Building a Maternal and Child Cohort Amidst Lebanon’s Socioeconomic Collapse: Preliminary Results and Navigating Research Challenges

doi:10.21203/rs.3.rs-3332264/v2

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Building a Maternal and Child Cohort Amidst Lebanon’s Socioeconomic Collapse: Preliminary Results and Navigating Research Challenges

https://doi.org/10.21203/rs.3.rs-3332264/v2

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In recent years, research has shown how connected systems influence health. Lebanon's financial predicament and political unrest have created a multifaceted crisis landscape with shortage in essential services. Social determinants like socioeconomic status and social support along with maternal mental health have been linked to preterm birth. Preterm infants are particularly disadvantaged, needing comprehensive, multidisciplinary support for optimal development. This study delves into exploring the impact of the social environment on preterm infants' developmental outcomes amidst Lebanon’s complex crises. Exploring the links between determinants of health and preterm outcomes gains urgency in this context. Lebanon's healthcare and economic deterioration over the past years is expected to amplify these risks, emphasizing the need to understand their impacting on both birth outcomes and infants’ cognitive development.

We aimed to establish a prospective cohort study to evaluate the impact of the social environment on birth and developmental outcomes. This multicenter prospective cohort faced challenges that can be categorized into recruitment, follow-up, and in data collection challenges. Emigration of Lebanese citizens affected recruitment, reducing the pool of eligible participants. Birth rates decreased due to the socioeconomic and political crises. Follow-up assessments were hindered by rising healthcare costs and obstacles with transportation.

Whilst the study is still ongoing, preliminary results highlight the importance of the social environment and contextual conditions. The WHO Quality of Life Questionnaire scores of the preterm infants’ mothers were significantly lower than those of term infants across physical, psychological, and social domains. Stress levels were noted to be high across most of the mothers. Economic challenges decreased the purchasing power and limited income measurement in the cohort.

Findings from this study aim to provide critical data on the crises’ effect on social determinants, child developmental outcomes, and their relationship. Results can have important implications for informed resource allocation and timely interventions.

Maternal fetal cohort

preterm birth

research challenges

socioeconomic factors

Lebanon

In recent decades, research in crisis setting has been evolving and progressing towards a more interdisciplinary approach (Bergman-Rosamond, A et al., 2020). As the world advances and becomes more and more interconnected, the effects of the multilevel systems that affect health outcomes ought to be addressed. Indeed, crises cannot be managed as events occurring in silos, rather they are a manifestation of the complex web of social, political, economic, and health systems which affect lives and health outcomes.

For the past few years, Lebanon has been an unfortunate perfect representation of a country being faced with multiple simultaneous crises. Economically, the financial crisis which started in late 2019 is still ongoing and is manifesting in the depreciation of the local currency at more than 90% its value, in an increasingly soaring inflation at more than 200%, and in significant restrictions on banking transactions and funds use (Blair E, 2022). From a political perspective, since 2019, Lebanon has been gripped by a national revolution, political unrest, presidential vacuum, and widespread corruption across multiple public sectors (Ibrahim, A., & Jawhar, S., 2023). From a public perspective, lack of essential services from electricity to fuel, to medications, has severely impacted the lives of Lebanon’s residents for the past several years (Doctors Without Borders, 2021).

Lebanon’s infrastructure, particularly healthcare infrastructure, has also been further strained by the impact of the COVID-19 pandemic, the financial challenges, and the catastrophic August 2020 Beirut port explosion. The healthcare crisis is multifaceted and has been characterized by staffing shortage, closure of medical centers (Bou Sanayeh, E., El Chamieh, C, 2023), shortage of medications, and shortage of instruments and lab kits (Nassar M., et al., 2023) to name a few.

In this context, exploring the impact of crises on vulnerable groups becomes imperative. Preterm babies and their parents are already at a disadvantage with a need for medical, social, and emotional support especially during the critical 1000 days for them to reach their developmental potential. Several risk factors have been identified for preterm birth. Some of the main determinants of preterm birth are social disadvantage and low socioeconomic conditions (Abbot A, 2015; Sebayang S.K et al., 2012; Harrison, M.S. & Goldenberg R.L., 2016), lower mothers’ educational status, and higher maternal anxiety and stress in pregnancy (Dolatian M., et al., 2013). In addition, studies have revealed that preterm birth is more common in mothers who suffer from anxiety and depression (Sharifi N., et al., 2018; Rahman, A, et al., 2019; Goldenberg R.L., 2016; Strange, L.B., et al., 2009). Other studies have also shown that lower income is among the structural factors which affect preterm birth, and perceived stress, perceived social support and financial support are also associated with preterm birth (Goldenberg R.L., 2016; Strange, L.B., et al., 2009; Dolatian, M., et al., 2014; Kumar,S., et al., 2017; Chiavarini, M, et al., 2012).

