Background The global impact of stillbirths and maternal deaths is enormous, with over two million deaths occurring each year, affecting public health outcomes and global development practices. Despite Pakistan's commitment to the Sustainable Development Goals, the country faces a substantial burden of stillbirths and maternal deaths. However, data on cause-specific mortality and the timing of deaths remains limited. In this context, we aimed to estimate the cause distribution and proportion of stillbirths (antepartum and intrapartum) and maternal deaths among married women aged 12-49 years in Pakistan. Methods We conducted a cross-sectional household survey with retrospective ascertainment in urban and rural households from all four provinces of Pakistan (Sindh, Punjab, Balochistan, and Khyber Pakhtunkhwa) and three administrative regions (Gilgit Baltistan, Azad Jammu and Kashmir, and the Islamabad Capital Territory) using the sampling frame of the Pakistan National Nutrition Survey 2018. For the cause of death estimation, we calculated a target sample size of 2,100 stillbirths, allocated to provinces and regions in proportion to the population. Maternal deaths were ascertained using the same household enumeration and selection process. The mortality survey questionnaire collected information on births, stillbirths, and maternal deaths, while a Verbal and Social Autopsy questionnaire was used to assess causes of death. Following extensive training, the study teams conducted fieldwork to interview households with identified deaths. Data were captured electronically in the field to enable continuous quality control and remote monitoring. Causes of death were assigned both by trained physicians (physician-certified verbal autopsy) and by two computer-coded methods (InterVA-5 and InSilicoVA). Results We recorded 2,076 stillbirths and 848 maternal deaths from the identified households during the 2017-2018 study period. The overall rate of stillbirth at the country level was 30.5 per 1,000 total births, while the maternal mortality ratio was 176.2 per 100,000 live births, with higher rates observed in rural areas. The leading causes of death for both stillbirths and maternal deaths were generally similar, including pregnancy-induced hypertension, obstetric haemorrhage, sepsis, and obstructed labour. Delays in seeking and accessing care, both for stillbirths and maternal deaths, resulted from issues in the identification of illness severity, decision-making, transportation issues, and delayed provision of health care once reaching a provider. Conclusions The high stillbirth (30.5 per 1,000 births) and maternal mortality (176 per 100,000 live births) rates we observed exceed Pakistan's national targets and the Sustainable Development Goals 2030 targets. Persistent inequities, particularly in rural Balochistan and Khyber Pakhtunkhwa, are driven by delays in recognising illness, deciding to seek care, reaching facilities, and receiving timely facility-based care. Closing these gaps will require provincial investment in emergency obstetric and newborn care, scale-up of skilled birth attendance, and community awareness of danger signs.
Abstract Background Tippy-taps are widely promoted as a low-cost handwashing solution in rural sub-Saharan Africa, but post-programme coverage collapse is common and poorly understood at the mechanism level. Traditional Authority (T/A) Chiwere, Dowa District, Malawi, achieved 98.5% household tippy-tap coverage following Community-Led Total Sanitation (CLTS) mobilisation in 2018; coverage fell to 3.1% by 2022 after the implementing partner exited in 2021. Methods This was a cross-sectional analytical study of 415 households in T/A Chiwere, selected using multistage probability sampling with systematic random selection of households, conducted in 2024. Knowledge, attitudes, and functional status were analysed descriptively and with one-way ANOVA. A multivariable logistic regression model was fitted among the subset of households reporting a tippy-tap present with known functional status (n = 135) to identify correlates of functionality. The Capability-Opportunity-Motivation (COM-B) framework was applied after data analysis to organize interpretation of the quantitative findings. Results Most respondents (92.5%, 384/415) showed moderate knowledge of tippy-tap construction, use and maintenance; in univariate analysis, knowledge varied significantly by religion, household size and presence of an under-five child (all p < 0.05) but not significantly by gender. Only 145/415 households (34.9%) reported a tippy-tap present. Among the 135 households with both a tippy-tap present and known functional status, presence of a child under five was independently associated with lower odds of functionality (adjusted OR 0.27, 95% CI 0.10–0.72, p = 0.009), as was smaller household size (1–2 vs 3–5 members; OR 0.25, 95% CI 0.06–0.95, p = 0.042). Conclusions Functional collapse in T/A Chiwere is not explained by knowledge or attitude deficits, both of which were favourable across most households. Household-level caregiving and labour constraints indexed by presence of a young child and smaller household size were independently associated with non-functionality. Programmes should treat working tippy-taps, rather than distributed ones, as the unit of success, and target maintenance support to households with young children rather than relying on repeat sensitisation.
