Stillbirth 2010–2018: a prospective, population-based, multi-country study from the Global Network

Abstract Background Stillbirth rates are high and represent a substantial proportion of the under-5 mortality in low and middle-income countries (LMIC). In LMIC, where nearly 98% of stillbirths worldwide occur, few population-based studies have documented cause of stillbirths or the trends in rate of stillbirth over time. Methods We undertook a prospective, population-based multi-country research study of all pregnant women in defined geographic areas across 7 sites in low-resource settings (Kenya, Zambia, Democratic Republic of Congo, India, Pakistan, and Guatemala). Staff collected demographic and health care characteristics with outcomes obtained at delivery. Cause of stillbirth was assigned by algorithm. Results From 2010 through 2018, 573,148 women were enrolled with delivery data obtained. Of the 552,547 births that reached 500 g or 20 weeks gestation, 15,604 were stillbirths; a rate of 28.2 stillbirths per 1000 births. The stillbirth rates were 19.3 in the Guatemala site, 23.8 in the African sites, and 33.3 in the Asian sites. Specifically, stillbirth rates were highest in the Pakistan site, which also documented a substantial decrease in stillbirth rates over the study period, from 56.0 per 1000 (95% CI 51.0, 61.0) in 2010 to 44.4 per 1000 (95% CI 39.1, 49.7) in 2018. The Nagpur, India site also documented a substantial decrease in stillbirths from 32.5 (95% CI 29.0, 36.1) to 16.9 (95% CI 13.9, 19.9) per 1000 in 2018; however, other sites had only small declines in stillbirth over the same period. Women who were less educated and older as well as those with less access to antenatal care and with vaginal assisted delivery were at increased risk of stillbirth. The major fetal causes of stillbirth were birth asphyxia (44.0% of stillbirths) and infectious causes (22.2%). The maternal conditions that were observed among those with stillbirth were obstructed or prolonged labor, antepartum hemorrhage and maternal infections. Conclusions Over the study period, stillbirth rates have remained relatively high across all sites. With the exceptions of the Pakistan and Nagpur sites, Global Network sites did not observe substantial changes in their stillbirth rates. Women who were less educated and had less access to antenatal and obstetric care remained at the highest burden of stillbirth. Study registration Clinicaltrials.gov (ID# NCT01073475).

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Intrapartum-related events affecting the newborn

Oxford Textbook of Global Health of Women, Newborns, Children, and Adolescents ◽

10.1093/med/9780198794684.003.0030 ◽

2018 ◽

pp. 150-154

Author(s):

Saima Aftab ◽

Lauren Schaeffer ◽

Lian Folger ◽

Anne CC Lee

Keyword(s):

High Risk ◽

Secondary Prevention ◽

Neonatal Resuscitation ◽

Birth Asphyxia ◽

Obstetric Care ◽

Middle Income ◽

Neonatal Deaths ◽

Under Five ◽

Middle Income Countries ◽

Child Deaths

This chapter addresses the causes, burden, and interventions for intrapartum-related events, or ‘birth asphyxia’. Intrapartum-related neonatal deaths are among the leading causes of under-five child deaths, and account for 26% of all newborn deaths. An estimated one in ten babies will need some help to start breathing at birth. Approximately 98% of intrapartum deaths occur in low- and middle-income countries, as high rates of home births and unattended deliveries remain challenges. High-risk pregnancies should be monitored closely and deliver in facilities with capacity for obstetric and neonatal management. Here we present the evidence for interventions for primary and secondary prevention (including obstetric care, neonatal resuscitation), and tertiary prevention for infants with acute complications.

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Risk of childhood mortality associated with death of a mother in low-and-middle-income countries: a systematic review and meta-analysis

BMC Public Health ◽

10.1186/s12889-019-7316-x ◽

2019 ◽

Vol 19 (1) ◽

Cited By ~ 1

Author(s):

Diep Thi Ngoc Nguyen ◽

Suzanne Hughes ◽

Sam Egger ◽

D. Scott LaMontagne ◽

Kate Simms ◽

...

