Journal of Global Health

Background Global labor migration from LMIC to higher-income destinations has expanded rapidly, placing increasing pressure on destination-country health. Existing research on cross-border migrant workers has focused largely on occupational health, general healthcare utilization, and disease-specific risks, while there is considerably less evidence on their sexual and reproductive health. This study contributes to this understudied field by examining the policy and health-system factors that shape the sexual and reproductive health services for migrant workers in Taiwan. Methods A qualitative study was conducted in Taiwan between November 2025 and August 2026. 22 stakeholders were purposively recruited from academia, healthcare, nongovernmental organizations, government, labor brokerage, and employers. Data were collected through semi-structured interviews and small focus groups. Interviews were conducted in Mandarin Chinese, transcribed verbatim, and translated into English. Data were analyzed using framework analysis combining deductive coding based on the AAAQ framework with inductive coding of implementation and contextual themes. Results Gaps were identified across all four AAAQ dimensions. Participants described limited migrant-responsive SRH programming; physical, financial, administrative, social, and information barriers; shortcomings in linguistic and cultural responsiveness; and weaknesses in interpretation, coordination, and continuity of care, despite generally favorable views of Taiwan's clinical quality. Conclusions Our findings show that broad insurance coverage and strong clinical capacity do not by themselves ensure the realization of migrant workers' SRHR. In Taiwan, rights were mediated through labor brokerage, gendered live-in work arrangements, and fragmented governance across health, labor, immigration, and social-welfare systems. Improving migrant SRHR therefore requires stronger implementation of existing protections, reduced dependence on informal intermediaries, and more integrated institutional responsibility for cross-sector migrant health needs.

Background: Neonatal mortality remains a significant public health challenge in Sub Saharan Africa (SSA). The continuum of maternal care (COC), spanning antenatal care (ANC), skilled birth attendance (SBA), and postnatal care (PNC) represents an integrated pathway to improving neonatal survival. Multi-country evidence on how adherence to this full continuum affects neonatal outcomes across SSA is limited. Objectives: This study aimed to: (1) construct a composite COC indicator and describe its sociodemographic distribution; (2) estimate its association with neonatal mortality; (3) conduct a counterfactual analysis; and (4) examine cross country heterogeneity in the COC effect on neonatal mortality. Methods: Pooled Demographic and Health Survey (DHS) data from 35 SSA countries (2010 to 2026) were analyzed (N = 867,984 live births). A binary CoC indicator (coc1 = 1 if mother received [&ge;]4 ANC visits, skilled birth attendance, and PNC within 48 hours) was constructed. Survey-weighted logistic regression adjusted for wealth, education, residence, parity, maternal age, child sex, child age, and country. Counterfactual predictive margins and a COC and country interaction model were estimated in Stata 18. Results: Only 13.47% of mothers met the full COC threshold. COC completion was higher among wealthier, urban, more educated, and lower-parity women. After adjustment, CoC receipt was associated with significantly lower odds of neonatal death (aOR = 0.638, 95% CI: 0.577 - 0.706, p < 0.001). Counterfactual analysis showed the predicted neonatal mortality probability would fall from 3.15% (no CoC) to 2.04% (full CoC), an absolute risk reduction of 1.11 percentage points. Cross-country interaction terms were largely non-significant; only Namibia reached significance (p = 0.036). Conclusion: Completion of the full continuum of maternal care is independently associated with reduced neonatal mortality across SSA. Equity focused policies should prioritize integrated service delivery for rural, poor, and less educated women.

Introduction: Nutritional challenges are a global public health concern, especially among children under five in sub-Saharan African countries. The coexistence of an overweight/obese mother and an underweight child in the same household is recognized as a dual burden of malnutrition (DBM). Our study aimed to examine the prevalence and associated factors of DBM among mother-child dyads in Mozambique. Methods: We used nationally representative, cross-sectional data from the Mozambique Demographic and Health Survey 2022-2023 (n=3,605 mother-child dyads). The children's undernutrition condition and maternal BMI status were calculated using the WHO standard reference guidelines. The outcome variable, dual burden of malnutrition, was then created if the children had any undernutrition condition (stunting, wasting, or undernutrition) and the corresponding mother was overweight/obese. Multivariable binary logistic regression, Erreygers's concentration index, and concentration curve were analyzed to determine associated factors and social inequalities. Results: The prevalence of the dual burden of malnutrition was about 5.51%. Mothers aged [&ge;]34 years [aOR (95% CI): 4.01(1.44, 11.14); p<0.05] and mothers with four or more children [aOR (95% CI): 2.68(1.29, 5.57); p<0.05] had higher odds of DBM. Rural residence and using unimproved toilet facilities (latter an indicator) were also significantly associated with experiencing DBM. Additionally, maternal age modified the association between women's empowerment and mother-child DBM. Women aged 15-19 years at the lowest and highest empowerment levels were more likely to experience DBM compared to women 20 years or older. A positive and statistically significant concentration index indicates that wealth-related inequalities exist, with DBM more concentrated among wealthier mother-child dyads. Conclusion: Our study highlights the persistence of household-level DBM in Mozambique. These findings emphasize the need for targeted interventions addressing social and economic inequalities, including poor sanitation marker of broader household deprivation. Prioritizing integrated maternal-child nutrition interventions within national strategies is essential to improving equity in nutrition and health outcomes.

