Journal of Global Health

Dropout from essential maternal health services across pregnancy, childbirth, and the postnatal period remains a major barrier to improving maternal and neonatal outcomes in Bangladesh. This study examined stage-specific dropout patterns along the maternal continuum of care and identified factors associated with discontinuation. We analysed nationally representative data from the Bangladesh Demographic and Health Survey 2022 for 5,162 women with a recent live birth. Dropout from antenatal care, skilled birth attendance, and postnatal care was examined using multivariable logistic regression to estimate adjusted odds ratios and 95% confidence intervals, with comparisons to BDHS 2017-18 and assessment of regional variation. Only 44% of women received four or more antenatal care visits. Of these, 33% delivered with a skilled birth attendant, and among those receiving both antenatal care and skilled delivery, only 15% received postnatal care within 48 hours. Overall, 57% dropped out before completing adequate antenatal care, with additional dropouts between antenatal care and delivery (10%) and between delivery and postnatal care (18%). Compared with 2017-18, overall dropout from the maternal continuum of care more than doubled in 2022 (5.0% to 11.7%), driven by increased antenatal care dropout, while skilled birth attendance dropout declined and postnatal care dropout increased slightly. Higher maternal education, household wealth, media exposure, and womens decision-making power were consistently associated with lower odds of dropout, whereas higher birth order increased dropout risk. Substantial regional variation was observed, with the highest overall dropout in Sylhet and the lowest in Khulna. High dropout from the maternal continuum of care in Bangladesh occurs predominantly at the antenatal care stage and is shaped by socioeconomic status, birth order, womens access to information, and regional disparities. Strengthening early antenatal engagement and womens decision-making autonomy is critical to improving continuity of maternal care and reducing preventable maternal and neonatal risks.

Background Caesarean section (CS) rates in Bangladesh have increased rapidly in recent decades. This increase raises concerns about unnecessary procedures and their potential impacts on maternal health. Womens knowledge and positive attitudes toward CS influence delivery preferences and decisions, yet these aspects remain underexplored in Bangladesh. Objectives To assess knowledge and positive attitudes toward CS and to identify factors associated with knowledge and positive attitudes among married women in Bangladesh. Methods The study utilized a cross-sectional sample of married women of reproductive age. A structured questionnaire was used in face-to-face interviews to collect data covering socio-demographic information, obstetric experiences, knowledge, and positive attitudes toward CS. Descriptive statistics, independent sample t-tests, and multiple linear regression analysis were performed to identify factors. Results This study showed that knowledge was lower among rural than urban women; lower among women with a previous CS than those without, and higher among women from husband-headed households. Additionally, respondents without an income source had higher knowledge than those with an income. Regarding attitudes, higher monthly family income was associated with more positive attitudes, while larger family size was associated with lower positive attitudes. Women in husband-headed households had more positive attitudes than those in other-headed households, and women with previous CS had lower positive attitudes. Importantly, higher knowledge scores were strongly associated with more positive attitudes toward CS. Conclusion Strengthening antenatal care, including health, educational, and counselling services, particularly for rural women, larger families, husband-headed households, and women with prior CS, could improve knowledge and promote informed, positive attitudes toward appropriate CS use. Policies and programs should prioritize rural outreach, improve provider-patient communication (especially after a CS), and ensure high-quality counselling, informed consent, and male-inclusive antenatal sessions to support the appropriate use of CS.

BackgroundNigeria accounts for approximately 19% of global maternal deaths, yet skilled birth attendance (SBA) coverage stood at only 44.9% in 2018. Understanding the independent determinants of SBA after controlling for confounding is essential for evidence-based policy prioritisation. MethodsWe conducted a cross-sectional analysis of 21,465 women with a birth in the five years preceding the 2018 Nigeria Demographic and Health Survey (NDHS). Survey-weighted multivariable logistic regression was used to estimate adjusted odds ratios (aOR) for seven sociodemographic predictors of SBA. Confounding was quantified by comparing crude and adjusted estimates. ResultsOverall SBA prevalence was 44.9%, ranging from 17.7% in the North West to 85.6% in the South West. Higher education (aOR = 7.01, 95% CI: 5.68-8.67), richest wealth quintile (aOR = 6.27, 95% CI: 5.27-7.46), and attending [≥]4 antenatal care (ANC) visits (aOR = 3.80, 95% CI: 3.51-4.11) were the strongest independent predictors. Confounding was substantial: 89.0% of educations crude effect and 87.1% of the wealth effect were attributable to correlated socioeconomic factors. ANC utilisation showed the least confounding (56.3% attenuation), consistent with a more direct causal pathway. ConclusionsANC utilisation is the most modifiable and directly actionable determinant of skilled birth attendance in Nigeria. Geographically targeted investment in ANC coverage, demand-side financing, and girls education are urgently needed to close Nigerias SBA gap.

