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This study explores the correlation between heat exposure and perinatal depression in four low- and middle-income countries using a spatial, time-stratified case-crossover study. Cluster-level mental health data from the Demographic and Health Surveys (DHS) of Bangladesh, Lesotho, Mozambique, and Nepal was utilized. Availability of complete data on Patient Health Questionnaire 9 (PHQ-9) was an inclusion criterion. Heat exposure data was provided by the National Aeronautics and Space Administration (NASA). Spatial alignment between DHS clusters and meteorological points was achieved using bilinear interpolation. Heat exposure was defined as the daily maximum temperature exceeding the country-specific 50th percentile.

This study included 1836 perinatal women with depression. The pooled prevalence of perinatal depression was 27% (range: 19%–31%). Using distributed lag non-linear model (DLNM), in Bangladesh, lower maximum ambient temperatures (25th-centile) had 5.34 (4.28, 6.66) times higher cumulative odds for perinatal depression compared to the median temperature. In Lesotho, Mozambique, and Nepal, exposure to higher maximum ambient temperature (75th centile) had cumulative higher odds of 1.19 (0.98, 1.43), 2.51 (1.96, 3.20), and 9.41 (4.88, 18.1), respectively, in comparison to the median temperatures.The results suggest that heat exposure is correlated with perinatal depression, undermining the need for intersectoral responses that address environmental and healthcare system factors.

Background: Heat events have detrimental effects on maternal and neonatal health, increasing the risk for maternal complications, preterm birth, and neonatal mortality. There is an urgent need to explore pregnant women’s heat risk perceptions and adaptive measures. This study uses the Health Belief Model (HBM) to investigate pregnant women’s perception of heat risks and related prevention and mitigation strategies and identifies barriers to the adoption of such behaviours.

Methods: Using a concurrent cohort design, a baseline assessment was conducted through semi-structured interviews with 745 pregnant women in a heat prone district in Nepal. The interviews collected socio-demographic information and assessed the five HBM constructs of heat event risk perception using a Likert scale. Heat maps were created to visualise perceptions, and Principal Component Analysis was undertaken to create a nominal scale score for each construct. Crude and adjusted linear regressions were performed to assess associations of socio-demographic characteristics and HBM constructs.

Results: Among the pregnant women, 68% perceived dehydration due to heat as a risk to their pregnancy, and 37% perceived sunburn as a risk to foetal health. In terms of perceived benefit, 34% agreed that staying in an air-conditioned environment could reduce their chances of suffering during a heat event. Adjusted linear regression showed that wealthier women perceived higher susceptibility (adj. β = 0.14, 95% CI: 0.07, 0.21; p < 0.001) and severity (adj.β = 0.16, 95% CI: 0.08, 0.23; p < 0.001), and reported more barriers (adj. β = 0.16, 95%CI: 0.08, 0.23; p < 0.001). Conversely, urban residents had significantly lower perceived susceptibility (adjusted β = -0.32, 95% CI: -0.41, -0.24; p < 0.001) and severity (adj. β = -0.34, 95%CI: -0.42, -0.25; p < 0.001), fewer barriers (adj. β = -0.34, 95%CI: -0.42,-0.25; p < 0.001) towards heat events, and perceived more benefits (adj. β = 0.31, 95%CI: 0.22, 0.39; p < 0.001) from heat stress prevention and mitigation strategies compared to their rural counterparts.

Conclusion: To promote adaptive behaviours in this vulnerable population and strengthen maternal and foetal resilience against the growing threat of heat, we recommend focusing on closing knowledge, availability, and accessibility gaps. Maternal health considerations should be integrated into national climate change adaptation strategies to ensure that pregnant women are prioritised in policies and interventions. Statistics: IBM SPSS statistic software for Windows version 26 and Stata/SE 18.0 were used for this study.

Background: With a population of 275 million, Indonesia is the world’s fourth most populous country and has made considerable efforts to reduce its Total Fertility Rate from 5.6 in 1971 to a target of 2.1 by 2024. Women’s empowerment has been identified as a critical factor influencing fertility dynamics, gender equality, reproductive autonomy, and broader socioeconomic development. This study examines the association between four dimensions of women’s empowerment and three fertility-related outcomes among married women aged 22 years and older in Indonesia.

Methods: We used cross-sectional data from 34,017 married women participating in the 2017 Indonesia Demographic and Health Survey (IDHS). An outcome-wide analytical approach was adopted to explore three outcomes: total number of children ever born, ideal number of children, and fertility preference alignment, i.e. whether actual fertility matched stated preferences. Four empowerment domains were assessed: household decision-making, attitudes toward wife beating, attitudes toward refusing sex, and labour force participation. Stepwise multivariate Poisson regression modelling was applied, adjusting for key demographic and socioeconomic covariates.

