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Urban climate policy offers a significant opportunity to promote improved public health. The evidence around climate and health cobenefits is growing but has yet to translate into widespread integrated policies. This article presents two systematic reviews: first, looking at quantified cobenefits of urban climate policies, where transportation, land use, and buildings emerge as the most studied sectors; and second, looking at review papers exploring the barriers and enablers for integrating these health cobenefits into urban policies. The latter reveals wide agreement concerning the need to improve the evidence base for cobenefits and consensus about the need for greater political will and leadership on this issue. Systems thinking may offer a way forward to help embrace complexity and integrate health cobenefits into decision making. Knowledge coproduction to bring stakeholders together and advance policy-relevant research for urban health will also be required. Action is needed to bring these two important policy agendas together. [ABSTRACT FROM AUTHOR]

Few empirical studies have explored how different types of knowledge are associated with diverse objectivities and moral economies. Here, we examine these associations through an empirical investigation of the public policy debate in Israel around medical cannabis (MC), which may be termed a contested medicine because its therapeutic effects, while subjectively felt by users, are not generally recognized by the medical profession. Our findings indicate that beneath the MC debate lie deep-seated issues of epistemology, which are entwined with questions of ethics and morality. Whereas some stakeholder groups viewed evidence-based medicine and mechanical objectivity as the only valid knowledge base, others called for recognition of a particular experience-based knowledge, championing regulatory, administrative, or strong objectivity. Stakeholders' interpretations of what should be considered as ethical courses of (in)action corresponded to their epistemological views, with most criticizing the regulators for relying on regulatory subjectivity instead of objectivity. Our in-depth mapping of this arena allowed us not only to shed light on the emergence of the new entity called "medical cannabis" but also to reexamine the link between epistemology, ethics, and action and to elucidate how heterogeneous groups view the validity and objectivity of knowledge and the interface between medicine, science, and policy. [ABSTRACT FROM AUTHOR]

Health systems worldwide need to be adapted to cope with growing numbers of migrants and to climate-exacerbated morbidity. Heatwaves, water stress, desertification, flooding, and sea level rise are environmental stressors that increase morbidity, mortality, and poor mental health in Sub-Saharan Africa. While most migration is intra-African, climate change is also affecting migration patterns outside the continent. To tackle the health challenges induced by these events, such as infectious diseases and malnutrition, health care providers in Sub-Saharan Africa and in receiving countries in Europe must adapt their systems to provide appropriate health services to these communities. While health systems differ greatly across the global north and south, adaptation measures are similar and should be integrated. We present recommendations for adaptation of health systems to climate-related migration, including strengthening health systems, providing access to healthcare, culturally-appropriate services, policy-oriented research and training, and inter-sectoral collaboration. [ABSTRACT FROM AUTHOR]

Abstract Recent studies have explored how professionals draw boundaries to reach workable solutions in conflictual and contested areas. Yet they neglected to explore the relationships and dynamics between how boundaries are demarcated in rhetoric and in policy. This article examines these relationships empirically through the case of medical cannabis (MC) policy-making in Israel. Drawing on interviews with key stakeholders in the MC policy field, formal policy documents, and observations of MC conferences, this article sheds light on the dynamics between rhetorical boundary-work and what we term regulatory boundary-work , namely setting rules and regulations to demarcate boundaries in actual practice. Results show how certain definitions of and rationales for a discursive separation between "medical" and "recreational" cannabis and between cannabis "medicalization" and "legalization" prevailed and were translated into formal policy, as well as how stakeholders' reactions to this boundary-work produced policy changes and the shifting of boundaries. Both rhetorical and regulatory boundary-works emerge as ongoing contested processes of negotiation, which are linked in a pattern of reciprocal influence. These processes are dominated by certain actors who have greater power to determine how and why specific boundaries should be drawn instead of others. Highlights • Qualitative study exploring boundary-work in MC policy-making in Israel. • Most stakeholders draw boundaries between medical and recreational cannabis. • Rhetorical boundary work is translated into regulatory boundary-work. • Rhetorical and regulatory boundary-work are interrelated processes. • MC emerges as a classification system with distinct local meanings. [ABSTRACT FROM AUTHOR]

