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STUDY QUESTION What is the association between a country's level of gender equality and access to ART, as measured through ART utilization? SUMMARY ANSWER ART utilization is associated with a country's level of gender equality even after controlling for the level of development. WHAT IS KNOWN ALREADY Although gender equality is recognized as an important determinant of population health, its association with fertility care, a highly gendered condition, has not been explored. STUDY DESIGN, SIZE, DURATION A longitudinal cross-national analysis of ART utilization in 69 countries during 2002–2014 was carried out. PARTICPANTS/MATERIALS, SETTING, METHODS The Gender Inequality Index (GII), Human Development Index (HDI), and their component indicators were modelled against ART utilization using univariate regression models as well as mixed-effects regression methods (adjusted for country, time, and economic/human development) with multiple imputation to account for missing data. MAIN RESULTS AND THE ROLE OF CHANCE ART utilization is associated with the GII. In an HDI-adjusted analysis, a one standard deviation decrease in the GII (towards greater equality) is associated with a 59% increase in ART utilization. Gross national income per capita, the maternal mortality ratio, and female parliamentary representation were the index components most predictive of ART utilization. LIMITATIONS, REASONS FOR CAUTION Only ART was used rather than all infertility treatments (including less costly and non-invasive treatments such as ovulation induction). This was a country-level analysis and the results cannot be generalized to smaller groups. Not all modelled variables were available for each country across 2002–2014. WIDER IMPLICATIONS OF THE FINDINGS Access to fertility care is central to women's sexual and reproductive health, to women's rights, and to human rights. As gender equality improves, so does access to ART. This relation is likely to be reinforcing and bi-directional, with progress towards global, equitable access to fertility care also improving women's status and participation in societies. STUDY FUNDING/COMPETING INTEREST(S) External funding was not provided for this study. G.D.A. declares consulting fees from Labcorp and CooperSurgical. G.D.A. is the founder and CEO of Advanced Reproductive Care, Inc. as well as the Chair of the International Committee for Monitoring Assisted Reproductive Technologies (ICMART) and the World Endometriosis Research Foundation, both of which are unpaid roles. G.M.C. is an ICMART Board Representative, which is an unpaid role, and no payments are received from ICMART to UNSW, Sydney, or to G.M.C. to undertake this study. O.F. S.D. F.Z.-H. and E.K. report no conflicts of interest. TRIAL REGISTRATION NUMBER N/A. [ABSTRACT FROM AUTHOR]

From November 2019 to January 2020, eastern Australia experienced the worst bushfires in recorded history. Two months later, Sydney and surrounds were placed into lockdown for six weeks due to the COVID-19 pandemic, followed by ongoing restrictions. Many pregnant women at this time were exposed to both the bushfires and COVID-19 restrictions. To assess the impact of exposure to bushfires and pandemic restrictions on perinatal outcomes. The study included 60 054 pregnant women who gave birth between November 2017 and December 2020 in South Sydney. Exposure cohorts were based on conception and birthing dates: 1) bushfire late pregnancy, born before lockdown; 2) bushfires in early-mid pregnancy, born during lockdown or soon after; 3) conceived during bushfires, lockdown in second trimester; 4) conceived after bushfires, pregnancy during restrictions. Exposure cohorts were compared with pregnancies in the matching periods in the two years prior. Associations between exposure cohorts and gestational diabetes, preeclampsia, hypertension, stillbirth, mode of birth, birthweight, preterm birth and small for gestational age were assessed using generalised estimating equations, adjusting for covariates. A decrease in low birth weight was observed for cohort 1 (aOR 0.81, 95%CI 0.69, 0.95). Conversely, cohort 2 showed an increase in low birth weight, and increases in prelabour rupture of membranes, and caesarean sections (aOR 1.18, 95%CI 1.03, 1.37; aOR 1.21, 95%CI 1.07, 1.37; aOR 1.10 (1.02, 1.18) respectively). Cohort 3 showed an increase in unplanned caesarean sections and high birth weight babies (aOR 1.15, 95%CI 1.04, 1.27 and aOR 1.16, 95%CI 1.02, 1.31 respectively), and a decrease in gestational diabetes mellitus was observed for both cohorts 3 and 4. Pregnancies exposed to both severe climate events and pandemic disruptions appear to have increased risk of adverse perinatal outcomes beyond only experiencing one event, but further research is needed. [ABSTRACT FROM AUTHOR]