Background Ghana introduced the National Health Insurance Scheme (NHIS) in 2003 and the Free Maternal Healthcare Policy (FMHCP) in 2008 to remove financial barriers and promote universal health coverage. Despite these landmark policies, socioeconomic inequalities in maternal healthcare utilisation may persist. This study quantifies socioeconomic inequalities in antenatal care (ANC) receipt and place of delivery and decomposes the key drivers of inequality using the most recent nationally representative survey data. Methods We analysed the 2022 Ghana Demographic and Health Survey women's file, restricting to women who reported a live birth in the five years preceding the survey (n = 5,134; weighted population {approx} 4.66 million). Outcome variables were adequate ANC ([&ge;]4 visits, and [&ge;]8 visits in sensitivity analysis) and place of delivery (home, public facility, private facility). The concentration index (CI) was computed for adequate ANC, and the Wagstaff decomposition method was applied to quantify the contribution of wealth, education, residence, NHIS membership, and access barriers. Multinomial logistic regression examined factors associated with place of delivery. Missing data were handled using multiple imputation by chained equations (20 datasets). All analyses accounted for the complex survey design. Results Overall, 88.6% (95% CI: 87.0-90.2%) of women achieved [&ge;]4 ANC visits. The concentration index for adequate ANC was 0.0391 (95% CI: 0.0291-0.0491; p < 0.001), indicating statistically significant pro-rich inequality. Using the WHO threshold of [&ge;]8 visits, the CI increased more than fourfold to 0.1728 (95% CI: 0.1428-0.2028). Home delivery was most prevalent among the poorest women (46.7%), while private facility delivery dominated among the richest (46.1%). Decomposition showed that rural residence (16.4%), NHIS membership (16.4%), and geographical region (15.6%) were the largest positive contributors to pro-rich inequality, whereas secondary education exerted the strongest equalising effect (-22.5%). NHIS membership was associated with lower odds of home delivery (RRR = 0.24, 95% CI: 0.18-0.32) but did not eliminate the wealth gradient. Together, included determinants explained 71.3% of total inequality. Conclusions Despite high coverage of basic ANC, substantial and policy-relevant socioeconomic inequalities persist in maternal healthcare utilisation in Ghana. Inequalities widen markedly when the stricter WHO standard is applied. Educational attainment and rural residence are primary drivers; NHIS alone is insufficient to achieve equity. Policies should address non-financial barriers, strengthen rural health infrastructure, invest in public facility quality, and promote girls' secondary education to reduce persistent maternal health disparities.

Background: The Universal Periodic Review (UPR) is a peer-review mechanism established to hold UN Member States accountable for human rights including the right to health, yet evidence on its impact on health outcomes is limited. We evaluated whether UPR engagement is associated with accelerated improvements in maternal health trajectories. Methods and Findings: We conducted a longitudinal ecological analysis of 89 countries with a baseline maternal mortality ratio (MMR) of 70 or greater per 100,000 live births in 2005. Outcomes were trajectories of annual MMR, skilled birth attendance (SBA), and contraceptive prevalence rate (CPR), from 2005 to 2023. The exposure was the volume of health-related UPR recommendations received across three cycles, thematically classified using a validated rule-based algorithm. Mixed-effects models adjusted for time-varying GDP per capita and historical fragility. The 89 countries received 41,733 UPR recommendations across three cycles, of which 405 (1%) were related to maternal health. Maternal health recommendations were preferentially directed at countries with higher baseline MMR and lower SBA. After adjustment, each additional maternal health recommendation was associated with a 0.24% [95% confidence interval (CI): 0.08, 0.40] faster annual reduction in MMR, a 0.52% [0.12, 0.91] faster annual gain in the odds of SBA, and a 0.21% [0.09, 0.34] faster annual gain in the odds of CPR. Broader recommendations on women's health and health systems and services were also associated with faster annual improvements in trajectories across all three outcomes; recommendations on abortion, family planning, sexual health and wellbeing, and sexual education tended to be directed towards lower-burden countries and were not associated with differences in any trajectories. It is important to note that the ecological design precludes causal inference. Conclusions: Receiving UPR recommendations on the themes of maternal health, womens health, and health systems and services are associated with accelerated improvements in maternal health trajectories among high-burden countries. These findings suggest that international human rights accountability mechanisms may have a role in supporting national progress on maternal health.

