The disease burden of inguinal, femoral, and abdominal hernias in children from low- and middle-income countries, 1990–2023 with projections to 2050: a systematic analysis of the Global Burden of Disease Study

Introduction

Inguinal, femoral, and abdominal hernias (IFAH) are among the most common surgical conditions in childhood, closely associated with anatomical immaturity and abnormal intra-abdominal pressure (1). In resource-limited settings, they pose a significant public health challenge. Although technically curable with surgery, in low- and middle-income countries (LMICs), these hernias remain a major cause of preventable child mortality and long-term disability due to scarcity of medical resources, delayed diagnosis, and inadequate access to surgical services (2,3). Approximately 4.8 million children under five died globally in 2023, with over 80% of these deaths occurring in LMICs such as sub-Saharan Africa and South Asia (4). In regions with weak pediatric surgical care, treatable surgical emergencies like incarcerated inguinal hernia are key factors in avoidable mortality (5,6).

The Global Burden of Disease (GBD) Study provides an unprecedented opportunity to systematically evaluate the epidemiology of such conditions. However, existing research predominantly focuses on global trends or older populations (7), lacking in-depth analysis specifically targeting hernias in children from LMICs. This knowledge gap hampers resource allocation and precise public health intervention strategies. To address this critical gap, this study aims to comprehensively map the burden of IFAH among children aged 0–14 years in LMICs from 1990 to 2023 and project the future burden to 2050, utilizing the GBD 2023 database. The goal is to provide a robust evidence base for health policymakers and clinicians in LMICs to reduce hernia-related child mortality and disability. We present this article in accordance with the GATHER reporting checklist (available at https://tp.amegroups.com/article/view/10.21037/tp-2026-0319/rc).

Methods

Data sources and disease definition

Data were obtained from the GBD 2023 database (https://vizhub.healthdata.org/gbd-results/), coordinated by the Institute for Health Metrics and Evaluation. This study analyzed the GBD 2023 cause of IFAH among children aged 0–14 years. In the GBD 2023 supplementary methods, IFAH is defined as the protrusion of an abdominal internal organ through an opening in the tissue that holds it in place, regardless of symptoms, and this cause comprises disorders in which portions of the digestive tract protrude through defects in the walls of the abdominal cavity. The corresponding ICD-10 codes are K40, K41, K42, K44, K45, and K46 and all their 4-digit and 5-digit constituents. We did not apply an additional clinical exclusion based on the presumed congenital anatomical basis of pediatric inguinal hernia. Rather, this study followed the GBD cause hierarchy: conditions modelled separately by GBD as congenital anomaly causes, such as congenital diaphragmatic hernia and congenital malformations of the abdominal wall, were outside the IFAH cause analysed here. Definitions and code mappings followed the GBD 2023 supplementary appendices (8,9). The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments.

Study population and indicators

Following GBD 2023 Socio-demographic Index (SDI) stratification, the study area was limited to LMICs, including low (<0.53), low-middle (0.53–0.63), and middle (0.63–0.68) SDI regions, encompassing 10 GBD super-regions and 93 countries. Children were stratified into age subgroups: <1 year (0–11 months), 12–23 months, 2–4 years, 5–9 years, and 10–14 years. Analysis was also performed by sex. Core outcome indicators were incident cases, deaths, and disability-adjusted life years (DALYs) [with 95% uncertainty intervals (UI)], along with their corresponding rates per 100,000 population.

Statistical analysis

Trend estimation

To quantify the temporal trends in incidence, mortality, and DALY rates from 1990 to 2023, we calculated the estimated annual percentage change (EAPC) and its 95% confidence interval (CI) using a linear regression model: log(rate_y) = α + β·y + ε_y, where y is the calendar year. The EAPC was computed as 100×(e^β−1), with 95% CI derived from the standard error of β (10).

Correlation analysis

The relationship between the SDI and each burden rate was examined using Pearson correlation coefficients at both the GBD region level and the country level (93 LMICs) for the year 2023 (11).

