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. 2026 Feb 2;2(2):e70251. doi: 10.1002/pmf2.70251

Applying a climate lens framework to the World Health Organization's maternal and perinatal intervention recommendations

Daniela Febres‐Cordero 1, Bryton Fett 2, Michelle Joy Wang 1, Tyler Lueck 1, Anne R Waldrop 3, Akosua Oppong 1, Avery Lin Cox 1, Lucy Leness 4, Najma Abdullahi 1, Madeline A Cohen 5, John Perino 6, Emily Hansman 6, Doris Chou 7, Blair J Wylie 1,✉
PMCID: PMC13344246  PMID: 42597036

Abstract

Introduction

Climate change threatens global health, with pregnant individuals and newborns facing some of the gravest consequences. The World Health Organization (WHO) has published nearly 300 maternal and perinatal health recommendations; a structured approach integrating climate change considerations into guideline development has heretofore not been established.

Methods

We developed and applied a six‐criteria climate lens framework (climate sensitivity, sustainability, climate‐improved alternatives, mitigation, community resilience, and accountability) through an iterative process involving experts in obstetrics and gynecology and public health. The framework includes standardized rating schema and a detailed approach to review the climate impacts of WHO maternal and perinatal health guidelines. The intent is to add climate as an additional consideration within the Evidence to Decision (EtD) framework utilized by the WHO to integrate evidence alongside other crucial criteria such as patient and community values, cost and resource implications, and equity and acceptability.

Results

Eleven primary reviewers assessed 298 recommendations across 10 health topics through independent dual review and consensus adjudication using the six‐criteria climate lens framework. As a representative example of how to apply the proposed framework, we detail its utilization to assess the WHO's recommendation on the use of oxytocin as first‐line uterotonic for prevention of postpartum hemorrhage from a climate perspective. We identified climate‐related vulnerabilities primarily related to temperature sensitivity, cold‐chain dependence, and susceptibility to supply chain disruptions. When applied to the entire suite of WHO maternal and perinatal health recommendations, a climate lens evaluation revealed significant climate vulnerability to common obstetric interventions and also substantial evidence gaps.

Conclusions

This proposed standardized framework adds climate as a crucial consideration to the current EtD framework for evaluating maternity and perinatal guidelines. Evaluation of new and re‐evaluation of existing WHO maternity and perinatal guidelines through this climate lens will help inform global policymakers of climate realities that may impact implementation of clinical guidelines, making it especially useful in highly climate‐impacted areas. Systematic integration of this framework into the guideline development process further exposes critical climate vulnerabilities of our clinical practices, highlights opportunities for climate resilience, imagines adaptation strategies, and sets research priorities to address evidence gaps.

Keywords: climate change, climate lens framework, global health, maternal health, perinatal health

1. INTRODUCTION

Climate change is a growing threat to the health and survival of communities across the globe. The World Health Organization (WHO) has projected that, between 2030 and 2050, climate‐related factors will be responsible for roughly 250,000 deaths per year [1, 2]. Increasing ambient temperatures, extreme and destructive climate events, fluctuation in precipitation patterns, and rising sea levels are markers of climate change that have the potential to produce extreme heat waves, increase air and water pollution, deplete the quality of our food and water supplies, and change the incidence and distribution of infectious and vector‐borne illnesses [3]. Importantly, exposure to climate hazards and their subsequent health impacts is unequally distributed across the globe, such that low‐income and under‐resourced communities are most vulnerable to the negative health impacts of climate change [4].

While climate change will impact all individuals globally, pregnant individuals and newborns are uniquely susceptible to the deleterious health effects of climate change [5, 6]. As climate health research expands, increasing evidence has linked climate change to adverse pregnancy and perinatal outcomes [7, 8]. For example, exposure to increasing ambient temperatures during pregnancy has been associated with a higher risk of preterm birth and low birthweight [9, 10]. Further, exposure to extreme heat has been associated with hypertensive disorders of pregnancy and premature rupture of membranes [11, 12, 13]. Extreme weather events, such as wildfires, floods, and hurricanes, disrupt local infrastructure resulting in displacement, migration, and loss of critical perinatal medical care with wildfire smoke exposure specifically associated with increased rates preterm birth, fetal anomalies, gestational diabetes, and gestational hypertension [14, 15, 16]. The data linking climate change factors to adverse maternal and perinatal outcomes are incomplete and limited by methodological and data heterogeneity; nonetheless, available evidence suggests negative impacts that need consideration in perinatal care.

Currently, the WHO endorses nearly 300 individual maternal and perinatal health recommendations for antenatal, intrapartum, and postnatal care. These recommendations propose global implementation of a variety of interventions (i.e., pharmacologic, devices, person‐administered, and health systems‐based) and are developed by a Guideline Development Group following evaluation of an Evidence to Decision (EtD) framework through a formalized guideline development protocol [5, 17, 18]. EtDs are prepared to inform and structure the deliberations of guideline panel members and represent the core evidentiary and contextual foundation from which recommendations are formulated. They integrate available quantitative and qualitative evidence identified by systematic reviews with additional crucial criteria such as accessibility, equity, cost, and alignment with community values. Guidelines are presented accompanied by details on these additional criteria including cost‐effectiveness, impact on antimicrobial resistance, and application in humanitarian/emergency settings. Countries utilize these EtDs to adapt and implement WHO guidelines according to their specific context.

Currently, climate impacts are not integrated into this human rights approach to guideline development and review. Understanding that climate change, increasing heat, and extreme weather events may impact the ability of countries to implement WHO and other clinical recommendations, it is increasingly important to assess guidelines specifically through a climate lens to help inform context‐specific health policies and adaptation strategies. Incorporating climate‐related criteria into the EtD would ensure that potential climate impacts on interventions are explicitly considered during recommendation formulation, and would position panels to identify vulnerabilities, propose context‐appropriate adaptations, or consider alternative strategies where needed. With this background, we propose the creation of a climate criteria that can be incorporated into the WHO's current EtD framework as an additional category for consideration during guideline development and review.

In summary, given that climate change has the potential to increase perinatal morbidity and challenge delivery of health care, it is worthwhile to consider how climate change factors themselves may influence the implementation of health guidelines in impacted areas around the globe. This work describes the development and application of a climate lens framework to the current WHO maternal and perinatal health recommendations which can be applied to future recommendations developed by public health policymakers.