Ensuring the coverage of essential maternal health services during pregnancy is critical for reducing maternal morbidity and mortality. However, in low-resource settings such as Somaliland, the completeness of antenatal care remains a major challenge. This study aimed to assess the prevalence and determinants of suboptimal essential maternal health services among women in Somaliland. A cross-sectional study was conducted using data from the 2020 Somaliland Demographic and Health Survey (SLDHS). A total of 2,835 women were included in the analysis. A composite index was constructed based on key antenatal care components, including blood pressure measurement, urine testing, blood testing, iron supplementation, malaria prophylaxis, and deworming treatment. The outcome variable was categorized as suboptimal (1) and adequate (0). Multilevel logistic regression analysis was performed to identify factors associated with suboptimal maternal health services, accounting for the hierarchical structure of the data. The prevalence of suboptimal essential maternal health services was 59.9%, while only 40.1% of women received adequate services. Preventive interventions such as iron supplementation (28.5%), malaria prophylaxis (0.5%), and deworming (0.9%) were particularly low compared to routine screening services. Higher educational attainment and wealth status were significantly associated with lower odds of suboptimal care, while multiparity and regional disparities were associated with higher odds. Adequate antenatal care utilization was the strongest protective factor (AOR = 0.006; 95% CI: 0.002-0.018). Suboptimal maternal health service delivery remains a significant challenge in Somaliland. Improving maternal health outcomes requires not only increasing antenatal care coverage but also ensuring the completeness and quality of essential service components. Targeted interventions addressing socioeconomic and regional inequalities are crucial.

Pre-eclampsia (PE) is a major contributor to maternal and neonatal morbidity and mortality. Research in high-income countries has shown that biomarker-based PE screening can improve timely detection and management of women at high risk of PE. We conducted a pre-trail cost-effectiveness analysis of introducing biomarker screening in Tanzania to identify key parameters informing a full, trial-based economic evaluation. We developed a decision tree comparing current practice with two biomarker-based screening strategies: Strategy 1 introducing placental growth factor (PlGF), and Strategy 2 adding soluble fms-like tyrosine kinase-1 (sFlt-1)/PlGF ratio. Under both strategies we assumed early aspirin prophylaxis and/or close monitoring for high-risk women. For each of the three options, we modelled PE diagnosis, as well as maternal and neonatal outcomes over a one-year time horizon, assuming a healthcare sector perspective. We quantified health outcomes in terms of disability-adjusted life years (DALYs) and costs in 2023 US$. When compared to current practice, the incremental cost per DALY averted was $410.45 for Strategy 1 and $1,011.78 for Strategy 2. Limiting the novel strategies to nulliparous women, decreased incremental cost-effectiveness ratios to $184.15 (Strategy 1) and $413.33 (Strategy 2). Key parameters impacting cost-effectiveness were PE prevalence, biomarker screening accuracy, adherence to and effectiveness of preventive treatment and monitoring, and related costs. Based on our findings, biomarker screening has the potential to be cost-effective in Tanzania, particularly if introduced early in pregnancy and targeted at nulliparous women. Further research in low-resource settings is needed to overcome the current data and evidence gaps.

