Importantly, the results showed that the knowledge could potentially contribute to the players’ decision-making process for DRR by assisting them in making pre-decision. Beside this knowledge, the results expanded the range of influencing factors and solutions reported by previous literature on DRR under an urbanization background against climate hazards by constructing counterfactual scenarios, e.g., higher economic levels and policy incentives. In this study, the serious game was evaluated as an innovative communication and the EfS method in counterfactual scenarios. These findings of the study provide a reference for future practice, policymaking, and decision making so as to help harness lessons learned from unrealized environmental hazards to support a more resilient future through informed policies and plans.Urban development and disaster risk are deeply linked, especially now when we are facing increasingly frequent climate change. Hence, knowledge of the potential trade-offs between urban development and disaster risk reduction (DRR) may have potential to build a resilient and sustainable future. The objectives of this study are (1) to present education for a sustainability (EfS) program and to evaluate its performance: a serious game of knowledge communication for the interactions among climate change, disaster risk, and urban development; (2) to explore factors that will influence the players’ decision making in the trade-offs between urban development and DRR under an urbanization background through counterfactual scenarios constructed by a series of serious games. The Yudai Trench, once a critical component of the urban green infrastructure of ancient Guangzhou, has disappeared under rapid urban expansion, leaving the city exposed to environmental hazards caused by climate change. Is the disappearance of the Yudai Trench an inevitable event in the progress of urbanization? To answer this question, the study constructed counterfactual scenarios by recuring the historical progress through the same serious game. Gameplay involved the players’ decision making with associated impacts on the urbanization progress and the DRR in diverse climate hazard scenarios. For this study, 107 undergraduates from related majors, who are also would-be policymakers, were selected as players. The methodology combined questionnaire survey and participant observation complemented by interviews. The  Urbanization is a common development trend in the world and a sign of human civilization and progress. However, as cities and clusters of cities, or conurbations, expand, the higher infrastructure strain and the increasing energy demand have led to ecological degradation . More frPrevious studies on the relationships among urban development, climate change, and disaster risk are extensive.The complex and intertwined interaction between urban development and disaster risk has been illustrated in numerous studies: rapid urban development increases disaster risk and vulnerability, and disaster risk often leads to significant losses and hinders further urban development . FrequenFor the relationship between climate change and disaster risk, White et al.  argued tIdentifying the resilience building as one of the central concepts, the 2030 Agenda for Sustainable Development incorporates goals related to DRR into several Sustainable Development Goals (SDGs) . FurtherA possible view for this question is to consider the trade-offs between urban development and DRR processes in the context of climate change. Trade-offs, defined as choices involving diminishing or giving up one factor or fulfilling outcome in return for gaining another, have been explored in a wide variety of fields : financeObserving and recording the risk decision-making process in different scenarios may be a good way to visualize and analyse the trade-offs between urban development and DRR. Serious games, generally involving the use of scenarios for players to make decisions , are conAgainst this backdrop, selecting undergraduates in related majors, who are the would-be professionals, as typical and representative subjects, this study aimed to present a serious game to analyze the players’ decision making for trade-offs in development and DRR in the context of climate change. The main objectives of this study are (1) to propose an SG and evaluate its performance in climate disaster-related EfS for students who have received professional education; (2) simulating different scenarios in urbanization progress, climate hazards, and historical and policy scenarios in the SG to understand how DRR decisions are made and change with shifts in the process with factors such as an individual’s risk knowledge and economic and policy incentives.By reorganizing and understanding the trade-offs in would-be professionals’ decision making in the context of climate change, this study attempts to provide a creative perspective for improving the relationship between risk-generating development and disaster risk in the current climate change context, as a way to integrate DRR and resilience for sustainable development.The serious game was set using the history of the Yudai Trench. Once located in Guangzhou, China, and dug during the Song Dynasty in 1011, the Yudai Trench initially functioned as a safe harbor. Since its excavation, the Yudai Trench, which is more than 60 m wide, gradually developed functions, such as water supply, drainage, and flood resistance, making outstanding contributions to climate disaster risk reduction and urban resilience in the ancient city of Guangzhou . HoweverAs an important green infrastructure, Yudai Trench’s disappearance means that climate DRR has given way to urban development. In fact, the thousands of years of the rise and fall of Yudai Trench is a constant process of trade-off between urban development and climate DRR.Through counterfactual scenarios in the game, the study restored the width of the Yudai Trench when it was first excavated, allowing players to redo the trade-offs between urban development and climate DRR, and to rebuild the urban resilience. The 20-round game, which was a sequential process defined by several scenarios based on historical records about the socioecological system evolution of the Yudai Trench over thousands of years. Based on the historical data, the study selected 8 historically recorded climate disasters in Guangzhou as the climate hazard scenarios for the game. In addition, these scenarios also consisted of varying policy and historical contexts representing the urbanization progress . These sWhile combing through the historical data, we discovered that the long historical span of the Yudai Trench meant it had gone through several historical periods with different economic levels and different policy preferences: according to historical records, the coast of Yudai Trench was only a commodity market when it was first dug, then gradually developed into the most prosperous financial and commercial center of Guangzhou, and then gradually declined at the economic level after being affected by the blockage of the Yudai Trench and wars, etc. At the same time, according to historical records, the government organized the dredging of the Yudai Trench by implementing policies.That is, based on the compilation of historical data, economic levels and policy preferences may be factors influencing the trade-offs affecting urban development and climate DRR that existed in the historical process of the Yudai Trench. Furthermore, Lebel et al.  considerTherefore, this study focused on the effects of knowledge, economic level, and policy incentives on in-game decision making representing players’ trade-offs.At the beginning of the game, players have some initial funding and are told that there will be some climate disasters coming up in the game. Players can use the diverse cards to optimize development and climate DRR in the context of climate change or to achieve a balance between the two .The game moderator announced the specific game scenario for that turn ;Each player in the game session advanced on the game board in turn by rolling the dice. Players can buy arrival plots and construct on them for development or climate DRR;Each player in turn reckoned the gains and losses made during the turn.Each round of the game consisted of the following three steps:By constructing counterfactual situations, the game allowed players to make trade-offs and decisions freely. Over the course of the game, the overall resilience decreased as the width of the Yudai Trench narrowed, which induced more climate disasters. Players can slow or reverse the increasing level of silt in the Yudai Trench by purchasing and placing water cards on river plots, or