Toys and children's products may contain trace metals and organic compounds that are potentially harmful to the health and development of infants and young children. Intergovernmental organizations and individual countries regulate chemicals in consumer products, but a coordinated international approach is lacking. This paper examines the implications of chemical regulation in children's products in large markets for a smaller market, namely Israel. We compared chemical regulations in children's products in the U.S., EU and Israel, and conducted in-depth interviews with diverse stakeholders in the Israeli product standardization process. Israel adopted EU chemical standards for certain chemicals (e.g., trace metals, phthalates) but not others (e.g., bisphenol A, flame retardants, trace metals in children's jewelry). Israeli regulation of chemicals in consumer products relies on regulations in large markets such as the U.S. and EU, which therefore have impacts beyond their territories. However, Israel adopts only product-specific standards and has regulatory gaps due to the lack of an overarching regulatory approach that exists in the U.S. and the EU. Furthermore, Israeli policy is to adopt parallel standards from large markets in order to remove trade barriers, despite their different approaches to chemical regulation, an approach which prioritizes trade considerations over health considerations. We conclude with policy recommendations for Israel, which have relevance for other small markets. [ABSTRACT FROM AUTHOR]

Trace metals and synthetic chemicals including phthalates, bisphenol A and flame retardants, are widely used in toys and childcare products, and may pose acute or chronic adverse health effects in children. In Israel, certain chemicals are regulated in childcare products, but there are still regulatory gaps. We tested regulated and unregulated contaminants in 174 item parts from 70 childcare items with potentially high oral or dermal exposure, including 22 children's jewelry items, 14 toys, 7 diaper-changing mats, 6 baby mattresses, 7 baby textiles and 14 feeding and bathing items. In children's jewelry, an unregulated product in Israel, 23% of samples exceeded the US standard for lead. In toys, a regulated product, we did not detect trace metals above the Israeli standard. In textiles, baby mattresses and diaper-changing mats, phthalates exceeded the European Union standard in 14–45% of tests with a mean of 6.74% by mass for diisononyl phthalate, and 1.32% by mass for di(2-ethylhexyl) phthalate. BPA migration exceeded the EU standard in 14–45% of tests with a mean of 1.03 ppm. The flame retardants polybrominated biphenyls, pentabromodiphenyl, octabromodiphenyl ether, tris(2,3-dibromopropyl) phosphate and tris-(aziridinyl)-phosphine oxide were not detected. For products regulated in Israel, our findings suggest general compliance with mandatory standards. However, a lack of comprehensive chemical regulation means that there are regulatory gaps, and products not regulated in Israel may contain high levels of chemical contamination, exceeding US or EU regulations. The results of this study have prompted the development of an Israeli safety standard for children's jewelry. [ABSTRACT FROM AUTHOR]

Recent thinking in multicultural education can contribute to environmental education (EE) in culturally diverse societies. This article uses case studies of two minorities in Israel to illustrate the potential for bringing together these two areas of educational research that have developed significantly in recent years. After introducing the topics of EE and multicultural education, we discuss some compelling intersections between them. We then introduce the Arab and ultraorthodox sectors, and describe the ways in which issues of educational contents, representation, resources, and infrastructure affect EE in these sectors. We show how policies and concrete measures for forwarding EE in these groups in a multicultural manner can draw on their specific culture, education systems, and environmental situations. [ABSTRACT FROM PUBLISHER]

Despite the strong linkage between environment and health, institutions responsible for these fields operate in largely fragmented ways with limited interaction. As illustrated in the recent engagement between health and urban planning institutions, inter-institutional cooperation could support more effective and politically acceptable solutions for both local and global problems. Analysis of three case-studies, from three different continents, shows that HIA might serve to promote synergies among health and environmental disciplines in different local contexts, and could lead to institutional and procedural changes that promote health. Case examples provided supportive evidence for these effects, despite differences in approaches to HIA and governance levels. Obstacles to the use of HIA for inter-institutional integration also differed between countries. Lessons learned could support cooperation in other common interests of health and environment disciplines such as research, training and preparedness, and mitigation of public health emergencies related to the environment. [Copyright &y& Elsevier]

In a national evaluation of environmental literacy in Israel, (Negev, Sagy, Garb, Salzberg, & Tal, 2008), the authors included both multiple choice questions and open questions. In this article the authors describe the qualitative analysis of the answers to an open question regarding a local environmental problem. Most participants specified solid waste, open spaces, or air pollution as the main issues. The perceived solutions were generally at the governmental level, including planning, infrastructure, legislation, and enforcement. The authors describe relations in these responses between the problems, their causes and solutions, and between the quality of these answers and the general environmental literacy of the participants. The authors end with a discussion of the special contributions and potential of open-ended questions for environmental education research. [ABSTRACT FROM AUTHOR]