In Lebanon, the deterioration of the healthcare and economic systems is expected to have had large negative consequences on this vulnerable group. Indeed, economic disadvantage is not only a risk factor of preterm birth, but also of other important developmental outcomes, including cognitive functioning, and social, behavioral, and emotional development (Scharf, R.J., et al., 2016; McCoy DC, 2015; Rijlaarsdam J, et al, 2013).

Cohort studies are distinctive in supporting our understanding of child development, particularly in contexts like Lebanon, allowing for observation and follow-up for an extended period, capturing dynamic changes and long-term outcomes. Lebanon's multifaceted crises, which encompass economic downturns, political gridlock, infrastructural decay, and social unrest, serve as a poignant representation of similar challenges faced by many nations around the world (Gnesotto, 2019) (UN, 2023). As globalization intensifies the interconnectedness of nations, the domino effect of economic crises, as witnessed in Lebanon, can be a cautionary tale for even the most stable of economies. Whilst low- and middle-income countries traditionally had the most limited resources, recent political and economic developments are a warning sign for wealthier nations (Kammer, 2021). Moreover, the refugee crisis, driven by regional conflicts, and the subsequent strain on resources and social infrastructures, can be seen in various regions, from Africa, to Asia, to Europe (Björn Rother, 2016) (Zanfrini, 2016). Therefore, Lebanon, with its several concurrent crises, presents an important case for studying the impact of the social environment on vulnerable preterm infants' developmental outcomes, and can provide insight to other communities across the world facing similar challenges.

Objectives:

We originally aimed at building a cohort of 50 full term babies and their mothers and 50 full term babies and their mothers, recruited at birth, and followed up for up to 9-12 months post birth. The objectives of this cohort were to examine the association between social determinants and preterm birth, and to examine the association between preterm birth and developmental outcomes of infants. In parallel with the launch and establishment of the cohort, Lebanon’s rapid socio-political changes and complex financial and healthcare challenges began unfolding.

In this report, the objectives are to examine the feasibility of building a prospective mother and child cohort and on examining the challenges and barriers of conducting such research in a crisis ridden and low resource setting.

Population and sample size:

The study population of the originally planned cohort consisted of babies born before 37 weeks of gestation at the American University of Beirut Medical Center (AUBMC) and their mothers, and a comparator group of babies born at 37 weeks of gestation and above also born at AUBMC. Based on a review of the literature of previous studies, we estimated the sample size needed to be able to reject the null hypothesis that preterm children and full-term children will have similar scores on the developmental assessment. Thus, the original target sample was 50 full term babies and 50 preterm babies and their mothers to support detecting a difference in the mean scores on the developmental assessment between the two groups with an effect size of 0.6 and a probability of 0.85.

Non-Lebanese and those who are not permanent residents in Lebanon were excluded as these are likely to be the most mobile thus limiting the possibility of follow up and leading to high attrition rates. Also excluded were infants with major congenital anomalies (Trisomy 13, Trisomy 18, Holoprosencephaly, Anencephaly, Encephalocele) who exhibit severely impaired communication as they would be unable to undergo the needed developmental assessment during follow-up visits. Finally, babies who passed away in the Neonatal Intensive Care Unit (NICU) were excluded.

Design:

The original cohort was a single center prospective cohort. It was expanded to a multi-center cohort later on due to lack of recruitment. Recruitment at AUBMC was launched in September 2021, at Keserwan Medical Center (KMC) in June 2022, and at Bahman Hospital in October 2022. The original plan was for one year of data collection done at three time points: At recruitment in the postpartum unit after birth, at 4-6 months post birth, and at 9-12 months post birth.

The project has been approved by the Institutional Review Board (IRB) of all participating centers and informed consent from the mothers is secured upon recruitment.

