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.

Background: Nigeria bears one of the highest maternal mortality burdens globally, with skilled birth attendance (SBA) remaining critically low in many regions. Understanding the independent determinants of SBA is essential for designing targeted interventions. Methods: This cross sectional study analyzed 21,465 births from the 2018 Nigeria Demographic and Health Survey (NDHS), a nationally representative household survey using stratified two stage cluster sampling. SBA was defined as delivery attended by a doctor, nurse, midwife, or auxiliary midwife. Multivariable logistic regression was used to estimate adjusted odds ratios (aOR) with 95% confidence intervals for the associations between SBA and maternal education, household wealth, place of residence, geopolitical region, maternal age, parity, and antenatal care (ANC) utilization, after accounting for confounding. Results: The overall prevalence of SBA was 44.9%. In the fully adjusted model, 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 ANC visits (aOR = 3.80, 95% CI: 3.51-4.11) were the strongest independent predictors of SBA. Regional inequalities were pronounced, with SBA prevalence ranging from 17.7% in the North West to 85.6% in the South West. Crude effect estimates for education and wealth were substantially attenuated after adjustment, indicating large confounding by correlated socioeconomic factors. Conclusions: Maternal education, household wealth, ANC utilization, and geopolitical region are independent determinants of SBA in Nigeria. Scaling up ANC programs represents the most immediately actionable intervention, while long term gains require investment in girls' education and wealth equity. Targeted strategies for the northern regions are urgently needed. Keywords: skilled birth attendance, maternal mortality, Nigeria, DHS, antenatal care, logistic regression, health equity

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.

BackgroundCommunity mobilisation through participatory womens groups (PWGs) has been shown to be an effective intervention to improve maternal and neonatal survival in low-income settings, including Bangladesh. Despite WHO recommendations and scale-up in some contexts, the intervention has not been widely scaled-up in Bangladesh. To add to the existing evidence-base for PWGs and to renew calls for effective, scalable interventions to improve neonatal outcomes in the post-Sustainable Development Goals era, we report the design, implementation and evaluation of a volunteer-led model for PWGs delivered in rural Bangladesh in 2014/15. MethodsWorking in three rural unions in Faridpur, Bangladesh, we applied a volunteer-led, lower coverage and shorter duration PWG intervention. Mixed methods evaluation monitored key indicators of intervention delivery, uptake and receipt. Prospective quantitative surveys gathered data on birth outcomes, health care utilisation and essential newborn care practices. Data from before and after the implementation period were compared and interpreted in relation to historical trends in the study area and other rural areas of Bangladesh. Results180 participatory womens groups facilitated by 45 volunteer facilitators over a period of 15 months were successfully implemented giving a population coverage of one group per 500 population. An average of 32 (min.=18, max.=64) participants attended each PWG meeting, 42% of participants attended meetings on a monthly basis and 11% reported that they actively shared information from the PWGs with non-attenders. 30% of women of reproductive age and 54% of pregnant women participated in the. Focus group discussions with participants and community members revealed positive attitudes towards the groups. A change in trend in extended perinatal mortality rates was observed during the intervention period, corresponding temporally with indicators of improved rates of service utilisation and essential newborn care practices relative to the pre-implementation period. ConclusionThe modified PWG intervention likely contributed to positive changes in delivery and neonatal care practices similar to previous studies in Bangladesh. The PWG model remains an important approach to community empowerment that could contribute to enhanced efforts to end preventable neonatal deaths as we move towards the end of the Sustainable Development Goal era and beyond.