they can build farmland and forest to improve the overall resilience of the site in another way. Of course, players can also focus on city development, population expansion, and store construction.Ultimately, the winner in each game session was the player who had established better balance with the most hazards resistance and profit. While none of players knew the winning criteria until the end of the game, which was consistent with the reality that no one would tell you exactly what you should do to be right, it all depended on the player’s own judgment.t-test questionnaire after the game for personal reasons, so we did not accept his feedback as research data. The participants’ mean age was M = 21.7 (SD = ±1.88), and the gender distribution was even .One hundred and eight junior to senior undergraduates, who majored in landscape architecture from 6 classes in Guangzhou, China, participated in the serious game . The maxn = 36); the group provided with risk knowledge about the damages brought by climate hazards and how to resist them in the game ; and the group with three times the initial funding than the other two .From October 2020 to March 2021, 18 game sessions were organized. These game sessions were equally assigned to three experimental groups corresponding to different treatments: the control group  of the knowledge scale was 0.81, and the written feedback form enabled players to express their subjective feelings of the game. Players were asked to give feedback on their first thoughts and emotions of the game and to evaluate the learning effect in the game. Players were asked to complete the post-test data and the feedback form.The questionnaire survey: consisted of a scale and a written feedback form . The scaThe in-game observations: because of the large number of observations, three observers, who were responsible for keeping track of different things, were assigned to every game session. The observers consisted of postgraduates, who were asked to record the player’s decisions and strategies without interfering with them. The recorded decisions included the overall performance, process, and results of players’ decision making .The follow-up interview: the question posed to the students covered strategies used in the game to increase resilience; considerations when making certain decisions; their understanding of the interaction between urbanization and climate hazards; and their feelings during the risk decision-making progress.In the collection of players’ decision-making outcomes, participatory data collection methods such as interviews, workshops, and in-game observations are considered effective heuristics ,38. PartWe used six indicator variables to describe different aspects of the players’ decision making, which were recorded during the in-game observations. First were two measures of the overall resilience performance: Climate DRR and Efficiency in Climate DRR.Green Infrastructure Development and Economic Development in the aggregation dimension: the aggregation dimension incorporates the conflict between desired planned economic growth and the damage to social and environmental well-being that comes with economic growth . During Timeliness in the time dimension: the time dimension tackles the conflict between potential long-term disaster risk and short-term high-return gains ,46,47. BImprovement in participation dimension: the participation dimension involves the stakeholders’ sharing of power, communication, and cooperation in the decision-making process . In the Because the gameplay did not fully cover the dimensions of the typology framework proposed by Tuhkanen et al. , we chosOverall, effectiveness of the SG as an EfS method was evaluated by (1) the improvement of the players’ knowledge level by the end of the game; (2) requiring the players to judge the SG based on the theme, length, game strategy, ease, entertainment, and balance of mechanics . In addit-tests to analyze the quantitative data.All statistical analyses of the quantitative data were performed using SPSS. In our study, we used t-tests to evaluate whether there is a significant difference between the pre-test and post-test results of participants’ knowledge scale of the same group. In the analysis of in-game observations, we used independent t-tests for data analysis as a way to determine whether there are significant differences in the recorded data generated by players in groups with different control conditions during game play. This is because independent t-tests are applied to mean comparisons between two independent groups, while for paired data, paired t-tests can be performed [In our study, we chose to use paired erformed .t-test allows us to compare the means of two data sets and establishes the problem statement by assuming a null hypothesis that the two means are equal as a way to determine if there is a significant difference between the two data sets. Therefore, if the t-test values show that the null hypothesis qualifies to be rejected  [Essentially, the e level) , it meant-tests to analyze the pre-test and post-test data of the three groups of players before and after the intervention, respectively. The three experimental groups corresponded to different treatments: T1 was the control group (n = 36); T2 was the group provided with risk knowledge about the damages brought by climate hazards and how to resist them in the game (n = 36); T3 was the group with three times the initial funding than the other two (n = 35). The average scores for knowledge for the three groups before and after the serious game are listed in t-test results indicate that the knowledge levels of all of the students were significantly enhanced by the end of the serious game .We used paired The player feedback on the SG is present in “It is effective to deliver the knowledge about climate change via games, especially for those who dig in this topic for the first time.”“It was an interesting experience. I got to know some knowledge about city resilience via an intuitional and visual method, such as how to prevent some risks or disasters effectively by strengthening green infrastructure construction.”“The contents of the game are actually closely related to our daily life, which made me feel like thinking of strategies for real practice. Besides, I learnt that the implementation of city resilience depends on many factors, one of which is the reasonable configuration of land resources.”“For the first time I got to know we can learn from games. I think the topic implied by this game is of practice significance. I hope I can apply the knowledge that I learnt from this game in my real life someday.”The game sessions improved knowledge by allowing players to experience conflicting social, economic, and environmental values in a socioecological system through counterfactual scenarios. Over 91% of players confirmed that they gained new knowledge by playing the SG, 6% were unsure if they learned anything new, and 2% thought they gained no knowledge in the game. We learnt that even the professionally educated players generated new relevant knowledge about climate hazards during the SG. The relevant feedback from players was as follows:Based on the feedback in the questionnaire survey and interviews, we concluded that players increased their knowledge of resiliency of socioecological systems, as well as the types, causes, and impacts of variable climate hazards underlying an urbanization background. More importantly, this program inspired the players in that they could link EfS with gamification design and viewed serious games as a promising method to educate and learn about socioecological decision making.p = 0.001 < 0.01) and Effectiveness in Climate DRR at the end of the game . Meanwhile, players with risk knowledge showed better Timeliness in Climate DRR of risk decision making in hazard response  and a better balance between Green Infrastructure Development and Economic Development  are presented in elopment .As displayed in “It took me five to six attempts before I got the right way to resist a flood, but I had lost a lot of profit before that.” It may suggest the importance of risk knowledge in accurate and timely DRR action [Furthermore, there was a significant lag between starting to build green infrastructure and being able to resist climate hazards (Effectiveness in Climate DRR) for players without a risk knowledge a, which R action .At first, I didn’t know what the implications of the hazards would be. After playing for a while, I felt I knew how to play”.Additionally, despite the statistically significant differences on the level of Effectiveness in Climate DRR between T1 and T2 by the end of the game, it was found that the gap narrowed significantly