The cohort aims at collecting information on several aspects including social determinants, perceived stress level, social support, and quality of life. In addition, developmental assessment of all babies is performed at 4-6 months post birth and at 9-12 months post birth. These are presented in further detail below:

The social determinants assessed include maternal age, educational level, place of residence, and household crowding index. Given that participants might not be willing/able to disclose their income, income is measured via both a direct question and via proxy variables including ability to acquire basic needs (food, shelter, clothing, sanitation, education, and healthcare); assets owned; and perception of wealth inequality.

Also assessed are the mothers’ perceived stress level, social support, and quality of life at birth, at 4-6 months, and at 9-12 months using the following validated and standardized tools:

Arabic version of the Cohen perceived stress scale (PSS-10), a validated tool used to measure stress during pregnancy and the postpartum period. The tool generates a 10-item scale which correlates with depression, anxiety, decreased satisfaction, and perception of poor health. It has been translated and validated in Arabic in a Lebanese population sample.
Arabic version of the Multidimensional Scale of Perceived Social Support (MSPSS), a tool of 12 items that assesses social support in the individual’s community consisting of family, friends, and significant others. It has been translated and validated in Arabic in a Lebanese population sample.
Arabic version of the WHO Quality of Life Instrument-Bref (WHOQoL‐BREF). The questionnaire measures physical and psychological health, social relationships, and the environment and has been validated in an Arabic population.

Developmental assessment of all babies is performed at two time points: at the 4-6 months and at 9-12 months visit using the Ages & Stages Questionnaire. The Bayley Scales of Infant & Toddler Development is administered at the 9-12months visit. The Ages & Stages Questionnaires is a developmental screening tool for developmental delays. The questionnaire assesses 5 areas of development (Communication, gross motor, fine motor, problem solving, personal-social) with 6 questions/area. Depending on the score generated, the results indicate either that the child’s development is on schedule, and they receive a result of “pass”, either that there are behaviors of concern, and the child should be “provided activities and retested”, either that there is concern and further assessment by a professional is needed and they receive a result of “refer”. It has been tested in the Lebanese population with adequate reliability and validity (Charafeddine, L., et al., 2019). The Bayley Scale for Infant and Toddler Development is recognized internationally as a gold standard test to assess development; it is administered in English by a certified trained professional.

Finally, clinical and health related variables are collected through medical records review. These include medical history, and pregnancy and delivery history. Based on a review of the literature, data is also collected on the following potential confounders to be adjusted for in the analysis: gender; neonatal morbidities defined as: sepsis, intraventricular hemorrhage, and respiratory distress syndrome; parity; multiple births; babies undergoing physiotherapy; and babies undergoing speech therapy.

The preliminary results reported at this stage consist of basic descriptive statistics and the profile of the study population. The comparison of the WHO QoL scores between the full term and preterm infants is done through the independent t-test. A timeline of the study and the data collection schedule is detailed in figure 1.

Challenges in recruitment

We were initially expecting to recruit 100 mother-baby pairs in the first year of the study, we were only able to recruit 70 mother-baby pairs by the end of the first year. Although some of the mothers who were approached did not want to partake in the study, a significant number of those who were interested were not eligible to be included in the cohort, thus decreasing the sample pool. Specifically, 36% of those who were approached but not recruited were not eligible since, although they were Lebanese, they were not permanent residents in Lebanon.

Challenges in follow-up assessment

Our study is a longitudinal cohort with follow up assessments scheduled at two time points after birth, at 4-6 months, and at 9-12 months. While a common limitation of all cohorts is the loss to follow up, we have noted that in our sample several of the women who are not completing the follow up visits are not withdrawing due to lack of interest in partaking. Rather, rising transportation costs and rising charges for consultation visits are impacting the ability to complete follow-up assessments. To date, only 71% of the mothers who have reached the follow-up stage have completed the first follow-up visit. For those who did not complete the follow-up visit, and whom we were able to contact, around 40% stated the rising fuel costs, inability to cover transportation costs, and inability to come to AUBMC for follow up as the main reason for withdrawal.

Challenges in data collection

One of the main challenges we have faced is in collecting data on finances and economic resources. In the cohort, 40% of the mothers were not able to disclose their income, partly because they are getting paid part of their salaries in USD and could not calculate the equivalent in LBP.