BackgroundUterine fibroids cause significant morbidity, psychosocial stress, and poor quality of life due to symptoms including heavy menstrual bleeding, anemia, pain, and bulk symptoms, as well as reproductive complications including infertility, early pregnancy loss, and preterm birth. Fibroids represent a 42.2 billion USD annual economic burden to the United States healthcare system. Despite reported delays in diagnosis of fibroids even in symptomatic women, clinical guidelines do not recommend screening for fibroids. High risk patient groups are well known. Earlier detection of fibroids through ultrasound screening could allow for earlier intervention with secondary prevention strategies or less invasive treatment options and improve the quality of life of women living with fibroids. ObjectiveThe study aimed to evaluate the cost-effectiveness of annual ultrasound screening for fibroids in women aged 25-54 years in the United States. Study DesignIn this economic evaluation, conducted in January-February 2026, a decision-analytic Markov model was developed using a healthcare payer perspective to analyze the cost-effectiveness of ultrasound screening for women in the United States. The time horizon was 25 to 55 years of age. Costs were adjusted for inflation to 2025 average according to the yearly medical care index of the United States consumer price index. Discounting (3% per cycle) and half-cycle corrections were calculated. Deterministic and probabilistic sensitivity analyses were performed to explore uncertainty, analyzed using TreeAge Pro Healthcare software. Model variables were obtained from published literature. All women residing in the United States aged 25-54 years were assumed to have been invited to the screening program. ResultsUltrasound screening for fibroids for women was found to be not only cost-effective but also cost-saving, with an incremental cost-effectiveness ratio (ICER) of -$56,605.631 per QALY (quality-adjusted life-year) gained in the base-case analysis, at a willingness to pay threshold of $30,000 per QALY. Ultrasound screening was cost-effective at all starting ages from 25 to 54 years, with even greater benefit at younger ages. Sensitivity analyses demonstrated the robustness of these findings across a wide range of variable ranges. Ultrasound screening for fibroids showed a cumulative potential to save $1,169 billion and increase 20.7 million QALYs per year compared to no screening for a population of 63.89 million American women between 25 and 54 years old. The subset of 9.32 million Black American women experienced greater benefits, with potential savings of 183 billion and an increase of 3 million QALYs. ConclusionBased on the model-based analysis, annual ultrasound screening for uterine fibroids for women aged 25-54 years in the United States was cost-effective and cost-saving, even more so for Black women. These model-based findings highlighted the potential value of guidelines for annual ultrasound screening for fibroids, which could enable earlier diagnosis, secondary prevention, and timely intervention, with positive impact on both quality of life and healthcare costs. Tweetable StatementAnnual ultrasound screening for uterine fibroids in U.S. for women aged 25-54 years was cost-effective and cost-saving. Study at a GlanceO_ST_ABSA. Why was this study conducted?C_ST_ABSO_LITo evaluate whether annual ultrasound screening for fibroids in women aged 25-54 years in the U.S. is cost-effective. C_LI B. What are the key findings?O_LIAnnual ultrasound screening beginning at 25 years was both cost-effective and cost-saving, with an ICER of -$56,605.631/QALY for women in the US. C_LIO_LIScreening resulted in potential savings of $1,169 billion for US healthcare payers and 20.7 million QALYs for U.S. women. C_LI C. What does this study add to what is already known?O_LIAnnual ultrasound screening for fibroids is not only cost effective but also cost saving, highlighting its potential to reduce diagnostic delays and enable earlier, less invasive interventions. C_LIO_LIThe results support development and implementation of fibroid screening guidelines. C_LI

ObjectiveTo determine the magnitude of obstetric referral and to explore contextual factors influencing referral practices in public health centres of Addis Ababa, Ethiopia. DesignExplanatory sequential mixed-methods study. Setting and periodFifty public health centres in Addis Ababa City Administration, January-April 2021. MethodsDelivery and referral registers from 50 health centres were reviewed retrospectively for 12 months (8 July 2019-7 June 2020). Facility observations and interviews with maternity unit heads were conducted in all selected centres. In-depth interviews were conducted with 20 midwives and 13 health-centre managers. Quantitative data were analysed descriptively, and qualitative data were analysed thematically using Colaizzis method. ResultsEighty percent of health centres had a functional referral system. The overall obstetric referral rate was 32%, with substantially higher referral rates in facilities without caesarean section (CS) services compared with those providing CS (39% vs 21%). Qualitative findings indicated that high referral rates were associated with limitations in the predictive capacity of the partograph, variability in providers clinical skills, and risk-averse practices driven by accountability concerns related to maternal and perinatal outcomes. ConclusionAlthough referral systems were largely functional, obstetric referral rates were high, suggesting potential over-referral. Updating labour monitoring tools, strengthening provider competencies, and clarifying accountability mechanisms may reduce unnecessary referrals.

