A Lancet Commission on 70 years of women's reproductive, maternal, newborn, child, and adolescent health in China

Non-pharmacological interventions involving traditional Chinese medicine for assisted reproductive technology: A group consensus

Background

Assisted reproductive technologies (ART) are being increasingly utilized for mitigating fertility problems. Nonpharmacological interventions of traditional Chinese medicine (TCM) are widely used as an adjunct to ART, which may improve the rate of pregnancy. Currently, no standard treatment guidelines or consensus are available for non-pharmacological interventions of TCM for patients undergoing ART. The aim of this study was to establish a consensus on the use of non-pharmacological TCM interventions during the ART treatment cycle.

Methods

This study utilized existing data and developed a consensus among a panel of experts on non-pharmacological interventions of TCM for ART. Through face-to-face or online contact, the listed recommendations were revised one by one, and a consensus was reached when >70 % of the experts agreed with the recommendation. The writing group of the expert panel then created the first draft of the expert consensus based on the discussion in the first round. The second round was held to reach a consensus on content improvements based on the opinions of the experts in the previous round.

Results

After the literature search, a total of 873 related articles were retrieved, and 59 studies were ultimately included according to the inclusion and exclusion criteria. After two rounds of the survey, a total of 24 experts from 18 Chinese provinces across China and five international experts from the United Kingdom, Korea, and Serbia provided vital insight and support for the formulation of this consensus. The consensus outlines eight non-pharmacological interventions for seven different stages of the ART cycle and three major complications during ART, involving 23 items of clinical practice recommendations.

Conclusions

Expert consensus provides a foundation for integrating non-pharmacological TCM interventions into clinical practice during ART. As more high-quality, large-scale, multicenter clinical trials are conducted, these recommendations may be refined and updated to better inform clinical guidelines and improve patient outcomes in ART.

A study on equity in the allocation of health human resources in maternal and child health institutions in China (2002-2021) and forecasting the five-year future trends (2022-2026)

BACKGROUND

Strengthening health systems and ensuring equity and access to human resources can significantly reduce maternal and child mortality and improve maternal and child health outcomes. This mixed-methods study aimed at the quantity, quality, and equity of the allocation of human resources for health (HRH) in Chinese maternal and child healthcare institutions from 2002 to 2021 while providing a reference for optimally allocating HRH in the new era.

METHODS

Relying on health-related data obtained from statistical yearbooks in 2003-2022, the study analysed the allocation status using descriptive statistics, examined the allocation equity with the Gini coefficient and the Health resource agglomeration degree/Health resource population agglomeration degree (HRAD/HRPAD). Finally, the study predicted the future allocation trend by compiling a grey prediction model GM (1,1).

RESULTS

HRH quantity in Chinese maternal and child healthcare institutions experienced steady growth. However, the composition of educational background and professional titles was unreasonable. The quality structure needs to be further optimized. The equity of demographic allocation (Gini < 0.2) was superior to the geographic allocation (Gini = 0.631-0.678), with significant regional differences. The HRAD values of HRH in different regions were as follows: eastern region (3.50-3.70) > central region (1.69-1.92) > western region (0.36-0.44); HRPAD (2021): western region (1.150) > central region (0.991) > eastern region (0.912). The equity of sparsely populated regions was superior to that of densely populated regions. The HRH future allocation trend is positive.

CONCLUSIONS

Emphasis should be placed on the status quo of unreasonable allocation and unbalanced distribution. Careful consideration must be given to factors like service population, service radius, economic development, and population mobility while considering demographic and geographic equity to promote the reasonable allocation and full utilisation of HRH.

Association between epigenome-wide DNA methylation changes and early neurodevelopment in preschool children: Evidence from a former impoverished county in Central China

BACKGROUND

Existing epigenome-wide association studies (EWAS) investigating the association between DNA methylation (DNAm) and child neurodevelopment have been predominantly conducted within Western populations, and yielded inconsistent results, leading to a significant gap within non-Western setting, particularly in resource-limited rural areas of Central China.

OBJECTIVES

To investigate the association between altered epigenome-wide DNAm and neurodevelopment in preschool children from resource-limited rural areas of Central China.

METHODS

This case-control study involved 64 preschoolers. We assessed children's neurodevelopment using the Gesell Developmental Diagnostic Scale. The neurodevelopmental potential was expressed as a global developmental quotient (DQ) score. We conducted an EWAS with an Illumina Infinium MethylationEPIC v1.0 BeadChip array, using blood samples from 32 suspected developmental delay children (DQ scores < 85) and 32 controls (DQ scores ≥ 85). Differentially methylated probes (DMPs) and differentially methylated regions (DMRs) between the suspected developmental delay and control groups were analyzed. Multivariate linear regression models were used to evaluate the association between global DQ scores and DNAm. Functional enrichment analyses were conducted using Gene Ontology (GO) and the Kyoto Encyclopedia of Genes and Genomes (KEGG). The BECon tool was utilized to estimate the concordance of CpGs between blood and the human brain.

RESULTS

A total of 66 DMRs (PFDR < 0.05) were identified between the two groups, but no DMPs were found. After FDR correction, 844 methylated CpG sites exhibited significant associations with the global DQ scores in children. Genes annotated by methylated CpGs were mainly enriched in the "oxytocin signaling pathway", "mTOR signaling pathway", and "thyroid hormone signaling pathway". They were also involved in the "regulation of cell development", "cell-cell junction", and "ATPase activity". Among the top 20 CpGs, nine global DQ scores related-CpGs had blood-brain DNA methylation correlations, and six CpGs among them had an absolute Spearman correlation coefficient bigger than 0.2.

CONCLUSIONS

Preschoolers from a former impoverished county exhibited epigenome-wide DNAm changes strongly linked to early neurodevelopment. This study enhances our understanding of the epigenetic landscape associated with early neurodevelopment, and suggests the potential for developmenting epigenetic biomarkers that could facilitate the early identification of children at a higher risk of compromised neurodevelopment, as well as holding implication to inform novel interventions, especially in underprivileged regions.

Nature-based mind-body intervention for test anxiety in adolescents: a feasibility study

Introduction

Traditional interventions for test anxiety often fall short of addressing the specific needs of adolescents and educational institutions due to issues of stigmatization and professionalization. In contrast, nature-based interventions (NBIs) have gained traction for their potential to enhance mental health, as they are generally accepted and cost-effective, thereby offering a promising alternative for alleviating test anxiety.

Methods

This study seeks to investigate the feasibility of a nature-based mind- body intervention (NMI) designed to reduce test anxiety among adolescents by integrating elements of NBIs and mind-body therapies (MBTs).

Results

The findings suggest that NMI can significantly diminish excessive test anxiety and academic stress, along with alleviating symptoms of general anxiety and depression.

Discussion

This approach presents a low-stigma, low-cost strategy for managing test anxiety in adolescents and offers valuable insights for mental health policymakers. Furthermore, it may enhance academic performance and broaden educational access for disadvantaged populations in developing countries.

Willingness to bear the first child among the Chinese childless population: a national survey study

BACKGROUND

Having a first child is a contributing factor to having a second or third child; however, current research focuses on second and third children, and the present study aims to investigate the intention to have a first child and its main influencing factors among the childless population aged 15-49 in China, as well as analysing the influencing factors by age group.

METHOD

As part of the 'Survey on the Psychology and Behaviour of Chinese Residents', this survey was conducted on 6941 residents aged 15-49 in 32 provinces across China. The survey was conducted from 20 June to 31 August 2022.

RESULT

Out of 6941 respondents, the mean score of willingness to have a first child (score range: 0-100) was 42.51. 17.33% of the respondents had no willingness to have a child (0), while 9.54% had a high willingness to have a child (100). Intention to have a first child seems to peak in the age group 30-34 years (p < 0.0001). Being male (p < 0.000, OR = 0.178), having siblings (p1 < 0.035, OR1 = 1.324; p2 < 0.000, OR2 = 1.995) and good family communication (p < 0.003, OR = 1.023), and high self-efficacy (p = 0.001, OR = 1.558) were associated with higher fertility intentions. Influential factors in the lower age group (15-24 years) were mainly related to family and social support, in the 25-29 years age group they were more related to personal, family and social, while in the 30-39 years age group they were related to economic stability such as property and marital status.

CONCLUSIONS

The willingness to have a child is at a low to medium level among those of childbearing age who have not had children in China. There is a need to adopt a staggered policy for the younger age group to reduce perceived economic pressure, reduce occupational pressure on the age group, and increase childcare and occupational fertility friendly environments. In addition, there is a need for multisectoral economic compensation and educational district planning to alleviate the "don't want to save" and solve the "don't dare to give birth" problem. People who have had one child are more likely to want to have a second child, so the government and society need to do more to support the desire to have a child, thereby increasing the national fertility rate.

Mendelian randomization study reveals causal associations between plasma metabolites, immune cell phenotypes, and ovarian hyperstimulation syndrome

In this study, we employed Mendelian randomization (MR) analysis to explore the causal relationships between immune cell phenotypes, plasma metabolites, and ovarian hyperstimulation syndrome (OHSS). Through the analysis of 731 immune cell phenotypes and 1400 plasma metabolites, we identified 32 immune cell phenotypes that are causally related to OHSS, with 18 phenotypes identified as protective and 14 as risk factors. Notably, the TCRgd AC phenotype was the most significant risk factor associated with OHSS. Our findings also revealed that among the 10 plasma metabolites causally linked to OHSS, three acted as protective factors, while seven were identified as risk factors. The Alpha-ketoglutarate to alanine ratio stood out as the most significant protective metabolite. Further investigation established a causal link between the EM DN (CD4-CD8-) AC immune cell phenotype and the Alpha-ketoglutarate to alanine ratio. Reverse MR analysis indicated that OHSS influences the expression of HLA-DR on myeloid OC cells. Mediation analysis suggested a non-significant mediation effect of the Alpha-ketoglutarate to alanine ratio in the pathway from immune cells to OHSS, accounting for -8.68 % of the total effect. Collectively, our results underscore the role of specific immune cell phenotypes and plasma metabolites in the pathogenesis of OHSS, revealing potential targets for developing interventions aimed at reducing the risk of OHSS.