Background In the Democratic Republic of the Congo (DRC), health care financing relies heavily on out-of-pocket payments, limiting access to essential services. In a context of declining external funding and ongoing efforts toward Universal Health Coverage (UHC), understanding households willingness to pay (WTP) for health care is critical for designing sustainable financing strategies. This study aimed to assess WTP for primary health care services and identify its associated factors in Eastern Kasai Province. Methods A cross-sectional study based on the contingent valuation method was conducted from 10 to 30 July 2025 among 633 randomly selected households using a multistage probabilistic sampling approach. Data were collected through semi-structured interviews using KoboToolBox. WTP was assessed using a stated preference approach. Logistic regression analyses using R 4.5.0 were performed to identify factors associated with WTP at a significance level of p < 0.05. Adjusted odds ratios (aORs) with 95% confidence intervals (95% CI) were reported. Results Overall, 70% of household heads reported willingness to pay for their own health care, and 73% for other household members. WTP decreased significantly as the cost of services increased, dropping from 95.5% for free care to 6.3% at the highest cost levels (above CDF 230,000). Poor perceived quality of care was a consistent reason for refusal, alongside financial constraints such as low income and indebtedness. Multivariable analysis showed that having a professional activity (OR = 1.9; 95% CI: 1.2-3.0; p = 0.006), residence in rural areas (OR = 2.1; 95% CI: 1.3-3.7; p = 0.008), and higher household income (OR = 2.2; 95% CI: 1.2-4.0; p = 0.011) were significantly associated with WTP. Despite relatively low absolute health care costs, the majority of households perceived them as high. Conclusion Willingness to pay for health care services in Eastern Kasai is moderate but highly sensitive to cost and strongly influenced by socioeconomic conditions and perceived quality of care. These findings underscore the need to strengthen financial protection mechanisms, particularly prepayment and risk-pooling systems, while improving service quality to enhance health care utilization and progress toward UHC in the DRC.

BackgroundNigeria accounts for approximately 19% of global maternal deaths, yet 4 in 10 Nigerian women do not meet the World Health Organization minimum standard of four antenatal care (ANC) visits. Understanding which women are being left behind, and how early they initiate care, is essential for designing effective maternal health programmes. MethodsWe conducted a cross-sectional analysis of 21,465 women with a birth in the five years preceding the 2018 Nigeria Demographic and Health Survey (NDHS). Survey-weighted multivariable logistic regression was used to estimate adjusted odds ratios (aOR) for seven sociodemographic predictors of adequate ANC attendance (4 or more visits). Kaplan-Meier survival analysis and Cox proportional hazards modelling were additionally applied to 16,084 women with complete ANC timing data to examine time to first ANC visit. Confounding was quantified by comparing crude and adjusted estimates. ResultsThe national weighted prevalence of adequate ANC was 57.8% (95% CI: 56.2%-59.4%). The median gestational age at first ANC visit was 5 months, two months later than WHO recommendations. Higher education (aOR = 5.64, 95% CI: 4.45-7.15) and richest wealth quintile (aOR = 3.93, 95% CI: 3.11-4.95) were the strongest independent predictors. Urban residence lost significance entirely after adjustment (aOR = 1.12, p = 0.113), indicating that the crude urban advantage is fully explained by the higher education and wealth of urban women. Educated women initiated ANC 35% faster than uneducated women (HR = 1.35, 95% CI: 1.23-1.47). Confounding was substantial: 74.9% of higher educations crude effect was attributable to correlated socioeconomic factors. ConclusionsEducation and wealth are the dominant independent determinants of both adequate ANC attendance and earlier ANC initiation in Nigeria. The apparent urban advantage is entirely confounded. Targeted investment in girls education, wealth-sensitive demand-side financing, and community-based early ANC outreach particularly in the North West and North East are urgently needed.

IntroductionReliable estimates of resource requirements for essential health interventions are critical for universal health coverage (UHC) planning. Existing benchmarks provide limited operational guidance for national decision-making. MethodsWe developed an ingredient-based costing model aligned with the WHO Universal Health Coverage Compendium (UHCC), which specifies delivery platforms, actions and technologies for 544 interventions. We estimated resource needs and costs associated with delivery of all UHCC-defined interventions at 80% coverage across 122 low- and middle-income countries, applying a multimorbidity adjustment to reduce potential double counting and using authoritative epidemiological, demographic and cost data. ResultsModeled delivery of Core UHCC interventions is estimated at USD 2.0 trillion annually (5.7% of aggregate gross domestic product) or USD$249, 294 and 363 per capita in low-, lower-middle- and upper-middle-income countries, respectively. Cost estimates closely aligned with WHO projections for achieving Sustainable Development Goal 3, but were 1.7-2.7x higher than Disease Control Priorities Network internal cost estimates. ConclusionThe UHCC aligned cost model provides transparent resource need and cost data under normative service delivery assumptions, and offers a practical starting point for country-level contextualization for health service packages planning.

