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Particulate matter <2.5 micrometer (PM2.5) is associated with adverse perinatal outcomes, but the impact on disease burden mediated by this pathway has not previously been included in the Global Burden of Disease (GBD), Mortality, Injuries, and Risk Factors studies. We estimated the global burden of low birth weight (LBW) and preterm birth (PTB) and impacts on reduced birth weight and gestational age (GA), attributable to ambient and household PM2.5 pollution in 2019. We searched PubMed, Embase, and Web of Science for peer-reviewed articles in English. Study quality was assessed using 2 tools: (1) Agency for Healthcare Research and Quality checklist; and (2) National Institute of Environmental Health Sciences (NIEHS) risk of bias questions. We conducted a meta-regression (MR) to quantify the risk of PM2.5 on birth weight and GA. The MR, based on a systematic review (SR) of articles published through April 4, 2021, and resulting uncertainty intervals (UIs) accounted for unexplained between-study heterogeneity. Separate nonlinear relationships relating exposure to risk were generated for each outcome and applied in the burden estimation. The MR included 44, 40, and 40 birth weight, LBW, and PTB studies, respectively. Majority of the studies were of retrospective cohort design and primarily from North America, Europe, and Australia. A few recent studies were from China, India, sub-Saharan Africa, and South America. Pooled estimates indicated 22 grams (95% UI: 12, 32) lower birth weight, 11% greater risk of LBW (1.11, 95% UI: 1.07, 1.16), and 12% greater risk of PTB (1.12, 95% UI: 1.06, 1.19), per 10 μg/m3 increment in ambient PM2.5. We estimated a global population-weighted mean lowering of 89 grams (95% UI: 88, 89) of birth weight and 3.4 weeks (95% UI: 3.4, 3.4) of GA in 2019, attributable to total PM2.5. Globally, an estimated 15.6% (95% UI: 15.6, 15.7) of all LBW and 35.7% (95% UI: 35.6, 35.9) of all PTB infants were attributable to total PM2.5, equivalent to 2,761,720 (95% UI: 2,746,713 to 2,776,722) and 5,870,103 (95% UI: 5,848,046 to 5,892,166) infants in 2019, respectively. About one-third of the total PM2.5 burden for LBW and PTB could be attributable to ambient exposure, with household air pollution (HAP) dominating in low-income countries. The findings should be viewed in light of some limitations such as heterogeneity between studies including size, exposure levels, exposure assessment method, and adjustment for confounding. Furthermore, studies did not separate the direct effect of PM2.5 on birth weight from that mediated through GA. As a consequence, the pooled risk estimates in the MR and likewise the global burden may have been underestimated. Ambient and household PM2.5 were associated with reduced birth weight and GA, which are, in turn, associated with neonatal and infant mortality, particularly in low- and middle-income countries.

The unprecedented emission reductions during the COVID-19 lockdowns in 2020 provided a natural experiment to elucidate aerosol–radiation-cloud interactions and their effect on convective weather phenomena, particularly thunderstorm occurrence and lightning flash rate density (FRD), across the Indian subcontinent. The significant reduction in anthropogenic aerosol emissions, especially across the most polluted Indo-Gangetic Plain, led to a marked decrease in aerosol optical depth (AOD), altering regional cloud-aerosol interactions and radiative effects. A rise in ENSO-compensated lightning FRD and an increase in thunderstorm days (TDs) were associated with aerosol depletion, suggesting a favorable environment for convective initiation under relatively cleaner atmospheric conditions over the extremely polluted region. The reduced AOD likely led to enhanced surface heating and decreased upper-level warming, reversing the previously stable stratification caused by very high aerosol loading. This natural instability favored the formation of a greater number of widespread thunderstorms. However, the observed reduction in lightning FRD per TD during the pandemic year indicates that, while more storms formed, each storm exhibited lower electrification, likely due to diminished cloud condensation nuclei. Relatively lower aerosol concentrations can promote an increase in storm frequency through radiative destabilization of the atmosphere. However, these relatively cleaner conditions also tend to reduce lightning frequency within individual storms, as the limited presence of aerosols constrains non-inductive charging processes in clouds. Thus, environments with fewer aerosols are associated with more frequent storm development but a decrease in lightning flashes per storm, reflecting a complex interplay between atmospheric composition and convective electrification. These insights advance understanding of convective storm responses to aerosol variability and have important implications for future atmospheric electrification trends under changing emission scenarios. This dual effect highlights the complexity of aerosol–cloud-precipitation-electrification interactions. It has implications for understanding convective weather responses to air quality changes and future climate scenarios driven by aerosol management strategies.