Decomposition analysis

We performed a decomposition analysis to disentangle the relative contributions of three drivers to the absolute change in death counts and DALY counts from 1990 to 2023: (I) population growth, (II) population aging (i.e., shifts in the age structure of the child population toward higher-risk age groups), and (III) epidemiological change (i.e., changes in age- and sex-specific risk of hernia-related death or disability) (11). For each location, sex, and age group, we applied the step-wise replacement method, holding two components constant while varying the third. Positive contributions indicate an increase in absolute burden, whereas negative contributions indicate a reduction.

Frontier analysis

To evaluate health system efficiency in controlling pediatric hernia burden relative to socio-economic development, we conducted a frontier analysis. For each country in 2023, we plotted its observed mortality rate (and separately, DALY rate) against its SDI value. The efficient frontier was defined as the lowest (optimal) rate achievable at any given SDI level, estimated using a bootstrap approach with 1,000 replicates to account for sampling variability. A country’s efficiency gap was calculated as the vertical distance between its observed rate and the frontier. Countries with a gap exceeding the 90th percentile of all gaps were classified as “under-performers” (11). This exploratory analysis allows identification of countries where the same level of SDI yields substantially worse outcomes, suggesting potential system-level inefficiencies.

Bayesian age period-cohort (BAPC) modeling

We projected the future burden (incidence, mortality, and DALYs) from 2023 to 2050 using BAPC models with Integrated Nested Laplace Approximations (INLA) for computational efficiency (12,13). In brief, the BAPC framework estimates age-specific rates by combining age, calendar-period, and birth-cohort components, with adjacent effects smoothed by random-walk priors. All hyperparameters were estimated from the observed data from 1990 to 2023. Model selection among different combinations of random walk orders was based on the deviance information criterion (DIC), with lower DIC indicating better fit. This modeling strategy is consistent with previous GBD-based BAPC projection studies (14). We compared first- and second-order random-walk specifications and selected the final model according to DIC. Projections were performed for each SDI region (low, low-middle, middle) and for each GBD super-region, with 95% UIs derived from the posterior distribution of the fitted model. Because the projection period extends to 2050, these estimates should be interpreted as model-based extrapolations under continuation of historical trends rather than forecasts that account for future policy shocks or health emergencies.

Calculating uncertainty

Uncertainty was propagated throughout the estimation process by taking 250 draws from posterior distributions. Mean estimates represent the mean across draws, and 95% UIs were calculated as the 2.5th and 97.5th percentiles of the draws.

All analyses were performed in R 4.4.2 using the mgcv, INLA, dplyr, and ggplot2 packages.

Results

Proportion of global pediatric IFAH burden borne by LMICs in 2023

In 2023, the global number of incident cases of IFAH in children aged 0–14 years was 2,535,924 (95% UI: 1,726,706–3,364,685), with 2,539 deaths (95% UI: 1,551–3,975) and 470,743 DALYs (95% UI: 330,327–631,307). LMICs accounted for 58.4% of cases but 83.8% of deaths and 74.0% of DALYs, indicating a disproportionate burden of severe outcomes (Tables 1-3).

Trends in disease burden in LMIC areas, 1990–2023

Incidence trends

Regarding incidence, in low SDI regions, the number of incident cases increased from 476,510 to 713,595, while the incidence rate decreased from 132.91 to 107.74 per 100,000. In low-middle SDI regions, incident cases decreased from 478,490 to 467,494, with the incidence rate falling from 167.96 to 137.14 per 100,000. In middle SDI regions, incident cases decreased from 307,642 to 298,875, and the incidence rate declined from 135.00 to 116.63 per 100,000. Among GBD regions, all ten showed declining incidence rates, with Central Latin America and the Caribbean experiencing the most significant declines. Central Asia had the smallest decline (Table 1). At the country level, 84 countries showed declining incidence trends, with Guatemala, Venezuela, and El Salvador showing the fastest declines; 9 countries showed increasing incidence, most notably Viet Nam and Equatorial Guinea (Table S1 and Figure 1A).