Caesarean section rates in Nigeria remain suboptimal, with significant disparities across socioeconomic and geographic strata. The objective of this research is to identify and characterize distinct obstetric risk profiles associated with caesarean section utilization in Nigeria using K-means cluster analysis, and to examine the sociodemographic and geographic factors driving these disparities. We analyzed data from 13,915 women with recent births in the 2024 Nigeria Demographic and Health Survey. Fourteen variables spanning demographics, socioeconomic status, healthcare access, medical history, and geography were used as clustering features. K-Means clustering was performed with optimal cluster selection based on silhouette score, Davies Bouldin index, and Calinski Harabasz index. Bootstrap validation with 100 iterations assessed cluster stability, while chi-square tests and logistic regression examined associations between cluster membership and surgical delivery. Ten distinct clusters were identified with rates ranging from 1.7% to 14.4%, representing an 8.4-fold variation. The highest utilization cluster at 14.4% comprised urban, highly educated, wealthy women with extensive antenatal care averaging 16.5 visits, while the lowest utilization cluster at 1.7% consisted of rural, poorly educated, impoverished women with minimal healthcare access averaging 2.3 visits. Cluster membership was significantly associated with utilization, and bootstrap analysis confirmed cluster stability with a mean silhouette of 0.220. Machine learning based clustering reveals profound disparities in utilization across distinct population subgroups in Nigeria, highlighting the dual challenge of underutilization among disadvantaged rural populations and potential overutilization among urban elites. Targeted interventions addressing geographic, economic, and healthcare access barriers are essential to optimize utilization across all population segments.

BackgroundUgandan women and their children suffer from high maternal and perinatal mortality, often due to low antenatal care (ANC) and skilled birth usage. We partnered with community members, women and the Ugandan Ministry of Health to formatively develop an intervention (Support-Moms app) to improve health education, engage social support networks, and augment access to ANC and delivery by a formal health care provider (HCP) for pregnant women in rural Uganda. MethodsWe conducted a type 1 hybrid effectiveness-implementation trial to test the effectiveness of the Support-Moms intervention. We enrolled 824 pregnant women (<20 weeks gestation) living in Southwestern Uganda and randomized them (1:1) to standard of care or Support-Moms intervention. The primary effectiveness outcome was completion of a HCP-led skilled birth (discharge card) and was analyzed as intention-to-treat. Secondary outcomes included number of ANC visits, institution-based delivery, social support, quality-of-life, mode of infant delivery, pre-term birth, birth weight, obstetric complications and deaths (maternal, fetal, newborn). ResultsA total of 1,216 women were screened, and 824 pregnant women enrolled (mean age [~]28 years; gestation at enrolment [~]13 weeks). Complete outcomes were available for 818 (99%). The Support-Moms intervention increased HCP-led skilled births compared to standard of care (93% vs 84%; OR 2.51, 95% CI 1.57-4.03, p<0.001). Women in the intervention group were more likely to achieve [&ge;]4 ANC visits (84.1% vs 75.1%; OR 1.76, 95% CI 1.24-2.50, p=0.001) and less likely experience postpartum hemorrhage (9.1% vs 22.7%, OR 0.34, 95% CI 0.22-0.52, p<0.001) or for their neonates to require resuscitation (9.8% vs 13.7%, OR 0.69, 95% CI 0.45-0.99, p=0.001). Initiation of breastfeeding within an hour was higher (97.1% vs 71.7%, OR 1.76, 95% CI 1.15-3.44, p=0.001) and postnatal depression decreased (20.1% vs 27.1%, OR 0.68, 95% CI 0.49-0.94, p=0.019). More intervention participants reported adequate support, were birth-prepared and had a birth companion. There were no maternal deaths or differences in term births, birthweight, mode of delivery, perinatal mortality or other obstetric complications. ConclusionsIn rural Uganda, the Support-Moms mHealth-based, social-support intervention significantly increased HCP-led skilled births compared with routine care, while also improving ANC attendance, early breastfeeding initiation, birth preparedness, perceived social support and higher presence of companion at birth. Less women experienced PPH, neonatal resuscitation, and postnatal depression. Further evaluation should focus on the cost effectiveness and sustainability of this program. Trial registrationClinicaltrials.gov NCT05940831

