This is a comprehensive review containing the most up-to-date information on Equine Hepacivirus, one of the recently discovered hepatic equine viruses, together with an analysis of serological and biomolecular presence presented in apreviously published papers, and an update on its genetic relationship within the species and with similar species. Extensive description of the EqHV features is included, and results are presented with several tables and figures, providing a valuable reference guide for further studies.Flaviviridae family that can cause subclinical hepatitis in horses, occasionally evolving into a chronic disease. EqHV, to date, is considered the closest known relative of human HCV. EqHV has been reported worldwide therefore assessing its features is relevant, considering both the wide use of blood products and transfusions in veterinary therapies and its similitude to HCV. The present review resumes the actual knowledge on EqHV epidemiology, risk factors and immunology, together with potential diagnostics and good practices for prevention. Moreover, adhering to PRISMA guidelines for systematic reviews a meta-analysis of serological and biomolecular prevalence and an updated phylogenetic description is presented as a benchmark for further studies.Viral hepatitis has recently assumed relevance for equine veterinary medicine since a variety of new viruses have been discovered. Equine Hepacivirus (EqHV) is an RNA virus belonging to the  Hepatitis is an inflammation of the liver which can occur by toxic, autoimmune, or infective causes. Among the latter, viral hepatitis has recently assumed greater relevance for equine clinical practice as a variety of new viruses have been discovered, such as the Non-primate Hepacivirus  , the equFlaviviridae family, which includes more than 60 species . The analysis detected heterogeneity among the studies, even though the statistical test for funnel plot asymmetry resulted not significant. The selection model and the RoBMA confirmed the presence of heterogeneity, while publication bias resulted not significant . Analysis for area, country, and species revealed a significant heterogeneity among the three areas investigated, in particular the prevalence in Europe  seems to be lower than for the other continents. This datum is in concordance with the results of [The meta-analysis for biomolecular prevalence resulted in an estimated medium prevalence around the world of 6.95% [CI 95% 5.41–8.50]. The analysis detected heterogeneity among the studies, even though the statistical test for funnel plot asymmetry resulted discordant with the rank correlation test not significant, even with a The results of phylogenetic analysis on the three main segment and on the full genome of eqHV resulted robust for several reasons: the sum of vertexes of the Tree puzzle analysis was always higher than 80%; the sequence included as controls always clustered in the same subtype as in the original publication , the booHepacivirus confirms the similarity among the EqHV and the HCV. Furthermore, several newly discovered hepaciviruses have been included in the phylogenetic analysis as the wenling shark virus, that clusters with Hepacivirus J; the duck hepacivirus, that clusters with Hepacivirus D; the sloth hepacivirus, clustering together with Hepacivirus P, as presented by [The NS5B tree for the whole genus ented by , and resented by .In conclusion this review provides a valuable reference guide for practitioners and for researchers in conducting further study to confirm the data or to deeply explore some of the characteristic investigated but not completely assessed.


Environmental pollution liability insurance (EPLI) is a type of insurance purchased by an enterprise to compensate the loss of the victims in the event of an environmental pollution incident. Although EPLI can realize the post-treatment of environmental pollution to a certain extent, there is still less understanding of whether EPLI can improve the environmental performance of enterprises. This study takes A-share listed companies in heavily polluting industries as the research object, determines the treatment group samples according to the Insurance coverage list published by the Ministry of Environmental Protection in 2014 and 2015, and then constructs the empirical test model. In order to ensure that there is no sample selection bias, the PSM method is used to preprocess the samples in this study to ensure the robustness of the conclusions. The empirical tests show that EPLI can significantly improve corporate environmental performance. Further analysis showed that higher public visibility is conducive to the positive environmental effects of EPLI. Compared with state-owned enterprises, non-state-owned enterprises have more significant implementation effects after introducing EPLI. On further examination, the result indicates that environmental pollution liability insurance can improve environmental performance by alleviating corporate financing constraints. The findings of this paper enrich the theory of the economic impact of environmental pollution liability insurance, which has some meaningful theoretical guidance for enterprises and policy makers. The massive urbanization in mainland China has raised issues related to industrial pollution affecting population health , 2. ThisEnvironmental pollution events often bring huge losses, both economically and environmentally. In recent years, the scope of responsibility of the principal responsible for pollution incidents has been expanding from international practice, which means that once the environmental pollution happens to the enterprise, the enterprise often has to face the huge capital repayment pressure. EPLI is a type of insurance used to compensate for injuries and deaths caused by pollution and related restoration and clean-up costs toward the third party. Therefore, EPLI can play a role in dispersing enterprise environmental risks. Scholars have conducted research on the effects of EPLI from different perspectives. On the one hand, some scholars compared the effects of EPLI in different implementation modes. Feng et al.  used a cPublic visibility refers to the degree to which a company receives attention from the public . AccordiAnother influence of corporate environmental performance is corporate governance structure, such as ownership structure. The environmental performance of state-owned firms tends to be higher than that of non-state-owned enterprises because the goal of state-owned firms is to maximize economic welfare . EPLI imAs the largest developing country, the Chinese government has paid particular attention to environmental issues in recent years . The govThe contributions of this study are: First, this paper enriches the literature on the microeconomic effects of EPLI and uses empirical methods to explore the impact of EPLI on corporate environmental performance. Second, this study focuses on the institutional effects of EPLI, which enriches the theoretical research on the effects of EPLI's implementation. Third, this paper uses stakeholder theory as the main theoretical support, combined with agency theory and resource dependence theory, to construct a theoretical framework to explain the effect of EPLI on corporate environmental performance, enriching the connotation of existing theories.The remainder part of this paper is structured as follows. The following section will introduce the relevant research on EPLI and environmental performance, theoretical background and hypothesis derivation. In the following chapters, we will report the design and the findings of our empirical research. The last part will summarize the whole study and put forward optimization suggestions.It can be found from the dimension of stakeholder theory that since the needs of stakeholders are different and sometimes contradictory, managers will respond to the needs of stakeholders according to certain priorities, which are determined by stakeholder salience. Stakeholder salience can be described as the degree of pressure imposed by stakeholders on management, which is the function of power, legitimacy and urgency . The cenFurthermore, according to stakeholder-agency theory, adequate disclosure of internal information will increase the pressure on managers to act in line with stakeholders' interests. EPLI can alleviate the degree of information asymmetry by introducing external supervision. On the one hand, the governance structure of China's EPLI system is generally dominated by the government , and theIn summary, EPLI can alleviate the problem of information asymmetry between major stakeholders in the EPLI system and enterprises to a certain extent and thus increase the pressure on managers to improve environmental performance. Based on the above discussion, we propose our first hypothesis:Hypothesis 1. EPLI has a positive impact on corporate environmental performance.According to stakeholder-agency theory, even though enterprises are faced with pressure from stakeholders, the management