Figure 1 The burden of childhood inguinal, femoral, and abdominal hernias in 93 low- and middle-income countries and territories in 2023. (A) Incidence rate. (B) Death rate. (C) DALY rate. Darker colors indicate higher burden values in each panel. DALY, disability-adjusted life year.

Mortality trends

Mortality rates declined across all SDI regions. In low SDI regions, deaths decreased from 1,506 to 1,078, and the mortality rate fell from 0.42 to 0.16 per 100,000. In low-middle SDI regions, deaths decreased from 1,316 to 614, with the mortality rate declining from 0.46 to 0.18 per 100,000. In middle SDI regions, deaths decreased from 1,204 to 436, and the mortality rate dropped from 0.53 to 0.17 per 100,000. At the GBD region level, all regions showed declining mortality rates, with Central Latin America and the Caribbean improving most rapidly, and Southern Sub-Saharan Africa showing the smallest decline (Table 2). At the country level, apart from Zimbabwe and Uzbekistan, the vast majority of countries exhibited declining mortality trends. The Dominican Republic and Venezuela (Bolivarian Republic of) showed the most significant declines. Eswatini and Tajikistan had the smallest reductions (Table S2 and Figure 1B).

DALY trends

Trends in DALY rates across levels mirrored those for mortality. At the SDI level, in low SDI regions, DALYs decreased from 192,731 to 183,657, and the DALY rate fell from 53.76 to 27.73 per 100,000. In low-middle SDI regions, DALYs decreased from 167,987 to 98,223, and the DALY rate declined from 58.97 to 28.81 per 100,000. In middle SDI regions, DALYs decreased from 137,855 to 66,538, and the DALY rate dropped from 60.49 to 25.96 per 100,000. At the GBD region level, all ten regions showed declining DALY rates, with Central Latin America experiencing the most rapid decline and Southern Sub-Saharan Africa the smallest (Table 3). At the country level, apart from Zimbabwe and Uzbekistan, nearly all countries showed declining trends. The Dominican Republic and Guatemala had the most significant declines. Eswatini and Kyrgyzstan had the smallest (Table S3 and Figure 1C).

Age distribution and sex disparities

Across all regions, infants <1 year consistently accounted for >85% of deaths and >75% of DALYs in 2023, with the highest infant death proportion in low SDI regions (Figure 2). Sex disparities were pronounced: male children had higher incidence, mortality, and DALY rates in most regions. The male-to-female mortality ratio reached 5.02 in Southeast Asia, while Oceania showed near-equality (Figure 3).

Figure 2 Changing patterns of childhood inguinal, femoral, and abdominal hernias: age-specific patterns by region and Socio-demographic Index, 1990–2023. (A) Incidence rate. (B) Death rate. (C) DALY rate. DALY, disability-adjusted life year; SDI, Socio-demographic Index.

Figure 3 Sex disparities in the burden of childhood inguinal, femoral, and abdominal hernias across regions and Socio-demographic Index groups in 2023. (A) Incidence rate. (B) Death rate. (C) DALY rate. DALY, disability-adjusted life year; SDI, Socio-demographic Index.

Correlation between SDI and disease burden

We assessed the correlation between SDI and pediatric hernia burden across 10 GBD regions and 93 LMICs (Figure 4). At the regional level, SDI showed a weak positive correlation with incidence (r=0.159, P=0.002), but no significant associations with mortality or DALY rates. At the country level, no significant correlation was found for incidence, while a weak negative correlation emerged for mortality (r=−0.228, P=0.028). DALY rates showed a non-significant negative trend (r=−0.168, P=0.108).

Figure 4 The relationship between the burden of childhood inguinal, femoral, and abdominal hernias and the SDI across regions and countries. Scatter plots depict the association of SDI with the incidence rate (A), death rate (B), and disability-adjusted life year rate (C) from 1990 to 2023. (D-F) The correlations within 93 low- and middle-income countries for the year 2023. SDI, Socio-demographic Index.

