in Sweden. Obstet Gynecol. 2006;108(6):1499–1505. doi:10.1097/01.AOG.0000247174.27979.6b Kramer MS, Goulet L, Lydon J et al. Socio-economic disparities in preterm birth: causal pathways and mechanisms. Paediatr Perinat Epidemiol. 2001;15(Suppl. 2):104–123. Andersen GL, Irgens LM, Skranes J et al. Is breech presentation a risk factor for cerebral palsy? A Norwegian birth cohort study. Dev Med Child Neurol. 2009;51:860–865. Mynarek M, Bjellmo S, Lydersen S et al. Prelabor rupture of membranes and the association with cerebral palsy in term born children: a national registry-based cohort study. BMC Pregnancy Childb. 2020;20:67. doi:10.1186/s12884-020-2751-3 Glinianaia SV, Rankin J, Colver A. Cerebral palsy rates by birth weight, gestation and severity in North of England, 1991–2000 singleton births. Arch Dis Child. 2010;87(Nov 10). Himmelmann K, Ahlin K, Jacobsson B, Cans C, Thorsen P. Risk factors for cerebral palsy in children born at term. Acta Obstet Gynecol Scand. 2011;90:1070–1081. Tables Table 1. Comparison of child-, delivery-, and maternal characteristics in children with CP and the reference group. Children with CP N=351 (%) Reference group N=417 (%) P-Value Child related factors Gender (male) 209 (59) 192 (46) .000 GA<37 gestational weeks 101 (29) 72 (17) .000 BW 2500g 241 (69) 339 (81) .001 Apgar score at 5 min 0-3 20 (6) 4 (1) 4-6 79 (22) 77 (18) 7-10 252 (72) 336 (81) .000 Small for gestational age 96 (27) 88 (21) .051 Multiple gestation 42 (12) 30 (7) .016 Hyperbilirubinemia >1 week 118 (34) 31 (7) .000 Delivery factors Breech delivery 50 (14) 19 (5) .000 Csection 84 (24) 99 (23) .509 Fundal Pressure* 24 (7) 9 (2) .001 Assisted Vaginal Delivery* 65 (19) 18 (4) .000 Home births 16 (5) 3 (1) .001 Premature Rupture Membranes 18 hours 43 (13) 10 (3) .000 Meconium waters aspiration 121 (35) 120 (28) .053 Umbilical Cord around neck 108 (31) 58 (14) .000 Demographic characteristics Rural 251 (72) 184 (44) .000 Low social-economic status 120 (34) 142 (34) .969 Maternal Factors Parity 45 (13) 15 (4) .000 Maternal age 35 years old 35 (10) 66 (16) .057 Mother low educational level 77 (22) 71 (17) .052 Alcohol consumption 67 (19) 46 (11) .000 Mother chronic diseases Hypertension 71 (20) 42 (10) .000 Hepatitis 27 (8) 18 (4) .034 Pyelonephritis 100 (29) 120 (28) .497 Diabetes 40 (11) 35 (8) .180 Intellectual disability 20 (6) 12 (3) .069 Epilepsy 18 (5) 5 (1) .001 *Fundal Pressure – Krissteller’s maneuver, belt *Assisted Vaginal Delivery – vacuum, forceps Table 2. Child and delivery related risk factors for CP Odds Ratio 95 % CI Lower Upper P-value AR* % Child related factors Gender (male) GA<37 gestational weeks BW 2500g Apgar score at 5 min 0-3 4-6 7-10 Small for gestational age Multiple Gestation Hyperbilirubinemia Delivery factors Breech delivery C-section Fundal Pressure* Assisted Vaginal Delivery* Home birthsy Premature Rupture of Membranes 18 hours Meconium waters aspiration Umbilical Cord around neck 1.334 1.162 1.876 2.374 1.884 6.187 1.318 1.342 1.407 3.941 6.304 3.48 1.01 15.529 47.149 6.591 .185 .197 .835 2.751 1.142 1.073 .778 1.252 1.273 2.059 .921 .935 1.01 2.157 4.112 2.01 .724 3.573 11.455 1.904 .090 .088 .677 1.923 1.557 1.258 4.521 4.502 2.789 18.589 3.34 1.928 1.962 7.203 9.671 6.02 1.410 64.909 194.15 22.810 .380 .438 1.029 3.936 .000 .000 .001 .161 .008 .002 .002 .059 .111 .027 .000 .000 .000 .036 .000 .000 .001 .000 .000 .000 .053 .000 25 14 47 58 48 84 24 25 29 75 84 71 1 94 98 85 <1 <1 <1 64 *Fundal Pressure – Krissteller’s maneuver, belt *Assisted Vaginal Delivery – vacuum, forceps *AR – attributable risk, the effect of a risk factor on the exposed group % Table 3. Demographical and maternal related risk factors for CP Odds Ratio 95 % CI Lower Upper P-value AR* % Demographic characteristics Rural Low Social-economic status Maternal Factors Parity Maternal age >35 years old Mother educational level Low Alcohol consumption Mother chronic diseases -Hypertension -Hepatitis -Pyelonephritis -Diabetes -Intellectual Disability -Epilepsy 1.961 .994 .601 1.7 3.889 1.903 2.264 1.847 1.010 1.404 1.03 1.133 1.628 .737 .385 1.096 2.8 1.269 1.5 1.0 .807 .871 .999 1.075 2.363 1.341 .940 2.638 5.248 2.855 5.417 3.414 1.264 2.263 1.062 1.194 .000 .514 .016 .018 .000 .002 .000 .034 .497 .163 .530 .000 49 <1 <1 41 74 47 56 46 1 <1 <1 12 *AR – attributable risk, the effect of a risk factor on the exposed group % Table 4. Multivariate analyses of risk factors for CP Odds Ratio 95 % CI Lower Upper P-value AR* % Child related factors Gender (male) Hyperbilirubinemia Delivery factors Breech deliveryHome births Premature Rupture of Membranes >18 hours Umbilical Cord around neck Maternal Factors Rural >35 years old Mother chronic diseases -Hypertension .691 5.406 2.982 7.646 4.895 .278 2.795 1.995 .240 .482 3.121 1.498 1.868 1.956 .169 1.914 1.254 .126 .992 9.363 5.939 31.303 12.249 .458 4.082 3.174 .457 .045 .000 .002 .005 .001 .000 .000 .004 .000 <1 82 67 87 80 <1 64 50 <1 AR* – attributable risk, the effect of a risk factor on the exposed group % Table 5. Characteristics of singletons at term with CP compared to the reference group Children with CP N=351 (%) Reference Group N=417 (%) P-value Child related factors Gender (male) Apgar score at 5 min 0-3 4-6 7-10 Small for gestational age Hyperbilirubinemia >1 week Delivery factors Breech delivery C-section Fundal Pressure Assisted Vaginal Delivery Home births Premature Rupture of Membranes >18 hours Meconium waters Umbilical Cord around neck Demographic characteristics Rural Low Social-economic status Maternal Factors Parity 35 years old Low educational level Alcohol consumption Mother chronic diseases -Hypertension -Hepatitis -Pyelonephritis -Diabetis -Intellectual Disability -Epilepsy 153 (61) 14 (6) 36 (14) 200 (80) 33 (13) 83 (33) 37 (15) 61 (24) 18 (7) 45 (18) 11 (4) 9 (13) 89 (36) 81 (32) 174 (70) 84 (34) 32 (13) 16 (6) 209 (84) 25 (10) 53 (21) 48 (19) 52 (21) 18 (7) 72 (29) 32 (13) 13 (5) 16 (6) 153 (44) 0 (0) 36 (10) 309 (90) 55 (16) 27 (8) 9 (3) 70 (20) 8 (2) 16 (5) 3 (1) 9 (3) 93 (27) 47 (14) 140 (41) 113 (33) 22 (6) 22 (6) 269 (78) 54 (16) 57 (16) 35 (10) 33 (10) 14 (4) 92 (27) 31 (9) 11 (3) 5 (1) .000 .000 .413 .000 .000 .270 .007 .000 .011 .000 .025 .000 .000 .860 .009 .131 .164 .003 .000 .100 .578 .134 .291 .002 Table 6. Child and delivery related risk factors for CP in singletons born at term Odds Ratio 95 % CI Lower Upper P-value AR* % Child related factors Gender (male) Apgar score at 5 min (0-3) Small for gestational age Hyperbilirubinemia Delivery factors Breech delivery C-section Fundal pressure Assisted Vaginal Delivery Home births Premature Rupture of Membranes 12-18 hours >18 hours Meconium waters aspiration Umbilical Cord around neck 1.434 1.494 3.941 5.854 6.485 1.268 3.268 4.514 5.247 .192 .196 1.498 3.039 1.196 .889 2.157 3.648 3.068 .858 1.398 2.486 1.448 .088 .081 1.054 2.025 1.721 2.512 7.203 9.393 13.707 1.873 7.642 8.196 19.008 .419 .472 2.129 4.560 .000 .130 .000 .000 .000 .232 .004 .000 .005 .000 .000 .024 .000 30 33 <1 83 85 <1 69 78 81 <1 <1 33 67 *AR – attributable risk, the effect of a risk factor on the exposed group % Table 7. Maternal related risk factors for CP in singletons born at term Odds Ratio 95 % CI Lower Upper P-value AR* % Demographic characteristics Rural Low Social-economic status Maternal Factors Parity Maternal age >35 years old Mother educational level Low Alcohol consumption Mother chronic diseases -Hypertension -Hepatitis -Pyelonephritis -Diabetes -Intellectual Disability -Epilepsy 1.955 .963 2.115 1.650 1.359 2.105 2.483 1.834 1.112 1.487 1.666 4.650 1.589 .681 1.220 .869 .897 1.315 1.550 .894 .774 .881 .734 1.680 2.404 1.360 3.808 2.809 2.060 3.369 3.997 3.762 1.559 2.509 3.782 12.867 .000 .829 .007 .065 .147 .002 .000 .094 .565 .136 .218 .001 48 <1 53 40 26 52 60 <1 <1 <1 <1 78 *AR – attributable risk, the effect of a risk factor on the exposed group % Table 8. Multivariate analysis of risk factors for CP in singletons born at term Odds Ratio 95 % CI Lower Upper P-value AR* % Child related factors Gender (male) Hiperbilirubinemia Apgar at 5 min (0-3) Delivery factors Breech delivery Parity Meconium waters aspiration Premature Rupture of Membranes >18 hours Umbilical Cord around neck Maternal Factors Rural >35 years old Mother chronic diseases -Hypertension 2.210 4.866 .471 5.464 .367 .035 3.026 8.695 3.714 .361 .252 1.384 2.414 .240 2.016 .172 .004 .965 3.122 2.260 .160 .102 3.530 9.811 .925 14.807 .783 .331 9.485 24.216 6.102 .816 .624 .001 .000 .029 .001 .010 .003 .058 .000 .000 .014 .003 55 79 <1 82 <1 <1 n/s 89 73 <1 <1 *AR – attributable risk, the effect of a risk factor on the exposed group % Supplementary Files 1791576summary.pdf AuthorDeclaration.jpg Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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CP is the most common physical disability of childhood, describing a group of permanent disorders of movement and posture attributed to non-progressive disturbances in the developing foetal or infant brain [1]. Potential risk factors have been studied in depth in many developed countries since the 1970s [2\u0026ndash;4]. Preterm birth (\u0026lt;37 gestational weeks, GW), multiple birth, infection in pregnancy, and low birth weight are factors associated with an increased risk for CP [3\u0026ndash;5].\u003c/p\u003e\n\u003cp\u003eIn a systematic review conducted in 2016 by Pascal Van Liesholt et al. [5], included studies indicated that lower gestational age, maternal medical diagnoses, preeclampsia, low birth weight, and the combination of male gender with preterm birth or low birth weight were found to be positively associated with CP [6].\u003c/p\u003e\n\u003cp\u003eA 2013 systematic review of risk factors for CP among children born at term in developed countries found that 10 risk factors were statistically significant in each study: placental abnormalities, major and minor birth defects, low birth weight, meconium aspiration, instrumental or emergency Caesarean delivery, birth asphyxia, neonatal seizures, respiratory distress syndrome, hypoglycaemia and neonatal infections. Instrumental deliveries (compared with spontaneous vaginal or elective Caesarean deliveries) were associated with increased risk of CP, as was breech delivery. However, the study concluded that there is a need for more in-depth investigation of the associations [7].\u003c/p\u003e\n\u003cp\u003eA study from the Australian Collaborative Cerebral Palsy Research Group in 2011, including 587 individuals with CP and a large control group, concluded that preterm birth, intrauterine growth retardation, perinatal infections and multiple births were the largest risk factors for CP [8].\u003c/p\u003e\n\u003cp\u003eA study from Botswana in 2017 showed that significant risk factors for CP included serious neonatal infections, complications during delivery, and maternal human immunodeficiency virus (HIV). The study concluded that the major risk factors for CP in Botswana differ from those described in high-resource settings [9].\u003c/p\u003e\n\u003cp\u003eA 2017 study from China indicated 20 significant risk factors for CP, among which the most important were maternal age \u0026gt;30 years, maternal alcohol consumption during pregnancy, rural residence, paternal occupational exposure to harmful substances, and multiple births. This study concluded that maternal habits during pregnancy and rural residence had an important role and that the CP incidence could probably be further lowered if these factors were considered [10].\u003c/p\u003e\n\u003cp\u003eA population-based cohort study from 1999 to 2010, performed in 2014 in Sweden, concluded that vacuum-assisted delivery was associated with an increased risk of neonatal intracranial haemorrhages compared to Caesarean section [12].\u003c/p\u003e\n\u003cp\u003eIn 2015, a study on the influence of high bilirubin levels in newborns showed that advances in the care of neonatal hyperbilirubinemia have decreased the incidence of kernicterus. However, neonatal exposure to high levels of bilirubin continues to cause CP. New categories of bilirubin-induced neurological dysfunction, either independent or characterised by subtle bilirubin encephalopathy following moderate hyperbilirubinemia, have been implicated in long-term motor function [13].\u003c/p\u003e\n\u003cp\u003eA particular interest for us was to examine the existing literature regarding the consequences to the newborn of fundal pressure manoeuvres. Both the Kristeller manoeuvre and inflatable belts are still frequently used in obstetric practice in Moldova. A 2017 systematic review in the Cochrane Database [9] concluded that evidence from randomised controlled trials was insufficient to show whether manual fundal pressure or fundal pressure by inflatable belt have a severely harmful impact on the baby. However, some of the studies showed a decrease in the five-minute Apgar score. The findings being uncertain, the authors advised that \u0026ldquo;in the future studies should be of good quality, clearly describe how fundal pressure was applied, and focus on safety of the unborn baby\u0026rdquo; [11].