With the lack of official tracking systems available to monitor the value of the Lebanese Lira, this has impacted the socioeconomic status evaluation of the mothers in our sample. Issues in data collection due to limited resources and nation-wide barriers has been reported in neighbouring countries including the occupied Palestinian territory (Khatib, 2016)

Addressing the challenges:

To mitigate the effects of these issues in recruitment, follow-up, and data collection process, we implemented some changes in terms of study site, follow-up process, and study personnel. The cohort was originally planned in one centre only; however, nine months after recruitment was launched at AUBMC, and to support recruitment efforts, particularly for preterm infants, another center, Keserwan Medical Center (KMC), was added as a recruitment center. A year after recruitment launched, a third center, Bahman Hospital was also added, to both support recruitment efforts, and to extend the sampling frame to those of lower socioeconomic levels. The inclusion and exclusion criteria were the same across the different centers. AUBMC serves a diverse population of patients, including the more central and urban residents of the capital Beirut, as well as employees of the institution who benefit from the HIP and who have diverse socioeconomic levels, in addition to the outpatient clinic which specializes in offering services for residents with limited financial or healthcare coverage resources. KMC is located to the north of Lebanon and serves residents who are further from the capital. Bahman offers medical care to residents with limited resources for medical care support and financial means.

After the inclusion of the two additional sites, the target sample was increased to 80 full term babies and 80 preterm babies and their mothers. At the time of continuing review, permission was granted from the Institutional Review Board to extend recruitment at all sites considering the challenges being faced particularly regarding the decreasing number of admissions at the hospitals.

In terms of follow-up visits, these are being scheduled alongside the children’s paediatrician’s visit to limit the need for transportation to the medical centre for the mothers. In the event of mothers choosing to follow up with paediatricians in other centres that are not part of the sample, they are being granted the opportunity of completing the follow-up questionnaires over the phone thus limiting the rate of missing data. Finally, an additional research assistant was hired to support with recruitment and follow-up efforts across the centres.

Preliminary analysis:

Until May 2023, 113 mother-baby pairs have been recruited including 79 full term babies and 34 babies born preterm. Out of those, 59 mother-baby pairs completed the first follow-up visit at 4-6 months, and 26 mother-baby pairs completed the second follow-up visit at 9-12 months.

Sample characteristics

In terms of sociodemographic characteristics at baseline, although 89% of mothers have a university degree, 50% of them were unemployed and 17% of them either did not have insurance or were insured by the national security fund which is a governmental fund known for not covering medical costs in most instances.

When looking at mothers’ health status, almost a third (27%) had complications during their pregnancy, and 17% had other comorbidities. Whereas 48% gave birth via normal vaginal delivery, 28% had an urgent C-section. As expected, mothers who gave birth to a preterm baby had a higher rate of urgent C-sections as compared to mothers of full-term babies. Finally, only 50% of the babies were exclusively breastfed within 24-48 hours post birth. Refer to table 1 for sample characteristics.

Quality of life

In terms of quality of life measured by the WHO-QoL questionnaire, significant differences were noted in terms of quality of life between the full term and the preterm group at baseline. Compared to mothers of full-term infants, mothers of preterm infants had lower scores on the WHO-QOL physical (35.8 vs 58.6, p<0.01), psychological (54.6 vs 67.2, p=0.005), and social (58.7 vs 68.6, p=0.215) domains. They also scored lower on the environment domain, but the difference was not statistically significant (Table 2) On follow-up, 50% of preterm infants were provided activities and retested or referred per the ages and stages questionnaire, compared to 36% of full-term infants.

Economic impact

The effects of the economic crisis on the decreased purchasing power were evident in our sample. In fact, during the first follow-up visit at 4-6 months post birth, the percent of mothers who are unable to financially support their older children’s education doubled, the percent of mothers unable to acquire clothing more than tripled, and the percent of mothers unable to acquire healthcare increased by almost 8-fold. As well, in a sample who were all previously able to acquire food, shelter, and sanitation, at follow-up 4% were unable to acquire these necessities anymore. The financial instability also affected our ability to collect the needed data. In fact, with the severe fluctuations of the Lebanese Lira rate, several mothers were unable to calculate their average monthly income and 40% were unable to report their income as its value would differ from one day to the other and hence, they were unable to accurately calculate it.

Stress and social support

At baseline, 47% of mothers reported moderate stress levels on the PSS10 scale and 15% reported high perceived stress. And during the first follow-up visit, the total percent of mothers who reported moderate to severe stress increased to 66%.

Despite the relatively high levels of stress that were reported, 85% of mothers indicated that they benefit from high perceived social support, and 15% benefit from moderate social support.