Association between snoring and in vitro fertilization outcomes among infertile women

OBJECTIVE

To explore the association between snoring and in vitro fertilization (IVF) outcomes in infertile women, focusing on embryological parameters and pregnancy outcomes.

METHODS

This study represents a secondary analysis of the PKU-ERC study (NCT05373290). We included a cohort of 632 infertile women, aged 24-45 years, undergoing their first IVF treatment from the Reproductive Center of Peking University People's Hospital between January 2018 and November 2021. All patients with the assistance of their husbands completed a questionnaire including snoring status and frequency before ovulation induction (OI). Embryology parameters were evaluated during the first IVF cycle, and pregnancy outcomes were assessed through follow-up.

RESULTS

Among 579 subjects, 33.5 % reported occasional snoring, and 8.8 % reported frequent snoring. After adjusting for confounding factors, multiple linear regression model showed that frequent snorers had higher β-coefficients for the number of blastocysts and available embryos compared to non-snorers (both P < 0.05). Among 551 subjects who completed the first embryo transfer, 6.2 % suffered biochemical pregnancy loss. Frequent snorers were more likely to experience biochemical pregnancy loss compared to non-snorers and occasional snorers (5.7 % vs. 14.6 %, P = 0.033; 4.8 % vs. 14.6 %, P = 0.026). Multivariable analysis revealed that frequent snoring was a risk factor for biochemical pregnancy loss (adjusted odds ratio, aOR: 2.95, 95 % confidence interval, CI: 1.06-8.24, P = 0.039), while high-density lipoprotein cholesterol (HDL-C) level was a protective factor after IVF (aOR: 0.21, 95 % CI: 0.05-0.92, P = 0.038).

CONCLUSION

Frequent snoring is associated with a decreased number of available oocytes and an increased risk of biochemical pregnancy loss following IVF. However, the potential influence of undiagnosed obstructive sleep apnea (OSA) should be considered when interpreting these results.

A nomogram prediction model for embryo implantation outcomes based on the cervical microbiota of the infertile patients during IVF-FET

The microbiota of the female genital tract is crucial for reproductive health. This study aims to investigate the impact of the lower genital tract microbiota on in vitro fertilization and frozen embryo transfer (IVF-FET) outcomes. This study included 131 women aged 20-35 years who underwent their first or second IVF-FET cycle with no obvious unfavorable factors for implantation. Cervical microbiota samples were collected on the embryo transfer day and analyzed using 16S rDNA full-length sequencing. Clinical outcomes were followed up for analysis. Clinical pregnancy (CP) was achieved in 84 patients, and 47 patients experienced non-pregnancy (NP). The cervical microbiota diversity between NP and CP groups showed no significant differences, but some genera such as Halomonas (P = 0.018), Klebsiella (P = 0.039), Atopobium (P = 0.016), and Ligilactobacillus (P = 0.021) were obviously different between the two groups. Notably, there was no significant difference in the abundance of Lactobacillus between the two groups. A nomogram prediction model was developed using the random forest algorithm and logistic regression, including the classification of Halomonas, Atopobium, and Veillonella, as well as the relative abundance of Lactobacillus, to identify high-risk patients with embryo implantation failure. Both internal (area under the curve [AUC] = 0.718, 95% confidence interval [CI]: 0.628-0.807, P < 0.001) and external validation (AUC = 0.654, 95% CI: 0.553-0.755, P = 0.037) of the model performed well. In conclusion, this study established a correlation between cervical microbiota and embryo implantation failure in infertile women undergoing IVF-FET and developed a prediction model that could help in early identification of patients at high risk of implantation failure.IMPORTANCEThis study investigated the potential role of abnormal cervical microbiota in the pathology of implantation failure after in vitro fertilization and frozen embryo transfer (IVF-FET) treatment. Despite nearly half a century of advancements in assisted reproductive technology (ART), the implantation rate of high-quality embryos still hovered around 50%. Moreover, unexplained recurrent implantation failure (RIF) remains a significant challenge in ART. To our knowledge, we first discovered a prediction model for embryo implantation failure, identifying Halomonas and Veillonella as significantly adverse factors for embryo implantation. Despite some limitations, the internal and external validation of the model could bode well for its clinical application prospect. The insights gained from this study pave the way for intervention in the genital tract microbiota prior to IVF-FET, particularly in patients with RIF and RSA.

Prevalence and impact of parental co-morbid anxiety and depression during the first 2 years postpartum in China

BACKGROUND

Parental postpartum co-morbid anxiety and depression negatively impact personal well-being, family dynamics, and child developmental outcomes. This study investigates the prevalence of co-morbid anxiety and depression in both mothers and fathers during the first 2 years postpartum in China, and to explore its associations with parental family support, maternal health-related quality of life (HRQoL), and child development.

METHODS

This cross-sectional study was conducted in China, involving families with children aged 0-2 years who participated in community child health care. Data were collected via questionnaires administered to parents by pediatricians and nurses at community health service (CHS) centers. Path analysis was utilized to test the hypothesized model, which links parental co-morbid anxiety and depression to parental family support, maternal HRQoL, and child development.

RESULTS

A total of 2073 pairs of both parents who completed the survey were included in the final analyses. The prevalence of maternal and paternal co-morbid anxiety and depression, was 5.7 % and 4.4 %, respectively. Among mothers, the prevalence ranged from 4.3 % to 6.5 % within the first 6 months, and 7.9 % in the second year. After adjusting for covariates, severe family dysfunction was significantly associated with maternal and paternal co-morbid anxiety and depression. The path analysis showed that maternal co-morbid anxiety and depression were directly associated with child development and maternal HRQoL.

CONCLUSIONS

These findings highlight the importance of prioritizing family support, addressing both depression and anxiety, involving both parents and extending support beyond the first year postpartum.

Association between imprinting disorders and assisted reproductive technologies

Aberrant expression of imprinted genes results in imprinting disorders (IDs). Differentially methylated regions (DMRs) reveal parental-origin-specific DNA methylation on CpGs and regulate the expression of the imprinted genes. One etiology of IDs is epimutation (epi-IDs) induced by some error in the establishment or maintenance of methylation imprint during the processes of gametogenesis, fertilization, or early embryonic development. Therefore, it has been a concern that assisted reproductive technologies (ART) increase the risk for the development of IDs, particularly epi-IDs. We review the effects of ART on DNA methylation of the genome, including DMRs in gametes, embryos, and offspring, and the risk of advanced parental age (a confounding factor of ART) and infertility itself for the development of IDs, particularly epi-IDs.

Perinatal and Neonatal Outcomes Following In Vitro Fertilisation in Poor Ovarian Responders: A Prospective Single-Centre Observational Study

OBJECTIVE

To compare the risk of adverse perinatal and neonatal outcomes between individuals with poor ovarian response (POR) and those with normal ovarian response (NOR) following in vitro fertilisation (IVF).

DESIGN

A prospective single-centre observational study.

SETTING

University hospital.

POPULATION

Overall, 1663 patients who underwent embryo transfer cycles between June 2017 and August 2019 were evaluated.

METHODS

The patients were divided into the POR and NOR groups based on the Bologna diagnostic criteria. The risk of perinatal and neonatal complications was then compared between groups with adjustment made for confounding factors.

MAIN OUTCOME MEASURES

The risk of perinatal and neonatal complications between the POR and NOR groups.

RESULTS

Compared with the NOR group, the POR group had poor pregnancy outcomes but comparable overall risks of poor perinatal and neonatal outcomes. The overall incidence rate of complications was 25.42% and 25.30% in the POR and NOR groups respectively [risk ratio (RR): 1.01; 95% confidence interval (CI): 0.63-1.59]. In subgroup analysis of singleton live births, the overall risk of total complications was higher in the POR group than in the NOR group (24.07% vs. 15.21%; RR: 1.77; 95% CI: 1.04-3.00); however, the risks became comparable between them after logistic regression adjustment.

CONCLUSIONS

The overall risk of perinatal and neonatal complications among singleton live births was higher in patients with POR than in those with NOR; however, the risks became similar after logistic regression adjustment. Our findings provide overall comforting evidence for POR patients with IVF treatment.

Comprehensive Health Assessment of School-Age Children Conceived by Assisted Reproductive Technology: A Prospective Cohort Follow-Up Study

OBJECTIVE

To assess the comprehensive health status of school-age children conceived through assisted reproductive technology (ART) compared to that of those conceived naturally.

DESIGN

A prospective cohort study of children conceived through ART.

SETTING

First Affiliated Hospital of Nanjing Medical University, China.

POPULATION SAMPLE

One hundred school-age children were enrolled and followed up (51 conceived via ART and 49 naturally conceived (controls)).

METHODS

A comprehensive health status assessment was performed in children aged 6-12 years, including anthropometric measurements, glucose-lipid metabolism, echocardiography, intelligence, behaviour, vision and hearing. Multivariate regression models were used to adjust for sociodemographic and perinatal covariates.

MAIN OUTCOME MEASURES

Comprehensive health status of children conceived via ART.

RESULTS

Children conceived by ART had similar height, weight, blood pressure, blood glucose and lipid profiles compared to the controls. Echocardiography showed similar cardiac geometric morphology and left/right ventricular diastolic-systolic function between the two groups. ART children had lower carotid intima-media thickness than controls (0.52 ± 0.11 vs. 0.58 ± 0.11). Visual acuity, hearing and intellectual and behavioural assessments were similar. An alternating covering test for the eyes showed a higher incidence of abnormal eye movement in the ART group than in the control group (87.76% vs. 68.89%).