\u003c/p\u003e\n\u003cp\u003eThe present study aimed to identify and describe potential risk factors for CP among children born in Moldova. Data from the birth years 2009\u0026ndash;2010 were linked with data from the National Agency for Public Health in Moldova to investigate risk factors for CP.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThe recruitment area of the present study covered both rural and urban localities in Moldova. To perform this study, we first conducted a cohort study that allowed us to describe the characteristics of total births for two years (2009\u0026ndash;2010): total number of births, neonatal mortality, gestational age, birth presentation and the total number of children diagnosed with CP versus those without CP.\u003c/p\u003e\n\u003cp\u003eBased on the findings, and because no detailed information on other variables was available, a second case-control study was performed, with two groups of children: one with a confirmed diagnosis of CP and one without.\u003c/p\u003e\n\u003cp\u003eA cohort of 417 children without CP born in Moldova between the 1\u003csup\u003est\u003c/sup\u003e of January 2009 and 31\u003csup\u003est\u003c/sup\u003e of December 2010, who survived the early neonatal period (first seven days of life), were included. This group was randomly selected by place of residence and place of birth (rural or urban), to have a reference group that was as representative as possible. The Institute of Mother and Child provides services to children from all over the country and University Clinics to children from the capital. The group number is comparatively small in both subgroups because the complete pre- and perinatal data were only available for these children. The second group comprised 351 children with a confirmed CP diagnosis born in the same period.\u003c/p\u003e\n\u003cp\u003eThe CP diagnoses were ascertained by studying the medical records of all children born during the two birth years at the maternity wards, state hospitals for children, orphanages and rehabilitation centres across the country. Each ascertained diagnosis was tracked backwards from the age of seven years, when the diagnosis was confirmed, to the neonatal period, using the medical records from all the relevant departments of the hospitals, such as child neurology, neonatal intensive care units and maternity wards. In this way, we succeeded in covering approximately 95% of the population. In the first article on CP in Moldova from 2018, we described a cohort based on 75% population coverage, with subtypes, severity and prevalence of CP diagnosed in children [14].\u003c/p\u003e\n\u003cp\u003eData on maternal health, pregnancy, delivery and the early neonatal period were obtained from the National Agency of Public Health, Chisinau, Moldova. Detailed data on preconception, antenatal and intrapartum risk factors, as well as CP subtypes and the physical and intellectual development of children with CP born during the outlined period, were collected from hospital medical records. The clinical information on CP was collected between 1\u003csup\u003est\u003c/sup\u003e of July 2016 and 20\u003csup\u003eth\u003c/sup\u003e of December 2017, when the children were at least seven years old, with the following inclusion criteria: children (1) born exclusively in Moldova, (2) meeting the criteria for CP defined by Surveillance of Cerebral Palsy in Europe (SCPE) [2] and (3) without a genetic diagnosis. Orphanages and habilitation centres in Moldova also provided summary and detailed perinatal and clinical data. SCPE criteria for the diagnosis of CP were applied based on detailed neurological descriptions in the medical records [2,14]. Only those children with CP with complete perinatal information were included in the present study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy population\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe total number of births in 2009\u0026ndash;2010 was 81,670, of which 393 children died during the neonatal period (0\u0026ndash;7 days after birth). CP was diagnosed in 396 children. Twenty-seven children were abandoned at orphanages with no medical records, and thus perinatal data were missing. Eighteen children had a post-neonatal cause (i.e. traumatic brain damage took place more than 28 days after birth) and were excluded. Thus, the study population comprised 351 children). The reference group of 417 children with complete pre- and perinatal data was randomly selected from the total of 81,277 children using the medical records of the Institute of Mother and Child and the University Clinics, Chisinau, Moldova (Figure 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eVariables\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eExposure variables\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eRegistration of obstetric and perinatal data at birth is compulsory in Moldova. Data recorded in the hospital medical records include gender, pre-labour rupture of membrane (any rupture of membranes persisting for more than 24 hours and occurring before the onset of labour), plurality (twins or triplets) and gestational age (GA) in weeks. GA was calculated from the first day of the last menstrual period and classified into term-born (37 weeks or more) or preterm-born (any birth before 37 completed weeks of gestation). Birth weight (BW) was recorded in grams, and being small for gestational age (SGA) was defined as BW below the 10th percentile for the GA. GA was also analysed as a continuous variable. Children with missing GA data were excluded. Birth presentation (vertex, breech or transverse) and mode of delivery were recorded as either vaginal birth (vertex or breech) or Caesarean section (but without specification of planned or emergency delivery).\u003c/p\u003e\n\u003cp\u003eDeliveries outside a maternity ward were considered home births. Home births also included deliveries at rural general practitioners\u0026rsquo; offices with no specialised medical assistance and/or ambulance available.\u003c/p\u003e\n\u003cp\u003eMaternal age at delivery was retrieved from the National Agency for Public Health and recorded in three age groups (a: 14\u0026ndash;18 years; b: 19\u0026ndash;34 years; and c: \u0026ge;35 years). Place of birth was recorded as urban or rural; maternal highest education was recorded as low (primary school), medium (high school) or high (university or college); and maternal employment was recorded as yes or no.\u003c/p\u003e\n\u003cp\u003eAssisted vaginal delivery (AVD) included instrumental implication (using forceps or vacuum extraction) and fundal pressure, defined as physical manipulation during the second stage of labour (Kristeller manoeuvre and/or inflatable belt).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAll variables, for a better understanding, were classified into three categories:\u003c/em\u003e\u003c/p\u003e\n\u003col\u003e\n\u003cli\u003eChild-related variables: gender, birth year, GA, birth presentation, Apgar score at five minutes, multiple gestation, plurality, SGA, BW.\u003c/li\u003e\n\u003cli\u003eDelivery-related variables: breech delivery, fundal pressure (Kristeller manoeuvre and/or inflatable belt), Caesarean section, place of birth, birth out of maternity, AVD, premature rupture of membranes (PROM), meconium waters aspiration, and umbilical cord around neck.\u003c/li\u003e\n\u003cli\u003eMother-related variables: maternal age categories, socioeconomic status, educational level, parity (number of previous births), alcohol consumption during pregnancy, and chronic diseases (hypertension, hepatitis, diabetes, intellectual disability, epilepsy and pyelonephritis) [15].\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003cem\u003eOutcome variables\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAccording to the SCPE recommendations, all children diagnosed with CP were classified with spastic, dyskinetic, ataxic or not classified subtypes [16].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the National Committee for Ethical Expertise of Clinical Trials (number 266), the Center of Early Intervention \u0026lsquo;Voinicel\u0026rsquo; Ethical Committee (number 01/17) and the National Centre for Personal Data Protection. A statement of agreement of collaboration between the State Medical and Pharmacy University and the Institute of Mother and Child was signed, and permission to conduct the study was obtained from the Ministry of Health (12th of July, number 08/88), the Municipality Council of Social Protection, (13th of July 2016, number 070117/957) and the Ministry of Labour, Social Protection and Family of the Republic of Moldova.\u003c/p\u003e\n\u003cp\u003eParents or primary caregivers of patients treated at all the hospitals sign an informed consent form stating that medical data collected as part of the admission process may be used for research purposes. The use of this regularly collected medical information in the present study was approved as described and did not require a new individual consent form to be completed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical analyses\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData analyses were performed using SPSS for Windows version 22.0 (SPSS Inc., Chicago, IL, USA). A significance level of 0.05 was chosen.\u003c/p\u003e\n\u003cp\u003eDescriptive statistics with frequencies, proportions and Chi-square tests were used to compare the children with and without CP. Odds ratios (ORs) with 95% confidence intervals (CIs) were used to calculate the risk for CP among children using the three categories of variables (child-, delivery- and mother-related). We calculated the attributable risk (AR) to identify the excess risk attributed to each of the exposure variables.\u003c/p\u003e\n\u003cp\u003eA variable was considered a confounder if it was associated both with exposure and outcome (CP). Thus, gender, plurality, GA, maternal age, birth out of maternity and SGA were assessed as possible confounders. Following the proposed hierarchical model of Victora et al. [17], several confounders were explored using logistic regression analyses. Singletons born at term were assessed separately for possible confounders to identify whether they had different risk factors for CP.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eOver the study period, there were 81,670 births and 81,277 (99.5%) children survived the neonatal period. Among those who survived, 3,770 (4.6%) were born preterm (22\u0026ndash;36 GA) and 77,507 (95.4%) at term (\u0026ge;37 GA; Figure 1).\u003c/p\u003e\n\u003cp\u003eAmong the 81,277 children, 351 (4.3 per 1,000 live births) were diagnosed with CP, and we successfully identified complete information on the variables of interest in 417 children without CP, used as a reference group. Table 1 presents a comparison of the two groups regarding child-, delivery- and mother-related characteristics.\u003c/p\u003e\n\u003cp\u003eOf the 351 children diagnosed with CP, 209 (59.5%) were boys, 26% had unilateral, 54% bilateral, 13% dyskinetic, and 5% ataxic CP, with 2% unclassified. The proportion of preterm children (29%) was higher among those with CP than among those in the reference group (17%), giving an OR for CP among those born preterm of 1.162 and 95% CI 1.073\u0026ndash;1.258. Low Apgar score (\u0026lt;4) at five minutes also showed an increased risk of CP, with OR 6.187 and 95% CI 2.059\u0026ndash;18.59 (Table 2).\u003c/p\u003e\n\u003cp\u003eWe also found an increased risk of CP among children born SGA, with OR 1.407 and 95% CI 1.01\u0026ndash;1.962. Children with hyperbilirubinemia had an overall greater risk of CP, with OR 6.304 and 95% CI 4.112\u0026ndash;9.671 (Table 2).\u003c/p\u003e\n\u003cp\u003eHyperbilirubinemia and Apgar score at five minutes (0\u0026ndash;3) had an 84% AR of CP, multiple gestation almost 75%, and BW \u0026gt;1,500 grams had a 58% excess risk of CP (Table 2).\u003c/p\u003e\n\u003cp\u003eWhen we examined potential risk factors during delivery, we found that children born in breech delivery had an increased risk of developing CP, with an OR of 3.48 and 95% CI 2.01\u0026ndash;6.02 compared to the reference group (Table 2).