Keyword(s):

Meta Analysis ◽

Child Death ◽

Population Based ◽

Childhood Mortality ◽

Child Rearing ◽

Case Control Studies ◽

Middle Income ◽

Middle Income Countries ◽

Increased Risk ◽

Low And Middle Income

Abstract Background Death of a mother at an early age of the child may result in an increased risk of childhood mortality, especially in low-and-middle-income countries. This study aims to synthesize estimates of the association between a mother’s death and the risk of childhood mortality at different age ranges from birth to 18 years in these settings. Methods Various MEDLINE databases, EMBASE, and Global Health databases were searched for population-based cohort and case-control studies published from 1980 to 2017. Studies were included if they reported the risk of childhood mortality for children whose mother had died relative to those whose mothers were alive. Random-effects meta-analyses were used to pool effect estimates, stratified by various exposures (child’s age when mother died, time since mother’s death) and outcomes (child’s age at risk of child death). Results A total of 62 stratified risk estimates were extracted from 12 original studies. Childhood mortality was associated with child’s age at time of death of a mother and time since a mother’s death. For children whose mother died when they were ≤ 42 days, the relative risk (RR) of dying within the first 1–6 months of the child’s life was 35.5(95%CI:9.7–130.5, p [het] = 0.05) compared to children whose mother did not die; by 6–12 months this risk dropped to 2.8(95%CI:0.7–10.7). For children whose mother died when they were ≤ 1 year, the subsequent RR of dying in that year was 15.9(95%CI:2.2–116.1,p [het] = 0.02), compared to children whose mother lived. For children whose mother died when they were ≤ 5 years of age, the RR of dying before aged 12 was 4.1(95%CI:3.0–5.7),p [het] = 0.83. Mortality was also elevated in specific analysis among children whose mother died when child was older than 42 days. Overall, for children whose mother died < 6 and 6+ months ago, RRs of dying before reaching adulthood (≤18 years) were 4.7(95%CI:2.6–8.7,p [het] = 0.2) and 2.1(95%CI:1.3–3.4,p [het] = 0.7), respectively, compared to children whose mother lived. Conclusions There is evidence of an association between the death of a mother and childhood mortality in lower resource settings. These findings emphasize the critical importance of women in family outcomes and the importance of health care for women during the intrapartum and postpartum periods and throughout their child rearing years.

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Stillbirth rates in low-middle income countries 2010 - 2013: a population-based, multi-country study from the Global Network

Reproductive Health ◽

10.1186/1742-4755-12-s2-s7 ◽

2015 ◽

Vol 12 (S2) ◽

Cited By ~ 52

Author(s):

Elizabeth M McClure ◽

Sarah Saleem ◽

Shivaprasad S Goudar ◽

Janet L Moore ◽

Ana Garces ◽

...

Keyword(s):

Population Based ◽

Global Network ◽

Middle Income ◽

Middle Income Countries ◽

Low Middle Income Countries ◽

Country Study

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Development of the Global Network for Women’s and Children’s Health Research’s socioeconomic status index for use in the network’s sites in low and lower middle-income countries

Reproductive Health ◽

10.1186/s12978-020-01034-2 ◽

2020 ◽

Vol 17 (S3) ◽

Author(s):

Archana B. Patel ◽

Carla M. Bann ◽

Ana L. Garces ◽

Nancy F. Krebs ◽

Adrien Lokangaka ◽

...

Keyword(s):