CONCLUSIONS

The similar overall health status of ART- and naturally conceived children is reassuring for those receiving ART. However, our study shows a possible increase in the incidence of latent exotropia among ART children. Long-term follow-up is warranted to assess the overall health status associated with ART throughout the lifespan.

Essential Regulation of Spermatogonial Stem Cell Fate Decisions and Male Fertility by APBB1 via Interaction with KAT5 and GDF15 in Humans and Mice

Spermatogonial stem cells (SSCs) are essential for initiating and maintaining normal spermatogenesis, and notably, they have important applications in both reproduction and regenerative medicine. Nevertheless, the molecular mechanisms controlling the fate determinations of human SSCs remain elusive. In this study, we identified a selective expression of APBB1 in dormant human SSCs. We demonstrated for the first time that APBB1 interacted with KAT5, which led to the suppression of GDF15 expression and consequent inhibition of human SSC proliferation. Intriguingly, Apbb1-/- mice assumed the disrupted spermatogenesis and markedly reduced fertility. SSC transplantation assays revealed that Apbb1 silencing enhanced SSC colonization and impeded their differentiation, which resulted in the impaired spermatogenesis. Notably, 4 deleterious APBB1 mutation sites were identified in 2,047 patients with non-obstructive azoospermia (NOA), and patients with the c.1940C>G mutation had a similar testicular phenotype with Apbb1-/- mice. Additionally, we observed lower expression levels of APBB1 in NOA patients with spermatogenic arrest than in obstructive azoospermia patients with normal spermatogenesis. Collectively, our findings highlight an essential role of APBB1/KAT5/GDF15 in governing human SSC fate decisions and maintaining normal spermatogenesis and underscore them as therapeutic targets for treating male infertility.

Type D personality, and quality of life in couples undergoing in vitro fertilization treatment:the role of dyadic coping

There is limited research on the relationship between type D personality, dyadic coping, and quality of life (QoL), with most studies focusing on the individual perspective rather than the dyadic perspective. Additionally, evidence for the systemic-transaction model (STM) is limited, and research on infertile couples is scarce. This study investigated the relationship between type D personality and QoL in couples with infertility through the mediation of dyadic coping mechanisms. The present descriptive cross-sectional study recruited 452 infertile couples (N = 904) receiving in vitro fertilization (IVF) treatment from a tertiary hospital in Hefei, China, between January and May of 2022. Information on sociodemographic and clinical characteristics, type D personality, dyadic coping, and the QoL of the dyads was collected. The dyadic data were examined using the Actor-Partner Interdependence Mediation Model approach (APIMeM). The results suggest that type D personality, dyadic coping, and QoL in infertile couples have Actor-Partner Interdependence effects. The negative impact of Type D personality can spill over from individuals to the dyadic domain of couples. In the later stage, the negative impact of type D personality on QoL can be reduced by enhancing the dyadic coping level of both members of the infertile couple.

The Effects of Online Cognitive Behavioral Therapy on Postpartum Depression: A Systematic Review and Meta-Analysis

BACKGROUND/OBJECTIVES

Postpartum depression seriously affects the safety and health of mothers and children. Online cognitive behavioral therapy is considered to be a promising treatment; however, whether it is effective at improving postpartum depression is inconsistent and the specific intervention measures are not the same. The objectives of this study were to comprehensively review the effects of online cognitive behavioral therapy on postpartum depression and further explore the specific intervention measures.

METHODS

A literature search was conducted using thirteen electronic databases and two clinical trial registries from the establishment of the databases to 31 December 2023. The study selection and data extraction were independently performed by two researchers. The latest Cochrane Risk of Bias tool was selected to evaluate the quality of the included studies. Data were analyzed using Review Manager 5.4, and the certainty of the evidence was evaluated using the online GRADEpro tool. Eighteen studies involving 3689 women were included.

RESULTS

The results showed that online cognitive behavioral therapy was effective at improving postpartum depression. A subgroup analysis showed that the duration of online cognitive behavioral therapy with total intervention was 9 weeks and above, the total intervention number was 12 times or fewer, and using a website or Zoom online conference room as the intervention platform could more significantly improve postpartum depression. In particular, providing professional guidance could be more effective.

CONCLUSIONS

In summary, online cognitive behavioral therapy was effective for postpartum depression. Furthermore, this study found out how specific intervention measures of online cognitive behavioral therapy could be more effective. Finally, nurses can participate in the therapy to improve access to evidence-based treatment.

Early Origins of Asthma and Allergies: Clues From Studies in China

Asthma and allergies have emerged as some of the most common chronic diseases, particularly in developed countries. Epidemiological studies have consistently demonstrated that children growing up in farming/rural environments are less likely to develop these conditions. Over the past three decades, China has experienced unprecedented economic development and urbanisation, accompanied by a rapid rise in the prevalence of allergic disorders. Despite the substantial number of affected individuals, allergy management in China remains inconsistent and often inadequate, compounded by variations in diagnostic criteria and limited healthcare access in less developed regions. Furthermore, the vast population, regional disparities, and methodological inconsistencies in data collection have hindered the acquisition of comprehensive, large-scale epidemiological data. This review examines the factors contributing to asthma and allergies from their early origins, focusing on modifiable factors from a specific perspective of China. Factors related to traditional lifestyle, such as early-life exposure to agricultural farming and poultry, diverse dietary patterns, and early introduction of allergenic foods, appear to offer protection against allergies. Conversely, exposure to open-fire cooking, incense burning, tobacco smoke, as well as early-life antibiotic use and perinatal factors like Caesarean section delivery and prematurity may represent potential risks. A clear understanding of the role of these factors would pave the way for developing effective interventions to mitigate the substantial health and socioeconomic burdens associated with asthma and allergies.

Perceptions of Health System Professionals on Integrating Fertility Care into Reproductive Health Policy in China

Background: Infertility is a neglected global public health issue, particularly in the Global South, where policy interventions and research remain limited. In China, rising public demand and declining birth rates have renewed interest in integrating fertility care into reproductive health policies, though operational challenges and systemic gaps persist. Objectives: This study aims to explore the perceptions of health system professionals regarding the opportunities and barriers to integrating fertility care into China's reproductive health policy. Methods: This qualitative study involved 31 interviewees, including health system leaders (n = 5), health practitioners (n = 21), and civil society advocates (n = 5), from November 2023 to October 2024. The transcribed and anonymized data were thematically analyzed using MAXQDA version 2020, guided by the World Health Organization's health system building blocks framework. Results: Interviewees reported that integrating fertility care has markedly improved service accessibility and quality, driven by strong governmental leadership. They identified opportunities for further progress through focused government initiatives, expanded public-private partnerships, and the adoption of international best practices, while also noting obstacles such as operational challenges, systemic policy gaps, uneven resource distribution, and persistent cultural stigma. Conclusions: The findings underscore the need for a robust national policy framework, sustainable funding mechanisms, and enhanced primary healthcare capabilities, along with cultural advocacy and awareness campaigns to reduce stigma and foster equitable access.

Children-specific environmental protection strategies are needed in China

China, home to over 250 million children, has witnessed remarkable economic development in recent decades, successfully addressing many issues related to basic hygiene and sanitation in children, thereby altering the childhood disease spectrum. However, the emergence of environment-related disorders among children has become a significant concern. Despite the rapid accumulation of scientific knowledge on the adverse effects of environmental pollution on child health, the availability of children-specific protective strategies and actions remains alarmingly low. This commentary synthesizes the information and viewpoints presented and discussed by experts at the International Forum on Children's Environmental Health in China. It summarizes the strategies and actions proposed to reduce adverse environmental exposure and protect children's short- and long-term health and a call for more children-centered evidence-action transformation. The following four specific actions were proposed: (1) strengthen health education in parents, caregivers, and children, and personal protection for children; (2) monitor child exposure and environment-related health status; (3) set up child-specific interventions and regulations; and (4) conduct more research on environment exposures and child health.

Translation and Psychometric Evaluation of the Chinese Version of the Gynecological Cancers Awareness Scale

OBJECTIVE

To translate the Gynecological Cancers Awareness Scale (GCAS) into Chinese and validate its reliability and validity in assessing awareness of gynecologic cancer prevention and treatment among women in China.

DESIGN

Descriptive psychometric study.

SETTING

People's Republic of China.

PARTICIPANTS

Adult women who lived in China (N = 434).

METHODS

We conducted the research in two phases. Phase 1 involved the translation and adaptation of the GCAS into Chinese. Phase 2 involved administering a cross-sectional survey using an electronic questionnaire.

RESULTS

The translated GCAS had a Cronbach's α of .92, an intraclass correlation coefficient of 0.83, and an adequate content validity index. We used exploratory factor analysis to identify four factors that explained 64.01% of the variance and found that most fit indices in the confirmatory factor analysis were acceptable.

CONCLUSION

Among our participants, the Chinese version of the GCAS was a valid and reliable tool for assessing awareness of gynecologic cancer risk, prevention, and treatment among women in China.

Trps1 regulates mouse zygotic genome activation and preimplantation embryo development via the PDE4D/AKT/CREB signaling pathway

Despite zygotic genome activation (ZGA) is crucial for early embryonic development, its regulatory mechanism is still unclear in mammals. In the present study, we demonstrate that TRPS1, a maternal factor, plays an essential role in mouse early embryogenesis by regulating the transition from 2-cell to 4-cell embryos during preimplantation development. The absence of Trps1 could leads to impaired ZGA through AKT/CREB signaling pathway. Furthermore, our findings suggest that TRPS1 may modulate the transcription of Pde4d to influence AKT and CREB phosphorylation. Interestingly, compared to Trps1 knockdown alone, co-injection of Trps1 siRNA and Pde4d mRNA significantly enhances the development rate of 4-cell embryos. Collectively, these results indicate a negative involvement of Trps1 in mouse preimplantation embryo development by targeting the PDE4D/AKT/CREB pathway to regulate ZGA.