[This corrects the article DOI: 10.1371/journal.pmed.1003718.].[This corrects the article DOI: 10.1371/journal.pmed.1003718.].

Maternal and neonatal mortality in Bihar, India was far higher than the aspirational levels set out by the Sustainable Development Goals. Provider training programs have been implemented in many low-resource settings to improve obstetric and neonatal outcomes. This longitudinal investigation assessed diagnoses and management of postpartum hemorrhage (PPH), hypertensive disorders of pregnancy, birth asphyxia (BA), and low birth weight (LBW), as part of the CARE’s AMANAT program in 22 District Hospitals in Bihar, between 2015 and 2017. Physicians and nurse mentors conducted clinical instruction, simulations and teamwork and communication activities, infrastructure and management support, and data collection for 6 consecutive months. Analysis of diagnosis included 11,259 non-referred and management included 11,800 total (non-referred and referred) admissions that were observed. Data were analyzed using the chi-square test for trend. PPH was diagnosed in 3.7% with no significant trend but diagnosis of hypertensive disorders increased from 1.0% to 1.7%, (p trend = 0.04), over the 6 months. BA was diagnosed in 5.8% with no significant trend but LBW diagnoses increased from 11% to 16% (p trend <0.01). Among PPH patients, 96% received fluids, 85% received uterotonics and 11% received Tranexamic Acid (TXA). There was a significant positive trend in the number of patients receiving TXA for PPH (6% to 13.8%, p trend = 0.03). Of all neonates with BA, there were statistically significant increases in the proportion who were initially warmed, dried, and stimulated (78% to 94%, p trend = 0.02), received airway suction (80% to 93%, p trend = 0.03), and supplemental oxygen without positive pressure ventilation (73% to 86%, p trend = 0.05). Diagnoses of hypertensive disorders and LBW as well as initial management of BA increased during the AMANAT program. However, underdiagnoses of PPH and hypertensive disorders relative to population levels remain critical barriers to improving maternal morbidity and mortality.

Background Obstetric Point-of-Care Ultrasound (O-POCUS) holds promise for strengthening maternal health services particularly in low- and middle-income countries (LMICs). However, its widespread use is hindered by limited provider training and resource constraints within health facilities. To address this gap, a large-scale O-POCUS program was implemented across eight counties of Kenya whereby 468 healthcare providers (HCPs) from 224 facilities were trained in five basic O-POCUS parameters. This study evaluated the reach, effectiveness, adoption, implementation, and maintenance of this program using the RE-AIM framework. Methods For this cross-sectional evaluation study, trained research staff conducted surveys and in-depth interviews with HCPs, stakeholders, and antenatal and postnatal care clients for one week from a random sample of about half of these facilities ( n  = 114) six months after O-POCUS introduction. A total of 249 HCPs, 2,292 antenatal and 1,704 postnatal clients were surveyed, and 96 HCPs/stakeholders and 114 clients were interviewed. Data were analyzed using descriptive and thematic methods and mapped onto the RE-AIM framework to assess program implementation. Results The findings revealed that O-POCUS was implemented across all 114 health facilities and 1937 (49%) of surveyed clients received a scan (reach). Over 80% of trained HCPs reported moderate to high confidence in performing key obstetric assessments, and 72% reported that O-POCUS influenced clinical decision-making including referrals (effectiveness). 41% of HCPs conducted more than 20 scans per month and 89% of the clients reported that they were likely to recommend O-POCUS to others (adoption). Lack of resources such as gel and paper towels were identified as major challenges (implementation), while 60% of HCPs reported the need for further training and mentorship (maintenance). Conclusion These findings demonstrate successful large-scale implementation of O-POCUS in Kenya and provide valuable insights for policymakers and healthcare organizations seeking to implement similar O-POCUS programs in resource-limited settings. Continuous strengthening through mentorship, supportive supervision and resource provision is recommended for sustained success of O-POCUS in improving maternal healthcare.