still tends to engage in opportunistic behaviors that are inconsistent with the expectations of stakeholders. However, more visible companies will face more burdensome external constraints and higher public demands for corporate citizenship, which will set a higher threshold for managers' opportunistic behavior .On the one hand, widespread public attention can help stakeholders in the EPLI system determine whether a company's activities meet green standards . CompaniOn the other hand, with the increase in visibility, the company is faced with pressure from the public, a potential stakeholder, which urges the company to participate more in social responsibility activities . FlammerHypothesis 2. Public visibility plays a positive role in moderating the relationship between EPLI and corporate environmental performance.Existing research provides evidence for the relationship between ownership structure and environmental performance . State-oOn the other hand, SOEs face more political intervention to engage in more socially beneficial activities , 33. ThiHypothesis 3. Compared with SOEs, EPLI has a more significant positive effect on corporate environmental performance in non-SOEs.This study selected heavily polluting industry companies in the A-share market listed on the Shanghai and Shenzhen exchanges as our sample. The reason for selecting companies in heavily polluting industries as samples is that most companies in the insurance coverage list are from heavily polluting industries. Focusing on heavily polluting industries can eliminate the problem of sample selection bias to a certain extent.According to 2003, 2008, and 2012 classification standards of heavily polluting industries announced by the Ministry of Environmental Protection and the listed company classification guidelines announced by the China Securities Regulatory Commission in 2012, we selected a total of 44 industries, including the metal products industry, pharmaceutical manufacturing industry, chemical raw materials and chemical products manufacturing industry as our target industries. We screened the listed companies in these industries according to the following criteria: 1. Exclude listed companies that regulators give special treatment (ST) because of questions about the authenticity of their financial data. 2. Eliminate the missing company samples of key variables. We ended up with a total of 912 company-year observations, of which EPLI covered 116 samples. The EPLI coverage data is manually collected according to the Insurance coverage list announced by the Ministry of Environmental Protection in 2014 and 2015 and the iFind database. The company's financial data comes from the China Stock Market and Accounting Research (CSMAR) financial database. The environmental performance data comes from Rankins CSR rating database. Statistics software is Stata 15.0.There are two options for measuring environmental performance in the existing literature: The first one is taking the company's pollutant emission level as the measurement standard. For example, Quying  adopted In this paper, we chose the RKS ratings to measure the company's environmental performance from the RKS dataset because we believe it can reflect a company's environmental performance more comprehensively . RKS is Since the firm's decision to purchase Environmental Pollution Liability Insurance for the Group and its subsidiaries does not require the consent of the board of directors, it is not feasible to obtain insurance coverage data totally from public information disclosed by listed companies. We finally selected the insurance coverage list announced by the Ministry of Environmental Protection (only published in 2014 and 2015) as the primary data source and supplemented by the public information disclosure of listed companies in the iFind database. We adopted a dummy variable (Ins) to measure EPLI, which equals 1 if the company is insured that year; otherwise, 0.We measured public visibility (Vis) by the percentage of revenue a company spent on advertising . The comPrevious studies on environmental performance examined the role of some company characteristics. To avoid interference of other factors in our observed relationship between EPLI and CEP, we controlled for the following factors in our model. Specifically, we selected firm size, leverage, return on asset (ROA), management expense ratio, firm age and property nature as our control variables. Each variable is explained as follows:Size): According to stakeholder theory, larger companies often face greater stakeholder pressure. They also control more resources to ensure they can engage in activities that improve environmental performance (Firm size (formance . Therefoformance .Lev): The asset-liability ratio reflects a company's capital structure and financial condition. The existing empirical studies show that the leverage ratio reflects the pressure of the company to bear from the creditors and thus positively affects the company's environmental performance. However, Cormier and Magnan (Leverage (d Magnan  found thROA): ROA measures a company's financial performance. The company's profitability will affect the resources that the company can invest to improve the environmental performance and thus have an influence on the environmental performance. We used the net profit ratio to weighted average total assets to calculate ROA in this article.Return on asset (GA): The ratio of administrative expenses to operating income. The management expense ratio is also an indicator of the company's financial performance. We take this index as the control variable in this paper.Management expense ratio (Age): Referring to the empirical study of Cole et al. : China's state-owned enterprises often face stronger institutional pressure to improve their environmental performance : Corporate transparency can be defined as the extent to which a corporate discloses important management and operation information to the outside world. Greater firm transparency means that companies are devoting more resources to addressing information asymmetry with their stakeholders  and the interaction term of EPLI and public visibility (Ins*Vis) based on Model 1. Ins is a categorizing variable, and Vis is a continuous variable. We can judge the moderating effect of public visibility when the company is insured EPLI  by testing the significance of the interaction term coefficient. Regarding the moderating effect of the ownership structure, this paper tests it through group regression.Model 2 adds public visibility variables  are 0.082 and 0.492, respectively. It indicates that the volatility of variable ROA is stronger than that of GA.Statistics for critical variables of the model are reported in CEP and Ins show a positive correlation at the level of 0.01, which preliminarily confirms hypothesis 1, assuming that EPLI has a promoting role on CEP. The correlation coefficient between the variables CEP and SOE is significantly positive, which also reflects that the environmental performance of state-owned enterprises is better.The correlation coefficient matrix reflecting the correlation between variables is reported in The regression results of Models 1 and 2 are reported in The regression results of model 2 show that the interaction term coefficients of Ins and Vis are positive and significant at the 1% level. As described in the previous model setting section, if the interaction term coefficient is significantly positive, we can reasonably assume that public visibility can expand the impact of EPLI on corporate environmental performance. In other words, the higher the public visibility of the company, the deeper the impact of EPLI on the company's environmental performance.p-value of the coefficient test of variable Ins of the non-state-owned enterprises' group is 0.051, while the p-value of the state-owned enterprise group is 0.147. This result indicates that EPLI has little effect on the improvement of the environmental performance of state-owned enterprises. In contrast, for non-state-owned enterprises, EPLI is an effective means to improve their environmental performance, which supports hypothesis 3.We divided the samples into groups of SOEs and groups of non-SOEs and conducted regression, respectively, to test the moderating effect of the company's ownership structure. The regression results are reported in EID, other variables are not significant in the t-test after matching, indicating that the matching effect is good. We used the matched samples for the model test, and the results were reported in Due to the low coverage rate of EPLI (12.7%) in the samples we used, the empirical test with such samples may lead to the problem of sample self-selection. We adopted the propensity score matching (PSM) procedure to process the samples. The aim is to match a group of samples with the most similar propensity score for those who purchase EPLI. Specifically, we matched the samples based on three key variables: company size, ROA and the number of years of company listing (1:2 matching). The