Decomposition analysis

From 1990 to 2023, epidemiological change (reduced age-sex-specific risk) drove burden reductions in most regions, particularly in South and Southeast Asia and Central Latin America. However, in Sub-Saharan Africa (e.g., Western, Eastern, Central) and Oceania, population growth and aging offset these gains, leading to increased absolute deaths and DALYs (Figure 5A,5B).

Figure 5 Decomposition and frontier analysis of the childhood inguinal, femoral, and abdominal hernias burden. Decomposition analysis of the number of deaths (A) and DALYs (B) across SDI and GBD regions; frontier analysis of death rates (C) and DALY rates (D) from 1990 to 2023. Each point represents a country. The efficient frontier, shown by the black line, represents the optimal mortality rate achievable at each SDI level. The vertical distance between a country’s observed rate and the frontier represents the health system efficiency gap, with larger gaps indicating greater inefficiency. DALYs, disability-adjusted life years; GBD, Global Burden of Disease; SDI, Socio-demographic Index.

Frontier analysis

To systematically assess the relative efficiency of health systems in different LMICs in controlling pediatric hernia burden, we conducted a frontier analysis (Figure 5C,5D). The results showed substantial overlap between countries identified as under-performers for both mortality and DALY rates. Myanmar, Haiti, and Guatemala were among the top three with the largest efficiency gaps, indicating significant potential for their health systems to improve effectiveness in preventing deaths and reducing overall health loss. Following closely were Indonesia, Zimbabwe, Bolivia, Lao People’s Democratic Republic, and Suriname, collectively forming a cluster of “hotspot” countries with high burden and low health system efficiency. In stark contrast, in environments with extremely limited resources (SDI <0.5), Somalia and Vanuatu achieved or approached their theoretical optimal performance for both mortality and DALY rates, serving as exemplary performers. Afghanistan and Papua New Guinea also demonstrated near-optimal efficiency in mortality control.

Disease burden projection to 2050

Using historical data from 1990 to 2023, the BAPC model projected the burden of IFAH in LMICs from 2023 to 2050 (Figure 6). In low SDI regions, incident cases are projected to rise from approximately 714,000 in 2023 to about 1.308 million in 2050, while the age-standardized incidence rate (ASIR) is projected to decline from 107.74 to 73.66 per 100,000, the age-standardized mortality rate (ASMR) from 0.16 to 0.11 per 100,000, and the age-standardized DALY rate (ASDR) from 27.73 to 11.10 per 100,000. In low-middle SDI regions, incident cases are projected to decrease from about 467,000 to 205,000, and the ASIR is projected to decline from 137.14 to 10.21 per 100,000. In middle SDI regions, incident cases are projected to fall to about 9,538, with the ASIR reaching 0.35 per 100,000.

Figure 6 Forecasts of age-standardized incidence, death, and DALY rates of childhood inguinal, femoral, and abdominal hernias by SDI region, 2023–2050. Projected trends in ASIR (A,D,G), ASMR (B,E,H), and ASDR (C,F,I) rates per 100,000 from 2023 to 2050 are shown for middle (A-C), low-middle (D-F), and low-SDI regions (G-I). ASDR, age-standardized DALY rate; ASIR, age-standardized incidence rate; ASMR, age-standardized mortality rate; DALY, disability-adjusted life year; SDI, Socio-demographic Index.

At the GBD region level, projected trends clearly reflect the continuation of historical driving patterns. Several regions where epidemiological improvement was dominant are projected to experience continued burden reduction. Central Latin America is exemplary, with incident cases projected to decline sharply from about 50,000 in 2023 to about 9,000 in 2050. The Caribbean and Southeast Asia also show favorable trends (Tables 1-3).

However, projected patterns varied across regions. In Central Asia, incident cases are projected to decrease from approximately 45,000 in 2023 to approximately 39,000 in 2050, and the ASIR is projected to remain high at 138.30 per 100,000. Western and Central Sub-Saharan Africa are also projected to retain large numbers of incident cases in 2050, approximately 179,000 and 39,000, respectively, despite declines from their 2023 levels. Eastern Sub-Saharan Africa may remain an important future contributor because of demographic pressure and wide UIs. These regions therefore remain priority areas despite declining age-standardized rates (Tables 1-3).