The global rise of herbicide-resistant weeds underscores the urgent need for sustainable weed management strategies. Eupatorium capillifolium (Lam.) Small, a perennial invasive weed native to North America and widespread in the Southeastern United States, presents untapped potential as a bioherbicide. This study evaluated the effects of its aqueous extract on seed germination and early seedling growth of thirteen weed species (nine broadleaf and four grasses) and four major crops ( Arachis hypogaea, Zea mays, Glycine max, and Gossypium hirsutum ). The extract significantly inhibited seed germination (92.62–100%) of four Amaranthus species ( A. palmeri , A. tuberculatus , A. retroflexus, and A. hybridus) with minimal effects on Zea mays and Arachis hypogaea (6.12–6.25%). Other weeds showed a limited response. Inhibition of shoot and root growth confirmed the extract’s allelopathic activity. Principal component analysis indicated inhibition of seed germination as the primary mode of action. The order of pigweeds’ sensitivity to the aqueous extract was A. hybridus  >  A. retroflexus  >  A. palmeri  >  A. tuberculatus . Phytochemical screening identified 36 allelopathic compounds with gallic acid and hydroxy-1,4-benzoquinone as the dominant components. This is the first report demonstrating the bioherbicidal potential of E. capillifolium aqueous extract against Amaranthus spp. under laboratory conditions, highlighting its promise as a sustainable alternative to synthetic herbicides and a candidate for further field-based evaluation in integrated weed management systems.

In the state of Bihar, India a multi-faceted quality improvement nurse-mentoring program was implemented to improve provider skills in normal and complicated deliveries. The objective of this analysis was to examine changes in diagnosis and management of postpartum hemorrhage (PPH) of the mother and intrapartum asphyxia of the infant in primary care facilities in Bihar, during the program. During the program, mentor pairs visited each facility for one week, covering four facilities over a four-week period and returned for subsequent week-long visits once every month for seven to nine consecutive months. Between- and within-facility comparisons were made using a quasi-experimental and a longitudinal design over time, respectively, to measure change due to the intervention. The proportions of PPH and intrapartum asphyxia among all births as well as the proportions of PPH and intrapartum asphyxia cases that were effectively managed were examined. Zero-inflated negative binomial models and marginal structural methodology were used to assess change in diagnosis and management of complications after accounting for clustering of deliveries within facilities as well as time varying confounding. This analysis included 55,938 deliveries from 320 facilities. About 2% of all deliveries, were complicated with PPH and 3% with intrapartum asphyxia. Between-facility comparisons across phases demonstrated diagnosis was always higher in the final week of intervention (PPH: 2.5-5.4%, intrapartum asphyxia: 4.2-5.6%) relative to the first week (PPH: 1.2-2.1%, intrapartum asphyxia: 0.7-3.3%). Within-facility comparisons showed PPH diagnosis increased from week 1 through 5 (from 1.6% to 4.4%), after which it decreased through week 7 (3.1%). A similar trend was observed for intrapartum asphyxia. For both outcomes, the proportion of diagnosed cases where selected evidence-based practices were used for management either remained stable or increased over time. The nurse-mentoring program appears to have built providers' capacity to identify PPH and intrapartum asphyxia cases but diagnosis levels are still not on par with levels observed in Southeast Asia and globally.

Research on group antenatal care in low- and middle-income contexts suggests high acceptability and preliminary implementation success. We studied the effect of group antenatal care on gestational age at birth among women in Rwanda, hypothesizing that participation would increase mean gestational length. For this unblinded cluster randomized trial, 36 health centers were pair-matched and randomized; half continued individual antenatal care (control), half implemented group antenatal care (intervention). Women who initiated antenatal care between May 2017 and December 2018 were invited to participate, and included in analyses if they presented before 24 weeks gestation, attended at least two visits, and their birth outcome was obtained. We used a generalized estimating equations model for analysis. In total, 4091 women in 18 control clusters and 4752 women in 18 intervention clusters were included in the analysis. On average, women attended three total antenatal care visits. Gestational length was equivalent in the intervention and control groups (39.3 weeks (SD 1.6) and 39.3 weeks (SD 1.5)). There were no significant differences between groups in secondary outcomes except that more women in control sites attended postnatal care visits (40.1% versus 29.7%, p = 0.003) and more women in intervention sites attended at least three total antenatal care visits (80.7% versus 71.7%, p = 0.003). No harms were observed. Group antenatal care did not result in a difference in gestational length between groups. This may be due to the low intervention dose. We suggest studies of both the effectiveness and costs of higher doses of group antenatal care among women at higher risk of preterm birth. We observed threats to group care due to facility staff shortages; we recommend studies in which antenatal care providers are exclusively allocated to group antenatal care during visits. ClinicalTrials.gov NCT03154177.