Results: Our study found that the association between each type of women’s empowerment and fertility-related outcomes varied, reinforcing the notion that empowerment does not uniformly affect reproductive behaviour. Among the four empowerment indicators, rejecting all justifications for wife beating emerged as the most consistent and significant predictor across all fertility outcomes. It was association with fewer children ever born (β = 0.03), a lower ideal number of children (β = 0.04), and a higher likelihood of meeting fertility preferences (PR = 1.02). Attitudes toward refusing sex were also significantly associated with fewer children (β = 0.02) and lower fertility ideals (β = 0.07). However, participation in decision-making and labour force participation showed mixed or non-significant associations, indicating that different empowerment dimensions may influence reproductive behaviour in diverse ways.

Conclusions: Women’s empowerment - particularly in the domains of gender-based violence and sexual autonomy - is closely linked to fertility preferences and behaviours. The findings underscore that empowerment is a multidimensional construct, with varying influences across its domains. Strengthening women’s autonomy and addressing gender-based violence are essential steps toward enhancing reproductive rights and achieving Sustainable Development Goal 5 in Indonesia. Gender-sensitive data systems and interventions tailored to different aspects of empowerment are urgently needed.

The balls are rolling for climate change, with increasing vulnerability to women and children related to climate extreme events. Recent evidence has shown that acute exposure to heat wave during pregnancy can be associated with adverse health outcomes in childhood, with the risk being significantly higher among socially disadvantaged population, despite their lack of contribution to global carbon dioxide emissions and the rising global ambient temperature. This unequal impact requires utmost attention to develop tools, establish interdisciplinary teams, and to implement evidence-based interventions for the betterment of women and children in climate-vulnerable populations.

Aim: To study the development of overweight, obesity and underweight among 4-year-olds from 2007 to 2022, covering the COVID-19 pandemic period.

Methods: This repeated cross-sectional analysis was conducted in Västerbotten County, northern Sweden. It used data on weight, height, age and sex, which were collected when children attended their 4-year check-ups at any of the 38 Child Health Centres.

Results: The data comprised 42 614 4-year-old children (52% boys). From 2007 to 2022, the prevalence of overweight decreased from 13.4% to 9.5% in the boys and from 14.9% to 12.0% in the girls. The prevalence of obesity decreased from 3.7% to 1.8% in the boys and from 2.4% to 2.0% in the girls. During the first year of the COVID-19 pandemic, overweight and obesity temporarily increased for both the boys and girls, but the levels had returned to pre-pandemic levels by 2022. The prevalence of underweight increased among both boys and girls.

Conclusion: Our study documents a decline in the prevalence of overweight and obesity among Swedish 4-year-olds over more than a decade, except for a surge during the early COVID-19 pandemic. Additionally, we observed an unexpected increase in the prevalence of underweight during the same period.

Background: Obesity is a global public health issue with increasing prevalence and notable differences across population. Previous studies on body mass index (BMI) trends and inequalities have focused on overweight/obesity prevalence or average BMI changes, overlooking differences across the BMI distribution. This study investigates whether changes in BMI distribution are uniform or different over time and educational attainment.

Methods: This study is based on repeated cross-sectional surveys in Västerbotten, Sweden. Study participants were expectant parents visiting antenatal care (2010–2019) as part of the Salut Programme. During early pregnancy, 18,215 women and 17,890 male partners completed questionnaires. Quantile regression analyses were conducted to assess BMI distribution changes over time and by education for men and women.

Results: The BMI distribution for women showed a sharper increase in the upper tail in 2018/19 compared to 2010/11, whereas for men, the upper tail showed a gradual rise over years. Similar changes in BMI distributions were observed over time across both educational groups, with a notable increase in the higher BMI segments.

Conclusion: The study revealed weight gain inequalities, with higher BMI segments experiencing a disproportionately higher rise compared to others. Identifying high-risk groups in vulnerable settings will better equip decision-makers to design and implement targeted intervention strategies to reduce overweight and obesity.

Introduction: The 1.2 °C rise of global ambient temperature since the pre-industrial era has led to an increase the intensity and frequency of heatwaves. Given the heightened vulnerability of pregnant women to heat stress, there is an urgent need for tools which accurately assess the knowledge, risk, and perception of pregnant woman toward heatwaves, enabling effective policy actions. In this research, we developed and validated tools to evaluate pregnant women’s perceptions of heat wave risks and behaviors.

Method: We developed 50 items across seven constructs using the Health Belief Model, identified through a systematic literature review. The constructs comprised 8 Knowledge(K) items, 4 in Perceived Vulnerability (PV), 5 in Perceived Severity (PS), 6 in Perceived Benefit (PB), 4 in Perceived Barrier (PBa), 5 in Cue to Action(Cu) and 18 in Adaptation(A). Cognitive testing was performed with a separate group of pregnant women(n = 20). The tested tools were then administered to 120 pregnant women residing during the spring-summer 2023. Construct validation utilized exploratory factor analysis.