differences in critical variables between the control and treatment groups before and after matching are shown in Considering that the possible inverse causality between environmental performance and EPLI may bring about the problem of endogeneity in the model, we construct the model using the explained variables 1 year in advance for regression. The reason for choosing the explained variable 1 year in advance is that our explanatory variable has only two data periods. The model used for the robustness test is shown as follows:We controlled the models' fixed effects of industry, year and region, effectively avoiding the endogenous problem caused by missing variables. The test results of Models 3 and 4 are reported in In view of the widespread concern about the green issue, the environmental responsibility of enterprises, especially the heavily polluting ones, is becoming increasingly important , 52. In Using panel data from listed companies in China's heavily polluting industries from 2014 to 2015, we examined whether and how EPLI affects companies' environmental performance. Our empirical results showed the following findings. First, our results indicated that EPLI has a positive impact on corporate environmental performance. This discovery extended the research conclusions of Yang et al.  and provSecond, we found that public visibility positively moderates the relationship between EPLI and corporate environmental performance. This finding revealed that EPLI is more effective in improving the environmental performance of companies with higher public visibility, which is in line with the findings of Wu et al. . As Dou Third, we found that EPLI has a significant impact on the environmental performance of non-SOEs but has no significant impact on SOEs. Our findings further provide empirical evidence for the study of ownership structure on enterprise environmental performance . CompareScholars have paid much attention to the research on corporate environmental performance in recent years . The infFirst, this study promotes the research on environmental performance and expands the application connotation of stakeholder theory by identifying the impact of EPLI on environmental performance and its mechanism. Previous studies have examined the impact of measures taken by companies such as ISO 14001 certification and environmental management systems (EMS) on environmental performance , 58. HowSecond, the influence of public visibility on the environmental performance of corporates is considered in this study, which enriches the research on public visibility. As an important concept in stakeholder theory, previous literature has examined the effect of public visibility on corporate social responsibility , 60. HowThird, we contribute to the resource dependence theory by dividing the sample into state-owned and non-state-owned enterprise groups and examining the effect of EPLI on their environmental performance separately. Compared with the situation in other countries, the differences in political connections between China's SOEs and non-SOEs are greater . We analUnder the background that enterprises pay more and more attention to environmental social responsibility , the conFirst, the company can actively purchase EPLI for senior executives to encourage them to improve the environmental performance. EPLI is an effective way to motivate companies to improve their environmental performance for companies in heavily polluting industries. The company's decision-makers should realize that it is necessary to introduce external environmental pressure to improve the environmental performance of the company in the context of China's inadequate environmental laws and regulatory systems, and EPLI has the effect of increasing environmental pressure on company. In particular, under the modern corporate governance structure with the separation of ownership and management, EPLI introduces a multi-subject system, which, to a certain extent, intensifies the environmental pressure of stakeholder groups on the corporate, thus playing a role in regulating corporate behavior.Second, the government can take administrative measures to force SOEs to implement EPLI, so as to enhance SOEs to actively fulfill their environmental responsibilities. Although the environmental effect of EPLI is satisfactory, the low insurance rate of enterprises is still a serious problem due to the imperfect environmental laws and regulations in China . TherefoThird, environmental policy makers can adopt the strategy of forcing enterprises to disclose EPLI information to improve the environmental performance of enterprises. At present, the company's purchase of EPLI is not included in the scope of compulsory information disclosure for listed companies in China. However, the compulsory disclosure of this information may help EPLI to play its role in easing financing constraints. Furthermore, perfecting the information communication channels between companies and stakeholders is conducive to improving the companies' public visibility, which can promote a more significant improvement in environmental performance.This study explains the relationship between EPLI and environmental performance from both theoretical and empirical perspectives. However, our study still has several limitations that need to be discussed. First, we used data from listed companies in heavily polluting industries for empirical testing, so the applicability of our results is limited to specific countries and industries. We have tried to obtain the company's insurance information from the public information disclosure . However, since the EPLI is not a compulsory disclosure of the listed company, the samples obtained by this method are generally inefficient. We believe that with the improvement of the information disclosure system of listed companies, follow-up research can be carried out based on larger sample size.Second, our study only focused on the impact of whether a company has EPLI on environmental performance. For future research, more potential factors such as CEO characteristics , 62 needhttps://www.gtarsc.com/.The datasets presented in this study can be found in online repositories. The names of the repository/repositories and accession number(s) can be found at: Ethics approval for this research was not required as per institutional and national guidelines. Consent from all research participants was obtained by virtue of survey completion.All authors listed have made a substantial, direct, and intellectual contribution to the work and approved it for publication.This paper was supported by the National Social Science Foundation of China (Grant No. 21BGL061), a major social science project of Tianjin Education Commission (No. 2019JWZD33), and Tianjin philosophy and social science planning project (TJGL20-026).The authors declare 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. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Vascularized Composite Allotransplantation (VCA) has evolved in recent years, encompassing hand, face, uterus, penile, and lower extremity transplantation. Accordingly, without centralized oversight by United States Organ Procurement and Transplantation Network (OPTN) or European Programs, centers have developed their own practices and procedures that likely vary, and accordingly, present different levels of rigor to the evaluation process, internationally. The importance of psychosocial factors in the selection process and treatment course has been widely recognized, and therefore, several approaches have been developed to standardize and guide care of VCA candidates and recipients. We propose to develop an international multidisciplinary platform for the exchange of expertise that includes clinical, patient, and research perspectives. Patient perspectives would derive from peer education and the assessment of patient-reported outcomes. To establish a foundation for such a platform, future research should review and combine current VCA protocols, to develop the ethical framework for a standardized psychosocial evaluation and follow-up of VCA candidates and recipients. This review presents a comprehensive overview of recent results in the field of VCA, developments in structural aspects of VCA, and provides viewpoints driven from clinical experience. HoweverPsychosocial factors are important elements in the assessment and follow-up care for VCA and require multidisciplinary evaluation protocols. The Chauvet workgroup has been convened with membership from a number of transplant centers to address these issues and to call for ongoing global research collaboration. A multicenter research network, a consortium of collaborating VCA centers, would share similar evaluation approaches so that meaningful research on psychosocial variables could inform the transplant community and patients about psychosocial factors relevant for optimal VCA outcomes .via American Society of Transplantation (AST), so that future developments in the field of VCA could orientate to such protocols  