2. METHODS

2.1. Development of climate lens framework

Criteria for the climate lens framework were developed through an iterative, multidisciplinary, and evidence‐informed process, incorporating structured discussions with public health collaborators and synthesis of relevant empirical and policy literature. The resulting criteria are grounded in established domains of climate change and health policy research, integrating elements related to climate mitigation, adaptation, health impact pathways, policy implementation dynamics and equity, and vulnerability considerations. The goal of the developed climate lens framework is to enable the systematic assessment of policy recommendations for their complete climate implications, including climate‐related barriers to implementation, potential contributions to or reductions in greenhouse gas (GHG) emissions, and the capacity of proposed actions to mitigate climate‐related health risks. Six core criteria (climate sensitivity, sustainability, climate‐improved alternatives, mitigation, community resilience, and accountability) with accompanying guiding questions were proposed (Table 1; Appendix SI).

TABLE 1.

Climate lens framework criteria and explanations.

Criteria Question
Climate sensitivity Is the intervention sensitive to any specific climate‐related factors?
Sustainability and decarbonization Does the intervention increase GHG emissions and contribute to worsening of climate change?
Climate‐improved alternatives Is there an alternative intervention that has improved climate resilience or reduced environmental impact compared to the current intervention?
Mitigation Does the intervention have the potential to mitigate the impact of climate‐related factors on the health of individual pregnant people?
Resilience Does the intervention have the ability to contribute to resilience of the community to the negative impacts of climate change?
Accountability What entities are responsible for addressing the climate‐related vulnerabilities of the intervention at baseline and in climate emergencies?
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Abbreviation: GHG, greenhouse gas.

2.2. Search iteration strategy

Currently, no established framework or agreed‐upon MeSH terms exist to systematically search literature or other information sources for relevant evidence to address each criterion of the proposed climate lens framework. We therefore conducted an exploratory review combining high‐yield key search terms related to climate change with the specific health category and intervention under review. Data sources included PubMed, Embase, Web of Science, PubChem, AccessGUDID, and Devices@FDA. Given the emerging nature of climate‐health research not consistently indexed in traditional medical databases, we also utilized Google Scholar and news sources. For pharmaceutical interventions, search terms included International Council for Harmonisation (ICH) stability zones, temperature and humidity effects on drug stability, and cold chain vulnerabilities. Key search terms were chosen to reflect the highest yield direct and indirect climate factors that may impact health interventions, as well as common climate change terms used to define environmental impact and climate resilience (Appendix SII).

To contextualize the framework and ensure it was grounded in current evidence, we conducted targeted literature reviews examining associations between climate‐related factors and pregnancy complications across specific maternal and perinatal health topics included in WHO guidelines. Each umbrella health topic (e.g., postpartum hemorrhage [PPH], preeclampsia, induction of labor, augmentation of labor, preterm birth, maternal peripartum infections, antenatal corticosteroids, fistula, antenatal care, intrapartum care, and cesarean sections) was reviewed to document known or proposed associations between the topic's incidence or prevalence and climate‐related factors.

Conventionally, climate change research separates climate‐related factors into direct (i.e., immediate, physical manifestations of climate change that directly affect people and environments) and indirect (i.e., secondary or downstream consequences of climate‐related events that affect health through disruption of socioeconomic and health systems) factors [4]. Direct factors we considered were heat, floods, drought, rising sea levels/salination, extreme weather events (e.g., wildfires, cyclones, hurricanes, and related wind/dust exposures), and ambient air pollution. Indirect factors we considered were displacement/migration, health system service disruptions, food and water insecurity, and infectious diseases/vector‐borne illnesses. Where no data were available or associations between the health topic and climate‐related factors had not yet been established, attention was then given to major risk factors that may predispose that health area to climate change. Those risk factors were then evaluated for their associations with climate‐related factors to identify potential impacts.

2.3. Intervention categorization

To support consistent application of the climate lens framework across the WHO maternal and perinatal health intervention recommendations, each recommendation was first assigned to one of six primary intervention categories (device, drug/supplement, maneuver, counseling, testing, and policy/system) (Appendix SII). While the primary categories offer a general framework, many recommendations benefit from further subcategorization to allow for more nuanced analysis of similar interventions/recommendations. For instance, in obstetric care, several recommendations involve the use of intravenous oxytocin for PPH. Grouping these under an “oxytocin” subcategory enables more consistent evaluation, as the climate‐related considerations are often similar. Appendix SIII outlines the category and subcategory assignments.

2.4. Intervention rating

After collecting evidence, determinations were made for how each intervention would be impacted by the six criteria of the climate lens framework. Given the nature of climate‐health research as an emerging field and the limited availability of direct empirical evidence, we developed a rating scale that explicitly accommodates uncertainty in assessing how likely the intervention interacts with a changing climate (likely; possible; unlikely; uncertain; not applicable; see Table 2). This classification does not evaluate intervention efficacy but rather assesses climate vulnerability and potential climate‐related impact on implementation, access, or performance. This iterative process incorporated all available evidence, including indirect or analogous sources, and, when evidence was lacking, relied on common sense and empiric reasoning.

TABLE 2.

Intervention rating for climate lens framework criteria.

Rating Description
Likely Evidence exists to suggest that the key criterion question is true for this intervention.
Possible There is potential that the key criterion question is true based on a known feature of the intervention coupled with a physiologic understanding of that feature's possible outcome.
Unlikely Evidence exists to suggest that the key criterion question is untrue, or the nature of the intervention makes it extremely logically unlikely that the key criterion question is related to the intervention.
Uncertain There is neither data nor a common‐sense rationale to link the intervention to the key criterion question.
Not applicable The intervention pertains to the avoidance of an intervention rather than its application or is a duplicate recommendation to another existing recommendation already reviewed and graded.
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In Table 3, we describe our systematic approach for evidence‐based or empirically guided rating and standardized explanatory language for rating rationales (Table 3). This is designed to encourage consideration of key factors (e.g., type, scale, and delivery context of the intervention) that may influence its potential vulnerability to or impact from climate‐related factors. Users are encouraged to reflect on how specific categories may shift the rating and to document their reasoning in a transparent and systematic way. Devices and diagnostic testing, for example, are frequently rated as climate‐sensitive due to their reliance on stable electricity, sterile environments, and supply chains. In contrast, counseling and policy recommendations are generally less sensitive or emit fewer GHGs and may be critical for resilience and mitigation.

TABLE 3.

Systematic approach to climate lens rating by intervention type.