Despite growing recognition of the intergenerational effects of maternal mental health, evidence from tea garden communities remains limited. This study assessed the mental health status of working mothers in tea gardens of Moulvibazar, Bangladesh, examined its association with children's well-being, and explored contextual factors shaping maternal mental health. A convergent cross-sectional mixed-methods study was conducted. Using a purposive and stratified random sampling technique, the quantitative data were collected from 451 working mothers with at least one child aged 2-7 years. Mothers' psychological well-being was assessed using the Depression, Anxiety, Stress Scale-21 and World Health Organisation-Five scales, while children's behavioural and emotional well-being was measured using the Strengths and Difficulties Questionnaire (SDQ). The qualitative component included 11 key informant interviews and two focus group discussions (FGDs) from Moulvibazar, Bangladesh. Quantitative data were analysed using descriptive and inferential statistics, and qualitative data were thematically analysed. A substantial proportion of mothers reported high levels of psychological distress, with 32.4%, 29.9% and 31.7% experiencing moderate to extremely severe depression, anxiety and stress, respectively, while 33.9% had poor well-being. Age was significantly associated with stress (p = 0.014) and overall well-being (p = 0.002), whereas no significant association was observed between childcare arrangements and anxiety (p = 0.171). Among children, 87.8% were classified as having abnormal SDQ scores based on maternal report. Addressing maternal mental health through improved working conditions, accessible childcare and targeted mental health interventions is critical for breaking cycles of intergenerational vulnerability.
Childhood exposure to famine represents a severe early-life shock that may shape health, cognitive, and labour-market outcomes across the life course. Yet evidence on its causal consequences in later life remains limited. This study examines whether early-life starvation during the Great Chinese Famine (1959-1961) affected later-life health, cognitive functioning, and labour-market outcomes. The analysis draws on data from the China Health and Retirement Longitudinal Study (CHARLS), collected in 2014 and 2018, and uses a final analytical sample of 15,471 individuals born between 1941 and 1974. We exploit prefecture-level famine intensity and famine exposure to instrument for self-reported childhood starvation, allowing for the identification of heterogeneous effects across childhood age stages. Our findings point to early childhood (ages 0-5) as a particularly sensitive period. Starvation during this stage is associated with poorer memory and a higher prevalence of arthritis and rheumatism, with more tentative evidence of adverse labour-market consequences, including health-related job discrimination and early retirement. Cognitive and physical outcomes are more pronounced for females, while economic penalties are concentrated among males, reflecting the gendered allocation of intra-household resources and labour pressures. Exposure during later childhood shows weaker effects. Overall, this study demonstrates that early-life nutritional shocks have long-lasting, age- and gender-specific consequences, emphasising the critical role of early childhood nutrition in shaping human capital, cognitive development, and labour-market participation in later life. These findings highlight the long-term costs of early-life deprivation and suggest that policies protecting children during periods of crisis may generate benefits across the life course.