BackgroundPostnatal care is crucial for assessing and improving the health of both mothers and newborns, yet its coverage remains low in Ethiopia. Timely, high-quality postnatal care, especially within the first week after birth, is essential to reduce maternal and neonatal mortality. Family-led postnatal care is an innovative model for reaching postnatal mothers and newborns during the first week after birth. Leveraging self-care principles, mothers, with the support from family and guided by a checklist, perform daily postnatal health checks on themselves and their newborns. This study evaluated the effect of a family-led postnatal care intervention on coverage of postnatal checks within seven days of birth. MethodsThis study used pre- and post-intervention cross-sectional surveys in four health centers. Eligible postnatal mothers who gave birth in the study health centers were interviewed pre- (November 2022 to January 2023) and post-intervention (February to April 2023) using a structured questionnaire. Bivariate tests and descriptive analyses were used to assess changes in postnatal care coverage over time. ResultsSurveys were completed with a total of 119 mothers pre-intervention and 110 mothers post-intervention. In the pre-intervention period, 9% (11/119) of mothers and 11% (13/119) of newborns had a postnatal check between 24 and 72 hours after birth, whereas in the post-intervention period this increased to 96% (105/110) mothers and 96% (105/110) newborns (P<0.0001). A similar increase occurred in the proportion of mothers and newborns having postnatal checks between 73 hours and 7 days (3% vs. 96%, P< 0.0001). Compared to pre-intervention, a larger proportion of mothers detected a maternal danger sign during the post-intervention period (6.7% vs 18.2%, P<0.008). ConclusionFamily-led postnatal care is a promising self-care model that may increase postnatal checks for mothers and newborns who would not otherwise have received care. Evaluating this model in other settings using a more rigorous design is recommended. Trial registrationClinicalTrials.gov (NCT05563974), first posted on 3 October 2022.

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.

Malnutrition among infants aged under six months (u6m) is a global public health problem. As countries begin implementing 2023 WHO malnutrition guidelines, local prevalence and epidemiology must be well understood. We analysed Bangladesh Demographic Health Survey data (2004 - 2022), describing the prevalence and time trends of infant u6m wasting (weight-for-length z-score [WLZ] <-2), stunting (length-for-age z-score [LAZ] <-2), and underweight (weight-for-age z-score [WAZ] <-2). In bivariate and multivariate analyses, we tested the association between wasting and underweight and established risk factors for malnutrition. Over the last 20 years, Bangladesh has seen a substantial reduction in stunting and underweight while wasting has remained relatively stable. In 2022, out of 476 infants u6m, 10.6% were wasted, 12.8% stunted, 13.7% underweight, 0.5% concurrently wasted/stunted, and 14.8% were reported small at birth. This translates to 185,390 infants u6m being wasted, 223,867 stunted, and 239,608 underweight, in 2022. WAZ had the lowest percentage of flagged data (0.8%) compared to WLZ (6.0%) and LAZ (6.4%). Underweight was associated with delivery place, small birth size, infant sex, post-natal check-ups, fever in the past 2 weeks, drinking water source, maternal BMI, and maternal height. Fewer factors were associated with being wasted, including the sex of the household head. Our findings support the urgent need to roll out 2023 WHO Guidelines in Bangladesh. They also support the superiority of underweight as a measure of undernutrition. Packages of care tackling a wide range of potential underlying causes are important for effective local interventions tailored to this age group.

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: 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.