The authors conducted a national survey of 6th- and 12th-grade students in Israel to evaluate their environmental literacy, including the dimensions of environmental knowledge, attitudes, and behavior. In this article, the authors present the results of the survey, the correlations between these different dimensions, and their associations with demographic and experiential data. The authors did not find a significant correlation between knowledge and behavior. Ethnic and socioeconomic characteristics were moderately associated with environmental literacy, whereas the presence of an adult who mediated children's relation to nature was strongly related to environmental attitudes and behavior and weakly related to knowledge. The results suggest that the intended objectives of environmental education in Israel have not been achieved. The authors call for additional research to identify ways to improve environmental education in the Israeli public schools. [ABSTRACT FROM AUTHOR]

Global health threats including epidemics and climate change, know no political borders and require regional collaboration if they are to be dealt with effectively. This paper starts with a review of the COVID-19 outbreak in Israel, Palestine and Jordan, in the context of the regional health systems, demography and politics. We suggest that Israel and Palestine function as one epidemiological unit, due to extensive border crossing of inhabitants and tourists, resulting in cross-border infections and potential for outbreaks' transmission. Indeed, there is a correlation between the numbers of confirmed cases with a 2–3 weeks lag. In contrast, Jordan has the ability to seal its borders and better contain the spread of the virus. We then discuss comparative public health aspects in relation to the management of COVID-19 and long term adaptation to climate change. We suggest that lessons from the current crisis can inform regional adaptation to climate change. There is an urgent need for better health surveillance, data sharing across borders, and more resilient health systems that are prepared and equipped for emergencies. Another essential and currently missing prerequisite is close cooperation within and across countries amidst political conflict, in order to protect the public health of all inhabitants of the region. Unlabelled Image • Global health threats know no political borders and effective response requires regional collaborations. • We review the COVID-19 outbreak in Israel, Palestine and Jordan, in the context of regional demography and politics. • As a lesson from COVID-19, health systems should be better prepared for climate change impacts. • Stronger economies should take a leading role in developing regional resilience and promoting public health. • Regional cooperation can be important for promoting cross-border collaborations to address future climate and public health challenges. [ABSTRACT FROM AUTHOR]

Since its establishment in 1948, the State of Israel has been oriented towards economic development and industrialization, with a transportation sector increasingly focused on private cars. In 1961, initial awareness of environmental risks led to the adoption of the Abatement of Nuisances Law, which served as the platform for air pollution policy for several decades, even as population growth and growth of the industrial sector, including fossil fuel power plants, led to a continuous increase in air pollution. In the early 2000s, the environmental movement in Israel criticized local air pollution policy as being out of date and started to promote a new Clean Air Law. The law, which was adopted in 2008 and came into force in 2011, was a watershed in air pollution policy in Israel. It includes ambient air quality values for 28 contaminants, emission permits for the industrial sector based on best available techniques (BAT), an enforcement system, and a unified and transparent monitoring system. This paper reviews the history of air pollution policy in Israel from 1948, through the 1961 and 2008 landmark legislations and their strengths and weaknesses, to the present. The paper ends with recommendations for future air pollution policy in Israel. [ABSTRACT FROM AUTHOR]

The role of the chief scientist (CS), a key administrative position in various Israeli ministries, is to fund policy‐oriented research and support evidence‐based decision‐making. Has the CS's role promoted or constrained incorporation of scientific advice regarding climate change adaptation into governmental policy? Have administrative traditions affected the adaptation planning process in Israel? Analysis of documents and 26 in‐depth interviews with key stakeholders sheds light on the ongoing climate change adaptation policy formulation process. Our study reveals that the CS of the Ministry of Environmental Protection functions as a bridge at different interfaces and can be characterized as a boundary worker between institutions. The inherent independence of this position facilitates the CS's ability to initiate, foster, and prioritize complex issues such as adaptation. Our findings further suggest that the perception that Israel has already adapted, or will easily adapt, has negatively affected the adaptation process. [ABSTRACT FROM AUTHOR]