Background: Neonatal mortality remains disproportionately high in sub-Saharan Africa (SSA), accounting for nearly half of all deaths in children under five. Although antenatal care, skilled birth attendance, and postnatal care are individually associated with improved newborn survival, few studies have examined whether their integrated receipt as a continuum of care (CoC) confers additional protection against neonatal death, particularly after accounting for sociodemographic confounding and heterogeneity across country contexts. Methods: A pooled cross-sectional analysis was conducted using DHS-8 Births Recode files from five countries: Nigeria (2024), Mali (2023-2024), Congo DRC (2023-2024), Kenya (2022), and Lesotho (2023-2024). The analytical sample comprised 37,351 births within the 36-month postnatal care reference window. Complete CoC was defined as receipt of adequate antenatal care ([&ge;]4 visits with first-trimester initiation), skilled birth attendance, and postnatal care within 48 hours for the mother or newborn. Neonatal mortality was defined as death within 27 days of birth. Survey-weighted logistic and log-Poisson regression models estimated adjusted odds ratios (aOR) and adjusted prevalence ratios (aPR). G-computation quantified the population attributable fraction (PAF). Country-specific heterogeneity was examined through random-effects meta-analysis (DerSimonian-Laird method) and a two-level multilevel logistic regression model. Results: The overall neonatal mortality rate was 29.3 per 1,000 live births (95% CI: 27.6-31.0). Complete CoC prevalence was 19.2% (95% CI: 18.5-19.9%), ranging from 7.8% in Congo DRC to 47.8% in Lesotho. In unadjusted analysis, complete CoC was associated with a 24% reduction in neonatal death odds (cOR: 0.764, 95% CI: 0.583-1.000, p = 0.050). After adjustment for wealth, education, residence, parity, maternal age, child sex, and country, the association was substantially attenuated and non-significant (aOR: 0.961, 95% CI: 0.717-1.289; aPR: 0.962, 95% CI: 0.722-1.282). The PAF under universal complete CoC was 3.2%. The pooled meta-analytic estimate was aOR 0.718 (95% CI: 0.447-1.152), with moderate heterogeneity (I{superscript 2} = 38.9%; {tau}{superscript 2} = 0.089). Country-specific estimates ranged from aOR 0.455 (95% CI: 0.256-0.810) in Kenya to 1.447 (95% CI: 0.496-4.220) in Lesotho. Conclusion: Complete continuity of maternal healthcare was not independently associated with reduced neonatal mortality after full adjustment, suggesting that the unadjusted benefit was attributable to sociodemographic selection rather than a direct causal pathway. These findings underscore the insufficiency of service utilisation metrics in isolation and highlight the need to address the structural and contextual determinants that simultaneously constrain both care access and neonatal survival. Country-level heterogeneity in the CoC-mortality relationship points to the importance of tailored, context-specific interventions.

