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We study policy instruments to correct inefficiently low investment in maternal nutrition in India, where one-fifth of all births occur. We focus on fiscal externalities: healthier babies become more productive adults, who pay more tax. However, parents do not internalize this externality, which, combined with other distortions, results in mothers weighing too little during pregnancy. We calibrate the first sufficient-statistics policy model for the quantitatively important case of fiscal externalities and maternal nutrition in developing countries. The optimal subsidy is large. Yet, welfare gains are even greater from public investment in state capacity to monitor nutrition, enabling targetted incentives., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: Abnormal ventricular activation at rest is reported in Brugada syndrome (BrS)., Objectives: The aim of this study was to evaluate the usefulness of dynamic changes in ventricular activation during exercise to improve disease phenotyping and diagnosis of BrS., Methods: Digital 12-lead electrocardiograms during stress testing were analyzed retrospectively at baseline, peak exercise, and recovery in 53 patients with BrS and 52 controls. Biventricular activation was assessed from QRS duration (QRSd), whereas right ventricular activation was assessed from S wave duration in the lateral leads (I and V 6 ) and terminal R wave duration in aVR. Exercise-induced changes in QRS parameters to predict a positive procainamide response were assessed in separate test and validation cohorts with suspected BrS., Results: Baseline electrocardiogram parameters were similar between BrS and controls. QRSd shortened with exercise in all controls but prolonged in all BrS (-6.1 ± 6.0 ms vs 7.1 ± 6.5 ms [P < 0.001] in V 6 ). QRSd in recovery was longer in BrS compared with controls (90 ± 12 ms vs 82 ± 11 ms in V 6 ; P = 0.002). Both groups demonstrated exercise-induced S duration prolongation in V6, with greater prolongation in BrS (8.2 ± 14.3 ms vs 1.2 ± 12.4 ms; P < 0.001). Any exercise-induced QRSd prolongation in V 6 differentiated those with a positive vs negative procainamide response with 100% sensitivity and 95% specificity in the test cohort, and 87% sensitivity and 93% specificity in the validation cohort., Conclusions: Exercise-induced QRSd prolongation is ubiquitous in BrS primarily owing to delayed right ventricular activation. This electrocardiogram phenotype predicts a positive procainamide response and may provide a noninvasive screening tool to aid in the diagnosis of BrS before drug challenge., Competing Interests: Funding Support and Author Disclosures Dr Chakraborty is supported by George Mine Traveling Fellowship from the Canadian Heart Rhythm Society. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2024 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

The size of the human population is projected to peak in the 21st century. But quantitative projections past 2100 are rare, and none quantify the possibility of a rebound from low fertility to replacement-level fertility. Moreover, the most recent long-term deterministic projections were published a decade ago; since then there has been further global fertility decline. Here we provide updated long-term cohort-component population projections and extend the set of scenarios in the literature to include scenarios in which future fertility (a) stays below replacement or (b) recovers and increases. We also characterize old-age dependency ratios. We show that any stable, long-run size of the world population would persistently depend on when an increase towards replacement fertility begins. Without such an increase, the 400-year span when more than 2 billion people were alive would be a brief spike in history. Indeed, four-fifths of all births-past, present, and future-would have already happened., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Spears et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: It has been postulated that long QT syndrome (LQTS) can cause fetal loss through putative adverse effects of the channelopathy on placenta and myometrial function. The authors aimed to describe the fetal death rate in a population of pregnant women with long QT syndrome and investigate whether women with more severe phenotype had worse fetal outcomes., Methods and Results: The authors retrospectively evaluated fetal outcomes of 64 pregnancies from 23 women with long QT syndrome followed during pregnancy in a tertiary pregnancy and heart disease program. Thirteen of 64 pregnancies (20%) resulted in a fetal loss, 12 miscarriages (19%), and 1 stillbirth (1.6%). Baseline maternal characteristics, including age and use of β-blockers, did not differ between women who experienced a fetal death or not. Maternal corrected QT interval (QTc) was significantly longer in pregnancies that resulted in fetal death compared with live births (median, 518 ms [interquartile range (IQR), 482-519 ms] versus 479 ms [IQR, 454-496 ms], P <0.001). Mothers treated with β-blockers had babies born at term with lower birth weight compared with untreated women (2973±298 g versus 3470±338 g, P =0.002). In addition, the birth weight of babies born at term to treated women with QTc >500 ms was significantly lower compared with women with QTc <500 ms (2783±283 g versus 3084±256 g, P =0.029)., Conclusions: Women with long QT syndrome with more severe phenotypes have a higher incidence of fetal death. Maternal QTc is longer in pregnancies that result in fetal loss, and the birth weight of babies born to patients taking β-blockers with a QTc >500 ms is lower, suggesting that patients with more marked phenotype may experience worse fetal outcomes.

Background Polypharmacy is common among older people and may be associated with adverse drug events (ADEs) and poor health outcomes. Pharmacists are well-positioned to reduce polypharmacy and potentially inappropriate medications. Objective The objective of this narrative review was to summarize the results from randomized-controlled trials that evaluated pharmacist-led interventions with the goal or effect to deprescribe medications in older individuals. Data Sources We searched Medline, Embase, CINAHL Complete, APA PsycInfo, Web of Science Core Collection, and Cochrane Central Register of Controlled Trials. Data Synthesis Of the 25 studies included, the interventions were conducted in nursing facilities (n = 8), outpatient/community dwellings (n = 8), or community pharmacies (n = 9). Interventions were categorized as comprehensive medication reviews (n = 10), comprehensive medication reviews with pharmacist follow-up (n = 11), and educational interventions provided to patients and/or providers (n = 4). Pharmacist-led interventions had a beneficial effect on 22 out of 32 total medication-related outcomes (eg, number of medications, potentially inappropriate medications, or discontinuation). Most (n = 18) studies reported no evidence of an effect for other outcomes such as health care use, mortality, patient-centered outcomes (falls, cognition, function, quality of life), and ADEs. Discussion Interventions led to improvement in 69% of the medication-related outcomes examined across study settings. Five studies measured ADEs with none accounting for adverse drug-withdrawal events. Large well-designed studies that are powered to find an effect on patient-centered outcomes are needed. Conclusion Pharmacist-led interventions had a significant beneficial effect on medication-related outcomes. There was little evidence of benefit on other outcomes.