in the later stage of the game . It may p = 0.001 < 0.01), which indicates that with the improvement in the economic development level, players devoted greater resources to safety, including implementing precautionary measures designed to reduce the impacts of climate hazards. As displayed in p = 0.001 < 0.01). This concurs well with the previous findings [findings ,54.p = 0.339 > 0.05). Surprisingly, no significant difference was found between players in T1 and T3 regarding Timeliness in Climate DRR . This was probably due to the security sense brought by the ease of availability of funds, which makes players more willing to try. As in the follow-up interviews, some players in T3 expressed a willingness to try different strategic decisions to resist the hazards without being overly cautious, as the extra income significantly reduced their trial-and-error costs.Furthermore, the Policy incentives related to urban resilience can also have an impact on players’ decision making. As displayed in Policy incentives related to urban resilience can also have an impact on players’ decisions making. As displayed in The strategies represent a series of the decision making between development and climate DRR of players systematically and distinctly. Different developments of resilience strategies can be observed in various game sessions with different prerequisites. We categorized the strategies observed throughout the sessions into two main types: fast-growth fatalist and protectionist.Fast-growth fatalist is defined in the game as a player who used more social cards than ecological cards, whose strategy was to compensate for the losses caused by climate hazards by engaging in more economic activities. The players spent almost all resources developing new stores and expanding their land, while limited or no ecological cards were collected. The players tended to have a lot of stores and residences to sustain. When impacted by hazards or when losing access to resources due to a broken capital chain, the player could no longer sustain all stores and residences, resulting in bankruptcy. Contrarily, protectionist strategies focused on risk reduction and resilience development. Players adopting such a strategy tended to develop their stores and expand their land slowly and used more ecological cards. Stores and residences therefore had a higher chance of surviving climate hazards and green infrastructures were more adapted to resist it.We found that players in T2 and T3 preferred playing as protectionists, while players in T1 tended to play as fast-growth fatalists. Furthermore, when there were more protectionists than fast-growth fatalists in the game session, it was more likely that the Yudai Trench survived in the context of urban expansion, which was an improvement over the actual situation . HoweverThe overall analysis of decision making between development and climate DRR indicated that risk knowledge, higher economic levels, and policy incentives can positively influence and guide players’ climate DRR decisions, which are reflected in the dimensions of aggregation, time, and participation in the trade-off framework.DRR is an important approach to respond to disasters caused by climate change and is essential to building urban resilience and achieving sustainable development. A better understanding of the trade-offs that exist with urban development and climate DRR is needed to find development strategies that promote climate disaster resilience while maintaining stable urban development. Hence, the main objectives of our study were to explore how risk knowledge, economic levels, and policy incentives influenced the decision-making process and to assess the effectiveness of serious games as an EfS method.Risk knowledge and climate DRR have proved to be closely linked, and these connections can help us to improve DRR ,56. Our Furthermore, we found that risk knowledge provided professionals, as decision makers, with a sustainable perspective, which is used to guide climate DRR decisions. The findings show that in the time dimension, risk knowledge would guide professionals to take a long-term perspective and prepare in advance for unhappened or unknown climate hazards. In the aggregation dimension, adequate risk knowledge would help professionals clearly perceive the importance of environmental well-being, rather than focusing only on economic construction. For the participation dimension, risk knowledge would be effective in enhancing the degree of consensus among professionals representing different interests in DRR decision makings, to some extent, creating a basic common perception of the value of green infrastructure for sustainable development. The sustainable DRR decisions may be influenced by higher risk perception and more proactive disaster-preparedness behaviors resulting from risk knowledge ,57,58 anBased on the understanding that risk knowledge provides sustainable perspective for decision making, further work might focus on some of the challenges related to knowledge production and implementation in the DRR in real situations, which is a simplified part of the game. For example, these may include how to systematically collect and share disaster-related facts, data, and information ,59, and Our study revealed that the DRR decisions at higher economic levels did not appear to have significantly better performance on each of the trade-off dimensions, while the overall resilience performance was effectively improved. That is, higher economic levels were not the decisive factor affecting the development–DRR trade-offs but can, to some extent, translate into DRR decisions that favor resilience.This finding confirms previous evidence that the critical underlying factor in any economy’s response to a natural disaster is its level of wealth . A possiHowever, why the higher economic levels failed to make a sufficient impact on the development–DRR trade-offs? The same evidence can be seen in the history of the Yudai Trench: it began to fill with silt during its economic heyday, as the surrounding inhabitants began to fill in the river in order to acquire a larger area of land for economic development. In the study, we found that with a high economic level as a prerequisite, knowledge of the disaster risk may be an important turning point for DRR decisions: most players began to make decisions about DRR only after experiencing losses from climate disasters. The Sendai Framework for Disaster Risk Reduction also emphasizes the importance of disaster risk cognition .Based on these results, we believe that low-income people and the communities in which they congregate should be the focus of attention in climate DRR policy and resilience building, because they face greater vulnerability in both pre-disaster prevention and post-disaster response due to their low economic levels. At the same time, we argue that economic level is not the only important development measure in disaster risk reduction and that higher levels of cognition are equally important. Thus, in addition to more direct DRR efforts, long-term climate DRR policies may include efforts to improve education and further raise the overall economic level.Our study revealed that policy incentives on climate DRR can go some way toward guiding and encouraging professionals to make relevant decisions. Although these professionals represented their own interests in the game, and the decision situations varied across experimental conditions, the motivation of stakeholders in different decision situations for climate DRR decision making under the relevant policy incentives showed a consistent upward trend. This finding confirms previous evidence of the importance of incentives in collective action and decision addressing environmental degradation issue ,63,64.However, this conclusion seems to be contrary to the historical development process of the Yudai Trench in reality. According to historical records, there have been several dredgings of the Yudai Trench under the organization and incentive of the government in order to maintain the width; however, the effect was not obvious. The continuous siltation of the Yudai Trench has further exposed the city to the risk of climate hazards. This may be due to the fact that most of the dredging policies at that time were only motivated by shipping and water supply requirements, and there was a serious lack of recognition about the value of Yudai Trench, an important green infrastructure for the city, in climate DRR. The cognitive limitation at the policy level made the policy incentives’ lack of DRR pertinent, which makes it impossible to spontaneously form behaviors and decisions favorable for climate DRR. A study by Weichselgartner