BackgroundNewborns requiring inpatient care, particularly small and sick newborns (SSNBs), face high risk of mortality. Newborns referred from other facilities may experience worse outcomes than those born and managed within the same hospital (inborn newborns). Understanding factors contributing to this disparity in outcomes could support efforts to scale-up care and accelerate progress towards achieving Sustainable Development Goals target 3.2. MethodsData on 130,773 newborns admitted to 13 hospitals implementing with NEST360 in Kenya were obtained from the Neonatal Inpatient Dataset, between January 2019-October 2024. We described characteristics and primary diagnoses. Logistic regression was used to evaluate factors associated with mortality. ResultsAmong admissions, 114,084 (87.2%) were inborn and 16,689 (12.8%) referred. Referred newborns were more likely to be extremely preterm (6.1% vs 3.1%), have extremely low birthweight (<1,000g) (4.6% vs 2.6%) and present with respiratory distress (26.2% vs 15.0%) and hypoxia (23.2% vs 15.3%) compared to those inborn. Only 59.6% of referred newborns were admitted on first day of life compared to 80.2% inborn newborns. Unadjusted mortality among referred newborns was 29.0% compared to 11.3% in those inborn. Risk factors associated with mortality among referred newborns included being extremely low birthweight (odds ratio [OR] 13.57, 95% CI 11.19-16.44), respiratory distress (OR 4.07, 95% CI 3.77-4.39), and congenital anomalies (OR 1.66, 95% CI 1.41-1.95). Prematurity and intrapartum-related complications were also associated with increased odds of death. In multivariable analysis, being referred remained strongly associated with mortality (adjusted OR [aOR] 2.54, 95% CI 2.39-2.71). ConclusionReferred newborns had nearly three times higher odds of mortality compared to those inborn. This may highlight referral selection bias amongst this group and could also be related to inadequate pre-referral stabilisation, unsafe neonatal transportation and admission delays. If successfully implemented, a strong hub-and-spoke approach may improve care at lower levels of care and decongest receiving facilities. Overall, improving quality of care across the continuum of referral process is a cornerstone in strategies to reduce neonatal mortality towards attainment of national and global newborn survival targets. KEY FINDINGSO_ST_ABS1. WHAT WAS KNOWN?C_ST_ABSO_LINeonatal mortality remains high in sub-Saharan Africa and newborns referred from other health facilities may experience poorer outcomes than those born and managed within the same hospital. C_LIO_LIThere is limited evidence on morbidity and mortality outcomes among inborn and referred newborns. This is important to inform specialised newborn care and targeted improvements in referral. C_LI 2. WHAT WAS DONE THAT IS NEW?O_LIThis study analysed routinely collected clinical data on 130,773 newborns admitted to 13 hospitals implementing with NEST360 in Kenya between 2019 and 2024. C_LIO_LIDiagnoses outcomes and neonatal characteristics were described and compared between inborn and referred newborns. Factors associated with neonatal mortality were also examined using logistic regression analysis. C_LI 3. WHAT WAS FOUND?O_LIReferred newborns had higher unadjusted mortality rate than inborn newborns (29.0% vs 11.3%; p<0.001), with 3 times higher odds of death in univariable logistic regression analysis (OR 3.20, 95% CI 3.08-3.33). C_LIO_LIReferred newborns were more clinically vulnerable at admission and had higher proportions of extreme prematurity (6.1% vs 3.1%), very preterm birth (14.0% vs 8.6%), and extremely low birthweight (4.6% vs 2.6%). Among both groups, key risk factors associated with mortality included birthweight, gestational age, respiratory distress, hypothermia, and clinical diagnoses. C_LIO_LIAmong referred newborns some of the risk factors associated with mortality included being extremely low birthweight (OR 13.57, 95% CI 11.19-16.44), respiratory distress (OR 4.07, 95% CI 3.77-4.39), congenital anomalies (OR 1.66, 95% CI 1.41-1.95), and intrapartum-related complications (OR 1.35, 95% CI 1.20-1.52). C_LI 4. WHAT NEXT?O_LIStrengthen neonatal referral systems through clearer referral criteria, improved pre-referral stabilisation, better neonatal transport, and prompt triage on arrival at receiving hospitals. Routine clinical data should be used to monitor referral processes and outcomes and to guide continuous quality improvement. C_LIO_LIFurther research is needed to capture referral to admission time, transport characteristics, and quality of pre-referral stabilisation. Linking neonatal admission data with maternal records and assessing outcomes beyond hospital discharge would also improve understanding of referral pathways and long-term outcomes. C_LI