Objective: Malnutrition and micronutrient deficiency are significant public health problems affecting the well-being of both the mother and her offspring. It is important to first quantify their burden in underserved communities and then to tackle this problem. The objective of this study was to assess the nutritional status, micronutrient deficiency profile, and associated determinants among pregnant women attending antenatal care clinics under PMSMA in selected government health facilities across three districts of Jharkhand, India. Design: The study employed a cross-sectional study design to assess the burden of malnutrition and micronutrient deficiency among pregnant women. Setting: The study was conducted in 4 health facilities in 3 districts of Jharkhand. The selected facilities were Rajendra Institute of Medical Sciences (RIMS), Ranchi; District Hospital (Sadar), Ranchi; District Hospital (Sadar), Godda; and Community Health Centre (Gamharia, Saraikela) under RHTC, Department of Community Medicine, Manipal Tata Medical College, Jamshedpur. The study was conducted during the period of September to December, 2022. Participant: Eligible pregnant women attending ANC clinics under PMSMA in the selected health facilities were enrolled until the required sample size of 977 was achieved. Pregnant women who were critically ill or those who presented with some emergency conditions were excluded from the study. Result: Based on BMI assessment, 38.6% of participants were malnourished, with 17.7% being underweight and 20.9% overweight or obese. Anaemia affected 69.3% of women, while clinical features suggestive of iron deficiency were observed among 21.1% of the participants. Vitamin A deficiency, iodine deficiency, and fluoride excess were also identified among a smaller proportion of women. Conclusion: The present study highlights a substantial burden of both malnutrition and micronutrient deficiency among pregnant women in Jharkhand and justifies the need for integrated maternal nutrition strategies during antenatal care.

Background In sub-Saharan Africa, women are navigating overlapping burdens of undernutrition and rising overweight/obesity, often within fragile health system and rapidly changing food environments. In the DRC, theses tensions may be intensified by rapid urbanization, socioeconomic disparities, insecurity and shifting lifestyles. Despite those changes, national level evidence on who is the most affected by excess weight and why remains scarce. This study assessed the determinant of overweight and obesity among Congolese women of reproductive age, aiming to highlight the social and geographic inequalities. Methods We analysed nationally representative data from the 2023 DHS. The analysis included 10,740 non-pregnant women aged 15-49 years with valid anthropometric measurements. Overweight/obesity was defined as BMI [&ge;] 25 Kg/m2. We examined a broad range of potential associated factors, including province, residence, socioeconomic status, household structure, education level, marital status, occupation, dietary diversity score, healthy diet related indicators, media exposure, internet use and health service utilisation. Weighted analyses accounted for the DHS sampling design. Variables associated at p value < 0.20 were retained for multivariable modelling. Multicollinearity was assed via adjusted GVIFs. Four hierarchical weighted logistic regression were built; the fully adjusted model guided final interpretation. Results Nearly on five women of reproductive age (19.5%) lived overweight or obesity. However, this burden was not evenly distributed. Women from Kongo Central and Tshuapa exhibited significantly lower odds, while those in Bas-Uele, Nord-Kivu, Sud-Kivu and Maniema were substantially more affected, highlighting spatial inequities. Women living in rural areas had lower odds of overweight/obesity compared with their urban counterparts (aOR=0.6; 95% CI: 0.48-0.79; p<0.001). A pronounced socioecomic gradient was observed. Compared with the poorest households, the likelihood of excess weight increases progressively among women in middle income household (aOR=1.65;95% CI:1.13-2.41), rich households (aOR=2.41; 95%CI:1.62-3.60), and was highest among the richest (aOR=4.19; 95%CI: 2.45-7.16). Larger households appeared protective, with lower odds observed in household of 4-5 members (aOR=0.68; 95%CI:0.5-0.92), 6-7 (aOR=0.72;95% CI: 0.54-0.97) and [&ge;]8 members (aOR=0.69; 95%CI:0.50-0.95) compared with smaller household. Age was the strongest predictor, with risk sharply accelerating after 30 years. Being married or in union was associated with higher odds. Notably, frequent internet use independently predicted overweight/obesity. In contrast, dietary diversity and unhealthy food indicators were not significantly significant in the fully adjusted models. Conclusion Overweight and obesity are rising among Congolese women, but unevenly and unjustly. Urban residence, socioeconomic status, age and digital exposure strongly sharply shape who is the most affected, revealing deep social and geographic inequities. Addressing this growing epidemic requires equity-oriented, province specific actions, alongside stronger primary prevention. Key-word: Overweight-obesity-associated factors, DRCongo, DHS