Arrhythmogenic cardiomyopathy is an inherited cardiomyopathy that can involve both ventricles. Several genes have been identified as pathogenic in arrhythmogenic cardiomyopathy, including TMEM43 . However, there are limited data on cardiac MRI findings in patients with TMEM43 variants to date. In this case series, cardiac MRI findings and clinical outcomes are described in 14 patients with TMEM43 variants, including eight (57%) with the pathogenic p.Ser358Leu variant (six female patients; mean age, 33 years ± 15 [SD]) and six (43%) with a TMEM43 variant of unknown significance (three female patients; mean age, 38 years ± 11). MRI findings demonstrated left ventricular systolic dysfunction in eight (57%) patients and right ventricular dysfunction in four (29%) patients. Among the nine patients with late gadolinium enhancement imaging, left ventricular late gadolinium enhancement was present in seven (78%; all subepicardial) patients. In summary, TMEM43 variants are associated with high prevalence of subepicardial late gadolinium enhancement and left ventricular dysfunction. Keywords: Arrhythmogenic Cardiomyopathy, Arrhythmogenic Right Ventricular Cardiomyopathy, TMEM43 , Cardiac MRI, Genetic Variants Supplemental material is available for this article ., (© RSNA, 2023.)

Aims: Rare variants in the KCNQ1 gene are found in the healthy population to a much greater extent than the prevalence of Long QT Syndrome type 1 (LQTS1). This observation creates challenges in the interpretation of KCNQ1 rare variants that may be identified as secondary findings in whole exome sequencing.This study sought to identify missense variants within sub-domains of the KCNQ1-encoded Kv7.1 potassium channel that would be highly predictive of disease in the context of secondary findings., Methods and Results: We established a set of KCNQ1 variants reported in over 3700 patients with diagnosed or suspected LQTS sent for clinical genetic testing and compared the domain-specific location of identified variants to those observed in an unselected population of 140 000 individuals. We identified three regions that showed a significant enrichment of KCNQ1 variants associated with LQTS at an odds ratio (OR) >2: the pore region, and the adjacent 5th (S5) and 6th (S6) transmembrane (TM) regions. An additional segment within the carboxyl terminus of Kv7.1, conserved region 2 (CR2), also showed an increased OR of disease association. Furthermore, the TM spanning S5-Pore-S6 region correlated with a significant increase in cardiac events., Conclusion: Rare missense variants with a clear phenotype of LQTS have a high likelihood to be present within the pore and adjacent TM segments (S5-Pore-S6) and a greater tendency to be present within CR2. This data will enhance interpretation of secondary findings within the KCNQ1 gene. Further, our data support a more severe phenotype in LQTS patients with variants within the S5-Pore-S6 region., Competing Interests: Conflict of interest: None declared., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.)

This international multidisciplinary expert consensus statement is intended to provide comprehensive guidance that can be referenced at the point of care to cardiac electrophysiologists, cardiologists, and other health care professionals, on the management of cardiac arrhythmias in pregnant patients and in fetuses. This document covers general concepts related to arrhythmias, including both brady- and tachyarrhythmias, in both the patient and the fetus during pregnancy. Recommendations are provided for optimal approaches to diagnosis and evaluation of arrhythmias; selection of invasive and noninvasive options for treatment of arrhythmias; and disease- and patient-specific considerations when risk stratifying, diagnosing, and treating arrhythmias in pregnant patients and fetuses. Gaps in knowledge and new directions for future research are also identified., (Copyright © 2023 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Utilitarianism is the most prominent social welfare function in economics. We present three new axiomatic characterizations of utilitarian (that is, additively-separable) social welfare functions in a setting where there is risk over both population size and individuals' welfares. We first show that, given uncontroversial basic axioms, Blackorby et al.'s (1998) Expected Critical-Level Generalized Utilitarianism is equivalent to a new axiom holding that it is better to allocate higher utility-conditional-on-existence to possible people who have a higher probability of existence. The other two characterizations extend and clarify classic axiomatizations of utilitarianism from settings with either social risk or variable-population, considered alone.

Background: The sustainable development goals (SDG) aim at satisfying three-fourths of family planning needs through modern contraceptive methods by 2030. However, the traditional methods (TM) of family planning use are on the rise, along with modern contraception in Uttar Pradesh (UP), the most populous Indian state. This study attempts to explore the dynamics of rising TM use in the state., Methods: We used a state representative cross-sectional survey conducted among 12,200 Currently Married Women (CMW) aged 15-49 years during December 2020-February 2021 in UP. Using a multistage sampling technique, 508 primary sampling units (PSU) were selected. These PSU were ASHA areas in rural settings and Census Enumeration Blocks in urban settings. About 27 households from each PSU were randomly selected. All the eligible women within the selected households were interviewed. The survey also included the nearest public health facilities to understand the availability of family planning methods. Univariate and bivariate analyses were conducted. Appropriate sampling weights were applied., Results: Overall, 33.9% of CMW were using any modern methods and 23.7% any TM (Rhythm and withdrawal) at the time of survey. The results show that while the modern method use has increased by 2.2 percentage points, the TM use increased by 9.9 percentage points compared to NFHS-4 (2015-16). The use of TM was almost same across women of different socio-demographic characteristics. Of 2921 current TM users, 80.7% started with TM and 78.3% expressed to continue with the same in future. No side effects (56.9%), easy to use (41.7%) and no cost incurred (38.0%) were the main reasons for the continuation of TM. TM use increased despite a significant increase (66.1 to 81.3%) in the availability of modern reversible methods and consistent availability of limiting methods (84.0%) in the nearest public health facilities., Conclusion: Initial contraceptive method was found to have significant implications for current contraceptive method choice and future preferences. Program should reach young and zero-parity women with modern method choices by leveraging front-line workers in rural UP. Community and facility platforms can also be engaged in providing modern method choices to women of other parities to increase modern contraceptive use further to achieve the SDG goals., (© 2022. The Author(s).)