Climate sensitivity
Device Most devices are at least “possibly” sensitive to climate factors due to their reliance on vulnerable infrastructure, electricity, or storage conditions. While vulnerability varies, a baseline climate sensitivity is usually present.
  1. Is the device affected by heat, flooding, or power outages?
  2. Does it rely on electricity, sterilization, or controlled storage?
  3. Are materials or safety impacted by extreme temperatures or humidity?
  4. Could supply chains or infrastructure disruptions affect availability or cost?
  5. Would climate emergencies increase demand or limit access?
Drug or supplement Drugs and supplements are often sensitive to climate factors, especially when cold storage is required. Even shelf‐stable products can be impacted by heat, humidity, or transport disruptions, affecting safety and availability.
  1. Does the product require refrigeration or cold chain storage?
  2. Can heat, humidity, or transport disruptions affect stability or packaging?
  3. Are storage conditions realistic in climate‐affected settings?
  4. Could supply chain delays impact access or availability?
  5. Is the drug still effective if ambient conditions exceed recommended limits?
Maneuvers, counseling, and policies Maneuvers, counseling, and policy recommendations are generally not directly affected by climate factors, but indirect impacts may limit their effectiveness.
  1. Could weather events limit access to services?
  2. Is the intervention dependent on vulnerable infrastructure?
  3. Could workforce shortages affect delivery?
  4. Are recommended actions feasible in climate‐impacted settings?
  5. Could climate stressors reduce impact or uptake of recommendations?
Testing Testing depends on electricity, temperature control, and supply chains, making it vulnerable to climate disruptions. Heat, flooding, or outages can affect equipment, samples, and processing, including portable tests.
  1. Do tests or equipment rely on electricity or cold storage?
  2. Could weather impact sample integrity, equipment, or access?
  3. Are supply chains or materials at risk from climate disruptions?
  4. Could climate events affect staff availability or delay services?
  5. Are backup systems in place for continuity during disruptions?
Sustainability
Device Devices often contribute to GHG emissions, especially those made of plastics or requiring energy‐intensive processes like sterilization. Most devices lack life cycle analyses quantifying their carbon footprint across production, use, and disposal.
  1. Is there a life cycle analysis quantifying the device's carbon footprint?
  2. Is the device made from materials contributing to GHG emissions?
  3. Does it require energy‐intensive processes (e.g., sterilization)?
  4. Does it rely on packaging or cold chain logistics that impact emissions?
  5. Is the device single use, increasing its environmental impact?
Drug or supplement Drugs and supplements contribute to GHG emissions through energy‐intensive manufacturing, cold chain storage, and global distribution, with refrigeration and high‐volume production as major contributors. Packaging waste, like single‐use blister packs or syringes, also adds to the environmental impact.
  1. Are there studies on the environmental impact of the drug/supplement?
  2. Does it require energy or cold storage that contribute to emissions?
  3. Does its packaging waste increase environmental impact?
  4. Do the clinical benefits outweigh its environmental footprint?
  5. Do petrochemical ingredients in supplements contribute to its carbon footprint?
Maneuvers, counseling, and policies Recommendations in these sub‐categories are generally “unlikely” to directly contribute to GHG emissions. However, for counseling, maneuvers, and policies, emissions may increase or decrease based on provider transportation, training needs, or service reorganization.
  1. Could provider transport or training increase emissions?
  2. Do policies indirectly affect emissions through service changes?
  3. Do counseling or maneuvers require resources that increase emissions?
Testing Diagnostic testing, including lab and imaging, contributes to GHG emissions from energy use, consumables, and supply chains. Power‐intensive equipment and continuous electricity for imaging add to the carbon footprint, along with test kit manufacturing and waste disposal.
  1. Does the test use power‐intensive equipment?
  2. Does imaging require continuous electricity?
  3. Are consumables or reagents used that contribute to emissions?
  4. Does medical waste disposal increase emissions?
  5. Does test kit manufacturing contribute to the carbon footprint?
Climate‐improved alternatives
Device Climate‐resilient alternatives, such as manual or solar‐powered devices, can reduce reliance on electricity and material waste. These tools may offer improved climate resilience, but their availability and clinical equivalence vary.
  1. Are there non‐electric or reusable alternatives available for the device?
  2. Do solar‐powered models reduce reliance on electricity?
  3. Can alternative devices reduce material waste or supply chain dependence?
  4. Are climate‐resilient alternatives clinically equivalent to standard devices?
  5. Do alternative devices offer improved portability or simplified sterilization?
Drug or supplement Alternatives to standard drugs or supplements, like shelf‐stable or thermostable options, can improve climate resilience. Oral formulations may have a lower climate burden than injectables, but substitution must balance efficacy, feasibility, and local access.
  1. Are shelf‐stable or thermostable alternatives available?
  2. Could oral options reduce climate impact versus injectables?
  3. Are there more climate‐resilient production methods for the supplement?
  4. Can regimens be adjusted to reduce climate impact (e.g., using whole foods)?
  5. Are heat‐stable alternatives available, and how do they compare in efficacy?
Maneuvers, counseling, and policies Clinical maneuvers, counseling, and policy are generally low‐impact and sustainable. However, some alternatives may reduce emissions.
  1. Can telehealth or task‐shifting reduce emissions?
  2. Do substitutions consider effectiveness and access?
  3. Can decentralized care improve sustainability?
Testing Some diagnostic tests have climate‐resilient alternatives, like point‐of‐care tests or portable devices, that don't require electricity or refrigeration. However, these alternatives may not achieve similar diagnostic sensitivity, cost, or scalability. Decentralizing testing may reduce climate vulnerability.
  1. Can mobile testing reduce reliance on central facilities?
  2. Could point‐of‐care offer climate‐resilient alternatives?
  3. Are solar‐powered devices viable for sustainable imaging?
  4. Can decentralized diagnostics improve access in climate‐affected areas?
  5. Do paper‐based or dry reagents reduce environmental impact?
Mitigation
Device If the device prevents or manages adverse outcomes (e.g., hemorrhage) potentially worsened by climate impacts (e.g., heat, displacement), it may offer indirect mitigation.
  1. Can the device mitigate climate‐worsened outcomes?
  2. Could the device help with climate‐related health complications?
Drug or supplement Drugs or supplements that reduce the severity or incidence of complications influenced by climate‐sensitive pathways (e.g., infection, inflammation, malnutrition).
  1. Can the drug/supplement mitigate climate‐related pregnancy outcomes?
  2. Does the drug/supplement address climate‐induced factors like heat or infection?
Maneuver Timely, low‐resource interventions may reduce morbidity that is climate‐sensitive (e.g., intrapartum complications worsened by heat or infrastructure failure).
  1. Can the maneuver reduce climate‐related pregnancy complications?
  2. Could the maneuver minimize delays in extreme conditions?
Counseling Counseling on hydration, infection prevention, or heat exposure could reduce individual exposure to climate‐related health stressors.
  1. Can counseling mitigate climate‐related pregnancy outcomes?
  2. Could counseling reduce climate‐related risks like dehydration or hypertension?
Policy Policies that safeguard continuity of care or prepare systems for climate events may reduce risk to individuals during crises.
  1. Can policy/system mitigate climate‐related pregnancy outcomes?
  2. Can policy/system ensure service continuity during climate disruptions?
Testing Early detection of climate‐sensitive conditions (e.g., vector‐borne illness, anemia) may prevent worsening of maternal health during climate stress.
  1. Can testing mitigate climate‐related pregnancy outcomes?
  2. Could testing detect climate‐related health risks like anemia or malaria?
Resilience
Device Durable, mobile, or infrastructure‐independent devices help maintain services when facilities or supply chains are compromised.
  1. Can the device help to maintain care during climate disruptions?
  2. Can integrating the device strengthen community resilience?
Drug or supplement Shelf‐stable or widely available formulations support care continuity when supply chains are disrupted.
  1. Can this drug or supplement have ensured access during crises?
  2. Can inclusion in emergency plans strengthen system resilience?
Maneuver Low‐tech, hands‐on techniques preserve quality care when electricity or advanced equipment is unavailable.
  1. Can the maneuver provide safe care without reliance on fragile infrastructure?
  2. Can training and protocol integration enhance resilience in climate‐stressed contexts?
Counseling Community‐centered education improves preparedness and adaptive capacity.
  1. Can counseling improve preparedness for climate stress?
  2. Can counseling strengthen resilience to climate‐related risks?
Policy Long‐term system planning and investments reduce maternal service vulnerability to climate shocks.
  1. Can policy/system strengthen maternal care resilience?
  2. Can long‐term planning reduce vulnerability to climate shocks?
Testing Decentralized or point‐of‐care tools maintain diagnostic services when centralized labs are inaccessible.
  1. Can point‐of‐care testing maintain diagnostic services?
  2. Can community‐based testing reduce reliance on central infrastructure?
Accountability
International agency Governments Manufacturers Health care systems Health care providers Local communities
Device x x x x
Drug or supplement x x x x x
Maneuver x x x x
Counseling x x x x
Policy x x x x
Testing x x x x x
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Abbreviation: GHG, greenhouse gas.