Socioeconomic Status ◽

Reliability And Validity ◽

Population Based ◽

Central American ◽

Global Network ◽

Middle Income ◽

Middle Income Countries ◽

Maternal And Neonatal Health ◽

Sub Saharan ◽

Health Registry

Abstract Background Socioeconomic status (SES) is an important determinant of health globally and an important explanatory variable to assess causality in epidemiological research. The 10th Sustainable Development Goal is to reduce disparities in SES that impact health outcomes globally. It is easier to study SES in high-income countries because household income is representative of the SES. However, it is well recognized that income is poorly reported in low- and middle- income countries (LMIC) and is an unreliable indicator of SES. Therefore, there is a need for a robust index that will help to discriminate the SES of rural households in a pooled dataset from LMIC. Methods The study was nested in the population-based Maternal and Neonatal Health Registry of the Global Network for Women’s and Children’s Health Research which has 7 rural sites in 6 Asian, sub-Saharan African and Central American countries. Pregnant women enrolling in the Registry were asked questions about items such as housing conditions and household assets. The characteristics of the candidate items were evaluated using confirmatory factor analyses and item response theory analyses. Based on the results of these analyses, a final set of items were selected for the SES index. Results Using data from 49,536 households of pregnant women, we reduced the data collected to a 10-item index. The 10 items were feasible to administer, covered the SES continuum and had good internal reliability and validity. We developed a sum score-based Item Response Theory scoring algorithm which is easy to compute and is highly correlated with scores based on response patterns (r = 0.97), suggesting minimal loss of information with the simplified approach. Scores varied significantly by site (p < 0.001). African sites had lower mean SES scores than the Asian and Central American sites. The SES index demonstrated good internal consistency reliability (Cronbach’s alpha = 0.81). Higher SES scores were significantly associated with formal education, more education, having received antenatal care, and facility delivery (p < 0.001). Conclusions While measuring SES in LMIC is challenging, we have developed a Global Network Socioeconomic Status Index which may be useful for comparisons of SES within and between locations. Next steps include understanding how the index is associated with maternal, perinatal and neonatal mortality. Trial Registration NCT01073475 Plain English summary Socioeconomic status (SES) is an important determinant of health globally, and improving SES is important to reduce disparities in health outcomes. It is easier to study SES in high-income countries because it can be measured by income and what income is spent on, but this concept does not translate easily to low and middle income countries. We developed a questionnaire that includes 10 items to determine SES in low-resource settings that was added to an ongoing Maternal and Neonatal Health Registry that is funded by the National Institutes of Child Health and Human Development’s Global Network. The Registry includes sites that collect outcomes of pregnancies in women and their babies in rural areas in 6 countries in South Asia, sub-Saharan Africa and Central America. The Registry is population based and tracks women from early in pregnancy to day 42 post-partum. The questionnaire is easy to administer and has good reliability and validity. Next steps include understanding how the index is associated with maternal, fetal and neonatal mortality.

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Regional trends in birth weight in low- and middle-income countries 2013–2018

Reproductive Health ◽

10.1186/s12978-020-01026-2 ◽

2020 ◽

Vol 17 (S3) ◽

Author(s):

Irene Marete ◽

Osayame Ekhaguere ◽

Carla M. Bann ◽

Sherri L. Bucher ◽

Paul Nyongesa ◽

...

Keyword(s):

Birth Weight ◽

South Asian ◽

Regional Differences ◽

Population Based ◽

Central American ◽

Global Network ◽

Middle Income ◽

Middle Income Countries ◽

Sub Saharan ◽

Over Time

Abstract Background Birth weight (BW) is a strong predictor of neonatal outcomes. The purpose of this study was to compare BWs between global regions (south Asia, sub-Saharan Africa, Central America) prospectively and to determine if trends exist in BW over time using the population-based maternal and newborn registry (MNHR) of the Global Network for Women'sand Children's Health Research (Global Network). Methods The MNHR is a prospective observational population-based registryof six research sites participating in the Global Network (2013–2018), within five low- and middle-income countries (Kenya, Zambia, India, Pakistan, and Guatemala) in threeglobal regions (sub-Saharan Af rica, south Asia, Central America). The birth weights were obtained for all infants born during the study period. This was done either by abstracting from the infants' health facility records or from direct measurement by the registry staff for infants born at home. After controlling for demographic characteristics, mixed-effect regression models were utilized to examine regional differences in birth weights over time. Results The overall BW meanswere higher for the African sites (Zambia and Kenya), 3186 g (SD 463 g) in 2013 and 3149 g (SD 449 g) in 2018, ascompared to Asian sites (Belagavi and Nagpur, India and Pakistan), 2717 g (SD450 g) in 2013 and 2713 g (SD 452 g) in 2018. The Central American site (Guatemala) had a mean BW intermediate between the African and south Asian sites, 2928 g (SD 452) in 2013, and 2874 g (SD 448) in 2018. The low birth weight (LBW) incidence was highest in the south Asian sites (India and Pakistan) and lowest in the African sites (Kenya and Zambia). The size of regional differences varied somewhat over time with slight decreases in the gap in birth weights between the African and Asian sites and slight increases in the gap between the African and Central American sites. Conclusions Overall, BWmeans by global region did not change significantly over the 5-year study period. From 2013 to 2018, infants enrolled at the African sites demonstrated the highest BW means overall across the entire study period, particularly as compared to Asian sites. The incidence of LBW was highest in the Asian sites (India and Pakistan) compared to the African and Central American sites. Trial registration The study is registered at clinicaltrials.gov. ClinicalTrial.gov Trial Registration: NCT01073475.