Developmental outcomes

Here we report our interim findings of the 4-6 months ages and stages questionnaire: Out of 58 babies who completed the questionnaire (43 full term babies and 16 preterm babies), 35 babies passed the questionnaire, 13 were provided activities and advised to be retested, and 10 needed referrals to a professional.

Establishing a prospective mother and child cohort does not come without its challenges. In a crisis ridden and low resource setting, challenges and barriers are expected to occur more frequently and to have a bigger impact on both the study population and the day-to-day activities of the research project. The establishment of our cohort was done as the crises were unfolding in Lebanon.

In the past few years, the number of Lebanese individuals seeking refuge from the escalating crisis has increased significantly with almost half of the citizens stating that they desire to emigrate (Arab Barometer, 2022), with this number increasing to almost two thirds when looking at those between 18-29 years old (Arab Barometer, 2022).

Another aspect affecting recruitment is the decreased birth rate. From 2017 to 2021, the births rate in Lebanon has decreased by around 24% (Lbci, 2023), reaching the lowest rate recorded for the nation. Given the economic situation and political crises, women in Lebanon are becoming more reluctant to get pregnant and are delaying childbearing (Lbci, 2023) (Raseef 22, 2022) (A. Al-Awsat, 2021). Indeed, in one of the study centres, the NICU which used to be fully occupied with 15 beds, is now hosting 3-5 babies at a time at most.

We have also been facing challenges in allocating resources and in identifying healthcare professionals who are able to support with the study. With the exodus of healthcare workers and the lingering effects of the Covid-19 pandemic, healthcare professionals who have remained in Lebanon are overworked and cannot properly dedicate the time to support in research projects. The Lebanese health sector has been badly strained by the effects of the compounding crises. The World Health Organization has estimated in September 2021 that nearly 40% of Lebanon's doctors and almost 30% of nurses had departed since October 2019 (T. Ramadan, 2022). With no expected resolution of the crises any time soon, this number is estimated to have increased as well. Indeed, we have witnessed the effects of this exodus first hand with two of our investigators and one of our research assistants leaving the country over the past 2 years. In developing countries, operational barriers including difficulty in patient recruitment and lack of human research capacity is a major barrier to research which has been reported in several other studies (Alemayehu, 2018).

Financial challenges were a main barrier faced more and more frequently as the study progressed. Some mothers have shared that the increasingly high costs of consultations, which are being charged in USD rather than the collapsing Lebanese Lira, is leading them to schedule their children’s follow-up visits with paediatricians at tertiary care centres rather than with the paediatricians at private medical centres. The economic collapse along with the COVID 19 pandemic has made healthcare inaccessible to many residents in Lebanon (Unicef, 2021). In a country in which the local currency is in free fall and having lost more than 97% of its value already (Reuters, 2023), it has been very challenging to document and report individual financial resources.

In addition, limited basic infrastructure such as reliable transportation and stable electricity (as is the case in Lebanon) pose real challenges towards research progress in resource-limited settings. Often, the priorities of research funders do not align with the most urgent needs of low- and middle-income countries (CIOMS, 2021). While access to healthcare is predominantly a concern in developing countries, it is still a universal issue as manifested by the growing demand for sustainable models which separate research costs from other costs (CIOMS, 2021).

In a context of crisis settings, shedding the light on the intricated social determinants and adversities is of outmost importance for guiding resources and interventions. With this backdrop, stress levels are expected to be affected, particularly with mothers of newborns who are undergoing life changing events. Researching in crisis settings is essential for illuminating the complex interplay of social determinants and adversities. With Lebanon at the center of combined upheavals, recruitment and data collection challenges have been substantial.

Our results highlight the need for research funds that prioritize hard to reach populations and on integrating design and measurement approaches that can capture rapid changing social environments and their impact on child outcomes. Limited information on certain socioeconomic indicators is not only a manifestation of the ongoing socioeconomic collapse but it could also be a source of information bias in our sample which is ought to be addressed. We are monitoring participation and attrition rates and documenting reasons for participation refusal and withdrawal. Indeed, collecting information on participation and attrition not only provides insight into potential barriers and how to address them but is also necessary to identify any selection bias. In crisis settings, this becomes an even more critical concern, ensuring that resources and interventions can be accurately guided by the research findings.