Objective: To compare fertility in India to both low-to-middle-income and high-income countries (LMICs and HICs) and describe the patterns that have accompanied India's transition to low fertility., Methods: We use data from the Demographic and Health Surveys (DHS), the United Nations (UN), and the Organisation for Economic Co-operation and Development (OECD) to observe factors associated with fertility decline in 36 Indian states and 76 countries., Results: Although fertility in India has declined to levels similar to HICs, women's entry into marriage and initiation of childbearing are more in line with patterns found in LMICs. The vast majority of women in India (97%) are married by age 30, and their average age at first birth is only 21.3 years old. In spite of these patterns, average fertility has declined in India as a result of earlier termination of childbearing. Among more recent cohorts, fewer women progressed to higher-order births and about half of women obtained a sterilization by age 35., Conclusions: India has reached low fertility by mechanisms outside the traditional indicators of fertility decline. In contrast to countries that have achieved low fertility through delayed age at first birth, women in India have continued to enter unions and bear children early, lowered their age at last birth, and increasingly ended their fertility via sterilization following the birth of two children., Contribution: Evidence from India reveals an alternative pathway to low fertility, highlighting the limitations of traditional socioeconomic indicators for explaining fertility decline.

Background Patients with hypertrophic cardiomyopathy (HCM) are at risk of ventricular arrhythmia (VA) attributed to abnormal electrical activation arising from myocardial fibrosis and myocyte disarray. We sought to quantify intra-QRS peaks (QRSp) in high-resolution ECGs as a measure of abnormal activation to predict late VA in patients with HCM. Methods and Results Prospectively enrolled patients with HCM (n=143, age 53±14 years) with prophylactic implantable cardioverter-defibrillators had 3-minute, high-resolution (1024 Hz), digital 12-lead ECGs recorded during intrinsic rhythm. For each precordial lead, QRSp was defined as the total number of peaks detected in the QRS complex that deviated from a smoothing filtered version of the QRS. The VA end point was appropriate implantable cardioverter-defibrillator therapy during 5-year prospective follow-up. After 5 years, 21 (16%) patients had VA. Patients who were VA positive had greater QRSp (6.0 [4.0-7.0] versus 4.0 [2.0-5.0]; P <0.01) and lower left ventricular ejection fraction (57±11 versus 62±9; P =0.038) compared with patients who were VA negative, but had similar established HCM risk metrics. Receiver operating characteristic analysis revealed that QRSp discriminated VA (area under the curve=0.76; P <0.001), with a QRSp ≥4 achieving 91% sensitivity and 39% specificity. The annual VA rate was greater in patients with QRSp ≥4 versus QRSp <4 (4.4% versus 0.98%; P =0.012). In multivariable Cox regression, age <50 years (hazard ratio [HR], 2.53; P =0.009) and QRSp (HR per QRS peak, 1.41; P =0.009) predicted VA after adjusting for established HCM risk metrics. In patients aged <50 years, the annual VA rate was 0.0% for QRSp <4 compared with 6.9% for QRSp ≥4 ( P =0.012). Conclusions QRSp predicted VA in patients with HCM who were eligible for an implantable cardioverter-defibrillator after adjusting for established HCM risk metrics, such that each additional QRS peak increases VA risk by 40%. QRSp <4 was associated with a <1% annual VA risk in all patients, and no VA risk among those aged <50 years. This novel ECG metric may improve patient selection for prophylactic implantable cardioverter-defibrillator therapy by identifying those with low VA risk. These findings require further validation in a lower risk HCM cohort. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02560844.

Background: Implantable cardioverter defibrillators (ICDs) improve survival in patients at risk for cardiac arrest, but are associated with intravascular lead-related complications. The subcutaneous ICD (S-ICD), with no intravascular components, was developed to minimize lead-related complications., Objective: To assess key ICD performance measures related to delivery of ICD therapy, including inappropriate ICD shocks (delivered in absence of life-threatening arrhythmia) and failed ICD shocks (which did not terminate ventricular arrhythmia)., Design: Randomized, multicenter trial. (ClinicalTrials.gov: NCT02881255)., Setting: The ATLAS trial., Patients: 544 eligible patients (141 female) with a primary or secondary prevention indication for an ICD who were younger than age 60 years, had a cardiogenetic phenotype, or had prespecified risk factors for lead complications were electrocardiographically screened and 503 randomly assigned to S-ICD (251 patients) or transvenous ICD (TV-ICD) (252 patients). Mean follow-up was 2.5 years (SD, 1.1). Mean age was 49.0 years (SD, 11.5)., Measurements: The primary outcome was perioperative major lead-related complications., Results: There was a statistically significant reduction in perioperative, lead-related complications, which occurred in 1 patient (0.4%) with an S-ICD and in 12 patients (4.8%) with TV-ICD (-4.4%; 95% CI, -6.9 to -1.9; P  = 0.001). There was a trend for more inappropriate shocks with the S-ICD (hazard ratio [HR], 2.37; 95% CI, 0.98 to 5.77), but no increase in failed appropriate ICD shocks (HR, 0.61 (0.15 to 2.57). Patients in the S-ICD group had more ICD site pain, measured on a 10-point numeric rating scale, on the day of implant (4.2 ± 2.8 vs. 2.9 ± 2.2; P  < 0.001) and 1 month later (1.3 ± 1.8 vs. 0.9 ± 1.5; P = 0.035)., Limitation: At present, the ATLAS trial is underpowered to detect differences in clinical shock outcomes; however, extended follow-up is ongoing., Conclusion: The S-ICD reduces perioperative, lead-related complications without significantly compromising the effectiveness of ICD shocks, but with more early postoperative pain and a trend for more inappropriate shocks., Primary Funding Source: Boston Scientific.

All leading long-term global population projections agree on continuing fertility decline, resulting in a rate of population size growth that will continue to decline toward zero and would eventually turn negative. However, scholarly and popular arguments have suggested that because fertility transmits intergenerationally (i.e., higher fertility parents tend to have higher fertility children) and is heterogeneous within a population, long-term population growth must eventually be positive, as high-fertility groups come to dominate the population. In this research note, we show that intergenerational transmission of fertility is not sufficient for positive long-term population growth, for empirical and theoretical reasons. First, because transmission is imperfect, the combination of transmission rates and fertility rates may be quantitatively insufficient for long-term population growth: higher fertility parents may nevertheless produce too few children who retain higher fertility preferences. Second, today even higher fertility subpopulations show declining fertility rates, which may eventually fall below replacement (and in some populations already are). Therefore, although different models of fertility transmission across generations reach different conclusions, depopulation is likely under any model if, in the future, even higher fertility subpopulations prefer and achieve below-replacement fertility. These results highlight the plausibility of long-term global depopulation and the importance of understanding the possible consequences of depopulation., (Copyright © 2022 The Authors.)