Background Large-for-gestational-age (LGA) and macrosomic newborns are at increased risk of adverse perinatal outcomes, including death, yet the burden of neonatal mortality associated with these conditions in low- and middle-income countries (LMICs), where ongoing nutritional and epidemiological transitions suggest their prevalence will rise, remains poorly quantified. In this study, we quantify the neonatal mortality risk associated with LGA and macrosomia from 16 subnational birth cohorts in low- and middle-income countries between 2000 and 2017. Methods and findings This is an individual-participant meta-analysis to estimate neonatal mortality rates (NMRs) and relative risks among LGA infants (>90th and >97th percentile birth weight-for-gestational-age using INTERGROWTH-21st) versus appropriate-for-gestational-age (AGA, 10th-90th percentile) infants. Macrosomic ([&ge;]4000 g and [&ge;]4500 g) neonates were compared with those weighing 2500 g-3999g. Missing birth weights were imputed using recalibration and multiple imputation methods. We used random effects meta-analysis to pool relative risks. Median prevalences of LGA >90th and >97th percentile were 5.3% (interquartile range 3.6-8.2) and 2.6% (IQR 1.3-4.5), respectively; macrosomia ([&ge;]4000 g and [&ge;]4500 g) prevalences were 1.0% (IQR 0.3-3.1) and 0.06% (IQR 0.0, 0.30), respectively. Mortality was highest among preterm plus LGA infants (61.3 per 1000). LGA infants in the >90th percentile had over twofold increased mortality compared with appropriate-for-gestational-age infants (RR: 2.46; 95% CI: 1.86-3.25), while >97th percentile infants had a higher risk (RR: 3.77; 95% CI: 2.50-5.69). Term LGA >97th percentile infants also showed elevated mortality (RR: 3.14; 95% CI: 1.58-6.22). For LGA >97th percentile, the risk was higher in the early neonatal period (RR: 2.71; 95% CI: 1.92-3.82) than late (RR: 1.69; 95% CI: 1.22-2.34). There was no overall association between macrosomia ([&ge;]4000 g) and neonatal mortality. Population attributable fractions were 7.2% for LGA >90th percentile and 0.4% for macrosomia ([&ge;]4000 g). Conclusions Neonatal mortality risks were elevated among LGA infants in low- and middle-income countries, particularly at extreme values (>97th percentile) and during the early neonatal period. Macrosomia showed weaker, less robust associations. Although LGA prevalence is currently low ([~]5%) and contributes less to neonatal mortality than small newborns, ongoing nutritional and epidemiological transitions suggest increasing prevalence. This highlights the need for strengthened surveillance, monitoring, and improved delivery planning to ensure that no population is left behind.

BackgroundAccess to safe, equitable, and affordable surgical and anesthesia care is critical to reducing the burden of surgical diseases in Africa. To understand the state of access in South Sudan, we conducted a baseline assessment of surgical services in Central Equatoria State (CES) in May 2024. ObjectivesThis study aimed to survey public healthcare facilities in CES capable of providing essential surgical services. We used the capacity to perform cesarean section, laparotomy, and open fracture management--Bellwether procedures--as a proxy for assessing workforce, infrastructure, financing, information management, and service delivery. MethodsWe used a validated and contextualized Surgical Assessment Tool developed by the Harvard Program on Global Surgery and Social Change and the World Health Organization. Data were collected at the facility level and summarized descriptively using percentages, means (standard deviations), medians (minimum, maximum), and visualized in graphs, charts, and tables. ResultsAll three public health facilities assessed could perform Bellwether procedures for their catchment populations. However, workforce availability, financing, and surgical infrastructure were major constraints. The surgical workforce density was 2.27 surgical, anesthesia, and obstetric specialists per 100,000 population. Specialized procedures--such as repair of cleft lip and palate, clubfoot, and hydrocephalus shunt--were unavailable at all sites. None had magnetic resonance imaging (MRI) machines. The total average annual facility budget was $918,850, ranging from $3,960 to $800,000 at the teaching hospital--insufficient for proper operations. ConclusionWhile Bellwether procedures are routinely performed, access to quality and affordable care is compromised by deficits in workforce, financing, and infrastructure. We recommend that the Ministry of Health scale this survey nationally and develop a surgical policy and strategic plan focused on improving infrastructure, workforce, and financing for surgical and anesthesia care in South Sudan.