Regarding the final climate criterion, we considered who should be accountable for climate‐related vulnerabilities relevant to a specific guideline, across a spectrum from the individual health care provider to the broader health care system, communities, governmental bodies, and international stakeholders. In our framework development, we felt it was important for each category of intervention to consider which stakeholders are best positioned and obligated to address the specific climate vulnerabilities. In Table 3, we outline a mapping of general stakeholders responsible for climate‐related vulnerabilities for each intervention category. This mapping should be considered dynamic and subject to change, particularly as the roles of health care systems, governments, and global organizations evolve or differ across countries and local contexts.

2.5. Bias mitigation

Framework development and application inherently require interpretive judgment, which may introduce potential biases, especially in areas where empirical evidence is sparse or indirect. To address this, we incorporated the following strategies: (1) multidisciplinary perspectives (obstetrics and gynecology, public health, environmental science) in framework development, (2) standardized rating criteria and explanatory language, (3) independent dual review of all ratings, and (4) senior author consensus to resolve discrepancies. Collectively, these measures helped balance diverse disciplinary perspectives while promoting transparent and methodologically rigorous application of the framework.

2.6. Systematic approach

Finally, we describe here the practical approach of how our team integrated these considerations and applied this framework. Our team reviewed all WHO guidelines published between 2011 and 2022 that outline clinical recommendations for routine care and management of common pregnancy complications (Appendix SIV). In total, we reviewed 298 unique recommendations across the 10 maternal and perinatal health topics that were published by the WHO. We organized our work into a table categorized by health topic, coded with a unique WHO identifier listing the individual recommendation. Certain recommendations were excluded from our analysis if the intervention pertained primarily to the avoidance of an action (e.g., guidance to recommend against a supplement) rather than its application, or if the recommendation duplicated content already captured and graded elsewhere.

Our team included a total of 11 primary reviewers with reproductive health training. Each maternal or perinatal health category was assigned to a subset of reviewers who divided the recommendations within that category among themselves to ensure consistency and familiarity with the topic area. Each individual recommendation was first evaluated by the assigned primary reviewer using the climate lens framework. For each of the six criteria, a focused literature review was conducted to identify available supporting evidence as described above. The primary reviewer then assigned a preliminary rating for each criterion and provided written rationale for each rating determination. A secondary reviewer then evaluated the assigned ratings to confirm that each rating aligned with the available evidence and framework guidance with clear, logical, and adequately justified rationales. Once all primary and secondary reviews were complete, all recommendations and their associated ratings were subsequently reviewed by a panel of senior authors. Recommendations with discrepant ratings were discussed until a final consensus was achieved. Common sources of discrepancy included differing interpretations of limited evidence, varying judgments about the applicability of indirect or analogous evidence, and different weightings of theoretical versus empirical considerations. Each recommendation was assigned final ratings for each of the six criteria, accompanied by a consensus‐derived rationale and the available supporting evidence.

3. RESULTS

The full review of all recommendations and associated evidence is available in the Supporting Information (see Appendices SIV and SV). To better demonstrate the process so that this framework may be applied, expanded, or updated by others as new WHO recommendations arise, we detail here the application of the climate lens framework to the recommendation on the use of oxytocin for PPH as a representative example. We present the rationale, findings, recommendations, and supporting evidence used to inform the climate lens framework of determinations for this recommendation and describe the iterative process in detail.

3.1. Application of climate lens framework to postpartum oxytocin use

The recommendation categorized by WHO ID ‘’PPH 08″ is as follows: “In settings where multiple uterotonic options are available, oxytocin (10 IU, IM/IV) is the recommended uterotonic agent for the prevention of PPH for all births.” This recommendation applies specifically to settings with access to multiple uterotonic agents, is intended for prevention rather than treatment of PPH, and is framed as a universal recommendation applicable to all births. When evaluated through a climate lens, this recommendation necessitates consideration of storage requirements, supply chain reliability, feasibility across diverse settings, and implications for large‐scale implementation. Assessment of this WHO recommendation utilizing the framework followed a structured, multistep review process as described in Section 2 and rating determinations are summarized in Table 4.

TABLE 4.

Climate lens evaluation of WHO recommendation on postpartum oxytocin use.

WHO ID Recommendation Category Sensitivity Sustainability Alternatives Resilience Mitigation
PPH008 In settings where multiple uterotonic options are available, oxytocin (10 IU, IM/IV) is the recommended uterotonic agent for the prevention of PPH for all births.

Drug or supplement

Subcategory: oxytocin

 Likely Possible Likely Uncertain Uncertain
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Abbreviations: PPH, postpartum hemorrhage; WHO, World Health Organization.