The premise that a woman's social status has intergenerational effects on her children's health has featured prominently in population science research and in development policy. This study focuses on an important case in which social hierarchy has such an effect. In joint patrilocal households in rural India, women married to the younger brother are assigned lower social rank than women married to the older brother in the same household. Almost 8% of rural Indian children under 5 years old-more than 6 million children-live in such households. We show that children of lower-ranking mothers are less likely to survive and have worse health outcomes, reflected in higher neonatal mortality and shorter height, compared with children of higher-ranking mothers in the same household. That the variation in mothers' social status that we study is not subject to reporting bias is an advantage relative to studies using self-reported measures. We present evidence that one mechanism for this effect is maternal nutrition: although they are not shorter, lower-ranking mothers weigh less than higher-ranking mothers. These results suggest that programs that merely make transfers to households without attention to intrahousehold distribution may not improve child outcomes., (Copyright © 2022 The Authors.)

Background: The diagnosis of Brugada syndrome by 12-lead electrocardiography (ECG) is challenging because the diagnostic type 1 pattern is often transient., Objectives: This study sought to improve Brugada syndrome diagnosis by using deep learning (DL) to continuously monitor for Brugada type 1 in 24-hour ambulatory 12-lead ECGs (Holters)., Methods: A convolutional neural network was trained to classify Brugada type 1. The training cohort consisted of 10-second standard/high precordial leads from 12-lead ECGs (n = 1,190) and 12-lead Holters (n = 380) of patients with definite and suspected Brugada syndrome. The performance of the trained model was evaluated in 2 testing cohorts of 10-second standard/high precordial leads from 12-lead ECGs (n = 474) and 12-lead Holters (n = 716)., Results: DL achieved a receiver-operating characteristic area under the curve of 0.976 (95% CI: 0.973-0.979) in classifying Brugada type 1 from 12-lead ECGs and 0.975 (95% CI: 0.966-0.983) from 12-lead Holters. Compared with cardiologist reclassification of Brugada type 1, DL had similar performance and produced robust results in experiments evaluating scalability and explainability. When DL was applied to consecutive 10-second, clean ECGs from 24-hour 12-lead Holters, spontaneous Brugada type 1 was detected in 48% of patients with procainamide-induced Brugada syndrome and in 33% with suspected Brugada syndrome. DL detected no Brugada type 1 in healthy control patients., Conclusions: This novel DL model achieved cardiologist-level accuracy in classifying Brugada type 1. Applying DL to 24-hour 12-lead Holters significantly improved the detection of Brugada type 1 in patients with procainamide-induced and suspected Brugada syndrome. DL analysis of 12-lead Holters may provide a robust, automated screening tool before procainamide challenge to aid in the diagnosis of Brugada syndrome., Competing Interests: Funding Support and Author Disclosures The authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: The sudden death (SD) risk stratification algorithm in hypertrophic cardiomyopathy (HCM) has evolved, underscored recently by novel cardiac magnetic resonance (CMR)-based risk markers (left ventricular apical aneurysm, extensive late gadolinium enhancement, and end-stage disease with systolic dysfunction) incorporated into the 2020 American Heart Association (AHA)/American College of Cardiology (ACC) HCM guidelines., Objective: The purpose of this study was to assess the specific impact of newer, predominantly CMR-based risk markers in a large multicenter HCM population that underwent primary prevention implantable cardioverter-defibrillator (ICD) implants., Methods: Longitudinal study of 1149 consecutive HCM patients from 6 North American and European HCM centers prospectively judged to be at high SD risk based on ≥1 AHA/ACC individual risk markers and prophylactically implanted with an ICD was performed. European Society of Cardiology (ESC) risk score was retrospectively analyzed with respect to the known clinical outcome., Results: Of 1149 patients with an ICD, 162 (14%) experienced device therapy terminating ventricular tachycardia/ventricular fibrillation 4.6 ± 4.2 years after implant. CMR-based markers solely or in combination led to ICD implantation in 49 of the 162 patients (30%) experiencing device therapy. Particularly low ESC scores (<4%/5 years) would have excluded an ESC ICD recommendation for 67 patients who nevertheless experienced appropriate ICD therapy, including 26 with the CMR-based risk markers not part of the ESC formula., Conclusion: Identification and incorporation of novel guideline-supported CMR-based risk markers enhance selection of HCM patients for SD prevention with ICDs. Absence of CMR-based markers from the ESC risk score accounts, in part, for it not identifying many HCM patients with SD events. These data support inclusion of CMR as a routine part of HCM patient evaluation and risk stratification., (Copyright © 2021 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Development economists study both anthropometry and intra-household allocation. In these literatures, the Demographic and Household Surveys (DHS) are essential. The DHS censors its anthropometric sample by age: only children under five are measured. We document several econometric consequences, especially for estimating birth-order effects. Child birth order and mothers' fertility are highly correlated in the age-censored anthropometric subsample. Moreover, family structures and age patterns that permit within-family comparisons of siblings' anthropometry are unrepresentative. So strategies that could separate birth order and fertility in other data cannot here. We show that stratification by mother's fertility is important. We illustrate this by comparing India and sub-Saharan Africa (SSA). Children in India born to higher-fertility mothers are shorter, on average, than children of lower-fertility mothers. Yet, later-born children in India are taller, adjusted for age, than earlier-born children of the same sibsize. In SSA, neither of these associations is large., (© 2021 The Authors.)

Inversions-in which the popular vote winner loses the election-have occurred in four US presidential races. We show that rather than being statistical flukes, inversions have been ex ante likely since the early 1800s. In elections yielding a popular vote margin within 1 point (one-eighth of presidential elections), about 40 percent will be inversions in expectation. We show this conditional probability is remarkably stable across historical periods-despite differences in which groups voted, which states existed, and which parties participated. Our findings imply that the United States has experienced so few inversions merely because there have been so few elections (and fewer close elections).