\u003c/p\u003e\n\u003cp\u003eOther factors that could lead to traumatic hypoxic events during delivery also increased the risk for CP: fundal pressure (OR 15.529, 95% CI 3.573\u0026ndash;64.909), birth out of maternity (OR 6.591, 95% CI 1.904\u0026ndash;22.81), umbilical cord around the neck (OR 2.751, 95% CI 1.293\u0026ndash;3.936) and PROM (OR 0.197, 95% CI 0.088\u0026ndash;0.438; Table 2). The AR was 87% for birth out of maternity, 80% for PROM and 67% for breech delivery (Table 2).\u003c/p\u003e\n\u003cp\u003eMother-related variables showed that 251 children (72%) were born to mothers living in rural areas (Table 1), with an overall OR for CP of 1.961 and 95% CI 1.628\u0026ndash;2.363 (Table 3). Other mother-related variables that showed an increased risk for CP were age above 35 years (OR 1.7, 95% CI 1.096\u0026ndash;2.638), low education level (OR 3.889, 95% CI 2.8\u0026ndash;5.248), alcohol consumption during pregnancy (OR 1.903, 95% CI 1.269\u0026ndash;2.885), and chronic diseases such as hypertension (OR 2.264, 95% CI 1.5\u0026ndash;5.417) and epilepsy (OR 1.133, 95% CI 1.075\u0026ndash;1.194; Table 3). Other severe conditions among mothers, such as diabetes, intellectual disability and pyelonephritis, did not increase the risk for CP (Table 3). Epilepsy had an AR of 78%, hypertension 60% and parity 53% for CP (Table 3).\u003c/p\u003e\n\u003cp\u003eMultiple logistic regression analyses left only two child-related risk factors for CP: male gender and hyperbilirubinemia in the newborn (Table 4).\u003c/p\u003e\n\u003cp\u003eAmong delivery-related variables, breech delivery showed an OR for CP of 2.982 and 95% CI 1.498\u0026ndash;5.939, birth out of maternity an OR of 7.646 and 95% CI 1.868\u0026ndash;31.303, and PROM an OR of 4.895 and 95% CI 1.956\u0026ndash;12.249. Umbilical cord around the neck gave a 28% increased risk of developing CP (Table 4). Multiple regression analysis also showed that the AR for CP was 82% for hyperbilirubinemia, 87% for home births, 80% for PROM and 64% for the mother coming from a rural area (Table 4).\u003c/p\u003e\n\u003cp\u003eAnalysis of mother-related variables showed that hypertension (OR 0.240, 95% CI 0.126\u0026ndash;0.457) and age above 35 years (OR 1.995, 95% CI 1.254\u0026ndash;3.174) remained statistically significant (Table 4). Mothers from rural areas had a 64% AR for CP, and those older than 35 years had a 50% AR (Table 4).\u003c/p\u003e\n\u003cp\u003eTable 5 shows that among the 217 singletons born at term with CP, 174 (70%) were from rural areas, a larger number in comparison to the 140 (41%) in the reference group. In the term singleton group, the number of boys with CP was 153 (61%), higher compared to the total group of children.\u003c/p\u003e\n\u003cp\u003eAmong all singletons, 14 (6%) of those with CP had an extremely low Apgar score at five minutes compared to none in the reference group. Parity among mothers of children with CP was twice as high at 32 (13%) compared to 22 (6%) children in the reference group (OR 2.115, 95% CI 1.22\u0026ndash;3.808). Singletons born SGA had an OR 3.941 and 95% CI 2.157\u0026ndash;7.203 of developing CP (Table 6). The AR among all singletons for CP was 83% for hyperbilirubinemia, 33% for Apgar score (0\u0026ndash;3) and 69% for fundal pressure (Table 6).\u003c/p\u003e\n\u003cp\u003eA higher risk of CP was also discovered among singletons born at term in breech presentation (OR 6.485, 95% CI 3.068\u0026ndash;13.707) and among those born with the help of fundal pressure (OR 3.268, 95% CI 1.398\u0026ndash;7.642; Table 6). The AR for CP was 85% for breech presentation, 81%for home births, 78% for AVD and 69% for fundal pressure (Table 6).\u003c/p\u003e\n\u003cp\u003eMother-related risk factors for CP among singletons born at term particularly included maternal chronic diseases, such as hypertension (OR 2.248, 95% CI 1.55\u0026ndash;3.997) and epilepsy (OR 4.65, 95% CI 1.68\u0026ndash;12.87), and maternal alcohol consumption during pregnancy (OR 2.105, 95% CI 1.315\u0026ndash;3.369; Table 7). The hierarchical split of AR was epilepsy 78%, hypertension 60% and parity 53% (Table 7).\u003c/p\u003e\n\u003cp\u003eThe multiple regression analysis, presented in Table 8, showed that the highest risk factors for CP among singletons born at term were home births, hyperbilirubinemia, umbilical cord around the neck, and birth presentation. The AR for CP was 79% for hyperbilirubinemia, ,89% for umbilical cord around the neck and 82% for breech delivery (Table 8).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003e\u003cstrong\u003eIn this first study on risk factors for CP in Moldova, we found that\u003c/strong\u003e\u003cstrong\u003ea combination of risk factors related to the child, delivery, and mother was significant and that the potential interdependency of variables should be the base for future in-depth studies.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe found that boys had a higher risk for CP, especially among singletons born at term, but the major risk for CP was found among children with hypoxic-traumatic events during delivery and hyperbilirubinemia during the neonatal period. Maternal residence in rural areas, low socioeconomic status, and alcohol consumption during pregnancy all increased the risk of CP. Chronic disease among mothers, an important public health issue in Moldova, was found to increase the risk of CP substantially. These risk factors were significant both in the total number of children with CP and among singletons born at term. The child- and delivery-related risks of hyperbilirubinemia, Apgar score (0\u0026ndash;3) at five minutes, multiple gestation, birth out of maternity, and breech delivery all had highAR for CP, both in the total group and in term-born singletons. Assisted vaginal deliveries and fundal pressure manoeuvres, still performed in Moldova, had the highest AR for CP allthough not significant in multiple logistic regression analyses.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStrengths and limitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA strength of the study is that in all 351 children with CP, the diagnosis was confirmed based on the medical records and physical examination of the children by the age of seven years. The CP diagnosis was classified in accordance with SCPE recommendations by the first author, based on detailed neurological descriptions from the children\u0026rsquo;s medical records [2]. However, the cohort for the present study is small, only two birth years (2009\u0026ndash;2010), in comparison with other, larger studies [6\u0026ndash;8, 21\u0026ndash;29]. Therefore, the results should be interpreted with caution. Detailed perinatal data were obtained from the National Agency of Public Health, and we were able to match 351 (89%) of 396 children diagnosed with CP, in addition to obtaining general perinatal data for all children with CP and all live births in Moldova in 2009\u0026ndash;2010. Due to the general but not detailed information on child-, delivery- and mother-related factors in all children born in 2009\u0026ndash;2010, the reference group is small, and thus the results have to be interpreted with caution.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eComparison with other studies\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOur first study from 2018, on the prevalence and severity of CP in Moldova in comparison to industrial developed countries in Europe, showed an almost two-fold increase in the number of children with severe forms of CP and associated impairments [14]. The present manuscript is a follow-up study to examine in depth the potential risk factors for CP from three presented groups of variables.\u003c/p\u003e\n\u003cp\u003eThe present study showed a lower proportion of prematurely born children with CP compared to a Norwegian study, which could be explained by a different structure of risk factors for CP in Moldova, i.e. intra- and postnatal risk factors among children born at term constitute a large proportion of the CP population [18].\u003c/p\u003e\n\u003cp\u003eAnother explanation of the low incidence of CP in Moldova among preterm children could be the high rate of neonatal deaths in Eastern Europe. According to a UNICEF report, over the last three decades (1990\u0026ndash;2017), neonatal mortality has been decreasing in industrial developed countries in Europe. However, in Eastern Europe, neonatal mortality was three times higher than in western countries in 2019, at 153.240 versus 30.804, respectively [19]. In Moldova, in 2009\u0026ndash;2010, the birth years of this study population, the neonatal mortality index was estimated to be 14.8, six times higher than the Norwegian neonatal mortality index (2.6) in the same period [19].\u003c/p\u003e\n\u003cp\u003eThe largest proportion of total neonatal deaths is due to extremely premature babies, as shown in the results of a local study by Paladi et al. [20]. The study included 863 babies born with extremely low BW (500\u0026ndash;1,000 grams) between the 22\u003csup\u003end\u003c/sup\u003e and 28\u003csup\u003eth\u003c/sup\u003e gestational weeks during 2008\u0026ndash;2012. The authors determined a 3\u0026ndash;4 times lower survival of these children compared to those in perinatal centres in developed countries. Due to Ministry of Health perinatology strategies implemented in recent years, neonatal mortality has decreased from 100.2\u0026permil; to 56.6\u0026permil; [20].\u003c/p\u003e\n\u003cp\u003eThe proportion of children born prematurely or SGA among those who developed CP was significantly higher compared to the reference group. We also found that children born with a low or extremely low Apgar score at five minutes had a six-fold increased risk of developing CP, results in line with a registry-based Norwegian study [18] and a systematic review of risk factors for CP in developed countries [7].\u003c/p\u003e\n\u003cp\u003eAn important finding related to the child was hyperbilirubinemia, which was found to be almost seven times higher among children with CP than in the reference group. This finding is in line with a study conducted in the USA on the total of children born at term from 1995\u0026ndash;2011. The authors concluded that CP consistent with kernicterus occurred with an incidence of 0.57 per 100,000 births; all had high total serum bilirubin levels and at least two risk factors for neurotoxicity, such as prematurity, glucose-6-phosphate dehydrogenase deficiency or hypoxia-ischemia [21].\u003c/p\u003e\n\u003cp\u003eHypoxic-traumatic events during labour were found to be important delivery-related risk factors for CP among children born in Moldova. We found that in Moldova, children born in breech delivery, after fundal pressure manoeuvres, or in AVD had a greatly increased risk of developing CP. These results are in line with a study performed in Sweden in 2006, where the authors concluded that several obstetric factors and low Apgar scores were associated with CP [22].\u003c/p\u003e\n\u003cp\u003eA Cochrane review on fundal pressure during the second stage of delivery showed that the existing publications did not prove the importance of these manoeuvres in shortening labour or reducing harmful impacts on the health status of the mother and child, such as foetal distress, failure to progress, and maternal exhaustion. Our study showed that the Kristeller manoeuvre is an important risk factor for developing CP. However, when we performed the multiple logistic regression analyses, both fundal pressure and AVD were not statistically significant [11].\u003c/p\u003e\n\u003cp\u003eWe found that AVD among children born in Moldova also was a statistically significant risk factor for CP. However, the 95% CI is very wide, and thus a more in-depth study should be performed, using a larger group of children diagnosed with CP and a larger reference group. Vacuum extraction and forceps are frequently used in Moldova, so further population-based studies are crucial.\u003c/p\u003e\n\u003cp\u003eOur study identified that home births was an important risk factor associated with insufficient perinatal care for both mothers and newborns. These results are in line with a study from China where the authors concluded that home births were indicators of low socioeconomic status. Such deliveries are likely to have higher risks because they are mostly performed by untrained birth attendants. Rural residence and home birthsbirths were found more commonly in the group with CP in our study. Low levels of births at hospitals have also been found to be related to CP in other studies from China and the USA [10,23].\u003c/p\u003e\n\u003cp\u003eWe found that breech delivery was a significant risk factor for CP, particularly among singletons born at term (\u0026gt;37 GW). The same results were obtained in the 2009 Norwegian study by Andersen et al. and a study from Sweden [22,24]. However, in our study, breech delivery was not described in correlation with other variables because of insufficient available data. Thus, a more detailed study is required in Moldova.