3.1.1. Criterion 1: Climate sensitivity

Oxytocin requires storage at 2°C–8°C and therefore depends on reliable cold‐chain infrastructure [19, 20]. Studies continue to demonstrate significant barriers to maintaining consistent cold storage for oxytocin, with a lack of refrigeration facilities and unreliable electricity cited as major challenges [21, 22, 23]. Although recent evidence suggests that certain oxytocin formulations may retain acceptable potency during short‐term storage at temperatures up to approximately 30°C, degradation in drug concentration has been reported [24, 25]. Especially in settings with high ambient temperatures, prolonged heat exposure, high humidity, or when packaging is compromised by flooding or transport disruptions, oxytocin may lose potency. Extreme weather events may also interrupt supply chains and delay distribution. As a result, oxytocin demonstrates sensitivity to climate‐related factors, particularly in contexts where storage and transport conditions cannot be consistently maintained. The final consensus rating for Criterion 1 for this recommendation was “Likely.”

3.1.2. Criterion 2: Sustainability

No studies were identified that directly evaluate the environmental impacts of oxytocin production, distribution, use, or disposal. A life cycle analysis, which is commonly used in climate and environmental science to assess the full environmental footprint of products and interventions, systematically evaluates impacts across all stages of a product's lifespan, including raw material extraction, manufacturing, storage, transport, clinical use, and waste disposal. To date, a life cycle analysis specific to synthetic oxytocin has not been published, limiting the ability to quantify its carbon footprint or identify opportunities for more sustainable manufacturing or distribution practices. Despite the absence of such data, the clinical benefit of oxytocin for prevention of PPH is likely to outweigh any potential environmental impacts associated with its production or medical waste. The final consensus rating for Criterion 2 for this recommendation was “Possible.”

3.1.3. Criterion 3: Climate‐improved alternatives

Among uterotonics used for prevention and treatment of PPH, temperature stability emerged as the primary climate‐related vulnerability.

Heat‐stable carbetocin (HCS), a long‐acting oxytocin analogue, does not require refrigeration and is less susceptible to storage and transport disruptions [26, 27, 28]. It has been shown to be noninferior to oxytocin for prevention of PPH and is available at subsidized pricing in many public health sectors [29]. Furthermore, a recent study in Uganda demonstrated that when compared to misoprostol, there were better outcomes and significantly lowered public health care costs [30]. However, its use is limited to prevention, its administration still requires trained personnel for intramuscular or intravenous delivery and unlike oxytocin, and it is not available in fixed‐dose combination with ergometrine.

Misoprostol represents a second‐line, heat‐stable alternative that does not require cold‐chain storage and may be distributed for use in community settings by trained birth attendants. This may enhance both individual and community resilience when health facilities are inaccessible due to climate‐related disruptions. However, misoprostol is less effective for prevention of PPH than oxytocin or ergometrine‐based regimens, and its stability may be compromised without appropriate packaging (i.e., blistering in double‐aluminum foil to protect tablets from humidity). Beyond these storage considerations, the feasibility of community‐distributed misoprostol for prevention and treatment PPH may be limited by legal and social restrictions related to its association with pregnancy termination [31, 32]. However, it is important to note that the 2025 WHO PPH guideline update explicitly recommends the administration of misoprostol by trained community or lay health workers and, in settings without skilled birth attendants, permits self‐administration for PPH prevention. Emerging evidence cited in these expanded recommendations underscores the role of misoprostol to strengthen PPH prevention in crisis settings, including those driven by climate‐related disruptions [33]. Finally, a novel heat‐stable inhaled (IH) oxytocin formulation has been tested in Phase I trials in healthy non‐pregnant patients. While initial studies have demonstrated that IH oxytocin can provide a similar oxytocin systemic exposure compared to intramuscular oxytocin, Phase II efficacy trials evaluating clinical outcomes such as PPH rates and maternal morbidity have not been published [34]. The final consensus rating for Criterion 3 for this recommendation was “Likely.”

3.1.4. Criterion 4: Mitigation

No studies were identified demonstrating that oxytocin mitigates climate‐induced adverse pregnancy outcomes. While it does not directly address climate‐related exposures such as heat or infection, oxytocin may plausibly mitigate downstream consequences of such exposures by preventing PPH. The final consensus rating for Criterion 4 for this recommendation was “Uncertain.”

3.1.5. Criterion 5: Resilience

Although oxytocin does not directly contribute to climate resilience, its availability supports health system resilience by ensuring continued access to essential maternal medications during emergencies. A system dynamic modeling study completed using publicly available data from Zanzibar and Sub‐Saharan Africa demonstrated the substantial gaps between oxytocin procurement and actual availability and suggests that there are opportunities to strengthen community maternal health resilience through improved procurement strategies and more adaptive storage facilities for oxytocin [35]. Inclusion of oxytocin and alternative uterotonics in emergency preparedness planning or local stockpiling strategies may also strengthen resilience in settings affected by climate‐related disruptions. The final consensus rating for Criterion 5 for this recommendation was “Uncertain.”

3.1.6. Criterion 6: Accountability

Similar to most drugs and supplements evaluated using the climate lens framework (Table 3), accountability for climate‐related vulnerabilities associated with oxytocin spans multiple levels, including health care providers, health systems, supply chain stakeholders, and governmental or international bodies. Responsibilities include appropriate procurement of oxytocin produced in countries with stringent regulatory authorities, appropriate storage and cold‐chain monitoring at the facility level, procurement and transport logistics at the health system level, and regulatory oversight and emergency preparedness planning at broader governance levels [21, 23, 36]. These accountability considerations informed the overall rating and resilience assessment for this recommendation.

3.2. Climate assessment and rationale for all WHO recommendations

In addition to the representative example described above, we conducted a climate‐related assessment of the complete set of WHO maternal health recommendations based on the iteration available in early 2025, which is detailed in the Appendix. The climate rating for each intervention in Appendix SIV uses a color‐coded “heat map” format, designed to help researchers and clinicians quickly visualize which recommendations are most or least likely to be influenced by climate‐related factors such as temperature sensitivity, supply chain vulnerabilities, or sustainability challenges. This visual tool also aims to highlight areas where there is limited supporting evidence and uncertain climate vulnerability to support targeted areas of focus for future research. Appendix SV provides the accompanying references, where available, for each intervention's rating. Together, these appendices summarize both the existing evidence base and the empiric or hypothetical climate‐related considerations that informed rating decisions and identify priority areas for future research.

Specifically, across interventions, there was limited or no published evidence evaluating the environmental lifecycle impacts of commonly used medications, including GHG emissions associated with production, distribution, storage, and disposal. Data linking specific interventions to mitigation of climate‐induced adverse pregnancy outcomes were similarly sparse. In addition, evidence assessing the performance of maternal health interventions under climate‐stressed conditions, such as extreme heat, supply chain disruption, or health system strain, was frequently indirect, extrapolated, or absent. For alternative or climate‐resilient interventions, available studies often focused on efficacy under standard conditions, with limited evaluation of real‐world feasibility, legal constraints, or implementation during climate‐related emergencies.