Background Unlike T-wave alternans (TWA), the relation between QRS alternans (QRSA) and ventricular arrhythmia (VA) risk has not been evaluated in hypertrophic cardiomyopathy (HCM). We assessed microvolt QRSA/TWA in relation to HCM risk factors and late VA outcomes in HCM. Methods and Results Prospectively enrolled patients with HCM (n=130) with prophylactic implantable cardioverter-defibrillators underwent digital 12-lead ECG recordings during ventricular pacing (100-120 beats/min). QRSA/TWA was quantified using the spectral method. Patients were categorized as QRSA+ and/or TWA+ if sustained alternans was present in ≥2 precordial leads. The VA end point was appropriate implantable cardioverter-defibrillator therapy over 5 years of follow-up. QRSA+ and TWA+ occurred together in 28% of patients and alone in 7% and 7% of patients, respectively. QRSA magnitude increased with pacing rate (1.9±0.6 versus 6.2±2.0 µV; P =0.006). Left ventricular thickness was greater in QRSA+ than in QRSA- patients (22±7 versus 20±6 mm; P =0.035). Over 5 years follow-up, 17% of patients had VA. The annual VA rate was greater in QRSA+ versus QRSA- patients (5.8% versus 2.0%; P =0.006), with the QRSA+/TWA- subgroup having the greatest rate (13.3% versus 2.6%; P <0.001). In those with <2 risk factors, QRSA- patients had a low annual VA rate compared QRSA+ patients (0.58% versus 7.1%; P =0.001). Separate Cox models revealed QRSA+ (hazard ratio [HR], 2.9 [95% CI, 1.2-7.0]; P =0.019) and QRSA+/TWA- (HR, 7.9 [95% CI, 2.9-21.7]; P <0.001) as the most significant VA predictors. TWA and HCM risk factors did not predict VA. Conclusions In HCM, microvolt QRSA is a novel, rate-dependent phenomenon that can exist without TWA and is associated with greater left ventricular thickness. QRSA increases VA risk 3-fold in all patients, whereas the absence of QRSA confers low VA risk in patients with <2 risk factors. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02560844.

The number of women of childbearing age with cardiovascular disease (CVD) is growing because of increased survival of children with congenital heart disease. More women are also becoming pregnant at an older age, which is associated with increased rates of comorbidities including hypertension, diabetes, and acquired CVD. Over the past decade the field of cardio-obstetrics has significantly advanced with the development of multidisciplinary cardio-obstetric programs (COPs) to address the increasing burden of CVD in pregnancy. With the introduction of formal COPs, pregnancy outcomes in women with heart disease have improved. COPs provide preconception counselling, antenatal and postpartum cardiac surveillance, and labor and delivery planning. Prepregnancy counselling in a COP should be offered to women with suspected CVD who are of childbearing age. In women who present while pregnant, counselling should be performed in a COP as early as possible in pregnancy. The purpose of counselling is to reduce the risk of pregnancy to the mother and fetus whenever possible. This is done through accurate maternal and fetal risk stratification, optimizing cardiac lesions, reviewing safety of medications in pregnancy, and making a detailed plan for the pregnancy, labor, and delivery. This Clinical Practice Update highlights the COP approach to prepregnancy counselling, risk stratification, and management of commonly encountered cardiac conditions through pregnancy. We highlight "red flags" that should trigger a more timely assessment in a COP. We also describe the approach to some of the cardiac emergencies that the care provider might encounter in a pregnant woman., (Copyright © 2021 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Existing estimates of optimal climate policy ignore the possibility that carbon tax revenues could be used in a progressive way; model results therefore typically imply that near-term climate action comes at some cost to the poor. Using the Nested Inequalities Climate Economy (NICE) model, we show that an equal per capita refund of carbon tax revenues implies that achieving a 2°C target can pay large and immediate dividends for improving well-being, reducing inequality and alleviating poverty. In an optimal policy calculation that weighs the benefits against the costs of mitigation, the recommended policy is characterized by aggressive near-term climate action followed by a slower climb towards full decarbonization; this pattern-which is driven by a carbon revenue Laffer curve-prevents runaway warming while also preserving tax revenues for redistribution. Accounting for these dynamics corrects a long-standing bias against strong immediate climate action in the optimal policy literature., Competing Interests: Competing interests The authors declare no competing interests.

Tachycardia-induced cardiomyopathy is rare during pregnancy and is reversible when the underlying arrhythmia is effectively treated. Management can be complex due to the risks of antiarrhythmic medications and cardiac interventions on the developing fetus. The care requires a well-coordinated multidisciplinary team of cardiologists, electrophysiologists, and maternal-fetal specialists. In this report, we describe a case of recurrent atrial tachycardia-induced cardiomyopathy in pregnancy., (© The Author(s) 2020.)

Tools are needed to benchmark carbon emissions and pledges against criteria of equity and fairness. However, standard economic approaches, which use a transparent optimization framework, ignore equity. Models that do include equity benchmarks exist, but often use opaque methodologies. Here we propose a utilitarian benchmark computed in a transparent optimization framework, which could usefully inform the equity benchmark debate. Implementing the utilitarian benchmark, which we see as ethically minimal and conceptually parsimonious, in two leading climate-economy models allows for calculation of the optimal allocation of future emissions. We compare this optimum with historical emissions and initial nationally determined contributions. Compared with cost minimization, utilitarian optimization features better outcomes for human development, equity and the climate. Peak temperature is lower under utilitarianism because it reduces the human development cost of global mitigation. Utilitarianism therefore is a promising inclusion to a set of benchmarks for future explorations of climate equity., Competing Interests: Competing interests N.K.D. is a member of the committee advising the Government of India on analysis of low carbon trajectories. All other authors declare no competing interests.

The population ethics literature has long focused on attempts to avoid the repugnant conclusion. We show that a large set of social orderings that are conventionally understood to escape the repugnant conclusion do not in fact avoid it in all instances. As we demonstrate, prior results depend on formal definitions of the repugnant conclusion that exclude some repugnant cases, for reasons inessential to any "repugnance" (or other meaningful normative properties) of the repugnant conclusion. In particular, the literature traditionally formalizes the repugnant conclusion to exclude cases that include an unaffected sub-population. We relax this normatively irrelevant exclusion, and others. Using several more inclusive formalizations of the repugnant conclusion, we then prove that any plausible social ordering implies some instance of the repugnant conclusion. This understanding - that it is impossible to avoid all instances of the repugnant conclusion - is broader than the traditional understanding in the literature that the repugnant conclusion can only be escaped at unappealing theoretical costs. Therefore, the repugnant conclusion provides no methodological guidance for theory or policy-making, because it does not discriminate among candidate social orderings. So escaping the repugnant conclusion should not be a core goal of the population ethics literature.