Epidemiological characteristics of infertility, 1990-2021, and 15-year forecasts: an analysis based on the global burden of disease study 2021

BACKGROUND

Infertility, defined as the inability to achieve pregnancy after 1 year of regular unprotected intercourse, affects approximately 186 million people globally, with consistent prevalence across different income levels. Globally, the rising infertility rates are impacting population growth and individual quality of life. Infertility is not just a personal issue but also a public health concern, with social and economic implications, including stigmatization, marital discord, and mental strain. The COVID-19 pandemic has further exacerbated mental health issues among individuals with infertility, underscoring the need for research into the mental health impacts and access to fertility services. Economically, infertility poses a significant financial burden, especially in regions where Assisted Reproductive Technology (ART) costs can be up to 200% of the GDP per capita. Understanding the complexities and spread of infertility is essential for guiding policy decisions and program rollouts, with studies analyzing infertility issues based on the Global Burden of Disease (GBD) database.

METHODS

The study leverages data from the GBD 2021, encompassing 371 conditions or injuries and 88 risk factors across 204 nations. It examines prevalence, disability-adjusted life years (DALYs), age-standardized prevalence rate (ASPR), and age-standardized DALYs rate (ASDR) for infertility, categorized by sex, age, regions, and nations. The Social and Demographic Index (SDI), reflecting socio-economic levels, is used to analyze its correlation with infertility burden. The study employs decomposition analysis and frontier analysis methods to assess changes in infertility prevalence and DALYs, and Spearman's rank correlation coefficient to confirm relationships between age-standardized rates (ASRs) and SDI. The estimated annual percentage change (EAPC) of rates, with 95% confidence intervals (CIs), was calculated.

RESULTS

In 2021, it was calculated that the global ASPR for male infertility stood at 1354.76 cases per 100,000 individuals, with a 95% Uncertainty Interval ranging from 802.12 to 2174.77 cases per 100,000 individuals. For female infertility, the ASPR was recorded at 2764.62 per 100,000 individuals (95% UI: 1476.33-4862.57 per 100,000 individuals). Between 1990 and 2021, the EAPC in ASPR was observed to be 0.5% (95% CI 0.36-0.64) for males and 0.7% (95% CI 0.53-0.87) for females. In that same year, the global ASDR attributed to male infertility was 7.84 per 100,000 individuals (95% UI: 2.85-18.56 per 100,000 individuals), while for female infertility, it amounted to 15.12 per 100,000 individuals (95% UI: 5.35-36.88 per 100,000 individuals). The EAPC for ASDR linked to male and female infertility from 1990 to 2021 was assessed at 0.51% (95% CI 0.38-0.65) and 0.71% (95% CI 0.54-0.88), respectively. Among the 204 countries and territories in 2021, India ranked first in both the prevalence of cases and DALYs associated with male and female infertility, followed by China and Indonesia. Additionally, the investigation revealed a slight negative correlation between the ASPR and ASDR of infertility and the SDI. Decomposition analysis indicated that approximately 65% of the rise in the global burden of infertility could be attributed to population growth. Frontier analysis suggested that the variations in efficiency frontiers across specific SDI levels diminish as the SDI increases. Looking forward, the study projects a global rise in ASPR and ASDR for infertility between 2022 and 2036.

CONCLUSIONS

The worldwide prevalence of infertility has substantially increased between 1990 and 2021, largely as a result of population growth. This trend highlights the pressing necessity for better strategies concerning prevention, diagnosis, and treatment, particularly in low and middle-income nations. Strengthening healthcare infrastructures, enhancing access to high-quality medical services, and raising awareness about infertility are vital measures to tackle this issue. The results of the study offer essential information to help policymakers and health officials formulate targeted strategies for the prevention and management of infertility.

Assessment of patient preferences for assisted reproductive technology in China: a discrete choice experiment

OBJECTIVES

Given China's low fertility rate, assisted reproductive technology (ART) can be used assist infertile patients in having children. This study aimed to analyse patients' preferences for ART and to determine the relative importance (RI) and willingness to pay (WTP) of key attributes.

DESIGN

We identified six attributes of ART and used a D-efficient design to generate choice sets for conducting a discrete choice experiment. Patients were asked to choose between two scenarios that differed in participation in treatment decision-making (TDM), clinical pregnancy rate, live birth rate, risk of maternal and neonatal complications, and out-of-pocket cost.

SETTING

Jiangsu province, China. The anonymous survey was carried out between December 2022 and February 2023.

PARTICIPANTS

Female patients aged 20-45 years, with low fertility or experience of ART treatment. We recruited 465 participants.

OUTCOMES MEASURES

Patient-reported preferences for each attribute were estimated using a mixed logit model. The latent class model was also used to investigate preference heterogeneity.

RESULTS

All attributes were associated with patient preferences. Patients considered the live birth rate as the most important attribute (RI=29.05%), followed by participation in TDM (RI=21.91%). The latent class model revealed two distinct classes named 'outcome driven' and 'cost driven'. Preferences varied according to their age, monthly household income and location.

CONCLUSIONS

This study investigated the preferences of infertile patients when seeking medical assistance for infertility. The study outcomes can contribute to evidence-based counselling and shared decision-making and provide an empirical basis for creating and implementing future policies.

Height development trends among 7-18-year-old school-age children in central plains of China between 2000 and 2019: A serial cross-sectional surveillance study in China

OBJECTIVE

The aim of this study was to analyze changes in height of 7-18-year-old school-age children in China during the year of 2000-2019.

METHODS

We used the survey data from the Chinese National Survey on Students' Constitution and Health in Henan Province for the years 2000, 2005, 2010, 2014, and 2019. Data were categorized into subgroups based on geographic location, gender, and age; mean, standard deviation, and Pearson's correlation coefficient were used to analyze trends in height change among children and adolescents and the correlation between socioeconomic indicators and height change.

RESULTS

The height of children and adolescents in Henan has shown a continuous upward trend. The height difference between urban and rural areas has gradually narrowed but has not disappeared. The correlation of height development trends between neighbouring urban areas was higher than in other areas. The level of medical care was significantly associated with the change in height for both boys (r = 0.950, p = 0.013) and girls (r = 0.897, p = 0.039); GDP per capita (r = 0.940，p = 0.018) was significantly associated with the change in height for boys only.

CONCLUSION

The height of Chinese children and adolescents will continue to maintain a positive growth trend, but we need to pay attention to the health status and nutritional intake of children and adolescents in economically disadvantaged areas in order to narrow the height disparity between different socio-economic groups.

Comparison of EQ-5D-Y-3L Utility Scores Using Nine Country-Specific Value Sets in Chinese Adolescents

OBJECTIVE

This study aimed to assess and compare the measurement properties of EQ-5D-Y-3L utilities derived from available countries' value sets (Chinese, Japanese, Slovenian, German, Spanish, Hungarian, Netherlandish, Belgian, and Indonesian), among Chinese adolescents.

METHODS

From July to September 2021, a large-scale cross-sectional survey was administered across 16 cities in Shandong, China, with the objective of assessing the health status of junior high school students aged 10-18 years. Supported by the educational authorities, quick response (QR) codes and questionnaire links were disseminated to schools. A total of 97,413 junior high school students completed the questionnaire. Agreement, convergent validity, and known-group validity were determined in the nine country-specific value sets.

RESULTS

The Indonesian value set demonstrated the highest mean health utility score (0.970), followed by the Japanese (0.961), Chinese (0.960), Netherlandish (0.948), Hungarian (0.942), German (0.938), Belgian (0.932), Slovenian (0.926), and Spanish (0.926) value sets, respectively. The utility scores derived from Asian value sets were higher than those from Europe. Good or excellent agreements (intraclass correlation coefficients > 0.7) were found between each paired value set. In Bland-Altman plots, the 95% limits of agreement for any two value sets were 0.046-0.348. A strong relationship (Spearman's correlation coefficients > 0.99) between any two value sets was found. The EQ-5D-Y-3L utility scores discriminated equally well for the nine value sets across three known groups. The effect size and the relative efficiency statistics showed the Chinese value sets were more sensitive in general. Referring to the Chinese value set, all the relative efficiency values in each value set were similar across three known groups, ranging from 0.9 to 1.0.

CONCLUSIONS

A total of nine country-specific EQ-5D-Y-3L value sets showed an overall high level of agreement, strong correlation, and good known-group validity. However, the utility scores derived from nine EQ-5D-Y-3L value sets were different and the country-specific value sets were not interchangeable.

IQUB mutation induces radial spoke 1 deficiency causing asthenozoospermia with normal sperm morphology in humans and mice

BACKGROUND

Asthenozoospermia (ASZ) accounts for about 20-40% of male infertility, and genetic factors, contributing to 30-40% of the causes of ASZ, still need further exploration. Radial spokes (RSs), a T-shaped macromolecular complex, connect the peripheral doublet microtubules (DMTs) to a central pair (CP), forming a CP-RS-DMT structure to regulate the beat frequency and amplitude of sperm flagella. To date, many components of RSs and their functions in human sperm flagella remain unclear.