4. DISCUSSION

In this document, we have outlined the development and application of a climate lens framework to the full library of current WHO recommendations for maternal and perinatal health. We have detailed numerous climate‐relevant search keywords related to both direct and indirect climate factors to aid others in conducting similar exploratory reviews of evidence. Additionally, we also propose several climate‐related criteria to assess new and existing health interventions and policies for their climate vulnerabilities and sustainability. We have detailed the application of our climate lens framework to a representative example, the use of oxytocin for the prevention of PPH, to demonstrate how the framework criteria and search strategy can be applied to current and future clinical recommendations. Overall, this iterative work draws from collaborators across the fields of obstetrics and gynecology, public and global health, and environmental science to build a framework that we believe will be applicable during the development and revision of clinical guidelines with an eye toward climate resilience, adaptability, and sustainability. The methodology developed and proposed herein can guide future policymakers when considering evaluation and adoption of novel guidelines.

Integration of climate considerations into the WHO maternal and perinatal health recommendations helps stakeholders anticipate the climate‐relevant limitations of formalized guidelines, supports climate preparedness and resilience, and informs nations and communities how WHO recommendations may be adapted to fit unique geographic and ecologic contexts. Systematically detailing how a medication, for example, may be climate vulnerable due to its cold storage requirements may seem obvious when viewed through the high‐income and well‐resourced perspective; however, member states that rely on WHO guidelines to inform clinical practices are currently grappling with these trade‐offs and face true barriers to implementation of recommendations. For these nations and localities, the evidence outlined by this framework may inform their policy adoption, tailoring, and resource prioritization.

Overall, our initial framework application shows multiple climate‐related vulnerabilities of WHO maternal health recommendations that warrant attention. The distribution, delivery, and administration of temperature‐sensitive pharmaceuticals is a key concern that must be addressed to deliver climate‐resilient health care. Further, we highlight potential sources of individual and community resilience in the example intervention that could be implemented at the community level, particularly in settings where access to highly trained health care personnel or resource‐intensive facilities is limited. It is important to emphasize that even if an intervention contributes to GHG emissions or other climate factors, this should not be translated as an unworthy practice to protect and optimize the health of maternal‐newborn populations. In short, identifying climate‐related contributions should not and does not imply that the intervention's clinical use ought to be revised or withheld from patients.

The largest limitation of our work relates to a lack of robust and extensive research on the intersection of the recommended interventions, health outcomes, and climate‐related factors. Our framework in its current form relies in part on the use of common‐sense interpretation in the absence of definitive data. Relatedly, we acknowledge that quantifying climate impacts of clinical practices is challenging—however, we argue that this complexity makes a systematic framework with multiple criteria even more essential in fully assessing the scope of climate change on recommendations. Despite these limitations, this first‐application effort is valuable as the increasing burden of climate change on health outcomes creates an urgent need for more research and innovative solutions. While this represents a first iteration of a climate assessment framework that will benefit from further refinement, we believe it is a novel and actionable approach, offering a practical tool for immediate use and foundation for identifying future research priorities that merit further attention and funding.

Nations are currently envisioning resilience and adaptation strategies to answer real‐time, climate‐driven barriers to health care access. Several communities in geographies subject to excessive ambient heat or extreme heat waves, such as Ahmedabad, India and Senegal's Sahel region have established high heat early warning systems to increase community knowledge of heat‐related health risks and reduce exposure to high heat [37, 38, 39]. Understanding the critical nature of cold supply for implementation of many evidence‐based clinical guidelines, novel refrigeration techniques are being employed in Malawi to extend refrigeration capacity in the event of power failures. Another resilience mechanism comes from Rwanda's use of drones for the delivery of blood products, showing how technology can be utilized to overcome transport and infrastructure barriers to life‐saving obstetric care in climate‐vulnerable settings [39, 40, 41]. Evaluating clinical guidelines for their climate vulnerabilities and limitations in a systematic way may better highlight focus areas for countries developing climate mitigation programming. Findings from climate lens framework may also highlight further climate mitigation research priorities, such as the WHO‐led Research to Expand Access to Heat‐Stable Carbetocin (REACH) trial, an international phase III trial across seven countries studying the effect of HSC in the prevention of PPH [42]. Implementation of a climate lens framework may elucidate further knowledge gaps or areas for programmatic development with the goal of increasing access to evidence‐based clinical practices.

In summary, we propose that climate be an additional consideration in the WHO's EtD framework during guideline development alongside other critical considerations such as equity and cost‐effectiveness. We developed a climate lens framework that was then applied to the current ∼300 guidelines espoused by the WHO for maternal‐newborn health to illustrate the potential incorporation of such an approach into guideline development. Through the systematic application of our framework, we identified multiple vulnerabilities of current WHO recommendations to climate factors that will be important for health systems and policymakers to address in the face of a changing global climate. Key next steps in this work will involve further defining climate accountability for maternal‐newborn guidelines and conducting more research to clarify the health impacts of climate change.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflicts of interest.

Supporting information

Supporting Information

PMF2-2-e70251-s001.docx (7.1MB, docx)

ACKNOWLEDGMENTS

This work was funded by the UNDP‐UNFPA‐UNICEF‐WHO‐World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), a co‐sponsored program executed by the World Health Organization (WHO). The funding body had no role in designing the study, data collection and analysis, data interpretation, or in the writing of the manuscript. The authors alone are responsible for the views expressed in this article and they do not necessarily represent the views, decisions, or policies of the institutions with which they are affiliated.