\u003c/p\u003e\n\u003cp\u003eThe univariate analyses showed that PROM \u0026gt; 18 h was found to have a 20% increased risk for CP among sigletons born at term born in Moldova. This finding may suggest a poor delivery protocol in these cases. A national registry cohort study in Norway on term-born singletons from 1999\u0026ndash;2009 concluded that intervals of more than 24\u0026thinsp;hours between PROM and delivery were associated with CP, but not with neonatal mortality or death during delivery [25].\u003c/p\u003e\n\u003cp\u003eRegarding mother-related variables, our study showed that mothers above the age of 35 had a higher risk of a baby developing CP. This might be explained both by chronic diseases at older ages, including hypertension, hepatitis and pyelonephritis as described, and by higher parity. However, this effect can be prevented if women receive quality prenatal care and deliver in a healthcare facility well-equipped to care for high-risk pregnancies and neonates. We also found that this category of women had low socioeconomic status, which might indicate poor nutrition and low access to quality medical care. Other studies have also concluded a higher risk of a child with CP among women over 30 years old [10]. However, some studies show that maternal age below 20 years is also associated with an increased risk of CP [26].\u003c/p\u003e\n\u003cp\u003eMultivariate analyses revealed that rural residence, alcohol consumption and chronic disease among mothers increased the risk of developing CP. Parturient women who had gestational hypertension and other diseases such as pyelonephritis, hepatitis and epilepsy also had an increased risk of children with CP, probably due to premature birth, low BW, foetal distress, SGA infants and other abnormal perinatal outcomes. These risk factors for CP were identified in a 2011 systematic review by Himmelmann et al. [27].\u003c/p\u003e\n\u003cp\u003eIn Moldova, because particular attention is paid to non-communicable diseases (NCD), the largest causes of morbidity and mortality in the local population, these diseases are recorded in detail for parturient women. The Millennium Goals established by the World Health Organization for the end of 2020 in Moldova are to reduce the morbidity of NCD in the population. A more detailed, population-based study is required to identify potential harms to the foetus during the perinatal period [15].\u003c/p\u003e\n\u003cp\u003eThe restricted analyses on singletons born at term in Moldova showed the same variables as causes for CP, with a higher risk among boys, children who had experienced hyperbilirubinemia, children born in breech delivery, and children born to mothers with chronic diseases. These results are comparable with several other international studies both from high- and low-income countries [18\u0026ndash;27].\u003c/p\u003e"},{"header":"Conclusion and policy implications","content":"\u003cp\u003eIn this study, we found that a combination of factors related to the child, the delivery process and the mother were risk factors for CP among children born in Moldova. Our findings suggest that improved perinatal care, following protocols in PROM and other potential hypoxic events, better follow-up during pregnancy, avoiding harmful habits and encouraging birth at maternity wards would potentially reduce the risk of CP. Further studies with larger numbers of participants are required in Moldova to be able to draw conclusions at the population level. Thus, we strongly recommend the creation of a national CP registry in Moldova, which should be linked to the National Agency for Public Health Data, to enable studies at a national level.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAR: attributable risk, the effect of a risk factor on the exposed group\u003c/p\u003e\n\u003cp\u003eAVD: assisted vaginal delivery\u003c/p\u003e\n\u003cp\u003eBW: birth weight\u003c/p\u003e\n\u003cp\u003eCP: cerebral palsy\u003c/p\u003e\n\u003cp\u003eFP: fundal pressure\u003c/p\u003e\n\u003cp\u003eGA: gestational age\u003c/p\u003e\n\u003cp\u003eGMFCS: Gross Motor Function Classification System\u003c/p\u003e\n\u003cp\u003eBFMF: Bimanual Fine Motor Function\u003c/p\u003e\n\u003cp\u003eNNM: neonatal mortality\u003c/p\u003e\n\u003cp\u003eSCPE: Surveillance of Cerebral Palsy in Europe\u003c/p\u003e\n\u003cp\u003eSGA: small for gestational age\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe express our gratitude to state and private paediatric clinics, as well as the rehabilitation centres across the country and the orphanage administration in Moldova, who provided the clinical data of children diagnosed with CP. We also wish to thank the National Agency of Public Health, who provided us with the database of all live births in 2009\u0026ndash;2010 including complete perinatal data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the National Committee for Ethical Expertise in Clinical Trials (number 266) and the Centre of Early Intervention \u0026lsquo;Voinicel\u0026rsquo; Ethical Committee (number 01/17). A statement of agreement of collaboration between the State Medical and Pharmacy University and the Institute of Mother and Child was signed. Finally, permission to conduct the study was obtained from the Ministry of Health (12\u003csup\u003eth\u003c/sup\u003e of July, number 08/88), the Municipality Council of Social Protection (13\u003csup\u003eth\u003c/sup\u003e of July 2016, number 070117/957) and the Ministry of Labour, Social Protection and Family of the Republic of Moldova.\u003c/p\u003e\n\u003cp\u003ePermission to access the children\u0026rsquo;s data was obtained from the Republican Ethics Committee, the State Medical and Pharmacy Ethics Committee, the Ministry of Health, the Ministry of Labour and Social Protection, and the directors of the Institute of Mother and Child, the main hospital for children in the Republic of Moldova.\u003c/p\u003e\n\u003cp\u003eConsent for publication \u0026ndash; not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials section\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and analysed in this study are not publicly available due to restrictions regarding the sharing of data with third parties. The Management Committee of the Institute of Mother and Child, the hospital that provided the data, has specified that it is forbidden to share the data with third parties. Data are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by a student grant from the Ministry of Foreign Affairs of Norway and AHEAD-Moldova, Norway, within the PhD program at Oslo Metropolitan University, Faculty of Health Sciences, Oslo, Norway.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEGB designed the study, extracted and analysed the data, performed the statistical analyses and participated in drafting and improving the manuscript. RJ, LS and GA contributed to the design and conceptualisation of the study, provided critical input and oversight of fieldwork and reviewed the final manuscript as submitted. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eRosenbaum P, Paneth N, Leviton A et al. A report: the definition and classification of cerebral palsy April 2006. Dev Med Child Neurol. 2007;49 Suppl 109:8\u0026ndash;14. (Erratum in: Dev Med Child Neurol. 2007;49:480.)\u003c/li\u003e\n\u003cli\u003eSurveillance of Cerebral Palsy in Europe. Surveillance of cerebral palsy in Europe: a collaboration of cerebral palsy surveys and registers. Dev Med Child Neurol. 2000;42:816\u0026ndash;824.\u003c/li\u003e\n\u003cli\u003eNelson KB, Ellenberg JH. Antecedents of cerebral palsy. I. Univariate analysis of risks. Am J Dis Child. 1985;139:1031\u0026ndash;1038.\u003c/li\u003e\n\u003cli\u003eStanley FJ, Watson L. Methodology of a cerebral palsy register. The Western Australian experience. Neuroepidemiology. 1985;4:146\u0026ndash;160.\u003c/li\u003e\n\u003cli\u003eCerebral Palsies: Epidemiology and Causal Pathways by Fiona Stanley, Eve Blair, Eva Alberman (Clinics in Developmental Medicine No. 151) London, UK: MacKeith Press, 2000.\u003c/li\u003e\n\u003cli\u003eVan Lieshout P, Candundo H, Martino R, Shin S, Barakat-Haddad C. Onset factors in cerebral palsy: a systematic review. Neurotoxicology. 2017;61:47\u0026ndash;53. doi:10.1016/j.neuro.2016.03.021\u003c/li\u003e\n\u003cli\u003eMcIntyre S, Taitz D, Keogh J et al. A systematic review of risk factors for cerebral palsy in children born at term in developed countries. Dev Med Child Neurol. 2013;55:499\u0026ndash;508.\u003c/li\u003e\n\u003cli\u003eO'Callaghan ME, MacLennan AH, Gibson CS et al. Epidemiologic associations with cerebral palsy. Obstet Gynecol. 2011;118:576\u0026ndash;582.\u003c/li\u003e\n\u003cli\u003eMonokwane B, Johnson A, Gambrah-Sampaney C et al. Risk factors for cerebral palsy in children in Botswana. Pediatr Neurol. 2017;77:73\u0026ndash;77. doi:10.1016/j.pediatrneurol.2017.07.014\u003c/li\u003e\n\u003cli\u003eGao J, Zhao B, He L, Sun M, Yu X, Wang L. Risk of cerebral palsy in Chinese children: a N:M matched case control study. J Paediatr Child Health. 2017;53(5):464\u0026ndash;469. doi:10.1111/jpc.13479\u003c/li\u003e\n\u003cli\u003eHofmeyr GJ, Vogel JP, Cuthbert A, Singata M. Fundal pressure during the second stage of labour. Cochrane Database Syst Rev. 2017;3(3):CD006067. Published 2017 Mar 7. doi:10.1002/14651858.CD006067.pub3\u003c/li\u003e\n\u003cli\u003eEk\u0026eacute;us C, H\u0026ouml;gberg U, Norman M. Vacuum assisted birth and risk for cerebral complications in term newborn infants: a population-based cohort study. BMC Pregnancy Childbirth. 2014;14:36. Published 2014 Jan 20. doi:10.1186/1471-2393-14-36\u003c/li\u003e\n\u003cli\u003eRose J, Vassar R. Movement disorders due to bilirubin toxicity. Semin Fetal Neonatal Med. 2015;20(1):20\u0026ndash;25. doi:10.1016/j.siny.2014.11.002\u003c/li\u003e\n\u003cli\u003eGincota EB, Andersen GL, Vik T, Jahnsen R. Cerebral palsy in Moldova: subtypes, severity and associated impairments. BMC Pediatrics. 2018;18:332. doi:10.1186/s12887-018-1305-6\u003c/li\u003e\n\u003cli\u003ehttp://www.euro.who.int/en/countries/republic-of-moldova/publications/tackling-noncommunicable-diseases-in-the-republic-of-moldova (last accessed 02.06.2020)\u003c/li\u003e\n\u003cli\u003eCans C, Dolk H, Platt MJ et al. Recommendations from the SCPE collaborative group for defining and classifying cerebral palsy. Dev Med Child Neurol. 2007;Suppl 109:35\u0026ndash;38.\u003c/li\u003e\n\u003cli\u003eVictora CG, Huttly SR, Fuchs SC et al. The role of conceptual frameworks in epidemiological analysis: a hierarchical approach. Int J Epidemiol. 1997;26:224\u0026ndash;227.\u003c/li\u003e\n\u003cli\u003eStoknes M, Andersen GL, Elkamil AI et al. The effects of multiple pre- and perinatal risk factors on the occurrence of cerebral palsy. A Norwegian register based study. Eur J Paediatr Neurol. 2012;16(1):56\u0026ndash;63. doi:10.1016/j.ejpn.2011.10.004\u003c/li\u003e\n\u003cli\u003ehttps://data.unicef.org/topic/child-survival/neonatal-mortality/ (last access 02.06.2020)\u003c/li\u003e\n\u003cli\u003ePaladi G, Bogdan-Moraru A. The Perinatological Journal, 2014, State Medical and Pharmacy University \u0026lsquo;N. Testimitanu\u0026rsquo;.\u003c/li\u003e\n\u003cli\u003eWu YW, Kuzniewicz MW, Wickremasinghe AC et al. Risk for cerebral palsy in infants with total serum bilirubin levels at or above the exchange transfusion threshold: a population-based study. JAMA Pediatr. 2015;169(3):239\u0026ndash;246. doi:10.1001/jamapediatrics.2014.3036\u003c/li\u003e\n\u003cli\u003eThorngren-Jerneck K, Herbst A. Perinatal factors associated with cerebral palsy in children born in Sweden. Obstet Gynecol. 2006;108(6):1499\u0026ndash;1505. doi:10.1097/01.AOG.0000247174.27979.6b\u003c/li\u003e\n\u003cli\u003eKramer MS, Goulet L, Lydon J et al. Socio-economic disparities in preterm birth: causal pathways and mechanisms. Paediatr Perinat Epidemiol. 2001;15(Suppl. 2):104\u0026ndash;123.\u003c/li\u003e\n\u003cli\u003eAndersen GL, Irgens LM, Skranes J et al. Is breech presentation a risk factor for cerebral palsy? A Norwegian birth cohort study. Dev Med Child Neurol. 2009;51:860\u0026ndash;865.\u003c/li\u003e\n\u003cli\u003eMynarek M, Bjellmo S, Lydersen S et al. Prelabor rupture of membranes and the association with cerebral palsy in term born children: a national registry-based cohort study. BMC Pregnancy Childb. 2020;20:67. doi:10.1186/s12884-020-2751-3\u003c/li\u003e\n\u003cli\u003eGlinianaia SV, Rankin J, Colver A. Cerebral palsy rates by birth weight, gestation and severity in North of England, 1991\u0026ndash;2000 singleton births. Arch Dis Child. 