We document a novel fact about neonatal death, or death in the first month of life. Globally, neonatal mortality is disproportionately concentrated in India. We identify a large effect of birth order on neonatal mortality that is unique to India: later-born siblings have a steep survival advantage relative to the birth-order gradient in other developing countries. We show that India's high prevalence of maternal undernutrition and its correlation with age and childbearing can explain this pattern. We find that Indian mothers exit the underweight body mass range at an internationally comparatively high rate as they progress through childbearing careers.

Economic policy evaluations require social welfare functions for variable-size populations. Two important candidates are critical-level generalized utilitarianism (CLGU) and rank-discounted critical-level generalized utilitarianism, which was recently characterized by Asheim and Zuber (2014) (AZ). AZ introduce a novel axiom, existence of egalitarian equivalence (EEE). First, we show that, under some uncontroversial criteria for a plausible social welfare relation, EEE suffices to rule out the Repugnant Conclusion of population ethics (without AZ's other novel axioms). Second, we provide a new characterization of CLGU: AZ's set of axioms is equivalent to CLGU when EEE is replaced by the axiom same-number independence.

Three important features of Indian labor markets enduringly coexist: rent-seeking, occupational immobility, and caste. These facts are puzzling, given theories that predict static, equilibrium social inequality without conflict. Our model explains these facts as an equilibrium outcome. Some people switch caste-associated occupations for an easier source of rents, rather than for productivity. This undermines trust between castes and shuts down occupational mobility, which further encourages rent-seeking due to an inability of workers to sort into occupations. We motivate our contribution with novel stylized facts exploiting a unique survey question on casteism in India, which we show is associated with rent-seeking.

Competing Interests: Dr. Ercumen reports grants from Bill & Melinda Gates Foundation, outside the submitted work. All other authors report nothing.

What are the prospects for using population policy as tool to reduce carbon emissions? In this paper, we review evidence from population science, in order to inform debates in population ethics that, so far, have largely taken place within the academic philosophy literature. In particular, we ask whether fertility policy is likely to have a large effect on carbon emissions, and therefore on temperature change. Our answer is no. Prospects for a policy of fertility-reduction-as-climate-mitigation are limited by population momentum, a demographic factor that limits possible variation in the size of the population, even if fertility rates change very quickly. In particular, a hypothetical policy that instantaneously changed fertility and mortality rates to replacement levels would nevertheless result in a population of over 9 billion people in 2060. We use a leading climate-economy model to project the consequence of such a hypothetical policy for climate change. As a standalone mitigation policy, such a hypothetical change in the size of the future population - much too large to be implementable by any foreseeable government program - would reduce peak temperature change only to 6.4°C, relative to 7.1°C under the most likely population path. Therefore, fertility reduction is unlikely to be an adequate core approach to climate mitigation.

Background: Identifying patients with hypertrophic cardiomyopathy (HCM) who warrant a primary prevention implantable cardioverter-defibrillator (ICD) is crucial. ICDs are effective in terminating life-threatening arrhythmias; however, ICDs carry risks of complications., Objective: The purpose of this study was to assess the incidence and predictors of appropriate ICD therapies, inappropriate shocks, and device-related complications in patients with HCM and primary prevention ICDs., Methods: All patients with HCM who underwent primary prevention ICD implantation at Toronto General Hospital between September 2000 and December 2017 were identified. Therapies (shocks or antitachycardia pacing) for ventricular tachycardia >180 beats/min or ventricular fibrillation were considered appropriate., Results: Three hundred two patients were followed for a mean 6.1 ± 4.3 years (1801 patient-years of follow-up). Thirty-eight patients (12.6%) received at least 1 appropriate ICD therapy (2.3%/y); the 5-year cumulative probability of receiving appropriate ICD therapy was 9.6%. None of the conventional risk factors nor the European Society of Cardiology risk score was associated with appropriate ICD therapy. In multivariable analysis, age < 40 years at implantation and atrial fibrillation were independent predictors of appropriate ICD therapy. In a subgroup of patients who had undergone cardiac magnetic resonance imaging before ICD implantation, severe late gadolinium enhancement was the strongest predictor of appropriate ICD therapies. ICD-related complications or inappropriate shocks occurred in 87 patients (28.8%), with an inappropriate shock rate of 2.1%/y; the 5-year cumulative probability was 10.7%., Conclusion: The incidence of appropriate ICD therapies in patients with HCM and primary prevention ICDs is lower than previously reported; a high proportion of patients suffer from an ICD-related complication. Traditional risk factors have low predictive utility. Severe late gadolinium enhancement, atrial fibrillation, and young age are important predictors of ventricular tachyarrhythmias in HCM., (Copyright © 2020 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Economic policy evaluations require social welfare functions for variable-size populations. Two important axioms in the population ethics literature are Mere Addition and avoidance of the Sadistic Conclusion, both of which focus on the sign of lifetime utility. The population ethics literature treats these axioms as closely related but distinct: one influential review calls avoidance of the Sadistic Conclusion "less controversial." Here, we provide weak, uncontroversial sufficient conditions for these two principles to be equivalent. Related results exist in prior literature, but these include only same-number utilitarian orderings and therefore exclude recent and theoretically important rank-dependent social evaluations that we include. [100 words].

Population ethics is widely considered to be exceptionally important and exceptionally difficult. One key source of difficulty is the conflict between certain moral intuitions and analytical results identifying requirements for rational (in the sense of complete and transitive) social choice over possible populations. One prominent such intuition is the Asymmetry, which jointly proposes that the fact that a possible child's quality of life would be bad is a normative reason not to create the child, but the fact that a child's quality of life would be good is not a reason to create the child. This paper reports a set of questionnaire experiments about the Asymmetry in the spirit of economists' empirical social choice. Few survey respondents show support for the Asymmetry; instead respondents report that expectations of a good quality of life are relevant. Each experiment shows evidence (among at least some participants) of dual-process moral reasoning, in which cognitive reflection is statistically associated with reporting expected good quality of life to be normatively relevant. The paper discusses possible implications of these results for the economics of population-sensitive social welfare and for the conflict between moral mathematics and population intuition.