REFERENCES

  • 1. World Health Organization . 2015. Quantitative Risk Assessment of the Effects of Climate Change on Selected Causes of Death, 2030s and 2050s. Accessed February 2, 2025. https://iris.who.int/server/api/core/bitstreams/785da4b3‐7797‐44f5‐a01b‐eab29c3ac99b/content.
  • 2. World Health Organization . 2018. COP24 Special Report: Health & Climate Change. Accessed February 2, 2025. https://iris.who.int/server/api/core/bitstreams/4fccdf46‐2319‐41a8‐8765‐34bedfa1d6c0/content.
  • 3. Romanello, M. , McGushin A., Di Napoli C., Drummond P., Hughes N., Jamart L., Kennard H., et al. 2021. “The 2021 Report of the Lancet Countdown on Health and Climate Change: Code Red for a Healthy Future.” Lancet 398(10311): 1619–22. 10.1016/S0140-6736(21)01787-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 4. Bianco, G. , Espinoza‐Chávez R. M., Ashigbie P. G., Junio H., Borhani C., Miles‐Richardson S., and Spector J., 2024. “Projected Impact of Climate Change on Human Health in Low‐ and Middle‐Income Countries: A Systematic Review.” BMJ Global Health 8(Suppl 3): e015550. 10.1136/bmjgh-2024-015550. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 5. World Health Organization . 2014. Gender, Climate Change, and Health. Accessed February 2, 2025. https://iris.who.int/server/api/core/bitstreams/70319151‐2a0c‐467b‐9dea‐8183fb4c8ebf/content.
  • 6. Segal, T. R. and Giudice L. C.. 2022. “Systematic Review of Climate Change Effects on Reproductive Health.” Fertility and Sterility 118(2): 215–23. [DOI] [PubMed] [Google Scholar]
  • 7. Ha, S. 2022. “The Changing Climate and Pregnancy Health.” Current Environmental Health Reports 9(2): 263–75. 10.1007/s40572-022-00345-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 8. Fan, W. and Zlatnik M. G.. 2023. “Climate Change and Pregnancy: Risks, Mitigation, Adaptation, and Resilience.” Obstetrical & Gynecological Survey 78(4): 223–36. 10.1097/OGX.0000000000001116. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 9. Chersich, M. F. , Pham M. D., Areal A., Haghighi M. M., Manyuchi A., Swift C. P., Wernecke B., et al. 2020. “Associations Between High Temperatures in Pregnancy and Risk of Preterm Birth, Low Birth Weight, and Stillbirths: Systematic Review and Meta‐Analysis.” BMJ 371: m3811. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 10. Bekkar, B. , Pacheco S., Basu R., and DeNicola N.. 2020. “Association of Air Pollution and Heat Exposure With Preterm Birth, Low Birth Weight, and Stillbirth in the US: A Systematic Review.” JAMA Network Open 3(6): e208243. 10.1001/jamanetworkopen.2020.8243. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 11. Mao, Y. , Gao Q., Zhang Y., Yue Y., Ruan T., Yang Y., and Xiong T., 2023. “Associations Between Extreme Temperature Exposure and Hypertensive Disorders in Pregnancy: A Systematic Review and Meta‐Analysis.” Hypertension in Pregnancy 42(1): 2288586. 10.1080/10641955.2023.2288586. [DOI] [PubMed] [Google Scholar]
  • 12. Ha, S. , Liu D., Zhu Y., Sherman S., and Mendola P.. 2018. “Acute Associations Between Outdoor Temperature and Premature Rupture of Membranes.” Epidemiology 29(2): 175–82. 10.1097/EDE.0000000000000779. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 13. Jiao, A. , Sun Y., Sacks D. A., Avila C., Chiu V., Molitor J., Chen J.‐C., et al. 2023. “The Role of Extreme Heat Exposure on Premature Rupture of Membranes in Southern California: A Study From a Large Pregnancy Cohort.” Environment International 173: 107824. 10.1016/j.envint.2023.107824. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 14. Pappas, A. , Kovats S., and Ranganathan M.. 2024. “Extreme Weather Events and Maternal Health in Low‐Income and Middle‐Income Countries: A Scoping Review.” BMJ Open 14(6): e079361. 10.1136/bmjopen-2023-079361. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 15. Suter, M. A. and Aagaard K. M.. 2023. “Natural Disasters Resulting From Climate Change: The Impact of Hurricanes and Flooding on Perinatal Outcomes.” Seminars in Perinatology 47(8): 151840. 10.1016/j.semperi.2023.151840. [DOI] [PubMed] [Google Scholar]
  • 16. Evans, J. , Bansal A., Schoenaker D., Cherbuin N., Peek M. J., and Davis D. L.. 2022. “Birth Outcomes, Health, and Health Care Needs of Childbearing Women Following Wildfire Disasters: An Integrative, State‐of‐the‐Science Review.” Environmental Health Perspectives 130(8): 86001. 10.1289/EHP10544. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 17. World Health Organization . 2023. Protecting Maternal, Newborn and Child Health From the Impacts of Climate Change: A Call for Action. Accessed February 2, 2025. https://iris.who.int/server/api/core/bitstreams/731c186b‐c1ed‐42e5‐99d5‐835b7b98b1c3/content.
  • 18. Cochrane Norway . Evidence to Decision Frameworks (EtDs) for Policy Makers. Accessed November 1, 2025. https://www.cochrane.no/decide‐frameworks‐policy‐makers.
  • 19. Office of the Commissioner, U.S. Food and Drug Administration . Oxytocin (High Potency Powder). Prescribing Information. DailyMed. Accessed July 18, 2025. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=36eff826-723b-4f6d-891c-79f3282109e4.
  • 20. Oxytocin (High Potency Powder) . Prescribing Information. DailyMed. GRINDEKS Joint Stock Company. Updated January 14, 2025. Accessed July 21, 2025. https://dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl.cfm?setid=36eff826-723b-4f6d-891c-79f3282109e4&type=display.
  • 21. de Vries, E. L. , van Tetering A. A. C., van der Hout M. B., Derijks L. J. J., Sseguya S. P., Namagembe I., Byamugisha J., and Oei S. G.. 2021. “Storage Conditions of Oxytocin in a Tropical Climate in a Low‐Income Country.” International Journal of Gynaecology and Obstetrics 154(1): 44–8. 10.1002/ijgo.13505. [DOI] [PubMed] [Google Scholar]
  • 22. Oliver, V. L. , Lambert P. A., Than K. K., Mohamed Y., Luchters S., Verma S., Yadav R., et al. 2018. “Knowledge, Perception and Practice Towards Oxytocin Stability and Quality: A Qualitative Study of Stakeholders in Three Resource‐Limited Countries.” PLoS ONE 13(9): e0203810. 10.1371/journal.pone.0203810. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 23. Hagen, N. , Khuluza F., and Heide L.. 2020. “Quality, Availability and Storage Conditions of Oxytocin and Misoprostol in Malawi.” BMC Pregnancy Childbirth 20: 184. 10.1186/s12884-020-2810-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 24. Lee, C. C. , Gwaza L., Rombouts K., Hu P., Kuwana R., Remmerie B., Ejekam C., Okunade K., and Lambert P.. 2025. “Closing the Gaps in the Access to Quality‐Assured Medicines for Global Health: The Case for Oxytocin for Postpartum Haemorrhage.” Expert Review of Clinical Pharmacology 18(1–2): 41–9. 10.1080/17512433.2024.2447775. [DOI] [PubMed] [Google Scholar]