Objectives To analyse the long-term effects of a cruciate ligament (CL) injury on health and socioeconomic outcomes. Methods We used a comprehensive national injury insurance database to identify CL injuries occurring in New Zealand between 2009 and 2022, and employed a doubly robust staggered difference-in-differences research design to identify the effects of these injuries on outcomes up to 10 years after injury. The outcomes of interest were healthcare use (hospitalisations, emergency department visits, medications, knee replacement surgery for osteoarthritis), associated healthcare costs, and labour market outcomes (employment rates, income, and government benefit payments). Results We identified 61 344 CL injuries for inclusion in the analysis. Over 10-year follow-up, a CL injury resulted in increased healthcare use (0.6 more hospitalizations [95%CI 0.4 to 0.7], 1.7 more days spent in hospital [95%CI 1.3 to 2.1], 0.4 more emergency department visits [95%CI 0.3 to 0.6], 2.5 more outpatient visits [95%CI 1.8 to 3.2], and 4.7 more medications dispensed [95%CI -1.8 to 11.2]) and public healthcare costs ($7 537; 95%CI 5 888 to 9 186), reduced income (-$6 060; 95%CI -11 644 to -475), and increased benefit payments ($1 152; 95%CI 542 to 1 761). Conclusion CL injuries have long-term impacts on healthcare use and socioeconomic outcomes. Strategies to reduce the incidence of CL injuries have the potential to realise large health and economic benefits.

Background Obstetric ultrasound is an essential tool for assessing fetal growth and wellbeing. While evidence-based recommendations advise one routine scan before 24-weeks of gestation, research suggests its use in low- and middle-income countries often extends beyond medical necessity. This study examined how ultrasound technology has become integrated into antenatal practices in rural Pakistan and how cultural, economic, and institutional factors shape its use. Methods Drawing on data from two qualitative and one mixed-method studies conducted across six rural districts of Punjab, we used a pragmatic mixed-methods approach integrating latent content analysis of interviews, focus group discussions and observations with quantitative survey data. Results Ultrasound use is common, with nearly 80-percent of women reported having at least one ultrasound and many undergoing three to six scans. For some participants, ultrasound had become synonymous with antenatal care, overtaking basic tests such as blood and urine analysis. The technology was widely perceived as both diagnostic and therapeutic, with some women believing it could cure health problems. Providers, particularly in the private sector, promoted frequent scans to meet patient expectations and financial targets, while womens demand was driven by reassurance, perceived modernity, and son preference. This dynamic created a self-reinforcing supply-demand cycle in which clinical need played a secondary role. Conclusions In rural Pakistan, obstetric ultrasound has evolved into a central socio-technical feature of pregnancy care that extends far beyond its clinical purpose. These findings highlight the interplay of technology, culture, and market forces in shaping maternal health behaviors and underscore the need for context-sensitive policy responses that align ultrasound use with evidence-based care while engaging with the social realities that sustain its widespread adoption.

Background Cardiovascular disease remains the leading cause of death worldwide, yet progress in reducing its burden has not been shared equally across regions. Sub-Saharan Africa has previously been identified as the only world region where age-standardized cardiovascular mortality failed to decline, but long-term, disease-specific trends in Western Sub-Saharan Africa (WSSA) remain poorly characterized. Methods We conducted an ecological trend analysis using Global Burden of Disease (GBD) 2023 data to evaluate age-standardized mortality and disability-adjusted life years (DALYs) for stroke and ischemic heart disease (IHD) in WSSA and globally from 1990 to 2023. Linear and segmented regression assessed long-term trends and breakpoints, risk factor attribution examined six major cardiovascular risk factors, and Pearson correlation evaluated associations between the Socio-demographic Index (SDI) and mortality. Results Global stroke and IHD mortality declined by 51.7% and 38.2%, respectively, between 1990 and 2023. In WSSA, stroke mortality declined by only 21.8%, while IHD mortality increased by 3.3%. Segmented regression identified a breakpoint in IHD mortality around 2007, after which the trend reversed from declining to increasing. High systolic blood pressure was the leading attributable risk factor for both diseases, while obesity, ambient air pollution, and elevated fasting glucose showed the largest relative increases. SDI rose 69.5% in WSSA but correlated strongly only with stroke mortality (r = 0.87), not IHD (r = 0.21). Conclusions WSSA is falling behind global cardiovascular progress, with IHD mortality reversing course despite substantial socioeconomic development. Targeted investment in hypertension control, cardiometabolic risk reduction, and cardiovascular care capacity is urgently needed to prevent this divergence from deepening.