Nearly seventy years after India adopted one of the most progressive constitutions in the world ensuring equality for all its citizens irrespective of caste, class, race, and gender, the mind-set of its vast majority Indian remains steeped in gender and caste bias. Results from a new telephonic survey confirm persistence of conservative gender and caste attitudes in Indian society. High proportions of men and women across all social groups disapprove of women working outside their homes, consider it 'acceptable for husbands to beat their wives', and would object to relatives marrying a Dalit person. Analyzing data from the National Family Health Survey and the India Human Development Survey, it has been found that outcomes associated with these attitudes are even more conservative: a smaller fraction of women work than those who feel it is okay to step out of the house for work; a larger fraction of women experience violence in marriage than men who consider marital violence acceptable, and an even smaller fraction of people have inter-caste marriages than people who say they would not oppose such an alliance. An overwhelming majority is opposed to an inter-caste marriage with a Dalit in the family. With a few exceptions, the attitudes and outcomes we studied vary, surprisingly, little by respondent gender, caste, and religion. Dr.Ambedkar's legacy is indeed unfinished-people from all backgrounds must continue to work for the equality and dignity of women and Dalits.

The UN Sustainable Development Goals call for the elimination of open defecation by 2030. Assessing global progress will require learning from India's sanitation efforts because of its ambitious program of high-profile behavior change messaging to tackle open defecation, and because open defecation is widespread in India. In 2014, the Prime Minister announced a policy called the Swachh Bharat Mission (SBM), which aimed to eliminate open defecation by 2019. However, the 2015-16 National Family Health Survey -4 found that about 55% of rural and 11% of urban Indian households lack a toilet or latrine. To assess the extent of public awareness of the SBM, we use a mobile phone survey to ask about people's knowledge of the existence and purpose of the SBM. We report representative estimates of awareness of the SBM among adults in Delhi (2016), Uttar Pradesh (2016), Mumbai (2016-17), Rajasthan (2016-17), Bihar (2018), Jharkhand (2018), and Maharashtra (2018). While much of the SBM's activities took place in its last two years, we find that, at the time of the survey, no more than one-third of adults in any state are aware that the SBM intends to promote toilet and latrine use. Awareness was particularly low in Uttar Pradesh, where one in eight people who defecates in the open worldwide lives. While the SBM was very active in constructing latrines, the lack of awareness we find suggests that the SBM was less successful in raising the awareness required for large-scale behavior change in promoting latrine use.

Physical height is an important measure of human capital. However, differences in average height across developing countries are poorly explained by economic differences. Children in India are shorter than poorer children in Africa, a widely studied puzzle called "the Asian enigma." This paper proposes and quantitatively investigates the hypothesis that differences in sanitation - and especially in the population density of open defecation - can statistically account for an important component of the Asian enigma, India's gap relative to sub-Saharan Africa. The paper's main result computes a demographic projection of the increase in the average height of Indian children, if they were counterfactually exposed to sub-Saharan African sanitation, using a non-parametric reweighting method. India's projected increase in mean height is at least as large as the gap. The analysis also critically reviews evidence from recent estimates in the literature. Two possible mechanisms are effects on children and on their mothers., (© 2018 The Author.)

Since October 2014, the Government of India has worked towards the goal of eliminating open defecation by 2019 through the Swachh Bharat Mission. Since October 2014, the Government of India (GOI) has worked towards the goal of eliminating open defecation by 2019 through the Swachh Bharat Mission (SBM). In 2014, several of the co-authors reported on a survey of rural sanitation behaviour in North India (Coffey et al 2014) conducted by the Research Institute for Compassionate Economics (r.i.c.e.). Different statistical methods produce slightly different numbers, but results from a wide range of approaches used concur that approximately 40% to 50% of rural people in these states defecated in the open in late 2018. The 2014 survey used a multistage sampling strategy to select households: first, districts were purposively selected to match the state-level trend in rural open defecation between the 2001 and 2011 Censuses; second, villages were randomly drawn using proportional-to-size sampling from a frame taken from the Government of India's District Level Health Survey; third, households were selected using an in-field randomisation technique similar to that used for Pratham's Annual Status of Education Report (ASER) survey.

Background: Pregnancy can lead to complications in women with heart disease, and these complications can be life threatening. Understanding serious complications and how they can be prevented is important., Objectives: The primary objectives were to determine the incidence of serious cardiac events (SCEs) in pregnant women with heart disease, whether they were preventable, and their impact on fetal and neonatal outcomes. Serious obstetric events were also examined., Methods: A prospectively assembled cohort of 1,315 pregnancies in women with heart disease was studied. SCEs included cardiac death or arrest, ventricular arrhythmias, congestive heart failure or arrhythmias requiring admission to an intensive care unit, myocardial infarction, stroke, aortic dissection, valve thrombosis, endocarditis, and urgent cardiac intervention. The Harvard Medical Study criteria were used to adjudicate preventability., Results: Overall, 3.6% of pregnancies (47 of 1,315) were complicated by SCEs. The most frequent SCEs were cardiac death or arrest, heart failure, arrhythmias, and urgent interventions. Most SCEs (66%) occurred in the antepartum period. Almost one-half of SCEs (49%) were preventable; the majority of preventable SCEs (74%) were secondary to provider management factors. Adverse fetal and neonatal events were more common in pregnancies with SCEs compared with those without cardiac events (62% vs. 29%; p < 0.001). Serious obstetric events were less common (1.7%) and were primarily due to pre-eclampsia with severe features., Conclusions: Pregnant women with heart disease are at risk for serious cardiac complications, and approximately one-half of all SCEs are preventable. Strategies to prevent serious cardiac complications in this high-risk cohort of women need to be developed., (Copyright © 2020 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Survey evidence from rural North India showing persistent solid fuel use despite increases in liquefied petroleum gas ownership is presented. Although three-quarters of survey households in these states had LPG, almost all also had a stove that uses solid fuels. Among those owning both, almost three-quarters used solid fuels the day before the survey. Household economic status, relative costs of cooking fuels, gender inequality, and beliefs about solid fuels were important contributors to high solid fuel use. To realise the full health benefits of the LPG expansion, attention must now be turned towards encouraging exclusive LPG use.