Discussion

This first comprehensive analysis of pediatric IFAH burden in LMICs from 1990 to 2023, with projections to 2050, reveals several key findings. First, children in LMICs bear a disproportionate burden of severe outcomes: 58.4% of global cases but 83.8% of deaths and 74.0% of DALYs, highlighting profound inequities in surgical care. Second, although burden rates have declined across most LMICs over three decades, improvement varies substantially by SDI level and region. Third, infants under one year account for over 85% of deaths, and male children experience higher burden in most regions. Decomposition analysis shows that positive epidemiological changes drove reductions in rapidly progressing regions, such as South Asia, while in Sub-Saharan Africa, population growth and demographic shifts offset these gains. Finally, projections to 2050 indicate that low-middle and middle SDI regions may reduce burden to very low levels through sustained epidemiological improvement. However, in low SDI regions, particularly Sub-Saharan Africa, despite declining rates, absolute incident cases are expected to rise substantially due to population growth, presenting formidable future challenges.

Our finding that LMICs accounted for 58.4% of global pediatric hernia cases but 83.8% of deaths and 74.0% of DALYs in 2023 starkly illustrates that a technically curable condition remains a lethal threat in these settings (2). This inequity stems not from disease complexity but reflects vast disparities in the accessibility, quality, and equity of surgical care globally. In well-resourced settings, pediatric hernias are typically repaired electively before life-threatening complications like incarceration or strangulation occur, resulting in minimal mortality (15). However, in LMICs, multiple barriers—including diagnostic delays, inefficient referral systems, shortages of surgical and anesthesia personnel, high costs, and geographical inaccessibility—mean many children only receive treatment after developing complications, leading to entirely preventable deaths and disabilities (16,17). Our results corroborate previous reports on avoidable under-five mortality and underscore hernia-related complications as a significant contributor.

The period 1990–2023 saw positive progress in controlling pediatric hernia burden in most LMICs, with generally declining incidence and mortality rates. This trend may be attributed to sustained global and national efforts to improve child survival, expand primary healthcare coverage, and strengthen surgical systems (e.g., initiatives like “Global Surgery 2030”) (18). However, the pace and drivers of progress were heterogeneous. Our decomposition analysis clarifies the reasons behind these differences. In regions with marked improvement like South Asia, Southeast Asia, and Central Latin America, epidemiological change (reduction in age-sex-specific disease risk) was the dominant factor, likely due to strengthened health systems, improved public awareness, and better surgical access (19). In contrast, in parts of Sub-Saharan Africa like West, East, and Central Africa, although rates declined, absolute deaths and DALYs increased or improved minimally due to rapid population growth and aging (here referring to shifts within the child population’s age structure toward higher-risk groups) (20). This finding warns us that in these regions undergoing rapid demographic transition, medical advancement alone is insufficient to counter absolute burden growth; it must be paired with health resource investment and surgical service capacity expansion that keep pace with population growth (21,22).

We found that over 85% of deaths occur in infants under one year, which aligns with the higher risk of incarceration and strangulation, faster disease progression, and greater surgical and anesthetic challenges associated with infant hernias (23,24). This finding strengthens the clinical relevance of early physical examination, caregiver education, low-threshold referral, and timely access to pediatric anesthesia and surgery for suspected infant hernias. Male children showed higher incidence, mortality, and DALY rates in most regions, consistent with the higher biological incidence of pediatric inguinal hernia in males (25). However, because this study did not include individual-level data on care-seeking, referral, treatment timing, or surgical access by sex, the observed male predominance should not be interpreted as direct evidence of gender-based healthcare inequity. Alternative explanations include biological differences in incidence, differential case ascertainment, reporting patterns, and unmeasured differences in severity at presentation (26).