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Neonatal deaths in rural Karnataka, India 2014–2018: a prospective population-based observational study in a low-resource setting

Reproductive Health ◽

10.1186/s12978-020-01014-6 ◽

2020 ◽

Vol 17 (S2) ◽

Author(s):

Sangappa M. Dhaded ◽

Manjunath S. Somannavar ◽

Janet L. Moore ◽

Elizabeth M. McClure ◽

Sunil S. Vernekar ◽

...

Keyword(s):

Neonatal Mortality ◽

Research Study ◽

Birth Asphyxia ◽

Population Based ◽

Substantial Proportion ◽

Global Network ◽

Middle Income ◽

Neonatal Deaths ◽

Resource Setting ◽

The Impact

Abstract Background Neonatal mortality causes a substantial proportion of the under-5 mortality in low and middle-income countries (LMIC). Methods We undertook a prospective, population-based research study of pregnant women residing in defined geographic areas in the Karnataka State of India, a research site of the Global Network for Women’s and Children’s Health Research. Study staff collected demographic and health care characteristics on eligible women enrolled with neonatal outcomes obtained at delivery and day 28. Cause of neonatal mortality at day 28 was assigned by algorithm using prospectively defined variables. Results From 2014 to 2018, the neonatal mortality rate was 24.5 per 1,000 live births. The cause of the 28-day neonatal deaths was attributed to prematurity (27.9%), birth asphyxia (25.1%), infection (23.7%) and congenital anomalies (18.4%). Four or more antenatal care (ANC) visits was associated with a lower risk of neonatal death compared to fewer ANC visits. In the adjusted model, compared to liveborn infants ≥ 2500 g, infants born weighing < 1000 g RR for mortality was 25.6 (95%CI 18.3, 36.0), for 1000-1499 g infants the RR was 19.8 (95% CI 14.2, 27.5) and for 1500–2499 g infants the RR was 3.1 (95% CI 2.7, 3.6). However, more than one-third (36.8%) of the deaths occurred among infants with a birthweight ≥ 2500 g. Infants born preterm (< 37 weeks) were also at higher risk for 28-day mortality (RR 7.9, 95% CI 6.9, 9.0) compared to infants ≥ 37 weeks. A one-week decrease in gestational age at delivery was associated with a higher risk of mortality with a RR of 1.3 (95% CI 1.3, 1.3). More than 70% of all the deliveries occurred at a hospital. Among infants who died, 50.3% of the infants had received bag/mask ventilation, 47.3% received antibiotics, and 55.6% received oxygen. Conclusions Consistent with prior research, the study found that infants who were preterm and low-birth weight remained at highest risk for 28-day neonatal mortality in India. Although most of births now occur within health facilities, a substantial proportion are not receiving basic life-saving interventions. Further efforts to understand the impact of care on infant outcomes are needed. Study registration The trial is registered at clinicaltrials.gov. ClinicalTrial.gov Trial Registration: NCT01073475

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Neonatal deaths in infants born weighing ≥ 2500 g in low and middle-income countries

Reproductive Health ◽

10.1186/s12978-020-01013-7 ◽

2020 ◽

Vol 17 (S2) ◽

Author(s):

Sarah Saleem ◽

Farnaz Naqvi ◽

Elizabeth M. McClure ◽

Kayla J. Nowak ◽

Shiyam Sunder Tikmani ◽

...

Keyword(s):