and VCA recipients  could guide a targeted expert counseling. That will help to address the specific needs of these patients: e.g., information-related questions, psychosocial issues . Moreover, such assessment routines could help to identify patients at risk, offering a specific consultation first, evaluate by routinely collecting psychosocial outcomes (PROs), and decide whether additional intensive care may be needed.2.2.1.First, it must be noted that there are financial differences between European countries such as the United Kingdom and France, compared to the United States, which may account for differences in what is considered a contraindication for VCA. Finances are generally not considered a significant barrier to healthcare in European countries due to caregiving, hospital, and post-transplant state-sponsored support, like in United States, where the family is commonly expected to provide some financial support to help the patient meet co-payments for care along the continuum of pre-to post-transplant periods . While f2.2.There is early consensus among global VCA centers that active substance use at the time of evaluation is a contraindication to any VCA procedure . HoweverRecent research suggests that a period of longitudinal follow-up should be part of the protocol, to allow re-assessment and follow-up at multiple time points prior to VCA. The optimal proposed follow-up period was for 1 year from the time of assessment for the potential VCA procedure .Particularly in the case of patients with a history of non-adherence with medical recommendations, the evaluation and development of coping and (non-)adherence is important. It is proposed that a psychometric instrument may help with tracking adherence with immunosuppressive medications in the post-transplant period . Recent 2.3.Most centers consider risk factors in VCA to be relative, and potentially modifiable . CertainIn terms of appropriate psychological acceptance of the disfigured body (in case of hand and face transplantation), research found that some patients with bodily disfigurement become social recluses, indicating a possible maladaptive coping mechanism . TherefoAny one risk factor, if severe enough, may constitute an absolute contraindication. The presence of multiple risk factors may also constitute a prohibitive risk. In particular, severe personality disorders, active substance abuse, schizophrenia, and unrealistic expectations would typically be considered risk factors that would be associated with a decision not to approve candidates for VCA transplantation.2.4.The psychosocial assessment is considered the principal means of assessing personality, emotional preparedness, cognitive status, coping style, motivation and expectations, and social support. Psychiatrists, psychologists, and social workers are typically involved in this evaluation process.Research recommends that candidates undergo the psychosocial evaluation after meeting with the surgical and medical team members . This se2.5.The first point made in investigations was that sex and sexuality in VCA are not openly discussed by the transplant team . TherefoThe value of social support for maintaining and restoring good health is well established, and the assessment of social support has been an aspect in the screening of transplant patients for some time, including VCA patients ,b. NonetResearch also show that assessing the success of VCA functionality and the ability to return to work are important , and that it is necessary to consider the pre-morbid occupational function of the patient in order to gain perspective on occupation as an index of success of the transplantation . The sal2.6.Uterine transplantation differs from other forms of transplantation (solid organs or VCA) in many ways: (i) it gives women with absolute uterine factor infertility a chance to realize their wish for a biological child; (ii) the clinical outcome is not only relevant for the patient but also for the child conceived; (iii) transplantation is transitory and its endpoint is marked by graft hysterectomy; (iv) the surgical success rate is defined by a technically successful transplantation with a subsequent regular menstrual pattern potentially allowing for pregnancy and live birth of a child to round off surgical success ; (v) eveMedically assisted reproduction is a highly complex field not only clinically but also ethically. Some procedures are highly invasive for women and the children they conceive with the technologies applied. This is certainly even more pronounced in the context of assisted reproduction after uterus transplantation. Patients in this scenario are thus transplant patients as well as patients undergoing fertility treatment to fulfil their wish for a biological child. While this wish can be considered “natural,” it is also highly shaped by sociocultural context rendering those patients particularly vulnerable.The new recommended framework of preoperative psychological evaluation has been published  and was 3.Quality of life (QOL) is considered the most important domain for study both before and after transplantation . The Cha4.Within Reach, has been developed to provide patients, families, and healthcare providers with patient-centered information to make informed decisions about upper extremity VCA , the burdens and long-term commitments of VCA regarding immunosuppression and physiotherapy, and the complexity of how to provide new information on outcomes, particularly those referring to risks and complications in order to improve adherence and care management. An expert group (Brocher bioethics working group) recommended consent as a dynamic covenant in order to promote awareness of the importance of transplant recommendations for both patients and caregivers .In order to implement such ethical considerations, Chauvet participants discussed a model of initiating the informed consent process by asking the patient what they know and understand particularly about face transplantation in the last meeting. This serves as a baseline for the physician to appreciate the areas in which the patient requires education about the process. Chauvet participants recognized that there is a spectrum of understanding and that there will be different levels of sophistication in different patients. Yet it remains the physician’s responsibility to facilitate informed consent by providing education to meet the level of sophistication of the patient. This process is best achieved by: (1) ensuring that a patient has the capacity to consent (can iterate the risks and benefits and weigh them); (2) conveying the ‘nuts and bolts’ of the procedure; and (3) a longitudinal process with a proposed time of approximately 1 year from the time of initial evaluation, during which the face transplant team should work to understand the patient’s motivations for wanting face transplantation. These recommendations have been discussed at length in the context of face transplantation . But thePediatric VCA is particularly challenging because the effects of the transplant on childhood growth and development are unknown, unlike in the context of kidney, liver, heart, and lung transplantation . VCA tra6.There are fundamental differences between types of VCA, and we have focused much of this manuscript on common psychological dilemmas and future approaches that exist in VCA the majority of patients. Several VCA procedures  have emerged as feasible options to provide a functional restoration following traumatic injuries or of infertility. International experience thus far has shown that successful VCA transplantation requires multi-stage multidisciplinary evaluation and follow-up. Candidate selection and evaluator training regarding assessment and ongoing follow-up to address recipients’ post-transplant demoralization, depression, and adherence issues require further refinement to optimize candidate evaluation and follow-up protocols. More broadly, the elaboration of a comprehensive psychosocial framework is needed to provide guidance for individual VCA centers in standardizing their protocols and care procedures. We recommend establishing an international consortium of health care professionals and candidates/recipients , to facilitate the sharing of experiences and individual perspectives. Use of systematic PROs assessment and follow-up by the recommended interdisciplinary transplant consortium may foster the identification of risk factors and patients’ needs outside of routine clinical care, where patients’ needs are often not addressed. Ultimately, we envision that such a consortium will greatly improve the exchange and networking among VCA providers and patients through international research that will support the advancement of psychosocial evaluation of VCA.MK participated in research design, the writing of the paper, performance of the research, and contributed new insights. SJ-G, EG, and GW-F participated in the writing of the paper, performance of the research, and contributed new insights. All authors contributed to the article and approved the submitted version.The authors declare 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. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Nonspecific neck pain is a multifactorial and very common condition in adult individuals, traditional acupuncture (TA) and laser acupuncture (LA) may be treatment options for certain individuals in such a condition. However, no reports were found in the literature comparing the effectiveness of TA and LA in cases of chronic nonspecific neck pain. Therefore, the aim of the present study is to investigate the effectiveness of TA and LA therapies in individuals with chronic nonspecific neck pain, noting which one is more efficient for this condition. The result of this research will have direct implications for pain management and, consequently, may benefit individuals suffering from nonspecific chronic neck pain.Tianzhu, Fengchi, Jianjing, and Jianzhongshu) will be stimulated bilaterally. The primary outcome will be pain intensity, determined using the Numerical Rating Scale. The secondary outcomes will be pressure pain threshold, temporal summation of pain, conditioned pain modulation, use of analgesic medicines after treatment, and the global perceived effect scale. The assessments will be performed immediately before and after the treatment, which will be a single session, at the follow-up and 1 month after the end of the treatments; evaluation will be made of the pain intensity and the global perceived effect. Statistical analysis of the data obtained will consider a significance level of p < 0.05.This will be a controlled and randomized clinical trial. Eighty-four individuals will be recruited and distributed equally and randomly into 3 groups: TA (which will receive the acupuncture treatment with needles), LA (which will receive the laser acupuncture treatment), and Sham (who will receive the placebo intervention). The acupuncture points (This study will provide evidence concerning the effects of LA treatment, in comparison with TA and sham intervention, leading to benefits for individuals suffering from chronic nonspecific neck pain.RBR-7vbw5gd. Date of registration: August 06th, 2021.Brazilian Registry of Clinical Trials - ReBEC  The order of the items has been modified to group similar items.Neck pain is a very common condition that causes considerable disability and economic losses , 2. BetwVarious strategies can be used for the treatment of neck pain, including acupuncture, which originated over 3000 years ago and constitutes part of traditional Chinese medicine –15. The There are now alternative acupuncture techniques available that do not use needles, such as laser acupuncture (LA), which combines the use of the traditional Chinese acupuncture points with stimulation by laser light energy , 27, 28.An obvious difference between acupuncture using needles and LA is that the laser enables the stimulation of acupuncture points without damaging the skin tissue . The lasAcupuncture using needles is a widely accepted technique that provides good results and can be effective in reducing chronic neck pain , 35–44.Meanwhile, the clinical use of LA is increasing, since it offers the advantages of being totally painless, non-invasive, and safe , 33, 43,However, more studies are needed, and until the present moment, no studies were found that compared traditional acupuncture with LA in individuals with chronic nonspecific neck pain. There is a need for thorough research concerning LA, with robust methodologies, large sample sizes, and standardized and reproducible parameters, in order to increase understanding of this therapy and establish possible future clinical applications , 49, 50.The aim of this study is to compare the effects of traditional acupuncture and laser acupuncture therapies in individuals with chronic nonspecific neck pain.The primary objective is to assess the pain intensity at rest and during cervical active movements  using the Numerical Rating Scale (NRS), immediately after the end of the therapies and with follow-up after 1 month.The secondary objective is to evaluate the pain using pressure pain threshold (PPT); temporal summation (TS) of pain; conditioned pain modulation (CPM); global perceived effect (GPE), immediately after the end of the therapies; and consumption of analgesic medications for neck pain, and global perceived effect (GPE) will follow up after 1 month.This study will be a randomized controlled clinical trial (RCT) with a blinded assessor, conducted according to the established standards for reporting clinical trials: Consolidated Standards of Reporting Trials (CONSORT) and Standards for Reporting Interventions in Clinical Trials of Acupuncture (STRICTA). The acupuncture style adopted will be traditional acupuncture and laser acupuncture, and the protocol was developed following the recommendations of Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT).The study will be undertaken at the Physiotherapy Department of the Federal University of São Carlos (UFSCar), in the city of São Carlos, São Paulo State, Brazil.After screening using an online form, the potential participants will be registered, and checks will be performed considering the inclusion and exclusion criteria.Individuals will be recruited if they meet the following conditions: age between 18 and 60 years, complete primary education of both sexes, neck pain complaints , score ≥ 3 for pain intensity on the Numerical Rating Scale (NRS), consent to random allocation and present consent and in accordance with the conditions of the treatments, and possible adverse effects, presented and explained in the consent form.Individuals will be excluded if they present fracture or history of vertebral injury, spondylolisthesis, spinal canal stenosis, ankylosing spondylitis, signs of radiculopathy, cancer, acute infections, hemorrhagic diseases, rheumatologic diseases, systemic inflammatory diseases, diagnostic changes in skin sensitivity, hearing deficits (uncorrected), difficulty in answering questionnaires, in conditions of pregnancy, puerperium and breastfeeding; individuals who have started or underwent any type of intervention or treatment in the last 3 months; individuals who will be orientated not to ingest any sedative, anti-inflammatory and analgesic medications (narcotics and non-narcotics), and any type of alcoholic substance in the last 48 h before the evaluation; individuals who do not comply with the conditions and treatments, or who refuse to participate in the research, will be excluded; individuals who could not remain in the ventral decubitus position, upper limbs along the body and cervical in neutral position during the time of interventions; and individuals will be free to discontinue the treatment at any time, and if they make the most recent data, they will be computed for analysis, as well as the reason for the interruption.Data collection will only start after the participants have signed an informed consent form, which will be explained by the evaluator.Not applicable for this study.No studies were found in the literature that effectively compared traditional acupuncture (TA) with laser acupuncture (LA) for the treatment of chronic nonspecific neck pain. Therefore, the proposed research will focus on evaluating and comparing the changes in pain symptoms and neck functional capacity, after the application of TA and LA in cases of chronic nonspecific neck pain.Tianzhu, Fengchi, Jianjing, and Jianzhongshu) will be stimulated bilaterally with needles, laser, or sham. The participant will be positioned in a ventral decubitus position, upper limbs along the body, and cervical in neutral position and asked to rest for 5 min, prior to the intervention. At the locations where the therapies will be applied, the skin will be hygienized with gauze and 70% alcohol solution. A dermatograph pencil (COLOURED®) will be used to draw circles with diameters of 2 cm around the application points. The same researcher, an acupuncturist with specialization in the field and 9 years of clinical experience, will perform all the interventions (R3). The individuals will be asked not to use any other treatment for neck pain during the study period. All the data collected about the participants will be confidential  will be stimulated bilaterally. The manual needle stimulation technique known as sparrow pecking will be used  , laser acupuncture [AL] , and sham [S] (subjects who will receive placebo intervention). The researcher, responsible for the randomization, will have no other role in this study.http://randomization.com) generates a numerical sequence for an allocation, the concealment of selected individuals will be achieved through opaque sealed envelopes, which will be stored in a safe cabinet that only the allocation investigator will have access to. The envelopes will be opened immediately before the intervention by the researcher responsible for applying the treatments.After the website , will be responsible for recruiting and registering the participants. The researcher (R2) will