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.

BackgroundInterventions and policies to optimise preconception health are increasing internationally. This stems from growing recognition that improving preconception health can improve maternal and child health outcomes and advance equity by reducing inequalities and address inequities for people of reproductive age and any children they may have. Interventions and policies should be evaluated through population-level surveillance of preconception health to inform the development of new initiatives, monitor effectiveness, and support advocacy for international adoption of successful strategies. However, there is currently no internationally agreed set of preconception health indicators available and suitable for international surveillance. The International Core Indicators for Preconception Health and Equity (iCIPHE) Alliance was established to address this gap. AimTo prioritise core indicators that can be used in low-, middle- and high-income countries for surveillance of preconception health and equity. MethodsWe held two workshops with the iCIPHE Alliance (multi-sectoral stakeholders from low-, middle- and high-income countries) to inform the design of this international consensus study. The development of core indicators will consist of three steps: (1) identifying an initial long-list of candidate surveillance indicators, and defining principles for scoring the importance of each indicator, through a literature review, public involvement, and workshops with iCIPHE Alliance members; (2) scoring each candidate indicator in terms of its importance for surveillance through a two-round Delphi survey among study participants; and (3) agreeing on the final core indicators through a series of consensus meetings with a selected group of study participants. We will recruit study participants from all World Health Organization (WHO) regions across four stakeholder groups: people of reproductive age (who do not belong to any of the other stakeholder groups); health and social care professionals; policy and programme professionals; and researchers. Ethical approvalThis study has been approved by the University of Southampton Faculty of Medicine Ethics Committee (ERGO 104447). DisseminationWe will disseminate the priority core indicators through peer-reviewed publication, lay summaries, policy briefs and presentations. An implementation strategy, to enable monitoring of inequalities, inequities, and changes in preconception health over time within and between countries, will be developed with relevant national and international organisations to inform next steps.

IntroductionNational surveys in Pakistan are typically representative only at national or provincial levels, leaving large uncertainties in district-level contraceptive prevalence. This obscures local heterogeneity and limits data-driven program planning. Administrative data, although more frequent and detailed, are often underused due to reporting and measurement challenges. This study develops a multi-source small area estimation (SAE) framework to generate district-level estimates of contraceptive prevalence rate (CPR) and modern contraceptive prevalence rate (mCPR) using routine commodities data. MethodsA two-stage Bayesian SAE model was constructed to integrate survey, supply, and census data. In Stage 1, contraceptive dispensation data from the Contraceptive Logistics Management Information System (cLMIS) were converted into inferred users, normalized to married women of reproductive age (MWRA) from the 2023 Census, and scaled to provincial CPR benchmarks from the Pakistan Social and Living Standards Measurement Survey (PSLM). In Stage 2, a bivariate hierarchical Bayesian model jointly estimated CPR and mCPR, accounting for measurement error and borrowing statistical strength from socioeconomic and demographic covariates. Convergence and model stability were assessed through standard diagnostics (R-hat, ESS, BFMI, divergence checks). ResultsDistrict-level estimates were produced for 121 districts. CPR ranged from 9% to 46% and mCPR from 6% to 35%. Aggregated provincial estimates were consistent with PSLM benchmarks (within {+/-} 0.6 percentage points). Comparison with published district studies showed mean absolute deviations around 4 percentage points. ConclusionThe Bayesian SAE framework generates statistically coherent, high-resolution contraceptive prevalence estimates, substantially improving visibility into geographic inequities in Pakistans family planning landscape. These granular metrics offer policymakers an actionable basis for prioritizing underserved districts and tailoring context-sensitive interventions.