METHODS

We recruited a cohort of 323 infertile males with ASZ between August 2019 and June 2024. Genetic mutations were identified by whole-exome sequencing. Computer-aided sperm analysis, Papanicolaou staining, and electron microscopy were applied to evaluate the motility, morphology, and ultrastructure of spermatozoa, respectively. Protein mass spectrometry, western blotting, and bioinformatic analyses were performed to identify critical components of mammalian RS1 to model its structure and explore the pathological mechanism of IQUB deficiency. Intracytoplasmic sperm injection (ICSI) was applied for the patient and Iqub-/- mice.

RESULTS

We identified a novel homozygous IQUB mutation [c.842del (p.L281Pfs*28)] in an ASZ male with normal sperm morphology (ANM), which resulted in the complete loss of IQUB in sperm flagella. Deficiency of RS1, but not RS2 or RS3, was observed in both IQUB842del patient and Iqub-/- mice, and resulted in the reduction of sperm kinetic parameters, indicating the critical role of IQUB in regulating mammalian RS1 assembly and sperm flagellar beat. More importantly, we identified twelve critical components of RS1 in humans and mice, among which RSPH3, RSPH6A, RSPH9 and DYDC1 constituting the head, DYDC1, NME5, DNAJB13 and PPIL6 assembling into the head-neck complex, AK8, ROPN1L, RSPH14, DYNLL1, and IQUB forming the stalk of RS1. Along with the RS1 defect, the IQUB deficiency caused significant down-regulation of the inner dynein arms of DNAH7 and DNAH12, highlighting their nearby location with RS1. Finally, ICSI can effectively resolve the male infertility caused by IQUB genetic defects.

CONCLUSIONS

We demonstrate that IQUB may serve as an adapter for sperm flagellar RS1 in both humans and mice and consolidated the causal relationship between IQUB genetic mutations and ANM, further enriching the genetic spectrum of male infertility.

Impact of dapagliflozin on metabolic phenotype, hormone levels, and fertility in female mice after prolonged high-fat diet

Introduction

A long-term high-fat diet (HFD) cause obesity and infertility through hypothalamic inflammation and insulin resistance, leading to metabolic abnormalities and ovulation dysfunction. The sodium-glucose cotransporter 2 inhibitors (SGLT2i) have emerged as a treatment for type 2 diabetic patients, regulating adipose tissue metabolism, hypothalamic inflammation, and ovulation in women with polycystic ovary syndrome (PCOS). The study aimed to investigate the pharmacological effects of dapagliflozin on improving insulin resistance, energy metabolism, sex hormones, and fertility in female mice following prolonged consumption of HFD.

Methods

At 6 weeks of age, female mice were fed a HFD and treated with dapagliflozin. Serum hormone concentrations and inflammatory factors in mice aged 28 weeks or 38 weeks were quantified using ultrasensitive enzyme-linked immunosorbent assays (ELISAs). Metabolic parameters were also assessed and documented at different stages of the experiment. At 34 weeks of age, half of the experimental mice in each of the four groups fed with standard chow were mated with male mice. Pregnancy rate, abortion rate, pregnancy-related deaths, and perinatal outcomes were systematically recorded.

Results

After 16 weeks of HFD feeding, dapagliflozin significantly attenuated visceral fat deposition, weight gain, glucose intolerance, and insulin resistance induced by the diet. However, these effects diminished after 32 weeks. Unexpectedly, neither HFD nor dapagliflozin treatment elicited any significant changes in serum IL-6 and TNFα levels. Throughout the experiment period, dapagliflozin exhibited favorable effects on reproductive function along with insulin sensitivity and luteinizing hormone (LH) release from the pituitary gland.

Discussion

In conclusion, this study demonstrates that dapagliflozin alleviated HFD-induced reproductive dysfunction independently of obesity, peripheral tissue insulin resistance, and systemic inflammation, suggesting its potential as a promising treatment for diet-related ovulation disorders.

Pay-it-forward strategy reduced HPV vaccine delay and increased uptake among catch-up age girls: A randomized clinical trial

Background

Catch-up HPV vaccination is challenging in many low and middle-income countries (LMICs). Pay-it-forward offers an individual a subsidized vaccine, then an opportunity to donate to help others access vaccinations. Our randomized control trial assessed the effectiveness of pay-it-forward in improving HPV vaccination among girls aged 15-18 years in China.

Methods and findings

Eligible participants were randomly assigned to either the pay-it-forward arm or standard-of-care arm (self-paid vaccination). The primary outcome was the first-dose HPV vaccination rate, verified against clinical records. Among 321 participants enrolled, most caregivers were female (80.1%). In the pay-it-forward arm, 55 of 161 (34.2%) girls received the HPV vaccine, compared with 28 of 160 (17.5%) girls in the standard-of-care arm (adjusted proportion difference = 17.9%, 95% CI: 8.7, 27.0, P<0.001). Among 55 girls in the pay-it-forward arm who received the vaccination, 37 (67.3%) wrote a postcard message, and 39 (70.9%) of their caregivers donated to support future girls. The financial cost per person vaccinated was $294 in the standard-of-care arm and $230 in the pay-it-forward arm.

Conclusions

The pro-social pay-it-forward strategy was effective to increase catch-up HPV vaccination among teenage girls with comparable costs.

Trial registration

ChiCTR2200055542.

Global disease burden of cervical cancer and the association of screening coverage with quality of disease management

OBJECTIVES

To analyze the global disease burden of cervical cancer and the association between screening coverage and the quality of disease management.

METHODS

The data of global burden of cervical cancer 2021 and the data of cervical cancer screening 2019 were obtained from IHME Global Burden of Disease (GBD) and the WHO Global Health Observatory (GHO), respectively. The age-standardized disease burden index was calculated, the Quality of Disease Management Index (QCI) was determined with principal component analysis, the correlation between QCI and cervical cancer screening coverage was examined with linear regression analysis by regions and populations.

RESULTS

The burden of cervical cancer and the quality of its management exhibited significant variability across countries with differing levels of social development. The indicators of cervical cancer burden in China were close to the average level of countries with higher socia-demographic index (SDI). The global QCI was 22.22 (10.50, 35.43), and that of China was 26.30. The global screening coverage rate for cervical cancer was 42% (12%, 86%) and that in China was 31%. After adjusting for the social development level of countries, the coverage level of cervical cancer screening was associated with QCI (β=0.27, P<0.01), no matter in countries with low or high SDI (P>0.05). The association was significantly stronger among younger women (β=1.48, P<0.05).

CONCLUSIONS

There are discrepancies in both the disease burden of cervical cancer and the quality of disease management among countries with different socioeconomic levels, and there is still considerable room for improvement in China. Expanding coverage of cervical cancer screening may be an effective strategy to enhance the management quality of cervical cancer, particularly among younger women where the screening benefits are most pronounced.

Geographic variations, temporal trends, and equity in healthcare resource allocation in China, 2010-21

Background

Inequity in healthcare resources has been identified as a global public health priority, yet the geographic variations and temporal trends in distribution and inequity in China remain unclear. We aimed to investigate these variations and temporal trends in healthcare resources and evaluate inequity in healthcare resource allocation in China.

Methods

In this nationwide descriptive study, we used provincial-level data on healthcare infrastructure, human, and service resources from 31 provinces of mainland China, publicly released by the National Health Commission of China between 2010-21. We assessed the spatial autocorrelation of healthcare infrastructure, human, and service resources using Moran's I index, and identified spatial clusters of resource allocation. We evaluated the equity in healthcare resource allocation using the Lorenz curve, Gini coefficient, and Theil index by population and geographic dimensions.

Results

Between 2010-21, the density of healthcare infrastructure and human resources in China increased, with the average stay decreasing from 10.5 to 9.2 days. There were substantial regional disparities, with higher resource density exhibited in eastern regions compared to western regions. Spatial autocorrelation was more pronounced for the density of practising (assistant) physicians (Moran's I = 0.465; P < 0.001), practising physicians (Moran's I = 0.351; P < 0.001), and bed occupancy rate (Moran's I = 0.256; P < 0.001), with significant geographic clusters of resource allocation. Lorenz curves showed that healthcare resource allocation was closer to the absolute equity by population but not geographic dimension, with Gini coefficients indicating severe inequity (>0.6) by geographic dimension compared to perfect equity (<0.2) by population dimension. Intraregional Theil index by population was higher than the inter-regional index, with contribution rates exceeding 60%.

Conclusions

Per capita access to healthcare resources in China has improved, but significant geographic variations and clustering exist, particularly with higher resource density in eastern regions. While resource allocation by population showed better equity than by geographic area, substantial intra-regional disparities highlight the need for targeted strategies to enhance equitable distribution, particularly in the western regions.

Allelic transcriptomic profiling identifies the role of PRD-like homeobox genes in human embryonic-cleavage-stage arrest

Cleavage-stage arrest in human embryos substantially limits the success rate of infertility treatment, with maternal-to-zygotic transition (MZT) abnormalities being a potential contributor. However, the underlying mechanisms and regulators remain unclear. Here, by performing allelic transcriptome analysis on human preimplantation embryos, we accurately quantified MZT progression by allelic ratio and identified a fraction of 8-cell embryos, at the appropriate developmental time point and exhibiting normal morphology, were in transcriptionally arrested status. Furthermore, we identified PAIRED (PRD)-like homeobox transcription factors divergent paired-related homeobox (DPRX) and arginine-fifty homeobox (ARGFX) as factors involved in MZT, whose deficiency severely impairs MZT and lineage specification and leads to aberrant retention of histone acetylation. By reversing the acetylation retention caused by DPRX and ARGFX defects, embryonic arrest can be partially rescued. Our study identifies factors involved in human MZT and elucidates the etiology underlying human cleavage-stage arrest.