Background: A major earthquake in Israel is inevitable. Individual risk perceptions and preparedness can mitigate harm and save lives. The gap between the public's concerns and those of experts is reflected in their differential perceptions regarding the components that influence the occurrence of an earthquake in Israel. Whereas the public believes that geographic location is the critical variable, the experts note additional variables that need to be considered. Common knowledge regarding the risks of earthquake occurrence in Israel is based on a distinction between high and low-risk areas, such that the closer a residential area is to the Great Rift Valley, the higher the risk that an earthquake will occur. Objectives: To examine the variables affecting public preparedness in Israel (effective communication agent (communicator), high and low earthquake risk areas) and the degree to which experts' knowledge contradicts respondents' common knowledge. Methods: The study used a mixed-methods approach combining qualitative and quantitative research. The first stage included in-depth interviews with earthquake experts (n = 19). The second stage consisted of an experiment conducted among a representative sample of the public (n = 834). Results: Most people believe that geographical location constitutes the main risk factor for earthquakes in Israel. Yet experts claim that additional variables affect earthquake intensity and damage: building strength, earthquake magnitude, distance from earthquake epicenter, soil type, and interaction between these four. The study found that knowledge of expert information affects public willingness to prepare. The direction of this influence depends on participants' risk perceptions regarding residential area and on degree of consistency with common knowledge. In low-risk areas, added knowledge increased willingness to prepare whereas in high-risk areas this knowledge decreased willingness. Conclusion: To turn expert information into common knowledge and to increase earthquake preparedness, the authorities must educate the public to generate a new public preparedness norm. [ABSTRACT FROM AUTHOR]

The prediction of the occurrence of infectious diseases is of crucial importance for public health, as clearly seen in the ongoing COVID-19 pandemic. Here, we analyze the relationship between the occurrence of a winter low-pressure weather regime - Cyprus Lows - and the seasonal Influenza in the Eastern Mediterranean. We find that the weekly occurrence of Cyprus Lows is significantly correlated with clinical seasonal Influenza in Israel in recent years (R = 0.91; p <.05). This result remains robust when considering a complementary analysis based on Google Trends data for Israel, the Palestinian Authority and Jordan. The weekly occurrence of Cyprus Lows precedes the onset and maximum of Influenza occurrence by about one to two weeks (R = 0.88; p <.05 for the maximum occurrence), and closely follows their timing in eight out of ten years (2008–2017). Since weather regimes such as Cyprus Lows are more robustly predicted in weather and climate models than individual climate variables, we conclude that the weather regime approach can be used to develop tools for estimating the compatibility of the transmission environment for Influenza occurrence in a warming world. Furthermore, this approach may be applied to other regions and climate sensitive diseases. This study is a new cross-border inter-disciplinary regional collaboration for appropriate adaptation to climate change in the Eastern Mediterranean. Unlabelled Image • The occurrence of Cyprus Lows and Influenza are significantly correlated over Israel, the Palestinian Authority and Jordan. • The occurrence of Cyprus Lows precedes the onset/maximum of Influenza incidence by 1-2 weeks and follows their timing. • This relationship can be used to develop tools to estimate the compatibility of the environment for Influenza occurrence. [ABSTRACT FROM AUTHOR]

To examine whether high ambient temperature and diurnal temperature range during the summer are associated with risk of stroke/transient ischemic attack (TIA). A time-stratified case-crossover study design was conducted. The study sample comprised all individuals aged ≥50 years who had a stroke/TIA reported to the Israeli National Stroke Registry between 2014 and 2016 during the summer season. Daily temperature data were retrieved from the Israel Meteorological Service. Conditional logistic regression models were used with relative humidity and air pollution as covariates. The sample included 15,123 individuals who had a stroke/TIA during the summer season (mean age 73 ± 12 years; 54% males). High ambient temperature was associated with stroke/TIA risk starting from the day before the stroke event, and increasing in strength over a six-day lag (OR = 1.10 95%CI 1.09–1.12). Moreover, a larger diurnal temperature range prior to stroke/TIA occurrence was associated with decreased stroke/TIA risk (OR = 0.96 95%CI 0.95–0.97 for a six-day lag). High ambient temperature may be linked to increased risk of cerebrovascular events in subsequent days. However, relief from the heat during the night may attenuate this risk. • Weather conditions are emerging as novel risk factors for stroke. • High temperatures were associated with increased stroke risk. • A lag period of 1–6 days existed between the day of exposure and the stroke event. • Larger diurnal temperature ranges were linked with reduced stroke risk. [ABSTRACT FROM AUTHOR]