be responsible for randomization and for generating a random allocation sequence. The researcher (R3) will only be responsible for applying the interventions . The researcher (R4) will carry out all research evaluations . The last researcher (R5) will analyze and register the data.The evaluator will be blinded to the randomization and intervention processes, be responsible only for recruitment and evaluations, and receive no information regarding the allocation of the individuals to the groups. The participants and the researcher responsible for the treatment will not be blinded, due to the nature of the interventions.The evaluator will not be allowed to unblock the blinding. However, the acupuncturist researcher responsible for applying the treatments will not be blinded.The interventions will follow an application protocol. The evaluator will be trained in the application of the questionnaires and tests, while intra-examiner reliability will be estimated by calculation of ICC.The participants will be provided with guidance when they sign the informed consent form and commit to attending on the scheduled treatment dates. They will receive a card with the dates of the treatment sessions, a contact telephone number, and a WhatsApp contact number used only for this research. This will ensure that they receive the necessary attention and will assist in fully accompanying them during the research. If individuals abandon the trial, the reasons will be recorded, the most recent data will be computed, and analysis will be performed using the intention-to-treat principle.A data management plan was created using the dmptool template. All the data will be collected weekly, will be saved as PDF files, and will be stored on the UFSCar institutional Google Drive. A researcher (R5) will be responsible for the data management. During the development of this research, the data will be restricted and for the exclusive use of registered researchers and participants. In addition, it will be available in folders saved in Google Drive. The confidential data of participants will not be available to the public.The data will be stored on the institutional Google Drive of the Federal University of São Carlos (UFSCar). Only researchers from the UFSCar, who participate in this research, will have the authorization to access these stored documents. The metadata will be stored for the long term in the UFSCar research data repository.Not applicable to this research.p < 0.05.An assessor blinded to the randomization and assessment processes will make the statistical inferences for the primary and secondary outcomes. The intention-to-treat principle will be adopted in the analyses. The normality of the data will be evaluated using the Kolmogorov-Smirnov test. Specific analyses will be used, depending on the distribution  of the data. Parametric and nonparametric analyses will be used for normally and non-normally distributed data, respectively. These analyses will be performed using the SPSS v.17 statistical software , considering a statistical power of 80% for all the tests, with a significance level of No provisional analyses will be performed. In cases of discontinuity, the intention-to-treat principle will be adopted.No subgroups will be analyzed.In the case of discontinuity, missing data will be handled by adopting the intention-to-treat principle, in order to make statistical inferences.Not applicable to this research.Not applicable to this research.Data monitoring committees are generally considered to better organize selected survey data. A researcher (R5) will be responsible for registering and organizing the data obtained in this research that will come from the documents and registration records: free and informed consent term (TCLE), screening, demographic data and clinical characteristics of the individuals participating in the research, Numerical Rating Scale, pressure pain threshold, conditioned pain modulation, temporal summation of pain, analgesic medication consumption during therapy, and global perceived effect. Metadata will be descriptive and administrative, derived from data collection, and made available in digital repositories. For metadata, the Dublin Core standard will be used.In the case of any harm or complication related to the treatments, this will be reported to the UFSCar Ethics Committee for Human Research. The same applies to possible ethical issues that may arise during the research. The guideline recommendations will be strictly followed.Not applicable to this research.This protocol was approved by the Human Research Ethics Committee (UFSCar) and registered in the Brazilian Registry of Clinical Trials - ReBEC (RBR-7vbw5gd). All amendments were described and submitted to the responsible centers, the university’s ethics committee, and ReBEC.The results of this study will be published in a scientific journal. After that, the metadata will be deposited in the Institutional Repository of UFSCar (RI-UFSCar) and also disseminated to the local and national community through the press office of UFSCar, and in zenodo.org, for international Open Science access.The purpose of this study is to compare the TA and LA techniques, assessing which is most effective in reducing chronic nonspecific neck pain. Since the 1970s, the World Health Organization (WHO) has encouraged the use of TA , consideUntil the present moment, there are no studies in the literature that have effectively compared TA and LA in cases of chronic nonspecific neck pain. This research will be based on evaluating and comparing the changes in pain symptoms and the functional capacity of the neck, after the application of the treatments. The results obtained for the groups will be quantified and compared. Based on the findings, it will be possible to establish the therapeutic potential of each treatment, considering the outcomes of pain and cervical disability, making it possible to identify whether there is a difference between the techniques in the treatment of chronic nonspecific neck pain.Some limitations include the inability to blind the researcher who will be responsible for applying the therapies, due to the nature of the interventions. To minimize a possible bias, this researcher will follow a script to standardize the treatments of all study groups. Individuals will be blinded to the true laser acupuncture and placebo intervention. However, due to the characteristics and differences of needle and laser, we will not be able to blind individuals between these therapies.The protocol registration was approved on 6 June 2021. The initial recruitment date will be on 10 March 2021, and the approximate date of completion of the recruitment of participants will be up to the second half of 2022.


Healthcare sector is one of the most pivotal pillars of the administrative setup of a country. It addresses one of the most important dilemmas that countries have to face: provision of quality healthcare to public in affordable prices. Africa lags behind in many health indicators. One of the contemporary health issues faced by countries, especially for those in sub-Sahara countries, is maternal mortality rate (MMR). It has had a significant part to play in the social conditions of the population and needs immediate attention. In spite of many years of civil war and the terrible genocide in the mid-1990s, as of late, Rwanda is showing signs of improvement in healthcare sector. This research is aimed at studying the current state of maternal mortality rate in Rwanda and the factors behind its performance, in a comparative study with India and Bangladesh for a cross-section of time mainly between 1990 and 2015. After a literature review, pivotal indicators that affect healthcare are shortlisted and a comparative analysis of the three countries is made on the basis of these indicators. A regression is run between historical MMR data and these indicators. A directly significant relationship is found between MMR and healthcare expenditure per capita and government commitment to health, closely followed by female literacy and healthcare infrastructure. In spite of many years of civil war and the terrible genocide in the mid-1990s which crushed the nation's health framework, as of late, Rwanda has been a model of enhancing access to maternal human services. Rwanda has a big poverty problem, and the nation has an expansive rustic populace, influencing access to healthcare facilities, especially for women. Unintended pregnancies lead to prebirth complications and risky premature births, which, coupled with strained assets at the provincial and regional levels, adds to maternal dismalness and mortality.However, the Rwandan government has made enhancing family planning services a national priority. Working with the World Health Organization, the Rwandan Ministry of Health has organized contracting and preparing health workers to give family planning instruction, family counseling, and such services to the men and women throughout the nation. Thus, Rwanda's maternal mortality rate (MMR) fell