Interestingly, our correlation analysis showed a weak negative correlation between SDI and child hernia mortality at the country level. Because this was an ecological analysis based on aggregate regional and country-level data, these correlations cannot be used to infer individual-level relationships between socioeconomic development and hernia outcomes. The observed pattern may reflect a combination of true health-system differences and data-related factors: in very low SDI countries, many hernia-related deaths might be unrecorded or attributed to other immediate causes, such as intestinal obstruction or sepsis, whereas in slightly higher SDI countries, reporting systems might be more complete but health system efficiency may still be suboptimal (6,7,27). These findings therefore suggest, but do not prove, that economic development alone is insufficient to address surgical disease burden; it must be accompanied by targeted strengthening of basic surgical, anesthesia, and nursing capacity.

Frontier analysis results reveal profound heterogeneity in health system performance beyond socio-economic development levels. Myanmar, Haiti, Guatemala, and others constitute a cluster of “high efficiency-gap hotspots” for pediatric hernia burden. This phenomenon indicates that challenges in these countries may extend beyond simple resource scarcity, reflecting deeper structural deficiencies within their surgical care systems. Such defects might be evident in the failure to effectively integrate basic surgical and anesthesia services into primary healthcare networks, or in the lack of clear referral pathways for pediatric surgical emergencies (28,29). These systemic “bottlenecks” hinder the translation of limited resources into effective health outcomes, causing their actual disease burden to persistently deviate from the optimal trajectory corresponding to their development level. Conversely, countries near the frontier, such as Somalia and Vanuatu, should be viewed as hypothesis-generating examples rather than definitive proof of superior service delivery. Their position may reflect context-specific referral pathways, population structure, data availability, or coding/reporting differences; nevertheless, the comparison is useful because it highlights that SDI alone does not fully explain pediatric hernia outcomes (30,31).

Projections based on historical data provide a useful perspective for examining future challenges and opportunities, but they should not be viewed as deterministic forecasts. Our 2050 disease burden projection paints a mixed picture. On the positive side, low-middle and middle SDI regions are expected to experience marked reductions in burden if historical epidemiological improvements continue. This pattern suggests possible gains from sustained investment, rather than proving the effect of any specific policy. On the concerning side, in low SDI regions, particularly parts of Sub-Saharan Africa, the absolute number of incident cases is projected to rise significantly due to persistent population growth. This means that despite improving medical efficiency, health systems in these regions will face an increasingly large patient population in the future, placing severe strain on already scarce surgical resources (32). Because future surgical policies, financing, conflict, migration, and public health emergencies could alter these trajectories, the 2050 estimates should be interpreted as scenario-based projections under continuation of historical patterns. This projection reinforces the urgency implied by our earlier analyses. It indicates that without targeted action, global inequities in pediatric hernia burden may widen, not narrow. Regions bearing the heaviest burden today are projected to face the greatest challenges tomorrow.

There are several limitations in this study. First, GBD estimates rely on modeled data, with accuracy dependent on source data quality. In low-income regions with incomplete registration systems, UIs are wide and mortality may be underestimated due to under-reporting. Second, the GBD database lacks clinical details—such as hernia subtypes, complications, surgical timing, or postoperative outcomes—precluding deeper analysis of treatment gaps or care quality. Third, while we used SDI and frontier analysis, unmeasured confounders, such as health policies, workforce distribution, and cultural factors, may influence regional disparities; these analyses are ecological and should not be interpreted as evidence of individual-level associations. Fourth, the dataset did not include sex-specific data on healthcare access, referral, operative treatment, or postoperative outcomes, limiting interpretation of sex differences. Fifth, grouping inguinal, femoral, and abdominal hernias together may obscure distinct epidemiological patterns; additionally, although the GBD framework separates IFAH from congenital anomaly categories, clinical overlap between developmental mechanisms and coded hernia diagnoses may still require cautious interpretation. Finally, projections assume continuation of historical trends and could be affected by future policy changes or health emergencies; the further the horizon extends, the greater the uncertainty around the estimates.

Conclusions

This study demonstrates that although overall progress has been made in reducing the burden of pediatric hernias in LMICs over the past three decades, significant inequities and preventable deaths persist. Future success will depend on focusing global attention and resources on the most vulnerable groups (infants and children in low SDI regions) and strengthening basic surgical care systems to ensure that every child in need can access safe, affordable, and timely surgical treatment. Our projections serve both as a warning and a call to action—only through such efforts can the label of a “curable” condition become a reality for every child, everywhere in the world.