et al.  also argTherefore, linking policy incentives and risk knowledge may be an effective way to further address the DRR issue. Policy incentives targeted at effectively improving DRR would help reconcile potential conflicts among stakeholders that exist in the trade-offs between development and DRR, while also better integrating multiple scales, different decision makers, various sources of knowledge, and different disciplines into disaster risk research.Our study revealed that the SG presented in the study facilitated the players’ understanding of resiliency of socioecological systems, as well as the types, causes, and impacts of variable climate hazards with an urbanization background. In addition, players could adjust their decisions and strategies by learning about climate risks in the game’s scenarios. Learning in the game scenarios is actually a double-loop learning process, referring to a revisiting of assumptions and to questioning the governing variables themselves by means of a critical reexamination , which mThe results also show the potential of the SG as a data collection approach because it effectively identifies the dynamics of the decision-making process representing multiple dimensions about the trade-offs between urban development and climate DRR that exist under the influence of potential factors.This study explored the effects of risk knowledge, economic level, and policy incentives on professionals’ climate DRR decision-making process by constructing counterfactual scenarios about the Yudai Trench with the help of a serious game. The results from questionnaire surveys, in-game observations, and interviews suggest that while all three factors favored DRR, the impact of risk knowledge was the most prominent and fundamental, with the effects reflected in the three dimensions in the trade-off framework and the overall resilience performance. In addition, neither economic level nor policy incentives could contribute to the development–DRR trade-off in isolation from risk knowledge. Moreover, the study demonstrates that the proposed serious game is an effective EfS method for enhancing professionals’ understanding of the complexity of climate hazards.The results of this study can contribute to the students involved in this serious game, who are also would-be policymakers, so that they can be aware of the importance of risk knowledge and the fact that different methods of decision making in the face of climate hazards can have completely different consequences. The results of this study can also help university teaching staff and authorities to adapt their curricula and approaches to the requirements of the Sustainable Development Goals for building a more resilient future.Limited by the cognitive limitations brought about by the context of the times, the demise of the Yudai Trench seemed inevitable in the past, but it should not be in the present. In conclusion, this study is configured as an exploratory study that opens the way for new research. Insights from the serious game, combined with other theoretical research and practical experiences on DRR, should help advance more systematic and comprehensive decision support to improve climate risk management and policy in the context of urbanization and ultimately develop realistic strategies to achieve a resilient and sustainable future.Future research could include expanding the sample to include undergraduate students with degrees in other fields or at other educational levels, or even the general public. Therefore, comparing the results obtained in this paper with cross-cutting expertise needed to achieve the Sustainable Development Goals would enrich the literature.


Nature Communications, has far-reaching implications relating to the way scientific research and agriculture is conducted. According to James Turner, one of the corresponding authors of the paper, at least 25 000 publications in the past 5 years have used mice in sex-specific research studies. Multiple reasons might explain this preference, such as the study of particular cancers, sex-specific hormones, or reproductive tissues. The farming industry has similar biases, including hens for eggs, cows for milk, and boars for pork, resulting in the culling of a vast number of animals that are considered to be an undesirable sex. These practices are inefficient and ethically questionable, and strategies like this gene editing approach represent a potential means to mitigate such waste.On Dec 3, 2021, The Francis Crick Institute issued a press release titled “Gene editing used to create single-sex mouse litters”, describing the ability of scientists to generate all-male or all-female mice with 100% efficiency. At first glance, this might be construed as another example of humans playing God. However, the significance of this technology, as described in The Principles of Humane Experimental Technique. The goal of the 3Rs is to find alternatives to animal testing (replacement), to optimise the amount of information obtained from fewer animals (reduction), and to adopt methods that alleviate distress (refinement). These guiding principles aim to improve both the quality of the science and animal welfare, when the use of animals is unavoidable, and has been adopted by many countries who ensure the 3Rs have been fully considered when conducting animal research.The use of animals in scientific research is guided by the principles of the 3Rs , first described in 1959 by WMS Russell and RL Burch in a publication called eBiomedicine has published articles on lab-on-chip technology , and the tractable use of organoids to model a variety of tissues . The full replacement of animals has been achieved by improving the in vivo culture methods of primary human cells , maximising the information that can be obtained from patient biopsies , and through the application of AI and computational methods to model biological processes in silico .The 3Rs are not a static set of directives and the technological developments that fuel scientific progress also stimulate innovations in the way the 3Rs are accomplished. For example, the development of new cell culture strategies has facilitated the partial replacement of animals in research and Reducing the number of animals used in scientific research can be achieved in a variety of ways. For example, using the gene editor CRISPR-Cas9 strategy to produce litters of the desired sex, as mentioned above, is one approach that should  be translatable into other model organisms. Improvements in experimental design is another tactic and the use of non-invasive procedures, improved sampling techniques, and use of longitudinal study designs could enable more information to be gathered per animal, resulting in fewer animals having to be used overall.National Centre for the Replacement, Refinement & Reduction of Animals in Research (NC3Rs), resulting in potentially unreliable data.Consideration should also be given to refining methods, such as housing and husbandry protocols  to help animals acclimatise to their surroundings, and by adopting procedural techniques that minimise distress . This is especially important as pain and stress have been proven to alter animal behaviour and physiology, as outlined by the UK's Annual Statistics of Scientific Procedures on Living Animals showed a year-on-year decrease in experimental procedures since 2015, with 2020 showing the lowest number of procedures since 2004 (affected in part by the COVID-19 pandemic disrupting research). Although this decline is encouraging, 2•88 million animal procedures were still done in the UK in 2020, and NC3Rs promote several funding schemes to support the adoption of alternative models, tools, and technologies to drive the impact of the 3Rs.A small shift in the way preclinical studies are carried out can have a profound impact on animal welfare and the quality of the scientific data obtained. According to the UK Home Office's most recent report, published on July 15, 2021, the eBioMedicine takes animal welfare extremely seriously and we have guidelines in place to ensure that research incorporating animal use has been carried out rigorously. Our editors make sure that primary research articles contain an ethics section that complies with the relevant institutional regulations. Explicit procedures must be provided in the methods section, and the use of analgesics and anaesthesia is scrutinised (the manuscript is rejected if deemed inappropriate). All studies featuring animal procedures require a completed Animal Research: Reporting of in vivo Experiments (ARRIVE) checklist prior to publication to maximise the quality and reliability of the published research. We also mandate a Data Sharing Statement to increase data transparency. The preregistration of preclinical trials on publicly available platforms, such as www.preclinicaltrials.eu, is also encouraged to help avoid unplanned duplication of experiments and minimise publication bias in animal studies. We hope that more of our authors will embrace this worthy initiative.eBioMedicine, we are passionate about championing the best preclinical models that yield reliable, relevant, and responsibly conducted translational research. We urge the biomedical research community to help us in this endeavour.“All models are wrong, but some are useful” is an aphorism attributed to the statistician George Box. At