Our preliminary results showcase significant differences in quality-of-life measures between mothers of preterm babies and those of full-term babies, in a crisis setting. This highlights the intricated social determinants and adversities important for guiding resources & interventions. Mothers are experiencing levels of stress which are increasing with time. Although it is not clear whether this is impacted by the new challenges they are facing as mothers, or the effects of the economic, social, and health crises, or both, nonetheless, the rising challenges and limited availability of resources are expected to lead Lebanon into a mental health epidemic (Farran N, 2021).

On average, the mothers in our sample ranked themselves 6/10 at the society scale, keeping in mind that the presented results are of a majority of mothers visiting the top ranked medical centre in the capital which attracts communities of higher socioeconomic strata. Our results represent the tip of the iceberg as stronger impact is expected in lower socioeconomic communities.

Quality research is crucial to address the health needs of those in resource-limited areas, including women and children. However, the majority of research still occurs in high-income countries, and is designed to cater to their specific health priorities. This means that many communities globally lack access to advanced health interventions and lack the needed research specific resources and infrastructure.

Ethical considerations:

Mothers who have just given birth and babies, particularly preterm infants, are particularly vulnerable. In the context of socioeconomic challenges like those faced by Lebanon, conducting research with mothers and babies poses several additional ethical considerations.

Due to the vulnerability of the situation, especially in a crisis-hit area, ensuring that consent is freely given without undue pressure or perceived obligation is paramount. The emotional and psychological stress associated with giving birth to a preterm infant might be exacerbated by participating in a study, particularly when inquiring about specific variables that might be associated with developmental outcomes of preterm babies. It is important to reinforce to the mother that she should not feel any guilt or responsibility over socioeconomic factors which are not within her control. Providing equitable access is not only limited to healthcare services. Our research project is giving mothers the chance to assess their infants’ developmental progress, which they would not have otherwise had access to, and should not only target one specific socioeconomic category. In a nation grappling with socioeconomic challenges, we aimed at including multiple medical centres across the country which target different communities and not only those who are easily accessible.

Finally, in the event when a developmental delay is identified through assessment, the child is referred to a specialist. However, in the context of limited resources and limited financial capabilities, some mothers might not possess the ability (financial, logistic, transportation…. etc) to take their children to specialists, which opens the doors to the ethical dilemma of offering a diagnosis but not the needed support and follow up.

While research in such settings can offer invaluable insights and potential solutions to pressing issues related to vulnerable groups, it is imperative to approach the process whilst respecting ethical considerations and with a commitment to the well-being of the participants and the wider community.

Establishing a prospective mother and child cohort in a crisis-ridden and low-resource setting like Lebanon presents numerous challenges. The simultaneous occurrence of economic collapse, political instability, decreased birth rates, healthcare worker exodus, financial challenges, and infrastructure limitations has made conducting research in this context exceptionally difficult. There is a pressing need for research funding that prioritizes hard-to-reach populations, that supports building research capacity, and that incorporates adaptable measurement approaches to capture the rapidly changing social environments affecting child developmental outcomes. In Lebanon and similar settings, the challenges faced in establishing and conducting such cohorts serve as a reminder of the imperative to address health disparities in times of crisis and resource scarcity. Upon completion of recruitment and follow up, the study will assess the relationship between social determinants and developmental outcomes. In a country that has been going through one crisis after the other, interventions can be built based on the results and later tested thus guiding resources and management approaches.

Acknowledgments: The authors would like to acknowledge the Reproductive Health Working Group (RHWG) for the funding provided to support the set-up of the cohort. The authors would also like to acknowledge Ms. Fatima Nasser, Ms. Rayan Hojeij, Ms. Reine Zankar, and Ms. Alice Recho their efforts in the recruitment of participants and conducting follow-up visits, and Ms. Saadieh Masri for her efforts in leading the Bayley Developmental Assessment.

Ethical Approval

The Institutional Review Board at the American University of Beirut has approved the study. Approval was also secured from the ethical committees at Bahman and Keserwan Medical Center. Informed consent is secured from mothers before participating in the study.

Funding

The primary author has received seed funding from the Reproductive Health Working Group (RHWG).

Availability of data and materials

Not applicable as the study is still ongoing. Once the study is completed, data will be made available.

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No competing interests reported.

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Building a Maternal and Child Cohort Amidst Lebanon’s Socioeconomic Collapse: Preliminary Results and Navigating Research Challenges

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