Antimicrobial use among children in Japan has declined substantially; however, tetracycline use has increased among adolescents, particularly after 2017 and during the COVID-19 period, and the underlying clinical indications remain unclear. We aimed to characterize long-term trends in oral tetracycline use, changes in clinical indications, and treatment patterns among individuals aged < 20 years in Japan. We conducted a time-series analysis using a nationwide administrative claims database of Japan Health Insurance Association from 2015 to 2023, including 24 million individuals aged < 20 years. Oral tetracycline use was measured as days of therapy (DOTs) per 1000 inhabitants per day, and clinical indications were identified using ICD-10 codes. We assessed trends in tetracycline use and indications over time and described treatment patterns, including concomitant therapies, among patients with acne vulgaris. Oral tetracycline use increased from 0.95 to 1.76 DOTs per 1000 inhabitants per day between 2015 and 2023, primarily driven by doxycycline, with a marked rise after 2020 and highest use among adolescents. The clinical indications shifted substantially, with the proportion of acne vulgaris increasing from 34.1% to 73.6% while respiratory infections decreased, and the mean treatment duration for acne was 37.9 days. Among patients with acne, concomitant use of adapalene- and benzoyl peroxide-based therapies was limited, whereas topical antibiotics were commonly used. Oral tetracycline use among individuals aged < 20 years in Japan increased substantially, with a marked shift in clinical indications toward acne vulgaris. These findings provide a basis for further evaluation of acne treatment patterns, including the use of oral tetracyclines and non-antibiotic topical therapies, in Japan.
This article examines a recent Russian surrogacy case through a bioethical and socio-legal lens to assess the regulation of commercial surrogacy, the public response it generated, and the role of bioethics in contemporary Russian debate. Focusing on a criminal case involving medical professionals accused of child trafficking in connection with cross-border surrogacy, the article argues that the controversy exposed deep tensions among law, medicine, religion, public policy, and child protection. It shows that public discussion centred largely on legal control, national security, and reproductive market regulation, while key bioethical questions concerning the commodification of women's reproductive labour, the objectification of children, and the vulnerability of surrogate mothers remained largely absent. The article further demonstrates that the Russian regulatory framework is fragmented and paternalistic, insufficiently protecting the interests of surrogate mothers, intended parents, and children alike. By analysing both the case and the surrounding debates, the study concludes that Russian bioethics remains weakly institutionalized as an interdisciplinary forum capable of mediating between medical, legal, and moral perspectives. The article ultimately calls for broader, more inclusive ethical deliberation that meaningfully incorporates medical professionals, legal experts, civil society, and religious communities in the governance of surrogacy.
Migrant parents of children and young people (CYP) living with sickle cell disease (SCD) must manage complex care needs within unfamiliar healthcare systems. Drawing on qualitative interviews with migrant parents in England, this study examines how migration reshapes healthcare navigation. Using navigation as an analytical lens, the findings show that parents act as de facto navigators, coordinating services across healthcare, education and welfare domains without structured support. Beyond practical coordination, navigation involved sustained relational, emotional and identity work. Parents described learning to interpret new institutional rules, (re)negotiating expectations of 'good' parenting in a different national context and managing stigma linked to illness, ethnicity and immigration status. Migration intensified caregiving responsibilities through disrupted support networks, legal and economic constraints and uneven access to resources. Although UK services were valued for specialist expertise, parents reported the need for continual self-advocacy within fragmented systems. The study extends navigation scholarship by foregrounding migrant parents' unpaid and often unrecognised labour and demonstrates how healthcare navigation is shaped by intersecting migration, policy and racialised contexts. The findings highlight the importance of embedding condition-specific navigation support within existing specialist services.
Objectives A population approach focuses on improving the health status of the entire population, depending on the fact that the majority of diseases occur among low-risk individuals rather than high-risk individuals. However, the onset of permanent tooth caries in children with high or low caries risk remains unclear, especially among children of different socioeconomic statuses. This study investigated the distribution of caries occurrence in children across different caries experience and income groups. Methods This cohort study was based on the Adachi Child Health Impact of Living Difficulty (A-CHILD) study, which surveyed all elementary school children in Adachi City, Japan. The explanatory variables were the number of permanent carious teeth and three tertiles of income when children were 7 or 8 years old in 2016. The outcome was an increase in permanent carious teeth when children were 11 or 12 years old, between 2016 and 2020. Negative binomial regression analyses were applied with adjustment for sex. Results Among the participants (n=3,321), the low-income group had 1.44 (95% CI: 1.14; 1.81) times higher risk than the high-income group. Children with two or more carious teeth showed 2.52 (95% CI: 1.57; 4.06) times higher caries risk than caries-free children. However, over 80% of carious teeth occurred among caries-free children in all income groups. Conclusions The majority of new caries cases occurred not merely in high-risk children but in a large number of initially low-risk children, regardless of income level. These findings suggest the importance of a population approach in preventing caries. Clinical significance The majority of new caries lesions occurred in caries-free children across all income statuses. The population approach appears appropriate for preventing the incidence of dental caries among elementary school children.