Background & objectives: India's fifth National Family Health Survey measured anaemia in all 707 districts, whereas the sixth survey did not. Anaemia is now assessed through a venous blood survey covering 183 districts and reported only at the national level. Using the most recent district-level measurements, we examined whether the remaining survey indicators could predict district anaemia, whether omitting district anaemia altered programme prioritisation, and the value of repeating district-level measurement. Methods: We estimated district anaemia prevalence and uncertainty for children aged 6-59 months and non-pregnant women aged 15-49 years using small-area estimation with design-based variances. We evaluated prediction from the retained survey indicators using both district-level and leave-one-State-out validation, compared district prioritisation under three information scenarios using matched preference draws, and estimated the value of repeating measurement of the same underlying prevalence. Results: Median standard errors of district estimates were 3.57 percentage points for children and 2.22 percentage points for women. The best predictive surrogate had a root mean squared error of 10.14 percentage points for children, of which 9.44 percentage points reflected structural error, representing approximately 2.5 times the root mean squared measurement error. In leave-one-State-out validation, predictions performed worse than the training-set mean. Among the 71 districts prioritised using current estimates, 19.1% were not among the latent top 71 districts. Measuring 183 districts recovered 46.3% of this prioritisation gap when districts were selected according to decision value, compared with 9.6% under equal allocation across States. Interpretation & conclusions: Available survey indicators did not adequately substitute for direct measurement of district anaemia. When measurement resources are limited, the choice of districts to be measured has a greater influence on programme prioritisation than the total number of districts measured, provided differences between measurement platforms are addressed before comparison.

Background: Low birth weight remains a primary driver of neonatal and infant mortality in Ethiopia. Machine learning models can assist early risk identification, yet clinical adoption is often limited by black box algorithms and late pregnancy predictor variables. This study aimed to develop and validate interpretable machine learning models using early pregnancy and sociodemographic features from a national survey dataset. Methods: Secondary data from the nationwide Ethiopian Demographic and Health Survey were analyzed. Predictors were restricted to features accessible during early antenatal visits. Six machine learning algorithms were trained and evaluated on an independent holdout test set: Logistic Regression, Decision Tree, Support Vector Machine, Gradient Boosting, Random Forest and Extreme Gradient Boosting (XGBoost). Imbalance was addressed using synthetic oversampling on the training set. Model explainability was established through Shapley Additive exPlanations (SHAP). Results: Out of 12876 births, 4249 (33%) were categorized as low birth weight / small birth size. XGBoost achieved superior predictive performance with an AUC-ROC of 0.947 (95% CI: 0.910-0.938) on the test set, outperforming standard logistic regression (0.8088). Key global predictive drivers identified by SHAP values included maternal anemia status, short inter pregnancy interval (< 18 months), low maternal BMI (< 18.5 kg/m^2), rural residence, lowest household wealth quintile and delayed or non-attendance of first trimester antenatal care. Conclusion: Machine learning models trained on early pregnancy and demographic features can accurately predict low birth weight risk in Ethiopia. Integrating interpretable frameworks into primary healthcare decision support tools provides a viable strategy for early risk stratification and targeted interventions in resource-limited settings.

Given high mortality rates and low access to health facilities, the International Rescue Committee introduced Community-based Maternal and Newborn Care (CBMNC) Programs in rural areas of Somalia and South Sudan. The programs included distribution of evidence-based commodities for maternal or newborn health as well as health counseling during home visits, delivered by low-literate community health workers. The pre-post study used population-representative cross-sectional surveys among women who delivered in the twelve months preceding the program, conducted before and 18-24 months after the CBMNC program introduction (n=338 baseline, n=340 endline in South Sudan, n=351 baseline, n=302 endline in Somalia). The study employed rigorous statistical methods to adjust for potential confounding factors and strengthen inference regarding changes associated with the program despite the non-experimental study design. Program enrollment was high (79.1% in South Sudan, 87.7% in Somalia). In South Sudan, Skin-to-skin care, clean cord care, early initiation of breastfeeding, and use of Fansidar were statistically significantly higher among those who received four or more visits, but marginally significantly lower uptake of institutional delivery and SBA. For Somalia, skin-to-skin care showed statistically significant positive change among those who received four or more visits, with early initiation of breastfeeding, no prelacteal feeding, and making four or more facility-based ANC visits demonstrated marginally significant higher uptake. The positive change in uptake of evidence-based community-based MNH services showed promise in Somalia, but mixed results in South Sudan. This shows promise for change in service uptake even in a relatively short duration of program implementation, but also underscores that community health interventions do not operate in isolation and that parallel investment in facility strengthening and consistent messaging on the complementary roles of community and facility-based care remains essential.