2010;87(Nov 10).\u003c/li\u003e\n\u003cli\u003eHimmelmann K, Ahlin K, Jacobsson B, Cans C, Thorsen P. Risk factors for cerebral palsy in children born at term. Acta Obstet Gynecol Scand. 2011;90:1070\u0026ndash;1081.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1. \u0026nbsp;Comparison of child-, delivery-, and maternal characteristics in children with CP and the reference group.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" width=\"510\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"68\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e\u003cstrong\u003eChildren with CP \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eN=351 (%)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e\u003cstrong\u003eReference group\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eN=417 (%)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003eP-Value\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"3\" width=\"196\"\u003e\n\u003cp\u003e\u003cstrong\u003eChild related factors\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" width=\"132\"\u003e\n\u003cp\u003eGender (male)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e209 (59)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e192 (46)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e.000\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"3\" width=\"196\"\u003e\n\u003cp\u003eGA\u0026lt;37 gestational weeks\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e101 (29)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e72 (17)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e.000\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" width=\"132\"\u003e\n\u003cp\u003eBW \u0026lt;1000g\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e12 (3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e9 (2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" width=\"132\"\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; 1000-1499g\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e27 (8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e16 (4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" width=\"132\"\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; 1500-2499g\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e71 (20)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e53 (13)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" width=\"132\"\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; \u0026gt;2500g\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e241 (69)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e339 (81)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"3\" width=\"196\"\u003e\n\u003cp\u003e\u003cstrong\u003eApgar score at 5 min\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"68\"\u003e\n\u003cp\u003e0-3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e20 (6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e4 (1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"68\"\u003e\n\u003cp\u003e4-6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e79 (22)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e77 (18)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"68\"\u003e\n\u003cp\u003e7-10\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e252 (72)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e336 (81)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e.000\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"3\" width=\"196\"\u003e\n\u003cp\u003eSmall for gestational age\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e96 (27)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e88 (21)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e.051\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" width=\"132\"\u003e\n\u003cp\u003eMultiple gestation\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e42 (12)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e30 (7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e.016\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"68\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"3\" width=\"196\"\u003e\n\u003cp\u003eHyperbilirubinemia \u0026gt;1 week\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e118 (34)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e31 (7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e.000\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"68\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" width=\"132\"\u003e\n\u003cp\u003e\u003cstrong\u003eDelivery factors\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" width=\"132\"\u003e\n\u003cp\u003eBreech delivery\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e50 (14)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e19 (5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e.000\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"68\"\u003e\n\u003cp\u003eCsection\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e84 (24)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e99 (23)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e.509\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" width=\"132\"\u003e\n\u003cp\u003eFundal Pressure*\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e24 (7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e9 (2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"3\" width=\"196\"\u003e\n\u003cp\u003eAssisted Vaginal Delivery*\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e65 (19)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e18 (4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e.000\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"3\" width=\"196\"\u003e\n\u003cp\u003eHome births\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e16 (5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e3 (1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"4\" width=\"260\"\u003e\n\u003cp\u003ePremature Rupture Membranes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" width=\"132\"\u003e\n\u003cp\u003e\u0026lt;12 hours\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e261 (74)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e347 (83)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" width=\"132\"\u003e\n\u003cp\u003e12-18 hours\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e47 (13)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e60 (14)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" width=\"132\"\u003e\n\u003cp\u003e\u0026gt;18 hours\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e43 (13)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e10 (3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e.000\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"3\" width=\"196\"\u003e\n\u003cp\u003eMeconium waters aspiration\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e121 (35)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e120 (28)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e.053\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"3\" width=\"196\"\u003e\n\u003cp\u003eUmbilical Cord around neck\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e108 (31)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e58 (14)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e.000\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"68\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"3\" width=\"196\"\u003e\n\u003cp\u003e\u003cstrong\u003eDemographic characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"68\"\u003e\n\u003cp\u003eRural\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e251 (72)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e184 (44)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e.000\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"3\" width=\"196\"\u003e\n\u003cp\u003eLow social-economic status\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e120 (34)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e142 (34)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e.969\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" width=\"132\"\u003e\n\u003cp\u003e\u003cstrong\u003eMaternal Factors\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParity\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e45 (13)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e15 (4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e.000\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" width=\"132\"\u003e\n\u003cp\u003eMaternal age\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" width=\"132\"\u003e\n\u003cp\u003e\u0026lt;18 years old\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e23 (7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e26 (6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" width=\"132\"\u003e\n\u003cp\u003e19-34 years old\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e293 (83)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e325 (78)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" width=\"132\"\u003e\n\u003cp\u003e\u0026gt;35 years old\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e35 (10)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e66 (16)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e.057\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"68\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"3\" width=\"196\"\u003e\n\u003cp\u003eMother low educational level\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e77 (22)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e71 (17)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e.052\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"3\" width=\"196\"\u003e\n\u003cp\u003eAlcohol consumption\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e67 (19)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e46 (11)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e.000\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"3\" width=\"196\"\u003e\n\u003cp\u003e\u003cstrong\u003eMother chronic diseases\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" width=\"132\"\u003e\n\u003cp\u003eHypertension\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e71 (20)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e42 (10)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e.000\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"68\"\u003e\n\u003cp\u003eHepatitis\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e27 (8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e18 (4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e.034\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" width=\"132\"\u003e\n\u003cp\u003ePyelonephritis\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e100 (29)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e120 (28)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e.497\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"68\"\u003e\n\u003cp\u003eDiabetes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e40 (11)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e35 (8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e.180\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"3\" width=\"196\"\u003e\n\u003cp\u003eIntellectual disability\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e20 (6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e12 (3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e.069\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"68\"\u003e\n\u003cp\u003eEpilepsy\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003e18 (5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e5 (1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003ctable\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"510\"\u003e\n\u003cp\u003e*Fundal Pressure \u0026ndash; Krissteller\u0026rsquo;s maneuver, belt\u003c/p\u003e\n\u003cp\u003e*Assisted Vaginal Delivery \u0026ndash; vacuum, forceps\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2. Child and delivery related risk factors for CP\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"168\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u0026nbsp; Odds Ratio\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"161\"\u003e\n\u003cp\u003e\u003cstrong\u003e95 % CI\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u0026nbsp; Lower\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Upper\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"49\"\u003e\n\u003cp\u003e\u003cstrong\u003eAR* %\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"168\"\u003e\n\u003cp\u003e\u003cstrong\u003eChild related factors\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGender (male)\u003c/p\u003e\n\u003cp\u003eGA\u0026lt;37 gestational weeks\u003c/p\u003e\n\u003cp\u003eBW \u0026lt;1000g\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; 1000-1499g\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; 1500-2499g\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; \u0026gt;2500g\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eApgar score at 5 min\u003c/p\u003e\n\u003cp\u003e0-3\u003c/p\u003e\n\u003cp\u003e4-6\u003c/p\u003e\n\u003cp\u003e7-10\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSmall for gestational age\u003c/p\u003e\n\u003cp\u003eMultiple Gestation\u003c/p\u003e\n\u003cp\u003eHyperbilirubinemia\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDelivery factors\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBreech delivery\u003c/p\u003e\n\u003cp\u003eC-section\u003c/p\u003e\n\u003cp\u003eFundal Pressure*\u003c/p\u003e\n\u003cp\u003eAssisted Vaginal Delivery*\u003c/p\u003e\n\u003cp\u003eHome birthsy\u003c/p\u003e\n\u003cp\u003ePremature Rupture of Membranes\u003c/p\u003e\n\u003cp\u003e\u0026lt;12 hours\u003c/p\u003e\n\u003cp\u003e12-18 hours\u003c/p\u003e\n\u003cp\u003e\u0026gt;18 hours\u003c/p\u003e\n\u003cp\u003eMeconium waters aspiration\u003c/p\u003e\n\u003cp\u003eUmbilical Cord around neck\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e1.334\u003c/p\u003e\n\u003cp\u003e1.162\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e1.876\u003c/p\u003e\n\u003cp\u003e2.374\u003c/p\u003e\n\u003cp\u003e1.884\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e6.187\u003c/p\u003e\n\u003cp\u003e1.318\u003c/p\u003e\n\u003cp\u003e1.342\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e1.407\u003c/p\u003e\n\u003cp\u003e3.941\u003c/p\u003e\n\u003cp\u003e6.304\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e3.48\u003c/p\u003e\n\u003cp\u003e1.01\u003c/p\u003e\n\u003cp\u003e15.529\u003c/p\u003e\n\u003cp\u003e47.149\u003c/p\u003e\n\u003cp\u003e6.591\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e.185\u003c/p\u003e\n\u003cp\u003e.197\u003c/p\u003e\n\u003cp\u003e.835\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e2.751\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e1.142\u003c/p\u003e\n\u003cp\u003e1.073\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e.778\u003c/p\u003e\n\u003cp\u003e1.252\u003c/p\u003e\n\u003cp\u003e1.273\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e2.059\u003c/p\u003e\n\u003cp\u003e.921\u003c/p\u003e\n\u003cp\u003e.935\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e1.01\u003c/p\u003e\n\u003cp\u003e2.157\u003c/p\u003e\n\u003cp\u003e4.112\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e2.01\u003c/p\u003e\n\u003cp\u003e.724\u003c/p\u003e\n\u003cp\u003e3.573\u003c/p\u003e\n\u003cp\u003e11.455\u003c/p\u003e\n\u003cp\u003e1.904\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e.090\u003c/p\u003e\n\u003cp\u003e.088\u003c/p\u003e\n\u003cp\u003e.677\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e1.923\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e1.557\u003c/p\u003e\n\u003cp\u003e1.258\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e4.521\u003c/p\u003e\n\u003cp\u003e4.502\u003c/p\u003e\n\u003cp\u003e2.789\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e18.589\u003c/p\u003e\n\u003cp\u003e3.34\u003c/p\u003e\n\u003cp\u003e1.928\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e1.962\u003c/p\u003e\n\u003cp\u003e7.203\u003c/p\u003e\n\u003cp\u003e9.671\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e6.02\u003c/p\u003e\n\u003cp\u003e1.410\u003c/p\u003e\n\u003cp\u003e64.909\u003c/p\u003e\n\u003cp\u003e194.15\u003c/p\u003e\n\u003cp\u003e22.810\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e.380\u003c/p\u003e\n\u003cp\u003e.438\u003c/p\u003e\n\u003cp\u003e1.029\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e3.936\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e.000\u003c/p\u003e\n\u003cp\u003e.000\u003c/p\u003e\n\u003cp\u003e.001\u003c/p\u003e\n\u003cp\u003e.161\u003c/p\u003e\n\u003cp\u003e.008\u003c/p\u003e\n\u003cp\u003e.002\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e.002\u003c/p\u003e\n\u003cp\u003e.059\u003c/p\u003e\n\u003cp\u003e.111\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e.027\u003c/p\u003e\n\u003cp\u003e.000\u003c/p\u003e\n\u003cp\u003e.000\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e.000\u003c/p\u003e\n\u003cp\u003e.036\u003c/p\u003e\n\u003cp\u003e.000\u003c/p\u003e\n\u003cp\u003e.000\u003c/p\u003e\n\u003cp\u003e.001\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e.000\u003c/p\u003e\n\u003cp\u003e.000\u003c/p\u003e\n\u003cp\u003e.000\u003c/p\u003e\n\u003cp\u003e.053\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e.000\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"49\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e25\u003c/p\u003e\n\u003cp\u003e14\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e47\u003c/p\u003e\n\u003cp\u003e58\u003c/p\u003e\n\u003cp\u003e48\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e84\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e24\u003c/p\u003e\n\u003cp\u003e25\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e29\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e75\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e84\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e71\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e94\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e98\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e85\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026lt;1\u003c/p\u003e\n\u003cp\u003e\u0026lt;1\u003c/p\u003e\n\u003cp\u003e\u0026lt;1\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e64\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"6\" width=\"548\"\u003e\n\u003cp\u003e*Fundal Pressure \u0026ndash; Krissteller\u0026rsquo;s maneuver, belt\u003c/p\u003e\n\u003cp\u003e*Assisted Vaginal Delivery \u0026ndash; vacuum, forceps\u003c/p\u003e\n\u003cp\u003e*AR \u0026ndash; attributable risk, the effect of a risk factor on the exposed group %\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"168\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"49\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3. Demographical and maternal related risk factors for CP\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"177\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u0026nbsp; Odds Ratio\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"189\"\u003e\n\u003cp\u003e\u003cstrong\u003e95 % CI\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u0026nbsp; Lower\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Upper\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u003cstrong\u003eAR* %\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"177\"\u003e\n\u003cp\u003e\u003cstrong\u003eDemographic characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Rural\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Low Social-economic status\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMaternal Factors\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParity\u003c/p\u003e\n\u003cp\u003eMaternal age\u003c/p\u003e\n\u003cp\u003e\u0026gt;35 years old\u003c/p\u003e\n\u003cp\u003eMother educational level Low\u003c/p\u003e\n\u003cp\u003eAlcohol consumption\u003c/p\u003e\n\u003cp\u003eMother chronic diseases\u003c/p\u003e\n\u003cp\u003e-Hypertension\u003c/p\u003e\n\u003cp\u003e-Hepatitis\u003c/p\u003e\n\u003cp\u003e-Pyelonephritis\u003c/p\u003e\n\u003cp\u003e-Diabetes\u003c/p\u003e\n\u003cp\u003e-Intellectual Disability\u003c/p\u003e\n\u003cp\u003e-Epilepsy\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e1.961\u003c/p\u003e\n\u003cp\u003e.994\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e.601\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e1.7\u003c/p\u003e\n\u003cp\u003e3.889\u003c/p\u003e\n\u003cp\u003e1.903\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e2.264\u003c/p\u003e\n\u003cp\u003e1.847\u003c/p\u003e\n\u003cp\u003e1.010\u003c/p\u003e\n\u003cp\u003e1.404\u003c/p\u003e\n\u003cp\u003e1.03\u003c/p\u003e\n\u003cp\u003e1.133\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e1.628\u003c/p\u003e\n\u003cp\u003e.737\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e.385\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e1.096\u003c/p\u003e\n\u003cp\u003e2.8\u003c/p\u003e\n\u003cp\u003e1.269\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e1.5\u003c/p\u003e\n\u003cp\u003e1.0\u003c/p\u003e\n\u003cp\u003e.807\u003c/p\u003e\n\u003cp\u003e.871\u003c/p\u003e\n\u003cp\u003e.999\u003c/p\u003e\n\u003cp\u003e1.075\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e2.363\u003c/p\u003e\n\u003cp\u003e1.341\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e.940\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e2.638\u003c/p\u003e\n\u003cp\u003e5.248\u003c/p\u003e\n\u003cp\u003e2.855\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e5.417\u003c/p\u003e\n\u003cp\u003e3.414\u003c/p\u003e\n\u003cp\u003e1.264\u003c/p\u003e\n\u003cp\u003e2.263\u003c/p\u003e\n\u003cp\u003e1.062\u003c/p\u003e\n\u003cp\u003e1.194\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e.000\u003c/p\u003e\n\u003cp\u003e.514\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e.016\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e.018\u003c/p\u003e\n\u003cp\u003e.000\u003c/p\u003e\n\u003cp\u003e.002\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e.000\u003c/p\u003e\n\u003cp\u003e.034\u003c/p\u003e\n\u003cp\u003e.497\u003c/p\u003e\n\u003cp\u003e.163\u003c/p\u003e\n\u003cp\u003e.530\u003c/p\u003e\n\u003cp\u003e.000\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e49\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026lt;1\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026lt;1\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e41\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e74\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e47\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e56\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e46\u003c/p\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003cp\u003e\u0026lt;1\u003c/p\u003e\n\u003cp\u003e\u0026lt;1\u003c/p\u003e\n\u003cp\u003e12\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"6\" width=\"603\"\u003e\n\u003cp\u003e*AR \u0026ndash; attributable risk, the effect of a risk factor on the exposed group %\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"177\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cbr /\u003eTable 4. Multivariate analyses of risk factors for CP\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"177\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u0026nbsp; Odds Ratio\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"189\"\u003e\n\u003cp\u003e\u003cstrong\u003e95 % CI\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u0026nbsp; Lower\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Upper\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u003cstrong\u003eAR* %\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"177\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eChild related factors\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGender (male)\u003c/p\u003e\n\u003cp\u003eHyperbilirubinemia\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDelivery factors\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBreech deliveryHome births\u003c/p\u003e\n\u003cp\u003ePremature Rupture of Membranes\u003c/p\u003e\n\u003cp\u003e\u0026gt;18 hours\u003c/p\u003e\n\u003cp\u003eUmbilical Cord around neck\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMaternal Factors\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRural\u003c/p\u003e\n\u003cp\u003e\u0026gt;35 years old\u003c/p\u003e\n\u003cp\u003eMother chronic