Rationale Intravenous oxytocin is widely used to induce labour or to augment labour (i.e. enhance contractions to promote progression), with approximately one-quarter of pregnant women at term receiving the medication. While continuous administration of intravenous oxytocin stimulation from induction until birth is recommended by most clinical guidelines, this may increase the risk of uterine hyperstimulation, foetal distress, and adverse maternal and neonatal outcomes. Discontinuation of oxytocin in the active phase of labour could reduce these risks without compromising labour progression. However, evidence from randomised trials is conflicting, and optimal management is unclear. Objectives To assess the effects of the discontinuation of intravenous oxytocin stimulation in pregnant women during the active phase of induced or augmented labour. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, Embase, Scopus, and Web of Science Core Collection, as well as ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform. We also screened reference lists of included studies and relevant reviews, and contacted trial authors for additional data. No language or date restrictions were applied. The last search was conducted on 17 November 2025. Eligibility criteria We included randomised controlled trials comparing continuation versus discontinuation (or placebo) of intravenous oxytocin in the active phase of labour (≥ 4 cm cervical dilation) in term singleton pregnant women undergoing labour induction or augmentation. No restrictions to inclusion were applied regarding parity, maternal age, comorbidities, labour setting, or presence or absence of previous caesarean section. Outcomes The critical outcome was caesarean section. Important maternal outcomes included instrumental vaginal birth (vacuum extraction or forceps delivery), postpartum haemorrhage, maternal infection, maternal satisfaction, duration of the active phase of labour, uterine hyperstimulation (tachysystole with abnormal CTG (cardiotocography)), and uterine tachysystole with normal CTG. Important neonatal outcomes included admission to neonatal unit, hypoxic ischaemic encephalopathy or therapeutic hypothermia, neonatal infection, perinatal death, acidotic cord blood gases (arterial pH < 7.10), and Apgar score < 7 at five minutes. Risk of bias Two review authors independently assessed the risk of bias for each trial using Cochrane's risk of bias tool RoB 1, following the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions. We assessed random sequence generation, allocation concealment, blinding, incomplete outcome data, selective reporting, and other potential sources of bias. We resolved disagreements through discussion or by involving a third review author. We assessed potentially eligible and included trials using the Cochrane Pregnancy and Childbirth Trustworthiness Screening Tool. Synthesis methods For dichotomous outcomes, we calculated risk ratios (RR) with 95% confidence intervals (CIs). For continuous outcomes, we calculated mean differences (MDs) with 95% CIs. For our primary analysis, we used the fixed-effect model, implemented using the Mantel-Haenszel method for dichotomous outcomes and inverse variance for continuous outcomes. We prespecified random-effects meta-analysis as a secondary analysis to explore the robustness of the findings in the presence of between-study heterogeneity. We conducted sensitivity and subgroup analyses for the critical outcome only. We assessed statistical heterogeneity using Tau², I² and Chi² statistics. We evaluated the certainty of evidence using the GRADE approach for the prespecified outcomes included in our summary of findings table. Included studies During the study selection process, we placed 10 studies in the 'awaiting classification' category because we needed additional information to assess eligibility or trial trustworthiness. These studies could potentially change the review's conclusions once verified and incorporated. This review includes a total of nine trials evaluating nine comparisons and involving 4814 women. The overall risk of bias of included trials varied. Several studies were open label, and allocation concealment was unclear in some. The certainty of evidence ranged from high to low, mainly due to risk of bias, inconsistency, and imprecision across