Background Little evidence is available on the epidemiology of different knee injuries at a whole-of-population level. The objective of this article is to provide accurate estimates of knee injury incidence by harnessing the unique comprehensive, population-wide data of New Zealand's universal no-fault injury insurance provider, the Accident Compensation Corporation (ACC). Methods We obtained insurance claims data from ACC covering all knee injury insurance claims approved between 2015 and 2024. We calculated the number of injuries and the incidence rate per 100 000 population, by injury type, year, sex, ethnicity, and age. Results The total number of injuries increased from 184 710 (4 067 per 100 000 population) in 2015 to 244 155 (4 701 per 100 000) in 2024. The most common injuries were other/unspecified ligament sprains, contusions, and collateral ligament sprains. Ligament and cartilage injuries were more common for males than for females, while contusions were more common for females. Ligament tears and dislocations were more common in younger people (15 to 35 years of age), while cartilage injuries were more common at older ages (40 to 65 years). Discussion and Conclusions The rate of knee injuries observed in this study was higher than previously reported in other settings, probably due to broader coverage of injuries treated in primary and community care settings. A broad range of injuries were common, including those that have received less attention in the epidemiological literature to date. More research is needed on the prevention, burden, and outcomes of different knee injuries, beyond a narrow focus on cruciate ligament injuries.

Inappropriate antibiotic use presents a major global health challenge, particularly in low-resource settings where access to quality care is limited but antibiotics remain relatively unrestricted. This study estimates the causal effect of frontline primary care quality on inappropriate community antibiotic use, combining detailed community-based data from approximately 100 rural villages in rural China with an instrumental variable (IV) approach embedded within a double/debiased machine learning (DML) framework. We linked objective measures of village doctor clinical practice quality, measured through unannounced standardized patient visits, to household-level antibiotic use data collected from the same villages. To identify the causal effect, we constructed multiple candidate instruments from extensive provider characteristics and used an ensemble of machine learning algorithms within a flexible DML-IV framework to approximate an optimal instrument, addressing a many-weak-instruments problem. We found that improving village provider clinical practice quality reduced both antibiotic receipt during healthcare encounters for common diseases and household antibiotic storage for future self-medication. Our findings suggest that strengthening frontline primary care quality can meaningfully reduce inappropriate community antibiotic use without restricting access to essential treatment. More broadly, this study illustrates how causal machine learning can strengthen conventional causal estimation in complex observational settings in global health economics research.

Background: Early-life growth is associated with individual cardiometabolic risk factors, but its relationship with overall cardiovascular health (CVH) in low- and middle-income countries (LMICs) is unclear. We examined associations of maternal, household, and child growth factors with young-adult CVH across four LMIC birth cohorts. Methods: We analyzed harmonized data from the Consortium of Health-Oriented Research in Transitioning Societies (COHORTS), including 4,582 participants ages 18-30 years from Brazil, Guatemala, the Philippines, and South Africa. CHV was assessed using a modified American Heart Association Life's Simple 7 score based on body mass index (BMI), blood pressure (BP), fasting blood glucose (FBG), and smoking. Site-specific multivariable ordinal logistic regression models evaluated associations between early-life factors and CVH. Results: Men had poorer CVH than women across most sites, largely because of less favorable BP and smoking profiles. Higher birthweight was associated with lower odds of better CVH in Brazil (AOR=0.81; 95% CI: 0.71-0.94) and the Philippines (AOR=0.63; 95% CI: 0.45-0.87). Greater conditional relative weight at 2 years was also inversely associated with CVH in both sites. Birthweight, conditional height and conditional relative weight at 2 years were strongly associated with adult BMI, whereas associations with BP and FBG were weaker. Attained schooling was associated with CVH in Brazil (AOR = 1.13 per year; 95% CI: 1.10-1.16), and the Philippines (AOR = 1.17; 95% CI: 1.10-1.24). Conclusions: Early-life growth patterns and educational attainment are associated with cardiovascular health in young adulthood across diverse LMIC settings, supporting life-course strategies to promote cardiovascular health.

Introduction Hearing loss (HL) affects over 1{middle dot}5 billion people globally and India shares a disproportionately high burden including Disabling Hearing Loss (DHL). HL affects an Individual socio-economically, but there are limited studies on the broader societal economic consequences of HL in India.Methods Using Cost-of-Illness (COI) approach, we studied the societal economic burden of HL in India. This study uses epidemiological and macroeconomic data and modelling to estimate the loss of Gross National Income (GNI) due to HL and DHL across three economic pathways. Uncertainty is evaluated using deterministic and Probabilistic Sensitivity Analyses (PSA).Results The model estimates that there are in India, 289 million and 85{middle dot}9 million people with HL and DHL respectively. Direct Loss of GNI and Indirect Loss of GNI (Caregiver burden) are estimated as INR 4,648{middle dot}4 billion (USD 55{middle dot}6 billion) and INR 3,268 billion (USD 39 billion) respectively. The Loss of GNI due to Low Education amongst those with HL is estimated as INR 1,041{middle dot}9 billion (USD 12{middle dot}45 billion).Discussion Economic burden of HL is presented across three pathways with Direct Loss of GNI due to DHL being the greatest. It also presents age stratified caregiver economic burden. The findings of the study help in estimating similar cost pathways, advocacy, and policy decisions towards reducing HL prevalence in India and LMICs. This study also highlights the need for India specific estimations related to the HL attributable low education, state-wise disaggregates, and prevalence studies. Funding This study has not received any funding.