This study explores the effect of the recently enacted Foreigners’ Working Management Emergency Decree, 2017 on migrant insurance coverage between January 2016 and December 2018. We employed an interrupted time series (ITS) model to estimate the level and trend changes of the number of migrants enrolled in Social Health Insurance (SHI) for formal workers and the Health Insurance Card Scheme (HICS) for other migrants. Before the Decree’s implementation, SHI covered roughly a third of the total migrants holding work permits, while HICS covered over half of migrants in the country. We found that the new employment law contributed to a rise in the volume of SHI members and a decline in the HICS members in the long run, which might be partly due to a switch from the HICS members in the formal sector to the SHI, as originally intended by the law. In addition to the law effect, some coincided political force from international trade partners and supranational organizations might also contribute to the progress in protecting the rights of migrant workers. The long-term monitoring of migrant insurance coverage and a mapping against the changes in migrant-related laws and contexts are recommended. Human migration has gained significant momentum in policy discussion of the 21st century ; howeverThailand is a member of the Association of Southeast Asian Nations (ASEAN). It has an estimated population of 66 million. Of its 77 administrative provinces, 33 are border provinces, situated adjacent to Myanmar, Lao PDR, Cambodia, and Malaysia . ThailanTo work in the country legitimately, the Thai employment law requires a migrant worker to hold a work permit. The process of work permit registration requires a medical check-up alongside the issuance of health insurance . There aDespite the existence of public insurance schemes for migrants, a number of migrants were left uninsured. Previous literature suggests a variety of reasons contributing to the lack of insurance amongst migrants, such as a lack of knowledge and awareness of the insurance package amongst migrants, unaffordability for the less well-off migrants, and red tape in the registration process ,17,18,19This study thus aims to evaluate the effect of the new Decree on the insurance coverage for migrant workers in Thailand, using insurance coverage data between January 2016 and December 2018.We conducted an interrupted time series (ITS) analysis on time series cross-sectional data to estimate the level and trend change in the number of migrants enrolled in the SHI and the HICS. This method is a useful tool, which is commonly exercised for evaluating policy interventions and estimating the change in trend following the intervention of interest ,22,23.Three sets of data were used. First, we obtained monthly statistics of migrants holding work permits from the Foreign Workers Administration Office of the DOE, which was a publicly accessible dataset . Second,We estimated SHI and HICS coverage by dividing the numbers of SHI and HICS members with all documented migrant workers (migrants holding a work permit) before inputting these data into the model. The analysis followed a multiple linear regression, To understand the effect of law implementation across geography, the results were presented for three different regions: (i) nationwide dataset (77 provinces), (ii) Greater Bangkok , and (iii) 33 border provinces where most migrants were engaged in the informal sector, such as agriculture business and informal construction. We used Stata/SE 16.1  to perform all statistical computations.As this study was part of the monitoring of the health system performance of the International Health Policy Program, the MOPH, and we used only secondary data accessible to the public, no ethics clearance was required. However, we followed the ethical standards for research by not exposing the individual information in the datasets and thus all personal information was kept anonymous.The descriptive statistics about all documented migrant workers and those enrolled in the SHI and the HICS are presented in Overall, we found that the number of HICS enrollees remained higher than the number of SHI enrollees throughout the observed period, but the gap became much smaller in 2018, when the numbers of HICS dropped and SHI rose. From the macro-perspective of all 77 provinces in Thailand, the number of migrants insured with the HICS remained stable at approximately 1.5–1.6 million in 2016–2017, and then dropped to approximately 1.1–1.3 million in 2018.The coverage of SHI membership remained at around a third of all work permit holders in 2016–2017 but peaked to nearly a half in 2018. A similar picture was observed for Greater Bangkok. In contrast, the HIC enrollees exceeded the number of all work permit holders (109–132%) and remained around 3–5 times larger than the SHI enrollees in the border provinces during these years.p-value cut-off at 0.05.For the HICS, the baseline coverage was 82.93% for the whole country, 58.73% for Greater Bangkok, and 87.34% for the border provinces. The increasing baseline monthly coverage trend was observed by 1.47%, 1.40%, and 3.14%. No significant change was expected immediately after the Decree’s promulgation. However, a negative trend change in the monthly coverage by 5.11–5.68% was observed in all areas, with statistical significance when assessed against a The estimated numbers of SHI and HICS during the 36 months from January 2016 to December 2018 from interrupted time series models are pictorially presented in Overall, this study is amongst the first studies to apply rigorous statistical techniques to evaluate the new law on the employment of migrants in Thailand. Moreover, it is amongst the very few studies in the migrant field that highlight the relationship among the employment law and the health security of migrants, which is a significant concern in not only Thailand but also many other nations where migrant health is in the political spotlight. We found that the new employment law implemented in 2017 was associated with a decline in HICS members in the long run but, at the same time, contributed to a rise in the volume of SHI members, though an immediate change in the insurance enrollment was not obvious. A possible explanation is that the Decree caused a switch from the HICS members in the formal sector to the SHI as intended by the law. This phenomenon reflects some long-standing operational problems of the SHI enrolment, which has resulted in migrants enrolling in the more convenient HICS instead. First, the registration of the HICS is easier for employers than that of the SHI. As the HICS targets migrant workers in the informal sector, where an employer is not required to register his/her business with the MOL, the documents required for purchasing the insurance are only the residence permit of the purchaser and the name and address of the employer. Second, the HICS is solely governed by the MOPH. It does not have a strong legal instrument to support its enforcement—unlike the SHI, which is founded by the employment law . Last, rAnother interesting finding is the discovery that the SHI and HICS combined outnumbered the work permit holders. This reflected the non-synchroneity of the data recording systems between the MOPH and the MOL. Migrants returning to their home countries (thus dropping out from the work permit holder list) might still have their names existing in the insured list . Another possible explanation is the duplication in the name lists of the HICS and the SHI as there is a three-month transition period during which the insured need to have their salary deducted for three months before the SHI is activated. The applicants are encouraged to buy the HICS during this period. It is still possible that the applicant paid with the full annual cost to have full one-year coverage .We also found that the number of HICS was relatively high in the border provinces, where nature of the economy mostly relies on informal businesses, including seasonal cropping or informal construction ,7,27.It should be noted that the