studies. Synthesis of results Discontinuation of oxytocin at the onset of the active phase of induced or augmented labour may make little or no difference to the risk of caesarean section compared with continuation (RR 0.98, 95% CI 0.85 to 1.13; I² = 5%; 8 studies, 4710 participants; low-certainty evidence). In a sensitivity analysis for the critical outcome excluding trials with high risk of bias in one or more domains, only one trial remained (RR 1.17, 95% CI 0.90 to 1.53; 1198 women). Discontinuation makes little or no difference to the risk of instrumental vaginal birth (RR 1.05, 95% CI 0.90 to 1.21; I² = 0%; 5 studies, 3776 participants; high-certainty evidence). The duration of the active phase of labour may be longer after discontinuation, with a mean difference of 34.72 minutes compared to continued stimulation, but the certainty of this evidence is very low (MD 34.72, 95% CI 26.34 to 43.11; I² = 82%; 8 studies, 4141 participants; very low-certainty evidence). Discontinuation may reduce uterine hyperstimulation (RR 0.65, 95% CI 0.55 to 0.77; I² = 56%; 3 studies, 1371 participants; low-certainty evidence). Discontinuation makes little or no difference to admission to a neonatal unit (RR 0.98, 95% CI 0.76 to 1.27; I² = 0%; 7 studies, 4606 participants; high-certainty evidence) or acidotic cord gasses at birth (arterial pH < 7.10) (RR 1.01, 95% CI 0.75 to 1.35; I² = 0%; 6 studies, 4086 participants; high-certainty evidence). Discontinuation probably makes little or no difference to the risk of having an Apgar score less than seven at five minutes (RR 0.92, 95% CI 0.40 to 2.11; I² = 0%; 5 studies, 2096 participants; moderate-certainty evidence). Authors' conclusions Discontinuation of oxytocin in the active phase of induced or augmented labour may have little or no effect on caesarean birth and has little or no effect on instrumental birth. It may reduce uterine hyperstimulation at the expense of a longer duration of the active phase of labour, but this evidence is of very low certainty. The discontinuation strategy appears safe for both mother and baby, provided that adequate monitoring of uterine activity and foetal heart rate is maintained. Funding None REGISTRATION: The protocol for this Cochrane review was published in November 2024.
Introduction Cervical oedema during labour is relatively common, but severe circumferential oedema persisting at advanced dilation is rare, particularly in multiparous women. In such cases, the swollen cervix may mimic an obstructive mass and raise concern for labour obstruction, cervical laceration or avulsion if pushing is initiated. Case presentation We report the case of a 41-year-old Gravida 5, Para 4 woman who underwent induction of labour at 39 weeks' gestation for diet-controlled gestational diabetes. Labour progressed to 8 cm dilation, at which point a tense, circumferential, purple-hued cervical swelling developed. The clinical presentation raised concern for obstructed labour and potential cervical trauma, although maternal and fetal parameters remained reassuring. The main diagnostic challenge was to distinguish severe reactive cervical oedema from cervical prolapse, haematoma or other cervical pathology. After interdisciplinary discussion and detailed counselling, the patient chose to proceed with a cautious trial of pushing. This decision was based on multiparity, a deeply engaged fetal head, reassuring fetal status, the absence of clinical obstruction to descent and the immediate availability of senior obstetric support and emergency resources. She achieved spontaneous vaginal delivery of a healthy infant within two pushes, without instrumentation, cervical trauma, postpartum haemorrhage or neonatal complication. The cervix remained oedematous but intact. Partial resolution was observed by postpartum Day 3, and follow-up colposcopy at 2 months showed no suspicious cervical lesion. Written informed consent for publication was obtained from the patient. Discussion This case illustrates that, in carefully selected multiparous women, severe reactive cervical oedema at advanced dilation may not necessarily preclude vaginal birth. However, this observation is hypothesis generating and should not be generalised to nulliparous women, cases with high fetal station, suspected obstruction, fetal compromise or limited access to emergency obstetric care.