Introduction: Antenatal depression is a major public health concern linked to adverse maternal and neonatal outcomes, including preterm birth, impaired fetal growth, low birth weight, infant malnutrition, and increased episodes of childhood illness. This study assessed the magnitude and factors associated with antenatal depression among pregnant women attending public health centers in Shire town, Tigray, Ethiopia. Methods: This facility-based cross-sectional study allocated the sample proportionally across health centers based on November-December 2025 antenatal care caseloads. After selecting the first participant by lottery, every third eligible attendee was enrolled through systematic sampling. Variables with p[&le;]0.25 in bivariable analysis were entered into a multivariable logistic regression model to identify factors associated with antenatal depression among pregnant women in post-war Shire Town, Tigray, Ethiopia. Results: All 463 participants were included (response rate: 100%). The magnitude of antenatal depression was 34.3% (95% CI: 30-38.7%). Increased odds of depression were observed among age group 25-34 years (AOR = 3.43; 95% CI: 1.7-7.2), those with unplanned pregnancies (AOR=2.2; 95% CI: 1.25-3.87), exposure to conflict-related traumatic events (AOR=2.6; 95% CI: 1.41-4.81), Internally displaced people (AOR=2.02; 95% CI: 1.05-3.92), experience of intimate partner violence (AOR=2.22; 95% CI: 1.31-3.8), poor partner relationship (AOR=2.17; 95% CI: 1.2-3.96), and low perceived neighborhood safety (AOR=2.7; 95% CI: 1.5-5.08). Protective factors included middle income (AOR=0.54;(95% CI:0.31-0.93), higher income (AOR=0.15; 95% CI: 0.065-0.33), and very good pre-war economic status (AOR=0.4; 95% CI: 0.16-0.94). Conclusion: Antenatal depression was common among pregnant women in this post-war population, with internally displaced women experiencing higher odds. Integrating mental health and psychosocial support into antenatal care, alongside interventions addressing conflict-related trauma, intimate partner violence, socioeconomic vulnerability, and community safety, is warranted.

Background. Nigeria carries one of the world's largest burdens of neonatal death and remains far from the Sustainable Development Goal target. Whether health financing and macroeconomic instability are associated with newborn survival has rarely been examined for neonatal mortality specifically. Methods. We conducted an ecological time-series analysis of national annual data, covering 1990-2024 for macroeconomic models (n = 35) and 2000-2023 for health-financing models (n = 24), the periods for which published data exist; no values were imputed. Neonatal mortality came from the UN Inter-agency Group for Child Mortality Estimation 2025 round with 90% uncertainty intervals, and other series from the World Development Indicators. The primary model regressed log neonatal mortality on government health expenditure per capita (purchasing power parity), out-of-pocket share and currency instability, with a linear trend, a post-break trend spline and Newey-West standard errors; first differences without trend terms were the main sensitivity analysis. The break was located by segmented regression; currency instability was tested under four constructions. Results. The decline broke around 2010, the trend moving from -0.74 to +0.14 deaths per 1,000 annually (F = 145.4, p < 0.001). The subsequent rise fell within estimation uncertainty (2012: 37.6, 90% interval 33.9-41.5; 2022: 39.3, 33.4-46.4), supporting stagnation rather than reversal; Demographic and Health Surveys concur, reporting 42 per 1,000 for the five years preceding the 1990 survey and 41 preceding the 2024 survey. Government health expenditure per capita was inversely associated with neonatal mortality (-0.040, 95% CI -0.051 to -0.029, p < 0.001; first differences -0.016, p = 0.033) and was the only expenditure measure surviving both specifications; share-of-GDP measures did not (p = 0.196 and 0.889) and correlated positively in raw terms. Currency instability showed no association under any construction (p = 0.65-0.83). Public expenditure per capita moved non-monotonically, peaking in 2005, falling by 2010 and recovering by 2023 to a level still below the 2005 peak. Conclusions. Neonatal mortality in Nigeria is ecologically associated with public health expenditure per capita, but not with commonly used share-based measures, nor with currency instability. Rising public spending accompanied stalled progress, directing attention toward how health resources are converted into services. Annual modelled mortality estimates could not support year-to-year inference, a limitation relevant to comparable studies