Objectives: To investigate differences in reported open defecation between a question about latrine use or open defecation for every household member and a household-level question., Setting: Rural India is home to most of the world's open defecation. India's Demographic and Health Survey (DHS) 2015-2016 estimates that 54% of households in rural India defecate in the open. This measure is based on a question asking about the behaviour of all household members in one question. Yet, studies in rural India find substantial open defecation among individuals living in households with latrines, suggesting that household-level questions underestimate true open defecation., Participants: In 2018, we randomly assigned latrine-owning households in rural parts of four Indian states to receive one of two survey modules measuring sanitation behaviour. 1215 households were asked about latrine use or open defecation individually for every household member. 1216 households were asked the household-level question used in India's DHS: what type of facility do members of the household usually use?, Results: We compare reported open defecation between households asked the individual-level questions and those asked the household-level question. Using two methods for comparing open defecation by question type, the individual-level question found 20-21 (95% CI 16 to 25 for both estimates) percentage points more open defecation than the household-level question, among all households, and 28-29 (95% CI 22 to 35 for both estimates) percentage points more open defecation among households that received assistance to construct their latrines., Conclusions: We provide the first evidence that individual-level questions find more open defecation than household-level questions. Because reducing open defecation in India is essential to meeting the Sustainable Development Goals, and exposure to open defecation has consequences for child mortality and development, it is essential to accurately monitor its progress., Trial Registration Number: Registry for International Development Impact Evaluations (5b55458ca54d1)., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ.)

The links among social inequality, economic inequality, and health have long been of interest to social scientists, but causal links are difficult to investigate empirically. In particular, studies examining the impact of social status on one's own health may overlook important effects of inequality on the health of populations as a whole occurring due to negative externalities of social forces. A recent literature on caste, sanitation, and child net nutrition provides an example of one social context where social inequality makes an entire population less healthy. This paper presents new observational analysis of the India Human Development Survey that provides descriptive evidence of this mechanism. We show that, on average, children in rural India are shorter if they live in villages where more people report practicing untouchability-meaning that they enforce caste hierarchies in their interactions with people from the lowest castes. This association is explained by the association between casteism and the prevalence of rural open defecation., Competing Interests: Conflict of interest All authors declare that they have no conflict of interest.

Background: Three large new trials of unprecedented scale and cost, which included novel factorial designs, have found no effect of basic water, sanitation and hygiene (WASH) interventions on childhood stunting, and only mixed effects on childhood diarrhea. Arriving at the inception of the United Nations' Sustainable Development Goals, and the bold new target of safely managed water, sanitation and hygiene for all by 2030, these results warrant the attention of researchers, policy-makers and practitioners., Main Body: Here we report the conclusions of an expert meeting convened by the World Health Organization and the Bill and Melinda Gates Foundation to discuss these findings, and present five key consensus messages as a basis for wider discussion and debate in the WASH and nutrition sectors. We judge these trials to have high internal validity, constituting good evidence that these specific interventions had no effect on childhood linear growth, and mixed effects on childhood diarrhea. These results suggest that, in settings such as these, more comprehensive or ambitious WASH interventions may be needed to achieve a major impact on child health., Conclusion: These results are important because such basic interventions are often deployed in low-income rural settings with the expectation of improving child health, although this is rarely the sole justification. Our view is that these three new trials do not show that WASH in general cannot influence child linear growth, but they do demonstrate that these specific interventions had no influence in settings where stunting remains an important public health challenge. We support a call for transformative WASH, in so much as it encapsulates the guiding principle that - in any context - a comprehensive package of WASH interventions is needed that is tailored to address the local exposure landscape and enteric disease burden.

This study investigates disparities in child height-an important marker of population-level health-among population groups in rural India. India is an informative context in which to study processes of health disparities because of wide heterogeneity in the degree of local segregation or integration among caste groups. Building on a literature that identifies discrimination by quantifying whether differences in socioeconomic status (SES) can account for differences in health, we decompose height differences between rural children from higher castes and rural children from three disadvantaged groups. We find that socioeconomic differences can explain the height gap for children from Scheduled Tribes (STs), who tend to live in geographically isolated places. However, SES does not fully explain height gaps for children from the Scheduled Castes (SC) and Other Backward Classes (OBCs). Among SC and OBC children, local processes of discrimination also matter: the fraction of households in a child's locality that outrank her household in the caste hierarchy predicts her height. SC and OBC children who are surrounded by other lower-caste households are no shorter than higher-caste children of the same SES. Our results contrast with studies from other populations where segregation or apartheid are negatively associated with health.

Background: Children in India are exposed to high levels of ambient fine particulate matter (PM 2.5 ). However, population-level evidence of associations with adverse health outcomes from within the country is limited. The aim of our study is to estimate the association of early-life exposure to ambient PM 2.5 with child health outcomes (height-for-age) in India., Methods: We linked nationally-representative anthropometric data from India's 2015-2016 Demographic and Health Survey (n = 218,152 children under five across 640 districts of India) with satellite-based PM 2.5 exposure (concentration) data. We then applied fixed effects regression to assess the association between early-life ambient PM 2.5 and subsequent height-for-age, analyzing whether deviations in air pollution from the seasonal average for a particular place are associated with deviations in child height from the average for that season in that place, controlling for trends over time, temperature, and birth, mother, and household characteristics. We also explored the timing of exposure and potential non-linearities in the concentration-response relationship., Results: Children in the sample were exposed to an average of 55 μ g/m 3 of PM 2.5 in their birth month. After controlling for potential confounders, a 100 μg/m 3 increase in PM 2.5 in the month of birth was associated with a 0.05 [0.01-0.09] standard deviation reduction in child height. For an average 5 year old girl, this represents a height deficit of 0.24 [0.05-0.43] cm. We also found that exposure to PM 2.5 in the last trimester in utero and in the first few months of life are significantly (p < 0.05) associated with child height deficits. We did not observe a decreasing marginal risk at high levels of exposure., Conclusions: India experiences some of the worst air pollution in the world. To our knowledge, this is the first study to estimate the association of early-life exposure to ambient PM 2.5 on child height-for-age at the range of ambient pollution exposures observed in India. Because average exposure to ambient PM 2.5 is high in India, where child height-for-age is a critical challenge in human development, our results highlight ambient air pollution as a public health policy priority.