diseases\u003c/p\u003e\n\u003cp\u003e-Hypertension\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e.691\u003c/p\u003e\n\u003cp\u003e5.406\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e2.982\u003c/p\u003e\n\u003cp\u003e7.646\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e4.895\u003c/p\u003e\n\u003cp\u003e.278\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e2.795\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e1.995\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e.240\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e.482\u003c/p\u003e\n\u003cp\u003e3.121\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e1.498\u003c/p\u003e\n\u003cp\u003e1.868\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e1.956\u003c/p\u003e\n\u003cp\u003e.169\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e1.914\u003c/p\u003e\n\u003cp\u003e1.254\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e.126\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e.992\u003c/p\u003e\n\u003cp\u003e9.363\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e5.939\u003c/p\u003e\n\u003cp\u003e31.303\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e12.249\u003c/p\u003e\n\u003cp\u003e.458\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e4.082\u003c/p\u003e\n\u003cp\u003e3.174\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e.457\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e.045\u003c/p\u003e\n\u003cp\u003e.000\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e.002\u003c/p\u003e\n\u003cp\u003e.005\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e.001\u003c/p\u003e\n\u003cp\u003e.000\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e.000\u003c/p\u003e\n\u003cp\u003e.004\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e.000\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026lt;1\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e82\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e67\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e87\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e80\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026lt;1\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e64\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e50\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026lt;1\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"177\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003ctable\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"603\"\u003e\n\u003cp\u003eAR* \u0026ndash; attributable risk, the effect of a risk factor on the exposed group %\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5. \u003c/strong\u003eCharacteristics of singletons at term with CP compared to the reference group\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"171\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"133\"\u003e\n\u003cp\u003e\u003cstrong\u003eChildren with CP \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eN=351 (%)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"124\"\u003e\n\u003cp\u003e\u003cstrong\u003eReference Group\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eN=417 (%)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"86\"\u003e\n\u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"171\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eChild related factors\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGender (male)\u003c/p\u003e\n\u003cp\u003eApgar score at 5 min\u003c/p\u003e\n\u003cp\u003e0-3\u003c/p\u003e\n\u003cp\u003e4-6\u003c/p\u003e\n\u003cp\u003e7-10\u003c/p\u003e\n\u003cp\u003eSmall for gestational age\u003c/p\u003e\n\u003cp\u003eHyperbilirubinemia \u0026gt;1 week\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDelivery factors\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBreech delivery\u003c/p\u003e\n\u003cp\u003eC-section\u003c/p\u003e\n\u003cp\u003eFundal Pressure\u003c/p\u003e\n\u003cp\u003eAssisted Vaginal Delivery\u003c/p\u003e\n\u003cp\u003eHome births\u003c/p\u003e\n\u003cp\u003ePremature Rupture of Membranes\u003c/p\u003e\n\u003cp\u003e\u0026gt;18 hours\u003c/p\u003e\n\u003cp\u003eMeconium waters\u003c/p\u003e\n\u003cp\u003eUmbilical Cord around neck\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDemographic characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRural\u003c/p\u003e\n\u003cp\u003eLow Social-economic status\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMaternal Factors\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParity\u003c/p\u003e\n\u003cp\u003e\u0026lt;18 years old\u003c/p\u003e\n\u003cp\u003e19-34 years old\u003c/p\u003e\n\u003cp\u003e\u0026gt;35 years old\u003c/p\u003e\n\u003cp\u003eLow educational level\u003c/p\u003e\n\u003cp\u003eAlcohol consumption\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMother chronic diseases\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e-Hypertension\u003c/p\u003e\n\u003cp\u003e-Hepatitis\u003c/p\u003e\n\u003cp\u003e-Pyelonephritis\u003c/p\u003e\n\u003cp\u003e-Diabetis\u003c/p\u003e\n\u003cp\u003e-Intellectual Disability\u003c/p\u003e\n\u003cp\u003e-Epilepsy\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"133\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e153 (61)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e14 (6)\u003c/p\u003e\n\u003cp\u003e36 (14)\u003c/p\u003e\n\u003cp\u003e200 (80)\u003c/p\u003e\n\u003cp\u003e33 (13)\u003c/p\u003e\n\u003cp\u003e83 (33)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e37 (15)\u003c/p\u003e\n\u003cp\u003e61 (24)\u003c/p\u003e\n\u003cp\u003e18 (7)\u003c/p\u003e\n\u003cp\u003e45 (18)\u003c/p\u003e\n\u003cp\u003e11 (4)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e9 (13)\u003c/p\u003e\n\u003cp\u003e89 (36)\u003c/p\u003e\n\u003cp\u003e81 (32)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e174 (70)\u003c/p\u003e\n\u003cp\u003e84 (34)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e32 (13)\u003c/p\u003e\n\u003cp\u003e16 (6)\u003c/p\u003e\n\u003cp\u003e209 (84)\u003c/p\u003e\n\u003cp\u003e25 (10)\u003c/p\u003e\n\u003cp\u003e53 (21)\u003c/p\u003e\n\u003cp\u003e48 (19)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e52 (21)\u003c/p\u003e\n\u003cp\u003e18 (7)\u003c/p\u003e\n\u003cp\u003e72 (29)\u003c/p\u003e\n\u003cp\u003e32 (13)\u003c/p\u003e\n\u003cp\u003e13 (5)\u003c/p\u003e\n\u003cp\u003e16 (6)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"124\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e153 (44)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e0 (0)\u003c/p\u003e\n\u003cp\u003e36 (10)\u003c/p\u003e\n\u003cp\u003e309 (90)\u003c/p\u003e\n\u003cp\u003e55 (16)\u003c/p\u003e\n\u003cp\u003e27 (8)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e9 (3)\u003c/p\u003e\n\u003cp\u003e70 (20)\u003c/p\u003e\n\u003cp\u003e8 (2)\u003c/p\u003e\n\u003cp\u003e16 (5)\u003c/p\u003e\n\u003cp\u003e3 (1)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e9 (3)\u003c/p\u003e\n\u003cp\u003e93 (27)\u003c/p\u003e\n\u003cp\u003e47 (14)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e140 (41)\u003c/p\u003e\n\u003cp\u003e113 (33)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e22 (6)\u003c/p\u003e\n\u003cp\u003e22 (6)\u003c/p\u003e\n\u003cp\u003e269 (78)\u003c/p\u003e\n\u003cp\u003e54 (16)\u003c/p\u003e\n\u003cp\u003e57 (16)\u003c/p\u003e\n\u003cp\u003e35 (10)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e33 (10)\u003c/p\u003e\n\u003cp\u003e14 (4)\u003c/p\u003e\n\u003cp\u003e92 (27)\u003c/p\u003e\n\u003cp\u003e31 (9)\u003c/p\u003e\n\u003cp\u003e11 (3)\u003c/p\u003e\n\u003cp\u003e5 (1)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"86\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e.000\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e.000\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e.413\u003c/p\u003e\n\u003cp\u003e.000\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e.000\u003c/p\u003e\n\u003cp\u003e.270\u003c/p\u003e\n\u003cp\u003e.007\u003c/p\u003e\n\u003cp\u003e.000\u003c/p\u003e\n\u003cp\u003e.011\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e.000\u003c/p\u003e\n\u003cp\u003e.025\u003c/p\u003e\n\u003cp\u003e.000\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e.000\u003c/p\u003e\n\u003cp\u003e.860\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e.009\u003c/p\u003e\n\u003cp\u003e.131\u003c/p\u003e\n\u003cp\u003e.164\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e.003\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e.000\u003c/p\u003e\n\u003cp\u003e.100\u003c/p\u003e\n\u003cp\u003e.578\u003c/p\u003e\n\u003cp\u003e.134\u003c/p\u003e\n\u003cp\u003e.291\u003c/p\u003e\n\u003cp\u003e.002\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 6. \u003c/strong\u003eChild and delivery related risk factors for CP in singletons born at term\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"158\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"113\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u0026nbsp; Odds Ratio\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"198\"\u003e\n\u003cp\u003e\u003cstrong\u003e95 % CI\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u0026nbsp; Lower\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Upper\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u003cstrong\u003eAR* %\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"158\"\u003e\n\u003cp\u003e\u003cstrong\u003eChild related factors\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGender (male)\u003c/p\u003e\n\u003cp\u003eApgar score at 5 min (0-3)\u003c/p\u003e\n\u003cp\u003eSmall for gestational age\u003c/p\u003e\n\u003cp\u003eHyperbilirubinemia\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDelivery factors\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBreech delivery\u003c/p\u003e\n\u003cp\u003eC-section\u003c/p\u003e\n\u003cp\u003eFundal pressure\u003c/p\u003e\n\u003cp\u003eAssisted Vaginal Delivery\u003c/p\u003e\n\u003cp\u003eHome births\u003c/p\u003e\n\u003cp\u003ePremature Rupture of Membranes\u003c/p\u003e\n\u003cp\u003e12-18 hours\u003c/p\u003e\n\u003cp\u003e\u0026gt;18 hours\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMeconium waters aspiration\u003c/p\u003e\n\u003cp\u003eUmbilical Cord around neck\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"113\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e1.434\u003c/p\u003e\n\u003cp\u003e1.494\u003c/p\u003e\n\u003cp\u003e3.941\u003c/p\u003e\n\u003cp\u003e5.854\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e6.485\u003c/p\u003e\n\u003cp\u003e1.268\u003c/p\u003e\n\u003cp\u003e3.268\u003c/p\u003e\n\u003cp\u003e4.514\u003c/p\u003e\n\u003cp\u003e5.247\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e.192\u003c/p\u003e\n\u003cp\u003e.196\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e1.498\u003c/p\u003e\n\u003cp\u003e3.039\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e1.196\u003c/p\u003e\n\u003cp\u003e.889\u003c/p\u003e\n\u003cp\u003e2.157\u003c/p\u003e\n\u003cp\u003e3.648\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e3.068\u003c/p\u003e\n\u003cp\u003e.858\u003c/p\u003e\n\u003cp\u003e1.398\u003c/p\u003e\n\u003cp\u003e2.486\u003c/p\u003e\n\u003cp\u003e1.448\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e.088\u003c/p\u003e\n\u003cp\u003e.081\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e1.054\u003c/p\u003e\n\u003cp\u003e2.025\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e1.721\u003c/p\u003e\n\u003cp\u003e2.512\u003c/p\u003e\n\u003cp\u003e7.203\u003c/p\u003e\n\u003cp\u003e9.393\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e13.707\u003c/p\u003e\n\u003cp\u003e1.873\u003c/p\u003e\n\u003cp\u003e7.642\u003c/p\u003e\n\u003cp\u003e8.196\u003c/p\u003e\n\u003cp\u003e19.008\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e.419\u003c/p\u003e\n\u003cp\u003e.472\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e2.129\u003c/p\u003e\n\u003cp\u003e4.560\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e.000\u003c/p\u003e\n\u003cp\u003e.130\u003c/p\u003e\n\u003cp\u003e.000\u003c/p\u003e\n\u003cp\u003e.000\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e.000\u003c/p\u003e\n\u003cp\u003e.232\u003c/p\u003e\n\u003cp\u003e.004\u003c/p\u003e\n\u003cp\u003e.000\u003c/p\u003e\n\u003cp\u003e.005\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e.000\u003c/p\u003e\n\u003cp\u003e.000\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e.024\u003c/p\u003e\n\u003cp\u003e.000\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e30\u003c/p\u003e\n\u003cp\u003e33\u003c/p\u003e\n\u003cp\u003e\u0026lt;1\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e83\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e85\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026lt;1\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e69\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e78\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e81\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026lt;1\u003c/p\u003e\n\u003cp\u003e\u0026lt;1\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e33\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e67\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"158\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"113\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003ctable\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"603\"\u003e\n\u003cp\u003e*AR \u0026ndash; attributable risk, the effect of a risk factor on the exposed group %\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 7. \u003c/strong\u003eMaternal related risk factors for CP in singletons born at term\u003c/p\u003e\n\u003ctable border=\"1\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"164\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u0026nbsp; Odds