Spatio-temporal distribution and socioeconomic inequality of low birthweight rate in China from 1992 to 2021 and its predictions to 2030

This paper aims to investigate the trend, spatio-temporal distribution, and socioeconomic inequality of the low birthweight rate (LBWR) in China from 1992 to 2021 and to project the LBWR to 2030. We performed a secondary analysis of data from the China Health Statistics Yearbook. LBWR refers to the ratio of the number of infants born with a birth weight less than 2,500 grams to the number of live births in a given year. We used joinpoint regression models to estimate LBWR trends from 1992 to 2021 for the whole country and from 2002 to 2021 for the three regions (eastern, central, and western regions) and each province. The slope index of inequality (SII) and relative index of inequality (RII) were calculated for each year from 2002 to 2021 based on provincial data. LBWR increased from 2.52% (1992) to 3.70% (2021), and the average annual percentage change (AAPC) (95% confidence interval [CI]) was 1.35% (0.22%, 2.49%) in China. The overall LBWR from 2002 to 2021 was greatest in the Eastern region, but LBWR had the fastest increase in the Western region, with an AAPC (95% CI) of 3.15% (2.59%, 3.12%). There were spatio-temporal differences in the LBWR and trends between provinces. The SII and RII increased linearly from -0.15 and 0.94 to 0.53 (B = 0.035%, p < 0.001) and 1.16 (B = 0.011, p < 0.01), respectively, over the past 20 years. The results of the ARIAM model showed that the National LBWR will be increasedfrom 3.70% in 2021 to 5.28% in 2030. The LBWRs in the eastern, central and western regions in 2030 will be 4.93%, 6.02% and 5.82%, respectively. National and local governments must prioritize disadvantaged groups to mitigate the rapid prevalence of LBWR, reduce regional disparities, and improve perinatal and infant health and health equity in China.

A Glimpse of Research Trends and Frontiers in the Etiology of Premature Ovarian Insufficiency via Bibliometric Analysis

INTRODUCTION

Premature Ovarian Insufficiency (POI) is the most common reproductive aging disorder in women of reproductive age, which is characterized by decreased ovarian function in women before the age of 40. Etiology research of POI has garnered interest and attention from scholars worldwide over the past decades.

METHODS

However, to the best of our knowledge, no comprehensive survey with bibliometric analysis has been conducted yet on the research trends of POI etiology. This article aimed to analyze current scientific findings on the etiology of POI, offering innovative ideas for further research. Research articles on the etiology of POI from 1994 to 2023 were collected from the Web of Science Core Collection. A total of 456 research articles were included, and the total number of publications increased annually. We used VOSviewer and bibliometric.com to analyze the keywords, terms, institution, publication country/region, author name, publication journal, and the sum of times the articles have been cited.

RESULTS

This study has shown that a research hotspot is the genetic etiology of POI; however, there is still a lack of research on the impact of epigenetic alterations, iatrogenic injuries, environmental pollution, social stress, and unhealthy lifestyles on the pathogenesis of POI.

CONCLUSION

The factors illustrated here represent potential future directions for POI etiology research and warrant more attention from researchers.

Does the reduction in obstetric hospitals result in an unintended decreased in-hospital delivery utilisation? A causal multilevel analysis in China

Introduction

China's progress towards achieving Sustainable Development Goals for maternal health is largely attributed to a reduction in maternal mortality rates, driven by increased in-hospital delivery services utilisation. However, recent reductions in the number of obstetric hospitals have raised concerns about compromised access to these services. This study investigates the impact of reduced obstetric hospitals on spatial accessibility and the utilisation of in-hospital delivery services.

Methods

Data from 2016 to 2020 were collected from a densely populated province with approximately 83 million residents. Directed Acyclic Graph was applied to identify a minimally sufficient set of confounders, including residential characteristics and transportation-related factors. Multilevel regression models were employed to analyse the causal effects, with sensitivity analysis using fixed effect and quantile regression models.

Results

Between 2017 and 2020, the number of obstetric hospitals decreased by 21.3% (from 1209 to 951), leading to a decline in the proportion of pregnant women covered within a 2-hour driving radius (from 97.4% to 97.1%) and an increase in the maximum of shortest driving time within county (from 117.2 to 121.0 min). Multilevel regression models, adjusted for confounders, showed that a 1 percentage point increase in the proportion of pregnant women covered within a 2-hour driving radius was associated with a 13 percentage point (95% CI: 11.4 to 14.7) increase in in-hospital delivery rates, especially in areas with lower coverage and in-hospital delivery rates.

Conclusions

The reduction in obstetric hospitals increased travel distances, negatively impacting in-hospital delivery utilisation. Expanding the proportion of pregnant women covered within a 2-hour driving radius may be more effective than reducing the maximum of shortest travel distance within a county when optimising obstetric hospital locations. These findings provide insights for optimising obstetric facility locations in similar low- and middle-income countries. While improving spatial accessibility is important, the potential quality gains from centralising obstetric resources should also be considered.

Machine learning-enabled mental health risk prediction for youths with stressful life events: A modelling study

BACKGROUND

Youths face significant mental health challenges exacerbated by stressful life events, particularly in the context of the COVID-19 pandemic. Immature coping strategies can worsen mental health outcomes.

METHODS

This study utilised a two-wave cross-sectional survey design with data collected from Chinese youth aged 14-25 years. Wave 1 (N = 3038) and Wave 2 (N = 539) datasets were used for model development and external validation, respectively. Twenty-five features, encompassing dimensions related to demographic information, stressful life events, social support, coping strategies, and emotional intelligence, were input into the model to predict the mental health status of youth, which was considered their coping outcome. Shapley additive explanation (SHAP) was used to determine the importance of each risk factor in the feature selection. The intersection of top 10 features identified by random forest and XGBoost were considered the most influential predictors of mental health during the feature selection process, and was then taken as the final set of features for model development. Machine learning models, including logistic regression, AdaBoost, and a backpropagation neural network (BPNN), were trained to predict the outcomes. The optimum model was selected according to the performance in both internal and external validation.

RESULTS

This study identified six key features that were significantly associated with mental health outcomes: punishment, adaptation issues, self-regulation of emotions, learning pressure, use of social support, and recognition of others' emotions. The BPNN model, optimized through feature selection methods like SHAP, demonstrated superior performance in internal validation (C-index [95 % CI] = 0.9120 [0.9111, 0.9129], F-score [95 % CI] = 0.8861 [0.8853, 0.8869]). Additionally, external validation showed the model had strong discrimination (C-index = 0.9749, F-score = 0.8442) and calibration (Brier score = 0.029) capabilities.

LIMITATIONS

Although the clinical prediction model performed well, the study it still limited by self-reported data and representativeness of samples. Causal relationships need to be established to interpret the coping mechanism from multiple perspectives. Also, the limited data on minority groups may lead to algorithmic unfairness.

CONCLUSIONS

Machine learning models effectively identified and predicted mental health outcomes among youths, with the SHAP+BPNN model showing promising clinical applicability. These findings emphasise the importance and effectiveness of targeted interventions with the help of clinical prediction model.

Newborn morbidities and care procedures at the special newborn care units of Gandaki Province, Nepal: a retrospective study

BACKGROUND

Despite recent improvements in the overall health status of Nepal's population, newborn morbidities and mortalities have remained a challenge. This study explores the situation and care strategies for newborn health problems in the Gandaki Province of Nepal.

METHODS

This is a retrospective hospital records analysis. A structured questionnaire was employed to collect data on socio-demographic, clinical, and outcome variables in 1,355 newborns admitted to the Special Newborn Care Unit (SNCU) between May 1, 2021, and April 30, 2022, in five hospitals within the Gandaki Province.

RESULTS

Among all newborns, 60% were male, and 40% belonged to Janajati indigenous families. The mean age of mothers at the time of delivery was 24.4 years; the average birth weight of babies was 2.8 kg; and the gestational week was 38 weeks. Around 96% of births occurred in healthcare facilities. The average inpatient hospital stay was 4.7 days. The reasons for SNCU admission were newborn sepsis (51%), neonatal hyperbilirubinemia (23%), respiratory distress syndrome (18%), and low birth weight (11%). Approximately 7% of the newborns were found to have died due to various causes, including sepsis, asphyxia, and indirect medical reasons. Female newborns had a 0.45-times (CI: 0.23-0.84) lower risk of mortality compared to male newborns. Underweight newborns had 8.8 times (CI: 4.5-17.2) higher risk of death than newborns with a normal birth weight, even after adjusting for other factors like sex, delivery site, mode of delivery, mother's age, respiratory distress syndrome, neonatal hyperbilirubinemia, neonatal sepsis, and age at admission to SNCU. The most common treatments included injectable antibiotics (73%), intravenous fluids (53%), oxygen delivery (39%), and phototherapy (36%), while 3% received "Kangaroo Mother Care (KMC)".

CONCLUSIONS

The study showed that newborns suffered from multiple health complications such as sepsis, hyperbilirubinemia, or asphyxia, and many newborns received essential medical services from hospitals. Birth weight, sex of the newborn, and respiratory distress syndrome were significantly associated with neonatal mortality. Hospitals should focus on reinforcing KMC, neonatal resuscitation, and early infection control measures.

Observed Effects on Very Early Pregnancy Linked to Ambient PM2.5 Exposure in China among Women Undergoing In Vitro Fertilization-Embryo Transfer

The adverse effect of ambient PM2.5 exposure on very early pregnancy (VEP) remains controversial among epidemiological studies but is supported by toxicological evidence. We adopted a multicenter retrospective cohort of 141,040 cycles to evaluate the effect of PM2.5 exposure on the VEP using the in vitro fertilization and embryo transfer platform and high-resolution PM2.5 data in China. We first investigated the association between PM2.5 exposure 1 week before and 1 week after the embryo transfer date and VEP. The average PM2.5 concentrations of the 2 weeks were approximately 47 μg/m3. The pooled results revealed a negative association between women's accumulated PM2.5 exposure during the 2 weeks near the day of embryo transfer and success odds of VEP with the relative risk of 0.999 (95% CI: 0.997-0.999) at each increase of 10 μg/m3. The women with the fresh cycle or one transplanted embryo were considered as a vulnerable population. Furthermore, seven periods for the fresh cycle and five periods for the frozen cycle from 85 days before oocyte retrieval to the day of gestational sac detection by ultrasound detection were defined. For these exposure periods, no association between the average PM2.5 exposure and VEP risk was identified. Our study provided large-scale population evidence for the association between PM2.5 exposure near embryo transfer day and VEP and identified vulnerable populations among women undergoing in vitro fertilization-embryo transfer.