Acknowledgments

We are grateful to the Global Burden of Disease Study 2023 collaborators.

Footnote

Reporting Checklist: The authors have completed the GATHER reporting checklist. Available at https://tp.amegroups.com/article/view/10.21037/tp-2026-0319/rc

Peer Review File: Available at https://tp.amegroups.com/article/view/10.21037/tp-2026-0319/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tp.amegroups.com/article/view/10.21037/tp-2026-0319/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Gödeke J, Muensterer OJ. Femoral, Direct, and Rare Inguinal Hernias in Children-An Update. Eur J Pediatr Surg 2017;27:484-94. [Crossref] [PubMed]
2. Löfgren J, Beard J, Ashley T. Groin Hernia Surgery in Low-Resource Settings - A Problem Still Unsolved. N Engl J Med 2018;378:1357-8. [Crossref] [PubMed]
3. Martucci C, Frediani S, Accinni A, et al. Femoral hernia in pediatric population: a diagnostic and surgical challenge. Hernia 2024;28:593-7. [Crossref] [PubMed]
4. World Health Organization. Child mortality and causes of death. Available online: https://www.who.int/data/gho/data/themes/topics/sdg-target-3_2-newborn-and-child-mortality. Accessed March 24, 2026.
5. Abdulhai SA, Glenn IC, Ponsky TA. Incarcerated Pediatric Hernias. Surg Clin North Am 2017;97:129-45. [Crossref] [PubMed]
6. Ma Q, Jing W, Liu X, et al. The global, regional, and national burden and its trends of inguinal, femoral, and abdominal hernia from 1990 to 2019: findings from the 2019 Global Burden of Disease Study - a cross-sectional study. Int J Surg 2023;109:333-42. [Crossref] [PubMed]
7. Li GX, Wang G, Han CJ, et al. Global and regional burden of inguinal, femoral, and abdominal hernia among older population: Findings from Global Burden of Disease database. Surgery 2025;188:109673. [Crossref] [PubMed]
8. Burden of 375 diseases and injuries, risk-attributable burden of 88 risk factors, and healthy life expectancy in 204 countries and territories, including 660 subnational locations, 1990-2023: a systematic analysis for the Global Burden of Disease Study 2023. Lancet 2025;406:1873-922.
9. Global burden of 292 causes of death in 204 countries and territories and 660 subnational locations, 1990-2023: a systematic analysis for the Global Burden of Disease Study 2023. Lancet 2025;406:1811-72.
10. Liu T, Mei H, Zheng J, et al. Global, Regional, and National Burden of Neonatal Encephalopathy due to Birth Asphyxia and Trauma, Its Attributable Risk Factors, 1990-2021: Results from the Global Burden of Disease Study 2021. Neuroepidemiology 2025; Epub ahead of print. [Crossref]
11. Zhang J, Pan L, Guo Q, et al. The impact of global, regional, and national population ageing on disability-adjusted life years and deaths associated with diabetes during 1990-2019: A global decomposition analysis. Diabetes Metab Syndr 2023;17:102791. [Crossref] [PubMed]
12. Riebler A, Held L. Projecting the future burden of cancer: Bayesian age-period-cohort analysis with integrated nested Laplace approximations. Biom J 2017;59:531-49. [Crossref] [PubMed]
13. Rue H, Martino S, Chopin N. Approximate Bayesian inference for latent Gaussian models by using integrated nested Laplace approximations. J R Stat Soc Series B Stat Methodol 2009;71:319-92.
14. Yuan L, Tao J, Wang J, et al. Global, regional, national burden of asthma from 1990 to 2021, with projections of incidence to 2050: a systematic analysis of the global burden of disease study 2021. EClinicalMedicine 2025;80:103051. [Crossref] [PubMed]