Pregnant Women ◽

Neonatal Mortality ◽

Global Network ◽

Middle Income ◽

Neonatal Deaths ◽

Live Births ◽

Middle Income Countries ◽

High Resource ◽

Low Middle Income Countries ◽

Increased Risk

Abstract Background Babies born weighing ≥ 2500 g account for more than 80% of the births in most resource-limited locations and for nearly 50% of the 28-day neonatal deaths. In contrast, in high-resource settings, 28-day neonatal mortality among this group represents only a small fraction of the neonatal deaths. Yet mortality risks for birth weight of ≥ 2500 g is limited. Knowledge regarding the factors associated with mortality in these babies will help in identifying interventions that can reduce mortality. Methods The Global Network’s Maternal Newborn Health Registry (MNHR) is a prospective, population-based observational study that includes all pregnant women and their pregnancy outcomes in defined geographic communities that has been conducted in research sites in six low-middle income countries (India, Pakistan, Democratic Republic of Congo, Guatemala, Kenya and Zambia). Study staff enroll all pregnant women as early as possible during pregnancy and conduct follow-up visits to ascertain delivery and 28-day neonatal outcomes. We analyzed the neonatal mortality rates (NMR) and risk factors for deaths by 28 days among all live-born babies with a birthweight ≥ 2500 g from 2010 to 2018 across the Global Network sites. Results Babies born in the Global Network sites from 2010 to 2018 with a birthweight ≥ 2500 g accounted for 84.8% of the births and 45.4% of the 28-day neonatal deaths. Among this group, the overall NMR was 13.1/1000 live births. The overall 28-day NMR for ongoing clusters was highest in Pakistan (29.7/1000 live births) and lowest in the Zambian/Kenyan sites (9.3/1000) for ≥ 2500 g infants. ≥ 2500 g NMRs declined for Zambia/Kenya and India. For Pakistan and Guatemala, the NMR remained almost unchanged over the period. The ≥ 2500 g risks related to maternal, delivery and newborn characteristics varied by site. Maternal factors that increased risk and were common for all sites included nulliparity, hypertensive disease, previous stillbirth, maternal death, obstructed labor, severe postpartum hemorrhage, and abnormal fetal presentation. Neonatal characteristics including resuscitation, hospitalization, congenital anomalies and male sex, as well as lower gestational ages and birthweights were also associated with increased mortality. Conclusions Nearly half of neonatal deaths in the Global Network sites occurred in infants born weighing ≥ 2500 g. The NMR for those infants was 13.1 per 1000 live births, much higher than rates usually seen in high-income countries. The changes in NMR over time varied across the sites. Even among babies born ≥ 2500 g, lower gestational age and birthweight were largely associated with increased risk of mortality. Since many of these deaths should be preventable, attention to preventing mortality in these infants should have an important impact on overall NMR. Trial registration: https://ClinicalTrials.gov Identifier: NCT01073475

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Maternal mortality in six low and lower-middle income countries from 2010 to 2018: risk factors and trends

Reproductive Health ◽

10.1186/s12978-020-00990-z ◽

2020 ◽

Vol 17 (S3) ◽

Author(s):

Melissa Bauserman ◽

Vanessa R. Thorsten ◽

Tracy L. Nolen ◽

Jackie Patterson ◽

Adrien Lokangaka ◽

...

Keyword(s):

Risk Factors ◽

Maternal Mortality ◽

Maternal Deaths ◽

Middle Income ◽

Maternal Risk ◽

Live Births ◽

Middle Income Countries ◽

Risk Of Death ◽

Increased Risk ◽

Over Time

Abstract Background Maternal mortality is a public health problem that disproportionately affects low and lower-middle income countries (LMICs). Appropriate data sources are lacking to effectively track maternal mortality and monitor changes in this health indicator over time. Methods We analyzed data from women enrolled in the NICHD Global Network for Women’s and Children’s Health Research Maternal Newborn Health Registry (MNHR) from 2010 through 2018. Women delivering within research sites in the Democratic Republic of Congo, Guatemala, India (Nagpur and Belagavi), Kenya, Pakistan, and Zambia are included. We evaluated maternal and delivery characteristics using log-binomial models and multivariable models to obtain relative risk estimates for mortality. We used running averages to track maternal mortality ratio (MMR, maternal deaths per 100,000 live births) over time. Results We evaluated 571,321 pregnancies and 842 maternal deaths. We observed an MMR of 157 / 100,000 live births (95% CI 147, 167) across all sites, with a range of MMRs from 97 (76, 118) in the Guatemala site to 327 (293, 361) in the Pakistan site. When adjusted for maternal risk factors, risks of maternal mortality were higher with maternal age > 35 (RR 1.43 (1.06, 1.92)), no maternal education (RR 3.40 (2.08, 5.55)), lower education (RR 2.46 (1.54, 3.94)), nulliparity (RR 1.24 (1.01, 1.52)) and parity > 2 (RR 1.48 (1.15, 1.89)). Increased risk of maternal mortality was also associated with occurrence of obstructed labor (RR 1.58 (1.14, 2.19)), severe antepartum hemorrhage (RR 2.59 (1.83, 3.66)) and hypertensive disorders (RR 6.87 (5.05, 9.34)). Before and after adjusting for other characteristics, physician attendance at delivery, delivery in hospital and Caesarean delivery were associated with increased risk. We observed variable changes over time in the MMR within sites. Conclusions The MNHR is a useful tool for tracking MMRs in these LMICs. We identified maternal and delivery characteristics associated with increased risk of death, some might be confounded by indication. Despite declines in MMR in some sites, all sites had an MMR higher than the Sustainable Development Goals target of below 70 per 100,000 live births by 2030. Trial registration The MNHR is registered at NCT01073475.