Effect of early essential newborn care on breastfeeding and outcomes of mothers/newborns post-cesarean section: a randomized controlled trial in China

BACKGROUND

The implementation of early essential newborn care (EENC) is important to maternal and neonatal health. However, few studies have conducted a complete procedure of EENC in cesarean section. This study aimed to systematically evaluate the effects of EENC during and after cesarean section.

METHODS

A randomized controlled trial was conducted at a tertiary hospital in Wuhan, China. Full-term pregnant women who had no comorbidities and underwent elective cesarean section were recruited and received EENC intervention or routine health care. The Infant Breastfeeding Assessment Tool (IBFAT), the Breastfeeding Self-Efficacy Scale-Short Form (BSES-SF), a questionnaire of the breastfeeding behavior, the Maternal Postnatal Attachment Scale (MPAS) and the Edinburgh Postnatal Depression Scale (EPDS) were used to collect data. The correlation between EENC implementation and breastfeeding, maternal-infant attachment, postpartum depression, and other maternal and neonatal outcomes was analyzed.

RESULTS

Mother-newborn pairs (N = 157) were enrolled in this study, 78 in the EENC group and 79 in the control group. A total of 155 (98.8%) were followed up at 14 days, 144 (91.7%) at 42 days, and 123 (78.3%) at 3 months. For the primary outcomes, generalized linear mixed model analysis showed that implementing EENC during cesarean section was beneficial for initiating breastfeeding (OR = 0.021), shortening the breastfeeding initiation time (β = - 45.321), improving the IBFAT scores (β = 2.740), and enhancing breastfeeding self-efficacy (β = 4.880). These effects were not influenced by time interaction. However, no difference was observed in the rate of exclusive breastfeeding between these two groups (P > 0.05). Implementing EENC during cesarean section significantly improved maternal-infant attachment (β = 9.668). Moreover, univariate analysis showed benefits of EENC in improving postpartum depression (P < 0.001) and decreasing maternal perinatal blood loss (P < 0.05).

CONCLUSIONS

According to our small sample study, there is a trend of improvement in breastfeeding related behavior and maternal infant attachment in women who received EENC during cesarean deliveries. The effects of EENC on exclusive breastfeeding should be further explored in the future.

TRIAL REGISTRATION

Chinese Clinical Trial Register at www.chictr.org.cn , ChiCTR2300074760, retrospectively registration. Registration Date: August 15, 2023.

[Analysis of treatment outcomes of extremely preterm infants in a real-world single center]

OBJECTIVES

To study the treatment outcomes of extremely preterm infants.

METHODS

A retrospective analysis was performed for the clinical data of extremely preterm infants who were admitted to the neonatal intensive care unit of the Third Affiliated Hospital of Zhengzhou University from January 2016 to December 2022. The infants were divided into a non-in-hospital death group and a survival group. SPSS 29.0 was used for data analysis.

RESULTS

A total of 422 extremely preterm infants were included, of which 155 were in the non-in-hospital death group and 267 in the survival group. The gestational age, birth weight, cesarean section rate, and proportion of mothers with premature rupture of membranes >18 hours in the non-in-hospital death group were all lower than those in the survival group (P<0.05). In contrast, the proportions of Apgar score ≤3 at 1 minute, intubation, neonatal respiratory distress syndrome, early-onset sepsis, periventricular-intraventricular hemorrhage (grades III-IV), and pneumorrhagia were higher in the non-in-hospital death group compared to the survival group (P<0.05).

CONCLUSIONS

Low gestational age, low birth weight, the history of birth asphyxia, severe intracranial hemorrhage, and pneumorrhagia may be the main causes of non-in-hospital death in extremely preterm infants, and therefore, perinatal health care should be enhanced to reduce the onset of asphyxia and severe diseases.

Halving premature death and improving quality of life at all ages: cross-country analyses of past trends and future directions

BACKGROUND

Although death in old age is unavoidable, premature death-defined here as death before age 70 years-is not. To assess whether halving premature mortality by 2050 is feasible, we examined the large variation in premature death rates before age 70 years and trends over the past 50 years (1970-2019), covering ten world regions and the 30 most-populous nations. This analysis was undertaken in conjunction with the third report of The Lancet Commission on Investing in Health: Global Health 2050: the path to halving premature death by mid-century.

METHODS

In this cross-country analysis of past mortality trends and future directions, all analyses on the probability of premature death (PPD) were conducted using life tables from the UN World Population Prospects 2024. For each sex, country, and year, probability of death was calculated from these life tables with 1-year age-specific mortality rates.

FINDINGS

Globally, PPD decreased from 56% in 1970 to 31% in 2019, although some countries saw reversals because of conflict, social instability, or HIV and AIDS. Child mortality has decreased faster than adult mortality. Among all countries, 34 halved their PPD over three decades between 1970 and 2019. Among the 30 most-populous countries, seven countries, with varying levels of baseline PPD and income, halved their PPD in the past half century. Seven of the most-populous countries had average annual rates of improvement in the period 2010-19 that, if sustained, could lead to a halving of PPD by 2050, including Korea (3·9%), Bangladesh (2·8%), Russia (2·7%), Ethiopia (2·4%), Iran (2·4%), South Africa (2·4%), and Türkiye (2·3%).

INTERPRETATION

Halving premature death by 2050 is feasible, although substantial investments in child and adult health are needed to sustain or accelerate the rate of improvement for high-performing and medium-performing countries. Particular attention must be paid to countries with very low or a worsening rate of improvement in PPD. By reducing premature mortality, more people will live longer and more healthy lives. However, as people live longer, the absolute number of years lived with chronic disease will increase and investments in services reducing chronic disease morbidity are needed.

FUNDING

The Norwegian Agency for Development Cooperation, the Bill & Melinda Gates Foundation, and a Norwegian Research Council Centre of Excellence grant.

Case report: Carcinosarcoma of uterus in nulliparous women

Background

Uterine carcinosarcoma (UCS), or malignant mixed Müllerian tumor, is a cancer that include both carcinomatous and sarcomatous components, resembling endometrial carcinoma. A 55-year-old woman was admitted to the hospital with postmenopausal vaginal bleeding. Gross examination of the specimen revealed brittle tissue in the fundus and the left wall of the endometrium. Postoperative pathology revealed a mixture of well-differentiated endometrioid adenocarcinoma and osteosarcoma. The patient was never given birth, which may be relevant to the diagnosis. Literature review suggests that being nulliparous may be a significant risk factor for developing uterine carcinosarcoma.

Case description

In December 2023, a 55-year-old female patient was admitted to the hospital with postmenopausal vaginal bleeding. Hysteroscopic surgery was performed, and the postoperative pathology showed endometrial cancer accompanied by ossified tissue with necrosis. The immunohistochemical results indicated positive Estrogen receptors (ER), positive Progesterone receptors (PR), ki67 positivity at 70%, negative PTEN, mutated positive p53, focal positive Pax-8, positive SATB2, positive Cytokeratin 7 (CK7), positive EMA and positive Vimentin (Vim). The patient was diagnosed with Uterine carcinosarcoma. On December 18, 2023, the patient underwent partial vaginal resection, bilateral salpingo-oophorectomy, pelvic lymph node dissection, and a sub-extensive laparoscopic hysterectomy. Postoperatively, the patients received radiotherapy and four cycles of chemotherapy in the DC regimen. As of July 2024, laboratory and impact test results showed no tumor recurrence. The patient's disease-free survival (DFS) was seven months.

Conclusion

The rate of childless in patients with uterine carcinosarcoma is at a high level.

Cellular and molecular regulations of oocyte selection and activation in mammals

Oocytes, a uniquely pivotal cell population, play a central role in species continuity. In mammals, oogenesis involves distinct processes characterized by sequential rounds of selection, arrest, and activation to produce a limited number of mature eggs, fitting their high-survival yet high-cost fertility. During the embryonic phase, oocytes undergo intensive selection via cytoplasmic and organelle enrichment, accompanied by the onset and arrest of meiosis, thereby establishing primordial follicles (PFs) as a finite reproductive reserve. Subsequently, the majority of primary oocytes enter a dormant state and are gradually recruited through a process termed follicle activation, essential for maintaining orderly fertility. Following activation, oocytes undergo rapid growth, experiencing cycles of arrest and activation regulated by endocrine and paracrine signals, ultimately forming fertilizable eggs. Over the past two decades, advancements in genetically modified animal models, high-resolution imaging, and omics technologies have significantly enhanced our understanding of the cellular and molecular mechanisms that govern mammalian oogenesis. These advances offer profound insights into the regulatory mechanisms of mammalian reproduction and associated female infertility disorders. In this chapter, we provide an overview of current knowledge in mammalian oogenesis, with a particular emphasis on oocyte selection and activation in vivo.

Deprivation-related adverse childhood experiences and cognitive function among older adults: Mediating role of depression symptoms

BACKGROUND

Cognitive dysfunction imposes a heavy economic burden on families and society. Depression and deprivation-related adverse childhood experiences (ACEs) are important factors that contribute to cognitive dysfunction. However, few studies have explored these complex interactions.