  • 25. Hodgins, S. and Lukulay P. H.. 2017. “The Impact of Thermal Stability of Oxytocin on Access, and the Importance of Setting Proper Product Specifications.” International Journal of Gynaecology and Obstetrics 136(3): 253–4. 10.1002/ijgo.12071. [DOI] [PubMed] [Google Scholar]
  • 26. Adnani, Q. E. S. , Adepoju V. A., and Jamil S.. 2025. “Heat‐Stable Carbetocin in the Management of Postpartum Haemorrhage in Low‐ and Middle‐Income Countries: A Comprehensive Review of Clinical Evidence, Cost‐Effectiveness, Implementation Challenges and Adoption Strategies.” International Journal of Women's Health 17: 1615–30. 10.2147/IJWH.S515252. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 27. 2018. WHO Recommendations: Uterotonics for the Prevention of Postpartum Haemorrhage. Geneva: World Health Organization. Web Annex 2, Carbetocin Versus Placebo or no Treatment: Evidence to Decision framework. https://www.ncbi.nlm.nih.gov/books/NBK535977/. [PubMed] [Google Scholar]
  • 28. Su, L. L. , Chong Y. S., and Samuel M.. 2012. “Carbetocin for Preventing Postpartum Haemorrhage.” Cochrane Database of Systematic Reviews 2012(4): CD005457. 10.1002/14651858.CD005457.pub. [DOI] [PubMed] [Google Scholar]
  • 29. Widmer, M. , Piaggio G., Nguyen T. M. H., Osoti A., Owa O. O., Misra S., Coomarasamy A., et al. 2018. “Heat‐Stable Carbetocin Versus Oxytocin to Prevent Hemorrhage After Vaginal Birth.” New England Journal of Medicine 379(8): 743–52. 10.1056/NEJMoa1805489. [DOI] [PubMed] [Google Scholar]
  • 30. Ononge, S. , Kakaire O., Mwembezi J., Nakatudde H., Mutumba R., and Mugahi R.. 2025. “Cost‐effectiveness Results Comparing Heat‐Stable Carbetocin & Other Uterotonics in Postpartum Haemorrhage Prevention in Uganda.” PLOS Global Public Health 5(4): e0003562. 10.1371/journal.pgph.0003562. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 31. Oladapo, O. T. , Blum J., Abalos E., and Okusanya B. O.. 2020. “Advance Misoprostol Distribution to Pregnant Women for Preventing and Treating Postpartum Haemorrhage.” Cochrane Database of Systematic Reviews 6(6): CD009336. 10.1002/14651858.CD009336.pub3. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 32. Tiruneh, G. T. , Yakob B., Ayele W. M., Yigzaw M., Roro M. A., Medhanyi A. A., Hailu E. G., and Bayou Y. T., 2019. “Effect of Community‐Based Distribution of Misoprostol on Facility Delivery: A Scoping Review.” BMC Pregnancy Childbirth 19(1): 404. 10.1186/s12884-019-2521-7. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 33. Papageorghiou, A. T. , Kihara A.‐B., Dunkley‐Bent J., Ahsan S., Begum F., Escobar Vidarte M. F., Homer C., et al. 2025. “New Guidelines for the Prevention, Diagnosis, and Treatment of Postpartum Haemorrhage: Ending the Geography of Risk.” Lancet Global Health 13(11): e1796–e8. 10.1016/S2214-109X(25)00404-8. [DOI] [PubMed] [Google Scholar]
  • 34. Fernando, D. , Siederer S., Singh S., Schneider I., Gupta A., Powell M., Richards D., McIntosh M. P., Lambert P., and Fowles S.. 2017. “Safety, Tolerability and Pharmacokinetics of Single Doses of Oxytocin Administered via an Inhaled Route in Healthy Females: Randomized, Single‐Blind, Phase 1 Study.” EBioMedicine 22: 249–55. 10.1016/j.ebiom.2017.07.020. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 35. Nadkarni, D. , Gravelyn S., Brova M., Rashid S., Yee R., Guttieres D., Clifford K., Desai D., and Zaman M.. 2018. “Modeling Patient Access to Therapeutic Oxytocin in Zanzibar, Tanzania.” BMC Health Services Research 18(1): 645. 10.1186/s12913-018-3452-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 36. Morris, K. , Pasha A., Li X., and Qiao S.. 2026. “Disaster Preparedness of Health Systems in LMICs in the Face of Climate Change: A Systematic Mapping Review of Vulnerabilities and Response Strategies.” BMC Public Health 26: 217. 10.1186/s12889-025-25873-5.. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 37. Hess, J. J. , LM S., Knowlton K., Saha S., Dutta P., Ganguly P., Tiwari A., et al. 2018. “Building Resilience to Climate Change: Pilot Evaluation of the Impact of India's First Heat Action Plan on All‐Cause Mortality.” Journal of Environmental and Public Health 2018: 7973519. 10.1155/2018/7973519. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 38. USAID . 2024. Case Study: A Health Early Warning System to Reduce Extreme Heat Impacts in the Sahel. https://heathealth.info/wp‐content/uploads/CASA_Global‐Health_Senegal‐Case‐Study.pdf.
  • 39. Sharma, L. , Singh J., Dhiman R., Vargas Nunez D. R., Ba A. E., Joshi K. J., Modi B., Padhi A., Tandon J. K., and Seidel M.. 2024. “Advancing Solar Energy for Primary Healthcare in Developing Nations: Addressing Current Challenges and Enabling Progress Through UNICEF and Collaborative Partnerships.” Cureus 16(1): e51571. 10.7759/cureus.51571. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 40. Amukele, T. 2022. “Using Drones to Deliver Blood Products in Rwanda.” Lancet Global Health 10(4): e463–e4. 10.1016/S2214-109X(22)00095-X. [DOI] [PubMed] [Google Scholar]
  • 41. Nisingizwe, M. P. , Ndishimye P., Swaibu K., Nshimiyimana L., Karame P., Dushimiyimana V., Musabyimana J. P., Musanabaganwa C., Nsanzimana S., and Law M. R., 2022. “Effect of Unmanned Aerial Vehicle (Drone) Delivery on Blood Product Delivery Time and Wastage in Rwanda: A Retrospective, Cross‐Sectional Study and Time Series Analysis.” Lancet Global Health 10(4): e564–e9. 10.1016/S2214-109X(22)00048-1. [DOI] [PubMed] [Google Scholar]
  • 42. World Health Organization . 2023. Research to Expand Access to Heat‐Stable Carbetocin for the Treatment of Postpartum Haemorrhage (REACH): Current Project Brief. https://cdn.who.int/media/docs/default-source/hrp/projects/mph/project-brief-reach.pdf?sfvrsn=4e022a83_3&download.

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