by a lot recently. The maternal mortality rate in Rwanda has seen a huge drop from 750 in 2005 (DHS) to 540 in year 2008 and under 400 as indicated by Health Management Information System (HMIS: 2010) and under 300 (RDHS) in 2015. Deliveries by Health Workers expanded from 38 percent in 2005 (DHS) to 52 percent in 2007 (DHS 2007) and 63.5 percent in 2010 (HMIS). The maternal mortality rate has fallen as of late, but is still high. Enhanced healthcare reconnaissance and responsibility have assumed a huge part in diminishing the MMR and expanding the quantity and quality of assisted deliveries in Rwanda. Enhanced surveillance has enabled Rwanda's Ministry of Health to better track the reasons for maternal deaths all through the nation, bringing about more focused approaches and techniques to counter the issues. Some important factors comprise the high percentage of births that take place without skilled assistance (52%) and the lesser utilization of family planning and basic obstetrics care (CPR: 27%).UNFPA is another organization that has been working in these fields in Rwanda since 1975. From that time on, it has been effective in progressing and supporting reproductive health and rights, gender, population, and development in Rwanda at both the focal and decentralized levels. According to UNFPA, roughly 800 women pass away from preventable issues during pregnancy and childbirth, 99% of all maternal deaths happen in developing nations, and they are to a great extent preventable –4. This In the Rwandan context, MMR has had a significant part to play in the social conditions of the population. The issue of MMR is not being given serious thought and that is why it needs the immediate attention for the betterment of healthcare provision to adult Rwandan females. If we look on the global scale, sustained health plans, government commitment and foreign aid for health programs have shown meaningful results all across the globe in reducing MMR. Some countries like Bangladesh, Nepal, India, and Honduras have taken concrete steps and performed really well, indicating that if the vision is correct, things shall and do get better. It is important that we learn from the past and not repeat the same mistakes. A previous research by a study  evidentlThis study intends to investigate some facets of Rwandan economy, society, social set-up, governance, and the relevant infrastructure in place and their contributions to the health of an average Rwandan woman. In this regard, this research is aimed at studying the current state of maternal mortality rate in Rwanda and the factors behind its performance, in a comparative study with India and Bangladesh which have been able to perform very well in decreasing MMR for the adult female populations. The choice of variables used in this study resulted from the review of the literature and as a result pivotal indicators or factors that affect healthcare are shortlisted, and we have identified country's economy represented by GDP per capita, health expenditure per capita, government commitment, female literacy rate, healthcare infrastructure and improvement in sanitation, sanitation facilities, and presence of nurses and midwives as commendable studies recommend these factors as building blocks contributing to maternal health –14.As per the United Nations Maternal Mortality Estimation Inter-office Group, which comprises delegates from the World Health Organization (WHO), United Nations Children's Fund (UNICEF), the United Nations Population Fund (UNFPA), United Nations Population Division, the World Bank, and widely acclaimed academicians, maternal demise is the passing of a woman while pregnant or within 42 days after delivery of a baby, regardless of the term and the site of the pregnancy, from any reason identified with or exasperated by the pregnancy or its administration, not from inadvertent or accidental causes . MaternaVariables that determine maternal death can either be direct or indirect. For the most part, direct causes of maternal demise occur as the after effect of an issue of the pregnancy, delivery, or mismanagement of either of these; indirect maternal demise is a pregnancy-related death in a patient with a prior or recently created health issue not related to pregnancy. Fatalities, during but not related to pregnancy, are namely accidental, incidental, or nonobstetrical maternal deaths. As expressed by a study  “Make EaAnother study  considerThe four measures of maternal demise are maternal mortality proportion (MMP), maternal mortality ratio (MMR), lifetime risk of maternal demise, and extent of maternal demise among deaths of Women of Reproductive Years (PM). Maternal mortality proportion (MMP) is the proportion of the quantity of maternal deaths amid a given time period per 100,000 live births over the same time period. Maternal mortality rate (MMR) is the quantity of maternal deaths in a populace isolated by the quantity of women of regenerative age, normally measured per 1,000 women. Lifetime risk of maternal death alludes to the likelihood that a 15-year-old female will pass on in the end from a maternal reason on the off chance that she encounters, all through her lifetime, the dangers of maternal demise, and the general levels of fertility and mortality that are watched for a given population. This rate can be determined utilizing either the maternal mortality proportion (MMP) or the maternal death rate (MMR). Finally, the extent of maternal` deaths among deaths of women of reproductive age (PM) is the quantity of maternal deaths in a given day and age partitioned by the aggregate demises among women between the ages of 15 and 49 years. This study employs and uses the MMR for countries in comparison and analysis/results. Ways to deal with estimating maternal mortality incorporate civil registration framework, household reviews, census, Reproductive Age Mortality Studies (RAMOS), and verbal autopsies.At the end of the last century, sub-Saharan Africa still had high maternal mortality and death rates, with the objectives of safe parenthood eluding numerous administrations. The Program of Action of the International Conference on Population and Development, 1994, and the Fourth World Conference on Women, 1995, were made to handle these issues. These projects drew extraordinary regard for reproductive well-being and rights and to sexual orientation value and equality. The scourge of the Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS) desolated the population and left in its wake untold demolition in the statistic, monetary, and social circles . Statistics from the most recent decade are in sharp contrast to those in the 1980s, while diminishing infant, young, and grown-up death rates and maternal mortality proportions (MMP) were prompting expanding life expectancy and better health status for women in the locale.Bangladesh is a great instance of a low and middle wage nation accomplishing the improbable, which numerous others neglected to do. It lessened its maternal mortality by 66 percent in the period of 1990 and 2010; the decrease was 40 percent from 2001 and 2010 alone. These were accomplished by bringing down the maternal mortality rate  from 574 to fewer than 200 in the period from 1990 to 2010. The diminishment was significant for eight years (1990 to 1998), as MMR diminished from 574 to 322 for each 100,000 live births. According to the 2012 WHO statistics, the normal yearly rate of this decrease was 5.9 percent in a period from 1990 to 2010, which is more than the Millennium Development Goal 5 focus of 5.5 percent or more. What is all, the more astonishing is that the diminishment in MMR  was nearly the same in both the urban and provincial territories. At the present rate, Bangladesh is well on its way in achieving the MDG 5 focus of 143 for each 100,000 live births an entire year before its designated time. Another example is India which has been able to excessively lessened maternal mortality by 65 percent from 569 to 190 for each 100,000 live births from 1990 to 2013. However, with 4.5 percent annual decrease in MMR, India might just miss the MDG 5 focus of 5.5 percent or more abatement rate before 2015. Be that as it may, the execution by India has been excellent from that point onward. [th century in northwestern Europe . The concept of MMR expanded later in Britain and USA, moving in to lesser developed countries as a pivotal factor of maternal well-being. Today, maternal health is an important measure of national health. How did Bangladesh, one of the poorest nations on the planet with the most population density and where 75 percent of the populace lives in rural areas, rapidly accomplish MMR decrease? Furthermore, how did India oversee such a change? It is a difficult inquiry to reply to. As indicated by [A study  exhibitecated by , the staBetween 1930 and 1995, Malaysia and Sri Lanka succeeded, through similar means, in diminishing their MMRs significantly every 6-12 years down to fewer than 50 for each 100,000 live- births by 1995. In the 1930s, Malaysia, notwithstanding