Background: The traditional wealth index, based on principal component analysis (PCA), used in the Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS), suffers from urban bias, distorting estimates of health inequality. We compared the traditional index (PEAR1) with an alternative two-component polychoric PCA index (POLY2) using annual expenditure from 12 LSMS surveys as the gold standard to determine which provides more accurate SEP measures for equitable policy targeting. Methods: We compared the traditional wealth index (PEAR1) with a two-component polychoric PCA approach (POLY2) using 12 LSMS (Living Standards Measurement Study) surveys (2015-2022) from 12 African countries. Annual household consumption expenditure was the gold standard. We assessed agreement using weighted Cohen's kappa and validated against education (proportion of households with secondary or higher education) using the concentration index (CIX) and slope index of inequality (SII). Results: The POLY2 index showed higher agreement with expenditure quintiles (average national weighted kappa = 43.3%) than the PEAR1 index (35.1%), with notable improvements in urban (43.5% vs. 27.5%) and rural (35.3% vs. 22.4%) areas. POLY2 also attenuated extreme household distributions observed in PEAR1. Education validation showed that POLY2 produced intermediate inequality gradients between the flatter expenditure-based gradient and the steeper PEAR1-based gradient. Conclusion: The POLY2 wealth index is superior to the traditional index, reducing urban-rural bias and providing more accurate socioeconomic classifications. Its adoption in large-scale surveys such as DHS and MICS is recommended to improve equitable monitoring of health inequalities in low- and middle-income countries.

Introduction: Induction of labour is a widely used obstetric intervention, yet its use varies markedly, with underuse in some settings and increasing elective use in others. However, the global prevalence and trends worldwide is unknown. We aimed to synthesise national and subnational data to estimate the prevalence of labour induction internationally and assess trends over time. Methods: We sought data from 194 countries through a structured search of national databases and relevant websites. For countries lacking adequate national data, we conducted a systematic review of published studies. Eligible data were pooled to estimate the prevalence of labour induction for 2019, and to examine temporal trends from 2010 to 2022. We used mixed-effects negative binomial regression models with missing data handled using multiple imputation by chained equations. Results: Data were obtained for 62 countries, including national-level data from 19 countries and 176 studies from 43 countries. Overall, 40 countries contributed to the 2019 estimate and 43 to the trend analysis. Most countries with data were high-income (N=37, 86.0%) and in Europe (N=29, 67.4%); there were no eligible data for sub-Saharan Africa. The estimated rate of labour induction for 2019 was 23.7% (95% confidence interval (CI): 19.3% to 29.2%). Induction had an estimated annual increase of 4% between 2010 and 2022 (incidence rate ratio 1.04, 95% CI 1.02 to 1.06). Conclusion: This study provides the first international estimates of labour induction, revealing high and rising rates globally. These trends likely reflect expanded clinical indications and improved access, but also signal potential overuse in resource-rich contexts. Our findings highlight a critical data gap in LMICs, particularly in Sub-Saharan Africa. Strengthening national perinatal data systems, especially in these settings, is essential for monitoring and guiding appropriate use. Identifying the optimal induction rate should be a priority for future research and clinical practice.

Background: Severe acute malnutrition (SAM) remains a major public health problem among under-five children, particularly in low-income countries. Comorbidity, especially pneumonia and diarrhea, significantly increases the risk of morbidity and mortality among affected children. Methods: An institutional-based cross-sectional study was conducted from April 20 to May 20, 2024, among children aged 6-59 months admitted with SAM to public hospitals in North Shoa Zone, Ethiopia. A total of 394 participants were included using systematic random sampling. Data were collected through caregiver interviews and medical record reviews using a structured, pre-tested questionnaire. Data were entered into Epi Info version 7 and analyzed using Stata version 16.1. Logistic regression analyses were performed to identify factors associated with comorbidity. Statistical significance was declared at p-value < 0.05. Results: The prevalence of comorbidity (pneumonia and diarrhea) among severely acutely malnourished children was 15.48% (95% CI: 11.89-19.06). Children with low dietary diversity (<5 food groups) were twice as likely to develop comorbidity (AOR = 2.00, 95% CI: 1.09-3.98). Children of single mothers had higher odds of comorbidity (AOR = 3.00, 95% CI: 1.21-7.65). Additionally, very low perceived birth weight was strongly associated with comorbidity (AOR = 7.11, 95% CI: 1.43-35.48). Conclusions: A substantial proportion of children with SAM had comorbid pneumonia and diarrhea. Key predictors included poor dietary diversity, maternal marital status, and low birth weight. Strengthening integrated child health and nutrition interventions is essential to reduce comorbidity and improve outcomes among vulnerable children.