observed increasing SHI coverage might not be the sole effect of the 2017 Decree. There are also coincided political force and international events that might lead to more migrants earning formal employment status. Thailand has been pressured by its important trade partners, notably the United States (US) and the European Union (EU), on human trafficking, slavery, and illegal unreported unregulated (IUU) fishing ,29. In 2From a macro-view, the Decree is successful in expanding the health security of the migrants through SHI. However, the SHI has not cleared up all underlying problems concerning the insurance coverage for migrants. For instance, the SHI protection stops if either the employer or employee stops paying a monthly contribution for at least three consecutive months . More imTo tackle this problem, certain provinces along the Thai-Myanmar border have implemented their own initiatives. Some worked closely with a private not-for-profit organization to initiate a voluntary micro-insurance program. The nature of such initiatives is quite similar; that is, by allowing those dropping out from the SHI and the HICS, or non-registered migrants and migrant children, to be insured with the insurance scheme internally created by the provinces ,27. HoweOur study provides an example of an intervention that positively affects migrant health protection in a middle-income country setting and describes related challenges that may be useful for other countries with similar context. By showing research evidence on the impact of a non-health policy, our study advocates for better policy coherence across sectors and good policy governance in the near future. This study is not without limitations. The major weakness is the lack of undocumented migrant data, which are extremely difficult to trace. This limitation inevitably compromises the accuracy of the insurance coverage. In addition, the HICS dataset available to us is not granular enough to sort migrants by work status, such as how many are currently engaged in the informal sector and how many formal-sector migrants were insured with the HICS. Moreover, the results should be cautiously interpreted as migrant health policy is extremely dynamic. The impact of the Decree is always subject to change given new policies or changes in the contextual environment, and international policies that affect migrant flow, such as the fluctuations in the country’s economy, will definitely have an impact.Further studies that explore the factors influencing the enrolment of the different insurance schemes at an individual level are recommended, including research on proper and feasible insurance options for non-Thais as a whole. The existing insurance schemes with a larger financing pool  should also be considered to accommodate migrants. An approach that unbinds the employment process and insurance entitlement should be contemplated. Further studies that investigate factors associated with the enrolment of different insurance schemes at an individual level and a mapping of migrant insurance coverage against the changes in migrant-related laws and contexts are recommended.The new employment law on migrants in Thailand, proclaimed in 2017, contributed to a positive change in SHI enrolment. In contrast, the volume of HICS insurees gradually declined after the introduction of the law. The rising trend of the SHI insuree toll might not be due to the new law alone, but also a result of the political context and foreign affairs influence at that time. Continued actions to promote migrants’ health security should be maintained, with special attention given to undocumented migrants and migrants’ dependants. Further research should explore proper insurance options, especially a scheme with a larger financing pool for all non-Thai residents. A mapping of migrant insurance coverage against changes in migrant-related laws and the contextual environment of the employment policies for migrants would be useful.


The quality of one’s adult health and the chances of maintaining cognitive ability in aging stem directly from the quality of care one receives as an infant. Formal studies of maternal care can be traced back at least a century. Revelations of behavioral outcomes after maternal deprivation in primates were followed by discoveries of systemic and brain growth factors mediated by the caregiver–offspring relationship in rodents. More recently, much of the genetic/epigenetic bases of maternal care has been defined and positively linked to adult health and cognitive ability in senescence. The history of this field is both tragic and fascinating. The early primate work, while informative, was abusive. The initial rodent work was ridiculed before its importance was recognized. The final lesson learned is that infant/toddler care matters a lot. Today, we have a better understanding of the biology underlying maternal care and its transmission across generations as well as a scientific basis for massaging premature infants and hugging our children. Altricial animals require parental care during the neonatal period. Nurturing physical and emotional interactions between offspring and caregivers are instrumental in the processes of early postnatal growth and brain maturation . NeglectGua, treated as a human child, behaved like a human child except when the structure of her body and brain prevented her. This being shown, the experiment was discontinued.” . In this story, we possibly learn more about the importance of the caretaker–infant bond than we do about nature versus nurture. First, the caretaker–infant bond is real and of life importance (win for nurture). Second, the caretaker–infant bond can occur across species given that Gua thrived with the Kelloggs as replacements for her biological mother (win for nurture). Third, the final outcome of this study clearly illustrates that the primate is not an ideal animal model for this type of research. Fourth, one’s own human infant is not a reasonable subject for scientific research. While direct connections cannot be made to being an infant research subject, being reared with a chimpanzee, or losing his “sister” as a toddler, Donald committed suicide at age 43 . Most of those who survived into adulthood exhibited enduring physical and psychological debilitations.By the late twentieth century, decades of research had confirmed that maternal deprivation is inhumane for humans, apes, and monkeys. Nonetheless, Dr. Ned Kalin at the University of Wisconsin earned a grant from the National Institutes of Health in 2014 to perform similar research. Dr. Kalin had been studying stress responsiveness in maternally separated monkeys since the late 1980s. A concerted effort by Mr. Rick Bogle, former Executive Director of Alliance for Animals, a petition signed by hundreds of thousands of concerned citizens, and likely action by the University of Wisconsin Board of Visitors in 2015, resulted in removal of the maternal deprivation portions of Dr. Kalin’s research. Dr. Kalin is an MD with a focus on treating human diseases. As the medical system in the U.S. continues to shift from treatment to prophylaxis, so too will the underlying basic and translational research shift from primarily studying pathology to a greater concentration on wellbeing and from deprivation to enrichment.Sidenote: similar procedures imposed on older rat pups do alter corticosterone levels and disparate types of stressors do not elevate corticosterone in very young rats  come to fruition from federal funding (the Golden Goose). Now conferred annually by the American Association for the Advancement of Science, the Golden Goose Award is presented to researchers who, through federal funds, made findings that significantly altered society or medicine, but upon initial discovery, were considered relatively inconsequential or impractical by other researchers and politicians. Cynthia Kuhn and Saul Schanberg, Gary Evoniuk, and Tiffany Field received this award in 2014 for their work on maternal separation and the importance of neonatal massage and tactile stimulation (see Footnote 1). An award well-deserved.To this point, much had been gleaned about the behavioral and biological outcomes of maternal deprivation, but one big question remained. How does mom’s behavior, or lack thereof, create the lasting effects in the offspring that persist into adulthood? Michael Meaney at McGill University was keen on this issue and, like Dr. Evoniuk, paid close attention to the dam-pup interactions. He noticed substantial variability in the ways the dams treated their newborns. Really good moms dug a nest in the corner of the cage, dragged all the pups there, created a tent with her body over the pups (arched-back nursing), and