gloating a moderately solid economy, and Sri Lanka, a low-salary nation with extraordinarily large amounts of female education, were both tormented by MMRs of more than 500 for every 100,000 Live Births and more than 2000 for every 100,000 Live-Births, respectively. Understanding the overwhelming impact of the poor providence of maternal health on national development and advancement, the two nations actualized exhaustive national systems to diminish maternal mortality. Four key parts added to the achievement of both national projects: extensive strengthening of human development programs  particularly in poor and underserved territories; noteworthy interests in enhanced maternal well-being administrations, enhanced access to proficient nurses and midwives; and progressing political help will decrease MMR. Outstandingly, concurrent with maternal mortality decay amid this period, Sri Lanka additionally diminished its TFR from 5 to 2.2 live births per woman in age of conception and Malaysia from 6.3 to 3.4 live births per women of reproductive age. Supported by great political will and dynamic political bodies focused on decreasing Maternal Mortality in both nations, infrastructure investments, rural health facilities, and human resources empowered the administrations of Sri Lanka and Malaysia to help underprivileged masses . Access A research study suggested that skilled attendance at childbirth is effectively linked to decrease in maternal mortality in Sweden. On the other hand, the researches that have been done in USA and Netherlands in the 1900s attributed a decline in maternal mortality to the changes in population age and parity .In this study, we shall take a special look at the four human development factors  recommended in many studies –14, whicA detailed cross-sectional comparative study between Rwanda and the South East Asian countries of Bangladesh and India shall be done. These are countries that have been able to effectively achieve their MDG 5 goals, especially in maternal mortality, as per the WHO guidelines. The studies shall focus on the most important points relevant to this study as mentioned in the literature and shall elaborate how; over time, these countries have fared. This study  defines The indicator MMR, that measures number of annual maternal deaths as a fraction of 100,000 live births of a country in the same period, is the most important feature. An optimum value to be achieved for it is 143, which shall be used as a benchmark. The comparison is in To measure the rate of economic wealth per person for all three countries (gross domestic product divided by midyear population as per World Bank), following is a comparative study of GDP/capita (in USD) of the countries over a period starting from 1990, although data from commendable sources is from 2000 onwards to 2017.A very important factor of those mentioned before has been the government commitment to making health a priority in policy setting for country and appreciable budget allocation to improving healthcare. An important indicator when talking about health is the government commitment. The budget committed to the cause of health is a direct indicator of how seriously a country wants to address this issue. A comparison for the three countries is done, and Rwanda has especially surpassed both India and Bangladesh due to appreciable foreign funding for health sector, which is bringing about major changes in the way things are shaping up. Especially in the 2000s the commitment to health has been solid, with the record high of 16% for Rwanda in 2003 and then a whopping 23% in 2006. The number for Rwanda presented here is in 2012 at around 24%. The government commitment trend remains somehow linear for India and Bangladesh, standing at 9% and 8%, respectively.Another important indicator especially for this specific research is the female education. It is a very relevant indicator to give us an insight into how lives can be saved through education. The following comparison shows the numbers for adult female literacy rates in these countries in Bangladesh has shown a very optimum improvement in the literacy rate when in 1991 it was recorded to be around 26 percent and it went up to around 70% in 2015, a figure which is commendable. The percentage for India was 63% in 2015, which is appreciable, but the rise has been steady, starting from 34 percent in 1991. Rwanda has also shown a somehow steady rise in adult female literacy rate, going up from 37% in 1991 to around 67% in 2015.A prime factor that is being measured is the investment in healthcare infrastructure by the government and improvement in access to sanitation facilities. Governments of the three countries Rwanda, Bangladesh, and India have endeavored to improve health through providing better sanitation facilities to the public. The ratio of nurses and midwives is among the factors that are highly considered in analyzing the progress of health sector. Therefore, following Now that we have had a cursory look at the data, this paper utilizes simple regression model in estimating the factors that affect maternal mortality in Rwanda. The software used is R. The model is specified as follows:Xt in equation , budget committed to health (BCH), health expenditure (HE), nurses and midwives (NMd), and sanitation and facilities (SF) as grouped in one single variable equation . The depFrom the results of regression presented in After presenting all of these results, the conclusions in a nutshell and an analysis of how Rwanda is progressing in the quest to decrease MMR shall be presented. The MMR rate for Rwanda has gone down at an appreciable extent, and it is ably competing with other countries, which have been doing well in this regard. At the present rate, Rwanda shall also be listed in countries that have successfully battled with maternal mortality, especially among those of sub-Saharan Africa where it still remains a big issue. Rwanda is on the way to a steady recovery after a slump in the early 2000s, as the government is also investing more towards health as it has now a very impressive share in the GDP per capita spending. Rwanda has shown the most improvement in Health expenditure per capita, whereby the per capita spending increased exponentially after 2002, reaching a record high of 59 USD in 2014, and it has kept on increasing. Rwanda has surpassed both India and Bangladesh in Government Commitment of Budget to health sector with the record high of 16 percent commitment in 2003 and a whopping 23 percent in 2006, currently standing at around 25 percent. Rwanda has also shown a somehow steady rise in adult female literacy rate, going up from 37 percent in 1991 to around 67 percent according to the latest data, which is appreciable but more needs to be done here. In infrastructure development, Rwandan progress has been steady, boasting good numbers for public access to healthcare facilities and sanitation facilities as compared to India and Bangladesh with a little improvement needed in the sector of training healthcare professionals and caregivers during pregnancy and childbirth. A good explanation of these phenomena can be attributed to the health and Medicare aid provided to Rwanda from external sources and other countries, which currently fund 53 percent of all healthcare resources of Rwanda, which is bringing about major changes in the way things are shaping up. We believe that Rwanda is firmly progressing upon its path to a decreasing MMR and provision of quality healthcare, and the changes are appreciable as seen through the indicators.The current healthcare system of Rwanda has been a revelation, whereby the populace is now getting more healthcare coverage in affordable prices. More studies need to be done in the healthcare sector to build upon this good work, which shall help fortify Rwanda reputation not only among sub-Sahara but also Africa as a good example to follow in healthcare delivery. It is believed that this study has a direct impact on the Rwandan maternal healthcare system and it was conducted so that some indicators in the Rwandan healthcare industry may be highlighted and reasons for some shortcomings are investigated. A policy recommendation could be that the Rwandan government and the healthcare sector should take relevant measures that enhance healthcare system, and this ultimately will reduce maternal mortality. This study shows how pivotal the prescribed indicators are when studying the MMR. We can conclude from this study that increase in per capita healthcare expenditure is the most effective element to diminish MMR, followed by numbers of nurses and midwives, budget committed to health, female literacy, and sanitation conditions finally. GDP was not found to have a significant relationship with MMR. More detailed studies may also be conducted to further this idea or to conduct this research in a different way. The idea of this study can be duplicated and can also act as a roadmap for other studies in healthcare provision in Africa and other continents.