Based on the 2023 Global Burden of Disease (GBD) database, this study analyzed the global burden of preterm birth from 1990 to 2023 and predicted its development trend by 2050, while exploring the disparities in disease burden across regions with different Socio-demographic Index (SDI) levels, income groups and countries. A retrospective trend analysis was conducted to collect data on preterm birth incidence, prevalence, death and disability-adjusted life years (DALYs) in 204 countries and regions worldwide from 1990 to 2023 from the GBD 2023 database. ARIMA model (p=2,d=1,q=1) and grey prediction model (GM(1,1)) were combined to predict the preterm birth burden from 2023 to 2050. In 2023, preterm birth was the primary cause of the global neonatal disease burden, with its four core indicators significantly higher than other neonatal diseases. From 1990 to 2023, the global incidence, death and DALYs of preterm birth decreased to 0.91, 0.44 and 0.52 times of the 1990 levels respectively, while the prevalence increased to 1.54 times of the baseline. Projection results showed that by 2050, the incidence, death and DALYs of preterm birth would drop to 0.79, 0.08 and 0.32 times of the 2023 levels, and the prevalence would rise to 1.23 times of 2023. Low SDI regions, lower-middle income countries, as well as India and Nigeria, bore the heaviest disease burden. Over the past three decades, the global acute health burden of preterm birth such as death has decreased notably, but the continuous rise in prevalence and severe regional and age disparities remain prominent public health challenges. The 0-6 days and 6-11 months age groups are the key time windows for preterm birth intervention. It is urgent to implement targeted prevention and control measures for low SDI regions and lower-middle income countries to reduce the global burden of preterm birth.

BackgroundMaternal immunization (MI) can prevent major infectious diseases in mothers and children by boosting the immunity of pregnant women. Antenatal care (ANC) delivery platforms could be leveraged to effectively provide MI. Adding MIs into ANC could potentially enhance ANC services, positively influencing both maternal and infant health outcomes and yielding broader benefits. We model these potential ANC-mediated health benefits in five low- and middle-income countries: Ethiopia, Ghana, Kenya, Pakistan, and South Africa. MethodsWe first developed a conceptual framework delineating pathways through which MI-ANC could enhance ANC utilization and quality, leading to improved care-seeking for facility delivery, postnatal care, and major childhood vaccinations (e.g., measles, diphtheria-pertussis-tetanus [DPT] third dose), as well as decreased infant mortality. Using a decision-analytic model informed by Demographic and Health Survey data, we simulated the potential benefits of MI-ANC delivery across socioeconomic groups at varying hypothetical MI coverage levels. ResultsMI-ANC integration would be associated with improvements in maternal and child health outcomes across all countries studied, mediated through enhanced engagement with ANC services. Under a scenario of full MI-ANC coverage, for example, infant mortality in Ethiopias poorest quintile was projected to decline from approximately 60 to 50 deaths per 1,000 live births. In-facility delivery rates were estimated to increase from 11% to 35%, postnatal care utilization from 4% to 11%, measles-containing vaccine coverage from 43% to 71%, and DPT3 immunization from 36% to 63%. These improvements would vary substantially by country and socioeconomic group, with the largest gains observed in populations with lower baseline ANC utilization. ConclusionsIntegrating MIs into ANC services has the potential to yield ANC-mediated health benefits, particularly in settings with low baseline ANC utilization. These findings can help inform priority-setting, support the design of targeted pilot programs, and guide future empirical implementation research on the possible broader impacts of MI-ANC delivery.