licked and groomed them at a very high rate. In contrast, bad moms dug a nest and laid down. The pups had to approach the bad mom on their own and periodically she would lick one or another pup. The behavior of most dams was somewhere in between these two extremes. So, Dr. Meaney along with Dr. Paul Plotsky, then at the Salk Institute, quantified licking and grooming rates, calculated the mean across the dams, rank-ordered the dams according to licking and grooming rates, and defined those above the mean as “high-rate” licker-groomer dams and the rest as “low-rate” licker-groomer dams . Like huA receptor levels in the locus coeruleus, nucleus of the tractus solitarius, amygdala and frontal cortex  and two groups of suicide victims, those physically abused early in life and those who were not . Only tht Ridley .The core work of Golden Goose team, Drs. Meaney and Szyf, and colleagues has been expanded considerably by others to include alterations in gut microbiota in pups experiencing maternal deprivation  and atteIncreased public awareness of the importance of the neonate–caretaker bonding and interactions for adult health and greater translation of scientific findings into human practice has the potential to substantially improve health, longevity, and quality of life for perhaps tens to hundreds of millions of individuals. Additional federal funding and larger investments at the state level to support Birth to Three Programs would go a long way in achieving this goal and, in the long term, the increased worker production and reduced healthcare costs would far outweigh the initial investment.All authors listed have made a substantial, direct, and intellectual contribution to the work and approved it for publication.Production of the article was supported by funding from the National Institutes of Health .The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. 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Accomplishing unremitting favorable health outcomes, especially reducing maternal mortality, remains a challenge for South Asian countries. This study explores the relationship between health expenditure and maternal mortality by using data set consisting of 18 years from 2000 to 2017. Fully modified ordinary least squares (FMOLS) and dynamic ordinary least squares (DOLS) models were employed for the empirical analysis. The outcomes revealed that a 1% rise in health expenditure increased the maternal mortality rate by 1.95% in the case of FMOLS estimator and 0.16% in the case of DOLS estimator. This reflects that the prevailing health care system is not adequate for reducing maternal mortality. Moreover, the meager system and the priorities established by an elitist system in which the powerless and poor are not considered may also lead to worsen the situation. In addition, the study also added population, economic growth, sanitation, and clean fuel technology in the empirical model. The findings revealed that population growth has a significant long-term effect on maternal mortality—an increase of 40% in the case of FMOLS and 10% in the case of DOLS—and infers that an increase in population growth has also dampened efforts towards reducing maternal mortality in the South Asian panel. Further, the results in the case of economic growth, sanitation, and clean fuel technologies showed significant long-term negative effects on maternal mortality by 94%, 7.2%, and 11%, respectively, in the case of the FMOLS estimator, and 18%, 1.9%, and 5%, respectively, in the case of the DOLS estimator. The findings imply that GDP and access to sanitation and clean fuel technologies are more nuanced in declining maternal mortality. In conclusion, the verdict shows that policymakers should formulate policies considering the fundamental South Asian aspects warranted to reduce maternal mortality. Human capital is an imperative factor for attaining the desired economic growth and development of any country . Under tGlobally, the maternal mortality ratio has declined from 342 to 311 (by nearly 38%) from 2000 to 2017 . This imDespite significant investments in the health sector, expenditure on health in governments’ financial plans in developing regions, including South Asian countries, is still under-represented due to resource scarcity . Even ifBased on the above discussion, the current study was designed to explore the following research question: “Does health expenditure contribute to decreased maternal mortality in South Asian countries?” Exploring this question will enable policymakers to prepare strategies accordingly to accomplish the sustainable development goal of reducing maternal mortality, as health expenditure is regarded as the clearest policy variable . InvestiAs discussed above, many previous studies have explored the relationships between health outcomes  by using different datasets and have used different research methods and found diverse findings, particularly for the maternal mortality ratio ,32,33,34This section is an attempt to review the previous efforts of scholars and researchers on the subject matter of the current study. This section concisely reviews the studies available in the literature. According to previous studies, the health expenditure level in a nation is one of the key measures for determining the health investment level; hence, it is acknowledged as an imperative input factor, like diet and exercising, for enhancing health. An extensive body of literature has scrutinized the association between health expenditure and health outcomes across countries. Despite these efforts, the pivotal link between health expenditure and health outcomes is still not clear. It is generally presumed that increasing health expenditure will inevitably improve health outcomes. In this regard, Aldogan, Austill, and Kocakülâh  observedOn the other side, several other studies found no causal association between expenditure on health and health outcomes ,40. AshiBased on the literature review mentioned above, it is apparent that the results on heath expenditure and health outcome are inconclusive and there has been variance in the use of specific econometric methods. To explore the phenomenon empirically by using advanced econometric techniques, the current study utilized the data of South Asian countries. Finally, by using a more robust empirical strategy, the current study offers new empirical evidence concerning health expenditures and it impact on maternal mortality in the South Asian panel.Based on the availability, the data set of eight South Asian countries including Pakistan, Bangladesh, Bhutan, Nepal, Sri Lanka, India, Maldives and Afghanistan was collected. The maternal mortality ratio (MMR) was used as an outcome variable; this numerically shows the women died during pregnancy or pregnancy-related causes or within 42 days of pregnancy termination per 100,000 live births, while the predictor variables included total health expenditure (HE), population (POP), economic growth (LNGDP), basic sanitation (BS), and access to clean technologies (CT). Health expenditure was measured in current USD. Economic growth (LNGDP) was measured in constant 2010 USD and was used in natural logarithmic form for empirical analysis. The variable population (POP) was measured as the annual percentage growth in the population. The other variables, basic sanitation (BS) and clean technologies (CT), measured the proportion of the population using at least basic sanitation services and clean fuel technologies for cooking. The data for the desired variables used in the current study were sourced from the World Bank Development Indicators databank from 2000 to 2017. Furthermore, the quarterly data were used for applying the quadratic match sum method. Many previous studies have used this method . This meβk  are the coefficients of the lag of maternal mortality ratio, health expenditure, economic growth, population, basic sanitation, and clean fuel technology; and i,tμ shows the error term. Our models remained confined to these variables to avoid over fitting the model and to allow our core variables of interest to show the association.It is a crucial and well recognized fact that a better understanding of various aspects in the economy leads to the formulation of effective economic policy, including the nexus among maternal mortality, health expenditure, economic growth, population, basic sanitation, and clean technologies. As the present study intended to explicate the long-run relationship of health expenditure effects on maternal mortality in South Asian regions while controlling for population, economic growth, basic sanitation, and access to clean technologies, the subsequent model was designed to analyze the relationship