Results: The Principal Axis Factoring Method was employed in the EFA with oblimin rotation for 51 items, considering communality > 0.20, and aiming to extract three factors. Across the three factors with Cronbach’s alpha > 0.70, a total of 11 items were distributed. Factor 1 included Perceived Severity (PS1, PS2, PS3 and PS5); Factor 2 included Cue to Action (Cu1, Cu2, Cu3, and Cu4); and Factor 3 encompassed Perceived Vulnerability (PV1, PV2, PV4). Only two of the retained items had factor loadings > 0.50, namely PV4 and PS5. Consequently, the three constructs measuring Perceived Severity, Cues to Action, and Perceived Vulnerability using the HBM among pregnant women were deemed valid.

Conclusion: Our study has successfully validated a highly reliable tool which stands ready for application in assessing pregnant women’s risk perception regarding heatwaves.

Background: The ongoing increase in the mean global temperature due to human induced climate change, indicates that women and infants will have higher exposure to heat events leading to adverse outcomes. The study investigates the effect of non-optimal ambient temperature on the risk of preterm birth stratified by social position in Nepal.

Method: This is a space–time-stratified case-crossover design, based on hospital-registered perinatal data between 2017 and 2021 (n = 47,807). A daily count of pregnant women residing in seven heat-prone districts was extracted together with their social status (ethnicity), obstetric complication and gestation of birth. The daily count of events was matched with the daily ambient temperature of their residence using the NOAA spatial temperature recording. Ambient temperature exposure was analysed using conditional Poisson regression and distributed lag non-linear models.

Findings: In the general population, with exposure to ambient temperature at the 75th centile (28 °C) the cumulative risk of preterm birth over 28 days was 1·29 times higher (RR, 1·29; 95% CI; 1·09, 1·54) than at median temperature (24.1 °C), and even higher among the socially disadvantaged population. Cumulative risk of preterm birth to cold ambient temperature at the 1st centile was high but not significant. Exposure to ambient temperature at the 90th centile (32·5 °C) had the highest cumulative risk of preterm birth for pregnant women from socially disadvantaged populations (RR 1·81; 95% CI; 1·28, 2·55). The delayed effect after exposure to temperatures above the 75th percentile was more prolonged in the disadvantaged than the advantaged social group.

Conclusion: Although exposure to cold with certain effect on preterm births, heat (increase in ambient temperature) carries a risk of preterm birth in Nepal, and is more profound among socially disadvantaged populations.

Background: Social-emotional difficulties in early childhood are associated with a range of outcomes across the life course and are related to socioeconomic factors. The aim of this study was to examine intersectional inequalities in social-emotional problems in preschool children relating to their parents’ income, education and country of birth in addition to investigating the public health implications.

Methods: This population-based study with a repeated cross-sectional design in the Västerbotten County of Sweden used the Ages and Stages Questionnaires: Social-Emotional (ASQ:SE) for children aged 3 in child health care services over the years of 2014-2018 and socio-economic information from national population registers. The effective sample of 8,823 individuals was analyzed using additive binomial regression in combination with an analysis of individual heterogeneity and discriminatory accuracy (AIHDA) approach to estimate risk differences for social-emotional problems across 27 intersectional groups and discriminatory accuracy.

Results: Average risk differences generally increased in the groups where multiple dimensions of social inequality intersected, with risk differences as high as 18% (95% CI 8 to 28%) and 25% (95% CI 14 to 37%) compared to the most advantaged category. The discriminatory accuracy of all three included regression models was estimated as moderate, but improved in a slight but statistically significant way with the addition of social inequalities.

Conclusions: This study increases our understanding of intersectional and social inequalities in social-emotional problems in preschool children. It supports the need for universal public health policies in addition to policies targeting more vulnerable groups when addressing this issue, consistent with the concept of proportionate universalism. An intersectional research perspective including discriminatory accuracy could increase our knowledge of health inequities and improve public health effectiveness.

Background: Trends in overweight and obesity among expectant parents can provide useful information about the family environment in which children will grow up and about possible social inequalities that may be passed on to them. Therefore, we aimed to assess whether the prevalence of underweight, overweight and obesity changed over time in pre-pregnant women and their male partners in northern Sweden, and if there were any educational inequalities.

Methods: This study is based on cross-sectional data from a repeated survey of the population in Västerbotten, Sweden. The study population included 18,568 pregnant women and 18,110 male partners during the period 2010–2019. Multinomial logistic regression models were fitted separately for pregnant women and male partners to assess whether the prevalence of age-adjusted underweight, normal weight, overweight and obesity had evolved between 2010 and 2019, and whether trends differed by educational level.

Results: Among women, obesity prevalence increased from 9.4% in 2010 to 11.7% in 2019. Among men, it went from 8.9 to 12.8%. Educational inequalities were sustained across the study period. In 2019, the prevalence of obesity was 7.8 percentage points (pp) (CI = 4.4–11.3) higher among women with low compared to high education. The corresponding figure for men was 6.4 pp (CI = 3.3–9.6).

Conclusions: It is not obvious that the prevalence of obesity among parents-to-be will decrease under current dispositions. Public health policies and practice should therefore be strengthened.