Estimates of the marginal cost per disability-adjusted life year (DALY) averted from government health expenditure (GHE) provide an empirical basis for allocating scarce health resources to maximise population health. Existing cross-country estimates have informed priority setting in several countries and international policy discussions but are based on data that are now more than a decade old. Since then, patterns of health expenditure, disease burden, and global health financing have changed substantially. This paper provides updated estimates of the marginal cost per DALY averted for 92 low- and middle-income countries (LMIC) by applying previously estimated elasticities of the effect of GHE on health outcomes from Ochalek et al. (2018) to recent data on mortality, morbidity, population structure, and GHE. Two policy options for improving health in LMIC are assessed: (1) the implications of countries allocating 15% of general government expenditure to health consistent with the Abuja Declaration; and (2) reallocating development assistance for health (DAH) to maximise health across countries. Scenario analyses use the estimated elasticities to reflect diminishing marginal returns to health expenditure when calculating the health gains associated with additional resources. Updated estimates of the marginal costs per DALY averted range from approximately $78 to $15,789 across countries. In most countries (72%), estimates are higher than in the previous analysis, largely reflecting increases in GHE. Increasing domestic expenditure to achieve the Abuja Declaration objective would avert 234 million DALYs but require $563 billion across countries. Reallocating $39.1 billion in existing DAH could avert 133.6 million DALYs. Updated estimates provide an empirical basis for informing both domestic priority setting and the allocation of international health financing. Aligning donor funding with country-specific opportunity costs could substantially increase the global health gains achieved with limited resources.

Objectives and study: This study aimed to examine predictors of post-partum maternal mental health (MMH) and coping during COVID-19 lockdown across seven countries (the UK, China, Japan, Malaysia, Mexico, Argentina, and Thailand). Methods: An anonymous questionnaire, developed in the UK in English and translated into local languages, was used in 2021-2022 to collect data on MMH and perceived coping ability from women aged [&ge;]18 years with an infant born before or during lockdowns. Five MMH components (worry, sadness, loneliness, difficulty relaxing, annoyance) and coping were assessed on a 4-point Likert scale, then dichotomised. MMH and coping were compared across countries using Chi-square tests with post-hoc pairwise comparisons conducted via Bonferroni-adjusted z-tests. Predictors of MMH and coping were examined using multivariable logistic regression. Results: A total of 7,650 women were analysed. Younger infant age, higher income, walking and exercise, and level of support were associated with better MMH and coping, whereas higher education was associated with better coping but poorer MMH. MMH and coping differed across countries (all p<0.001), which remained after adjusting for covariates: mothers in Asian countries reported better MMH, while those in the UK and Thailand reported better coping. Conclusions: Postpartum MMH and coping during lockdown were shaped by both individual and contextual factors. Findings highlight cross-country differences and underscore the need to strengthen maternal support system during future disruptions to perinatal care. Keywords: Mental Health, COVID-19, Postpartum Period, Coping Behaviour, Social Support, Cross-Cultural Comparison

Abstract Objective: This study aimed to assess the magnitude of undernutrition and associated factors among pregnant women attending public health facilities in the Goba district, Bale zone, Oromia Region, Ethiopia, 2022. Design: Institution-based, cross-sectional study design was used. Setting: The study was conducted in selected public health facilities from May to June 2022. Participants: The study population consisted of pregnant women who lived for at least 6 months in the study area and who attended antenatal care follow-up at selected public health facilities during the study period. Pregnant women who lived for less than six months in the study area and those who were critically ill were excluded from the study. Results: 487 respondents participated in this study with a 100% response rate. More than half (50.7%) of pregnant mothers were undernourished. The significant factors associated with maternal undernutrition during pregnancy in this study were mothers with no formal education (AOR = 5.050; 95% CI: 1.470- 17.346), a history of illness during pregnancy (AOR = 2.089; 95% CI: 1.246-3.504), and eating frequency of meals less than or equal to three times per day (AOR = 3.292; 95% CI: 1.040- 10.42). Poor nutritional knowledge (AOR = 5.588; 95% CI: 2.921-10.689), poor household (HH) wealth status (AOR = 4.774; 95% CI: 2.216- 10.285), and mothers who had >= 4 pregnancies were included (AOR = 0.852; 95% CI: 342-0.989). Conclusion: The magnitude of Undernutrition among pregnant women was 50.7%. Significant associations with Undernutrition were found in mothers with no formal education, poor dietary knowledge, a meal frequency of three or fewer times per day, a history of illness during pregnancy, lower and medium household wealth status, and those who had experienced four or more pregnancies while attending antenatal care (ANC) services at public health facilities.