The Mediterranean Basin is undergoing a warming trend with longer and warmer summers, an increase in the frequency and the severity of heat waves, changes in precipitation patterns and a reduction in rainfall amounts. In this unique populated region, which is characterized by significant gaps in the socio-economic levels particularly between the North (Europe) and South (Africa), parallel with population growth and migration, increased water demand and forest fires risk - the vulnerability of the Mediterranean population to human health risks increases significantly. Indeed, climatic changes impact the health of the Mediterranean population directly through extreme heat, drought or storms, or indirectly by changes in water availability, food provision and quality, air pollution and other stressors. The main health effects are related to extreme weather events (including extreme temperatures and floods), changes in the distribution of climate-sensitive diseases and changes in environmental and social conditions. The poorer countries, particularly in North Africa and the Levant, are at highest risk. Climate change affects the vulnerable sectors of the region, including an increasingly older population, with a larger percentage of those with chronic diseases, as well as poor people, which are therefore more susceptible to the effects of extreme temperatures. For those populations, a better surveillance and control systems are especially needed. In view of the climatic projections and the vulnerability of Mediterranean countries, climate change mitigation and adaptation become ever more imperative. It is important that prevention Health Action Plans will be implemented, particularly in those countries that currently have no prevention plans. Most adaptation measures are "win-win situation" from a health perspective, including reducing air pollution or providing shading solutions. Additionally, Mediterranean countries need to enhance cross-border collaboration, as adaptation to many of the health risks requires collaboration across borders and also across the different parts of the basin. • Climate change impacts the health of the Mediterranean population. • The main effects are related to extreme events, VBD and changes in local conditions. • The poorer countries, mainly in North Africa and the Levant, are at highest risk. • Based on projections, mitigation and adaptation become ever more imperative. • Prevention plans related to health should be implemented together with cross-border collaboration. [ABSTRACT FROM AUTHOR]

A growing body of literature reports associations between exposure to particulate matter with aerodynamic diameters ≤2.5 μm (PM 2.5) and 2.5–10 μm (PM 10-2.5) during pregnancy and preterm birth (PTB). However, the role of ambient temperature in PM-PTB associations was rarely investigated. In Israel, we used Maccabi Healthcare Services data to establish a population-based cohort of 381,265 singleton births reaching 24–42 weeks' gestation and birth weight of 500–5000 g (2004–2015). Daily PM and ambient temperature predictions from a satellite-based spatiotemporal model, at a 1 × 1 km spatial resolution, were linked to the date of birth and maternal residence. Mixed effects Cox regression models, adjusted for covariates, with a random intercept at the mother level were used to assess associations between mean exposure during pregnancy and PTB. We found that exposure to PM 2.5 was positively associated with PTB when the average exposure during pregnancy was either low (first quintile) or high (fifth quintile), compared to exposure in the 2nd-4th quintiles, with hazard ratios (HRs) 1.18 (95% confidence interval [CI], 1.13–1.24) and 1.07 (95% CI, 1.02–1.12), respectively. The results revealed effect modification of temperature. For mothers exposed to low (below median) average temperature during pregnancy, HRs of PTB were 0.93 (95% CI, 0.87–1.00) and 1.21 (95% CI, 1.14–1.29) for the first and fifth PM 2.5 quintiles, respectively, when compared to the 2nd-4th quintiles. However, a reverse trend was indicated for high-temperature pregnancies, where the corresponding HRs were 1.48 (95% CI, 1.39–1.58) and 0.92, (95% CI, 0.96–0.98). In conclusion, consideration of climatic factors can provide new insights into the risk of PTB as a result of exposure to PM 2.5 during pregnancy. [ABSTRACT FROM AUTHOR]

Exposure to low levels of lead in children can cause cognitive deficits (reduced IQ) and behavioral changes such as reduced attention span and increased antisocial behavior. There are no mandatory limits on lead in paint in Israel, with the exception of paints used on toys and children's furniture. However, paints in playgrounds and public areas may be a source of exposure to lead in young children. In this study, we quantified lead concentrations in painted surfaces in public playgrounds and public areas, and in spray paints in Israel, using X-ray fluorescence (XRF). Lead was detected in 43/48 (90%) of surfaces; concentrations exceeded the US regulatory limit for lead in paint (90 ppm) in 4/5 (80%) of tested surfaces on wooden picnic tables and benches, and 22/25 (88%) of surfaces in playgrounds. In 15 surfaces, lead concentrations were 10–700 times higher than the US limit. Out of 11 spray paints sampled, three (27%) had concentrations above the US standard for residential paints. In order to prevent exposure of the general public to lead in playgrounds and public areas and in spray paints, we recommend an integrated approach, including regulatory restrictions (mandatory lead limit of 90 ppm in all paints except labeled industrial paints); awareness raising in the public and in national agencies and local authorities responsible for maintenance in playgrounds, schools and public areas; and encouragement of voluntary measures by industry to prevent sale of industrial paints for use in areas accessible to the public. [ABSTRACT FROM AUTHOR]