Ratio\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"184\"\u003e\n\u003cp\u003e\u003cstrong\u003e95 % CI\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u0026nbsp; Lower\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Upper\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"83\"\u003e\n\u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"53\"\u003e\n\u003cp\u003e\u003cstrong\u003eAR* %\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"164\"\u003e\n\u003cp\u003e\u003cstrong\u003eDemographic characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Rural\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Low Social-economic status\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMaternal Factors\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParity\u003c/p\u003e\n\u003cp\u003eMaternal age\u003c/p\u003e\n\u003cp\u003e\u0026gt;35 years old\u003c/p\u003e\n\u003cp\u003eMother educational level Low\u003c/p\u003e\n\u003cp\u003eAlcohol consumption\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMother chronic diseases\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e-Hypertension\u003c/p\u003e\n\u003cp\u003e-Hepatitis\u003c/p\u003e\n\u003cp\u003e-Pyelonephritis\u003c/p\u003e\n\u003cp\u003e-Diabetes\u003c/p\u003e\n\u003cp\u003e-Intellectual Disability\u003c/p\u003e\n\u003cp\u003e-Epilepsy\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e1.955\u003c/p\u003e\n\u003cp\u003e.963\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e2.115\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e1.650\u003c/p\u003e\n\u003cp\u003e1.359\u003c/p\u003e\n\u003cp\u003e2.105\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e2.483\u003c/p\u003e\n\u003cp\u003e1.834\u003c/p\u003e\n\u003cp\u003e1.112\u003c/p\u003e\n\u003cp\u003e1.487\u003c/p\u003e\n\u003cp\u003e1.666\u003c/p\u003e\n\u003cp\u003e4.650\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"92\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e1.589\u003c/p\u003e\n\u003cp\u003e.681\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e1.220\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e.869\u003c/p\u003e\n\u003cp\u003e.897\u003c/p\u003e\n\u003cp\u003e1.315\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e1.550\u003c/p\u003e\n\u003cp\u003e.894\u003c/p\u003e\n\u003cp\u003e.774\u003c/p\u003e\n\u003cp\u003e.881\u003c/p\u003e\n\u003cp\u003e.734\u003c/p\u003e\n\u003cp\u003e1.680\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"92\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e2.404\u003c/p\u003e\n\u003cp\u003e1.360\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e3.808\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e2.809\u003c/p\u003e\n\u003cp\u003e2.060\u003c/p\u003e\n\u003cp\u003e3.369\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e3.997\u003c/p\u003e\n\u003cp\u003e3.762\u003c/p\u003e\n\u003cp\u003e1.559\u003c/p\u003e\n\u003cp\u003e2.509\u003c/p\u003e\n\u003cp\u003e3.782\u003c/p\u003e\n\u003cp\u003e12.867\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"83\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e.000\u003c/p\u003e\n\u003cp\u003e.829\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e.007\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e.065\u003c/p\u003e\n\u003cp\u003e.147\u003c/p\u003e\n\u003cp\u003e.002\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e.000\u003c/p\u003e\n\u003cp\u003e.094\u003c/p\u003e\n\u003cp\u003e.565\u003c/p\u003e\n\u003cp\u003e.136\u003c/p\u003e\n\u003cp\u003e.218\u003c/p\u003e\n\u003cp\u003e.001\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"53\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e48\u003c/p\u003e\n\u003cp\u003e\u0026lt;1\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e53\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e40\u003c/p\u003e\n\u003cp\u003e26\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e52\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e60\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026lt;1\u003c/p\u003e\n\u003cp\u003e\u0026lt;1\u003c/p\u003e\n\u003cp\u003e\u0026lt;1\u003c/p\u003e\n\u003cp\u003e\u0026lt;1\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e78\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"164\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"110\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"92\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"92\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"83\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"53\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003ctable\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"595\"\u003e\n\u003cp\u003e*AR \u0026ndash; attributable risk, the effect of a risk factor on the exposed group %\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 8.\u003c/strong\u003e Multivariate analysis of risk factors for CP in singletons born at term\u003c/p\u003e\n\u003ctable border=\"1\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"177\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u0026nbsp; Odds Ratio\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"189\"\u003e\n\u003cp\u003e\u003cstrong\u003e95 % CI\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u0026nbsp; Lower\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Upper\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u003cstrong\u003eAR* %\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"177\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eChild related factors\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGender (male)\u003c/p\u003e\n\u003cp\u003eHiperbilirubinemia\u003c/p\u003e\n\u003cp\u003eApgar at 5 min (0-3)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDelivery factors\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBreech delivery\u003c/p\u003e\n\u003cp\u003eParity\u003c/p\u003e\n\u003cp\u003eMeconium waters aspiration\u003c/p\u003e\n\u003cp\u003ePremature Rupture of Membranes\u003c/p\u003e\n\u003cp\u003e\u0026gt;18 hours\u003c/p\u003e\n\u003cp\u003eUmbilical Cord around neck\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMaternal Factors\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRural\u003c/p\u003e\n\u003cp\u003e\u0026gt;35 years old\u003c/p\u003e\n\u003cp\u003eMother chronic diseases\u003c/p\u003e\n\u003cp\u003e-Hypertension\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e2.210\u003c/p\u003e\n\u003cp\u003e4.866\u003c/p\u003e\n\u003cp\u003e.471\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e5.464\u003c/p\u003e\n\u003cp\u003e.367\u003c/p\u003e\n\u003cp\u003e.035\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e3.026\u003c/p\u003e\n\u003cp\u003e8.695\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e3.714\u003c/p\u003e\n\u003cp\u003e.361\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e.252\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e1.384\u003c/p\u003e\n\u003cp\u003e2.414\u003c/p\u003e\n\u003cp\u003e.240\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e2.016\u003c/p\u003e\n\u003cp\u003e.172\u003c/p\u003e\n\u003cp\u003e.004\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e.965\u003c/p\u003e\n\u003cp\u003e3.122\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e2.260\u003c/p\u003e\n\u003cp\u003e.160\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e.102\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e3.530\u003c/p\u003e\n\u003cp\u003e9.811\u003c/p\u003e\n\u003cp\u003e.925\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e14.807\u003c/p\u003e\n\u003cp\u003e.783\u003c/p\u003e\n\u003cp\u003e.331\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e9.485\u003c/p\u003e\n\u003cp\u003e24.216\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e6.102\u003c/p\u003e\n\u003cp\u003e.816\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e.624\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e.001\u003c/p\u003e\n\u003cp\u003e.000\u003c/p\u003e\n\u003cp\u003e.029\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e.001\u003c/p\u003e\n\u003cp\u003e.010\u003c/p\u003e\n\u003cp\u003e.003\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e.058\u003c/p\u003e\n\u003cp\u003e.000\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e.000\u003c/p\u003e\n\u003cp\u003e.014\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e.003\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e55\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e79\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026lt;1\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e82\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026lt;1\u003c/p\u003e\n\u003cp\u003e\u0026lt;1\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003en/s\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e89\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e73\u003c/p\u003e\n\u003cp\u003e\u0026lt;1\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026lt;1\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"177\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"85\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003ctable\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"603\"\u003e\n\u003cp\u003e*AR \u0026ndash; attributable risk, the effect of a risk factor on the exposed group %\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Cerebral palsy, Moldova, risk factors, breech presentation, hyperbilirubinemia, asphyxia, quality register","lastPublishedDoi":"10.21203/rs.3.rs-39000/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-39000/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground\u003c/p\u003e\u003cp\u003eThis is the first study assessing risk factors for cerebral palsy (CP) among children born in Moldova.\u003c/p\u003e\u003cp\u003eMethods\u003c/p\u003e\u003cp\u003eWe identified 351 children with CP born during 2009 and 2010 in state hospitals, maternity wards, orphanages and rehabilitation centres in Moldova. Detailed information on 417 children without CP (of the total number of 81,277 children) served as a reference group. Logistic regression analyses were applied to calculate crude and adjusted odds ratios (OR) with 95% confidence intervals (CI) in addition to attributable risk (AR).\u003c/p\u003e\u003cp\u003eResults\u003c/p\u003e\u003cp\u003eAmong children with CP (40.5% girls), 26% had unilateral, 54% bilateral, 13% dyskinetic, and 5% ataxic CP, with 2% unclassified. Almost three quarters of children with CP were from rural areas and 101 (29%) were prematurely born.\u003c/p\u003e\u003cp\u003eSignificant risk factors for CP included low Apgar score at five minutes (OR 6.187, 95% CI 2.059–18.59), hyperbilirubinemia (OR 6.3, 95% CI 4.1–9.6), breech delivery (OR 3.5, 95% CI 2–6.01), assisted vaginal delivery (OR 47, 95% CI 11–194), birth out of maternity (OR 6.591, 95% CI 1.904–22.81), low education level (OR 3.889, 95% CI 2.8–5.248), alcohol consumption (OR 1.903, 95% CI 1.269–2.885) and hypertension (OR 2.264, 95% CI 1.5–5.417).\u003c/p\u003e\u003cp\u003eFor singletons born at term, significant risk factors were low Apgar score (OR 2.115, 95% CI 1.22–3.808), hyperbilirubinemia (OR 5.854, 95% CI 3.648–9.393), breech delivery (OR 6.48, 95% CI 3.1–13.7), fundal pressure (OR 3.268, 95% CI 1.398–7.642), maternal hypertension (OR 2.248, 95% CI 1.55–3.997) and alcohol consumption (OR 2.105, 95% CI 1.315–3.369).\u003c/p\u003e\u003cp\u003eHyperbilirubinemia, Apgar score (0–3), birth out of maternity and breech delivery had the highest AR for CP both in the total and term singleton groups. Chronic diseases among mothers also had a high AR for CP.\u003c/p\u003e\u003cp\u003eConclusions\u003c/p\u003e\u003cp\u003eA combination of factors related to the child, the delivery and the mother were risk factors for CP among children born in Moldova, many of them possibly avoidable. The results may indicate a need for better maternal and perinatal childcare. A national CP register in Moldova is recommended as an opportunity to follow up these findings.\u003c/p\u003e","manuscriptTitle":"Risk factors for cerebral palsy in Moldova","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2020-07-01 16:52:44","doi":"10.21203/rs.3.rs-39000/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9e6253a3-aa10-4e57-a19c-a7751265ce5e","owner":[],"postedDate":"July 1st, 2020","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":137194,"name":"Pediatrics"}],"tags":[],"updatedAt":"2020-07-02T15:45:33+00:00","versionOfRecord":[],"versionCreatedAt":"2020-07-01 16:52:44","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-39000","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-39000","identity":"rs-39000","version":["v1"]},"buildId":"GqpaHPwrfC8PjnIFayRh5","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}