Background Lower respiratory infections (LRI) remain the leading infectious cause of death in children, and survival once ill is a direct tracer of health-system quality. Whether countries are converging toward the best survival performance achieved within their own region has never been tested at national level. We measured each country's distance to an empirical episode-fatality-ratio (EFR) frontier in 204 countries from 1990 to 2023. Methods For each country and year we computed EFR = LRI deaths/incident episodes using Global Burden of Disease (GBD) 2023 estimates for ages 0-19 years. Deaths span the full 1990-2023 series; episodes are observed for 1990, 2019 and 2023, with intermediate years linearly interpolated. The frontier was the 10th-percentile country EFR within each GBD super-region and year (sensitivity: 5th and 25th percentiles); the gap = EFR_country/EFR_frontier. We classified 33-year gap trajectories into catch-up phenotypes, ranked COVID-window (2019-2023) movers, cross-tabulated gap against avoidable deaths to build a priority list, and benchmarked upper respiratory infections (URI) at three time points as a near-zero-fatality contrast. Findings The median country's gap was 1.86 in 1990, 1.80 in 2019 and 1.86 in 2023; the share of countries more than twice their regional frontier was 44.6% in 1990 and 46.6% in 2023. Of 137 eligible countries, 67 narrowed and 69 widened their gap, with one unchanged. Nineteen countries achieved sustained catch-up, concentrated in North Africa and the Middle East (7) and Latin America (5), with China closing from 2.43 to 0.50, below its regional frontier; 28 countries regressed, led by Central Asia (Uzbekistan x3.5) and including the United States (x2.0). Over the COVID-19 window the median gap peaked at 2.00 in 2021 (+10.8% versus 2019, from unrounded medians) before returning to 1.86. Combining gap with avoidable deaths identifies two distinct policy problems: high-burden, moderate-gap giants (Nigeria 67,490 avoidable deaths, gap 2.4; India 54,109, gap 1.6) and extreme-gap outliers (Uzbekistan, gap 28.6). The Sub-Saharan Africa frontier fell further behind the High-income frontier (ratio 4.2 in 1990, 9.5 in 2023); the median Sub-Saharan African country sits 11.0 times the global 10th-percentile frontier but only 1.78 times its own regional frontier, so within-region benchmarking understates the region's true distance. URI gaps likewise did not converge (median 4.15 to 4.60). Interpretation Convergence toward the survival frontier is not the default national trajectory: over three decades the typical country made no net progress toward the best decile of its own region, and pandemic-era divergence was only partly reversed. National gap trajectories separate system-wide quality shortfalls from extreme outliers warranting audit, and expose a measurement trap in which regions whose frontiers stagnate appear closer to best practice than they are.

Objectives: Estimate fertility rate ratios (FRR) of HIV-positive relative to HIV-negative women in sub-Saharan Africa (SSA) by age group, CD4 stage, ART status, and country. Design: Analysis of nationally representative household surveys with HIV serological testing. Methods: We analysed current pregnancy and births in the past three years by HIV status from 72 nationally-representative household surveys in SSA between 2003 and 2017. Spectrum 2018 estimates for the distribution by CD4 stage and ART status were used to infer fertility of women on ART from changes in fertility of all HIV-positive women as ART coverage increased. We allowed regional differences in the age pattern of relative fertility and estimated country-specific random effects. Results: The ratio of fertility in untreated HIV-positive women with CD4 [&ge;]500 to HIV-negative women was 1.6 to 1.8 for age 15-19, relatively similar to 10% times lower for age 20-29, and 15-50% lower above age 30. Among age 15-19, each 15-point increase in percent sexually active reduced relative excess fertility by 24%. Fertility decreased with lower untreated CD4 count stages, consistent with previous estimates. Women on ART >6 months had fertility closer to that of HIV-negative women for ages 15-29, but still 25-40% lower above age 30. There was substantial variation across countries. Conclusions: Fertility differences for HIV-positive women compared to HIV-negative women are smaller than previous estimates, but vary substantially across countries. Recent data suggest fertility of women on ART is greater than that of untreated HIV-positive women, but remains lower than HIV-negative women. This conclusion should be reviewed as new evidence becomes available.