OBJECTIVE

This study aimed to elucidate the mediating effect of depression on the relationship between deprivation-related ACEs and cognitive function in older adults.

METHODS

This national, cross-sectional study used data from the 2020 Chinese Longitudinal Aging Social Survey. Information regarding depression, ACEs, and cognitive function was collected from individuals aged 60 years and older. A structural equation model was used to examine the mediating effect of depression on the relationship between deprivation-related ACEs and cognitive function.

RESULTS

A total of 9828 participants were included in this study. Their mean total cognitive function score was 13.488 ± 3.006. The results showed that sex, age, educational level, marital status, body mass index, registered residence, chronic disease situation, health, smoking, living alone, life satisfaction, social security, and internet use were all related to cognitive function (P < 0.05). Deprivation-related ACEs were negatively correlated with cognitive function (r = -0.132, P < 0.01). And depression symptoms were negatively correlated with cognitive function (r = -0.158, P < 0.01). The mediating effect analysis indicated that depression symptoms had a significant mediating effect between the 3 dimensions of deprivation-related ACEs and cognitive function.

CONCLUSIONS

This study highlighted that improvement of deprivation-related ACEs was indirectly related to a reduced likelihood of cognitive dysfunction through depression in older adults. With the limitations of cross-sectional studies, validation through longitudinal design studies is deemed necessary. Future interventions should focus on alleviating depression symptoms to prevent cognitive decline and impairment in this population.

Which Side of the Coin Are You on Regarding Possible Postnatal Oogenesis?

It is well known that oocytes are produced during fetal development and that the total number of primary follicles is determined at birth. In humans, there is a constant loss of follicles after birth until about two years of age. The number of follicles is preserved until the resumption of meiosis at puberty and there is no renewal of the oocytes; this dogma was maintained in the last century because there were no suitable techniques to detect and obtain stem cells. However, following stem cell markers, several scientists have detected them in developing and adult human ovarian tissues, especially in the ovarian surface epithelial cells. Furthermore, many authors using different methodological strategies have indicated this possibility. This evidence has led many scientists to explore this hypothesis; there is no definitive consensus to accept this idea. Interestingly, oocyte retrieval from mature ovaries and other tissue sources of stem cells has contributed to the development of strategies for the retrieval of mature oocytes, useful for assisted reproductive technology. Here, we review the evidence and controversies on oocyte neooogenesis in adult women; in addition, we agree with the idea that this process may occur in adulthood and that its alteration may be related to various pathologies in women, such as polycystic ovary syndrome, premature ovarian insufficiency, diminished ovarian reserve and several infertility and genetic disorders.

Impact of pre-delivery medication treatment on delivery outcome in patients with primary immune thrombocytopenia: a cohort study

BACKGROUND

Clinical research data showed a series of adverse events in the delivery period of primary immune thrombocytopenia (ITP) patients, including high cesarean section rate. Consensus report proposed that for patients with platelet count below 50 × 109/L, prednisone or intravenous immunoglobulins (IVIg) can be given to raise the platelet count in third trimester in preparation for labor.

OBJECTIVES

To evaluate the effect of low-dose prednisone or IVIg therapy on delivery outcomes in patients with ITP.

STUDY DESIGN

This was a cohort study that included pregnant women with ITP from January 2017 to December 2022. Patients with platelet counts of (20-50) ×109/L at the time of delivery (≥34 weeks) and who had not received any medication before were enrolled in the study. Patients were divided into the pre-delivery medication group (oral prednisone or IVIg) and untreated group according to their preferences. The differences in vaginal delivery rate, postpartum bleeding rate, and platelet transfusion volume between the two groups were compared using t-test, Wilcoxon rank-sum test, and χ2 test. Logistic regression analysis was used to identify the factors affecting vaginal delivery rate and postpartum bleeding rate, and multiple linear regression analysis was used to identify the factors affecting platelet transfusion volume.

RESULTS

During the study period, a total of 96 patients with ITP were enrolled, including 70 in the pre-delivery medication group and 26 in the untreated group. The platelet count of pre-delivery medication group was 54.8 ± 34.5 × 109/L, which was significantly higher than that of untreated group 34.4 ± 9.0 × 109/L (p = .004). The vaginal delivery rate of the medication group was higher than the untreated group [60.0% (42/70) vs. 30.8% (8/26), χ2 = 6.49, p = .013]. After adjusting for the proportion of multiparous women and gestational weeks, the results showed that medication therapy during the peripartum period was associated with vaginal delivery (OR = 4.937, 95% CI: 1.511-16.136, p = .008). The postpartum bleeding rates were 22.9% (16/70) and 26.9% (7/26) in the medication group and untreated group, respectively, with no significant difference between the two groups (χ2 = 0.17, p = .789), while the platelet transfusion volume was lower in the medication group than untreated group [(1.1 ± 1.0) vs. (1.6 ± 0.8) U].

CONCLUSION

Pre-delivery medication therapy can increase vaginal delivery rate, reduce platelet transfusion volume, but does not decrease the incidence of postpartum hemorrhage.

Development of a nomogram for predicting myopia risk among school-age children: a case-control study

OBJECTIVES

To analyze the factors influencing myopia and construct a nomogram to forecast the risk of myopia among school-age children, providing a reference for identifying high-risk groups to aid prevention and control.

METHODS

This case-control study enrolled 3512 students from three primary schools in Shenzhen using random cluster sampling for a questionnaire survey, myopia screening and ocular biometric parameter measurement. Logistic regression was used to analyze the influencing factors of myopia, and a nomogram was constructed to forecast myopia risk. Bootstrap resampling was used to verify the practicability of the nomogram.

RESULTS

Older age (odds ratio[OR] = 1.164; 95% confidence interval [CI]: 1.111-1.219), female sex (OR = 2.405; 95% CI: 2.003-2.887), maternal myopia (OR = 1.331; 95% CI: 1.114-1.589), incorrect posture during reading and writing (OR = 1.283; 95% CI: 1.078-1.528) and axial length (OR = 7.708; 95% CI: 6.044-8.288) are risk factors for myopia, whereas an increase in corneal radius (OR = 0.036; 95% CI: 0.025-0.052) is a protective factor against myopia. The area under the receiver operating characteristic (ROC) curve of the nomogram was 0.857, and the net benefit was high when the risk threshold of the decision curve analyses (DCA) ranged from 0.20 to 1.00. The measured values were consistent with the prediction.

CONCLUSION

The nomogram was accurate in predicting the risk of myopia among schoolchildren. This study provides a reference for screening high-risk students and for individualized myopia prevention and control.

Changes in the epidemiology of under-5 mortality in China from 2016 to 2022: an observational analysis of population-based surveillance data

BACKGROUND

Sustainable Development Goal (SDG) 3.2 aims to end preventable deaths of newborns and children younger than 5 years. China's progress towards SDG 3.2 has not been evaluated on multiple dimensions. We aimed to assess mortality rates in children younger than 5 years (hereafter referred to as under-5 mortality) and to quantify preventable child mortality and geospatial and temporal trends in child mortality in China from 2016 to 2022.

METHODS

In this observational analysis, we used data from the Chinese National Maternal and Child Health Surveillance System (MCHSS) for the period Jan 1, 2016, to Dec 31, 2022 and conducted all-cause mortality and cause-specific mortality analyses for different age groups (age 0-6 days, 7-27 days, 0-27 days, 1-5 months, 6-11 months, 12-23 months, 24-59 months, and birth to 59 months) separately at the national, residential (rural vs urban), and regional (eastern vs central vs western China) levels. All mortality rates were adjusted by age group, type of residency, region, and region-residency strata using a 3-year moving average of the under-reporting rates. National deaths were estimated using the number of livebirths from 2016 to 2022 from the Health Statistics Yearbook of China. Estimated national-level and regional-level mortality rates were weighted by the proportion of the population living in urban and rural areas from the 2010 national census. Optimal survival metrics for neonates and children younger than 5 years were calculated by cause of death in 2020-22 (termed the national optimum), on the basis of the lowest mortality observed among the six region-residency strata.

FINDINGS

In 2022, approximately 65 700 (95% CI 62 700-68 800) children younger than 5 years died in China, with 45·1% (42·7-47·4) of these deaths occurring in the neonatal period (age <28 days). China's under-5 mortality rate decreased from 10·2 deaths (9·9-10·5) per 1000 livebirths in 2016 to 6·8 deaths (6·5-7·2) per 1000 livebirths in 2022; the neonatal mortality rate decreased from 4·9 deaths (4·7-5·1) per 1000 livebirths in 2016 to 3·1 deaths (2·9-3·3) per 1000 livebirths in 2022. The relative risk of death in children younger than 5 years in rural areas compared with urban areas decreased from 2·4 (2·2-2·6) in 2016 to 1·9 (1·7-2·1) in 2022, and in the western region compared with the eastern region decreased from 3·4 (3·0-3·9) in 2016 to 2·3 (1·9-2·8) in 2022. The leading causes of under-5 mortality in 2022 were injuries (23·1% [21·1-25·1] of all-cause deaths), congenital malformations (14·8% [13·1-16·4]), preterm birth complications (14·1% [12·5-15·7]), intrapartum-related events (10·1% [8·7-11·5]), and acute respiratory infections (9·5% [8·2-10·9]). The leading cause of death in the neonatal period was preterm birth complications (12·8% [11·4-14·2] of deaths in children younger than 5 years).

INTERPRETATION

Under-5 mortality in China declined between 2016 and 2022. Disparities across regions and in urban versus rural areas narrowed over time, but they still exist. Therefore, efforts should be made to further reduce child mortality in China, including consistent investments and implementing of policies, programmes, and interventions, especially for the western rural areas.

FUNDING

None.

TRANSLATION

For the Chinese translation of the abstract see Supplementary Materials section.