Background: The developing fetus is susceptible to environmental insults. Studying the effects of environmental exposures on fetal growth is essential for understanding the causal pathway between prenatal exposures and pregnancy outcomes. Here we describe the Haifa Pregnancy Cohort Study (HPCS) and discuss challenges and opportunities in applying "big data" paradigm.Methods: Maccabi Healthcare Services (MHS), is the second largest Israeli health maintenance organization (HMO) providing care services to two million beneficiaries. The HPCS cohort potentially includes ~750,000 newborns born between 1998 and 2017. We will estimate daily exposures to air pollutants, temperature and greenness, using satellite-based data and models. We hypothesize that residents of Haifa have higher exposures to environmental pollutants and that in pregnant women this higher exposure is associated with poorer fetal growth. We will evaluate outcomes such as birth-weight, head-circumference and gestational age at birth. We will adjust for pregnancy complications such as pre-eclampsia and gestational diabetes and parental variables, such as maternal weight, age and smoking habits as potential confounders. In addition, we will conduct a multi-tiered field study, nested within this population, among 150 pregnant women residing in two geographical regions-one in the polluted Haifa area, and one in a relatively unpolluted area in central Israel. Blood and urinary samples will be collected, as well as personal and indoor exposure to air pollution.Discussion: Evaluating environmental exposures of pregnant women and assessing in utero growth over the course of the pregnancy during different exposure windows, is of great scientific and public health interest. Recent advances in data collection and analysis pose great promise to provide insights into contribution of environment to the health of the developing fetus, but also pose major challenges and pitfalls, such as data management, proper statistical framework and integration of data in the population-based study and selectiveness in the nested field study. Yet the continuing follow-up of the study cohort, integrating data from different services, health-promotion, and eventually, application later in real life of our main promises. Our study aims to meet these challenges and to provide evidence of the environmental exposures associated with fetal growth. [ABSTRACT FROM AUTHOR]

A growing body of literature reports associations between exposure to particulate matter with diameter ≤2.5 μm (PM 2.5) during pregnancy and birth outcomes. However, findings are inconsistent across studies. To assess the association between PM 2.5 and birth outcomes of fetal growth in a cohort with high prevalence of siblings by multilevel models accounting for geographical- and mother-level correlations. In Israel, we used Maccabi Healthcare Services data to establish a population-based cohort of 381,265 singleton births reaching 24–42 weeks' gestation and birth weight of 500–5000 g (2004–2015). Daily PM 2.5 predictions from a satellite-based spatiotemporal model were linked to the date of birth and maternal residence. We generated mean PM 2.5 values for the entire pregnancy and for exposure periods during pregnancy. Associations between exposure and birth outcomes were modeled by using multilevel logistic regression with random effects for maternal locality of residence, administrative census area (ACA) and mother. In fully adjusted models with a mother-level random intercept only, a 10-μg/m3 increase in PM 2.5 over the entire pregnancy was positively associated with term low birth weight (TLBW) (Odds ratio, OR = 1.25, 95% confidence interval, CI: 1.09,1.43) and small for gestational age (SGA) (OR = 1.15, 95% CI: 1.06,1.26). Locality- and ACA-level effects accounted for <0.4% of the variance while mother-level effects explained ∼50% of the variability. Associations varied by exposure period, infants' sex, birth order, and maternal pre-pregnancy BMI. Consideration of mother-level variability in a region with high fertility rates provides new insights on the strength of associations between PM 2.5 and birth outcomes. • New evidence from the Middle East – a region with scarce data. • Maternal exposure to PM2.5 was associated with fetal growth outcomes. • Associations were clearer when mother-level clustering in the data was accounted for. • Associations were modified by infant's sex, birth order and maternal pre-pregnancy BMI. • Associations were highest for low socio-economic status and for third trimester of pregnancy. [ABSTRACT FROM AUTHOR]