empirically:Determination of the long-run relationships among the study variables was undertaken via the following essential steps. Firstly, panel unit root tests were used to examine the stationarity properties of the variables. Testing stationarity is vital for both time and panel data because non-stationary data lead to spurious results . Thus, IOnce the stationarity had been checked, the next step was to test the variables’ cointegration. Cointegration expresses the association among the studied variables in the long run. The cointegration test of  for paneTo indicate the direction, the study primarily used fixed effect and random effect models , but as The variables used in the current study and their descriptive statistics are presented in Before performing the regression analysis, the variables’ stationarity was required to be checked. First, the variables’ stationarity properties were checked using the conventional unit root tests of Im, Pesaran, and Shin . In TablBefore checking cointegration, the present study used the cross-sectional dependency. It has been argued that orthodox unit root tests do not offer robust outcomes in data series with cross-sectional dependence. Therefore, according to the cross-section dependency test results, it was apparent that there was cross-sectional dependence, as the results were found to be significant for all variables at the 1% significance level see .For paneOnce the stationarity features of all variables had been proven, panel data cointegration was valid to apply. To check the cointegration, the study used the panel cointegration test of Pedroni . The resAs a preliminary analysis, the conventional panel data models, i.e., fixed and random effects were applied. The results of the fixed effect model showed that health expenditure, economic growth, and population positively influenced maternal mortality in South Asian countries by 43%, 58%, and 71%, respectively, while in the case of random effects, the coefficients were similar: 42%, 44%, and 72%, respectively. The findings for health expenditure are unexpected and reveal that an increase in health expenditure increased maternal mortality in the South Asian panel. In contrast, access to sanitation and clean fuel technologies were proven to reduce maternal mortality. The random effect model also reported the same findings, with similar coefficients in the sample countries. Hausman’s  test wasThis study contributes to the rising debate regarding maternal mortality and health expenditure. The data from eight South Asian countries over 2000–2017 is used for the FMOLS and DOLS estimation techniques. The study findings revealed that there is rise in the maternal mortality ratio in developing countries and it is less likely to obtain better health facilities. The results further imply that majority of females in developing countries belong to resource-poor settings, and even when the females reach a health center, they face innumerable hurdles such as inappropriate and inadequate care, and also other factors such as failures in the delivery of health services, a shortage of equipment or personnel, and—worst of all—faulty management. Despite increasing health expenditure in the sampled region, the unsatisfactory and meager quality of management and substandard health care services may dampen efforts to reduce maternal mortality. The result further suggests that though funds allocated for health care have increased in South Asian countries, the funds might be poorly distributed and mismanaged. Previous studies also found that a large share of the health budget is spent on pharmaceuticals, which reduces the share for other health programs . VariousRegarding infant mortality, the study revealed that total expenditure on health significantly reduced infant mortality in South Asian countries . In contSimilarly, the positive coefficient of population growth revealed the expected finding that an increase in population also leads to increased maternal mortality. South Asia comprises a considerable proportion of the global population and includes some of the peak child and maternal mortality rates internationally. The reason could be that when households have more family members, they may be less likely to provide adequate nutrition and healthcare services ,69. SuchSetting health expenditure and population growth aside, the significance of economic growth, access to sanitation, and clean fuel technologies in decreasing mortality rate cannot be disregarded. This suggests that maternal mortality can be reduced with an increase in income. Moreover, dietary preferences and lifestyle can also be enhanced with an increased share of income ,75. ManyFurther, several studies have shown a link between sanitation and improved health outcomes ,81. ManyThe mother’s health is crucial for a child’s cognitive growth and time spent caring for children. Given the rising maternal mortality rates in South Asian countries, reducing maternal mortality remains a noteworthy challenge for human development in South Asian countries. The current study unpacked the myth of increased health expenditure and reduced maternal mortality in South Asian countries by utilizing panel data from 2000–2017. The current study applied heterogeneous panel estimation techniques to examine the overlooked time-invariant heterogeneity and cross-dependency across countries.The outcomes revealed that increased health expenditure and population growth were associated with an increased maternal mortality ratio. Health expenditure is a vital matter that can govern policy decisions at the national and international levels. Nevertheless, as indicated above, merely increasing health expenditure is insufficient; access, price, and consistency may influence the extent to which they are used, as well as, most importantly, their accessibility by deprived women. Thus, it is essential to go beyond simply expanding. Though increasing governments’ health care spending is essential for reducing mortality and enhancing health outcomes, the results for the sample countries indicate that governments should support the accountability and transparency of the amounts allocated for maternal health care services. In the nonexistence of transparent financial support, the possibility of achieving the SDG in South Asian countries will be difficult. This evidence should support officials in the health sector in countries with rising rates of maternal mortality to lower the mortality rate, either directly by increasing access to better health amenities for underprivileged women or indirectly by increasing the financial capability of officials to allow sufficient funds to the maternal health sector in general and programs for the prevention of mortality in particular . The govThe findings of this study area new addition to the literature concerning health expenditure and maternal mortality in similar nations of South Asia. The findings show that each region has its challenges for health, and how sensibly expenditure on health is directed is the crux of the matter. Another area of action is improving the quality of health care facilities and competent people. This encompasses more than guaranteeing equipment availability; it also requires making the health services more publicly liable. The prevailing healthcare system adds to the rising maternal mortality due to meager and incompetent arrangements or meager administrative competencies. It also reflects the priorities established by an elitist system in which the powerless and poor do not count.This study has also certain notable limitations. For example, the analysis only added a few control variables and ignored other potential confounding variables, such as the literacy rate, the physician to population ratio, and many other aspects of health. The reason for this was the high rate of missing data for these variables, which resulted in the exclusion of these variables from the model. Moreover, it is also likely that not all of the indicators of the World Bank databank are recounted each year. Thus the World Bank data might not remain consistent with the annually reported data of the Ministry of Health of each country. Further, the World Development data only give the data at the national level and, in this case, may not be helpful for showing the situation at the individual and community levels. Moreover, the present study utilized data from an South Asian panel, so the outcome may not be generalized to other developing countries. Regardless of these limitations, it is expected that the current study will provide impactful and meaningful results for policy makers to devise strategies, keeping in view the fundamental South Asian aspects warranted to reduce maternal mortality.