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Prevalence and Risk of Mild Cognitive Impairment in Low and Middle-Income Countries: A Systematic Review

Journal of Alzheimer s Disease ◽

10.3233/jad-201043 ◽

2020 ◽

pp. 1-20

Author(s):

Andrea M. McGrattan ◽

Yueping Zhu ◽

Connor D. Richardson ◽

Devi Mohan ◽

Yee Chang Soh ◽

...

Keyword(s):

Systematic Review ◽

Cognitive Impairment ◽

Mild Cognitive Impairment ◽

Resource Planning ◽

Cognitive State ◽

Middle Income ◽

Total N ◽

Middle Income Countries ◽

Increased Risk ◽

Low And Middle Income

Background: Mild cognitive impairment (MCI) is a cognitive state associated with increased risk of dementia. Little research on MCI exists from low-and middle-income countries (LMICs), despite high prevalence of dementia in these settings. Objective: This systematic review aimed to review epidemiological reports to determine the prevalence of MCI and its associated risk factors in LMICs. Methods: Medline, Embase, and PsycINFO were searched from inception until November 2019. Eligible articles reported on MCI in population or community-based studies from LMICs. No restrictions on the definition of MCI used as long as it was clearly defined. Results: 4,621 articles were screened, and 78 retained. In total, n = 23 different LMICs were represented; mostly from China (n = 55 studies). Few studies from countries defined as lower-middle income (n = 14), low income (n = 4), or from population representative samples (n = 4). There was large heterogeneity in how MCI was diagnosed; with Petersen criteria the most commonly applied (n = 26). Prevalence of aMCI (Petersen criteria) ranged from 0.6%to 22.3%. Similar variability existed across studies using the International Working Group Criteria for aMCI (range 4.5%to 18.3%) and all-MCI (range 6.1%to 30.4%). Risk of MCI was associated with demographic (e.g., age), health (e.g., cardio-metabolic disease), and lifestyle (e.g., social isolation, smoking, diet and physical activity) factors. Conclusion: Outside of China, few MCI studies have been conducted in LMIC settings. There is an urgent need for population representative epidemiological studies to determine MCI prevalence in LMICs. MCI diagnostic methodology also needs to be standardized. This will allow for cross-study comparison and future resource planning.

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The global network of ports supporting high seas fishing

Science Advances ◽

10.1126/sciadv.abe3470 ◽

2021 ◽

Vol 7 (9) ◽

pp. eabe3470

Author(s):

Jorge P. Rodríguez ◽

Juan Fernández-Gracia ◽

Carlos M. Duarte ◽

Xabier Irigoien ◽

Víctor M. Eguíluz

Keyword(s):

Fishing Effort ◽

Global Network ◽

Automatic Identification ◽

Identification System ◽

Middle Income ◽

Middle Income Countries ◽

Fishing Vessels ◽

National Jurisdiction ◽

The Commons ◽

High Seas

Fisheries in waters beyond national jurisdiction (“high seas”) are difficult to monitor and manage. Their regulation for sustainability requires critical information on how fishing effort is distributed across fishing and landing areas, including possible border effects at the exclusive economic zone (EEZ) limits. We infer the global network linking harbors supporting fishing vessels to fishing areas in high seas from automatic identification system tracking data in 2014, observing a modular structure, with vessels departing from a given harbor fishing mostly in a single province. The top 16% of these harbors support 84% of fishing effort in high seas, with harbors in low- and middle-income countries ranked among the top supporters. Fishing effort concentrates along narrow strips attached to the boundaries of EEZs with productive fisheries, identifying a free-riding behavior that jeopardizes efforts by nations to sustainably manage their fisheries, perpetuating the tragedy of the commons affecting global fishery resources.

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