15. Matovu A, Nordin P, Wladis A, et al. Open Anterior Mesh Repair vs Modified Open Anterior Mesh Repair for Groin Hernia in Women: A Randomized Clinical Trial. JAMA Surg 2025;160:946-53. [Crossref] [PubMed]
16. Ologunde R, Maruthappu M, Shanmugarajah K, et al. Surgical care in low and middle-income countries: burden and barriers. Int J Surg 2014;12:858-63. [Crossref] [PubMed]
17. Haggui B, Hidouri S, Ksia A, et al. Femoral hernia in children: How to avoid misdiagnosis? Afr J Paediatr Surg 2021;18:164-7. [Crossref] [PubMed]
18. Meara JG, Leather AJ, Hagander L, et al. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet 2015;386:569-624. [Crossref] [PubMed]
19. Mitra S, Shetty R, Rao S, et al. Prioritization of Surgical, Obstetric, Trauma, and Anesthesia Care in South and Southeast Asian Countries’ Health Planning and Policy‑making: SOTA Care Policies in South and Southeast Asia. Ann Glob Health 2024;90:80. [Crossref] [PubMed]
20. Ohene-Yeboah M, Abantanga FA. Inguinal hernia disease in Africa: a common but neglected surgical condition. West Afr J Med 2011;30:77-83.
21. Ameh EA. Realigning Global Health Realities Towards Children’s Surgery: Progress and Possibilities. J Pediatr Surg 2023;58:1039-47. [Crossref] [PubMed]
22. Seyi-Olajide JO, Anderson JE, Kaseje N, et al. Inclusion of Children’s Surgery in National Surgical Plans and Child Health Programmes: the need and roadmap from Global Initiative for Children’s Surgery. Pediatr Surg Int 2021;37:529-37. [Crossref] [PubMed]
23. Chen N, Lv M, Chen Y, et al. Investigation of risk factors and predictive model development for the progression of incarcerated inguinal hernia to strangulation. Hernia 2025;29:301. [Crossref] [PubMed]
24. Taverner F, Krishnan P, Baird R, et al. Perioperative management of infant inguinal hernia surgery; a review of the recent literature. Paediatr Anaesth 2023;33:793-9. [Crossref] [PubMed]
25. Wang K, Tan SS, Xiao Y, et al. Characteristics and treatments for pediatric ordinary and incarcerated inguinal hernia based on gender: 12-year experiences from a single center. BMC Surg 2021;21:67. [Crossref] [PubMed]
26. Williams S, Serhan O, Wang J, et al. The impact of gender on pediatric surgical access and outcomes in Africa. Pediatr Surg Int 2025;41:243. [Crossref] [PubMed]
27. Sitkin NA, Ozgediz D, Donkor P, et al. Congenital anomalies in low- and middle-income countries: the unborn child of global surgery. World J Surg 2015;39:36-40. [Crossref] [PubMed]
28. Friedman JM, Hagander L, Hughes CD, et al. Distance to hospital and utilization of surgical services in Haiti: do children, delivering mothers, and patients with emergent surgical conditions experience greater geographical barriers to surgical care? Int J Health Plann Manage 2013;28:248-56. [Crossref] [PubMed]
29. Landrum KR, Hall BJ, Smith ER, et al. Challenges with pediatric surgical financing and universal health coverage in Guatemala: A qualitative analysis. PLOS Glob Public Health 2022;2:e0000220. [Crossref] [PubMed]
30. Qin RX, Zhang G, Lim MX, et al. Assessment of essential surgical and anaesthesia care capacity: a cross-sectional study in five Pacific Island Countries. Lancet Reg Health West Pac 2023;39:100830. [Crossref] [PubMed]
31. Calisti A, Belay K, Mazzoni G, et al. Promoting major pediatric surgical care in a low-income country: a 4-year experience in Eritrea. World J Surg 2011;35:760-6. [Crossref] [PubMed]
32. Elhalaby EA, Uba FA, Borgstein ES, et al. Training and practice of pediatric surgery in Africa: past, present, and future. Semin Pediatr Surg 2012;21:103-10. [Crossref] [PubMed]