Four years of Indian Institute of Tropical Meteorology lightning location network lightning observation data are used to determine the seasonal and spatial (over different geographical locations) distribution of the ratio of intra‐cloud (IC) lightning to cloud‐to‐ground (CG) lightning in thunderstorms over the Indian subcontinent. The ratio is high (6–10) in the northwestern parts and low (0.5–3.5) in the northeastern parts. No prominent latitudinal variation of the IC to CG ratio exists, but a climatological seasonal variability exists over all regions. In the pre‐monsoon season (March–May), the mean ratio is observed to be 3.81 with a standard deviation of 0.79, and during the monsoon season (June–September), a value of 3.04 with a standard deviation of 0.50. Although convective available potential energy is the regulating factor, little dependency has been found between the ratio of IC to CG lightning (IC:CG ratio) and the total flash rate (f), as well as with cold cloud depths. The ratio is observed to be proportional to the total flash rate as f0.61. The cold cloud depth is most prominently linked with the regional and seasonal IC:CG ratio. The implication of these observed results has the importance of separating CG lightning flash from total and can be used in numerical models to give a proper prediction of CG lightning in hazard mitigation. Plain Language Summary Pre‐monsoon thunderstorms exhibit more intra‐cloud (IC) discharge than monsoonal thunderstorms; hence, the IC:cloud‐to‐ground (CG) ratio is also high in pre‐monsoon. In this paper, we have shown that CG lightning is approximately 20% of total lightning in pre‐monsoon whereas 25% of total lightning in monsoon all over the Indian region. A stronger vertical updraft associated with high convective available potential energy enhances the cold cloud depth. It may expand the mixed phase region, which can broaden and uplift the size of the upper positive charge center inside a thunderstorm. In contrast, the middle negative charge center remains at the same temperature level. Therefore, this process may enhance IC discharge between the upper positive charge center and the middle negative charge center, increasing the IC:CG ratio of a thunderstorm. Key Points The mean intra‐cloud:cloud‐to‐ground (IC:CG) ratio remains high in the Pre‐monsoon season compared to the Monsoon season over the Indian land mass The high cold cloud depth associated with stronger updrafts expand the mixed‐phase region and increases the IC flash rate and IC:CG ratio High flash rate associated with high IC flash occurrences is also responsible for a high IC:CG ratio

ObjectiveThe vast majority of the 300 000 pregnancy-related deaths every year occur in South Asia and sub-Saharan Africa. Increased access to quality antepartum and intrapartum care can reduce pregnancy-related morbidity and mortality worldwide. We used a population-based cross-sectional cohort design to: (1) examine the sociodemographic risk factors and structural barriers associated with pregnancy care-seeking and institutional delivery, and (2) investigate the influence of residential distance to the nearest primary health facility in a rural population in Mali.MethodsA baseline household survey of Malian women aged 15–49 years was conducted between December 2016 and January 2017, and those who delivereda baby in the 5 years preceding the survey were included. This study leverages the baseline survey data from a cluster-randomised controlled trial to conduct a secondary analysis. The outcomes were percentage of women who received any antenatal care (ANC) and institutional delivery; total number of ANC visits; four or more ANC visits; first ANC visit in the first trimester.ResultsOf the 8575 women in the study, two-thirds received any ANC in their last pregnancy, one in 10 had four or more ANC visits and among those that received any ANC, about one-quarter received it in the first trimester. For every kilometre increase in distance to the nearest facility, the likelihood of the outcomes reduced by 5 percentage points (0.95; 95% CI 0.91 to 0.98) for any ANC; 4 percentage points (0.96; 95% CI 0.94 to 0.98) for an additional ANC visit; 10 percentage points (0.90; 95% CI 0.86 to 0.95) for four or more ANC visits; 6 percentage points (0.94; 95% CI 0.94 to 0.98) for first ANC in the first trimester. In addition, there was a 35 percentage points (0.65; 95% CI 0.56 to 0.76) decrease in likelihood of institutional delivery if the residence was within 6.5 km to the nearest facility, beyond which there was no association with the place of delivery. We also found evidence of increase in likelihood of receiving any ANC care and its intensity increased with having some education or owning a business.ConclusionThe findings suggest that education, occupation and distance are important determinants of pregnancy and delivery care in a rural Malian context.Trial registration number NCT02694055.