BackgroundGlobal under-5 mortality has declined by approximately 60% since 1990, driven largely by reductions in communicable, maternal, neonatal, and nutritional (CMNN) diseases. Yet the degree to which genetic disorders now impede further progress toward Sustainable Development Goal (SDG) 3.2 remains poorly quantified. No prior study has assessed the aggregate burden of genetically determined conditions as a unified category across the full spectrum of countries and development levels. MethodsUsing data from the Global Burden of Disease (GBD) Study 2021, we defined a composite "Total Genetic Burden" by aggregating 16 genetically determined causes of death, encompassing congenital birth defects, hemoglobinopathies, cystic fibrosis proxies, and spinal muscular atrophy proxies, across 204 countries and territories from 1990 to 2021. Age-standardized mortality rates (ASMR), proportional mortality ratios (PMR), years of life lost (YLLs), and 95% uncertainty intervals (UIs) were calculated. Temporal trends were assessed to evaluate the shifting burden over the study period. Age-specific mortality density was computed to identify periods of peak vulnerability. Deterministic frontier analysis (log-transformed quadratic quantile regression at the 5th percentile) was applied to quantify potentially avoidable mortality relative to best-observed global performance at each level of socioeconomic development. ResultsThe age-standardized mortality rate of genetic disorders in children under 5 declined from 1990 to 2021; however, the proportional mortality ratio nearly doubled (from 5.76% to 10.76%), and genetic disorders rose from the fifth to the third leading cause of under-5 death. This shift was most pronounced in high Socio-demographic Index (SDI) countries, where genetic disorders accounted for over 40% of all under-5 deaths in some nations (e.g., Libya, 46.32%). An "Epidemiological Paradox" emerged: absolute mortality correlated negatively with SDI (R = -0.79, P < 0.001), whereas proportional mortality correlated positively (R = 0.80, P < 0.001). Age-specific analysis revealed a "Neonatal Stronghold," with genetic disorders accounting for 57% of combined genetic-versus-infectious deaths in the first week of life but only 8% in children aged 1-4 years. Frontier analysis identified substantial efficiency gaps across all SDI quintiles; China and Japan sat on the effective frontier, while Afghanistan, Nigeria, and even the United States exhibited considerable potentially avoidable mortality. ConclusionsGenetic disorders have shifted from a secondary concern to a leading structural barrier to further reductions in child mortality. Achieving SDG 3.2 will require broadening global child health priorities beyond infection control to include prenatal screening, newborn screening programs, and pediatric surgical capacity building, particularly in low- and middle-income countries.

Childhood malnutrition remains a major public health challenge in Ethiopia, where stunting and wasting co-exist but may arise from distinct spatial and etiological processes. Analyses focusing on a single outcome may overlook the interdependence of these conditions and their geographic heterogeneity. This study aimed to disentangle the determinants of stunting and wasting among children under five years of age using a Bayesian bivariate spatial modelling framework. Data from 5,405 children included in the 2019 Ethiopia Mini Demographic and Health Survey were analyzed. Stunting and wasting were modelled as correlated binary outcomes using Bayesian bivariate hierarchical geostatistical models implemented through SPDE-INLA, accounting for child, maternal, household, and environmental covariates, non-linear age effects, and spatial dependence. Model performance was assessed using the deviance information criterion, Watanabe-Akaike information criterion, and marginal log-likelihood. The bivariate model identified shared socio-economic and biological determinants. Multiple births, male sex, low maternal education, a higher number of under-five children, and household poverty were associated with increased risks of both outcomes. Female-headed households were associated with lower odds of stunting but higher odds of wasting. Spatial analysis revealed elevated residual stunting risk in the northern and central highlands, whereas wasting hotspots were concentrated in northeastern pastoralist regions. Residual spatial correlation was weak ({rho} = -0.12), indicating largely independent geographic patterns. These findings suggest that effective child nutrition policies in Ethiopia require outcome-specific and regionally tailored interventions addressing both chronic and acute forms of malnutrition.